GA \4 '800. f'6 ;;, WlP FFY.2000 1000 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) . IN-2 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. IN-4 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 IN-11 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. IN-12 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 IN-14 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 IN-15 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 IN-16 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 IN-20 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 IN-21 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$;j1ofteqttiree\@rlifi 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~in tliei~h:i.ff~~iiq~:ff9.fu#, l~: 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,~~! fartfibntti'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 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~.iiPJ.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!~ issigrtature.. )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 Il9~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 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 71bs/month) . Elevated Blood Lead level (Blood Lead level ?.10 U 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 NUcifv 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 10 -- Gestational Oiabeles (most - ....;..,,,,_., ......._,,ofPN!lermlnfantCsl(""""recenf----'l 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 (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 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 .SIGl10a,al) NutritiOn r26. 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 OETERMIHlfocrt :,ocs;J 20 18 w~~ 16 fd not cc<:o<"ded iR =ttl 1( 04t'E -..,..:., tz WEIC>- ~~,J~r~ . .l!:!t = lir - ;..r. , Z:,-,1 (.'il:: :;:,~ t t t . ;,;,,.- ,-~,:: . . -1,'~4- - :.a,: t a ' 1.1-":' ~ 6 V " V 7 r , 2 , 0 -2 . .( ~ !-.,o-a t ' " 2 6 e 10 12 16 18 20 22 24 26 2S 30 32 ; ,3Q :JS ,O '2 CT-148 GAWICPROCEDURESMANUAL Attachment CT-26 PRENATAL WEIGHT GRID FOR UNDERWEIGHT AND OVERWEIGHT ....-_- Wl:'.IClocsl 20 ts w~~ t6 (c!t>ot~c - . , - : , ; 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,umbonc _ _ _ _ _ _ _ _ _ _ _ __ 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 ~ (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 marle,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 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<] !PEAS/BEANS lb Dried I l> ~ {i "~'=' 0 {i tf'j 0 ~ ~ 00 ~ z r~ > 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<-w Ou> ... ~ ..."~'O IL 0.. .:t.:.s. 0.. E 0 u -~ t ..u::cs 0 ;> :.E"...' c:: 0 c:: -0~ .8c:: (:;-;-i I I ~\< !> .0...0.. 00 >> .c...o.. 00 >> .. .0...0.. ...... 00 <.D - - - - - - :i: 0 >>0 00 00 m (Y)- z 00 >> .,. o::;j" ,-. 0 u"' 0 0 N 0 ~ ..r er ..r O" D n.J D ..r ..r rn D.r...n.. ..uJ D ... ~ ::, C. E u 0 I 2 VN-84 w z < 00 VI 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 ~ (j :",":C, 0 (j tfj 0 ~ ~ rJ) =-:n > r:,:i ~ ~ tfj :,:, > t""' ~ --I~ !Z z ~ -~ ~ t""' ~ OS. r - IIIKtnG'l1&:a-:1:1 1 111 "t..1 S-,1dlG1:01W ...:f'A1 - 1 ---..-w-21,1;-zw,~-."rtnvtif~,.,,,ul!lOtPi!I -r~ I3:C-:'"" "'+'-'l&'"'tl,-"'V'-I.WtlRfll!tffl:J 1..>...... ~ (:':)r 3 :0.:.:.,. ., .z<.I.. 0 (') .0::.:.,. 0. GA WIC PROCEDURES MANUAL Attachment VN-10 cont'd CASHIER TRAINING PAMPHLET r;-:., l~i! I ~ 18~:!1 I !l!