FFY 2003 WIC procedures manual, and Georgia state plan for program operation in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) fiscal year 2003 [2003]

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 (VM) ......................................................................................IN-4 F. Food Package (FP) ..............................................................................IN-4 G. Nutrition Education (NE) ....................................................................IN-4 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-6 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-15

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 staff during on-site monitoring visits. Ninety (90) days prior to a program review, District/Local agency staff must not contact the Georgia WIC Branch for a
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GA WIC PROCEDURES MANUAL
copy of Policy Memos. During the fourth quarter of each year, the Procedures Manual will be completely revised and reprinted and all policy memos from the year will be incorporated into the manual.
VI. SECTIONS
The Georgia WIC Program Procedures Manual is divided into sixteen (16) sections, which are described as follows:
A. Introduction (IN) Section includes: 1. Purpose 2. Scope 3. References 4. Prior Approval 5. Policy Memos 6. Sections 7. Administration 8. Addresses (Local and State)
B. Certification (CT) Section includes: 1. General 2. Eligibility Requirements 3. Initial Application 4. Processing Standards 5. Participant Identification 6. Income Eligibility 7. Nutritional Risk Determination 8. Nutritional Risk Criteria 9. Nutritional Risk Priority System 10. Changes Within A Valid Certification Period 11. Certification Periods 12. Infant Mid-Certification Nutrition Assessment 13. WIC Assessment/Certification Form 14. Ineligibility Procedures (Notification Requirements) 15. Transfer of Certification 16. Correcting Mistakes 17. Certified Waiting List
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GA WIC PROCEDURES MANUAL
18. Patient Flow Analysis 19. Systems Information Management 20. Immunization Coverage Assessment C. Rights and Obligations (RO) Section includes: 1. Rights and Obligations of WIC Applicants/Participants 2. Non-discrimination Clause 3. Public Notification 4. Civil Rights 5. Fair Hearing Procedures - Participants 6. Fair Hearing Procedures - Migrants 7. Administrative Appeals - Local Agency 8. Availability of Hearing Records 9. National Voter Registration Act D. Administrative (AD) Section includes: Section I 1. Agreement with State Agency 2. Financial Procedures 3. Nutrition Services and Administrative Cost Categories 4. Random Moment Sample Study (RMSS) 5. Expense Categories 6. Allocation Expense Categories 7. Program Income
Section II 1. Retention of Records 2. WIC Acronym & Logo 3. Lobbying Restrictions 4. Confidentiality 5. Faxing Confidentiality Information 6. WIC Volunteer and Confidentiality 7. Retroactive Benefits and Reimbursement 8. Mandatory No Smoking Policy in Local WIC Clinics 9. Subpoenas 10. Search Warrants
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GA WIC PROCEDURES MANUAL
11. Program Participation 12. System Maintenance Indicator Report 13. Documentation 14. Establishing New Clinics/Clinic Changes E. Vendor (VN) Section includes: 1. Introduction 2. Vendor Coordinator 3. Enrollment of New Vendors 4. Vendor Agreements 5. Vendor Stamp 6. Vendor Training 7. Vendor Materials 8. Monitoring 9. Compliance Investigations 10. Vendor Sanctions 11. Complaints Against Vendors 12. Terminations/Disqualification 13. Vendor Fair Hearing Procedures 14. High Risk Vendor Identification 15. Minimum Inventory Requirements Waiver F. Food Package (FP) Section includes: 1. Authorization of Foods 2. Prescribing Foods - General 3. Infants 4. Children and Women with Special Dietary Needs 5. Children 1-5 6. Pregnant and Breastfeeding Women 7. Postpartum, Non-Breastfeeding Women 8. Homelessness, Migrancy, and Disaster Situation G. Nutrition Education (NE) Section includes: 1. Purpose 2. Definition 3. Goals
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GA WIC PROCEDURES MANUAL
4. State Agency 5. Local Agency 6. Participant Nutrition Education 7. Participant Referrals to Other Agencies 8. Nutrition Education Materials H. Special Population (SP) Section includes: 1. Introduction 2. Individuals Residing in Non-Traditional Housing or Institutions 3. Other Special Populations 4. Referral and Outreach to Special Populations I. Outreach (OR) Section includes: 1. General 2. Methods of Outreach 3. Agencies to Contact for Outreach 4. Public Notification 5. Public Comments 6. Outreach During A Waiting List 7. Program Costs 8. Coordination/Integration of Services J. Food Delivery (FD) Section includes: 1. General 2. Types of WIC Vouchers 3. Voucher Issuance - General 4. Computer Printed Voucher 5. Manual Vouchers 6. Georgia WIC Program Identification (ID) Card 7. Proxies 8. Mailing/Delivery of WIC Vouchers 9. Voided Vouchers 10. Prorated Vouchers 11. Late Pick-up of Vouchers 12. Coordination of Health Services and Voucher Issuance 13. Redemption of WIC Vouchers
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GA WIC PROCEDURES MANUAL
14. Lost, Stolen or Damaged Vouchers 15. Borrowed Vouchers 16. Cumulative Unmatched Redemption Report (CUR) K. Compliance Analysis (CA): 1. Introduction 2. Monitoring 3. Participant Abuse 4. Procedures for Repayment of WIC Funds 5. Guidelines for Investigating Employee Abuse 6. Procedures to Request an Employee Investigation 7. Vendor Compliance Investigation 8. Compliance Investigation Food Purchases 9. Disqualified Vendor/Participant Hardship 10. Investigation of Missing Vouchers/VOC Cards 11. Security of Issuance Material 12. Voucher Issuance Security L. Monitoring (MO) Section includes: 1. State Agency Monitoring 2. Quality Assurance Self-Reviews 3. Technical Assistance M. Breastfeeding (BF) Section includes: 1. Introduction 2. Definitions 3. State Agency 4. Local Agency 5. Participant Education 6. Participant Referral 7. Breastfeeding Materials and Resources 8. Allowable Cost for the Promotion and Support of Breastfeeding 9. Documentation of Breastfeeding Rates N. Disaster Plan (DP) Section includes: 1. Introduction 2. Policies
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GA WIC PROCEDURES MANUAL 3. Assessing Impact of Disaster 4. Concept of Operation 5. Responsibilities 6. 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.
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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

COUNTIES SERVED

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)
Thomas Chester, M.D., M.P.H. District Health Director Louise Hambrick, MSN, MBA, RNCS, FNP 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

Dade, Walker, Catoosa, Polk, Chattooga, Gordon, Floyd, Bartow, Paulding, Haralson
Whitfield, Murray, Gilmer, Fannin, Pickens, Cherokee
Banks, Dawson, Forsyth, Franklin, Habersham, Hall, Hart, Lumpkin, Rabun, Towns, Stephens, Union, White

# OF WIC CLINIC SITES 17
7
13

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GA WIC PROCEDURES MANUAL

DISTRICT/ADDRESS

COUNTIES SERVED

# OF WIC CLINIC SITES

District 3, Unit 1 (Cobb)

Cobb, Douglas

8

Alpha Bryan, M.D.

District Health Director Lisa Crossman

Director for Health Promotion and Prevention Jack Gutkins

Program Manager Beverly Demetrius, R.D., M.A, L.D.

Nutrition Services Director Shanice H. King, R.D., L.D.

Nutrition Manager Metro West Health District Office 1650 County Services Pkwy.

Marietta, GA 30008

(770) 514-2325

District 3, Unit 2 (Fulton)

Fulton

23

Adewale Troutman, M.D., M.D.H.
District Health Director Dennis Daniels, M.PH., PhD
Deputy Director for
Personal and Population Health and
Clinical Services 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

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GA WIC PROCEDURES MANUAL

DISTRICT/ADDRESS
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 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 Clayton
Gwinnett, Rockdale, Newton
DeKalb

# OF WIC CLINIC SITES 3
6
5

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GA WIC PROCEDURES MANUAL

DISTRICT/ADDRESS
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

COUNTIES SERVED

# OF WIC CLINIC SITES

Burretta Shepherd Director South DeKalb Health Center 3110 Clifton Springs Road, SuiteD 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 Nutrition Services Director District 4 Public Health 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

Fayette, Heard, Henry,

17

Butts, Carroll, Coweta,

Lamar, Pike, Meriwether,

Troup, Spalding, Upson

Bleckley, Dodge,

10

Laurens, Montgomery,

Pulaski, Telfair, Treutlen,

Wilcox, Wheeler,

Johnson

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GA WIC PROCEDURES MANUAL
DISTRICT/ADDRESS
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 Roy Moore Program Manager 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 (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
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COUNTIES SERVED

# OF WIC CLINIC SITES

Hancock, Houston,

21

Jasper, Baldwin, Bibb,

Crawford, Jones,

Monroe, Peach, Putnam,

Twiggs, Washington,

Wilkinson

Burke, Columbia,

23

Emanuel, Glascock,

Jefferson, Wilkes,

Warren, Jenkins, Lincoln,

McDuffie, Richmond,

Screven, Taliaferro

Harris, Talbot, Dooly,

23

Quitman, Taylor, Marion,

Macon, Crisp, Sumter,

Clay, Schley, Webster,

Randolph, Stewart,

Muscogee,

Chattahoochee

GA WIC PROCEDURES MANUAL

DISTRICT/ADDRESS
P.O. Box 2299 Columbus, GA 31902 (706) 321-6300/FAX (706) 321-6126 District 8, Unit 1 (Valdosta)
Lynne D. Feldman, M.D., M.P.H. District Health Director Vickie Wilkinson Program Manager Janet McClure, R.D., 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 (229) 430-4111 District 9, Unit 1 (Savannah)
Melinda G. Rowe, M.D., M.P.H., MBA District Health Director Al Mungin Program Manager Patricia Jackson-Milton, B.S.N., L.D. Director of Nutrition Services East Health District 1602 Drayton Street Savannah, GA 31401 (912) 651-2571

COUNTIES SERVED

# OF WIC CLINIC SITES

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

Chatham, Effingham

10

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GA WIC PROCEDURES MANUAL

DISTRICT/ADDRESS
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 Northeast Health District Office 468 North Milledge Avenue Room 101-B Athens, GA 30601-3808 (706) 542-9547 Southside Medical Center
David Williams, M.D. Director Vacant Program Manager Laverne Montgomery, M.A., R.D., L.D.
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COUNTIES SERVED
Appling, Atkinson, Bacon, Jeff Davis, Brantley, Ware, Bulloch, Candler, Clinch, Charlton, Evans, Coffee, Wayne, Pierce, Toombs, Tattnall

# OF WIC CLINIC SITES
21

Bryan, Liberty, Long,

15

McIntosh, Camden,

Glynn

Barrow, Clarke, Elbert,

17

Green, Jackson, Madison,

Morgan, Oconee,

Walton, Oglethorpe

Portions of Fulton ad

3

Dekalb Counties

GA WIC PROCEDURES MANUAL

DISTRICT/ADDRESS
District WIC Coordinator Southside Medical Center 1039 Ridge Avenue, S.W. Atlanta, Ga 30315 (404) 688-1350, Ext. 244 Grady Maternal & Infant Care Project
Tom Arrendale Assistant Vice-President for Professional and Clinical Services Bernadine Joubert, M.S., R.D., L.D. Director of Nutrition Services Leigh Ann Feast, M.P.H., R.D., L.D. WIC Supervisor Nutrition Services/WIC Program. Grady Health System P. O. Box 26011 80 Jesse Hill Jr. Drive, SE Atlanta, GA 30303 (404) 616-5401 (404) 616-7657 Fax

COUNTIES SERVED

# OF WIC CLINIC SITES

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
For technical assistance regarding nutrition-related topics, contact the Nutrition Section.
Georgia Department of Human Resources Division of Public Health
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GA WIC PROCEDURES MANUAL Family Health Section Nutrition Section Two Peachtree Street, N.E. 11th Floor Atlanta, Georgia 30303 (404) 657-2884 FAX (404) 657-2884
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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-7 V. Participant Identification....................................................................................... CT-7 VI. Georgia WIC Branch 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-27 E. Applicants with Zero (0) Income..................................................................... CT-27 F. Verification of Income .................................................................................... CT-28

GA WIC PROCEDURES MANUAL
IX. Nutritional Risk Determination .............................................................................. CT-28 A. Required Data................................................................................................. CT-29 B. Referral Data .................................................................................................. CT-29 C. Medical Data Date.......................................................................................... CT-30
X. Nutrition Risk Criteria ........................................................................................... CT-32 XI. Nutrition Risk Priority System ............................................................................... CT-32
A. General Priorities I -IV ................................................................................ CT-32 B. Special Considerations .................................................................................... CT-33 C. Specific........................................................................................................... .CT-33 D. Assignment ..................................................................................................... .CT-34 XII. Changes Within a Valid Certification Period.......................................................... .CT-35 A. Women Who Cease Breastfeeding .................................................................. .CT-35 B. Upgrading a Priority ....................................................................................... .CT-35 XIII. Certification Periods .............................................................................................. .CT-35 XIV. Infant Mid-Certification Nutrition Assessment ....................................................... .CT-35 XV. WIC Assessment/Certification Form ..................................................................... .CT-36 A. General........................................................................................................... .CT-36 B. Completion..................................................................................................... .CT-36 XVI. Ineligibility Procedures (Notification Requirements)............................................... .CT-43 A. Written Notification........................................................................................ .CT-43 B. Completion of Notice of Termination/Ineligibility/Waiting List Form........... CT-44 C. Ineligibility File .............................................................................................. .CT-44 XVII. Transfer of Certification........................................................................................ .CT-45 A. Verification of Certification (VOC) Card....................................................... .CT-45 B. Other Methods of Verification ........................................................................ .CT-46 C. Instructions for VOC Card Use....................................................................... .CT-47 D. Orders ..... ...................................................................................................... .CT-48 E. Inventories...................................................................................................... CT-48 F. Issuance... ...................................................................................................... .CT-49 G. Security ... ...................................................................................................... .CT-50 H. Lost/Stolen/Misplaced VOC Cards ................................................................. CT-50
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GA WIC PROCEDURES MANUAL
XVIII. WIC Overseas Program ......................................................................................... CT-50 A. General... ...................................................................................................... CT-50 B. Impact on USDA's WIC Program.................................................................. CT-51 C. New VOC Card Requirements ....................................................................... CT-51 D. Completion of the VOC Card......................................................................... CT-52 E. Acceptance of WIC Overseas Program VOC Cards........................................ CT-52
XIX. Correcting Mistakes .............................................................................................. CT-52 XX. Documentation Procedures .................................................................................... CT-52 XXI. Certified Waiting List ............................................................................................ CT-53
A. Procedures for Maintaining a Waiting List....................................................... CT-53 B. Procedures for Removal from the Waiting List ................................................ CT-53 XXII. Patient Flow Analysis............................................................................................. CT-53 XXIII. System Information Management........................................................................... CT-57 XXIV. Immunization Coverage Assessment ..................................................................... CT-57 Attachments: CT-1 WIC Assessment/Certification Form - Pregnant Women ........................................ CT-59 CT-2 WIC Assessment/Certification Form - Post Partum Breastfeeding ......................... CT-61 CT-3 WIC Assessment/Certification Form - Post Partum Non Breastfeeding ................. CT-63 CT-4 WIC Assessment/Certification Form - Infants ........................................................ CT-65 CT-5 WIC Assessment/Certification Form - Children...................................................... CT-67 CT-6 Signed Statement of Income .................................................................................. CT-69 CT-7 Data and Documentation Required for WIC Assessment/Certification - Women..... CT-70 CT-8 Data and Documentation Required for WIC Assessment/Certification - Infants...... CT-71 CT-9 Data and Documentation Required for WIC Assessment/Certification - Children ... CT-72 CT-10 Nutritional Risk Criteria - Prenatal Women............................................................ CT-73 CT-11 Nutritional Risk Criteria - Postpartum, Breastfeeding Women................................ CT-87 CT-12 Nutritional Risk Criteria - Postpartum, Non-Breastfeeding Women........................ CT-101 CT-13 Nutritional Risk Criteria - Infants........................................................................... CT-103 CT-14 Nutritional Risk Criteria - Children ........................................................................ CT-126 CT-15 Notice of Termination/Ineligibility/Waiting List Form ............................................ CT-137 CT-16 Verification of Certification (VOC) Card ............................................................... CT-138
CT-3

GA WIC PROCEDURES MANUAL CT-17 VOC Card Inventory Log (Clinic).......................................................................... CT-139 CT-18 VOC Card Inventory Log (Local Agency) ............................................................. CT-140 CT-19 Measuring Length.................................................................................................. CT-141 CT-20 Measuring Height ................................................................................................. CT-142 CT-21 Measuring Weight ................................................................................................ CT-143 CT-22 Measuring Weight Standing .................................................................................. CT-144 CT-23 Equipment Maintenance......................................................................................... CT-145 CT-24 Instructions for Use of Prenatal Weight
Gain Grid (Form #3059)........................................................................................ CT-147 CT-25 Prenatal Weight Grid for Normal Weight and Twins ............................................. CT-148 CT-26 Prenatal Weight Grid for Underweight and Overweight.......................................... CT-149 CT-27 Dietary Assessment................................................................................................ CT-150 CT-28 Instructions for Use of the Growth Charts.............................................................. CT-151 CT-29 Weight for Height Table for Determining WIC Eligibility....................................... CT-154 CT-30 Weight for Height Table for Women, Based on the Body Mass Index (BMI) ......... CT-155 CT-31 Physical Signs Suggestive of Nutrient Deficiencies................................................. CT-156 CT-32 Recommended Daily Servings Chart ...................................................................... CT-158 CT-33 Inappropriate Food Practices ................................................................................. CT-159 CT-34 Georgia WIC Program Referral Form ................................................................... CT-161 CT-35 WIC Income Poverty Guidelines........................................................................... CT-162 CT-36 VOC Card Agreement .......................................................................................... CT-163 CT-37 VOC Card Form.................................................................................................... CT-164 CT-38 Central Supply Requisition..................................................................................... CT-165 CT-39 State/District/Clinic Transmittal Form.................................................................... CT-166 CT-40 Medicaid Right From the Start............................................................................... CT-167 CT-41 No Cost Flyer ....................................................................................................... CT-168 CT-42 Letter of Household Income ................................................................................. CT-169 CT-43 Georgia WIC Program No Proof Form ................................................................. CT-170 CT-44 Family Plus.....................................................................................CT-171 CT-45 Health Department/Clinic Report Form ................................................................. CT-172
CT-4

GA WIC PROCEDURES MANUAL CT-46 Income Calculation Form ...................................................................................... CT-173 CT-47 Identification, Residency and Income Proof List .................................................... CT-174 CT-48 Thirty (30) Day Certification/Termination Form .................................................... CT-175 CT-49 Department of Defense WIC Overseas Program VOC Card................................... CT-176 CT-50 WIC Overseas Program Contacts.......................................................................... CT-177 CT-51 Proof of Residency Form for Applicants with P.O. Box Address ........................... CT-178 CT-52 Income Verification Letter .................................................................................... CT-179
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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 Georgia WIC Branch, 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
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woman; breastfeeding woman; postpartum, non-breastfeeding woman; infant; 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 Branch 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.
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The following people may determine if special considerations are required:
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
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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)
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
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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); 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
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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.
When reviewing the records of employees on the Georgia WIC Branch, 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.
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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.
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 Georgia WIC Branch 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
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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.
VI. GEORGIA WIC PROGRAM IDENTIFICATION (ID) CARD
General
A Georgia WIC Branch 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. 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.
The Georgia WIC 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 WIC 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:
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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.
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 appear 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 when need 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.).
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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 Georgia 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 Georgia 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.
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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
5. 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.
6. 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) above 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
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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. 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:
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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. 5. Other Income Section: a) Complete the dollar amount earned by each family member. Circle if the
amount earned is weekly/bi-weekly, monthly/yearly. b) Total the amount of all income earned. Circle if the amount earned is
weekly/bi-weekly, monthly/yearly. c) Answer the question Is the applicant income eligible?" YES or NO? d) Transfer this total to the Certification Form. e) Have applicant read their Right and Obligations. f) Have the applicant sign this form.
B. 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
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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
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.
2. PeachCare WC applicants/participants must present a PeachCare for Kids Letter
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that contains the following paragraph within a square enclosure to qualifiy for the WIC Program. "Additionally, if your child(ren) is/are under the age of five, she/he is income eligible for the WOMEN, INFANT and CHILDREN (WIC) PROGRAM which provides healthy food and nutrition information for pregnant, post-partum and for breastfeeding women, infants and children. Please be sure to take this letter with you when you go the your appointment for WIC certification. Please call 1-800-2289173".
A copy of the letter must be placed in the medical record. Document information on the back of the Certification form or in the Computer (See Attachment CT-4 and CT-5 on page CT-63) as follows: Medical (U) for unverified Gross income self declared Other PeachCare Georgia WIC Branch Turnaround Document (if used, record P in field # 61) or
place it in the comment section of the electronic certification form. This letter indicates Medicaid eligibility for the PeachCare receipt.
3. 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. Continue to use the Food Stamp ID card/number or TANF ID card/number for proof of income.
4. 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.
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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 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.).
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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 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.
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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, when an applicant is in the military:
1. Review the Leave and Earning Statement (LES) and find the
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amount received. 2. Subtract the following amount, if any apply:
BAH (Basic Allowance Housing) 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 BAH (Basic Allowance Housing) - dollar amount received. BAQ - dollar amount they receive Basic Allowance Quarters. 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
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unit) to determine income eligibility under the program.
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 applicants' 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 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
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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
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 Certification
1. Inform the applicant that he/she must bring the proof document to the clinic within 30 days.
2. Complete the top portion of the Thirty (30) Day Certification/Termination Form down through "WIC Representative and date" (Attachment CT-48 in the WIC Procedure Manual). Also complete the Fair Hearing Section at the bottom. Have the applicant sign the form as well as WIC Representative.
3. If the applicant failed to bring proof of income, have the applicant self-declare their income until they bring proof of actual income to the clinic.
4. Complete the certification form and write "OT-pending" in the applicable proof code field(s).
5. Write "Proof Pending" on the computer screen in the comment section and on the WIC ID card beside the next appointment. Highlight it on the WIC ID card.
6. Issue ONLY a one-month supply of vouchers. 7. Place a copy of the Thirty (30) Day Certification/Termination form in the pending
file. Give the original to the applicant this serves as their termination notice if they fail to bring back proof (Place a copy in the health record).
Procedures when applicant/participant brings back required proof:
1. Pull a copy of the Thirty (30) Day Certification/Termination form from the pending file.
2. Pull the applicant/participant medical record. Draw a line through the word "pending" on the certification form. Write in the presented proof, initial and date. File the Certification/Termination Notice in their medical record.
3. If the applicant is bringing back proof of income, be sure to also change the income dollar amount in the patient and information screens on the computer. If the income remains the same, initial and write the dollar amount on the WIC Certification/Assessment Form.
4. If the applicant/participant brings back proof of income, which places them over income, complete the middle portion of the Certification/Termination Form. Give applicant a copy and file a copy in their medical record.
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NOTE: The applicant/participant must return with the information. A proxy may not provide the necessary documentation to complete the Thirty (30) Day Certification process.
Procedures when applicant/participant fails to bring back proof:
1. At the end of the week, pull those records from the pending file of applicants/participants that failed to bring back proof within 30 days.
2. Terminate the participant in the computer. 3. Place one copy of the Thirty (30) Day Certification/Termination Form in the
participant's medical record and one copy in the monthly termination file.
Reversing Terminations:
If applicant returns after the Thirty (30) day grace period with the client proof, reverse the termination, reinstate the applicant and issue vouchers accordingly.
TRANSFERS:
1. The Thirty (30) day expiration date should be clearly displayed on the certification form when used for transfer.
2. Place the 30-day expiration date clearly on the VOC Card when transferring clients in or out of state.
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.
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
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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.
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
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(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. Childcare 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 salable service and merchandise used by the family of self-employed persons is not
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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
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situation of the household. Examples of such payment include legal or medical settlements that provide reimbursement for lost property and medical expenses, as 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.).
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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 "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
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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.
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.
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.
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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 the entire 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.
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. Anthropometrics data required for certification (length/height and weight), may
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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 eligibility is based on other criteria.
The Georgia WIC Program has elected to use special codes to be entered into the hematological data field, when hemoglobin is not determined. Please use the following codes, based on the computer systems in your districts:
ATVS: 88.8 Mitchell & McCormick (M&M): 88.8 Athens System: 88.8 DeKalb System: 88.8 HOST: 88.8 Aegis: 88.8
Viking is set up to accept these values to indicate that no bloodwork has been performed, and will not send this data to the Centers for Disease Control and Prevention (CDC).
Bloodwork should not be performed on infants younger than 9 months of age, unless there is a medical reason.
In most cases, infants will have bloodwork performed around 12 months of age (infant status bloodwork) and then 6 months later (child status bloodwork). If the child's bloodwork is normal, bloodwork does not have to be performed for a year. If the bloodwork is abnormal, follow one of the two following procedures:
For infants and children receiving their health care through the health department, follow the protocol for treatment of low hemoglobin, and submit to Viking each hemoglobin value determined as part of the follow-up. Once the hemoglobin becomes normal, it does not have to be determined for another year (the subsequent certification visit closest to that year).
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For infants and children receiving health care from a private provider, refer the participants with low hemoglobin values to their providers. At the next certification visit repeat the hemoglobin test or enter a referral value from the private provider. Once the value has reached a normal level, it does not have to be determined for another year (the subsequent certification visit closest to that year).
Postpartum, breastfeeding women who have breastfed for 6 months will not have to have bloodwork performed at their second postpartum WIC certification unless there is a medical reason.
Bloodwork is not routinely performed on women prior to discharge from the hospital. When postpartum breastfeeding and non-breastfeeding women are certified in the hospital, follow these procedures:
Enter the Date of Certification in the Hematological Data Date field. Enter the value 88.8 in the Hemoglobin field. If the applicant is determined to be WIC eligible, issue one month of
vouchers and follow District procedures for obtaining bloodwork, by the next voucher issuance.
NOTE: Each District must develop a written procedure to be used in obtaining bloodwork on postpartum breastfeeding and non-breastfeeding women certified in the hospital. This procedure must be approved by the Nutrition Section prior to implementation, and written approval must be kept on file in the District Office.
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 anthropometrics 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 CT-14. 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.
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XI. NUTRITION RISK PRIORITY SYSTEM
A. General
Each nutrition 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.
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
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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.

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

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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

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.

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:

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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.
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.
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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.
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 that 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.
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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.
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 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).
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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".
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:
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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.
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. Medicaid recipients must self declare income.
2. PeachCare Recipients. See acceptable Proof of Eligibility Adjunctive Eligibility. Mark "U" under Medicaid for unverified, self-declared under
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gross income, PeachCare in other, or document "P" in field #61 on Georgia WIC Program Turnaround Document.
3. 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.
4. 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.
5. Participants not receiving Food Stamps, Medicaid, or TANF. Complete according to CT-VIII. C.
6. Income Eligibility. Check "Yes" or "No" to indicate applicant's income status. Transfer 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.
Note: Income must be recorded for all applicants, including Medicaid and Food Stamps.
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
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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.
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., 165 = 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.
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(4) Last Weight Prior to Delivery. Enter the last weight taken prior to delivery, rounded to the nearest whole pound, e.g. 165 = 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.
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. (3) 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
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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.
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.
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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:
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
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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/ 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
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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)
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
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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.
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
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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: GeorgiaWIC Branch, 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.
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.
NOTE: Effective January 2001, the white VOC card were replaced with blue cards. Please observe the recommended security methods and destroy all white VOC Cards.
A physical inventory of VOC cards must be performed monthly by local agencies and clinics. The following must be recorded on the inventory log:
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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 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 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 7. Initials of one (1) clerical staff and a second staff member.
G. Security
VOC cards are negotiable instruments; therefore, the security of the cards and the accompanying inventory log is imperative. VOC cards, 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.
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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)
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
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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.
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.
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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).
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.
XIX. 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 shall determine when a waiting list will be implemented.
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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 address and telephone number c. Applicant's status (e.g. pregnant, breastfeeding, age of applicant, etc.) 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?
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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?
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.
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7. Reason for Visit - Documents the reason the applicant/participant made a visit to the WIC clinic. 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: a. A record of the staff person's initials must be placed with the actual Patient Flow Analysis documentation for audit purposes.
b. 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.
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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.
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:
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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
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
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GA WIC PROCEDURES MANUAL are coordinated is a local agency option. The GeorgiaWIC Branch 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.
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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?
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.
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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. 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: a. A record of the staff person's initials must be placed with the actual Patient Flow Analysis documentation for audit purposes.
b. 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.
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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.
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
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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
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
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GA WIC PROCEDURES MANUAL with all program coordination efforts, the method by which WIC and immunization services are coordinated is a local agency option. The GeorgiaWIC Branch and the Immunization
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GA WIC PROCEDURES MANUAL 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.
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Attachment CT 1

WIC ASSESSMENT/CERTIFICATION FORM - PREGNANT (FRONT)

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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

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

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Attachment CT-2

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

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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

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

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Attachment CT-3

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

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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

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

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Attachment CT-4

WIC ASSESSMENT/CERTIFICATION FORM - INFANT (FRONT)

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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

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-66

GA WIC PROCEDURES MANUAL

Attachment CT-5

WIC ASSESSMENT/CERTIFICATION FORM - CHILDREN (FRONT)

CT-67

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

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-68

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).

( Family 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-69

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
Required Required

Postpartum Breastfeeding
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-70

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
Birth Data or other measurement
Birth Data or other measurement

Infant 0-6 Months
Required 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-71

GA WIC PROCEDURES MANUAL

Attachment CT-9

DATA AND DOCUMENTATION REQUIRED FOR WIC ASSESSMENT/CERTIFICATION
CHILDREN

Data Length or Height Weight Hemoglobin or Hematocrit Weight for Age Plotted Length/Height for Age Plotted Weight for Length 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-72

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): Non-Smokers Smokers

Hemoglobin
10.9 gm or lower 11.2 gm or lower

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

10.4 gm or lower 10.7 gm or lower

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

10.9 gm or lower 11.2 gm or lower

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

PRIORITY I

High Risk: Hemoglobin OR hematocrit at treatment level

101 PRE-PREGNANCY UNDERWEIGHT

I

Pre-pregnancy weight is 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 CT-30, 31.

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

CT-73

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 (pre-pregnancy weight may be self-declared). If the two measurements are >1 month apart, calculate the average weight gain per month.

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

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

211 ELEVATED BLOOD LEAD LEVELS

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-74

GA WIC PROCEDURES MANUAL

Attachment CT-10 (cont'd)

CODE

PRIORITY

I 301 HYPEREMESIS GRAVIDARUM

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

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

Document: Diagnosis and the name of the physician that is treating this condition in the participant's health 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-75

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-76

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-77

GA WIC PROCEDURES MANUAL

Attachment CT-10 (cont'd)

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-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

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

I

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

small bowel enterocolitis and syndrome, pancreatitis, malabsorption syndromes,

gallbladder disease, inflammatory bowel disease (including ulcerative colitis and

crohn s disease).

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

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

High Risk: Diagnosed gastro-intestinal disorder.

343 DIABETES 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-78

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 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 cancer.

CT-79

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

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

High Risk: Diagnosed inborn error of metabolism.

CT-80

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
See Medical Record for documentation purposes.

High Risk: Diagnosed infectious disease, as described above.

353 FOOD ALLERGIES

I

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

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

High Risk: Diagnosed food allergy.

354 CELIAC DISEASE

I

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

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

High Risk: Diagnosed celiac disease.

CT-81

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-82

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 within the past 2 months, document surgery, trauma and/or burns in the participant's health record. If occurred more than 2 months ago, document description of how the surgery, trauma and/or burns currently affects nutritional status and include date.

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-83

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
< 1 can or bottle of beer (12 fluid ounces) < 5 ounces of wine < 1 fluid ounces of liquor

ounces of alcohol) is:

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-84

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.

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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:
< mental disability/delay, and/or a mental illness such as clinical depression (diagnosed by a physician or licensed psychologist).
< physical disability which restricts or limits food preparation abilities < current use of or 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-86

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 CT-30, 31.

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

CT-87

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-88

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-89

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 insufficient

I

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-90

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-91

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-92

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-93

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-94

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 within the past 2 months, document surgery, trauma and/or burns in the participant's health record. If occurred more than 2 months ago, document description of how the surgery, trauma and/or burns currently affects nutritional status and include date.

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

CT-95

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-96

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
< 1 can or bottle of beer (12 fluid ounces) < 5 ounces of wine < 1 fluid ounces of liquor

ounces of alcohol) is:

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-97

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 Comments section of the WIC Assessment/Certification Form.

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

I, II, IV

A breastfeeding woman whose breastfeeding infant has been determined to be at nutritional risk.

Document: Infant s risks on mother s WIC Assessment/Certification Form.

CT-98

GA WIC PROCEDURES MANUAL

Attachment CT-11 (cont'd)

CODE 602 BREASTFEEDING COMPLICATIONS OR POTENTIAL COMPLICATIONS

PRIORITY I

A breastfeeding woman with any of the following complications or potential

Complications for 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-99

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:
< mental disability/delay, and/or a mental illness such as clinical depression (diagnosed by a physician or licensed psychologist).
< physical disability which restricts or limits food preparation abilities < current use of or 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-100

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: Hematocrit:

12.2 gm or lower (> 15 years of age) 12.0 gm or lower (< 15 years of age) 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-101

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-102

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-103

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 micronutrients. 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-104

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-105

GA WIC PROCEDURES MANUAL

Attachment CT-12 (cont'd)

CODE 348 CENTRAL NERVOUS SYSTEM DISORDERS

PRIORITY

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

VI

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

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

(NTD) such as spina bifida and myelomeningocele.

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

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

High Risk: Diagnosed central nervous system disorder.

349 GENETIC AND CONGENITAL DISORDERS

VI

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

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

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

High Risk: Diagnosed genetic/congenital disorder.

351 INBORN ERRORS OF METABOLISM

VI

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

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

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

High Risk: Diagnosed inborn error of metabolism.

CT-106

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
See Medical Record for documentation purposes.

High Risk: Diagnosed infectious disease, as described above.

353 FOOD ALLERGIES

VI

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

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

High Risk: Diagnosed food allergy.

354 CELIAC DISEASE

VI

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

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

High Risk: Diagnosed celiac disease.

CT-107

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-108

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 within the past 2 months, document surgery, trauma and/or burns in the participant's health record. If occurred more than 2 months ago, document description of how the surgery, trauma and/or burns currently affects nutritional status and include date.

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-109

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
< 1 can or bottle of beer (12 fluid ounces) < 5 ounces of wine < 1 fluid ounces of liquor

ounces of alcohol) is:

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-110

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 Comments section of the WIC Assessment/Certification Form.

Regression cannot be used for the initial certification period.

801 HOMELESSNESS

VI

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

802 MIGRANCY

VI

Migrancy as defined in the Special Populations Section of the Georgia WIC

Program Procedures Manual.

CT-111

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 ABILITY

VI

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:
< mental disability/delay, and/or a mental illness such as clinical depression (diagnosed by a physician or licensed psychologist).
< physical disability which restricts or limits food preparation abilities < current use of or 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-112

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-113

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 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 ounces per week in the next two weeks.

Infants being certified during period from 1 to 5 months of age: < This assessment is optional, if an infant who is >1 month but <5 months of age

qualifies for WIC based on any other risk factor. If there is no other reason to

qualify the infant, use the following information to determine eligibility:

Minimum Acceptable

Age

Weight Gain

1 month 1-2 months 2-3 months 3-4 months 4-5 months 5-6 months

19 ounces 27 oz/month (6 oz/wk) 19 oz/month (4 oz/wk) 17 oz/month (4 oz/wk) 15 oz/month (3 oz/wk) 13 oz/month (3 oz/wk)

Infants 6 months to 12 months of age:
Age in Months at Certification
< 5 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-114

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-115

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-116

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-117

GA WIC PROCEDURES MANUAL

Attachment CT-13 (cont'd)

CODE 348 CENTRAL NERVOUS SYSTEM DISORDERS

PRIORITY I

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

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

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

High Risk: Diagnosed central nervous system disorder.

349 GENETIC AND CONGENITAL DISORDERS

I

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

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

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

High Risk: Diagnosed genetic/congenital disorder.

350 PYLORIC STENOSIS

I

Gastrointestinal obstruction with abnormal gastrointestinal function, affecting nutritional status.

Presence of pyloric stenosis diagnosed by a physician, as self reported by caregiver; or as reported or documented by a physician, or health professional acting under orders of a physician.

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

High Risk: Diagnosed pyloric stenosis.

CT-118

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
See Medical Record for documentation purposes.

High Risk: Diagnosed infectious disease, as described above.

353 FOOD ALLERGIES

I

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

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

High Risk: Diagnosed food allergy.

CT-119

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-120

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 within the past 2 months, document surgery, trauma and/or burns in the participant's health record. If occurred more than 2 months ago, document description of how the surgery, trauma and/or burns currently affects nutritional status and include date.

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-121

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-122

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-123

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-124

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:
< mental disability/delay, and/or a mental illness such as clinical depression (diagnosed by a physician or licensed psychologist).
< physical disability which restricts or limits food preparation abilities < current use of or history of abusing alcohol or other drugs.

Document: The caregivers 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-125

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: Hematocrit:

10.9 gm or lower 32.8% or lower

24 months-5 years of age:

Hemoglobin: Hematocrit:

11.0 gm or lower 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-126

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-127

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-128

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-129

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-130

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
See Medical Record for documentation purposes.

High Risk: Diagnosed infectious disease, as described above.

353 FOOD ALLERGIES

III

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

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

High Risk: Diagnosed food allergy.

354 CELIAC DISEASE

III

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

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

High Risk: Diagnosed celiac disease.

CT-131

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-132

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 within the past 2 months, document surgery, trauma and/or burns in the participant's health record. If occurred more than 2 months ago, document description of how the surgery, trauma and/or burns currently affects nutritional status and include date.

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

III 360 OTHER MEDICAL CONDITIONS
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-133

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-134

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 Comments section of the WIC Assessment/Certification Form.

Regression cannot be used for the initial certification period.

801 HOMELESSNESS

V

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

802 MIGRANCY

V

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

CT-135

GA WIC PROCEDURES MANUAL

Attachment CT-14 (cont'd)

CODE

PRIORITY

901 RECIPIENT OF ABUSE

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:
< mental disability/delay, and/or a mental illness such as clinical depression (diagnosed by a physician or licensed psychologist)
< physical disability which restricts or limits food preparation abilities < current use of or history of abusing alcohol or other drugs.
Document: The caregivers 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-136

GA WIC PROCEDURES MANUAL

Attachment CT-15

NOTICE OF TERMINATION/INELIGIBILITY/WAITING LIST FORM

DHR GEORGIA DEPARTMENT OF
HUMAN RESOURCES NAME:
ADDRESS:
CITY/ZIP CODE:

Georgia Department of Human Resources Division of Public Health WIC Program
NOTICE OF TERMINATION / INELIGIBILITY / WAITING LIST
DATE:_______________________________ DATE OF BIRTH:
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-137

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-138

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-139

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-140

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-141

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-142

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 ounce.

