FFY 2000 WIC Procedures Manual [2000]

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WIC

PROCEDURES MANUAL

GEORGIA WIC PROGRAM



GA WIC PROCEDURES MANUAL

TABLE OF CONTENTS

Page

I.

Purpose........................................................................................................................... IN- I

II. Scope .............................................................................................................................. IN-2

III. References ...................................................................................................................... IN-3

IV. Prior Approval ............................................................................................................... IN-4

V. Policy Memos ................................................................................................................ IN-5

VI. Sections .......................................................................................................................... IN-6

A. Introduction (IN) .................................................................................... IN-6

B. Certification (CT)................................................................................... IN-6

C. Rights and Obligations (RO) ................................................................. IN-7

D. Administrative (AD) .............................................................................. IN-7

E. Vendor (VN) .......................................................................................... IN-8

F. Food Package (FP) ................................................................................. IN-8

G. Nutrition Education (NE) ....................................................................... IN-9

H. Special Population (SP) ......................................................................... IN-9

I.

Outreach (OR) ........................................................................................ IN-9

J.

Food Delivery (FD)................................................................................ IN-9

K. Quality Improvement (QI) ................................................................... IN-10

L. Monitoring (MO) ............... ,................................................................. IN-I 0

M. Breastfeeding (BF) ............................................................................... IN-I 0

N. Disaster Plan (DP) ................................................................................ IN-11

0. WIC Procedures Manual Glossary ....................................................... IN-11

VII. Administration ............................................................................................................. IN-12

A. Food and Nutrition Service (FNS)/USDA ........................................... IN-I2



GA WIC PROCEDURES MANUAL B. State Agency .........................:-IN-12
VIII. Addresses ..................................................................................................................... IN-13
A. Local Agencies.............................................................................. '....... IN-13 B. State Agency ........................................................................................ IN-21







GA WIC PROCEDURES MANUAL
I. PURPOSE The purpose of the Georgia WIC Program Procedures Manual is to provide local agency staff with a guide to WIC Program operations. The information in this manual is to be used in the delivery of services to WIC Program applicants and participants in the State of Georgia.





IN-1



GA WIC PROCEDURES MANUAL
II. SCOPE The information in the Georgia WIC Progr~ 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 Branch encourages coordination of WIC and nutrition services with other health programs (e.g. maternal and child health, family planning, immunization), as well as health care providers in each local area (e.g. private physicians, hospitals, voluntary health organizations) .





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GA WIC PROCEDURES MANUAL
III. REFERENCES
This manual reflects State policies, USDA Regional instructions, and Federal regulations. It is strongly recommended that a copy of the WIC Program Federal Register be filed with the Procedures Manual for cross-referencing.





IN-3



GA WIC PROCEDURES MANUAL
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.





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GA WIC PROCEDURES MANUAL
V. POLICY MEMOS
Georgia WIC policy memos, distributed throughout the year, reflect current policy in the Georgia WIC Program. Policy Memos must not be re-written by District Staff. The content of the re-written memos may change the entire meaning of what is intended. 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. In the monthly/quarterly meetings held with WIC and non-WIC staff, policy memos and changes must be discussed to keep staff abreast of current procedures. Policy Memos 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-5



GA WIC PROCEDURES MANUAL
VI. SECTIONS
The Georgia WIC Program Procedures Manual is divided into sixteen (16) sections which are described as follows:
A. Introduction (IN) Section includes:
Purpose Scope References Prior Approval Policy Memos Sections Administration Addresses (Local and State)
B. Certification (CT) Section includes:
General
Eligibility Requirements
Initial Application
Processing Standards Participant Identification Income Eligibility 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 Ineligibility Procedures (Notification Requirements) Transfer of Certification Correcting Mistakes Certified Waiting List Patient Flow Analysis
IN-6



GA WIC PROCEDURES MANUAL
Systems Information Management Immunization Coverage Assessment
C. Rights and Obligations (RO) Section includes:
Rights and Obligations of WIC Applicants/Participants Nondiscrimination Clause Public Notification Civil Rights Fair Hearing Procedures - Participants Fair Hearing Procedures - Migrants Administrative Appeals - Local Agency Availability of Hearing Records National Voter Registration Act
D. Administrative (AD) Section includes:
Section I
Agreement with State Agency Financial Procedures Administrative Cost Categories Shared Costs Random Moment Sample Study Purchasing Procedures Allocation of Funds Food Cost Projection Report
Program Income Section II
Retention of Records WIC Acronym & Logo Lobbying Restrictions Confidentiality Faxing Confidentiality Information WIC Volunteer and Confidentiality Retroactive Benefits and Reimbursement Mandatory No Smoking Policy in Local WIC Clinics
IN-7



GA WIC PROCEDURES MANUAL
Subpoenas Search Warrants Program Participation System Maintenance Indicator Report Documentation Establishing New Clinics/Clinic Changes
E. Vendor (VN) Section includes:
Introduction Vendor Coordinator Enrollment of New Vendors Vendor Agreements Vendor Stamp Vendor Training Vendor Materials Monitoring Compliance Investigations Vendor Sanctions Complaints Against Vendors Terminations/Disqualification ._ Vendor Fair Hearing Procedures High Risk Vendor Identification Minimum Inventory Requirements Waiver
F. Food Package (FP) Section includes:
Authorization of Foods Prescribing Foods - General Infants Children and Women with Special Dietary Needs Children 1-5 Pregnant and Breastfeeding Women Postpartum, Non-Breastfeeding Women Homelessness, Migrancy, and Disaster Situation

IN-8



GA WIC PROCEDURES MANUAL
G. Nutrition Education (NE) Section includes:
Purpose Definition Goals State Agency Local Agency Participant Nutrition Education Participant Referrals to Other Agencies Nutrition Education Materials
H. Special Population (SP) Section includes:
Introduction Individuals Residing in Non-Traditional Housing or Institutions Other Special Populations Referral and Outreach to Special Populations
I. Outreach (OR) Section includes:
General Methods of Outreach Agencies to Contact for Outreach Public Notification Public Comments Outreach During A Waiting List Program Costs Coordination/Integration of Services
J. Food Delivery (FD) Section includes:
General Types of WIC Vouchers Voucher Issuance - General Computer Printed Voucher Manual Vouchers Georgia WIC Program Identification (IO) Card
Proxies Mailing/Delivery of WIC Vouchers
IN-9



GA WIC PROCEDURES MANUAL
Voided Vouchers Prorated Vouchers Late Pick-up of Vouchers Coordination of Health Services and Voucher Issuance Redemption ofWIC Vouchers Lost, Stolen or Damaged Vouchers Borrowed Vouchers Cumulative Unmatched Redemption Report (CUR)
K. Quality Improvement (QI) Section includes:
Introduction Monitoring Participant Abuse Procedures for Repayment of WIC Funds Guidelines for Investigating Employee Abuse Procedures to Request an Employee Investigation Vendor Compliance Investigation Compliance Investigation Food Purchases Disqualified Vendor/Participant Hardship Investigation of Missing VouchersNOC Cards Security of Issuance Material Voucher Issuance Security
L. Monitoring (MO) Section includes:
State Agency Monitoring Quality Assurance Self-Reviews Technical Assistance
M. Breastfeeding (BF) Section includes:
Introduction Definitions State Agency Local Agency Participant Education Participant Referral
IN-10



GA WIC PROCEDURES MANUAL
Breastfeeding Materials and Resources Allowable Cost for the Promotion and Support of Breastfeeding Documentation of Breastfeeding Rates
N. Disaster Plan (DP) Section includes:
Introduction Policies Assessing Impact of Disaster Concept of Operation Responsibilities Resource Requirement
0. WIC Procedures Manual Glossary





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GA WIC PROCEDURES MANUAL
VII. ADMINISTRATION
A. Food and Nutrition Services (FNS)/USDA FNS/USDA administers the Program nationwide and provides grants to state health agencies.
B. State Agency In Georgia, the Department of Human Resources, Division of Public Health, administers the Program and allocates funds to local agencies. Most local agencies are district health units which are comprised of county health departments. Two (2) local agencies, Southside, Inc. and Grady Maternal and Infant Care Project, contract with DHR to administer and operate the WIC Program.





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GAWICPROCEDURESMANUAL

VIII. ADDRESSES

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

DISTRICT/ADDRESS
District I, Unit I (Rome)
C. Wade Sellers, M.D., M.P.H. District Health Director Gary Marcum Program Manager Rosemarie Newman, L.D. District WIC Coordinator Northwest Georgia Health District NW GA Regional Hospital 1305 Redmond Road Rome, GA 30161 (706) 295-6661/GIST 231-6661 District I, Unit 2 (Dalton)
Joy Benson, M.D. District Health Director Roy Moore Program Manager Sandy Akins, R.D., L.D., M.P.H. District WIC Coordinator Northwest Health District Office JOO W Walnut Avenue Suite #92 Dalton, GA 30720 (706) 272-2342/GIST 234-2342 District 2 (Gainesville)
Melody A. Stancil, M.D. District Health Director David Oberhausen Deputy Program Director Jean Garner, L.D. District WIC Coordinator DHR Health District 2 Office 1280 Athens Street Gainesvi//e, GA 30507 (770) 535-5743/GIST 261-5743
IN-13

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

#OFWIC CLINIC SITES
17

Whitfield, Murray,

7

Gilmer, Fannin, Pickens,

Cherokee

Banks, Dawson, Forsyth, 13 Franklin, Habersham, Hall, Hart, Lumpkin, Rabun, Towns, Stephens, Union, White



GA WIC PROCEDURES MANUAL

DISTRICT/ADDRESS
District 3, Unit 1 (Cobb)
Virginia Galvin, M.D. District Health Director Lisa Crossman Deputy Director for Prevention and Wellness Jack Gutkins Program Manager Beverly Demetrius, R.D., M.A. District WIC Coordinator Metro West Health District Office 1650 County Services Pkwy. Marietta, GA 30008 (770) 514-2325 District 3, Unit 2 (Fulton)
Adewale Troutman, M.D., M.D.H. District Health Director Paulette McCray, L.D., M.S., C.N.S., L.D. Nutrition Services Manager Fulton County Health Department 75 Piedmont Avenue Suite #362 Atlanta, GA 30303 (404) 730-4050 District 3, Unit 3 (Clayton)
Stephen Morgan, M.D. District Health Director Paula Sherrer Program Manager Kathy Thomas, R.D., L.D. District WIC Coordinator Clayton County Health Department 1380 Southlake Plaza Dr. Morrow, Georgia 30260 (770) 96/-1330

COUNTIES SERVED Cobb, Douglas
Fulton Clayton

#OFWIC CLINIC SITES 8
23
3



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GA WIC PROCEDURES MANUAL
DISTRICT/ADDRESS
District 3, Unit 4 (Gwinnett)
Patrick J. Meehan, M.D. District Health Director Jane Atkinson Program Manager Maxine Moore, R.D., L.D. District WIC Coordinator East Metro Health District District Health Office P.O. Box 897 Lawrenceville, GA 30246-0897 324 W. Pike Street Lawrenceville, GA 30045-0897 (770) 339-4260



COUNTIES SERVED
Gwinnett, Rockdale, Newton

#OFWIC CLINIC SITES
6



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GA WIC PROCEDURES MANUAL

DISTRICT/ADDRESS

COUNTIES SERVED

District 3, Unit 5 (DeKalb)
Paul J. Wiesner, M.D. District Health Director
Carolyn Wetzel, R.D., M.P.H. Director East District Health Center 2277 So. Stone Mountain-Lithonia Road Lithonia, Georgia 30058-5252 Contact: Marsha Canning, L.D.
Central Dekalb Health Center 320 Winn Way Decatur, GA 3003 I Contact: Martin Alvarez
DeKalb -Atlanta- Health Center . 30 Warren Street Atlanta, GA 303 I 7 Contact: Cynthia Clark,
Vicki Clark
Robert V. Taylor Director North Dekalb Health Centers 1954 Airport Road Suite #I 50 Chamblee, GA 3034/-4953 Contact: Carol Boe, R.D., L.D.
Burretta Shepherd Director South DeKalb Health Center 3 I JO Clifton Springs Road, SuiteD Decatur, GA 30034 Contact: Magoo Mbudugha, M.S., C.D.M.

DeKalb

#OFWIC CLINIC SITES
5



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GA WIC PROCEDURES MANUAL
DISTRICT/ADDRESS
District 4 (LaGrange)
Michael Brackett, M.D., F.A.A., F.P. Interim District Health Director Gus Morgan Program Manger Blanche Deloach, R.D., L.D. District WIC Coordinator District 4 Health Services Office l 22 Gordon Commercial Drive Suite A LaGrange, Georgia 30240 (706) 845-4035 District 5, Unit I (Dublin)
Lawton Davis, M.D. District Health Director Jannell Knight, M.S.A., L.D. Progtam Manager Wanda Foskey, B.A. District WIC Coordinator Brent Gibbs, R.D., L.D. Nutrition Manager South Central Health District Office 2121-B Bellevue Road Dublin, GA 3 /021 (912) 275-6545 District 5, Unit 2 (Macon)
Joseph R. Swartwout, M.D. District Health Director Jacquelynn Nelson, M.S.A., R.D., L.D., C.P.M. Nutrition Services Director 187 Robertson Mill Rd., Suite 103 Milledgeville, GA 31061 (912)445-1137 Fax(912)445-1139

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

#OFWIC CLINIC SITES
17

Bleckley, Dodge,

IO

Laurens, Montgomery,

Pulaski, Telfair,

Treutlen, Wilcox,

Wheeler, Johnson

Hancock, Houston,

20

Jasper, Baldwin, Bibb,

Crawford, Jones,

Monroe, Peach, Putnam,

Twiggs, Washington,

Wilkinson



IN-17



GA WIC PROCEDURES MANUAL
DISTRICT/ADDRESS
District 6 (Augusta)
Frank Rumph, M.D. District Health Director East Central Health District Office /916 North leg Road Augusta, GA 30909 (706) 667-4250 John Nolan Program Manager Frances Wilkinson, M.S., R.D., L.D. District WIC Coordinator East Central Health District Office I 9 I 6 North leg Road Augusta, GA 30909 (706) 667-4287 District 7 (Columbus)
Zsolt Kippanyi, M.D. District Health Director Dorothy (Dee) Cantrell Program Manager Jackie Miller, R.D., L.D., M.S.P.H District WIC Coordinator West Central Health District Office 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, L.D. District WIC Coordinator P.O. Box 5147 Valdosta, GA 3 I 603 3 I 2 N. Patterson Street Valdosta, GA 31601 (9 I2) 333-5290
IN-18

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

#OFWIC CLINIC SITES
23

Harris, Talbot, Dooly,

23

Quitman, Taylor,

Marion, Macon, Crisp,

Sumter, Clay, Schley,

Webster, Randolph,

Stewart, Muscogee,

Chattahoochee

Ben Hill, Berrien,

12

Brooks, Cook, Echols,

Irwin, Tift, Turner,

Lanier, Lowndes



GA WIC PROCEDURES MANUAL
DISTRICT/ADDRESS
District 8, Unit 2 (Albany)
J. Paul Newell, M.D. District Health Director Barbara Evans Program Manager Martha Shackelford, M.P.H., R.D., L.D., C.P.M. District WIC Coordinator Southwest Health District Office 231 Tift Avenue Albany, GA 31701 (912) 430-4111 District 9, Unit 1 (Savannah)
Barbara N. Samuels, M.D. District Health Director Al Mungin Program Manager Patricia Jackson, B.S.N., L.D. Director ofNutrition Services East Health District 1602 Drayton Street Savannah. GA 31401 (912) 651-2571 District 9, Unit 2 (Waycross)
Ted Holloway, M.D. District Health Director Sue Scaffe, R.N. Program Manager Susan Horne, M.P.H., L.D. District WIC Coordinator Southeast Health District 1115-B Church Street Waycross.GA 31501 (912) 285-6031

COUNTIES SERVED
Terrell, Lee, Calhoun, Worth, Early, Dougherty, Baker, Grady, Mitchell, Colquitt, Miller, Thomas, Seminole, Decatur

#OFWIC CLINIC SITES
15

Chatham, Effingham

9

Appling, Atkinson,

20

Bacon, Jeff Davis,

Brantley, Ware, Bulloch,

Candler, Clinch,

Charlton, Evans, Coffee,

Wayne, Pierce, Toombs,

Tattnall



IN-19



GA WIC PROCEDURES MANUAL
DISTRICT/ADDRESS
District 9, Unit 3 (Brunswick)
B. Brooks Taylor, M.D. District Health Director Billy Griner Program Manager Jo Bishop Manning, L.D. District WIC Coordinator Coastal Health District Office 1609 Newcastle Street Brunswick, GA 31521 (912) 264-3907 District 10 (Athens)
Claude A. Burnett, M.D. District Health Director John McKinley Program Manager Vicky Moody, M.P.H., L.D. Director of Nutrition Services Northeast Health District Office 468 North Milledge Avenue Room 101-B Athens, GA 30601-3808 (706) 542-9547 Southside Healthcare, Inc.
David Williams, M.D. Director Dominic Mack, M.D. Program Manager Laverne Montgomery, M.A., R.D., L.D. District WIC Coordinator Southside Healthcare, Inc. 1039 Ridge Avenue, S. W. Atlanta, Ga 30315 (404) 688-1350, Ext. 244

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

#OFWIC CLINIC SITES
15

Barrow, Clarke, Elbert,

17

Green, Jackson,

Madison, Morgan,

Oconee, Walton,

Oglethorpe

Portions of Fulton ad

2

Dekalb Counties



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GA WIC PROCEDURES MANUAL

DISTRICT/ADDRESS

COUNTIES SERVED

#OFWIC CLINIC SITES

Grady Maternal & Infant Care Project

ALL

6

Joseph A. Taylor Director Amy Kloeben, M.P.H., R.D., L.D., C.H.E.S. Chief Nutritionist Maternal & Child Health Nutrition Dept. Grady Health System P. 0. Box 2601 I Atlanta, GA 30335 (404) 616-6745

B. State Agency

For technical assistance regarding all areas, except nutrition-related topics, contact the State WIC Office.

Georgia Department of Human Resources .

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 or (404) 651;..6728

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) 657-2886

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GA WIC PROCEDURES MANUAL
TABLE OF CONTENTS
I. General ...................................................................................................................... CT-1 Il. Eligibility Requirements............................................................................................ CT-2
A. Category ............................................................................................................. CT-2 B. Residency ........................................................................................................... CT-3 C. Income................................................................................................................ CT-4 D. Nutritional Risk .................................................................................................. CT-4 III. Initial Application ..................................................................................................... CT-5 IV. Processing Standards ................................................................................................. CT-7 A. Timeframes .................... ......... .... .............. .. ....................................................... CT-7 B. Walk-in Clinics .................................................................................................. CT-7 C. Request for Extension ........... .. .. .. .. .. ....... .. ......... ... ... ..... .. ...... ...... ........................ CT-7 V. Participant Identification........................................................................................... CT-8 VI. Income Eligibility...................................................................................................... CT-9 A. Procedures ....... ................. ....... ... ................... ......... ..... .. ..................................... CT-9 B. Proxies ................................................................................................................ CT-10 C. Adjunctive (Automatic) Eligibility .................................................................... CT-11 D. Computing Income ............................................................................................ CT-13 E. Documented Proof of Income ........ .... .. .. ... ................... .. ..... .. .. ....................... .. .. CT-22 F. Applicants with Zero (0) Income ....................................................................... CT-23 G. Verification of Income ....................................................................................... CT-24
vn. Nutritional Risk Determination ................................................................................. CT-25
A. Required Data..................................................................................................... CT-25 B. Referral Data ...................................................................................................... CT-25 C. Medical Data Date.............................................................................................. CT-26 VIII. Nutrition Risk Criteria............................................................................................... CT-28 IX. Nutrition Risk Priority System .................................................................................. CT-29 A. General ............................................................................................................... CT-29 B. Special Considerations ....................................................................................... CT-29



GAWICPROCEDURESMANUAL
C. Specific............................................................................................................... CT-30 D. Assignment......................................................................................................... CT-31 X. Changes Within a Valid Certification Period........................................................... CT-32 A. Women Who Cease Breastfeeding..................................................................... CT-32 B. Upgrading a Priority .......................................... ;................................................ CT-32 XI. Certification Periods .................................................................................................. CT-33 XII. Infant Mid-Certification Nutrition Assessment......................................................... CT-34 XIlI. WIC Assessment/Certification Form ....................................................................... CT-35 XIV. Ineligibility Procedures (Notification Requirements) ............................................... CT-41 A. Written Notification ........................................................................................... CT-41 B. Completion of Notice of Termination/Ineligibility/Waiting List Form ............. CT-42 C. Ineligibility File ........................................................................................... CT-43 XV. Transfer of Certification ............................................................................................ CT-44 A. Verification of Certification (VOC) Card .......................................................... CT-44 B. Other Methods of Verification ........................................................................... CT-45 C. Instructions for VOC Card Use .......................................................................... CT-46 D. Orders ................................................................................................................ CT-47 E. Inventories .......................................................................................................... CT-47 F. Issuance ............................................................................................................. CT-48 G. Security.............................................................................................................. CT-48 H. Lost/Stolen/Misplaced VOC Cards .................................................................... CT-48 XVI. Correcting Mistakes .................................................................................................. CT-50 XVII. Certified Waiting List................................................................................................ CT-51 A. Procedures for Maintaining a Waiting List........................................................ CT-51 B. Procedures for Removal from the Waiting List ................................................. CT-52 XVIII. Patient Flow Analysis ................................................................................................ CT-53 XIX. System Information Management ............................................................................. CT-57 XX. Immunization Coverage Assessment ........................................................................ CT-58 Attachments: CT-1 WIC Assessment/Certification Form - Pregnant Women ........................................ CT-59 CT-2 WIC Assessment/Certification Form - Post Partum Breastfeeding ......................... CT-61




GA WIC PROCEDURES MANUAL
CT-3 WIC Assessment/Certification Form - Post Partum Non Breastfeeding ................. CT-63 CT-4 WIC Assessment/Certification Form - Infants .......................................................... CT-65 CT-5 WIC Assessment/Certification Form - Children ....................................................... CT-67 CT-6 Signed Statement of Income...................................................................................... CT-69 CT-7 Data and Documentation Required for WIC Assessment/Certification - Women.... CT-70 CT-8 Data and Documentation Required for WIC Assessment/Certification - Infants ..... CT-71 CT-9 Data and Documentation Required for WIC Assessment/Certification - Children .. CT-72 CT-10 Nutritional Risk Criteria - Prenatal Women .............................................................. CT-73 CT-11 Nutritional Risk Criteria-Postpartum, Breastfeeding Women ................................ CT-88 CT-12 Nutritional Risk Criteria - Postpartum, Non-Breastfeeding Women .......:................ CT-102 CT-13 Nutritional Risk Criteria - Infants ............................................................................. CT-114 CT-14 Nutritional Risk Criteria- Children .......................................................................... CT-127 CT-15 Notice of Termination/Ineligibility/Waiting List Form............................................. CT-138 CT-16 Verification of Certification (VOC) Card ................................................................. CT-139 CT-17 VOC Card Inventory Log (Clinic)............................................;................................ CT-140 CT-18 VOC Card Inventory Log (Local Agency) ................................................................ CT-141 CT-19 Measuring Length.......................................... ;........................................................... CT-142 CT-20 Measuring Height ..................................................................................................... CT-143 CT-21 Measuring Weight .................................................................................................... CT-144 CT-22 Measuring Weight Standing ..................................................................................... CT-145 CT-23 Equipment Maintenance.................................................;:......................................... CT-146 CT-24 Instructions for Use of Prenatal Weight
Gain Grid (Form #3059) ........................................................................................... CT-147 CT-25 Prenatal Weight Grid for Normal Weight and Twins .............................................. CT-148 CT-26 Prenatal Weight Grid for Underweight and Overweight........................................... CT-149 CT-27 Dietary Assessment ................................................................................................... CT-150 CT-28 Instructions for Use of the Growth Charts ................................................................ CT-151 CT-29 Weight for Height Table for Determining WIC Eligibility: CT-153 CT-30 Weight for Height Table for Women, Based on the Body Mass Index (BMI).......... CT-154 CT-31 Physical Signs Suggestive of Nutrient Deficiencies ................................................. CT-155 CT-32 Recommended Daily Servings Chart ........................................................................ CT-157




GAWICPROCEDURESMANUAL
CT-33 Inappropriate Food Practices ..................................................................................... CT-158 CT-34 Georgia WIC Program Referral Form ....................................................................... CT-160 CT-35 WIC Income Poverty Guidelines.......................:.................................................:.... CT-161 CT-36 VOC Card Agreement .............................................................................................. CT-162 CT-37 VOCCardForm ........................................................................................................ CT-163 CT-38 Central Supply Requisition ....................................................................................... CT-164 CT-39 State/District/Clinic Transmittal Form ...................................................................... CT-165 CT-40 Medicaid Right From the Start .................................................................................. CT-166 CT-41 No Cost Flyer ........................................................................................................... CT-167 CT-42 Letter of Household Income ..................................................................................... CT-168 CT-43 Georgia WIC Program No Proof Form .................................................................... CT-169 CT-44 Family Plus ........................................................................................................... CT-170 CT-45 Health Department/Clinic Report Form ..............................................................:.... CT-171 CT-46 Income Calculation Form.....................................................................CT-172





GA WIC PROCEDURES MANUAL
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. 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 of the certification period or the end of categorical eligibility, whichever occurs first, as long as the person complies with program rules and regulations. If ineligible, the individual is properly notified and is not placed on the program (See Ineligibility Procedures CT-XIV).
Local agencies are encouraged to perform WIC certifications and issue vouchers in coordination with other public health services. However, WIC applicants/participants must not be required to participate in other programs in order to receive WIC benefits .



CT-1



GA WIC PROCEDURES MANUAL
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:
1. A pregnant woman; OR 2. A postpartum, non-breastfeeding woman within six (6) months of the end of a
pregnancy; OR 3. A postpartum, breastfeeding woman within twelve (12) months of the end of a
pregnancy; OR 4. An infant up to one (1) year of age; OR 5. A child up to five (5) years of age.
* The end of a pregnancy is the date the pregnancy terminates, e.g. date of delivery, abortion, miscarriage, etc. When a par:ticipant no longer meets the definition of pregnant woman; breastfeeding woman; postpartum, non-breastfeeding woman; infant; or child, he/she becomes categorically ineligible for the program (see Ineligibility Procedures CT-XIV). Refer to A Women Who Ceases Breastfeeding, for procedures regarding the breastfeeding woman who becomes categorically ineligible.
MC Prpqfq(~it1:z~#sffip:;1$;j1ofteqttire<ifor alie~s:r~fugees, or founigrants to,receiv
b&~~fit~..The ;ge~rgi~ WIC:1:P~9gl'.ain is exelllpt from 'any.restpctions jn:regard:'to ali~ns,
~~fugee$t~d::imtjgi:@ts.
~!~I:f 0 xrJ!t~~~~t~*t:fiitJ:t~~~~:~~~~:~!Je:;r~,~~~~t~~tn!:Jta~:it ~~s~
may b~::gi\r~rt fo\i' niqther/~hild who. be. bedridden :of a. child\vho niay have. special
medicaljlln~sses (i;e;tespirator dependence, etc.).. The,following:peopie inaydetermirie
ate ifsp&ial considerations required. A, statenientreflecting the reasQn (or;special
consideration) must'be do<ttnent~ 111 the i~dical rec:ord in 'the 'soap Notes orion
theCeriificati6n,:Iforfu~

CT-2

GA WIC PROCEDURES MANUAL



B. Residency

Applicants must reside within the jurisdiction of the State of Georgia. There is no requirement for length of residency. 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. Pi-bof
;E:1t:liil~!:E:!;1r!t!:t~~:::~::::Ea!i11t!t;1t

not a requirdmeilt thatap:;p;iicaritspresentcitizenship". documentation. ... ,.: .. , .............. -,. ...;: ............,...,. ,................... : .......-, .. - .... ' ...- .. , .. ,...,, ... ., .....:... ' '"' . .

. . .: .


1lf Irf :!1W"Mffilil
. :~t~fi~~f~pt . ,..... . .
, M:dic:aicl;car-ct(11oti:Lbill)
z;.,iril~ili!lLX!l'bfllie c!i@!e)ll yi~\\:~'06!l>e\@rlifi<O~li<!nf~)

CT-3

GA WIC PROCEDURES MANUAL


a Hom~le~s itiijjvidu~I :t~fyrtto Worn~)}, infant 6t.thild _who :iac_ks a regular or primary night
tim~:ar~s'.tgenpe;:pr 'o/hgs~:t~i.de~<:e,js::Aiteltiporary.-accomnipcl~tiort of no.t more than 365days
~i~lt~~~~tl!i!lii~~];~tt!tc:~trxli~~t:~;1~::;i:ti
mtenafctt0'be 1nstlruiiona1.ized. ., .,. : ,;.1, .. .: ., ... , ,.. ~,

C. Income



Applicants m~st have_a gross _fatnily income at or below 185% of _the Federal Pov~rty Level. All
~Bim.~~!B~tli~ip~~~,~~~'i:sJ;t9~mrQ~~.~mm~9fo~1.9i:~4jW!~!!'\1::ip}~J!le~~~~~fity.

0. Nutritional Risk

Applicants must have an identifiable nutritional risk, as determined through a nutritional risk assessment.

CT-4



GAWICPROCEDURESMANUAL

III. 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 defined as missing a certification appointment after the current certification expires, or the participant is terminated and not reinstated during a valid certification period. An initial contact date may change when:

L, 'Partic,(pan~strari'sfers in with a VOC Card.

2. > P~ciparits;,trartsfer infrom,another,district

3/i:,pariicip' Oil~ ~ts,frarisfdrirom clinic to:another\vithin the district. ... ........:.:...., "'' .:. .. .. ,'..,, :....,:, :- , ,:. .... : ....: . ..: . ................ ,...

-. :.

....

,.

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 of documentation include, but are not limited to, a personal visit log, the WIC Certification/Assessment Form (Attachments CT-1-CT-5) or an appointment book.

C. If the applicant does not reside within the jurisdiction of the state, ineligibility procedures will be followed (see Ineligibility Procedures).

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 Ineligibility Procedures). Income eligibility is valid for instream migrant farmworkers and their families for a period of 12 months. The income determination can occur either in the migrant's home base area before the migrant has entered the stream, or in an instream area during the agricultural season.

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 employees family member(s) requests certification/recertification, another clinic or health department staff must process the application and notify the WIC Coordinator. If this is not possible, arrangements must
CT- 5

GAWICPROCEDURESMANUAL
be made to transfer this applicant/participant toth~nearestWIC. ~linic. Arrangements
can also be made to assign another Q~rti:fi~(f:i;fiof~~s!p~g!i;~4~lj9~ty (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.
1~d?~~XtH:)DgartfuftiF:1~~po~((:A~~s~irtf 45): ,rilusF.t>cf (;otpplet~d by dinic .staff
arin~~yt(rinfonn Di~fiict.s(#f of_.th~i,refaniily partidpation on.the WIC Program. This folll1, mstbe c::orr;ipJ~te.ctb:.the iocalagei;lcy and]7.etumedto the WIC Cqordi11atorby iSJef:p/t4e~m4btteipr t3r0rp:oors.:iesa.ch.y.e..a...r...:.A.. .c.op. y o.. f" t.l..us..fo.rm. m.t.i~t.rema.i.n.in t'h.e He. .alth.I..).e.. pa...rtm..e.nt



[l:>~~~4.ur~s for'.c<>iJ.lpletin'g-iffie'IIe~Jt~'J)epartme~tRepori (Attachment 45):
~i~\: : ~i~ti~:1:;f!rii~:.:dyjttf9*ic:.

3. CheckYES or>N(j.jf you are a:WIC participant.

4. Answe(the question if you have any relative participating On' the WIC .Program:

5: f

/..:;:I$fJy~~ ,~: figll@irtr~th1Jeh~n1afoni@e;.r..e.1laWtiroi1t1\sifhriipy2:a#nfidtjJdIat:e

of

certif


i

cation


pn.

t

his


:form.


~~~iH'~tl$~,:.@!1i~iil'!~~~~,:~fiij~~~f~~.:9'.ti~@:9~::1~~,i~~i--t.<>gr~

Note~ Staff Dllly,Dof.tiike:the income~ t~i<l~11cy, ID, :c~rtify"nor:~sue roch~rs to
theffiselves,:of. famif :: members.
.. .Y
F. Special provisions must 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 for specific appointment times to meet federaUstate requirements.

G. Each local agency shail attempt at least one contact for a pregnant woman who misses

her first appointment to apply for participation in the program. In order to reschedule

the appointment, the local agency must have on file an address and telephone number

where the pregnant woman can be reached. Documentation of the contact (s) must be

noted in the client's record.



CT- 6



GA WIC PROCEDURES MANUAL
IV. PROCESSING STANDARDS
A. Timeframes
Processing standard time frames 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 and breastfeeding women, infants and members of migrant farmworker families will be notified of their eligibility or ineligibility within ten (10) calendar days of their initial contact date for program benefits. All other applicants will be notified of their eligibility or ineligibility within twenty (20) calendar days of their initial contact date for program benefits.
Ifl.ari appHd~t::J~i~')it9':/bii?,g Jifqp(of ,IP,/Jgome or r~siq~ncy, .res.chedule. an
#.ppgin~~tj(witliin::@~';p:r;q~ssirigtiine.franie;
B. Walk-in Clinics
Walk-in clinics are an excellent way to meet processing standards. The nine (9) items collected at the time of the initial application (See ll-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 to minimize the time these applicants/participants are absent from the workplace.
C. Request for Extension
On an annual basis the State agency may grant an extension from ten (10) to fifteen (15) days to local agencies experiencing difficulty in meeting processing standards. Those local agencies in need of an extension are required to submit a written request, including justification, to the State agency by October 1 of each year. Justifiable reasons for granting an extension include, but are not limited to:
1. Rural or satellite clinics unable to provide services more than twice permonth. 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-7

GA WIC PROCEDURES MANUAL



V . PARTICIPANT IDENTIFICATION
At initial certification, the parent/caretaker/pregnant, breastfeeding, postpartum woman must
~!I!i!fi~i~i,itl~~ti;i:!~lil~It

i4Il:tif}\0ther records which clinic staff consider adequate to establish identity may be used

if approved by the WIC Program Coordinator or designated CPA. Other records used for

qy:thi identification purposes which have been approved

~st:ribtmy.st b~ 4oc4m.eri}~,rC>n

tliei~h:i.ff~~iiq~:ff9.fu#,

l<Jentifi~.t~91f~ ld~ritificati~ri m~~s th,at the applicant must present proof which validates
whohe/slle\s: rderitificatiqn isrequiiec:lfbr.any applicant who applies for the WICProgram.
a If moth.~ri~iap~~yirigJotherchilt(sh~mustbring::proofofher child's ident~ty and he own
identity. /rh~::fyt>~: tjf :Identifi~tion pi-~ented must :be docmnented ()D the 'Certification
Form~

~,Ir~mmau~illiidi~zLati~idobrrid.R..e.c. oi.d



!l{i!;f~7-nc~tjph
+rffl}veri~::iNtertse'

Ifflitli~~t,:~~r\~~2Y~~Si)
fbM':tehdi~t:f:a.'i}c,i(-Ca r..c.i (w.. ith. 1:.0:).

CT-8



GAWICPROCEDURESMANUAL
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. Income is defined as gross cash income before deductions. Georgia WIC income guidelines are implemented simultaneously with the Medicaid program income guidelines.
Public Law 103-438, the Healthy Meals for Healthy Americans Act provides new regulations for conducting the WIC Program income assessment/determination 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 acting health professional under standing orders of a physician and documented in the participant's health record. The change in policy applies to income determination of a pregnant woman and her children. For example, if a pregnant woman is counted as two on her first visit to the office, and the pregnant woman comes back to the clinic to place her child(ren) on the program, the pregnant woman and fetus will continue to be counted as two people in the family. The use/implementation of this policy must not conflict with cultural, personal or religious beliefs of the individuals.
A. Procedures
All local agencies must use the following procedures and criteria to determine income eligibility for all WIC Program applicants/participants.
1. Pre-screening by Telephone. Pre-screening for income over the phone is a local agency/clinic option. The formal application for WIC however, begins when the applicant/participant visits the clinic. Income eligibility must be assessed 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 VI.C.) Then, the income for that family must be calculated and compared to the maximum income allowed for that family size (see Attachment CT-35). Income eligibility must be determined before nutritional risk eligibility. When determining the income of the WIC applicant, the Income Calculation Form must be completed (see Attachment 46) if the applicant does not qualify for Adjunctive or Presumptive Eligibility.
CT-9



GAWICPROCEDURESMANUAL
Procedures for completing the Income Calculation Form:
All local agencies must complete the Income Calculation Form if the applicant does not qualify for presumptive or adjunctive eligibility. When completing this form:
1. Write/type in the I.D. Number, The I.D. number is a two digit number. 2. Write/type name of the WIC applicant. 3. Write/type the address of the WIC applicant. 4. Complete the Income Calculation by filling in the:
a) Date b) Fill in the relationship and name of the person whose income is being given c) Fill in the income source which is a two digit alphabet (i.e., pay stub P.S.) d) Dollar amount earned is weekly/bi-weekly, monthly/yearly.
5. Other Income Section: a) Complete the dollar amount earned by each family member. Circle if the amount earned is weekly/bi-weekly, monthly/yearly. b) Total the amount of all income earned. Circle if the amount earned is weekly/bi-weekly, monthly/yearly. c) Answer the question "Is the applicant income eligible? YES or NO"? d) Transfer this total to the Certification Form. e) Have applicant read their Right and Obligations. f) Have the applicant sign this form.
B. Proxies (See Food Delivery Section for additional information)
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.
The alternate parent/guardian should be listed in the health record as the proxy whenever possible. Without this documentation, local agencies have no proof of legal responsibility and health services may be denied. 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 of parent(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:
CT-10



GAWICPROCEDURESMANUAL
a. A statement of family size and documentation of income (or medicaid, food stamps) residency and I.D. must be signed and dated by the child's parent/guardian/caretaker. A form for this purpose has been developed by the State (see Attachment CT-6). Use of this form is required.
b. Proxies I.D.
c. A thorough knowledge of the child's medical history and dietary habits/normal nutritional intake.
d. The ability to discuss the child's health and diet with the competent professional authority.
NOTE: The knowledge the proxy must have regarding (c) and (d) will be the same as you would expect the parent to have.
All signed statements of family size and gross income, identification and residency 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 Temporary Assistance For Needy Families (TANF) and family members.
Recipients of Medicaid or members of families in which a pregnant woman or infant receives Medicaid. This includes Presumptively Eligible Medicaid Recipients.
M~~ij~ti':tjft~~:':(ainiiy\vljicJ:i,:~::prea~l.wQQ:i~ri-,orihf;:iri{~e~~iv~ Medicaid m~=
1~ If'a,,pf~gn~t:mtjth~tqrialifiesfori medicai4 Wld.ison:We WIC :Prograin,
h;~t::tf=fu!"~d ~ijclre,n:q~~I,ifjr:fqf:tMC (Incpre oriJy).

CT-11



GAWICPROCEDURESMANUAL
3}-fJ~1.~tiJ~ii;:)p1t1e~g~ii~~r~tFf~,#il6fufu~~~-~,i,riFqi~nafJai1rji/i;\igtiiri:~thit'''i:~:pstQ1:tg6fta"j!}rit~ied,i~i1..a'.:otheri(~1tiir.lr~11 )

(Please refer to D.3 for the definition of "family".)

:~~iii;ap/~p~C~t:qh.~i~sfgr::i4jns#ye, apcII1ehtii.t:i>rog[~_.re>r::~$ch !h~i:~PP!t:~#(i~::~tgigl:
Note: Persons who are adjunctively income eligible for WIC must still be categorically eligible and determined to be at medical/nutritional risk to qualify for the program.

Acceptable Proof of Eligibility

The WIC applicant may present either of the following as acceptable proof of income eligibility.

1. Medicaid: 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 "Adjunctive Eligibility", for instructions on documenting Medicaid information.

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

If a participant is enrolled in Medicaid but does not have a current Medicaid card at certification, clinic staff should call the toll free Medicaid HOTLINE number (800) 766-4456 to verify the participant's Medicaid status. If eligible, document the Medicaid number from the automated system.

WIC applicants/participants who qualify for Medicaid now have the opportunity to use HMOs or Georgia Better Health Care. If qualified, the Medicaid recipient will carry a beige card containing HMO information. If qualified for Georgia Better Health Care, the Medicaid recipient will have a green Medicaid card.

csee 44li~ Th~:Faniily:Plul.HM0:'.l\1eclicaidCard ,AttachmeritCT

1atceptabie ,proof

of Me_clicaideligibilit}< However; the.Family Plus'ffMO:Medicaid carc(ctd~s-not
have the naine ofthe.parent/guardian'-oicaretaker:On if :Therefore; to en_sure:that

lflfiJiillfAlifiiiil?i

CT-12



GAWICPROCEDURESMANUAL
NOTE: All WIC applicants/participants not receiving Medicaid must be given Medicaid information at each certification and recertification (See Attachment CT40).
2. Food Stamps: Must present a Notification Letter (with dates of eligibility), or a Food Stamp Identification (ID) Card with a valid Food Stamp Number and expiration date.
Either the Food Stamp I.D. Card number or a copy of the actual card must be placed in the medical record as appropriate documentation.
Electronic Benefit Transfer (EBT) Card: EBT cards are currently being used for the Food Stamps and Temporary Assistance for Needy Families (TANF) Programs.
'The,~~! far<i ,S~.11ot 1't! ~~~4-~~ pro9f~fe,Fgibility for the Food Stamp Program. C1odrci>tfibntti'ier:ittoo:runs~e~::th.e.: .F..o.o.d.S.t.am.p m..D'..."c..atdl.nu.m..b"-er o..r TANF. .ID car.d./numbe.ffor
P...,.,..., .... ::.........:., ................. -
3. Temporary Assistance for Needy Families (TANF):
TANF recipients will continue to use their current ID. However, ninety-eight (98%) of all TANF recipients (according to State TANF staff) will qualify for Medicaid.
D. 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
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
CT .13

GAWICPROCEDURESMANUAL

::ff:.li!fil!l!~~:~w~~~~~11r~,~!tfl1t~4t

.:t{if~}a~!liLi~ded;~Y:~g~t-~oo:;fla1e: - -- --.- . ,,A,h:imp siiriLpayinent:should0be1divided by'12:to':estimate a:niorithly!income
i
lv.fonthJY payfuehtsa'shoulc;l'be used :aS the. monthly income amount.
G...,..t.in...v...e....r..t..i..l..i. g..f.r..~. a..l.id:c..a...f..o..ul.a....t..i..r..i.g 'a. n.n...u...a. linc.o. me.. :.

All income sources may be converted to annual income and added to reach the total

annualdncotriefor the household. Actual: amounts as documented-should be used

(ridfro4~dedf

"







L~i6iici>WR$J:fl6i~f'.~th:~iG4\i4i6i~isatlel:i~coi:mt~e)llyih~~i:ci~izm).:JiiJih e1hlt6fil~:iax!:tonrtt B'setli.,~. ::d. 6i1~~bunt
3. Definition of Family/Economic Unit
Family is defined as a group of related or non-related individuals who are living together as one economic unit, except that residents of a homeless facility or an institution shall not all be considered members of a single family.
a. Children Residing with Caretakers. A child is counted in the family size of the parent, guardian or caretaker with whom the child lives, with the exception of the foster child (See [b]). For example, an abandoned child being cared for by a grandparent would be counted in the family size/household of the grandparent.
b. Foster Child. If the child is a foster child who is living with a family but who remains the legal responsibility of a welfare or other agency, the child is CT-14

GA WIC PROCEDURES MANUAL



considered a family of one (1). The payments made by the welfare agency or any other source for the care of that child are considered to be the income of that foster child.
c. Adopted Child. If a child lives with a family who has accepted legal 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).



f. Absent Spouse (excluding military families). A household where the spouse is away and maintains a separate residence due to job related assignments shall be considered a separate economic unit without the inclusion of the spouse. Only income received by the household would be used to determine eligibility.
g. Students
(1) College students who maintain a separate residence at school but who are supported by parents/guardians must be counted in the household of the parent/guardian. Students who maintain a separate residence and are self-supported must be counted as a separate household. Any regular cash supplements received from parents or guardians must be included in the student's total income.

(2) If a student receives financial assistance from any program funded under Title IV (e.g. the Pell Grant, Supplemental Educational Opportunity Grant,

Byrd Scholarship, Student Incentive Grant, National Direct Student Loan, PLUS, (College Work Study, etc.) the following guidelines must be followed:

The portion of federally-funded student aid that is used by the student for books, materials, tuition, fees, supplies and transportation will not be counted as income. Any portion of the aid that is used for room and board or dependent care costs will be counted as income.



h. Aliens/Foreign Students. It is legal for an alien/foreign student and his or her family to receive WIC benefits. Neither WIC authorizing legislation nor the WIC regulations require citizenship or make aliens categorically ineligible for

CT- 15



GA WIC PROCEDURES MANUAL
-
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. 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). Participation should not be needlessly discouraged, and clinics should not further advise applicants on this subject.

Military Families

I. Military personnel serving overseas or assigned to a military base are considered to be members of the family and their income should be included when determining family income.

2. If children are in the temporary care of others while their parent is assigned elsewhere or if the child(ren) and one parent temporarily move in with friends or relatives, choose one of the following options:

(1) Count absent parents and exclude current caregivers.



(2) Count children as a separate economic unit. The children are considered to have 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 the caregiver's household. Determine family size based on the family the child(ren) is/are living with. I Include the children in !he family size.
Wheritakingincoine'for ~~ fuilitary.employee the pay stubfor
,d1e_militaryiscalJeffthe.Leave.andEarningStateme~t qESf
. 1:herfgry; ;\hen an :~ppli~~u~ris.inJqe milhary:
:~)}~if~~~Jlj~i~~"~~ctj~~rtg/$foi~ui.iPt\@$):~~-~rt4.ih~
::;:\,;p_bnt'r~~t~ed,



: BAQ::(Basic..AllowanceQuarters), ifany. apply: LQA(Living Quru:ters Allowance)
: ..._.VILA {Variable Housing AlJowance)
CT- 16

GAWICPROCEDURESMANUAL


Pt{~:~T;:J~ TJ:i~

Nattie, s()darSecurity Number

Rerson'rank-and-yeats:ofisrvice
B~e ~ay .. dollar ajn6urttihey receiv.e
;;;:;~:r;-~~:1:J1:i:,~:-~i1M:t~~~r~~iY .



ll~~i1;:f~ii\~~ti~i~i~r:::t;t;~r~,:::~ilt!tt:i\t:,1
~4::~!~.9!m~~~:i~!:~:l}~~gi:i>~4~J~

J. Children Not Residing in the Household (excluding military families as outlined

above). Children not residing in the household to whom child support is paid as a

result of divorce, may not be considered part of the WIC applicant's family. A WIC

applicant may count in his/her family size, a child family member who resides in

a school or institution if the child's support is paid for by the WIC applicant's

family.

k ~t~~t1~~:;i;:1;:::;1:~t~t~Jt~ii~i'~t;l~~=t~!t tjiertj,:in com~~r~rig, nc~sary docQmentatioO:'from ,ofuer:0ril~IIibrs -Of the family (economic tihit) ~o.,det~rif4!1e tncoie:eii~bi!ityude,~;tjle pfqgr,am'. . . . . .

F,rq~d\i~s\(jr::9i:np1_efi:fig:-;we:@iief,6fH:puseh<Si4:,tri~'9_rri;f



i. -- Writi In',th~ riafue(s)::(jf thd WI<> appliiant(s}alonfwifu. the adch'.ess tha.t is
giyen.

CT-17

GAWICPROCEDURESMANUAL



~,: .)~ni,it~~ei~.iij}M,ri~:ifait~:~'.'~t~i~ciivga)fucfttie:f:s~gij~fur~.pf;th~peffsc,n.~ho

receiveff:it.

,:.,.,.,,,,.,_:......:c, .. .

IricoII1eLfor iriigrantf iritjSt' betAf<:eri>arirmallf Migrants will not be .r~quired to :show prOofofhiconie: Howver, ~apts'imisfgive their'.income.. When amigr~t~qes not
have pr-oof~ :;\ttac~~nt43.::: .Tlie'No.ProofForm.mustbe signed. This.form mus~ be
PI.~s~c:i in:tllt\#pplic~~~.!'v.fecli~.a1r~9ord.

J:h~::No}~fo9f:,fqfaji~tj.c,J:l?~bf~e4:'f()f.!l).:{cHJd~i.ngi~i~atioijs:.

ti;,:c\FirJ



2a1i?:i:fi'Ti:irB>ig~r~t~t~i
. -\(fiffifl~:t~~~ii1~fi~ti,ill'fuP@~\@9~IDPl9Y~\iI~.ii<l.irl

tlfi!i~t~if(fl~1;iii~!s:;;t;:!!!

r:r{:.l:I()spi,@f9~f!.~~itj

llospitafreords,are :riof ~'"7ays available to :W:IC Staff' to .review. Thetefote, it



w.o.u..ld...b..e,i.m... P.os.s.ib. le.".:..,.1...6......,.Pl.i.ic.e,.a. ifa..PPli.c.i.m...t.o.n..t.h..e..P.r...o. ~ . . w....i.t..h...,o.u. t d.o.c.u.m en.t..a...t..i..o...n.

CT-18

GAWICPROCEDURESMANUAL



Jffi11~11\i~j~ilit~r~~:;1i?J!&i~11:%\t1tiii,~~
@~(1Q1}h9pitaj}rleasf



See tco~~:Eiigi!,ility - Do~umente~:lProofofliicrne VI. E. 3. Income Inclusions
a. Monetary compensation for services, including wages, salary, commissions, or fees;
b. Net income from farm and non-farm self employment; c. Social Security benefits and/or Supplemental Security Income (SSI); d. Dividends or interest on savings or bonds, income from estates or trusts, or net
rental income; e. Public assistance or welfare payments; f. Unemployment compensation; g. Government civilian employee or military retirement, pensions, or veterans'
payments; h. Private pensions or annuities; 1. Alimony or child support payments; J. Regular contributions from persons not living in the household;
1. Net royalties; m. Other cash income. This includes, but is not limited to, cash amounts received
or withdrawn from any source including savings, investments, trust accounts, and other resources which are available to the family, e.g. money from friends and relatives.
CT-19



GAWICPROCEDURESMANUAL

4. 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

(2) The Food Stamp Act of 1977

(3) Job Training Partnership Act

(4) Home Energy Assistance Act of 1980

(5) National Older Americans Volunteer Program

(6) Domestic Volunteer Service Act of 1973 (VISTA, foster

(7) 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

.

(l0)Military Housing - B'a~ii i118w~C~:,f()ri'Qu~:@~Q)

(1 l)Title IV student financial assistance.

c. Bank loans, other payments or benefits provided under certain federal programs or acts to be excluded may be found in the Federal Regulations governing WIC 7 CFR Part 246.7(d)(2)(iv).

d. Child care benefits provided under grant programs to states shall not be treated as income in federal programs such as WIC. Child care benefits provided under section 402 (g)(l)(E) of the Social Security Act, At-Risk Child Care Programs, and Child Care and the Development Block Grant Programs in Georgia are excluded from the WIC income eligibility process.

Non-payment of child care benefits is not considered income. Benefits received in the form of cash or any other instrument that can be converted into cash, may be considered income in the WIC income eligibility process. For WIC purposes, current program policy regarding any cash available to a family is applied.

5. Unemployment. Applicants from families with adult members who are unemployed shall be eligible based on income during the period of unemployment ifthe loss of income causes the current rate of income to be less than the income guidelines. Persons who are on leave that they 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
CT-20



GA WIC PROCEDURES MANUAL
appropriate to use current income to determine eligibility.
6. Self-Employment. In families where adult members are self-employed they may not know their net income. To calculate net income, use the most current income tax statement or on-going records and the following guidelines:
Net income for self-employment is figured by subtracting operating expenses from gross receipts. Gross receipts include the total value of goods sold or service rendered by the business. Operating expenses include, but are not limited to, the cost of goods purchased; rent; heat; utilities; depreciation; wages and salaries paid; and business taxes (not personal Federal, State, or local income taxes). The value of salable service and merchandise used by the family of self-employed persons is not to be included as an operating expense.
Net income for self-employed farmers 1s figured by subtracting the farmer's operating expenses from the gross receipts. Gross receipts include, but are not limited to, the value of all products sold; money received from the rental of farm land, buildings or equipment to others; and incidental receipts from the sale of items such as wood, sand, or gravel. A farmer's operating expenses include, but are not limited to, the cost of feed, fertilizer, seed and other farming supplies; cash wages paid to farmhands; depreciation; cash rent; interest on farm mortgages; farm building repairs; and farm taxes (but not State and Federal income taxes). The value of fuel, food, or other farm products consumed by the family is not included as an operating expense.
NOTE: For farm and non-farm self-employed persons, documentation of depreciation must be obtained before accepting such charges as operating expenses. Either Federal or State income tax forms for the most recent tax year would provide the most reliable documentation of these amounts. In a household where there are wage earners and self-employed members, the wage earner's income may not be reduced by the business losses of the self-employed member. If the self-employed person's income is negative it should be listed as zero (0).
7. Hardship Conditions. Hardship conditions have been calculated in the Income Poverty Guidelines Chart. Hardship conditions are not to be considered when determining income.
8. Lump Sum Payments. Lump sum payments may be classified in two ways, reimbursement or new money.
Reimbursement payment(s) represents money received for loss of assets or injuries to real or personal property. Reimbursement lump sum payment(s) should not be counted as income for WIC eligibility purposes.
Examples include but are not limited to insurance reimbursement, payment on specified household expenses or medical expenses.
CT-21



GAWICPROCEDURESMANUAL
New Money is money received as gifts, inheritances, lottery winnings, workman's compensation for lost wages, or severance pay. Lump sum payments that represent new money intended to be used as income should be considered as "Other Cash Income."
The lump sum payment must not be counted for one month of current income. Rather, the lump sum payment should be counted as annual income, or be divided by 12 to estimate a monthly income.
Some lump sum payments may not be easily classified into either of the two categories, reimbursement or new money; but may represent both. In such instances treat 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.
9. WIC Income Eligibility For Furloughed Federal Employees
In determining income eligibility of categorically eligible persons affected by the Federal shutdown(s), State and local agencies should use the same policies and procedures normally used to assess the income eligibility of a person experiencing a temporary loss of income such as temporarily laid-off or striking workers. Current income should be used to determine eligibility.
Assuming that Federal shutdown(s) are temporary, local agencies should continue to provide benefits for the duration of the furlough. There is no Federal policy which requires the value of benefits to be paid back in such circumstances.

E. Documented Proof of Income
jh~\~~~g~l};wiQi'i~~9111~ :::s~,r~~~~g\p~li~y: f~qh~f~~i(pi@~f:. ~f\:i~o#i.1tk9~;;:~n
aii>PJ.i~iiii.t:s~ This policy applies to State employees and military
dependents/personnel as well.



t ;,- The type ofirtcome
T~e ti.mi p~rip4 iriwhichlJle-iiiconie i~r:r~~eiyed'(weeltjy,bi:weekly;, eic_.)

CT-22

GA WIC PROCEDURES MANUAL


Wijn,requ~sting proof 6-fincome,. you'MUSTask for one of the, following:

l. . ':fay sri.i~Sfck all people in yor family who work or who receive an income from
$,11' sour9_s or a~sistance payments. -.Some pay stulJs will not t:iave a narn,~ but will
;;;;:lilli@ltjl=::;:~:;e havi{a:$QctaliSecrity'N:u.lJer.. AskfortheS_ociaj, Se9urity.Carel. foo/~i f~Ii{9r ~~er



~:::.;:iji1i~!~ltiftiit~~i.i9.p)i


CT .23

GA WIC PROCEDURES MANUAL



G. Verification of Income




CT-24



GA WIC PROCEDURES MANUAL
VII. 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. If the 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-7 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 of pregnancy 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 CTf8 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-9 lists the required assessment data and documentation requirements for all children. This data must be collected and documented for each assessment. All required medical data used to determine nutritional risk must be reflective of the applicant's status at the time of certification.
B. Referral Data
The determination of nutritional risk can be based on referral data submitted by a CPA not on staff at the clinic. Referral data must then be evaluated by a CPA or staff at the clinic. Local agencies should make available to area health care providers referral forms in order to facilitate entry into the WIC Program and the certification process.
CT .25



GA WIC PROCEDURES MANUAL
Local agencies may use the Georgia WIC Referral Form (see Attachment CT-34, 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 a 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(s) 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 '.ij,mm required referral data/information has been completed
properly. The data/information must be documented on official letterhead 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 the risk criteria.
C. Medical Data Date



Anthropometric data required for certification (length/height and weight), may precede the date .of certification by up to sixty.(60) days. Required medical data that are greater than sixty:(6Q) days old cannot be used to assess WIC eligibility. The sixty(60) day limit applies to the anthropometric data (length/height and weight) even if the applicant/participant's eligibility is based on other criteria.
CT-26

GA WIC PROCEDURES MANUAL



CT-27



GAWICPROCEDURESMANUAL
VIII. NUTRITION RISK CRITERIA
Nutrition risk criteria are set by the State agency, in accordance with federal rules and regulations. The criteria are based on detrimental or abnormal nutrition conditions detectable by biochemical or anthropometric measurements, other nutrition related medical conditions, dietary deficiencies that impair or endanger health, or conditions that predispose persons to inadequate nutritional patterns or nutritionally related conditions.
Nutrition risk criteria, risk factor codes and priority designations used for Georgia
WIC Program certification are listed in Attachments cr".10, CT~ll, CT".12;cT-13,
and CT.;~4. The nutrition risk criteria are listed by applicant/participant status at the time
~q4~. of certification. Each criterion is id~11tifii4~y.a"tlu;~. :clig1t numenpaj
The WIC Assessment/Certification Forms utilize a checklist format to document the applicable nutritional risk criteria. Refer to CT-XIII for information regarding the completion of the WIC Assessment/Certification Form.




CT-28




GA WIC PROCEDURES MANUAL
IX. NUTRITION RISK PRIORITY SYSTEM
A. General
Each nurtition risk criterion is assigned a specific priority. Statewide priorities are set in accordance with the following guidelines:
1. Priority I: Pregnant women, breastfeeding women, and infants with nutritional need. This need is determined by measuring length/height and weight, taking a blood test and medical history.
2. Priority II: Breastfeeding women who do not qualify under Priority I, but are breastfeeding Priority II infants.
Infants up to six (6) months of age 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 and weight, taking a blood test and medical history.
Postpartum teenagers who are not breastfeeding ~4!;:~lib~~ ~i4Y~ff #f~\vas priqr t2}\;l$f&~#~iJQ11i19fitHs9i,_c1,g~'.
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 of poor diet or homeless/migrancy status.
6. Priority VI: Postpartum, non-breastfeeding women with a nutritional need, or homeless/migrancy status.
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 defined as the feeding of breastmilk to an infant at least once every 24 hours, on the average. Even if an infant is receiving a food package with the maximum amount of formula (i.e., 31 cans of infant formula), both the mother and infant are classified as breastfeeding if they fit the above definition.
CT-29



GA WIC PROCEDURES MANUAL

2. Possibility of Regression. If it has been determined that the only applicable risk criterion is Possibility of Regression 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, Possibility of Regression cannot be used as a reason for certification.

C. Specific

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

1. Pregnant Women

Priority I:

:19},;JJX;:"f$:t1/i3?,I33,.29!;,g11;30J~.30~;::~o.3, .Ji1}3t2,,3~1,

33,v,332 333:,334 ,335 ,s36337 :'33'8 339 :341 .342 343 344

<-.'I ...:::;/}:::=; 1'1_; '=; ..~;. : .:: '. :;, 1 : . ':'.::. .,},:'-:.:,: ..,. --~. -: :\' -:-- < :.~ :_,_., ~-.,'. . ' .._ --~ ... :. ':: . -'-~

3jq4Q5.,;.3s4o(o>,,3,36fit:.,7:,3'36428,,3374L9,3.3152.,l,,33'.512:3,,33:583L,530524,:355,3.5..6,.35. 7 ,

358, . .

Priority IV: ~~~. :s9;,;.s9J;:so.2.: 9:0:1;:~92

2. Breastfeeding Women

Priority I:

~f~~,!~l!i~~iI1~t~;1~tM~l~'~~I: i~;it4}~!~ti *li i~ffl~~;

353354 , . .

. .'.,

35. ,

5....,'..

3 ,_

5

6'

'

35 .. .

7'

3..5. :8

, '

3. 5. 9. '...3..6"0'3- 6.1. ' -3,6' 2. ,,..3,..7: .1.,...,.,-..3.72'

373
. ...

'

3~1, 501, 502~:601, 602

Priority II: ?02,,601
Priority IV: 4z2,::$Pl, soi;::;6or; Soi; ijq~~::2q1,:QQi

3. Postpartum, Non-Breastfeeding Women

Priority ill: iii/502

Priority VI: 4. Infants

1'02, 112)33, 201,211,303, .311,312, 321,332,333,335,337, 339~.:341/342,.343, 344;.345;346;'.'.3:47,)48;,349;351,352,,353;
:::a:::;~~ii!it::~i:-!6:.:.:~:~~;_,2q9;.:36.f-$6:2. -3_72.37p.;:.~-8};.42~;

Priority I:

::f03;-ti'3/1:fa';i$4,.135';:1.4(;'.:~42,.1,5j,i:201,:211,:34J;:342,~43,

344,345, 346;347, 348,349;J50, 351','352,353; 354; 355,356,

357,359,360,362,381, 382,502,603;jo2,103



CT-30



GA WIC PROCEDURES MANUAL

Priority II: Priority IV:

1$:tiiQft~lig.
422;;?iE2Q~}i!ij9;f,;'ijogf,!9qJ':JJb2

5. Children

Priority III:

{Q3,:n3.)J#X;;:'.JI'.34!1}s~,:t'.4J,20J;2li;}4t,$4i,343,344;345, 346,347,348; 349;351,352,:353,354, 355,356,357,359,360,
3(,_f)p.2,.}.~J.,:~?t, $Q!;.i?0~ . . . . . . .

Priority V: D. Assignment

422a:soit:so1'. sc>2:9oi' , 902 ...,".,:,. ,.,, ,.- :. ~ ,......, ' ... ..' " ......., ~ .. . . ...

.

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



CT-31



GA WIC PROCEDURES MANUAL
X. 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. If the woman is more than six (6) months postpartum, she is categorically ineligible and must be removed from the program immediately (See CT-XIV., Ineligibility Procedures). The termination must be documented in the participant's health record.
2. If the 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 nutrition risk reason, the woman's status, priority, and food package must be changed. If no nutrition 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 entered into the automated system.
B. Upgrading a Priority
New data that has been collected and assessed during the certification period can be used to place a participant in a higher priority. A priority cannot be downgraded during a participant's certification period (with the exception of a breastfeeding woman changing status to a postpartum non-breastfeeding woman).

CT-32



GA WIC PROCEDURES MANUAL
XI. 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 of their pregnancy.
Infants (six [6] months of age or younger): until their first birthday.
Infants (greater than six [6] months of age): for six (6) months from date of certification.
Children: for six (6) months from the date of certification and ending with the end of the month in which they reach their fifth birthday.
Vouchers may only be issued to participants who are in a valid certification period. The certification period always begins with the date of certification. In the event a participant becomes categorically ineligible during this time, and the date of termination is before the end of the month, eligibility is extended to the end of the month. (See FD-111.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.

CT-33



GAWICPROCEDURESMANUAL
XII. INFANT MID-CERTIFICATION NUTRITION ASSESS1\1ENT
Infants certified prior to six (6) months of age will be subsequently certified on their first birthday. A in.id-certification nutrition assessment, by the CPA, should be completed between five (5) and seven (7) months of age. To ensure accessibility to quality health care services, the following procedures must be in place:
1. The initial certification of the infant less than six (6) months of age will follow the standard procedures. The infant shall be assigned the highest priority for which he/she is eligible.
2. The mid-certification nutrition assessment must consist of: a. measuring length and weight b. plotting weight for length, length for age, and weight for age C. measuring hemoglobin or hematocrit (six(6) ~onths of a.g~ or greateD d. recording, summarizing, and evaluating dietary intake e. assessing nutrition risk criteria f. assigning the highest priority for which the infant is eligible
W4 g. reviewing food package needs, 1~~ighlfa,fra,ppfopijaf~fqo4p~~~age
&,flJ~1i1fi[ilt!t~il!3Si1~tt
3. The mid-certification nutrition assessment information will be documented in the second column of the Infant WIC Assessment/Certification Form. Note: Income screening is not a part of the mid-certification assessment.
risks 4. If .additibrial are identified atany tihle ch.iring the one (T~ yeat 'certification p~riod, :iliai'Couidtesultill an infantbeing a~signeci' a>higher priority, this priority shouictiB:Uf>gr~de&:Aiii11fant:1n~s,t.rieverh~:~Jigrieda,pri6.titY16~e.rthanthe o,rig 'i.n.,al .P 'r.i.o.riYf .
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.
Note( Itis notihecessary tq fequist:proofoffifdurihg the rrtid.:certification visit.

CT-34



GA WIC PROCEDURES MANUAL
XIII. WIC ASSESSMENT/CERTIFICATION FORM
General
1. State WIC Assessment/Certification Form
Certification data for each applicant/participant will be recorded on the form provided
htig by the State agency """"" e,.r:i.e' r,...a. t:e d:.i.:.b'.:lv. ..ie..a;;c:.h...:i;l.i... :s.:t.:n...':.d.. f:,s ..i.,c: .o.. n.'ip:.'u..t.ei.s,,y.s.te.r.n.:
2. Local Agency WIC Assessment/Certification Form
If a local agency/clinic chooses to use other forms and/or documentation procedures in the certification process which are different from the procedures outlined in this manual, then all forms and/or procedures must be submitted to the state agency, in writing, for approval prior to implementation. Local agencies 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.
Each form is two-sided. Both sides must be accurately completed each time an individual is certified. A portion of the required information is common to each form. The following are instructions for completion:
Completion
All items on the WIC Assessment/Certification form must be completed as follows:
1. Identification Information. Applicant's name, birthdate, address, telephone number, social security number (optional), ethnic origin, migrant status., courity.'qf t~~i4ihYo:Pr0o:f of :residence ahdproof ofodentificatiort, clinic number, sort (site), WIC ID number and parent or guardian/caretaker's name (infants and children o~lY.), mt1~~ be fille::d in on eac.~ fonn used. AllJ~gallyfrespon$ible persons rpustbe
g9p!Ji~n.t~ddrttit..9eijtp rei;qf4l({e; ;~~~: qffatl:ier{gqardJ~p/~~etaker);

2. Breastfeeding Information. Complete each line in this section, using the following information:
Infants' and Children's Forms:
a. Breastfed Now (1) On Infant's Form, check "Yes" if this infant is currently breastfeeding. (2) On Children's Form, check "Yes" if this child is currently breastfeeding.
b. Breastfed Ever
CT .35



GA WIC PROCEDURES MANUAL

(1) On Infants' Form, check "Yes" if this infant was ever breastfed (even if currently not breastfeeding)
(2) On Children's Form, check "Yes" if this child was ever breastfed (even if currently not breastfeeding)
(3) If the answer is "No", two times for an infant or one time for a child, this question does not need to be asked again.

c. Record the Number of Weeks Infant/Child Breastfed. If the infant/child is currently or ever breastfed, record the number of weeks up to a maximum of 99 weeks (2 years of age). (See the key for entering weeks breastfed in Attachment BF-9, Breastfeeding Section)

d. Date of Most Recent Breastfeeding Response. Record the date on which you asked the participant/guardian/caregiver about breastfeeding.

Women's Form:

a. R6stpa:ffufu::13f~~stf~bdingn:A:ssessment/Certffic:~tion; Fbrrti. Breastfeeding an
Infant Less than 1 Year of Age.
(1) Enter the weeks breastfed in the "\1/~~" column. (See the key for
entering weeks breastfed in Attachment BF-9, the Breastfeeding Section).

b. i>&sipllitt.rti'::1"fatVBi1e~tfe~iling;'~ss;es~fil'.~htic~rtifita:ifot1 Fonrt[ Less than 6

!!:~t~f~t~:r~I~f Months Postpartum.

( 1)

t'!~fr~tjtjy:'ii~i~,tf.~~cifo'g:;~'ilj~j:~fe~~tfcll::~hik:)~:y~'..'

(2) ff the ~~sp~~~~'t5':13f~~stfe4::gyft is"Yes", enter the weeks breastfed in the
key "N~Rs" column.. (See the ior entering weeks breastfed in Attachment
BF-9, Breastfeeding Section)
the: (3) If the response t9,:Breastfed!i{vei-'iiiN9!'.;eht~t,''.(f::iri "Wei~'.': Coiu~.

3. Initial Contact Date. The initial contact date must be filled in at each certification,
m even if it has not changed. The initial contact date must be accurately documented
to ensure that processing standards are being met. Se~id~rtifica:tior1:$_~~tjg for the definition of "initial contact date."
4. Medical Data Date. See th~:'i,~fflfic:~!i,<:,>h;i$iti911 YW for definition of required
medical data. Enter the date medical data was taken for certification purposes. If the anthropometric measurements were taken on a date different from the hematological measurements, the date of the 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.

CT .36



GAWICPROCEDURESMANUAL

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. Nutrition Risk Criteria. Complete each line in this section using the following procedure:

a. Check "Yes" when the nutrition risk criterion is present.

b. Check "No" when the risk criterion is not present.

c. Write IIN/A" when the risk criterion does not apply or was not assessed.

Ri9fa. & ;

~c1<4ii6h~id<>c.ulii~'.titi~fr (dt:{*J risk criterioni

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. High Risk: Check "Yes" when at least one nutrition risk meets the High Risk Criteria. (See Attachment NE-7, Nutrition Education Section)

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

a. the applicant resides within the State of Georgia; b. the applicant is income eligible; c. at least one (1) nutrition risk criterion is checked "Yes".
d. tH~i~pB~~i'[itjg~j!~~i:~!:Ji;if~~#;;~hi~P\IJr~g#_@fr:1~9stp~4m-:()_~:Rf~~-.tft?_4i_11g

@W:9f Check "No" when "a"

"b" from the above list and/or all nutrition risk factors

are checked "No" (Ineligibility Procedures).

11. Priority. Enter correct priority (I - VI). Refer t6itji~.~rffficatidn Section for risk factor codes and priorities.

12. Food Package. Enter the appropriate food package code (See Section the Food Packages Section).

13. 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.< Entolnerit
itj qr1Rifrt~?i~;J:;~(Foqci:Strupps aii~fMedic~ict:M'Psl,'--bic:I.ocurt"J.~nJq.

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

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

14. Today's Date. Enter the date the assessment is completed.

CT-37

GA WIC PROCEDURES MANUAL



15. Signature/Title. Enter signature and title (Nutr., R.D., L.D., R.N., M.D., etc.). An
appropriate signature consists of first and last name or first initial, riddi initiaJ and
last name.
16. Income Determination

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

b. Number in Family. Fill in according to CT-VI A.3.

c. Gross Income/Mo.

1. Medicaid Recipients. - {See Acceptable Proof of Eligibility - Adjunctive
::~Z!f~~ Eligibility:-l(Vl)(C)(1)]~ Mark yes (Y) if the participant bas pro~fthaJtli~y't~eive Medi~d ~d,~oculent.Mec:licaid
.......... ,.,,, ....,,...

2. Fo.od. Stamp Recipients. {See Acceptable Proof of Eligibility-Adjunctive
!tM~iM~~ih(O'l)(~)(\)Ki~~:;y~~:cn:itl}~p~1P~tij'ks:46~~e~i~ pf9'q/,Jh'.~J@.~y.':ie~Jvi1f 09distaII1ps.



3. l?~~p<>r~ 1\ssi~tari<;e for Needy.Families (TANF) - See Acceptable Proof
of Eligibility-Adjunctive.Eligibility ~[(1)(C)(l)]..A ''notice:Ofcase
?t~~ij~#!t1lJ~~~#~~ij~~}#~.~f~.*1N~~E?ieP~~~~r1ti~.::1ipFr~Q~:?;f':,l~~ft':1:5:~9~at~~#~~i:i1:~~~ftiij~.QuwJ#)~~J#!t!,t:y:;;rq~'fi~:tY~

~f~i':Y~.,()1:tt:1~~,ip~-~b~@t::1!~:~~~!t~'.i~~~fftij#it:Jl;l~Y:t~lY~

~~~-

4. Participants not receiving Food Stamps, Medicaid. or TANF. Complete according to CT-VI. C.

5. .Income Eligibility. Ch~ck "Yes" or "No" 'to indicate applicant's incoine
th~ statu$:. .Tranferthe total from the Iricoine Qalc::ulati6n>:F,or:rrito section
l;iil!~~iii:i;iiiJ~i~~ii;



d. Staff Signature(s). The WIC official's signature verifies that the income, residency and family size are correct as stated by the applicant/participant. The signature also verifies/witnesses the participants' signature. An appropriate signature consists of first and last name or first initial, middle initial, and last
name; ~#~:2.f:.:p:~r~q~:verifyip.g fo_99ijie.
e. Date. The date must be completed by either the participant/authorized representative or a clinic staff person.
CT-38



GAWICPROCEDURESMANUAL
f. Applicant/Participant Signature The participant, parent/guardian/caretaker, or proxy must be asked to read (or have read to them if they are unable to read) and sign the following statement each time they are certified:
I have been advised of my rights and obligations under the program. I certify that the information I will provide, or have provided is correct, to the best of my knowledge. The income I have given is my total gross household income (all cash income before deductions). This certification form is being submitted in connection with the receipt of Federal assistance. Program officials may verify information on this form. I understand that intentionally making a false or misleading statement or intentionally misrepresenting, concealing, or withholding facts may result in paying the State agency, in cash, the value of the food benefits improperly issued to me and may subject me to civil or criminal prosecution under State and Federal law. I understand that the WIC Program may give my certification information to other public health assistance programs to see if my family is eligible for their services. I understand that these agencies may contact me, but they may not give my information to anyone else without asking my permission.
g. Applicant rirtable.to>writeIf the. ;<:1.pplic@tlpartiiparit/3:u~qri2:ed representative
I!f[t{li~rmlli!~ is<linabliJp\vrite., 'he/she .will.rifor his!Qer'in~kirt''lieu.~f:a>sigrtature.. )rhe r&:ft1ii:itt~trt-1eI1~#i.to.:fh~:ih~~.:.AA:4ittiaj;~h~Il!~k ""' HH"';,;:,.,,,:"'1:.,.',: "',''
17. Data Needed for Pregnancy Surveillance
Infants' Form: (1) Mother's WIC ID#. Enter the WIC ID number of the mother, if the mother
is currently a WIC participant.
(2) Last Weight Before Delivery. Enter the last weight of the mother, taken prior to delivery. Round the weight to the nearest whole pound, e.g., 165 = 166.
Women's Form: (1) Marital Status. Enter numerical code indicating current marital status, i.e.,
O=married, 1=not married, 9=unknown (2) Years of Education Completed. Enter a 2-digit number to indicate years
of education completed, e.g., Ol=lst grade, 02=2nd grade, 14=2 years of college, 99=unknown. (3) Month of Gestation at Time of First Prenatal Exam. Enter a one-digit code to indicate the month of gestation at the first prenatal exam, e.g., O=No Prenatal Care, l=lst month, 8=8th or 9th month, 9=;.unknown (4) Last Weight Prior to Delivery. Enter the last weight taken prior to delivery, rounded to the nearest whole pound, e.g. 165 = 166.
CT-39

GAWICPROCEDURESMANUAL



(~~ififi~l\ilil!i~~~t~i~~t&t~0$ii ::;

fl1!11~:1;1r~:1i~1t~~f:r2~1t::~:,1gi~1r~:

.,.. ::,.. _,,,,,:.:i.,,,.:... ;,.i..

vllc P~~h::~~~ica~F:;Pt4fei@s~n'c~et,lis:~':1:1"1~or@: r{e:ufif.rfei~di>!fo~r:~,die infGan~trd .orchild" when.the

For Migrants, See the Migrant Section
VOC Card (Received from Out of State or within the State of Georgia) (1) Place a two letter abbreviation for the state the card is coming from (i.e.
Maryland- ]Ml)) or the Georgia voe Card number.
(2) Issued/Received Box - Place a "R" in the box. (3) Date - Enter the date the card is received.
(4) Signature of WIC Official - The signature of the Wie official who received
the card.



VOC Card (Issued within the State)
(1) Place the number of the voe Card being issued.
(2) Issued/Received Box - Place an "I" in the box. (3) Date - Enter the date the card is issued. (4) Signature of WIC Official - The signature of the WIC official who issued
the card.
19. Comments (Date/Signature/Title) - This sections is to be used at the discretion of the district/clinic.

CT .40



GA WIC PROCEDURES MANUAL
XIV. INELIGIBILITY PROCEDURES (NOTIFICATION REQUIREMENTS)
Persons may be ineligible or disqualified for Program benefits on the basis of residence, category, income or nutrition risk. All applicants/participants who do not meet program requirements and are determined to be ineligible or disqualified for WIC benefits must be given a written notification of ineligibility. The Notice of Termination/Ineligibility/ Waiting List Form is official documentation that local agencies must use to notify applicants/participants of ineligibility or termination (Attachment CT-15). Ineligibility/ Termination notices must be issued according to the processing standards (See Processing Standards).
When applicants/participants are ineligible or terminated from the program and a Notice of Termination is issued, they must be informed of their right to a fair hearing. A fair hearing may be requested when program participation is denied or a participant is disqualified for benefits.
The Right to a Fair Hearing notification shall include the method by which a fair hearing may be requested. The individual must be informed that any positions or arguments on their behalf may be presented personally or by a representative such as a relative, friend, legal counsel or other spokesperson.
Local agencies must follow program procedures for "written notification" and "processing standards" whenever an ineligibility/termination decision is made. All procedures followed must be documented in the medical record or agency file.
The following notifications shall be made in writing and comply with programmatic time frames:
A. Written Notification
1. Ineligibility. An applicant/participant determined to be ineligible for program benefits on the basis of residence, income, or nutrition risk will receive a Notice of Termination/Ineligibility/Waiting List Form on site which states the reason(s) for ineligibility. A copy of the form will be filed in the individual's health record and/or the ineligibility file (See Attachment CT-15).
NOTE: Please complete the Fair Hearing Section of the Notice of Termination/ Ineligibility/Waiting List Form.
2. Expiration of Certification Period. Each participant will be notified at least (15) days before the expiration of their certification period that certification for the program is about to expire. Homeless participants will be notified at least (30) days before the expiration of their certification period.
3. Disqualification. A participant who is about to be disqualified from program participation at any time during the certification period must be notified, in writing, at least fifteen (15)days lJe:fotrie}~riniitation of participation of the reason(s) for
CT-41



GAWICPROCEDURESMANUAL

this action and of the right to a fair hearing. In the event the state agency mandates that the local agency must suspend or terminate benefits to participants due to a shortage of funds, The Notice of Termination/Ineligibility/Waiting List Form must be issued to the participant. A copy of this form must be filed in the individual's health record. This notification does not need to be provided to persons who will be disqualified for failing to pick up vouchers for two consecutive months provided the participant has been given or read the Rights and Obligations.
4. Ched~'tbe::R~asori fiofliiefrgibilit llfan applicant: is s6ree~ediort~rtificatfon or recei;tifitatiori:artd is f~llildilO be',rjvet'income, faprily-members'alreacly participating
and ofrthe ':w:IC:.:Pr6grani nnisf;be,termin~t~d, for ,being overincome as. well. An
examp1)s # a~pW::ant'wJ;io)s }iewly prgnant has a:t~dcll~t currently on WIC.
,'I'hetodg}.er:m1J,st:ajsobe keri:offthe prograr:nif the,motheris not: income eligible.
Participa11ts fo~rid t~ exceed the income standard during. a current certification
period; deto.,reassessmeritoftheir income eligibility, mustreceive benefits to the
end, of th~ ieqaired fifteeri {15);day period to coincide with the notification of t.~rrhlnatioir of. ,benefits.

5. Interim Income Change. Reassessment of Income Eligibility - Local agencies may

disqualify an individual at any time during a Certification Period, on the basis of a

11~,i~t~ tt~riitJ;t~i~1~rt& t1a!rt::~::; reassessment of program eligibility status if the individual is determined ineligible.

1 ~~'

6

ti

insjqw.J;Iy.tig\*':qt~Jfic:~ti911;p~p:99: Reassessment of a participant's income

eligibility status is not mandated but must be done if there is reason to believe

a participant's income status has changed (e.g. laid off workers being rehired).

In the event a participant's income changes, a thorough re-evaluation of the

programs for which the individual could be determined adjunctively income eligible

is required. If a participant or any other family members who are WIC participants

are determined to be ineligible, the local agency must disqualify all fam1ly
irtdn:ibers'. The Notice of Termination/Ineligibility/ Waiting List Form must be

issued.

6. Waiting List. Applicants shall be notified of their placement on a waiting list within twenty (20) days of their initial contact date. Notification will be made using a Notice of Termination/Ineligibility/Waiting List Form. A copy of this form must be filed in the applicant's health record. (See Waiting List Attachment CT-15)

B. Completion of Notice of Termination/Ineligibility/Waiting List Form:

1. Fill in applicant's name and date at the top of the form including the date of birth, phone number, and address.

2. Mark the box which states "You are not eligible for the WIC Program because you... "
3. Complete the information at the bottom of the form regarding the name and address of the WIC Program. The Fair Hearing Section must be completed
CT-42

GA WIC PROCEDURES MANUAL



when using this form. If a stamp is used for this purpose, all copies must be
istamlpefd.~t1r,t:t~~,i~~:~1~~~:::j~!'$itr1~t!



!~!1ttl~!tltl;fll!li!t~!!i!~l~
ij. ,t~#NP:*,~4::Wi&t:'~};94 Ai
Processing standards regarding notification shall apply. Applicants will be notified of their right to request a fair hearing regarding the ineligibility determination. A copy of the form must be filed in the individual's health record and/or the ineligibility file.
Persons determined to be ineligible must als.o be asked to read (or have read to them if they cannot read) the Rights and Obligations and must read and sign the back of the WIC Assessment/Certification Form.
C. Ineligibility File
Clinics are required to maintain an ineligibility file. Each clinic may establish their own system for maintaining such a file, as long as the following guidelines are followed:
1. Ineligible Applicants Without Health Records
For applicants who do not have a health record in the clinic, the ineligibility file must contain the following:
a. Applicant's name b. A copy of the Notice of Termination/Ineligibility/Waiting List Form c. Date the ineligibility action was taken d. All supporting documentation, e.g. dietary recall, growth charts, WIC
Assessment/Certification Form, progress notes, etc.
2. Ineligible Applicants With Health Records
The four items listed above must be documented and may either be filed in the applicant's health record or in the ineligibility file. For those who have these items filed in their health records, a list of their names or a copy of their Notice of Termination/Ineligibility/Waiting List Form must be kept in the ineligibility file. If a copy of their Notice of Termination/Ineligibility/Waiting List Form is filed in the ineligibility file, it does not also need to be filed in the health record.
CT-43



GA WIC PROCEDURES MANUAL
xv. TRANSFER OF CERTIFICATION
WIC certification is transferable to another WIC clinic in Georgia or another state within a valid certification period. The certification must be documented before it is deemed valid. A Verification of Certification (VOC) card is the official document for validating WIC certification nationwide. This card allows WIC participants to transfer certification from one clinic, city or state to another.
During a waiting list period, if properly documented, a participants' eligibility is tran~ferable and they must be placed on the program regardless of priority.
A. Verification of Certification (VOC) Card
The Verification of Certification card is a negotiable instrument used to validate WIC certification. Since the VOC card is a negotiable instrument, strict care must be taken to maintain accurate records of issuance, security, and receipt from participants. Local Agencies and clinics are responsible for maintaining an inventory of all VOC cards. The State VOC Card Inventory Logs must be used by all local agencies and clinics (Attachments CT 17 and 18). When VOC cards are received, the card numbers must be recorded on the inventory log.
All clinics must accept a valid VOC card as proof of eligibility for WIC benefits. Outof- state participants with a valid VOC card must be placed on the program even if they do not meet Georgia's eligibility criteria. A transferred certification is valid until the
certification period expires. bocaf ~g~ncies:must be aw~re' th~tsofu~ s~t~ftise the
t&i::~~1111i~\l!@lli~1
\V4~rt.ahapplicanttr;msferin withavoc Card,.the.parent,guardia.norcareUlkerisnot
tequire,ltq brit;1g that infant()f child. The yoc Gard se!"es as::tpe P.J?oof9f:e}igi1Jih!Y
A participant's certification is transferable only when properly documented with a VOC card or a copy of the WIC record. The Georgia WIC ID card may be used to document
current certification 3:~cq:rp.panie~f::\Vithg!ber ID. However, the receiving clinic must
verify the documentation with the originating clinic by telephone or written correspondence. The source of documentation must be recorded in the medical record.
Migrant farm workers mo:ve frequently up and down stream, from one county/state and their WIC certification is transferable. Some may or may not present a VOC card. Any migrant who presents a current Verification of Certification (VOC) card must automatically be placed on the local WIC Program, even if a waiting list exists.
CT-44



GA WIC PROCEDURES MANUAL
1. Required Data
When a VOC card (Attachment CT-16) is issued to a participant, at a minimum, the card must contain the following information:
1. Participant's name 2. Date the last certification was performed 3. Date income eligibility was last determined 4. Nutrition risk criteria (Do not use Georgia risk factor codes) 5. Date the certification period expires 6. Signature and printed/typed name of the certifying official 7. Name and address of the certifying clinic 8. Participant's WIC ID # 9. Participant's date of birth 10. EDC date (if applicable)
2. Incomplete VOC Cards
Participants must not be penalized or denied benefits because of an incomplete card. Whenever possible, contact the certifying local agency/clinic for complete information. An incomplete VOC card must be accepted as long as the certification period has not expired and the card contains: (1) participant's name and (2) date of certification. The VOC card must be placed in the participant's file/record.
B. Other Methods of Verification
1. Phone Call
If a VOC card is presented which does not contain the necessary information, or the participant does not have a VOC card, clinic staff should attempt to contact the certifying local agency/clinic for the information. Documentation of the phone call must be made in the participant's health record and should include the following:
1. Date of the call 2. Name of the person conversed with 3. Certification date 4. Height, weight, and hematocrit/hemoglobin 5. Nutrition risk factors 6. Priority 7. Assigned food package 8. Date vouchers were last issued 9. Date income eligibility was last determined (migrant farmworkers only) 10. Participant's WIC I.D. number (Georgia transfers only)
The phone call must be followed up with a request for written documentation of the above from the certifying local agency/clinic. A release of information form should be sent to the certifying clinic.
CT-45

GAWICPROCEDURESMANUAL



2. Transfer with A VOC card within the State of Georgia.
If clinic staff are unable to obtain the necessary information by phone, .a valid Georgia WIC I.D. card may be accepted in lieu of a VOC card with proper I.D. and proof of residency. This should be done only when immediate certification seems imperative and staff feel the I.D. card strongly indicates that the individual is eligible. A participant who is transferred using a Georgia WIC I.D. card will be issued vouchers for one (1) month. Prior to the next issuance, clinic staff must contact the certifying clinic for verification of eligibility and certification information. The phone call and all information obtained must be documented in the participant's health record. The call must be followed up with written documentation from the clinic.

3. Certification Record

Participants may want to transfer into a clinic with a copy of their WIC certification record from Georgia or another state, in lieu of a VOC card. This is allowable as long as the certification record contains all of the following:



1. Participant's name 2. Certification date 3. Height, weight, and hematocrit/hemoglobin 4. Nutrition risk factors 5. Priority 6. Assigned food package 7. Date vouchers were last issued 8. Date income eligibility was last determined (migrant farmworkers only) 9. WIC I.D. number (Georgia transfers only) 10. Signature of certifying local agency/clinic official

t~ce When a:,partic:ipan.t transfers to andther \VIC :dinic; :parent/gu~dian imay
of corr1plet:a.relMe: iri:fotnlation form to allow. the trru.'isfer ofWIG arid/otmedical
~t!tfut!tfite;~~t;f~:e;;:,.:~~:t:::tr~:1&it::t;:r:~~:::1~!:~
cettifieit. Local agency staffmm;t fax or riiai:l the. completed(orni or:foq4sied
information to theteceiving.agency promptly. Whenever the requested.information
is Il<f)t t~~eived withitii!~o:(2), weeks ,ofthe initialrequest ct.ate, loqil ~genY,:staff
:~s!t:!rtif;~j:;;~a:t~:::~:;t~tir:::;.~f~eft:le!~f~!:
pa~~ipajits::w1ch.~~1,1:1~a<ft~ 11~~1~onseqijenc:~:ror ~~eioc.ar~gency.

C. Instruction for VOC Card Use



Clinic staff must:
1. Inform all WIC participants that if they move, they should request a VOC Card. All migrant farmworkers are to be issued VOC cards. If the migrant is not moving, CT-46



GAWICPROCEDURESMANUAL
document this on the VOC Card Log. For non-migrant participants transferring within the State of Georgia only, a copy of both sides of the WIC Assessment/Certification Form may be given to a participant in lieu of a VOC card. However, records must be retrievable at the initial Clinic/District site.
2. Instruct the participant receiving a VOC card on its use and encourage them to continue participation in the program in their new location. Note: A Notice of Termination/Ineligibility/Waiting List form must be issued on site, whenever a VOC Card is issued to a participant, with the exception of a migrant participant.
3. A proxy may not act on behalf of the participant when issuing or accepting a VOC card. The proxy line on the VOC card should be crossed out before issuance.
D. Orders
VOC cards can be ordered by the clinic directly from the State or District Office. The District Office shall determine how/where clinics order VOC cards. In the event the District Office agrees that VOC Cards may be ordered directly from the State, the coordinator must submit a VOC Card Agreement (see Attachment CT-36) and a VOC Card form (Attachment CT-37). These two forms must be completed, signed and forwarded to the State WIC Office at the address below. No orders will be accepted from any clinic unless these forms have been received.
The VOC Agreement (Attachment CT-36) must be completed by the WIC Coordinator who must indicate which clinic representative is responsible for requesting VOC Cards from the State. NO PHONE CALL REQUESTS WILL BE HONORED.
When ordering VOC cards directly from the State, a Central Supply request form (Attachment CT-38) must be completed and mailed to: Georgia WIC Program, c/o Policy and Procedures Unit, 2 Peachtree Street, NE, Room 8-400, Atlanta, Georgia 30303.
E. Inventories
All local agencies and clinics are responsible for maintaining an inventory of all VOC cards. The State VOC Card Inventory Logs (Attachments CT-17 and CT-18) 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 of VOC cards must be performed monthly by local agencies and clinics. The physical inventory must be documented on the State VOC Card Inventory Log. One staff person must conduct the inventory and a second staff member must verify by signing their 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) second staff member).
CT-47



GAWICPROeEDURESMANUAL
F. Issuance
A record of the issuance of each card must be maintained. When a voe card is
issued to a participant in the clinic, the following must be recorded on the inventory log: (See Attachment CT-17)
I. VOC card number 2. Participant's name 3. Participant's WIC I.D. number 4. Date the card was issued 5. Initials of the 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.
When the Local Agency issues VOC Cards to the clinic, the following information must be documented: (See Attachment CT-18)
1. Clinic name 2. VOC card numbers issued 3. Number of current cards on hand. 4. Number of cards received from State 5. Name of Clinic Representative 6. Date 7. Initials of one (1) clerical staff and a second staff member
G. Security
VOC cards are negotiable instruments, therefore, the security of the cards and the accompanying inventory log is imperative. VOC cards and their inventory log must be stored in separate locked locations.
Only authorized personnel may have access to the VOC cards/inventory log. These authorized personnel are determined by the local agency.
H. Lost/Stolen/Misplaced VOC Cards
In the event a VOC Card is lost, stolen or misplaced, contact the Policy Unit immediately and complete the Lost/Stolen/Destroyed/Voided Voucher Report. This report is located in the Food Delivery Section.
Anytime a voe 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 the status of the card.
CT-48



GA WIC PROCEDURES MANUAL
When five (5) or more VOC Cards are lost, stolen or misplaced, the Notification Summary of Missing 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 in the Department of Human Resources. Notification of lost VOC Cards must also be reported to USDA and States in the Southeast Region.




CT-49



GAWICPROCEDURESMANUAL
XVI. CORRECTING MISTAKES
At a minimum the following procedure must be followed when a mistake is made on an official WIC document:
1. Make a single line through the error. 2. The person who made the error places his/her initials and date near the error. 3. The correct response should be written near the line.
The word "error" may be written just above the actual error.
Correction fluid ("white-out") must not be used to correct mistakes on official WIC documents.
"Official WIC documents" include, but are not limited to: WIC Assessment/ Certification Forms, I.D. cards, VOC cards, voucher registers, inventory logs, and health records.
Under no circumstances may WIC vouchers be altered or corrected.
*All WIC documentation must be completed in blue or black ink or it can be typed. NEVER use a pencil or red ink.


CT-50



GA WIC PROCEDURES MANUAL
XVII. CERTIFIED WAITING LIST
A Certified Waiting List is intended to facilitate the placement of participants on the program as soon as additional program funds are made available. If it ever becomes necessary, the State WIC Office with guidance from the State Allocation Committee, shall determine when a waiting list of WIC applicants will be implemented.
Local agencies must establish a waiting list in the following situations:
1. The WIC Program, statewide, is spending in excess of 100% of the available food dollars.
2. The local agency is spending in excess of 100% of their allocated food dollars.
A. Procedures for Maintaining a Waiting List
1. A waiting list shall be maintained with individuals who gualify and express an interest in receiving program benefits. Applicants must be kept in order, according to the date they were placed on the waiting list. Once a waiting list has been established for any of the above reasons, only applicants who are still eligible in the priority group(s) which is/are being added from the waiting list are enrolled on the program.
2. To facilitate contacting the applicant when caseload space becomes available, the waiting list must include the following:
a. Date applicant was placed on the waiting list b. Applicant's name c. Applicant's address and telephone number d. Applicant's status (e.g. pregnant, breastfeeding, age of applicant, etc.) e. Applicant's priority
3. All persons must be notified of their placement on the waiting list within twenty (20) days of their initial contact date. This notification must be made, in writing, using a Notice of Termination/Ineligibility/Waiting List Form (see Attachment CT -15).
NOTE: The Notice of Termination/Ineligibility/Waiting List Form should not specify the length of time (no specific date) for remaining on a waiting list (See attachment CT-15).
4. Transfers - When a waiting list is in effect, migrants and other transferring participants with a valid Verification of Certification (VOC) card must be placed on the Program regardless of priority.
CT .51



GA WIC PROCEDURES MANUAL
B. Procedures for Removal from the Waiting List
The CPA must ensure that the following procedures are followed when removing persons from the waiting list as caseload expansion is re-established.
1. Only those individuals who are still categorically eligible need to be contacted. All others can be periodically purged from the list.
2. Those persons on the waiting list who are still in a current certification period will be contacted to come to the clinic immediately to receive vouchers. All others will be informed that current medical data is required and must be evaluated before certification will be possible.
3. Applicants will be contacted by phone or letter.




CT .52



GA WIC PROCEDURES MANUAL
XVIII. PATIENT FLOW ANALYSIS
A Patient Flow Analysis (PFA) is a tool to analyze the following:
1. The range of time for certification of clients from sign-in to first face service provided.
2. The range of time for certification of clients from sign-in to exit. 3. The range of time for clients scheduled for issuance of vouchers. 4. Clinic bottlenecks. 5. Whether clients are seen in the order of appointments? 6. Are clients scheduled at a rate appropriate for services received and staff
availability? 7. Are there down times for any staff? 8. Are the appropriate staff present for first a.m. appointments? 9. How many appointments were there?# of no-shows?
The Patient Flow Analysis Forms (see Monitoring Tool) have been included in this manual for State and District use. In an effort to address corrective actions issued to the SWO by USDA, we are requiring that a Patient Flow Analysis be conducted yearly in your largest clinic at the time of your self review. In the event your district has conducted a Patient Flow Analysis during the fiscal year of the review, the district must present this documentation .
p'.tiort (see ...: ,_ .. "'" ,: ,..1:f,"2o;:.,r,..tt'' a,. ,,:i.n,.:: t.th't.e. -i. f(3., )' fo.ri.b'..'s"' . Mo. n. =i-~t. o''r'ing' S.e" c. -ti.o' n) w.' ,;:h...,ic.,. h.. inc.l,u.: .. de:



1. Ro()m:# < ' (ifapplica.ble)~Rooi:n#.is contpleted in the event a clirticis divided by alphabets and each staff person is keeping his/her own Sjgn.:Jn form (FORM I).
2. Clinj~:-Pst the n..ame of the dinic wl1ere t,he ana}ysis is bein.g conduc~~d.
CT .53

GA WIC PROCEDURES MANUAL
4. ~11i:h;,~ t>9~iiir,i~gts)tll~;,11~~:d(th~:app}J~~~part!cip~i. 5. Dat~;S~~-~'Rqi:r1,ntfth~:~Cfoa1'aate'the'Patintifl6:w'Aftalysisi~'talqngph1ce.

7. Rthe~~Wn.IfGordVini~icfr:~bocur'ri~,r,its.th, e'reas' on the applicant'/partic' ipant made avisit to

Reason fof :VisitYJodes ~ Definitiotzs Itii'tial::Certification

,t11raitii~jC,fille11H!'fi')jit;CqnjJ!)~iiJli,;&,@1,a~~tt,pi,#~S)

ReHisiate



fr~tfil,i~~tJ~t Gttr~m?~i:~~)
~2!J:sh~i;sJ9tj1y:;q~~\nHt:titi91'1:l~4.p;~tfgn)

Qtli~r,:i(pl~~.:;~~.ify)'

8. ~PP2P.!!~~~!)~@.~:1Pij'pg~m~hti{,~ppq~p.tm~~1 yi~'}:f~ePPE@~p~l~!foWJ

9. f~.t'$~::!(J?~c4~~ri1J:::t11J' at,riia1jtriii'.illJfifu~acI1ruc':st~16~mri~ i ~8ric :Witti
the \\ITC :parti~ip~f

XQi :ittt~,ti:~t~p~{~lllents,.tijeactuaLH~e ill~t#af(fiajin.~d working.:'Ytth.the

fi~JS~iaj#~i~> )'.Jit'ili~'.ii.fi(iajs p(the: st#fthat Si:ycttij~f:wi:c:applic:aii:Vi>~~tip~f

Nq~e?i :'Ii, :'.1;}e9r4 .or~~is~,:in.iti3:1 mp~t.:)>e::p1(!.8e~:'.~1tfr:tije;~9ruaj P~ti~~t IIIow
:Analysis i::locumentation for. audit pUfPOSes.
2.: Each appli~antf:participant' must have his/b~r:-own ;Patient flow
12. rati~n(.Afr~~tc~i~;~;:[t\~if!1~f!!;;_~:!1~h!~i!i~.9wnfonn.



Time Patient Left - 13.

Documents the time the applicant completed all WIC services

and is leaving the clinic.

CT-54



GAWICPROCEDURESMANUAL

15. ~,~9fmW~i[:[yp~ifoP.ti9~tt'P2~p:i~ni::1,g:wJ9ffotjnulaiyp~ :if:llpplic~ble
foriDistrictuse:,
' ,.,.,. :::;,,..,, k: .":, :..::..~...:!',:..:. :.,:. ~< ,;:...

16. sp~ti~f :s~@tf~~}PtQ\,1d~coD11D~Iits: - b8~urrieritsany.specia1)ietvices or

'i*e circumstatiies ..\1/hich:: mlly cau~e: yqu to

additional time with the

app. licant/p.atticipant.
.:: :.. ' , ....,:... ,, . . . ,, . . .

FdRMflll."'hlJESTIONS'T()ANSWER FROM THE MODIFIED PFA '" ............. ,........ ::.:~---'':...... ~ ........:............ :...........:,........... '.. ..........

.

"-'

_, .. . .

. '



Option II contains six (6) forms {$~eM9nttorihgSection) which include:
1) Patient Flow Analysis Sign In Form 2) Patient Register 3) Personnel I.D. Code Form 4) Questions to answer from the modified PFA Form 5) Client Category Form 6) Reason for Visit Code Form
EORNI...."I.:.~.:P,A'-. ,T:, IE.N.,.T'"/FL.O. W' AN' AL: Y .S..IS'1=:-:.. S.I..G,. N,~...I. ,NSH' E.E..T.
FORM II - PATIENT REGISTER FORM
The Patient Register Form is to be placed on the record of each participant as they sign in, unless participant is in clinic for voucher pick-up only and record is not routinely pulled. The Patient Register Form documents the following:
1. Patient Number (Should match the number on the sign in sheet). 2. Reason for visit (See Reason For Visit Code Form) 3. Patient Category (See Form V Patient Category Form) 4. Time of Arrival (Same as Sign In Sheet) 5. Time of clinic appointment (Same as Sign In Sheet) 6. Patient Service Time
CT-55



GAWICPROCEDURESMANUAL
a. Contact# (must match the # on the Participant Sign In Form). b. Personnel I. D. code form which must list the staff persons C. involved in the PF analysis Form ID.
n. C. Start Time (time identified on the sign in sheet Form
d. End Time ( time services are completed). e. Service provided (see the reason for visit code Form VI).
FORM III - PERSONNEL I.D. CODE FORM
The Personnel I.D. Code Form is used to identify clinic staff and title involved (i.e., R.N.) in the PFA. An alphabet must be assigned to each employee before the PFA begins. This form must be completed at the beginning.of the Patient Flow Analysis so that each clinic staff is aware of what code is assigned to them to use for the PFA.
FORM IV - QUESTIONS TO ANSWER FROM THE MODIFIED PFA
Questions from the modified PFA are listed on this form to indicate the type of information you can expert to receive from the PFA.
FORM V - PATIENT CATEGORY FORM
The client category form identifies the codes you must use to identify the type of clients you are serving during the PFA (i.e., pregnant women Code A).
FORM VI REASON FOR VISIT CODES
The Reason For Visit Code Form is used to identify the type of services being rendered to the WIC applicant/participant.


CT-56



GAWICPROCEDURESMANUAL
XIX. SYSTEM INFORMATION MANAGE:MENT
One of the goals for the System Information Unit is to implement a fully integrated health department environment by replacing the WIC Automated TAD and Voucher System (ATVS) with the Health Outcome Service and Tracking System (HOST).
HOST has been installed and is operating in eight (8) districts as of this writing. Certification forms printed by the HOST System are acceptable proof of eligibility for the Georgia WIC Program and must be filed in the medical record of the WIC applicant/participant. For more information on installation of HOST see the State Plan.




CT-57

GAWICPROCEDURESMANUAL
xx.
;:~i!m=~~i?r:ti;;tii;fe:1;:i~~r;
lltJ!J!!il\~\ii!fi~7i~~l~li3~
Program appt9yed ,,ijie Atheils WI~ Vtiucher issuance Policy. as <one. possible .model for assessing>and:in:iproyin,g ,immuniza~ion- co:verage. among.WIC participants iri _t~92~ The Athens m.odehpfc\ved;to be :Very efficient and effective method for providing WIC. benefits
wfiile ::i1;n.pr~yitj1rthe.i ti~~1th st~t~i; ::of:ind1viduals to whorri services were provided..
f~!flilttt~~zt:;;~~J'.$~:::r;~t:11~Ji~t\;1: Ho\Ve'l~r',;sin"eith;-adoptiqn:6ftJlat Model,-c:()mputersystems.are>now.in place.to'det~nriine


CT-58



GA WIC PROCEDURES MANUAL

Attachment CT-1

WIC ASSESSMENT/CERTIFICATION FORM PREGNANT (FR~NT)

NAME LAST

ADDRESS
( )

1UEPMOOE

,_
I

WIC ASSESSMENT/CERTIFICATION FORM
A PRENATAL WOMAN
.._,,......_

- 1 WIC ID

I I II I I I I I

wsP I -o-... o.. ....,.._,,.,._

Cff'(

,..,_

0- GJ- En4NC~G)dl~lmGSJAS GJ-

DI

PROOF OF RESIOENCY

INITIAL CONTACT CATI;: CATI; OF FIRST VISIT REQUESTING WIC SERVICES

PROOFOFI.O.

ENTER EOC DATE

/1,td,C-..,.,.,~--~,

,.cnlCAL DATA OATI; . '6w...,..,_..,wajgilW----CS-__,

i........,hl

... I -

Hematocril/Hemoglobin (Value ll"IISI be ~ 90 davs)

a.sJPmaravid W,,,.,hf

lbs. .:.~..;.~r;/:;~~:~~~::::;~~~:~~:t~~~~;~~::~~:~::.::-~~1~.
...,

Select appropriate risk criteria per state guidelines (See Risk Criteria Handbook for definitions)

-.ES

"

' Anemia

- ~ n a " " " Underweinht Overweiaht

Low Gestational Weiaht Gain

. Gestational Weinhl Loss DurinQ

. High Gestational Wei<lht Gain (WeiQnt aain of> 71bs/month)

. Elevated Blood Lead level (Blood Lead level ?.10 U<JJm

. H

Gravidarum

. Gestational Diabetes

. Historv of Gestational Diabetes

. Historv of Pn!tenn Oeliverv (Enter deliverv datelsl and weeks ae=tion:

. Historv of Low Birth Weinhl lnfant(s) (Enter birth weiQnt(s) and birth date(s):

. Historv of Fetal/Neonatal death (Enter = s > of death(sJ:

)

at a Yotm<1 A!le IEDC at less than 18 vears and 10 months of aoe

201

101

IHR ?1 111

131
IHR ?I 132

133

211

301 302

303

)

311

)

312

321
IHR 71 331

C1ose1V Snaced PreQnanc:ies rEnter tennination date of last =nancv:

)

. High Parity and Young Age (Enter delivery dates of previous oreananc:ies:

)

. Lack of, or lna"""""1e Prenatal Care ,..,...natal care beginnina after 1st Trimester 10-13 wks.)1

. MultH'etal Gestation

. Fetal Growth Restriction

. Historv of Birth of a Large for Gestational Age Infant (Enter birth weiclht/sl:

)

negnant vvoman Currenuv

. Historv of Birth with Nutrition Related Conoenital or Birth Oefect(s) (Soecilv defecllsJ:

)

. Nutrition Related Medical Conditions (List c:ode(s):

)

332 333 334
33$ 336 337
.,.. 71 338
339

~mokmg 1uaily smo,ang of agarettes, pipes or agars)

Enter number of cmrettes or cigars smoked or number of times nine smoked (#/dav:

. Alcohol Use: /Circle tvoe) Routine (Enter oz./Wk:

) Bi...,,.. drinker. Heavv drinker

. Street uruo Use (Entertv"" ofd1UQ1sl:

)

. Dental Problems

. lnaceauate Oietarv Pattem

l

371 372 373
381 422

Homelessness

801

NU<Jrdn<.V
. R - of Abuse . Woman with Umtted Abilitv to Make Feeding Decisions and/or Precare Food

8Cl2 901 902

Transfer of Certification

502

HIGHRJSK (YesorNol

ELIGIBLE FOR W1C
PRIORITY: 1 = (101,111,131,132,133,201,211,301,302,303,311,312,321,331,332,333,334,335,336,337,

338,339,341,342,343,344,345,346,347,348,349,351,352,353,354,355,356.357,358.359,360,361,
362.371,3n.373,381,502) = (422. 502,ao1.802.901.902\

FOOD PACKAGE:ISaecifv Tailoring lnstnlctions} SERVICE: CH (A), Health Check (8), CMS (C), Women's Health (0), PCM (E), PRS (F), lmmun (G),
m Lead Screen (H), Dental Health (I), STD (J), Private MO (K), Food Stamps (L), Medicaid (M),TANF (N).
Mental Health (0). Head Start (Pl,NA/None (Q),Refused IR),Communitv Health Center (S), Olher SN>cifv TODAY'S DATE
.SIGNAT\JRE ANO TITI.E OF HEALTH PROFESSIONAL
Adclltorw Oocumentat,on Required FGr11!1329CPC-....J.ft>

Enrolled In: Referred To:

CT-59



GAWICPROCEDURESMANUAL

Attachment CT-1 (cont'd)

WIC ASSESSMENT/CERTIFICATION FORM - PREGNANT (BACK)

DATE
-.

INCOME DETERMINATION (Income must be documented}

MEDICAID
CURRENT Y/NAJ y ( ) N( )

MEDICAID 10 NUMBER fMUST HAVE CURRENT CARDI

FOOD STAMPS Y/N/U
(MUST OOCUMENTI
y ( ) u( )

u( )

N( )

NO.IN FAMILY

GROSS INCOME/MONTH (CURRENT. OR ANNUAL)

Documentation of Income must be completed for an applicant who does not qualify for adjunctive eligibility. Documentation ofIncome Source: Write in all that apply.

Source of Income

Olher None

(Wt/N In types/

H- ls food, shelter, clothing and Medical Care obtained?:!-

-

--

use the.Income Calc:ulation Form to document the applicant"s Income. The total from the Income Calculation Fonn must be documented on this form.

Date

Income$ :

Is the Client Income Eligible?

YES NO

Note: The /ncame Calculation Form must be filed In the Client's Medical Record.

Weekly/Bi-Weekly/Monthly/Yearly. No. in Family_ _ _

I have been advised of my rights and obligations under the Program. I certify that the Information I will provide, or have provided Is correct. to the best of my knowledge.

The Income I have 9"""' is my total gn>SS household income (all cash Income befonl deductions). This certification form Is being submitted In conneclion with the receipt

of F-.al assistance. Progr.am officials may ""rlfy lnfonnatian on this foml. I understand that lntenlionally malcing a false or misleading statement or intantionally mis-

npresentlng. --=ealing, or willlhokling facts may nisull In paying the Stale agency, In cash, the value of the food benefits lmpropetfy Issued to me and may subject me to

"""" __, civil or criminal pn,seculion under Slale and Federal law. I under.stand that the WIC Program may givemy certification information to OIiier heallll or public assistance
agencies to see If my family is eligible for their services. I understand Iha! these agencies may c:antacl me, but they may not give my infonnallon to anyone else without asl<ing my permission.
SIGNATURE OF WIC OFFICIAL

PARENT/GUARDIAN/CAREGIVER SIGNATURE

DATE

- - DATA NEEDED FOR PREGNANCY SURVEILLANCE a..o

-

Marilal Sta1us .

(O=Mamed 1=Not Married

9=Unlcnown)

Years of Educ:alion completed (e.g. 1st grade = 01, 2 yrs. c:ollege=14, Unknown=99)

or care, Mcnlh gestation at time of filst prenatal exam (O=No Prenatal

1=1st mo.,B=alh or 91h mo. S=Unknown)

-.a;,,vocCan:1-00-
0UTotSTATE-

- D Dale-----------------

Signature ofWICOfficial: ______________________________________

Comments:(Date\Sign\Trtle):

CT-60



GAWICPROCEDURESMANUAL

Attachment CT-2

WIC ASSESSMENT/CERTIFICATION FORM - POSTPARTUM BREAS!FEEDING

.

(FRONT)

N/IME LAST

~ c ASSESSMENTICERTIRCATION FORM

A

1 POS

t

PA

R

T

UM

I

N

O

N~ING WOMAN r
mcoMn<Sa!I

-

-,

---

-,

---r
I

~--..-
I I

-

,~.--

,-..,...;:;:
I 1

~::;
I I

RRST

llllDOC..EINITIAI.

I

BIRTHDATE

CITY

ZIPCODE

SOCW.SB:IJRJTYIMMER

____ __.._, (
OOUNTY OF RESIDENCY

PROOF OF RESIDENCY

"'""' , INll1AL CONTACT DA'TE: DA"TE OF FIRSTVISIT REQUESTING WIC SERVICES

GJ- CJ. GJ.. . . ETIOOC ORICi:IN (c::n.c:a:-, G]... G]..

I

MIGRANT

GJ..,.I =

PROOFOFI.D.

{&Jar0.--,0...

, l.SS 'ftW,I 6 MONTHS POSTPARTUvl

} ~

,,.

vesO D E...., B<easlfeed

No

. ~ DATADATE ,,,_ _ _ _ _ _ _,,_,,

..........

.. L

... L

~ (VU,oamtlle 80dlp)

O O Smoldng Ya

No

(Enler# cig/day:

select apixoptlate risk criteria per State guidelines (See Risk Crtterta Handboolc for definitions)

---HCT

)

YES

Anemia

201

102

--..::,,;-71 112

KohGeslationafw.-.h!Gain

Elevated Blood Lead Level

"""""lead.....,.> 10 --

Gestational Oiabeles (most -

....;..,,,,_.,

......._,,ofPN!lermlnfantCsl(""""recenf----'l<!..,_v,eeks........,=-:

I

-..orr.-llirlhW...hl -...,s1 (most-

erbirth-'""''sl and.....,__.......,s,:

FelaflNeonala!Dealh (most mcenl _______. ,.,.,._....,..,s\ ofdeallt and - . . a - - :

a,..,'"""" .,____al a Ynunn

recent,,_,_....,,

......_., s

'(most mcenl

-

- - = dates of last 12\

Koh P2rilv and Y~- &....

-

sl of

:

\

133

211

303

311

\ 312

\ 321 n.,o71 331

l

332

333

Mulll-Felal Gestation (most recent - -

Bir1h ofa 1~ - farGestatianal,.,,,,, lnfant(most mcent - - ~ - _..,_.,. > 98>s. """"-ms\1

Bir1h wilh Nulrtion Relaled r . - 1 o r Birth ....._.,sl fmosl """"11
'' Nutrtllcnal Related Medical Conditions-: n ........,sl:

defed.:

335

337

-,\

339

AbJhal Use:

Roulne (

azlwk.l ""'- drinker, Heaw drinker

372

Slreel"'"-lJset<!..._..._of.._..,s\:

\

373

Oenlal PR,l,lems

381

..._ ..............,ofR-----'I lomelessness

422 501 801

1102

901

Woman will, Un-iled ......... lo Make.,_,.,__ Decisions a n d / - Food

902

Tr.ansfer ofCerlificalion

502

HIGHRISK tvesorHol

EUGlBlE FOR WIC

PRIORfTY; 3 (33UCl2) C (2111,1QZ,112.133.211,303,311,31'Z,321.33l,33Z,333.335.337,339,3C1~,346,3C7,348,349,:SSUS2,353,

354,3S5.., 357 ... 359.38).361. 362.372.373.3111.422.S,1.!!02.801.802.901"""



HG8 NO

FOOD PACKAGE: , , , _TIIR,vf- lnstn(ctJonsl
r x = ~ CH~. HeallhChed< (B), CMS (C), 1/Vomen Heallh (D), PCM (E), PRS (F), llmv1 (G), Lead Screen (H),
Denial Heaml ffl, S1t> (J), Privale MO (1(), Food Stamps (IJ, Medicaid (M), TANF (N), Menial HeaJlh (0), Head Start (P), NAINone ( Q ) . ~ (R), Camu,ly Heallh Center($). Olher-Specify (I)

Rdt:nec:ITo:

TODAY'S DATE

SIGNATURE AND TITLE OF HEALTH PROFESSIONAL Additional Documentation Required

CT-61


:j



GA WIC PROCEDURES MANUAL

Attachment CT-2 (cont'd)

WIC ASSESSMENT/CERTIFICATION FORM - POSTPARTUM BREASJ:'FEEDING (BACK)

DATE
~

INCOME DETERMINATION (Income must be documented}

MEDICAID
CURRENT Y/N/U y( ) N( )

MEDICAID 10 NUMBER (MUST HAVE CURRENT CARDI

FOOD STAMPS Y/N/U
(MUST OOCUMENTI
y ( ) u( )

u( )

N( )

NO.IN FAMILY

GROSS INCOME/MONTH (CURRENT OR ANNUAL!

Documentation of Income must be completed for an applicant who does not qualify for adjunctive eligibility. Documentation ofIncome Source: Write in all that apply.

Source of Income
0th
None _ _ _ _ _ __

H- ls food, sheller, clothing and Medical care obtained?

Stlfflniliaf
Use the Income Calculation Form to document the applicant's income. The total from the CalcuJation Form must be documented on this form.

Date._ _ _ _ _ _ _ _ _ _ _ _ _ _,lncome $._ _ _ _ _ _ _ _ _ _Weekly/Bi-Weekly/Monthly/Yearly No. In Family_ __
Is the Client Income Blg,"llle? YES NO

Note: TIJe Income Calculation Form must be filed In the Client's Medical Ret:d.

I have been advised of my rights - obligations und lhe Program. I certify-Ille ~ I will provide, or have provided Is c:om,ct, to Ille best of my knowledge.

The -

I haw gl-, Is my total gross household Income (all cash Income befon, deduclions). This ces1ificatian tom, Is being submillecl In mnnec:tian wllh Ille receipt

o f ~ assistanca. Program ofliclals may wrify lnfonnalion on this fann. I undeffland lhal lntantionally making a false or mlslaacling -

or lnlionlionally mis-

ftjlreSenling. conceallng, or wilhholding facts may result In paying Ille Stata agency, In cash, Ille value of the food benefits Improperly Issued to - and may subject - to

cml o r - . , , . . . _ under Slate a n d ~ law. I unclerstand lhallhe WIC Program may give myc:erlification lnrarmationto Olher,_orpubOcassistanc:e

agencies to - If my family Is ellgible fotthelrsemces. I understand - t h e s e ~ may conlael me, but they may - gm, my lnformalion to anyone else without
aslclng my ponnlsslan.

PARENT/GUARDIAN/CAREGIVER SIGNATURE

DATE

SIGNATURE OF WIC OFFICIAL

(wl,o _

_,

DATA NEEDED FOR PREGNANCY SURVEIUANCE .. ::,~~-~: ~:-:;, . :-~, .__ ";" :~~..;,r:.:. -:;,.-;:: ;_;.,_-"'.,::t;:..~-"::f ~ ~ :..- .,. -..:, ..,_. -~. -~-,..._ __ .._ ":.,-; __,. ... -::, _ ~Z-.::-.:~ ~ ~ : ' ~ ~'=-1 .,} . ~;-:::::.-:-:-7_7::-_,c.,:t.~:,"!__~:-!,::-~

Marita1Stall$

( 0 = ~ 1=Not Manied 9=Unknown)

Ye;llS of Education axnpleled (e.g. 1st grade C 01, 2 y!'S. college=14, Unknown=99)

Month of gestation at 1illle of first prenalal exam (O=No Prenatal Cate, 1=1st mo.,8=8111 or 9tt1 mo., 9=Unknown)

Last weight prior ID delivery (Round ID Ille nearest pound)

6--giaVOC:Card- OUTclSfATE-

Signature of WIC Official: Comments:(Date\Sign\Trtle);

CT-62

GAWICPROCEDURESMANUAL

Attachment CT-3



WIC ASSESSMENT/CERTIFICATION FORM - POST PARTl.Jl\Y NON BREASTFEEDING (FRONT)

NAME USf

~c ASSESSMENTICERTIACAllON FORM

A

ARST

POSTPARTUINNON~REASlFEEDING WOMAN r-
I I I I I I ...croNUMBERI

-

-

r

-

-

-r---,.--..I--rI-.,.-~-r---r..:::;;

=:

.

==;

I MIDOLE INITIAi.

BIRTHOA.TE

AOORESS

(

D O D COUNTY OF RES1DENC'Y

PROOF OF RESIDENCY

INITW.. COfllTACT DNA_ TE: _ DAT_ E O,F_ FlR_ ST_ VlS_ ITn REQoUEtS_ TINlG WIC SERVICES

CffY

ZIPCCC

ETIOaCOfUGUC--=---,

I

MIGRANT

CJ... G].. G].. CJ.. G].. [J..I - ONO

PROOFOFI.D.

lFS:DING, LESS THAN 6 MONl1iS POSTPARTUM

.-o,,,,e,yo,o,

} ~

..,

D Ever Breastfeed YesO No

Weelcs B"'2Slfed:

~ (VaO,e ...., .. 90 ClayS)

O O Smoking Yes

No

(Enter ti cig/day:

select appropriate risk atterta per State guidelines (Sff Risk Criteria Handbook ror definitions)

----- HCT

HGB

)

YES

NO

Anemia

201

Underwei!lht

102

IHR?I 112

133



EleWted - Lead LeYOI

-~,.m tBlnnd lead level> 10

GeslalionalDiabeleslmostrec:en! _ _,,

l'>,li-,,ofPtelenn lnlantlsl /most"""'"'_.....,, /Enterv,eeb -ion:

\

n..o...... afl.awBirth w.:..M lnfantfs\ /most recent

birth """""hlls\ and......_, dale<sl:

Felal/NeonatalOeatt! (most recenl _ _ _, ,c-erdalelsl ofdeath and weeks-'-:

- ~ a t av~-.._ (fl"OSI recenl _____..

211 303 311 \ 312
' 321 ?I 331

r

-

-

-

(most -

M.nhP.orilvandY~-a-tr="'er......_,,...._,slaf

M&dtM'etal Gestation (mostteeenl ___..

erlermination da!esoflasl m -nancies:

noes:

l

\

332

333

335

Birth o/ a I ~ - far GeslalJonaf "'- Infant/mos! recent -

"""" -..f11 > 911>$. " ~ "

Birth wilt, Nulrilion Related r-enilal or Elir1h De..,..'' /most recenl

def'ed:

Nutltdonal Related Medical Cond1tions: n kl """""sl:

Alcohol

Rouline I

oz.Ml<.l ..,__ drinker .,_,_ drinker

337

\

339

\

372

Slreel 0....0 Use /Enter"""' of dn""sl:

l

Dental Problems

,__._,,,..,~ Diewv Pattern

373 ..
381 422

501

lie< I 1eSS

801

~

802

R__.,,_,,. ofAbuse

901

IM>man wilh l.imifed '""""" to Make Fcr,na Decisions and/or....__,, Food

902

Tr.msfer af Cer1ificallon

502

HlGHRISK fYesorNol

EUGIBl.E FOR 1MC PRIORITY: 3 1331.502) c 12>1.102.112.133.211,303.311.312.x,1,331,332.333.335,337.339,><1,32.3:U44.345.3C6.347.3<8.3-19.351.352.353.
lSC.355.356 357.358.359.360.361. . _ - 37J.381.C22.S01.502,801.802.901,atn1.

FOOD PACKAGE: ""-_,,,, Ta.1a.,;,.,. lnstTUctionsl
SERV1a: CH (A,), Heall!> Check (B), CMS (C). Wxnen Heaflh (D). PCM (E). PRS (F), lmmun (G), lead Screen (H). Denial Heath (fl, SlO (J), Ptw.u MO (I(), Food Stamps (l.). Medicaid (M), TANF (N), Menial HealUl (0), Head Slart (P), NA/None (q), Refused (R). Cortwnunily Heallh Center (S), Other- Specify (l)

Entoledln; RdeffeCITo:

TODAY'S DATE



SIGNATURE ANO TTTlE OF HEALlli PROFESSIONAL Additional Documentation Reqwred
Form 32961< (Rev. M9)

CT-63



GAWICPROCEDURESMANUAL

Attachment CT-3 (cont'd)

WIC ASSESSMENT/CERTIFICATION FORM - POSTPARTUM

NON BREASTFEEDING (BACK)

.

DATE .

INCOME DETERMINATION (Income must be documented)

MEDICAID
CURRENT Y/N/U
y ( I N( I

MEDICAID 10 NUMBER /MUST HAVE CURRENT CARDI

FOOD STAMPS Y/NAJ
IMUST OOCUMENTI
y ( I u( I

u( )

N( I

NO.IN FAMILY

GROSS INCOME/MONTH ICURRENTORANNUALI

Documentation of Income must be completed for an applicant who does not qualify for adjunctive eligibility. Documentation ofIncome Source: Write in all that apply.

Source of Income
Other
None _ _ _ _ _ __

How is food, sheller, dothing and Medical Care obtained?

Slafflnltial
Use the Income Calculation Fonn to document the applicant's income. The toW from the calculation Form must be documented on this form.

Oale_ _ _ _ _ _ _ _ _ _ _ _ _ _ _.lncome $,_ _ _ _ _ _ _ _ _ _ _W,eekly/81-Weekly/Monthly/Yearty No. In Family_ __
Is the Client Income Eligible? YES NO

Note: The Income Calculation Fann must be tiled In the Client's Medical Record.

I have been advised of my rights and obr,gatlons under the Program. I certify Illa! the Information I will provide, or have pnmded Is con-ect. to the beSI of my ""-'edge. The Income I have given Is my tocal gross household Income (all cash Income before deduc:lions). This cettffic:alion lonn ls being submltled in connectian witll lhe receipt of Federal assistance. Program officials 1113)' verify information on this fonn. I und8"Stand that Intentionally making a false or misleading statemenl or intentionally mis representing, concealing, or withholding bets 1113)' result In paying the State agency, In casll,. the value of the food benefits Improperly issued to me and 1113)' subject me to civil or criminal prosecution under St3te and Federal law. I understand that the WIC Program 1113)' give my certifialion infonnat;on to other heald, or public assistance agencies to see If my family is eligible for their services. I understand that these agencies 1113)' contact me. but they may not give my lnfonnation to anyone else witbout asking my permission.

PARENTIGUARDIAN/CAREGIVER SIGNATURE

DATE

SIGNATURE OF WIC OFFICIAL (who ssesud , , _ ,

DATA NEEDED FOR PREGNANCY SURVEIUANCE
:.. ......... ..r... rr,, ......_. ~- ._--~~c;:,__...-:-.;.:..:,,)E"=::t .. , ....:,,,, ~~' - ~ - ~-..::...~--~,.. - ...~.--::-.:.':~~~-:;;.:~~~-~- ., ._-.c..,;; _, ~ ,:..-1.:.- :-...... :?::-:t---:-:-:..:. t:<("=''t~ ~;._;,,;,::..-:. -.;;,-:_;.::..:- :~i;7_...:~..:::...--

Mari1a1 Status

(O=Manied 1=Not Manled 9=Unkn0wn)

Year.; of Education completed (e.g. 1st grade= 01, 2 yrs. C011ege=14, Unknown=99)

Month of gestation at time offilst prenatal exam (O=No Prenatal Care. 1=1st mo.,8=8111 or 9th mo., 9=UnknownJ last weight pnor to delivery (Round to the nearest pound)

GeorgiavoeCan!-., _____________._______.I -
OUT of S T A T E -

Do. _ _ _ __

Signature ofWIC Official: Comments:(Date\Sign\Title):

CT-64



GA WIC PROCEDURES MANUAL

Attachment CT-4

WJ;~ ~SSESS1\.1ENT/CERTIFICATION FORM - INFANT (FRO~)

~ o . . - - c ...- - - - - -

~ UST

SOfU AMT

AIXlRESS

WIC
ASSESSMENT/CERTIFICATION FORM
INFANT
.._.......

WC I) NUMBER!

atY

1ELEPH0NE

(

)

C0UlTY OF RESlce::Y
D D

PAle~VER!WE:

SOC::W.SECURITY-

El1CIO:OltlG:IN(c:611d:_,
GJ-GJ- G:J... GJ N G).,s GJ-

PROOF OF RESIIS:Y

GENDER

MOllER'SWCIOS INITIAl CONTACT OI\TE: Oll'IEOFRRST VISIT RE0l.ES'T1NG SERI/ICES
QecllElldla..tioaYeaotNoWrihiNIA(pe,Slal.-.-r-.)
__,._,,..__~- 8RJ:ASTFEDNON EVER ; RECORD '11-E NlJl48S'l OFW:EKS INFANT BR1:AS1FED (RaundlD~~e.t;.000,,31"-"" 014-~ 021117~
T'>l\lE OF MOST RECENT BREASTFEECING RESPONSE
MBJICAL llll,TA Ol\'IE

LAST V.SGHT BS'ORE OB.NERY

YES

110

- ~~1~~~~1;~}

_ A ...
I
-ZJPCOOE
Oves 0110
PR00f OF ID.

MAL.ED

FEMALE

l.BS.

YES

NO

- :~t~JJi~tt~~t;

1.8,gth

In

lweiatit (&lier birthweigllt

lbs.

CZ)

HefflalocrillHe __,....,.. ~ SIOdaysl
-----perStateguidelinos (See Rislt Qillona H a _ to, cldlnltioRs)

lbs.

GZ

lbs.

ft?\f:f?Jt1tfi~~ii~lf;t~\g\! !CT

YES

NO

YES

Anemia

201

~ (l..ess than or equal to 10%)

[HR?]

103

~ (Greater than or equal to 90%)
. Short Stalure (l..ess than or equal to 10%) Failure To Thrive

(HR 7)

113

[HR?]

1,2,1.

Inadequate Growth

. Law Bir1h Weight (Bir1I, weigh! ~5112 bs. or g:500gms)

. Premalurity (Entet weeks gestation:

)

. Large for Gestational Age,......, weight?.91bs.(4000gmsl1

135 141 142 153

Elevated Blood Lead l.ew,l(Bloocl lead le';ef a1Qi,g /di)
. Nutrition Related Medical Conditions (List code(s):
. Denial Plablems . Fetal Alcohol Syndrome . Inadequate Dietary Pattern . Breastfeeding Complications or Potential Complications

)

211
3..8,1
42:2
an

Infants (up to 6 monlhs old) of a WIC Mother or a ...,man

. who ...,uld have been eligible during pregnancy 8'ea$lfeeding Infant of a Woman at NUlritional Risk

101

. (Enter molhel's risk fac:tots: Infants born to Mother will\ Mental Retardation. or

l

1112

:

Alcohol or DNg Abuse During Most Recent P,egnancy

103

Hou el: ss LESS

801

Migrancy
. Redpient of Abuse
. Primaly Categiver with linited Abaily to
__, Make Feeding Decisiofts and/or Prepare Food Transfer of Cettific:alioft

aaz
1101
-9Q2

(YesorHoJ

BJG&ER:lRWC
PRIORITY: 1 =(201.103,113.121,134.135.141,142,153,211,341,342.343,

344.345.346.347,348,349,350.351.352.353.354.355.356,

357.359.360,362,381.382.502.603.702.703)

2 =(S02.701.702)

4 C (422_502_702_801.802.901,902)

fll(f"'9~111HKr.SfllallMm:,
FOOO PACKAGE '-""""'YT-.,-,

SBW:ES:QCW..._..0.-(8).CUSt'C).--.(G).\acl~(H). Denralllcaltl(IJ.STI>CJ).
...__,(IO.~. .ClJ.llildcaid(lll. TNCF(IO.llaltll.....,.C0).Mead:$art(P).KMIGM(Ql.
.._.(IU.~...... c...-(S).O...-~(T)

-Ill:
Rdened'To:

Emoaedln: ~To:

1'00A'l"S OATE

.SIGl<AT\JREANO TITI.EOFHEAL.ll<-_
Additional Documentation Req,ared

Fona 3299 (Rev. 2-99)

In
GZ
.....
NO

CT-65



GAWICPROCEDURESMANUAL

Attachment CT-4 (cont'd)

WIC ASSESSMENT/CERTFICATION FORM INFANT (BACK)

DATE
.

INCOME DETERMINATION (Income must be documented)

MEDICAID CURRENT Y/NAJ
y ( I N( )

MEDICAID 10 NUMBER (MUST HAVE CURRENT CAROi

FOOD STAMPS Y/N/U
(MUST DOCUMENT)
y ( I u( I

u( )

N( )

NO.IN FAMILY

GROSS INCOME/MONTH (CURRENT OR ANNUAL)

..

.

Documentation of Income must be completed for an applicant who does not qualify for adjunctive eligibility. Documentation ofIncome Source: Write in all that apply.
Source of Income

Other

(Writefntypos} None _ _ _ _ _ __

How Is food, shelter, dothing and Medical Care obtained?



Use the lncne calculation Form to document the applicant's Income. The total from the calculation Form must be documented on this form.

Oate,_ _ _ _ _ _ _ _ _ _ _ _ _ _ _lncome $._ _ _ _ _ _ _ _ _ _Weekly/Bi.Weekly/Monthly/Yearly No. in Family_ __
Is the Client Income Eligible? YES NO

Note: TIie Income calculation Fann must be filed In the Client's Medical Recd.

I llaw been advised of my rights and obligations under the Pn,g,am. I certify Iha! the Information I will pnmde. or haw provided Is --.eel, to the best of my knowledge.
The Income I haw given Is my total gross household Income (aU cash Income before deductions). This certification form Is being submffled In connection With the receipt of F - . i asslslance. Program ofllclals may Yecffy Information on this fonn. I undemand that lnlenlionally malclng a false or misleading statement or lnlenllonally misrapresentlng. concealing, or wllhholcfang facts may resutt In paying the State agency, In cash, the value of the food benefits Improperly Issued to me and may subjecl me to civil or ciminal pn,sec:ution under State and Federal law. I under.stand Iha! the WIC Program may give my certification lnfonnallon to other health or public; assistance
agencies to see If my family Is eligible for their se<vices. I understand Iha! these agencies may c:ontacl me, but they may not give my Information to anyone else Without
asldng my pennlssion.

PARENT/GUARDIAN/CAREGIVER SIGNATURE

DATE

SIGNA(wTtU,oR_ E OF W_ IC OF,ACIAL

6-gioVOCCard-or OUTclsrATEAbbnMotlon
Signature of WIC Official: Comments:(Date\Sign\Tltle):

D b s u -

Dato _ _ _ _ _ _ _ _ _ _ _ _ _ _ __


CT-66



GA WIC PROCDURES MANUAL

Attachment CT-5

WIC ASSESSMENT/CERTIFICATION FORI\1 - CHILDREN (FRONT)

c..-t11:1o.---a.....- - -

--- A cue:I I I I
,......., &ASr

SORT
ARSr

WIC ASSESSMENT/CERTIFICATION FORM
CHILD
__._
QTY

I I

I

_,_TE

ZIPCODE

--- ---- I -- (

)

ll:ICW.lllCURIIY-

GJ -GJ- G]... GJ.. G].. [J..

0-o

COUNTY OF RESICENCY

COUNTY OF RESIDENCY

p,ARENT.QJARDIAN/CAREG NAME:

PROOF OF RESIDENCY PROOF OF RESICENCY

PROOFOFLD. PROOFOFLD.
GelOER MALE

falAI.E[J

INITIAL CONTACT DATE: DATE OF FIRST VISIT REQUESTING SERVICES ,.,._,........,,,.date,""'1llicaflons...,natcor1:11ealfiveJ

~

es or NO-- -- -- - 9 ~

\'ES

NO

'YES

NO

NON

EVER ~ TI-IE NUMBER OF VEEKS CH11D BREASTFED
,..,,,_,,.,,_Wllel(.e.a.00=0,,3"""' 01=4-10..,_, 02=11-17"'""'}
DATE OF MOST RECENT BREASTFEEDING RESPONSE

-~i~42:;~

- ~~1~~

MEDICAL DATA DATE IEnler date

measurements """"tal<en)

1, - ~ e,gtrt

... We/<IM (En!e<Bilttt-

bs.

oz.I

HCT

Hematoail/Hemoglobin (Value must be ~ 90 days)

- _ _...,._r1s1<..-persate.---11ac...._1o<...,._l

\'ES

Anemia

:201

Underweight (Less than or equal to 10%)

[HR?] 103

Overweight ( Greater than or equal to 90%)

[HR 113

Short Stature (Less than or equal to 10%) rauure 10 1nnve
maaequ-ne=

[HR 121
134 135

.. Low Birth Weight (Children <24 months of age) Blood Lead. Level (Blood lead level>10a,al) NutritiOn r<e&ated Meu1ca1 Conditions (List code(s}:

141 211
)

Dental Problems

381

,-....., ~ :;ynarome

382

Inadequate Dietary Pattern

422

Possibility of Regression

501

Homelessness

801

Mtgrancy

802

Recipient of Abuse

901

r-umary .....regiver with LJmited Ability to Make reeamg

Decisions and/or Prepare Food

902

Transfer of Certification

502

HIGH RISI( (Yes orNol

BJGIBLE FOR'WIC

PRIORITY: :a= (201,103,113,121,134.135,141,211,341,342,343,...........,,346,347,

348,349,351,3S2,353,3S4,355,356,3S7,359,360,361,362.381,382,

501,502)

Ii= (422.502.801,802.901,902)

FOOOPAO<AGE: ,.,,._.,,,,T.........,.lnstlUctionsl

seRVICES: CH(A). Health Checl<(Bi CMS (C). lrrl!ul !Gl Lead 5aeen (H). Healttl
(1). STD (J), Pmale MOi'K). Food Slan1)S (I.). Oxmunily Health cener (S). Medicaid
{M), TNF (Nl, Menial Heallh (0). Head start (P). NA/None (0), Refused (R), Denial

-lo:

=rs -

{S), Olher - Specify (T)

DATE

. .. SIGNAT\JRE ANOlTTlE OF HEALTI4 PROFESSIONAL
Additional Documentation Requued

~To:

r-:sasi-.M!II

a
az HCT
HG8 NO

lbs 'YES

..

-In:
RefeffedTo:

a
az
HGI NO

CT-67

GAWICPROCEDURESMANUAL

Attachment CT-5 (cont'd)

WIC ASSESS1\1ENT/CERTIFICATION FORM - CIDLDREN (BACK)



INCOME DETERMINATION (Income must be documented}

MEDICAID

MEDICAID ID NUMBER

FOOD STAMPS Y/NJU

NO.IN

GROSS INCOME/MONTH

DATE .

CURRENT Y/NJU
y ( ) u( )
N( )

(MUST HAVE CURRENT- CARD)

(MUST DOCUMENTI

y( )

u( )

N( )

FAMILY (CURRENT OR ANNUAL!

y ( ) u( )

y( )

u( )

N( )

N( )

....

Documentation of Income must be completed for an applicant who does not quahfy for adJunctive ehg1b1hty.

Documentation of Income Source: Write in all that apply.

RRSTCEJmRCATION

Source of Income

0thet"
(Wdfo/nr,pes/
--------

"Howlsfood-.dolha,g--C:--

:Use the Income Calculation Form to document the applicant's Income. The tlJtal from the Income calculation Form must be documented on this fonn. Date,_ _ _ _ _ _ _ _ _ _ _ _ _ _-'lncome $._ _ _ _ _ _ _ _ _ _ _Weekly/Bi-Weekly/Mon1111y/Yearly No. In Family_ __

Is the Client Income Eligible? YES NO

Note: The Income Calculation Form must be 6/ed In the Client"s Medical Record.

SECOND CERTlRCATION Source of Income
Olhet' (W.rfOt In IJPU)
--------

Howlsfood-.cloltllng----Care-

Use the Income Calculation Form to document the applicant's Income. The total from the Income calculation Form must be documented on this fotm. Date_ _ _ _ _ _ _ _ _ _ _ _ _ _ _.lncome Sc,.__ _ _ _ _ _ _ _ _Weekly/Bi-Weekly/Monlhly/Yearly No. In Family_ __

Is the Client Income Eligible? YES NO Note: The Income calculation Form must be filed in the Client's Medical Record.

I have been acMsed of my rights and obligations under the Program. I cartify lhal the lnformalion I will pn,vide, or have pn,vided Is correct. to the best of my lcnowtedge.

The income I have given Is my total gross hous4!hold Income (all cash Income befo<a clecluc:llons).. This certification form is being submitted In connec:tion with the receipt

-nc:y. of.,_. assistlnce. Pn,gTam officials may verify Information on llds form. I understand - lnlentionally making a false or misleading -

or lnlenlionally mis-

repnsenting. concealing. or- . . g bets may result In paying the Stale

In cash, the value of the food benefits Improperly Issued to me and may subjec:1 me to

cMI or criminal prosecution -Stale and .,_ral lilw. -
- - to see If my family Is eligt"ble for their services. asking my permission.

- the WIC Pn,gram may give my certification lnfonnalion to - - or public assistance - these agencies may contact me. but they may not give my lnfonnation to anyone else without

SIGNATURE OF WIC OFACIAL

PARENT/GUARDIAN/CAREGIVER SIGNATURE

DATE

(wt,o--)

6-'gQVQC Canl-at OUT of S T A T E -

....__._--L........I...__._____.____.I -

-or ._....__.__....._....._.....___.I - Signature ofWICOffic:lal:
_ . . voe Card
OUTofSTATE-

Signature of WIC Official:

Comments:(Date\Sign\Tdle):

D

Dam _ _ _ __

D - ____...;..____

CT-68



GA WIC PROCEDURES MANUAL

Attachment CT-6

SIGNED STATEMENT OF INCOME, RESIDENCY AND IDENTIFICATION

I, _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _, cannot come in to apply for WIC for my
Parent/Guardian
child(ren)_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _. I have given permission to
Name(s)
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ to file my application.
Proxy Name
Documentation listed below for my family and me is attached. The number of people in my family is _ _ _ ("Family"
means related or non-related individuals living together).

Parent, Guardian of Caretaker Signature

Date



The proxy who comes with the child for the recertification up must have: 1. This Form 2. Your WIC I.D. Folder 3. Current Medicaid or Food Stamp Letter or Card 4. If not eligible for Medicaid, Proof of your income (example Pay stub) 5. Proof of your residency 6. Proxy Identification 7. Knowledge of the child's health and diet "The USDA is an equal opportunity provider and employer."


CT- 69



GAWICPROCEDURESMANUAL

Attachment CT-7

DATA AND DOCUMENTATION REQUIRED FOR WIC ASSESSMENT/CERTIFICATION

WOMEN

Data

Documentation Prenatal

Height Weight Hemoglobin or Hematocrit Prenatal Weight Grid Dietary Intake and Summary Dietary Evaluation Risk Factor Assessment

Required Required Required Required Required Required Required

Postpartum Breastfeeding
Required Required Required
NIA Required Required Required

Postpartum NonBreastfeeding Required Required Required NIA Required Required Required

NOTE: Refer to Attachment CT-20 for information regarding the collection of height data. Refer to Attachment CT-21 for information regarding the collection of weight data. Refer to Attachment CT-23 for information regarding equipment maintenance. Refer to Attachment CT-25 for information regarding use of the prenatal weight gain grid. Refer to Attachment CT-27 for information regarding diet assessment. Refer to Attachments CT-10, CT-11, CT-12 and CT-13 for information regarding risk factor assessment .


CT-70



GA WIC PROCEDURES MANUAL

Attachment CT-8

DATA AND DOCUMENTATION REQUIRED FOR WIC ASSESSMENT/CERTIFICATION

INFANTS

Data
Length Weight Hemoglobin or Hematocrit Dietary Intake and Summary Dietary Evaluation Risk Factor Assessment

Documentation

Infant Certified in Hospital Prior to Initial Discharge .

Infant 0-6 Months

Birth Data or other measurement

Required

Birth Data or other measurement

Required

NIA

NIA

Optional

Required

Optional

Required

Required

Required

Infant 6-12 Months
Required
Required Required Required Required Required

NOTE: Refer to Attachment CT-19 for information regarding the collection of length data. Refer to Attachment CT-21 for information regarding the collection of weight data. Refer to Attachment CT-23 for information regarding equipment maintenance. Refer to Attachment CT-27 for information regarding diet assessment. Refer to Attachment CT-29 for information on plotting growth grids. Refer to Attachment CT-14 for information regarding risk factor assessment.


CT-71



GA WIC PROCEDURES MANUAL

Attachment CT-9

DATA AND DOCUMENTATION REQUIRED FOR WIC ASSESSMENT/CERTIFICATION
CHILDREN

Data Length or Height Weight Hemoglobin or Hematocrit Weight for Age Plotted Length/Height for Age Plotted Weight for Length/Height Plotted Dietary Intake and Summary Dietary Evaluation Risk Factor Assessment

Documentation Required Required Required Required Required Required Required Required Required

NOTE: Refer to Attachment CT-20, 27 for information regarding the collection of height data. Refer to Attachment CT-22 for information regarding the collection of weight data. Refer to Attachment CT-23 for information regarding equipment maintenance. Refer to Attachment CT-27 for information regarding diet assessment. Refer to Attachment CT-29 for information on plotting growth grids Refer to Attachment CT-15 for information regarding risk factor assessment.


CT-72



GAWICPROCEDURESMANUAL
NUTRITION RISK CRITERIA PRENATAL WOMEN

Attachment CT-10

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



CODE

201 ANEMIA

1st Trimester (0-13 weeks):

Hemoglobin

Non-Smokers

10.9 gm or lower

Smokers

11.2 gm or lower

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

10.4 gm or lower 10.7 gm or lower

3rd Trimester (27-40 weeks): Non-Smokers Smokers

10.9 gm or lower 11.2 gm or lower

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

PRIORITY I

High Risk: Hemoglobin OR hematocrit at treatment level

101 PRE-PREGNANCY UNDERWEIGHT

I

Pre-pregnancy weight is greater than or equal to 10% below the mean normal weight for height OR Body Mass Index (BMI) is <19.8. Refer to Weight for Height Table, Attachment OR BMI Table, Attachment CT-30-31.

High Risk: Pre-pregnancy weight greater than or equal to I0% below normal weight for height, OR BMI <19.8

111 PRE-PREGNANCY OVERWEIGHT

I

Pre-pregnancy weight is greater than or equal to 21 % above the mean normal weight for height OR BMI is >26. Refer to Weight for Height Table, OR BMI Table, Attachment CT-30-31.

High Risk: Pre-pregnancy weight greater than or equal to 36% above normal weight for height OR BMI >29


CT-73



GAWICPROCEDURESMANUAL

Attachment CT-10 (cont'd)

CODE
131 LOW GESTATIONAL WEIGHT GAIN

PRIORITY I

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

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

132 GESTATIONAL WEIGHT LOSS DURING PREGNANCY

I

During first trimester (0-13 weeks), any weight loss below pre-pregnancy weight; based on pre-pregnancy weight and current weight.
OR During second and third trimesters (14-40 weeks gestation), 2:'.2 pounds weight
loss; based on two weight measures recorded at 14 weeks gestation or later.

Document: Two weight measures, as specified above.

High Risk: Weight loss of 2:'.2 pounds in the second and third trimesters

133 HIGH GESTATIONAL WEIGHT GAIN

I

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

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

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

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

211 ELEVATED BLOOD LEAD LEVELS Blood lead level 2:: 10 g/ Document: Date of blood test and blood lead level in the participant's health record. Must be within the past 6 months High Risk: Blood lead level 2:: 10 g/decilieter.
CODE

I
PRIORITY I

CT-74



GAWICPROCEDURESMANUAL

Attachment CT-10 (cont'd)

30.1 HYPEREMESIS GRAVIDARUM

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

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

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

High Rick: Diagnosed hyperemesis gravidamm

302 GESTATIONAL DIABETES
Presence of gestational diabeters diagnosed by physician, as self-reported by applicant/participant/caregiver; or as reported or documented by a physician or a health professional acting under standard orders of a physician.
Document: Diagnosis, name of physician that is treating this condition, and current diet prescription (if provided); in the participant's health record.
High Risk: Diagnosed gestational diabetes.

303 HISTORY OF GESTATIONAL DIABETES

I

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

Document: Diagnosis gestational diabetes

311 DELIVERY OF PREMATlJRE INFANT(S)

I

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

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

312 HISTORY OF LOW BIRTH WEIGHT INFANT(S)

I

Woman has delivered one (1) or more infants with a birth weight of 5 pounds 8 ounces (2500 grams) or less.

Document: Weight(s) and birth date(s) in the participant's health record.
CODE
321 HISTORY OF FETAL OR NEONATAL DEATH

PRIORITY I

CT-75



GAWICPROCEDURESMANUAL

Attachment CT-10 (cont'd)

Any fetal deaths (death ~20 weeks gestation) or neonatal deaths (death occurring from 0-28 days of life.
Document: Date(s) of fetal/neonatal death(s) in the participant's health record; weeks gestation for fetal death(s); age, at death, of neonate(s). This does not include elective abortions.

331 PREGNANCY AT A YOUNG AGE

I

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

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

High Risk: EDC at less than 17 years of age

332 CLOSELY SPACED PREGNANCIES

I

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

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


CT-76



GA WIC PROCEDURES MANUAL

Attachment CT-10 (cont'd)

CODE 333 IDGH PARITY AND YOUNG AGE

PRIORITY I

The following two (2) conditions must both apply:

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

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

334 LACK OF, OR INADEQUATE PRENATAL CARE

I

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

Document: Weeks gestation when prenatal care begin; in participant's health record. A preimancy test is not prenatal care.

335 MULTI-FETAL GESTATION

I

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

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

High Risk: Multi-fetal gestation

336 FETAL GROWTH RESTRICTION

I

Fetal growth restriction (FGR) must be diagnosed by a physician or a health professional acting under orders of a physician.

Document: Diagnosis in participant's health record.

337 IDSTORY OF BIRTH OF A LARGE FOR GESTATIONAL AGE INFANT

I

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

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

CT-77



GAWICPROCEDURESMANUAL

Attachment CT-10 (cont'd)

CODE 338 PREGNANT WOMAN CURRENTLY BREASTFEEDING

PRIORITY I

Breastfeeding woman who is now pregnant.

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

339 IDSTORY OF BIRTH WITH NUTRITION RELATED CONGENITAL OR

I

BIRTH DEFECT(S)

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

Document: Infant's congenital defect in participant's health record.

341 NUTRIENT DEFICIENCY DISEASES
Diagnosis of clinical signs of nutrient deficiencies or a disease caused by insufficient dietary intake of macro- and micro-nutrients. Diseases include, but are not limited to, protein energy malnutrition, scurvy, rickets, beriberi, hypocalcemia, osteomalacia, vitamin K deficiency, pellagra, cheilosis, menkes disease, xerothalmia. (See Attachment CT-32)
The presence of nutrient deficiency diseases diagnosed by a physician, as selfreported by applicant/participant/caregiver; or as reported or documented by a physician or a health professional acting under orders of a physician.
Document: Diagnosis and name of the physician that is treating this condition; in the participant's health record.
High Risk: Diagnosed nutrient deficiency disease.


CT-78



GAWICPROCEDURESMANUAL

Attachment CT-10 (cont'd)

CODE 342 GASTRO-INTESTINAL DISORDERS

PRIORITY

Diseases or conditions that interfere with the intake or absorption of nutrients. The

I

conditions include, but are not limited to: stomach or intestinal ulcers, liver

disease, small bowel enterocolitis and syndrome, pancreatitis, malabsorption

syndromes, gallbladder disease, inflammatory bowel disease (including ulcerative

colitis and crohn's disease).

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

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

High Risk: Diagnosed gastro-intestinal disorder

343 DIABETES IvtELLITUS

I

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

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

High Risk: Diagnosed diabetes mellitus.

344 THYROID DISORDERS

I

Presence of thyroid disorders (hypothyroidism or hyperthyroidism) diagnosed by a physician, as self-reported by applicant/participant/caregiver; or as reported or documented by a physician or a health professional acting under orders of a physician.

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

High Risk: Diagnosed thyroid disorder


CT-79



GAWICPROCEDURESMANUAL

Attachment CT-10 (cont'd)

CODE 345 HYPERTENSION

PRIORITY I

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

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

High Risk: Diagnosed hypertension

346 RENAL DISEASE

I

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

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

High Risk: Diagnosed renal disease

347 CANCER

I

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

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

High Risk: Diagnosed cancer


CT-80



GAWICPROCEDURESMANUAL

Attachment CT-10 (cont'd)

CODE
348 CENTRAL NERVOUS SYSTEM DISORDERS

PRIORITY I

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

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

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

High Risk: Diagnosed central nervous system disorder

351 INBORN ERRORS OF METABOLISM

I

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

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

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

High Risk: Diagnosed inborn error of metabolism


CT-81



GA WIC PROCEDURES MANUAL

Attachment CT-10 (cont'd)

CODE
352 INFECTIOUS DISEASES

PRIORITY I

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

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

Document: Diagnosis, appropriate dates of each occurrence, and name of the physician that is treating this condition; in the participant's health record. When using IDV/AIDS positive status as a nutritionly related medical condition, write "See Medical Record" for documentation purposes.

High Risk: Diagnosed infectious disease, as described above

353 FOOD ALLERGIES

I

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

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

High Risk: Diagnosed food allergy

354 CELIAC DISEASE

I

Presence of celiac disease (also known as celiac sprue, gluten enteropathy, nontropical sprue) diagnosed by a physician, as self-reported by applicant/participant/caregiver; or as reported or documented by a physician or a health professional acting under orders or a physician.

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

High Risk: Diagnosed celiac disease


CT-82



GA WIC PROCEDURES MANUAL .

Attachment CT-10 (cont'd)

CODE 355 LACTOSE INTOLERANCE

PRIORITY
I

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

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

the participant's health record; OR list of symptoms described by the

applicant/participant/ caregiver (i.e., nausea, cramps, abdominal bloating, and/or

diarrhea). With list of symptoms, indicate that ingestion of dairy products causes

these, and avoidance of such products eliminates them.



High Risk: Lactose intolerance

356 HYPOGLYCEMIA

I

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

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

High Risk: Diagnosed hypoglycemia

357 DRUG NUTRIENT INTERACTIONS

I

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

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

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

358 EATING DISORDERS

I

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

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

High Risk: Diagnosed eating disorder

CT-83



GAWICPROCEDURESMANUAL

Attachment CT-10 (cont'd)

CODE 359 RECENT MAJOR SURGERY, TRAUMA OR BURNS

PRIORITY I

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

Document: If occurred in the past 2 months, dates or surgery, trauma and/or bums in the participant's health record. If occurred more than 2 months ago, approximate dates or occurrence, and description of how the surgery, trauma and/or burns currently affects nutritional status; in the participant's health record.

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

360 OTHER MEDICAL CONDmONS

I

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

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

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

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

361 DEPRESSION

I

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

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

CT-84



GA WIC PROCEDURES MANUAL

Attachment CT-10 (cont'd)

CODE
362 DEVELOPMENTAL, SENSORY OR MOTOR DELAYS INTERFERING WITH THE ABILITY TO EAT

PRIORITY I

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

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

High Risk: Developmental, sensory or motor delays interfering wit the ability to eat

371 MATERNAL SMOKING

I

Daily smoking of cigarettes, pipes or cigars.

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

372 ALCOHOL USE

I

Any alcohol use:

A standard serving of a drink containing alcohol (1 ounces of alcohol) is: 1 can or bottle of beer (12 fluid ounces) 5 ounces of wine 1 fluid ounces of liquor

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

Heave drinking is defined as ~5 drinks on the same occasion, on five or more days in the past 30 days.

Document: Enter the number of ounces of alcohoVweek intake on WIC Assessment/ Certification Form.

373 STREET DRUG USE

I

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

Document: Type of drug(s) being used.

CT-85



GAWICPROCEDURESMANUAL

Attachment CT-10 (cont'd)

CODE 381 DENTAL PROBLEMS

PRIORITY I

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

Document: Description of how the dental problems interfere with mastication, and/or have other nutritionally related implications; in the participant's health record.

422 INADEQUATE DIETARY PATTERN

IV

1. Any food group missing, based on the Recommended Daily Servings Chart (Attachment CT-33).

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

3. Practice of two (2) inappropriate food practices, based on the Inappropriate Food Practices List (Attachment CT-34).

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

801 HOMELESSNESS

IV

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

802 MIGRANCY

IV

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

901 RECIPIENT OF ABUSE

IV

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

Battering refers to violent assaults on women.

CT-86



GA WIC PROCEDURES MANUAL

Attachment CT-10 (cont'd)

CODE

PRIORITY

902 PRENATAL WOMAN WITH LIMITED ABILITY TO MAKE FEEDING

IV

DECISIONS AN/OR PREPARE FOOD

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

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

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

502 TRANSFER OF CERTIFICATION

IV

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

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


CT-87



GAWICPROCEDURESMANUAL

Attachment CT-11

NUTRITION RISK CRITERIA POSTPARTUM, BREASTFEEDING WO1\1EN

NOTE: Hi2h Risk Critena, as defined below, are to be used for referral purposes, not certification.

CODE

PRIORITY

201 ANEMIA

I

Non-Smokers:

Hemoglobin: Hematocrit:

11.9 gm or lower (2: 15 years of age) 11.7 gm or lower(< 15 years of age) 35.8% or lower

Smokers:

Hemoglobin: Hematocrit:

12.2 gm or lower (2: 15 years of age) 12.0 gm or lower (< 15 years of age) 36.8% or lower

High Risk: Hemoglobin OR hematocrit at treatment level

102 POSTPARTUM UNDERWEIGHT

I

Postpartum weight is greater than or equal to 10% below the mean normal weight for height OR Body Mass Index (BMI) is <19.8. Refer to Weight for Height Table OR BMI Table, Attachment CT-_3~:}i.

High Risk: Postpartum weight greater than or equal to 10% below normal weight for height, OR BMI <19.8

112 POSTPARTUM OVERWEIGHT

I

Postpartum weight is greater than or equal to 21 % above the mean normal weight for height OR BMI is >26. Refer to Weight for Height Table OR BMI Table, Attachment CT-jQ~3.J{

High Risk: Postpartum weight greater than or equal to 36% above normal weight for height OR BMI >29

133 HIGH GESTATIONAL WEIGHT GAIN

I

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

Pre-Pregnancy Weight Group

Cut-Off Value

Underweight

~O pounds

Normal Weight

~35 pounds

Overweight

~25 pounds

Obese

~15 pounds

Multi-Fetal Pregnancy

~5 pounds

Document: Pre-pregnancy weight and last weight before delivery.

CT-88



GA WIC PROCEDURES MANUAL

Attachment CT-11 (cont'd)

CODE 211 ELEVATED BLOOD LEAD LEVELS
Blood lead level ~ 10 g/
Document: Date of blood test and blood lead level in the participant's health record. Must be within the past 6 months.

PRIORITY I

High Risk: Blood lead level ~ 10 g/deciliter.

303 GESTATIONAL DIABETES (Most Recent Pregnancy)

I

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

Document: Diagnosis in the participant's health record.

311 DELIVERY OF PREMATURE INFANT(S)

I

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

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

312 DELIVERY OF LOW BIRTH WEIGHT INFANT(S)

I

Woman has delivered one (1) ore more infants with a birth weight of 5 pounds 8 ounces (2500 grams) ore less. Applies to most recent pregnancy only.

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

321 FETAL OR NEONATAL DEATH

I

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

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

331 PREGNANCY AT A YOUNG AGE

I

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

Document: Delivery date on the WIC Assessment/Certification Form

CT-89



GAWICPROCEDURESMANUAL

Attachment CT-11 (cont'd)

CODE 332 CLOSELY SPACED PREGNANCIES

PRIORITY I

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

Document: Termination dates of last two pregnancies in the participant's health record.
333 HIGH PARITY AND YOUNG AGE I
The following two (2) conditions must both apply:

1. The woman was under age 20 at date of conception for most recent pregnancy, AND
2. She has had 3 or more pregnancies of at least 20 weeks duration (regardless of birth outcome), previous to the most recent pregnancy

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

335 MULTIFETAL GESTATION

I

Had greater than one fetus in most recent pregnancy.

