FFY 2002 WIC procedures manual [2002]

FFY 2002 WIC
Procedures Manual
Georgia WIC Branch

GA WIC PROCEDURES MANUAL TABLE OF CONTENTS Page
I. Purpose........................................................................................................................... IN-1 II. Scope.............................................................................................................................. IN-1 III. References...................................................................................................................... IN-1 IV. Prior Approval ............................................................................................................... IN-1 V. Policy Memos ................................................................................................................ IN-1 VI. Sections .......................................................................................................................... IN-2
A. Introduction (IN).................................................................................... IN-2 B. Certification (CT) .................................................................................. IN-2 C. Rights and Obligations (RO) ................................................................. IN-3 D. Administrative (AD) .............................................................................. IN-3 E. Vendor (VN) .......................................................................................... IN-4 F. Food Package (FP)................................................................................. IN-4 G. Nutrition Education (NE)....................................................................... IN-5 H. Special Population (SP) ......................................................................... IN-5 I. Outreach (OR)........................................................................................ IN-5 J. Food Delivery (FD) ............................................................................... IN-5 K. Compliance Analysis (CA) .................................................................... IN-6 L. Monitoring (MO) ................................................................................... IN-6 M. Breastfeeding (BF)................................................................................. IN-6 N. Disaster Plan (DP) ................................................................................. IN-7 O. WIC Procedures Manual Glossary ........................................................ IN-7 VII. Administration ............................................................................................................... IN-7 A. Food and Nutrition Service (FNS)/USDA............................................. IN-7 B. State Agency .......................................................................................... IN-7

GA WIC PROCEDURES MANUAL VIII. Addresses ....................................................................................................................... IN-8
A. Local Agencies ...................................................................................... IN-8 B. State Agency ........................................................................................ IN-14

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.
II. SCOPE The information in the Georgia WIC Program Procedures Manual applies to all Department of Human Resource (DHR) agencies, including district health units and non-DHR agencies that contract with DHR to administer and operate a WIC Program. The Georgia WIC Program 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).
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.
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, purchasing of ADP equipment, etc.
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 Branch staff during on-site monitoring visits. During the fourth
IN-1

GA WIC PROCEDURES MANUAL
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.
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
IN-2

GA WIC PROCEDURES MANUAL
Certified Waiting List Patient Flow Analysis 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
IN-3

GA WIC PROCEDURES MANUAL
Retroactive Benefits and Reimbursement Mandatory No Smoking Policy in Local WIC Clinics 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-4

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 (ID) Card Proxies Mailing/Delivery of WIC Vouchers
IN-5

GA WIC PROCEDURES MANUAL
Voided Vouchers Prorated Vouchers Late Pick-up of Vouchers Coordination of Health Services and Voucher Issuance Redemption of WIC Vouchers Lost, Stolen or Damaged Vouchers Borrowed Vouchers Cumulative Unmatched Redemption Report (CUR)
K. Compliance Analysis (CA): 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 Vouchers/VOC 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 Breastfeeding Materials and Resources
IN-6

GA WIC PROCEDURES MANUAL
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 O. WIC Procedures Manual Glossary
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-7

GA WIC PROCEDURES MANUAL

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 1, Unit 1 (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 1, 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 100 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 Gainesville, GA 30507 (770) 535-5743/GIST 261-5743 District 3, Unit 1 (Cobb)

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

# OF WIC CLINIC SITES
17

Whitfield, Murray,

7

Gilmer, Fannin, Pickens,

Cherokee

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

Cobb, Douglas

8

IN-8

GA WIC PROCEDURES MANUAL

DISTRICT/ADDRESS
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) 961-1330 District 3, Unit 4 (Gwinnett)
Alan Sievert, 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

COUNTIES SERVED
Fulton Clayton Gwinnett, Rockdale, Newton

# OF WIC CLINIC SITES
23
3
6

IN-9

GA WIC PROCEDURES MANUAL

DISTRICT/ADDRESS
Lawrenceville, GA 30246-0897 324 W. Pike Street Lawrenceville, GA 30045-0897 (770) 339-4260 District 3, Unit 5 (DeKalb)
Paul J. Wiesner, M.D. District Health Director
Sharon Wilson, 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. (770) 484-2621
Central Dekalb Health Center 320 Winn Way Decatur, GA 30031 Contact: Karmen Tweed, M.S., I.B.C.L.C.,
C.H.E.S. (404) 508-7836

COUNTIES SERVED DeKalb

# OF WIC CLINIC SITES
5

Betty Jones, RN, M.P.H. DeKalb - Atlanta- Health Center 30 Warren Street Atlanta, GA 30317 Contact: Laurice Howell-Williams, (404) 370-4666
Robert V. Taylor Director North Dekalb Health Centers 1954 Airport Road Suite #150 Chamblee, GA 30341-4953 Contact: Carol Boe, R.D., L.D. (770) 454-1144

Burretta Shepherd Director South DeKalb Health Center 3110 Clifton Springs Road, SuiteD
IN-10

GA WIC PROCEDURES MANUAL

DISTRICT/ADDRESS
Decatur, GA 30034 Contact: Magon Mbudugha, M.S., C.D.M. (404) 244-2210 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 122 Gordon Commercial Drive Suite A LaGrange, Georgia 30240 (706) 845-4035 District 5, Unit 1 (Dublin)
Lawton Davis, M.D. District Health Director Jannell Knight, M.S.A., L.D. Program 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 31021 (478) 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 (478) 445-1137 Fax (478) 445-1139 District 6 (Augusta)
Frank Rumph, M.D. District Health Director East Central Health District Office 1916 North Leg Road Augusta, GA 30909

COUNTIES SERVED

# OF WIC CLINIC SITES

Fayette, Heard, Henry,

17

Butts, Carroll, Coweta,

Lamar, Pike,

Meriwether, Troup,

Spalding, Upson

Bleckley, Dodge,

10

Laurens, Montgomery,

Pulaski, Telfair,

Treutlen, Wilcox,

Wheeler, Johnson

Hancock, Houston,

20

Jasper, Baldwin, Bibb,

Crawford, Jones,

Monroe, Peach, Putnam,

Twiggs, Washington,

Wilkinson

Burke, Columbia,

23

Emanuel, Glascock,

Jefferson, Wilkes,

Warren, Jenkins,

Lincoln, McDuffie,

Richmond, Screven,

IN-11

GA WIC PROCEDURES MANUAL

DISTRICT/ADDRESS
(706) 667-4250 John Nolan Program Manager Frances Wilkinson, M.S., R.D., L.D. District WIC Coordinator East Central Health District Office 1916 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 31603 312 N. Patterson Street Valdosta, GA 31601 (229) 333-5290 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

COUNTIES SERVED Taliaferro

# OF WIC CLINIC SITES

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

Terrell, Lee, Calhoun,

15

Worth, Early,

Dougherty, Baker,

Grady, Mitchell,

Colquitt, Miller,

Thomas, Seminole,

Decatur

IN-12

GA WIC PROCEDURES MANUAL
DISTRICT/ADDRESS
(229) 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 of Nutrition 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
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
IN-13

COUNTIES SERVED

# OF WIC CLINIC SITES

Chatham, Effingham

9

Appling, Atkinson,

20

Bacon, Jeff Davis,

Brantley, Ware, Bulloch,

Candler, Clinch,

Charlton, Evans, Coffee,

Wayne, Pierce, Toombs,

Tattnall

Bryan, Liberty, Long,

15

McIntosh, Camden,

Glynn

Barrow, Clarke, Elbert,

17

Green, Jackson,

Madison, Morgan,

Oconee, Walton,

Oglethorpe

GA WIC PROCEDURES MANUAL

DISTRICT/ADDRESS
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 Grady Maternal & Infant Care Project
Joseph A. Taylor Director VACANT Chief Nutritionist Maternal & Child Health Nutrition Dept. Grady Health System P. O. Box 26011 Atlanta, GA 30335 (404) 616-6745

COUNTIES SERVED

# OF WIC CLINIC SITES

Portions of Fulton ad

2

Dekalb Counties

ALL

6

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 Branch Two Peachtree Street, N.E. 10th Floor Atlanta, Georgia 30303 (404) 657-2900 Hotline 1-800-228-9173 FAX (404) 657-2910 or (404) 651-6728

IN-14

GA WIC PROCEDURES MANUAL For technical assistance regarding nutrition-related topics, contact the Nutrition Section. Georgia Department of Human Resources Division of Public Health Family Health Section Nutrition Section Two Peachtree Street, N.E. 11th Floor Atlanta, Georgia 30303 (404) 657-2884 FAX (404) 657-2884
IN-15

GA WIC PROCEDURES MANUAL
TABLE OF CONTENTS Page
I. General........................................................................................................................CT-1 II. Eligibility Requirements .............................................................................................CT-1
A. Category...............................................................................................................CT-1 B. Physical Presence.................................................................................................CT-2 C. Residency.............................................................................................................CT-3 D. Income .................................................................................................................CT-4 E. Nutritional Risk ....................................................................................................CT-4 III. Initial Application .......................................................................................................CT-4 IV. Processing Standards ..................................................................................................CT-6 A. Timeframes ..........................................................................................................CT-6 B. Walk-in Clinics ....................................................................................................CT-6 C. Request for Extension..........................................................................................CT-6 V. Participant Identification.............................................................................................CT-7 VI. Georgia WIC Program Identification (ID) Card.........................................................CT-8 A. Required Data ......................................................................................................CT-8 B. Participant Instructions........................................................................................CT-9 VII. Proxies ........................................................................................................................CT-10 A. Reasons for Proxies .............................................................................................CT-10 B. Authorization .......................................................................................................CT-10 C. Voucher Pick Up, Issuance, and Use...................................................................CT-11 D. Restrictions ..........................................................................................................CT-11 E. Participant Instructions ........................................................................................CT-11 VIII. Income Eligibility .......................................................................................................CT-11 A. Procedures............................................................................................................CT-12 B. Adjunctive (Automatic) Eligibility..................................................................... CT-13 C. Computing Income ............................................................................................ CT-15 D. Documented Proof of Income............................................................................. CT-25 E. Applicants with Zero (0) Income........................................................................ CT-25 F. Verification of Income........................................................................................ CT-26

GA WIC PROCEDURES MANUAL IX. Nutritional Risk Determination ................................................................................. CT-26
A. Required Data ..................................................................................................... CT-27 B. Referral Data....................................................................................................... CT-28 C. Medical Data Date .............................................................................................. CT-29 X. Nutrition Risk Criteria ............................................................................................... CT-29 XI. Nutrition Risk Priority System .................................................................................. CT-29 A. General................................................................................................................ CT-29 B. Special Considerations........................................................................................ CT-30 C. Specific ................................................................................................................CT-31 D. Assignment ..........................................................................................................CT-32 XII. Changes Within a Valid Certification Period ............................................................CT-33 A. Women Who Cease Breastfeeding ......................................................................CT-33 B. Upgrading a Priority ............................................................................................CT-33 XIII. Certification Periods ...................................................................................................CT-33 XIV. Infant Mid-Certification Nutrition Assessment ..........................................................CT-34 XV. WIC Assessment/Certification Form .........................................................................CT-35 A. General ................................................................................................................CT-35 B. Completion ..........................................................................................................CT-35 XVI. Ineligibility Procedures (Notification Requirements) ................................................CT-40 A. Written Notification.............................................................................................CT-41 B. Completion of Notice of Termination/Ineligibility/Waiting List Form........... CT-42 C. Ineligibility File ..................................................................................................CT-42 XVII.Transfer of Certification .............................................................................................CT-43 A. Verification of Certification (VOC) Card..........................................................CT-44 B. Other Methods of Verification.............................................................................CT-44 C. Instructions for VOC Card Use ...........................................................................CT-46 D. Orders ...... ...........................................................................................................CT-46 E. Inventories ...........................................................................................................CT-46 F. Issuance.... ...........................................................................................................CT-47 G. Security .... ...........................................................................................................CT-48 H. Lost/Stolen/Misplaced VOC Cards ....................................................................CT-48
CT-2

GA WIC PROCEDURES MANUAL
XVIII. WIC Overseas Program .............................................................................................CT-48 A. General .... ..........................................................................................................CT-48 B. Impact on USDA's WIC Program .....................................................................CT-49 C. New VOC Card Requirements...........................................................................CT-49 D. Completion of the VOC Card ............................................................................CT-50 E. Acceptance of WIC Overseas Program VOC Cards ..........................................CT-50
XIX. Correcting Mistakes...................................................................................................CT-50 XX. Documentation Procedures ........................................................................................CT-50 XXI. Certified Waiting List ................................................................................................CT-50
A. Procedures for Maintaining a Waiting List ........................................................CT-50 B. Procedures for Removal from the Waiting List..................................................CT-51 XXII. Patient Flow Analysis ................................................................................................CT-51 XXIII. System Information Management..............................................................................CT-55 XXIV. Immunization Coverage Assessment........................................................................CT-55 Attachments: CT-1 WIC Assessment/Certification Form - Pregnant Women..........................................CT-56 CT-2 WIC Assessment/Certification Form - Post Partum Breastfeeding ..........................CT-58 CT-3 WIC Assessment/Certification Form - Post Partum Non Breastfeeding ..................CT-60 CT-4 WIC Assessment/Certification Form - Infants ..........................................................CT-62 CT-5 WIC Assessment/Certification Form - Children........................................................CT-64 CT-6 Signed Statement of Income ......................................................................................CT-66 CT-7 Data and Documentation Required for WIC Assessment/Certification - Women ....CT-67 CT-8 Data and Documentation Required for WIC Assessment/Certification - Infants......CT-68 CT-9 Data and Documentation Required for WIC Assessment/Certification - Children...CT-69 CT-10 Nutritional Risk Criteria - Prenatal Women ..............................................................CT-70 CT-11 Nutritional Risk Criteria - Postpartum, Breastfeeding Women.................................CT-84 CT-12 Nutritional Risk Criteria - Postpartum, Non-Breastfeeding Women.........................CT-98 CT-13 Nutritional Risk Criteria - Infants..............................................................................CT-110 CT-14 Nutritional Risk Criteria - Children ...........................................................................CT-123 CT-15 Notice of Termination/Ineligibility/Waiting List Form.............................................CT-134
CT-3

GA WIC PROCEDURES MANUAL
CT-16 Verification of Certification (VOC) Card..................................................................CT-135 CT-17 VOC Card Inventory Log (Clinic).............................................................................CT-136 CT-18 VOC Card Inventory Log (Local Agency) ................................................................CT-137 CT-19 Measuring Length ......................................................................................................CT-138 CT-20 Measuring Height .....................................................................................................CT-139 CT-21 Measuring Weight .....................................................................................................CT-140 CT-22 Measuring Weight Standing .....................................................................................CT-141 CT-23 Equipment Maintenance ............................................................................................CT-142 CT-24 Instructions for Use of Prenatal Weight
Gain Grid (Form #3059) ............................................................................................CT-143 CT-25 Prenatal Weight Grid for Normal Weight and Twins ...............................................CT-144 CT-26 Prenatal Weight Grid for Underweight and Overweight ...........................................CT-145 CT-27 Dietary Assessment....................................................................................................CT-146 CT-28 Instructions for Use of the Growth Charts.................................................................CT-147 CT-29 Weight for Height Table for Determining WIC Eligibility .......................................CT-150 CT-30 Weight for Height Table for Women, Based on the Body Mass Index (BMI)..........CT-151 CT-31 Physical Signs Suggestive of Nutrient Deficiencies..................................................CT-152 CT-32 Recommended Daily Servings Chart.........................................................................CT-154 CT-33 Inappropriate Food Practices .....................................................................................CT-155 CT-34 Georgia WIC Program Referral Form .......................................................................CT-157 CT-35 WIC Income Poverty Guidelines ............................................................................. CT-158 CT-36 VOC Card Agreement.............................................................................................. CT-159 CT-37 VOC Card Form.........................................................................................................CT-160 CT-38 Central Supply Requisition........................................................................................CT-161 CT-39 State/District/Clinic Transmittal Form ......................................................................CT-162 CT-40 Medicaid Right From the Start ..................................................................................CT-163 CT-41 No Cost Flyer ............................................................................................................CT-164 CT-42 Letter of Household Income .....................................................................................CT-165 CT-43 Georgia WIC Program No Proof Form .....................................................................CT-166 CT-44 Family Plus.....................................................................................CT-167 CT-45 Health Department/Clinic Report Form ...................................................................CT-168
CT-4

GA WIC PROCEDURES MANUAL CT-46 Income Calculation Form ..........................................................................................CT-169 CT-47 Identification, Residency and Income Proof List ......................................................CT-170 CT-48 Thirty (30) Day Certification/Termination Form......................................................CT-171 CT-49 Department of Defense WIC Overseas Program VOC Card ....................................CT-172 CT-50 WIC Overseas Program Contacts..............................................................................CT-173 CT-51 Proof of Residency Form for Applicants with P.O. Box Address.............................CT-174 CT-52 Income Verification Letter ........................................................................................CT-175
CT-5

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-XVI).
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.
Note: WIC services must be provided to the applicant/participant at no cost. The "No Cost for Services" flyer must be placed in an area where it is immediately seen by applicants/participants. During program reviews, the "No Cost for WIC Services" flyer (See Attachment CT-41) will be monitored by the review team.
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, breastfeeding woman within twelve (12) months of the end of a
pregnancy; OR 3. A postpartum, non-breastfeeding woman within six (6) months of the end of a
pregnancy; OR 4. An infant up to one (1) year of age; OR 5. A child up to five (5) years of age.
* The end of a pregnancy is the date the pregnancy terminates, e.g. date of delivery, abortion, miscarriage, etc. When a participant no longer meets the definition of pregnant woman; breastfeeding woman; postpartum, non-breastfeeding woman; infant;
CT-1

GA WIC PROCEDURES MANUAL or child, he/she becomes categorically ineligible for the program (see Ineligibility Procedures CT-XVI). Refer to A Women Who Ceases Breastfeeding (see Changes Within a Valid Certification Period CT-XII.A.), for procedures regarding the breastfeeding woman who becomes categorically ineligible.
Proof of citizenship is not required for aliens, refugees, or immigrants to receive WIC benefits. The Georgia WIC Program is exempt from any restrictions in regard to aliens, refugees, and immigrants.
B. Physical Presence
The local agency must require all applicants (women, infants and children) to be physically present at each WIC certification. If the applicant does not present themselves at the clinic/Health Department, the reason for the exception must be documented in the comment section of the certification form or progress notes. Below is a list of applicable exceptions:
1. Disabilities - The local agency must grant an exception to applicants who are qualified individuals with disabilities and are unable to be physically present at the WIC clinic because of their disabilities, or applicants whose parents or caretakers are individuals with disabilities that meet this standard. Examples of such situations include:
(a) A medical condition that necessitates the use of medical equipment that is not easily transportable;
(b) A medical condition that requires confinement to bed rest; and (c) A serious illness that may be exacerbated by coming in to the WIC clinic.
2. Receiving Ongoing Health Care. An infant or child who was present at his/her initial WIC certification and has documentation of ongoing health care from a health care provider (other than the local WIC agency) may be exempted from physical presence requirements by the local agency, if unreasonable barriers exist.
3. Working parents or caretakers. The local agency may exempt an infant or child from the physical presence requirements:
If the infant/child was present for his/her initial WIC certification. If the infant/child was present at a WIC certification within the last year and
determined eligible. If the infant/child is under the care of working parents/guardian whose
working status presents a barrier to bringing the infant/child into the WIC clinic.
The following people may determine if special considerations are required:
CT-2

GA WIC PROCEDURES MANUAL
Doctor Nurse Nutritionist Physician Assistant Competent Professional Authority (CPA) WIC Coordinator or Designee
Unless a participant qualifies for an exemption as stated above physical presence is required. A child or an infant must accompany the parent/guardian or caretaker to the WIC clinic even with a Physician's Referral.
C. Residency
Applicants must reside within the jurisdiction of the State of Georgia. There is no requirement for length of residency. The applicant should apply for WIC benefits in the county in which he/she resides. However, if the applicant(s) routinely receives health care services at a clinic outside their county of residence, they may apply for and receive WIC benefits at the same clinic. Proof of residency must be provided at each certification. Written proof of residency must include the name and street address. Post Office (P.O.) Boxes are not acceptable proof of residency. However, if that is all the applicant/participant has, the Proof of Residency Form for Applicants with a P.O. Box Address (Attachment CT-51) must be completed by the applicant/participant. File the completed form in the applicant/participant's health record. Attachment 51 may be used for multiple certifications if the following applies:
No change in P.O. Box; and Same physical address.
Residency shall be determined by presenting an item, from the list of acceptable proof of residency, established in the applicant's name (see list below). In cases of prenatal minor applicants or applicants that reside with parents/guardians with no evidence of Presumptive Medicaid eligibility, a Letter of Household Income accompanied with a bill from the parent/guardian must be presented to determine residency. Proof of residency must be documented on the WIC Certification Form by documenting the type of proof verified (i.e. Electric Bill). The information on the Letter of Household Income Form must be transferred to the WIC Assessment/Certification Form.
Acceptable proofs of residency include:
Electric bill Gas bill Telephone Service bill Water bill Cable TV bill Rent Receipt
Medicaid card (not a bill) Health Record (not a bill) Other (must verify the name of the document viewed on the Certification form)
CT-3

GA WIC PROCEDURES MANUAL
If an applicant/participant presents proof of residency containing a different name, refer to the definition of family (CT-VIII. C. 3.).
What about other special populations?
Homeless Individuals and Migrants - The Homeless and Migrant applicants may not be able to provide proof of residency and are not required to present proof to receive WIC benefits. However, the No Proof Form (Attachment CT-43) must be completed by the applicant.
Migrant Farmworkers - Migrants farmworkers are considered "residents" of the local agency service area in which they apply for program benefits. Migrants are not required to show proof of residency. They must complete the No Proof Form.
Military personnel may vote and pay taxes in one state, but have one or more temporary duty stations in another state. Their temporary duty station is their residence for WIC purposes.
Homeless individual refers to 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; a public or privately operated shelter designated as temporary living and/or sleeping accommodations (including a welfare hotel, shelter for domestic violence victims); an institution that provides temporary residence for individuals intended to be institutionalized.
D. Income
Applicants must have a gross family income at or below 185% of the Federal Poverty Level. All applicants/participants, except applicants/participants using the No Proof Form, MUST show proof of income or adjunctive income eligibility (See Migrants CT-VIII.C.l.).
E. Nutritional Risk
Applicants must have an identifiable nutritional risk, as determined through a nutritional risk assessment.
III. INITIAL APPLICATION
A. Initial contact date is defined as the date the individual first visits the clinic during office hours and requests WIC benefits, orally or in writing. An individual's initial contact date will remain the same unless there is a break in enrollment. A break in enrollment is defined as missing a certification appointment after the current certification expires, or the participant is terminated and not reinstated during a valid certification period.
B. When an individual first visits the clinic during office hours and specifically requests WIC benefits (orally or in writing) and benefits are not provided, 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);
CT-4

GA WIC PROCEDURES MANUAL 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 items 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 CT-XVI).
D. An income eligibility determination should be made either prior to rendering WIC clinical assessment services 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 CT-XVI). 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, recertify, or issue vouchers to family members or blood relations (i.e. their children, spouse, cousins, other blood related persons or those persons related by marriage) nor other persons residing in the same household. In cases where an employee's 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 be made to transfer this applicant/participant to the nearest WIC clinic. Arrangements can also be made to assign another Certified Professional Authority (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.
The Health Department Report (Attachment CT-45) must be completed by clinic staff annually to inform District staff of their family participation on the WIC Program. This form must be completed by the local agency and returned to the WIC Coordinator by September 30th of each year. A copy of this form must remain in the Health Department for audit purposes.
Procedures for completing the Health Department Report (Attachment CT-45):
1. Fill in the County where you work. 2. Complete your name and title. 3. Check YES or NO if you are a WIC participant. 4. Answer the question about whether you have any relative(s) within your service
delivery area participating on the WIC Program. 5. If yes, fill in the name, relationship and date of certification on this form. 6. Sign and date the form. Write in your title.
CT-5

GA WIC PROCEDURES MANUAL When reviewing the records of employees on the WIC Program, use the Record Review Form located in the Monitoring Section of the Procedure Manual.
Note: Staff may not take the income, residency or identification information, certify or issue vouchers to themselves or family members.
F. Special provisions must be made for scheduling employed, rural and migrant participants. In the event normal working hours are not convenient, early morning or late clinics should be held or an appointment given to meet the needs of the client.
G. Each local agency shall attempt at least one contact for a pregnant woman who misses her first appointment to apply for participation in the program. In order to reschedule the appointment, the local agency must have on file an address and telephone number where the pregnant woman can be reached. Documentation of the contact(s) must be noted in the client=s record.
IV. PROCESSING STANDARDS
A. Timeframes
Processing standard time frames begin when the applicant visits the clinic in person, during WIC office hours, to make an oral or written request for program benefits (i.e. initial contact date). Pregnant and breastfeeding women, infants and members of migrant farmworker families must be notified of their eligibility or ineligibility within ten (10) calendar days of their initial contact date for program benefits. All other applicants will be notified of their eligibility or ineligibility within twenty (20) calendar days of their initial contact date for program benefits.
B. Walk-in Clinics
Walk-in clinics are an excellent way to meet processing standards. The six (6) items collected at the time of the initial application (See CT-III.B) must be documented.
A clinic that does not routinely schedule appointments shall schedule appointments for employed adult applicants/participants to apply or reapply for participation in the WIC Program for themselves or on behalf of others, to minimize the time these applicants/participants are absent from the workplace.
C. Request for Extension
On an annual basis the State agency may grant an extension of ten (10) to fifteen (15) days to local agencies experiencing difficulty in meeting processing standards. Those local agencies in need of an extension are required to submit a written request, including justification, to the State agency by October 1 of each year. Justifiable reasons for granting an extension include, but are not limited to:
1. Rural or satellite clinics unable to provide services more than twice per month. 2. Agencies with a high migrant participation population. 3. Agencies experiencing a continuous backlog in appointments reflecting ongoing
difficulty in scheduling clients for prenatal/well-child appointments.
CT-6

GA WIC PROCEDURES MANUAL
V. PARTICIPANT IDENTIFICATION
General
At initial certification and recertification, identification must be checked and documented for both the participant and parent/guardian/caretaker. However, if only one can be entered, it must be the identification of the person being certified for the program. (The code for that identification is entered in the computer system.) The parent/guardian or caretaker applying for an infant or child must bring proof of his/her infant/child's identity. (The code for that identification is entered in the computer system.) The parent/guardian or caretaker is required to also bring identification of himself/herself and that identification is documented for issuance of benefits on behalf of an infant or child participant at certification. (For person picking up vouchers See Food Delivery Section ). Clinic staff may not personally identify an applicant/participant even if they know their identity. Other records which clinic staff considers adequate to establish identity may be used if approved by the WIC Program Coordinator or designated CPA. Other records used for identification purposes that have been approved by the district, must be documented on the Certification Form.
Acceptable Documentation:
Immunization Record Health/Medical Record (existing/transfers) Birth Certification/Confirmation of Birth Letter State ID Driver s License Military ID Work or School ID Social Security Card Voter Registration Card (must match residency address) WIC ID (For Voucher Issuance Only) Hospital ID Bracelets (Mother & Baby) Other
For a categorical list of acceptable proofs of identification that must be used for women, infants or children see the Monitoring Section.
Note: Only one (1) piece of identification is required per applicant.
CT-7

GA WIC PROCEDURES MANUAL
VI. GEORGIA WIC PROGRAM IDENTIFICATION (ID) CARD
General
A Georgia WIC Program Identification (ID) card (see the Food Delivery Section) must be completed and issued, during the certification appointment, to any person who is enrolled in the Program. An ID card must never be issued to a proxy at initial certification. In instances where more than one (1) family member has been certified, each name should be listed on the ID card rather than issuing each family member a separate card. The ID card may be used for four (4) 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 or caretaker does not possess, or has lost his/her ID card, other identification is acceptable as verification and a new ID card issued. (Valid examples are: Social Security Card, Birth Certificate, Driver's License, etc.).
When identity is checked for the person picking up vouchers at issuance, it must be documented. Accept the same information used for certification, use the same codes and document as listed below:
Manual vouchers Document on the manual voucher copy under the date.
Voucher Printed on Demand (VPOD) Document on the receipt under User's ID.
Voucher Register Document on the left side of the voucher register under the WIC ID number.
A. 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, 5. Expected Date of Confinement (EDC),
6. Signature of proxy(ies), if the participant designates one: A. Refer to Food Delivery Section if the participant/parent/guardian/ caretaker or proxy is unable to write.
CT-8

GA WIC PROCEDURES MANUAL B. This may be accomplished by the participant/parent/guardian/caretaker after he/she has left the clinic.
7. Signature of clinic WIC official, 8. Date card was issued, 9. The WIC Program stamp must be stamped in the designated box. 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. B. 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 ID 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.).
CT-9

GA WIC PROCEDURES MANUAL
VII. PROXIES
General
1. 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.
2. 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.
3. 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.
4. 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.
5. Documentation of proxies must be recorded on the WIC ID card and either the: Certification form, Computer, Tickler file system.
A. Reasons for Proxies
Situations where proxies may participate in the subsequent certification of a child include:
1. Illness of the guardian, 2. Imminent or recent childbirth, 3. Guardian's inability to come to the issuance site during business hours, and 4. Other extenuating circumstances.
B. 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 the Food Delivery Section if a proxy is unable to write).
The alternate parent/guardian/caretaker 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.
CT-10

GA WIC PROCEDURES MANUAL
C. 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 the voucher register, VPOD receipt or manual vouchers (refer to Food Delivery Section if a proxy is unable to write).
D. Restrictions
1. Age. A proxy must be at least sixteen (16) years old, unless prior approval is obtained from the District WIC Coordinator or designated certified professional authority (CPA). Approval must be documented in the participant's health record.
2. Staff. Health Department staff and volunteers working for the health department may not act as proxies for participants (See Proxies CT-VII).
E. 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.
The proxy must have or be able to provide the following information in order to certify a child:
a. A statement of family size and documentation of income (or medicaid, food stamps), residency, and ID 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. Proxy's ID
c. Knowledge of the child's medical history and dietary habits/normal nutritional intake.
NOTE: The knowledge the proxy must have regarding (c) will be the same as you would expect the parent to have.
VIII. 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 for pregnant women.
CT-11

GA WIC PROCEDURES MANUAL 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/Privacy. Clinic personnel who interview applicants for the WIC Program must determine the family size and income eligibility in a confidential and private manner.
3. Determining Family Size/Income Eligibility. Family size must be determined first (See Income Eligibility CT-VIII.) 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 CT-46) if the applicant does not qualify for Adjunctive or Presumptive Eligibility and if the applicant has more than one income to calculate. If only one income was reported place a check in the designated space behind the statement "check here if only one income reported".
Procedures for completing the Income Calculation Form:
All local agencies must complete the Income Calculation Form if the applicant does not qualify for adjunctive eligibility and has more than one income to calculate. When completing this form:
1. Write/type in the ID Number if applicable (the ID number is an eleven-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) The relationship and name of the person whose income is being given; c) The income source, which is a two-digit alphabet (i.e., P.S. for pay stub); and d) The Dollar amount earned which can be weekly/bi-weekly, monthly/yearly.
CT-12

GA WIC PROCEDURES MANUAL 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 AIs 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. Adjunctive (Automatic) Eligibility
"Adjunctive" or automatic income eligibility for WIC applicants/participants is mandated for the following individuals:
- Recipients of Food Stamps and members of a household currently participating in Food Stamps.
- 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.
When a prenatal woman or infant receive Medicaid other family member(s) may qualify:
1. If a pregnant mother qualifies for Medicaid and is on the WIC Program, her infant and children qualify for WIC (Income only).
2. If an infant qualifies for Medicaid, his/her pregnant, breastfeeding or postpartum/non-breastfeeding mother may be placed on the program using the infant's Medicaid number.
3. If a pregnant woman or infant qualifies for Medicaid, other categorically eligible family member(s) income qualifies for the program.
4. A child on Medicaid can not income qualify his/her mother or a sibling.
When an applicant qualifies for adjunctive eligibility, document the Program for which the applicant is eligible.
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
CT-13

GA WIC PROCEDURES MANUAL 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 that 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 (404) 298-1228 to verify the participant=s Medicaid status. If eligible, document the Medicaid number from the automated system.
Persons 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.
The Family Plus HMO Medicaid card (See Attachment CT-44) is acceptable proof of Medicaid eligibility. However, the Family Plus HMO Medicaid card does not have the name of the parent/guardian or caretaker on it. Therefore, to assure that the person who is applying or bringing their children to enroll in the WIC Program is the parent/guardian/caretaker, clinic staff must call the number on the back of the Family Plus card to verify eligibility and legal guardianship. When verification has been completed, document the name/date of the person verifying documentation in the comment section of the Certification Form.
The Family Planning Medicaid card is acceptable proof of Medicaid eligibility for the postpartum woman only. Her infant/children do not income qualify. If qualified for Family Planning Medicaid, the Medicaid recipient will carry a purple Medicaid card.
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 ID Card number or a copy of the actual card must be placed in the health 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 EBT Card can not be used as proof of eligibility for the Food Stamp Program.
CT-14

GA WIC PROCEDURES MANUAL Continue to use the Food Stamp ID card/number or TANF ID card/number for proof of income.
3. Temporary Assistance for Needy Families (TANF):
TANF recipients will continue to use their current ID. However, ninety-eight percent (98%) of all TANF recipients (according to State TANF staff) will qualify for Medicaid.
C. Computing Income
1. Current vs. Annual. Clinic staff, in determining income eligibility, must compare the income of the family during the past twelve (12) months as well as the family's current income to determine which indicator more accurately reflects the family's status. Current income is defined as income received by the household during the month prior to the application. This decision, whether to use current or annual income, should be made in each individual income determination.
2. Monthly income equals: a. Weekly income x 4.3 b. Bi-weekly income (every 2 weeks) x 2.15 c. Semi-monthly income (twice a month) x 2
Annual income equals: a. Weekly income x 52 b. Bi-weekly income (every 2 weeks) x 26 c. Semi-monthly income (twice a month) x 24
All income sources should be converted to monthly income and added to reach the total monthly income for the household. The factors listed below must be rounded off.
If paid a different amount every week, add the four paychecks for a given month and then divide by 4 (to get a weekly average) and then multiply by 4.3 to get a monthly average. Annual income is divided by 12. A lump sum payment should be divided by 12 to estimate a monthly income (i.e. Lottery winnings). Quarterly payments are divided by 3 to get a monthly rate.
Converting to and calculating annual income:
All income sources may be converted to annual income and added to reach the total annual income for the household. Actual amounts as documented should be used (not rounded).
Hourly: hourly rate x hours per week x 52 Daily: daily rate x 5 (or number or workdays per week) x 52 Twice a month: Pay rate x 24 Every two weeks: pay rate x 26
CT-15

GA WIC PROCEDURES MANUAL Monthly: pay rate x 12 Quarterly: pay rate x 4
When using an Income Tax Form to determine Income:
Look for the Gross Income line item on the income tax form. Use the dollar amount on this line and divide by twelve (12).
The number in the family will also be listed under exemptions. However, this number may change due to when the tax return was completed (i.e. a new baby, adoption etc.).
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. Families or individuals residing in a homeless facility or an institution shall be considered a separate economic unit.
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 living with a family but remains the legal responsibility of a welfare agency or other agency, the child is considered a family of one (1). The payments made by the welfare agency or any other source for the care of that child is 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. 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).
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
CT-16

GA WIC PROCEDURES MANUAL 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 the WIC Program. State and local agencies do not have the authority to exclude aliens solely on the basis of their alien status.
i. Military Families
1. Military personnel serving overseas or assigned to a military base are considered to be members of the family and their income should be included when determining family income.
2. If children are in the temporary care 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 as having their own source of income (e.g., child allotments). When using this method, Districts must decide whether the income is adequate to sustain the children. If the children's income allotments are not adequate, then option 1 or 3 should be used.
(3) Count children as members of the caregiver=s household. Determine family size based on the family the child(ren) is/are living with. Include the children in the family size.
When taking income for the military employee, the pay stub for the military is called the Leave and Earning Statement (LES). Therefore,
CT-17

GA WIC PROCEDURES MANUAL when an applicant is in the military:
1. Review the Leave and Earning Statement (LES) and find the amount received.
2. Subtract the following amount, if any apply:
BAQ (Basic Allowance Quarters), if any apply: LQA (Living Quarters Allowance) VHA (Variable Housing Allowance)
3. If the household appears to be over-income because the LES includes pay for any of the following, try to get a history to determine annual income:
Hazardous or foreign duty Back pay or combat pay Family separation Clothing allowance
EXAMPLE: Peter, Florence and their children Charles and Todd live off base. They receive $2,490 per month, which includes a Living Quarter Allowance (LQA).
$2,490 Monthly amount $350 LQA
$2,150 per month for four (4) people
The LES contains: The person's Name and Social Security Number Individual's rank Years of service Base Pay - dollar amount they receive Separate Rations (money for food) - dollar amount they receive BAQ (Money for Housing) - dollar amount they receive BASD (Basic Active Service Date) - when they started in the Army ETS (Expiration of Term) - when their enrollment is completed and allotments are paid out.
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. The Letter of Household Income Form (See Attachment CT-42) The Letter of Household Income form is to be given to any potential applicant to assist them in collecting necessary documentation from other members of the family (economic unit) to determine income eligibility under the program.
CT-18

GA WIC PROCEDURES MANUAL
Clinics are encouraged to conduct Presumptive Medicaid Eligibility prior to issuing the Letter of Household Income form to any potential applicant who does not qualify.
Procedures for Completing the Letter of Household Income:
1. Write in the name(s) of the WIC applicant(s) along with the address that is given.
2. Sign your name at the bottom portion of this form along with date given to the WIC participant.
3. Complete or fill in the date that the form must be delivered back to the clinic.
4. Once letter is received, write in the date received and have the person who received it, sign the letter.
l. Migrants
Income for migrants must be taken annually. Migrants will not be required to show proof of income. However, migrants must give their income and the No Proof Form, Attachment CT-43, must be signed. When the No Proof Form is completed, it becomes documented proof of income for that certification period and must be placed in the applicant=s Health record.
Limit use of the No Proof Form to applicants who are in a situation unlikely to yield written documentation, such as:
1. Fire, 2. Theft, 3. Disaster, 4. Migrants, 5. Homeless, or 6. Employer who refuses to write a letter for employee when employee is paid in
cash (day workers, domestic, etc), 7. Applicants whose spouse or partner refuse to give income information.
The No Proof Form is to be used when the applicant can not provide proof of ID, Residency or Income. If used, a detailed summary must be written by the applicant or adult applying on behalf of an infant/child applicant, as to the reason for not having this documentation (See Attachment CT- 43).
The applicant or adult applying in behalf of an infant/child applicant, must self-declare income and family size, and write and sign a statement explaining why they are unable to obtain proof of family income. Do not accept an incomplete No Proof Form. Do not certify and issue benefits to an applicant who self-declares an income for family size that exceeds the WIC income guidelines.
m. Temporary Thirty (30) Day Certification Policy
CT-19

GA WIC PROCEDURES MANUAL This is a documentation policy for identification, residency and family income. In an effort to place WIC applicants/participants on the WIC Program without a delay in services, the Georgia WIC Program has developed a Temporary Thirty (30) Day Certification Policy. This policy applies to clients who meet all other eligibility requirements, do have proof of identity, income and/or residency and fail to bring it to the clinic for the certification visit. The Identification, Residency and Income Proof List (Attachment CT-47) should be routinely given to the client to clearly communicate the kinds of information they will need to bring for certification visits.
Procedures for Issuing Vouchers for Thirty (30) Days (New Applicants)
In the event a WIC applicant fails to bring documentation of identity, residency or income for clinic review, staff must first determine if the client has proof and failed to bring it or if the client has no proof and is in a situation unlikely to yield written proof (such as an applicant or applicant's parent who is a migrant farm worker or other individual who works for cash).
9 The applicant that has proof of income, identity and/or residency but fails to bring it to clinic qualifies for Temporary Thirty (30) Day Certification.
9 The applicant that has "no proof" of income and is in a situation unlikely to yield written documentation qualifies for the "no proof" procedures. These procedures are to be used in very limited circumstances. The "no proof" procedures allow the applicant to self-declare income, accompanied by the applicant's signature on a statement specifying why he/she cannot provide documentation of income.
9 The applicant that has "no proof" of residency, income or identity, such as the applicant or parent of the applicant who is the victim of theft, loss, disaster, a homeless individual, or a migrant farm worker, is required to confirm in writing his/her residency, income or identity. The applicant signs the statement and it becomes a part of the permanent record.
Temporary Thirty (30) Day Certification
The procedure to be followed in using the Temporary Thirty (30) Day Certification is:
1. Inform the participant that he/she must bring the document back to clinic within thirty (30) days of the date they arrive at the clinic. Give the applicant a Thirty (30) Day Certification/Termination Form (Attachment CT-48) that states what documentation he/she must bring back to the clinic and the date he/she is expected to return.
2. The applicant/participant that has "no proof" of income must self-declare a family income. WIC staff must record self-declared family income on the back of the WIC Assessment/Certification Form. This amount must be adjusted to reflect actual income when the applicant/participant returns with documentation. To make this adjustment, use the error correction method.
3. Issue the WIC participant only thirty (30) days of vouchers. WIC staff must not provide 30 days of benefits to applicants/participants who self-declare an income for family size above the current guideline. Document "Proof Pending" on the
CT-20

GA WIC PROCEDURES MANUAL computer screen. Each District must make the decision as to where to place the words "Proof Pending" on the screen. Also document "Proof Pending" on the WIC ID Card.
4. Make a copy of the Thirty (30) Day Certification/Termination Form (Attachment CT-48) issued to the applicant/participant and place it in the pending file.
5. Complete the Certification Form/TAD by using the word "OT" (which stands for other) in the proof field. Place the word "Pending" in the description box.
6. When the participant returns with the required proof(s), draw a line through the word "pending" on the paper Certification Form (include your initials and date) and write in the actual document presented. If the applicant is found to be over WIC's income limit, the applicant shall be determined ineligible and given the completed Thirty (30) Day Notice of Certification/Termination with rights to a fair hearing.
Notification
Since this ends the 30-day temporary certification, the 15-day notification rule does not apply and vouchers must not be issued to any person who was placed on the program under the Thirty (30) Day Certification Policy.
Termination must occur when an applicant/participant certified for thirty (30) days does not return with the required proof(s), or returns without required proof(s). Use the Thirty (30) Day Certification/Termination Form.
Procedures for Issuing Vouchers for Participants Who Need Recertification
Follow the same procedures above. However, if the participant has two (2) months of computer generated vouchers and does not have proof at the certification visit, issue one (1) set of vouchers and document "Proof Pending" on the second line of the Voucher Register. This will not be effective once Voucher Printing on Demand (VPOD) becomes effective.
Reversible Termination
A termination may be reversed (in the computer) when a participant brings back his/her required proof(s) after the thirty (30) day rule and is found to be eligible. The applicant/participant may be reinstated for the remainder of the certification period. A new certification does not have to be performed.
n. Hospital Certification
If the local agency has a Memorandum of Agreement (MOA) or a completed Consent to Obtain Information form, document on the Certification Form that the Hospital Health Record was the source viewed for identification and residency.
If the Hospital Record has recorded a Medicaid number, document on the Certification Form that the hospital health record was the source viewed for income.
CT-21

GA WIC PROCEDURES MANUAL o. Applicant Earning Cash Income with No Documentation
There may be WIC applicants that have cash jobs with no documentation of their income. Therefore, ask them to complete the No Proof Form (Attachment CT- 43) indicating what their income is. Ask for documentation first.
p. Zero Income Applicants Complete applicable questions on back of assessment form.
See Income Eligibility Applicants with Zero (0) Income (CT-VIII. E.).
1. Income Inclusions
a. Monetary compensation for services, including wages, salary, commissions, or fees;
b. Net income from farm and non-farm self employment;
c. Social Security benefits and/or Supplemental Security Income (SSI);
d. Dividends or interest on savings or bonds, income from estates or trusts, or net rental income;
e. Public assistance or welfare payments;
f. Unemployment compensation;
g. Government civilian employee or military retirement, pensions, or veterans' payments;
h. Private pensions or annuities;
i. Alimony or child support payments;
j. Regular contributions from persons not living in the household;
k. Basic Allowance for Subsistence (BAS) is cash payment added to base pay and is counted as part of all cash income for military families;
l. Net royalties;
m. Other cash income. This includes, but is not limited to, cash amounts received or withdrawn from any source including savings, investments, trust accounts, and other resources which are available to the family (e.g. money from friends and relatives).
2. Income Exclusions
a. The value of in-kind housing and other in-kind benefits. An in-kind benefit is anything of value, which is not provided in the form of cash;
CT-22

GA WIC PROCEDURES MANUAL b. Income or benefits received under any federal program, which are excluded from consideration as income by any legislative prohibition. These include, but are not limited to: (1) National School Lunch Act and the School Breakfast Program; (2) The Food Stamp Act of 1977; (3) Job Training Partnership Act; (4) Home Energy Assistance Act of 1980; (5) National Older Americans Volunteer Program; (6) Domestic Volunteer Service Act of 1973 (VISTA, Foster Grandparents, Retired Senior Volunteers Program, Senior Companions Program); (7) Child Nutrition Act of 1966; (8) Small Business Act; (9) Uniform Relocation Assistance and Real Property Acquisitions Policies Act of 1970; (10)Military Housing - BAQ; (11) Title IV Student Financial Assistance.
c. Bank loans, other payments or benefits provided under certain federal programs or acts to be excluded may be found in the Federal Regulations governing WIC 7 CFR Part 246.7(d)(2)(iv).
d. Child care benefits provided under grant programs to states shall not be treated as income in federal programs such as WIC. Child care benefits provided under section 402 (g)(1)(E) of the Social Security Act, At-Risk Child Care Programs, and Child Care and the Development Block Grant Programs in Georgia are excluded from the WIC income eligibility process.
Non-payment of child care benefits is not considered income. Benefits received in the form of cash or any other instrument that can be converted into cash, may be considered income in the WIC income eligibility process. For WIC purposes, current program policy regarding any cash available to a family is applied.
3. Unemployment. Applicants from families with adult members who are unemployed shall be eligible based on income during the period of unemployment if the loss of income causes the current rate of income to be less than the income guidelines. Persons who are on leave that they requested themselves (e.g. maternity leave or a teacher not being paid during the summer) are not considered unemployed. In these instances, it may be more appropriate to use annual income to determine eligibility. If a woman is on extended maternity leave [greater than six (6) months], it may be more appropriate to use current income to determine eligibility.
4. Self-Employment. In families where adult members are self-employed, they may not know their net income. To calculate net income, use the most current income tax statement or on-going records and the following guidelines:
Net income for self-employment is figured by subtracting operating expenses from gross receipts. Gross receipts include the total value of goods sold or service rendered by the business. Operating expenses include, but are not limited to: the cost of goods purchased; rent; heat; utilities; depreciation; wages and salaries paid; and business taxes (not personal federal, state, or local income taxes). The value of
CT-23

GA WIC PROCEDURES MANUAL salable service and merchandise used by the family of self-employed persons is not to be included as an operating expense.
Net income for self-employed farmers is figured by subtracting the farmer's operating expenses from the gross receipts. Gross receipts include, but are not limited to, the value of all products sold; money received from the rental of farm land, buildings or equipment to others; and incidental receipts from the sale of items such as wood, sand, or gravel. A farmer's operating expenses include, but are not limited to: the cost of feed, fertilizer, seed and other farming supplies; cash wages paid to farmhands; depreciation; cash rent; interest on farm mortgages; farm building repairs; and farm taxes (but not state and federal income taxes). The value of fuel, food, or other farm products consumed by the family is not included as an operating expense.
NOTE: For farm and non-farm self-employed persons, documentation of depreciation must be obtained before accepting such charges as operating expenses. Either federal or state income tax forms for the most recent tax year would provide the most reliable documentation of these amounts. In a household where there are wage earners and self-employed members, the wage earner's income may not be reduced by the business losses of the self-employed member. If the self-employed person's income is negative it should be listed as zero (0).
5. Hardship Conditions. Hardship conditions have been calculated in the Income Poverty Guidelines Chart. Hardship conditions are not to be considered when determining income.
6. Lump Sum Payments. Lump sum payments may be classified in two ways, either as reimbursement or new money.
Reimbursement payment(s) represents money received for loss of assets or injuries to real or personal property. Reimbursement lump sum payment(s) should not be counted as income for WIC eligibility purposes.
Examples include but are not limited to insurance reimbursement, payment on specified household expenses or medical expenses.
New Money is money received as gifts, inheritances, lottery winnings, workman's compensation for lost wages, or severance pay. Lump sum payments that represent new money intended to be used as income should be considered as "Other Cash Income".
The lump sum payment must not be counted for one month of current income. Rather, the lump sum payment should be counted as annual income, or be divided by 12 to estimate a monthly income.
Some lump sum payments may not be easily classified into either of the two categories, reimbursement or new money; but may represent both. In such instances treat the lump sum payment in a way that most accurately reflects the economic situation of the household. Examples of such payment include legal or medical settlements that provide reimbursement for lost property and medical expenses, as
CT-24

GA WIC PROCEDURES MANUAL well as compensation for physical or mental injury.
7. WIC Income Eligibility for Furloughed Federal Employees
In determining income eligibility of categorically eligible persons affected by the federal shutdown(s), state and local agencies should use the same policies and procedures normally used to assess the income eligibility of a person experiencing a temporary loss of income such as temporarily laid-off or striking workers. Current income should be used to determine eligibility.
Assuming that Federal shutdown(s) are temporary, local agencies should continue to provide benefits for the duration of the furlough. There is no federal policy, which requires the value of benefits to be paid back in such circumstances.
8. Incarcerated Parent/Guardian
Children residing with a caretaker are counted in the family size of the caretaker with whom they live. Ideally legal custody is required. However, a note from the parent giving permission to the caretaker (i.e. grandmother) is acceptable and must be placed in the health record.
D. Documented Proof of Income
The Georgia WIC income screening policy requires income information from all applicants.
When requesting proof of income, you MUST ask for one of the following:
1. Pay stubs for all people in your household who work or who receive an income from all sources or assistance payments. Some pay stubs will not have a name but will have a Social Security Number. Ask for the Social Security Card.
2. A statement on Letterhead from employers for all people in your household. Attach non-letterhead statements from employers to the No Proof Form and file in the Health record.
3. Current tax return (W-2 or 1040). 4. On-going financial records (for self-employed only). 5. Unemployment Notice. 6. Other (See List of Income Inclusions).
For additional sources of income, see Income Inclusions (CT-VIII. P.2.).
E. Applicants with Zero (0) Income
When an applicant declares that they have no income (zero), the following question must be asked and documented on the back of the certification form (under source of income):
Question: How do you obtain food, shelter, clothing and medical care?
Document the answer and apply your initials (Staff initials) on the Certification Form. Check CT-25

GA WIC PROCEDURES MANUAL "Yes" the client is income eligible.
F. Verification of Income
"Verification" means a process whereby the information presented, such as a pay stub, is validated through an external source other than the applicant. Such external sources include employer verification of wages, local welfare office verification, etc.
Verification is required for questionable cases such as:
1. The person taking the income suspects that the income is incorrect.
2. A complaint is received alleging that a participant is not income eligible. An anonymous complaint must be handled in the same manner as any other complaint.
3. A conflict of information is found between WIC Program income data and income data provided from other programs. When income is verified, the income at the time of certification, rather than the current income, must be verified.
Based on the three (3) reasons above, clinic staff may also request that the participant, parent, guardian or caretaker bring proof of income back to the clinic. In the event clinic staff request proof, from the participant, parent, guardian or caretaker the Income Verification Letter (Attachment CT-52) may be used.
Failure of the participant, parent, guardian or caretaker to return to the clinic within thirty (30) days with proper documentation would result in the following:
1. Termination from the program. 2. Re-payment to the WIC Program for vouchers issued over $100.00.
Note: Information concerning payment to the WIC Program can be found in the CA Section of the Procedures Manual.
IX. 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 unable to perform the prescribed 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. Local clinics unable to perform required tests to determine program eligibility may be suspended by the State WIC Branch. The applicant cannot be required to obtain such data at her own expense.
CT-26

GA WIC PROCEDURES MANUAL 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. Proof of pregnancy is not required as a condition of eligibility for the WIC Program. However, if it is not physically apparent that the applicant is pregnant and if clinic staff has reason to believe that the applicant is not pregnant (e.g., a complaint is received alleging that a participant is not pregnant), the local agency may request proof of pregnancy after the initial certification. In this case, the participant can be given up to sixty (60) days to submit proof of pregnancy. If proof of pregnancy documentation is not provided as requested, the local agency may terminate 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.
CT-27

GA WIC PROCEDURES MANUAL
2. Infants. Attachment CT-8 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 on staff at the clinic. Local agencies should make authorized referral forms available to area health care providers in order to facilitate entry into the WIC Program and the certification process. Local agencies must accept the Georgia WIC Referral Form (see Attachment CT-34), and may develop a referral form to meet prescribed requirements and the individual local agency needs. All new and revised forms must be submitted to the Nutrition Section 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 private provider, provided that all of the minimum 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 a part of outreach efforts, local agencies may provide area health care providers with a current listing of nutritional risk criteria along with definitions and documentation requirements for the risk criteria.
CT-28

GA WIC PROCEDURES MANUAL
C. Medical Data
Medical data required for certification includes anthropometric (length/height and weight) and hematological (hemoglobin/hematocrit) measurements.
1. The Medical Data Date documented on the WIC Assessment/Certification Form must be the same as the date that the anthropometric data were taken. 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 (60) 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.
2. Hematological data required for certification (hemoglobin/hematocrit) may precede the date of certification by up to ninety (90) days. Required hematological data that are greater than ninety (90) days old cannot be used to assess WIC eligibility. The ninety (90) day limit applies to the required hematological data even if the applicant/participant=s eligibility is based on other criteria.
X. 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 hematological 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 CT-10, CT-11, CT-12, CT-13, and CT14. The nutrition risk criteria are listed by applicant/participant status at the time of certification. Each criterion is identified by a three digit numerical code.
The WIC Assessment/Certification Forms utilize a checklist format to document the applicable nutritional risk criteria. Refer to CT-XV for information regarding the completion of the WIC Assessment/Certification Form.
XI. 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, weight, hemoglobin/hematocrit and assessing nutrition status and nutrition related medical history.
CT-29

GA WIC PROCEDURES MANUAL
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 length/height, weight, hemoglobin/hematocrit and assessing nutrition status and nutrition related medical history.
Postpartum teenagers who are not breastfeeding and whose delivery date was prior to 18 years 10 months of age. 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 with a 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 on average at least once every 24 hours. 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.
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 and a waiting list is being maintained, "Possibility of Regression" cannot be used as a reason for certification.
CT-30

GA WIC PROCEDURES MANUAL

C. Specific

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

1. Pregnant Women

Priority I: Priority IV:

101, 111, 131, 132,133, 201, 211, 301, 302, 303, 311, 312, 321, 331, 332, 333, 334, 335, 336,337, 338, 339, 341, 342, 343, 344, 345, 346, 347, 348, 349, 351, 352, 353, 354, 355, 356, 357, 358, 359, 360, 361, 362,371, 372, 373, 381, 502 422, 502, 801, 802, 901, 902

2. Breastfeeding Women

Priority I:

102, 112, 133, 201, 211, 303, 311, 312, 321, 331, 332, 333, 335, 337, 339, 341, 342, 343, 344, 345, 346, 347, 348, 349, 351, 352, 353, 354, 355, 356, 357, 358, 359, 360, 361, 362, 371, 372, 373, 381, 501, 502, 601, 602

Priority II: 502, 601 Priority IV: 422, 501, 502, 601, 801, 802, 901, 902

3. Postpartum, Non-Breastfeeding Women

Priority III: 331, 502

Priority VI: 4. Infants

102, 112, 133, 201, 211, 303, 311, 312, 321, 331, 332, 333, 335, 337, 339, 341, 342, 343, 344, 345, 346, 347, 348, 349, 351, 352, 353, 354, 355, 356, 357, 358, 359, 360, 361, 362, 372, 373, 381, 422, 501, 502, 801, 802, 901, 902

Priority I:

103, 113, 121, 134, 135, 141, 142, 153, 201, 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

Priority II: 502, 701, 702. Priority IV: 422, 502, 702, 801, 802, 901, 902

5. Children

Priority III: Priority V:

103, 113, 121, 134, 135, 141, 201, 211, 341, 342, 343, 344, 345, 346, 347, 348, 349, 351, 352, 353, 354, 355, 356, 357, 359, 360, 361, 362, 381, 382, 501, 502 422, 502, 801, 802, 901, 902

CT-31

GA WIC PROCEDURES MANUAL D. Assignment 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-32

GA WIC PROCEDURES MANUAL XII. CHANGES WITHIN A VALID CERTIFICATION PERIOD
A. Women Who Cease Breastfeeding
The following procedures must be followed when clinic staff is 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-XVI, 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).
XIII. 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 initial and/or subsequent certification as a postpartum, breastfeeding woman. Eligibility ends when the certification period is over, when the breastfed infant turns one (1) or when breastfeeding is discontinued, whichever comes first.
Note: The certification period for the breastfeeding woman is six (6) months but she is eligible to be recertified as a breastfeeding postpartum if she is still breastfeeding an infant under one (1) year of age.
Postpartum, Non-Breastfeeding Women: for up to six (6) months from the termination of their pregnancy.
CT-33

GA WIC PROCEDURES MANUAL
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 until 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 Food Delivery Section).
In cases where there is difficulty in scheduling appointments for breastfeeding women, infants, and children, 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.
XIV. INFANT MID-CERTIFICATION NUTRITION ASSESSMENT
Infants certified prior to six (6) months of age will be subsequently certified on their first birthday. A mid-certification nutrition assessment, by the CPA, should be completed between five (5) and seven (7) months 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 (if mid-certification nutrition assessment is performed between 9-12 months of age); d. Recording, summarizing, and evaluating dietary intake; e. Assessing nutrition risk criteria; f. Assigning the highest priority for which the infant is eligible; and g. Reviewing food package needs, and assigning an appropriate food package.
3. The mid-certification nutrition assessment information will be documented in the second column of the Infant WIC Assessment/Certification Form.
4. If additional risks are identified at any time during the one (1) year certification period, the infant's priority should be upgraded.
CT-34

GA WIC PROCEDURES MANUAL 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: Proof of identification, residency and income are not required during the mid-certification assessment.
XV. WIC ASSESSMENT/CERTIFICATION FORM
A. General
1. State WIC Assessment/Certification Form
Certification data for each applicant/participant will be recorded on the form provided by the State agency or generated by each district=s computer system.
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 that 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.
Both sides of the certification form 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.
B. 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, county of residency, proof of residence and proof of identification (for applicant/participant and if applicable parent/guardian/caretaker), clinic number, sort, WIC ID number and parent or guardian/caretaker's name (infants and children only), must be filled in on each form used. All legally responsible persons must be documented in the health record (i.e. name of father/guardian/caretaker).
The local agency representative must ask the applicant to make a selfdeclaration of their ethnic origin and migrant status.
CT-35

GA WIC PROCEDURES MANUAL
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 (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. Postpartum Breastfeeding Assessment/Certification Form (Breastfeeding an Infant Less than 1 Year of Age). (1) Enter the weeks breastfed in the "Weeks" column. (See the key for entering weeks breastfed in Attachment BF-9, the Breastfeeding Section).
b. Postpartum Non-Breastfeeding Assessment/Certification Form (Less than 6 Months Postpartum). (1) If the women is not currently breastfeeding but has breastfed, check "Yes" to Breastfed Ever. (2) If the response to Breastfed Ever is "Yes", enter the weeks breastfed in the "Weeks" column. (See the key for entering weeks breastfed in Attachment BF-9, Breastfeeding Section) (3) If the response to Breastfed Ever is "No", enter "0" in the "Weeks" Column.
3. Initial Contact Date. The initial contact date must be filled in at each certification, even if it has not changed. The initial contact date must be accurately documented to ensure that processing standards are being met. See Initial Application CT-III for the definition of "initial contact date".
CT-36

GA WIC PROCEDURES MANUAL
4. Medical Data Date. See the Nutritional Risk Determination CT-IX for the definition of required medical data. Enter the date anthropometric measurements were taken for certification purposes.
5. Length/Height. Enter the length/height to the nearest eighth of an inch.
6. Weight. Enter the weight in pounds and ounces.
7. Hematological Data Date. Enter the date hematological measurement was taken for certification purposes. Hematological data date is required to be 90 days prior to certification for infants 9-12 months of age, children and women.
8. Hematocrit/Hemoglobin. Enter the hematocrit and/or the hemoglobin value(s) in the appropriate half of the box. Values are to be rounded to one decimal place.
9. 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 "N/A" when the risk criterion does not apply or was not assessed. d. Record additional documentation for risk criterion. Mark with (*).
This section of the form must be completed by a CPA during each certification appointment and at the infant's mid-certification nutrition assessment.
10. High Risk: Check "Yes" when at least one nutrition risk meets the High Risk Criteria (see Attachment NE-7, Nutrition Education Section).
11. 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. the applicant must be an infant, child, pregnant, postpartum or breastfeeding
woman.
Check "No" when "a" and/or "b" from the above list and/or all nutrition risk factors are checked "No" (Ineligibility Procedures CT-XVI).
12. Priority. Enter correct priority (I - VI). Refer to the Nutritional Risk Priority System CT-XI for risk factor codes and priorities.
13. Food Package. Enter the appropriate food package code (see Section FP, Food Packages Section).
14. 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. Enrollment in or Referral to TANF, Food Stamps and Medicaid MUST be documented. CT-37

GA WIC PROCEDURES MANUAL
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.
15. Today's Date. Enter the date the assessment is completed.
16. Signature/Title. Enter signature and title (Nutr., R.D., L.D., R.N., M.D., etc.). An appropriate signature consists of first initial, last name and title.
17. Income Determination.
a. Date. Fill in the date the income screening was completed. b. Number in Family. Fill in according to Income Eligibility CT-VIII. c. Gross Income/Month.
1. Medicaid Recipients. {See Acceptable Proof of Eligibility-Adjunctive Eligibility (CT-VIII.B.1)} Mark yes (Y) if the participant has documented proof that they receive Medicaid and document Medicaid number.
2. Food Stamp Recipients. {See Acceptable Proof of Eligibility-Adjunctive Eligibility (CT-VIII.B.2)} Mark yes (Y) if the participant has documented proof that they receive Food Stamps.
3. Temporary Assistance for Needy Families (TANF) {See Acceptable Proof of Eligibility-Adjunctive Eligibility (CT-VIII.B.3)} A "notice of case action" issued to TANF participants, with dates of eligibility for any TANF benefit, is acceptable proof of current enrollment in TANF. Mark yes (Y) if the participant has documented proof that they receive TANF.
4. Participants not receiving Food Stamps, Medicaid, or TANF. Complete according to CT-VIII. C.
5. Income Eligibility. Check "Yes" or "No" to indicate applicant's income status. Tranfer the total from the Income Calculation Form to the section of the Certification Form. The Income Calculation Form must be used to determine income eligibility if the applicant does not qualify for Medicaid, Food Stamps or TANF, or if the applicant has more than one source of family income.
CT-38

GA WIC PROCEDURES MANUAL
d. Staff Signature(s). The local WIC official 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; title of person verifying income.
e. Date. The date must be completed by either the participant/authorized representative or a clinic staff person.
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 unable to write. If the applicant/ participant/authorized representative is unable to write, he/she will enter his/her mark in lieu of a signature. The staff person will print the person=s name next to the mark and initial the mark to indicate that it has been witnessed.
18. Physical Presence.
a. Check "Yes" if the applying/re-applying applicant/participant is physically present.
b. Check "No" if the applying/re-applying applicant/participant is not physically present.
Note: If "No" is checked, document the reason in the health record. See Physical Presence CTII.B. for a list of applicable reasons.
CT-39

GA WIC PROCEDURES MANUAL
19. Data Needed for Pregnancy Surveillance.
Infants= Form: (1) Mother=s WIC ID#. Enter the name and/or 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., 1652 = 166.
Women=s Form: (1) Marital Status. Enter numerical code indicating current marital status, i.e.,
0=married, 1=not married, 9=unknown.
(2) Years of Education Completed. Enter a 2-digit number to indicate years of education completed, e.g., 01=1st 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., 0=No Prenatal Care, 1=1st 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. 1652 = 166.
20. Verification of Certification (VOC) Card Information (Required)
Residency and identification are required for each participant listed on the VOC Card. Identity must be documented for both the infant and child participant and the parent/guardian/caretaker upon receipt of a valid VOC Card.
Physical Presence is not required for the infant or child when the parent/guardian or caretaker brings in a VOC Card.
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 - MD) or the Georgia VOC 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 WIC official who received
the card.
CT-40

GA WIC PROCEDURES MANUAL
VOC Card (Issued within the State) (1) Place the number of the VOC 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. 21. Comments (Proxy 1/Proxy 2) This section may be used to maintain a record of
proxy names designated by participants or parents/caretakers at certification for review prior to voucher issuance.
XVI. 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 (NTIWL) Form is official documentation that local agencies must use to notify applicants/participants of ineligibility or termination (Attachment CT-15).
When applicants/participants are ineligible or terminated from the program and a NTIWL 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 (See Fair Hearing Section in Rights and Obligations).
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 health 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.
CT-41

GA WIC PROCEDURES MANUAL
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 before the termination of participation of the reason(s) for 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.
4. Notification does not need to be provided to persons terminated for failing to pick up vouchers for two consecutive months and failing to return for subsequent certification provided the participant has been given or read the Rights and Obligations.
5. Interim Income Change (Reassessment of Income Eligibility). Individuals will be disqualified at any time during the certification period when family income exceeds eligibility requirements. A fifteen (15) day notice must be issued.
B. Completion of Notice of Termination/Ineligibility/Waiting List Form:
1. Fill in applicant's name and the date at the top of the form including the date of birth, phone number, and address.
2. Mark the box with the correct option and check the reason for termination. 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 when using this form. If a stamp is used for this purpose, all copies must be stamped. Appropriate documentation and termination procedures must be followed. A written notice of termination must be given for each member of the family on the program.
C. Ineligibility File
Clinics are required to maintain an ineligibility file. The five items listed below are critical documentation that must be presented when a fair hearing is requested by an applicant or other persons on behalf of an applicant. Each clinic may establish their own system for maintaining such a file, as long as the following guidelines are followed:
CT-42

GA WIC PROCEDURES MANUAL
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
(Completely fill out with signatures, dates and the Fair Hearing Section); c. The date the ineligibility action was taken; d. WIC Assessment/Certification Form (Complete all sections on the WIC
Assessment/Certification Form when an applicant is not eligible for the program. This includes income documentation, date, signature of the participant or applying parent/guardian of the participant and the signature of the person who took income information); and e. All supporting documentation, e.g. dietary recall, growth charts, progress notes, Income Calculation Form, etc.
2. Ineligible Applicants with Health Records
The five 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.
XVII. TRANSFER OF CERTIFICATION
WIC certification is transferable during a valid certification period. 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.
VOC cards are honored during a waiting list period regardless of priority.
A. Verification of Certification (VOC) Card
The Verification of Certification card is a negotiable instrument used to validate WIC certification. Local agencies must maintain accurate records of issuance, security, and receipt from participants. Local agencies and clinics are responsible for maintaining an inventory of all VOC cards (See Inventory CT-XVII.E.).
Out-of-state participants with a valid VOC card must be placed on the program even if they do not meet Georgia=s eligibility criteria. Local agencies must be aware that some states use the combination WIC ID/VOC card and must read all VOC cards carefully. Under no circumstances should a WIC participant transferring into a clinic with a valid VOC card be denied WIC benefits or reassessed for eligibility. Transfers with valid VOC cards or other valid certification evidence (i.e. certification record) must be enrolled immediately. Proxies can not present a VOC card. The parent/guardian/
CT-43

GA WIC PROCEDURES MANUAL caretaker must present the VOC card, proof of identity and residency. If the participant does not have proof of residency, use the No Proof Form. When an applicant transfers in with a VOC card, the parent, guardian, or caretaker is not required to bring that infant or child.
The Georgia WIC ID card may be used to document current certification accompanied with other 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 health record.
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 include codes) 5. Expiration date of certification 6. Printed/typed name of the certifying official and the signature 7. Name and address of the certifying clinic 8. Participant's WIC ID # 9. Participant's date of birth
2. Incomplete VOC Cards
An incomplete VOC card must be accepted as long as the certification period has not expired and the card contains: (1) participant=s name, (2) date of certification and (3) date certification expires. The participant must also present proof of identification and residency. The VOC card must be placed in the participant=s file/record.
B. Other Methods of Verification
1. Phone Call
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 (no codes) 6. Priority 7. Assigned food package (no codes) 8. Date vouchers were last issued 9. Date income eligibility was last determined (migrant farmworkers only) 10. Participant's WIC ID number (Georgia transfers only)
CT-44

GA WIC PROCEDURES MANUAL 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.
2. Transfer with a Georgia WIC ID card within the State of Georgia.
If clinic staff is unable to obtain the necessary information by phone, a valid Georgia WIC ID card may be accepted in lieu of a VOC card with proper ID and proof of residency. This should be done only when immediate certification seems imperative and staff feels the ID card strongly indicates that the individual is eligible. A participant who is transferred using a Georgia WIC ID 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 ID number (Georgia transfers only) 10. Signature of certifying local agency/clinic official
When a participant transfers to another WIC clinic, the parent/guardian may complete a release of information form to allow the transfer of WIC and/or health records to the new site. However, the original WIC Assessment/Certification Form must be retained in the District/Clinic where the participant was certified. Local agency staff must fax or mail the completed form or requested information to the receiving agency promptly. Whenever the requested information is not received within two (2) weeks of the initial request date, local agency staff must notify the WIC Coordinator for follow-up and further action.
CT-45

GA WIC PROCEDURES MANUAL
C. Instruction for VOC Card Use
Clinic staff must:
1. Inform all WIC participants if they plan to move, they should request a VOC Card. All migrant farmworkers are to be issued VOC cards. If the migrant is not moving, document this on the VOC Card Log. For non-migrant participants transferring within the State of Georgia only, a copy of both sides of the WIC Assessment/Certification Form may be given to a participant in lieu of a VOC card. However, records must be retrievable at the initial Clinic/District site.
2. Instruct the participant on the use of the VOC card.
3. Do not issue a VOC card to a proxy.
Note: A Notice of Termination/Ineligibility/Waiting List form must be issued on site, whenever a VOC Card is issued to a participant, with the exception of a migrant participant.
D. Orders
VOC cards can be ordered by the clinic directly from the State or District Office. The District Office shall determine how/where clinics order VOC cards. In the event the District Office agrees that VOC Cards may be ordered directly from the State, the coordinator must submit a VOC Card Agreement (see Attachment CT-36) and a VOC Card form (Attachment CT-37). These two forms must be completed, signed and forwarded to the State WIC Branch at the address below. No orders will be accepted from any clinic unless these forms have been received.
The VOC Agreement (Attachment CT-36) must be completed by the WIC Coordinator who must indicate which clinic representative is responsible for requesting VOC Cards from the State. NO PHONE CALL REQUESTS WILL BE HONORED.
When ordering VOC cards directly from the State, a Central Supply request form (Attachment CT-38) must be completed and mailed to: Georgia WIC Program, c/o Policy and Procedures Unit, 2 Peachtree Street, NE, Atlanta, Georgia 30303.
E. Inventories
All local agencies and clinics are responsible for maintaining an inventory of all VOC cards. The State VOC Card Inventory Logs (Attachments CT-17 and CT-18) must be used by all local agencies and clinics. When VOC cards are received, the following must be recorded on the inventory log:
1. The date; 2. The series numbers must be recorded in the beginning/ending number columns; 3. The number of VOC cards received; 4. Total number of VOC cards on hand; and 5. Staff initials must be recorded on the inventory log.
CT-46

GA WIC PROCEDURES MANUAL
The above documentation must be completed the same day the VOC cards are received by the responsible WIC staff person. VOC cards must be used in the order in which they were received; first in, first out. All VOC cards must be used in sequential order until depleted.
A physical inventory of VOC cards must be performed monthly by local agencies and clinics. The following must be recorded on the inventory log:
1. The date; 2. The series numbers must be recorded in the beginning/ending number columns; 3. "Physical Inventory Conducted"; 4. Total numbers of cards on hand; 5. Initials of staff person conducting the physical inventory; and 6. Initials of staff person verifying the physical inventory.
F. Issuance
A record of the issuance of each card must be maintained. When a VOC card is issued to a participant in the clinic, the following must be recorded on the inventory log: (See Attachment CT-17)
1. Date the card was issued; 2. VOC card number; 3. Participant's name; 4. Participant's WIC ID number; 5. Signature of Parent/Guardian/Caretaker (A Proxy cannot pick up a VOC Card); 6. Name/City/State Participant is moving to; 7. Number of cards on hand; and 8. Initials of the staff person issuing the card.
When the Local Agency issues VOC Cards to the clinic, the following information must be documented (See Attachment CT-18):
1. Date; 2. VOC card series numbers issued (beginning/ending number columns); 3. Number of cards issued; 4. Name of clinic cards is issued to; 5. Name of Clinic Representative; 6. Total number of cards on hand; and 7. Initials of one (1) clerical staff and a second staff member.
CT-47

GA WIC PROCEDURES MANUAL
G. Security
VOC cards are negotiable instruments, therefore, the security of the cards and the accompanying inventory log is imperative. VOC cards, their inventory log and the WIC stamp must be stored in separate locked locations.
Only authorized personnel may have access to the VOC cards/inventory log. These authorized personnel are determined by the local agency.
H. Lost/Stolen/Misplaced VOC Cards
In the event a VOC Card is lost, stolen or misplaced, contact the Policy Unit immediately and complete the Lost/Stolen/Destroyed/Voided Voucher Report. This report is located in the Food Delivery Section.
Anytime a VOC Card is lost, stolen, misplaced, or reissued, an Action Memo will be sent to all Local Agencies by the State Agency so that you are aware of the status of the card.
VOC Cards must not be reissued to WIC participants within a certification period. If a VOC Card is issued to a participant and they later say that they lost it; inform the participant you will send the information to the new location.
When five (5) or more VOC Cards are lost, stolen or misplaced, the Notification Summary of Missing Vouchers/VOC Card Form must be completed (See CA Section). Once this report is received, an investigation will be conducted by the Office of Fraud and Abuse in the Department of Human Resources. Notification of lost VOC Cards must also be reported to USDA and to other states in the Southeast Region.
XVIII. WIC OVERSEAS PROGRAM
A. General
The Department of Defense (DOD) has implemented a program like WIC overseas. This program is called the WIC Overseas Program.
DOD recently began to phase in implementation of the WIC Overseas Program in five (5) locations. These location include: 1. Lakenheath, England (Air Force) 2. Yokosuka, Japan (Navy) 3. Baumholder, Germany (Army) 4. Okinawa, Japan (Marines and Air Force) 5. Guantanamo Bay, Cuba (Navy)
CT-48

GA WIC PROCEDURES MANUAL
Additional WIC Overseas Programs will be phased in at other locations where WIC Overseas Program services and benefits can be provided. Information about DOD's WIC Overseas Programs can be found on the TRICARE Website at: http://www.tricare.osd.mil.
B. IMPACT ON USDA's WIC PROGRAMS
Legislation limits eligibility in the WIC Overseas Program to:
1. Members of the armed forces on duty at stations outside the U.S. and their dependents.
2. Civilians who are employees of a military department (i.e. Army, Navy or Air Force) who are U.S. nationals and live outside the U.S and their dependents.
3. Contractors employed by DOD who are U.S. nationals living outside the U.S. and their dependents as defined by DOD.
All other eligibility requirements for the WIC Overseas Program mirror USDA's WIC Program requirements. Therefore, DOD guidelines provide that WIC Program participants who are transferred overseas and meet eligibility requirements are eligible to participate in the WIC Overseas Program until the end of the certification period. Additionally, any WIC Overseas Program participant who returns to the U.S. with a valid WIC Overseas Program Verification of Certification (VOC) Card must be provided continued participation in USDA's WIC Program until the end of his/her certification period. The WIC Overseas VOC Card is a full-page document which also serves as a Participant Profile Report (Attachment CT-49).
Note: A "dependent" includes a spouse and "U.S. national" are individuals who are U.S. citizens or individuals who are not U.S. citizens but owe permanent allegiance to the U.S. as determined in accordance with the Immigration and Nationality Act.
C. NEW VOC CARD REQUIREMENTS
State and local agencies must begin to issue WIC VOC Cards to WIC participants affiliated with the military who will be transferred overseas. WIC participants issued VOC cards when they transfer overseas must be instructed that:
1. There is no guarantee that the WIC Overseas Program will be operational at the overseas sites where they are being transferred.
2. By law, only certain individuals are eligible for the WIC Overseas Program. 3. Issuance of a WIC VOC card does not guarantee continued eligibility and
participation in the WIC Overseas Program. Eligibility for the overseas program will be determined at the overseas WIC service site.
CT-49

GA WIC PROCEDURES MANUAL
D. COMPLETION OF THE VOC CARD
When completing the VOC card for a transfer overseas, please following the same procedures outlined in CT-XVII. A. 1. TRANSFER OF CERTIFICATION SECTION (Required Data). Special emphasis should be placed on completing these cards with the necessary data to prevent long distance overseas communications.
E. ACCEPTANCE OF WIC OVERSEAS PROGRAM VOC CARDS
Local agencies must accept a valid WIC Overseas Program VOC card presented at a WIC clinic by WIC Overseas Program participants returning to the U.S. from an overseas assignment. Follow the current procedures outlined in the CT-XVII. A. 2. TRANSFER OF CERTIFICATION SECTION (Incomplete VOC cards).