8. Record the second reading promptly.

CT-143

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-144

GA WIC PROCEDURES MANUAL

Attachment CT-23 (cont'd)

EQUIPMENT MAINTENANCE

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.

The Georgia WIC Program has elected to use special codes to be entered into the hematological data field, when hemoglobin is not determined. Please use the following codes, based on the computer systems in your district.
v ATAVS: 88:8 v Mitchell & McCormick (M&M): 88.8 v Athens System: 88:8 v DeKalb System: 88:8 v HOST: 88:8 v Aegis: 88:8

Viking is set up to accept hese values to indicate that no blood work has been performed, and will not send this data to the Centers for Disease Control and Prevention (CDC).

Blood work should not be performed on infants younger than 9 months or age, unless there is a medical reason.

In most cases, infants will have blood work performed around 12 months or age (infant status blood work) and then 6 months later (child status blood work). If the child's blood work is normal, blood work does not have to be performed for a year. If the blood work is abnormal, follow one of the two following procedures:

a. For infants and children receiving their health care through the health department, follow the protocol for treatment of low hemoglobin, and

CT-145

GA WIC PROCEDURES MANUAL

Attachment CT-23 (cont'd)

submit to Viking each hemoglobin value determined as part of the follow-up. Once the hemoglobin become normal, it does not have to be determined for another year (the subsequent certification visit closest to that year).

b. For infants and children receiving health care from a private provider, refer the participants with low hemoglobin values to their providers. At the next certification visit repeat the hemoglobin test or enter a referral value from the private provider. Once the value has reached a normal level, it does not have to be determined for another year (the subsequent certification visit closet to that year.

Postpartum, breastfeeding women who have breastfed for 6 months will not have to have blood work performed at their second postpartum WIC certification unless there is a medical reason.

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-146

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 Body Mass Index Table (Attachments CT29, 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-147

GA WIC PROCEDURES MANUAL

Attachment CT-25

PRENATAL WEIGHT GRID FOR NORMAL WEIGHT AND TWINS

CT-148

GA WIC PROCEDURES MANUAL

Attachment CT-27

PRENATAL WEIGHT GRID FOR UNDERWEIGHT AND OVERWEIGHT

CT-149

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 CT-33).

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-150

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:

Year

Month Day

Date of Measurement

2002

4

21

Birth date

-1997

-8

-10

Child's Age

4 y

8m

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-151

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 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, Infant Section, III. d. for instructions on adjusting for prematurely. Use measurements plotted at actual age to determine WIC eligibility.

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.

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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-153

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 medium frame weight range, and calculating 10% below, 21% above and 36% above.
1. Measure height in inches, without shoes. 2. Measure weight in pounds. Allowance provided for indoor clothing.
Reference: Prepared by the Nutrition Section, Division of Public Health, Georgia Department of Human Resources, October 1998. Based on the 1957 Metropolitan Life Tables.

CT-154

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-155

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-156

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-157

GA WIC PROCEDURES MANUAL
RECOMMENDED DAILY SERVINGS CHART

Attachment CT-32

Food Group

Birth to 5/6 Months

5/6 Months to 1 Year

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
cup cooked dry beans 2 tablespoons peanut butter

1-3 Years old1

4-6 Years old4

Pregnant Teen/ Pregnant Adult4

2 servings (16 ounces total)

2 servings (16 ounces total)

3-4 servings2

3 ounces

5 ounces

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

2 servings

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

3 servings

6 servings
1 serving = slice or
cup cooked 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
cup pieces
Vegetable Group: 1 serving =
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-158

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-159

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-160

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-161

GA WIC PROCEDURES MANUAL

Attachment CT- 35

GEORGIA WIC PROGRAM INCOME ELIGIBILITY GUIDELINES (Effective from April 15, 2002 to April 15, 2003) 48 CONTIGUOUS UNITED STATES, DISTRICT OF COLUMBIA,
GUAM AND TERRITORIES

Reduced Price Miles 185% Federal Poverty Guidelines

Household Size

Annually

Monthly

TwiceMonthly

Bi-Weekly

Weekly

1

16,391

2

22,089

3 4

27,787

5

33,485

6

39,183

7

44,881

8

50,579

56,277

Each Additional Member Add

+5,698

1,366 1,841 2,316 2,791 3,266 3,741 4,215 4,690
+475

683 921 1,158 1,396 1,633 1,871 2,108 2,345
+238

631 850 1,069 1,288 1,508 1,727 1,946 2,165

316 425 535 644 754 864 973 1,083

+220

+110

CT-162

GA WIC PROCEDURES MANUAL GEORGIA WIC PROGRAM

Attachment CT- 36

VOC CARD AGREEMENT

District ______, Unit ______ would like to have a clinic representative order VOC Cards directly from the Georgia 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 GEORGIA WIC BRANCH TO INFORM THEM OF THE CHANGE.

CT-163

GA WIC PROCEDURES MANUAL VOC CARD FORM

Attachment CT-37

District ____, Unit ____

In an effort to begin sending VOC cards directly to the clinic from the Georgia WIC Branch, the following form must be on record at the Georgia 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-164

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

Forms Supply

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

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.) -

SEND ORIGINAL AND TWO COPIES TO CENTRAL SUPPLY TERMINAL COPY

CT-165

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 Georgia WIC Branch to the Clinic. This Form must be signed by clinic staff within five (5) days of Receipt then returned to sender. The Georgia 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 - Georgia WIC Branch

Canary Clinic

Pink - District

CT-166

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-167

DHR
Georgia Department of Human Resources

GA WIC PROCEDURES MANUAL

Attachment CT-41

THERE IS NO CHARGE FOR WIC SERVICES

Georgia WIC Program Promoting healthy nutrition for Women,
Infants and Children since 1974 1-800-228-9173
This is an Equal Opportunity Program. If you believe you have been discriminated against because of race, color, national origin, sex, age, or handicap, write immediately to the Secretary of Agriculture, Washington, D.C. 20250.
CT-168

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. ( Family 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-169

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-170

GA WIC PROCEDURES MANUAL
FAMILY PLUS MEDICAID CARD

Attachment CT-44

BENEFIT DESCRIPTION

CO-PAY

FamilyPlus*

COPAYS

RX USE ONLY

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

OV $0

| BIN # 600426 MEMBER #

EFF DATE

SP $0

| PCN #6F

403967045P

02/01/98

ER $0

| 1 (800) 433-4893

UC $0

|

GROUP# M00101 BIRTH

SEX

RX $0

|

MEDICAID OF GA 06/03/94

F

AFD

|

(404) 525-0600

*CALL YOUR PCP TO COORDINATE *ATLANTA CHILDREN S HEALTH NETWORK

*ALL OF YOUR HEALTHCARE NEED

*The family of health plans that fits.

CT-171

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 Yes to either of the above questions, please complete the form below.

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

(If more space is needed, list 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-172

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-173

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-174

GA WIC PROCEDURES MANUAL

Attachment CT-47 (Cont'd)

AYUDE PARA QUE EL WIC LE AYUDE!

Cada vez que su nino/infante /o usted son certificados para WIC, usted DEBE presentar una (1) prueba de cada una de las siguientes categorias:

Prueba de identificacion, direccion e ingresos son necesarios para cadaaplicante/participante,padre, guardian, infante o nino. Si usted llega a la oficina del WIC sin esta informacion, le daremos una nueva cita. Por favor llame a su Departamento de Salud local si tiene alguna pregunta. Si esta embarazada, traiga su prueba de embarazo.

Prueba de IDENTIFICACION (una por cada uno)

INFANTE: Certificado de nacimiento Confirmacion de nacimiento Brazalete de identificacion del Hospital(mama y hijo) Record de vacunas Record Medico Tarjeta de Seguro Social Papeles de alta de hospital

NINO Certificado de nacimiento Record de vacunas Record Medico Tarjeta de Seguro Social

MUJER: Certificado de nacimiento Licencia de Conducir Record de Vacunas Tarjeta Militar Record Medico Tarjeta de Seguro Social Identificacion de Estado/Escuela Tarjeta VOC(con identificacion
adicional) Registracion para votar Identificacion del Trabajo

Prueba de DIRECCION (una)

Recibo de Cable/TV Recibo de Gas Recibo dela Agua

Recibo de Electricadad Recibo de Telefono Recibo de Renta/Casa

Record Medico Tarjeta de Medicaid

NUMERO DE BUZON DE CORREO NO SON ACEPTADOS

Prueba de INGRESOS (traiga prueba de ingreso de cada persona en el hogar que tenga empleo)

Pagos de mantenimiento para hijo

Anuidades

Asistencia basica de subsistenciac

Contribuciones de personas

Talon de cheque

tarjeta actual de Medicaid

Forma corriente de Ingreso annual Pensiones

Pensiones privadas

Seguro Social

Ingreso de Finca Raiz

Dividendos.interes de inversion

Ingreso de Renta

Retiro Militar

Auto Empleo(Ingreso Neto)

Record finacieros

Pago de Veteranos

Seguro Social Suplementario

Notificacion de Desempleo

Carta de su empleador

Compensacion de Desempleo

Compensacion monetaria

Documentacion de estampillas

Pagos de Asistencia Publica/Welfare(TANF)

de comida

"Esta institucion es un proveedor de oportunidades equitativas."

CT-175

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-176

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-177

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-178

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-179

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-180

GEORGIA WIC PROCEDURES MANUAL

TABLE OF CONTENTS

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

GEORGIA WIC PROCEDURES MANUAL

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 Participant - 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

GEORGIA 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 signing, 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 form 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

GEORGIA 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 Georgia 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

GEORGIA WIC PROCEDURES MANUAL
To file a complaint of discrimination, write to: USDA, 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). USDA is an equal opportunity provider and employer. [SEP Regional Letter 290-7, Rev .2]
"This institution is an equal opportunity provider."
The USDA "And Justice for All" poster should be used.
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 Georgia WIC Branch.
RO - 3

GEORGIA WIC PROCEDURES MANUAL
B. Training
Civil Rights training must be provided annually for all staff that have contact with WIC applicants/participants. This training must be provided to State and District staff annually. New staff must have Civil Rights Training 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 asks 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 are requirements 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 for four (4) years under safeguards, which will restrict access to authorized personnel. 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, Office of Civil Rights, Room 326-W, Whitten Building, 1400 Independence Avenue, SW, Washington, DC 202509410 or call (202) 720-5964 (voice and TDD). USDA is an equal opportunity provider and employer. [SEP Regional Letter 290-7, Rev .2] if he/she feels discrimination has
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GEORGIA WIC PROCEDURES MANUAL
occurred. A copy of the complaint must be sent to the Georgia WIC Branch, 2 Peachtree Street, Suite 10-394, Atlanta, Georgia 30303 to the attention of the Technical Assistant Unit.
1. Written Complaints
Persons seeking to file discrimination complaints may file their complaint at the same address. A copy must be sent to the Georgia 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 Georgia 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 the 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 to 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
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GEORGIA WIC PROCEDURES MANUAL
his/her right to a fair hearing and of the method by which a hearing may be requested.
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.
4. Render a hearing decision based exclusively on the hearing record and matters
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GEORGIA WIC PROCEDURES MANUAL
officially noticed.
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, Georgia 30303. A copy of the form shall be sent to the Georgia 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.
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GEORGIA 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 changes, pending the hearing decision.
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GEORGIA 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 scheduled 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.
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GEORGIA 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.
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GEORGIA 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.
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GEORGIA 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 Georgia WIC Branch.
VII. ADMINISTRATIVE APPEALS PARTICIPANT - LOCAL AGENCY
An entity such as a doctor, hospital or HMO, applying to become a WIC provider, can appeal a decision of the state or local agency if the decision resulted in the denial of that application.
The appeal must be filed within thirty (30) days of the adverse action and the fair hearing must be scheduled within thirty (30) days of the filing of the appeal. Fifteen (15) days advance notice of the hearing date will be given to the applying entity with an option to reschedule one (1) time with just cause.
The applying entity will have ample opportunity to present its case at the hearing, including the opportunity to confront and cross-examine witnesses. Counsel may represent the applying entity if desired. The applying entity may review the case file prior to the hearing.
RO - 12

GEORGIA 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 obligations 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.
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GEORGIA 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 you to use these services.

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

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

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

7. You may be taken off WIC if:

You do not tell the truth. You get vouchers from more than one (1) WIC program at the same time. You do not keep your certification appointments. (Rescheduling WIC appointments may
take from 7 to 20 days depending on the clinic schedule).
You do not get your vouchers for two (2) months in a row. You sell 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.

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GEORGIA 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."

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GEORGIA 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.

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GEORGIA 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.
2. Does not live in local program area.
3. Has reached expiration of regulatory eligibility.
4. Is not pregnant, postpartum, breastfeeding or Infant/Child under five (5) years of age.

__________ Date __________ Date __________ Date __________ Date

5. Does not meet nutritional risk criteria.

6. Failed certification appointment on: ____________________.

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

8. Violated program rules and was suspended for three

(3) months for:

.

9. Is in Priority and program has funds to serve

only Priority(ies)

.

10. Other

.

B. Agency Inaction (Circle item number):

__________ Date __________ Date __________ Date
__________ Date
___________ Date
___________ Date

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

2. Other: (specify) ________________________________________________________

_____________________________________________________________________

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GEORGIA 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 - Georgia WIC Branch File Copy - District/Local Agency

_______________________________ Signature of WIC Coordinator

________________________________

City

State

Zip Code

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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 VI. Inventory ........................................................................................................ AD-4 VII. Allocation of Nutrition Services and Administration Funds ............................ AD-5 VIII. Program Income ............................................................................................. AD-6

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-7 D. Prior Approval/Duplication of WIC Records ............................................. AD-8
II. WIC Acronym and Logo ................................................................................ AD-9 A. Authority ............................................................................................ AD-9 B. Official Use ............................................................................................. AD-10 C. Special Use.............................................................................................. AD-10 D. WIC Food Vendors................................................................................. AD-11 E. 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
A. Subpoena ...........................................................................AD-13 B. Procedure for Responsibility to a Subpoena ...................................AD-14 X. Search Warrants ............................................................................................ AD-15 XI. Program Participation.................................................................................... AD-15 XII. System Maintenance Indicator Report/Pending ............................................. AD-15

GA WIC PROCEDURES MANUAL
XIII. Establishing New Clinics/Clinic Changes ..................................................... AD-15 XIV. Clinic Closings ............................................................................................. AD-16 XV. Central Supply Forms .... ................................................................... AD-17 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.
4. 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 Georgia 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 Georgia 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 Georgia 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 Georgia WIC Director at least 45 days prior to the anticipated purchase date. The request must include the following:
1. A statement that the requested equipment is not part of a larger ADP project.
2. A brief description of the need for the equipment and justification of the proposed purchase.
3. 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.
VI. 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 Georgia WIC Branch no later than September 30th of each year, by regular mail or e-mail. Failure to comply with these requirements will result in a Corrective Action for the District. 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)
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GA WIC PROCEDURES MANUAL Please refer to the Department of Human Resources Real and Personal Property Management Manual to properly dispose of those pieces of equipment that are damaged, deleted or discarded. If the equipment has been stolen, enclose a copy of the police report with the inventory form. All equipment (deleted, damaged, stolen or discarded) should be indicated as such on your 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.
Surplus Inventor
Equipment that is surplused must be kept on a separate Inventory and submitted to the Georgia WIC Branch by September 30th. Also, this equipment will also be checked on the program review (See Surplus Inventory example AD-6).
Please refer to the Department of Human Resources Real and Personal Property Management manual to properly dispose of those pieces of equipment that are damaged, deleted or discarded. If the equipment has been stolen, enclose a copy of the police report with the inventory form. All equipment (deleted, damaged, stolen or discarded) should be indicated as such on your 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.
VII. 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 Georgia 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
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GA WIC PROCEDURES MANUAL distribution of funds and the succeeding year's caseload strategies. However, meetings are convened on an as needed basis.
VIII. 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, and Section 3016.25.
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.
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GA WIC PROCEDURES MANUAL C. Retention Schedule
The following documents must be retained for five (5) years, as stated in the DHR Record Retention Policy, issued November 12, 1986:
(1) WIC Assessment/Certification Forms (2) Diet Histories (3) Growth Charts/Weight Gain Grids (4) VOC 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
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GA WIC PROCEDURES MANUAL (9) Canceled food instruments
*The original copy of these reports with their manual reconciliation must be sent to the Georgia WIC Branch prior to being destroyed. The Georgia 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.
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 Georgia 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
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GA WIC PROCEDURES MANUAL
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 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
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GA WIC PROCEDURES MANUAL 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 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 Georgia 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 Georgia WIC Branch must respond in writing on whether such use is authorized.

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GA WIC PROCEDURES MANUAL
D. WIC Food Vendors At the discretion of the Georgia 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.
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.
E. 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. LOBBYING RESTRICTIONS
The State/Local Agencies must not use federal funds for lobbying for specific federal awards and requires recipients of any federal grants, contracts, loans, and cooperative agreements to disclose expenditures made with their own funds for such 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
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GA WIC PROCEDURES MANUAL 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.
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.
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GA WIC PROCEDURES MANUAL
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.
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 No Smoking Sign. These signs must be visible somewhere in the clinic.
The prohibition against smoking applies only during the hours of actual WIC operations. In the event the clinics for voucher issuance 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 Georgia WIC Branch for legal advice.
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GA WIC PROCEDURES MANUAL
B. Procedures for Responding to a Subpoena
1. 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.
2. Decisions to release WIC information as requested by a subpoena or to attempt to quash a subpoena must be based on the requirements and restrictions set forth in 7 CFR 246.26(d) of the WIC regulations, any pertinent State laws, FNS Instruction 800-1, and WIC Policy Memorandum 94-3. Any conflicts identified between Federal and State requirements should be referred to the DHR Legal Services Office where appropriate.
3. 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:
A. consider the appropriateness of an appeal of the decision,
B. 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
C. 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).
4. 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
5. 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.
6. 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.
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GA WIC PROCEDURES MANUAL
7. 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 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 Georgia WIC Branch within thirty (30) days of the date the change occurs.
Clinic changes are reported using the Request for Establishing New Clinic/Clinic Changes Form (Attachment AD-10). The form must be completed and forwarded to the Georgia 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:
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GA WIC PROCEDURES MANUAL
1. A Local Agency wishing to establish a new clinic must contact the Georgia WIC Branch in writing or via telephone.
2. The Georgia 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 Georgia WIC Branch.
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 Georgia WIC Branch will provide technical assistance, consultation, and training to the Local Agency in the start up procedures of a new clinic.
8. Any District/Local agency that opens a clinic without following the above procedures will be in violation of State requirements. Being in violation of State requirements means.
1. The Georgia WIC Branch will not fund that clinic. 2. In the event of any investigation or complaints, the local agency is on their own for
support and money.
*No vouchers can be delivered to any clinic that does not have a clinic number. All clinics, hospitals, etc. must have a clinic number.
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 Georgia 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.
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GA WIC PROCEDURES MANUAL 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 Georgia 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 Georgia 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.
XVI. DAMAGE VOUCHER 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 Georgia WIC Branch. The Fax Number (404) 657-2910.
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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

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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 x 100% = % of time spent

individual's total time

performing WIC

worked

duties (P)

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

Use the same formula used in "Rate" above.

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Page 1

SFY 2003 ANNEX H OF THE DEPARTMENT OF HUMAN RESOURCES 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 7CFR 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, 2002 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.
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 WIC Branch Policy and
Procedures Manual and the Georgia WIC Branch State Plan for Program 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 for Program Operation and the Georgia WIC Branch Policy and Procedures Manual.
2. To comply with the Georgia DHR Administrative Policy and Procedures and DHR Grants-toCounties 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 shall submit the program plan to the Georgia WIC Branch by September 1st of the fiscal year.

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Agreement

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

5. 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 using Generally Accepted Accounting Principles (GAAP).

6. 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 federal caseload mandate.

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

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

9. 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.

10. To implement the Food Delivery System under terms prescribed by the Georgia WIC Branch and as outlined by 7CFR246.

11. 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 instruments, the local agency is responsible for payment to the State WIC Branch .

12. 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.

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

14. To provide a quarterly report listing breast pump expenditures including quantity and dollar amount by the 15th of the month following the end of the quarter.
15. To submit a Caseload Management Plan as prescribed by the Georgia WIC Branch by October 15th of the fiscal year.

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Agreement

16. To submit signed copies of all Inter/Intra Agency Agreements for WIC Services between the District and the County Boards of Health by August 15th of the fiscal year.

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.
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 7CFR 246.24, Administrative Appeals. A Local Agency is allowed two opportunities to reschedule a hearing.

GA WIC PROCEDURES MANUAL

ATTACHMENT AD-3 (cont'd)

WIC FORMS AVAILABLE IN CENTRAL SUPPLY

Contact: Anquinette Reid

(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 Postpartum Breastfeeding Pad/100..................................................... #3296B(Rev.9-00)*

3. 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)

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

5. Georgia Department of Human Resources Division of Public Health/WIC Program Food List Spanish Insert - Pkg/100 .......................................................................................... #3794
6. Georgia Department of Human Resources Division of Public Health/WIC Program Georgia WIC Program No Proof Form - Pad/100.................................................................... #3019
7. Georgia Department of Human Resources Division of Public Health/WIC Program Georgia WIC Program Signed Statement of Income, Residency and Identification - Pad/100...................................................................... #3035
8. Georgia Department of Human Resources Division of Public Health/WIC Program Thirty Day Certification Form ..............................................................................#3318
9. Georgia Department of Human Resources Division of Public Health/WIC Program Letter of Household Income.................................................................................#3026

AD - 22

GA WIC PROCEDURES MANUAL

ATTACHMENT AD-3 (cont'd)

10. Georgia Department of Human Resources Division of Public Health/WIC Program Georgia WIC No Proof Forms (English).................................................................#3019
11. Georgia Department of Human Resources Division of Public Health/WIC Program Income Calculation Form..................................................................................#3020

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 Witness)

(Title or Relationship

to Client)

__________________________________
(Signature of Client/Patient/Applicant)

__________________________________

(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
EFFECTIVE DATE OF CHANGE TYPE OF CHANGE

CLINIC CHANGE CLINIC NUMBER

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

I.

Number and Distribution of Authorized Vendors .................................. VM-1

II.

Vendor Application Periods.................................................................. VM-1

III.

Vendor Selection and Authorization ..................................................... VM-1

IV.

Peer Groups ......................................................................................... VM-1

V.

Vendor Agreements.............................................................................. VM-2

VI.

Vendor Training ................................................................................... VM-2

VII.

High Risk Identification System............................................................ VM-2

VIII.

Routine Monitoring .............................................................................. VM-2

IX.

Vendor Sanction System....................................................................... VM-3

X.

Administrative Review.......................................................................... VM-3

XI.

Coordination With Food Stamp Program (FSP) .................................... VM-3

XII.

Staff Training in Vendor Management .................................................. VM-3

Attachments: VM-1 ............ Application for Vendor Authorization VM-2 ............ Vendor Handbook VM-3 ............ Vendor Agreement (2 years) VM-4 ............ Vendor Agreement (3 years) VM-5 ............ Pharmacy Price List VM-6 ............ Corporate Attachment Form VM-7 ............ Vendor Training Checklist VM-8 ............ Corporate Vendor Training Checklist VM-9 ............ WIC Incident/Complaint Form VM-10 .......... Vendor Review Form VM-11 .......... Cooperative Agreement Between the Georgia WIC Program and FNS
Field Office

GA WIC PROCEDURES MANUAL

VENDOR MANAGEMENT

I.

NUMBER AND DISTRIBUTION OF AUTHORIZED VENDORS

The Georgia WIC Branch does not use limiting criteria to limit the number of vendors it authorizes.

II.

VENDOR APPLICATION PERIODS

Applications are accepted on an ongoing basis, except sixty (60) days prior to the expiration of the two (2) and three (3) year agreement. See attachment 1, Application for Vendor Authorization

III.

VENDOR SELECTION AND AUTHORIZATION

A. Selection Criteria
For selection criteria see attachment 2, Vendor Handbook, page 4.
For minimum variety and quantity of supplemental foods criteria, see Vendor Handbook, page 9.
For business integrity criteria, see Vendor Handbook, pages 3-4.
For all other selection criteria, see Vendor Handbook, page 4.

B. On Site Visit and Authorization Onsite visits are conducted to verify the information received during the application process including minimum variety and quantity of supplemental foods.

The Food Stamp number is verified using STARS database or by requesting USDA's Food and Nutrition Service to provide the number for a specific applicant.

IV.

PEER GROUPS

For peer group information, see attachment 2, Vendor Handbook page 4.

VM-1

GA WIC PROCEDURES MANUAL

V. VI. VII.
VIII.

VENDOR AGREEMENTS
The Georgia WIC Branch enters into two (2) year and three (3) year agreements with food retailers, pharmacies and military commissaries. See attachments 3 and 4 (WIC Agreement 2 year and 3 year respective), and attachment 5, Pharmacy Price List.
Food retailers with the same federal employment identification number and a corporate /home office or a single owner business entity that serves as a parent may sign a single agreement that include all the stores in the chain. See attachment 6, Corporate Attachment Form#3771A.
VENDOR TRAINING
For training information see Vendor Handbook, page 5. For documentation of vendor training see attachment 7, Form #3757, Vendor Training Checklist and attachment 8, Form #3757A Corporate Vendor Training Checklist.
HIGH RISK IDENTIFICATION SYSTEMS
VENDOR COMPLAINTS
The Georgia WIC Branch has a toll free number for participants and vendors to call to report complaints about vendors. The participant may also contact their local WIC clinic where the complaint is documented and forward to the Georgia WIC Branch, see attachment 9 Complaint Form. Vendors have a toll free customer service hotline that can be used to report complaints or make inquiries, 1-866-8145468.
IDENTIFYING HIGH-RISK VENDORS
For criteria used in identifying high risk vendors see Vendor Handbook, page 14
ROUTINE MONITORING
Performance monitoring is described in the Vendor Handbook, page 14. Overt monitoring is performed on five percent of total vendors

VM-2

GA WIC PROCEDURES MANUAL

annually using a standardized monitoring instrument. See attachment 10, Vendor Review Form. Vendors are selected for routine monitoring visits based on complaints, random selection and scores on internal reports.

IX.

VENDOR SANCTION SYSTEM

See 1, Vendor Handbook, pages 15-17.

X.

ADMINISTRATIVE REVIEW

For administrative review procedures, see 1, Vendor Handbook, pages 17-18. The Georgia WIC Branch conducts only full Administrative Reviews and includes all of the items listed in the above referenced pages.

XI.

COORDINATION WITH FOOD STAMP PROGRAM (FSP)

An information sharing agreement between the Georgia WIC Branch and the Food and Nutrition Service is maintained at the State Agency. See attachment 11.

The Georgia WIC Branch compliance investigations unit routinely coordinates their activities with their Food Stamp Program counterparts on Georgia's high-risk WIC vendors.

XII.

STAFF TRAINING ON VENDOR MANAGEMENT

New employees receive orientation and in service training on the following Vendor Management topics.

1. The application process (selection and authorization) 2. Vendor Training 3. Routine Monitoring 4. Compliance Investigations 5. Inventory Audits 6. Sanctions 7. Vendor Appeals/Administrative Reviews 8. Federal and State WIC regulations 9. High Risk Vendor Identification 10. VIPS (Vendor Integrity Profile System) internal vendor database.

VM-3

GA WIC PROCEDURES MANUAL

Attachment VM-1

Georgia Department of Human Resources
Division of Public Health
GEORGIA WIC PROGRAM APPLICATION FOR VENDOR AUTHORIZATION AND INSTRUCTIONS

Please print or type legibly. Incomplete applications, including attachments will be returned unprocessed. FOR GEORGIA WIC BRANCH (GWB) USE ONLY

District/Unit

Vendor Number

Peer Group

Date Received

F/P

Cost

Maximum

Date Approved

F/P

Cost

Maximum

Date Denied

F/P

Cost

Maximum

Reason Denied

Processed By Check one
Re-Application (Enter current vendor number) _______________________

Initial Application

Will this store participate as a corporate vendor?

Yes

PART I STORE IDENTIFICATION

1. Store Name Manager's Name Business Telephone Number
E-mail Address 2. Physical Location
Street Address/Rural Route City State Mailing Address Street Address/P. O. Box City

-
Area Code

-

Fax Number

Area Code

County Zip +4
State

Zip + 4

3. Square Footage of Store (including storage area)

4. Food Sales Establishment License Number

5. Does this store now participate in the Food Stamp Program?

Yes

If yes, indicate the Food Stamp Authorization Number

6. Type of Business - Check Only One Independent

Commissary

Chain

Pharmacy

7. Federal Employer Identification Number

or Owner's SSN

No

-

-

No

-

-

Page 1 of 9

GA WIC PROCEDURES MANUAL

Attachment VM-1

8. A. What date will the store have the required minimum inventory of

Month

Day

Year

approved WIC food items in stock?

B. What date did (or will) the store open under the applying ownership?

/

/

Month

Day

Year

9. Store History A. Are you related to the previous owner(s) by blood or marriage? If YES, what is the relationship?

Yes

No

B. Have the owner(s) ever owned a business(es) authorized by the Georgia WIC

Program?

Yes

No

If YES, attach a list of stores.

C. How long has this store been in business?

D. Has this store ever operated under another name in Georgia?

Yes

No

If YES, indicate name.
PART II STORE OWNERSHIP AND MANAGEMENT

10. Complete the following information on the individual you designate as the Authorized Representative.

Name

Title

Street Address/Rural Route

City Business Telephone E-mail address

-

-

Area Code

State
Fax Number
Area Code

Zip+4

-

-

11. Type of Ownership Check one Sole proprietorship
Partnership Limited Liability Corporation

Privately owned corporation Publicly owned corporation Government owned

12. Names and Titles of Principal Officer(s)/Owner(s)

Name

Title

Name

Title

Name

Title

13. Ownership History

A. Including this store, has the current owner(s), officer(s) or manager(s) ever

owned or managed a business that violated the Georgia WIC Program, receiving

a warning letter, probation, disqualification or assessment of a Civil Money

Penalty?

Yes

No

If YES, attach an explanation identifying the person, business name, location

and nature of violation.

B. Including this store, has the current owner(s), officer(s) or manager(s) ever

owned or managed a business that violated the Food Stamp Program, receiving a

warning letter or was withdrawn, disqualified or assessed a Civil Money

Penalty?

Yes

No

Page 2 of 9

GA WIC PROCEDURES MANUAL

Attachment VM-1

If YES, attach an explanation identifying the person, business name and nature of violation.

C. Has the current owners, officers or managers ever been convicted of or had a

civil judgment for fraud, antitrust violations, embezzlement, theft, forgery,

bribery, falsification or destruction of records, making false statements, receiving stolen property, making false claims or obstruction of justice?

Yes

No

If YES, attach an explanation identifying the person, date and nature of

violation.

PART III OPERATIONS AND SALES

14. Hours of Business Sunday Monday Tuesday Wednesday
15. A. Number of scanners

Thursday Friday Saturday

B. Can the scanner detect WIC eligible foods? C. Does your store have a Point of Sale device?

Yes

No

Yes

No

16. Bank Information Name of Bank Street Address City

State

Zip

Page 3 of 9

GA WIC PROCEDURES MANUAL

Attachment VM-1

PART IV STORE PRICE LIST AND INVENTORY

Food Item

Brand Name

FOR GWB USE ONLY

Size

Highest Negotiated On-Site

Price

Price

Price

17. Juice
18. Cereal 19. Peas/Beans 20. Peanut Butter 21. Infant Cereal
Rice 22. Contract Formula Milk
Based 23. Contract Formula Soy
Based 24. Pasteurized Milk 25. Cheese 26. Eggs (Large Only)

46 oz. can 46 oz. plastic bottle 12 oz. box 1 pound bag 18 oz. jar 8 oz. box
13 oz. can 13 oz. can
1 gallon container 1 pound package 1 dozen carton

Page 4 of 9

GA WIC PROCEDURES MANUAL

Attachment VM-1

Food Item

Brands (B) Types (T) Size

Item In Stock? Minimum Quantity In Stock?

27. Juice

2 (T) 46 oz.

Yes

No

24

Yes

No

28. Cereal (2 types must be in 12 oz.)

4 (T) 9 to 24 oz. Yes

No

30

Yes

No

29. Dried Peas/Beans 30. Peanut Butter 31. Infant Cereal
(1 type must be rice)

2 (T) 1 lb. pkg. Yes

No

8

Yes

No

2 (B)

18 oz.

Yes

No

8

Yes

No

2 (T)

8 oz.

Yes

No

12

Yes

No

32. Contract Formula Milk Based 1 (B)

13 oz.

Yes

No

138

Yes

No

33. Contract Formula Soy Based

1 (B)

13 oz.

Yes

No

32

Yes

No

34. Pasteurized Milk

1 (B) 1 gallon

Yes

No

20

Yes

No

35. Cheese

2 (T) 1 pound

Yes

No

16

Yes

No

36. Eggs

1 (B)

1 dozen

Yes

No

16

Yes

No

PART V STATEMENTS AND CERTIFICATION

PRIVACY ACT STATEMENT The collection of this information is authorized by Part 246.12 of Federal Regulations 7CFR, Ch.11 which
governs the Special Supplemental Nutrition Program for Women, Infants and Children. It will be used to determine whether a store qualifies to participate in the WIC Program, monitor compliance with program regulations and for program management. The provision of the requested information, including the Federal Employer Identifier Number or Social Security Number, is voluntary. However, failure to provide information may result in the denial or termination of authorization to participate in the WIC Program. The purpose of collection of this information is for audit and enforcement of WIC regulations.

WARNING STATEMENT Information in this application may be verified with other agencies. The authorization of the vendor to participate in
the Georgia WIC Program can be denied or terminated if it is determined that the vendor applicant provided false statements, made false representations, or used any false writing or documentation in conjunction with this application. WIC participation can be terminated if the business violates any laws or regulations issued by Federal or State programs including the Food Stamp Program and Food Stamp Program regulations.

CERTIFICATION AND SIGNATURE OF OWNER OR AUTHORIZED REPRESENTATIVE
1. I have authority to apply for authorization for this store to participate in the Georgia WIC Program. 2. I will update the information on this application as required by the WIC Program. 3. I affirm that all statements made in this application are true.

SIGNATURE

DATE

PRINT NAME

TITLE

DAYTIME NUMBER

-

-

Area Code

E-MAIL ADDRESS

FAX NUMBER

-

-

Area Code

The United States Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national
origin, sex, age, or disability. (Not all prohibited bases apply to all programs) Persons with disabilities who require alternative means for communication
of program information (Braille, larger print, audiotape, etc.) should contact USDA's TARGET Center at (202) 720-5964 (voice and TDD). To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 14th and Independence Avenue,
S.W., Washington, D.C. 20250-9410 or call (202) 720-5964 (voice and TDD). USDA is an equal opportunity provider and employer.

Return application to: DO NOT FAX

Georgia WIC Branch Vendor Management Section 2 Peachtree Street, NW Suite 10-476 Atlanta, Georgia 30303-3142 Toll free 1-866-814-5468 or 404-657-2900

Page 5 of 9

GA WIC PROCEDURES MANUAL

Attachment VM-1

Instructions for Completing the Vendor Application

Print legibly or type. Incomplete applications will be returned unprocessed.
Check if the application is an initial application or if it is a re-application. An initial application is for the vendor applicant who has never been authorized by the Georgia WIC Branch. A re-application is for a vendor who is currently authorized by the Georgia WIC Branch and wishes to continue as a vendor beyond the expiration of the current agreement. If this is a re-application, enter the current Georgia WIC Vendor Number in the space provided.

Answer yes or no if the store is applying as a corporate vendor. A corporate vendor is defined as a business entity having two (2) or more stores under the same Federal Employer Identification Number (FEIN) and have a corporate/home office or a single owner/business entity that serves as the parent.

PART I - STORE IDENTIFICATION

1. Enter the information regarding the identification of the store STORE NAME. Enter the name of the store. Corporate vendors, enter the name of the corporation. MANAGER'S NAME. Enter the name of the person responsible for this store location. Corporate vendors, enter Not Applicable (N/A). BUSINESS TELEPHONE NUMBER. Enter the main telephone number at the place of business listed above. FAX NUMBER. Enter the fax number for the store (or corporation) entered above. E-MAIL ADDRESS. Enter the e-mail address for the manager listed above. If e-mail is not available for the person listed above, enter Not Applicable (N/A).

2

Enter the information regarding the addressof the store.

Physical Location

STREET ADDRESS. Enter the street name and number for the store (or corporation) listed above. DO

NOT enter a Post Office Box for this location.

CITY. Enter the name of the city.

COUNTY. Enter the name of the county.

STATE. Enter the name of the state in which the business is located.

ZIP+4. Enter the postal code + the four digit locator code.

Mailing Address STREET ADDRESS. Enter the street name and number for the store (or corporation) where mail is delivered to the location above. A Post Office Box may be entered in this space. CITY. Enter the name of the city. STATE. Enter the name of the state in which the business is located. ZIP+4. Enter the postal code + the four digit locator code.

3. SQUARE FOOTAGE. Enter the store's total square footage including storage area.

4. GEORGIA DEPARTMENT OF AGRICULTURE NUMBER. Enter the Food Sales Establishment License Number issued in the current owner's name. The owner's name listed on the application must match the name on the license. Pharmacies and military commissaries are exempt and should enter Not Applicable (N/A).

5. Answer yes or no. Does this store participate in the Food Stamp Program? If yes, enter the authorization number for this location.

Page 6 of 9

GA WIC PROCEDURES MANUAL

Attachment VM-1

6. TYPE OF BUSINESS. Check the box that best fits the type of business for your store. Independent A store independently owned by a person or group. Chain. A business entity that has multiple locations throughout one or more states.

Commissary. A military outlet providing goods and services for military personnel and their families. Commissaries receive exemptions through the 1983 Memorandum of Understanding between the Food and Nutrition Service and the United States Department of Defense. Pharmacy. A "drug" store redeeming infant formula and WIC-eligible medical foods only.

7. TAXPAYER IDENTIFICATION NUMBER. Enter the Federal Employer Identification Number (FEIN) assigned to the store by the Internal Revenue Service. If the owner is a sole proprietor, enter the owner's Social Security Number (SSN). If a FEIN is entered, the SSN is not required.

8.

Answer the question regarding minimum inventory and opening date

A. MINIMUM INVENTORY. Enter the specific month, day and year that ALL required quantity and

variety of WIC approved food items (including perishables) will be in stock and ready for

inspection? Enter Not Applicable (N/A) if the store is currently authorized as a WIC vendor.

B. OPENING DATE. Enter the specific month, day and year that the store will open under the

applying ownership. If the store is currently open for business at the time of application, enter the

official date the store opened or the date the change of ownership became effective. Enter Not

Applicable (N/A) if the store is currently authorized as a WIC vendor.