High Risk: Multi-fetal gestation

337 BIRTH OF A LARGE FOR GESTATIONAL AGE INFANT

I

Birth of an infant with a birth weight of 9 pounds (4000 grams) or more, OR infant diagnosed as large for gestational age by a physician or a health professional acting under orders of a physician. Applies to most recent pregnancy only.

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

339 BIRTH OF INFANT WITH NUTRITION RELATED CONGENITAL OR

I

BIRTH DEFECT(S)

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

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

CT-90



GAWICPROCEDURESMANUAL

Attachment CT-11 (cont'd)

CODE

PRIORITY

341 NUTRIENT DEFICJENCY DISEASES
I Diagnosis of clinical signs of nutrient deficiencies or a disease caused by insufficient dietary intake of macro- and micro-nutrients. Diseases include, but are not limited to, protein energy malnutrition, scurvy, rickets, beriberi, hypocalcemia, osteomalacia, vitamin K deficiency, pellagra, cheilosis, menkes disease, xerothalmia. (See Attachment CT-3i)

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

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

High Risk: Diagnosed nutrient deficiency disease.

342 GASTRO-INTESTINAL DISORDERS

I

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

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

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

High Risk: Diagnosed gastro-intestinal disorder

343 DIABETES MELLITUS

I

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

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

High Risk: Diagnosed diabetes mellitus

CT-91



GA WIC PROCEDURES MANUAL

Attachment CT-11 (cont'd)

CODE 344 THYROID DISORDERS

PRIORITY I

Presence of thyroid disorders (hypothyroidism or hyperthyroidism) diagnosed by a physician, as self reported by caregiver; or as reported or documented by a physician, or health professional acting under orders of a physician.

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

High Risk: Diagnosed thyroid disorder

345 HYPERTENSION

I

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

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

High Risk: Diagnosed hypertension

346 RENAL DISEASE

I

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

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

High Risk: Diagnosed renal disease


CT-92



GA WIC PROCEDURES MANUAL

Attachment CT-11 (cont'd)

CODE
347 CANCER

PRIORITY I

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

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

High Risk: Diagnosed cancer

348 CENTRAL NERVOUS SYSTEM DISORDERS

I

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

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

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

High Risk: Diagnosed central nervous system disorder

349 GENETIC AND CONGENITAL DISORDERS

I

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

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

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

High Risk: Diagnosed genetic/congenital disorder


CT-93



GAWICPROCEDURESMANUAL

Attachment CT-11 (cont'd)

CODE
351 INBORN ERRORS OF METABOLISM

PRIORITY I

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

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

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

High Risk_: Diagnosed inborn error of metabolism

352 INFECTIOUS DISEASES

I

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

Document: Diagnosis, appropriate dates of each occurrence, and name of the physician that is treating this condition; in the participant's health record. When using HIV/AIDS positive status as a nutritionally related medical condition, write "See Medical Record" for documentation purposes.

High Risk: Diagnosed infectious disease, as described above.

353 FOOD ALLERGIES

I

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

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

High Risk: Diagnosed food allergy


CT-94



GA WIC PROCEDURES MANUAL

Attachment CT-11 (cont'd)

CODE 354 CELIAC DISEASE

PRIORITY I

Presence of celiac disease (also known as celiac sprue, gluten enteropathy, nontropical sprue) diagnosed by a physician, as self-reported by applicant/participant/caregiver; or as reported or documented by a physician or a health professional acting under orders or a physician.

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

High Risk: Diagnosed celiac disease

355 LACTOSE INTOLERANCE

I

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

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

High Risk: Lactose intolerance

356 HYPOGLYCEl\tIIA

I

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

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

High Risk: Diagnosed hypoglycemia


CT-95



GA WIC PROCEDURES MANUAL

Attachment CT-11 (cont'd)

CODE 357 DRUG NUTRIENT INTERACTIONS

PRIORITY I

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

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

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

358 EATING DISORDERS

I

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

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

High Risk: Diagnosed eating disorder

359 RECENT MAJOR SURGERY, TRAUMA OR BURNS

I

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

Document: If occurred in the past 2 months, dates or surgery, trauma and/or bums in the participant's health record. If occurred more than 2 months ago, approximate dates or occurrence, and description of how the surgery, trauma and/or bums currently affects nutritional status; in. the participant's health record.

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


CT-96



GAWICPROCEDURESMANUAL

Attachment CT-11 (cont'd)

CODE 360 OTHER MEDICAL CONDITIONS

PRIORITY I

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

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

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

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

361 DEPRESSION

I

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

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

362 DEVELOPMENTAL, SENSORY OR MOTOR DELAYS INTERFERING WITH

I

THE ABILITY TO EAT

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

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

High Risk: Developmental, sensory or motor delays interfering wit the ability to eat


CT-97



GA WIC PROCEDURES MANUAL

Attachment CT-11 (cont'd)

CODE
371 MATERNAL SMOKING

PRIORITY I

Daily smoking of cigarettes, pipes or cigars.

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

372 ALCOHOL USE

I

Routine current use of ~2 drinks per day, OR binge drinking, OR heavy
drinking.

A standard serving of a drink containing alcohol (1 ounces of alcohol) is: 1 can or bottle of beer (12 fluid ounces) 5 ounces of wine 1 fluid ounces of liquor

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

Heave drinking is defined as ~5 drinks on the same occasion, on five or more days in the past 30 days.

Document: Enter the number of ounces of alcohol/week intake on WIC Assessment/ Certification Form.

373 STREET DRUG USE

I

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

Document: Type of drug(s) being used.

381 DENTAL PROBLEMS

IV

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

Document: Description of how the dental problems interfere with mastication, and/or have other nutritionally related implications; in the participant's health record .

CT-98



GAWICPROCEDURESMANUAL

Attachment CT-11 (cont'd)

CODE 422 INADEQUATE DIETARY PATTERN

PRIORITY IV

1. Any food group mi,ssing, based on the Recommended Daily Servings Chart (Attachment CT-3~).

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

3. Practice of two (2) inappropriate food practices, based on the Inappropriate Food Practices List (Attachment CT-:3:f!l

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

501 POSSIBILITY OF REGRESSION

I, IV

Possibility of regression is the likelihood of returning to a nutrition risk that was used during the most recent certification period. This category is only to be used when there are no other nutrition risk factors present, and does not apply to inadequate diet. Use is at the discretion of the competent professional authority.

Document: Reasons for possibility of regression in the "Comments" section of the WIC Assessment/Certification Form.

Regression cannot be used for the initial certification period. 601 BREASTFEEDING AN INFANT AT NUTRITIONAL RISK

I, II, IV

A breastfeeding woman whose breastfeeding infant has been determined to be at nutritional risk.
'
Document: Infant's risks on mother's WIC Assessment/Certification Form.


CT-99



GAWICPROCEDURESMANUAL

Attachment CT-11 (cont'd)

CODE
602 BREASTFEEDING COMPLICATIONS OR POTENTIAL COMPLICATIONS

PRIORITY I

A breastfeeding woman with any of the following complications or potential Complications for brestfeeding: Severe breast engorgement Recurrent plugged ducts Mastiti flat or inverted nipples cracked, bleeding or severely sore nipples
+ age ~0 years
failure of milk to come in by 4 days postpartum tandem nursing (nursing two siblings who are not twins)

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

801 HOMELESSNESS

IV

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

802 MIGRANCY

IV

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

901 RECIPIENT OF ABUSE

IV

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

Battering refers to violent assaults on women.


CT-100



GA WIC PROCEDURES MANUAL

Attachment CT-11 (cont'd)

CODE

PRIORITY

902 BREASTFEEDING WOMAN WITH LilvllTED ABILITY TO MAKE FEEDING

IV

DECISIONS AN/OR PREPARE FOOD

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

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

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

502 TRANSFER OF CERTIFICATION

IV

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

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


CT-101



GA WIC PROCEDURES MANUAL

Attachment CT-12

NUTRITIONAL RISK CRITERIA POSTPARTUM, NON-BREASTFEEDING WOMEN

NOTE: Hi2h Risk Criteria, as defined below, are to be used for referral purposes. not certification.

CODE

PRIORITY

201 ANEMIA

VI

Non-Smokers:

Hemoglobin: 11.9 gm or lower(~ 15 years of age)

11.7 gm or lower (< 15 years of age)

Hematocrit: 35.8% or lower

Smokers:

Hemoglobin: Hematocrit:

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

High Risk:.Hemoglobin OR hematocrit at treatment level

102 POSTPARTUM UNDERWEIGHT

VI

Postpartum weight is greater than or equal to 10% below the mean normal weight for height OR Body Mass Index (BMI) is <19.8. Refer to Weight for Height
Table OR BMI Table, Attachment CT-3()2~1.

High Risk: Postpartum weight greater than or equal to 10% below normal weight for height, OR BMI <19.8

112 POSTPARTUM OVERWEIGHT

VI

Postpartum weight is greater than or equal to 21 % above the mean normal weight for height OR BMI is >26. Refer to Weight for Height Table OR BMI Table, Attachment CT-$Q3J.

High Risk: Postpartum weight greater than or equal to 36% above normal weight for height OR BMI >29

133 HIGH GESTATIONAL WEIGHT GAIN

VI

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

Pre-Pregnancy Weight Group

Cut-Off Value

Underweight Normal Weight Overweight Obese Multi-Fetal Pregnancy

~0pounds ~35 pounds ~25 pounds ~15 pounds ~5 pounds

Document: Pre-pregnancy weight and last weight before delivery.

CT-102



GAWICPROCEDURESMANUAL

Attachment CT-12 (cont'd)

CODE 303 GESTATIONAL DIABETES (Most Recent Pregnancy)

PRIORITY VI

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

Document: Diagnosis in the participant's health record.

311 DELIVERY OF PREMATURE INFANT(S)

VI

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

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

312 DELIVERY OF LOW BIRTH WEIGHT INFANT(S)

VI

Woman has delivered one (1) ore more infants with a birth weight of 5 pounds 8 ounces (2500 grams) ore less. Applies to most recent pregnancy only.

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

321 FETAL OR NEONATAL DEATH

VI

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

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

331 PREGNANCY ATA YOUNG AGE

m

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

Document: Delivery date on the WIC Assessment/Certification Form.

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


CT-103



GAWICPROCEDURESMANUAL

Attachment CT-12 (cont'd)

CODE 333 IDGH PARITY AND YOUNG AGE

PRIORITY

The following two (2) conditions must both apply:

VI

1. The woman was under age 20 at date of conception for most recent pregnancy, AND
2. She has had 3 or more pregnancies of at least 20 weeks duration (regardless of birth outcome), previous to the most recent pregnancy

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

335 MULTIFETAL GESTATION

VI

Had greater than one fetus in most recent pregnancy.

.High Risk: Multi-fetal gestation

337 BIRTH OF A LARGE FOR GESTATIONAL AGE INFANT

VI

Birth of an infant with a birth weight of 9 pounds (4000 grams) or more, OR infant diagnosed as large for gestational age by a physician or a health professional acting under standing orders of a physician. Applies to most recent pregnancy only.

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

339 BIRTH OF INFANT WITH NUTRITION RELATED CONGENITAL OR BIRTH

VI

DEFECT(S)

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

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


CT-104



GAWICPROCEDURESMANUAL

Attachment CT-12 (cont'd)

CODE

PRIORITY

341 NUTRIENT DEFICIENCY DISEASES VI
Diagnosis of clinical signs of nutrient deficiencies or a disease caused by insufficient dietary intake of macro- and micro-nutrients. Diseases include, but are not limited to, protein energy malnutrition, scurvy, rickets, beriberi, hypocalcemia, osteomalacia, vitamin K deficiency, pellagra, cheilosis, menkes disease, xerothalmia. (See Attachment CT-32)

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

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

High Risk: Diagnosed nutrient deficiency disease.

342 GASTRO-INTESTINAL DISORDERS

VI

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

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

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

High Risk: Diagnosed gastro-intestinal disorder

343 DIABETES :MELLITUS

VI

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

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

High Risk: Diagnosed diabetes mellitus

CT-105



GA WIC PROCEDURES MANUAL

Attachment CT-12 (cont'd)

CODE 344 THYROID DISORDERS

PRIORITY I

Presence of thyroid disorders (hypothyroidism or hyperthyroidism) diagnosed by a physician, as self reported by caregi"'.er; or as reported or documented by a physician, or health professional acting under orders of a physician.

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

High Risk: Diagnosed thyroid disorder

345 HYPERTENSION

VI

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

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

High Risk: Diagnosed hypertension

346 RENAL DISEASE

VI

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

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

High Risk: Diagnosed renal disease

347 CANCER

VI

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

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

High Risk: Diagnosed cancer

CT-106



GA WIC PROCEDURES MANUAL

Attachment CT-12 (cont'd)

CODE
348 CENTRAL NERVOUS SYSTEM DISORDERS

PRIORITY

Conditions which affect energy requirements and may affect the individual's

I

ability to feed self, that alter nutritional status metabolically, mechanically, or both.

Includes, but is not limited to: epilepsy, cerebral palsy (CP), and neural tube

defects (NTD) such as spina bifida and myelomeningocele.

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

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

High Risk: Diagnosed central nervous system disorder

349 GENETIC AND CONGENITAL DISORDERS

VI

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

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

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

High Risk: Diagnosed genetic/congenital disorder

351 INBORN ERRORS OF METABOLISM

VI

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

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

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

CT-107



GAWICPROCEDURESMANUAL

Attachment CT-12 (cont'd)

CODE 352 INFECTIOUS DISEASES

PRIORITY

A disease caused by growth of pathogenic microorganisms in the body severe

VI

enough to affect nutritional status. Includes, but is not limited to: tuberculosis,

pneumonia, meningitis, parasitic infection, hepatitis, bronchiolitis (3 episodes in

last 6 months), HIV/AIDS.

The infectious disease MUST have been present in the past 6 months and

diagnosed by a physician, as self reported by caregiver; or as reported or

documented by a physician, or health professional acting under orders of a

physician.



Document: Diagnosis, appropriate dates of each occurrence, and name of the physician that is treating this condition; in the participant's health record. When using IUV/AIDS positive status as a nutritionally related medical condition, write "See Medical Record" for documentation purposes.

High Risk: Diagnosed infectious disease, as described above

353 FOOD ALLERGIES

VI

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

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

High Risk: Diagnosed food allergy

354 CELIAC DISEASE

VI

Presence of celiac disease (also known as celiac sprue, gluten enteropathy, nontropical sprue)diagnosed by a physician, as self-reported by applicant/participant/caregiver; or as reported or documented by a physician or a health professional acting under orders of a physician.

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

High Risk: Diagnosed celiac disease


CT-108



GAWICPROCEDURESMANUAL

Attachment CT-12 (cont'd)

CODE 355 LACTOSE INTOLERANCE

PRIORITY VI

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

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

High Risk: Lactose intolerance

356 HYPOGLYCE1\.11A

VI

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

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

High Risk: Diagnosed hypoglycemia

358 EATING DISORDERS

VI

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

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

High Risk: Diagnosed eating disorder


CT-109



GA WIC PROCEDURES MANUAL

Attachment CT-12 (cont'd)

CODE
359 RECENT MAJOR SURGERY, TRAUMA OR BURNS

PRIORITY VI

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

Document: If occurred in the past 2 months, dates or surgery, trauma and/or bums in the participant's health record. If occurred more than 2 months ago, approximate dates or occurrence, and description of how the surgery, trauma and/or bums currently affects nutritional status; in the participant's health record.

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

360 OTHER :MEDICAL CONDITIONS

VI

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

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

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

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

361 DEPRESSION

VI

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

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

CT-110



GA WIC PROCEDURES MANUAL

Attachment CT-12 (cont'd)

CODE

PRIORITY

362 DEVELOPMENTAL, SENSORY OR MOTOR DELAYS IN1ERFERING WITH

VI

THE ABILITY TO EAT

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

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

High Risk: Developmental, sensory or motor delays interfering wit the ability to eat

372 ALCOHOL USE

VI

Routine current use of ;?:2 drinks per day, OR binge drinking, OR heavy drinking.

A standard serving of a drink containing alcohol (1 ounces of alcohol) is: 1 can or bottle of beer (12 fluid ounces) 5 ounces of wine 1 fluid ounces of liquor

Binge drinking is defined as ;?:5 drinks on the same occasion, on at least one day in the past 30 days.

Heave drinking is defined as ;?:,5 drinks on the same occasion, on five or more days in the past 30 days.

Document: Enter the number of ounces of alcohol/week intake on WIC Assessment/ Certification Form.

373 STREET DRUG USE

VI

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

Document: Type of drug(s) being used,


CT-111



GA WIC PROCEDURES MANUAL

Attachment CT-12 (cont'd)

CODE 381 DENTAL PROBLEMS

PRIORITY VI

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

Document: Description of how the dental problems interfere with mastication, and/or have other nutrition related implications; in the participant's health record.

422 INADEQUATE DIETARY PATTERN

VI

1. Any food group missing, based on the Recommended Daily Servings Chart (Attachment CT-27).

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

3. Practice of two (2) inappropriate food practices, based on the Inappropriate Food Practices List (Attachment CT-28).

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

501 POSSIBILITY OF REGRESSION

VI

Possibility of regression is the likelihood of returning to a nutritional risk that was used during the most recent certification period. This category is only to be used when there are no other nutrition risk factors present, and does not apply to inadequate diet. Use is at the discretion of the competent professional authority.

Document: Reasons for possibility of regression in the "Comments" section of the WIC Assessment/Certification Form.

Regression cannot be used for the initial certification period.

801 HOMELESSNESS

VI

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

802 MIGRANCY

VI

Migrancy as defined in the Special Populations Section of the Georgia WIC

Program Procedures Manual.

CT-112



GA WIC PROCEDURES MANUAL

Attachment CT-12 (cont'd)

CODE
901 RECIPIENT OF ABUSE

PRIORITY VI

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

Battering refers to violent assaults on women.

902 POSTPARTUM, NON-BREASTFEEDING WOMAN WITH LIMITED

VI

ABILITY TO MAKE FEEDING DECISIONS AN/OR PREPARE FOOD

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

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

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

502 TRANSFER OF CERTIFICATION

VI

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

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


CT-113



GAWICPROCEDURESMANUAL

Attachment CT-13

NUTRITIONAL RISK CRITERIA
INFANT

NOTE: Hi2h Risk Criteria, as defmed below, are to be used for referral purposes, not certification.

CODE

PRIORITY

201 ANEMIA

I

Hemoglobin: 10.9 gm or lower (6-11 months of age) Hematocrit: 32.8% or lower (6-11 months of age)

High Risk: Hemoglobin OR hematocrit at treatment level.

103 UNDERWEIGHT

I

Less than or equal to the 10th percentile weight for length, based on the National Center for Health Statistics (NCHS) age/sex specific growth charts.

High Risk: Weight for length $_5th percentile

113 OVERWEIGHT

I

Greater than or equal to the 90th percentile weight for length, based on the NCHS age/sex specific growth charts.

High Risk: Weight for length ~95th percentile

121 SHORT STATURE

I

Less than or equal to the 10th percentile length for age, based on the NCHS age/sex specific growth charts.

High Risk: Length for age $_5th percentile

134 FAILURE TO THRIVE

I

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

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

High Risk: Diagnosed failure to thrive


CT-114



GAWICPROCEDURESMANUAL

Attachment CT-13 (cont'd)

CODE 135 INADEQUATE GROWTH

PRIORITY I

An inadequate rate of weight gain as defmed below:

Infants being certified during period from birth to 1 month of age: Excessive weight loss after birth: in the first week of life, weight loss of
greater than pound OR ~8% (below birth weight) Not back to birth weight by 2 weeks of age A gain of less than 19 ounces by 1 month of age

Note: The average infant should, at minimum, regain birth weight by 2 weeks of age, then gain 4 ounces per week in the next two weeks.

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

This assessment is optional, if an infant who is >1 month but <5 months of

age qualifies for WIC based on any other risk factor. If there is no other reason

to qualify the infant, use the following information to determine eligibility:

Minimum Acceptable

Age

Weight Gain

1 month 1-2 months 2-3 months 3-4 months 4-5 months 5-6 months

19 ounces 27 oz/month (6 oz/wk) 19 oz/month (4 oz/wk) 17 oz/month (4 oz/wk) 15 oz/month (3 oz/wk) 13 oz/month (3 oz/wk)

Infants 6 months to 12 months of age:
Age in Months at Certification

Weight Gain per 6-Month Interval*

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

$. 7 lbs $. 5 lbs $. 3 lbs

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

High Risk: Inadequate growth

141 LOW BIRTH WEIGHT

I

Birth weight 5 pounds 8 ounces (2500 grams) or less.

Document: Birth weight in participant's health record.

High Risk: Birth weight$. 5 lbs 8 oz($. 2500 gms) CODE

PRIORITY

CT-115



GAWICPROCEDURESMANUAL

Attachmenl CT-13 (cont'd)

142 PREMATURITY

I

Infant born at 37 weeks gestation or less

Document: Weeks gestation in participant's health record

153 LARGE FOR GESTATIONAL AGE

I

Greater than or equal to 90th percentile weight for gestational age at birth, OR ~ 9 pounds, OR large for gestational age diagnosed by a physician as self-reported by caregiver; or as reported or documented by a physician, or health care professional working under orders of a physician.

Document: Weight of infant OR diagnosis; in participant's health record.

High Risk: Weight for gestational age~ 90%, OR birth weight~ 9 lbs, OR diagnosis of large for gestational age

211 ELEVATED BLOOD LEAD LEVELS

I

Blood lead level of ~10 g/deciliter

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

High Risk: Blood lead level of ~10 g/deciliter NUTRITION RELATED MEDICAL CONDITIONS

341 NUTRIENT DEFICIENCY DISEASES

I

Diagnosis of clinical signs of nutrient deficiencies or a disease caused by insufficient dietary intake of macro- and micro-nutrients. Diseases include, but are not limited to, protein energy malnutrition, scurvy, rickets, beriberi, hypocalcemia, osteomalacia, vitamin K deficiency, pellagra, cheilosis, menkes disease, xerothalmia. (See Attachment CT-32)

The presence of nutrient deficiency diseases diagnosed by a physician, as selfreported by caregiver; or as reported or documented by a physician, or health professional acting under orders of a physician.

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

High Risk: Diagnosed nutrient deficiency disease.


CT-116

GAWICPROCEDURESMANUAL

Attachment CT-13 (cont'd)



CODE 342 GASTRO-INTESTINAL DISORDERS

PRIORITY I

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

The presence of gastro-intestinal disorders The presence of nutrient deficiency diseases diagnosed by a physician, as self-reported by caregiver; or as reported or documented by a physician, or health professional acting under orders of a physician.

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

High Risk: Diagnosed gastro-intestinal disorder

343 DIABETES MELLITUS

I

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

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

High Risk: Diagnosed diabetes mellitus

344 THYROID DISORDERS

I

Presence of thyroid disorders (hypothyroidism or hyperthyroidism) diagnosed by a physician, as self reported by caregiver; or as reported or documented by a physician, or health professional acting under orders of a physician.

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

High Risk: Diagnosed thyroid disorder


CT-117



GA WIC PROCEDURES MANUAL

Attachment CT-13 (cont'd)

CODE 345 HYPERTENSION

PRIORITY I

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

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

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

I
'

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

High Risk: Diagnosed renal disease

347 CANCER

I

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

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

High Risk: Diagnosed cancer
'


CT-118

GAWICPROCEDURESMANUAL

Attachment CT-13 {cont'd)



CODE
348 CENTRAL NERVOUS SYSTEM DISORDERS

PRIORITY I

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

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

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

High Risk: Diagnosed central nervous system disorder

349 GENETIC AND CONGENITAL DISORDERS

I

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

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

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

High Risk: Diagnosed genetic/congenital disorder

350 PYLORIC STENOSIS

I

Gastrointestinal obstruction with abnormal gastrointestinal function, affecting nutritional status.

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

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

High Risk: Diagnosed pyloric stenosis

CT-119

GAWICPROCEDURESMANUAL

Attachment CT-13 (cont'd)



CODE
351 INBORN ERRORS OF l'v1ETABOLISM

PRIORITY I

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

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

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

High Risk: Diagnosed inborn error of metabolism

352 INFECTIOUS DISEASES

I

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

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

Document: Diagnosis, appropriate dates of each occurrence, and name of the
physician that is treating this condition; in the participant's health record. When
using mv/AIDS positive status as a nutritionally related medical condition, write
"See Medical Record" for documentation purposes.

High Risk: Diagnosed infectious disease, as described above

353 FOOD ALLERGIES

I

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

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

High Risk: Diagnosed food allergy

CT-120



GA WIC PROCEDURES MANUAL

Attachmenl CT-13 (cont'd)

CODE
354 CELIAC DISEASE

PRIORITY I

Presence of celiac disease (also known as celiac sprue, gluten enteropathy, nontropical sprue)diagnosed by a physician, as self reported by caregiver; or as reported or documented by a physician, or health professional acting under orders of a physician.

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

High Risk: Diagnosed celiac disease

355 LACTOSE INTOLERANCE

I

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

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

High Risk: Lactose intolerance

356 HYPOGLYCE:MIA

I

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

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

High Risk: Diagnosed hypoglycemia

357 DRUG NUTRIENT INTERACTIONS

I

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

Document: Drug/medication being used, and respective nutrient interacti<;>n; in participant's health record.

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

CT-121



GAWICPROCEDURESMANUAL

Attachment CT-13 (cont'd)

CODE 359 RECENT MAJOR SURGERY, TRAUMA OR BURNS

PRIORITY I

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

Document: If occurred in the past 2 months, dates of surgery, trauma and/or bums in the participant's health record. If occurred more than 2 months ago, approximate dates of occurrence, and description of how the surgery, trauma and/or burns currently affects nutritional status; in the participant's health record.

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

360 OTHER MEDICAL CONDITIONS

I

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

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

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

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


CT-122

GAWICPROCEDURESMANUAL

Attachment CT-13 (cont'd)



CODE

PRIORITY

362 DEVELOPMENTAL, SENSORY OR MOTOR DELAYS INIERFERING WITH

I

THE ABILITY TO EAT

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

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

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

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

381 DENTAL PROBLEMS

I

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

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

Document: Description of how the dental problems interfere with mastication, and/or have other nutritionally related implications; in the participant's health record.

382 FETAL ALCOHOL SYNDROME

I

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

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

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

High Risk: Diagnosed fetal alcohol syndrome


CT-123

GA WIC PROCEDURES MANUAL

Attachment CT-13 (cont'd)



CODE 422 INADEQUATE DIETARY PATTERN

PRIORITY IV

1. Any food group missing, based on the Recommended Daily Servings Chart (Attachment CT-33).

2. Failure to me~t the recommended number of servings from two (2) food groups.

3. Practice of two (2) inappropriate food practices, based on the Inappropriate Food Practices List (Attachment CT-34.

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

5. Consuming less than the recommended amount of iron-fortified or prescription formula for infants, or consuming a low-iron formula without a prescription and appropriate diagnosis.

603 BREASTFEEDING COMPLICATIONS OR POTENTIAL CO:MPLICATIONS

I

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

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

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

High Risk: Breastfeeding complications or potential complications. Refer for, or provide infant's mother with appropriate breastfeeding counseling.

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

II

WHO WOULD HAVE BEEN ELIGIBLE DURING PREGNANCY

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

CT-124

GA WIC PROCEDURES MANUAL

Attachment CT-13 (cont'd)



CODE 702 BREASTFEEDING INFANT OF A WOMAN AT NUTRITIONAL RISK

PRIORITY
I, II, IV

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

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

703 INFANT BORN TO MOTHER WITH MENTAL RETARDATION, OR

I

ALCOHOL OR DRUG ABUSE DURING MOST RECENT PREGNANCY

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

Document: Diagnosis of mental retardation, OR reported use of alcohol or illegal drugs during most recent pregnancy.

801 HOMELESSNESS

IV

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

802 MIGRANCY

IV

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

901 RECIPIENT OF ABUSE

IV

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

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

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

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

CT-125



GAWICPROCEDURESMANUAL

Attachment CT-13 (cont'd)

CODE

PRIORITY

902 PRIMARY CAREGIVER WITH LIMITED ABILITY TO MAKE FEEDING

IV

DECISIONS AN/OR PREPARE FOOD

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

have a mental disability/delay, and/or a mental illness. such as clinical depression (diagnosed by a physician or licensed psychologist)
have a physical disability which restricts or limits food preparation abilities are currently using or have a history of abusing alcohol or other drugs

Document: Caregiver's limited abilities in the participant's health record. 502 TRANSFER OF CERTIFICATION

I, II, IV

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

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


CT-126



GA WIC PROCEDURES MANUAL NUTRITIONAL RISK CRITERIA CHILDREN

Attachment CT-14

NOTE: Hi2h Risk Critena, as defined below, are to be used for referral purposes, not certification.

CODE

PRIORITY

201 ANEMIA

III

12-23 months of age:

Hemoglobin: 10.9 gm or lower Hematocrit: 32.8% or lower

24 months-5 years of age:

Hemoglobin: 11.0 gm or lower Hematocrit: 32.9% or lower

High Risk: Hemoglobin OR hematocrit at treatment level

103 UNDERWEIGHT

III

Less than or equal to the 10th percentile weight for length, based on the National Center for Health Statistics (NCHS) age/sex specific growth charts.

High Risk: Weight for length $5th percentile

113 OVERWEIGHT

III

Greater than or equal to the 90th percentile weight for length, based on the NCHS age/sex specific growth charts.

High Risk: Weight for length ~95th percentile

121 SHORT STATURE

III

Less than or equal to the 10th percentile length for age, based on the NCHS age/sex specific growth charts.

High Risk: Length for age $5th percentile


CT-127



GAWICPROCEDURESMANUAL

Attachment CT-14 (cont'd)

CODE 135 INADEQUATE GROWTH

PRIORITY
m

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

Age in Months at Certification

Weight Gain in Previous 6-Month Interval*

12 months >12 - 60 months

5 3 pounds 5 l pound

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

High Risk: Inadequate growth

141 LOW BIRTH WEIGHT (Children< 24 months of age)

m

Birth weight 5 pounds 8 ounces (2500 grams) or less.

Document: Birth weight in participant's health record

211 ELEVATED BLOOD LEAD LEVELS

m

Blood lead level of ~10 g/deciliter

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

High Risk: Blood lead level of ~IO g/deciliter

NUTRITION RELATED MEDICAL CONDITIONS

m

341 NUTRIENT DEFICIENCY DISEASES

Diagnosis of clinical signs of nutrient deficiencies or a disease caused by insufficient dietary intake of macro- and micro-nutrients. Diseases include, but are not limited to, protein energy malnutrition, scurvy, rickets, beriberi, hypocalcemia, osteomalacia, vitamin K deficiency, pellagra, cheilosis, menkes disease, xerothalmia. (See Attachment CT-32)

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

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

High Risk: Diagnosed nutrient deficiency disease.

CT-128



GAWICPROCEDURESMANUAL

Attachment CT-14 (cont'd)

CODE
342 GASTRO-INTESTINAL DISORDERS

PRIORITY
m

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

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

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

High Risk: Diagnosed gastro-intestinal disorder

343 DIABETES MELLITUS

m

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

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

High Risk: Diagnosed diabetes mellitus

344 THYROID DISORDERS

m

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

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

High Risk: Diagnosed thyroid disorder

345 HYPERTENSION

m

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

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

High Risk: Diagnosed hypertension

CT-129



GA WIC PROCEDURES MANUAL CODE 346 RENAL DISEASE

Attachment CT-14 (cont'd) PRIORITY
m

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

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

High Risk: Diagnosed renal disease

347 CANCER

m

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

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

High Risk: Diagnosed cancer

348 CENTRAL NERVOUS SYSTEM DISORDERS

m

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

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

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

High Risk: Diagnosed central nervous system disorder


CT-130



GAWICPROCEDURESMANUAL

Attachment CT-14 (cont'd)

CODE
349 GENETIC AND CONGENITAL DISORDERS

PRIORITY
ill

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

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

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

High Risk: Diagnosed genetic/congenital disorder

351 INBORN ERRORS OF METABOLISM

ill

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

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

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

High Risk: Diagnosed inborn error of metabolism


CT-131



GAWICPROCEDURESMANUAL

Attachment CT-14 (cont'd)

CODE 352 INFECTIOUS DISEASES '

PRIORITY III

A disease caused by growth of pathogenic microorganisms in the body severe enough to affect nutritional status. Includes, but is not limited to: tuberculosis, pneumonia, meningitis, parasitic infection, hepatitis, bronchiolitis (3 episodes in
I
last 6 months), IIlV/AIDS. :
I
The infectious disease MUST have been present in the past 6 months and diagnosed by a physician, as self reported by caregiver; or as reported or documented by a physician, or health professional acting under orders of a physician.

Document: Diagnosis, appropriate dates of each occurrence, and name of the physician that is treating this condition; in the participant's health record. When using IIlV/AIDS positive status as a nutritionally related medical condition, write "See Medical Record" for documentation purposes.

High Risk: Diagnosed infectious disease, as described above



353 FOOD ALLERGIES

III

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

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

High Risk: Diagnosed food allergy

354 CELIAC DISEASE

III

Presence of celiac disease (also known as celiac sprue, gluten enteropathy, nontropical sprue) diagnosed by a physician, as self reported by caregiver; or as reported or documented by a physician, or health professional acting under orders of a physician.

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



High Risk: Diagnosed celiac disease 355 LACTOSE INTOLERANCE

CT-132



GAWICPROCEDURESMANUAL

Attachment CT-14 (cont'd)

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

PRIORITY
m

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

High Risk: Lactose intolerance



356 HYPOGLYCEMIA

m

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

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

High Risk: Diagnosed hypoglycemia

357 DRUG NUTRIENT INTERACTIONS

m

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

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

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


CT-133



GA WIC PROCEDURES MANUAL

Attachment CT-14 (cont'd)

CODE
359 RECENT MAJOR SURGERY, TRAUMA OR BURNS

PRIORITY
m

Major surgery, trauma or bums severe enough to compromise nutritional status. Any occurrence within the past 2 months may be self reported, by caregiver. Any occurrence more than 2 months previous MUST have the continued need for nutritional support diagnosed by a physician or health care provider working under the orders of a physician.
Document: If occurred in the past 2 months, dates of surgery, trauma and/or bums in the participant's health record. If occurred more than 2 months ago, approximate dates of occurrence, and description of how the surgery, trauma and/or bums currently affects nutritional status; in the participant's health record.

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

360 OTHER MEDICAL CONDITIONS

m

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

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

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

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

361 DEPRESSION

m

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

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

CODE

CT-134

PRIORITY



GAWICPROCEDURESMANUAL

Attachment CT-14 (cont'd)

362 DEVELOPMENTAL, SENSORY OR MOTOR DELAYS INTERFERING WITH

ill

THE ABILITY TO EAT

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

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

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

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

381 DENTAL PROBLEMS

ill

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

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

Document: Description of how the dental problems interfere with mastication, and/or have other nutritionally related implications; in the participant's health record.

382 FETAL ALCOHOL SYNDROME

ill

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

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

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

High Risk: Diagnosed fetal alcohol syndrome.

CODE

CT-135

PRIORITY



GAWICPROCEDURESMANUAL
422 INADEQUATE DIETARY PATTERN

Attachment CT-14 (cont'd)
V

1. Any food group missing, based on the Recommended Daily Servings Chart (Attachment CT-27).

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

3. Practice of two (2) inappropriate food practices, based on the Inappropriate Food Practices List (Attachment CT-28).

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

5. Consuming less than the recommended amount of formula prescribed.

501 POSSIBILITY OF REGRESSION

ill

Possibility of regression is the likelihood of returning to a nutritional risk that was used during the most recent certification period. This category is only to be used when there are no other nutrition risk factors present, and does not apply to inadequate diet. Use is at the discretion of the competent professional authority.

Document: Reasons for possibility of regression in the "Comments" section of the WIC Assessment/Certification Form.

Regression cannot be used for the initial certification period.

801 HOMELESSNESS

V

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

802 MIGRANCY

V

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


CT-136



GAWICPROCEDURESMANUAL

Attachment CT-14 (cont'd)

CODE

PRIORITY

902 PRIMARY CAREGIVER WITH LIMITED ABILITY TO MAKE FEEDING

V

DECISIONS AN/OR PREPARE FOOD

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

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

Document: Caregiver's limited abilities in the participant's health record. 502 TRANSFER OF CERTIFICATION

m,v

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

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


CT-137



GA WIC PROCEDURES MANUAL .... - .

Attachment CT-15

NOTICE OF TERMINATION/INELIGIBILITY/WAITING LIST FORM

iii
oHR
GEORGIA DEIWnMEKT OF HUMAH RESOUflCES
NAME:

Georg.. Oepar1ment of ........... Resouroes Division of Pub&c Health - WIC Progrmn
NOTICE OF TERMINATION / INELIGIBILITY / WAITING LIST
IDATE:
DATE Of BIRTH:

ADDRESS: CITY/ZIP CODE:

IPHONE NUMBER:

TERMINATION I INELIGIBILITY SECTION:
D You are not eligible for the WIC Program because you: D You are being terminated from the WIC Program because you:

_._ have an income that is too high for the WIC Program _ _ do not IM! in the area served by this WIC Program _ _ are not pregnant, postpartum. or breastfeeding woman; ch~d under five (5) years. _ _ do not have a medical / nutritional health problem. _ _ did not return to the clinic for your recertification appointment on _ _ did not pick-up your food vouchers for two (2) months. Yau will be terminated on
(date). Other _ _ Fund are not available ta serve postpartum non-breastfeeding women.
--
SUSPENSION SECTION:
D You are being suspended from the WIC Program for three (3) months because you broke the following
WIC Program rule(s)

ii
(date).

WAmNG LIST SECTION:

D You are being placed on a waiting list Funds are not a-.aooble to senoe priorityfies)

. You are

in priority

Yau may still receNe nutritional education and other services provided by the Health Department If you need information or would like ta cflSCUSS this decision, please contact the WIC Program at the
address below:

FAIR HEARING SECTION:

You have a right ta a fail' hearing if you do not agree with the reason for your termination / inefigibi1ity or waiting rtSt placement A request for a fair hearing must be made within 60 days of the date of this notice. Fair hearing requests should be acldressed to:

WICPROGRAM ADDRESS CITY/ZIP CODE

/
PHONE NUMBER



PARTIOPANT SIGNAWRE/PARENT/CARETAKER/GUARDIAN

WIC REPRESENTATIVE SIGNATURE/TITLE

This is an Equal Opportunity Program. If you berlE!Ye you have been cfiscriminated against because of race, color, ncrtional origin, age, sex or hancficap, write immediately to the Secretary of Agriculture, Washington, D. C. 20250.

Fann 3293 (Re. 6-95)

CT-138



GAWICPROCEDURESMANUAL

AttachmentCT-16

VERIFICATION OF CERTIFICATION (VOC) CARD

STATE OF GEORGIA DEPARTMENT OF HUMAN RESOURCES
VERFICATION OF CERTIFICATION CARD

PARTICIPANT/PARENT/GUARDIAN SIGNATURE

SIGNATURE OF WIC OFFICIAL

AUTHORIZED PROXY SIGNATURE

COUNTY/CLINIC

TELEPHONE NUMBER

CLINIC ADDRESS

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

.................................................................................PARTICIPANT RIGHTS......................................................................................... . Standards for participation in the program are the same for everyone regardless of race, color, national origin, age, sex, or handicap.

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

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

................................................................................ DERECHOS DE PARTICIANTS ........................................................................... .

Las normal para Ia participacion en el program son las mismas para todas las personas no importa la raza, color, el lugar de nacimiento, edad, sex o fisico o mental impedimento.

Usted puede apelar la decision tomada por la agencia local con respecto a su participacion en el Program.

La agencia local arreglara papa useted la disponibilidad de servicios de salud y de educacion en asuntos de nutricion y se recomienda que Ud. Haga uso de estos servicios.
(Front)

PARTICIPANT CERTIFICATION INFORMATION

PARTICIPANT NAME DATE OF BIRTH CERTIFICATION DATE

LO.NUMBER DATE OF INCOME TAKEN MEDICAL DATA DATE

DATE CERTIFICATION EXPIRES

HEIGHT

WEIGHT

FOOD PACKAGE

PRIORITY

NUTRITION RISK CRITERIA HEMATOCRIT EDCDATE

LAST DATE OF VOUCHER ISSUANCE

LAST DATE OF NUTRmON EDUCATION

FORM 3292 (REV. 1998)


(BACK)
CT-139



GA WIC PROCEDURES MANUAL
CLINIC voe CARD INVENTORY LOG
GEORGIA WIC PROGRAM
voe CARD INVENTORY LOG

Attachment CT-17
DISTRICT_ _ _ _ _ __ CLINIC_ _ _ _ _ __

CARD NUMBERS (RECEIVED)

CARD NUMBER (ISSUED)

PARTICIPNTS NAME
(PRINT)

SIGNATURE PARENT/GUARDIAN
CARETAKER

CITY STATE


WIC l.D. NUMBER

NUMBER OF CARDS ON
HAND

DATE

STAFF
INITIALS

STAFF lNITlALS


NOTE: A physical Inventory of VOC Cards must be performed by the local agency and clinics monthly. One staff member must conduct the inventory (initial the Log) and a second member must verify the accuracy of the inventory (initial the Log also).
* If a migrant is issued a VOC card and I not moving, please placed "Not Moving" on the column marked
City/State.

CT-140



GAWICPROCEDURESMANUAL
LOCAL AGENCY
voe CARD INVENTORY LOG

Attachment CT-18

CARD NUMBERS (fil;CEIVED}

CARD NUMBER {ISSUED}

PARTICIPNTS NAME ~

SIGNATURE PARENT/GUARDIA
NCARETAKER

CITY STATE


WIC I.D. NUMBER

NUMBER OF CARDS ON HAND

DATE

STAFF INITIALS

STAFF INITIALS




CT-141



GAWICPROCEDURESMANUAL

Attachment CT-19

l\1EASURING LENGTH

Age:



Birth to 24 months



24-36 months, if proper position to measure stature cannot be achieved. or with children less

than 35 inches in stature.

Material/Equipment:



Recumbent length board with fixed headboard and movable footboard, both at right angles;

marked in increments of 1/8 inch



Two (2) people required

Procedure:

1.

Check to be sure that moveable foot piece slides easily and the headboard is at the zero (0)

mark.

2.

Remove headgear, shoes and bulky clothing. Instruct caretaker to apply gentle traction to

ensure that the child's head is firmly against the headboard so that the eyes are pointing

directly upward.

3.

With the child positioned so that the shoulders, back and buttocks are flat along the center

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

against the board with one (1) hand to fully extend the child. With the other hand the

measurer should slide the footboard to the child's feet until both heels touch the foot piece.

Toes should be pointing directly upward.

4.

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

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

hand.

5.

Measure length in inches to the nearest 1/8 inch. Repeat the measurement by sliding

footboard away and starting again until two (2) readings agree within 1/4 inch.

6.

Record the second reading promptly.


CT-142

GA WIC PROCEDURES MANUAL

Attachment CT-20



MEASURING HEIGHT

Age:



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



Adults

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

MateriaVEquipment:



Wall mounted or portable stadiometer or metal measuring tape mounted on wall.



A right angle head board marked in increments of 1/8 inch.

Procedure:

1.

Remove all bulky clothing, head and foot wear.



2.

Position the child/adult against the measuring device, instructing the child/adult to stand

straight and tall.

3. Make sure the child/adult stands flat footed with feet slightly apart and knees extended; then check for three (3) contact points: (a) shoulders, (b) buttocks, and the back of the heels.

4.

Lower the moveable head board until it firmly touches the crown of the head. The

child/adult should be looking straight ahead, not upward or down at the floor.

5.

Read the stature to the nearest 1/8 inch.

6.

Repeat the adjustment of the headboard and re-measure until two (2) readings agree within

1/4 inch.

7.

Record the second reading promptly.


CT-143



- -----------

GAWICPROCEDURESMANUAL

Attachment CT-21

:MEASURING WEIGHT

Age:



Infants



Young children up to 35 pounds

Materials/Equipment:



Scales with beam balance and non-detachable weights.



Scales must be calibrated yearly (see Attachment CT-21)

Procedure:

1.

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

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

beam is in zero (0) balance.

2.

Remove shoes and clothes. Remove diaper if wet.

3.

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

4. Move the weight on the main beam away from the zero (0) position (left to right) until the indicator shows excess weight, then move the weight back (right to left) towards the zero (0) position until too little weight has been obtained.

5.

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

the indicator is centered and stationary. (Record weight)

6.

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

ounce.

7.

Record the second reading promptly.


CT-144



GAWICPROCEDURESMANUAL
:MEASURING WEIGHT STANDING

Attachment CT 22

Age:



Children who can stand unattended by an adult



Adults

Materials/Equipment:



Standard platform beam scale with non-detachable weights; marked in increments of at least

1/4 pound or 100 grams



Scales must be calibrated yearly (see Attachment CT-24)

Procedure:

1.

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

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

beam is in zero (0) balance.

2.

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

heavy jewelry. Be sure pockets are empty.

3.

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

must be free standing.

4.

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

weight has been added, then move the weight back towards the zero (0) position (right to

left) until just barely too much weight has been removed.

5.

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

the indicator is centered.

6.

Make sure the child/adult is still not holding on, then record to the nearest 1/4 lb.

7.

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

readings agree within 1/4 pound.

8.

Record the second reading promptly.

Sources:


Georgia Child and Adolescent Health Program Manual. DHR, Division of Public Health; 1987. A Guide to Pediatric Weighing and Measuring, DHHS; 198L
CT-145



GA WIC PROCEDURES MANUAL

Attachment CT-23

EQUIPMENT MAINTENANCE

1.

A yearly calibration of scales is required for proper usage. To arrange for your equipment

to be calibrated, please contract a scale company licensed by the Georgia Department of

Agriculture or each local agency/clinic may calibrate its scales by using the Procedures for

Testing Scales developed by the Georgia Department of Agriculture.

Georgia Department of Agriculture Fuel and Measures Division Agriculture Building, Room 321 Capitol Square Atlanta, Georgia 30334 (404) 656-3605

2.

A yearly calibration of centrifuges and other hematological equipment used to detennine

anemia status of WIC applicants/participants is recommended. There is no State agency

that is responsible for this procedure. Calibration of hematological equipment should

follow manufacturer recommendations. Each local agency/clinic should establish a

. calibration procedure.

3.

It is recommended that hematological equipment be checked for accuracy (balanced)

according to a regular schedule, based on usage. Several methods are available for

checking equipment. These methods include:

A. Spinning one (1) sample of blood twice:

1. Obtain a blood sample and centrifuge it. 2. Read the hematocrit value. 3. Spin the same blood sample a second time. 4. Read the hematocrit value. 5. If the two (2) value readings are the same, the centrifuge is packing/spinning the
red blood cells sufficiently and the centrifuge is calibrated. 6. If the two (2) values are different, the centrifuge is not calibrated and needs to
be serviced.

B. Spinning two (2) tubes of blood collected from the same person, and centrifuging both samples at the same time. Values obtained should be approximately the same.

C. Running a standard solution and obtaining an acceptable reading for that solution.


CT-146



GAWICPROCEDURESMANUAL

Attachment CT-24

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

Record applicant/participant's name.
2. Use"Weight for Height Table" or "Body Mass Index Table" (Attachment CT-23) to determine if the applicant is Normal Weight, Underweight for Height or Overweight for Height, using pre-pregnancy 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 pre-pregnancy weight as indicated. Enter date and weight at each visit.
6. Plot today's weight using the following steps:
a. Record the pre-pregnancy weight at the initial point of the selected weight curve which is located on the left side of the grid at zero (0) point. From the chart or gestation calculator, determine the weeks of gestation.
b. Using the gain (or loss) in weight from the pre-pregnancy weight baseline and the gestational weeks (this visit) place an X on the point at which these two (2) lines meet.
c. If the patient does not know her pre-pregnancy weight, or if the weight she gives seems disproportionate to her current weight, place an X on the dotted line for the calculated gestational week. Let this be a beginnirig 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-147

GAWICPROCEDURESMANUAL

Attachment CT-25

PRENATAL WEIGHT GRID FOR NORMAL WEIGHT AND TWINS



----



WEICHT FOR H1CHT T A.8t.E

FOR OETERMIHlf<C WIC Et.lC<81UTY

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PRENATAL WEIGHT GRID FOR

NORMAL WEIGHT ANO TWINS

-

NAME

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CT-148



GAWICPROCEDURESMANUAL

Attachment CT-26

PRENATAL WEIGHT GRID FOR UNDERWEIGHT AND OVERWEIGHT
....-_-

Wl:'.ICl<T f'OR t<ECCt<T T..r.et.e

f'OR 0ETERMINCNC WIC ELIC:1811.ITY

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1S7

PnENATAL WEIGHT GRID FOR UNOER'NEIGHT ANO OVERW:tGHT

NAME _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ -

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CT-149




GAWICPROCEDURESMANUAL

Attachment CT-27

DIETARY ASSESSMENT

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

Diet assessment forms and/or methods are evaluated by the Office of Nutrition using the following criteria:
of 1. Space for the signature and title of the professional, and the date the diet evaluation.

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

3. A method for documenting inappropriate food practices (see Attachment CT-34).

4. Evidence that the Recommended Daily Servings Chart is the basis for determining missing food groups and failure to meet recommended number of servings (see Attachment CT-33).

5. A method for determining, for infants the amount of breastmilk and/or iron-fortified formula consumed. This should include:

a. For breastfed infants: frequency and duration of feeds, to include frequency and amount of breastmilk consumed from a bottle; number of wet diapers/24 hours; number of stools/24 hours; and detection of audible swallow (as stated by mother, or observed by health care professional).

b. For formula fed infants: frequency of feeds, and amount of formula in each bottle/cup.

6. A method for documenting poor dietary pattem(s).


CT-150



GAWICPROCEDURESMANUAL

Attachment CT-28

INSTRUCTIONS FOR USE OF THE GROWTH CHARTS

1. Select the appropriate chart for sex and age of the individual. When length measurements are taken with the individual lying down use the "Birth to 36 Months of Age" chart.

2. Record name and/or identifying number ofthe chart. Document birth date.

3. The child's age on the date on which measurements are taken must be determined before you start plotting the measurements. To figure out a child's age, follow this example:

Date of Measurement Birth date Child's Age

Year Month

1981

4

-1975

~

5

8

or 5-3/4 years

Day 21 -10 11 days

As this example shows, you may have to borrow thirty (30) days from the month column and/or 12 months from the year column when subtracting the child's birth date from the date on which the measurements are taken.



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

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

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

Rounding Method:

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

2-18 Years Growth Chart - Calculate age to the nearest 1/4 year and plot on the corresponding line.


CT-151



GAWICPROCEDURESMANUAL

Attachment CT-28 (cont'd)

To round off the child's age, follow these rules:

0-15 days 16 -31 days 0- 1 month 2- 4 months 5- 7 months 8- l0months 11 - 12 months

-round off tc:i the previous month -round off to the next highest month -round off to the previous whole year -round off to 1/4 year -round off to year -round off to 3/4 year -round off to the next whole year

5. To plot the length or height for age and weight for age charts:

a. Follow a vertical line at the appropriate age.

b. Using a straight-edge, line up as closely as possible to the measured length or height and weight and mark the point where the two (2) lines intersect.

c. Write the date above the point.

6. To plot the length of height/weight chart:

a. Follow a vertical line at the point of the correct length of height.

b. Using a straight-edge, line up as closely as possible to the weight and mark the point where the two (2) lines intersect.

c. Write the date on the point.

7. To plot an infant's head circumference:

a. Follow a vertical line as near as possible to the appropriate age.

b. Using a straight-edge, line up as closely as possibly the measured head circumference and mark the point where the two (2) lines intersect.

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


CT-152



GAWICPROCEDURESMANUAL

Attachment CT-29

WEIGHT FOR HEIGHT TABLE FOR DETERMINING WIC ELIGIBILITY*

Height 4'10" (58") 4'11" (59") 5'0" (60") 5'1'' (61 ") 5'2" (62") 5'3" (63") 5'4" (64") 5'5" (65") 5'6" (66") 5'7" (67") 5'8" (68") 5'9" (69") 5'10" (70") 5'11" (71") 6'0" (72")

Underweight 91 94 96 99 102 104 108 111 115 118 122 126 129 133 136

Normal Weight 92-122 95-125 97-128 100-132 103-136 105-139 109-144 112-148 116-153 119-158 123-163 127-168 130-173 134-177 137-182

Overweight 123 126 129 133 137 140 145 149 154 159 164 169 174 178 183

.

..

..O. b:..e.s.e. ..,.

..: .t3s

':;:, ....

':.141
.. . '
:-14(>
- . , - : ,
;
150
, ..
154

. .
:
.

158

.. ... ,

Ii...

: .J6i

...

167 :..: .... ., ..

,.. . . ... .:.
, ' '.

.

.,:
.: ;,,:

173. ' .. . .,,.

II:i ..... . ". 179: ...

:;

<:1:si 1

., ;;:,; .,...;,
..
:;;

..,

..
:,..;:;.;..,:;-'..'.,;.:.'..,::.:t;{:.,-

;i90. .
;, ., '....-.~:,;

.. ,

..
....

.

\);;..,,: ., .. )J9'? ..,i .. "'

" .... ::;-,:, ... ,,.,,.,...,.... ..

.,. :::\:.::j~ot .

,.. ..,

...,c ... :

... . :: .... ....

,' .. ,,;

} .-::-/:; ::: .. ,206. .. '. :

* Table developed using the mean weight in the "medium frame weight range," and calculating 10% below, 21 % above and 36% above.

1. Measure height in inches, without shoes. 2. Measure weight in pounds. Allowance provided for indoor clothing.

Reference: Prepared by the Office of Nutrition, Division of Public Health, Georgia Department of Human Resources, October 1998. Based on the 1957 Metropolitan Life Tables.


CT-153



GAWICPROCEDURESMANUAL

Attachment CT-30

WEIGHT FOR HEIGHT TABLE FOR WOMEN, BASED ON THE BODY MASS INDEX (BMI)*

Height 4'10" (58") 4'11" (59") 5'0" (60") 5'1" (61 ") 5'2" (62")

Underweight 95 98 101 105 108

Normal Weight 96-123 99-128 102-132 106-137 109-141

Overweight 124 129 133 138 142

...

,-

: >Obese:.

,139.>.. :.

144 :.., .
..

:149,::). .

:

1,,; :-',: ;' ..

: ..

; .-c: :.:1.s4: :

..

,...,

159'

5'3" (63")

112

113-146

147

164

5'4" (64")

115

5'5" (65")

119

5'6" (66")

123

5'7" (67")

126

5'8" (68")

130

5'9" (69")

134

5'10" (70")

138

5'11" (71 ")

142

6'0" (72")

146

116-150 120-155 124-160 127-165 131-170 135-175 139-180 143-185 147-190

151

169

156 161

.. '.

..
174.''' -~ ..,. ,, . '"' , ..

. ~
; .,

.. :x~f. :<: 1:.,. : ; :i'. .

i"'' ,,,:.;._._,
. :.! : ........

.

166

I

.:.,.

,,..

171

<:}9:i: :0'
.....

176

196

181

::'202 :::,:::':'.';.:.;,-,;.

' .. ' : ..
:f.:::;;:/:

186 191

l)ir) '"'!)~9t .... ',.'

Yzlt:i{''i,i. i .. .: : ..
,, : : :

..::::::::::: : <

k .... ... . ,.,,......:,:,-.. . .

*BMI = lbsfm2 x 703

Underweight is defined as:< 19.8 Overweight is defined as:> 26 Obese is defmed as:>29


CT-154

GAWICPROCEDURESMANUAL

Attachment CT-31



PHYSICAL SIGNS SUGGESTIVE OF NUTRIENT DEFICIENCIES

Bodv Area Normal Appearance

Signs Suggestive of Nutrient Deficiency(ies)

Nutrient Consideration(s)

Hair

shiny; firm; not easily

plucked

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

inadequate protein and calories

Eyes

bright; clear; shiny; no

eye membranes pale;

anemia (inadequate iron,

sores at comers of eyelids;

folacin, or Vitamin B-12)

membranes healthy pink and

Bitot's spots; red membranes; dryness of membranes

moist; no prominent blood

dull appearance of cornea (cornmeal xerosis);

inadequate Vitamin A

vessels

softening of cornea (keratomalacia);

inadequate riboflavin,

redness and fissuring of eyelid comers

Vitamin B-6, and niacin

Lips

smooth; not chapped or

swollen

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

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

Gums

healthy; red; do not bleed; not swollen

spongy; bleeding; receding

inadequate ascorbic acid

Tongue

deep red; not swollen or smooth

Face and Neck

skin color uniform, smooth, pink; healthy appearing; not swollen

scarlet; raw; edematous (glossitis)

inadequate niacin, riboflavin,

folacin, iron, and Vitamins

B-6 and B-12

purplish color (magenta);

inadequate riboflavin

smooth; pale; slick; atrophied taste buds (papillae) inadequate folacin,

Vitamin B-12, iron and

niacin

diffuse depigmentation;
darkening of skin over cheeks and under eyes; scaling of skin around nostrils (nasolabial seborrhea)

inadequate protein inadequate calories and niacin inadequate riboflavin, niacin, and Vitamin B-6

swollen (moon) face; front of neck swollen (thyroid enlargement) swollen cheeks (bilateral parotid enlargement)

inadequate protein inadequate protein inadequate iodine inadequate protein

Skin

no signs of swelling, rashes,

dry and scaly (xerosis); sandpaper-like feel

inadequate Vitamin A or

dark or light spots

(follicular hyperkeratosis);

essential fatty acids

pinhead-size purplish skin hemorrhages

inadequate Vitamin C

(petechiae);

excessive bruising;

inadequate Vitamin K

red, swollen pigmentation of areas exposed

inadequate niacin and

to sunlight (pellagrous dermatitis);

tryptophan

extensive lightness and darkness of skin (flaky,

inadequate protein,

pressure sores (decubiti)

Vitamin C, and zinc

Teeth Glands

no cavities, no pain, bright face not swollen

may be some missing or erupting abnormally; gray inadequate Vitamin D

or black spots (fluorosis); cavities (caries)

inadequate Vitamin A

[signs are to be severe enough to interfere with

mastication and/or other health implications]*

thyroid enlargement (front ofneck); parotid enlargement (cheeks become swollen)

inadequate iodine inadequate protein


CT-155

GA WIC PROCEDURES MANUAL

Attachment CT-31 (cont'd)



Body Area Normal Appearance

Nails

firm, pink

Muscular and skeletal systems

good muscle tone; some fat under skin; can walk or run without pain

Signs Suggestive of Nutrient Deficiency(ies)

Nutrient Consideration(s)

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

inadequate iron Vitamin A toxicity

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

inadequate protein

are thin and soft (craniotabes); round swelling of

inadequate thiarnin

front and side of head (frontal and parietal bossing);

inadequate Vitamin D

swelling of ends of bones (epiphyseal enlargement);

small bumps on both sides of chest wall (on ribs)

beading of ribs; baby's soft spot on head does not

harden at proper time (persistently open anterior fontanelle);

knock-knees or bow-legs; bleeding into muscle (muscular-

skeletal hemorrhages); person cannot get up or walk properly

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




CT-156

GA WIC PROCEDURES MANUAL

Attachment CT-32



RECOMMENDED DAILY SERVINGS CHART

Food Group
Milk, Yogurt &Cheese
Mea~ Poultry, Dry Beans, Eggs, Nuts Group Fruit Group

Birth to 5/6 Mouths
Brcasunilk, every 2-3 hrs or Iron fortified formula, 2.5 oz/lb (18-35 ozs)
None
None

S/6 Mouths to I Year
Breasunilk, every 2-4 hrs or Iron fortified formula, 2.5 oz/lb (24-35 ozs)
Add after 6 months and before 9 months
Add after 6 months and before 9 months

Vegetable Group

None

Add after 6 months and before 9 months

Bread, Cereal, Rice & Pasta Group

None

Add iron Fortified cereal at 5-6 months

Other

None

None

I Portion size is reduced by approximately 113rd, except for milk 2 Pregnant and breastfeeding teenagers need 4 servings 3 Women 24 years and under need 3 servings 4 Recommended serving sizes:
Milk, Yogurt & Cheese Group: 1 Serving=
1 cup milk/yogurt 11/2 ounces natural cheese(i.e. cheddar, colby, longhorn) 2 ounces processed cheese(i.e. amcrican. swiss) 11/2 cup ice cream 2 cups cottage cheese
Meat, Poultry, Dry Beans, Eggs, Nuts Group: Other foods from this group count as 1 ounce of lean meat 1 serving=
I egg 1/3 cup nuts cup cooked dry beans 2 tablespoons peanut butter

1-3 Year old1
2 servings (16 ounces total)

4-6 Year old'
2 servings (I6 ounces total)

Pregnant Teen/ Pregnant Adult'
3-4 servings'

3 ounces

5 ounces

6 ounces

2 servings I serving= 3Tcooked/ pieces fruit cjuice

2 servings_

3 servings I serving= 3Tcooked or chopped 2/3 craw leafy

3 servings

6 servings I serving= slice or 1/4 c cooked cdry
cereal

6 servings

As needed to meet RDA for energy

3 servings 4 servings 9 servings

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

BFTeeo/ BF Adult' 3-4 servings2
6 ounces 3 servings
4 servings
11 servings

Teen PP/ Adult PF' 2-3 servings'
5 ounces 2 servings
3 servings
6 servings


CT-157




GA WIC PROCEDURES MANUAL

Attachment CT-33

INAPPROPRIATE FOOD PRACTICES

Inappropriate Food Practices for Women, Infants, and Children:

1. Use of nutritional supplement(s) in excess of 100% of the RDA's other than those prescribed by physician. (1)

2. Any practice of pica. (1)

Additional Inappropriate Food Practices for Prenatal Women:

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

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

Additional Inappropriate Food Practices for Breastfeeding Women:

Intake of 300 mg or more of caffeine per day.(10)

Additional Inappropriate Food Practices for Infants:

1. Use of an infant feeder. (1)

2. Routinely drinking from bottle while lying down. (1)

3. Liquids and/or food in the bottle except for formula, breast milk or water. (1)

4. Inappropriate formula preparation. (1)

5. Introduction of solids prior to 5 months of age. (1, 2)

6. Food consistently used as a pacifier or reward for the infant. (1)

7. Introduction of mixed food groups prior to the introduction of the ingredients singly. (2)

8. Unflavored water not offered daily, once diet intake includes anything other than breastmilk/infant formula. (1)

9. Feeding any amount of honey to infants under 1 year of age (added to liquids or solid foods, used in cooking, as part of processed foods, on a pacifier, etc.). (11)

Additional Inappropriate Food Practices for Children:

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

2. Unflavored water not offered daily. (1)

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

CT-158




GA WIC PROCEDURES MANUAL

Attachment CT-33 (cont'd)

References for Inappropriate Food Practices

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

(1) Office of Nutrition, Division of Public Health, Georgia Department of Human Resources: Nutrition Guidelines for Practice. 1997.

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

(3) American Dietetic Association: Meal Time! Happy Time! A Guide for Parents. Chicago, Illinois.

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

(5) Berger, Alvin: Effects of Caffeine Consumption on Pregnancy Outcome. Joumal of Reproduction Medicine, 33 (12):945-956, 198~.

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

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

(8) Georgia Dietetic Association, Inc., Diet Manual, Fourth Edition, 1992.

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

(10) National Academy of Sciences, Institute of Medicine: Nutrition During Lactation. Washington, D.C., 1991.

(11) FNS-288: Infant Nutrition and Feeding; 1993.

CT-159



GAWICPROCEDURESMANUAL

Attachment CT-34

GEORGIA WIC PROGRAM REFERRAL FORM

Gawgi,WICl'n>gnm RcfcmdForm

USDA policy does not permit discri.Jnuuuioa bcc4usc of tllCC, color,

rwiono.l origin,. sex, a&c or handicap. Any pcnoa wbo believes be she

_,__________________________________________________________ Dt11eof8inb:

bllll bc:c:a discriminated agninsl i.n a.'ly USDA rdaicd 11c:tivity should write immediately to the Sccretmy or Agric:ultu.rc, Washington, D.C. 20250.

Do.ccMemurcmcntsObwncd: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Daae:

Current Height

Hcawocrit

Hcm,globin,

Any nurritiorually rclar.cd moclical conditions?

No

If yes, ,p,cify

Any clinic.Al manifestwoas of mala.writioa?

No

Any dmtw problems seven: CQOQgb to interfere with ma.sticalion1

No



Anycvidcn,cc oflcad poisoning?

WOMENEODNCL/YDdivayDmc: _ _ _ _ _ _ _ _ _ __

Blood Pressure: Number of Previous Pneg,um<iu _ _ _ _ LlvcBirtm _ _ _ _ __

INFANTS ONLY Brcu1feeding,

y.,

No

Birch weight::

Weeks GestllUOO:

HEALTH PROFESSIONAL

Signalmc/Tide

Currcndy 8rcAJtfcccling: O~Taken:
M--.Abmtioa, - - - - - - -

Prcgruvid Weight _ _ _ _ _ _ __

Birtbkog,I<_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Ai;cnoyTelq>bonc _ _ _ _ _ _ _ _ _ _ _ __

Ye,

No

Ye,

No



CT-160



GAWICPROCEDURESMANUAL

Attachment CT- 35

GEORGIA WIC PROGRAM INCOME ELIGIBILITY GUIDELINES (Effective from April 15, 1999 to April 15, 2000) 48 CONTIGUOUS UNITED STATES, DISTRICT OF COLUMBIA,
GUAM AND TERRITORIES

Household Size
1 2 3 4 5 6 7 8 For each additional family member add

Reduced Price Meals - 185% of Federal Poverty Guidelines

Annual
15,244 20,461 25,678 30,895 36,112 41,329 46,546 51,763 +5,217

Month
1,271 1,706 2,140 2,575 3,010 3,445 3,879 4,314 +435

Week
294 394 494 595 695 795 896 996 +101



CT-161



GA WIC PROCEDURES MANUAL

Attachment CT- 36

GEORGIA WIC PROGRAM
voe CARD AGREEMENT
District ___, Unit ___ would like to have a clinic representative order VOC Cards direct from the State WIC Office.
In order to accommodate this request, the attached form (Attachment II Cont'd) must be completed.



Signed_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ WIC Program Coordinator

Date- - - - - -

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



CT-162



GAWICPROCEDURESMANUAL
voe CARD FORM

Attachment CT-37

District_, Unit_

VOC Card Form

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

1. Please list the information requested below:

CLINIC NAME/#

# OF voe CARDS ISSUED
(Three Month Period)

STAFF PERSON
Clinic Representative





2. How many cards do you currently have on hand at the District Office? _ __
NOTE: nns SURVEY IS A ONE TIME SURVEY TO BEGIN THIS PROCESS
CT-163



WICPROCEDURESMANUAL

Attachment CT-38

CENTRAL SUPPLY REQUISITION

I . . GEORGlA.

OEPARTill'IEl\ll"

O

F

HUMAN .

.RESOURCES

CENlRAL SUPPLY REO.UtSmOl'I

.

Suite .J

.





1150 Mutpf1v Aw:nue: S.W. Adanta. Georgia 30310

INVOICE N. 0.7 3 2 2 2 9

j INVOIO:NO. 732229

SENOTO: _________.,....,,..,,e-:-------(Namc ol OfCccl

COUNTY:;..-------,,...,....-=---- ---

(Natnc:J

~

(NameafOMsoll (Stn:et Address O<' S1:1tc Of(cc Room Numbct1

CAl"E: .

LLJ--=-LLJ-l..J..J

~ N W-1 , , l~I....,.........1L.u

(Sate)

(2,pCode)

C>MSlOO IO NUM8ER:

I I

EXPt.ANATION OF CODES

BO ~ER-00 NOT REORDER C QUANTITY CUT/Pl.EASE REOROER N NOT STORED tN CENTRAL SUPPLY

r I R REfERREO l REPRoouce l.OCAU.Y

:

..J RUED

I o I OtSCONnNUED

:

V VO<O. PRBttOUSlY SHlP?EO

.CHEO:: ONE: Offo: Supply 10Xl00

f-ocmsSupply

formfb.,lttattNa.

U-.tol b:sue

0r.latUity

Code

~

.

:

. .

.

.

.

.

-



.
-

FOR CENTRAL SUPPLY USE OM.Y
OROER08Y:
TELEPHONE:

STOO:NO.
1000000450 1000000451 1000000452

OOIT OF ISSUE
EA EA EA

UNITCOST

(Name)

.

QTY.

~ C00E

C00E oe.souP'l10r

l
, , 1 Li..J-1 ' l

l-l.L..J..J-1 I I

U'S(:3-ZZ~ Pa..:df'ost ~

FOR CENTRAL SUPP!.Y USE OM.Y

(Gist. NoJ

(Arc~ Code)

(Pt,oneNa.J .

Form S014 (Rev. l<HISJ

sevo ORIGINAL AND ~ COP!ES ro c&ffRAI. SUPPt..Y
TERMtNAL COPY
CT-164



GAWICPROCEDURESMANUAL

Attachment CT-39

STATE/DISTRICT/CLINIC TRANSMITTAL FORM

GEORGIA DEPARTMENT OF HUMAN RESOURCES
STATE/DISTRICT/CLINIC TRANSMITTAL FORM

The State/District Clinic Transmittal Form is a three (3) part form used to transmit VOC Cards from the State WIC Office to the Clinic. This Form must be signed by clinic staff within five (5) days of Receipt then returned to sender. The State WIC Office will forward orders of VOC Cards within five (5) days of receipt.

State Use Only

District - Name/#: - - - - - - - - - - - - - - - - - - - - - - - - - -

- - - - - - - - Clinic Name/ #:
Staff Name/Title Making Request: _

_ -

-_-_-_-_-_-_-_-_-_-_-_-_-_-_-_-_-_-_-

Date of Request: _ _ _ _ _ _ _ _ _ _ _ # of Card(s) Sent: _ _ _ _ _ _ __

Signature of Requesting State Staff: _____________________ Serial# of Card(s) Mailed: _ _ _ _ _ _ _ _ to: _ _ _ _ _ _ _ _ _ _ _ __

Clinic Use Only
Date VOC Card(s) Received: _ _ _ _ _ _ _ __
Date
# of Card(s) Received: _ _ _ _ _ _ _ _ _ _ __
Serial# of Card(s) Received: _ _ _ _ _ _ _ _ _ _ to: _ _ _ _ _ _ __
Signature of Staff Requesting/Receiving VOC Card(s):

Signature
Date Copy Sent to State/District Office: ____________
Date

Form 3699 (12-95) White Copy - State WIC Office

Canary - Clinic

Pink District



CT-165

GAWICPROCEDURESMANUAL

Attachment CT-40



MEDICAID
INFORMATION

Right from the Start Medicaid (RSM)

What is Right from the Start Medicaid?

RSM provides Medicaid coverage for pregnant women and children under the age of 19. Income limits are higher than those of Temporary Assistance to Needy Families (TANF) and Medically needy programs. Working families may be eligible even if both parents live in the home or if other insurance coverage is in place.



How do I Apply? Persons should contact their county Department of Family and

Children Services (DFCS) or their county health department.

Outreach workers will also take applications at other community

locations and will make home visits if necessary. RSM staff

members are available during non-traditional hours (before 8 a.m.

and after 5 p.m., including weekends) so that work, school, and

childcare are not a problem.

For more information on application sites, please contact your local health department or the Right from the Start Medicaid Project office:
(404) 657-4085 .



CT-166

GA WIC PROCEDURES MANUAL

Attachment CT-41



THERE IS NO CHARGE

FOR WIC SERVICES

OHR
Georgia

Department of

Human Resources


Georgia WIC Program
Promoting healthy nutrition for Women,
Infants and Children since 1974
1-800-228-9173
"This is an Equal Opportunity Program. If you believe you have been discriminated against because of race, color, national origin, sex, age, or handicap, write immediately to the Secretary of Agriculture, Washington, D.C. 20250."



CT-167



GA WIC PROCEDURES MANUAL
Georgia WIC Program LETTER OF HOUSEHOLD INCOME

Attachment CT-42

Household Section:

I, _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _, have the person listed below living with me.
Print Name

Name of WIC Applicants:

Address:



Including the applicant listed above, I have _ _ _ _ _ _ of people in my family. ("Family" means related
or non-related individuals living together)
I give the above listed applicant permission to bring my family's documentation of income (example: pay stub), residency and I.D. to the Georgia WIC Program. This information is attached.

Signature

Date

Address: _ _ _ _ _ _ _ _ _ __

City: _ _ _ _ _ _ _ _ _ _ _ State: _ _ _ _ Zip Code: _ _ _ _ _ _ _ _ _ __

Telephone No.: _ _ _ _ _ _ _ _ _ __

Clinic Section: This form must be returned on _ _ _ _ _ __ to

WIC Official WIC Official

Date Date Received

WE RESERVE THE RIGHT TO VERIFY THIS INFORMATION, IF NECESSARY. "The USDA is an equal opportunity provider and employer."



Form 3019

CT-168



GAWICPROCEDURESMANUAL

Attachment CT-43

GEORGIA WIC PROGRAM NO PROOF FORM

The Georgia WIC Program requires each applicant to show documentation of identification, residence (address), and income to be eligible for the WIC Program. This form is to be completed by those who can not get documentation, such as paycheck stub. Please read the following statement before completing this form.

I understand that by completing, signing, and dating this form, I am certifying that the information I am providing below is correct. I understand that intentional misrepresentation may result in paying the state agency, in cash, the value of the food benefits improperly received.

1. Completion of this form is for: Income Address Identification (circle the appropriate proof (s))

2. Who do you work for?

How much did you make last month?
$ _ _ _ _ _ _ _ _ _ _ _ __

List working family members?

How much did they make last month?
$ _ _ _ _ _ _ _ _ _ _ _ _ __

$ _ _ _ _ _ _ _ _ _ _ _ _ __

$ _ _ _ _ _ _ _ _ _ _ _ _ __ (Family means related or not-related individuals living together)

3. Reason for No Documentation:

List family members applying for WIC: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __



(Signature of Applicant)

(Date)

(Signature of Clinic Staff)

(Date)

"The USDA is an equal opportunity provider and employer."

CT-169



GAWICPROCEDURESMANUAL

Attachment CT-44

BENEFIT DESCRIPTION

CO-PAY

COPAYS

RX USE ONLY

FamilyPlus*

ov

$ 0 I BIN # 600426

SP $ 0

I PCN # 6F

ER

$ 0 I 1 (800) 433-4893

UC

$0 I

RX

$0 I

I

* CALL YOUR PCP TO COORDINATE *

*ALL OF YOUR HEALTHCARE NEED

:tv!EMBER# 403967045P

EFFDATE 02/01/98

GROUP# MOOlOl BIRTH SEX TIE

:tv!EDICAID OF GA 06/03/94 F

AFD

(404) 525-0600

ATLANTA CHILDREN'S HEALTH NETWORK

* The family of health plans that fits.





CT-170



GA WIC PROCEDURES MANUAL

Attachment CT-45

HEALTH DEPARTMENT/CLINIC REPORT FORM

Employee/Staff who participate in the WIC Program or have relatives or household members who participate in the WIC Program must complete this form.
County _________

Name (Please print) _ _ _ _ _ _ _ _ _ _ __ Title - - - - - - - - - -

Are you a WIC Participant? _____ Yes - - - - - - - No
Do any of the following relatives or household members participate in the WIC Program?

- - - - Yes

- - - - No

Children, grandchildren, sisters, brothers, nieces, nephews, aunts, uncles, parents, spouses, first cousins, in-laws or any person who lives in your household.

If you answered "Yes" to either of the above questions, please complete the form below.

Name of your relative or household member

Relationship* Date of Cert.



(If more space is needed, list ori back)
* Children, grandchildren, sisters, brothers, nieces, nephews, aunts, uncles, parents, spouses, first cousins, in-laws or any person who lives in your household.
I Certify that the above information is correct.

Signature/Title

Date

CT-171





GAWICPROCEDURESMANUAL
GEORGIA WIC PROGRAM INCOME CALCULATION FORM
(This fonn must be compleud itaoy applicant doos no! qualified for Adju-ve eligibility)

Attachment CT-46

-- WIC ID NUMBER:

Ctn' ADDRRESS._ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

DocumentaUon ofIncome must be e,,mpleted for an applicant who does not quaOfy for adjunctJve eligibility.

Use This SecUon to Cfttwfate taeome

Date_ _ _ _ _ _ _ _ _ __

Relationship and Name

Income Soun:e

Wllat Is &ch Family Member's Income?

(cln:loOMJ

s

Weeldy/81.Weekly/Momhly/Yearty

s

Weekly/Bl.Weekly/Monthly/Yearly

s

Weekly/Bl.Weekly/Monthly/Yearly

s

Weekly/Bl.Weekly/Monthly/Yearly

s

Weekly/BI.Weekly/Monthly/Year1y

Other Income Is there other regular Income or contributions received by the family (I.e. unemployment. child support)?

s

Weekly/81.Weekly/Monthly/Yearfy

s

Weeldy/81.Weekly/Monthly/Yearfy

_s_ _ _ _ _ _ _ Total Applicant's Income (Weekly/Bl-Weekly/Monthly/Yearly)

No. In Family_ _ __

IS THE CUENT INCOME ELIGIBLE? YES NO

(Transfer total to the Certification Fonn}

Relatlonshlp and Name

Use This Sf:dioa to t;alt:ulate Income
Income

,__, Date___________

Source

What Is &ch Family Member's Income?

s

Weeldy/81.Weeldy/Monthly/Yearty

s

Weekly/81.Weeldy/Monthly/Yearfy

s

Weekly/Bf.Weekly/Monthly/Yearly

s

Weekly/Bl.Weekly/Monthly/Yearly

s

Weekly/Bi.Weekly/Monthly/Yearfy

Other Income Is there other regular Income or contributions received by the family Le. (unemplayment. child support)?

s

Weekly/81-Weeldy/Monthly/Yearfy

s

Weeldy/81-Weekly/Monthly/Yearfy

_s_ _ _ _ _ _ _ Total Applicant's Income (Weekly/Bi-Weekly/Monthly/Yearly)

No. In Family_ __

IS THE CLIENT INCOME ELIGIBLE? YES NO

(Transfer total to the Cerlificatlon 'Fonn}

I have been advised of my rights and obllgatlons under the Program. I certify that the Information I wlll provide, or have'provided Is correct. to the best of my knowledge. The Income I have given Is my total gross household Income (aD cash Income befon, deductions). This certification form Is being submitted In connection with the receipt of Federal assistance. Program officials may verify Information on this form. I understand that lntentlonaDy mal<lng a false or misleading statement or Intentionally misrepresenting. concealing, or withholding facts may result In paying the State agency, In cash, the value of the food benefits lmpn,perly Issued to me and may subject me to civil or cnmliw prosecution under State and Federal law. I understand that the WIC Program may give my certification Information to other health or public assistance agencies to see ff my tamlly Is eligible for their services. I understand that these agencies may contact me, but they may not give my Information to anyone else without asking my permission.

PARENT/GUARDIAN/CAREGIVER SIGNATURE

DATE

SIGNATURE OF WIC OFFICIAL /WIIOHHsud-)

Please place this fOtTT1 in the Client's Medical Record behind the Certification Form

CT-172





GA WIC PROCEDURES MANUAL TABLE OF CONTENTS

Page

I.

Rights and Obligations of WIC Applicants/Participants .................................. RO-1

II.

Nondiscrimination Clause ................................................................................ RO-3

ill.

Public Notification ........................................................................................... RO-5

IV.

Civil Rights ...................................................................................................... RO-6

A. "And Justice for All" ............................................................................ RO-6

B. Training ................................................................................................ RO-6

C. Racial/Ethnic Identification .................................................................. RO-6

D. Collection of Racial Ethnic Data.......................................................... RO-6

E. Discrimination Complaints .................................................................. RO-7

1.

Written Complaints .................................................................. RO-7

2.

Verbal Complaints....................................................... :............ RO-7

V.

Fair Hearing Procedures - Participants ............................................................. RO-9

A. Hearing Official .................................................................................... RO-9

B. Request(s) for Hearing ....................................................................... RO-10

C. Claimant's WIC Program Record Summary Form ............................. RO-10

D. Case Record Disclosure Prior to Hearing........................................... RO-11

E. Adjusting Complaints......................................................................... RO-11

F. Continuation of Benefits .................................................................... RO-12

G. Denial or Dismissal of a Request for a Hearing ................................. RO-12

H. Notification of the Hearing................................................................. RO-12



GA WIC PROCEDURES MANUAL FFY '98

I.

Conduct of the Hearing and the Claimant's Rights ............................ RO-13

J.

Attendance at the Hearing .................................................................. RO-14

K. The Hearing Record ........................................................................... RO-14

L. The Hearing Decision ......................................................................... RO-14

M. Notification of the Hearing Decision ................................................. RO-15

N. Appeal Rights of the Claimant.. ......................................................... RO-15

0. State Rules of Procedure .................................................................... RO-15

P. Participant Complaint.. ....................................................................... RO-15

VI.

Fair Hearing Procedures - Migrants ............................................................... RO-16

VII.

Administrative Appeals - Local Agency ........................................................ RO-17

VID.

Availability of Hearing Records ..................................................................... RO-18

IX.

National Voter Registration Act.. ................................................................... RO-19

Attachments: RO-1 Rights and Obligations ............................................................................................... RO-20

RO-2 Claimant's WIC Program Record Summary .............................................................. RO-22





GA WIC PROCEDURES MANUAL
I. RIGHTS AND OBLIGATIONS OF WIC APPLICANTS/PARTICIPANTS
WIC applicants/participants are entitled to certain rights including, but not limited to, protection against discrimination and the right to a fair hearing when benefits are denied. ' WIC applicants/participants are obligated to provide true information and follow program requirements.
At each certification, the participant or parent/caretaker/guardian must sign the certification statement on the WIC Assessment Certification Form. Prior to this signature, the applicant must read (or have read to them) the certification statement on the WIC Assessment Certification Form. See the statement below:
I have been advised of my rights and obligations under the Program. I certify that the information I will provide, or have provided is correct to the best of my knowledge. The income I have given is my total gross household income (all cash income before deductions). This certification form is being submitted in connection with the receipt of Federal assistance. Program officials may verify information on this form. I understand that intentionally making a false or misleading statement or intentionally misrepresenting, concealing or withholding facts may result in paying the State agency, in cash, the value of the food benefit improperly issued to me and may subject me to civil or criminal prosecution under State and Federal law. I authorize the WIC Program to share my certification information with other health care and/or
public assistance programs to see if my family is eligible for their services. I
understand that other agencies may contact me but they may not share my certification information with any person or agency without asking my permission.
After sharing the Rights and Obligations with the participant, an explanation of the following items must take place in order to complete the certification process.
1. Certification Reason 2. Benefit of Program 3. Rights and Obligations while on the program 4. Ineligibility Reason 5. Items that can/can not be purchased.
In addition to the rights and obligations stated on the I.D. Card, the applicant/ participant also must not be charged for any WIC service (i.e. copying of WIC records). Local agencies may use their administrative funds to reimburse WIC Service delivery agencies for authorized services provided to applicants/participants.
Each participant on the WIC Program is entitled to be treated with courtesy while in the health department or grocery store. A WIC participant must never be singled out in a grocery store by the use of intercom systems or coding systems that would draw attention to the fact
RO- 1



GA WIC PROCEDURES MANUAL
that they are WIC participants. The use of intercom systems or coding systems in this manner is discriminatory. This type of discrimination, when reported to the State WIC Office, will be handled by the Program Management and Review Unit and/or the Vendor Management Unit.
The section, Special Populations (SP), outlines procedures for insuring program participation for Non-English speaking populations, Refugees, Migrant Farm workers, Homeless, and Native Americans.
Handicapped persons must be treated the same as all other applicants/participants. WIC Program services must be accessible without hardship to disabled applicants and participants, and applicants must not be discriminated against because of lifestyle (i.e. dress, automobile, jewelry, personal relationships and cultural differences).



R0-2



GA WIC PROCEDURES MANUAL
II. NONDISCRIMINATION CLAUSE
WIC State agencies are required to implement a public notification program to inform participants and applicants of their rights and responsibilities, their protection against discrimination, and the procedures for filing a complaint. Therefore, any materials that provide information about WIC Program benefits and eligibility, regardless of the intent, design, or source, must contain the nondiscrimination statement. These materials include brochures, posters; visuals, and any other literature produced by vendors, formula companies or other interested parties. Examples of materials which require the nondiscrimination statement include:
1. Notices of warning or adverse action to applicants/participants, local agencies, vendors, and employees or employment applicants. This includes items such as notices of ineligibility or disqualification, fair hearing procedures, and cards or letters for missed appointments.
2. All outreach and referral materials.
3. Participant identification cards (ID), food instrument folders, or food lists for participants and vendors that describe the WIC Program's participation requirements and benefits.
4. Letters of invitation to participate in the public hearing process that are sent to vendors, health department staff, and advocates; organizations and other interested parties and media announcements of the public hearing.
5. Newsletters that convey WIC benefits and participation requirements.
The current nondiscrimination statement is:
"The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, gender, religion, age and disability. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA's TARGET Center at (202) 720-5964 (voice and TDD)."
"To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, Room 326-W., Whitten Building, 14th and Independence Avenue, SW., Washington, DC 202504-9410 or call (202) 720-5964 (voice and TDD). USDA is an equal opportunity provider and employer."
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GA WIC PROCEDURES MANUAL
If any public material are too small to permit the full statement to be included, the material will, at a minimum, in print size no smaller than the text, include the following statement:
"USDA is an equal opportunity provider and employer."
The New statement should be used immediately in all publications. The new USDA "And Justice for All" poster should be used as soon as supplies are received.
USDA prohibits discrimination in the administration of its programs.
The nondiscrimination statement is not required on items like cups, buttons, magnets, and pens that identify the WIC Program. In addition, the nondiscrimination statement does not have to be read on radio and television public service announcements. Instead, a statement such as "WIC is an equal opportunity program" is sufficient to meet the nondiscrimination requirement. Finally, promotion and nutrition education materials that solely provide a nutrition message, without mentioning the program, are not required to contain the nondiscrimination statement.

R0-4



GA WIC PROCEDURES MANUAL
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 of WIC by local program staff should be documented for review by the state agency monitoring staff. The Office of Public Affairs for the Georgia Department of Human Resources prepares a news release annually to publicize the availability of WIC benefits. The news release is distributed to newspapers statewide.
B. WIC Program regulations and guidelines must be made available to the public on request. These documents include WIC components of the Federal Register, the Georgia WIC Program State Plan, and the Georgia WIC Program Procedures Manual. Income Guidelines are part of the Procedures Manual and must be given to the public upon request.



R0-5



GA WIC PROCEDURES MANUAL
IV. CIVIL RIGHTS
A. "--And Justice fot All"
The "--And Justice for All" poster must be displayed in a conspicuous location in each WIC clinic. The poster is available in English and Spanish and may be ordered from the State WIC Office.
B. Training
Civil rights trammg must be provided for all staff who have contact with WIC applicants/participants. This training must be provided for all new employees, as well as annually (federal fiscal year) for all current employees. A list of participants and an agenda for each training must be documented and kept on file for three (3) years plus the current year.
C. Racial/Ethnic, Migrant/Homeless Identification
Each applicant/participant must be identified by race or ethnic group and as a migrant or a homeless person. In order to do this, local agency staff must:
1. Request that the applicant make a self-identification. When self-identification is made, the interviewer should make it clear to the applicant that the information is for statistical use only and that no other use will be made of the information.
2. 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 of racial and ethnic participation data is a requirement of Title VI of Civil Rights Act of 1964. The "Ethnic Participation Summary Report" provides information on client participation by ethnic status and priority. The report records data by local clinic and summarizes the data by distri~t/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 four (4) 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, age, and disability .
R0-6



GA WIC PROCEDURES MANUAL
E. Discrimination Complaints
All discrimination complaints, written or verbal, must be filed within one hundred and eighty (180) days of the alleged discriminatory action. No applicant/participant should be discouraged from filing a complaint directly with USDA, Director, Office of Civil rights, Room 326-W., Whitten Building, 14th and Independence Avenue, SW., Washington, DC 20250-9410 or call (202) 720-5964 (voice and TDD) if he/she feels discrimination has occurred. A copy of the complaint must be sent to the State WIC Office, 2 Peachtree Street, Atlanta, Georgia 30303.
1. Written Complaints
Persons seeking to file discrimination complaints write USDA, Director of Civil Rights, Room 326-W., Whitten Building, 14th and Independence Avenue, SW., Washington, DC 20250 -9410 or Call (202) 720-5964 (voice and TDD). A copy must be sent to the State WIC Office. ~II complaints must be received by the AFNS no later than ten (10) days from the initial receipt of the complaint. The State WIC Office will send a copy of the discrimination complaint to the USDA Regional Office .
The complaints should include the name of the agency and/or individual towards which the complaint is directed, and include a description of the alleged violation. Anonymous complaints will 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 will write up the elements of the complaint for the complainant. Every effort will be made to have the complainant provide the following information:
a. Name, address and telephone number of the complainant.
b. The specific location and name of the local agency, and person delivering 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).
R0-7



GA WIC PROCEDURES MANUAL
e. The names, titles, and addresses of persons who may have knowledge of the discriminatory action.
f. The date(s) during which the alleged discriminatory action occurred, or if continuing, the duration of such actions.



RO- 8



GA WIC PROCEDURES MANUAL
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 of the method by which a hearing may be requested. Due to an increase in the number of Fair Hearing requests and budget constraints, the following procedures have been developed in order to (1) reduce the number of Fair Hearings and (2) improve our current procedures.
In order to insure that the above occurs, the following procedures must be discussed with each new applicant/participant at certification:
1. Limited funding of program 2. The Priority System 3. Waiting List 4. Reasons for the denial of benefits or termination from the program.
Focusing on the procedures of the program at the time of application 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 Administrative Law Judge, the time frame for final decisions and any other pertinent information. Cases can then be heard on an individual basis with the specifics of each case being separately discussed.
In the event a participant requests a fair hearing, all benefits remain in force until a final decision has been rendered.
The following is the Georgia WIC Fair Hearing Procedure:
A. Hearing Official
The Office of State and Administrative Hearing (OSAH) is responsible for action on each fair hearing request. The Office of State and Administrative Hearings, an impartial party, is vested with full authority in conducting the hearing process. This includes the conduct
R0-9



GA WIC PROCEDURES MANUAL
of hearings, keeping all files and records, and furnishing information for proper reports. The Office of State and Administrative Hearings is fully responsible for conducting hearings properly and promptly in accordance with the rules and regulations established by the State. The Office of State and Administrative Hearings 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; and
4. Render a hearing decision based exclusively on the hearing record and matters officially noticed.
B. Request(s) for Hearing
A request for a hearing is defined as any clear expression by the individual or the individual's parent, guardian, caretaker, or other representative, that an opportunity to present his/her 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 DHR Legal Services Office (LSO), 2 Peachtree Street, Atlanta, Georgia 30303.
A hearing request shall be effective upon receipt of a verbal or written request. A verbal request received within the sixty (60) day time limit by the local agency shall be accepted as timely filed. The forty-five (45) day period allowed for rendering a hearing decision shall begin on the day the fair hearing request is received by the local agency.
Upon request, the local agency shall assist the claimant in submitting a request for a fair hearing. The claimant shall be advised by the local agency of any legal services available that can provide representation at the hearing.
C. Claimant's WIC Program Record Summary Form
The local agency shall prepare the Claimant's WIC Program Record Summary Form (Attachment RO-2). Within three (3) working days the completed form and written request shall be submitted to the DHR Legal Services Office, 2 Peachtree Street,
RO-10



GA WIC PROCEDURES MANUAL
Atlanta, GA 30303. A copy of the form shall be sent to the State WIC Office. If the hearing request is filed initially with the DHR Legal Services Office (LSO), a copy will be immediately forwarded to the local agency.
The local agency has the responsibility of maintaining contact with the claimant and must report promptly to the Legal Services Office any change in circumstances, including changes in mailing address. As soon as the local agency receives notification that a hearing has been scheduled, the local agency WIC Program Coordinator shall immediately review the record to:
1. Re-examine the action of the local agency and the circumstances 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 Legal Services Office. The local agency will secure any additional evidence necessary for the hearing.
D. Case Record Disclosure Prior to the Hearing
All documents and records to be used in the hearing will be available for examination by the claimant 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/her representative to determine whether a hearing should be requested or to prepare for a hearing. The claimant and/or his/her 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. If the local agency and the claimant arrive at a mutually satisfactory decision prior to the hearing, the claimant may withdraw his/her request for the hearing in accordance with the withdrawal
procedures. The local agency may amend or reverse its decision at any time prior to a
hearing, regardless of the claimant's decision on withdrawal. In the case of withdrawal,
RO - 11



GA WIC PROCEDURES MANUAL
amendment, or reversal, the local agency shall notify the Legal Services Office immediately, attaching a copy of the withdrawal or new notification and a summary supporting the corrective action taken by the local agency. If time does not permit written notification, the Legal Services Office shall be notified verbally with immediate follow-up in writing.
F. Continuation Of Benefits
Participants who appeal the termination of benefits within fifteen (15) days from date of notification shall continue to receive program benefits until the final administrative decision. '
Applicants who are denied benefits at initial certification or at subsequent certifications may appeal the denial, but shall not receive benefits while awaiting the hearing.
The local agency shall promptly inform the individual, in writing, if participation status changed, pending the hearing decision.
G. Denial or Dismissal of a Request for a Hearing by LSO or OSAH
A Request for a hearing shall not be denied or dismissed unless:
1. The request for hearing is not received within the sixty (60) day time limit.
2. The request is withdrawn in writing by the appellant or a representative.
3. The appellant or representative fails, without good cause, to appear at the scheduling hearing.
4. The appellant has been denied participation by a previous hearing and cannot provide evidence that circumstances relevant to program eligibility have changed in such a way as to justify a hearing.
H. Notification of the Hearing
The hearing shall be conducted within three (3) weeks from the date the State received the hearing request. A time and place shall be arranged in order for the hearing to be accessible to the participant/designated representative.
At least ten (10) days prior to the hearing, the Office of State and Administrative Hearings shall provide written notice to all parties involved to permit adequate preparation of the case. The notice shall contain the following:
RO- 12



GA WIC PROCEDURES MANUAL
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/her representative fails to appear at the hearing without good cause.
6. A statement that the participant/designated representative may examine the case file prior to the hearing.
The Administrative Law Judge may change the time and place of the hearing upon his own motion or that by the parties. The Administrative Law Judge may adjourn, postpone, or reopen the hearing upon receipt of additional information at any time prior to mailing the hearing decision.
Should the Administrative Law Judge exercise the option of rescheduling the hearing, the claimant shall be given at least ten (10) days advance notice of such action.
I. Conduct of the Hearing and the Claimant's Rights
If, at the hearing, it becomes evident that the issue involved is different from the one on which the hearing was requested, the Administrative Law Judge shall exercise discretion and may conduct the hearing on the newly 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.
R0-13



GA WIC PROCEDURES MANUAL
J. Attendance at the Hearing
The Administrative hearing shall be attended by a representative of the agency that initiated the action being contested and may be attended by the individual and/or his/her representative. Other local agency staff may attend and participate in the hearing process at the discretion of the Administrative Law Judge. The hearing may also be attended by friends and relatives of the claimant if the claimant so chooses.
K. The Hearing Record
The Administrative Law Judge shall compile the official hearing record. (i.e., and entirely new records) that covers all points of eligibility dealing with the issues directly related to the action being appealed. The record shall include:
1. All pleadings, motions, and intermediate rulings.
2. A summary of the oral testimony and all other evidence received or considered, except that oral proceedings, and any part thereof, shall be transcribed or recorded upon request. Upon written request, a transcript or tape of such oral proceedings, or any part thereof, shall be furnished to any party to the proceedings.
3. A statement of matters officially noted.
4. Questions of matters officially noted.
5. The decision by the Hearing Officer.
6. All staff memoranda and dates submitted to the Hearing Officer in connection with the case.
L. The Hearing Decision
Decisions of the Administrative Law Judge shall comply with Federal law, regulations, and policy and shall be based on the hearing record. The Administrative Law Judge's decision shall take into consideration only those issues directly related to the action being appealed and shall be based exclusively on evidence and other material introduced at the hearing. A decision by the Administrative Law Judge shall be binding on the local agency and shall summarize the facts of the case, specify the reasons for the decision, and identify the supporting evidence and the pertinent regulations or policy. The decision shall become a part of the record.
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GA WIC PROCEDURES MANUAL
M. Notification of the Hearing Decision
Within forty-five (45) days of the receipt of the request for a hearing the claimant and/or his/her representative shall be notified in writing of the decision. If the decision is in favor of the claimant and participation was denied or discontinued, benefits shall begin immediately.
If the decision is in favor of the agency, as soon as administratively feasible, any continued benefits shall be terminated as decided by the Administrative Law Judge and efforts will be made to collect the claims.
In addition, the decision will inform the claimant of any right to appeal known to the Administrative Law Judge and shall advise that an appeal request may result in a reversal of the decision.
N. Appeal Rights of the Claimant
When a decision is adverse to the claimant, he/she has the right to appeal to a DHR Appeal Reviewer. The claimant shall be allowed thirty (30) days to request review of the decision by the DHR Appeal Reviewer. The DHR Appeal Reviewer shall have all the powers and delegated authority of the Commissioner to make a decision. He/she may take additional testimony or remand the case to the Administrative Law Judge for such purpose. The decision will be based upon the record from the original hearing as augmented before the Appeal Reviewer and shall either affirm, reverse, or modify the original decision to assure full compliance with Federal law, regulations, and policy.
If the claimant requests review of the Administrative Law Judge's decision, the usual standard of promptness is automatically waived. The claimant and his/her legal representative shall be notified, in writing, of the decision of the Appeal Reviewer and of his/her right to judicial review. If the claimant is dissatisfied with the decision of the Appeal Reviewer, he/she has the right to pursue judicial review (e.g., civil court).
0. State Rules of Procedure
The State agency shall provide and distribute upon request, to any interested party, that portion of the Georgia WIC Program Procedures Manual which outlines the Fair Hearing Procedures.
P. Participant complaint
The WIC participant may file a complaint (written or oral) due to staff or clinic treatment (unrelated to discrimination or ineligibility/disqualification decision). Documentation of this complaint may be written on the Incident/Complaint Form.
R0-15



GA WIC PROCEDURES MANUAL
VI. FAIR HEARING PROCEDURES MIGRANTS
Because migrant farm workers and their families may leave a program area after a very short time, it is important that fair hearing procedures for migrants be expedited, by contacting them immediately for the hearing process. When a local agency receives a fair hearing request from a migrant, they should attempt to find out how long the migrant will be in the program area and should convey this information to the DHR Legal Services Office and State WIC Office.



RO- 16



GA WIC PROCEDURES MANUAL
VII. ADMINISTRATIVE APPEALS - LOCAL AGENCY
The applicant/participant may appeal a local agency decision when an application to participate in the WIC Program is denied or terminated, or when a decision is made which adversely affects the local agency's participation in the program, such as a reduction in food or administrative funds.
The local agency must request a hearing from the State agency within thirty (30) days after the action which is being appealed was taken. The hearing must be scheduled no later than thirty (30) days after the request for hearing is received by the State agency with the local agency being given fifteen (15) days advance notice of the time and place of the hearing. The 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 WIC 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 of law. The local agency will be notified of the decision within sixty (60) days from the date of the request. If a State decision is rendered against the local agency, the local agency may pursue judicial review of the decision.

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GA WIC PROCEDURES MANUAL
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.



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GA WIC PROCEDURES MANUAL
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 all applicants/participants entering a clinic for the application or re-certification 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 of 12 months.



RO - 19





GA WIC PROCEDURES MANUAL

Attachment R0-1

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

RIGHTS AND OBLIGATIONS

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

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

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

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

5. The WIC Program may disclose specific applicant information to designated health or welfare agencies for the purpose of determining eligibility and conducting outreach to WIC applicants and participants.

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

7. You may be taken off WIC if:

* You do not tell the truth.
* You get vouchers from more than one (1) WIC program at the same time. * You do not keep your certification appointments. (Rescheduling WIC appointments may
take from 7 to 20 days depending on the clinic schedule).
* You do not get your vouchers for two (2) months in a row. * You sell your vouchers for money. * You trade your vouchers for anything. * You use your vouchers to buy food that is not on the list. * You exchange your WIC food items after purchase for any item(s) not listed on the
voucher.
* 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.

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GA WIC PROCEDURES MANUAL

Attachment RO-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~umber of Davs Late Less than 7 days late
7-13 days late

14-20 days late

I

I

21-31 days late

Women & .Children
full package
3 vouchers issued (3/4 package)
2 vouchers issued ( package)
1 voucher issued (1/4 package)

Infants full package full package
1 voucher issued () package
1 voucher issued ( package)

If you have any questions about this form, you may ask for help or call the clinic.

LATE PICK-UP SCHEDULE ADDENDUM/ALTERNATE FOOD PACKAGES

Number of Days Late Less than 7 days late
7 - 13 days late
14-20 days late
21-31 days late

Women & Children
full package
6 vouchers issued (3/4 package)
4 vouchers issued ( package)
2 vouchers issued (1/4 package)

Infants full package full package
1 voucher issued ( package)
1 voucher issued ( package)

This is an Equal Opportunity Program. If you believe you have been discriminated against because of race, color, national origin, sex, age, or handicap, write immediately to the Secretary of Agriculture, Washington, D.C. 20250.
Form 3768 (Rev.)

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GA WIC PROCEDURES MANUAL

Attachment R0-2

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

SECTION I - IDENTIFICATION

District/Unit- - - - - - - - - - - - WICID# - - - - - - - - - - - -
Applicant/Participant: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

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



- Address: ----------------------------Street Number and Name

City

State

Zip Code

Phone - Number: - - - - - - - - - - - - - - - - -
Representative: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

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

1. white male

2. white female

County:_ _ _ _ _ _ _ _ __

3. nonwhite male

4. nonwhite female

Date of Request:_ _ _ _ _ _ _ _ _ __

Date of Appointment:______ Date of Notification:__ _ _ _ _ _ _ __

FOR STATE OFFICE USE ONLY:

Request number:_ _ _ __

Date request filed: _ _ _ _ _ __

Time limits: 7 CFR 246.9(j) Hearing is to be held within three (3) weeks from the date the State or local agency receives the request for hearing. 7CFR 246.9(k)(3) The decision is to be issued within 45 days of the date the request for hearing was received by the State or local agency.

R0-22



GA WIC PROCEDURES MANUAL

Attachment RO-2 cont'd

SECTION II - TYPE OF AGENCY ACTION OR INACTION

A. Agency Action (Circle item number) Participation denied/terminated because client:

1. Is not income eligible Date
2. Does not live in local program area Date
3. Has reached expiration of regulatory eligibility Date
4. Is not pregnant, postpartum, breastfeeding or Infant/Child under five (5) years of age Date
5. Does not meet nutritional risk criteria Date
6. Failed certification appointment on Date
7. Did not pick up vouchers for two (2) consecutive months Date
8. Violated program rules and was suspended for three (3) months for: Date
9. Is in Priority_ and program has funds to serve only Priority(ies) Date
10. Other Date
B. Agency Inaction (Circle item number):

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

2. Other: (specify)


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GA WIC PROCEDURES MANUAL

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:



Signatureffitle of WIC Personnel

Signature of WIC Coordinator

Prepare in triplicate Original - DHR Legal Services Office File Copy - State WIC Office File Copy - District/Local Agency

Program Name

Address

City

State

Zip Code

Telephone Number

R0-24





GA WIC PROCEDURES MANUAL

TABLE OF CONTENTS SECTION ONE - FINANCIAL MANAGEMENT

Page

I. Agreement with State Agency ..................................................................................... AD-1 II. Financial Procedures ......... ,.......................................................................................... AD-2
A Local Agencies................................................................................................. AD-2 B. Non-profit Agencies......................................................................................... AD-2 III. Administrative Cost Categories ................................................................................... AD-2 A. General Administration .................................................................................... AD-2 B. Nutrition Education Costs ................................................................................ AD-3 C. Breastfeeding Costs ......................................................................................... AD-4 D. Client Services ................................................................................................. AD-6 E. Indirect Costs ................................................................................................... AD-6 IV. Shared Costs................................................................................................................. AD-7 A. Shared Operational Costs................................................................................. AD-7 B. Shared Equipment ............................................................................................ AD-7 C. Shared Personnel Costs .................................................................................... AD-8 V. Random Moment Sample Study .................................................................................. AD-9 A. Individuals to be Sampled ............................................................................. AD-10 B. Costs to be Distributed.................................................................................. AD-10 C. Study Period.................................................................................................. AD-10





GA WIC PROCEDURES MANUAL

Page VI. Purchasing Procedures ............................................................................................... AD-13
A. Equipment (Excluding Medical Equipment) ................................................. AD-13 B. Medical Equipment ........................................................................................ AD-14 C. ADP Equipment Purchases less than-$25,000 ............................................... AD-16 D. ADP Equipment Purchases $25,000-$200,000 .............................................. AD-16 E. Supplies .......................................................................................................... AD-17 F. Central Supply Forms .................................................................................... AD-17 G. Prior Approval/Duplication of WIC Forms ................................................... AD-18 H. Rental of Space .............................................................................................. AD-18 I. Rearrangement and Alteration of Facilities ................................................... AD-19 J. Inventory ........................................................................................................ AD-20 VII. Allocation of Funds.................................................................................................... AD-21 A. Food Funds .................................................................................................... AD-21 B. Administrative Funds ..................................................................................... AD-21 VIII. Food Cost Projection Report...................................................................................... AD-22 IX. Program Income ..........................................;.............................................................. AD-23

SECTION TWO - PROGRAM ADMINISTRATION

I.

Retention of Records.................................................................................................. AD-24

A. Definition of Records ..................................................................................... AD-24

B. Records and Reports - Accessibility of Records........................................... AD-24

C. Retention Schedule ........................................................................................ AD-24



GA WIC PROCEDURES MANUAL
Page II. WIC Acronym and Logo ........................................................................................... AD-28
A. Authority'. AD-28 B. Official Use .................................................................................................... AD-28 C. Special Use..................................................................................................... AD-28 D. Unauthorized Use........... :: .............................................................................. AD-29 III. Lobbying Restrictions ................................................................................................ AD-30 IV. Confidentiality ..................................................................................:........................ AD-31 V. Faxing Confidential Information ............................................................................... AD-32 VI. WIC Volunteer and Confidentiality ........................................................................... AD-33 VII. Retroactive Benefits and Reimbursement.................................................................. AD-34 VIII. Mandatory No Smoking Policy in Local WIC Clinics .............................................. AD-35 IX. Subpoenas .................................................................................................................. A_D-36 X. Search Warrants ......................................................................................................... AD-38 XI. Program Participation ................................................................ :............................... AD-39 XII. System Maintenance Indicator Report ....................................................................... AD-41 XIII. Documentation ........................................................................................................... AD-42 XIV. Establishing New Clinics/Clinic Changes ................................................................. AD-43
xv. Clinic Closings.......................................................................................................... AD-44



Attachments:

AD-1

Sample Formulas ........................................................................................... AD-45

AD-2

Information Needed for USDA Approval of Non-Major ADP Equipment... AD-47

AD-3

Memorandum of Understanding/Master Agreement .................................... AD-48

AD-4

Contract Budget ............................................................................................. AD-54



GA WIC PROCEDURES MANUAL

AD-5 AD-6 AD-7 AD-8 AD-9 AD-10 AD-11 AD-12 AD-13

Page Monthly Expenditure Report ......................................................................... AD-55 WIC Forms Available in Central Supply ....................................................... AD-56 Equipment Inventory Form ............................................................................. AD-58 System Maintenance Indicator Technical Assistance Procedures ................. AD-59 System Maintenance Indicator/Technical Assistance Report ........................ AD-60 System Maintenance Indicator/Technical Assistance Summary Report ....... AD-61 Agreement for Disclosure oflnformation...................................................... AD-62 Release of Information Form ......................................................................... AD-63 Request to Establish New Clinic/Clinic Changes......................................... AD-64





GAWICPROCEDURESMANUAL
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/Master Agreement (Attachment AD-3). One (1) copy of the agreement must be signed by the District Health Officer and returned to the State WIC Office. The State Office will then take the signed copy to the state Public Health Director for signature. Once the agreement is signed by the Public Health Director, a copy will be forwarded to the District Director.
Contracted local agencies sign a contract with the Georgia WIC Program on August 15th of each year. Contracted agencies timeframes are on a federal fiscal year.





AD- I

GA WIC PROCEDURES MANUAL II. FINANCIAL PROCEDURES
A. Local Agencies
Adhere to: Georgia WIC Procedures Manual USDA FNS Instruction 808-1 0MB Circular A-87 and A-102 Grant-in-Aid Policy & Procedure Manual, Parts 111.E, Attachment 1 and IX.A,B. 7 CFR 3016 B. Non-profit Agencies
Adhere to the tenets of the negotiated contract.

III.


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 costs generally considered to be overhead or management costs.

2. Costs associated with program monitoring, prevention of fraud, general oversight, food instrument accountability, and reconciliation.

3. General management clerical support, the cost of payroll and personnel systems, accounting and bookkeeping, audits, and other financial and legal services.

4. WIC administrative salaries/benefits are 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.



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GA WIC PROCEDURES MANUAL
7. Liability Insurance*.
8. The cost of batching 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 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. Expenditures with a unit value in excess of $25,000. 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. Indirect costs.
Note: *The following are allowable Automated Data Processing (ADP) costs that do not require prior approval.
1. ADP service treated as indirect costs and included in a cost allocation plan approved by OHR.
2. Software and minor components intended for the maintenance of existing systems. 3. Commercially available software packages.
B. Nutrition Education Costs
Federal regulators require that each WIC State Agency spend one-sixth of its Nutrition Service and Administrative Grant for Nutrition Education. Therefore, it is recommended that a local agency spend a minimum of one-sixth ( l /6) of its administrative funds on nutrition education to provide the necessary Nutrition Education Services to clients to meet the state requirements .
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GA WIC PROCEDURES MANUAL
Only act1v1t1es directed toward helping part1c1pants 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 nutrition education expenditure.

C. Breastfeeding Costs



A local agency is required to spend WIC breastfeeding funds for breastfeeding-related costs and activities. As long as there is sufficient and appropriate documentation, the following breastfeeding costs are allowable:
1. Salaries of employees who plan and/or perform breastfeeding promotion and support activities.
2. Breastfeeding
a. Breastfeeding aids such as breast pumps, breast shells, nursing supplements, 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 of breastfeeding. This includes the time necessary to plan, prepare for, and conduct the sessions.
4. Training of persons conducting breastfeeding promotion and support activities.
5. Evaluation and monitoring of breastfeeding promotion and support activities, including participant surveys.
6. Development/procurement and distribution of materials, instructional curricula, etc., related to breastfeeding promotion and support.
7. Development and updating of the biennial Breastfeeding Promotion and Support Plan. AD-4



GA WIC PROCEDURES MANUAL
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. 11. Prorated costs of clinic space devoted to educational and training activities related to breastfeeding, including space and furniture set aside for nursing during clinic hours.





AD-5

GA WIC PROCEDURES MANUAL 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 of WIC staff who issue food instruments and explain their use. 3. Cost necessary to refer clients to other health care and social services, and 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 of WIC 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 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 the 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



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GA WIC PROCEDURES MANUAL

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 on an equivalent prorated charge. Listed below are examples of an allowable basis for allocating costs shared by two (2) or more programs.

Cost

Basis of Allocation

a. Copy Machine Use

Per Copy, Based on Log

b. Janitorial Services

Square Footage

c. Maintenance

Square Footage

d. Printing

Per Job

e. Telephone

Number of Extensions (pay share or basic charge per month) Long Distance calls

f. Utilities

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 other programs may be charged to WIC if it is prorated on an equitable basis. The agency may claim the appropriate share of the equipment cost as a direct WIC Program cost. This applies to medical equipment, nutrition education materials, and any other shared administrative expense. As stated in 0MB Circular A-87, a cost is allowable to a program to the extent of benefits received by that program.

AD-7

GA WIC PROCEDURES MANUAL C. Shared Personnel Costs



WIC payrolls must be supported by a time study or by random moment sampling (RMS). 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.
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 of average salaries, and the dates when rates were established.
2. Daily Time Logs
For agencies not employing RMS, 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.
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GA WIC PROCEDURES MANUAL
V. RANDOM MOMENT SAMPLE STUDY (RMSS)
The Division of Public Health has two (2) RMSS, each serves a different purpose:
One is the State-level Administrative RMSS, which is used to allocate indirect administrative costs of the division to its programs. Costs included in this pool are personnel costs and related support costs for the divisional administrative offices and for each of the nineteen district offices. The WIC Program, as a part of the Division of Public Health, shares in the distribution of costs from this cost pool.
In addition to the indirect administrative division costs discussed above, departmental indirect administrative costs and statewide central service costs are distributed to the division's programs via the results of the State-level Administrative RMSS. Costs included in this pool include the departments' administrative offices such as the Commissioner's Office, Personnel, Budgeting, Financial Services, etc. and the indirect costs 9f the various state agencies that provide services to the Department of Human Resources, such as our Department of Administrative Services, the Georgia Building Authority, the Department of Archives and Records, etc.
RMSS will be used to document and allocate all salary expenditures. All items which can be identified as the direct costs (for all programs) will be removed from the administrative cost pool and charged to the benefiting cost objective. All remaining administrative expenditures, are allocated based on the results of RMSS samples.
The mechanics are the same for both of the RMSS. They are designed to replace the use of time sheets and in that function, their results are used exactly as the results of time sheets. The theory is that when there is a pool of costs that are attributed to more than one program, a fair method of allocation is to distribute these costs in the same proportion that the workers, whose wages/salaries and benefits help comprise the cost pool, spend their time. In order to measure how workers spend their time, time sheets were formerly employed. But, they are cumbersome, burdensome and easily manipulated.
The RMSS was designed to measure employees' time in a more scientific and accurate way. By taking a randomly selected sample, that is a sample of randomly selected employees at randomly selected times, and determining the amount of time spent on divisional programs by that sample, we are able to impute these results to the population as a whole. We conduct our sample on a quarterly basis. It has a standard deviation of +/-3%. It is audit-able and conforms to scientific standards as to the properties it must have in order to mathematically describe a specific population. Our results are given in the following context:



AD-9

GA WIC PROCEDURES MANUAL



A. Individuals to be Sampled
The universe of workers to be sampled is all of the county health department workers. It is through the efforts of the county health department workers that most of the services of the Division of Public Health are provided to the state's citizens. There are many part time workers in this universe. The Department of Human Resources (DHR) will sample all of these workers because excluding them could give false sample results. We will measure the number of strikes that report a worker is not present because they are not scheduled for work (because they are part time) and increase the sample size to accommodate for that.
In addition, some of the workers are now currently charged to Grant-in-Aid programs which represent a broad range of programs that one can find at county health departments and others are directly charged to a single program, such as the WIC program. We will place all of the workers into the same cost pool and sample them all, whether they are currently being direct charged or not.
B. Costs to be Distributed
RMSS will be used to document and allocate all sal~ expenditures. All items which can be identified as the direct costs (for all programs) will be removed from the administrative cost pool and charged to the benefiting cost objective. All remaining administrative expenditures will be allocated based on the results of RMSS samples.
c. Study Period
The study period is the first 55 work days of a fiscal quarter. Fiscal quarters begin on July l, October 1, January 1 and March 1.



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GA WIC PROCEDURES MANUAL

Division of Public Health - County Health Department RMSS Program Activities to be Measured and Related Funding

Activity

Funding

Medicaid- ................................................................................................................ Title XIX, State Administration Community Care Dental Services Early Periodic Screening, Diagnosis and Treatment (EPSDT) Perinatal Case Management Program, Pregnancy Related Services Program Rehabilitative Services Option Program

Acquired lmmunedeficiency Syndrome (AIDS) ................................................. Ryan White Grant ......................................................................................................................... Seroprevalence Grant ...................................................................................................................... Behavioral Risk Factor ................................................................................................................................. HIV Prevention

Women, Infants & Children Program (WIC) ..................................................... USDA WIC Grant Administration Nutrition Education Client Services Breast-feeding Information

Diabetes........................................................................................ ,................. Diabetes Grant, State Tuberculosis ................................................................................................ TB Control Grant, State Sexually Transmitted Diseases (STD)......................................................STD Control Grant, State Family Planning..................................................................................Family Planning Grant, State Immunization........................................................................Childhood Immunization Grant, State Cancer Control ...........................................................................................................................State Chronic Disease .........................................................................................................................State
Arthritis Cerebrovascular Central Nervous System Diseases Kidney Diseases Environmental Health................................................................................................................State Epidemiology .............................................................................................................................State Laboratory Services ..............................................:....................................................................State



AD- 11

GA WIC PROCEDURES MANUAL Activity

Funding

Primary Health Care..................................................................................................................State Maternal and Child Health Services ........................................................MCHS Block Grant, State
Child Health Children's Medical Services Genetic Services High Risk Pregnant Women and Infants Lead Based Paint Poisoning Prevention Program Newborn Care Follow-up Prenatal Services

Preventive Health Program...................................................................... PHHS Block Grant, State Community Health Management Emergency Health Injury Control Stroke and Heart Attack Prevention





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GA WIC PROCEDURES MANUAL
VI. 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 accordance with CFR Part 3016 and State purchasing policies, all of which should be on file at the local agency. Requests to USDA for approval of non-major ADP equipment should include the information contained in Attachment AD-2.
As a general rule, all items costing over $1,000.00 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 be purchased if funds are available in the local agency's current budget. Equipment purchases exceeding $25,000 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 Office 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 of the Monthly Income and Expenditure Report, Form #5110, on the following lines:
a. EQUIPMENT $1,000 or MORE PER ITEM:
All equipment purchased whose unit cost exceeds or equals $1,000.00 should be reported .
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GA WIC PROCEDURES MANUAL b. EQUIPMENT UNDER $1,000 PER ITEM:
All equipment costing under $1,000 per item should be reported here. If you purchase two files at the same time, at a cost of $500.00 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 if there are appropriated monies in their budget for the purchase of the needed medical equipment, the cost of the medical equipment does not exceed the maximum medical ($25,000), 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) .Medical equipment specifically listed in the WIC regulations, Section 246.14(c) (2) (iii), may be approved for purchase. The list of equipment includes 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 $25,000 limit established by the Food Nutrition Service (FNS) in accordance with the Office of Management and Budget Circular A-87 for capitaf expenditures. While this amount is the maximum allowed, equipment can often be obtained for substantially less than the maximum. If the cost of any one (1) piece of equipment exceeds the $25,000 maximum, the equipment must have prior approval by the State WIC Office and USDA prior to purchase.



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GAWICPROCEDURESMANUAL
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 of the manufacturer and the price. The price should be itemized sufficiently to identify the cost of attachments (if priced separately), transportation charges, discounts, taxes, etc.
(b) List the price of each bid. A minimum of three (3) bids must be obtained. If the lowest bid was not selected, please include justification for favoring a higher bid. If the equipment was purchased under a pre-negotiated State contract, please indicate this in the request.
(c) Include a statement certifying that the equipment will be used exclusively for WIC Program purposes. If the item of equipment is to be shared, describe how the cost will be prorated between users.
(d) Include a statement that procurement was made in accordance with the provisions of 7 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.
3. Year End Administrative Funds Obligations
WIC funds are allowed to be obligated in one federal fiscal year with no requirement that the desired goods/services are to be received in the federal fiscal year in which the obligation was made. In order to utilize current year administrative funds, all purchase orders must be properly dated, completed, and forwarded to the vendor prior to September 30.



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GA WIC PROCEDURES MANUAL C. Automated Data Processing (ADP) Equipment Purchases less than $25,000



Computer equipment purchases not requiring prior approval under this policy are limited to individual, occasional purchases of computer equipment with a unit cost of less than $25,000 which are not related to a multi-unit procurement such as a state-wide automation system. Software purchases in this range do not require approval. Prior approval from the State WIC Office and the USDA must be obtained for all ADP equipment purchases above $25,000.
I. 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 should 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 the equipment to be purchased, associated cost and the agency where the equipment will be located.
Note: 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 90 I.
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:
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GA WIC PROCEDURES MANUAL
(a) A statement that the requested equipment is not a part of a larger ADP Project. (b) A description of the 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 of the service to be provided and the anticipated cost.
E. Supplies
Supplies are expendable items used in the course of WIC Program activities, and are obtained using the local agency's purchasing procedures. Purchases must be made in accordance with State purchasing regulations and sufficient documentation must be maintained for each purchase.
Funds for supplies must be budgeted and submitted to Grant-in-Aid on the Budget Expense and Resource Summary Form, Form #5410 and (copied to the State WIC Office). However, no approval of supply purchases is necessary, either from Grant-in-Aid or from the State WIC Office. Refer to the Georgia WIC User Manual for information on ordering of supplies for the ADP System.
F. Central Supply Forms
All Central Supply requests for WIC and Office of Nutrition forms must be ordered by the District through the State WIC Office and the Office of Nutrition. All orders must be correctly completed and separated from orders for other programs, e.g. Immunization, Women's Health, Child Health (see Attachment AD-6). All requisitions must be sent to the State WIC Office or the Office of Nutrition for approval before the orders will be filled. DO NOT SEND ORDERS DIRECTLY TO CENTRAL SUPPLY. Requests will not be approved by telephone.



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GA WIC PROCEDURES MANUAL
G. Prior Approval/Duplication of WIC Forms
Prior approval must be requested by the District for all forms in the current years' Procedures Manual that the District plans to reformat, modify or develop.
If the District duplicates a State WIC form, (i.e. Notice of Termination/Ineligibility/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 on 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 will 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 expenses.
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 expei;ises.
The purchase, repair, or renovation of real property are capital expenditures that do require prior approval. Only in areas where other options are not available should the State WIC Office approve capital expenditures for the purchase, repair, or renovation of buildings.
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GA WIC PROCEDURES MANUAL
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 (identify each 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 0MB Circular, Cooperative Agreements with State and Local Governments.
Tentative approval will be granted only when an estimate is submitted so that the bidding process may begin. Once the bids have been received and a vendor selection made, the State WIC Office must be provided with the final amount of expenditures required in order that final approval may be granted.
Maintenance and repair are not considered under this cost category.
2. If the rearrangements and/or alterations are to be made to a privately owned building and the work involves structural modification, installation of plumbing, wiring or ducting, or results in a permanent alteration to the facility, we strongly recommend that written approval be obtained from the lessor.



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GA WIC PROCEDURES MANUAL
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 purchased with WIC funds whose unit cost exceeds or equals $ I 000.00 must be conducted, this information must be documented on the State Equipment Inventory Form (Attachment AD-7) and submitted to the State WIC Office no later than September 30 of each year. This inventory must be completed and submitted, regardless of whether or not equipment was purchased during the year. The staff person conducting the inventory must sign and date the form. Each item must be recorded with the following information:
1. Inventory Number 2. Equipment Description 3. Serial Number 4. Equipment Location 5. Date of Purchase 6. Purchase Price 7. Percentage of WIC funds used to purchase equipment
Please refer to the Department of Human Resources Real and Personal Property Management manual to properly dispose of those pieces of equipment that are damaged, deleted, or discarded. If the equipment has been stolen, enclose a copy of the police report with the inventory form. All equipment (deleted, damaged, stolen, or discarded) should be indicated as such on your Equipment Inventory Form (column #4).
WIC purchased equipment reported missing must be noted on the Equipment Inventory Form. A notation in the 4th column "Location" should specify "missing" and the date. An anecdotal note at the bottom of the form (or attachment) should specify details/comments related to the circumstances. When the equipment is located, an additional anecdotal note at the bottom of the form (or attachment) must be made and corresponding location of the equipment noted accordingly.
If the local agency chooses to use a form other than the State form, the above information must be documented.



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GA WIC PROCEDURES MANUAL
VII. ALLOCATION OF FUNDS
A. Food Funds
The allocation and reallocation of food funds is based on a methodology developed by the WIC Allocation Advisory Committee. This includes an analysis of each district's participation at the beginning of the fiscal year by WIC type, within priority. The projected amount to be spent for the total fiscal year is then calculated and, based on priorities, the committee determines which priorities will be served. The methodology for allocating food funds is described in the Financial Management Section of the State Plan.
When food money is reallocated, it may be necessary to reallocate administrative funds.
B. Administrative Funds
The allocation of administrative funds is based on an average cost per participant.
First, the cost of State agency operations (State WIC Office and Office of Nutrition) is subtracted from the total administrative grant received from USDA. Of the remaining funds, additional yearly expenses are deducted from the adjusted administrative balance (indirect cost paid to OHR, ADP contractor fees). The new adjusted balance is then available for statewide District (Local Agency) distribution and is allocated based on a Statewide average cost per participan~ and participation of the last two (2) closed out program months.



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GA WIC PROCEDURES MANUAL
VIII. FOOD COST PROJECTION REPORT
The Food Cost Projection Report is generated monthly and contains information to assist with district caseload management. Please refer to the letter of credit in the State Plan (item 6) located in the District Office.





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GA WIC PROCEDURES MANUAL
IX. PROGRAM INCOME
Any revenue generated as a result of administering the WIC Program is considered Program Income. All Program Income will be used to further program objectives and must be added to the program budget in accordance with 7 CFR 3016.25 regulations.





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GA WIC PROCEDURES MANUAL
SECTION TWO - PROGRAM ADMINISTRATION
I. RETENTION OF RECORDS
A. Definition of Records Federal regulations state: "Records shall include, but not be limited to, information pertaining to financial operations, food delivery system, food instrument issuance and inventory, certification, nutrition education, civil rights and fair hearing procedures" [7CFR 246.25(a)(l)].
State policy memos from the previous year may be destroyed once the new Procedures Manual has been received, unless otherwise instructed. For example, FFY '99 Policy Memos may be destroyed once the FFY 2000 Procedures Manual has been received.
B. Records and Reports - Accessibility of Records
The Office of the Inspector General (OIG) has been given total access to WIC Program Records since that Office has overall authority and responsibility for the examination of the Food and Nutrition Service Program. The WIC Certification file is part of the documentation for determining food cost charge. Therefore, certification records when requested must be made available to the OIG.
If a certification file does not contain the required information, local agency personnel are required to make available to the OIG a medical case record or other documentation which will substantiate that the cost incurred by serving the participant is a proper charge to the WIC Program.
In cases where the OIG finds that certification data is insufficient, and is denied access to the medical record or other documentation is not made available, a claim will result against the State Agency. C. Retention Schedule
l. The following documents must be retained for five (5) years, as stated in the DHR Record Retention Policy, issued November 12, 1986:
(1) WIC Assessment/Certification Forms (2) Diet Histories (3) Growth Charts/Weight Gain Grids (4) VOC Carel Inventories
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GA WIC PROCEDURES MANUAL
2. The following documents must be retained for three (3) years plus the current Federal Fiscal Year:
(1) Vendor Monitoring Reports (2) Computer Generated Voucher Registers (3) Manual Voucher Inventory Records (4) Budgets and Expenditure Reports (5) Contracts (6) Indirect Cost Plan (7) Shared Costs Documentation (8) Fair hearing and civil rights complaints and all related documentation (9) Federal, State, District, County Audit reports (10) Copies of manual vouchers (11) Dual Participation Report (12)TAD's
3. The following documents must be retained for one (1) year plus the current year:
I. Waiting List 2. Voucher Packing List
4. The following documents may be destroyed after the required correction, verification, and reconciliation has been completed:
(1) Dual Participation Report* (2) Cumulative Unmatched Redemptions Part 1* (not matched to issuance
record) (3) Cumulative Unmatched Redemption Part 2* (not matched to a valid
certification record) (4) Batch Control Report (5) Batch Control Form and Module (6) Critical Error Report (7) Canceled food instruments
*The original copy of these reports with their manual reconciliation must be sent to the State WIC Office prior to being destroyed. The State WIC Office will maintain these reports for four (4) years.



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GA WIC PROCEDURES MANUAL
5. The following documents will be maintained on microfiche at the State WIC Office for a period of three (3) years plus the current Federal Fiscal Year. These documents may be destroyed by the local agency when they are no longer useful to the districts and/or clinics:
a. Monthly Reconciliation - Enrollment Cycle
1. Alphabetic Master File Listing 2. Critical Error Report 3. Enrollee Income by Household Size 4. Grady Hospital Enrollee Distribution 5. Medicaid-Enrollee Income by Household Size 6. Medicaid-Percentage of Poverty Income by Type and Age Categories 7. Medicaid-Priority Counts by Percentage by Poverty Income Level 8. Numeric Master File Listing 9. Percentage of Poverty Level Income Level by Type and Age Categories 10. Priority Counts by Percentage of Poverty Income Level 11. Trimester Analysis Report 12. Unduplicated Participation Report State Fiscal Year 13. Unduplicated Participation Report Federal Fiscal Year 14. Waiting List Report 15. WIC Status (Type) by Reason Certified
b. Monthly Reconciliation
1. Bank Exception Report 2. Bank Listing 3. Closeout Reconciliation Report 4. Cumulative Unmatched Redemptions Over 30 Days-Part 1 5. Cumulative Unmatched Redemption Over 30 Days Based on CUR-Part2 6. DU/County Compliance Summary (Cone. Pwdr. RTF) 7. Dual Participation Report-Part 1 8. Ethnic Enrollment and Participation by Priority Issue 30 Day and
Closeout 9. Ethnic Participation Summary 10. Financial and Program Status 11. Food Cost Allocation (Projection) 12. Food Package Create Report 13. Food Package Expenditures Report 14. Infant Formula Rebate Report (Cone. Pwdr. RTF) 15. Infant Rebate County Summary
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GA WIC PROCEDURES MANUAL

16. Infant Rebate District Unit Summary 17. Migrant Participation Summary 18. Migrant Enrollment and Participation by Priority Issue. 30 Day and
Closeout 19. Monthly Report of Food Expenditures Summary Issue. 30 Day and
Closeout 20. Monthly Report of Food Expenditures by Vouchers Code Issue 30 Day
Closeout 21. Participant Totals 22. Participation Summary by District/Unit 23. Previously Unmatched Redemptions Which Were Matched 24. System Maintenance Indicators 25. Unmatched Redemptions Report
c. Monthly Reconciliation - Vendor Cycle

1. Cumulative Vendor Totals

2. Detailed Flagged Voucher Listing

3. Flagged Voucher by Vendor per Peer Average

4. Maximum Amount Input Update

5. Statistics File for Vouchers

6. Vendor Exception Report

7. Vendor Listing



8. Vendor Update Listing

9. Vendor Voucher Deviation Report

10. Voucher Redemption Fluctuation Report

11. Voucher Variation Report

12. Voucher by Day Cashed

13. Vouchers Cashed by Clinics

14. Financial Records



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GA WIC PROCEDURES MANUAL

II. WIC ACRONYM AND LOGO

A. Authority
The acronym "WIC" was registered with the U.S. Patent and Trademark Office January 1, 1991. The WIC logo a stylized representation of a woman holding an infant in her arms and a child by the hand was registered April 16, 1991. Regulations authorizing the use of the WIC acronym and logo are provided in 42 U.S.C. 1786, 15 U.S.C. 1051 et seq., and 7 CFR Part 246.

It is an on-going policy to discourage industrial use of the WIC acronym and logo on products to avoid certain difficulties that may be encountered.
B. Official Use
Use of the acronym "WIC" and the WIC logo is reserved for the official use of national, regional, state, and local agencies administering the WIC Program. FNS instructions and policies restrict use to purposes consistent with the WIC Program regulations. Materials which display WIC identifiers will be used primarily for identification, public notification, and outreach purposes. Below is a list of the possible uses of the WIC acronym and logo. This list is not inclusive and there may be other WIC ideas. FNS reserves the right to approve any use of the WIC acronym or logo.

Brochures Bulletins Business Cards (for employees) Cups Directories Food Instruments Forms (i.e. Cert. forms) Guides Immunizations Initiatives

Leaflets Letters Manuals Newspapers Posters Radio and T.V. Announcements Reports Studies T-shirts

C. Special Use

1. Profit and Non-Profit Organizations -The WIC logo and acronym can not be used by for-profit organizations. These organizations are not permitted to display the acronym or logo in total, or in part including close facsimiles on any product or materials they produce. Non-profit organizations may be permitted to use the acronym and/or the logo for non-commercial educational purposes when such use is essential to public service and will contribute to public information and education concerning the WIC Program. Nonprofit organizations are those organizations that are exempt from taxation under Federal law, including charitable and educational organizations. Nonprofit organizations within the jurisdiction of the state of Georgia shall submit a request for use of the WIC acronym or logo to the State WIC Office in writing. The written request must

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GA WIC PROCEDURES MANUAL
include a copy/sample of the way in which the acronym or logo will be used. The State Office must respond in writing on whether such use is authorized.
2. WIC Food Vendors
At the discretion of the State WIC Agency, in a standard contract or agreement a vendor may be authorized to use the acronym and/or logo for the following purposes: a. To identify the retailer as an authorized WIC food vendor.
b. To identify authorized WIC foods by attaching channel strips or Shelf-talkers stating "WIC-approved" or "WIC-eligible to Grocery store shelves.
FNS reserves the right to approve any uses of the WIC acronym or logo; and any uses that are considered inappropriate shall be discontinued. Request for use of the WIC Acronym or Logo must be made in writing along with a copy/sample of the way it will be used. A written response will be issued on whether such use is authorized .
D. Unauthorized Use
Any person who uses the acronym "WIC" or the WIC logo in an unauthorized manner, including close facsimiles thereof, in total or in part, may be subject to injunction and the payment of damages. Any person who is aware of violators should provide the information to the Food Nutrition Services (FNS) .



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GA WIC PROCEDURES MANUAL
III. LOBBYING RESTRICTIONS The State/Local Agency must not use federal funds for lobbying for specific federal awards and requires recipients of any federal grants, contracts, loans, and cooperative agreements to disclose expenditures made with their own funds for such purposes.





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GA WIC PROCEDURES MANUAL
IV. CONFIDENTIALITY
The State/local agencies are required to restrict the disclosure of information obtained from any program applicant/participant.
WIC program information must not be released except in the following situations: 1. The WIC applicant/participant signed a release of information. (See Attachment AD-12)
2. The State or local agencies enter into a written agreement with an organization (i.e. immunization). This agreement must be signed by the Director of Public Health. In the event an agreement is entered into with the organization and the Director of Public Health, a release of information would not need to be signed by the WIC applicant/participant. Information shared with that agency however, is restricted (see Attachment AD-11 ). Note: The WIC Certification and Rights and Obligations Form has been revised to meet these requirements.
3. For the Comptroller General of the U.S. for audit and examinations authorized by law.
Disclosure of information with other organizations may be used for the sole purpose of:
1. Determining eligibility for programs administered by the recipient organization. 2. Conducting outreach for the program.
NOTE: Information on the use of drugs and alcohol must not be shared.



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GA WIC PROCEDURES MANUAL
V. FAXING CONFIDENTIAL INFORMATION
If your District/Clinic makes the decision to fax confidential information, you should incorporate the Confidentiality Provision" statement into your fax cover sheet information. The following represents an example of such a statement:

"This message is intended only for the use of the individual or entity to which it is addressed and may contain information that is privileged, confidential and exempt from disclosure under applicable law. If the reader of this message is not the intended recipient or the employee or agent responsible, the dissemination, distribution or copying of this communication is strictly prohibited. If you have received this communication in error, please notify us immediately by telephone and return the original message to us at the above address."





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GA WIC PROCEDURES MANUAL
VI. WIC VOLUNTEERS AND CONFIDENTIALITY
In order to prevent a breach of confidentiality, the Georgia WIC Program must exercise discretion in screening and selecting capable volunteers who would have access to confidential information. It is therefore the responsibility of the local agency to ensure that volunteers who are given access to client information are well-trained and knowledgeable of the restrictions in disclosure of patient information.
The following action steps must be taken in order to maintain participant information: 1. Once volunteers are selected, specific confidentiality requirements governing the WIC
Program must be covered in the orientation or training of volunteers.
2. Follow-up training must be conducted periodically to remind volunteers, as well as paid staff, of the importance of maintaining the confidential nature of participant information.
3. The selecting agency may have volunteers sign an agreement acknowledging restriction on the disclosure of confidential information. By signing such a form, the volunteer would agree to keep information confidential or forfeit the volunteer assignment. Such an agreement would reinforce the importance of maintaining confidential participant information .
4. If a potential volunteer does not appear to be a good candidate for keeping information confidential, there may be other activities that the person can perform that would not include access to participant information.



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GA WIC PROCEDURES MANUAL
VII. RETROACTIVE BENEFITS AND REIMBURSEMENTS WIC regulations do not provide for retroactive benefits and reimbursement regardless of the circumstances. The WIC Food Packages are designed to be consumed within a specified time period when participants are experiencing critical growth and development.





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GAWICPROCEDURESMANUAL
VIII. MANDATORY NO-SMOKING POLICY IN LOCAL WIC CLINICS
Public Law 103-111 prohibits the allocation of Administrative Funds to any clinic providing WIC services if that clinic allows smoking within the space used to perform program functions. In order to avoid administrative penalties, Local Health Department or WIC Clinics must display a "No Smoking Sign." These signs must be visible somewhere in the clinic.
The prohibition against smoking applies only during the hours of actual WIC operations. In the event the clinics for voucher issuance is being held at a satellite clinic (i.e. church, public housing clinic site, community health center only once or twice per week) then the no-smoking policy would only be in effect during WIC operation hours. If the health department is a nosmoking facility, and such signs are displayed throughout the health department, then there is no need to display a WIC specific no-smoking sign.





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GA WIC PROCEDURES MANUAL

IX. SUBPOENAS

I.

Subpoenas

A subpoena is a request for information issued by a clerk of a court in response to a request by an attorney representing a party. A subpoena may be directed to an individual or an entity. In the event, the local agency receives a subpoena, please follow the instructions below. Also, please contact the State WIC Office for legal advice.
II. Procedures For Responding To A Subpoena

* State or local agencies, in consultation with their legal counsel, must make a determination based on the content of the subpoena and the requested information whether or not to comply with the subpoena and release the information as requested or to attempt to quash the subpoena. In making the determination, State or local agencies must determine whether the information is protected under 7 CFR 246.26(d) of the WIC regulations.
* Decisions to release WIC information as requested by a subpoena or to attempt to quash a subpoena must be based on the requirements and restrictions set forth in 7 CFR 246.26(d) of the WIC regulations, any pertinent State laws, FNS Instruction 800-1, and WIC Policy Memorandum 94-3. Any conflicts identified between Federal and State requirements should be referred to the DHR Legal Services, where appropriate.
* If the court denies the motion to quash the subpoena and requires the WIC State or local agency to release the requested information, the State or local agency or legal counsel acting on its behalf shall attempt to:
consider the appropriateness of an appeal of the decision,
ensure information produced is only what is essential to respond to the subpoena (i.e. provide related documents reflecting only the requested WIC information), and
attempt to negotiate the extent to which the WIC information actually produced becomes public information (i.e. reviewed in camera by the court, limited entry into the public record).



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GA WIC PROCEDURES MANUAL
* If the motion to quash the subpoena is denied by the court, we recommend that legal counsel acting on behalf of the State or local agency request the parties reduce to writing theterms of the release of the subpoenaed information so that all parties are in accord as to the use of such information:' Ideally, counsel should seek a warrant of attachment or similar court order. A warrant of attachment is a written order by the court based on State law which orders a law enforcement officer to seize specific documents and deliver them to the court, essentially forcing the State or local agency to comply. In this way, there is a record that WIC State or local officials disregarded the Federal law protecting the confidentiality ofWIC records only after having been compelled to do so by a court.
* State or local agencies should advise and consult legal counsel if any formal complaint form or notice of litigation by a program applicant or participant is received as a result of the State or local agency releasing WIC information in response to a subpoena or search warrant.
* In some instances, a State or local agency may be required to release confidential information in response to a subpoena or search warrant. However, if the release of such information is made pursuant to and in keeping with WIC Program regulations, instructions, and policy, that release will not result in FNS or its agents taking adverse action against the State and local agency or any individuals acting on their behalf.



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GA WIC PROCEDURES MANUAL
X. SEARCH WARRANTS
In addition to the issuance of subpoenas, search warrant have been used by police investigators to obtain WIC applicant and participant information. State and local agencies must comply with search warrants. A search warrant differs from a subpoena in which a time frame is established to either comply with the subpoena or attempt to quash the request. Failure to fully comply with a search warrant at the time it is served could result in the incarceration of WIC State and local agency staff.





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GAWICPROCEDURESMANUAL

XI. PROGRAM PARTICIPATION

Definition: A participant is a pregnant, postpartum or breastfeeding woman, infant, or child who is certified to receive WIC vouchers. Program participation is the sum total of participants who receive vouchers during a specified reporting period. Participation is a valuable indicator for the WIC Program operations and must be monitored on a regular basis. The participation reports generated by data processing contractors are tools for monitoring program participation.

Non-Participation: Non-participation is determined by vouchers created (manual or computer) for a WIC ID that are returned voided to the bank or data processing contractor. Participants in a valid certification period who do not pick-up or redeem vouchers are counted as non-participants. Non-participants rates above the state standard of 10% is considered a deficiency in Program Management and Operations.

1. The designated state staff will contact the WIC Coordinator whose district(s) has a clinic(s) with a non-participation rate above 10% by telephone.

2. Within twenty (20) days of the telephone call, the Coordinator must submit a written report

(see Attachment AD-I 0) which includes the following:



a. The possible reason(s) for the rate of non-participation. b. Plan for correction (including objective(s), action steps, milestone timeframes,
monitoring plan, re-evaluation plan). The coordinator will have ninety (90) days to improve the non-participation rate.

3. If the non-participation rate has not improved by the end of the ninety (90) day action plan period, state staff will provide on-site technical assistance.

4. _The Non-Participation Rate/Technical Assistance Summary Report (Attachment AD-10) will be used to document district response to the non-participation report.

When a technical assistance visit is required, the following procedure will be followed:

a. State staff will contact the WIC Coordinator to schedule the date and time. This technical

assistance visit must be scheduled within thirty (30) days from the last day of the ninety

(90) day action plan period.





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GAWICPROCEDURESMANUAL
b. Training will be district or clinic specific at the discretion of the WIC Coordinator and designated state staff.
Follow-up monitoring of Local Agency action will begin after two (2) months of successively high no show rates.





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GAWICPROCEDURESMANUAL
XII. SYSTEM MAINTENANCE INDICATOR REPORT
In an ongoing effort to assist with improving overall program operations statewide, the Program Management and Review Unit (PMR) Staff will contact WIC Program district staff by phone or arrange an on-site technical assistance visit concerning the rates on the System Maintenance Indicator Reports. The Systems Unit at the State WIC Office will assist the Program Management and Review Unit with any necessary training needed to improve the overall rates of these indicators in the State. Additionally, data collected from reports will be forwarded to the district under separate cover.
Any District whose rates are above the State average will be contacted by phone. (the NonParticipation Rate must be .:S 10%).
The PMR staff and District will follow the procedures outlined in Attachment AD-8. Attachment AD-9 (The SMI/Technical Assistance Report) is a copy of the report that will be completed by the State staff. A copy of this form will be forwarded to your District. Attachment AD-10 is the SMI Technical Assistance Summary Report.



AD-41



GA WIC PROCEDURES MANUAL XIII. DOCUMENTATION
All WIC documentation must be written in Blue or Black ink or typed. NEVER use a pencil.





AD-42



GAWICPROCEDURESMANUAL
XIV. ESTABLISIIlNG NEW CLINICS/CLINIC CHANGES
All local agencies must submit clinic changes to the State WIC Office within thirty (30) days of the date the change occurs.
Clinic changes are reported using the "Request for Establishing New Clinic/Clinic Changes" Form (Attachment AD-13). 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.
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 via telephone.
2. The State WIC Office Systems Information Unit will forward to the requesting agency a Request to Establish New Clinic /Clinic Changes Form within five (5) days from the date of the request.
3. The Local Agency co~pletes the form (see Attachment AD-13) 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 the date of receipt.
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 (i.e., TAD, Vouchers, etc.).
7. The State WIC Office will provide technical assistance, consultation, and training to the Local Agency in the start up procedures of a new clinic.



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GA WIC PROCEDURES MANUAL
XV. CLINIC CLOSINGS
In the event a clinic is going to be closed temporarily due to some emergency or meeting, please notifiy the Policy Unit at the State WIC Office as early as possible. This will enable the local/state staff to better serve the applicants/participants and clinic staff. Closing of clinics causes the participants/applicant hardship when they are not notified in writing or in advance.
If your district plans to close a WIC clinic permanently, please complete the Clinic Change form and mail it to the WIC Office System Unit.





AD-44



GAWICPROCEDURESMANUAL SAMPLE FORMULAS

ATTACHMENT AD-1

1. RATE FOR SERVICES PROVIDED <RFS)

The following may be used to compute a RFS:

Step 1.

Employee A: (# hrs. worked*) x (hourly pay**)= $(A) Employee B: (#hrs.worked*) x (hourly pay**)= $(B)
etc.

Step 2. $(A) + $(B) + $(C) + $(D)... = $$

Step 3.

$$

= Rate Per Participant or Assessment

# participants*** (cost per participant or assessment)

OR

# assessments***



* The source for this data is the RMSS data collection sheets. Data must be collected on WIC and non-WIC paid personnel to substantiate all WIC costs, however, the employees in Step 1 must be non-WIC paid personnel only.
NOTE: You do not include WIC paid employees when computing a rate for reimbursement because WIC paid employees have already been paid with WIC funds and to include them in the rate would mean paying them twice.
** To Compute an Employee's Hourly Pay:
NOTE: Those employees who receive fringe benefits must have these benefits included in their hourly pay rate.
Step 1. Salary x Fringe Benefit Rate = F
Fringe benefits are a percentage of the employee's salary. They are the combined total of . FICA, retirement, and health insurance. This rate periodically changes and the most current rate should be used.
Step 2. F +Salary= Total Salary (incl. fringe) Step 3. Yearly Salary/hours per year= Hourly Rate

AD-45



GAWICPROCEDURESMANUAL

ATTACHMENT AD-1

Monthly Salary/hours per month= Hourly Rate

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

2. FULL-TIME EQUIVALENTS <FTE's}

The following may be used to compute FTE's:

Step 1. individual's time worked performing WIC duties
individual's total time worked

x 100% =

% of time spent performing WIC duties (P)

Step 2. (P) x (individual's hourly/monthly pay*) = portion of hourly/monthly pay to be reimbursed by WIC.

* Use the same formula used in "Rate" above.



AD-46



GAWICPROCEDURESMANUAL

ATTACHMENT AD-2

INFORMATION NEEDED FOR USDA APPROVAL OF NON-MAJOR ADP EQUIPMENT
1. Description of the ADP equipment to be purchased and the anticipated cost. If the cost is not to be borne solely by federal WIC administrative funds, the funding sources should be itemized.
2. Identification of the intended user(s).
3. Explanation of the program functions which the ADP equipment would perform.
a. The explanation must be detailed and specific. b. If the equipment is not to be used solely for WIC
administration/operations, the application must demonstrate that its use for WIC purposes will be commensurate with WIC participation in its cost.
4. Explanation of the cost benefits the local agency anticipates will result from the acquisition of the ADP equipment (such as reduced cost per certification). The explanation must show:
a. Why management information systems already in the place (such as the state food delivery ADP system) cannot meet the need which is why the local agency is proposing to acquire additional ADP equipment.
b. The local agency has considered all possible options and identified the proposed ADP acquisitions as the most cost effective. Example of options the local agency should consider might include: 1. Performing the functions manually; 2. Arranging for the function(s) to be performed by a contractor, by the state, or by another unit of the local agency. 3. Purchasing other types of ADP equipment.
5. Explanation of how the proposed ADP acquisition conforms to an overall longrange plan for the acquisition and use of ADP hardware, software, and services.
6. Certification that the procurement methods are m compliance with state purchasing regulations.

AD-47



GAWICPROCEDURESMANUAL

ATTACHMENT AD-3

FFY 2000 GEORGIA MEMORANDUM OF UNDERSTANDING/MASTER AGREEMENT

PROGRAMMATIC REPORTING REQUIREMENTS

FY 2000

ANNEXH

PROGRAM NAME: PROGRAM CODE:


Women Infant and Children (WIC) Program
301 WIC Cost Pool 007 WIC Nutrition Services 009 WIC Breastfeeding

AD-48



GAWICPROCEDURESMANUAL

ATTACHMENT AD-3

FFY 2000 GEORGIA MEMORANDUM OF UNDERSTANDING/MASTER AGREEMENT
BETWEEN STATE AND LOCAL AGENCIES
FOR THE SPECIAL SUPPLEMENTAL FOOD PROGRAM
FOR WOMEN, INFANTS, AND CHILDREN (WIC)



This provider agreement is made pursuant to the Georgia Department of Human Resources (DHR) Administrative Policy and Procedures Manual, Part II A.I., 'Administration of Grants;' and; United State Department of Agriculture/Food and Nutrition Services (USDA/FNS) 7 CFR 246.6, Agreements with Local Agencies. This agreement is between the Georgia Department of Human Resources, Division of Public Health hereinafter referred to as the "Georgia WIC Branch" and the District Health Program hereinafter referred to as the "Local Agency." This agreement is effective the first day of July 1, 1999 and shall continue for one (1) year unless revised or terminated as provided herein.
This agreement must be signed annually by the District Health Director and the Director of Public Health.
THE STATE AND LOCAL AGENCY AGREE:
1. To comply with the State of Georgia requirements for Year 2000, certification and compliance testing and the Georgia OHR Administrative Policy and Procedures and OHR Grants-to-Counties Policies for Administration of Funds.
2. To collect data as required by the Georgia WIC Branch.
3. To ensure that all WIC Participants data or other information is collected and maintained within state and federal confidentiality requirements.
4. To further comply with USDA program regulations 7 CFR 246.6, and State Policies and Procedures as outlined in the Georgia WIC Branch State Plan of Operation and the Georgia WIC Branch Policy and Procedures Manual.
THE STATE AGENCY AGREES:



1. To allocate administrative funds on an annual basis to the Local Agency in meeting all allowable administrative, nutrition education, breastfeeding and client service expenses of the Georgia WIC Program as indicated by documented costs.
2. To pay cost of food vouchers issued by the Local AgE!ncy and redeemed by retailers for eligible participants.
3. To monitor and evaluate the Local Agency to insure maximum effectiveness and efficiency; to provide technical assistance and consultation; and to provide training for Local Agency staff on a routine basis and as requested.
4. To provide specific manuals, forms, and nutrition education materials required for operation of the Georgia WIC Program as specified in the Georgia State Plan of Operation.
THE LOCAL AGENCY AGREES:
1. To employ and train competent professionals and clerical staff to carry out WIC responsibilities: and to provide necessary facilities and equipment to perform WIG assessment and certification procedures. Competent professional authorities must perform WIC nutritional assessments as prescribed by federal regulations.
2. To make appropriate WIC health services available to participants in accordance with USDA income guidelines, and nutritional criteria; and refer applicants to other available health and social services.
3. To maintain and have available for the State and Federal agency all documentation required for standard review, special review, audit and evaluation, all criteria used for certification including information on the areas served, income

AD-49



GA WIC PROCEDURES MANUAL

ATTACHMENT AD-3

guidelines, and specific criteria used to determine nutritio!lal risk. A review and site visit may be made at any time by the Georgia WIC Branch and Office of Nutrition Staff.
4. Any forms designed by the Local Agency used in the WIC certification process must receive prior approval from the Georgia WIC Branch.
5. To ensure timely submission of responses to all required and requested program information including but not limited to reports, program reviews, policy, action and information memorandums. When warranted, corrective action plans must be developed and implemented to correct program deficiencies in accordance to Georgia WIC Branch policies and procedures.
6. To conduct self-reviews annually for evaluation of local program operations and assessments of program accomplishments in accordance with WIC Regulations Subpart F 246.19(b)(6) and Georgia WIC Branch guidelines for program monitoring. Documentation of reviews will be maintained and made available for program audit purposes. Self-review locations and dates of review must be submitted by September 30 of each year.
7. To ensure that no employee nor applicant for employment will be discriminated against on the basis of race, color, national origin, age, sex, or handicap.
8. To comply with Title VI of the Civil Rights Act of 1964 (P.L. 88-352) and all requirements imposed by the regulations of the Department of Agriculture (7 CAR Part 15), Department of Justice (28 CAR parts 42 and 50), and FNS directives or regulations issued pursuant to that Act; to the effect that, no person in the United States shall on the grounds of race, color, national origin, age, sex or handicap be excluded from participation in, be denied the benefits of, or be otherwise subject to discrimination under any program or activity for which the program applicant received federal financial assistance from the Division of Public Health and hereby gives assurance that it will immediately take any measures necessary to effectuate this agreement.
9. To conduct Public Hearings in the local service area in accordance with WIC Regulations CFR 246 Subpart B 246.4. The Public Hearings solicit public comments on the State Plan, and give local citizens an opportunity to comment on services provided to them. Correspondence announcing the Public Hearing must be made available to the general public, to special interest groups and to organizations serving significant numbers of eligible persons. All Public Hearings must be completed by April 30 each year, and proceedings from the hearing must be submitted to the Georgia WIC Branch by June 1 for inclusion in the State plan.
10. To make available to the Georgia WIC Branch and the Office of Inspector General (OIG) all WIC participants' medical records or other documentation, which substantiate the provision of service and the cost, incurred to serve WIC participants.
11. To comply with program regulations that ensure program accessibility for participants and applicants identified as special populations. Including but not limited to communication capabilities for non-English speaking individuals and vision and hearing impaired individuals, and facility accessibility for persons with disabilities. All facilities where WIC related services are provided must be accessible from the outside and on the inside. Bilingual staff, volunteers, and translation resources should be available to serve non-English speaking clients as appropriate.
12. To comply with basic requirements for local agency participation in the development of the Georgia WIC State Plan consistent with WIC Regulations 19 246 Subpart B, the Local Agency will develop and submit for inclusion in the State Plan a three-year program plan beginning FFY '2000. This plan will cover 2000 -2002. By September 1, the Local Agency shall submit the program plan to the Georgia WIC Branch. However, the narrative summary of the plan must be submitted to the Georgia WIC Branch by November 30. The plan must include, but not limited to: a narrative summary of program objectives and accomplishments for the preceding fiscal year; a plan for the early enrollment of pregnant women; objectives and interventions to improve and/or expand WIC operation and administration for the coming fiscal year. Objectives must be developed in accordance with the following program functions: (Local Agencies Monitoring Plan, Non-Participation Plan, Collaboration with Immunization, Vendor Monitoring Plan, Food Instrument and Quality Improvement Plan (for security reasons) and Early Trimester Enrollment. The Nutrition Education portion of the Georgia WIC State Plan must be in accordance with WIC regulations 246-ll(d)(2) and FNS guidelines. Also submit an annual Local Agency Breastfeeding Promotion Plan.
13. To implement the Food Delivery System agreed upon between the Georgia WIC Branch and Local Agency, under terms prescribed by the Georgia WIC Branch as necessary to implement a uniform system in accordance with WIC regulations

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GAWICPROCEDURESMANUAL

ATTACHMENT AD-3

and approved by the Food and Nutrition Services (FNS). The Local Agency will execute an agreement with all vendors providing WIC foods in the local service area in accordance with Georgia WlC Branch instructions. The Local Agency will monitor participating vendors in accordance with the terms of the Vendor Provider Agreement.
14. To maintain complete and accurate documentation of allocated funds received and expended, employing Generally Accepted Accounting Principles (GAAP) and to make these records available for audit upon request by the State or Federal Agency. To establish budgets for RMSS Cost Pool expenses, direct Nutrition Education expenses and direct Breastfeeding expenses. In the cases of an audit exception the Local Agency may be responsible for repayment to the Georgia WIC Branch from the Local Agency's non-participating funds.
15. To request and obtain through the Georgia WIC Branch prior approval for all capital expenditures, insurance and identification, subcontracts, management studies, equipment purchases and maintenance and/or rental agreements.
16. To implement a security system for unissued food instruments (vouchers) which will protect and reduce the risk of onsite lost/stolen vouchers. In the event unissued vouchers are lost or stolen resulting in USDA sanctions. The Local Agency may be responsible for repaying the Georgia WIC Branch for the value of those food instruments.
17. To ensure that Dual Participation Reports are submitted to the Georgia WIC Branch quarterly.
18. To provide nutrition education services to participants in compliance with 7 CFR 246.11 and FNS and State policies guidelines and instructions.
19. To provide breastfeeding promotion and support services to participants in compliance with 7 CFR 246.11 and FNS and state policy guidelines and instructions.
20. To insure that appropriate actions are taken to guard and protect all automated systems and data elements in the event of a disaster or emergency affecting the operation of a local agency (or agencies) and to have a disaster recovery plan available for Georgia WIC Branch review.
21. To perform full system backups on a daily basis for processing WlC applicants, generating vouchers and to secure the media used to retain the backup in a secure location. This includes all WlC systems.
22. To ensure the Cumulative Unmatched Redemption Reports are submitted to the Georgia WIC Branch on a monthly basis.
23. To ensure all hardware, software and telecommunication devices used by the Local Agency and each county under the aegis of the Local Agency, are tested and certified as being year 2000 compliant and consistent with core systems requirements as prescribed by the Georgia WIC Branch.
24. To meet program performance requirements as defined by USDA, the Georgia WlC program is required to expend not less than1/6 of its administrative funds on nutrition education. Each local agency is expected to expend approximately 1/6 of its administrative grant (GIA) for nutrition education.
25. Federal regulations require the Georgia WlC Branch to spend 97% of its food grant dollars. Failure to meet this mandate may result in the imposition of a penalty. To be consistent with the federal mandate each Local Agency will be expected to serve a minimum number of WlC participants as determine by the Georgia WIC Branch.





GA WIC PROCEDURES MANUAL

ASSURANCE

ATTACHMENT AD-3

This assurance is given in consideration of and for the purpose of obtaining any and all federal financial assistance, grants, and loans of federal funds, reimbursable expenditures, grants, or donation of federal property and interest in property, the detail of federal personnel, the sale and lease of, and the permission to use, federal property or interest in such property or the furnishing of services without consideration or at a nominal consideration, or at a consideration which is reduced for the purpose of assisting the recipient, or in recognition of the public interest to be served by such sale, lease, or furnishing of services to the recipient, or any improvements made with federal financial assistance extended to the program applicant by the State. This includes any federal agreement, arrangement, or other contract, which has as one of its purposes, the provision of assistance of food service equipment or any other financial assistance extended in reliance on the representations and agreements made in this assurance.