XIX.

If questions arise about the VOC Card presented, a current list of WIC Overseas Program contacts is attached (Attachment CT-50). The list of current contacts will be revised on the website mentioned. Local agencies are also reminded that individuals presenting a valid VOC card must provide proof of residency and identification (with limited exceptions) in accordance with WIC Program regulations and policies. CORRECTING MISTAKES

The following procedure must be followed when a mistake is made on an official WIC document:

1. Make a single line through the error. 2. Initial 3. Date 4. Make the correction near the line. 5. Write the word error just above the actual error (optional).

XX. DOCUMENTATION PROCEDURES

1. All WIC documentation must be completed in blue or black non-erasable ink or it can be typed.
2. Never use a pencil or red ink. 3. Do not use correction fluid (white out), scratch out or write over the error. 4. Under no circumstances may WIC vouchers be altered or corrected.

"Official WIC documents" include, but are not limited to: WIC Assessment/Certification Forms, ID cards, VOC cards, voucher registers, inventory logs, and health records.

XXI. CERTIFIED WAITING LIST

A Certified Waiting List is intended to facilitate the placement of participants on the program as soon as additional program funds are made available. If it becomes necessary, the State WIC Branch (with guidance from its State Allocation Committee) shall determine when a waiting list will be implemented.

CT-50

GA WIC PROCEDURES MANUAL A. Procedures for Maintaining a Waiting List
1. A waiting list shall be maintained with individuals who qualify and express an interest in receiving program benefits. Applications must be kept in order, according to the date and priority they were placed on the waiting list.
2. To facilitate contacting the applicant when caseload space becomes available, the waiting list must include the following:
a. Date applicant was placed on the waiting list b. Applicant=s name c. Applicant's address and telephone number d. Applicant's status (e.g. pregnant, breastfeeding, age of applicant, etc.) e. Applicant's priority
NOTE: The Notice of Termination/Ineligibility/Waiting List Form should not specify the length of time (no specific date) for remaining on a waiting list (See Attachment CT-15). B. Procedures for Removal from the Waiting List
The Program Coordinator or designee must ensure that the following procedures are followed when removing persons from the waiting list as caseload expansion is reestablished:
1. Only those individuals who are still categorically eligible need to be contacted. All others can be periodically purged from the list.
2. Those persons on the waiting list who are still in a current certification period will be contacted to come to the clinic immediately to receive vouchers. All others will be informed that current medical data is required and must be evaluated before certification will be possible.
3. Applicants will be contacted by phone or letter.
XXII. PATIENT FLOW ANALYSIS
A Patient Flow Analysis (PFA) is optional and is a tool to analyze the following:
1. The range of time for certification of clients from sign-in to first face-to-face visit where service provided.
2. The range of time for certification of clients from sign-in to exit. 3. The range of time for clients scheduled for issuance of vouchers. 4. Clinic bottlenecks. 5. Whether clients are seen in the order of appointments? 6. Are clients scheduled at a rate appropriate for services received and staff availability? 7. Are there down times for any staff? 8. Are the appropriate staff present for first a.m. appointments? 9. How many appointments were there? Number of no-shows?
CT-51

GA WIC PROCEDURES MANUAL Procedures for the Patient Flow Analysis consist of the following two options: OPTION I Option I contains three (3) forms which include: 1) Patient Flow Analysis (PFA) Sign-In Sheet 2) Patient Flow Analysis (PFA) Form 3) Questions to Answer from the Modified PFA Form
FORM I - PATIENT FLOW ANALYSIS SIGN-IN SHEET The Patient Flow Analysis Sign-In Sheet is designed to have all WIC applicants/participants sign in at the time of arrival. Each applicant/participant must signin and document the arrival time. FORM II - CLINIC FLOW ANALYSIS FORM The Clinic Flow Analysis form documents the following: 1. Room # (if applicable) - Room number is completed in the event a clinic is divided
by alphabets and each staff person is keeping his/her own Sign-In form .
2. Clinic - List the name of the clinic where 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. WIC Type P __ N __ B __ I __ C
Place a check mark by the category which identifies whether the applicant/participant is a pregnant, postpartum or breastfeeding women, infant or child. 7. Reason for Visit - Documents the reason the applicant/participant made a visit to the WIC clinic.
CT-52

GA WIC PROCEDURES MANUAL
Reason for Visit Codes - 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 nutrition education) Other (please specify)
8. Appointment Time - Documents appointment time of the applicant/participant.
9. Time Started - Documents the actual time that the clinic staff begins to work with the WIC participant.
10. Time finished - Documents the actual time that staff finishes working with the applicant/participant.
11. Staff initials - Staff that serves the WIC applicant/participant list their initials.
Note: 1. A record of the staff person's initials must be placed with the actual Patient Flow Analysis documentation for audit purposes.
2. Each applicant/participant must have his/her own Patient Flow Analysis Form. Each family member must have his/her own form.
12. Patient Arrived - Actual time that participant signed in at the clinic.
13. Time Patient Left - Documents the time the applicant completes 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. Food Package Change (FPC)/Formula Type (optional) - Document the FPC or formula type if applicable for District use.
16. Special Services Provided/Comments - Documents any special services or circumstances which may cause you to take additional time with the applicant/participant.
FORM III - 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 expect to receive from the PFA.
CT-53

GA WIC PROCEDURES MANUAL OPTION II
Option II contains six (6) forms (see Monitoring Section) which include:
1) Patient Flow Analysis (PFA) Sign In Form 2) Personnel Identification Codes 3) Reason for Visit Code Form 4) Patient Category Form 5) Patient Register Form 6) Questions to Answer from the Modified PFA Form
FORM I - PATIENT FLOW ANALYSIS (PFA) SIGN-IN SHEET
The Patient Flow Analysis (PFA) Sign-In Sheet is designed to have all WIC applicants / participants sign in at the time of arrival. Each applicant/participant must sign-in and document their arrival time.
FORM II - PERSONNEL IDENTIFICATION CODE FORM
The Personnel Identification Code is used to identify clinic staff/title involved (i.e., R.N.) in the PFA. A letter from the 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 III - REASON FOR VISIT CODES
The Reason for Visit Code is used to identify the type of services being rendered to the WIC applicant/participant.
FORM IV PATIENT CATEGORY FORM
The client category identifies the codes you must use to identify the type of clients you are serving during the PFA.
FORM V - PATIENT REGISTER FORM
The Patient Register Form is to be placed on the record of each participant as they sign in, unless the participant is in the clinic for voucher pick-up only and the 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 Codes); 3. Patient Category (See Form IV, Patient Category Form); 4. Time of Arrival (Same as sign in sheet); 5. Time of clinic appointment (Same as sign in sheet); and
CT-54

GA WIC PROCEDURES MANUAL
6. Patient Service Time. a. Contact number (Must match the number on the Participant Sign In Form); b. Personnel ID code form (Must list the staff persons involved in the PF Analysis Form II); c. Start Time (Time identified on the sign in sheet Form I); d. End Time (Time services are completed); and e. Service provided (See the reason for visit code Form III).
FORM VI - 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 expect to receive from the PFA.
XXIII. SYSTEM INFORMATION MANAGEMENT
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). All District/Units with the exception of Grady Maternal & Infant Program now have an automated clinic system. HOST sites are being converted to the Aegis System, a Y2K compliant, Windows based program.
HOST is currently being used in the Valdosta clinics for all functions except WIC. The District will be converted to Aegis in the near future.
Fulton County and Grady M & I will be converted to Aegis in the near future.
XXIV. IMMUNIZATION COVERAGE ASSESSMENT
The WIC and Immunization programs at the federal and state levels have an agreement to work together toward the goal of reducing the occurrence of vaccine-preventable diseases and improving the general health status of program participants.
All WIC agencies are required to coordinate with and refer participants to a variety of allied nutrition and primary health care services including immunization [7 CFR 246.4(a) (8)]. As with all program coordination efforts, the method by which WIC and immunization services are coordinated is a local agency option. The Georgia WIC Program and the Immunization Program have a signed agreement to work together to improve the immunization coverage among WIC participants. The objective of this agreement is to raise the immunization coverage rate for infants and children 0 to 36 months of age.
It is recommended that the local WIC clinic staff assess the immunization status of all infants and children participating in the WIC Program. An immunization assessment should be performed at initial, mid-certification and subsequent certifications.
Immunizations should be scheduled in conjunction with WIC visits by the Health Departments. If the infant/child is under the care of a physician for their immunizations, request that the parent, guardian or caretaker bring the immunization record to the next visit.
CT-55

GA WIC PROCEDURES MANUAL

Attachment CT 1

WIC ASSESSMENT/CERTIFICATION FORM - PREGNANT (FRONT)

CT-56

GA WIC PROCEDURES MANUAL

Attachment CT 1 (cont'd)

WIC ASSESSMENT/CERTIFICATION FORM - PREGNANT (BACK)
INCOME DETERMINATION (income must be documented)

PHYSICAL DATE PRESENCE
Y( ) N( )

MEDICAID

MEDICAID I.D. NUMBER

FOOD STAMPS N/Y/U

CURRENT N/Y/U (MUST HAVE CURRENT CARD) (MUST DOCUMENT)

Y( ) U( )

Y( ) U( )

N( )

N( )

NO. IN GROSS INCOME FAMILY CURRENT/ANNUAL
C( ) A( )

* See Procedures Manual (CT Physical Presence) for a list of applicable reasons. Source of Income Code (MUST Document In Health Record)

Other (Write in type)

No Proof ( ) How is food, shelter, clothing and Medical Care obtained?

Staff Initials

Is the Client Income Eligible? YES ( ) NO ( )

Check Here if Only One Income Reported ( )

NOTE: The Income Calculation Form must be completed and filed in the Client's Medical Record if more than one Income was calculated.

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 health or public assistance agencies to see if my family is eligible for their services. I understand that these agencies may contact me, but they may not give my information to anyone else without asking my permission.

PARENT/GUARDIAN/CAREGIVER SIGNATURE

DATE

SIGNATURE OF WIC OFFICIAL (who assessed income)

DATA NEEDED FOR PREGENCY SURVEILLANCE

Marital Status

(0=Married 1=Not Married 9=Unknown)

Years of Education completed (e.g. 1st grade = 01, 2 yrs. College = 14, Unknown = 99)

Month of gestation at time of first prenatal exam (0=No Prenatal Care, 1=1st mo., 8=8th or 9th mo., 9=Unknown)

Georgia VOC Card Number or OUT of STATE Abbreviation
Signature of WIC Official:
Comments: (Date/Sign/Title):

Issued/Received

Date

Proxy 1

Proxy 2

CT-57

GA WIC PROCEDURES MANUAL

Attachment CT-2

WIC ASSESSMENT/CERTIFICATION FORM - POST PARTUM BREASTFEEDING (FRONT)

CT-58

GA WIC PROCEDURES MANUAL

Attachment CT-2 (cont'd)

WIC ASSESSMENT/CERTIFICATION FORM - POST PARTUM BREASTFEEDING (BACK)
INCOME DETERMINATION (income must be documented)

FIRST CERTIFICATION

PHYSICAL MEDICAID

MEDICAID I.D. NUMBER

FOOD STAMPS N/Y/U

DATE PRESENCE CURRENT N/Y/U (MUST HAVE CURRENT CARD) (MUST DOCUMENT)

Y( )

Y( ) U( )

Y( ) U( )

N( )

N( )

N( )

NO. IN GROSS INCOME FAMILY CURRENT/ANNUAL
C( ) A( )

* See Procedures Manual (CT Physical Presence) for a list of applicable reasons. Source of Income Code (MUST Document In Health Record)

Other (Write in type)

No Proof ( ) How is food, shelter, clothing and Medical Care obtained?

Staff Initials

Is the Client Income Eligible? YES ( ) NO ( )

Check Here if Only One Income Reported ( )

NOTE: The Income Calculation Form must be completed and filed in the Client's Medical Record if more than one Income was calculated.

SECOND CERTIFICATION

PHYSICAL MEDICAID

MEDICAID I.D. NUMBER

FOOD STAMPS N/Y/U

DATE PRESENCE CURRENT N/Y/U (MUST HAVE CURRENT CARD) (MUST DOCUMENT)

Y( )

Y( ) U( )

Y( ) U( )

N( )

N( )

N( )

NO. IN GROSS INCOME FAMILY CURRENT/ANNUAL
C( ) A( )

* See Procedures Manual (CT Physical Presence) for a list of applicable reasons. Source of Income Code (MUST Document In Health Record)

Other (Write in type)

No Proof ( ) How is food, shelter, clothing and Medical Care obtained?

Staff Initials

Is the Client Income Eligible? YES ( ) NO ( )

Check Here if Only One Income Reported ( )

NOTE: The Income Calculation Form must be completed and filed in the Client's Medical Record if more than one Income was calculated.

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 health or public assistance agencies 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.

SIGNATURE OF WIC OFFICIAL

PARENT/GUARDIAN/CAREGIVER SIGNATURE

DATE

(who assessed income)

DATA NEEDED FOR PREGENCY SURVEILLANCE

Marital Status

(0=Married 1=Not Married 9=Unknown)

Years of Education completed (e.g. 1st grade = 01, 2 yrs. College = 14, Unknown = 99)

Month of gestation at time of first prenatal exam (0=No Prenatal Care, 1=1st mo., 8=8th or 9th mo., 9=Unknown)

Last weight prior to delivery (Round to the nearest pound)

Georgia VOC Card Number or OUT of STATE Abbreviation

Issued/Received

Date

Signature of WIC Official:

Georgia VOC Card Number or OUT of STATE Abbreviation

Issued/Received

Date

Signature of WIC Official:

Comments: (Date/Sign/Title):

Proxy 1

Proxy 2

CT-59

GA WIC PROCEDURES MANUAL

Attachment CT-3

WIC ASSESSMENT/CERTIFICATION FORM - POST PARTUM/ NON BREASTFEEDING (FRONT)

CT-60

GA WIC PROCEDURES MANUAL

Attachment CT-3 (cont'd)

WIC ASSESSMENT/CERTIFICATION FORM - POST PARTUM

NON BREASTFEEDING (BACK)

INCOME DETERMINATION (income must be documented)

PHYSICAL DATE PRESENCE
Y( ) N( )

MEDICAID

MEDICAID I.D. NUMBER

FOOD STAMPS N/Y/U

CURRENT N/Y/U (MUST HAVE CURRENT CARD) (MUST DOCUMENT)

Y( ) U( )

Y( ) U( )

N( )

N( )

NO. IN GROSS INCOME FAMILY CURRENT/ANNUAL
C( ) A( )

* See Procedures Manual (CT Physical Presence) for a list of applicable reasons. Source of Income Code (MUST Document In Health Record)

Other (Write in type)

No Proof ( ) How is food, shelter, clothing and Medical Care obtained?

Staff Initials

Is the Client Income Eligible? YES ( ) NO ( )

Check Here if Only One Income Reported ( )

NOTE: The Income Calculation Form must be completed and filed in the Client's Medical Record if more than one Income was calculated.

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 health or public assistance agencies to see if my family is eligible for their services. I understand that these agencies may contact me, but they may not give my information to anyone else without asking my permission.

PARENT/GUARDIAN/CAREGIVER SIGNATURE

DATE

SIGNATURE OF WIC OFFICIAL (who assessed income)

DATA NEEDED FOR PREGENCY SURVEILLANCE

Marital Status

(0=Married 1=Not Married 9=Unknown)

Years of Education completed (e.g. 1st grade = 01, 2 yrs. College = 14, Unknown = 99) Month of gestation at time of first prenatal exam (0=No Prenatal Care, 1=1st mo., 8=8th or 9th mo., 9=Unknown)

Last weight prior to delivery (Round to the nearest pound)

Georgia VOC Card Number or OUT of STATE Abbreviation
Signature of WIC Official:

Issued/Received

Date

Comments: (Date/Sign/Title):

Proxy 1

Proxy 2

CT-61

GA WIC PROCEDURES MANUAL

Attachment CT-4

WIC ASSESSMENT/CERTIFICATION FORM - INFANT (FRONT)

CT-62

GA WIC PROCEDURES MANUAL

Attachment CT-4 (cont'd)

WIC ASSESSMENT/CERTFICATION FORM INFANT (BACK)

INCOME DETERMINATION (income must be documented)

PHYSICAL DATE PRESENCE
Y( ) N( )

MEDICAID

MEDICAID I.D. NUMBER

FOOD STAMPS N/Y/U

CURRENT N/Y/U (MUST HAVE CURRENT CARD) (MUST DOCUMENT)

Y( ) U( )

Y( ) U( )

N( )

N( )

NO. IN GROSS INCOME FAMILY CURRENT/ANNUAL
C( ) A( )

* See Procedures Manual (CT Physical Presence) for a list of applicable reasons. Source of Income Code (MUST Document In Health Record)

Other (Write in type)

No Proof ( ) How is food, shelter, clothing and Medical Care obtained?

Staff Initials

Is the Client Income Eligible? YES ( ) NO ( )

Check Here if Only One Income Reported ( )

NOTE: The Income Calculation Form must be completed and filed in the Client's Medical Record if more than one Income was calculated.

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 health or public assistance agencies to see if my family is eligible for their services. I understand that these agencies may contact me, but they may not give my information to anyone else without asking my permission.

PARENT/GUARDIAN/CAREGIVER SIGNATURE

DATE

SIGNATURE OF WIC OFFICIAL (who assessed income)

Georgia VOC Card Number or OUT of STATE Abbreviation Signature of WIC Official:
Comments: (Date/Sign/Title):
Proxy 1

Issued/Received

Date

Proxy 2

CT-63

GA WIC PROCEDURES MANUAL

Attachment CT-5

WIC ASSESSMENT/CERTIFICATION FORM - CHILDREN (FRONT)

CT-64

GA WIC PROCEDURES MANUAL

Attachment CT-5 (cont'd)

WIC ASSESSMENT/CERTIFICATION FORM - CHILDREN (BACK)

INCOME DETERMINATION (income must be documented)

FIRST CERTIFICATION

PHYSICAL MEDICAID

MEDICAID I.D. NUMBER

FOOD STAMPS N/Y/U

DATE PRESENCE CURRENT N/Y/U (MUST HAVE CURRENT CARD) (MUST DOCUMENT)

Y( )

Y( ) U( )

Y( ) U( )

N( )

N( )

N( )

NO. IN GROSS INCOME FAMILY CURRENT/ANNUAL
C( ) A( )

* See Procedures Manual (CT Physical Presence) for a list of applicable reasons. Source of Income Code (MUST Document In Health Record)

Other (Write in type)

No Proof ( ) How is food, shelter, clothing and Medical Care obtained?

Staff Initials

Is the Client Income Eligible? YES ( ) NO ( )

Check Here if Only One Income Reported ( )

NOTE: The Income Calculation Form must be completed and filed in the Client's Medical Record if more than one Income was calculated.

SECOND CERTIFICATION

PHYSICAL MEDICAID

MEDICAID I.D. NUMBER

FOOD STAMPS N/Y/U

DATE PRESENCE CURRENT N/Y/U (MUST HAVE CURRENT CARD) (MUST DOCUMENT)

Y( )

Y( ) U( )

Y( ) U( )

N( )

N( )

N( )

NO. IN GROSS INCOME FAMILY CURRENT/ANNUAL
C( ) A( )

* See Procedures Manual (CT Physical Presence) for a list of applicable reasons. Source of Income Code (MUST Document In Health Record)

Other (Write in type)

No Proof ( ) How is food, shelter, clothing and Medical Care obtained?

Staff Initials

Is the Client Income Eligible? YES ( ) NO ( )

Check Here if Only One Income Reported ( )

NOTE: The Income Calculation Form must be completed and filed in the Client's Medical Record if more than one Income was calculated.

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 health or public assistance agencies 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.

SIGNATURE OF WIC OFFICIAL

PARENT/GUARDIAN/CAREGIVER SIGNATURE

DATE

(who assessed income)

Georgia VOC Card Number or OUT of STATE Abbreviation Signature of WIC Official: Georgia VOC Card Number or OUT of STATE Abbreviation Signature of WIC Official:
Comments: (Date/Sign/Title): Proxy 1

Issued/Received

Date

Issued/Received

Date

Proxy 2

CT-65

GA WIC PROCEDURES MANUAL

Attachment CT-6

SIGNED STATEMENT OF INCOME, RESIDENCY AND IDENTIFICATION

I,
Parent/Guardian

, cannot come in to apply for WIC for my

child(ren)

Name(s)

. I have given permission to

Proxy Name

to file my application.

The requested documentation listed below is attached. The number of people in my family is related or non-related individuals living together).

(AFamily@ means

Parent, Guardian or Caretaker's Signature

Date

The proxy who comes with the child for the recertification appointment must have: 1. This Form; 2. The participant's WIC ID Folder; 3. Parent/guardian or participant's current Medicaid or Food Stamp Letter or Card; 4. If not eligible for Medicaid, Proof of your income (e.g. Pay stub); 5. Proof of your residency; 6. Proxy Identification; 7. Knowledge of the child=s health and diet.

"This institution is an equal opportunity provider."

CT-66

GA WIC PROCEDURES MANUAL

Attachment CT-7

DATA AND DOCUMENTATION REQUIRED FOR WIC ASSESSMENT/CERTIFICATION
WOMEN

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

Documentation

Prenatal

Postpartum Breastfeeding

Required

Required

Required

Required

Required

Required

Required

N/A

Required

Required

Required

Required

Required

Required

Postpartum NonBreastfeeding Required Required Required N/A Required Required Required

NOTE: Refer to Attachment CT-20 for information regarding the collection of height data. Refer to Attachment CT-22 for information regarding the collection of weight data. Refer to Attachment CT-23 for information regarding equipment maintenance. Refer to Attachment CT-24 for information regarding use of the prenatal weight gain grid. Refer to Attachment CT-27 for information regarding diet assessment. Refer to Attachments CT-10, CT-11, and CT-12 for information regarding risk factor assessment.

CT-67

GA WIC PROCEDURES MANUAL

Attachment CT-8

DATA AND DOCUMENTATION REQUIRED FOR WIC ASSESSMENT/CERTIFICATION

INFANTS

Data
Length Weight
Weight/age Length/age Weight/length

Documentation

Infant Certified in Hospital Prior to Initial Discharge

Infant 0-6 Months

Birth Data or other measurement

Required

Birth Data or other measurement

Required

Optional Optional Optional

Required Required Required

Infant 6-12 Months
Required
Required Required Required Required

Hemoglobin or Hematocrit
Dietary Intake and Summary Dietary Evaluation Risk Factor Assessment

N/A
Optional Optional Required

N/A
Required Required Required

Required (9-12 months)
Required Required Required

NOTE: Refer to Attachment CT-19 for information regarding the collection of length data. Refer to Attachment CT-21 for information regarding the collection of weight data. Refer to Attachment CT-23 for information regarding equipment maintenance. Refer to Attachment CT-27 for information regarding diet assessment. Refer to Attachment CT-28 for information on plotting growth grids. Refer to Attachment CT-13 for information regarding risk factor assessment.

CT-68

GA WIC PROCEDURES MANUAL

Attachment CT-9

DATA AND DOCUMENTATION REQUIRED FOR WIC ASSESSMENT/CERTIFICATION
CHILDREN

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

Documentation Required Required Required Required Required Required Required Required Required

NOTE: Refer to Attachment CT-19, 20 for information regarding the collection of height data. Refer to Attachment CT-21,22 for information regarding the collection of weight data. Refer to Attachment CT-23 for information regarding equipment maintenance. Refer to Attachment CT-27 for information regarding diet assessment. Refer to Attachment CT-28 for information on plotting growth grids Refer to Attachment CT-14 for information regarding risk factor assessment.

CT-69

GA WIC PROCEDURES MANUAL
NUTRITION RISK CRITERIA PRENATAL WOMEN

Attachment CT-10

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

CODE

201 LOW HGB/HCT

1st Trimester (0-13 weeks):

Hemoglobin

Non-Smokers

10.9 gm or lower

Smokers

11.2 gm or lower

2nd Trimester (14-26 weeks):

Non-Smokers

10.4 gm or lower

Smokers

10.7 gm or lower

3rd Trimester (27-40 weeks):

Non-Smokers

10.9 gm or lower

Smokers

11.2 gm or lower

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

PRIORITY I

High Risk: Hemoglobin OR hematocrit at treatment level

101 PRE-PREGNANCY UNDERWEIGHT

I

Pre-pregnancy weight is 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, Attachments CT-30, 31.

High Risk: Pre-pregnancy weight 10% below normal weight for height, OR BMI <19.8.

111 PRE-PREGNANCY OVERWEIGHT

I

Pre-pregnancy weight is 21% above the mean normal weight for height OR BMI is >26. Refer to Weight for Height Table, OR BMI Table, Attachments CT30, 31.

High Risk: Pre-pregnancy weight 36% above normal weight for height OR BMI >29.

CT-70

GA WIC PROCEDURES MANUAL

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 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 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 (prepregnancy 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

I

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

High Risk: Blood lead level 10 g/deciliter.

CT-71

GA WIC PROCEDURES MANUAL

Attachment CT-10 (cont'd)

CODE 301 HYPEREMESIS GRAVIDARUM

PRIORITY I

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 record

High Risk: Diagnosed hyperemesis gravidarum.

302 GESTATIONAL DIABETES I
Presence of gestational diabetes 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, as self-reported by application/participant/caregiver; or as reported or documented by a physician or a health professional acting under orders of a physician.

Document: Pregnancy or pregnancies when gestational diabetes was diagnosed.

311 DELIVERY OF PREMATURE INFANT(S)

I

Any history of infants born at 37 weeks gestation or less.

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.

CT-72

GA WIC PROCEDURES MANUAL

Attachment CT-10 (cont'd)

CODE 321 HISTORY OF FETAL OR NEONATAL DEATH

PRIORITY I

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 expected date of confinement (EDC) less than 18 years and 10 months of age.

Document: (EDC) date 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.

333 HIGH PARITY AND YOUNG AGE

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 (0 13 weeks gestation).

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

CT-73

GA WIC PROCEDURES MANUAL

Attachment CT-10 (cont'd)

CODE

PRIORITY

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 HISTORY OF BIRTH OF A LARGE FOR GESTATIONAL AGE INFANT

I

Prenatal woman has delivered one 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.

338 PREGNANT WOMAN CURRENTLY BREASTFEEDING

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 HISTORY 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.

CT-74

GA WIC PROCEDURES MANUAL

Attachment CT-10 (cont'd)

CODE 342 GASTRO-INTESTINAL DISORDERS

PRIORITY

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

I

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 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-75

GA WIC PROCEDURES MANUAL

Attachment CT-10 (cont'd)

CODE

PRIORITY

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.

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 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-76

GA WIC PROCEDURES MANUAL

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.

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 diagnoses 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 genetic/congenital 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 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 inborn error of metabolism.

CT-77

GA WIC PROCEDURES MANUAL

Attachment CT-10 (cont'd)

CODE

PRIORITY

352 INFECTIOUS DISEASES

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), HIV/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 HIV/AIDS positive status as a nutritionly related medical condition, write ASee 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-78

GA WIC PROCEDURES MANUAL

Attachment CT-10 (cont'd)

CODE

PRIORITY

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 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-79

GA WIC PROCEDURES MANUAL

Attachment CT-10 Cont'd

CODE 359 RECENT MAJOR SURGERY, TRAUMA OR BURNS

PRIORITY I

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 burns 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 burns within the past 2 months.

360 OTHER MEDICAL CONDITIONS

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-80

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 with 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 2 ounces of alcohol) is: < 1 can or bottle of beer (12 fluid ounces) < 5 ounces of wine < 1 2 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.

CT-81

GA WIC PROCEDURES MANUAL

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-32).

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-33).

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 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-82

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-83

GA WIC PROCEDURES MANUAL

Attachment CT-11

NUTRITION RISK CRITERIA POSTPARTUM, BREASTFEEDING WOMEN

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

CODE

PRIORITY

201 LOW HGB/HCT

I

Non-Smokers: Smokers:

Hemoglobin: Hematocrit:
Hemoglobin: Hematocrit:

11.9 gm or lower (> 15 years of age) 11.7 gm or lower (< 15 years of age) 35.8% or lower (15 years of age to < 18 years of age) 35.6% or lower (< 15 years of age or 18 years of age and older) 12.2 gm or lower (> 15 years of age) 12.0 gm or lower (< 15 years of age) 36.8% or lower (15 years of age to < 18 years of age) 36.6% or lower (< 15 years of age or 18 years of age and older)

High Risk: Hemoglobin OR hematocrit at treatment level.

102 POSTPARTUM UNDERWEIGHT

I

Postpartum weight is 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, Attachments CT-30, 31.

High Risk: Postpartum weight 10% below normal weight for height, OR BMI <19.8.

112 POSTPARTUM OVERWEIGHT

I

Postpartum weight is to 21% above the mean normal weight for height OR BMI is >26. Refer to Weight for Height Table OR BMI Table, Attachments CT30, 31.

High Risk: Postpartum weight 36% above normal weight for height OR BMI >29.

CT-84

GA WIC PROCEDURES MANUAL

Attachment CT-11 (cont'd)

CODE 133 HIGH GESTATIONAL WEIGHT GAIN

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

>40 pounds

Normal Weight

>35 pounds

Overweight

>25 pounds

Obese

>15 pounds

Multi-Fetal Pregnancy

>45 pounds

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

PRIORITY I

211 ELEVATED BLOOD LEAD LEVELS

I

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.

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.

CT-85

GA WIC PROCEDURES MANUAL

Attachment CT-11 (cont'd)

CODE 321 FETAL OR NEONATAL DEATH

PRIORITY I

A fetal death (death >20 weeks gestation) or a neonatal death (death occurring from 0-28 days of life). Applies to most recent pregnancy in which there was a multifetal gestation with one or more fetal or neonatal deaths but with one or more infants still living.

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, 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.

332 CLOSELY SPACED PREGNANCIES

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.

CT-86

GA WIC PROCEDURES MANUAL

Attachment CT-11 (cont'd)

CODE 337 BIRTH OF A LARGE FOR GESTATIONAL AGE INFANT

PRIORITY 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 BIRTH

I

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.

341 NUTRIENT DEFICIENCY DISEASES

Diagnosis of clinical signs of nutrient deficiencies or a disease caused by

I

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-31).

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-87

GA WIC PROCEDURES MANUAL

Attachment CT-11 (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 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.

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.

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.

CT-88

GA WIC PROCEDURES MANUAL

Attachment CT-11 (cont'd)

CODE 346 RENAL DISEASE

PRIORITY 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 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 (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.

CT-89

GA WIC PROCEDURES MANUAL

Attachment CT-11 (cont'd)

CODE 349 GENETIC AND CONGENITAL DISORDERS

PRIORITY 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.

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 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), HIV/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.

CT-90

GA WIC PROCEDURES MANUAL

Attachment CT-11 (cont'd)

CODE 353 FOOD ALLERGIES

PRIORITY 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.

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 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.

CT-91

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 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 burns 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 burns within the past 2 months.

CT-92

GA WIC PROCEDURES MANUAL

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 with 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 pipes smoked, on WIC Assessment/Certification Form.

CT-93

GA WIC PROCEDURES MANUAL

Attachment CT-11 (cont'd)

CODE 372 ALCOHOL USE

PRIORITY I

Routine current use of >2 drinks per day, OR binge drinking, OR heavy drinking.
A standard serving of a drink containing alcohol (1 2 ounces of alcohol) is: < 1 can or bottle of beer (12 fluid ounces) < 5 ounces of wine < 1 2 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.

Heavy 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

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.

CT-94

GA WIC PROCEDURES MANUAL

Attachment CT-11 (cont'd)

CODE 422 INADEQUATE DIETARY PATTERN

PRIORITY IV

1. Any food group missing, based on the Recommended Daily Servings Chart (Attachment CT-32).

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-33).

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 AComments@ 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-95

GA WIC PROCEDURES MANUAL

Attachment CT-11 (cont'd)

CODE

PRIORITY

602 BREASTFEEDING COMPLICATIONS OR POTENTIAL COMPLICATIONS

I

A breastfeeding woman with any of the following complications or potential Complications for breastfeeding: Severe breast engorgement Recurrent plugged ducts Mastitis Flat or inverted nipples Cracked, bleeding or severely sore nipples Age >40 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.

High Risk: Refers to or provides the mother with appropriate breastfeeding counseling.

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

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-96

GA WIC PROCEDURES MANUAL

Attachment CT-11 (cont'd)

CODE

PRIORITY

902 BREASTFEEDING 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-97

GA WIC PROCEDURES MANUAL

Attachment CT-12

NUTRITIONAL RISK CRITERIA POSTPARTUM, NON-BREASTFEEDING WOMEN

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

CODE

PRIORITY

201 LOW HGB/HCT

VI

Non-Smokers:

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

11.7 gm or lower (< 15 years of age)

Hematocrit: 35.9% or lower

Smokers:

Hemoglobin: 12.2 gm or lower (> 15 years of age) 12.0 gm or lower (< 15 years of age)
Hematocrit: 36.9% or lower

High Risk: Hemoglobin OR hematocrit at treatment level

102 POSTPARTUM UNDERWEIGHT

VI

Postpartum weight is 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, Attachments CT-30, 31.

High Risk: Postpartum weight 10% below normal weight for height, OR BMI <19.8.

112 POSTPARTUM OVERWEIGHT

VI

Postpartum weight is 21% above the mean normal weight for height OR BMI is >26. Refer to Weight for Height Table OR BMI Table, Attachments CT-30, 31.

High Risk: Postpartum weight 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

>40 pounds >35 pounds >25 pounds >15 pounds >45 pounds

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

CT-98

GA WIC PROCEDURES MANUAL

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) or more infants with a birth weight of 5 pounds 8 ounces (2500 grams) or 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 death (death >20 weeks gestation) or a neonatal death (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

III

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-99

GA WIC PROCEDURES MANUAL

Attachment CT-12 (cont'd)

CODE 333 HIGH 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-100

GA WIC PROCEDURES MANUAL

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-31)

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-101

GA WIC PROCEDURES MANUAL

Attachment CT-12 (cont'd)

CODE 344 THYROID DISORDERS

PRIORITY VI

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

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-102

GA WIC PROCEDURES MANUAL

Attachment CT-12 (cont'd)

CODE

PRIORITY

348 CENTRAL NERVOUS SYSTEM DISORDERS

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

VI

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 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 inborn error of metabolism.

CT-103

GA WIC PROCEDURES MANUAL

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 HIV/AIDS positive status as a nutritionally related medical condition, write ASee 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-104

GA WIC PROCEDURES MANUAL

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 HYPOGLYCEMIA

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.

357 DRUG NUTRIENT INTERACTIONS

VI

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 shown to interfere with nutrient intake or utilization, to extent that nutritional status is compromised.

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-105

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 burns 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 burns 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-106

GA WIC PROCEDURES MANUAL

Attachment CT-12 (cont'd)

CODE

PRIORITY

362 DEVELOPMENTAL, SENSORY OR MOTOR DELAYS INTERFERING 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 with 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 2 ounces of alcohol) is: < 1 can or bottle of beer (12 fluid ounces) < 5 ounces of wine < 1 2 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.

Heavy 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-107

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-32).

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-33).

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 AComments@ 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-108

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-109

GA WIC PROCEDURES MANUAL

Attachment CT-13

NUTRITIONAL RISK CRITERIA INFANT

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

CODE

PRIORITY

201 LOW HGB/HCT

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-110

GA WIC PROCEDURES MANUAL

Attachment CT-13 (cont'd)

CODE 135 INADEQUATE GROWTH

PRIORITY I

An inadequate rate of weight gain as defined 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 2 pound OR >8% (below birth weight)
Percent Weight Loss = (birth weight current weight) birth weight x 100 < 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 2 ounces per week in the next two weeks.

Infants being certified during period from 1 to 5 2 months of age: < This assessment is optional, if an infant who is >1 month but <5 2 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 2 oz/wk) 19 oz/month (4 2 oz/wk)
17 oz/month (4 oz/wk) 15 oz/month (3 2 oz/wk)
13 oz/month (3 oz/wk)

Infants 6 months to 12 months of age: Age in Months at Certification
< 5 2 mos - 6 mos < > 6 mos - 9 mos < > 9 mos - 12 mos

Weight Gain per 6-Month Interval*
< < 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).

CT-111

GA WIC PROCEDURES MANUAL

Attachment CT-13 (cont'd)

CODE 142 PREMATURITY

PRIORITY 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.

211 ELEVATED BLOOD LEAD LEVELS

I

Blood lead level of >10 Fg/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 Fg/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-112

GA WIC PROCEDURES MANUAL

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-113

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

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 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

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-114

GA WIC PROCEDURES MANUAL

Attachment CT-13 (cont'd)

CODE

PRIORITY

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 (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-115

GA WIC PROCEDURES MANUAL

Attachment CT-13 (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 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), 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 HIV/AIDS positive status as a nutritionally related medical condition, write ASee 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-116

GA WIC PROCEDURES MANUAL

Attachment 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 HYPOGLYCEMIA

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 interaction; 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-117

GA WIC PROCEDURES MANUAL

Attachment CT-13 (cont'd)

CODE 359 RECENT MAJOR SURGERY, TRAUMA OR BURNS

PRIORITY I

Major surgery, trauma or burns 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 burns 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 burns 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-118

GA WIC PROCEDURES MANUAL

Attachment CT-13 (cont'd)

CODE

PRIORITY

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.

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-119

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-32).

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-33)..

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 COMPLICATIONS

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-120

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-121

GA WIC PROCEDURES MANUAL

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-122

GA WIC PROCEDURES MANUAL

Attachment CT-14

NUTRITIONAL RISK CRITERIA CHILDREN

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

CODE

PRIORITY

201 LOW HGB/HCT

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.

134 FAILURE TO THRIVE

III

Presence of failure to thrive diagnosed by a physician or health professional acting under standing orders of a physician.

Document: Diagnosis in participant's health record.

High Risk: Diagnosed failure to thrive.

CT-123

GA WIC PROCEDURES MANUAL

Attachment CT-14 (cont'd)

CODE 135 INADEQUATE GROWTH

PRIORITY III

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

< < 3 pounds < < 1 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)

III

Birth weight 5 pounds 8 ounces (2500 grams) or less.

Document: Birth weight in participant=s health record.

211 ELEVATED BLOOD LEAD LEVELS

III

Blood lead level of >10 Fg/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 Fg/deciliter.

NUTRITION RELATED MEDICAL CONDITIONS

III

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-31)

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-124

GA WIC PROCEDURES MANUAL

Attachment CT-14 (cont'd)

CODE 342 GASTRO-INTESTINAL DISORDERS

PRIORITY III

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

III

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

III

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

III

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-125

GA WIC PROCEDURES MANUAL

Attachment CT-14 (cont'd)

CODE

PRIORITY

346 RENAL DISEASE

III

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

III

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

III

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-126

GA WIC PROCEDURES MANUAL

Attachment CT-14 (cont'd)

CODE 349 GENETIC AND CONGENITAL DISORDERS

PRIORITY III

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

III

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-127

GA WIC PROCEDURES MANUAL

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 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 HIV/AIDS positive status as a nutritionally related medical condition, write ASee 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.

CT-128

GA WIC PROCEDURES MANUAL

Attachment CT-14 (cont'd)

CODE 355 LACTOSE INTOLERANCE

PRIORITY III

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 HYPOGLYCEMIA

III

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

III

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-129

GA WIC PROCEDURES MANUAL

Attachment CT-14 (cont'd)

CODE

PRIORITY

359 RECENT MAJOR SURGERY, TRAUMA OR BURNS

III

Major surgery, trauma or burns 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 burns 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 burns within the past 2 months.

360 OTHER MEDICAL CONDITIONS

III

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.

361 DEPRESSION

III

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-130

GA WIC PROCEDURES MANUAL

Attachment CT-14 (cont'd)

CODE

PRIORITY

362 DEVELOPMENTAL, SENSORY OR MOTOR DELAYS INTERFERING WITH

III

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

III

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

III

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-131

GA WIC PROCEDURES MANUAL

Attachment CT-14 (cont'd)

CODE 422 INADEQUATE DIETARY PATTERN

PRIORITY V

1. Any food group missing, based on the Recommended Daily Servings Chart (Attachment CT-32).

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 - 33).

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

III

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 AComments@ 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-132

GA WIC PROCEDURES MANUAL

Attachment CT-14 (cont'd)

CODE 901 RECIPIENT OF ABUSE

PRIORITY V

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.

902 PRIMARY CAREGIVER WITH LIMITED ABILITY TO MAKE FEEDING 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
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.

V III, V

CT-133

GA WIC PROCEDURES MANUAL

Attachment CT-15

NOTICE OF TERMINATION/INELIGIBILITY/WAITING LIST FORM

DHR GEORGIA DEPARTMENT OF
HUMAN RESOURCES
NAME:

Georgia Department of Human Resources Division of Public Health WIC Program
NOTICE OF TERMINATION / INELIGIBILITY / WAITING LIST
DATE:_______________________________
DATE OF BIRTH:

ADDRESS:

CITY/ZIP CODE:

PHONE NUMBER:

TERMINATION/INELIGIBILITY SECTION:

You are not eligible for the WIC Program because you:

You are being terminated from the WIC Program because you:
______have an income that is too high for the WIC Program. ______do not live in the area served by this WIC Program. ______are not pregnant, postpartum, or breastfeeding woman; child under five (5) years. ______do not have a medical/nutritional health problem. _____ did not return to the clinic for your recertification appointment on_____________________________ (date). ______did not pick-up your food vouchers for two (2) months. You will be terminated on
______________________________(date). Other________ Fund are not available to serve postpartum non-breastfeeding women.
_______ ________________________________________________________.

SUSPENSION SECTION:

You are being suspended from the WIC Program for three (3) months because you broke the following WIC Program rule(s)

WAITING LIST SECTION:

You are being placed on a waiting list. Funds are not available to serve priority(ies)______________ . You are in priority___________________.
You may still receive nutritional education and other services provided by the Health Department. If you need information or would like to discuss this decision, please contact the WIC Program at the address below:
FAIR HEARING SECTION:

You have a right to a fair hearing if you do not agree with the reason for your termination/ineligibility or waiting list placement.

A request for a fair hearing must be made within 60 days of the date of this notice. Fair hearing requests should be addressed to:

___________________________________________________________________

WIC PROGRAM

___________________________________________________________________________

ADDRESS

_____________________________________________/______________________________

CITY/ZIP CODE

PHONE NUMBER

______________________________ ___________________________________

PARTICIPANT SIGNATURE/PARENT/CARETAKER/GUARDIAN

WIC RESPRENTATIVE SIGNATURE/TITLE

This is an Equal Opportunity Program. If you believe you have been discriminated against because of race, color, national origin, age, sex or

handicap, write immediately to the Secretary of Agriculture, Washington, D.C. 20250.

Form 3293 (Rev. 6-95)

CT-134

GA WIC PROCEDURES MANUAL

Attachment CT-16

VERIFICATION OF CERTIFICATION (VOC) CARD

VERFICATION OF CERTIFICATION (VOC) CARD STATE OF GEORGIA
DEPARTMENT OF HUMAN RESOURCES

PARTICIPANT/PARENT/ GUARDIAN SIGNATURE
SIGNATURE OF WIC OFFICIAL

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 USDA prohibits discrimination in the administration of its program. 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 PARTICIPANTES USDA prohibe la discriminacin de su programa. Usted puedo apelar la decision tomada por la agencia local con respecto a su participation en el Programa. La agencia local arreglar papa useted la disponibilidad de services de salud y de educatin en asuntos de nutricin y se recomienda que Ud. Haga uso de estos servicios.

PARTICIPANT CERTIFICATION INFORMATION
PARTICIPANT NAME ID NUMBER DATE OF BIRTH CERTIFICATION DATE DATE CERTIFICATION EXPIRES HEIGHT FOOD PACKAGE EDC DATE

WEIGHT PRIORITY

FORM 3292 (REV. 8-98)

CT-135

GA WIC PROCEDURES MANUAL____________________________________________________________________ Attachment CT-17
CLINIC VOC CARD INVENTORY LOG

GEORGIA WIC PROGRAM VOC CARD INVENTORY LOG

DISTRICT

CLINIC

Date Beginning Ending

No.

Card

No.

No. Received No.

Issued

Participants Name (Print)

WIC ID Number

Signature of Parent, Guardian or Caretaker

City Total No. Staff Staff State* of Cards Initials Initials
on Hand

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 is not moving, please place "Not Moving" in the column marked City/State.
CT-136

GA WIC PROCEDURES MANUAL____________________________________________________________________ Attachment CT-18

DISTRICT

LOCAL AGENCY VOC CARD INVENTORY LOG
GEORGIA WIC PROGRAM VOC CARD INVENTORY LOG

Date Beginning Ending

No.

No.

No.

No. Received Issued

Clinic Name (Print)

Name of Clinic Representative

Total No. Staff Staff of Cards Initials Initials on Hand

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).
CT-137

GA WIC PROCEDURES MANUAL

Attachment CT-19

MEASURING LENGTH

Age:

<

Birth to 24 months.

<

24-36 months, if proper position to measure stature cannot be achieved or with children less

than 32 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

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 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 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 sliding footboard away and starting again until two readings agree within 1/4 inch.

6.

Record the second reading promptly.

CT-138

GA WIC PROCEDURES MANUAL

Attachment CT-20

MEASURING HEIGHT

Age:

<

Children two (2) years of age and older who are at least 32 inches in stature.

<

Adults.

NOTE: Once measurements have been taken with child standing, all subsequent measurements must be done standing.

Material/Equipment:

<

Wall mounted or portable stadiometer or metal measuring tape mounted on wall.

<

A right angle headboard marked in increments of 1/8 inch.

Procedure:

1.

Remove all bulky clothing, head and foot wear.

2. Position the child/adult against the measuring device, instructing the child/adult to stand straight and tall.

3.

Make sure the child/adult stands flat footed with feet slightly apart and knees

extended; then check for three (3) contact points: (a) shoulders, (b) buttocks, and

(c) the back of the heels.

4. Lower the moveable headboard 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.

Estimate the child's height to the nearest 1/8 inch.

6.

Repeat the adjustment of the headboard and re-measure until two readings agree

within 1/4 inch.

7.

Record the second reading promptly.

CT-139

GA WIC PROCEDURES MANUAL

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-23).

Procedure:

1. Check scales at zero position. With weights in zero position, indicator should point to zero. If not, use the adjustment screws to move adjustable zeroing weight until the beam is in zero 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 position (left to right) until the indicator shows excess weight, then move the weight back (right to left) towards the zero position until too little weight has been obtained.

5. Move the weight on the fractional beam away from the zero position (left to right) until the indicator is centered and stationary.

6. Record the reading.

7. Repeat the measurements by moving the fractional beam until two readings agree within 2 ounce.

8. Record the second reading promptly.

CT-140

GA WIC PROCEDURES MANUAL 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-23).

Procedure:

1. Check scales at zero position. With weights in zero position indicator should point to zero. If not, use adjustment screws to move the adjustable zeroing weight until the beam is in zero 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 until the indicator shows that excess weight has been added, then move the weight back towards the zero 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 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 pound.

7. Have the child/adult step off scale and return weight to zero. Repeat until two readings agree within 1/4 pound.

8. Record the second reading promptly.

Sources:

Georgia Child and Adolescent Health Program Manual. DHR, Division of Public Health; 1987.
A Guide to Pediatric Weighing and Measuring, DHHS; 1981.

CT-141

GA WIC PROCEDURES MANUAL EQUIPMENT MAINTENANCE

Attachment CT-23

1.

A yearly calibration of scales is required for proper usage. To arrange for your

equipment to be calibrated, please contact a scale company licensed by the

Georgia Department of Agriculture for service 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

Please contact the Nutrition Section for a list of Licensed Scale Calibration Companies.

2.

A yearly calibration of centrifuges and other hematological equipment used to

determine 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 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 value readings are the same, the centrifuge is packing/spinning
the red blood cells sufficiently and the centrifuge is calibrated. 6. If the two values are different, the centrifuge is not calibrated and needs
to be serviced.

B. Spinning two 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-142

GA WIC PROCEDURES MANUAL

Attachment CT-24

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

1.

Record applicant/participant's name.

2.

Use "Weight for Height Table" or ABody Mass Index Table@ (Attachments CT-

29, 30) to determine if the applicant is Normal Weight, Underweight for Height

or Overweight for Height, using pre-pregnancy weight. Select 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 point. From the chart or gestation calculator, determine the completed weeks of gestation.

b. Using the gain (or loss) in weight from the pre-pregnancy weight baseline and the completed gestational weeks (this visit) place an X on the point at which these two 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 completed gestational week. Let this be a beginning point to plot future weights. Indicate that this weight is an estimate by writing "estimate" vertically on the grid next to the X. Use the "Normal" weight curve unless it is very obvious that the prenatal woman was overweight or underweight prior to gestation. Document this observation in the health record.

d. At the second and each subsequent visit, the weight gain for completed weeks of gestation should be plotted on the grid.

CT-143

GA WIC PROCEDURES MANUAL

Attachment CT-25

PRENATAL WEIGHT GRID FOR NORMAL WEIGHT AND TWINS

CT-144

GA WIC PROCEDURES MANUAL

Attachment CT-26

PRENATAL WEIGHT GRID FOR UNDERWEIGHT AND OVERWEIGHT

CT-145

GA WIC PROCEDURES MANUAL

Attachment CT-27

DIETARY ASSESSMENT

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

Diet assessment forms and/or methods are evaluated by the Nutrition Section using the following criteria:

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

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

3. A method for documenting inappropriate food practices (see Attachment CT33).

4. Evidence that the Recommended Daily Servings Chart is the basis for determining missing food groups and failure to meet recommended number of servings (see Attachment CT-32).

5. A method for determining the amount of breastmilk and/or iron-fortified formula consumed by infants. This should include:

a. For breastfed infants: frequency and duration of feeds, to include frequency and amount of breastmilk consumed from a bottle; number of wet diapers/24 hours; number of stools/24 hours; and detection of audible swallow (as stated by mother, or observed by health care professional).

b. For formula fed infants: frequency of feeds, and amount of formula in each bottle/cup.

6. A method for documenting poor dietary pattern(s).

CT-146

GA WIC PROCEDURES MANUAL

Attachment CT-28

INSTRUCTIONS FOR USE OF THE GROWTH CHARTS

1. Select the appropriate chart for sex and age of the individual. When length measurements are taken with the individual lying down use the "Birth to 36 Months of Age" chart.

2. Record name and/or identifying number of the chart. Document birth date.

3. The child's age on the date on which measurements are taken must be determined before you start plotting the measurements. To figure out a child's age, follow this example:

Date of Measurement Birth date Child's Age

Year

Month Day

2000

4

21

-1999

-8

-10

5

8

11

days

or 5-2/3 years

As this example shows, you may have to borrow thirty (30) days from the month column and/or 12 months from the year column when subtracting the child's birth date from the date on which the measurements are taken.

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

Interpolation Method:

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

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

Rounding Method:

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

2-18 Years Growth Chart - Calculate age to the nearest 1/4 year and plot on the corresponding line.

CT-147

GA WIC PROCEDURES MANUAL

Attachment CT-28 (cont'd)

To round off the child's age, follow these rules:

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

-round off to the previous month -round off to the next highest month -round off to the previous whole year -round off to 1/4 year -round off to 2 year -round off to 3/4 year -round off to the next whole year

5. To plot the length or height for age and weight for age charts:

a. Follow a vertical line at the appropriate age.

b. Using a straight-edge, line up as closely as possible to the measured length or height and weight and mark the point where the two (2) lines intersect.

c. Write the date above the point.

6. To plot the length/weight or BMI/age chart (see 9. for steps to calculate BMI/age):

a. Follow a vertical line at the point of the correct length or height.

b. Using a straight-edge, line up as closely as possible to the weight and mark the point where the two (2) lines intersect.

c. Write the date on the point.

7. To plot an infant's head circumference:

a. Follow a vertical line as near as possible to the appropriate age.

b. Using a straight-edge, line up as closely as possible the measured head circumference and mark the point where the two (2) lines intersect.
8. See the Nutrition Guidelines for Practice (available in each clinic site) for instructions on adjusting for prematurity.

9. The formula for calculating BMI for age is: [weight (lb.) height (in.) height (in.) x 703]

This can be calculated on a hand-held calculator or by computer systems in the district. Once calculated, BMI must be rounded to one decimal point. A reference for converting fractions to decimals and guidance for rounding to one decimal point follows.

CT-148

GA WIC PROCEDURES MANUAL

Attachment CT-28 (cont'd)

Reference for Converting Fractions to Decimals

1/8 = .125 2/8 or = .25
3/8 = .375 4/8 or = .5
5/8 = .625 6/8 or = .75
7/8 = .875

Guidance for Rounding to One Decimal Point
When calculating Body Mass Index (BMI) round the final answer to one decimal point. To do this you will round up to the next number if the second number past the decimal point is five or greater and you will round down if the second number past the decimal point is four or less.
Example:
If the final BMI calculation equals 17.158829, the BMI would be 17.2
If the final BMI calculation equals 17.14829, the BMI would be 17.1

CT-149

GA WIC PROCEDURES MANUAL

Attachment CT-29

WEIGHT FOR HEIGHT TABLE FOR DETERMINING WIC ELIGIBILITY*

Height 4'10" (58") 4'11" (59") 5'0" (60") 5'1" (61") 5'2" (62") 5'3" (63") 5'4" (64") 5'5" (65") 5'6" (66") 5'7" (67") 5'8" (68") 5'9" (69") 5'10" (70") 5'11" (71") 6'0" (72")

Underweight 91 94 96 99 102 104 108 111 115 118 122 126 129 133 136

Normal Weight 92-122 95-125 97-128 100-132 103-136 105-139 109-144 112-148 116-153 119-158 123-163 127-168 130-173 134-177 137-182

Overweight 123 126 129 133 137 140 145 149 154 159 164 169 174 178 183

Obese 138 141 146 150 154 158 163 167 173 179 184 190 195 201 206

* Table developed using the mean weight in the Amedium 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 Nutrition Section, Division of Public Health, Georgia Department of Human Resources, October 1998. Based on the 1957 Metropolitan Life Tables.

CT-150

GA WIC PROCEDURES MANUAL

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") 5'3" (63") 5'4" (64") 5'5" (65") 5'6" (66") 5'7" (67") 5'8" (68") 5'9" (69") 5'10" (70") 5'11" (71") 6'0" (72")

Underweight 95 98 101 105 108 112 115 119 123 126 130 134 138 142 146

Normal Weight 96-123 99-128 102-132 106-137 109-141 113-146 116-150 120-155 124-160 127-165 131-170 135-175 139-180 143-185 147-190

Overweight 124 129 133 138 142 147 151 156 161 166 171 176 181 186 191

*BMI = lbs/in2 x 703

Underweight is defined as:< 19.8 Overweight is defined as:> 26 Obese is defined as:>29

Obese 139 144 149 154 159 164 169 174 180 185 191 196 202 208 214

CT-151

GA WIC PROCEDURES MANUAL

Attachment CT-31

PHYSICAL SIGNS SUGGESTIVE OF NUTRIENT DEFICIENCIES

Body Area

Normal Appearance

Signs Suggestive of Nutrient Deficiency (ies)

Nutrient Consideration(s)

Hair

shiny; firm; not easily

lack of natural shine; dull; dry; thin; loss of curl;

inadequate protein and

plucked

color changes (flag sign); easily plucked

calories

Eyes

bright; clear; shiny; no

eye membranes pale;

anemia (inadequate iron,

sores at corners 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 corners

Vitamin B-6, and niacin

Lips

smooth; not chapped or

redness of swelling of mouth or lips (cheilosis);

inadequate niacin and

swollen

riboflavin

bilateral cracks, white or pink lesions at corners

inadequate riboflavin, niacin,

of mouth (angular stomatitis) and/or scars

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

scarlet; raw; edematous (glossitis)
purplish color (magenta); smooth; pale; slick; atrophied taste buds (papillae)

inadequate niacin, riboflavin, folacin, iron, and Vitamins B-6 and B-12 inadequate riboflavin inadequate folacin, Vitamin B-12, iron and niacin

Face and Neck

skin color uniform, smooth, pink; healthy appearing; not swollen

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

no cavities, no pain, bright

may be some missing or erupting abnormally; gray or black spots (fluorosis); cavities (caries) [signs are to be severe enough to interfere with mastication and/or other health implications]*

inadequate Vitamin D inadequate Vitamin A

Glands

face not swollen

thyroid enlargement (front of neck); parotid enlargement (cheeks become swollen)

inadequate iodine inadequate protein

CT-152

GA WIC PROCEDURES MANUAL

Attachment CT-31 (cont'd)

Body Area Nails
Muscular and skeletal systems

Normal Appearance firm, pink
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 thiamin

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-153

GA WIC PROCEDURES MANUAL
RECOMMENDED DAILY SERVINGS CHART

Attachment CT-32

Food Group

Birth to 5/6 Months

5/6 Months to 1 Year

1-3 Years old1

4-6 Years old4

Pregnant Teen/ Pregnant Adult4

Milk, Yogurt & Cheese
Meat, Poultry, Dry Beans, Eggs, Nuts Group Fruit Group

Breastmilk, every 2-3 hrs or Iron fortified formula, 2.5 oz/lb (18-35 ozs)
None
None

Breastmilk, 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

1 Portion size is reduced by approximately 1/3rd, except for milk 2 Pregnant and breastfeeding teenagers need 4 servings 3 Women 24 years and under need 3 servings 4 Recommended serving sizes: 5 AAP recommends no more than 6 ounces of juice per day
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. american, 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 =
1 egg 1/3 cup nuts 2 cup cooked dry beans 2 tablespoons peanut butter

2 servings (16 ounces total)

2 servings (16 ounces total)

3-4 servings2

3 ounces

5 ounces

2 servings
1 serving = 3T cooked/ pieces 2 fruit 2 c juice5

2 servings

3 servings
1 serving = 3T cooked or chopped 2/3 c raw leafy

3 servings

6 servings
1 serving = 2 slice or 1/4 c cooked 2 c dry cereal

6 servings

As needed to meet RDA for energy

6 ounces 3 servings 4 servings 9 servings

Fruit Group: 1 serving =
1 medium fruit 6 ounces juice 2 cup pieces
Vegetable Group: 1 serving =
2 cup cooked or chopped 1 cup raw leafy
Bread, Cereal, Rice & Pasta Group: 1 serving =
1 slice 1/2 cup cooked cereal, rice or pasta 3/4 cup dry cereal

Breadtfeeding Teen/ Brestfeeding Adult4 3-4 servings2
6 ounces 3 servings
4 servings
11 servings

Teen Postpartum/ Adult Postpartum4 2-3 servings3
5 ounces 2 servings
3 servings
6 servings

CT-154

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:

1. 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. Not offering unflavored water 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 year of age, unless medically indicated. (7)

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

References for Inappropriate Food Practices

CT-155

GA WIC PROCEDURES MANUAL

Attachment CT-33 (cont'd)

(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. Journal of Reproduction Medicine, 33 (12):945-956, 1988.
(6) Martin, T.R., Bracken, M.B.: The Association Between Low Birth Weight and Caffeine Consumption During Pregnancy. American Journal of Epidemiology, 126:813-821, 1987.
(7) Watkinson, B., Fried, 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) United States Department of Agriculture and United States Department of Health and Human Services: Home and Garden Bulletin No. 232, 1985.
(10) United States Department of Agriculture and United States Department of Health and Human Services: Home and & Garden Bulletin No. 232, 1986.
(11) National Academy of Sciences, Institute of Medicine: Nutrition During Lactation. Washington, D.C., 1991.
(12) United States Department of Agriculture and United States Department of Health and Human Services: Home and Garden Bulletin No. 232, 1986.

CT-156

GA WIC PROCEDURES MANUAL

Attachment CT- 34

Georgia WIC Program Referral Form

GEORGIA WIC PROGRAM REFERRAL FORM

"This institution is an equal opportunity provider"

Name: ________________________________________________________ Address: ________________________________________________________
________________________________________________________

Date of Birth:_____________________________________ Telephone Number:________________________________

Date Measurements Obtained:__________________________

Hematological Data Date:_________________________________

Current Height:

_________________________________

Hematocrit:_________________________________

Current Weight: _________________________________

Hemoglobin:_________________________________

Any nutritionally related medical conditions?

Yes

No

If yes, specify:___________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

Any clinical manifestations of malnutrition?

Yes

No

If yes, specify:___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

Any dental problems severe enough to interfere with mastication?

Yes

No

If yes, specify:___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

Any evidence of lead poisoning?

Yes

No

If yes, specify:___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

WOMEN ONLY EDC/Delivery Date:_________________________ Blood Pressure:____________________________ Number of Previous Pregnancies:_________ Live Births:_________

INFANTS ONLY

Breastfeeding:

Yes

No

Birth weight: _____________________________

Weeks Gestation:____________________________

Currently Breastfeeding:

Yes

No

Date Taken:______________________________

Miscarriages, Abortions:________

Pregravid Weight _________________

Birth length:______________________________

HEALTH PROFESSIONAL Signature/Title:_________________________________________________________ Agency Address:_______________________________________________________
_______________________________________________________

Agency Telephone:_________________________

CT-157

GA WIC PROCEDURES MANUAL

Attachment CT- 35

GEORGIA WIC PROGRAM INCOME ELIGIBILITY GUIDELINES (Effective from April 15, 2001 to April 15, 2002) 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

Month

Week

15,892 21,479 27,066 32,653 38,240 43,827 49,414 55,001

1,325 1,790 2,256 2,722 3,187 3,653 4,118 4,584

306 414 521 628 736 843 951 1,058

+5,587

+466

+108

CT-158

GA WIC PROCEDURES MANUAL

Attachment CT- 36

GEORGIA WIC PROGRAM
VOC CARD AGREEMENT
District ______, Unit ______ would like to have a clinic representative order VOC Cards directly from the State WIC Branch.
In order to accommodate this request, the attached form (Attachment CT-37) 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 BRANCH TO INFORM THEM OF THE CHANGE.

CT-159

GA WIC PROCEDURES MANUAL

Attachment CT-37

VOC CARD FORM

District ____, Unit ____

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

1. Please list the information requested below:

CLINIC NAME/#

# OF VOC CARDS ISSUED
(Three Month Period)

STAFF PERSON
Clinic Representative

2. How many cards do you currently have on hand at the District Office? CT-160

GA WIC PROCEDURES MANUAL

Attachment CT-38

CENTRAL SUPPLY REQUISITION

GEORGIA DEPARTMENT OF HUMAN RESOURCES

CENTRAL SUPPLY REQUISITION Suite J
1150 Murphy Avenue, S.W.
Atlanta, Georgia 30310

INVOICE NO. 732229

INVOICE NO. 732229

SEND TO:___________________________________

COUNTY:________________________ ________

Name of Office)

(Name)

(Number)

___________________________________

DATE:

(Name of Division)

___________________________________

ORGANIZATION

(Street Address or State Office Room Number)

CODE:

___________________________________

(City)

(State)

(Zip Code)

DIVISION ID

NUMBER:

_________________________________________________________________________________________________

BO BACKORDER DO NOT REORDER

R REFERRED

L REPRODUCE LOCALLY

EXPLANATION

C QUANTITY CUT/PLEASE REORDER

FILLED

D DISCONTINUED

OF CODES

N NOT STORED IN CENTRAL SUPPLY

VOID, PREVIOUSLY SHIPPED

CHECK ONE:

Office Supply 100000

Form No./Item No. Unit of Quantity Code Issue

Forms Supply
Description

_________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________

FOR _STOCK NO. UNIT OF ISSUE UNIT COST QTY. ORGANIZATIONAL CODE

CODE DESCRIPTION

CENTRAL _1000000450

EA

1

UPS (3-22-475)

SUPPLY 1000000451

EA

1__

Parcel Post __

USE ONLY 1000000452

EA

1___

Freight_______

FOR CENTRAL SUPPLY USE ONLY

ORDERED BY: ___________________________________________________

(Name)

TELEPHONE: ________________ _______ ________________ ______

(Gist No.)

(Area Code) (Phone No.) -

Form 5014 (Rev. 10-88)

SEND ORIGINAL AND TWO COPIES TO CENTRAL SUPPLY TERMINAL COPY

CT-161

GA WIC PROCEDURES MANUAL

Attachment CT-39

GEORGIA DEPARTMENT OF HUMAN RESOURCES
STATE/DISTRICT/CLINIC TRANSMITTAL FORM
The State/District Clinic Transmittal Form is a three (3) part form used to transmit VOC Cards from the State WIC Branch to the Clinic. This Form must be signed by clinic staff within five (5) days of Receipt then returned to sender. The State WIC Branch will forward orders of VOC Cards within five (5) days of receipt.
State Use Only
District Name/ #:_____________________________________________________________
Clinic Name/ #:______________________________________________________________ Staff Name/Title Making Request:_______________________________________________ Date of Request:___________________________ # of Card(s) Sent:____________________
Signature of Requesting State Staff:______________________________________________ Serial # of Card(s) Mailed: ____________________Mailed To:________________________

Clinic Use Only
Date VOC Card(s) Received:___________________________
Date
# of Card(s) Received:_________________________________
Serial # of Card(s) Received: ________________________to:________________________
Signature of Staff Requesting/Receiving VOC Card(s):
____________________________________________
Signature
Date Copy Sent to State/District Office: ___________________________
Date

Form 3699 (12-95)

White Copy - State WIC Branch

Canary Clinic

Pink - District

CT-162

GA WIC PROCEDURES MANUAL

Attachment CT-40

MEDICAID INFORMATION
Right from the Start Medicaid (RSM)
What is Right from the Start Medicaid?
RSM provides Medicaid coverage for pregnant women and children under the age of 19. Income limits are higher than those of Temporary Assistance to Needy Families (TANF) and Medically needy programs. Working families may be eligible even if both parents live in the home or if other insurance coverage is in place.
How do I Apply?
Persons should contact their county Department of Family and Children Services (DFCS) or their county health department. Outreach workers will also take applications at other community locations and will make home visits if necessary. RSM staff members are available during non-traditional hours (before 8 a.m. and after 5 p.m., including weekends) so that work, school, and childcare are not a problem.
For more information on application sites, please contact your local health department or the Right from the Start Medicaid Project office: (404) 657-4085.

CT-163

DHR
Georgia Department of Human Resources

GA WIC PROCEDURES MANUAL

Attachment CT-41

THERE IS NO CHARGE FOR WIC SERVICES

WIC Program

Georgia

Promoting healthy nutrition for Women,

Infants and Children since 1974

1-800-228-9173
AThis is an Equal Opportunity Program. If you believe you have been discriminated against because of
race, color, national origin, sex, age, or handicap, write immediately to the Secretary of Agriculture, Washington, D.C. 20250.@

CT-164

GA WIC PROCEDURES MANUAL
Georgia WIC Program LETTER OF HOUSEHOLD INCOME

Attachment CT-42

Household Section:

I,________________________________________, have the person(s) listed below living with me.
Print Name

Name of WIC Applicant(s): ________________________________

Address: __________________________________

________________________________

__________________________________

Including the applicant(s) listed above, I have___________of people in my family. (AFamily@ means related or non-related individuals living together.)

I give the above listed applicant(s) permission to bring my family's documentation of income (example: pay stub), residency and ID to the Georgia WIC Program. This information is attached.

__________________________________________________________________________________

Signature

Date

Address:_________________________________________

City:_______________________________State:_________________Zip Code:________________

Telephone No.:_______________________________

Clinic Section:

This form must be returned on_____________________to_______________________________

______________________________________________________________________________________

WIC Official

Date

_______________________________________________________________________________

WIC Official

Date Received

WE RESERVE THE RIGHT TO VERIFY THIS INFORMATION, IF NECESSARY. "This institution is an equal opportunity provider."

CT-165

GA WIC PROCEDURES MANUAL

Attachment CT-43

GEORGIA WIC PROGRAM NO PROOF FORM

The Georgia WIC Program requires each applicant to show documentation of identification, residence (address), and income to be eligible for the WIC Program. This form is to be completed by those who can not get documentation, such as paycheck stub. Please read the following statement before completing this form.

I understand that by completing, signing, and dating this form, I am certifying that the information I am providing below is correct. I understand that intentional misrepresentation may result in paying the state agency, in cash, the value of the food benefits improperly received.

1. Completion of this form is for:Income Address (circle the appropriate proof (s))

Identification

2. Who do you work for?

How much did you make last month?

_____________________________________

$_______________________________

List working family members:

How much did they make last month?

______________________________________ $_______________________________

______________________________________ $_______________________________

______________________________________ $_______________________________
(Family means related or non-related individuals living together)

3. Reason for No Documentation: ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________

List family members applying for WIC: _________________________________________

_________________________________________

____________________________________ (Signature of Applicant)

___________________________ (Date)

____________________________________ (Signature of Clinic Staff)

__________________________ (Date)

"This institution is an equal opportunity provider."

CT-166

GA WIC PROCEDURES MANUAL
FAMILY PLUS MEDICAID CARD

Attachment CT-44

BENEFIT DESCRIPTION

CO-PAY

FamilyPlus*

COPAYS

RX USE ONLY

------------------- ---------------------------

OV $0

| BIN # 600426

SP $0

| PCN #6F

ER $0

| 1 (800) 433-4893

UC $0

|

TIE

RX $0

|

AFD

|

*CALL YOUR PCP TO COORDINATE *ALL OF YOUR HEALTHCARE NEED

MEMBER # 403967045P

EFF DATE 02/01/98

GROUP# M00101 BIRTH

SEX

MEDICAID OF GA 06/03/94

F

(404) 525-0600

*ATLANTA CHILDREN=S HEALTH NETWORK *The family of health plans that fits.