9. Answer the questions regarding ownership history. A. RELATION RO OWNER. Check yes or no if the vendor applicant is related to the previous owner by blood or marriage. If yes, indicate the relationship. A vendor applicant cannot be related to the seller by blood or marriage if it is determined that the store is being sold to circumvent a WIC sanction. B. OTHER WIC AUTHORIZED STORES BY OWNER. Check yes or no if the vendor applicant also owns other WIC authorized stores. Attach a list of stores and addresses to the application. C. OPERATION UNDER ANOTHER NAME. Check yes or no if your store has operated under another name. If yes, indicate the name.

Part II STORE OWNERSHIP AND MANAGEMENT

10. AUTHORIZED REPRESENTATIVE. Provide the information for the person designated to be responsible for the authorization of your business entity. A corporate vendor may list a person other than the owner(s) or officer(s). Complete each space. Enter Not Applicable (N/A) if there is not a fax number or e-mail address for the individual. Enter "same as #1" if the authorized representative is the same person listed on line 1 (one).

11. TYPE OF OWNERSHIP. Check the one type that closely represents your business. Sole proprietorship. A business owned by a single individual who has total control of the business. Partnership. A business owned by two or more individuals who share the management of the business. Limited Liability Company (LLC). A business combining both corporations and partnerships in that the business is required to register with the Secretary of State but do not have the same filing and record maintenance as a corporation. Privately owned corporation. For purposes of this application, a privately owned corporation is one which has shares or stock that are not traded on a stock exchange or available for purchase by the general public.

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GA WIC PROCEDURES MANUAL

Attachment VM-1

Publicly owned corporation. For purposes of this application, a publicly owned corporation is one which has shares or stock that are traded on a stock exchange and are available for purchase by the general public. Government owned entity. A business entity that may include pharmacies or clinics owned and operated by county, state or federal government agencies.

12. NAMES OF OWNERS/OFFICERS. Supply the names of owners with a 5% or more interest in the store (attach additional sheet with additional names if necessary). For corporations, supply the names and titles of the primary officers of the corporation. Provide the name of the President, Vice-President, Secretary or Treasurer of the corporation.
13. OWNERSHIP HISTORY A. PREVIOUS GEORGIA WIC VIOLATIONS. Check yes or no if the current owners, officers or managers have ever violated Georgia WIC Program by receiving a warning, probation, disqualification, or have been assessed a civil money penalty. If yes, attach an explanation identifying the date, the person, store and nature of the violation. B. FOOD STAMP VIOLATIONS. Check yes or no if the current owners, officers or managers have ever violated the Food Stamp Program by receiving a warning, disqualification, or have been assessed a civil money penalty. If yes, attach an explanation identifying the date, person, store and nature of the violation. C. CONVICTIONS/JUDGEMENTS. Check yes or no if the owner, current officers, or manager ever had a civil judgment involving civil judgment for fraud, antitrust violations, embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, receiving stolen property, making false claims or obstruction of justice? If yes, attach an explanation identifying the person, date and nature of the violation.
PART III OPERATIONS AND SALES
14. HOURS OF BUSINESS. Enter the hours the store is actually open for business each day. Corporate vendors, enter the hours that the majority of the stores are actually open for business.
15. A. NUMBER OF SCANNERS. Enter the number of scanners in the store. Corporate vendors, enter the average number of scanners per store.
B. OPTICAL SCANNERS. Check yes or no if the register(s) can detect WIC eligible products. C. POINT OF SALE (POS) DEVICES. Check yes or no if there is a Point of Sale (POS) device at
each register. This is the machine used to swipe credit or debit cards at each checkout.
16. BANK. Enter the name, address and telephone number of the bank where WIC vouchers will be deposited. Corporate vendors, if more than one bank is used, enter the information about your primary bank.
PART IV STORE PRICE LIST AND INVENTORY
Enter the brand name and highest price of each approved WIC food item in the sizes listed on the application. Use the October 1, 2002 WIC Approved Foods List to complete this section. Do not complete the shaded area.
Page 8 of 9

GA WIC PROCEDURES MANUAL
17. Juice 18. Cereal 19. Dried peas or beans 20. Peanut butter 21. Infant cereal - rice 22. Contract formula milk based

Attachment VM-1

23. Contract formula soy based 24. Pasteurized cow's milk 25. Cheese 26. Eggs Check yes or no if the number (#) of brands and if the required quantity of inventory items of approved WIC
foods are in your current inventory. Corporate vendors must assure the required quantity is in stock at each location. 27. Juice 28. Cereal 29. Dried peas or beans 30. Peanut butter 31. Infant cereal 1 type must be rice 32. Contract formula milk based 33. Contract formula soy based 34. Pasteurized cow's milk 35. Cheese 36. Eggs Review the Privacy Act Statement, Warning Statement and Certification. The applying owner or authorized representative must sign this application. Indicate the daytime number and e-mail address (if available).

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GA WIC PROCEDURES MANUAL

Attachment VM-2

Georgia WIC Program Vendor Handbook
October 2002

WIC WORKS WONDERS with PARTNERS

Table of Contents
The Vendor Handbook............................................................................................................................. 1
The Georgia Women, Infants and Children (WIC) Program .................................................................... 1
WIC Acronym and Logo ........................................................................................................................... 2
Authorized Vendors ................................................................................................................................. 2
Vendor Authorization ............................................................................................................................... 2
Responsibilities and Procedures for Selected Vendor Types Corporate Vendors ............................................................................................................................... 3 Pharmacy Vendors............................................................................................................................... 3
Vendor Training Authorized Training .............................................................................................................................. 3 Corporate Authorized Training.............................................................................................................. 3 Customized Training ............................................................................................................................ 3
WIC Approved Foods List ........................................................................................................................ 4
Minimum Inventory Requirements............................................................................................................ 7
Policy for Granting Waivers...................................................................................................................... 7
The WIC Voucher .................................................................................................................................... 8
Voucher Descriptions............................................................................................................................... 8
Processing WIC Vouchers Customer Transactions ...................................................................................................................... 10 Returned Voucher Payment Procedures............................................................................................. 10 Important Notes about the WIC Customer .......................................................................................... 11 Important Notes for the Store Manager ............................................................................................... 11
Changes in Vendor Information Changes in Store Location ................................................................................................................. 11 Changes in Ownership and Cessation of Operations .......................................................................... 11
Performance Compliance Covert Compliance Investigations....................................................................................................... 12 Overt Monitoring................................................................................................................................. 12 Audits................................................................................................................................................. 12 Programmatic Reports........................................................................................................................ 12
Termination ........................................................................................................................................... 12
Sanctions............................................................................................................................................... 13
Sanction System.................................................................................................................................... 13
Disqualification ...................................................................................................................................... 15
Administrative Reviews and Appeal Procedures Actions Subject to Administrative Review ........................................................................................... 15 Actions Not Subject to Administrative Review ..................................................................................... 16 Administrative Review Procedures ..................................................................................................... 16
Inadequate Participant Access Cases .................................................................................................... 16
Civil Money Penalties (CMP) Methodology for Mandatory Sanctions................................................................................................ 17 Methodology for State Agency Sanctions............................................................................................ 17

THE VENDOR HANDBOOK The Georgia WIC Program Vendor Handbook is intended to serve as a reference and is considered an addendum to the Vendor Agreement. Food retailers (hereafter called vendors), pharmacies and military commissaries should adhere to all the information provided in this book to assure compliance with federal regulations, state policies and procedures. The vendor's role is important to the success of the Georgia WIC program. Vendors must assure that the participant, parent, caretaker and/or proxy, also known as the WIC customer, purchase only the prescribed foods. Prices changed by the vendor must be reasonable and competitive. Competitive prices will enable the Georgia WIC program to maximize services to its citizens. Authorized WIC vendors redeemed 136 million in WIC food vouchers during federal fiscal year 2001.
THE GEORGIA WIC PROGRAM WIC (Women, Infants and Children) special supplemental food program , is a federally funded program that provide supplemental foods, nutrition education and counseling to Georgia's citizens. WIC saves lives and improves the health of nutritionally at-risk women, infants and children. Since it's beginning in 1974, the WIC program has earned the reputation of being one of the most successful federally funded programs in the United States. Collective findings of studies, reviews and reports illustrate that the WIC program is cost-effective in protecting and improving the nutritional status of low-income women, infants and children. Improved outcomes attributed to WIC:
WIC reduces fetal deaths and infant mortality WIC reduces low birthweight rates and increases the duration of pregnancy. WIC improves the growth of nutritionally at-risk infants and children. WIC decreases the incidence of iron deficiency anemia in children. WIC improves the dietary intake of pregnant and postpartum women and improves weight gain in pregnant
women. Pregnant women participating in WIC receive prenatal care earlier. Children enrolled in WIC are more likely to have a regular source of medical care and have more up to date
immunizations. WIC helps children get ready to start school; children who receive WIC benefits demonstrate improved
intellectual development. WIC significantly improve children's diets. Georgia's health professionals determine who is eligible to participate in the WIC program. They also provide nutrition education, counseling and prescribe nutritious foods. Instruments used to obtain the supplemental foods are called vouchers, which are redeemed through authorized food retailers statewide.
1

WIC ACRONYM AND LOGO

A WIC vendor is not permitted to use either the acronym "WIC" or the WIC logo pictured above, including close facsimiles thereof, in total or in part, either in the official name in which the vendor is registered or in the name under which it does business, if different.
Any person who uses the acronym "WIC" or the WIC logo in a non-authorized manner, including close facsimiles thereof, in total or in part, may be subject to injunction by the United States Department of Agriculture and the payment of damages.

AUTHORIZED VENDORS
An authorized vendor is a sole proprietorship, partnership, cooperative association, corporation or other business entity operating one or more vendors. A vendor is authorized by the State agency to provide authorized supplemental foods to participants, parents, caretakers and/or proxies. The program is operated in accordance with federal laws and regulations, the Georgia State Plan of Program Operations and Administration and the policies and procedures of the Special Supplemental Nutrition Program for Women, Infants and Children (WIC), pursuant to the laws of the State of Georgia and the Child Nutrition Act (CNA) of 1966 as amended.
VENDOR AUTHORIZATION
To become a vendor, a store must apply for program authorization, meet or exceed the selection criteria and enter into an agreement with the Georgia WIC Program. The selection criteria are the same for vendors statewide with the exception of commissary and pharmacy vendors. The criteria include but are not limited to: 1) Competitive price and price limitations, based on peer grouping 2) Minimum variety and quantity of supplemental foods 3) Business integrity 4) Absence of current Food Stamp Program disqualification or civil money penalty for hardship
Upon a successful price and inventory analysis and an acceptable business integrity profile, the Georgia WIC Program will approve the application and authorize the vendor. The newly authorized vendor will sign a Vendor Agreement and will be provided a uniquely numbered vendor stamp. Vendors are placed into peer groups (see below) based on the type and/or square footage of the store including storage areas.

Peer Group Type

1

SMALL

2

AVERAGE

3

MEDIUM

4

CHAIN

5

MILITARY COMMISSARY

6

PHARMACY

7

LARGE INDEPENDENT

Description
0 to 5,000 Square Feet. 5,001 to 10,000 Square Feet.
10,001 to 15,000 Square Feet >15,001 Square Feet and 20 or more locations
Located on Military Bases serving military personnel only Redeem infant formula only, including special infant formula through the pharmacist. >15,001 Square Feet and less than 20 locations

2

RESPONSIBILITIES AND PROCEDURES FOR SELECTED VENDOR TYPES Corporate Vendors
A business entity having two (2) or more stores operating under the same Federal Employer Identification Number (FEIN) and a corporate/home office or single owner/business entity that serves as the parent, shall be classified as a corporate vendor. An authorized representative of the corporate office shall sign one agreement and list pertinent information about each store on the Corporate Attachment Form 3771A. Corporate vendors must send a representative(s) to the Authorized Training session and ensure that training is provided to a management representative from each store. The Corporate Training Checklist Form 3757A must be completed and returned to the Georgia WIC Branch, documenting that training has occurred. Signature of the store representative is required on this form.
To add a new store, the corporate vendor must first amend their agreement by submitting the corporate Attachment Form 3771A that includes required information about the new location. The new store shall not begin to accept vouchers until a vendor stamp has been received. Pharmacy Vendors
Pharmacy vendors are authorized by the Georgia WIC Program to provide infant formula and WIC-eligible medical foods. Pharmacy vendors are also exempt from maintaining minimum inventory requirements. Programmatic reports will be used to verify whether a pharmacy vendor is redeeming only infant formula vouchers. If authorized pharmacy vendors wish to change their classification to allow for the redemption of all WIC approved foods, a new application must be submitted.
VENDOR TRAINING
Vendor training, including annual training, will be conducted to inform vendors of the appropriate program policies and procedures in one of the following formats: newsletters, video, videoconferences, or interactive. Authorized Training The Georgia WIC Program will provide interactive training prior to, or at the time of authorization. Attendance at training will be documented, a checklist of items discussed will be signed and a Post Vendor Training Evaluation will be given to each participant. Each participant must receive a passing score of seventy (70) or above on the Post Vendor Training Evaluation.
Attendance at a training session, prior to becoming an authorized vendor, does not grant the right to begin accepting WIC vouchers. Only a fully executed agreement, signed by both parties, constitutes authorization.
Corporate Authorized Training The corporate vendor may conduct training to each of their stores. The training must be conducted prior to authorization. The corporate vendor shall submit documentation to the Georgia WIC Program, verifying that each new store has completed interactive training that includes the required training topics determined by the Georgia WIC Program. The corporate vendor has the option to allow any of their store representatives to attend the authorized training sessions conducted by the Georgia WIC Program.
Customized Training The Georgia WIC Program may conduct training for employees of WIC vendors at their request. Training should be requested in writing to the Georgia WIC Program, Vendor Management Section, 2 Peachtree Street, Suite 10-476, Atlanta, Georgia, 30303. Please specify the desired training topic(s) and the type and number of employees who will attend. Both parties will mutually agree upon location and dates.
WIC APPROVED FOODS The WIC Approved Foods listed are foods that are available to the WIC customer. ONLY these foods are allowed to be purchased. The vendor will receive an updated list of approved foods any time changes are made. Vendors will periodically receive pamphlets and posters of WIC approved food items that the can be used as marketing displays or as a training resource.
3

FOOD ITEM PASTEURIZED COW MILK
MEYENBERG GOAT MILK

WIC Approved Foods List October 1, 2002
Only the following list of foods may be purchased with WIC vouchers

BRAND OR TYPE

CONTAINER/PACKAGE SIZE

INELIGIBLE ITEMS

Skim, Low Fat (1%), Reduced Fat (2%) or Whole Milk
Least Expensive Brand Only
Powdered Milk
Evaporated Milk
UHT - Ultra High Temperature Milk (If listed on voucher)
Acidophilus, Enjoy, Lactaid, Lactaid 100 (Fat Free/Skim ,1% , 2% or Whole Milk)
NUTRISH or Dairy Ease (If listed on voucher)
Low Fat Milk or Whole Milk (If listed on voucher)

One Gallon ONLY
Makes 3 Quarts Makes 5 Quarts
12 oz. Can 8 oz. Box
Gallon 1 Quart Carton
1 Quart Carton

Flavored Milk Buttermilk Soy Milk Rice Milk Raw Milk (nonpasteurized milk)

Powdered Milk (If listed on voucher)

12 oz. Can

Evaporated Milk (If listed on voucher)

12 oz. Can

UHT Milk (If listed on voucher)

1 Quart Carton

CHEESE Fat Free, Low Fat or 2% Allowed

Slices Any Brand
(Wrapped or unwrapped)
Block Any Brand
(Combinations allowed i.e. Colby/Jack)

American
American Cheddar Colby Monterey Jack Mozzarella

9 oz. to 16 oz.

Flavored Cheese Cheese Food Shredded Cheese Deli Cheese 8 oz. package

EGGS
DRIED PEAS/BEANS

Least Expensive Brand Only Any Brand

1 Dozen Carton Grade A Large ONLY
1 lb. Package ONLY

CANNED PEAS/BEANS (Legumes Only)

Any Brand

15 oz. Can ONLY

PEANUT BUTTER Any Brand Creamy, Crunchy or Extra Crunchy (Regular, Natural, Low-Salt or Reduced Fat)

18 oz. Jar ONLY

Any other size or quantity
Any other size or quantity Flavored Peas Flavored Beans
Any other size or quantity Flavored Peas Flavored Beans
Any other size or quantity Marshmallow Added Chocolate Added Honey Spread Jelly Added

4

FOOD ITEM INFANT FORMULA INFANT CEREAL
TUNA

WIC Approved Foods List October 1, 2002 Continued
The following list of foods may be purchased with WIC vouchers.

BRAND OR TYPE

CONTAINER/PACKAGE SIZE

INELIGIBLE ITEMS

As listed on the front of the voucher Brands: Beech Nut, Gerber or Heinz Types: Rice, Barley, Oatmeal, Mixed

As listed on the front of the voucher
Dry Cereal in 8 oz. or 16 oz. Box ONLY

Formula not listed on the voucher
Baby Food in Jars Dry Cereal w/ Fruit Dry Cereal with Formula

Any Brand - Water Packed Only

6 oz. Can

Tuna packed in oil

CARROTS
C E R E

Any Brand - Fresh (Whole)

Any Brand - Canned (Sliced, Medium-Cut)

Brand Name

What Kind (Type)

General Mills

Cheerios Corn Chex Rice Chex Wheat Chex Country Corn Flakes Kix Total Corn Flakes

Kellogg's

Complete Wheat Bran Flakes Complete Oat Bran Flakes Corn Flakes Crispix Mini Wheats-Frosted Bite-size Mini Wheats Raisin Mini Wheats Strawberry Product 19 Special K

Post

Bran Flakes

Nabisco

Cream of Wheat Regular flavor

10 minutes 2 minutes

1 minute

Instant

Quaker

Instant Grits Instant Oatmeal Regular Crunchy Corn Bran

Jim Dandy

Quick Grits - Iron Fortified

1 lb Pre-sealed Plastic Bag 15 oz. Can
9 oz. or above, not to exceed the maximum amount listed on the voucher. Can mix and match sizes and types.

Bulk, frozen, shredded or baby carrots
8 oz. box or less Flavored Oatmeal Flavored Grits

Hy-Top
A

Crisp Rice Toasted Oats Corn Flakes Enriched Bran Flakes

Shurfine

Corn Flakes Crispy Corn Puffs

Crispy Rice

Enriched Bran Flakes

L

Nutty Nuggets

Instant Oatmeal Regular

Toasted Oats

5

FOOD ITEM
C E R E A L
J
U
I
C
E
100% Juice Vitamin C Fortified

WIC Approved Foods List October 1, 2002 Continued
The following list of foods may be purchased with WIC vouchers.

Brand Name

BRAND OR TYPE What Type

CONTAINER/ PACKAGE SIZE

Great Value (Wal-Mart)

Corn Flakes Instant Oatmeal Regular Toasted Oat Silly Corn Crisp Rice Crunchy Nuggets Nature's Grain Enriched Bran Flakes

9 oz. or above, not to exceed the maximum amount listed on the voucher.

All 7 brands of cereal on the left may be purchased in any of the types on the right.

Flavorite IGA Kroger Kountry Fresh Nature's Best Ralston Red & White

Corn Flakes Crispy Corn Puffs Instant Oatmeal Regular Tasteeos Toasted Oats Silly Spheres (Ralston Only) Crispy Rice or Crisp Rice Nutty Nuggets Whole Grain 100 Enriched Bran Flakes Enriched Wheat Bran Flakes (Ralston Only)

Can mix and match sizes and types.

Least Expensive Brand Only Hy-Top Kroger Lucky Leaf

Orange Grapefruit
Apple Apple Apple

Pineapple

46 oz. Ready to Serve Cans 46 oz. Ready to Serve Plastic Bottles 11.5 oz. or 12 oz. Frozen Concentrate

Seneca (Red Label)

Apple

Shurfine

Apple

Thrifty Maid

Apple

White House

Apple

Welch's

Grape White Grape

Seneca

Grape White Grape

Libby's Juicy Juice

All Flavors

46 oz. Cans 46 oz. Plastic Bottles

Welch's (Blends)

White-Grape-Raspberry White-Grape-Cranberry White-Grape-Peach White-Grape-Pear

11.5 oz. Frozen Concentrate

Dole

Pineapple Orange Pine-Orange Banana

12 oz. Frozen Concentrate

Libby's Juicy Juice Welch's

All flavors

Apple

White Grape

Cherry Sensation Grape

Fruit Fantastic

11.5 oz. Non-frozen pourable concentrate

INELIGIBLE ITEMS
8 oz. box or less Flavored Oatmeal Flavored Grits
Juice drink Fresh squeezed juice Infant juice Juice with sugar added Sports drink Cartons Calcium Fortified

6

MINIMUM INVENTORY REQUIREMENTS
The participants, parents, caretakers and/or proxies may receive vouchers for specific kinds of highly nutritious foods. Vendors are required to maintain in stock, a minimum variety and quantity of the WIC foods below.

WIC Minimum Inventory Requirements*

This list details the required sizes, types and/or brands that the store must carry in order to become and continue as a WIC vendor.

FOOD ITEM

QUANTITY

SIZE

TYPES/BRANDS

Pasteurized Milk Skim, 1%, 2% or Whole

20

Cheese

16

1 Gallon 1 Pound

1 Brand 2 Types

Eggs Grade A Large
Juice

16

1 Dozen

1 Brand

24

46 oz. Can or Plastic Bottle

2 Types

Cereal

4 Types

30

9 to 24 oz. Box

(2 types must be in

12 oz. boxes)

Peas/Beans

8

1 Pound

2 Types

Peanut Butter

8

18 oz.

2 Brands

Infant Cereal

12

8 oz.

2 Types

(1 type must be rice)

Infant Formula w/ Iron Low iron cans do not meet minimum requirement

170 TOTAL
138 Milk-Based 32 Soy-Based

13 oz.

Contract Brand of Formula Only

* Military commissaries and pharmacies are exempt from maintaining minimum inventory requirements.

POLICY FOR GRANTING WAIVERS
A waiver to become exempt from the minimum inventory requirement may be requested in writing from the Georgia WIC Branch. The waiver is only for specific quantities of selected WIC foods. The following criteria will be used to determine whether a waiver will be granted:
1) WIC business volume less than $500 each month. 2) The vendor has been on the program for at least one year. 3) There is not another WIC vendor within ten (10) miles of the vendor requesting the waiver.

7

THE WIC VOUCHER The WIC voucher is a check. A vendor must accept all valid vouchers, with the exception of a pharmacy vendor, who is authorized to accept infant formula and WIC-eligible medical food vouchers only. The vendor should not accept altered vouchers. When vouchers are properly redeemed the vendor will receive credit for the amount of purchase by depositing the voucher into the bank. However, no voucher will be redeemed for more than the maximum amount printed on the face of each voucher, with the exception of "special " infant formula vouchers. VOUCHER DESCRIPTIONS There are four (4) types of WIC vouchers: laser printed, blank manual, standard manual and computer generated. Laser Printed Vouchers: The laser printed voucher is printed at the clinic site at the time of the participant, parent's, caretaker's and/or proxy's visit.
Blank Manual Vouchers: All information on the voucher is either handwritten or typed. Redeem only for the amount of food indicated. Only one (1) number should appear in each box. X's are placed in all boxes where there is no number. This helps to eliminate any possible unauthorized alterations on the voucher.
8

Standard Manual Vouchers: All information on the voucher is written or typed by the staff at the clinic. Computer Generated Vouchers: All information on voucher is computer printed.
9

PROCESSING WIC VOUCHERS
The vendor's bank should be informed that vouchers are negotiable instruments that must be processed through the Federal Reserve Bank. The Georgia WIC Program will provide each vendor a stamp that is embossed with a unique WIC identification number. All vouchers accepted by the vendor must be stamped with this number in preparation for a bank deposit. Lost, stolen or damaged stamps must be reported to the Georgia WIC Program immediately. DO NOT REPRODUCE THE VENDOR STAMP.
Payment will be assured if:
Voucher(s) are accepted on the "First Day to Use" date through the "Last Day to Use" date.
An authorized WIC vendor stamp appears on the voucher.
Deposited within sixty (60) days of the "First Day to Use" date.
A signature is obtained, in ink, at the time of purchase.
The amount of purchase is entered in the "PAY EXACTLY SPACE". Note: If the purchase price for "special" infant formula or WIC eligible medical foods exceeds the maximum allowed, you must submit the original voucher directly to the Georgia WIC Program for payment. Attach the voucher and the receipt to the Returned Voucher Payment Log.
WIC Customer Transactions at the Store
WIC participants, parents, caretakers and/or proxies (WIC Customer), redeem WIC vouchers at authorized vendor locations. WIC customers are required to take the WIC ID folder upon each visit to the store. However, it is the option of each vendor to request the WIC customer to present the WIC ID folder at the time of the transaction.
WIC foods should be separated from other food purchases prior to the WIC transaction. When approved supplemental food is purchased with a WIC voucher, the cashier must do the following:
1. For vouchers requiring two signatures, check to see if the voucher has been signed (once) by the WIC participant, parent, caretaker and/or proxy on the left side of the voucher (Sign Here at WIC Office).
2. Check the dates on the voucher. Vouchers cannot be used before the "First Day to Use" or after the "Last Day to Use" dates.
3. Ring up the shelf price of the food for each voucher. Make sure that the exact types and amounts of approved WIC foods are being purchased. Do not include sales tax.
4. Print the amount of the WIC purchase in the "Pay Exactly" space on the voucher in the presence of the WIC customer.
5. If the amount of the transaction is less than the maximum amount listed on the voucher, the cashier must not give change from the WIC voucher purchases. Credit must not be given to WIC customers in exchange for WIC vouchers. If the cashier makes a mistake entering the price on the voucher, the incorrect price should be marked through and the correct written above the error. The cashier must initial the correction as verification of the change in the amount of the voucher. If the cash registers do not automatically imprint "WIC" on the receipt, cashiers must write "WIC" vertically on all receipts for food purchased with WIC vouchers.
Returned Voucher Payment Procedure
If the price on the voucher exceeds the maximum purchase price, it will be returned to the vendor marked "Not for Resubmission." A voucher marked "Not for Resubmission" should be sent to the Georgia WIC Program attached to the Return Voucher Payment Log to be processed for payment. Price adjustments may be made by the Georgia WIC Program.
In order for vouchers to be paid, the Georgia WIC Program must obtain the vendor's Federal Employer Identification Number (FEIN) or owner's Social Security Number (SSN). The Return Voucher Payment Log must be completed and sent with the original WIC voucher(s)
The vendor should retain the last copy of the form for their records. If a voucher(s) is approved for payment, a copy of the form, with the payment is forwarded to the
vendor. If a voucher(s) is denied payment, a copy of the form and the original voucher(s) is returned to the vendor
with an explanation of denial. Voucher(s) sent without the voucher payment log attached will be returned unprocessed. WIC Voucher(s) returned by the bank to the vendor because of a stale date will not be paid.
10

Important notes about the WIC Customer
The WIC participant, parent, caretaker, and/or proxy: 1. Must sign the voucher at the time of purchase. 2. May not use a WIC voucher to purchase items not listed on the voucher. 3. Must never be required to pay cash for items purchased. 4. Must be allowed to purchase all foods listed on the voucher, regardless of price. 5. Must be afforded the same courtesy given to other store customers. 6. Must be permitted to purchase eligible food items without making other purchases. 7. Must be allowed to enter the same check-out lines as other customers and must be charged the same shelf prices as other customers, not to exceed the maximum amount allowed on the voucher(s). 8. Must not be charged sales tax. 9. Must be reported to the Georgia WIC Program immediately if they attempt to purchase foods that are not approved or create other problems in the store. 10. May not be contacted regarding restitution or any payment. 11. Must not be required to purchase every item on the voucher.
Important Notes for the Store Manager
1. If the amount entered on the WIC voucher exceeds the maximum amount listed on the voucher, the Georgia WIC Program may make price adjustments.
2. WIC approved foods purchased with a WIC voucher cannot be returned for a cash refund. 3. WIC vouchers must not be accepted from other states. 4. If a manager is called to approve a WIC voucher transaction, it is imperative that the customer is not
identified as a WIC participant, parent, caretaker and/or proxy. Every effort must be made to protect confidentiality and discussion of the transaction should be kept at a conversational level. 5. Separate checkout lines for WIC participants, parents, caretakers, and/or proxies in stores are prohibited. Signs such as "WIC vouchers not allowed in this line" or "No Checks, No WIC" cannot be displayed since they are considered discriminatory. However, vendors who wish to ensure that WIC participants, parents, caretakers, and/or proxies do not enter certain lines, such as express lines, may post "Cash Only" signs in those lines. 6. Every store has the option of checking the customer's WIC identification card for the proper WIC ID number and authorized signature(s). WIC participants, parents, caretakers, and/or proxies have been instructed about the importance of carrying the WIC ID card to the grocery store when using WIC vouchers. 7. Vendors with self-check out lines must ensure that clerks verify the items purchased are listed on the vouchers. 8. Whenever vouchers are lost or stolen from a clinic, the Georgia WIC Program will notify area vendors that a stop payment has been placed on the vouchers. Vendors will be provided the voucher numbers and informed not to accept the vouchers for redemption. These vouchers will not be paid. 9. The vendor must not provide refunds or permit exchanges for authorized supplemental foods obtained with food vouchers except for exchanges of an identical authorized supplemental food item when the original authorized supplemental food item is defective, spoiled, or has exceeded its "sell by" or "best if used by," or other date limiting the sale or use of the food item. 10. Must allow WIC participants, parents, caretakers and/or proxies, to participate in both or either in-store and/or manufacturer promotions that include WIC approved food items.
CHANGES IN VENDOR INFORMATION
Changes to the information provided on the vendor application must be communicated to the Georgia WIC Branch. This information will be used to update files as necessary. The Georgia WIC Branch requires the vendor to provide advance written notification of any changes in ownership, store location or cessation of operations.
Changes in Store Location
The vendor must provide the Georgia WIC Branch with at least twenty-one (21) days advance notification of any changes in location. Each store is authorized based on the ownership and location at the time of approval. If a change in location is more than one-quarter of a mile, the vendor authorization number must be terminated and the vendor must submit a new application for the change in location. If the change in location is less than one-quarter mile, the vendor authorization number will not be terminated and there will be no change in the vendor's status.
Changes in Ownership and Cessation of Operation
The vendor must submit a notice to the Georgia WIC Branch within twenty-one (21) days of any change in ownership (sale) or cessation of business (closure) and the effective date. The Georgia WIC Branch will acknowledge the receipt of this information with a confirmation. Upon the effective date, the vendor authorization number will be terminated. Any
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vouchers submitted for payment after that date will be returned unpaid. If the vendor wishes to change the effective date or retract the termination request, a written notification is required. If the vendor fails to properly notify the Georgia WIC Program of an effective date change or retraction of the termination, the vendor authorization number will be terminated, as originally confirmed, and the vendor must apply as a new vendor and meet all current selection criteria.
Should the Georgia WIC Branch discover that a change in ownership has already occurred, the vendor authorization number will be immediately terminated. All vouchers submitted for payment will be returned unpaid.
Upon the sale of the business, the vendor should inform the new owner that the Georgia WIC Vendor Agreement is nontransferable and that the new owner must submit an application for authorization.
PERFORMANCE COMPLIANCE
A vendor, with the exception of a military commissary vendor, is subject to review by Georgia WIC Program. Any violations that are found may result in program sanctions (See Sanction System). Compliance with the Georgia WIC Branch policies and procedures is determined using the following methods:
1. Covert compliance investigations (military commissary and pharmacy vendors exempt) 2. Overt monitoring visits (military commissary and pharmacy vendors exempt) 3. Inventory audits (military commissary and pharmacy vendors exempt) 4. Programmatic reports (military commissaries exempt ONLY)
Covert Compliance Investigation
Vendors will not receive prior notice when an investigation has been scheduled. Vendors will receive notification of any violations after the investigation is considered closed by the Georgia WIC Program.
Vendors will be identified for covert compliance investigations as follows: 1. Total score is 200 or greater on the Vendor Profile. 2. Vendors may be investigated who have been reported to the WIC Program for potentially violating program policies. 3. Random selection.
Overt Monitoring
Representatives of the federal, or state agencies may monitor a vendor at any time the store is open for business. All records pertinent to this monitoring visit must be available for review by the representative of the agency upon request.
Audits The Georgia WIC Program may conduct record audits on any vendor at any time. Inventory audits will include the examination of food invoices or other proofs of purchase to determine whether a vendor has purchased sufficient quantities of supplemental foods to provide participants, parents, caretakers and/or proxies the quantities specified on food vouchers redeemed by the vendor during a given period of time. During an audit, the vendor must supply the WIC representative with documentation of pertinent records upon request. Vendors must retain copies of all invoices relating to the purchase of WIC food items for a period of three (3) years, plus current.
Programmatic Reports
The WIC Program will generate specific programmatic reports to identify vendors who may be out of compliance. If a vendor is out of compliance because of overpricing based on a programmatic report (as opposed to a covert compliance investigation), notification will be given to provide an opportunity to reimburse the Georgia WIC program for the excess amount. Failure to repay overcharges will result in a program sanction(s) (see Sanction System). Programmatic reports will also be generated to determine if a pharmacy vendor is accepting voucher(s) other than "special" infant formula or WIC-eligible medical foods. If a pharmacy vendor is out of compliance, the vendor agreement may be terminated for cause.
TERMINATION
Termination is the ending, by either party, of the agreement between the Georgia WIC Program and the authorized vendor. A written notification of the termination shall be mailed to the affected party at least twenty-one (21) calendar days in advance. Reasons for termination, by either party, may include but are not limited to:
1. Voluntary withdrawal from the WIC program. 2. The decision to sell the store. 3. Failure to notify the Georgia WIC Program of a change in ownership. 4. Expiration of the agreement without a new application being submitted.
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SANCTIONS
Any WIC vendor found to be in violation of federal regulations and/or Georgia WIC Program policy will be assessed a sanction consistent with the severity and nature of the violation. Sanctions may include disqualification or a civil money penalty. State agency sanctions are imposed by the Georgia WIC Branch and approved by USDA. Mandatory Sanctions are mandated by the United States Department of Agriculture.
Violations are categorized by the nature and severity of the violation. The nature and severity of the violation(s) shall determine which sanction will be assessed, the duration of the probationary period, and/or the period of disqualification. Each category has a prescribed period of disqualification, probation or warning assessed. Therefore, sanctions shall be assessed as follows:
1. The highest sanction assessed to a vendor shall determine the period of probation and disqualification. 2. All State Agency Sanctions and warnings assessed are retained in the vendor's file for a period of one
year and will roll off one year from the date of receipt. 3. Probationary periods granted by the Georgia WIC Branch are not subject to a fair
hearing. Vendors will continue to operate their business during the probationary period. A vendor found to be in violation of WIC policies and procedures during the probationary period will be disqualified for not less than the full probationary period. 4. If a disqualification for a mandatory sanction is not upheld during the administrative review process, then the remaining State Agency Sanction(s) if any, will remain on the vendor's record for one year.
If a vendor receives a warning letter and decides to dispute the allegation(s) regarding the non-compliant activity, the vendor may request to be heard by the Georgia WIC Branch. To have the decision reviewed, the vendor may select from the following options:
- Call the Georgia WIC Branch and speak with the Vendor Management Section Director. - Submit written correspondence to the Georgia WIC Branch. - Request in writing a consultation with the Georgia WIC Branch, to be held with the vendor and/or the
vendor's advisor(s).
SANCTION SYSTEM
Following is a description of the Georgia WIC Program Sanction System and how it works. Civil Money Penalties (CMP) may be assessed in Categories I-V in lieu of disqualification for State Agency sanctions only. However, CMP shall only be assessed in lieu of disqualification for mandatory sanctions if the disqualification results in inadequate participant access.
A. Any violation from Category I, II or III may be assessed a CMP in lieu of disqualification.
Category I - Warning on first and second offense, third offense probation for six (6) months. While on probation if a violation occurs in Categories I, II or III the vendor will be disqualified for six (6) months.
State Agency Sanctions Violations: 1. Stocking a WIC food item(s) outside of manufacturer's expiration date(s). 2. Prices not marked clearly on WIC food items or near WIC food items. 3. Allowing WIC food items to exceed the quantity specified on the voucher. (Except for promotional
items) 4. Failure to allow the purchase of any WIC food item(s).
Category II - Warning on first offense, second offense-probation for eight (8) months. While on probation if a violation occurs in Categories I, II or III the vendor will be disqualified for eight (8) months.
State Agency Sanctions Violations: 1. Failure to properly process vouchers at the store (this includes failure to calculate ring
up sales of WIC purchases or failure to write the price on voucher before the participant signs). 2. Failure to stock the required inventory of contracted formula or failure to stock the required inventory of two or more WIC food items (types and/or brands). A WIC representative must view the physical inventory at the time of visit. Proof of an order for WIC food items is not acceptable.
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3. Refusing to accept valid WIC vouchers from participants in exchange for WIC food items.
4. Allowing the substitution of one WIC approved food item listed on the voucher for another WIC approved food item not listed on the voucher, or allowing the purchase of WIC foods in unauthorized container sizes.
5. Failure to remain open for business at least eight hours per day, six days per week. 6. Failure to repay overcharges within thirty (30) days.
Category III - Warning on first offense, second offense - probation for ten (10) months. While on probation if a violation occurs in Categories I, II or III the vendor will be disqualified for ten (10) months.
State Agency Sanctions Violations: 1. Issuing rain checks/IOU's for WIC approved foods. 2. Contacting WIC participants for any reason regarding a WIC transaction. 3. Requiring participant to pay cash to redeem WIC vouchers. 4. Allowing the purchase of any formula other than the one specified on the front of the voucher. 5. Failure to allow participants, parents, caretakers, and/or proxies to purchase all WIC approved food
items listed on the face of the voucher regardless of the price on the voucher. 6. Providing incentive items as part of WIC transaction. 7. One occurrence during a compliance investigation of a violation in Category IV, violations 1-2. 8. One occurrence during a compliance investigation of a violation in Category V, violations 1-5.
B. Any violation from category IV or V that occurs at any time will result in immediate disqualification for the period specified in category IV & V (no warning will be given prior to the completion of a covert compliance investigation). A pattern is established when the same violation occurs twice during a covert compliance investigation. When a pattern is not established, one occurrence during a compliance investigation will result in a Category III sanction.
Category IV - Immediate disqualification for one (1) year [twelve months (12)] for each violation.
Mandatory Sanctions Violations: 1. A pattern of providing unauthorized food items in exchange for WIC vouchers. 2. A pattern of charging for supplemental foods provided in excess of those listed on the voucher.
State Agency Sanctions Violations: 3. Intentionally providing false information on vendor records. 4. Discrimination. 5. Failure to provide vouchers or inventory records upon request. 6. Failure to allow monitoring by WIC representatives.
Category V - Immediate disqualification for three (3) years (thirty-six months) for each violation.
Mandatory Sanctions Violations:
1. A pattern of receiving, transacting, and/or redeeming food vouchers in locations different from the authorized locations listed on the Agreement including the use of an unauthorized vendor and/or an unauthorized person.
2. A pattern of providing credit or non-food items in exchange for WIC vouchers. 3. A pattern of overcharging on WIC vouchers (charging a WIC participant more than the current shelf
price or charging a WIC participant more for food than a non-WIC customer) during a compliance investigation. 4. A pattern of charging for supplemental food not received by the participant. 5. A pattern of claiming reimbursement for the sale of an amount of a specific supplemental food item which exceeds the store's documented inventory of that supplemental food item for a specific period of time. 6. One incidence of the sale of alcohol or alcoholic beverages or tobacco products in exchange for WIC vouchers.
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C. Any violation from category VI or VII that occurs at any time will result in immediate disqualification for the period specified in category VI & VII (No warning will be given prior to the completion of the overt compliance investigation).
Category VI - Disqualification for six (6) years [seventy-two months (72)] for each violation.
Mandatory Sanctions Violations:
1. One incidence of buying or selling of WIC vouchers for cash. 2. One incidence of exchanging WIC vouchers for firearms. 3. One incidence of exchanging WIC vouchers for ammunition. 4. One incidence of exchanging WIC vouchers for explosives. 5. One incidence of exchanging WIC vouchers for controlled substances.
Category VII - Permanent disqualification for a conviction of each violation [Conviction refers to an action by a criminal court as defined in section 102 of the Controlled Substances Act (21 U.S.C. 802)].
Mandatory Sanctions Violations:
1 Conviction for buying or selling WIC vouchers for cash. 2. Conviction for buying or selling WIC vouchers for firearms. 3. Conviction for buying or selling WIC vouchers for ammunition. 4. Conviction for buying or selling WIC vouchers for explosives. 5. Conviction for buying or selling WIC vouchers for controlled substances.
DISQUALIFICATION
When a vendor accumulates the maximum number of sanctions for violating WIC Program rules/regulations, the store shall be disqualified from the WIC program. An exception may be granted for inadequate participant access cases. Disqualification from WIC Program participation could result in a civil money penalty or disqualification from the Food Stamp Program. If a vendor is disqualified from the Food Stamp Program, or assessed a CMP the vendor shall be disqualified from WIC Program participation for the same period of time. (Refer to Food Stamp Federal Regulations 7 CFR; Part 278). If a vendor is disqualified or assessed a CMP for a mandatory sanction from the WIC Program in another state, the vendor may be disqualified from the Georgia WIC Program for the same period of time.
The period of disqualification is determined by the severity and nature of the violation, the number of violations and past disqualifications. Therefore, the highest sanctions assessed to a vendor shall determine the period of probation or disqualification. The actual disqualification period is determined using the same criteria for every vendor. The Georgia WIC Branch will not accept voluntary withdrawal as an alternative to disqualification.
A vendor may be granted a Civil Money Penalty (CMP) in lieu of disqualification when prescribed procedures are met (see Civil Money Penalties and Sanction System). Upon the Georgia WIC Branch approval of a CMP, the disqualification period may be waived.
Follow-up visits will be conducted during a waived disqualification period. If violations occur during a follow-up visit, the vendor will be disqualified for a period equal to the period that the CMP was assessed.
ADMINISTRATIVE REVIEW AND APPEAL PROCEDURES
Actions Subject to Administrative Review
If the vendor disagrees with an adverse action(s) taken by the Georgia WIC Program, an administrative review may be requested. Vendors may request an administrative review for the following reason(s):
1. Denial of authorization based on the vendor selection criteria for competitive price or for minimum variety and quantity of authorized supplemental foods or the determination that the vendor is attempting to circumvent a sanction.
2. Termination for cause including but not limited to change in ownership, location (more than mile) or cessation of operations.
3. Disqualification. 4. Imposition of a civil money penalty in lieu of disqualification. 5. Denial of authorization based on the vendor selection criteria for business integrity or for a current Food
Stamp Program disqualification or civil money penalty for hardship.
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6. Denial of authorization because a vendor submitted its application outside the established timeframes. 7. Disqualification based on a trafficking conviction. 8. Disqualification based on the imposition of a Food Stamp Program civil money penalty for hardship.
Actions Not Subject to Administrative Review
The following actions are not subject to administrative review: 1. The validity or appropriateness of the vendor selection criteria. 2. The validity or appropriateness of the participant access criteria and participant access determinations. 3. The determination whether a vendor had an effective policy program in effect to prevent trafficking and that the ownership of the vendor was not aware of, did not approve of, and was not involved in the conduct of the violation. 4. The expiration of a vendor's agreement. 5. Disputes regarding food instrument payment and vendor claims (other than the opportunity to justify or correct a vendor overcharge or other error). 6. Disqualification of a vendor as a result of disqualification from the Food Stamp Program.
Vendors requesting an Administrative Review must contact the Georgia WIC Program in writing within twenty-one (21) days of the adverse action. Vendors may choose to be represented by legal counsel. An Administrative Review shall be scheduled only in Atlanta, Georgia at the Office of State Administrative Hearings.
Administrative Review Procedures
The procedures for an administrative review of the adverse action include the following: 1. Written notification of the adverse action. 2. The opportunity to appeal the action. 3. Adequate advance notice of the time and place of the administrative review. 4. The opportunity to present its case and at least one opportunity to reschedule. 5. The opportunity to cross-examine adverse witnesses (When necessary to protect the identity of WIC Program investigators, such examinations may be conducted behind a protective screen or other device). 6. The opportunity to be represented by counsel. 7. The opportunity to examine prior to the review the evidence upon which the action is based. 8. An impartial decision-maker, whose determination is based solely on whether the Georgia WIC Program has correctly applied Federal and State statutes, regulations, policies and procedures governing the Program, according to the evidence presented at the review. 9. Written notification of the review decision, including the basis for the decision, within 90 days from the date of the receipt of a vendor's request for an administrative review.
When the initial decision of a review is ruled in the State's favor, the vendor may file a motion for reconsideration to the administrative law judge within the time provided by law. When such motions are filed with the Administrative Law Judge, the vendor must also notify the Georgia WIC Branch, in writing, within ten (10) days of the initial decision date.
When the initial decision of the review is ruled in the State's favor, the vendor may choose to request a departmental appeal within the time provided by law. When such an appeal has been requested, the vendor must notify the Georgia WIC Branch in writing that the motion has been filed, within thirty (30) days of the initial decision date.
Prior to the Administrative Review date, if a vendor would like to review their WIC records, contact the Georgia WIC Program in writing for an appointment. The request must be made within the allowable time frames as detailed in the code of Federal Regulations 7 CFR 246.18. The Georgia WIC Branch will determine the location for the record review. The vendor may have a legal representative present.
In the event an appointment cannot be negotiated, a conference call may be scheduled. The Georgia WIC Branch will mail all the records pertaining to the adverse action prior to the conference call. The conference call will be documented.
INADEQUATE PARTICIPANT ACCESS CASES
An inadequate participant access case is granted only when there is not an authorized WIC vendor within 10 miles of the violative vendor. Geographical barriers will be considered. The validity or appropriateness of the participant access criteria and participant access determinations are not subject to administrative review.
If the State Agency determines that disqualifying a vendor causes inadequate participant access, the State Agency must impose a Civil Money Penalty (CMP) in lieu of disqualification in Categories I-VII [except that the State Agency may not
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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 7 CFR 246.12(l)(1)(vi)].