By accepting this assurance, the program applicant agrees to compile data, maintain records, and submit reports as required, to permit effective enforcement of Title VI and to permit authorized USDA personnel during normal working hours to review such records, books, and accounts as needed to ascertain compliance with Title VI. If there are any violations of this assurance, the Department of Agriculture, Food and Nutrition Service, shall have the right to seek judicial enforcement of this assurance. This assurance is binding on the program applicant, its successors, transferees and assignees as long as it receives assistance or retains possession of any .assistance from the State. The person or persons whose signatures appear below are authorized to sign this assurance on behalf of the program applicant



Either party upon sixty-(60) days written notice may terminate this provider agreement. Non-renewal of this provider agreement is not cause for appeal.
The Local Agency has the right to appeal decisions of the Georgia WIC Branch which affect program participation as specified in 7 CFR 246.24, Administrative Appeals. A Local Agency is allowed two opportunities to reschedule a hearing.

Authorized Signatories:

In witness whereof the parties have here unto affixed their signatures and dates.

Kathleen Toomey, M.D., M.P.H. Director Division of Public Health or designated representative
DATE:_ _ _ _ _ _ _ _ _ _ _ __

District Health Director or the designated representative acting collectively for the Counties in District~--Unit'--------
DATE:_ _ _ _ _ _ _ _ _ _ _ _ _ __

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GA WIC PROCEDURES MANUAL
MAIL AGREEMENT TO:

ATTACHMENT AD-3

Georgia Department of Human Resources Division of Public Health C/o Alwin K. Peterson, Director Women, Infants and Children (WIC) Program Branch
#2 Peachtree Street
8th Floor, Suite 300 Atlanta, Georgia 30303 Telephone Number: (404) 657-2900 Fax: (404) 657-2910



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GAWICPROCEDURESMANUAL

CONTRACT BUDGET

ATTACHMENT AD-4

ANNEX_ _ _ _ _ _ _ __



Contract Period A. Personal Services
Salaries Fringe Benefits Other
B. Supplies
C. Printing
D. Equipment Office Facility
E. Contractual Client Services Per Diem & Fees Consultants
F. Travel
G. Client Transportation
H. Space Rent
- Utilities
I. Audit
J. Insurance/Bonding
K. Other (specify)

CONTRACT BUDGET
to



BUDGET GRAND TOTAL Narrative Justification:
* Travel Reimbursement to a contractor from funds provided under this contract shall not exceed the rates
established in the Statewide Travel Regulations.
AD-54

GAWICPROCEDURESMANUAL

ATTACHMENT AD-5



MONTHLY EXPENDITURE REPORT
CONTRACTOR NAME: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ CONTRACT NUMBER:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
CUMULATIVE CONTRACT EXPENDITURE REPORT ]MONTHLY ]]QOUTHARERTE_RL_Y _ _ _ _ _ _ _ _ _ _ __

PRIOR CUMULATIVE

TYPE EXPENSE
A. Personal Services Salaries Fringe Benefits Other
B. Supplies

APPROVED BUDGET AMOUNT

PRIOR CUMULATIVE CONTRACT EXPENDITURES

MONTH OF EXPENDITURES FOR REIMBURSEMENT.



C. Printing
D. Equipment Offices Facility
E. Contractual Client Services Per Diem & Fees Consultants
F. Travel
G. Client Transportation
H. Space Rent Utilities
I. Audit
J. Insurance/Bonding
K. Other (Specify)

BALANCE

TOTALS Payment Amounts



I, the undersigned, certify that the Expenditures reported have been made for Program accomplishments within the approved budgeted items:
Signed Date Submitted to DUR Division:

Date Received by DHR Division _ _ _ _ _ _ _ _ _ _ _ _ _ __ Approved for Payment: DHR Division Budget Officer

AD-55



GAWICPROCEDURESMANUAL

ATTACHMENT AD-6

WIC FORMS AVAILABLE IN CENTRAL SUPPLY

Contact: Cindy Woods

(404) 657-2900

FORMNAME

FORM#

Georgia Department of Human Resources
Division ofPublic Health/WIC Program I.D. Card - Box/500........................................................ (Spanish) #3793 (English)#3769 (Rev. 9-96)

2. Georgia Department of Human Resources Division of Public Health/WIC Program WIC Assessment/Certification Form Prenatal - Pad/I 00 ................................................................................................... #3296P (Rev. 2-99)

3. Georgia Department of Human Resources
Division ofPublic Health/WIC Program
WIC Assessment/Certification Form Postpartum/Non-Breastfeeding - Pad/I00.............................................................. #3296N (Rev. 2-99)

4. Georgia Department of Human Resources Division of Public Health/WIC Program WIC Assessment/Certification Form Postpartum Brestfeeding - Pad/100..........................................................................#3296B (Rev. 2-99)

5. Georgia Department of Human Resources Division ofPublic Health/WIC Program
WIC Assessment/Certification Form Infants - Pad/I 00 ...................................................................................................... #3299 (Rev. 2-99)

6. Georgia Department of Human Resources Division ofPublic Health/WIC Program
WIC Assessment/Certification Form Children - Pad/I 00 ................................................................................................... #3285 (Rev. 2-99)

7. Georgia Department of Human Resources Division ofPublic Health/WIC Program Batch Control Form - Pad/100 ................................................................................. #3762 (Rev. 5-92)

8. Georgia Department of Human Resources Division of Public Health/WIC Program
Invalid Participant ID Correction Form - Pkg/250 .................................................. #3763 (Rev. 7-95)

9. Georgia Department of Human Resources Division ofPublic Health/WIC Program Notice of Termination/Ineligibility/Waiting List - Pkg/250 ............................................................... (Spanish) #3009 (English) #3293 (Rev. 6-95)

10. Georgia Department of Human Resources Divis10n ofPublic Health/WIC Program Food List Brochure - Pkg/100 ................................................................................... #3777 (Rev.9-96)

11. Georgia Department of Human Resources Division of Public Health/WIC Program Food List Spanish Insert- Pkg/100 ...............................................................................................#3794

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GAWICPROCEDURESMANUAL

ATTACHMENT AD-6 (CONT'D}

12. Georgia Department of Human Resources Divis10n ofPublic Health/WIC Program Georgia WIC Program No Proof Form - Pacl/100 ....................................................................... #3019
13. Georgia Department of Human Resources Division of Public Health/WIC Program Georgia WIC Program Income Calculation Form - Pacl/100 ...................................................... #3020
14. Georgia Department of Human Resources Division of Public Health/WIC Program Georgia WIC Program Signed Statement of Income, Residency and Identification - Paci/I 00 ......................................................................... #3035



AD-57



GAWICPROCEDURESMANUAL
EQUIPMENT INVENTORY FORM

ATTACHMENT AD-7

WIC PROGRAM EQUIPMENT INVENTORY (3 Year Life Expectancy and-$1000.00 or Above) HEALmDISTRICT: _ _ _ _ _ _ _ _ _ _ _ _ _ __

INVENTORY NUMBER

DESCRIPTION

SERIAL NUMBER

LOCATION

PURCHASE PRICE

PURCHASE DATE

WICFUNDS EXPENDED



Inventory Completed by: - - - - - - - - - - - - - - - Date:- - - - - -



AD-58



GAWICPROCEDURESMANUAL

ATTACHMENT AD-8

SYSTEM MAINTENANCE INDICATOR TECHNICAL ASSISTANCE PROCEDURES

1. The designated State staff will contact the WIC Coordinator whose District's System Maintenance Indicator(s)indicates action needs to be taken. The purpose of the phone call is to discuss the indicators and make suggestions.

2. Within twenty (20) days of the telephone call, the Coordinator must submit a written report which includes the following:

a.

The possible reason(s) for the non-compliant rate.

b.

Plan for correction (including objective(s), action steps, milestone

timeframes, monitoring plan and re-evaluation plan).

The Coordinator will have (120) days to improve the non-participation rate and any other outstanding indicator.

3.

If the rate has not improved by the end of the (120) day action plan period, State staff

will provide on-site technical assistance.

4. The SMI/Technical Assistance Summary Report will be used to document District response to the SMI rates. (Attachment AD-15)

When a technical assistance visit is required, the following procedures will be followed:

a.

State staff will contact the WIC Coordinator to schedule the date and time.

This technical assistance visit must be scheduled within thirty (30) days

from the last day ofthe (120) day action plan period.

b. Training will be district or clinic specific at the discretion ofthe WIC Coordinator and designated State staff

AD-59



GA WIC PROCEDURES MANUAL

ATTACHMENT AD-9

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

DATE OF CONSULTATION: (by phone or site visit)

STATE STAFF:

DATE REPORT DUE TO STATE:

DISTRICT:

DISTRICT STAFF:

DISTRICT REPORT DATE:

1.

Reason for low non-participation rate:

2.

Which clinics are involved:

3.

Plan of action taken:

4.

Is Technical Assistance requested? Yes_ No

Report submitted by:_ _ _ _ _ _ _ _ _ _ _ _ __

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GAWICPROCEDURESMANUAL

ATTACHMENT AD-10

STATE WIC OFFICE SYSTEM MAINTENANCE INDICATOR/TECHNICAL
ASSISTANCE SUMMARY REPORT
State Report

District - - -Unit- - - - Coordinator's Name: - - - - - - - - - - - - - - - -
Date call was made to District: Date report (from the District) is due: (20 days) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ Actual date report received: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Non-Participation rate based on phone call:

Non-Participation Rate 80 days from the phone call:

Is a Technical Assistance visit needed? Yes

No

If yes, when is the date for the visit? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

The visit will cover:
- - - - - - - - - - - - District/Clinic - - - - - - - - - - - - District/Clinic
District/Clinic_ _ _ _ _ _ _ _ _ _ __

- - - - - - - - - - - - District/Clinic - - - - - - - - - - - - District/Clinic

AD-61



GAWICPROCEDURESMANUAL

ATTACHMENT AD-11

AGREEMENT FOR DISCLOSURE OF INFORMATION BETWEEN THE GEORGIA DMSION OF PUBLIC HEALTH
WIC PROGRAM and
THIS AGREEMENT is entered into between the Georgia Division of Public Health for the Special Supplemental Nutrition Program for Women, Infants, and Children, hereinafter referred to as WIC, and _ _ _ _ _ _ _ _ _ _ _ _ __, hereinafter referred to' as the Receiving Organization.
This agreement is entered into by both parties in accordance with Federal Regulation 7 CFR 246.26(d) which allows for the disclosure of specific WIC applicant and participant information (current and historical) for the purpose of (1) establishing the eligibility of the WIC applicant or participants for health or public assistance programs; and (2) conducting outreach to WIC applicants and participants. This agreement will be in effect for one year or until a written request is submitted by either agency to modify or cancel it.
THE PARTIES AGREE:
A. 1. WIC will provide the following applicant or participant information to the Receiving Organization as needed: information on the WIC Assessment/Certification Form or in the computer system including, but not limited to, name, address, phone number, social security number, ethnic origin, and birthdate;
2. Medical data will not be provided;
B. Receiving Organization agrees:
1. That the WIC Program information may be used only for the purpose of establishing the eligibility of WIC applicants and participants for health or welfare programs administered by the Receiving Organization, and for the purpose of conducting outreach to WIC applicants and participants for such programs.
2. The Receiving Organization agrees and assures that it will not disclose information provided by WIC under this agreement to a third party and that it will resist other efforts to obtain this information. It further assures that it will restrict the use or disclosure of WIC program information according to WIC guidelines, including 7 CFR 246.26(d).



Kathleen E. Toomey, M.D., M.P.H. Director
Division of Public Health
DATE

Director Receiving Organization
DATE

AD-62



GA WIC PROCEDURES MANUAL,_

ATTACHMENT AD-12

RELEASE OF INFORMATION FORM Georgia Department of Human Resources
Name of Client/Patient/Applicant

Date ofBirth
IF AVAILABLE:

ID Number Used by Requesting Agency

ID Number used by Releasing Agency

AUTHORIZATION FOR RELEASE OF INFORMATION

I hearby request and authorize: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
(Name of Person or Agency Requesting Information)

(Address)
to obtain from:------------,---.,..------------:-:------:----------
(Name of Person or Agency Holding the Information)

(Address)
the following type(s) of information from my records (and any specific portion thereof):



for the purpose o f : - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

All information I hereby authorize to be obtainedfrom this agency will be held strictly confidential and cannot be released by the recipient without my written consent. I understand that his
oauthorization will remain in effect/or: ninety (90) days unless I specify an earlier expiration date here: _ _ _ __



one (I) year.

(Date)

D

the period necessary to complete all transactions on accounts related to services provided

tome.

I understand that unless otherwise limited by state orfederal regulation, and except to the extent that action has been taken which was based on my consent, I may withdraw this consent at any time.

(Date)

(Signature of Client/Patient/Applicant)

(Signature ofWitness)

(fitle or Relationship to Client)

(Signature of Parent or Authorized Representative, where applicable)

USE THIS SPACE ONLY IF CLIENT WITHDRAWS CONSENT

(Date)

(Date this consent is revoked by client)

(Signature of Client)

AD-63



GAWICPROCEDURESMANUAL

ATTACHMENT AD-13

REQUEST TO ESTABLISH NEW CLINIC/CLINIC CHANGE

PURPOSE OF REQUEST: EST. NEW CLINIC

CLINIC CHANGE CLINIC NUMBER

B

EFFECTIVE DATE OF CHANGE

TYPE OF CHANGE

DIST/UNIT

DATE SUBMITTED

COUNTY#

COORDINATOR

CONTRACT# (IF LOCATED OUTSIDE OF HEALTH DEPT.)

CONTACT PERSON

NEW CLINIC NAME

MAILING ADDRESS

(NOT P.O. BOX)

PHONE#

ATTENTION:

CLINIC DAYS AND HOURS OF OPERATION

PURPOSE OF PROPOSED CLINIC (circle) monthly

re-certification nutrition education vendor issuance

Other (specify)

SCHEDULE OF VOUCHER ISSUANCE

(circle)

monthly

bi-monthly odd

bi-monthly even

PLEASE INDICATE IF TADS AND VOUCHERS ARE TO BE SlilPPED TO ANOTHER LOCATION OTHER THAN TlilS CLINIC

VOUCHER ORDERS SPECIAL VOUCHERS _ _ _ _ _ _ _ _ __
BLANK VOUCHERS _ _ _ _ _ _ _ _ __

TAD ORDERS BLANK TADS_ _ _ _ _ _ _ _ _ __
PREPRINlED TADS _ _ _ _ _ _ _ __

PREPRINTED VOUCHER PACKAGES

WOMEN(P&B) INFANTS

_ _ _ _ _ _PACKAGES _ _ _ _ _ _PACKAGES

WOMEN(N) CHILDREN

_ _ _ _ _ PACKAGES _ _ _ _ _ PACKAGES

PLEASE INDICATE A BEGINNING TAD NUMBER (EXAMPLE: CLINIC #123 WOULD BE 123000001 FOR THE BEGINNING TAD NUMBER _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
VIKING WILL ASSIGN A MAXIMUM NUMBER OF INDMDUAL VOUCHERS TO BE PRINTED. TlilS NUMBER WILL EQUATE TO I00 PACKAGES FOR WOMEN, I00 PACKAGES FOR INFANTS AND 100 PACKAGES FOR CHILDREN IF YOU WISH TO INCREASE TlilS NUMBER PLEASE INDICATE YES_ _ _ _ _NO_ _ _ __

AD-64





GA WIC PROCEDURES MANUAL

TABLE OF CONTENTS

Page

I.

Introduction .................................................................................................................. VN-1

II. Vendor Coordinator ..................................................................................................... VN-2

III. Enrollment of New Vendors ........................................................................................ VN-3

A. Application Requirements of Vendors............................................................. VN-3

B. Approval and Reauthorization Criteria for Vendors ........................................ VN-5

IV. Vendor Agreements ..................................................................................................... VN-7

V. Vendor Stamp .............................................................................................................. VN-9

VI. Vendor Training ......................................................................................................... VN-10

VII. Vendor Materials ....................................................................................................... VN-12

VIII. Monitoring ................................................................................................................. VN-13

A. Vendor Monitoring Procedures...................................................................... VN-13

B. Local WIC Agency Monitoring Procedures .................................................. VN-14

IX. Compliance Investigations ......................................................................................... VN-16

X. Vendor Sanctions ......................................................................:................................ VN-17

XI. Complaints Against Vendors ..................................................................................... VN-18

XII. Terminations/Disqualifications .................................................................................. VN-19

XIII. Vendor Fair Hearing Procedures ............................................................................... VN-22

XIV. High Risk Vendor Identification................................................................................ VN-24

XV. Minimum Inventory Requirements Waiver ............................................................... VN-25





GA WIC PROCEDURES MANUAL

Attachments:

Page

VN-1

Vendor Application Booklet .......................................................................... VN-26

VN-2

Application for Vendor Certification ............................................................. VN-45

VN-3

Vendor Input/Registration Document ............................................................ VN-47

VN-4

Vendor Agreement......................................................................................... VN-48

VN-5

Military Commissary Agreement .................................................................. VN-52

VN-6

Pharmacy Agreement ..................................................................................... VN-53

VN-7

Vendor Training Checklist............................................................................. VN-57

VN-8

Vendor Training Sign-In Sheet.. .................................................................... VN-58

VN-9

Vendor Handbook .......................................................................................... VN-59

VN-10

Cashier Training Pamphlet ............................................................................ VN-83

VN-11

Return Voucher Payment Log ....................................................................... VN-89

VN-12

Post Vendor Training Evaluation................................................................... VN-90

VN-13

Vendor Review Form (includes Price Report List) ....................................... VN-92

VN-14

Vendor Review Form Instructions ................................................................. VN-96

VN-15

Incident/Complaint Form ................................................................. '............ VN-100

VN-16

Vendor Profile Report .................................................................................. VN-101

VN-17

Vendor Application Booklet Cover Letter.. ................................................. VN-102

VN-18

Pharmacy Handbook .................................................................................... VN-103

VN-19

Minimum Inventory Waiver Contract Addendum ....................................... VN-126





GA WIC PROCEDURES MANUAL
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 .





VN-1



GA WIC PROCEDURES MANUAL
II. VENDOR COORDINATOR
It is the responsibility of the Local WIC Agency to designate one or more people to act as the local Vendor Coordinator. This person(s) will be responsible for all Local WIC Agency vendor activities and will be the primary contact person for the vendors in the district.





VN-2



GA WIC PROCEDURES MANUAL
III. ENROLLMENT OF NEW VENDORS
A. Application Requirements 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 WIC Approved Food Pamphlet (Form #3777), and the Vendor Review Form (Attachment VN-13). Applications are accepted each weekday and should be returned to the Local WIC Agency to be processed along with the Vendor Review Form that is completed by the vendor. The application process takes 45 working days for completion. Therefore, vendors who wish to receive approval or denial regarding WIC vendor authorization must submit a completed WIC application form 45 working days prior to the 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 applicants during the application process.
Local Agencies may consider using Attachment VN-17, which is a typical form letter that should accompany the application packet.
2. Application process:
1st - 5th working day: The Local WIC Agency will forward the Vendor Application for Certification with the Vendor Review Form (vendor's self review) to the State WIC Office within five working days.
6th - 20th working day: The State WIC Office will review the above documents within 15 working days for the following: a. The application will be reviewed for accuracy and a background check will be conducted. b. The vendor's prices will be analyzed. to ascertain if prices charged for WIC approved foods meet the state pricing standards. c. The vendor's Department of Agriculture and Food Stamp Program eligibility will be verified. d. The State WIC Office will fax/mail preliminary approval notices to the Local WIC Agency within this time period.



VN-3



GA WIC PROCEDURES MANUAL
e. The State WIC Office will fax and mail denial letters to vendors and the Local WIC Agency within this time period. Denied vendors may correct deficiencies within 35 working days of denial. If a vendor does not correct the deficiencies within 35 working days of denial, a new vendor application must be resubmitted to the Local WIC Agency.
21st - 35th working day: Upon receipt of the State WIC Office preliminary approval of a vendor, the Local WIC Agency will conduct an on-site monitoring visit of the store and tentatively schedule vendor training for new store personnel (owners/manager/cashiers/etc.) within 15 working days. The following processes will take place during the Local WIC Agency review: a. Non-perishable items must be in the vendor's store within 15 days prior to store opening or change of ownership as specified in the WIC application. b. The Local WIC Agency must be allowed to conduct an unannounced on-site monitoring visit anytime during this 15 day period, during standard business hours (8am - 5pm). c. The Local WIC Agency will fax and mail the Vendor Review Form (pre-approval visit outcome) to the State WIC Office within this time period.
36th - 40th working day: 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 WIC Agency with a copy of the application and the vendor registration form. Therefore, the Local WIC 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 Agreement/Contract. b. If a vendor is denied, the State WIC Office will fax the notice to the Local WIC Agency within five 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 WIC Agency will cancel the tentatively scheduled vendor training session upon receipt of the denial notification. Vendor applicants may correct deficiencies within 35 working days of denial. If a vendor does not correct the deficiencies within 35 working days of denial, a new vendor application must be re-submitted to the Local WI C Agency.
VN-4



GA WIC PROCEDURES MANUAL
41st - 45th working day: New vendor training may take place if trammg did not 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.
46th - 75th day: The Local WIC Agency will conduct a new vendor on-site monitoring review within 30 days after WIC vendor authorization. The Local WIC Agency representative must conduct a vendor review of WIC approved perishable food items within 30 days after vendor authorization, only when WIC approved perishable food items were not available upon the pre-approval visit. The store must meet the WIC minimum inventory requirements for perishable and nonperishable WIC approved food items anytime the store is open for business.
3. The State WIC Office has the authority to deny a vendor applicant from WIC Program participation, if the applicant previously was an authorized vendor/manager that voluntarily withdrew from WIC Program participation with one or more of the following derogatory standings: High risk according to the State WIC Office's high risk indicator(s) Abusive by the State WIC Office's outlined sanctions Food Stamp Program disqualification
B. Approval and Reauthorization 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 proof that a sale took place by presenting a legitimate bill of sale that complies with the Bulk Sale Law of Georgia (see Georgia Official Code Annotated for the Law).
The Georgia WIC Program vendor selection criteria includes only "fixed stores" (i.e., pharmacy, grocery, and commissary stores) for WIC vendor authorization.



VN-5



GA WIC PROCEDURES MANUAL

"Fixed Stores" are WIC authorized immobile stores which transact WIC vouchers in a building site bearing a street address. This policy is necessary as a cost containment measure and is supported by the Commissioner of the Department of Human Resources, as well as the administrators in the Division of Public Health.

Retailers outside the State of Georgia requesting authorization must be located within ten miles of the Georgia State line. These retailers must request approval following the same criteria for retailers inside the State of Georgia.

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:

The vendor applicant's prices will be compared to the statewide standard maximum prices. Prices must not exceed 15 percent above the state average for small stores/peer group one. 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 is completed by the State WIC Office. Do not complete the vendor type when completing a Vendor Input/Registration Document (Attachment VN-3).

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.

The following is a list of vendor peer group codes, square footage, and vendor type:

Peer 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 OR MORE

Chain Fixed Location

5

N.A.

Commissary Fixed Location

6

N.A.

Pharmacy Fixed Location

7

15,001 OR MORE

Independent Large

Fixed Location



VN-6



GA WIC PROCEDURES MANUAL
IV. VENDOR AGREEMENTS
When a store has been approved for participation in the WIC Program, a Vendor Agreement (Attachment VN-4) must be signed between the Local WIC Agency and the new vendor. 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 WIC Agency will be responsible for retrieving vendor stamps from any vendor that does not sign an agreement by the specified date. Vendors who do not sign a new Vendor Agreement within the specified time period may reapply for WIC authorization.
Military commissaries must sign the Military Commissary Agreement (Attachment VN5).
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. If the store manager 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 30 days from the date the contract is signed. Vendor Agreements, to renew current vendors, must be received no later than November 1 of each year.
When Vendor Agreements are not received within these specified time frames, the State WIC Office will proceed as follows:
1. After 30 days, a phone call will be made to the Vendor Coordinator. 2. After 60 days, a letter will be sent to the WIC Program Coordinator. 3. After 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.



VN-7



GA WIC PROCEDURES MANUAL

When a store name changes and the owner remains the same, the Local WIC 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 and the ADP contractor. Vendor type should not be completed; this field is for State WIC Office use only.

When a store address changes, the Local WIC Agency must submit a copy of the Vendor Input/Registration form to the State WIC Office and the ADP contractor.

When ownership changes:



When a WIC authorized store is purchased ,by a WIC unauthorized store

owner/manager, an application for vendor authorization must be completed by the

new owner. The previous vendor stamp must be terminated at the time the

ownership changes. A new vendor number will be issued to the new owner upon

application approval (see Page VN-5 for Approval and Reauthorization Criteria

for Vendors) by the State WIC Office. A new Vendor Agreement must be signed

by the new owner.

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. The Vendor Agreement must be signed and a vendor stamp must be issued prior to vouchers being accepted.



If the. manager who signed the original Vendor Agreement Contract and/or

Vendor Training Checklist remains the same, the Local WIC Agency will have

the manager update the vendor file with a new Vendor Agreement Contract,

Vendor Training Checklist, and an Application for Certification bearing the new

owner's name, pertinent new information, and signature to be forwarded to the

State WIC Office.

The vendor stamp will remain in the possession of the new owner unless a replacement stamp issuance is necessary. If a replacement stamp is necessary, an input form must be forwarded to the ADP contractor and the Local WIC Agency by the State WIC Office to update the database system. If the vendor stamp remains the same, an input form must be forwarded to the ADP contractor and the State WIC Office by the Local WIC Agency to update the database system. The Local WIC Agency representative must conduct a vendor review of WIC approved food items within 30 days after the store's authorization.

VN-8



GA WIC PROCEDURES MANUAL
V. VENDOR STAMP
The State WIC Office will provide the Local WIC Agency with three vendor stamps at the initial certification of the vendor. After the third stamp has been issued, it is the responsibility of the vendor to pay for any additional replacement stamps.





VN-9



GA WIC PROCEDURES MANUAL

VI. VENDOR TRAINING
Vendor training will be conducted to inform vendors of the appropriate program policies and procedures pertaining to WIC vendors. (See Page VN-66.)



All new vendors must be trained prior to accepting any WIC vouchers.



A training will be required for vendors who do not comply with policy and

procedures (high VIPS scores/flags, complaint letters/calls, previous warning

letters, and/or sanctions). Refer to the Vendor Training Checklist (Attachment

VN-7) for acceptable training tools.



All authorized WIC stores must be represented at the annual WIC vendor training

by at least one store personnel representative prior to reauthorization.

Vendor Agreement Renewal - store representatives that attend annual training may take the Vendor Agreement Contract to the manager who is legally responsible for the store for attainment of signatures (these contracts must be mailed to the Local WIC Agency within seven days after annual training via certified mail).

OR
The Local WIC Agency may require vendor managers who are legally responsible for the store to come to the local vendor training site or the Local WIC Agency Office to sign Vendor Agreement Contracts by September 30 of the federal fiscal year.
If annual Vendor Agreement Contracts and training packets are mailed to vendors, they must be sent via certified mail. The store owner/manager who receives the training packet will be responsible for training store employees and may designate an employee(s) to conduct in-store training. Documentation of who the store owner/manager designated to provide training shall be substantiated in writing to the Local WIC Agency via certified mail. State and District WIC staff are available for conducting subsequent training. A notarized Vendor Agreement/Contract must be returned to the State WIC Office by the designated deadline.
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-10).



VN-10



GA WIC PROCEDURES MANUAL
All training must be documented, using the Vendor Training Checklist (Attachment VN7), Vendor Training Sign-In Sheet (Attachment VN-8), and Post Vendor Training Evaluation (Attachment VN-12). 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 Sign-In Sheet 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 WIC Agency should allow vendors a grace period of ten working days to attend the District/Unit make-up training session prior to September 30 of the federal 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 WIC program participation. A copy of this form, along with a copy of the Vendor Input/Registration form for terminated vendors and the vendor stamp(s), must be sent to the State WIC Office within 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 30 days after the final training session. The Local WIC 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-9) must be provided to vendors.



VN-11



GA WIC PROCEDURES MANUAL
VII. VENDOR MATERIALS
The following materials are available from the State WIC Office for vendor training and store use:
-Shelf Markers/Stickers -- - - - - - -Is A WIC Food
-WIC Cashier Training Pamphlet -Window Poster - We Welcome WIC Customers -WIC Approved Food Picture Pamphlet -WIC Approved Food Poster -Vendor Agreement -Pharmacy Agreement -Vendor Training Check-List -Vendor Review Form -Application for Vendor Certification Form -Return Voucher Payment Log -Vendor Handbook -Pharmacy Handbook -Vendor Application Booklet -Vendor Training Sign-In Sheet -Post Vendor Training Evaluation -Incident/Complaint Form
These materials can be ordered through the State WIC Office.
Also, the State WIC Office will distribute to Local WIC Agencies, the Voucher Rejection Summary Report and highlight the information that indicates the number of vouchers that were flagged due to stale dating, post dating, and exceeding the voucher maximum. This report should be used as a training tool during vendor training.



VN-12



GA WIC PROCEDURES MANUAL
VIII. MONITORING
A. Vendor Monitoring Procedures
All vendors must receive an on site visit at least once every two federal fiscal years. A minimum of one half of a district's vendors must be visited each year. The Vendor Review Form (Attachment VN-13) must be used for monitoring visits. (Attachment VN-14, provides instructions for completing the form.) The following procedures must be used when monitoring vendors:
1. Each visit must be unannounced. 2. Introduce yourself to the store owner or manager and explain the purpose
of your visit. 3. Complete the monitoring form, which will include recording vendor's
compliance with minimum inventory requirements and recording of vendor's shelf price information. 4. Review vendor's on hand vouchers for proper redemption procedures (i.e. signatures, purchase amount, and voucher use/deposit dates). 5. Discuss findings with the owner or manager. 6. The owner or manager must sign the form in the space provided. If they are unavailable, obtain the signature and date from the person in charge. 7. Give a copy of the form to the vendor (in the absence of the owner/manager give copy to the store representative). 8. Send a copy of the form to the State WIC Office.
The State WIC Office will review the form, assign sanctions for violations when applicable, and notify the vendor of the sanctions issued within 60 days of receipt of the Vendor Review Form.
Ifviolations are found during a monitoring visit (excluding vendor self reviews),
another visit (follow-up) should be made within 60 days to determine if the violation(s) has been corrected. If the violation(s) has not been corrected, additional sanctions will be assigned.
By March 1 of each federal fiscal year, the State WIC Office will submit to each District Office a list of vendors who were not monitored during the previous year. This will assist the District Office in planning the monitoring prior to the annual vendor training.
VN-13



GA WIC PROCEDURES MANUAL
By August 1 of each federal fiscal year, the State WIC Office will submit to each District Office a list of vendors who have been monitored and the percentage of vendors monitored federal fiscal year-to-date. This procedure will provide Districts with information that will assure that all vendors are monitored by September 30, every two years.
The State \VIC Office will provide information to the District Office related to whether or not follow-up monitoring visits occurred within 60 days after violation letters are received by the Local WIC Agency.
B. Local WIC Agency Monitoring Procedures
The Local WIC Agency Monitoring Tool shall be used to review the vendor activities (see Monitoring Section, Local WIC Agency Monitoring Tool). This tool has been incorporated into the Local WIC Agency program review process to evaluate the Local WIC Agency vendor management practices and compliance with Federal Regulations and State Policies and Procedures, relating to vendor activities. (See Local WIC Agency's Responsibilities below.)
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 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.
State WIC Office Interim Procedures of District Vendor Management Review
With the assistance of the WIC Program Vendor Coordinator, the State Reviewer shall identify high risk vendors, through the evaluation of Vendor Integrity Profile System (VIPS) Reports. Once the high risk vendors are identified, the reviewer will conduct unannounced vendor monitoring visits upon request by the Local WIC Agency. (Depending upon the number of high risk vendors, Local WIC Agency assistance may be required.)
VN-14



GA WIC PROCEDURES MANUAL
Local WIC Agency's Responsibilities
The Local WIC Agency should prepare a file for each vendor, inclusive of at least the following information for record retention:
Copy of the 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 if training is provided by Local or State Agency) Monitoring Forms within past three years, plus the current year Copies of Participant Complaints that involve vendors (when applicable) Correspondence copies forwarded to the Local WIC Agency in reference to
their district's specific vendors Copies of Vendor Input/Registration forms or VIPS Transaction Keypunch
forms sent to the ADP Contractor and the State WIC Office Post Vendor Training Evaluation (if training is provided by Local or State
Agency).
The Local WIC Agency must conduct on site vendor monitoring for half of the vendors per year to assure that all vendors are monitored every two years.
The Local WIC Agency must conduct a vendor review of perishable items within 30 days after vendor authorization only when WIC approved perishable food items were not available upon the pre-approval visit. 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 after a vendor has received a sanction letter for failure to meet the WIC approved foods minimum inventory requirements.
The Local WIC Agency must establish a vendor application file that includes all pending vendor applications.



VN-15



GA WIC PROCEDURES MANUAL
IX. 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-16



GA WIC PROCEDURES MANUAL
X. VENDOR SANCTIONS
Vendor violations are categorized by the severity and nature of the offense. The nature and severity of a violation(s) shall determine the sanction assessed, the duration of the probationary period, and the period of disqualification. Therefore, the highest sanctions assessed to a vendor shall determine the period of probation and disqualification.
If a 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 a permanent disqualification. (Refer to Food Stamp Program Federal Regulations 7CFR; Part 278). Disqualification from the WIC Program may also result in disqualification from the Food Stamp Program.
The actual probation and disqualification periods are determined using the same formula for every vendor. All State Agency sanctions earned are retained in the vendor file for a period of one year. Mandatory sanctions will remain on the vendor's file permanently. A description of the sanction system and how it works can be found on Page VN-70 of the Vendor Handbook (Attachment VN-9) and the Sanction System (Page VN-51).



VN-17



GA WIC PROCEDURES MANUAL
XI. COMPLAINTS AGAINST VENDORS
All complaints made against a grocery store must be documented usmg the Incident/Complaint Form (Attachment VN-15). Individuals making complaints may choose not to give their names. Copies of this form should be mailed to the appropriate agencies (i.e., Local WIC Agency, State WIC Office).
When complaints are received against WIC vendors, a letter should be sent stating details of the complaint and quoting regulations that are potentially in violation and the sanction (if applicable) that could be assessed.
In the event an immediate resolution is not reached, the Local WIC Agency must update the State WIC Office of all unresolved complaints and vice versa. When a complaint is related to potential fraud (exchanging WIC vouchers for gas, cash, non food items, etc.) the Local WIC Agency must follow these procedures at a minimum:
1. Send a letter notifying the vendor of the reported potential violations, and inform them of the sanctions that could be assessed for such violations. Advise vendors that a WIC investigator may visit their store to conduct a compliance investigation .
2. Send a copy of the vendor notification letter to the State WIC Office.
3. Send a copy of the complaint form to the State WIC Office.
4. Send a Request for Investigation form to the State WIC Office..
Documentation of all complaints must remain on file in accordance with the program's record retention policy .



VN-18



GA WIC PROCEDURES MANUAL

XII. TERMINATIONSffiISQUALIFICATIONS

When a store is terminated for any reason, the Local WIC Agency must submit a Vendor Input/Registration form or VIPS Transaction Keypunch form to the ADP Contractor and the State WIC Office.

Contract/Agreement Termination Policy

A. 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 15 percent above the district average by peer groups of similar store type and/or size. The State WIC Office shall provide written notification to the vendor(s) regarding the amount of overpricing involved by voucher code type. Consequently, the vendor(s) shall reimburse the State WIC Program for any overpayment(s). If the vendor does not submit his/her payment within thirty (30) days, the State WIC Office will forward a second written notification to the vendor requesting the overpaid amount. If the vendor fails to submit the requested overpayment after the second notification, the vendor will be given a third and final opportunity to submit the overpayment. If the vendor does not submit the overpaid amount by the requested date, the vendor will be terminated from WIC program participation for a ninety (90) day period. Exceptions will be made if the vendor termination creates inadequate participant access (refer to Page VN-20, Inadequate Participant Access Cases.)

B. Vendors that voluntarily withdraw, sell their businesses, or do not renew their

Vendor Agreement, must be terminated by the Local WIC Agency. Terminated

vendors must be notified, in writing, of the date of termination. A separate letter

of termination must be used for all other terminations initiated by the State WIC

Office.



The Local WIC Agency is responsible for completing the Vendor Input/Registration form or VIPS Keypunch Transaction 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.



VN-19



GA WIC PROCEDURES MANUAL
A copy of the termination letter and Vendor Input/Registration form or VIPS Keypunch Transaction form must be sent to the ADP contractor and the State WIC Office within 30 days of termination.
Every six months, the State WIC Office will distribute to the District Offices a vendor activity report to update the District of outstanding Vendor Input/Registration forms or VIPS Keypunch Transaction forms. The District Office should utilize this report to identify if there are errors or terminated vendors listed. If there ~e errors, the District Office will utilize the Vendor Input/Registration form or VIPS Keypunch Transaction form to make all corrections. Copies must be forwarded to the State WIC Office and the ADP Contractor, unless directed otherwise by the State.
C. 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. Disqualified vendors will be notified in writing, at least 15 days before termination. The notice will include reasons for the action and information on the right to a fair hearing.
Inadequate Participant Access Cases
If disqualifying a vendor causes inadequate participant access, the State WIC Office must impose a Civil Money Penalty (CMP) in lieu of disqualification (except that the State WIC Office may not impose a CMP in lieu of disqualification either as a result of a Food Stamp Program/Civil Money Penalty or for a third or subsequent sanction as specified in 246.12(k)(l)(vi)).
If a vendor does not pay, only partially pays or fails to timely pay a CMP, the State WIC Office must disqualify the vendor for the full length of the disqualification corresponding to the violation for which the CMP was assessed.
An inadequate participant access case is granted only when the nearest authorized WIC vendor is 10 miles or more away from the nearest WIC clinic. Geographical barriers will be assessed .



VN-20



GA WIC PROCEDURES MANUAL
Verification of inadequate participant access must be documented by the WIC Coordinator or designee and original forwarded to the State WIC Office. The WIC Coordinator or designee must complete the "Verification Form" (Attachment QI-6) after physically driving the distance to obtain the exact mileage. This will be used to determine if a disqualified vendor will create inadequate participant access within the District/Unit. If another WIC vendor is within ten (10) miles of the Health Department or within ten (10) miles of the disqualified vendor, then this disqualification would not create Inadequate Participant Access. The Inadequate Participant Access form must be received by the State WIC Office within ten working days after receipt of the correspondence copy of a vendor disqualification letter, and no later than five working days prior to an administrative hearing for a disqualified vendor appellant.





VN-21



GA WIC PROCEDURES MANUAL
XIII. VENDOR FAIR HEARING PROCEDURES
To request a fair hearing, the vendor will call their WIC Coordinator and send a written request to the State WIC Office. Should a fair hearing be requested prior to the deadline stated in the disqualification notice, the vendor authorization shall remain unchanged until final resolution has been attained at the administrative level. If a fair hearing request is received after the deadline stated in the disqualification notice, the vendor shall no longer be authorized for WIC Program participation.
Vendors may appeal decisions of the State WIC Office or Local WIC Agency when an application to participate in the WIC Program is denied, when participation is terminated, or when other actions are taken which adversely affect the vendor's participation in the program.
A vendor must submit a written request for a fair hearing, to the State WIC Office within 15 days from the date of notification of an adverse action they wish to appeal.
The State WIC Office will notify the Office of State Administrative Hearings of a vendor's request for a fair hearing.
The Office of State Administrative Hearings will schedule a hearing date within 45 days of the hearing request. The vendor will be notified of the time and place 15 days prior to the fair hearing date. All hearings will be held in the county where the vendor's store is located.
The proposed adverse action must be postponed from the time an administrative fair hearing is requested until a decision is reached by the Administrative Law Judge. Vendor hearings may be rescheduled one time by the vendor or the State WIC Office.
The vendor will have ample opportunity to present his case at the hearing, including the opportunity to confront and cross-examine adverse witnesses. The vendor may be represented by couns~l, if desired. The appellant may review the case file prior to the hearing.
The Administrative Law Judge (ALJ), Office of State Administrative Appeals, is an impartial decision maker with no personal involvement or interest in the outcome of the hearing. The ALJ' s decision shall rest solely on the evidence presented at the hearing and the statutory and regulatory provisions governing the program. The basis for the decision shall be stated in writing, although it need not amount to a full opm10n or contain formal findings of fact and conclusions of law.
The ALJ and the State WIC Office shall provide written notification of the decision to the vendor within 60 days from the date of the original request for a hearing.
VN-22



GA WIC PROCEDURES MANUAL
The vendor must continue to comply with all written agreements if program participation continues during the appeal process.
The ALJ will explain any additional appeal mechanism upon request, including the right to a judicial review. If a vendor desires to appeal after an administrative hearing decision that has been granted in the State's favor, the vendor must follow the provisions of the Georgia Administrative Procedure Act (Code Section 50-13-16 and 50-13-17).





VN-23



GA WIC PROCEDURES MANUAL

XIV. HIGH RISK VENDOR IDENTIFICATION

Vendor Integrity Profile System (VIPS)

Georgia WIC voucher redemptions are analyzed monthly by the contracted automated Data Processing System. VIPS tracks the activity of WIC vouchers and formulates detailed summary information through analysis of the voucher activity (data). Vendors that exemplify high average value for vouchers redeemed or an abnormally low value for vouchers redeemed are flagged. VIPS also analyzes other indicators (the following definitions correspond with the alpha-numeric variables listed under the "vendor scores" field of Attachment VN-16):

A

Small amount of price variation

B

Large percent of food instruments (Fl) redeemed at same price

C

High average price C 1 - Peer C2 - Flag

D

Redeemed price higher than vendor price list

E

Large percent of high-priced FI EI-Peer E2 - Flag E3 - Deviation

F

WIC business high volume

G

Large increase in volume over six months

H

Vendor has large percent of total area redemption

I

WIC sales high percent of total vendor sales

J

WIC and Food Stamps high percent of total sales

K

High WIC to Food Stamp ratio

L

Complaints from clients, Local WIC Agency, other vendors

M

Large percent of participants outside vendor area

N

Large number of clients at high risk redeeming FI

0

Large percent of manual FI redeemed by vendor

p

Large percent of FI with consecutive serial #'s redeemed by vendor

Q

High percent of FI cashed same day

For each vendor these indicators are ranked monthly using a scoring system. The scoring system used to identify "high-risk" vendors (i.e., vendors who may be violating WIC Program rules, regulations and procedures), is used as a guide for scheduling compliance buy investigations. The Vendor Profile Report (Attachment VN-16) summarizes the vendor's activity.

Local WIC Agencies may use the Vendor Profile Report from their District version of VIPS as part of their local monitoring efforts.



VN-24



GA WIC PROCEDURES MANUAL
XV. MINIMUM INVENTORY REQUIREMENTS WAIVER
Minimum inventory requirement waivers will be granted to vendors whose store services fewer than six WIC women and/or children and six WIC infants per month. Therefore, the minimum inventory requirements will be reduced to satisfy the needs of the WIC participant population that reside in the vendor's area. The minimum inventory requirements reduction will be determined by the State WIC Office within 30 days of receipt. The vendor must comply with the waiver requirement detailed in the Minimum Inventory Waiver Contract Addendum (Attachment VN-19) .





VN-25



GA WIC PROCEDURES MANUAL VENDOR APPLICATION BOOKLET

WIC

Attachment VN-1

Vendor Application

Booklet

Georgia Department of Human Resources



FFY 2000



DPHP98.8(b)HW

1-800-228-9173 VN-26



GA WIC PROCEDURES MANUAL

Attachment VN-1 cont'd

VENDOR APPLICATION BOOKLET



Contents
Introduction The Application Process Vendor Application Deadlines WIC Minimum Inventory Requirements WIC Approved Foods List Form 3770 -Application for Vendor Certification Form 3774 - Vendor Review Form Form 3771 - Vendor Agreement WIC Vendor Agreement Between Military Commissaries and Local Agencies

Page 1 Pages 1, 2, 4, and 5 Page4 Page 2 Page 3 Pages 6-7 Pages 8-11 Pages 12-15 Page 16

VN-27



GA WIC PROCEDURES MANUAL

Attachment VN-1 cont'd

VENDOR APPLICATION BOOKLET

R I n t r o d u c t i o n - - - - - - - - - - - - - - - etail food stores play a critical part in the WIC direct contribution of WIC food sales, but because

Program. As the actual distributors of the special the WIC participants who go to an authorized

WIC foods, the vendors are essential in their role to vendor to obtain WIC foods normally purchase

help improve the nutritional status of the members other products at the same time. In return, vendors

of their communities.

are expected to exhibit accountable behavior--both.

The WIC Program benefits the vendors who are with the participant as well as with the WIC

selected to participate-not only because of the Program.

.

The Application Process
Step 1 - Completing the Application

The retail store must contact the Local WIC Agency in its area to obtain a vendor application. The store owner must complete the application (see pages 6-7 for a copy of the application) and the Vendor Review Form (pages 8-11) and return. these forms to the Local WIC Agency.
Step 2 - Processing the Application After the Local WIC Agency receives the
completed application, a pre-approval visit will be made to the store by the Local WIC Agency's representative.
The following criteria must be met before a store can be approved for WIC participation.
1. Upon the sale of a WIC-authorized store and the purchase of a previous WIC-authorized store, the new owner/vendor applicant shall prove that a sale took place by presenting a legitimate bill of sales the complies with the Bulk Sale Law found in the Georgia Official Code Annotated and Unannotated.

current Food Stamp Program sanctions.

s.

The store must be eligible for Food

Stamp Program authorization.

6.

The store must be licensed by the

Georgia Department of Agriculture.

The store appearance must be sanitary

with no evidence of general lack of

cleanliness. The State WIC Office will

work with the Georgia Department of

Agriculture Sanitarians to determine the

appropriateness of this criteria if it is used

as a reason for disapproval of a vendor

application.

7.

The store must be open for business at

least eight hours per day, six days per

week.

8.

WIC foods must be within current

manufacturer's date limit for human

consumption.

2. Store must have the minimum inventory. All retail grocery stores are required to stock a minimum inventory of WIC approved foods. Outdated foods will not be counted in the minimum inventory
figures. Stores will not be Wit authorized
if they do not have the minimum inventory of non-perishable WIC food items at the time of the pre-approval visit.
3. Shelf prices (on WIC-approved foods) of the vendor must be compatible with other stores within the state. "Compatible" means prices must not be more than ,U percent above the state average of peer group l store prices.
4. The store must be free from any

9.

The vendor must be located within a

reasonable distance of participants.

10. The Food and Consumer Services Office of the United States Department of Agriculture reserves the right to approve any uses of the WIC acronym. The "WIC" acronym and logo cannot be utilized by a store or on a vehicle with the exception of documents distributed by the Georgia WIC Program.

Applications are accepted each weekday and should be returned to the Local Agency to be processed along with the Vendor Review Form that is completed by the vendor. The application process takes forty-five (45) working days for completion .

1
VN-28



GA WIC PROCEDURES MANUAL

Attachment VN-1 cont'd

VENDOR APPLICATION BOOKLET

Therefore, vendors who wish to receive

approval or denial regarding WIC vendor

authorization must submit a completed WIC

application form forty-five (45) working days prior

to store opening or change of ownership. All retail

vendors will be subject to the same application

process. WIC vouchers must not be accepted by

vendor applicants during the application

process.

The Local Agency will forward the

Vendor Application for Certification with the

Vendor Review Form (vendor's self review) to the

State WIC Office within five (5) working days.

The State Agency will review the above

documents within fifteen (15) working days for the

following:

a.

The application will be reviewed

for accuracy and a background

check will be conducted.

b.

The vendor's prices will be analyzed

to ascertain if prices charged for WIC

approved foods meet the state pricing

standards.

C.

The vendor's Department of

Agriculture and Food Stamp Program

eligibility will be verified.

d.

The State WIC Office will fax/mail

preliminary approval notices to the

Local Agency within this time period.

e.

The State WIC Office will fax/mail

denial letters to vendors and the Local

Agency within this time period.

Denied vendors may correct

deficiencies within thirty-five (35)

working days of denial. If a vendor

does not correct the deficiencies within

thirty-five (35) working days of denial,

a new vendor application must be

resubmitted to the Local Agency.

WIC Minimum Inventory Requirements The following is a list of the minimum inventory requirements for WIC vendors which outline the required quantities, sizes, types or brands, which the store must carry in order to become or remain a WIC vendor.

Food Item

Quantity

Size

Number of

Types/Brands

Milk: (Pasteurized)

20

1 gal. jug

1 Brand

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

Cheese:
Eggs: (Grade A Large) Juice:

16

I lb. pkg.

2 Types

16

1 doz. eggs per

1 Brand

carton

24

46 oz. can

2 Types

Cereal:

30

9-24 oz. box

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

4 Types

Peas/Beans:

8

1 lb. pkg.

2 Types

Peanut Butter:

8

18 oz. jar

2 Brands

Formula: (With Iron)

170*

13 oz. can

1 Brand

Contract brand of formula only. Vendor must be able to supply soy, powdered, ready-to-feed, concentrate or a different brand of formula upon request. *Vendor must stock a minimum of 32 cans of soy-base contracted brand formula and 138 cans of milk-base
contracted brand formula. Note: Low iron formula does not meet WIC minimum inventory requirements for formula.

Infant Cereal:

12

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

8 oz. box

2 Types

2

VN-29



GA WIC PROCEDURES MANUAL

Attachment VN-1 cont'd

VENDOR APPLICATION BOOKLET

WIC Approved Foods List

Food Item
MILK (Pasteurized)
CEREAL
CHEESE (Reduced Fat, Lowfat or
Fat Free Cheese is Allowed)
JUICE (100% USRDA Vitamin C Fortified)
EGGS (Grade A Large Only)
DRIED PEAS/BEANS CANNED PEAS/BEANS
PEANUT BUTTER INFANT FORMULA
INFANT CEREAL (Boxes Only) TUNA CARROTS

Brand or Type

Container/Pkg. Size Cannot Buy

Whole, Skim, Lowfat (I%), or Reduced Fat (2%) (l..cast Expensive Brand Only)
Acidophilus, Enjoy, Lactaid, Lactaid 100, Nutrish or Dairy Ease, Evaporated, Powdered or UHT Milk (if. listed on voucher)

One Gal. Size ONLY (Exception: Gal. or Qts: of Enjoy, Lactaid, Lactaid 100, Nutrish, Dairy Ease and/or Acidophilus, 12 Oz. Cans Evaporated, 3 or 5 Qt. Boxes Powdered, 8 Oz. Box UHT Milk)

Flavored Milk, Buttennilk. or Goat's Milk

Cheerios, Chcx (Corn. Rice or Wheat), Country Com Flakes, Kix, Nabisco Quick Cream of Wheat (Regular Flavor), Product 19, Jim Dandy Quiel:: Grits
(Iron Fortified), Harvest Instant Oatmeal (Regular Flavor), Quaker Instant Grits or Oatmeal (Regular Flavor), Total Com Flakes, Kellogg's Special Kor
Com Flakes, Kellogg's Complete Bran Flakes, Sun Country Quick Oats (Regular Flavor), Quaker
Crunchy Com Bran Ralston: Optima 100 Whole Wheat Flakes, Enriched Bran Flakes. Nutty Nuggets, Instant Oatmeal (Regular Flavor), Crispy Rice, Com Flakes,
Tastccorroasted Oats, Crispy Com Puffs Ralston Store Brands Allowed: Kroger, Kountry Fresh, IGA, Red & White, Flavorite or Nature's Best

9 Oz. Sizes and Above ONLY
Can purchase more than one (I ) type/brand of cereal as long as the amount does not go over the quantity on the front of the voucher

Eight (8) Oz. or Less Size Boxes

American (Individually Wrapped or Unwrapped Sliced or Block), Cheddar (Block), Colby (Block), Monterey Jack (Block), Mozzarella (Block)

9 Oz. Up to 16 Oz. (One (I] Pound) Size ONLY

Cheese Food, Shredded or Deli Cheese, and/or 2-8 Oz. Pkgs. for 1-16 Oz. Pkg. (no 8 Oz. Pkgs. of Cheese)

Orange: l..cast Expensive Brand Only

Grapefruit: Least Expensive Brand Only

Grape: Welch's, Juicy Juice or Seneca

White Grape: Welch's

Apple: Flavorite, Lucky Leaf, Staff, Shur Fine,

Kroger, Seneca (Red Label Only), Thrifty Maid,

White House, Juicy Juice

Other:

Dole:

Orange/Pineapple.

Orange/Pineapple/Banana; Pineapple/Grapefruit

Juicy Juice: Cherry, Punch, Tropical, Strawberry,

Apple/Grape, Orange Punch, Berry

Pourables: Welch's Juice Maker (Apple, Grape or

White Grape)

Juicy Juice (Punch, Grape, Cherry, Berry, Strawberry

or Apple)

46 Oz. Cans, 6 Oz. Cans (if listed on voucher), 12 Oz. Cans Frozen or I 1.5 Oz. Pourables

Juice Drinks, Fresh Squeezed Juice, Infant Juices, Juices With Sugar Added

l..cast Expensive Brand Only

One (I) Dozen

Any Other Size/Qty.

Any Brand Without Flavoring Added Any Brand Without Flavoring Added Any Brand Without Jelly or Hooey Spread Added As Listed on the Front of the Voucher
Beech Nut. Gerber, Heinz
Water Packed Only Fresh, Whole, Canoed-Medium Cut or Sliced

One (I) Pound Size ONLY

Any Other Size/Qty.

15 Oz. Cans ONLY

Any Other Size/Qty.

18 Oz. Jars ONLY

Any Other Size/Qty.

As Listed on the Front of the Formula not listed on the

Voucher

voucher

Dry Cereal in 8 or 16 Oz. Sizes Any Baby Food in Jars or

ONLY

Any Dry Cereal with Fruit

or Formula Added

6 Oz. Cans Only

Tuna Packed in Oil

I Lb. Presealed Plastic Bag or I5 Bulk, Frozen,

Oz. Canoed Sliced

Shredded, or Baby Carrots

3
VN-30



GA WIC PROCEDURES MANUAL

Attachment VN-1 cont'd

VENDOR APPLICATION BOOKLET

Upon receipt of the State WIC Office preliminary

approval of a vendor, the Local Agency will

conduct an on-site monitoring visit (pre-approval)

of the store and tentatively schedule vendor

training for new store personnel

(owners/managers/cashiers/etc.) within fifteen (15)

working days. The following process will take

place during the Local Agency review:

a.

Non-perishable items must be in the

vendor's store within fifteen (15) days

prior to the store opening or change of

ownership as specified in the WIC

application.

b.

Thus, the Local Agency must be allowed

to conduct an unannounced on-site

monitoring visit (pre-approval) anytime

during this fifteen (15) day period, during

standard business hours (8a.m.-5p.m.).

c.

The Local Agency will fax and mail the

Vendor Review Form (pre-approval visit

outcome) to the State WIC 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 Agreement Contract.

b.

If a vendor is denied, the State WIC Office

will fax and mail 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

resubmitted to the Local Agency.

APPLICATION PROCESS

Working Days

Procedures for Vendor Certification

State WIC Office (SWO)

Local Agency (LA)

1st-5th 6th-20th 2lst-35th 36th-40th
4lst-45th 46st-75th

LA forwards Vendor Application for Cenification and Vendor Review Form (Vendor Self-Review) to SWO
a SWO will review application and Self Review Form b. SWO will fax/mail preliminary approval/denial notice to Local Agency c. Denied vendor will be given 35 working days to correct deficiencies and to contact LA
a. LA conducts pre-approval visit within 15 working days (non-perishable items must be in store) b. LA will tentatively schedule training for store personnel c. LA will fax/mail pre-approval outcome to the SWO
a If vendor is approved, the stamps will be forwarded to LA with a copy of the Vendor Application and the Vendor Registration Form within 5 working days
b. LA will conduct vendor training and the Vendor Agreement/Contract will be signed by owner/manager c. If vendor is denied, SWO will fax/mail denial letter to LA and vendor within 5 working days d. Denied vendor will be given 35 working days to correct deficiencies and to contact LA
Vendor with deficiencies: a If approved, the stamps will be forwarded to LA, training of vendor is conducted and the Vendor Agreement.
will be signed by owner/manager b. If denied, vendor must resubmit Application for Cenification and Vendor Self-Review Form to LA
LA will conduct new vendor review within 30 days for vendor that did not have perishable food items in stock at the time of pre-approval visit

4
VN - 31



GA WIC PROCEDURES MANUAL

Attachment VN-1 cont'd

VENDOR APPLICATION BOOKLET

New vendor training may take place if training did not 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 receives the training packet, they will be responsible for training store employees and may designate employees to conduct in-store training. State and District WIC staff are available to provide subsequent training.
The Local Agency must conduct a vendor on-site review of WIC approved perishable food items within thirty (30) days after vendor authorization, only when WIC approved perishable food items were not available upon the preapproval visit. 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.
Any additional information regarding the WIC Program can be obtained from your Local WIC Office.
Thank you for your interest in the WIC Program.
State WIC Office Two Peachtree Street, N.W., 8th Floor
Atlanta, Georgia 30303 (404) 657-2900 or WIC Hotline
1-800-228-9173

5
VN -32



GA WIC PROCEDURES MANUAL

Attachment VN-1 cont'd

VENDOR APPLICATION BOOKLET
Georgia Department of Human Resources DIVISION OF PUBLIC HEALTH
FOR WOMEN, INFANTS AND CHILDREN WICPROGRAM
APPLICATION FOR VENDOR CERTIFICATION

Area Code Store Name _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Telephone Number(__) _ _ _ _ _ _ __
Store Location _ _ _ _ _ _ _ _ _ City _ _ _ _ _ _ GA Zip Code _ _ _ _ _ _ __

Mailing Address (If Different)

County _ _ _ _ _ __

Store Owner _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Store Manager _ _ _ _ _ _ _ _ _ __

F.E.1. Number

or Owner's Social Security Number _ _ _ _ _ _ _ _ __

(Federal Employer Identifier)

TYPE OF STORE
Chain

HOURS OF BUSINESS
Sunday _____ Monday _ _ _ _ __

Independent

Tuesday

Wednesday _ _ _ __

Franchise

Thursday

Friday _ _ _ _ __

Drug

Saturday _ _ _ __

Square Footage of Store _ _ _ _ _ _ _ _ _ Number of Check-out Counters _ _ _ _ _ _ __

(Square Footage of Grocery Store and Gro=y Siorage Space).
Average Annual Gross Sales $_______ Estimated Total % of Food Sales ---~'rl.,_o_ __ Food Stamp Authorization Number _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

(A store must be eligible for Food Stamp Program Authorization to be a WIC Vendor.) Department of Agriculture License Number _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

(A store must be licensed by the Department ofAgriculture to be a WIC vendor) Business License Number _ _ _ _ _ _ _ _ Sales Tax Number _ _ _ _ _ _ _ _ _ _ __
Length of time business has operated at the present site _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ Date store will open/change of ownership date _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Yes No

D

D

D

D

Do you sell beer, wine or other alcoholic beverages? Has the business ever operated under another name? If yes, what was the name of the business?

D

D

Is this a change of ownership?

D

D

Does this store now participate in the Food Stamp Program?

D

D

Has this store ever applied for WIC? If yes, state when _ _ _ _ _ _ _ _ _ _ __

D

D

Has this store ever received a warning, been suspended, disqualified, or had a penalty

assessed against it by WIC or Food Stamps? If yes, state when and explain._ _ _ __

STATE WIC OFFICE USE ONLY Food Pkg.# _ _ _ Vendor Cost _ _ _ Max _ _ _ _ Price Approved _ _ Denied _ _ __

Food Pkg.# _ _ _ Vendor Cost _ _ _ _ Max _ _ _ _.Price Approved _ _ Denied _ _ __

Food Pkg.# _ _ _ _Vendor Cost _ _ _ _ Max _ _ _ _.Price Approved _ _ Denied _ _ __

Are Store prices competitive with other stores in State?

Yes ____.No

Application: Approved _____ Date _____ Vendor Number Assigned Denied _ _ _ _ _ Date _ _ _ _ Processed by _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ Reason Denied _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

6

VN-33



GA WIC PROCEDURES MANUAL

Attachment VN-1 cont'd

VENDOR APPLICATION BOOKLET
Store Name _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ Name 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) / drug store(s)? Yes No If yes, list name and addresses of store(s) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

To the best of my knowledge, all of the above answers are correct. I understand that, should my store be accepted as a WIC vendor, I will abide by WIC Program regulations and policies including, but not limited to the following:

l.

Attend Vendor Education

2.

Train employees regarding WIC procedures

3.

Periodical monitoring

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 ATTENDED VENDOR TRAINING AND I HAVE BEEN ISSUED A WIC VENDOR STAMP.
Signature _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Date _ _ _ _ _ __

Title _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

"The USDA is an equal opportunity provider and employer."

FOR LOCAL USE ONLY

YES NO



D

Is the state required minimum inventory of WIC approved foods in the store during the Pre-Approval

visit?



D

Have you provided the vendor with the Georgia WIC Application Packet?

Comments: - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

I certify that I have visited this store and do / do not recommend its approval for participation. If this application is not recommended for approval, please explain why: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __



DISTRICT/UNIT

LOCAL AGENCY WIC COORDINATOR OR DESIGNEE 7
VN-34

DATE



GA WIC PROCEDURES MANUAL

Attachment VN-1 cont'd

VENDOR APPLICATION BOOKLET

Georgia Department or Human Resources Division of Public Health WICProgram
VENDOR REVIEW FORM

Vendor Number

District

Date of Visit

I

I

Page 1 of 4 Unit

Vendor Name

Store Owner

Store Manager

Street Address City

County

I Zip Code

Review Type

Vendor Self Review (attach to Vendor Application)

Pre-Approval Visit (Non-perishable Food Review) c Yearly Visit CJ Minimum Inventory Waiver Granted

New Vendor (not applicable as yearly visit)

CJ Follow-Up CJ Regular Minimum Inventory Required

Note: Ph sical Invento must be viewed b WIC re resentative at the time of visit. Proof of order of food items shall not be acce ted.

A. Minimum Inventory Requirements

Juice: 1. Are there at least 24 cans of 46 oz. size juice in stock? If no, how many ? 2. Are there 2 types of canned juice? If no, how many? _ __
3. Was price marked on juice or posted on the shelf/dairy case?_ _ __ 4. Was juice within date limit? If no, how many were not? _ __

Yes No

CJ

CJ

CJ

CJ

CJ

CJ

CJ

CJ

A le
Ora WhilCGra Oran e:
liuic Other: Dole
Jui Juice

Brand Name Flav-o-rile
Seneca (Red Label) Shur Fine Staff Thrir Maid While House Juic Juice Welch's 100% Seneca

Juic Juice 11.S oz. Welch's Juice Maker

NIS

Prices: 46 oz.

$

$

$

$

$

$

$

$
s

$

$

$

$
s

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

, .
. . .., ..,~,1-~
$ $ $

8
VN -35



GA WIC PROCEDURES MANUAL

Attachment VN-1 cont'd

VENDOR APPLICATION BOOKLET
Vendor Number _ _ _ _ _ _ _ __

Page 2 of 4

Cereals: (At least two types in 12 oz. sizes)

Yes

No

1. Are there at least 30 boxes of 9 oz. to 24 oz. size cereal in stock? If no, how many? _ _

0

0

2. Are there at least 4 types of cereal in stock? If no, how many? _ _ _

0

0

3. Are there at least 2 types of 12 oz. size boxes of cereal in stock? If no, how many? _ _

0

0

4. Was price marked on cereal or on shelf?

0

0

5. Was cereal within date limit? If no, how many were not? _ _ _

0

0

Cheerios ComChex RiceCbex WheatCbex CounlrY Com Flakes Kix Kcllo22's Com Flakes Soecial K Product 19 Total. Com Flakes Harvest Instant Oatmeal (Reeular) Jim Dandy Quick Grits (Iron Fortified) Nabisco Quick Cream or Wheat (Re2ular) Quaker Instant Grits (Original) Quaker Instant Oatmeal (Rel!lllar) Kello22's Complete Wheat Bran Flakes Quaker Sun Country Quick Oats (Regular Flavor) Quaker Oats Crunch Com Bran IWstoo: Optima I00 Whole Wheat Flalces
Enriched Bran Flakes Nutty Nuggets lnslant Oatmeal (Reoular Flavor) Crispy Rice Com Flakes Tasle<'foasted Oats Crispy Com Puff IWstoo Store Brands Allowed: Kroger. Kountrv Fresh, IGA. Red & White. Aavorite or Nature"s Best
Comments on Cereal:

NIS

Oz. Size

Highest Prices $ $ $
s
$
s s
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

Peas/Beans

1. Are there at least 8 bags of 16 oz. size peas/beans in stock?

If no, how many?

NIS

2. Are there at least 2 types of peas/beans? If no, how many?

3. Was price marked on peas/beans, or on shelf?

Yes

No





..



0



0

Brand

Type

0
Highest Prices
$

$

Comments on Peas/Beans

Peanut Butter: (No peanut butter/jelly combinations or honey spreads)

Yes

No

1. Are there at least 8 jars of 18 oz. size peanut butter in stock?

If no, how many?

NIS_ _

0

0

2. Are there at least 2 brands of peanut butter? If no, how many?

0

0

3. Was price marked on peanut butter, or on shelf?

0

0

Highest Price $

and

Brand of Peanut Butter

Comments on Peanut Butter:

9
VN-36



GA WIC PROCEDURES MANUAL

Attachment VN-1 cont'd

VENDOR APPLICATION BOOKLET

Vendor Number _ _ _ _ _ _ _ _ __

Page 3 of 4

Infant Cereal: (At least one type or cereal must be rice)

I. Ne there at least 12 boxes of 8- 16 oz. size infant cereal in stock? If no, how many boxes?_ __

2. Is rice cereal in stock?

3. ls there one other type, other than rice, in stock?

4. Was price marked on cereal or on shelf?

5. Was cereal within current date limit? If no, how many were not? _ _ __

Brand and Price of Infant Cereals: Rice (Highest Price) NIS

Beechnut

$_ _ _ _ __

Other (Highest Price) NIS

Gerber

$_ _ _ _ __

Yes

No





















Heinz

$

Comments on Infant Cereal:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Formula: (Minimum or 32 cans or contracted soybase and 138 cans or milk base)

Yes

No

I. Ne there at least 138 cans of 13 oz. concentrate milk based contracted formula with iron in stock? If



no, how many? _ _ __

2. Ne there at least 32 cans of 13 oz. concentrate soy based contracted formula with iron in stock? If no,



how many?_ _ __

3. Is formula within current date limit? If no how many cans were not?_____ 4. Was price marked on cans or on shelf!









Prices 13 Ounce NIS

Prices: Ready to Feed NIS

Prices: Powdered NIS

Contracted Milk based

$

$

$

Contracted Soy based

$

$

Alimentum

Nutramigen

$

Portagen

$

Pregestimil

$

Milk: (Minimum or 20 gals. whole milk, 2%, 1% & skim milk or the least expensive brand) I. Ne there at least 20 gals. of milk in stock? If no, how many? _ _ _ NIS_ _ __

2. Was price marked on milk or posted on the dairy case?

3. Was milk within current date limit? If no, how many were not?_ _ __

Lowest Price: $

and

Brand Milk

Yes

No













Comments on Milk:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Cheese

Yes

No

I. Ne there at least 16 one pound packages of cheese in stock? If no, how many?____





2. Ne there at least 2 types of cheese in stock? If no, how many? _ _ _





3. Was price marked on cheese or posted on the shelf/dairy case?





4. Was cheese within date limit? If no, how many were not?___





Highest Prices of Cheese: American$_ _ NIS _ _ Colby $_ _ NIS _ _ Cheddar$_ _ NIS _

Monterey Jack$_ _ NIS _ _ Mozzarella$_ _ _ NIS _ _

Comments on Cheese:

Eggs: (Least Expensive Brand)

1. Ne there at least 16 doz. Grade A Large eggs in stock? If no, how many? _ __

2. Was price marked on eggs or posted on the dairy case?

3. Were eggs within date limit? If no, how many were not?_ __

Lowest Price:$

and (Grade A Large)

Brand of Eggs

Yes

No













Comments on Eggs:

VN-37



GA WIC PROCEDURES MANUAL

Attachment VN-1 cont'd

VENDOR APPLICATION BOOKLET

Vendor Number
B. Participant/Vendor Observation (Not applicable for pre-approval)
I. Were any WIC vouchers on hand in the store? If yes, were all voucher amounts filled in? _ _ _ If the voucher amount is not filled in, list the voucher number(s) in the comments section.
2. Observed WIC participant making a purchase? If yes, were appropriate procedures followed?
Comments:
C. General Questions/Observations
l. Does the store need to be referred to the Georgia Department of Agriculture for inspection? 2. Is store open for business at least 8 hours a day, 6 days a week? 3. Has discrimination been reported or observed? 4. Is there a need for additional training at this time? 5. Are all price columns for foods, which meet minimum inventory requirements, marked N.I.S.
(Not in Store)? This answer must be yes. 6. Does the cash register have the capability to place the date and amount of the WIC transaction on the
back of the voucher?

Page 4 of 4 Yes No NA













Yes

No

























To the best of his/her knowledge, the Retail Vendor Representative hereby agrees and covenants that neither the vendor/owner, the vendor's manager(s), or the vendor's other employee(s) is related by blood or marriage to any WIC representative, unless otherwise revealed in writing, upon execution of the contract/agreement or within the contract period. The results of this monitoring visit have been discussed with me and I understand the violations (if applicable) that were found and the food prices listed above are correct.

Signature of Vendor Representative

Date: _ _ _ _ _ _ _ _ _ _ __

Print Name of Vendor Repres.entative

I have discussed all findings, any violations, and training needs (if applicable) with the appropriate vendor representative.

Signature of WIC Representative

Date: _ _ _ _ _ _ _ _ _ _ __

Print Name of WIC Representative District _ _ _ _ _ _ _ _ Unit _ _ _ _ __
Vendor Representative Comments: ___________________________

WIC Representative Comments: ___________________________



11

VN-38



GA WIC PROCEDURES MANUAL

Attachment VN-1 cont'd

VENDOR APPLICATION BOOKLET

Georgia Department of Human Resources

Division of Public Health

WIC Program

(SPECIAL SUPPLEMENTAL FOOD PROGRAM FOR WOMEN, INFANTS & CHILDREN)

VENDOR AGREEMENT

Page 1 or4

This Vendor/Provider Agreement is made by and between the Georgia Department of Human Resources, Division of Public Health, WIC Program State Agency, (hereinafter referred to as the WIC Program) and _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ (hereinafter referred

to as the Vendor) to provide a mechanism for the distribution of special supplemental foods to eligible WIC participants. This agreement will become effective on - - - - - - - - - - - - - - - - - ' a n d will terminate on _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

WIC VENDOR NUMBER



The undersigned represents the Vendor as the sole proprietor or the store manager to contract for and onbehalf of the Vendor identified below. (Signature MUST be of owner or store manager.)

Signature of Store Owner or Manager

Date

(Pnnl) Name of Store owner or Manager

Name of Vendor (Store)

Ma1hng Address P. 0. Box

Street Location of Store Street Address

City

Slate

Zlp Code

1elephone Number

Name of Store owner (11 different from above)

Mailing Address

Slate

ZlpCode

Notary Public Signature and Seal

The undersigned represents the Local Agency, District and has the authonty to contract for ancf on oehalf of tneWTC Program State Agency.

Signature of Local Agency Aulhonzed Representative (Pnnf) Name of Local Agency Aulhonzed Representative

Name of Local Agency

Ma1hng Address P. 0. Box

C1fy

Slate

Zip Code

1elephone Number

Estimated of Food Sales

Average Annual Gross Sales

Square Footage of Store

Number of Cash Registers

Or Federal Employer identifier Number - .S..oc"""'1""ai~s.,..,e-cu-n""l-y..,N-um..,..be_r_

Date

-Notary Public's Commission Expires

PURPOSE:

This Agreement is for the purpose of providing a mechanism for the distribution of certain listed foods to eligible participants and the redemption of negotiable food instruments for the purchase of said food items. The Vendor is retained solely for the purpose set forth herein and shall not be considered as an employee or agent of the Department.
THE VENDOR HANDBOOK IS AN ADDENDUM TO THIS AGREEMENT.
COMMERCIAL/BUSINESS BANK ACCOUNT NAME

BANK NAME

ADDRESS

12
VN-39



GA WIC PROCEDURES MANUAL

Attachment VN-1 cont'd

VENDOR APPLICATION BOOKLET
WIC VENDOR NUMBER

Page 2 or 4



I. THE RETAIL VENDOR HEREBY AGREES AND COVENANTS AS FOLLOWS:

A.

To stock an adequate supply of authorized types and brands of WIC Program foods, In all categories, as determined by the Georgia

WIC Program.

8.

That all prices will be clearly marked either on the food Item or promlnentiy displayed,

C.

To post the acceptable WIC Approved Foods Ust In a oonsplcuous place by all cash registers.

D.

To accept WIC vouchers for payment of the purchase of only eligible WIC foods (see Approved Foods Ust). In addition, the vendor

must accept all valid WIC vouchers and allow participants lo purchase all foods on the voucher(s) regardless of price.

E.

To accept no WIC vouchers as payment on past or present credit account(&).

F.

To accept no WIC vouchers from participants presented after thirty (30) days from the Issuance date or prior to Issue date shown on

the voucher.

G.

To accept only vouchers which oontain a Georgia WIC Program SEAL.

H.

To refuse acceptance of any WIC voucher on which any alterations have been made.

I.

To sell WIC food Items at or below the nonnal store shelf price, but not to exceed the maximum amount listed on the voucher (excluding

Infant formula vouchers).

J.

To permit WIC Program participants to purchase eligible food Items without making other purchases and to accord such participants

the same oourtesy given to other store customers. In addition, the vendor must provide the participant with a receipt for WIC purchases.

K.

To keep all Information oonfidential on WIC participants.

L.

To direct questions ooncemlng pa}'nlent, program operations, etc., lo the Local Agency; participants will not be oonlacted concerning

these or other problem areas. (Food vendors shall not seek restitution from participants for vouchers not paid by the State.)

M.

To ensure that no exchange of money between the store and participant takes place during a WIC voucher transaction.

N.

To allow no ralncheck& or exchanges of any voucher for cash, credit, ooupons, stamps, premiums or nonlisted foods; however, a vendor

Is not precluded from giving or accepting ooupons, stamps, or premiums with purchases as if purchased with cash.

0.

To obtain al the time of purchase an original customer signature on the WIC voucher and request the participant to show a WIC

Identification card before the purchase of WIC foods can be oompleted. If the customer Is unable to show a WIC Identification card

bearing the same signature as signed on the voucher, the vendor should not accept the WIC voucher as payment for the food(s).

P.

To Insert, In Ink, the actual cost of the WIC foods on the WIC voucher face at the time of purchase in the presence of the customer.

a.

To stamp all vouchers with the authorized vendor stamp (provided by the Local Agency) before depositing In the bank and to deposit

all WIC vouchers In a timely manner, preferably within fifteen (15) days of redemption but vendor must deposit within sixty (60) days

of the "Flrst Day To Use" shown on the voucher face.

R.

1.

The owner or manager who Is legally responsible for the store must slgn the Vendor Agreement and shall attend all mandatory

scheduled (required) training sessions for WIC vendors, of which the vendor will be notified by the Local Agency. The owner

or manager who receives WIC vendor training material via certified mail or attends any training sesslon(s) will provide the
Information received as training material for ell their employees who are Involved In WIC program participation, Including the

checkout clerks.

2.

A vendor owner or manager who signs an authentic WIC Vendor AgreemenVContract in the absence of a local or state agency

WIC representative must have hiSlher Vendor AgreemenVContract signed In the presence of a Notary Public whose

Commission does not expire prior to the date that the AgreemenVContrect Is signed.

.

3.

A statewide uniform Post-Test shall be given to each vendor manager/owner/other store personnel during vendor training,

to evaluate If objectives and guidelines set by the State WIC Agency were achieved. Therefore, each vendor manager/owner

who soores below the desired passing grade of seventy (70) shall reschedule for additional training, In deficient areas, with

the Local WIC Agency representative.

4.

To distribute, to ail employees Involved In the Vendor's WIC Program participation, all oommunications received from the Local

Agency pertinent to the employee's Involvement in the WIC Program. To Instruct cashiers, and all other employees, Involved

In the Vendor's WIC Program participation of the eligible food and the oorrect processing of WIC vouchers.

5.

The vendor shall be accountable for actions of employees In the utilization of vouchers or provision of supplemental foods.

s.

To abide by rules and regulations of Federal, State and Local Agencies and ell procedures as outlined In the Vendor's Handbook.

T.

1.

That the Stale Agency may deny payments to the Vendor for Improper food vouchers or may demand refunds for

payments already made on Improper food vouchers.

2.

To reimburse the State Agency within thirty (30) days of notification for amounts paid by the State Agency on WIC Program

food vouchers processed by the vendor which are above the normal shelf price of foods.

u.

To allow representatives of the Local, State or Federal Agency to monitor the vendor's store In an unannounced manner at any time

the store Is open for business. All reoords pertinent lo lhls Agreement will be made available for review by the representative of the

agency.

V.

That vendor stamps are the property of the State of Georgia and that said stamps will be returned lo the WIC Program Immediately upon

terminatlon/suspenslon/disquallfication/voluntary withdrawal from program participation.

w.

1.

That the vendor or the vendor's employee(&) wtJI not reimburse WIC participants or exchange WIC food Items, especially infant

formula, when WIC vouchers were used for the purchase unless:

a.

Notified In writing by a health department representative.

b.

The vendor Is exchanging a WIC purchased ltem(s) due to Inappropriately selling out-of-date WIC foods.

2.

Thal any out-of-date foods will be removed from stock and replaced with foods that have expiration dates which do not exceed

the period of normal expected usage.

X.

That any vendor disqualified from another FNS Program shall be disqualified from participation In the WIC Program for the same period

of time, up lo a permanent disqualification.

Y.

A vendor who oommits fraud or abuse of the program Is liable lo prosecution under applicable federal, state or local laws. Those who

have willfully misapplied, stolen or fraudulentiy obtained WIC funds shall be subject lo a line of not more than $10,000, or Imprisonment

for not more than five (5) years, or both.



AA.

To notify the Local Agency of changes In management or when the vendor ceases operation or when ownership changes. This

Agreement is null and void II ownership changes.

AB.

State of Georgia or Local Sales taxes will not be oollected on food Items purchased with WIC vouchers.

AC.

To declare that neither the vendor/owner, the vendor's manager(&), or the vendor's other employee(s) Is related by blood or marriage

to any WIC representative, unless otherwise revealed In writing, upon execution of the Contract/Agreement or within the contract period,

(space provided on page three (3) of this Contract/Agreement for disclosure of relative(s).

AD.

To visibly display the Vendor's store name, as listed on the front page of this oontract/agreement, on the outside of the store building/

facility.

AE.

To abide by the U.S. Patent and Trademari< Laws, which prohibits unauthorized use of the WIC acronym and logo (refer to Registration

Number 1,630,468, provided In 42 U.S.C. 1876, 15, U.S.C. 1051 et seq. and 7 CFR Part 246).

AF.

That the WIC Program shall not be liable for bank fees that the Vendor may Incur for WIC vouchers which are rejected and

returned from the bank. The Vendor may not reoover from the WIC Program bank charges Incurred as a result of the Vendor's
violation of any part of lhls Agreement or as a resuH of the Vendor's decision to submit WIC vouchers for payment In an amount In excess

of the maximum redemption price(s) set by the Georgia WIC Program.

AG.

To declare the store owner(s) or employee(&) employed by a Georgia WIC Agency Is listed on page three (3) of this Contract/Agreement.

13

VN-40



GA WIC PROCEDURES MANUAL

Attachment VN-1 cont'd

VENDOR APPLICATION BOOKLET
WIC VENDOR NUMBER

Page 3 of 4



Name and Title of relative who represents the Georgia WIC Program or is employed by the Georgia WIC Program or is employed by the Local Agency:

Name and Title of WIC employee(s) who owns or is employed by the Georgia WIC Vendor:

Store Employee WIC Employee

Name

Title

(Please attach additional page(s) if necessary)

(_ _)-=-,,-,---,-,--~------
Telephone Number (office/daytime)

II.

THE LOCAL AGENCY (WIC PROGRAM) HEREBY AGREES AND COVENANTS AS FOLLOWS:

A.

To instruct the vendor upon entry into the program of the appropriate procedures to process WIC vouchers.

B.

To provide the vendor with the airrent list of foods approved for disbursement to WIC Program partrcipants and to issue updates to this

food list as they occur.

C.

To provide educational material about the WIC Program to the vendor.

D.

To instruct WIC participants and proxies in proper use of WIC vouchers.

.

E.

To ensure that an authorized participant or proxy signature is affixed to any manual voucher prior to releasing the voucher for

redemption.

.

F.

To notify the vendor with a copy of any changes in vouchers or use of vouchers and any changes in the Federal and State Regulations

that may affect the vendor, and to provide the vendor with a copy of any WIC regulation(s) o~ policy issuance(s) affecting the vendor's

participation in the WIC Program.

G.

To assist the vendor with any problem relating to the WIC Program.

H.

To provide the vendor with a uniquely numbered stamp.

Ill.

BOTH PARTIES AGREE ANO COVENANT AS FOLLOWS:

A.

That no conflict of Interest exists between the vendor and the Local Agency (See Section I., AC.).

B.

Not to discriminate for reasons of age, race, color, sex, national origin or handicap.

C.

The vendor has the right to appeal any decision made by the Local Agency affecting the vendor's ability to participate in the WIC

Program under the terms of this Agreement.

0.

The period of this Agreement is set forth on the signature page. New agreements will be executed each year.

E.

This Agreement shall become null and void in Its entirety upon any changes of ownership of retailer.

F.

This Agreement may be canceled by either party with thirty (30) days written notice.

G.

In the event of termination of funds by the funding agency to the State Agency for the WIC Program, this Agreement terminates

immediately.

H.

That neither the Local Agency nor the vendor has an obligation to renew the Vendor Agreement.

I.

This Agreement/Contract does not constitute a license or property interest. The relationship between the Local Agency and the vendor

ends with the expiration date of this Agreement/Contract.

J.

Instances where blocks of vouchers are lost or stolen from a WIC clinic, the Local Agency will notify area WIC retail food vendors that

a stop payment has been placed on these vouchers. Vendors will be provided the voucher numbers and informed not to accept these

vouchers for redemption. These.vouchers will not be paid.

IV.

SANCTIONS ANO APPEAL PROCEDURES:

A.

SANCTIONS

Vendors shall be disqualified from WIC Program participation for a period of up to six (6) years if violations occur during a compliance

purchase, monitoring visit by a WIC representative, or Food Stamp Program participation. Procedures for imposing the sanctions are

outlined in the Retail Vendor Handbook. (See page 4 of 4 of the Vendor Agreement - WIC Program Sanction System). Ally vendor

disqualified from WIC participation may be disqualified from Food Stamp Program participation. Refer to 7 CFR 278. Such

disqualification may not be subject to administrative or judicial review from Food Stamp Program. Vendor shall be permanently

disqualified from the WIC Program if convicted for WIC Program violations and/or permanently disqualified from the Food Stamp

Program.

B.

APPEAL PROCEDURE

Vendors are entitled to a fair hearing upon disqualification from the WIC Program. Any vendor requesting a fair hearing must contact

the Local Agency by telephone, and contact the State WlC Office in writing within fifteen (15) days after the action which is being taken.

WIC vendors who are disqualified from the Food Stamp Program are not entitled to administrative or judicial review when disqualified

from the WIC Program (it does not eliminate administrative review for vendors who are disqualified from WIC based on a Food Stamp

Program Civil Money Penalty).

C.

CIVIL MONEY PENALTY

The State Agency may impose a Civil Money Penalty (CMP) in lieu of disqualification (except that the State Agency may not impose

a CMP in lieu of disqualification either as a result of a Food Stamp Program disqualification or for a third or subsequent sanction as

specified in 7 CFR 246.12(k)(l)(vi)).

V.

TERMINATION POLICIES:

A.

A vendor shall be terminated from WIC Program participation if the store is ltQI licensed by the Georgia Department of Agriculture .

B.

A vendor shall be terminated from WIC Program participation if the store is ltQI eligible for Food Stamp Program

participation/authorization or a vendor is withdrawn from Food Stamp Program participation.

C.

A vendor shall be terminated from WIC Program participation if the owner/manager who is legally responsible for the store does not

attend any required vendor training session(s).

14

VN -41



GA WIC PROCEDURES MANUAL

Attachment VN-1 cont'd

I I VENDOR APPLICATION BOOKLET WIC VENDOR NUMBER'

Page4 of4

The following Is a description of the sanction system and how It wori<s. Civil Money Penalties (CMP) may be assessed ln Categories I-VII In lieu

of disqualification. However, for mandatory sanctions, no CMP shall be allowed unless the State has detennlned that there would be inadequate

participant access.

A.

Any Violation From Category I, II or Ill May Be Assessed A Civil Money Penality (CMP) In Lieu Of Disqualification.(State Agency

sanctions)

Category I Warning on first and second offense, third offense-probation for six (6) months, fourth offense In category I, II, or Ill

disqualification for six (6) months

1.

Stocking a WIC food item(s) that Is outside of manufacturer's not-to-exceed date(s).

2.

Prices not marked clearly on WIC food Items or near WIC food Items.

3.

Allowing WIC food items to exceed the quantity specified on the voucher (except for promotional items).

4.

Failure to give a receipt for WIC purchases.

5.

Failure to allow the purchase of any WIC food ltem(s).

Category II Warning on first offense, second offense-probation for eight (8) months, third offense In category I, II, or Ill-

disqualification for eight (8) months

1.

Failure to properly process vouchers at the store (this includes failure to calculate (ring up) sales of WIC purchases or not

writing price on voucher before participant signs).

2,

Failure to stock the required Inventory of contracted formula or failure to stock the required inventory of lwo or more

WIC food items (types and/or brands). {Physical inventory must be viewed by a WIC representative at the time of visit.

Proof of order of food Items Is not acceptable}.

3.

Refusing to accept valid WIC vouchers from participants In exchange for WIC food Items.

4.

Allowing substitutions for food Items listed on WIC vouchers or allowing the purchase of WIC foods in unauthorized container sizes.

5.

Failure to remain open for business at least eight hours per day, six days per week.

6.

Failure to repay overcharges within a specified period (30 days, 60 days, 90 days).

Category Ill Warning on first offense, second offense-probation for ten (10) months, third offense.In category I, II, or 111

disqualification for ten (10) months

1.

Issuing rain checks/lOU's.

2.

Contacting WIC participants for any reason regarding a WIC transaction.

3.

Requiring participant to pay cash to redeem WIC vouchers.

4.

Allowing the purchase of any formula other than the one specified on the front of the voucher.

5.

Failure to allow participant(s)/proxy(ies) to purchase all WIC food items listed on the face of the voucher regardless of price.

B.

Any Violation From Category IV or V That Occurs At Any Time Will Result In Immediate Disqualification For The Period Specified In

Category IV or V (no prior warning given). A Civil Money Penalty May Be Assessed In Lieu Of Disqualification.

Category IV -Immediate disqualification for one (1) year (twelve months) for each violation(f&2 Mandatory sanctions, 3-7 State Agency

sanctions)

1.

A pattem of providing unauthorized food Items in exchange for WIC vouchers.

2.

A pattem of charging for supplemental foods provided In excess of those listed on the WIC voucher.

3.

Intentionally providing false information on vendor records.

4.

Discrimination.

5.

Failure to provide vouchers or inventory records upon request.

6.

Transacting WIC vouchers outside of the WIC authorized fixed store location.

7.

Failure to allow monitoring by WIC representatives.

Category V - Immediate disqualification for three (3) years (thirty-six months) for each vlolation(Mandatory sanctions)

1.

A pattem of receiving, transacting, or redeeming vouchers from authorized or unauthorized stores or other unauthorized sources.

2.

A pattem of allowing an authorized store to redeem vouchers from another authorized store.

3.

A pattem of providing credit or non-food Items In exchange for WIC vouchers.

4.

A pattern of overcharging on WIC vouchers (charging a WIC participant more than the current shelf price or charging a WIC participant

more for food than a non-WIC customer) during a compliance investigation.

5.

A pattem of charging for supplemental food not received by the WIC participant.

6.

One incidence of the sale of alcohol or alcholic beverages or tobacco products in exchange for WIC voucher(s).

7.

A pattem of claiming relmbursments In excess of documented inventory.

C.

Any Violation From Category VI or VII That Occurs At Any Time Will Result In Immediate Disqualification For The Period Specified In

Category VI or VII (no prior warning given). CIVIL MONEY PENALTY MAY BE ASSESSED FOR INADEQUATE PARTICIPANT ACCESS

CASES ONLY.(Mandatory sanctions)

Category VI - Disqualification for six (6) years (seventy-two months) for each violation

1.

One incidence of buying or selling of WIC vouchers for cash.

2.

One Incidence of exchanging WIC vouchers for firearms.

3.

One Incidence of exchanging WIC vouchers for ammunition.

4.

One Incidence of exchanging WIC vouchers for explosives.

5.

One Incidence of exchanging WIC vouchers for controlled substances.

Category VII Permanent disqualification for a conviction of each violation [(conviction refers to an action by a criminal court

as defined In section 102 of the Controlled Substances Act (21 U.S.C. 802).)

1.

Conviction for buying or selling of WIC vouchers for cash.

2.

Conviction for exchanging WIC vouchers for firearms.

3.

Conviction for exchanging WIC vouchers for ammunition.

4.

Conviction for exchanging WIC vouchers for explosives.

5.

Conviction for exchanging WIC vouchers for controlled substances.

Vendor violations are categorized by the severity and nature of the offense. The nature and severity of a violation(s) shall determine the sanction
assessed, the duration of the probationary period and the period of disqualification. Therefore, the highest sanction assessed to a vendor shall determine the period of probation and disqualification. Each category has a prescribed period of disqualification, probation, or warnings
assessed. State Agency warnings remain active on the vendor case file for a twelve (12) month period. Mandatory sanctions remain on the
vendor's case file pennaoeotly. A vendor fQund to be lo violatlon within the probationary period shall be disqualified tor 001 less lhan the full probationary period or not more than six (6) years Probationary periods are granted by the State WIC Office and are not subject to a fair hearing. A vendor will continue to operate hlsfher business during the probationary period. If a 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 a permanent disqualification.
(Refer to Food Stamp Program Federal Regulations 7 CFR 278). Disqualification from the WIC Program may also result In disqualification from
the Food Stamp Program. As per Federal Regulation 7 CFR 246.12 (k)(1 ), the Georgia WIC Program has taken Into account the severity and nature of violations In establishing the Sanction System.

15

VN-42



GA WIC PROCEDURES MANUAL

Attachment VN-1 cont'd

VENDOR APPLICATION BOOKLET
WIC Vendor Agreement Between Military Commissaries and Local Agencies or
The Special Supplemental Food Program For Women, Inants, and Children (WIC)

T he purpose of this WIC vendor agreement is to
outline the basic responsibilities of WIC local agencies and military commissaries which have been authorized to be WIC food vendors.
1. In order to be an authorized WIC food vendor, the commissary shall fulfill State criteria for authorization and shall sign an agreement with the local agency.
2. The Local WIC Agency shall agree that commissaries shall be reimbursed for the provision of authorized supplemental foods to participants, based on the standard commissary price system of procurement costs plus a percentage surcharge. The Local Agency shall further agree that commissaries are only obliged to serve active or retired military personnel and their dependents.
3. The Local Agency shall provide the commissary with a list of approved WIC supplemental foods. The Local Agency may not direct the commissary to carry a specific brand of merchandise, if that product does not fall within the items authorized for sale in commissaries or if the commissary carries an equivalent product from the approved list of WIC 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 call WIC vouchers), acceptance of WIC vendor training within funding/personnel constraints, and other

Local Agency guidelines agreed to by the appropriate commissary headquarters except those excluded in item five (5) below. The commissary shall not discriminate on the basis of race, color, national origin, sex, age, or handicap.
5. In view of Federal immunity from State claims or review, the Local Agency may not conduct on-site monitoring reviews of commissaries (except upon invitation by the constituted military authority) or require claims to be paid. However, the State agency may review redeemed food instruments prior to payment. If the food instruments are found to contain errors or omissions, payment may be denied unless or until further justification or correction is provided by the submitting commissary.
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 the 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) Federal Employer Identification Number (FEI#) Signature of Authorized Military Personnel Date Signed Telephone Number

District/Unit

Vendor Number

Local Agency Representative Name (Print)

Signature of Local Agency Representative

Date Signed

16

VN-43



GA WIC PROCEDURES MANUAL

Attachment VN-1 cont'd

VENDOR APPLICATION BOOKLET



iri
DHR
Georgia Department of Hwnao Resources
Georgia WIC Program Branch
Two Peachtree Street, NW, 8th Floor Atlanta, Georgia 30303 1-800-228-9173
''The United States Department of Agriculture (USDA) prohibits discrimination in its programs and activities on the basis of race, color, national origin, sex, age, or disability. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information (Braille, larger print, audiotape, etc.) should contact USDA's TARGET Center at (202) 720-5964 (voice and TDD).
To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 14th and Independence Avenue, SW, Washington, DC 20250-9410 or call (202) 720-5964 (voice and TDD). USDA is an equal opportunity provider and employer."
Form No. 3746 (Revised 5-99)

VN-44



GA WIC PROCEDURES MANUAL

Attachment VN-2

APPLICATION FOR VENDOR CERTIFICATION
Georgia Department of Human Resources DIVISION OF PUBLIC HEALTH
FOR WOMEN, INFANTS AND CHILDREN WICPROGRAM
APPLICATION FOR VENDOR CERTIFICATION

Area Code
Store Name _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Telephone Number(__) _ _ _ _ _ _ __
Store Location _ _ _ _ _ _ _ _ _ City _ _ _ _ _ _ GA Zip Code _ _ _ _ _ _ __

Mailing Address (If Different)

County _ _ _ _ _ __

Store Owner _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Store Manager _ _ _ _ _ _ _ _ _ _ __

F.E.I. Number

or Owner's Social Security Number _ _ _ _ _ _ _ _ __

(Federal Employer Identifier)

TYPE OF STORE
Chain

HOURS OF BUSINESS Sunday _____ Monday _ _ _ _ __

Independent

Tuesday

Wednesday _ _ _ __

Franchise

Thursday

Friday _ _ _ _ _ __

Drug

Saturday _ _ _ __

Square Footage of Store _ _ _ _ _ _ _ _ _ Number of Check-out Counters _ _ _ _ _ _ __

(Square Fooaagc of Grocery Store and Grocery Storage Space).

Average Annual Gross Sales $_ _ _ _ _ _ _ Estimated Total % of Food Sales _ _ _ _o/i"'"'o'---Food Stamp Authorization Number _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

(A store must be eligible for Food Stamp Program Authorization to be a WIC Vendor.) Department of Agriculture License Number _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

(A store must be licensed by the Department ofAgriculture to be a WIC vendor) Business License Number _ _ _ _ _ _ _ _ Sales Tax Number _ _ _ _ _ _ _ _ _ _ _ __ Length of time business has operated at the present site _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ Date store will open/change of ownership date _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Yes No

D

D

D

D

Do you sell beer, wine or other alcoholic beverages? Has the business ever operated under another name? If yes, what was the name of the

business?

D

D

ls this a change of ownership?

D

D

Does this store now participate in the Food Stamp Program?

D

D

Has this store ever applied for WIC? If yes, state when _ _ _ _ _ _ _ _ _ _ _ __

D

D

Has this store ever received a warning, been suspended, disqualified, or had a penalty

assessed against it by WIC or Food Stamps? If yes, state when and explain_ _ _ __

STATE WIC OFFICE USE ONLY

Food Pkg.# _ _ _ Vendor Cost ____ Max _ _ _ _ Price Approved _ _ Denied _ _ __

Food Pkg.# _ _ _ Vendor Cost _ _ _ _ Max _ _ _ _Price Approved _ _ Denied _ _ __

Food Pkg.# ____Vendor Cost _ _ _ _ Max _ _ _ _Price Approved _ _ Denied _ _ __

Are Store prices competitive with other stores in State?

Yes ____No

Application:

Approved _ _ _ _ _ Date _ _ _ _ _ Vendor Number A~signed

Denied

Date _ _ _ _ Processed by _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Reason D e n i e d - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

DPHP98.8(b)HW Form 3770 (Rev. 4199)

VN -45

Page I of 2



GA WIC PROCEDURES MANUAL

Attachment VN-2 cont'd

APPLICATION FOR VENDOR CERTIFICATION
Store N a m e - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Name 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) / drug store(s)? Yes No If yes, list name and addresses of store(s) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __



To the best of my knowledge, all of the above answers are correct. I understand that, should my store be accepted as a WIC vendor, I will abide by WIC Program regulations and policies including, but not limited to the following:

I.

Attend Vendor Education

2.

Train employees regarding WIC procedures

3.

Periodical monitoring

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 HA VE ATTENDED VENDOR TRAINING AND I HAVE BEEN ISSUED A WIC VENDOR STAMP.
Signature _________________________ Date _ _ _ _ _ __

Title-----------------------------------"The USDA is an equal opportunity provider and employer."

FOR LOCAL USE ONLY

YES NO

D

D

Is the state required minimum inventory of WIC approved foods in the store during the Pre-Approval

visit?

D

D

Have you provided the vendor with the Georgia WIC Application Packet?

Comments:----------------------------------

I certify that I have visited this store and do/ do not recommend its approval for participation. If this application is not recommended for approval, please explain why: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

DISTRICT/UNIT
DPIIP98.8(b)HW Form 3770 (Rev. 4/99)

LOCAL AGENCY WIC COORDINATOR OR DESIGNEE
VN-46

DATE
Page 2 of 2







STATUS 1-ADD 2-UPDATE 3. TERMINATE

TERMINATION CODE 1 - VOLUNTARY WITHDRAWAL 2 - SALE OF BUSINESS 3 TERMINATION 4 DISQUALIFICATION
(STATE WIC OFFICE USE ONLY)

MAIL TO: VIKING COMPUTING, INC. GA WIC UNIT 1000 N. MADISON, S-3 GREENWOOD, IN 46142

STATUS VENDOR #10

STORE NAME

LJ I I I I I

VENDOR TYPE (SWO USE ONLY)
LJ

STREET ADDRESS

GEORGIA DEPARTMENT OF HUMAN RESOURCES WICPROGRAM
VENDOR REGISTRATION

PLEASE PRINT DATE ORIGINAL WAS PREPARED _ _ / _ _/ _ _

~
->
~
(j

VENDOR REPRESENTATIVE NAME

~

DATE PREPARED _ / _ /_ _

~
0

(j

tT-1

CITY

STATE

ZIP CODE

..____ _ ____,~II

I

I

I I

1-1

I I I

I

z ~
t::'

ct::' ~
rJ')

DIST/UNIT COUNTY

TELEPHONE

APPROVAL DATE

IIIIIII II I II I I I I I III II II

(AREA CODE)

STATUS VENDOR #ID

STORE NAME

LJ I I I I I

z <

VENDOR TYPE STREET ADDRESS (SWO USE ONLY)

:j LJ

VENDOR REPRESENTATIVE NAME CITY

DIST/UNIT COUNTY

TELEPHONE

APPROVAL DATE

TERM DATE

TERM CODE

I I I I I I I I I I I I I I I I I I I I I I r I I I I I I I I I LJ

(AREA CODE)

STATUS VENDOR #10

STORE NAME

LJ I I I I I

VENDOR REPRESENTATIVE NAME

STAMPS ISSUED
LJ

c=z>=

DATE PREPARED _ _ / _ / _ _

>r--

STATE

ZIP CODE

-r.n

--3

~

~JI I I I I 1-1 I I I I >

STAMPS RETURNED:

~

YES _ _ NA _ _
- NO __

0 z

HOW MANY? _ _

It:,

DATE PREPARED_/_/ _ _

~iO

~

VENDOR TYPE STREET ADDRESS (SWO USE ONLY)

CITY

STATE

ZIP CODE

1Z
~

LJ

IGIAI I I I I I 1-1 I I I I ..........

DIST/UNIT COUNTY

TELEPHONE

APPROVAL DATE

TERM DATE

TERM CODE

STAMPS RETURNED:

~

I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I LJ

YES _ _ NA _ _

()
::r

NO _ _

3

(AREA CODE)

HOW MANY? _ _

(b
:..:.l..

ONE FORM PER VENDOR

z <

I

ROUTING:

VIKING - ORIGINAL

L.A. - YELLOW

SWO-PINK

t,.)



GA WIC PROCEDURES MANUAL

Attachment VN-4

VENDOR AGREEMENT

Georgia Department of Human Resources Division of Public Health WIC Program

(SPECIAL SUPPLEMENTAL FOOD PROGRAM FOR WOMEN, INFANTS & CHILDREN)

VENDOR AGREEMENT

Page 1 or 4

This Vendor/Provider Agreement is made by and between the Georgia Department or Human Resources, Division of Public Health, WIC

Program State Agency, (hereinaher referred to as the WIC Program) and _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

--------------,---,--,--------:,---.,....,.---,,-----,-,-----,-----,,,---,--:-:-:-:-:::--,--,-- (hereinaher referred to as the Vendor) to provide a mechanism for the distribution of special supplemental foods to eligible WIC participants. This agreement will become effective on _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _and will terminate on _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

WlC VENDOR NUMBER



The undersigned represents the Vendor as the sole proprietor or the store manager to contract for and on behalf of the Vendor identified below. (Signature MUST be of owner or store manager.)

Signature of Store Owner or Manager

Date

(Pnnij Name of Store OWner or Manager

Name of Vendor (Store)
Ma1hng Address P. o. Box

Street Location of Store - Street Address

C,ty

Stale

zip Code

1elephone Number

Name of Store owrier (11 d1ilerenl from above)

Ma1hng Address

Caty

Stale

Zap Code

Notary Public Signature and Seal

The undersigned represents the Local Agency, District

and has the authonty to contract for ancf on behalf of tneWTC

Program State Agency.

.



Signature of Local Agency Authorized Representative (Pnnt) Name of Local Agency Authonzed Representative

Name of Local Agency
Ma1hng Address - P. o. Sox

Caty

Stale

21p Code

Telephone Number

Estimated of Food Sales

Average Annual Gross Sales

Square Footage of Store

Number of Cash Regaslers

Or Federal Employer Identifier Number -..-S0et=-"a""l""S,..,.ec.,..u_r,..,ty..,N""u_m..,b_e_r-

Date

Notary Public's Commission Expires

PURPOSE:

This Agreement is for the purpose of providing a mechanism for the distribution of certain listed foods to eligible participants and the redemption of negotiable food instruments for the purchase of said food items. The Vendor is retained solely for the purpose set forth herein and shall not be considered as an employee or agent of the Department.
THE VENDOR HANDBOOK IS AN ADDENDUM TO THIS AGREEMENT.
COMMERCIALJBUSINESS BANK ACCOUNT NAME
BANK NAME
ADDRESS

Form 3771 (Rev. 4/99) OPH99.11HW

Routing: White State WIC Office, Yellow Local Agency,

Pink Vendor

VN-48



GA WIC PROCEDURES MANUAL
VENDOR AGREEMENT
WIC VENDOR NUMBER

Attachment VN-4 cont'd
Page 2 or4



I. THE RETAIL VENDOR HEREBY AGREES ANO COVENANTS AS FOLLOWS:

A.

To stock an adequate supply of authorized types and brands of WIC Program foods, in all categories, as determined by the Georgia

WIC Program.

B.

That all prices will be clearly marked either on the lood item or prominently displayed.

C.

To post the acceptable WIC Approved Foods List in a conspicuous place by all cash registers.

0.

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 WIC vouchers and allow participants to purchase all foods on the voucher(s) regardless of price.

E.

To accept no WIC vouchers as payment on past or present credit account(s).

F.

To accept no WIC vouchers from participants presented after thirty (30) days from the issuance date or prior to issue date shown on

the voucher.

G.

To accept only vouchers which contain a Georgia WIC Program SEAL.

H.

To refuse acceptance of any WIC voucher on which any alterations have been made.

I.

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 formula vouchers).

J.

To permit WIC Program participants to purchase eligible food items without making other purchases and to accord such participants

the same oourtesy given to other store customers. In addition, the vendor must provide the participant with a receipt for W IC purchases.

K.

To keep all Information confidential on WIC participants.

L.

To direct questions concerning payment, program operations, etc., to the Local Agency; participants will not be contacted oonceming

these or other problem areas. (Food vendors shall not seek restitution from participants for vouchers not paid by the State.)

M.

To ensure that no exchange of money between the store and participant takes place during a WIC voucher transaction.

N.

To allow no rainchecks or exchanges of any voucher for cash, credit coupons, stamps, premiums or nonlisted foods; however, a vendor

is not precluded from giving or accepting coupons, stamps, or premiums with purchases as If purchased with cash.

0.

To obtain at the lime of purchase an original customer signature on the WIC voucher and request the participant to show a WIC

Identification card before the purchase of WIC foods can be completed. If the customer is unable to show a WIC identification card

bearing the same signature as signed on the voucher, the vendor should not accept the WIC voucher as payment for the food(s).

P.

To Insert, in ink, the actual cost of the WIC foods on the WIC voucher face at the time of purchase in the presence of the customer.

a.

To stamp all vouchers with the authorized vendor stamp (provided by the Local Agency) before depositing in the bank and to deposit

all WIC vouchers In a timely manner, preferably within fifteen (15) days of redemption but vendor must deposit within sixty (60) days

of the "First Day To Use shown on the voucher face.

R.

1.

The owner or manager who is legally responsible for the store must sign the Vendor Agreement and shall attend all mandatory

scheduled (required) training sessions for WIC vendors, of which the vendor will be notified by the Local Agency. The owner

or manager who receives WIC vendor training material via certified mail or attends any training session(s) will provide the

information received as training material for all their employees who are involved in WIC program participation, including the

checkout clerks.

2.

A vendor owner or manager who signs an authentic WIC Vendor Agreement/Contract in the absence of a local or state agency

WIC representative must have his/her Vendor Agreement/Contract signed in the presence of a Notary Public whose

Commission does not expire prior to the date that the Agreement/Contract is signed.

3.

A statewide uniform Post-Test shall be given to each vendor manager/owner/other store personnel during vendor training,

to evaluate if objectives and guidelines set by the State WIC Agency were achieved. Therefore, each vendor manager/owner

who scores below the desired passing grade of seventy (70) shall reschedule for additional training, in deficient areas, with

the Local WIC Agency representative.

4.

To distribute, to all employees involved in the Vendor's WIC Program participation, all communications received from the Local

Agency pertinent to the employee's Involvement in the WIC Program. To Instruct cashiers, and all other employees, involved

in the Vendor's WIC Program participation of the eligible food and the correct processing of WIC vouchers.

5.

The vendor shall be accountable for actions of employees In the utilization of vouchers or provision of supplemental foods.

s.

To abide by rules and regulations of 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 Vendor for Improper food vouchers or may demand refunds for

payments already made on improper food vouchers.

2.

To reimburse the State Agency within thirty (30) days of notification for amounts paid by the State Agency on WIC Program

food vouchers processed by the vendor which are above the normal shelf price of foods.

u.

To allow representatives of the Local, State or Federal Agency to monitor the vendor's store in an unannounced manner at any time

the store is open for business. All records pertinent to this Agreement will be made available for review by the representative of the

agency.

V.

That vendor stamps are the property of the State of Georgia and that said stamps will be returned to the WIC Program immediately upon

termination/suspension/disqualification/voluntary withdrawal from program participation.

W.

1.

That the vendor or the vendor's employee(s) will not reimburse WIC participants or exchange WIC food items, especially lnfanl

formula, when WIC vouchers were used for the purchase unless:

a.

Notified in writing by a health department representative.

b.

The vendor is exchanging a WIC purchased item(s) due to inappropriately selling out-of-date WIC foods.

2.

That any out-of-date foods will be removed from stock and replaced with foods that have expiration dates which do not exceed

the period of normal expected usage.

X.

That any vendor disqualified from another FNS Program shall be disqualified from participation in the WIC Program for the same period

of time, up to a permanent disqualification.

Y.

A vendor who commits fraud or abuse of the program Is liable to prosecution under applicable federal, state or local laws. Those who

have willfully misapplied, stolen or fraudulently obtained WIC funds shall be subject to a fine of not more than $10,000, or imprisonment

for not more than five (5) years, or both.

AA.

To notify the Local Agency of changes In management or when the vendor ceases operation or when ownership changes. This

Agreement is null and void if ownership changes.

AB.

State of Georgia or Local Sales taxes will not be oollected on food items purchased with WIC vouchers.

AC.

To declare that neither the vendor/owner, the vendor's manager(&), or the vendor's other employee(s) is related by blood or marriage

to any WIC representative, unless otherwise revealed in writing, upon execution of the Contract/Agreement or within the contract period,

(space provided on page three (3) of this Contract/Agreement for disclosure of relalive(s).

AO.

To visibly display the Vendor's store name, as listed on the front page of this contract/agreement, on the outside of the store building/

facility.

AE.

To abide by the U.S. Patent and Trademark Laws, which prohibits unauthorized use of the WIC acronym and logo (refer to Registration

Number 1,630,468, provided in 42 U.S.C. 1876, 15, U.S.C. 1051 et seq. and 7 CFR Part 246).

AF.

That the WIC Program shall not be liable for bank fees that the Vendor may incur for WIC vouchers which are rejected and

returned from the bank. The Vendor may not recover from the WIC Program bank charges incurred as a result of the Vendor's

violation of any part of this Agreement or as a result of the Vendor's decision to submit WIC vouchers for payment in an amount in excess

of the maximum redemption price(s) set by the Georgia WIC Program.

AG.

To declare the store owner(s) or employee(&) employed by a Georgia WIC Agency is listed on page three (3) of this Contract/Agreement.

Form 3TT1 (Rev. 4199) DPIIP99.11IIW

Routing: White State WtC Office, Yellow Local Agency,

Pink Vendor

VN-49



GA WIC PROCEDURES MANUAL
VENDOR AGREEMENT
WIC VENDOR NUMBER

Attachment VN-4 cont'd
Page 3 of 4



Name and Title of relative who represents the Georgia WIC Program or is employed by the Georgia WIC Program or is employed by the Local Agency:

Name and Title of WIC employee(s) who owns oc is employed by the Geocgia WIC Vendor.

Store Employee WIC Employee

Name

_(

_Title )

___________ _

(Please attach additional page(s) if necessary)

Telephone Number (otroce/daytime)

II.

THE LOCAL AGENCY (WIC PROGRAM) HEREBY AGREES AND COVENANTS AS FOLLOWS:

A.

To instruct the vendoc upon entry into the program of the appropriate procedures to process WIC vouchers.

B.

To provide the vendor with the ainent list of foods approved fOf disbursement to WIC Program participants and to issue updates to this

food list as they occur.

C.

To provide educational material about the WIC Program to the vendor.

D.

To instruct WIC participants and proxies in proper use of WIC vouchers.

E.

To ensure that an authorized participant or proxy signature Is affixed to any manual voucher prioc to releasing the voucher for

redemption.

F.

To notify the vendocwith a copy of any changes In vouchers oc use of vouchers and any changes in the Federal and State Regulations

that may affect the vendoc, and to provide the vendor with a oopy of any WIC regulation(s) or policy issuance(s) affecting the vendor's

participation in the WIC Program.

G.

To assist the vendor with any problem relating to the WIC Program.

H.

To provide the vendor with a uniquely numbered stamp.

Ill.

BOTH PARTIES AGREE AND COVENANT AS FOLLOWS:

A.

That no oonflict of Interest exists between the vendor and the Local Agency (See Section I., AC.).

B.

Not to discriminate for reasons of age, race, oolor, sex, national origin or handicap.

C.

The vendor has the right to appeal any decision made by the Local Agency affecting the vendor's ability to participate in the WIC

Program under the terms of this Agreement.

D.

The period of this Agreement is set fOflh on the signature page. New agreements will be executed each year.

E.

This Agreement shall become null and void in its entirety upon any changes of ownership of retailer.

F.

This Agreement may be canceled by either party with thirty (30) days written notice.

G.

In the event of termination of funds by the funding agency to the State Agency for the WIC Program, this Agreement terminates

immediately.

H.

That neither the Local Agency nor the vendoc has an obligation to renew the Vendor Agreement.

I.

This Agreement/Contract does not oonstitute a license oc property interest. The relationship between the Local Agency and the vendor

ends with the expiration date of this Agreement/Contract.

J.

Instances where blocks of vouchers are lost or stolen from a WIC dinic, the Local Agency will notify area WIC retail food vendors that

a stop payment has been placed on these vouchers. Vendors will be provided the voucher numbers and Informed not to accept these

vouchers for redemption. These vouchers will not be paid.

IV.

SANCTIONS AND APPEAL PROCEDURES:

A.

SANCTIONS

Vendors shall be disqualified from WIC Program participation for a period of up to six (6) years If violations occur during a oompliance

purchase, monitoring visit by a WIC representative, or Food Stamp Program participation. Procedures for imposing the sanctions are

outtined in the Retail Vendoc Handbook. (See page 4 of 4 of the Vendor Agreement - WIC Program Sanction System). Any vendor

disqualified from WIC participation may be disqualified from Food Stamp Program participation. Refer to 7 CFR 278. Such

disqualification may not be subject to administrative or Judicial review from Food Stamp Program. Vendor shall be permanently

disqualified from the WIC Program if oonvicted for WIC Program violations and/or permanently disqualified from the Food Stamp

Program.

B.

APPEAL PROCEDURE

Vendors are entitled to a fair hearing upon disqualification from the WIC Program. Any vendor requesting a fair hearing must oontact

the Local Agency by telephone, and contact the State WIC Office in writing within fifteen (15) days after the action which is being taken.

WIC vendors who are disqualified from the Food Stamp Program are not entitled to administrative or judicial review when disqualified

from the WIC Program (it does not eliminate administrative review fOf vendors who are disqualified from WIC based on a Food Stamp

Program Civil Money Penalty).

C.

CIVIL MONEY PENALTY

The State Agency may impose a Civil Money Penalty (CMP) in lieu of disqualification (except that the State Agency may not impose

a CMP in lieu of disqualification either as a result of a Food Stamp Program disqualification or for a third or subsequent sanction as

specified in 7 CFR 246.12(k)(l)(vi)).

V.

TERMINATION POLICIES:

A.

A vendoc shall be terminated from WIC Program participation if the store is HO.I licensed by the Georgia Department of Agriculture .

B.

A vendor shall be terminated from WIC Program participation if the stoce is HO.I eligible for Food Stamp Program

participation/authorization or a vendor is withdrawn from Food Stamp Program participation.

C.

A vendoc shall be terminated from WIC Program participation if the owner/manager who is legally responsible for the store does not

attend any required vendor training session(s).

Form 3771 (Rev. 9/99)

Routing: White - State WIC Office, Yellow - Local Agency,

Pink - Vendor

DPIIP99.I I IIW

VN- 50



GA WIC PROCEDURES MANUAL VENDOR AGREEMENT
I I WIC VENDOR NUMBER

Attachment VN-4 cont'd
Page 4 of 4

The following is a description of the sanction system and how It wOfks. Civil Money Penalties (CMP) may be assessed in Categories I-VII in lieu

of disqualification. However, for mandatory sanctions, CMP may be assessed only in cases of inadequate participant access.

A.

Any Violation From Category I, II or Ill May Be Assessed A Civil Money Penality (CMP) In Lieu Of Disqualification.(State Agency

sanctions)



Category I Warning on first and second offense, third offense1>robation for six (6) months, fourth offense In category I, II, or Ill

disqualification for six (6) months

1.

Stocking a WIC food item(s) that Is outside of manufacturer's not-to-exceed date(s).

2.

Prices not marked dearly on WIC food items or near WIC food items.

3.

Allowing WIC food items to exceed the quantity specified on the voucher (except for promotional items).

4.

Failure to give a receipt for WIC purchases.

5.

Failure to allow the purchase of any WIC food item(s).

Category II Warning on first offense, second offense1>robation tor eight (8) months, third offense in category I, II, or Ill-

disqualification for eight (8) months

1.

Failure to property process vouchers at the store (this includes failure to calculate (ring up) sales of WIC purchases or not

writing price on voucher before participant signs).

2.

Failure to stock the required inventory of contracted formula or failure to stock the required inventory of two or more

WIC food Items (types and/or brands). {Physical inventory must be viewed by a WIC representative at the time of visit.

Proof of order of food items is not acceptable).

3.

Refusing to accept valid WIC vouchers from participants in exchange for WIC food items.

4.

Allowing substitutions for food items listed on WIC vouchers or allowing the purchase of WIC foods in unauthorized container sizes.

5.

Failure to remain open for business at least eight hours per day, six days per week.

6.

Failure to repay overcharges within a specified period (30 days, 60 days, 90 days).

Category Ill Warning on first offense, second offense1>robation for ten (10) months, third offense In category I, II, or Ill-

disqualification for ten (10) months

1.

Issuing rain checks/lOU's.

2.

Contacting WIC participants for any reason regarding a WlC transaction.

3.

Requiring participant to pay cash to redeem WIC vouchers.

4.

Allowing the purchase of any formula other than the one specified on the front of the voucher.

5.

Failure to allow participant(s)/proxy(ies) to purchase all WIC food items listed on the face of the voucher regardless of price.

B.

Any Violation From Category IV or V That Occurs At Any Time Will Result In immediate Disqualification For The Period Specified In

Category IV or V (no prior warning given). A Civil Money Penalty May Be Assessed In Lieu Of Disqualification.

Category IV ~mmediate disqualification for one (1) year (twelve months) for each violation(1&2 Mandatory sanctions, 3-7 State Agency

sanctions)

1.

A pattern of providing unauthorized food items in exchange for WlC vouchers.

2.

A pattern of charging for supplemental foods provided in excess of those listed on the WIC voucher.

3.

Intentionally providing false information on vendor records.

4.

Discrimination.

5.

Failure to provide vouchers or inventory records upon request.

6.

Transacting WIC vouchers outside of the WiC authorized fixed store location.

7.

Failure to allow monitoring by WIC representatives.

Category V - Immediate disqualification for three (3) years (thirty-5ix months) for each violation(Mandato,y sanctions)

1.

A pattern of receiving. transacting, or redeeming vouchers from authorized or unauthorized stores or other unauthorized sources.

2.

A pattern of allowing an authorized store to redeem vouchers from another authorized store.

3.

A pattern of providing aedit or non-food items in exchange for WIC vouchers.

4.

A pattem of overcharging on WIC vouchers (charging a WIC participant more than the current shelf price or charging a WiC participant

more for food than a non-WIC customer) during a compliance investigation.

5.

A pattern of charging for supplemental food not received by the WIC participant.

6.

One incidence of the sale of alcohol or alcholic beverages or tobacco products in exchange for WIC voucher(s).

7.

A pattern of claiming reimbursments in excess of documented inventory.

C.

Any Violation From Category VI or VII That Occurs At Any Time Wlll Result In Immediate Disqualification For The Period Specified In

Category VI or VII (no prior warning given). CIVIL MONEY PENALTY MAY BE ASSESSED FOR INADEQUATE PARTICIPANT ACCESS

CASES ONLY.(Mandatory sanctions)

Category VI Disqualification for six (6) years (seventy-two months) for each violation

1.

One incidence of buying or selling of WIC vouchers for cash.

2.

One incidence of exchanging WIC vouchers for firearms.

3.

One incidence of exchanging WIC vouchers for ammunition.

4.

One incidence of exchanging WIC vouchers for explosives.

5.

One incidence of exchanging WIC vouchers for controlled substances.

Category VII Permanent disqualification for a conviction of each violation [(conviction refers to an action by a criminal court

as defined in section 102 of the Controlled Substances Act (21 U.S.C. 802).]

1.

Conviction for buying or selling of WIC vouchers for cash.

2.

Conviction for exchanging WIC vouchers for firearms.

3.

Conviction for exchanging WIC vouchers for ammunition.

4.

Conviction for exchanging WIC vouchers for explosives.

5.

Conviction for exchanging WIC vouchers for controlled substances.

Vendor violations are categorized by the severity and nature of the offense. The nature and severity of a violation(s) shall determine the sanction

assessed, the duration of the probationary period and the period of disqualification. Therefore, the highest sanction assessed to a vendor shall

determine the period of probation and disqualification. Each category has a prescribed period of disqualification, probation, or warnings

assessed. State Agency warnings remain active on the vendor case file for a twelve (12) month period. Mandatory sanctions remain on the

vendor's case file pennanently. A vendor found to be la violatjon within the probationary period shall be disqualified for not less than the tun

probationary period or not more than six (Iii years Probationary periods are granted by the State WIC Office and are not subject to a fair hearing.

A vendor will continue to operate his/her business during the probationary period. If a 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 a permanent disqualification.

(Refer to Food Stamp Program Federal Regulations 7 CFR 278). Disqualification from the WIC Program may also result in disqualification from

the Food Stamp Program. As per Federal Regulation 7 CFR 246.12 (k)(1 ), the Georgia WIC Program has taken Into account the severity and nature

of violations in establishing the Sanction System.

Form 3771 (Rev.9/99)DPHP99.I I HW Routing: White-State WIC Office

Yellow-t.ocal Agency

Pink-Vendor

VN - 51



GA WIC PROCEDURES MANUAL

Attachment VN-5

MILITARY COMMISSARY AGREEMENT
WIC Vendor Agreement Between Military Commissaries and Local Agencies for
The Special Supplemental Food Program For Women, Infants, and Children (WIC)

T he purpose of this WIC vendor agreement is to
outline the basic responsibilities of WIC local agencies and military commissaries which have been authorized to be WIC food vendors.
I. In order to be an authorized WIC food vendor, the commissary shall fulfill State criteria for authorization and shall sign an agreement with the local agency.
2. The Local WIC Agency shall agree that commissaries shall be reimbursed for the provision of authorized supplemental foods to participants, based on the standard commissary price system of procurement costs plus a percentage surcharge. The Local Agency shall further agree that commissaries are only obliged to serve active or retired military personnel and their dependents.
3. The Local Agency shall provide the
commissary with a list of approved WIC supplemental foods. The Local Agency may not direct the commissary to carry a specific brand of merchandise, if that product does not fall within the items authorized for sale in commissaries or if the commissary carries an equivalent product from the approved list of WIC 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 call WIC vouchers), acceptance of WIC vendor training within funding/personnel constraints, and other

Local Agency guidelines agreed to by the appropriate commissary headquarters except those excluded in item five (5) below. The commissary shall not discriminate on the basis of race, color, national origin, sex, age, or handicap.
5. In view of Federal immunity from State claims or review, the Local Agency may not conduct on-site monitoring reviews of commissaries (except upon invitation by the constituted military authority) or require claims to be paid. However, the State agency may review redeemed food instruments prior to payment. If the food instruments are found to contain errors or omissions, payment may be denied unless or until further justification or correction is provided by the submitting commissary.
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 the 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)

District/Unit

Vendor Number

Federal Employer Identification Number (FEI#)

Local Agency Representative Name (Print)

Signature of Authorized Military Personnel

Signature of Local Agency Representative

Date Signed

Date Signed

Telephone Number

VN-52



GA WIC PROCEDURES MANUAL

Attachment VN-6

PHARMACY AGREEMENT

Georgia Department of Human Resources Division of Public Health WICProgram
(SPECIAL SUPPLEMENTAL FOOD PROGRAM FOR WOMEN, INFANTS & CHILDREN)

PHARMACY AGREEMENT

Page I or 4

This Pharmacy/Provider Agreement is made by and between the Georgia Department of Human Resources, Division of Public Health, WIC Program, State Agency, (hereinafter referred to as the WIC Program) and _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ (hereinafter

referred to as the Phannacy) to provide a mechanism for the distribution of special supplemental formula to eligible WIC participants. This agreement will become effective on _ _ _ _ _ _ _ _ _ _ _ _ _ _and will terminate on _ _ _ _ _ _ _ _ __

WIC PHARMACY NUMBER



The undersigned represents the Vendor as the sole proprietor or the pharmacy manager to contract for and on behalf of the vendor identified below. (Signature MUST be of owner or pharmacy manager.)

Signature of Pharmacy Owner

Date

(Print) Name of Pharmacy Owner or Manager

Name of Pharmacy

Ma1hng Address Street P.O. Box
Street Location of Pharmacy Street Address

city

State

Zip Code

Telephone Number

Name of Pharmacy Owner (11 different from above)

Mailing Address

city

State

Zip Code

The undersigned represents the Local Agencyh District and lias the authority to contract for and on be all of the
Wl<:;15rogram State Agency.

Signature of Local Agency Authorized Representative

(Print) Name of Local Agency Authorized Representative

Name of Local Agency
o. Ma1hng Address - Street P. Box

City

State

Zip code

Telephone Number

Estimated % of Formula Sales

Average Annual Gross Sales

Square Footage of Store

Number of Cash Registers

'"F-ed..,.e_r_a.,.,IE~m-p,..lo_y_e_r.,..d...e._n.,.t1f""1e-r""N...u_m...,b,...e_r_Ors"'o-c-,a...,l'""s""e_c_u...,ri.,..ty....,N..u_m....,...be-r

Notary Public Signature and Seal

Date

Notary Public's Commission Expires

PURPOSE:

This Agreement is for the purpose of providing a mechanism for the distribution of certain listed formula to eligible participants and the redemption of negotiable food instruments (vouchers) for the purchase of said food items . The Pharmacy is retained solely for the purpose set forth herein and shall not be considered as an employee or agent of the Department.
THE PHARMACY HANDBOOK IS AN ADDENDUM TO THIS AGREEMENT.

COMMERCIAUBUSINESS BANK ACCOUNT NAME

BANK NAME

ADDRESS

Form 3782 (Rev.5/99)DPHP99.11 HW

Routing: While State WIC Office,

Yellow Local Agency,

Pink Vendor

VN-53



GA WIC PROCEDURES MANUAL
PHARMACY AGREEMENT
WIC PHARMACY NUMBER

Attachment VN-6 cont'd
Page 2 of 4



I. THE PHARMACY HEREBY AGREES AND COVENANTS AS FOLLOWS:

A.

Upon notification from the Local Agency, to supply, within a time period agreed upon by the Pharmacy and the Local Agency, the

necessary supply of any one of the "Special Infant Formulas.

B.

That all prices will be clearly marked either on the food item or prominently displayed:

C.

To accept WIC vouchers for payment of the purchase of only eligible WIC formulas. In addition, the pharmacy must accept all valid

WIC vouchers and allow participants to purchase all formula on the voucher(s) regardless ol price.

0.

To not accept WIC vouchers as payment on past or present credit account(s).

E.

To not accept WIC vouchers lrom participants presented alter thirty (30) days lrom the issuance date or prior to issue date shown on

the voucher.

F.

To accept only vouchers which contain a Georgia WIC Program SEAL.

G.

To refuse acceptance of any voucher on which any alterations have been made.

H.

To sell WIC formula at or below the normal pharmacy shelf price.

I.

To permit WIC Program participants to purchase eligible formula without making other purchases and to accord such participants the

same courtesy given to other pharmacy customers.

J.

To keep all Information confidential on WIC participants.

K.

To direct questions concerning payment, program operations, etc., to the Local Agency; participants will not be contacted concerning

these or other problem areas. (Pharmacies shall not seek restitution from participants for vouchers not paid by the State.)

L.

To ensure that no exchange ol money between the pharmacy and participant takes place during a WIC voucher transaction.

M.

To not allow rain checks or exchanges of any voucher for cash, credit, coupons, stamps, premiums, or non-listed formulas; however,

a pharmacy is not precluded from giving or accepting coupons, stamps, or premiums with purchases as if purchased with cash.

N.

To obtain at the lime of purchase an original customer signature on the WIC voucher and request that the participant show a WIC

Identification card before the purchase of WIC formula can be completed. If the customer is unable to show a WIC identification card

bearing the same signature as signed on the voucher, the pharmacy should not accept the WIC voucher as payment for the formula.

0.

To insert, in ink, the actual cost of the WIC foods on the WIC voucher face at the time of purchase in the presence of the customer.

P.

To stamp all vouchers with the authorized pharmacy stamp (provided by the Local Agency) before depositing in the bank and to

deposit all WIC vouchers in a timely manner, preferably within filteen (15) days of redemption but within sixty (60) days of the "First

Day to Use shown on the voucher face.

a.

1.

To distribute to all employees involved in the Pharmacy's WIC Program participation all communications received from the

Local Agency pertinent to the employee's involvement in the WIC Program. To Instruct cashiers, and all other employees,

involved In the Pharmacy's WIC Program participation of the eligible formula and the correct processing of WIC vouchers .

2.

The Pharmacy will be accountable for actions of employees in the utilization of vouchers or provision of supplemental

foods.

3.

A pharmacy owner or manager who signs an authentic WIC Pharmacy Agreement/Contract in the absence of a Local or

State Agency WIC representative must have his/her Pharmacy Agreement Contract signed in the presence of a Notary

Public whose commission does not expire prior to the date that the Agreement Contract is signed.

R.

To abide by rules and regulations of Federal, State, and Local Agencies and all procedures as outlined in the WIC Pharmacy

Handbook.

s.

1.

That the State Agency may deny payments to the Pharmacy for improper food vouchers or may demand refunds for

payments already made on Improper vouchers.

2.

To reimburse the State Agency within thirty (30) days of notification tor amounts paid by the State Agency on WIC Program

food vouchers processed by the pharmacy which are above the normal shelf price of formula.

T.

To allow representatives of the Local, State, or Federal Agency to monitor the pharmacy in an unannounced manner at any lime the

pharmacy is open for business. All records pertinent to this Agreement will be made available for review by the representative of the

agency.

u.

That pharmacy stamps are the property of the State of Georgia and that said stamps will be returned to the WIC Program

immediately upon termination/suspension/disqualification/voluntary withdrawal from program participation.

V.

1.

That the pharmacy or the pharmacy's employee(s) will not reimburse WIC participants or exchange WIC formula, when

WIC vouchers were used for the purchase unless:

a. Notified in writing by a health department representative.

b. The Pharmacy Is exchanging a WIC purchased item(s) due to Inappropriately selling out-of-date WIC formula.

2.

That any out-of-date formula will be removed from stock and replaced with formula that have expiration dates which do not

exceed the period of normal expected usage.

w.

That any pharmacy disqualified from another Food and Nutrition Services (FNS) Program shall be disqualified from participation in

the WIC Program for the same period of lime, up to three (3) years.

X.

A pharmacy who commits fraud or abuse of the program is liable to prosecution under applicable Federal, State or Local laws.

Those who have willfully misapplied, stolen, or fraudulently obtained WIC funds shall be subject to a fine of not more than $10,000 or

imprisonment for not more than five (5) years or both.

Y.

To notify the Local Agency of changes In management or when the pharmacy ceases operation or ownership changes. This

Agreement is null and void if ownership changes.

z.

State of Georgia or Local Sales taxes will not be collected on formula items purchased with WIC vouchers.

AA.

To declare that neither the pharmacy/owner, the pharmacy's manager(s), or the pharmacy's other employee(s) is related by blood or

marriage to any WIC representative, unless otherwise revealed in writing, upon execution of the Agreement/Contract or within the

contract period (space provided on Page three (3) of this Agreement/Contract for disclosure of relatives).

AB.

To visibly display the pharmacy's store name, as listed on the front page of the Agreement/Contract, on the outside of the store

building/facility.

AC.

To abide by the U.S. Patent and Trademark Laws, which prohibits unauthorized use of the WIC acronym and logo (refer to

Registration Number 1,630,468, provided in 42 U.S.C. 1876, 15 U.S.C. 1051 et. seq. and 7 CFR Part 246).

AD.

To declare that the pharmacy owner(s) or employee(s) employed by a Georgia WIC Agency is listed on Page three (3) of this

Agreement/Contract.

AE.

That the WIC Program shall not be liable for bank fees that the Pharmacy may incur for WIC vouchers which are rejected and

returned from the bank. The Pharmacy may not recover from the WIC Program bank charges incurred as a result of the Pharmacy's

violation of any part of the Agreement or as a result of the Pharmacy's decision to submit W IC vouchers for payment in an amount in

excess of the maximum redemption price(s) set by the Georgia WIC Program.

Form 3782 (Rev. 5/99) OPHP99.11 HW

Routing: White - Stale WIC Office Yellow - Local Agency Pink - Vendor

VN-54



GA WIC PROCEDURES MANUAL

Attachment VN-6 cont'd

PHARMACY AGREEMENT

WIC PHARMACY NUMBER

Page 3 of 4

I

I

Name and Title of relative who represents the Georgia WIC Program or is employed by the Georgia WIC Program or is employed by the Local Agency.

Name and Title of WIC employee(s) who owns or is employed by the Georgia WIC Phannacy.

Phannacy Employee WIC Employee

Name

Tille

(Please attach additional page(s) if necessary)

Telephone Number (Office/daytime)

II. THE LOCAL AGENCY (WIC Program) HEREBY AGREES AND COVENANTS AS FOLLOWS:

A.

To instruct the Phannacy upon entry into the program of the appropriate procedures to process WIC vouchers.

B.

To provide the Phannacy with the current list of formulas approved for disbursement to WIC Program participants and to issue

updates to this fonnula list as they occur.

C.

To provide educational material about the WIC Program to the Phannacy.

D.

To instruct WIC participants and proxies in the proper use of WIC vouchers.

E.

To ensure that an authorized participant or proxy signature is affixed to any manual voucher prior to releasing the voucher for

redemption.

F.

To notify the Phannacy with a copy of any changes in vouchers or use of vouchers and any changes in the Federal and State

Regulations that may affect the Phannacy, and to provide the Phannacy with a copy of any WIC regulation(s) or policy issuance(s)

affecting the Phannacy's participation in the WIC Program.

G.

To assist the Phannacy with any problem relating the WIC Program.

H.

To provide the Phannacy with a uniquely numbered stamp.

111. BOTH PARTIES AGREE AND COVENANTS AS FOLLOWS:

A.

That no conflict of interest exists between the Phannacy and the Local Agency (See Section I., AA.).

B.

Not to discriminate for reasons of age, race, color, sex, national origin or handicap.

C.

The Phannacy has the right to appeal any decision made by the Local Agency affecting the Phannacy's ability to participate in the

WIC Program under the tenns of this Agreement.

D.

The period of this Agreement is set forth on the signature page. New agreements will be executed each year.

E.

This Agreement shall become null and void in its entirety upon any changes of ownership of the Phannacy.

F.

This Agreement may be canceled by either party with thirty (30) days written notice.

G.

In the event of termination of funds by the funding agency to the State Agency for the WIC Program, this Agreement terminates

immediately.

H.

That neither the Local Agency nor the Phannacy has an obligation to renew the Pharmacy Agreement.

I.

This Agreement does not constitute a license or property interest. The relationship between the Local Agency and the Pharmacy

ends with the expiration date of this Agreement.

J.

In instances where blocks of vouchers are lost or stolen from a WIC clinic, the Local Agency will notify area WIC retail fonnula

vendors that a stop payment has been placed on these vouchers. Phannacies will be provided the voucher numbers and infonned

not to accept these vouchers for redemption. These vouchers will not be paid.

IV. SANCTIONS AND APPEAL PROCEDURES:

A.

SANCTIONS

Phannacies shall be disqualified from WIC Program participation for a period of up to six (6) years if violations occur during a

compliance purchase, monitoring visit by a WIC representative, or Food Stamp Program participation. Procedures for imposing the

sanctions are outlined in the WIC Phannacy Handbook. (See Page 4 of 4 of the Phannacy Agreement - WIC Program Sanction

System.) Any Phannacy disqualified from WIC participation may be disqualified from Food Stamp Program participation. Refer to

7 CFR 278. Such disqualification may not be subject to administrative or judicial review from the Food Stamp Program. The

Phannacy shall be pennanentty disqualified from the WIC Program if convicted for WIC Program violations and/or pennanentty

disqualified from the Food Stamp Program.

B.

APPEAL PROCEDURE

Phannacies are entitled to a fair hearing upon disqualification from the WIC Program. Any Phannacy requesting a fair hearing

must contact the Local Agency by telephone, and contact the State WIC Office in writing within fifteen (15) days after the action

which is being taken. WIC Phannacies who are disqualified from the Food Stamp Program are not entitled to administrative or

judicial review when disqualified from the WIC Program (it does not eliminate administrative review for phannacies who are

disqualified from WIC based on a Food Stamp Program Civil Money Penalty).

C.

CIVIL MONEY PENALTY

The State Agency may impose a Civil Money Penalty (CMP) in lieu of disqualification (except that the State Agency may not

impose a CMP in lieu of disqualification either as a result of a Food Stamp Program disqualification or for a third or subsequent

sanction as specified in 7 CFR 246.12(k)(l)(vi)).

V. TERMINATION POLICIES:

A.

A Phannacy shall be terminated from WIC Program participation if the store is NOT licensed by the Georgia Department of

Agriculture .

B.

A Phannacy shall be tenninated from WIC Program participation if the store is eligible for Food Stamp Program

participation/authorization and is disqualified from Food Stamp Program participation.

For_m 3782 (Rev.9/99) DPHP99.11HW

Routing: White - State WIC Office Yellow - Local Agency Pink - Vendor

VN - 55



GA WIC PROCEDURES MANUAL

Attachment VN-6 cont'd

PHARMACY AGREEMENT

WIC PHARMACY NUMBER

Pag< 4 or 4

I

I

The following Is a description of the sanction system and how It wor1ts. Civil Money Penalties (CMP) may be assessed In Categories I-VII in lieu

of disqualification. However, for mandatory sanctions, no CMP shall be allowed unless the State has determined that there would be inadequate

participant access.

A.

Any Violation From Category I, II or Ill May Be Assessed A Civil Money Penalty (CMP) In Lieu Of Disqualification.(State Agency sanctions)

Category I - Warning on first and second offense, third offense-probation for six (6) months, fourth offense in category I, II, or Ill -

disqualification for six (6) months

1.

Stocking a WIG food item(s) lhat is outside of manufacturer's not-to-exceed date(s).

2.

Prices not marl<ed dear1y on WIG food items or near WIG food items.

3.

Allowing WIG food items to exceed lhe quantity specified on the voucher (except for promotional items).

4.

Failure to give a receipt for WIG purchases.

5.

Failure to allow lhe purchase of any WIG food item(s).

Category II Warning on first offense, second offense-probation for eight (8) months, third offense in category I, II, or Ill-

disqualification for eight (8) months

1.

Failure to properly process vouchers at lhe store (this indudes failure to calculate (ring up) sales of WIG purchases or not

writing price on voucher before participant signs).

. 2.

Failure to stock lhe required inventory of contracted formula or failure to stock lhe required inventory of two or more

WIG food items (types and/or brands). {Physical inventory must be viewed by a WIG representative at the time of visit.

Proof of order of food items is not acceptable}.

3.

Refusing to accept valid WIC vouchers from participants in exchange for WIC food items.

4.

Allowing substitutions for food items listed on WIG vouchers or allowing the purchase of WIC foods in unauthorized container sizes.

5.

Failure to remain open for business at least eight hours per day, six days per week.

6.

Failure to repay overcharges wilhin a specificied period (30 days, 60 days, 90 days).

Category Ill - Warning on first offense, second offense-probation for ten (1 OJ months, third offense In category I, II, or Ill-

disqualification for ten (10) months

1.

Issuing rain checks/lOU's.

2.

Contacting WIC participants for any reason regarding a WIC transaction.

3.

Requiring participant to pay cash to redeem WIC vouchers.

4.

Allowing the purchase of any formula olher than the one specified on lhe front of the voucher.

5.

Failure to allow participant(s).'proxy(ies) to purchase all WIG food Items listed on the face of lhe voucher regardless of price.

B.

Any Violation From Category IV or V That Occurs At Any Time Will Result In Immediate Disqualification For The Period Specified In

Category IV or V (no prior warning given). A Civil Money Penalty May Be Assessed In Lieu Of Disqualification.

Category IV -Immediate disqualification for one (1) year (twelve months) for each violation (!&2 Mandatory sanctions, 3-7 Stale Agency

sanctions)

1.

A pattern of providing unaulhorized food items in exchange for WIC vouchers.

2.

A pattern of charging for supplemental foods provided in excess of those listed on the WIC voucher.

3.

Intentionally providing false information on vendor records.

4.

Discrimination.

5.

Failure to provide vouchers or inventory records upon request.

6.

Transacting WIC vouchers outside of the WIC authorized fixed store location.

7.

Failure to allow monitoring by WIC representatives.

Category V - Immediate disqualification for three (3) years (thirty-six months) for each violation/Mandatory sanctions)

1.

A pattern of receiving, transacting, or redeeming vouchers from authorized or unauthorized stores or other unauthorized sources.

2.

A pattern of providing credit or non-food items in exchange for WIG vouchers.

3.

A pattern of allowing an authorized store to redeem vouchers from another authorized store.

4.

A pattern of pvercharging on WIC vouchers (charging a WIG participant more lhan lhe current shelf price or charging a WIC participant

more for food than a non-WIC customer) during a compliance investigation.

5.

A pattern of charging for supplemental food not received by the WIC participant.

6.

One incidence of the sale of alcohol or alcholic beverages or tobacco products in exchange for WIC voucher(s).

7.

A pattern of daiming reimbursments in excess of documented inventory.

C.

Any Violation From Category VI or VII That Occurs At Any Time Will Result In Immediate Disqualification For The Period Specified In

Category VI or VII (no prior warning given). CIVIL MONEY PENALTY MAY BE ASSESSED FOR INADEQUATE PARTICIPANT ACCESS

CASES ONLY.(Mandatory sanctions)

Category VI Disqualification for six (6) years (seventy-two months) for each violation

1.

One incidence of buying or selling of WIG vouchers for cash.

2.

One incidence of exchanging WIC vouchers for firearms.

3.

One incidence of exchanging WIG vouchers for ammunition.

4.

One incidence of exchanging WIG vouchers for explosives.

5.

One incidence of exchanging WIC vouchers foc controlled substances.

Category VII Permanent disqualification for a conviction of each violation [(conviction refers to an action by a criminal court as defined

in section 102 of the Controlled Substances Act (21 U.S.C. 802).)

1.

Conviction for buying or selling of WIG vouchers for cash.

2.

Conviction for exchanging WIG vouchers for firearms.

3.

Conviction for exchanging WIG vouchers lor ammunition.

4.

Conviction for exchanging WIC vouchers for explosives.

5.

Conviction for exchanging WIG vouchers for controlled substances.

Vendor violations will be categorized by the severity and nature of the offense. The nature and severity of a vlolation(s) shall determine the

sanction assessed, the duration of the probationary period and the period of disqualification. Therefore, the highest sanction assessed to a

vendor shall determine the period of probation and disqualification. Each category has a prescribed period of disqualification, probation, or

warnings assessed. Warnings remain active on the vendor case file for a twelve (12) month period. A vendor found to be in violation within the

proba!jonaiy period shall be disqualified for not less than the fun probaUonaiy period or not more than sjx (6) years Probationary periods are

granted by the State WIC Office and are not subject to a fair hearing. A vendor will continue to operate his/her business during the probationary

period. If a 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 a permanent disqualification. (Refer to Food Stamp Program Federal Regulations 7 CFR 278). Disqualification

from the WIC Program may also result In disqualification from the Food Stamp Program. As per Federal Regulation 7 CFR 246.12 (k)(1), the

Georgia WIC Program has taken into account the severity and nature of violations in establishing the Sanction System.

Form 3782 (Rev. 9/99) DPHP99.l lllW Routing: White-State WIG Office

Yellow-Local Agency

Pink-Vendor

VN-56



GA WIC PROCEDURES MANUAL
VENDOR TRAINING CHECKLIST
Georgia Department of Human Resources Georgia WIC Program
VENDOR TRAINING CHECKLIST

Attachment VN-7
WIC VENDOR NUMBER

YES

NO

NIA

I.

Discussed purpose of the WIC Program. (See Vendor Handbook and Vendor

Agreement).

2.

Discussed purpose of vendor training for new and current vendors and also

who is required to auend vendor training. (See Vendor Handbook and Vendor

Agreement).

3.

Reviewed and discussed the Vendor Agreement. Discussed purpose

of Vendor Agreement and who is authorized to sign the agreement. (Refer

to the Vendor Application Booklet and Vendor Agreement page lof 4 and

l.(R)(I).

4.

Discussed how to contact Local and State WIC representatives.

5.

Discussed WIC approved foods. (See page I of the Vendor Handbook.)

6.

Discussed minimum inventory requirements. (See page 2 of the Vendor

Handbook.)

7.

Discussed how to apply for a minimum inventory waiver ofWIC Approved

Foods. (See Page 3 of the Vendor Handbook.)

8.

Examine and discussed WIC vouchers in detail. (Refer to the Vendor

Handbook.)

9.

Discussed procedure for processing WIC vouchers. (Refer to the Vendor

Handbook and Vendor Agreement-1.(0-1) and (M-Q).

Discussed payment of WIC vouchers. (Refer 10 the Vendor Handbook and Vendor Agreemenl-1.(T)(l) and (2).

II.

Discussed checking out the WIC customer and the WIC 1.0. Card.

(Refer to the Vendor Handbook and Vendor Agreement-1.(0).

12.

Discussed the procedure for processing bank-returned vouchers. (Refer to the

Vendor Handbook).

13.

Conducted an in-depth discussion of compliance performance, sanctions,

disqualifications, tenninations. civil money penalties and hearing/appeal

procedures.

(Refer to the Vendor Handbook and Vendor Agreement l.(S), IV and page 4.)

14.

Completed the Federal Fiscal Year Vendor Training Post-Test.

(Refer to the Vendor Agreement-1.(R)(J).

15.

I have received a copy of the Vendor Handbook and the content of the

information provided was discussed.

16.

Other (Specify) _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

I acknowledge discussion of the Vendor Handbook, the WIC Vendor Agreement, and all other items checked "Yes" as outlined by the Vendor Training Checklist above.

Comments: - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Store Owner/Manager/Representative's Signature

Date

Local Agency Authorized Representative's Signature

Date

Name Owner/Manager/Representative (PRINT)

Name of Vendor (Store)

Mailing Addrcss-Sircc~ Location, P. 0. Box

City

State

Form 3757 (Rev. S-99)DPIIP98.8(g)IIW

Zip Code

Local Agency Authorized Representative (PRINT)

Name of Local Agency

Mailing Address Sircc~ Location, P. 0. Box

State Routing: White. State WIC Office

City Yellow District

Zip Code Pink Vend or

VN -57



GA WIC PROCEDURES MANUAL
VENDOR TRAINING SIGN-IN SHEET
Georgia Department of Human Resources DIVISION OF PUBLIC HEALTH WICOFFICE
VENDOR TRAINING INFORMATION FORM SIGN-IN SHEET

Attachment VN-8

DISTRICT_ _ _ _ UNIT _ _ _ __

DATE_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

TYPE OF TRAINING: INITIAL [ ]

ANNUAL[]

FOLLOW-UP []

LOCATIONOFTRAINING: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

TRAINING CONDUCTED BY:

Print Name

Title

VENDOR NUMBER

VENDOR/STORE NAME

PRINT OWNER/MANAGER/ REPRESENTATIVE NAME

REPRESENTATIVE'S SIGNATURFlTITLE





(Please attach a copy of each vendor's Vendor Agreement, Training Checklist, and the Vendor Post Evaluation TesL)

(TO BE TERMINATED)
LIST STORE OWNER<Sl/M .. NAGER<Sl WHO DID NOT ATTEND ANN11AL TR4 INING AND DID NOT RENEW VENDOR AGREEMENT:

VENDOR NUMBER

VENDOR/STORE NAME

PRINT OWNER/MANAGER NAME

COMMENT(S)

(Please attach a copy of each terminated vendor's Input/Registration form or VIPS Transaction Keypunch form.)

FORM 3756 (REV. 4/99)

ROUTING: WHITE- STATE WIC OFFICE

YELLOW - DISTRICT OFFICE

VN -58



GA WIC PROCEDURES MANUAL VENDOR HANDBOOK

Attachment VN-9

WIC Vendor Handbook
FFY 2000
Georgia Department of Human Resources


DPHP99.l 1HW


1-800-228-9173 VN-59



GA WIC PROCEDURES MANUAL
VENDOR HANDBOOK Contents

Attachment VN-9 cont'd

WhatisWIC?

WIC Approved Food List

What Foods Can a WIC Customer

(Participant) Purchase?

2

Minimum Inventory Requirements

2

The WIC Food Vouchers

3-4

About the WIC Acronym and Logo

5

Processing WIC Vouchers

5

Checking out the WIC Customer

5

Important Notes

5-6

Voucher Payment Policy

6

Vendor Payment Procedure

6

Vendor Training

6-7

Sale/Purchase of Store or Change of Ownership

7

Changing Store Location

7

Compliance Performance

7-8

Sanctions

8

Oisqualifications/Terminalions

8-9

. Contract/Agreement Termination Policy

9

Civil Money Penalties

9

Hearing/Appeal Procedures

10

Pre-appeal Administrative Review

10

Inadequate Participant Access Cases

10

Sanction System

10s12

Sample Vendor Profile Report

13

Incident/Complaint Form

14

Vendor Review Form

15-18

WIC Transaction Report

19

Minimum Inventory ReQuest for Waiver

20

Return Voucher Payment Log

21

Where to Get More Information?

Backcover

VN-60



GA WIC PROCEDURES MANUAL

Attachment VN-9 cont'd

VENDOR HANDBOOK

What Is WIC?

WIC stands for Women, Infants and Children. The WIC program is funded by the U.S. Department of Agriculture and is administered in Georgia by the Department of Human Resources through state, district, and local health offices.
WIC provides Important food to pregnant women and their infants and/or young children. Proper nutrition at the beginning of life may help prevent serious health problems. WIC gives children a chance to grow up healthy and lead

active, productive lives. WIC program participants are examined by health professionals who determine the need for supplemental food and nutritional guidance.
The participants receive vouchers for specific kinds of highly nutritious foods. These vouchers are redeemed by participating grocers or pharmacies (vendors) who have signed an agreement to follow all WIC program requirements.

WIC Approved Foods List The following list of foods may be purchased using WIC vouchers:

Food Item

Brand or Type

Container/Pkg. Size

Cannot Buy

MILK (Pasteurized)
CEREAL
CHEESE (Reduad Fa~ Lowfat or Fat
Free Cheese ls Allowed) JUICE (100'1, USRDA VllalDh, C For11fied)

Whole. Skim, Lowfat (l'I,). or Reduced Fat (2'1,) (Least Expensive Brand Only)
Acidopbilus, Enjoy, Lacta.id, Lacta.id 100, Nutrish or Dairy Ease, Evaporaitd, powdeied or UHT Milk (if lisltd oo voucher)

Ooe Gal. Siu: ONLY (E,ccption: Gal. or Qts. of Enjoy. Lacta.id, Lacta.id 100, aod/or Acidophilus. 12 Oz. cans Evaporaitd, J or 5 Oz. boxes powducd, 8 Oz. box UHT Milk)

Flavored Milk, Buttennilk, or Goat's Milk

Cieerios, O,ex (Corn, Rice or Wheat), Country Coro Flalces, IGx, Nabisco Quick Oum of Wheat (Regular Flavor), Product 19, Jim Dandy Quick Grits (lroo Fortificd),Har>e,t lmiant Oatmeal (Regular Flavor), Qualltr losta111 Grits or Oatmoal (Regular Flavor), TOOII Corn Flakes, K,Uogg's Special K or Corn Flake,, Kellogg's
Complcit Bran Flal:es. Quaker Sun Country Quick Oats (Regular Flavor), Quaker Oats Cruachy Com Bnlll RaJstoo: Optima JOO Whole Wheat Flalces, Enriched Bran Flakes. Nuny Nuggets, losta111 Oatmeal (Regular Flavor), Crispy Rice, Coro Flalces, Taslteofl'oasltd Oats, Crispy Com Puff Ralston Start Brands Allowed: Kroger, Kounuy Fmh. IGA, Red & Wbiit, Flavoriit or Nanins Best

9 Oz. Sizes and Above ONLY
Cao pun:hase roore than ooe (I) type/brand of cereal as long u the amount docs not go over the quanti1y on the front of the voucher

8 Oz. or Less Siu: Boxes

American (Individually Wrapped or Unwrapped Sliced or Block), Cheddar (Block), Colby (Block), Monitrty Jack (Block) a.od Mozzarella (Block)

9 Oz. up to 16 Oz. I lb. Siu: ONLY

Oieese Food, Shredded or Deli Cheese and/or 2-8 Oz. Pkgs. for 1-16 Oz. Pkg. (No 8 Oz. Pkgs.
ofOieese)

Ora111e: Leut Expcnsivo Brand Only Grapefruit: Leut Expcosivo Brand .Only Gnpe: Welcb's, Juicy Juice or Seoeca White Grape: Welcb's Apple: Aavoriit, Lucky LeaJ, Staff, Shur FlllO, Kroger, Setloca (Red Label), Thrifty Maid, Wbiit House, Juicy Juice
Other: Dole: Orange/PiDeapplc, Orange/Pineapple/Banana.
Pineapplc/Grapefruil
Juicy Juice: Oicny. l'uoch. Tropical. Strawberry, Apple/Grape. ~ Pllnch. Berry
Pourablei: Welch's Juice Maken (Apple, Grape or Whiit Grape) Juicy Juice (Pl&och. Grape, Chcn-y, Deny. Strawberry or Apple)

46 Oz. Cans, 6 oz. Caru. 12 Oz. Cans Frozen ONLY or 11.5 oz. Poorablcs

Juice Drinks, Fresh Squeezed Juice, Want Juices, Juices With Sugar Added

EGGS (Grade A Laree Ooly) DRIED PEAS/BEANS

Least Expeosive Brand Only Any Brand Without Flavoring Added

One (I) Dozen One (I) lb. Siu: ONLY

Any Other Siu/Qty. Any Other Size/Qty.

CANNED PEAS/BEANS

Any Brand Without Flavoring Added

15 Oz. Cans ONLY

Any Other Size/Qty.

PEANUT BUTTER

Any Brand Without JeUy Added..- Honey Sprud

18 Oz. Jars ONLY

Any Other Siu/Qty.

INFANT FORMULA

As Lisitd on the Front or the Voochcr

M Listed on the Front of the Voucher Uolisitd on Voucher

INFANT CEREAL (Boxes Ooly)

Beech Nu~ Geiter, Heinz

TIJNA CARROTS

Wa1tr Packed Only Fre,h. Whole, Canned-Medium Cu~ Sliced

Dry CueaJ in 8 o, 16 Oz. Sizes ONLY

Any Baby Food in Jar, or Any Dry Cerul with Fruit/Fomada
Added

6 Oz. Cans Only

Tuna Packed in Oil

1 Lb. Presealed Plastic Bag or 15 Oz. Bull<. Frozen.

Canned Sliced

Shredded, or Baby Cm-ots

VN -61



GA WIC PROCEDURES MANUAL

Attachment VN-9 cont'd

VENDOR HANDBOOK

What Foods Can a WIC Customer (Participant) Purchase?
The WIC participant may become a regular customer at a participating store and purchase any groceries there. However, the WIC

vouchers can only be used to purchase specific types of food. Each voucher lists the food that can be purchased.

WIC Minimum Inventory Requirements The following is a list of the minimum inventory requirements for WIC vendors which outline the required quantities, sizes, types or brands which the store must carry in order to become or remain a WIC vendor.

Food Item

Quantity

Size

Number of

Types/Brands

Milk: (Pasteurized)

20

1 gal. jug

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

1 Brand

Cheese:

16

l lb. pkg.

2 Types

Eggs: (Grade A Large)

16

1 doz. eggs per carton

1 Brand

Juice:

24

46 oz. can

2 Types

Cereal:

30

9-24 oz. box

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

4 Types

Peas/Beans:

8

l lb. pkg.

2 Types

Peanut Butter:

8

18 oz.jar

2 Brands

Formula: (With Iron)

170*

13. oz. can

1 Brand

Contract brand of formula only. Vendor must be able to supply soy, powdered, ready-to-feed, concentrate,

or a different brand of formula upon request.

*Vendor must stock a minimum of 32 cans of soy-base contracted brand formula and 138 cans of milk-base

contracted brand formula.

Note: Low iron formula does not meet WIC minimum inventory requirements for formula.

Infant Cereal:

12

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

8 oz. box

2 Types

Pharmacies are exempt from the minimum inventory requirements, but must meet the maximum pricing criteria.

In an effort to continue serving as many WIC eligible Georgians as possible, the following food items must be purchased in the following quantities and/or sizes:
MILK: Gallon size container only, with the exception of: Enjoy, Lactaid, Nutrish, Acidophilus, Lactaid 100, Dairy Ease and UHT Milk (if listed on voucher).
CHEESE: Nine (9) oz. to one (1) pound package(s) of cheese only, no eight (8) oz. packages of cheese are allowed to be purchased.
JUICE: Only twelve (12) oz. containers frozen, 11.5 oz. pourable concentrate, six (6) oz. cans (if listed on voucher) and forty-six (46) oz. cans of juice may be purchased.

Combinations Allowed:
Women . and children may receive vouchers for milk, cheese (not cheese food), eggs, certain brands of cereal with a high iron content, fruit juice (not fruit drink) which is high in Vitamin C, dried beans/peas, or peanut butter. Infants may receive iron fortified formula, infant cereal, and juice.
The food prescriptions are carefully selected, and substitution of other foods is prohibited. Vendors receive a new list of approved foods any time changes are made.

2
VN-62



GA WIC PROCEDURES MANUAL

Attachment VN-9 cont'd

VENDOR HANDBOOK

Vendors are required to keep a minimum Inventory of the approved foods and offer them at competltlve prices (see page 2).
If a vendor experiences difficulty selling specific WIC approved food ltem(s), then the vendor may write to the Local Agency or State WIC Office to request a minimum Inventory waiver from stocking the hard to sell ltem(s). The State WIC Office will determine If a vendor meets the waiver criteria within thirty
(30) days of receipt by the State WIC Office.
The WIC Food Vouchers
The voucher for WIG foods is a check and should be redeemed just as carefully. When a

voucher is properly redeemed, the vendor will receive credit for the amount of purchase by depositing it in his/her bank account. The vendor Is responsible for any mistakes that cashiers make with WIC vouchers, so heJshe must be sure that they know all WIC voucher redemption requirements. The Local and State WIG Offices can assist with cashier training as
needed. A WIG vendor must accept all valid WIG
vouchers. However, no voucher will be redeemed for more than the maximum amount printed on the face of each voucher (excluding infant formula vouchers).

There are four (4) types of WIG vouchers, computer generated, standard manual, blank manual and laser printed vouchers.