CT-167

GA WIC PROCEDURES MANUAL

Attachment CT-45

HEALTH DEPARTMENT/CLINIC REPORT FORM

Employees/Staff who participate in the WIC Program or have relatives or household members who participate in the WIC Program must complete this form.

County_______________________

Name (Please print)___________________________, Title_______________________

Are you a WIC Participant?________Yes

________No

Do any of the following relatives or household members participate in the WIC Program?

Children, grandchildren, sisters, brothers, nieces, nephews, aunts, uncles, parents, spouses, first cousins, in-laws or any person who lives in your household.

_________Yes

__________No

If you answered AYes@ to either of the above questions, please complete the form below.

Name of your relative or household member Relationship* Date of Cert.

(If more space is needed, list on back)
* Children, grandchildren, sisters, brothers, nieces, nephews, aunts, uncles, parents, spouses, first cousins, in-laws or any person who lives in your household.
I Certify that the above information is correct.

_______________________________________
Signature/Title

_______________________
Date

CT-168

GA WIC PROCEDURES MANUAL

Attachment CT-46

GEORGIA WIC PROGRAM INCOME CALCULATION FORM
(This form must be completed if applicant does not qualify for Adjunctive eligibility)
WIC ID NUMBER: _____________________________________

Last

First

Middle Initial

Date of Birth

NAME ___________________________________________________________________________________________________________

City

Zip Code

ADDRESS__________________________________________________________________________________________________________

Documentation of Income must be completed for an applicant who does not qualify for adjunctive eligibility.

First Certification
Relationship and Name
__________________________ __________________________ __________________________ __________________________ __________________________

Use This Section to Calculate Income

Date_______________________

Income

Source

What Is Each Family Member's Income?

(circle one)

__________ $______________________ Weekly/Bi-Weekly/Monthly/Yearly

__________ $______________________ Weekly/Bi-Weekly/Monthly/Yearly

__________ $______________________ Weekly/Bi-Weekly/Monthly/Yearly

__________ $______________________ Weekly/Bi-Weekly/Monthly/Yearly

__________ $______________________ Weekly/Bi-Weekly/Monthly/Yearly

Other Income Is there other regular income or contributions received by the family (i.e., unemployment, child support)?

__________________________ __________ $______________________ Weekly/Bi-Weekly/Monthly/Yearly __________________________ __________ $______________________ Weekly/Bi-Weekly/Monthly/Yearly

$________________Total Applicant's Income (Weekly/Bi-Weekly/Monthly/Yearly)

No. In Family_____

IS THE CLIENT INCOME ELIGIBLE? YES

NO

(Transfer total to the Certification Form)

First Certification
Relationship and Name
__________________________ __________________________ __________________________ __________________________ __________________________

Use This Section to Calculate Income

Date_______________________

Income

Source

What Is Each Family Member's Income?

(circle one)

__________ $______________________ Weekly/Bi-Weekly/Monthly/Yearly

__________ $______________________ Weekly/Bi-Weekly/Monthly/Yearly

__________ $______________________ Weekly/Bi-Weekly/Monthly/Yearly

__________ $______________________ Weekly/Bi-Weekly/Monthly/Yearly

__________ $______________________ Weekly/Bi-Weekly/Monthly/Yearly

Other Income Is there other regular income or contributions received by the family (i.e., unemployment, child support)?

__________________________ __________ $______________________ Weekly/Bi-Weekly/Monthly/Yearly __________________________ __________ $______________________ Weekly/Bi-Weekly/Monthly/Yearly

$________________Total Applicant's Income (Weekly/Bi-Weekly/Monthly/Yearly)

No. In Family_____

IS THE CLIENT INCOME ELIGIBLE? YES

NO

(Transfer total to the Certification Form)

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 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 statement or intentionally misrepresenting, concealing, or withholding facts may result in paying the State agency, in cash, the value of the food benefits improperly issued to me and may subject me to civil or criminal prosecution under State and Federal law. I understand that the WIC Program may give my certification information to other health or public assistance agencies to see if my family is eligible for their services. I understand that these agencies may contact me, but they may not give my information to anyone else without asking my permission.

PARENT/GUARDIAN/CARETAKER SIGNATURE

DATE

SIGNATURE OF WIC OFFICIAL (Who assessed income)

Please place this form in the Client's Medical Record behind the Certification Form

CT-169

GA WIC PROCEDURES MANUAL

Attachment CT-47

IDENTIFICATION, RESIDENCY & INCOME PROOF LIST

Help WIC help you!

Every time you are certified for WIC, you must show proof from each category below:

PROOF OF IDENTIFICATION

Birth Certificate/Confirmation of Birth Letter

Social Security Card

Driver's License

State ID/School ID

Hospital ID Bracelet (Mom & Baby)

VOC Card (with Additional ID)

Immunization Record

Voter Registration Card

Military ID

WIC ID (Voucher Pick Up Only)

Health Record

Work ID

Cable TV Bill Electric Bill Gas Bill Medicaid Card

PROOF OF RESIDENCY (ADDRESS) (One form of proof required) Health Record Rent/Mortgage Receipt Telephone Bill Water Bill
*P.O. Box numbers are not acceptable

PROOF OF INCOME

(Bring proof of income for each household member)

Alimony

Net Royalties

Annuities

Pay Stub

Basic Allowance from Subsistence

Pensions

Child Support Payments

Private Pensions

Contribution from People

Public Assistance/Welfare

Current Medicaid Card

Payments (TANF)

Current Tax Return Form

Rental Income (Net)

Dividends or Interest on Bonds

Self Employment (Net Income)

Estate Income

Social Security

Financial Records

Supplemental Social Security

Food Stamps Documentation

Trust

Government Retirement

Unemployment Compensation

Letter from Your Employer

Unemployment Notice

Military Retirement

Veteran's Payment

Monetary Compensation

Proof of ID, residency and income is needed for each applicant/participant, parent/guardian/ caretaker and infant/child. If you arrive at the WIC Office without this information, you may be rescheduled. Please call your local Health Department if you have any questions.

"This institution is an equal opportunity provider."

CT-170

GA WIC PROCEDURES MANUAL

Attachment CT-48

GEORGIA WIC PROGRAM

Thirty (30) Day Certification/Termination Form

This Thirty (30) Day Certification Form allows you to be on the Georgia WIC Program for thirty (30) days only. The certification period will be extended if the required documentation is brought back to the clinic within 30 days and eligibility is confirmed.

DATE_________________________

NAME:

DATE OF BIRTH:

ADDRESS: CITY/ZIPCODE:

PHONE NUMBER:

____You will be terminated from the WIC Program if you failed to bring in the following information by______________.
(date) Proof of: _____ Family Income or _____Medicaid, TANF or Food Stamp Documentation (check one)

_____Identification

________Residency

WIC Representative

Date

FAILURE TO BRING THIS DOCUMENTATION TO THE HEALTH DEPARTMENT ON OR BEFORE THE ABOVE DATE WILL RESULT IN TERMINATION FROM THE WIC PROGRAM
_____You are being terminated from the WIC Program because you have been found to be over WIC's income limit.
WIC Representative_____________________________________Date_____________________

FAIR HEARING SECTION:

You have the right to a fair hearing if you do not agree with the reason for your termination. A request for a fair hearing must be made within 60 days of the date of this notice. Fair hearing requests should be addressed to:

_______________________________________________

WIC Program

_______________________________________________

Address

_______________________________________________

City/Zip Code

Phone Number

____________________________________ Participant Signature/Parent/Caretaker/Guardian

_________________________________________ WIC Representative Signature/Title

"This institution is an equal opportunity provider"

CT-171

GA WIC PROCEDURES MANUAL

Attachment CT-49

Session Date:

Participant's Name:
Department of Defense WIC Overseas Program Participant Profile Report/Verification of Certification Card (VOC)

Address 1:

Gender:

DOB:

Marital:

Participant ID:

Spouse/Parent Guardian Name:

Address 1:

Annual Income:

Sponsor Name:

Sponsor Address 1:

Relationship:

Authorized Proxy:

Encounter Type:

Height:

Weight: BMI:

Nutrition Risks:

Nutrition Education:

Food Prescription ID:

FI One: xxxxxxxxxxxxxxxxxxxx Xxxxxxxxxxxxxxxxxxxx Xxxxxxxxxxxxxxxxxxxxx

Address 2: Education: Unit Phone #: Language:
Address 2: Primary Source:
Sponsor Address 2: UIC:
WIC Site ID: Hematocrit: Priority: Date Provided:
FI Two: xxxxxxxxxxxxxxxxxxx Xxxxxxxxxxxxxxxxxxxx Xxxxxxxxxxxxxxxxxxxx

Participant Type: Category: Home Phone: Race/Ethnic: Home Phone: Unit Phone: Econ. Unit: Home Phone #: Unit Phone #: DEROS:
Begin Cert Date: End Cert Date: Date of Measurement: EDD: Health Care Source:
FI Three: xxxxxxxxxxxxxxxxxxx Xxxxxxxxxxxxxxxxxxx Xxxxxxxxxxxxxxxxxxx

Food Instrument Issued for Dates:

Participant Rights and Obligations:
I have been advised of my rights and obligations under the program. I certify that the information I have provided for my eligibility determination is correct, to the best of my knowledge. I understand I have a right to appeal any decision which I am aggrieved. This certification form is being submitted in connection with the receipt of Federal funds. 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 hereby certify that I am not currently enrolled in any other WICO or WIC Program. I understand that to do so would be deliberate misuse of program benefits and could result in the loss of these benefits.

Participant or Parent/Guardian Signature:

Date:

Competent Professional Authority:

Print Name:

CT-172

GA WIC PROCEDURES MANUAL

Attachment CT-50

WIC OVERSEAS PROGRAM CONTACTS (as of April 2001)

Lakenheath, England -- Nancy Czarzasty nancy.czarzasty@lakenheath.af.mil

Yokosuka, Japan

-- Yokosuka Naval Hospital, Honshu, Japan --- Gina Gagui gaguig@nhyoko.med.navy.mil

Baumholder, Germany -- LTC Barbara Fretwell barbara.fretwell@cmtymzil.104asg.army.mil

-- Kadena Air Force Base Theresa Reiter theresa.reiter@kadena.af.mil

-- Camp Foster --- Emily Bartz okibartz@konnect.net

-- Camp Courtney --- Theresa Reiter wicoc@mcbbutler.usmc.mil

-- Camp Kinser --- Emily Bartz okibartz@konnect.net

Guantanamo Bay, Cuba -- Dana T. Martin dtmartin@gtmo.med.navy.mil

For further questions regarding a WIC Overseas Program contact and/or email address, please visit DoD/Tricare's Web Site at http://www.tricare.osd.mil for updated information or contact:
Choctaw Management/Services Enterprise 2161 NW Military Drive, Suite 308 San Antonio, Texas 78213 Phone: 1-877-267-3728 (toll-free number) Fax: 210-341-3455 Email: jbrewer@cmse.net

CT-173

GA WIC PROCEDURES MANUAL

Attachment CT-51

PROOF OF RESIDENCY FORM FOR APPLICANTS WITH P.O. BOX ADDRESS
The WIC applicant must complete this form when giving a post office box address:
Directions to House

Participant Signature Participant Signature Participant Signature

Date Date Date

This form must be filed in the applicant/participant's health record.

CT-174

GA WIC PROCEDURES MANUAL INCOME VERIFICATION LETTER

Attachment CT-52

Date
Ms. Jane Doe 111 5th Street Mercer, Georgia 33333
Dear Ms. Doe:
It has been brought to the attention of the Georgia WIC Program that the income reported in the clinic may not be accurate. In order to qualify for the Georgia WIC Program, you must meet the income guidelines of the program.
Please bring in proof of family income on your next clinic appointment on ___________ at _____a.m./p.m. At that time, you may bring either a copy of your most recent pay stub, a letter from your employer verifying your current wages, a copy of your most recent federal tax return, or a verification letter from the local welfare office. Failure to do so will result in termination from the program, an investigation and may require you to pay the State Agency in cash the value of the benefits improperly issued to you or your family member(s).
Sincerely,

__________________ Title
c:

CT-175

GA WIC PROCEDURES MANUAL

TABLE OF CONTENTS

Page

I.

Rights and Obligations of WIC Applicants/Participants ..................................RO-1

II.

Nondiscrimination Clause.................................................................................RO-2

III.

Public Notification............................................................................................RO-3

IV.

Civil Rights .......................................................................................................RO-3

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

B. Training.................................................................................................RO-4

C. Racial/Ethnic, Migrant/Homeless Identification ..................................RO-4

D. Collection of Racial/Ethnic Data ..........................................................RO-4

E. Discrimination Complaints ...................................................................RO-4

1. Written Complaints.........................................................................RO-5

2. Verbal Complaints ..........................................................................RO-5

V.

Fair Hearing Procedures - Participants .............................................................RO-5

A. Hearing Official ....................................................................................RO-6

B. Request (s) for Hearing ......................................................RO-7

C. Claimant's WIC Program Record Summary Form..................... RO-7

D. Case Record Disclosure Prior to the Hearing..............................RO-8

E. Adjusting Complaints.........................................................RO-8

F. Continuation of Benefits.....................................................RO-8

G. Denial or Dismissal of a Request for a Hearing...........................RO-9

H. Notification of the Hearing..................................................RO-9

GA WIC PROCEDURES MANUAL

Page I. Conduct of the Hearing and the Claimant's Right.......................RO-10

J. Attendance at the Hearing...................................................................RO-10

K. The Hearing Record............................................................................RO-10

L. The Hearing Decision .........................................................................RO-11

M. Notification of the Hearing Decision......................................RO-11

N. Appeal Rights of the Claimant............................................................RO-11

O. State Rules of Procedure.....................................................................RO-12

P. Participant Complaint .........................................................................RO-12

VI.

Fair Hearing Procedures - Migrants................................................................RO-12

VII.

Administrative Appeals - Local Agency ........................................................RO-12

VIII.

Availability of Hearing Records .....................................................................RO-13

IX.

National Voter Registration Act .....................................................................RO-13

Attachments:

RO-1 Rights and Obligations................................................................................................RO-14

RO-2 Claimants WIC Program Record Summary................................................................RO-16

GA WIC PROCEDURES MANUAL
I. RIGHTS AND OBLIGATIONS OF WIC APPLICANTS/PARTICIPANTS
WIC applicants/participants are entitled to certain rights including, but not limited to, protection against discrimination and the right to a fair hearing when benefits are denied. WIC applicants/participants are obligated to provide true information and follow program requirements.
At each certification, the participant or parent/caretaker/guardian must sign the certification statement on the WIC Assessment Certification Form. Prior to this signature, the applicant must read (or have read to them) the certification statement on the WIC Assessment Certification Form. See the statement below:
I have been advised of my rights and obligations under the Program. I certify that the information I will provide, or have provided, is correct to the best of my knowledge. The income that 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 my paying the State agency, in cash, the value of the food benefit improperly issued to me and may subject me to civil or criminal prosecution under State and Federal law. I authorize the WIC Program to share my certification information with other health care and/or public assistance programs to see if my family is eligible for their services. I understand that other agencies may contact me, but they may not share my certification information with any person or agency without asking my permission.
After signing the certification, the participant must receive an explanation of the following:
1. Reason for Certification 2. Benefits of Program. 3. Reasons for Ineligibility. 4. Items that can/can not be purchased.
In addition to the rights and obligations stated on the I.D. Card, the applicant/participant also must not be charged for any WIC service (i.e. copying of WIC records). Local agencies may use their administrative funds to reimburse WIC Service delivery agencies for authorized services provided to applicants/participants.
Each participant on the WIC Program is entitled to be treated with courtesy while in either the health department or grocery store. A WIC participant must never be singled out in a grocery store by the use of intercom systems or coding systems that would draw attention to the fact that they are WIC participants. The use of intercom systems or coding systems in this manner is discriminatory.
RO - 1

GA WIC PROCEDURES MANUAL
The Program Management and Review Unit and/or the Vendor Management Unit will handle this type of discrimination, when reported to the State WIC Branch.
The section, Special Populations (SP), outlines procedures for insuring program participation for non-English speaking populations, refugees, migrant farm workers, homeless, and Native Americans.
Persons with disabilities must be treated the same as all other applicants/participants. WIC Program services must be accessible without hardship to disabled applicants and participants, and applicants must not be discriminated against because of lifestyle choices (i.e. dress, automobile, jewelry, personal relationships and cultural differences).
II. NONDISCRIMINATION CLAUSE
WIC State agencies are required to implement a public notification period to inform participants/applicants of their rights and responsibilities, their protection against discrimination, and the procedures for filing a complaint. Therefore, any materials that provide information about WIC Program benefits and eligibility, regardless of the intent, design, or source, must contain the nondiscrimination statement. These materials include brochures, posters, visuals, and any other literature produced by vendors, or other interested parties. Examples of materials that are required:
1. Notices of warning or adverse action to applicants/participants, local agencies, vendors, and employees or employment applicants. This includes items such as notices of ineligibility or disqualification, fair hearing procedures, and cards or letters for missed appointments.
2. All outreach and referral materials.
3. Participant Identification (ID) Folder, or food lists for participants and vendors that describe the WIC Program's participation requirements and benefits.
4. Letters of invitation to participate in the public comment process that are sent to vendors, health department staff, and advocates, organizations and other interested parties, and media announcements of the public hearing.
5. Newsletters that convey WIC benefits and participation requirements.
The current nondiscrimination statement is:
In accordance with Federal Law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, age, sex or disability.
RO - 2

GA WIC PROCEDURES MANUAL
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.
"This institution is an equal opportunity provider."
The new statement should be used immediately in all publications. The new USDA "And Justice for All" poster should be used as soon as supplies are available.
The nondiscrimination statement is not required on items like cups, buttons, magnets, and pens that identify the WIC Program. In addition, the nondiscrimination statement does not have to be read on radio and television public service announcements. Instead, a statement such as "This institution is an equal opportunity provider" is sufficient to meet the nondiscrimination requirement. Finally, promotion and nutrition education materials that solely provide a nutrition message, without mentioning the program, are not required to contain the nondiscrimination statement.
III. PUBLIC NOTIFICATION
When WIC Program Coordinators give interviews to the local media, the nondiscrimination statement should be included in verbal statements and on written documents. Any public or media discussions of WIC by local program staff should be documented for review by the state agency monitoring staff. The Office of Communications of Georgia Department of Human Resources prepares a news release annually to publicize the availability of WIC benefits. The news release is distributed to newspapers statewide.
WIC Program regulations and guidelines must be made available to the public on request. These documents include WIC components of the Federal Register, the Georgia WIC Program State Plan, and the Georgia WIC Program Procedures Manual. Income Guidelines are parts of the Procedures Manual and must be given to the public upon request.
IV. CIVIL RIGHTS
A. "--And Justice for All"
The "--And Justice for All" poster must be displayed in a conspicuous location in each WIC clinic. The poster is available in English and Spanish and may be ordered from the State WIC Branch.
RO - 3

GA WIC PROCEDURES MANUAL
B. Training
Civil rights training must be provided for all staff that has contact with WIC applicants/participants. This training must be provided to State and District staff annually. New staff must be trained in Civil Rights prior to working clinics. A list of participants and an agenda for each training must be documented and kept on file for three (3) years plus the current year.
Note: When conducting any training, it is required that District/Clinic and State Staff ask if anyone needs any special accommodations.
C. Racial/Ethnic, Migrant/Homeless Identification
Each applicant/participant must be identified by race or ethnic group and as a migrant or a homeless person. In order to do this, local agency staff must:
1. Request that the applicant make a self-identification. When self-identification is made, the interviewer should make it clear to the applicant that the information is for statistical use only and that no other use will be made of the information.
2. Accept race information that is provided by the applicant. WIC staff must not dispute an applicant/participant's statement of his/her race.
D. Collection of Racial/Ethnic Data
Collection and reporting of racial and ethnic participation data is a requirement of Title VI of Civil Rights Act of 1964. The "Ethnic Participation Summary Report" provides information on client participation by ethnic status and priority. The report records data by local clinic and summarizes the data by district/unit and state. This report should be reviewed and maintained in district/unit files. Data must be maintained under safeguard, which will restrict access to authorized personnel and maintained for four (4) years. The Georgia WIC Program must not allow any coding system on the outside of medical records, tickler cards, appointment or any related WIC document which can openly distinguish applicants/participants by race, color, national origin, sex, age, and disability.
E. Discrimination Complaints
All discrimination complaints, written or verbal, must be filed within one hundred and eighty (180) days of the alleged discriminatory action. No applicant/participant should be discouraged from filing a complaint directly with USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 1400 Independence Avenue, SW, Washington, DC 20250-9410 or call (202) 720-5964 (voice and TDD) if he/she feels discrimination has occurred. A copy of the complaint must be sent to the State WIC Branch, 2 Peachtree Street, Suite 10-394, Atlanta, Georgia 30303.
RO - 4

GA WIC PROCEDURES MANUAL
1. Written Complaints
Persons seeking to file discrimination complaints may file their complaint at the same address. A copy must be sent to the State WIC Branch. The Food Nutrition Service (FNS) must receive all complaints no later than ten (10) days from the initial receipt of the complaint. The State WIC Branch will send a copy of the discrimination complaint to the USDA Regional Office.
Complaints should include the name of the agency and/or individual to whom the complaint addresses and a description of the alleged violation. Anonymous complaints will be handled in the same manner as any other complaint.
2. Verbal Complaints
In the event a complainant makes verbal allegations and refuses, to place such allegations in writing, the person to whom the allegations are made will write up the elements of the complaint for the complainant. Every effort will be made to have the complainant provide the following information:
a. Name, address and telephone number of the complainant.
b. The specific location and name of the local agency, and person delivering WIC services.
c. The nature of the incident or action that led the complaint.
d. The basis on which the complainant feels discrimination exists (e.g. race, color, national origin, sex, age, or disability).
e. The names, titles, and addresses of persons who may have knowledge of the discriminatory action.
f. The date(s) during which the alleged discriminatory action occurred.
V. FAIR HEARING PROCEDURES - PARTICIPANTS
WIC Federal Regulations require the State agency to establish a hearing procedure under which a person, or his/her guardian, will be guaranteed the right to appeal a decision or action by the State or local agency which results in the individual's denial of participation, suspension, or termination from the program. The participant must be informed in writing of his/her right to a fair hearing and of the method by which a hearing may be requested.
RO - 5

GA WIC PROCEDURES MANUAL
In the event of denial of benefits followed by a request for a fair hearing, the following should be discussed with the participant:
1. Limited funding of program. 2. The Priority System. 3. Waiting List. 4. Reasons for the denial of benefits or termination from the program.
At the time of Fair Hearing request, the WIC Coordinator will need to conduct a preliminary conference with the applicant. This conference may resolve the issues, particularly when the individual may misunderstand a program policy or not be aware that certain procedures are required by regulations. The State Agency must also conduct a preliminary conference with the applicant/participant prior to the actual hearing. In the event a Fair Hearing is still requested, the State Agency will try when possible to hold group- hearing procedures on the same day. The applicant could receive information on fair hearing procedures, and their rights and responsibilities concerning the hearing process. Included will be the role of the Administrative Law Judge, the time frame for final decisions and any other pertinent information. Cases can then be heard on an individual basis with the specifics of each case being separately discussed.
In the event a participant requests a fair hearing, all benefits remain in force until a final decision has been rendered.
The following is the Georgia WIC Fair Hearing Procedure:
A. Hearing Official
The Office of State and Administrative Hearings (OSAH) is responsible for action on each fair hearing request. OSAH, an impartial party, is vested with full authority in conducting the hearing process. This includes the conduct of hearings, keeping all files and records, and furnishing information for proper reports. OSAH is fully responsible for conducting hearings properly and promptly in accordance with the rules and regulations established by the State. OSAH shall have the authority to do the following:
1. Administer oaths or affirmations;
2. Request, receive, and make a part of the hearing record all evidence determined necessary to decide the issues being raised;
3. Regulate the conduct in the course of the hearing consistent with due process to insure an orderly hearing; and
4. Render a hearing decision based exclusively on the hearing record and matters officially noticed.
RO - 6

GA WIC PROCEDURES MANUAL
B. Request(s) for Hearing
A request for hearing is defined as any clear expression by the individual or the individual's parent/guardian/caretaker or other representative, that an opportunity to present his/her case to a higher authority is desired. The State and local agency shall not limit or interfere with the individual's freedom to request a hearing.
The participant must request the hearing within sixty (60) days from the date the local agency issues the notice of adverse action to deny, suspend, or terminate benefits. Fair hearing requests shall be submitted to the DHR Legal Services Office (LSO), 29th Floor, 2 Peachtree Street, Atlanta, Georgia 30303.
A hearing request shall be effective upon receipt of a verbal or written request. A verbal request received within the sixty (60) days shall be accepted. The forty-five (45) day period allowed for rendering a hearing decision shall begin on the day the fair hearing request is received by the local agency.
Upon request, the local agency shall assist the claimant in submitting a request for a fair hearing. The claimant shall be advised by the local agency of any legal services available that can provide representation at the hearing.
C. Claimant's WIC Program Record Summary Form
The local agency shall prepare the Claimant's WIC Program Record Summary Form (Attachment RO-2). Within three (3) working days, the completed form and written request shall be submitted to the DHR Legal Services Office (LSO), 2 Peachtree Street, Atlanta, GA 30303. A copy of the form shall be sent to the State WIC Branch If the hearing request is filed initially with the DHR LSO, a copy will be immediately forwarded to the local agency.
The local agency has the responsibility of maintaining contact with the claimant and must report promptly to the LSO any change in circumstances, including changes in mailing address. As soon as the local agency receives notification that a hearing has been scheduled, the local agency WIC Program Coordinator shall immediately review the record to:
1. Re-examine the action of the local agency and the circumstances of the claimant to determine if an adjustment can be made.
2. Review claimant eligibility on all points other than the point at issue. All hearing requests, whether timely or not, must be submitted to the LSO. The local agency will secure any additional evidence necessary for the hearing.
RO - 7

GA WIC PROCEDURES MANUAL
D. Case Record Disclosure Prior to the Hearing
All documents and records to be used in the hearing will be available for examination by the claimant and/or his/her designated representative prior to the fair hearing. Such examination shall be made at the local agency. "Designated representative" is understood to mean an attorney, friend, or personal counselor of the claimant. Upon request, the local agency shall make available, without charge, the specific materials necessary for a claimant or his/her representative to determine whether a hearing should be requested or to prepare for a hearing. The claimant and/or his/her representative will be given an opportunity to copy any materials in the file, which are relevant to the appeal. Confidential materials, which cannot be released to the claimant or his/her representative, shall be removed from the file prior to such copying and will not be used at the hearing. When local agency reproduction equipment and supplies are available, the agency staff will operate the equipment. When reproduction equipment is not available, the claimant or his/her representative may make longhand notes.
E. Adjusting Complaints
The local agency has the responsibility of taking proper action in adjusting all complaints. If an applicant/participant is dissatisfied, the local agency shall review their status with them. If the claimant so desires, the local agency shall assist him/her in filing the hearing request and preparing for the hearing. If the local agency and the claimant arrive at a mutually satisfactory decision prior to the hearing, the claimant may withdraw his/her request for the hearing in accordance with the withdrawal procedures. The local agency may amend or reverse its decision at any time prior to a hearing, regardless of the claimant's decision on withdrawal. In the case of withdrawal, amendment, or reversal, the local agency shall notify the LSO immediately, attaching a copy of the withdrawal or new notification and a summary supporting the corrective action taken by the local agency. If time does not permit written notification, the LSO shall be notified verbally with immediate follow-up in writing.
F. Continuation of Benefits
Participants who appeal the termination of benefits within fifteen (15) days from date of notification shall continue to receive program benefits until the final administrative decision.
Applicants who are denied benefits at initial certification or at subsequent certifications may appeal the denial, but shall not receive benefits while awaiting the hearing.
The local agency shall promptly inform the individual, in writing, if participation status changed, pending the hearing decision.
RO - 8

GA WIC PROCEDURES MANUAL
G. Denial or Dismissal of a Request for a Hearing by LSO or OSAH
A Request for a hearing shall not be denied or dismissed unless:
1. The request for hearing is not received within the sixty-(60) day time limit.
2. The request is withdrawn in writing by the appellant or a representative.
3. The appellant or representative fails, without good cause, to appear at the scheduling hearing.
4. The appellant has been denied participation by a previous hearing and cannot provide evidence that circumstances relevant to program eligibility have changed in such a way as to justify a hearing.
H. Notification of the Hearing
The hearing shall be conducted within twenty-one (21) days from the date the State received the hearing request. A time and place shall be arranged in order for the hearing to be accessible to the participant/designated representative.
At least ten (10) days prior to the hearing, the Office of State and Administrative Hearings shall provide written notice to all parties involved to permit adequate preparation of the case. The notice shall contain the following:
1. A statement of the time, place, and nature of the hearing.
2. A statement of the legal authority and jurisdiction under which the hearing is to be held.
3. A reference to the statutes and regulations involved.
4. A short statement of the complaint. If the agency or other party is unable to state the complaint in detail, the notice may be limited to a statement of the issues involved.
5. A statement that the State will dismiss the hearing request if the individual or his/her representative fails to appear at the hearing without good cause.
6. A statement that the participant/designated representative may examine the case files prior to the hearing.
The Administrative Law Judge may change the time and place of the hearing upon his own motion or that by the parties. The Administrative Law Judge may adjourn, postpone, or reopen the hearing upon receipt of additional information at any time prior to mailing the hearing decision.
RO - 9

GA WIC PROCEDURES MANUAL
Should the Administrative Law Judge exercise the option of rescheduling the hearing, the claimant shall be given at least ten 10 days advance notice of such action.
I. Conduct of the Hearing and the Claimant's Rights
If, at the hearing, it becomes evident that the issue involved is different from the one on which the hearing was requested, the Administrative Law Judge shall exercise discretion and may conduct the hearing on the newly emerged issue. In such instances, the hearing may be continued so all concerned may prepare additional evidence.
The claimant/designated representative shall be provided with an opportunity to:
1. Bring witnesses; 2. Advance arguments without undue interference; 3. Question or refute any testimony or evidence, including an opportunity to
confront and cross-examine adverse witnesses; 4. Submit evidence to establish all pertinent facts and circumstances in the case.
The local agency shall have the same opportunities listed above.
J. Attendance at the Hearing
The Administrative hearing shall be attended by a representative of the agency that initiated the action being contested and may be attended by the individual and/or his/her representative. Other local agency staff may attend and participate in the hearing process at the discretion of the Administrative Law Judge. Friends and relatives of the claimant may also attend the hearing if the claimant so chooses.
K. The Hearing Record
The Administrative Law Judge shall compile the official hearing record that covers all points of eligibility dealing with the issues directly related to the action being appealed. The record shall include:
1. All pleadings, motions, and intermediate rulings.
2. A summary of the oral testimony and all other evidence received or considered, except that oral proceedings, and any part thereof, shall be transcribed or recorded upon request. Upon written request, a transcript or tape of such oral proceedings, or any part thereof, shall be furnished to any party to the proceedings.
RO - 10

GA WIC PROCEDURES MANUAL
3. A statement of matters officially noted. 4. Questions of matters officially noted. 5. The decision by the Hearing Officer.
6. All staff memoranda and dates submitted to the Hearing Officer in connection with the case.
L. The Hearing Decision
Decisions of the Administrative Law Judge shall comply with State and Federal law, rules, regulations and policy and shall be based on the hearing record. The Administrative Law Judge's decision shall take into consideration only those issues directly related to the action being appealed and shall be based exclusively on evidence and other material introduced at the hearing. A decision by the Administrative Law Judge shall be binding on the local agency and shall summarize the facts of the case, specify the reasons for the decision, and identify the supporting evidence and the pertinent regulation(s) or policy. The decision shall become a part of the record.
M. Notification of the Hearing Decision
Within forty-five (45) days of the receipt of the request for a hearing, the claimant and/or his/her representative shall be notified in writing of the decision. If the decision is in favor of the claimant and participation was denied or discontinued, benefits shall begin immediately.
If the decision is in favor of the agency, as soon as administratively feasible, any continued benefits shall be terminated as decided by the Administrative Law Judge and efforts will be made to collect the claims.
In addition, the decision will inform the claimant of any right to appeal known to the Administrative Law Judge and shall advise that an appeal request may result in a reversal of the decision.
N. Appeal Rights of the Claimant
When a decision is adverse to the claimant, he/she has the right to appeal to a DHR Appeal Reviewer. The DHR Appeal Reviewer shall allow the claimant thirty (30) days to request review of the decision. The DHR Appeal Reviewer shall have all the powers and delegated authority of the Commissioner to make a decision. He/she may take additional testimony or remand the case to the Administrative Law Judge for such purpose. The decision will be based upon the record from the original hearing as presented before the Appeal Reviewer and shall either affirm, reverse, or modify the original decision to assure full compliance with State and Federal law, rules, regulations, and policy.
RO - 11

GA WIC PROCEDURES MANUAL
If the claimant requests review of the Administrative Law Judge's decision, the usual standard of promptness is automatically waived. The claimant and his/her legal representative shall be notified, in writing, of the decision of the Appeal Reviewer and of his/her right to judicial review. If the claimant is dissatisfied with the decision of the Appeal Reviewer, he/she has the right to pursue judicial review (e.g., civil court).
O. State Rules of Procedure
The State agency shall provide and distribute upon request, to any interested party, that portion of the Georgia WIC Program Procedures Manual that outlines the Fair Hearing Procedures.
P. Participant Complaint
The WIC participant may file a complaint (written or oral) regarding staff or clinic treatment (unrelated to discrimination or ineligibility/disqualification decision). Documentation of this complaint may be written on the Incident/Complaint Form.
VI. FAIR HEARING PROCEDURES - MIGRANTS
Because migrant farm workers and their families may leave a program area after a very short time, it is important that fair hearing procedures for migrants be expedited, by contacting them immediately for the hearing process. When a local agency receives a fair hearing request from a migrant, they should attempt to find out how long the migrant will be in the program area and should convey this information to the DHR Legal Services Office and State WIC Branch.
VII. ADMINISTRATIVE APPEALS PARTICIPANT - LOCAL AGENCY
The applicant/participant may appeal a local agency decision when an application to participate in the WIC Program is denied or terminated, or when a decision is made which adversely affects the local agency's participation in the program, such as a reduction in food or administrative funds.
The local agency must request a hearing for a participant from the State agency within thirty (30) days after the action, which is being appealed, was taken. The hearing must be scheduled no later than thirty (30) days after the request for hearing is received by the State agency, with the local agency being given fifteen (15) days advance notice of the time and place of the hearing. The proposed adverse action must be postponed from the time a hearing is requested until a decision is reached. Upon request, the local agency may reschedule a hearing date one (1) time. Sixty (60) days advance notice must be provided to a local agency before disqualification from Program participation.
RO - 12

GA WIC PROCEDURES MANUAL The local agency will have ample opportunity to present its case at the hearing, including the opportunity to confront and cross-examine adverse witnesses. Counsel may represent the local agency, if desired. The local agency may review the case file prior to the hearing. In the event of a hearing, an administrative hearing panel will be appointed by the Director of the WIC Branch to hear local agency appeals. This panel will consist of one (1) local agency WIC Program Coordinator and two (2) representatives from the Division of Public Health. This panel will be an impartial decision maker with no personal interest or involvement in the outcome of the hearing or the statutory and regulatory provisions governing the program. The basis of the decision shall be stated in writing, though it need not amount to a full opinion or contain formal findings of fact and conclusions of law. The local agency will be notified of the decision within sixty (60) days from the date of the request. If a State decision is rendered against the local agency, the local agency may pursue judicial review of the decision.
VIII. AVAILABILITY OF HEARING RECORDS The State and local agencies shall make all hearing records and decisions available for public inspection and copying; however, the names and addresses of the participants and other members of the public must be kept confidential.
IX. NATIONAL VOTER REGISTRATION ACT The National Voter Registration Act of 1993 (NVRA) mandates the WIC Program's obligation to offer voter registration opportunities verbally to all applicants/participants entering a clinic for the application or re-certification of WIC benefits. Individuals wishing to register will be given a voter registration application and any assistance needed to complete the form. In the event an applicant/participant is already registered or does not wish to register a declaration statement will be appropriately coded reflecting their wishes. These declaration forms will be kept on file at the local agency for a period of twenty-four (24) months.
RO - 13

GA WIC PROCEDURES MANUAL

Attachment RO -1

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

RIGHTS AND OBLIGATIONS

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

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

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

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

5. The WIC Program may disclose specific applicant information to designated health or welfare agencies for the purpose of determining eligibility and conducting outreach to WIC applicants and participants.

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

7. You may be taken off WIC if:

You do not tell the truth. You get vouchers from more than one (1) WIC program at the same time. You do not keep your certification appointments. (Rescheduling WIC appointments may
take from 7 to 20 days depends on the clinic schedule). You do not get your vouchers for two (2) months in a row. You sell or trade your WIC vouchers or food for money or anything. You use your vouchers to buy food that is not on the list. You exchange your WIC food items after purchase for any item(s) not listed on the
voucher. You use abusive language with clinic staff, store clerks or managers. You are physically violent with clinic staff, other WIC clients, or store personnel.

8. If you do not keep your appointments, the number of vouchers issued to you or your child will be reduced.

RO - 14

GA WIC PROCEDURES MANUAL

Attachment RO-1(cont'd)

SCHEDULE FOR PICKING UP VOUCHERS LATE

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

LATE PICK-UP

Number of Days Late Less than 7 days late
7-13 days late 14-20 days late 21-31 days late

Women & Children full package
3 vouchers issued 2 vouchers issued 1 voucher issued

Infants Full package Full package 1 voucher issued 1 voucher issued

If you have any questions about this form, you may ask for help or call the clinic.

LATE PICK-UP SCHEDULE ADDITIONAL/ALTERNATE FOOD PACKAGES

Number of Days Late Less than 7 days late
7 - 13 days late 14-20 days late 21-31 days late

Women & Children full package
6 vouchers issued 4 vouchers issued 2 vouchers issued

Infants full package full package 1 voucher issued 1 voucher issued

Form 3768 (Rev.)

"This institution is an equal opportunity provider."

RO - 15

GA WIC PROCEDURES MANAUL

Attachment RO-2

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

SECTION I - IDENTIFICATION

District/Unit

WIC ID#

Applicant/Participant: Claimant (if different from above):

Address:

Street Number and Name

City

State

Zip Code

Phone Number:

Representative:

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

1. white male

2. white female

3. nonwhite male 4. nonwhite female

County:

Date of Request:

Date of Appointment:

Date of Notification:

FOR STATE OFFICE USE ONLY:

Request number:

Date request filed:

Time limits: 7 CFR 246.9(j) Hearing is to be held within three (3) weeks from the date the State or local agency receives the request for hearing. 7 CFR 246.9(k)(3) . The decision is to be issued within 45 days of the date the request for hearing was received by the State or local agency.

RO - 16

GA WIC PROCEDURES MANUAL

Attachment RO 2 (cont'd)

SECTION II - TYPE OF AGENCY ACTION OR INACTION

A. Agency Action (Circle item number)

Participation denied/terminated because client:

1. Is not income eligible.

Date

2. Does not live in local program area.

Date

3. Has reached expiration of regulatory eligibility.

Date

4. Is not pregnant, postpartum, breastfeeding or Infant/Child

under five (5) years of age.

Date

5. Does not meet nutritional risk criteria.

Date

6. Failed certification appointment on: ____________________.

Date

7. Did not pick up vouchers for two (2) consecutive months.

Date

8. Violated program rules and was suspended for three

(3) months for:

.

Date

9. Is in Priority and program has funds to serve

only Priority(ies)

.

Date

10. Other

.

Date

B. Agency Inaction (Circle item number):

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

2. Other: (specify)

RO - 17

GA WIC PROCEDURES MANUAL

Attachment RO 2 (cont'd)

SECTION III - NARRATIVE SUMMARY OF AGENCY'S ACTION OR INACTION AND PRINCIPAL ISSUES INVOLVED IN THE REQUEST FOR HEARING

A. Basis for local agency's action or inaction (specify briefly):

B. WIC regulations applied by local agency:

C. Participant's income eligibility information:
_______________________________ Signature/Title of WIC Personnel
________________________________ Program Name
________________________________ Address
_________________________________ Telephone Number
Prepare in triplicate Original - DHR Legal Services Office File Copy - State WIC Branch File Copy - District/Local Agency

_______________________________ Signature of WIC Coordinator

________________________________

City,

State,

Zip Code

RO - 18

GA WIC PROCEDURES MANUAL

TABLE OF CONTENTS

SECTION ONE - FINANCIAL MANAGEMENT

Page

I. Agreement with State Agency ........................................................................... AD-1 II. Financial Procedures .......................................................................................... AD-1
A. Local Agencies.............................................................................................. AD-1 B. Non-profit Agencies ..................................................................................... AD-1 C. Unliquidated Obligations .............................................................................. AD-1 D. Year End Funds Obligations ......................................................................... AD-1 III. Nutrition Services and Administration Cost Categories.................................... AD-2 A. Cost Pool....................................................................................................... AD-2 B. Nutrition Education Cost ............................................................................. AD-2 C. Breastfeeding Costs ..................................................................................... AD-2 IV. Random Moment Sample Study (RMSS) ......................................................... AD-3 V. Expense Categories ............................................................................................ AD-3 A. Expenditures with a Unit Value of $25,000................................................. AD-3 B. ADP Equipment less than $25,000 .............................................................. AD-3 C. ADP Equipment $25,000-$200,000............................................................. AD-4 D. Inventory ...................................................................................................... AD-4 VI. Allocation of Nutrition Services and Administration Funds ............................. AD-5 VII. Program Income ................................................................................................. AD-5

GA WIC PROCEDURES MANUAL
SECTION TWO - PROGRAM ADMINISTRATION I. Retention of Records ......................................................................................... AD-6 A. Definition of Records................................................................................... AD-6 B. Records and Reports -Accessibility of Records............................................ AD-6 C. Retention Schedule ...................................................................................... AD-6 D. Prior Approval/Duplication of WIC Records ............................................... AD-7 II. WIC Acronym and Logo ................................................................................... AD-9 A. Authority ...................................................................... ........................ AD-9 B. Official Use................................................................................................... AD-9 C. Special Use. ................................................................................................ AD-10 D. Unauthorized Use....................................................................................... AD-11 III. Lobbying Restrictions ...................................................................................... AD-11 IV. Confidentiality ................................................................................................. .AD-11 V. Faxing Confidential Information ..................................................................... AD-12 VI. WIC Volunteers and Confidentiality ............................................................... AD-12 VII. Retroactive Benefits and Reimbursements ...................................................... AD-13 VIII. Mandatory No Smoking Policy in Local WIC Clinic ...................................... AD-13 IX. Subpoenas ...............................................................................AD-13 X. Search Warrants ................................................................................................ AD-14 XI. Program Participation ....................................................................................... AD-15 XII. System Maintenance Indicator Report/Pending ............................................... AD-15 XIII. Establishing New Clinics/Clinic Changes ....................................................... AD-15 XIV. Clinic Closings ................................................................................................. AD-16 XV. Central Supply Forms ...................................................................................... AD-16

GA WIC PROCEDURES MANUAL
XVI. Damage Voucher Report................................................................ AD-17
Attachments: AD-1. Sample Formulas .............................................................................................. AD-18 AD-2. FFY 2002 Georgia WIC Branch Agreement .................................................... AD-20 AD-3. WIC Forms Available in Central Supply.......................................................... AD-22 AD-4. Equipment Inventory Form............................................................................... AD-24 AD-5. System Maintenance Indicator Technical Assistance Procedures .................... AD-25 AD-6. System Maintenance Indicator/Technical Assistance Report........................... AD-26 AD-7. State WIC Branch SMI/Technical Assistance Summary Report ..................... AD-27 AD-8. Agreement for Disclosure of Information......................................................... AD-28 AD-9. Release of Information Form ............................................................................ AD-29 AD-10. Request to Establish New Clinic/Clinic Changes .......................................... AD-30 AD-11. Damaged Formula Report ............................................................................... AD-31

GA WIC PROCEDURES MANUAL SECTION ONE - FINANCIAL MANAGEMENT

I. AGREEMENT WITH STATE AGENCY

Prior to July 1 of each year, all local agencies operating a WIC Program, excluding contracted local agencies, must sign Annex H of the DHR Master Agreement (See Attachment AD-2).
Prior to October 1 of each year, all contracted local agencies must sign a contract with the DHR, Division of Public Health. Contracted agencies' timeframes are on a federal fiscal year.

II. FINANCIAL PROCEDURES

A.

Local Agencies

Adhere to:
Georgia WIC Procedures Manual USDA FNS Instruction 808-1 OMB Circular A-87 and A-102 Grant-in-Aid Policy & Procedure Manual, Parts III.E, Attachment 1 and IX.A,B., from the Department of Human Resources.

B.

Non-profit Agencies

Adhere to the tenets of the negotiated contract.

C.

Unliquidated Obligations:

USDA requires that Unliquidated Obligations be reported. Local Agencies are to report these on their Monthly Income and Expense Reports (MIER).
D. Year End Funds Obligations
In order to utilize year-end Nutrition Services Administration (NSA) funds, all purchase orders must be completed, properly dated and forwarded to the vendor prior to September 30th.

AD - 1

GA WIC PROCEDURES MANUAL
III. NUTRITION SERVICES AND ADMINISTRATION COST CATEGORIES A. Cost Pool Allowable administrative and operational costs are those costs necessary to fulfill program objectives. Required costs to be distributed through the cost pool are:
1. All Salaries.
2. Purchases not specific to Nutrition Education or Breastfeeding.
3. Travel and training costs not specific to Nutrition Education or Breastfeeding.
Reimbursement to member counties for WIC services.
B. Nutrition Education Costs Federal regulations require that each WIC State Agency spend one-sixth of its NSA Grant for Nutrition Education. The cost of activities directed toward helping participants understand the importance of nutrition in relation to health, is allowed as nutrition education expense.
C. Breastfeeding Costs
A local agency is required to spend WIC breastfeeding funds for breastfeeding related costs and activities. The following breastfeeding costs are allowable: 1. Travel and training costs of staff associated with breastfeeding promotion and
support activities. 2. Contracts for services of breastfeeding specialist. 3. Breastfeeding aids, such as breast pumps, breast shells, nursing supplements, nursing
bras and nursing pads, which directly support the initiation and continuation of breastfeeding.
AD - 2

GA WIC PROCEDURES MANUAL
4. Items used for training and demonstration purposes to promote breastfeeding or assist participants in using breastfeeding aids. Such items may include models to illustrate the use of various breastfeeding aids, dolls used to illustrate nursing, etc.
5. Development, procurement and distribution of materials, instructional curricula, etc., related to breastfeeding promotion and support.
6. Developing and updating the biennial Breastfeeding Promotion and Support Plan.
7. Payments for interpreters and the translation of breastfeeding materials.
The costs of agreements with other organizations, whether public or private, to provide breastfeeding training and direct service delivery to WIC participants.
IV. RANDOM MOMENT SAMPLE STUDY (RMSS)
The Random Moment Sample Study (RMSS) is a method of measuring time worked per program by employees for cost allocation. This method uses a statistically valid sample to determine the time employees expend on individual programs. The results of the RMSS for a quarter are used as a basis for the distribution of each quarter's cost. A comprehensive and detailed procedural methodology of this process is included in Appendix B of the Cost Allocation Plan. A copy of the Cost Allocation Plan can be obtained from the State WIC Branch's Financial Section.
V. EXPENSE CATEGORIES
A. Expenditures with a unit value in excess of $25,000
Capital expenditures in excess of $25,000 must be requested with a letter of justification from the local agency. The State WIC Branch will review the request and approve or deny the request in writing.
B. Automated Data Processing (ADP) Equipment less than $25,000
Computer equipment expenditures not requiring prior approval under this policy are limited to individual, occasional purchases with a unit cost of less than $25,000. These purchases cannot be related to multi-unit procurement such as a statewide automation system.
AD - 3

GA WIC PROCEDURES MANUAL
C. ADP Equipment with a value in excess of $25,000
Prior approval from the State WIC Branch and USDA must be obtained for all ADP equipment purchases above $25,000 or if the equipment is to be part of a multi-unit procurement. The request should be in the form of a letter and should be submitted to the State WIC Director at least 45 days prior to the anticipated purchase date. The request must include the following:
A statement that the requested equipment is not part of a larger ADP project
A brief description of the need for the equipment and justification of the proposed purchase
A list of equipment to be purchased, the associated cost and the agency where the equipment will be located
Note: Larger ADP projects cannot be divided up to avoid the more complex approval requirements of higher threshold levels.
Note: For projects with anticipated costs above $500,000, please refer to Food and Nutrition Services (FNS) Handbook 901, page 5-3.
D. Inventory
A complete physical inventory of all equipment purchased with WIC funds whose unit cost equals or exceeds $1000 must be conducted annually (See Attachment AD-5). This information should be entered onto the State Equipment Inventory Form and submitted to the State WIC Branch no later than September 30th of each year. The inventory must be completed and submitted regardless of whether or not equipment was purchased during the year. The staff person completing the inventory must sign and date the form. Each item must be recorded with the following information:
Inventory Number Equipment Description Serial Number Equipment Location Date of Purchase Purchase Price Percentage of WIC Funds (used to purchase the equipment)
Please refer to the Department of Human Resources Real and Personal Property Management Manual to properly dispose of those pieces of equipment that are
AD - 4

GA WIC PROCEDURES MANUAL damaged, deleted or discarded. If the equipment has been stolen, enclose a copy of the police report with the inventory form. All equipment (deleted, damaged, stolen or discarded) should be indicated as such on your inventory form.
Any WIC purchased equipment reported as missing must be noted on the Equipment Inventory Form. A notation in the fourth column, "Location", should specify "missing" and the date. An anecdotal note at the bottom of the form (or attachment) should specify details/comments related to the circumstances. When the equipment is located, an additional anecdotal note on the bottom of the form (or attachment) must be made and the corresponding location of the equipment noted accordingly.
VI. ALLOCATION OF NUTRITION SERVICES AND ADMINISTRATION FUNDS
The WIC Allocation Advisory Committee is charged with assisting the Program and the Division of Public Health with developing an acceptable methodology for allocating federal grant funds to the Local Agencies. The State of Georgia WIC Branch approved funding formula has been well accepted by local agencies due to its accuracy and fairness. Additionally, the Georgia WIC Allocation Advisory Committee makes recommendations to the State WIC Branch concerning caseload management strategies. A District Health Director chairs the committee. Each position (coordinator, program manager or director) has one representative from a small, medium and large size district. The committee meets a minimum of two (2) times per year, first in January or after the federal grant award notification; and also in July or August to determine distribution of funds and the succeeding year's caseload strategies. However, meetings are convened on an as needed basis.
VII. PROGRAM INCOME
Any revenue generated as a result of administering the WIC Program is considered program income and, as such, will be used to further program objectives in accordance with the Code of Federal Regulations (CFR), Title 7, Section 3016.25.
AD - 5

GA WIC PROCEDURES MANUAL SECTION TWO - PROGRAM ADMINISTRATION
I. RETENTION OF RECORDS
A. Definition of Records: Federal regulations state: "Records shall include, but not be limited to, information pertaining to financial operations, food delivery systems, food instrument issuance and inventory, certification, nutrition education, civil rights and fair hearing procedures" [7 CFR 246.25(a)(1)].
State policy memos from the previous year may be destroyed once the new Procedures Manual has been received, unless otherwise instructed. For example, FFY 01 Policy Memos may be destroyed once the FFY `02 Procedures Manual has been received.
B. Records and Reports - Accessibility of Records
The Federal Office of the Inspector General (OIG) has been given total access to WIC Program Records since that Office has overall authority and responsibility for the examination of the Food and Nutrition Service Program. The WIC Certification file is part of the documentation for determining food cost charge. Therefore, certification records when requested must be made available to the OIG.
If a certification file does not contain the required information, local agency personnel are required to make available to the OIG a medical case record or other documentation which will substantiate that the cost incurred by serving the participant is a proper charge to the WIC Program.
In cases where the OIG finds that certification data is insufficient, and is denied access to the medical record or other documentation is not made available, a claim will result against the State Agency.
C. Retention Schedule
1. The following documents must be retained for five (5) years, as stated in the DHR Record Retention Policy, issued November 12, 1986:
(1) WIC Assessment/Certification Forms (2) Diet Histories (3) Growth Charts/Weight Gain Grids
AD - 6

GA WIC PROCEDURES MANUAL (4) VOC Card Inventories
2. The following documents must be retained for three (3) years plus the current Federal Fiscal Year:
(1) Vendor Monitoring Reports (2) Computer Generated Voucher Registers/Voucher Printing On Demand
(VPOD) Receipts (3) Manual Voucher Inventory Records (4) Budgets and Expenditure Reports (5) Contracts (6) Indirect Cost Plan (7) Shared Costs Documentation (8) Fair hearing and civil rights complaints and all related documentation (9) Federal, State, District, County Audit reports (10) Copies of manual vouchers (11) TAD=s (12) Vouchers Activity Report
3. The following documents must be retained for one (1) year plus the current year:
(1) Waiting List (2) Voucher Packing List/VPOD Confirmation Notice
4. The following documents may be destroyed after the required corrections, verifications and reconciliation's have been completed:
(1) Dual Participation Report* (2) Cumulative Unmatched Redemptions, (3) Part 1* (not matched to issuance record) (4) Cumulative Unmatched Redemptions, (5) Part 2* (not matched to a valid certification record) (6) Batch Control Report (7) Batch Control Form and Module (8) Critical Error Report (9) Canceled food instruments
*The original copy of these reports with their manual reconciliation must be sent to the State WIC Branch prior to being destroyed. The State WIC Branch will maintain these reports for four (4) years.
D. Prior Approval/Duplication of WIC Records
Local Agencies must request prior approval for the reformatting or modification of any office WIC forms.
AD - 7

GA WIC PROCEDURES MANUAL
If the Local Agency duplicates an official WIC form, the Local Agency is responsible for ensuring that the form contains the exact information as its original.
The following documents will be maintained on microfiche at the State WIC Branch for a period of three (3) years plus the current Federal Fiscal Year. These documents may be destroyed by the local agency when they are no longer useful to the districts and/or clinics:
a. Monthly Reconciliation - Enrollment Cycle
1. Alphabetic Master File Listing 2. Critical Error Report 3. Enrollee Income by Household Size 4. Grady Hospital Enrollee Distribution 5. Medicaid-Enrollee Income by Household Size 6. Medicaid-Percentage of Poverty Income by Type and Age Categories 7. Medicaid-Priority Counts by Percentage by Poverty Income Level 8. Numeric Master File Listing 9. Percentage of Poverty Level Income Level by Type and Age Categories 10. Priority Counts by Percentage of Poverty Income Level 11. Trimester Analysis Report 12. Unduplicated Participation Report, State Fiscal Year 13. Unduplicated Participation Report, Federal Fiscal Year 14. Waiting List Report 15. WIC Status (Type) by Reason Certified
b. Monthly Reconciliation
1. Bank Exception Report 2. Bank Listing 3. Closeout Reconciliation Report 4. Cumulative Unmatched Redemptions Over 30 Days-Based on CUR-Part 1 5. Cumulative Unmatched Redemption Over 30 Days-Based on CUR-Part 2 6. District Unit/County Compliance Summary (Concentrated Powder Ready To
Feed). 7. Dual Participation Report-Part 1 8. Ethnic Enrollment and Participation by Priority (Issue 30 Day) and Closeout 9. Ethnic Participation Summary 10. Financial and Program Status 11. Food Cost Allocation (Projection) 12. Food Package Create Report 13. Food Package Expenditures Report 14. Infant Formula Rebate Report Concentrated Powder Ready To Feed 15. Infant Rebate County Summary
AD - 8

GA WIC PROCEDURES MANUAL
16. Infant Rebate District Unit Summary 17. Migrant Participation Summary 18. Migrant Enrollment and Participation by Priority (Issue 30 Day) and Closeout 19. Monthly Report of Food Expenditures Summary (Issue 30 Day) and Closeout 20. Monthly Report of Food Expenditures by Vouchers Code (Issue 30 Day
Closeout 21. Participant Totals 22. Participation Summary by District/Unit
23. Previously Unmatched Redemptions Which Were Matched 24. System Maintenance Indicators 25. Unmatched Redemption's Report
c. Monthly Reconciliation - Vendor Cycle
1. Cumulative Vendor Totals 2. Detailed Flagged Voucher Listing 3. Flagged Voucher by Vendor per Peer Average 4. Maximum Amount Input Update 5. Statistics File for Vouchers 6. Vendor Exception Report 7. Vendor Listing 8. Vendor Update Listing 9. Vendor Voucher Deviation Report 10. Voucher Redemption Fluctuation Report 11. Voucher Variation Report 12. Voucher by Day Cashed 13. Vouchers Cashed by Clinics 14. Financial Records
II. WIC ACRONYM AND LOGO
A. Authority
The acronym "WIC" was registered with the U.S. Patent and Trademark Office January 1, 1991. The WIC logo, a stylized representation of a woman holding an infant in her arms and a child by the hand, was registered April 16, 1991. Regulations authorizing the use of the WIC acronym and logo are provided in 42 U.S.C. 1786, 15 U.S.C. 1051 et seq., and 7 CFR Part 246.
It is an on-going policy to discourage industrial use of the WIC acronym and logo on products to avoid certain difficulties that may be encountered.
B. Official Use
Use of the acronym "WIC" and the WIC logo is reserved for the official use of national, instructions and policies restrict use to purposes consistent with the WIC Program
AD - 9

GA WIC PROCEDURES MANUAL
regulations. Materials, which display WIC identifiers will be used primarily for identification, public notification, and outreach purposes. Below is a list of the possible uses of the WIC acronym and logo. This list is not inclusive and there may be other WIC ideas. FNS reserve the right to approve any use of the WIC acronym or logo.

Brochures Bulletins Business Cards (for employees) Cups Directories Food Instruments Forms (i.e. Cert. forms) Guides Immunizations Initiatives

Leaflets Letters Manuals Newspapers Posters Radio and T.V. Announcements Reports Studies T-shirts

C. Special Use

Profit and Non-Profit Organizations -The WIC logo and acronym cannot be used by for profit organizations. These organizations are not permitted to display the acronym or logo in total or in part, including close facsimiles, on any product or materials that produce. Non-profit organizations may be permitted to use the acronym and/or the logo for non-commercial educational purposes when such use is essential to public service and will contribute to public information and education concerning the WIC Program. Nonprofit organizations are those organizations that are exempt from taxation under Federal law, including charitable and educational organizations. Nonprofit organizations within the jurisdiction of the state of Georgia shall submit a request for use of the WIC acronym or logo to the State WIC Branch in writing. The written request must include a copy/sample of the way in which the acronym or logo will be used. The State WIC Branch must respond in writing on whether such use is authorized.
2. WIC Food Vendors
At the discretion of the State WIC Branch, in a standard contract or agreement a vendor may be authorized to use the acronym and/or logo for the following purposes:
a. To identify the retailer as an authorized WIC food vendor.
b. To identify authorized WIC foods by attaching channel strips or shelf-talkers stating "WIC-approved" or "WIC-eligible" to grocery store shelves.

AD - 10

GA WIC PROCEDURES MANUAL FNS reserves the right to approve any uses of the WIC acronym or logo; and any uses that are considered inappropriate shall be discontinued. Request for use of the WIC Acronym or Logo must be made in writing along with a copy/sample of the way it will be used. A written response will be issued on whether such use is authorized.
D. Unauthorized Use
Any person who uses the acronym "WIC" or the WIC logo in an unauthorized manner, including close facsimiles thereof, in total of in part, may be subject of injunction and the payment of damages. Any person who is aware of violators should provide the information to the Food and Nutrition Services (FNS) Office.
III. LOBBING RESTRICTIONS
The State/Local Agencies must not use federal funds for lobbing for specific federal awards and requires recipients of any federal grants, contracts, loans, and cooperative agreements to disclose expenditures made with their own funds for such purpose.
IV. CONFIDENTIALITY
The State/local agencies are required to restrict the disclosure of information obtained from any program applicant/participant ( See Attachment AD-8).
WIC program information must not be released except in the following situations: 1. The WIC applicant/participant signs a release of information (See Attachment AD-9).
2. The State or local agencies enter into a written agreement with an organization (i.e. immunization). The Director of Public Health must sign this agreement. In the event an agreement is entered into with the organization and the Director of Public Health, a release of information would not need to be signed by the WIC applicant/participant. Information shared with that agency however, is restricted (See Attachment AD-9). Note: The WIC Certification Form and Rights and Obligations Form have been revised to meet these requirements.
3. For the Comptroller General of the U.S. for audit and examinations authorized by law.
Disclosure of information with other organizations may be used for the sole purpose of:
1. Determining eligibility for programs administered by the recipient organization. 2. Conducting outreach for the program.
NOTE: Information on the use of drugs and alcohol must not be shared.
AD - 11

GA WIC PROCEDURES MANUAL V. FAXING CONFIDENTIAL INFORMATION
Districts that decide to fax confidential information should incorporate a confidentiality provision statement into your fax cover sheet information. The following represents an example of such a statement:
This message is intended only for the use of the individual or entity to which it is addressed and may contain information that is privileged, confidential and exempt from disclosure under applicable law. If the reader of this message is not the intended recipient or the employee or agent responsible, the dissemination, distribution or copying of this communication is strictly prohibited. If you have received this communication in error, please notify us immediately by telephone and return the original message to us at the above address.
VI. WIC VOLUNTEERS AND CONFIDENTIALITY
In order to prevent a breach of confidentiality, the Georgia WIC Program must exercise discretion in screening and selecting capable volunteers who will handle confidential information. It is therefore the responsibility of the local agency to ensure that volunteers who are given access to client information are well trained and knowledgeable of the restrictions in disclosure of patient information.
The following action steps must be taken in order to protect participant information: 1. Once volunteers are selected, specific confidentiality requirements governing the
WIC Program must be covered in the orientation or training of volunteers.
2. Follow-up training must be conducted periodically to remind volunteers, as well as paid staff, of the importance of maintaining the confidential nature of participant information.
3. The selecting agency may have volunteers sign an agreement acknowledging restrictions on the disclosure of confidential information. By signing such a form, the volunteer would agree to keep information confidential or forfeit the volunteer assignment. Such an agreement would reinforce the importance of maintaining confidential participant information.
4. If a volunteer does not appear to be a good candidate for keeping information confidential, assign the volunteer to other activities in the program.
AD - 12

GA WIC PROCEDURES MANUAL VII. RETROACTIVE BENEFITS AND REIMBURSEMENTS
WIC regulations do not provide for retroactive benefits and reimbursement. The WIC Food Packages are designed to be consumed within a specified time period when participants are experiencing critical growth and development.
VIII. MANDATORY NO-SMOKING POLICY IN LOCAL WIC CLINICS
Public Law 103-111 prohibits the allocation of Administrative Funds to any clinic providing WIC services if that clinic allows smoking within the space used to perform program functions. In order to avoid administrative penalties, Local Health Department or WIC Clinics must display a ANo Smoking Sign.@ These signs must be visible somewhere in the clinic.
The prohibition against smoking applies only during the hours of actual WIC operations. In the event the clinics for voucher issuance are being held at a satellite
clinic (i.e. church, public housing, clinic site, community health center only once or twice per week) then the no-smoking policy would only be in effect during WIC operation hours. If the health department is a no-smoking facility, and such signs are displayed throughout the health department, then there is no need to display a WIC specific no-smoking sign.
IX. SUBPOENAS A. Subpoenas A subpoena is a request for information issued by a clerk of a court in response to a request by an attorney representing a party. A subpoena may be directed to an individual or an entity. In the event, the local agency receives a subpoena, please follow the instructions below. Also, please contact the State WIC Branch for legal advice.
B. Procedures for Responding to A Subpoena State or local agencies, in consultation with their legal counsel, must make a determination based on the content of the subpoena and the requested information whether or not to comply with the subpoena and release the information as requested or to attempt to quash the subpoena. In making the determination, State or local agencies must determine whether the information is protected under 7 CFR 246.26(d) of the WIC regulations.
* Decisions to release WIC information as requested by a subpoena or to attempt to quash a subpoena must be based on the requirements and restrictions set forth in 7 CFR 246.26(d) of the WIC regulations, any pertinent State laws, FNS Instruction 800-1, and WIC Policy Memorandum 94-3. Any
AD - 13

GA WIC PROCEDURES MANUAL conflicts identified between Federal and State requirements should be referred to the DHR Legal Services Office where appropriate.
* If the court denies the motion to quash the subpoena and requires the WIC State or local agency to release the requested information, the State or local agency or legal counsel acting on its behalf shall attempt to:
-- consider the appropriateness of an appeal of the decision,
-- ensure that the information produced is only what is essential to respond to the subpoena (i.e. provide related documents reflecting only the requested WIC information), and
-- attempt to negotiate the extent to which the WIC information actually produced becomes public information (i.e. reviewed in camera by the court, limited entry into the public record).
* If the motion to quash the subpoena is denied by the court, we recommend that legal counsel acting on behalf of the State or local agency request the parties reduce to writing the terms of the release of the subpoenaed information so that all parties are in accord as to the use of such information. Ideally, counsel should seek a warrant of attachment or similar court order. A warrant of attachment is a written order by the
* Court based on State law, which orders a law enforcement officer to seize specific documents and deliver them to the court, essentially forcing the State or local agency to comply. In this way, there is a record that WIC State or local officials disregarded the Federal law protecting the confidentiality of WIC records only after having been compelled to do so by a court.
* State/local agencies must advise legal counsel of any formal complaints that may result in litigation. Receipt of a subpoena or search warrant must also be reported to the WIC Branch and legal counsel.
In some instances, a State or local agency may be required to release confidential information in response to a subpoena or search warrant. However, if the release of such information is made pursuant to and in keeping with WIC Program regulations, instructions, and policy, that release will not result in FNS or its agents taking adverse action against the State and local agency or any individuals acting on their behalf.
X. SEARCH WARRANTS
In addition to the issuance of subpoenas, search warrants have been used by police investigators to obtain WIC applicant and participant information. State and local agencies
AD - 14

GA WIC PROCEDURES MANUAL must comply with search warrants. A search warrant differs from a subpoena in which a time frame is established to either comply with the subpoena or attempt to quash the request. Failure to fully comply with a search warrant at the time it is served could result in the incarceration of WIC State and local agency staff.
XI. PROGRAM PARTICIPATION
The definition for a participant and enrollee is listed below:
Participant: A participant is a client who has been issued at least one voucher during the reporting month.
Enrollee: A client who is active, during a valid certification period, but did not receive vouchers during the reporting month.
XII. SYSTEM MAINTENANCE INDICATOR (SMI) REPORT/PENDING SMI reports are being evaluated for 2002. Once approved, the Local Agency will be trained on the new reports (See Attachments AD 6-7).
XIII. ESTABLISHING NEW CLINICS/CLINIC CHANGES
All local agencies must submit clinic changes to the State WIC Branch within thirty (30) days of the date the change occurs. Clinic changes are reported using the ARequest for Establishing New Clinic/Clinic Changes@ Form (Attachment AD-10). The form must be completed and forwarded to the State WIC Branch when there is a change in clinic address or a request to establish a new clinic site.
All Local Agencies must utilize the following procedures to establish new clinic sites:
1. A Local Agency wishing to establish a new clinic must contact the State WIC Branch in writing or via telephone.
2. The State WIC Branch Systems Information Unit will forward to the requesting agency a Request to Establish New Clinic /Clinic Changes Form within five (5) days from the date of the request.
3. The Local Agency completes the form (see Attachment AD-10) and returns it to the State WIC Branch.
AD - 15

GA WIC PROCEDURES MANUAL 4. Upon receipt of the completed form, the Systems Information Unit verifies the information and forwards the form to the data processing contractor within five (5) days from the date of receipt. 5. The data processing contractor assigns a number for the new clinic site. If the Local Agency selects its own new number, the data processing contractor must verify and approve the number before it may be considered a valid number. 6. The data processing contractor mails the new clinic the supplies necessary to start clinic operations (i.e., TAD, Vouchers, etc.). 7. The State WIC Branch will provide technical assistance, consultation, and training to the Local Agency in the start up procedures of a new clinic.
XIV. CLINIC CLOSINGS
In the event a clinic is going to be closed temporarily due to an emergency or meeting, please notify the Policy Unit at the State WIC Branch as early as possible. This will enable the local/state staff to better serve the applicants/participants and clinic staff. Closing of clinics causes the participants/applicant hardship when they are not notified in writing or in advance. If your district plans to close a WIC clinic permanently, please complete the Clinic Change form and mail it to the WIC Branch System Unit (See Attachment AD-10).
XV. CENTRAL SUPPLY FORMS All Central Supply requests for WIC forms must be ordered by the district through the State WIC Branch (See Attachment AD-3). All orders must be correctly completed and separated from orders for other programs (i.e. Women's Health, Immunization, etc.) All requisitions must be sent to the State WIC Branch for approval before the order will be processed. Do not send orders directly to Central Supply. Requests will not be approved by telephone or fax.
AD - 16

GA WIC PROCEDURES MANUAL XVI. DAMAGE VOUCHER REPORT
Damage Formula Report The Damage Formula Report (Attachment AD-11) must be used to report free trade formula that is damaged on receipt. When a formula shipment is sent damaged, complete and fax this form to the System Unit Attention at the State WIC Branch. The Fax Number (404) 657-2910.
AD - 17

GA WIC PROCEDURES MANUAL SAMPLE FORMULAS

ATTACHMENT AD-1

1. RATE FOR SERVICES PROVIDED (RFS)

The following may be used to compute a RFS:

Step 1.

Employee A: (# hrs. worked*) x (hourly pay**) = $(A) Employee B: (# hrs. worked*) x (hourly pay**) = $(B)
etc.

Step 2. $(A) + $(B) + $(C) + $(D)... = $$

Step 3.

$$

= Rate Per Participant or Assessment

# participants*** (cost per participant or assessment)

OR

# assessments***

* The source for this data is the RMSS data collection sheets. Data must be collected on WIC and non-WIC paid personnel to substantiate all WIC costs, however, the employees in Step 1 must be non-WIC paid personnel only.
NOTE: You do not include WIC paid employees when computing a rate for reimbursement because WIC paid employees have already been paid with WIC funds and to include them in the rate would mean paying them twice.
** To Compute an Employee's Hourly Pay:
NOTE: Those employees who receive fringe benefits must have these benefits included in their hourly pay rate.
Step 1. Salary x Fringe Benefit Rate = F
Fringe benefits are a percentage of the employee's salary. They are the combined total of FICA, retirement, and health insurance. This rate periodically changes and the most current rate should be used.
Step 2. F + Salary = Total Salary (incl. fringe) Step 3. Yearly Salary/hours per year = Hourly Rate

AD -18

GA WIC PROCEDURES MANUAL

ATTACHMENT AD-1 (cont'd)

Monthly Salary/hours per month = Hourly Rate

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

2. FULL-TIME EQUIVALENTS (FTE's)

The following may be used to compute FTE's:

Step 1. individual's time worked performing WIC duties
individual's total time worked

x 100% =

% of time spent performing WIC duties (P)

Step 2. (P) x (individual's hourly/monthly pay*) = portion of hourly/monthly pay to be reimbursed by WIC.

Use the same formula used in "Rate" above.

AD - 19

GA WIC PROCEDURS MANUAL

ATTACHMENT AD-2

FFY 2002 ANNEX H OF THE DHR MASTER AGREEMENT
BETWEEN DIVISION OF PUBLIC HEALTH/GEORGIA WIC BRANCH
AND DISTRICT HEALTH OFFICE
FOR THE SPECIAL SUPPLEMENTAL NUTRITION PROGRAM
FOR WOMEN, INFANTS AND CHILDREN (WIC)

This provider agreement is made pursuant to the Georgia Department of Human Resources (DHR) Administrative Policy and Procedures Manual, Part II A.l., and United State Department of Agriculture/Food and Nutrition Services (USDA/FNS) regulations being 7 CFR 246. This agreement is between the Georgia Department of Human Resources, Division of Public Health (hereinafter referred to as the Georgia WIC Branch) and the District Health Office (hereinafter referred to as the Local Agency. This agreement is effective the first day of July 1, 2001 and shall continue for one (1) year unless revised or terminated as provided herein.

THE STATE AGENCY AGREES:

1. To allocate administrative funds to the Local Agency for their use in meeting all allowable administrative, nutrition education, breastfeeding and client service expenses of the Local Agency as indicated by documented costs.

2. To pay cost of food vouchers issued by the Local Agency and redeemed by retailers for eligible participants.

3. To monitor and evaluate the Local Agency to insure maximum effectiveness and efficiency; to provide technical assistance and consultation; and to provide training for Local Agency staff on a routine basis and as requested.

4. To provide specific manuals, forms, and nutrition education materials required for operation of the Local Agency WIC Program as specified in the Georgia State Plan of Operation.

THE LOCAL AGENCY AGREES:

1 To comply with USDA program regulations 7 CFR 246 and state policies and procedures as outlined in the Georgia WIC Branch State Plan of Operation and the Georgia WIC Branch Policy and Procedures Manual.

2. To comply with the State of Georgia WIC Branch requirements for State Fiscal Year 2002, the Georgia DHR Administrative Policy and Procedures and DHR Grants-to-Counties Policies for Administration of Funds.

3. To comply with basic requirements for local agency participation in the development of the Georgia WIC State Plan. The Local Agency will develop and submit for inclusion in the State Plan a three-year program plan beginning FFY 2000. This plan will cover 2000 2002. By September 1, the Local Agency shall submit the program plan to the Georgia WIC Branch. However, the narrative summary of the plan must be submitted to the Georgia WIC Branch by November 30. The plan must include, but not limited to: a narrative summary of program objectives and accomplishments for the preceding fiscal year objectives and interventions to improve and/or expand WIC operation and administration for the coming fiscal year. Objectives must be developed in accordance with the following program functions: Local Agencies Monitoring Plan, Collaboration with Immunization, Vendor Monitoring Plan, Food Instrument and Compliance Analysis Plan (for security reasons), Early Trimester Enrollment and Marketing and Outreach Plan. The Nutrition Education portion of the Georgia WIC State Plan must be in accordance with USDA/ FNS guidelines. The Local Agency agrees to submit a triennial Local Agency Breastfeeding Promotion Plan.