CIVIL MONEY PENALTIES (CMP)
CMPs may be assessed in lieu of disqualification for State Agency sanctions based on the methodology outlined in the Vendor Handbook. CMPs may only be assessed for mandatory sanctions if the disqualification would result in inadequate participant access. The CMP formula for mandatory sanctions shall be based on 7 CFR 246.12 (l)(1)(x). For a violation that warrants permanent disqualification, the amount of the CMP shall be $10,000.
The amount of the penalty will be established using the standard formula (based on a six month WIC redemption total). The first CMP will be reduced by 50% if the vendor presents documented proof that they had an effective training procedure in place. The vendor must also submit documentation listing the names of the vendor personnel trained and the date of training. This training date must be during the fiscal year but before the disqualification notification. A CMP must be paid within 30 days of the Civil Money Penalty approval notice. Installments may be considered up to a maximum of six months. If a CMP is not requested in the specified time period, all rights to a CMP are forfeited. When a CMP is approved, the waived disqualification period will begin as outlined in the disqualification notice. If a vendor fails to pay the CMP, the State Agency must disqualify the vendor for a period equal to the violation for which the CMP was assessed.
Civil Money Penalties cannot exceed $10,000 per violation and/or $40,000 per investigation. If more than one violation is detected during a compliance investigation, a CMP must be imposed for each violation (up to the $10,000/$40,000 limits). Only two CMPs can be granted within a waived disqualification period.
Methodology for Mandatory Sanctions
For each violation subject to a mandatory sanction, the following formula will be used to calculate the amount of the CMP imposed in lieu of disqualification. The Georgia WIC Branch will:
1. Determine the vendor's average monthly redemptions for at least the 6 month period ending with the month immediately preceding the month during which the notice of the adverse action is dated.
2. Multiply the average monthly redemptions figure by ten percent (.10). 3. Multiply the product from the figure in the above statement by the number of months for which the
store would have been disqualified. This is the amount of the civil money penalty, provided that the civil money penalty shall not exceed $10,000 per violation. The total of violations during a single investigation may not exceed $40,000.
When a vendor, who previously has been assessed a mandatory sanction, receives another sanction for any of these violations, the Georgia WIC Program must double the second sanction. Civil money penalties may only be doubled up to the maximum limits.
When a vendor, who has previously been assessed two or more sanctions, receives another sanction for any of these violations, the Georgia WIC Branch must double the third sanction and subsequent sanctions. The Georgia WIC Program may not impose civil money penalties in lieu of disqualification for third or subsequent sanctions for mandatory sanctions.

Methodology for State Agency Sanctions The formula for calculating Civil Money Penalties for State Agency sanctions, imposed by the Georgia WIC Program will be calculated using the chart below.
Civil Money Penalty Formula Based on a Six Month WIC Redemption Total

Category
Category I Category II Category III

$0-10,000 (Base Rate) $500 $1000 $1500

Amount Above $10,000 (Base Rate + % of Total Redemption over $10,000) $500 + 1% of redemption over $10,000 $1000 + 2% of redemption over $10,000 $1500 + 3% of redemption over $10,000

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WHERE TO GET MORE INFORMATION
The Georgia WIC Branch has a vendor customer service hotline (toll free in Georgia) available to assist Georgia WIC vendors with any aspect of the WIC Program. The hotline is available Monday through Friday, except State holidays, from 8:00-5:00 PM Eastern Standard Time (EST). Contact us at: Georgia WIC Branch Vendor Management Section 2 Peachtree Street, NW Suite 10-476 Atlanta, Georgia 30303-3142 404-657-2900 Customer service hotline 1-866-814-5468 (toll free within Georgia) The United States Department of Agriculture (USDA) prohibits discrimination in its program and activities on the basis of race, color, national origin, sex, age or disability. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information (Braille, larger print, audiotape, etc.) should contact USDA's Target Center at (202) 720-5964 (voice and TDD). To file a complaint, of discrimination, write USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 14th and Independence Avenue, SW, Washington, DC 20250-9410 or call (202) 720-5964 (voice and TDD). USDA is an equal opportunity provider and employer.
DHR Georgia Department of Human Resources Form No. 3783 (Rev. 8/2002)

GA WIC PROCEDURES MANUAL

ATTACHMENT VM-3

GEORGIA DEPARTMENT OF HUMAN RESOURCES
DIVISION OF PUBLIC HEALTH WIC VENDOR AGREEMENT

Legal Name of Vendor

Vendor Address

City

Business Telephone
Mailing Address
If different from above

(Area Code)

State
Number

Zip County

City

State

Zip

Business Telephone
(Area Code)
Federal Employer Identification Number

Number

WIC VENDOR NUMBER

This Agreement is by and between the Georgia Department of Human Resources, Division of
Public Health, WIC Branch, hereinafter known as the "Georgia WIC Program," having a mailing address of Two Peachtree Street NW, 10th Floor, Suite 476, Atlanta, Georgia, 30303-3142, and
the above named vendor hereinafter known as "the Vendor." This agreement is effective for the
period beginning October 1, 2002 and ending September 30, 2004.

I.

PURPOSE

The purpose of this agreement is to establish the terms and conditions for an authorized vendor to sell prescribed nutritious supplemental foods in accordance with federal laws and regulations and the Georgia Nutrition Program for Women, Infants and Children (WIC) pursuant to the laws of the State of Georgia and the Child Nutrition Act (CNA) of 1966 as amended.

II. VENDOR ELIGIBILITY AND LOCATION

A. An eligible vendor is a business entity that is 1) licensed by the Georgia Department of Agriculture and, 2) without a debarment or suspension from United States Department of Agriculture. Pharmacies and military commissaries do not have to be licensed by the Georgia Department of Agriculture.

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ATTACHMENT VM-3

B. An eligible vendor must be identified as a fixed location with an official physical address. For corporate vendors owning two (2) or more locations, the following information for each location must be listed on the Corporate Attachment (Form 3771A) and made part of the agreement: 1.) vendor name 2.) vendor number 3.) bank name 4.) Food Stamp Program authorization number 5.) Georgia Department of Agriculture number 6.) physical address 7.) city, state and zip code 8.) authorized contact person(store manager) 9.) telephone number 10.) Federal Employer Identification Number
C. An eligible vendor must meet all requirements as described in the 2002 Georgia WIC Program Vendor Handbook and all addendums.
D. The vendor must comply with the selection criteria throughout the agreement period including any changes to the criteria. Using the current vendor selection criteria, the Georgia WIC Program may reassess the vendor at any time during the agreement. The Georgia WIC Program will terminate the vendor agreement if the vendor fails to meet the current vendor selection criteria.
E. An eligible vendor, authorized as a military commissary, pharmacy or corporate vendor will be given certain exceptions to this agreement. The exceptions are outlined in the 2002 Georgia WIC Program Vendor Handbook and all addendums.
III. RESPONSIBILITIES VENDOR
The Vendor agrees to adhere to all federal and state laws, policies, procedures, rules and regulations, including the most recent State Plan of Program Operation and Administration and any subsequent revisions to the policies, procedures, laws, rules and regulations issued by the federal government and/or the Georgia WIC Program. This agreement will be interpreted based on the laws of the State of Georgia.
A. The vendor agrees and covenants: 1. To be fully accountable for the actions of its paid or unpaid owners, officers, managers, agents and employees. 2. To abide by the rules, policies and procedures as outlined in the most recent publication of the Georgia WIC Program Vendor Handbook and all addendums. 3. To provide training to paid and unpaid employees, agents and all personnel involved in WIC transactions. 4. To not solicit WIC participants, parents, caretakers and/or proxies on the premises of WIC clinics.
B. VENDOR TRAINING
Prior to accepting WIC vouchers, the vendor or his authorized representative must receive interactive authorized training. The Georgia WIC Program will provide the date, time and location of the training. The vendor may submit a
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ATTACHMENT VM-3

written request, for the Georgia WIC Program to provide subsequent training to store personnel at anytime after both parties have signed the agreement.
The vendor agrees and covenants:
1. To not participate in the Georgia WIC Program until Authorized Training has been completed and a vendor stamp has been issued.
2. To not participate until the vendor has received a passing score of seventy (70) points or above on the Post Vendor Training Evaluation.
3. To provide documentation that a management representative(s) from each location has been trained on the required topics as listed on the Corporate Vendor Training Checklist (form 3757A).

C. NO SUBSTITUTIONS, CASH, REFUNDS, OR EXCHANGES The vendor agrees and covenants:
1. To only charge for authorized supplemental foods listed on the food voucher.
2. To not provide unauthorized food items, non-food items or cash in exchange for food vouchers.
3. To not provide refunds or permit exchanges for authorized supplemental food vouchers except for exchanges of an identical authorized supplemental food item when the original authorized supplemental food item is defective, spoiled or has exceeded its "sell by" or "best if used by" or other date limiting the sale or use of the food item.

D. FOOD VOUCHER TRANSACTIONS The vendor agrees and covenants:
1. To not accept WIC food vouchers before the "First Date to Use" or after the "Last Date to Use" as printed on the voucher.
2. To submit vouchers to the bank for payment within sixty (60) days from the "First Date to Use" as indicated on each voucher.
3. To assure that WIC food voucher transactions are processed in accordance with the procedures set forth in the 2002 Georgia WIC Program Vendor Handbook and all addendums.
4. To not demand that a WIC participant, parent, caretaker and/or proxy purchase every eligible WIC food item listed on the voucher.
5. To allow participants, parent, caretakers and/or proxies the right to purchase the eligible foods of their choice as listed on the WIC food voucher and the approved food list.
6. To not transfer Georgia WIC Program vouchers from vendor to vendor or to not accept Georgia WIC Program vouchers from another vendor for payment or to not accept WIC vouchers in an unauthorized location for payment in an authorized location.
7. To not contact or seek restitution from participants, parents, caretakers and/or proxies for WIC food vouchers not paid or partially paid by the Georgia WIC Program.
8. To not request cash from the WIC participant, parents, caretakers or proxies for any WIC transaction.

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ATTACHMENT VM-3

9. To not provide WIC participants, parents, caretakers and/or proxies with rain checks/IOU's, credit slips, due bills or other similar receipts for WIC foods not obtained at the time of the purchase.
10. To allow WIC participants, parents, and caretakers and/or proxies to participate in both or either in-store and/or manufacturer promotions that include WIC approved food items.
11. To not collect sales tax on prescribed WIC food purchases. 12. To not charge the participant, parents, caretaker, and/or proxy or the WIC
Program for bank fees or other fees related to voucher redemption. 13. To advise participants, parents, caretakers and/or proxies that the Georgia
WIC Program is not responsible for the home delivery of food items or any other in-store promotions. 14. To insert, in ink the actual cost of the WIC foods on the WIC voucher face at the time of purchase in the presence of the customer.
E. PRICING The vendor agrees and covenants:
1. To clearly mark the price of WIC foods on the item, container, shelf or sign.
2. To provide each WIC food item at or below the current shelf price. 3. To accept an adjustment if the price on the voucher(s) submitted for
payment exceeds the maximum price printed on the voucher.
F. OVERCHARGING The vendor agrees and covenants:
1. To not overcharge the WIC participant, parent, caretaker and/or proxy, or the Georgia WIC Program by charging more than the vendor's current shelf price for a WIC approved food item(s). (Overcharging is considered a violation and will result in sanction(s) if it occurs during a covert investigation).
G. CIVIL RIGHTS The vendor agrees and covenants:
1. To abide by the United States Civil Rights Act and the United States Civil Rights Policy Statement and to assure that discrimination is prohibited towards WIC Program participants, caretakers, parents or proxies and all related activities, on the basis of race, color, national origin, sex, religion, age, disability, political beliefs, sexual orientation or marital status.
2. To offer WIC participants, parents, caretakers and/or proxies the same courtesies offered to other customers.
3. To display the "We Welcome WIC'' decal on the door glass or other prominent place.
4. To assure that all information, including the identity of the WIC participant, parent, caretaker and/or proxy is kept confidential in accordance with state and federal law.
H. CHANGE OF OWNERSHIP, LOCATION OR CESSATION OF OPERATION The vendor agrees and covenants:
1. To submit, upon request, to the Georgia WIC Program a copy of all acceptable proof of ownership and related documents, (e.g. articles of
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incorporation, bill of sale and partnership declaration and evidence of sole proprietorship, etc). 2. To notify the Georgia WIC Program in writing at least twenty-one (21) days in advance if the vendor plans to cease business operation, change ownership and/or when the vendor plans to move from the authorized location.

I.

COMPLIANCE AND MONITORING

The vendor agrees and covenants:

1. To permit unannounced visits by federal or state agency representatives to review adherence to federal laws and to the Georgia WIC Program's policies and procedures.
2. To provide access to WIC food vouchers on hand, vendor inventory records (invoices) and any other business records during a monitoring visit or inventory audit by an authorized federal or state agency representative.
3. To maintain required records for four years or until pending investigations are adjudicated.
4. To disclose any potential or actual conflict of interest between the vendor and Georgia WIC Program employees.
5. To not attempt to circumvent a sanction(s) by selling the store to a relative by blood or marriage.

J. VENDOR SANCTION SYSTEM AND VENDOR CLAIMS The vendor agrees and covenants:
1. To pay claims and penalties levied for audit citations and for sanctions levied pursuant to this agreement and in the Georgia WIC Program Vendor Handbook and all addendums.
2. That the Georgia WIC Program can impose claims, sanctions and penalties as outlined in Section XIII of this agreement and the Georgia WIC Program Vendor Handbook and all addendums.

K. STATE PROPERTY The vendor agrees and covenants:
1. To return the vendor stamp(s) to the Georgia WIC Program upon termination, change of ownership or disqualification.
2. To report lost, stolen or damaged vendor stamps to the Georgia WIC Program immediately.

IV. RESPONSIBILITIES GEORGIA WIC PROGRAM
The Georgia WIC Program agrees to adhere to federal and/or state laws, policies, procedures, rules and regulations, including the most recent State Plan of Program Operation and Administration.
Any subsequent revisions to the policies, procedures, laws, rules and regulations that relate to the Georgia WIC Program issued by the federal government are hereby made a part of this agreement.
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The Georgia WIC Program further agrees to the following:

A. To supply the vendor with the 2002 Georgia WIC Program Vendor Handbook and

all addendums.

B. To assure that WIC participants, parents, caretakers and/or proxies are informed

of the proper voucher redemption procedures and the correct use of WIC

vouchers.

C. To assure that vouchers are provided to qualified women, infants and children.

D. To notify the vendor of new requirements as set forth by the U.S. Department of

Agriculture's regulations and/or the Georgia WIC Program's policies and

procedures.

E. To provide training for the vendor to obtain information on policies and procedures

of the WIC Program, at a time, place and in a manner prescribed by the Georgia

WIC Program.

F. To monitor and audit the vendors for possible violations of the Georgia WIC

Program rules, regulations, policies or procedures.

G. To enforce rules, regulations, policies and procedures of the Georgia WIC

Program through a system of claims, penalties, and/or sanctions against the

vendor as described in the most recent publication of the Georgia WIC Program

Vendor Handbook and all addendums.

H. To provide an appropriate written notice of intent or reason(s) to terminate this

agreement.

I.

To notify the vendor of the right to appeal adverse actions.

J. To provide payment for vouchers validly redeemed and submitted to the Georgia

WIC Program as prescribed in the most recent publication of the Georgia WIC

Vendor Handbook and all addendums.

K. To deny payment for vouchers improperly completed, redeemed or submitted in

accordance with the most recent publication of the Georgia WIC Program Vendor

Handbook and all addendums.

L. To refuse authorization to a vendor applicant if it is determined that the store(s)

is/are being sold in an attempt to circumvent a Georgia WIC Program sanction.

M. To notify vendor of stolen vouchers. The stolen vouchers may not be redeemed.

V. RENEWABILITY
This agreement is not renewable. If the vendor wishes to continue to be authorized beyond the period of its current agreement, the vendor must reapply for authorization.
VI. NON TRANSFERABILITY This agreement is not transferable.
VII. EXPIRATION, TERMINATION AND DISQUALIFICATION
A. Expiration of this agreement is not subject to appeal by the vendor. B. Either party may terminate the agreement. C. The Georgia WIC Program may terminate for cause, after providing a twenty-one
(21) day advance written notice. Vendors have the right to request an Administrative Review. D. Disqualification is an adverse action taken by the Georgia WIC Program and is based on the sanction system outlined in the 2002 Georgia WIC Program Vendor Handbook and all addendums.

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VIII. ADVERSE ACTIONS AND REVIEW PROCEDURES A vendor may request an Administrative Review for the following:
A. Denial of authorization based on the vendor selection criteria for competitive price or for minimum variety and quantity of authorized supplemental foods or on a determination that the vendor is attempting to circumvent a sanction.
B. Termination for cause, including but not limited to change in ownership, location (more than mile) or cessation of operations.
C. Disqualification. D. Imposition of a civil money penalty in lieu of disqualification. E. Denial of authorization based on the vendor selection criteria for business integrity
or for a current Food Stamp Program disqualification or civil money penalty for hardship. F. Denial of authorization because a vendor submitted its application outside the established timeframes. G. Disqualification based on a trafficking conviction. H. Disqualification based on the imposition of a Food Stamp Program civil money penalty for hardship.
Administrative Review Procedures are outlined in the most recent Georgia Vendor Handbook.
IX. PENALTIES
A. The Georgia WIC Program may penalize the vendor by issuing sanctions in accordance with the procedures prescribed in the most recent publication of the Georgia WIC Vendor Handbook and all addendums.
The Georgia WIC Program sanctions may include disqualification, warnings, probation and civil money penalties in lieu of disqualification. The State agency does not have to provide the vendor with prior warning about those violations before imposing such sanctions (7CFR 246.12 XVIII).
B. A vendor maybe subject to criminal penalties as a result of a violation of the Georgia WIC Program in additional to civil money penalties described above. Vendors who have willfully misapplied, stolen or fraudulently obtained WIC funds shall be subject to a fine of not more than $25,000.00 imprisonment for not more than five (5) years or both. If the value of the funds is less than $100.00 then the penalties may be a fine of not more than $1,000.00, imprisonment for not more than one (1) year or both.

X. SEVERABILITY If any provision of this agreement or form attached to or incorporated by reference is waived or held to be invalid, such waiver or invalidity shall not affect other provisions of this agreement.

XI. SANCTIONS/VIOLATIONS FROM PREVIOUS AGREEMENT PERIODS A. Sanctions - any sanction(s) that are in the vendor's record at the time of reauthorization will remain on the vendor's record. Prior year's sanctions may result
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in denial of application and/or additional sanctions up to and including disqualification, in accordance with the 2002 Georgia WIC Program Vendor Handbook and all addendums.
B. Violations - Pending and/or potential violations, that exists at the time of reauthorization will accrue and will result in sanctions up to and including disqualification, in accordance with the 2002 Georgia WIC Program Vendor Handbook and all addendums.
XII. SANCTION SYSTEM
Following is a description of the Georgia WIC Program Sanction System and how it works. Civil Money Penalties (CMP) may be assessed in Categories I-V in lieu of disqualification for State Agency sanctions only. However, CMP shall only be assessed for mandatory sanctions if the disqualification results in inadequate participant access. Vendor violations will be categorized by the severity and nature of the offense. The nature and severity of a violation(s) shall determine the sanction assessed, the duration of the probationary period and the period of disqualification. Therefore, the highest sanction assessed to a vendor shall determine the period of probation and disqualification. Disqualification from the WIC program may also result in disqualification from the Food Stamp Program.
A. Any violation from Category I, II or III may be assessed a CMP in lieu of disqualification.
Category I - Warning on first and second offense, third offense probation for six (6) months. While on probation if, a violation occurs in Categories I, II or III the vendor will be disqualified for six (6) months.
State Agency Sanctions Violations: 1. Stocking a WIC food item (s) outside of manufacturer's expiration date(s). 2. Prices not marked clearly on WIC food items or near WIC food items. 3. Allowing WIC food items to exceed the quantity specified on the voucher
(Except for promotional items). 4. Failure to allow the purchase of any WIC food item(s).
Category II - Warning on first offense, second offense probation for eight (8) months. While on probation, if a violation occurs in Categories I, II or III the vendor will be disqualified for eight (8) months.
State Agency Sanctions Violations: 1. Failure to properly process vouchers at the store [(this includes failure to
calculate (ring up) sales of WIC purchases or failure to write the price on voucher before the participant signs)]. 2. Failure to stock the required inventory of contracted formula or failure to stock the required inventory of two or time of the visit. Proof of an order for WIC food items is not acceptable. 3. Refusing to accept valid WIC vouchers from participants in exchange for WIC food items.

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4. Allowing the substitution of one WIC approved food item listed on the voucher for another WIC approved food item not listed on the voucher or allowing the purchase of WIC foods in unauthorized container sizes.
5. Failure to remain open for business at least eight hours per day, six days per week.
6. Failure to repay overcharges within thirty (30) days.
Category III - Warning on first offense second offense probation for ten (10) months. While on probation if a violation occurs in Categories I, II or III the vendor will be disqualified for ten (10) months.
State Agency Sanctions Violations: 1. Issuing rain checks/IOU's for WIC food items. 2. Contacting WIC participants for any reason regarding a WIC transaction. 3. Requiring participant to pay cash to redeem WIC vouchers. 4. Allowing the purchase of any formula other than the one specified on the
front of the voucher. 5. Failure to allow participants, parents, caretakers and/or proxies to
purchase all WIC approved food items listed on the face of the voucher regardless of the price on the voucher. 6. Providing incentive items as part of WIC transaction. 7. One occurrence during a covert compliance investigation of a violation(s) in Category IV, violations #1-2. 8. One occurrence during a covert compliance investigation of a violation (s) in Category V, violations #1-5.
B. Any violation from Category IV or V that occurs at any time will result in immediate disqualification for the period specified in Category IV or V (no warning will be given prior to the completion of a covert compliance investigation). A pattern is established when the same violation occurs twice during a covert compliance investigation. When a pattern is not established, one occurrence during a compliance investigation will result in a Category III sanction.
Category IV - Immediate disqualification for one (1) year (twelve months) for each violation.
Mandatory Sanctions Violations: 1. A pattern of providing unauthorized food items in exchange for WIC
vouchers. 2. A pattern of charging for supplemental foods provided in excess of those
listed on the voucher.
State Agency Sanctions Violations: 3. Intentionally providing false information on vendor records. 4. Discrimination. 5. Failure to provide vouchers or inventory records upon request. 6. Failure to allow monitoring by WIC representatives.

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Category V - Immediate disqualification for three (3) years (thirty-six months) for each violation.

Mandatory Sanctions

Violations:

1.

A pattern of receiving, transacting, and/or redeeming food vouchers in

locations different from the authorized locations listed on the Agreement

including the use of an unauthorized vendor and/or an unauthorized

person.

2.

A pattern of providing credit or non-food items in exchange for WIC

vouchers.

3.

A pattern of overcharging on WIC vouchers (charging a WIC participant

more than the current shelf price or charging a WIC participant more for

food than a non-WIC customer) during a compliance investigation.

4.

A pattern of charging for supplemental food not received by the

participant.

5.

A pattern of claiming reimbursement for the sale of an amount of a

specific supplemental food item which exceeds the store's documented

inventory of that supplemental food item for a specific period of time.

6.

One incident of the sale of alcohol or alcoholic beverages or tobacco

products in exchange for WIC vouchers.

C. Any violation from Category VI or VII that occurs at any time will result in immediate disqualification.

Category VI - Disqualification for six (6) years (seventy-two months) for each violation.

Mandatory Sanctions Violations: 1. One incidence of buying or selling of WIC vouchers for cash. 2. One incidence of exchanging WIC vouchers for firearms. 3. One incidence of exchanging WIC vouchers for ammunition. 4. One incidence of exchanging WIC vouchers for explosives. 5. One incidence of exchanging WIC vouchers for controlled substances.

Category VII - Permanent disqualification for a conviction of each violation [Conviction refers to an action by a criminal court as defined in section 102 of the Controlled Substances Act (21 U.S.C. 8020)]

Mandatory Sanctions Violations: 1. Conviction for buying or selling WIC vouchers for cash. 2. Conviction for exchanging WIC vouchers for firearms. 3. Conviction for exchanging WIC vouchers for ammunition. 4. Conviction for exchanging WIC vouchers for explosives. 5. Conviction for exchanging WIC vouchers for controlled substances.

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XIII. SPECIAL CERTIFICATION
The vendor acknowledges through the signature of the owner, or an authorized representative, that he or she understands and accepts all terms of this agreement. The individuals signing this agreement certify that they are authorized to sign the agreement on behalf of the vendor.
This agreement becomes valid only upon the signature of an authorized representative of the Georgia WIC Program and upon receipt, by the vendor, of an executed copy along with vendor stamps for each authorized location.

VENDOR SIGNATURE

Signature of Authorized Representative

Date

Authorized Representative (Type or Print)

Title (Type or Print)

GEORGIA WIC PROGRAM SIGNATURE

Signature of Authorized Representative Authorized Representative (Type or Print) Title (Type or Print)

Date

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GEORGIA DEPARTMENT OF HUMAN RESOURCES
DIVISION OF PUBLIC HEALTH WIC VENDOR AGREEMENT

Legal Name of Vendor

Vendor Address

City

Business Telephone
Mailing Address
If different from above

(Area Code)

State
Number

Zip County

City

State

Zip

Business Telephone
(Area Code)
Federal Employer Identification Number

Number

WIC VENDOR NUMBER

This Agreement is by and between the Georgia Department of Human Resources, Division of
Public Health, WIC Branch, hereinafter known as the "Georgia WIC Program," having a mailing address of Two Peachtree Street NW, 10th Floor, Suite 476, Atlanta, Georgia, 30303-3142, and
the above named vendor hereinafter known as "the Vendor." This agreement is effective for the
period beginning October 1, 2002 and ending September 30, 2005.

I.

PURPOSE

The purpose of this agreement is to establish the terms and conditions for an authorized vendor to sell prescribed nutritious supplemental foods in accordance with federal laws and regulations and the Georgia Nutrition Program for Women, Infants and Children (WIC) pursuant to the laws of the State of Georgia and the Child Nutrition Act (CNA) of 1966 as amended.

II. VENDOR ELIGIBILITY AND LOCATION

A. An eligible vendor is a business entity that is 1) licensed by the Georgia Department of Agriculture and, 2) without a debarment or suspension from United States Department of Agriculture. Pharmacies and military commissaries do not have to be licensed by the Georgia Department of Agriculture.

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B. An eligible vendor must be identified as a fixed location with an official physical address. For corporate vendors owning two (2) or more locations, the following information for each location must be listed on the Corporate Attachment (Form 3771A) and made part of the agreement: 1.) vendor name 2.) vendor number 3.) bank name 4.) Food Stamp Program authorization number 5.) Georgia Department of Agriculture number 6.) physical address 7.) city, state and zip code 8.) authorized contact person(store manager) 9.) telephone number 10.) Federal Employer Identification Number
C. An eligible vendor must meet all requirements as described in the 2002 Georgia WIC Program Vendor Handbook and all addendums.
D. The vendor must comply with the selection criteria throughout the agreement period including any changes to the criteria. Using the current vendor selection criteria, the Georgia WIC Program may reassess the vendor at any time during the agreement. The Georgia WIC Program will terminate the vendor agreement if the vendor fails to meet the current vendor selection criteria.
E. An eligible vendor, authorized as a military commissary, pharmacy or corporate vendor will be given certain exceptions to this agreement. The exceptions are outlined in the 2002 Georgia WIC Program Vendor Handbook and all addendums.
III. RESPONSIBILITIES VENDOR
The Vendor agrees to adhere to all federal and state laws, policies, procedures, rules and regulations, including the most recent State Plan of Program Operation and Administration and any subsequent revisions to the policies, procedures, laws, rules and regulations issued by the federal government and/or the Georgia WIC Program. This agreement will be interpreted based on the laws of the State of Georgia.
A. The vendor agrees and covenants: 1. To be fully accountable for the actions of its paid or unpaid owners, officers, managers, agents and employees. 2. To abide by the rules, policies and procedures as outlined in the most recent publication of the Georgia WIC Program Vendor Handbook and all addendums. 3. To provide training to paid and unpaid employees, agents and all personnel involved in WIC transactions. 4. To not solicit WIC participants, parents, caretakers and/or proxies on the premises of WIC clinics.
B. VENDOR TRAINING
Prior to accepting WIC vouchers, the vendor or his authorized representative must receive interactive authorized training. The Georgia WIC Program will provide the date, time and location of the training. The vendor may submit a
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written request, for the Georgia WIC Program to provide subsequent training to store personnel at anytime after both parties have signed the agreement.
The vendor agrees and covenants:
1. To not participate in the Georgia WIC Program until Authorized Training has been completed and a vendor stamp has been issued.
2. To not participate until the vendor has received a passing score of seventy (70) points or above on the Post Vendor Training Evaluation.
3. To provide documentation that a management representative(s) from each location has been trained on the required topics as listed on the Corporate Vendor Training Checklist (form 3757A).

C. NO SUBSTITUTIONS, CASH, REFUNDS, OR EXCHANGES The vendor agrees and covenants:
1. To only charge for authorized supplemental foods listed on the food voucher.
2. To not provide unauthorized food items, non-food items or cash in exchange for food vouchers.
3. To not provide refunds or permit exchanges for authorized supplemental food vouchers except for exchanges of an identical authorized supplemental food item when the original authorized supplemental food item is defective, spoiled or has exceeded its "sell by" or "best if used by" or other date limiting the sale or use of the food item.

D. FOOD VOUCHER TRANSACTIONS The vendor agrees and covenants:
1. To not accept WIC food vouchers before the "First Date to Use" or after the "Last Date to Use" as printed on the voucher.
2. To submit vouchers to the bank for payment within sixty (60) days from the "First Date to Use" as indicated on each voucher.
3. To assure that WIC food voucher transactions are processed in accordance with the procedures set forth in the 2002 Georgia WIC Program Vendor Handbook and all addendums.
4. To not demand that a WIC participant, parent, caretaker and/or proxy purchase every eligible WIC food item listed on the voucher.
5. To allow participants, parent, caretakers and/or proxies the right to purchase the eligible foods of their choice as listed on the WIC food voucher and the approved food list.
6. To not transfer Georgia WIC Program vouchers from vendor to vendor or to not accept Georgia WIC Program vouchers from another vendor for payment or to not accept WIC vouchers in an unauthorized location for payment in an authorized location.
7. To not contact or seek restitution from participants, parents, caretakers and/or proxies for WIC food vouchers not paid or partially paid by the Georgia WIC Program.
8. To not request cash from the WIC participant, parents, caretakers or proxies for any WIC transaction.