Computer Generated Vouchers: All information on voucher is computer printed.

i1 00439868 l

GEORGIA WIC PROGRAM
DEPARTMENT OF HUMAN RESOURCES

00439868

PAY TO THE ORDER OF AlfY AUTHORIZED GEORGIA WIC VENDOR
FOR THESE ffEMS / QUAN1lT1ES ON.Y - NO SUBSmun0NS
FOOD PACKAGE CODE!603 VOUCHERCODE-047
HILK:. 1 GAL (OR> 412 OZ CNS EVAP
<OR> 1-5 QT BOX
.JUICE: .1~12 oz CAN FROZEN OR l-46 oz CAN
CEREAL: UP TO 24 OUNCES

S016e

~;;G;.;~,
I WITHOUT \,"J:C I
_ I I vENOOR STA.W
'--~'.'.:_ _)

YOUR BABY NEEDS SHOTS AT 2 MONTHS, 4 MONTHS,

IMPROPER USE OF THIS VOUCHER IS SUBJECT TO

6 MONTHS, 15 MONTHS, & 5 YEARS

STATE ANO FEDERAL.

PROSECVTION

Aral Alliance ~ 1 1 11

HE A
VOID VOID VOID VOID VOID VOI OID VOID VOID VOID VOID VOI

Standard Manual: Manual vouchers are processed in the same manner as computer generated vouchers.

LO. . .. ... .,.~}" _ anual youcher has the name, number, and dates written or typed by the staff at the clinic.

:_~~:._.::.-.<<~ttf >.tr:' OISTlUC1"/UNIT /0.NC -:;~_'i,-t,p:~,!WICIDNO. ;.f"::; ., . .'.'_ C P ., ::.-_--..,.: , .

PARTICIPANT._;.:;.:.,:,:. ._} ..-__!;~_ :. :: . RSN; ,:

11 o 570 100

00 8 1 SMITH, CARMEN J

N ~~g~~:[;! 05/27/99

...

.,,,,,

78730369
...._MI 7 8 73 03 6:J 2

GEORGIA WIC PROGRAM
DEPARTMENT OF HUMAN RESOURCES

7 8 7 3 36 9 VOUCHERNO.
Q

:LASToAv::.'~(
f--T;...o....;.y_s_!:.,;.-:~~*j"..w~'--L-<~:LI

VENDOR MUST~

OEPOS'T_ ~X/}'

C 404 vc 028
MILK 1 1 GAL OR 4-12 OZ CNS EVAP OR 1-5 QT BOX EGGS 1 1 DOZEN
JUICE, 2-12 OZ CANS FROZEN OR 2-46 OZ CANS

S 12.00

r . ; .:;.;,,_.-;;'\

\..._.:"'.'.: _ I I I I 1----+---'-'I

WITHOUT WIC VENDOR STAI.IP

_)

0 2 0 q L, q L,111

,.....

3

VN-63



GA WIC PROCEDURES MANUAL

Attachment VN-9 cont'd

VENDOR HANDBOOK

Blank Manual Vouchers
The blank manual voucher has the name, I.D. number and dates written or typed by the staff at the clinic. The amount of food to be received is also written or typed. Redeem only for the amount of food indicated. Only one (1) number should appear in each box.

Examples:

Ilxfl][[l]

Correct Correct

Incorrect Incorrect

X's are placed in all boxes where there is no number. This helps to eliminate any possible unauthorized alterations on the voucher(s). A description of all voucher coda numbers are detailed in the Vendor Newsletter, which is distributed to vendors quarterly.



VOUCHER NO.
99559355

VENDOR MUST DEPOSrr BY

FOODPACKAGECODE 4oq"THESE=~ERCODE ;,- u

I FORMULA

II CEREAi.

~
~

oz Infant

I~ JUICE

-

-

~ ~

48 oz Cini

12ozean./F,zn.

OJ:Adutt

C&n ~ : : : : : : 10 F-
,, or 18 oz Powdered

lb C&n Nutramlgon P011agon

~ PtegeatimH

WI. -

Typo -

jcU<IBse I '

Form-----

( \/0:ti:S

!CHEESE
jEoGs

lXJ lb
! / I Doz

~ : J I L K Gol Fluid ~=~vap.

!===~===!><] !PEAS/BEANS

lb Dried

I l><J PEANllT BUTTER

up IO 18 oz CARROTS

I\Gol LAcloll FrN 01.1 LactoH FrN 1lb Proualld Pl<g

jwNA

!Xi 8 1/8 oz C&n

)

IMPROPER USE OF THIS VOUCHER IS SUBJECT TO
STATE ANO FEOEF\Al.

(

PROSECUTION

FlrI Alliance 64-334-611

,010.

Laser Printed Vouchers: The laser printed voucher is printed at the clinic site at the time of the participant's visit.

)
,....



4

VN-64



GA WIC PROCEDURES MANUAL

Attachment VN-9 cont'd

VENDOR HANDBOOK

About the WIC Acronym and Logo
The acronym "WIC" was registered with the U.S. Patent and Trademark Office on January 1, 1991, Registration Number 1,630,468. Authority to use the "WIC" acronym and the logo are provided in 42 U.S.C. #1876, 15 U.S.C. 1051 et. seq., and 7 CFR Part 246. Therefore, this notice is to inform you that the Food and Consumer Services Office of the United States Department of Agriculture reserves the right to approve any uses
of the WIC acronym, and any ~ses t_hat are considered inappropriate shall be discontinued.

Processing WIC Vouchers
After a grocer has signed an agreement with the WIC program, he/she will receive a W_IC 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 yendor s~ould 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 Premier
Bank of Marietta, Georgia.

Payment will be assured, prior to the deposit, If:

1.

Vendor does not accept voucher before

the "First Day to Use Date" listed on the

face of the voucher.

2.

A WIC program authorization seal

appears on the face of the voucher(s).

(Does not apply to laser printed

voucher(s).)

3.

An authorized WIC vendor stamp

appears on the face of the voucher. .

4.

The total amount of the purchase 1s

entered in the presence of the customer.

5.

The amount of purchase does not

exceed the maximum amount printed

on the face of the voucher.

6.

The vendor must not accept the

voucher after the "Last Day to Use"

date on the voucher. Vouchers

deposited after sixty (60) days from the

"First Day to Use" date shall not be

paid.

7.

Endorsements should appear at the

bottom left-comer (for manual vouchers

only) and right-corner of all voucher(s).

The participant must sign the area

"Sign Here at WIC Office," prior to

redemption of manual vouchers and/or

sign a voucher register for redemption of

computer-generated vouchers.

In

addition, in the area "Sign Here at

Grocery Store," a signature should be

obtained upon redemption of WIC food

item(s).

ALL VOUCHERS WHICH DO NOT MEET THESE REQUIREMENTS WILL BE RETURNED UNPAID TO THE VENDOR.

Checking Out the WIC Customer
When food is purchased with a WIC
voucher, the cashier must do the following:

1.

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).

2.

Check the dates on the voucher.

Vouchers cannot be used before the

"First Day to Use" nor after the "Last

Day to Use" dates.

3.

Separate the food listed on the voucher

from other purchases, if the WIC

customer has not done so.

4.

Ring up the shelf price on item(s) of WIC

food(s) for each voucher. Make sure that

the exact types and amounts of approved

WIC foods are being purchased. Do not

Include sales tax.

5.

Print the amount of the purchase in

the "Pay Exactly" space on the

voucher in the presence of the WIC

customer.

6.

Have the WIC customer/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.

7.

If the WIG customer cannot sign

his/her name, the WIG 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 WIC customer

also signed the ID card with his/her

mark.

IMPORTANT NOTES



Any WIC customer who attempts to

purchase foods that are not approved or

creates other problems in the store should

be reported to the Local or State WIG

Office immediately.

WIG 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 . yv1c

participants in retail stores are proh1b1ted.

Signs such as ~IC vouchers not allowed

in this line" or "No checks, No WIG"

cannot be displayed since they are

considered discriminatory. However,

grocers who wish to ensure t~at _WIG

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 WIG

voucher transaction, it is imperative that

5
VN-65



GA WIC PROCEDURES MANUAL

Attachment VN-9 cont'd

VENDOR HANDBOOK

the customer is not identified as a WIC

participant over the public address

system. Every effort must be made to

protect the confidentiality of the

participant/proxy, and discussion of the

transaction should be kept at a

conversational level. Provisions I.J. and

I.K. 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 13 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 cannot be redeemed for

more than the maximum purchase

price listed on the front of each

voucher (excluding Infant formula

vouchers).



Every store has the option of checking 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.

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 ~orrect price written above the error along with the cashier's initials. The voucher should then be processed through the bank as a normal voucher. If the price on the voucher exceeds the maximum purchase price, it will be returned to the vendor marked "Not For Resubmission." These vouchers should be sent to the State WIC Program with the Return Voucher Payment Log to be processed for payment. The State WIC Office shall only reimburse vendors for vouchers at a rate of the

vendor's shelf price(s) up to, but not over, the "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 vendor's Federal Employer Identifier (FEI) number or Social Security Number (SSN) if the FEI number is
unavailable.

WIC vouchers returned by the bank to the vendor because of a stale date will not be paid.

Voucher Payment Procedure
If a voucher has been returned to the WIC vendor not paid, the vendor may submit the
voucher(s) to the State WIC Office for possible payment. The correct voucher procedures are
listed below:



The Return Voucher Payment Log (Form

3760) must be completed and sent with

the original WIC voucher(s) to the State

WIC Office.

The vendor should retain 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

(excluding Infant formula vouchers).

Payment on vouchers received without

the Return Voucher Payment Log 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:

1.

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 (only when WIC

approved perishable food items were not

available upon pre-approval visit). If the

store is not stocked with the required

perishable WIC approved foods at the

time of the visit, the vendor shall receive

sanctions.

3.

Annual Vendor Training

a.

The store owner/manager who

is legally responsible for the

store, must attend all required

training sessions (vendors who do

not comply with policies and

procedures) for WIC vendors, of

which the vendor is notified by the

6
VN-66

GA WIC PROCEDURES MANUAL

Attachment VN-9 cont'd

VENDOR HANDBOOK

Local or State Agency.

b.

The store owner/manager, who

is legally responsible for the

store, will send at least one

forwarded to the State WIG Office. The vendor stamp will remain in the possession of the new owner unless replacement stamp issuance is necessary. If a replacement stamp is issued a

store personnel representative

vendor registration form or transaction keypunch

to all required training sessions,

form is forwarded to the ADP contractor and the

of which the vendor is notified

Local Agency by the State WIC Office to update

by the Local or State Agency.

the database systems. If the vendor stamp

4.

Subsequent Training

The State Agency/Local Agency will

remains the same, a vendor registration fonn or transaction keypunch form must be forwarded by

conduct on-site training for WIC vendor

personnel at the request of the store

owner/manager.

5.

Compliance Investigation Training

The State Agency may conduct

the Local Agency to the ADP contractor and the State WIG Office to update the database. The Local Agency representative must conduct a vendor review of WIC approved food items within thirty (30) days after the vendor authorization.

compliance investigation training visits.

If violations are found during this visit,

Changing Store Location

the State Agency may require mandatory

When a store moves to a new location

training (no sanctions will be assessed).

under the same management, the local WIG

Sale/Purchase of Store or Change

agency must be notified of the address change immediately.

of Ownership

Compliance Performance

Vendors who wish to receive WIG vendor authorization for additional store openings or

Compliance investigations may include but are not limited to monitoring visits, covert

change of ownership must submit a completed

investigations, audits, and system reports. The

WIC application form to the Local Agency 45

performance of every vendor is reviewed in at

)

working days prior to store opening or change of

least one of the following ways:

ownership date. All retail vendors will be subject



Monitoring



to the same application process. WIC vouchers must not be accepted by vendor applicant during the application process.
Upon the sale of a WIG-authorized store and the purchase of a previous WIG-authorized store, the new owner/vendor applicant shall prove

All WIC vendors will be reviewed through on-site visits (at a minimum of once every two years). Representatives of the Local, State, or Federal agencies will monitor your store at any time the store is open for business. (See pages 14-17 for a copy of the Vendor Review Form.) All

that a sale took place by presenting a legitimate

records pertinent to this monitoring visit must be

bill of sale that complies with the Bulk Sale Law found in the Georgia Official Code Annotated and

available for review by the representative of the agency upon request. The monitoring visit is

Unannotated. When a WIC authorized store is

used to review program policies and procedures

purchased by a WIG unauthorized store owner/manager an application for vendor

compliance, merchant training needs and personal contact with the merchant.

authorization must be completed by the new

Audits

owner. The previous vendor stamp must be terminated at the time the ownership changes. A

The State WIC Office may conduct record audits on any vendor at any time. During an audit,

new vendor number will be issued to the new

the vendor must supply the WIC representative

owner upon application approval (see page VN-5

with documentation of pertinent records upon

for Approval and Reauthorization Criteria for Vendors) by the State WIG Office. A new Vendor

request. Vendors must retain copies of all invoices relating to the purchase of WIC food items

Agreement must be signed by the new owner.

for a period of two (2) years.

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



Covert Compliance Investigation

Compliance investigations shall be

conducted in authorized WIC vendors' stores.

Vendors identified for investigation will consist of

those considered to be potentially high risk by

system reports. The performance of every vendor

is analyzed carefully with computer reports on

each WIG voucher transaction. Vendors will be

will not be paid for those vouchers. The Vendor

investigated who have been reported to the WIC



Agreement must be signed and vendor stamp must be issued prior to vouchers being accepted.
If the manager who signed the original Vendor Agreement Contract and/or Vendor Training Checklist remains the same, the Local Agency will have the manager update the vendor file with a new Vendor Agreement Contract, Vendor Training Checklist and an Application for Certification bearing the new owner's name, pertinent new information and signature to be

Program for potentially violating program regulations. Non-potential high risk vendors will be randomly selected for investigation. Investigators shall conduct covert investigation visits to determine whether a store is complying with WIC program requirements. A WIC Transaction Report will be completed after each visit to the vendor's store. (See page 18 for a copy of the WIG Transaction Report) .

7

VN -67



GA WIC PROCEDURES MANUAL

Attachment VN-9 cont'd

VENDOR HANDBOOK

Vendors wHI receive Vendor Profile sheets

on an annual basis. (See page 12 for a sample of

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 vendor's shelf price. Notification of

investigation results will be forwarded to the vendor

in writing.

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:

1.

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 10-11 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 fifteen (15) percent

above the state average for small stores

(peer group 1 WIC vendors).

3.

The store must be licensed by the

Georgia Department of Agriculture. 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 be eligible for Food

Stamp Program authorization.

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
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 system.) Each violation of program policy and/or regulations has a specific time period during which the sanction(s), warning(s), probation, or disqualification will remain on the vendor's record.
If a vendor receives a warning letter in which he or she disputes the allegation(s) regarding non-compliant activity, the retailer may request to be heard by the Local or State Agency WIC representatives to resolve the circumstance(s). This may be by telephone, correspondence or scheduled Local or State Office consultation with the retailer and/or his advisor(s).
All State Agency sanctions/warnings earned are retained on the vendor file for a period of one year and will "roll off" one year from the date of receipt. Mandatory sanctions will remain on the vendor's file permanently.
Disqualifications
When a vendor accumulates the maximum number of warnings for violating WIC Program rules/regulations during a probationary period (administrative sanctions), the store shall be disqualified from the WIC program, with the exception of inadequate participant access cases. Disqualification from WIC Program participation could result in disqualification from Food Stamp Program participation. If a 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 a permanent disqualification (Refer to Food Stamp Federal Regulations 7CFR; Part 278). The period of disqualification is determined by the severity and nature of the violation, the number of violations and past disqualifications. Therefore, the highest sanctions assessed to a vendor shall determine the period of probation or disqualification. The actual disqualification periods are determined using the same criteria for every vendor.
Vendors will receive Vendor Profile sheets on an annual basis. Any vendor identified as potentially high risk may 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 for violations occurring in each investigative visit or will be disqualified according to the sanction system.
Vendors not involved in a current investigation wm be notified of sanctions as they are assessed or assigned.
The State Agency wai not accept voluntary withdrawal or use non-renewal of a vendor agreement as an alternative to disqualification.

Terminations

1.

A vendor shall be terminated from WIC

Program participation if he/she voluntarily

withdraws from the WIC program,

8

VN-68



GA WIC PROCEDURES MANUAL

Attachment VN-9 cont'd

VENDOR HANDBOOK

and the owner must:

Notify the Local WIC Agency of their

decision.

2.

A vendor shall be terminated from WIC

Program participation if he/she decides to

sell the business (store), and the owner

must:

Notify the Local WIC Agency of the

transaction.

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.

5.

A vendor shall be terminated from WIC

Program participation if the

owner/manager does not attend the

required annual training sessions.

6.

A vendor shall be terminated from WIC

Program participation for a ninety (90) day

period if the vendor does not submit the

overpayment amount requested by the

State WIC Office.

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 15 percent above the district average by peer groups of similar store type and/or size. The State WIC Office shall provide written notification to the vendor regarding the amount of overpricing involved by voucher code type. Consequently, the vendor shall reimburse the State WIC Program for any overpayment. If the vendor does not submit his/her payment within thirty (30) days, the State WIC Office will forward a second written notification to the vendor requesting the overpaid amount. If the vendor fails to submit the requested overpayment after the second notification, the vendor will be given a third and final opportunity to submit the overpayment. If the vendor does not submit the overpaid amount by the requested date, the vendor will be terminated from WIC program participation for a ninety (90) day period. Exceptions will be made if the vendor termination creates inadequate participant access (refer to Inadequate Participant Access Cases).

Civil Money Penalties
Civil Money Penalties (CMP) cannot exceed $10,000 per violations $40,000 per investigation. If more than one violation is detected during a single investigation, a CMP must

be imposed for each violation (up to the $10,000/$40,000 limits).
If a vendor fails to pay the CMP, the State Agency must disqualify the vendor for a period equal to the violation for which the CMP was

assessed.
Second mandatory sanctions, excluding convictions for trafficking and Food Stamp Program disqualifications, result in double the disqualification or double the CMP (up to the maximum limits).
Third or subsequent mandatory sanctions, excluding convictions for trafficking and Food
Stamp Program disqualifications, result in double the disqualification with no option for a CMP.

Formula For Calculating Civil Money Penalties (CMP)

The following is the methodology for calculating CMPs:
Determine the vendor's average monthly redemptions for a 6 month period ending with the last month immediately preceding the month during which the notice was provided to the vendor. Multiply the average redemptions by the prescribed percentage.
Multiply the result by the number of months for which the vendor would have been disqualified.
*Category I at 2% category II at 4% category Ill at 6% category IV at 8% category V
Sanctions 1 & 2 at 10% (Not to exceed $10,000 per violation and $40,000 per investigation) Sanctions 3-7 at 8% category VI and VII at 10% (Not to exceed $10,000 per violation up to $40,000 per investigation) CMPs may be assessed in lieu of disqualification in Categories 1-V or for inadequate participant access cases in Categories I-VII.

Civil Money Penalty Assessment Procedures

In addition to the State determination of

inadequate participant access when necessary,

WIC vendors may be eligible for a CMP if they

meet the following criteria:

1.

Vendor must request, in writing,

consideration for a CMP.

2.

Vendor must submit substantial

evidence that an effective

compliance policy and program is

in effect to prevent violations.

3.

Vendor must establish that both

its compliance policy and program

were in operation at the location

where the violation(s) occurred

ru:.iQr to the sanctions and/or

disqualification notices.

4.

The vendor had developed and

instituted an effective personnel

training program.

If the vendor meets the above criteria for

levy of CMP, vendor must also meet all prescribed

deadlines for payment of CMP.

9

VN-69



GA WIC PROCEDURES MANUAL

Attachment VN-9 cont'd

VENDOR HANDBOOK

Hearing/Appeal Procedures
Vendors are entitled to a fair hearing upon disqualification from the WIC Program. Any vendor requesting a fair hearing must contact the Local Agency by telephone and contact the State WIC Office in writing within fifteen (15) days of the adverse action.

Pre-appeal Administrative Review

A vendor that has been disqualified from

WIC Pro_gram participation may request (in writing)

an ap_poIntment to review his WIC activity records,

pertaining to the potential disqualification,

consistent with the allowable time frames as

detailed in the Federal Regulations 7 CFR 246.18.

The location for this review will be determined by

the State Agency.

In the event an appointment cannot be

negotiated, a conference call shall be scheduled

by the State Agency. The State Agency shall

forward to the vendor all records pertaining to the

potential disqualification for use during a

conference call (conference will be followed up by

documentation). The conference call shall be

scheduled and may include the State Agency

representative(s) and Legal Counsel, Local

Agency

representative(s),

Vendor

representative(s), and Vendor Legal Counsel

representative(s) for the purpose of discussing the

ad"'.erse action for possible resolution, record

review and addressing all concerns pertaining to

the vendor.

Inadequate Participant Access Cases If the State Agency determines that
disq_u~lifying a vendor causes inadequate partIC!p_ant access, the State Agency must impose a C1v1I Money Penalty (CMP) in lieu of disqualification in Categories I-VII (except that the State Agency may not impose a CMP in lieu of disqualifica~i~n either as a result of a Food Stamp Program/C1vll Money Penalty or for a third or subsequent sanction as specified in 7 CFR 246.12(k)(l)(vi)).
If a vendor does not pay, only partially pays or fails to timely pay a CMP, the State Agency must disqualify the vendor for the full length of the disqualification corresponding to the violation for which the CMP was assessed.
An inadequate participant access case is granted only when the nearest authorized WIC vendor is 10 miles or more away from the nearest
WIC clinic. Geographical barriers will be
assessed.

Sanction System

. The following is a description of the

sanction system and how it works. Civil Money

~e~alties (~MP) _may be assessed in Category I-V

in heu of disqualification; however, for mandatory

sanction, no civil money penalty shall be allowed

unless the State has determined that there would

be inadequate participant access.

A.

Any Violation From Category I, II or Ill

May Be Assessed A CMP In Lieu Of

Disqualification.(State

Agency

sanctions)

10

Category I - Warning on first and

second offense, third offense-

probation for six (6) months, fourth

offense in Category I, II, or Ill

disqualification for six (6) months

1.

Stocking a WIC food item(s)

outside of manufacturer's not-to-

exceed date(s).

2.

Prices not marked clearty on WIC

food items or near WIC food

items.

3.

Allowing WIC food items to

exceed the quantity specified on

the voucher. (Except for

promotional items)

4.

Failure to give a receipt for WIC

purchases.

5.

Failure to allow the purchase of

any WIC food item(s).

Category II - Warning on first offense,

second offense-probation for eight (8)

months! third _offense in Category I, II,

or 111-disquahficalion for eight (8)

months

1.

Failure to property process

vouchers at the store (this

includes failure to calculate [ring

up] sales of WIC purchases or not

writing the price on voucher

before participant signs).

2.

Failure to stock the required

inventory of contracted formula or

failure to stock the required

inventory of two or more WIC food

items (types and/or brands).

Physical inventory must be

viewed by a WIC representative at

the time of visit. Proof of order of

food items is not acceptable.

3.

Refusing to accept valid WIC

vouchers from participants in

exchange for WIC food items.

4.

Allowing substitutions for

food items listed on WIC

vouchers; or allowing the

purchase of WIC foods in

unauthorized container sizes.

5.

Failure to remain open for

business at least eight hours per

day, six days per week.

6.

Failure to repay overcharges

within specified period (30 days,

60 days, 90 days).

Category Ill - Warning on first offense,

second offense-probation for ten (10)

months, third offense in category I, 11,

or Ill-disqualification for ten (10)

months

1.

Issuing rain checks/lOU's.

2.

Contacting WIC participants for

any reason regarding a WIC

transaction.

3.

Requiring participant to pay cash

to redeem WIC vouchers.

4.

Allowing the purchase of any

formula other than the one

specified on the front of the

voucher.

VN-70



GA WIC PROCEDURES MANUAL

Attachment VN-9 cont'd

VENDOR HANDBOOK

5.

Failure to allow participant(s)/

proxy(ies) to purchase all WIC

approved food items listed on the

face of the voucher regardless of

price on the voucher.

B.

Any Violation From Category IV or V

That Occurs At Any Time Will Result In

Immediate Disqualification For The

Period Specified In Category IV & V. A

CMP May Be Assessed In Lieu Of

Disqualification.

Category IV - Immediate

disqualification for one (1) year

(twelve months) for each violation (1&2

Mandatory sanctions, 3-7 State Agency

sanctions)

1.

A pattern of providing

unauthorized food items in

exchange for WIC vouchers.

2.

A pattern of charging for

supplemental foods provided in

excess of those listed on the

voucher.

3.

Intentionally providing false

information on vendor records.

4.

Discrimination.

5.

Failure to provide vouchers or

inventory records upon request.

6.

Transacting WIC vouchers

outside of the WIC authorized

fixed store location .

7.

Failure to allow monitoring by WIC

representatives.

Category V - Immediate disqualification

for three (3) years (thirty-six months)

for each violation (Mandatory sanctions)

1.

A pattern of receiving, transacting,

or redeeming vouchers from

authorized or unauthorized stores

or other unauthorized sources.

2.

A pattern of allowing an

authorized store to redeem

vouchers from another authorized

store.

3.

A pattern of providing credit or

non-food items in exchange for

WIC vouchers.

4.

A pattern of overcharging on WIC

vouchers (charging a WIC

participant more than the current

shelf price or charging a WIC

participant more for food than a

non-WIC customer) during a

compliance investigation.

5.

A pattern of charging for

supplemental foods not received

by the WIC participant.

6.

One incidence of the sale of

alcohol or alcoholic beverages or

tobacco products in exchange for

WIC vouchers.

7.

A pattern of claiming

reimbursements in excess of

documented inventory.

C.

Any Violation From Category VI or VII

That Occurs At Any Time Will Result

In Immediate Disqualification For The

Period Specified In Category VI or VII

CMP MAY BE ASSESSED FOR

INADEQUATE PARTICIPANT ACCESS

CASES ONLY. (Mandatory sanctions)

Category VI - Disqualification for six

(6) years (seventy-two months) for

each violation

1.

One incidence of buying or

selling of WIC vouchers for

cash.

2.

One incidence of exchanging

WIC vouchers for firearms.

3.

One incidence of exchanging

WIC vouchers for ammunition.

4.

One incidence of exchanging

WIC vouchers for explosives.

5.

One incidence of exchanging

WIC vouchers for controlled

substances.

Category VII Permanent

disqualification for a conviction of

each violation (Conviction refers to

an action by a criminal court as

defined in section 102 of the Controlled

Substances Act (21 U.S.C. 802)

1 .

Conviction for buying or

selling of WIC vouchers for

cash.

2.

Conviction for exchanging

WIC vouchers for firearms.

3.

Conviction for exchanging

WIC vouchers for ammunition.

4.

Conviction for exchanging

WIC vouchers for explosives.

5.

Conviction for exchanging

WIC vouchers for controlled

substances.

Vendor violations will be categorized
by the severity and nature of the offense. The nature and severity of a violation(s) shall determine the sanction assessed, the duration
of the probationary period, and the period of disqualification. Therefore, the highest sanction assessed to a vendor shall determine the period of probation and disqualification.
Each category has a prescribed period of disqualification, probation or warning assessed. State Agency warnings remain
active on the vendor case file for a twelve (12) month period. Mandatory sanctions remain on the vendor's case file permanently. A vendor found to be in violation within the probationary period shall be disqualified for not less than the full probationary period, up to six (6) 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. If a 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 a permanent disqualification. (Refer to Food Stamp Program Federal Regulations 7CFR; Part 278). Disqualification from the WIC Program may also result in disqualification from the Food Stamp Program.

11

VN - 71



GA WIC PROCEDURES MANUAL VENDOR HANDBOOK

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 System.
If a mandatory sanction disqualification is not upheld during an appeal, State Agency sanctions and/or disqualification that have previously been assessed to the vendor may remain on the vendor's record or qualify the vendor for a State Agency disqualification.

Attachment VN-9 cont'd





12

VN -72



GA WIC PROCEDURES MANUAL VENDOR HANDBOOK

Attachment VN-9 cont'd



06116/99

STATE OF GEORGIA WIC PROGRAM VENDOR PROFILE FOR
#0000 - WICSTER STORE

* * * Vendor Information * * *

Activity Date: District Unit: County: Store Type:

April 1999

000

.

000 00

Address:

100 ANYWHERE RD OUR TOWN, GA 00000 MR. WICSTER (111) 111-1111

* * * Volume of Business * * *

# Vouchers Paid (April 1999) $ Amount Paid (April 1999) # Vouchers Paid (FY to Date) $ Amount Paid (FY to Date) % Vouchers Exceed Fiscal Year 6 Month Average # Vouchers Exceed 6 Month Average % of Total D/U Vouchers % of County Vouchers # Vouchers Outside Vendor Area $ Amount Earned for Vouchers Received Outside Vendor Area % Vouchers Outside Vendor Area

711 $11,927 5 , 168 $86, 610
I. 7 % 35. 3 % 152 $2, 632 21. 4 %

# Vouchers Paid Last 6 Months

6

5

4

3

2

I

731

673

910

622

660

861

A B Cl 62 42 2

* * * Vendor Scores (04/1999: Federal Fiscal Year ) * * *

C2 El E2 E3 F G H

17 18 14 15 2

4





M

N

0

p

Q

21

7

I

12

TOT 217

430 275 18

159 144 133 27 14

22

131

55

I I

93

1512



13

VN -73


District/Unit/Clinic.:_ _ _ _ __ County. _________ Date of Incident.:_______ Date Reported:_ _ _ _ __ Follow-up Date:_ _ _ _ __
Person Fllln11 {;;oml!lalnl Name: Address
Telephone Number ( ) Incident/Complaint:
z <
:;;:
-...J
.j::.
Local Agency Resolution:


Georgia Department Of Human Resources WICProgram
INCIDENT/CO:MPLAINT FORM

Pa[lkll!ant lnform!tlon Name:
Guardian: WIC I.D. Number. DOB: Telephone Number: ( )

Ve!!!!!![ ln[o[!!!atlon

-

VcndorNcndor Number.

Employee Name:

Title:

Telephone Number: ( )

State WIC Office Resolution/Comments:
'
Follow-up Report: State WIC Office Customer Service Coordinator:

lYPe of CompJalo\i
Participant ( ) Vendor ( ) Local Agency/State WIC Office Staff ( )
l.d!gl AIIED~l!!!e mi;; In[O!:!l!!!!I!![!
Staff Name:
Telephone Number. ( )


~
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"~'='
0
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0
~
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00
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Signature:

Can complaint be closed at Local Agency? Yes() No()
Signature and Title:

Date:

Can complaint be closed at State WIC Office? Yes() No()

........

Signature and Title:

~

:r

3

Date:

.:0.:.,.

z < I
\0

(")

Date:

:.0.:.,.

0.



GA WIC PROCEDURES MANUAL

Attachment VN-9 cont'd

VENDOR HANDBOOK

Georgia Dcpanmcnt or Human Resources
Division of Public Health WIC Program
VENDOR REVIEW FORM

Vendor Number

District

Date of Visit

I

I

Page I of 4 Unit

Vendor Name

Store Owner

Store Manager

Street Address City

County

I Zip Code

Review Type

Vendor Self Review (attach to Vendor Application)

Pre-Approval Visit (Non-perishable Food Review) a Yearly Visit a Minimum Inventory Waiver Granted

New Vendor (not applicable as yearly visit)

Follow-Up a Regular Minimum lnventorv Reauired

Note: Ph s1cal Invento must be viewed b WIC re resentattve at the ttme of vi.si.t. Proof of order of food items shall not be acce ted.

A. Minimum Inventory Requirements

Juice: l. Are there at least 24 cans of 46 oz. size juice in stock? If no, how many ? 2. Are there 2 types of canned juice? If no, how many? _ __
3. Was price marked on juice or posted on the shelf/dairy case?_ _ __ 4. Was juice within date limit? If no, how many were not? _ __

Yes No

a

a

a

a

a

a

a

a

A le Jui Juice

Brand Name Flav-o-rite Kroger Jui Juice
Luctcy Lear
Seneca (Red Label) Shur Fine Staff Thrifty Maid White House Juicy Juice Welch's t00% Seneca Welch's Least ex ivc onl Least ex ivc onl

Welch's Juice Maker

NIS

Prices: 46 oz.

$

$

$

$

$

$

$

$

$

$
s s s

$

$

$

$

$
s s s s s

$

$
s s

$

$

s

$

$

$

15

VN - 75



GA WIC PROCEDURES MANUAL

Attachment VN-9 cont'd

VENDOR HANDBOOK
Vendor Number _ _ _ _ _ _ _ _ __

Page 2 of 4

Cereals: (At least two types in 12 oz. sius)

Yes

No

I. Are there at least 30 boxes of 9 oz. to 24 oz. size cereal in stock? If no, how many? _ _

a

0

2. Are there at least 4 types of cereal in stock? If no, how many? ___

a

0

3. Are there at least 2 types of 12 oz. size boxes of cereal in stock? If no, how many? _ _

a

0

4. Was price marked on cereal or on shelf?

a

0

5. Was cereal within date limit? If no, how many were not?

a

0

Cheerios ComCbex RiceCbcx WbcatCbcx CounlJY Com Flakes Kix Kel.loi>e' s Com flakes Soccial K Product 19 Tocal, Can flakes tbrvest Instant OalmCal (Regular) Jim Dandy Quick Grits (Iron Fortified) Nabisco Quick Cream of Wheat (Reoubr) Quaker Instant Grits (Original) Quaker Instant Oabneal (Regular) Kellogg's Complere Wheat Bran Flam Quaker Sun Country Quick Oats (Rel!ldar Flavor) Quaker Oats Crunch Com Bran Ralston: Ootima 100 Whole Wheat Flakes
Enriched Bran Flam Nutty Nuggets Instant Oabneal (Regular Flavor) Crispy Rice Comflaus Tastooo/Toastcd Oats Crispy Com Puff Ralston Sl<R Brands Allowed: Kroger, Kounb')I Frail, IGA. Red & While, Aavoriie or Nature's Best
Comments on Cereal:

NIS

Oz. Size

Hihcsl Prices

$

$

$

$

$

$

$

$

$

-$ $

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

Peas/Beans

l. Are there at least 8 bags of 16 oz. size peas/beans in stock?

If no, how many?

NIS

2. Are there at least 2 types of peas/beans? If no, how many?

3. Was price marked on peas/beans, or on shelf?

Yes

No

0

0

0

0

0

0

Brand

Type

Highest Prices

$

$

Comments on Peas/Beans

Peanut Butter: (No peanut butter/jelly combinations or honey spreads)

l. Are there at least 8 jars of 18 oz. size peanut butter in stock?

If no. how many?

NIS

2. Are there at least 2 brands of peanut butter? If no, how many?

Yes

No

a

D

0

D

3. Was price marked on peanut butter, or on shelf?

Highest Price $

and

0

0

Brand of Peanut Butter

Comments on Peanut Butter:

16

VN -76



GA WIC PROCEDURES MANUAL

Attachment VN-9 cont'd

VENDOR HANDBOOK
Vendor Number _ _ _ _ _ _ _ _ __

Page 3 of 4

Infant Cereal: (At least one type of cereal must be rice) I. Are there at least 12 boxes of 8-16 oz. size infant cereal in stock? If no, how many boxes?_ __

2. Is rice cereal in stock?

3. Is there one other type, other than rice, in stock?

4. Was price marked on cereal or on shelf? 5. Was cereal within current date limit? If no, how many were not? _ _ __

Brand and Price of Infant Cereals: Rice (Highest Price) NIS Other (Highest Price) NIS

Beechnut

$_ _ _ _ _ __

Gerber

$._ _ _ _ __

Yes

No

D

D

D

D

D

D

D

D

D

D

Heinz

$

Comments on Infant Cereal:._ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Formula: (Minimum of 32 cans of contracted soybase and 138 cans of milk base)

Yes

No

l. Arc there at least 138 cans of 13 oz. concentrate milk based contracted formula with iron in stock? If

D

no, how many? _ _ __

2. Arc there at least 32 cans of 13 oz. concentrate soy based contracted formula with iron in stock? If no,

D

how many?_ _ __

3. Is formula within current date limit? If no how many cans were not?_____



D

4. Was price marked on cans or on shelf?



D

Prices 13 Ounce NIS

Prices: Ready to Feed NIS

Prices: Powdered NIS

Contracted Milk based

$

$

$

Contracted Soy based

$

$

$

Alimcnturn

Nutramigen

$

Portagen

$

Pregestimil

$

Comments on F o r m u l a : - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Milk: (Minimum of 20 gals. whole milk, 2 %, 1% & skim milk of the least expensive brand) I. Are there at least 20 gals. of milk in stock? If no, how many? ___ NIS_ _ __

2. Was price marked on milk or posted on the dairy case?

3. Was milk within current date limit? If no, how many were not?_ _ __

Lowest Price: $

and

Brand Milk

Yes

No

D

D

D

D

D

D

Comments on Milk:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Cheese

Yes

No

I. Are there at least 16 one pound packages of cheese in stock? If no, how many? _ _ _ _



D

2. Are there at least 2 types of cheese in stock? If no, how many? _ _ _



D

3. Was price marked on cheese or posted on the shelf/dairy case?



D

4. Was cheese within date limit? If no, how many were not?___

o

D

Highest Prices of Cheese: American$_ _ NIS _ _ Colby $_ _ NIS _ _ Cheddar$_ _ NIS _

Monterey Jack$_ _ NIS _ _ Mozzarella$_ _ _ NIS

Comments on Cheese:

Eggs: (Least Expensive Brand)

l. Arc there at least 16 doz. Grade A Large eggs in stock? If no, how many? _ __

2. Was price marked on eggs or posted on the dairy case?

3. Were eggs within date limit? If no, how many were not?_ __

Lowest Price:$

and (Grade A Large)

Brand of Eggs

Yes

No

D

D

D

D

D

D

Comments on Eggs:

17

VN -77



GA WIC PROCEDURES MANUAL

Attachment VN-9 cont'd

VENDOR HANDBOOK

Vendor N umber B. Participant/Vendor Observation (Not applicable for pre-approval)
I. Were any WIC vouchers on hand in the store? If yes, were all voucher amounts filled in? _ _ _ If the voucher amount is not filled in, list the voucher number(s) in the comments section.
2. Observed WIC participant making a purchase? If yes, were appropriate procedures followed?
Comments:

Pae:e 4 0 f4 Yes No NA



0

0





0

C. General Questions/Observations

Yes

No

I. Does the store need to be referred to the Georgia Department of Agriculture for inspection? 2. ls store open for business at least 8 hours a day, 6 days a week? 3. Has discrimination been reported or observed? 4. Is there a need for additional training at this time? 5. Are all price columns for foods, which meet minimum inventory requirements, marked N.1.S.
(Not in Store)? This answer must be yes. 6. Does the cash register have the capability to place the date and amount of the WIC transaction on the
back of the voucher?

0

0

0

0



0



0

0

0

0

0

-

To the best of his/her knowledge, the Retail Vendor Representative hereby agrees and covenants that neither the vendor/owner, the vendor's manager(s), or the vendor's other employee(s) is related by blood or marriage to any WIC representative, unless otherwise revealed in writing, upon execution of the contract/agreement or within the contract period. The results of this monitoring visit have been discussed with me and I understand the violations (if applicable) that were found and the food prices listed above are correct.

Signature of Vendor Representative

Date: _ _ _ _ _ _ _ _ _ _ __

Print Name of Vendor Representative
I have discussed all findings, any violations, and training needs (if applicable) with the appropriate vendor representative.

Signature of WIC Representative

Date:

Print Name of WICRepresentative District _ _ _ _ _ _ _ _ Unit _ _ _ _ _ __
Vendor Representative Comments:

WIC Representative Comments: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __



18

VN -78



GA WIC PROCEDURES MANUAL

Voucher
I
Store Name and Address:

VENDOR HANDBOOK
Georgia Department of Human Resources Di vision of Public Health
WICProgram
WIC TRANSACTION REPORT (WTR)
WTR Returned to WIC Agency:

Attachment VN-9 cont'd
Vendor Number
I



I. At the Check-out counter there (was/were) Person(s) In line ahead of me..On

,at about

. I entered the subject's store. I

selected the ltem(s) specified below. The food Instrument Indicated above was used for this transaction. The dark sold the ltem(s) below at a

total cost of (lf available) $ During checkout, the voucher was In plain view of the derk who served the Investigator. The price of the

ltems(s) were marked on the item(s) or shelf, for ltem(s) not marked, they were verified by:

2.

Time: Entered Store:

Time Approached Checkout:

Time Left Store:

3. ~

YIN

R= Prices Marked on Foods or Shelf Rcrordcd Pria: on Voucher

4. Comments

..

Rang up Sale Checked ID Cards

YIN
I I

Adcquaie Supply of WIC Foods on Shelf Gave Receipt to Investigator
-

YIN
I I

5.

Uescription of Clerk (Approximate)

SEX

RACE

I AGE I

I

I

6 Other Identifying Information:

7 Identified During Transaction as (Title/Name):

EUGWU: ITEMS
QUANTITY

SUMMARY OF PURCHASE
BRAND NAME

HEIGHT

I

I

ITEM

WEIGHT

I HAIR COLOR I
PRICE

INEUGWU: ITEMS
QUANTITY

ITEM

PRICE

ITEMS REFUSED
QUANTITY

ITEM



I

, an investigator of the Georgia WIC Program,

make the above statement freely and voluntarily knowing that this statement may be used as evidence.

Name:

Daie:

Tide:

I Investigator Signature:

J"-onn 3773 (6199)

19

VN -79



GA WIC PROCEDURES MANUAL

Attachment VN-9 cont'd

VENDOR HANDBOOK

Georgia WIC Program Minimum Inventory Request for Waiver

The minimum inventory requirement regarding Georgia WIC approved foods must be sufficient to

fill:



six (6) standard Infant Food Packages



of a lactose reduced Infant Formula Food Package



six (6) Women and/or Children Food Packages

However, if a vendor experiences difficulty selling specific WIC approved food item(s), then the vendor may write or submit this form to the Local or State WIC Agency office(s) to request a minimum inventory waiver for stocking hard to sell item(s). The State WIC Office will determine if a vendor meets the waiver criteria within thirty (30) days of receipt.
Date _______ Vendor Number _ _ _ _ _ _ _ District Unit _ _ _ _ _ __

Owner/Manager's Narne._ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PRINT Owner/Manager's Signature _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Store Name and Number _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PRINT Store Address _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PRINT Telephone Number_.__ __.__ _ _ _ _ _ _ _ _ _ _ __

RE: Request for minimum inventory waive of requirements for specific Georgia WIC approved foods (list your request below):




Please explain the reason for your request:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __



*Please be aware that submission of this request does not constitute approval. You will receive written notification regarding the outcome of your request.
20
VN-80



GA WIC PROCEDURES MANUAL VENDOR HANDBOOK

Attachment VN-9 cont'd

Georgia Department of Human Resources
RETURN VOUCHER PAYMENT LOG

TO:

Georgia WIC Program Branch

Two Peachtree Street, NW,

Suite 8.300

Atlanta, Georgia 30303-3181

FROM:_ _ _ _ _ _ _ _ _ _ _ _ _ __ (Corporate Office/Store Name)

(Address)

(City, State, Zip Code)

(FEI #- Federal Employee Identification Number)

VENDOR NUMBER

VOUCHER NUMBER

AMOUNT

VOUCHERS WILL NOT BE PAID FOR THE

FOLWWING REASONS:

A.

Redeemed before "First Day To Use" date

(Post Dated)

B.

Deposited after sixty (60) days from ''First

Day to Use" Date (Stale Dated)

C.

Received by the State WIC Office more than

120 days after the ''First Date To Use" date

(Stale Dated)

D.

Signature of participant missing

E.

Exceeded Maximum Amount Allowed

F.

If vouchers have been reported stolen

(STATE WIC OFFICE USE ONLY)

REASON NOT PAID



Vendor (or Representative) Signature

Date
2 1

Note: It is recommended that vendor keep a copy or front and back or the original vouchers forwarded to the State WIC Office for payment.

VN - 81



GA WIC PROCEDURES MANUAL VENDOR HANDBOOK

Attachment VN-9 cont'd



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., NW, 8th Floor Atlanta, Georgia 30303 (404) 657-2900 or call the WIC Hotline 1-800-228-9173
"The United States Department of Agriculture (USDA) prohibits discrimination in its programs and activities on the basis of race, color, national origin, sex, age, or disability. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information (Braille, larger print, audiotape, etc.) should contact USDA's TARGET Center at (202) 720-5964 (voice and TDD).
To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 14th and Independence Avenue, SW, Washington, DC 20250-9410 or call (202) 720-5964 (voice and TDD). USDA is an equal opportunity provider and employer."
iri
DUR
Georgia Department of Human Resources
Georgia WIC Program Branch
Two Peachtree Street, NW, 8th Floor Atlanta, Georgia 30303 1-800-228-9173
Form No. 3783 (Revised 5-99)
VN - 82



GA WIC PROCEDURES MANUAL CASHIER TRAINING PAMPHLET

Cashier Training Pamphlet FFY 2000

Attachment VN-10



WIC - Special Supplemental Food Program For Women, Infants, and Children

VN-83



GA WIC PROCEDURES MANUAL

Attachment VN-IOcont'd

CASHIER TRAINING PAMPHLET

G rocery store cashiers are the most

important part of the WIC voucher

redemption process. It is the responsibility of

the cashier to make sure that the WIC

vouchers are within the proper date limits, that

a signature appears on the left side of a manual

voucher, that a WIC Program authorization

seal appears on the face of the voucher(s), and

that the WIC customer receives the correct

WIC food items.

We hope that the following

information will help the cashier to process

WIC vouchers in the appropriate manner.

What is WIC?



WIC stands for Women, Infants, and

Children



WIC provides important food to

pregnant women, infants, and young

children.



WIC program participants have been

examined by health professionals who

determine the need for supplemental

food and nutrition education.



WIC participants receive vouchers for

specified kinds of highly nutritious

foods. The vouchers are redeemed by

grocery stores who have signed an

agreement with the State. It is very

important that the WIC participant

receive only the foods listed on the

face of the voucher.



WIC gives children a chance to grow

up healthy and lead active, productive

lives.

Processing WIC Vouchers

The WIC voucher is similar to a check

and should be redeemed just as carefully.

There are four (4) types of WIC

vouchers: computer generated, standard

manual, blank manual and laser pririted

vouchers .

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VN-84


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Standard Manual Vouchers: Manual vouchers are processed in the same manner as computer generated vouchers. The standard manual voucher has the name, I.D. number and dates writen or typed by the staff at the clinic.

0ISTRJCT / UNIT / CLINIC
11 0 570 1100
__:A 787 30369 1'1 78730363 2

WIC 10 NO.
000 1000

CIP

PARTICIPANT

811 ISMITH, CARMEN J

GEORGIA WIC PROGRAM
DEPARTMENT OF HUMAN RESOURCES

RSN

N

9 I ;.. . . VOUCHER NO. 1:

.J I ,

{_)

FITROSTUSDEAY
LAST DAY _TOUSE

105 / 27 /99
I I
06122199

VENDOR MUST DEPOSIT BY

FOR THESE ITEMS I QUANTITIES ONLY - NO SUBSTJTUTIONS
FPC 404

vc 028

MILK 1 1 GAL OR 4-12 OZ CNS EVAP OR

1-5 QT BOX

EGGS, 1 DOZEN

l !C/c:iio~J : CLI<I EEE I

JUICE, 2-12 OZ CANS FROZEN OR 2-46 OZ CANS

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S 12.00
1 OOUARS I CENTS

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Laser Printed Voucher: All information is printed on this voucher at the clinic site at the time of the participant's visit.



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GA WIC PROCEDURES MANUAL

Attachment VN-10 cont'd

CASHIER TRAINING PAMPHLET



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Blank Manual Voucher: The blank manual voucher has the name,
I.D. number, and dates written or typed by the staff at the clinic. The amount of food to be received by the WIC customer is also written or typed. Redeem only the amount of food indicated. Only one (l} number should appear in each box.

Example:
Correct Correct

rn Incorrect
Incorrect

X's are placed in all boxes where there is no number. This _helps to eliminate any possible unauthorized alterations on the voucher(s).

Checking out the WIC Customer

When food is purchased with a WIC voucher, the cashier must do the following:

For manual voucher(s), check to

see if the voucher has been signed

(once) by the WIC customer on the

left side of the voucher (Sign Here at

the WIC Office).

2. Check the dates on the voucher.

Vouchers cannot be used before

the ''First Day to Use" nor after the ''Last

Day To Use."

3. Separate the food listed on the voucher

from other purchases, if the WIC

customer has not done so.

4.

Ring up the shelf price of the food for

each voucher. Make sure that the

exact types and amounts of approved

WIC foods are being purchased. DO

NOT INCLUDE SALES TAX.

5


6

VN - 86



GA WIC PROCEDURES MANUAL

Attachment VN-10 cont'd

CASHIER TRAINING PAMPHLET

5. Print the amount of the purchase ' in the ''Pay Exactly" space on the voucher in the presence of the WIC customer.
6. . Have the WIC customer/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 part1c1pant has signed, compare signature with the WIC ID card. If the customer's name does not appear on the ID card, do not accept the voucher.
7. If the WIC customer cannot sign his/her name, the WIC customer must make his/her mark on the voucher. The cashier must initial the mark as a witness to the signature. Make sure that the WIC customer also signed the ID card with his/her mark.

Important Notes:



Any WIC customer who attempts to

purchase foods that are not approved

or creates other problems in the store

should be reported to the State or

Local WIC Office immediately.



WIC participants will enter the same

checkout 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

7

VN-87

effort must be made to protect the

confidentiality of the participant/proxy, and

discussion of the transaction should be kept at

a conversational level. Provisions I.J. and I.K.

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.



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 the WIC

voucher. A WIC voucher can not be

redeemed for more than the maximum

purchase price listed on the front of

each voucher (excluding infant

formula vouchers). If a voucher is

rejected by the bank, the voucher with

an explanation on the return voucher

payment log, should be sent to the

State WIC Office for reimbursement.



Every store has the option of checking

the customer's WIC identification

card for the proper WIC ID number

and authorized person(s) signatures.

The customer is not allowed to use

WIC vouchers in the store if he/she

does not have the WIC ID card.

8



GA WIC PROCEDURES MANUAL

Attachment VN-10 cont'd

CASHIER TRAINING PAMPHLET

WIC Approved Foods Lisi

Food Hem Brand or Typ<!

Not Allowed

MILK: (Pasieurized) I Gal Size ONLY
Whole, Slcim. lA>w Fal (l'I>), or Reduced Fal (2'1,) (l.casl Expensive Brand Only)
Acidophilus, Enjoy, Laclaid. Laclaid 100, NUTRISH Dairy Ease ( Gal or QI. ONLY) Evaporated ( 12 Oz Cans ONLY) Powdered() or 5 QI. Boxes ONLY) UHT Mill: (8 Oi Box-if listed oo voucher)

CANNOT BUY: Flavon:d Milk, Buttermilk,
Goal's Milk

CEREAL: (9 Oz. Sin,s or Above-Can Mix

Si-trypes)

Cheerios

Chex (Com. Rice or Wheal) .

Counuy Com FWccs

Harvell lnstanl Oauncal (Regular Flavor)

Jim Dandy Quick GrilS (Iron Forufied)

Kix

Nabisco Quick Cream of Wheat (Regular Flavor)

Producl 19

Quaker Instant Grits or Quaker Instant Oa~al

(Regular Flavor)

Total Com Flakes

Kellogg's ~lal Kor Com Flakes



8:::t~; ~t Kellogg's 001)1ctc Bran Aakes

~co:,n~yc;~

(Regular Flavor)