~g I It:; i ~ I ~~_J . . I-. >- ,; l ~w QU> =Il>l m ::!:t: ... f' 8~ : . "~'o ~ ~~ . ,0._ Q z 12 --J m 8 LO I LO ~ i ~ I If l>U..t:D. w i sl ~('Y) ~I~ I J ffiO} ~ s ; ! B liLO ll ll t ~ ~ . 1-4Q? gLO a.. .wn -=~ (,I ::, . ;;0> ~ u;: ~ -; ~" iH ::, = ~ ~= ~ = . l1f~~;~~ ii=5 w ~ 0) 0) ::t:: V) a: ~ c:,::"w' a::,: :Si ~ CJ8 Oa:~"'3-: oD~.~a: -:c 3 i~ ~IL 0 c<;~!ia-: 0 0 ..z er ..z 0 CJ'" 8 s!tl!! f>:-:o~ 0 LLwwZ ~~~ 3"'oo D a::!!!~::! ~i~~ .: fg~ .r ;;!~"' ..z r-n UJ a. a. ;:? r-n 0 ...... (") a:::c ~ ! . j .... I .. ~ O <) < w~< (!Jo~ cc fi! C) t"'-- w 0 s1 ~fj 8 ~i 1l s iii ~?; g~ c) .~.. c.D D ~ ..z s I 0z 9 0 3: ~ ~ ~ . ~ w C, ll ll lS i ~ ~ ~ ;! s :s E ~~ ~ l0:::, IL lJ1 lJ1 r-n er . lJ1 lJ1 er er 0 z ij 0N .a ~ z ;:::::, N !!l t') 0 ..,_ c- :S =<.!!C:A.:.?.i (.) ~;i IL 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 Typw 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 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: ~ -> ~ ('j ;g 0 (i trl 0 ~ .~ ~ - 00 ~ s ~ > ztrl t- ~ ('j 10 ~ z > I~ 1~ 0 I~ ..... ~ :::,- 3 ('II :..:.,.. -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 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 !>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") -> ~ n :~,= 0 n l:'.!j ~ ~ 00 ~ z :! ~ :>,= > ~ 3: > n ~ ::c: > =0~ 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 . 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. 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 i~ p !~ 2lb~CNStgQ;At ,.{OH:}1 , , . 'Tl ,JtJICij Vl =OZ..QAN 0 I VI N M@~;:O:, ' r,s, .oR 1-1'1.SOZ.-'ChNPO ~ ~ . . ....~. ,.1({ . _ i ~ ~ . ,7., . '"'_:_,e.-,;_-.,~. ~~! it.' if t.'J/ ,.fl :. ~iii'ffci :_ ~ ~~ ~~ =~~~~-~4_;J1 . : ~ > ~ Ci "~'= Ci t'j t::, ~ ~ ,00 ~ ~ :a > t"" 0 t::, a ~ ;,C,;i .Jl,IPRO!.,.~~SE ~ - ,.....,..,._.._ OF THIS VOl,/_()IER ,'jilf),. IS SUBJECT T9 .$If.TE ~ -~ ANO F.EO ~ ~ ~R9~ECUTION .,Jtr.~. . .-*.. .,j>:;~ 0 ~CIP~r~~XVSIGW.~~+ ~ ~-: ,... 111 8E,SOt.O?E,11 1: GJ.J.O:i:it.t.1: 02 oc, i..c, i..1: i > =-f') a .=~... ~ t::, I 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 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 > ~ ~ ("'.) -: ~ ("'.) ~ ~ ~ ~~~ ~L~ . . . . . _____ ;,?Ro~RAM1{{ 1'1~ i ll~c}n1c1s;~lI i~l66cf{~i ~ ~ ~~~ - it WE;tt.1 \\:!,.ef;DEP.11,l;f WI<; 10#: 06209000341- ,. 6'~N/~if~!~.:fi!AIALNLERN~.(r!d)lfljARc~:$,,:~.~. J ,< ~- ~Jlat POnt:,'Elifl-f' -~,ozri~/1999 "' ~,,,/ . -~:~wr.User ID: ~b,-,,:f.. '\JRr."' .-/f.' .,_..-. ..'.',. I~ 00 ~ 'Tl 0 I 0\ 'D ~~~~)!-'~~~41~; / ~~'~~,:~- -~t\t~: '~,,. }'(1dl11ou;c~h11Sh . . . t ,_. iJi ~ <" ~ ;, ~ti ., .... C . "'f:IMW . --~ i8j_">- f-,_, -~-;,1~1,m:_,..'.11:.-, II1,1~, . z f1 ' /.'1- .. . ' . -, . -~. 1,,,;;.- ,J 5 . J:(r 1~- I '-l5 it.> Y.'9 fol ~~, .-j... /f. ~,}) {I . -.;~;.i::.' ':t, ;,;,:, -t~.~ :.,-.s,:; d Cv- ..,;'.fSi ic\i ~- . "' . .. .aJJ.).). ..!',VJ f{~~::~. ft '(sl ;k!.1{/1 # -...... i,--!,f 'h jt .,-,::;; ., ... , ''. d,~~- ~:f.<\5i ?<-..... ~ ';~ -.;:~ ;. __ , _ t,:f. :..., ..- /: ... 1: 1.. 'i~ :,{~;/ _-,r, .... "" .:, . -.... ,. .,.. ,,. ,.,_-._;; . WJ'OlO'B' -~ ~~ERECENED~HE~~t ~--~JkA.~M~ - ik 1Ji<'l'-). ,~ ~ ~- ..~ .--1~ :a 0 ~ ~ t::, ~ ("'.) ~ -~ : 1-3 > ~ ti;. -e=f)- = ~ ~ t::, I N N 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 . 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. 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 i~ p !~ 2lb~CNStgQ;At ,.{OH:}1 , , . 