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9. To not provide WIC participants, parents, caretakers and/or proxies with rain checks/IOU's, credit slips, due bills or other similar receipts for WIC foods not obtained at the time of the purchase.
10. To allow WIC participants, parents, and caretakers and/or proxies to participate in both or either in-store and/or manufacturer promotions that include WIC approved food items.
11. To not collect sales tax on prescribed WIC food purchases. 12. To not charge the participant, parents, caretaker, and/or proxy or the WIC
Program for bank fees or other fees related to voucher redemption. 13. To advise participants, parents, caretakers and/or proxies that the Georgia
WIC Program is not responsible for the home delivery of food items or any other in-store promotions. 14. To insert, in ink the actual cost of the WIC foods on the WIC voucher face at the time of purchase in the presence of the customer.
E. PRICING The vendor agrees and covenants:
1. To clearly mark the price of WIC foods on the item, container, shelf or sign.
2. To provide each WIC food item at or below the current shelf price. 3. To accept an adjustment if the price on the voucher(s) submitted for
payment exceeds the maximum price printed on the voucher.
F. OVERCHARGING The vendor agrees and covenants:
1. To not overcharge the WIC participant, parent, caretaker and/or proxy, or the Georgia WIC Program by charging more than the vendor's current shelf price for a WIC approved food item(s). (Overcharging is considered a violation and will result in sanction(s) if it occurs during a covert investigation).
G. CIVIL RIGHTS The vendor agrees and covenants:
1. To abide by the United States Civil Rights Act and the United States Civil Rights Policy Statement and to assure that discrimination is prohibited towards WIC Program participants, caretakers, parents or proxies and all related activities, on the basis of race, color, national origin, sex, religion, age, disability, political beliefs, sexual orientation or marital status.
2. To offer WIC participants, parents, caretakers and/or proxies the same courtesies offered to other customers.
3. To display the "We Welcome WIC'' decal on the door glass or other prominent place.
4. To assure that all information, including the identity of the WIC participant, parent, caretaker and/or proxy is kept confidential in accordance with state and federal law.
H. CHANGE OF OWNERSHIP, LOCATION OR CESSATION OF OPERATION The vendor agrees and covenants:
1. To submit, upon request, to the Georgia WIC Program a copy of all acceptable proof of ownership and related documents, (e.g. articles of
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incorporation, bill of sale and partnership declaration and evidence of sole proprietorship, etc). 2. To notify the Georgia WIC Program in writing at least twenty-one (21) days in advance if the vendor plans to cease business operation, change ownership and/or when the vendor plans to move from the authorized location.

I.

COMPLIANCE AND MONITORING

The vendor agrees and covenants:

1. To permit unannounced visits by federal or state agency representatives to review adherence to federal laws and to the Georgia WIC Program's policies and procedures.
2. To provide access to WIC food vouchers on hand, vendor inventory records (invoices) and any other business records during a monitoring visit or inventory audit by an authorized federal or state agency representative.
3. To maintain required records for four years or until pending investigations are adjudicated.
4. To disclose any potential or actual conflict of interest between the vendor and Georgia WIC Program employees.
5. To not attempt to circumvent a sanction(s) by selling the store to a relative by blood or marriage.

J. VENDOR SANCTION SYSTEM AND VENDOR CLAIMS The vendor agrees and covenants:
1. To pay claims and penalties levied for audit citations and for sanctions levied pursuant to this agreement and in the Georgia WIC Program Vendor Handbook and all addendums.
2. That the Georgia WIC Program can impose claims, sanctions and penalties as outlined in Section XIII of this agreement and the Georgia WIC Program Vendor Handbook and all addendums.

K. STATE PROPERTY The vendor agrees and covenants:
1. To return the vendor stamp(s) to the Georgia WIC Program upon termination, change of ownership or disqualification.
2. To report lost, stolen or damaged vendor stamps to the Georgia WIC Program immediately.

IV. RESPONSIBILITIES GEORGIA WIC PROGRAM
The Georgia WIC Program agrees to adhere to federal and/or state laws, policies, procedures, rules and regulations, including the most recent State Plan of Program Operation and Administration.
Any subsequent revisions to the policies, procedures, laws, rules and regulations that relate to the Georgia WIC Program issued by the federal government are hereby made a part of this agreement.
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The Georgia WIC Program further agrees to the following:

A. To supply the vendor with the 2002 Georgia WIC Program Vendor Handbook and

all addendums.

B. To assure that WIC participants, parents, caretakers and/or proxies are informed

of the proper voucher redemption procedures and the correct use of WIC

vouchers.

C. To assure that vouchers are provided to qualified women, infants and children.

D. To notify the vendor of new requirements as set forth by the U.S. Department of

Agriculture's regulations and/or the Georgia WIC Program's policies and

procedures.

E. To provide training for the vendor to obtain information on policies and procedures

of the WIC Program, at a time, place and in a manner prescribed by the Georgia

WIC Program.

F. To monitor and audit the vendors for possible violations of the Georgia WIC

Program rules, regulations, policies or procedures.

G. To enforce rules, regulations, policies and procedures of the Georgia WIC

Program through a system of claims, penalties, and/or sanctions against the

vendor as described in the most recent publication of the Georgia WIC Program

Vendor Handbook and all addendums.

H. To provide an appropriate written notice of intent or reason(s) to terminate this

agreement.

I.

To notify the vendor of the right to appeal adverse actions.

J. To provide payment for vouchers validly redeemed and submitted to the Georgia

WIC Program as prescribed in the most recent publication of the Georgia WIC

Vendor Handbook and all addendums.

K. To deny payment for vouchers improperly completed, redeemed or submitted in

accordance with the most recent publication of the Georgia WIC Program Vendor

Handbook and all addendums.

L. To refuse authorization to a vendor applicant if it is determined that the store(s)

is/are being sold in an attempt to circumvent a Georgia WIC Program sanction.

M. To notify vendor of stolen vouchers. The stolen vouchers may not be redeemed.

V. RENEWABILITY
This agreement is not renewable. If the vendor wishes to continue to be authorized beyond the period of its current agreement, the vendor must reapply for authorization.
VI. NON TRANSFERABILITY This agreement is not transferable.
VII. EXPIRATION, TERMINATION AND DISQUALIFICATION
A. Expiration of this agreement is not subject to appeal by the vendor. B. Either party may terminate the agreement. C. The Georgia WIC Program may terminate for cause, after providing a twenty-one
(21) day advance written notice. Vendors have the right to request an Administrative Review. D. Disqualification is an adverse action taken by the Georgia WIC Program and is based on the sanction system outlined in the 2002 Georgia WIC Program Vendor Handbook and all addendums.

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VIII. ADVERSE ACTIONS AND REVIEW PROCEDURES A vendor may request an Administrative Review for the following:
A. Denial of authorization based on the vendor selection criteria for competitive price or for minimum variety and quantity of authorized supplemental foods or on a determination that the vendor is attempting to circumvent a sanction.
B. Termination for cause, including but not limited to change in ownership, location (more than mile) or cessation of operations.
C. Disqualification. D. Imposition of a civil money penalty in lieu of disqualification. E. Denial of authorization based on the vendor selection criteria for business integrity
or for a current Food Stamp Program disqualification or civil money penalty for hardship. F. Denial of authorization because a vendor submitted its application outside the established timeframes. G. Disqualification based on a trafficking conviction. H. Disqualification based on the imposition of a Food Stamp Program civil money penalty for hardship.
Administrative Review Procedures are outlined in the most recent Georgia Vendor Handbook.
IX. PENALTIES
A. The Georgia WIC Program may penalize the vendor by issuing sanctions in accordance with the procedures prescribed in the most recent publication of the Georgia WIC Vendor Handbook and all addendums.
The Georgia WIC Program sanctions may include disqualification, warnings, probation and civil money penalties in lieu of disqualification. The State agency does not have to provide the vendor with prior warning about those violations before imposing such sanctions (7CFR 246.12 XVIII).
B. A vendor maybe subject to criminal penalties as a result of a violation of the Georgia WIC Program in additional to civil money penalties described above. Vendors who have willfully misapplied, stolen or fraudulently obtained WIC funds shall be subject to a fine of not more than $25,000.00 imprisonment for not more than five (5) years or both. If the value of the funds is less than $100.00 then the penalties may be a fine of not more than $1,000.00, imprisonment for not more than one (1) year or both.

X. SEVERABILITY If any provision of this agreement or form attached to or incorporated by reference is waived or held to be invalid, such waiver or invalidity shall not affect other provisions of this agreement.

XI. SANCTIONS/VIOLATIONS FROM PREVIOUS AGREEMENT PERIODS A. Sanctions - any sanction(s) that are in the vendor's record at the time of reauthorization will remain on the vendor's record. Prior year's sanctions may result
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in denial of application and/or additional sanctions up to and including disqualification, in accordance with the 2002 Georgia WIC Program Vendor Handbook and all addendums.
B. Violations - Pending and/or potential violations, that exists at the time of reauthorization will accrue and will result in sanctions up to and including disqualification, in accordance with the 2002 Georgia WIC Program Vendor Handbook and all addendums.
XII. SANCTION SYSTEM
Following is a description of the Georgia WIC Program Sanction System and how it works. Civil Money Penalties (CMP) may be assessed in Categories I-V in lieu of disqualification for State Agency sanctions only. However, CMP shall only be assessed for mandatory sanctions if the disqualification results in inadequate participant access. Vendor violations will be categorized by the severity and nature of the offense. The nature and severity of a violation(s) shall determine the sanction assessed, the duration of the probationary period and the period of disqualification. Therefore, the highest sanction assessed to a vendor shall determine the period of probation and disqualification. Disqualification from the WIC program may also result in disqualification from the Food Stamp Program.
A. Any violation from Category I, II or III may be assessed a CMP in lieu of disqualification.
Category I - Warning on first and second offense, third offense probation for six (6) months. While on probation if, a violation occurs in Categories I, II or III the vendor will be disqualified for six (6) months.
State Agency Sanctions Violations: 1. Stocking a WIC food item (s) outside of manufacturer's expiration date(s). 2. Prices not marked clearly on WIC food items or near WIC food items. 3. Allowing WIC food items to exceed the quantity specified on the voucher
(Except for promotional items). 4. Failure to allow the purchase of any WIC food item(s).
Category II - Warning on first offense, second offense probation for eight (8) months. While on probation, if a violation occurs in Categories I, II or III the vendor will be disqualified for eight (8) months.
State Agency Sanctions Violations: 1. Failure to properly process vouchers at the store [(this includes failure to
calculate (ring up) sales of WIC purchases or failure to write the price on voucher before the participant signs)]. 2. Failure to stock the required inventory of contracted formula or failure to stock the required inventory of two or time of the visit. Proof of an order for WIC food items is not acceptable. 3. Refusing to accept valid WIC vouchers from participants in exchange for WIC food items.

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GA WIC PROCEDURES MANUAL

Attachment VM-4

4. Allowing the substitution of one WIC approved food item listed on the voucher for another WIC approved food item not listed on the voucher or allowing the purchase of WIC foods in unauthorized container sizes.
5. Failure to remain open for business at least eight hours per day, six days per week.
6. Failure to repay overcharges within thirty (30) days.
Category III - Warning on first offense second offense probation for ten (10) months. While on probation if a violation occurs in Categories I, II or III the vendor will be disqualified for ten (10) months.
State Agency Sanctions Violations: 1. Issuing rain checks/IOU's for WIC food items. 2. Contacting WIC participants for any reason regarding a WIC transaction. 3. Requiring participant to pay cash to redeem WIC vouchers. 4. Allowing the purchase of any formula other than the one specified on the
front of the voucher. 5. Failure to allow participants, parents, caretakers and/or proxies to
purchase all WIC approved food items listed on the face of the voucher regardless of the price on the voucher. 6. Providing incentive items as part of WIC transaction. 7. One occurrence during a covert compliance investigation of a violation(s) in Category IV, violations #1-2. 8. One occurrence during a covert compliance investigation of a violation (s) in Category V, violations #1-5.
B. Any violation from Category IV or V that occurs at any time will result in immediate disqualification for the period specified in Category IV or V (no warning will be given prior to the completion of a covert compliance investigation). A pattern is established when the same violation occurs twice during a covert compliance investigation. When a pattern is not established, one occurrence during a compliance investigation will result in a Category III sanction.
Category IV - Immediate disqualification for one (1) year (twelve months) for each violation.
Mandatory Sanctions Violations: 1. A pattern of providing unauthorized food items in exchange for WIC
vouchers. 2. A pattern of charging for supplemental foods provided in excess of those
listed on the voucher.
State Agency Sanctions Violations: 3. Intentionally providing false information on vendor records. 4. Discrimination. 5. Failure to provide vouchers or inventory records upon request. 6. Failure to allow monitoring by WIC representatives.

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GA WIC PROCEDURES MANUAL

Attachment VM-4

Category V - Immediate disqualification for three (3) years (thirty-six months) for each violation.

Mandatory Sanctions

Violations:

1.

A pattern of receiving, transacting, and/or redeeming food vouchers in

locations different from the authorized locations listed on the Agreement

including the use of an unauthorized vendor and/or an unauthorized

person.

2.

A pattern of providing credit or non-food items in exchange for WIC

vouchers.

3.

A pattern of overcharging on WIC vouchers (charging a WIC participant

more than the current shelf price or charging a WIC participant more for

food than a non-WIC customer) during a compliance investigation.

4.

A pattern of charging for supplemental food not received by the

participant.

5.

A pattern of claiming reimbursement for the sale of an amount of a

specific supplemental food item which exceeds the store's documented

inventory of that supplemental food item for a specific period of time.

6.

One incident of the sale of alcohol or alcoholic beverages or tobacco

products in exchange for WIC vouchers.

C. Any violation from Category VI or VII that occurs at any time will result in immediate disqualification.

Category VI - Disqualification for six (6) years (seventy-two months) for each violation.

Mandatory Sanctions Violations: 1. One incidence of buying or selling of WIC vouchers for cash. 2. One incidence of exchanging WIC vouchers for firearms. 3. One incidence of exchanging WIC vouchers for ammunition. 4. One incidence of exchanging WIC vouchers for explosives. 5. One incidence of exchanging WIC vouchers for controlled substances.

Category VII - Permanent disqualification for a conviction of each violation [Conviction refers to an action by a criminal court as defined in section 102 of the Controlled Substances Act (21 U.S.C. 8020)]

Mandatory Sanctions Violations: 1. Conviction for buying or selling WIC vouchers for cash. 2. Conviction for exchanging WIC vouchers for firearms. 3. Conviction for exchanging WIC vouchers for ammunition. 4. Conviction for exchanging WIC vouchers for explosives. 5. Conviction for exchanging WIC vouchers for controlled substances.

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GA WIC PROCEDURES MANUAL

Attachment VM-4

XIII. SPECIAL CERTIFICATION
The vendor acknowledges through the signature of the owner, or an authorized representative, that he or she understands and accepts all terms of this agreement. The individuals signing this agreement certify that they are authorized to sign the agreement on behalf of the vendor.
This agreement becomes valid only upon the signature of an authorized representative of the Georgia WIC Program and upon receipt, by the vendor, of an executed copy along with vendor stamps for each authorized location.

VENDOR SIGNATURE

Signature of Authorized Representative

Date

Authorized Representative (Type or Print)

Title (Type or Print)

GEORGIA WIC PROGRAM SIGNATURE

Signature of Authorized Representative Authorized Representative (Type or Print) Title (Type or Print)

Date

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GA WIC PROCEDURES MANUAL

Attachment VM-5

Georgia WIC Program PHARMACY PRICE LIST

VENDOR NAME

VENDOR NUMBER

Please fill in the price per can for all infant formulas available in your pharmacy.

FORMULA TYPE

13 oz. Concentrate

32 oz. ReadyTo-Feed

14 oz. or 16 oz.
Powdered

Other Size

SIMILAC LACTOSE FREE

ALIMENTUM

NUTRAMIGEN

PORTAGEN

PREGESTIMIL

PEDIASURE (8.oz RTF can)

PEDIASURE WITH FIBER (8 oz. RTF can)

Form 3809 Revised 7/02

GA WIC PROCEDURES MANUAL

Attachment VM-6

CORPORATE ATTACHMENT FORM
Please provide the following information for each location in your corporation. This form or a facsimile of the form will be accepted.

Store Name and Number

Store Address

City

State

Business Telephone
(Area Code)

Number

Store Contact or Manager

Federal Employer Identification Number

Food Stamp Authorization Number

Georgia Department of Agriculture License Number
Date store representative received Authorized Training (Include Form #3757A Corporate Training
Checklist.)
Date WIC minimum inventory will be in store (For locations opening after October 1, 2002)
Date store will open (For locations opening after October 1, 2002)

WIC Vendor Number
Zip County

Signature of Authorized Representative Authorized Representative (Type or Print) Title (Type or Print) Name of Company (Type or Print)

Date

Form 3771A (07/02)

GA WIC PROCEDURES MANUAL

Attachment VM-7

Instructions: Please print all information. STORE NAME

Georgia Department of Human Resources Georgia WIC Program
VENDOR TRAINING CHECKLIST
VENDOR NUMBER

STAFF PRESENT 1. 2. 3. 4.

TITLE

Check items reviewed, discussed and explained to vendor.
1. The purpose of the Georgia WIC Program and how to contact the Georgia WIC Branch.
2. Terms of the Vendor Agreement. The agreement is null and void upon change of ownership. The vendor must re-apply to continue as a vendor upon expiration of agreement.
3. The responsibility of maintaining the qualifications to become a vendor. This includes but not limited to: a. Minimum quantity and variety of approved WIC foods in stock. b. Prices compatible to stores in same peer group. c. Compliance with Food Stamps Program (FSP) regulations. d. Business integrity
4. The purpose of vendor training and the requirement to attending training. The vendor is responsible for training its employees on the information discussed at training. The vendor is responsible for the actions of its officers, managers, agents and paid or unpaid employees.
5. The WIC approved food items and the requirement to stock and maintain the minimum inventory of approved WIC food items.
6. The types of valid WIC vouchers and the procedures for transacting Georgia WIC vouchers.
7. The procedures for redeeming Georgia WIC vouchers and the use of the vendor stamp.
8. Returned voucher payment procedures and the provision for the Georgia WIC Program to make price adjustments.
9. The responsibility of the vendor to be in compliance with the review of the store via overt monitoring, audits, covert investigations and analyses of programmatic reports.
10. Violations of program and applicable sanctions, including the federally mandated sanctions, disqualification periods, and civil money penalties. Disqualifications from the Georgia WIC Program may result in disqualification from the Food Stamp Program.
11. The right to request an administrative review for adverse action(s) taken against the vendor.

AUTHORIZED REPRESENTATIVE
I ACKNOWLEDGE THAT I HAVE BEEN TRAINED ON THE ITEMS LISTED ABOVE. I FURTHER ACKNOWLEDGE THAT I HAVE COMPLETED THE POST VENDOR TRAINING EVALUATION AND I HAVE RECEIVED A CURRENT GEORGIA WIC VENDOR HANDBOOK.

SIGNATURE

TITLE

DATE

PRINT NAME

Form 3757 (Rev. 07-02)

GA WIC PROCEDURES MANUAL

Attachment VM-8

Instructions: Please print all information. CORPORATION NAME

Georgia Department of Human Resources
Georgia WIC Program
CORPORTE VENDOR TRAINING CHECKLIST

Attach additional list if necessary STORE NAME & NUMBER 1. 2. 3. 4.

REPRESENTATIVE'S NAME & TITLE

Check items reviewed, discussed and explained to vendor.

1.

The purpose of the Georgia WIC Program and how to contact the Georgia WIC Branch.

2.

Terms of the Vendor Agreement. The agreement is null and void upon change of ownership. The vendor must re-apply to continue

as a vendor upon expiration of agreement.

3.

The responsibility of maintaining the qualifications to become a vendor. This includes but not limited to:

a. Minimum quantity and variety of approved WIC foods in stock.

b. Prices compatible to stores in same peer group.

c. Compliance with Food Stamps Program (FSP) regulations.

d. Business integrity

4.

The purpose of vendor training and the requirement to attending training. The vendor is responsible for training its employees on

the information discussed at training. The vendor is responsible for the actions of its officers, managers, agents and paid or unpaid

employees.

5.

The WIC approved food items and the requirement to stock and maintain the minimum inventory of approved WIC food items.

6.

The types of valid WIC vouchers and the procedures for transacting Georgia WIC vouchers.

7.

The procedures for redeeming Georgia WIC vouchers and the use of the vendor stamp.

8.

Returned voucher payment procedures and the provision for the Georgia WIC Program to make price adjustments.

9.

The responsibility of the vendor to be in compliance with the review of the store via overt monitoring, audits, covert investigations

and analyses of programmatic reports.

10. Violations of program and applicable sanctions, including the federally mandated sanctions, disqualification periods, and civil money penalties. Disqualifications from the Georgia WIC Program may result in disqualification from the Food Stamp Program.

11. The right to request an administrative review for adverse action(s) taken against the vendor.

AUTHORIZED REPRESENTATIVE
I ACKNOWLEDGE THAT I HAVE TRAINED THE REPRESENTATIVE(S) OF EACH LOCATION ON THE ITEMS LISTED ABOVE AND PROVIDED EACH REPRESENTATIVE(S) WITH A CURRENT GEORGIA WIC VENDOR HANDBOOK.

SIGNATURE

TITLE

DATE

PRINT NAME

Form 3757A (Rev. 07-02)

GA WIC PROCEDURES MANUAL
District/Unit/Clinic: County: Date of Incident: Date Reported: Follow-up Date:

GEORGIA DEPARTMENT OF HUMAN RESOURCES
WIC PROGRAM
INCIDENT/COMPLAINT FORM

Person Filing Complaint Name: Address:
Phone: () Incident/Complaint:

Participant Information Name: Guardian: WIC I.D. Number: DOB: Phone: ()

Vendor Information Vendor/Vendor #: Employee Name:
Title: Phone: ()

Attachment VM-9
Type of Complaint: Participant [] Vendor [] Civil Rights []
Local Agency/GA WIC Branch Staff []
Local Agency/State WIC Information
Staff Name: Phone: ()

Local Agency Resolution:
Georgia WIC Branch Resolution/Comments: Follow-up Report: GWB Customer Service Coordinator:

Can Complaint be Closed at Local Agency? Yes [] No [] Signature and Title: Date:
Can Complaint be Closed at GA WIC Branch? Yes [] No [] Signature and Title: Date:
Date:

GA WIC PROCEDURES MANUAL

Attachment VM-10

Georgia Department of Human Resources
Division of Public Health WIC Program
VENDOR REVIEW FORM
Vendor Name

Vendor Number

District/Unit Date of Visit

/
Month

/

Day

Year

Store Owner

Store Manager

Store Address

City

County

State

Zip

Review Type - Check One Pre-Approval Monitoring

Follow-Up Complaint

Inventory Type - Check One Regular Inventory
Waived Inventory

Minimum Inventory Requirements - Physical inventory must be in stock and within the date limit when viewed by WIC Representative at time of visit. Proof of order of food items shall not be accepted.

Juice 1. Are there at least 24 plastic or cans of 46 oz. juice in stock? If no, how many? __________

YES

NO

2. Are there two flavors of juice in stock in 46 oz. cans or plastic bottles? If no, how many?_________

3. Was the price marked on juice or posted on or above the shelf/dairy case?

Cereals 1. Are there at least 30 boxes of 9 oz. to 24 oz. cereal in stock? If no, how many? ___________ 2. Are there at least 4 kinds of cereal in stock? If no, how many? ____________ 3. Are at least 2 kinds of cereal in the 12 oz. size? If no, how many? _____________ 4. Was price marked on cereal or on the shelf? 5. Was cereal within date limit? If no, how many were not? ____________
Peas/Beans 1. Are there at least 8 bags of 16 oz. size peas/beans in stock? If no, how many? ________________ 2. Are there at least 2 kinds of peas/beans in stock? If no, how many? _________________________ 3. Was the price marked on the bags of peas/beans, or on the shelf?

YES

NO

YES

NO

Peanut Butter

YES

NO

1. Are there at least 8 jars of 18 oz. Size peanut butter in stock? If no, how many? _______________

2. Are there at least 2 brands of peanut butter? If no, how many? ____________________

3. Was the price marked on the peanut butter or on the shelf?

Infant Cereal At least one type must be rice

YES

NO

1. Are there at least 12 boxes of 8 oz. size infant cereal in stock? If no, how many? ____________

2. Is rice cereal in stock?

3. Is there one type, other than rice in stock?

4. Was priced marked on the cereal or on the shelf?

5. Was cereal within the date limit? If no, how many were not? ____________

GA WIC PROCEDURES MANUAL

Attachment VM-10

Formula: Minimum 138 cans of milk based and 32 cans of soy based contract formula 1. Are there at least 138 cans of 13 oz. concentrate milk based contract formula with iron in stock? If no, how many? ___________ 2. Are there at least 32 cans of 13 oz. concentrate soy based contract formula with iron in stock? If no, how many? ___________ 3. Is formula within current date limit? If no, how many? ____________ 4. Was price marked on cans or shelf?
Milk: Minimum 20 gallons whole milk, 2 %, 1% or skim milk of the least expensive brand 1. Are there at least 20 gallons of milk in stock? If no, how many? ____________ 2. Was price marked on milk or on the dairy case? 3. Was milk within the date limit? If no, how many were not? _________
Cheese 1. Are there at least 16 one pound packages of cheese in stock? If no, how many? _________ 2. Are there at least two kinds of cheese in stock? If no, how many? ___________ 3. Was price marked on cheese or posted on the shelf/dairy case? 4. Was the cheese within date limit? If no, how many were not? ___________
Eggs: Least Expensive Brand 1. Are there at least 16 dozen grade A large eggs in stock? If no, how many? _________ 2. Was price marked on eggs or posted on the dairy case? 3. Were eggs within date limit? If no, how many were not? ___________

YES

NO

YES

NO

YES

NO

YES

NO

General Observations and Questions

N/A YES

NO

1. Were any WIC vouchers on hand in the store? If yes, were the amounts filled in? ____________

2. Did you observe a participant making a purchase? If yes, were appropriate procedures followed? ____________

3. Is there a need for additional training at this time?

4. Is the store open for business 6 days per week 8 hours per day?

Does the store have scanners? If yes, can it scan WIC eligible foods?

The results of this monitoring review have been discussed with me and I have been informed of any violation(s) that were found.

Signature of Vendor Representative

Date

Print Name of Vendor Representative

Title

Comments:

I hereby certify that I have reviewed all WIC approved food items listed on this form. I have discussed all findings and informed the vendor representative of any violation(s). I have provided the vendor representative an opportunity for questions and answers. I have discussed any training needs.

Signature of WIC Representative

Date

Comments:

Print Name of WIC Representative

GA WIC PROCEDURES MANUAL

Attachment VM-11

COOPERATIVE AGREEMENT BETWEEN{PRIVATE } THE GEORGIA WIC PROGRAM AND FNS FIELD OFFICE

In order to promote cooperation and reduce vendor/retailer abuse in the Food Stamp Program (FSP) and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), the undersigned parties agree to the following:

I. Responsibilities of the FNS Field Office

Provide the WIC State agency with the name, title, and address of the FNS Field Office where information on violative WIC vendors should be sent.

Name/Title: Address:
Telephone: Fax:
E-mail:

Rosie V. Daugherty, Officer In Charge Atlanta Field Office 61 Forsyth Street SW, Suite 8T25 Atlanta, Georgia 30303 (404) 562- 7060 (404) 562 -7120 rosie.daugherty@fns.usda.gov

Provide the WIC State agency with general information on the process of authorizing FSP retailers.
Provide the WIC State agency, upon request, with a list of all FSP authorized retailers statewide.
Provide WIC State agency investigative staff with training on FSP compliance investigation techniques. Such training will be scheduled to the extent to which resources are available.
Provide the WIC State agency with the following:
Final summary report of letters of determination after all appeal rights have been exhausted by the 10th of each month
Provide the WIC State agency with the above letters and notices:
No later than 45 days after a retailer's opportunity to appeal a FSP sanction has either expired or been exhausted.
Include the statement--"Disqualification from the Food Stamp Program may also result in a WIC Program disqualification which is not subject to administrative or judicial review under the WIC Program. A civil money penalty from the Food Stamp Program may also result in a WIC Program disqualification, but such

disqualification would be subject to administrative and/or judicial review under the WIC Program"-- on the following letters and notices:

Charge letters Letters of determination Final notices
Provide the WIC State agency, upon request, with information on specific FSP authorized retailers that are not available to the WIC State agency through the FNS Store Tracking and Redemption Subsystem (STARS) database.

Responsibilities of the Supplemental Nutrition Programs:
Facilitate communications between the WIC State agency and the FNS Field Office.
Coordinate the WIC State agency's access to STARS.
Monitor the effectiveness of this vendor/retailer cooperative agreement.
Provide the FNS Field Office with the annual The Integrity Profile (TIP) vendor report.
Forward to the FNS Field Office any WIC State agency requests for training on FSP compliance investigation techniques.

III. Responsibilities of the WIC State agency.
Provide the FNS Field Office with the name, title, and address of the WIC State agency office where all information on abusive FSP retailers should be sent.

Name/Title: Alwin K. Peterson, Program Director

Name/Title: Vera Green, Director, Vendor Management Section

Address: Georgia WIC Branch

2 Peachtree Street NW. Suite 10-476

Atlanta, Georgia 30303-3186

Telephone: (404) 657-2900

Fax:

(404) 657-2910

E mail:

alpeterson@dhr.state.ga.us

vmgreen@dhr.state.ga.us

Provide FNS Field Office with general information on the process of authorizing WIC vendors.

2

Provide the FNS Field Office, no later than 15 days after a vendor's opportunity to appeal a WIC sanction has either expired or been exhausted, a copy of all notices of administrative action for the mandatory sanctions set forth in section 46.12(k)(1)(i) through (k)(1)(vi) of the federal WIC regulations. Such notice must include the name, address, and FSP retailer identification number of the vendor, the type(s) of violation(s), and the length of disqualification or the length of the disqualification corresponding to the violation for which a civil money penalty was assessed.
Provide ongoing written notice of all Judicial Appeal results, i.e. stay of stamp, etc.
Include on all disqualification notices to WIC vendors the following statement: "This disqualification from WIC may result in disqualification as a retailer in the Food Stamp Program per section 278.6(e)(8) of the federal Food Stamp Program regulations. Such disqualification may not be subject to administrative or judicial review under the Food Stamp Program."
Provide the FNS Field Office, upon request, a copy of all notices of administrative action for the State agency established sanctions authorized by section 246.12(k)(2) of the federal WIC regulations, or letters of warning for any such violation.
Provide the FNS Field Office, upon request; information on specific WIC authorized vendors.
Submit to the Supplemental Nutrition Program, all requests for training on FNS compliance investigation techniques.
IV. The undersigned parties further mutually agree that:
Information exchanged in accordance with this agreement must be disclosed and used only in direct connection with the administration and enforcement of WIC and FSP regulations and procedures, except that such information must be disclosed to the Comptroller General of the United States and other authorized officials for audit and examination authorized by law. Under no circumstances should such information be disclosed to any State personnel who are not directly involved in the management of vendors in the WIC Program, other public or private agencies, or to private citizens or enterprises not directly involved in State agency vendor management. The protected information includes all information exchanged about retailers/vendors, as well as about investigations of retailers/vendors, such as the identities of investigators and investigative aides.
Information exchanged in accordance with this agreement is not subject to the Federal and State freedom of information laws and regulations.
Upon mutual consent, the WIC State agency and the FNS will work together on
3

joint compliance investigations.
To prevent possible damage to planned or ongoing investigations by either the WIC State agency or the FNS, the WIC State agency must submit to the FNS Compliance Branch (with a copy the FNS Field Office), a list of projected vendor investigations and also may receive identification of FSP retailers currently under investigation. Any request of such information from either party must be accompanied by assurances that the information will be kept confidential.
Information received by the WIC State agency on FSP investigations must not be disclosed to local agencies unless specific prior approval has been given by the FNS.
The parties agree to explore the greater use of FNS and WIC State agency automated systems for the sharing of retailer/vendor information.
Any further restrictions by the WIC State agency regarding information exchanged must be listed below:
Any of the offices listed below may terminate this agreement with 30 days advance notice to the other parties. This agreement will remain in effect until such notice is given.

___________________________________ Regional Director Supplemental Nutrition Programs
___________________________________ Director WIC State Agency
___________________________________ Officer In Charge Field Office
___________________________________ Regional Director Field Operations

______________________ Date
_______________________ Date
_____________________ Date
_____________________ Date

4

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
NE-1

GA WIC PROCEDURES MANUAL
assignments are available from the Nutrition Section.
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
NE-2

GA WIC PROCEDURES MANUAL responsibilities and participant nutrition education contacts.
NE-3

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 20032004. Based on the findings, the requirement will be fully implemented in FFY 2005. 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:
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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
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nutrition and lactation management.
b. All nutrition training and continuing education activities conducted or attended by the local staff must be recorded and kept on file by the local agency. The 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. A local agency may use a different format, as long as the required components are included.
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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:
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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
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GA WIC PROCEDURES MANUAL sizes for the 2-3 year old; ways to increase fluid intake).
b. The POMR (Problem Oriented Medical Record)/SOAP note format is the recommended method of documentation. A flow sheet may be used as long as it contains all components of a SOAP note.
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).
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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.

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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.
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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.

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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

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GA WIC PROCEDURES MANUAL WIC MATERNAL HIGH RISK CRITERIA

Attachment NE-2

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

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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 Underweight (weight for length/height <5th %) Obesity (weight for length/height > 95th %) Short stature (length/height for age <5th %)

Risk Code 201 103 113 121

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

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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.

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GA WIC PROCEDURES MANUAL 8. List notification requirements.

Attachment NE-3 cont'd

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.

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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.

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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.

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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

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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

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GA WIC PROCEDURES MANUAL

Attachment NE-5 cont'd

EVALUATION CRITERIA LANGUAGE USAGE

MINIMALLY ACCEPTABLE

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

ADEQUATE

SUPERIOR

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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

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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
Replacement reasonable work life (durability) predisposed to obsolescence ease of repair (include shipping/handling) cost of replacement
Duplication allowable/legal cost of duplication

MINIMALLY ACCEPTABLE

ADEQUATE

SUPERIOR

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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.