Ralston: Optima 100 Whole Wheal Flakes,
Enriched Bran Flakes, Nuny NuggclS, lnslalll
~~~~~;"&~t!:Pii~ Flakes.
Ralstoa Slorc Brands Allowed.: Ktoscr. Kounuy Fresh. IGA, Red & White, AaYDritc or Nature', Best

CANNOT BUY: 8 Oz. Or Smaller Bo""s

CHEESE: (9-l60z {Ubl SizH ONLY) (Reduced Fat, l..owfal or Fat Frtt Cheese Is Allowed) American Individually wrapped or unwrapped (Sliced or Block)
Colby (Block)
Monterey Jack (Block)
Mozurclla (Block) Cheddar (Block)

CANNOT BUY: Cheese Food,
Shredded Cheese Deli Cheese. 2-8 Oz. Pkgs. for 1-16 Oz. Pkg. Any 8 Oz. o, Smaller Pkgs.

JUICE: (100'1, USRDA Vi!Jlmlo C Fortuoecl, <46 Oz. Cans, 6 Oz. Cans (If listed on the
voucher), 11.S Oz. Pourabtes or 12 Oz. Froi.en Cans ONLY) Grape: (Welch's or Seneca) Whit, Grape: Welch's
Orange: Least Expcosivc Brand ONLY Grapefruit: I.cast Expensive Brand ONLY

t~~~e~~:'.';;.,;~t.'iai':.'~1:'~c!.~~uicc,

Seneca (Red Label Only)

Other:

.

Dole: Orange/Pineapple,

Oraogc/Pincapple/Banana,

Pincapplc/Grapcfruil

Juicy Juice: Cherry, Punch, Sirawbcrry,

Tropical, Berry. Apple/Grape,

Orange Punch

:;;,~~~~.:~~J;t~~(~tm~~rapc. Cherry, Berry, Strawberry or Apple)

CANNOT BUY: Juice Drinks, lnfanl Juices. Juices With
Sugar Added Fresh Squeezed Juice,

EGGS: (Grade A Large, I Doz. Size ONLY) Leas! Expensive Brand Only

CANNOT BUY
Any Other Sizc/Quantily

DRIED PEAS/BEANS (lib Siu Package) Canned Peas/Beans: (15 Oz. Cans) Any Brand Withoul Flavoring Added

CANNOT BUY
Any Other Sizc/Quantily

Spread PEANUT Bl.TITER: (18 oz. Jars ONLY)
Any Brand Wilhout Jelly or Honey

CANNOT BUY Any Other
SizcJQu:mti1y

INFANT FORMULA As Listed on the Fronl of the Voucher

CANNOT BUY
~:f!~r:~~rd

INFANT CEREAL (Dry, 8 or 16 Oz. Boxes ONLY) Beech Nut. Gerber, Heinz

:m:CANNOT BUY ~l~D~bal Added

TUNA: (60z. Cans ONLY) Water Pacl.:.cd

CANNOT BUY Oil Packed

Sliced/ CARROTS: (Lb Pre-Scaled PlaSlic Bag of
Fresh or Whok Carrots or 15 Oz. can Medium Cut

CANNOT BUY Bulk, Frozen,
Shredded or Baby
Ca.rrOIS

"The U. S. Department of Agriculture (USDA) prohibits discrimination in its programs and activities on the basis of race, color, national origin, gender, religion, age, dr disability. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication ofprogram information (Braille, large print, audiotape.etc.) should contact USDA 's TARGET Center at (202) 720-5964 (voice and TDD). To file a complaint ofdiscrimination, write USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 14th and Independence Avenue, SW, Washington, DC 20250-9410 or call (202) 720-5964 (voice and TDD). USDA is an equal opportunity providerand employer. "
DUR
Georgia ll<partm<otOC Human Resouras
Georgia WIC Program Branch
Division of Public Health Two Peachtree Street, 8th floor Atlanta, Georgia 30303 1-800-228-9 l 73
Fonn No. 3791 (Revised 5/99)

VN - 88



GA WIC PROCEDURES MANUAL

Attachment VN-11

RETURN VOUCHER PAYMENT LOG
Georgia Department of Human Resources
RETURN VOUCHER PAYMENT LOG

TO:

Georgia WIC Program Branch

Two Peachtree Street, NW,

Suite 8.300

Atlanta, Georgia 30303-3181

FROM:_ _ _ _ _ _ _ _ _ _ _ _ __ (Corporate Office/Store Name)

(Address)

(City, State, Zip Code)

(FEI #- Federal Employee Identification Number)

VENDOR NUMBER

VOUCHER NUMBER

AMOUNT

VOUCHERS WILL NOT BE PAID FOR THE

FOLLOWING REASONS:

A.

Redeemed before "First Day To Use" date

(Post Dated)

8.

Deposited after sixty (60) days from "First

Day to Use" Date (Stale Dated)

C.

Received by the State WIC Office more than

120 days after the "First Date To Use" date

(Stale Dated)

D.

Signature of participant missing

E.

Exceeded Maximum Amount Allowed

F.

If vouchers have been reported stolen

(STATE WIC OFFICE USE ONLY)

PAID

REASON NOT PAID



Vendor (or Representative) Signature

Date

DPll98.8 (c)IIW Form 3760 (Rev.4199)
ROUTING: White. Yellow and Pink - SWO, Gold - Vendor

Total Paid
Note: It is recommended that vendor keep a copy of front and back of the original vouchers forwarded to the State WIC Office for payment.

VN-89



GA WIC PROCEDURES MANUAL

Attachment VN-12

POST VENDOR TRAINING EVALUATION
GEORGIA WIC PROGRAM POST VENDOR TRAINING EVALUATION
FORM FOR FFY '2000

Page I of2

WIC VENDOR NUMBER _ _ _ _ _ _ _ _ DISTRICT UNIT _ _ __ TEST SCORE _ _ __

STORE NAME AND NUMBER _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

STORE REPRESENTATIVE'S NAME _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

I.

Which of the following are WIC approved cereals?

a.

Cheerios, Product 19 and Total Corn Flakes

b.

Quaker Instant Grits (Regular Flavor)

c.

Fruit and Fiber

!1.

a and bonly

e.

All of the above

2.

Which of the following juices are WIC approved?

a.

Hawaiian Punch

b.

Dole Pineapple

i;__,_

Welch's 100% juice (purple or white)

d.

All of the above

3.

Whole, skim, lowfal (I%) or reduced fat (2%) pasteurized milk may be purchased by a WIC participant.

ih

True

b.

False

4.

If a cashier neglects lo have a WIC participant sign the WIC voucher, you should:

a.

Call the WIC participant and request her/him lo return lo the store and sign the voucher.

b_,_

Contact the Local Heahh Deparlment/WIC Office.

c.

Hold the voucher until a training session and ask the coordinator how 10 handle the voucher.

5.

Which of the following food items must be purchased in the least expensive brand?

a.

Milk (in gallon size) and eggs

b.

Orange juice and grapefruit juice

c.

Carrots and tuna

!1.

a and b only

6.

How many cans of Simi lac (milk-base) iron fortified infant formula must be in your store daily?

ih

I38 - 13 oz. Cans

b.

45 - 13 oz. Cans

c.

51 - 13 oz. Cans

7.

How many cans of Isomil (soy-base) iron fortified infant formula must be in your store daily?

a.

170- 13 oz. Cans

b_,_

32 - 13 oz. Cans

c.

43 - 13 oz. Cans

8.

Whal must you do with a voucher that has been rejected by the bank, stamped "Not For Resubmission"?

a.

Contact the participant 10 pay the amount on the voucher.

b_,_

Immediately send the original voucher(s) and completed voucher payment log to the Stale WIC Office

for reimbursement.

9.

WlC participants are allowed 10 substitute other nutritious foods for WIC Approved foods.

a.

True

b_,_

False

10.

WIC vouchers can be used in your store before the "First Day 10 Use" date.

a.

True

b_,_

False

Form 3795 (R<.5199>

Routing: White - STATE WIC OFFICE
VN-90

Yellow - LOCAL AGENCY



GA WIC PROCEDURES MANUAL

Attachment VN-12 cont'd

POST VENDOR TRAINING EVALUATION

GEORGIA WIC PROGRAM POST VENDOR TRAINING EVALUATION
FORM FOR FFY "2000
rage 2 of2
WIC VENDOR NUMBER _ _ _ _ STORE NAME _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

11. Cashiers should write "WIC" on all receipts given for food purchased with the WIC vouchers.

l!..,.

True

b.

False

12. The WIC participant must sign the WIC voucher(s) _____ the "pay exactly" area has been

completed by the cashier.

l!..,.

-~

b.

Before

13. The WIC participant can purchase an 18 oz. jar of creamy, crunchy or extra crunchy peanut butter as long as

it has no jelly or honey added.

l!..,.

True

b.

False

14. The WIC voucher shows 15 cans of concentrated Similac or Isomil with iron. The participant tells the cashier

that the doctor has changed the baby to Nutramigen. What should the cashier do?

l!..,.

Ask the participant to return the vouchers to the WJC clinic in order to have the formula change

documented and have new vouchers issued.

b.

Allow the participant to get as many cans of Nutramigen as the price will allow on the voucher.

15. A WIC participant needs to purchase a gallon of milk but your store is currently out of stock of the least

expensive brand. What should the cashier do?

a.

Allow the participant to purchase two half gallons and charge the gallon price.

1h

Allow the participant to purchase the next least expensive brand of milk in the gallon size.

c.

Give the participant a raincheck/lOU.

16. If your store accepts a voucher after the "Vendor must deposit by date" will you receive payment for it?

a.

Yes

Q.,.

lli2

17. Dried peas or beans can only be purchased in what size bag?

a.

12oz.

12.

16 oz/I lb.

C.

15 OZ.

18. Cashiers must not accept WIC vouchers from other States.

l!..,.

True

b.

False

19. The cashier must not charge sales tax for WIC purchases?

l!..,.

True

b.

False

20. If an infant formula voucher exceeds the "maximum purchase price," what should you do?

a.

Ask the participant to put back some of the cans of formula.

b.

Ask the participant to pay the difference in the price.

c.

Write the price that exceeds the "maximum purchase price" on the voucher and send the original

voucher and the Return Voucher Payment Log to the State WIC Office for reimbursement.

d.

Write the price, at or below the "maximum purchase price," on the voucher and send to the bank for

reimbursement.

~

c and d only

Form 3795 (Rev.5/99)

Routing: White . STATE WIC OFFICE
VN -91

Yellow LOCAL AGENCY



GA WIC PROCEDURES MANUAL

Attachment VN-13

VENDOR REVIEW FORM

Georgia Oepanmcnt or Human Resources
Division of Public Health WICProgram
VENDOR REVIEW FORM

Vendor Number

District

Date of Visit

I

I

Page 1 of 4 Unit

Vendor Name

Store Owner

Store Manager

Street Address City

County

I Zip Code

Review Type

Vendor Self Review (attach to Vendor Application)

Pre-Approval Visit (Non-perishable Food Review) Yearly Visit Minimum Inventory Waiver Granted

New Vendor (not applicable as yearly visit)

Follow-Up Regular Minimum lnventorv Reouired

Note: Physical Inventorv must be viewed by WIC representative at the lime of vi.si.t. 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? 2. Are there 2 types of canned juice? If no, how many? _ __
3. Was price marked on juice or posted on the shelf/dairy case?_ _ __ 4. Was juice within date limit? If no, how many were not? _ __

Yes No

















Apple
White Graoc: Orange: Grapefruit: Other: Dole Juicy Juice
Juicy Juice I 1.5 oz. oourables Welch's Juice Maker

Brand Name Aav-o-ritc Kroger Juicy Juice Lucky Leaf Seneca (Red Label) Shur Fine Scaff Thrifty Maid White House Juicy Juice Welch's 100%
Welch's Least expensive only Least cxocnsivc only Pinc-Orange-Banana Pineapple-Orange Pineapple-Passion-Banana Mandarin Tangerine Pineapple-Grapefruit Cherry Tropical Punch Sirawbcrry Applc-Graoc
Orange Punch
Berry Cherry, Strawberry, Graoc, Apolc, Punch or Berry Annie Graoc or White G,a.,..

Nts

Prices: 46 oz. Nts

Prices: I 1.5 oz.

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

s

s

' .., $--

$

$

$

$

$

s

Form 3774 (Rev 5199)) DPHP98.8(c)HW

Routing: White - Seate WIC Office Ycllow - Local Agau:y Pink - Vrodur

VN-92



GA WIC PROCEDURES MANUAL

Attachment VN-13 cont'd

VENDOR REVIEW FORM
Vendor Number _ _ _ _ _ _ _ _ __

Page 2 of 4

Cereals: (At least two types in 12 oz. sizes)

Yes

No

I. Are there at least 30 boxes of9 oz. to 24 oz. size cereal in stock? If no, how many? _ _

0

0

2. Are there at least 4 types of cereal in stock? If no, how many? _ _ _



0

3. Are there at least 2 types of I 2 oz. size boxes of cereal in stock? If no, how many? _ _

0

0

4. Was price marked on cereal or on shelf?

0

0

5. Was cereal within date limit? If no, how many were not?

0

0

'cheerios ComOiex Ric,,O,ex WheatChex Country Com Flakes IGx Kellogg's Com Rakes Special K Product 19 Total, Com Flakes Harvest Instant Oatmeal (Regular) Jim Dandy Quick Grits (Iron Fortified) Nabisco Quick Cream of Wheal (Regular) Quaker Instant Grits (Original) Quaker Instant Oatmeal (Regular) Kellogg's Complete Wheat Bran Flakes Quaker Sun Country Quick Oats (Regular Flavor) Quaker Oats Crunch Com Bran Ralstoo: Optima 100 Whole Wheal Flakes
Enriched Bran Flakes Nunv Nuggets Instant Oatmeal (Regular Flavor) Crispy Ric,, Com Rakes Tasteoofl'oasted Oats Crispy Com Puff Ralstoo Store Brands Allowed: Kroger, Kountry Fresh. IGA. Rod&. White, Aavori1e or Nature's Bcsl
Comments on Cereal:

NIS

Oz. Size

Highest Prices

$
s s s s s s s s

-

$
s

$

$

$

$

$
s s s s s

$
s

$

$

$

Peas/Beans

I. Are there at least 8 bags of 16 oz. size peas/beans in stock?

If no, how many?

NIS

2. Are there at least 2 types of peas/beans? If no, how many?

3. Was price marked on peas/beans, or on shelf?

Yes

No

0

0

0

0

0

0

Brand

Type

Highest Prices

$

$

Comments on Peas/Beans

Peanut Butter: (No peanut butter/jelly combinations or honey spreads)

Yes

No

I. Are there at least 8 jars of 18 oz. size peanut butter in stock?



0

If no, how many?

NIS- - -

2. Are there at least 2 brands of peanut butter? If no, how many?





3. Was price marked on peanut butter, or on shelf?





Highest Price $

and

Brand of Peanut Butter

Comments on Peanut Butter:

Form 3774 ( Rev 5/99) Dl'HP98.8(c)HW

Routing: White - State WICOffoce Yellow - l.ocaJ Agency Pink - Vendor

VN -93



GA WIC PROCEDURES MANUAL

Attachment VN-13 cont'd

VENDOR REVIEW FORM
Vendor Number _ _ _ _ _ _ _ _ __

Page 3 of 4

Infant Cereal: (At least one type of cereal must be rice)

I. Are there at least 12 boxes of 8- 16 oz. size infant cereal in stock? If no, how many boxes?_ __

2. Is rice cereal in stock?

3. Is there one other type, other than rice, in stock?

4. Was price marked on cereal or on shelf?

5. Was cereal within current date limit? If no, how many were not? _ _ __

Brand and Price of Infant Cereals: Rice (Highest Price) NIS

Beechnut

$_ _ _ _ _ __

Other (Highest Price) NIS

Gerber

$._ _ _ _ _ __

Yes

No

0

0

0

0

0

0

0

0

0

0

Heinz

$

Comments on Infant Cereal:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Formula: (Minimum of 32 cans of contracted soybase and 138 cans of milk base)

Yes

No

I. Are there at least 138 cans of 13 oz. concentrate milk based contracted formula with iron in stock? If

0

no, how many? _ _ __

2. Are there at least 32 cans of 13 oz. concentrate soy based contracted formula with iron in stock? If no, o

0

how many?_ _ __

3. Is formula within current date limit? If no how many cans were not?_____

o

0

4. Was price marked on cans or on shelf?

o

0

Pried 13 Ounce NIS

Prices: Ready to Feed NIS

Prices: Powdered NIS

Contracted Milk based

$

$

$

Contracted Soy based

$

$

$

Alimentum

Nutramigen

$

Portagen

$

Pregestimil

$

Comments on F o r m u l a : - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Milk: (Minimum of 20 gals. whole milk, 2 %, I% & skim milk of the least expensive brand)

I. Are there at least 20 gals. of milk in stock? If no, how many? _ _ _ NIS_ _ __

2. Was price marked on milk or posted on the dairy case?

3. Was milk within current date limit? If no, how many were not?_ _ __

Lowest Price: $

and

Brand Milk

Yes

No

0

0

0

0

0

0

Comments on Milk:._ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Cheese

Yes

No

I. Are there at least 16 one pound packages of cheese in stock? If no, how many? _ _ _ _

o

0

2. Are there at least 2 types of cheese in stock? If no, how many? _ _ _

o

0

3. Was price marked on cheese or posted on the shelf/dairy case?

o

0

4. Was cheese within date limit? If no, how many were not?___

D

0

Highest Prices of Cheese: American $_ _ NIS _ _ Colby $_ _ NIS _ _ Cheddar$_ _ NIS _

Monterey Jack$_ _ NIS _ _ Mozzarella$_ _ _ NIS

Comments on Cheese:

Eggs: (Least Expensive Brand)

I. Are there at least 16 doz. Grade A Large eggs in stock? If no, how many? _ __

2. Was price marked on eggs or posted on the dairy case?

3. Were eggs within date limit? If no, how many were not?_ __

Lowest Price: $

and (Grade A Large)

Brand of Eggs

Yes

No

0

0

0

0

0

0

Comments on Eggs:

Fonn 3774 (Rev. 5199) DPHP98.8(c)IIW

Routing: White - State WIC Office Yellow - Local Agency Pink Vendor

VN-94



GA WIC PROCEDURES MANUAL

Attachment VN-13 cont'd

VENDOR REVIEW FORM
Vendor Number _ _ _ _ _ _ _ __

B. Participant/Vendor Observation (Not applicable for pre-approval)

I. Were any WIC vouchers on hand in the store? If yes, were all voucher amounts filled in? _ _ _ If the voucher amount is not filled in, list the voucher number(s) in the comments section.
2. Observed WIC participant making a purchase? If yes, were appropriate procedures followed?

Comments:

C. General Questions/Observations

I. Does the store need to be referred to the Georgia Department of Agriculture for inspection?

2. Is store open for business at least 8 hours a day, 6 days a week?

3. Has discrimination been reported or observed?

4. Is there a need for additional training at this time?

5. Are all price columns for foods, which meet minimum inventory requirements, marked N.I.S.

(Not in Store)? This answer must be yes.

-

6. Does the cash register have the capability to place the date and amount of the WIC transaction on the

back of the voucher?

Page 4 of 4

Yes No NA













Yes

No

























To the best of his/her knowledge, the Retail Vendor Representative hereby agrees and covenants that neither the vendor/owner, the vendor's manager(s), or the vendor's other employee(s) is related by blood or marriage to any WIC representative, unless otherwise revealed in writing, upon execution of the contract/agreement or within the contract period. The results of this monitoring visit have been discussed with me and I understand the violations (if applicable) that were found and the food prices listed above are correct.

Signature of Vendor Representative

Date: _ _ _ _ _ _ _ _ _ __

Print Name of Vendor Representative

I have discussed all findings, any violations, and training needs (if applicable) with the appropriate vendor representative.

Signature of WIC Representative

Date:

Print Name of WIC Representative District ________ Unit ______ Vendor Representative Comments:

WIC Representative Comments: _____________________________

Form 3774 (Rcv.5199) DPHP98.8(c)HW

Routing: White State WIC Orficc
VN -95

Yellow - Local Agency

Pink - Vendor



GA WIC PROCEDURES MANUAL

Attachment VN-14

VENDOR REVIEW FORM INSTRUCTIONS

VENDOR NUMBER

Enter the number assigned to the vendor.

DISTRICT/UNIT

Enter the District/Unit number.

DATE OF VISIT

Enter the date of the monitoring visit.

VENDOR NAME

Enter the name of the vendor.

STORE OWNER

Enter the name of the owner.

STORE MANAGER

Enter the name of the manager in charge.

STREET ADDRESS

Enter the complete street address (vendor location).

CITY

Enter the city in which the vendor is located.

COUNTY

Enter the county in which the vendor is located.

ZIP CODE

Enter the zip code of the vendor's address.

REVIEW TYPE

Check the appropriate box to indicate what type of visit you are conducting. Vendor Self Review: Vendor submits with Application For Certification listing food item prices. Pre-Approval Visit: WIC representative submits form after preliminary approval of Application For Certification listing minimum inventory categories available and prices of food items, store must have non-perishable items at time of this visit. New Vendor: WIC representative submits within 30 days after vendor authorization listing minimum inventory categories available and prices of food items only when WIC approved perishable food items were not available upon the pre-approval visit. The store will be sanctioned for inadequate inventory. Yearly Visit: WIC representative submits on a yearly basis showing minimum inventory status of Vendor and prices of food items. Follow-Up Visit: WIC representative submits after visit to stores that have received sanctions.

VN -96



GA WIC PROCEDURES MANUAL

Attachment VN-14 cont'd

VENDOR REVIEW FORM INSTRUCTIONS

A. Minimum Inventory Requirements for WIC Foods: If any required food items are not in the store, check the "NIS" box for that particular item to indicate that it was Not In Store.

1. For each food item category, check the appropriate box "Yes" or "No" to indicate if the required inventory is in stock at the time of your visit. If the inventory is not adequate, enter the exact amount of each food item found on the shelf.

Example: _yes _x_No
Example:

Are there at least 30 boxes of 9 oz. to 24 oz. WIC cereal in stock?

If no, how many? _Q_

Are there at least 8 bags of 16 oz. size peas/beans in stock?

If no, how many? _ _ NIS _x_

-

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 _x_No

Was the price marked on the cereal or the 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 (current date limit). 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 current date limit? If no, how many were not? _L

Comments on Cereal: Two boxes of Kix were three weeks past the expiration date of March, 1997.

4. Record in areas specified, Vendor Shelf/Item Prices for foods that meet the minimum inventory requirements.

Example: Highest prices of Cheese: American $4.99 NIS

Cheddar $3.59 NIS

VN-97



GA WIC PROCEDURES MANUAL

Attachment VN-14 cont'd

VENDOR REVIEW FORM INSTRUCTIONS

B. Participant/Vendor Observation: (Not applicable for pre-approval)

Check the WIC vouchers on hand in the vendor's cash register(s). If all voucher amounts were filled in, check "Yes". If the voucher amounts are not filled in, check "No" and list the voucher number(s) along with an explanation in the space provided.

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. If you were not able to observe a participant while visiting a vendor, indicate that there was not a participant to 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. If the store needs to be referred to the Georgia Department of Agriculture for inspection, check "Yes" and explain conditions in the space provided. If conditions are sanitary, check "No".

2. Is the 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 the 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 for foods which meet minimum inventory requirements are marked NIS.

6. Does the cash register have the capability to place the date and amount of the WIC transaction on the back of the voucher? Check "Yes" or "No".

7. 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 on the form, in the space provided at the bottom of the last page or you may attach additional pages if necessary.

VN -98



GA WIC PROCEDURES MANUAL

Attachment VN-14 cont'd

VENDOR REVIEW FORM INSTRUCTIONS

D. Signatures and Vendor Comments
Signature of WIC Representative:
The person who monitors the vendor should sign the form in the space provided and print his/her name in the space provided. Upon signing, make sure the vendor understands all findings and any violations.
WIC Representative Date:
The date of the WIC Representative's signature.
Signature of Vendor Representative:
The owner or manager should sign the form in the space provided and print his/her name in the space provided. If they are not available, obtain the signature of the person in charge.
Vendor Representative Comments:
The vendor representative should place any comments in this space. Additional pages should be attached if necessary.
WIC Representative Comments:
The WIC representative should place any comments in this space. Additional pages should be attached if necessary.


VN-99


District/Unit/Clinic:_ _ _ __ County:_ _ _ _ _ _ _ __ Date of Incident:_ _ _ _ __ Date Reported:_ _ _ _ _ __ Follow-up Date:_ _ _ _ __
Person Filini: Comglaint Name: Address
Telephone Number: ( ) Incident/Complaint:
-z <
0 0
Local Agency Resolution:


Georgia Department Of Human Resources WIC Program
INCIDENT/COMPLAINT FORM

Pgrtiinant Information Name:
Guardian:
WIC 1.D. Number: DOB: Telephone Number: ( )

Vend2r lnfo[matign VendorNendor Number:
Employee Name:
Title:
Telephone Number: ( )

State \VIC Office Resolution/Comments:
'

Follow-up Report:

State WIC Office Customer Service Coordinator:

DPHP98.8(c)HW Form 3772 (Rev. 4/98)

Routing: White-State WIC Office,

Yellow-Local Agency,

Pink-Vendor



Type of Complaint;
Participant ( ) Vendor ( ) Local Agency/State WIC Office Staff ( )
l.2al ~i:tny~tatt WIC lof2cmgti2n Staff Name: Telephone Number: ( )
Signature:
Can complaint be closed at Local Agency? Yes () No() Signature and Title: Date: Can complaint be closed at State WIC Office? Yes () No() Signature and Title: Date:
Date:

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:..:.,..
-z<
'
Vl



GA WIC PROCEDURES MANUAL

06/ 16/99

STATE OF GEORGIA WIC PROGRAM VENDOR PROFILE FOR
#0000 - WICSTER STORE

Attachment VN-16



* * * Vendor Information * * *

Activity Date: District Unit: County: Store Type:

April 1999 000 000 00

Address:

100 ANYWHERE RD OUR TOWN, GA 00000 MR. WICSTER (111) 111-1111

* * * Volume of Business * * *

# Vouchers Paid (April 1999) $ Amount Paid (April 1999) # Vouchers Paid (FY to Date) $ Amount Paid (FY to Date) % Vouchers Exceed Fis ca I Year 6 Month Average # Vouchers Exceed 6 Month Average % of Total D/U Vouchers % of County Vouchers # Vouchers Outside Vendor Area $ Amount Earned for Vouchers Received Outside Vendor Area % Vouchers Outside Vendor Area

711 $11,927 5 , 168 $86, 610
1 . 7 % 35. 3 % 152 $2, 632 21. 4 %

# Vouchers Paid Last 6 Months

6

5

4

3

2

1

731

673

910

622

660

861

* * * Vendor Scores (04/1999: Federal Fiscal Year ) * * *

A B Cl C2 El E2 E3 F G H

62 42 2

17 18 14 15 2

4





M

N

0

p

Q

21

7

1

12

TOT 217

430 275 18

159 144 133 27 14

22

131

55

11

93

1512


VN-101



GA WIC PROCEDURES MANUAL

Attachment VN-17

VENDOR APPLICATION BOOKLET COVER LETTER HEALTH DEPARTMENT LETTERHEAD



Dear Perspective WIC Vendor (Store Owner):
Per your request, enclosed is a WIC Vendor Application Booklet and a two page application. You must submit all of the application for processing.
The Georgia Department of Agriculture number is required on your appli~ation; without it, your application will not be approved. If you do not already have a number, you may call (404) 656-3632 to apply.
If you are purchasing a store that is currently WIC approved, the WIC vendor stamp from the previous (or former) owner must be received before your application is approved. You must also submit a copy of the bill of sale.
The completed WIC Vendor Application must be returned to me at the address below no later than 4:00 p.m. on _ _ _ _ _ _ _ _ _ _ _. After that date, a pre-approval visit will be made to your store. The evaluation will consist of a check of the minimum inventory of WIC items, your store's appearance, and your shelf prices. After your store has been inspected, your application will then be forwarded to the State WIC Office for approval or disapproval. The State WIC Office will mail you a letter indicating approval or denial. If approved, you will be scheduled to attend a Vendor Training session; if disapproved, you may call and request another Vendor Application and reapply for the next application period.
Your completed application should be mailed to:



Enclosed in this package are the following: WIC Vendor Application Booklet, a two page application, and a four page review form .
VN - 102



GA WIC PROCEDURES MANUAL PHARMACY HANDBOOK

Attachment VN-18

WIC
PHARMACY
HANDBOOK
FFY 2000
GEORGIA DEPARTMENT OF HUMAN RESOURCES




DPHP98.8(d)HW

1-800-228-9173 VN - 103



GA WIC PROCEDURES MANUAL PHARMACY HANDBOOK
CONTENTS
What is WIC The Application Process Training and Signing the Agreement The WIC Food (Formula) Voucher Changing Pharmacy Location Sale/Purchase of Pharmacy or Change of Ownership Processing WIC Vouchers Checking out the WIC Customer Important Notes Voucher Payment Policy Voucher Payment Procedure Compliance Performance Compliance Investigation/Pharmacy Profile Pharmacy Agreement Renewal Sanctions, Disqualifications andTerminations Contract/Agreement Termination Policy Civil Money Penalties Inadequate Participant Access Cases Hearing/Appeal Procedures Sanction System Where to get More Information Application for Pharmacy Certification Form Pharmacy Price List Pharmacy Agreement Fonn Incident/Complaint Form
VN - 104

Attachment VN-18 cont_'d
1-2 2 2-4 5 5 5-6 6 6-7 7 7 7 7-8 8 8 8 9 9 IO 10-12 12 13-14 15 16-19 20



GA WIC PROCEDURES MANUAL

Attachment VN-18 cont'd

PHARMACY HANDBOOK

What is WIC?
WIC stands for Women, Infants, and Children. The WIC Program is funded by the U.S. Department of Agriculture and is administered in Georgia by the Department of Human Resources through state, district and local health offices.
WIC provides important food to pregnant women and their infants and/or young children. Proper nutrition at the beginning of life may help prevent serious health problems. WIC gives children a chance to grow up healthy and lead active, productive lives. WIC Program participants have been examined by health professionals who determine the need for supplemental foods and nutritional guidance.
The participants receive vouchers for special kinds of highly nutritional foods. These vouchers are redeemed by participating pharmacies who have signed an agreement to follow all WIC Program requirements.
The Application Process
Step I-Completing the Application The phannacy must contact the Local WIC
Agency in its area to obtain a pharmacy application.
The pharmacy owner/manager must complete the application and pharmacy price list (see pages 12-14) and return these forms to the Local WIC Agency.
Step 2-Processing the Application I. Upon the sale of a WIC-authorized
pharmacy and the purchase of a previous WIC-authorized pharmacy, the new owner applicant shaU prove that a sale took place by presenting a legitimate bill of sale that complies with the Bulk Sale Law found in the Georgia Official Code Annotated and Unannotated.
2. Shelf prices (on WIC approved formula) of the pharmacy must be compatible with other pharmacies within the state. "Compatible" means prices must not be more than 15 percent above the state average for the pharmacy peer group .

3. The pharmacy must be free from any

current Food Stamp Program

Sanctions.

4.

The pharmacy appearance must be

sanitary with no evidence of general

lack of cleanliness. The State WIC Office

will work with the Georgia Department of

Agriculture Sanitarians to determine the

appropriateness of this criteria if it is used

as a reason for disapproval of a pharmacy

application.

5. The pharmacy must be open for

business at least eight hours per day,

six days per week.

6.

WIC food (formula) must be within

current manufacturer's date limit for

human consumption.

7. WIC pharmacies are only allowed to

sell special formula.

8. The "WIC" acronym or logo cannot be

utilized by a pharmacy with the

exception of documents distributed to

the pharmacy by the Georgia WIC

Program.

Applications are accepted each weekday and should be returned to the Local Agency to be processed along with the pharmacy price list that is completed by the pharmacy. The application process takes 45 working days for completion. Therefore, a pharmacy that wishes to receive approval regarding WIC pharmacy authorization, must submit a completed WIC application form 45 days prior to the pharmacy opening or change of ownership.
ff the pharmacy's prices charged for WIC approved formula meets the state pricing criteria standards, the State WIC Office will forward the WIC authorization stamp to the Local Agency with a copy of the application and the pharmacy registration form. The Local Agency will give the appropriate training, have the owner/manager of the pharmacy sign the Pharmacy Agreement, and issue the WIC authorized stamp. Do not accept WIC vouchers prior to training and signing the WIC Pharmacy Agreement (contract).

1

VN - 105



GA WIC PROCEDURES MANUAL

Attachment VN-18 cont'd

PHARMACY HANDBOOK

If a pharmacy application is denied, the State WIC Office will write a letter to the pharmacy explaining the reason(s) for denial. The pharmacy can correct the deficiencies within 35 working days of denial.

If a phannacy does not correct the deficiencies within 35 working days of denial, a new application must be resubmitted to the Local Agency.

APPLICATION PROCESS

Working Days

Procedure for Pharmacy Certification State WIC Office (SWO) Local Agency (LA)

1st-5th 6th-20th
21st-35th

LA forwards Pharmacy Application for Certification and Pharmacy Price List to SWO
a. SWO will review application and Self Review Fonn b. SWO will fax/mail preliminary approval/denial notice to LA c. Denied pharmacy will be given 35 working days to correct deficiencies and to contact LA
a. LA conducts pre-approval visit within 15 working days (non-perishable items must be in store) b. LA will tentatively schedule training for store personnel c. LA will fax/mail pre-approval outcome to the SWO

36th-40th

a. If pharmacy is approved, the stamps will be forwarded to LA with a copy of the Phamw:y Application and the Pharmacy Registration Form within 5 working days
b. LA will conduct pharmacy training and the Pharmacy Agreement/Contract will be signed by owner/manager c. If pharmacy is denied, SWO will fax/mail denial letter to LA and pharmacy within 5 working days d. Denied pharmacy will be given 35 working days to correct deficiencies and to contact LA

41st-45th

Pharmacy with deficiencies: a. If approved, the stamps will be forwarded to LA, training of pharmacy is conducted and the Pharmacy Agreement will be signed by owner/manager b. If denied, pharmacy must resubmit Application for Certification and Pharmacy Self Review Fonn to LA

46th-75th LA will conduct new pharmacy review within 30 days for pharmacy that did not have perishable food items in stock at the time of pre-approval visit

Step 3-Training and Signing the Agreement Once a pharmacy has been approved, the
pharmacy will be trained by the Local WIC Agency and a WIC pharmacy agreement will be signed by the pharmacy owner or pharmacy manager prior to issuance of the pharmacy stamp and the acceptance of WIC vouchers.
A WIC pharmacy is expected to comply with all requirements stated in the pharmacy agreement. A copy of the application for certification, pharmacy price list, and phannacy agreement are included in this handbook.
A WIC pharmacy is expected to comply with all policies and procedures as outlined in the WIC Phannacy Handbook.
Any pharmacy that is denied from participation in the program has the right to a fair hearing. A hearing must be requested within fifteen (15) days of receipt of the denial notification. The original appeal should be submitted to the State WIC Office address and a copy to the Local WIC Agency.

State WIC Office Two Peachtree St., NW; 8th Floor
Atlanta, Georgia 30303 (404) 657-2900 or
WIC Hotline: 1-800-228-9173
The WIC Voucher
The voucher is a check and should be redeemed just as carefully. When a voucher is properly redeemed, the pharmacy will receive credit for the amount of purchase by depositing it in his/her bank account. The pharmacy is responsible for any mistakes that cashiers make with WIC vouchers, so he/she must be sure that they know all WIC voucher redemption requirements. The State and Local WIC Offices can assist with cashier training as needed.
A WIC pharmacy must accept all valid WIC vouchers. If a voucher exceeds the maximum, please submit the original voucher with a copy of the return voucher payment log to the State WIC Office for reimbursement.
There are four(4) types ofWIC vouchers: computer generated, standard manual, blank manual and laser printed.

2

VN - 106



GA WIC PROCEDURES MANUAL

Attachment VN-18 cont'd

PHARMACY HANDBOOK
Computer generated voucher: All infonnation on this voucher is computer printed.



i1

ARSTOAY .,. TOUSE

0043 9868 1

GEORGIA WIC PROGRAM
DEPARTMENT OF HUMAN RESOURCES

LAST DAY ;,_ .TOUSE
00439868 )ENOORMUST '.),DEPOSIT BY

PAY TO TliE ORDER OF ANY AUTHORIZED GEORGIA WIC VENDOR
FOR 1HESE IT'EMS I OUNfflT1ES 000.V - NO SU8S111l/OONS

FOOD PACK AGE CODE 603 VOUCHER CODE 047

S0l6a

"ILK: 1 GAL (OR> 4-12 OZ CNS EVAP

<OR> 1-5 QT BOX

.JUICE: 1-12 OZ CAN FROZEN OR 1-46 OZ CAN

DOUAAS CENTS

CEREAL: UP TO 24 OUNCES

.YOUR BABY NEEDS SHOTS AT 2 MONTHS, 4 MONTHS,

IMPROPER USE OF ms
VOUCHER IS SUBJECT TO

6 MONTHS, 15 MONTHS, & 5 YEARS

STATE AND FEDERAL

PROSECUTION

Arst Alliance
64-334-611 a

VOID VOID VOID VOID VOID VOID

r:: ,;r.;,.:~;--'\
I 1 WiTHOl,T ',',"(.
_ _ I I \'ENOOR $:t-,P
\.. _:':_ _)
12196

Standard manual voucher: Manual vouchers are processed in the same manner as computer generated vouchers. The standard manual voucher has the name, I.D. number, and dates written or typed by the staff at the clinic.

DIST1U(;T /UNIT/0.HC. ;}:,;,:};. . .WIC 10 NO.

C p

PARTICIPANT

RSH

11 O 570 100 000 00 8 1 SMITH, CARMEN J

N

i1 78730369 7873036:1 2

GEORGIA WIC PROGRAM
DEPARTMENT OF HUMAN RESOURCES

--, ..,-:, -. ,- ~.. ',~. 9 VOUCHER NO.

i (j ; .._J'

.J

LAST DAY . TO USE _ :_,'

:VENDOR MUST

_,:\DEPOSIT',3".':i

FOR 1HESE ffEMS I OUAHmES ONLY - NO SlBSmVT10NS
FPC 404 MILK1 1 GAL OR 4-12 OZ CNS EVAP OR 1-5 QT BOX

vc 028

EGGS1 1 OOZEN

JUICE1 2-12 OZ CANS FROZEN OR 2-46 OZ CANS

$ 12.00

DOU.AAS

CENTS ..

t:;;G;l;L~
I I VIITttQUTWiC I I vEr--,ooR S1'.t..M?
I.__ _.:_c::_ .J

12196



3

VN - 107



GA WIC PROCEDURES MANUAL

Attachment VN-18 cont'd

PHARMACY HANDBOOK

Blank Manual Vouchers: The blank manual voucher has the name, 1.D.
number, and dates written or typed by the staff at the clinic. The amount of food to be received is also written or typed. Redeem only for the amount of food indicated. Only one (1) number should appear in each box.

Examples I.Correct Incorrect
2.Correct Incorrect



X's are placed in all boxes where there is no number. This helps to eliminate any possible unauthorized alterations on the voucher(s).



i.:DIST=-:.::'UNIT::.::.:.:.i.:::CUN=IC+-:c.;:.:,.:.::~:..;..:a;..:r.:.:.:o~-'rN;""WIC=ID;.:.;NO.=,.'.'_ _ _+-c=+-'-p-+-------.;.;PARTICl..::.=;;;;P_;_;mf;.;.;___ _ _ _ _ _+:.'RSN~ . ARST DAY .

03 2 &21t qqg f.-0 7g3 0 3 Wr~TER SHERRI

1--...;T..;;O...:U.;;.SE;;:__-+-..,,._.=Jt......!...L..1
L ~u~y

.99559355 5
PAY
I FOOO PN:IJE. CODE FOAMtAA

!'O.F.OR ~ ~ lHESEVITOEUMCSH/ E0lRWCffOlTD1EES~ ON.!.,-,.tlO f iJ~ "te_E_ __

!!CEREAL ~ lb! ~ oz lrdanl oz Aduft

~

-46 oz cans
12 oz Cans/F17!'

VENDOR MUST . DEPOSIT BY
S070e

lcucl886 i

1332 oozz CCaannss CReoandey. 10 Feed ~ 14 or 18 oz Cans
. b Cans N~ utramigen
~ Pregestimil :,,.- Type -
'

ICHEESE IEGGS

I><] l>s
! !I Doz

: J I L KI Gal Fluid
:-:::;yap,

I !><J :P=E:A=S/B=E=AN=S ~;:=:: lb Dried .

I l><I PEANUT BtrrTER

up lo 18 Ol CARROTS

jruNA

lX! 6 1/8 oz Cans

II Gal Lactose Free 0ts lactose Free
1lb Pnlsealed Pl<g

IMPROPER USE OF THIS VOUCHER IS SUBJECT TO
STATE AND FEDERAL PROSECUTION

First Alliance

64-334-611

12/96

Laser Printed Vouchers: The laser printed voucher is printed at the clinic site at the time of the participant's visit.



4

VN - 108



GA WIC PROCEDURES MANUAL

Attachment VN-18 cont'd

PHARMACY HANDBOOK

Changing Pharmacy Location
When a pharmacy moves to a new location but is still under the same management, the Local WIC Agency must be notified of the address change immediately.
Sale/Purchase of Pharmacy or Change of Ownership
Pharmacies who wish to receive WIC pharmacy authorization for additional store openings or change of ownership must submit a completed WIC application form to the Local Agency 45 working days prior to store opening or change of ownership date. All pharmacies will be subject to the same application process. WIC vouchers must not be accepted by pharmacy applicant during the application process.
Upon the sale of a WIC-authorized store and the purchase of a previous WIC-authorized store, the new owner/pharmacy applicant shall prove that a sale took place by presenting a legitimate bill of sale that complies with the Bulk Sale Law found in the Georgia Official Code Annotated and Unannotated. When a WIC authorized store is purchased by a WIC unauthorized store owner/manager, an application for pharmacy authorization must be completed by the new owner. The previous pharmacy stamp must be terminated at the time the ownership changes. A new pharmacy number will be issued to the new owner upon application approval (see page VN-3 for Approval Criteria for Pharmacies) by the State WIC Office. A new Pharmacy Agreement must be signed by the new owner.
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 pharmacy 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 pharmacy will not be paid for those vouchers. The Pharmacy Agreement must be signed and pharmacy stamp must be issued prior to vouchers being accepted.
If the manager who signed the original Pharmacy Agreement Contract and/or Pharmacy Training Checklist remains the same, the Local Agency will have the manager update the pharmacy file with a new Pharmacy Agreement Contract, Pharmacy Training Checklist and an Application for Certification bearing the new

owner's name, pertinent new information and signature to be forwarded to the State WIC Office. The pharmacy stamp will remain in the possession of the new owner unless replacement stamp issuance is necessary. If a replacement stamp is issued, a Vendor Registration Form or a Transaction Keypunch form is forwarded to the ADP contractor and the Local Agency by the State WIC Office to update the database systems. If the pharmacy stamp remains the same, a Vendor Registration Form or a Transaction Keypunch form must be forwarded by the Local Agency to the ADP contractor and the State WIC Office to update the database. The Local Agency representative must conduct a pharmacy review of WIC approved food items within thirty (30) days after the pharmacy authorization.

Processing WIC Vouchers
After a pharmacy has signed an agreement with the WIC Program, he/she will receive a WIC Pharmacy Identification Number and a stamp with this number. After the vouchers are accepted, they must be stamped with this number in preparation for a bank deposit. The pharmacy should inform his/her bank before or at the time of his/her first deposit that the vouchers can be delivered through the Federal Reserve System to the Premier Bank Marietta, Georgia. Payment will be assured, prior to the deposit, if:

1. Pharmacy does not accept voucher before

the "First Day to Use Date" listed on the

face of the voucher.

2.

A WIC Program authorization seal

appears on the face of the voucher(s).

(Does not apply to laser printed vouchers).

3. An authorized WIC pharmacy stamp

appears on the face of the voucher.

4.

The total amount of the purchase is

entered in the presence of the customer.

5.

The amount of purchase does not exceed

the maximum amount printed on the face

of the voucher.

6.

The pharmacy must not accept the

voucher after the "Last Day to Use"

date on the voucher. Vouchers

deposited after sixty (60) days from the

"First Day to Use" date shall not be

paid.

7. Endorsements should appear at the bottom

left-comer (for manual vouchers only)

and right-comer of all voucher(s). The

5
VN - 109



GA WIC PROCEDURES MANUAL

Attachment VN-18 cont'd

PHARMACY HANDBOOK

participant must sign the area "Sign Here at WIC Office," prior to redemption of manual vouchers and/or sign a voucher register for redemption of computergenerated vouchers. In addition, in the area "Sign Here at Grocery Store," a signature should be obtained upon redemption of WIC voucher(s). All vouchers which do not meet these requirements will be returned unpaid to the pharmacy.

Checking Out the WIC Customer
When fonnula is purchased with a WIC voucher, the cashier must do the following:

1.

For manual vouchers, check to see if the

voucher has been signed (once) by the

WIC customer on the left side of the

voucher (Sign Here at WIC Office).

2.

Check the dates on the voucher. Vouchers

cannot be accepted before the "First

Day to Use" nor after the "Last Day to

Use" dates.

3.

Ring up the shelf price or price on item(s)

of WIC food(s) for each voucher. Make

sure that the exact types and amounts of

approved WIC foods are being purchased.

Do not include sales tax.

4.

Print the amount of the purchase in the

"Pay Exactly" space on the voucher in

the presence of the WIC customer.

5.

Have the WIC customer sign the bottom

right side of the voucher in the "Sign

Here at the Grocery Store" space after

the amount is written in. After the

participant has signed, compare the

signature with the WIC ID card. If the

customer's name does not appear on the

ID card, do not accept the voucher.

6.

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 WIC

customer also signed the ID card with

his/her mark.

Important Notes

Any WIC customer who attempts to

purchase foods that are not approved or

creates other problems in the store should

be reported to the State or Local WIC

Office immediately.

WIC participants will enter the same

check-out lines as other customers and

must be charged the same prices as other

customers (not to exceed the maximum

amount allowed on the voucher(s)).

However, WIC purchases are exempt

from Sales Tax.

Separate check-out lines for WIC

participants in pharmacies are prohibited.

Signs such as "WIC vouchers not allowed

in this line" or "No checks, No WIC"

cannot be displayed since they are con-

sidered discriminatory. However,

pharmacies who wish to ensure that WIC

participants do not enter certain lines, such

as express lines, may post "Cash Only"

signs in those lines.

If a manager is called to approve a WIC

voucher transaction,"it is imperative that

the customer is not identified as a WIC

participant over the public address system.

Every effort must be made to protect the

confidentiality of the participant/proxy,

and discussion of the transaction should

be kept at a conversational level.

Provisions I.J. and I.K. of the Pharmacy

Agreement state that WIC participants

must be accorded "the same courtesy

given to other store customers," and store

personnel must "keep all infonnation

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 17 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).

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. If a

voucher exceeds the maximum purchase

priced listed on the voucher, submit the

6

VN - 110



GA WIC PROCEDURES MANUAL

Attachment VN-18 cont'd

PHARMACY HANDBOOK

original voucher with a copy of the Return Voucher Payment Log to the State WIC Office for reimbursement. Every store has the option of checking 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.

Voucher Payment Policy
Any WIC voucher returned by the bank to the pharmacy because of a missing pharmacy stamp may be stamped and returned to the bank for payment.
Prior to deposit, if a mistake is made upon entering the price on the voucher, the incorrect price should be marked through and the correct price written above the error along with the cashier's initials. The voucher should then be processed through the bank as a normal voucher. If the price on the voucher exceeds the maximum purchase price, it will be returned to the pharmacy 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 pharmacies for vouchers at a rate of the pharmacy's 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 pharmacy's Federal Employer Identifier (FEI) number or the owner's Social Security Number (SSN) if the FEI number is unavailable.
Any WIC voucher returned by the bank to the pharmacy because of a stale date will not be paid.

Voucher Payment Procedure

If a voucher has been returned to the WIC

pharmacy not paid, the pharmacy 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

# 3760) must be completed and sent with

the original WIC voucher(s) to the State

WIC Office.

The pharmacy should retain the last copy of the form for their records.

If a voucher(s) is approved for payment, a

copy of the form, with the payment, will

be forwarded to the pharmacy.



If a voucher(s) is denied payment, a copy

of the form will be returned to the

pharmacy with an explanation for denial.

Also, the original voucher will accompany

the form.

Payment on vouchers received without the

form will be delayed.

Compliance Performance
The performance of every pharmacy is reviewed in the following way:
The State WIC Office may conduct record audits on any pharmacy at any time. During an audit, the pharmacy must supply the WIC representative with documentation of pertinent records upon request.
Pharmacies must retain copies of all invoices relating to the purchase of WIC food items for a period of two (2) years. The State WIC Office reserves the right to monitor a pharmacy to determine compliance.

Compliance Investigation/Pharmacy Profile
Compliance investigations shall be conducted in authorized WIC pharmacies. Pharmacies identified for investigation will consist of those phannacies that are considered to be potentially high risk by system reports, and those pharmacies who have been reported to the WIC Program for potentially violating program regulations. Non-potential high risk pharmacies will be randomly selected for investigation. Investigators shall shop with WIC vouchers to determine whether a store is complying with WIC Program requirements.
Any pharmacy identified as being potentially high risk will be investigated by the State WIC Office. If the pharmacy 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. Notification of investigation

7
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GA WIC PROCEDURES MANUAL

Attachment VN-18 cont'd

PHARMACY HANDBOOK

results will be forwarded to the pharmacy in writing.
Pharmacies not involved in a current investigation will be notified of other administrative sanction assessments at the time they are assigned.
Pharmacy Agreement Renewal
By federal regulations, the State does not have to renew agreements with WIC pharmacies. Any WIC pharmacy who has not signed a pharmacy agreement within 30 days after the expiration date will be terminated and may reapply by submitting a pharmacy application. In order for a WIC pharmacy agreement to be renewed each year, the pharmacy must meet requirements 1-8 listed under The Application Process.
Sanctions, Disqualifications, and Terminations
Any WIC pharmacy found to be in violation ofprogram policy and/or regulations will be assessed a sanction consistent with the severity and nature of the violation. Each violation of program policy and/or regulations has a set sanction and a specific time period during which the sanction will remain on the pharmacy record. In addition, a pharmacy shall be disqualified from WIC Program participation if disqualified from Food Stamp Program participation.
All State Agency sanctions earned are retained in the pharmacy file for a period of one year and will "roll off' of the pharmacy file one year from date ofreceipt. Mandatory sanctions will remain on the vendor's record permanently.
Disqualifications
All sanctions earned are retained in the pharmacy file for a period of one (I) year. Sanctions will "roll-off" one (I) year from the date of receipt. The period of disqualification is determined by the severity and nature of the violation, the number of violations, probations, and past disqualifications. Any pharmacy disqualified from WIC Program participation may be disqualified from the Food Stamp Program.

If a pharmacy is disqualified from Food Stamp Program participation, the pharmacy shall be disqualified from WIC Program participation for the same period of time, up to a permanent disqualification. (Refer to Food Stamp Federal Regulations 7CFR; Part 278).
In the event a pharmacy receives a warning letter in which he.or.she disputes the allegation(s) regarding non-compliant activity, upon request the retailer shall be heard by Local Agency or State Agency WIC representatives to resolve the circumstance(s) via telephone, correspondence or scheduled Local or State Office consultation with the pharmacy and/or his advisor(s).
In the event that a pbarmacy receives a disqualification notice, he or she will be granted an opportunity for a record review.

Terminations

If a pharmacy voluntarily withdraws

from WIC Program participation, the owner

must notify the Local WIC Agency of their

decision.



If a pharmacy decides to sell the

business, the owner must notify the Local

WIC Agency of the transaction.

Contract/Agreement Terminaton Policy Shelf prices (on WIC-approved foods)
of the pharmacy must be compatible with other pharmacies within the state. "Compatible" means prices must not be more than 15 percent above the state average for the pharmacy peer group. The State WIC Office shall provide written notification to the pharmacy regarding the amount ofoverpricing involved by voucher code type. Consequently, the pharmacy shall reimburse the State WIC Office for any overpayment. If the pharmacy does not submit his/her payment within thirty (30) days, the State WIC Office will forward a second written notification to the pharmacy requesting the overpaid amount. If the pharmacy fails to submit the requested overpayment after the second notification, the pharmacy will be given a third and final opportunity to submit the overpayment by the requested date, the pharmacy will be

8

VN - 112



GA WIC PROCEDURES MANUAL

Attachment VN-18 cont'd

PHARMACY HANDBOOK

terminated from WIC Program participation for a ninety (90) day period. An exception will be made if the termination of the pharmacy creates inadequate participant access (refer to Inadequate Participant Access Cases).

Civil Money Penalties
Civil Money Penalties (CMP) cannot exceed $10,000 per violations/$40,000 per . investigation. If more than one violation is detected during a single investigation, a CMP must be imposed for each violation (up to the $10,000/$40,000 limits).
If a pharmacy fails to pay the CMP, the State Agency must disqualify the pharmacy for a period equal to the violation for which the CMP was assessed.
. Second mandatory sanctions, excluding convictions for trafficking and Food Stamp Program disqualifications, result in double the disqualification or double the CMP (up to the maximum limits).
Third or subsequent mandatory sanctions, excluding convictions for trafficking and Food Stamp Program disqualifications, result in double the disqualification with no option for a CMP.

Formula For Calculating Civil

Money Penalties (CMP)

The following is the methodology for

calculating CMPs:



Determine the vendor's average

monthly redemptions for a 6 month

period ending with the last month

immediately preceding the month

during which the notice was provided

to the vendor.



Multiply the average redemptions by

the prescribed percentage.*



Multiply the result by the number of

months for which the vendor would

have been disqualified.

*Category I at 2%

*Category II at 4%

*Category III at 6%

*Category IV at 8%

Sanctions 1 & 2 at 10%

(Not to exceed $10,000

per violation and

$40,000 per investigation) Sanctions 3-7 at 8% *Category V-VII at 10% (Not to exceed $10,000 per violation up to $40,000 per investigation) CMPs may be assessed in lieu of disqualification. In Categories IV, sanctions #1 and #2, Categories V through VII, CMPs may only be assessed if the disqualification would result in inadequate participant access.
Civil Money Penalty Assessment Procedure
In addition to the State's determination of inadequate participant access when necessary, WIC vendors may be eligible for a CMP if they meet the following criteria:
l. Vendor must request, in writing, consideration for a CMP.
2. Vendor must submit substantial evidence that an effective compliance policy and program is in effect to prevent violations.
3. Vendor must establish that both its compliance policy and program were in operation at the location where the violation(s) occurred prim to the sanctions.and/or disqualification notices.
4. The vendor had developed and instituted an effective personnel training program.
If the vendor meets the above criteria for levy of CMP, vendor must also meet all prescribed deadlines for payment ofCMP.
Inadequate Participant Ac~ess Cases
If the State Agency determines that disqualifying a vendor causes inadequate participant access, the State Agency must impose a Civil Money Penalty (CMP) in lieu of disqualification in Categories I-VII (except that the State WlC Office may not impose a CMP in lieu of disqualification either as a result ofa Food Stamp Program/Civil Money Penalty or for a third or subsequent sanction

9
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GA WIC PROCEDURES MANUAL

Attachment VN-18 cont'd

PHARMACY HANDBOOK

as specified in 246.12(k)(l)(vi)). If a pharmacy does not pay, only
partially pays or fails to timely pay a CMP, the State WIC Office must disqualify the pharmacy for the full length of the disqualification corresponding to the violation for which the CMP was assessed.
An inadequate participant access case is granted only when the nearest authorized WIC pharmacy is 10 miles or more away from the nearest WIC clinic. Geographical barriers will be assessed.
Hearing/Appeal Procedures Pharmacies are entitled to a fair
hearing upon disqualification from the WIC Program. Any pharmacy requesting a fair hearing must contact the Local Agency by telephone and contact the State WIC Office in writing within fifteen (15) days of the adverse action.
Sanction System
The following is a description of the sanction system and how it works. Civil money penalties (CMP) may be assessed in Category I-VII in lieu disqualification; however, for mandatory sanctions, no CMP shall be allowed unless the State has determined that there would be inadequate participant access. A. Any Violation From Category I, II
or III May Be Assessed A CMP In Lieu Of Disqualification. (State Agency sanctions)
Category I - Warning on the first and second offense, third offenseprobation for six (6) months, fourth offense in category I, II, or III disqualification for six (6) months 1. Stocking a WIC food item(s)
outside of manufacturer's notto-exceed date(s). 2. Prices not marked clearly on WIC food items or near WIC food items. 3. Allowing WIC food items to exceed the quantity specified . on the voucher. (Except for promotional items).

4. Failure to give a receipt for WIC purchases.
5. Failure to allow the purchase of any WIC food item(s).
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 l. Failure to properly process
vouchers at the store (this includes failure to calculate [ring up] sales of WIC purchases; not writing price on voucher before participant signs). _ 2. Failure to stock the required inventory of contracted formula or failure to stock the required inventory of two or more WIC food items (types and/or brands). Physical inventory must be viewed by a WIC representative at the time of visit. Proof of order of food items is not acceptable. 3. Refusing to accept valid WIC vouchers from participants in exchange for WIC food items. 4. Allowing substitutions for food items listed on WIC vouchers; or allowing the purchase of WIC foods in unauthorized container sizes. 5. Failure to remain open for business at least eight hours per day, six days per week. 6. Failure to repay overcharges within specified period (30 days, 60 days, 90 days).
Category III - Warning on first offense, second offenseprobation for ten (10) months, third offense in category I, II, or III disqualification for ten (10) months 1. Issuing rain checks/IOU's. 2. Contacting WIC participants
for any reasdn regarding a WIC transaction.

10

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GA WIC PROCEDURES MANUAL

Attachment VN-18 cont'd

PHARMACY HANDBOOK

3. Requiring participant to pay cash to redeem WIC vouchers.

unauthorized sources. 2. A pattern of allowing an

4. Allowing the purchase of any

authorized store to redeem

formula other than the one specified on the front of the voucher. 5. Failure to allow

vouchers from another, authorized store. 3. A pattern ofproviding credit or non-food items in exchange for

participant(s)/proxy(ies) to

WIC vouchers.

purchase all WIC approved food items listed on the face of

4. A pattern of overcharging on WIC vouchers (charging a

the voucher regardless of price on the voucher.
B. Any Violation From Category IV or V That Occurs At Any Time Will Result In Immediate Disqualification For The Period Specified In Category IV or V. ACMP May Be Assessed In Lieu of

WIC participant more than the current shelf price or charging a WIC participant more for food than a non-WIC customer) during a compliance investigation. 5. A pattern of charging for supplemental - foods not

Disqualification.

received by the WIC

Category IV - Immediate disqualification for one (1) year (twelve months) for each violation (1&2 Mandatory sanctions, 3-7 State Agency sanctions) l. A pattern of providing
unauthorized food items in

participant. 6. One incidence of the saie of
alcohol or alcoholic beverages or tobacco products in exchange for WIC vouchers. 7. A pattern of claiming reimbursements in excess of documented inventory.

exchange for WIC vouchers.

2. A pattern of charging for

C. Any Violation From Category VI or

supplemental foods provided in

VII That Occurs At Any Time Will Result

excess of those listed on the voucher. 3. Intentionally providing false information on pharmacy records. 4. Discrimination. 5. Failure to provide vouchers or inventory records upon request. 6. Transacting WIC vouchers outside of the WIC authorized fixed store location. 7. Failure to allow monitoring by WIC representatives. Category V - Immediate disqualification for three (3) years (thirty-six months) for each violation (Mandatory sanctions) 1. A pattern of receiving, transacting, or redeeming vouchers from authorized or unauthorized stores or other

In Immediate Disqualification For The Period Specified In Category VI or VII. CMP MAY BE ASSESSED FOR INADEQUATE PARTICIPANT ACCESS CASES ONLY. (Mandatory sanctions)
Category VI - Disqualification for six (6) years (seventy-two months) for each violation 1. One incidence of buying or
selling of WIC vouchers for cash. 2. One incidence of exchanging WIC vouchers for firearms. 3. One incidence of exchanging WIC vouchers for ammunition. 4. One incidence of exchanging WIC vouchers for explosives. 5. One incidence of exchanging WIC vouchers for controlled substances . Category VII - Permanent

11

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GA WIC PROCEDURES MANUAL

Attachment VN-18 cont'd

PHARMACY HANDBOOK

Category VII - Permanent disqualification for a conviction of each violation (Conviction refers to an action by a criminal court as defined in section 102 of the Controlled Substances Act (21
u.s.c. 802)
1. Conviction for buying or selling of WIC vouchers for cash.
2. Conviction for exchanging WIC vouchers for firearms.
3. Conviction for exchanging WIC vouchers for ammunition.
4. Conviction for exchanging WIC vouchers forxplosives.
5. Conviction for exchanging WIC vouchers for controlled substances.
Pharmacy violations will be categorized by the severity and nature of the offense. The nature and severity of a violation(s) shall determine the sanction assessed, the duration of the probationary period, and the period of disqualification. Therefore, the highest sanction assessed to a pharmacy shall determine the period of probation and disqualification. Each category has a prescribed period of disqualification, probation, or warnings assessed. State Agency warnings remain active on the pharmacy case file for a twelve (12) month period. Mandatory sanctions remain on the pharmacy's case file permanently. A pharmacy found to be in violation within the probationary period shall be disqualified for not less than the full probationary period, up to six (6) years. Probationary periods are granted by the State WIC Office and are not subject to a fair hearing. A pharmacy will continue to operate during the probationary period. lf a pharmacy is disqualified from Food Stamp Program participation, the pharmacy shall be disqualified from WIC Program participation for the same period of time, up to a permanent disqualification. (Refer to Food Stamp Program Federal Regulations 7CFR; Part 278). Disqualification from the WIC Program

may also result in disqualification from the Food Stamp Program.
As per Federal Regulation 246.12 (k)(l), the Georgia WIC Program has taken into account the severity and nature of violations in establishing the Sanction System. If a mandatory sanction disqualification is not upheld during an appeal, State WIC Office sanctions and/or disqualification that have previously been assessed to the vendor may remain on the vendor's record or qualify the vendor for a State WIC Office disqualification.
Where to Get More Information
Local WIC Offices can offer help to pharmacies if questions or problems arise. Most WIC offices can be contacted through the county Health 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 pharmacy number available when calling or listed when writing):
Georgia Department of Human Resources State WIC Office
Two Peachtree St., NW 8th floor
Atlanta, Georgia 30303 (404) 657-2900
or call the WIC Hotline 1 -800-228-9173

12

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GA WIC PROCEDURES MANUAL

Attachment VN-18 cont'd

PHARMACY HANDBOOK

Georgia Department of Human Resources DIVISION OF PUBLIC HEALTH
FOR WOMEN, INFANTS AND CHil..DREN
WICPROGRAM
APPLICATION FOR VENDOR CERTIFICATION

Area Code Store Name _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Telephone Number(_) _ _ _ _ _ _ __
Store Location _ _ _ _ _ _ _ _ _ City _ _ _ _ _ _ GA Zip Code _ _ _ _ _ _ __

Mailing Address (If Different)

County _ _ _ _ _ __

Store Owner _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Store Manager _ _ _ _ _ _ _ _ _ __

F.E.I. Number

or Owner's Social Security Number _ _ _ _ _ _ _ _ __

(Federal Employer Identifier)

TYPE OF STORE
Chain

HOURS OF BUSINESS Sunday _____ Monday _ _ _ _ __

Independent

Tuesday

Wednesday _ _ _ __

Franchise

Thursday

Friday _ _ _ _ __

Drug

Saturday _ _ _ __

Square Footage of Store _ _ _ _ _ _ _ _ _ Number of Check-out Counters _ _ _ _ _ _ __

(Square Foocage of Grocery Store and Grocery Storage Space).
Average Annual Gross Sales $_ _ _ _ _ _ _ Estimated Total % of Food Sales _ _ ___,'fl-"-o_ __ Food Stamp Authorization Number _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

(A store must be eligible for Food Stamp Program Authorization to be a WIC Vendor.) Department of Agriculture License Number _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

(A store must be licensed by the Department ofAgriculture to be a WIC vendor) Business License Number _ _ _ _ _ _ _ _ Sales Tax Number _ _ _ _ _ _ _ _ _ _ __
Length of time business has operated at the present site _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ Date store will open/change of ownership date _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Yes No

a

a

a

D

Do you sell beer, wine or other alcoholic beverages? Has the business ever operated under another name? If yes, what was the name of the business?

a

D

Is this a change of ownership?

a

D

Does this store now participate in the Food Stamp Program?

a

D

Has this store ever applied for WIC? If yes, state when _ _ _ _ _ _ _ _ _ _ __

a

D

Has this store ever received a warning, been suspended, disqualified, or had a penalty

assessed against it by WIC or Food Stamps? If yes, state when and explain_ _ _ __

STATE WIC OFFICE USE ONLY

Food Pkg.# _ _ _ Vendor Cost _ _ _ Max _ _ _ _ Price Approved _ _ Denied _ _ __

Food Pkg.# _ _ _ Vendor Cost _ _ _ _ Max ---~Price Approved _ _ Denied _ _ __

Food Pkg.# _ _ _ _Vendor Cost _ _ _ _ Max ---~Price Approved _ _ Denied _ _ __

Are Store prices competitive with other stores in State?

Yes _ _ _No

Application: Approved _ _ _ _ _ Date _ _ _ _ _ Vendor Number Assigned Denied _ _ _ _ _ Date _ _ _ _ Processed by _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Reason Denied _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

13
VN - 117



GA WIC PROCEDURES MANUAL

Attachment VN-18 col)t'd

PHARMACY HANDBOOK
Store Name _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Name 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) / drug store(s)? Yes No If yes, list name and addresses of store(s) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __



To the best of my knowledge, all of the above answers are correct. I understand that, should my store be
accepted as a WIC vendor, I will abide by WIC Program regulations and policies including, but not limited to the following:

I.

Attend Vendor Education

2.

Train employees regarding WIC procedures

3.

Periodical monitoring

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 ATTENDED VENDOR TRAINING AND I HAVE BEEN ISSUED A WIC VENDOR STAMP.
Signature _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Date _ _ _ _ _ __
Title _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

"The USDA is an equal opponunity provider and employer."

FOR WCAL USE ONLY

YES NO





Is the state required minimum inventory ofWIC approved foods in the store during the Pre-Approval

visit?





Have you provided the vendor with the Georgia WIC Application Packet?

Comments: - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

I cenify that I have visited this store and do/ do not recommend its approval for panicipation. If this appli_cation is not recommended for approval, please explain why: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __



DISTRICT/UNIT

LOCAL AGENCY WIC COORDINATOR OR DESIGNEE

14

VN - 118

DATE



GA WIC PROCEDURES MANUAL

Attachment VN-18 cont'd

PHARMACY HANDBOOK
Vendor Name _ _ _ _ _ _ _ _ _ _ _ __ Vendor Number_ _ _ _ _ _ _ _ _ _ __
GEORGIA WlC PROGRAM
PHARMACY PRICE LIST
Please fill In the prices ror all ronnulas available In your phannacy.

FORMULA TYPE
SIMILAC WITH IRON SIMILAC LOW IRON ISOMll. LACfOSEfREE IS0Mll,[)f PROSOBEE ALIMENl1.IM NtrTRAMJGEN PORTAGEN PREGESTIMIL ENFAMll. WITH IRON 24 CALORIE (3 OZ. RTF bolllc) SIMILAC SPCIAL CARE 24 CALORIE (4oL RTF bolllc) MODUCAL PEDIASURE (8 oz. RTF can) PEDIASURE WITH ABER (8oz. RTF can) PRODUCT 800S6 REABll.AN (12.6 oz. RTF can) 3232-A ENSURE ENSUREHN ENSURE PLUS ENSURE WITH FIBER KINDERCAL MCT POLYCOSE RESOURCE SIMILAC NEOCARE SUSTACAL WITH ABER SUSTAGEN VIVONEX MICROUPID OTHER FORMULAS/SIZES:

13m. Conaatnte

32oz. Read To-Feed

I oz. Or 16m. Powdtted

15
VN - 119



GA WIC PROCEDURES MANUAL

Attachment VN-18 cont'd

PHARMACY HANDBOOK

Georgia Department of Human Resour<:es Division of Public Health WICProgram
(SPECIAL SUPPLEMENTAL FOOD PROGRAM FOR WOMEN, INFANTS & CHILDREN)

PHARMACY AGREEMENT

Page I or 4

This Pharmacy/Provider Agreement is made by and between the Georgia Department of Human Resources, Division of Public Health, WIC Program, State Agency, (hereinafter referred to as the WIC Program) and _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ (hereinafter

referred to as the Pharmacy) to provide a mechanism for the distribution of special supplemental formula to eligible WIC participants. This agreement will become effective on _ _ _ _ _ _ _ _ _ _ _ _ _ _and will terminate on _ _ _ _ _ _ _ _ __

WIC PHARMACY NUMBER



The undersigned represents the Vendor as the sole proprietor or the pharmacy manager to contract for and on behalf of the vendor identified below. (Signature MUST be of owner or pharmacy manager.)

Signature of Pharmacy Owner

Date

(Pnnt) Name of Pharmacy Owner or Manager

Name of Pharmacy

Ma1hng Address - Street P. 0. Box

Street Locallon of Pharmacy - Street Address

c,ty

State

Zip Code

Telephone Number

Name of Pharmacy Owner (11 different from above)

Mailing Address

City

State

Z1peode

The undersigned ~ a n d lias the

represents authority to

cothnetracLtofcoar lanAd goennbceyn1 alDf oisfttrhicet

vvI1., rrogram State Agency.

Signature of Local Agency Authorized Representative

(Print) Name of Local Agency Authorized Representative

Name of Local Agency

Ma1hng Address - Street P.O. Box

c,ty

State

Zip code

Telephone Number

Estimated % of Formula Sales

Average Annual Gross Sales

Square Footage of Store

Number of cash Registers

_ _ _ _ _ _ _ _ _ _ _ _ _ _Or;.-::-=,..,..,,..,..=--n---,,--

FederaI Employer Identifier Number Social Security Number

Notary Public Signature and Seal

Date

Notary Public's Commission Expires

PURPOSE:

This Agreement is for the purpose of providing a mechanism for the distribution of certain listed formula to eligible participants and the redemption of negotiable food instruments (vouchers) for the purchase of said food items . The Pharmacy is retained solely for the purpose set forth herein and shall not be considered as an employee or agent of the Department.
THE PHARMACY HANDBOOK IS AN ADDENDUM TO THIS AGREEMENT.

COMMERCIAUBUSINESS BANK ACCOUNT NAME

BANK NAME ADDRESS

16

VN - 120



GA WIC PROCEDURES MANUAL PHARMACY HANDBOOK
WIC PHARMACY NUMBER

Attachment VN-18 cont'd
Page 2 of 4



I. THE PHARMACY HEREBY AGREES AND COVENANTS AS FOLLOWS:

A.

Upon notification from the Local Agency, to supply, within a time period agreed upon by the Pharmacy and the Local Agency, lhe

necessary supply of any one of the "Special Infant Formulas.

B.

That all prices will be ciearty marked either on the food Item or prominenUy displayed.

C.

To accept WIC 110uchers for payment of the purchase of only eligible WIC formulas. In addition, the pharmacy must accept all valid

WIC 110uchers and allow participants to purchase all formula on the 110ucher(s) regardless of price.

. o.

To not accept WIC vouchers as payment on past or present credit acoount(s) .

E.

To not accept WIC vouchers from participants presented after thirty (30) days from the issuance date or prior to issue date shown on

the voucher.

F.

To accept only vouchers which oontain a Georgia WIC Program SEAL.

G.

To refuse acceptance of any IIOucher on which any alterations have been made.

H.

To sell WIC formula at or below the normal pharmacy shelf price.

I.

To permit WIC Program participants to purchase eligible formula without making other purchases and to accord such participants the

same oourtesy given to other pharmacy customers.

J.

To keep all information confidential on WIC participants.

K.

To direct questions concerning payment, program operations, etc., to the Local Agency; participants will not be contacted concerning

these or other problem areas. (Pharmacies shall not seek restitution from participants for 110uchers not paid by the State.)

L.

To ensure that no exchange of money between the pharmacy and participant takes place during a WIC voucher transaction.

M.

To not allow rain ched<s or exchanges of any voucher for cash, credit, ooupons, stamps, premiums, or non-listed formulas; however,

a pharmacy Is not precluded from giving or aocepting coupons, stamps, or premiums with purchases as ii purchased with cash.

N.

To obtain at the time of purchase an original customer signature on the WIC voucher and request thai the participant show a WIC

Identification card before the purchase of WIC formula can be completed. If the customer is unable to show a WIC identification card

bearing the same signature as signed on the 110ucher, the pharmacy should not accept the WIC voucher as payment for the formula.

o.

To insert, in ink, the actual cost of the WIC foods on the WIC 110ucher lace at the time of purchase in the presence of the customer.

P.

To stamp all vouchers with the authorized pharmacy stamp (provided by the Local Agency) before depositing in the bank and to

deposit ail WIC vouchers in a timely manner, preferably within fifteen (15) days of redemption but within si>cty (60) days of the "First

Day to Use" shown on the voucher face.

a.

1.

To distribute to all employees Involved in the Pharmacy's WIC Program participation all communications received from the

Local Agency pertinent to the employee's involvement in the WIC Program. T9 instruct cashiers, and ail other employees,

in110lved in the Pharmacy's WIC Program participation of the eligible formula and the correct processing of WIC vouchers.

2.

The Pharmacy will be aocountable for actions of employees in the utilization of vouchers or provision of supplemental

foods.

3.

A pharmacy owner or manager who signs an authentic WIC Pharmacy AgreemenVContract in the absence of a Local or

State Agency WIC representative must have hiSiher Pharmacy Agreement Contract signed In the presence of a Notary

Public whose commission does not expire prior to the date that the Agreement Contract is signed.

R.

To abide by rules and regulations of Federal, State, and Local Agencies and all procedures as ouHined in the WIC Pharmacy

Handbook.

s.

1.

That the State Agency may deny payments to the Pharmacy for improper food vouchers or may demand relunds for

payments already made on improper vouchers.

2.

To reimburse the State Agency within thirty (30) days of notification for amounts paid by the State Agency on WIC Program

food vouchers processed by the pharmacy which are above the normal shelf price of formula.

T.

To allow representatives of the Local, State, or Federal Agency to monitor the pharmacy in an unannounced manner at any time the

pharmacy is open for business. Ali records pertinent to this Agreement will be made available for review by the representative of the

agency.

u.

That pharmacy stamps are the property of the State of Georgia and that said stamps will be returned to the WIC Program

immediately upon termination/suspension/disqualification/voluntary withdrawal from program participation.

v.

1.

That the pharmacy or the pharmacy's employee(s) will not reimburse WIC participants or exchange WIC formula, when

WIC vouchers were used for the purchase unless:

a. Notified in writing by a health department representative.

.

b. The Pharmacy is exchanging a WIC purchased ilem(s) due to inappropriately selling out-of-date WIC formula.

2.

That any out-of-date formula will be removed from stock and replaced with formula that have expiration dates which do not

exceed the period of normal expected usage.

w.

That any pharmacy disqualified from another Food and Nutrition Services (FNS) Program shall be disqualified from participation in

the WIC Program for the same period of time, up to three (3) years.

x.

A pharmacy who commits fraud or abuse of the program is liable to prosecution under applicable Federal, State or Local laws.

Those who have willfully misapplied, stolen, or fraudulenUy obtained WIC funds shall be subject to a fine of not more than $10,000 or

imprisonment for not more than live (5) years or both.

Y.

To notify the Local Agency of changes In management or when the pharmacy ceases operation or ownership changes. This

Agreement is null and void if ownership changes.

z.

State of Georgia or Local Sales taxes will not be collected on formula items purchased with WIC vouchers.

AA.

To declare that neither the pharmacy/owner, the pharmacy's manager(s), or the pharmacy's other employee(s) is related by blood or

marriage to any WIC representative, unless otherwise revealed in writing, upon execution of the AgreemenVContract or within the

contract period (space provided on Page three (3) of this AgreemenVContract for disclosure of relatives).

AB.

To visibly display the pharmacy's store name, as listed on the front page of the AgreemenVContract, on the outside of the store

building/facility.

AC.

To abide by the U.S. Patent and Trademark Laws, which prohibits unauthorized use of the WIC acronym and logo (refer to

Registration Number 1,630,468, provided in 42 U.S.C. 1876, 15 U.S.C. 1051 et. seq. and 7 CFR Part 246).

AD.

To declare that the pharmacy owner(s) or employee(s) employed by a Georgia WIC Agency is listed on Page three (3) ol this

AgreemenVContract.

AE.

That the WIC Program shall not be liable for bank fees that the Pharmacy may incur for WIC vouchers which are rejected and

returned from the bank. The Pharmacy may not recover from the WIC Program bank charges incurred as a result of the Pharmacy's

violation of any part of the Agreement or as a result of the Pharmacy's decision to submit WIC vouchers for payment in an amount in

excess of the maximum redemption price(s) set by the Georgia WIC Program.

17

VN - 121



GA WIC PROCEDURES MANUAL

Attachment VN-18 cont'd

PHARMACY HANDBOOK

WIC PHARMACY NUMBER

Page 3 of 4

I

I

Name and TiUe of relative who represents the Georgia WIC Program or is employed by the Georgia WIC Program or is employed by the Local Agency.

Name and nue of WIC employee(s) who owns or is employed by the Georgia WIC Pharmacy.

Pharmacy Employee WIC Employee

Name

TiUe

(Please attach additional page(s) if necessary)

Telephone Number (Office/dayUme)

II. THE LOCAL AGENCY (WIC Program) HEREBY AGREES AND COVENANTS AS FOLLOWS:

A.

To instruct the Pharmacy upon enlly into the program of the appropriate procedures to process WIC vouchers.

B.

To provide the Pharmacy with the aJrrent list of formulas approved for disbursement to WIC Program parUcipants and to issue

updates to this formula list as they occur.

C.

To provide educational material about the WIC Program to the Pharmacy.

0.

To instruct WIC participants and proxies in the proper use of WIC vouchers.

E.

To ensure that an authorized parUcipant or proxy signature is affixed to any manual voucher prior to releasing the voucher for

redemption.

F.

To notify the Pharmacy with a copy of any changes in vouchers or use of vouchers and any changes in the Federal and State

Regulations that may affect the Pharmacy, and to provide the Pharmacy with a copy of any WIC regulation(s) or policy issuance(s)

affecting the Pharmacy's parUclpation in the WIC Program.

G.

To assist the Pharmacy with any problem relating the WIC Program.

H.

To provide the Pharmacy with a uniquely numbered stamp.

Ill. BOTH PARTIES AGREE AND COVENANTS AS FOLLOWS:

A.

That no conflict of interest exists between the Pharmacy and the Local Agency (See Section I., AA.).

B.

Not to discriminate for reasons of age, race, color, sex, national origin or handicap.

C.

The Pharmacy has the right to appeal any decision made by the Local Agency affecting the Pharmacy's ability to participate in the

WIC Program under the terms of this Agreemenl

D.

The period of this Agreement is set forth on the signature page. New agreements will be exeaJted each year.

E.

This Agreement shall become null and void In its entirety upon any changes of ownership of the Pharmacy.

F.

This Agreement may be canceled by either party with thirty (30) days written notice.

G.

In the event of termination of funds by the funding agency to the State Agency for the WIC Program, this Agreement terminates

immediately.

H.

That neither the Local Agency nor the Pharmacy has an obligation to renew the Pharmacy Agreement.

I.

This Agreement does not constitute a license or property Interest. The relationship between the Local Agency and the Pharmacy

ends with the expiration date of this Agreement.

J.

In Instances where blocks of vouchers are lost or stolen from a WIC clinic, the Local Agency will notify area WIC retail formula

vendors that a stop payment has been placed on these vouchers. Pharmacies will be provided the voucher numbers and Informed

not to accept these vouchers for redemption. These vouchers will not be paid.

IV. SANCTIONS AND APPEAL PROCEDURES:

A.

SANCTIONS

Pharmacies shall be disqualified from WIC Program parUcipation for a period of up to six (6) years If violations occur during a

compliance purchase, monitoring visit by a WIC representative, or Food Stamp Program parUdpalion. Procedures for imposing the

sanctions are ouUined In the WIC Pharmacy Handbook. (See Page 4 of 4 of the Pharmacy Agreement - WIC Program Sanction

System.) Any Pharmacy disqualified from WIC parUcipation may be disqualified from Food Stamp Program parUcipation. Refer to

7 CFR 276. Such disqualification may not be subject to administrative or Judicial review from the Food Stamp Program. The

Pharmacy shall be permanently disqualified from the WlC Program if convicted for WIC Program violations and/or pennanenUy

disqualified from the Food Stamp Program.

8.

APPEAL PROCEDURE

Pharmacies are entitled to a fair hearing upon disqualification from the WIC Program. Any Pharmacy requesting a fair hearing

must contact the Local Agency by telephone, and contact the State WIC Office in writing within fifteen (15) days after the action

which is being taken. WIC Pharmacies who are disqualified from the Food Stamp Program are not entitled to administrative or

judicial review when disqualified from the WIC Program (it does not eliminate administrative review for pharmacies who are

disqualified from WIC based on a Food Stamp Program Civil Money Penalty).

C.

CIVIL MONEY PENALTY

The State Agency may impose a Civil Money Penalty (CMP) in lieu of disqualification (except that the State Agency may not

impose a CMP in lieu of disqualification either as a result of a Food Stamp Program disqualification or for a third or subsequent

sanction as specified in 7 CFR 246.12(k)(l)(vi)).

V. TERMINATION POLICIES:

A.

A Pharmacy shall be terminated from WIC Program parUcipation if the store is NOT licensed by the Georgia Department of

Agriculture.

8.

A Phannacy shall be terminated from WIC Program parUcipation if the store is eligible for Food Stamp Program

participation/authorization and is disqualified from Food Stamp Program parUcipation.

18

VN - 122



GA WIC PROCEDURES MANUAL

Attachment VN-18 cont'd

PHARMACY HANDBOOK

WIC PHARMACY NUMBER

Page 4 or 4

I

I

The following Is a description of the sanction system and how It works. Civil Money Penalties (CMP) may be assessed In Categories I-VII In lieu

of disqualification. However, for mandatory sanctions, no CMP shall be allowed unless the State has determined that there would be Inadequate

participant access.

A.

Any Violation From Category I, II or Ill May Be Assessed A Civil Money Penalty (CMP) In Ueu Of Disqualificatlon.(State Agency sanctions)

Category I Warning on first and second offense, third offense-probation for six (6) months, fourth offense In category I, II, or Ill

disqualification for six (6) months

1.

Stocking a WIC food ltem(s) that is outside of manufacturer's not-to-exceed date(s).

2.

Prices not marked dear1y on WIC food Items or near WIC food items.

3.

Allowing WIC food items to exceed the quantity specified on the voucher (except for promotional items).

4.

Failure to give a receipt for WIC purchases.

5.

Failure to allow the purchase of any WIC food ltem(s).

Category II Warning on first offense, second offense-probation for eight (8) months, third offense In category I, II, or Ill-

disqualification for eight (8) months

1.

Failure to proper1y process vouchers at the store (this indudes failure to calculate (ring up) sales of WIC purchases or not

writing price on voucher before participant signs).

2.

Failure to stock the required inventory of contracted formula or failure to stock the required inventory of two or more

WIC food Items (types and/or brands). {Physical inventory must be viewed by a WIC representative at the time of visit.

Proof of order of food Items is not acceptable).

3.

Refusing to accept valid WIC vouchers from participants In exchange for WIC food Items.

4.

Allowing substitutions for food Items listed on WIC vouchers or allowing the purchase of WIC foods in unauthorized container sizes.

5.

Failure to remain open for business at least eight hours per day, six days per week.

6.

Failure to repay overcharges within a speclficied period (30 days, 60 days, 90 days).

Category Ill Warning on first offense, second offense-probation for ten (10) months, third offense In.category I, II, or Ill-

disqualification for ten (10) months

1.

Issuing rain checks/lOU's.

2.

Contacting WIC participants for any reason regarding a WIC transaction.

3.

Requiring participant to pay cash to redeem WIC vouchers.

4.

Allowing the purchase of any formula other than the one specified on the front of the voucher.

5.

Failure to allow participant(s).lproxy(ies) to purchase all WIC food items listed on the face of the voucher regardless of price.

B.

Any Violation From Category IV or V That Occurs At Any Time Will Result In Immediate DlsqHalificatlon For The Period Specified In

Category IV or V (no prior warning given). A Civil Money Penalty May Be Assessed In Lieu Of Disqualification.

Category IV -Immediate disquallficatlon for one (1) year (twelve months) for each violaUon (!&2 Mandatory sanctions, 3-7 State Agency

sanctions)

1.

A pattern of providing unauthorized food Items in exchange for WIC vouchers.

2.

A pattern of charging for supplemental foods provided In excess of those listed on the WIC voucher.

3.

Intentionally providing false Information on vendor records.

4.

Discrimination.

5.

Failure to provide vouchers or inventory records upon request.

6.

Transacting WIC vouchers outside of the WIC authorized fixed store location.

7.

Failure to allow monitoring by WIC representatives.

Category V Immediate disqualification for three (3) years (thirty-six months) for each vlolation(Mandatory sanctions)

1.

A pattern of receiving, transacting, or redeeming vouchers from authorized or unauthorized stores or other unauthorized sources.

2.

A pattern of providing credit or non-food Items In exchange for WIC vouchers.

3.

A pattern of allowing an authorized store to redeem vouchers from another authorized store.

4.

A pattern of pvercharging on WIC vouchers (charging a WIC participant more than the current shelf price or charging a WIC participant

more for food than a non-WIC customer) during a compliance Investigation.

5.

A pattern of charging for supplemental food not received by the WIC participant.

6.

One Incidence of the sale of alcohol or alcholic beverages or tobacco products In exchange for WIC voucher(s).

7.

A pattern of dalmlng reimbursments in excess of documented inventory.

C.

Any Violation From Category VI or VII That Occurs At Any Time WIii Result In Immediate Disqualification For The Period Specified In

Category VI or Vil (no prior warning given). CIVIL MONEY PENALTY MAY BE ASSESSED FOR INADEQUATE PARTICIPANT ACCESS

CASES ONLY.(Mandatory sanctions)

Category VI Disqualification for six (6) years (seventy-two months) for each violation

1.

One incidence of buying or selling of WIC vouchers for cash.

2.

One Incidence of exchanging WIC vouchers for firearms.

3.

One Incidence of exchanging WIC vouchers for ammunition.

4.

One Incidence of exchanging WIC vouchers for explosives.

5.

One Incidence of exchanging WIC vouchers for controlled substances.

Category VII Permanent disqualification for a conviction of each violation [(conviction refers to an action by a criminal court as defined

In section 102 of the Controlled Substances Act (21 U.S.C. 802).]

1.

Conviction for buying or selling of WIC vouchers for cash.

2.

Conviction for exchanging WIC vouchers for firearms.

3.

Conviction for exchanging WIC vouchers for ammunition.

4.

Conviction for exchanging WIC vouchers for explosives.

5.

Conviction for exchanging WIC vouchers for controlled substances.

Vendor violations will be categorized by the severity and nature of the offense. The nature and severity of a vlolation(s) shall determine the

sanction assessed, the duration of the probationary period and the period of disqualification. Therefore, the highest sanction assessed to a

vendor shall determine the period of probation and disqualification. Each category has a prescribed period of disqualification, probation, or

warnings assessed. Warnings remain active on the vendor case file for a twelve (12) month period. A vendor found to be In violation within lhe

probationary period shall be disqualified for not less than the full probationary period or not more than stx (Ii) years Probationary periods are

granted by the State WIC Office and are not subject to a fair hearing. A vendor will continue to operate his/her business during the probationary

period. H a 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 a permanent disqualificatlon. (Refer to Food Stamp Program Federal Regulations 7 CFR 278). Disqualification

from the WIC Program may also result In disqualification from the Food Stamp Program. As per Federal Regulation 7 CFR 246.12 (k)(1), the

Georgia WIC Program has taken Into account the severity and nature of violations in establishing the Sanction System.

19

VN - 123







Disoicl/Unit/Clinic:_ _ _ __ County:_ _ _ _ _ _ _ __ Date or Incident:_______ Date Reponed:_______ Follow-up Date:_______
emon Eilia& Complaint Name: Address

Telephone Number ( ) lncident/Complalnt:

z <

-, I
N
~

N 0

Local Agency Resolution:

Georgia Department Of Human Resources WIC Program
INCIDENT/COMPLAINT FORM

eort1,111aot 1ur2cma11sm Name:
Guardian:
WIC 1.0, Number: DOB: Telephone Number: ( )

l'.todoc loCocmaUoo
VendorNendor Number: Employee Name: Tide: Telephone Number: ( )

Type or Complaint;
Participant ( ) Vendor ( ) Local Agency/State WJC Office Starr ( )
L!!!;al A&eo,rLState l:1C l0Cocma1100 Staff Name: Telephone Number: ( )
Signature:
Can complaint be closed at Local Agency? Yes() No() Signature and Tide:

C")
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~

00

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z

:! ~

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~

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0
~

Stale WIC Office Resolulion/Comrnents:
Follow-up Report: Stale WIC Office Customer Service Coordinator:

Da~:

Can complaint be closed at Sta~ WJC Office?

Yes () No()

'

Signature and Tide:

,...
~

::r

Da~:

3

:.~.:.,.

Date:

-z< I
00

0
:,0.:.,.

0:



GA WIC PROCEDURES MANUAL

Attachmenf VN-18 cont'd

PHARMACY HANDBOOK



DHR
Georgia Department of Human Resources
Georgia WIC Program Branch
Two Peachtree Street, NW, 8th Floor Atlanta, Georgia 30303 1-800-228-9173
"The United States Department of Agriculture (USDA) prohibits discrimination in its programs and activities on the basis of race, color, national origin, sex, age, or disability. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information (Braille, larger print. audiotape, etc.) should contact USDA's TARGET Center at (202) 720-5964 (voice and TDD).
To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 14th and Independence Avenue, SW, Washington, DC 20250-9410 or call (202) 720-5964 (voice and TDD). USDA is an equal opportunity provider and employer."
Form No. 3809 (Revised 5-99)


VN - 125



GA WIC PROCEDURES MANUAL

Attachment VN-19

MINIMUM INVENTORY WAIVER CONTRACT ADDENDUM
Georgia WIC Program Minimum Inventory Request for Waiver

The minimum inventory requirement regarding Georgia WIC approved foods must be sufficient to

fill:



six (6) standard Infant Food Packages



of a lactose reduced Infant Formula Food Package



six (6) Women and/or Children Food Packages

However, if a vendor experiences difficulty selling specific WIC approved food item(s), then the vendor may write or submit this form to the Local or State WIC Agency office(s) to request a minimum inventory waiver for stocking hard to sell item(s). The State WIC Office will determine if a vendor meets the waiver criteria within thirty (30) days of receipt.
Date _ _ _ _ _ _ _ Vendor Number _ _ _ _ _ _ _ District Unit _________

Owner/Manager's Name_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PRINT
Owner/Manager's Signature _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Store Name and Number _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PRINT
Store Address _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PRINT
Telephone Number_.__ ___.__ _ _ _ _ _ _ _ _ _ _ __

RE: Request for minimum inventory waive of requirements for specific Georgia WIC approved foods (list your request below):
Please explain the reason for your request:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __



*Please be aware that submission of this request does not constitute approval. You will receive written notification regarding the outcome of your request.
VN - 126





GA WIC PROCEDURES MANUAL

TABLE OF CONTENTS

Page

I. Authorization of Foods .................................................................................................. FP-1

II. Prescribing Foods, General ............................................................................................ FP-2

A. Contract Versus Non-Contract Formula ............................................................... FP-2

B. Food Groups................................................................................ :......................... FP-4

C. Food Packages ........................................................................:.............................FP-5

D. Documentation Required ...................................................................................... FP-5

III. Infants .......................................................................................................................FP-7

A. Tailoring.............................................................................................................FP-7

B. Infants 0 Through 4 Months .............................................................................. FP-8

C. Infants 5 Through 12 Months .......................................................................... FP-12

IV. Children and Women with Special Dietary Needs ...................................................... FP-16

A. Tailoring........................................................................................................... FP-16

B. Food Package Assignment ...............................................................................FP-16

C. Standard Manual Food Package....................................................................... FP-16

D. Additional Documentation ............................................................................... FP-16

V. Children 1 to 5 Years ................................................................................................... FP-20

A. Tailoring........................................................................................................... FP-20

B. Food Package Assignment ...............................................................................FP-20

C. Standard Manual Food Package....................................................................... FP-20

D. Additional Documentation ............................................................................... FP-21

VI. Pregnant and Breastfeeding Women ............................................................................ FP-22

A. Tailoring........................................................................................................... FP-22

B. Food Package Assignment ...............................................................................FP-22

C. Standard Manual Food Package....................................................................... FP-23

D. Additional Documentation ............................................................................... FP-23



FP-1



GA WIC PROCEDURES MANUAL Page
VII. Postpartum, Non-Breastfeeding Women ..................................................................... FP-24 A. Tailoring::.................... FP-24 B. Food Package Assignment ................................:.............................................. FP-24 C. Additional Documentation ............................................................................... FP-24
VIII. Homelessness, Migrancy, and Disaster Situations ...................................................... FP-26 A. Alternate Food Package Assignment. .............................................................. FP-26 B. Method for Food Package Assignment.. .......................................................... FP-26 C. Assignment of Food Package Number ............................................................ FP-26 D. Documentation Requirements.......................................................................... FP-27 E. Alternate Food Packages.................................................................................. FP-27
Attachments: FP-1 Infant Food Packages, Maximum Monthly Amounts Authorized ....................................................... FP-31
FP-2 Infant Food Packages, Contract Formula.........................................................FP-32
FP-3 Infant Food Packages, Non-Contract Formula ................................................ FP-41
FP-4 Alternate Food Package for Infants (0-4 Months), Maximum Monthly Amounts Authorized, Contract Formula ........................ FP-45
FP-5 Alternate Food Package for Infants (0-4 Months), Contract Formula ............................................................................................. FP-46
FP-6 Alternate Food Package for Infants (5-12 Months), Maximum Monthly Amounts Authorized, Contract Formula ......................... FP-47
FP-7 Alternate Food Package for Infants (5-12 Months), Contract Formula .............................................................................................. FP-48
FP-8 Food Packages for Children and Women with Special Dietary Needs, Maximum Monthly Amounts Authorized ........................................... FP-49
FP-9 Children's and Women's Packages, Prescription Required .............................. FP-50
FP-1



GA WIC PROCEDURES MANUAL Attachments (cont'd):

Page

FP-10 Alternate Food Packages for Children and Women with Special Dietary Needs, Maximum Monthly Amounts Authorized .............................. FP-58

FP-11 Alternate Food Packages For Children and Women with Special Dietary Needs..............................................................................FP-59

FP-12 Children's Food Packages, Maximum Monthly Amounts Authorized .......................................................FP-60

FP-13 Children's Food Packages ................................................................................ FP-61

FP-14 Alternate Food Packages for Children 1 Through 5 Years, Maximum Monthly Amounts Authorized .......................................................FP-66

FP-15 Alternate Food Packages for Children 1 Through 5 Years ..............................FP-67

FP-16 Women's Food Packages, Maximum Monthly Amounts Authorized .......................................................FP-68

FP-17 Pregnant and Breastfeeding Women's Food Packages .................................... FP-69

FP-18 Alternate Food Packages for Pregnant and Breastfeeding Women, Maximum Monthly Amounts Authorized ....................................................... FP-74

FP-19 Alternate Food Packages for Pregnant and Breastfeeding Women .................FP-75

FP-20 Postpartum, Non-Breastfeeding Women's Food Packages, Maximum Monthly Amounts Authorized .......................................................FP-77

FP-21 Postpartum, Non-Breastfeeding Women's Food Packages .............................. FP-78

FP-22 Alternate Food Packages for Postpartum, Non-Breastfeeding Women, Maximum Monthly Amounts Authorized ......................................... FP-80

FP-23 Alternate Food Package for Postpartum, Non-Breastfeeding Women ............................................................................................................. FP-81

FP-24 Georgia WIC Program Formula Referral Form ............................................... FP-82

FP-1



GA WIC PROCEDURES MANUAL

Attachments (cont'd):

Page

FP-25 Georgia WIC Approved Food List, Criteria to Evaluate an Eligible Food Item ........................................................................................... FP-83

FP-26 Georgia WIC Program, WIC Approved Food List.. ........................................ FP-86

FP-27 Georgia WIC Program, WIC Approved Alternate Food List ................................................................FP-87

FP-28 WIC Approved Formulas/Medical Foods........................................................ FP-88

FP-29 Procurement of Hospital Based Formula ........................................................ FP-93

FP-30 Hospital Based Formula Order Form...............................................................FP-94

FP-31 Supplemental Formula Conversion Table ....................................................... FP-95

FP-32 Procurement of Banked Donor Human Milk ...................................................FP-96

FP-33 Donor Human Milk Order Form ......................................................................FP-97



FP-1



GA WIC PROCEDURES MANUAL
I. AUTHORIZATION OF FOODS
The State food package tailoring policy is:
A competent professional authority (CPA)* shall prescribe types ofsupplemental foods and the food package in quantities appropriate for 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, licensed dietitian, registered or licensed
practical nurse, physician, or physician's assistant.





FP-1



GA WIC PROCEDURES MANUAL

II. PRESCRIBING FOODS, GENERAL

A. Contract Versus Non-Contract Formula

The State of Georgia has entered into a contract with Ross Products Division, Abbott Laboratories (effective date: August 1, 1998 through September 30, 2001), to provide formula for WIC participants. All infants participating in the Georgia WIC Program will be provided with vouchers for a contract formula. The contract infant formulas are Similac with Iron Infant Formula (milk based), lsomil Soy Formula with Iron and Similac Lactose Free with iron (milk based-lactose free). This contract also covers children and women who require a contract formula as a source of nutrition. The contract currently provides the following rebate on each can of Similac with Iron, lsomil purchased or Similac Lactose Free purchased:

Concentrate (13 ounces): Powder (14 ounces): Ready-To-Feed (32 ounces):

$2.5809 $8.2243 $3.2684

When Ross Products' wholesale formula price increases, the amount of Georgia's rebate increases cent for cent beginning the month in which the increase goes into effect.

1. Milk Based Formula:

All participants who receive a milk based formula, will receive the contract formula Similac with Iron.

The following non-contract milk based formulas are NOT APPROVED for distribution by the Georgia WIC Program. Prescriptions will not be accepted for:

Carnation Follow-Up Carnation Good Start

Enfamil Enfamil Next Step

Whenever medical conditions/diagnoses warrant a change from the contract milk based formula to the contract formula/prescription required (Similac Lactose Free) or non-contract formula approved for use in the Georgia WIC Program, the WIC Program may provide the infant with the formula. Vouchers will specify the prescribed formula. Refer to pages FP-9 through FP-19 for information regarding the documentation required for a diagnosis and prescription.



FP-2



GAWICPROCEDURESMANUAL

2. Soy Based Formula:

All participants who receive a soy based formula, will receive the contract formula lsomil with Iron.

Whenever medical conditions/diagnoses warrant a change from the contract soy formula to the contract formula/prescription required (Similac Lactose Free) or non-contract formula approved for use in the Georgia WIC Program, the WIC Program may provide the infant with the formula. Vouchers will specify the prescribed formula. Refer to pages FP-9 through FP-19 for information regarding the documentation required for a diagnosis and prescription.

The following non-contract soy based formulas ARE APPROVED for distribution by the Georgia WIC Program with a valid written prescription with medical conditions/diagnoses:

Carnation Alsoy with Iron Prosobee with Iron

Enfamil Next Step Soy with iron Carnation Follow-Up Soy with iron

3. Lactose Free Formula:

All participants who receive a milk based, lactose free formula will receive the contract formula Simi/ac Lactose Free.

Similac Lactose Free can only be distributed by the Georgia WIC Program with a valid written medical conditions/diagnoses and prescription. Refer to pages FP-9 through FP-19 for information regarding the documentation required for a diagnosis and prescription.

The following non-contract milk based, lactose free formula is NOT APPROVED for distribution by the Georgia WIC Program. Prescriptions will not be accepted for:

Enfamil Lactofree



Whenever medical conditions/diagnoses warrant a change from the contract milkbased, lactose free formula to a non-contract formula approved for use in the Georgia WIC Program, the WIC Program may provide the infant with the formula. Vouchers will specify the physician prescribed formula. Refer to pages FP-9 through FP-19 for information regarding the documentation required for a diagnosis and prescription.
FP-3_



GA WIC PROCEDURES MANUAL

B. Food Groups
There are seven (7) 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
I

Age/Condition

Computer Food Package Series Number

Infants OThrough 3 Months (0 through 4 months in the Georgia WIC Program

111, 152, 153, 121, 163, 133, 134,180,183,243,246,248, 256,262,263,273,283,293, 299,999

II

Infants 4 Through 12

114, 155, 156, 157, 158, 166,

Months (5 through 12

131, 136, 137, 181, 186, 221,

months in the Georgia WIC 226,228,244,245,247,257,

Program)

264,265,266,286,296,297,

999

III

Children/Women with

303, 306, 307, 311, 315, 318,

Special Dietary Needs

352,353,354,356,357,359,

362,363,366,367,369,372,

373,376,377,379,381,382,

383,390,392,999

IV

Children 1 to 5 Years

600-607, 610, 999

V

Pregnant and Breastfeeding 401- 408,410,999

Women

VI

Postpartum, Non-

501-504, 510, 999

Breastfeeding Women

VII

Breastfeeding Women

408, 411, 999

whose infants receive

no infant formula from the

WICProgram



FP-4



GA WIC PROCEDURES MANUAL
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-4, FP6, FP-8, FP-10, FP-12, FP-14, FP-16, FP-18, FP-20, and FP-22.
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-5, FP-7, FP-9, FP-11, FP-13, FP-15, FP-17, FP-19, FP-21, and FP23 list numbered food packages.
No matter how many family members are participating in the WIC Program, each participant's nutritional needs must be given individual consideration.
2. Assignment of Food Package Number. The CPA assigns the computer food package number that coincides with the quantity/items desired. If there is no computer food package which meets the needs of the participant, the CPA specifies the quantities/items desired and assigns a food package 999. A food package 999 may include any allowed food combination, within the maximum allowed, 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
Only CPA staff are authorized to assign food packages.
D. Documentation Required
1. General Documentation
a. During the WIC assessment/certification, the CPA must enter the food package number in the "Food Package" space provided on the WIC Assessment/Certification Form. Specific tailoring instructions for food package 999 must be documented on the WIC Assessment/Certification FP-5



GA WIC PROCEDURES MANUAL
Form, or in the progress notes of the participant's health record.
b. Between WIC assessments/certifications, the CPA must document food package changes on the WIC Assessment/Certification Form. The date of the food package change, and the signature and title of the CPA must be included in the documentation. The use of a signature stamp is not acceptable.
2. Additional Documentation. Additional documentation is required for:
a. Contract formula/prescription required (Similac Lactose Free)
b. Non-contract formulas (e.g., as indicated for chronic diseases or medical conditions)
c. Ready-to-feed formulas
d. Lactose intolerant women and children who require more than two (2) pounds ofcheese per month
e. Low iron formulas (e.g., as indicated for conditions such as hemochromatosis)
f. Hospital based formulas
g. Donor human milk
h. Disaster situations



FP-6



GA WIC PROCEDURES MANUAL
III. INFANTS
Food Group I is for infants Othrough 4 months of age and consists only of iron-fortified formula. Food Group II is for infants 5 through 12 months of age and consists of iron fortified formula, iron-fortified cereal, and juice. In the Georgia WIC Program, iron-fortified cereal and juice may not be assigned to an infant until at least 5 months of age.
Cow's and goat's milk are not authorized for infants in the first 12 months of life.
A. Tailoring
1. Breastfed Infants. The best food for the normal infant is breastmilk. Until the maternal milk supply is well established at 4-6 weeks of lactation, no formula should be offered. Infant formula should not be provided, through food package assignment or free samples, to breastfeeding participants who do not want or need it. Breastfeeding is defined as feeding a mother's breastmilk to her infant(s) at least once a day.
If a mother chooses to both breastfeed and formula feed her infant, powdered formula is recommended. However, liquid concentrated formula is available. The maximum amount of formula may be assigned to breastfed infants by the CPA. The need for the maximum allowance must be thoroughly documented in the infant's health record.
2. Formula Fed Infants. When the participant is not breastfeeding, iron-fortified formula is the recommended formula for healthy infants. The definition of iron-fortified formula is:
A complete formula not requiring the addition ofany ingredients other than water prior to being served in a liquid state, and which contains at least ten (1 OJ milligrams of iron per liter of formula at standard dilution which supplies sixty-seven (67) kilocalories per one-hundred (100) milliliters, i.e., approximately twenty (20) kilocalories per fluid ounce of formula 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 Nutrition Service, United States Department of Agriculture. The Office of Nutrition may then approve distribution of the product through the Georgia WIC Program. For a list of Georgia WIC Program approved infant formulas see Attachment FP-28.
WIC approved non-contract formulas and medical foods designed for enteral feeding may be authorized when a physician determines that the infant has a
FP-7



GA WIC PROCEDURES MANUAL
medical condition/diagnosis which contraindicates the use of the contract infant formulas. These conditions/diagnoses 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 the ICD-9-CM publication, International Classification ofDiseases, 10th Revision; Clinical 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 by the WIC Program.
For guidance in assessing infant formula tolerance consult the Department of Human Resources Protocol For Infant Formula Intolerance and the Office of Nutrition, Nutrition Guidelines 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 of body weight. A general recommendation is to provide 2.5 ounces of iron-fortified formula per pound of body weight, or 5.5 ounces per kilogram of body weight, when formula is the only source of nutrition.
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 FP1, FP-4, and FP-6. The adjusted age is to be used with premature infants.
3. Cereal. Cereal is not authorized for the infant Othrough 4 months of age. The Office of Nutrition, Nutrition Guidelines for Practice recommend that cereal be introduced when the infant is 5-6 months of age and developmentally ready. A maximum of twenty-four (24) ounces of cereal per month is authorized.
4. Juice. Juice is not authorized for the infant Othrough 4 months of age. The Office ofNutrition, 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 OThrough 4 Months
Food Group I consists only of formula. No cereal or juice is authorized for this food group.
1. Food Package Assignment. The food packages for infants Othrough 4 months of age are listed on Attachments FP-2, FP-3, and FP-5. The use of the contract
FP-8



GA WIC PROCEDURES MANUAL
formula is required unless a contract formula/prescription required or noncontract formula or medical food is prescribed by an appropriate provider for a documented medical condition/diagnosis. The food package numbers are:
a. No formula: 299
b. Contract formula: 152, 153, 163,256,262,263, 180 and 999
c. Contract formula/prescription required (Similac Lactose Free): 243, 246, 248, 273, 293, and 999
d. Non-contract formula: 111, 121, 133, 134, 183,283, and 999
2. Standard Manual Food Package. The CPA will assign a food package to the participant upon certification and enter the food package number on the WIC Assessment/Certification Form. The standard manual food package for infants (food package 153) will be issued for all infants until the computer vouchers for the assigned food package are generated. The CPA may require the assigned food package be given to the participant. The CPA must state this in on 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 formula to a contract formula/prescription required, non-contract formula, hospital based formula, ready to feed formula, low iron formula, or donor human milk.
a. Contract formula/prescription required or Non-contract formula
(1) All changes from the contract formula to a contract formula/ prescription required or non-contract formula must be written on a prescription pad, private medical office letterhead, district/county letterhead or the Georgia WIC Formula Referral Form, stating the name of the alternative formula and the medical condition/diagnosis. Orders must have an original signature of the physician or licensed/certified health professional working under standing orders. Prescription pads with preprinted or prestamped contract formula/prescription required or 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
FP-9



GA WIC PROCEDURES MANUAL
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 nutrition assessment, and with any change in the order.
(4) Certified nurse practitioners/midwives/specialists working under the Public Health Nurse Protocols, may order a contract formula/prescription required or non-contract formula (excluding low iron formula, hospital based formula, and donor human milk). The nurse's order must be documented in the participant's health record. When a written order is not present, confirmation of a verbal order must be documented in the participant's health record.
(5) A Registered or Licensed Dietitian or other qualified WIC Competent Professional Authority (CPA) following the Department of Human Resources Protocol on Infant Formula Intolerance may:
(a) Recommend to a physician or certified nurse practitioner/midwife/specialist a suitable alternative formula, or
(b) Refer a participant to a physician or certified nurse practitioner/midwife/specialist for evaluation.
b. Ready-to-feed formula
The CPA must document in the participant's health record that there is an unsanitary or restricted water supply, poor refrigeration, or that the person who is caring for the infant has difficulty in diluting concentrated or powdered formula.
c. Low iron formula
(1) Low iron or no iron formula may be indicated for infants with hemochromatosis, hemosiderosis, neonatal iron storage disease, polycythemia, thalassemia major, hyperferremia, sickle cell anemia, liver disease, pancreatic insufficiency,
FP-10



GA WIC PROCEDURES MANUAL
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.
d. Hospital based formula
Hospital based infant formulas may be ordered, by a physician (only), to meet the nutrition needs of preterm infants and children with special health care needs. Generally these products are designed for use in a hospital setting and are not available for retail sale. County health departments may acquire these products through a system established by the Office of Nutrition or in rare instances through a local pharmacy that is a WIC Vendor. See Attachment FP-29 for procedures and Attac.hment FP-30 for the order form to use when acquiring a product through the Office of Nutrition. The following requirements must be met before a hospital based formula can be ordered or issued:
(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, 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.
e. Donor Human Milk
Banked donor human milk may be ordered by a physician (only) to meet the nutrition needs of preterm infants and children with special health care needs, in cases where there are no infant formulas that can foster the growth and development of these infants or children.
Banked donor human milk is not available for purchase through the use ofWIC vouchers. County health departments may acquire these products through a system established by the Office of
FP-11



GA WIC PROCEDURES MANUAL
Nutrition. When acquiring the donor human milk, follow the procedures outlined on Attachment FP-32, Procurement ofHuman Donor Milk, and the Human Donor Milk Order Form on Attachment FP-33. The following requirements must be met before banked donor human milk can be ordered:
(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, district/county letterhead, or Georgia WIC Formula Referral Form statingthe diagnosis (physical condition), that infant formulas cannot support growth and development of the infant or child, and the expiration date of the order.
C. Infants 5 Through 12 Months
Food Group II consists of formula, iron-fortified cereal, and juice.
I. Food Package Assignment. The food packages for infants 5 through 12 months of age are listed on Attachments FP-2, FP-3, and FP-7. The use of the contract formula is required unless a contract formula/prescription required or noncontract formula or medical food by an appropriate provider. The food package numbers are:
a. No formula: 221 and 299
b. Contract formula: 155, 156, 157, 158, 166,257,264,265, 181 and 999
c. Contract formula/prescription required (Similac Lactose Free): 228,244,245,247,266,296,297,and999
d. Non-contract formula: 114, 131, 136, 137, 186, 286, 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 156. 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 on the WIC
FP-12



GA WIC PROCEDURES MANUAL

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/diagnoses warrant a

change from the contract formula to a contract formula/prescription required,

non-contract formula, hospital based formula, ready to feed formula, low iron

formula, or donor human milk.



a. Contract formula/prescription required or Non-contract formula

( 1) All changes from the contract formula to a contract formula/prescription required or non-contract formula must be written on a prescription pad, private medical office letterhead, district/county letterhead, or the Georgia WIC Formula Referral Form, stating the name of the alternative formula and the medical condition/diagnosis. Orders must have an original signature of the physician or licensed/certified health professional working under standing orders. Prescription pads with preprinted or prestamped contract formula/prescription required or 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). Wh_en 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 nutrition assessment, and with any change in the order.

(4) Certified nurse practitioners/midwives/specialists working under the Public Health Nurse Protocols, may order a contract formula/prescription required or non-contract formula (excluding low iron formula, hospital based formula, and donor human milk). 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.

FP-13



GA WIC PROCEDURES MANUAL
(5) A Registered or Licensed Dietitian or other qualified WIC Competent Professional Authority (CPA) following the Department of Human Resources Protocol on Infant Formula Intolerance may:
(a) Recommend to a physician or certified nurse practitioner/ midwife/specialist a suitable alternative formula, or
(b) Refer a participant to a physician or certified nurse practitioner/ midwife/specialist for evaluation.
b. Ready-to-feed formula
The CPA must document in the participant's health record that there is an unsanitary or restricted water supply, poor refrigeration, or that the person who is caring for the infant has difficulty in diluting concentrated or powdered formula.
c. Low iron formula
( 1) Low iron or no iron formula may be indicated for infants with hemochromatosis, hemosiderosis, 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 breast fed infants.
d. Hospital based formula
Hospital based infant forinulas may be ordered, by a physician (only), to meet the nutrition needs of preterm infants and children with special health care needs. Generally these products are designed for use in a hospital setting and are not available for retail sale. County health departments may acquire these products through a system established by the Office of Nutrition or in rare instances through a local pharmacy that is a WIC Vendor. See Attachment FP-29 for procedures and Attachment FP-30 for the order form to use when acquiring a product through the Office of
FP-14



GA WIC PROCEDURES MANUAL
Nutrition. The following requirements must be met before a hospital based formula can be ordered or issued:
(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, 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.
e. Donor Human Milk
Banked donor human milk may be ordered by a physician (only) to meet the nutrition needs of preterm infants and children with special health care needs, in cases where there are no infant formulas that can foster the growth and 'development of these infants or children.
Banked donor human milk is not available for purchase through the use ofWIC vouchers. County health departments may acquire these products through a system established by the Office of Nutrition. When acquiring the donor human milk, follow the procedures outlined on Attachment FP-32, Procurement ofHuman Donor Milk, and the Human Donor Milk Order Form on Attachment FP-33. The following requirements must be met before banked donor human milk can be ordered:
(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, district/county letterhead, or Georgia WIC Formula Referral Form stating the diagnosis (physical condition), that infant formulas cannot support growth and development of the infant or child, and the expiration date of the order.
FP-15



GA WIC PROCEDURES MANUAL

IV.

CHILDREN AND 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.

1. Formula. WIC-approved formulas designed for enteral feeding and prescribed by a physician may be authorized. Formulas designed for parenteral infusion are not authorized for distribution by the WIC Program. Formula may not be authorized solely for the purpose of enhancing nutrient intake or managing body weight of children and women participants. The WIC Program does not prohibit the use of authorized formulas for tube fed individuals. For a list of Georgia WIC Program approved formulas see Attachment FP-28.

2. Cereal. A maximum of thirty-six (36) ounces of cereal per month is authorized.

3. Juice. A maximum of one hundred thirty-eight (138) ounces of single strength juice per month is authorized.

B. Food Package Assignment

The food packages for children and women with special dietary needs are listed on Attachments FP-9 and FP-11. The food package numbers are 303, 306,307,311,315,318,352,353,354,356,357,359,362,363,366,367,369, 372, 373, 376, 377, 379, 381, 382, 383,390, 392, and 999. Formula types, sizes, and amounts as well as, amounts for cereal and juice are included in Attachments FP-8 and FP-10.

C. Standard Manual Food Package

There is no standard manual food package for Food Group III.

D. Additional Documentation

Additional documentation is required in the participant's health record whenever medical conditions/diagnosis warrant a change from the contract formula to a contract formula/prescription required, non-contract formula, ready-to-feed formula, low iron formula, hospital based formula, or donor human milk.
FP-16



GA WIC PROCEDURES MANUAL
1. Contract formula/prescription required or Non-contract formula
(a) All changes from the contract formula to a contract formula/prescription required or non-contract formula must be written on either a prescription pad or private physician office letterhead, district/county letterhead, or the Georgia WIC Formula Referral Form stating the name of the alternative formula and the medical condition/diagnosis. A prescription expiration date is also recommended. Orders must have an original signature of the physician or a licensed/certified health professional working under an MD's orders. Prescription pads with preprinted or prestamped contract formula/prescription required or 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/Midwives/Specialists working under Public Health Nurse Protocol, may order a contract formula/prescription reguired or non-contract formula (excluding low iron formulas, hospital based formulas, and donor human milk). 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. A Registered or Licensed Dietitian or other qualified WIC Competent Professional Authority (CPA) following the Department of Human Resources Protocol on Infant Feeding Problems may:
a. Recommend to a physician or certified nurse practitioner/midwife/ specialist a suitable alternative formula, or
b. Refer a participant to a physician or certified nurse practitioner/ midwife/specialist for evaluation.

FP-17



GA WIC PROCEDURES MANUAL
4. Ready-to-feed Formula. The CPA must document in the participant's health record that there is an unsanitary or restricted water supply, poor refrigeration, or that the person who is caring for the infant has difficulty in diluting concentrated or powdered formula.
5. Low Iron Formula
(a) Low iron or no iron formula may be indicated for clients with hemochromatosis, hemosiderosis, 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.
6. Hospital Based Formula
Hospital based infant formulas may be ordered, by a physician (only), to meet the nutrition needs of preterm infants and children with special health care needs. Generally these products are designed for use in a hospital setting and are not available for retail sale. County health departments may acquire these products through a system established by the Office ofNutrition or in rare instances through a local pharmacy that is a WIC Vendor. See Attachment FP-29 for procedures and Attachment FP-30 for the order form to use when acquiring a product through the Office of Nutrition. The following requirements must be met before a hospital based formula can be ordered or issued:
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, 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.



FP-18



GA WIC PROCEDURES MANUAL
7. Donor Human Milk
Banked donor human milk may be ordered by a physician (only) to meet the nutrition needs of preterm infants and children with special health care needs, in cases where there are no infant formulas that can foster the growth and development of these infants or children.
Banked donor human milk is not available for purchase through the use of WIC vouchers. County health departments may acquire these products through a system established by the Office of Nutrition. When acquiring the donor human milk, follow the procedures outlined on Attachment FP-32, Procurement of Human Donor Milk, and the Human Donor Milk Order Form on Attachment FP-33. The following requirements must be met before banked donor human milk can be ordered:
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 Georgia WIC Formula Referral Form stating the diagnosis (physical condition), that infant formulas cannot support growth and development of the infant or child, and the expiration date of the order.
8. 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-8 and FP-10 for maximum formula amounts .



FP-19



GAWICPROCEDURESMANUAL

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 increase requirements. To meet the nutrient needs of 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-13 and FP-15. The food package numbers are 600-607, 610 and 999. Refer to Attachments FP-12 and FP-14 for the maximum amounts of each food item allowed per month.
C. Standard Manual Food Package
The CPA will assign a food package upon certification and the computer food package number which matches the assigned food package will be given to the participant. The standard manual food package for children is 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
FP-20



GA WIC PROCEDURES MANUAL
the assigned food package be given to the participant at the time of certification. The CPA must state this on the WIC Assessment/Certification Form. The actual assigned food package must then be issued instead of the standard manual.
D. Additional Documentation
Additional documentation is required in the following situations:
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 that requires a therapeutic diet, and a special food package. Examples of additional acceptable medical conditions/diagnoses can be found in the 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 moderate food packages (i.e, 603/604) and/or to modify the type of food (i.e., lowfat milk) given to the participant.



FP-21



GA WIC PROCEDURES MANUAL

VI.

PREGNANT AND BREASTFEEDING WOMEN

Food Group V consists of milk, cheese, cereal, juice, eggs, 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. This food group is limited to use with breastfeeding women who receive no infant formula/medical food from the WIC Program.

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. Therefore, if the CPA assigns a food package that provides less than the standard (404) food package, reasons for doing so must be thoroughly documented in the participant's health record.

3. Modified Food Packages. A tailored food package may be created by the CPA to include modified foods, i.e. lower fat cheese, lowfat milk, etc.



B. Food Package Assignment
The food packages for prenatal and breastfeeding women are listed on Attachments FP-17 and FP-19. The food package numbers are 401- 408, 410, 411, and 999. Food package 408 may be assigned to all women who are exclusively breastfeeding infants (defined as those women who do not receive any infant formula from the WIC Program). If at any time the mother requests formula supplementation, the CPA should change the food package of the mother and infant to reflect the change in their status. Refer to Attachments FP-16 and FP-18 for the authorized foods and the maximum amounts allowed per month.
FP-22



GA WIC PROCEDURES MANUAL
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 prenat~l 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
Additional documentation is required in the following situations:
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 and a special food package. Examples of additional acceptable medical conditions/diagnoses can be found in the 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 moderate food package (i.e., 404) and/or to modify the type of food (i.e., lowfat milk) given to the participant.



FP-23



GA WIC PROCEDURES MANUAL

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. However, if a food package is assigned which contains less than the moderate (502) food package, reasons for this must be thoroughly documented in the participant's health record.

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-21 and FP-23. 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 FP-

20 and FP-22 for the foods and maximum amounts allowed.



C. Additional Documentation

Additional documentation is required in the following situations:

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 that requires a therapeutic diet and a special food package. Examples of additional acceptable medical conditions/diagnoses can be found in the ICD-9-CM publication, International Classification of Diseases, 9th Revision; Clinical
FP-24



GA WIC PROCEDURES MANUAL
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 moderate food package (i.e., 502) and/or to modify the type of food (i.e., lowfat cheese) given to a participant.





FP-25



GAWICPROCEDURESMANUAL

VIII.

HOMELESSNESS, MIGRANCY, AND DISASTER SITUATIONS

A. Alternate Food Package Assignment

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's primary residence lacks refrigeration and/or contains a contaminated or limited water supply.

B. Method for Food Package Assignment

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.

Only CPA staff are authorized to assign food packages.

C. Assignment of Food Package Number

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 of the participant, the CPA specifies the quantities/items desired and assigns a food package 999. A food package 999 should not exceed the
FP-26



GA WIC PROCEDURES MANUAL
maximum monthly amount per item or include unapproved combinations of WIC foods. Ifretail purchase is not an option, direct distribution measures will be considered. The local agency, State WIC Office and the Office of Nutrition should be consulted 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. If a food package 999 is assigned, document specific tailoring instructions on the WIC Assessment/Certification form or in the progress notes of the participant's health record.
b. Between WIC Assessments/Certifications, the CPA must document food package changes on the WIC Assessment/Certification form. The CPA must date and sign (include title) any changes. The use of a signature stamp is not acceptable .
2. Additional Documentation. Additional documentation is required in the participant's health record for the following:
a. Contract formula/prescription required (Similac Lactose Free)
b. Non-contract formula
c. Low iron formula
d. Hospital based formulas
e. Donor human milk
f. Disaster situations
E. Alternate Food Packages
1. Infants OThrough 4 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-5. FP-27



GA WIC PROCEDURES MANUAL

Breastrnilk 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 with infant formula, powdered fonnula is recommended. However ready-to-feed is available. The use of the contract fonnula is required unless a contract formula/prescription required or noncontract formula or medical food is prescribed by an appropriate provider. The food package numbers are:

(1) No formula:

299

(2) Contract formula:

180

(3) Contract formula/prescription required

or Non-contract formula:

999



b. Additional documentation is required in the participant's health record whenever medical conditions/diagnosis warrant a change from a contract formula to a contract formula/prescription required, non-contract formula, a hospital based formula, a low iron formula, or donor human milk. See FP-9 through FP-12 for specific documentation requirements.

2. Infants 5 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 Jmce. The food packages for these infants are listed on Attachment FP-7. Breastmilk is the best food for most infants. 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 also available. The use of the contract fonnula is required unless a contract formula/prescription required or noncontract formula or medical food is prescribed by an appropriate provider. The food package numbers are:

(1) No formula:

299

(2) Contract standard formula:

181

(3) Contract formula/prescription required

or Non-contract formula:

999

FP-28



GA WIC PROCEDURES MANUAL

b. Additional documentation is required in the participant's health

record whenever medical conditions/diagnosis warrant a change

from a contract formula to a contract formula/prescription

required, non-contract formula, a hospital based formula, a low

iron formula, or donor human milk. See FP-13 through FP-15 for

specific documentation requirements.



3. Children and Women with Special Dietary Needs

a. Food packages for this group consist of formulas/medical foods, iron fortified cereal, and 100% vitamin C fortified juice. The food packages for these participants are listed on Attachment FP-11. 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 390 and 999.

b. Additional documentation is required in the participant's health record. See FP-16 through FP-19 for specific documentation requirements.

4. Children 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-15. General nutrient requirements for children vary with age, nutrition 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 that requires a therapeutic diet. See FP-21 for specific documentation requirements.

5. Pregnant and Breastfeeding Women

a. Food packages for this group consist of ultra high temperature (UHT) milk, iron fortified cereal, I 00%, vitamin C fortified juice, and peanut butter. Food package 410 may be assigned to pregnant and breastfeeding women. Exclusively breastfeeding women
FP-29



GA WIC PROCEDURES MANUAL
(defined as women receiving no infant formula from the WIC Program) receive additional items such as canned tuna, canned beans/peas, and canned carrots. The food packages for these participants are listed on Attachment FP-19. Food package 411 may be assigned to all women who are 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 of the mother and infant to reflect the change in their status. The food package numbers are 410, 411 and 999.
b. Additional documentation is required with the 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 that requires a therapeutic diet. See FP-23 for specific documentation requirements.
6. Postpartum, Non-Breastfeeding Women
a. Food packages for this group consist 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-23. 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 the 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 that requires a therapeutic diet. See FP-24 through FP-25 for specific documentation requirements.



FP-30



GA WIC PROCEDURES MANUAL

Attachment FP-1

INFANT FOOD PACKAGES MAXIMUM MONTHLY AMOUNTS AUTHORIZED

A. FORMULA TYPES, SIZES,. AND MAXIMUM AMOUNTS (Contract and Non-Contract)

TYPE1

SIZE2

MAXIMUM AMOUNTS3

Concentrate

13 ounces

31 cans, 403 ounces concentrate or 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

9 cans

12 ounces

10 cans

1 For each type listed, the most economical size is recommended. 2 Sizes listed are not inclusive. 3 Maximum amounts are listed for each type. 4 Powdered size listed by can weight. Reconstituted amounts vary. Refer to product label for
specific reconstitution instruction.



B. CEREAL AND JUICE MAXIMUM MONTHLY AMOUNTS (For Infants 4 Through 12 Months)

FOOD

SIZE

MAXIMUM AMOUNTS

Infant Cereal

8 ounces

24 ounces

Single Strength Juice OR Frozen Concentrated Juice OR Pourable Concentrated Juice

46 fluid ounces OR
12 fluid ounces OR
11.5 fluid ounces

92 fluid ounces OR
96 fluid ounces, reconstituted OR
92 fluid ounces, reconstituted

FP-31



GA WIC PROCEDURES MANUAL
INFANT FOOD PACKAGES CONTRACT FORMULA

Attachmemt FP-2

FOOD PACKAGE NUMBER
152 25 CANS 3202 READY TO FEED IRON FORTIFIED SIMILAC OR ISOMIL
153* 31 CANS 13 OZ CONCENTRATE IRON FORTIFIED SIMILAC ORISOMIL
* STANDARD MANUAL
155 25 CANS 32 OZ READY TO FEED IRON FORTIFIED SIMILAC OR ISOMIL 2 CANS JUICE 24 OZ INFANT CEREAL

VOUCHER CODE

VOUCHER MESSAGE

002

FORMULA: '' 12 - 32 OZ CANS READY TO FEED

: SIMILAC OR ISOMIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

'

003

FORMULA: : 13 - 32 OZ CANS READY TO FEED

: SIMILAC OR ISOMIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

'

004

FORMULA: : 15 - 13 OZ CANS CONCENTRATE

: SIMILAC OR ISOMIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

005

FORMULA: : 16- 13 OZ CANS CONCENTRATE

: SIMILAC OR ISOMIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

007

FORMULA:

:'' 13 - 32 OZ CANS READY TO FEED

: SIMILAC OR ISOMIL

JUICE:

: I - 12 OZ CAN FROZEN OR 1 -46 OZ CAN

: OR 1-11 ..5 OZ CAN POURABLE

CEREAL:

: UP TO 24 OZ INFANT

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

'

Oil

FORMULA: : 12 - 32 OZ CANS READY TO FEED

: SIMILAC OR ISOMIL

JUICE:

: I - 12 OZ CAN FROZEN OR I - 46 OZ CAN

: OR 1-11.5 OZ CAN POURABLE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED



FP-32



GA WIC PROCEDURES MANUAL

Attachment FP-2 cont'd

FOOD PACKAGE NUMBER
156 31 CANS 13 OZ CONCENTRATE IRON FORTIFIED SIMILAC OR ISOMIL 2 CANS JUICE 24 OZ INFANT CEREAL

VOUCHER CODE
I
008

FORMULA:

JUICE:

CEREAL:

VOUCHER MESSAGE
16 - 13 OZ CANS CONCENTRATE SIMILAC OR ISOMIL 1 -12 OZ CAN FROZEN OR I -46 OZ CAN OR 1-11.5 OZ CAN POURABLE UP TO 24 OZ INFANT

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

012

FORMULA:

15 - 13 OZ CANS CONCENTRATE

SIMILAC OR ISOMIL

JUICE:

I - 12 OZ CAN FROZEN OR I - 46 OZ CAN

, OR 1-11.5 OZ CAN POURABLE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

157 31 CANS 13 OZ CONCENTRATE IRON FORTIFIED SIMILAC ORISOMIL 2CANSJUICE

009

FORMULA: : 16- 13 OZ CANS CONCENTRATE

: SIMILAC OR ISOMIL

JUICE:

: I - 12 OZ CAN FROZEN OR I -46 OZ CAN

: OR 1-11.5 OZ CAN POURABLE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

012

FORMULA:

I5 - 13 OZ CANS CONCENTRATE

SIMILAC OR ISOMIL

JUICE:

I - 12 OZ CAN FROZEN OR I - 46 OZ CAN

OR 1-1 1.5 OZ CAN POURABLE

158 31 CANS 13 OZ CONCENTRATE IRON FORTIFIED SIMILAC OR ISOMIL 2 CANS JUICE 16 OZ INFANT CEREAL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

012

FORMULA:

' :

I5 - I3 OZ CANS CONCENTRATE

JUICE:

: SIMILAC OR ISOMIL

: I -12 OZ CAN FROZEN OR 1 -46 OZ CAN

:' OR 1-11.5 OZ CAN POURABLE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

087

FORMULA: : 16 - 13 OZ CANS CONCENTRATE

JUICE:

: SIMILAC OR ISOMIL

: I - 12 OZ CAN FROZEN OR I -46 OZ CAN

: OR 1-11.5 OZ CAN POURABLE

CEREAL:

: UP TO 16 OZ INFANT ' '

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FP-33



GA WIC PROCEDURES MANUAL

Attachment FP-2 cont'd

FOOD PACKAGE NUMBER

VOUCHER CODE

VOUCHER MESSAGE

163

088

FORMULA:

5- 14.1 OZ CANS POWDER SIMILIC OR

9 CANS 14.1 OZ POWDER

5 - 14 OZ CANS POWDER ISOMIL

IRON FORTIFIED SIMILAC

OR 9 CANS 14 OZ POWDER

IRON FORTIFIED

ISOMIL

NO LOW IRON FORMULA ALLOWED

'

488

FORMULA:

: 4 - 14.1 OZ CANS POWDER SIMILAC OR

: 4 - 14 OZ CANS POWDER ISOMIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

166 9 CANS 14.81 OZ POWDER IRON FORTIFIED SIMILAC OR 9 CANS 14 OZ POWDER ISOMIL 2 CANS JUICE 24 OZ INFANT CEREAL

088 488

FORMULA:

: 5-14.1 OZ CANS POWDER SIMILAC OR : 5 - 14 OZ CANS POWDER ISOMIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA:

:' 4 - 14.1 OZ CANS POWDER SIMILAC OR : 4- 14 OZ CANS POWDER ISOMIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

073

JUICE:

CEREAL:

2 - 12 OZ CANS FROZEN OR 2 - 46 OZ CANS OR 2-11.5 OZ CANS POURABLE UP TO 24 OZ INFANT

256 13 CANS 13 OZ CONCENTRATE IRON FORTIFIED SIMILAC ORISOMIL

089

FORMULA:

13 - 13 OZ CANS CONCENTRATE

SIMILAC OR ISOMIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

257 13CANS 13OZ CONCENTRATED IRON FORTIFIED SIMILAC ORISOMIL 2 CANS JUICE 24 OZ INFANT CEREAL

089

FORMULA:

:'' 13 - 13 OZ CANS CONCENTRATE

: SIMILAC OR ISOMIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

073

JUICE:

CEREAL:

2- 12 OZ CANS FROZEN OR 2-46 OZ CANS OR 2-11.5 OZ CANS POURABLE UP TO 24 OZ INFANT



FP-34



GA WIC PROCEDURES MANUAL

Attachment FP-2 cont'd

FOOD PACKAGE NUMBER
221 2CANS JUICE 24 OZ INFANT CEREAL

VOUCHER CODE

073

JUICE:

CEREAL:

VOUCHER MESSAGE
2 - 12 OZ CANS FROZEN OR 2 - 46 OZ CANS OR 2-11.5 OZ CANS POURABLE UP TO 24 OZ INFANT

262 I CAN 14. I OZ POWDER IRON FORTIFIED SIMILAC OR I CAN 14 OZ POWDER ISOMIL
263 4 CANS 14.1 OZ POWDER IRON FORTIFIED SIMILAC OR 4 CANS 14 OZ POWDER ISOMIL
264 I CAN 14.1 OZ POWDER IRON FORTIFIED SIMILAC OR I CAN 14 OZ POWDER ISOMIL 2 CANS JUICE 24 OZ INFANT CEREAL
265 4 CANS 14.1 OZ POWDER IRON FORTIFIED SIMILAC OR 4 CANS 14 OZ POWDER ISOMIL 2 CANS JUICE 24 OZ INFANT CEREAL
299 BREASTFEEDING
MESSAGE

014

FORMULA:

I - 14.1 OZ CAN POWDER SIMILAC OR I - 14 OZ CANS POWDER ISOMIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

015

FORMULA:

: 4 - 14.1 OZ CAN POWDERSIMILAC OR

: 4- 14 OZ CANS POWDER ISOMIL

'

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

016

FORMULA:

:' I - 14.1 OZ CAN POWDER SIMILAC OR

: I - 14 OZ CANS POWDER ISOMIL

JUICE:

: 2-12 OZ CANS FROZEN OR 2-46 OZ

: CANS OR 2-11.5 OZ CANS POURABLE

CEREAL:

: UP TO 24 OZ INFANT

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

017

FORMULA:

: 4 - 14.1 OZ CAN POWDER SIMILAC OR

: 4-14 OZ CANS POWDER ISOMIL

JUICE:

: 2- 12 OZ CANS FROZEN OR 2 - 46 OZ

: CANS OR 2-11.5 OZ CANS POURABLE

CEREAL:

: UPTO24OZINFANT

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

059

NURSE YOUR BABY OFTEN

THE MORE YOU BREASTFEED, THE MORE MILK YOU

WILL HAVE FOR YOUR BABY



FP-35



GA WIC PROCEDURES MANUAL

Attachment FP-2 cont'd

FOOD PACKAGE NUMBER
999
FORMULA AS ORDERED BY A PHYSICIAN FORMULA EQUALS 8 LBS OR 403 OZ CONC. OR 800 OZ RTF JUICE: 2-46 OZ OR 2-12 OZ FROZEN CANS OR 2-11.5 OZ CANS POURABLE CEREAL: 24 OZ FORMULA ONLY MAY BE PRESCRIBED

VOUCHER CODE

VOUCHER MESSAGE

999

AS PRESCRIBED

A TAILORED PACKAGE DESIGNED BY THE CPA WHICH MUST NOT EXCEED THE MAXIMUM QUANTITY OF SUPPLEMENTAL FOODS FOR THE PARTICIPANT'S CATEGORY





FP-36



GA WIC PROCEDURES MANUAL
INFANT FOOD PACKAGES CONTRACT FORMULA Prescription Required

Attachment FP-2 cont'd

FOOD PACKAGE NUMBER 293
31 CANS 1302 CONCENTRATE IRON FORTIFIED SIMILAC LACTOSE FREE
296 31 CANS 1302 CONCENTRATE IRON FORTIFIED SIMILAC LACTOSE FREE 2CANSJUICE 24 OZ INFANT CEREAL
297 31 CANS 1302 CONCENTRATE IRON FORTIFIED SIMILAC LACTOSE FREE 2 CANS JUICE

VOUCHER CODE 364 365 368
372
369
372

VOUCHER MESSAGE

FORMULA: ''' 15~ 13 OZ CANS CONCENTRATE : SIMILAC LACTOE FREE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED
FORMULA: : 16-13 OZ CANS CONCENTRATE : SIMILAC LACTOSE FREE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA- : 16-13 OZ CANS CONCENTRATE

: SIMILAC LACTOSE FREE

JUICE:

: 1-12 OZ CAN FROZEN OR 1-46 OZ CAN : OR 1-11.5 OZ CAN POURABLE

: UP TO 24 OZ INFANT CEREAL: '
'

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA- : 15-13 OZ CANS CONCENTRATE

: SIMILAC LACTOSE FREE

JUICE:

: 1-12 OZ CAN FROZEN OR 1-46 OZ CAN : OR 1-11.5 OZ CAN POURABLE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA : 16-13 OZ CANS CONCENTRATE

: SIMILAC LACTOSE FREE

: 1-12 OZ CAN FROZEN OR 1-46 OZ CAN

JUICE:

:' OR 1-11.5 OZ CAN POURABLE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA- : 15-13 OZ CANS CONCENTRATE

: SIMILAC LACTOSE FREE

JUICE:

: 1-12 OZ CAN FROZEN OR 1-46 OZ CAN : OR 1-11.5 OZ CAN POURABLE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED



FP-37



GA WIC PROCEDURES MANUAL

Attachment FP-2 cont'd

FOOD PACKAGE NUMBER
228 31 CANS 13 OZ CONCENTRATE IRON FORTIFIED SIMILAC LACTOSE FREE 2 CANS JUICE 16 OZ INFANT CEREAL
243 3 CANS 14 OZ POWDER IRON FORTIFIED SIMILAC LACTOSE FREE
244 1 CAN 14 OZ POWDER IRON FORTIFIED SIMILAC LACTOSE FREE 2 CANS JUICE 24 OZ INFANT CEREAL
245 3 CANS 14 OZ POWDER IRON FORTIFIED SIMILAC LACTOSE FREE 2 CANS JUICE 24 OZ INFANT CEREAL
246 13 CANS 13 OZ CONCENTRATE IRON FORTIFIED SIMILAC LACTOSE FREE

VOUCHER CODE 390
372
385 376
377
392

VOUCHER MESSAGE

FORMULA: JUICE: CEREAL:

16-13 OZ CANS CONCENTRATE SIMILAC LACTOSE FREE 1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-11.5 OZ CAN POURABLE UP TO 16 OZ INFANT

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA: JUICE:

' : 15-13 OZ CANS CONCENTRATE : SIMILAC LACTOSE FREE
: 1-12 OZ CAN FROZEN OR 1-46 OZ CAN
: OR 1-11.5 OZ CAN POURABLE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED
' FORMULA: : 3-14 OZ CANS POWDER
:' SIMILAC LACTOSE FREE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA: JUICE:
CEREAL:

' : 1-14 OZ CAN POWDER : SIMILAC LACTOSE FREE
: 2-12 OZ CANS FROZEN OR 2-46 OZ : CANS OR 2-11.5 OZ CANS POURABLE : UP TO 24 OZ INFANT

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA: JUICE: CEREAL:

:'' 3-14 OZ CANS POWDER : SIMILAC LACTOSE FREE : 2-12 OZ CANS FROZEN OR 2-46 OZ : CANS OR 2-11.5 OZ CANS POURABLE : UP TO 24 OZ INFANT

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA: : 13-13 OZ CANS CONCENTRATE : SIMILAC LACTOSE FREE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED



FP-38



GA WIC PROCEDURES MANUAL

Attachment FP-2 cont'd

FOOD PACKAGE NUMBER 247
31 CANS 13 OZ CONCENTRATE IRON FORTIFIED SIMILAC LACTOSE FREE 2 CANS JUICE 24 OZ INFANT CEREAL
248 I CAN 14OZPOWDER IRON FORTIFIED SIMILAC LACTOSE FREE
266 9 CANS 14 OZ POWDER IRON FORTIFIED SIMILAC LACTOSE FREE 2 CANS JUICE 24 OZ INFANT CEREAL
273 9 CANS 14 OZ POWDER IRON FORTIFIED SIMILAC LACTOSE FREE

VOUCHER CODE
392

VOUCHER MESSAGE 13-13 OZ CANS CONCENTRATE FORMULA: SIMILAC LACTOSE FREE

073 374 391 475
073 391 475

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE: CEREAL:

: 2-12 OZ CANS FROZEN OR 2-46 OZ : CANS OR 2-11.5 OZ CANS POURABLE : UP TO 24 OZ INFANT

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED
FORMULA: : 1-14 OZ CAN POWDER : SIMILAC LACTOSE FREE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED
: 5-14 OZ CANS POWDER FORMULA: :' SIMILAC LACTOSE FREE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED
: 4-14 OZ CANS POWDER FORMULA: '
: SIMILAC LACTOSE FREE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE: CEREAL:

: 2-12 OZ CANS FROZEN OR 2-46 OZ : CANS OR 2-11.5 OZ CANS POURABLE : UP TO 24 OZ INFANT

: 5-14 OZ CANS POWDER FORMULA:
: SIMILAC LACTOSE FREE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED
: 4-14 OZ CANS POWDER FORMULA: :' SIMILAC LACTOSE FREE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED



FP-39



GA WIC PROCEDURES MANUAL

Attachment FP-2 cont'd

FOOD PACKAGE NUMBER
999
FORMULA AS ORDERED BY A PHYSICIAN FORMULA EQUALS UP TO 8 LBS POWDER OR 403 OZ CONCENTRATE
JUICE: 2-46 OZ OR 2-12 OZ FROZEN CANS OR 2-11.5 OZ CANS POURABLE CEREAL: 24 OZ
FORMULA ONLY MAY BE PRESCRIBED

VOUCHER CODE
999

VOUCHER MESSAGE
AS PRESCRIBED A TAOLORED PACKAGE DESIGNED BY THE CPA WHICH MUST NOT EXCEED THE MAXMUM QUANTITY OF SUPPLEMENTAL FOODS FOR THE PARTICIPANTS CATEGORY





FP-40

----------



GA WIC PROCEDURES MANUAL

Attachment FP-3

INFANT FOOD PACKAGES NON-CONTRACT FORMULA
Prescription Required

FOOD PACKAGE NUMBER

VOUCHER CODE

VOUCHER MESSAGE

Ill 8 CANS 16 OZ POWDER PORTAGENOR PREGESTIMIL
114 8 CANS 16 OZ POWDER PORTAGENOR PREGESTIMIL 2CANS JUICE 24 OZ INFANT CEREAL
121 8 CANS 16 OZ POWDER OR 31-13 OZ CANS CONCENTRATE NUTRAMIGEN OR 25 QTS READY -TO-FEED ALIMENTUM
131 8 CANS 16 OZ POWDER OR 31-13 OZ CANS CONCENTRATE NUTRAMIGEN OR25 QTS. READY-TOFEED ALIMENTUM 2 CANS JUICE 24 OZ INFANT CEREAL

060

FORMULA: :' 4 - I LB CANS POWDER PORTAGEN OR

'

M ..,,,.,. 1n.n

'

060

FORMULA: : 4 - I LB CANS POWDER PORTAGEN OR

: PREGESTIMIL

'

060

FORMULA: 4 - I LB CANS POWDER

PORTAGEN OR PREGESTIMIL

060

FORMULA: 4 - I LB CANS POWDER

PORTAGEN OR PREGESTIMIL

073

JUICE:

2 - 12 OZ CANS FROZEN OR

2-46 OZ CANS OR2-l l.5 OZ CANS

POURABLE

CEREAL:

: UP TO 24 OUNCES INFANT

: 4 - I LB CANS POWDER OR

160

FORMULA: 15 - 13 OZ CANS CONCENTRATE

NUTRAMIGEN OR 12 QTS READY-TO-

, FEED ALIMENTUM

161

FORMULA: 4 - I LB CANS POWDER OR

16 - 13 OZ CANS CONCENTRATE

NUTRAMIGEN OR 13 QTS READY-TO-

FEED ALIMENTUM

160

FORMULA: 4 - I LB CANS POWDER OR

15 - 13 OZ CANS CONCENTRATE

NUTRAMIGEN OR 12 QTS READY-TO-

: FEED ALIMENTUM

161

FORMULA: 4 - I 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 OZ

CANS OR 2- 11.5 OZ CANS POURABLE

CEREAL:

UP TO 24 OUNCES INFANT



FP-41



GA WIC PROCEDURES MANUAL

Attachment FP-3 cont'd

FOOD PACKAGE NUMBER
133 31 CANS 13 OZ CONCENTRATE LOW IRON FORMULA
134 8-16 OZ CANS OR 9-14 OZ CANS POWDER LOW IRON FORMULA
136 31 CANS 13 OZ CONCENTRATE LOW IRON FORMULA 2 CANS JUICE 24 OZ INFANT CEREAL
137 8-16 OZ OR 9-14 OZ CANS POWDER INFANT LOW IRON FORMULA 2CANSJUICE 24 OZ INFANT CEREAL

VOUCHER CODE 094 095 194
195
094 095 073 194
195
073

VOUCHER MESSAGE

FORMULA: 15 - 13 OZ CANS CONCENTRATE

LOW IRON FORMULA ALLOWED FORMULA: : 16- 13 OZ CANS CONCENTRATE

LOW IRON FORMULA ALLOWED
FORMULA: : 4- 16 OZ CANS OR 5- 14 OZ CANS : POWDER INFANT FORMULA

LOW IRON FORMULA ALLOWED
FORMULA: : 4 - 16 OZ OR 4- 14 OZ CANS POWDER : INFANT FORMULA

LOW IRON FORMULA ALLOWED FORMULA: : 15 - 13 OZ CANS CONCENTRATE

LOW IRON FORMULA ALLOWED FORMULA: : 16 - 13 OZ CANS CONCENTRATE

LOW IRON FORMULA ALLOWED

JUICE: CEREAL:

: 2- 12 OZ CANS FROZEN OR 2- 46 OZ : CANS OR 2-11.5 OZ CANS POURABLE : UP TO 24 OZ INFANT

FORMULA: : 4 - 16 OZ CANS OR 5 - 14 OZ CANS : POWDER INFANT FORMULA

LOW IRON FORMULA ALLOWED '
FORMULA: : 4- 16 OZ OR 4- 14 OZ CANS POWDER : INFANT FORMULA

LOW IRON FORMULA ALLOWED

JUICE: CEREAL:

: 2- 12 OZ CANS FROZEN OR 2 -46 OZ : CANS OR 2-11.5 OZ CANS POURABLE : UP TO 24 OZ INFANT



FP-42



GA WIC PROCEDURES MANUAL

Attachment FP-3 cont'd

FOOD PACKAGE NUMBER
183 31 CANS 13 OZ CONCENTRATE IRON FORTIFIED NONCONTRACT SOY FORMULA
186 31 CANS 13 OZ CONCENTRATE IRON FORTIFIED NON-CONTRACT SOY FORMULA 2 CANS JUICE 24 OZ INFANT CEREAL
283 9-14 OZ CANS POWDER IRON FORTIFIED NON-CONTRACT SOY FORMULA

VOUCHER CODE 057
058 073 057
058
857
858

VOUCHER MESSAGE

FORMULA: 15 - 13 OZ CANS CONCENTRATE PROSOBEE OR CARNATION ALSOY

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA: : 16 - 13 OZ CANS CONCENTRATE : PROSOBEE OR CARNATION ALSOY

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE: CEREAL:

: 2 - 12 OZ CANS FROZEN OR 2-46 OZ : CANS OR 2-11.5 OZ CAN POURABLE : UP TO 24 OZ INFANT

FORMULA: : 15 - 13 OZ CANS CONCENTRATE: : PROSOBEE OR CARNATION ALSOY

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA: : 16 - 13 OZ CANS CONCENTRATE: : PROSOBEE OR CARNATION ALSOY

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA:

' : 5 - 14 OZ CANS POWDER: PROSOBEE : OR CARNATION ALSOY OR GERBER : SOY

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA:

: 4 - 14 OZ CANS POWDER: PROSOBEE
: OR CARNATION ALSOY OR GERBER
: SOY '

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED



FP-43



GA WIC PROCEDURES MANUAL

Attachment FP-3 cont'd

FOOD PACKAGE NUMBER
286 9-14 OZ POWDER IRON FORTIFIED NON-CONTRACT SOY FORMULA 2 CANS JUICE 24 OZ INFANT CEREAL

VOUCHER CODE 073 857
858

VOUCHER MESSAGE

JUICE: CEREAL:

2- 12 OZ CANS FROZEN OR 2-46 OZ CANS OR 2-11.5 OZ CANS POURABLE UP TO 24 OZ INFANT

FORMULA: : 5 - 14 OZ CANS POWDER: PROSOBEE : OR CARNATION ALSOY OR GERBER : SOY

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA:

i 4 - 14 OZ CANS POWDER: PROSOBEE
: OR CARNATION ALSOY OR GERBER
: SOY

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED





FP-44



GA WIC PROCEDURES MANUAL

Attachment FP-4

ALTERNATE FOOD PACKAGE FOR INFANTS (0-4 MONTHS) MAXIMUM MONTHLY AMOUNTS AUTHORIZED, CONTRACT FORMULA



TYPE Ready-To-Feed Powder

SIZE 100 - 8 fluid oz cans
8 - 16 oz cans 9 - 14 oz cans 10 - 10 oz cans

MAXIMUM AMOUNT 800 fluid ounces
8 cans 9 cans 10 cans

This food package consist of eight (8) vouchers per month.



FP-45



GA WIC PROCEDURES MANUAL

Attachment FP-5

ALTERNATE FOOD PACKAGE FOR INFANTS (0-4 MONTHS) CONTRACT FORMULA

FOOD PACKAGE NUMBER
180
I00 -8 OZ CANS READYTO -FEED IRON FORTIFIED SIMILAC OR ISOMIL

VOUCHER CODE 200
200

VOUCHER MESSAGE

FORMULA:

'':''

12-8 OZ CANS READY-TO- FEED SIMILAC OR ISOMIL

-------------------------------------------------------------

IRON FORTIFIED

NO LOW IRON FORMULA ALLOWED

FORMULA: ''' 12-8 OZ CANS READY- TO- FEED
----------------'' -S--IM---IL--A-C---O-R---I-S-O-M--I-L----------------------IRON FORTIFIED
NO LOW IRON FORMULA ALLOWED

200

FORMULA: ''' 12-8 OZ CANS READY -TO- FEED

---------------1'' -S-I-M--I-L-A--C--O--R---IS--O-M--I-L-----------------------

IRON FORTIFIED

NO LOW IRON FORMULA ALLOWED

200

FORMULA: 12-8 OZ CANS READY- TO- FEED SIMILAC OR ISOMIL '' L--

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

201

FORMULA: '' 13-8 OZ CANS READY- TO -FEED

---------------~''' -S-I-M--I-L-A--C--O--R--I-S-O--M--I-L-----------------------

IRON FORTIFIED

NO LOW IRON FORMULA ALLOWED

201

FORMULA: 13-8 OZ CANS READY -TO -FEED

SIMILAC OR ISOMIL ------------------------------------------------------------

IRON FORTIFIED

NO LOW IRON FORMULA ALLOWED

201

FORMULA:

' ' ' ' '

13-8 OZ CANS READY- TO -FEED SIMILAC OR ISOMIL

----------------' ---------------------------------------------

IRON FORTIFIED

NO LOW IRON FORMULA ALLOWED

201

FORMULA: '' 13-8 OZ CANS READY-TO- FEED

----------------' -S--IM---IL--A-C---O-R---I-S-O-M--I-L-----------------------

IRON FORTIFIED

NO LOW IRON FORMULA ALLOWED



FP-46



GA WIC PROCEDURES MANUAL

Attachment FP-6

ALTERNATE FOOD PACKAGE FOR INFANTS (5-12 MONTHS) MAXIMUM MONTHLY AMOUNTS AUTHORIZED, CONTRACT FORMULA .



TYPE Ready-To-Feed Powder

SIZE 100 - 8 fluid ounces 8 - 16 oz cans 9 - 14 oz cans

Cereal, Infants Juice

3 - 8 boxes, dry 12 - 6 oz cans

This food package consist of eight (8) vouchers.

MAXIMUM AMOUNT 800 fluid ounces 8 cans 9 cans
24 ounces 72 ounces



FP-47



GA WIC PROCEDURES MANUAL

Attachment FP-7

ALTERNATE FOOD PACKAGE FOR INFANTS (5-12 MONTHS) CONTRACT FORMULA

FOOD PACKAGE NUMBER
181
100-8 OZ CANS READY- TO- FEED IRON FORTIFIED SIMILAC OR ISOMIL
3-8 OZ BOXES OF INFANT CEREAL 12-6 OZ CANS JUICE

VOUCHER CODE 200
200

VOUCHER MESSAGE

FORMULA: FORMULA:

' ' ' '

12-8 OZ CANS READY -TO- FEED SIMILAC OR ISOMIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED
:
, 12-8 OZ CANS READY- TO- FEED SIMILAC OR : ISOMIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

200

FORMULA:

' 12-8 OZ CANS READY TO -FEED SIMILAC OR

: ISOMIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

200

FORMULA:

'' 12-8 OZ CANS READY~ TO -FEED SIMI LAC OR

: ISOMIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

200

FORMULA:

' '

; 12-8 OZ CANS READY -TO -FEED SIMILAC OR

: ISOMIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

202

FORMULA:

'' 13-8 OZ CANS READY TO -FEED ENFAMIL OR

: PROSOBEE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

INFANT CEREAL:

'
1-8 OZ BOX, DRY

JUICE:

.''' 6-6OZCANS
'

202

FORMULA:

13-8 OZ CANS READY TO -FEED SIMILAC OR

ISOMIL

INFANT CEREAL:
JUICE:

1-8 OZ BOX, DRY
'' 6-6OZCANS

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

203

FORMULA:

'' 14-8 OZ CAN READY -TO-FEED SIMILAC OR

: ISOMIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

INFANT CEREAL:

1-8OZBOX, DRY

FP-48



GA WIC PROCEDURES MANUAL

Attachment FP-8

FOOD PACKAGES FOR CHILDREN AND WOMEN WITH SPECIAL DIETARY NEEDS
MAXIMUM MONTHLY AMOUNTS AUTHORIZED



A.

FORMULA 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)

Powder

16 ounces

8 cans (960 oz reconstituted)

1 can (120 oz reconstituted)

14 ounces

9 cans (945 oz reconstituted)

1 can (105 oz reconstituted)

B.

CEREAL AND JUICE MAXIMUM MONTHLY AMOUNTS

FOOD

SIZE

MAXIMUM AMOUNT

Cereal

9 ounces and above

36 ounces

Single Strength Juice
OR
Frozen Concentrate Juice
OR
Pourable Concentrate Juice

46 fluid ounces
OR
12 fluid ounces
OR
11.5 fluid ounce

138 fluid ounces
OR
144 fluid ounces
OR
138 fluid ounces



FP-49



GA WIC PROCEDURES MANUAL

Attachment FP-9

CHILDREN'S AND WOMEN'S PACKAGES Prescription Required

FOOD PACKAGE NUMBER
311 8 CANS 16 OZ POWDER PORTAGENOR PREGESTIMIL

VOUCHER CODE

060

FORMULA:

060

FORMULA:

VOUCHER MESSAGE
'
: 4-1 LB CANS POWDER PORTAGEN OR : PREGESTIMIL
'
: 4-1 LB CANS POWDER PORTAGEN OR : PREGESTIMIL

315 8 CANS 16 OZ POWDER PORTAGENOR PREGESTIMIL 3 CANS JUICE 24OZCEREAL

060

FORMULA: : 4-1 LB CANS POWDER PORTAGEN

: OR PREGESTIMIL

060

FORMULA: : 4 - I LB CANS POWDER PORTAGEN

066

JUICE:

: OR PREGESTIMIL
'
:' 3 - 12 OZ CANS FROZEN OR 3 -46 OZ

: CANS OR 3-11.5 OZ CAN S POURABLE

CEREAL:

: UP TO 24 OUNCES

318

170

FORMULA: : 4- 1 LB CANS POWDER OR 16- 13 OZ

9 CANS 16 OZ POWDER OR

: CANS CONCENTRATE NUTRAMIGEN

35 CANS 13 OZ

: OR 14 QTS. READY-TO-FEED

CONCENTRATE

: ALIMENTUM

NUTRAMIGEN OR 28 QUARTS

'

171

FORMULA: : 5 - I LB CANS POWDER OR 19- 13 OZ

READY-TO-FEED

: CANS CONCENTRATE NUTRAMIGEN

ALIMENTUM

: OR 14 QTS. READY-TO-FEED

3 CANS JUICE

: ALIMENTUM

36OZCEREAL

070

JUICE:

:' 3 - 12 OZ CANS FROZEN OR 3 -46 OZ

: CANS OR 3-11.5 OZ CANS POURABLE

CEREAL:

: UP TO 36 OUNCES

372 31 CANS 13 OZ CONCENTRATE IRON FORTIFIED
SIMILAC LACTOSE FREE

'

364

FORMULA: : 15-13 OZ CANS CONCENTRATE

:' SIMILAC LACTOSE FREE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

'

365

FORMULA: : 16-13 OZ CANS CONCENTRATE

: SIMILAC LACTOSE FREE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED



FP-50



GA WIC PROCEDURES MANUAL

Attachment FP-9 cont'd

FOOD PACKAGE NUMBER 373
25 CANS 13 OZ CONCENTRATE IRON FORTIFIED SIMILAC LACTOSE FREE 2 CANS JUICE 2402 CEREAL
376 31 CANS 13 OZ CONCENTRATE IRON FORTIFIED SJMILAC LACTOSE FREE 2 CANS JUICE 240ZCEREAL
377 31 CANS 13 OZ CONCENTRATE IRON FORTIFIED SIMILAC LACTOSE FREE 2 CANS JUICE 36 OZ CEREAL

VOUCHER CODE

VOUCHER MESSAGE

378

FORMULA:

12-13 OZ CANS CONCENTRATE

SlMlLAC LACTOSE FREE

JUICE:

1-12 OZ CAN FROZEN OR 1-46 OZ

CAN OR 1-11.5 OZ CAN POURABLE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

'

379

FORMULA: : 13-13 OZ CANS CONCENTRATE

: SIMILAC LACTOSE FREE

JUICE:

: 1-12 OZ CAN FROZEN OR 1-46 OZ

CEREAL

: CAN OR 1-11.5 OZ CAN POURABLE

: UPT0240Z

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

382

FORMULA: :' 15-13 OZ CANS CONCENTRATE

: SIMILAC LACTOSE FREE

JUICE:

: 1-12 OZ CAN FROZEN OR 1-46 OZ

: CAN OR 1-11.5 OZ CAN POURABLE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

383

FORMULA: : 16-13 OZ CANS CONCENTRATE

: SIMI LAC LACTOSE FREE

JUICE:

: 1-12 OZ CAN FROZEN OR 1-46 OZ

: CAN OR 1-1 I .5 OZ CAN POURABLE

CEREAL:

: UPT0240Z

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

'

382

FORMULA: : 15-13 OZ CANS CONCENTRATE

: SIMILAC LACTOSE FREE

JUICE:

: 1-12 OZ CAN FROZEN OR 1-46 OZ

: CAN OR 1-11.5 OZ CAN POURABLE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

384

FORMULA:

16-13 OZ CANS CONCENTRATE

SIMILAC LACTOSE FREE

JUICE:

1-12 OZ CAN FROZEN OR 1-46 OZ

CEREAL:

CAN OR I - I 1.5 OZ CAN POURABLE

UP TO 36 OZ



FP-51



GA WIC PROCEDURES MANUAL

Attachment FP-9 cont'd

FOOD PACKAGE NUMBER 379
35 CANS 13 OZ CONCENTRATE IRON FORTIFIED SIMILAC LACTOSE FREE 2 CANS JUICE 36 OZ CEREAL
392 9 CANS 14 OZ POWDER IRON FORTIFIED SIMILAC LACTOSE FREE
303 SCANS 14OZPOWDER IRON FORTIFIED SIMILAC LACTOSE FREE 3 CANS JUICE 24 OZ CEREAL

VOUCHER CODE

VOUCHER MESSAGE

384

FORMULA:

16-13 OZ CANS CONCENTRATE

SIMILAC LACTOSE FREE

JUICE:

1-12 OZ CAN FROZEN OR 1-46 OZ

CEREAL:

CAN OR 1-11.5 OZ CAN POURABLE

UP TO36 OZ

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

386

FORMULA: : 19-13 OZ CANS CONCENTRATE

: SIMILAC LACTOSE FREE

JUICE:

: 1-12 OZ CAN FROZEN OR 1-46 OZ

: CAN OR 1-11.5 OZ CAN POURABLE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

391

FORMULA

: 5-14 OZ CANS POWDER

: SIMJLAC LACTOSE FREE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

475

FORMULA:

:' 4-14 OZ CANS. POWDER

: SIMILAC LACTOSE FREE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

066

JUICE:

: 3-12 OZ CANS FROZEN OR 3-46 OZ

: CANS OR 3-11.5 OZ CANS POURABLE

CEREAL:

: UP TO 24 OZ

475

FORMULA: : 4-14 OZ CANS POWDER

: SIMI LAC LACTOSE FREE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

475

FORMULA: : 4-14 OZ CANS POWDER

: SIMILAC LACTOSE FREE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED



FP-52




GA WIC PROCEDURES MANUAL

Attachment FP-9 cont'd

FOOD PACKAGE NUMBER 306
9.CANS 14 OZ POWDER IRON FORTIFIED SIMILAC LACOSE FREE 3 CANS JUICE 24OZCEREAL
307 9 CANS 14 OZ POWDER IRON FORTIFIED SIMILAC LACTOSE FREE 3 CANS JUICE 36OZCEREAL
352 31 CANS 13 OZ CONCENTRATE IRON FORTIFIED SIMILAC OR ISOMIL
353 25 CANS 13 OZ CONCENTRATE IRON FORTIFIED SIMILAC OR ISOMIL 2 CANS JUICE 24 OZ CEREAL

VOUCHER CODE 066 391
475
070 391
475
004 005 018
019

VOUCHER MESSAGE

JUICE: CEREAL: FORMULA:

3-12 OZ CANS FROZEN OR 3-46 OZ CANS OR 3-11.5 OZ CANS POURABLE UPTO 24 OZ
' 5-14 OZ CANS POWDER SIMILAC LACTOSE FREE

IRON FORTIFIED

NO LOW IRON FORMULA ALLOWED

FORMULA:

:
4-14 OZ CANS POWDER

SIMILAC LACTOSE FREE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE: CEREAL: FORMULA:

' 3-12 OZ CANS FROZEN OR 3-46 OZ CANS OR 3-11.5 OZ CANS POURABLE
' UPTO 3602
5-14 OZ CANS POWDER
: SIMILAC LACTOSE FREE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA:

'' 4-14 OZ CANS POWDER SIMILAC LACTOSE FREE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA:

15 - 13 OZ CANS CONCENTRATE SIMILAC '' ORISOMIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA:

16 - 13 OZ CANS CONCENTRATE SIMILAC ORISOMIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA: JUICE:

12-13OZCANSCONCENTRATE SIMILAC

' ' '

ORISOMIL I - 12 OZ CAN FROZEN OR

I - 46 OZ CAN

OR 1-11.5 OZ CAN POURABLE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA: JUICE: CEREAL:
FP-53

13 - 13 OZ CANS CONCENTRATE SIMILAC ORISOMIL I - 12 OZ CAN FROZEN OR 1 - 46 OZ CAN OR 1-11.5 OZ CAN POURABLE UP TO 24 OZ



GA WIC PROCEDURES MANUAL

Attachment FP-9 cont'd

FOOD PACKAGE NUMBER 354
25 CANS 32 OZ READY -TO-FEED IRON FORTIFIED SIMILAC ORISOMIL 2 CANS JUICE 24 OZ CEREAL
356 31 CANS 13 OZ CONCENTRATE IRON FORTIFIED SIMI LAC OR ISOMIL 2 CANS JUICE 24 OZ CEREAL
357 31 CANS 13 OZ CONCENTRATE IRON FORTIFIED SIMI LAC OR ISOMIL 2 CANS JUICE 36 OZ CEREAL

VOUCHER CODE

VOUCHER MESSAGE

020

FORMULA:

12 - 32 OZ CANS READY-TO-FEED

SIMILAC OR ISOM IL

JUICE:

I - 12 OZ CAN FROZEN OR I -46 OZ

CAN OR 1-11.5 OZ CAN POURABLE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

021

FORMULA: : 13 - 32 OZ CANS READY-TO-FEED

: SIMILAC OR ISOMIL

JUICE:

: I - 12 OZ CAN FROZEN OR I - 46 OZ

: CAN OR 1-11.5 OZ CAN POURABLE

CEREAL:

: UPTO24OZ

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

022

FORMULA: : 15 - 13 OZ CANS CONCENTRATE

: SIMI LAC OR ISOMIL

JUICE:

: I - 12 OZ CAN FROZEN OR I - 46 OZ

: CAN OR 1-11.5 OZ CAN POURABLE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

023

FORMULA: : 16 - 13 OZ CANS CONCENTRATE

: SIMILAC OR ISOMIL

JUICE:

: I - 12 OZ CAN FROZEN OR I - 46 OZ

: CAN OR 1-11.5 OZ CAN POURABLE

CEREAL:

: UP TO 24 OUNCES

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

022

FORMULA: : 15 - 13 OZ CANS CONCENTRATE

: SIMILAC OR ISOM IL

JUICE:

: I - 12 OZ CAN FROZEN OR I - 46 OZ

: CAN OR 1-11.5 OZ CAN POURABLE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

024

FORMULA: :' 16- 13 OZ CANS CONCENTRATE

: SIMILAC OR ISOMIL

JUICE:

: I - 12 OZ CAN FROZEN OR I - 46 OZ

: CAN OR 1-11.5 OZ CAN POURABLE

CEREAL:

: UPTO36 OZ

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED



FP-54



GA WIC PROCEDURES MANUAL

Attachment FP-9 cont'd

FOOD PACKAGE NUMBER 359
35 CANS 13 OZ CONCENTRATE IRON FORTIFIED SIMILAC OR ISOMIL 2 CANS JUICE 36OZCEREAL
362 10 CANS 14.1 OZ POWDER IRON FORTIFIED SIMILAC OR I0-14 OZ CANS POWDER ISOMIL
363 8 CANS 14.1 OZ POWDER IRON FORTIFIED SIMILAC OR 8 CANS 14 OZ POWDER ISOMIL 3 CANS JUICE 24OZCEREAL

VOUCHER CODE 024
026
088 088 066 015 015

VOUCHER MESSAGE

FORMULA: JUICE: CEREAL:

16 - 13 OZ CANS CONCENTRATE SIMILAC OR ISOMIL I - 12 OZ CAN FROZEN OR I - 46 OZ CAN OR 1-11.5 OZ CAN POURABLE , UPTO36OZ

IR.ON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA: JUICE:

' : 19 - 13 OZ CANS CONCENTRATE
: SIMILAC OR ISOMIL
: I - I2 OZ CAN FROZEN OR I - 46 OZ : CAN OR 1-11.5 OZ CAN POURABLE
'

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA:

: 5 - 14.1 OZ CANS POWDER SIMILAC : OR 5 - 14 OZ CANS POWDER ISOMIL
'

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA:

'
: 5 - 14.1 OZ CANS POWDER SIMILAC : OR 5 - 14 OZ CANS POWDER ISOMIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE: CEREAL:

3 - 12 OZ CANS FROZEN OR 3 - 4602 CANS OR 3-11.5 OZ CAN S POURABLE UP TO 24 OUNCES

FORMULA:

4 - 14.1 OZ CANS POWDER SIMILAC OR 4 - 14 OZ CANS POWDER ISOMIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA:

' : 4 - 14.1 OZ CANS POWDER SIMILAC
: OR 4 - 14 OZ CANS POWDER ISOMIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED



FP-55



GA WIC PROCEDURES MANUAL

Attachment FP-9 cont'd

FOOD PACKAGE NUMBER 366
9 CANS 14.1 OZ POWDER IRON FORTIFIED SIMILAC OR 9 CANS 14 OZ POWDER ISOMIL 3 CANS JUICE 24OZCEREAL
367 9 CANS 14.1 OZ POWDER IRON FORTIFIED SIMILAC OR 9 CANS 14 OZ POWDER ISOMIL 3 CANS JUICE 36OZCEREAL
369 10 CANS 14.1 OZ POWDER IRON FORTIFIED SIMILAC OR 10 CANS 14 OZ POWDER ISOMIL 3 CANS JUICE 36OZCEREAL

VOUCHER CODE 066 015
088
070 088
488
070 088
088

VOUCHER MESSAGE

JUICE: CEREAL:

3 - 12 OZ CANS FROZEN OR 3 - 4602 CANS OR 3-11.5 OZ CANS POURABLE UP TO 24 OUNCES

FORMULA:

4 - 14.1 OZ CANS POWDER SIMILAC OR 4 - 14 OZ CANS POWDER ISOMIL

IRON FORTIFIED
.NO LOW IRON FORMULA ALLOWED
FORMULA: :' 5 - 14. I OZ CANS POWDER SIMILAC : OR 5 - 14 OZ CANS POWDER ISOMIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE: CEREAL:

' : 3 - 12 OZ CANS FROZEN OR 3 -46 OZ : CANS OR 3-11.5 OZ CANS POIRABLE : UP TO 36 OUNCES

'
FORMULA: : 5 - 14. I OZ CANS POWDER SIMILAC : OR 5 - 14 OZ CANS POWDER ISOMIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA: : 4-14.1 OZ CANS POWDER SIMILAC : OR 4 - 14 OZ CANS POWDER ISOMIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE: CEREAL: FORMULA:

3- 12 OZ CANS FROZEN OR 3 -46 OZ CANS OR 3-11.5 OZ CANS POURABLE , UP TO 36 OUNCES
'
: 5 - 14.1 OZ CANS POWDER SIMILAC : OR 5 - 14 OZ CANS POWDER ISOMIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA:

'
: 5 - 14.1 OZ CANS POWDER SIMILAC : OR 5 - 14 OZ CANS POWDER ISOMIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED



FP-56



GA WIC PROCEDURES MANUAL

Attachment FP-9 cont'd

FOOD PACKAGE NUMBER
381 9 CANS 16 OZ POWDER PORTAGENOR PREGESTIMIL 3 CANS JUICE 36OZCEREAL
382 8 CANS 16 OZ POWDER OR 31 CANS 13 OZ CONCENTRATE NUTRAMIGEN OR 25 QTS READY-TO-FEED ALIMENTUM
383 8 CANS 16 OZ POWDER OR 31 CANS 13 OZ CONCENTRATE NUTRAMIGEN OR 25 QTS READY-TO-FEED ALIMENTUM 3 CANS JUICE 2402 CEREAL
999 FORMULA IS ORDERED BY A PHYSICIAN FORMULA EQUALS UP TO 8-9 CANS 16 OZ POWDER, OR 9-10 CANS 14 OZ POWDER, OR 403455 OZ CONCENTRATE, 800-910 OZ READY TO FEED
3-12 OZ FROZEN CANS 36OZCEREAL
FORMULA ONLY MAY BE PRESCRIBED

VOUCHER CODE 060 181 070 182
183
182
183
066 999

VOUCHER MESSAGE

FORMULA:

4 - 1 LB CANS POWDER PORTAGEN OR PREGESTIMIL

FORMULA:

5 - 1 LB CANS POWDER PORTAGEN OR PREGESTIMIL

JUICE: CEREAL:

3 - 12 OZ CANS FROZEN OR 3 - 46 OZ CANS OR 11.5 CANS POURABLE : UP TO 36 OUNCES

FORMULA:

4- I LB CANS POWDER OR 15 - 13 OZ CANS CONCENTRATE NUTRAMIGEN OR 12 QTS. READY-TO-FEED ALIMENTUM

FORMULA:

4- 1 LB CANS POWDER OR 16- 13 OZ CANS CONCENTRATE NUTRAMIGEN OR 13 QTS. READY-TO-FEED ALIMENTUM

FORMULA:

4- 1 LB CANS POWDER OR 15 - 13 OZ CANS CONCENTRATE NUTRAMIGEN OR 12 QTS. READY-TO-FEED ALIMENTUM

FORMULA:

4- 1 LB CANS POWDER OR 16- 13 OZ CANS CONCENTRATE NUTRAMIGEN OR 13 QTS. READY-TO-FEED ALIMENTUM

JUICE: CEREAL:

3 - 12 OZ CANS FROZEN OR 3 -46 OZ CANS OR 11.5 OZ CAN POURABLE UPTO24OZ

AS PRESCRIBED

A TAILORED PACKAGE DESIGNED BY THE CPA WHICH MUST NOT EXCEED THE MAXIMUM QUANTITY OF SUPPLEMENTAL FOODS FOR THE PARTICIPANTS CATEGORY



FP-57



GA WIC PROCEDURES MANUAL

Attachment FP-10

ALTERNATE FOOD PACKAGES FOR CHILDREN AND WOMEN WITH SPECIAL DIETARY NEEDS
MAXIMUM MONTHLY AMOUNTS AUTHORIZED



FOOD

SIZE

Ready-To-Feed Formula

100-8 oz cans

Cereal

4-9 oz boxes

Juice

23-6 oz cans

MAXIMUM MONTHLY AMOUNTS 800 ounces
36 ounces
138 ounces

This food package consists of eight (8) vouchers

ADDITIONAL AMOUNTS
13-8 oz cans ( 104 ounces)



FP-58



GAWICPROCEDURESMANUAL

Attachment FP-11

ALTERNATE FOOD PACKAGES FOR CHILDREN AND WOMEN WITH SPECIAL DIETARY NEEDS

FOOD PACKAGE NUMBER

VOUCHER CODE

VOUCHER MESSAGE

390 100-8 OZ CANS READY TO- FEED IRON FORTIFIED ENFAMIL OR PROSOBEE 4-9OZBOXES CEREAL 23-6 OZ CANS JUICE

200

FORMULA: : 12-8 OZ CANS READY- TO- FEED SIMILAC OR

: ISOMIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

200

FORMULA:

: 12-8 OZ CANS READY-TO-FEED SIMILAC OR

: ISOMIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

'

302

FORMULA:

: 14-8 OZ CANS READY- TO -FEED SIMILAC OR

: ISOMIL

CEREAL:

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED
'' 1-9OZBOX

JUICE:

: 6-6OZCANS

303

FORMULA:

, 14-8 OZ CANS READY-TO- FEED SIMILAC OR

, lSOMIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

CEREAL: JUICE:

, l-9OZBOX :'' S-6OZCANS

304

FORMULA:

: 12-8 OZ CANS READY- TO- FEED SIMILAC OR

ISOMIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

CEREAL:

: 190ZBOX

304

FORMULA:

:' 12-8 OZ CANS READY- TO -FEED SIMILAC OR

, ISOMIL

CEREAL:

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED
', l-9OZBOX

305

FORMULA:

, 12-8 OZ CANS READY- TO FEED SIMILAC OR

ISOMIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE:

' 6 6 OZ CANS

:

305

FORMULA:

, 12-8 OZ CANS READY- TO- FEED SIMILAC OR

ISOMIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE:

: 6-6OZCANS

FP-59



GA WIC PROCEDURES MANUAL

Attachment FP-12

FOOD Milk1

CHILDREN'S FOOD PACKAGES MAXIMUM MONTHLY AMOUNTS AUTHORIZED
MAXIMUM AMOUNT PER MONTH
24 quart equivalents2

Cheese

4pounds3

Eggs

2 dozen

Juice Cereal

6-46 ounce cans OR 6-12 ounce frozen OR 6-11.5 ounce pourable
36 ounces

Dried Beans/Peas OR Peanut Butter

1 pound bags OR 18 ounce jar

1 Substitute up to 24 quarts of lactose reduced milk for up to 6 gallons of milk. 2 Substitution amounts for fluid milk include:

ITEM

FLUID MILK EQUIVALENTS

Cheese, l pound Evaporated milk, whole or skim , 13 ounces Dry whole milk, l pound Nonfat or lowfat dry milk, l pound

3 quarts l quart 3 quarts 5 quarts

3 Subtract from monthly milk allotment. A maximum of two (2) pounds of cheese per month is recommended except for those with lactose intolerance.

FP-60



GA WIC PROCEDURES MANUAL CHILDREN'S FOOD PACKAGES

Attachment FP-13

FOOD PACKAGE NUMBER
MINIMUM600 2GALSMILK I LB CHEESE I DOZ EGGS 18OZCEREAL 4CANS JUICE
MINIMUM601 4GALS MILK I DOZ EGGS 4CANS JUICE 24OZCEREAL I LB BEANS/PEAS OR 1802 PEANUT BUTTER

VOUCHER CODE 042 040 039
049 040 039
040 037

VOUCHER MESSAGE

CHEESE: JUICE:

' : UPTO I LB : 1-12 OZ CAN FROZEN OR 1-46 OZ CAN

MILK: JUICE

: OR 1-11.5 OZ CAN POURABLE ' '' I GALOR4-12OZCANS EVAP
OR 1-5 QT BOX 1-12 OZ CAN FROZEN OR 1-46 OZ CAN

OR 1-11.6 OZ CAN POURABLE

MILK: EGGS: JUICE:
JUICE: CEREAL:

I GAL OR 4-12 OZ CANS EVAP OR 1-5 QT BOX I DOZEN 1-12 OZ CAN FROZEN OR 1-46 OZ CAN :' OR 1-11.5 OZ CAN POURABLE '
1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-11.5 OZ CAN POURABLE UP TO 18 OUNCES

MILK: JUICE:

I GALOR4-12 OZ CANS EVAP OR l-5QTBOX 1-12 OZ CAN FROZEN OR 1-46 OZ CAN
OR 1-11.5 OZ CAN POURABLE

MILK:
EGGS: JUICE:

I GAL OR4-12 OZ CANS EVAP OR 1-5 QT BOX I DOZEN 1-12 OZ CAN FROZEN OR 1-46 OZ CAN
OR 1-11.5 OZ CAN POURABLE

MILK: JUICE:

I GAL OR 4-12 OZ CANS EVAP OR 1-5 QT BOX 1-12 OZ CAN FROZEN OR 1-46 OZ CAN
OR 1-11.5 OZ CAN POURABLE

MILK:
JUICE:
CEREAL: BEANS/PEAS /PEANUT BUTTER:

I GAL OR 4-12 OZ CANS EVAP OR 1-5 QT BOX 1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-11.5 OZ CAN POURABLE UP TO 24 OUNCES I LB DRIED BEANS/PEAS OR 18 OZ PEANUT BUTTER



FP-61



GA WIC PROCEDURES MANUAL

Attachment FP-13 cont'd

FOOD PACKAGE NUMBER 602
LIMITED MILK LACTOSE INTOLERANT 2GALSMILK 2 LBS CHEESE 2 DOZ EGGS 4 CANS JUICE 24OZCEREAL 1LB BEANS/PEAS OR 18 OZ PEANUT BUTTER
MODERATE603* 4GALS MILK 1 LB CHEESE 2 DOZEN EGGS 4 CANS JUICE 24OZCEREAL I LB BEANS/PEAS
STANDARD MANUAL

VOUCHER CODE 042 043
048
039 047 039 025
039

VOUCHER MESSAGE

CHEESE: JUICE:

UPTO 1 LB 1-12 OZ CAN FROZEN OR 1-46 OZ CAN
OR 1-11.5 OZ CAN POURABLE

CHEESE: JUICE:
BEANS/PEAS OR PEANUT BUTTER:

UPTO 1 LB 1-1202 CAN FROZEN OR 1-46 OZ CAN OR 1-11.5 OZ CAN POURABLE
I LB DRIED BEANS/PEAS OR 18 OZ PEANUT BUTTER

MILK:
EGGS: JUICE:
CEREAL:

I GAL OR4-12 OZ CANS EVAP OR 1-5QTBOX 1 DOZEN 1-1202 CAN FROZEN OR 1-46 OZ CAN OR 1-11.5 OZ CAN POURABLE UP TO 24 OUNCES

MILK:
EGGS: JUICE:

1 GALOR4-12OZCANSEVAP OR 1-5 QT BOX 1 DOZEN 1-12 OZ CAN FROZEN OR 1-46 OZ CAN
OR 1-11.5 OZ CAN POURABLE

MILK: JUICE: CEREAL:

1 GALOR4-12 OZ CANS EVAP OR 1-5 QT BOX 1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-11.5 OZ CAN POURABLE UP TO 24 OUNCES

MILK:
EGGS: JUICE:

1 GAL OR 4-12 OZ CANS EVAP OR 1-5 QT BOX 1 DOZEN 1-12 OZ CAN FROZEN OR 1-46 OZ CAN

. OR 1-11.5 OZ CAN POURABLE

MILK:

1 GALOR4-12 OZ CANS EVAP

CHEESE: JUICE:

OR 1-5QTBOX UPTO I LB 1-12 OZ CAN FROZEN OR 1-46 OZ CAN

OR 1-11.5 OZ CAN POURABLE

BEANS/PEAS I LB DRIED BEANS/PEAS

MILK:
EGGS: JUICE:

1 GALOR4-12OZCANSEVAP OR 1-5QTBOX I DOZEN 1-12 OZ CAN FROZEN OR 1-46 OZ CAN
OR 1-11.5 OZ CAN POURABLE



FP-62



GA WIC PROCEDURES MANUAL

Attachment FP-13 cont'd

FOOD PACKAGE NUMBER 604
4GALSMILK 2 LBS CHEESE 2 DOZEN EGGS 4CANS JUICE 24OZCEREAL I LB DRIED BEANS/PEAS OR 18 OZ PEANUT BUTTER
605 LACTOSE REDUCED MILK LACTOSE .INTOLERANT 16 QTS LACTOSE REDUCED MILK 2 LBS CHEESE 2 DOZ EGGS 6CANS JUICE 24OZCEREAL I LB BEANS/PEAS OR 18 OZ JAR PEANUT BUTTER

VOUCHER

CODE

VOUCHER MESSAGE

031

MILK:

CHEESE: JUICE:

' ' ' ' ' ' ' ' ' ' ' '

I GAL OR 4-12 OZ CANS EVAP OR 1-5QTBOX UPTO I LB 1-12 OZ CAN FROZEN OR 1-46 OZ CAN
OR 1-11.5 OZ CAN POURABLE

037

MILK:

I GAL OR 4-12 OZ CANS EVAP

OR l-5QTBOX

JUICE:

1-12 OZ CAN FROZEN OR 1-46 OZ CAN

OR 1-11.5 OZ CAN POURABLE

CEREAL:

UP TO 24 OUNCES

BEANS/PEAS/

I LB DRIED BEANS/PEAS OR

PEANUT

18 OZ PEANUT BUTTER

BUTTER:

039

MILK:

EGGS: JUICE:

I GALOR4-12OZCANSEVAP OR 1-5QTBOX I DOZEN 1-12 OZ CAN FROZEN OR 1-46 OZ CAN
OR 1-11.5 OZ CAN POURABLE

055

MILK:

CHEESE: EGGS: JUICE:

I GAL OR4-12 OZ CANS EVAP OR l-5QTBOX UPTO I LB I DOZEN 1-12 OZ CAN FROZEN OR 1-46 OZ CAN
OR 1-11.5 OZ CAN POURABLE

044

MILK:

CHEESE: JUICE:
CEREAL:

4 QTS OR 2-1/2 GAL ACIDOPHILUS OR ENJOY OR LACTAID OR LACTAID I00 OR NUTRISH OR DAIRY EASE UPTO I LB 1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-11.5 OZ CAN POURABLE UP TO 24 OUNCES

034

MILK:

EGGS: JUICE:

4 QTS OR 2-1/2 GAL ACIDOPHILUS OR ENJOY OR LACTAID OR LACTAID I00 OR NUTRISH OR DAIRY EASE I DOZEN 2-12 OZ CAN FROZEN OR 2-46 OZ CAN
OR 1-11.5 OZ CAN POURABLE

045

MILK:

4 QTS OR 2-1/2 GAL ACIDOPHILUS OR

ENJOY OR LACTAID OR LACTAID I00 OR

NUTRISH OR DAIRY EASE

CHEESE:

UPTO I LB

JUICE:

1-12 OZ CAN FROZEN OR 1-46 OZ CAN

BEANS/PEAS/

OR 1-11.5 OZ CAN POURABLE

PEANUT

I LB DRIED BEANS/PEAS OR

BUTTER:

18 OZ PEANUT BUTTER

034

MILK:

EGGS:
. JUICE:

FP-63

4 QTS OR 2-1/2 GAL ACIDOPHILUS OR ENJOY OR LACTAID OR LACTAID I00 OR NUTRISH OR DAIRY EASE I DOZEN 2-12 OZ CAN FROZEN OR 2-46 OZ CAN
OR 2-11.5 OZ CANS POURABLE



GA WIC PROCEDURES MANUAL

Attachment FP-13 cont'd

FOOD PACKAGE NUMBER 606
4GALS MILK 2 LBS CHEESE 2 DOZEN EGGS 6 CANS JUICE 36OZCEREAL I LB BEANS/PEAS OR 18 OZ PEANUT BUTTER
MAXIMUM607 6GALS MILK 2DOZENEGGS 6 CANS JUICE 36OZCEREAL I LB BEANS/PEAS OR 18 OZ PEANUT BUTTER

VOUCHER CODE 028
031

VOUCHER MESSAGE

MILK:
EGGS: JUICE:

' : I GAL OR 4-12 OZ CANS EVAP OR : 1-5 QT BOX : I DOZEN : 2-12 OZ CANS FROZEN OR 2-46 OZ : CANS OR 1-11.5 OZ CAN POURABLE

MILK:
CHEESE: JUICE:

' : I GAL OR 4-12 OZ CANS EVAP OR : 1-5 QT BOX
UPTO I LB 1-12 OZ CANS FROZEN OR 1-46 OZ , CAN OR 1-11.5 OZ CAN POURABLE

055

MILK:

CHEESE: EGGS: JUICE:

I GAL OR4-12OZCANS EVAPOR 1-5 QT BOX UPTO I LB I DOZEN 1-12 OZ CAN FROZEN OR 1-46 OZ CANS OR 1-11.5 OZ CAN POURABLE

056

MILK:

I GALOR4-12OZ CANS EVAP OR

1-5 QT BOX

JUICE:

2-12 OZ CANS FROZEN OR 2-46 OZ

CEREAL:

CAN OR 2-11.5 OZ CAN POURABLE

BEANS/PEAS/ UP TO 36 OUNCES

P'NUT

I LB DRIED BEANS/PEAS OR

BUTTER:

18 OZ PEANUT BUTTER

027

MILK:

2GAL OR 8-1202 CANS EVAP OR

2-3 QTS

JUICE:

1-12 OZ CANS FROZEN OR 1-46 OZ

CEREAL:

CAN OR 1-11.5 OZ CAN POURABLE

BEANS/PEAS/ UP TO 36 OUNCES

P'NUT

I LB DRIED BEANS/PEAS OR

BUTTER:

18 OZ PEANUT BUTTER

028

MILK:

EGGS: JUICE:

I GAL OR 4-12 OZ CANS EVAP OR 1-5 QT BOX I DOZEN 2-12 OZ CANS FROZEN OR 2-46 OZ CANS OR 2-11.5 OZ CANS POURABLE

032

MILK:

EGGS: JUICE:

2 GAL OR 8-12 OZ CANS EVAPOR 2-3 QT BOXES I DOZEN 2-12 OZ CANS FROZEN OR 2-46 OZ CANS OR 2-11.5 OZ CANS POURABLE

046

MILK:

JUICE:

I GAL OR 4-12 OZ CANS EVAP OR 1-5 QT BOX 1-12 OZ CANS FROZEN OR 1-46 OZ CANS

FP-64



GA WIC PROCEDURES MANUAL

Attachment FP-13 cont'd

FOOD PACKAGE NUMBER

VOUCHER

CODE

VOUCHER MESSAGE

999*

999

AS PRESCRIBED

6 GALS OR 24 QTS MILK 4 LBS CHEESE 2 DOZEN EGGS 6 CANS JUICE 36OZCEREAL I LB BEANS/PEAS OR 18 OZ PEANUT BUTTER

A TAILORED PACKAGE DESIGNED BY THE CPA WHICH MUST NOT EXCEED THE MAXIMUM QUANTITY OF SUPPLEMENTAL FOODS FOR THE PARTICIPANT'S CATEGORY.

A maximum of 2 pounds of cheese per month is recommended except for those with lactose intolerance





FP-65



GA WIC PROCEDURES MANUAL

Attachment FP-14

ALTERNATE FOOD PACKAGES FOR CHILDREN 1 TRHOUGH 5 YEARS MAXIMUM MONTHLY AMOUNTS AUTHORIZED



FOOD UHTMilk OR Lactose Reduced Milk
Cereal Juice Peanut Butter

SIZE 96-8 oz boxes
22 quarts or 11-1/2 gallons 4-9 oz boxes 42-6 oz cans 2-18 ozjars

This food package consists of eight (8) vouchers.

MAXIMUM AMOUNTS 768 ounces.
704 ounces 36 ounces 252 ounces 36 ounces



FP-66



GA WIC PROCEDURES MANUAL

Attachment FP-15

ALTERNATE FOOD PACKAGES FOR CHILDREN 1 THROUGH 5 YEARS

FOOD PACKAGE NUMBER
610
96- 8 OZ BOXES UHT MILK OR 22 QTS OR 11 - GALLONS LACTOSE REDUCED MILK 4-9 BOXES CEREAL 42-6 OZ CANS JUICE 2-18 OZ JARS PEANUT BUTTER

VOUCHER CODE 610
611 611 611 612
613 614
615

VOUCHER MESSAGE

MILK:
CEREAL: JUICE: PEANUT BUTTER:

12-8 OZ BOXES UHT OR 4 QTS OR 2-1/2 GAL LACTOSE REDUCED 1-9OZBOX 6-6OZCANS
1-18 OZ JAR

MILK: JUICE:

12-8 OZ BOXES UHT OR 2 QTS OR 1-1/2 GAL LACTOSE REDUCED 6-6OZCANS

MILK: JUICE:

12-8 OZ BOXES UHT OR 2 QTS OR 1-1/2 GAL LACTOSE REDUCED 6-6 OZ CANS

MILK: JUICE:

12-8 OZ BOXES UHT OR 2 QTS OR 1-1/2 GAL LACTOSE REDUCED 6-6 OZ CANS

MILK:
CEREAL: JUICE:

12-8 OZ BOXES UHT OR 2 QTS OR 1-1/2 GAL LACTOSE REDUCED 1-9OZBOX 6-6OZCANS

MILK: CEREAL:

12-8 OZ BOXES UHT OR 2 QTS OR 1 - 1/2 GAL LACTOSE REDUCED 1-9OZBOX

MILK:
CEREAL: JUICE:

12 - 8 OZ BOXES UHT OR 4 QTS OR 2 -1/2 GAL LACTOSE REDUCED 1-902 BOX 6-6 OZ CANS

MILK:
PEANUT BUTTER: JUICE:

12-8 OZ BOXES UHT OR 4 QTS OR 2 - 1/2 GAL LACTOSE REDUCED
1-18 OZ JAR 6-6OZCANS



FP-67



GA WIC PROCEDURES MANUAL

Attachment FP-16

WOMEN'S FOOD PACKAGES MAXIMUM MONTHLY AMOUNTS AUTHORIZED

.FOOD

PREGNANT, BREASTFEEDING AND NON-BREASTFEEDING

EXCLUSIVELY BREASTFEEDING I

Milk2

28 quart equivalents 3

28 quart equivalents

Cheese

4

pounds

45 '

I pound

Eggs

2 dozen

2 dozen

Juice

6-46 oz cans or 6-12 oz cans frozen or
6-11.5 oz cans pourable

7-46 oz cans or 7-12 oz cans frozen or
6-11.5 oz cans pourable

Cereal

36 ounces

36 ounces

Dried Beans/Peas or Peanut Butter

1 pound bag or 1-18 oz jar

1 lb. bag or 18 oz jar plus an additional 1 lb. bag

Carrots'

NA

2 pounds, fresh, whole

Tuna'

NA

1 Additional items authorized for exclusively breastfeeding .women only. 2 Substitute up to 28 quarts of reduced milk for up to 7 gallons of milk. 3 Substitution amounts for fluids milk include:

4-6 oz cans

ITEM
Cheese, 1 pound
Evaporated milk whole or skim (13 oz)
Dry whole milk 1 pound
Nonfat or lowfat dry milk, 1 pound

FLUID MILK
EQUIVALENTS 3 quarts
1 quart
3 quarts
5 quarts

4 Subtract from monthly milk allotment. A maximum of two (2) pounds of cheese per month is recommended
except for those with lactose intolerance. 5 Substitute up to 4 lbs cheese for up to 7 gallons of milk.



FP-68



GA WIC PROCEDURES MANUAL

Attachment FP-17

PREGNANT AND BREASTFEEDING WOMEN'S FOOD PACKAGES

FOOD PACKAGE NUMBER
MINIMUM401 4GALS MILK I DOZ EGGS 4 CANS JUICE 24OZCEREAL I LB BEANS/PEAS OR 18 OZ PEANUT BUTTER
402 LIMITED MILK LACTOSE INTOLERANT 2GALSMILK 2 LBS CHEESE 2 DOZ EGGS 6 CANS JUICE 3602 CEREAL I LB BEANS/PEAS OR 18 OZ PEANUT BUTTER

VOUCHER

CODE

VOUCHER MESSAGE

040

MILK:

JUICE:

I GALOR4-12OZ CANS EVAPOR 1-5 QT BOX 1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-11.5 OZ CAN POURABLE

039

MILK:

EGGS: JUICE:

I GAL OR4-12 OZ CANS EVAPOR 1-5 QT BOX I DOZEN 1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-11.5 OZ CAN POURABLE

037

MILK:

I GAL OR4-12 OZ CANS EVAPOR

1-5 QT BOX

JUICE:

1-12 OZ CAN FROZEN OR 1-46 OZ CAN

CEREAL:

OR 1-11.5 OZ CAN POURABLE

BEANS/PEAS/ UP TO 24 OUNCES

P'NUT

I LB DRIED BEANS/PEAS OR

BUTTER:

18 OZ PEANUT BUTTER

040

MILK:

JUICE:

I GALOR4-12OZ CANS EVAPOR 1-5 QT BOX 1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-11.5 OZ CAN POURABLE

041

MILK:

EGGS: JUICE:

CEREAL:

I GALOR4-12OZCANSEVAPOR 1-5 QT BOX I DOZEN 2-12 OZ CANS FROZEN OR 2-46 OZ CANS OR 2-11.5 OZ CAN POURABLE UP TO 36 OUNCES

042

CHEESE:

JUICE:

UPTO I LB 1-12 OZ CAN FROZEN OR 1-46 OZ CAN
OR 1-11.5 OZ CAN POURABLE

028

MILK:

EGGS: JUICE:

I GALOR4-12OZCANSEVAPOR 1-5 QT BOX I DOZEN 2-12 OZ CAN FROZEN OR 2-46 OZ CANS OR 2-11.5 OZ CANS POURABLE

043

CHEESE:

UPTO I LB

JUICE:

1-12 OZ CAN FROZEN OR 1-46 OZ CAN

BEANS/PEAS/ OR 1-11.5 OZ CAN POURABLE

P'NUT

I LB DRIED BEANS/PEAS OR

BUTTER:

18 OZ PEANUT BUTTER



FP-69



GA WIC PROCEDURES MANUAL

Attachment FP-17 cont'd

FOOD PACKAGE NUMBER 403
4GALS MILK 1 LB CHEESE 1 DOZ EGGS 4 CANS JUICE 24OZCEREAL I LB BEANS/PEAS OR 18 OZ PEANUT BUTTER
404* 4GALS MILK 2 LBS CHEESE 2 DOZ EGGS 6 CANS JUICE 24OZCEREAL 1 LB BEANS/PEAS OR 18 OZ PEANUT BUTTER
*STANDARD MANUAL

VOUCHER CODE 037
039

VOUCHER MESSAGE

MILK:
JUICE: CEREAL: BEANS/PEAS/ P'NUT BUTTER:

'
: 1 GAL OR 4-12 OZ CANS EVAP OR : 1-5 QT BOX ' 1-12 OZ CAN FROZEN OR 1-46 OZ CAN
OR 1-11.5 OZ CAN POURABLE UP TO 24 OUNCES I LB DRIED BEANS/PEAS OR 18 OZ PEANUT BUTTER

MILK:
EGGS: JUICE

''' I GALOR4-12OZCANSEVAPOR : 1-5 QT BOX
: 1 DOZEN : 1-12 OZ CAN FROZEN OR 1-46 OZ CAN : OR 1-11.5 OZ CAN POURABLE

031

MILK:

CHEESE: JUICE:

I GALOR4-12 OZ CANS EVAPOR 1-5 QT BOX UPTO 1 LB. 1-12 OZ CAN FROZEN OR 1-46 OZ CAN
: OR 1-11.5 OZ CAN POURABLE

040

MILK:

JUICE:

028

MILK:

EGGS: JUICE:

: I GALOR4-12OZCANSEVAPOR : l-5QTBOX : 1-12 OZ CAN FROZEN OR 1-46 OZ CAN : OR 1-11.5 OZ CAN POURABLE
'
: I GAL OR 4-12 OZ CANS EVAP OR : 1-5 QT BOX : I DOZEN : 2-12 OZ CANS FROZEN OR 2-46 OZ : CANS OR 2-11.5 OZ CANS POURABLE

031

MILK:

CHEESE: JUICE:

: 1 GALOR4-12OZCANS EVAPOR : 1-5 QT BOX : UPTO 1 LB : 1-12 OZ CAN FROZEN OR 1-46 OZ CAN : OR 1-11.5 OZ CAN POURABLE

037

MILK:

: 1 GALOR4-12 OZ CANS EVAPOR

: 1-5QTBOX

JUICE:

' 1-12 OZ CAN FROZEN OR 1-46 OZ CAN

CEREAL:

OR 1-11.5 OZ CAN POURABLE

BEANS/PEAS/ UP TO 24 OUNCES

P'NUT

1 LB DRIED BEANS/PEAS OR

BUTTER:

'' 18 OZ PEANUT BUTTER

054

MILK:

CHEESE: EGGS: JUICE:

' 1 GALOR4-12 OZ CANS EVAPOR 1-5 QT BOX UPTO 1 LB 1 DOZEN
2-12 OZ CAN FROZEN OR 2-46 OZ CAN

: OR 2-11.5 OZ CANS POURABLE

FP-70



GA WIC PROCEDURES MANUAL

Attachment FP-17 cont'd

FOOD PACKAGE NUMBER

VOUCHER CODE VOUCHER MESSAGE

405

033

MILK:

4 QTS OR 2-1/2 GAL ACIDOPHILUS OR

ENJOY OR LACTAID OR LACTAID 100

LACTOSE

OR NUTRISH OR DAIRY EASE

REDUCED MILK

CHEESE:

UPTO 1 LB

JUICE:

1-12 OZ CAN FROZEN OR 1-46 OZ CAN

LACTOSE INTOLERANT

CEREAL:

OR 1-11.5 OZ CAN POURABLE

UP TO 36 OUNCES

12 QTS LACTOSE

REDUCED MILK

MILK:

4 QTS OR 2-1/2 GAL ACIDOPHILUS OR

3 LBS CHEESE

034

ENJOY OR LACTAID OR LACTAID 100

2DOZEGGS

OR NUTRISH OR DAIRY EASE

6CANSJUICE

EGGS:

I DOZEN

36 OZ CEREAL

JUICE:

2-12 OZ CANS FROZEN OR 2-46 OZ

I LB BEANS/PEAS OR

CANS OR 2-11.5 OZ CANS POURABLE

18 OZ PEANUT BUTTER

035

MILK:

2 QTS OR GAL ACIDOPHILUS OR

ENJOY OR LACTAID OR LACTAID 100

OR NUTRISH OR DAIRY EASE

CHEESE:

UPTO 1 LB

JUICE:

2-12 OZ CANS FROZEN OR 2-46 OZ

CANS OR 2-11.5 OZ CANS POURABLE

BEANS/PEAS/

1 LB DRIED BEANS/PEAS OR

P'NUT BUTTER: 18 OZ PEANUT BUTTER

036

MILK:

CHEESE: EGGS: JUICE:

2 QTS OR GAL ACIDOPHILUS OR ENJOY OR LACTAID OR LACTAID 100 OR NUTRISH OR DAIRY EASE UPTO I LB I DOZEN 1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-11.5 OZ CAN POURABLE



FP-71



GA WIC PROCEDURES MANUAL

Attachment FP-17 cont'd

FOOD PACKAGE NUMBER
406
5 GALS MILK 2 LBS CHEESE 2 DOZEN EGGS 6 CANS JUICE 36 OZ CEREAL I LB BEANS/PEAS OR 18 OZ PEANUT BUTTER

VOUCHER CODE 027
028
031
054

VOUCHER MESSAGE

MILK:
JUICE:
CEREAL: BEANS/PEAS/ P'NUT BUTTER:

' : 2 GAL OR 8-12 OZ CANS EVAP OR : 2-3 QT BOX : 1-12 OZ CAN FROZEN OR 1-46 OZ CAN ' OR 1-11.5 OZ CAN POURABLE
UP TO 36 OUNCES I LB DRIED BEANS/PEAS OR 18 OZ PEANUT BUTTER

MILK:
EGGS: JUICE:

' '

I GALOR4-12 OZ CANS EVAP OR

' '

1-5 QT BOX I DOZEN

: 2-12 OZ CANS FROZEN OR 2-46 OZ

: CANS OR 2-11.5 OZ CANS POURABLE

MILK:
CHEESE: JUICE:
MILK:
CHEESE: EGGS: JUICE:

:' I GALOR4-12OZCANSEVAPOR : 1-5 QT BOX : UPTO I LB : 1-12 OZ CAN FROZEN OR 1-46 OZ CAN : OR 1-11.5 OZ CAN POURABLE ' :' I GAL OR 4-12 OZ CANS EVAP OR : 1-5 QT BOX : UPTO I LB : I DOZEN : 2-12 OZ CANS FROZEN OR 2-46 OZ CAN
: OR 2-11.5 OZ CAN S POURABLE

MAXIMUM407
7GALS MILK 2 DOZEN EGGS 6 CANS JUICE 360ZCEREAL I LB BEANS/PEAS OR 18 OZ PEANUT BUTTER

027

MILK:

: 2 GALOR8-12 OZ CANS EVAP OR

: 2-3 QT BOX

JUICE:

: 1-12 OZ CAN FROZEN OR 1-46 OZ CAN

' OR 1-11.5 OZ CAN POURABLE

CEREAL:

UP TO 36 OUNCES

BEANS/PEAS/

I LB DRIED BEANS/PEAS OR

P'NUT BUTTER: 18 OZ PEANUT BUTTER

'

028

MILK:

' : I GALOR4-12OZCANSEVAPOR

: 1-5 QT BOX

EGGS:

: I DOZEN

JUICE:

: 2-12 OZ CANS FROZEN OR 2-46 OZ

: CANS OR 2-11.5 OZ CANS POURABLE

029

MILK:

JUICE:

2 GAL OR 8-12 OZ CANS EVAP OR 2-5 QT BOXES 1-12 OZ CAN FROZEN OR 1-46 OZ CAN
OR 1-11.5 OZ CAN POURABLE

030

MILK:

EGGS: JUICE:

2 GAL OR 8-12 OZ CANS EVAP OR 2-5 QT BOX I DOZEN 2-12 OZ CANS FROZEN OR 2-46 OZ CANS OR 2-11.5 OZ CANS POURABLE

FP-72



GA WIC PROCEDURES MANUAL

Attachment FP-17 cont'd

EXCLUSIVELY BREASTFEEDING FOOD PACKAGES

FOOD PACKAGE NUMBER
408** EXCLUSIVELY BREASTFEEDING
7GALSMILK I LB CHEESE 2 DOZEN EGGS 7 CANS JUICE 36OZCEREAL I LB BEANS/PEAS OR 1-18 OZ PEANUT BUTTER PLUS I LB BEANS/PEAS 2 LBS CARROTS 4CANSTUNA

VOUCHER CODE
001

VOUCHER MESSAGE

CHEESE: JUICE:
CARROTS: TUNA: BEANS/PEAS:

' UPTO I LB 1-12. OZ FROZEN OR 1-46 OZ CAN OR 1-11.5 OZ CAN POURABLE 2-1 LB SEALED PLASTIC BAGS 4-6 OZ CANS I LB DRIED BEANS OR PEAS

027

MILK:

2 GAL OR 8-12 OZ CANS EVAP OR

2-3 QT BOX

JUICE:

1-12 OZ CAN FROZEN OR 1-46 OZ CAN

OR 1-11.5 OZ CAN POURABLE

CEREAL:

UP TO 36 OUNCES

BEANS/PEAS/ I LB DRIED BEANS/PEAS OR

P'NUT

18 OZ PEANUT BUTTER

BUTTER:

028

MILK:

EGGS: JUICE:

I GAL OR4-12 OZ CANS EVAPOR 1-5 QT BOX I DOZEN 2-12 OZ CANS FROZEN OR 2-46 OZ CANS OR 2-11.5 OZ CANS POURABLE

029

MILK:

JUICE:

2 GAL OR 8-12 OZ CANS EVAP OR 2-5 QT BOXES 1-12 OZ CAN FROZEN OR 1-46 OZ CAN
OR 1-11.5 OZ CAN POURABLE

030

MILK:

EGGS: JUICE:

2 GAL OR 8-12 OZ CANS EVAP OR 2-5 QT BOXES I DOZEN 2-12 OZ CANS FROZEN OR 2-46 OZ CANS OR 2-11 :5 OZ CANS POURABLE

999

999

AS PRESCRIBED

7 GALS OR 28 QTS MILK 4 LBS CHEESE 2 DOZ EGGS 7 CANS JUICE 36OZCEREAL I LB BEANS/PEAS OR 18 OZ PEANUT BUTTER

A TAILORED PACKAGE DESIGNED BY THE CPA WHICH MUST NOT EXCEED THE MAXIMUM QUANTITY OF SUPPLEMENTAL FOODS FOR THE PARTICIPANT'S CATEGORY.

These food packages may be issued to breastfeedmg women who are not receiving formula from the WIC Program, for their infants (defined here as exclusively breastfeeding).
a. Food package 408 can be issued to the mother immediately afler delivery. Food package 999, voucher code 999, may be tailored for exclusively breastfeeding women not to exceed the maximum amounts listed in package 408.
b. Substitution for food package 408 only: I. 5 gallons of milk and 2 lbs. cheese to replace 7 gallons of milk 2. 4 lbs cheese to replace 7 gallons of milk
c. A maximum of 2 pounds of cheese per month is recommended except for those with lactose intolerance.

FP-73



GA WIC PROCEDURES MANUAL

Attachment FP-18

ALTERNATEFOODPACKAGESFORPREGNANTAND BREASTFEEDING WOMEN
MAXIMUM MONTHLY AMOUNTS AUTHORIZED

FOOD
UHTMilk
Lactose Reduced Milk Cereal Juice

PREGNANT, AND BREASTFEEDING 112-8 oz boxes
OR
16 quarts or 8 - gallons
4-9 oz boxes
42 - 6 oz cans

EXCLUSIVELY BREASTFEEDING* 124 - 8 oz boxes
31 quarts or 15 - gallons 4-9 oz boxes 56-6 oz cans



Peanut Butter Beans/Peas Tuna Carrots

2-18 oz jars
-----------------

3-18 oz jars 4-15 oz cans 6-6 oz cans 2-15 oz cans only

This food package consists of 8-9 vouchers
*Exclusively breastfeeding is defined here as receiving no formula from the WIC Program, for their infants .



FP-74



GA WIC PROCEDURES MANUAL

Attachment FP-19

ALTERNATE FOOD PACKAGES FOR PREGNANT AND BREASTFEEDING WOMEN

FOOD PACKAGE NUMBER
410 (PREGNANT AND BREASTFEEDING)
112 - 8 OZ BOXES UHT MILK OR 16QTOR 8 - GAL LACTOSE REDUCED MILK 4-9 "OZ BOXES CEREAL 42-6 OZ CANS JUICE 2-18 OZ JARS PEANUT BUTTER

VOUCHER CODE 620
621 621 621 622
622
623 624

VOUCHER MESSAGE

MILK:
CEREAL: JUICE: PEANUT Bl.JTTER:

:
14-8 OZ BOXES UHT OR 2 QTS OR 1-1/2 GAL LACTOSE REDUCED 1-9OZBOX 6-6 OZ CANS
1-18 OZ JAR

MILK: JUICE:

14-8 OZ BOXES UHT OR 2 QTS OR 1-1/2 GAL LACTOSE REDUCED 6-6 OZ CANS

MILK: JUICE:

14-8 OZ BOXES UHT OR 2 QTS OR 1-1 /2 GAL LACTOSE REDUCED 6-6 OZ CANS

MILK: JUICE:

14-8 OZ BOXES UHT OR 2 QTS OR 1 - I/2 GAL LACTOSE REDUCED 6-6OZ CANS

MILK:
CEREAL: JUICE:

14-8 OZ BOXES UHT OR 2 QTS OR 1-1/2 GAL LACTOSE REDUCED 1-9 OZ BOX 6-602 CANS

MILK:
CEREAL: JUICE:

14-8 OZ BOXES UHT OR 2 QTS OR 1-1/2 GAL LACTOSE REDUCED 1-902 BOX 6-6 OZ CANS

MILK: CEREAL:

14-8 OZ BOXES UHT OR 2 QTS OR 1-1/2 GAL LACTOSE REDUCED 1-9OZBOX

MILK:
JUICE: PEANUT BUTTER:

14-8 OZ BOXES UHTOR 2 QTS OR 1-1/2 GAL LACTOSE REDUCED 6-602 CANS
1-18 OZ JAR



FP-75



GAWICPROCEDURESMANUAL

Attachment FP-19 cont'd

FOOD PACKAGE NUMBER

VOUCHER CODE VOUCHER MESSAGE

411

630

MILK:

15-8 OZ BOXES UHT OR 4 QTS OR 2-1 /2

(EXCLUSIVELY

GAL LACTOSE REDUCED

BREAST FEEDING)

CEREAL:

l-9OZBOX

JUICE:

7-6 OZ CANS

124-8 OZ BOXES UHT MILK

P'NUT

1-18 OZ JAR

31 QUARTS OR 15-1/2 GAL

BUTTER:

LACTOSE REDUCED MILK

BEANS/ PEAS: 1-15 OZ CAN

36OZCEREAL

CARROTS:

1-15 OZ CAN

56-6 OZ CANS JUICE

3-18 OZ JAR PEANUT

631

MILK:

15-8 OZ BOXES UHT OR 4 QTS OR 2-1 /2

BUTTER

GAL LACTOSE REDUCED

6-6 OZ CANS TUNA

JUICE:

7-6 OZ CANS

4-15 OZ CANS BEANS/PEAS

TUNA:

2-6 OZ CANS

2-15 OZ CANS CARROTS

631

MILK:

' 15-8 OZ BOXES UHT OR 4 QTS OR 2-1 /2

GAL LACTOSE REDUCED

JUICE:

7-6 OZ CANS

TUNA:

: 2-6 OZ CANS

632

MILK:

CEREAL: JUICE: P'NUT BUTTER:

' : 15-8 OZ BOXES UHT OR 4 QTS OR 2-1 /2 ' GAL LACTOSE REDUCED
1-9OZBOX 7-6 OZ CANS 1-18 OZ JAR

634

MILK:

JUICE: P'NUT BUTTER:

15-8 OZ BOXES UHT OR 4 QTS OR 2-1 /2 GAL LACTOSE REDUCED 7-6 OZ CANS 1-18 OZ JAR

635

MILK:

15-8 OZ BOXES UHT OR 4 QTS OR 2-1/2

GAL LACTOSE REDUCED

CEREAL:

1-902 BOX

JUICE:

7-6 OZ CANS

BEANS/ PEAS: 1-15 OZ CAN

CARROTS:

1-15 OZ CAN

636

MILK:

19-8 OZ BOXES UHT OR 4 QTS OR 2-1 /2

GAL LACTOSE REDUCED

JUICE:

7-6 OZ CANS

BEANS/ PEAS: 1-15 OZ CAN

CEREAL:

1-902 BOX

633

MILK:

15-8 OZ BOXES UHT OR 3 QTS OR 1-1 /2

GAL LACTOSE REDUCED

JUICE:

7-6 OZ CANS

BEANS/ PEAS: 1-15 OZ CAN

TUNA:

2-6OZ CANS



FP-76



GA WIC PROCEDURES MANUAL

Attachment FP-20

POSTPARTUM, NON-BREASTFEEDING WOMEN'S FOOD PACKAGES MAXIMUM MONTHLY AMOUNTS AUTHORIZED

FOOD

MAXIMUM AMOUNT PER MONTH

Milk'

24 quart equivalents2

Cheese

4 pounds3

Eggs

2 dozen



Juice Cereal

4-46 oz cans or 4-12 oz frozen or 4-11.5 oz pourable
36 ounces

'Substitute up to 24 quarts oflactose reduced milk to replace up to 6 gallons of milk. 2Substitution amounts for fluid milk include: ITEM FLUID MILK EQUIVALENTS
Cheese, 1 pound 3 quarts
Evaporated milk, whole or skim (13 oz) 1 quart
Dry whole milk, 1 pound 3 quarts
Nonfat or lowfat dry milk, 1 pound 5 quarts 3Subtract from monthly milk allotment. A maximum of two (2) pounds of cheese per month is recommended
except for those with lactose intolerance.



FP-77



GAWICPROCEDURESMANUAL

Attachment FP-21

POSTPARTUM, NON-BREASTFEEDING WOMEN'S FOOD PACKAGES

FOOD PACKAGE NUMBER
MINIMUM 501 3.GALSMILK I DOZEN EGGS 3 CANS JUICE 18 OZ CEREAL
502 3 GALS MILK 2 LBS CHEESE I DOZ EGGS 4 CANS JUICE 24OZCEREAL
*STANDARD MANUAL

VOUCHER CODE 040
040
053 052 040
042 047
055

VOUCHER MESSAGE

MILK: JUICE:

I GALOR4-12OZ CANS EVAPOR 1-5 QT BOX 1-12 OZ CAN FROZEN OR 1-46 OZ CAN
OR 1-11.5 OZ CAN POURABLE

MILK: JUICE:

I GALOR4-12 OZ CANS EVAP OR 1-5 QT BOX 1-12 OZ CAN FROZEN OR 1-46 OZ CAN
OR 1-11.5 OZ CAN POURABLE

MILK: CEREAL:

I GALOR4-12OZCANSEVAPOR 1-5 QT BOX UP TO 18 OUNCES

JUICE: EGGS:

1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-11.5 OZ CAN POURABLE I DOZEN

MILK: JUICE:

I GALOR4-l2OZCANSEVAPOR 1-5 QT BOX 1-12 OZ CAN FROZEN OR 1-46 OZ CAN
OR 1-11.5 OZ CAN POURABLE

CHEESE: JUICE:

UPTO I LB 1-12 OZ CAN FROZEN OR 1-46 OZ CAN
OR 1-11.5 OZ CAN POURABLE

MILK: JUICE: CEREAL:

I GALOR4-12 OZ CANS EVAPOR 1-5 QT BOX 1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-11.5 OZ CAN POURABLE UP TO 24 OUNCES

MILK:
CHEESE: EGGS: JUICE:

I GALOR4-12OZCANSEVAPOR 1-5 QT BOX UPTO I LB I DOZEN 1-12 OZ CAN FROZEN OR 1-46 OZ CAN
OR 1-11.5 OZ CAN POURABLE



FP-78



GA WIC PROCEDURES MANUAL

Attachment FP-21 cont'd

FOOD PACKAGE NUMBER
MAXIMUM 503 6 GALS MILK 2 DOZEN EGGS 4 CANS JUICE 36OZCEREAL
504 LACTOSE REDUCED MILK LACTOSE INTOLERANT 12 QTS MILK 2 LBS CHEESE I DOZEN EGGS 4 CANS JUICE 24OZCEREAL
999*
6 GALS OR 24 QTS MILK SUBSTITUTE I LB CHEESE FOR 3 QTS MILK 2 DOZEN EGGS 4 CANS JUICE 36 OZ CEREAL

VOUCHER CODE 050
051 039 051 501
502 503
504
999

VOUCHER MESSAGE

MILK: JUICE:
CEREAL: EGGS:

: 1 GALOR4-12OZCANSEVAPOR : 1-5 QT BOX : 1-12 OZ CAN FROZEN OR 1-46 OZ CAN : OR 1-11.5 OZ CAN POURABLE : UP TO 36 OUNCES AND 1 DOZEN

MILK:
JUICE:
MILK: EGGS: JUICE:

: 2 GALS OR 8-12 OZ CANS EVAP OR : 2-5 QT BOX : 1-12 OZ CAN FROZEN OR 1-46 OZ CAN
' 1 GAL OR 4-12 OZ CANS EVAP OR 1-5 QT BOX AND EGGS 1 DOZEN 1-12 OZ CAN FROZEN OR 1-46 OZ CAN
: OR 1-11.5 OZ CAN POURABLE

MILK: JUICE:
MILK:
CHEESE: JUICE:

: 2 GALS OR 8-12 OZ CANS EVAP OR : 2-5 QT BOX : 1-12 OZ CAN FROZEN OR 1-46 OZ CAN
: OR 1-11.5 OZ CAN POURABLE
' : 4 QTS OR 2-1/2 GAL ACIDOPHILUS OR : ENJOY OR LACTAID OR LACTAID 100 : NUTRISH OR DAIRY EASE: UPTO 1 LB : 1-12 OZ CAN FROZEN OR 1-46 OZ CAN
: OR 1-11.5 OZ CAN POURABLE

MILK:
EGGS; JUICE:

: 4 QTS OR 2-1/2 GAL ACIDOPHILUS OR : ENJOY OR LACTAID OR LACTAID 100 : NUTRISH OR DAIRY EASE: I DOZEN : 1-12 OZ CAN FROZEN OR 1-46 OZ CAN

MILK:
CHEESE: JUICE:

: 2 QTS OR 1-1/2 GAL ACIDOPHILUS OR : ENJOY OR LACTAID OR LACTAID 100 : NUTRISH OR DAIRY EASE : UPTO I LB : 1-12 OZ FROZEN OR 1-46 OZ CAN ': OR 1-11.5 OZ CAN POURABLE

MILK:
JUICE: CEREAL:

: 2 QTS OR 1-1/2 GAL ACIDOPHILUS OR : ENJOY OR LACTAID OR LACTAID 100 : NUTRISH OR DAIRY EASE : 1-12 OZ CAN FROZEN OR 1-46 OZ CAN : UP TO 24 OUNCES

AS PRESCRIBED A TAILORED PACKAGE DESIGNED BY THE CPA MUST NOT EXCEED THE MAXIMUM QUANTITY OF SUPPLEMENTAL FOODS FOR THE PARTICIPANTS CATEGORY

FP-79



GA WIC PROCEDURES MANUAL

Attachment FP-22