4. To implement the Food Delivery System under terms prescribed by the Georgia WIC Branch and approved by the Food and Nutrition Services (FNS).

5. To maintain complete and accurate documentation of allocated funds received and expended, employing Generally Accepted Accounting Principles (GAAP) and to make these records available for audit upon request of the State WIC Branch or Federal Agencies. To establish budgets for Random Moment Sample System (RMSS) Cost Pool expenses, direct nutrition education expenses and direct breastfeeding expenses and 100% direct WIC administrative expenses.

6.

In case of an audit exception, the Local Agency may be responsible for repayment to the Georgia WIC Branch

from the Local Agency's non-participating funds.

AD-20

GA WIC PROCEDURES MANUAL

ATTACHMENT AD-2 (con't)

7. To request and obtain through the Georgia WIC Branch prior approval for all computer hardware and capital expenditures.

8. To implement a security system for unissued food instruments (vouchers), which will protect and reduce the risk of on-site lost/stolen vouchers. In the event unissued vouchers are lost or stolen resulting in USDA sanctions, the Local Agency may be responsible for repaying the Georgia WIC Branch for the value of those food instruments. In the event of over Issuance of food instrument, the local agency is responsible for re-payment to the State WIC Branch.

9. To provide a quarterly report-listing breast pump expenditures including quantity and dollar amount.

10. To insure that appropriate actions are taken to guard and protect all automated systems and data elements in the event of a disaster or emergency affecting the operation of a local agency (or agencies) and to have a disaster recovery plan available for Georgia WIC Branch review.

11. To perform full system backups on a daily basis for processing WIC applicants, generating vouchers and to secure the media used to retain the backup in a secure location. This includes all WIC systems.

12. To meet program performance requirements as defined by USDA, the Georgia WIC Program is required to expend not less than 1/6 of its administrative funds on nutrition education. Each local agency's portion of this requirement is calculated through RMSS. Direct charges are to be documented to the extent possible.

13. Federal regulations require the Georgia WIC Branch to spend 97% of its food grant dollars. Failure to meet this mandate may result in the imposition of a penalty. To be consistent with the federal mandate each Local Agency will be expected to serve a minimum number of WIC participants as determine by the Georgia WIC Branch caseload mandate.
14. To submit a Caseload Management Plan as prescribed by the Georgia WIC Branch by October 15th of the federal fiscal year.

15. To provide the Georgia WIC Branch immediate and complete access to all clinics and all records maintained by WIC clinics within the District.

ASSURANCE
This assurance is given in consideration of and for the purpose of obtaining any and all federal financial assistance, grants, and loans of federal funds, reimbursable expenditures, grants, or donation of federal property and interest in property, the detail of federal personnel, the sale and lease of, and the permission to use, federal property or interest in such property or the furnishing of services without consideration or at a nominal consideration, or at a consideration which is reduced for the purpose of assisting the recipient, or in recognition of the public interest to be served by such sale, lease, or furnishing of services to the recipient, or any improvements made with federal financial assistance extended to the program applicant by the State. This includes any federal agreement, arrangement, or other contract, which has as one of its purposes, the provision of assistance of food service equipment or any other financial assistance extended in reliance on the representations and agreements made in this assurance.
By accepting this assurance, the program applicant agrees to compile data, maintain records, and submit reports as required, to permit effective enforcement of Title VI and to permit authorized USDA personnel during normal working hours to review such records, books, and accounts as needed to ascertain compliance with Title VI. If there are any violations of this assurance, the Department of Agriculture, Food and Nutrition Service, shall have the right to seek judicial enforcement of this assurance. This assurance is binding on the program applicant, its successors, transferees and assignees as long as it receives assistance or retains possession of any assistance from the State. The person or persons whose signatures appear below are authorized to sign this assurance on behalf of the program applicant.
Either party upon sixty (60) days written notice may terminate this provider agreement. Non-renewal of this provider agreement is not cause for appeal.
The Local Agency has the right to appeal decisions of the Georgia WIC Branch, which affect program participation as specified in 7 CFR 246.24, Administrative Appeals. A Local Agency is allowed two opportunities to reschedule a hearing.

AD-21

GA WIC PROCEDURES MANUAL

ATTACHMENT AD-3

WIC FORMS AVAILABLE IN CENTRAL SUPPLY

Contact: Cindy Woods

(404) 657-2900

FORM NAME

FORM #

1. Georgia Department of Human Resources Division of Public Health/WIC Program I.D. Card - Box/500 ........................................................ (Spanish) #3793 (English)#3769 (Rev. 3/00)

2. Georgia Department of Human Resources Division of Public Health/WIC Program WIC Assessment/Certification Form Prenatal - Pad/100....................................................................................................#3296P (Rev. 9-00)

3. Georgia Department of Human Resources Division of Public Health/WIC Program WIC Assessment/Certification Form Postpartum/Non-Breastfeeding - Pad/100 .............................................................. #3296N (Rev. 9-00)

4. Georgia Department of Human Resources Division of Public Health/WIC Program WIC Assessment/Certification Form Postpartum Breastfeeding - Pad/100 ....................................................................... #3296B (Rev. 9-00)

5. Georgia Department of Human Resources Division of Public Health/WIC Program WIC Assessment/Certification Form Infants - Pad/100........................................................................................................ #3299 (Rev. 9-00

6. Georgia Department of Human Resources Division of Public Health/WIC Program WIC Assessment/Certification Form Children - Pad/100....................................................................................................#3285 (Rev. 9-00)

7. Georgia Department of Human Resources Division of Public Health/WIC Program Batch Control Form - Pad/100..............................................................................#3762 (Rev. 114-99)

8. Georgia Department of Human Resources Division of Public Health/WIC Program Invalid Participant ID Correction Form - Pkg/250 ...................................................#3763 (Rev. 7-95)

9. Georgia Department of Human Resources Division of Public Health/WIC Program Notice of Termination/Ineligibility/Waiting List - Pkg/250 ..................................................................(Spanish) #3009 (English) #3293 (Rev. 6-95)

10. Georgia Department of Human Resources Division of Public Health/WIC Program Food List Brochure - Pkg/100 ................................................................................. #3777 (Rev.12/99)

11. Georgia Department of Human Resources Division of Public Health/WIC Program Food List Spanish Insert - Pkg/100 .............................................................................................. #3794

AD 22

GA WIC PROCEDURES MANUAL

ATTACHMENT AD-3 (cont'd)

12. Georgia Department of Human Resources Division of Public Health/WIC Program Georgia WIC Program No Proof Form - Pad/100 .......................................................................#3019
13. Georgia Department of Human Resources Division of Public Health/WIC Program Georgia WIC Program Income Calculation Form - Pad/100.......................................................#3020
14. Georgia Department of Human Resources Division of Public Health/WIC Program Georgia WIC Program Signed Statement of Income, Residency and Identification - Pad/100 .........................................................................#3035

AD -23

GA WIC PROCEDURES MANUAL

ATTACHMENT AD-4

EQUIPMENT INVENTORY FORM

WIC PROGRAM EQUIPMENT INVENTORY (3 Year Life Expectancy and $1000.00 or Above)
HEALTH DISTRICT:

INVENTORY NUMBER

DESCRIPTION

SERIAL NUMBER

LOCATION

PURCHASE PRICE

PURCHASE DATE

WIC FUNDS EXPENDED

Inventory Completed by: ______________________________________ Date: _________________
AD-24

GA WIC PROCEDURES MANUAL

ATTACHMENT AD-5

SYSTEM MAINTENANCE INDICATOR TECHNICAL ASSISTANCE PROCEDURES
1. The designated State staff will contact the WIC Coordinator if the indicators do not meet state target. The purpose of the phone call is to discuss the indicators and make suggestions.
2. Within twenty (20) days of the telephone call, the Coordinator must submit a written report, which includes the following:
a. The possible reason(s) for the non-compliant rate.
b. Plan for correction [including objective(s), action steps, milestone timeframes, monitoring plan and re-evaluation plan].
The Coordinator will have (120) days to improve the non-participation rate and any other outstanding indicator.
3. If the rate has not improved by the end of the (120) day action plan period, State staff will provide on-site technical assistance.
4. The SMI Technical Assistance Summary Report will be used to document District response to the SMI rates.
When a technical assistance visit is required, the following procedures will be followed:
a. State staff will contact the WIC Coordinator to schedule the date and time. This technical assistance visit must be scheduled within thirty (30) days from the last day of the (120) day action plan period.
b. Training will be district or clinic specific at the discretion of the WIC Coordinator and designated State staff.

AD - 25

GA WIC PROCEDURES MANUAL

ATTACHMENT AD-6

GEORGIA DEPARTMENT OF HUMAN RESOURCES STATE WIC PROGRAM
SYSTEM MAINTENANCE INDICATOR/TECHNICAL ASSISTANCE REPORT DATE OF CONSULTATION: (by phone or site visit) STATE STAFF:
DATE REPORT DUE TO STATE: DISTRICT:
DISTRICT STAFF: DISTRICT REPORT DATE: 1. Reason for low non-participation rate: 2. Which clinics are involved: 3. Plan of action taken: 4. Is Technical Assistance requested? Yes No Report submitted by: _____________________________________________________

AD-26

GA WIC PROCEDURES MANUAL

ATTACHMENT AD-7

STATE WIC BRANCH SYSTEM MAINTENANCE INDICATOR/TECHNICAL
ASSISTANCE SUMMARY REPORT State Report
District ______ Unit_______ Coordinator's Name: ____________________________________ Date call was made to District: ____________________________________________________ Date report (from the District) is due (20 days from the phone call): _______________________ Actual date report received: _______________________________________________________ Non-Participation rate based on phone call: __________________________________________ Non-Participation Rate (80 days from the phone call): __________________________________ Is a Technical Assistance visit needed? Yes _______________ No ______________________ If yes, when is the date for the visit? ________________________________________________ The visit will cover: District/Clinic ____________________________ District/Clinic ____________________________ District/Clinic ____________________________ District/Clinic ____________________________ District/Clinic ____________________________

AD - 27

GA WIC PROCEDURES MANUAL

ATTACHMENT AD-8

AGREEMENT FOR DISCLOSURE OF INFORMATION BETWEEN THE GEORGIA DIVISION OF PUBLIC HEALTH
WIC PROGRAM and __________________________________

THIS AGREEMENT is entered into between the Georgia Division of Public Health for the Special Supplemental Nutrition Program for Women, Infants, and Children, (hereinafter referred to as "WIC"), and _________________________________, (hereinafter referred to as the "Receiving Organization").
This agreement is entered into by both parties in accordance with Federal Regulation 7 CFR 246.26(d) which allows for the disclosure of specific WIC applicant and participant information (current and historical) for the purpose of (1) establishing the eligibility of the WIC applicants or participants for health or public assistance programs; and (2) conducting outreach to WIC applicants and participants. This agreement will be in effect for one year or until a written request is submitted by either agency to modify or cancel it.
THE PARTIES AGREE:
A. WIC agrees:
1. To provide the following applicant or participant information to the Receiving Organization as needed: information on the WIC Assessment/Certification Form or in the computer system including, but not limited to, name, address, phone number, social security number, ethnic origin, and birthdate;
2. Not to provide Medical data.
B. Receiving Organization agrees:
1. That the WIC Program information may be used only for the purpose of establishing the eligibility of WIC applicants and participants for health or welfare programs administered by the Receiving Organization, and for the purpose of conducting outreach to WIC applicants and participants for such programs.
2. The Receiving Organization agrees and assures that it will not disclose information provided by WIC under this agreement to a third party and that it will resist others efforts to obtain this information. It further assures that it will restrict the use or disclosure of WIC program information according to WIC guidelines, including 7 CFR 246.26(d).

_______________________________
Kathleen E. Toomey, M.D., M.P.H. Director
Division of Public Health
______________________________________ DATE

______________________________
Director
___________________________________ Receiving Organization
___________________________________ DATE

AD - 28

GA WIC PROCEDURES MANUAL

ATTACHMENT AD-9

RELEASE OF INFORMATION FORM

Georgia Department of Human Resources

__________________________________________
Name of Client/Patient/Applicant

__________________________________________
Date of Birth

IF AVAILABLE:

___________________
ID Number Used by Requesting Agency

_______________
ID Number used by Releasing Agency

AUTHORIZATION FOR RELEASE OF INFORMATION

I hereby request and authorize:_____________________________________________________________
(Name of Person or Agency Requesting Information)
_____________________________________________________________________________________
(Address)
to obtain from: _________________________________________________________________________
(Name of Person or Agency Holding the Information)
_____________________________________________________________________________________
(Address)
the following type(s) of information from my records (and any specific portion thereof):
_____________________________________________________________________________________

_____________________________________________________________________________________
for the purpose of:_______________________________________________________________________
_______________________________________________________________________ All information I hereby authorize to be obtained from this agency will be held strictly confidential and cannot be released by the recipient without my written consent. I understand that this authorization will remain in effect for:
ninety (90) days unless I specify an earlier expiration date here:___________ .
(Date)
one (1) year.

the period necessary to complete all transactions on accounts related to services provided to me.

I understand that unless otherwise limited by state or federal regulation, and except to the extent that action has been taken which was based on my consent, I may withdraw this consent at any time.

______________________________________
(Date)

__________________________________
(Signature of Client/Patient/Applicant)

______________________________________

(Signature of Witness)

(Title or Relationship

to Client)

__________________________________

(Signature of Parent or Authorized

(Date)

Representative, where applicable)

USE THIS SPACE ONLY IF CLIENT WITHDRAWS CONSENT

______________________________________
(Date this consent is revoked by client)

__________________________________
(Signature of Client)

AD - 29

GA WIC PROCEDURES MANUAL

ATTACHMENT AD-10

REQUEST TO ESTABLISH NEW CLINICS/CLINIC CHANGE

PURPOSE OF REQUEST: EST. NEW CLINIC

CLINIC CHANGE CLINIC NUMBER

EFFECTIVE DATE OF CHANGE

TYPE OF CHANGE

DIST/UNIT

DATE SUBMITTED

COUNTY#

COORDINATOR

CONTRACT # (IF LOCATED OUTSIDE OF HEALTH DEPT.)

CONTACT PERSON

NEW CLINIC NAME

MAILING ADDRESS (not a Post Office Box)

PHONE#

ATTENTION:

CLINIC DAYS AND HOURS OF OPERATION

PURPOSE OF PROPOSED CLINIC (circle) initial certification re-certification nutrition education voucher issuance

Other (specify)

SCHEDULE OF VOUCHER ISSUANCE

(circle)

monthly

bi-monthly odd

bi-monthly even

PLEASE INDICATE IF TADS AND VOUCHERS ARE TO BE SHIPPED TO ANOTHER LOCATION OTHER THAN THIS CLINIC

VOUCHER ORDERS SPECIAL VOUCHERS _______________________________ BLANK VOUCHERS ________________________________

TAD ORDERS BLANK TADS __________________________________ PREPRINTED TADS _____________________________

PREPRINTED VOUCHER PACKAGES

WOMEN (P&B) INFANTS

_________________ PACKAGES _________________ PACKAGES

WOMEN (N) CHILDREN

_________________ PACKAGES _________________ PACKAGES

PLEASE INDICATE A BEGINNING TAD NUMBER (EXAMPLE: CLINIC #123 WOULD BE 123000001 FOR THE BEGINNING TAD NUMBER ) ____________________________________________________________________________

VIKING WILL ASSIGN A MAXIMUM NUMBER OF INDIVIDUAL VOUCHERS TO BE PRINTED. THIS NUMBER WILL

EQUATE TO 100 PACKAGES FOR WOMEN, 100 PACKAGES FOR INFANTS AND 100 PACKAGES FOR CHILDREN. IF

YOU WISH TO INCREASE THIS NUMBER, PLEASE INDICATE: YES

NO

FOR STATE WIC BRANCH USE

APPROVED

DISAPPROVED

FOR VIKING USE

NEW CLINIC # ASSIGNED

______________________________________________________________

EFFECTIVE DATE

______________________________________________________________

COMPLETED BY

______________________________________________________________

SYSTEM MAINTENANCE REPORT #

AD- 30

GA WIC PROCEDURES MANUAL DAMAGED FORMULA REPORT

DISTRICT: _______________________

CLINIC/SITE

TOTAL NUMBER OF
CASES DELIVERED

TOTAL NUMBER OF
CASES CONTAINING
DAMAGED CANS

TOTAL NUMBER
OF DAMAGED
CANS

Attachment AD-11

DESCRIPTION

HOW WAS DORMULA DELIVERED (I.E., UPS)

AD-31

GA WIC PROCEDURES MANUAL
TABLE OF CONTENTS Page
I. Introduction ................................................................................................................ VN-1 II. Vendor Coordinator ................................................................................................... VN-1 III. Enrollment of New Vendors ...................................................................................... VN-1
A. Application Requirements of Vendors................................................................. VN-1 B. Approval and Reauthorization Criteria for Vendors ............................................ VN-4 IV. Vendor Agreements ................................................................................................... VN-6 V. Vendor Stamp............................................................................................................. VN-8 VI. Vendor Training ......................................................................................................... VN-8 VII. Vendor Materials........................................................................................................ VN-9 VIII. Monitoring ............................................................................................................... VN-11 A. Vendor Monitoring Procedures......................................................................... VN-11 B. Local Agency's Responsibilities ....................................................................... VN-11 IX. Compliance Investigations ....................................................................................... VN-12 X. Vendor Sanctions ..................................................................................................... VN-12 XI. Complaints Against Vendors ................................................................................... VN-12 XII. Terminations/Disqualifications ................................................................................ VN-13 XIII. Vendor Fair Hearing Procedures.............................................................................. VN-14 XIV. High Risk Vendor Identification.............................................................................. VN-15 XV. Minimum Inventory Requirements Waiver ............................................................. VN-16

GA WIC PROCEDURES MANUAL Page
Attachments: VN-14 Vendor Review Form Instructions ........................................................................... VN-17 VN-16 Vendor Profile Report .............................................................................................. VN-21 VN-17 Vendor Application Booklet Cover Letter............................................................... VN-22

GA WIC PROCEDURES MANUAL
I. INTRODUCTION
The retail grocery vendor plays a major role in the success of the WIC Program. The vendors must assure that the participants purchase the correct foods. Prices charged by vendors must be reasonable and competitive, thus allowing the WIC Program to serve a greater number of indigent women, infants, and children in Georgia. The guidelines set forth in this section are to assure program success through Federal and State Program requirements.
I. VENDOR COORDINATOR
It is the responsibility of the local agency to designate one or more people to act as the local Vendor Coordinator. This person(s) will be responsible for all local agency vendor activities and will be the primary contact person for the vendors in the district.
III. ENROLLMENT OF NEW VENDORS
A. Application Requirements of Vendors
1. Any merchant expressing an interest in participating in the WIC Program will be sent a Vendor Application Booklet (Attachment VN-1), including an Application for Vendor Certification (Attachment VN-2), the WIC Approved Food Pamphlet (Form #3777), and the Vendor Review Form (Attachment VN-13). Applications are accepted each weekday and should be returned to the local agency to be processed along with the Vendor Review Form that is completed by the vendor. The application process takes 45 working days for completion. Therefore, vendors who wish to receive approval or denial regarding WIC vendor authorization must submit a completed WIC application form 45 working days prior to the store opening or change of ownership. All retail vendors will be subject to the same application process. New vendor applications will not be approved during the annual training period (August 1 - September 30).
WIC vouchers must not be accepted by vendor applicants during the application process.
Local agencies may consider using Attachment VN-17, which is a typical form letter that should accompany the application packet.
VN - 2

GA WIC PROCEDURES MANUAL
2. Application process:
1st - 5th working day: The Local Agency will forward the Vendor Application for Certification with
the Vendor Review Form (vendor's self review) to the State WIC Branch within five working days.
6th - 20th working day: The State Agency will review the above documents within 15 working days
for the following: a. The application will be reviewed for accuracy and a background check
will be conducted. b. The vendor's prices will be analyzed to ascertain if prices charged for WIC
approved foods meet the state pricing standards. c. The vendor's Department of Agriculture and Food Stamp Program
eligibility will be verified. d. The State WIC Branch will fax/mail preliminary approval notices to the
Local Agency within this time period. e. The State WIC Branch will fax and mail denial letters to vendors and the
Local Agency within this time period. Denied vendors may correct deficiencies within 35 working days of denial. If a vendor does not correct the deficiencies within 35 working days of denial, a new vendor application must be re-submitted to the Local Agency.
21st - 35th working day: Upon receipt of the State WIC Branch preliminary approval of a vendor, the
Local Agency will conduct an on-site monitoring visit of the store and tentatively schedule vendor training for new store personnel (owners/manager/cashiers/etc.) within 15 working days. The following processes will take place during the Local Agency review: a. Non-perishable items must be in the vendor's store within 15 days prior to
store opening or change of ownership as specified in the WIC application. b. The Local Agency must be allowed to conduct an unannounced on-site
monitoring visit anytime during this 15-day period, during standard business hours (8am - 5pm). c. The Local Agency will fax and mail the Vendor Review Form (preapproval visit outcome) to the State WIC Branch within this time period.
36th - 40th working day: The State WIC Branch will render approval or denial of the vendor
application. a. If a vendor is approved the WIC authorization stamp will be forwarded to
the Local Agency with a copy of the application and the vendor
VN - 3

GA WIC PROCEDURES MANUAL
registration form. Therefore, the Local Agency can proceed with vendor training as scheduled and the owner or manager who is legally responsible for the store can sign the WIC Vendor Agreement/Contract. b. If a vendor is denied, the State WIC Branch will fax the notice to the Local Agency within five working days. Likewise, the State WIC Branch will mail the vendor his/her denial notice via regular mail within the same time period. The Local Agency will cancel the tentatively scheduled vendor training session upon receipt of the denial notification. Vendor applicants may correct deficiencies within 35 working days of denial. If a vendor does not correct the deficiencies within 35 working days of denial, a new vendor application must be re-submitted to the Local Agency.
41st - 45th working day: New vendor training may take place if training did not occur previously. In addition, the vendor owner/manager will sign the Vendor Agreement/Contract and receive his/her WIC authorization stamp during this time period.
46th - 75th day: The Local Agency will conduct a new vendor on-site monitoring review within 30 days after WIC vendor authorization. The Local Agency representative must conduct this review only when WIC approved perishable food items were not available at the pre-approval visit. The store must meet the WIC minimum inventory requirements for perishable and non-perishable WIC approved food items anytime the store is open for business.
3. The State WIC Branch has the authority to deny a vendor applicant from WIC Program participation, if the applicant previously was an authorized vendor/manager that voluntarily withdrew from WIC Program participation with one or more of the following derogatory standings:
- High risk according to the state agency's high risk indicator (s) - Food Stamp Program disqualification
B. Approval and Reauthorization Criteria for Vendors
Approval by the State WIC Branch for vendors applying for WIC Program participation will be based on the selection criteria listed in the Vendor Application Booklet (see Attachment VN-1).
VN - 4

GA WIC PROCEDURES MANUAL

Upon the purchase of a previous WIC approved store or in case of changing ownership of a previous WIC authorized store, the new vendor applicant must submit to the State WIC office proof that a legitimate or valid bill of sale took place between both parties by complying with the Bulk Sale Law of Georgia (see Official Code of Georgia Annotated 11-6-102).

The Georgia WIC Program vendor selection criteria include only "fixed stores" (ie., pharmacy, grocery, and commissary stores) for WIC vendor authorization.
Fixed Stores@ are WIC authorized immobile stores, which transact WIC, vouchers in a building site bearing a street address. This policy is necessary as a cost containment measure and is supported by the Commissioner of the Department of Human Resources, as well as the administrators in the Division of Public Health.

Retailers outside the State of Georgia requesting authorization must be located within ten miles of the Georgia State line. These retailers must request approval following the same criteria for retailers inside the State of Georgia.

The following price comparison criteria will be used for all vendors applying for WIC authorization. The process for defining the price comparison is as follows:

The vendor applicant's prices will be compared to the statewide standard maximum prices. Prices must not exceed 15% above the state average for small stores/peer group one. Groups are categorized according to the square footage and/or type of store. The vendor type noted on the input form will identify each group. This field is designated for initial certification and is completed by the State WIC Branch. Do not complete the vendor type when completing a Vendor Input/Registration Document (Attachment VN-3).

Authorization and reauthorization, including exceptions to the approval criteria, will be made by the State WIC Branch only. Reports used to determine certification are
listed in the State Plan. The same price comparison criteria required for original
approval must be met for reauthorization of an existing vendor.

The following is a list of vendor peer group codes, square footage, and vendor type:

Peer Group Code/

Vendor Type Code Square Footage

Vendor Type

1

0 - 5,000

Small Fixed Location

2

5,001 - 10,000

Average Fixed Location

3

10,001 - 15,000

Medium Fixed Location

4

15,001 OR MORE

Chain Fixed Location

VN - 5

GA WIC PROCEDURES MANUAL

5

N.A.

Commissary

Fixed

Location

6

N.A.

Pharmacy Fixed Location

7

15,001 OR MORE

Independent Large

Fixed Location

IV. VENDOR AGREEMENTS

When a store has been approved for participation in the WIC Program, a Vendor Agreement (Attachment VN-4) must be signed between the WIC local agency and the new vendor. The contract year for a Vendor Agreement is October 1 through September 30 The Vendor who fails to renew a Vendor Agreement will terminated from the Georgia WIC Program. Vendor stamps will be retrieved from any vendor that does not sign an agreement by the specified date. Vendors who do not sign a new Vendor Agreement within the specified time period may reapply for WIC authorization.

Military commissaries must sign the Military Commissary Agreement (Attachment VN5).

Pharmacies are exempt from the minimum inventory requirements. Pharmacies must sign a Pharmacy Agreement (Attachment VN-6).

The Vendor Agreement must be signed by the storeowner or the store manager who is legally responsible for the store. If the store manager leaves the store, a new Vendor Agreement must be signed by the new store manager. The vendor stamp number will remain the same.

A copy of the Vendor Agreement (new vendors) must be submitted to the State WIC Branch within 30 days from the date the contract is signed. Vendor Agreements, to renew current vendors, must be placed in the vendor files no later than November 1.

When Vendor Agreements are not received within these specified time frames, the State WIC Branch will proceed as follows:

1. After 30 days, a phone call will be made to the Vendor Coordinator.

2. After 60 days, a letter will be sent to the WIC Program Coordinator.

3. After 90 days, a letter will be sent to the Health Officer.

4. After 120 days, a letter will be sent to the vendor, notifying him that his store is not authorized to participate in the WIC Program.

VN - 6

GA WIC PROCEDURES MANUAL
When a store name changes and the owner remains the same, the local agency must have a new Vendor Agreement signed, update the system with a name change, and submit a copy of the Vendor Input/Registration form to the State WIC Branch and the ADP contractor. Vendor type should not be completed; this field is for State WIC Branch use only.
When a store address changes, the local agency must submit a copy of the Vendor Input/Registration form to the State WIC Office and the ADP contractor.
When ownership changes:
When a WIC authorized store is purchased by a WIC unauthorized store owner/manager, an application for vendor authorization must be completed by the new owner. The previous vendor stamp must be terminated at the time the ownership changes. A new vendor number will be issued to the new owner upon application approval (see Page VN-5 for Approval and Reauthorization Criteria for Vendors) by the State WIC Branch. A new Vendor Agreement must be signed by the new owner. WIC vouchers must not be accepted by a new owner during the application processing time for a change of ownership. If, for any reason, the store is not approved for WIC participation, the vendor will not be paid for any vouchers the store has redeemed. Should there be a delay in processing the application and the new owner is in possession of stale dated vouchers, the vendor will not be paid for those vouchers. The Vendor Agreement must be signed and a vendor stamp must be issued prior to vouchers being accepted.
If the manager who signed the original Vendor Agreement Contract and/or Vendor Training Checklist remains the same, the Local Agency will have the manager update the vendor file with a new Vendor Agreement Contract, Vendor Training Checklist, and an Application for Certification bearing the new owner's name, pertinent new information, and signature to be forwarded to the State WIC Branch.
The vendor stamp will remain in the possession of the new owner unless a replacement stamp issuance is necessary. If a replacement stamp is necessary, an input form must be forwarded to the ADP contractor and the Local Agency by the State WIC Branch to update the database system. If the vendor stamp remains the same, an input form must be forwarded to the ADP contractor and the State WIC Branch by the Local Agency to update the database system. The Local Agency representative must conduct a vendor review of WIC approved food items within 30 days after the store's authorization.
VN - 7

GA WIC PROCEDURES MANUAL
V. VENDOR STAMP
The State WIC Branch will provide the local agency with three vendor stamps at the initial Certification of the vendor. After the third stamp has been issued, it is the responsibility of the vendor to pay for any additional replacement stamps.
VI. VENDOR TRAINING
Vendor training will be conducted to inform vendors of the appropriate program policies and procedures pertaining to WIC vendors. (See Page VN-53.)
All new vendors must be trained prior to accepting any WIC vouchers.
Training will be required for vendors who do not comply with policy and procedures (high VIPS scores/flags, complaint letters/calls, previous warning letters, and/or sanctions). Refer to the Vendor Training Checklist (Attachment VN-7) for acceptable training tools.
All authorized WIC stores must be represented at the annual WIC vendor training by the owner/manager. Owner/manager may bring other store personnel to the training sessions.
Vendor Agreement Renewal - The owner/manager who is legally responsible for the store must attend vendor-training sessions and sign the Vendor Agreement on or before September 30 of the federal fiscal year. The store owner/manager who receives the training packet will be responsible for training store employee and may designate an employee(s) to conduct in-store training.
Pharmacy Agreement Renewal Annual Pharmacy Agreements and training packets are mailed to each pharmacy via certified mail. The pharmacy owner/manager who receive the training packet will be responsible for training pharmacy employees and may designate an employee(s) to conduct in-store training. Documentation of whom the pharmacy owner/manager designated to provide training shall be substantiated in writing to the State WIC Branch Via certified mail by September 20. A notarized Pharmacy Agreement must be returned to State WIC Branch by the designated deadline.
Included in the vendor training process, for the convenience of the vendor, is a Cashier Training Pamphlet. This pamphlet gives detailed instructions on how cashiers should redeem and process WIC vouchers (Attachment VN-10).
All training must be documented, using the Vendor Training Checklist (Attachment VN7), Vendor Training Sign-In Sheet (Attachment VN-8), and Post Vendor Training Evaluation (Attachment VN-12). The Vendor Training Checklist must be completed by the vendor at the end of each training session and submitted to the State WIC Branch attached to the Vendor Agreement.
VN - 8

GA WIC PROCEDURES MANUAL
The Vendor Training Sign-In Sheet must be completed for each training session. This form will indicate which vendors did not attend training, but later signed a Vendor Agreement. It will also indicate which vendors did not renew their Vendor Agreement. Vendor is allowed a grace period of ten working days to attend a make-up training session prior to September 30 of each year. Those vendors who do not renew their annual agreement will be terminated from the WIC Program.
Vendor Training Sign-In Sheets must be completed as follows: 1. When a local agency conducts vendor training, a copy of the Vendor Training Sign-In
Sheet must be sent to the State WIC Branch With 30 days after the training session.
2. When the State WIC Branch conducts vendor training, a copy of the Vendor Training Sign-In Sheet must be sent to the local agency within 30 days after the training session.
An owner/manager may be asked to show picture identification to ascertain that the person signing in for training is legally responsible for the store. Vendor Handbooks (Attachment VN-9) must be provided to all vendors.
VII. VENDOR MATERIALS
The following materials are available from the State WIC Office for vendor training and store use:
-Shelf Markers/Stickers - Is A WIC Food -WIC Cashier Training Pamphlet -Window Poster - We Welcome WIC Customers -WIC Approved Food Picture Pamphlet -WIC Approved Food Poster -Vendor Agreement -Pharmacy Agreement -Vendor Training Check-List -Vendor Review Form -Application for Vendor Certification Form -Return Voucher Payment Form (Log) -Vendor Handbook
VN - 9

GA WIC PROCEDURES MANUAL
-Pharmacy Handbook -Vendor Application Booklet -Vendor Training Sign-In Sheet -Post Vendor Training Evaluation -Incident/Complaint Form These materials can be ordered through the State WIC Office. The State WIC Branch will also distribute to Local Agencies, the Voucher Rejection Summary Report and highlight the information that indicates the number of vouchers that were flagged due to stale dating, post dating, and exceeding the voucher maximum.
VN - 10

GA WIC PROCEDURES MANUAL
VIII. MONITORING
A. Vendor Monitoring Procedures
All vendors will receive an on site visit. The Vendor Review Form (Attachment VN13) must be used for these monitoring visits. (Attachment VN-14, provides instructions for completing the form.) The following procedures must be used when monitoring vendors:
1. Each visit must be unannounced. 2. Introduce yourself to the storeowner or manager and explain the purpose of your
visit. 3. Complete the monitoring form, which will include recording the vendors'
compliance with minimum inventory requirements and recording of the vendors' shelf price information. 4. Review vendors' on hand vouchers for proper redemption procedures (i.e. signatures, purchase amount, and voucher use/deposit dates). 5. Discuss findings with the owner or manager. 6. The owner or manager must sign the form in the space provided. If they are unavailable, obtain the signature and date from the person in charge. 7. Give a copy of the form to the vendor (in the absence of the owner/manager give copy to the store representative). 8. Send a copy of the form to the State WIC Branch or local agency whichever applies.
The State WIC Branch will review the form, assign sanctions for violations when applicable, and notify the vendor of the sanctions issued within 60 days of receipt of the Vendor Review Form.
If violations are found during a monitoring visit (excluding vendor self reviews), another visit (follow-up) should be made within 60 days to determine if the violation(s) has been corrected. If the violation(s) has not been corrected, additional sanctions will be assigned.
B. Local Agency=s Responsibilities
Local Agencies should prepare a file for each vendor, inclusive of at least the following information for record retention:
* Copy of the original Application * Store Manager/Owner Signed Vendor Agreements (three years prior, plus the
current year) * Store Manager/Owner Signed Vendor Training Checklist (three years prior, plus
the current year if training is provided by Local or State Agency) * Monitoring Forms within past three years, plus the current year * Copies of Participant Complaints that involve vendors (when applicable)
VN - 11

GA WIC PROCEDURES MANUAL
* Correspondence copies forwarded to the Local Agency in reference to their district's specific vendors
* Copies of Vendor Input/Registration forms or VIPS Transaction Keypunch forms sent to the ADP Contractor and the State WIC Office
* Post Vendor Training Evaluation (if training is provided by Local or State Agency).
Local Agencies must conduct on site pre-approval monitoring visits for all vendor applicants.
Local Agencies must conduct a vendor review of perishable items within 30 days after vendor authorization only when WIC approved perishable food items were not available upon the pre-approval visit. Also, the use of the Annual Post Vendor Training Evaluation is optional to examine vendor/cashier training needs.
The Local Agency must establish a vendor application file that includes all pending vendor applications.
IX. COMPLIANCE INVESTIGATIONS
Compliance investigations will be coordinated by the Quality Improvement Unit of the State WIC Office (Refer to Quality Improvement Section of the Manual).
X. VENDOR SANCTIONS
Vendor violations are categorized by the severity and nature of the offense. The nature and severity of a violation(s) shall determine the sanction assessed, the duration of the probationary period, and the period of disqualification. Therefore, the highest sanctions assessed to a vendor shall determine the period of probation and/or disqualification.
Disqualification from the WIC Program may also result in disqualification from the Food Stamp Program. 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; Part 278). Such disqualification is not subject to administrative or judicial review by the Food Stamp Program.
The actual probation and disqualification periods are determined using the same formula for every vendor. All State Agency sanctions earned are retained on the vendor file for a period of one year. Mandatory sanctions will remain on the vendor=s file permanently. A description of the sanction system and how it works can be found on Page VN-55 of the Vendor Handbook (Attachment VN-9) and the Sanction System (Page VN-38).
XI. COMPLAINTS AGAINST VENDORS
All complaints made against a grocery store must be documented using the Incident/Complaint Form (Attachment VN-15). Individuals making complaints may
VN - 12

GA WIC PROCEDURES MANUAL
choose not to give their names. Copies of this form should be mailed to the appropriate agencies (i.e., District WIC Office, State WIC Branch).
When complaints are received against WIC vendors, a letter should be sent stating details of the complaint and quoting regulations that are potentially in violation and the sanction (if applicable) that could be assessed.
In the event an immediate resolution is not reached, the Local Agency must update the State WIC Branch of all unresolved complaints and vice versa. When a complaint is related to potential fraud (exchanging WIC vouchers for gas, cash, non food items, etc.) the Local Agency must follow these procedures at a minimum:
1. Send a letter notifying the vendor of the reported potential violations, and inform them of the sanctions that could be assessed for such violations. Advise vendors that a WIC investigator may visit their store to conduct a compliance investigation.
2. Send a copy of the vendor notification letter to the State WIC Branch.
3. Send a copy of the complaint form to the State WIC Branch.
4. Send a Request for Investigation form to the State WIC Branch.
Documentation of all complaints must remain in files for three years plus current year.
XII. TERMINATIONS/DISQUALIFICATIONS
When a store is terminated for any reason, the local agency must submit a Vendor Input/Registration form or VIPS Transaction Keypunch form to the ADP Contractor and the State WIC Branch (SWB).
A. Contract/Agreement Termination Policy Shelf prices (on WIC approved foods) of the vendor must be compatible with other stores within the same district. ACompatible@ means prices must not be more than 15 percent above the district average by peer groups of similar store type and/or size. The State WIC Branch shall provide written notification to the vendor(s) regarding the amount of overpricing involved by voucher code type. The vendor(s) shall reimburse the State WIC Program for any overpayment(s). If the vendor does not submit his/her payment within thirty (30) days, the State WIC Branch will forward a second written notification to the vendor requesting the overpaid amount. If the vendor fails to submit the requested overpayment after the second notification, the vendor will be given a third and final opportunity to submit the overpayment. If the vendor does not submit the overpaid amount by the requested date, the vendor will be terminated from WIC program participation for a ninety (90) day period. Terminated vendors must be notified, in writing, of the date of termination. Exceptions will be made if the vendor termination creates inadequate participant access (refer to Page VN-19, Inadequate Participant Access Cases).
VN - 13

GA WIC PROCEDURES MANUAL
B. The State WIC Branch will initiate vendor terminations for SWB disqualifications, USDA disqualifications and contract non-renewal. Each vendor is notified in writing of the termination.
All other terminations are initiated by the local agency. A copy of the Vendor Input/Registration form or VIPS Keypunch Transaction form must be sent to the State WIC Branch and the ADP Contractor within 30 days of termination.
C. Disqualifications will be based on the sanction system, compliance investigations, Food Stamp Program disqualified, etc. Any vendor disqualified from WIC may be disqualification fro the Food Stamp Program. Disqualified vendors will be notified in writing, at least 15 days before disqualification. This notice will include reasons for the action and information on the right to a fair hearing.
D. Inadequate Participant Access Cases If disqualifying a vendor causes inadequate participant access, the State Agency must 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/Civil Money Penalty or for a third or subsequent sanction as specified in 246.12(k)(l)(vi)).
If a vendor does not pay, only partially pays or fails to timely pay a CMP, the State Agency must disqualify the vendor for the full length of the disqualification corresponding to the violation for which the CMP was assessed.
An inadequate participant access case is granted only when the nearest authorized WIC vendor is 10 miles or more away from the nearest WIC clinic.
Verification of inadequate participant access must be conducted by the WIC Coordinator or designee and determined by the State Agency. The WIC Coordinator or designee must complete the "Verification Form" (Attachment QI-6) after physically driving the distance to obtain the exact mileage. This will be used to determine if a disqualified vendor will create inadequate participant access within the District/Unit. This form shall be received by the State Agency ten working days after receipt of the correspondence copy of a vendor disqualification letter, and no later than five working days prior to an administrative hearing for a disqualified vendor appellant.
III VENDOR FAIR HEARING PROCEDURES
To request a fair hearing, the vendor will call their WIC Coordinator and send a written request to the State WIC Branch. Should a fair hearing be requested prior to the deadline stated in the disqualification notice, the vendor authorization shall remain unchanged until final resolution has been attained at the administrative level. If a fair hearing request is received after the deadline stated in the disqualification notice, the vendor shall no longer be authorized for WIC Program participation.
Vendors may appeal decisions of the State WIC Branch or local agency when an application to participate in the WIC Program is denied, when participation is terminated,
VN - 14

GA WIC PROCEDURES MANUAL
or when other actions are taken which adversely affect the vendor's participation in the program.
A vendor must submit a written request for a fair hearing to the State WIC Branch within 15 days from the date of notification of an adverse action they wish to appeal.
The State WIC Branch will notify the Office of State Administrative Hearings of a vendor's request for a fair hearing.
The Office of State Administrative Hearings will schedule a hearing date within 45 days of the hearing request. The vendor will be notified of the time and place 15 days prior to the fair hearing date. All hearings will be held in the county where the vendor's store is located.
The proposed adverse action must be postponed from the time an administrative fair hearing is requested until a decision is reached by the Administrative Law Judge. Vendor hearings may be rescheduled one time by the vendor or the State WIC Branch.
The vendor will have ample opportunity to present his case at the hearing, including the opportunity to confront and cross-examine adverse witnesses. The vendor may be represented by counsel, if desired. The appellant may review the case file prior to the hearing.
The Administrative Law Judge (ALJ), Office of State Administrative Appeals, is an impartial decision maker with no personal involvement or interest in the outcome of the hearing. The ALJ=s decision shall rest solely on the evidence presented at the hearing and the statutory and regulatory provisions governing the program. The basis for the decision shall be stated in writing, although it need not amount to a full opinion or contain formal findings of fact and conclusions of law.
The ALJ and the State WIC Branch shall provide written notification of the decision to the vendor within 60 days from the date of the original request for a hearing.
The vendor must continue to comply with all written agreements if program participation continues during the appeal process.
The ALJ will explain any additional appeal mechanism upon request, including the right to a judicial review. If a vendor desires to appeal after an administrative hearing decision that has been granted in the State's favor, the vendor must follow the provisions of the Georgia Administrative Procedure Act (Code Section 50-13-16 and 50-13-17).
XIV. HIGH RISK VENDOR IDENTIFICATION
Vendor Integrity Profile System (VIPS)
Georgia WIC voucher redemptions are analyzed monthly by the contracted automated Data Processing System. VIPS tracks the activity of WIC vouchers and formulates detailed summary information through analysis of the voucher activity (data). Vendors
VN - 15

GA WIC PROCEDURES MANUAL
that exemplify high average value for vouchers redeemed or an abnormally low value for vouchers redeemed are flagged. VIPS also analyzes other indicators (the following definitions correspond with the alpha-numeric variables listed under the "vendor scores" field of Attachment VN-16):
A - Small Amt. of Price Variation B - Large percent of food instruments redeemed at same price C - High average price C1 - Peer C2 - Flag D - Redeemed price higher than Vendor Price List E - Large percent of High-priced FI E1 - Peer E2 - Flag E3 - Deviation F - WIC business High Volume G - Large increase in Volume over six months H - Vendor has large percent of total area redemption I - WIC Sales High percent of Total Vendor Sales J - WIC and Food Stamps High percent of Total Sales K - High WIC to Food Stamp Ratio L - Complaints from Clients, LA, Other Vendors M - Large percent of participants outside Vendor area N - Large number of clients at High Risk redeeming FI O - Large percent of Manual food instruments redeemed by Vendor P - Large percent of food instruments with consecutive serial #'s redeemed by
vendor Q - High percent of food instruments cashed same day
For each vendor these indicators are ranked monthly using a scoring system. The scoring system used to identify "high-risk" vendors (i.e., vendors who may be violating WIC Program rules, regulations and procedures), is used as a guide for scheduling compliance buy investigations. The Vendor Profile Report (Attachment VN-16) summarizes the vendor's activity.
XV. MINIMUM INVENTORY REQUIREMENTS WAIVER
Minimum inventory requirement waivers will be granted to vendors whose stores service fewer than six WIC women and/or children and six WIC infants per month. Therefore, the minimum inventory requirements will be reduced to satisfy the needs of the WIC participant population that reside in the vendor's area. The State WIC Branch will determine the minimum inventory requirements reduction within 30 days of receipt. The vendor must comply with the waiver requirement detailed in the Minimum Inventory Waiver Contract Addendum (Attachment VN-19) .
VN - 16

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 - 17

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 NoAre there at least 30 boxes of 9 oz. to 24 oz. WIC cereal in stock?

If no, how many? 6

Example:

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 Nowas 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 X No was cereal within current date limit? If no, how many were not? 2

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 - 18

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 - 19

GA WIC PROCEDURES MANUAL

Attachment VN-15

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 - 20

GA WIC PROCEDURES MANUAL

EXAMPLE

VENDOR PROFILE

*** Vendor Information ***

Vendor ID:

0482

Vendor Name:Mom and Pop Mini-Mart

Activity Date: 07/31/98

District Unit: 51

Vendor Type: 2

County:

116

*** Volume of Business ***

Vouchers Paid (Current Month):

553

$ Amount Paid (Current Month):

5,603

Vouchers Paid - Fiscal Year To Date:

3,558

$ Amount Paid - Fiscal Year To Date:

67,084

% Vouchers Exceed Fiscal Year 6-Month Average:

10.4

# Vouchers Exceed 6-Month Average:

52

% Of Total D/U Vouchers:

3.3

% Of County Vouchers:

82.7

# Vouchers Outside Vendor Area:

210

$ Amount earned for vouchers received outside Vendor Area: 2,092

% Vouchers Outside Vendor Area:

38.0

# Vouchers Paid Last 6 Months:

6

5

4

3

2

1

524

473

500

497

492

519

Attachment VN-16

*** Vendor Scores (07/98: Federal Fiscal Year 1998) ***

A B C1 C2 E1 E2 E3 F G H I M N O P Q TOT

95 98 8 0 100 0 0 1 1 0 8 0 38 0 3 20 392

XX

X

665 686 23 0 1125 0 0 12 12 0 60 0 266 0 3 120 2972

VN - 21

GA WIC PROCEDURES MANUAL

Attachment VN-19

VENDOR APPLICATION BOOKLET COVER LETTER HEALTH DEPARTMENT LETTERHEAD

__________________________ _____________________________________________ _____________________________________________ _____________________________________________

Dear Perspective WIC Vendor (Store Owner):

Per your request, enclosed are 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 application; without it, your application will not be approved. If you do not already have a number, you may call (404) 6563632 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 - 22

GA WIC PROCEDURES MANUAL
Attachments: VN-1 Vendor Application Booklet VN-2 Application for Vendor Certification VN-3 Vendor Input/Registration Document VN-4 Vendor Agreement VN-5 Military Commissary Agreement VN-6 Pharmacy Agreement VN-7- Vendor Training Checklist VN-8- Vendor Training Sign-In-Sheet VN-9 Vendor Handbook VN-10 Cashier Training Pamphlet VN-11 Return Voucher Payment Log VN-12 Post Vendor Training Evaluation VN-13 Vendor Review Form (include Price Report List) VN-14 Vendor Review Form Instructions VN-15 Incident/Complaint Form VN-16 Vendor Profile Report VN-17 Vendor Application Booklet Cover Letter VN-18 Pharmacy Handbook VN-19 Minimum Inventory Waiver Contract Addendum
VN - 23

GA WIC PROCEDURES MANUAL

TABLE OF CONTENTS

Page

I. Authorization of Foods ..................................................................................................FP-1

II. Prescribing Foods, General............................................................................................FP-1

A. Contract Versus Non-Contract Formula ...............................................................FP-1

B. Food Groups..........................................................................................................FP-3

C. Food Packages ......................................................................................................FP-4

D. Documentation Required ......................................................................................FP-5

III. Infants .......................................................................................................................FP-6

A. Tailoring.............................................................................................................FP-6

B. Infants 0 Through 4 Months ..............................................................................FP-8

C. Infants 5 Through 12 Months ..........................................................................FP-11

IV. Children and Women with Special Dietary Needs ......................................................FP-14

A. Tailoring...........................................................................................................FP-14

B. Food Package Assignment...............................................................................FP-14

C. Standard Manual Food Package ......................................................................FP-14

D. Additional Documentation...............................................................................FP-14

V. Children 1 to 5 Years ...................................................................................................FP-17

A. Tailoring...........................................................................................................FP-17

B. Food Package Assignment...............................................................................FP-17

C. Standard Manual Food Package ......................................................................FP-17

D. Additional Documentation...............................................................................FP-18

VI. Pregnant and Breastfeeding Women............................................................................FP-18

A. Tailoring...........................................................................................................FP-18

B. Food Package Assignment...............................................................................FP-19

C. Standard Manual Food Package ......................................................................FP-19

D. Additional Documentation...............................................................................FP-20

GA WIC PROCEDURES MANUAL
Page VII. Postpartum, Non-Breastfeeding Women .....................................................................FP-20
A. Tailoring...........................................................................................................FP-20 B. Food Package Assignment...............................................................................FP-21 C. Additional Documentation...............................................................................FP-21 VIII. Homelessness, Migrancy, And Disaster Situations .....................................................FP-22 A. Alternate Food Package Assignment ...............................................................FP-22 B. Method for Food Package Assignment............................................................FP-22 C. Assignment of Food Package Number ............................................................FP-22 D. Documentation Requirements..........................................................................FP-23 E. Alternate Food Packages .................................................................................FP-23 Attachments: FP-1 Infant Food Packages,
Maximum Monthly Amounts Authorized .......................................................FP-27

FP-2 Infant Food Packages, Contract Formula ........................................................FP-28

FP-3 Infant Food Packages, Non-Contract Formula ................................................FP-38

FP-4 Alternate Food Package for Infants (0-4 Months), Maximum Monthly Amounts Authorized, Contract Formula ........................FP-42

FP-5 Alternate Food Package for Infants (0-4 Months), Contract Formula .............................................................................................FP-43

FP-6 Alternate Food Package for Infants (5-12 Months), Maximum Monthly Amounts Authorized, Contract Formula .........................FP-44

FP-7 Alternate Food Package for Infants (5-12 Months), Contract Formula .............................................................................................FP-45

FP-8 Food Packages for Children and Women with Special Dietary Needs, Maximum Monthly Amounts Authorized ...........................................FP-46

FP-9 Children's and Women's Packages, Prescription Required..............................FP-47

Attachments (cont'd):

Page

GA WIC PROCEDURES MANUAL
FP-10 Alternate Food Packages for Children and Women with Special Dietary Needs, Maximum Monthly Amounts Authorized ..............................FP-57
FP-11 Alternate Food Packages For Children and Women with Special Dietary Needs..............................................................................FP-58
FP-12 Children's Food Packages, Maximum Monthly Amounts Authorized .......................................................FP-59
FP-13 Children's Food Packages ................................................................................FP-60
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 Exclusively Breastfeeding Food Packages ......................................................FP-73
FP-19 Alternate Food Packages for Pregnant and Breastfeeding Women, Maximum Monthly Amounts Authorized .......................................................FP-74
FP-20 Alternate Food Packages for Pregnant and Breastfeeding Women .................FP-75
FP-21 Postpartum, Non-Breastfeeding Women's Food Packages, Maximum Monthly Amounts Authorized .......................................................FP-77
FP-22 Postpartum, Non-Breastfeeding Women's Food Packages..............................FP-78
FP-23 Alternate Food Packages for Postpartum, Non-Breastfeeding Women, Maximum Monthly Amounts Authorized.........................................FP-81
FP-24 Alternate Food Package for Postpartum, Non-Breastfeeding Women ............................................................................................................. FP-82

GA WIC PROCEDURES MANUAL Attachments (cont'd):

Page

FP-25 Georgia WIC Program Formula Referral Form...............................................FP-83

FP-26 Georgia WIC Approved Food List, Criteria to Evaluate an Eligible Food Item ...........................................................................................FP-84

FP-27 Georgia WIC Program, WIC Approved Food List ..........................................FP-87

FP-28 Georgia WIC Program, WIC Approved Alternate Food List ................................................................FP-88

FP-29 WIC Approved Formulas/Medical Foods........................................................FP-89

FP-30 Procurement of Hospital Based Formula ........................................................FP-94

FP-31 Hospital Based Formula Order Form...............................................................FP-95

FP-32 Supplemental Formula Conversion Table .......................................................FP-96

FP-33 Formula Food Package Index Reference Pages ...............................................FP-97

GA WIC PROCEDURES MANUAL

I. AUTHORIZATION OF FOODS

The State food package tailoring policy is:

A competent professional authority (CPA)* shall prescribe types of supplemental foods and the food package in quantities appropriate for each participant, taking into consideration the participant's age and dietary needs. The amounts of supplemental foods 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.

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, 2002), 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), Isomil 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, Isomil 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.

FP-1

GA WIC PROCEDURES MANUAL

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

Enfamil

Carnation Good Start

Enfamil Next Step

Store Brand milk based formulas that are USDA approved

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.

2. Soy Based Formula:

All participants who receive a soy based formula, will receive the contract formula Isomil 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

Enfamil Next Step Soy with iron

Prosobee with Iron

Carnation Follow-Up Soy with iron

Store Brand soy based formulas that are USDA approved

3. Lactose Free Formula:

All participants who receive a milk based, lactose free formula will receive the contract formula Similac 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
FP-2

GA WIC PROCEDURES MANUAL
and prescription.
The following non-contract milk based, lactose free formula is NOT APPROVED for distribution by the Georgia WIC Program: Enfamil Lactofree. 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.
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
II
III
IV V

Age/Condition

Computer Food Package Series Number

Infants 0 Through 3 Months (0 through 4 months in the Georgia WIC Program

111, 152, 153, 121, 163, 133, 134, 180, 183, 243, 246, 248, 252, 256, 262, 263, 273, 283, 293, 299, 999

Infants 4 Through 12 Months (5 through 12 months in the Georgia WIC Program)

114, 155, 156, 157, 158, 166, 131, 136, 137, 181, 186, 221, 226, 228, 244, 245, 247, 255, 257, 264, 265, 266, 286, 296, 297, 999

Children/Women with Special Dietary Needs
Children 1 to 5 Years

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, 394, 999
600-607, 610, 999

Pregnant and Breastfeeding 401- 408, 410, 999 Women

FP-3

GA WIC PROCEDURES MANUAL

Food Group from the Federal WIC Regulations
VI
VII

Computer Food Package Series Number
501-504, 510, 999
408, 411, 999

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-19, FP-21, and FP-23.
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-20, FP-22, and FP24 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.
FP-4

GA WIC PROCEDURES MANUAL 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 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 of cheese per month e. Low iron formulas (e.g., as indicated for conditions such as hemochromatosis) f. Hospital based formulas g. Disaster situations
FP-5

GA WIC PROCEDURES MANUAL
III. INFANTS
Food Group I is for infants 0 through 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 of any ingredients other than water prior to being served in a liquid state, and which contains at least ten (10) 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 Nutrition Section 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-29.
FP-6

GA WIC PROCEDURES MANUAL
WIC approved non-contract formulas and medical foods designed for enteral feeding may be authorized when a physician determines that the infant has a medical condition/diagnosis which contraindicates the use of 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 of Diseases, 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 Nutrition Section, 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 Nutrition Section, 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 0 through 4 months of age. The Nutrition Section, Nutrition Guidelines for Practice recommend that cereal be introduced when the infant is 5-6 months of age and developmentally ready. A maximum of twenty-four (24) ounces of cereal per month is authorized.
4. Juice. Juice is not authorized for the infant 0 through 4 months of age. The Nutrition Section, 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.
FP-7

GA WIC PROCEDURES MANUAL
B. Infants 0 Through 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 0 through 4 months of age are listed on Attachments FP-2, FP-3, and FP-5. The use of the contract 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, 252, 255, 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, or low iron formula.
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
FP-8

GA WIC PROCEDURES MANUAL
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 non-contract formula orders will not be accepted.
(2) A physician's written or verbal order is required prior to food package assignment by the WIC Competent Professional Authority (CPA). When a written order is not present, confirmation of a verbal order must be requested from the physician. The verbal order and the request for confirmation must be documented in the patient's health record.
(3) A current order is required at initial and subsequent certification, mid-certification 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 and hospital based formula). 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.
FP-9

GA WIC PROCEDURES MANUAL
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 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 Nutrition Section or in rare instances through a local pharmacy that is a WIC Vendor. See Attachment FP-30 for procedures and Attachment FP-31 for the order form to use when acquiring a product through the Nutrition Section. 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.
FP-10

GA WIC PROCEDURES MANUAL
C. Infants 5 Through 12 Months
Food Group II consists of formula, iron-fortified cereal, and juice.
1. 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 non-contract 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, and 999
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 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, or low iron formula.
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
FP-11

GA WIC PROCEDURES MANUAL
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 pre-stamped contract formula/prescription required or non-contract formula orders will not be accepted.
(2) A physician's written or verbal order is required prior to food package assignment by the WIC Competent Professional Authority (CPA). When a written order is not present, confirmation of a verbal order must be requested from the physician. The verbal order and the request for confirmation must be documented in the patient's health record.
(3) A current order is required at initial and subsequent certification, mid-certification 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 and hospital based formula). 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.
FP-12

GA WIC PROCEDURES MANUAL
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 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 Nutrition Section or in rare instances through a local pharmacy that is a WIC Vendor. See Attachment FP-30 for procedures and Attachment FP-31 for the order form to use when acquiring a product through the Nutrition Section. 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.
FP-13

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 (tube 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. For a list of Georgia WIC Program approved formulas see Attachment FP-29.
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, 394, 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, or hospital based formula.
FP-14

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 required or non-contract formula (excluding low iron formulas, and hospital based formulas). The nurse's order must be documented in the participant's health record. When a written order is not present, confirmation of a verbal order must be documented in the participant's health record.
3. 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-15

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 Nutrition Section or in rare instances through a local pharmacy that is a WIC Vendor. See Attachment FP30 for procedures and Attachment FP-31 for the order form to use when acquiring a product through the Nutrition Section. 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.
7. Additional Formula. The need for additional formula above the maximum must be documented by the CPA in the participant's health record. See Attachments FP-8 and FP-10 for maximum formula amounts.
FP-16

GA WIC PROCEDURES MANUAL
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.
FP-17

GA WIC PROCEDURES MANUAL
The CPA may require 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.
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.
FP-18

GA WIC PROCEDURES MANUAL
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-20. 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-19 for the authorized foods and the maximum amounts allowed per month.
C. Standard Manual Food Package
The CPA will assign a food package upon certification and the computer food package number that matches the assigned food package will be given to the participant. The standard manual food package for prenatal and breastfeeding women is food package 404. The standard manual will be issued for all prenatal and breastfeeding women until the computer vouchers for the assigned food package are generated. The CPA may require the assigned food package be given to the participant at the time of certification. The CPA must state this in the "Comments" section of the WIC Assessment/Certification Form. The actual assigned food package must then be issued instead of the standard manual.
FP-19

GA WIC PROCEDURES 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.
VII. POSTPARTUM, NON-BREASTFEEDING WOMEN
Food Group VI consists of milk, cheese, cereal, juice, and eggs.
A. Tailoring
Generally, this group of participants does not have the increased nutrient needs of the prenatal and breastfeeding women. Therefore, the maximum amounts allowed for each food group are reduced.
1. Increased Need. Adolescents have a higher need for calcium than the adult woman. Caloric needs may also be higher, thus the maximum amounts are recommended. Underweight women may also need the maximum amounts 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 FP-20

GA WIC PROCEDURES MANUAL 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-22 and FP-24. 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-21 and FP-23 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 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-21

GA WIC PROCEDURES MANUAL
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 maximum monthly amount per item or include unapproved combinations of WIC foods. If retail purchase is not
FP-22

GA WIC PROCEDURES MANUAL
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. Disaster situations
E. Alternate Food Packages
1. Infants 0 Through 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. Breastmilk is the best food for the normal infant. Infant formula should not be provided to breastfeeding participants unless requested. If a mother chooses to supplement her breastfeeding with infant formula, powdered formula is recommended. However ready-to-feed is available. The use of the FP-23

GA WIC PROCEDURES MANUAL

contract formula is required unless a contract formula/prescription required or non-contract 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, noncontract 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 juice. 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-to-feed formula is also available. The use of the contract formula 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

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, or a low iron formula. See FP-13 through FP-15 for specific documentation requirements.
FP-24

GA WIC PROCEDURES MANUAL
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, 100%, vitamin C fortified juice, and peanut butter. Food package 410 may be assigned to pregnant and breastfeeding women. Exclusively breastfeeding women (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-20. Food package 408 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
FP-25

GA WIC PROCEDURES MANUAL 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-26

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-27

GA WIC PROCEDURES MANUAL
INFANT FOOD PACKAGES CONTRACT FORMULA

Attachmemt FP-2

FOOD PACKAGE NUMBER

VOUCHER CODE

VOUCHER MESSAGE

152

002

FORMULA:

12 1 QT (946 mL) PLASTIC BOTTLES

25- 1QT (946 mL) PLASTIC

READY TO FEED SIMILAC OR 12- 1 QT

BOTTLES READY TO FEED

(946 mL) CANS ISOMIL

IRON FORTIFIED SIMILAC

OR 25- 1 QT (946 mL) CANS

IRON FORTIFIED

ISOMIL

NO LOW IRON FORMULA ALLOWED

003

FORMULA:

13 1 QT (946 mL) PLASTIC BOTTLES

READY TO FEED SIMILAC OR 13- 1 QT

(946 mL) CANS ISOMIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

153* 31 CANS 13 OZ CONCENTRATE IRON FORTIFIED SIMILAC OR ISOMIL

004

FORMULA:

15 - 13 OZ CANS CONCENTRATE

SIMILAC OR ISOMIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

* STANDARD MANUAL

005

FORMULA:

16 - 13 OZ CANS CONCENTRATE

SIMILAC OR ISOMIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

155 25- 1 QT (946 mL) PLASTIC BOTTLES READY TO FEED IRON FORTIFIED SIMILAC OR 25- 1 QT (946 mL) CANS ISOMIL 2 CANS JUICE 24 OZ INFANT CEREAL

007

FORMULA:

13 1 QT (946mL) PLASTIC BOTTLES

READY TO FEED SIMILAC OR 13-1 QT

(946 mL) CANS ISOMIL

JUICE:

1 - 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

011

FORMULA:

12 1 QT (946 mL) PLASTIC BOTTLES

READY TO FEED SIMILAC OR 12-1 QT

(946 mL) CANS ISOMIL

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-28

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
157 31 CANS 13 OZ CONCENTRATE IRON FORTIFIED SIMILAC OR ISOMIL 2 CANS JUICE
158 31 CANS 13 OZ CONCENTRATE IRON FORTIFIED SIMILAC OR ISOMIL 2 CANS JUICE 16 OZ INFANT CEREAL

VOUCHER CODE

VOUCHER MESSAGE

008

FORMULA:

16 - 13 OZ CANS CONCENTRATE

SIMILAC OR ISOMIL

JUICE:

1 - 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

012

FORMULA:

15 - 13 OZ CANS CONCENTRATE

SIMILAC OR ISOMIL

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

009

FORMULA:

16 - 13 OZ CANS CONCENTRATE

SIMILAC OR ISOMIL

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

012

FORMULA:

15 - 13 OZ CANS CONCENTRATE

SIMILAC OR ISOMIL

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

012

FORMULA:

15 - 13 OZ CANS CONCENTRATE

SIMILAC OR ISOMIL

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

087

FORMULA:

16 - 13 OZ CANS CONCENTRATE

SIMILAC OR ISOMIL

JUICE:

1 - 12 OZ CAN FROZEN OR 1 - 46 OZ CAN OR 1-11.5 OZ CAN POURABLE

CEREAL:

UP TO 16 OZ INFANT

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FP-29

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 SIMILAC 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 14.1 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 OR ISOMIL

089

FORMULA:

13 - 13 OZ CANS CONCENTRATE

SIMILAC OR ISOMIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

257 13 CANS 13 OZ CONCENTRATE IRON FORTIFIED SIMILAC OR ISOMIL 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-30

GA WIC PROCEDURES MANUAL

Attachment FP-2 cont'd

FOOD PACKAGE NUMBER

VOUCHER CODE

VOUCHER MESSAGE

221 2 CANS JUICE 24 OZ INFANT CEREAL

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

262 1 CAN 14.1 OZ POWDER IRON FORTIFIED SIMILAC OR 1 CAN 14 OZ POWDER ISOMIL

014

FORMULA:

1 - 14.1 OZ CAN POWDER SIMILAC OR

1 - 14 OZ CANS POWDER ISOMIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

263

015

FORMULA:

4 - 14.1 OZ CANS POWDER SIMILAC

4 CANS 14.1 OZ POWDER

OR 4 - 14 OZ CANS POWDER ISOMIL

IRON FORTIFIED SIMILAC

OR 4 CANS 14 OZ POWDER

IRON FORTIFIED

ISOMIL

NO LOW IRON FORMULA ALLOWED

264 1 CAN 14.1 OZ POWDER IRON FORTIFIED SIMILAC OR 1 CAN 14 OZ POWDER ISOMIL 2 CANS JUICE 24 OZ INFANT CEREAL

016

FORMULA:

1 - 14.1 OZ CAN POWDER SIMILAC OR

1 - 14 OZ CAN 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

265

017

FORMULA:

4 - 14.1 OZ CANS POWDER SIMILAC OR

4 CANS 14.1 OZ POWDER

4 - 14 OZ CANS POWDER ISOMIL

IRON FORTIFIED SIMILAC OR 4 CANS 14 OZ POWDER ISOMIL 2 CANS JUICE

JUICE: CEREAL:

2 - 12 OZ CANS FROZEN OR 2 - 46 OZ CANS OR 2-11.5 OZ CANS POURABLE
UP TO 24 OZ INFANT

24 OZ INFANT CEREAL

IRON FORTIFIED

NO LOW IRON FORMULA ALLOWED

299 BREASTFEEDING
MESSAGE

059

NURSE YOUR BABY OFTEN

THE MORE YOU BREASTFEED, THE MORE MILK YOU

WILL HAVE FOR YOUR BABY

FP-31

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-32

GA WIC PROCEDURES MANUAL
INFANT FOOD PACKAGES CONTRACT FORMULA Prescription Required

Attachment FP-2 cont'd

FOOD PACKAGE NUMBER 252
25- 1QT (946 mL) CANS READY TO FEED IRON FORTIFIED SIMILAC LACTOSE FREE
293 31 CANS 13 OZ CONCENTRATE IRON FORTIFIED SIMILAC LACTOSE FREE
255 25- 1QT (946 mL) CANS READY TO FEED IRON FORTIFIED SIMILAC LACTOSE FREE 2 CANS JUICE 24 OZ INFANT CEREAL

VOUCHER CODE 102
103
364 365
107

VOUCHER MESSAGE

FORMULA:

12-1 QT (946 mL) CANS READY TO FEED SIMILAC LACTOSE FREE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA:

13-1 QT (946 mL) CANS READY TO FEED SIMILAC LACTOSE FREE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA: 15-13 OZ CANS CONCENTRATE SIMILAC LACTOSE 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: JUICE CEREAL:

13-1 QT (946 mL) CANS READY TO FEED SIMILAC LACTOSE FREE
1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-11.5 OZ CAN POURABLE
UP TO 24 OZ INFANT

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

111

FORMULA: 12-1 QT (946 mL) CANS READY TO FEED

SIMILAC LACTOSE FREE

JUICE:

1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-15 OZ CAN POURABLE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FP-33

GA WIC PROCEDURES MANUAL

Attachment FP-2 cont'd

FOOD PACKAGE NUMBER 296
31 CANS 13 OZ CONCENTRATE IRON FORTIFIED SIMILAC LACTOSE FREE 2 CANS JUICE 24 OZ INFANT CEREAL
297 31 CANS 13 OZ CONCENTRATE IRON FORTIFIED SIMILAC LACTOSE FREE 2 CANS JUICE

VOUCHER CODE 368
372
369
372

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 24 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: JUICE:

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

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

FP-34

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 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-35

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 1 CAN 14 OZ POWDER 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 392 073
374
391
475
073 391
475

VOUCHER MESSAGE

FORMULA: 13-13 OZ CANS CONCENTRATE 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

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED
FORMULA: 1-14 OZ CAN POWDER SIMILAC LACTOSE FREE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED
FORMULA: 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:

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 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

FP-36

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-37

GA WIC PROCEDURES MANUAL

Attachment FP-3

FOOD PACKAGE NUMBER
111 8 CANS 16 OZ POWDER PORTAGEN OR PREGESTIMIL
114 8 CANS 16 OZ POWDER PORTAGEN OR PREGESTIMIL 2 CANS 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 OR 25 QTS. READY TO FEED ALIMENTUM 2 CANS JUICE 24 OZ INFANT CEREAL

INFANT FOOD PACKAGES NON-CONTRACT FORMULA
Prescription Required

VOUCHER CODE

VOUCHER MESSAGE

060

FORMULA: 4 - 1 LB CANS POWDER PORTAGEN OR

PREGESTIMIL

060

FORMULA: 4 - 1 LB CANS POWDER PORTAGEN OR

PREGESTIMIL

060

FORMULA: 4 - 1 LB CANS POWDER

PORTAGEN OR PREGESTIMIL

060

FORMULA: 4 - 1 LB CANS POWDER

PORTAGEN OR PREGESTIMIL

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

160

FORMULA: 4 - 1 LB CANS POWDER OR

15 - 13 OZ CANS CONCENTRATE

NUTRAMIGEN OR 12 QTS READY-TO-

FEED ALIMENTUM

161

FORMULA: 4 - 1 LB CANS POWDER OR

16 - 13 OZ CANS CONCENTRATE

NUTRAMIGEN OR 13 QTS READY-TO-

FEED ALIMENTUM

160

FORMULA: 4 - 1 LB CANS POWDER OR

15 - 13 OZ CANS CONCENTRATE

NUTRAMIGEN OR 12 QTS READY-TO-

FEED ALIMENTUM

161

FORMULA: 4 - 1 LB CANS POWDER OR

16 - 13 OZ CANS CONCENTRATE

NUTRAMIGEN OR 13 QTS READY-TO-

FEED ALIMENTUM

073

JUICE:

2 - 12 OZ CANS FROZEN OR 2 -46 OZ CANS OR 2- 11.5 OZ CANS POURABLE

CEREAL:

UP TO 24 OUNCES INFANT

FP-38

GA WIC PROCEDURES MANUAL

Attachment FP-3 con't

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 2 CANS JUICE 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 CANS 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 CANS 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-39

GA WIC PROCEDURES MANUAL

Attachment FP-3 con't

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 CANS 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-40

GA WIC PROCEDURES MANUAL

Attachment FP-3 con't

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:

4 - 14 OZ CANS POWDER PROSOBEE OR CARNATION ALSOY OR GERBER SOY

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FP-41

GA WIC PROCEDURES MANUAL

Attachment FP-4d

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-42

GA WIC PROCEDURES MANUAL

Attachment FP-5

ALTERNATE FOOD PACKAGE FOR INFANTS (0-4 MONTHS) CONTRACT FORMULA

FOOD PACKAGE NUMBER

VOUCHER CODE

VOUCHER MESSAGE

180
100 -8 OZ CANS READY TO FEED IRON FORTIFIED SIMILAC OR ISOMIL

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

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

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

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

FP-43

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-44

GA WIC PROCEDURES MANUAL

Attachment FP-7

ALTERNATE FOOD PACKAGE FOR INFANTS (5-12 MONTHS) CONTRACT FORMULA

FOOD PACKAGE NUMBER

VOUCHER CODE

VOUCHER MESSAGE

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

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

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

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 SIMILAC OR

ISOMIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

INFANT CEREAL:

1-8 OZ BOX, DRY

JUICE:

6-6 OZ CANS

202

FORMULA:

13-8 OZ CANS READY- TO -FEED SIMILAC OR

ISOMIL

INFANT CEREAL:

1-8 OZ BOX, DRY

JUICE:

6-6 OZ CANS

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:

1-8 OZ BOX, DRY

FP-45

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 806 oz 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-46

GA WIC PROCEDURES MANUAL

Attachment FP-9

CHILDREN'S AND WOMEN'S PACKAGES Prescription Required

FOOD PACKAGE NUMBER

VOUCHER CODE

VOUCHER MESSAGE

311 8 CANS 16 OZ POWDER PORTAGEN OR PREGESTIMIL

060

FORMULA:

4-1 LB CANS POWDER PORTAGEN OR

PREGESTIMIL

060

FORMULA:

4-1 LB CANS POWDER PORTAGEN OR

PREGESTIMIL

315 8 CANS 16 OZ POWDER PORTAGEN OR PREGESTIMIL 3 CANS JUICE 24 OZ CEREAL

060

FORMULA:

4 - 1 LB CANS POWDER PORTAGEN

OR PREGESTIMIL

060

FORMULA:

4 - 1 LB CANS POWDER PORTAGEN

OR PREGESTIMIL

066

JUICE:

CEREAL:

3 - 12 OZ CANS FROZEN OR 3 - 46 OZ CANS OR 3-11.5 OZ CANS POURABLE
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 - 1 LB CANS POWDER OR 19 - 13 OZ

READY TO FEED

CANS CONCENTRATE NUTRAMIGEN

ALIMENTUM

OR 14 QTS. READY-TO-FEED

3 CANS JUICE

ALIMENTUM

36 OZ CEREAL

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-47

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 24 OZ CEREAL
376 31 CANS 13 OZ CONCENTRATE IRON FORTIFIED SIMILAC LACTOSE FREE 2 CANS JUICE 24 OZ CEREAL
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