'Tl ,JtJICij Vl =OZ..QAN 0 I VI N M@~;:O:, ' r,s, .oR 1-1'1.SOZ.-'ChNPO ~ ~ . . ....~. ,.1({ . _ i ~ ~ . ,7., . '"'_:_,e.-,;_-.,~. ~~! it.' if t.'J/ ,.fl :. ~iii'ffci :_ ~ ~~ ~~ =~~~~-~4_;J1 . : ~ > ~ Ci "~'= Ci t'j t::, ~ ~ ,00 ~ ~ :a > t"" 0 t::, a ~ ;,C,;i .Jl,IPRO!.,.~~SE ~ - ,.....,..,._.._ OF THIS VOl,/_()IER ,'jilf),. IS SUBJECT T9 .$If.TE ~ -~ ANO F.EO ~ ~ ~R9~ECUTION .,Jtr.~. . .-*.. .,j>:;~ 0 ~CIP~r~~XVSIGW.~~+ ~ ~-: ,... 111 8E,SOt.O?E,11 1: GJ.J.O:i:it.t.1: 02 oc, i..c, i..1: i > =-f') a .=~... ~ t::, I 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 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 > ~ ~ ("'.) -: ~ ("'.) ~ ~ ~ ~~~ ~L~ . . . . . _____ ;,?Ro~RAM1{{ 1'1~ i ll~c}n1c1s;~lI i~l66cf{~i ~ ~ ~~~ - it WE;tt.1 \\:!,.ef;DEP.11,l;f WI<; 10#: 06209000341- ,. 6'~N/~if~!~.:fi!AIALNLERN~.(r!d)lfljARc~:$,,:~.~. J ,< ~- ~Jlat POnt:,'Elifl-f' -~,ozri~/1999 "' ~,,,/ . -~:~wr.User ID: ~b,-,,:f.. '\JRr."' .-/f.' .,_..-. ..'.',. I~ 00 ~ 'Tl 0 I 0\ 'D ~~~~)!-'~~~41~; / ~~'~~,:~- -~t\t~: '~,,. }'(1dl11ou;c~h11Sh . . . t ,_. iJi ~ <" ~ ;, ~ti ., .... C . "'f:IMW . --~ i8j_">- f-,_, -~-;,1~1,m:_,..'.11:.-, II1,1~, . z f1 ' /.'1- .. . ' . -, . -~. 1,,,;;.- ,J 5 . J:(r 1~- I '-l5 it.> Y.'9 fol ~~, .-j... /f. ~,}) {I . -.;~;.i::.' ':t, ;,;,:, -t~.~ :.,-.s,:; d Cv- ..,;'.fSi ic\i ~- . "' . .. .aJJ.).). ..!',VJ f{~~::~. ft '(sl ;k!.1{/1 # -...... i,--!,f 'h jt .,-,::;; ., ... , ''. d,~~- ~:f.<\5i ?<-..... ~ ';~ -.;:~ ;. __ , _ t,:f. :..., ..- /: ... 1: 1.. 'i~ :,{~;/ _-,r, .... "" .:, . -.... ,. .,.. ,,. ,.,_-._;; . WJ'OlO'B' -~ ~~ERECENED~HE~~t ~--~JkA.~M~ - ik 1Ji<'l'-). ,~ ~ ~- ..~ .--1~ :a 0 ~ ~ t::, ~ ("'.) ~ -~ : 1-3 > ~ ti;. -e=f)- = ~ ~ t::, I N N 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 70 GA WIC PROCEDURES MANUAL ATTACHMENT MO-01 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. 71 GA WIC PROCEDURES MANUAL PART VI - FINANCIAL MANAGEMENT ATTACHMENT MO-01 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. 72 GA WIC PROCEDURES MANUAL ATTACHMENT MO-01 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. 73 GA WIC PROCEDURES MANUAL ATTACHMENT MO-1 PART VII CERTIFICATION/NUTRITION EDUCATION/AND BREASTFEEDING - OON 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 . 74 .WIC PROCEDURES MANUAL ATTACHMENT MO-1 PART VII CERTIFICATION/NUTRITION EDUCATION/A~D BREASTFEEDING - OON 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. 75 GA WIC PROCEDURES MANUAL ATTACHMENT MO-1 PART VII CERTIFICATION/NUTRITION EDUCATION/AND BREASTFEEDING - OON GUIDELINES 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 . 76 WIC PROCEDURES MANUAL ATTACHMENT MO-1 PART VII CERTIFICATION/NUTRITION EDUCATION/AND BREASTFEEDING - OON GUIDELINES 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. 77 GA WIC PROCEDURES MANUAL ATTACHMENT MO-1 PART VII CERTIFICATION/NUTRITION EDUCATION/AND BREASTFEEDING - OON GUIDELINES 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 . 78 WICPROCEDURESMANUAL ATTACHMENTM0-1 PART VII CERTIFICATION/NUTRITION EDUCATION/AND BREASTFEEDING - OON GUIDELINES 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. 79 GA WIC PROCEDURES MANUAL ATTACHMENT MO-1 PART VII CERTIFICATION/NUTRITION EDUCATION/AND BREASTFEEDING-OON GUIDELINES 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. 80 WIC PROCEDURES MANUAL ATTACHMENT MO-1 PART VII CERTIFICATION/NUTRITION EDUCATION/AND BREASTFEEDING - OON 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 . 