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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-9 E. Persons With Disabilities ................................................................................. SP-9
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

SP-8 List of Interpreter Services ......................................................................SP-20

SP-9 Directory of Spanish Translators and Interpreters ...........................................SP-21

SP-10 Foreign Language Services for Africa, Asia and Europe ....................................SP-24

GA WIC PROCEDURES MANUAL
I. INTRODUCTION
This section of the manual outlines program procedures for assuring access to WIC services and minimizing hardship for the segment of the population that requires nontraditional services. The program regulations require that all eligible and potentially eligible individuals have equal access to WIC benefits and services. Therefore, the local agency must make every effort to identify and reduce barriers that prohibit enrollment and service to eligible and potentially eligible clients.
WIC defines a special population as a group of persons with common needs that require special assistance and/or specific services to access and participate in WIC related services. Special population groups referenced in this section are: migrants, loggers, applicants/participants residing in institutions, and 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.
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GA WIC PROCEDURES MANUAL
WIC certification must be documented with a VOC card or a copy of the Georgia WIC assessment form. In lieu of a VOC card, a Georgia WIC Identification (ID) card is acceptable. However, the receiving clinic must verify the information on the Georgia WIC ID Card. Vouchers must only be issued for thirty (30) days if clinic staff cannot verify certification information with the originating clinic.
C. Food Delivery
Migrants frequently remain in a local area for very short periods. It is essential that migrant certification, transfer of eligibility, and receipt of WIC foods are received as expeditiously as possible. Vouchers must be issued on the same day the migrant participant is certified.
When a migrant presents WIC vouchers from another state, the certifying clinic should void the vouchers and issue Georgia WIC vouchers as replacements. The certifying clinic must send the voided vouchers 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 a Yes (Y) or No (N). To accurately determine the migrant status of an applicant or a participant, the following question must be asked, "Are you a migrant"? If necessary, WIC's definition of a migrant should be explained to the applicant/participant.
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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 the Georgia WIC Procedure Mamual. 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 nontraditional housing as living accommodations where individuals or families reside for a particular purpose or need. These accommodations include, but are not limited to, private and public institutions, homeless shelters, 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 Georgia 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.
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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) designated to provide temporary living accommodations.
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.
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).
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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 powder milk.
3. Offer ready-to-feed and/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.
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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. Participants must have full, free, and direct access to all program benefits and services available.
The above conditions have been established to ensure that:
a. Participants benefit from the program rather than the institution.
b. 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.
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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 agencies 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 persons. A variety of Spanish Nutrition education and breastfeeding materials are available through the Nutrition Section.
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GA WIC PROCEDURES MANUAL
If a local agency needs materials in other languages, contact the Georgia 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-5). The Nutrition Section will assist local agencies in identifying multilingual translators or interpreters.
WIC applicants/participants shall not be denied WIC services or benefits because they did not bring an interpreter to their appointment. It is the responsibility of the WIC Program to provide interpreters for WIC Services.
Federal Regulations, Section 246.14 (c) (5) states that the cost of translators for materials and interpreters are allowable cost. Therefore, these services are allowable and WIC funds may be used to secure these services.
The local agency must post the Notice of Interpretation Services Sign in the waiting room, front office and voucher issuance area 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 SP-7).
C. Refugees
A refugee is someone who flees his or her country due to persecution or a well-founded fear of persecution because of race, religion, nationality, political opinion, or membership in a social group. With the significant number of refugees, such as Cuban, Haitian, Asians, and Vietnamese, in Georgia, every effort will be made to ensure service is extended to these populations (See Attachment SP-4). Aliens (legal and illegal) are eligible to apply for participation in the program on the same basis as United States Citizens.
The Division of Public Health, Refugee Health Program staff includes interpreters who speak Amharic, Bosnian, Cambodian, Russian, Somali, Tigtinya and Vietnamese. Program interpreters help refugees' access health care by making appointments, arranging transportation, and providing interpretation at appointments.
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GA WIC PROCEDURES MANUAL
D. Native Americans
The WIC Program should make every effort to locate and enroll all eligible Native Americans residing within a local agencies 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. The local programs should provided 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 person serving and providing resources to special population groups and minority populations. The local agency should advise the Georgia WIC Branch 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 services agencies within your area, such as:
1. Public Assistance/TANF client assistance services 2. Food pantries/meal programs 3. Local shelters 4. Food Stamps 5. Legal services
Other pertinent outreach and referral procedures may be found in the Outreach Section of the Procedures Manual.
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GA WIC PROCEDURES MANUAL

Attachment SP-1

Georgia Farmworker Health Program Post Office Box 310
Cordele, Georgia, 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 Telephone/Fax Address Staff

Counties Served

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, Georgia, 30427 E-mail: fwhealth@pineland.net
Candler County Health Department PO Box 205 Metter, Georgia, 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, Georgia, 31533-4920

6/27/01
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

Jody Horne, Cost Reports

Tel: 229-891-7100

Colquitt Health Department Moultrie, Georgia

Valdosta

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: 229-430-4575 Fax: 229 912-430-5143
Tel & Fax: 229-5599910 Steve Graham's Fax: 229-242-0490

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
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, Georgia 31709 (229) 937-5341
Migrant Education Association Live Oak
P.O. Box 780 Brooklet, Georgia 30415
(912) 424-5400
Piedmont Migrant Education Association 3536 East Hall Road
Gainesville, Georgia 30507 (770) 536-5717
Southern Pine Migrant Education Association P.O. Drawer 745
Nashville, Georgia 31639 (229) 686-2053

Attachment SP-2

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, Georgia 31204-1167
(478) 873-6575

Offices Valdosta Office 200 East Mary Street Valdosta, Georgia. 31601

Field Offices

Supervisors Carmen Wilkinson Program Coordinator

Lyons Office 120 East Liberty Avenue 1020 Lyons, Georgia 30436 (912) 526-3094 (912) 526-5906 (FAX)
Dublin Office 112 East Johnson Street Dublin, Georgia. 31021 (478) 275-0127 (478) 275-7548 (FAX)
Douglas Office 613 West Baker Hwy. P.O. Box 966 Douglas, Georgia. 31533 (478) 384-8856 (478) 384-8929 (FAX)
Statesboro Office 105 Elm Street P.O. Box 645 Statesboro, Georgia. 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, Georgia. 31776 (229) 985-7507 (229) 985-7305 (FAX)
Blackshear Office 3351 West Highway 84 P.O. Box 413 Blackshear, Georgia. 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, Georgia. 30445

(912) 526-9556

(912) 526-3434 (FAX)

2)

Ms. Betty Mincey, Director

KIDDLE KASTLE II

111 Oliver Lane

Glennville, Georgia. 30427

(912) 654-2182

(912) 654-2190 (FAX)

3)

Ms. Gloria Sandoval, Director

KIDDLE KASTLE III

133 Serena Drive

Norman Park, Georgia 31771

(229) 769-3627

(229) 761-3182 (FAX)

Attachment SP-4

SP-15

GA WIC PROCEDURES MANUAL INTERPRETER SERVICES

Attachment SP-5

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
Gainesville

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

Anita Gougelmann

Vietnamese

DFAC STATE REFUGEE COORDINATOR

(770 ) 531-5600 GIST 261-5600

Barbara Burham
2 Peachtree St., NW 19th Floor
Atlanta, Georgia 30303

(404) 657-3428

GEORGIA INTERPRETER SERVICES FOR THE HEARING IMPAIRED

David Cowan, Director 44 Broad Street, NW Suite 503 Atlanta, Georgia 30303

(404) 521-9100 Fax: (404) 521-9121

SP-16

GA WIC PROCEDURES MANUAL ASSURANCE STATEMENT

Attachment SP-6

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 Georgia WIC Branch until such time as the shelter/facility notifies the Georgia 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
Assurance Statement Page Two

Attachment SP-6 (cont'd)

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
LIST OF INTERPRETER SERVICES
SIGN LANGUAGE
The Interpreting Resources of Georgia, Inc. Qualified Sing Language Interpreting Services 4651 Woodstock Road Suite 203-125 Rosewell, Georgia 30075
Contact: Don Clark (770) 928-6735 (Voice/TTY) (770) 928-6596 E-mail: Declark@aol.com
INTERPRETER SERVICE (148 Different Languages)
Language Line Services Open 24 hours a day
Contact: Julia Metzger to set up contact Toll Free Number: (877) 862-1302 E-mail: www.LanguageLine.com
MEDICAL INTERPRETERS
Medical Interpreters Network of Georgia (Spanish Only) Contact: Susan Martorell (404) 378-5067

Attachment SP-8

SP-20

GA WIC PROCEDURES MANUAL

Attachment SP-9

Directory of Spanish Translators and Interpreters
Atlanta Association of Translators and Interpreters (AATI) Post Office Box 12172, Atlanta, Georgia 30355
AATI, a non-profit, profession association serving Atlanta and Georgia communities, it is a communications linkage to people with limited English proficiency. These professional men and women specialize in Spanish, French, Portuguese and other languages in medicine/health, government, education, business and law. They are certified translators and interpreters by universities and college, US Federal Govern, US State Department, American Translators Association and Georgia State University. AAIT members come from all corners of the world and possess extensive cultural sensitivity, along with a deep understanding of customs, mores, business, and etiquette.
AATI Members that specialize in Spanish
Translator Solution (Spanish translator and Interpreter) 2830 Biscayne Drive, Conyers, Georgia 30012 Contact: Marilu Montalvo Tel: (770) 482-2517 Cell: (404) 323-1904 E-mail: m660-@quixnet.net
Susana Marci Brady (Spanish translators, interpreter, voice-over-talent) 1076 Greenbriar Circle, Decatur, Georgia 30033 Tel: (404) 296-1363 E-mail: susanamb@aol.com
Maloof Language Services, Inc. (Spanish/Portuguese/French to English) 7346 Cardigan Circle, Atlanta, Georgia 30328 Contact: Mary C. Maloof Tel: (770) 698- 9149 Fax: (770) 698-8112 E-mail: mmaloof@printmail.com
FC Translation Services (English to Spanish) 1656 Tichenor Court, Dunwoody, Georgia 30338 Contact: Floralba Chincilla Tel: (770) 395-1029 Fax: (770) 359-9936 E-Mail: CO102@mindspring.com
Business Linguistics, Inc. (Spanish language and cultural classes) 14 West Peachtree Place, NW, Atlanta, Georgia 30308 Contact: Monica Redondo Tel: (404) 892-9666 Fax: (404) 588-1188 E-mail: BusLinguis@aol.com
SP-21

GA WIC PROCEDURES MANUAL

Attachment SP-9 (cont'd)

Judy R. Palmer (Freelance translator, interpreter, editor, proofreader in Spanish) 879 Springdale Road, Atlanta, Georgia 30306 Contact: Judy R. Palmer (404) 373-9621 Fax: (404) 479-6260 E-mail: Jurepal@mindspring.com

Elena N. Treto (Freelance translator in Spanish) Post Office Box 13623, Atlanta, Georgia 30324 Tel: (404) 633-7290 Fax: (404) 248-9645 E-mail: entreto@mindspring.com

Claudia Mendez Porter (Spanish translator and interpreter) Tel: (770) 736-2994 Fax: (770) 609-5242 E-mail: cmp@avana.net

Cathy McCabe (Spanish interpreter and translator) E-mail: cathspan@mindspring.com

Joaquin J. Coello (Certified Mediator and Arbitrator) 479 Wall Street, Marietta, Georgia 30068 Tel: (770) 973-5094 Fax: (770) 973-5094? E-mail: jcoello@csi.com

Clara Marcela Lievano (Spanish translator and interpreter services for legal/medical) 246 Ennisbrook Drive, Smyrna, Georgia 30082 Tel: (770) 803-0093 Work #(404) 250-2877 E-mail: clievano@mindspring.com

Ligia Mejia (English-Spanish translator) Tel: (770) 345-1251 E-mail: Lsrey@bellsouth.net

Maria Luisa Saucedo (Spanish translator) Tel: (340) 713-1584 E-mail: marilu85@go.com

Daniel G. Saavedra (Spanish translator and interpreter) 2772 Hawk Trace Court, Marietta, Georgia 30066-1535 Tel: (770) 982-8216 Fax: (770) 924-4707 E-mail: dansaav@mindspring.com

LW Translation Service 7185 Amberleigh Way, Duluth, Georgia 30097 Tel: (770) 622-4176 E-mail: lourdeswyly@mediaone.net

SP-22

GA WIC PROCEDURES MANUAL

Attachment SP-9 (cont'd)

Lingo Link (Professor of Spanish language and small business owner) Contact: Bunderlai Souto Duhham Tel: (770) 753-8882 Fax: (770) 442-6040 E-mail: Bunderlai@mindspring,com

Bilingual Crosscultural Communications (Spanish translation, voice talent, writer) 2519 Gravey Drive NE, Atlanta, Georgia 30345 Contact: Yvonne de Wright Tel: (770) 493-6518 Fax: (770) 934-6996 E-mail: ydwright@aol.com
Annie Lidback Castro (Spanish, Portuguese and Italian translation services) E-mail: TransAL@alo.com
Velasco Language Services (Spanish translation of immigrant documents, etc.) 5715 Sunset Maple drive, Alpharetta, Georgia 30005 Contact: Pablo Velasco Tel: (770) 663-4042 E-mail: pvelasco@worldnet.att.net
Susie Maratorell (Spanish translations of medical, legal and government policies) 1006 Clifton Road, Atlanta, Georgia 30307 Tel: (404) 931-6619 E-mail: susy@mindspring.com
Workplace Spanish, Inc. (Full services Spanish translations and classes) Contact: Tom Sutula Tel: (770) 993-4075 Fax: (770) 992-0390 E-mail: tom@workplaceSpaish.com

SP-23

GA WIC PROCEDURES MANUAL Foreign Language Services for Africa, Asia and Europe

Attachment SP-10

Georgia Mutual Assistance Association Consortium (GMAAC) 4151 Memorial Drive, Suite 200-D, Decatur, Georgia 30032 Contact: Fatana Pirzad or Marge Flaherty Tel: (404) 296-5400 Fax: (404) 296-0036
GMAAC is a non-profit organization that provides social adjustment, case management, and other services to refugees and immigrants' in the greater Atlanta area. GMAAC was organized in 1984 by refugees and has served the refugee and immigrant community for over 16 years. The staff at Georgia Mutual Assistance Association Consortium has a staff that speaks 11 different languages. Interpretation and translation and translation services for people of different cultures for medical and legal issues with emphasis on languages from Somali, Serbo-Croatian, Amharic, Farsi, Vietnamese, Cambodian, Russian, Albanian, Arabic, Laotian, Korean, French, Gujarti, Hindi, German, Italian, and Spanish.
MAAAC operates youth programs for refugee children in Clarkston, Stone Mountain and South Atlanta. Community Interpreter Services charges the service provider a fee of $35.00 per hour for such services with a prior notice of 7 to 10 days before the scheduled appointment.
Vietnamese American Social Service Liaison Post Office Box 941694, Atlanta, Georgia 30041 Contact: Y n Tran Tel: (770) 493-7705 A volunteer group that helps the Vietnamese community with free medical and legal translation and interpreter services at no charge.

SP-24

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.
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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.
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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.
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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 the 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.
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GA WIC PROCEDURES MANUAL

Attachment I OR-1

Special Supplemental Nutrition Program for Women, Infants and Children

FFY 2001 Fact Sheet

WIC IN GEORGIA

Georgia Department of Human Resources

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.

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GA WIC PROCEDURES MANUAL

Attachment I OR-1

Why is WIC Important?

Georgia has one of the highest infant mortality rates in the nation. Good nutrition and regular prenatal care during pregnancy, and good nutrition and preventive health care for infants are key to preventing babies from dying or becoming disabled.

Low income women in Georgia who receive both WIC and Medicaid health insurance have a significantly lower infant mortality rate than do other low income women in the state. They are more likely to get prenatal care early in their pregnancy and to seek preventive care, such as immunizations, for their children.
Every dollar spent on WIC saves up to three dollars in health care costs, according to a national study.

Who Gets WIC?

To qualify for WIC benefits, a woman must have a total family income of no more than 185 percent of the federal poverty level. She must be pregnant, breastfeeding an infant less than one (1) year of age, or a postpartum non-breastfeeding woman who has given birth with the last six (6) months. Children are eligible up to their fifth birthday.

The two highest priorities are: enrolling women in their first trimester of pregnancy and

encouraging women to breastfeed. Enrolling eligible working women is also a high priority.

A women or child on WIC must be at risk of impaired health due to nutritional deficiencies

including but not limited to: low birth weight, anemia, abnormal weight gain during

pregnancy, a history of high risk pregnancies, or inadequate diet.

Women wishing to apply for WIC benefits for themselves or their children should contact

their local health departments. In Atlanta, WIC applications are also available 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

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GA WIC PROCEDURES MANUAL
TABLE OF CONTENTS Page
I. General.......................................................................................................................... FD-1 II. Types of WIC Vouchers .............................................................................................. FD-1
A. Vouchers Printed On Demand (VPOD).............................................................. FD-1 B. Blank Manual Vouchers..................................................................................... FD-2 C. Preprinted Standard Manual Vouchers ............................................................... FD-2 D. Computer Printed Vouchers.............................................................................. FD-2 E. Automated Special Manual Voucher ................................................................. FD-2 III. Voucher Issuance - General........................................................................................... FD-3 A. Valid Certification Period................................................................................... FD-3 B. Identification of Person Picking Up Vouchers .................................................... FD-3 C. Corrections ........................................................................................................ FD-3 D. 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-9 E. Transporting VPOD Vouchers from a Site within a Site............................ FD-11 F. Ordering VPOD Vouchers............................................................... FD-11

GA WIC PROCEDURES MANUAL V. Manual Vouchers (Blank and Standard) .........................................................FD-11
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-12 E. Issuance of Manual Vouchers........................................................................... FD-13 F. Distribution of Manual Voucher Copies ........................................................... FD-14 VI. VPOD Procedures .................................................................................................. .. FD-15 A. General............................................................................................................ FD-15 B. Issuing VPOD Vouchers .................................................................................. FD-15 C. Voucher Reconciliation.................................................................................... FD-16 D. VPOD Inventory Log Sheets............................................................................ FD-16 E. Corrective Action for VPOD............................................................................ FD-16 VII. Mailing/Delivery of WIC Vouchers............................................................................... FD-17 A. Conditions for Mailing/Delivering Vouchers..................................................... FD-17 B. Acceptable Reasons for Mailing/Delivering Vouchers....................................... FD-17 C. Mailing/Delivery Procedures ............................................................................ FD-18 D. Voucher Mailing Process ................................................................................. FD-19 E. Returned Vouchers .......................................................................................... FD-19 VIII. Voided Vouchers ......................................................................................................... FD-19 IX. Prorated Vouchers ....................................................................................................... FD-20 X. Late Pick-Up of Vouchers............................................................................................. FD-22 XI. Coordination of Health Services and Vouchers Issuance.............................................. . FD-23 XII. Lost, Stolen or Damaged Vouchers ............................................................................... FD-23

GA WIC PROCEDURES MANUAL A. Replacement of Vouchers ................................................................................ FD-23 B. Lost/Stolen/ Destroyed/Voided Voucher Report .............................................. FD-23 C. Vouchers Lost, Stolen, or Destroyed Prior to Issuance..................................... FD-24 D. Change of Formula Order................................................................................. FD-25
XIII. Borrowed Voucher...................................................................................................... FD-26 XIV. Cumulative Unmatched Redemption Report (CUR).................................................... FD-26
A. Introduction..................................................................................................... FD-26 B. Procedures for Reconciliation........................................................................... FD-27 C. Manually Reconciliating CUR Part 1................................................................ FD-28 D. Manually Reconciliation CUR Part 2................................................................ FD-29 E. Procedures for Both Reports............................................................................ FD-29 Attachments: FD-1 Computer Printed Voucher.......................................................................... FD-31 FD-2 Blank Manual Voucher................................................................................ FD-32 FD-3 Preprinted Standard Manual Voucher .......................................................... FD-33 FD-4 Automated Special Manual Voucher............................................................ FD-34 FD-5 Voucher Printed On Demand (VPOD) Voucher .......................................... FD-35 FD-6 Voucher Creation Calendar ......................................................................... FD-36 FD-7 Voucher Cycle Packing List......................................................................... FD-37 FD-8 Computer Printed Voucher Register ............................................................ FD-38 FD-9 Voucher Register Summary Page ................................................................ FD-39 FD-10 Transmittal Form......................................................................................... FD-40 FD-11 Form and Manual Voucher (Order Supply Form)......................................... FD-41 FD-12 Manual Voucher Inventory.......................................................................... FD-42

GA WIC PROCEDURES MANUAL FD-13 Voucher Printed On Demand Log Sheet ...................................................... FD-43 FD-14 Batch Control Form .................................................................................... FD-44 FD-15 Batch Control Exception Report.................................................................. FD-45 FD-16 Georgia WIC Program Identification Card................................................... FD-46 FD-17 Daily Roster/Monthly Mailed Voucher Report............................................. FD-47 FD-18 Borrowed Voucher Report Form................................................................. FD-48 FD-19 Cumulative Unmatched Redemptions Part I................................................. FD-49 FD-20 Cumulative Unmatched Redemptions Part II................................................ FD-50 FD-21 Lost, Stolen, Destroyed, Voided Voucher Report ........................................ FD-51 FD-22 Vouchers Printed On Demand (VPOD) Receipt........................................... FD-52

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 Georgia WIC Program contracts with a data processing firm 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 a third party contractor in order to establish a participant masterfile. Most local agencies have the capability of electronically transmitting WIC vouchers issuance data.
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 Georgia 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 Automated Data Processing (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.
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 receipts generated from printing these vouchers are maintained by the clinic.
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GA WIC PROCEDURES MANUAL
B. Blank Manual Vouchers
These vouchers maybe issued if or when automated systems are inoperable. These vouchers may be completed for (1) new or transferring participants; (2) to replace voided computer printed vouchers; (3) to adjust a food package in the event of late pick up by a participant, or (4) to supplement the preprinted manual voucher food package. (See FD-V., A. Manual Vouchers and FD-V.,-E. Issuance of Manual Vouchers for procedures). The clinic identification number 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. These vouchers must be stored in a secured location and must be logged in the Manual/Inventory log within three (3) days. The four (4) types of food packages are:
1. Infants (Food Package 113). These preprinted manual vouchers provide formula only.
2. Pregnant and Breastfeeding Women (Food Package 404). These preprinted manual vouchers provide a moderate food package for pregnant and breastfeeding women.
3. Postpartum, Non-Breastfeeding Women (Food Package 502). These preprinted manual vouchers provide a moderate food package for postpartum, non-breastfeeding women.
4. Children (Food Package 603). These preprinted manual vouchers provide a moderate food package for children.
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
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GA WIC PROCEDURES MANUAL 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 not certified or in a valid certification period. Pregnant = thru 6 weeks after delivery; Postpartum = 6 months from delivery date; 1 year if breast-feeding; Children = 6 months up to age 5; I = till 1st birthday. Vouchers must not be issued past the end of the certification period.
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
1. Voucher Printed on Demand (VPOD) - Document the proof code on the voucher receipt under the user's ID.
2. Manual Vouchers - Document the proof code on the manual voucher under the date the vendor must deposit by.
3. Voucher Registers - Document the proof code on the left side of the voucher register.
C. Corrections
Vouchers must not be corrected or altered. 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.
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GA WIC PROCEDURES MANUAL 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.
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. Vouchers must not be issued past the month of categorically ineligible.
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:
1. Children
2. Grandchildren
3. Sisters
4. Brothers
5. Nieces
6. Nephews
7. Aunts
8. Uncles
9. Parents
10. Spouses
11. First Cousins
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GA WIC PROCEDURES MANUAL 12. In-laws
Note: Failure to comply with these procedures will result in payment of food cost to the Georgia 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 Turn-Around Document (TAD).
Self-Check Digit. Calculated by the ADP Contractor.
Participant Number (P). This is a one-digit number that specifies an individual family member in a multi-WIC participant family.
3. Participant's Name. The full name of the participant (last name, first name, 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).
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.
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GA WIC PROCEDURES MANUAL 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
Computer printed vouchers are delivered to the clinic 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 transmitted to each clinic (or clinic package #1 if there is more than one [1]).
a. Voucher Cycle Packing List
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.
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GA WIC PROCEDURES MANUAL

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.

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.

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GA WIC PROCEDURES MANUAL
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).
RECERT OVDUE- MMDDYY: For breastfeeding women and children, subsequent certification is overdue based on the certification date plus six (6) months.
RECERT OVDUE (P) MMDDYY: For pregnant women, subsequent certification is overdue based on the EDC plus forty-five (45) days. 1ST B'DATE-MMDDYY: Infant's birth date is in the month after the voucher issue month. The date printed is the birth date.
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GA WIC PROCEDURES MANUAL
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 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.] 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.
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GA WIC PROCEDURES MANUAL
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.
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.
FD-10

GA WIC PROCEDURES MANUAL 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 Georgia 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 ADP contractor 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-V., C.).
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: a. First copy (blue) participant. b. Second copy (red) - ADP Contractor or clinic copy if automated transfer is used. c. 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.
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GA WIC PROCEDURES MANUAL
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 Compliance Analysis 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 Georgia 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.
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 Georgia 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 FD-12). This documentation must be completed the same day the vouchers are received by
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GA WIC PROCEDURES MANUAL 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) (Manual Vouchers & VPOD Vouchers)
The perpetual inventory accounts for the voucher numbers issued, voided, and on hand. The perpetual inventory should be conducted daily, and must be done at a minimum weekly and documented on the Manual Voucher Inventory Log Sheet (Attachment FD-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.
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 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.
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GA WIC PROCEDURES MANUAL 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.
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 for 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).
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GA WIC PROCEDURES MANUAL
If there are discrepancies, the ADP Contractor will send the clinic a form referred to as "Batch Control Exception Report (Attachment FD-15)," describing the discrepancy. 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 ADP contractor, 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.

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

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GA WIC PROCEDURES MANUAL
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.

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 ADP contractor 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. FD-16

GA WIC PROCEDURES MANUAL 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.

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:
a. Participant due for re-certification. b. Participant due for nutrition education. c. 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 Certified Public Authority (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.

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GA WIC PROCEDURES MANUAL 2. Imminent or recent childbirth requiring bed rest and no proxy is available.
3. Environmental crisis as a result of a tornado, hurricane, flood, snowstorm, 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.
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:
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.
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GA WIC PROCEDURES MANUAL
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:
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 have 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 day 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; when there is a food package change.
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GA WIC PROCEDURES MANUAL
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 must return the original voucher (s) if possible to the contracted bank stamped "VOID." The ADP Contractor will input this voided voucher information into the system to void the issue record. 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) manual voucher 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. Do not send out- of- date vouchers back to the bank, (only those vouchers that are voided due to package changes, formula changes, etc). The address to send vouchers back to Covansys Bank is, Covansys Services Inc., 1625 Williams Drive, Marietta, Georgia 30066. Covansys will provide addressed envelopes or labels to be used when returning vouchers.

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. FD-20

GA WIC PROCEDURES MANUAL 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)

a) ALTERNATE FOOD PACKAGES

Number of Days Late

Women & Children

Infants

Less than 7 days late

full package

full package

7 - 13 days late

6 vouchers issued (3/4 package)

full package

14-20 days late

4 vouchers issued (1/2 package)

1 voucher issued (1/2 package)

21-31 days late

2 vouchers issued

1 voucher issued

(1/4 package)

(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.

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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. FD-22

GA WIC PROCEDURES MANUAL 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.
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:
a. 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.
b. 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*
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GA WIC PROCEDURES MANUAL
e. Quantity of Vouchers in Range f. Participant's WIC ID Number g. Participant's Status Code h. Participant's Last Name and Replacement Voucher Numbers in the
"Comments" block.
* If a participant reports that part of a voucher package was lost/stolen/destroyed and the other portion was cashed, but cannot determine which voucher serial numbers were lost/stolen/destroyed, include all of the voucher serial numbers on the form. Note in the 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 Georgia 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 Georgia 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 CA 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.
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GA WIC PROCEDURES MANUAL 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 Georgia 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).
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 must 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.
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GA WIC PROCEDURES MANUAL
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. The ADP contractor must be notified of all manual voucher reassignments as soon as possible. Any borrowed voucher reassignments not received the ADP contractor 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.

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.

The ADP contractor 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.

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 Georgia 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
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GA WIC PROCEDURES MANUAL
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.

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 GWB.

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GA WIC PROCEDURES MANUAL

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 GWB. The CUR Report should always be submitted to the GWB in its entirety. Do not send copies of vouchers to the Georgia 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.

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 GWB.

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.

FD-28

GA WIC PROCEDURES MANUAL

2.

If the vouchers were issued within a valid certification period, verify

whether the TAD transaction creating the valid certification was

batched and submitted to the ADP Contractor. If there is no batch

acknowledgment, resubmit the entire batch to the ADP Contractor.

3.

If the TAD was submitted to the ADP Contractor, it may have

contained a critical error. Review critical error reports and resubmit

a corrected TAD transaction as appropriate.

Correct only those voucher(s) listed in the last 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 Georgia WIC Branch. If there are no vouchers on the report to be manually reconciled, the CUR report should still be forwarded to the GWB 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 Georgia WIC Branch by the 22nd of the month following the report's run date month (i.e., FD-29

GA WIC PROCEDURES MANUAL
if the run date is 2/18/94, the manually reconciled CUR report is due to the Georgia 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 Georgia 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

Attachment FD-1

COMPUTER PRINTED VOUCHER

31

GA WIC PROCEDURES MANUAL

Attachment FD-2

BLANK MANUAL VOUCHER

32

GA WIC PROCEDURES MANUAL

Attachment FD-3

PREPRINTED STANDARD MANUAL VOUCHER

33

GA WIC PROCEDURES MAMUAL

Attachment FD-5

VOUCHER PRINTED ON DEMAND (VPOD VOUCHER)

FD-35

GA WIC PROCEDURES MANUAL
VOUCHER CREATION CALENDAR

Attachment FD-6

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-36

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 PGS 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-37

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-38

GA WIC PROCEDURES MANUAL VOUCHER REGISTER SUMMARY PAGE

Attachment FD-9

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-39

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-40

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-41

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-42

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 - 43

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-44

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-45

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
PARTICIPANTS

NOT VALID WITHOUT WIC PROGRAM STAMP
EXP. EXP. DATE DATE

BRING THIS FOLDER EVERY VISIT

APPOINTMENTS

APPOINTMENT DATE

TIME VOUCHER NUTRITION PICK-UP EDUCATION

SUBSEQUENT 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- 46

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-47

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-48

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-49

GA WIC PROCEDURES MANUAL CUMULATIVE UNMATCHED REDEMPTIONS PART II EXAMPLE

Attachment FD-20

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 NUMBER NUMBER

ISSUE 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-50

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-51

GA WIC PROCEDURES MANUAL

Attachment FD- 22

Voucher Printed on Demand (VPOD) Receipt

52

GA WIC PROCEDURES MANUAL
TABLE OF CONTENTS
I. Introduction.............................................................................................................. CA-1 II. Monitoring ......................................................................................................... CA-2 III. Participant Abuse...................................................................................................... CA-2
A. Dual Participation ......................................................................................... CA-2 B. Duplicate Participation Verification Form...................................................... CA-4 C. Participant Abuses and Sanctions .................................................................. CA-4 IV. Procedures 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-11 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-13 A. Manual Voucher Inventory.......................................................................... CA-13 B. Georgia WIC Voucher Investigation Log .................................................... CA-13 C. Stop Payment of WIC Vouchers.................................................................. CA-14 XI. Security of Issuance Materials................................................................................. CA-14 A. WIC Program Stamps ...................................................................................... CA-14 B. VOC Cards ..................................................................................................... CA-14

GA WIC PROCEDURES MANUAL

XII. Voucher Issuance Security...................................................................................... CA-14 A. WIC Vouchers ............................................................................................ CA-14 B. Voucher Security ........................................................................................ CA-15 C. Voucher Storage ......................................................................................... CA-16 D. Voucher Printing on Demand (VPOD) ....................................................... 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 Investigative Services 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 Georgia WIC Branch. Investigating agencies may include the DHR Investigative Services 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 Quarterly 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 .
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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 Georgia WIC Branch and proceed with the investigation. The Georgia 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 Georgia WIC Branch and proceed with the investigation.
4. The Georgia WIC Branch shall retrieve voucher copies when the Coordinator determines the need during an investigation. These vouchers will be reviewed by the Georgia 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 Georgia 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.
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
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GA WIC PROCEDURES MANUAL
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 Quarterly to the Georgia 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 Georgia 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 (See Attachment 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.
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.
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Investigate to determine if the participant has received vouchers at both clinic sites. If not, it is possible that two turnaround documents (TADs) were inadvertently printed. The TAD that is incorrect (based on the clinic site the participant is attending) must be deleted. If the participant has picked up vouchers in both sites for the same month, a possible case of participant abuse exists. Refer to the "Participant Abuses and Sanctions" section below for procedures regarding this type of abuse. Documentation must be forwarded to the Georgia 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, ADP, yellow copy-Georgia WIC Branch, pink copy-District Office, gold copy-WIC Clinic. Distribution of this form will be handled by the ADP contractor. 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.
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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.
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1. ABUSE: Participating in more than one WIC Program simultaneously (dual participation).
SANCTION: When dual participation is discovered, the participant must be removed from one (1) program. The two (2) Local Agencies involved must agree on which program will terminate the participant. The participant must be 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:
1. Copy of the front and back of the WIC Assessment/Certification Form signed by the participant or authorized representative.
2. The serial number of all WIC vouchers, manual and computer, issued to the participant or authorized representative within the certification period.
3. A written summary specifying what information was supplied by the participant or authorized representative, what the actual information is CA - 6

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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: 1. Secure the vouchers cashed by the participant from the contract bank and/or CD ROM of vouchers previously cashed.
2. Determine the total value of the cashed vouchers.
3. 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.
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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).
If the total value of benefits is $100 or greater, the repayment procedures outlined above (Sanction #2d) will be implemented.
The Georgia 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
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authorities, i.e. police, and may also suspend the participant(s) from the program for a period not to exceed one (1) year
IV. PROCEDURES 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.
2. If total payment is not made within the ninety (90) day timeframe, the local agency will notify the state agency which will in turn proceed with recovery actions prescribed under 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.
V. GUIDELINES FOR INVESTIGATING EMPLOYEE ABUSE Department of Human Resources Policy 1201 Standard Code of Conduct states that any employee that violates WIC policies and procedures will be terminated, requires to funds back to the agency and face possible prosecution. 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
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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 Georgia WIC Branch and the Georgia WIC Branch shall notify USDA-FNS.
6. The Georgia 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 Georgia 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 Georgia 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 Georgia WIC Branch. The Director's Office shall then forward the request for investigation along with a cover letter to DHR-OFA.
3. DHR-OFA investigation results will be forwarded to the office, which initiates the request. The initiating agency shall submit the results to the District WIC
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Coordinator, Program Manager, District Health Director and a copy to the Georgia WIC Branch.
VII. VENDOR COMPLIANCE INVESTIGATION
Compliance investigations will be coordinated by the Georgia WIC Branch.
Investigations will occur at stores that have been identified as "Potentially High Risk" by the Georgia 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 Georgia 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 Georgia 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 Georgia WIC Branch. Upon notification by the local agency, the Georgia 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 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:
1. City and Count Fire Department(s) 2. City and County Police Department(s) 3. Retirement Homes 4. Battered Women Shelters 5. Church Organizations 6. Homeless Shelters
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7. Salvation Army 8. Food Pantry (Bank) 9. Head Start 10. Boy Scouts 11. Girl Scouts
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 nonprofit 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 Georgia WIC Branch within ten (10) working days.
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GA WIC PROCEDURES MANUAL
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.
The WIC Coordinator or designee must submit the Notification Summary to the Georgia WIC Branch within three (3) working days of the discovery of missing vouchers/VOC cards. Immediately following initial contact from the local agency, the Georgia WIC Branch will notify WIC vendors and instruct 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. MANUAL VOUCHER INVENTORY
Document the serial numbers of the vouchers that are lost or stolen on the manual voucher inventory. B. 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 Georgia 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.
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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 Georgia WIC Branch during an investigation of missing vouchers. When a determination has been made that potential employee fraud exist, the DHR Investigative Services must be contacted (See V. and VI. of the CA Section).
C. STOP PAYMENT OF WIC VOUCHERS The Georgia WIC Branch will immediately upon notification, place a stop payment on WIC vouchers reported stolen from WIC clinics.
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 that 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.
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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 unused 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.
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. CA - 15

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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. 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 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).
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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

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

CLINIC PAGE

9

D/U/CL 09-1-259

RUN DATE 07/13/95

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)

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-18

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-19

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-20

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- 21

GA WIC PROCEDURES MANUAL

ATTACHEMENT CA-6

GEORGIA WIC PROGRAM
PARTICIPANT ACCESS VERIFICATION FORM

District/Unit __________________

Vendor Number

Name of Disqualified Vendor Address

WIC Vendors within ten (10) miles of Disqualified Vendor:

Vendor Name

______________________________________________________________

Address (Street/Hwy) ______________________________________________________________

______________________________________________________________

Distance In Miles

Latitude _________ Longitude __________ Miles _____________

List any physical barriers _____________________________________________________________

_____________________________________________________________

____________________________________________________________

Vendor Name

______________________________________________________________

Address (Street/Hwy) ______________________________________________________________

______________________________________________________________

Distance In Miles

Latitude _________ Longitude __________ Miles _____________

List any physical barriers ____________________________________________________________

_____________________________________________________________

_____________________________________________________________

List WIC Vendors within ten (10) miles of Health Department in this area:

Vendor Name Address(Street/Hwy)
Distance In Miles
Comments:

______________________________________________________________

______________________________________________________________

______________________________________________________________

Latitude __________

Longitude __________

Miles __________

______________________________________________________________

______________________________________________________________

______________________________________________________________

Investigator's Signature _______________ Date __________

CA-22

GA WIC PROCEDURES MANUAL

ATTACHMENT CA-7

Product Type
Milk

Brand

GEORGIA DEPARTMENT OF HUMAN RESOURCES STATE WIC PROGRAM DONATION LIST

Quantity/ C.B.

Size

Date

Vendor #

Non WIC Foods Items

Items Purchased Type

Brand Quant./ Size

CB Date

Vendor #

Cereal
Peanut B. Peas/ Beans Juice
Cheese
Formula Eggs
Form 3818 (4/02)

Other WIC Approved Items:

Comments:
Organization Name: Organization Representative:
Phone #: Address: City: WIC Representative: Date: CA-23

Zip Code: Please Use Ink

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 Coordinator notified:

Date

Time

am 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- 24

GA WIC PROCEDURES MANUAL

ATTACHMENT CA-9

GEORGIA DEPARTMENT OF HUMAN RESOURCES WIC PROGRAM

Duplicate Participation Verification Form

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

CLINIC GOLD COPY

CA- 25

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-26

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-27

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-28

GA WIC PROCEDURES MANUAL

TABLE OF CONTENTS

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-4

G. On-Site Visit................................................................................... MO-5

1. Entrance Conference ........................................................... MO-5

2. Exit Conference .................................................................. MO-5

H. Special Site Visits........................................................................... MO-6

I. Written Reports.............................................................................. MO-7

J. Close-Out Report ........................................................................... MO-8

II.

Quality Assurance Self-Review............................................................. MO-8

A. Purpose .................................................................................. MO-8

B. Self Reviews................................................................................... MO-8

III.

Technical Assistance .......................................................................... MO-9

Attachment: MO-1 Local Agency Monitoring Tool.......................................................... 01

Special Note: Monitoring Tool Description next page

GA WIC PROCEDURES MANUAL
Monitoring Tool Description
Part I......................... Administration Section ................................................................... 02 Part II ....................... Clinic Review Section..................................................................... 08 Part III ...................... Forms Section ................................................................................ 20 Part IV...................... Food Instrument Accountability...................................................... 49 Part V ....................... Civil Rights..................................................................................... 64 Part VI...................... Nutrition Certification, Education/Breastfeeding Section................. 65

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 each of the twenty-one (21) local agencies, for the purpose of reviewing local WIC agency operation. The local 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 three (3) clinics 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 Georgia WIC Branch (GWB) 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 MO6, H. Special Site Visits). B. Monitoring Schedule A schedule of on-site monitoring visits will be developed and coordinated by the Georgia WIC Branch (GWB) 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 health records 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.
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 largest clinic in each local agency will be monitored during each program review.
a. 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.
b. Clinics that have not been reviewed for at least four (4) years may be handselected in place of randomly selected clinics, to ensure regular reviews of all clinics.
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.
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 GWB.
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 MO-2).
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 MO-2).
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 Branch will review the migrant report.
MO 2

GA WIC PROCEDURES MANUAL
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. Health Department Employee WIC Participation Form 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. Federal WIC Regulations 11. Fair Hearing and Civil Rights Complaints 12. Participant Abuse Reports 13. Manual Voucher Inventories 14. Verification Of Certification (VOC) Cards and Inventory 15. Batch Control Modules 16. Completed Computer Voucher Registers 17. Voucher Packing Lists 18. Copies of Manual Vouchers 19. Daily Activity Reports
MO 3

GA WIC PROCEDURES MANUAL

20. Vouchers Printed On Demand (VPOD) Receipts

21. Ineligibility Files

22. District Specific Policies and Procedures

23. Local Agency Nutrition Education and Breastfeeding Plan

24. Nutrition Education Materials

25. Breastfeeding Education Materials

26. Lesson Plans

27. Staff Training Files

28. Equipment Inventory (current year)

29. Voter's Registration Files

30. Contracts With Other Agencies (other than Health Departments) Where WIC Programs Are Located.

31. Temporary Thirty (30) Day Certification Files

32. Free Trade Formula Tracking

F. Timeframes

The program review process will be conducted within the following timeframes:

ACTIVITY

TIMEFRAME

1. Notification of intent to conduct a review, GWB contacts Local Agency to discuss 30 days prior to the scheduled date. possible review dates.

2. GWB prepares and submits a report of program observation and review to Local Within 60 days of the exit interviews. Agency after the site visit/exit interview.

3. Local Agency submits a corrective action Within 60 days of the date of receipt of

report to GWB.

program review report is received.

4. GWB submits written response to the Within 30 days of the receipt of Local

Local Agency review.

Agency response.

5. Local Agency submits written response to Within 30 days of the date of the GWB request for additional information. written request.

MO 4

GA WIC PROCEDURES MANUAL

6. Program review closed.

Within 180 days of the exit interview, unless an extension was negotiated.

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.
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: A Districtwide Correction Action Plan is due to
the Georgia WIC Branch if two (2) or more clinics fail to meet standards. If one clinic fails to meet standards, a Correction Action Plan must be conducted at that clinic site only. d. Recommendations.

MO 5

GA WIC PROCEDURES MANUAL
H. Special Site Visits
The GWB 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 Georgia WIC Branch or USDA deems necessary.
Special Site Visit Procedures:
In the event a special site visit is requested by the Georgia WIC Branch (GWB) 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 GWB, 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 GWB will contact the WIC Coordinator to set up a site visit and schedule.
4. After careful observation and investigation, a report will be generated and mailed to the District WIC Coordinator within thirty (30) days of the site visit.
5. The WIC Coordinator must respond to the GWB 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. The WIC Coordinator using the Procedures Manual for each Local Agency involved must conduct training to close a special site visit.
MO 6

GA WIC PROCEDURES MANUAL
The review will not be closed until all corrective actions have been completed.
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 sixty (60) 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-4, F. Timeframes).
A written plan of action must be developed for all program deficiencies identified during the program review. A District-Wide Correction Plan is due to the Georgia WIC Branch if two (2) or more clinics fail to meet standards. If one clinic fails to meet standards, a Correction Action Plan must be conducted at that clinic site only. 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 ninety (90) 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, 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.
MO 7

GA WIC PROCEDURES MANUAL
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.
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 180 days of the exit interview.
II. QUALITY ASSURANCE SELF-REVIEWS
A. Purpose The purpose of Self-Reviews is to improve the quality of Local Agency program operations. Self-Reviews 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.
B. Conducting 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 GWB by September 30th of each year. The assessment will include all phases of the program operations. The GWB "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:
1. Outreach and Referrals 2. Processing Standards 3. Certification Procedures
MO 8

GA WIC PROCEDURES MANUAL
4. Chart Audit 5. Accountability of Food Instrument and Issuance Materials 6. Nutrition Services 7. Breastfeeding Promotion and Support Services 8. Civil Rights Compliance 9. Participant Complaints 10. Fair Hearing 11. Review Certification/Voucher Issuance Records for employees and their relatives 12. Temporary Thirty (30) Day Certification Purging of Files 13. Voter Registration 14. Equipment Inventory
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 QualityAssurance 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 Georgia WIC Branch in October of each year. Self-reviews are not required on clinics sites that are monitored by the State. 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 made available by the State agency to all local agencies on an on-going basis as requested or deemed necessary. On-site assistance provided to local agencies will be documented on a Technical Assistance Report form. Program consultants are assigned to each district to provide technical assistance.
MO 9

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

STATE OF GEORGIA
Department of Human Resources Division of Public Health
Georgia WIC Branch
LOCAL AGENCY FFY 2003
MONITORING TOOL

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

LOCAL AGENCY MONITORING TOOL
PURPOSE: Federal Regulations require state agencies to establish procedures for reviewing local program operations. The "Local Agency Monitoring Tool" was designed as the instrument to be used in completing this review.