ALTERNATE FOOD PACKAGES FOR POSTPARTUM, NON-BREASTFEEDING WOMEN
MAXIMUM MONTHLY AMOUNTS AUTHORIZED



FOOD
UHTMilk OR Lactose Reduced Milk
Cereal
Juice
Peanut Butter

SIZE
72-8 ounce boxes 18 quarts OR 9-1/2 gallons
4-9 ounce boxes
30-6 ounce cans
1-18 ounce jar

This food package consists of eight (8) vouchers.

MAXIMUM AMOUNT 576 ounces
36 ounces 184 ounces 18 ounces



FP-80



GA WIC PROCEDURES MANUAL

Attachment FP-23

ALTERNATE FOOD PACKAGE FOR POSTPARTUM, NON-BREASTFEEDING WOMEN



FOOD PACKAGE NUMBER
510
72 - 8 OZ BOXES UHT MILK 18 QTS OR 9-1/2 GAL LACTOSE REDUCED MILK 4-9 OZ BOXES CEREAL 30-6 OZ CANS JUICE 1-18 OZ JAR PEANUT BUTTER

VOUCHER CODE 642
645
642
641 642
641 641 642

VOUCHER MESSAGE

MILK:
CEREAL: JUICE:

9-8 OZ BOXES UHT OR 2 QTS OR 1-1 /2 GAL LACTOSE REDUCED 1-9OZBOX 6-6OZCANS

MILK:
PEANUT BUTTER: JUICE:

9-8 OZ BOXES UHT OR 4 QTS OR 2-1/2 GAL LACTOSE REDUCED
1-18 OZ JAR 6-6OZCANS

MILK:
CEREAL: JUICE:

9-8 OZ BOXES UHT OR 2 QTS OR 1-1 /2 GAL LACTOSE REDUCED 1-9 OZ BOX 6-6OZCANS

MILK:

9-8 OZ BOXES UHT OR 2 QTS OR 1-1 /2 GAL LACTOSE REDUCED

MILK:
CEREAL: JUICE:

9-8 OZ BOXES UHT OR 2 QTS OR 1-1 /2 GAL LACTOSE REDUCED 1-9 OZ BOX 6-6OZCANS

MILK:

9-8 OZ BOXES UHT OR 2 QTS OR 1-1/2 GAL LACTOSE REDUCED

MILK:

9-8 OZ BOXES UHTOR 2 QTS OR 1-1/2 GAL LACTOSE REDUCED

MILK:
CEREAL: JUICE:

9-8 OZ BOXES UHT OR 2 QTS OR 1-1 /2 GAL LACTOSE REDUCED 1-9OZBOX 6-6OZCANS



FP-81



GA WIC PROCEDURES MANUAL
GEORGIA WIC PROGRAM FORMULA REFERRAL FORM (To Be Completed By Referral Agency)

DATE: TO: FROM:
PHONE#:

WICPROGRAM Signatureffitle (Physician) Health Facility - Location

Attachment FP-24



1. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ is a resident of _ _ _ _ _ _ _ _ _ __

(NAME)

(COUNTY)

He/She receives treatment for _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ His/Her local physician is
(DIAGNOSIS)

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _. Please provide _ _ _ _ _ ounces of _ _ _ __

(NAME)

(AMOUNT)

(NAME)

formula monthly. I estimate he/she will need this formula for _ _ _ _ months.
(NUMBER)
2. Check the correct statement:

D This client has been assessed for the WIC Program. A WIC Program Assessment/Certification is attached.

D Please assess this client for the WIC Program. The following information was collected on----=------

(DATE)

Length/Height* _ _ __

Weight* _ _ __

Hematocrit/Hemoglobin* _ _ __

3. Diet Order: Please list other WIC approved foods allowed and any follow-up diet instructions. The WIC Program authorizes the following distribution to infants and children: Infants, 5-12 months old - up to 92 ounces of fruit juice and 24 ounces of infant cereal. Children - up to 4 quarts of fruit juice and 36 ounces of cereal.

Please include this information, if available.



[SAMPLE FORM. MAY BE ADAPTED FOR LOCAL AGENCY USE] FP-82



GA WIC PROCEDURES MANUAL

Attachment FP-25

GEORGIA WIC APPROVED FOOD LIST CRITERIA TO EVALUATE AN ELIGIBLE FOOD ITEM

I. Administrative Adjustments

A.

A food company interested in participating in the Georgia WIC Program should submit product

statewide availability, package size, unit cost per ounce and nutrient composition information to

the Office of Nutrition by October 1st of each year.

B.

A review of potentially new food items shall be conducted biennially. Consequently, the WIC

Approved Food List shall be printed biennially only. Biennial review of the WIC Food List does

not necessarily constitute a change in the food list. Changes to the WIC Approved Food List shall

occur more frequently only to accommodate Federal mandates.

C.

A product must be commercially available as a brand name, or a store brand, for a minimum of

twelve ( 12) consecutive months prior to October 1st of each year.

D.

The food item cost cannot exceed 10 percent (10%) of the State average cost per ounce for that

food group. Food groups include:

1.

Milk

2.

Eggs

3.

Cereal

4.

Infant Cereal

5.

Tuna

6.

Cheese

7.

Juice

8.

Dried Beans/Peas and Peanut Butter

9.

Carrots

E.

The food item must be acceptable to participants.

II. Nutrition Quality

A.

Cereal - Adult

1.

Contains a minimum of 28 mg o,f iron per 100 gm of dry cereal.

2.

Contains not more than 14.1 gm of sucrose and other sugars per 100 gm of dry cereal

(less than 4 gm per ounce). High fiber cereals (5 gm or more) must not contain more

than 6 gm of total sugar per 100 gm of dry cereal.

3.

Contains not more than 500 mg of sodium per 1 ounce of dry cereal.

4.

Contains no artificial or non-nutritive sweeteners.

B.

Cereal - Infant

1.

Contains a minimum of 45 mg of iron per 100 gm of dry cereal.

2.

Contains rio added sugar.

3.

Contains no added fruit.

4.

Contains no added formula

C.

Milk

1.

Contains 400 IU vitamin D per quart.

2.

Contains 2,000 IU vitamin A per quart.

3.

Contains no added sugar or flavorings.

4 .

No Buttermilk or Goat's milk.

FP-83



GA WIC PROCEDURES MANUAL

Attachment FP-25 cont'd

D.

Cheese

Domestic Cheese (pasteurized, processed American, Monterey Jack, Colby, Natural Cheddar, Mozzarella).

E.

Peanut Butter and Canned/ Dried Beans and Peas

1.

Including, but not limited to: black, navy, kidney, garbanzo, soy, pinto, great northern,

red, white, lima, black, broad, fava, cranberry, roman, and mung beans; crowder, cow,

split, blackeyed and pigeon peas, chickpeas, and lentils.

2.

No flavored beans/peas allowed.

3.

No peanut butter and jelly or honey combinations.

F.

Juice

1.

Single strength or frozen concentrate or canned concentrate or pourable, l 00% fruit juice

2.

30 mg vitamin C per I00 ml of reconstituted juice, minimum.

3.

Contains no added sugar.

4.

Contains no added calcium.

5.

No infant juices allowed.

G.

Eggs

Whole, large, grade A.

H.

Carrots

Mature, raw or canned, packaged in water only.

I.

Tuna

100% tuna, water packed only.

III. Packaging

A.

Food must be prepackaged, no bins.

B.

Cereal (adult and infant)

I.

No single serving containers.

2.

Adult cereal weight must be in whole numbers, minimum of9 ounces, not to exceed 36

ounces.

3.

Infant cereal only in eight (8) ounce packages.

C.

Cheese

1.

Brick or sliced cheese only, no shredded.

2.

Cheese from the dairy case only, no deli cheese.

3.

Plain cheese only, no additions ofproducts such as jalapeno peppers.

4 .

A minimum of 9 ounces, not to exceed 16 ounces.

FP-84



GA WIC PROCEDURES MANUAL

Attachment FP-25 cont'd

D.

Juice

1.

No single serving containers.

2.

No fresh squeezed.

3.

Containers must be easily and clearly identified as fortified with 30 mg of vitamin C per

100 ml ofjuice, except orange juice and grapefruit juice.

4.

Forty-six (46) ounce cans, 12 ounce frozen cans, 12 ounce cans concentrate, or 11.5 oz

pourable cans or 6 ounce cans only.

E.

Eggs

One dozen size carton only.

F.

Milk

1.

One gallon size: Whole, Reduced Fat (2%), Lowfat ( 1%), Lite(%), Skim (Non-Fat).

2.

One-half gallon or quart size containers only for Lactose Reduced milk.

3.

Twelve ounce cans only for Evaporated milk.

4.

Three or 5 quart boxes for Powdered milk.

5.

8 ounce box for ultra high temperature (UHT) milk.

G.

Carrots

One pound plastic bag, pre-packaged with wire or adhesive tape or 15 ounce can only.

H.

Tuna

6 ounce can only.

I.

Peanut Butter

18 ounce jar only.

J. . Dried Beans/Peas

1 pound bag or 15 ounce can only.

IV. Formula

A.

Complete Formula

1.

Iron fortified infant formula that contains at least 10 mg iron per liter of formula at

standard dilution.

2.

67 kcal per milliliter (approximately 20 kcal per fluid ounce at standard dilution).

B.

Formula Not Meeting the Requirements for a Complete Formula

1.

Formula intended for use as an oral feeding and prescribed by a physician when the

participant has a medical condition that precludes the use of conventional formula or

food.

2.

Allow supplements to be used in conjunction with an appropriate prorated food package.

Substitute a specified amount of supplement per quart or can of milk or formula .

Address: Georgia Division of Public Health, Office of Nutrition, 2 Peachtree Street, NW, Suite 8-413, Atlanta, Georgia 30303-3186

FP-85



GA WIC PROCEDURES MANUAL

Attachment FP-26

Georgia WIC Program WIC APPROVED FOOD LIST

FOOD ITEM
MILK (Pasteurized)

ONLY the followin list of foods may be =ased usin WIC vouchers:

BRAND OR TYPE

CONTAINER/PACKAGE SIZE

Whole, Skim, 99% Fat Free, or Low Fat (2%) (Least Expensive Brand ONLY)
Acidophilus, Enjoy, Lactaid, Lactaid 100, Daily Ease, or Nutrish
(Evaporated or Powder)

One ( I) Gallon Size ONLY (Exception: Gallons or Quarts of Enjoy, Lactaid, Lactaid JOO, Dairy Ease, Nutrish ,and/or Acidophilus,
12-0unce Cans Evaporated, 3-S Quart Boxes Powdered

NOT ALLOWED
Flavored Milk, Buttermilk, or Goat's Milk

CEREAL

Cheerios, Com Chex. Rice Chex or Wheat Chex, Country Com Flakes, Harvest Instant Oatmeal (Regular Flavor), Kix, Nabisco Cream of Wheat (Regular Flavor), Product 19, Jim Dandy Quick Grits (Iron Fortified), Quaker Instant Grits (Regular Flavor), Total Com Flakes, Kellogg's Special K, Kelloggs's Com Flakes.Kellogg's Complete Bran Flakes, Quaker Sun Country Quick Oats (Regular Flavor), Quaker Crunchy Com Bran, *Ralston Optima JOO Whole Wheat Flakes. Ralston Enriched Bran Flakes.Ralston Nutty Nuggets, Ralston Instant Oatmeal (Regular Flavor), Ralston Crispy Rice, Ralston Corn Flakes, Ralston Tasteeo, Ralston Crispy Carn Puff
*R11lsto11 Store Brands Allowed: Kroger, Kounty Fresh, /GA, Red &White, Flavorite or Nature's Best

Nine (9) Ounce Sizes and Above ONLY
Can Purchase More Than One (I) Type/Brand of Cereal As Long As The Amount Does Not Go Over The Quantity on the Front of The
Voucher

Eight (8) Ounces or Less Size Boxes

CHEESE

American (Sliced, Singly Wrapped or Block), Cheddar (Block), Colby (Block), Monterey Jack (Block),
Mozzarella (Block),
(Reduced Fat, Low Fat or Fat Free Cheese Is Allowed)

Nine (9) Ounce, Up to 16-0unce One (I) Pound Size ONLY

Cheese Food, Shredded or Deli Cheese, Two (2) Eight (8) Ounce Packages for One (I)
I6-0unce Package, or any Eight (8) Ounce or Smaller
Package

JUICE
(100% USRDA Vitamin C Fortified)

ORANGE: Least Expensive Brand ONLY GRAPEFRUIT: Least Expensive Brand ONLY GRAPE: Welch's Seneca or Juicy Juice WHITE GRAPE: Welch's or Seneca APPLE: Flavoriu:, Kroger, Lucky Leaf, Juicy Juice, Seneca lRed Label Only}, Staff, Thifly Maid, ShurFine, White House OTHERSDOLE: Orange/Pineapple, Orange/Pineapple/Banana, Pineapple/Grapefrui~ Mandarin Tangerine, Orchard Peach, JUICY JUICE: Cherry, Punch, Tropical, Deny, Apple, Grape, Orange/ Punch, Strawbmy Pourables:
WELCH'S: Juicemakcrs -Apple, Grape or Whiu: Grape
JUICY JUICE: Punch, Grape, Cherry, Deny, Strawbmy or Apple

46-0unce Cans or 12-0unce Frozen Cans or 11.S Ounce Pourable Can ONLY

Juice Drinks, Fresh Squeezed Juice Single Serving Sizes, Infant Juices, Juices with Sugar Added Seneca Frozen White Grape Juice Cocktail

EGGS (Grade A Large ONLY)

Least Expensive Brand ONLY

One (I) Dozen

Any Other Size/Quantity

DRIED PEAS/BEANS

Any Brand Without Flavoring Added

One (I) Pound Size ONLY

Any Other Size/Quantity

PEANUT BUTTER

Any Brand Without Jelly Added or Honey Spread

18-0unce Jars ONLY

Any Other Size/Quantity

INFANT FORMULA

As Listed On The Front of the Voucher

As Listed On Front of the Voucher Any Type Not Listed On Front of Voucher

INFANT CEREAL (Boxes ONLY)

Beech Nut, Gerber, Heinz

Dry Cereal in Eight (8) Ounce Sizes ONLY

Any Baby Food in Jars or Any Dry Cereal with Fruit or Formula Aided

TUNA

Water Packed ONLY

6 Ounce Cans ONLY

Tuna Packed in Oil

CARROTS

Fresh, Whole

One (I) Pound Pre-Sealed Plastic Bag ONLY
FP-86

Bulk, Frozen, Canned, Shredded, or Baby Carrots



GA WIC PROCEDURES MANUAL
Georgia WIC Program WIC APPROVED ALTERNATE FOOD LIST

Attachment FP-27

FOOD ITEM MILK
(Pasteurized) CEREAL
JUICE
CANNED PEAS/ BEANS..!!! LENTILS PEANUT BUTTER INFANT FORMULA INFANT CEREAL (Boxes ONLY) TUNA CARROTS

ONLY the followina list of foods mm, be ourchased usina WIC vouthen

BRAND oa TYPE

CONTAINER/PACKAGE SIZE

UHT, MILK, Whole or 2% (least expensive brand)
or Acidophilus, Enjoy, Lactaid 100, Lactaid, Dairy Ease or Nutrish

8 Ounce Box or Gallon Or Quart of Lactose Reduced Milk

Cheerios, Com Chex, Rice Chex, or Wheat Chex, Country Com Flakes, Kix, Product 19, Com Tola!, Nabisco Cream of Wheat (Regular Flavor), Jim Dandy Quick Grits (Iron Fortified), Harvest Instant Oatmeal (Regular Flavor) Quaker Instant Oatmeal (Regular Flavor) Kellogg's Special K, Kellogg's Com Flakes, Kellogg's Complete Bran Flakes, Quaker Sun Country Quick Oats (Regular Flavor), Quaker Crunchy Com Bran, *Ralsr,,n Optima 100 WholeWheat Flakes, Ralston Enriched Bran Flakes, Ralston Nutty Nuggets, Ralston Instant Oatmeal (Regular Flavor), Ralston Crispy Rice, Ralston Bran Flakes, Ralston Com Flakes, Ralston Tasteeo, Ralston Crispy Com Puff

Nine (9) Ounce Size Can Purchase More than One (I) Type/Brand of
Cereal as Long as the Amount Does Not Go over the Quantity on
the front of the Voucher

*Rahton Store Brands Allowed:Kroger, Kounty Fresh, /GA, Red& White, Flavorite, or Nature's Best

ORANGE: Least Expensive Brand ONLY GRAPEFRUIT: Least Expensive Brand ONLY GRAPE: Welch's, Seneca or Juicy Juice WHITE GRAPE: Welch's APPLE: Flavorite, Kroger, Lucky Leaf, Staff, ShurFine, Whitehouse, Thrifty Maid, Seneca (Red Label ONLY), Juicy Juice OTHERSDOLE:Orange/Pineapple, Orange/Pineapple/Banana, Pineapple/Grapefruit JUICY JUICE: Cherry, Punch, Tropical, Berry, Apple/Grape, Orange Punch, Sbawberry

6 ounce can

Any Brand without Flavoring Added

IS ounce can only

Any Brand without Jelly Added or Honey Spread
As listed on the front of the Voucher
Beech Nut, Gerber, Heinz
Water Packed ONLY Any Brand Without Flavoring Added

18 ounce jar only As listed on front of Voucher Dry Cereal in 8 ounce size only
6 ounce cans only IS ounce canned sliced, medium
cut

NOT ALLOWED Flavored Milk, Buttermilk, or
Goat's Milk
8 Ounce or less Size Boxes

Juice Drinks, Fresh Squeezed Juice, Infant Juice, Juice with Sugar
Added Seneca Frozen White Grape Juice Cocktail

Any other size/quantity.

Circcn peas. Grc1..n 1

Snap1

Ycl111w or Wa, !>cans, b~an$

wi1l1 added fl:ivoring

Any other size/quantity

Any type not listed on front of the voucher
Any baby food in jars or any dry cereal with fruit or formulas added
Tuna packed in oil
Bulk, frozen shredded or baby carrots



FP-87



GA WIC PROCEDURES MANUAL WIC Approved Formulas/Medical Foods

Attachment FP-28

Contract Infant Formula: a,b
Similac with Iron Isomil Similac Lactose Free (Prescription required)

Ross Products Ross Products Ross Products

Non-Contract Formu1as/Med'1caIF00dS Reqmrm2 a prescn'pf10n andD'1a2nos1s.: a,d,,c

Acerflex
Advera Alimentum AlitraO Analog MSUD AnalogXLEU Analog XLYS,TRY Analog XMET
Analog XMTVI AnalogXP

Scientific Hospital Sunnlies Ross Products Ross Products Ross Products SHS SHS SHS

Crucial
Cvclinex 1 Cvclinex 2 Deliver 2.0 Duocal Elecare Elementra

SHS

Enfamil 22

SHS

EnfamilAR

SHS

Enfamil Next

Sten Soy

Nestle
Ross Products . Ross Products Mead Johnson SHS Ross Nestle
Mead Johnson
Mead Johnson Mead Johnson

Hominex-1
Hominex-2 lntrolite Isocal Isomil Isomil DF lsoPro
lsoSource Standard lsoSource HN lsoSource 1.5

Ross Products
Ross Products Ross Products Mead Johnson Ross Products Ross Products Nutrition Medical Novartis
Novartis Novartis.

Analog XPHEN.TRY Analog XPTM
Boost Boost Fiber Boost High Protein

SHS
SHS
Mead Johnson Mead Johnson Mead Johnson

Ensure

Ross Products

Ensure High Protein Ensure Plus Ensure Plus HN Ensure Pudding

Ross Products
Ross Products Ross Products Ross Products

I-Valex-1
I-Valex-2
Jevitv Ketonex-1 Ketonex-2

Ross Products
Ross Products
Ross Products Ross Products Ross Products

Boost Plus

Mead Johnson

Boost Pudding Mead Johnson

Carnation Alsoy Carnation

Carnation Follow-up Sov Casec

Carnation Mead Johnson

Choice d.m. Citrisource Ctrotein Compleat Modified Compleat Pediatric Compleat Regular

Mead Johnson Novartis Novartis Novartis
Novartis
Novartis

Ensure with Fiber Entrition 0.5

Ross Products Ross Products

Entrition HN

Nestle

EO28 Extra

SHS

FiberPro
Fiber Source Fiber Source HN Forta Drink Forta Shake

Nutrition Medical Novartis Novartis Ross Products Ross Products

Kindercal

Mead Johnson

L-Elemental
L-Elemental Hepatic L-Elemental Pediatric L-Elemental Plus Lipisorb Lofenalac LoPro Magnacal Renal

Nutrition Medical Nutrition Medical Nutrition Medical Nutrition Medical Mead Johnson Mead Johnson Med-Diet Labs Mead Johnson

Gluco-Pro Glucerna

Nutrtion Medical Maxamaid

SHS

MSUD

Ross Products Maxamaid UCD SHS

Criticare HN

Mead Johnson

Glytrol

Nestle

Maxamum

SHS

XLEU

FP-88



GA WIC PROCEDURES MANUAL

Attachment FP-28 cont'd

r Non-ContractFormuIas/Med"1caIF00dS R equ1rme: a p rescnp 100 andD"1ae:nos1s: a,d,c

Maxmaid XMET SHS

Nutren 1.0

Nestle

Pregestimil 24 Mead Johnson

Maxamaid

SHS

XMTVI

Nutren 1.0 with Nestle Fiber

Pro Balance

Nestle

MaxamaidXP SHS

Nutren 1.5

Nestle

Product 3200 AB

Mead Johnson

Maxamaid

SHS

Nutren 2.0

Nestle

Product 3232 A Mead Johnson

XPHEN,TYR

Maxamum

SHS

Nutren Junior

Nestle

Product 80056 Mead Johnson

MSUD

Maxamum

SHS

XLYS,TRY

Nutren Junior with Fiber

Nestle

ProMod

Ross Products

Maxamum

SHS

NutriHep

Nestle

Promote

Ross Products

XMET

Maxamum

SHS

XMTVI

NutriVent

Nestle

Pro-Peptide

Nutrition Medical

MaxamumXP SHS

Osmolite

Ross Products

Pro-Peptide for Nutrition

Kids

Medical

MCTOil

Mead Johnson

Osmolite HN

Ross Products Pro-Peptide

Nutrition

Plus

VHN

Medical

Meritene

Novartis

Pediasure

Ross Products Pro-Phree

Ross Products

Methionaid

SHS

Pediasure with Ross Products Propimex-1

Ross Products

Fiber

Microlioid

Mead Johnson

Peotamen

Nestle

Prooimex-2

Ross Products

Moducal

Mead Johnson

Peptamen Junior Nestle

Prosobee

Mead Johnson

MSUDAID

SHS

Peptamen Junior Nestle Oral

ProViMin

Ross Products

NeoSure

Ross Products

Peptamen VHP Nestle

Pulmocare

Ross Products

Neocate

SHS

Peptamen VHP Nestle

RCF

Ross Products

Oral

Neocate One + SHS

Peptide

Novartis

Reabilan

Nestle

Nepro

Ross Products

Perative

Ross Products Reabilan HN

Nestle

Nitro-Pro

Nutrition Medical Periflex

SHS

Renalcal Diet

Nestle

NovaSource

Novartis

Phenex 1

Ross Products RE/Neph HP/HC Nutra/Balance

Renal

NuBasics

Nestle

Phenex 2

Ross Products RE/Neph LP/HC Nutra/Balance

NuBasics 2.0

Nestle

PhenylAde

Foodtek

Replete

Nestle

Drink Mixes

NuBasics with Fiber

Nestle

Phenyl-Free

Mead Johnson

Replete with Fiber

Nestle

NuBasics VHP Nestle

Polvcose

Ross Products Resoalor

Mead Johnson

NuBasics Plus Nestle

Portagen

Mead Johnson Resource

Novartis

Diabetic

Nutramigen

Mead Johnson

Pregestmil 20

Mead Johnson Resource Fruit Novartis

Beverage



FP-89



GA WIC PROCEDURES MANUAL

Attachment FP-28 cont'd

Non-Contract FormuIas/Med"1caIF00dS Requ1rm2 a prescr1pt1on andff1a2nos1s: a,d,c

Resource Just for Novartis Kids

Resource Plus Resource Standard Scandishake Scandishake Lactose Free

Novartis Novartis
Scandiphann Scandiphann

Scandishake Sugar Free Subdue Suplena Sustacal Sustacal with Fiber Sustacal Plus Sustacal Pudding

Scandiphann
Mead Johnson Ross Products Mead Johnson Mead Johnson
Mead Johnson Mead Johnson

Tolorex

Mead Johnson

TraumaCal TwoCalHN Ultracal Ultra-Pro Vital High Nitrogen

Mead Johnson Ross Products Mead Johnson Nutrition Medical Ross Products

Vivonex Pediatric Vivonex Plus Vivonex T.E.N.

Novartis
Novartis Novartis

FP-90



GAWICPROCEDURESMANUAL

Attachment FP-28 cont'd

Non-ContractHOS >J"atlBasedFormuIas: c,d

Enfamil Premature Mead

20

Johnson

Enfamil Human Mille Fortifier

Mead Johnson

Sirnilac Special Care 20

Ross Products

Enfamil Premature Mead

20 with iron

Johnson

Enfamil Human Mille Fortifier with iron

Mead Johnson

Similac Special Care with Iron 20

Ross Products

Enfamil Premature Mead

24

Johnson

Similac 24

Ross Products

Similac Special Care 24

Ross Products

Enfamil Premature Mead

24 with iron

Johnson

Sirnilac 24 with iron

Ross Products

Sirnilac Special Care with Iron 24

Ross Products

Enfamil 24

Mead Johnson

Similac Natural Care

Ross Products

Enfamil 24 with iron

Mead Johnson

Similac PM 60/40 Ross Products

a. Low iron formula may be indicated only for limited conditions. Low iron formulas may be indicated for participants with hemochromatosis, hemosiderosis, neonatal iron storage disease, polycythemia, thalassemia, hyperferremia, sickle cell anemia, liver disease, pancreatic insufficiency, cardiac defects with cyanosis, and those participants requiring frequent transfusions. Low iron formula is not authorized for colic, spitting up, vomiting, cramps, constipation, diarrhea, fussiness, or for partially breastfed infants/children.
b. Ready-to-feed formula may be indicated in limited documented cases, such as: ( 1) Unsanitary or restricted water supply (2) Inadequate refrigeration (3) Caregiver has a documented condition which inhibits the proper dilution of concentrated or powder formula.
c. If a physician orders a product that is not on this list, contact the Office of Nutrition to determine whether the product is authorized for distribution through the WIC Program.
d. Hospital based products may be acquired through the Office of Nutrition. See the Georgia WIC Program Procedures Manual, Food Package Section for appropriate procedure and forms.



FP-91



GA WIC PROCEDURES MANUAL Formula Manufacturers

Attachment FP-28 cont'd

Carnation Nutritional Products 800 No. Brand Boulevard Glendale, California 91203 (800) 628-BABY [2229]

Nutra/Balance Products 7155 Wadsworth.Way Indianapolis, Indiana 46219 (800) 432-3134

Foodtec Manufacturing Company 273 Franklin Road Randolph, New Jersey 07869 (201) 361-7004

Nutrition Medical 308 12th Avenue, South Buffalo, Minnesota 55313 (800) 569-7828

Mead Johnson Nutritional Group 2400 W. Lloyd Expressway Evansville, Indiana 47721 (800) 247-7893 - Adult Products (800) BABY-123 [222-9123] - Pediatric Products

Ross Products Division 625 Cleveland Avenue Columbus, Ohio 43216 (800) 551-5838 (800) 227-5767: Consumer Information

Med-Diet Laboratories, Inc. 3050 Ranchview Lane Plymouth, Minnesota 55447 (612) 550-2020; FAX (612) 550-2022 (800) 633-3438: Consumer Telephone Number

Scandipbarm, Inc. 2200 Inverness Center Parkway Suite 310 Birmingham, Alabama 35242 (800) 950-8085

Nestle Clinical Nutrition (formerly Clintec Nutrition) Three Parkway North, Suite 500 P.O. box 760 Dearfield, Illinois 60015-3186 (708) 317-2800; FAX (708) 317-3186 (800) 422-ASK2 [2752]: Infolink

Scientific Hospital Supplies, Inc. (SHS) P.O. Box 117 Gaithersburg, Maryland 20884 (800) 365-7354 or (301) 840-0408 FAX (301) 963-7026

Novartis Nutrition (formely Sandoz Nutrition) 5320 W. Twenty-third St. St. Louis Park, Minnesota 55416 (800) 333-3785



FP-92



GA WIC PROCEDURES MANUAL

Attachment FP-29

PROCUREMENT OF HOSPITAL BASED FORMULA

Hospital based infant formulas may be ordered by a physician (only) to meet the nutritional needs of preterm infants and children with special health care needs.
Generally these products are designed for use in a hospital setting and are not available for retail sale. County health departments may acquire these products through a system established by the Office of Nutrition (OON) or in rare instances through a local pharmacy (WIC Vendor). When acquiring a product through the OON use the following procedure:
1. District WIC Coordinator or designated staff will fax to OON the Procurement of Hospital Based Formula form complete with the following information (see Attachment FP-30):
a. Date b. Name of client c. Birth date
d. Diagnosis
e. Name of formula f. Manufacturer's name g. Amount of formula requested, list as number of cases or total fluid ounces h. Type of formula, list as ready-to-feed, concentrate, powder I. Estimated time on formula J. Formula issue month k. Prescribing physician I. Hospital discharged form m. Clinic contact person/telephone number n. District contact person/signature
2. Call OON to notify of incoming fax.
3. Document request for formula and distribution in participant's health record..
4. Verify that the order meets requested specifications, then complete and sign the shipping receipt form. Also complete and sign the OHR Receiving Report and return to the address provided on the form.
Submit order(s) monthly. The total fluid ounces per order must not exceed the maximum monthly allowance. County health departments should receive shipment within 5 working days.
Notify OON immediately if an incorrect order is delivered, or if there is a change in the formula order.
Only a complete case(s) may be returned by the OON to the formula company for credit.



FP-93



GA WIC PROCEDURES MANUAL
HOSPITAL BASED FORMULA ORDER FORM

Attachment FP-30

I. TO BE COMPLETED BY DISTRICT/LOCAL STAFF

Date _ _ _ _ _ _ __

1. Name ofWIC client _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

2. Birth date _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ 3. Diagnosis _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ 4. Name of formula requested _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ 5. Product number/manufacturer of formula _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ 6. Amount of formula requested _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
7. Type of formula: ready to feed, concentration, powder, single use bottle, etc. _ _ _ _ _ __ 8. Estimated time on formula _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
9. Formula issue month _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
10. Clinic contact person/phone no. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ 11. Address/telephone number to ship formula._ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ 12. Prescribing Physician _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
13. Hospital discharged from _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
14. District contact person _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ 15. WIC/Nutrition Coordinator's signature _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
CALL OON AND FAX TO FRANCES COOK, OFFICE OF NUTRITION: FAX: (404) 657-2886



II. TO BE COMPLETED BY OFFICE OF NUTRITION 1. Formula Cost of this order (including price per case) _ _ _ _ _ _ _ _ _ _ _ _ _ __ 2. Date order placed to formula company _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ 3. Clinic/District's account number _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ 4. Contact person at formula company/phone no. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ 5. Anticipated date of delivery _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ 6. OON Nutrition Consultant's signatuature_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
III. TO BE COMPLETED BY STATE WIC BUDGET OFFICER 1. Purchasing authorization number/initial date _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ 2. Field Purchase Order#/ initial date _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ 3. WIC Financial Director's signature_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
FP-94



GA WIC PROCEDURES MANUAL

Attachment FP-31

SUPPLEMENTAL FORMULA CONVERSION TABLE Caloric Displacement Method

Monthly RX
*Moducal (13 oz powder) 1 can 2 cans 3 cans 4 cans

Maximum Cans of Formula Allowed

Infant

Child/Woman

Concentrate Powder

Concentrate

28

7

32

25

6

29

23

5

27

20

5

24

** Polycose (12 oz powder)

1 can 2 cans 3 cans 4 cans

28

7

32

25

6

29

23

5

27

20

5

24

*** MCT Oil (32 fl oz bottle)

1 bottle 2 bottles

17

4

21

3

7

Infant is allowed a maximum of 403 fl oz of concentrated formula per month.

Child/Woman is allowed a maximum of 455 fl oz of concentrated formula per month.



Moducal powder: 1 can contains 46 TBSP/1400 Calories



Polycose powder: 1 can contains 59 TBSP/1330 Calories



MCT Oil: 1 bottle contains 960 cc/64 TBSP/7300 Calories

3 teaspoons = I TBSP
1 fl oz= 30 cc
13 oz can standard concentrated contract formula = 40 Cal/fl oz 13 oz can standard reconstituted contract formula = 20 cal/fl oz

Powder
8 7 6 6
8 7 6 6
5 2

FP-95



GA WIC PROCEDURES MANUAL

Attachment FP-32

PROCUREMENT OF BANKED DONOR HUMAN MILK

Donor human milk may be ordered only by a physician to meet the nutrition needs of preterm infants and children with special health care needs, in cases where there are no infant formulas that can foster the growth and development of these infants or children..

Donor human milk is not available for purchase through the use of WIC vouchers, but must be acquired directly from a Milk Bank. County health departments may acquire these products through a system established by the Office of Nutrition (OON). When acquiring a product through the OON the following procedures must be followed:

1. District WIC Coordinator or designated staff will FAX to OON the Donor Human Milk Form complete with the following information (see Attachment FP-33):

a. Date b. Name ofWIC Participant C. Birth date
d. Diagnosis e. Prescription, including date, amount needed in 24 hours, and the number of days
or weeks needed (not to exceed one month) f. Prescribing physician's name
g. Prescribing physician's phone number h. Hospital from which discharged
I. Date donor human milk needed by participant J. Information on where to ship the donor human milk: parent/caregiver's name,
street address, city, state, zip code, and telephone number
k. Reason mother is not providing her own breastmilk
I. District contact person/phone number m. Clinic contact person/telephone number n. WIC/Nutrition Coordinator's signature

2. Call OON to notify of incoming FAX.

3. Document request for and distribution of donor human milk in participant's health record.

4. Verify that the order received by the mother meets requested specifications, and inform the Office of Nutrition immediately, if it does not.

The order may include a request for donor human milk for up to one month. The medical prescription, however, will be honored for up to three (3) months. Before each monthly order is placed, the local agency nutritionist must review the participant's case to ensure continued need for the donor human milk. The total fluid ounces per order must not exceed the maximum monthly allowance. The WIC Program will provide the donor breastmilk for a maximum of one month. Notify OON immediately if an incorrect order is delivered, or if there is no longer a need for the milk.

FP-96



GA WIC PROCEDURES MANUAL

Attachment FP-33

DONOR HUMAN MILK ORDER FORM

I. TO BE COMPLETED BY DISTRICT/LO~AL STAFF

Date_ _ _ _ _ _ _ _ _ __

1. Nanie of WIC participant_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

2. Birth date of participant 3. Diagnosis (medical reason milk is needed)_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

4. Prescription: Date of prescription:_ _ _ _ _ _ _ _ _ _ _ _ _ __
Donor Human Milk needed per 24 hours = ____ ounces

Duration: _ _ _ _ days OR

weeks needed (NOT TO EXCEED ONE MONTH)

5. Prescribing Physician's name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

6. Presciribing Physician's phone number:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ 7. Hospital from which discharged:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ 8. Date Donor Human Milk needed by participant:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

9. SHIP MILK TO: Parent/caregiver's name:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ Street address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
City, State, Zip Code:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ Telephone number:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

10. Reason mother is not providing her own breastmilk:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

11. District contact person/phone no. :_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ 12. WIC/Nutrition Coordinator's signature:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ CALL THE OFFICE OF NUTRITION, AND FAX COMPLETED FORM: (404) 657-2884, FAX:(404) 657-2886 II. TO BE COMPLETED BY OFFICE OF NUTRITION 1. Donor human milk cost of this order (including price per unit) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ 2. Date order placed:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
3. Clinic/District's account n u m b e r - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 4. Contact person/phone number at Milk Bank_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ 5. Anticipated date of delivery _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ 6. OON Nutrition Consultant's signature _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __



FP-97

GA WIC PROCEDURES MANUAL

Attachment FP-33



III. TO BE COMPLETED BY STATE WIC BUDGET OFFICER

1. Purchasing authorization number/initial date _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

2. Field Purchase Order#/ initial date _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

3. WIC Financial Director's signature _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __





FP-98





GA WIC PROCEDURES MANUAL
TABLE OF CONTENTS Page
I. Purpose .......................................................................................................................NE-1 II. Definition....................................................................................................................NE-2 III. Goals ..........................................................................................................................NE-3 IV. State Agency...............................................................................................................NE-4
A. Nutrition Staff......................................................................................................NE-4 B. Nutrition Education Responsibilities ...................................................................NE-4 C. Breastfeeding Promotion and Support Responsibilities ......................................NE-5 V. Local Agency..............................................................................................................NE-6 A. Nutrition Staff. .....................................................................................................NE-6 B. Breastfeeding Coordinator ...................................................................................NE-6 C. Nutrition Education Responsibilities ...................................................................NE-6 D. Training................................................................................................................NE-7 E. Nutrition Education Plan .....................................................................................NE-8 VI. Participant Nutrition Education ..................................................................................NE-9 A. Participant Nutrition Education
Requirements ........................................................................................................NE-9 B. Documentation of Nutrition Education................................................NE-10 VII. Participant Referral To Other Agencies .................................................................... NE-12 A. Referrals .............................................................................................................. NE-12 B. Documentation .................................................................................................... NE-13 VIII. Nutrition Education Materials ................................................................................... NE-14 A. Criteria for Development and Use ...................................................................... NE-14 B. Available Nutrition Education Materials ............................................................ NE-14 C. Procedures for Ordering Nutrition
Education Materials ............................................................................................ NE-14





GA WIC PROCEDURES MANUAL

Page Attachments: NE-1 Format for Nutrition Education Plan ........................................................................NE-16

NE-2 Nutrition Inservice Programs Attended by Local Professional Staff......................................................................................................NE-17

NE-3
NE-4 NE-5 NE-6 NE-7 NE-8 NE-9

Nutrition Inservice Programs Conducted by Local Professional Staff......................................................................................................NE-18 District Nutrition Education Plan .............................................................................NE-19 District Nutrition Education Plan Update.................................................................NE-20 WIC High Risk Criteria............................................................................................NE-21 Guidelines for Paraprofessional Training .................................................................NE-23 SOAP Note Documentation Format .........................................................................NE-27 Material Evaluation Form.........................................................................................NE-28





GAWICPROCEDURESMANUAL
I. PURPOSE
This section ofthe procedures manual defines the concept of nutrition education; states the goals for nutrition education; and explains the requirements for providing nutrition education to WIC participants.



NE-1



GA WIC PROCEDURES MANUAL
II. DEFINITION
"Nutrition Education" is a dynamic process by which individuals gain the understanding, skills, and motivation necessary to promote and protect their nutritional well-being through their food choices. Nutrition education shall be designed based on ethnic, cultural and geographic preferences and with consideration for language, educational, and environmental factors .



NE-2



GA WIC PROCEDURES MANUAL
III. GOALS
Nutrition education for WIC participants is designed to achieve two broad goals:
A. Emphasize the relationship between proper nutrition and good health, with emphasis on the nutritional needs of pregnant, breastfeeding and postpartum non-breastfeeding women, infants, and children under five (5) years of age.
B. Assist the individual who is at nutritional risk in achieving a positive change in food habits, resulting in improved nutritional status, and in the prevention of nutrition-related problems, through optimal use of supplemental foods and other nutritious foods .



NE-3



GA WIC PROCEDURES MANUAL

IV. STATE AGENCY

A. Nutrition Staff

The delegation of WIC nutrition education activities is vested within the Georgia Department of Human Resources, Division of Public Health, Family Health Section, Office ofNutrition.

The nutrition education component of the WIC Program is carried out under the direction of a qualified nutritionist (M.A., M.S. or M.P.H., and a registered dietitian, or eligible for registration as a dietitian). The responsibilities of this person are to plan, direct and coordinate the nutrition education component of the WIC Program.

A qualified nutritionist (M.A., M.S., or M.P.H., and R.D. or eligible for registration) is designated as the State Breastfeeding Coordinator. The responsibilities of this person are to plan, direct and coordinate the breastfeeding promotion and support component of the WIC Program. Nutrition Program Consultants in the Office of Nutrition are available to districts/units as a resource for facilitating the State's efforts in strengthening and integrating MCH and WIC nutrition services. Current staff assignments are available from the Office of Nutrition.

B. Nutrition Education Responsibilities

The following are the State agency responsibilities for nutrition education:

1. Develop, implement, and evaluate the State Nutrition Education Plan. Periodically review and evaluate, and make appropriate revisions as necessary.

2. Develop guidelines for local agency Nutrition Education Plan development. Review each plan and provide feedback.

3. Monitor the progress oflocal agency Nutrition Education Plans on a periodic basis through on-site visits and reports.

4. Evaluate nutrition services of all local agencies.

5. Develop and implement a plan for providing training and technical assistance. for WIC competent professional authorities (CPA's) and paraprofessional/nutrition assistant staff at local clinics. Training and technical assistance provides WIC competent professional authorities with current information on the nutritional management of normal and high risk special problems and emerging issues in nutrition.

6.

Identify and develop resource and education materials for use at local

NE-4



GA WIC PROCEDURES MANUAL
agencies. Provide materials in languages other than English in areas where a substantial number ofpersons are non-English speaking.
7. Coordinate WIC nutrition education activities with related programs and professional groups such as the Cooperative Extension Service, Food Stamp Program, professional organizations, advisory committees, etc.
8. Develop and implement procedures to assure that nutrition education is offered to all adult participants and to parents or caretakers of infant or child participants, as well as child participants whenever possible.
9. Perform and document evaluation of nutrition education activities for each local agency on an annual basis. The evaluation shall include an assessment of participant's views concerning the effectiveness of the nutrition education which they received.
10. Establish standards for participant contact that ensure adequate nutrition education.
11. Monitor local agency activities to ensure compliance with defined local agency responsibilities and participant nutrition education contacts.
C. Breastfeeding Promotion and Support Responsibilities
See the Breastfeeding Section for State Breastfeeding Promotion and Support Responsibilities .

NE-5



GA WIC PROCEDURES MANUAL
V. LOCAL AGENCY
A. Nutrition Staff
1. Each of the WIC local agencies must be staffed with a minimum of one (1) public health nutritionist in the class ofNutrition Services Director, Nutrition Program Manager, or Nutrition Manager. This nutritionist will be designated as the District Nutrition Coordinator. Duties include: planning, organizing, implementing, and evaluating the nutrition service component of the WIC Program. This encompasses development and approval of nutrition education materials, development of the nutrition education plan, and implementation of nutrition risk criteria.
2. Each WIC local agency must be staffed with a mm1mum of one (1) nutritionist for every one thousand (1,000) high risk participants. The ability of each local WIC agency to meet this requirement will be assessed in FFY '99. Based on the findings, the requirement will be fully implemented in FFY 2000.
3. Nutrition positions should be appropriately classified according to the Georgia Merit System/Georgia Gain class specifications for nutrition personnel. The Georgia Merit System/Georgia Gain Nutritionist class specifications should be used for nutritionists providing direct client nutrition services, and these nutritionists should receive supervision from a higher level public health nutritionist.
4. The Georgia Merit System/Georgia Gain class specifications for nutrition personnel and qualifications and compensation levels are available on request from the Merit System of Personnel Administration or from the Office of Nutrition.
B. Breastfeeding Coordinator
Each local agency must designate a staff person to coordinate breastfeeding promotion and support activities. It is recommended that the breastfeeding coordinator position be filled by a qualified nutritionist, nurse, health educator or certified lactation consultant (See Breastfeeding Section for additional information).
C. Nutrition Education Responsibilities
The local agencies shall perform the following activities in carrying out their nutrition education responsibilities:
1. Provide nutrition education to all adult participants, to parents or caretakers of infant or child participants, and whenever possible, to child participants.
NE-6



GA WIC PROCEDURES MANUAL
Program participants may be encouraged to assist in providing nutrition education to other participants (e.g. the use of a breastfeeding participant to talk with participants who are interested in breastfeeding). Individual or group sessions and/or education materials designed for program participants may be utilized for the delivery of nutrition education services to non-participating women, infants, and children who take part in other local agency health services.
2. Provide in-service training and technical assistance for competent professional authorities (CPA's) and paraprofessionals/nutrition assistants at local clinics.
3. Develop a biennial Nutrition Education Plan consistent with the nutrition education portion of the State Plan (see Attachment NE-1).
4. Develop an annual Breastfeeding Plan consistent with the breastfeeding portion of the State Plan. For further clarification, see the Breastfeeding Section of the Procedures Manual.
D. Training
1. Orientation
The WIC CPA must attend levels I and II of the Competency Based Nutrition Skills Workshops and the Competency Based Breastfeeding Skills Workshop, or a comparable local level training, within 24 months of employment. The WIC CPA's, in particular the nutrition staff, should also attend Level III of the Competency Based Nutrition Skills Workshops.
The Competency Based Skills Workshops are conducted by the Office of Nutrition. These workshops provide WIC CPA's with current information on the nutritional management of normal and high risk prenatal women, infants, children, and adolescents; breastfeeding management in normal and special situations; and an update on special problems and emerging issues in nutrition. Presenters are nationally known and provide state of the art practice methods.
2. Continuing Education
a. The WIC CPA must receive at least four (4) hours ofnutrition training each year. All CPA's are encouraged to attend local, state, or national workshops for meetings for the purpose of developing and updating skills and knowledge in nutrition and lactation management.
b. All nutrition training and continuing education activities conducted or
NE-7



GA WIC PROCEDURES MANUAL

attended by the local staff must be recorded and kept on file by the local agency. The file should include the name and title of the participant and the title and date of the workshop (see Attachments NE-2 and NE-3 for recommended forms).

E. Nutrition Education Plan

1. Biennial Nutrition Education

A two (2) year Nutrition Education Plan covering FFY 2000-2002 must be submitted to the Office of Nutrition by September 1, 1999. This plan may be integrated with the overall WIC plan that is due to the State WIC Office on the same date.

a.

The local agency Nutrition Education Plan must include:

(1) Needs assessment for each objective (2) Each objective in behavioral terms (3) Evaluation design for each objective (4) Action steps, including activities and methods for each
objective (5) Resources to conduct each objective (6) Milestone of activities for each objective.

b. Plans must relate to nutrition education services.

c. The Nutrition Education Plan should address the following areas at a minimum: nutrition education contacts and nutrition education materials.

2. Nutrition Education Plan Update

The update is a progress report and must be submitted to the Office of Nutrition by November 30 of each year and should include the following:

(1) Brief description of milestones accomplished (2) Revision, deletion, and/or addition of objectives (3) Revision, deletion, and/or addition of action steps.

3. Format and Form - See Attachments NE-I, NE-4 and NE-5 .

NE-8



GA WIC PROCEDURES MANUAL
VI. PARTICIPANT NUTRITION EDUCATION
A. Participant Nutrition Education Requirements
1. All adult participants and caretakers of child participants must be provided with two (2) nutrition education contacts (must receive nutrition education on two different occasions) during each six (6) month certification period, but not within the same day/clinic visit. For prenatal women and parents/caretakers of infant participants certified for a period in excess of six (6) months, nutrition education contacts shall be made available at a quarterly rate, but not necessarily taking place within each quarter.
2. The nutrition education contacts shall be made available through individual or group sessions which are appropriate to the individual participant's nutritional needs.
3. All participants shall receive nutrition education contacts which relate to their particular nutrition risk condition and the need for a well balanced diet.
4. All high risk WIC participants (as defined in Attachment NE-6) must be scheduled to receive a high risk_ nutrition education contact from a nutritionist, during the current certification period. If the high risk contact is provided by someone other than a nutritionist, adequate documentation explaining why the intervention is more appropriate for the participant must be provided.
5. Prenatal/breastfeeding/non breastfeeding women must receive exit counseling by the final nutrition education contact of the postpartum period. Exit counseling js defined as counseling which includes the following topics which are to be discussed by the final nutrition education contact:
a. Importance of folic acid intake
b. Health risks of using alcohol, tobacco, and other drugs
c. Continued breastfeeding as the preferred method of infant feeding (for those women who are breastfeeding)
d. Importance of up-to-date immunizations.
6. The Nutrition Guidelines for Practice are the established guide for nutrition education contacts.
7. All pregnant participants must be encouraged to breastfeed unless contraindicated for health reasons. As recommended in the Nutrition
NE-9



GA WIC PROCEDURES MANUAL
Guidelines for Practice, encouragement to breastfeed should continue throughout the prenatal period. See the Breastfeeding Section for additional breastfeeding promotion and support requirements.
8. Nutrition education contacts must be provided by a nutritionist, registered dietitian, registered and licensed practical nurses, physician, physician's assistant, or other certified health professional that has been trained by the State or local agency. Paraprofessionals can provide nutrition education contacts when appropriate nutrition education training has been received. The training plan must be approved by the Office of Nutrition. (See Attachment NE-7 for the Guidelines for Paraprofessional Training and list of items to be submitted for approval.)
9. An individual nutrition care plan should be developed for a participant based on the need for such plan as determined by the competent professional authority. The Nutrition Care Plan should be written using the SOAP (Subjective - Objective - Assessment - Plan) note format. (See Attachment NE-8 for the SOAP Note Documentation Format.)
10. A lesson plan must be developed when group classes are used to provide the nutrition education contact. Lesson plans must be kept at the clinic site for use by clinic staff and provided to the Office of Nutrition at the time of program reviews.
11. If the participant/caregiver is unable to receive services at the clinic for an extended period of time, home visits are the recommended method for providing secondary nutrition education contacts.
B. Documentation ofNutrition Education
1. All nutrition education services and contacts received by participants must be documented in the participant's health record.
a. In order to facilitate continuity of care, specific aspects of nutrition counseling should be documented (e.g., introduce food singularly; portion sizes for the 2-3 year old; ways to increase fluid intake).
b. The POMR (Problem Oriented Medical Record)/SOAP note format is the recommended method of documentation. A flow sheet may be used as long as it contains all components of a SOAP note.
C. Group nutrition education contacts may be documented with the participant's signature on a class attendance sheet or voucher register and a class roster which contains the lesson objective(s) and the original signature of the staff conducting the class. A description of
NE-10



GA WIC PROCEDURES MANUAL
the district's method of documentation must be submitted for approval prior to implementation.
2. Documentation of encouragement to breastfeed should include all aspects of breastfeeding discussed with the participant (e.g., barriers to breastfeeding; emotional and nutritional advantages of breastfeeding; positioning).
3. Missed appointments for nutrition education contacts and the refusal of a participant/caregiver to receive nutrition education must be documented in the participant's health record.



NE-11




GA WIC PROCEDURES MANUAL

VII. PARTICIPANT REFERRAL TO OTHER AGENCIES

Participants must be assessed for referrals during each certification appointment.

A. Referrals

1. Participants who appear to be eligible for the Food Stamp Program and Temporary Assistance for Needy Families (TANF), shall be informed of these programs and, if needed, be provided with the addresses and telephone numbers oflocal/State offices. Participants must be referred to the Medicaid Program.

2. Local agencies are encouraged to coordinate with and refer participants to the Cooperative Extension Service, Expanded Food and Nutrition Education Program (EFNEP).

3.

Local agencies should refer participants to other health services offered

within the health department system and other agencies and services. These

include, but are not limited to:

Maternal Health Programs
High Risk Pregnancy Program Family Planning Program Sexually Transmitted Disease
Assistance Programs
Food Stamps Medicaid Right from the Start Temporary Assistance for
Needy Families (TANF) Headstart

Child Health Programs
Children's Medical Services Immunization Program Lead Screening Program Health Check Dental Health Program
Community Resources
AIDS Program Private Physician Mental Health and Substance Abuse Program



4. Prenatal or breastfeeding part1c1pants needing additional breastfeeding information, assistance or support should be referred to the appropriate person(s) designated through the local agency breastfeeding program.
NE-12



GA WIC PROCEDURES MANUAL
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.



NE-13




GA WIC PROCEDURES MANUAL
VIII. NUTRITION EDUCATION MATERIALS
A. Criteria for Development and Use
1. All nutrition education materials and forms used and developed locally for WIC participants must be approved by the District Nutrition Coordinator. See Materials Evaluation Form for guidance (Attachment NE-9).
The Office of Nutrition is available for consultation and technical assistance to review nutrition education materials.
2. Sample copies of all nutrition e4ucation materials used by the local agency, which are not provided by Central Supply, must be made available to the Office of Nutrition during the program review.
3. All nutrition education materials used must accurately reflect current documented scientific knowledge of nutrition.
4. Reading levels should be evaluated for appropriateness for the target audience.
5. The Office of Nutrition reserves the right to disapprove the use of nutrition education materials if it determines them to be inappropriate.
6. Materials must be prepared to meet needs of the specific population group to be served, including migrant farm workers. Consideration must be given to the cultural and language needs of clients.
7. If a local agency develops materials that are applicable statewide, the Office of Nutrition may seek approval from the local agency to duplicate these materials.
B. Available Nutrition Education Materials
A catalog of nutrition education materials can be obtained from the Office of Nutrition. Districts are encouraged to order and utilize Office ofNutrition materials prior to ordering materials prepared by pharmaceutical or other companies.
C. Procedure for Ordering Nutrition Education Materials
1. All counties/clinic sites must order WIC nutrition education materials through their district office.
2. All education materials must be ordered. on Requisition Form #5014 (Attachment CT-33, Certification Section) by the district WIC Coordinator
NE-14



GA WIC PROCEDURES MANUAL
for all local WIC clinics, and sent to the Office of Nutrition. This requisition will be forwarded to Central Supply by the Office of Nutrition, and the materials will be mailed directly to the district.



NE-15



GA WIC PROCEDURES MANUAL

Attachment NE-1

FORMAT FOR NUTRITION EDUCATION PLAN

TITLE PAGE
District/Unit Time Period of Plan Name(s) and Title(s) of Person(s) Preparing Plan

BODY OF PLAN Needs Assessment:

Objectives:


J

Evaluation Design: Action Steps/Activities/Methods: Resources: Milestones of Activities:

A statement of the problem. It tells why something should be done. Include facts and/or statistics.
Should begin with "To..." and include an action verb; desired results or outcome; a target group; and a time frame of completion date.
Process of determining the extent to which the outcome is commensurate with State objective.
Tasks that relate directly to the achievement of goals and objectives as identified.
Staff, facilities (space available, etc.), materials and technical assistance.
Target dates for accomplishment of key activities.

NE-16



GA WIC PROCEDURES MANUAL

Attachment NE-2

NUTRITION INSERVICE PROGRAMS ATTENDED BY LOCAL PROFESSIONAL STAFF

DATE

NAME AND TITLE OF PARTICIPANTS

TITLE OF WORKSHOP

FUNDING SOURCE



NE-17



GA WIC PROCEDURES MANUAL

Attachment NE-3

NUTRITION IN-SERVICE PROGRAMS CONDUCTED BY LOCAL PROFESSIONAL STAFF

DATE

TITLE OF WORKSHOP

INSTRUCTOR

NUMBER OF LOCAL STAFF ATTENDING, BY DISCIPLINE

NURSES

NUTRITIONISTS OTHER (SPECIFY)



NE-18



GA WIC PROCEDURES MANUAL DISTRICT NUTRITION EDUCATION PLAN

DISTRICT FFY
DISTRICT WIC COORDINATOR: NEEDS STATEMENT:

NUTRITION EDUCATION PLAN

Attachment NE-4

OBJECTIVE: EVALUATION DESIGN:



ACTION STEPS/ACTIVITIES/METHODS

RESOURCES

MILESTONE OF ACTIVITIES

NE-19



GA WIC PROCEDURES MANUAL
NUTRITION EDUCATION PLAN UPDATE DISTRICT _ _ __
FFY -----
District Nutrition Coordinator: - - - - - - - -
Date: _ _ _ __

Attachment NE-5

Objective:



Brief Description of Action Steps/Activities Accomplished: Revision, Deletion, and/or Addition of Objective:

Revision, Deletion, and/or Addition of Action Steps for Objective:

NE-20



GA WIC PROCEDURES MANUAL

Attachment NE-6

WIC MATERNAL HIGH RISK CRITERIA

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

High Risk Criteria Hemoglobin or hematocrit at treatment level
Pre-pregnancy/postpartum underweight (~10% below midpoint of normal weight for height range OR Body Mass Index <19.8)

Risk Code 201
101, 102

Anoendix
B-1
C-1 Weight for Height Table; C-2 Body Mass Index Table; C-3 BMI Chart

Pre-pregnancy/postpartum obesity (~36% above mid-point of normal weight for height range OR Body Mass Index >29)

111,112

C-1 Weight for Height Table; C-2 Body Mass Index Table; C-3 BMI Chart

Low maternal weight gain or weight loss during pregnancy

131,132

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

341-349 and
351-362

EDC or delivery prior to 1]lh birthday

331

Blood lead level~ 10 g/dl

211

Breastfeeding complications; referral to appropriate BF

602

counselor must be made

Hyperemesis Gravidarum

301

Gestational diabetes or history of gestational diabetes

302,303

Multifetal gestation

335

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

NE-21



GA WIC PROCEDURES MANUAL

Attachment NE-6, cont'd

WIC HIGH RISK CRITERIA FOR INFANTS AND CHILDREN

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

High Risk Criteria
Hemoglobin or hematocrit at treatment level

Risk Code 201

Underweight (weight for length/height ~5th %)

103

Obesity (weight for length/height~ 95th %)

113

Short stature (length/height for age ~5th %)

121

Failure to thrive; inadequate growth

134 and/or 135

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

341-360; 362;382

Low birthweight infant (infant weighing 2500 grams (5

141

pounds) or less at birth). May be used for infants only as

high risk criteria.

Blood lead level ~ 10g/dl

211

Breastfeeding complications; infants only; referral to

603

appropriate BF counselor must be made

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

Appendix B-2

NE-22



GA WIC PROCEDURES MANUAL

Attachment NE-7

GUIDELINES FOR PARAPROFESSIONAL TRAINING

I. Qualifications for Paraprofessionals

Who can be trained:

A. WIC clerical staff and health services technicians.

B. Expanded Food and Nutrition Education Program (EFNEP) agents.

C. Volunteers with a background in Home Economics, Nutrition, Medical Science, and Health Education.

D. Nursing students who have taken at least one (1) nutrition course.

E. University students who have done nutrition/health course work.

II. Competencies for Paraprofessionals

A. Basic WIC Program Knowledge. The WIC paraprofessional will be able to:

1. Describe the basic goal of the WIC Program.

2. List eligibility requirements for the WIC Program.

3. Name the State and Federal agencies that fund and administer the WIC Program.

4. Identify the district WIC staff, including the Nutrition Services Director or the Nutrition Program Manager, and where to locate the district WIC office (address and phone number).

5. Locate: (a) the local WIC clinic policies and procedures; (b) list oflocal area WIC vendors; (c) personal reference book (if one is developed); and (d) USDA rules and regulations or Georgia WIC Program Procedures Manual policies relating to supplemental foods and nutrition education.

6. Describe the process of how a WIC participant obtains WIC foods.

7. List the various WIC approved foods.

8.

List notification requirements.

9. Demonstrate a thorough knowledge of individual lesson plans and content, as outlined by the district nutrition coordinator/designee. The

NE-23



GA WIC PROCEDURES MANUAL

Attachment NE-7, cont'd

paraprofessional should score ninety percent or above on the written test.

B. Communication Skills. The WIC paraprofessional will be able to:

1. Demonstrate each of the following factors in a participant interview or group class:

-Making introductions -Explaining purpose of class/contact -Working within a given time frame -Listening -Using open-ended questions -Being non-judgmental -Using simple language -Conveying sincere interest -Conveying positive body language and attitude

2. Identify problems, during the individual contact or class, which are WIC, health, or staff-participant relationship oriented.

C. Referral Skills. The WIC paraprofessional will be able to:

1. Refer problems encountered during the class/individual contact to appropriate personnel.

2. Refer medical and nutrition related problems to the appropriate professional, as written in the lesson plans.

III. Requirements for Training/Continuing Education

Secondary nutrition education contacts can be provided within the following parameters:

A. A training session must be completed,

B. The test and clinic observation must be completed for each topic area, and

C. Nutrition information given to participants must be limited to that received in the training sessions (topic area) by the paraprofessional.

Paraprofessionals must receive at least 12 hours of continuing education per year. These hours can be attained through attendance of the Annual Competency Based Skills Workshop for paraprofessionals, provided by the Office of Nutrition.

1. Other nutrition conferences/workshops.

NE-24



GA WIC PROCEDURES MANUAL

Attachment NE-7, cont'd

2. Other health conferences with a nutrition component, covering at least two (2) hours of nutrition information.
Nutrition information bei~g used to fulfill the continuing education requirement must be pertinent to the areas of nutrition education in which the paraprofessional has received or is receiving training.

IV. Parameters for Paraprofessionals

Paraprofessionals will be trained to provide very specific and limited nutrition information to WIC participants. Information will be limited to that learned in training. Referrals will be made, based on guidance in lesson plans training manual, and/or questions beyond the scope of the training received by the paraprofessional.

V. Evaluation Component

Evaluation of the paraprofessional includes the following:

A. The paraprofessional must score the required percentage on a test for each topic area, before being able to proceed to the next step.

B. The paraprofessional must observe a professional providing secondary nutrition education contacts for at least one (1) clinic day, before being able to provide these her/himself.

C. The paraprofessional must be observed conducting at least three (3) secondary nutrition education contacts before being able to do so routinely.

D. The paraprofessional's immediate supervisor must be readily accessible to assist the paraprofessional with problems.

E. The district nutrition coordinator (or designee) will conduct quarterly record reviews and observe the paraprofessional providing secondary nutrition education contacts.

F. The district nutrition coordinator (or designee) will be available to provide technical supervision and to act as a resource.

NE-25



GA WIC PROCEDURES MANUAL

Attachment NE-7, cont'd

PARAPROFESSIONAL TRAINING PLAN CHECKLIST FOR ITEMS TO SUBMIT FOR APPROVAL
Training Plan:
Lesson Plans for use in training paraprofessionals, including post-tests. Note: these may be submitted on an on-going basis.
Evaluation Component
Plan for paraprofessional to observe professional(s) providing secondary nutrition contacts.
Plan for nutrition coordinator (or designee) to observe paraprofessional(s) providing secondary nutrition education contacts.
Plan for conducting quarterly chart reviews and observation of paraprofessional(s).
Lesson Plans for use by paraprofessional(s) in providing secondary nutrition education contacts - group class or individual counseling.
Documentation Procedures to be used by paraprofessionals.
Additional Information:
Name(s) of paraprofessional(s) being trained, and clinic(s) in which trainee is working.
Name(s) of direct supervisor(s).
Name of district nutritionist designated to provide technical assistance.

NE-26



GA WIC PROCEDURES MANUAL

Attachment NE-8

SOAP NOTE DOCUMENTATION FORMAT
Once the nutritional status of an individual has been determined, the assessment of the problem and intervention plans need to be communicated to other health professionals. The use of the SOAP Note format is an excellent way of conveying this nutritional information. The data gathered during the nutrition assessment can be incorporated into the SOAP Note in the following manner:
S- Subjective Data: statement of the individual's thoughts and feelings individual complaints, "quotable" significant information, individual's description of his or her problem, individual's statement of needs information gained from talking with the individual, from others working with the individual, or from the individual's relatives dietary intake and reported food habits
0- Objective Data: facts, tangible findings, clinical observations, documented information physical findings, signs, symptoms anthropometric data laboratory data factual information regarding background, history environment, progress or problems
A- Assessment: your assessment or impression of the individual's nutritional status, needs, problems; assessment of the overall situation summary and evaluation of dietary intake meaning, value ofthe information presented information still needed problem definition, interpretation
P- Plan: what you plan to do to obtain more information and/or educate and treat the individual referrals recommendations and plans for follow-up visits educational materials used and given to the individual

NE-27



GA WIC PROCEDURES MANUAL

Attachment NE-9

MATERIAL EVALUATION FORM

Material Name/Title._ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _Type._ _ _ _ _ _ __

Obtained from._ _ _ _ _ _ _ _ _ _ _ _Date Received,_ _ _ _ _ _ _By_ _ _ _ _ __

EVALUATION CRITERIA SPONSOR BIAS OR PROMOTION
Product name not visible

MINIMALLY ACCEPTABLE

ADEQUATE

SUPERIOR

CONTENT Non-discrimination clause present

Accurate and up-to-date

Outcome
no more than 3 objectives does not promote undesirable behavior
Scope
topics deemed necessary useful and relevant to target audience
Appropriate for target audience's lives and environment

Clear purpose of material

Organization
main ideas are clear smooth flow of material

Learning experiences

seeks learner involvement

appropriate knowledge/skill level



suggests further learning I

Summarization of ideas

References are accurate, up-to-date and usable

NE-28



GA WIC PROCEDURES MANUAL

Attachment NE-9, cont'd

EVALUATION CRITERIA LANGUAGE USAGE

MINIMALLY ACCEPTABLE

ADEQUATE

Reading level appropriate for audience present (use SMOG)

Few technical terms used with definitions provided

Style
personal few instances of negative wording respectful, non-condescending tone sentences simple, short, specific

Use of words is consistent

STEREOTYPING Appropriate role models

Minority representation
presented in a factual manner variety in roles, occupation, values

Lifestyle/cultural differences are reflected

SUPERIOR

NE-29



GA WIC PROCEDURES MANUAL
EVALUATION CRITERIA FORMAT
Paper quality is acceptable for intended use Print
style acceptable size appropriate
Topic headings/typographic cueing Line width and spacing Placement and use of illustrations Placement and use of charts, table, graphs Color
good choice good quality
Pages
appropriate length face to face
Overall visual appearance is pleasing Quality of sound track is good

Attachment NE-9, cont'd

MINIMALLY ACCEPTABLE

ADEQUATE

SUPERIOR

NE-30



GA WIC PROCEDURES MANUAL

Attachment NE-9, cont'd

Other Areas to be Considered Prior to Purchase:
EVALUATION CRITERIA
COST Original
material cost shipping/handling discount for multiples easy to obtain time to obtain
Replacement
reasonable work life (durability) predisposed to obsolescence ease of repair (include shipping/handling) cost of replacement
Duplication
allowable/legal cost of duplication

MINIMALLY ACCEPTABLE

ADEQUATE

SUPERIOR

NE-31



GA WIC PROCEDURES MANUAL

Attachment NE-9, cont'd

EVALUATION CRITERIA
VIEWING/USAGE Space
available for viewing/use of materials available for storage

MINIMALLY ACCEPTABLE

ADEQUATE

Easy to Use
staff audience/client

Geared for
group classes individua~ counseling/use waiting room use

Is there an easier, more efficient way to stimulate the same behavior?

RECOMMENDATIONS:

SUPERIOR

SIGNATUREfflTLE OF EVALUATOR._ _ _ _ _ _ _ _ _ _ _DATE._ _ _ _ __ Adapted from: E.M.P.O.W.E.R. (Evaluate Materials to Promote Optimal Use of WIC Education Resources), Massachusetts WIC Program, Department of Public Health, April 1985.
NE-32



GA WIC PROCEDURES MANUAL

TABLE OF CONTENTS



I. Introduction .................................................................................................................. SP-1 A. Definitions ........................................................................................................... SP-1 B. Certification......................................................................................................... SP-2 C. Food Delivery......................................................................:............................... SP-2 D. Outreach and Referral ......................................................................................... SP-3 E. Reporting and Monitoring .....:............................................................................. SP-3
II. Individuals Residing in Non-Traditional Housing or Institutions ................................ SP-4 A. Definitions ...........................................................................................................SP-4 B. Services for Applicants and Participants Residing In Temporary Housing ;............................................................................................ SP-5 C. Meals In Institutions & Temporary Housing ...................................................... SP-6
III. Other Special Populations ....................................................................................... .-.... SP-8 A. Definitions ..................................................................................... '. ..................... SP-8 B. Non-English Speaking Populations................................... :SP-8 C. Refugees .............................................................................................................. SP-9 D. Native Americans ................................................................................................ SP-9 E. Persons With Disabilities .................................................................................... SP-1 O
IV. Referral & Outreach to Special Population ...._. ............................................................. SP-10





GA WIC PROCEDURES MANUAL

Attachments:

Page

SP-1

Georgia Migrant Health Prograrn ................................................................................. SP-11

SP-2

Migrant Education Staff/Five Regional Offices ........................................................... SP-12

SP-3

Telarnon Corporation (Migrant and Seasonal Farmworker

Association, Inc.) .......................................................................................................... SP-13

SP-4

Migrant Head Start Programs.......................................................................................SP-15

SP-5

Interpreter Services ....................................................................................................... SP-16

SP-6

Assurance Statement .................................................................................................... SP-17







GA WIC PROCEDURES MANUAL
I. INTRODUCTION
This section of the manual outlines program procedures for assuring access to WIC services and minimizing hardship for the segment of the population that requires nontraditional services. The program regulations require that all eligible and potentially eligible individuals have equal access to WIC benefits and services. Therefore, the local agency must make every effort to identify and reduce barriers that prohibit enrollment and service to eligible and potentially eligible clients.
WIC defines a special population as a group of persons with common needs that require special assistance and/or specific services to access and participate in WIC related services. Special population groups referenced in this section are: migrants, loggers, applicants/participants residing in institutions, homeless people, non-english speaking refugees, Native Americans and persons with disabilities. Local WIC Programs are responsible for ensuring accessability to WIC services for these populations.
A. Definitions
WIC Regulations categorized agriculture occupations as jobs related to the production, growth, and harvesting of any commodity growing in or on land. WIC's definition of migrants is restricted to farm workers employed in agriculture occupations as described above. The harvesting of trees satisfies the definition of an agricultural occupation. Loggers who meet both conditions of seasonal employment and moving from place to place establishing temporary residence for the purpose of such work may be classified as migrants.
There are other seasonal agriculture workers who are not classified as migrant farm worker because they do not move from place to place, nor do they establish temporary residence for employment purposes. To be classified as a migrant farm wor_ker for the WIC program, the individual/family must move up and down the migration stream, be employed in an agriculture occupation and have a temporary residence for this employment.
Migrant Farm Workers are individuals (and family members) employed in agriculture occupations seasonally, who establish temporary residence for the purpose of such employment, and have been employed in such occupation within the last twenty-four (24) months.
Loggers are individuals whose principle employment is seasonal harvesting
SP - 1



GA WIC PROCEDURES MANUAL
of trees; who have been employed in this activity within the last twenty-four months (24); and for such employment established a temporary abode. (See WIC Regulation 246.2; FNS Instrution 803.14).
Seasonal farm workers employed in agriculture occupations who do not move from place to place establishing temporary residence for the purpose of work, ARE NOT migrant farm workers as defined by the WIC Program.
B. Certification
The process for certifying migrant farm workers must comply with standard program procedures (see Certification Section). The green card is not a requirement for program benefits and should never be required. WIC eligibility is transferable to another WIC clinic in Georgia or another state within a valid certification period. Therefore, the local agency must issue a Verification of Certification (VOC) card to every migrant at the time of certification. A valid VOC card helps migrant farm workers access WIC services. (See Certification Section - Transfer of Certification). The Verification of Certification card is valid until the certification period expires.
WIC certification must be documented with a VOC card or a copy of the Georgia WIC assessment form. In lieu of a VOC card, a Georgia WIC identification card is acceptable. However, the receiving clinic must verify the information on the Georgia WIC ID Card. Vouchers must only be issued for thirty (30) days if clinic staff cannot verify certification information with the originating clinic.
C. Food Delivery
Migrants frequently remain in a local area for very short periods. It is essential that migrant certification, transfer of eligibility, and receipt of WIC foods are received as expeditiously as possible. Vouchers must be issued on the same day the migrant participant is certified.
When a migrant presents WIC vouchers from another state, the certifying clinic should void the vouchers and issue Georgia WIC vouchers as replacements. The certifying clinic must send the voided vouchers to the local agency. The local agency must forward the voided vouchers to the appropriate state agency. If a migrant presents vouchers from another clinic in Georgia, the clinic staff should instruct the migrant to redeem them if they bear a valid issue date. (See Food Delivery Section).
SP-2



GA WIC PROCEDURES MANUAL
D. Outreach and Referral
In geographical areas where there is significant movement of migrant activities or dwellings, the local agencies are required to make special effort to reach out and serve this population. The local agency should decide whether evening clinics or certifications at migrant camps are necessary. This decision should be based on migrant outreach efforts and consultation with organizations serving migrants and other migrant activities in the service area. All services necessary to serve migrant populations should be implemented. Special outreach and referral efforts implemented by a local agency to provide access to health services for the migrants and their families should be documented.
E. Reporting and Monitoring
The number of migrants participating in the Georgia WIC Program is reported on the Racial/Ethnic Participation Report generated by the ADP Contractor each month. Information on the Turnaround Document (TAD) is completed with "Yes (Y) or No (N)". To accurately determine the migrant status of an applicant or a participant, the following question must be asked, "Are you a migrant?" If necessary, WIC's definition of a migrant should be explained to the applicant/participant.
Migrant activity and expenditures are also reported on the Quarterly Status Report. The state agency is responsible for monitoring migrant services provided by local agencies. Migrant activities will be monitored according to procedures outlined in the Monitoring Section of this manual. Local agencies with significant migrant populations, as outlined in the Monitoring Section, must conduct migrant specific outreach to ensure that the numbers reported adequately represent the migrant population in the service area. All migrant specific activities must be documented in the clinic and local agency's files .



SP - 3



GA WIC PROCEDURES MANUAL
II. INDIVIDUALS RESIDING IN NON-TRADITIONAL HOUSING OR INSTITUTIONS
Local agencies must continue to serve and enroll eligible participants and applicants living in non-traditional housing environments. The Georgia WIC Program defines nontraditional housing as living accommodations where individuals or families reside for a particular purpose or need. These accommodations include but are not limited to private and public institutions, homeless shelters, temporary housing, including the residences of another person, and special drug rehabilitation homes for pregnant women. Both applicant/participant and non-traditional housing representatives must comply with program procedures and policies as outlined in Section SP-JII, C.
Non-traditional housing representatives who provide accommodations for WIC participants must sign an Assurance Statement (Attachment SP-6). The signed copy of this agreement, in accordance with USDA Federal Register, Volume 54, No. 239, must be on file in the State WIC Office before clients may be served.
A. Definitions
The following program definitions define non-traditional housing applicants/participants for the purpose of this procedures manual. Services and program benefits must be tailored to meet the special needs of individuals defined in these groups.
Institution refers to any residential facility or accommodation dedicated to promote a specific cause which provides meals and sleeping accommodations to a special group of people, or a facility designated as a residence for individuals intended to be in a controlled environment. Excluded are private residences and homeless facilities.
Homeless facility is a public or private supervised facility which provides temporary living accommodations and meal services for individuals who lack a _ fixed and regular night time residence.
Homeless person refers to an individual who lacks a fixed and regular night time residence, or whose primary night time residence is a publicly or privately operated shelter designated as temporary housing. WIC defines a homeless individual as a woman, infant, or child who lacks a regular or primary night time residence, or whose residence is: a temporary accommodation of not more than 365 days in the residence of another individual residence; a publicly or privately operated shelter designated as temporary living and/or sleeping accommodations
SP-4



GA WIC PROCEDURES MANUAL
(including a welfare hotel or a shelter for domestic violence victims); a temporary accommodation in a residence of another person which may not exceed 365 consecutive days; or an institution that provides temporary residence for an individual intended to be institutionalized.
Temporary Housing refers to a residential facility or home for individuals who have lost their primary place of residence and relocate to a temporary lodging facility in a private or public residence. Individuals in this category include, but are not limited to: Battered women and their children in temporary shelters; homeless persons; pregnant teenagers in a group home; and individuals whose primary residence is lost as the result of a disaster. (see Disaster Section)
B. Services for Applicants/Participants Residing in Temporary Housing
Local WIC Programs are responsible for ensuring accessibility to WIC services for individuals who have lost their usual (or primary) place of residence or who may be residing in temporary housing. Individuals who reside in temporary housing represent a high-risk population due to their compromised health and nutrition status and high levels of anxiety and stress. Sensitivity should be displayed with these individuals when gathering application and certification information. WIC procedures should be explained thoroughly. Applicants and participants must be provided services in accordance with the regulations and requirements of the Georgia WIC Program (See Certification Section for Program Policies).
Individuals in this category include, but are not limited to: battered women and their children; homeless persons who may be residing in vehicles, parks, hallways, doorsteps, sidewalks, abandoned buildings, temporary shelters, hotels, motels, etc.; pregnant women residing in drug rehabilitation facilities and pregnant teenagers in a group home. Also included are individuals whose primary residence is lost as the results of a disaster (See Disaster Section).
Local agencies should make every effort to certify these applicants immediately, i.e., during the initial clinic visit. Local agencies should be flexible when issuing vouchers. If a participant is no longer residing in the clinic service area where they last received vouchers, the vouchers should be issued and the participant transferred to the nearest clinic. Employees of institutions may not serve as proxies for the residents.
Due to the nature of their temporary residence, cooking facilities, refrigeration, and acceptable storage areas may not be available. Therefore, special consideration
SP - 5



GA WIC PROCEDURES MANUAL
must be given to the issuance of supplemental food packages in order to meet the participant's nutritional needs. The types of supplemental foods prescribed must take into account the cooking and storage facilities available to the participant. The food package should be tailored using alternative food packages or manual vouchers to:
1. Offer smaller amounts of more perishable foods and larger amounts of less perishable foods (amounts not to exceed Federal Regulations).
2. Offer canned evaporated milk and/or dry milk powder.
3. Offer ready-to-feed or powdered formula when sanitation or storage is a problem.
Education related to the use and storage of food is very important for WIC participants who reside in temporary residences. The educational information should include the following:
1. Discuss spreading out redemptiori of vouchers over the 4-week period.
2. Offer information on food storage and sanitation, when applicable.
C. Meals in Institutions and Temporary Housing
WIC Program applicants/participants who reside in institutions or temporary housing which serve meals may participate in the Georgia WIC Program. This may be a permanent or temporary residence such as a homeless shelter, group home, shelter for battered women, rehabilitation facility, etc.
The following requirements must be adhered to by the institution and participant when determining eligibility for participation in the Georgia WIC Program.
1. When determining income eligibility and family size of the individual(s) residing in temporary housing accommodations, do not include other residents of the institution or the temporary housing facility. The applicant's income is also separate from the general revenues of the institution.
2. The residential facility must not accrue financial or in-kind benefit from a person's participation in WIC. For example, transferring WIC foods to the general inventories of the facility or reducing the quantity of food provided
SP-6



GA WIC PROCEDURES MANUAL
to WIC participants.
3. Food items purchased with WIC vouchers must not be used in communal feedings. WIC foods are supplemental foods intended to enhance the participants' diet and nutritional needs. If these foods are used in the communal food supply, the intent of the supplemental foods is not fulfilled.
4. No institutional constraints may be placed on the WIC participant's ability to partake of the supplemental foods and WIC associated services and benefits. Participants must have full, free, and direct access to all program benefits and services available.
The above conditions have been established to ensure that:
Participants benefit from the program rather than the institution, and;
All eligible persons participate 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 institution where applicant/participant resides.
2. The above conditions addressed in Section II C. 2, 3, and 4 were discussed and are understood by the applicant/participant.
3. Each applicant/participant has been informed of their Rights and Obligations, both verbally and in writing.



SP- 7



GAWICPROCEDURESMANUAL
III. OTHER SPECIAL POPULATIONS
The local agencies must make every effort to alleviate barriers to WIC services for all eligible and potentially eligible individuals during critical times of growth and development. Other special population groups which the Georgia WIC Program seeks to serve include but are not limited to individuals who may experience barriers to program services due to physical conditions, language, vision and hearing impairment, and cultural differences.
A. Definitions
The following definitions define groups identified in this section as other special population groups.
Hearing impaired refers to a person who cannot hear or has limited ability to hear.
Multilingual means the persons speaks two or more languages fluently.
Native American is used to designate an American Indian or original inhabitants of America .
Non-English speaking refers to an individual whose primary language is not English or an individual who speaks little or no English.
Vision Impaired refers to an individual with limited ability or the inability to see.
Refugee refers to someone who flees his or her country to another country to seek protection or relief from persecution because of race, religion, nationality, political opinion, or membership in a social group.
B. Non-English Speaking Populations
Individuals whose primary language is not English, or speak little or no English should have access to WIC services and benefits provided in local clinics. The Local agencies are responsible for ensuring that multilingual staff, volunteers, or other translation resources are available to serve non-English speaking participants or non-English speaking applicants.
In areas where a substantial number of persons do not speak English, local agencies must carry out outreach activities to insure that eligible members of such populations participate in the program. Contact should be made with other agencies and community
SP- 8



GAWICPROCEDURESMANUAL
organizations serving non-English speaking persons. A variety of Spanish nutrition education and breastfeeding materials are available through the Office of Nutrition (see Nutrition Education Section 6). If a local agency needs materials in other languages, contact the State WIC Office or the Office of Nutrition for assistance. The Refugee Health Program has developed and compiled a library of translated health education materials. These materials are distributed, upon request, to organizations and individuals (See Attachment SP-3).
Local agencies may contract with translators or interpreters as needed. However, local agencies are encouraged to first hire multilingual staff in their programs to provide these services. Limited language interpretation services are available through the State Refugee Health Program. Specific areas of the state have identified available interpreters (See Attachment SP-4). The Office of Nutrition will assist local agencies in identifying multilingual translators or interpreters.
C. Refugees
A refugee is someone who flees his or her country due to persecution or a well-founded fear of persecution because of race, religion, nationality, political opinion, or membership in a social group. With the significant number of refugees, such as Cuban, Haitian, Asians, and Vietnamese, in Georgia, every effort will be made to ensure service is extended to these populations (See Attachment SP-4). Aliens (legal and illegal) are eligible to apply for participation in the program on the same basis as United States Citizens.
The Division of Public Health Refugee Health Program staff includes interpreters who speak Amharic, Bosnian, Cambodian, Russian, Somali, Tigtinya and Vietnamese. Program interpreters help refugees access health care by making appointments, arranging transportation, and providing interpretation at appointments.
D. Native Americans
The WIC Program should make every effort to locate and enroll all eligible Native Americans residing within a local agency's service area.



SP- 9



GA WIC PROCEDURES MANUAL
E. Persons With Disabilities
The Georgia WIC Program is required to make program services accessible to individuals covered by the American Disabilities Act. Local agencies are responsible for ensuring that individuals with disabilities are accommodated in the WIC Program. All facilities where WIC and related services are provided must be physically accessible from the outside as well as on the inside. Capabilities for communicating with vision and hearing impaired participants and applicants should be provided by the local programs. Interpreters for the hearing impaired, are available through the State Rehabilitation Program (See Attachment SP-4).

IV. REFERRAL & OUTREACH TO SPECIAL POPULATIONS
The local agency must develop a network for coordinating activities with local organizations and persons serving and providing resources to special population groups and minority populations. The local agency should advise the State WIC Office of organizations and resources available in the local service area in order to maintain a current listing of statewide resources and services for migrants and special population minorities. Using updated information provided by the local agencies, the state agency will compile a statewide listing for persons/organizations serving migrants and other minority populations (See Attachments SP-1, SP-2, SP-3).
Local agencies should contact and distribute outreach materials to other agencies offering services to persons who reside in temporary locations. Health care may not be accessible to individuals who reside in temporary locations. Therefore, these individuals should be referred to any and all health services provided by your agency. These high risk individuals must be refe_rred to appropriate health and human service agencies within your area, such as:
* Local welfare/TANF client assistance services * Food pantries/meal programs * Local shelters
..* Food Stamps Legal services
Other pertinent outreach and referral procedures may be found in the Outreach Section of the Procedures Manual.



SP - 10

G.IC PROCEDURES MANUAL
(404) 657-6620


GEORGIA MIGRANT HEALTH PROGRAM State Office of Rural Health and Primary Health Care 2 Peachtree St., NW, Sixth Floor, Atlanta, GA 30303-3186
Alice Long, Director Ambra Surrency, Assistant (404) 657-6620

Attachmen- 1
Fax (404) 657-6624

HEALTH DISTRICT
Columbus Macon Valdosta
Waycross
Coffee Co.

MIGRANT PROGRAM STAFF
Mary Anne Shepherd, FNP & Project Coordinator Merle Jernigan, LPN Ella Vento, Outreach Worker Angelica Carranza, Outreach Worker Angie Mcilrath, Outreach Worker Pat Schaefer, Support Staff Sr. Helen Schaefer, RN Shirley Jones, Receptionist Mark Burcham, Accounting
Helen Hudson, Project Coordinator Patricia Naugle, Outreach Worker Ted Meisner, Support Staff
Russell Paulk, Program Manager Jeanet Carey, RN Julissa Clapp, Outreach Worker Tomi McCain, Outreach Worker Ester Spillane, Outreach Worker B.J. Croft, Support Staff Sharon Ingram, Budgets Carol Dotson, RN Filiberto Hernandez, Outreach Worker Jo Cattrell, Secretary
Frank Stilp, FNP & Project Coordinator Marie Motes, Secretary Mariana Munoz, Support Staff Manuela Galvan, Outreach Worker Irene Cariamar, Outreach Worker Norma Lidia Andrade, Outreach Worker Pat Sieferman, NP
Sue Scaffe, District Office Cindy Sowell, Budgets Vicky Martineau, Cost Reports Gwen Kirkland, Support Staff Barbara Walling, Outreach Worker Maria Trevino, Outreach Worker Josie ltaklin, RN Sherrill Carver, Cost Reports Gayle Wombie, Adult Health Director

Albany

Bianette Hanson, FNP & Project Coordinator Alisha Fletcher, Secretary Marisela Resendiz, Nurse's Aide

FAX NUMBER
(912) 937-2232
(912)931-1125 (912) 825-6792 (912) 333-7822
(912) 388-8537 (912) 685-333 I
(912) 526-4783 (912) 285-6004 (912) 287-4033 (912) 389-4326
(9 I2) 430-5143 (912) 891-7106

PHONE NUMBER
(912) 937-5321

ADDRESS

(912) 931-1287

Ellaville Primary Medicine Center I03 Broad Street Ellaville, GA 3 I806-9428

(912) 825-6975 (1111)
(912) 825-6939 (TM) (912) 245-6415 (RP) (912) 333-5290 (Gen.)

Peach Co. Health Department P.O. Box 1149 Ft. Valley, GA 31030-1149
District 8, Unit I P.O. Box 5147 Valdosta, GA 31603-5147

(912) 245-6442 (BJ) (912) 388-1391 (9 I2) 685-5765
(912) 654-2153

Tift County Migrant Health Clinic P.O. Box J Tifton, GA 3 I793-07 I5
Candler Co. Health Department P.O. Box 255 Metter, GA 30439-0255

(912) 526-9355
(912) 285-6020 (SVS) (912) 285-6037 (CMS) (912) 685-5765 (VM) (912) 389-4450

District 9, Unit 2 I IO I Church Street Waycross, GA 31501-3525
Coffee Co. Health Department 1111 West Baker Hwy. Douglas, GA 3I533-4920

(912) 430-4576

I 109 N. Jackson St. Albany, GA 31701-2022

(912)-891-7100

Colquitt Co. Health Department P.O. Box 644 Moultrie, GA 31776-0644

COUNTY SERVED

LEAD NURSE

PHONE NUMBER

Schley Sumiter Macon Taylor Crisp

Vicki Wilder Luneda Brown Brenda Oglesby Dorothy Brown Alicia Brown

(912) 937-2308 (912) 924-3637 (912) 472-8121 (912) 862-5628 (912) 276-2680

Crawford Peach

Linda Houck Bertha Ashley

(912) 836-3167 (912) 825-6939

Brooks

Norma Jean Johnson

(912) 263-7585

Cook

Velma Bennett

(9 I2) 896-3030

Echols

Becky Neece

(912) 559-5103

Lowendes

Debra Adams

(912) 245-2314

Hahira

Becky Flyth

(912) 744-2665

I

Lake Park

Teresa Lavind

(912) 559-6470

Tift

Penny Davis

(912) 386-8373

Candler Tattnall Toombs

Diane Bryant Angela Harden Mamie Thomas

(912) 685-5765 (912)557-6791 (912) 526-8108

Atkinson Coffee

Peggy James Sandy Bradford

(912) 422-3332 (9 I2)383-4450

Colquitt

Pat Singletary

(912) 891-7100

SP - 11



GA WIC PROCEDURES MANUAL
MIGRANT EDUCATION STAFF
Sonia Francis-Harvey, Program Manager 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- 12



GA WIC PROCEDURES MANUAL

Attachment SP-3

TELAMON CORPORATION (Migrant and Seasonal Farmworker Association, Inc.)

Herbert Williams, State Director 2720 Sheraton Dr., Suite 140D Macon, GA 31204-1167 (912) 873-6575

Field Offices

Offices Valdosta Office 1012 Williams Street Valdosta, Ga. 31601(912) 244-4920 (912) 244-0907 (FAX)

Supervisors Carmen Wilkinson Program Coordinator

Lyons Office 143 East Liberty Avenue Lyons, Ga. 30436 (912) 526-3094 (912) 526-5906 (FAX)

Elmira Reynolds Employment and Training Specialist

Dublin Office 112 East Johnson Street Dublin, Ga. 31021 (912) 275-0127 (912) 275-7548 (FAX)

Irving Dawson Employment and Training Specialist

Douglas Office 613 West Baker Hwy. P.O. Box 966 Douglas, Ga. 31533 (912) 384-8856 (912) 384-8929 (FAX)

Myrtice Moore Employment and Training Specialist

Statesboro Office I05 Elm Street P.O. Box 645 Statesboro, Ga. 30358 (912) 764-6169 (912) 489-6516 (FAX)

Elsie Trethaway Employment and Training Specialist

SP- 13



GAWICPROCEDURESMANUAL
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)

Attachment SP-3 (con't)
Supervisors
Beverly Scretchen Employment and Training Specialist
James Dixon Deputy Director
Thomas Jackson Employment and Training Specialist



SP- 14



GA WIC PROCEDURES MANUAL

MIGRANT HEAD START PROGRAMS

1)

Ms. Sandra Adams, Director

KIDDIE KASTLE I

684 N. Washington Street

Lyons, Ga. 30445

(912) 526-9556

(912) 526-3434 (FAX)

2)

Ms. Betty Mincey, Director

KIDDLE KASTLE II

111 Oliver Lane

Glennville, Ga. 30427

(912) 654-2182

(912) 654-2190 (FAX)

3)

Ms. Gloria Sandoval, Director

KIDDLE KASTLE III

133 Serena Drive

Norman Park, Ga 31771

(912) 769-3627

(912) 761-3182 (FAX)

Attachment SP-4



SP - 15



GA WIC PROCEDURES MANUAL

Attachment SP-5

INTERPRETER SERVICES

STATE REFUGEE HEALTH PROGRAM INTERPRETERS

Alice Long, Director

(404) 657-6620

Below are lists of interpreters available in specific areas of the State. For interpreter services not listed below, or for general information regarding health services for refugees, call the State Refugee Health Program at (404) 657-2550.



Greater Atlanta
Sabina Brovic Chanthary Chea Bay Ngyun ZyanAmedi SiyaKim Margarita Tselesin Halema Hasashi
Gainesville
Anita Gougelmann

REFUGEE HEALTH INTERPRETERS
Bosian Cambodian, Vietnamese Vietnamese Kurdish Cambodian Russian Somalia
Vietnamese

(404) 294-3816 (404) 508-7785 (404) 657-2552 (404) 294-3816 (404) 657-2563 (404) 657-2641 (404) 657-6716
(770 ) 531-5600 GIST 261-5600

GEORGIA INTERPRETER SERVICES FOR THE HEARING IMPAIRED

Robin Titterington, Director Brian Green, contact person Two Peachtree Street, N.E. Atlanta, GA 30303

(404) 894-8558 TTD (404) 894-5604 TTD 1-800-228-4992



SP - 16



GA WIC PROCEDURES MANUAL

Attachment SP-6

ASSURANCE STATEMENT

In accordance with USDA Federal Register, Volume 54, No.239, regarding the homeless and provision of the Special Supplemental Nutrition Program for Women, Infants and Children (WIC),



(Name of shelter/facility)
assures the Georgia WIC Program that they will adhere to the following conditions:
I. The facility will not accrue financial or in-kind benefits from the resident's participation in WIC. For example, the facility may not transfer WIC foods to its own general inventories or reduce the quantity of food that would have otherwise been provided to the WIC participant.
2. Food items purchased by the WIC Program will not be used in communal feedings. WIC provides specific supplemental food intended to meet the individual needs of participants in crucial stages of growth and development. If WIC foods were used in communal feedings, they would not enhance the WIC participant's diet to the degree intended.
3. The facility places no constraints on the ability of the WIC participant to partake of supplemental foods and all associated WIC services made available to participants by the WIC local agency. The participant must be given free, full, and direct access to all WIC program benefits such as are available to participants not associated with an institution.
The Georgia WIC Program or the local WIC agency may at its discretion, make site visits to monitor compliance to the above conditions and/or investigate complaints.
I
The "Assurance Statement" will remain on file in the State WIC Office until such time as the shelter/facility notifies the State WIC Office that it no longer wishes to participate according to the ascribed conditions and/or it is determined by the Georgia WIC Program that the agency is not in compliance.



SP - 17



GA WIC PROCEDURES MANUAL
Assurance Statement Page Two

Attachment SP-6 {con't)

The undersigned agre~s to the conditions stated and declares that he/she is the duly authorized representative of the named shelter/facility, and as such, is authorized to enter into the agreement:

(Name of shelter/facility)

(Street address or P.O.Box)



(City, State, Zip, County)

(Area code- telephone number)

(Hours of telephone coverage am to pm)

Signature (Authorized Representative)

Date



Title
Please return completed and signed statement to:
Georgia WIC Program Division of Public Health Georgia Department of Human Resources Two Peachtree Street, NW
8th Floor, Suite 300 Atlanta, Georgia 30303
SP - 18





GAWICPROCEDURESMANUAL

TABLE OF CONTENTS



I. General ........................................................................................................................... OR-1 II. Methods of Outreach ..................................................................................................... OR-3 III. Agencies to Contact for Outreach.................................................................................. OR-4 IV. Public Notification .......................................................................................................... OR-5 V. Public Comments ........................................................................................................... OR-6 VI. Outreach During a Waiting List..................................................................................... OR-7 VII. Program Costs................................................................................................................ OR-8 VIII. Coordination/Integration of Services ............................................................................. OR-9
A. Outreach ................................................................................................................... OR-9 B. WIC/Medicaid Coordination.................................................................................... OR-9 C. Information and Referral ........................................................................................ OR-10 Attachments: OR-1 Georgia WIC Program Fact Sheet:.............................................................................. OR-12 OR-2 Public Meetings ........................................................................................................... OR-14





GA WIC PROCEDURES MANUAL
I. GENERAL
Outreach activities are those promotional efforts designed to encourage and/or increase participation in the WIC Program. The purpose of outreach is to:
1, Improve the health of pregnant women and children.
2. Increase public awareness of the benefits of the WIC Program.
3. Inform potentially eligible persons about the WIC Program in order to encourage and promote their participation in the program.
4. Inform health and social service agencies 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.
6. Promote a positive image of the WIC Program.
7. Generate additional information for the Hispanic and other ethnic populations.
Each local agency must 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 must be documented and kept on file for four (4) years.
Outreach activities should also be aimed at other health and social service agencies that 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 that may be of interest to or benefit WIC participants. Additionally, it requires a cooperative relationship between the local agency and these other service providers. For these reasons, the State agency strongly encourages districts to conduct outreach activities at the clinic level as well as the district level.
OR- I



.GA WIC PROCEDURES MANUAL
When funds are available, the State WIC Office will develop and provide general outreach materials for use by local programs.



OR-2



GA WIC PROCEDURES MANUAL
II. l\1ETHODS OF OUTREACH
Outreach activities should be aimed directly at potentially eligible persons through the use of informational posters, brochures, displays in public places, presentations at meetings and clubs, and advertisements through local newspapers, radio, or television. If a local agep.cy 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. WIC Fact Sheet (Attachment 1) 2. Public Service Announcement Tapes for television use
The WIC HOTLINE continues to be available for information on WIC services. The WIC HOTLINE was installed to give vendors, clients, staff, and the general public direct access to the State WIC Office at no cost. This toll-free number, 1-800-228-9173, is available on printed materials and is provided during radio and television interviews.
The twenty-one (21) local agencies are encouraged to communicate regularly with agencies providing services to mothers and children. These agencies are inclusive of governmental, quasi-governmental, private not-for-profit organizations, and citizen participation groups.

OR-3



GAWICPROCEDURESMANUAL
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. Migrarit Offices 16. Military Bases 17. Retail Stores (KMART, Walmart, etc.) 18. Day Care Centers 19. Charitable Organizations (Goodwill, Salvation Army, etc.) 20. Headstart Programs



OR-4



GAWICPROCEDURESMANUAL
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.





OR' -5



GAWICPROCEDURESMANUAL
V. PUBLIC COMMENTS
The Georgia WIC Program solicits public concerns regarding the State Plan of Operation and Administration through a series of regional public hearings annually. The public meetings also give local citizens an opportunity to comment on how WIC services are provided to them. Correspondence announcing these regional meetings are forwarded to interested individuals and groups. The following listings are examples of local groups notified with regard to the public hearings: boards of health, economic opportunity authorities, community action agencies, migrant and seasonal farm workers association, March of Dimes, Division of Family and Children Services, Legal Aid Societies, Head Start Programs, unemployment claim centers, hospitals, elected officials, associations of elected officials, choruses, religious groups, special interest health groups, minority groups, grassroots organizations, community health centers, retail vendors, and grocers associations.
In addition to the public hearing, the news media is utilized for public notification of where and how the general public may review and make comments on the plan for the Georgia WIC Program. District Health Directors, District Program Managers, WIC Program Coordinators, vendors, and WIC participants are sent correspondence encouraging them to comment and express their concerns in regards to WIC Program operations (see Attachment OR-2) .
A list of locations and contact persons where public meetings were held in Federal Fiscal Year 1999 (FFY '99) is attached (see Attachment OR-2). Plans are being considered to place the State WIC Plan Plans and Procedures Manuals on the web.
WIC Program regulations and guidelines are made available to the public upon request. This includes the Federal Regulations, the state plan, the procedures manual, and the income guidelines. When the WIC Program Coordinators give interviews to local media outlets, the statement that participation in WIC is the same for everyone regardless of race, color, national origin, age, sex or handicap is included. Information on where and how the public may review the Plan and Procedures Manual for operating Georgia WIC Programs is also shared. The Georgia Department of Human Resources Office of Public Affairs prepares news releases to notify the public of WIC benefits and notices soliciting public comments in regards to WIC operations. The news releases are sent to statewide newspapers annually.



OR-6



GA WIC PROCEDURES MANUAL
VI. OUTREACH DURING A WAITING LIST
When local agencies reach their maximum caseload and a waiting list is instituted by the State, outreach activities should begin. A local Agency can not decide to have a waiting list within their district due to caseload problems.





OR-7



GA WIC PROCEDURES MANUAL
VII. PROGRAM COSTS
Costs of promotional efforts designed to encourage and increase participation in the WIC Program are reimbursable. Outreach efforts should be consistent with the health-oriented nature of the WIC Program.





OR-8



GA WIC PROCEDURES MANUAL
VIII. COORDINATION/INTEGRATION OF SERVICES
A. Outreach
Integration of WIC services with other health clinic services has been a major thrust for the State WIC Office and the Division of Public Health. All districts have taken positive steps toward decentralization and the integration of WIC with existing services.
The Georgia WIC Program will continue to interact with Maternal and Child Health Branch Programs such as Child Health, Dental Health, Genetics, Children's Medical Services, Immunization, Women's Health, Family Planning, and other Division of Public Health Programs (i.e. Migrant Health, Rural Health, Refugee Health, and State Legislation Impact Assistance Grant Programs). The State WIC staff encourages interaction of all programs on the State and local level.
B. WIC/Medicaid Coordination
To date several measures have been implemented statewide to address the coordination of the WIC and Medicaid Programs. They include:
1. The WIC intake form includes a section (if an applicant is participating in the Medicaid Program) and provides a space for their Medicaid number.
2. The State of Georgia "Right From The Start" program makes Medicaid available to more pregnant women, infants and children up to age nineteen (19). The program is operated jointly by county Departments of Family and Children's Services (DFACS) and the Division of Public Health. DFACS has been provided with a complete schedule of caseworkers to maximize their effectiveness in reaching the target population as they come in for WIC services. Effective July 1, 1993, Medicaid coverage options for pregnant women and infants expanded to 185% of federal poverty guidelines; while also expanding coverage for children up to age 19 in families at 100% of federal poverty.
3. The Child Nutrition and WIC Re-authorization Act of 1989 (P.L. 101-147) requires state agencies to provide information about and referrals to Medicaid at the time of initial application and reapplication of such individuals who appear to be Medicaid eligible but are not participating. Implicit in the law is a mandate for greater coordination between programs. To satisfy the requirements of the law, representatives from WIC; the Division of Public Health, Maternal and Child Health Branch; the Division of Family and Children Services; the
OR-9



GAWICPROCEDURESMANUAL
Department of Medical Assistance; and the Department of Health and Human Services (DHHS) elected to develop a joint, single page Multi Service application form. The ultimate goal of this joint application form is to improve service delivery and access to services for potential participants by integrating/coordinating the application/eligibility process; thereby eliminating or greatly reducing the duplication of services.
4. As an on-going effort, the Georgia WIC Program plans to employ a part-time medical epidemiologist to collect and analyze data on birth outcomes for WIC participants. This will enable the State agency to fully assess the impact of WIC/Medicaid coordination on infant mortality. Furthermore, an association between early prenatal WIC enrollment and prenatal care is also being investigated.
C. Information and Referral
WIC is designed to provide for the nutritional care of participants. However, some clients seeking WIC services may have other medical or social service needs. To assist in addressing the needs of WIC participants and applicants seeking WIC services, referrals are made to other available resources. Intra-agency services and programs are sources of referrals for local WIC Programs, as well as, local and state inter-agency programs. Referrals are essential for the coordination and the maximization of services and resources.
Other food assistance programs and services that are common referral resources for local WIC Programs include: food stamp programs; food banks; food cooperatives; churches/synagogues food pantries; the Salvation Army; general assistance funds and other community organizations such as fraternities, sororities, and clubs, etc.
During the past several fiscal years, efforts have been directed toward developing coordination and linkage strategies among federally-funded programs at both federal and state levels. The SWO compiles information related to coordination and referral linkages associated with the delivery of WIC services in Georgia. Such information is shared with the USDA and other service-related programs at state and federal levels. To improve the quality and validity of the information, all local agencies must participate in the process.
Local agencies are responsible for developing referral networks with public and private health and social services providers. The referral process includes the identification of referral needs and making provision for tracking incoming and outgoing referrals of WIC participants. Benefits of a systematic referral process at the local level includes the identification of referral trends within the WIC Program; maximization of program
OR-10



GA WIC PROCEDURES MANUAL
resources; outreach to the hard to reach potentially eligible applicants; identification of areas for expanding and improving WIC outreach and marketing; and validation of referral information compiled by the SWO. Local Agencies are required to document referral activities and report to the SWO upon request



OR-11





GA WIC PROCEDURES MANUAL

Attachment OR-1

Special Supplemental Nutritional Program for Women, Infants and Children

FFY 2000 Fact Sheet

Georgia Department of Human Resources

WIC in Georgia

The Women, Infants and Children Nutrition program provides special supplemental foods, nutritional counseling, and breast-feeding support and education to low income women and their children up to age five (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 peas and beans, peanut butter, fruit juices, and infant formula (for those
who do not breastfeed).

WIC staff encourage women to breast-feed and counsel them about nutrition. They identify affordable prenatal care and encourage participants to apply for Medicaid, food stamps, TANF, immunization, and other services.

Georgia WIC will receive approximately $116 million in federal funds during FFY 2000. An additional $48 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 approximately three quarters (75 percent) of those women and children

estimated to be eligible in Georgia. "WIC Works Wonders", a special outreach effort

to increase participation, began in February 1991.



The Georgia WIC program served an average of 224,026 women, infants and

children per month during FFY '99.



Infant formula rebates gave Georgia a $48 million savings last year. This allowed the

program to serve thousands of additional clients.



WIC brought about $164 million into the Georgia economy during Fiscal Year '98.



The average WIC benefit is about $47 worth of food vouchers per month.

OR-12



GA WIC PROCEDURES MANUAL

Attachment OR-1

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.

Who Gets WIC?

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 pregnant, breastfeeding an infant less than one (1) year of age, or a postpartum non-breastfeeding woman who has given birth with the last six (6) 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. Enrolling eligible working women is also a high priority.



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 ~t Grady

Hospital and Southside Healthcare, Inc.



For FFY '99 an income of 185 percent of the federal poverty level equals:

Family Size

Yearly Income

1

$15,244

2

20,461

3

25,678

4

30,895



OR-13

GA WIC PROCEDURE MANUAL

- Attachment 0R-2



1999 PUBLIC MEETINGS/DATES
Georgia Department of Human Resources' WIC Program will hold public meetings during April 1999. The public meetings give local citizens a chance to comment on how WIC services are provided in their community.

Thursday, April 29, 1999
Thursday, April 29, 1999
Friday, April 30, 1999
Tuesday, April 20, 1999
Thursday, April 22, 1999
Thursday, April 29, 1999
Friday, April 30, 1999
Tuesday, April 27, 1999
Wednesday, April 28, 1999
Thursday, April 29, 1999

3:00 p.m. to 7:00 p.m. 4:00 p.m. to 6:00 p.m. 11 :00 a.m. to 1:00 p.m.
10:00 a.m. to 12:00 p.m. (Noon) 2:00 p.m. to 4:00 p.m. 4:00 p.m. to 6:00 p.m.
4:00 p.m. to 6:00 p.m.
3:00 p.m. to 6:00 p.m.
3:00 p.m. to 6:00 p.m.
3:00 p.m. to 6:00 p.m.

Floyd County Health Department 315 West 10th Street Rome, GA 30161
Whitfield County Health Department 808 Professional Blvd. Dalton, GA 30720
Woodstock Health Department 7545 N. Main Street - Suite 100
Woodstock, GA 30188
Towns County Health Department 1104 Fuller Circle
Young Harris, GA 30582
Franklin County Senior Center 6885 Hwy. 145 South Carnesville, GA 30521
Cobb County Community Health Center
1650 County Services Parkway Room226
Marietta, GA 30008
Douglas County Health Department Board Room
6770 Selman Drive Douglasville, GA 30134
North Annex 7741 Roswell Road Conference Room #208 Atlanta, GA 30350
Center Hill Health Center 3201 Atlanta Industrial Parkway
Suite 302 Atlanta, GA 30331
College Park Regional Health Center 1920 John Wesley Avenue College Park, GA 30337

Rosemarie Newman Sandy Akins Sandy Akins Jean Garner Jean Garner
Beverley Demetrius
Beverley Demetrius Paulette McCray Paulette McCray Paulette McCray

14

GA WIC PROCEDURE MANUAL

Attachement OR-2 (cont'd)

Friday, April 30, 1999

3:00 p.m. to 6:00 p.m.

South Annex 5600 Stonewall Tell Road College Park, GA 30349

Paulette McCray

Wednesday, April 28, 1999
Tuesday, April 27, 1999
Wednesday, April 28, 1999

9:00 a.m. to 12:00 p.m. (Noon)

Clayton County Health Department Administrative Office
1380 Southlake Plaza Drive Morrow, GA 30260

3:00 p.m. to 4:00 p.m.

District 3, Unit 4 District Health Office 320 W. Pike Street
LawrenceviUe, GA 30046

10:00 a.m. to 11 :00 a.m.

Rockdale County Extension Service 1329 Portman Drive, Suite B Conyers, GA 30094

Kathy Thomas Maxine Moore Maxine Moore

Wednesday, April 28, 1999

1:00 p.m. to 2:00 p.m.

Salvation Army 5193 Washington Street Covington, GA 30014

Maxine Moore

Thursday, April 29, 1999

3:00 p.m. to 4:00 p.m.

Norcross Housing Authority 19 Gamer Street
Norcross, GA 30071'

Maxine Moore

Thursday, April 29, 1999
Tuesday, April 27, 1999
Tuesday, April 27, 1999
Wednesday, April 28, 1999
Wednesday, April 28, 1999
Tuesday, April 27, 1999

5:30 p.m. to 7:30 p.m.
11 :00 a.m. to 12:00 p.m. (Noon) 3:00 p.m. to 4:00 p.m.
11 :00 a.m. to 12:00 p.m. (Noon) 1:45 p.m. to 2:45 p.m.
4:00 p.m. to 6:00 p.m.
15

Bohan Auditorium Richardson Building
445 Winn Way Decatur, GA 30030
Carroll County Health Department 1004 Newnan Road
Carrollton, GA 30116
Troup County Health Department 107 Medical Drive
LaGrange, GA 30240
Spalding County Health Department 1007 Memorial Drive Griffin, GA 30223
Henry County Health Department 135 Henry Parkway
McDonough, GA 30253
Oconee Regional Library Laurens County
801 Bellevue Avenue Dublin, GA 31021

Carol Boe
Blanche DeLoach
Blanche DeLoach
Blanche DeLoach
Blanche DeLoach
Wanda Foskey Brent Gibbs
Mary Ann Tripp

GA WIC PROCEDURES MANUAL

Attachment OR-2 (cont'd)

Thursday, April 29, 1999

9:00 a.m. to 12:00 p.m. (Noon)

Roberta City Hall 262 E. Agency Street Roberta, GA 31078

Shirleen Crocker

Thursday, April29,1999
Thursday, April 29, 1999
Tuesday, April 27, 1999
Wednesday, April28,1999
Tuesday, April 27, 1999
Wednesday, April 28, 1999
Wednesday, April 28, 1999
Friday, April 30, 1999
Tuesday, April 27, 1999
Friday, April 23, 1999

9:00 a.m. to 12:00 p.m. (Noon)
9:00 a.m. to 12:00 p.m. (Noon) 9:00 a.rn. to 11 :00 a.rn.
9:00 a.m. to 11:00 a.rn.
9:00 a.m. to 10:30 a.m. (Non-Spanish Speaking)
10:30 a.m. to '12:00 p.m. (Noon) (Spanish Speaking) 4:00 p.m. to 6:00 p.m.
9:00 a.m. to 11 :30 a.rn.
9:00 a.m. to 11:30 a.m. (Non-Spanish Speaking) 1:00 p.m. to 3:30 p.m.
(Spanish Speaking) 2:00 p.m. to 4:00 p.m.
1:00 p.m. to 4:30 p.m.

Irwinton Court House Grand Jury Room 100 Bacon Street
Irwinton, GA 31078
Bowden Homes 2301 Houston Avenue
Macon, GA 31206
Jenkins County Health Department Conference Room
709 Virginia Avenue Millen, GA 30442
Warren County Public Library (Beside the Methodist Church)
Warrenton, GA 30828
Ft. Benning Youth Activity Center Building 1056 McVier Street
Ft. Benning, GA 31905
Wilson Rental Office Community Room 3101 9th Avenue
Columbus, GA 31904
West Central Health District Columbus Health Department
District WIC Office 2100 Comer Avenue
P.O. Box 2299 Columbus, GA 31902-2299
Sumter County Health Department 208 Rucker Street P.O. Box 806
Americus, GA 31709
Lowndes County Health Department 206 South Patterson Street Valdosta, GA 31601
Worth County Health Department 1012 W. Franklin Street Sylvester, GA 31791

Shirleen Crocker Shirleen Crocker Barbara Turner Barbara Turner
Ms. Thorne
Linda Day Tonga McClinton
Milly Rivera
Karla Wilson
Janet McClure Molly Orwig

16

GA WIC PROCEDURES MANUAL

Attachment OR-2 (cont'd)

Friday, April 30, 1999
Thursday, April 15, 1999
Tuesday, April 20, 1999
Thursday, April 22, 1999
Thursday, April 29, 1999
Thursday, April 29, 1999
Tuesday, April 27, 1999
Wednesday, April 28, 1999
Tuesday, April 27, 1999
Wednesday, April 28, 1999

2:00 p.m. to 5:00 p.m.
9:00 a.m. to 10:30 a.m. 9:00 a.m. to 10:30 a.m.
9:00 a.m. to 10:30 a.m.
10:00 a.m. to 12:00 p.m. (Noon) 5:00 p.m. to 7:00 p.m.
10:00 a.m to 12 p.m. (Noon) 10:30 a.m. to 2:00 p.m. 2:00 p.m. to 3:00 p.m.
12:00 p.m. (Noon) to2:00p.m.

Dougherty County Health Department 1710 South Slappey Drive Albany, GA 31706

Molly Orwig

Chatham County Health Department 1602 Drayton Street Savannah, GA 31401

Pat Jackson

Chatham County Health Department 2011 Eisenhower Drive Savannah, GA 31406

Pat Jackson

Effingham County Health Department 802 Hwy. 119 West
Springfield, GA 31329

Pat Jackson

Waycross Housing Center 1125 Tebeau Street
Waycross, GA 31501

Susan Home or Anita Craft

Wayne County Health Department 240 Peachtree Street Jesup, GA 31545

Susan Home or Anita Craft

Howard Coffin Recreation Building Glynn Avenue
Brunswick, GA 31520

Tracy Wallace

Clarke County Health Department 345 North Harris Street Athens, GA 30601

Vicky Moody

Southside Healthcare Inc. Department of WIC & Nutrition Services Nutrition Classroom
1039 Ridge Avenue S.W. Atlanta, GA 30315

Laverne Montgomery

Grady Health System Maternal WIC Program
Waiting Room Clinic Building, 2nd Floor
80 Butler Street Atlanta, GA 30335

Leigh Ann Feast

17





GA WIC PROCEDURES MANUAL TABLE OF CONTENTS

Page

I.

General .......................................................................................................................... FD- I

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

E. Vouchers Printed On Demand (VPOD)............................................................ FD-3

Ill. Voucher Issuance - General .......................................................................................... FD-4

A. Valid Certification Period ................................................................................ : FD-4 B. Identification of Person Picking Up Vouchers ................................................. FD-4 C. Corrections ........................................................................................................ FD-4 D. Bi - Monthly Issuance ....................................................................................... FD-5 E. Categorically Ineligible ............................. ~ ...................................................... FD-5

F. Issuance of Vouchers to Family Members ....................................................... FD-5

IV. Computer Printed Vouchers ......................................................................................... FD-6 A. Data Elements ................................................................................................... FD-6

B. Voucher Cycles................................................................................................. FD-7

C. Voucher Packaging ........................................................................................... FD-7 D. Voucher Shipments ......................................................................................... FD-11 E. Receipt of Vouchers........................................................................................ FD-11 F. Inventory Control. ........................................................................................... FD-12



GA WIC PROCEDURES MANUAL G. Issuance of Computer Printed Vouchers ........................................................ FD-12 H. Transporting VPOD Vouchers from a Site Within a Site ............................... FD-15 I. Ordering VPOD Vouchers .............................................................................. FD-15
V. Manual Vouchers ........................................................................................................ FD-16 A. Blank Manual Vouchers ................................................................................. FD-16 B. Preprinted Manual Vouchers or Special Automated Vouchers ...................... FD- I 7 C. Ordering Manual Vouchers ............................................................................ FD-17 D. Receipt of Manual Vouchers .......................................................................... FD-17 E. Inventory Control of Manual Vouchers .......................................................... FD-18 F. Issuance of Manual Vouchers ......................................................................... FD-19 G. Distribution of Manual Voucher Copies......................................................... FD-22
VI. Georgia WIC Program Identification (ID) Card ........................................................ FD-23 A. General ............................................................................................................ FD-23 B. Required Data ................................................................................................. FD-23 C. Participant Instructions ................................................................................... FD-24
VII. Proxies ....................................................................................................................... FD-25 A. General ............................................................................................................ FD-25 B. Reasons for Proxies ........................................................................................ FD-25 C. Authorization .................................................................................................. FD-25 D. Voucher Pick Up, Issuance, and Use .............................................................. FD-25 E. Restrictions ..................................................................................................... FD-26 F. Participant Instructions ................................................................................... FD-26
VIII. Mailing/Delivery ofWIC Vouchers .......................................................................... FD-27



GA WIC PROCEDURES MANUAL A. Conditions for Mailing/Delivering Vouchers ................................................. FD-27

B. Acceptable Reasons for Mailing/Delivering Vouchers .................................. FD-27 C. Mailing/Delivery Procedures .......................................................................... FD-28

D. Vouchers Mailing Process .............................................................................. FD-28

E. Returned Vouchers ......................................................................................... FD-29

IX. Voided Vouchers ....................................................................................................... FD-30

A. Voided Computer Vouchers ........................................................................... FD-30

B. Voided Manual Vouchers ............................................................................... FD-31

X.

Prorated Vouchers...................................................................................................... FD-32

XI. Late Pick-Up of Vouchers ........................................................................:................ FD-34

XII. Coordination of Health Services and Vouchers Issuance ..........................................FD-35

A. Policy Statement ............................................................................................ FD-35

B. Procedures.......................................................................................................FD-35

XIII. Redemption ofWIC Vouchers .................................................................................. FD-38

A. General ...................:........................................................................................ FD-38

B. Checkout ......................................................................................................... FD-38
c. Cashier Validation .......................................................................................... FD-38

D. Voucher Redemption and Signatures ................ ;................:........................... FD-39

XIV. Lost, Stolen or Damaged Vouchers ........................................................................... FD-40

A. Replacement of Vouchers ............................................................................... FD-40

B. Lost/Stolen/ DestroyedNoided Voucher Report ............................................ FD-40

C. Vouchers Lost, Stolen, or Destroyed Prior to Issuance .................................. FD-41

D. Change of Formula Order ............................................................................... FD-42



GA WIC PROCEDURES MANUAL XV. Borrowed Vouchers ................................................................................................... FD-43 XVI. Cumulative Unmatched Redemption Report (CUR) ................................................. FD-44
A. Introduction..................................................................................................... FD-44 B. Procedures For Reconciliation ........................................................................ FD-44 C. Manually Reconciliating CUR Part 1............................................................. FD-45 D. Manually Reconciliating CUR Part 2 ............................................................. FD-46 E. Procedures For Both Reports ....................................................................... '. .. FD-47 Attachments: FD- I Computer Printed Voucher ........................................................................ FD-48 FD-2 Blank Manual Voucher .............................................................................. FD-49 FD-3 Preprinted Standard Manual Voucher. ....................................................... FD-50 FD-4 Automated Special .Manual Voucher ......................................................... FD-51 FD-5 Voucher Printed On Demand (VPOD) Voucher........................................ FD-52 FD-6 Voucher Create Calendar ........................................................................... FD-53 FD-7 Voucher Cycle Packing List ...................................................................... FD-54 FD-8 Computer Printed Voucher Register .......................................................... FD-55 FD-9 Voucher Register Summary Page .............................................................. FD-56 FD-IO Transmittal Form ....................................................................................... FD-57 FD-11 Form and Manual Voucher Orders ............................................................ FD-58 FD-12 Manual Voucher Inventory ..............................:......................................... FD-59 FD-13 Voucher On Demand Daily Log Sheet ...................................................... FD-60 FD-14 Batch Control Form ................................................................................... FD-61 FD-15 Batch Control Exception Report ................................................................ FD-62 FD-16 Georgia WIC Program Identification Card ................................................ FD-63



GA WIC PROCEDURES MANUAL FD-17 Daily Roster/Monthly Mailed Voucher Report ......................................... FD-64 FD-18 Borrowed Voucher Report Form .............................................................. FD- 65 FD-19 Cumulative Unmatched Redemptions Part 1.. ............................................ FD-66 FD-20 Cumulative Unmatched Redemptions Part II ............................................ FD-67 FD-21 Lost, Stolen, Destroyed, Voided Voucher Report ..................................... FD-68 FD-22 Vouchers Printed On Demand (VPOD) Receipt........................................ FD-69







GA WIC PROCEDURES MANUAL
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 bi-monthly basis. Georgia has a fully automated food delivery and management information system. The State agency contracts with a data processing firm, Viking Computing, Inc. to operate and maintain the system.
Persons requesting WIC benefits are screened for program eligibility and are certified if the applicant qualifies. Electronic Transfer Data containing demographic, financial, medical/nutritional, and food package information is forwarded directly to the Contractor in order to establish a participant masterfile. Most local agencies have the capability of electronically transmitting WIC data to the ADP contractor. Local Agencies use many different kinds of automated systems.
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 ADP Contractor also provides preprinted manual vouchers and special vouchers that can be issued to new and transferring participants.
Participants redeem the vouchers for specified kinds and quantities of foods at authorized vendors. Vendors then deposit the redeemed vouchers in their local bank accounts. The vouchers proceed through the banking system to a central clearing bank where they are edited for missing or invalid information. Vouchers that are not paid are sent back to the appropriate local bank and the vendor's account is reduced by the value of the 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 that tracks the status of all vouchers. The ADP Contractor also produces participation, financial, vendor, and other management reports at regular intervals for use by State and local agencies.



FD-I



GA WIC PROCEDURES MANUAL
II. TYPES OF WIC VOUCHERS
There are five (5) types of WIC 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 Turn Around Document (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 staff at the time of issuance (see FD-V- Manual Vouchers and FD-F- Issuance of Manual Vouchers for procedures). The clinic information is preprinted on blank manual vouchers (Attachment FD-3).
c. Preprinted Standard Manual Vouchers
Standard manual vouchers are unseparated sets of four (4) food package types. These vouchers contain a preprinted standard food package (Attachment FD-3). Standard voucher sets should not be broken to issue single standard vouchers. The four (4) types of food packages available are:
I. Infants (Food Package 153). 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



D. Automated Special Manual Voucher

Automated Special Manual Vouchers are similar to Preprinted Standard Manual Vouchers except the vouchers area message is blank. Automated clinics may use these forms to prepare manual vouchers for any food package (see Attachment FD4). All vouchers must be stored in a secured location and must be logged on the Manual Inventory log within three (3) days of receipt in the clinic.

E. Vouchers Printed On Demand (VPOD)

Vouchers Printed On Demand (VPOD) generated on site by the clinic's automated system for each qualified participant that qualifies for the WIC Program. The receipt generated from printing these vouchers becomes the voucher inventory (see Attachment 5).





FD-3



GA WIC PROCEDURES MANUAL

III. 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 staff must check the WIC ID card for signatures of the participant/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. When identity is checked for the person picking up vouchers at issuance, it must be documented on the voucher register, manual voucher copy or the VPOD receipt. Use the same ID codes in the certification process to document proof ofID for voucher pickup. The current WIC ID card (WC) can be used as ID for voucher pickup.

Documentation of ID Proof codes for Voucher Pickup



Computer Printed Voucher Issuance - Document the proof code on the

voucher register (left-hand side of the ID number).



Voucher Printed on Demand (VPOD) - Document the proof code on the

voucher receipt under the user's ID.



Manual Vouchers - Document the proof code on the manual voucher under

the date the vendor must deposit by.

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") must not be used on vouchers for any reason.

FD-4



GA WIC PROCEDURES MANUAL
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 issuance, prior approval from the State WIC office must be obtained. With bi-monthly issuance, 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.
E. Categorically Ineligible
Categorically ineligible refers to the period of time a client is no longer eligible to receive WIC benefits because of selected categories. Participants who are subject to be categorically ineligible are postpartum women, infants who have reached their first (151) birthday, children who have reached their fifth (5th) birthday, 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.
When a participant becomes categorically ineligible before the end of the month, eligibility is extended to the end of the month. In case of suspected 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 five (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 of Vouchers to Family Members
Vouchers must never be issued by an employee to an immediate family member (children, grandchildren, sisters, brothers, nieces, nephews, aunts, uncles, parents, spouses, first cousins, and in-laws) or other persons residing in the same household. Failure to comply with these procedures will result in payment of food cost to the State WIC Office and may result in administrative disciplinary action by the local agency .
FD-5



GA WIC PROCEDURES MANUAL
IV. COMPUTER PRINTED VOUCHERS AND VOUCHER PRINTING ON DEMAND (VPOD)
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.
2. WIC ID Number. The participant's unique identification number that corresponds to the number on the TAD (Tum-Around Document).
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, middle initial).
4. First Day to Use {MMDDYY). The first valid date when the voucher may be used to purchase foods.
5. Last Day to Use {MMDDYY). The last valid date, after which the voucher can no longer be used by the participant. The voucher may be used on this date, but not after this date.
6. Vendor Must Deposit by {MMDDYY). The date by which the vendor must deposit the voucher is sixty (60) days of the first day of use. Vouchers not deposited by this date are considered stale 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.
9. Maximum Purchase Price. The actual purchase price may not exceed this amount.
10. Pay Exactly. This space is left blank for the vendor to enter the actual amount of the WIC foods purchased. FD-6



GA WIC PROCEDURES MANUAL 11. WIC Vendor Stamp. Stamped by the vendor prior to deposit.
12. Sign Here At Grocery Store. The participant/proxy signs his/her name in this space when the voucher is redeemed at a WIC vendor.
The reverse side of the computer printed vouchers contains an area for endorsement by the authorized WIC vendor location.
B. Voucher Cycles
The voucher pickup day is determined by the clinic staff and participant. This day
is entered as a Pickup Code on the TAD.
Whether or not computer printed vouchers will be printed for the participant during 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 work-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 last work 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 (I = monthly; 2 = bimonthly, even; 3 = bimonthly, odd).
Please refer to the "Voucher Create Calendar," for a one (1) year calendar of voucher issuance dates (Attachment FD-6).
C. Voucher Packaging
In each clinic package the vouchers are in alphabetical order based on the last name of the lead family member within each Site Code. The lead family member is the one with WIC Type P, N, or B or the one with the lowest Participant ID Number (usually #1).
I. The following items will be included in each clinic package (or clinic package #1 if there is more than one [I]):
a. Voucher Cycle Packing List (Attachment FD-7)
This (2-ply) packing list provides the specific beginning and ending voucher numbers for all the computer printed vouchers (and for the
FD-7



GA WIC PROCEDURES MANUAL
manual vouchers when appropriate) for the clinic. It also lists the appropriate pages of the Computer Voucher Register that accompany the clinic's computer printed vouchers. Two copies of the packing list are provided. 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-8)

Purpose - To provide a listing of participants that have computer generated vouchers produced during a cycle and to provide a signature space for verification of receipt of vouchers. The register is organized in the same order as the computer generated vouchers.

Distribution - Clinic

I copy

District/Unit

1 copy, Summary

State

1 microfiche copy

Frequency - twice each month, with each voucher cycle

Sequence - District/Unit, clinic, Site Code, alphabetic by name of lead family member.

Register Description -

Line 1

WIC ID: The WIC ID number of each participant.

PARTICIPANT NAME: The name of the woman participant or the participant in the family having the lowest Participant ID Number. The register is in sequence by this name, and 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 part1c1pation or income as a percent of the Federal Poverty Guidelines. The numbers indicate the level of poverty and are as follows:

FD-8



GA WIC PROCEDURES MANUAL M: If the client is enrolled in Medicaid.

0-1

0-100%

2

101-125%

3

126-150%

4

151-175%

5

176-185%

TYPE: WIC type P, N, B, I, C

Poverty Poverty Poverty Poverty Poverty

PR: Priority

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 or voided.

Line 2

TELEPHONE NUMBER: Phone number of participant.

VOUCHER NUMBERS: The voucher numbers are listed across the four (4) columns below the name. NOTE: If the participant has an interval code of2 or 3, a second line of information is printed for the second set of vouchers.

TOTAL: The number of vouchers 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.

FD-9



GA WIC PROCEDURES MANUAL RECERT DUE - MMDDYY Subsequent certification is due in the same month as or the month after the voucher issue month. For breastfeeding women and children, the date is the certification date plus six (6) months. RECERT DUE (P) - MMDDYY Subsequent certification is due in the same month as, or in the month after, the voucher issue month. For pregnant women, the date is forty-five (45) days from the Expected Date of Confinement (EDC). RECERT OVDUE - MMDDYY For breastfeeding women and children, subsequent, certification is overdue based on the certification date plus six (6) months. RECERT OVDUE (P) - MMDDYY For pregnant women, subsequent certification is overdue based on the EDC plus forty-five (45) days. 1ST B'DATE - MMDDYY Infant's birthdate is in the month after the voucher issue month. The date printed is the birthdate. CATEG TERM - MMDDYY The participant is categorically ineligible in the month after voucher issuance month. A message ac~ompanies the last set of vouchers. The date printed is the categorical termination date.
FOR N - Delivery Date plus 6 months
FOR B - Delivery Date plus 12 months
FOR C - At 5th birthday
ISSUE DATE: The date of issue printed on the vouchers.
2. The District/Unit receives the following items with each voucher shipment:
a. Voucher Cycle Packing List (Attachment FD-6) (See FD IV, C. l .a.)
b. Voucher Register Summary Page (Attachment FD-9)
This summary page includes:
(1) Total participants who receive computer generated vouchers. FD-10



GA WIC PROCEDURES MANUAL
(2) Total vouchers for the District/Unit.
(3) Total number of messages by message type.
(4) Signature line and certifying statement of persons closing out the voucher register, two signatures are required to closeout the register. The signatures must be for each month by two different staff members.
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 the clinic. Vouchers are shipped by UPS and are received by local agencies on the 22nd day of the month for the next month's cycle I and on the 7th day 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 immediately. To insure that all items have been received, the voucher numbers must be checked and verified with the Voucher Cycle Packing List (Attachment FD-7). Any discrepancies must be reported to the ADP Contractor 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 ofreceipt of the vouchers. The original must be retained by the clinic for one (1) year 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.



FD-11



GA WIC PROCEDURES MANUAL
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 one (1) to ten ( 10) computer generated vouchers issued depending on the Food Package and the Interval Codes for participants with special needs who are receiving alternate food packages, the number of vouchers may be as high as sixteen ( 16). The following procedures must be followed when issuing computer printed vouchers:
1. Identification. Verify the identity of the person picking up the vouchers. Please refer to FD-III.B., "Identification of Person Picking Up Vouchers," for procedures.
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 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 of vouchers received OR the
FD-12



GA WIC PROCEDURES MANUAL
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 and date the appropriate line(s). "Failed to sign" must not be abbreviated.
(3) During a monitoring review, if one (1) percent or more "fail to sign" notations appear 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.
(4) If the participant or proxy is unable to write, he/she wiH 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 also be entered when vouchers are VOIDED.
c. Clerk Initial. The staff person must initial here when vouchers are issued or 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 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
FD-13



GA WIC PROCEDURES MANUAL
voucher(s) must be voided and replaced with manually issued vouchers if the food package is changed.
5. Transfer of Vouchers 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 to document voucher pick-up and the disposition of the 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, in this situation 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.
The following procedure must be followed:
a. A copy of the appropriate page(s) of the voucher register (see Attachment FD-8) or transmittal form (see Attachment FD-I 0) must accompany the vouchers.
All other forms of documentation (i.e. void) utilizing the transmittal form must be followed in accordance with the computer printed voucher register procedures. Please refer to 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) (see Attachment 10).
c. The signed page(s) of this copy of the register or transmittal form will be returned to the original clinic and attached to the original voucher register.
d. An individual site code should be assigned when participants are in a specified geographical or otherwise related area (i.e. common site of employment or established "satellite clinic").
6. Damaged/MisprintedVoucher. If a computer printed voucher is damaged during issuance and is voided, a blank manual voucher will be issued by clinic staff.
7. Mailing/Delivery of WIC Vouchers (See FD-VIII) FD-14



GA WIC PROCEDURES MANUAL
H. Transporting VPOD Vouchers from a site within a site
1. When VPOD Vouchers are transferred to a site within a site (Voucher issuance clinic only), the vouchers must be printed the afternoon prior to going to the clinic or printed the day of the clinic.
Special written permission must be given prior to transporting these vouchers (see Attachment 5).
Vouchers not issued on site must be voided immediately. Each time a voucher issuance clinic is held, the same procedure must be followed.
See Transporting procedures in the Quality Improvement Section of the Procedure Manual.
I. Ordering VPOD Vouchers
Voucher Printing On Demand (VPOD) voucher numbers are received in the clinic via FAX from the ADP Contractor. No paper vouchers are involved because VPOD utilizes a special blank stock. The voucher serial number is added at the time of printing. All numbers must be entered upon time of receipt as with other manual vouchers. There will be no inventory to keep. At the end of each day the clinic staff prints a report that shows how many vouchers were printed for each participant and the initials of the issuing clerk.
When a clerk prints vouchers under VPOD, the printer produces the food packages along with a receipt. The receipt contains the clients' WIC ID number, Name, Issue Date, Last Date To Use, Food Package Number, Voucher Code, Voucher Number, any appropriate message and a place for the client/proxy to sign. The receipt takes that place of voucher inventory as well as the voucher register. The client signs the receipt and then is handed the vouchers. The receipt must then be immediately filed in order.



FD-15



GA WIC PROCEDURES MANUAL
V. MANUAL VOUCHERS
When manual vouchers are received, the serial numbers must be recorded in the "Received" column of the "Manual Voucher Inventory" log (see Attachment FD-12). This documentation must be completed the same day the vouchers are received by the responsible WIC staff person. The voucher numbers must be entered into the computer . at that time as well. For stand-alone systems, vouchers must be used in the order in which they were received; first in, first out. All vouchers must be used in sequential order until depleted. Do not use two voucher batches at the same time; complete one batch before using another.
For Networked Systems, batches must still be used in order. However, it is likely that more than one batch will be used at one time.
Manual vouchers are very similar to computer printed vouchers. The primary differences are:
1. Manual vouchers are three (3) part forms. The parts are color-coded for distribution as follows: First copy (blue) - participant Second copy (red) - ADP Contractor or clinic copy if automated transfer is used Third copy (black) - clinic or may be destroyed if automated transfer
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.
A. Blank Manual Vouchers
Blank manual vouchers are issued for the following reasons:
To provide vouchers for a food package (other than those provided by ~he 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 .
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GA WIC PROCEDURES MANUAL
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 Automated Vouchers

Preprinted manual vouchers or special automated vouchers are issued for the following reasons:

I. To provide vouchers to newly certified, reinstated, or transferring participants until computer printed vouchers are available.

2. As a 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 the prior month after computer vouchers have been

returned to the ADP Contractor as unclaimed.

C. Ordering Manual Vouchers

Local agencies must order manual vouchers from the ADP Contractor. Orders must be made using the "Form and Manual Voucher Orders" Form (Attachment
FD-11) and must be received by the ADP Contractor by the I0th 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

I. 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
FD-17



GA WIC PROCEDURES MANUAL must be signed and dated to verify receipt. A copy of the signed/dated packing list must be mailed to the local agency/district office within five (5) days of receipt of the vouchers. The original must be retained by the clinic for one (1) year plus the current Federal Fiscal Year.
2. District/Unit
The District/Unit receives a copy of each detailed clinic packing list for control, and a summary copy showing total vouchers received from the District/Unit. Any discrepancies must be 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 of the "Manual Voucher Inventory" log (see Attachment FD12). This documentation must be completed the same day the vouchers are received by the responsible WIC staff person. Vouchers must be used in the order in which they were received; first in, first out. All vouchers must be used in sequential order until depleted. Do not use two voucher batches at the same time; complete one batch before using another.
1. VPOD Vouchers
When VPOD Vouchers are printed, a receipt is generated which becomes the inventory of voucher (see Attachment 22). This inventory eliminates the need to keep weekly manual inventory. However, it is vital that copies of the receipt be filed in voucher order numbers by date.
In an effort to maintain the daily use of vouchers, at the end of the day clinic staff must run a query report of all vouchers used. That daily query report must be maintained in a file until the end of the month. Therefore, each clinic must maintain a file for each month with the daily query (i.e. March 1999 Query).
2. Perpetual Inventory (Weekly) (For Blank Manuals, Preprinted Standard Manual, Automated Special Manual Vouchers and VPOD Vouchers).
The perpetual inventory accounts for the number of vouchers issued, voided, and on hand. The perpetual inventory must be conducted weekly and documented on the Manual Voucher Log. All col~mns of the log must be completed accurately, legibly, and initialed, by a responsible staff
FD-18



GA WIC PROCEDURES MANUAL member. For Vouchers Printed On Demand (VPOD), use the VPOD Log Sheet (Attachment 13).
3. Physical Inventory (Monthly)
A monthly physical inventory of all manual vouchers must be conducted. Another staff person must verify the inventory and initial the inventory log. Physical inventory documentation must include the serial numbers of the vouchers and the total number of vouchers on hand. The physical inventory must be documented on the "Manual Voucher Inventory Log" and labeled "Physical Inventory Conducted and Verified by." Two staff members must initial and date the physical inventory.
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. Inventories must be completed in black or blue ink.
F. Issuance of Manual 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 of vouchers. 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 of vouchers. The dates on the first set of vouchers must be the date on which the vouchers are issued. The dates on the second set of vouchers must correspond to the pick-up code of the first set of vouchers.
In certain circumstances, when the TAD input cutoff date to the ADP Contractor cannot be met, enough vouchers should be issued to carry the participant until the next pickup date. Preprinted manual vouchers may be combined with blank manual vouchers in order to issue the correct number of vouchers until the next pick up date.
The following procedure must be followed when issuing manual vouchers:
FD-19



GA WIC PROCEDURES MANUAL Identification

1. Verify the identity of the person picking up vouchers. See page FD-111.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. The 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 damaged computer

vouchers must be written on the manual voucher to retain the original

information.

On a blank manual voucher, the following additional information must be completed:

Food Prescription Data blocks. Enter quantities for appropriate foods, enter an "X" in all unassigned blocks.

3. The participant or proxy must sign each voucher in the left signature space, in the presence of the issuing staff person. Refer to FD-IV.G.2.a.(4), "Signature of Participant or Proxy", for instructions regarding the signature of participants who are unable to write.

4. Give the top copy (blue) to the participant.

5. When manual vouchers are issued to a new participant during the initial certification appointment, the participant must receive an explanation on the proper procedure for redeeming vouchers. Whenever possible, the participant's proxy should be present during this explanation. The following

FD-20



GA WIC PROCEDURES MANUAL
is a guide for the information the participant/proxy should receive regarding the vouchers:

a. The participant signs on the left hand side of the voucher in clinic; he/she countersigns on the right hand side of the voucher in the grocery store.

b. Explain "First Day to Use" and "Last Day to Use."

c.

If vouchers 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 which foods are 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 participants who are 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.
c. How often they come to clinic to pick up vouchers (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.



FD-21



GA WIC PROCEDURES MANUAL
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-14). 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 batched separately. When sending via Express Mail, do not use a Post Office Box. -The clinic address must be used with this process.
2. For clinics with Automated Manual Voucher Systems, the second copy (red) must be filed following the above procedures. The third copy (black) may be destroyed since the diskette provides the issue information to the ADP Contractor.
3. If batch is mailed to the ADP Contractor, the third copy (black) of the Manual Vouchers must be retained by the clinic and attached to a copy of the Batch Control Form, creating a Batch Control Module (BCM). BCM's must remain intact until they are reconciled.
Upon receipt of a manual voucher BCM, the ADP Contractor will 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-15). Discrepancies should be resolveq 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 lined binders, post binders, or expanding file folders in order to maintain them neatly.
Voucher copies must be retained for three (3) years plus the current Federal Year.



Signed/stamped Batch Control Forms and forms describing discrepancies can be destroyed after the reconciliation is complete.
FD-22



GA WIC PROCEDURES MANUAL

VI. GEORGIA WIC PROGRAM IDENTIFICATION (ID) CARD

A. General

A Georgia WIC Program Identification (ID) card (Attachment FD-16) 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 (I) 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.).

When identity is checked for the person picking up vouchers at issuance, it must be documented. Accept the same information as for certification and use the same codes.



Computer printed vouchers - document on the left-hand side of WIC I.D.

number on the voucher register.



Manual vouchers - document on the manual voucher copy under date.



Voucher Printed on Demand (VPOD) document on the receipt under User's

I.D.

B. Required Data

Before issuing the ID Card, all items on the front must be completed.

FRONT:

1. Participant's name,

2.

WIC ID number,

3. Date certification period expires,

4. Participant/parent/guardian/caretaker's signature,

FD-23



GA WIC PROCEDURES MANUAL

5. EDC date, 6. Signature of proxy(ies), 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 if the participant/parent/guardian/caretaker, or proxy is unable to write.

B.

This may be accomplished by the participant/parent/guardian/ caretaker after he/she has left the clinic

It is recommended that all of the information on the back of the ID card also be completed.



BACK:
1. Appointment information, 2. Voucher pickup code, 3. Voucher interval code, 4. Comments, 5. Clinic identifying information, 6. Clinic Telephone Number.
C. Participant Instructions
Participants/parents/guardians/caretakers must receive an explanation of the instructions on the purpose and use of the ID card. The following is a guide to the information that should be given to the participant regarding the WIC ID Card. Whenever possible, the participant's proxy(ies) should be present during the explanation.
1. This ID card is to identify you as an authorized WIC participant when picking up and/or redeeming vouchers. You should keep vouchers with the I.D. card. You must have your ID card when picking up vouchers, at certifications or when redeeming vouchers at the grocery store. A proxy must have the ID card to pick up or redeem vouchers. (Refer to the section below for more information regarding proxies).
2. Notify the clinic if the ID card is lost or stolen.
3. Explain the "Expiration Date" and when the participant will be due to be screened for eligibility again.
4. Explain shopping procedures (i.e., review allowable items, importance of separating foods, etc.). FD-24



GA WIC PROCEDURES MANUAL
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 a proxy.
A proxy is a person who acts on behalf of the participant. An authorized proxy may pick up and or redeem vouchers and may bring a child in for subsequent certifications in restricted situations (see Certification Section).
A proxy should be a responsible person whom the 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.(4) 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 Section FD-IV.G.2.a.(4) if a proxy is unable to write):
FD-25



GA WIC PROCEDURES MANUAL
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). The participant must be informed at the initial certification appointment that this is their responsibility. Proxies must also be informed of their right to complain to the clinic about improper vendor practices.
E. Restrictions
1. 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. All 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.



FD-26



GA WIC PROCEDURES MANUAL
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 to mail vouchers (i.e. permanent difficulty accessing the clinic(s) for mailing/delivering vouchers to participants).
2. Vouchers must not be mailed in the following situations: I. Participant due for re-certification. 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 vouchers to a participant, the issuing WIC professional must obtain prior approval from the WIC Coordinator, and a copy of the page of the Voucher Register must be signed by the participant. Once the page is signed, it must be attached to the Voucher Register.
4. The hardship condition and the WIC Coordinator/designated CPA's approval must be documented in the participant's health record. Once the initial hardship has been resolved, the mailing or delivery of WIC Vouchers must be discontinued and the action documented.
B. Acceptable Reasons for Mailing/Delivering Vouchers
I. Difficulties of the participant and his/her proxy in obtaining vouchers for reasons such as illness.
2. Imminent or recent childbirth.
3. Environmental crisis as a result of a tornado, hurricane, flood, snow-storm, or ice storm.
4. Closure of clinic due to structural damage, relocation, etc.
5. Other special circumstances approved by the WIC Coordinator.
FD-27



GA WIC PROCEDURES MANUAL

NOTE:

*If the Food Stamp Program has discontinued or does not routinely mail Food Stamps Coupons to a geographical location, WIC Vouchers can not be mailed to this area.

C. Mailing /Delivery 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 the post office box; and must note on the mail roster the participant's name, identification number and sequence of voucher numbers returned in the mail and a full signature of the person documenting this information.

6. A roster must be maintained on a weekly basis by the local office noting all vouchers mailed and participant names and identification numbers. This roster should be mailed to the District Office (see Attachment FD-17).

The procedure for delivering a voucher (s) are as follows:

1. 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 mst be attached to the original voucher register. The original computer voucher register must have the statement "See Attachment" on the Register.

D. Voucher Mailing Process

When mailing vouchers, the computer voucher register or voucher copy must be documented with the disposition of the vouchers. The WIC official must document the signature line(s) with the statement "mailed vouchers" or "delivered vouchers," the reason(s) for mailing, the date mailed, and the signature of the person preparing vouchers for mailing. It is recommended
FD-28



GA WIC PROCEDURES MANUAL
that vouchers be mailed via certified mail; mailed vouchers will not be replaced.
E. Returned Vouchers
When vouchers are returned by the postal service, the following steps must be followed:
1. If the voucher(s) are still valid for redemption, the local agency will attempt to contact the participant in an effort to issue. This contact must be recorded on the voucher register. If the local agency is unable to contact the participant, "void" the voucher(s) immediately, and maintain on site until the scheduled time that they are mailed to the bank, except for manual vouchers which are returned to Data Processing. If a record of manual vouchers has been sent to the ADP Contractor, manual vouchers must be voided and sent to the bank.
2. If the vouchers are out of date, stamp the word "void" on the food instrument. Note on the Voucher Register or receipt "returned by postal service" at the corresponding voucher numbers and maintain on site until the scheduled time that they are mailed to the bank. Voucher(s) should be "voided" immediately and processed as customary.



FD-29



GA WIC PROCEDURES MANUAL
IX. VOIDED VOUCHERS
Voided vouchers should be marked "void" if the 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 the contracted bank. Package the vouchers securely to prevent breakage and send them to arrive at the Contracted Bank by noon of the fifth (5th) workday of the following month.
A. Voided Computer Vouchers
1. Computer printed vouchers are voided in the following situations:
(a) The 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 the contracted bank to arrive by noon of the fifth (5th) workday of the following month. Never staple a voided voucher to any other voucher.
(d) Voided vouchers must be securely stored according to program procedures (lock the vouchers in a cabinet, closet or safe) until they are forwarded to the contracted Bank.
FD-30



GA WIC PROCEDURES MANUAL
B. Voided Manual Vouchers
Manual vouchers, blank vouchers, or preprinted vouchers will be voided if the participants name is misspelled; when any of the participant information is entered incorrectly; when there is damage during issuance; or if a voucher(s) is returned unused by participant.
1. 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 the contracted bank (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 the 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 Section 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 voided information into the system to identify the disposition of the vouchers. All voided and destroyed vouchers must be reported to the ADP Contractor's Bank.



FD-31



GA WIC PROCEDURES MANUAL
X. PRORATED VOUCHERS
The objective of prorated vouchers is to ensure that participants receive benefits for which they are entitled during a valid time frame. Vouchers are issued based on the number of weeks within a valid redemption time period. A voucher is valid for only 30 days from the date of issuance. When it is determined that a participant cannot redeem vouchers within the valid time frame, the number of vouchers issued must be prorated.
Prorating is the partial issuance of vouchers by retrieving one or more vouchers from the designated voucher series. Vouchers must be prorated when:
( 1) A participant is late picking up vouchers (procedures for voiding vouchers must be followed as outlined in IX Voided Vouchers).
(2) Vouchers are replaced because they are damaged or there is a change in the prescribed food package or agency error.
Note: The procedures in Section FD-XIV must be followed when replacing vouchers.
To ensure consistency when prorating vouchers the guidelines below must be followed .

I Number of Days Late I Less than 7 days late
7-13 days late
14-20 days late
21-31 days late

I Women & Children

full package

I

3 vouchers issued

(3/4 package)

2 vouchers issued

( l /2 package)

1 voucher issued (1/4 package)

Infants full package full package
1 voucher issued (1/2) package 1 voucher issued (l /2 package)



FD-32



GA WIC PROCEDURES MANUAL a) ALTERNATE FOOD PACKAGES

Number of Days Late

Women & Children

Less than 7 days late

I

full package

I

7 - 13 days late

6 vouchers issued

(3/4 package)

14-20 days late

4 vouchers issued ( l /2 package)

21-31 days late

2 vouchers issued (1/4 package)

Infants full package full package
1 voucher issued ( l /2 package)
1 voucher issued ( l /2 package)

Note: Ifa scheduling error is made by the clinic which results in the loss ofvouchers
by. the participant, there are two options. Either issue the entire food package and follow procedures noted above, or change the pickup code and submit to the ADP Contractor .



FD-33



GA WIC PROCEDURES MANUAL
XI. LATE PICK-UP OF VOUCHERS
Participants who are late picking up their vouchers must be issued a prorated food package based on the schedule in FD-X. If participants come in for their vouchers after they have been returned to the ADP Contractor 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 be prorated to reflect the period of time left until the participant's next scheduled pickup date.
To determine the number of days a participant is late for pickup, the following guidelines must be followed.
1. Count calendar days, including weekends.
2. If the participant's scheduled pickup day was before the "First Day to Use" on the vouchers, begin counting days late from the "First Day to Use" date.
3. If the participant's scheduled pickup day was after the "First Day to Use" on the vouchers, begin counting days late from the appointment date.
The appointment date must be documented on the voucher register in addition to the required pickup date.
To prorate voucher issuance for late pickup follow procedures for prorating vouchers (See FD-X).
An option to prorating voucher(s), when a participant is late picking up vouchers, is to change the pick up date. The pick up date is changed to the date the vouchers are picked up. A full set of vouchers is issued with the current date.
To use this option the clinic staff must:
(1) Document the 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 is necessary to void any of the computer generated vouchers.
(4) Give the participant an appointment for next month's pickup with the new pickup date .
FD-34



GA WIC PROCEDURES MANUAL
XII. COORDINATION OF HEALTH SERVICES AND VOUCHERS ISSUANCE
Routinely, WIC food .vouchers are issued based on the number of weeks in a valid redemption time period. The following procedures modify voucher issuance in order to enhance coordination and linkage of Georgia's Immunization and WIC Programs. The policy governing the modified vouchers issuance procedures has a threefold purpose. (1) To ensure that the food delivery system is compatible with the delivery of health and nutrition education services to participants and caregivers (CFR 246. l 2(d)). (2) To enhance integration of health services (CFR 246.7(a); CFR 246.1 l(a)(l). (3) To prevent the occurrence of health problems and to improve the health status of WIC participants/caregiver. (CFR 246.1 ).
A. Policy Statement
Every effort must be made to coordinate the issuance of WIC vouchers with the delivery of health services. (CFR 246.12(d); CFR 246.1 l(a)(l) and (2)). Efforts must be made to provide health services so that the patients/families will not have to return more than once a month. However, vouchers may be issued for one month, if the participant/caregiver is to return for services at that time. (This is the exception not the rule).
Under no circumstances are vouchers to be withheld or denied nor are any services to be forced upon participant/caregiver [(CFR 246.ll(a)(2).] Participants/caregivers have the right to refuse other health services, but we have the responsibility to frequently offer and strongly encourage the use of all available health services (CFR 246.6(b)(3)(4)(5); CFR 246.7(I)(2)(iii); CFR 246.12(s)(7) (8)).
B. Procedures
1. Initial Visit
At initial visits the participant/caregiver is informed of the date of their next visit and that it will be coordinated with their next voucher issuance or other scheduled health department services. The date and the nature of the next services are recorded on the participant's identification card. The participant/caregiver is provided with enough vouchers to carry them through their next scheduled service or issuance. If the participant/caregiver states, they plan to receive the services elsewhere, document their response in the medical record and issue their full voucher package. In the event the service in question is immunization, the clinic staff should ask the participant/caregiver to bring with them documentation of the immunizations at the next visit. This request must also be recorded in the medical record.
FD-35



GA WIC PROCEDURES MANUAL
Ifthe participant/caregiver states that they do not wish to receive any other services, then counsel on the importance of good health care as a preventive measure toward future health problems. Advise them of the alternative places where they may receive care, encourage them to seek care somewhere if not at the current local clinic and issue their full voucher package. [(CFR 246.6(b)(3) & (4).]
2. Subsequent Visits
At the next subsequent certification or voucher issuance visit to the local clinic refer the clinic's tickler system to see if a service is due and/or past due. If a health service is due, and participant/caregiver is willing to receive that service, route them through the clinic for service and voucher issuance. If the participant/caregiver is to receive that service elsewhere, issue the vouchers and remind them of their next service and when it is due.
If the participant/caregiver is willing to receive the service but is unable to do so, due to a staffs member decision that is medically or logistically inappropriate; issue the full voucher package to the participant/caregiver and ask them to return at a date when the service would be more appropriate.
If the participant/caregiver state that they wish to receive the service, but are unable to do so today, ask them when would it be most convenient for them to return for the service. Document the date change in their medical record and issue vouchers, not to exceed one month) to carry them through to the next date.
When participant or caregiver had previously refused our services, ask if they are interested in them at this point (current visit). If the response is positive, route them through the clinic for the service and voucher issuance. If the response is no, the clinic staff should: (a) counsel on the importance of good health care as a preventive measure towards future health problems, (b) advise them of alternative places where they may receive care, (c) encourage them to seek care somewhere if not with the local clinic. and (d) issue their full voucher package.
3. Completing the voucher register
When participant/caregiver receives full voucher package, have them complete the signature and date lines per procedures of the Georgia WIC User Manual. If the participant/caregiver receives vouchers bi-monthly, issue the participant/caregiver only one month. Document on voucher register the appointment or health services the participant is to receive.
FD-36



GA WIC PROCEDURES MANUAL
If participant/caregiver was scheduled to return for a.service prior to closeout .and failed to do so; contact the participant/caregiver to notify them that they need to come in to pick up the next set of vouchers. If they still fail to pick up their vouchers by the time of final closeout; void their remaining vouchers and write void on the voucher register over the nwnber of vouchers voided.
If the participant/caregiver comes in after their remaining vouchers have been voided and prior to their next issue date, write manual voucher to replace all of the voided vouchers.

1.




FD-37



GA WIC PROCEDURES MANUAL
XIII. 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 (if they have accompanied the participant to clinic) so that they fully understand their responsibilities regarding the use of WIC vouchers.
A. General
1. Participants or their proxies should present the WIC ID card. They do not need any other ID (see FD-VI).
2. It does not cost anything to use WIC vouchers. Under no circumstances will participants/proxies get change or be required to pay anything.
3. A participant does not have to purchase everything on each voucher. However, all the foods the participant wants to purchase from the voucher must be purchased at the same time. Participants/proxies may not get rain checks.
4. Food or formula must never be returned for cash or credit.
5. Proxies must be properly educated before being allowed to redeem vouchers.
8. 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 vouchers are valid. Vouchers cannot be used before "The First Day to Use" and they cannot be used after the "Last Day to Use". Participants have thirty (30) days from the "First Day to Use" in which to redeem the vouchers.
2. The types and quantities of food being purchased are the same as those prescribed on the vouchers.
3. The vouchers have not been altered.
FD-38



GA WIC PROCEDURES MANUAL
D. Voucher Redemptions and Signatures
The cashier must enter the exact purchase price on the voucher prior to the participant's signature. The participant/proxy will countersign each voucher in the cashier's presence. If the signature on the vouchers does not match the signature on the WIC ID card, the cashier must not accept the vouchers and must immediately notify the clinic of the situation. Participants must be instructed not to countersign until the cashier has written in the total cost of the foods. If a name has been signed in the counter signature block then the grocery store must obtain a signature above the pre-signed name.
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.





FD-39



GA WIC PROCEDURES MANUAL
XIV. LOST, STOLEN OR DAMAGED VOUCHERS
A. Replacement of Vouchers
1. Lost or Stolen vouchers will not be.replaced.
2. Damaged Vouchers
When a participant/parent/guardian/caretaker reports that their vouchers have been damaged the following procedure may be implemented:
If vouchers are damaged, any pieces of the vouchers that can be salvaged should be. brought to clinic. Vouchers that can be identified by voucher numbers may be replaced.
3. Vouchers destroyed due to fire will be replaced with a copy of the fire report.
B. Lost/Stolen/DestroyedNoided Voucher Report
When vouchers are reported as lost, stolen, or destroyed, complete the Lost/Stolen /Destroyed/ Voided Voucher Report (Attachment FD-21) with the following items: a. District/Unit/Clinic b. Current Date c. Beginning Voucher Number in Range* d. Ending Voucher Number in Range* e. Quantity of Vouchers in Range f. Participant's WIC ID Number .g. Participant's Status Code h. Participant's Last Name and Replacement Voucher Numbers (in the
"Comments" block)
* If a participant reports that part of a voucher package was lost/stolen/destroyed and the other portion was cashed, but cannot determine which voucher serial numbers were lost/stolen/destroyed, include all of the voucher serial numbers on the form. Note in the comments section of the Lost/Stolen Destroyed Voided Voucher Report that 1-4 vouchers may have been cashed.
Mail the completed Lost/Stolen/Destroyed Voided Voucher Report to the ADP Contractor, retain a copy in the clinic, and forward a copy to the State WIC Office, System Information Unit. Upon receipt of the Report, the ADP Contractor will enter this information into the system. If the vouchers are
FD-40



GA WIC PROCEDURES MANUAL
subsequently paid by the contract bank, they will be identified on the Bank Exception Report during the monthly reporting process.
The State WIC Office cannot initiate "stop payments" on lost/stolen/ destroyed vouchers issued to WIC participants. When fraud is suspected, the local agency should notify the Quality Improvement Unit to request assistance with an investigation. To obtain copies of suspect vouchers, the Local Agency must submit a Quality Improvement Voucher Investigation Log (Attachment QI-2) to the Quality Improvement Unit (see Section X of Quality Improvement Section of the Georgia WIC Procedures Manual).
C. Vouchers Lost, Stolen, or De~troyed Prior to Issuance
When a clinic determines that vouchers have been lost, stolen, or destroyed prior to issuance, the following procedure must be implemented:
1. Complete the Lost/Stolen/Destroyed Voided Voucher Report (Attachment FD-21) with the following items: a. District/Unit/Clinic b. Current Date C. Beginning Voucher Number in Range d. Ending Voucher Number in Range e. Quantity of Vouchers in Range
2. Mail the completed Lost/Stolen/Destroyed Voided Voucher Report to the ADP Contractor, retain a copy in the clinic, and forward a copy to the State WIC Office, System Information Unit. Upon receipt of the Report, the ADP Contractor will enter this information into the system. If the vouchers are subsequently paid by the contract bank, they will be identified on the Bank Exception Report during the monthly reporting process.
The System Information Unit will review Lost, Stolen, or Destroyed voucher reports in conjunction with the Cumulative Unmatched Redemption (CUR) report to identify potential fraud and refer findings to the Quality Improvement Unit. The Quality Improvement Unit will work in conjunction with the Local Agency to investigate potential fraud. When a block of 25 or more vouchers are missing see QI Section X, Investigation of Missing Vouchers .



FD-41



GA WIC PROCEDURES MANUAL
D. Change of Formula Order
In the event that a formula order is changed after a participant has been issued vouchers for an original formula order, replacement vouchers may be issued. When vouchers are replaced within the same month of original issuance, the following procedures must be implemented:
Standard Formula, Special Formula 1. Participants must return unused formula to the clinic if available, and/or 2. Return unredeemed voucher(s) to the clinic for voiding. 3. Supplemental vouchers issued must be prorated for the remainder of time
in the issuance period. 4. Document the amount, type, and disposition of formula returned to clinic
on the voucher register or the clinic's copy of the manual voucher.
Hospital Based Formula
Ifa formula is changed by a physician, the participant must return all unopened case(s) of formula to the clinic.
The Clinic must then:
I. Issue supplemental vouchers prorated for the remainder of time in the issuance
period.
2. Document the amount, type, and disposition of formula returned to clinic on the Voucher Register or on the clinic's copy of the manual voucher.
3. Document formula change and receipt of an updated written or verbal order from the physician in the participant's health record.
4. If the formula is ordered by the Office of Nutrition, all unopened cases of formula should be returned to the company. Notify the Office of Nutrition so that a refund may be obtained from the company.



FD-42



GA WIC PROCEDURES MANUAL
XV. BORROWED VOUCHERS
Vouchers may be borrowed within a District from one clinic by a clinic whose current stock is depleted.
Submitting the form in a timely manner 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 18 of the Food Delivery Section.



FD-43



GA WIC PROCEDURES MANUAL

XVI. 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 with the ADP contractor or a manual reconciliation should be performed with the State WIC Office, depending on how much time has elapsed since the voucher was redeemed. The CUR Report has two parts:

Part I : A cumulative list of manual vouchers issued by clinics and cashed by the participant, when there is no record that the voucher was issued on the ADP Contractor's mainframe computer system (see Attachment FD-19).

Part 2: A cumulative list of manual vouchers issued by the clinics and cashed by the participants, which have not matched to a valid WIC ID number, issue date, or participant certification record on the ADP Contractor's mainframe computer system (see Attachment FD-20).

The Local Agency may correct an unmatched redemption list that is over 30 days old. The second month the item appears, the Local Agency must manually reconcile the items described below. These manually reconciled items, should not be submitted to the ADP Contractor since the items are purged from the system after they are listed the second time.

B. Procedures For Reconciliation

Cumulative Unmatched Redemptions that have not matched to an issuance record.

CUR Part I:

Attachment FD-19 provides an example of cumulative unmatched redemptions which are not matched to an issuance record. The third
and fourth columns on the CUR Part I has the $ amount of the
redeemed voucher(s).

If the voucher appears in the third column or the Ist $ amount column, confirm the
batch of vouchers appearing in the l st $ amount column was sent to the ADP Contractor.

I. Ifthere is no acknowledgment from the ADP Contractor that the batch was received, resubmit to the ADP Contractor.

2. If there is acknowledgement that the ADP Contractor received the vouchers appearing in the 1st $ amount column, the vouchers may have contained an error or were processed incorrectly by the bank. Photocopy the entire set of vouchers that FD-44



GA WIC PROCEDURES MANUAL
were issued to that participant even if all the vouchers are not listed on the report, and make the necessary corrections on the photocopy. Correct only those voucher(s) listed in the 1st $ amount column with the ADP Contractor.

Corrections and resubmitted batches must be received by the ADP Contractor by the end of the month cut-off (7th working day of the month following the month in which the report was received). Complete a Batch Control Form. Batch and submit to the ADP Contractor. Do not submit copies of the CUR report to the ADP Contractor and do not send copies of vouchers to the SWO.

C. Manually Reconciling CUR Part 1

Those voucher(s) listed in the second$ amount column are too old to correct through the ADP Contractor and must be manually reconciled by the clinic.

1. .Locate a copy of the voucher(s) listed in the second$ amount column.

2. Record the issue date only of the voucher (the actual date as it appears on the voucher) on the dotted line adjacent to the voucher number on the CUR Part 1 report, sign and date the report. If there are no vouchers appearing on the CUR Part 1 report that have to be manually reconciled, the report should still be forwarded to the SWO. The CUR Report should always be submitted to the SWO in its entirety. Do not send copies of vouchers to the State WIC Office.

Cumulative Unmatched Redemptions that have not matched to a valid certification record.

CUR Part 2:

Attachment FD-20 provides _and example of cumulative unmatched redemptions which are not matched to a valid certification record. The fifth and sixth columns on the CUR Part 2 have the $ amount of the redeemed voucher.

1. Verify that the issue date and /or the ID number is correct as it appears on the voucher and the CUR report. If both or either the issue date or the ID number is incorrect, complete only the appropriate column of the CUR PART 2 CORRECTION FORM with the correct issue date and/or ID number for the entire set of vouchers listed. Mail the top copy of the form to the ADP Contractor. Retain the bottom copy for your files. Do not submit a copy of the CUR Part 2 Correction Form to the SWO.

When the issue date and the ID number on the voucher(s) and the CUR Part 2 report are correct.

FD-45



GA WIC PROCEDURES MANUAL 1. Verify that the participant was in a valid certification period as of the voucher issue date. If the participant was not within a valid certification period when the voucher was issued, there is no correction to be made and the voucher will appear on the next CUR report. Briefly document on the dotted line adjacent to the voucher number on the CUR report, why the vouchers were issued outside of a valid certification period.
2. If the vouchers were issued within a valid certification period, verify whether the TAD transaction creating the valid certification was batched and submitted to the ADP Contractor. If there is no batch acknowledgment, resubmit the entire batch to the ADP Contractor.
3. If the TAD was submitted to the ADP Contractor, it may have contained a critical error. Review critical error reports and resubmit a corrected TAD transaction as appropriate.
Correct only those voucher(s) listed in the last$ amount column on the report with the ADP Contractor. Corrections and resubmitted batches must be received by the ADP Contractor by the end of the month cut-off (7th working day of the month following the month in which the report was received).
D. Manually Reconciling CUR Part 2
Vouchers listed in the second$ amount column (sixth column) are too old to correct through the ADP Contractor. Those vouchers must be manually reconciled by the clinic. A note in the last column explains why the vouchers appear on the CUR Part 2.
1. Locate the copy of the voucher(s) and check the ID number, name, and issue date.
2. If the issue date or the ID number on the voucher(s) or the CUR Part 2 report is erroneous, record only the corrected information on the dotted line adjacent to the voucher number on the CUR Part 2 report.
3. If the issue date and the ID number on the CUR Part 2 are correct, record briefly the reason the voucher(s) were issued.
4. The first voucher of a set of vouchers issued to a participant appearing in the second $ amount column must be manually reconciled. (See Attachment FD-20)
5. Sign and date the completed report and submit to the State WIC Office. If there are no vouchers on the report to be manually reconciled, the CUR report should still be forwarded to the SWO in its entirety. Do not send CUR reports to the ADP Contractor.
FD-46



GA WIC PROCEDURES MANUAL E. Procedures For Both Reports

1. Submit the completed reports to the District Office and the District Office will submit all the reports from each clinic in a batch to the State WIC Office by the 22nd of the month following the report's run date month (i.e., if the run date is 2/18/94, the manually reconciled CUR report is due to the State WIC Office by 3/22/94).

2. If you are unable to locate a copy of a specific voucher(s), send a memo to the State WIC Office requesting a copy of the vouchers. Please include the redemption month along with the voucher number(s).

NOTE:

The vouchers in the second $ amount columns on Part 1 and Part 2 can no longer be reconciled by the ADP Contractor and must be manually reconciled by the clinic.





FD-47

GA WIC PROCEDURES MANUAL COMPUTER PRINTED VOUCHER

Attachment FD-1



FD-48



GA WIC PROCEDURES MANUAL BLANK MANUAL VOUCHER

Attachment FD-2



FD-49



GA WIC PROCEDURES MANUAL

Attachment FD-3

PREPRINTED STANDARD MANUAL VOUCHER



FD-50



GAWICPROCEDURESMANUAL

Attachment FD-4

AUTOMATED SPECIAL MANUAL VOUCHER



FD-51







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GA WIC PROCEDURES MANUAL
1999 FEB MAR APR

VOUCHER CREATE CALENDAR JUN JUL

Attachment FD-6

NOV

DEC

2000

13 14

CYCLE I 1st 14th
CYCLE2 I 5th - Month end


I - Cycle I TAD INPUT CUTOFF ( 15th) 2 - Date Federal Express shipped VOUCHERS ARRIVE at D/U (22nd) 3 - ESTIMATED date UPS shipped VOUCHERS ARRIVE at Clinic 4 - Cycle 2 TAD INPUT CUTOFF (last workday of each month) 5 - Date Federal Express shipped VOUCHERS ARRIVE at D/U (7th) 6 - ESTIMATED date UPS shipped VOUCHERS ARRIVE at Clinic
FD-53



GA WIC PROCEDURES MANUAL

Attachment FD-7

VOUCHER CYCLE PACKING LIST

PAGE60 REPORT ENCR2006
DISTRIBUTION:

STATE OF GEORGIA WIC SYSTEM VOUCHER CYCLE PACKING LIST (CLINIC)
FOR THE SECOND CYCLE OF JULY

CLINIC PAGE 2 D/U/CL

CLINIC KEEPS TOP COPY

CLINIC RETURN SECOND COPY TO DISTRICT/UNIT

( )

VOUCHER REGISTER POS 1508 - 1566

( )

COMPUTER PRINTED VOUCHER FROM 1006547 TO 1008499





IF THE ACTUAL CONTENTS OF THIS SHIPMENT DIFFER FROM THIS PACKING SLIP. CONTACT EDS-WIC IMMEDIATELY. TELEPHONE 1-800-221-9182. CONTENTS VERIFICATION

WIC REPRESENTATIVE SIONATURE

DATE

EDS SHIPPING USE

COMMENTS

NUMBER OF PIECES FOR THIS DISTRICT/UNIT _ _ _ _ _ __

EDS QUALITY CONTROL INITIALS_ _ _ _ _ _ _ _ _ __

FD-54



GA WIC PROCEDURES MANUAL

PAGE

6570

COMPUTER PRINTED VOUCHER REGISTER
STATE OF GEORGIA WIC SYSTEM

Attachment FD-8
CLINIC PAGE 34

REPORT EWCR201G

COMPUTER GENERATED VOUCHER REGISTER D/U/CL

09-

03-632

COASTAL HEALTH

RUN DATE

3/19/99

INPUT CUTOFF DATE 03/15/99

WICID FAMILY

C p LAST

FIRST I M y R SIGNATURE OF PARTICIPANT DATE CLK



FD-55

GA WIC PROCEDURES MANUAL

Attachment FD-9

PAGE 708 REPORT EWCR201G D/U---01-1 MESSAGE TOTALS

VOUCHER REGISTER SUMMARY PAGE

TOTAL OF TOTAL OF
1496 214 919 162 226
0 72 0 0

STATE OF GEORGIA WIC SYSTEM COMPUTER GENERATED VOUCHER REGISTER

DIST/UT 01-1 RUN DATE_/_/_ INPUT CUTOFF DATE_/_/_

3,639 PARTICIPANTS RECEIVING 3,374 PARTICIPANTS RECEIVING RECERT DUE - MM/DD/YY CATG TERM MM/DD/YY NUTRITIONAL ASSESSMENT-MM/DD/VY IST BDATE-MM/DD/YY RECERT DUE (P)-MM/DD/YY NO-SHOW PRIOR NO-MM RECERT OVERDUE (P)-MM/DDNY RECERT OVERDUE (F2)-MM/DDNY RECERT DUE (PRl2)-MM/DDNY

12,809 VOUCHERS

FOR 01/92

11,913 VOUCHERS

FOR 01/92

(DUE FOR RECERT-SEE CERT-DUE)

(CATEGORICAL TERM DUE ON DATE SHOWN)

(NUTRITIONAL ASSESSMENT DUE-DATE SHOWN)

(INFANT TO CHOLD CHANGE IN DATE SHOWN)

(PASSED CERT-DUE DATE)

(CLIENT DID NOT PICK UP VOUCHER IN MONTH)

(PASSED CERT-DUE-DATE P)

([PASSED CERT DUE DATE PRIORITY 2)

(DUE FOR RECERT (PRI-W) SEE CERT DUE)



FD-56



GA WIC PROCEDURES MANUAL

Attachment FD-10

TRANSMITTAL FORM
Verification Receipt of WJC Vouchers

Client'.s Name____________

Clinic _ _ _ _ _ _ _ _ _ _ _ _ __

This is to certify that I received the following WIC vouchers:

# _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
# ----------------

# #

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

Participant/Proxy

Date

Staff/Initials

Date

Verification Receipt of WIC Vouchers

Client's Name___________

Clinic _ _ _ _ _ _ _ _ _ _ _ _ __

This is to certify that I received the following WIC vouchers:

# _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ # _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Participant/Proxy

Date

# #

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

Staff/Initials

Date

Verification Receipt of WIC Vouchers

Client's Name___________

Clinic _ _ _ _ _ _ _ _ _ _ _ _ __

This is to certify that I received the following WIC vouchers:

# _ _ _ _ _ _ _ _ _ _ _ _ __ # _ _ _ _ _ _ _ _ _ _ _ _ __

#--------------#---------------

Participant/Proxy

Date

Staff/Initials

Date

Verification Receipt of WIC Vouchers

Client's Name___________

Clinic _ _ _ _ _ _ _ _ _ _ _ _ __

This is to certify that I received the following WIC vouchers:

# _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ # _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

# #

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

Participant/Proxy

Date

Staff/Initials

Date

Verification Receipt of WIC Vouchers

Client's Name___________

Clinic _ _ _ _ _ _ _ _ _ _ _ _ __

This is to certify that I received the following WIC vouchers:

# _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ # _ _ _ _ _ _ _ _ _ _ _ _ __

Participant/Proxy

Date

# _ _ _ _ _ _ _ _ _ _ _ _ _ __
#---------------

Staff/Initials

Date

FD-57



GA WIC PROCEDURES MANUAL

Attachment FD-11

FORM AND MANUAL VOUCHER ORDERS

GEORGIA WIC PROGRAM FORM AND MANUAL VOUCHER SUPPLY ORDER FORM (REV l/95)

Return to:

Viking Computing, Inc. 1000 North Madison Ave., Suite W-l l Greenwood, Indiana 46142

Your District/Unit:

Clinic name:

Address:

Phone l-800-899-7913
FAX: l-317-889-9485 This order is for clinic #:_ _ _ __

Contact person: ---------------=Phone:_ _ _ _ _ _-----'Date Mailed:_ _ __

NOTE: Viking processes Georgia WIC Program orders twice a month. Orders received at Viking by the 10th of the month are processed so that the order is delivered by the 25th of the month. Orders received at Viking by the 25th of the month are processed so that the order is delivered by the l 0th
of the following month. If the 10th or 25th fall on the weekend or on a holiday, the cut-off is the

workday before.



MANUALVOUCHERORDER

BLANK MANUAL VOUCHERS FOR HAND COMPLETION
Blank manual voucher (no tuna or carrots) 408 (blank manual voucher with tuna and carrots)
PREPRINTED MANUAL VOUCHER PACKAGE SETS FOR HAND COMPLETION
Sets of prenatal/breastfeeding women package 404 Sets of postpartum non-breastfeeding women package 502 Sets of infant package 113 Sets of child package 603
SPECIAL MANUAL VOUCHERS FOR USE ON COMPUTER
Special manual vouchers for use on computer (ATVS, MVS, M&M, or other State approved system)
CERTIFICATION FORM (TAD) ORDER
Blank TAD (no preprinted ID number) Pre-numbered TAD (preprinted ID number)
OTHER FORMS
Form and Manual Voucher Supply Order forms Lost/Stolen/Destroyed voided Voucher Report forms Vendor Input Form

FD-58

GA WIC PROCEDURES MANUAL

Attachment FD-12

STANDARD MANUAL_ _ __

MANUALVOUCHERINVENTORY
MANUAL VOUCHER INVENTORY

CLINIC_ _ __

BALANCE BROUGH FORWARD_ _ __

DATE

RECEIVING NO.

ENDING NO. NO. RECEIVED

NO. ISSUED NO. VOID NO.ON HAND

INITIALS



FD-59



GA WIC PROCEDURES MANUAL

Attachment FD-13

VOUCHER ON DEMAND LOG SHEET PRINTER ONE

BATCH# _ _ _ _ BEGINNING# _ _ _ _ _ _ _ _ _ _ _ ENDING# _ _ __