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

379

FORMULA:

13-13 OZ CANS CONCENTRATE

SIMILAC LACTOSE FREE

JUICE:

1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-11.5 OZ CAN POURABLE

CEREAL

UP TO 24 OZ

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

SIMILAC LACTOSE FREE

JUICE:

1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-11.5 OZ CAN POURABLE

CEREAL:

UP TO 24 OZ

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 CAN OR 1-11.5 OZ CAN POURABLE

CEREAL:

UP TO 36 OZ

FP-48

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
394 25 - 1 QT (946 mL) CANS READY TO FEED IRON FORTIFIED SIMILAC LACTOSE FREE 2 CANS JUICE 24 OZ CEREAL
392 9 CANS 14 OZ POWDER IRON FORTIFIED SIMILAC LACTOSE FREE

VOUCHER CODE

VOUCHER MESSAGE

384

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

CEREAL:

UP TO 36 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

120

FORMULA:

12-1 QT (946 mL) CANS READY TO

FEED 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

121

FORMULA:

13-1 QT (946 mL) CANS READY TO

FEED SIMILAC LACTOSE FREE

JUICE:

1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-11.5 OZ CAN POURABLE

CEREAL:

UP TO 24 OZ

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

391

FORMULA

5-14 OZ CANS POWDER

SIMILAC 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-49

GA WIC PROCEDURES MANUAL

Attachment FP-9 cont'd

FOOD PACKAGE NUMBER 303
8 CANS 14 OZ POWDER IRON FORTIFIED SIMILAC LACTOSE FREE 3 CANS JUICE 24 OZ CEREAL
306 9 CANS 14 OZ POWDER IRON FORTIFIED SIMILAC LACOSE FREE 3 CANS JUICE 24 OZ CEREAL

VOUCHER CODE

VOUCHER MESSAGE

066

JUICE:

CEREAL:

3-12 OZ CANS FROZEN OR 3-46 OZ CANS OR 3-11.5 OZ CANS POURABLE
UP TO 24 OZ

475

FORMULA:

4-14 OZ CANS POWDER

SIMILAC 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:

CEREAL:

3-12 OZ CANS FROZEN OR 3-46 OZ CANS OR 3-11.5 OZ CANS POURABLE
UP TO 24 OZ

391

FORMULA:

5-14 OZ CANS POWDER

SIMILAC 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-50

GA WIC PROCEDURES MANUAL

Attachment FP-9 cont'd

FOOD PACKAGE NUMBER 307
9 CANS 14 OZ POWDER IRON FORTIFIED SIMILAC LACTOSE FREE 3 CANS JUICE 36 OZ CEREAL
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

VOUCHER MESSAGE

070

JUICE:

CEREAL:

3-12 OZ CANS FROZEN OR 3-46 OZ CANS OR 3-11.5 OZ CANS POURABLE
UP TO 36 OZ

391

FORMULA:

5-14 OZ CANS POWDER

SIMILAC 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

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

018

FORMULA:

12 - 13 OZ CANS CONCENTRATE

SIMILAC OR ISOMIL

JUICE:

1 - 12 OZ CAN FROZEN OR 1 - 46 OZ CAN OR 1-11.5 OZ CAN POURABLE

IRON FORTIFIED NO LOW IRON FORMLA ALLOWED

019

FORMULA:

13 - 13 OZ CANS CONCENTRATE

SIMILAC OR ISOMIL

JUICE:

1 - 12 OZ CAN FROZEN OR 1 - 46 OZ CAN OR 1-11.5 OZ CAN POURABLE

CEREAL:

UP TO 24 OZ

FP-51

GA WIC PROCEDURES MANUAL

Attachment FP-9 cont'd

FOOD PACKAGE NUMBER

VOUCHER CODE

VOUCHER MESSAGE

354

020

FORMULA:

12 1 QT (946 mL) PLASTIC BOTTLES

25- 1 QT (946 mL) PLASTIC

READY-TO-FEED SIMILAC OR 12-1

BOTTLES

QT (946 mL) CANS ISOMIL

READY TO FEED IRON FORTIFIED SIMILAC OR 25- 1 QT (946 mL) CANS

JUICE:

1 - 12 OZ CAN FROZEN OR 1 - 46 OZ CAN OR 1-11.5 OZ CAN POURABLE

ISOMIL 2 CANS JUICE 24 OZ CEREAL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

021

FORMULA:

13 1 QT (946mL) PLASTIC BOTTLES

READY-TO-FEED SIMILAC OR 13-1

QT (946 mL) CANS ISOMIL

JUICE:

1 - 12 OZ CAN FROZEN OR 1 - 46 OZ CAN OR 1-11.5 OZ CAN POURABLE

CEREAL:

UP TO 24 OZ

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

356 31 CANS 13 OZ CONCENTRATE IRON FORTIFIED SIMILAC OR ISOMIL 2 CANS JUICE 24 OZ CEREAL

022

FORMULA:

15 - 13 OZ CANS CONCENTRATE

SIMILAC OR ISOMIL

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

023

FORMULA:

16 - 13 OZ CANS CONCENTRATE

SIMILAC OR ISOMIL

JUICE:

1 - 12 OZ CAN FROZEN OR 1 - 46 OZ CAN OR 1-11.5 OZ CAN POURABLE

CEREAL:

UP TO 24 OUNCES

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FP-52

GA WIC PROCEDURES MANUAL

Attachment FP-9 cont'd

FOOD PACKAGE NUMBER 357
31 CANS 13 OZ CONCENTRATE IRON FORTIFIED SIMILAC OR ISOMIL 2 CANS JUICE 36 OZ CEREAL
359 35 CANS 13 OZ CONCENTRATE IRON FORTIFIED SIMILAC OR ISOMIL 2 CANS JUICE 36 OZ CEREAL

VOUCHER CODE

VOUCHER MESSAGE

022

FORMULA:

15 - 13 OZ CANS CONCENTRATE

SIMILAC OR ISOMIL

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

024

FORMULA:

16 - 13 OZ CANS CONCENTRATE

SIMILAC OR ISOMIL

JUICE:

1 - 12 OZ CAN FROZEN OR 1 - 46 OZ

CAN OR 1-11.5 OZ CAN POURABLE

CEREAL:

UP TO 36 OZ

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

024

FORMULA: 16 - 13 OZ CANS CONCENTRATE

SIMILAC OR ISOMIL

JUICE:

1 - 12 OZ CAN FROZEN OR 1 - 46 OZ CAN OR 1-11.5 OZ CAN POURABLE

CEREAL:

UP TO 36 OZ

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

026

FORMULA: 19 - 13 OZ CANS CONCENTRATE

SIMILAC OR ISOMIL

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-53

GA WIC PROCEDURES MANUAL

Attachment FP-9 cont'd

FOOD PACKAGE NUMBER
362 10 CANS 14.1 OZ POWDER IRON FORTIFIED SIMILAC OR 10-14 OZ CANS POWDER ISOMIL
363 8 CANS 14.1 OZ POWDER IRON FORTIFIED SIMILAC OR 8 CANS 14 OZ POWDER ISOMIL 3 CANS JUICE 24 OZ CEREAL

VOUCHER CODE

VOUCHER MESSAGE

088

FORMULA: 5 - 14.1 OZ CANS POWDER SIMILAC

OR 5 - 14 OZ CANS POWDER ISOMIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

088

FORMULA: 5 - 14.1 OZ CANS POWDER SIMILAC

OR 5 - 14 OZ CANS POWDER ISOMIL

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 OUNCES

015

FORMULA: 4 - 14.1 OZ CANS POWDER SIMILAC

OR 4 - 14 OZ CANS POWDER ISOMIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

015

FORMULA: 4 - 14.1 OZ CANS POWDER SIMILAC

OR 4 - 14 OZ CANS POWDER ISOMIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FP-54

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 24 OZ CEREAL
367 9 CANS 14.1 OZ POWDER IRON FORTIFIED SIMILAC OR 9 CANS 14 OZ POWDER ISOMIL 3 CANS JUICE 36 OZ CEREAL
369 10 CANS 14.1 OZ POWDER IRON FORTIFIED SIMILAC OR 10 CANS 14 OZ POWDER ISOMIL 3 CANS JUICE 36 OZ CEREAL

VOUCHER CODE 066 015
088
070 088
488
070 088
088

VOUCHER MESSAGE

JUICE: CEREAL:

3 - 12 OZ CANS FROZEN OR 3 - 46OZ 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 - 14.1 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 - 46 OZ CANS OR 3-11.5 OZ CANS POURABLE
UP TO 36 OUNCES

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

JUICE: CEREAL:

3 - 12 OZ CANS FROZEN OR 3 - 46 OZ CANS OR 3-11.5 OZ CANS POURABLE
UP TO 36 OUNCES

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

FP-55

GA WIC PROCEDURES MANUAL

Attachment FP-9 cont'd

FOOD PACKAGE NUMBER
381 9 CANS 16 OZ POWDER PORTAGEN OR PREGESTIMIL 3 CANS JUICE 36 OZ CEREAL
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 24 OZ 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 36 OZ CEREAL
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 - 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

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
UP TO 24 OZ

AS PRESCRIBED

A TAILORED PACKAGE DESIGNED BY THE CPA WHICH MUST NOT EXCEED THE MAXIMUM QUANTITY OF SUPPLEMENTAL FOODS FOR THE PARTICIPANT'S CATEGORY

FP-56

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

MAXIMUM MONTHLY AMOUNTS
800 ounces

ADDITIONAL AMOUNTS
13-8 oz cans (104 ounces)

Cereal

4-9 oz boxes

36 ounces

---

Juice

23-6 oz cans

138 ounces

---

This food package consists of eight (8) vouchers

FP-57

GA WIC PROCEDURES MANUAL

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 SIMILAC OR ISOMIL 4-9 OZ BOXES 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

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

CEREAL:

1-9 OZ BOX

JUICE:

6-6 OZ CANS

303

FORMULA:

14-8 OZ CANS READY-TO- FEED SIMILAC OR ISOMIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

CEREAL:

1-9 OZ BOX

JUICE:

5-6 OZ CANS

304

FORMULA:

12-8 OZ CANS READY- TO- FEED SIMILAC OR ISOMIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

CEREAL:

1-9 OZ BOX

304

FORMULA:

12-8 OZ CANS READY- TO -FEED SIMILAC OR ISOMIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

CEREAL:

1-9 OZ BOX

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

JUICE:

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED
6 - 6 OZ CANS

FP-58

GA WIC PROCEDURES MANUAL

Attachment FP-12

CHILDREN'S FOOD PACKAGES MAXIMUM MONTHLY AMOUNTS AUTHORIZED

FOOD

MAXIMUM AMOUNT PER MONTH

Milk1

24 quart equivalents2

Cheese

4 pounds3

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, 1 pound Evaporated milk, whole or skim , 13 ounces Dry whole milk, 1 pound Nonfat or lowfat dry milk, 1 pound

3 quarts 1 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-59

GA WIC PROCEDURES MANUAL CHILDREN'S FOOD PACKAGES

Attachment FP-13

FOOD PACKAGE NUMBER
MINIMUM 600 2 GALS MILK 1 LB CHEESE 1 DOZ EGGS 18 OZ CEREAL 4 CANS JUICE
MINIMUM 601 4 GALS MILK 1 DOZ EGGS 4 CANS JUICE 24 OZ CEREAL 1 LB BEANS/PEAS OR 18 OZ PEANUT BUTTER

VOUCHER CODE 042 040 039
049 040 039
040 037

VOUCHER MESSAGE

CHEESE: JUICE:

UP TO 1 LB
1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-11.5 OZ CAN POURABLE

MILK: JUICE

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

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

JUICE: CEREAL:

1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-11.5 OZ CAN POURABLE
UP TO 18 OUNCES

MILK: JUICE:

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

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: JUICE:

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

MILK:
JUICE:
CEREAL: BEANS/PEAS /PEANUT 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 1 LB DRIED BEANS/PEAS OR 18 OZ PEANUT BUTTER

FP-60

GA WIC PROCEDURES MANUAL

Attachment FP-13 cont'd

FOOD PACKAGE NUMBER 602
LIMITED MILK LACTOSE INTOLERANT 2 GALS MILK 2 LBS CHEESE 2 DOZ EGGS 4 CANS JUICE 24 OZ CEREAL 1LB BEANS/PEAS OR 18 OZ PEANUT BUTTER
MODERATE 603* 4 GALS MILK 1 LB CHEESE 2 DOZEN EGGS 4 CANS JUICE 24 OZ CEREAL 1 LB BEANS/PEAS
* STANDARD MANUAL

VOUCHER CODE 042 043
048
039 047 039 025
039

VOUCHER MESSAGE

CHEESE: JUICE:

UP TO 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:

UP TO 1 LB 1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-11.5 OZ CAN POURABLE
1 LB DRIED BEANS/PEAS OR 18 OZ PEANUT BUTTER

MILK:
EGGS: JUICE:
CEREAL:

1 GAL OR 4-12 OZ CANS EVAP OR 1-5 QT BOX 1 DOZEN
1-12OZ 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: JUICE: CEREAL:

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

MILK: EGGS: JUICE:
MILK: CHEESE: JUICE: BEANS/PEAS

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
1 GAL OR 4-12 OZ CANS EVAP OR 1-5 QT BOX UP TO 1 LB 1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-11.5 OZ CAN POURABLE 1 LB DRIED BEANS/PEAS

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

FP-61

GA WIC PROCEDURES MANUAL

Attachment FP-13 cont'd

FOOD PACKAGE NUMBER
604
4 GALS MILK 2 LBS CHEESE 2 DOZEN EGGS 4 CANS JUICE 24 OZ CEREAL 1 LB DRIED BEANS/PEAS OR 18 OZ PEANUT BUTTER

VOUCHER CODE VOUCHER MESSAGE

031

MILK:

CHEESE: JUICE:

1 GAL OR 4-12 OZ CANS EVAP OR 1-5 QT BOX
UP TO 1 LB
1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-11.5 OZ CAN POURABLE

037

MILK:

JUICE:

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

CEREAL:

UP TO 24 OUNCES

BEANS/PEAS/ 1 LB DRIED BEANS/PEAS OR

PEANUT BUTTER:

18 OZ PEANUT BUTTER

039

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

055

MILK:

CHEESE: EGGS: JUICE:

1 GAL OR 4-12 OZ CANS EVAP OR 1-5 QT BOX UP TO 1 LB 1 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
605
LACTOSE REDUCED MILK LACTOSE INTOLERANT 16 QTS LACTOSE REDUCED MILK 2 LBS CHEESE 2 DOZ EGGS 6 CANS JUICE 24 OZ CEREAL 1 LB BEANS/PEAS OR 18 OZ JAR PEANUT BUTTER

VOUCHER CODE

044

MILK:

CHEESE: JUICE:

CEREAL:

034

MILK:

EGGS: JUICE:

045

MILK:

CHEESE: JUICE:

BEANS/PEAS/
PEANUT BUTTER:

034

MILK:

EGGS: JUICE:

VOUCHER MESSAGE
4 QTS OR 2-1/2 GAL ACIDOPHILUS OR ENJOY OR LACTAID OR LACTAID 100 OR NUTRISH OR DAIRY EASE UP TO 1 LB 1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-11.5 OZ CAN POURABLE UP TO 24 OUNCES
4 QTS OR 2-1/2 GAL ACIDOPHILUS OR ENJOY OR LACTAID OR LACTAID 100 OR NUTRISH OR DAIRY EASE 1 DOZEN 2-12 OZ CAN FROZEN OR 2-46 OZ CAN OR 1-11.5 OZ CAN POURABLE
4 QTS OR 2-1/2 GAL ACIDOPHILUS OR ENJOY OR LACTAID OR LACTAID 100 OR NUTRISH OR DAIRY EASE UP TO 1 LB 1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-11.5 OZ CAN POURABLE 1 LB DRIED BEANS/PEAS OR 18 OZ PEANUT BUTTER
4 QTS OR 2-1/2 GAL ACIDOPHILUS OR ENJOY OR LACTAID OR LACTAID 100 OR NUTRISH OR DAIRY EASE 1 DOZEN 2-12 OZ CAN FROZEN OR 2-46 OZ CAN OR 2-11.5 OZ CANS POURABLE

FP-63

GA WIC PROCEDURES MANUAL

Attachment FP-13 cont'd

FOOD PACKAGE NUMBER
606 4 GALS MILK 2 LBS CHEESE 2 DOZEN EGGS 6 CANS JUICE 36 OZ CEREAL 1 LB BEANS/PEAS OR 18 OZ PEANUT BUTTER
MAXIMUM 607 6 GALS MILK 2 DOZEN EGGS 6 CANS JUICE 36 OZ CEREAL 1 LB BEANS/PEAS OR 18 OZ PEANUT BUTTER

VOUCHER CODE VOUCHER MESSAGE

028

MILK:

EGGS: JUICE:

1 GAL OR 4-12 OZ CANS EVAP OR 1-5 QT BOX
1 DOZEN
2-12 OZ CANS FROZEN OR 2-46 OZ CANS OR 2-11.5 OZ CANS POURABLE

031

MILK:

CHEESE: JUICE:

1 GAL OR 4-12 OZ CANS EVAP OR 1-5 QT BOX
UP TO 1 LB
1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-11.5 OZ CAN POURABLE

055

MILK:

CHEESE: EGGS: JUICE:

1 GAL OR 4-12 OZ CANS EVAP OR 1-5 QT BOX
UP TO 1 LB
1 DOZEN
1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-11.5 OZ CAN POURABLE

056

MILK:

JUICE:

1 GAL OR 4-12 OZ CANS EVAP OR 1-5 QT BOX
2-12 OZ CANS FROZEN OR 2-46 OZ CANS OR 2-11.5 OZ CANS POURABLE

CEREAL: BEANS/PEAS/ P=NUT BUTTER:

UP TO 36 OUNCES 1 LB DRIED BEANS/PEAS OR 18 OZ PEANUT BUTTER

027

MILK:

2 GAL OR 8-12 OZ CANS EVAP OR 2-3 QT BOX

JUICE:

1-12 OZ CANS FROZEN OR 1-46 OZ CAN OR 1-11.5 OZ CAN POURABLE

CEREAL:

UP TO 36 OUNCES

BEANS/PEAS/

1 LB DRIED BEANS/PEAS OR

P=NUT BUTTER: 18 OZ PEANUT BUTTER

028

MILK:

EGGS: JUICE:

1 GAL OR 4-12 OZ CANS EVAP OR 1-5 QT BOX
1 DOZEN
2-12 OZ CANS FROZEN OR 2-46 OZ CANS OR 2-11.5 OZ CANS POURABLE

032

MILK:

EGGS: JUICE:

046

MILK:

JUICE:

2 GAL OR 8-12 OZ CANS EVAP OR 2-3 QT BOXES
1 DOZEN 2-12 OZ CANS FROZEN OR 2-46 OZ CANS OR 2-11.5 OZ CANS POURABLE
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

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 36 OZ CEREAL 1 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 UHT Milk 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 oz jars

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 - 2 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 1-9 OZ BOX 6-6 OZ CANS 1-18 OZ JAR

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: 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 1-9 OZ BOX 6-6 OZ CANS

MILK: CEREAL:

12-8 OZ BOXES UHT OR 2 QTS OR 1 - 1/2 GAL LACTOSE REDUCED
1-9 OZ BOX

MILK:
CEREAL: JUICE:

12 - 8 OZ BOXES UHT OR 4 QTS OR 2 -1/2 GAL LACTOSE REDUCED 1-9 OZ 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 6-6 OZ CANS

FP-67

GA WIC PROCEDURES MANUAL

Attachment FP-16

WOMEN'S FOOD PACKAGES MAXIMUM MONTHLY AMOUNTS AUTHORIZED

FOOD
Milk2 Cheese

PREGNANT, BREASTFEEDING AND NON-BREASTFEEDING
28 quart equivalents 3
4 pounds 4,5

EXCLUSIVELY BREASTFEEDING 1
28 quart equivalents 1 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

Carrots1

NA

2 pounds, fresh, whole

Tuna1

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
MINIMUM 401 4 GALS MILK 1 DOZ EGGS 4 CANS JUICE 24 OZ CEREAL 1 LB BEANS/PEAS OR 18 OZ PEANUT BUTTER
402 LIMITED MILK LACTOSE INTOLERANT 2 GALS MILK 2 LBS CHEESE 2 DOZ EGGS 6 CANS JUICE 36 OZ CEREAL 1 LB BEANS/PEAS OR 18 OZ PEANUT BUTTER

VOUCHER CODE VOUCHER MESSAGE

040

MILK:

JUICE:

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

039

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

037

MILK:

1 GAL OR 4-12 OZ CANS EVAP OR 1-5 QT BOX

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/ P=NUT BUTTER:

1 LB DRIED BEANS/PEAS OR 18 OZ PEANUT BUTTER

040

MILK:

JUICE:

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

041

MILK:

EGGS:

JUICE:

CEREAL:

1 GAL OR 4-12 OZ CANS EVAP OR 1-5 QT BOX 1 DOZEN
2-12 OZ CANS FROZEN OR 2-46 OZ CANS OR 2-11.5 OZ CANS POURABLE UP TO 36 OUNCES

042

CHEESE:

JUICE:

UP TO 1 LB
1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-11.5 OZ CAN POURABLE

028

MILK:

EGGS: JUICE:

1 GAL OR 4-12 OZ CANS EVAP OR 1-5 QT BOX
1 DOZEN
2-12 OZ CANS FROZEN OR 2-46 OZ CANS OR 2-11.5 OZ CANS POURABLE

043

CHEESE:

JUICE:

UP TO 1 LB
1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-11.5 OZ CAN POURABLE

BEANS/PEAS/ 1 LB DRIED BEANS/PEAS OR

P=NUT BUTTER:

18 OZ PEANUT BUTTER

FP-69

GA WIC PROCEDURES MANUAL

Attachment FP-17 cont'd

FOOD PACKAGE NUMBER 403
4 GALS MILK 1 LB CHEESE 1 DOZ EGGS 4 CANS JUICE 24 OZ CEREAL 1 LB BEANS/PEAS OR 18 OZ PEANUT BUTTER
404* 4 GALS MILK 2 LBS CHEESE 2 DOZ EGGS 6 CANS JUICE 24 OZ CEREAL 1 LB BEANS/PEAS OR 18 OZ PEANUT BUTTER
*STANDARD MANUAL

VOUCHER CODE VOUCHER MESSAGE

037

MILK:

1 GAL OR 4-12 OZ CANS EVAP OR 1-5 QT BOX

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/

1 LB DRIED BEANS/PEAS OR 18 OZ

P=NUT BUTTER: PEANUT BUTTER

039

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

031

MILK:

CHEESE: JUICE:

MILK: 040
JUICE:

1 GAL OR 4-12 OZ CANS EVAP OR 1-5 QT BOX UP TO 1 LB 1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-11.5 OZ CAN POURABLE
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

028

MILK:

EGGS: JUICE:

1 GAL OR 4-12 OZ CANS EVAP OR 1-5 QT BOX
1 DOZEN
2-12 OZ CANS FROZEN OR 2-46 OZ CANS OR 2-11.5 OZ CANS POURABLE

031

MILK:

CHEESE: JUICE:

1 GAL OR 4-12 OZ CANS EVAP OR 1-5 QT BOX
UP TO 1 LB
1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-11.5 OZ CAN POURABLE

037

MILK:

1 GAL OR 4-12 OZ CANS EVAP OR 1-5 QT BOX

JUICE: CEREAL:

1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-11.5 OZ CAN POURABLE UP TO 24 OUNCES

BEANS/PEAS/

1 LB DRIED BEANS/PEAS OR

P=NUT BUTTER: 18 OZ PEANUT BUTTER

054

MILK:

CHEESE: EGGS: JUICE:

1 GAL OR 4-12 OZ CANS EVAP OR 1-5 QT BOX UP TO 1 LB 1 DOZEN
2-12 OZ CANS FROZEN OR 2-46 OZ CANS 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:

LACTOSE REDUCED MILK
LACTOSE INTOLERANT

CHEESE: JUICE:

12 QTS LACTOSE REDUCED MILK 3 LBS CHEESE 2 DOZ EGGS 6 CANS JUICE 36 OZ CEREAL 1 LB BEANS/PEAS OR 18 OZ PEANUT BUTTER

CEREAL:
MILK: 034
EGGS: JUICE:

4 QTS OR 2-1/2 GAL ACIDOPHILUS OR ENJOY OR LACTAID OR LACTAID 100 OR NUTRISH OR DAIRY EASE UP TO 1 LB 1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-11.5 OZ CAN POURABLE UP TO 36 OUNCES
4 QTS OR 2-1/2 GAL ACIDOPHILUS OR ENJOY OR LACTAID OR LACTAID 100 OR NUTRISH OR DAIRY EASE 1 DOZEN 2-12 OZ CANS FROZEN OR 2-46 OZ CANS OR 2-11.5 OZ CANS POURABLE

035

MILK:

2 QTS OR 2 GAL ACIDOPHILUS OR ENJOY OR LACTAID OR LACTAID 100 OR NUTRISH OR DAIRY EASE

CHEESE:

UP TO 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 2 GAL ACIDOPHILUS OR ENJOY OR LACTAID OR LACTAID 100 OR NUTRISH OR DAIRY EASE
UP TO 1 LB
1 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 1 LB BEANS/PEAS OR 18 OZ PEANUT BUTTER
MAXIMUM 407 7 GALS MILK 2 DOZEN EGGS 6 CANS JUICE 36 OZ CEREAL 1 LB BEANS/PEAS OR 18 OZ PEANUT BUTTER

VOUCHER CODE 027
028

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
1 LB DRIED BEANS/PEAS OR 18 OZ PEANUT BUTTER

MILK:
EGGS: JUICE:

1 GAL OR 4-12 OZ CANS EVAP OR 1-5 QT BOX
1 DOZEN
2-12 OZ CANS FROZEN OR 2-46 OZ CANS OR 2-11.5 OZ CANS POURABLE

031

MILK:

CHEESE: JUICE:

1 GAL OR 4-12 OZ CANS EVAP OR 1-5 QT BOX
UP TO 1 LB
1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-11.5 OZ CAN POURABLE

054

MILK:

CHEESE: EGGS: JUICE:

1 GAL OR 4-12 OZ CANS EVAP OR 1-5 QT BOX UP TO 1 LB 1 DOZEN
2-12 OZ CANS FROZEN OR 2-46 OZ CANS OR 2-11.5 OZ CANS POURABLE

027

MILK:

JUICE:

CEREAL:

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

BEANS/PEAS/ P=NUT BUTTER:

1 LB DRIED BEANS/PEAS OR 18 OZ PEANUT BUTTER

028

MILK:

EGGS: JUICE:

1 GAL OR 4-12 OZ CANS EVAP OR 1-5 QT BOX
1 DOZEN
2-12 OZ CANS FROZEN OR 2-46 OZ CANS OR 2-11.5 OZ CANS POURABLE

029

MILK:

JUICE:

030

MILK:

EGGS: 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
2 GAL OR 8-12 OZ CANS EVAP OR 2-5 QT BOX
1 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-18

EXCLUSIVELY BREASTFEEDING FOOD PACKAGES*

FOOD PACKAGE NUMBER 408**
EXCLUSIVELY BREASTFEEDING 7 GALS MILK 1 LB CHEESE 2 DOZEN EGGS 7 CANS JUICE 36 OZ CEREAL 1 LB BEANS/PEAS OR 1-18 OZ PEANUT BUTTER PLUS 1 LB BEANS/PEAS 2 LBS CARROTS 4 CANS TUNA
999

VOUCHER CODE 001
027
028 029 030 999

VOUCHER MESSAGE

CHEESE: JUICE:
CARROTS: TUNA: BEANS/PEAS:

UP TO 1 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 1 LB DRIED BEANS OR PEAS

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 1 LB DRIED BEANS/PEAS OR 18 OZ PEANUT BUTTER

MILK: EGGS: JUICE: MILK:
JUICE:

1 GAL OR 4-12 OZ CANS EVAP OR 1-5 QT BOX 1 DOZEN 2-12 OZ CANS FROZEN OR 2-46 OZ CANS OR 2-11.5 OZ CANS POURABLE
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

MILK:
EGGS: JUICE:

2 GAL OR 8-12 OZ CANS EVAP OR 2-5 QT BOXES
1 DOZEN
2-12 OZ CANS FROZEN OR 2-46 OZ CANS OR 2-11.5 OZ CANS POURABLE

AS PRESCRIBED

7 GALS OR 28 QTS MILK 4 LBS CHEESE 2 DOZ EGGS 7 CANS JUICE 36 OZ CEREAL 1 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 breastfeeding 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 after 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: 1. 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-19

ALTERNATE FOOD PACKAGES FOR PREGNANT AND BREASTFEEDING WOMEN
MAXIMUM MONTHLY AMOUNTS AUTHORIZED

FOOD UHT Milk
Lactose Reduced Milk Cereal Juice

PREGNANT, AND BREASTFEEDING 112-8 oz boxes
OR 16 quarts or 8 - 2 gallons
4-9 oz boxes
42 - 6 oz cans

EXCLUSIVELY BREASTFEEDING* 124 - 8 oz boxes
31 quarts or 15 - 2 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-20

ALTERNATE FOOD PACKAGES FOR PREGNANT AND BREASTFEEDING WOMEN

FOOD PACKAGE NUMBER
410 (PREGNANT AND BREASTFEEDING)
112 - 8 OZ BOXES UHT MILK OR 16 QT OR 8 - 2 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 BUTTER:

14-8 OZ BOXES UHT OR 2 QTS OR 1-1/2 GAL LACTOSE REDUCED 1-9 OZ BOX 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 -1/2 GAL LACTOSE REDUCED
6 - 6 OZ CANS

MILK:
CEREAL: JUICE:

14-8 OZ BOXES UHT OR 2 QTS OR 1-1/2 GAL LACTOSE REDUCED 1-9 OZ BOX 6-6 OZ CANS

MILK:
CEREAL: JUICE:

14-8 OZ BOXES UHT OR 2 QTS OR 1-1/2 GAL LACTOSE REDUCED 1-9 OZ BOX 6-6 OZ CANS

MILK: CEREAL:

14-8 OZ BOXES UHT OR 2 QTS OR 1-1/2 GAL LACTOSE REDUCED
1-9 OZ BOX

MILK:
JUICE: PEANUT BUTTER:

14-8 OZ BOXES UHT OR 2 QTS OR 1-1/2 GAL LACTOSE REDUCED 6-6 OZ CANS
1-18 OZ JAR

FP-75

GA WIC PROCEDURES MANUAL

Attachment FP-20 cont'd

FOOD PACKAGE NUMBER

VOUCHER CODE VOUCHER MESSAGE

411 (EXCLUSIVELY BREAST FEEDING)

630

MILK:

CEREAL:

15-8 OZ BOXES UHT OR 4 QTS OR 2-1/2 GAL LACTOSE REDUCED
1-9 OZ BOX

124-8 OZ BOXES UHT MILK

JUICE:

7-6 OZ CANS

31 QUARTS OR 15-1/2 GAL

P=NUT

1-18 OZ JAR

LACTOSE REDUCED MILK

BUTTER:

36 OZ CEREAL 56-6 OZ CANS JUICE 3-18 OZ JAR PEANUT

BEANS/ PEAS: CARROTS:

1-15 OZ CAN 1-15 OZ CAN

BUTTER 6-6 OZ CANS TUNA

631

MILK:

4-15 OZ CANS BEANS/PEAS 2-15 OZ CANS CARROTS

JUICE: TUNA:

15-8 OZ BOXES UHT OR 4 QTS OR 2-1/2 GAL LACTOSE REDUCED 7-6 OZ CANS 2-6 OZ CANS

631

MILK:

JUICE: TUNA:

15-8 OZ BOXES UHT OR 4 QTS OR 2-1/2 GAL LACTOSE REDUCED 7-6 OZ CANS 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 1-9 OZ BOX 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:

1-9 OZ 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:

1-9 OZ 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:

2-6 OZ CANS

FP-76

GA WIC PROCEDURES MANUAL

Attachment FP-21

POSTPARTUM, NON-BREASTFEEDING WOMEN'S FOOD PACKAGES MAXIMUM MONTHLY AMOUNTS AUTHORIZED

FOOD

MAXIMUM AMOUNT PER MONTH

Milk1

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

1Substitute up to 24 quarts of lactose reduced milk to replace up to 6 gallons of milk. 2Substitution amounts for fluid milk include:

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-77

GA WIC PROCEDURES MANUAL

Attachment FP-22

POSTPARTUM, NON-BREASTFEEDING WOMEN'S FOOD PACKAGES

FOOD PACKAGE NUMBER
MINIMUM 501 3 GALS MILK 1 DOZEN EGGS 3 CANS JUICE 18 OZ CEREAL
502 * 3 GALS MILK 2 LBS CHEESE 1 DOZ EGGS 4 CANS JUICE 24 OZ CEREAL
*STANDARD MANUAL

VOUCHER CODE 040
040
053 052 040
042 047
055

VOUCHER MESSAGE

MILK: JUICE:

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

MILK: JUICE:

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

MILK: CEREAL:

1 GAL OR 4-12 OZ CANS EVAP OR 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 1 DOZEN

MILK: JUICE:

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

CHEESE: JUICE:

UP TO 1 LB 1-12 OZ CAN FROZEN OR 1-46 OZ CAN
OR 1-11.5 OZ CAN POURABLE

MILK: JUICE: CEREAL:

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

MILK:
CHEESE: EGGS: JUICE:

1 GAL OR 4-12 OZ CANS EVAP OR 1-5 QT BOX UP TO 1 LB 1 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-22 cont'd

FOOD PACKAGE NUMBER
MAXIMUM 503 6 GALS MILK 2 DOZEN EGGS 4 CANS JUICE 36 OZ CEREAL
504 LACTOSE REDUCED MILK LACTOSE INTOLERANT 12 QTS MILK 2 LBS CHEESE 1 DOZEN EGGS 4 CANS JUICE 24 OZ CEREAL

VOUCHER CODE 050
051 039
051 501
502 503
504

VOUCHER MESSAGE

MILK:
JUICE: CEREAL: EGGS:

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 36 OUNCES
1 DOZEN

MILK: JUICE:

2 GALS OR 8-12 OZ CANS EVAP OR 2-5 QT BOX 1-12 OZ CAN FROZEN OR 1-46 OZ CAN

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: 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

MILK:
CHEESE: JUICE:

4 QTS OR 2-1/2 GAL ACIDOPHILUS OR ENJOY OR LACTAID OR LACTAID 100 NUTRISH OR DAIRY EASEUP TO 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 EASE1 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 UP TO 1 LB 1-12 OZ CAN 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 OR 1-11.5 OZ CAN POURABLE UP TO 24 OUNCES

FP-79

GA WIC PROCEDURES MANUAL

Attachment FP-22 cont'd

FOOD PACKAGE NUMBER
999* 6 GALS OR 24 QTS MILK SUBSTITUTE 1 LB CHEESE FOR 3 QTS MILK 2 DOZEN EGGS 4 CANS JUICE 36 OZ CEREAL

VOUCHER CODE
999

VOUCHER MESSAGE
AS PRESCRIBED A TAILORED PACKAGE DESIGNED BY THE CPA MUST NOT EXCEED THE MAXIMUM QUANTITY OF SUPPLEMENTAL FOODS FOR THE PARTICIPANT'S CATEGORY

FP-80

GA WIC PROCEDURES MANUAL

Attachment FP-23

ALTERNATE FOOD PACKAGES FOR POSTPARTUM, NON-BREASTFEEDING WOMEN
MAXIMUM MONTHLY AMOUNTS AUTHORIZED

FOOD
UHT Milk 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-81

GA WIC PROCEDURES MANUAL

Attachment FP-24

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 1-9 OZ BOX
6-6 OZ CANS

MILK:
PEANUT BUTTER: JUICE:

9-8 OZ BOXES UHT OR 4 QTS OR 2-1/2 GAL LACTOSE REDUCED
1-18 OZ JAR 6-6 OZ CANS

MILK:
CEREAL: JUICE:

9-8 OZ BOXES UHT OR 2 QTS OR 1-1/2 GAL LACTOSE REDUCED 1-9 OZ BOX 6-6 OZ CANS

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 6-6 OZ CANS

MILK:

9-8 OZ BOXES UHT OR 2 QTS OR 1-1/2 GAL LACTOSE REDUCED

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 6-6 OZ CANS

FP-82

GA WIC PROCEDURES MANUAL

Attachment FP-25

DATE: TO: FROM:
PHONE #:

GEORGIA WIC PROGRAM FORMULA REFERRAL FORM (To Be Completed By Referral Agency)
WIC PROGRAM Signature/Title (Physician) Health Facility - Location

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:

This client has been assessed for the WIC Program. A WIC Program Assessment/Certification is attached.

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-83

GA WIC PROCEDURES MANUAL

Attachment FP-26

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 Nutrition Section* by October 1st of each year.

*Address: Nutrition Section, 2 Peachtree Street NW, Suite 11-222, Atlanta, GA 30303-3142.

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 of iron per 100 gm of dry cereal.

2.

Contains not more than 14.1 gm of sucrose and other sugars per 100 gm of dry cereal

(less than 4 gm per ounce). High fiber cereals (5 gm or more) must not contain more than

6 gm of total sugar per 100 gm of 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 no added sugar.

3.

Contains no added fruit.

4.

Contains no added formula

C.

Milk

1.

Contains 400 IU vitamin D per quart.

2.

Contains 2,000 IU vitamin A per quart.

3.

Contains no added sugar or flavorings.

4.

No Buttermilk or Goat's milk.

FP-84

GA WIC PROCEDURES MANUAL

Attachment FP-26 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, 100% fruit juice

2.

30 mg vitamin C per 100 ml of reconstituted juice, minimum.

3.

Contains no added sugar.

4.

Contains no added calcium.

5.

No infant juices allowed.

G.

Eggs

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)

1.

No single serving containers.

2.

Adult cereal weight must be in whole numbers, minimum of 9 ounces, not to exceed 36

ounces.

3.

Infant cereal only in eight (8) ounce packages.

C.

Cheese

1.

Brick or sliced cheese only, no shredded.

2.

Cheese from the dairy case only, no deli cheese.

3.

Plain cheese only, no additions of products such as jalapeno peppers.

4.

A minimum of 9 ounces, not to exceed 16 ounces.

D.

Juice

1.

No single serving containers.

2.

No fresh squeezed.

3.

Containers must be easily and clearly identified as fortified with 30 mg of vitamin C per

100 ml of juice, 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

FP-85

GA WIC PROCEDURES MANUAL

Attachment FP-26 cont'd

One dozen size carton only.

F.

Milk

1.

One gallon size: Whole, Reduced Fat (2%), Lowfat (1%), Lite (2%), 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.

FP-86

GA WIC PROCEDURES MANUAL

Attachment FP-27

FOOD ITEM
MILK
(Pasteurized)
CEREAL
CHEESE
JUICE
(100% USRDA Vitamin C Fortified)
EGGS (Grade A Large ONLY) DRIED PEAS/BEANS

Georgia WIC Program
WIC APPROVED FOOD LIST
ONLY the following list of foods may be purchased using WIC vouchers:

BRAND OR TYPE

CONTAINER/PACKAGE SIZE

NOT ALLOWED

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 ( 1) Gallon Size ONLY (Exception: 2 Gallons or Quarts of Enjoy, Lactaid, Lactaid 100,
Dairy Ease, Nutrish ,and/or Acidophilus, 12-Ounce Cans
Evaporated, 3-5 Quart Boxes Powdered

Flavored Milk, Buttermilk, or Goat's Milk

Cheerios, Corn Chex, Rice Chex or Wheat Chex, Country Corn 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 Corn Flakes, Kellogg's Special K, Kelloggs's Corn Flakes,Kellogg=s Complete Bran Flakes, Quaker Sun Country Quick Oats (Regular Flavor), Quaker Crunchy Corn Bran, *Ralston Optima 100 Whole Wheat Flakes, Ralston Enriched Bran Flakes,Ralston Nutty Nuggets, Ralston Instant Oatmeal (Regular Flavor), Ralston Crispy Rice, Ralston Corn Flakes, Ralston Tasteeo, Ralston Crispy Corn Puff
*Ralston Store Brands Allowed: Kroger, Kounty Fresh, IGA, Red &White, Flavorite or Nature=s Best

Nine (9) Ounce Sizes and Above ONLY
Can Purchase More Than One (1) 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

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 16Ounce One (1) Pound Size
ONLY

Cheese Food, Shredded or Deli Cheese, Two (2) Eight (8) Ounce Packages for One (1) 16-Ounce Package, or any Eight (8) Ounce
or Smaller Package

ORANGE: Least Expensive Brand ONLY GRAPEFRUIT: Least Expensive Brand ONLY GRAPE: Welch's , Seneca or Juicy Juice WHITE GRAPE: Welch=s or Seneca APPLE: Flavorite, Kroger, Lucky Leaf, Juicy Juice, Seneca {Red Label Only}, Staff, Thifty Maid, ShurFine, White House OTHERS DOLE: Orange/Pineapple, Orange/Pineapple/Banana, Pineapple/Grapefruit, Mandarin Tangerine, Orchard Peach, JUICY JUICE: Cherry, Punch, Tropical, Berry, Apple, Grape, Orange/ Punch, Strawberry Pourables:
WELCH=S: Juicemakers Apple, Grape or White Grape
JUICY JUICE: Punch, Grape, Cherry, Berry, Strawberry or Apple

46-Ounce Cans or 12-Ounce Frozen Cans or 11.5
Ounce Pourable Can ONLY

Juice Drinks, Fresh Squeezed Juice Single Serving Sizes, Infant Juices, Juices with Sugar Added Seneca Frozen White Grape Juice
Cocktail

Least Expensive Brand ONLY

One (1) Dozen

Any Other Size/Quantity

Any Brand Without Flavoring Added

One (1) Pound Size ONLY

Any Other Size/Quantity

PEANUT BUTTER
INFANT FORMULA
INFANT CEREAL (Boxes ONLY)
TUNA CARROTS

Any Brand Without Jelly Added or Honey Spread
As Listed On The Front of the Voucher
Beech Nut, Gerber, Heinz
Water Packed ONLY Fresh, Whole

18-Ounce Jars ONLY

Any Other Size/Quantity

As Listed On Front of the Voucher
Dry Cereal in Eight (8) Ounce Sizes ONLY
6 Ounce Cans ONLY
One (1) Pound Pre-Sealed Plastic Bag ONLY

Any Type Not Listed On Front of Voucher
Any Baby Food in Jars or Any Dry Cereal with Fruit or Formula
Aided
Tuna Packed in Oil
Bulk, Frozen, Canned, Shredded, or Baby Carrots

FP-87

GA WIC PROCEDURES MANUAL

Attachment FP-28

FOOD ITEM MILK
(Pasteurized)
CEREAL
JUICE
CANNED PEAS/
BEANS or
LENTILS PEANUT BUTTER INFANT FORMULA INFANT CEREAL (Boxes ONLY) TUNA CARROTS

Georgia WIC Program WIC APPROVED ALTERNATE FOOD LIST

ONLY the following list of foods may be purchased using WIC vouchers

BRAND OR TYPE

CONTAINER/PACKAGE SIZE

NOT ALLOWED

UHT, MILK, Whole or 2% (least expensive brand)
or Acidophilus, Enjoy, Lactaid 100, Lactaid, Dairy Ease or Nutrish

8 Ounce Box or 2 Gallon Or Quart of Lactose Reduced Milk

Flavored Milk, Buttermilk, or Goat's Milk

Cheerios, Corn Chex, Rice Chex, or Wheat Chex, Country Corn Flakes, Kix, Product 19, Corn Total, 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 Corn Flakes, Kellogg=s Complete Bran Flakes, Quaker Sun Country Quick Oats (Regular Flavor), Quaker Crunchy Corn Bran, *Ralston Optima 100 WholeWheat Flakes, Ralston Enriched Bran Flakes, Ralston Nutty Nuggets, Ralston Instant Oatmeal (Regular Flavor), Ralston Crispy Rice, Ralston Bran Flakes, Ralston Corn Flakes, Ralston Tasteeo, Ralston Crispy Corn Puff

Nine (9) Ounce Size Can Purchase More than One (1) Type/Brand of Cereal as Long as the Amount Does Not Go over the Quantity on the
front of the Voucher

8 Ounce or less Size Boxes

*Ralston Store Brands Allowed:Kroger,
Kounty Fresh, IGA, 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 OTHERS DOLE:Orange/Pineapple, Orange/Pineapple/Banana, Pineapple/Grapefruit JUICY JUICE: Cherry, Punch, Tropical, Berry, Apple/Grape, Orange Punch, Strawberry

6 ounce can

Juice Drinks, Fresh Squeezed Juice, Infant Juice, Juice with Sugar
Added Seneca Frozen White Grape Juice Cocktail

Any Brand without Flavoring Added

15 ounce can only

Any other size/quantity. Green peas, Green, Snap, Yellow or Wax beans; beans
with added flavoring

Any Brand without Jelly Added or Honey Spread

18 ounce jar only

Any other size/quantity

As listed on the front of the Voucher

As listed on front of Voucher

Any type not listed on front of the voucher

Beech Nut, Gerber, Heinz

Dry Cereal in 8 ounce size only

Any baby food in jars or any dry cereal with fruit or formulas added

Water Packed ONLY

6 ounce cans only

Tuna packed in oil

Any Brand Without Flavoring Added

15 ounce canned sliced, medium cut

Bulk, frozen shredded or baby carrots

FP-88

GA WIC PROCEDURES MANUAL

Attachment FP-29

WIC Approved Formulas/Medical Foods

Contract Infant Formula: a,b

Similac with Iron

Ross Products

Isomil

Ross Products

Similac Lactose Free (Prescription required)

Ross Products

Non-Contract Formulas/Medical Foods Requiring a Prescription and Diagnosis: a,d,c

Acerflex

Scientific

Crucial

Hospital Supplies

Nestle

Glucerna

Ross Products

Advera

Ross Products

Cyclinex 1

Ross Products

Glytrol

Nestle

Alimentum AlitraQ
Analog MSUD Analog XLEU Analog XLYS,TRY Analog XMET Analog XMTVI Analog XP

Ross Products Ross Products
SHS SHS SHS
SHS SHS SHS

Analog

SHS

XPHEN,TRY

Analog XPTM

SHS

Boost Boost Fiber Boost High Protein Boost Plus Boost Pudding Carnation Alsoy Carnation Followup Soy Casec

Mead Johnson Mead Johnson Mead Johnson
Mead Johnson Mead Johnson Carnation Carnation
Mead Johnson

Choice d.m.

Mead Johnson

Citrisource

Novartis

Ctrotein Compleat Modified Compleat Pediatric Compleat Regular Criticare HN

Novartis Novartis
Novartis
Novartis Mead Johnson

Cyclinex 2 Deliver 2.0
Duocal Elecare Elementra

Ross Products Mead Johnson
SHS Ross Nestle

Hominex-1 Hominex-2
Intolite Isocal Isomil

Ross Products Ross Products
Ross Products Mead Johnson Ross Products

EnfaCare Enfamil AR Enfamil Next Step Soy Ensure

Mead Johnson Mead Johnson Mead Johnson
Ross Products

Isomil DF IsoPro IssSource Standard IsoSource HN

Ross Products Nutrition Medical Novartis
Novartis

Ensure High Protein Ensure Plus Ensure Plus HN Ensure Pudding

Ross Products
Ross Products Ross Products Ross Products

IsoSource 1.5
I-Valex-1 I-Valex-2 Jevity

Novartis
Ross Products Ross Products Ross Products

Ensure with Fiber Enlive Entrition 0.5 Entrition HN

Ross Products Ross Products Nestle Nestle

Ketonex-1 Ketonex-2 Kindercal L-Elemental

Ross Products Ross Products Mead Johnson Nutrition Medical

E028 Extra

SHS

EO28 Pediatric SHS

Fiber Pro

Novartis

Fiber Source

Novartis

Fiber Source HN Novartis

L-Elemental Hepatic L-Elemental Pediatric L-Elemental Plus Lipisorb Lofenalac

Nutrition Medical Nutrition Medical Nutrition Medical Mead Johnson Mead Johnson

Forta Drink

Ross Products

Lo*Pro

Med-Diet Labs

Forta Shake Gluco-Pro

Ross Products Nutrition Medical

Magnacal Renal Mead Johnson

Maxamaid

SHS

MSUD

FP-89

GA WIC PROCEDURES MANUAL

Attachment FP-29 cont'd

Non-Contract Formulas/Medical Foods Requiring a Prescription and Diagnosis: a,d,c

Maxamaid

SHS

UCD

NuBasics

Nestle

Polycose

Ross Products

Maxamum

SHS

XLEU

Nutramigen

Mead Johnson Portagen

Mead Johnson

Maxamaid

SHS

XMET

Nutren 1.0

Nestle

Pregestimil 20 Mead Johnson

Maxamaid

SHS

XMTVI

Nutren 1.0 with Nestle Fiber

Pregestimil 24 Mead Johnson

Maxamaid XP SHS

Nutren1.5

Nestle

ProBalance

Nestle

Maxamaid

SHS

XPHEN,TYR

Nutren 2.0

Nestle

Product 3200AB Mead Johnson

Maxamum

SHS

MSUD

Nutren Junior Nestle

Product 3232 A Mead Johnson

Maxamum

SHS

XLYS,TRY

Nutren Junior with Fiber

Nestle

Product 80056 Mead Johnson

Maxamum

SHS

XMET

NutriHep

Nestle

ProMod

Ross Products

Maxamum

SHS

XMTVI

NutriRenal

Nestle

Promote

Ross Products

Maxamum XP SHS

NutriVent

Nestle

Pro-Peptide

Nutrition Medical

MCT Oil

Mead Johnson

Osmolite

Ross Products

Pro-Pepetide for Nutrition

Kids

Medical

Meritene

Novartis

Osmolite HN Plus

Ross Products

Pro-Peptide VHN

Nutrition Medical

Methionaid

SHS

Pediasure

Ross Products Pro-Phree

Ross Products

Microlipids

Mead Johnson

Pediasure with Fiber

Ross Products

Propimex-1

Ross Products

Moducal

Mead Johnson

Peptamen

Nestle

Propimex-2

Ross Products

MSUD AID

SHS

Peptamen Junior Nestle

Prosobee

Mead Johnson

NeoSure

Ross Products

Peptamen Junior Nestle Oral

ProViMin

Ross Products

Neocate

SHS

Peptamen VHP Nestle

Pulmocare

Ross Products

Neocate Junior SHS

Peptament VHP Nestle

RCF

Oral

Ross Products

NeocateOne+

SHS

Pepdite One + SHS

Reabilan

Nestle

Nepro

Ross Products

Peptide

Novartis

Reabilan HN

Nestle

Nitro-Pro

Nutrition Medical Preative

Ross Products Renalcal Diet Nestle

NovaSource Renal

Novartis

Periflex

SHS

RE/Neph HP/HC Nutra/Balance

NuBasics

Nestle

Phenex 1

Ross Products RE/Neph LP/HC Nutra/Balance

NuBasics 2.0

Nestle

Phenex 2

Ross Products Replete

Nestle

NuBasics with Fiber

Nestle

PhenylAde Drink Mixes

Foodtek

Replete with Fiber

Nestle

NuBasics VHP Nestle

Phenyl-Free

Mead Johnson Respalor

Mead Johnson

FP-90

GA WIC PROCEDURES MANUAL

Attachment FP-29 cont'd

Non-Contract Formulas/Medical Foods Requiring a Prescription and Diagnosis: a,d,c

Resource Diabetic

Novartis

Resource Fruit Beverage

Novartis

Resource Just for Novartis Kids

Resource Just for Novartis Kids with Fiber

Resource Plus Novartis

Resource Standard

Novartis

Scandishake

Scandipharm

Scandishake Lactose Free

Scandipharm

Scandishake Sugar Free

Scandipharm

Subdue

Mead Johnson

Suplena

Ross Products

Sustacal

Mead Johnson

Sustacal with Fiber

Mead Johnson

Sustacal Plus

Mead Johnson

Sustacal Pudding Mead Johnson

Tolorex

Mead Johnson

TraumaCal

Mead Johnson

TwoCal HN

Ross Products

Ultracal

Mead Johnson

Ultra-Pro

Nutrition Medical

Vital High Nitrogen

Ross Products

Vivonex Pediatric

Novartis

Vivonex Plus

Novartis

Vivonex T.E.N. Novartis

FP-91

GA WIC PROCEDURES MANUAL

Attachment FP-29 cont'd

Non-Contract Hospital Based Formulas: c,d

Enfamil Premature Mead

20

Johnson

Enfamil Human Milk Fortifier

Mead Johnson

Similac PM 60/40

Ross Products

Enfamil Premature Mead

20 with iron

Johnson

Enfamil Human Milk Fortifier with iron

Mead Johnson

Similac Special Care 20

Ross Products

Enfamil Premature Mead

24

Johnson

Similac 24

Ross Products

Similac Special Care with Iron 20

Ross Products

Enfamil Premature Mead

24 with iron

Johnson

Enfamil 24

Mead Johnson

Similac 24 with iron
Similac Human Milk Fortifier with iron

Ross Products
Ross Products

Similac Special Care 24
Similac Special Care with Iron 24

Ross Products
Ross Products

Enfamil 24 with iron

Mead Johnson

Similac Natural Care

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 Nutrition Section to determine whether the product is authorized for distribution through the WIC Program.
d. Hospital based products may be acquired through the Nutrition Section. See the Georgia WIC Program Procedures Manual, Food Package Section for appropriate procedure and forms.

FP-92

GA WIC PROCEDURES MANUAL Formula Manufacturers

Attachment FP-29 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

Scandipharm, 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-93

GA WIC PROCEDURES MANUAL

Attachment FP-30

PROCUREMENT OF HOSPITAL BASED FORMULA

Hospital based infant formulas may be ordered by a physician (only) to meet the nutritional needs of pre-term 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 Nutrition Section or in rare instances through a local pharmacy (WIC Vendor). When acquiring a product through the Nutrition Section use the following procedure:
1. District WIC Coordinator or designated staff will fax to the Procurement of Hospital Based Formula form complete with the following information (see Attachment FP-31):
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 l. Hospital discharged form m. Clinic contact person/telephone number n. District contact person/signature
2. Call the Nutrition Section 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 DHR Receiving Report and return to the address provided on the form.
Submit order(s) monthly. The total fluid ounces per order must not exceed the maximum monthly allowance. County health departments should receive shipment within 5 working days.
Notify the Nutrition Section immediately if an incorrect order is delivered, or if there is a change in the formula order.
Note: For accounting purposes return the special order packing slip to the Nutrition Section, 2 Peachtree Street NW, Suite 11-222, Atlanta, GA 30303-3142.
Only a complete case(s) may be returned by the Nutrition Section to the formula company for credit.

FP-94

GA WIC PROCEDURES MANUAL

Attachment FP-31

HOSPITAL BASED FORMULA ORDER FORM

I. TO BE COMPLETED BY DISTRICT/LOCAL STAFF

Date

Nutrition Section called and notified of incoming fax. Written prescription with medical diagnosis attached.
Returned packing slip to the Nutrition section when formula was received.

1. Name of WIC 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, concentrate, 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 THE NUTRITION SECTION AND FAX TO FRANCES COOK, NUTRITION SECTION: PHONE: (404) 657-2884 FAX: (404) 657-2886
II. TO BE COMPLETED BY NUTRITION SECTION 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. Nutrition Section Nutrition Consultant's signature
III. TO BE COMPLETED BY STATE WIC BUDGET OFFICER 1. Purchasing authorization number/initial date 2. Field Purchase Order # / initial date 3. WIC Financial Director's signature

FP-95

GA WIC PROCEDURES MANUAL

Attachment FP-32

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

1

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 = 1 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-96

GA WIC PROCEDURES MANUAL

Attachment FP-33

Formula Food Package Index Reference Pages:
B
BREASTFEEDING Message.............................................................................................................................................................32
C
CONCENTRATE Low Iron Formula 31-13oz. cans ......................................................................................................................40 Low Iron Formula 31-13oz. cans w/ Juice & Infant Ceral ................................................................................40 Non Contract Soy 31-13oz. cans.......................................................................................................................41 Non Contract Soy 31-13oz. cans w/ Juice & Infant Cereal ...............................................................................41 Similac / Isomil 13-13oz. cans ..........................................................................................................................31 Similac / Isomil 13-13oz. cans w/ Juice & Infant Cereal ..................................................................................31 Similac / Isomil 31-13oz. cans ..........................................................................................................................29 Similac / Isomil 31-13oz. cans w/ Juice ............................................................................................................30 Similac / Isomil 31-13oz. cans w/ Juice & Infant Cereal ..................................................................................30 Similac Lactose Free 13-13oz. cans ..................................................................................................................36 Similac Lactose Free 31-13oz. cans ..................................................................................................................34 Similac Lactose Free 31-13oz. cans w/ Juice ....................................................................................................35 Similac Lactose Free 31-13oz. cans w/ Juice & Infant Cereal ..............................................................35, 36, 37
CONCENTRATE Children & Women Similac / Isomil 25-13oz. cans w/ Juice & Cereal.............................................................................................52 Similac / Isomil 31-13oz. cans ..........................................................................................................................52 Similac / Isomil 31-13oz. cans w/ Juice & Cereal.......................................................................................53, 54 Similac / Isomil 35-13oz. cans w/ Juice & Cereal.............................................................................................54 Similac Lactose Free 25-13oz. cans w/ Juice & Cereal.....................................................................................49 Similac Lactose Free 31-13oz. cans ..................................................................................................................48 Similac Lactose Free 31-13oz. cans w/ Juice & Cereal.....................................................................................49 Similac Lactose Free 35-13oz. cans w/ Juice & Cereal.....................................................................................50
F
FORMULA AS ORDERED BY A PHYSICIAN 999...............................................................................................................................................................33, 38
FORMULA IS ORDERED BY A PHYSICIAN Children & Women 999.....................................................................................................................................................................57
J
JUICE / CEREAL 2 cans Juice, 24oz. Infant Cereal.......................................................................................................................32
P
POWDER Low Iron Formula 8-16oz. cans or 9-14oz. cans ...............................................................................................40 Low Iron Formula 8-16oz. cans or 9-14oz. cans w/ Juice & Infant Cereal .......................................................40 Non Contract Soy 9-14oz. cans.........................................................................................................................41 Non Contract Soy 9-14oz. cans w/ Juice & Infant Cereal .................................................................................42 Portagen / Pregestimil 8-16oz. cans ..................................................................................................................39 Portagen / Pregestimil 8-16oz. cans w/ Juice & Infant Cereal ..........................................................................39 Similac / Isomil 1-14oz. can..............................................................................................................................32 Similac / Isomil 1-14oz. can w/ Juice & Infant Cereal......................................................................................32

FP-97

GA WIC PROCEDURES MANUAL

Attachment FP-33 cont'd

Similac / Isomil 4-14oz. cans ............................................................................................................................32 Similac / Isomil 4-14oz. cans w/ Juice & Infant Cereal ....................................................................................32 Similac / Isomil 9-14oz. cans ............................................................................................................................31 Similac / Isomil 9-14oz. cans w/ Juice & Infant Cereal ....................................................................................31 Similac Lactose Free 1-14oz. can......................................................................................................................37 Similac Lactose Free 1-14oz. can w/ Juice & Infant Cereal..............................................................................36 Similac Lactose Free 3-14oz. cans ....................................................................................................................36 Similac Lactose Free 3-14oz. cans w/ Juice & Infant Cereal ............................................................................36 Similac Lactose Free 9-14oz. cans ....................................................................................................................37 Similac Lactose Free 9-14oz. cans w/ Juice & Infant Cereal ............................................................................37 POWDER Children & Women Nutramigen 8-16oz. cans OR 31-13oz. cans .....................................................................................................57 Nutramigen 8-16oz. cans OR 31-13oz. cans w/ Juice & Cereal........................................................................57 Portagen / Pregestimil 8-16oz. cans ..................................................................................................................48 Portagen / Pregestimil 8-16oz. cans w/ Juice & Cereal.....................................................................................48 Portagen / Pregestimil 9-16oz. cans w/ Juice & Cereal.....................................................................................57 Similac / Isomil 10-14oz. cans ..........................................................................................................................55 Similac / Isomil 10-14oz. cans w/ Juice & Cereal.............................................................................................56 Similac / Isomil 8-14oz. cans w/ Juice & Cereal...............................................................................................55 Similac / Isomil 9-14oz. cans w/ Juice & Cereal...............................................................................................56 Similac Lactose Free 8-14oz. cans w/ Juice & Cereal.......................................................................................51 Similac Lactose Free 9-14oz. cans ....................................................................................................................50 Similac Lactose Free 9-14oz. cans w/ Juice & Cereal.................................................................................51, 52 POWDER OR CONCENTRATE Nutramigen 8-16oz. cans OR 31-13oz. cans .....................................................................................................39 Nutramigen 8-16oz. cans OR 31-13oz. cans w/ Juice & Infant Cereal .............................................................39 POWDER OR CONCENTRATE Children & Women Nutramigen 9-16oz. cans OR 35-13oz. cans w/ Juice & Cereal........................................................................48
R
READY TO FEED Alimentum 25-1qt. cans ....................................................................................................................................39 Alimentum 25-1qt. cans w/ Juice & Infant Cereal ............................................................................................39 Similac / Isomil 100-8oz. cans ..........................................................................................................................44 Similac 25-1qt. bottles / Isomil 25-1qt. cans .....................................................................................................29 Similac 25-1qt. bottles / Isomil 25-1qt. cans w/ Juice & Infant Cereal .............................................................29 Similac Isomil 100-8oz. cans w/ Juice & Infant Cereal ....................................................................................46 Similac Lactose Free 25-1qt. cans.....................................................................................................................34 Similac Lactose Free 25-1qt. cans w/ Juice & Infant Cereal.............................................................................34
READY TO FEED Children & Women Alimentum 25-1qt. cans ....................................................................................................................................57 Alimentum 25-1qt. cans w/ Juice & Cereal.......................................................................................................57 Alimentum 28-1qt. cans w/ Juice & Cereal.......................................................................................................48 Similac / Isomil 100-8oz. cans w/ Juice & Cereal.............................................................................................59 Similac 25-1qt. bottles / Isomil 25-1qt. cans w/ Juice & Cereal........................................................................53 Similac Lactose Free 25-1qt. cans w/ Juice & Cereal .......................................................................................50

FP-98

GA WIC PROCEDURES MANUAL TABLE OF CONTENTS

Page

I.

Purpose..............................................................................................NE-1

II. Definition ..........................................................................................NE-1

III. Goals.................................................................................................NE-1

IV. State Agency........................................................................................NE-1

A. Nutrition Staff...............................................................................NE-1

B. Nutrition Education Responsibilities.....................................................NE-2

V. Local Agency.......................................................................................NE-3

A. Nutrition Staff..............................................................................NE-3

B. Nutrition Education Responsibilities....................................................NE-3

C. Training.....................................................................................NE-4

D. Nutrition Education Plan.................................................................NE-5

VI. Participant Nutrition Education.................................................................NE-6

A. Participant Nutrition Education Requirements........................................NE-6

B. Documentation of Nutrition Education................................................NE-7

VII. Participant Referral to Other Agencies.........................................................NE-8

A. Referrals.....................................................................................NE-8

B. Documentation.............................................................................NE-9

VIII. Nutrition Education Materials...................................................................NE-9

A. Criteria for Development and Use......................................................NE-9

B. Available Nutrition Education Materials.............................................NE-10

C. Procedure for Ordering Nutrition Education Materials. ............................NE-10

GA WIC PROCEDURES MANUAL

Attachments:

Page

NE-1 Format for Nutrition Education Plan................. .......................................... NE-11

NE-1 WIC Nutrition Education Strategic Plan (blank form)..................................NE-12

NE-2 WIC Maternal High Risk Criteria ........................................................................... NE-13

NE-2 WIC High Risk Criteria for Infants and Children ................................................... NE-14

NE-3 Guidelines for Nutrition Assistant Training............................................................ NE-15

NE-4 SOAP Note Documentation Format........................................................................ NE-19

NE-5 Material Evaluation Form ....................................................................................... NE-20

GA WIC PROCEDURES MANUAL I. PURPOSE
This section of the Georgia WIC Program 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.
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, physical activity, and behavioral choices. Nutrition education shall be focused on the client's interests and designed based on ethnic, cultural, and geographic preferences and with consideration for language, educational, and environmental factors.
III. GOALS
Nutrition education for WIC participants is designed to achieve two broad goals:
A. Emphasize the relationship between proper nutrition, physical activity, 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 positive changes in food and physical activity behaviors, in order to improve nutritional status and to prevent nutrition-related problems, through the optimal use of supplemental foods and other nutritious foods.
IV. STATE AGENCY
A. Nutrition Staff
The delegation of WIC nutrition education activities is vested within the Georgia Department of Human Resources, Division of Public Health, Family Health Branch, Nutrition Section.
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.
Nutrition Program Consultants in the Nutrition Section are available to districts/units as a resource in order to facilitate the State's efforts to strengthen and integrate Maternal and Child Health services (MCH) and WIC nutrition services. Current staff assignments are available from the Nutrition Section.
NE-1

GA WIC PROCEDURES MANUAL B. Nutrition Education Responsibilities
The State agency responsibilities for nutrition education:
1. Develop, implement, and evaluate the State Nutrition Education Plan. Periodically review, and evaluate, and make appropriate revisions as necessary.
2. Develop guidelines for local agency Nutrition Education Plan development. Review each plan and provide feedback.
3. Monitor the progress of local agency Nutrition Education Plans on a periodic basis through on-site visits and reports.
4. Evaluate the 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 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 participants, special problems, and emerging issues in nutrition.
6. Identify and develop resource and education materials for use at local agencies. Provide materials in languages other than English in areas where a substantial number of persons are non-English speaking.
7. Coordinate WIC nutrition education activities with related programs and professional groups such as the Cooperative Extension Service, Food Stamp Program, professional organizations, advisory committees, etc.
8. Develop and implement procedures to assure that nutrition education is offered to all adult participants, child participants whenever possible, and to parents or caretakers of infant or child participants.
9. Perform and document evaluation of nutrition education activities on an annual basis. The evaluation shall include an assessment of participant's views concerning the effectiveness of the nutrition education they received.
10. Establish standards for participant contacts that ensure adequate nutrition education.
11. Monitor local agency activities to ensure compliance with defined local agency responsibilities and participant nutrition education contacts.
NE-2

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 of Nutrition 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 minimum 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 2001-2002. Based on the findings, the requirement will be fully implemented in FFY 2003. 3. Nutrition positions should be appropriately classified according to the Performance Plus class specifications for nutrition personnel. The Performance Plus 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 Performance Plus class specifications for nutrition personnel and qualifications and compensation levels are available on request from the Georgia Merit System of Personnel Administration.
B. Nutrition Education Responsibilities The local agencies shall perform the following activities in carrying out their nutrition education responsibilities:
NE-3

GA WIC PROCEDURES MANUAL 1. Provide nutrition education to all adult participants, parents or caretakers of infant or child participants, and whenever possible, to child participants. Program participants may be encouraged to assist in providing nutrition education to other participants (e.g. the use of a breastfeeding participant to talk with participants who are interested in breastfeeding). Individual or group sessions and/or education materials designed for program participants may be utilized for the delivery of nutrition education services to non-participating women, infants, and children who take part in other local agency health services.
2. Provide in-service training and technical assistance for competent professional authorities (CPA's) and nutrition assistants at local clinics.
3. Develop a triennial Nutrition Education Plan consistent with the nutrition education portion of the State Plan (see Attachment NE-1).
4. Develop a system for the regular assessment of participant views on nutrition education and breastfeeding promotion, at least on an annual basis. This data shall be used in the development and revision of the Nutrition Education Plan. The findings shall be reported annually in the Nutrition Education Plan Update that is due to the Nutrition Section by November 30th of each year.
C. 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 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 Nutrition Section. These workshops provide 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. Many presenters are nationally recognized and provide state of the art practice methods.
2. Continuing Education
a. The CPA must receive at least four (4) hours of nutrition training each year. All CPA's are encouraged to attend local, state, or national workshops or meetings to develop and update skills and knowledge in nutrition and lactation management.
NE-4

GA WIC PROCEDURES MANUAL b. All nutrition training and continuing education activities conducted or attended by the local staff must be recorded and kept on file by the local agency. The file should include the name and title of the participant and the title and date of the workshop.
D. Nutrition Education Plan
1. Triennial Nutrition Education Plan
A three (3)-year Nutrition Education Plan covering FFY 2003-2005 must be submitted to the Nutrition Section by September 1, 2002. This plan may be integrated with the overall WIC plan that is due to the Georgia WIC Program Branch on the same date.
a. The local agency Nutrition Education Plan must include:
(1) The local agency GOAL for Nutrition education; (2) OBJECTIVES to reach the stated goal; (3) STRATEGIES to achieve the objective; (4) ACTION STEPS for activities/methods for each strategy; (5) PERSON RESPONSIBLE for each action step; (6) TIME FRAME to complete action steps; (7) RESOURCES NEEDED to accomplish each step; (8) STATUS of implementation or completion of action steps.
b. Plans must relate to nutrition education services.
c. The Nutrition Education Plan should address at a minimum: nutrition education contacts, nutrition materials, local and state goals.
2. Nutrition Education Plan Update
The update is a progress report and must be submitted to the Nutrition Section by November 30th of each year and should include the following:
STATUS of each action step accomplished in the previous Fiscal Year. Revision, deletion, and/or addition of any portion of the Plan. Report of assessment of participant views on nutrition education and
breastfeeding promotion.
3. Format and Form - see Attachment NE-1.
NE-5

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. Participants must be encouraged to attend and participate in nutrition education activities, but cannot be denied supplemental foods for failure to attend or participate in the provided activities.
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. As much as is reasonably possible, nutrition education sessions should focus on the participant's nutritional interests.
4. All participants shall receive at least one nutrition education contact during each certification period which relates to their own (or their child's) dietary intake, as assessed by the CPA. Visual aids, such as food models or measuring cups, should be used to obtain a good assessment of dietary intake and to help the participant learn about portion sizes.
5. Counseling in regards to the need for regular physical activity may be documented as nutrition education, since physical activity relates to energy balance, and thus contributes to nutritional status. Encouragement to decrease physical inactivity should be provided.
6. All high-risk WIC participants (as defined in Attachment NE-2) must be scheduled to receive a high-risk nutrition education contact during the current certification period. If someone provides the high-risk contact other than a nutritionist, adequate documentation must be provided.
7. All women participants must receive exit counseling by the final nutrition education contact of the postpartum period. Exit counseling is defined as counseling which includes the following topics which are to be discussed by the final nutrition education contact:
NE-6

GA WIC PROCEDURES MANUAL
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)
8. Importance of up-to-date immunizations.
9. Parents or caretakers of WIC infants and children must also be provided with information about abuse of drugs and other harmful substances.
10. The Nutrition Guidelines for Practice are the established guide for nutrition education contacts.
11. 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. Nutrition assistants can provide nutrition education contacts when appropriate nutrition education training has been received. The Nutrition Section must approve the training plan. (See Attachment NE-3 for the Guidelines for Nutrition Assistant Training and list of items to be submitted for approval.)
12. An individual nutrition care plan should be developed for a participant, based on need, as determined by the CPA. The Nutrition Care Plan should be written using the SOAP (Subjective Objective Assessment Plan) note format. (See Attachment NE-4 for the SOAP Note Documentation Format).
13. 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 Nutrition Section at the time of program reviews.
14. If the participant/caregiver is unable to receive services at the clinic for an extended period of time, home visits are the recommended method for providing secondary nutrition education contacts.
B. Documentation of Nutrition Education
1. All individual 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 must be documented (e.g., introduction of solids; portion sizes for the 2-3 year old; ways to increase fluid intake).
NE-7

GA WIC PROCEDURES MANUAL 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.
2. Group nutrition education contacts may be documented with the participant's signature on a class attendance sheet, voucher register (or VPOD receipt) and a class roster which contains the lesson objective(s) and the original signature of the staff conducting the class. A description of the district's method of documentation must be submitted for approval prior to implementation.
3. Documentation of nutrition education contacts must include the date, topic, and method by which the nutrition education contact was provided (e.g., class, kiosk, individual counseling, etc.).
4. 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.
VII. PARTICIPANT REFERRAL TO OTHER AGENCIES Participants must be assessed for referrals during each certification appointment. A. Referrals 1. Participants must be referred to the Food Stamp Program, Medicaid and Temporary Assistance for Needy Families (TANF). Participants shall be informed of these programs and, if needed, be provided with the addresses and telephone numbers of local/State offices. 2. Local agencies are encouraged to coordinate with and refer participants to the Cooperative Extension Service, Expanded Food and Nutrition Education Program (EFNEP).
NE-8

GA WIC PROCEDURES MANUAL 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

5. Prenatal or breastfeeding participants needing additional breastfeeding information, assistance or support should be referred to the appropriate person(s) designated through the local agency breastfeeding program.
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.
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 or designee. See Materials Evaluation Form for guidance (Attachment NE-5).
The Nutrition Section is available for consultation and technical assistance to review nutrition education materials.