GENERAL INSTRUCTIONS: Local agencies are encouraged to use this tool as a guide in preparing for the State agency review. Monitoring efforts will ensure compliance as well as emphasize quality assurance. The format of the monitoring tool has been designed to enable local agency responses to be recorded in a narrative form.

SPECIFIC INSTRUCTIONS: The monitoring tool is divided into six (6) parts as follows:

I. Administrative Section Local Program Management

II. Clinic Review Clinic Operation Clinic Observation Record Review

III. Forms, For Administrative Review
.

IV. Food Instrument Accountability

V. Civil Rights Administration Training Complaints
VI. Nutrition Certification, Education / Breastfeeding Section Certification/Nutrition Education (Nutrition Section) Record Review Clinic Observation: Individual Nutrition Education Session Group Nutrition Education Session Questions for Clinic Staff Anthropometric Equipment Hematologic Equipment Anthropometric Measurements

1

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

PART I - ADMINISTRATIVE SECTION 1. Name of District/Local Agency: ____________________________________________

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:

Exit Conference:

Place:

Date:

Time:

Place:

2

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

PART I - ADMINISTRATIVE SECTION ( FOR DISTRICT USE ONLY)

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

Corrective Action

A. Policy and Procedures 1. Does the District Office have a copy of all Policy Memorandums on file?

Looking for:



Up to date Manual.



Policy is in place.



Staff understands policy.

2. Is a copy of the Memorandum of Agreement on file?

Looking for:



Whether or not the Coordinator has a copy.

COMMENTS

Corrective Action Corrective Action Corrective Action

3. Is a copy of the Procedures Manual located at the District Office?

Looking for:



Manual is in place in the event of questions.



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:



Copy of each agreement with the Local Agency.

B.

Caseload Management (must have approval from

State)

1. Has the District implemented a waiting list

since the last review? Looking for:

Ensure that Clinic/District does not begin its own

waiting list

Corrective Action

2. Is there a current waiting list? If yes, what priorities are being served?

Looking for:



Whether or not correct priorities are being served.

C.

Internal Communication

3

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

PART I - ADMINISTRATIVE SECTION ( FOR DISTRICT USE ONLY)

GUIDELINES

AREAS OF REVIEW

YES NO NA * COMMENTS

Corrective Action

1. Are new policies and State memos sent to staff?
Are staff meetings held regularly? Date of the last meeting: ___________ Looking for: Whether or not all staff are informed on all new policies.

Corrective Action

2. Is there a planned method of
communication between WIC staff and
non-WIC staff? (i.e. staff meetings) Looking for:
Ensure that if staff meetings are not held, communication is taking place with non-WIC staff.

Corrective Action

3. Is in-service training conducted regularly for WIC and non-WIC staff providing WIC services?

Date of the last meeting: ______________ Looking for: Whether or not staff members are
updated regularly.

Corrective Action

D.

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:



Is documentation on file at the State office?



Were proper procedures followed?

Corrective Action Corrective Action

2. Were Fair Hearings/Participant Complaints handled/resolved according to program procedures?

If no, please explain (in comments section): Looking for:
Check documentation for compliance.

E.

Self Review

1. Does the District conduct Self

Reviews?

(Attach a copy of the Review Schedule) Looking for:



Copy of Monitoring Tool of all sites reviewed.

4

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

GUIDELINES

PART I - ADMINISTRATIVE SECTION ( FOR DISTRICT USE ONLY)

AREAS OF REVIEW

YES NO NA * COMMENTS



Copy of the review schedule.

2. Is there a list of deficiencies identified

Looking for:

for each clinic?



Types of deficiencies found.



Corrective action given.



Plan in place for correction.

Looking for:

3. Were repeated errors found?



If repeated errors are made, is training being

conducted?

4. If yes, were additional monitoring

Looking for:

visits made or training conducted?



Documentation for training(s) is available from

the clinic.

Corrective Action

5. Are the following program indicators included in the local assessment? (District)



A Record Review of Employees and Their

Relative(s)



Check the Voucher Registers for ID Proof



Waiting List



Outreach and Referral

RefLooking for: Record Review (Income, Residency and Identification). Whether or not all the areas are reviewed in the event the Monitoring Tool is not used.

6. Have any special initiative efforts been implemented as a result of the internal monitoring?

Corrective Action

F.

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?
5

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

GUIDELINES

PART I - ADMINISTRATIVE SECTION ( FOR DISTRICT USE ONLY)

AREAS OF REVIEW

YES NO NA * COMMENTS

3. If no, explain how WIC information is disseminated to applicants/participants and local communities.

Looking for: Plan for reaching potential WIC applicants.

Corrective Action

4. Has the district or local clinic conducted outreach activities within the last 12 months?

Corrective Action

5. Are all outreach activities documented and
available for review? (See Outreach File) Looking for:
Documentation that outreach was conducted yearly.

6

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

PART I - ADMINISTRATIVE SECTION ( FOR DISTRICT USE 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

6. Have special provisions been made for scheduling the following applicants? Please explain your answer.

Participants Who Work

Clinic

__________________ __________________ __________________ __________________ __________________

Rural Participants

Clinic

__________________ __________________ __________________ __________________ __________________

Migrants

Clinic

__________________ __________________ __________________ __________________ __________________

Looking for: Documentation of staff scheduling employed, rural or
migrant applicants at time other than traditional hours if possible.

Corrective Action

G. 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: If clinics are not meeting processing standards, have
they asked for extension? Written proof of request.

7

GA WIC PROCEDURES MANUAL____________________ATTACHMENT MO-1

PART II CLINIC REVIEW

GUIDELINES

AREAS OF REVIEW

Corrective Action I. PROGRAM MANAGEMENT (Clinical Review)

YES NO NA COMMENTS

A. Caseload Management 1. Does the clinic have a waiting list?

Corrective Action

Looking for: Ensure that clinic does not begin it own waiting list.
2. Are proper procedure followed when maintaining a waiting list?

Recommendation

Looking for: Clinic staff follows proper procedures 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: Verification

Recommendation

2. How is this coordinated? (records, appointment, Clinics, etc.)

Corrective Action

Looking for: Documentation verifying integration/coordination of services.
3. Are initial contacts dates documented and available for review?

Clinic_________________ _________________ _________________ _________________

Looking for: Is the clinic meeting processing standards?

Corrective Action

4. When a prenatal applicant misses an appointment, Who reschedules the appointment?

Clinic__________________ __________________ __________________ __________________
Looking for: Attempts by the clinic to reschedule prenatal participants who miss appointments.

Note: Recommendations are not requirements for completing

8

self-reviews. *NA- stands for Not Applicable

GA WIC PROCEDURES MANUAL____________________ATTACHMENT MO-1

PART II CLINIC REVIEW

GUIDELINES Corrective Action

AREAS OF REVIEW

YES NO NA COMMENTS

5. When is the next available appointment for a walk-

In applicant requesting WIC benefits?

Clinic Women(P)______ Infant_________ Women(B)______ Child_________
________ Women(PP)_____

Clinic Women(P)______ Infant_________ Women(B)______ Child_________
________ Women(PP)_____

Clinic Women(P)______ Infant_________ Women(B)______ Child_________
________ Women(PP)_____

Clinic Women(P)______ Infant_________ Women(B)______ Child_________
________ Women(PP)_____

Clinic Women(P)______ Infant_________ Women(B)______ Child_________
________ Women(PP)_____

Note: Recommendations are not requirements for completing

9

self-reviews. *NA- stands for Not Applicable

GA WIC PROCEDURES MANUAL____________________ATTACHMENT MO-1

PART II CLINIC REVIEW

GUIDELINES Corrective Action

AREAS OF REVIEW 6. Ask clinic staff the processing standards time
frames for each category below. Time Frames

Clinic (1)___________________ Prenatal _________________ Postpartum _________________ Infants _________________ Children _________________ Migrants _________________

YES NO NA COMMENTS

Clinic (2)___________________ Prenatal _________________ Postpartum _________________ Infants _________________ Children _________________ Migrants _________________
Clinic (3)___________________ Prenatal _________________ Postpartum _________________ Infants _________________ Children _________________ Migrants _________________

Clinic (4)___________________ Prenatal _________________ Postpartum _________________ Infants _________________ Children _________________ Migrants _________________

Clinic (5)___________________ Prenatal _________________ Postpartum _________________ Infants _________________ Children _________________ Migrants _________________
Looking for: Ensure that staff members are knowledgeable about processing time frames.

Note: Recommendations are not requirements for completing 10
self-reviews. *NA- stands for Not Applicable

GA WIC PROCEDURES MANUAL____________________ATTACHMENT MO-1

PART II CLINIC REVIEW

GUIDELINES

AREAS OF REVIEW

Corrective Action C. Income Assessment

1. Is income taken before or after the certification process?

Clinic _______________ _______________ _______________ _______________

Corrective Action

Looking for: Is income assessed as the first step in the certification process?
2. What is the definition of "family"?

Clinic _______________ _______________ _______________ _______________

Corrective Action

Looking for: Does staff know how to determine a family/household
3. Does the clinic staff ask the applicant to report income for the entire family?

Clinic _______________ _______________ _______________ _______________

Looking for: Is total family income accurately assessed in determining eligibility

YES NO NA COMMENTS

Corrective Action

4. How are inclusions and exclusions for income taken into consideration when taking income (i.e. military housing or rations)?

Clinic _________________ _________________ _________________ _________________

Looking for: Is the WIC staff aware of the proper procedures for determining income eligibility?

Note: Recommendations are not requirements for completing 11
self-reviews. *NA- stands for Not Applicable

GA WIC PROCEDURES MANUAL____________________ATTACHMENT MO-1

PART II CLINIC REVIEW

GUIDELINES Corrective Action

AREAS OF REVIEW 5. Does the clinic determine an applicant to be
income eligible based on presumptive eligibility requirements? Where is it documented?

YES NO NA COMMENTS

Clinic ______________ ______________ ______________ ______________

Corrective Action

Looking for: Is the WIC staff aware of the proper procedures for determining income eligibility?
D. 1. What forms of participant identification do you accept?

Clinic ______________ ______________ ______________ ______________

Corrective Action

Looking for: Is the clinic staff aware of the acceptable forms of I.D.?
2. Are participants notified that their WIC certification is about to expire before termination ?

Clinic ______________ ______________ _ _____________ _______________

Corrective Action

Looking for: To ensure that participants are given appropriate notification prior to the expiration of certification.
3. How are participants notified and is the Notification documented?

Clinic ______________ ______________ ______________ ______________

Looking for: Is the clinic staff documenting and/or notifying the participants?

Note: Recommendations are not requirements for completing 12
self-reviews. *NA- stands for Not Applicable

GA WIC PROCEDURES MANUAL____________________ATTACHMENT MO-1

PART II CLINIC REVIEW

GUIDELINES Corrective Action

AREAS OF REVIEW 4. Are participants who are terminated during a
valid certification period notified prior to termination?

YES NO NA COMMENTS

Clinic ______________ ______________ ______________ ______________

Looking for: Are proper procedures followed prior to termination during a valid certification?

Corrective Action

5. Certification Periods

Is the staff knowledgeable of certification periods? (Staff interviews)

Time Frames

Time Periods

Clinic Women(P)_______ Infant____________ Women(BF)______ Child____________
______ Women(PP)__________

Clinic Women(P)_______ Infant____________ Women(BF)______ Child____________
______ Women(PP)__________

Clinic Women(P)_______ Infant____________ Women(BF)______ Child____________
______ Women(PP)__________

Clinic Women(P)_______ Infant____________ Women(BF)______ Child____________
______ Women(PP)__________

Clinic Women(P)_______ Infant____________ Women(BF)______ Child____________
______ Women(PP)__________

Looking for: 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. CT-33

Note: Recommendations are not requirements for completing 13
self-reviews. *NA- stands for Not Applicable

GA WIC PROCEDURES MANUAL____________________ATTACHMENT MO-1

PART II CLINIC REVIEW

GUIDELINES Corrective Action

AREAS OF REVIEW 6. Does the clinic provide WIC benefits only
During a valid certification period? (Select a sample of records with the message "RECERT OVERDUE MMDDYY" to who vouchers were issued to review for compliance, use Attachment 2.)

YES NO NA COMMENTS

Corrective Action

Looking for: Ensure that proper procedures are being followed when recertifying participants. Vouchers issued outside a valid certification period.
7. Under what circumstances are proxy allowed to bring a child in for re-certification or voucher pick-up?

Clinic _________________ _________________ _________________ _________________

Corrective Action

Looking for: Proxy statement forms signed and dated (Statement of Family)
8. Are voided VOC cards marked void on the VOC Card Inventory?

Clinic ________________ ________________ ________________ ________________

Corrective Action

Looking for: Accountability of all issued and voided VOC cards. 9. Is the inventory of VOC cards conducted monthly according to program procedures? (Review physical inventory of VOC card Log)

Clinic ______________ ______________ ______________ ______________

Looking for: Maintenance and accurate issuance of VOC cards. Procedure conducted monthly for security purposes.

Note: Recommendations are not requirements for completing 14
self-reviews. *NA- stands for Not Applicable

GA WIC PROCEDURES MANUAL____________________ATTACHMENT MO-1

PART II CLINIC REVIEW

GUIDELINES Corrective Action

AREAS OF REVIEW 10. Are two initials of Local Agency Staff on the
VOC card Inventory monthly?

YES NO NA COMMENTS

Clinic ______________ ______________ ______________ ______________

Corrective Action

Looking for: Two initials of staff verifying that physical inventory is being conducted.
E. Voter Registration 1. Is each participant offered an opportunity to complete a Voter Registration Application?

Clinic ______________ ______________ ______________ ______________

Corrective Action

Looking for: Declaration File
F. Policy Memos/Procedure Manuals 1. Is there a Procedure Manual located in the clinic?

Clinic ______________ ______________ ______________ ______________

Corrective Action

Looking for: Is Procedure Manual paper or on disk. 2. Are current federal fiscal year Policy Memos on file?

Clinic ______________ ______________ ______________ ______________

Looking for: Policy memos on file for the current federal fiscal year.

Note: Recommendations are not requirements for completing 15
self-reviews. *NA- stands for Not Applicable

GA WIC PROCEDURES MANUAL____________________ATTACHMENT MO-1

PART II CLINIC REVIEW

GUIDELINES

AREAS OF REVIEW

Corrective Action G. Special Population

1. Does the local population include migrants? If

so, are they being served? If not, why?

YES NO NA COMMENTS

Clinic ________________ ________________ ________________ ________________

Corrective Action

Looking for: Clinics that serve migrants. 2. Is the staff knowledgeable of procedures for reviewing migrants?

Clinic ______________ ______________ ______________ ______________

Corrective Action

Looking for: Knowledge of the staff on proper procedures for ensuring accessibility to WIC services for the migrant population. 3. Does the population included Limited English Proficiant (LEP) persons?

Clinic ____________ _____________ _____________ _____________

Corrective Action

Looking for: Whether the clinic serves non-English speaking participants.
4. Are interpreters or bilingual staff available for the LEP clients, if applicable?

Clinic _______________ _______________ _______________ _______________

Looking for: Local agencies are responsible for ensuring that multilingual staff, volunteers or other translators are available.

Note: Recommendations are not requirements for completing 16
self-reviews. *NA- stands for Not Applicable

GA WIC PROCEDURES MANUAL____________________ATTACHMENT MO-1

PART II CLINIC REVIEW

GUIDELINES Corrective Action

AREAS OF REVIEW 5. Is the local agency in compliance with program
policy regarding racial or ethic coding and filing of participants' records? (Review Clinic Medical Records)

YES

NO NA

COMMENTS

Clinic ______________ ______________ ______________ ______________

Corrective Action

Looking for: Ensure that records are not coded for filed by racial/ethnic origin.
H. Complaint Handling 1. Is the staff knowledgeable of proper procedures For handling Civil Rights complaints? (Discrimination)

Clinic ______________ ______________ ______________ ______________

Corrective Action

Looking for: Staff is knowledge of the process and time frame for filing Civil Rights Complaints. Notification of proper person Ability to identify a civil right/discrimination complaint based on race, color, national origin, etc.
2. How is the race of a participant determined?

Clinic _____________ _____________ _____________ _____________

Looking for: Participant self-identification

Note: Recommendations are not requirements for completing 17
self-reviews. *NA- stands for Not Applicable

GA WIC PROCEDURES MANUAL____________________ATTACHMENT MO-1

PART II CLINIC REVIEW

GUIDELINES

AREAS OF REVIEW

Corrective Action II. STORAGE AND SECURITY

YES NO NA COMMENTS

A. In the event VOC cards are revised were the old stock of VOC cards security destroyed?

Clinic ____________ ____________ ____________ ____________

Corrective Action

Looking for: Are obsolete VOC cards properly destroyed. Destroyed report stating the date, series #, amount and staff initials for security destroyed VOC cards.
B. Are the following items stored in a separate, secure location?

1. Program Stamp 2. VOC Cards 3. VOC Card Inventory

Clinic ______________ ______________ ______________ ______________

Corrective Action

Looking for: Security of Program Stamp and/VOC Cards.
III. RECORD REVIEW

(Complete record Review Work Sheet Form 5) Copy additional sheets

Corrective Action

Looking for: Monitoring clinic records to make certain WIC guidelines are being followed and certification is being processed properly.
IV. CLINIC OBSERVATION

(See Form 6)

Corrective Action

Looking for: Monitoring procedures for participant certification.
V. EQUIPMENT INVENTORY

(See Form 7)

Looking for: Checking equipment purchased with WIC Administrative funds.

Note: Recommendations are not requirements for completing 18
self-reviews. *NA- stands for Not Applicable

GA WIC PROCEDURES MANUAL____________________ATTACHMENT MO-1

PART II CLINIC REVIEW

GUIDELINES

AREAS OF REVIEW

Corrective Action VI. PATIENT FLOW ANALYSIS

(See Forms 8A 9F)

Corrective Action

Looking for: Bottlenecks Long waiting period Need for additional staff Need for interpreters
VII. NO PROOF OBSERVATION FORM

(See Form 10)

Corrective Action

Looking for: Proper use of form. Improper use of this form. Reason for use. Too much use.
VIII. PROOF OF IDENTIFICATION OBSERVATION FORM

(See Form 11)

Corrective Action

Looking for: Use of correct identification. Identification for proxies.
XI. NOTICE OF TERMINATION/INELIGIBILITY /WAITING LIST FORM

(See Form 12)

Corrective Action

Looking for: Proper use of form. Documentation accuracy.
X. TEMPORARY THIRTY (30) DAY CERTIFICATION RECORD REVIEW FORM

(See Form 13)

Looking for: Proper use of the form Documentation at clinic Over issuance of voucher.

YES NO NA COMMENTS

Note: Recommendations are not requirements for completing 19
self-reviews. *NA- stands for Not Applicable

GA WIC PROCEDURES MANUAL

FORMS SECTION MO-1

PART III 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 Floe 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 form 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

20

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?

21

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?

22

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

23

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 { }

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 { }

24

GA WIC PROCEDURES MANUAL

FORM 4-A

CLINIC ISSUED VOC CARDS

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 { }

25

GA WIC PROCEDURES MANUAL

FORM 4-A

26

GA WIC PROCEDURES MANUAL

FORM 4-A

Pull five (5) records in each clinic from the VOC Card Log.

Clinic Name

Participant's Name

VOC CARD SECURITY REPORT

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 { }

27

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?

Immunizations

Note: Make copies of this form for Record Review. Must have 100% compliance. 27

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" Displayed in a visible location in each clinic site.

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?

5. Was the "Interpreter" sign posted in a visible place?

(N/A if a DHR Building)

Clinic

Yes

No

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

_____________ ______ ____

_____________ ______ ____

_____________ ______ ____

_____________ ______ ____

_____________ ______ ____

28

GA WIC PROCEDURES MANUAL

FORM- 6

CERTIFICATION
1. Was Medicaid/Food Stamps/PeachCare 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 questions 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 required for certification/re-certification and pickup (Form 11)?

Clinic

Yes

No

______________ ______ ____

______________ ______ ____

______________ ______ ____

______________ ______ ____

______________ ______ ____

29

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) if applicable?

Clinic

Yes

______________ ______

______________ ______

______________ ______

______________ ______

______________ ______

No ____ ____ ____ ____ ____

12. Was the 30 Day Form used appropriately, if applicable?

Clinic

Yes

No

______________ ______ ____

______________ ______ ____

______________ ______ ____

______________ ______ ____

______________ ______ ____

13. Was the applicant asked to read the certification statement before signing?

Clinic

Yes

No

______________ _____ ____

______________ _____ ____

______________ _____ ____

______________ _____ ____

______________ _____ ____

14. Was proper use of ID card explained?

Clinic

Yes

______________ ______

______________ ______

______________ ______

______________ ______

______________ ______

No ____ ____ ____ ____ ____

30

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

31

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

32

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)

33

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.

34

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.

35

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.

36

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?

37

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)

38

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

39

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)

40

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)

41

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.

42

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?

43

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 __________________________________________

44

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

45

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/

Voucher

Subsequent Certification 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.

46

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?

47

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. 48

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

PART IV - FOOD INSTRUMENT ACCOUNTABILITY (LOCAL AGENCY ONLY)

NOTE: Recommendations are not requirements for completing self-reviews. *NA stands for Not Applicable.

Guidelines

Areas of Review

Yes No NA Comments

I. Food Instrument Accountability (District Review)

Corrective Action Corrective Action 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?
Looking for: Packing slips in the District Office within 5 days of
receipt with signature.
B. Voucher Issuance
1. Does the Local Agency have a policy for issuing vouchers to eligible WIC employees and their family members?
Looking for: District policy that is different from the procedures manual.
2. Are any local agency staff receiving WIC benefits at the clinic site where they work?
Looking for: Staff receiving benefits at the site where they are located
and review file?

Corrective Action Corrective Action

3. Are any family members of WIC staff receiving benefits at the local clinic where the staff is employed?
Looking for: Documentation of family members of staff receiving
benefits where the staff is employed.
4. Are staff members at the clinic allowed to issue vouchers or process certification for family members?
Looking for: District awareness 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: Reports of participant abuse and the nature of the abuse
and review.

49

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

PART IV - FOOD INSTRUMENT ACCOUNTABILITY (LOCAL AGENCY ONLY)

NOTE: Recommendations are not requirements for completing self-reviews. *NA stands for Not Applicable.

Guidelines Corrective Action Corrective Action
Corrective Action

Areas of Review

Yes No NA Comments

2. Was the report of abuse investigated?

Looking for: Proper procedure being followed for processing report

3. Was the report sent to the Georgia WIC Branch?

Looking for: Reports at the local level that were not forwarded to the
Georgia WIC Branch.

D. Dual Participation

1. Have there been any cases of intentional dual participation since the last monitoring review?

Looking for: Dual participation

2. Was the report sent to the Georgia WIC Branch?

Looking for: Documentation of what was investigated and findings sent Georgia WIC Branch.

E. Missing Voucher/VPOD Receipt

1. Has the District Office received notice of any missing vouchers/VPOD receipts from any WIC clinic since the last Program Review?

Looking for: Clinic report of any missing vouchers to the District office.

2. Was the report investigated?

Looking for: Proper procedures when vouchers/VPOD receipts are missing.

2. Was the report sent to the State WIC Branch?

Looking for: District notification to the State WIC Branch of any
missing vouchers/VPOD receipts.

II. Food Instrument Accountability (Clinical Review) A. Manual Voucher Inventory Log
1. Is the log being completed on all vouchers?

50

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

PART IV - FOOD INSTRUMENT ACCOUNTABILITY (LOCAL AGENCY ONLY)

NOTE: Recommendations are not requirements for completing self-reviews. *NA stands for Not Applicable.

Guidelines

Areas of Review

Yes No NA Comments

Corrective Action

Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________
Looking for: Assurance that 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: Assurance that all columns of the log are completed accurately, legibly, initialed and verified.
Two (2) sets of initials

Corrective Action

B. Perpetual Inventory
1. Is the perpetual inventory done on all VPOD vouchers?
Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________
Looking for: Assurance that the inventory is kept on all vouchers on
a weekly basis.

51

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

PART IV - FOOD INSTRUMENT ACCOUNTABILITY (LOCAL AGENCY ONLY)

NOTE: Recommendations are not requirements for completing self-reviews. *NA stands for Not Applicable.

Guidelines Corrective Action
Corrective Action
Corrective Action

Areas of Review

Yes No NA Comments

2. Is the perpetual inventory complete and accurate?

Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________

Looking for: Assurance that all columns of the log are completed accurately.

C. Manual Voucher Physical Inventory

1. Are any vouchers missing?

Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________

Looking for: A complete and actual physical inventory to ensure that all vouchers are accounted for.

2. Does physical inventory match the inventory log?

Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________

Corrective Action

Looking for: Assurance that the actual physical inventory matches
the inventory log.
3. Is a physical inventory conducted monthly?
Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________
Looking for: Documentation on the inventory log that a physical count of all vouchers was completed and verified each month.

52

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

PART IV - FOOD INSTRUMENT ACCOUNTABILITY (LOCAL AGENCY ONLY)

NOTE: Recommendations are not requirements for completing self-reviews. *NA stands for Not Applicable.

Guidelines Corrective Action
Corrective Action Corrective Action Corrective Action

Areas of Review

Yes No NA Comments

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: Assurance that all voucher receipts are stored neatly
and in serial number order.

2. Are any receipts/ manual voucher copies missing or misfiled?

Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________

Looking for: Assurance that all vouchers are accounted for.

3. Are daily activity reports maintained correctly?

Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________

Looking for: Assurance that daily activity reports are kept in a
folder or with the receipts.

4. Have any vouchers been altered with write overs or scratch outs?

Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________

Looking for: Unauthorized corrections or alterations.

53

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

PART IV - FOOD INSTRUMENT ACCOUNTABILITY (LOCAL AGENCY ONLY)

NOTE: Recommendations are not requirements for completing self-reviews. *NA stands for Not Applicable.

Guidelines Corrective Action
Corrective Action
Corrective Action Corrective Action

Areas of Review

Yes No NA Comments

5. Are any participant's signatures missing on the receipts/manual voucher copies?

Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________

Looking for: Missing participant's signature.
6. Does the VPOD receipts contain the entry "Failed to Sign" more than 1% for the entire month.

Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________
Clinic_______________________________

Looking for:

More than 1% "Failed to Sign" entries on the VPOD receipts. 7. Are any clerk initials or dates missing?

Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________
Clinic_______________________________

Looking for:

Missing clerk initials and/or dates. E. Reconciled Packing List/Confirmation Notices

1. Is the Packing List/Confirmation Notice verified, signed, and dated?
Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________

Looking for: Packing list/ signed and dated confirmation notices.

54

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

PART IV - FOOD INSTRUMENT ACCOUNTABILITY (LOCAL AGENCY ONLY)

NOTE: Recommendations are not requirements for completing self-reviews. *NA stands for Not Applicable.

Guidelines

Areas of Review

Yes No NA Comments

Corrective Action

2. Are vouchers accurately recorded on the VPOD Log Sheet or the Manual Inventory Log?

Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________

Looking for: Assurances that serial numbers received are recorded
accurately on the manual voucher inventory/VPOD log.

Corrective Action

3. Are copies of packing list/confirmation notice sent to the District Office?

Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________

Looking for: Assurance that a copy of the signed /dated
packing/confirmation notice is in all the District Offices within five days of receipt of the vouchers.

Corrective Action

F. Voucher Registers

1. Are all lines completed on the voucher register?

Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________

Looking for: Assurance that all lines on the vouchers register is
completed.

Corrective Action

2. Are any participant's signatures missing on the voucher register?

Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________

Looking for The participant or proxy's signature.

55

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

PART IV - FOOD INSTRUMENT ACCOUNTABILITY (LOCAL AGENCY ONLY)

NOTE: Recommendations are not requirements for completing self-reviews. *NA stands for Not Applicable.

Guidelines

Areas of Review

Yes No NA Comments

Corrective Action Corrective Action Corrective Action Corrective Action

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: More than one percent "fail to sign" on the voucher
register.
4. Are any clerk initials or dates missing?
Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________
Looking for: 1. Missing clerk initials and/or dates.
5. Does voucher register contain required closeout signatures and dates?
Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________
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: Proper voucher security

56

GA WIC PROCEDURES MANUAL

ATTACHMENT MO-1

PART IV - FOOD INSTRUMENT ACCOUNTABILITY (LOCAL AGENCY ONLY)

NOTE: Recommendations are not requirements for completing self-reviews. *NA stands for Not Applicable.

Corrective Action

2. Are vouchers properly secured overnight?

Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________

Looking for: Proper voucher security procedure when the clinic is
closed.

Corrective Action

3. Are vouchers securely stored separately from ID cards and voucher registers?

Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________

Looking for: Are Vouchers and WIC program stamps 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: WIC ID cards 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: Assure that unauthorized personnel do not have access
to secure area?

Corrective Action

6. Is the key properly secured only with authorized personnel?

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NOTE: Recommendations are not requirements for completing self-reviews. *NA stands for Not Applicable.
Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________

Looking for: Make sure the key to the locked storage space is secure and in the possession of authorized personnel.

Guidelines Corrective Action
Corrective Action
Corrective Action Corrective Action

Areas of Review 7. What security measures are currently in place to
prevent voucher theft by participants?
Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________
Looking for: Assurance that vouchers are not easily assessable to
clients.
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: The proper procedures for prorating is performed.
2. Are vouchers transported from one site to another?
Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________
Looking for: Clinics that transport vouchers to other clinic sites.
3. When vouchers are transported, are they in a locked container (lock box, briefcase)?

Yes No NA Comments

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NOTE: Recommendations are not requirements for completing self-reviews. *NA stands for Not Applicable.

Guidelines

Areas of Review
Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________

Yes No NA Comments

Looking for: Assurance that Vouchers are transported in locked
briefcase or lockbox.

Corrective Action Corrective Action Corrective Action 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: Assurance that clinic employees are knowledgeable of
district policy.
2. Do any employees of this clinic receive WIC benefits?
Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________
Looking for: Assurance that employees are not certifying or issuing
vouchers to family members.
3. Are family members of staff receiving WIC benefits at these locations?
Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________
Looking for: Assurance that employees are not certifying or issuing vouchers to family members.
4. Is clinic staff allowed to issue vouchers or to certify family members?

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NOTE: Recommendations are not requirements for completing self-reviews. *NA stands for Not Applicable.

Guidelines

Areas of Review
Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________

Yes No NA Comments

Looking for: Check medical records of family members of staff to determine if the staff certified their family members.

Corrective Action Corrective Action Corrective Action Corrective Action

5. Is the District aware of all staff/family members enrolled on the WIC Program?
Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________
Looking for: District awareness 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: Problems with participants (verbal abuse, misconduct, dual participation, etc).
2. Was the coordinator notified?
Clinic_____________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________
Looking for: If participant abuse identified, was coordinator informed about abuse? 3. To your knowledge, was there an investigation?

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Guidelines

Areas of Review

Yes No NA Comments

Clinic_____________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________

Looking for: The outcome of the situation.

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NOTE: Recommendations are not requirements for completing self-reviews. *NA stands for Not Applicable.

Guidelines Recommendation
Corrective Action
Corrective Action

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_______________________________

Looking for: 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: Make sure all vouchers were accounted for, and record if the clinic was aware of any missing vouchers.
2. Was a Lost, Stolen, Destroyed Voucher Report sent to the Georgia WIC Branch?

Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________

Looking for: Make sure the proper procedures and forms were completed when vouchers were reported missing.

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NOTE: Recommendations are not requirements for completing self-reviews. *NA stands for Not Applicable.

Guidelines Corrective Action

Areas of Review 3. Was supervisor/coordinator notified of the
missing vouchers?
Clinic_____________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________ Clinic_______________________________
Looking for: If the coordinator was made aware of any missing vouchers.

Yes No NA Comments

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GUIDELINES Corrective Action

AREAS OF REVIEW I. CIVIL RIGHTS

YES NO NA

A. Civil Rights Training

1. Is Civil Rights training conducted annually for local WIC staff? (District)

When? ____________________________

By Whom? __________________________
Looking for: Whether or not all staff received Civil Rights
training. Ensure that all staff knows what to do in the event of
a complaint.

COMMENTS

Corrective Action Corrective Action

2. Is Civil Rights training a part of new employee orientation? (Review list of new employees and documentation of Civil Rights Training.)
Looking for: Documentation of training
B. Civil Rights Complaints
Are Civil Rights complaints handled in accordance with established program procedures? (Review Complaint File - Number of Complaints)
Looking for: Was the Civil Rights complaint handled according to
procedures?

NOTE: Recommendations are not requirements for completing self-review. *NA stands for Not Applicable

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GUIDELINES

AREAS OF REVIEW

YES NO NA

NOTE: Recommendations are not requirements for completing self-reviews. * NA - stands for Not Applicable.

Corrective Action

FOOD PACKAGE ASSIGNMENT
A. List title(s) of competent professional authorities (CPA's) who assign food packages for participants:
Looking for:
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:

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:
Compliance with Federal requirements and State policy.

COMMENTS

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GUIDELINES Recommendation

AREAS OF REVIEW

YES NO NA

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:
Consistency among clinic staff in methods used to assign, obtain and track the use of prescription formulas/metabolic foods.
Whether or not participants receive follow-up from the appropriate source, (i.e., private M.D., health department).
Whether FFY 2003 food packages comply with federal regulations.

COMMENTS

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GUIDELINES

AREAS OF REVIEW

YES NO NA

NOTE: Recommendations are not requirements for completing self-reviews. * NA - stands for Not Applicable.

Corrective Action

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:
Whether or not all staff providing WIC services receive adequate training as required by State policy.

COMMENTS

Recommendation

2. How are training needs assessed?
Looking for:
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:
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: Ensure that NAs are not certifying participants.

Corrective Action

2. Are NAs used to provide secondary nutrition education contacts?

Looking for: Ensure that NAs are not being used without State approval.

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GUIDELINES

AREAS OF REVIEW

YES NO NA

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:
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.

COMMENTS

Looking for:
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:



A current list of approved NA staff on file in the

Nutrition Section.

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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:
Compliance with Federal requirements that a local plan be developed that is consistent with the State plan.

GUIDELINES

AREAS OF REVIEW

YES NO NA

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:
Compliance with the Federal requirement for development of an annual local agency plan.

Corrective Action

D. Participant Nutrition Education Contacts
1. If the district provides group Nutrition Education, please provide the reviewer with a copy of the lesson plans developed since last review.
Looking for: Compliance with Federal requirements and State policy
that standards for nutrition education are followed. Compliance with State policy that only approved materials
are used for the provision of nutrition education.

COMMENTS

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Recommendation

2. Describe the system used to provide two (2) nutrition education contacts for each six (6) month certification period or quarterly for certification greater than 6 months
Looking for:
Adequacy of system to provide education contacts. 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: Compliance with Federal requirements and State policy.

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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 missed nutrition education appointments documented?
If yes, describe the method used:
Looking for: Compliance with Federal requirements and State policy. Identify and correct potential problems with the system in
place.

Recommendation

5. How are the Nutrition Guidelines for Practice being used?
Looking for:
Whether or not the Guidelines have been implemented at the clinic level.

COMMENTS

Corrective Action

6. Do you have a system in place to assure the provision of high risk nutrition education contacts?
Describe the method:
Looking for:
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: A qualified designated nutritionist

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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.
2. Compliance with Federal regulation for educational materials appropriate for participant use.

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? (New materials only since last review.
Looking for:
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:
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:
Compliance with Federal requirements for education materials appropriate for participant use.

Corrective Action for No Breastfeeding Coordinator

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:
Compliance with Federal requirements.

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Recommendation

2. How many hours per week/month does the Breastfeeding Coordinator spend on breastfeeding promotion and support activities?
Looking for:
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:
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:
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:
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.

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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:
Compliance with Federal requirements for prenatal education.

Recommendation

2. Describe the process for individual contacts that are provided (when, by whom, documentation).
Looking for:
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:
Activities performed by the Breastfeeding Coordinator and other clinic staff to monitor and assess the system for education contacts as well as the variety of staff able to perform these required functions.

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GUIDELINES

AREAS OF REVIEW

YES NO NA

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: Compliance with Federal requirements for training of new staff. Adequacy of continuing education for all staff providing WIC services.

COMMENTS

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:
Compliance with the Federal requirements for assuring adequate breastfeeding support for participants.

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GUIDELINES

AREAS OF REVIEW

YES NO NA

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:
Compliance with Federal requirements regarding a clinic atmosphere that promotes and supports breastfeeding.

COMMENTS

Recommendation

5. Other
Please describe any breastfeeding activities not addressed above (e.g., peer counseling, special projects, media exposure, etc.).
Looking for:
Activities that go beyond the Federal requirements, but serve to promote, educate, and support breastfeeding.

For Office of Nutrition Use

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?

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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:
Compliance with Federal requirements and State policy.

Corrective Action Corrective Action Corrective Action

2. Does NE relate to participant status? Looking for: Compliance with Federal requirements and State policy.
3. Does NE relate to participant risk factors? Looking for: Compliance with Federal requirements and State policy.
4. Does NE relate to diet recall/assessment? Looking for: Compliance with Federal requirements and State policy.

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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: Compliance with Federal requirements and State policy.

Corrective Action

6. Does NE include total food intake and its relationship to participant risk?
Looking for: Compliance with Federal requirements and State policy.

Corrective Action

7. Does NE follow Nutrition Guidelines for Practice? Looking for: 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.

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Recommendation

3. Is session conducted in a language the participant speaks/understands?
Looking for: Compliance with Federal requirements and State policy.

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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:

Compliance with Federal requirements and State policy.

Corrective Action

2. Do materials relate to risk factor? Looking for: Compliance with Federal requirements and State policy.

Corrective Action

3. Do materials relate to counseling session?
Looking for:
Compliance with Federal requirements and State policy.

Recommendation

D. Space 1. Is space private?
Looking for: Appropriate counseling skills. Need for additional training. Clinic limitations.

Recommendation

2. Is there seating for the counselor? Looking for:
Appropriate counseling skills. Need for additional training. Clinic limitations..

Recommendation

3. Is there seating for the participant and others in the session?
Looking for: Appropriate counseling skills. Need for additional training.
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Clinic limitations.

Recommendation

4. Is space quiet enough to talk normally? Looking for:
Appropriate counseling skills. Need for additional training. Clinic limitations.