DATE (when vouchers were printed.)

BEGINNING (the number of the
first voucher printed for that
day.) (A)

ENDING (the number of the
last voucher printed for that
day.) (8)

TOTAL (the number of vouchers used for that day.)
(8-A = total)

VOIDED (the number of vouchers that were voided for that day ... good to know.)

INITIALS (always sign your initials for that day.)





GRAND TOTAL OF VOUCHERS REMAINING IN STOCK. (After completing this form.)
REMAINING STOCK INITIALS
FD-60



GA WIC PROCEDURES MANUAL

Attachment FD-14

BATCH CONTROL FORM .

GEORGIA DEPARTMENT OF HUMAN RESOURCES WIC PROGRAM

BATCH CONTROL FORM

DATE

NUMBER

I

I

I

I

DISTRICT/UNIT

CLINIC

INSTRUCTIONS
VIKING INPUT SECTION
COMMENTS:

I. USE THIS FORM AS A COVER SHEET TO FORWARD ALL TADS (CERTIFICATIONS, UPDATES, TRANSFERS AND TERMINATIONS) AND ISSUEDNOIDED MANUAL VOUCHERS.

2. DO NOT BATCH TADS WITH MANUAL VOUCHERS

3. DO NOT SUBMIT VOIDED/UNCLAIMED COMPUTER VOUCHERS TO VIKING.

4. SUBMIT THE 15T AND 2ND COPIES OF THIS FORM AND ACCOMPANYING MATERIALS TO:

VIKING COMPUTING, INC P.O. BOX 2504 GREENWOOD, IN 46142-2504

5. RETAIN THE 3RD COPY OF THIS FORM IN THE CLINIC WITH COPIES OF THE TADS OR MANUAL VOUCHERS, CREATING A BATCH CONTROL MODULE.

TYPE OF DOCUMENT

NUMBER IN BATCH

TURNAROUND

ISSUED MANUAL VOUCHERS

VOIDED MANUAL VOUCHERS



DATE SENT BY DISTRICT/UNIT DATE RECEIVED AT VIKING DATE ENTERED AT VIKING
FORM 3762(REV.02-92)

PREPARER'S SIGNATURE SIGNATURE SIGNATURE
FD-61



GA WIC PROCEDURES MANUAL

Attachment FD-15

BATCH CONTROL EXCEPTION REPORT

GEORGIA DEPARTMENT OF HUMAN RESOURCES WICPROGRAM

DISTRICT/UNIT

CLINIC

VOUCHER BATCH EXCEPTION FORM

DATE

NUMBER

THIS FORM HAS BEEN GENERATED AS A RESULT OF:
THE QUANTITY ON THE CLINIC COMPLETED BATCH CONTROL FORM DOES NOT AGREE WITH THE ACTUAL QUANTITY RECEIVED
THE VOUCHERS WERE RECEIVED IN A BATCH OF TADS.
ONLY ONE (I) COPY OF THE BATCH CONTROL FORM WAS RECEIVED WITH THE VOUCHERS.
NO BATCH CONTROL FORM WAS RECEIVED WITH THE VOUCHERS.

TYPE OF DOCUMENT

VIKING INPUT

SECTION

ISSUED MANUAL VOUCHERS

VOIDED MANUAL VOUCHERS

APPROXIMATE NUMBER IN BATCH

DATE BATCH RECEIVED AT


FD-62

GA WIC PROCEDURES MANUAL

Attachment FD-16


ill
ID#& NAME

GEORGIA WIC PROGRAM IDENTIFICATION CARD

STATE OF GEORGIA
Department of Human Resources Division of Public Health
WIC PROGRAM IDENTIFICATION CARD

ii

PARTICIPANTS

NOT VALID WITHOUT
WIC
EXP. EXP. DATE DATE

BRING THIS FOLDER EVERY VISIT

APPOINTMENTS

APPOINTMENT DATE

TIME VOUCHER NUTRITION SUBSEQUENT PICK-UP EDUCATION CERTIFICATION BRING YOUR CHILD(REN) &
PROOF OF I.D.

ID#& NAME

ID#& NAME

ID#&NAME

ID#& NAME

AUTHORIZED PERSON:

PARTICIPANTIPARENT/GUAIIDIAN SIGNATURE
Other authorized to pick up vouchers and food:

EDC DATE

I.------------,,-PRo=xv"""sm=NA=TURE,.,,...---------*lt is the responsibility of the participants to educate proxies on the proper use of WIC vouchers

2. - - - - - - - - - - - - - - - - - - - - PROXY SIGNATURE



SIGNATURE OF WIC OFFICIAL

ISSUEDATE

BRING THIS FOLDER EVERY VISIT

Form 3769 (Rev. 9-96)

PICK UP CODE _ _ _ _ VOUCHER INTERVAL CODE_ _ __ COMMENTS _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
LOCAL: AGENCY: CLINIC: NAME: ADDRESS:
PHONE:

FD-63

GA WIC PROCEDURES MANUAL



DAILY ROSTER/MONTHLY MAILED VOUCHER REPORT

Attachment FD-17

Participant's Name

I.D. Number

Number of Vouchers Issued

Number of Vouchers Returned

Signature of CPA

Date Returned

Replaced Voucher Redemption Value of

Numbers Lost/Stolen

Lost Vouchers

D

A

I

L y

End of Month
Totals
- - Date:

Total# of Participants:

Total # Issued:

Total# Returned:

*Redemption Rate must be completed by the District Office.

Total # Replaced:

Total Redemption Value:
s

FD-64



GA WIC PROCEDURES MANUAL

Attachment FD-18

BORROWED VOUCHER REPORT FORM

GEORGIA DEPARTMENT OF HUMAN RESOURCES WJCPROGRAM

BORROWED VOUCHER REPORT

BORROWING DISTRICT/UNIT: LLU

CLINIC: LI.J I

DATE:

INSTRUCTIONS

.


USE FORM TO REPORT MANUAL VOUCHERS BORROWED FROM ANOTiffiR CLINIC RETURN TO VIKING AS SOON AS POSSIBLE. MAIL TO: VIKING COMPUTING, INC.

GEORGIA WIC UNIT

.

IOOO N. MADISON AVENUE, SUITE GREENWOOD, IN 48142 OR FAX TO: (317)889-9485

DISTRICT(S)
II II

CLINIC(S)
I I II

BEGINNING VOUCHER NO.
I I I I I I I I

ENDING VOUCHER
I I I I I I II

QUANTITY
I I I I I I

I I I I I I II I I I I I I I I I I I I I I II I I I I I I

I I I I I I II I I I I I I I I I I I I I I II I I I I I I

I I I I I I II I I I I I I I I I I I I I I II I I I I I I

I I I I I I II I I I I I I I I I I I I I I II I I I I I I

I I I I I I II I I I I I I I I I I I I I I II I I I I I I

I I I I I I II I I I I I I I I I I I I I I II I I I I I I

I I I I I I II I I I I I I I I I I I I I I II I I I I I I

I I I I I I II I I I I I I I I I I I I I I II I I I I I I

I I I I I I II I I I I I I I I I I I I I I II I I I I I I

I I I I I I II I I I I I I I I I I I I I I II I I I I I I

I I I I I I II I I I I I I I I I I I I I I II I I I I I I

u u REASON(S): INSUFFICIENT QUANTITY

ORDERED LA TE

COMMENTS:

u ORDER NOT RECEIVED FROM VIKING

u OTHER



DISTRICT OFFICE APPROVAL DATE

VIKING - WHITE COPY

SWO - YELLOW COPY

DISTRICT OFFICE - PINK COPY

CLINIC - GOLD COPY

FD-65



GA WIC PROCEDURES MANUAL

Attachment FD-19

CUMULATIVE UNMATCHED REDEMPTIONS PART I EXAMPLE

PAGE I REPORT EWRR350G COOSA VALLEY HEALTH

STATE OF GEORGIA WIC SYSTEM

CUMULATIVE UNMATCHED REDEMPTIONS

FOR THE MONTH OF _ _ __

19_

CLINIC PAGE I D/U/CL 01-1-008 RUN DATE_/_/_

PART I NOT MATCHED TO ISSUANCE RECORD

VOUCHER REFERENCE NUMBER NUMBER

FEBRUARY S AMOUNT

JANUARY S AMOUNT

ISSUE DATE

74622188 74623694 74623736 74623812

36698524 36614713 55658120 36551839

R

66.36

R

39.75

R

36.15

R

4.77

TOTAL

TOTAL *****STATUS

147.03

147.03

VOID

REDEEMED

4

4

TOTAL

4

4

FD-66

GA WIC PROCEDURES MANUAL

Attachment FD-20

PAGE I REPORTEWRR351G COOSA VALLEY HEALTH

CUMULATIVE UNMATCHED REDEMPTIONS PART II EXAMPLE

STATE OF GEORGIA WIC SYSTEM

CUMULATIVE UNMATCHED REDEMPTIONS

FOR THE MONTH OF _ _ __

19_

CLINIC PAGE I D/U/CL 01-1-008 RUN DATE_/_/

PART 2 NOT MATCHED TO ISSUANCE RECORD

VOUCHER REFERENCE NUMBER NUMBER

ISSUE DATE

WICID FAMILY C P

FEBRUARY

JANUARY

s AMOUNT s AMOUNT

RECONCILIATIONS

74620912 74620913 74620914 74620915 74621454 74621455

15692612 I 1454716 I 1454717 34537674 36190860 55336318

01/12/96 01/12/96 01/12/96 01/12/96 02/05/96 02/05/96

008007741 5 I 008007741 5 008007741 5 008007741 5 008008287 8 008008287 8 1

R 4.14
R 7.17 R 4.17

R 5.13 R 11.06 R 8.27



TOTAL



74621456 74621457 74621502 74621504 74621505 74621506 74621507 74621509 74621755 74621818 74621820 74621821 74621822 74621823

36163633 36163632 60056231 34792625 60056230 32816278 36598558 36332739 36698773 36698562 15835402 55637585 36593568 42729901

02/05/96 02/05/96 01/02/96 01/02/96 01/02/96 02/06/96 02/06/96 02/06/96 02/13/96 02/13/96 02/13/96 02/13/96 01/09/96 01/09/96

008008287 8 008007096 8 1 008007096 4 2 008007096 4 2 008007096 4 2 008007096 4 2 008007096 4 2 008007096 4 2 440134495 9 2 008008171 4 I 008008171 4 008008171 4 I 008006036 2 008006036 2

R 6.47 R 4.17
R 8.48 R 4.45 R 4.46 R 8.85 R 3.48 R 7.97 R 8.31 R 9.10

R 9.00 R 7.52 R 4.30
R 4.40

... -
.....


FD-67



GAWIC PROCEDURES MANUAL
LOST/STOLEN/DESTROYED VOIDED VOUCHER REPORT

Attachment FD-21

GEORGIA DEPARTMENT OF HUMAN RESOURCES WICPROGRAM

LOST/STOLEN/DESTROYED VOIDED VOUCHER REPORT

. DISTRICT/UNIT/CLINIC:

DATE:
USE THIS FORM TO REPORT VOUCHERS (COMPUTER OR MANUAL) WHICH HA VE BEEN LOST, STOLEN, OR DESTROYED BY EITHER

INSTRUCTIONS

THE PARTICIPANT OR THE CLINIC.

.

SUBMIT AT LEAST MONTHLY. MAIL TO VIKING COMPUTING, INC.

GEORGIA WIC UNIT

P.O. BOX 2504

GREENWOOD, IN 46 I42-25041:

BEGINNING VOUCHER NO.

ENDING VOUCHER NO.

QUANTITY

WICI.D. NUMBER

STATUS

STATUS CODES LOST/STOLEN/DESTROYED - 2
VOIDED-3
COMMENTS





TOTAL VOUCHERS
FD-68







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GA WIC PROCEDURES MANUAL TABLE OF CONTENTS

Page

I.

General .......................................................................................................................... FD- I

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

E. Vouchers Printed On Demand (VPOD)............................................................ FD-3

Ill. Voucher Issuance - General .......................................................................................... FD-4

A. Valid Certification Period ................................................................................ : FD-4 B. Identification of Person Picking Up Vouchers ................................................. FD-4 C. Corrections ........................................................................................................ FD-4 D. Bi - Monthly Issuance ....................................................................................... FD-5 E. Categorically Ineligible ............................. ~ ...................................................... FD-5

F. Issuance of Vouchers to Family Members ....................................................... FD-5

IV. Computer Printed Vouchers ......................................................................................... FD-6 A. Data Elements ................................................................................................... FD-6

B. Voucher Cycles................................................................................................. FD-7

C. Voucher Packaging ........................................................................................... FD-7 D. Voucher Shipments ......................................................................................... FD-11 E. Receipt of Vouchers........................................................................................ FD-11 F. Inventory Control. ........................................................................................... FD-12



GA WIC PROCEDURES MANUAL G. Issuance of Computer Printed Vouchers ........................................................ FD-12 H. Transporting VPOD Vouchers from a Site Within a Site ............................... FD-15 I. Ordering VPOD Vouchers .............................................................................. FD-15
V. Manual Vouchers ........................................................................................................ FD-16 A. Blank Manual Vouchers ................................................................................. FD-16 B. Preprinted Manual Vouchers or Special Automated Vouchers ...................... FD- I 7 C. Ordering Manual Vouchers ............................................................................ FD-17 D. Receipt of Manual Vouchers .......................................................................... FD-17 E. Inventory Control of Manual Vouchers .......................................................... FD-18 F. Issuance of Manual Vouchers ......................................................................... FD-19 G. Distribution of Manual Voucher Copies......................................................... FD-22
VI. Georgia WIC Program Identification (ID) Card ........................................................ FD-23 A. General ............................................................................................................ FD-23 B. Required Data ................................................................................................. FD-23 C. Participant Instructions ................................................................................... FD-24
VII. Proxies ....................................................................................................................... FD-25 A. General ............................................................................................................ FD-25 B. Reasons for Proxies ........................................................................................ FD-25 C. Authorization .................................................................................................. FD-25 D. Voucher Pick Up, Issuance, and Use .............................................................. FD-25 E. Restrictions ..................................................................................................... FD-26 F. Participant Instructions ................................................................................... FD-26
VIII. Mailing/Delivery ofWIC Vouchers .......................................................................... FD-27



GA WIC PROCEDURES MANUAL A. Conditions for Mailing/Delivering Vouchers ................................................. FD-27

B. Acceptable Reasons for Mailing/Delivering Vouchers .................................. FD-27 C. Mailing/Delivery Procedures .......................................................................... FD-28

D. Vouchers Mailing Process .............................................................................. FD-28

E. Returned Vouchers ......................................................................................... FD-29

IX. Voided Vouchers ....................................................................................................... FD-30

A. Voided Computer Vouchers ........................................................................... FD-30

B. Voided Manual Vouchers ............................................................................... FD-31

X.

Prorated Vouchers...................................................................................................... FD-32

XI. Late Pick-Up of Vouchers ........................................................................:................ FD-34

XII. Coordination of Health Services and Vouchers Issuance ..........................................FD-35

A. Policy Statement ............................................................................................ FD-35

B. Procedures.......................................................................................................FD-35

XIII. Redemption ofWIC Vouchers .................................................................................. FD-38

A. General ...................:........................................................................................ FD-38

B. Checkout ......................................................................................................... FD-38
c. Cashier Validation .......................................................................................... FD-38

D. Voucher Redemption and Signatures ................ ;................:........................... FD-39

XIV. Lost, Stolen or Damaged Vouchers ........................................................................... FD-40

A. Replacement of Vouchers ............................................................................... FD-40

B. Lost/Stolen/ DestroyedNoided Voucher Report ............................................ FD-40

C. Vouchers Lost, Stolen, or Destroyed Prior to Issuance .................................. FD-41

D. Change of Formula Order ............................................................................... FD-42



GA WIC PROCEDURES MANUAL XV. Borrowed Vouchers ................................................................................................... FD-43 XVI. Cumulative Unmatched Redemption Report (CUR) ................................................. FD-44
A. Introduction..................................................................................................... FD-44 B. Procedures For Reconciliation ........................................................................ FD-44 C. Manually Reconciliating CUR Part 1............................................................. FD-45 D. Manually Reconciliating CUR Part 2 ............................................................. FD-46 E. Procedures For Both Reports ....................................................................... '. .. FD-47 Attachments: FD- I Computer Printed Voucher ........................................................................ FD-48 FD-2 Blank Manual Voucher .............................................................................. FD-49 FD-3 Preprinted Standard Manual Voucher. ....................................................... FD-50 FD-4 Automated Special .Manual Voucher ......................................................... FD-51 FD-5 Voucher Printed On Demand (VPOD) Voucher........................................ FD-52 FD-6 Voucher Create Calendar ........................................................................... FD-53 FD-7 Voucher Cycle Packing List ...................................................................... FD-54 FD-8 Computer Printed Voucher Register .......................................................... FD-55 FD-9 Voucher Register Summary Page .............................................................. FD-56 FD-IO Transmittal Form ....................................................................................... FD-57 FD-11 Form and Manual Voucher Orders ............................................................ FD-58 FD-12 Manual Voucher Inventory ..............................:......................................... FD-59 FD-13 Voucher On Demand Daily Log Sheet ...................................................... FD-60 FD-14 Batch Control Form ................................................................................... FD-61 FD-15 Batch Control Exception Report ................................................................ FD-62 FD-16 Georgia WIC Program Identification Card ................................................ FD-63



GA WIC PROCEDURES MANUAL FD-17 Daily Roster/Monthly Mailed Voucher Report ......................................... FD-64 FD-18 Borrowed Voucher Report Form .............................................................. FD- 65 FD-19 Cumulative Unmatched Redemptions Part 1.. ............................................ FD-66 FD-20 Cumulative Unmatched Redemptions Part II ............................................ FD-67 FD-21 Lost, Stolen, Destroyed, Voided Voucher Report ..................................... FD-68 FD-22 Vouchers Printed On Demand (VPOD) Receipt........................................ FD-69







GA WIC PROCEDURES MANUAL
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 bi-monthly basis. Georgia has a fully automated food delivery and management information system. The State agency contracts with a data processing firm, Viking Computing, Inc. to operate and maintain the system.
Persons requesting WIC benefits are screened for program eligibility and are certified if the applicant qualifies. Electronic Transfer Data containing demographic, financial, medical/nutritional, and food package information is forwarded directly to the Contractor in order to establish a participant masterfile. Most local agencies have the capability of electronically transmitting WIC data to the ADP contractor. Local Agencies use many different kinds of automated systems.
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 ADP Contractor also provides preprinted manual vouchers and special vouchers that can be issued to new and transferring participants.
Participants redeem the vouchers for specified kinds and quantities of foods at authorized vendors. Vendors then deposit the redeemed vouchers in their local bank accounts. The vouchers proceed through the banking system to a central clearing bank where they are edited for missing or invalid information. Vouchers that are not paid are sent back to the appropriate local bank and the vendor's account is reduced by the value of the 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 that tracks the status of all vouchers. The ADP Contractor also produces participation, financial, vendor, and other management reports at regular intervals for use by State and local agencies.



FD-I



GA WIC PROCEDURES MANUAL
II. TYPES OF WIC VOUCHERS
There are five (5) types of WIC 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 Turn Around Document (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 staff at the time of issuance (see FD-V- Manual Vouchers and FD-F- Issuance of Manual Vouchers for procedures). The clinic information is preprinted on blank manual vouchers (Attachment FD-3).
c. Preprinted Standard Manual Vouchers
Standard manual vouchers are unseparated sets of four (4) food package types. These vouchers contain a preprinted standard food package (Attachment FD-3). Standard voucher sets should not be broken to issue single standard vouchers. The four (4) types of food packages available are:
I. Infants (Food Package 153). 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



D. Automated Special Manual Voucher

Automated Special Manual Vouchers are similar to Preprinted Standard Manual Vouchers except the vouchers area message is blank. Automated clinics may use these forms to prepare manual vouchers for any food package (see Attachment FD4). All vouchers must be stored in a secured location and must be logged on the Manual Inventory log within three (3) days of receipt in the clinic.

E. Vouchers Printed On Demand (VPOD)

Vouchers Printed On Demand (VPOD) generated on site by the clinic's automated system for each qualified participant that qualifies for the WIC Program. The receipt generated from printing these vouchers becomes the voucher inventory (see Attachment 5).





FD-3



GA WIC PROCEDURES MANUAL

III. 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 staff must check the WIC ID card for signatures of the participant/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. When identity is checked for the person picking up vouchers at issuance, it must be documented on the voucher register, manual voucher copy or the VPOD receipt. Use the same ID codes in the certification process to document proof ofID for voucher pickup. The current WIC ID card (WC) can be used as ID for voucher pickup.

Documentation of ID Proof codes for Voucher Pickup



Computer Printed Voucher Issuance - Document the proof code on the

voucher register (left-hand side of the ID number).



Voucher Printed on Demand (VPOD) - Document the proof code on the

voucher receipt under the user's ID.



Manual Vouchers - Document the proof code on the manual voucher under

the date the vendor must deposit by.

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") must not be used on vouchers for any reason.

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GA WIC PROCEDURES MANUAL
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 issuance, prior approval from the State WIC office must be obtained. With bi-monthly issuance, 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.
E. Categorically Ineligible
Categorically ineligible refers to the period of time a client is no longer eligible to receive WIC benefits because of selected categories. Participants who are subject to be categorically ineligible are postpartum women, infants who have reached their first (151) birthday, children who have reached their fifth (5th) birthday, 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.
When a participant becomes categorically ineligible before the end of the month, eligibility is extended to the end of the month. In case of suspected 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 five (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 of Vouchers to Family Members
Vouchers must never be issued by an employee to an immediate family member (children, grandchildren, sisters, brothers, nieces, nephews, aunts, uncles, parents, spouses, first cousins, and in-laws) or other persons residing in the same household. Failure to comply with these procedures will result in payment of food cost to the State WIC Office and may result in administrative disciplinary action by the local agency .
FD-5



GA WIC PROCEDURES MANUAL
IV. COMPUTER PRINTED VOUCHERS AND VOUCHER PRINTING ON DEMAND (VPOD)
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.
2. WIC ID Number. The participant's unique identification number that corresponds to the number on the TAD (Tum-Around Document).
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, middle initial).
4. First Day to Use {MMDDYY). The first valid date when the voucher may be used to purchase foods.
5. Last Day to Use {MMDDYY). The last valid date, after which the voucher can no longer be used by the participant. The voucher may be used on this date, but not after this date.
6. Vendor Must Deposit by {MMDDYY). The date by which the vendor must deposit the voucher is sixty (60) days of the first day of use. Vouchers not deposited by this date are considered stale 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.
9. Maximum Purchase Price. The actual purchase price may not exceed this amount.
10. Pay Exactly. This space is left blank for the vendor to enter the actual amount of the WIC foods purchased. FD-6



GA WIC PROCEDURES MANUAL 11. WIC Vendor Stamp. Stamped by the vendor prior to deposit.
12. Sign Here At Grocery Store. The participant/proxy signs his/her name in this space when the voucher is redeemed at a WIC vendor.
The reverse side of the computer printed vouchers contains an area for endorsement by the authorized WIC vendor location.
B. Voucher Cycles
The voucher pickup day is determined by the clinic staff and participant. This day
is entered as a Pickup Code on the TAD.
Whether or not computer printed vouchers will be printed for the participant during 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 work-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 last work 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 (I = monthly; 2 = bimonthly, even; 3 = bimonthly, odd).
Please refer to the "Voucher Create Calendar," for a one (1) year calendar of voucher issuance dates (Attachment FD-6).
C. Voucher Packaging
In each clinic package the vouchers are in alphabetical order based on the last name of the lead family member within each Site Code. The lead family member is the one with WIC Type P, N, or B or the one with the lowest Participant ID Number (usually #1).
I. The following items will be included in each clinic package (or clinic package #1 if there is more than one [I]):
a. Voucher Cycle Packing List (Attachment FD-7)
This (2-ply) packing list provides the specific beginning and ending voucher numbers for all the computer printed vouchers (and for the
FD-7



GA WIC PROCEDURES MANUAL
manual vouchers when appropriate) for the clinic. It also lists the appropriate pages of the Computer Voucher Register that accompany the clinic's computer printed vouchers. Two copies of the packing list are provided. 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-8)

Purpose - To provide a listing of participants that have computer generated vouchers produced during a cycle and to provide a signature space for verification of receipt of vouchers. The register is organized in the same order as the computer generated vouchers.

Distribution - Clinic

I copy

District/Unit

1 copy, Summary

State

1 microfiche copy

Frequency - twice each month, with each voucher cycle

Sequence - District/Unit, clinic, Site Code, alphabetic by name of lead family member.

Register Description -

Line 1

WIC ID: The WIC ID number of each participant.

PARTICIPANT NAME: The name of the woman participant or the participant in the family having the lowest Participant ID Number. The register is in sequence by this name, and 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 part1c1pation or income as a percent of the Federal Poverty Guidelines. The numbers indicate the level of poverty and are as follows:

FD-8



GA WIC PROCEDURES MANUAL M: If the client is enrolled in Medicaid.

0-1

0-100%

2

101-125%

3

126-150%

4

151-175%

5

176-185%

TYPE: WIC type P, N, B, I, C

Poverty Poverty Poverty Poverty Poverty

PR: Priority

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 or voided.

Line 2

TELEPHONE NUMBER: Phone number of participant.

VOUCHER NUMBERS: The voucher numbers are listed across the four (4) columns below the name. NOTE: If the participant has an interval code of2 or 3, a second line of information is printed for the second set of vouchers.

TOTAL: The number of vouchers 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.

FD-9



GA WIC PROCEDURES MANUAL RECERT DUE - MMDDYY Subsequent certification is due in the same month as or the month after the voucher issue month. For breastfeeding women and children, the date is the certification date plus six (6) months. RECERT DUE (P) - MMDDYY Subsequent certification is due in the same month as, or in the month after, the voucher issue month. For pregnant women, the date is forty-five (45) days from the Expected Date of Confinement (EDC). RECERT OVDUE - MMDDYY For breastfeeding women and children, subsequent, certification is overdue based on the certification date plus six (6) months. RECERT OVDUE (P) - MMDDYY For pregnant women, subsequent certification is overdue based on the EDC plus forty-five (45) days. 1ST B'DATE - MMDDYY Infant's birthdate is in the month after the voucher issue month. The date printed is the birthdate. CATEG TERM - MMDDYY The participant is categorically ineligible in the month after voucher issuance month. A message ac~ompanies the last set of vouchers. The date printed is the categorical termination date.
FOR N - Delivery Date plus 6 months
FOR B - Delivery Date plus 12 months
FOR C - At 5th birthday
ISSUE DATE: The date of issue printed on the vouchers.
2. The District/Unit receives the following items with each voucher shipment:
a. Voucher Cycle Packing List (Attachment FD-6) (See FD IV, C. l .a.)
b. Voucher Register Summary Page (Attachment FD-9)
This summary page includes:
(1) Total participants who receive computer generated vouchers. FD-10



GA WIC PROCEDURES MANUAL
(2) Total vouchers for the District/Unit.
(3) Total number of messages by message type.
(4) Signature line and certifying statement of persons closing out the voucher register, two signatures are required to closeout the register. The signatures must be for each month by two different staff members.
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 the clinic. Vouchers are shipped by UPS and are received by local agencies on the 22nd day of the month for the next month's cycle I and on the 7th day 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 immediately. To insure that all items have been received, the voucher numbers must be checked and verified with the Voucher Cycle Packing List (Attachment FD-7). Any discrepancies must be reported to the ADP Contractor 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 ofreceipt of the vouchers. The original must be retained by the clinic for one (1) year 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.



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GA WIC PROCEDURES MANUAL
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 one (1) to ten ( 10) computer generated vouchers issued depending on the Food Package and the Interval Codes for participants with special needs who are receiving alternate food packages, the number of vouchers may be as high as sixteen ( 16). The following procedures must be followed when issuing computer printed vouchers:
1. Identification. Verify the identity of the person picking up the vouchers. Please refer to FD-III.B., "Identification of Person Picking Up Vouchers," for procedures.
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 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 of vouchers received OR the
FD-12



GA WIC PROCEDURES MANUAL
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 and date the appropriate line(s). "Failed to sign" must not be abbreviated.
(3) During a monitoring review, if one (1) percent or more "fail to sign" notations appear 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.
(4) If the participant or proxy is unable to write, he/she wiH 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 also be entered when vouchers are VOIDED.
c. Clerk Initial. The staff person must initial here when vouchers are issued or 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 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
FD-13



GA WIC PROCEDURES MANUAL
voucher(s) must be voided and replaced with manually issued vouchers if the food package is changed.
5. Transfer of Vouchers 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 to document voucher pick-up and the disposition of the 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, in this situation 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.
The following procedure must be followed:
a. A copy of the appropriate page(s) of the voucher register (see Attachment FD-8) or transmittal form (see Attachment FD-I 0) must accompany the vouchers.
All other forms of documentation (i.e. void) utilizing the transmittal form must be followed in accordance with the computer printed voucher register procedures. Please refer to 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) (see Attachment 10).
c. The signed page(s) of this copy of the register or transmittal form will be returned to the original clinic and attached to the original voucher register.
d. An individual site code should be assigned when participants are in a specified geographical or otherwise related area (i.e. common site of employment or established "satellite clinic").
6. Damaged/MisprintedVoucher. If a computer printed voucher is damaged during issuance and is voided, a blank manual voucher will be issued by clinic staff.
7. Mailing/Delivery of WIC Vouchers (See FD-VIII) FD-14



GA WIC PROCEDURES MANUAL
H. Transporting VPOD Vouchers from a site within a site
1. When VPOD Vouchers are transferred to a site within a site (Voucher issuance clinic only), the vouchers must be printed the afternoon prior to going to the clinic or printed the day of the clinic.
Special written permission must be given prior to transporting these vouchers (see Attachment 5).
Vouchers not issued on site must be voided immediately. Each time a voucher issuance clinic is held, the same procedure must be followed.
See Transporting procedures in the Quality Improvement Section of the Procedure Manual.
I. Ordering VPOD Vouchers
Voucher Printing On Demand (VPOD) voucher numbers are received in the clinic via FAX from the ADP Contractor. No paper vouchers are involved because VPOD utilizes a special blank stock. The voucher serial number is added at the time of printing. All numbers must be entered upon time of receipt as with other manual vouchers. There will be no inventory to keep. At the end of each day the clinic staff prints a report that shows how many vouchers were printed for each participant and the initials of the issuing clerk.
When a clerk prints vouchers under VPOD, the printer produces the food packages along with a receipt. The receipt contains the clients' WIC ID number, Name, Issue Date, Last Date To Use, Food Package Number, Voucher Code, Voucher Number, any appropriate message and a place for the client/proxy to sign. The receipt takes that place of voucher inventory as well as the voucher register. The client signs the receipt and then is handed the vouchers. The receipt must then be immediately filed in order.



FD-15



GA WIC PROCEDURES MANUAL
V. MANUAL VOUCHERS
When manual vouchers are received, the serial numbers must be recorded in the "Received" column of the "Manual Voucher Inventory" log (see Attachment FD-12). This documentation must be completed the same day the vouchers are received by the responsible WIC staff person. The voucher numbers must be entered into the computer . at that time as well. For stand-alone systems, vouchers must be used in the order in which they were received; first in, first out. All vouchers must be used in sequential order until depleted. Do not use two voucher batches at the same time; complete one batch before using another.
For Networked Systems, batches must still be used in order. However, it is likely that more than one batch will be used at one time.
Manual vouchers are very similar to computer printed vouchers. The primary differences are:
1. Manual vouchers are three (3) part forms. The parts are color-coded for distribution as follows: First copy (blue) - participant Second copy (red) - ADP Contractor or clinic copy if automated transfer is used Third copy (black) - clinic or may be destroyed if automated transfer
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.
A. Blank Manual Vouchers
Blank manual vouchers are issued for the following reasons:
To provide vouchers for a food package (other than those provided by ~he 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 .
FD-16



GA WIC PROCEDURES MANUAL
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 Automated Vouchers

Preprinted manual vouchers or special automated vouchers are issued for the following reasons:

I. To provide vouchers to newly certified, reinstated, or transferring participants until computer printed vouchers are available.

2. As a 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 the prior month after computer vouchers have been

returned to the ADP Contractor as unclaimed.

C. Ordering Manual Vouchers

Local agencies must order manual vouchers from the ADP Contractor. Orders must be made using the "Form and Manual Voucher Orders" Form (Attachment
FD-11) and must be received by the ADP Contractor by the I0th 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

I. 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
FD-17



GA WIC PROCEDURES MANUAL must be signed and dated to verify receipt. A copy of the signed/dated packing list must be mailed to the local agency/district office within five (5) days of receipt of the vouchers. The original must be retained by the clinic for one (1) year plus the current Federal Fiscal Year.
2. District/Unit
The District/Unit receives a copy of each detailed clinic packing list for control, and a summary copy showing total vouchers received from the District/Unit. Any discrepancies must be 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 of the "Manual Voucher Inventory" log (see Attachment FD12). This documentation must be completed the same day the vouchers are received by the responsible WIC staff person. Vouchers must be used in the order in which they were received; first in, first out. All vouchers must be used in sequential order until depleted. Do not use two voucher batches at the same time; complete one batch before using another.
1. VPOD Vouchers
When VPOD Vouchers are printed, a receipt is generated which becomes the inventory of voucher (see Attachment 22). This inventory eliminates the need to keep weekly manual inventory. However, it is vital that copies of the receipt be filed in voucher order numbers by date.
In an effort to maintain the daily use of vouchers, at the end of the day clinic staff must run a query report of all vouchers used. That daily query report must be maintained in a file until the end of the month. Therefore, each clinic must maintain a file for each month with the daily query (i.e. March 1999 Query).
2. Perpetual Inventory (Weekly) (For Blank Manuals, Preprinted Standard Manual, Automated Special Manual Vouchers and VPOD Vouchers).
The perpetual inventory accounts for the number of vouchers issued, voided, and on hand. The perpetual inventory must be conducted weekly and documented on the Manual Voucher Log. All col~mns of the log must be completed accurately, legibly, and initialed, by a responsible staff
FD-18



GA WIC PROCEDURES MANUAL member. For Vouchers Printed On Demand (VPOD), use the VPOD Log Sheet (Attachment 13).
3. Physical Inventory (Monthly)
A monthly physical inventory of all manual vouchers must be conducted. Another staff person must verify the inventory and initial the inventory log. Physical inventory documentation must include the serial numbers of the vouchers and the total number of vouchers on hand. The physical inventory must be documented on the "Manual Voucher Inventory Log" and labeled "Physical Inventory Conducted and Verified by." Two staff members must initial and date the physical inventory.
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. Inventories must be completed in black or blue ink.
F. Issuance of Manual 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 of vouchers. 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 of vouchers. The dates on the first set of vouchers must be the date on which the vouchers are issued. The dates on the second set of vouchers must correspond to the pick-up code of the first set of vouchers.
In certain circumstances, when the TAD input cutoff date to the ADP Contractor cannot be met, enough vouchers should be issued to carry the participant until the next pickup date. Preprinted manual vouchers may be combined with blank manual vouchers in order to issue the correct number of vouchers until the next pick up date.
The following procedure must be followed when issuing manual vouchers:
FD-19



GA WIC PROCEDURES MANUAL Identification

1. Verify the identity of the person picking up vouchers. See page FD-111.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. The 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 damaged computer

vouchers must be written on the manual voucher to retain the original

information.

On a blank manual voucher, the following additional information must be completed:

Food Prescription Data blocks. Enter quantities for appropriate foods, enter an "X" in all unassigned blocks.

3. The participant or proxy must sign each voucher in the left signature space, in the presence of the issuing staff person. Refer to FD-IV.G.2.a.(4), "Signature of Participant or Proxy", for instructions regarding the signature of participants who are unable to write.

4. Give the top copy (blue) to the participant.

5. When manual vouchers are issued to a new participant during the initial certification appointment, the participant must receive an explanation on the proper procedure for redeeming vouchers. Whenever possible, the participant's proxy should be present during this explanation. The following

FD-20



GA WIC PROCEDURES MANUAL
is a guide for the information the participant/proxy should receive regarding the vouchers:

a. The participant signs on the left hand side of the voucher in clinic; he/she countersigns on the right hand side of the voucher in the grocery store.

b. Explain "First Day to Use" and "Last Day to Use."

c.

If vouchers 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 which foods are 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 participants who are 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.
c. How often they come to clinic to pick up vouchers (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.



FD-21



GA WIC PROCEDURES MANUAL
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-14). 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 batched separately. When sending via Express Mail, do not use a Post Office Box. -The clinic address must be used with this process.
2. For clinics with Automated Manual Voucher Systems, the second copy (red) must be filed following the above procedures. The third copy (black) may be destroyed since the diskette provides the issue information to the ADP Contractor.
3. If batch is mailed to the ADP Contractor, the third copy (black) of the Manual Vouchers must be retained by the clinic and attached to a copy of the Batch Control Form, creating a Batch Control Module (BCM). BCM's must remain intact until they are reconciled.
Upon receipt of a manual voucher BCM, the ADP Contractor will 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-15). Discrepancies should be resolveq 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 lined binders, post binders, or expanding file folders in order to maintain them neatly.
Voucher copies must be retained for three (3) years plus the current Federal Year.



Signed/stamped Batch Control Forms and forms describing discrepancies can be destroyed after the reconciliation is complete.
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GA WIC PROCEDURES MANUAL

VI. GEORGIA WIC PROGRAM IDENTIFICATION (ID) CARD

A. General

A Georgia WIC Program Identification (ID) card (Attachment FD-16) 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 (I) 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.).

When identity is checked for the person picking up vouchers at issuance, it must be documented. Accept the same information as for certification and use the same codes.



Computer printed vouchers - document on the left-hand side of WIC I.D.

number on the voucher register.



Manual vouchers - document on the manual voucher copy under date.



Voucher Printed on Demand (VPOD) document on the receipt under User's

I.D.

B. Required Data

Before issuing the ID Card, all items on the front must be completed.

FRONT:

1. Participant's name,

2.

WIC ID number,

3. Date certification period expires,

4. Participant/parent/guardian/caretaker's signature,

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GA WIC PROCEDURES MANUAL

5. EDC date, 6. Signature of proxy(ies), 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 if the participant/parent/guardian/caretaker, or proxy is unable to write.

B.

This may be accomplished by the participant/parent/guardian/ caretaker after he/she has left the clinic

It is recommended that all of the information on the back of the ID card also be completed.



BACK:
1. Appointment information, 2. Voucher pickup code, 3. Voucher interval code, 4. Comments, 5. Clinic identifying information, 6. Clinic Telephone Number.
C. Participant Instructions
Participants/parents/guardians/caretakers must receive an explanation of the instructions on the purpose and use of the ID card. The following is a guide to the information that should be given to the participant regarding the WIC ID Card. Whenever possible, the participant's proxy(ies) should be present during the explanation.
1. This ID card is to identify you as an authorized WIC participant when picking up and/or redeeming vouchers. You should keep vouchers with the I.D. card. You must have your ID card when picking up vouchers, at certifications or when redeeming vouchers at the grocery store. A proxy must have the ID card to pick up or redeem vouchers. (Refer to the section below for more information regarding proxies).
2. Notify the clinic if the ID card is lost or stolen.
3. Explain the "Expiration Date" and when the participant will be due to be screened for eligibility again.
4. Explain shopping procedures (i.e., review allowable items, importance of separating foods, etc.). FD-24



GA WIC PROCEDURES MANUAL
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 a proxy.
A proxy is a person who acts on behalf of the participant. An authorized proxy may pick up and or redeem vouchers and may bring a child in for subsequent certifications in restricted situations (see Certification Section).
A proxy should be a responsible person whom the 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.(4) 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 Section FD-IV.G.2.a.(4) if a proxy is unable to write):
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GA WIC PROCEDURES MANUAL
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). The participant must be informed at the initial certification appointment that this is their responsibility. Proxies must also be informed of their right to complain to the clinic about improper vendor practices.
E. Restrictions
1. 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. All 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.



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GA WIC PROCEDURES MANUAL
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 to mail vouchers (i.e. permanent difficulty accessing the clinic(s) for mailing/delivering vouchers to participants).
2. Vouchers must not be mailed in the following situations: I. Participant due for re-certification. 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 vouchers to a participant, the issuing WIC professional must obtain prior approval from the WIC Coordinator, and a copy of the page of the Voucher Register must be signed by the participant. Once the page is signed, it must be attached to the Voucher Register.
4. The hardship condition and the WIC Coordinator/designated CPA's approval must be documented in the participant's health record. Once the initial hardship has been resolved, the mailing or delivery of WIC Vouchers must be discontinued and the action documented.
B. Acceptable Reasons for Mailing/Delivering Vouchers
I. Difficulties of the participant and his/her proxy in obtaining vouchers for reasons such as illness.
2. Imminent or recent childbirth.
3. Environmental crisis as a result of a tornado, hurricane, flood, snow-storm, or ice storm.
4. Closure of clinic due to structural damage, relocation, etc.
5. Other special circumstances approved by the WIC Coordinator.
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GA WIC PROCEDURES MANUAL

NOTE:

*If the Food Stamp Program has discontinued or does not routinely mail Food Stamps Coupons to a geographical location, WIC Vouchers can not be mailed to this area.

C. Mailing /Delivery 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 the post office box; and must note on the mail roster the participant's name, identification number and sequence of voucher numbers returned in the mail and a full signature of the person documenting this information.

6. A roster must be maintained on a weekly basis by the local office noting all vouchers mailed and participant names and identification numbers. This roster should be mailed to the District Office (see Attachment FD-17).

The procedure for delivering a voucher (s) are as follows:

1. 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 mst be attached to the original voucher register. The original computer voucher register must have the statement "See Attachment" on the Register.

D. Voucher Mailing Process

When mailing vouchers, the computer voucher register or voucher copy must be documented with the disposition of the vouchers. The WIC official must document the signature line(s) with the statement "mailed vouchers" or "delivered vouchers," the reason(s) for mailing, the date mailed, and the signature of the person preparing vouchers for mailing. It is recommended
FD-28



GA WIC PROCEDURES MANUAL
that vouchers be mailed via certified mail; mailed vouchers will not be replaced.
E. Returned Vouchers
When vouchers are returned by the postal service, the following steps must be followed:
1. If the voucher(s) are still valid for redemption, the local agency will attempt to contact the participant in an effort to issue. This contact must be recorded on the voucher register. If the local agency is unable to contact the participant, "void" the voucher(s) immediately, and maintain on site until the scheduled time that they are mailed to the bank, except for manual vouchers which are returned to Data Processing. If a record of manual vouchers has been sent to the ADP Contractor, manual vouchers must be voided and sent to the bank.
2. If the vouchers are out of date, stamp the word "void" on the food instrument. Note on the Voucher Register or receipt "returned by postal service" at the corresponding voucher numbers and maintain on site until the scheduled time that they are mailed to the bank. Voucher(s) should be "voided" immediately and processed as customary.



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GA WIC PROCEDURES MANUAL
IX. VOIDED VOUCHERS
Voided vouchers should be marked "void" if the 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 the contracted bank. Package the vouchers securely to prevent breakage and send them to arrive at the Contracted Bank by noon of the fifth (5th) workday of the following month.
A. Voided Computer Vouchers
1. Computer printed vouchers are voided in the following situations:
(a) The 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 the contracted bank to arrive by noon of the fifth (5th) workday of the following month. Never staple a voided voucher to any other voucher.
(d) Voided vouchers must be securely stored according to program procedures (lock the vouchers in a cabinet, closet or safe) until they are forwarded to the contracted Bank.
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GA WIC PROCEDURES MANUAL
B. Voided Manual Vouchers
Manual vouchers, blank vouchers, or preprinted vouchers will be voided if the participants name is misspelled; when any of the participant information is entered incorrectly; when there is damage during issuance; or if a voucher(s) is returned unused by participant.
1. 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 the contracted bank (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 the 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 Section 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 voided information into the system to identify the disposition of the vouchers. All voided and destroyed vouchers must be reported to the ADP Contractor's Bank.



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GA WIC PROCEDURES MANUAL
X. PRORATED VOUCHERS
The objective of prorated vouchers is to ensure that participants receive benefits for which they are entitled during a valid time frame. Vouchers are issued based on the number of weeks within a valid redemption time period. A voucher is valid for only 30 days from the date of issuance. When it is determined that a participant cannot redeem vouchers within the valid time frame, the number of vouchers issued must be prorated.
Prorating is the partial issuance of vouchers by retrieving one or more vouchers from the designated voucher series. Vouchers must be prorated when:
( 1) A participant is late picking up vouchers (procedures for voiding vouchers must be followed as outlined in IX Voided Vouchers).
(2) Vouchers are replaced because they are damaged or there is a change in the prescribed food package or agency error.
Note: The procedures in Section FD-XIV must be followed when replacing vouchers.
To ensure consistency when prorating vouchers the guidelines below must be followed .

I Number of Days Late I Less than 7 days late
7-13 days late
14-20 days late
21-31 days late

I Women & Children

full package

I

3 vouchers issued

(3/4 package)

2 vouchers issued

( l /2 package)

1 voucher issued (1/4 package)

Infants full package full package
1 voucher issued (1/2) package 1 voucher issued (l /2 package)



FD-32



GA WIC PROCEDURES MANUAL a) ALTERNATE FOOD PACKAGES

Number of Days Late

Women & Children

Less than 7 days late

I

full package

I

7 - 13 days late

6 vouchers issued

(3/4 package)

14-20 days late

4 vouchers issued ( l /2 package)

21-31 days late

2 vouchers issued (1/4 package)

Infants full package full package
1 voucher issued ( l /2 package)
1 voucher issued ( l /2 package)

Note: Ifa scheduling error is made by the clinic which results in the loss ofvouchers
by. the participant, there are two options. Either issue the entire food package and follow procedures noted above, or change the pickup code and submit to the ADP Contractor .



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GA WIC PROCEDURES MANUAL
XI. LATE PICK-UP OF VOUCHERS
Participants who are late picking up their vouchers must be issued a prorated food package based on the schedule in FD-X. If participants come in for their vouchers after they have been returned to the ADP Contractor 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 be prorated to reflect the period of time left until the participant's next scheduled pickup date.
To determine the number of days a participant is late for pickup, the following guidelines must be followed.
1. Count calendar days, including weekends.
2. If the participant's scheduled pickup day was before the "First Day to Use" on the vouchers, begin counting days late from the "First Day to Use" date.
3. If the participant's scheduled pickup day was after the "First Day to Use" on the vouchers, begin counting days late from the appointment date.
The appointment date must be documented on the voucher register in addition to the required pickup date.
To prorate voucher issuance for late pickup follow procedures for prorating vouchers (See FD-X).
An option to prorating voucher(s), when a participant is late picking up vouchers, is to change the pick up date. The pick up date is changed to the date the vouchers are picked up. A full set of vouchers is issued with the current date.
To use this option the clinic staff must:
(1) Document the 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 is necessary to void any of the computer generated vouchers.
(4) Give the participant an appointment for next month's pickup with the new pickup date .
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GA WIC PROCEDURES MANUAL
XII. COORDINATION OF HEALTH SERVICES AND VOUCHERS ISSUANCE
Routinely, WIC food .vouchers are issued based on the number of weeks in a valid redemption time period. The following procedures modify voucher issuance in order to enhance coordination and linkage of Georgia's Immunization and WIC Programs. The policy governing the modified vouchers issuance procedures has a threefold purpose. (1) To ensure that the food delivery system is compatible with the delivery of health and nutrition education services to participants and caregivers (CFR 246. l 2(d)). (2) To enhance integration of health services (CFR 246.7(a); CFR 246.1 l(a)(l). (3) To prevent the occurrence of health problems and to improve the health status of WIC participants/caregiver. (CFR 246.1 ).
A. Policy Statement
Every effort must be made to coordinate the issuance of WIC vouchers with the delivery of health services. (CFR 246.12(d); CFR 246.1 l(a)(l) and (2)). Efforts must be made to provide health services so that the patients/families will not have to return more than once a month. However, vouchers may be issued for one month, if the participant/caregiver is to return for services at that time. (This is the exception not the rule).
Under no circumstances are vouchers to be withheld or denied nor are any services to be forced upon participant/caregiver [(CFR 246.ll(a)(2).] Participants/caregivers have the right to refuse other health services, but we have the responsibility to frequently offer and strongly encourage the use of all available health services (CFR 246.6(b)(3)(4)(5); CFR 246.7(I)(2)(iii); CFR 246.12(s)(7) (8)).
B. Procedures
1. Initial Visit
At initial visits the participant/caregiver is informed of the date of their next visit and that it will be coordinated with their next voucher issuance or other scheduled health department services. The date and the nature of the next services are recorded on the participant's identification card. The participant/caregiver is provided with enough vouchers to carry them through their next scheduled service or issuance. If the participant/caregiver states, they plan to receive the services elsewhere, document their response in the medical record and issue their full voucher package. In the event the service in question is immunization, the clinic staff should ask the participant/caregiver to bring with them documentation of the immunizations at the next visit. This request must also be recorded in the medical record.
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GA WIC PROCEDURES MANUAL
Ifthe participant/caregiver states that they do not wish to receive any other services, then counsel on the importance of good health care as a preventive measure toward future health problems. Advise them of the alternative places where they may receive care, encourage them to seek care somewhere if not at the current local clinic and issue their full voucher package. [(CFR 246.6(b)(3) & (4).]
2. Subsequent Visits
At the next subsequent certification or voucher issuance visit to the local clinic refer the clinic's tickler system to see if a service is due and/or past due. If a health service is due, and participant/caregiver is willing to receive that service, route them through the clinic for service and voucher issuance. If the participant/caregiver is to receive that service elsewhere, issue the vouchers and remind them of their next service and when it is due.
If the participant/caregiver is willing to receive the service but is unable to do so, due to a staffs member decision that is medically or logistically inappropriate; issue the full voucher package to the participant/caregiver and ask them to return at a date when the service would be more appropriate.
If the participant/caregiver state that they wish to receive the service, but are unable to do so today, ask them when would it be most convenient for them to return for the service. Document the date change in their medical record and issue vouchers, not to exceed one month) to carry them through to the next date.
When participant or caregiver had previously refused our services, ask if they are interested in them at this point (current visit). If the response is positive, route them through the clinic for the service and voucher issuance. If the response is no, the clinic staff should: (a) counsel on the importance of good health care as a preventive measure towards future health problems, (b) advise them of alternative places where they may receive care, (c) encourage them to seek care somewhere if not with the local clinic. and (d) issue their full voucher package.
3. Completing the voucher register
When participant/caregiver receives full voucher package, have them complete the signature and date lines per procedures of the Georgia WIC User Manual. If the participant/caregiver receives vouchers bi-monthly, issue the participant/caregiver only one month. Document on voucher register the appointment or health services the participant is to receive.
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GA WIC PROCEDURES MANUAL
If participant/caregiver was scheduled to return for a.service prior to closeout .and failed to do so; contact the participant/caregiver to notify them that they need to come in to pick up the next set of vouchers. If they still fail to pick up their vouchers by the time of final closeout; void their remaining vouchers and write void on the voucher register over the nwnber of vouchers voided.
If the participant/caregiver comes in after their remaining vouchers have been voided and prior to their next issue date, write manual voucher to replace all of the voided vouchers.

1.




FD-37



GA WIC PROCEDURES MANUAL
XIII. 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 (if they have accompanied the participant to clinic) so that they fully understand their responsibilities regarding the use of WIC vouchers.
A. General
1. Participants or their proxies should present the WIC ID card. They do not need any other ID (see FD-VI).
2. It does not cost anything to use WIC vouchers. Under no circumstances will participants/proxies get change or be required to pay anything.
3. A participant does not have to purchase everything on each voucher. However, all the foods the participant wants to purchase from the voucher must be purchased at the same time. Participants/proxies may not get rain checks.
4. Food or formula must never be returned for cash or credit.
5. Proxies must be properly educated before being allowed to redeem vouchers.
8. 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 vouchers are valid. Vouchers cannot be used before "The First Day to Use" and they cannot be used after the "Last Day to Use". Participants have thirty (30) days from the "First Day to Use" in which to redeem the vouchers.
2. The types and quantities of food being purchased are the same as those prescribed on the vouchers.
3. The vouchers have not been altered.
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GA WIC PROCEDURES MANUAL
D. Voucher Redemptions and Signatures
The cashier must enter the exact purchase price on the voucher prior to the participant's signature. The participant/proxy will countersign each voucher in the cashier's presence. If the signature on the vouchers does not match the signature on the WIC ID card, the cashier must not accept the vouchers and must immediately notify the clinic of the situation. Participants must be instructed not to countersign until the cashier has written in the total cost of the foods. If a name has been signed in the counter signature block then the grocery store must obtain a signature above the pre-signed name.
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.





FD-39



GA WIC PROCEDURES MANUAL
XIV. LOST, STOLEN OR DAMAGED VOUCHERS
A. Replacement of Vouchers
1. Lost or Stolen vouchers will not be.replaced.
2. Damaged Vouchers
When a participant/parent/guardian/caretaker reports that their vouchers have been damaged the following procedure may be implemented:
If vouchers are damaged, any pieces of the vouchers that can be salvaged should be. brought to clinic. Vouchers that can be identified by voucher numbers may be replaced.
3. Vouchers destroyed due to fire will be replaced with a copy of the fire report.
B. Lost/Stolen/DestroyedNoided Voucher Report
When vouchers are reported as lost, stolen, or destroyed, complete the Lost/Stolen /Destroyed/ Voided Voucher Report (Attachment FD-21) with the following items: a. District/Unit/Clinic b. Current Date c. Beginning Voucher Number in Range* d. Ending Voucher Number in Range* e. Quantity of Vouchers in Range f. Participant's WIC ID Number .g. Participant's Status Code h. Participant's Last Name and Replacement Voucher Numbers (in the
"Comments" block)
* If a participant reports that part of a voucher package was lost/stolen/destroyed and the other portion was cashed, but cannot determine which voucher serial numbers were lost/stolen/destroyed, include all of the voucher serial numbers on the form. Note in the comments section of the Lost/Stolen Destroyed Voided Voucher Report that 1-4 vouchers may have been cashed.
Mail the completed Lost/Stolen/Destroyed Voided Voucher Report to the ADP Contractor, retain a copy in the clinic, and forward a copy to the State WIC Office, System Information Unit. Upon receipt of the Report, the ADP Contractor will enter this information into the system. If the vouchers are
FD-40



GA WIC PROCEDURES MANUAL
subsequently paid by the contract bank, they will be identified on the Bank Exception Report during the monthly reporting process.
The State WIC Office cannot initiate "stop payments" on lost/stolen/ destroyed vouchers issued to WIC participants. When fraud is suspected, the local agency should notify the Quality Improvement Unit to request assistance with an investigation. To obtain copies of suspect vouchers, the Local Agency must submit a Quality Improvement Voucher Investigation Log (Attachment QI-2) to the Quality Improvement Unit (see Section X of Quality Improvement Section of the Georgia WIC Procedures Manual).
C. Vouchers Lost, Stolen, or De~troyed Prior to Issuance
When a clinic determines that vouchers have been lost, stolen, or destroyed prior to issuance, the following procedure must be implemented:
1. Complete the Lost/Stolen/Destroyed Voided Voucher Report (Attachment FD-21) with the following items: a. District/Unit/Clinic b. Current Date C. Beginning Voucher Number in Range d. Ending Voucher Number in Range e. Quantity of Vouchers in Range
2. Mail the completed Lost/Stolen/Destroyed Voided Voucher Report to the ADP Contractor, retain a copy in the clinic, and forward a copy to the State WIC Office, System Information Unit. Upon receipt of the Report, the ADP Contractor will enter this information into the system. If the vouchers are subsequently paid by the contract bank, they will be identified on the Bank Exception Report during the monthly reporting process.
The System Information Unit will review Lost, Stolen, or Destroyed voucher reports in conjunction with the Cumulative Unmatched Redemption (CUR) report to identify potential fraud and refer findings to the Quality Improvement Unit. The Quality Improvement Unit will work in conjunction with the Local Agency to investigate potential fraud. When a block of 25 or more vouchers are missing see QI Section X, Investigation of Missing Vouchers .



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GA WIC PROCEDURES MANUAL
D. Change of Formula Order
In the event that a formula order is changed after a participant has been issued vouchers for an original formula order, replacement vouchers may be issued. When vouchers are replaced within the same month of original issuance, the following procedures must be implemented:
Standard Formula, Special Formula 1. Participants must return unused formula to the clinic if available, and/or 2. Return unredeemed voucher(s) to the clinic for voiding. 3. Supplemental vouchers issued must be prorated for the remainder of time
in the issuance period. 4. Document the amount, type, and disposition of formula returned to clinic
on the voucher register or the clinic's copy of the manual voucher.
Hospital Based Formula
Ifa formula is changed by a physician, the participant must return all unopened case(s) of formula to the clinic.
The Clinic must then:
I. Issue supplemental vouchers prorated for the remainder of time in the issuance
period.
2. Document the amount, type, and disposition of formula returned to clinic on the Voucher Register or on the clinic's copy of the manual voucher.
3. Document formula change and receipt of an updated written or verbal order from the physician in the participant's health record.
4. If the formula is ordered by the Office of Nutrition, all unopened cases of formula should be returned to the company. Notify the Office of Nutrition so that a refund may be obtained from the company.



FD-42



GA WIC PROCEDURES MANUAL
XV. BORROWED VOUCHERS
Vouchers may be borrowed within a District from one clinic by a clinic whose current stock is depleted.
Submitting the form in a timely manner 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 18 of the Food Delivery Section.



FD-43



GA WIC PROCEDURES MANUAL

XVI. 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 with the ADP contractor or a manual reconciliation should be performed with the State WIC Office, depending on how much time has elapsed since the voucher was redeemed. The CUR Report has two parts:

Part I : A cumulative list of manual vouchers issued by clinics and cashed by the participant, when there is no record that the voucher was issued on the ADP Contractor's mainframe computer system (see Attachment FD-19).

Part 2: A cumulative list of manual vouchers issued by the clinics and cashed by the participants, which have not matched to a valid WIC ID number, issue date, or participant certification record on the ADP Contractor's mainframe computer system (see Attachment FD-20).

The Local Agency may correct an unmatched redemption list that is over 30 days old. The second month the item appears, the Local Agency must manually reconcile the items described below. These manually reconciled items, should not be submitted to the ADP Contractor since the items are purged from the system after they are listed the second time.

B. Procedures For Reconciliation

Cumulative Unmatched Redemptions that have not matched to an issuance record.

CUR Part I:

Attachment FD-19 provides an example of cumulative unmatched redemptions which are not matched to an issuance record. The third
and fourth columns on the CUR Part I has the $ amount of the
redeemed voucher(s).

If the voucher appears in the third column or the Ist $ amount column, confirm the
batch of vouchers appearing in the l st $ amount column was sent to the ADP Contractor.

I. Ifthere is no acknowledgment from the ADP Contractor that the batch was received, resubmit to the ADP Contractor.

2. If there is acknowledgement that the ADP Contractor received the vouchers appearing in the 1st $ amount column, the vouchers may have contained an error or were processed incorrectly by the bank. Photocopy the entire set of vouchers that FD-44



GA WIC PROCEDURES MANUAL
were issued to that participant even if all the vouchers are not listed on the report, and make the necessary corrections on the photocopy. Correct only those voucher(s) listed in the 1st $ amount column with the ADP Contractor.

Corrections and resubmitted batches must be received by the ADP Contractor by the end of the month cut-off (7th working day of the month following the month in which the report was received). Complete a Batch Control Form. Batch and submit to the ADP Contractor. Do not submit copies of the CUR report to the ADP Contractor and do not send copies of vouchers to the SWO.

C. Manually Reconciling CUR Part 1

Those voucher(s) listed in the second$ amount column are too old to correct through the ADP Contractor and must be manually reconciled by the clinic.

1. .Locate a copy of the voucher(s) listed in the second$ amount column.

2. Record the issue date only of the voucher (the actual date as it appears on the voucher) on the dotted line adjacent to the voucher number on the CUR Part 1 report, sign and date the report. If there are no vouchers appearing on the CUR Part 1 report that have to be manually reconciled, the report should still be forwarded to the SWO. The CUR Report should always be submitted to the SWO in its entirety. Do not send copies of vouchers to the State WIC Office.

Cumulative Unmatched Redemptions that have not matched to a valid certification record.

CUR Part 2:

Attachment FD-20 provides _and example of cumulative unmatched redemptions which are not matched to a valid certification record. The fifth and sixth columns on the CUR Part 2 have the $ amount of the redeemed voucher.

1. Verify that the issue date and /or the ID number is correct as it appears on the voucher and the CUR report. If both or either the issue date or the ID number is incorrect, complete only the appropriate column of the CUR PART 2 CORRECTION FORM with the correct issue date and/or ID number for the entire set of vouchers listed. Mail the top copy of the form to the ADP Contractor. Retain the bottom copy for your files. Do not submit a copy of the CUR Part 2 Correction Form to the SWO.

When the issue date and the ID number on the voucher(s) and the CUR Part 2 report are correct.

FD-45



GA WIC PROCEDURES MANUAL 1. Verify that the participant was in a valid certification period as of the voucher issue date. If the participant was not within a valid certification period when the voucher was issued, there is no correction to be made and the voucher will appear on the next CUR report. Briefly document on the dotted line adjacent to the voucher number on the CUR report, why the vouchers were issued outside of a valid certification period.
2. If the vouchers were issued within a valid certification period, verify whether the TAD transaction creating the valid certification was batched and submitted to the ADP Contractor. If there is no batch acknowledgment, resubmit the entire batch to the ADP Contractor.
3. If the TAD was submitted to the ADP Contractor, it may have contained a critical error. Review critical error reports and resubmit a corrected TAD transaction as appropriate.
Correct only those voucher(s) listed in the last$ amount column on the report with the ADP Contractor. Corrections and resubmitted batches must be received by the ADP Contractor by the end of the month cut-off (7th working day of the month following the month in which the report was received).
D. Manually Reconciling CUR Part 2
Vouchers listed in the second$ amount column (sixth column) are too old to correct through the ADP Contractor. Those vouchers must be manually reconciled by the clinic. A note in the last column explains why the vouchers appear on the CUR Part 2.
1. Locate the copy of the voucher(s) and check the ID number, name, and issue date.
2. If the issue date or the ID number on the voucher(s) or the CUR Part 2 report is erroneous, record only the corrected information on the dotted line adjacent to the voucher number on the CUR Part 2 report.
3. If the issue date and the ID number on the CUR Part 2 are correct, record briefly the reason the voucher(s) were issued.
4. The first voucher of a set of vouchers issued to a participant appearing in the second $ amount column must be manually reconciled. (See Attachment FD-20)
5. Sign and date the completed report and submit to the State WIC Office. If there are no vouchers on the report to be manually reconciled, the CUR report should still be forwarded to the SWO in its entirety. Do not send CUR reports to the ADP Contractor.
FD-46



GA WIC PROCEDURES MANUAL E. Procedures For Both Reports

1. Submit the completed reports to the District Office and the District Office will submit all the reports from each clinic in a batch to the State WIC Office by the 22nd of the month following the report's run date month (i.e., if the run date is 2/18/94, the manually reconciled CUR report is due to the State WIC Office by 3/22/94).

2. If you are unable to locate a copy of a specific voucher(s), send a memo to the State WIC Office requesting a copy of the vouchers. Please include the redemption month along with the voucher number(s).

NOTE:

The vouchers in the second $ amount columns on Part 1 and Part 2 can no longer be reconciled by the ADP Contractor and must be manually reconciled by the clinic.





FD-47

GA WIC PROCEDURES MANUAL COMPUTER PRINTED VOUCHER

Attachment FD-1



FD-48



GA WIC PROCEDURES MANUAL BLANK MANUAL VOUCHER

Attachment FD-2



FD-49



GA WIC PROCEDURES MANUAL

Attachment FD-3

PREPRINTED STANDARD MANUAL VOUCHER



FD-50



GAWICPROCEDURESMANUAL

Attachment FD-4

AUTOMATED SPECIAL MANUAL VOUCHER



FD-51







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tll

GA WIC PROCEDURES MANUAL
1999 FEB MAR APR

VOUCHER CREATE CALENDAR JUN JUL

Attachment FD-6

NOV

DEC

2000

13 14

CYCLE I 1st 14th
CYCLE2 I 5th - Month end


I - Cycle I TAD INPUT CUTOFF ( 15th) 2 - Date Federal Express shipped VOUCHERS ARRIVE at D/U (22nd) 3 - ESTIMATED date UPS shipped VOUCHERS ARRIVE at Clinic 4 - Cycle 2 TAD INPUT CUTOFF (last workday of each month) 5 - Date Federal Express shipped VOUCHERS ARRIVE at D/U (7th) 6 - ESTIMATED date UPS shipped VOUCHERS ARRIVE at Clinic
FD-53



GA WIC PROCEDURES MANUAL

Attachment FD-7

VOUCHER CYCLE PACKING LIST

PAGE60 REPORT ENCR2006
DISTRIBUTION:

STATE OF GEORGIA WIC SYSTEM VOUCHER CYCLE PACKING LIST (CLINIC)
FOR THE SECOND CYCLE OF JULY

CLINIC PAGE 2 D/U/CL

CLINIC KEEPS TOP COPY

CLINIC RETURN SECOND COPY TO DISTRICT/UNIT

( )

VOUCHER REGISTER POS 1508 - 1566

( )

COMPUTER PRINTED VOUCHER FROM 1006547 TO 1008499





IF THE ACTUAL CONTENTS OF THIS SHIPMENT DIFFER FROM THIS PACKING SLIP. CONTACT EDS-WIC IMMEDIATELY. TELEPHONE 1-800-221-9182. CONTENTS VERIFICATION

WIC REPRESENTATIVE SIONATURE

DATE

EDS SHIPPING USE

COMMENTS

NUMBER OF PIECES FOR THIS DISTRICT/UNIT _ _ _ _ _ __

EDS QUALITY CONTROL INITIALS_ _ _ _ _ _ _ _ _ __

FD-54



GA WIC PROCEDURES MANUAL

PAGE

6570

COMPUTER PRINTED VOUCHER REGISTER
STATE OF GEORGIA WIC SYSTEM

Attachment FD-8
CLINIC PAGE 34

REPORT EWCR201G

COMPUTER GENERATED VOUCHER REGISTER D/U/CL

09-

03-632

COASTAL HEALTH

RUN DATE

3/19/99

INPUT CUTOFF DATE 03/15/99

WICID FAMILY

C p LAST

FIRST I M y R SIGNATURE OF PARTICIPANT DATE CLK



FD-55

GA WIC PROCEDURES MANUAL

Attachment FD-9

PAGE 708 REPORT EWCR201G D/U---01-1 MESSAGE TOTALS

VOUCHER REGISTER SUMMARY PAGE

TOTAL OF TOTAL OF
1496 214 919 162 226
0 72 0 0

STATE OF GEORGIA WIC SYSTEM COMPUTER GENERATED VOUCHER REGISTER

DIST/UT 01-1 RUN DATE_/_/_ INPUT CUTOFF DATE_/_/_

3,639 PARTICIPANTS RECEIVING 3,374 PARTICIPANTS RECEIVING RECERT DUE - MM/DD/YY CATG TERM MM/DD/YY NUTRITIONAL ASSESSMENT-MM/DD/VY IST BDATE-MM/DD/YY RECERT DUE (P)-MM/DD/YY NO-SHOW PRIOR NO-MM RECERT OVERDUE (P)-MM/DDNY RECERT OVERDUE (F2)-MM/DDNY RECERT DUE (PRl2)-MM/DDNY

12,809 VOUCHERS

FOR 01/92

11,913 VOUCHERS

FOR 01/92

(DUE FOR RECERT-SEE CERT-DUE)

(CATEGORICAL TERM DUE ON DATE SHOWN)

(NUTRITIONAL ASSESSMENT DUE-DATE SHOWN)

(INFANT TO CHOLD CHANGE IN DATE SHOWN)

(PASSED CERT-DUE DATE)

(CLIENT DID NOT PICK UP VOUCHER IN MONTH)

(PASSED CERT-DUE-DATE P)

([PASSED CERT DUE DATE PRIORITY 2)

(DUE FOR RECERT (PRI-W) SEE CERT DUE)



FD-56



GA WIC PROCEDURES MANUAL

Attachment FD-10

TRANSMITTAL FORM
Verification Receipt of WJC Vouchers

Client'.s Name____________

Clinic _ _ _ _ _ _ _ _ _ _ _ _ __

This is to certify that I received the following WIC vouchers:

# _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
# ----------------

# #

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

Participant/Proxy

Date

Staff/Initials

Date

Verification Receipt of WIC Vouchers

Client's Name___________

Clinic _ _ _ _ _ _ _ _ _ _ _ _ __

This is to certify that I received the following WIC vouchers:

# _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ # _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Participant/Proxy

Date

# #

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

Staff/Initials

Date

Verification Receipt of WIC Vouchers

Client's Name___________

Clinic _ _ _ _ _ _ _ _ _ _ _ _ __

This is to certify that I received the following WIC vouchers:

# _ _ _ _ _ _ _ _ _ _ _ _ __ # _ _ _ _ _ _ _ _ _ _ _ _ __

#--------------#---------------

Participant/Proxy

Date

Staff/Initials

Date

Verification Receipt of WIC Vouchers

Client's Name___________

Clinic _ _ _ _ _ _ _ _ _ _ _ _ __

This is to certify that I received the following WIC vouchers:

# _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ # _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

# #

-

-

-

-

-

-

-

-

-

-

-

-

-

-

-

Participant/Proxy

Date

Staff/Initials

Date

Verification Receipt of WIC Vouchers

Client's Name___________

Clinic _ _ _ _ _ _ _ _ _ _ _ _ __

This is to certify that I received the following WIC vouchers:

# _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ # _ _ _ _ _ _ _ _ _ _ _ _ __

Participant/Proxy

Date

# _ _ _ _ _ _ _ _ _ _ _ _ _ __
#---------------

Staff/Initials

Date

FD-57



GA WIC PROCEDURES MANUAL

Attachment FD-11

FORM AND MANUAL VOUCHER ORDERS

GEORGIA WIC PROGRAM FORM AND MANUAL VOUCHER SUPPLY ORDER FORM (REV l/95)

Return to:

Viking Computing, Inc. 1000 North Madison Ave., Suite W-l l Greenwood, Indiana 46142

Your District/Unit:

Clinic name:

Address:

Phone l-800-899-7913
FAX: l-317-889-9485 This order is for clinic #:_ _ _ __

Contact person: ---------------=Phone:_ _ _ _ _ _-----'Date Mailed:_ _ __

NOTE: Viking processes Georgia WIC Program orders twice a month. Orders received at Viking by the 10th of the month are processed so that the order is delivered by the 25th of the month. Orders received at Viking by the 25th of the month are processed so that the order is delivered by the l 0th
of the following month. If the 10th or 25th fall on the weekend or on a holiday, the cut-off is the

workday before.



MANUALVOUCHERORDER

BLANK MANUAL VOUCHERS FOR HAND COMPLETION
Blank manual voucher (no tuna or carrots) 408 (blank manual voucher with tuna and carrots)
PREPRINTED MANUAL VOUCHER PACKAGE SETS FOR HAND COMPLETION
Sets of prenatal/breastfeeding women package 404 Sets of postpartum non-breastfeeding women package 502 Sets of infant package 113 Sets of child package 603
SPECIAL MANUAL VOUCHERS FOR USE ON COMPUTER
Special manual vouchers for use on computer (ATVS, MVS, M&M, or other State approved system)
CERTIFICATION FORM (TAD) ORDER
Blank TAD (no preprinted ID number) Pre-numbered TAD (preprinted ID number)
OTHER FORMS
Form and Manual Voucher Supply Order forms Lost/Stolen/Destroyed voided Voucher Report forms Vendor Input Form

FD-58

GA WIC PROCEDURES MANUAL

Attachment FD-12

STANDARD MANUAL_ _ __

MANUALVOUCHERINVENTORY
MANUAL VOUCHER INVENTORY

CLINIC_ _ __

BALANCE BROUGH FORWARD_ _ __

DATE

RECEIVING NO.

ENDING NO. NO. RECEIVED

NO. ISSUED NO. VOID NO.ON HAND

INITIALS



FD-59



GA WIC PROCEDURES MANUAL

Attachment FD-13

VOUCHER ON DEMAND LOG SHEET PRINTER ONE

BATCH# _ _ _ _ BEGINNING# _ _ _ _ _ _ _ _ _ _ _ ENDING# _ _ __

DATE (when vouchers were printed.)

BEGINNING (the number of the
first voucher printed for that
day.) (A)

ENDING (the number of the
last voucher printed for that
day.) (8)

TOTAL (the number of vouchers used for that day.)
(8-A = total)

VOIDED (the number of vouchers that were voided for that day ... good to know.)

INITIALS (always sign your initials for that day.)





GRAND TOTAL OF VOUCHERS REMAINING IN STOCK. (After completing this form.)
REMAINING STOCK INITIALS
FD-60



GA WIC PROCEDURES MANUAL

Attachment FD-14

BATCH CONTROL FORM .

GEORGIA DEPARTMENT OF HUMAN RESOURCES WIC PROGRAM

BATCH CONTROL FORM

DATE

NUMBER

I

I

I

I

DISTRICT/UNIT

CLINIC

INSTRUCTIONS
VIKING INPUT SECTION
COMMENTS:

I. USE THIS FORM AS A COVER SHEET TO FORWARD ALL TADS (CERTIFICATIONS, UPDATES, TRANSFERS AND TERMINATIONS) AND ISSUEDNOIDED MANUAL VOUCHERS.

2. DO NOT BATCH TADS WITH MANUAL VOUCHERS

3. DO NOT SUBMIT VOIDED/UNCLAIMED COMPUTER VOUCHERS TO VIKING.

4. SUBMIT THE 15T AND 2ND COPIES OF THIS FORM AND ACCOMPANYING MATERIALS TO:

VIKING COMPUTING, INC P.O. BOX 2504 GREENWOOD, IN 46142-2504

5. RETAIN THE 3RD COPY OF THIS FORM IN THE CLINIC WITH COPIES OF THE TADS OR MANUAL VOUCHERS, CREATING A BATCH CONTROL MODULE.

TYPE OF DOCUMENT

NUMBER IN BATCH

TURNAROUND

ISSUED MANUAL VOUCHERS

VOIDED MANUAL VOUCHERS



DATE SENT BY DISTRICT/UNIT DATE RECEIVED AT VIKING DATE ENTERED AT VIKING
FORM 3762(REV.02-92)

PREPARER'S SIGNATURE SIGNATURE SIGNATURE
FD-61



GA WIC PROCEDURES MANUAL

Attachment FD-15

BATCH CONTROL EXCEPTION REPORT

GEORGIA DEPARTMENT OF HUMAN RESOURCES WICPROGRAM

DISTRICT/UNIT

CLINIC

VOUCHER BATCH EXCEPTION FORM

DATE

NUMBER

THIS FORM HAS BEEN GENERATED AS A RESULT OF:
THE QUANTITY ON THE CLINIC COMPLETED BATCH CONTROL FORM DOES NOT AGREE WITH THE ACTUAL QUANTITY RECEIVED
THE VOUCHERS WERE RECEIVED IN A BATCH OF TADS.
ONLY ONE (I) COPY OF THE BATCH CONTROL FORM WAS RECEIVED WITH THE VOUCHERS.
NO BATCH CONTROL FORM WAS RECEIVED WITH THE VOUCHERS.

TYPE OF DOCUMENT

VIKING INPUT

SECTION

ISSUED MANUAL VOUCHERS

VOIDED MANUAL VOUCHERS

APPROXIMATE NUMBER IN BATCH

DATE BATCH RECEIVED AT


FD-62

GA WIC PROCEDURES MANUAL

Attachment FD-16


ill
ID#& NAME

GEORGIA WIC PROGRAM IDENTIFICATION CARD

STATE OF GEORGIA
Department of Human Resources Division of Public Health
WIC PROGRAM IDENTIFICATION CARD

ii

PARTICIPANTS

NOT VALID WITHOUT
WIC
EXP. EXP. DATE DATE

BRING THIS FOLDER EVERY VISIT

APPOINTMENTS

APPOINTMENT DATE

TIME VOUCHER NUTRITION SUBSEQUENT PICK-UP EDUCATION CERTIFICATION BRING YOUR CHILD(REN) &
PROOF OF I.D.

ID#& NAME

ID#& NAME

ID#&NAME

ID#& NAME

AUTHORIZED PERSON:

PARTICIPANTIPARENT/GUAIIDIAN SIGNATURE
Other authorized to pick up vouchers and food:

EDC DATE

I.------------,,-PRo=xv"""sm=NA=TURE,.,,...---------*lt is the responsibility of the participants to educate proxies on the proper use of WIC vouchers

2. - - - - - - - - - - - - - - - - - - - - PROXY SIGNATURE



SIGNATURE OF WIC OFFICIAL

ISSUEDATE

BRING THIS FOLDER EVERY VISIT

Form 3769 (Rev. 9-96)

PICK UP CODE _ _ _ _ VOUCHER INTERVAL CODE_ _ __ COMMENTS _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
LOCAL: AGENCY: CLINIC: NAME: ADDRESS:
PHONE:

FD-63

GA WIC PROCEDURES MANUAL



DAILY ROSTER/MONTHLY MAILED VOUCHER REPORT

Attachment FD-17

Participant's Name

I.D. Number

Number of Vouchers Issued

Number of Vouchers Returned

Signature of CPA

Date Returned

Replaced Voucher Redemption Value of

Numbers Lost/Stolen

Lost Vouchers

D

A

I

L y

End of Month
Totals
- - Date:

Total# of Participants:

Total # Issued:

Total# Returned:

*Redemption Rate must be completed by the District Office.

Total # Replaced:

Total Redemption Value:
s

FD-64



GA WIC PROCEDURES MANUAL

Attachment FD-18

BORROWED VOUCHER REPORT FORM

GEORGIA DEPARTMENT OF HUMAN RESOURCES WJCPROGRAM

BORROWED VOUCHER REPORT

BORROWING DISTRICT/UNIT: LLU

CLINIC: LI.J I

DATE:

INSTRUCTIONS

.


USE FORM TO REPORT MANUAL VOUCHERS BORROWED FROM ANOTiffiR CLINIC RETURN TO VIKING AS SOON AS POSSIBLE. MAIL TO: VIKING COMPUTING, INC.

GEORGIA WIC UNIT

.

IOOO N. MADISON AVENUE, SUITE GREENWOOD, IN 48142 OR FAX TO: (317)889-9485

DISTRICT(S)
II II

CLINIC(S)
I I II

BEGINNING VOUCHER NO.
I I I I I I I I

ENDING VOUCHER
I I I I I I II

QUANTITY
I I I I I I

I I I I I I II I I I I I I I I I I I I I I II I I I I I I

I I I I I I II I I I I I I I I I I I I I I II I I I I I I

I I I I I I II I I I I I I I I I I I I I I II I I I I I I

I I I I I I II I I I I I I I I I I I I I I II I I I I I I

I I I I I I II I I I I I I I I I I I I I I II I I I I I I

I I I I I I II I I I I I I I I I I I I I I II I I I I I I

I I I I I I II I I I I I I I I I I I I I I II I I I I I I

I I I I I I II I I I I I I I I I I I I I I II I I I I I I

I I I I I I II I I I I I I I I I I I I I I II I I I I I I

I I I I I I II I I I I I I I I I I I I I I II I I I I I I

I I I I I I II I I I I I I I I I I I I I I II I I I I I I

u u REASON(S): INSUFFICIENT QUANTITY

ORDERED LA TE

COMMENTS:

u ORDER NOT RECEIVED FROM VIKING

u OTHER



DISTRICT OFFICE APPROVAL DATE

VIKING - WHITE COPY

SWO - YELLOW COPY

DISTRICT OFFICE - PINK COPY

CLINIC - GOLD COPY

FD-65



GA WIC PROCEDURES MANUAL

Attachment FD-19

CUMULATIVE UNMATCHED REDEMPTIONS PART I EXAMPLE

PAGE I REPORT EWRR350G COOSA VALLEY HEALTH

STATE OF GEORGIA WIC SYSTEM

CUMULATIVE UNMATCHED REDEMPTIONS

FOR THE MONTH OF _ _ __

19_

CLINIC PAGE I D/U/CL 01-1-008 RUN DATE_/_/_

PART I NOT MATCHED TO ISSUANCE RECORD

VOUCHER REFERENCE NUMBER NUMBER

FEBRUARY S AMOUNT

JANUARY S AMOUNT

ISSUE DATE

74622188 74623694 74623736 74623812

36698524 36614713 55658120 36551839

R

66.36

R

39.75

R

36.15

R

4.77

TOTAL

TOTAL *****STATUS

147.03

147.03

VOID

REDEEMED

4

4

TOTAL

4

4

FD-66

GA WIC PROCEDURES MANUAL

Attachment FD-20

PAGE I REPORTEWRR351G COOSA VALLEY HEALTH

CUMULATIVE UNMATCHED REDEMPTIONS PART II EXAMPLE

STATE OF GEORGIA WIC SYSTEM

CUMULATIVE UNMATCHED REDEMPTIONS

FOR THE MONTH OF _ _ __

19_

CLINIC PAGE I D/U/CL 01-1-008 RUN DATE_/_/

PART 2 NOT MATCHED TO ISSUANCE RECORD

VOUCHER REFERENCE NUMBER NUMBER

ISSUE DATE

WICID FAMILY C P

FEBRUARY

JANUARY

s AMOUNT s AMOUNT

RECONCILIATIONS

74620912 74620913 74620914 74620915 74621454 74621455

15692612 I 1454716 I 1454717 34537674 36190860 55336318

01/12/96 01/12/96 01/12/96 01/12/96 02/05/96 02/05/96

008007741 5 I 008007741 5 008007741 5 008007741 5 008008287 8 008008287 8 1

R 4.14
R 7.17 R 4.17

R 5.13 R 11.06 R 8.27



TOTAL



74621456 74621457 74621502 74621504 74621505 74621506 74621507 74621509 74621755 74621818 74621820 74621821 74621822 74621823

36163633 36163632 60056231 34792625 60056230 32816278 36598558 36332739 36698773 36698562 15835402 55637585 36593568 42729901

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R 4.40

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FD-67



GAWIC PROCEDURES MANUAL
LOST/STOLEN/DESTROYED VOIDED VOUCHER REPORT

Attachment FD-21

GEORGIA DEPARTMENT OF HUMAN RESOURCES WICPROGRAM

LOST/STOLEN/DESTROYED VOIDED VOUCHER REPORT

. DISTRICT/UNIT/CLINIC:

DATE:
USE THIS FORM TO REPORT VOUCHERS (COMPUTER OR MANUAL) WHICH HA VE BEEN LOST, STOLEN, OR DESTROYED BY EITHER

INSTRUCTIONS

THE PARTICIPANT OR THE CLINIC.

.

SUBMIT AT LEAST MONTHLY. MAIL TO VIKING COMPUTING, INC.

GEORGIA WIC UNIT

P.O. BOX 2504

GREENWOOD, IN 46 I42-25041:

BEGINNING VOUCHER NO.

ENDING VOUCHER NO.

QUANTITY

WICI.D. NUMBER

STATUS

STATUS CODES LOST/STOLEN/DESTROYED - 2
VOIDED-3
COMMENTS





TOTAL VOUCHERS
FD-68







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GA WIC PROCEDURES MANUAL

TABLE OF CONTENTS

Page

I. State Agency Monitoring ............................................................................................. MO-1

A. Introduction .......................................................................................... MO-1

B. Monitoring Schedule............................................................................ MO-1

C. Clinic & Health Record Selection....:.................................................... MO-2

D. Pre-Review Activities .......................................................................... MO-3

E. Files ...................................................................................................... MO-3

F. Timeframes .......................................................................................... MO-5

G. On-Site Visit ........................................................................................ MO-6

1. Entrance Conference ................................................................ MO-6

2. Exit Conference ....................................................................... MO-6

H. Special Site Visits ................................................................................ MO-7

I.

Written Reports .................................................................................... MO-8

J. Close-Out Report ............................................................................... MO-10

II. Quality Assurance Self-Reviews ............................................................................... MO-11

A. Purpose ............................................................................................... MO-11

B. Self Reviews ...................................................................................... MO-11

III. Technical Assistance ................................................................................................... MO-13 Attachment: MO-I Local Agency Monitoring Tool ................................................................................... MO-14





GA WIC PROCEDURES MANUAL
STATE AGENCY MONITORING
A. Introduction
The State agency will conduct an on-site monitoring visit every two (2) years at all nineteen (19) public health district WIC programs and two (2) contracted WIC agencies, for the purpose of reviewing local agency operation. The districts/agencies that are not monitored for the year will receive priority for on-site technical assistance. The purpose of the monitoring visit is to ensure local agency compliance with State policies and Federal WIC regulations. The review will consist of an evaluation of program administration, staff training, voucher issuance, certification, food package assignment, nutrition education, and breastfeeding.
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 (one per clinic). 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 (SWO) and the Office of Nutrition (OON). Every effort will be made to conduct all portions (Programmatic, Financial, Vendor, Quality Improvement, Nutrition, and Breastfeeding) of the review during the same time period.
District reviews may be conducted yearly for clinics with specific problems (State Agency Monitoring Section #MO - H (Special Site Visits).
B. Monitoring Schedule
A schedule of on-site monitoring visits will be developed and coordinated by the State WIC Office and the Office of Nutrition, prior to the start of each Federal Fiscal Year (FFY). A Statewide schedule containing the dates and monitoring teams for each review will be sent to all local agencies.
The WIC Coordinator will be notified by phone, approximately one (1) month prior to the review, of the specific clinics (clinics and staff are randomly selected) to be monitored. At the time of the notification by phone, the team leader will offer the District the option of having the Vendor Unit monitor on site or conduct the review from the SWO. 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 (i.e., Patient Flow Analysis, directions).
MO 1



GA WIC PROCEDURES MANUAL
C. Clinic and Health Record Selection
1. Clinic Site
Every two (2) years, twenty percent (20%) of the total number of clinics in the State are randomly selected for program monitoring. The following limitations have been imposed on the random selection:
a. Clinics that were monitored during the two most recent program review cycles will not be included in the random selection, with the exception of the largest clinic.
b. Each local agency may have a maximum of five (5) clinics selected for review. If more than five (5) clinics are randomly selected, those in excess will be eliminated from the selection.
c. The largest clinic in each local agency will be monitored during each program review. If it is not randomly selected, it will be added to the list of clinics to be reviewed within a local agency. If a maximum of five (5) clinics have already been chosen, the largest clinic in the local agency will replace the last clinic on the random selection list of clinics to be reviewed.
d. Clinics that have not been reviewed for at lt:rast four (4) years may be hand selected in place of some randomly selected clinics, to ensure regular reviews of all clinics.
Within each local agency, at least twenty percent (20%) of the clinics or two (2) clinics, whichever is greater will be monitored during the on-site review. Once the randomly selected clinics are grouped according to districts, additional clinics may be selected by the State in order to ensure that the minimum requirement is met.
2. Record Selection
Health records monitored during the program reviews will be randomly selected. The following constraints will be applied to the random selection:
a. Two (2) records will be randomly selected for each 100 participants enrolled in a clinic, up to one thousand participants. If a clinic has more than one thousand participants, an additional two (2) records will be selected for each five hundred (500) participants above one thousand. Note: a minimum of six (6) records will be reviewed in each clinic.
b. Fifty percent (50%) 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.
. MO 2



GA WIC PROCEDURES MANUAL
3. Migrant Health Records
The State must review migrant health records during a local agency program monitoring visit. Migrant health records will be randomly selected at the State WIC office. 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.C.2.a; above. b. If a clinic site serving a significant number of migrants is not selected for program review, migrant health records will be selected and reviewed according to the procedures in, I.C.2.a; above. 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 agency's 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:
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
MO 3



GA WIC 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. Local Agency Nutrition Education and Breastfeeding Plan

25. Nutrition Education Materials

26. Breastfeeding Education Materials

27. Lesson Plans
28. Training Files

30. Financial Management Files:



General Ledger (current and previous year)



General Journal (current and previous year)



Check Register (current and previous year)



Certified Payroll (current and previous year)

MO 4



GA WIC PROCEDURES MANUAL



Bank Reconciliation (current and previous year)



Back-up Documentation for Line Item Expenditures (e.g. travel, regular

operating expenses, etc.)



Competitive Bids Documentation (one [1] month)



Last Independent Audit



Equipment Inventory (current year)



Chart of Accounts

31. Voter's Registration Files

32. Contracts with other agencies (other than Health Departments) where WIC Programs are located.

33. Patient Flow Analysis F. Timeframes
The program review process will be conducted within the following timeframes:

ACTIVITY

TIMEFRAME

1. Notifications of intent to conduct a review, SWO/OON contact Local Agency 30 days prior to the scheduled date. to discuss possible review dates.

2. SWO/OON prepares and submits a report of program observation and review to Local Agency after the site visit.

Within 60 interviews.

days

of

the

exit

3. Local Agency submits response to Within 60 days of the date of

program review to SWO/OON.

program review report.

4. SWO/OON submits written response to Within 15 days of the date of the

the Local Agency review.

Local Agency response.

5. Local Agency submits written response to Within 15 days of the date of the SWO request for additional information. written request.

6. Program review closed.

Within 135 days of the exit interview.

Note: Failure to resolve any outstanding deficiency found during the review could result in a delay of funding for the next fiscal year.

MO 5



GA WIC PROCEDURES MANUAL
G. On-Site Visit
During the on-site visit, the local agency will make accessible all reports, forms, and files requested. Local agency staff will be asked to respond to questions asked by State staff. Staff must be available to answer questions during the clinic visit. The average review for a district will take three (3) to five (5) days.
1. Entrance Conference
An Entrance Conference may be requested by the district to officially begin the review. The District Health Director, Program Manager, WIC Coordinator, and any other pertinent staff are invited to participate in the entrance conference. During this conference, District staff will have the opportunity to provide an overview of their district and ask questions of the State monitoring team. State staff will:
a. Make introductions; b. Explain the purpose of the visit; c. Review the district specific monitoring schedule; d. Briefly explain what will take place during the review; and e. Discuss pertinent district specific information/data.
2. Exit Conference
An Exit Conference with clinic staff may be held in each clinic monitored to review the specific clinic findings.
Upon completion of the on-site District Review, the monitoring team will meet privately to prepare for the Exit Conference. State staff will then meet with the District Health Director, Program Manager, WIC Coordinator, and other local agency staff as designated by the District Health Director for the Exit Conference. Findings reported by the reviewers at the Exit Conference are preliminary. The final report will be forwarded to the local agency within 60 days. The following will be discussed at this conference:
a. Areas deserving commendation;
b. Achievements; c. Corrective actions (NOTE: Clinics and records are randomly selected,
therefore all corrective actions apply district-wide); and d. Recommendations.



MO 6



GA WIC PROCEDURES MANUAL

H. Special Site Visits

The SWO in accordance with federal requirements may have to make special site visits at any time due to the following problems:



Voucher Theft (over 25 vouchers stolen)



Requiring Fees for WIC Services



Falsification of Records by employees



Employee abuse of the WIC Program (See Food Delivery Section)



WIC Participant Complaints



<60% in five or more areas from the Nutrition record review



Any reason the State WIC Office or USDA deems necessary

Special Site Visit Procedures:

In the event a special site visit is requested by the State WIC Office or Local Agency Coordinator, Health Director or Program Manager, the following procedures must be followed:

1. The State Agency or WIC Coordinator may identify the problem and collect as much information as possible.

2. After a review of the information, it may be determined (from the State WIC Office, Local Agency Coordinator, Health Director, or Program Manager) that a site visit is necessary.

3. In the event a site visit is necessary, a staff person from the SWO will contact the WIC Coordinator to set up a site visit and schedule.

4. After careful observation and investigation, a report will be generated and mailed to the District WIC Coordinator within thirty 30 days of the site visit.

5. The WIC Coordinator must respond to the State WIC Office with a written report within thirty 30 days of receipt. All district responses must address a resolution to the exiting problem (Who has trained, what the training was about, when, and how the training was conducted). All supporting documentation must also be included in the plan:



An agenda and dates of training and a list of staff that have attended the

training.



A copy of all the memorandums sent out to local agency staff by the WIC

Coordinator addressiQ.g problems found during the special site visit.

MO 7



GA WIC PROCEDURES MANUAL



Copies of any information that could not be located during the special site

visit that relate to the specific corrective actions, must be forwarded to the

site.



Training must be conducted to close a special site visit by the WIC

Coordinator using the Procedures Manual for each Local Agency

involved.

The review will not be closed until training has been conducted.

Once the State agency has received the local agency response to the written report, it may elect to do one or more of the following, based on the action plan:



Close the review after another site visit within thirty (30) days.



Request additional information. This information will be due within thirty

(30) days from the date of the request.



Make all the follow-up monitoring visits within fifteen (15) days of the

exit conference.



Offer technical assistance to help develop a corrective plan or train local

agency staff.

The local agency will receive written notification of the above from the State agency, within fifteen (15) days from the receipt of the action plan.

I. Written Reports

The State will send a written report of the review to the District Health Director within forty-five (45) days of the exit conference. The report will address areas of special achievement, recommendations, and corrective actions. The district will respond to all corrective actions within sixty (60) days from the date of the State agency report (See Sections I. State Agency Monitoring, F. Time frames).

A written plan of action must be developed for all program deficiencies identified during the program review. The action plan must be district-wide and address each corrective action. Addressing recommendations in the plan is optional. The plan must ensure that the questions Who?, What?, When?, Where?, and How? are addressed. For example: who will be trained, what will the training be on, when will they be trained, where will the training be held, and how will the training be conducted.



MO 8



GA WIC PROCEDURES MANUAL

NOTE:

All training must be performed within sixty (60) days from the date

on the Program Review Report.

All supporting documentation must be included in this plan. Supporting documentation includes:
1. An agenda and dates of training and a list of staff that have attended the training.

2. A copy of all the memorandum sent out to local agency staff by the WIC Coordinator addressing problems found during the program review.

3.

Copies of information that could not be located during the on-site monitoring visit

that relate to specific corrective actions.

The review will not be closed until all planned training's have been conducted.

Once the State agency has received the local agency response to the written report, it may elect to do one or more of the following, based on the action plan:

1.

Close the review.

2.

Request additional information. This information will be due fifteen ( 15) days

from the date of the request.

3. Make a follow-up monitoring visit within six (6) months of the exit conference.

4. Offer technical assistance to help develop a corrective action plan or train local agency staff.

The local agency will receive written notification of the above from the State agency, within fifteen ( 15) days from the receipt of the action plan.



MO 9



GA WIC PROCEDURES MANUAL
J. Close-Out Report
A written close-out report will be sent to the Local Agency upon the satisfactory resolution of all corrective actions. The close-out report is written documentation that the corrective action plan has been accepted and the program review is closed. All program reviews must be closed within 135 days of the exit interview.





MO 10



GA WIC PROCEDURES MANUAL
II. QUALITY ASSURANCE SELF-REVIEWS
A. Purpose
The purpose of self-evaluation is to improve the quality of Local Agency program operations. Internal self-evaluations allow local agencies to assess compliance of program operations with WIC policies and procedures. Early identification and resolution of non-compliance improves the quality and strengthens the operations of the local agency.
Non-compliance with WIC Program policy and procedures is considered a deficiency in Program Management and Operation. Through self-reviews the Local Agency can identify deficiencies and take immediate action to correct noncompliance, prior to the program review conducted by the state.
B. Self Reviews
The Local Agency must conduct an internal self-review annually by September 30th. Half of the District Clinics must be reviewed one year and all other clinics must be reviewed the following year. A schedule of review dates and clinics must be submitted to the State WIC Office by September 30th of each year. The assessment will include all phases of the program operations. The State WIC Office "Local Agency Monitoring Tool" may be utilized to evaluate operations of each clinic in the district. In instances where the Local Agency has developed an evaluation tool, the local agency internal review must include at a minimum:
Caseload Trends System Maintenance Indicator Reports Non-Participation Evaluation Service Integration and Clinic Flow Outreach and Referrals Processing Standards Certification Procedures Chart Audit Accountability of Food Instrument and Issuance Materials Nutrition Services Breastfeeding Promotion and Support Services Financial Records & Expenditures Civil Rights Compliance Participant Complaints Fair Hearing Review Records of Employees on the WIC Program Review CertificationNoucher Issuance Records for Employee's Relatives
MO 11



GA WIC PROCEDURES MANUAL
Patient Flow Analysis at the Largest Clinic Internal Review of Employee/Family Records
At the time of the Local Agency program review, the State review team will review all documentation pertaining to the self-reviews. If repeated errors are found when conducting self reviews, the District must conduct additional monitoring reviews and one on one training (i.e. errors in issuance of VOC Cards or the prorating of vouchers). Special attention must be given in the area of voucher registers. This is an area where the coordinator could detect potential fraud. The District must submit documentation for the completion of all self reviews to the Policy Unit by September 30th. USDA recommends that a nutritionist be a member of the Local Agency Quality-Assurance team conducting self-reviews. Copies of Self Reviews must be submitted to the State WIC Office in October of each year beginning Fiscal Year 1999.
Non-compliance with the internal self-review procedure constitutes a deficiency in the local agencies program operations. Like all other program deficiencies, an action plan must be developed to correct each deficiency.
NOTE: The District WIC Coordinator must request the names of employees and family members enrolled on the WIC Program for internal audit purposes. This information is confidential and must be seen by the WIC Coordinator only.



MO 12



GA WIC PROCEDURES MANUAL
III. TECHNICAL ASSISTANCE
Technical assistance will be provided by the State agency to all local agencies on an ongoing basis. On-site technical assistance will be provided when requested by the local agency. Technical assistance may also be provided to the local agency through telephone contact or correspondence with the State agency. On-site assistance provided to local agencies will be documented on a Technical Assistance Report form. A copy of this report will be placed in the District's file and a copy will be sent to the District WIC Coordinator. Effective in FFY 2000, program consultants will be assigned to each district to provide technical assistance. In the event there is a problem/concern or if the WIC coordinator would like to request training on technical assistance, the assigned consultant will provide assistance upon request.



M0-13



GA WIC PROCEDURES MANUAL

ATTACHMENT M0-1

STATE OF GEORGIA
Department of Human Resources Division of Public Health
State WIC Office Office ofNutrition

LOCAL AGENCY



MONITORING TOOL



GA WIC PROCEDURES MANUAL

ATTACHMENTM0-1

PART I

ADMINISTRATIVE SECTION

PURPOSE: Federal Regulations require state agencies to establish procedures for reviewing local program operations. The "Local Agency Monitoring Tool" was designed as the instrument to be used in
completing this review.

GENERAL INSTRUCTIONS: Local agencies are encouraged to use this tool as a guide in preparing for the State agency review. Monitoring efforts will ensure compliance as well as emphasize quality assurance. The format of the monitoring tool has been designed to enable local agency responses to be recorded in a narrative form.

SPECIFIC INSTRUCTIONS: The monitoring tool is divided into six (6) parts as follows:

I. Administration Section Local Program Management Clinic Operation Clinic Observation Record Review

II. Civil Rights Administration Training Complaints

III. Food Instrument Accountability IV. Vendor Management

V. Financial Management

VI. Certification and Nutrition Services Certification/Nutrition Education (Office of Nutrition) Clinic Observation: Individual Nutrition Education Session Clinic Observation: Group Nutrition Education Session Clinic Observation: Questions for Clinic Staff Anthropometric Equipment Hematologic Equipment Clinic Observation Anthropometric Measurements Record Review

*NA - Stands for not applicable

1

GA WIC PROCEDURES MANUAL PART I

ATTACHMENT MO-1 ADMINISTRATIVE SECTION

1. Name of District/Local Agency: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Address: - - - - - - - - - - - - - - - - - - - - - - - - - - -

WIC Coordinator: _ _ _ _ _ _ _ Telephone# _ _ _ _ _ _ _ _ _ _ __

2.
3.

Clinic(s) to be Reviewed: (Attach a copy of the District Clinic Listing)

1. Clinic#

Clinic Name

2.
Clinic#

Clinic Name

3. Clinic#

Clinic Name

4. Clinic#

Clinic Name

5. Clinic#

Clinic Name

Review Schedule

Entrance Conference:

Date:

Time:

Place:

Exit Conference:

Date:_ _ __ Time:- - - Place:


2

GA WIC PROCEDURES MANUAL PARTI

ADMINISTRATIVE SECTION

ATTACHMENT MO-1

GUIDELINES Corrective Action

AREAS OF REVIEW

I.

Program Management (District Office)

YES NO NA* COMMENTS

A. Policy and Procedures I. Does the District Office have a copy of all Policy Memorandums on file?
Looking for: I. Up to date Manual 2. Policy is in place 3. Staff understands policy

Corrective Action

2. ls a copy of the Memorandum of Agreement on file?

Looking for: I. Whether or not the Coordinator has a copy.

Corrective Action

3. Is a copy of the Procedures Manual located at the District Office?
Looking for: I. Ensure that manual is in place in the event of questions. 2. Ensure that services are delivered according to the
manual.

Corrective Action
Corrective Action Corrective Action

B.

System Maintenance Indicators

I. Are System Maintenance Indicators in

compliance with State Standards? Review

these reports prior to an on site

monitoring/self-review visit(s). In the event

a District/local agency non-participation rate

is I0% or above a technical assistance visit

and/or a plan must be submitted to the State

WIC Office.

Looking for:

I. Meet federal requirements for participation

2. Meet state rate.

2. Is at least 60% of the prenatal caseload enrolled in the first trimester?
Looking for: Ensure that 60% of prenatal are enrolled their first trimester.

C.

Caseload Management (must have approval from

state)

I. Has the District implemented a waiting list

since the last review?

Looking for:

I. Ensure that Clinic/District does not begin its own

waiting list.

3



GAWICPROCEDURESMANUAL

ATTACHMENT M0-1

PART I

ADMINISTRATIVE SECTION

GUIDELINES

AREAS OF REVIEW

YES NO NA*

NOTE: Recommendations are not requirements for completing self reviews * NA - stands for Not Applicable.

Corrective Action

2. Is there a current waiting list? If yes, what priorities are being served?

Looking for: 1. Whether or not correct priorities are being served.

Corrective Action

D.

Internal Communication

I. Are new policies and State Memos sent to

staff?

Are staff meetings held regularly?

Date of the last meeting: _ _ _ __

Looking for:

I. Whether or not all staff are informed on all new

policies.

Corrective Action

2. Is there a planned method of communication between WIC staff and non-WIC staff? (i.e. staff meetings)
Looking for: 1. Ensure that if staff meetings are not held,
communication is taking place with non-WIC staff.

Corrective Action

3. Is in-service training conducted regularly for WIC and non-WIC staff providing WIC services?

Date of the last meeting: _ _ _ _ __

COMMENTS

Corrective Action

Looking for: 1. Whether or not staff members are updated regularly.

E.

Fair Hearings/Participant Complaints (Review

District files prior to monitoring Review)

1. Is there documentation for Fair Hearings and resulting action taken on file? Is it available for review at the District and State Office?

Corrective Action

Looking for: 1. Is documentation on file at the state office? 2. Were proper procedures followed?
2. Were they handled/resolved according to program procedures?
lfno, please explain:



Looking for: I. Check documentation for compliance
4

GA WIC PROCEDURES MANUAL PART I

ADMINISTRATIVE SECTION

GUIDELINES

AREAS OF REVIEW

YES NO

ATTACHMENT MO-1
NA* COMMENTS

Corrective Action

F.

Quality Assurance Self Review

I. Does the District conduct internal monitoring? (Review) (Attach a copy of the Review Schedule)
Looking for: I. Copy of Monitoring Tool of all sites reviewed
2. Copy of the review schedule

2. Is there a list of deficiencies identified for
each clinic? Looking for: I. Types of deficiencies found.
2. Corrective action given.
3. Plan in place for correction.

3. Were repeated errors found? Looking for: I. If repeated errors are made, is training being conducted?

Corrective Action

4. If yes, were additional monitoring visits made or training conducted?
Looking for: I. Documentation for training(s) is available from the
clinic.
5. Are the following program indicators included in the local assessment? (District)
Record Review of employees Voucher Registers SMI Reports Caseload Trends Non-Participation Waiting List Service Integration and Patient Flow Outreach and Referral Trimester of Enrollment Patient Flow Analysis
Looking for: I. Record Review (Income, Residency and Identification).
Whether or not all the areas are reviewed in the event the Monitoring Tool is not used.
6. Have any special initiative efforts been implemented as a result of the internal monitoring?

5



GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

GUIDELINES Recommendation

PART I

ADMINISTRATIVE SECTION

AREAS OF REVIEW

YES NO NA* COMMENTS

G.

Outreach

1. Does the District have a plan for developing and conducting outreach activities pertinent to the local service area? Are grassroots organizations included?

Corrective Action



Corrective Action

2. If yes, are outreach activities documented and available for review?
3. lfno, explain how WIC information is disseminated to applicants/participants and local communities.
Looking for: 1. Plan for reaching potential WIC applicants.
4. Has the district or local clinic conducted
outreach activities within the last 12 months?
5. Are all outreach activities documented and available for review? (See Outreach File)
Looking for: I. Documentation of outreach was conducted yearly.

6

GA WIC PROCEDURES MANUAL PART I

ADMINISTRATIVE SECTION

ATTACHMENT M0-1

GUIDELINES Recommendation

AREAS OF REVIEW
6. Have special provisions been made for scheduling the following applicants? Explain:

YES NO NA

COMMENTS

Employed Participants

Clinic

Rural Participants Clinic

Clinic

Migrants

Corrective Action

Looking for: I. Documentation of staff scheduling employed, rural or
migrant applicants at time other than traditional hours if possible.
H. Processing Standards I. Has the District requested an extension processing standard?
If yes, is the written approval of extension on file and available for review?
Lookini:; for: I. If clinics are not meeting processing standards, have
they asked for extension? 2. Written proof of request.

7



GAWICPROCEDURESMANUAL PART II CIVIL RIGHTS

GUIDELINES

AREAS OF REVIEW

ATTACHMENT M0-1

YES NO NA

COMMENTS

Corrective Action

I. Civil Rights Training l. Is Civil Rights training conducted annually for local WIC staff? (District)

When

By Whom

Looking for: I. Whether or not all staff received Civil Rights
training. 2. Ensure that all staff knows what to do in the event
of a complaint.



Corrective Action Corrective Action Corrective Action Corrective Action

2. Is Civil Rights training included in new employee orientation? (Review List of New employees and Documentation of Civil Rights Training District.)
Looking for: I. After training is conducted for staff and new
employees are hired, are they trained?
3. Civil Rights complaints are handled in accordance with established program procedures. (Review Complaint File - Number of Complaints)
Looking for: I. Was the Civil Rights complaint handled according
to procedures?
J. Public Notification/Public Hearings l. Has the District conducted Public Hearings? Review the Public Hearing File concerning the date(s) of the most recent hearings and locations.
Looking for: I. Ensure that public hearings are being conducted. 2. Copy of the hearings are on file.
2. Was a summary of the Hearings sent to the State WIC Office?
Looking for: I. Documentation at the State.
8

.GA WIC PROCEDURES MANUAL

PART II CIVIL RIGHTS

GUIDELINES

AREAS OF REVIEW

YES

Corrective Action

K. Public Notification l. Has the general public been notified of WIC Program information with regards to nondiscrimination policy within the last 12 months? (District)

ATTACHMENT M0-1

NO NA

COMMENTS

If yes, is there documentation of how it was done?

lfno, please explain:
Lookin2 for: I. Ensure that the District has made efforts to promote
WIC participation according to procedure.



9



GA WIC PROCEDURES MANUAL PART III CLINIC REVIEW

GUIDELINES

AREAS OF REVIEW

YES

ATTACHMENT M0-1
NO NA COMMENTS

Corrective Action

A. Caseload Management

I. Does the clinic have a waiting list?

Corrective Action

Looking for: 1. Ensure that clinic does not begin it own waiting list.
2. Are proper procedures followed when maintaining a waiting list?

Recommendation
Recommendation

Looking for: Proper procedures are followed by clinic staff if waiting list is implemented and correct priorities are served.
B. Coordination and Integration
I. Are WIC services coordinated or integrated with other health department services?
Looking for: 1. To ensure that WIC appointments are coordinated
with appointments for other services.
2. How is this coordinated? (Records, Appointments, Clinics, etc.)
Looking for: I. Documentation verifying integration/coordination
of services.



. A WIC PROCEDURES MANUAL PART III CLINIC REVIEW

ATTACHMENT M0-1

GUIDELINES Corrective Action

AREAS OF REVIEW
3. Are initial contact dates documented and available for review?
Clinic

YES NO NA

COMMENTS

Looking for: 1. Is the clinic meeting processing standards?
4. When an applicant misses an appointment who reschedules the appointment?
Clinic

Corrective Action

Looking for: 1. Attempts by the clinic to re-schedule participants
who miss appointments.
5. What is the next available appointment for an applicant requesting WIC benefits? (See appointment book)

Clinic

Women(P)_ _Infant Women(B)_ _Child Woman(PP)_ _

Clinic

Women(P)_ _Infant Women(B)_ _Child Woman(PP)_ _

Clinic

Women(P)_ _lnfant Women(B)_ _Child Woman(PP)_ _

Clinic

Women(P)_ _Infant Women(B)_ _Child Woman(PP)_ _

Clinic

Women(P)_ _ _lnfant Women(B)_ _Child Woman(PP)_ _

Looking for: Is the clinic meeting processing standards?

11



GA WIC PROCEDURES MANUAL

GUIDELINES Corrective Action

PART III CLINIC REVIEW

AREAS OF REVIEW

YES

6. What are the processing standards time frames for: (Ask Staff)?

Time Frames

Clinic(l)

Prenatal

Postpartum

Infants

Children

Migrants

ATTACHMENT M0-1

NO NA

COMMENTS

Clinic(2) Prenatal Postpartum Infants Children Migrants



Clinic(3) Prenatal Postpartum Infants Children Migrants

Clinic(4) Prenatal Postpartum Infants Children Migrants

Clinic(5) Prenatal Postpartum Infants Children Migrants



Looking for:

I.

Ensure that staff members are knowledgeable

about processing time frames.

12

.GA WIC PROCEDURES MANUAL

PART III CLINIC REVIEW

GUIDELINES

AREAS OF REVIEW

YES

Corrective Action

D. Income Assessment

ATTACHMENTM0-1

NO NA

COMMENTS

I. Is income taken before or after the certification process?

Clinic

Corrective Action

Looking for:

I.

Is income assessed as the first step in the

certification process?

2. What is the definition of"family"?

Clinic


Corrective Action

Looking for:

I.

Does staff know how to determine a

family/household?

3. How does clinic staff determine family size when assessing eligibility?

Clinic

Corrective Action

Looking for:

I.

Does clinic staff correctly determine family size

when assessing eligibility?

4. Is the participant required to provide proof of income at certification and recertification?

Clinic



Looking for:

I.

If applicant shows proof of income.

13



GA WIC PROCEDURES MANUAL PART III CLINIC REVIEW

ATTACHMENTM0-1

GUIDELINES Corrective Action

AREAS OF REVIEW 5. Does the clinic staffask the applicant to
report the income for the entire family?
Clinic

YES NO NA

COMMENTS



Corrective Action Corrective Action

Looking for: I. Is total household income accurately assessed in
determining eligibility?
6. How are inclusions and exclusions for income taken into consideration when taking income (i.e. military housing or rations)?
Looking for: I. Is the WIC staff aware of the proper procedures for
determining income eligibility?
7. Does the clinic determine an applicant to be income eligible based on presumptive eligibility requirements? Where is it documented?
Clinic

Looking for: I. Is the WIC staff aware of the proper procedures for
determining income eligibility?

14

.GA WIC PROCEDURES MANUAL PART III CLINIC REVIEW

ATTACHMENT M0-1

GUIDELINES

AREAS OF REVIEW
7. Is the a "No Charge For WIC Services" sign located in each clinic?
Clinic

YES NO NA

COMMENTS

Corrective Action

Corrective Action

Looking for: I. To ensure that WIC applicants/participants are not
being charged for WIC Services. 8. Are there certain situations when an applicant's income must be verified? When?
Clinic
Looking for: I. Is the clinic aware of the circumstances when income
must be verified? E. Certification Process
I. Are there instances when you must request/require applicant/participant's identification?
Clinic



Looking for:

I.

Is clinic staff aware of WIC protocol for

participant I.D.?

If yes, please explain.

Clinic

15



GA WIC PROCEDURES MANUAL PART III CLINIC REVIEW

GUIDELINES

AREAS OF REVIEW

YES

2. Does the staff require documentation of residency?

Clinic

ATTACHMENT M0-1

NO NA

COMMENTS

Corrective Action

Lookin& for:

l.

Is staff requesting proof of residency?

3. What forms of participant identification do you accept?
Clinic



Corrective Action

Lookin& for: l. Is the clinic staff aware of the acceptable forms of
I.D.?
4. Is the local staff knowledgeable of proper procedures for notifying applicants and participants of their eligibility or ineligibility? (Staff interview and review Ineligible File) (Use Attachment I)
Clinic

Looking for: l. Is the clinic staff following proper procedures when
notifying applicants/participants of WIC eligibility or ineligibility?

16

GA WIC PROCEDURES MANUAL



PART III CLINIC REVIEW

ATTACHMENT M0-1

GUIDELINES Corrective Action

AREAS OF REVIEW 5. Are participants notified that their WIC
certification is about to expire prior to expiration of their certification period?
Clinic

YES NO NA

COMMENTS

Looking for: I. To ensure that participants are given appropriate
notification prior to the expiration of certification

Corrective Action

Corrective Action

6. How are they notified and is the notification documented? Clinic
Looking for: I. Is the clinic staff documenting and/or notifying the
participants? 7. Are persons who are terminated during a valid certification period notified prior to termination? Clinic

Looking for: I. Are proper procedures followed prior to termination
during a valid certification?

17



GA WIC PROCEDURES MANUAL PART III CLINIC REVIEW

ATTACHMENT M0-1



GUIDELINES Corrective Action
Corrective Action

AREAS OF REVIEW 8. Certification Periods

YES NO NA

Is the staff knowledgeable of certification periods? (Staff interviews)

Time Frames

Time Periods

Clinic

Women(P)_ _Infant Women(BF)_ _Child Woman(PP)_ _ _ _

Clinic Clinic

Women(P)_ _ Infant Women(BF)_ _Child
Woman(PP)__ - - -
Women(P)_ _Infant Women(BF)_ _Child Woman(PP)_ _

Clinic

Women(P)_ _Infant Women(BF)_ _Child Woman(PP)_ _

Clinic

Women(P)_ _Infant Women(BF)_ _Child Woman(PP)_ _

Looking for: 1. To ensure that WIC staff members are aware of
certification periods for each type of WIC participant so that vouchers are issued only during a valid certification.
9. Does the clinic provide WIC benefits only during a valid certification period?

(Select a sample of records with the message "RECERT OVERDUE MMDDYY" to whom vouchers were issued to review for compliance, use Attachment 2.)

Looking for: I. Ensure that proper procedures are being followed
when re-certifying participants. 2. Ensure that participants are not receiving benefits
during an invalid certification period.

COMMENTS

18

.GA WIC PROCEDURES MANUAL

PART III CLINIC REVIEW

GUIDELINES

AREAS OF REVIEW

YES

ATTACHMENTM0-1

NO NA

COMMENTS

Corrective Action

10. Does the clinic allow a proxy to bring a child in for re-certification or to pick up vouchers? Under what circumstances?

Clinic

Corrective Action

Looking for: 1. Knowledge of the staff regarding proxy
responsibilities.
11. Are voe cards issued and accepted by the
local clinic to verify WIC certification?
Clinic


Corrective Action

Looking for: 1. Staff knowledge of proper usage of VOC Cards for
transfer into the WIC clinic.
12. Are the VOC card records accurate and monitored according to program policy? Complete VOC Monitoring Work Sheet Attachments 4 A and B.
Clinic

Looking for: 1. Proper security and documentation ofVOC card
supply .

19



GA WIC PROCEDURES MANUAL

PART III CLINIC REVIEW

GUIDELINES

AREAS OF REVIEW

YES

Corrective Action

13. Are VOC cards stored in a locked place separate from the inventory log?

Clinic

ATTACHMENT M0-1

NO NA

COMMENTS

.

Corrective Action

Lookin1:; for: I. Ensure that proper security of VOC cards is in place.
14. Is the inventory of VOC cards conducted monthly according to program procedures? (Review physical inventory of VOC Card Log)
Clinic



Corrective Action

Looking for: I. Maintenance and accurate issuance ofVOC cards.
Procedure conducted monthly for security purposes.
15. Are two signatures of Local Agency Staff on the VOC Card Inventory monthly? Clinic

Looking for: I. Verification that a physical inventory is being
conducted .

20

GA WIC PROCEDURES MANUAL



PART III CLINIC REVIEW

ATTACHMENT M0-1

GUIDELINES

AREAS OF REVIEW

Corrective Action

F.

Special Population (Migrant)

YES NO NA

COMMENTS

I. Does the local agency caseload include migrants?

2. Is the staff knowledgeable of procedures for handling migrants?

Clinic

Corrective Action

Looking for: I. Clinics that serve migrants. 2. Knowledge of the staff on proper procedures for
ensuring accessibility to WIC services for the migrant population.
G . Voter Registration I. Is each participant offered an opportunity to complete a Voter Registration Application?
Clinic

Corrective Action


Looking for: I. The National Voter Registration Act of 1993
mandates the WIC Program's obligation to offer voter registration opportunities to anyone entering a clinic for the application or re-certification of WIC benefits.
H. Smoking
I. Are No Smoking signs posted?
Clinic
Looking for: I. Public Law 103-III prohibits the allocation of
Administrative Funds to any clinic providing WIC Services if that clinic allows smoking within the space used to perform program functions .
21



GA WIC PROCEDURES MANUAL . PART III CLINIC REVIEW

GUIDELINES

AREAS OF REVIEW

YES

lfno, why not?

ATTACHMENT M0-1

NO NA

COMMENTS

Corrective Action

I. Policy Memos/Procedures Manuals I. Is there a Procedures Manual located in the clinic?
Clinic



Corrective Action

Looking for: 1. To ensure that manual is in place in the event of
questions. 2. To ensure that services are delivered according to the
manual.
2. Are all Policy Memos on file?
Clinic

Corrective Action

Looking for: 1. Policy memos on file for the current federal fiscal
year to assure that the staff is being updated on current policies in effect.
3. Are WIC facilities accessible to physical impaired persons? (Observation)
Clinic



Looking for: I. The Georgia WIC program is required to make
program services accessible to individuals covered by the American Disabilities Act.
22

. A WIC PROCEDURES MANUAL PART III CLINIC REVIEW

ATTACHMENT M0-1

GUIDELINES Corrective Action

AREAS OF REVIEW
4. Does the clinic serve non-English speaking applicants/participants?
Clinic

YES NO NA

COMMENTS

Corrective Action

Looking for: I. If the clinic serves non-English speaking participants.
5. Are interpreters or bilingual staff available for the non-English speaking clients, if applicable?
Clinic

Looking for: I. Local agencies are responsible for ensuring that
multilingual staff, volunteers or other translators are available.
If no, explain how WIC information is communicated to them.
Clinic

23



GA WIC PROCEDURES MANUAL PART III CLINIC REVIEW

GUIDELINES Corrective Action

AREAS OF REVIEW

YES

6. ls the local agency in compliance with
program policy regarding racial or ethnical coding and filing of participants records? (Review Clinic Medical Records)

Clinic

ATTACHMENT M0-1
NO NA COMMENTS



Corrective Action

Looking for: 1. Ensure that records are not coded or filed by
racial/ethnic origin. The 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 handicap.
J. Complaint Handling I. Is that staff knowledgeable of proper procedures for handling Civil Rights complaints?
Clinic

Corrective Action

Looking for: 1. To ensure that the staff is knowledgeable of the
process and time frame for filing C.ivil Rights Complaints.
2. How is the race of a participant determined?
Clinic



Looking for: I. Ensure that the staff is knowledgeable of participant
24

GAWICPROCEDURESMANUAL



PART III CLINIC REVIEW

ATTACHMENTM0-1

GUIDELINES Corrective Action

AREAS OF REVIEW ISSUANCE MATERIALS
1. Are vouchers mailed? Clinic

YES NO NA

COMMENTS


Corrective Action

Lookina:; for: 1. Is the staff is knowledgeable of acceptable reasons
for mailing or delivery of vouchers?
. 2. If yes, what procedures are used to mail vouchers.

Looking for: 1. Is the staff knowledgeable of acceptable reasons for
mailing or delivery of vouchers?
3. Why are vouchers mailed?

Looking for: l. Is the staff knowledgeable of acceptable reasons for
mailing or delivery of vouchers?
4. Are the following items stored in a secure location?

I.

Program Stamp

2.

VOC Cards

Clinic



Looking for: I. Security of Program Stamp and /VOC Cards. To
ensure that both are out of the reach ofnon-WIC persons .
25



GA WIC PROCEDURES MANUAL

PART III CLINIC REVIEW

GUIDELINES

AREAS OF REVIEW

YES

Corrective Action

V. RECORD REVIEW

ATTACHMENT M0-1

NO NA

COMMENTS

(See Attachment 5) Copy additional sheets

Looking for: I. Monitoring clinic records to make certain WIC
guidelines are being followed and certification is being processed properly.

Corrective Action

Corrective Action



Corrective Action

VI. CLINIC OBSERVATION
(See Attachment 6)
Looking for: I. Monitoring procedures for participant certification. VII. EQUIPMENT INVENTORY
(See Attachment 7)
Looking for: I. Checking equipment purchased with WIC
Administrative funds. VIII.PATIENT FLOW ANALYSIS OF LARGEST
CLINIC
Looking for: I. Bottlenecks. 2. Long waiting period. 3. Need for additional staff 4. Need for interpreters.

26



GA WIC PROCEDURES MANUAL

ATTACHMENT M0-1

ATTACHMENTS FOR ADMINISTRATIVE REVIEW

Attachment l Attachment 2 Attachment 3 Attachment 4A Attachment 48 Attachment 4C Attachment 5 Attachment 6 Attachment 7 Attachment 8A -
Attachment 88 Attachment 8C Attachment 8D Attachment 8E Attachment 9A Attachment 98 Attachment 9C Attachment 9D -
Attachment 9E Attachment 9F

Ineligible Certification Work Sheet

Recert Overdue

Transfer of Certification Work Sheet

District Issued VOC Cards

Clinic Issued VOC Cards

VOC Card Security Report

Record Review

Clinic Observation

Equipment Inventory

Option l Form I (Patient Flow Analysis Sign In Form

Procedures)



Option I Form II Patient Flow Analysis Sign-In

Option I Form Ill Procedures for Completion

Option I Form IV Patient Flow Analysis Form

Option I Form V Question and Answer

Option II Form I (Patient Flow Analysis Sign In Form)

Option II Form II (Patient Register)

Option II Form III (Personnel ID Code)

Option II Form IV (Questions to Answer from the

Modified PFA)

Option II Form V (Patient Category)

Option II Form VI (Reason For Visit Codes)

27

GAWICPROCEDURESMANUAL

ATTACHMENT 1



INELIGIBLE CERTIFICATION WORK SHEET

Review three (3) records in each clinic of individuals found ineligible at the time of certification a.nd/or of individuals who were terminated from the Program within the last year. Note: This information may be retrievedfrom your ineligiblefile.
District_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Clinic

Name

Reason for Ineligibility or Termination

Was Notice of Fair Hearing
Given?

Signature & Date of Person Determining Eligibility Complete?

28

GA WIC PROCEDURES MANUAL

ATTACHMENT 2

RECERT OVERDUE
Select a random sample of at least three (3) records for which the following message "RECERT OVDUE MMDDYY' appears and to whom vouchers were issued. It is important that six-week postpartum women be in the sample. NOTE: This information should be taken offthe current voucher register.

District _ _ _ _ _ _ _ _ _ _ __

Clinic#_ _ _ _ _ __

Clinic Name

Participant Name

Month of
Report

WIC Delivery Issue Pick Up

Status

Date

Date

Date

Recert Due Date

Were Vouchers Validly Issued?


29

GA WIC PROCEDURES MANUAL



TRANSFER OF CERTIFICATION WORK SHEET

What is the District policy for accepting transfers?

--
Clinic Name:

VOCCARD

CALL TRANSFERRING CLINIC

WRITE FOR RELEASE OF MEDICAL INFORMATION

ASSESS AS AN APPLICANT

ASSESS AS AN APPLICANT & WRITE FOR TRANSFERRING INFORMATION

GIVE ASSESSMENT APPOINTMENT

GAI.D.CARD

-

CERTIFICATION RECORD

OTHER:

ATTACHMENT 3
I
I

30



GA WIC PROCEDURES MANUAL
DISTRICT ISSUED voe CARDS

ATTACHMENT 4-A

VOC Card Numbers
(Beginning#) Issue Date:
(Beginning #) Issue Date:

(Ending#) (Ending#)

(Beginning #) Issue Date:

(Ending#)

District/Clinic Name

VOC Card Numbers
(Beginning #) Issue Date:
(Beginning #) Issue Date:

(Ending#) (Ending#)

(Beginning #) Issue Date:

(Ending#)

# Of Cards Issued

Date Cards Issued



Clinic Name

Yes

No

# of voe Cards on Hand



l. Do these # 's match at District and Clinic? Clinic

yes { J
yes { yes ( yes { yes { yes {

no { J
no { no { no { no { no {

31

2.

Is Inventory accurate?

Are there two (2) signalllres?

Clinic

yes { J yes { J
yes { yes { yes { yes { yes {

no { }
no { J
no { no { no { no { no {

GA WIC PROCEDURES MANUAL

ATTACHMENT 4-B



voe Card Numbers
(Beginning #) Issue Date:
(Beginning #) Issue Date:

(Ending#) (Ending#)

CLINIC ISSUED voe CARDS

voe Card Numbers

(Beginning #) Issue Date:

(Ending#)

(Beginning #) Issue Date:

(Ending#)

(Beginning #) Issue Date:

(Ending#)

District/Clinic Name

(Beginning #) Issue Date: # Of Cards Issued

(Ending#) Date Cards Issued



Clinic Name

Yes

No

# of VOC Cards on Hand

/

l. Do these #'s match at District and Clinic? Clinic

yes ( J
yes I
yes { yes { yes {
yes I

no ( J
no I
no { no { no { no {

2.

ls Inventory accurate?

Are there two (2) signatures?

Clinic

yes ( J yes { J
yes { yes { yes {
yes I
yes (

no ( J no ( J
no { no { no {
no I no I

32

GA WIC PROCEDURES MANUAL

ATTACHMENT 4-C

voe CARD SECURITY REPORT

. u l l five (5) records in each clinic from the VOC Card Log,

Clinic Name

Participant's Name

Date Issued

Signature or Parent/Guardian/
Caretaker
- Yes No_
Yes_ No_ Yes_ No_
Yes_ No_
- Yes_ No
- Yes_ No
Yes_ No_ Yes_ No_ Yes_ No_
Yes- No-
Yes_ No_
- Yes No_
Yes_ No_ Yes_ No_ Yes_ No_ Yes_ No_
- Yes_ No
Yes_ No_ Yes_ No_ Yes_ No_ Yes_ No_
Yes_ No_
Yes_ No_
- Yes_ No - Yes_ No
Yes_ No_ Yes_ No_

Migrant
Yes_ No_
- Yes_ No - Yes_ No
Yes_ No_
Yes- No-
Yes_ No_
Yes_ No_
- Yes_ No
- Yes_ No - Yes No_ - Yes No_ - Yes_ No
Yes_ No_ Yes_ No_
- Yes_ No
- - Yes No
Yes_ No_ Yes_ No_
Yes_ No_ Yes_ No_
- Yes_ No - Yes_ No
Yes_ No_
- Yes_ No
Yes_ No_ \'es_ No_
- Yes_ No

Signatures Match
Yes_ No_ Yes_ No_
- Yes_ No
Yes_ No_ Yes_ No_ Yes_ No_ Yes_ No_ Yes_ No_ Yes_ No_ Yes_ No_
Yes- No-
Yes_ No_ Yes_ No_ Yes_ No_ Yes_ No_ Yes_ No_ Yes_ No_ Yes_ No_
- Yes No_ - Yes_ No
Yes_ No_
- Yes No_
Yes_ No_
- Yes_ No - Yes No_ - Yes_ No
Yes_ No_

Note: When reviewing these records, was the VOC card section of the certifications form completed? Clinic

33



GA WIC PROCEDURES MANUAL

ATTACHMENT 5

RECORD REVIEW
Review the following criteria in the records randomly selected by the Office of Nutrition CLINIC_ _ _ _ _ _ _ __

CRITERIA TO REVIEW: Name, Address (Demographics)
Initial Contact Date
Residency Proof
Proof of Identification
Categorically Eligible?
Signatureffitle of Person Collecting Income/Residence Data Participant's Signature/Date
Medicaid Eligibility Documented Medicaid Number
Food Stamps YIN?
Number in Family?
Income Information Documented Income Eligible?
Error Correction
How many Records had the No Proof Form? Is there a pattern for accepting zero income? Was the VOC card section completed on transfers?
Note: Make copies of this form for Record Review.
Must Have 100% Compliance.

34

GA WIC PROCEDURES MANUAL



CLINIC OBSERVATION

ENVIRONMENT

1. Handicap Ramp

Clinic

Yes

--

--

--

--

2. "And Justice For All Poster"

No Clinic

Yes

No

--

-- --

--

-- --

--

-- --

--

-- --

ATTACHMENT-6

3. Was the applicant receiving WIC benefits present?

Clinic

Yes

No

--- --- --- --- -



4. Were clinic participants waiting s. Does the clinic offer privacy for

for long periods of time?

health screening and counseling?

Clinic

Yes

No Clinic

Yes

No

-- --
-- --- --- --

-- --
-- --
-- --- --

6. Does the reviewer observe any practices that could be considered discriminating?

Clinic

Yes

No

--- --- --- --- -

7. Medicaid/Food Stamps verified?

Clinic

Yes

No

-- --
-- --- --
-- --

8. Was a Patient Flow Analysis performed in the largest clinic?

Clinic

Yes

No

-- --- --
-- --
-- --

CERTIFICATION (INCOME)

I. Is income determined prior to nutritional risk assessment?

Clinic

Yes

No

--- --- --- --- -

35

GA WIC PROCEDURS MANUAL

ATTACHMENT 6 (con't)



a. Was the correct form used for income?

Clinic

Yes

No

-- --- --
-- --
-- --- --

b. Was the Income calculation
form used accurately?

Clinic

Yes

No

--- ---- ---- ---- ---- --

c. Were the right questions asked for income?

Clinic

Yes

No

--- ---- ---- ---- ---- --



d. Required to show proof of income at certification/recertification.

Clinic

Yes

No

-- --- --- --- --

g. Were participants informed of their Rights and Obligations

Clinic

Yes

No

-- --- --- --
-- --

e. Required to show proof of residence at certification/recertification.

Clinic

Yes

No

--- ---- ---- ---- --

f. What proof of I.D. was asked for at certification and pickup?

Clinic

Yes

No

--- ---- ---- ---- --

h. Was the No Proof form used too i. Was proper use of I.D. Card

much?

explained?

Clinic

Yes

No Clinic

Yes

No

--- ---- ---- ---- --

--- ---- ---- ---- --

36

GA WIC PROCEDURES MANUAL

ATTACHMENT 7

EQUIPMENT INVENTORY



Was the equipment inventory sent in by October 1 of the new fiscal year?

Can all the equipment be located?

Yes

No - - -

Clinic (Write in name)


Equipment Number

Located Yes_ _ No_ _

Yes- Yes- Yes- -
Yes_ _

No No No No_ _

Yes- Yes- -
Yes_ _

No_ _ No_ _ No_ _

Yes- -
Yes
Yes- -
Yes_ _
Yes_ _

No No_ _ No_ _ No No_ _

Yes- - No

Yes

No

Yes- - No
Yes- - No

Comment

37



GA WIC PROCEDURES

ATTACHMENT 8-A

FORMI

OPTION I

Patient Flow Analysis Sign In Form Procedures

The Patient Flow Analysis Sign In Form is designed to have all WIC applicants/participants sign in at the time of arrival. Each applicant/participant must:

1. Sign In 2. Document the arrival time




38



GA WIC PROCEDURES

ATTACHMENT 8-B

FORMII

PATIENT FLOW ANALYSIS SIGN IN

OPTION I

Clinic - - - - - - - - - - Date - - - - - Start Time

Patient Number 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0

Name

Arrival Time

(See instructions for PFA in the Certification section of the Procedures Manual)

39



GA WIC PROCEDURES

ATTACHMENT 8-C

FORM III

PROCEDURES FOR COMPLETION

OPTION 1

Clinic Flow Analysis Form

The Clinic Flow Analysis form documents the following:

Room # ___ (If applicable) - room # is completed in the event a clinic is divided by alphabets and each staff person is keeping her/his own Sign-In Form (FORM I).

2.

Clinic - List the name of the clinic that the analysis is being conducted.

3.

Patient # - Documents the number that is assigned on the Patient Flow Analysis

Sign-In Form.

4.

Name - Documents the name of the applicant/participant.

5.

Date Seen - Documents the actual date the Patient Flow Analysis is taking

place.

6.

Reason For Visit - Document the reason the applicant/participant made a visit

to the WIC clinic.

Reason for Visit Code Definitions Initial Certification Recertification (Subsequent) Incomplete Certification (i.e. - Client left without completing certification process) Reinstate Transfer Education (with or without vouchers) Special Formula or Formula Change Vouchers only (no nutritional education)

7.

WICType- P_ N_B_I __ C_

Place a check mark by the category which identify whether the applicant/participant is a pregnant, post-partum or breastfeeding women, infant or child.

8 .

Appointment Time - Documents appointment time of the applicant/participant.

40



GA WIC PROCEDURES

ATTACHMENT 8-C {con't)

9 .

Time Started - Documents the actual time that the clinic staff begins to work with WIC

applicant/participant.

10.

Time finished - Document the actual time that staff finished working with the

applicant/participant.

11.

Staff initials - List the initials of the staff that serve the WIC

applicant/participant.

Note: 1. A record of the staff initial must be placed with the actual Patient Flow Analysis documentation for audit purpose.

2. Each applicant/participant must have his/her 'own Patient Flow Analysis Form. Each family member must have his/her own form

12.

Patient Arrival - Actual time that participant signed in the clinic.

13.

Time Patient Left - Documents the applicant completed all WIC services and is

leaving the clinic.

14.

Total Time in Clinic - Documents the amount of time from arrival to departure

for applicant/participant to receive WIC services.

15.

FPC/Formula Type (optional) - Document the FPC or formula type if

applicable for District Use.

16.

Special Service Provided/Comments - Documents any special services or

circumstances which may cause you to take additional time with the

applicant/participant .

41



GA WIC PROCEDURES

ATTACHMENT 8-D

FORM IV Patient Flow Analysis Form

OPTION I

Room# _ _ _ _ _ _ _ (If Applicable)
Clinic: - - - - - - - - - - - - - - - - - Patient#: ----------------Name: - - - - - - - - - - - - - - - - - Date Sent: - - - - - - - - - - - - - - - - Reason for Visit: - - - - - - - - - - - - - - -
WIC Type: _ _ P_ _ N _ _B _ _ I _ _ _ C
Appointment Time: _ _ _ _ _ _ _ _ _ _ _ _ __

Patient Arrived:

Time

Time Started

Time Finished

Staff Initials

Initiate Worker:

Clerk:

Lab Worker:

Nurse:

Nutritionist:

Clerk:

Time Patient Left:

Total Time in Clinic:

FPC/Formula Type: (Optional)

Special Services Provided/Comments:- - - - - - - - - - - - - - - - - - - - -



Note: 1. 2.

A record ofstaffinitials must be kept on file for audit purposes. Each applicant/participant must have her/his own Patient Flow Analysis Form .

42



GA WIC PROCEDURES

ATTACHMENT8-E

FORMV

OPTION I

Questions to Answers for Option I

1.

What was the time during certification appointments for clients from sign-in to

first face-to-face services provider contact?

2.

What was the range of time for certification clients from sign-in to exit?.

For clients scheduled for issuance?

3.

Were there any clinic bottlenecks?

4.

Are clients seen by order of appointment?

5.

Are clients scheduled at a rate appropriate for services received and staff

availability?

6.

Are there down times for any staff?

7.

Are the appropriate staff present for first am appointments?

8 .

How many appointments were there? Number of no-shows?


43



GA WIC PROCEDURES

ATTACHMENT 9-A

FORMI

OPTION II

PATIENT FLOW ANALYSIS SIGN IN

Clinic - - - - - - Date - - - - - Start Time - - - - -

Patient Number 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0

Name

Arrival Time

Appt. Time

(See instructions for PFA in the Certification section ofthe Procedures Manual)

44



GA WIC PROCEDURES FORM II
Patient Number (from sign-in sheet)

PATIENT REGISTER

ATTACHMENT 9-B OPTION II

Reason for Visit

Patient Category

Time of Arrival (from sign-in sheet)

Time of Clinic Appointment

Patient Service Time

Contact# 1.

Personnel ID Code

2.

3.

4.

5.

6.

7.

8.

9. 10.

11.

12.

Start Time End Time

Service Provided

45

GA WIC PROCEDURES

ATTACHMENT 9-C



FORMIII

CODES

A

B

C

D

E

F

G

H

I

J



K L

M

N

0 p

PERSONNEL ID CODES NAME

OPTION II OFFICIAL FUNCTION

Q R
s
T
u

V
w


46



GA WIC PROCEDURES

ATTACHMENT 9-D

FORM IV

OPTION II

Questions to Answer from the Modified PFA

1. What was the time during certification appointments for clients from sign-in to first face to face service provider contact?

2. What was the range of time for certification clients from sign-in to exit?

For clients scheduled for issuance?

3. Were there any clinic bottlenecks?
4. Are clients seen by order of appointment?
5. Are clients scheduled at a rate appropriate for services received and staff availability?

6. Are there down times for any staff? 7. Are the appropriate staff present for first am appointments? 8. How many appointments were there? # of no-shows?

47



GA WIC PROCEDURES

ATTACHMENT 9-E

FORMV

OPTION II

PATIENT CATEGORY

A

Pregnant Woman

B

Postpartum Woman

C

Breastfeeding Woman

D Infant

E

Child

F

Family (use only when a combination of family members receive WIC services)

G

Other (specify)



48



GA WIC PROCEDURES

FORM VI

REASON FOR VISIT CODES

ATTACHMENT 9-F
OPTION II

Code A. B. C. D. E. F. G. H. I.

Definition Initial Certification Recertification (Subsequent) Incomplete Certification (i.e.~ Client left without completing certification process) Reinstate Transfer Education (with or without vouchers) Special Formula or Formula Change Vouchers only (no nutritional education) Other (please specify)

49



GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

PART IV FOOD INSTRUMENT ACCOUNTABILITY (LOCAL AGENCY ONLY)

Guidelines Corrective Action Corrective Action
Corrective Action Corrective Action Corrective Action Corrective Action

Areas of Review

Yes No

A. Packing List

Is a copy of the voucher packing list received by the District within five days of clinic verification?

Looking for: I. To make sure clinics are sending the packing slips to the
District Office.
B. Voucher Issuance

I. Does the Local Agency have a policy for issuing vouchers to eligible WIC employees and their family members?

Looking for: I. To see if the District has a policy that is different from
the procedures manual.
2. Are any local agency staff receiving WIC benefits
at the clinic site where they work?

Looking for: I. Is the District aware of any staff receiving benefits at the
site where they are located?

3. Are any family members of WIC staff receiving benefits at the local clinic where the staff is employed?
Looking for: I. To be aware of any family members of staff receiving
benefits where the staff is employed.
4. Are staff members at the clinic allowed to issue
vouchers or process certification for family members?
Looking for: I. To make sure the District is aware of the policy on
family certification and voucher issuance.
C. Participant Abuse
1. Has the District received any reports of participant's abuse since the last Program Review?
Looking for: I. To review any reports of participant abuse and the
nature of the abuse.

NA Comments



50

GAWICPROCEDURESMANUAL

ATTACHMENT MO-1

PART IV FOOD INSTRUMENT ACCOiJNTABiLITY (LOCAL AGENCY ONLY)

uidelines Corrective Action Corrective Action

Areas of Review

Yes No

2. Was the report investigated?

Looking for: I. Report was properly handled.

3. Was the report sent to the State WIC Office?

Looking for: I. Make sure the State WIC Office was made aware of
report, and a copy of all findings in the investigation report was forwarded to the SWO.

D. Dual Participation

1. Have there been any cases of intentional dual participation since the last monitoring review?

Looking for: I. Any cases on the dual participation report that were
actually dual participants.

2. Was the report sent to the State WIC Office?

Looking for: I. To make sure report was investigated and findings sent
to State WIC Office.
E. Missing Vouchers

1. Has the District Office received notice of any missing vouchers from any WIC clinic since the last Program Review?

Looking for: I. To make sure the clinics report any missing voucher to
the District office.

2. Was the report investigated?

Looking for: I. To make sure the proper procedures were followed
when vouchers are missing.
3. Was the report sent to the State WIC Office?

Looking for: I. To make sure the District is notifying the State WIC
Office of any missing vouchers.

NA Comments

51



GA WIC PROCEDURES MANUAL

ATTACHMENT M0-1

PART IV FOOD INSTRUMENT ACCOUNTABILITY (LOCAL AGENCY ONLY)

Guidelines

Areas of Review

Yes No

III. Food Instrument Accountability (Clinical Review)

NA Comments

Corrective Action

A. Manual Voucher Inventory Log

I. Is the Log being completed on all vouchers?

Clinic Clinic Clinic Clinic Clinic

Corrective Action

Looking for: 1. Making sure all vouchers are recorded on the Manual
Inventory Log (both Standard preprinted and special blank manuals.
2. Is the Manual Voucher Log complete and
accurate?



Clinic Clinic Clinic Clinic Clinic
Looking for I. All columns of the log must be completed accurately,
legibly, and initialed.

3. Are clerk's initials on the Inventory Log?

Looking for:

I. Clerk's initials on the Inventory Log.

,

Corrective Action

8. Perpetual Inventory

'
I. Is the perpetual inventory done on all manual vouchers weekly?

Clinic Clinic Clinic Clinic Clinic

Looking for 1. Making sure that the inventory is kept on all vouchers
on a weekly basis.

52

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

PART IV FOOD INSTRUMENT ACCOUNTABILITY (LOCAL AGENCY ONLY)

uidelines Corrective Action
Corrective Action
orrective Action

Areas of Review

Yes No

2. Is the perpetual inventory complete and accurate?

Clinic Clinic Clinic Clinic Clinic

Looking for I. Making sure all columns of the log are completed
accurately.

C. Manual Voucher Physical Inventory

I. Are any vouchers missing?

Clinic Clinic Clinic Clinic Clinic

Looking for I. A complete an actual physical inventory to ensure that
all vouchers are accounted for.

2. Does physical inventory match the inventory log?

Clinic Clinic Clinic Clinic Clinic

NA Comments

Corrective Action

Looking for I. Making sure that the actual physical inventory matches
the inventory log.
3. Is a physical inventory conducted monthly?
Clinic Clinic Clinic Clinic Clinic
Looking for I. Documentation on the inventory log that a physical
count of all vouchers was completed each month.

53



GA WIC PROCEDURES MANUAL

ATTACHMENT M0-1

PART IV FOOD INSTRUMENT ACCOUNTABILITY (LOCAL AGENCY ONLY)

Guidelines Corrective Action
Corrective Action Corrective Action

Areas of Review

Yes No NA Comments

4. Is a physical inventory done on all manual vouchers?

Clinic Clinic Clinic Clinic Clinic

Looking for I. Making sure physical inventory is conducted on
standard preprinted manuals and special computer vouchers.

5. Do all voucher copies contain the participants signature?

Looking for: I. To make sure all vouchers have signatures.

D. Manual Voucher Copies

I. Are vouchers filed by serial number order?

Clinic Clinic Clinic Clinic Clinic

Looking for I. Making sure that all voucher copies are stored neatly
and in serial number order.

2. Are any vouchers missing or misfiled?

Clinic Clinic Clinic Clinic Clinic

Looking for I. Making sure all vouchers are accounted for and are kept
in order.

54

GA WIC PROCEDURES MANUAL

ATTACHMENT M0-1

PART IV FOOD INSTRUMENT ACCOUNTABILITY (LOCAL AGENCY ONLY)

Guidelines Corrective Action
Corrective Action
Corrective Action

Areas of Review 3. Are vouchers kept in a binder or folder?

Yes No

Clinic Clinic Clinic Clinic Clinic

Looking for I. Voucher copies must be stored in binding materials such
as vinyl line binders, post binders, or expanding file folders.
4. Have any vouchers been altered with write over or scratch outs?

Clinic Clinic Clinic Clinic Clinic

Looking for I. Vouchers may not be corrected or altered in any way
unless prior authorization is received from the State WIC Office.
E. Reconciled Packing List

I. Is the Packing List verified, signed, and dated?

Clinic Clinic Clinic Clinic Clinic

Looking for I. The packing list must be signed and dated to verify
receipt.

NA Comments

Corrective Action

2. Are vouchers accurately recorded on the Manual Inventory Log?

Clinic

Clinic

Clinic

Clinic

'

Clinic

Looking for I. When manual vouchers are received, the serial numbers
must be recorded accurately on the Manual Voucher Inventory Log.

55



GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

PART IV FOOD .INSTRUMENT ACCOUNTABiLITY (LOCAL AGENCY ONLY)

Guidelines Corrective Action
Corrective Action
Corrective Action Corrective Action

Areas of Review

Yes No

3. Are copies of packing list sent to the District Office?

Clinic Clinic Clinic Clinic Clinic

Looking for 1. A copy of the signed /dated packing list must be mailed
to the district office within five days of receipt of the vouchers.
F. Voucher Register Documentation

I. Are there any blank lines on the Voucher Register?

Clinic Clinic Clinic Clinic Clinic

Looking for 1. All lines on the register are completed to ensure the
reconciliation of the vouchers.

2. Are the clerk's initials missing?

Clinic Clinic Clinic Clinic Clinic

Looking for I. The staff initials who issued or voided the vouchers.

3. Are any dates missing?

Clinic Clinic Clinic Clinic Clinic

Looking for 1. The actual date the participant picked up the vouchers.

NA Comments

56

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

PART IV FOOD INSTRUMENT ACCOUNTABILITY (LOCAL AGENCY ONLY)

uidelines Corrective Action Corrective Action Corrective Action Corrective Action


Areas of Review

Yes No

4. Are any participant's signatures missing?

Clinic Clinic Clinic Clinic Clinic

Looking for I. The participant or proxy's signature.

5. Does the Voucher Register contain required closeout signatures and dates?

Clinic Clinic Clinic Clinic Clinic

Looking for: I. Two signatures are required to closeout the voucher
register.

6. Does the voucher register contain more than one percent "fail to sign" for the entire register?

Clinic Clinic Clinic Clinic Clinic

Looking for: I. If more than.one percent "fail to sign" the voucher
register, a corrective action will be issued.

G. Voucher Security

I. During office hours, are vouchers securely stored or in the possession of authorized staff?

Clinic Clinic Clinic Clinic Clinic

Looking for: I. All vouchers must be properly secured as checks or cash
in order to help prevent voucher theft, and deter program fraud .

NA Comments

57



GA WIC PROCEDURES MANUAL

ATTACHMENT M0-1

PART IV FOOD INSTRUMENT ACCOUNTABILITY (LOCAL AGENCY ONLY)

Guidelines Corrective Action Corrective Action
Corrective Action
Corrective Action

Areas of Review

Yes No

2. Are vouchers properly secured overnight?

Clinic Clinic Clinic Clinic Clinic

Looking for 1. To make sure the districts are following proper voucher
storage procedures when the clinic is closed.

3. Are vouchers stored separately from the voucher register?

Clinic Clinic Clinic Clinic Clinic

Looking for: 1. Voucher registers must be stored separately from the
vouchers in a locked location.

4. Are vouchers securely stored separately from ID cards?

Clinic Clinic Clinic Clinic Clinic

Looking for I. WIC program stamps must be stored in a location
separately from WIC vouchers, ID cards, and VOC cards.

5. Are WIC ID cards stored separate from the Program Stamp?

Clinic Clinic Clinic Clinic Clinic

Looking for: I. WIC ID cards must be stored in a separate location from
the vouchers, registers, and the program stamp?

NA Comments

58

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

PART IV FOOD INSTRUMENT ACCOUNTABiLITY (LOCAL AGENCY ONLY)

Guidelines Corrective Actions
Corrective Action Corrective Action
Corrective Action

Areas of Review

Yes No

6. What security measures are taken when an employee resigns or is no longer authorized to issue voucher(s)?

Clinic Clinic Clinic Clinic Clinic

Looking for: I. Are measures in place when a staff person is no longer
authorized to issue vouchers?

7. Is the key properly secured with only authorized personnel?

Clinic Clinic Clinic Clinic Clinic

Looking for I. Make sure the key to the locked storage space is secure
and in the possession of authorized personnel.
8. What security measures are currently in place to prevent voucher theft by participants?

Clinic Clinic Clinic Clinic Clinic

Looking for: I. Make sure vouchers are not placed on top of the desk,
vouchers are not easily accessible to patients, and one of the proper issuance procedures are being used.
H. Voucher Issuance

1. Does the Voucher Register show documentation of prorating vouchers?

Clinic Clinic Clinic Clinic Clinic

Looking for I. Documentation on the register that vouchers are being
prorated properly.

NA Comments

59



GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

PART IV FOOD INSTRUMENT ACCOUNTABILITY (LOCAL AGENCY ONLY)

Guidelines Corrective Action
Corrective Action
Corrective Action
Corrective Action

Areas of Review

Yes No

2. Is prorating consistent?

Clinic Clinic Clinic Clinic Clinic

Looking for: I. To make sure all vouchers that should have been
prorated were prorated.
3. Are unissued prorated vouchers stamped "void" at the time of issuance?

Clinic Clinic Clinic Clinic Clinic

Looking for: I. To make sure all prorated vouchers were stamped void I at the time of prorating.
4. Is staff knowledgeable of the proper procedures for prorating?

Clinic Clinic Clinic Clinic Clinic

Looking for: I. Are the proper procedures for prorating being followed?
5. Are voided vouchers stored according to procedures until forwarded to the ADP contractor?

Clinic Clinic Clinic Clinic Clinic

Looking for: I. Voided vouchers must be securely stored until they are
forwarded to the ADP contractor.

NA Comments

60

GAWICPROCEDURESMANUAL

ATTACHMENT M0-1

PART IV FOOD INSTRUMENT ACCOUNTABILITY (LOCAL AGENCY ONLY)

.uidelines Corrective Action Corrective Action orrective Action
Corrective Action

Areas of Review
6. Are vouchers transported from one site to
another?

Yes No

Clinic Clinic Clinic Clinic Clinic

Looking for: I. If the clinics are transporting vouchers to any other
clinic sites.

7. When vouchers are transported, are they in a locked container (lock box, briefcase)?

Clinic Clinic Clinic Clinic Clinic

Looking for I. Vouchers' must be transported in locked briefcase or
lockbox.

I. Local Agency Policies

I. Does the local agency have a policy for issuing vouchers to employees/family members?

Clinic Clinic Clinic Clinic Clinic

Looking for I. Check Medical records of WIC employee's relatives to
make sure employees are not certifying or issuing vouchers to family members.
2. Is any staff in this clinic receiving WIC benefits?

Clinic Clinic Clinic Clinic Clinic

Looking for: I. To be aware of any employee participating in the WIC
program.

NA Comments
.

61



GA WIC PROCEDURES MANUAL

ATTACHMENT M0-1

PART IV FOOD INSTRUMENT ACCOUNTABILITY (LOCAL AGENCY ONLY)

Guidelines Corrective Action
Corrective Action Corrective Action
Corrective Action

Areas of Review
3. Are family members of staff receiving WIC benefits at these locations?
Clinic Clinic Clinic Clinic Clinic
Looking for: I. To be aware of any family members of staff receiving
WIC at the clinic.
4. Is clinic staff allowed to issue vouchers or to
certify family members?
Clinic Clinic Clinic Clinic Clinic
Looking for: I. Check medical records of family members of staff to
determine if the staff certified their family members.
5. Is the District aware of all staff/family members
enrolled on the WIC Program?
Clinic Clinic Clinic Clinic Clinic
Looking for: I. If the District is aware of any staff or family
members participating on the program. J. Participant Abuse
I. Has the clinic had any problems with participant abuse since the last program review?
Clinic Clinic Clinic Clinic Clinic
Looking for: I. If the clinic has problems with participants (verbal
abuse, misconduct, dual participation, etc).

Yes No

NA Comments

62

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

PART IV FOOD INSTRUMENT ACCOUNTABILITY (LOCAL AGENCY ONLY)

Guidelines Corrective Action Corrective Action Recommendation
Corrective Action

Areas of Review 2. Was the coordinator notified?

Yes No

Clinic Clinic Clinic Clinic Clinic

Looking for: I. If participant abuse identified, was coordinator
infonned about abuse.

3. To your knowledge, was there an investigation?

Clinic Clinic Clinic Clinic Clinic

Looking for: I. The outcome of the situation.
K. Dual Participation

I. Has the clinic followed up on each dual participation case received at the clinic?

Clinic Clinic Clinic Clinic Clinic

Looking for: I. Make sure the clinics are completing the dual
participation reports and handling any cases of dual participation.
L. Missing Vouchers

I. Have any vouchers been reported missing during the last twelve months?

Clinic Clinic Clinic Clinic Clinic

Looking for: I. Make sure all vouchers were accounted for, and
record if the clinic was aware of any missing vouchers.

NA Comments

63



GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

PART IV FOOD INSTRUMENT ACCOUNTABILITY (LOCAL AGENCY ONLY)

Guidelines Corrective Action
Corrective Action

Areas of Review

Yes No NA Comments

2. Was a Lost, Stolen, Destroyed Voucher Report sent to the State WIC Office?

Clinic Clinic Clinic Clinic Clinic

Looking for: 1. Make sure the proper procedures and forms were
completed when vouchers were reported missing.
3. Was supervisor/coordinator notified of the missing vouchers?

Clinic Clinic Clinic Clinic Clinic

Looking for: 1. If the coordinator was made aware of any missing
vouchers .


64



GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

PART V VENDOR MANAGEMENT

Guidelines

Areas of Review

Yes

No NA Comments

Corrective Action

Does the Local Agency maintain individual vendor files to include all correspondence and reports pertaining to each specific vendor?

Looking for: 1. Copy of Original Application 2. Signed Vendor Agreements 3. Signed Vendor Training Checklists 4. Monitoring Forms 5. Vendor Activity Monitoring Profiles 6. Copies of complaints that involve vendors
Copies of correspondence forwarded to Local 7. Agency in reference to their specific vendors 8. Copies of Vendor Input/Registration Forms 9. Sanction System Form 10 Post Vendor Training Evaluation



Corrective Action Corrective Action Corrective Action Corrective Action

I. Does the Local Agency ensure that its method of documentation and maintenance of vendor information is accurate and effectively meets the needs of the Local Agency and State Agency?
Looking for: I . Ensure that correspondence and reports are in
place .
2. Does the Local Agency's vendor files include the Post Vendor Training Evaluation and the Sanction System forms?
Looking for: I. Completed Post Vendor Training Evaluation.
Signed Sanction System Form.
During the Vendor Application Process, did the Local Agency Representative visit the stores and complete the Vendor Review Forms accurately (Attachment VN-16)?
Looking for: 1. Completed Vendor Review Form.
I. Are Vendor Applications and the Vendor Review Forms submitted to the State WIC Office within five (5) working days after the vendor submits to the Local Agency?
Looking for: I. Submission of application and review forms.
65



GA WIC PROCEDURES MANUAL

ATTACHMENT M0-1

PART V VENDOR MANAGEMENT

Guidelines Corrective Action
Corrective Action
Corrective Action Corrective Action Corrective Action Corrective Action

Areas of Review

Yes No NA Comments

After the approval of each vendor, did the Local Agency issue one vendor stamp to the vendor and give the appropriate training, as stated in the Vendor Section of the FFY' 99 Procedures Manual (as evidenced by a completed Ve.odor Input/ Registration Form and the Vendor Training Checklist Form)?

Looking for: 1. Ensure that forms are in place.

Has the Local Agency replaced any lost or damaged vendor stamps?

Looking for: 1. Ensure that Local Agency meet requirements.

If a replacement or additional stamp was issued to a vendor, was the State WIC Office notified?

If yes, what means of documentation was submitted to the State WIC Office?

If a vendor was terminated, was a copy of the Vendor Input/Registration Form submitted to ADP Contractor and SWO within 30 days?

Looking for: 1. Copy of Input/Registration Form.

Has a Vendor Agreement (Attachment VN-4) been signed between the Local Agency and the new vendor?

Looking for: 1. Store manager/owner signed agreement.

1. Did the Local Agency submit a copy of the Vendor Agreement to the State WIC Office within thirty (30) days from the date the contract was signed?

Looking for: 1. Whether or not guidelines are met.

2. Ifno, did the Local Agency terminate the vendor and submit a Vendor Input/Registration Form to the ADP Contractor and SWO for any vendor that did not sign an agreement within thirty (30) days?

Looking for: 1. Whether or not guidelines are met.

66



GA WIC PROCEDURES MANUAL

ATTACHMENT M0-1

PART V VENDOR MANAGEMENT

Guidelines Corrective Action Corrective Action
Corrective Action Corrective Action Corrective Action Corrective Action Corrective Action

Areas of Review

Yes

Was a new Vendor Agreement signed by October 1 of each Federal Fiscal Year in order for a vendor to renew his/her authorization to accept WIC vouchers?

Looking for: I. Signed vendor agreement by specified date.

I. Were Vendor Agreements to renew current vendors received by the State WIC Office no later than November 1 of each Federal Fiscal year?

Looking for: I. Whether or not guidelines are met.

2. Ifno, explain the reason for the delay.

Did the Local Agency complete the Vendor Training Infonnation Fonn within thirty (30) days after the final training session in the District/Unit?

Looking For: I. Compliance with program policy.
I. Does the Local Agency allow the vendor(s) a grace period often (IO) working days, prior to September 30 of the fiscal year, to attend the District/Unit make-up training session?

Looking for: I. Compliance with program policy.

What percentage of a district's vendors were visited during the past two Federal Fiscal years?

Looking for: I. Completed monitoring review forms.

I. Has the Local Agency made a monitoring visit of all the vendors in their district at least once every two (2) years?

Looking for: I. Are guidelines for monitoring met?
Completed monitoring review forms.

2. Did the Local Agency monitoring representative accurately complete each section of the Review Tool when each Vendor was monitored?

Looking for: I. Completed monitoring review form.
Review fonn must be signed and dated.

No NA Comments

67



GA WIC PROCEDURES MANUAL

ATTACHMENT M0-1

PART V VENDOR MANAGEMENT

Guidelines

Areas of Review

Yes No NA Comments

Corrective Action

Did the Local Agency revisit all required stores wi_thin sixty (60) days if violations were found during the monitoring visit to see if the violations have been corrected?
Looking for: 1. Compliance with program policy.




68



GAWICPROCEDURESMANUAL

ATTACHMENT MO-01

PART VI - FINANCIAL MANAGEMENT

GUIDELINES

AREAS OF REVIEW

YES NO NA

Corrective Action A. Review of Previous Audit Findings

Comments

Administration Section

I. Has an audit been perfonned recently by an independent accounting finn?

7 CFR246.20
Administration Section

Looking for: l. Ensure that the District has been audited by an
independent accounting finn.
2. Were any findings noted? (If yes, attach a copy of the audit containing these findings.)

7 CFR246.20
Administration Action

Looking for: l. Any findings.
3. Were measures taken in response to these findings?

7 CFR 246.13 (F) Looking for: l. Measures taken in response to findings.
Corrective Action B. Budgets

Administration Section

I. Are the appropriate WIC budgets and revisions for the current fiscal year available for review?

AD-53 #S
Administration Section

Looking for: I. Ensure that appropriate budgets and revisions are
available for review.
2. Are budgets revised and submitted in a timely manner when allocations are made?

STATE PLAN pg.31 (A) pg. 37 (I)

Looking for: I. Appropriate timeframes for the submission of budget
revisions.

Corrective Action C. Expenditures

Administration Section

I . Are expenditure reports entered in a timely manner?

AD-4 (C)

Looking for: I. Appropriate timeframes for the submission of
expenditure reports.

Corrective Action
Administration Section
STATE PLAN pg. 38 (4)

2. Are expenditures appropriate under federal guidelines?
Looking for: I. Appropriateness of WIC expenditures.

69



GA WIC PROCEDURES MANUAL PART VI - FINANCIAL MANAGEMENT

ATTACHMENT MO-01

GUIDELINES

AREAS OF REVIEW

YES NO NA

I
Administration D. Generally Accepted Accounting Practices
Section I. Are accounting records maintained by WIC paid staff or by the district accounting personnel?

Looking for: I. Which staff member maintains accounting records.

Administration Section

2. Does the local agency maintain a separate account for WJC funds?

If not, is adequate documentation maintained to identify revenues and disbursements for the WIC Program?

Administration Section

Looking for: I. Type of bank account used and whether funds are
identified as being WIC monies.
3. Are revenues for the WIC Program deposited in an interest bearing account?

Administration Section

Looking for: 1. Determine whether or not the bank account pays
interest on its deposits.
4. Are source documents protected from damage or unauthorized access?

Looking for: 1. Assurance that WIC records are protected from
damage and authorized access.

Administration Section
Administration Section

5. Does the Local Agency use a computerized accounting system?
If yes, is the hard drive backed up daily on floppy diskettes?
t
Looking for: 1. Determine if the district employs a computerized
accounting system and whether there is a daily back up procedure.
6. Are floppy diskettes maintained in the financial office and protected from unauthorized access?
Looking for: 1. Determine location and security of diskettes.

Comments

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GUIDELINES
Administration Section

PART VI - FINANCIAL MANAGEMENT

AREAS OF REVIEW
7. Are hard copies of all accounting transactions printed and maintained for reference?

YES NO NA

Comments

Administration Section

Looking for: I. Printed records of accounting transactions.
8. ls there a separation of duties for the various accounting tasks?

Administration Section

Lookin2 for: 1. Separation of duties of the accounting personnel.
9. ls the bank reconciliation performed by an employee who is independent of cash disbursements or receipts and general ledger maintenance?

Administration Section
Administration Section

Lookin2 for: I. Separation of duties of the accounting personnel.
10. ls the signing of checks independent from the approval of invoices?
Lookin2 for: I. Separation of duties of the accounting personnel.
11. Is the preparation of checks independent from the approval of invoices?

Administration Section

Looking for: I. Separation of duties of the accounting personnel.
12. Are the receiving duties independent of the purchasing function?

Administration Section

Lookin2 for: 1. Separation of duties of the accounting personnel.
13. ls there a limitation on the dollar amount for checks that only require one signature?

AD 23 (J)
Administration Section

Looking for: I. Check amount requiring multiple signatures.
14. Are invoices and supporting documentation examined at the time of signing and marked. "paid" to prevent duplication of payment?

Administration Section
AD 28 (2)

Looking for: I. Documents that are marked "paid" to avoid
duplication of payment.
15. Are records maintained for the required length Of time? (3 years plus current).
Looking for: I. Whether or not the local agencies are keeping
records for three years plus current year.

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GUIDELINES

AREAS OF REVIEW

Corrective Action E. Equipment

Administration Section

1. Are proper equipment inventory records maintained?

AD 23 (J)

YES NO NA

Comments

Administration Section

2. Has a physical inventory been conducted within the fiscal year?

AD 23 (J) AD 23 (J)

Looking for: 1. Evidence that the district has completed its annual
equipment inventory.
3. Do inventory records indicate:

Administration Section

a. Inventory decal number b. Description of equipment
c. Serial number (if applicable)
d. Location of equipment
e. Date of purchase f. Acquisition cost g. Percentage of WIC participation in the
purchase

Administration Section
AD 16, 17, 18, 19, 20
Administration Section

Looking for:

1. Completeness of inventory record.

,

4. Has USDA and/or the State WIC Office approval been obtained for equipment purchases as required?

Looking for: 1. Whether or not prior approval has been requested
when required.
5. Are the proper procedures followed to dispose of obsolete or damaged equipment?

AD 23 (J)
Administration Section

Looking for: 1. Whether or not proper disposal procedures are being
followed:
6. Are the proper procedures followed when equipment is lost or stolen?

AD 23 (J)

Looking for: 1. Whether or not proper procedures being followed for
discovered lost or stolen equipment.

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GUIDELINES

PART VI - FINANCIAL MANAGEMENT

AREAS OF REVIEW

YES NO NA

Administration Section
AD 9 (E)

F. Indirect Costs
I. Does the District charge any indirect costs to the WIC Program?

Comments

If yes, does the local agency have an approved Indirect Cost Allocation Plan on file?

Looking for: I. Cost allocation plan if warranted.

Administration Section
AD 10 (A)

2. Have costs charged to the WIC program also been charged to all other programs for which they benefit?
Looking for: I. Whether or not all costs have been appropriately
charged.

Administration Section

3. Has the cost allocation plan been applied correctly in making reimbursements?



AD 10 (A)

Looking for: I. A cost allocation plan that has been correctly used in
the reimbursement process.


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GUIDELINES

AREAS OF REVIEW

Corrective Action

I. FOOD PACKAGE ASSIGNMENT
A. List title(s) of competent professional authorities (CPA's) who assign food packages for participants:
Looking for:
I. Compliance with Federal requirements and State policy that only CPA's can assign/tailor food packages.

YES NO NA COMMENTS IS /U



Corrective Action

B. Is there a protocol for infant food package changes from the contract formula to the non-contract formula?

If yes, which of the following do you use:

State Protocol:

Local Agency Policy:

(Please provide a copy to the reviewer)

Looking for:

I. Compliance with, and consistent application of State policies and procedures regarding food package changes.

Corrective Action C.

What guidelines are used for food package tailoring? (Please provide reviewer with any written communications to clinic staff on food package tailoring.)

Looking for:

I. Compliance with Federal requirements and State policy.

Recommendation D. What procedures are used for obtaining and tracking the use of prescription formulas/metabolic foods; and providing follow-up for participants on special formulas/metabolic foods?

Looking for:

I. Consistency among clinic staff in methods used to

assign, obtain and track the use of prescription formulas/metabolic foods.

.

2. Ways to assist local agency in identifying and correcting

potential problems.

3. Whether or not participants receive follow-up from the

appropriate source, i.e., private M.D., health department.



4. Whether 2000 food packages comply with federal regulations .

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GUIDELINES

AREAS OF REVIEW

YES NO NA COMMENTS IS /U

Corrective Action

II. NUTRITION EDUCATION
A. Training
l. At the time of the program review, please provide the reviewer with a summary of all nutrition training attended by local staff since the last review.
List provided?
Looking for:
l. Whether or not all staff providing WIC services receive adequate training, as required by State policy.

Recommendation

2. How are training needs assessed?
Looking for:
l. Adequacy of continuing education of all staff providing WIC services.

Recommendation

3. Hciw do you assess the effectiveness of the training, over time?
Looking for:
l. Monitor adequacy of continuing education for all staff providing WIC services.

Corrective Action

B. Paraprofessionals/Nutrition Assistants (NAs)
l. Are paraprofessionals/NAs used to certify participants? (Circle which one)
Looking for:
l. Ensure that paraprofessionals/NAs are not certifying participants.

Corrective Action

2. Are paraprofessionals/NAs used to provide secondary nutrition education contacts?
Looking for:
I. Ensure that paraprofessionals/NAs are not being used without State approval.


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AREAS OF REVIEW

Corrective Action

3. Has the training plan for paraprofessionals/NAs been approved by the Office of Nutrition?
If yes, the date:
Looking for:
I. Whether or not a training plan approved by the Office of Nutrition has been implemented.

YES NO NA IS /U

COMMENTS



Corrective Action

4. Have all lesson plans for training paraprofessionals/NAs been submitted to the Office of Nutrition for approval?

Ifno, please provide reviewer with lesson plans at

the time of review.

,

Looking for:

I. Ensure that the Office of Nutrition has all lesson plans on file, and all plans have been approved.

Corrective Action

5. Has the district submitted, to the Office of Nutrition, a list of paraprofessional/NA staff providing secondary nutrition education contacts?
If yes, date provided: ___
Ifno, please provide the reviewer a list at the time of review.
Looking for:
I. A current list of approved paraprofessional/NA staff on file in the Office of Nutrition.

Corrective Action

C. Nutrition Education Plan
I. Was a three-year Nutrition Education Plan received by the Office of Nutrition by September l?
If yes, date: Ifno, date received: Not Received:



Looking for:
I. Compliance with Federal requirements that a local plan has been developed, that is consistent with the State plan .

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AREAS OF REVIEW

Corrective Action

2. Was an annual progress report received by the Office of Nutrition by November 30, 1999?
If yes, date: _ _ If no, date received:
Not received: - - -
Lookin2 for:
I. Compliance with the Federal requirement for development of an annual local agency plan.

YES NO NA COMMENTS IS /U

Recommendation

3. Give status of each Nutrition Education Plan objective:
Lookin2 for:
I. Whether or not the Plan is implemented at the local level.

Corrective Action

D. Participant Nutrition Education Contacts
I. What lesson plans for nutrition education have been developed since the last review? Please provide the reviewer with a copy at the time of review.
Looking for:
I. Compliance with Federal requirements and State policy that standards for nutrition education are followed.
2 Compliance with State policy that only approved materials are used for the provision of nutrition education.

Recommendation

2. Describe the system used to provide two (2) nutrition education contacts for each six (6) month certification period (or quarterly) per participant.
Lookin2 for:
I. Adequacy of system to provide education contacts. 2. Potential problems in the system, that can be identified
and corrected.

Recommendation


3. What method is used to document secondary nutrition education contacts?
Looking for:
I. Compliance with Federal requirements and State policy.

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AREAS OF REVIEW

YES NO NA COMMENTS IS /U

Recommendation

3. Since the last program review, has the system for providing and/or documenting nutrition education contacts changed?
If yes, explain how:
Lookin2 for:
I. Adequacy of system in place and improvements resulting from any changes that have been made.



Corrective Action

4. Are missed nutrition education appointments documented?
If yes, describe the method used:
Lookin2 for: I. Compliance with Federal requirements and State policy. 2. Identify and correct potential problems with the system
in place.

Recommendation 3. How are the Nutrition Guidelines for Practice being used?

Lookin2 for:

I. Whether or not the Guidelines have been implemented at the clinic level.

Corrective Action

4. Do you have a system in place to assure the provision of high risk nutrition education contacts?

Describe the method:

Lookin2 for:

I. Compliance with Federal requirements for appropriate nutrition education contacts, and State policy regarding development of care plans for high risk participants.



Corrective Action

E. Nutrition Education Materials
I. Who approves nutrition education materials and forms not provided by the State?
Looking for:
I. Compliance with Federal requirements for education materials appropriate for participant use .

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AREAS OF REVIEW

YES NO NA COMMENTS IS /U

Recommendation

2. What method(s) is/are used to evaluate nutrition education materials?
Looking for:
I. Whether or not materials are evaluated on a regular basis using consistent methods.

Corrective Action

3. A list of all approved nutrition education
materials and a copy of those not available through Central Supply are to be provided to the Office of Nutrition. List provided?
Lookin1:; for:
I. Compliance with Federal requirements for education materials appropriate for participant use.

Corrective Action

4. Are materials provided which meet the needs of specific population groups?
Lookin1:; for:
I. Compliance with Federal requirements for education materials appropriate for participant use.

Corrective Action

5. Are inappropriate nutrition education materials available for participant's use?
Looking for:
I. Compliance with Federal requirements for education materials appropriate for participant use.

Corrective Action for No Breastfeeding Coordinator

III. Breastfeeding Promotion and Support
This section should be addressed with both the WJC coordinator and the local agency breastfeeding coordinator.
A. Breastfeeding Coordinator
I. What are the names and credentials/qualifications of the breastfeeding coordinator?
Looking for:
I. Compliance with Federal requirements.



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AREAS OF REVIEW

Recommendation
Breastfeeding Section

2. How many hours per week/month does the breastfeeding coordinator spend on breastfeeding promotion and support activities?
Looking for:
1. Adequacy of time provided to the breastfeeding coordinator to comply with Federal requirements.

YES NO NA COMMENTS IS /U

Recommendation
Breastfeeding Section

3. Is the breastfeeding coordinator position pennanent or a contract? .
Looking for:
1. Services provided by breastfeeding coordinator: cost factors, duties perfonned based on how hired.



Corrective Action
Breastfeeding Section

4. Does the breastfeeding coordinator conduct acti_vities agency-wide or primarily in one location?
Looking for:
1. Ability of breast feeding coordinator to meet Federal requirements throughout the local agency.

Recommendation
Breastfeeding Section

5. Describe the major responsibilities and activities of the breastfeeding coordinator:
Looking for:
I. Ability of the breastfeeding coordinator to conduct activities designed to comply with Federal requirements and State policy.



Recommendation
Breastfeeding Section

6. How are breastfeeding coordinator activities documented (i.e., counseling, classes)?
Central File _ _Participant health record _ _Other (please specify)
Looking for:
I. Complete documentation of all breastfeeding services provided.
2. Identification, for follow-up and monitoring purposes, of location of documentation.

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GUIDELINES

AREAS OF REVIEW

YES NO NA COMMENTS IS /U

Recommendation
'
Breastfeeding Section

3. For individual counseling done, describe the process for documentation including the time lag between counseling and documentation.
Looking for:
I. Complete documentation of all breastfeeding services provided.
2. Location of documentation for follow-up and monitoring purposes.

Corrective Action
Breastfeeding Section

B. Encouragement to Breastfeed
I. How is encouragement to breastfeed provided in the prenatal period? - -Individual Contact _ _Prenatal/Breastfeeding Class _ _Other (Please specify):
Looking for:
I. Compliance with Federal requirements for prenatal Education.

Recommendation
Breastfeeding Section

2. Describe the process for individual contacts that are provided (when, by whom, documentation).
Looking for:
I. Activities performed by the breastfeeding coordinator and other clinic staff to monitor and assess the system for education contacts as well as the variety of staff able to perform the required functions.

Recommendation
Breastfeeding Section

3. Describe the process for the provision of prenatal classes to include breastfeeding (when, by whom, documentation).
Looking for:
I. Activities performed by the breastfeeding coordinator and other clinic staff to monitor and assess the system for education contacts as well as the variety of staff able to perform these required functions .

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GUIDELINES

AREAS OF REVIEW

YES NO NA COMMENTS /S /U

Recommendation
Breastfeeding Section

C. Training
l. Please provide, at the time of the review, a list of:
_ _Trainings attended by the breastfeeding coordinator.
_ _Trainings provided by the breastfeeding coordinator.
Looking for: l. Compliance with Federal requirements for training of
new staff.
2. Adequacy of continuing education for all staff providing
WIC services.



Corrective Action
New Staff
Breastfeeding Section

2. Describe how you assure that clinic staff are
knowledgeable about current breastfeeding issues.
Looking for
l. Compliance with Federal requirement for training of new staff.
2. Adequacy of continuing education for all staff providing
WIC services.

Corrective Action
Breastfeeding Section

3. Do you have a referral system for participants who
request additional support/information; or require more in-depth counseling /assistance on breastfeeding?
If yes, describe how this is done and who provides the support, information, and in-depth counseling.
Looking for:
l. Compliance with the Federal requirements for assuring adequate breastfeeding support for participants.



Corrective Action Breastfeeding Section
I

4. Describe what the local agency is doing to create a clinic atmosphere that is supportive of breastfeeding.
Looking for:
l. Compliance with Federal requirements regarding a clinic atmosphere that promotes and supports breastfeeding.

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GUIDELINES

AREAS OF REVIEW

Recommendation
Breastfeeding Section

5. Other

.

Please describe any breastfeeding activities not addressed above (e.g., peer counseling, special projects, media exposure, etc.).

Looking for:

I. Activities that go beyond the Federal requirements, but serve to promote, educate and support breastfeeding.

YES NO NA COMMENTS IS /U

For Office of Nutrition Use

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?

For Office of Nutrition Use

B. Describe the special projects, initiatives, and/or

accomplishments in the area of breastfeeding, nutrition

education, and nutrition materials being implemented in

the Local Agency.

r

For Office of Nutrition Use

C. What requests does the District/Local Agency have of the Office of Nutrition staff to assist in implementing Nutrition Education and Breastfeeding Plans and providing nutrition services?

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PART VII CERTIFICATION/NUTRITION EDUCATION/AND BREASTFEEDING- OON

V. CLINIC OBSERVATION: INDIVIDUAL NUTRITION EDUCATION SESSION

DATE:

REVIEWER: Participant status:

p BN

Participant priority: I II III

Participant risk factors:

Time estimated for total contact:

Time estimated for NE contact:

CLINIC:
I C IV V VI



GUIDELINES AREAS OF REVIEW

YES NO NA IS /U

Corrective Action
Certification Section

A. Nutrition Education (NE)
l. Is diet evaluated according to Georgia WIC standards (intake, summary, food practices, evaluation)?
Looking for:
l. Compliance with Federal requirements and State policy.

COMMENTS

Corrective Action
Nutrition Education Section
Corrective Action
Nutrition Education Section

2. Does NE relate to participant status? Looking for: 1. Compliance with Federal requirements and State policy.
3. Does NE relate to participant risk factors? Looking for: I. Compliance with Federal requirements and State policy.

Corrective Action
Nutrition Education Section

4. Does NE relate to diet recall/assessment? Looking for: l. Compliance with Federal requirements and State policy.

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GUIDELINES

AREAS OF REVIEW

YES NO NA IS /lJ

Corrective Action
Nutrition Education Section

5. Does NE include WIC foods and their relationship
to participant risk?
Looking for:
I. Compliance with Federal requirements and State policy.

COMMENTS

Corrective Action
Nutrition Education Section

6. Does NE include total food intake and its relationship to participant risk?
Looking for:
I. Compliance with Federal requirements and State policy.

Corrective Action
Nutrition Education Section

7. Does NE follow Nutrition Guidelines for Practice? Looking for: I. Compliance with Federal requirements and State policy.

Recommendation
Nutrition Education Section

B. Communication
I. Does counselor invite questions?
Looking for: I. Appropriate counseling skills. I. Need for additional training.

Recommendation
Nutrition Education Section

2. Does the participant ask questions?
Looking for: I. Appropriate counseling skills. 2. Need for additional training.

Recommendation
Nutrition Education Section

2. Is session conducted in a language the participant speaks/understands?
Looking for:
1. Compliance with Federal requirements and State policy.

Recommendation
Nutrition Education Section

C. Materials (includes posters, flip charts, food models, pamphlets, etc.)
1. Are materials in participant's primary language?
Looking for:

1. Compliance with Federal requirements and State policy.

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GUIDELINES

AREAS OF REVIEW

YES NO NA IS /U

Corrective Action
Nutrition Education Section
Corrective Action
Nutrition Education Section

2. Do materials relate to risk factor? Looking for: I. Compliance with Federal requirements and State policy.
3. Do materials relate to counseling session? Looking for: I. Compliance with Federal requirements and State policy.

COMMENTS

Recommendation
Nutrition Education Section

D. Space
I. Is space private?
Looking for: I. Appropriate counseling skills
Need for additional training. 2. Clinic limitations.

Recommendation
Nutrition Education Section

2. ls there seating for the counselor?
Looking for: I. Appropriate counseling skills. 2. Need for additional training. 3. Clinic limitations.

Recommendation
Nutrition Education Section

3. Is there seating for the participant and others in the session?
Looking for: I. Appropriate counseling skills. 2. Need for additional training. 3. Clinic limitations.

Recommendation
Nutrition Education Section

4. Is space quiet enough to talk nonnally?
Looking for: I. Appropriate counseling skills. 2. Need for additional training. 3. Clinic limitations.

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AREAS OF REVIEW

YES NO NA IS /U

Recommendation
Nutrition Education Section

5. Is the view of the participant/counselor obstructed by materials on the desk or by the seating arrangement?
Looking for: I. Appropriate counseling skills. 2. Needs for additional training. 3. Clinic limitations..

COMMENTS



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VI. CLINIC OBSERVATION: GROUP

NUTRITION EDUCATION SESSION

DATE:

CLINIC:

REVIEWER:

Topic:

Composition of Group (prenatal, breastfeeding mothers, care givers of infants, etc.):



Expected Attendance:

Actual Attendance:

No show rate (calculate percent):

%

Time Estimate for NE Contact:

GUIDELINES AREAS OF REVIEW

Recommendation
Nutrition Education Section

A. Integration
Session conducted in connection with: Certification Voucher Pickup Other Appointment Specify
Looking for: 1. Clinic flow.
2. Efficiency in delivery of nutrition services in conjunction with other clinic services.

YES NO NA COMMENTS IS /U

Corrective Action
Nutrition. Education Section

B. Nutrition Education
1. Does NE include WIC foods and their relationship to nutritional status?
Looking for: 1. Compliance with Federal requirements and State policy.

Recommendation
Nutrition Education Section

2. Does NE include total food intake and its relationship to nutritional status?
Looking for: 1. Appropriate counseling skills. 2. Need for additional training.

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AREAS OF REVIEW

Corrective Action
Nutrition Education Section

3. Does NE follow Nutrition Guidelines for Practices? Looking for: I. Compliance with State policy

YES NO NA COMMENTS

IS

/U



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GUIDELINES

AREAS OF REVIEW

Recommendation
Nutrition Education Section

C. Communication
A. Does instructor invite questions?
Looking for: I. Appropriate counseling skills. 2. Need for additional training of staff.

YES NO NA COMMNTS IS /U

Recommendation
Nutrition Education Section

B. Do participants ask questions?
Looking for: I. Appropriate counseling skills. 2. Need for additional training of staff.

Recommendation
Nutrition Education Services

C. Does instructor respond to questions?
Looking for: I. Appropriate counseling skills. 2. Need for additional training of staff.

Recommendation
Nutrition Education Section

D. Materials/Media
A. Is the session conducted in a language(s) participants speak/understand?
Looking for : I. Compliance with Federal requirements and State policy.

Recommendation
Nutrition Education Section

B. Are materials/media in the participant(s) primary language?
Looking for:
I. Compliance with Federal requirements and State policy.

Recommendation
Nutrition Education Section

C. Media used:
Film/Filmstrip Slide/Tape Show Video Tape Poster/Flip Chart Food Models Pamphlets Other Specify:
Looking for:
I. Appropriate counseling skills. 2. Need for additional training of staff.

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GUIDELINES

AREAS OF REVIEW

Recommendation
Nutrition Education Section

D. Are print materials related to information covered during session?
Looking for: I. Appropriate counseling skills. 2. Need for additional training of staff.

YES NO NA COMMENTS

IS

/U

Corrective Action
Nutrition Education Section

E. Staff
Session conducted by:
Nurse Nutritionist Paraprofessional Other Specify: Looking for:

I. Compliance with Federal requirements and State policy

Recommendation
Nutrition Education Section

F. Evaluation of Knowledge and Satisfaction

l. Is there any evaluation of the participant's nutritional knowledge base?

Looking for:

I. Appropriate counseling skills.

2. Need for additional training of staff.