NE-9

GA WIC PROCEDURES MANUAL 2. Sample copies of all nutrition education materials used by the local agency, which are not provided by Central Supply, must be made available to the Nutrition Section during the program review. 3. All nutrition education materials used must accurately reflect current documented scientific knowledge of nutrition. 4. Materials must be prepared to meet needs of the specific population group to be served, including migrant farm workers, and homeless persons. Consideration must be given to the reading level as well as to cultural and language needs of clients. 5. The Nutrition Section reserves the right to disapprove the use of nutrition education materials if it determines them to be inappropriate. 6. If a local agency develops materials that are applicable statewide, the Nutrition Section may seek approval from the local agency to duplicate these materials.
B. Available Nutrition Education Materials A list of nutrition education materials can be obtained from the Nutrition Section. Districts are encouraged to order and utilize materials from the Nutrition Section prior to ordering materials prepared by other companies.
C. Procedure for Ordering Nutrition Education Materials 1. All education materials must be ordered on Requisition Form #5014 (Attachment CT-38, Certification Section) by the district WIC Coordinator for all local WIC clinics, and sent to the Nutrition Section. The Nutrition Section will forward this requisition to Central Supply, and the materials will be mailed directly to the district.
NE-10

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 Address, Telephone and Fax Number E-mail Address

BODY OF PLAN

Goal:

General statement of what you are trying to achieve. Keep your goal consistent with local, state, and national goals.

Objectives:

Should begin with "To..." and include an action verb, desired results or outcome in numerical terms. Each objective should have a target group and a time frame of completion date.

Strategies:

Interventions to achieve the goal and objectives.

Action Steps:

Tasks, activities and methods to achieve the goal and objectives.

Resources:

Staff, facilities (space available, etc.), materials and technical assistance to complete the tasks.

Person Responsible:

Person(s) responsible for each step.

Time Frame:

Target dates for accomplishment of action steps.

Resources Needed:

Staff, facilities, (space available, etc.) materials and technical assistance needed.

Status:

State of implementation or completion of the Action steps.

NE-11

GA WIC PROCEDURES MANUAL

Attachment NE-1cont'd

WIC Nutrition Education Strategic Plan

District/Unit:

Time period for plan:

Goal:

Objective:

Strategies: Action Steps

Person Responsible

Time Frame

Resources Status Needed

NE-12

GA WIC PROCEDURES MANUAL

Attachment NE-2

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, a nutritionist should provide this counseling. 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

Appendix
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
EDC or delivery prior to 17th birthday

341-349 and
351-362
331

Blood lead level > 10 g/dl

211

Breastfeeding (BF) complications; referral to appropriate

602

BF 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-13

GA WIC PROCEDURES MANUAL

Attachment NE-2 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 birth weight 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 breastfeeding 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-14

GA WIC PROCEDURES MANUAL

Attachment NE-3

GUIDELINES FOR NUTRITION ASSISTANT TRAINING

I. Qualifications for Nutrition Assistants:

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.

F. Dietetic interns.

II. Competencies for Nutrition Assistants
A. Basic WIC Program Knowledge. The WIC Nutrition Assistant 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 of local area WIC vendors; (c) personal reference book (if one is developed); and (d) USDA rules and regulations or Georgia WIC Program Procedures Manual policies relating to supplemental foods and nutrition education.
6. Describe the process of how a WIC participant obtains WIC foods.
7. List the various WIC approved foods.

NE-15

GA WIC PROCEDURES MANUAL

Attachment NE-3 cont'd

8. List notification requirements.
9. Demonstrate a thorough knowledge of individual lesson plans and content, as outlined by the district nutrition coordinator/designee. The nutrition assistant should score ninety percent or above on the written test.
B. Communication Skills. The Nutrition Assistant 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 Nutrition Assistant 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 nutrition assistant.
Nutrition Assistants must receive at least 12 hours of continuing education per year.
NE-16

GA WIC PROCEDURES MANUAL These hours can be attained through:

Attachment NE-3 cont'd

1. Participation in the annual Competency Based Skills Workshop for nutrition assistants, provided by the Nutrition Section

2. Other nutrition conferences/workshops

3. Other health conferences with a nutrition component, covering at least two (2) hours of nutrition information.

IV. Parameters for Nutrition Assistants

Nutrition Assistants will be trained to provide very specific and limited nutrition information to WIC participants. Information will be limited to that learned in training. Referrals to the nutritionist will be made based on guidance in lesson plans and/or the training manual, and/or for questions beyond the scope of the training received by the nutrition assistant.

V. Evaluation Component

Evaluation of the nutrition assistant includes the following:

A. The nutrition assistant must score the required percentage on a test for each topic area, before being able to proceed to the next step.

B. The nutrition assistant 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 nutrition assistant must be observed conducting at least three (3) secondary nutrition education contacts before being able to do so routinely.

D. The immediate supervisor must be readily accessible to assist the nutrition assistant with problems.

E. The district nutrition coordinator (or designee) will conduct quarterly record reviews and observe the nutrition assistant 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-17

GA WIC PROCEDURES MANUAL

Attachment NE-3 cont'd

NUTRITION ASSISTANT TRAINING PLAN CHECKLIST FOR ITEMS TO SUBMIT FOR APPROVAL
Training Plan:
Lesson Plans for use in training nutrition assistants, including post-tests. Note: these may be submitted on an on-going basis.
Evaluation Component
Plan for nutrition assistant to observe professional(s) providing secondary nutrition contacts.
Plan for nutrition coordinator (or designee) to observe nutrition assistant(s) providing secondary nutrition education contacts.
Plan to conduct quarterly chart reviews and observation of nutrition assistant(s).
Lesson Plans for use by nutrition assistant(s) in providing secondary nutrition education contacts - group class or individual counseling.
Documentation Procedures to be used by nutrition assistants.
Additional Information:
Name(s) of nutrition assistant(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-18

GA WIC PROCEDURES MANUAL

Attachment NE-4

SOAP NOTE DOCUMENTATION FORMAT

Once the nutritional status of an individual has been determined, the assessment of the problem and intervention plans needs 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

O- 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 of the 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-19

GA WIC PROCEDURES MANUAL

Attachment NE-5

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

Summarization of ideas

References are accurate, up-to-date and usable

NE-20

GA WIC PROCEDURES MANUAL

Attachment NE-5 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-21

GA WIC PROCEDURES MANUAL

Attachment NE-5 cont'd

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

MINIMALLY ACCEPTABLE

ADEQUATE

SUPERIOR

NE-22

GA WIC PROCEDURES MANUAL

Attachment NE-5 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

MINIMALLY ACCEPTABLE

ADEQUATE

Replacement reasonable work life (durability) predisposed to obsolescence ease of repair (include shipping/handling) cost of replacement

Duplication allowable/legal cost of duplication

SUPERIOR

NE-23

GA WIC PROCEDURES MANUAL

Attachment NE-5 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 individual counseling/use waiting room use

Is there an easier, more efficient way to stimulate the same behavior?

RECOMMENDATIONS:

SUPERIOR

SIGNATURE/TITLE 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-24

GA WIC PROCEDURES MANUAL

TABLE OF CONTENTS

Page

I. Introduction ..................................................................................................................SP-1

A. Definitions...........................................................................................................SP-1

B. Certification ........................................................................................................SP-1

C. Food Delivery......................................................................................................SP-2

D. Outreach and Referral .........................................................................................SP-2

E. Reporting and Monitoring...................................................................................SP-2

II. Individuals Residing in Non-Traditional Housing or Institutions................................SP-3

A. Definitions...........................................................................................................SP-3

B. Services for Applicants/Participants Residing In Temporary Housing .............................................................................................SP-4

C. Meals in Institutions and Temporary Housing....................................................SP-5

III. Other Special Populations ............................................................................................SP-7

A. Definitions...........................................................................................................SP-7

B. Limited English Proficient Population................................................................SP-7

C. Refugees..............................................................................................................SP-8

D. Native Americans................................................................................................SP-8

E. Persons With Disabilities ....................................................................................SP-8

IV. Referral and Outreach to Special Populations..............................................................SP-9

GA WIC PROCEDURES MANUAL

Attachments:

Page

SP-1

Georgia Farmworker Health Program ..........................................................................SP-10

SP-2

Migrant Education Staff/Four Regional Offices ..........................................................SP-12

SP-3

Telamon Corporation (Migrant and Seasonal Farmworker

Association, Inc.) ..........................................................................................................SP-13

SP-4

Migrant Head Start Program .......................................................................................SP-15

SP-5

Interpreter Services.......................................................................................................SP-16

SP-6

Assurance Statement ....................................................................................................SP-17

SP-7 Notice of Interpretation Services Sign ........................................................SP-19

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, and applicants/participants residing in institutions, homeless people. Limited English Proficient refugees, Native Americans and persons with disabilities. Local WIC Programs are responsible for ensuring accessability to WIC services for these populations.
A. Definitions
1. Migrant Farm Workers are individuals (and family members) employed seasonally in agriculture occupations, who establish temporary residence for the purpose of such employment, and have been employed in such occupation within the last twenty-four (24) months.
2. Loggers are individuals whose principal employment is seasonal harvesting of trees, who have been employed in this activity within the last twenty-four (24) months and for such employment established a temporary abode.
3. Seasonal Farm Workers and individuals 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 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 VOC card is valid until the certification period expires.
SP - 1

GA WIC PROCEDURES MANUAL
WIC certification must be documented with a VOC card or a copy of the Georgia WIC assessm (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 back to the state that the vouchers originated. 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 have a valid issue date (See Food Delivery Section).
D. Outreach and Referral
In geographical areas where there is significant movement of migrants' 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 as well as 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 Automated Data Processing (ADP) Contractor each month. Information on the Turnaround Document (TAD) is completed with AYes (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.
SP - 2

GA WIC PROCEDURES MANUAL
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.
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 non-traditional 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, and 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-II, 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 with the State WIC Branch before clients may be served.
A. Definitions
Services and program benefits must be tailored to meet the special needs of individuals defined in these groups. Institution is any residential accommodation, 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 nighttime residence.
SP - 3

GA WIC PROCEDURES MANUAL
Homeless Individual means a woman, infant or child:
(a) Who lacks a fixed and regular nighttime residence; (b) Whose primary nighttime residence is:
1. A supervised publicly or privately operated shelter (including a welfare hotel, a congregate shelter, or a shelter for victims of domestic violence) des
2. An institution that provides a temporary residence for individuals intended to be institutionalized;
3. A temporary accommodation of not more than 365 days in the residence of another individual; or
4. A public or private place not designed for, or ordinarily used as, a regular sleeping accommodation for human beings.
Temporary Housing refers to a residential facility or home for individuals who have lost their primary place of residence and relocate to a short term 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.
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).
SP - 4

GA WIC PROCEDURES MANUAL
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 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 redemption 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, and shelter for battered women, rehabilitation facility, etc.
The institution and participant when determining eligibility for participation in the Georgia WIC Program must adhere to the following requirements.
SP - 5

GA WIC PROCEDURES MANUAL
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 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. Pa
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 - 6

GA WIC PROCEDURES MANUAL
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 that 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 speak 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, and politician opinion, or membership in a social group.
B. Limited English Proficient (LEP) Population
Individuals whose primary language is not English, and who do not read or speak English well enough to have access to WIC services and benefits provided in local clinics. The Local agency are responsible for ensuring that multilingual staff, volunteers, or other translation resources are available to serve Limited English proficient (LEP) participants or LEP applicants.
In areas where a substantial number of persons are limited English Proficient, 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 organizations serving LEP, speaking persons. A variety of Spanish Nutrition education and breastfeeding materials are available through the Nutrition Section.
SP - 7

GA WIC PROCEDURES MANUAL
If a local agency needs materials in other languages, contact the State WIC Branch or the Nutrition Section 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-57). The Office of Nutrition will assist local agencies in identifying multilingual translators or interpreters.
The local agency must post the Notice of Interpretation Services Sign in the waiting room for WIC applicants. The purpose of this sign is to indicate to the applicant that services are available at no charge to them in other language based on request. This sign will be monitored on program and self reviews (See Attachment 7).
C. Refugees
A refugee is someone who flees his or her country due to persecution or a wellfounded 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.
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.
SP - 8

GA WIC PROCEDURES MANUAL The local programs should provide capabilities for communicating with vision and hearing impaired participants and applicants. Interpreters for the hearing impaired are available through the State Rehabilitation Program (See Attachment SP-5). IV. REFERRAL AND 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 and SP-4). 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 referred to appropriate health and human service agencies within your area, such as: * Public Assistance/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 - 9

GA WIC PROCEDURES MANUAL

Attachment SP-1

Georgia Farmworker Health Program Post Office Box 310
Cordele, Ga, 31010-0310 Phone: 229-401-3086 Fax: 229-401-3077
Isiah C. Lineberry, Executive Director, Office of Rural Health Services, Email: ilineberry@dch.state.ga.us Tony Brown, Migrant Health Coordinator, Office of Rural Health Services, Email: tbrown@dch.state.ga.us Ted Meisner, Field Data Consultant, 478-746-9659, Email: laermita@asburyusa.net FAX: 630-929-1364

Project Sites

Migrant Program Staff Telephone/Fax Address

Counties Served

6/27/01

Ellaville Glennville Coffee

Mary Anne Shepherd, FNP,

P/Coordinator

Shelby Clark, RN.

Angelica Carranza, ORW

Angie McIllrath, ORW

Rosa Cazares, ORW

Shirley Jones, Office

Manager

Michelle

Doggett,

Accounting

Christy Pike, FNP,

P/Coordinator

Linda Baxter, Data

Entry/Secretary

Manuela Galvan, ORW

Jean Ulbrick, ORW

Lydia Villalobos, ORW

Maria Contreras, ORW

Juanita Johnson, ORW

Sue Scaffe, District Office, Waycross

Tel: 229-937-5321 Fax: 229-9372232
Tel: 912-654-5300 Fax: 912-6545303
912-685-5765
912-526-8108

Ellaville Primary Medicine Clinic 103 Broad Street PO Box 65 Ellaville, Georgia, 31806-9428
E-Mail: mshepherd@sumterregional.org
Tattnall County Health Department 1001 N. Downing Musgrove Hwy Glennville, Ga, 30427 E-mail: fwhealth@pineland.net
Candler County Health Department PO Box 205 Metter, Ga, 30439
Toombs County Health Department PO Box 191 Lyons, Georgia, 30426

Josie Haklin, RN, P/Coordinator Kaye Hulett, Accounting Clerk Sherrill Carver, Cost Report Angelica Gomez, ORW

Tel: 912-389-4450 Fax: 912-3894326

Coffee County Health Department 1111 West Baker Highway Douglas, Ga, 31533-4920

Schley Sumter Macon Taylor Crisp
Tattnall
Candler
Toombs
6/27/01 Atkinson Coffee

SP - 10

GA WIC PROCEDURES MANUAL

Attachment SP-1 cont'd

Ellenton

Blainette Hanson, FNP Dana Reddick, Nurse Manager Marisela Resendiz, Nurse's Aid Kathy French, Data Entry Jose Palomares, ORW Celines Quinones, ORW

Tel: 229-324-2845 Fax: 229-324-3383

Ellenton Clinic 103 Baker Street PO Box 312 Ellenton, Georgia, 31747

Colquitt Tift Cook Brooks

Valdosta

Jody Horne, Cost Reports
Barbara Jackson, District Contact Mary Ann Bland, Accounting
Steve Graham, President/CEO Dr. Manual Tovar, MD Janie McGhin, ANP-C Lydia Naylor, RN Julissa (Julie) Clapp, ORW Tomi McCain, Receptionist, ORW Dr. Antonio Gracia, MD

Tel: 229-891-7100
Tel: 229-430-4575 Fax: 229 912-430-5143
Tel & Fax: 229-5599910 Steve Graham's Fax: 229-242-0490

Colquitt

Health

Department

Moultrie, Georgia

1109 N. Jackson Street Albany, Georgia, 317012022 Airport Medical Clinic Culpepper Road PO Box 889 Lake Park, Georgia, 31636

Echols Lowndes

SP 11

GA WIC PROCEDURES MANUAL

Attachment SP-2

MIGRANT EDUCATION STAFF
Mary Beth Heyer, Program Manager Georgia Migrant Education Program
State Department of Education 1852 Twin Towers East - 1958
Atlanta, Georgia 30334 (404) 656-4995
REGIONAL OFFICES
Chattahoochee Flint Regional Education Service Agency P.O. Box 588
Americus, GA 31709 (229) 937-5341
Migrant Education Association Live Oak
P.O. Box 780 Brooklet, GA 30415
(912) 424-5400
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 (229) 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 (478) 873-6575

Offices Valdosta Office 200 East Mary Street Valdosta, Ga. 31601

Field Offices

Supervisors Carmen Wilkinson Program Coordinator

Lyons Office 120 East Liberty Avenue 1020 Lyons, Ga 30436 (912) 526-3094 (912) 526-5906 (FAX)
Dublin Office 112 East Johnson Street Dublin, Ga. 31021 (478) 275-0127 (478) 275-7548 (FAX)
Douglas Office 613 West Baker Hwy. P.O. Box 966 Douglas, Ga. 31533 (478) 384-8856 (478) 384-8929 (FAX)
Statesboro Office 105 Elm Street P.O. Box 645 Statesboro, Ga. 30358 (912) 764-6169 (912) 489-6516 (FAX)

Elmira Reynolds Employment and Training Specialist
Barbara Mosley Employment and Training Specialist
Myrtice Moore Employment and Training Specialist
Elsie Trethaway Employment and Training Specialist

SP - 13

GA WIC PROCEDURES MANUAL
Offices
Moultrie Office 19 1st Street S.E. Moultrie, Ga. 31776 (229) 985-7507 (229) 985-7305 (FAX)
Blackshear Office 3351 West Highway 84 P.O. Box 413 Blackshear, Ga. 31516 (912) 449-3016 (912) 449-4579 (FAX)

Attachment SP-3 cont'd
Supervisors Beverly Scretchen Employment and Training Specialist
Sharon Moody Deputy Director

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

(229) 769-3627

(229) 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) 679-3031

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

REFUGEE HEALTH INTERPRETERS

Sabina Brovic Chanthary Chea Bay Ngyun Zyan Amedi Siya Kim Margarita Tselesin Halema Hasashi

Bosian Cambodian, Vietnamese Vietnamese Kurdish Cambodian Russian Somalia

(404) 294-3816 (404) 508-7785 (404) 657-2552 (404) 294-3816 (404) 657-2563 (404) 657-2641 (404) 657-6716

Gainesville

Anita Gougelmann

Vietnamese

(770 ) 531-5600 GIST 261-5600

DFAC STATE REFUGEE COORDINATOR

Barbara Burham
2 Peachtree St., NW 19th Floor
Atlanta, GA 30303

(404) 657-3428

GEORGIA INTERPRETER SERVICES FOR THE HEARING IMPAIRED

David Cowan, Director 44 Broad Street, NW Suite 503 Atlanta, GA 30303

(404) 521-9100 Fax: (404) 521-9121

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, Infant and Children (WIC),

(Name of shelter/facility)
assures the Georgia WIC Branch that they will adhere to the following conditions:
1. 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 Branch 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 it discretion, make site visits to monitor compliance to the above conditions and/or investigate complaints.
The "Assurance Statement" will remain on file in the State WIC Off Branch until such time as the shelter/facility notifies the State WIC Branch that it no longer wishes to participate according to the ascribed conditions and/or it is determined by the Georgia WIC Branch that the agency is not in compliance.

SP - 17

GA WIC PROCEDURES MANUAL

Attachment SP-6 cont'd

Assurance Statement Page Two
The undersigned agrees 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 Branch Division of Public Health Georgia Department of Human Resources Two Peachtree Street, NW
10th Floor, Suite 394 Atlanta, Georgia 30303

SP - 18

GA WIC PROCEDURES MANUAL

Attachment SP-7

NOTICE OF INTERPRETATION SERVICES SIGN

SP - 19

GA WIC PROCEDURES MANUAL
TABLE OF CONTENTS Page
I. General ...........................................................................................................................OR-1 II. Methods of Outreach ......................................................................................................OR-1 III. Agencies to Contact for Outreach ..................................................................................OR-2 IV. Public Notification .........................................................................................................OR-2 V. Public Comments Period ................................................................................................OR-3 VI. Outreach During a Waiting List .....................................................................................OR-3 VII. Program Costs ................................................................................................................OR-4 VIII. Coordination/Integration of Services .............................................................................OR-4
A. Outreach ...................................................................................................................OR-4 B. WIC/Medicaid Coordination ....................................................................................OR-4 Attachments: OR-1 Georgia WIC Program Fact Sheet .................................................................................OR-5

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. Increase public awareness of the benefits of the WIC Program.
2. Inform potentially eligible persons about the WIC Program in order to encourage and promote their participation in the program.
3. Inform health and social service agencies of the WIC Program's qualifications for participation and encourage referrals.
4. 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.
5. Promote a positive image of the WIC Program.
6. Generate additional information for other non-English speaking activities.
Each local agency must conduct outreach/referral activities to coordinate the WIC Program with other programs and services which serve potential WIC applicants. The outreach activities conducted must be documented and kept on file for four (4) years.
When funds are available, the State WIC Branch will develop and provide general outreach materials for use by local programs.
II. METHODS OF OUTREACH
Outreach activities should be aimed directly at potentially eligible persons through the use of informational posters, brochures, displays in public places, presentations at meetings and clubs, and advertisements through local newspapers, radio, or television. If a local agency serves a significant number of persons whose primary language is not English, the local agency must make outreach materials available to this population in their language.
The State Agency has developed the WIC Fact Sheet(Attachment I) to assist local agencies with outreach activities.
OR - 1

GA WIC PROCEDURES MANUAL
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 Branch 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.
III. AGENCIES TO CONTACT FOR OUTREACH
Examples of agencies, offices, and organizations that 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. Public Assistance Office 9. Unemployment Offices 10. Social Service Agencies 11. Religious and Community Organizations 12. Agencies Offering Services for Homeless Families and Individuals 13. Housing Authority 14. High Schools and Counselors 15. Migrant Offices 16. Military Bases 17. Retail Stores (KMART, Walmart, etc.) 18. Day Care Centers 19. Charitable Organizations (Goodwill, Salvation Army, etc.) 20. Headstart Programs
IV. PUBLIC NOTIFICATION
The State Agency, through the Office of Public Information, will distribute at least annually, outreach information to every newspaper and radio station in Georgia. All outreach materials must include the WIC non-discrimination statement.
OR - 2

GA WIC PROCEDURES MANUAL
V. PUBLIC COMMENTS PERIOD
Annually, the Georgia WIC Program solicits public comments regarding the State Plan of Operation and Administration through a public comment period. The public comment period also gives local citizens an opportunity to comment on how WIC services are provided to them. Correspondence announcing this public comment period is forwarded to interested individuals and groups. The following listing delineates the 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 comment letters being mailed, the news media is also informed of this comment period. 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.
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, sex, age or disability must be included. Information on where and how the public may review the State 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.
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 continue. A Local Agency cannot decide to have a waiting list within their district due to caseload problems.
OR - 3

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.
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 Branch and the Division of Public Health. All districts have taken positive steps toward decentralization and the integration of WIC with existing services. 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 Certification form includes a space for Medicaid number . 2. The State of Georgia "Right From The Start" program makes Medicaid available to pregnant women, infants and children up to age twenty-one (21). 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.
OR - 4

GA WIC PROCEDURES MANUAL

Attachment I

Special Supplemental Nutrition Program for Women, Infants and Children

FFY 2001 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, Temporary Assistance for Needy Families (TANF), immunization, and other services.
The Georgia WIC Program will receive approximately $116 million in federal funds during FFY 2001. 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 216,000 women, infants and children per month during FFY `00.
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 99.
The average WIC benefit is about $47 worth of food vouchers per month.

OR - 5

GA WIC PROCEDURES MANUAL

Attachment I

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 at Grady Hospital and Southside Healthcare, Inc.
For FFY 02 income of 185 percent of the federal poverty level equals:

Family Size

Year Income

1

$ 15,892

2

21,479

3

27,066

4

32,653

OR - 6

GA WIC PROCEDURES MANUAL TABLE OF CONTENTS Page
I. General...............................................................................................................................FD-1 II. Types of WIC Vouchers .................................................................................................. FD-2
A. Vouchers Printed On Demand (VPOD) ................................................................FD-2 B. Blank Manual Vouchers ........................................................................................FD-2 C. Preprinted Standard Manual Vouchers..................................................................FD-2 D. Computer Printed Vouchers.................................................................................. FD-3 E. Automated Special Manual Voucher .................................................................... FD-3 III. Voucher Issuance - General...............................................................................................FD-3 A. Valid Certification Period......................................................................................FD-3 B. Identification of Person Picking Up Vouchers ......................................................FD-3 C. Corrections.............................................................................................................FD-4 D. Issuance..................................................................................................................FD-4 E. Categorically Ineligible .........................................................................................FD-4 F. Issuance of Vouchers to Family Members ............................................................FD-4 IV. Voucher Printed on Demand (VPOD) Vouchers and Computer Generated Vouchers .....FD-5 A. Data Elements........................................................................................................FD-5 B. Voucher Cycles .....................................................................................................FD-6 C. Voucher Packaging................................................................................................FD-6 D. Voucher Issuance........................................................................................ FD-10 E. Transporting VPOD Vouchers from a Site within a Site............................ FD-11 F. Ordering VPOD Vouchers............................................................... FD-11 V. Manual Vouchers (Blank and Standard) .........................................................................FD-12

GA WIC PROCEDURES MANUAL A. Blank Manual and Preprinted Manual Vouchers ................................................FD-12 B. Ordering Manual Vouchers .................................................................................FD-12 C. Receipt of Manual Vouchers ...............................................................................FD-12 D. Inventory Control of Manual Vouchers...............................................................FD-13 E. Issuance of Manual Vouchers..............................................................................FD-14 F. Distribution of Manual Voucher Copies .............................................................FD-15
VI. VPOD Procedures ......................................................................................................... FD-15 A. General.................................................................................................................FD-15 B. Issuing VPOD Vouchers......................................................................................FD-16 C. Voucher Reconciliation .......................................................................................FD-16 D. VPOD Inventory Log Sheets ...............................................................................FD-17 E. Corrective Action for VPOD ...............................................................................FD-17
VII. Mailing/Delivery of WIC Vouchers..................................................................................FD-18 A. Conditions for Mailing/Delivering Vouchers......................................................FD-18 B. Acceptable Reasons for Mailing/Delivering Vouchers .......................................FD-18 C. Mailing/Delivery Procedures...............................................................................FD-19 D. Voucher Mailing Process.....................................................................................FD-19 E. Returned Vouchers ..............................................................................................FD-19
VIII. Voided Vouchers ..............................................................................................................FD-20 IX. Prorated Vouchers ............................................................................................................ FD-21 X. Late Pick-Up of Vouchers .................................................................................................FD-23 XI. Coordination of Health Services and Vouchers Issuance ................................................ FD-24 XII. Lost, Stolen or Damaged Vouchers ...................................................................................FD-24
A. Replacement of Vouchers....................................................................................FD-24

GA WIC PROCEDURES MANUAL B. Lost/Stolen/ Destroyed/Voided Voucher Report.................................................FD-24 C. Vouchers Lost, Stolen, or Destroyed Prior to Issuance.......................................FD-25 D. Change of Formula Order....................................................................................FD-26
XIII. Borrowed Voucher...........................................................................................................FD-26 XIV. Cumulative Unmatched Redemption Report (CUR)......................................................FD-28
A. Introduction .........................................................................................................FD-28 B. Procedures for Reconciliation .............................................................................FD-28 C. Manually Reconciliating CUR Part 1..................................................................FD-29 D. Manually Reconciliation CUR Part 2..................................................................FD-30 E. Procedures for Both Reports................................................................................FD-30 Attachments: FD-1 Computer Printed Voucher .............................................................................FD-32 FD-2 Blank Manual Voucher ...................................................................................FD-33 FD-3 Preprinted Standard Manual Voucher.............................................................FD-34 FD-4 Automated Special Manual Voucher ..............................................................FD-35 FD-5 Voucher Printed On Demand (VPOD) Voucher ............................................FD-36 FD-6 Voucher Creation Calendar ............................................................................FD-37 FD-7 Voucher Cycle Packing List ...........................................................................FD-38 FD-8 Computer Printed Voucher Register...............................................................FD-39 FD-9 Voucher Register Summary Page ...................................................................FD-40 FD-10 Transmittal Form ............................................................................................FD-41 FD-11 Form and Manual Voucher (Order Supply Form) ..........................................FD-42 FD-12 Manual Voucher Inventory .............................................................................FD-43 FD-13 Voucher Printed On Demand Log Sheet ........................................................FD-44

GA WIC PROCEDURES MANUAL FD-14 Batch Control Form ........................................................................................FD-45 FD-15 Batch Control Exception Report.....................................................................FD-46 FD-16 Georgia WIC Program Identification Card.....................................................FD-47 FD-17 Daily Roster/Monthly Mailed Voucher Report ..............................................FD-48 FD-18 Borrowed Voucher Report Form ....................................................................FD-49 FD-19 Cumulative Unmatched Redemptions Part I...................................................FD-50 FD-20 Cumulative Unmatched Redemptions Part II .................................................FD-51 FD-21 Lost, Stolen, Destroyed, Voided Voucher Report ..........................................FD-52 FD-22 Vouchers Printed On Demand (VPOD) Receipt ............................................FD-53

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 one, two, or three-month interval. Georgia has a fully automated food delivery and management information system. The State WIC Program contracts with a data processing firm, PDA Software Services, Inc. (PDA) to operate and maintain the system. Persons requesting WIC benefits are screened for program eligibility and are certified if the applicant qualifies. Data containing demographic, financial, medical/nutritional, and food package information is forwarded directly to PDA in order to establish a participant masterfile. Most local agencies have the capability of electronically transmitting WIC data to PDA. Local Agencies use many different kinds of automated systems. Currently the Automated Data Processing Contractor (ADP), PDA Inc. provides preprinted manual vouchers that can be issued to new and transferring participants. Participants redeem the vouchers for specific types and quantities of foods at authorized vendors. Vendors deposit the redeemed vouchers in 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. Vendors may appeal this process by submitting the vouchers to the State WIC Branch. Vouchers paid, but flagged as suspect, are investigated by the State agency. The State agency is responsible for any necessary reimbursement 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-1

GA WIC PROCEDURES MANUAL II. TYPES OF WIC VOUCHERS
There are five (5) types of WIC vouchers that may be issued to participants: A. Vouchers Printed On Demand (VPOD)
Vouchers Printed On Demand (VPOD) are generated on site by the clinic's automated system for each qualified participant for the WIC Program. The receipt generated from printing these vouchers becomes the voucher inventory. 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. Clinic staff must complete all information pertaining to the participant, as well as the food package prescribed, at the time of issuance (See FD-12-V Manual Vouchers and FD-14-E Issuance of Manual Vouchers for procedures). The clinic information is preprinted on blank manual vouchers (Attachment FD-2). 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 are: 1. 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. Computer Printed Vouchers
These vouchers contain a specific food package, individually tailored for each participant's nutritional needs. Computer printed vouchers are produced by the ADP Contractor and contain information based on the Turn Around Document (TAD) submitted by the clinics. District/clinic identification numbers are also printed on the vouchers.
E. Automated Special Manual Voucher
Automated Special Manual Vouchers are similar to Preprinted Standard Manual Vouchers except the food messages are blank on the automated forms. Automated clinics use these forms to prepare manual vouchers for any food package. These vouchers must be stored in a secured location and must be logged on the Manual Inventory Log within three (3) days.
III. VOUCHER ISSUANCE - GENERAL
A. Valid Certification Period
Vouchers must not be issued to participants who are overdue for certification. Over-issuance of manual, computer generated, or VPOD vouchers will result in an audit exception, which will require the local agency to pay funds back to the State WIC Branch (SWB).
B. Identification of Person Picking Up Vouchers
ID cards must be checked for signatures of participants/proxies before vouchers are issued. If a proxy is picking up 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.
Documentation of ID Proof codes for Voucher Pickup
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.
Voucher Registers- Document the proof code on the left side of the voucher register.
FD-3

GA WIC PROCEDURES MANUAL

C. Corrections

Vouchers must not be corrected or altered in any way unless prior authorization is received from the State WIC Branch. If an error is made during issuance, the voucher(s) must be voided (see FD-VIII Voided Vouchers). Correction fluid ("white-out") must not be used on vouchers for any reason.

D. Issuance

Local agencies have the option to issue vouchers to participants' at a one, two, or three-month interval. With two or three- month issuance, clinic staff must explain to participants not to use vouchers prior to the "First Day to Use" date on the vouchers. For VPOD vouchers, the actual date of receipt will be noted on the voucher receipt.

E. Categorically Ineligible

Categorically ineligible refers to the period of time a client is no longer eligible to receive WIC benefits. Participants who are subject to be categorically ineligible are postpartum women, children who have reached their fifth (5th) birthday, and breastfeeding women who stop breastfeeding and are greater than six (6) months postpartum. The categorically ineligible message will appear on the voucher receipt 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.

F. Issuance of Vouchers to Family Members

An employee must never issue vouchers to family members or other persons residing in the same household. Family members include but are not limited to:



Children



Grandchildren



Sisters



Brothers



Nieces



Nephews



Aunts



Uncles



Parents

FD-4

GA WIC PROCEDURES MANUAL



Spouses



First Cousins



In-laws

Note: Failure to comply with these procedures will result in payment of food cost to the State WIC Branch and may result in administrative disciplinary action by the local agency.

IV. VOUCHER PRINTED ON DEMAND (VPOD) AND COMPUTER GENERATED VOUCHERS

A. Data Elements

The following data elements appear on the face of the 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 (Turn-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 after the first day of use. Vouchers not deposited by this date are considered stale and will not be paid by the Contract Bank (not on VPOD Vouchers).

FD-5

GA WIC PROCEDURES MANUAL
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.
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 clinic staff and participant determine the voucher pickup day. This day is entered as a Pickup Code on the TAD.
Voucher interval codes are entered on the TAD (1= monthly; 2= two months even; 3= two months odd; 4= three months). Please refer to the "Voucher Creation Calendar," for a one (1) year calendar of voucher issuance dates (Attachment FD-6). Computer printed vouchers will be printed for the participant during the next printing of the selected voucher cycle is dependent upon the submission of the TAD to the ADP Contractor and the scheduled printing for that voucher cycle.
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).
1. The following items will be included in each clinic package (or clinic package #1 if there is more than one [1]).
a. Voucher Cycle Packing List
FD-6

GA WIC PROCEDURES MANUAL

This (2- ply) packing list provides the specific beginning and ending voucher numbers for all the computer printed vouchers (and for 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 must retain one copy and send one signed copy to the district/unit as acknowledgement of receipt of the vouchers.

b. Computer Voucher Register

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

1 copy

District/Unit

1 copy, summary

State

1 microfiche copy

Frequency twice each month, at each voucher cycle.

Sequence District/Unit, clinic, and 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 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 participant or income as a percent of the Federal Poverty Guidelines.

FD-7

GA WIC PROCEDURES MANUAL
M: If the client is enrolled in Medicaid
TYPE: WIC type P, N, B, I, C
PR: Priority
SIGNATURE OF PARTICIPANT: Space for participant/ proxy signature.
DATE: Space for the date vouchers were issued. The participant/guardian/caretaker/proxy or the issuing authority must fill in the date. 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.
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 messages.
NUTRITIONAL ASSESSMENT- MMDDYY: For infants who are certified prior to six (6) months of age, the infant's six (6) month anniversary is printed.
RECERT DUE- MMDDYY: Subsequent certification is due in the same month as 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 voucher issue month. For pregnant women, the date is forty-five (45) days from the Expected Date of Confinement (EDC).
FD-8

GA WIC PROCEDURES MANUAL
RECERT OVDUE- MMDDYY: For breastfeeding women and children, subsequent certification is overdue based on the certification date plus six (6) months. RECERT OVDUE (P) MMDDYY: For pregnant women, subsequent certification is overdue based on the EDC plus fortyfive (45) days. 1ST B'DATE-MMDDYY: Infant's birth date is in the month after the voucher issue month. The date printed is the birth date. CATEG TERM-MMDDYY: The participant is categorically ineligible in the month after voucher issuance month. A message accompanies 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 birth date ISSUE DATE- The date of issue printed on the vouchers 2. The District/Unit (clinic) receives the following items with each voucher shipment: a. Voucher Cycle Packing List b. Voucher Register Summary Page
This summary page includes: 1. Total participants who received computer generated
vouchers. 2. Total vouchers for the District/Unit (clinic). 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.
FD-9

GA WIC PROCEDURES MANUAL
D. Voucher Issuance
The following procedures must be followed when issuing 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. Vouchers Issuance. Vouchers will be issued to all participants in a valid certification period.
The serial numbers on the VPOD vouchers must match the serial numbers on the VPOD receipt. The name on the vouchers and the receipt must be identical.
The following items must be completed on the VPOD receipt and voucher register each time vouchers are issued:
a. Signature of Participant or Proxy. The participant or proxy must sign his/her name on the signature line to indicate that the proper person has received those specific vouchers. This signature must match the signature of the participant or proxy on the ID card.
(1) Vouchers must not be issued until after the participant/proxy signs the receipt/voucher register.
(2) If a participant or proxy leaves the clinic without signing the receipt/voucher register, clinic staff must document the issuance. 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 VPOD receipts/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 VPOD receipt/voucher register.
(4) If the participant or proxy is unable to write, he/she will enter his/her mark in lieu of a signature. Clinic staff will print the person's name next to the mark and initial the mark to indicate that it has been witnessed.
FD-10

GA WIC PROCEDURES MANUAL
3. Voucher Participant/Proxy Signature. The participant or proxy must sign only manual vouchers in the left signature space, in the presence of the issuing staff person.
4. When VPOD vouchers are printed, 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 the place of the voucher register. The client signs the receipt and then is handed the vouchers. The receipt must then be immediately filed in numerical order if possible. All receipts must be reconciled with the daily activity report. Any voucher numbers that are missing must have an explanation.
5. 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 Branch. Computer printed voucher(s) must be voided and replaced with manually issued vouchers if the food package is changed.
E. Transporting VPOD Vouchers from a site within a site
1. When VPOD vouchers are transported to a site that has no printer (voucher issuance clinic only), the vouchers must be printed the afternoon prior to going to the clinic or printed the day of the clinic visit.
Vouchers not issued on site must be voided immediately.
See Transporting procedures in the Compliance Analysis Section of the Procedures Manual.
F. Ordering VPOD Vouchers
Voucher Printing On Demand (VPOD) voucher numbers are received in the clinic from the ADP Contractor. All numbers must be entered upon time of receipt as with other manual vouchers. For VPOD vouchers, the confirmation notice of voucher numbers sent from PDA will take the place of the packing list and must be maintained in the same manner as the packing list (See Receipt of Manual Vouchers FD-12).
FD-11

GA WIC PROCEDURES MANUAL
V. MANUAL VOUCHERS (Blank and Standard)
Manual vouchers are different from VPOD 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) retain in clinic or may be destroyed if automated transfer is used.
2. All manual vouchers require completion of participant and issuance data.
3. Blank manual vouchers require entry of food quantities.
A. Blank Manual and Preprinted Manual Vouchers
Blank manual vouchers are issued for the following reasons:
1. To provide vouchers for a food package other than those provided by the preprinted manual vouchers.
2. To replace one or more VPOD vouchers that have been destroyed or damaged. (See CA-X).
B. 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 10th 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.
C. Receipt of Manual Vouchers
1. Clinic
Clinics will compare beginning and ending voucher numbers to those on the Clinic Voucher Cycle Packing List. Any discrepancies must be reported to the ADP Contractor and the State WIC Branch immediately. The packing list must be signed and dated to verify receipt. A copy of the signed/dated packing list must be mailed to the local agency/district office within five (5) days of receipt of the vouchers. The original must be retained by the clinic for one (1) year plus the current Federal Fiscal Year.
FD-12

GA WIC PROCEDURES MANUAL
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 Branch.
D. 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. Perpetual Inventory (Weekly)
The perpetual inventory accounts for the voucher numbers issued, voided, and on hand. The perpetual inventory should be conducted daily, and must done at a minimum weekly and documented on the Manual Voucher Inventory Log Sheet (Attachment 12). All columns of the log must be completed accurately, legibly, and initialed, by a responsible staff member. Always record the voucher numbers immediately after receiving them from the ADP contractor on the Log Sheet. 2. Physical Inventory (Monthly -Blank and Standard Manual Vouchers)
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.
FD-13

GA WIC PROCEDURES MANUAL
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.
E. 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 ballpoint pen. If an error is made on a voucher, void the voucher and issue a blank manual voucher.
The date on all vouchers must be the date on which the vouchers are issued (except two and three month issuance). The pickup code is generally the same day as the day on which vouchers are issued. The dates on the second and third set of vouchers must correspond to the pick-up code of the first set of vouchers.
Pre-printed standard/ blank manual vouchers must include the following information:
1. The participant's WIC ID number, including self-check and participant code.
2. Participant's name (last, first).
3. First Day to Use (MMDDYY).
4. Last Day to Use (MMDDYY) which is thirty (30) days from the "First Day to Use."
5. Vendor must deposit by (MMDDYY) which is sixty (60) days from the "First Day to Use."
6. 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 VPOD 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.
FD-14

GA WIC PROCEDURES MANUAL

F. Distribution of Manual Voucher Copies (Only when Handwriting Vouchers)

1. The red copy must be counted in numerical order, and mailed to the ADP Contractor using a Batch Control Form (Attachment FD-14). Do not separate or fold the red copies. DO NOT BATCH VOUCHER COPIES WITH TADs. They may be mailed together, 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. When a batch is mailed to the ADP Contractor, the black copy 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 send an acknowledgement receipt 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 resolved by recounting vouchers, and contacting the ADP Contractor to resolve count differences by WIC ID if necessary.

When the signed Batch Control Form is returned to the clinic, the copy of the Batch Control Form may be discarded. 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.

Voucher copies must be retained for three (3) years plus the current Federal Year.

VI. VPOD PROCEDURES

A.

General

Vouchers printed on demand (VPOD) are generated on site by the clinic's automated system for each participant on the WIC Program. The receipt generated from printing these vouchers becomes the voucher register.

When serial numbers are received from PDA, each clinic must log all numbers on the VPOD Inventory Log and in the computer. The confirmation notice must be signed and dated and a copy sent to the district office to be kept on file. The confirmation notice must also be kept on file in the clinics in the same manner as the packing list. The retention period is also the same.

FD-15

GA WIC PROCEDURES MANUAL

B.

Issuing VPOD Vouchers

The following procedures must be followed when issuing VPOD Vouchers:

1. Identification- Verify the identity of the person picking up the vouchers.

2. Issuance- Before vouchers are printed, the clerk must check the client's WIC History to determine if the participant is in a valid certification period, has a nutrition education appointment, or any other follow-up appointments the client may have.

3. The serial numbers on the VPOD vouchers must match the serial numbers on the VPOD receipt. The name of the participant will be compared to the participant's name on the WIC ID card and the computer.

4. The client must sign the receipt before receiving the VPOD vouchers. Vouchers must not be issued until after the participant/proxy signs the receipt.

C.

Voucher Reconciliation

At the end of each day, the clinic staff must print a daily activity report that includes:

1. Voucher numbers

2. Participant's name

3. Issue date

4. Initials of issuing clerk

All receipts must be reconciled with the daily activity report. The receipts must be filed in numerical order. Each clinic must maintain a file for the activity reports and keep it in the clinic. If vouchers are voided, they must be stamped void before filing them with the receipts. If the voucher does not print, use a blank voucher receipt to write those numbers, the date, and the clerk's initials on the receipt.

FD-16

GA WIC PROCEDURES MANUAL

D.

VPOD Inventory Log Sheets

The VPOD log sheet must be completed daily or at a minimum weekly. The log will be used to keep track of the voucher numbers issued, voided or not printed. Always record the voucher numbers received from PDA immediately on the log sheet. Separate log sheets can be used for each batch, but they must be kept in the inventory log book. The confirmation notice of numbers sent will take the place of the voucher-packing list and should be maintained in the same manner. All columns of the log sheet must be completed accurately, legibly, and initialed by a responsible staff member.

E.

Corrective Actions for VPOD

1. Any missing receipt.

2. Incomplete log sheets.

3. More than one percent "fail to sign" on receipts.

4. Vouchers issued during an invalid certification period.

5. Any missing daily activity reports.

6. Any vouchers filed with receipts that do not have void stamped or written on them.

FD-17

GA WIC PROCEDURES MANUAL

VII. 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:
1. 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/delivering vouchers, the issuing professional must obtain approval from the WIC Coordinator or a designated CPA. Written approval must be on file in the form of a local agency policy memorandum. Prior to mailing/delivering vouchers to a participant, the issuing person must obtain approval from the WIC Coordinator. The participant must sign a copy of the voucher register or receipt. Once the receipt or register page is signed by the participant, it must be returned to the clinic to be filed.

4. The hardship condition and the WIC Coordinator approval must be documented in the participant's health record. Once the initial hardship has been resolved, the mailing or delivery of WIC Vouchers must be discontinued and the action documented.

B. Acceptable Reasons for Mailing/Delivering Vouchers

1. Difficulties of the participant and his/her proxy in obtaining vouchers for reasons such as illness.

2. Imminent or recent childbirth requiring bed rest and no proxy is available.

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.

NOTE:

*If the Food Stamp Program has discontinued or does not routinely mail Food Stamp Coupons to a geographical location, WIC Vouchers can not be mailed to this area.

FD-18

GA WIC PROCEDURES MANUAL
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 procedures for delivering a voucher (s) are as follows:
1. The VPOD vouchers and receipts, or voucher register (when transporting vouchers) must be copied. The original receipt or voucher register must be left in the clinic. Once the participant signs the copied page, the copy must be attached to the original VPOD receipt or voucher register. The original VPOD receipt or voucher register must have the statement "See Attachment" on the receipt.
D. Voucher Mailing Process
When mailing vouchers, the VPOD receipt, 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. Vouchers must 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:
FD-19

GA WIC PROCEDURES MANUAL
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 or receipt. 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 that 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.
VIII. VOIDED VOUCHERS
Voided vouchers should be marked "void" if the participant is ineligible for the vouchers, if they are replaced with manual vouchers, or if a participant does not pick up their 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.
Voided Manual Vouchers and VPOD Vouchers
Manual vouchers, blank vouchers, VPOD vouchers, or preprinted vouchers will be voided if: the participant's 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/ VPOD Vouchers That Were Reported to the ADP Contractor as Issued. The system contains an issue record that 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/ VPOD Vouchers That 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.F. 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-20

GA WIC PROCEDURES MANUAL
IX. 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 FD-X - Late Pickup of Vouchers).
(2) Vouchers are replaced when they are damaged or there is a change in the prescribed food package or agency error.
Note: The procedures in Section FD-XII.A must be followed when replacing vouchers.
To ensure consistency when prorating vouchers, the guidelines below must be followed.

Number of Days Late

Women & Children

Infants

Less than 7 days late

full package

full package

7-13 days late

3 vouchers issued (3/4 package)

full package

14-20 days late

2 vouchers issued (1/2 package)

1 voucher issued (1/2) package

21-31 days late

1 voucher issued (1/4 package)

1 voucher issued (1/2 package)

FD-21

GA WIC PROCEDURES MANUAL
a) ALTERNATE FOOD PACKAGES

Number of Days Late Less than 7 days late
7 - 13 days late
14-20 days late
21-31 days late

Women & Children full package
6 vouchers issued (3/4 package)
4 vouchers issued (1/2 package)
2 vouchers issued (1/4 package)

Infants full package full package
1 voucher issued (1/2 package)
1 voucher issued (1/2 package)

Note: If a scheduling error is made by the clinic, which results in the loss of vouchers, by the participant, there are two options. These options are: either to issue the entire food package and follow procedures noted above, or change the pickup codes and submit to the ADP Contractor.

FD-22

GA WIC PROCEDURES MANUAL
X. 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-IX. If participants come in for their vouchers after they have been "VOIDED", they must be issued manual vouchers that 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 that 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.
Change pickup interval code
When a participant is late picking up vouchers, the pickup interval code must not be changed to avoid prorating vouchers. When it is necessary to change the pickup interval code, the code is changed to the date the vouchers are picked up, and a full set of vouchers are issued with the current date. We do not encourage staff to change pickup interval codes because it affects participation.
The only reasons to change a pickup interval code is adding a new family member or a change in circumstances such as a change in job or working hours that results in a hardship on the participant. The decision to change pickup interval code will be the responsibility of the clinic supervisor.
To change the participant's pickup interval code the clinic staff must:
1. Document the appointment date changes on the voucher receipt or voucher register.
2. Complete a TAD to change the pickup interval code and submit to the dataprocessing contractor.
3. Stamp the voucher "void" immediately.
4. Give the participant an appointment for next month's pickup with the new pickup date.
5. Document in participant's record the reason for change in pickup interval code.
FD-23

GA WIC PROCEDURES MANUAL
XI. COORDINATION OF HEALTH SERVICES AND VOUCHERS ISSUANCE
Every effort must be made to coordinate the issuance of WIC vouchers with the delivery of health services. [CFR 246.12(d); CFR 246.11(a)(1) 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 246.11(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)].
XII. 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/Destroyed/Voided 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)
FD-24

GA WIC PROCEDURES MANUAL
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 comment section of the Lost/Stolen Destroyed Voided Voucher Report that between 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 Branch, System Information Unit. Upon receipt of the Report, the ADP Contractor will enter this information into the system. If the contract bank subsequently pays the vouchers, they will be identified on the Bank Exception Report during the monthly reporting process.
The State WIC Branch cannot initiate "stop payments" on lost/stolen/ destroyed vouchers issued to WIC participants. When fraud is suspected, the local agency should notify the Compliance Analysis Unit to request assistance with an investigation. To obtain copies of suspect vouchers, the Local Agency must submit a Georgia WIC Program Voucher Investigation Log (Attachment CA-2) to the Compliance Analysis Section (See Section X of Compliance Analysis Section of the Georgia WIC Procedures Manual).
C. Vouchers Lost, Stolen, or Destroyed Prior to Issuance
When a clinic determines that vouchers have been lost, stolen, or destroyed prior to issuance, the following procedure must be implemented:
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 Branch, System Information Unit, 2 Peachtree Street Atlanta, GA 30303. Upon receipt of the Report, the ADP Contractor will enter this information into the system. If the contract bank subsequently pays the vouchers, 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 Compliance Analysis Section. The Compliance Analysis Section will work in conjunction with the Local Agency to investigate potential fraud. When a block of 25 or more vouchers are missing (see Section CA-X, Investigation of Missing Vouchers).
FD-25

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 receipt or the clinic's copy of the manual voucher. Hospital Based Formula
If a physician changes a formula, the participant must return all unopened case(s) of formula to the clinic.
The Clinic must then:
1. Issue supplemental vouchers prorated for the remainder of time in the issuance period.
2. Document the amount, type, and disposition of formula returned to clinic on the Voucher Receipt 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 Nutrition Section, all unopened cases of formula should be returned to the company. Notify the Nutrition Section so that a refund may be obtained from the company.
XIII. BORROWED VOUCHERS
Vouchers may be borrowed within a District from one clinic by a clinic whose current stock is depleted (See Attachment FD-18).
Submitting the form in a timely manner is important. PDA must be notified of all manual voucher reassignments as soon as possible. Any borrowed voucher reassignments not received by PDA before reconciliation (usually around the eighth 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 redemption the first month and would be listed on the Cumulative Unmatched Redemptions Report if not corrected by the second month.
FD-26

GA WIC PROCEDURES MANUAL 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. PDA 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 FD-18 of the Food Delivery Section.
FD-27

GA WIC PROCEDURES MANUAL

XIV. CUMULATIVE UNMATCHED REDEMPTION REPORT (CUR)

A. Introduction

The Cumulative Unmatched Redemption (CUR) Report identifies redeemed manual vouchers that 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 Branch, depending on how much time has elapsed since the voucher was redeemed. The CUR Report has two parts:

Part 1: 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 1:

Attachment FD-19 provides an example of cumulative

unmatched redemption that is not matched to an issuance record. The third and

fourth columns on the CUR Part 1 have the dollar amount of the redeemed

voucher(s).

If the voucher appears in the third column or the 1st dollar amount column, confirm the batch of vouchers appearing in the 1st dollar amount column was sent to the ADP Contractor.

1. If there 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 dollar amount column, the vouchers may have contained an error or been processed incorrectly by the bank. Photocopy the entire set of vouchers that 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 dollar amount column with the ADP Contractor.

FD-28

GA WIC PROCEDURES MANUAL

The ADP Contractor must receive corrections and resubmitted batches by the end of the month cut-off (seventh 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 SWB.

C. Manually Reconciling CUR Part 1

Those voucher(s) listed in the second dollar 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 dollar 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 SWB. The CUR Report should always be submitted to the SWB in its entirety. Do not send copies of vouchers to the State WIC Branch.

Cumulative Unmatched Redemption that have not matched to a valid certification record:

CUR Part 2:

Attachment FD-20 provides an example of cumulative unmatched redemption that is not matched to a valid certification record. The fifth and sixth columns on the CUR Part 2 have the dollar 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 SWB.

When the issue date and the ID number on the voucher(s) and the CUR Part 2 report are correct:

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.

FD-29

GA WIC PROCEDURES MANUAL
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 dollar amount column on the report with the ADP Contractor. The ADP Contractor must receive corrections and resubmitted batches by the end of the month cut-off (seventh 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 dollar 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 dollar amount column must be manually reconciled. (See Attachment FD-20)
5. Sign and date the completed report and submit to the State WIC Branch. If there are no vouchers on the report to be manually reconciled, the CUR report should still be forwarded to the SWB in its entirety. Do not send CUR reports to the ADP Contractor.
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 Branch 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 Branch 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 Branch requesting a copy of the vouchers. Please include the redemption month along with the voucher number(s).
NOTE: The vouchers in the second dollar 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-30

GA WIC PROCEDURES MANUAL COMPUTER PRINTED VOUCHER

Attachment FD-1

FD-32

GA WIC PROCEDURES MANUAL BLANK MANUAL VOUCHER

Attachment FD-2

FD-33

GA WIC PROCEDURES MANUAL

Attachment FD-3

PREPRINTED STANDARD MANUAL VOUCHER

FD-34

GA WIC PROCEDURES MANUAL

Attachment FD-4

AUTOMATED SPECIAL MANUAL VOUCHER

FD-35

GA WIC PROCEDURES MANUAL VPOD VOUCHER

Attachment FD-5

FD-36

GA WIC PROCEDURES MANUAL

Attachment FD-6

VOUCHER CREATION CALENDAR

1999

JAN FEB MAR APR

1

2

3

4

5

6

7

5

5

8

5

5

9

6

10

6

6

11 6

12

13

14

15 1

1

16

17

18 HOL

19

20

21

22 2

2

23

24 3

3

25

26 3

4

27

28

29 4

30

31

1

1

2

2

3

HOL 3

4 4

MAY JUN JUL AUG

HOL

5

5

5

6

6

5

6

6

1

1

2

2

2

2

3

3

3

3

4

4

4

HOL

4

SEP OCT NOV DEC

HOL

5

5

5

5

6

6

6

HOL HOL

6

1

1

1

1

2

2

2

2

3

3

3

HOL

3 HOL

HOL

4

4

4

4

HOL

2000 JAN
5 6 1
2 3 4

CYCLE 1 1st - 14th
CYCLE 2 15th - Month end

1 - Cycle 1 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-37

GA WIC PROCEDURES MANUAL

Attachment FD-7

VOUCHER CYCLE PACKING LIST

PAGE 60 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 SIGNATURE

DATE

COMMENTS

EDS SHIPPING USE

NUMBER OF PIECES FOR THIS DISTRICT/UNIT ____________________

EDS QUALITY CONTROL INITIALS _______________________________

FD-38

GA WIC PROCEDURES MANUAL

Attachment FD-8

PAGE

6570

REPORT EWCR201G

03-632

COASTAL HEALTH

COMPUTER PRINTED VOUCHER REGISTER

STATE OF GEORGIA WIC SYSTEM COMPUTER GENERATED VOUCHER REGISTER

CLINIC PAGE 34

D/U/CL

09-

RUN DATE INPUT CUTOFF DATE

3/19/99 03/15/99

WIC ID FAMILY

C P LAST

FIRST I M Y R SIGNATURE OF PARTICIPANT DATE CLK

FD-39

GA WIC PROCEDURES MANUAL

Attachment FD-9

VOUCHER REGISTER SUMMARY PAGE

PAGE 708 REPORT EWCR201G
D/U 01-1
MESSAGE TOTALS

STATE OF GEORGIA WIC SYSTEM COMPUTER GENERATED VOUCHER REGISTER

DIST/UT 01-1 RUN DATE __/__/__ INPUT CUTOFF DATE __/__/__

TOTAL OF TOTAL OF
1496 214 919 162 226 0 72 0 0

3,639 PARTICIPANTS RECEIVING 3,374 PARTICIPANTS RECEIVING RECERT DUE MM/DD/YY CATG TERM MM/DD/YY NUTRITIONAL ASSESSMENT-MM/DD/YY 1ST BDATE-MM/DD/YY RECERT DUE (P)-MM/DD/YY NO-SHOW PRIOR NO-MM RECERT OVERDUE (P)-MM/DD/YY RECERT OVERDUE (F2)-MM/DD/YY RECERT DUE (PRI2)-MM/DD/YY

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-40

GA WIC PROCEDURES MANUAL

Attachment FD-10

TRANSMITTAL FORM
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

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-41

GA WIC PROCEDURES MANUAL

Attachment FD-11

FORM AND MANUAL VOUCHER ORDERS

GEORGIA WIC PROGRAM FORM AND MANUAL VOUCHER SUPPLY ORDER FORM (REV 1/95)

Return to:

Viking Computing, Inc. 1000 North Madison Ave., Suite W-11 Greenwood, Indiana 46142

Your District/Unit:

Clinic name:

Address:

Phone 1-800-899-7913 FAX: 1-317-889-9485 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 10th of the following month. If the 10th or 25th fall on the weekend or on a holiday, the cut-off is the workday before.
MANUAL VOUCHER ORDER

BLANK MANUAL VOUCHERS FOR HAND COMPLETION
Blank manual voucher (no tuna or carrots) 408 (blank manual voucher with tuna and carrots)
PREPRINTED MANUAL VOUCHER PACKAGE SETS FOR HAND COMPLETION
Sets of 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-42

GA WIC PROCEDURES MANUAL

Attachment FD-12

STANDARD MANUAL

DATE

RECEIVING NO.

MANUAL VOUCHER INVENTORY
MANUAL VOUCHER INVENTORY

CLINIC

BALANCE BROUGHT FORWARD

ENDING NO. NO. RECEIVED

NO. ISSUED NO. VOID NO. ON HAND

INITIALS

FD-43

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.) (B)

ISSUED (the number of
vouchers issued for that day.) (B-A =
total)

VOIDED (the number of vouchers
that were voided for that day )

ON HAND (total amount of
numbers on hand)

INITIALS (always sign your
initials for that day.)

GRAND TOTAL OF NUMBERS REMAINING IN STOCK. (After completing this form.)

REMAINING STOCK INITIALS

_____________________ _____________________

FD - 44

GA WIC PROCEDURES MANUAL

Attachment FD-14

BATCH CONTROL FORM

GEORGIA DEPARTMENT OF HUMAN RESOURCES WIC PROGRAM

BATCH CONTROL FORM

DATE

NUMBER

/

/

/

/

DISTRICT/UNIT

CLINIC

INSTRUCTIONS
VIKING INPUT SECTION
COMMENTS:

1. USE THIS FORM AS A COVER SHEET TO FORWARD ALL TADS (CERTIFICATIONS, UPDATES, TRANSFERS AND TERMINATIONS) AND ISSUED/VOIDED MANUAL VOUCHERS.

2. DO NOT BATCH TADS WITH MANUAL VOUCHERS

3. DO NOT SUBMIT VOIDED/UNCLAIMED COMPUTER VOUCHERS TO VIKING.

4. SUBMIT THE 1ST AND 2ND COPIES OF THIS FORM AND ACCOMPANYING MATERIALS TO:

VIKING COMPUTING, INC P.O. BOX 2504 GREENWOOD, IN 46142-2504
5. RETAIN THE 3RD COPY OF THIS FORM IN THE CLINIC WITH COPIES OF THE TADS OR MANUAL VOUCHERS, CREATING A BATCH CONTROL MODULE.

TYPE OF DOCUMENT

NUMBER IN BATCH

TURNAROUND

ISSUED MANUAL VOUCHERS

VOIDED MANUAL VOUCHERS

DATE SENT BY DISTRICT/UNIT DATE RECEIVED AT VIKING DATE ENTERED AT VIKING
FORM 3762(REV.02-92)

PREPARER'S SIGNATURE SIGNATURE SIGNATURE
FD-45

GA WIC PROCEDURES MANUAL

Attachment FD-15

BATCH CONTROL EXCEPTION REPORT

GEORGIA DEPARTMENT OF HUMAN RESOURCES WIC PROGRAM

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 (1) 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-46

GA WIC PROCEDURES MANUAL

Attachment FD-16

GEORGIA WIC PROGRAM IDENTIFICATION CARD

ID# & NAME

STATE OF GEORGIA
Department of Human Resources Division of Public Health
WIC PROGRAM IDENTIFICATION CARD

NOT VALID WITHOUT WIC PROGRAM STAMP

PARTICIPANTS

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:
___________________________________________
PARTICIPANT/PARENT/GUARDIAN SIGNATURE

______________________________
EDC DATE

Other authorized to pick up vouchers and food:

1. ___________________________________________________________________________________
PROXY SIGNATURE
*It is the responsibility of the participants to educate proxies on the proper use of WIC vouchers

2. ___________________________________________________________________________________

PROXY SIGNATURE

___________________________________________

______________________________

SIGNATURE OF WIC OFFICIAL

ISSUE DATE

Form 3769 (Rev. 9-96)

BRING THIS FOLDER EVERY VISIT

PICK UP CODE _____________ VOUCHER INTERVAL CODE ____________
COMMENTS _______________________________________________________ __________________________________________________________________
LOCAL: AGENCY: CLINIC: NAME:
ADDRESS:
PHONE:

FD- 47

GA WIC PROCEDURES MANUAL ______________________________________Attachment FD-17
DAILY ROSTER/MONTHLY MAILED VOUCHER REPORT

Participant's Name

I.D. Number

Voucher Number (Range)

Number of Vouchers Returned

Signature of CPA

Date Returned

Replaced Voucher Numbers Lost/Stolen

Redemption Value of 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: $

FD-48

GA WIC PROCEDURES MANUAL

Attachment FD-18

BORROWED VOUCHER REPORT FORM

GEORGIA DEPARTMENT OF HUMAN RESOURCES WIC PROGRAM

BORROWED VOUCHER REPORT

BORROWING DISTRICT/UNIT: | | | |

CLINIC: | | | |

DATE: ______________

INSTRUCTIONS

USE FORM TO REPORT MANUAL VOUCHERS BORROWED FROM ANOTHER CLINIC RETURN TO VIKING AS SOON AS POSSIBLE. MAIL TO: VIKING COMPUTING, INC.
GEORGIA WIC UNIT 1000 N. MADISON AVENUE, SUITE GREENWOOD, IN 48142 OR FAX TO: (317)889-9485

DISTRICT(S)
|| ||

CLINIC(S)
| | ||

BEGINNING VOUCHER NO.
| | | | | | | |

ENDING VOUCHER
| | | | | | ||

QUANTITY
| | | | | |

|| ||

| | ||

| | | | | | | |

| | | | | | || | | | | | |

|| ||

| | ||

| | | | | | | |

| | | | | | || | | | | | |

|| ||

| | ||

| | | | | | | |

| | | | | | || | | | | | |

|| ||

| | ||

| | | | | | | |

| | | | | | || | | | | | |

|| ||

| | ||

| | | | | | | |

| | | | | | || | | | | | |

|| ||

| | ||

| | | | | | | |

| | | | | | || | | | | | |

|| ||

| | ||

| | | | | | | |

| | | | | | || | | | | | |

|| ||

| | ||

| | | | | | | |

| | | | | | || | | | | | |

|| ||

| | ||

| | | | | | | |

| | | | | | || | | | | | |

|| ||

| | ||

| | | | | | | |

| | | | | | || | | | | | |

|| ||

| | ||

| | | | | | | |

| | | | | | || | | | | | |

REASON(S):

INSUFFICIENT QUANTITY

ORDERED LATE

ORDER NOT RECEIVED FROM VIKING

OTHER

COMMENTS: ___________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________ DISTRICT OFFICE APPROVAL DATE

VIKING WHITE COPY

SWO YELLOW COPY

DISTRICT OFFICE PINK COPY

CLINIC GOLD COPY

FD-49

GA WIC PROCEDURES MANUAL

Attachment FD-19

CUMULATIVE UNMATCHED REDEMPTIONS PART I EXAMPLE

PAGE 1 REPORT EWRR350G COOSA VALLEY HEALTH

STATE OF GEORGIA WIC SYSTEM

CUMULATIVE UNMATCHED REDEMPTIONS

FOR THE MONTH OF ___________

19__

CLINIC PAGE 1 D/U/CL 01-1-008 RUN DATE __/__/_

PART 1 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-50

GA WIC PROCEDURES MANUAL

Attachment FD-20

CUMULATIVE UNMATCHED REDEMPTIONS PART II EXAMPLE

PAGE 1 REPORT EWRR351G COOSA VALLEY HEALTH

STATE OF GEORGIA WIC SYSTEM

CUMULATIVE UNMATCHED REDEMPTIONS

FOR THE MONTH OF ___________

19__

CLINIC PAGE 1 D/U/CL 01-1-008 RUN DATE __/__ /_

PART 2 NOT MATCHED TO ISSUANCE RECORD

VOUCHER REFERENCE ISSUE

NUMBER NUMBER

DATE

WIC ID FAMILY C P

FEBRUARY

JANUARY

S AMOUNT S AMOUNT

RECONCILIATIONS

TOTAL

74620912 74620913 74620914 74620915 74621454 74621455

15692612 11454716 11454717 34537674 36190860 55336318

01/12/96 01/12/96 01/12/96 01/12/96 02/05/96 02/05/96

008007741 5 1 008007741 5 1 008007741 5 1 008007741 5 1 008008287 8 1 008008287 8 1

R 4.14
R 7.17 R 4.17

R 5.13 R 11.06 R 8.27

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

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 1 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 1 008008171 4 1 008008171 4 1 008006036 1 2 008006036 1 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-51

GA WIC PROCEDURES MANUAL
LOST/STOLEN/DESTROYED VOIDED VOUCHER REPORT

Attachment FD-21

GEORGIA DEPARTMENT OF HUMAN RESOURCES WIC PROGRAM

LOST/STOLEN/DESTROYED VOIDED VOUCHER REPORT

DISTRICT/UNIT/CLINIC:

DATE:

INSTRUCTIONS
BEGINNING VOUCHER NO.

USE THIS FORM TO REPORT VOUCHERS (COMPUTER OR MANUAL)

WHICH HAVE BEEN LOST, STOLEN, OR DESTROYED BY EITHER

THE PARTICIPANT OR THE CLINIC.

SUBMIT AT LEAST MONTHLY.

MAIL TO VIKING COMPUTING, INC.

GEORGIA WIC UNIT

P.O. BOX 2504

GREENWOOD, IN 46142-25041:

ENDING VOUCHER NO.

QUANTITY

WIC I.D. NUMBER

STATUS

STATUS CODES LOST/STOLEN/DESTROYED - 2
VOIDED - 3
COMMENTS

TOTAL VOUCHERS
FD-52

GA WIC PROCEDURES MANUAL VPOD RECEIPT

Attachment FD-22

FD-53

GA WIC PROCEDURES MANUAL
TABLE OF CONTENTS PAGE
I. Introduction...................................................................................................................CA-1 II. Monitoring ....................................................................................................................CA-2 III. Participant Abuse ..........................................................................................................CA-3
A. Dual Participation .............................................................................................CA-3 B. Duplicate Participation Verification Form .......................................................CA-4 C. Participant Abuses and Sanctions .....................................................................CA-5 IV. Procedure for Repayment of WIC Funds .....................................................................CA-9 V. Guidelines for Investigating Employee Abuse ............................................................ CA-9 VI. Procedures to Request an Employee Investigation.....................................................CA-10 VII. Vendor Compliance Investigation ..............................................................................CA-10 VIII. Compliance Investigation Food Purchases .................................................................CA-11 IX. Disqualified Vendor/Participant Access.....................................................................CA-12 X. Investigation of Missing Vouchers/Verification of Certification Cards (VOC) ........CA-12 A. Vendor Notification ........................................................................................CA-13 B. Manual Voucher Inventory.............................................................................CA-13 C. Georgia WIC Voucher Investigation Log.......................................................CA-13 D. Stop Payment of WIC Vouchers.....................................................................CA-13 XI. Security of Issuance Materials....................................................................................CA-14 A. WIC Program Stamps ..........................................................................................CA-14 B. VOC Cards ..........................................................................................................CA-14

GA WIC PROCEDURES MANUAL

PAGE XII. Voucher Issuance Security..........................................................................................CA-14
A. WIC Vouchers ................................................................................................CA-14 B. Voucher Security ............................................................................................CA-15 C. Voucher Storage .............................................................................................CA-15 D. VPOD Printers ...............................................................................................CA-16 E. Transporting WIC Vouchers...........................................................................CA-16

Attachments:

CA-1

Closeout Reconciliation Report ......................................................................CA-17

CA-2

Georgia WIC Voucher Investigation Log.......................................................CA-18

CA-3

Participant Sample Warning Letter.................................................................CA-19

CA-4

Request for Investigation Form ......................................................................CA-20

CA-5

WIC Transaction Report .................................................................................CA-21

CA-6

Participant Access Verification Form.............................................................CA-22

CA-7

WIC Program Vendor Donation List..............................................................CA-23

CA-8

Notification Summary of Missing Vouchers/VOC Cards ..............................CA-24

CA-9

Duplicate Participation Verification Form .....................................................CA-25

CA-10

Participant Repayment Sample Letter ............................................................CA-26

CA-11

Participant Repayment Schedule Sample Letter.............................................CA-27

CA-12

Dual Participation Report Investigation Form................................................CA-28

GA WIC PROCEDURES MANUAL I. INTRODUCTION
The Compliance Analysis Section assesses programmatic compliance of over 1600 retail grocery stores (WIC Vendors) by performing onsite covert investigations to deter potential abuse and to ensure the appropriate delivery of WIC approved food items. The section works with the Office of Fraud and Abuse on clinical investigations when WIC vouchers are reported missing or stolen. The Section also investigates potential dual participation and evaluates and analyzes system- related fraud and abuse. Investigations: The section conducts covert investigations to assess authorized vendor compliance in distributing WIC foods to WIC participants based on program regulations and guidelines. WIC vouchers are redeemed through the vendor. Vendors found guilty of violations may be assessed program sanctions or can be disqualified. Investigations are performed based on the following indicators:
1. WIC program analysis of computerized vendor profile reports that provide a score based on vouchers redeemed by each vendor.
2. Complaints regarding the misuse of WIC vouchers at a specific retail store. 3. The random selection of vendors to be investigated. Clinic Reviews: The Compliance Analysis Section conducts assessments of the security of WIC vouchers, and voucher issuance materials in WIC clinics during issuance, staff breaks, and the close of business. Missing Vouchers: Vouchers reported missing or stolen from WIC clinics will be investigated by local agencies in conjunction with the Compliance Analysis Section of the State WIC Branch. Investigating agencies may include the DHR Office of Fraud and Abuse and the local police department. District offices may be subject to corrective action(s) and/or financial penalties if program regulations are not being followed. Reports Analysis: The section conducts semiannual reviews of Dual Participation Reports that may lead to the investigation of program participants. Financial penalties may be assessed to participants found guilty of violations. Other system reports, including system generated reports, manual reports, and ad hoc reports are also analyzed .
CA- 1

GA WIC PROCEDURES MANUAL II. MONITORING
1. Bi-annually, 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 Branch and proceed with the investigation. The State WIC Branch may notify USDA-Food Nutrition Service (FNS) 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 CA-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 have a questionable status ( i.e., 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 Branch and proceed with the investigation.
4. The State WIC Branch shall retrieve voucher copies when the Coordinator determines the need during an investigation. These vouchers will be reviewed by the State WIC Branch for compliance prior to being forwarded to the Local Agency. A Georgia WIC Voucher Investigation Log should be used when requesting voucher copies from the State WIC Branch (see Attachment CA-2).
5. Investigations may include but are not limited to review of the voucher inventory, cashed vouchers, certification records, employee/relative participation 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.
CA- 2

GA WIC PROCEDURES MANUAL
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 semiannually to the State WIC Branch 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 Branch within sixty (60) days from the run date of the 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. Please use the Dual Participation Investigation Form (CA-12) and attached it to the Dual Participation Report. 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. If the first names are spelled exactly the same, then investigate clinical records to determine if it is the same participant or two different participants. Document dual participation information obtained and the final action taken on each case in the participant's health and issuance records.
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
CA- 3

GA WIC PROCEDURES MANUAL 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 Branch as a part of the Dual Participation Report, and a copy of the same documentation must be placed in the participant's clinic file.
3. Participant Enrolled in Different Local Agencies Contact the other Local Agency and together investigate the possibility of dual participation. Each Local Agency should review health and issuance records. If the participant has moved, the Local Agency from which the participant moved must terminate the participant. If dual participation and/or intentional fraud is involved refer to the section on 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. Duplicate Participation Verification Form The Duplicate Participation Verification Form (Attachment CA-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 Duplicate Participation Verification Form must be completed when dual participation has been verified by the local agency, and the 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, Software Services Inc. (PDA), yellow copy-State WIC Branch, pink copy-District Office, gold copy-WIC Clinic. Distribution of this form will be handled by the system contractor (PDA).
CA- 4

GA WIC PROCEDURES MANUAL
C. Participant Abuses and Sanctions
The Georgia WIC Program may assess claims and penalties against a WIC participant when they have been found to be abusing the program guidelines. 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.
Exceptions
Before disqualifying a participant from the program, the local agency may warn a participant (see Attachment CA-3) or decide not to impose a mandatory sanction if:
1. Within 30 days of receipt of the letter demanding repayment, full restitution is made by the participant.
2. A repayment schedule is agreed upon. 3. Or in the case of and infant, child, or participant under the age of 18, the
state/local agency approves the designation of a proxy.
Terminations
The local agency may permit a participant to reapply for the program before the end of a mandatory disqualification period if:
1. Full restitution is made. 2. Repayment schedule is agreed upon. 3. In the case of a participant who is an infant, children or under age 18, the
state or local agency approves the designation of a proxy.
At the time of disqualification, the local agency must advise the participant of the procedure to follow to obtain a fair hearing (see Rights and Obligations Fair Hearing Section).
When appropriate, the local agency must refer participants who violate program requirements to Federal, State, or local authorities for prosecution under applicable statues.
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
CA- 5

GA WIC PROCEDURES MANUAL
agree on which program will terminate the participant. The participant must be given a warning in writing, that simultaneous participation in more than one (1) program is in violation of WIC regulations. (See Abuse #2 for further sanction procedures)
If the same individual is found to be a dual participant on a subsequent occasion, he/she must be disqualified for one (1) year (See Abuse #2 for further sanction procedures).
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, personal ID, residence, diet intake, and medical history.
SANCTION: The participant may be required to pay the State Agency, in cash, the value of benefits improperly issued to them. The "value of benefits" 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 WIC vouchers, manual and computer, issued to the participant or authorized representative within the certification period.
A written summary specifying what information was supplied by the participant or authorized representative, what the actual information is suspected to be, and a statement as to whether it is suspected that the falsification was intentional.
Based on the information received from the local agency, the state agency will make a determination as to whether falsification and/or intentional misrepresentation has occurred. If the misrepresentation or falsification is determined to be intentional, the state agency will proceed as follows:
Secure the vouchers cashed by the participant from the contract bank and/or CD ROM of vouchers previously cashed.
Determine the total value of the cashed vouchers.
CA- 6

GA WIC PROCEDURES MANUAL 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 disqualification period of one (1) year is to be imposed. The participant will be notified, by certified mail, of his/her disqualification and right to a fair hearing.
b. If the investigation findings establish that the participant is ineligible for program benefits, the participant will be immediately terminated from the program. The participant will be sent, by certified mail, a Notice of Termination Form which includes notification 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. If the total value of benefits issued is $100 or more, the local agency will notify the participant of the dollar value of WIC vouchers cashed and request repayment (see Attachment CA-10 and CA-11 for Sample Letters). 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.
SANCTION: When proof of abuse has been established, the participant may receive a first offense warning in writing. Subsequent abuse will result in disqualification from the program for a period not to exceed one (1) year. 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 (Sanction #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 one (1) year. The participant must be notified of his/her right to a fair hearing (see RO-SectionFair Hearing Procedures).
CA- 7

GA WIC PROCEDURES MANUAL If the total value of benefits is $100 or greater, the repayment procedures outlined above (Sanction #2d) will be implemented. The State WIC Branch 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 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 one (1) year.
6. ABUSE: Physically hurting, pushing, or inappropriate physical handling of 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 one (1) year.
CA- 8

GA WIC PROCEDURES MANUAL 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: DHR/WIC Program. 1. The local agency will immediately forward all repayments received to the State agency for processing. If total payment is not made within the ninety (90) day timeframe, the local agency will notify the state agency which will in turn proceed with recovery actions prescribed under the Georgia Statute. 3. The State agency shall continue collection procedures until it determines it is no longer cost effective.
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.
CA- 9

GA WIC PROCEDURES MANUAL
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 Branch, and may require a Department of Human Resource Office of Fraud and Abuse (DHR-OFA) investigation.
Intentional abuse is a deliberate effort to defraud the WIC program (example: illegally taking WIC vouchers; giving false/misleading information in order to become certified 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. A DHR-OFA investigation shall be handled in conjunction with the local agency.
4. Action to be taken as a result of 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 Branch and the State WIC Branch shall notify USDA-FNS.
6. The State WIC Branch 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 Branch shall inform USDA of any investigations of WIC related employee fraud.
VI. PROCEDURES TO REQUEST AN EMPLOYEE INVESTIGATION
1. The District Health Officer shall forward a letter requesting an investigation directly to the DHR-OFA and a copy of the letter must be forwarded to the Division of Public Health Director's Office and the State WIC Branch.
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 Branch. The Director's Office shall then forward the request for investigation along with a cover letter to DHR-OFA.
CA-10

GA WIC PROCEDURES MANUAL
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 Branch.