81 GA WIC PROCEDURES MANUAL ATTACHMENT MO-1 PART VII CERTIFICATION/NUTRITION EDUCATION/AND BREASTFEEDING - OON 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. 82 WIC PROCEDURES MANUAL ATTACHMENT MO-1 PART VII CERTIFICATION/NUTRITION EDUCATION/AND BREASTFEEDING - OON 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? 83 GA WIC PROCEDURES MANUAL ATTACHMENT M0-1 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. 84 WIC PROCEDURES MANUAL ATTACHMENT MO-1 PART VII CERTIFICATION/NUTRITION EDUCATION/AND BREASTFEEDING - OON 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. 85 GA WICPROCEDURESMANUAL ATTACHMENTM0-1 PART VII CERTIFICATION/NUTRITION EDUCATION/AND BREASTFEEDING - OON 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. 86 WIC PROCEDURES MANUAL ATTACHMENT M0-1 PART VII CERTIFICATION/NUTRITION EDUCATION/AND BREASTFEEDING - OON GUIDELINES 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 87 GA WIC PROCEDURES MANUAL ATTACHMENT MO-1 PART VII CERTIFICATION/NUTRITION EDUCATION/AND BREASTFEEDING - OON 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. 88 WIC PROCEDURES MANUAL ATTACHMENT M0-1 PART VII CERTIFICATION/NUTRITION EDUCATION/AND BREASTFEEDING - OON GUIDELINES 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 89 GA WIC PROCEDURES MANUAL ATTACHMENT MO-1 PART VII CERTIFICATION/NUTRITION EDUCATION/AND BREASTFEEDING-OON 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. 90 WIC PROCEDURES MANUAL ATTACHMENT MO-1 PART VII CERTIFICATION/NUTRITION EDUCATION/AND BREASTFEEDING - OON 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. 91 GA WIC PROCEDURES MANUAL ATTACHMENT MO-1 PART VII CERTIFICATION/NUTRITION EDUCATION/AND BREASTFEEDING - OON 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. 92 WIC PROCEDURES MANUAL ATTACHMENT MO-1 PART VII CERTIFICATION/NUTRITION EDUCATION/AND BREASTFEEDING - OON 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 93 GA WIC PROCEDURES MANUAL ATTACHMENT MO-1 PART VII CERTIFICATION/NUTRITION EDUCATION/AND BREASTFEEDING - OON 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. 94 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. 99 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. 101 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). 105 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 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) QI- 28 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 . BF-4 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.). BF-18 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. BF-19 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. BF-20 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. BF-21 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. BF-22 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. BF-23 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. BF-24 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. BF-25 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 BF-26 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. BF-28 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: BF-29 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 BF-30 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 BF-37 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 BF-38 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. 7