'

Recommendation
Nutrition Education Section

3. ls there any evaluation of the knowledge gained in the session?
Looking for: I. Appropriate counseling skills. 2. Need for additional training of staff.

Recommendation
Nutrition Education Section

3. Is there any evaluation of the participant's attitudes about nutrition and diet?
Looking for: l. Appropriate counseling skills. 2. Need for additional training of staff.

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GUIDELINES AREAS OF REVIEW

Recommendation
Nutrition Education Section

3. Is participant satisfaction evaluated? If yes, how?
Looking for: I. Appropriate counseling skills.
2. Need for additional training of staff.

YES NO NA COMMENTS IS /U

Recommendation
Nutrition Education Section

G. Space
I. How is the room arranged?
Looking for: I. Appropriate counseling skills.
2. Need for additional training of staff. 3. Clinic limitations.



Recommendation
Nutrition Education Section

4. Where is the session conducted:
Waiting room Private room Other Specify:
Looking for:
I. Appropriate counseling skills.
2. Need for additional training of staff. 3. Clinic limitations.

Recommendation
Nutrition Education Section

5. Is there seating for the participants?
Looking for: I. Appropriate counseling skills.
2. Need for additional training of staff. 3. Clinic limitations.

Recommendation
Nutrition Education Section

4. Can participants see the instructor?
Looking for:
I. Appropriate counseling skills.
2. Need for additional training of staff. 3. Clinic limitations.



Recommendation
Nutrition Education Section

5. Can participants hear the instructor?
Looking for:
I. Appropriate counseling skills.
2. Need for additional training of staff. 3. Clinic limitations.

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GUIDELINES AREAS OF REVIEW

,Recommendation
Nutrition Education Section

6. Can the participants see video, film, or other visual aids?
Looking for: I. Appropriate counseling skills. 2. Need for additional training of staff. 3. Clinic limitations.

YES NO NA COMMENTS IS /U

Recommendation
Nutrition Education Section

7. Can the participants hear any audio aids?
Looking for: I. Appropriate counseling skills. 2. Need for additional training of staff. 3. Clinic limitations.

H. Additional Comments



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VII. CLINIC OBSERVATION: QUESTIONS FOR CLINIC STAFF (Must be completed in at least one {I) clinic).

Date

Clinic

Staff person interviewed: Nurse Nutritionist

Paraprofessional

Reviewer

GUIDELINES

AREAS OF REVIEW

YES NO NA COMMENTS IS /U

Recommendation
Nutrition Education Section

A. How do you use the Nutrition Guidelines for Practice? Give some examples.
Lookini:; for: l. Staff knowledge. 2. Need for additional training.

Recommendation
Breastfeeding Section

B. How do you encourage breastfeeding?
Lookini:; for: l. Staff knowledge. 2. Need for additional training.

Recommendation
Food Package Section Recommendation Food Package Section

C. Who assigns food packages in the clinic?
Lookini:; for: l. Staff knowledge. 2. Need for additional training.
D. How do you decide which food package to assign to a participant?
Looking for: l. Staff knowledge. 2. Need for additional training.

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GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

RECORD REVIEW (Acceptable level of compliance: 90% Records Satisfactory)

ANTHROPOMETRIC EQUIPMENT



Date- - - - - -Clinic- - - - -Reviewer- - - - - - - - - - - - - - -

OBSERVATIONS

S-Satisfactory U-unsatisfactory
#1 #2 #3

COMMENTS

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

3. Standing Scales:

a.

Calibrated in last 12

months (use scale test

report or sticker)

b. Beam scale

4. Infant Scale: a. Calibrated in last 12 months (use scale test report or sticker)

b. Beam Scale



95



GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

RECORD REVIEW (Acceptable level of compliance: 90% Records Satisfactory)

HEMATOLOGIC EQUIPMENT/CLINIC OBSERVATION

Date- - - - - -Clinic- - - - -Reviewer- - - - - - - - - - - - - - - -
A. Type of equipment used (brand/model) for hgb. or hct.

B. 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

C. Calibration

, 1.

How is equipment calibrated?

2.

Who calibrates the equipment?

3.

How often is the equipment calibrated?

4.

How is calibration documented?

D. Does staff person use universal precautions when obtaining blood sample?

96



GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

RECORD REVIEW (Acceptable level of compliance: 90% Records Satisfactory)

CLINIC OBSERVATION: ANTHROPOMETRIC MEASUREMENTS

Date- - - - - - -Clinic- - - - - -Reviewer- - - - - - - - - - - - - - - - Observe at least one (1) standing height, standing weight, recumbent length, and infant scale weight.

Woman Status:

Child Age:

Woman/Child (Standing Height) 1. Participant measured without shoes 2. Proper stance used for reading measurement 3. Headboard is level, touches top of head 4. Correct angle used for measurement
5. Measurement taken to nearest I/8 inch
6. Two (2) measurements taken Woman/Child (Standing Weight) 1. Participant dressed in minimal clothing 2. Scale zeroed, prior to measurement 3. Correct angle used for reading measurement 4. Weight measured to nearest 1/4 pound
5. Two (2) measurements taken

Yes

No

Yes

No

Yes

No

Yes

No

Infant/Child (Recumbent Length)

Infant Age:

Yes

No

Child Age:

Yes

No

1. Participant measured with minimal clothing

2. Body straight, lined up with measuring board

3. Head is against headboard throughout measurement

4. Footboard resting firmly against heels

5. Correct angle used for reading measurement

6. Measurement read to nearest 1/8 inch

7. Two (2) measurements taken

Infant/Child (Infant Scale Weight)

Yes

No

I. Participant dressed in minimal clothing (without wet diaper)

Yes

No

2. Scale zeroed, prior to measurement

3. Correct angle used for reading measurement



4. Weight measured to nearest [I ounce 5. Two (2) measurements taken

97



GA WIC PROCEDURES MANUAL

ATTACHMENT M0-1

RECORD REVIEW (Acceptable level of compliance: 90% Records Satisfactory)

RECORD REVIEW

T

District

0

Clinic

T

Date

A

L

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

19. Food Pkg. Number

20. Referrals/Enrollment Documented



21. Today's Date 22. Professional's Signatures & titles
(Certification Form) 23. Primary NE Contact, Current Certification 24. Secondary NE Contact, Current or Prior
Certification 25. Breastfeeding Encouraged 26. High Risk Follow-up Documented 27. Exit Counseling Documented (Women) 28. Breastfeeding Data Collected
98



GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

RECORD REVIEW (Acceptable level of compliance: 90% Records Satisfactory)

RECORD REVIEW: INTERPRETATION

Areas on the record review are classified S (Satisfactory), U (Unsatisfactory), or NA (not applicable). Corrective action must be taken for an area of review when the percentage of S's is less than 90% for the applicable records reviewed. The satisfactory percentage is calculated for each individual area below, with the following exceptions: "satisfactory percentage" for Plotting is calculated after averaging numbers 6-9; for Diet Evaluation, after averaging numbers I0-14; for Documentation of Nutrition Risks, after averaging numbers 15-16; and for Nutrition Education, after averaging numbers 23-24.

1. Participant Status Recorded (Women Only) (Certification Section, IX.C., X.] The correct status must be checked on the WIC Assessment/Certification Form (prenatal; postpartum, breastfeeding; or postpartum, non-breastfeeding).
2. Medical Data Date (Certification Section, VII.C, XIII.5.] The date must be recorded by mm/dd/yy. The date recorded must be when the required anthropometric measurements (height/length, weight) were determined. The date must not be more than 60 days prior to certification dat'e. The data must be reflective of the applicant's status at the time of the application.
3. Length/Height Recorded (Certification Section, XIII.6.] Length or Height must be entered to the nearest 1/8 of an inch.
4. Weight Recorded (Certification Section, XIII.7.] Weight must be entered in pounds and ounces.
5. Hematocrit/Hemoglobin Recorded (Certification Section, XIII. 8.) Hematocrit/hemoglobin must be entered to one decimal place. The date ofthe hematological measurement, if different than the medical data date, must be documented in the health record. The date must not be more than 90 days prior to certification date. For women, the data must be reflective of the applicant's status at the time of the application.

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GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

RECORD REVIEW (Acceptable level of compliance: 90% Records Satisfactory)

6. Age Recorded [Certification Section, Attachment CT-22]

The participant's birth date must be recorded on the WIC Assessment/Certification Form. Age

calculation must be based on the birth date.

A woman's age need not be recorded.

Infant's and children's ages must be documented in their health records, preferably on the appropriate growth grids.

An infant's age may be entered in days, in months and days, or rounded appropriately. A child's age may be entered in years, months and days, or rounded appropriately.

7. Length/Height Plotted [Certification Section, Attachments CT-7, 8, 22]

The length/height for age must be plotted accurately, either by rounding the age appropriately or plotting as closely as possible to the exact age.

Length/height values must be plotted as accurately as possible.

On one growth grid, one method of plotting age must be used consistently.

8. Weight Plotted [Certification Section, Attachments CT-6, 7, 8, 22]

Weight for age must be plotted accurately, either by rounding age appropriately or plotting as closely as possible to the exact age.

Weight values must be plotted as accurately as possible.

Weight for gestational age must be plotted to the nearest completed week of gestation and nearest half pound.

9. Weight for Length/Height Plotted [Certification Section, Attachments CT-7, 8, 22]

Weight for length/height must be plotted as accurately as possible.

10. Diet Intake Recorded [Certification Section, XIII.9.; Attachments CT-6, 7, 8, 21, 25]

Diet intake must be recorded on an approved form.

Food frequency, 24-hour recall or food record should be used.

Evidence of amounts being assessed must be present, when a 24-hour recall or food record is being used .



GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

RECORD REVIEW (Acceptable level of compliance: 90% Records Satisfactory)

Evidence of frequency of intake being assessed must be present when a food frequency is being used.
11. Diet Summary Completed [Certification Section, XIII.9.; Attachments CT-6, 7, 8, 21, 26]
Total servings in each food group must be recorded on an approved form.
12. Food Practices Evaluated [Certification Section, XIII.9.; Attachments CT-6, 7, 8, 21, 26]
If inappropriate food practices are present, these must be identified on the approved diet form.
If no inappropriate food practices are present, this fact must be documented on the approved diet form.
13. Diet Evaluation Documented [Certification Section, XIII.9.; Attachments CT-6, 7, 8, 21, 25, 26]
The definition of Poor Dietary Pattern must be applied to the diet and inappropriate food practices available.
14. Date, Signature and Title (Diet Form) [Certification Section, XIII.9.; Attachments CT-6, 7, 8]
The date of the diet assessment must be documented on the approved form.
The signature and title of the assessing professional must be entered accurately on the approved diet form.
An appropriate signature consists of first initial and last name or first and last names.
15. All Nutritional Risks Checked [Certification Section, XIII.9.]
All applicable nutritional risks must be evaluated during each certification appointment and at the infant's mid-certification nutrition assessment.
All evident nutritional risks must be checked YES on the WIC Assessment/Certification Form.
If a nutritional risk is not present, the risk category must be checked NO on the WIC Assessment/Certification Form (except for systems in which only risks present are printed).
If a nutritional risk is not assessed/not applicable, a NA must be written/entered by the appropriate risk category on the WIC Assessment/Certification Form (except for systems in which only risks present are printed).
If documentation for a nutritional risk is found in the health record, the risk must be checked on the WIC Assessment/Certification Form.

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GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

RECORD REVIEW (Acceptable level of compliance: 90% Records Satisfactory)

16. All Nutritional Risks Documented (Certification Section, XIII.9.]
All nutritional risk criteria checked on the WIC Assessment/Certification Form must be supported by the appropriate documentation.
17. Priority Correct (Certification Section, XIII.12.]
The correct priority must be assigned according to a participant's status and nutritional risks.
A priority is determined to be incorrectly assigned if nutritional risks are present that would change the priority, even if these are not checked on the WIC Assessment/Certification Form.
18. Food Package Assigned (Certification Section, XIII.13.]
A food package must be assigned in a series that is appropriate to the participant's status.
Appropriate documentation and prescriptions must be in the health record, for those food packages and nutritional conditions requiring them.
19. Food Package Number (Certification Section, XIII.13.]
The reviewer will record the food package number assigned to each participant whose health record is being reviewed.' A compilation of these numbers will then be used, in conjunction with the Food Package Distribution Report and clinic observation, to assess whether food packages are being tailored in the clinic.
20. Referrals/Enrollment Documented (Certification Section, XIII.14.]
All applicants to the WIC Program must be screened for referral to the Food Stamp Program, Medicaid and/or TANF. Applicants should also be referred to other appropriate health and social services.
Referrals to other programs or services, current enrollment in other programs or services and/or a decision not to refer must be documented in the applicant's health record.
21. Today's Date (Certification Section, XIII.15.)
Today's Date corresponds to the date the certification process is completed.
Today's Date must be the same as or no more than 60 days later than the Medical Data Date.



102



GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

RECORD REVIEW (Acceptable level of compliance: 90% Records Satisfactory)

22. Professional's Signature and Title [Certification Section, XIII.16.)
The signature and title of the person completing the certification must be recorded An appropriate signature consists of first and last names, or first initial and last name.
23. Primary Nutrition Education Contact, Current Certification [Nutrition Education Section, VI.A., B.]
Individual nutrition education contacts must be documented in the participant's health record.
Documentation of group classes may consist of a participant's signature on a class attendance sheet,voucher register or class roster which contains the lesson object_ive(s) and the original signature of the staff person conducting the class. The method used must have the approval of the Office of Nutrition.
The education must be appropriate to the individual participants' one or group needs.
The primary nutrition education contact must be provided by a competent professional authority (CPA), not by a paraprofessional/nutrition assistant.
Specific aspects of nutrition counseling must be documented (not "Nutrition education provided").
Missed appointments or refusal of nutrition education must be documented in the health record.
The nutrition education must follow the Nutrition Guidelines for Practice.
24. Secondary Nutrition Education Contact, Current or Prior Certification [Nutrition Education Section, NE-VI., A., B.)
If a secondary contact is not documented for the current certification period, documentation must be present for a secondary contact provided during the previous period (infants, children, postpartum breastfeeding and non-breastfeeding women).
For infants, the mid-certification nutrition assessment will be equivalent to a certification visit for the purpose of evaluation of secondary contacts.
At least one secondary contact must be provided during each six-month certification period.
For certification periods that exceed six months (prenatal women), secondary contacts must be provided at a quarterly rate (i.e., a prenatal woman who is on the Program for greater than six months would have to receive a minimum of two secondary contacts) but not necessarily within each quarter.
Secondary contacts for prenatal women will be assessed when the EDC has been reached or a delivery date has been recorded.
103



GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

RECORD REVIEW (Acceptable level of compliance: 90% Records Satisfactory)

Individual nutrition education contacts must be documented in the participant's health record.
Documentation of group classes may consist of a participant's signature on a class attendance sheet, .voucher register or class roster which contains the lesson objective(s) and the original signature of the staff person conducting the class.
The education must be appropriate to the individual participant's health needs.
Nutrition education must be provided by a competent professional authority (CPA). Paraprofessional staff can provide these contacts when nutrition education training approved by the Office of Nutrition has been received. The method used must have the approval of the Office of Nutrition.
Missed appointments or refusal of nutrition education must be documented in the health record.
Specific aspects of nutrition counseling must be documented (not "Nutrition education provided").
The nutrition education musf follow the Nutrition Guidelines for Practice.
25. Breastfeeding Encouraged [Nutrition Education Section VI.A., B.; Breastfeeding Section, BFV.A., B.]
All pregnant participants must be encouraged to breastfeed unless contraindicated for health reasons.
If a pregnant participant is not encouraged to breastfeed, based on health reasons or the refusal of the participant to receive nutrition education, the reason(s) must be documented in the participant's health record.
It is not acceptable to not encourage a woman to breastfeed based simply on no answers to questions on whether she plans to breastfeed or is interested in breastfeeding.
Documentation must include all aspects of breastfeeding discussed (not, "Breastfeeding encouraged").
The breastfeeding education must follow the Nutrition Guidelines for Practice.
26. High Risk Follow-Up Documented [Certification Section, CT-XIII.to.; Nutrition Education Section, NE-VI.A.4., 9.)
A WIC participant who has any of the risk factors identified in the Procedures Manual must receive an individual care plan.
Documentation must indicate nutrition counseling specific to their nutritional condition and problems identified in their diet.

104



GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

RECORD REVIEW (Acceptable level of compliance: 90% Records Satisfactory)

27. Exit Counseling Documented
From the prenatal through the postpartum (breastfeeding or non-breastfeeding) period, a woman participant must receive education on the following topics:
a. Importance of folic acid intake b. Health risks of using alcohol, tobacco and other drugs c. Continued breastfeeding as the preferred method of infant feeding d. Importance of up-to-date immunizations
28. Breastfeeding Data Collected
The questions Ever Breastfed, Currently Breastfeeding, and Weeks Breastfed must be completed as follows:
a. Breastfeeding women: [initial and six-month certification visit (the weeks breastfed at six months after the initial certification must be more than the weeks breastfed at certification)].
b. Postpartum, non-breastfeeding women: certification visit. c. Infants: initial certification and mid-certification assessment visits (the weeks breastfed at
mid-certifcation must be the same or more than the weeks breastfed at certification). d. Children: one year of age certification ( 11-16 months of age).



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GA WIC PROCEDURES MANUAL
TABLE OF CONTENTS PAGE
I. Introduction.................................................................................................................... QI-I IL Monitoring ..................................................................................................................... QI-2 III. Participant Abuse ........................................................................................................... QI-3
A. Dual Participation .............................................................................................. QI-3 B. Dual Participation Verification Form ................................................................ QI-4 C. Participant Abuses and Sanctions ...................................................................... QI-5 IV. Procedure for Repayment ofWIC Funds ...................................................................... QI-9
V. Guidelines for Investigating Employee Abuse ............................................................ QI-I 0
VI. Procedures to Request an Employee Investigation ...................................................... QI-11 VII. Vendor Compliance Investigation ............................................................................... QI-12 VIII. Compliance Investigation Food Purchases .................................................................. QI-13 IX. Disqualified Vendor/Participant Hardship.................................'.................................. QI-14 X. Investigation of Missing VouchersNOC Cards .......................................................... QI-15
A. Vendor Notification ......................................................................................... QI-15 B. Voucher Register ............................................................................................. Ql-15 C. Quality Improvement Voucher Investigation Log ........................................... QI-15 D. Stop Payment ................................................................................................... QI-16 XI. Security oflssuance Materials ..................................................................................... QI-17 XII. Voucher Issuance Security ........................................................................................... QI-18 A. WIC Vouchers ................................................................................................. QI-18 B. Voucher Security ............................................................................................. QI-19



GA WIC PROCEDURES MANUAL

PAGE C. Voucher Storage............................................................................................... QI-19

D. Transporting WIC Vouchers ............................................................................ QI-20

Attachments:

QI-1

Closeout Reconciliation Report ....................................................................... QI-21

QI-2

Quality Improvement Voucher Investigation Log ........................................... QI-22

QI-3

Participant Sample Warning Letter.................................................................. QI-23

QI-4

Request for Investigation Form ....................................................................... QI-24

QI-5

WIC Transaction Report .................................................................................. QI-25

QI-6

Venfication Form Disqualified Vendor

Inadequate Participant Access ......................................................................... QI-26

QI-7

Georgia WIC Program Vendor Donation List ................................................. QI-27

QI-8

Notification Summary of Missing VouchersNOC Cards ............................... QI-28

QI-9

Duplicate Participation Verification Form....................................................... QI-29





GAWICPROCEDURESMANUAL
I. INTRODUCTION
The objective of the Quality Improvement Unit is to provide guidance and assistance to Local Agencies in program compliance and in the investigation of suspected fraud and abuse within the WIC Program. This area includes, but is not limited to, WIC participants, WIC clinical staff, WIC approved vendors, and any other applicable WIC Program abuse which would require investigation.



QI- 1



GAWICPROCEDURESMANUAL
II. MONITORING
1. On a periodic basis (not less than once per year), the WIC Program Coordinator or designee will visit each clinic for the purpose of reviewing clinical procedures, as outlined in the Monitoring Section-Self Reviews.
2. If the review of vouchers/voucher-related materials causes suspicion, and the Coordinator determines that an investigation is needed, the Coordinator shall notify the State WIC Office and proceed with the investigation. The State WIC Office may notify USDA-FCS of the impending investigation and keep them informed of case progress on a periodic basis or as requested/necessary.
3. The Closeout Reconciliation Report (see Attachment QI-1) is generated for the local agency and gives the final disposition of all computer-printed vouchers. This report should be used to monitor the disposition of any vouchers that has a questionable status, i.e. voucher register blank lines, voids, fail to sign, etc. If findings lead to suspicion and the Coordinator determines an investigation is needed, the Coordinator shall notify the State WIC Office and proceed with the investigation.
4. The State WIC Office shall retrieve voucher copies when the Coordinator determines the need during an investigation. These vouchers will be reviewed by the State WIC Office for compliance prior to being forwarded to the Local Agency. A Quality Improvement Voucher Investigation Log should be used when requesting voucher copies from.the State WIC Office (see Attachment QI-2).
5. Investigations may include but are not limited to review of the voucher register, voucher inventory, cashed vouchers, certification records, employee/relative participating in the WIC Program, and if necessary, contacting WIC participants to verify if vouchers were picked up.
6. Investigative/Monitoring clinical reviews will be conducted in conjunction with the monitoring team, and when deemed necessary during an investigation.

QI-2



GAWICPROCEDURESMANUAL
III. PARTICIPANT ABUSE
A. Dual Participation Dual participation occurs when individuals simultaneously participate in the program in one or more WIC clinics. The WIC Program Automated Data System generates a quarterly "Dual Participation Report." The report specifies possible duplicate enrollment in alphabetic sequence. (See Georgia WIC Report Manual for details). The report data is compiled into a composite state report as well as a report for each Local Agency.
The ADP Contractor mails a Composite Dual Participation Report to the State WIC Office and to 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. The report should include the status of the participant (active or terminated), last voucher pickup date, participant's mother, guardian or caretaker's name, and termination date if applicable. Upon receipt of these completed reports, the State Agency will eliminate obvious false duplicates by:
1. Transferring all actions taken by local agencies onto the State composite report and;
2. Notifying any local agencies that have participants whose enrollment has not been reconciled.
The local agency must conduct further investigation until all alleged dual participation is resolved.
The following are examples of possible dual participation situations and the procedures for reconciliation.
1. Participant Enrolled in the Same Local Agency at the Same Clinic Site.
Investigate to determine if there is any difference in .the spelling of the first name. If so, twins may be enrolled. Ifthe first names are spelled exactly the same, then investigate clinical records to determine if it is the same participant or two different participants. Document dual participation information obtained and the final action taken on each case in the participant's health and issuance records.
QI-3



GAWICPROCEDURESMANUAL
The current TAD field code #54 allows the system to identify multiple births. This should reduce, if not eliminate, twins from appearing on the dual participation report. 2. Participant Enrolled in the Same Local Agency at Different Clinic Sites.
Investigate to determine if the participant has received vouchers at both clinic sites. If not, it is possible that two turnaround documents (TADs) were inadvertently printed. The TAD that is incorrect (based on the clinic site the participant is attending) must be deleted. If the participant has picked up vouchers in both sites for the same month, a possible case of participant abuse exists. Refer to the "Participant Abuses and Sanctions" section below for procedures regarding this type of abuse. Documentation must be forwarded to the State WIC Office as a part ofthe 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. Documentation of dual participation information and final action on each case must become a part of the participant's clinic file.
B Dual Participation Verification Form The Dual Participation Verification Form (Attachment Ql-9) was initiated by the Georgia WIC Program System Contractor. The purpose of the form is for the districts to notify the system contractor to remove active participants from the targeted clinic where they appear as dual participants.
The Dual Participation Verification Form must be completed when dual participation has been verified by the local agency, and form should be mailed to the system contractor as soon as dual participation has been verified. Route the form as follows: white copy-System Contractor (Viking), yellow copy-State WIC Office, pink copyDistrict Office, gold copy WIC Clinic. Distribution ofthis form will be handled by the system contractor (Viking).
QI-4



GA WIC PROCEDURES MANUAL

C. 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) 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 of the 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 ofWIC regulations.
If the same individual is found to be a dual participant on a subsequent occasion, he/she must be removed from one program and suspended from the WIC program for a period not to exceed three (3) months provided that the violation is at least $100 or more.
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.
QI-5



GAWICPROCEDURESMANUAL
SANCTION: The participant may be required to pay the State Agency, in
cash, the value of benefits improperly issued to them. The "value ofbenefits" is the dollar amount of WIC 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:
Copy of the front and back of the WIC Assessment/Certification Form signed by the participant or authorized representative.
The serial number of all WJC 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 from contract bank and/or CD ROM 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 determine the participant is 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. QI-6



GAWICPROCEDURESMANUAL
b. Ifthe investigation findings establish that the participant is ineligible for program benefits, the participant will be immediately terminated from the program. The participant will be sent, by certified mail, a . Notice of Termination Form which includes notification of their right to a fair hearing.
c. If the 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 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. Ifthe total value of benefits issued is $100 or more, the participant will be given a notice, supplied to the local agency by the state agency, of the dollar value ofWIC vouchers cashed along with the opportunity for repayment. In no instance will repayment arrangements be extended beyond ninety (90) days from the date notification is provided to the participant.
3. ABUSE: Sale or exchange of vouchers or WIC food items with other
individuals or parties.
I
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 ROSection-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 of unauthorized food or other items of value in place of approved WIC foods.
SANCTION: When proof of abuse has been established, the participant will be suspended from the program for a period not to exceed three (3) months. The participant must be notified of his/her right to a fair hearing (see ROSection-Fair Hearing Procedures).
Ifthe total value of benefits is $100 or greater, the repayment procedures outlined above (Abuse #2d) will be implemented.
QI-7



GA WIC PROCEDURES MANUAL
The State WIC Office must be notified if this abuse is occurring in order for appropriate action to be taken with the vendor.
5. ABUSE: Speaking to clinic staff, vendor personnel, and/or other WIC
participants in an obnoxious, threatening, obscene or derogatory manner.
SANCTION: The participant should be warned, in writing, of the inappropriate verbal behavior and the action that will be taken if the problem continues.
If the 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.

QI-8



GAWICPROCEDURESMANUAL

IV. PROCEDURE FOR REPAYMENT OF WIC FUNDS
A. Repayments will be submitted to the local agency and must be in the form of a cashier's check or money order payable to: DHRIWIC Program.
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 tum proceed with recovery

actions prescribed under the 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-9



GAWICPROCEDURESMANUAL
V. GUIDELINES FOR INVESTIGATING EMPLOYEE ABUSE
When employee intentional abuse is found, it may be considered employee misconduct. Suspected intentional abuse shall be investigated by the Local Agency with 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 talcing WIC vouchers; giving false/misleading information in order to become certified for WIC, etc.)
1. Employees participating in the WIC Program shall have the same rights and obligations as any other WIC participant, however,' employees are not allowed to issue vouchers or certify themselves or family members.
2. Employees participating in 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 result of a DHR-OFA investigation findings, shall depend on
local agency personnel policy and procedures concerning the employee misconduct.
5. Prosecution shall be processed through the District Attorney's Office. The local agency requesting an order of prosecution, shall notify the State WIC Office and the State WIC Office shall notify USDA-FNS.
6. The State WIC Office recommends that any employee found to be abusing the WIC Program should be removed promptly from issuing or processing WIC vouchers, without reappointment rights.
7. The State WIC Office shall inform USDA of any investigations of WIC related employee fraud.

QI-10



GAWICPROCEDURESMANUAL
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 ofthe letter must be forwarded to the Division of Public Health Director's Office and the State WIC Office.
2. Contract agencies requesting an employee investigation shall submit their letter to the Division 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.
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 .



QI-11



GAWICPROCEDURESMANUAL
VII. VENDOR COMPLIANCE INVESTIGATION
Compliance investigations will be coordinated by the State WIC Office.
Investigations will occur at stores that have been identified as "Potentially High Risk" by the State WIC Office through the use of the ADP system reports, complaints, the Request for Investigation Forms received from the districts.
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. (See XIV Complaints Against Vendors, in the Vendor Procedures section ofthis manual).
Local Agencies that would like to conduct compliance buys in their stores must contact the State WIC Office for approval. Ifthe Local Agency conducts any compliance investigations, each buy must be documented by completing the WIC Transaction Report (Attachment QI5). The original copy of this form must be submitted to. the State WIC Office. Upon notification by the local agency, the State WIC Office will notify the contract bank to obtain the original copy ofthe vouchers to be used for these buys.
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.

QI-12



GAWICPROCEDURESMANUAL

VIII. COMPLIANCE INVESTIGATION FOOD PURCHASES
WIC foods and other food items purchased as a result of the compliance investigations, are donated to non-profit organizations. Such non-profit organizations are as follows but are not limited to:

*City and County Fire Department *City and County Police Department *Retirement Homes *Battered Women Shelters *Church Organiz.ations *Homeless Shelters

*Salvation Army *Food Pantry (Bank) *Head Start *Boy Scouts *Girl Scouts

The compliance investigator completes a Food Donation List (see Attachment QI-7) and submits it to the non-profit organiz.ation for verification of foods to be donated. A representative of the non-profit organization will sign the donation list to confirm the receipt of foods, and may obtain a copy of the list for their records.

QI-13



GAWICPROCEDURESMANUAL
IX. DISQUALIFIED VENDOR/PARTICIPANT HARDSIDP
If a vendor is found to be in violation of program policies and regulations through a compliance investigation(s), the vendor will be assessed sanctions for violations occurring in each investigative visit. If a vendor accumulates the maximum allowable sanctions, the store shall be disqualified from WIC Program participation. In the event a vendor disqualification creates inadequate participant access for WIC participants, procedures outlined in the Vendor Handbook (inadequate participant access cases) will be implemented. Procedures and guidelines for vendor disqualification, which are a result of an investigation, are found in the Vendor Section-Terminations/Disqualification.
To assess inadequate participant access in obtaining WIC foods as the result of a vendor disqualification, the State must initiate the verification process. The State will complete an Inadequate Participant Access Form (Attachment QI-6) and submit to the Local Agency Vendor Coordinator. The purpose of the "Access Form" is: (a) to verify if a disqualified vendor's absence will create inadequate access for WIC participants; (b) to verify that there is no adequate participant access in case of future administrative/judicial hearings. Verification of inadequate participant access will be in accordance with inadequate Participant Access Cases Procedures as stated in the Vendor Section.
The District Vendor Coordinator shall verify participant access cases based on regulations in the Vendor Section-Inadequate participant Access Cases. Once verification is completed, the Vendor. Coordinator shall return the original completed form to the State WIC Office within ten (I 0) working days.

QI-14 -



GAWICPROCEDURESMANUAL
X. INVESTIGATION OF MISSING VOUCHERSNOC CARDS
When twenty-five (25) or more WIC vouchers or five (5) or more VOC Cards are missing, the Notification Summary of Missing VouchersNOC Cards (Attachment QI-8) must be completed. When vouchersNOC cards are discovered to be missing, immediately notify the supervisor, WIC Coordinator, and the Police. The assigned police detective shall be given the WIC Coordinator's name or their designee for contact while conducting their investigation, this individual shall report details of investigation to the Quality Improvement Unit.
The WIC Coordinator or designee must submit the Notification Summary to the State WIC Office within three (3) working days of the discovery of missing vouchersNOC cards. Immediately following initial contact from the local agency, the State WIC Office will notify the contract bank to place a stop payment on the missing vouchers. For additional instructions on VOC cards, refer to the CT section of the procedures manual.
A. VENDOR NOTIFICATION Instances where blocks of vouchers are lost or stolen from a WIC clinic, the local agency should notify area retail food vendors that a stop payment has been placed on these vouchers. Vendors should be provided the voucher numbers, and informed not to accept these vouchers for redemption.
B. VOUCHER REGISTER Document the serial numbers ofthe vouchers that are lost or stolen, on the computer voucher register or manual voucher inventory.
C. QUALITY IMPROVEMENT VOUCHER INVESTIGATION LOG 1. To request WIC voucher copies, complete the Quality Improvement Voucher Investigation Log (Attachment QI-2) with the following: a. District/Unit; b. Current date; c. Reason for investigation (is fraud suspected, etc.); d. List voucher numbers; e. Issue date (date missing if manual voucher); f. Clinic number; g. Sign and date.
This form should be completed whenever any voucher copies are being requested.
QI-15



GA WIC PROCEDURES MANUAL
2. Mail the completed Quality Improvement Investigation Log to the State WIC Office, Quality Improvement Unit, along with the Lost/Stolen/Destroyed/Voided Voucher Report. The Quality Improvement Unit will follow up with the local agency immediately on reports that indicate potential fraud. All oth~r requests will be forwarded quarterly at a minimum.
3. Upon receipt of special request voucher copies, the local agency should conduct a review to determine if potential fraud exist, and notify the Quality Improvement Unit if further review or an investigation is required, within thirty (30) days of receipt.
4. The local agency shall work in conjunction with the State WIC Office during an investigation of missing vouchers. When a determination has been made that potential employee fraud exist, the Office of Fraud and Abuse must be contacted. (See V and VI of the QI Section)
D. STOP PAYMENT OF WIC VOUCHERS State WIC Office will place a stop payment on WIC vouchers reported stolen from WIC clinics.

Ql-16



GAWICPROCEDURESMANUAL
XI. SECURITY OF ISSUANCE MATERIALS A. WIC Program Stamps
1. Wie 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. Wie Program stamps must be stored in a location separate from Wie vouchers, I.D. cards, and voe cards.
B. VOC Cards
1. voe 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. voe cards must be stored separately from the voe card inventory.
C. Voucher Register The Voucher register must be stored separately from the vouchers in a locked location.

QI-17



GAWICPROCEDURESMANUAL
XII. VOUCHER ISSUANCE SECURITY
A. WIC Vouchers WIC vouchers are food instruments (checks, coupons, etc.) that are used by a participant to obtain supplemental foods. The State and local agency has the responsibility to maintain control and provide accountability for the receipt and issuance of supplemental foods and food instruments. The state and local agency must also ensure that there is secure transportation and storage of unissued food instruments.
WIC vouchers are negotiable items that are presented to the bank as a check for cash for reimbursement. Therefore all vouchers must be securely protected as checks or cash in order to help prevent voucher theft and deter program fraud.
In the event that unissued vouchers are lost or stolen as a result of security regulations not being followed, the local agency may receive a USDA sanction to repay the value of the lost or stolen vouchers in question. . 1. All vouchers must be stored in a locked cabinet, desk, or closet, when not
being issued. The key which locks the cabinet, desk, or closet must be stored in a secure location (change location of keys occasionally);
2. When issuing manual vouchers from a computer, the clerk must log out
before leaving the work station;
3. When more than one person is using the same terminal, each person must log out upon completion oftheir printing job;
4. Passwords must be changed at a minimum, twice a year;
5. When a voucher issuance employee resigns or is no longer authoriz.ed to issue vou~hers, the following procedures should be implemented: a. Employee resigns, delete employees log in computer access within three (3) business days b. Change all passwords that the employee had access to. c. Change voucher security door key (when applicable). d. Change location of all security keys.
6. Only authorized persons may be given access to WIC vouchers.
7. Computer printed WIC vouchers must be stored separately from the corresponding voucher registers.
QI-18



GAWICPROCEDURESMANUAL
B. Voucher Security WIC voucher stock must not be accessible to participants or other unauthorized persons. Except for the vouchers being issued to the participant you are serving, multiple vouchers must not be placed on top of the issuance space. One of the following methods must be used to assure minimum security of voucher issuance station. 1. Service Delivery Counter which will provide a shield between the issuance clerk and the participant; 2. HaH Door may be used in a small clinic with only one clerk; 3. Vouchers must be kept three (3) feet out of the reach of the participants, or there must be a physical barrier between the vouchers and the participant.
C. Voucher Storage At a minimum, districts must meet one of the following voucher storage procedures when clinics are closed:
I. If vouchers are locked in a standard cabinet, the cabinet must be in a locked room, within a locked building;
2. A locked cabinet in a locked building with an alarm system;
3. A fire proof insulated security file cabinet with combination lock, securely attached to the floor, in a locked building;
4. A safe securely attached to the floor in a locked building;
5. A vault in a locked building.

QI-19



GAWICPROCEDURESMANUAL
D. TRANSPORTING WIC VOUCHERS
1. When transporting WIC vouchers, the voucher register, program stamp, and VOC cards, to a clinic site, they must be secured in a locked box or locked briefcase (see Attachment FD-8).



QI-20

GAWICPROCEDURESMANUAL

ATTACHMENT 01-1

CLOSEOUT RECONCILIATION REPORT

.D/U #

CL #

PAGE 20634 REPORT EWRR840G
GRADY MAll. 15. INFANT CARE

STATE OF GEORGIA WIC SYSTEM CLOSEOUT RECONCILIAilON REPORT FOR niE CLOSEOUT MONni OF JUNE I 995

VOUCHER NUMBER 25709399 26499328

26488329

26488330

26488331

25709404

25709405

25709406

25709407

25709412

25709413

25709414

25709415

25709420

25709421

25709422

25709423

26488336



26488337 26488338 26488339 26488344 26488345 26488346

26488347

26488352

26488353

25709428

25709429

25709430

25709431

25488356

26488357

26488358

26488359

26488364

26488365

26488366

26488367

25709436

25709437

REFERENCE NUMBER
55236263 48629635
48629615 48629626 63771576 63771588 63771592 63771629 63771624 63771617 63771570 63771616 52185535 52185541 52185557 52185542 63851783 67212999 63851787 67213000 67212970 42701052 63778323 67212998 63851800 63851799 63867366 63867371 63867382 63857574 42501 104 68637805 42502548 68637825 42501097 68637806 42502547 68637826 638271 14 638271 13

WIC JO

FAMILY

C P

999054588 2 I 697012089 2 I
697012089 2 I 697012089 2 I 697012089 2 I 699126861 3 I 699126861 3 I 699126861 3 I 699126861 3 999043937 5 I 999043937 5 I 999043937 5 I 999043937 5 I 697010260 I I 697010260 I I 697010260 I I 697010260 I I 697008023 7 I 697008023 7 I 697008023 7 I 697008023 7 I 699148954 0 I 699148954 0 I 6991 48954 0 I 699148954 0 I 695100454 5 I 695100454 5 I 697004511 5 I 697004511 5 I 697004511 5 I 69700451 J 5 I 999051530 7 I 999051530 7 I 999051530 7 I 999051530 7 I 697009847 8 I 697009847 8 I 697009847 8 I 697009847 8 999047451 3 I 999047451 3 I

PARTICIPANT NAME

LAST

FlRST

VCHR lYPE
055 047
039 025 039 028 031 037 054 047 039 025 039 047 039 025 039 031 037 039 055 028 031 037 054 068 072 031 037 039 055 031 037 039 055 031 037 039 055 031 037

CLINIC PAGE

9

ON/CL 09-1-259

RUN DATE 07/13/95

REOMO AMI"
10.61 12.14
.00 9.82 6.33 8.20 8.92 14.54 12.26 12.14 6.33 9.82 6.33 12.22 6.13 10.37 6.13 8.92 13.71 6.33 9.10 7.18 7.23 14.54 8.37 58.87 51.40 8.92 14.54 6.33 9.91 8.92 14.54 6.33 9.91 8.92 14.54 6.33 9.91 6.87 6.95

OA1'E ISSUED
04/06/95 04/14/95
04/14/95 04/14/95 04/14/95 04/06/95 04/06/95 04/05/95 04/06/95 04/06/95 04/06/95 04/06/95 04/06/95 04/12/95 04/12/95 04/12/95 04/12/95 04/11/95 04/1 1/95 04/11/95 04/1 1/95 04/06/95 04/06/95 04/06/95 04/06/95 04/11/.95 04/1 1/95 04/1 1/95 04/1 1/95 04/1 1/95 04/1 1/95 04/1 1/95 04/1 1/95 04/1 1/95 04/1 1/95 04/10/95 04/10/95 04/10/95 04/10/95 04/06/95 04/06/95

STA1\JS OA1'E
05/10/95 04/18/95
04/14/95 04/18/95 04/10/95 04/10/95 04/10/95 04/10/95 04/10/95 04/10/95 04/10/95 04/10/95 04/19/95 04/19/95 04/19/95 04/12/95 04/13/95 05/01/95 04/13/95 05/01/95 05/01/95 05/26/95 04/10/95 05/01/95 04/13/95 04/13/95 04/13/95 04/13/95 04/13/95 04/13/95 05/12/95 05/05/95 05/12/95 05/05/95 05/12/95 05/05/95 05/12/95 05/05/95 04/10/95 04/10/95

CMNTS
EXP 04/18/95
VOID
VOID

TOTAL VOUCHERS CASHED

TOTAL VOUCHERS EXPIRED

TOTAL UNMATCHED TO CERT RECORDS



TOTAL VOUCHERS ISSUED VOIDED UNCLAIMED TOTAL VOUCHERS CREAlED

CLINIC 10TALS

VOUCHERS 805 73 0 878 135 0
1,013

AMOUNT 11,199.66
.00
11,199.66
11,199.66

QI-21

<TOTAL OF CASHED AND EXPIRED> <COMPUTED AND MANUAL VOUCHERS>



GAWICPROCEDURESMANUAL
QUALITY IMPROVEMENT VOUCHER INVESTIGATION LOG

ATTACHMENT 01-2

DISTRICT/UNIT_ _ _ _ _ _ _ _DATE:_ _ _ _ _ _ _ _ _ _ _ __ REASON FOR INVESTIGATION: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

VOUCHER ISSUE CLINIC

NUMBER DATE

#



COMPLETED BY_ _ _ _ _ _ _ _ _ _ _ _ _ _ _.DATE_ _ _ _ _ _ _ __

Form 3789 (>99)

Routing - White Copy - State WIC Office, Yellow - Local Agency

QI-22



GAWICPROCEDURESMANUAL

ATTACHMENTOI-3

PARTICIPANT SAMPLE WARNING LETTER

Dear Participant,
It has come to my attention that you have sold food that you get with your WIC vouchers. This is against WIC Program regulations.
The WIC foods are to be eaten by your child so that he/she can become healthy. The food must be given to him/her and not sold to anyone.
If you continue to sell your WIC food after this warning, your child may be taken off of the WIC Program for up to three (3) months. If you have any questions, please call me at_ _ _ _ ___

Sincerely,
WIC Program Coordinator

QI-23



GAWICPROCEDURESMANUAL

ATTACHMENT 01-4

REQUEST FOR INVESTIGATION FORM

Georgia Department of Human Resources

DATE

WIC REQUEST FOR INVESTIGATION

TO:

FROM:

NAME AND ADDRESS OF STORE (INCLUDE STREET. cm', STATE AND COUNTY) VENDOR NUMBER



NAME OF OWNER OR MANAGER ElHNIC MAKEUP OF STORE'S CLIENTELE

HAS STORE BEEN PREVIOUSLY INVESTIGATED?

YES D

NO

ARE TIIERE 01HER STORES UNDER 1HE SAME OWNERSHIP WlilCH ARE AU1HORIZED FOR PARTICIPATION?
YES NO
If Yes, fill in their names and address.

TYPES OF ABUSES FOR WlilCH INVESTIGATION IS REQUESTED. OlHER INFORMATION USEFUL TO 1HE INVESTIGATOR (PROVIDE ADDI710NAL SHEETS IF NECESSARY)



Form 3775 (3-97)

Form on disk ot district office

Ql-24

GA WIC PROCEDURES MANUAL



u

. ,T

V

1111.,1

I

Store Name and Address:

Georgia Department of Human Resources Division of Public Health
WICProgram WIC TRANSACTION REPORT (WTR)
WTR Returned to WIC Agency:

ATTACHMENT 01-5
VP.nnnr ~.,;..........
I

I. Af. the Check-out counter there (was/were) person(s) in line ahead of me. On

, at about_. I entered the subject's store. I selected the item(s) specified below. The food

instrument indicated above was used for this transaction. The derk sold the item(s) below at a total cost of (If available)$

. During checkout, the voucher was in

plain view of the derk who served the investigator. The price of the items(s) were marked on the ilem(s) or shelf, for ilem(s) not marked, they were verified by:

2.

Time Entered Store:

Time Approached Checkout:

Time Left Store:

3. ;::,t.,J,;~

,..,,.. ,,...

:::t::.,::..!'

!!:::::,::
, ,:,::

YIN

':I'I'!! I ::it!}::1ir1 )':'H

:i:1r:! 1 1)
::.!::':::h'

1

1rn1i:::11:,,i'1

1:i1:r':C:1itfot1 1:, : ,, -,,,:, ,::::::::;:::,.::::':

YIN

:'l(J{:::!([it?!;:'"JHl!:t\;'':, ,_,,,:,:::,,,,,,, ,,. .

YIN

I Prices Marked on Foods or Shelf

Rang up Sale

I

Adequate Supply ofWIC Foods on Shelf

Recorded Price on Voucher

I

Checked ID Cards

I

Gave Receipt to Investigator

4. Comments

5. ""''

,,..,.,..,:,~:,::l_!A' ......:,. ,... v. '""'.";'.....

1jkil'!i::::f;:;c:::tt'.):r:1f:iii'i' ::-:

SEX

RACE

AGE

:i,'f:f!, :::,,:,r::::::::}> ::: ,: ,.., :,:,:::,,::1,::::i:iii!:!}c!\:,1:::t:::::,: '"' : .:,::: ';f;l:'i!t!\l!:i::!;rn:::1;:1':iHJi!}\:'l:::

::

:_:,:,

,"':i''

iii;

HEIGHT

WEIGHT

HAIR COLOR



6. Other Identifying Information:

7. Identified During Transaction as (Title/Name):

,,::,,,, ...,__

,,.,

. .,:;,,,t:;\,,:;;::,,s::;:::;,::;::::c:;:::,:;::r. ,,,...,.,,.,,.,,:::,,,;;1;,,-:11t , .",: ,,;;;;;::~u :,;:::;:;::'.!:t;J.;:,:,;:::

'" ;::

QUALITITY

BRANDNAME

:

::;,;,!Ll:::::l:1

:::' ,,.,,.,, ?:::,:i:;i!ri1ti::111'1t1t::1 :11:,:1rn:::,:::i::; l]iii:1Iti'i:1,1: 1tt:::i,i:11:::i:::;;::11:Jl!rii'! .. , , ... :::::!11,:,::::::::1:::11:,111::fHI!J:

ITEM

PRICE

m .. .::.,, ,,,,,,:,:~ QUALITITY

'.. ;;. ,,..,,,:;:;:;;::;;;;, ,. ,,,..,,;;,;:,/")H+}::1/'i:!!',l[)u:::ru,::ci,::,,,, :1,,-, 2:.:,:,,,,.r,,,::,,u;:;:,Hij\I'il':!I:::r '"' ,,.,,, . , '"'' ,,.;':,,,,:+-:,,,::::::;,::::, ii'i::l'j,J};i@,Iii:: Ii'!:,;:

ITEM

PRICE

,.,,

roi,n,,;.:;;:;;;,,,,,,,\'i' """' ,,_,,

,... :,:;.,;:;:,::;;::

QUALITITY

,:: ,,,., ,::,,::?::,::::::::::'::;::':::;::rn'i::::Ii'i ii' ,,:,:::t' .....
ITEM

,.,.

''""'"'''"''"' ,:;.. _~::;;;;:;;,;:;:::'.::::::::,:::;;:i.il:!!:;:::;i~-::.: . ~



I

, an investigator of the Georgia WIC Program, Department ofHuman Resources,

make the above statement freely and voluntarily knowing that this statement may be used as evidence.

Name:

I Date:

Title:

Investigator Sigpature:

Form 3773 (6199)

QI-25



GAWICPROCEDURESMANUAL

ATTACHKMENT 01-6

VERIFICATION FORM

VERIFICATION FORM DISQUALIFIED VENDOR.



List WIC Vendors Located Near Disqualified Vendor:

Vendor Name Address (Street/Hwy)
Distance In miles (only)

Vendor Name Address(Street/Hwy)
Distance In miles (only)

Vendor Name Address (Street/Hwy)
Distance In miles (only)

Recommendations:

Local Agency Signature _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

QI-26





GA WIC_l_ROCEDURES MANUAL


ATTACHMENT_QI-7

GEORGIA DEPARTMENT OF HUMAN RESOURCES WICPROGRAM
VENDOR DONATION LIST

Georgia Department ofHuman Resources

WICProgram

VENDOR DONATION LIST

TYPE

BRAND

OUANTITY/SIZE

C.B.

VENDOR NO.

CARROT

TYPE

BRAND

OUANTITY/SIZE

C.B.

VENDOR NO.

MILK

ITEMS PURCHASED

NON W.I.C. FOODS ITEMS

TYPE

BRAND

QUANTITY/SIZE

C.B.

VENDOR NO.

JUICE
CEREAL
CHEESE
INFANT CEREAL CONTRACT FORMULA DRIED BEANS PEANUT BUTTER EGGS TUNA
Form 3818 (6-96)

VENDOR NAMES

VENDOR NUMBERS

VENDOR NAMES

VENDOR NUMBERS

ORIGANIZATION NAME: ORGANIZATION REPRESENTATIVE: ADRESS: CITY: W.I.C. REPRESENTATIVE: DATE:
PLEASE USE INK
QI-27

ZIP CODE:

GAWICPROCEDURESMANUAL
PLEASE USE INK

ATTACHMENT 01-8

Georgia Department of Human Resources WICProgram
NOTIFICATION SUMMARY OF MISSING VOUCHERSNOC CARDS
COMPLETE: When 25 or more WIC vouchers; S or more VOC cards; are missing. (A lost/stolen/voucher report must be completed for all missing vouchers) IMMEDIATELY: Notify Supervisor; WIC/Coordinator; and the Police.
Complete the following information: (ALL SECTIONS MUST BE COMPLETED)

SECTION I Name of person who discovered the vouchers/VOC cards missing Name of person completing this form, ifdifferent from above
SECTION II
Name ofperson(s), who is responsible for vouchcrs/VOC cards at this clinic.

D/U/C

SECTION Ill

Number of Missing Vouchcr(s)

Number of Missing voe Cards

NOTE: A separate form must be completed if both Vouchers and voe cards arc missing

Discovered missing: Date

Time

am

Supervisor notified: Date

Time

am

Coordinator notified:

Date

Time

VOUCHERSBeginning#
voe CARDS Beginning #

Ending# Ending#

SECTION IV

Complete a detailed summaiy of how vouchers/VOC cards were discovered missing.

nm

nm

am

pm

SECTIONV List any additional information that would apply to this case.

Use additional sheets of paper if needed, and attach

Use additional sheets of paper if needed. and attach

SECTION VI

Signature of person completing report

(Submit completed report to WIC Coordinator/Person in charge)

Person receiving the report

Title

Date

(Ibis signature is to verify receipt ofthis report, not to verify information on report)

WIC Coordinator or designee, shall submit a copy of this report to the State WIC Office within three (3) working days.

Routing: White Copy-SWO

Pink Copy-District

Yellow CopyClinic



Note:

In the event that unissued vouchers are lost or stolen as a result of an unsecured food instrument environment, thus resulting in USDA sanctions to repay the value of the lost or stolen vouchers in question, the Local Agency will be responsible for repaying the value of those food instruments.
Form (2-96)

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GAWICPROCEDURESMANUAL

ATTACHMENT 01-9

GEORGIA DEPARTMENT OF HUMAN RESOURCES WICPROGRAM

Duplicate Participation Verification Form

DISTRJCT/UNIT I I I I I CLINIC: I I I I I DATE: I I I I I I I

INSTRUCTIONS

USE TIDS FORM TO REMOVE PARTICIPANTS FROM THE DUPLICATE

PARTICIPATION REPORT

RETURN TO VIKING AS SOON AS POSSIBLE.

MAIL TO:

VIKING COMPUTING, INC.

GEORGIA WIC UNIT

1000 N. MADISON AVENUE, SUITE S-3

GREENWOOD, IN 46142

ORFAX TO: (3 I7) 889-9485

THE FOLLOWING CLIENT(S) LISTED BELOW ARE LEGITIMATE PARTICIPANTS. PLEASE REMOVE THEM FROM SUBSEQUENT DUAL PARTICIPATION REPORTS.

PARTICIPANT ID NUMBER
I I

PARTICIPANT NAME

II I I

SIGNATIJRE OF VERIFYING CLERK

PRINTED OR TYPED NAME OF VERIFYING CLERK

COMMENTS:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __



DISlRICTOffiCEAPPROVALDATE._ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

VIKING- WHITE COPY SWO - YELLOW COPY

DISTRICT omCE- PINK COPY

CUNIC-GOID

QI-29





GA WIC PROCEDURES MANUAL TABLE OF CONTENTS Page
I. Introduction .................................................................................................................. BF-1 II. Definitions..................................................................................................................... BF-2 III. State Agency ................................................................................................................. BF-3
A. Breastfeeding Coordinator ........................................................................:....... BF-3 B. Breastfeeding Promotion, Education and Support Responsibilities ................. BF-3 IV. Local Agency ............................................................................................................... BF-5 A. Breastfeeding Coordinator ................................................................................ BF-5 B. Breastfeeding Promotion, Education and Support Responsibilities ................. BF-5 C. Training ............................................................................................................ BF-6 D. Breastfeeding Promotion, Education and Support Plan ................................... BF-7 V. Participant Education ................................................................................................... BF-9 A. Participant Education Requirements ................................................................ BF-9 B. Documentation of Breastfeeding Services ..................................................... BF-11 VI. Participant Referral .................................................................................................... BF-12 A. Referrals ......................................................................................................... BF-12 B. Documentation ............................................................................................... BF-12 VII. Breastfeeding Materials and Resources ..................................................................... BF-13 A. Printed and Audio-Visual Materials ............................................................. BF-13 B. Breastfeeding Equipment and Supplies ......................................................... BF-13 VIII. Allowable Costs for the Promotion and Support of Breastfeeding............................. BF-16 A. Minimum Expenditure Requirement .............................................................. BF-16 B. Allowable Breastfeeding Promotion and Support Costs ................................ BF-16



GA WIC PROCEDURES MANUAL Page
C. Documentation of Costs...................................................:.............................. BF-17

IX. Documentation of Breastfeeding Rates....................................................................... BF-18

A. Documentation ofWIC Type.......................................................................... BF-18

B. Documentation of Weeks Breastfed ............................................................... BF-19

Attachments

BF-I Position Paper on Breastfeeding ................................................................................. BF-20

BF-2 Merit System of Personnel Administration, State of Georgia Class Title: Senior Public Health Educator - Lactation Consultant.. .......................... BF-21

BF-3 Georgia Gain Proposed Job Description: Breastfeeding Coordinator ........................ BF-23

BF-4 Guidelines for Breastfeeding Promotion and Support in the WIC Program .................................................................................................... BF-25



BF-5 Breastfeeding Resources Recommended by the Office of Nutrition .......................... BF-36

BF-6 Allowable and Unallowable Costs for the Promotion and Support of Breastfeeding ............................................................................................ BF-39

BF-7 Issues to Consider When Providing Breast Pumps ..................................................... BF-40

BF-8 Status Change from Prenatal to Breastfeeding and Assignment of Priority to Breastfeeding Mother and Infant............................................................... BF-43

BF-9 Key for Entering Weeks Breastfed ............................................................................. BF-45





GA WIC PROCEDURES MANUAL
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 W1C 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 of intense 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 of their clients. Through the WIC Program they have a unique opportunity to influence decisions on infant feeding. As stated in the Division of Public Health Position Paper on Breastfeeding (Attachment BF-1) a sound program of information and support is necessary to promote the successful establishment and maintenance of breastfeeding. Such a program should be integrated into the health care system and should encompass both the prenatal and postpartum periods.



1 Healthy People 2000: National Health Promotion and Disease Prevention Objectives, U.S. Department of Health and Human Services, 1990.
BF-1



GA WIC PROCEDURES MANUAL
II. DEFINITIONS
Breastfeeding promotion, education and support are components of a process through which individuals gain the understanding, skills and motivation necessary to be able to select breastfeeding as the preferred method of feeding, as well as to initiate and maintain breastfeeding for a significant period of time.
Federal Regulations 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 le~st once every 24 hours.
Relactation/induced lactation after a period of not breastfeeding, or by a woman who is not the biological mother of the infant, also qualifies the woman as breastfeeding.



BF-2



GA WIC PROCEDURES MANUAL
III. STATE AGENCY
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 of Nutrition.
A qualified nutritionist (Master's degree and Registered Dietitian, 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 of the WIC Program.
B. Breastfeeding Promotion, Education and Support Responsibilities
The following are the State Agency responsibilities for breastfeeding promotion, education and support:
1. Develop, implement and evaluate the State Breastfeeding Promotion, Education and Support Plan. Periodically review and evaluate the plan, and make appropriate revisions as necessary.
2. Develop guidelines for local agency Breastfeeding Promotion, Education and Support Plan development. Review each plan and provide feedback.
3. Monitor the progress of local agency breastfeeding promotion, education and support plans on a periodic basis through on-site visits and reports.
4. Evaluate breastfeeding promotion, education and support services of all local agencies.
5. Develop and implement a plan for providing training and technical assistance for Competent Professional Authorities (CPAs), paraprofessional staff, and clerical staff at local clinics. Training and technical assistance provide CPAs with current information on the management of normal breastfeeding issues and special problems in lactation. It provides all staff with an understanding of the importance of promoting, and ways to promote, breastfeeding in a clinic setting.
6. Identify and develop resource and education materials for use by local agencies. Provide materials in languages other than English in areas where a substantial proportion of the population needs the information in a language other than English, considering the size and concentration of such population and, where possible, the reading level of the participants.
BF-3



GA WIC PROCEDURES MANUAL
7. Coordinate WIC breastfeeding promotion, education and support activities with related programs and professional groups such as hospitals, private medical organizations, the Cooperative Extension Service, professional organizations, advisory committees, La Leche League, and other breastfeeding support and advocacy groups, private lactation consultants, etc.
8. Develop and implement procedures to assure that encouragement to breastfeed is offered to all prenatal participants, unless medically contraindicated.
9. Perform and document evaluation of breastfeeding promotion, education and support activities for each local agency on an annual basis. The evaluations shall include an assessment of the participant's views concerning the effectiveness of the education they received.
10. Establish standards for participant contact that ensure adequate breastfeeding education.
11. Monitor local agency activities to ensure compliance with defined local agency responsibilities and participant breastfeeding education contacts.
12. Establish breastfeeding promotion, education and support standards which include, at a minimum, the following:
a. A policy that creates a positive clinic environment which endorses breastfeeding as the preferred method of infant feeding.
b. A requirement that each local agency designate a staff person to coordinate the breastfeeding promotion and support activities.
c. A requirement that each local agency incorporate task-appropriate breastfeeding promotion and support training into orientation programs for new staff involved in direct contact with WIC clients.
d. A plan to ensure that women have access to breastfeeding promotion, education, and support activities during the prenatal and postpartum periods .

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GA WIC PROCEDURES MANUAL
IV. LOCAL AGENCY
A. Breastfeeding Coordinator
1. Each local agency must designate a staff person to coordinate breastfeeding promotion, education and support activities. The breastfeeding coordinator position may be a qualified nutritionist, nurse, health educator or certified lactation consultant. Attachment BF-2 lists a job description for Health Educator Senior, which may be used to assure that an individual is qualified to fill this position. A Georgia Gain job classification, entitled Breastfeeding Coordinator, specific to nutritionists can be found in Attachment BF-3.
2. It is recommended that this position be designated as a full-time position in order to facilitate coordinating services throughout the local agency and across program lines and to adequately meet Federal requirements.
3. It is recommended that the breastfeeding coordinator be, or work towards becoming, a certified lactation consultant. At a minimum, the breastfeeding coordinator should complete the Lactation Specialist SelfStudy Series which has been provided to each local agency by the Office of Nutrition.
4. It is recommended that the breastfeeding coordinator work across program lines to provide breastfeeding services, thus increasing opportunities for all current and potential WIC participants to be reached. This will also serve to integrate services, and assure that all clinic staff receive appropriate training and deliver consistent information on breastfeeding.
B. Breastfeeding Promotion, Education and Support Responsibilities
The Georgia WIC Program is committed to the implementation of the Guidelines for Breastfeeding Promotion and Support in the WIC Program, developed by the National 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:
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).
a. It is important to assure that relevant education materials available to participants portray breastfeeding as the preferred infant feeding method. The following items must be free of formula product names: print and audiovisual materials; and office supplies such as cups, pens and note-pads.
BF-5



GA WIC PROCEDURES MANUAL
b. Staff should be careful not to communicate overt or subtle endorsements of formula. Such messages may influence a mother's decision about infant feeding or her breastfeeding pattern. Once a mother initiates infant feeding, WIC staff should support her decision.

c. The local agency must minimize the visibility of formula and bottlefeeding equipment through storing supplies of formula, baby bottles and nipples out of view of participants.

d. Staff must not accept formula from formula manufacturer representatives for personal use.

e.

Staff should make every effort to provide a supportive environment

in which women feel comfortable breastfeeding their infants. The

clinic waiting area can be used advantageously to motivate women to

recognize breastfeeding as the "norm" rather than the exception. The

clinic area can also be used to provide worksite support for

breastfeeding WIC staff.

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).

C. Training

1. 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 of the Competency Based Nutrition Skills Workshops and the Competency Based Lactation Skills Workshop during their first twenty-four (24) months of employment. The Competency Based Nutrition Skills Workshops are conducted by the Office of Nutrition. These workshops provide WIC competent professional authorities (CPAs) with current information on nutrition issues, and include the topic ofbreastfeeding management in normal and special situations. The Competency Based Lactation Skills Workshop provides information, hands-on experience and round-table discussions on basic lactation management and special situations.

BF-6



GA WIC PROCEDURES MANUAL
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 of the workshops (see Attachments NE-2 and NE-3 for recommended forms).
D. Breastfeeding Promotion, Education and Support Plan
1. Annual Plan of Activities
The State Agency develops an annual Breastfeeding Promotion, Education and Support Plan which 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 shall submit to the State, by June 1 every two years, a Plan of Activities based on the State Plan objectives, and recommendations for additions or changes to the State Plan. A three (3) year Breastfeeding Promotion, Education and Support Plan covering FFY 2000-2002 was due in the Office of Nutrition by September 1, 1999. This Plan should be incorporated in the local agency strategic plan for WIC and nutrition services.
a. The local agency Breastfeeding Plan must include:
1) A listing of State Plan objectives that will be addressed by the local agency;
2) Action steps, including activities and methods for each objective selected;
3) Resources to conduct each objective; 4) Milestones of activities for each objective; 5) Evaluation design to determine the extent to which the
outcome is commensurate with the State objective.
b. The local agency Plan must address, at a minimum, the Federal requirements: establishment and maintenance of a local agency breastfeeding coordinator, 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
BF-7



GA WIC PROCEDURES MANUAL
the prenatal and postpartum periods.
C. The recommended format for submission of the Breastfeeding Plan can be found on Attachments NE-1 and NE-4, with exclusion of the 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 November 30 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 of the Update can be found on Attachment NE-5.

BF-8



GA WIC PROCEDURES MANUAL
V. PARTICIPANT EDUCATION
A. Participant Education Requirements
1. The Nutrition Guidelines for Practice are the established guide for breastfeeding education. Nutrition Guidelines for Practice manuals are located in each health department and with each local agency nutrition coordinator.
2. All pregnant part1c1pants 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 HIV positive, according to the Centers for Disease Control and Prevention guidelines, should also avoid breastfeeding.
3. As part of the prenatal breastfeeding education, the following information must be offered on WIC benefits for breastfeeding women:
a. Breastfeeding women are at a higher level in the priority system than non-breastfeeding postpartum women, and are more likely to be served than these women when local agencies do not have the resources to serve all qualified individuals.
b. Breastfeeding women may receive WIC benefits for up to one ( 1) year 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. Breastfeeding women should be taught hand expression of breastmilk. 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 be made to trained staff or the local agency breastfeeding coordinator.
2 Healthy People 2000: National Health Promotion and Disease Prevention Objectives, U.S. Department of Health and Human Services, 1990.
BF-9



GA WIC PROCEDURES MANUAL

5. Breastfeeding women must be taught signs of adequate intake by the breastfed infant. Signs of adequate intake are:

a. Nursing 8-12 times per 24 hours b. Wets diaper at least 6 times per 24 hours c. Several stools per 24 hours, in first month d. Breasts feel softer after feeding e. Visible or audible signs of swallowing f. Weight gain over time" (for moms who come in for weight checks)

It is recommended that adequate intake be assessed on during the diet assessment, and documented on the diet assessment form. See Certification Section, Dietary Assessment attachment.

6. 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.

7.

Local agencies are encouraged to use peer counselors trained by the State or

local agency to provide encouragement, education, and support to prenatal

and breastfeeding women.

8. Paraprofessionals can also provide breastfeeding education and support when appropriate training has been received. The Office of Nutrition must approve the training plan. See Attachment NE-6 for the Guidelines for Paraprofessional Training and list of items to be submitted for approval.

9. An individual care plan should be developed for a participant based on the need 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 - Plan) note format.

10. Lesson plans 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 of Nutrition at the time of program reviews.

11. If the participant/caregiver is unable to receive services at the clinic for an extended period of time, home visits are the recommended method for providing breastfeeding education contacts.

12. Local agencies are also encouraged to provide ongoing lactation support for prenatal and breastfeeding women by telephone. If possible, a breastfeeding

BF-10



GA WIC PROCEDURES MANUAL
hot-line should be established to facilitate access to information and support services.
B. Documentation of Breastfeeding Services
1. All breastfeeding education and support contacts received by participants must be documented in the participant's health record. A 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/nutritional advantages, positioning).
b. The POMR (Problem Oriented Medical Record)/SOAP note format is the recommended method of documentation. A flow sheet may be used as long as it contains all components of a SOAP note.
C. Group 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 of the staff person conducting the class. A description of the 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. Documentation of missed appointments and refusal to receive education is important for the purpose of monitoring and further education efforts.

BF-11



GA WIC PROCEDURES MANUAL
VI. PARTICIPANT REFERRAL
A. Referrals
1. Prenatal or breastfeeding part1c1pants 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.
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.

BF-12




GA WIC PROCEDURES MANUAL
VII. 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). As stated in IV.B. l. above:
a. It is important to assure that relevant educational materials available to participants portray breastfeeding as the preferred infant feeding method.
b. The following items must be free of formula product names: print and audiovisual materials, and office supplies such as cups, pens and note-pads. Staff should be careful not to communicate overt or subtle endorsements of formula. Such messages may influence a mother's decision about infant feeding or her breastfeeding pattern.
c. The local agency must minimize the visibility of formula and bottle-feeding equipment through storing supplies of formula, baby bottles and nipples out of view of participants.
Attachment BF-5 provides a list of resources that are recommended for use by the Office of Nutrition.
B. Breastfeeding Equipment and Supplies
1. Allowable Costs
Local agencies are encouraged to assess the need for breastfeeding equipment and supplies. Providing equipment and supplies should not generally be the primary means by which the State and local agencies meet their breastfeeding promotion and support target expenditures. Breastfeeding aids should be used in conjunction with appropriate counseling, education, and follow-up provided by trained staff.
Breast pumps and other breastfeeding aids may not be provided to all pregnant or breastfeeding women solely as an inducement to consider or to continue breastfeeding.
The policy on allowable costs for the promotion and support of breastfeeding is explained in VIII. below, and in the Administrative Responsibilities section of the Procedures Manual. Attachment BF-6 provides a list of allowable and unallowable costs, as specified in the Federal Regulations.
BF-13



GA WIC PROCEDURES MANUAL
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 or maternal hospitalization, or if temporary weaning is necessary.
Breast pumps are not a direct program benefit that State agencies are required to provide but rather are aids that may be offered to certain WIC participants to facilitate breastfeeding. The pumps may be offered free or at cost to WIC participants. Issues to consider when providing breast pumps are explained in Attachment BF-7.
3. Instructions for Breast Pump Use
Local agencies with breast pump loan and give-away programs must establish written policy and procedures regarding appropriate use, and instructions to be provided to breast pump recipients. The following must be included in the policy and procedures:
a. A trained, designated staff person is to provide instruc,tions to the breastpump recipient on the proper use, assembly and cleaning of the breast pump.
b. The participant rece1vmg the breast pump should be able to demonstrate the proper usage of the breast pump before leaving the issuing facility.
BF-14



GA WIC PROCEDURES MANUAL
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-15



GA WIC PROCEDURES MANUAL
VIII. ALLOWABLE COSTS FOR THE PROMOTION AND SUPPORT OF BREASTFEEDING
A. Minimum Expenditure Requirement
The State Agency's Breastfeeding Promotion and Support (BFPS) mm1mum expenditure requirement is equal to $21 (starting in FFY '91), adjusted for inflation as of October 1 of every year, multiplied by the average number of pregnant and breastfeeding women participating in the program in the months of July through September of the previous federal fiscal year.
On an annual basis, the State WIC Program Allocations Advisory Committee will make recommendations to the State Agency on the amounts of this requirement to be expended at the local agency and State levels.
B. Allowable Breastfeeding Promotion and Support Costs
State WIC Program expenditures that are classified and reported as breastfeeding promotion and support, and may count toward the BFPS spending requirement include, but are not limited to, the following:
Salaries:
1. Salary and other costs for time, including preparation and travel time, spent on BFPS training and consultations, both individual and group.
2. Salary and other costs, for staff to organize volunteers and community groups to support breastfeeding WIC participants.
3. Salary and benefit expenses of peer counselors and individuals hired to undertake home visits and other actions intended to assist women to continue breastfeeding.
4. Salary and other costs incurred in developing the BFPS portion of the State Plan and local agencies' BFPS action plans.
5. Interpreter or translator services to facilitate breastfeeding promotion and support.
Training:
6. Costs of training BFPS educators, including costs related to conducting training sessions and purchasing and producing training materials.
BF-16



GA WIC PROCEDURES MANUAL
Space and Facilities:
7. Costs of clinic space devoted to BFPS education and training activities, including space set aside for breastfeeding WIC infants.
Materials and Equipment:
8. Costs of procuring and producing BFPS materials and equipment.
9. Breastfeeding aids which directly support the initiation and continuation of breastfeeding. See Attachment BF-6 for a list of allowable and unallowable breastfeeding aids.
Monitoring and Evaluation:
10. Costs of documenting, monitoring, and/or evaluating BFPS staff, activities, methods and materials. This includes the cost of collecting, analyzing and evaluating data concerning WIC participants' opinions on the effectiveness of the BFPS they received and the incidence and duration of breastfeeding for WIC participants, to assess the effectiveness of breastfeeding promotion, education and support efforts.
Travel:
11. Travel and related expenses incurred by WIC staff to conduct any BFPS activity.
Other Sources:
12. Costs ofreimbursable agreements with other organizations, public or private, to undertake training and direct service delivery to WIC participants concerning breastfeeding promotion and support.
C. Documentation of Costs
The State and local agencies must document all Federal WIC grant funds expended to meet the minimum BFPS requirement. Documentation is necessary so that, when subject to audit, the WIC State Agency can clearly demonstrate the expenditure requirement has been satisfied.
Salary costs identified and reported as being for BFPS activities must be supported with employee payroll and time distribution records. Costs such as equipment purchases and travel must be supported with accounting records, including source documents such as invoices and travel statements.
BF-17




GA WIC PROCEDURES MANUAL
IX. DOCUMENTATION OF BREASTFEEDING RATES
The Georgia WIC Program documents breastfeeding rates by two different methods: percentage of women who are certified as breastfeeding (WIC Type B), and self-reported information on weeks breastfeed (initiation). It is important that documentation be accurate in both instances since they have a major impact on administration of the WIC Program. These two methods are described below:
A. Documentation ofWIC Type
The State agency must have breastfeeding promotion and support expenditures which are based on the number of prenatal (WIC Type P) and breastfeeding women (WIC Type B) on the WIC Program. In addition, the Southeast Regional Office of USDA monitors changes in breastfeeding rates based on the number of women who are listed as breastfeeding (Type B on the WIC System). Breastfeeding women should be entered into the system in the following ways:
1. Status Change from Prenatal (P) to Breastfeeding (B) During Subsequent Certification: A prenatal woman gives birth and is being certified as breastfeeding, within six weeks postpartum.
2. Status Change from Prenatal (P) to Breastfeeding (B) Without a Subsequent Certification: When a prenatal participant delivers her infant(s) and initiates breastfeeding, the local agency is encouraged to change the participant's status from that of Prenatal (P) to Breastfeeding (B) through an Update to the system. This should occur as soon as the local agency is made aware of the participant's change in status, as it will enable the program to capture those women who initiate breastfeeding, but may discontinue breastfeeding by their subsequent certification. A subsequent certification is not required in order to simply change the participant's status from P to B, as long as she is less than six (6) weeks postpartum. Note: This action does not exclude the participant from the required subsequent certification, in order to continue on the program past the six weeks postpartum. Attachment BF-8 provides instructions on making the status change.
3. Assignment of Breastfeeding Status During Certification: A woman was not on the program while she was pregnant but is being certified as a breastfeeding woman.
NOTE: A woman and her infant 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 II.).
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GA WIC PROCEDURES MANUAL
B. Documentation of Weeks Breastfed
The State agency uses this information to monitor changes in breastfeeding initiation and duration rates by State, local agency and individual clinic sites. This information is very useful in program planning and targeting of resources. The Infant Breastfeeding Characteristics Report, which includes this information, is sent to the local agencies on a monthly basis.
It is critical that all staffwho complete the WIC Assessment/Certification Forms and the Turnaround Documents be instructed on the importance 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 (11 - 16 months of age)
Participants/caregivers should be asked about weeks breastfed, using the following, or similar words: "How long have you breastfed this baby/child?" or "How long has this baby/child been breastfed?" The length of time breastfed must be entered in weeks. When the answer to the question is given in days or months, this information must be converted to weeks. See Attachment BF-9 for appropriate codes to use for weeks breastfed.

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GA WIC PROCEDURES MANUAL

Attachment BF-1

POSITION PAPER ON BREASTFEEDING

If the children of Georgia are to be healthy and strong, it is essential that they receive the best possible nutrition when they are infants. Breast milk is the ideal first food for the human infant. In addition to the nutritional benefits for the infant, this method of feeding offers unique physiological and psychological advantages to both the mother and the infant. Every infant, therefore, should receive the benefits of this ideal choice for infant feeding. This paper presents the recommendations of the State of Georgia for encouraging breastfeeding and defines the advantages of breastfeeding for the health of mothers and infants.

No formula, no matter how "humanized", can take the place of human milk. Decreased infant mortality and optimum infant health are the most important goals of the Division of Public Health. Breastfeeding can contribute significantly to the achievement of these goals because:

* breast milk provides an ideal balance of nutrients 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, sanitary food.

A sound program of information and support is necessary to promote the successful establishment and maintenance of breastfeeding. Such a program should be integrated into the health care system and should encompass both the prenatal and postpartum periods. Based on the World Health Organization/United Nations International Children's Fund (WHO/UNICEF) 1979 meeting on Infant and Young Child Feeding, the WHO 1981 Resolution and the recommendation of the American Academy of Pediatrics Committee on Nutrition, the Georgia Department of Human Resources recommends that:

* 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 of promoting 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 of breastfed infants. * infant formulas not be marketed or distributed in ways that may interfere with the protection and
promotion of breastfeeding.
* places of business, including government offices, facilitate the maintenance of lactation through
liberalized policies that would promote breastfeeding.

All the available knowledge indicates that breastfeeding is the best choice for infant feeding and should be promoted for mothers and infants of the State. Breast milk as this choice for infant nutrition will promote optimum health for future generations of Georgians.

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GA WIC PROCEDURES MANUAL

Attachment BF-2

SAMPLE JOB DESCRIPTION SENIOR PUBLIC HEALTH EDUCATOR- LACTATION CONSULTANT

The examples of work given are illustrative of the duties assigned to positions of this class. No attempt is made to be exhaustive. The intent of the listed examples is to give a general indication of the levels of difficulty and responsibility common to all positions of this class.

The standards for training and experience express the minimum background necessary as evidence of an

applicant's ability to qualify for positions of this class. Unless otherwise stated, the Applicant Services

division may allow substitution of appropriate education or experience for the training and experience

minimum listed.



DEFINITION

Under direction, performs work of moderate difficulty in planning and implementing breastfeeding education activities related to public health programs; and performs related work as required.

EXAMPLES OF DUTIES

I. Coordinates breastfeeding promotion project. Writes, revises, and evaluates the district's breastfeeding services.

A. Establishes relationships with community health centers and/or hospital staff to provide breastfeeding services.

B. Provides 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 their initial visit, to breastfeed by providing an array of educational material and counseling.

B. Provides additional breastfeeding counseling to prospective breastfeeding women during the last trimester through breastfeeding classes and/or individual counseling.

C. Provides postpartum assessment of breastfeeding dyad, education, and assistance in resolving problems upon request. Provides adequate documentation of services and makes appropriate referrals for continuity of care.

D. Develops and implements continuing education and support networks through a variety of methods, such as support groups, peer counselors, etc.

E.

Supervises and trains peer counselors.

F.

Has ability to communicate effectively in writing, including grant proposals.

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GA WIC PROCEDURES MANUAL

Attachment BF-2 cont'd

III. Evaluates effectiveness of breastfeeding program activities.

A. Produces reports to determine breastfeeding rate and duration.

B. Assists WIC Nutrition Coordinator in writing the breastfeeding promotion plan and annual update of breastfeeding activities.

C.

Shares reports at local district meetings and Statewide breastfeeding conferences.

IV. Attends inservice education programs and annual Statewide breastfeeding conferences.

V. Other miscellaneous duties, activities and responsibilities as program needs develop and change, and as assigned.

MINIMUM QUALIFICATIONS: NECESSARY KNOWLEDGE, SKILLS, AND ABILITIES

Considerable ability to assess the effectiveness and needs of a lactation education program and to plan and implement appropriate changes and improvement; and to assess and counsel an individual.

Considerable skill in the organization and preparation of lactation literature and visual aids; in making oral presentations of instructional programs to the general public and to other health specialists.

Good knowledge of educational program development and implementation as related to the preparation of health education displays, lectures, written material, and classroom programs; of data collection and evaluation techniques appropriate to the assessment of the breastfeeding program.

Good working skills in communicating effectively with the professional staff, general public and paraprofessionals; in use of educational literature and visual aids; in making oral presentations of instructional programs; in making recommendations for equipment needs; and in ability to budget.

TRAINING AND EXPERIENCE

Completion of a masters degree in public health education, education, nursing, home economics or a field directly related to public health activities. Has successfully completed the State certification or equivalent.

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GA WIC PROCEDURES MANUAL

Attachment BF-3

GEORGIA GAIN PROPOSED JOB DESCRIPTION

JOB CODE: JOB TITLE:

E0707% BREASTFEEDING COORDINATOR

GENERAL SUMMARY

Under general supervision, plans, develops, implements and evaluates strategies for promoting and supporting breastfeeding among the high risk, low income population, especially prenatal/breastfeeding women and infants.

RESPONSIBILITIES AND STANDARDS

Responsibility Number 1 (All)
-------------------------------------- --------------------------------------
Develops long and short-term goals for breastfeeding promotion and supports activities for the district.

STANDARDS:

1.

Works closely with the supervisor to develop an appropriate District Breastfeeding Promotion and Support

Plan.

2.

Coordinates breastfeeding services among all clinic sites to ensure efficiency of services provided.

3.

Accurately interprets federal/state regulations to ensure adherence to these.

4 .

Makes sound and defensible recommendations to the supervisor regarding the breastfeeding budget.

5.

Develops continuing education, support networks for mothers and networks for professionals in breastfeeding

promotion and support.

Responsibility Number 2 (Some)
---------------------------- ---------------------------------------------------
Implements breastfeeding promotion and support plans, to include staff development, community networks and services
to clients.

STANDARDS:

1.

Provides inservice education, materials and/or needed equipment for staff development in a timely manner.

2.

Establishes a good working relationship with community health centers and/or hospital staff to assure

continuity of breastfeeding services to clients.

3.

Serves as the District's primary resource person regarding breastfeeding education and support by providing

prompt responses to inquiries.

4.

Provides direct services to clients through prenatal classes, individual instruction, referral for appropriate case,

telephone consultations according to established laws and guidelines.

5.

Coordinates pump loan program to ensure maximum usage of available pumps and instructs both staff and

clients on use of breast pumps as needed.

6.

Serves as primary resource person to health department staff regarding current recommendations and

information in breastfeeding management.

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GA WIC PROCEDURES MANUAL

Attachment BF-3 cont'd

Responsibility Number 3 (All)

---------------------------------------

Works closely with the supervisor to evaluate the effectiveness of breastfeeding program activities.

STANDARDS:

1.

Monitors reports to accurately determine breastfeeding rates by county, district, and state.

2.

Writes the annual progress report on the breastfeeding promotion and support plan by providing appropriate

input in a timely manner.

3.

Maintains necessary reports and data for the purpose of documenting incidence and duration of breastfeeding,

client-centered activities, activities conducted with other agencies, community groups and local hospitals, and

training conducted.

Responsibility Number 4 (All)
----------------------------------------- - - - - ---------------------------------------------
Creates and maintains a high performance environment characterized by positive leadership and a strong team
orientation.

STANDARDS:

l.

Defines goals and/or required results at beginning of performance period and gains acceptance of ideas by

creating a shared vision.

2.

Communicates regularly with staff on progress toward defined goals and/or required results, providing specific

feedback and initiating corrective action when defined goals and/or results are met.

3.

Confers regularly with staff to review employee relations climate, specific problem areas and actions necessary

for improvement.

4.

Evaluates employees at scheduled intervals, obtains and considers all relevant information in evaluations and

supports staff by giving praise and constructive criticism.

5.

Recognizes contributions and celebrates accomplishments.

6.

Motivates staff to improve quantity and quality of work performed and provides training and development

opportunities as appropriate.

Responsibility Number 5 (All)
---------------------------------------------- ---------------------------
Maintains responsibility for personal professional continuing education to enable application of current professional
practice.

STANDARDS:

1.

Participates in professional workshops, seminars, nutrition staff meetings and other inservices as scheduled.

Summarizes relevant information received in the training sessions and shares with other staff either in verbal

or written form.

2.

Remains knowledgeable and up-to-date in the field of nutrition through reading nutrition and medical journals

and textbooks.

3.

Maintains CPR certification and proficiency by renewing certification bi-annually.

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GA WIC PROCEDURES MANUAL

Attachment BF-4

POSITION PAPER NATIONAL ASSOCIATION OF WIC DIRECTORS
April 1994
Guidelines for Breastfeeding Promotion and Support in the WIC Program
These guidelines were developed to assist local and state WIC agencies initiate and strengthen breastfeeding promotion and support programs. The guidelines address training, clinic environment, coordinated efforts, program evaluation, breastfeeding education and support, and the food packages for breastfed infants and breastfeeding women.
The guidelines are numbered for easy reference and are listed in random order. Therefore, the numbering system does not reflect rank order or priority.
GUIDELINE #1 Breastfeeding promotion and support are enhanced when local agency WIC staff receive orientation and task-appropriate training on breastfeeding as the preferred method of infant feeding.
GUIDELINE #2 Breastfeeding promotion and support are enhanced when policies encourage a positive clinic environment and endorse breastfeeding as the preferred method of infant feeding.
GUIDELINE #3 Breastfeeding promotion and support are enhanced when WIC agencies coordinate with the private and public health care systems, educational systems, and community organizations.
GUIDELINE #4 Breastfeeding promotion and support are enhanced when positive breastfeeding messages are incorporated in relevant educational activities, materials, and outreach efforts.
GUIDELINE #5 Breastfeeding promotion and support are enhanced when activities are evaluated on an annual basis.
GUIDELINE #6 Breastfeeding promotion and support are enhanced when appropriate breastfeeding education and support is offered to all pregnant WIC participants.
GUIDELINE #7 Breastfeeding promotion and support are enhanced when policies allow breastfeeding women to receive all WIC services regardless of their breastfeeding patterns.

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GA WIC PROCEDURES MANUAL

Attachment BF-4, cont'd

GUIDELINE #8 Breastfeeding promotion and support are enhanced when policies allow breastfeeding infants to receive a food package consistent with their nutritional needs.

GUIDELINE #9 Breastfeeding promotion and support are enhanced when breastfeeding support and assistance is provided throughout the postpartum period, particularly at critical times when the mother is most likely to need assistance.

SUGGESTIONS FOR IMPLEMENTATION

GUIDELINE #1

Breastfeeding promotion and support are enhanced when local agency WIC staff receive orientation and task-appropriate training on breastfeeding promotion and support.

Suggestions for Implementation

1. It is important to develop orientation gui.delines for new WIC employees that address:



clinic environment policies.



program goals and philosophy regarding breastfeeding



task-appropriate information

Rationale: All new employees (support staff, paraprofessionals and professionals) must be familiar with program policies, goals and philosophy regarding breastfeeding. When all program staff project a positive attitude about breastfeeding, clients will be more comfortable discussing their breastfeeding questions and concerns.

2. It is important that the state agency develop guidelines for on-going training that address:



culturally appropriate breastfeeding promotion strategies



current breastfeeding management techniques to

encourage and support the breastfeeding mother and infant



appropriate use of breastfeeding education materials



identification of individual needs and concerns about breastfeeding

Rationale: Ongoing training for staff providing breastfeeding education is needed because information about breastfeeding education continues to evolve. Addressing specific ethnic and culturally based needs fosters appropriately targeted messages in print and audiovisual materials.

3. It is important that local agency staff participate in breastfeeding training such as:



statewide and local conferences and workshops

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GA WIC PROCEDURES MANUAL



events sponsored by other agencies and organizations

Attachment BF-4 cont'd

Rationale: Local agencies' participation in breastfeeding training is essential to successful implementation of breastfeeding promotion programs.

4. It is important that the local agency and state agency appoint a breastfeeding coordinator.

Rationale: Appointing a breastfeeding coordinator helps ensure that breastfeeding promotion and support activities are integrated into WIC program operations. The specific responsibilities and tasks of breastfeeding coordinators will vary from agency to agency based on their breastfeeding promotion and support activities. Breastfeeding coordinators should participate in training opportunities related to their job responsibilities.

GUIDELINE #2

Breastfeeding promotion and support are enhanced when policies encourage a positive clinic environment and breastfeeding as the preferred method of infant feeding.

Suggestions for Implementation

1. It is important to assure that relevant educational materials available to participants portray breastfeeding as the preferred infant feeding method. Consider:



print and audiovisual materials free of formula product names



office supplies such as cups, pens, and note-pads free of formula product names

Rationale: Use of materials with product names sends a mixed message to clients and staff and might unconsciously put up barriers to breastfeeding.

2. It is important to establish a positive attitude toward breastfeeding in WIC clinics.

Rationale: Health care workers should be careful not to communicate overt or subtle endorsements of formula. Such messages may influence a mother's decision about infant feeding or her breastfeeding pattern. Once a mother initiates infant feeding, WIC staff should support her decision.

3. It is important that the local agency minimize the visibility of formula and bottle-feeding equipment. Consider:



storing supplies of formula out of view of participants



storing baby bottles and nipples out of view of participants

Rationale: Formula and bottle-feeding equipment in clear view of participants may influence a mother's decision on infant feeding.

BF-27



. GA WIC PROCEDURES MANUAL

Attachment BF-4 cont'd

4. It is important that staff not accept formula from formula manufacturer representatives for personal use.

Rationale: Acceptance of formula for personal use may influence staff to endorse a particular product, either consciously or unconsciously. Acceptance of formula also conflicts with the program's breastfeeding promotion and support activities.

5. It is important that the local agency try to provide a supportive environment in which women feel comfortable breastfeeding their infants. Consider:



chairs with arms



a breastfeeding area away from the entrance

Rationale: The clinic waiting area can be used advantageously to motivate women to recognize breastfeeding as the "norm" rather than the exception. The clinic area can also be used to provide worksite support for breastfeeding WIC staff.

6. It is important that the state agency assist local agencies in obtaining culturally sensitive and appropriate and translated breastfeeding education materials.

Rationale: The language and pictures in breastfeeding education materials should be relevant to the target population served by the program.

GUIDELINE #3

Breastfeeding promotion and support are enhanced when WIC agencies coordinate with the private and public health care systems, educational systems, and community organizations providing care and support for women, infants and children.

Suggestions for Implementation

1. It is important for local and state agencies to participate in and support coordinated activities with appropriate groups such as:



task forces, networks, or steering committees to exchange information and strategies



professional health organizations to secure resources and expertise and assure

communication with health professionals serving pregnant and breastfeeding women



existing peer support groups to facilitate local exchange of breastfeeding information

across the state



community leaders and citizen groups who support breastfeeding



the Breastfeeding Promotion Consortium and its efforts, including a national

breastfeeding promotion campaign

Rationale: A collaborative approach to breastfeeding promotion can create a strong supportive climate and help ensure more effective use of all available resources.

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GA WIC PROCEDURES MANUAL

Attachment BF-4 cont'd

2. It is important that the state agency disseminate information such as the NAWD position paper, Breastfeeding Promotion in the WIC Program and the Guidelines for Breastfeeding Promotion in the WIC Program to state and local affiliates of groups such as:



American Academy of Pediatrics



American Academy of Family Physicians



American college of Nurse Midwives



American College of Obstetricians and Gynecologists



American Dietetic Association



American Hospital Association



American Nurses Association



American Public Health Association



Association of Pediatric Nurse Practitioners



Association of Women's Health and Obstetrics Nurses



Healthy Mothers, Healthy Babies Coalitions



International Lactation Consultants Association



La Leche League International



Maternal and Child Health Directors



Medicaid Directors



National Association of Pediatric Nurse Associates and Practitioners

Rationale: Serving as an adjunct to health care is a vital component of the WIC Program. Therefore, it is important that the program's health-related policies be shared with appropriate health care programs and professional organization. such interaction encourages a strong cooperative working relationship with the health community to accomplish mutual goals.

3. It is important for local and state WIC agencies to participate in and support coordinated breastfeeding promotion and support activities such as:



co-sponsoring training and continuing education programs



sharing breastfeeding education materials for clients



developing local or state documents such as position statements, policies, model

hospital policies and counseling and referral protocols

GUIDELINE #4

Breastfeeding promotion and support are enhanced when positive breastfeeding messages are incorporated in relevant educational activities, materials and outreach efforts.

Suggestions for Implementation

1. It is important that positive breastfeeding messages are used in:

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GA WIC PROCEDURES MANUAL

Attachment BF-4 cont'd



participant orientation programs and materials



printed and audiovisual materials for professional audiences



printed, audiovisual, and display materials for potential clients

Rationale: Including positive breastfeeding messages promotes breastfeeding as the preferred infant feeding choice and reinforces WIC's position on breastfeeding.

GUIDELINE #5

Breastfeeding promotion and support are enhanced when activities are evaluated on an annual basis.

Suggestions for Implementation

1. It is important that evaluation include measures of incidence and duration such as:



incorporation of data collection into current WIC systems



periodic sample surveys ofprogram participants



Centers for Disease Control and Prevention surveillance systems



state surveillance systems



birth certificate information

Rationale: Since few data are available, data collection will help identify and direct further breastfeeding promotion efforts for this population. Assessment of successful strategies will help agencies measure progress toward meeting the health objectives for the nation.

2. If more in-depth information on the incidence and duration of breastfeeding is desired, it is important that information be collected on at least the following categories:



exclusive breastfeeding



patterns of combined breastfeeding and formula feeding, e.g.:



mostly breastfeeding



equal parts breastfeeding and formula feeding



mostly formula feeding



exclusive formula feeding

Rationale: Collecting data on breastfeeding patterns gives a better picture of the WIC population's infant feeding practices. This will help states better focus their breastfeeding promotion activities.

3. It is important that questions regarding breastfeeding attitudes, infant feeding decisions, and the WIC program's breastfeeding support activities are included in the annual participant survey .

Rationale: Collecting data on breastfeeding attitudes, infant feeding practices and

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GA WIC PROCEDURES MANUAL

Attachment BF-4 cont'd

WIC-related promotion activities about breastfeeding assists state and local agencies design more effective breastfeeding promotion program components.

4. It is important that the state agency management evaluation process reviews local agency breastfeeding promotion and support activities such as:



participant orientation and education materials



policies regarding formula samples and food package tailoring for breastfeeding

mothers and infants



clinic environment, including display materials and posters, and visibility of formula

supplies



staff interaction with participants regarding the infant feeding decision and

breastfeeding support



local agency linkages with other community programs providing services to

breastfeeding women



staff training plans

Rationale: Guidelines and policies must be implemented in . order to affect breastfeeding initiation and duration rates of WIC participants.

GUIDELINE #6

Breastfeeding promotion and support are enhanced when appropriate breastfeeding education and support is offered to all pregnant WICparticipants.

Suggestions for Implementation

1. It is important that a breastfeeding protocol is established to:



integrate breastfeeding promotion into the continuum of prenatal nutrition education



include an initial assessment ofparticipant knowledge, concerns and attitudes related

to breastfeeding



provide breastfeeding education and support sessions to each prenatal participant

based on the above assessment



define the roles of all staff in the promotion of breastfeeding



define situations when breastfeeding is contraindicated



establish referral criteria

Rationale: Making informed choices regarding the best methods of infant feeding is, in part, dependent on stafrs ability and efforts to address women's needs and concerns throughout the prenatal period.

2. It is important to develop a mechanism to incorporate positive peer influence into the prenatal

period, such as:



peer counselors

BF-31



GA WIC PROCEDURES MANUAL

Attachment BF-4 cont'd



an honor roll of successful breastfeeding WIC participants



an opportunity to watch other WIC participants breastfeed



classes with currently breastfeeding WIC participants talking about their experiences

Rationale: Positive peer influence has been shown to be a factor in a woman's decision to breastfeed.

3. It is important to include the participant's family and friends in breastfeeding education and support sessions.

Rationale: Assistance and emotional support from family and friends. are helpful to a woman's initiation and continuation of breastfeeding.

4. It is important to encourage the mother to communicate her decision to breastfeed to appropriate hospital staff and physicians.

Rationale: To overcome potential barriers due to hospital and physician practices, women should be aware of the need to request the services that will facilitate successful breastfeeding, e.g., baby put to the breast soon after delivery.

5. It is important for the local WIC agency to coordinate prenatal breastfeeding education activities with primary care providers by:



discussing WIC's position about breastfeeding as optimal for most women and infants



encouraging the sharing of educational materials between WIC and primary care

providers



identifying the breastfeeding promotion and support services available in the

community and referring participants as needed

Rationale: Coordinating activities in the community increases the likelihood of women and families receiving consistent messages and information about breastfeeding.

6. It is important that the local WIC agency know the breastfeeding practices of their community hospitals and primary health care providers.

Rationale: Local agency WIC staff should be part of the prenatal care team preparing women for their early breastfeeding experiences. Positive breastfeeding practices and policies facilitate successful breastfeeding.

GUIDELINE #7

Breastfeeding promotion and support are enhanced when policies allow breastfeeding women to receive all WIC services regardless of their breastfeeding patterns.

BF-32




GA WIC PROCEDURES MANUAL Suggestions for Implementation

Attachment BF-4 cont'd

1. It is important that eligible women who meet the definition of breastfeeding (the practice of feeding a mother's breast milk to her infant(s) on the average of at least once a day) be certified to the extent that caseload management permits.

Rationale: Breastfeeding women are among the highest priority groups of WIC participants.

2. It is important that breastfeeding women receive a food package consistent with their nutritional need.

Rationale: Breastfeeding women have the highest nutritional needs of any category of women participants and should receive a food package to meet those needs.

3. It is important that breastfeeding women receive support and assistance in order to maintain or increase breastfeeding.

Rationale: All breastfeeding women, regardless of their breastfeeding pattern, need ongoing support so that they feel positive about their breastfeeding experience.

GUIDELINE #8

Breastfeeding promotion and support are enhanced when policies allow breastfeeding infants to receive a food package consistent with their nutritional needs.

Suggestions for Implementation

1. It is important that the use of supplemental formula for breastfed infants be minimized.

Rationale: Support that encourages breastfeeding is more effective than offering more formula than the baby is currently using. Clear support which continues to build confidence includes praise and encouragement for her current level of breastfeeding.

2. It is important that vouchers with infant formula are not issued to exclusively breastfed infants. If a food instrument must be distributed to enroll the infant, consider printing a positive breastfeeding message on the voucher.

Rationale: A blank voucher emphasizes that the breastfeeding dyad may not be receiving as much food as the formula-feeding dyad and makes the mother feel as though she is missing out on some of the food available to her. A voucher with even a small amount of formula on it sends a message to the mother that she is expected to supplement. A positive breastfeeding message will reinforce the importance of breastfeeding.

BF-33



GA WIC PROCEDURES MANUAL

Attachment BF-4 cont'd

3. It is important to encourage the issuance of vouchers for powdered formula to breastfeeding mothers who wish to supplement.

Rationale: Powdered formula can be prepared in as small a quantity as needed. However, the minimum amount of the concentrated fluid formula that can be prepared is 26 ounces. This amount must be used within 48 hours, which could encourage more supplementation than originally intended.

4. It is important that breastfeeding women receive information about the potential impact of formula on lactation and breastfeeding before formula is given.

Rationale: Breastfeeding mothers may not fully understand the impact formula supplementation has on breastmilk supply. This is especially important during the first few critical weeks when the milk supply is being established.

5. It is important that formula vouchers or samples be given only when specifically requested.

Rationale: Offering formula to a breastfeeding woman undermines her confidence that she can breastfeed successfully, particularly in the first few weeks. She also may find it difficult to refuse the free formula even though she had not planned to use it.

GUIDELINE #9

Breastfeeding promotion and support are enhanced when breastfeeding support and assistance is provided throughout the postpartum period, particularly at critical times when the mother is most likely to need assistance.

Suggestions for Implementation

1. It is important to develop a plan to provide women with access to locally available breastfeeding support programs, making sure support is available early in the postpartum period and throughout lactation to:



Include professional support, such as management of lactation problems, hotline

contacts and telephone counselors



include peer support, such as peer counselors and resource mothers

Rationale: Professional support programs assist the mother experiencing lactation problems to resolve questions and problems with lactation management. Peer support programs use individuals who have successfully breastfed an infant and who express a positive, enthusiastic viewpoint of breastfeeding.

2. It is important to provide or identify education and support for breastfeeding women in special situations. Consider:

BF-34



GA WIC PROCEDURES MANUAL

Attachment BF-4 cont'd



mothers returning to paid employment or school; mothers separated from their infants

due to hospitalization or illness; mothers of multiples; infants with special needs



support program at times in keeping with the mother's schedule

Rationale: Breastfeeding mothers who are separated from their infants need support programs which include situation-specific information and support.

3. It is important that postpartum contacts with breastfeeding women provide positive reinforcement for the continuation of breastfeeding. Consider:



using appropriate posters and messages placed in the clinic waiting and nutrition

education areas



including a special breastfeeding message, on vouchers, encouraging the continuation

of breastfeeding

Rationale: Encouragement from professional staff and peers can provide motivation to succeed at breastfeeding.

4. It is important to coordinate breastfeeding support with other health care programs and providers, such as:



Maternal and Child Health



Family Planning



hospitals



Indian Health Service



community health providers

Rationale: Collaborative relationships result in consistent messages supporting breastfeeding, more efficient services and decreased lactation problems; and reach a larger number of women. These efforts will have a more far-reaching effect as the incidence of breastfeeding increases.

5. It is important that the state agency develop a protocol or guidelines regarding the distribution of breastfeeding aids, including:



circumstances when the breastfeeding aid might be provided



guidelines for participant instruction about using the breastfeeding aid

Rationale: Many women have successful breastfeeding experiences without using breastfeeding aids. Breastfeeding aids can enhance breastfeeding success when their distribution is based on individual need and when instruction about the aid is provided.

BF-35



GA WIC PROCEDURES MANUAL

Attachment BF-5

BREASTFEEDING RESOURCES RECOMMENDED BY THE OFFICE OF NUTRITION

PAMPHLETS

Breastfeeding Basics: Collecting and Storing Your Milk (#3850)

Breastfeeding Basics: Common Problems (#3848)

Breastfeeding Basics: The First Six Weeks (#3849)

Breastfeeding: Getting Started in Five Easy Steps - English, (#4002)



Breastfeeding: Getting Started in Five Easy Steps - Spanish, (#4003)



Good Nutrition for Breastfeeding (#4004)



Breastfeeding: A Time for Good Food Choices (#401_9)



Working and Breastfeeding (#4020)

BOOKS AND MANUALS

Breastfeeding: A Guide for the Medical Profession, by Ruth Lawrence C.V. Mosby Co., St. Louis, MO, 1999.



Breastfeeding: A Problem-Solving Manual, by Stephen Saunders, et. al.

Essential Medical Infonnation Systems, Inc., Dallas, TX, 1990.



Breastfeeding & Human Lactation, by Jan Riordan and Kathleen Auerbach

Jones & Bartlett, Publishers, Boston, MA, 1999.



The Breastfeeding Answer Book, by La Leche League International

La Leche League International, Franklin Park, IL, 1991.



Breastfeeding Triage Tool, by Sandra Jolley

Breastfeeding Promotion Project, Seattle-King County Public Health, Seattle, WA, 1990.



Counseling the Nursing Mother: A Reference Handbookfor Health Care Providers and Lay

Counselors, by Judith Lauwers and Candace Woesner

Avery Publishing Group, New York, NY, 1983.



Drugs in Pregnancy and Lactation: A Reference Guide to Fetal & Neonatal Risk, 4th

Edition, by Gerald G. Briggs, et. al.

Williams &Wilkins, Baltimore, MD, 1990.



Medication and Mothers' Milk, by Thomas Hale

Pharmasoft Medical Publishing, Amarillo, TX, 1999.



Nursing Mother's Companion, by Kathleen Huggins

Harvard Common Press, Boston, MA, 1990.

BF-36



GA WIC PROCEDURES MANUAL

Attachment BF-5 cont'd

Nutrition During Lactation, by the Institute of Medicine, National Academy of Sciences

National Academy Press, Washington, D.C., 1991



Nutrition Guidelines for Practice, by the Office of Nutrition Office of Nutrition, Family Health Branch, Division of Public Health, Georgia Department of Human Resources, Atlanta, GA, 1995.

A Practical Guide to Breastfeeding, by Amy Kathryn Spangler Amy Kathryn Spangler, Atlanta, GA, 1994.



Womanly Art ofBreastfeeding, by La Leche League International

La Leche League International, Franklin Park, IL.

VIDEOTAPES



Best Start: For All the Right Reasons, (also available in Spanish), Best Start, Inc., Tampa,

FL.

Best Start: Training Program, Best Start, Inc., Tampa, FL.

Breastfeeding Your Baby, The Office of Nutrition, 1994.



Yes, You Can Breastfeed, (also available in Spanish), Texas Public Health.

Available from Metro Post, Attn: Ecko, 501 N. IH 35, Austin, TX 28273;

(512) 476-3876.

TEACHING TOOLS



Breast Model

Childbirth Graphics Ltd., P.O. Box 20540, Rochester, NY, 14602



Flip Chart

Childbirth Graphics Ltd., P.O. Box 20540, Rochester, NY, 14602



Baby Model

Childbirth Graphics Ltd., P.O.. Box 20540, Rochester, NY, 14602

TELEPHONE INFORMATION SERVICES FOR HEALTH PROFESSIONALS



Georgia Poison Control Center

Grady Memorial Hospital, Atlanta, GA

(404) 616-9000 or (800) 282-5846

Service Provided: Answers to questions on Drugs and Lactation

Charge: There is no cost for this service

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GA WIC PROCEDURES MANUAL

Attachment BF-5 cont'd



Breastfeeding and Human Lactation Study Center

University of Rochester School of Medicine & Dentistry, Box 777, Rochester, New York,

14642

(716) 275-0088.

Service Provided: Data base to assist with questions about pharmaceutical drugs and

breastfeeding. Provides bibliographies on breastfeeding and lactation.

Charge: None, beyond cost of telephone call



The Lactation Program

1719 E. 19th Avenue, Denver, CO, 80218

(303) 869-1881

Service Provided: Phone consultation with lactation consultants for difficult breastfeeding

questions.

Charge: None, beyond cost of telephone call



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GA WIC PROCEDURES MANUAL

Attachment BF-6

ALLOWABLE AND UNALLOWABLE COSTS OF BREASTFEEDING AIDS USED FOR
THE PROMOTION AND SUPPORT OF BREASTFEEDING

The cost of breastfeeding aids which directly support the initiation and continuation ofbreastfeeding are allowable WIC nutrition services and administration (NSA) expenses. Such expenses can be applied to the State agency's breastfeeding spending target and/or its overall nutrition education expenditures.

Breastfeeding aids which are allowable NSA costs include:

Breast pumps Breastshells Nursing supplementers Nursing bras Nursing pads Costs associated with the purchase and availability of breastfeeding aids through the
WIC Program, such as insurance and service fees in providing breast pumps Items used for training and demonstration purposes to promote breastfeeding or assist
participants in using breastfeeding aids. For example: breast models, breastfeeding aids, dolls to illustrate nursing, etc. Other items which can be shown to directly support the initiation and continuation of breastfeeding.

UNALLOWABLE COSTS

Breastfeeding aids which do not directly support the initiation and continuation of breastfeeding and are not within the scope of the WIC Program cannot be purchased with NSA funds. Such items include, for example: topical creams, ointments, Vitamin E, other medicinals, foot stools, infant pillows or nursing blouses.

BF-39



GA WIC PROCEDURES MANUAL

Attachment BF-7

ISSUES TO CONSIDER WHEN PROVIDING BREAST PUMPS

WIC State agencies are currently making breast pumps available to WIC participants in a variety of ways, including:

a. giving away manual breast pumps or electric pump attachment kits;

b. selling manual breast pumps or electric pump attachment kits for a nominal charge;

c. loaning manual or electric breast pumps;

d. contracting with a third party to provide manual or electric breast pumps to WIC participants; and

e. referring WIC participants to providers who rent breast pumps directly to them for a fee.

While all of the above options are available to the Georgia WIC Program, the following issues should be considered in reference to each:

Giving Away Breast Pumps

Local agencies may give away breast pumps without any reimbursement from participants. This option applies to inexpensive manual breast pumps, small electric pumps, or electric pump attachment kits which do not represent a significant investment of program resources.

Selling Breast Pumps

Local agencies may provide breast pumps by charging a fee to WIC participants (i.e., the purchase price or a portion of the cost to the WIC Program), to partially or totally offset their cost. Since breast pumps are not a direct program benefit, they are not subject to the legislative requirement that WIC benefits must be provided at no cost to participants. Such a plan must be submitted to the Office of Nutrition for approval. A local agency that sells breast pumps to WIC participants must treat the receipts as an "applicable credit" against expenditures for program costs. As applicable credits, these receipts must be used to offset or reduce charges made to the Federal grant for such cost. Applicable credits against expenditures for program costs are discussed in Office of Management and Budget Circulars A-87, Attachment A, paragraph C.3., and A-122, Attachment A, paragraph A.5.

Loaning Breast Pumps and Liability Issues

Manual breast pumps, attachment kits for electric pumps and small electric or battery operated pumps should not be reused, due to the possibility of cross-contamination from improper sterilization. The possible liability cost is high when compared to the cost for a one-person use of a manual pump. In addition, the small electric/battery-operated pumps are often not durable enough

BF-40




GA WIC PROCEDURES MANUAL

.

I

Attachment BF-7 cont'd

to be used repeatedly and their cost is minimal.

Since large electric breast pumps represent a significant investment of WIC resources, loaning them is the only option. However, under this option, local agencies that directly purchase breast pumps for loan to participants may incur the financial liability of lost or damaged breast pumps. These pumps should be loaned in combination with some means to insur~ against loss or damage, such as:

a.

establishing procedures to ensure that participants fully understand their rights and

responsibilities when signing liability release forms;

b. developing an agreement between the program and the participant which stipulates the participant's responsibility to reimburse the program for the value of a lost or damaged pump;

c. monitoring through periodic visual inspection, frequent inventory counts and records, and telephone check-ins; or

d. limiting pump loans only to special circumstances, e.g., after a minimum duration of breastfeeding or for certain medical conditions; and

e. charging a refundable deposit.

Participants may not be terminated or suspended for unreimbursed loss or damage to loaned pumps. While a financial penalty, if included in the original agreement, could be imposed on a participant for failure to return or damage to a pump, the State WIC Program recommends that this approach not be taken. The resources required to recover the cost of the lost or damaged breast pump could easily exceed the value of the pump itself. Building a relationship of trust with WIC participants may minimize the risk of the participant not fulfilling the obligation to return the pump.

If it provides breast pumps, the WIC Program may also be liable for injury to a WIC participant resulting from improper breast pump use, even when there is a signed release of liability. This is true whether pumps are given, sold, or loaned. All participants provided with breast pumps by the WIC Program must be instructed on proper pump use.

Contracting with a Third Party

Local agencies may contract with a third party, such as a breast pump manufacturer, hospital pharmacy, or private lactation consultant, to loan or provide breast pumps to WIC participants. WIC employees must not be affiliated with the third party with whom they are contracting.

A major advantage to contracting with a third party is that it transfers liability for equipment loss or damage from the WIC Program to the third party provider, for example, through a loss or damage waiver or insurance fee.

BF-41




GA WIC PROCEDURES MANUAL

Attachment BF-7 cont'd

Referrals

A local agency may opt to refer WIC participants to providers who rent breast pumps directly to participants at a fee, such as breast pump manufacturers, hospital pharmacies, and private lactation consultants. This option avoids the liability and financial issues for the program. However, it is likely to pose a financial barrier to WIC participants. In the Georgia WIC Program, this does not meet the requirement for the provision of support to breastfeeding women.

Medicaid Reimbursement

The cost of manual pump purchase and electric pump rentals are generally not covered as a separate benefit under the Medicaid Program. However, in Georgia, the State Medicaid Program does cover the rental of an electric pump and the price of an attachment kit in some cases. Coverage is based on the mother's Medicaid eligibility and so is limited by the period of time the mother is covered by Medicaid in the postpartum period. In addition, coverage is provided for those cases in which the mother and infant are separated by hospitalization, i.e., premature birth.

The electric breast pump and attachment kit must be obtained by a Medicaid Durable Goods provider. It does not require that the provider give instructions to the client on proper use, maintenance and cleaning of the equipment. In these cases, the local agency staff should provide the necessary information and follow-up to the WIC participant.

BF-42



GA WIC PROCEDURES MANUAL

Attachment BF-8

STATUS CHANGE FROM PRENATAL TO BREASTFEEDING AND ASSIGNMENT OF PRIORITY TO BREASTFEEDING MOTHER AND INFANT

I. Status Change from Prenatal (P) to Breastfeeding (B) Without a Subsequent Certification:

When a prenatal participant delivers her infant(s) and initiates breastfeeding, the local agency is encouraged to change the participant's status from that of Prenatal (P) to Breastfeeding (B) through an update to the system. This should occur as soon as the local agency is made aware of the participant's change in status. A subsequent certification is not required in order to simply change the participant's status, as long as she is less than six (6) weeks postpartum. Note: This action does not exclude the participant from the required subsequent certification, in order to continue on the program past the six weeks postpartum.

Listed below are examples of situations in which the simple status change from Prenatal to Breastfeeding might occur:



A woman calls the clinic to state she has delivered her infant and is

breastfeeding.



A parent of a newborn breastfeeding infant comes to the clinic to enroll the

infant in the program.



A local agency does in-hospital certification of infants only.



A breastfeeding peer counselor notifies the clinic that a participant has

delivered her infant and is breastfeeding.

Follow the steps listed below to change the status of a prenatal women, prior to her subsequent certification (Source: ATVS User's Manual):

A. Change TYPE from P to B, since subsequent certification may not take place until 6 weeks postpartum.

B. Change/add the following: DELIVERY DATE, PREGNANCY OUTCOME, and NUMBER OF WEEKS BREASTFED.

C. Change the following if determined to be appropriate (these are optional changes):

1. PRIORITY. A breastfeeding woman's priority can be upgraded if one or more breastfeeding risk factors are identified. The risk factor(s) must be
documented in the participant's health record. See IL Assignment of Priority
to Breastfeeding Dyad, below.

2. FOOD PACKAGE. If the Competent Professional Authority (CPA) determines that a food package change is needed, assign a new food package. Participants who are exclusively b,reastfeeding (receiving no infant formula through WIC) should be assigned Food Package 408. If this participant has

BF-43



GA WIC PROCEDURES MANUAL

Attachment BF-8 cont'd

already picked up the current month's prenatal vouchers, you may print a single "001" voucher for her. This voucher includes the additional beans/peas or peanut butter, carrots and juice which are part of the 408 food package.

II. Assignment of Priority to Breastfeeding Dyad

When a participant's status is changed from Prenatal (P) to Breastfeeding_(B), prior to her postpartum certification, it may not be possible to assign the same priority to both mother and infant at this time. Please follow these steps in assigning the priorities:

A. When a participant's status is changed from Prenatal (P) to Breastfeeding (B) through a systems update, her priority may be upgraded if there is appropriate documentation. This is optional, however, and she can maintain her Prenatal priority until the subsequent certification.

B. When a breastfeeding infant is certified for, and enrolled in, the WIC Program prior to its mother being subsequently certified, the infant may be assigned one of the following priorities:

1. If the infant has a risk factor of its own that would result in it's being a Priority I, the infant must be assigned a Priority I .

2. If the infant has only nutritional risk factor "W" (Infant of a WIC Mother or Mother with Nutritional Risk During Pregnancy), assign a Priority II. It may be helpful to "flag" the infant's name/record through an internal tracking system (tickler card, computer, voucher register, etc.) to alert staff to the need to re-evaluate the infant's priority at the mother's postpartum certification.

3. If the infant's mother was assigned a Priority I based on documented postpartum breastfeeding risk factors, assign a Priority I to the infant.

C. When the mother of a breastfeeding infant is certified at a later time than the infant, one of the following actions must be taken:

1. If the mother is no longer breastfeeding, she must be assessed as a nonbreastfeeding postpartum woman (status is changed from P to N), and she must be assigned the appropriate priority based on the assessment. Her infant retains the priority assigned at its enrollment.

2. I f the mother is still breastfeeding, she must be assessed as a breastfeeding woman (status is changed from P to B). The highest priority of either the mother or her infant(s) must be assigned to both mother and infant(s). This priority and the supportive risk criteria must be documented in the health record of both the mother and her infant(s).

BF-44



GA WIC PROCEDURES MANUAL

Attachment BF-9

KEY FOR ENTERING WEEKS BREASTFED

The number of weeks breastfed must be entered on the WIC Assessment/Certification Form and Turnaround Document for:

Breastfeeding Women: initial and six-month certification visits

Postpartum, non-breastfeeding women: certification visit

Infants: initial certification and mid-certification nutrition assessment visits



Children: one-year of age certification visit ( 11 to 16 months of age)

Length of time breastfed must be entered in weeks (two-digit). When the answer to the question "how long have you breastfed this baby/child?" or "how long has this baby/ child been breastfed?" is given in days or months, use the following key to determine appropriate codes:

I. Codes to Enter When Breastfeeding is Given in Days

00 = Never breastfed to 3 days 01 (weeks)= 4 to 10 days 02 (weeks)= 11 to 17 days 03 (weeks)= 18 to 24 days 04 (weeks)= 25 to 31 days 05 (weeks)= 32 to 38 days 06 (weeks)= 39 to 45 days 07 (weeks)= 46 to 52 days 08 (weeks)= 53 to 59 days ETC.

II. Codes to Enter When Breastfeeding is Given in Months

Ifthe length of breastfeeding is given in months, simply multiply by 4.3 to calculate the number of weeks breastfed.

Example: A woman stated she breastfed her infant for 4 months. Calculate weeks breastfed as follows:

4 x 4.3 = 17.2 weeks

Enter 17 on the in the appropriate space for Weeks Breastfed, on the WIC Assessment/Certification Form and the Turnaround Document.

Sources: Enhanced Pregnancy Nutrition Surveillance System User's Manual. Division of Nutrition, Center for Chronic Disease Prevention & Health Promotion, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, Public Health Service. November 1989.
Georgia WIC User Manual, 1994.

BF-45





GAWICPROCEDURESMANUAL TABLE OF CONTENTS



I.

Introduction ....................................................................................................... DP-1

A. Purpose.................................................................................................. DP-1

B. Scope...................................................:...........;.........:........................... DP-1

II.

Policies ......................................:................................................................;...... DP-3

III.

Assessing Impact of Disaster .............................................:.............................. DP-4

IV.

Concept ofOperation ........................................................................................ DP-5

A. General ........................................:......................................................... DP-5

B. Organization (WIC Director Responsibilities, State Level Responsibilities, State and Local Agencies)..................................................................... DP-5

C. Notification ........................................................................................... DP-6

V.

Responsibilities ................................................................................................. DP-7

A. Facilities ................................................................................................ DP-7

B. Issuance ................................................................................................. DP-7

C. Certification .......................................................................................... DP-9

Q. Nutrition Education Contacts................................................................ DP-9

VI.

Resource Requirements .................................................................................. DP-11

A. Staff Requirements.............................................................................. DP-11

B. Infant Formula .................................................................................... DP-11
c. Food Instruments ................................................................................ DP-11

D. Transportation ..................................................................................... DP-12



GAWICPROCEDURESMANUAL

Attachments: DP-1 Staff Availability Following a Disaster ...................................................................... DP-13 DP-2 Disaster Employee Log ............................................................................................... DP-14 DP-3 Disaster Daily Work Activity Log .............................................................................. DP-15 DP-4 American Red Cross Emergency Numbers ................................................................ DP-16







GAWICPROCEDURESMANUAL
I. INTRODUCTION
The following information is provided to the Districts for incorporation into the District Disaster Plan. In contrast to commodity distribution of food stamps, WIC is a limited grant supplemental food program that serves a specific population with special nutritional needs. WIC is not designed or funded to meet the basic nutritional needs of disaster victims who would not otherwise be eligible for the program. Unlike the distribution of commodities or the emergency issuance of food stamps, there is no legislatively mandated role for WIC in disaster relief, nor is there legislative authority for using WIC food funds for purposes other than providing allowable food benefits to categorically eligible participants. Finally, no additional WIC funds are designated by law for WIC disaster relief, and WIC must operate in disaster situations within its current program context and funding. For these reasons, WIC is not to be considered a first-line of defense to respond to the nutritional needs of disaster victims, including the provision of infant formula.
A. Purpose
The Purpose of this Disaster Plan is to:
1. Restore WIC services to current participants as soon as possible.
2. Expand services to more of the eligible population in the disaster-affected areas.
B. Scope
These guidelines reflect the Operating Plan to be followed by the State WIC Agency in the event of a disaster or emergency creating a disruption in service delivery at a local agency. WIC local agency staff will be guided by their County Public Health Departments and District Procedures. Private agencies, which contract to provide WIC services, will use the disaster plans that are consistent with state policies and any developed by their parent agencies. State WIC Office guidelines will reflect the purpose, authority, and responsibilities developed by the DHR Emergency Plan (or Public Health).
The Georgia WIC Program, during some instances may briefly suspend WIC operations and rely entirely on other disaster feeding operations (i.e., American Red Cross, Salvation Army, churches etc.) until it is feasible to operate a direct distribution system or until retail distribution is available.
The State/local agency must also make an initial and on-going assessment as to the feasibility of distributing ready-to-feed infant formula. Every effort will be made to determine the food and formula acquisition and distribution in accordance with the
DP-1



GAWICPROCEDURESMANUAL
American Red Cross and other organizations (See Attachment DP- 4). The decision to use ready-to-feed infant formula will be made on a day by day assessment ofthe situation and type of disaster.
The emergency numbers for contacting the American Red Cross are also attached to this plan (See Attachment DP-4). The contact person as well as a fax number is also available in (Attachment DP-4).





DP-2



GAWICPROCEDURESMANUAL
II. POLICIES
Specific decisions concerning state agency actions during a disaster depend upon the duration and magnitude of the disaster, and upon specific directions from the State Health Director. The focus of State WIC Agency activity is to support local agency service delivery. These guidelines primarily reflect state agency responsibilities in the event of disruption of services in one local agency. In the event of an emergency at the state agency, state agency personnel will follow the rules developed by the State Health Director. In the event of a disaster or emergency involving both local and state agencies, the initial focus of the state agency will be to estimate the impact and determine the measures needed to support the restoration of services by the local agency. The state and local agencies will develop provisional operational policies following a disaster that respond to the specific needs created by the disaster.





DP-3



GAWICPROCEDURESMANUAL III. ASSESSING IMPACT OF DISASTER
The extent of damage caused by the disaster must be assessed by the local agency. To determine if delivery of services is feasible, the following questions should be answered:
1. Is the health department/local agency requesting help?
2. How many participants are affected, can they reach food instrument issuance sites, and are the issuance sites operational?
3. How many grc:>cery stores are closed due to the disaster and is retail purchase still feasible?
4. How many persons are made newly eligible as a result of the disaster? Would income be computed monthly or annually?
5. Are electric, water, communication, and transportation services disrupted?
6. How long could services be disrupted?.
7. What alternatives to current policies and procedures must be made?



DP-4



GAWICPROCEDURESMANUAL
IV. CONCEPT OF OPERATION
A. General
A Disaster Plan folder is kept by the State WIC Office Director and the Director of the Office ofNutrition. Included in the Disaster Plan folder are the current phone listings for the Regional Food Nutrition Services Offices, County Public Health Unit Disaster Coordinators, State Health Office Disaster Coordinators, statewide and local chapters of the American Red Cross, Department of Agriculture Food Distribution Program, and other non-profit and private programs. The folder also contains a listing of home addresses and phone numbers of selected State WIC Office and Nutrition Services staff. Home addresses and phone numbers are confidential and will only be used in an emergency.
B. Organization
WIC Director Responsibilities
The Director responsibilities will be to:
1) To contact formula manufacturers to secure Ready To Feed (RTF) formula, nipples and bottles.
2) Follow through on arrival/receipt of formula. 3) Visit area to make on-site assessment of support staff etc.
State Level Responsibilities
Various staff members have responsibilities in the WIC and Nutrition Services Disaster Plan. The overall responsibility for implementation and reporting on WIC's response to the disaster lies with the Directors of WIC and Nutrition Services or a designee. The Unit Managers and Consultants will have responsibilities related to coordination of staff and analysis of requirements resulting from the disaster. The Systems Information Unit (in conjunction with local WIC Program Coordinators) will be responsible for the coordination of mass supply shipment, storage, and responsibilities related to coordination of participant food instrument issuance, including remote printing, equipment issues and emergency procurement of vouchers. The Financial Unit has the responsibility of tracking and reconciling costs relating to the disaster. The Manager of the Quality Assurance Unit will be responsible for documenting the use of vouchers. Staff will be assigned to serve at the location according to a schedule. The Manager of the Vendor.Unit will provide the local agency with operational authorized WIC vendor sites. The Office of Nutrition Consultants will have responsibilities related to
DP-5



GAWICPROCEDURESMANUAL
certification and food package issuance, Nutrition Education and Food Safety Preparation, Breastfeeding Education, and support information. All contracts for formula procurement by Georgia WIC and Nutrition Services will contain a clause addressing alternative measures for acquisition and distribution of infant formula in the case of a disaster.
State and Local Agencies
The state and local agencies will coordinate efforts to obtain the appropriate type and quantity of staff to assist the local agency in need. Staff may be assigned from within the county, from another county, from another district or from the state agency to meet a specific county's needs during a disaster. The state and local agencies may be asked to provide staff at a designated disaster assistance location (not always a health department facility) in order to provide WIC services more expediently.
Followmg a disaster in which state or local agency offices are closed, staff should contact within eight (8) hours one oftheir supervisors to report their situation and availability for duty assignments. Ifnone of the local agency's immediate supervisors can be reached, local agency staff can call the State WIC Office at 1-800-228-9173 to report their status and phone number where they can be reached. Attachment DP-1 is a form designed to collect data for this purpose.
Staff Documentation Requirements:
1. Any office which has staff working on disaster activities must maintain a Disaster Office Employee Log, Attachment DP-2. One log per office should be maintained per pay period and kept on file.
2. Any departmental employee working on disaster activities should immediately begin to maintain a Disaster Daily Work Activity Log, Attachment DP-3. The completed acti_vity logs should be retained by each departmental employee. If the Federal Emergency Management Agency or other funding sources become available, the Disaster Daily Work Activity Logs will be used to help document staff time for federal reimbursements.
C. Notification Lines of communication during a disaster begin with sites contacting the main local agency office. Local agencies would contact their County Health Department and District Disaster Coordinators. The state agency disaster plan will be implemented following notification from the local WIC Coordinator, who has cleared these plans with
DP-6



GAWICPROCEDURESMANUAL
his or her District Disaster Coordinators. The State WIC Office would contact the State Health Office Disaster Coordinator and appropriate WIC retail vendors.



V. RESPONSIBILITIES
A. Facilities
During a disaster, it is imperative that the safety of staff and participants be considered. Therefore, it may be necessary to move to another location. In the event of a move, an immediate survey should be taken of all state buildings and offices in the affected area(s) to identify damage or the nature of the incident.
Necessary emergency action should be taken to protect the WIC Programs property where state buildings or offices have been damaged. This may include, but is not limited to, moving contents and equipment files, acquiring security services, securing buildings, or other necessary activities.
The records and invoices of any repair activity should identify the site location and/or facility address to assist in the filing of insurance claims. This information must be reported to the State WIC Financial Unit.
The state agency will cooperate with the local agency to identify buildings, equipment, medical services, general supplies, and any other resources required to continue service delivery. This will include assisting in locating potential points for direct distribution of infant formula and food. The state/local agencies will select and arrange to use those facilities and locations that are most accessible to participants. Whenever possible, the state agency will coordinate communications and services with other state program offices, such as Maternal and Child Health, TANF, Food Stamps, and Disaster Assistance Centers.
B. Issuance
During periods of emergency or disaster, every effort will be made to continue issuance of food instruments to participants. When adverse circumstances persist, such as the lack of available facilities, records or food instrument supplies, the state agency will coordinate efforts with the local agency to ensure that a minimum supply of food or food instruments are available for participants if such action is necessary. Securing formula for WIC infants effected by the disaster is the top priority of any state agency disaster relief plan. Ready-to-feed formula may be necessary if the area's water supply is contaminated and/or electrical power is disrupted. State government officials and state
DP-7



GA WIC PROCEDURES MANUAL
and local agencies will collaborate daily (or as needed) to determine the most appropriate food distribution method. In the event that ready-to-feed infant formula is required, efforts will be made to order appropriate amounts (along with disposable nipples and bottles). As soon as the disaster area returns to normal or if another agency accepts responsibility for formula (i.e. American Red Cross), distribution for ready-to-feed formula will be discontinued. Adult and child participants will be directed to emergency food centers in the event that direct distribution is necessary.
1. Retail Grocery Stores: The state and local agency will establish and maintain a list of retail grocery stores that remain in operation following the disaster, their operating hours, and their available stock ofWIC approved foods. The state and local agency will coordinate efforts to share this information with the participants.
2. Direct Distribution: If retail purchase is not viable, then direct distribution measures will be considered. The local agency, state staff, and disaster coordinator will determine that retail purchase is not viable when a significant number of clients are unable to purchase WIC approved foods. This could be due to the closure of many retail stores, the inability of many clients to get to a retail store, or disruption of the supply of food to stores.
State and local agencies will coordinate efforts to contact the Red Cross and other relief agencies to arrange for methods of food distribution to current participants and to newly eligible participants. The state agency will arrange for the supply and distribution of food items and/or food instruments to the local agency in need. For those local agencies in close proximity to the state agency, the state agency may become directly involved with the distribution. Ifthe district office is closer in proximity, efforts will be made by the State Office to coordinate distribution to the local agency through the district office. When district offices are affected by the disaster, the state agency may elect to take other appropriate measures to supply the local agency with infant formula, other food, i.e. alternate food packages or food instruments. "Ready-to-feed" formula will be used if the water supply is contaminated or limited.
All contracts for formula procurement by Georgia WIC and Nutrition Services will contain a clause addressing alternative measures for acquisition and distribution of infant formula in the case of a disaster.
3. Special Formula/Hospital Based Formula: The state agency and local agency will estimate the quantity of special formula and hospital based formula needed to sustain services until normal operations are restored. The state agency will then take measures to ensure that affected local agencies have supplies in the types and quantities needed. This may include state agency contracts with manufacturers,
DP-8



GAWICPROCEDURESMANUAL
wholesalers, suppliers, retailers, and other local agencies. Procurement, shipment, and local storage of infant formula will be the responsibility ofthe State WIC Office.
4. Food Instruments: Local agencies should maintain at all times a minimum back up supply of preprinted manual food instruments. These food instruments should be secured in such a way that they will be safe and accessible following the onset of the emergency. Based on the local agency needs, the state agency will help to sustain the local agency's inventory of food instruments.
5. Food Package: The WIC Competent Professional Authority (CPA) determines the type of food package to be issued in accordance with procedures found in the Food Package Section of the WIC Program Procedures Manual. Local agencies have the option to convert participants to the special food package (i.e. homeless package) under any of the following circumstances:
a. The participant does not have refrigeration. b. The state agency provides a means of direct distribution of WIC foods or the
local agency is able to issue food instruments and retail purchase is still viable. c. Lacks food preparation facilities such as living in a motel.
C. Certification
Depending on the duration and severity of the disaster, appropriate measures will be taken by the state agency to minimize the disruption of certification services at the local agency. When facilities, medical services, equipment, general supplies, and staff are available, the state agency will assist local agencies with maintenance of certification services. When specific facilities, medical services, or staff are needed, the state agency will enact measures to meet those needs through other local agency or state agency resources. Special provisions for expedited certifications may be authorized with approval from the State WIC Office. Special provisions to extend certification periods when the clinic does not have adequate lab facilities will be taken under consideration.
D. Nutrition Education Contacts
Nutrition education may be provided in group or individual setting during certification and voucher issuance during this crisis situation.
Nutrition Education should address:
* food safety
* meal planning
DP-9



GAWICPROCEDURESMANUAL
* food preparation * nutrition needs of the individual
* on-site education shelters
* safe water supply * general sanitation





DP-10



GAWICPROCEDURESMANUAL VI. RESOURCE REQUIREMENTS
The requirements for providing services to WIC participants during a disaster include providing staff, Infant formula, food instruments, and transportation. (See the information below):
A. Staff Requirements
1. Analysis of the needs caused by the disaster and monitoring and control of the response.
2. Coordination ofWIC and Nutrition Volunteer staff from around the state at the site of the disaster.
3. Scheduling shifts for volunteer staff and assistance with obtaining lodging at the site of the disaster.
4. Scheduling and coordinating staff at the local office and State WIC Office.
5. In coordination with the local agency financial staff, monitoring and tracking all costs related to the disaster recovery.
B. Infant Formula *
1. Obtain storage facilities near the affected disaster area for storing an extra supply of infant formula. Obtain manpower to move formula from trucks to storage to shelters.
2. There must be a plan for the procurement, shipping, storage, and method of distribution of supplies of infant formula to the disaster area.
3. Protocol of agency to contact distribution personnel (i.e., helicopters, airplanes, over land all terrain trucks.)
C. Food Instruments
1. Obtain a supply of blank food instruments for state office remote printing.
2. Printing and shipment of pre-printed food instruments to the disaster area.



DP-11



GAWICPROCEDURESMANUAL
D. Transportation
1. Arrange transportation for volunteer staff. 2. Arrange transportation for local distribution of infant formula.

* Need to ship in smaller shipments over an extended period of time. Ability to
change orders for formula as need arises.





DP-12



GA WIC PROCEDURES MANUAL

Attachment DP-1

STAFF AVAILABILITY FOLLOWING A DISASTER

DATE& TIME CALL
RECEIVED

DISTRICT/UNIT CLINIC

NAME

PHONE

DATE& TIME CAN RETURN
TO WORK

COMMENTS





DP-13



GA WIC PROCEDURES MANUAL
DISASTER EMPLOYEE LOG

Attachment DP-2

PAGE

OF

for PAY PERIOD _ _ _ _ _ to _ _ _ __

(beginning)

(ending)

DISASTER IDENTIFICATION/(CLINIC #): _ _ _ _ _ _ _ _ _ _ _ __

DISTRICT: _ __ OFFICE NAME: _ _ _ _ _ _ _ _ _ _ _ _ _ __

CONTACT NAME: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __





Note: Must attach completed Disaster Daily Work Activity Log for each employee listed on this form. RETAIN COMPLETED LOG FOR USE IN DOCUMENTING FUTURE FEDERAL CLAIMS.
DP-14



GAWICPROCEDURESMANUAL

DISASTER DAILY WORK ACTMTY LOG

DATE:

I

I

NAME: DISTRICT: _ _OFFICE:

SSN:

Attachment DP-3
PAGE OF

AM

AM

NEW ACTMTY TIME: --=--- PM to--=--- PM

BLDG:

OTHER:

ACTMTY LOCATION: Activity Description:----------------------------------



AM

AM

NEW ACTMTY TIME: _ __ PM to --=--- PM

BLDG:

OTHER:

ACTMTYLOCATION: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ Activity Description:----------------------------------

AM

AM

NEW ACTMTY TIME: --'--- PM to--'--- PM

BLDG:

OTHER:

ACTMTY LOCATION: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ Activity Description:----------------------------------

SIGNATURE: _ _ _ _ _ _ _ _ _ _ _ _DATE: _ _ _ _ __
NOTE: MUST ATTACH TO DISASTER EMPLOYEE LOG. RETAIN COMPLETED LOG FOR USE IN DOCUMENTING

FUTURE

FEDERAL

CLAIMS

DP-15

GAWICPROCEUDRESMANUAL

Attachment DP-4

CHAPTER
Albany Cluster I Coverage: Clay, Dougherty, Lee, Randolph, Terrell
Americus ClusterV Coverage: Sumter
Augusta Cluster II Coverage: Burke, Columbia, Glascock, Jefferson, Jenkins, Lincoln, McDuffie, Richmond, Screven, Taliaferro,Warren, Wilkes
Baldwin County Cluster VI Coverage: Baldwin, Putnam, Washington, Wilkinson
Bartow County Cluster VII Coverage: Bartow
Bulloch County Cluster III Coverage: Bulloch, Candler, Emanuel

AMERICAN RED CROSS CONTACT
Deborah Blanton 2421 N Slappey Blvd. Albany, GA 31701 (912) 436-4845 Fax:(912) 434-9610
Joan Mason P.O. Box2l4 Americus, GA 31709 (9 I 2) 924-2026 Fax:(912) 931-0811
Carolyn Maund 81 I 12th Street Augusta, GA 30901 (706) 826-4463 Fax: (706) 826-4507
Olsen Rogers P.O. Box 516 Milledgeville, GA 31061 (912) 454-2675 Fax:(912) 451-5376
Beth Kennedy I 05 North Bartow Street Cartersville, GA 30120 (404) 382-0981 Fax:(404) 606-1600
Vacant P.O. Box843 Statesboro, GA 30458 (912) 767-4468

Fort Gordon Dwight D. Eisenhower Army Medical Center

Rick Tuchscherer P.O. Box 7266 Fort Gordon, GA 30905 (706) 791-3169/634) After Hours:(706) 791-4517 Fax:(706) 790-4822

Fort McPherson

Kathy Staten Bldg. 536 Ft McPherson, Ga 30330 (404) 753-8315

Fort Stewart Winn Army Community
Hospital
Metropolitan Atlanta Cluster VIII Coverage: Fulton, DeKalb, Gwinnett, Cobb, Cherokee, Paulding, Fayette, Butts, Henry, Clayton, Douglas, Rockdale

Lynn Dowling Bldg. 8401 P.O. Box 3280 Fort Stewart, Ga 31314 (912) 767-8857/2197 After Hours:(912) 767-2197/8666 Fax:(912) 368-6353
Martha W. Ferguson 1955 Monroe Drive, N.E. Atlanta, Georgia 30324 (404) 881-9800 Fax: (404) 874-2993

CHAPTER Hunter Army Airfield
Marine Corp Supply School
Covered by: Albany Chapter

AMERICAN RED CROSS CONTACT
Mark Stall Building40I Hunter Army Airfield, GA 31409 (912) 352-5410 After Hours:(912)651-5310

Moody Air Force Base Naval Air Station, Albany

John Lukens 5124 Austin Ellipse Moody AFB, GA 31699 (912) 244-3570 Fax:(912) 333-3114

Georgia Low Country Cluster III Coverage: Liberty, Long, Tattnalli, Wayne

Kenny Murphy P.O. Box242 Hinesville, GA 31313 (912) 876-3975

Glynn County Cluster III Coverage: Appling, Glynn,
Gordon County Cluster VII Coverge: Gordon

MclntoshBeth VanDerbeck P.O. Box 1436 Brunswick, GA 31521 (912) 265-6467/1695 Fax:(912) 261-1443
Mary Thomas P.O. Box342 Calhoun, GA 30703-0342 (706) 629-4510

Griffin Cluster VIII Coverage: Spalding
Houston-Middle Georgia Cluster VI Coverage: Bleckley, Dooly, Hancock, Houston, Lamar, Macon, Pulaski, Taylor, Wilcox

Brenda Hoard 100 South Hill Street Griffin, Ga 30244 (404) 227-3145
Sam Register 346 Corder Wamer Robbins, GA 31088 (912) 923-6332 Fax:(912) 922-8858

Toombs County Cluster III Coverage: Montgomery, Toombs, Treutlen, Wheeler

Stan Bazemore P.O. Box49 Lyons, Georgia 30436 (912) 526-3150

DP-16



GAWICPROCEUDRESMANUAL

CHAPTER
Murray County Cluster VII Coverage: Murray

AMERICAN RED CROSS CONTACT
Annette Patton P.O.Box 1301 Chatsworth, Ga 30705 (706) 695-7605



Newton County Cluster II Coverage: Newton
Northeast Georgia Cluster I Coverage: Dawson, Fannin, Forsyth, Gilmer, Habersham, Hall, Lumpkin, Pickens, Rabun, Stephens, Towns, Union, White
Rome-Floyd County Cluster VII Coverage: Chattooga, Dade, Floyd, Polk
Savannah Chapter Cluster III Coverage: Bryan, Chatham, Effingham

Laura Bertram 7144 Floyd Street Covington, GA 30209 (404) 786-2018 Fax: (404) 287-1236
Pamela Watts 425 Bradford Street, N.W. Gainesville, GA 30501 (404) 532-8453 (800) 282-1722 (in GA)
Jean Lambert 311 Turner M~Call Blvd. Suite A Rome, GA 31065-2733 (706) 291-6648 Fax:(706) 235-2842
Angela Viney 422 Habersham Street Savannah, GA 31401 (912) 65 l-5300/5310/5385 Fax:(912) 651-5329

Southeast Georgia Cluster III Coverage: Atkinson, Bacon, Brantley, Clinch, Coffee, Jeff Davis, Pierce, Telfair, Ware

Ossie Andrews 809 Isabella Street Waycross, Georgia 31501 (912) 283-7846/4639

Thomas County Cluster IV Coverage: Decatur, Grady, Seminole, Thomas

Gardiner Hasty P.O. Box I 135 Thomasville, Georgia (912) 226-2181

31799-1135

Tift County Cluster IV Coverage: Ben Hill, Irwin, Tift, Turner, Worth
Troup County ClusterV Coverage: Troup



Upson County Cluster VI Coverage: Pike, Upson ...

Maxine Franks P.O. Drawer 70770 Tifton, Georgia 31793 (912) 382-3133
Barbara Hudson 411 South Greenwood St. Suite#B LaGrange, Georgia 30240 (706) 884-5818 Fax:(706)882-4364
Jeanne Hinson 310 North Church Street Thomaston, Georgia 30286 (706) 647-3023
DP-17

CHAPTER
Valdosta Cluster IV Coverage: Berrien, Brooks, Echols
Walker County Cluster VII Coverage: Walker
Naval Air Station Atlanta Covered by: Fort McPherson
Ranger School Covered by: Ft. Benning
Robins Air Force Base/ Robins AFB Hospital
Walton County Cluster II Coverage: Walton
West Central Georgia ClusterV Coverage: Calhoun, Chattahoochee, Harris, Marion, Meriwether, Muscogee, Putnam, Quitman, Stewart, Talbot, Webster
West Georgia Cluster VII Coverage: Carroll, Clay, Harralson, Randolph, Schley
Wilkes County Cluster II Coverage Wilkes
Fort Gillem Covered by: Fort McPherson

Attachment DP-4
AMERICAN RED CROSS CONTACT
Stephen Coyne 707 North Patterson Street Valdosta, Georgia 31601 (912) 242-7404 Fax: (912) 242-1553
Jerry Lipps P.O. Box372 Lafayette, Georgia 30728 (706) 638-2546
Chris Miller Family Support Center 825 9th Street, Suite # I09 Robins AFB, GA 31098 (912) 926-5493 After Hours: (912) 923-6332
Don Shedd 2499 Pannell Road, S.E. Monroe, GA 30655-9611 (404) 267-3534 Fax: (404) 207-4338
Jean Kent 3940 Rosemont Drive Columbus, Georgia31904 (706) 323-5614 Fax: (706) 322-2495
Marianne Chance 401 Bradley Street Carrollton, Georgia 30117 (404) 832-6112
Sniggy Eskew P.O. Box 774 Washington, GA 30673 (706) 678-4650 Fax: (706) 678-3752

GAWICPROCEUDRESMANUAL

CHAPTER
Dobbins Air Force Base Covered by: Fort McPherson

AMERICAN RED CROSS CONTACT

CHAPTER
Fort Benning/Martin Army Hospital

Attachment DP-4
AMERICAN RED CROSS CONTACT
Station Manager P.O. Box 51945 Fort Benning, GA 31995 (706) 545-5194 Fax: (706) 545-5118



DP-18







Georgia WIC Program

Procedures Manual



GLOSSARY



Acceptable Proof- Documentation reviewed by clinic staff to determine the qualification or disqualification of a WIC participant.
Adjunctive Eligibility - Automatic income eligibility for WIC applicants.

Administrative and Program Service Costs - Direct and indirect costs, exclusive of food costs, which State and local agencies determine to be necessary to support Program operations.

Adopted Child - A child that lives with a family who has accepted legal responsibility.

Affirmative Action Plan - Portion of the State Plan which describes how the Program will be initiated and expanded within the State's jurisdiction.

Agricultural Occupation - Employment related to the production, growth, and harvesting of commodities grown in or on land, or an adjunct to a part of a commodity grown in or on land.



Allocation of Funds - The allocation of funds is based on a methodology that includes an analysis of the district'Ds participation at the beginning of the fiscal year by WIC type, within priority. The projected amount to be spent for the total fiscal year is then calculated and, based on priorities, the Allocation Advisory Committee determines which types will be served. The allocation of administrative funds is based on an average cost per participant and is distributed to the local agencies after state administrative costs have been deducted.

Alphabetic Client Masterfile - An enrollment report which lists selected participant information for all active participants.

"And Justice For All Poster" - Poster which must be displayed in a conspicuous location in each WIC Clinic site indicating the WIC non-discriminatory clause.

ARMIS - Automated Reports Management Information System - Provides quick and accurate retrieval of WIC data at the State, D/U, and Clinic level without resorting to the time consuming effort of viewing paper or microfiche reports.

Automated Termination Action - The system which automatically terminates a participant when a child reaches his/her fifth birthday, a non-breast-feeding woman at 6 months, a breast-feeding woman at 12 months from delivery, failure to pickup vouchers for 2 full consecutive months, transfer out of clinic or district/unit, terminated from waiting list, pregnant woman at EDC + 75 days, or overdue for certification.



Automated TAONoucher System (ATVS) - Computer system developed by the State WIC Office to create vouchers and prepare automated turnaround documents {TADs). The vouchers and TADs are submitted to the ADP contractor via modem or diskette.

Automatic Update of Infant to Child - The system automatically updates an infant to a child when the infant reaches his/her first birthday .
BAQ - Basis Allowance for Quarters.
BASD- Basic Active Service Date for someone in the military.
Batch Control Form - A 3 ply form which is completed for each transmitted batch of TADs sent to Viking. This form is ordered from DOAS Central Supply through the State WIC Office. A completed form contains the date the batch was assembled, and a four digit sequence number assigned to this batch (can not be duplicated within the same date). The date and the sequence number combined is the Batch control number. This number is printed on the computer printed TAD. The district/unit code, clinic code, the number of TADs or Vouchers in the batch (do not mix TADs and vouchers in a batch), the person who prepares the batch should sign and date the Batch Control form upon completion. The top copy of the form goes to the ADP contractor. The second and third copies are retained by the clinic.
Blank Manual Vouchers - Vouchers that require manual entry of certain information by the clinic prior to issuance. It is commonly used for issuance when replacing only a part of a participant's computer generated voucher package, to a newly certified participant or transferring participants when a standard manual voucher package is inappropriate, or to supplement the preprinted manual voucher food package.
Breastfeeding Women - Women up to one year postpartum who are breastfeeding their infants.
Budget - An itemized summary of probable expenditures and income for a given period.
Calendar Year - The period oftime between January 1st and December 31st.
Cash Income - Applicants/participants who are paid money on site for services rendered.
Categorical Termination - Child who has reached his/her fifth birthday, Postpartum non-breast-feeding woman 6 months after delivery, Postpartum breast-feeding woman 12 months after delivery.
Categorical Eligibility - Woman, Infant or Child who meet the definitions of pregnant women, breastfeeding women, postpartum women, or infants or children.
Certification - The implementation of criteria and procedures to assess and document each applicant's eligibility for the Program.
Children - Child who have had their first birthday but have not yet attained their fifth birthday.

1

Clinic - A facility where applicants are certified.



Closeout Month - The third month (sixty days) after vouchers were issued.
Closeout Reconciliation Report - Report generated at the clinic level to give the final disposition of all computer-printed vouchers.

Collections - Repayment of WIC funds that were received fraudulently and must be made by cashiers check or money order.

Communal Feeding - Group meals or food supplies.

CSFP - The Commodity Supplemental Food Program administered by USDA.
Cumulative Unmatched Redemption - Identifies redeemed manual vouchers, which have not matched a valid client record. Local Agencies are required to review the redeemed manual vouchers appearing on the CUR report. The vouchers should be reconciled or a manual reconciliation should be done, depending on how much time has elapsed since the voucher was redeemed. CUR Part 1- Cumulative Unmatched Redemptions which have not matched to an issuance record.
CUR Part 2 - Cumulative Unmatched Redemptions which have not matched to a valid certification record.

Competent Professional Authority - An individual on the staff of the local agency authorized to determine nutritional risk and prescribe supplemental foods. The following persons are the only persons the State agency may authorize to serve as a competent professional authority: Physicians, nutritionists, (Bachelor's or Master's Degree in Nutritional Sciences, Community Nutrition, Clinical Nutrition, Dietetics, Public Health Nutrition or Home Economics with emphasis in Nutrition), dietitians, registered nurses, physician's assistants (certified by the National Committee on Certification of Physician's Assistants or certified by the State medical certifying authority), or State or local medically trained health officials. This definition also applies to an individual who is not on the staff of the local agency but who is qualified to provide
- data upon which nutritional risk determinations are made by a competent professional authority on the staff of the local agency.
Computer Generated Vouchers - These vouchers contain a specific food package, individually tailored for each participant's nutritional needs. These vouchers are produced by the ADP contractor and contain information based on the TAD submitted by the clinic. District/Clinic identification numbers are also printed on the vouchers.

Computer Printed Voucher Register - A listing of participants that have computer generated vouchers produced during a cycle and to provide a signature space for verification of receipt of vouchers.

Computing Income - Review documents (i.e. Check Stubs, IRS forms, etc.) to determine the income eligibility of the WIC participant.



Confidentiality - The WIC Program may give the participants certification information to other Health Public Assistance programs to see if the participant is eligible for their services. These agencies may contact the applicant, but they may not give any information to anyone else without obtaining the participants permission.
Cost Containment Measure - A competitive bidding, rebate or direct distribution implemented by a State agency as described in its approved State Plan of operation and administration.

Day Worker - Individual who contracts for labor or services on a daily basis.
Declination Statement Forms - A form used to document refusal to want to register to vote.
Delivery Date - Indicates the date of actual delivery ofan infant (or the date the pregnancy ended) for a postpartum woman
Disability - A physical incapacitated or disabling condition which prevents or restricts normal accessibility or activity included are visual and hearing impaired individuals.
Disqualification - The act of ending the program participation of a participant, authorized food vendor, or authorized State or local agency, whether as a punitive sanction or for administrative reasons.
Disqualified Vendors - Vendors that are found to be in violation of program policies and regulations through compliance investigation. Vendors will be assessed sanction points for violations occurring in each investigation visit.
Donations - WIC foods and other food items purchased as a result of the compliance investigations. These items are donated to non-profit organizations within the city (ies) where the purchases are made by the investigator.
Dual Participation Report - This report specifies possible dual participants in alphabetic sequence, which must be investigated by the local agency and submitted to the State WIC Office.
Dual Participation - WIC participants who receive benefits twice in the same clinic, or from more than one clinic.
EBT - Electronic Benefit Transfer
EDC (Estimated Date of Confinement) - Indicates the date of expected delivery for a pregnant woman.
Education Level - Indicates the highest level or grade completed, for women participants only.

2



Equipment Inventory - A detailed listing of all property purchased with WIC funds and valued at a minimum of $1000.00.
Fair Hearings - Procedures under which a person or his/her guardian will be guaranteed the right to appeal a decision or action by the State or local agency which results in the individuals denial of participation, suspension, or termination from the program.

Family - A group of related 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 ofa single family.
Family Size - Identifies the total number of individuals in a household.
Fiscal Year - The WJC Program operates under the constraints of both the federal fiscal year (October I through September 30) and the state fiscal year (July I through June 30).

temporary living accommodation; an institution that provides a temporary residence for individuals intended to be institutionalized; a temporary accommodation in the residence
of another individual; or a public or private place not designed
for, or ordinarily used as, a regular sleeping accommodation for human beings.
Homeless Facility - A supervised publicly or privately operated shelter (including a welfare hotel or congregate shelter) designed to provide temporary living accommodations; a facility that provides a temporary residence for individuals intended to be institutionalized; or a public or private place not designed for, or normally used as, a regular sleeping accommodation for human beings.
Hospital Certification - Reviewing hospital documentation for eligibility of applicants/participants for the WIC program.
HOST - Health Outcomes Services Tracking System.
Identification - Valid picture ID or other valid ID such as Drivers License, Birth Certificate, immunization record, etc.

FNS - The Food and Nutrition Service of the United States Department of Agriculture.

Food Delivery System - The method used by State and local agencies to provide supplemental foods to participants.



Food Costs - The costs of supplemental foods .
Food Instrument - A voucher, check, coupon or other document which is used by a participant to obtain supplemental foods.

Grant Award (Formula Grant/Grant Allocation) - Total (food and admin) dollars allocated to the State for the federal fiscal year based on funding formula.

Health Services - Ongoing, routine pediatric and obstetric care (such as infant and childcare and prenatal and postpartum examinations) or referral for treatment.

Height - The vertical length (depending on the age) of a participant to the nearest eighth inch.

Hematocrit - Medical criteria required to assess nutritional risk.

Incident/Complaint Form

Form #3772 titled

Incident/Complaint Form. This form is used to document

complaints from participants, vendors, USDA, etc.

Income - Gross cash income before deductions for income taxes, employee's social security taxes, insurance premiums, bonds, etc.

Income Exclusion - Income or benefits received that are not counted as income.

Income Inclusion - Monetary compensation for service including wage, salary, commissions or fees that ~counted as income.

Income Tax Form - Legal Statement of earnings and deduction as prescribed by the IRS Tax Codes.

Infant Mid-Certification Nutrition Assessment - This assessment to be completed between five and seven months of age for an infant. The infants weight, height, hemoglobin or hematocrit, diet, nutritional risk, and food package needs are evaluated during this assessment. This assessment ensures accessibility to quality health care services.

Hemoglobin - Medical criteria required to assess nutritional risk.

Homeless - A woman, infant or child who does not have regular fixed night time residence, or resides in a temporary public or private shelter.



Homeless Individual - A woman, infant or child who lacks a fixed and regular night time residence; or whose primary night time residence is: A supervised publicly or privately operated shelter (including a welfare hotel, a congregate shelter, or a shelter for victims of domestic violence) designated to provide

Initial Contact Date - The date an applicant first visits the WIC clinic during office hours and requests WJC benefits, orally or in writing.
Institution - Any residential facility designed to provide meals and living accommodations for individuals intended to be institutionalized but excludes private residences or homeless facilities.
Institutionalize - To reside in, by choice or otherwise, an established residential facility that provides accommodations and meals.

3

Issue Month - The month in which vouchers were issued.



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 parent who is applying on behalf of the child

LQA - Living Quarter Allowance.

Leave and Earnings Statement (LES) - Pay check stub for the military.

Legal Custody - Court ordered custody of a person. Letter of Household Income - Statement attesting to household income by wage eamer(s).

Native American - The original inhabitants of America; an American Indian.
No-Proof Form - Form used when an applicant for WIC cannot provide documented proof of identification, residence or income.
Non-Participation - Participants in a valid certification period who do not pick up (manual or computer) are counted as a nonparticipant.
Non-Breast-feeding - Postpartum woman who is not breast-feeding an infant. Non-English Speaking - Individual whose primary language is not English or speaks little English.

Local Agency - (a) A public or private, nonprofit health or human service agency which provides health services, either directly or through contract.

Nonprofit Agency - A private agency which is exempt from income tax under the Internal Revenue Code of 1954, as amended.

Logger - An individual whose primary employment is the harvesting of trees seasonally; and for such work the person establishes temporary residence.

Manual Voucher Inventory Log - Documentation that vouchers are inventoried on a weekly and monthly basis.



Medical Care Start Date - Indicates which month of the pregnancy the woman began receiving prenatal care
Members of Populations - Persons with a common special need who do not necessarily reside in a specific geographic area, such as off-reservation Indians or migrant farm workers and their families.

Numeric Client Masterfile - An enrollment report, which list all active participants. This report is a cross reference for the Alphabetic Client Masterfile. It provides the client names by ID number.
Nutrition Education - Individual or group education sessions and the provision of information and educational materials designed to improve health status, achieve positive change in dietary habits, and emphasize relationships between nutrition and health .
Nutritional Assessment - Contains medical data obtained and evaluated by a CPA, which determines a participant's nutritional risk.

Memorandum of Agreement - Written operation agreement between the State of Georgia and the Health District or agency where WIC services are delivered.

MIER ( Monthly Income and Expense Report) - An itemized summary of all WIC expenditures reported monthly by each Local Agency.

Migrant Farm workers - An individual whose principal employment is in agriculture on a seasonal basis, who has been so employed within the last 24 months, and who establishes, for the purposes of such employment, a temporary abode.

Migrant - A seasonal farm or agricultural worker or family member who travels from place to place for the purpose of work and such work requires the establishment of temporary residence.



Motor Voter Act - An act that mandates the WJC Program's obligation to offer voter registration opportunities to anyone entering a clinic for WIC benefits.
Motor Voter Forms - A form issued to applicants that registers them to vote.

Nutritional Risk - Detrimental or abnormal nutritional conditions detectable by biochemical or anthropometric measurements; other documented nutritionally related medical conditions; dietary deficiencies that impair or endanger health; or conditions that predispose persons to inadequate nutritional patterns or nutritionally related medical conditions.
OIG - The USDA Office of the Inspector General.
Participant Hardship - If disqualifying a vendor causes hardship to WJC participants, the vendor shall be granted a probationary period. A hardship case is granted if the nearest authorized WIC vendor is ten (10) miles or more away from the nearest WJC clinic. If a violation occurs within the probationary period, the vendor shall be disqualified for the full disqualification period.
Participation - The sum of the number of persons who have received supplemental foods or food instruments during the reporting period and the number of infants breast-fed by part1c1pant breastfeeding women (and rece,vmg no supplemental foods or food instruments) during the reporting period.

4



Patient Flow Analysis - A tool to analyze the ranges of time of a certification period form entry until exit. It also analysis voucher issuance time, bottlenecks and appointments.
Patient Flow Form - Tools used to measure the examination of patient flow.
Paid Cash - Applicant/Participant is paid in cash for work or services rendered.

Program participants during their pregnancy but had a nutritional need.
Priority III (Children) - Children with a nutritional need. This need is determined by measuring height/weight, taking a blood test and medical history.
Priority III (Postpartum) - Postpartum teenagers who are not breast-feeding.

Pay Stub - Statement of paid income earned.

PedNSS - The Pediatric Nutrition Surveillance System (PedNSS) is a national nutrition surveillance system administered by CDC.

Physical Presence - Applicant for WIC services must be present in the clinic to receive WIC services.

PNNS Data - The Pregnancy Nutrition Surveillance System (PNSS) is a national nutrition surveillance system administered by CDC.

Post Vendor Training Evaluation - A test pertaining to WIC vendor requirements given to all vendors when attending the initial and annual vendor training.



Postpartum Women - Women up to six months after termination of pregnancy.
Poverty Income Guidelines - The poverty income guidelines prescribed by the Department of Health and Human Services. These guidelines are adjusted annually by the Department of Health and Human Services, with each annual adjustment effective July I of each year.

Pregnancy Outcome - The results of the just ended pregnancy for the postpartum woman participant.

Pregnant Women - Women determined to have one or more embryos or fetuses in utero.

Prenatal Women - Pregnant female between the ages of IO and 55 years.

Prenatal Weight - Prenatal woman's weight prior to delivery.

Presumptive Eligibility - Individual presumed eligible for medicaid, benefits based upon information presented.

Priority I - Pregnant women, breast-feeding women, and infants at nutritional need determined by measuring height/weight, taking a blood test and medical history.



Priority II (Breast-feeding women) - Women who do not qualify under priority I, but are breast-feeding Priority JI infants.
Priority II (Infants) - Infants up to six months of age born to women who were WlC Program participants during their pregnancy, or infants born to women who were not WIC

Priority IV - Pregnant women, breast-feeding women, and infants with a nutritional need because of poor diet or homeless/migrancy status.

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

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

Processing Standards - Period from the time an applicant requests WIC services in person to the time he/she receives services.

Program - The Special Supplemental Food Program for Women, Infants and Children (WIC) authorized by section 17 of the Child Nutrition Act of 1966, as amended.

Prorate -The partial issuance of vouchers. The most common cause for the partial issuance of vouchers is missed appointments for voucher pick up. The number of vouchers withheld depends on the number of days the participants are late picking up their vouchers.

Proxy

Responsible person whom the

participant/parent/guardian/caretaker chooses to act on his/her

behalf. A participant may designate up to 2 persons to act as

proxy. The proxies must sign the space on the participant's

WIC ID card. An authorized proxy may pick up or redeem

vouchers and may bring the child in for subsequent

certifications, in restricted situations.

Racial Group of Participant - I=White, 2=Black, 3=Hispanic, 4=Native American, and 5=Asian, Pacific Islands and 6=Multiracial.

Reason for Certification - A participant's nutritional need for the WIC Program, based on the medical/nutritional data collected at the time of certification

Redemption -The exchange of WIC vouchers for supplemental foods at participating grocery stores. Only authorized foods (listed on the face of the voucher) may be purchased.

Refugee - Someone who flees his or her native country due to persecution or well-founded fear of persecution because of race, religion, nationality, political opinion, or membership.

5

Residency - Detennined by using the applicants documented proof of address.



Residual Funds - Funds remaining available for allocation to State agencies after every State agency has received the amount allocable to it as stability finds.
Return Voucher Payment Form - Fonn #3760 titled Return Voucher Payment Log. Vendors use this fonn used by Vendor when sending vouchers, that have been returned to them from the bank, to the State WIC Office for payment.

Sanction Points - Each violation has a set point value. When violations occur points are given based on the severity of the violation. Fonn #3 796 titled Sanction Point System lists all of the offenses and their point value.

Seasonal Farmworker - A worker employed in agriculture occupation whose residence is not temporary for the purpose of such work.

Secretary - The Secretary of Agriculture.

SFPD -The Supplemental Food Programs Division of the Food and Nutrition Service of the United States Department of Agriculture.



Special Formula - Fonnula that is not the standard contract fonnula. This fonnula is approved when a written prescription from a medical doctor with the diagnosis included is given to the participant.
Special Population - An Individual or a group of individuals with common needs who require special assistance or service to access and participate in WIC related services.

Special Site Visit - An official district/clinic visit requested by the State WJC Office due to various clinic problems. A district/clinic may be called one day on a site visit may take place the next day due to the severity of the problem identified.

Stability Funds - Funds allocated to any State agency for the purpose of maintaining its preceding year's Program operating level.

Staff Signature - The WIC Official signature verifies the income residency, identification and family size are correct as stated by the participant. The Staff signature also verifies/witness the participant signature and the participant has been advised to read (or have read to them) their rights and obligations.



Standard Formula - A particular type of fonnula provided by the State. All infants participating in the Georgia WIC Program will be provided with vouchers for the fonnula the program is under contract to use.
State - Any of the 50 States, the District of Columbia, the Commonwealth of Puerto Rico, the Virgin Islands, Guam, American Samoa, the Northern Marinas Islands and the Trust

Territory of the Pacific Islands.
State Agency - The health department or comparable agency of each State; an Indian tribe, band or group recognized by the Department of the Interior.
State Plan - A plan of Program operation and administration that describes the manner in which the State agency intends to implement and operate all aspects of Program administration within its jurisdiction.
Supplemental Foods - Those WIC foods containing nutrients detennined to be beneficial for pregnant, breastfeeding, and postpartum women, infants and children.
TANF - Temporary Assistance for Needy Families Program.
Temporary Accommodation - A public or private shelter or the residence of another person used for temporary living and sleeping accommodation.
Temporary Relocation - The establishment of a temporary residence for individuals whose primary place of residence is lost as the result of disaster, or other privation.
Time Study - A process of data collection and compilation designed to sample the activities of: *Non-WJC paid personnel if local agencies are using the time study to justify reimbursement of personnel costs. All staff whose salaries are paid in part or in full by WIC or whose time is used to offset shared costs.
Training Information Form - Form #3758 titled Vendor Training lnfonnation Form. This form is used to list owners/store managers that did not attend the annual training and whose Vendor Agreement was not renewed.
Transfers, Into - This transaction is used to transfer a participant already assigned an ID number on the computer system from one Georgia WIC Clinic to another. The transaction code is (X).
Turnaround Documents (TADs), Blank - A TAD which only has the Clinic Code field preprinted on it. This TAD is used for enrolling any additional family members onto the computer system through the use ofeither an Initial Certification, Waiting List, or Out of State Transfer input transaction. This TAD may also be used to complete an in-state transfer or any time a Computer Printed TAD is not available.
Turnaround Documents (TADs), Prenumbered - A TAD has the Clinic Code field and the complete WIC ID Number field (with participant code I) preprinted on it. The remainder of the form is blank. This TAD is used for enrolling the first member of a family onto the computer system through the use of either an Initial Certification, Waiting List, or Out of State Transfer input transaction.

6

Unemployed - Individual who is not currently being paid for labor or services.



Update/Infant Assessment - This transaction is used to change, correct, or update information for a participant already assigned an ID number on the computer system. This transaction is also used to enter the mid-certification nutritional assessment information for an infant already on the computer system. The transaction code is (~).

USDA - The United States Department of Agriculture.

VAMP - Vendor Activity Monitoring Profile. A report used to identify high risk vendors.

VHA - Variable Housing Allowance.

Vendor Training Sign-In Sheet - Form #3756 titled Sign-In Sheet. Form is used for store owners/managers to sign when attending the annual vendor training.
VOC - Verification of certification confirming that all requirements for WIC participation have been met.
VOC Card - A certification card from a WIC clinic verifying that the named person is a valid WIC participant entitling that individual to transfer certification to a new clinic.
Voided Vouchers -Both computer generated and manual vouchers may be voided for a variety of reasons. There are three different categories of voids: Voided Computer Generated Vouchers, Voided but issued manual vouchers, and Voided but Unissued Manual Vouchers.

Vendor Compliance Investigation - Vendors that have been identified as "High Risk" by the State WIC Office through the use of VAMP, complaints, or request for investigation forms received from the districts.

Vendor Input/Registration Document - A form that is used to add a new vendor to the active vendor list. Also used to make name, address and telephone number changes. Corrections in vendor type and county codes, and vendor termination/disqualification are submitted on this form. It does not have a form number and the title of the form is Vendor Registration.



Vendor Materials - A list of all the vendor forms and booklets that are available.
Vendor Monitoring - Local agencies must perform on site visits to all WIC vendors at least once every two (2) Federal Fiscal years.

Voucher Security - WIC vouchers are negotiable items which are presented to the bank as a check for cash reimbursement. Therefore all vouchers must be securely protected as checks or cash in order to help prevent voucher theft, and deter program fraud.
Voucher Number - The serial numbers of the vouchers produced for a participant.
Weight - Total weight in pounds and ounces of a participant.
Weight, Prior to Delivery - Indicates the woman's final weight immediately prior to delivery
WIC ID Number - Uniquely identifies the participant. It consist of 3 data elements. A 9 digit family identification number, a I digit check digit, and a I digit participant code. All members of a family should be assigned the same family identification number to facilitate voucher distribution.

Vendor Profile Report - A report that gives data on the disposition of vouchers cashed by each vendor. Also provides high risk indicators.

WIC Type - Classifies WIC participants i.e., P=Pregnant Woman (Prenatal), N=Non-breastfeeding postpartum woman, B=Breastfeeding postpartum woman, !=Infant, and C=Child

Vendors, Review Form - Form #3774 titled Vendor Review Form is used when the local agencies are performing a monitoring visit at a WIC vendor site. It is also used when performing an inspection of a store that has applied to be a WIC vendor.

Zero Income - Applicant/Participant receives no monies from work, services or any entitlement programs.

Vendor Sanctions - When a WIC vendor is found to be in violation of program policy and/or regulations, that vendor will be assessed sanction points according to the severity of the violation. When a vendor accumulates twenty-five (25) or more sanction points, the store shall be disqualified from the WIC Program.



Vendor Stamp - A rubber stamp with an assigned vendor number that is issued to each new WIC vendor.
Vendor Training Checklist - Form #3757 titled Vendor Training Checklist. This form is used to indicate subjects covered during training.

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