VII. VENDOR COMPLIANCE INVESTIGATION
Compliance investigations will be coordinated by the State WIC Branch.
Investigations will occur at stores that have been identified as "Potentially High Risk" by the State WIC Branch through the use of the Automated Data Processing (ADP) system reports, complaints, the Request for Investigation Forms received from the districts.
A Request for Investigation Form (Attachment CA-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 Branch for action. (See Complaints Against Vendors, in the Vendor Procedures section of this manual).
Local Agencies that would like to conduct compliance buys in their stores must contact the State WIC Branch for approval. If the Local Agency conducts any compliance investigations, each buy must be documented by completing the WIC Transaction Report (Attachment CA-5). The original copy of this form must be submitted to the State WIC Branch. Upon notification by the local agency, the State WIC Branch will notify the contract bank to obtain the original copy of the vouchers to be used for these buys.
Vouchers to be used by the State WIC Branch 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.

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 include but are not limited to:

*City and County Fire Department(s) *City and County Police Department(s) *Retirement Homes *Battered Women Shelters *Church Organizations *Homeless Shelters

*Salvation Army *Food Pantry (Bank) *Head Start *Boy Scouts *Girl Scouts

CA-11

GA WIC PROCEDURES MANUAL The compliance investigator completes a Food Donation List (see Attachment CA-7) and submits it to the non-profit organization for verification. A representative of the non-profit organization will sign the donation list to confirm the receipt of foods, and may obtain a copy of the list for their records.
IX. DISQUALIFIED VENDOR/PARTICIPANT ACCESS
If a vendor is found to be in violation of program policies and federal regulations following 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 (See Vendor Sanctions-Vendor Section of the Procedure Manual). 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, as a result of an investigation, are found in the Vendor SectionTerminations/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 forward a Participant Access Form (Attachment CA-6) 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; and/or (b) to verify that there is no inadequate participant access in case of future administrative/judicial hearings. Verification of inadequate participant access will be in accordance with inadequate Participant Access Procedures as stated in the Vendor Section.
The District WIC 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 Branch within ten (10) working days.
X. INVESTIGATION OF MISSING VOUCHERS/VERIFICATION OF CERTIFICATION CARDS (VOC)
When twenty-five (25) or more WIC vouchers or five (5) or more VOC Cards are missing, the Notification Summary of Missing Vouchers/VOC Cards (Attachment CA-8) must be completed. When vouchers/VOC cards are discovered to be missing, immediately notify the supervisor, WIC Coordinator, and the Police. The assigned police detective shall be given the name of either the WIC Coordinator or their designee as a contact person while conducting their investigation. The coordinator/designee shall report details of investigation to the Compliance Analysis Section.
CA-12

GA WIC PROCEDURES MANUAL
The WIC Coordinator or designee must submit the Notification Summary to the State WIC Branch within three (3) working days of the discovery of missing vouchers/VOC cards. Immediately following initial contact from the local agency, the State WIC Branch will notify the contract bank to place a stop payment on the missing vouchers. For additional instructions on VOC cards, refer to the Certification Section of the procedures manual.
A. VENDOR NOTIFICATION
In 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. MANUAL VOUCHER INVENTORY
Document the serial numbers of the vouchers that are lost or stolen on the manual voucher inventory.
C. GEORGIA WIC VOUCHER INVESTIGATION LOG
1. To request WIC voucher copies, complete the Georgia WIC Voucher Investigation Log (Attachment CA-2) with the following: a. District/Unit; b. Current date; c. Reason for investigation (suspected fraud, 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.
2. Mail the completed Georgia WIC Investigation Log to the State WIC Branch, Compliance Analysis Section, along with the Lost/Stolen/Destroyed/Voided Voucher Report. The Compliance Analysis Section will follow up with the local agency immediately on reports that indicate potential fraud.
3. Upon receipt of special request voucher copies, the local agency should conduct a review to determine if potential fraud exist, and to notify the Compliance Analysis Section 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 Branch during an investigation of missing vouchers. When a determination has been made that potential employee fraud exist, the DHR Office of Fraud and Abuse must be contacted (See V and VI of the CA Section).
D. STOP PAYMENT OF WIC VOUCHERS The State WIC Branch will immediately upon notification, place a stop payment on WIC vouchers reported stolen from WIC clinics.
CA-13

GA WIC PROCEDURES MANUAL XI. SECURITY OF ISSUANCE MATERIALS
A. WIC Program Stamps
1. WIC Program stamps must be stored in a locked desk, cabinet, or closet. The key which locks the desk, cabinet, or closet must be stored in a secure location.
2. WIC Program stamps must be stored in a location separate from WIC vouchers, I.D. cards, and VOC cards.
B. VOC Cards
1. VOC cards must be stored in a locked desk, cabinet, or closet. The key which locks the desk, cabinet, or closet must be stored in a secure location.
2. VOC cards must be stored separately from the VOC card inventory.
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 have 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 reimbursement. Therefore all vouchers must be as 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 failure to follow security regulations, 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 of their printing job; 4. Passwords must be changed every 90 days at a minimum;
CA-14

GA WIC PROCEDURES MANUAL 5. When a voucher issuance employee resigns or is no longer authorized to issue vouchers, the following procedures should be implemented: a. Within three (3) business days, delete employee's computer log in access. b. Change all passwords that the employee had access to. c. Change key to voucher security door (when applicable). d. Change location of all security keys. 6. Only authorized persons may be given access to WIC vouchers.
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 at least minimum security for voucher issuance station(s). 1. Service Delivery Counter which will provide a shield between the
issuance clerk and the participant; 2. Half Door may be used in a small clinic with only one clerk; 3. Vouchers must be kept three (3) feet out of the reach of the participants, or
there must be a physical barrier between the vouchers and the participant. C. Voucher Storage
At a minimum, when clinics are closed, districts must utilize at least one of the following voucher storage methods:
1. If vouchers are locked in a standard cabinet, the cabinet must be in a locked room, within a locked building;
2. A locked cabinet in a locked building with an alarm system;
3. A fire proof insulated security file cabinet with combination lock, securely attached to the floor, in a locked building;
4. A safe securely attached to the floor in a locked building;
5. A vault in a locked building.
CA-15

GA WIC PROCEDURES MANUAL D. Voucher Printing on Demand (VPOD) VPOD Printers must not be accessible to participants or other unauthorized personnel. The printers must be in a secure location and exclusively used to print VPOD vouchers. E. Transporting WIC Vouchers 1. When transporting WIC vouchers, program stamps, and VOC cards, to a clinic site, they must be secured in a locked box or locked briefcase (see Attachment FD-8).
CA-16

GA WIC PROCEDURES MANUAL

ATTACHMENT CA-1

CLOSEOUT RECONCILIATION REPORT

D/U # :

CL # :

PAGE 20634 REPORT EWRR840G GRADY MATL & INFANT CARE

STATE OF GEORGIA WIC SYSTEM CLOSEOUT RECONCILIATION REPORT FOR THE CLOSEOUT MONTH OF JUNE 1995

VOUCHER NUMBER 25709399 26499328
26488329 26488330 26488331 25709404 25709405 25709406 25709407 25709412 25709413 25709414 25709415 25709420 25709421 25709422 25709423 26488336 26488337 26488338 26488339 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 42501104 68637805 42502548 68637825 42501097 68637806 42502547 68637826 63827114 63827113

WIC ID FAMILY C P
999054588 2 1 697012089 2 1 -
697012089 2 1 697012089 2 1 697012089 2 1 699126861 3 1 699126861 3 1 699126861 3 1 699126861 3 1 999043937 5 1 999043937 5 1 999043937 5 1 999043937 5 1 697010260 1 1 697010260 1 1 697010260 1 1 697010260 1 1 697008023 7 1 697008023 7 1 697008023 7 1 697008023 7 1 699148954 0 1 699148954 0 1 699148954 0 1 699148954 0 1 695100454 5 1 695100454 5 1 697004511 5 1 697004511 5 1 697004511 5 1 697004511 5 1 999051530 7 1 999051530 7 1 999051530 7 1 999051530 7 1 697009847 8 1 697009847 8 1 697009847 8 1 697009847 8 1 999047451 3 1 999047451 3 1

PARTICIPANT NAME

LAST

FIRST

VCHR TYPE
055 047
039 025 039 028 031 037 054 047 039 025 039 047 039 025 039 031 037 039 055 028 031 037 054 068 072 031 037 039 055 031 037 039 055 031 037 039 055 031 037

CLINIC PAGE

9

D/U/CL 09-1-259

RUN DATE 07/13/95

REDMO AMT
10.61 12.14
.00 9.82 6.33 8.20 8.92 14.54 12.26 12.14 6.33 9.82 6.33 12.22 6.13 10.37 6.13 8.92 13.71 6.33 9.10 7.18 7.23 14.54 8.37 58.87 51.40 8.92 14.54 6.33 9.91 8.92 14.54 6.33 9.91 8.92 14.54 6.33 9.91 6.87 6.95

DATE ISSUED
04/06/95 04/14/95
04/14/95 04/14/95 04/14/95 04/06/95 04/06/95 04/05/95 04/06/95 04/06/95 04/06/95 04/06/95 04/06/95 04/12/95 04/12/95 04/12/95 04/12/95 04/11/95 04/11/95 04/11/95 04/11/95 04/06/95 04/06/95 04/06/95 04/06/95 04/11/.95 04/11/95 04/11/95 04/11/95 04/11/95 04/11/95 04/11/95 04/11/95 04/11/95 04/11/95 04/10/95 04/10/95 04/10/95 04/10/95 04/06/95 04/06/95

STATUS DATE
05/10/95 04/18/95
04/14/95 04/18/95 04/10/95 04/10/95 04/10/95 04/10/95 04/10/95 04/10/95 04/10/95 04/10/95 04/19/95 04/19/95 04/19/95 04/12/95 04/13/95 05/01/95 04/13/95 05/01/95 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 CREATED

CLINIC TOTALS

VOUCHERS 805 73 0 878 135 0
1,013

AMOUNT 11,199.66
.00 11,199.66
11,199.66

(TOTAL OF CASHED AND EXPIRED) (COMPUTED AND MANUAL VOUCHERS)

CA-16

GA WIC PROCEDURES MANUAL
GEORGIA WIC VOUCHER INVESTIGATION LOG

ATTACHMENT CA-2

DISTRICT/UNIT _____________________DATE:__________________________________ REASON FOR INVESTIGATION:

STATE WIC OFFICE USE ONLY

VOUCHER ISSUE CLINIC BOX PAID

NUMBER DATE

#

# YES/NO

COMMENTS

COMPLETED BY
Form 3789 (5-99)

___ DATE _______________________
Routing : White Copy - State WIC Branch, Yellow - Local Agency

CA-17

GA WIC PROCEDURES MANUAL

ATTACHMENT CA-3

PARTICIPANT SAMPLE WARNING LETTER

Dear Participant,

It has come to my attention that you sold food that was purchased utilizing 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 or given to anyone else.

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

CA-18

GA WIC PROCEDURES MANUAL

ATTACHMENT CA-4

REQUEST FOR INVESTIGATION FORM

Georgia Department of Human Resources

DATE

WIC REQUEST FOR INVESTIGATION

TO:

FROM:

NAME AND ADDRESS OF STORE (INCLUDE STREET, CITY, STATE AND COUNTY)

VENDOR NUMBER

NAME OF OWNER OR MANAGER ETHNIC MAKEUP OF STORE=S CLIENTELE

HAS STORE BEEN PREVIOUSLY INVESTIGATED?

YES

NO

ARE THERE OTHER STORES UNDER THE SAME OWNERSHIP WHICH ARE AUTHORIZED FOR PARTICIPATION?
YES NO
If Yes, fill in their names and address.

TYPES OF ABUSES FOR WHICH INVESTIGATION IS REQUESTED. OTHER INFORMATION USEFUL TO THE INVESTIGATOR (PROVIDE ADDITIONAL SHEETS IF NECESSARY)

Form 3775 (3-97)

Form on disk at district office

CA-19

GA WIC PROCEDURES MANUAL

VoucherNumber
Store Name and Address:

Georgia Department of Human Resources Division of Public Health
WIC Program WIC TRANSACTION REPORT (WTR)
WTR Returned to WIC Agency:

ATTACHMENT CA-5 Vendor Number

1. At the Check-out counter there (was/were) person(s) in line ahead of me. On

, at about . I entered the subject's store. I selected the item(s) specified

below. The food instrument indicated above was used for this transaction. The clerk sold the item(s) below at a total cost of (if available) $

. During checkout, the

voucher was in plain view of the clerk who served the investigator. The price of the items(s) were marked on the item(s) or shelf, for item(s) not marked, they were verified by:

2.

Time Entered Store:

3. Check List

Y / N

Prices Marked on Foods or Shelf

Time Approached Checkout: Y / N
Rang up Sale

Time Left Store: Y / N
Adequate Supply of WIC Foods on Shelf

Recorded Price on Voucher

Checked ID Cards

Gave Receipt to Investigator

4. Comments

5.

Description of Clerk (Approximate)

SEX

RACE

AGE

6. Other Identifying Information: 7. Identified During Transaction as (Title/Name):

ELIGIBLE ITEMS

SUMMARY OF PURCHASE

QUALITITY

BRAND NAME

HEIGHT

WEIGHT

ITEM

HAIR COLOR PRICE

INELIGIBLE ITEMS
QUALITITY

ITEM

PRICE

ITEMS REFUSED
QUALITITY

ITEM

I

, an investigator of the Georgia WIC Program, Department of Human Resources,

make the above statement freely and voluntarily knowing that this statement may be used as evidence.

Name:

Date:

Title:

Investigator Signature:

Form 3773 (6/99)

CA- 20

GA WIC PROCEDURES MANUAL

ATTACHEMENT CA-6

VERIFICATION FORM

GEORGIA WIC PROGRAM
PARTICIPANT ACCESS VERIFICATION FORM

To Be Completed by State WIC Office

District/Unit __________________

Vendor Number

Name of Disqualified Vendor Address

To Be Completed by Local Agency List WIC Vendors within ten (10) miles of Disqualified Vendor:

Vendor Name Address (Street/Hwy)
Distance In Miles (only)

_____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________

Vendor Name Address (Street/Hwy)
Distance In Miles (only)

_____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________

List WIC Vendors within ten (10) miles of Health Department in this area:

Vendor Name Address(Street/Hwy)
Distance In Miles (only)

_____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________

Recommendations:

________________________________________________________
____________________________________________________
Local Agency Signature ___________________________________

RETURN TO STATE WIC OFFICE WITHIN 15 DAYS OF RECEIPT

CA-21

GA WIC PROCEDURES MANUAL

ATTACHMENT CA-7

GEORGIA DEPARTMENT OF HUMAN RESOURCES WIC PROGRAM DONATION LIST

Georgia Department of Human Resources

WIC Program

VENDOR DONATION LIST

TYPE

BRAND

QUANTITY/SIZE

C.B.

VENDOR NO.

CARROT

TYPE

BRAND

QUANTITY/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

ORGANIZATION NAME: ORGANIZATION REPRESENTATIVE: ADDRESS: CITY:
W.I.C. REPRESENTATIVE: DATE:
PLEASE USE INK

ZIP CODE:

CA-22

GA WIC PROCEDURES MANUAL
PLEASE USE INK

ATTACHMENT CA-8

Georgia Department of Human Resources WIC Program
NOTIFICATION SUMMARY OF MISSING VOUCHERS/VOC CARDS
COMPLETE: When 25 or more WIC vouchers; 5 or more VOC cards; are missing. (A lost/stolen/voucher report must be completed for all missing vouchers) 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

D/U/C

Name of person completing this form, if different from above ____________________________________________________________________________________________________ SECTION II

Name of person(s), who is responsible for vouchers/VOC cards at this clinic.

_____________________________________________________

_________________________________________________

_____________________________________________________

_________________________________________________

SECTION III

Number of Missing Voucher(s)

Number of Missing VOC Cards

NOTE: A separate form must be completed if both Vouchers and VOC cards are missing

Discovered missing: Date

Time

am

Supervisor notified: Date

Time

am

Coordinator notified:

Date

Time

VOUCHER'S Beginning #

Ending #

VOC CARDS Beginning #

Ending #

SECTION IV

pm

pm

am

pm

Complete a detailed summary of how vouchers/VOC cards were discovered missing._________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________ Use additional sheets of paper if needed, and attach

SECTION V
List any additional information that would apply to this case. ____________________________________________________________________________________________________________________________________________________

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_________________________

(This signature is to verify receipt of this 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 Copy- Clinic

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 3827 (2-96)

CA-23

GA WIC PROCEDURES MANUAL

ATTACHMENT CA-9

WIC PROGRAM Verification Form

GEORGIA DEPARTMENT OF HUMAN RESOURCES

Duplicate Participation

DISTRICT/UNIT

CLINIC:

DATE:

INSTRUCTIONS

-

USE THIS 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

-

OR FAX TO: (317) 889-9485

THE FOLLOWING CLIENT(S) LISTED BELOW ARE LEGITIMATE PARTICIPANTS. PLEASE REMOVE THEM FROM SUBSEQUENT DUAL PARTICIPATION REPORTS.

PARTICIPANT ID NUMBER

PARTICIPANT NAME

SIGNATURE OF VERIFYING CLERK COMMENTS:

PRINTED OR TYPED NAME OF VERIFYING CLERK

DISTRICT OFFICE APPROVAL DATE VIKING WHITE COPY SWO YELLOW COPY

DISTRICT OFFICE PINK COPY

CA- 24

CLINIC GOLD

GA WIC PROCEDURES MANUAL

ATTACHMENT CA-9

CA- 24

GA WIC PROCEDURES _________________
Participant Repayment SAMPLE LETTER

ATTACHMENT CA-10

Date
CERTIFIED MAIL RETURN RECEIPT REQUESTED
Ms.

Dear Ms. :
We read an advertisement that you placed in the Swapper Newspaper selling 48 cans of Similac infant formula for $____ per can. Formula provided by WIC must not be sold by our participants.
Please return all 48 cans of formula to the health department or remit $______ to us by check or money order. This is the amount we paid for the formula.
If you are unable to make a full payment of $______, please contact your Local Health Department for a payment plan. The payment plan can not extend more than 90 days from the date of this letter.
Please send a cashier's check or money order payable to:
Georgia WIC Program Your address
We are a service organization, and it is our intent to be of assistance to our participants. We expect your cooperation to help make the WIC Program work effectively.
Please call me at _____________(your #) if you have any questions or need to establish a repayment schedule.
Sincerely,
WIC Coordinator's Name Address
CA-25

GEORGIA WIC PROGRAM_____________ ___________ATTACHMENT CA- 11
Participant Repayment Schedule SAMPLE LETTER

Date
CERTIFIED MAIL RETURN RECEIPT REQUESTED Ms.

Dear Ms.

:

This letter confirms your proposal to repay $______ to the Georgia WIC Program in monthly installments of $_______. If you fail to make payments on time, the full amount will be due immediately. The following is the payment schedule that we will require you to follow until the full amount is recovered:

DATE

AMOUNT

DATE

AMOUNT

Total Please send a cashier's check or money order payable to the Georgia WIC Program and mail it to the following address:
Georgia WIC Program Your address
If you have any questions, please call me at ________________. Sincerely,
WIC Coordinator's Name Address

CA-26

GEORGIA WIC PROGRAM_____________ ___________ATTACHMENT CA- 12
DUAL PARTICIPATION REPORT INVESTIGATION FORM
Please complete and return the following information listed below. Please send the information to the requesting clinic as soon as possible.
DU/Clinic:_____________________________________________ Name: ________________________________________________ WIC ID: ______________________________________________ Birthdate: _____________________________________________ Mother's Name: ________________________________________ Date of last voucher pickup: ______________________________ Date of Issue: __________________________________________ Is this client active or terminated? _________________________ (If terminated, indicate term date and term code) Has the client transferred into your area recently? ___________ (If yes, give date; ___________________________) Date of last certification: _________________________________ Social Security number: _________________________________
CA-27

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 and Health Record Selection.....................................................MO-2

D. Pre-Review Activities ..........................................................................MO-3

E. Files......................................................................................................MO-3

F. Timeframes ..........................................................................................MO-5

G. On-Site Visit ........................................................................................MO-5

1. Entrance Conference................................................................MO-5

2. Exit Conference .......................................................................MO-6

H. Special Site Visits ................................................................................MO-6

I. Written Reports....................................................................................MO-7

J. Close-Out Report .................................................................................MO-9

II. Quality Assurance Self-Reviews .................................................................................MO-9

A. Purpose.................................................................................................MO-9

B. Self Reviews ........................................................................................MO-9

III. Technical Assistance..................................................................................................MO-10 Attachment: MO-1 Local Agency Monitoring Tool ..........................................................................................01

Special Note: Monitoring Description next page:

GA WIC PROCEDURES MANUAL Monitoring Tool Description Page
Administration Section .................................................................................02 Administrative Forms...................................................................................26 Food Instrument ......................................................................................... 55 Certification/Nutrition Education ..................................................................... 69

GA WIC PROCEDURES MANUAL
I. 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 Branch (SWB) and the Nutrition Section (NS). Every effort will be made to conduct all portions (Programmatic, Compliance Analysis, Nutrition, and Breastfeeding) of the review during the same time period.
District reviews may be conducted yearly for clinics with specific problems (See page MO-6, H. Special Site Visits).
B. Monitoring Schedule A schedule of on-site monitoring visits will be developed and coordinated by the State WIC Branch (SWB) and the Nutrition Section (NS), 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. 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 least four (4) years may be hand- selected in place of 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 by the SWB.
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 clinic and health record selection procedures (page MO2).
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 clinic and health record selection procedures (page MO2).
c. If a significant number of the 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. Prior to a review the State Office will review the migrant report.
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. Ethnic Enrollment Participation Report
5. Clinic Schedules
6. Outreach Activities
7. Waiting List(s)
8. Georgia WIC Program Procedures Manual
9. WIC Policy Memorandums
10. Georgia WIC User Manual
MO 3

GA WIC PROCEDURES MANUAL
11. Federal WIC Regulations 12. Fair Hearing and Civil Rights Complaints 13. Participant Abuse Reports 14. Manual Voucher Inventories 15. Verification Of Certification (VOC) Cards and Inventory 16. Batch Control Modules 17. Completed Computer Voucher Registers 18. Voucher Packing Lists 19. Lost/Stolen Voucher Reports 20. Copies of Manual Vouchers 21. Daily Activity Reports 22. Vouchers Printed On Demand (VPOD) Receipts 23. Ineligibility Files 24. District Specific Policies and Procedures 25. Local Agency Nutrition Education and Breastfeeding Plan 26. Nutrition Education Materials 27. Breastfeeding Education Materials 28. Lesson Plans 29. Training Files 30. Equipment Inventory (current year) 31. Voter's Registration Files 32. Contracts With Other Agencies (other than Health Departments) Where WIC
Programs Are Located. 33. Patient Flow Analysis 34. Temporary Thirty (30) Day Certification Files
MO 4

GA WIC PROCEDURES MANUAL
F. Timeframes The program review process will be conducted within the following timeframes:

ACTIVITY

TIMEFRAME

1. Notification of intent to conduct a review, SWB/NS contacts Local Agency to 30 days prior to the scheduled date. discuss possible review dates.

2. SWB/NS prepares and submits a report of program observation and review to Local Agency after the site visit/exit interview.

Within 60 interviews.

days

of

the

exit

3. Local Agency submits a corrective action Within 60 days of the date of

report to SWB/NS.

program review report is received.

4. SWB/NS submits written response to the Within 15 days of the date of the

Local Agency review.

Local Agency response.

5. Local Agency submits written response to Within 15 days of the date of the SWB request for additional information. written request.

6. Program review closed.

Within 150 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.

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.

MO 5

GA WIC PROCEDURES MANUAL
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.
H. Special Site Visits
The SWB 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 Branch or USDA deems necessary.
Special Site Visit Procedures:
In the event a special site visit is requested by the State WIC Branch (SWB) 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 SWB, 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 SWB will contact the WIC Coordinator to set up a site visit and schedule.
MO 6

GA WIC PROCEDURES MANUAL
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 SWB with a written report within thirty (30) days of receipt. All district responses must address a resolution to the exiting problem (who has been 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 addressing problems found during the special site visit. 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 page MO-5, F. Timeframes).
MO 7

GA WIC PROCEDURES MANUAL
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?
NOTE: All training must be performed within sixty (60) days from the date the Program Review Report is received by the district. 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 memorandums sent out to local agency staff by the WIC
Coordinator addressing problems found during the program review. 3. Copies of information that could not be located during the on-site monitoring
visit that relate to specific corrective actions. The review will not be closed until all planned trainings 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 8

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 150 days of the exit interview.
II. QUALITY ASSURANCE SELF-REVIEWS
A. Purpose
The purpose of self-evaluation is to improve the quality of Local Agency program operations. Internal self-evaluations allow local agencies to assess compliance of program operations with WIC policies and procedures. Early identification and resolution 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 SWB by September 30th of each year. The assessment will include all phases of the program operations. The SWB "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:
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 Civil Rights Compliance Participant Complaints Fair Hearing
MO 9

GA WIC PROCEDURES MANUAL
Review Certification/Voucher Issuance Records for Employee/Employee's Relatives
Patient Flow Analysis at the Largest Clinic
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 and VPOD receipts. 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. A list of sites that will be reviewed, the dates of the reviews, and the name of person conducting the reviews must be submitted to the State WIC Branch in October of each year. Selfreviews are not required on clinics sites that are monitored by the State.
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.
III. TECHNICAL ASSISTANCE
Technical assistance will be provided by the State agency to all local agencies on an on-going basis. On-site technical assistance will be provided when requested by the local agency. Technical assistance may also be provided to the local agency through telephone contact or correspondence with the State agency. On-site assistance provided to 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. Program consultants are 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.
MO 10

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

STATE OF GEORGIA
Department of Human Resources Division of Public Health
State WIC Branch Nutrition Section
LOCAL AGENCY FFY 2002
MONITORING TOOL

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-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 five (5) parts as follows:

I. Administration Section Local Program Management

II. Civil Rights Administration Training Complaints

III. Clinic Review Clinic Operation Clinic Observation Record Review

IV. Food Instrument Accountability

V. Certification and Nutrition Services Certification/Nutrition Education (Nutrition Section) Clinic Observation: Individual Nutrition Education Session Clinic Observation Group Nutrition Education Session Clinic Observation Questions for Clinic Staff Anthropometric Equipment Hematologic Equipment Clinic Observation Anthropometric Measurements Record Review

1

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

PART I - ADMINISTRATIVE SECTION 1. Name of District/Local Agency: ____________________________________________
Address: _______________________________________________________________

WIC Coordinator:________________ Telephone # ___________________________

2. Clinic(s) to be Reviewed: (Attach a copy of the District Clinic Listing)

1. _________________________ Clinic #/Clinic Name

2. _________________________ Clinic #/Clinic Name

3. _________________________ Clinic #/Clinic Name

4. _________________________ Clinic #/Clinic Name

5. _________________________ Clinic #/Clinic Name

3. Attach a Copy of the Review Schedule

Entrance Conference:

Date:

Time:

Place:

Exit Conference:

Date:

Time:

Place:

2

GA WIC PROCEDURES MANUAL PART I - ADMINISTRATIVE SECTION

ATTACHMENT MO-1

GUIDELINES

AREAS OF REVIEW

YES NO NA *

NOTE: Recommendations are not requirements for completing self-reviews. * NA - stands for Not Applicable.

Corrective Action

I. ADMINISTRATION

A. Policy and Procedures 1. Does the District Office have a copy of all Policy Memorandums on file?

Corrective Action

Looking for: 1. Up to date Manual. 2. Policy is in place. 3. Staff understands policy.
2. Is a copy of the Memorandum of Agreement on file?

Looking for: 1. Whether or not the Coordinator has a copy.

COMMENTS

Corrective Action Corrective Action Corrective Action
Corrective Action

3. Is a copy of the Procedures Manual located at the District Office?

Looking for: 1. Manual is in place in the event of questions. 2. Services are delivered according to the manual.

4. Did the District Office submit a copy of the local agency contract(s) to the SWB by September 30th?
Looking for: 1. Copy of each agreement with the Local Agency.

B.

System Maintenance Indicators

1. 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 10% or above a technical assistance

visit and/or a plan must be submitted to the

SWB.

Looking for:

1. 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: 1. Ensure that 60% of prenatal are enrolled their first
trimester.

3

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

GUIDELINES

PART I - ADMINISTRATIVE SECTION

AREAS OF REVIEW

YES NO NA *

COMMENTS

NOTE: Recommendations are not requirements for completing self-reviews. * NA - stands for Not Applicable.

Corrective Action

C.

Caseload Management (must have approval from

State)

1. Has the District implemented a waiting list

since the last review?

Looking for:

1. Ensure that Clinic/District does not begin its own

waiting list.

Corrective Action Corrective Action
Corrective Action 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.

D.

Internal Communication

1. Are new policies and State memos sent to

staff?

Are staff meetings held regularly?

Date of the last meeting: ___________

Looking for:

1. Whether or not all staff are informed on all new

policies.

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.

3. Is in-service training conducted regularly for WIC and non-WIC staff providing WIC services?

Date of the last meeting: ______________ Looking for:
1. Whether or not staff members are updated regularly.

Corrective Action

E.

Fair Hearings/Participant Complaints (Review

District files prior to monitoring Review)

1. Is documentation on file for any Fair Hearings? Is it available for review at the District and State Office?

Looking for: 1. Is documentation on file at the State office? 2. Were proper procedures followed?

4

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

GUIDELINES

PART I - ADMINISTRATIVE SECTION

AREAS OF REVIEW

YES NO NA *

COMMENTS

NOTE: Recommendations are not requirements for completing self-reviews. * NA - stands for Not Applicable.

Corrective Action

2. Were Fair Hearings/Participant Complaints handled/resolved according to program procedures?

If no, please explain (in comments section): Looking for: 1. Check documentation for compliance.

Corrective Action

F.

Quality Assurance Self Review

1. Does the District conduct internal monitoring? (Review) (Attach a copy of the Review Schedule)
Looking for: 1. 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: 1. Types of deficiencies found. 2. Corrective action given. 3. Plan in place for correction.

3. Were repeated errors found? Looking for: 1. If repeated errors are made, is training being conducted?

4. If yes, were additional monitoring visits made or training conducted?
Looking for: 1. Documentation for training(s) is available from the
clinic.

Corrective Action

5. Are the following program indicators included in the local assessment? (District)

1. A Record Review of Employees and Their Relative(s)
2. Check the Voucher Registers for ID Proof 3. System Maintenance Indicator Reports 4. Non-Participation 5. Waiting List 6. Service Integration and Patient Flow 7. Outreach and Referral 8. Trimester of Enrollment 9. Patient Flow Analysis Looking for: 1. Record Review (Income, Residency and Identification). 2. Whether or not all the areas are reviewed in the event the

5

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

GUIDELINES

PART I - ADMINISTRATIVE SECTION

AREAS OF REVIEW Monitoring Tool is not used.

YES NO

NA *

NOTE: Recommendations are not requirements for completing self-reviews. * NA - stands for Not Applicable.

COMMENTS

6. Have any special initiative efforts been implemented as a result of the internal monitoring?

Recommendation
Corrective Action Corrective Action

G.

Patient Flow Analysis

1. Was a Patient Flow Analysis performed in the largest clinic?

Looking for: 1. Whether or not an annual Patient Flow Analysis was
conducted? 2. Documentation of bottlenecks.

H.

Outreach

1. Does the District have a plan for developing and conducting outreach activities pertinent to the local service area? Are grassroots organizations included?

2. If yes, are outreach activities documented and available for review?
3. If no, 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: 1. Documentation that outreach was conducted yearly.

6

GA WIC PROCEDURES MANUAL PART I - ADMINISTRATIVE SECTION

ATTACHMENT MO-1

GUIDELINES

AREAS OF REVIEW

YES NO NA

NOTE: Recommendations are not requirements for completing self-reviews. * NA - stands for Not Applicable.

Recommendation

6. Have special provisions been made for scheduling the following applicants? Please explain your answer.

Employed Participants

Clinic

__________________ __________________ __________________ __________________ __________________

Rural Participants

Clinic

__________________ __________________ __________________ __________________ __________________

Migrants

Clinic

__________________ __________________ __________________ __________________ __________________

Looking for: 1. Documentation of staff scheduling employed, rural or
migrant applicants at time other than traditional hours if possible.

COMMENTS

Corrective Action

I. Processing Standards 1. Has the District requested an extension for processing standards?
If yes, is the written approval of extension on file and available for review?
Looking for: 1. If clinics are not meeting processing standards, have
they asked for extension? 2. Written proof of request.

7

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

PART II - CIVIL RIGHTS

GUIDELINES

AREAS OF REVIEW

YES NO NA

NOTE: Recommendations are not requirements for completing self-reviews. * NA - stands for Not Applicable.

Corrective Action

I. CIVIL RIGHTS

COMMENTS

A. Civil Rights Training

1. Is Civil Rights training conducted annually for local WIC staff? (District)

When? ____________________________

By Whom? __________________________

Looking for: 1. 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

2. Is Civil Rights training included in new employee orientation? (Review list of new employees and documentation of Civil Rights Training.)
Looking for: 1. After training is conducted for staff and new
employees are hired, are they trained?
B. Civil Rights Complaints
Are Civil Rights complaints handled in accordance with established program procedures? (Review Complaint File - Number of Complaints)
Looking for: 1. Was the Civil Rights complaint handled according
to procedures?

8

GA WIC PROCEDURES MANUAL PART III - CLINIC REVIEW

ATTACHMENT MO-1

GUIDELINES

AREAS OF REVIEW

YES NO NA

NOTE: Recommendations are not requirements for completing self-reviews. * NA - stands for Not Applicable.

Corrective Action

I. PROGRAM MANAGEMENT (Clinical Review)

A. Caseload Management 1. 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?

COMMENTS

Recommendation Recommendation

Looking for: 1. Proper procedures are followed by clinic staff if
waiting list is implemented and correct priorities are served.
B. Coordination and Integration 1. 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: 1. Documentation verifying integration/coordination
of services.

9

GA WIC PROCEDURES MANUAL

GUIDELINES

PART III - CLINIC REVIEW

AREAS OF REVIEW

YES

ATTACHMENT MO-1
NO NA COMMENTS

NOTE: Recommendations are not requirements for completing self-reviews. * NA - stands for Not Applicable.

Corrective Action

3. Are initial contact dates documented and available for review?
Clinic__________________ __________________ __________________ __________________ __________________

Looking for: 1. Is the clinic meeting processing standards?

Corrective Action

4. When an applicant misses an appointment who reschedules the appointment?
Clinic__________________ __________________ __________________ __________________ __________________

Corrective Action

Looking for: 1. Attempts by the clinic to reschedule participants
who miss appointments.
5. When is the next available appointment for an applicant requesting WIC benefits? (See appointment book)

Clinic ____________

Women(P)______Infant_________ Women(B)______Child_________ Woman(PP)_____

Clinic ____________

Women(P)______Infant_________ Women(B)______Child_________ Woman(PP)_____

Clinic ____________

Women(P)______Infant_________ Women(B)______Child_________ Woman(PP)_____

Clinic ____________

Women(P)______Infant_________ Women(B)______Child_________ Woman(PP)_____

Clinic ____________

Women(P)______Infant_________ Women(B)______Child_________ Woman(PP)_____

Looking for: 1. Is the clinic meeting processing standards?

10

GA WIC PROCEDURES MANUAL

GUIDELINES

PART III - CLINIC REVIEW

AREAS OF REVIEW

YES

ATTACHMENT MO-1
NO NA COMMENTS

NOTE: Recommendations are not requirements for completing self-reviews. * NA - stands for Not Applicable.

Corrective Action

6. Ask clinic staff the processing standards time frames for each category below:

Time Frames

Clinic(1)

Prenatal

Postpartum

Infants

Children

Migrants

Clinic(2) Prenatal Postpartum Infants Children Migrants

Clinic(3) Prenatal Postpartum Infants Children Migrants

Clinic(4) Prenatal Postpartum Infants Children Migrants

Clinic(5) Prenatal Postpartum Infants Children Migrants
Looking for: 1. Ensure that staff members are knowledgeable
about processing time frames.

11

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

PART III - CLINIC REVIEW

GUIDELINES

AREAS OF REVIEW

YES NO NA

NOTE: Recommendations are not requirements for completing self-reviews. * NA - stands for Not Applicable.

Corrective Action

C.

Income Assessment

COMMENTS

1. Is income taken before or after the certification process?

Clinic __________________ __________________ __________________ __________________ __________________

Looking for:

1.

Is income assessed as the first step in the

certification process?

Corrective Action

2. What is the definition of "family"?

Clinic __________________ __________________ __________________ __________________ __________________

Looking for:

1.

Does staff know how to determine a

family/household?

Corrective Action

3. How does clinic staff determine family size when assessing eligibility?

Clinic __________________ __________________ __________________ __________________ __________________

Looking for:

1.

Does clinic staff correctly determine family size

when assessing eligibility?

Corrective Action

4. Is the participant required to provide proof of income at certification and recertification?

Clinic __________________ __________________ __________________ __________________ __________________
Looking for:

1. If applicant shows proof of income during visit.
12

GA WIC PROCEDURES MANUAL PART III - CLINIC REVIEW

ATTACHMENT MO-1

GUIDELINES

AREAS OF REVIEW

YES NO NA

NOTE: Recommendations are not requirements for completing self-reviews. * NA - stands for Not Applicable.

Corrective Action

5. Does the clinic staff ask the applicant to report income for the entire family?

Clinic __________________ __________________ __________________ __________________ __________________

Looking for: 1. Is total household income accurately assessed in
determining eligibility?

Corrective Action

6. How are inclusions and exclusions for income taken into consideration when taking income (i.e. military housing or rations)?

Clinic __________________ __________________ __________________ __________________ __________________
Looking for: 1. Is the WIC staff aware of the proper procedures for
determining income eligibility?

Corrective Action

7. Does the clinic determine an applicant to be income eligible based on presumptive eligibility requirements? Where is it documented?

Clinic __________________ __________________ __________________ __________________ __________________

Looking for: 1. Is the WIC staff aware of the proper procedures for
determining income eligibility?

COMMENTS

13

GA WIC PROCEDURES MANUAL PART III - CLINIC REVIEW

ATTACHMENT MO-1

GUIDELINES

AREAS OF REVIEW

YES NO NA

NOTE: Recommendations are not requirements for completing self-reviews. * NA - stands for Not Applicable.

Corrective Action

8. Are there certain situations when an applicant's income must be verified other than at certification/re-certification? When?

Clinic __________________ __________________ __________________ __________________ __________________

Looking for: 1. Is the clinic aware of the circumstances when income
must be verified?

Corrective Action

D. Certification Process

1. Are there instances when you must request/require applicant/participant's identification?

Clinic __________________ __________________ __________________ __________________ __________________

Looking for: 1. Is clinic staff aware of WIC protocol for
participant I.D.?
If yes, please explain.

Clinic __________________ __________________ __________________ __________________
__________________

2. Does the staff require documentation of residency?

Clinic __________________ __________________ __________________ __________________ __________________
Looking for: 1. Is staff requesting proof of residency?

COMMENTS

14

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

PART III - CLINIC REVIEW

GUIDELINES

AREAS OF REVIEW

YES NO NA

NOTE: Recommendations are not requirements for completing self-reviews. * NA - stands for Not Applicable.

COMMENTS

Corrective Action

3. What forms of participant identification do you accept?

Clinic __________________ __________________ __________________ __________________ __________________

Looking for: 1. Is the clinic staff aware of the acceptable forms of
I.D.?

Corrective Action

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 Form I Ineligible Certification Work Sheet)

Clinic __________________ __________________ __________________ __________________ __________________

Corrective Action

Looking for: 1. Is the clinic staff following proper procedures when
notifying applicants/participants of WIC eligibility or ineligibility?
5. Are participants notified that their WIC certification is about to expire before termination?

Clinic __________________ __________________ __________________ __________________ __________________
Looking for: 1. To ensure that participants are given appropriate
notification prior to the expiration of certification.

15

GA WIC PROCEDURES MANUAL PART III - CLINIC REVIEW

ATTACHMENT MO-1

GUIDELINES

AREAS OF REVIEW

YES NO NA

NOTE: Recommendations are not requirements for completing self-reviews. * NA - stands for Not Applicable.

Corrective Action

6. How are they notified and is the notification documented?

Clinic __________________ __________________ __________________ __________________ __________________

Looking for: 1. Is the clinic staff documenting and/or notifying the
participants?

COMMENTS

Corrective Action

7. Are persons who are terminated during a valid certification period notified prior to termination?
Clinic __________________ __________________ __________________ __________________ __________________
Looking for: 1. Are proper procedures followed prior to termination
during a valid certification?

16

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

PART III - CLINIC REVIEW

GUIDELINES

AREAS OF REVIEW

YES NO NA

NOTE: Recommendations are not requirements for completing self-reviews. * NA - stands for Not Applicable.

Corrective Action

8. Certification Periods

COMMENTS

Is the staff knowledgeable of certification periods? (Staff interviews)

Time Frames

Time Periods

Clinic

Women(P)______Infant_________

Women(BF)_____Child_________

_________ Woman(PP)_____ _____

Clinic

Women(P)______Infant_________

Women(BF)_____Child_________

_________ Woman(PP)_____ ______

Clinic

Women(P)______Infant_________

Women(BF)_____Child_________

_________ Woman(PP)_____ _________

Clinic

Women(P)______Infant_________

Women(BF)_____Child_________

_________ Woman(PP)_____ _________

Clinic

Women(P)______Infant_________

Women(BF)_____Child_________

_________ Woman(PP)_____ _________

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.

Corrective Action

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: 1. Ensure that proper procedures are being followed
when recertifying participants. 2. Ensure that participants are not receiving benefits
during an invalid certification period.

17

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

PART III - CLINIC REVIEW

GUIDELINES

AREAS OF REVIEW

YES NO NA

NOTE: Recommendations are not requirements for completing self-reviews. * NA - stands for Not Applicable.

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 __________________ __________________ __________________ __________________ __________________

Looking for: 1. Knowledge of the staff regarding proxy
responsibilities.

Corrective Action

11. Are VOC cards issued and accepted by the local clinic to verify WIC certification?

Clinic __________________ __________________ __________________ __________________ __________________

Looking for: 1. Staff knowledge of proper usage of VOC Cards for
transfer into the WIC clinic.

Corrective Action

12. Are the VOC card records accurate and monitored according to program policy? Complete VOC Monitoring Work Sheets, (Forms 4 A and B).

Clinic __________________ __________________ __________________ __________________ __________________

Looking for: 1. Proper security and documentation of VOC card
supply.

18

GA WIC PROCEDURES MANUAL PART III - CLINIC REVIEW

ATTACHMENT MO-1

GUIDELINES

AREAS OF REVIEW

YES NO NA

NOTE: Recommendations are not requirements for completing self-reviews. * NA - stands for Not Applicable.

Corrective Action

13. Are voided VOC cards marked void on the VOC Card Inventory?

Clinic __________________ __________________ __________________ __________________ __________________
Looking for: 1. Accountability of all issued and voided VOC cards.

COMMENTS

Corrective Action Corrective Action

14. Is the inventory of VOC cards conducted monthly according to program procedures? (Review physical inventory of VOC Card Log)
Clinic __________________ __________________ __________________ __________________ __________________
Looking for: 1. Maintenance and accurate issuance of VOC cards. 2. Procedure conducted monthly for security purposes.
15. Are two signatures of Local Agency Staff on the VOC Card Inventory monthly? Clinic __________________ __________________ __________________ __________________ __________________
Looking for: 1. Verification that a physical inventory is being
conducted.

19

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

PART III - CLINIC REVIEW

GUIDELINES

AREAS OF REVIEW

YES NO NA

NOTE: Recommendations are not requirements for completing self-reviews. * NA - stands for Not Applicable.

COMMENTS

Corrective Action

E. Voter Registration 1. Is each participant offered an opportunity to complete a Voter Registration Application?

Clinic

__________________ __________________ __________________ __________________ __________________

Looking for: 1. 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.

Corrective Action

F. Policy Memos/Procedures Manuals 1. 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 current federal fiscal year Policy Memos on file?

Clinic

__________________ __________________ __________________ __________________ __________________

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.

20

GA WIC PROCEDURES MANUAL PART III - CLINIC REVIEW

ATTACHMENT MO-1

GUIDELINES

AREAS OF REVIEW

YES NO NA

NOTE: Recommendations are not requirements for completing self-reviews. * NA - stands for Not Applicable.

Correction Action

G. Special Population

COMMENTS

1. Does the local agency caseload include migrants?

Corrective Action

Clinic __________________ __________________ __________________ __________________ __________________
Looking for: 1. Clinics that serve migrants.
2. Is the staff knowledgeable of procedures for handling migrants?

Corrective Action

Clinic __________________ __________________ __________________ __________________ __________________
Looking for: 1. Knowledge of the staff on proper procedures for
ensuring accessibility to WIC services for the migrant population.
3. Does the clinic serve non-English speaking applicants/participants?

Clinic __________________ __________________ __________________ __________________ __________________

Looking for: 1. Whether the clinic serves non-English speaking
participants.

21

GA WIC PROCEDURES MANUAL PART III - CLINIC REVIEW

ATTACHMENT MO-1

GUIDELINES

AREAS OF REVIEW

YES NO NA

NOTE: Recommendations are not requirements for completing self-reviews. * NA - stands for Not Applicable.

Corrective Action

4. Are interpreters or bilingual staff available for the non-English speaking clients, if applicable?

Clinic

__________________ __________________ __________________ __________________ __________________

Looking for: 1. 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

__________________ __________________ __________________ __________________ __________________

COMMENTS

Corrective Action

5. Is the local agency in compliance with program policy regarding racial or ethnical coding and filing of participants records? (Review Clinic Medical Records)

Clinic

__________________ __________________ __________________ __________________ __________________

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.

22

GA WIC PROCEDURES MANUAL PART III - CLINIC REVIEW

ATTACHMENT MO-1

GUIDELINES

AREAS OF REVIEW

YES NO NA

NOTE: Recommendations are not requirements for completing self-reviews. * NA - stands for Not Applicable.

Corrective Action

H. Complaint Handling 1. Is the staff knowledgeable of proper procedures for handling Civil Rights complaints?

Clinic

__________________ __________________ __________________ __________________ __________________

Looking for: 1. To ensure that the staff is knowledgeable of the
process and time frame for filing Civil Rights Complaints.

Corrective Action

2. How is the race of a participant determined?

Clinic

__________________ __________________ __________________ __________________ __________________

Looking for: 1. Ensure that the staff is knowledgeable of participant
self-identification.

Corrective Action

II. STORAGE AND SECURITY

1. In the event VOC cards are revised were the old stock of VOC cards security destroyed?

Clinic

__________________ __________________ __________________ __________________ __________________

Looking for: 1. Entry on the VOC Card Inventory and the Security
Destroyed report stating the date, series #, amount and staff initials for security destroyed VOC cards.

COMMENTS

23

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

PART III - CLINIC REVIEW

GUIDELINES

AREAS OF REVIEW

YES NO NA

NOTE: Recommendations are not requirements for completing self-reviews. * NA - stands for Not Applicable.

Corrective Action

2. Are VOC cards stored in a locked place separate from the inventory log?

COMMENTS

Clinic __________________ __________________ __________________ __________________ __________________

Looking for: 1. Ensure that proper security of VOC cards is in place.

Corrective Action

3. Are the following items stored in a secure location?

1.

Program Stamp

2.

VOC Cards

3.

VOC Card Inventory

Clinic

__________________ __________________ __________________ __________________ __________________

Looking for: 1. Security of Program Stamp and /VOC Cards. To
ensure that both are out of the reach of non-WIC persons.

Corrective Action

III. RECORD REVIEW

(Complete Record Review Work Sheet - Form 5) Copy additional sheets

Looking for: 1. Monitoring clinic records to make certain WIC
guidelines are being followed and certification is being processed properly.

Corrective Action

IV. CLINIC OBSERVATION
(See Form 6)
Looking for: 1. Monitoring procedures for participant certification.

24

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

PART III - CLINIC REVIEW

GUIDELINES

AREAS OF REVIEW

YES NO NA

NOTE: Recommendations are not requirements for completing self-reviews. * NA - stands for Not Applicable.

Corrective Action

V. EQUIPMENT INVENTORY

COMMENTS

(See Form 7)

Corrective Action

Looking for: 1. Checking equipment purchased with WIC
Administrative funds.
VI. PATIENT FLOW ANALYSIS OF LARGEST CLINIC
(Form 8A-9F)

Corrective Action

Looking for: 1. Bottlenecks. 2. Long waiting period. 3. Need for additional staff. 4. Need for interpreters.
VII. NO PROOF OBSERVATION FORM (See Form 10)

Corrective Action

Looking for: 1. Proper use of form. 2. Improper use of this form. 3. Reason for use. 4. Too much use.
VIII. PROOF OF IDENTIFICATION OBSERVATION FORM
(See Form 11)

Corrective Action

Looking for: 1. Use of correct identification. 2. Identification for proxies.
IX. NOTICE OF TERMINATION/INELIGIBILITY /WAITING LIST FORM
(See Form 12)

Corrective Action

Looking for: 1. Proper use of the form. 2. Documentation accuracy.
X. TEMPORARY THIRTY (30) DAY CERTIFICATION RECORD REVIEW FORM
(See Form 13)

Looking for: 1. Proper use of the form. 2. Documentation at clinic. 3. Over issuance of vouchers.

25

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

FORMS FOR ADMINISTRATIVE REVIEW

Form 1 Form 2 Form 3 Form 4A Form 4B Form 4C Form 5 Form 6 Form 7 Form 8A
Form 8B Form 8C Form 8D Form 8E Form 9A
Form 9B Form 9C Form 9D Form 9E Form 9F
Form 10 Form 11
Form 12
Form 13

- 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 I Form I Patient Flow Analysis Sign In Form
Procedures - Option I Form II Patient Flow Analysis Sign-In - Option I Form III 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 (PFA) Sign In
Form - Option II Form II Personnel Identification Code - Option II Form III Reason for Visit Codes - Option II Form IV Patient Category - Option II Form V Patient Register - Option II Form VI Questions to Answer from the
Modified Patient Flow Analysis - No Proof Observation Form - Proof of Identity for Women, Infants and Children
Observation Form - Notice of Termination/Ineligibility/Waiting List Form
Users' Checklist - Temporary Thirty (30) Day Certification Record
Review

26

GA WIC PROCEDURES MANUAL

FORM 1

INELIGIBLE CERTIFICATION WORK SHEET
Review three (3) records in each clinic of individuals found ineligible at the time of certification and/or of individuals who were terminated from the Program within the last year. Note: This information may be retrieved from your ineligible file.
District

Clinic

Name

Reason for Ineligibility or Termination

If reason for ineligibility is "A", was the income
section of the Assessment Form completed, dated and
signed .

Was Notice of Fair Hearing
Given?

Signature & Date of Person
Determining Eligibility Complete?

27

GA WIC PROCEDURES MANUAL

FORM 2

RECERT OVERDUE
Select a random sample of at least three (3) records for which the following message "RECERT OVERDUE MMDDYY" appears and to whom vouchers were issued. It is important that six-week postpartum women be in the sample.

District _____________________________

Clinic #

Clinic Name

Participant Name

Month of
Report

WIC Status

Delivery Issue Pick Up

Date

Date

Date

Recert Due Date

Were Vouchers Validly Issued?

28

GA WIC PROCEDURES MANUAL
TRANSFER OF CERTIFICATION WORK SHEET
(Write the names of the clinics reviewed in the shaded area.)
Clinic Name: Describe the process of accepting an out of state transfer.
Looking for: Immediate acceptance of VOC card information and/or verification of undocumented required information. When a VOC Card is received, what clinic staff has to see them?
Looking for: Unnecessary delays in processing a VOC card transfer. Are vouchers issued the same day of the transfer or would the client need to return at another time?
Looking for: Unnecessary delays in processing a VOC card transfer. Is it ever necessary to reschedule a VOC card transfer for another day?
If yes, under what circumstances?
Looking for: Circumstances that would cause a client to leave the facility without services.

FORM 3

29

GA WIC PROCEDURES MANUAL DISTRICT ISSUED VOC CARDS

FORM 4-A

VOC Card Numbers

________________________ (Beginning #)

_______________________ (Ending #)

Issue Date: _____________

_______________________________________________________

________________________ ________________________

(Beginning #)

(Ending #)

Issue Date: _____________ _______________________________________________________

________________________ (Beginning #)

________________________ (Ending #)

Issue Date: _____________

VOC Card Numbers

________________________ (Beginning #)

__________________________ (Ending #)

Issue Date: ______________

___________________________________________________________

_________________________

___________________________

(Beginning #)

(Ending #)

Issue Date: ______________ ___________________________________________________________

________________________ (Beginning #)

___________________________ (Ending #)

Issue Date: ______________

District/Clinic Name

# Of Cards Issued

Date Cards Issued

Clinic Name

Yes

No

# of VOC Cards on Hand

1. Do these #=s match at District and Clinic? yes { } no { }

Clinic ____________________________ ____________________________ ____________________________ ____________________________
____________________________

yes { } no { } yes { } no { } yes { } no { } yes { } no { }
yes { } no { }

2. Is Inventory accurate?

yes { } no { }

Clinic __________________________ __________________________ __________________________ __________________________
__________________________

yes { } no { } yes { } no { } yes { } no { } yes { } no { }
yes { } no { }

3.

Are there two (2) staff initials? yes { } no { }

Clinic

yes { } no { } yes { } no { } yes { } no { } yes { } no { } yes { } no { }

30

GA WIC PROCEDURES MANUAL CLINIC ISSUED VOC CARDS

FORM 4-B

VOC Card Numbers

________________________ ___________________________

(Beginning #)

(Ending #)

Issue Date: _____________

_______________________________________________________

________________________ ____________________________

(Beginning #)

(Ending #)

Issue Date: _____________ _______________________________________________________

________________________ ____________________________

(Beginning #)

(Ending #)

Issue Date: _____________

VOC Card Numbers

________________________ (Beginning #)

_____________________________ (Ending #)

Issue Date: ______________

___________________________________________________________

________________________ _____________________________

(Beginning #)

(Ending #)

Issue Date: ______________ ___________________________________________________________

________________________ (Beginning #)

____________________________ (Ending #)

Issue Date: ______________

District/Clinic Name

# Of Cards Issued

Date Cards Issued

Clinic Name

Yes

No

# of VOC Cards on Hand

1. Do these #=s match at District and Clinic? yes { } no { }

Clinic ___________________________ ___________________________ ___________________________ ___________________________ ___________________________

yes { } no { } yes { } no { } yes { } no { } yes { } no { } yes { } no { }

2. Is Inventory accurate?
Clinic _________________________ _________________________ _________________________ _________________________ _________________________

yes { } no { }
yes { } no { } yes { } no { } yes { } no { } yes { } no { } yes { } no { }

3.

Are there two (2) staff initials? yes { } no { }

Clinic

yes { } no { } yes { } no { } yes { } no { } yes { } no { } yes { } no { }

31

GA WIC PROCEDURES MANUAL

FORM 4-C

VOC CARD SECURITY REPORT

Pull five (5) records in each clinic from the VOC Card Log.

Clinic Name

Participant's Name

Date Issued

Signature of Parent/Guardian/
Caretaker Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___

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___ Yes___ 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 _____________ Yes { } No { } _____________ Yes { } No { } _____________ Yes { } No { } _____________ Yes { } No { } _____________ Yes { } No { }

32

GA WIC PROCEDURES MANUAL

FORM-5

RECORD REVIEW
Review the following criteria in the records randomly selected by the Nutrition Section CLINIC_______________________
CRITERIA TO REVIEW: Was the Name, Address (Demographics) completed? Was the correct initial contact date recorded? Was proof of residency recorded?
Was proof of identification recorded?
Was participant categorically eligible?
Was the signature/title of person collecting income/residence/I.D. data recorded? Was the participant's signature/date recorded? Was participant physically present?
If no to the above, was the exempt reason documented in the record? Was Medicaid eligibility documented?
Was Medicaid number documented?
Was Food Stamps documented?
Was number in family recorded?
Was income information documented?
Was it documented that participant was income eligible/ineligible? Was the error correction procedure used?
Was the No Proof Form used?
Was zero income accepted?
Was the VOC card section completed on transfers? Was form for Applicants with P.O. Box completed and filed in health record?
Note: Make copies of this form for Record Review. Must have 100% compliance.

33

GA WIC PROCEDURES MANUAL

FORM-6

CLINIC OBSERVATION

ENVIRONMENT

1. Are WIC facilities accessible to persons with special needs?

Clinic

Yes

No

______________ ______ ____

______________ ______ ____

______________ ______ ____

______________ ______ ____

______________ ______ ____

2. "And Justice For All Poster"

Clinic

Yes

______________ ______

No ___

______________ ______ ___

______________ ______ ___

______________ ______ ___

______________ ______ ___

3. Is the "No Charge for WIC Services" sign posted in the clinic?

Clinic

Yes

______________ ______

No ___

______________ ______ ___

______________ ______ ___

______________ ______ ___

______________ ______ ___

4. Are "No Smoking" signs posted?

(N/A if a DHR Building)

Clinic

Yes

No

______________ ______ ____

______________ ______ ____

______________ ______ ____

______________ ______ ____

5. Was the "Interpreter" sign posted?

Clinic

Yes

______________ ______

No ___

______________ ______ ___

______________ ______ ___

______________ ______ ___

______________ ______ ___

______________ ______ ____

6. Was the applicant receiving WIC benefits present?

Clinic

Yes

______________ ______

No ___

______________ ______ ___

______________ ______ ___

______________ ______ ___

______________ ______ ___

7. Were clinic participants waiting 8. Does the clinic offer privacy for

for long periods of time?

health screening and counseling?

Clinic

Yes

No Clinic

Yes

No

______________ ______ ____ ______________ ______ ___

______________ ______ ____ ______________ ______ ___

______________ ______ ____ ______________ ______ ___

______________ ______ ____ ______________ ______ ___

______________ ______ ____ ______________ ______ ___

9. Does the reviewer observe any practices that could be considered discriminating?

Clinic

Yes

______________ ______

No ___

______________ ______ ___

______________ ______ ___

______________ ______ ___

______________ ______ ___

34

GA WIC PROCEDURES MANUAL

FORM-6 (cont'd)

CERTIFICATION
1. Was Medicaid/Food Stamps verified?

Clinic

Yes

No

______________ ______ ____

______________ ______ ____

______________ ______ ____

______________ ______ ____

______________ ______ ____

2. Is there a place for documentation for proxy(s)?

Clinic ______________

Yes ______

No ____

______________ ______ ____

______________ ______ ____

______________ ______ ____

______________ ______ ____

3. Is income determined prior to nutritional risk assessment?

Clinic

Yes

No

______________ ______ ___

______________ ______ ___

______________ ______ ___

______________ ______ ___

______________ ______ ___

4. Was the correct form used for income?

Clinic

Yes

No

______________ ______ ____

______________ ______ ____

______________ ______ ____

______________ ______ ____

______________ ______ ____

5. Was the Income Calculation Form used accurately?

Clinic

Yes

No

______________ ______ ____

______________ ______ ____

______________ ______ ____

______________ ______ ____

______________ ______ ____

6. Were the right question asked for income?

Clinic

Yes

______________ ______

No ___

______________ ______ ___

______________ ______ ___

______________ ______ ___

______________ ______ ___

7. Required to show proof of income at certification/re-certification.

Clinic

Yes

No

______________ ______ ____

______________ ______ ____

______________ ______ ____

______________ ______ ____

______________ ______ ____

8. Required to show proof of residence at certification/recertification.

Clinic

Yes

No

______________ ______ ____

______________ ______ ____

______________ ______ ____

______________ ______ ____

______________ ______ ____

9. Was proof of ID asked for at
certification/re-certification and pickup (Form 11)?

Clinic

Yes

No

______________ ______ ___

______________ ______ ___

______________ ______ ___

______________ ______ ___

______________ ______ ___

35

GA WIC PROCEDURES MANUAL

FORM-6 (cont'd)

10. Were participants informed of their rights and obligations?

Clinic

Yes

No

______________ ______ ____

______________ ______ ____

______________ ______ ____

______________ ______ ____

______________ ______ ____

11. Was the No Proof form used appropriately (Form 10)?

Clinic

Yes No

______________ ______ ____

______________ ______ ____

______________ ______ ____

______________ ______ ____

______________ ______ ____

12. Was proper use of ID Card explained?

Clinic

Yes

______________ ______

No ___

______________ ______ ___

______________ ______ ___

______________ ______ ___

______________ ______ ___

36

GA WIC PROCEDURES MANUAL EQUIPMENT INVENTORY
Was the equipment inventory sent in by October 1 of the new fiscal year? Yes ______ No ______
Can all the equipment be located?

Clinic (Write in name)

Equipment Number

Located Yes_____ No_____ Yes_____ No_____ Yes_____ No_____ Yes_____ No_____ Yes_____ No_____ Yes_____ No_____ Yes_____ 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_____

FORM 7
Comment

37

GA WIC PROCEDURES

FORM 8-A

FORM I

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

FORM II

PATIENT FLOW ANALYSIS (PFA) SIGN IN

FORM 8-B 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

FORM 8-C

FORM III

PROCEDURES FOR COMPLETION

OPTION I

Clinic Flow Analysis Form (is completed by clinic staff)

The Clinic Flow Analysis form documents the following:

1.

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 # - Document the number that is assigned on the Patient Flow Analysis

Sign-In Form.

4.

Name - Document the name of the applicant/participant.

5.

Date Seen - Document 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.

WIC Type - P

N B I C

Place a check mark by the category which identifies whether the applicant/participant is a pregnant, post-partum or breastfeeding woman, infant, or child.

8.

Appointment Time - Document appointment time of the applicant/participant.

40

GA WIC PROCEDURES

FORM 8-C (cont'd)

9.

Time Started - Document 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 person's initials must be placed with the actual Patient Flow Analysis documentation for audit purposes.

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. Food Package Change (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

FORM 8-D

FORM IV Patient Flow Analysis (PFA) 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 of staff initials must be kept on file for audit purposes. Each applicant/participant must have her/his own PFA Form.

42

GA WIC PROCEDURES

FORM 8-E

FORM V

OPTION I

Questions to Answers for Option I

1.

What was the length of time that a client waited from sign-in to first clinic staff

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 morning appointments?

8.

How many appointments were there? Number of no-shows?

43

GA WIC PROCEDURES

FORM I

PATIENT FLOW ANALYSIS (PFA) SIGN IN

FORM 9-A OPTION II

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 of the Procedures Manual)

44

GA WIC PROCEDURES

FORM II

PERSONNEL IDENTIFICATION CODES

FORM 9-B OPTION II

CODES A B C D E F G H I J K L M N O P Q R S T U V W

NAME

OFFICIAL FUNCTION

45

GA WIC PROCEDURES

FORM III

REASON FOR VISIT CODES

FORM 9-C 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)

46

GA WIC PROCEDURES

FORM 9-D

FORM IV

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)

47

GA WIC PROCEDURES

FORM V
Patient Number: (from sign-in sheet)

PATIENT REGISTER ____________________________________

FORM 9-E 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
______

Start Time End Time

______

______

Service Provided *
_______________________

2.

______

______

______

_______________________

3.

______

______

______

_______________________

4.

______

______

______

_______________________

5.

______

______

______

_______________________

6.

______

______

______

_______________________

7.

______

______

______

_______________________

8.

______

______

______

_______________________

9.

______

______

______

_______________________

10.

______

______

______

_______________________

11.

______

______

______

_______________________

*Note: Service Provided If a phone call is received or anything out of the ordinary occurs while serving the participant, please make a note in this column.

48

GA WIC PROCEDURES

FORM 9-F

FORM VI

OPTION II

Questions to Answer from the Modified PFA

1. What was the length of time that a client waited from sign-in to first clinic staff 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 morning appointments?

8. How many appointments were there? Number of no-shows?

49

GA WIC PROCEDURES NO PROOF OBSERVATION FORM

FORM 10

1. Was the "No Proof Form" used as intended for the applicants/participants who are homeless, migrant farmworkers, applicants /participants who are paid in cash or in any situation where an applicant/participant was unlikely to provide written documentation of income?

Yes_______

No________

Comments:

2. If no, document the situation where this form was used: ____________________________________________________________________ ____________________________________________________________________

3. Was self-declaration allowed and the income documented on the Certification Form?

Yes_____

No ______

4. Was the reason for the use of the "No Proof Form" documented?

Yes_____

No _____

Comments: ______________________________________________________

5. In reviewing 20% of the records, how many times was the "No Proof Form" used?
# ____________ in Clinic __________________________________________ #____________ in Clinic __________________________________________ #_____________ in Clinic __________________________________________ #_____________ in Clinic __________________________________________ #_____________ in Clinic __________________________________________

50

GA WIC PROCEDURES

FORM 11

PROOF OF IDENTITY OBSERVATION FORM

The following proofs of identities are acceptable and can be used for a woman (participant, guardian or caretaker), infant, child and proxy. Use this form to document the identification proof shown at certification/subsequent certification and voucher issuance.
CLINIC NAME:
(Use one set of forms per clinic)

INFANT

Identification Proof
Birth Certificates/Confirmation of Birth Letter Hospital Identification Bracelet (Mom and Baby) Immunization Record (only if that record already exists in the clinic or in the record of a transferred person) Medical Record (only if that record already exists in the clinic or in the record of a transferred person) Social Security Card VOC Card (with additional ID) WIC ID (Voucher Pick Up Only)

Certification/ Subsequent Certification

CHILD

Identification Proof
Birth Certificate/Confirmation of Birth Letter Immunization Record (only if that record already exists in the clinic or in the record of a transferred person) Medical Record (only if that record already exists in the clinic or in the record of a transferred person) Social Security Card VOC Card (with additional ID)

Certification/ Subsequent Certification

51

GA WIC PROCEDURES

FORM 11 (cont'd)

WOMAN (participant)

Identification Proof
Birth Certificate Driver's License Military ID Medical Record (only if that record already exists in the clinic or the record of a transferred person) Social Security Card State ID/School Identification VOC Card (with additional ID) Voter Registration WIC ID (Voucher Pick Up Only) Work ID

Certification/ Subsequent Certification

Voucher Issuance

PROXY (parent/guardian/caretaker or proxy)

Identification Proof
Birth Certificate Driver's License Military ID Medical Record (only if that record already exists in the clinic or the record of a transferred person) Social Security Card State ID/School Identification Voter Registration Work ID

Subsequent Certification

Voucher Issuance

Note: Proxy must show identification in addition to the ID card.

52

GA WIC PROCEDURES

FORM 12

NOTICE OF TERMINATION/INELIGIBILITY/WAITING LIST FORM USERS' CHECKLIST

REMEMBER TO

YES NO

TERMINATION/INELIGIBILITY SECTION
Did you write in the date form is completed? Did you fill in the name, address, phone number and age of the client? Did you check "You are not eligible for the WIC Program because you"? Or did you check "You are being terminated from the WIC Program because you..."? Did you give the dates where necessary?
SUSPENSION SECTION
Did you write in the rules that the participant violated?
WAITING LIST SECTION
Did you give the priority(ies) you have funds to serve? Did you tell the participant what priority he/she is? Did you inform the participant that he/she may still continue to receive nutrition education and other services provided by the Health Department? Did you notify the participant that he/she may get additional information or discuss this decision by contacting the WIC Program?
FAIR HEARING SECTION
Did you give the complete name, address and phone number? (If you use a rubber stamp make certain all pages are stamped.) Did you have the parent/guardian/caretaker sign? Did you sign as the WIC representative and give your title?

53

GA WIC PROCEDURES

FORM 13

TEMPORARY THIRTY (30) DAY CERTIFICATION RECORD REVIEW (Use one of these forms for each clinic)

In each clinic randomly select five (5) records, from the Temporary Thirty (30) Day Certification file, to review the following criteria:

CLINIC

Participant's Name

Criteria required when applicant/participant is temporarily certified for thirty (30) days: Is the date recorded? Is the name, date of birth, address and telephone number completed? Is "You will be terminated from the WIC Program..." checked? Is the date (that information is due back to the clinic) recorded? Is the type of proof(s) client is to bring back to the clinic checked? Are the date and the WIC Representative's signature completed? Is the Fair Hearing Section completed? Is the participant or parent/guardian/caretaker's signature completed? Is the WIC Representative's signature/title completed? Is "OT" (other) placed in the missing proof(s) field and "pending" in the description box? If income was the missing proof, is self-declared income documented on the WIC assessment form? Did the participant or parent/guardian/caretaker sign the WIC assessment form? Did the WIC Representative sign and date the WIC assessment form? Was the participant issued more than thirty (30) days of vouchers?
Criteria required when the participant or parent/guardian/caretaker returns with the missing proof(s): If the participant or parent/guardian/caretaker returned with the missing proof(s), is a line drawn through the word "pending" and the actual document presented recorded? If income documentation was the missing proof, is the adjustment made on the WIC assessment form? Did the WIC Representative date and initial the above adjustment? Was the adjustment entered into the computer? If the participant is income ineligible, was "You are being terminated from the WIC Program..." checked? Are the date and the WIC Representative's signature completed?
Criteria required if the participant or parent/guardian/caretaker did not return with the missing proof(s): If the participant or parent/guardian/caretaker did not return with the missing proof(s), was the participant terminated? Was the temporary thirty (30) day certification extended and participant issued more vouchers?

Note: Make copies of this form for review of the Temporary Thirty (30) Day Certification file.

54

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

PART IV - FOOD INSTRUMENT ACCOUNTABILITY (LOCAL AGENCY ONLY)

Guidelines

Areas of Review

Yes No

I. Food Instrument Accountability (District Review)

NA Comments

NOTE: Recommendations are not requirements for completing self-reviews. * NA - stands for Not Applicable

Corrective Action

A. Packing List/Confirmation Notice

Is a copy of the voucher packing list/confirmation notice received by the District within five days of clinic verification?

Corrective Action

Looking for: 1. To make sure clinics are sending the packing slips to the
District Office.
B. Voucher Issuance

1. Does the Local Agency have a policy for issuing vouchers to eligible WIC employees and their family members?

Corrective Action

Looking for: 1. 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?

Corrective Action Corrective Action

Looking for: 1. 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: 1. 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?

Corrective Action

Looking for: 1. 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 program abuse by the participants since the last Program Review?

Looking for: 1. To review any reports of participant abuse and the
nature of the abuse.

55

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

PART IV - FOOD INSTRUMENT ACCOUNTABILITY (LOCAL AGENCY ONLY)

Guidelines

Areas of Review

Yes No NA Comments

NOTE: Recommendations are not requirements for completing self-reviews. * NA - stands for Not Applicable.

2. Was the report of abuse investigated?

Looking for: 1. Report was properly handled.

3. Was the report sent to the State WIC Branch?

Looking for: 1. Make sure the State WIC Branch was made aware of
report, and a copy of all findings in the investigation report was forwarded to the SWB.

Corrective Action

D. Dual Participation

1. Have there been any cases of intentional dual participation since the last monitoring review?

Looking for: 1. Any cases on the dual participation report that were
actually dual participants.

2. Was the report sent to the State WIC Branch?

Looking for: 1. To make sure report was investigated and findings sent
to State WIC Branch.

Corrective Action

E. Missing Vouchers/VPOD Receipts

1. Has the District Office received notice of any missing vouchers/VPOD receipts from any WIC clinic since the last Program Review?

Looking for: 1. To make sure the clinics report any missing vouchers to
the District office.

2. Was the report investigated?

Looking for: 1. To make sure the proper procedures are followed when
vouchers are missing.

3. Was the report sent to the State WIC Branch?

Looking for: 1. To make sure the District is notifying the State WIC
Branch of any missing vouchers.

56

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

PART IV - FOOD INSTRUMENT ACCOUNTABILITY (LOCAL AGENCY ONLY)

Guidelines

Areas of Review

Yes No

II. Food Instrument Accountability (Clinical Review)

NA Comments

NOTE: Recommendations are not requirements for completing self-reviews. * NA - stands for Not Applicable.

Corrective Action

A. Manual Voucher Inventory Log

1. 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: 1. All columns of the log must be completed accurately,
legibly, and initialed. 2. Clerk's initials on the Inventory Log.

Corrective Action

B. Perpetual Inventory
1. Is the perpetual inventory done on all VPOD vouchers?
Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________
Looking for: 1. Making sure that the inventory is kept on all vouchers
on a weekly basis.

57

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

PART IV - FOOD INSTRUMENT ACCOUNTABILITY (LOCAL AGENCY ONLY)

Guidelines

Areas of Review

Yes No NA Comments

NOTE: Recommendations are not requirements for completing self-reviews. * NA - stands for Not Applicable.

Corrective Action

2. Is the perpetual inventory complete and accurate?

Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________

Looking for: 1. Making sure all columns of the log are completed
accurately.

Corrective Action

C. Manual Voucher Physical Inventory

1. Are any vouchers missing?

Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________

Looking for: 1. A complete and actual physical inventory to ensure that
all vouchers are accounted for.

Corrective Action

2. Does physical inventory match the inventory log?

Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________

Corrective Action

Looking for: 1. Make sure that the actual physical inventory matches
the inventory log.
3. Is a physical inventory conducted monthly?
Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________
Looking for: 1. Documentation on the inventory log that a physical
count of all vouchers was completed each month.

58

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

PART IV - FOOD INSTRUMENT ACCOUNTABILITY (LOCAL AGENCY ONLY)

Guidelines

Areas of Review

Yes No NA Comments

NOTE: Recommendations are not requirements for completing self-reviews. * NA - stands for Not Applicable.

Corrective Action

D. Vouchers Printed On Demand (VPOD Vouchers)/Manual Voucher Copies

1. Are receipts/manual voucher copies filed in serial number order?

Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________

Looking for: 1. Make sure that all voucher receipts are stored neatly
and in serial number order.

Corrective Action

2. Are any receipts/ manual voucher copies missing or misfiled?

Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________

Looking for: 1. Are all vouchers are accounted for and kept in order?

Corrective Action

3. Are daily activity reports maintained correctly?

Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________

Looking for: 1. Are daily activity reports run daily and kept either in a
folder or with the receipts?

Corrective Action

4. Have any vouchers been altered with write overs or scratch outs?

Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________

Looking for: 1. Vouchers may not be corrected or altered in any way
unless prior authorization is received from the SWB.

59

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

PART IV - FOOD INSTRUMENT ACCOUNTABILITY (LOCAL AGENCY ONLY)

Guidelines

Areas of Review

Yes No NA

NOTE: Recommendations are not requirements for completing self-reviews. * NA - stands for Not Applicable.

Comments

Corrective Action

5. Are any participant's signatures missing on the receipts/manual voucher copies?

Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________

Corrective Action

Looking for: 1. Make sure participants are signing the receipts.
E. Reconciled Packing List/Confirmation Notice

1. Is the Packing List/Confirmation Notice verified, signed, and dated?

Corrective Action

Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Looking for: 1. The packing list and confirmation notice must be signed and dated to verify receipt.
2. Are vouchers accurately recorded on the VPOD Log Sheet or the Manual Inventory Log?

Corrective Action

Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Looking for: 1. When manual vouchers or voucher numbers are received, the serial numbers must be recorded accurately on the Manual Voucher Inventory Log.
3. Are copies of packing list/confirmation notice 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.

60

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

PART IV - FOOD INSTRUMENT ACCOUNTABILITY (LOCAL AGENCY ONLY)

Guidelines

Areas of Review

Yes No NA Comments

NOTE: Recommendations are not requirements for completing self-reviews. * NA - stands for Not Applicable.

Corrective Action

F. Voucher Registers

1. Are all lines completed on the voucher register?

Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________

Looking for: 1. Making sure all lines on the vouchers register are
completed.

Corrective Action

2. Are any participant's signatures missing on the voucher register?

Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________

Corrective Action

Looking for 1. The participant or proxy's signature.
3. Does the voucher register contain the entry "fail to sign" more than one percent for the entire month?

Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________

Looking for: 1. If more than one percent "fail to sign" on the voucher
register, a corrective action will be issued.

Corrective Action

4. Are any clerk initials or dates missing?

Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________

Looking for: 1. Any missing clerk initials and/or dates.

61

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

PART IV - FOOD INSTRUMENT ACCOUNTABILITY (LOCAL AGENCY ONLY)

Guidelines

Areas of Review

Yes No NA Comments

NOTE: Recommendations are not requirements for completing self-reviews. * NA - stands for Not Applicable.

Corrective Action

5. Does voucher register contain required closeout signatures and dates?

Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________

Corrective Action

Looking for: 1. Signature/date for employee that closed the register and
signature/date for employee that verified the closed register.
G. Voucher Security

1. During office hours, are vouchers securely stored or in the possession of authorized staff?

Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________

Looking for: 1. All vouchers must be properly secured as checks or cash
in order to help prevent voucher theft, and deter program fraud.

Corrective Action

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.

62

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

PART IV - FOOD INSTRUMENT ACCOUNTABILITY (LOCAL AGENCY ONLY)

Guidelines

Areas of Review

Yes No NA Comments

NOTE: Recommendations are not requirements for completing self-reviews. * NA - stands for Not Applicable.

Corrective Action

3. Are vouchers securely stored separately from ID cards and voucher registers?

Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________

Looking for: 1. WIC program stamps must be stored in a location
separately from WIC vouchers, ID cards, and VOC cards.

Corrective Action

4. Are WIC ID cards stored separately from the Program Stamp?

Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________

Looking for: 1. WIC ID cards must be stored in a separate location from
the vouchers, registers, and the program stamp?

Corrective Actions

5. 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: 1. Are measures in place when a staff person is no longer
authorized to issue vouchers?

Corrective Action

6. Is the key properly secured only with authorized personnel?

Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________

63

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

PART IV - FOOD INSTRUMENT ACCOUNTABILITY (LOCAL AGENCY ONLY)

Guidelines

Areas of Review

Yes No

Looking for: 1. Make sure the key to the locked storage space is secure
and in the possession of authorized personnel.

NA Comments

NOTE: Recommendations are not requirements for completing self-reviews. * NA - stands for Not Applicable.

Corrective Action

7. What security measures are currently in place to prevent voucher theft by participants?

Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________

Looking for: 1. 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 is being used.

Corrective Action

H. Prorating (Voucher Issuance)

1. Is staff knowledgeable of the proper procedures for prorating/ is prorating consistently performed?

Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Looking for: 1. Are the proper procedures for prorating being followed?

Corrective Action

2. Are vouchers transported from one site to another?

Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Looking for: 1. If the clinics are transporting vouchers to any other clinic sites.

Corrective Action

3. When vouchers are transported, are they in a locked container (lock box, briefcase)?

Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________

Looking for: 1. Vouchers must be transported in locked briefcase or
lockbox.

64

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

PART IV - FOOD INSTRUMENT ACCOUNTABILITY (LOCAL AGENCY ONLY)

Guidelines

Areas of Review

Yes No NA Comments

NOTE: Recommendations are not requirements for completing self-reviews. * NA - stands for Not Applicable.

Corrective Action

I. Local Agency Policies

1. Does the local agency have a policy for issuing vouchers to employees/family members?

Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Looking for: 1. Check medical records of WIC employee=s relatives to make sure employees are not certifying or issuing vouchers to family members.

Corrective Action

2. Do any employees of this clinic receive WIC benefits?

Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________

Looking for: 1. To be aware of any employee participating in the WIC
program.

Corrective Action

3. Are family members of staff receiving WIC benefits at these locations?

Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Looking for: 1. To be aware of any family members of staff receiving WIC at the clinic.

Corrective Action

4. Is clinic staff allowed to issue vouchers or to certify family members?

Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________

Looking for: 1. Check medical records of family members of staff to
determine if the staff certified their family members.

65

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

PART IV - FOOD INSTRUMENT ACCOUNTABILITY (LOCAL AGENCY ONLY)

Guidelines

Areas of Review

Yes No NA Comments

NOTE: Recommendations are not requirements for completing self-reviews. * NA - stands for Not Applicable.

Corrective Action

5. Is the District aware of all staff/family members enrolled on the WIC Program?

Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________

Corrective Action

Looking for: 1. If the District is aware of any staff or family
members participating on the program.
J. Participant Abuse

1. Has the clinic had any problems with participant abuse since the last program review?

Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________

Looking for: 1. If the clinic has problems with participants (verbal
abuse, misconduct, dual participation, etc).

Corrective Action

2. Was the coordinator notified?

Clinic_____________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________

Corrective Action

Looking for: 1. If participant abuse identified, was coordinator
informed about abuse?
3. To your knowledge, was there an investigation?

Clinic_____________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________

Looking for: 1. The outcome of the situation.

66

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

PART IV - FOOD INSTRUMENT ACCOUNTABILITY (LOCAL AGENCY ONLY)

Guidelines Recommendation

Areas of Review K. Dual Participation

Yes No NA Comments

1. Has the clinic followed up on each dual participation case received at the clinic?

Clinic_____________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________

Corrective Action

Looking for: 1. Make sure the clinics are completing the dual
participation reports and handling any cases of dual participation.
L. Missing Vouchers

1. Have any vouchers been reported missing during the last twelve months?

Clinic_____________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________

Looking for: 1. Make sure all vouchers were accounted for, and
record if the clinic was aware of any missing vouchers.

67

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

PART IV - FOOD INSTRUMENT ACCOUNTABILITY (LOCAL AGENCY ONLY)

Guidelines

Areas of Review

Yes No NA Comments

NOTE: Recommendations are not requirements for completing self-reviews. * NA - stands for Not Applicable.

Corrective Action

2. Was a Lost, Stolen, Destroyed Voucher Report sent to the State WIC Branch?

Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________

Looking for: 1. Make sure the proper procedures and forms were
completed when vouchers were reported missing.

Corrective Action

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.

68

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

PART V CERTIFICATION, NUTRITION EDUCATION, AND BREASTFEEDING

GUIDELINES

AREAS OF REVIEW

YES NO NA

COMMENTS

NOTE: Recommendations are not requirements for completing self-reviews. * NA - stands for Not Applicable.

Corrective Action

I. FOOD PACKAGE ASSIGNMENT
A. List title(s) of competent professional authorities (CPA's) who assign food packages for participants:
Looking for:
1. Compliance with Federal requirements and State policy that only CPA's can assign/tailor food packages.

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:

1. 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:

1. 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:
1. 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 FFY 2002 food packages comply with federal regulations.

69

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

PART V CERTIFICATION, NUTRITION EDUCATION, AND BREASTFEEDING

GUIDELINES

AREAS OF REVIEW

YES NO NA

COMMENTS

NOTE: Recommendations are not requirements for completing self-reviews. * NA - stands for Not Applicable.

Corrective Action

II. NUTRITION EDUCATION
A. Training
1. 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:
1. 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:
1. Adequacy of continuing education of all staff providing WIC services.

Recommendation

3. How do you assess the effectiveness of the training over time?
Looking for:
1. Monitor adequacy of continuing education for all staff providing WIC services.

Corrective Action

B. Nutrition Assistants (NAs) 1. Are NAs used to certify participants?
Looking for: 1. Ensure that NAs are not certifying participants.

Corrective Action

2. Are NAs used to provide secondary nutrition education contacts?

Looking for:
1. Ensure that NAs are not being used without State approval.

70

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

PART V CERTIFICATION, NUTRITION EDUCATION, AND BREASTFEEDING

GUIDELINES

AREAS OF REVIEW

YES NO NA

COMMENTS

NOTE: Recommendations are not requirements for completing self-reviews. * NA - stands for Not Applicable.

Corrective Action

3. Has the training plan for NAs been approved by the Nutrition Section?
If yes, the date: __________
Looking for:
1. Whether or not a training plan approved by the Nutrition Section has been implemented.

Corrective Action

4. Have all lesson plans for training NAs been submitted to the Nutrition Section for approval?
If no, please provide reviewer with lesson plans at the time of review.

Looking for:
1. Ensure that the Nutrition Section has all lesson plans on file, and all plans have been approved.

Corrective Action

5. Has the district submitted to the Nutrition Section, a list of NA staff who provides secondary nutrition education contacts?
If yes, date provided: ______
If no, please provide the reviewer a list at the time of review.

Looking for:
1. A current list of approved NA staff on file in the Nutrition Section.

Corrective Action

C. Nutrition Education Plan

1. Was a three-year Nutrition Education Plan received by the Nutrition Section by September 1?

If yes, date:

__________

If no, date received: __________

Not received:

__________

Looking for:
1. Compliance with Federal requirements that a local plan be developed that is consistent with the State plan.

71

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

PART V CERTIFICATION, NUTRITION EDUCATION, AND BREASTFEEDING

GUIDELINES

AREAS OF REVIEW

YES NO NA

COMMENTS

NOTE: Recommendations are not requirements for completing self-reviews. * NA - stands for Not Applicable.

Corrective Action

2. Was an annual progress report received by the Nutrition Section by November 30?
If yes, date: _____ If no, date received: _______ Not received: ______
Looking for:
1. Compliance with the Federal requirement for development of an annual local agency plan.

Recommendation

3. Give reviewer status of each Nutrition Education Plan objective:
Looking for:
1. Whether or not the Plan is implemented at the local level.

Corrective Action

D. Participant Nutrition Education Contacts
1. What lesson plans for nutrition education have been developed since the last review? Please provide the reviewer with a copy at the time of review.
Looking for:
1. 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.
Looking for:
1. 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:
1. Compliance with Federal requirements and State policy.

72

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

PART V CERTIFICATION, NUTRITION EDUCATION, AND BREASTFEEDING

GUIDELINES

AREAS OF REVIEW

YES NO NA

COMMENTS

NOTE: Recommendations are not requirements for completing self-reviews. * NA - stands for Not Applicable.

Recommendation

4. Since the last program review, has the system for providing and/or documenting nutrition education contacts changed?
If yes, explain how:

Looking for:
1. Adequacy of system in place and improvements resulting from any changes that have been made.

Corrective Action

5. Are missed nutrition education appointments documented?
If yes, describe the method used:
Looking for: 1. Compliance with Federal requirements and State policy. 2. Identify and correct potential problems with the system in
place.

Recommendation

6. How are the Nutrition Guidelines for Practice being used?
Looking for:
1. Whether or not the Guidelines have been implemented at the clinic level.

Corrective Action

7. Do you have a system in place to assure the provision of high risk nutrition education contacts?
Describe the method:
Looking for:
1. 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
1. Who approves nutrition education materials and forms not provided by the State?
Looking for:
1. Compliance with Federal requirements for education materials appropriate for participant use.

73

GUIDELINES

AREAS OF REVIEW

YES NO NA

NOTE: Recommendations are not requirements for completing self-reviews. * NA - stands for Not Applicable.

Recommendation

2. What method(s) is (are) used to evaluate nutrition education materials?
Looking for:
1. Whether or not materials are evaluated on a regular basis using consistent methods.

COMMENTS

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 Nutrition Section.
List provided?
Looking for:
1. 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?
Looking for:
1. Compliance with Federal requirements for education materials appropriate for participant use.

Corrective Action

5. Are inappropriate nutrition education materials available for participant use?
Looking for:
1. 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 WIC coordinator and the local agency breastfeeding coordinator.
A. Breastfeeding Coordinator
1. What are the names and credentials/qualifications of the breastfeeding coordinator?
Looking for:
1. Compliance with Federal requirements.

74

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

PART V CERTIFICATION, NUTRITION EDUCATION, AND BREASTFEEDING

GUIDELINES

AREAS OF REVIEW

YES NO NA

COMMENTS

NOTE: Recommendations are not requirements for completing self-reviews. * NA - stands for Not Applicable.

Recommendation

2. How many hours per week/month does the Breastfeeding Coordinator spend on breastfeeding promotion and support activities?
Looking for:
1. Adequate time provided to the breastfeeding coordinator to comply with Federal requirements.

Recommendation

3. Is the breastfeeding coordinator position permanent or a contract?
Looking for:
1. Services provided by Breastfeeding Coordinator: cost factors, duties performed based on how hired.

Corrective Action

4. Does the breastfeeding coordinator conduct activities agency-wide or primarily in one location?
Looking for:
1. Ability of Breastfeeding Coordinator to meet Federal requirements throughout the local agency.

Recommendation

5. Describe the major responsibilities and activities of the Breastfeeding Coordinator.
Looking for:
1. Ability of the Breastfeeding Coordinator to conduct activities designed to comply with Federal requirements and State policy.

Recommendation

6. How are Breastfeeding Coordinator activities documented (i.e., counseling, classes)?
_____Central File _____Participant health record _____Other (please specify)
Looking for:
1. Complete documentation of all breastfeeding services provided.
2. Identification, for follow-up and monitoring purposes, of location of documentation.

75

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

PART V CERTIFICATION, NUTRITION EDUCATION, AND BREASTFEEDING

GUIDELINES

AREAS OF REVIEW

YES NO NA COMMENTS

NOTE: Recommendations are not requirements for completing self-reviews. * NA - stands for Not Applicable.

Recommendation

7. For individual counseling done, describe the process for documentation including the time lag between counseling and documentation.
Looking for:
1. Complete documentation of all breastfeeding services provided.
2. Location of documentation for follow-up and monitoring purposes.

Corrective Action

B. Encouragement to Breastfeed
1. How is breastfeeding encouraged during the prenatal period? _____Individual Contact _____Prenatal/Breastfeeding Class _____Other (Please specify):
Looking for:
1. Compliance with Federal requirements for prenatal education.

Recommendation

2. Describe the process for individual contacts that are provided (when, by whom, documentation).
Looking for:
1. 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

3. Describe the process for the provision of prenatal classes to include breastfeeding (when, by whom, documentation).
Looking for:
1. 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.

76

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

PART V CERTIFICATION, NUTRITION EDUCATION, AND BREASTFEEDING

GUIDELINES

AREAS OF REVIEW

YES NO NA COMMENTS

NOTE: Recommendations are not requirements for completing self-reviews. * NA - stands for Not Applicable.

Recommendation

C. Training
1. 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: 1. Compliance with Federal requirements for training of
new staff. 2. Adequacy of continuing education for all staff providing
WIC services.

Corrective Action

2. Describe how you assure that clinic staff are knowledgeable about current breastfeeding issues.
Looking for
1. Compliance with Federal requirement for training of new staff.
2. Adequacy of continuing education for all staff providing WIC services.

Corrective Action

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:
1. Compliance with the Federal requirements for assuring adequate breastfeeding support for participants.

77

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

PART V CERTIFICATION, NUTRITION EDUCATION, AND BREASTFEEDING

GUIDELINES

AREAS OF REVIEW

YES NO NA COMMENTS

NOTE: Recommendations are not requirements for completing self-reviews. * NA - stands for Not Applicable.

Corrective Action

4. Describe what the local agency is doing to create a clinic atmosphere that is supportive of breastfeeding.
Looking for:
1. Compliance with Federal requirements regarding a clinic atmosphere that promotes and supports breastfeeding.

Recommendation

5. Other
Please describe any breastfeeding activities not addressed above (e.g., peer counseling, special projects, media exposure, etc.).
Looking for:
1. Activities that go beyond the Federal requirements, but serve to promote, educate, and support breastfeeding.

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.

For Office of Nutrition Use

C. What requests does the District/Local Agency have of the Nutrition Section staff to assist in implementing Nutrition Education and Breastfeeding Plans and providing nutrition services?

78

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

PART V CERTIFICATION, NUTRITION EDUCATION, AND BREASTFEEDING

V. CLINIC OBSERVATION: INDIVIDUAL NUTRITION EDUCATION SESSION
DATE: ___________________CLINIC:____________________________ REVIEWER:_____________________________ Participant status: P B N I C Participant priority: I II III IV V VI Participant risk factors:____________________________ Time estimated for total contact: _______________________ Time estimated for NE contact: ________________________

GUIDELINES AREAS OF REVIEW

YES NO NA COMMENTS

NOTE: Recommendations are not requirements for completing self-reviews. * NA - stands for Not Applicable.

Corrective Action

A. Nutrition Education (NE)
1. Is diet evaluated according to Georgia WIC standards (intake, summary, food practices, evaluation)?
Looking for:
1. Compliance with Federal requirements and State policy.

Corrective Action Corrective Action Corrective Action

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: 1. Compliance with Federal requirements and State policy.
4. Does NE relate to diet recall/assessment? Looking for: 1. Compliance with Federal requirements and State policy.

79

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

PART V CERTIFICATION, NUTRITION EDUCATION, AND BREASTFEEDING

GUIDELINES

AREAS OF REVIEW

YES NO NA COMMENTS

NOTE: Recommendations are not requirements for completing self-reviews. * NA - stands for Not Applicable.

Corrective Action

5. Does NE include WIC foods and their relationship to participant risk?
Looking for:
1. Compliance with Federal requirements and State policy.

Corrective Action

6. Does NE include total food intake and its relationship to participant risk?
Looking for:
1. Compliance with Federal requirements and State policy.

Corrective Action

7. Does NE follow Nutrition Guidelines for Practice? Looking for: 1. Compliance with Federal requirements and State policy.

Recommendation

B. Communication
1. Does counselor invite questions?
Looking for: 1. Appropriate counseling skills. 2. Need for additional training.

Recommendation

2. Does the participant ask questions?

Looking for:
1. Appropriate counseling skills. 2. Need for additional training.

Recommendation

3. Is session conducted in a language the participant speaks/understands?
Looking for:
1. Compliance with Federal requirements and State policy.

80

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

PART V CERTIFICATION, NUTRITION EDUCATION, AND BREASTFEEDING

GUIDELINES

AREAS OF REVIEW

YES NO NA COMMENTS

NOTE: Recommendations are not requirements for completing self-reviews. * NA - stands for Not Applicable.

Recommendation

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.

Corrective Action

2. Do materials relate to risk factor? Looking for: 1. Compliance with Federal requirements and State policy.

Corrective Action

3. Do materials relate to counseling session? Looking for: 1. Compliance with Federal requirements and State policy.

Recommendation

D. Space
1. Is space private?
Looking for: 1. Appropriate counseling skills. 2. Need for additional training. 3. Clinic limitations.

Recommendation

2. Is there seating for the counselor?
Looking for: 1. Appropriate counseling skills. 2. Need for additional training. 3. Clinic limitations.

Recommendation

3. Is there seating for the participant and others in the session?
Looking for: 1. Appropriate counseling skills. 2. Need for additional training. 3. Clinic limitations.

81

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

PART V CERTIFICATION, NUTRITION EDUCATION, AND BREASTFEEDING

GUIDELINES

AREAS OF REVIEW

YES NO NA COMMENTS

NOTE: Recommendations are not requirements for completing self-reviews. * NA - stands for Not Applicable.

Recommendation

4. Is space quiet enough to talk normally?
Looking for: 1. Appropriate counseling skills. 2. Need for additional training. 3. Clinic limitations.

Recommendation

5. Is the view of the participant/counselor obstructed by materials on the desk or by the seating arrangement?
Looking for: 1. Appropriate counseling skills. 2. Needs for additional training. 3. Clinic limitations.

82

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

PART V CERTIFICATION, NUTRITION EDUCATION, AND BREASTFEEDING

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

YES NO NA COMMENTS

NOTE: Recommendations are not requirements for completing self-reviews. * NA - stands for Not Applicable.

Recommendation

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.

Corrective Action

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

2. Does NE include total food intake and its relationship to nutritional status?
Looking for: 1. Appropriate counseling skills. 2. Need for additional training.

83

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

PART V CERTIFICATION, NUTRITION EDUCATION, AND BREASTFEEDING

GUIDELINES

AREAS OF REVIEW

YES NO NA COMMENTS

NOTE: Recommendations are not requirements for completing self-reviews. * NA - stands for Not Applicable.

Corrective Action

3. Does NE follow Nutrition Guidelines for Practices?

Looking for: 1. Compliance with State policy.

Recommendation C. Communication

1. Does instructor invite questions?

Looking for:
1. Appropriate counseling skills. 2. Need for additional training of staff.

Recommendation

2. Do participants ask questions?
Looking for: 1. Appropriate counseling skills. 2. Need for additional training of staff.

Recommendation

3. Does instructor respond to questions? Looking for:
1. Appropriate counseling skills. 2. Need for additional training of staff.

Recommendation

D. Materials/Media
1. Is the session conducted in a language(s) participants speak/understand?
Looking for: 1. Compliance with Federal requirements and State policy.

Recommendation

2. Are materials/media in the participant(s) primary language?
Looking for:
1. Compliance with Federal requirements and State policy.

84

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

PART V CERTIFICATION, NUTRITION EDUCATION, AND BREASTFEEDING

GUIDELINES

AREAS OF REVIEW

YES NO NA COMMNTS

NOTE: Recommendations are not requirements for completing self-reviews. * NA - stands for Not Applicable.

Recommendation

3. Media used:
Film/Filmstrip________ Slide/Tape Show________ Video Tape________ Poster/Flip Chart________ Food Models ________ Pamphlets________ Other________ Specify:________________________
Looking for:
1. Appropriate counseling skills. 2. Need for additional training of staff.

Recommendation

4. Are print materials related to information covered during session?
Looking for: 1. Appropriate counseling skills. 2. Need for additional training of staff.

Corrective Action E. Staff

Session conducted by:
Nurse_________ Nutritionist_________ Paraprofessional_________ Other_________ Specify: ____________________________
Looking for:

Compliance with Federal requirements and State policy.

Recommendation

F. Evaluation of Knowledge and Satisfaction 1. Is there any evaluation of the participant's nutritional knowledge base?
Looking for: 1. Appropriate counseling skills. 2. Need for additional training of staff.

85

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

PART V CERTIFICATION, NUTRITION EDUCATION, AND BREASTFEEDING

GUIDELINES

AREAS OF REVIEW

YES NO NA

COMMENTS

NOTE: Recommendations are not requirements for completing self-reviews. * NA - stands for Not Applicable.

Recommendation

2. Is there any evaluation of the knowledge gained in the session?
Looking for: 1. Appropriate counseling skills. 2. Need for additional training of staff.

Recommendation

3. Is there any evaluation of the participants' attitudes about nutrition and diet?
Looking for: 1. Appropriate counseling skills. 2. Need for additional training of staff.

Recommendation

4. Is participant satisfaction evaluated?
If yes, how?
Looking for: 1. Appropriate counseling skills. 2. Need for additional training of staff.

Recommendation

G. Space
1. How is the room arranged?
Looking for: 1. Appropriate counseling skills. 2. Need for additional training of staff. 3. Clinic limitations.

Recommendation

2. Where is the session conducted?
Waiting room_______ Private room_______ Other_______ Specify: ______________________
Looking for:
1. Appropriate counseling skills. 2. Need for additional training of staff. 3. Clinic limitations.

86

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

PART V CERTIFICATION, NUTRITION EDUCATION, AND BREASTFEEDING

GUIDELINES

AREAS OF REVIEW

YES NO NA

COMMENTS

NOTE: Recommendations are not requirements for completing self-reviews. * NA - stands for Not Applicable.

Recommendation

3. Is there seating for the participants?
Looking for: 1. Appropriate counseling skills. 2. Need for additional training of staff. 3. Clinic limitations.

Recommendation

4. Can participants see the instructor?
Looking for: 1. Appropriate counseling skills. 2. Need for additional training of staff. 3. Clinic limitations.

Recommendation

5. Can participants hear the instructor?
Looking for: 1. Appropriate counseling skills. 2. Need for additional training of staff. 3. Clinic limitations.

Recommendation

6. Can the participants see video, film, or other visual aids?
Looking for: 1. Appropriate counseling skills. 2. Need for additional training of staff. 3. Clinic limitations.

Recommendation

7. Can the participants hear any audio aids?
Looking for: 1. Appropriate counseling skills. 2. Need for additional training of staff. 3. Clinic limitations.

H. Additional Comments

87

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

PART V CERTIFICATION, NUTRITION EDUCATION, AND BREASTFEEDING

VII. CLINIC OBSERVATION: QUESTIONS FOR CLINIC STAFF

(Must be completed in at least one (1) clinic).

Date:___________________Clinic:_________________________Reviewer:______________________________________ Staff person interviewed: Nurse ______
Nutritionist_______ Paraprofessional_______

GUIDELINES

AREAS OF REVIEW

YES NO NA COMMENTS

NOTE: Recommendations are not requirements for completing self-reviews. * NA - stands for Not Applicable.
Recommendation A. How do you use the Nutrition Guidelines for Practice? Give some examples.
Looking for: 1. Staff knowledge. 2. Need for additional training.

Recommendation

B. How do you encourage breastfeeding?
Looking for: 1. Staff knowledge. 2. Need for additional training.

Recommendation

C. Who assigns food packages in the clinic?
Looking for: 1. Staff knowledge. 2. Need for additional training.

Recommendation

D. How do you decide which food package to assign to a participant?
Looking for: 1. Staff knowledge. 2. Need for additional training.

88

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

VIII. RECORD REVIEW (Acceptable level of compliance: 90% Records Satisfactory)

ANTHROPOMETRIC EQUIPMENT

Date_____________Clinic___________Reviewer____________________________________

OBSERVATIONS
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

S-Satisfactory U-unsatisfactory
#1 #2 #3

COMMENTS

89

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1(cont'd)

VIII. RECORD REVIEW (Acceptable level of compliance: 90% Records Satisfactory)

HEMATOLOGIC EQUIPMENT/CLINIC OBSERVATION

Date_____________Clinic___________Reviewer____________________________________

A. Type of equipment used (brand/model) for hemoglobin or hematocrit

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?

90

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1(cont'd)

VIII. 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 1/8 inch 6. Two (2) measurements taken Woman/Child (Standing Weight) 1. Participant dressed in minimal clothing 2. Scale zeroed prior to measurement 3. Correct angle used for reading measurement

Yes

No

Yes

No

Yes

No

Yes

No

4. Weight measured to nearest 1/4 pound

5. Two (2) measurements taken

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

1. 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 1/2 ounce

5. Two (2) measurements taken

91

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1(cont'd)

VIII. RECORD REVIEW (Acceptable level of compliance: 90% Records Satisfactory)

RECORD REVIEW

T

District _______________

O

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

92

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1(cont'd)

VIII. 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 10-14; 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.4.]
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 date.
The data must be reflective of the applicant's status at the time of the application.
3. Length/Height Recorded [Certification Section, XIII.5.]
Length or Height must be entered to the nearest 1/8 of an inch.
4. Weight Recorded [Certification Section, XIII.6.]
Weight must be entered in pounds and ounces.
5. Hematocrit/Hemoglobin Recorded [Certification Section, XIII. 7.]
Hematocrit/hemoglobin must be entered to one decimal place.
The date of the 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.

93

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1(cont'd)

VIII. RECORD REVIEW (Acceptable level of compliance: 90% Records Satisfactory)

6. Age Recorded [Certification Section, Attachment CT-28]
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, 9, 28] 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 each 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.8., Attachments CT-7, 8, 9, 32, 33]

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.

94

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1(cont'd)

VIII. 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.
95

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1(cont'd)

VIII. 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.

96

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1(cont'd)

VIII. 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 objective(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' individual 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, 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 expected date of confinement (EDC) has been reached or a delivery date has been recorded.

97

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1(cont'd)

VIII. 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 must follow the Nutrition Guidelines for Practice.

25. Breastfeeding Encouraged [Nutrition Education Section VI.A., B.; Breastfeeding Section, V.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 her answering no to 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, XIII.10.; Nutrition Education Section, 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.

98

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1(cont'd)

VIII. 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-certification must be the same or more than the weeks breastfed at certification). d. Children: one year of age certification (11-16 months of age).

99

GA WIC PROCEDURES MANUAL TABLE OF CONTENTS Page
I. Introduction .................................................................................................................. BF-1 II. Definitions .................................................................................................................... BF-1 III. State Agency ................................................................................................................. BF-2
A. Breastfeeding Coordinator ................................................................................ BF-2 B. Breastfeeding Promotion, Education and Support Responsibilities ................. BF-2 IV. Local Agency ............................................................................................................... BF-4 A. Breastfeeding Coordinator ................................................................................ BF-4 B. Breastfeeding Promotion, Education and Support Responsibilities ................. BF-4 C. Training ............................................................................................................ BF-5 D. Breastfeeding Promotion, Education and Support Plan ................................... BF-6 V. Participant Education ................................................................................................... BF-7 A. Participant Education Requirements ................................................................ BF-7 B. Documentation of Breastfeeding Services ....................................................... BF-9 VI. Participant Referral ......................................................................................................BF-10 A. Referrals ...........................................................................................................BF-10 B. Documentation .................................................................................................BF-10 VII. Breastfeeding Materials and Resources .......................................................................BF-11 A. Printed and Audio-Visual Materials ...............................................................BF-11 B. Breastfeeding Equipment and Supplies ...........................................................BF-11

GA WIC PROCEDURES MANUAL

Page

VIII. Allowable Costs for the Promotion and Support of Breastfeeding ............................ BF-13

A. Minimum Expenditure Requirement .............................................................. BF-13

B. Allowable Breastfeeding Promotion and Support Costs ................................ BF-13

C. Documentation of Costs.................................................................................. BF-14

IX. Documentation of Breastfeeding Rates ...................................................................... BF-15

A. Documentation of WIC Type.......................................................................... BF-15

B. Documentation of Weeks Breastfed ............................................................... BF-16

Attachments

BF-1 Position Paper on Breastfeeding ................................................................................. BF-17

BF-2 Sample Job Description: Senior Public Health Educator - Lactation Consultant............................................... BF-18

BF-3 Georgia Gain Proposed Job Description: Breastfeeding Coordinator ........................ BF-20

BF-4 Guidelines for Breastfeeding Promotion and Support in the WIC Program .................................................................................................... BF-22

BF-5 Breastfeeding Resources Recommended by the Nutrition Section ............................ BF-34

BF-6 Allowable and Unallowable Costs for the Promotion and Support of Breastfeeding ............................................................................................ BF-37

BF-7 Issues to Consider When Providing Breast Pumps..................................................... BF-38

BF-8 Status Change from Prenatal to Breastfeeding and Assignment of Priority to Breastfeeding Mother and Infant............................................................... BF-41

BF-9 Key for Entering Weeks Breastfed ............................................................................. BF-44

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 WIC Program participants.
Health professionals recognize that, in almost all circumstances, breastfeeding is the optimal method for ensuring proper infant nutrition, while simultaneously benefiting the lactating mother. The advantages of breastfeeding range from biochemical, immunological, and endocrinologic to psychosocial, developmental, sanitary, and economic. Human milk contains the ideal balance of nutrients, enzymes, immunoglobulins, anti-infective agents, anti-allergic substances, hormones, and growth factors. Further, breastmilk changes to match the changing needs of the infant. Breastfeeding provides a time of intense maternalinfant 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.
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 least 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.
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
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, Nutrition Section.
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
BF-2

GA WIC PROCEDURES MANUAL
other than English, considering the size and concentration of such population and, where possible, the reading level of the participants.
7. Coordinate WIC breastfeeding promotion, education 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-3

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 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 Self Study Series which has been provided to each local agency by the Nutrition Section.
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
BF-4

GA WIC PROCEDURES MANUAL
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.
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, staff should support her decision, and provide appropriate information.
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 staff who are breastfeeding.
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 Nutrition Section. These workshops provide WIC
BF-5

GA WIC PROCEDURES MANUAL
competent professional authorities (CPAs) with current information on nutrition issues, and include the topic of breastfeeding 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.
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 2003-2005 is due in the Nutrition Section by September 1, 2002. 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) The local agency GOAL for breastfeeding promotion, education and support;
2) OBJECTIVES to reach the stated goal; 3) STRATEGIES under each objective; 4) ACTION STEPS for each strategy; 5) PERSON RESPONSIBLE for each action step; 6) TIME FRAME for each action step; 7) RESOURCES NEEDED to accomplish each action step; 8) STATUS of each action step (this should be completed as
each action step is accomplished).
BF-6

GA WIC PROCEDURES MANUAL
b. The local agency Plan must address, at a minimum, the Federal requirements:
establishing and maintaining a local agency breastfeeding coordinator position;
prenatal encouragement to breastfeed; establishing a positive clinic atmosphere; incorporating breastfeeding training into staff orientation; ensuring that women have access to breastfeeding promotion and
support during the prenatal and postpartum periods.
c. The recommended format for submission of the Breastfeeding Plan can be found on Attachment NE-1.
2. Breastfeeding Plan Update
a. The Breastfeeding Plan Update is a progress report and must be submitted to the Nutrition Section by November 30th of each year. The Update must include the following:
STATUS of each action step accomplished in the previous Federal Fiscal Year;
Revision, deletion, and/or addition of any portions of the Plan.
b. The format for submission of the Update can be found on Attachment NE-1.
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 participants must be encouraged to breastfeed unless contraindicated for health reasons. As recommended in the Nutrition Guidelines for Practice, encouragement to breastfeed should continue throughout the prenatal period.
As stated in the Healthy People 2000 National Health Promotion and Disease Prevention objectives for breastfeeding, breastfeeding is not appropriate for infants whose mothers use drugs illicitly, or who receive certain therapeutic
BF-7

GA WIC PROCEDURES MANUAL
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 CPA's, breastfeeding counselors and nutrition assistants 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.
5. Breastfeeding women must be taught signs of adequate intake by the breastfed infant. Signs of adequate intake are:
a. baby is nursing 8-12 times per 24 hours b. baby wets diaper at least 6 times per 24 hours c. baby has several stools per 24 hours, in first month d. baby has visible and audible signs of swallowing e. mother's breasts feel softer after feeding f. baby has adequate weight gain over time (for infants who are presented
for weight checks).
It is recommended that adequate intake be assessed during the diet assessment, and documented on the diet assessment form. See Certification Section, Dietary Assessment attachment.
2 Healthy People 2000: National Health Promotion and Disease Prevention Objectives, U.S. Department of Health and Human Services, 1990.
BF-8

GA WIC PROCEDURES MANUAL
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 nutrition assistant 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. Nutrition assistants can also provide breastfeeding education and support when appropriate training has been received. The Nutrition Section must approve the training plan. See Attachment NE-3 for the Guidelines for Nutrition Assistant 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, 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 Nutrition Section 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 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
BF-9

GA WIC PROCEDURES MANUAL 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 date, lesson objective(s) and original signature of the staff person conducting the class.
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. Documenting missed appointments and refusal to receive education are important for the purpose of monitoring and further education efforts.
VI. PARTICIPANT REFERRAL A. Referrals 1. Prenatal or breastfeeding participants needing additional breastfeeding information, assistance or support should be referred to the appropriate person(s) designated through the local agency breastfeeding program. 2. Local agencies are encouraged to identify and develop a list of breastfeeding resources for prenatal and breastfeeding women. This list may include hospital staff, physicians, local support groups (both informal and organized, such as La Leche League), public health staff with expertise in handling breastfeeding questions, sources for breastfeeding pumps, peer counselors, etc. 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-10

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.1. 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 Nutrition Section.
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
BF-11

GA WIC PROCEDURES MANUAL
of the Procedures Manual. Attachment BF-6 provides a list of allowable and unallowable costs, as specified in the Federal Regulations.
2. Breast Pumps
Local agencies are encouraged to have a supply of manually operated and electric pumps on hand for situations that merit their use. It is neither necessary nor desirable to give breast pumps to every breastfeeding or potential breastfeeding mother. Some situations in which availability of a breast pump may be necessary to assure continuation of milk production are:
a. Mothers who have temporary breastfeeding problems, such as engorgement. These are situations in which hand expression or a manual pump may be all that is needed.
b. Mothers who are having difficulty in establishing or maintaining an adequate milk supply due to maternal illness or a premature/sick infant.
c. Mothers with inverted/flat nipples who are having latch-on problems.
d. Mothers attempting to build their milk supply for any reason.
e. Mothers choosing to express breastmilk for missed feedings due to work, school 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 instructions to the breastpump recipient on the proper use, assembly and cleaning of the breast pump.
b. The participant receiving the breast pump should be able to demonstrate the proper usage of the breast pump before leaving the
BF-12

GA WIC PROCEDURES MANUAL issuing facility.
c. Follow-up within a 24-hour period is recommended, to assure that the pump is operating correctly and that the mother is using it properly.
4. Equipment and Supplies Inventory
Local agencies should maintain an inventory of all breastfeeding equipment and supplies. It is recommended that the inventory be updated on a quarterly basis. An inventory of breast pumps and attachment kits must be submitted to the Nutrition Section by October 31st of every year.
VIII. ALLOWABLE COSTS FOR THE PROMOTION AND SUPPORT OF BREASTFEEDING
A. Minimum Expenditure Requirement
The State Agency's Breastfeeding Promotion and Support (BFPS) minimum expenditure requirement is equal to $21 (starting in FFY '91), adjusted for inflation as of October 1st 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.
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.
BF-13

GA WIC PROCEDURES MANUAL
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.
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 of reimbursable agreements with other organizations, public or private, to undertake training and direct service delivery to WIC participants concerning breastfeeding promotion and support.
BF-14

GA WIC PROCEDURES MANUAL
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 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.
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 of WIC 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 postpartum subsequent certification. See Attachment BF-8 for instructions on making the status change.
BF-15

GA WIC PROCEDURES MANUAL
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.).
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 staff who complete the WIC Assessment/Certification Forms and the Turnaround Documents be instructed on the importance of, and the process for accurate documentation of weeks breastfed.
It is a requirement that the weeks breastfed be completed on the WIC Assessment/Certification Form and the Turnaround Document for:
1. Breastfeeding women: initial and six-month certification visits
2. Postpartum, non-breastfeeding women: certification visit
3. Infants: initial certification and mid-certification assessment visits
4. Children: one year of age subsequent certification visit (11 - 16 months of age), if they participated as infants at initial certification (any age), if they did not participate as infants
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-16

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-17

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 in-service 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-18

GA WIC PROCEDURES MANUAL

Attachment BF-2

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-19

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-20

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:

1.

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 practice.

STANDARDS:

1.

Participates in professional workshops, seminars, staff meetings and other inservices as scheduled. Summarizes

relevant information received in training sessions; 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-21

GA WIC PROCEDURES MANUAL

Attachment BF-4 cont'd

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.

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

BF-22

GA WIC PROCEDURES MANUAL

Attachment BF-4 cont'd

provided throughout the postpartum period, particularly at critical times when the mother is most likely to need assistance.

SUGGESTIONS FOR IMPLEMENTATION

GUIDELINE #1

Breastfeeding promotion and support are enhanced when local agency WIC staff receive orientation and task-appropriate training on breastfeeding promotion and support.

Suggestions for Implementation

1. It is important to develop orientation guidelines for new WIC employees that address:

clinic environment policies program goals and philosophy regarding breastfeeding task-appropriate information

Rationale: All new employees (support staff, paraprofessionals and professionals) must be familiar with program policies, goals and philosophy regarding breastfeeding. When all program staff project a positive attitude about breastfeeding, clients will be more comfortable discussing their breastfeeding questions and concerns.

2. It is important that the state agency develop guidelines for on-going training that address:

culturally appropriate breastfeeding promotion strategies current breastfeeding management techniques to encourage and support the breastfeeding mother and infant appropriate use 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 events sponsored by other agencies and organizations

BF-23

GA WIC PROCEDURES MANUAL

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-24

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-25

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

It is important that positive breastfeeding messages are used in:

participant orientation programs and materials

BF-26

GA WIC PROCEDURES MANUAL

Attachment BF-4 cont'd

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 of program participants Centers for Disease Control and Prevention surveillance systems state surveillance systems birth certificate information

Rationale: Since few data are available, data collection will help identify and direct further breastfeeding promotion efforts for this population. Assessment of successful strategies will help agencies measure progress toward meeting the health objectives for the nation.

2. 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-27

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 WIC participants.

Suggestions for Implementation

1. It is important that a breastfeeding protocol is established to:

integrate breastfeeding promotion into the continuum of prenatal nutrition education include an initial assessment of participant knowledge, concerns and attitudes related to
breastfeeding provide breastfeeding education and support sessions to each prenatal participant based
on the above assessment define the roles of all staff in the promotion of breastfeeding define situations when breastfeeding is contraindicated establish referral criteria

BF-28

GA WIC PROCEDURES MANUAL

Attachment BF-4 cont'd

Rationale: Making informed choices regarding the best methods of infant feeding is, in part, dependent on staff's ability and efforts to address women's needs and concerns throughout the prenatal period.

2. It is important to develop a mechanism to incorporate positive peer influence into the prenatal period, such as: peer counselors an honor roll of successful breastfeeding WIC participants an opportunity to watch other WIC participants breastfeed classes with currently breastfeeding WIC participants talking about their 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.

BF-29

GA WIC PROCEDURES MANUAL

Attachment BF-4 cont'd

GUIDELINE #7
Breastfeeding promotion and support are enhanced when policies allow breastfeeding women to receive all WIC services regardless of their breastfeeding patterns.

Suggestions for Implementation
1. It is important that eligible women who meet the definition 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
BF-30

GA WIC PROCEDURES MANUAL

Attachment BF-4 cont'd

receiving as much food as the formula-feeding dyad and makes the mother feel as though she is missing out on some of the food available to her. A voucher with even a small amount of formula on it sends a message to the mother that she is expected to supplement. A positive breastfeeding message will reinforce the importance of breastfeeding.

3. It is important to encourage the issuance of vouchers for powdered formula to breastfeeding mothers who wish to supplement.

Rationale: Powdered formula can be prepared in as small a quantity as needed. However, the minimum amount of the concentrated fluid formula that can be prepared is 26 ounces. This amount must be used within 48 hours, which could encourage more supplementation than originally intended.

4. It is important that breastfeeding women receive information about the potential impact of formula on lactation and breastfeeding before formula is given.

Rationale: Breastfeeding mothers may not fully understand the impact formula supplementation has on breastmilk supply. This is especially important during the first few critical weeks when the milk supply is being established.

5. It is important that formula vouchers or samples be given only when specifically requested.

Rationale: Offering formula to a breastfeeding woman undermines her confidence that she can breastfeed successfully, particularly in the first few weeks. She also may find it difficult to refuse the free formula even though she had not planned to use it.

GUIDELINE #9

Breastfeeding promotion and support are enhanced when breastfeeding support and assistance is provided throughout the postpartum period, particularly at critical times when the mother is most likely to need assistance.

Suggestions for Implementation

1. It is important to develop a plan to provide women with access to locally available breastfeeding support programs, making sure support is available early in the 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

BF-31

GA WIC PROCEDURES MANUAL

Attachment BF-4 cont'd

Rationale: Professional support programs assist the mother experiencing lactation problems to resolve questions and problems with lactation management. Peer support programs using individuals who have successfully breastfed an infant and who express a positive, enthusiastic viewpoint of breastfeeding.
2. It is important to provide or identify education and support for breastfeeding women in special situations. Consider:
mothers returning to paid employment or school; mothers separated from their infants due to hospitalization or illness; mothers of multiples; infants with special needs
support program at times in keeping with the mother's schedule
Rationale: Breastfeeding mothers who are separated from their infants need support programs which include situation-specific information and support.
3. It is 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.

BF-32

GA WIC PROCEDURES MANUAL

Attachment BF-4 cont'd

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-33

GA WIC PROCEDURES MANUAL

Attachment BF-5

BREASTFEEDING RESOURCES RECOMMENDED BY THE NUTRITION SECTION

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 (#4019) 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 Information 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 Handbook for 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, 2000.

BF-34

GA WIC PROCEDURES MANUAL
Nursing Mother's Companion, by Kathleen Huggins Harvard Common Press, Boston, MA, 1990.

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 Nutrition Section Nutrition Section, 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 of Breastfeeding, 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 Nutrition Section, 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

BF-35

GA WIC PROCEDURES MANUAL

Attachment BF-5 cont'd

TELEPHONE INFORMATION SERVICES FOR HEALTH PROFESSIONALS

Georgia Poison Control Center Grady Memorial Hospital, Atlanta, GA (404) 616-9000 or (800) 282-5846 Service Provided: Answers to questions on Drugs and Lactation Charge: There is no cost for this service

Breastfeeding and Human Lactation Study Center University 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-36

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 of breastfeeding are allowable WIC nutrition services and administration (NSA) expenses. Such expenses can be applied to the State agency's breastfeeding spending target and/or its overall nutrition education expenditures.

Breastfeeding aids which are allowable NSA costs include:

Breast pumps Breastshells Nursing supplementers Nursing bras Nursing pads Costs associated with the purchase and availability 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-37

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 Nutrition Section 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-38

GA WIC PROCEDURES MANUAL to be used repeatedly and their cost is minimal.

Attachment BF-7 cont'd

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 insure against loss or damage, such as:

a. establishing procedures to ensure that participants fully understand their rights and responsibilities when signing liability release forms;

b. developing an agreement between the program and the participant which stipulates the participant's responsibility to reimburse the program for the value of a lost or damaged pump;

c. monitoring through periodic visual inspection, frequent inventory counts and records, and telephone check-ins; or

d. limiting pump loans only to special circumstances, e.g., after a minimum duration 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. Referrals

BF-39

GA WIC PROCEDURES MANUAL

Attachment BF-7 cont'd

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-40

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 II. 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 breastfeeding (receiving no infant formula

BF-41

GA WIC PROCEDURES MANUAL

Attachment BF-8 cont'd

through WIC) should be assigned Food Package 408. If this participant has already picked up the current month's prenatal vouchers, you may print a single A001" 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 (Infant of a WIC Mother or Mother with Nutritional Risk During Pregnancy), assign a Priority II. It may be helpful to 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. If the mother is still breastfeeding, she must be assessed as a breastfeeding

BF-42

GA WIC PROCEDURES MANUAL

Attachment BF-8 cont'd

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-43

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

If the 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 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-44

GA WIC PROCEDURES MANUAL TABLE OF CONTENTS

Page

I.

Introduction....................................................................................................... DP-1

A. Purpose.................................................................................................. DP-1

B. Scope..................................................................................................... DP-1

II.

Policies.............................................................................................................. DP-2

III.

Assessing Impact of Disaster ............................................................................ DP-2

IV.

Concept of Operation........................................................................................ DP-3

A. General.................................................................................................. DP-3

B. Organization (WIC Director Responsibilities, State Level Responsibilities, State and Local Agencies)...................... DP-3

C. Notification ........................................................................................... DP-5

V.

Responsibilities................................................................................................. DP-5

A. Facilities................................................................................................ DP-5

B. Issuance................................................................................................. DP-5

C. Certification .......................................................................................... DP-7

D. Nutrition Education Contacts................................................................ DP-7

VI.

Resource Requirements .................................................................................... DP-8

A. Staff Requirements................................................................................ DP-8

B. Infant Formula ...................................................................................... DP-8

C. Food Instruments .................................................................................. DP-9

D. Transportation....................................................................................... DP-9

GA WIC PROCEDURES MANUAL Page
Attachments: DP-1 Staff Availability Following a Disaster ...................................................................... DP-10 DP-2 Disaster Employee Log............................................................................................... DP-11 DP-3 Disaster Daily Work Activity Log.............................................................................. DP-12 DP-4 American Red Cross Emergency Numbers ................................................................ DP-13

GA WIC PROCEDURES MANUAL
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 Branch 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.
DP-1

GA WIC PROCEDURES MANUAL 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 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 of the situation and type of disaster.
The emergency numbers for contacting the American Red Cross are also attached to this plan (See Attachment DP-4). The contact person as well as a fax number is also available in (Attachment DP-4).
II. POLICIES
Specific decisions concerning state agency actions during a disaster depend upon the duration and magnitude of the disaster, and upon specific directions from the State Health Director. The focus of State WIC Agency activity is to support local agency service delivery. These guidelines primarily reflect state agency responsibilities in the event of disruption of services in one local agency. In the event of an emergency at the state agency, state agency personnel will follow the rules developed by the State Health Director. In the event of a disaster or emergency involving both local and state agencies, the initial focus of the state agency will be to estimate the impact and determine the measures needed to support the restoration of services by the local agency. The state and local agencies will develop provisional operational policies following a disaster that respond to the specific needs created by the disaster.
III. 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 grocery stores are closed due to the disaster and is retail purchase still feasible?
4. How many persons are made newly eligible as a result of the disaster? Would income be computed monthly or annually?
DP-2

GA WIC PROCEDURES MANUAL 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?
IV. CONCEPT OF OPERATION
A. General
A Disaster Plan folder is kept by the State WIC Branch Director and the Director of the Nutrition Section. 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 Branch 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's responsibilities will be to:
1) 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 Section Managers and Consultants will have responsibilities related to coordination of staff and analysis of requirements resulting from the disaster. The Systems Information Section(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,
DP-3

GA WIC PROCEDURES MANUAL
equipment issues and emergency procurement of vouchers. The Financial Section has the responsibility of tracking and reconciling costs relating to the disaster. The Manager of the Compliance Analysis Section 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 Section will provide the local agency with operational authorized WIC vendor sites. The Nutrition Section Consultants will have responsibilities related to certification and food package issuance, Nutrition Education and Food Safety Preparation, Breastfeeding Education, and support information. All contracts for formula procurement by Georgia WIC and Nutrition Services will contain a clause addressing alternative measures for acquisition and distribution of infant formula in the case of a disaster.
State and Local Agencies
The state and local agencies will coordinate efforts to obtain the appropriate type and quantity of staff to assist the local agency in need. Staff may be assigned from within the county, from another county, from another district or from the state agency to meet a specific county's needs during a disaster.
The state and local agencies may be asked to provide staff at a designated disaster assistance location (not always a health department facility) in order to provide WIC services more expediently.
Following a disaster in which state or local agency offices are closed, staff should contact one of their supervisors within eight (8) hours to report their situation and availability for duty assignments. If none of the local agency's immediate supervisors can be reached, local agency staff can call the State WIC Office at 1-800-228-9173 to report their status and phone number where they can be reached. Attachment DP-1 is a form designed to collect data for this purpose.
Staff Documentation Requirements:
1. Any office which has staff working on disaster activities must maintain a Disaster Office Employee Log, Attachment DP-2. One log per office should be maintained per pay period and kept on file.
2. Any departmental employee working on disaster activities should immediately begin to maintain a Disaster Daily Work Activity Log, Attachment DP-3. The completed activity logs should be retained by each departmental employee. If 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.
DP-4

GA WIC PROCEDURES MANUAL
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 his or her District Disaster Coordinators. The State WIC Branch 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 Section.
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
DP-5

GA WIC PROCEDURES MANUAL
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 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 of WIC approved foods. The state and local agency will coordinate efforts to share this information with the participants.
2. Direct Distribution: If retail purchase is not viable, then direct distribution measures will be considered. The local agency, state staff, 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. If the district office is closer in proximity, efforts will be made by the State Branch 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.
DP-6

GA WIC PROCEDURES MANUAL
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, wholesalers, suppliers, retailers, and other local agencies. Procurement, shipment, and local storage of infant formula will be the responsibility of the State WIC Branch.
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 Branch. 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
DP-7

GA WIC PROCEDURES MANUAL and voucher issuance during this crisis situation.
Nutrition Education should address:
* food safety * meal planning * food preparation * nutrition needs of the individual * on-site education shelters * safe water supply * general sanitation
VI. RESOURCE REQUIREMENTS
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 of WIC and Nutrition Volunteer staff from around the state at the site of the disaster.
3. Scheduling shifts for volunteer staff and assistance with obtaining lodging at the site of the disaster.
4. Scheduling and coordinating staff at the local office and State WIC Branch.
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
DP-8

GA WIC PROCEDURES MANUAL 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.
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-9

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-10

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: __________________

SOCIAL SECURITY #

NAME (Last, First, MI)

DISASTER WORK PERIOD Beginning Date Ending Date

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-11

GA WIC PROCEDURES MANUAL

Attachment DP-3
PAGE OF __

DATE:

/

NAME: DISTRICT:

/ OFFICE:

DISASTER DAILY WORK ACTIVITY LOG SSN: ____________________

NEW ACTIVITY TIME:

AM PM to

AM PM BLDG:

OTHER:

ACTIVITY LOCATION:

Activity Description

:

NEW ACTIVITY TIME: :

AM PM to :

AM PM

BLDG:

OTHER:

ACTIVITY LOCATION:

Activity Description

:

NEW ACTIVITY TIME: :

AM

AM

PM to : PM BLDG:

OTHER:

ACTIVITY LOCATION:

Activity Description

:

SIGNATURE:

DATE:

NOTE: MUST ATTACH TO DISASTER EMPLOYEE LOG. RETAIN COMPLETED LOG FOR USE IN DOCUMENTING FUTURE FEDERAL CLAIMS.

DP-12

GA WIC PROCEUDRES MANUAL

Attachment DP-4 (con't)

CHAPTER

AMERICAN RED CROSS CONTACT

Albany Cluster I Coverage: Clay, Dougherty, Lee, Randolph, Terrell

Deborah Blanton 2421 N Slappey Blvd. Albany, GA 31701 (229) 436-4845 Fax:(229) 434-9610

Americus Cluster V Coverage: Sumter

Joan Mason P.O. Box 214 Americus, GA 31709 (229) 924-2026 Fax:(229) 931-0811

Augusta Cluster II Coverage: Burke, Columbia, Glascock, Jefferson, Jenkins, Lincoln, McDuffie, Richmond, Screven, Taliaferro, Warren, Wilkes

Carolyn Maund 811 12th Street Augusta, GA 30901 (706) 826-4463 Fax: (706) 826-4507

Baldwin County Cluster VI Coverage: Baldwin, Putnam, Washington, Wilkinson

Olsen Rogers P.O. Box 516 Milledgeville, GA 31061 (912) 454-2675 Fax:(912) 451-5376

Bartow County Cluster VII Coverage: Bartow

Beth Kennedy 105 North Bartow Street Cartersville, GA 30120 (404) 382-0981 Fax:(404) 606-1600

Bulloch County Cluster III Coverage: Bulloch, Candler, Emanuel

Vacant P.O. Box 843 Statesboro, GA 30458 (912) 767-4468

Fort Gordon Dwight D. Eisenhower Army Medical Center

Rick Tuchscherer P.O. Box 7266 Fort Gordon, GA 30905 (706) 791-3169/6341 After Hours:(706) 791-4517 Fax:(706) 790-4822

Fort McPherson

Kathy Staten Bldg. 536 Ft. McPherson, Ga 30330 (404) 753-8315

Fort Stewart Winn Army Community
Hospital
Metropolitan Atlanta Cluster VIII Coverage: Fulton, DeKalb, Gwinnett, Cobb, Cherokee, Paulding, Fayette, Butts, Henry, Clayton, Douglas, Rockdale
Murray County Cluster VII

Lynn Dowling Bldg. 8401 P.O. Box 3280 Fort Stewart, Ga 31314 (229) 767-8857/2197 After Hours:(229) 767-2197/8666 Fax:(229) 368-6353
Martha W. Ferguson 1955 Monroe Drive, N.E. Atlanta, Georgia 30324 (404) 881-9800 Fax: (404) 874-2993
Annette Patton P.O. Box 1301 Chatsworth, Ga 30705

DP-13

CHAPTER Hunter Army Airfield
Marine Corp Supply School
Covered by: Albany Chapter

AMERICAN RED CROSS CONTACT
Mark Stall Building 401 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. Box 242 Hinesville, GA 31313 (912) 876-3975

Glynn County Cluster III Coverage: Appling, Glynn,
Gordon County Cluster VII Coverge: Gordon

McIntoshBeth VanDerbeck P.O. Box 1436 Brunswick, GA 31521 (912) 265-6467/1695 Fax:(912) 261-1443
Mary Thomas P.O. Box 342 Calhoun, GA 30703-0342 (706) 629-4510

Griffin Cluster VIII Coverage: Spalding

Brenda Hoard 100 South Hill Street Griffin, Ga 30244 (404) 227-3145

Houston-Middle Georgia Cluster VI Coverage: Bleckley, Dooly, Hancock, Houston, Lamar, Macon, Pulaski, Taylor, Wilcox

Sam Register 346 Corder Warner Robbins, GA 31088 (912) 923-6332 Fax:(912) 922-8858

Toombs County Cluster III Coverage: Montgomery, Toombs, Treutlen, Wheeler
Valdosta Cluster IV

Stan Bazemore P.O. Box 49 Lyons, Georgia 30436 (912) 526-3150
Stephen Coyne 707 North Patterson Street Valdosta, Georgia 31601

GA WIC PROCEUDRES MANUAL

Attachment DP-4 (con't)

CHAPTER Coverage: Murray

AMERICAN RED CROSS CONTACT
(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 McCall Blvd. Suite A Rome, GA 31065-2733 (706) 291-6648 Fax:(706) 235-2842
Angela Viney 422 Habersham Street Savannah, GA 31401 (912) 651-5300/5310/5385 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 1135 Thomasville, Georgia (229) 226-2181

31799-1135

Tift County Cluster IV Coverage: Ben Hill, Irwin, Tift, Turner, Worth
Troup County Cluster V Coverage: Troup
Upson County Cluster VI Coverage: Pike, Upson
Dobbins Air Force Base Covered by: Fort McPherson

Maxine Franks P.O. Drawer 70770 Tifton, Georgia 31793 (229) 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

CHAPTER
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 Cluster V 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
Fort Benning/Martin Army Hospital

AMERICAN RED CROSS CONTACT (912) 242-7404 Fax: (912) 242-1553
Jerry Lipps P.O. Box 372 Lafayette, Georgia 30728 (706) 638-2546
Chris Miller Family Support Center 825 9th Street, Suite #109 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, Georgia 31904 (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
Station Manager P.O. Box 51945 Fort Benning, GA 31995 (706) 545-5194 Fax: (706) 545-5118

DP-14

Georgia WIC Program Procedures Manual GLOSSARY 2002

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's participation at the beginning of the fiscal year by WIC type, within priority. The projected amount to be spent for the total fiscal year is then calculated and, based on priorities, the Allocation Advisory Committee determines which types will be served. The allocation of administrative funds is based on an average cost per participant and is distributed to the local agencies after state administrative costs have been deducted.
Alphabetic Client Masterfile - An enrollment report which lists selected participant information for all active participants.
AAnd Justice For All Poster@ - Poster which must be displayed in a conspicuous location in each WIC Clinic site indicating the WIC non-discriminatory clause.
Applicants Pregnant women, breastfeeding women, postpartum women, infants, and children who are applying to receive WIC benefits, and the breastfed infants of applicant breastfeeding women. Applicants include individuals who are currently participating in the program but are re-applying because their certification period is about to expire.
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 TAD/Voucher 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 Branch. 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 of time 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.

1

Children - Child who have had their first birthday but have not yet attained their fifth birthday.
Civil Money Penalty (CMP) May be assessed in lieu of disqualification. The amount of the penalty will be established using a standard formula. CMP's cannot exceed $10,000 per violation or $40,000 per investigation.
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.
Coding of Records Documenting special codes on record for special treatment for applicants/participants.
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.
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.

give any information to anyone else without obtaining the participants permission.
Cost Containment Measure - A competitive bidding, rebate or direct distribution implemented by a State agency as described in its approved State Plan of operation and administration.
CSFP - The Commodity Supplemental Food Program administered by USDA.
Cumulative Unmatched Redemption - Identifies redeemed manual vouchers, which have not matched a valid client record. Local Agencies are required to review the redeemed manual vouchers appearing on the CUR report. The vouchers should be reconciled or a manual reconciliation should be done, depending on how much time has elapsed since the voucher was redeemed.
CUR Part 1- Cumulative Unmatched Redemptions which have not matched to an issuance record.
CUR Part 2 - Cumulative Unmatched Redemptions which have not matched to a valid certification record.
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 of an infant (or the date the pregnancy ended) for a postpartum woman.
Disability - A physical incapacitated or disabling condition which prevents or restricts normal accessibility or activity included are visual and hearing impaired individuals.
Disqualification - The act of ending the program participation 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.
DOD Department of Defense
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 Branch.
Dual Participation - WIC participants who receive benefits twice in the same clinic, or from more than one clinic.

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

EBT - Electronic Benefit Transfer.
EDC (Estimated Date of Confinement) - Indicates the date of expected delivery for a pregnant woman.

2

Education Level - Indicates the highest level or grade completed, for women participants only.
Enrollee A client who is active and in a valid certification period, but did not receive vouchers during the reporting month.
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 of a single family.

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 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.

Family and Children Services Government agency responsible for the welfare of children.

Hospital Certification - Reviewing hospital documentation for eligibility of applicants/participants for the WIC program.

Family Size - Identifies the total number of individuals in a household.
Fiscal Year - The WIC Program operates under the constraints of both the federal fiscal year (October 1 through September 30) and the state fiscal year (July 1 through June 30).
FNS - The Food and Nutrition Service of the United States Department of Agriculture.
Food Delivery System - The method used by State and local 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.
Fraud Intentional deception.
Grant Award (Formula Grant/Grant Allocation) - Total (food and administrative) 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.
Hemoglobin - Medical criteria required to assess nutritional risk.

HOST - Health Outcomes Services Tracking System.
Identification - Valid picture ID or other valid ID such as Drivers License, Birth Certificate, immunization record, etc.
Inadequate Participant Access Cases If disqualifying a vendor causes inadequate participant access, the State Agency must impose a Civil Money Penalty (CMP) in lieu of disqualification. An inadequate participant access case is granted if the nearest authorized WIC vendor is ten (10) miles or more away from the nearest WIC clinic.
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 is 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.

Homeless - A woman, infant or child who does not have regular fixed night time residence, or resides in a temporary public or

Initial Contact Date - The date an applicant first visits the WIC clinic during office hours and requests WIC benefits, orally or

3

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.
Inventory A detailed list of all goods and materials on hand.

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.
Minimum Inventory Requirement Waiver This waiver is granted to reduce the minimum inventory when a WIC vendor has difficulty selling WIC food items.
Motor Voter Act - An act that mandates the WIC Program=s obligation to offer voter registration opportunities to anyone entering a clinic for WIC benefits.

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.

Motor Voter Forms - A form issued to applicants that registers them to vote.
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.

LEP Limited English Proficient.
Letter of Household Income - Statement attesting to household income by wage earner(s).
Local Agency - A public or private, nonprofit health or human service agency which provides health services, either directly or through contract.
Logger - An individual whose primary employment is the harvesting of trees seasonally; and for such work the person establishes temporary residence.
Manual Voucher Inventory Log - Documentation that vouchers are inventoried on a weekly and monthly basis.
Medical Care Start Date - Indicates which month of the pregnancy the woman began receiving prenatal care.
Members of Populations - Persons with a common special need who do not necessarily reside in a specific geographic area, such as off-reservation Indians or migrant farm workers and their families.
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.

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.
Nonprofit Agency - A private agency which is exempt from income tax under the Internal Revenue Code of 1954, as amended.
Numeric Client Masterfile - An enrollment report, which list all active participants. This report is a cross reference for the Alphabetic Client Masterfile. It provides the client names by ID number.
Nutrition Education - Individual or group education sessions and the provision of information and educational materials designed to improve health status, achieve positive change in dietary habits, and emphasize relationships between nutrition and health.
Nutritional Assessment - Contains medical data obtained and evaluated by a CPA, which determines a participant=s nutritional risk.
Nutritional Risk - Detrimental or abnormal nutritional conditions detectable by biochemical or anthropometric measurements; other documented nutritionally related medical conditions; dietary deficiencies that impair or endanger health; or conditions that predispose persons to inadequate nutritional patterns or nutritionally related medical conditions.

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.

OIG - The USDA Office of the Inspector General.
Overseas WIC Program A program similar to the USDA operated program that qualifies military persons, their dependents and government civilians for WIC benefits overseas.

4

Participant A participant is a client who has been issued at least one voucher during the reporting period.
Participation - The sum of the number of persons who have received supplemental foods or food instruments during the reporting period and the number of infants breast-fed by participant breastfeeding women (and receiving no supplemental foods or food instruments) during the reporting period.
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.
Pay Stub - Statement of paid income earned.

taking a blood test and medical history.
Priority II (Breast-feeding women) - Women who do not qualify under priority I, but are breast-feeding Priority II infants.
Priority II (Infants) - Infants up to six months of age born to women who were WIC Program participants during their pregnancy, or infants born to women who were not WIC Program participants during their pregnancy but had a nutritional need.
Priority III (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.
Priority IV - Pregnant women, breast-feeding women, and infants with a nutritional need because of poor diet or homeless/migrancy status.

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.

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.

PNNS Data - The Pregnancy Nutrition Surveillance System (PNSS) is a national nutrition surveillance system administered by CDC.
P.O. Box Post Office Box.
Post Vendor Training Evaluation - A test pertaining to WIC vendor requirements given to all vendors when attending the initial and annual vendor training.
Postpartum Women - Women up to six months after termination of pregnancy.
Poverty Income Guidelines - The poverty income guidelines prescribed by the Department of Health and Human Services. These guidelines are adjusted annually by the Department of Health and Human Services, with each annual adjustment effective July 1 of each year.
Pregnancy Outcome - The results of the just ended pregnancy for the postpartum woman participant.
Pregnant Women - Women determined to have one or more embryos or fetuses in utero.
Prenatal Women - Pregnant female between the ages of 10 and 55 years.

Procedures Manual A document that lists federal and state regulations for the WIC Program.
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.
Protective Services A program design to protect the rights of children.
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.

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,

Racial Group of Participant - 1=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.

5

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.
Residency - Determined 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 - Form #3760 titled Return Voucher Payment Log. Vendors use this form used by Vendor when sending vouchers, that have been returned to them from the bank, to the State WIC Office for payment.

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 determined 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.

Seasonal Farmworker - A worker employed in agriculture occupation whose residence is not temporary for the purpose of such work.

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.

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 - Formula that is not the standard contract formula. This formula is approved when a written prescription from a medical doctor with the diagnosis included is given to the participant.
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 WIC Branch 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.

Thirty (30) Day Issuance The issuance of vouchers to participants for thirty (30) days until documentation is received.
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 of either 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 1) 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.

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 formula provided by the State. All infants participating in the Georgia WIC Program will be provided with vouchers for the formula the program is under contract to use.

State - Any of the 50 States, the District of Columbia, the Commonwealth of Puerto Rico, the Virgin Islands, Guam, American Samoa, the Northern Marinas Islands and the Trust
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 (U).
USDA - The United States Department of Agriculture.
VPOD Vouchers printed on demand/on-site.
VHA - Variable Housing Allowance.
Vendor Compliance Investigation - Vendors that have been identified as AHigh Risk@ by the State WIC Branch 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 When vendors receive on site visits from the State WIC Branch.
Vendor Profile Report - A report that gives data on the disposition of vouchers cashed by each vendor. Also provides high risk indicators.
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.
Vendor Sanctions When a WIC vendor is found to be in violation of program policy and/or regulations, that vendor will be assessed sanctions according to the severity and nature of the violation. Form #3771, WIC Vendor Agreement, 4th page, lists all of the offenses and sanctions.
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.
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.

VIPS Vendor Integrity Profile System - A data base of all vendor information and identifies high risk vendors.
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.
Vouchers Printed On Demand Vouchers are printed as the participant appear in the clinic.
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 1 digit check digit, and a 1 digit participant code. All members of a family should be assigned the same family identification number to facilitate voucher distribution.
WIC Type - Classifies WIC participants i.e., P=Pregnant Woman (Prenatal), N=Non-breastfeeding postpartum woman, B=Breastfeeding postpartum woman, I=Infant, and C=Child.
Zero Income - Applicant/Participant receives no monies from work, services or any entitlement programs

7

8