Recommendation

5. Is the view of the participant/counselor obstructed by materials on the desk or by the seating arrangement?
Looking for: Appropriate counseling skills. Needs for additional training. Clinic limitations.

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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: Compliance with Federal requirements and State policy.

Recommendation

2. Does NE include total food intake and its relationship to nutritional status?
Looking for: Appropriate counseling skills. Need for additional training.

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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: h Compliance with State policy.

Recommendation C. Communication

1. Does instructor invite questions?

Looking for:
Appropriate counseling skills. Need for additional training of staff.

Recommendation

2. Do participants ask questions?
Looking for: Appropriate counseling skills. Need for additional training of staff.

Recommendation

3. Does instructor respond to questions? for:
Appropriate counseling skills. Need for additional training of staff.

Looking

Recommendation

D. Materials/Media
1. Is the session conducted in a language(s) participants speak/understand?
Looking for: Compliance with Federal requirements and State policy.

Recommendation

2. Are materials/media in the participant(s) primary language?
Looking for:
Compliance with Federal requirements and State policy.

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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:
Appropriate counseling skills. Need for additional training of staff.

Recommendation

4. Are printed materials related to information covered during session?
Looking for: Appropriate counseling skills. Need for additional training of staff.

Corrective Action E. Staff

Session conducted by:
Nurse_________ Nutritionist_________ Nutrition Assistant_________ 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 participants nutritional knowledge base?
Looking for: Appropriate counseling skills. Need for additional training of staff.

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GUIDELINES

AREAS OF REVIEW

YES NO NA

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: Appropriate counseling skills. Need for additional training of staff.

COMMENTS

Recommendation

3. Is there any evaluation of the participants' attitudes about nutrition and diet?
Looking for: Appropriate counseling skills. Need for additional training of staff.

Recommendation

4. Is participant satisfaction evaluated?
If yes, how?
Looking for: Appropriate counseling skills. Need for additional training of staff.

Recommendation

G. Space
1. How is the room arranged?
Looking for: Appropriate counseling skills. Need for additional training of staff. 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. Clinic limitations.

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GUIDELINES

AREAS OF REVIEW

YES NO NA

NOTE: Recommendations are not requirements for completing self-reviews. * NA - stands for Not Applicable.

Recommendation

3. Is there seating for the participants?
Looking for: Appropriate counseling skills. Need for additional training of staff. Clinic limitations.

Recommendation

4. Can participants see the instructor?
Looking for: Appropriate counseling skills. Need for additional training of staff. Clinic limitations.

Recommendation

5. Can participants hear the instructor?
Looking for: Appropriate counseling skills. Need for additional training of staff. Clinic limitations.

Recommendation

6. Can participants see video, film, or other visual aids?
Looking for:
Appropriate counseling skills. Need for additional training of staff. Clinic limitations.

Recommendation

7. Can participants hear any audio aids?
Looking for: Appropriate counseling skills. Need for additional training of staff. Clinic limitations.

H. Additional Comments

COMMENTS

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ATTACHMENT MO-1

PART VI NUTRITION CERTIFICATION, EDUCATION / BREASTFEEDING SECTION

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: Staff knowledge. Need for additional training.

Recommendation

B. How do you encourage breastfeeding?
Looking for: Staff knowledge. Need for additional training.

Recommendation Recommendation

C. Who assigns food packages in the clinic?
Looking for: Staff knowledge. Need for additional training.
D. How do you decide which food package to assign to a participant?
Looking for: Staff knowledge. Need for additional training.

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ATTACHMENT MO-1

ANTHROPOMETRIC EQUIPMENT

Date_____________Clinic___________Reviewer____________________________________

OBSERVATIONS

S-Satisfactory U-Unsatisfactory
#1 #2 #3

1. Length Board: a. Moveable foot piece at 90% angle that slides easily

b. Foot piece at a 90% angle

c. Fixed headboard

2. Height Board: a. Fixed measuring device (fixed to vertical flat surface, no skirting)

b. Right angle head board

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

COMMENTS

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ATTACHMENT MO-1

HEMATOLOGIC EQUIPMENT

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?

Date_____________Clinic___________Reviewer__________________________________ Observe at least one (1) standing height, standing weight, recumbent length, and infant scale weight.

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ATTACHMENT MO-1

ANTHROPEMETRIC MEASUREMENTS

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:

Child Age:

Yes

No

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)

2. Scale zeroed, prior to measurement

3. Correct angle used for reading measurement

4. Weight measured to nearest 1/2 ounce

Yes

No

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ATTACHMENT MO-1

5. Two (2) measurements taken
RECORD REVIEW (Acceptable Level of Compliance 90% Records Satisfactory)

RECORD REVIEW

T

District _______________

O

Clinic ________________

T

Date _________________

A

L

1. EDC Date

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. BMI or Prenatal weight gain 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

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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.

6. Age Recorded [Certification Section, Attachment CT-28]

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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. 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.
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12. Food Practices Evaluated [Certification Section, XIII.9.; Attachments CT-6, 7, 8, 21, 26]
If inappropriate food practices are present, these must be identified on the approved diet form.
If no inappropriate food practices are present, this fact must be documented on the approved diet form.
13. Diet Evaluation Documented [Certification Section, XIII.9.; Attachments CT-6, 7, 8, 21, 25, 26]
The definition of Poor Dietary Pattern must be applied to the diet and inappropriate food practices available.
14. Date, Signature and Title (Diet Form) [Certification Section, XIII.9.; Attachments CT-6, 7, 8]
The date of the diet assessment must be documented on the approved form.
The signature and title of the assessing professional must be entered accurately on the approved diet form.
An appropriate signature consists of first initial and last name or first and last names.
15. All Nutritional Risks Checked [Certification Section, XIII.9.]
All applicable nutritional risks must be evaluated during each certification appointment and at the infant's mid-certification nutrition assessment.
All evident nutritional risks must be checked YES on the WIC Assessment/Certification Form.
If a nutritional risk is not present, the risk category must be checked NO on the WIC Assessment/Certification Form (except for systems in which only risks present are printed).
If a nutritional risk is not assessed/not applicable, a NA must be written/entered by the appropriate risk category on the WIC Assessment/Certification Form (except for systems in which only risks present are printed).
If documentation for a nutritional risk is found in the health record, the risk must be checked on the WIC Assessment/Certification Form.

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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.
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.

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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.
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.
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ATTACHMENT MO-1

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. 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
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ATTACHMENT MO-1

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).

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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-15

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 maternal-infant interaction. Lactation also facilitates the physiologic return to the pre-pregnant state for the mother. 1
Public Health staff have a responsibility to provide services designed to optimize the health of their clients. Through the WIC Program they have a unique opportunity to influence decisions on infant feeding. As stated in the Division of Public Health Position Paper on Breastfeeding (Attachment BF-1) a sound program of information and support is necessary to promote the successful establishment and maintenance of breastfeeding. Such a program should be integrated into the health care system and should encompass both the prenatal and postpartum periods.
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
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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.
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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
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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
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GA WIC PROCEDURES MANUAL
conducted by the Nutrition Section. These workshops provide WIC 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;
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GA WIC PROCEDURES MANUAL
8) STATUS of each action step (this should be completed as each action step is accomplished).
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.
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As stated in the Healthy People 2000 National Health Promotion and Disease Prevention objectives for breastfeeding, breastfeeding is not appropriate for infants whose mothers use drugs illicitly, or who receive certain therapeutic or diagnostic agents such as radioactive elements and cancer chemotherapy.2 Women who are HIV positive, according to the Centers for Disease Control and Prevention guidelines, should also avoid breastfeeding.
3. As part of the prenatal breastfeeding education, the following information must be offered on WIC benefits for breastfeeding women:
a. Breastfeeding women are at a higher level in the priority system than non-breastfeeding postpartum women, and are more likely to be served than these women when local agencies do not have the resources to serve all qualified individuals.
b. Breastfeeding women may receive WIC benefits for up to one (1) year postpartum, while non-breastfeeding women are eligible for only six (6) months postpartum.
c. The WIC Program offers a greater variety and quantity of food to breastfeeding participants than to non-breastfeeding, postpartum participants.
4. Breastfeeding women should be taught hand expression of breastmilk. All 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).
2 Healthy People 2000: National Health Promotion and Disease Prevention Objectives, U.S. Department of Health and Human Services, 1990.
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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.
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.
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a. In order to facilitate continuity of care, documentation of encouragement to breastfeed should include all aspects of breastfeeding discussed with the participant (e.g., barriers to breastfeeding, emotional/nutritional advantages, positioning).
b. The POMR (Problem Oriented Medical Record)/SOAP note format is the recommended method of documentation. A flow sheet may be used as long as it contains all components of a SOAP note.
c. Group breastfeeding education contacts may be documented with the participant's signature on a class attendance sheet or voucher register. There must also be a class description with 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.
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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
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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
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demonstrate the proper usage of the breast pump before leaving the 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.
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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.
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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.
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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.
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Attachment BF-1

POSITION PAPER ON BREASTFEEDING

If the children of Georgia are to be healthy and strong, it is essential that they receive the best possible nutrition when they are infants. Breast milk is the ideal first food for the human infant. In addition to the nutritional benefits for the infant, this method of feeding offers unique physiological and psychological advantages to both the mother and the infant. Every infant, therefore, should receive the benefits of this ideal choice for infant feeding. This paper presents the recommendations of the State of Georgia for encouraging breastfeeding and defines the advantages of breastfeeding for the health of mothers and infants.

No formula, no matter how "humanized", can take the place of human milk. Decreased infant mortality and optimum infant health are the most important goals of the Division of Public Health. Breastfeeding can contribute significantly to the achievement of these goals because:

* breast milk provides an ideal balance of nutrients for the human infant. * the nutrients in breast milk are easily absorbed and digested. * breast milk contains immune factors and anti-infective properties that protect against infections. * breastfeeding allows the satiety mechanism in the infant to develop naturally. * infants who are breastfed have fewer allergies. * breastfeeding permits increased bonding between mother and infant. * breast milk is safe, sanitary food.

A sound program of information and support is necessary to promote the successful establishment and maintenance of breastfeeding. Such a program should be integrated into the health care system and should encompass both the prenatal and postpartum periods. Based on the World Health Organization/United Nations International Children's Fund (WHO/UNICEF) 1979 meeting on Infant and Young Child Feeding, the WHO 1981 Resolution and the recommendation of the American Academy of Pediatrics Committee on Nutrition, the Georgia Department of Human Resources recommends that:

* breast milk be the "house formula" in all hospitals in Georgia where maternity services are offered * all expectant parents be informed of the numerous advantages (both to infant and mother) of
breastfeeding. * every expectant mother receive practical information on how to initiate and maintain lactation. * obstetrical procedures and practices be consistent with the policy of promoting breastfeeding. * breastfeeding be initiated as soon as possible, preferably during the first hour after birth. * every hospital permit and encourage rooming-in and on-demand feeding of breastfed infants. * infant formulas not be marketed or distributed in ways that may interfere with the protection and
promotion of breastfeeding. * places of business, including government offices, facilitate the maintenance of lactation through
liberalized policies that would promote breastfeeding.

All the available knowledge indicates that breastfeeding is the best choice for infant feeding and should be promoted for mothers and infants of the State. Breast milk as this choice for infant nutrition will promote optimum health for future generations of Georgians.

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Attachment BF-2

SAMPLE JOB DESCRIPTION SENIOR PUBLIC HEALTH EDUCATOR - LACTATION CONSULTANT

The examples of work given are illustrative of the duties assigned to positions of this class. No attempt is made to be exhaustive. The intent of the listed examples is to give a general indication of the levels of difficulty and responsibility common to all positions of this class.

The standards for training and experience express the minimum background necessary as evidence of an applicant's ability to qualify for positions of this class. Unless otherwise stated, the Applicant Services division may allow substitution of appropriate education or experience for the training and experience minimum listed.

DEFINITION

Under direction, performs work of moderate difficulty in planning and implementing breastfeeding education activities related to public health programs; and performs related work as required.

EXAMPLES OF DUTIES

I. Coordinates breastfeeding promotion project. Writes, revises, and evaluates the district's breastfeeding services.

A. Establishes relationships with community health centers and/or hospital staff to provide breastfeeding services.

B. Provides inservice education material and/or needed equipment on breastfeeding for staff development.

C. Responsible for keeping daily communication sheets regarding telephone calls, correspondence, patients seen, meetings, and work related to breastfeeding funds.

II. Promotes breastfeeding services as an integral part of perinatal care.

A. Encourages all prenatal women, on their initial visit, to breastfeed by providing an array of educational material and counseling.

B. Provides additional breastfeeding counseling to prospective breastfeeding women during the last trimester through breastfeeding classes and/or individual counseling.

C. Provides postpartum assessment of breastfeeding dyad, education, and assistance in resolving problems upon request. Provides adequate documentation of services and makes appropriate referrals for continuity of care.

D. Develops and implements continuing education and support networks through a variety of methods, such as support groups, peer counselors, etc.

E. Supervises and trains peer counselors.

F. Has ability to communicate effectively in writing, including grant proposals.

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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.

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Attachment BF-3

GEORGIA GAIN PROPOSED JOB DESCRIPTION

JOB CODE: JOB TITLE:

E0707% BREASTFEEDING COORDINATOR

GENERAL SUMMARY Under general supervision, plans, develops, implements and evaluates strategies for promoting and supporting breastfeeding among the high risk, low income population, especially prenatal/breastfeeding women and infants.

RESPONSIBILITIES AND STANDARDS

Responsibility Number 1 (All) -----------------------------------------------------------------------------------------------------------------------------------------------Develops long and short-term goals for breastfeeding promotion and supports activities for the district.

STANDARDS:

1.

Works closely with the supervisor to develop an appropriate District Breastfeeding Promotion and Support Plan.

2.

Coordinates breastfeeding services among all clinic sites to ensure efficiency of services provided.

3.

Accurately interprets federal/state regulations to ensure adherence to these.

4.

Makes sound and defensible recommendations to the supervisor regarding the breastfeeding budget.

5.

Develops continuing education, support networks for mothers and networks for professionals in breastfeeding

promotion and support.

Responsibility Number 2 (Some) -----------------------------------------------------------------------------------------------------------------------------------------------Implements breastfeeding promotion and support plans, to include staff development, community networks and services to clients.

STANDARDS:

1.

Provides inservice education, materials and/or needed equipment for staff development in a timely manner.

2.

Establishes a good working relationship with community health centers and/or hospital staff to assure continuity of

breastfeeding services to clients.

3.

Serves as the District's primary resource person regarding breastfeeding education and support by providing

prompt responses to inquiries.

4.

Provides direct services to clients through prenatal classes, individual instruction, referral for appropriate case,

telephone consultations according to established laws and guidelines.

5.

Coordinates pump loan program to ensure maximum usage of available pumps and instructs both staff and clients

on use of breast pumps as needed.

6.

Serves as primary resource person to health department staff regarding current recommendations and information in

breastfeeding management.

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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.

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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.

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Attachment BF-4 cont'd

GUIDELINE #9 Breastfeeding promotion and support are enhanced when breastfeeding support and assistance is provided throughout the postpartum period, particularly at critical times when the mother is most likely to need assistance.

SUGGESTIONS FOR IMPLEMENTATION

GUIDELINE #1

Breastfeeding promotion and support are enhanced when local agency WIC staff receive orientation and task-appropriate training on breastfeeding promotion and support.
Suggestions for Implementation

1. It is important to develop orientation guidelines for new WIC employees that address:

C

clinic environment policies

C

program goals and philosophy regarding breastfeeding

C

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:

C

culturally appropriate breastfeeding promotion strategies

C

current breastfeeding management techniques to

encourage and support the breastfeeding mother and infant

C

appropriate use of breastfeeding education materials

C

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:

C

statewide and local conferences and workshops

C

events sponsored by other agencies and organizations

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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:

C

print and audiovisual materials free of formula product names

C

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:

C

storing supplies of formula out of view of participants

C

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.
4. It is important that staff not accept formula from formula manufacturer representatives for

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Attachment BF-4 cont'd

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:

C

chairs with arms

C

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:

C

task forces, networks, or steering committees to exchange information and strategies

C

professional health organizations to secure resources and expertise and assure

communication with health professionals serving pregnant and breastfeeding women

C

existing peer support groups to facilitate local exchange of breastfeeding information

across the state

C

community leaders and citizen groups who support breastfeeding

C

the Breastfeeding Promotion Consortium and its efforts, including a national

breastfeeding promotion campaign

Rationale: A collaborative approach to breastfeeding promotion can create a strong supportive climate and help ensure more effective use of all available resources.

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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:

C

American Academy of Pediatrics

C

American Academy of Family Physicians

C

American college of Nurse Midwives

C

American College of Obstetricians and Gynecologists

C

American Dietetic Association

C

American Hospital Association

C

American Nurses Association

C

American Public Health Association

C

Association of Pediatric Nurse Practitioners

C

Association of Women's Health and Obstetrics Nurses

C

Healthy Mothers, Healthy Babies Coalitions

C

International Lactation Consultants Association

C

La Leche League International

C

Maternal and Child Health Directors

C

Medicaid Directors

C

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:

C

co-sponsoring training and continuing education programs

C

sharing breastfeeding education materials for clients

C

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:

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GA WIC PROCEDURES MANUAL

C

participant orientation programs and materials

C

printed and audiovisual materials for professional audiences

C

printed, audiovisual, and display materials for potential clients

Attachment BF-4 cont'd

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:

C

incorporation of data collection into current WIC systems

C

periodic sample surveys of program participants

C

Centers for Disease Control and Prevention surveillance systems

C

state surveillance systems

C

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:

C

exclusive breastfeeding

C

patterns of combined breastfeeding and formula feeding, e.g.:

C

mostly breastfeeding

C

equal parts breastfeeding and formula feeding

C

mostly formula feeding

C

exclusive formula feeding

Rationale: Collecting data on breastfeeding patterns gives a better picture of the WIC population's infant feeding practices. This will help states better focus their breastfeeding promotion activities.
3. It is important that questions regarding breastfeeding attitudes, infant feeding decisions, and
the WIC program's breastfeeding support activities are included in the annual participant
survey.

Rationale: Collecting data on breastfeeding attitudes, infant feeding practices and

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GA WIC PROCEDURES MANUAL

Attachment BF-4 cont'd

WIC-related promotion activities about breastfeeding assists state and local agencies design more effective breastfeeding promotion program components.

4. It is important that the state agency management evaluation process reviews local agency breastfeeding promotion and support activities such as:

C

participant orientation and education materials

C

policies regarding formula samples and food package tailoring for breastfeeding

mothers and infants

C

clinic environment, including display materials and posters, and visibility of formula

supplies

C

staff interaction with participants regarding the infant feeding decision and

breastfeeding support

C

local agency linkages with other community programs providing services to

breastfeeding women

C

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:

C

integrate breastfeeding promotion into the continuum of prenatal nutrition education

C

include an initial assessment of participant knowledge, concerns and attitudes related

to breastfeeding

C

provide breastfeeding education and support sessions to each prenatal participant

based on the above assessment

C

define the roles of all staff in the promotion of breastfeeding

C

define situations when breastfeeding is contraindicated

C

establish referral criteria

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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:

C

peer counselors

C

an honor roll of successful breastfeeding WIC participants

C

an opportunity to watch other WIC participants breastfeed

C

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:

C

discussing WIC's position about breastfeeding as optimal for most women and infants

C

encouraging the sharing of educational materials between WIC and primary care

providers

C

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

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GA WIC PROCEDURES MANUAL policies facilitate successful breastfeeding.
GUIDELINE #7

Attachment BF-4 cont'd

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
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GA WIC PROCEDURES MANUAL

Attachment BF-4 cont'd

positive breastfeeding message on the voucher.

Rationale: A blank voucher emphasizes that the breastfeeding dyad may not be receiving as much food as the formula-feeding dyad and makes the mother feel as though she is missing out on some of the food available to her. A voucher with even a small amount of formula on it sends a message to the mother that she is expected to supplement. A positive breastfeeding message will reinforce the importance of breastfeeding.

3. It is important to encourage the issuance of vouchers for powdered formula to breastfeeding mothers who wish to supplement.
Rationale: Powdered formula can be prepared in as small a quantity as needed. However, the minimum amount of the concentrated fluid formula that can be prepared is 26 ounces. This amount must be used within 48 hours, which could encourage more supplementation than originally intended.

4. It is important that breastfeeding women receive information about the potential impact of formula on lactation and breastfeeding before formula is given.
Rationale: Breastfeeding mothers may not fully understand the impact formula supplementation has on breastmilk supply. This is especially important during the first few critical weeks when the milk supply is being established.

5. It is important that formula vouchers or samples be given only when specifically requested.
Rationale: Offering formula to a breastfeeding woman undermines her confidence that she can breastfeed successfully, particularly in the first few weeks. She also may find it difficult to refuse the free formula even though she had not planned to use it.
GUIDELINE #9

Breastfeeding promotion and support are enhanced when breastfeeding support and assistance is provided throughout the postpartum period, particularly at critical times when the mother is most likely to need assistance.
Suggestions for Implementation

1. It is important to develop a plan to provide women with access to locally available

breastfeeding support programs, making sure support is available early in the postpartum

period and throughout lactation to:

C

Include professional support, such as management of lactation problems, hotline

contacts and telephone counselors

C

include peer support, such as peer counselors and resource mothers

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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 use individuals who have successfully breastfed an infant and who express a positive, enthusiastic viewpoint of breastfeeding.

2. It is important to provide or identify education and support for breastfeeding women in special situations. Consider:

C

mothers returning to paid employment or school; mothers separated from their infants

due to hospitalization or illness; mothers of multiples; infants with special needs

C

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:

C

using appropriate posters and messages placed in the clinic waiting and nutrition

education areas

C

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:

C

Maternal and Child Health

C

Family Planning

C

hospitals

C

Indian Health Service

C

community health providers

Rationale: Collaborative relationships result in consistent messages supporting breastfeeding, more efficient services and decreased lactation problems; and reach a larger number of women. These efforts will have a more far-reaching effect as the incidence of breastfeeding increases.
5. It is important that the state agency develop a protocol or guidelines regarding the distribution
of breastfeeding aids, including:

C

circumstances when the breastfeeding aid might be provided

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GA WIC PROCEDURES MANUAL

Attachment BF-4 cont'd

C

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.

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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 Parent's Guide, by Amy Spangler Amy Spangler/Daddy, Mommy and Me, Atlanta, GA, 2000.

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, 1997.

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.

Evidence-Based Guidelines for Breastfeeding Management during the First Fourteen Days, International Lactation Consultant Association, April 1999.

Medication and Mothers' Milk, by Thomas Hale Pharmasoft Medical Publishing, Amarillo, TX, 2002.

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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.

The Pediatric Clinics of North America: Breastfeeding 2001, Part I (The Evidence for Breastfeeding) and Part II (The Management of Breastfeeding), W.B. Saunders Company, Philadelphia, PA, 2001.

Pocket Guide to Breastfeeding and Human Lactation, Second Edition, by Jan Riordan and Kathleen G. Auerbach, Jones and Bartlett Publishers, Sudbury, MA, 2001.

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

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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

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GA WIC PROCEDURES MANUAL

Attachment BF-6

ALLOWABLE AND UNALLOWABLE COSTS OF BREASTFEEDING AIDS USED FOR
THE PROMOTION AND SUPPORT OF BREASTFEEDING

The cost of breastfeeding aids which directly support the initiation and continuation 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.

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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 to be used

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GA WIC PROCEDURES MANUAL 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.

BF-39

GA WIC PROCEDURES MANUAL Referrals

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.

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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 through WIC) should be assigned Food Package 408. If this participant has

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GA WIC PROCEDURES MANUAL

Attachment BF-8 cont'd

already picked up the current month s prenatal vouchers, you may print a single 001" voucher for her. This voucher includes the additional beans/peas or peanut butter, carrots and juice which are part of the 408 food package.

II. Assignment of Priority to Breastfeeding Dyad

When a participant s status is changed from Prenatal (P) to Breastfeeding (B), prior to her postpartum certification, it may not be possible to assign the same priority to both mother and infant at this time. Please follow these steps in assigning the priorities:

A. When a participant s status is changed from Prenatal (P) to Breastfeeding (B) through a systems update, her priority may be upgraded if there is appropriate documentation. This is optional, however, and she can maintain her Prenatal priority until the subsequent certification.

B. When a breastfeeding infant is certified for, and enrolled in, the WIC Program prior to its mother being subsequently certified, the infant may be assigned one of the following priorities:

1. If the infant has a risk factor of its own that would result in it's being a Priority I, the infant must be assigned a Priority I.

2. If the infant has only nutritional risk factor W (Infant of a WIC Mother or Mother with Nutritional Risk During Pregnancy), assign a Priority II. It may be helpful to flag the infant s name/record through an internal tracking system (tickler card, computer, voucher register, etc.) to alert staff to the need to re-evaluate the infant s priority at the mother s postpartum certification.

3. If the infant s mother was assigned a Priority I based on documented postpartum breastfeeding risk factors, assign a Priority I to the infant.
C. When the mother of a breastfeeding infant is certified at a later time than the infant, one of the following actions must be taken:

1. If the mother is no longer breastfeeding, she must be assessed as a nonbreastfeeding postpartum woman (status is changed from P to N), and she must be assigned the appropriate priority based on the assessment. Her infant retains the priority assigned at its enrollment.

2. If the mother is still breastfeeding, she must be assessed as a breastfeeding

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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 KEY FOR ENTERING WEEKS BREASTFED

Attachment BF-9

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 on the in the appropriate space for Weeks Breastfed, on the WIC Assessment/Certification Form and the Turnaround Document.

Sources: Enhanced Pregnancy Nutrition Surveillance System User's Manual. Division of Nutrition, Center for Chronic Disease Prevention & Health Promotion, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, Public Health Service. November 1989.
Georgia WIC User Manual, 1994.

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GA WIC PROCEDURES

TABLE OF CONTENTS

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-8

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
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. Georgia 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?
5. Are electric, water, communication, and transportation services disrupted?
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GA WIC PROCEDURES MANUAL
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 Georgia 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 Georgia 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 responsibilities will be to:
1) To contact formula manufacturers to secure Ready To Feed (RTF) formula, nipples and bottles.
2) Follow through on arrival/receipt of formula. 3) Visit area to make on-site assessment of support staff etc.
State Level Responsibilities
Various staff members have responsibilities in the WIC and Nutrition Services Disaster Plan. The overall responsibility for implementation and reporting on WIC's response to the disaster lies with the Directors of WIC and Nutrition Services or a designee. The 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, equipment issues and emergency procurement of vouchers. The Financial Unit has the responsibility of tracking and reconciling costs relating to the disaster. The Manager of the Compliance Analysis
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GA WIC PROCEDURES MANUAL
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 within eight (8) hours one of their supervisors to report their situation and availability for duty assignments. If none of the local agency's immediate supervisors can be reached, local agency staff can call the Georgia WIC Branch 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.
C. Notification Lines of communication during a disaster begin with sites contacting the main local
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GA WIC PROCEDURES MANUAL
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 Georgia 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 Georgia 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 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
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GA WIC PROCEDURES MANUAL
effected by the disaster is the top priority of any state agency disaster relief plan. Readyto-feed formula may be necessary if the areas 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.
3. Special Formula/Hospital Based Formula: The state agency and local agency will
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GA WIC PROCEDURES MANUAL
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 Georgia 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 and
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GA WIC PROCEDURES MANUAL
voucher issuance during this crisis situation.
Nutrition Education should address: 1. food safety 2. meal planning 3. food preparation 4. nutrition needs of the individual 5. on-site education shelters 6. safe water supply 7. 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 distribution of supplies of infant formula to the disaster area.

DP-8

GA WIC PROCEDURES MANUAL 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.
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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

for PAY PERIOD

to (beginning)

DISASTER IDENTIFICATION/(CLINIC #):

DISTRICT:

OFFICE NAME:

CONTACT NAME:

Attachment DP-2
(ending)

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.
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GA WIC PROCEDURES MANUAL

Attachment DP-3
PAGE OF

DATE:

/

NAME: DISTRICT:

/ OFFICE:

DISASTER DAILY WORK ACTIVITY LOG SSN:

NEW ACTIVITY TIME: :
ACTIVITY LOCATION: Activity Description:

AM

AM

PM to : PM

BLDG:

OTHER:

NEW ACTIVITY TIME: :
ACTIVITY LOCATION: Activity Description:

AM PM to

AM : PM

BLDG:

OTHER:

NEW ACTIVITY TIME: :
ACTIVITY LOCATION: Activity Description:

AM

AM

PM to : PM

BLDG:

OTHER:

RETAIN

SIGNATURE:

DATE:

NOTE: MUST ATTACH TO DISASTER EMPLOYEE LOG.

COMPLETED

LOG

FOR

USE

IN

DOCUMENTING

FUTURE

FEDERAL

CLAIMS.

DP-12

GA WIC PROCEDURES MANUAL

CHAPTER

AMERICAN RED CROSS CONTACT

Albany Cluster I Coverage: Clay, Dougherty, Lee, Randolph, Terrell

Deborah Blanton 2421 N Slappey Blvd. Albany, GA 31701 (912) 436-4845 Fax:(912) 434-9610

Americus Cluster V Coverage: Sumter

Joan Mason P.O. Box 214 Americus, GA 31709 (912) 924-2026 Fax:(912) 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
Fort McPherson
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 Coverage: Murray

Rick Tuchscherer P.O. Box 7266 Fort Gordon, GA 30905 (706) 791-3169/6341 After Hours:(706) 791-4517 Fax:(706) 790-4822
Kathy Staten Bldg. 536 Ft. McPherson, Ga 30330 (404) 753-8315
Lynn Dowling Bldg. 8401 P.O. Box 3280 Fort Stewart, Ga 31314 (912) 767-8857/2197 After Hours:(912) 767-2197/8666 Fax:(912) 368-6353
Martha W. Ferguson 1955 Monroe Drive, N.E. Atlanta, Georgia 30324 (404) 881-9800 Fax: (404) 874-2993
Annette Patton P.O. Box 1301 Chatsworth, Ga 30705 (706) 695-7605

CHAPTER Hunter Army Airfield
Marine Corp Supply School
Covered by: Albany Chapter

Attachment DP-4
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
Glynn County Cluster III Coverage: Appling, Glynn,
Gordon County Cluster VII Coverge: Gordon

Kenny Murphy P.O. Box 242 Hinesville, GA 31313 (912) 876-3975
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
Houston-Middle Georgia Cluster VI Coverage: Bleckley, Dooly, Hancock, Houston, Lamar, Macon, Pulaski, Taylor, Wilcox

Brenda Hoard 100 South Hill Street Griffin, Ga 30244 (404) 227-3145
Sam Register 346 Corder Warner Robbins, GA 31088 (912) 923-6332 Fax:(912) 922-8858

Toombs County Cluster III Coverage: Montgomery, Toombs, Treutlen, Wheeler
Valdosta Cluster IV Coverage: Berrien, Brooks, Echols

Stan Bazemore P.O. Box 49 Lyons, Georgia 30436 (912) 526-3150
Stephen Coyne 707 North Patterson Street Valdosta, Georgia 31601 (912) 242-7404

GA WIC PROCEUDRES MANUAL

Attachment DP-4 cont'd

CHAPTER

AMERICAN RED CROSS CONTACT

Newton County Cluster II Coverage: Newton

Laura Bertram 7144 Floyd Street Covington, GA 30209 (404) 786-2018 Fax: (404) 287-1236

Northeast Georgia Cluster I Coverage: Dawson, Fannin, Forsyth, Gilmer, Habersham, Hall, Lumpkin, Pickens, Rabun, Stephens, Towns, Union, White

Pamela Watts 425 Bradford Street, N.W. Gainesville, GA 30501 (404) 532-8453 (800) 282-1722 (in GA)

Rome-Floyd County Cluster VII Coverage: Chattooga, Dade, Floyd, Polk

Jean Lambert 311 Turner McCall Blvd. Suite A Rome, GA 31065-2733 (706) 291-6648 Fax:(706) 235-2842

Savannah Chapter Cluster III Coverage: Bryan, Chatham, Effingham

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
Thomas County Cluster IV Coverage: Decatur, Grady, Seminole, Thomas

Ossie Andrews 809 Isabella Street Waycross, Georgia 31501 (912) 283-7846/4639

Gardiner Hasty P.O. Box 1135 Thomasville, Georgia (912) 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

Maxine Franks P.O. Drawer 70770 Tifton, Georgia 31793 (912) 382-3133
Barbara Hudson 411 South Greenwood St. Suite #B LaGrange, Georgia 30240 (706) 884-5818 Fax: (706) 882-4364
Jeanne Hinson 310 North Church Street Thomaston, Georgia 30286 (706) 647-3023

CHAPTER
Walker County Cluster VII Coverage: Walker
Naval Air Station Atlanta Covered by: Fort McPherson

AMERICAN RED CROSS CONTACT
Fax: (912) 242-1553
Jerry Lipps P.O. Box 372 Lafayette, Georgia 30728 (706) 638-2546

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

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

Fort Gillem Covered by: Fort McPherson

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GA WIC PROCEUDRES MANUAL

CHAPTER

AMERICAN RED CROSS CONTACT

Dobbins Air Force Base Covered by: Fort McPherson

CHAPTER
Fort Benning/Martin Army Hospital

Attachment DP-4 cont'd
AMERICAN RED CROSS CONTACT
Station Manager P.O. Box 51945 Fort Benning, GA 31995 (706) 545-5194 Fax: (706) 545-5118

DP-15

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.
And Justice For All Poster - Poster which must be displayed in a conspicuous location in each WIC Clinic site indicating the WIC non-discriminatory clause.
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.
Children - Child who have had their first birthday but have not yet attained their fifth birthday.

1

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.

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.

Coding of Records Documenting special codes on record for special treatment for applicants/participants.

CUR Part 2 - Cumulative Unmatched Redemptions which have not matched to a valid certification record.

Collections - Repayment of WIC funds that were received fraudulently and must be made by cashiers check or money order.

Day Worker - Individual who contracts for labor or services on a daily basis.

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, (Bachelors or Masters Degree in Nutritional Sciences, Community Nutrition, Clinical Nutrition, Dietetics, Public Health Nutrition or Home Economics with emphasis in Nutrition), dietitians, registered nurses, physicians assistants (certified by the National Committee on Certification of Physicians 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.

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 nonprofit 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.

Computing Income - Review documents (i.e. Check Stubs, IRS forms, etc.) to determine the income eligibility of the WIC participant.
Confidentiality - The WIC Program may give the participants certification information to other Health Public Assistance programs to see if the participant is eligible for their services. These agencies may contact the applicant, but they may not give any information to anyone else without obtaining the participants permission.

Dual Participation - WIC participants who receive benefits twice in the same clinic, or from more than one clinic.
EBT - Electronic Benefit Transfer.
EDC (Estimated Date of Confinement) - Indicates the date of expected delivery for a pregnant woman.
Education Level - Indicates the highest level or grade completed, for women participants only.

Cost Containment Measure - A competitive bidding, rebate or direct distribution implemented by a State agency as described in

Enrollee A client who is active and in a valid certification period, but did not receive vouchers during the reporting month.

2

Equipment Inventory - A detailed listing of all property purchased with WIC funds and valued at a minimum of $1000.00.

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.

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.

Homeless Facility - A supervised publicly or privately operated shelter (including a welfare hotel or congregate shelter) designed to provide temporary living accommodations; a facility that provides a temporary residence for individuals intended to be institutionalized; or a public or private place not designed for, or normally used as, a regular sleeping accommodation for human beings.
Hospital Certification - Reviewing hospital documentation for eligibility of applicants/participants for the WIC program.

Family and Children Services Government agency responsible for the welfare of children.
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.

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 A condition that exists when the nearest authorized WIC vendor is ten (10) miles or more away from another authorized WIC vendor.
Incident/Complaint Form - Form #3772 titled Incident/Complaint Form. This form is used to document complaints from participants, vendors, USDA, etc.

Food Delivery System - The method used by State and local agencies to provide supplemental foods to participants.

Income - Gross cash income before deductions for income taxes, employees social security taxes, insurance premiums, bonds, etc.

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.

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 are 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.
Initial Contact Date - The date an applicant first visits the WIC clinic during office hours and requests WIC benefits, orally or in writing.

Hemoglobin - Medical criteria required to assess nutritional risk.
Homeless - A woman, infant or child who does not have regular fixed night time residence, or resides in a temporary public or private shelter.
Homeless Individual - A woman, infant or child who lacks a fixed and regular night time residence; or whose primary night time residence is: A supervised publicly or privately operated shelter (including a welfare hotel, a congregate shelter, or a shelter for victims of domestic violence) designated to provide temporary living accommodation; an institution that provides a temporary residence for individuals intended to be

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.
Issue Month - The month in which vouchers were issued.

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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.

No-Proof Form - Form used when an applicant for WIC cannot provide documented proof of identification, residence or income.

LQA - Living Quarter Allowance.
Leave and Earnings Statement (LES) - Pay check stub for the military.
Legal Custody - Court ordered custody of a person.

Non-Participation - Participants in a valid certification period who do not pick up (manual or computer) are counted as a nonparticipant.
Non-Breast-feeding - Postpartum woman who is not breast-feeding an infant.

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.
Migrant Farm Workers - An individual whose principal employment is in agriculture on a seasonal basis, who has been so employed within the last 24 months, and who establishes, for the purposes of such employment, a temporary abode.
Migrant - A seasonal farm or agricultural worker or family member who travels from place to place for the purpose of work and such work requires the establishment of temporary residence.
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 Programs obligation to offer voter registration opportunities to anyone entering a clinic for WIC benefits.
Motor Voter Forms - A form issued to applicants that registers them to vote.
Native American - The original inhabitants of America; an American Indian.

Non-English Speaking - Individual whose primary language is not English or speaks little English.
Nonprofit Agency - A private agency which is exempt from income tax under the Internal Revenue Code of 1954, as amended.
Numeric Client Masterfile - An enrollment report, which list all active participants. This report is a cross reference for the Alphabetic Client Masterfile. It provides the client names by ID number.
Nutrition Education - Individual or group education sessions and the provision of information and educational materials designed to improve health status, achieve positive change in dietary habits, and emphasize relationships between nutrition and health.
Nutritional Assessment - Contains medical data obtained and evaluated by a CPA, which determines a participant s nutritional risk.
Nutritional Risk - Detrimental or abnormal nutritional conditions detectable by biochemical or anthropometric measurements; other documented nutritionally related medical conditions; dietary deficiencies that impair or endanger health; or conditions that predispose persons to inadequate nutritional patterns or nutritionally related medical conditions.
OIG - The USDA Office 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.
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.

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Pay Stub - Statement of paid income earned.

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.
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.
Prenatal Weight - Prenatal woman's weight prior to delivery.

Priority VI - Postpartum, non-breast-feeding women with a nutritional need, or homeless/migrancy status and homeless/migrant postpartum non-breast-feeding teenagers.
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.
Racial Group of Participant - 1=White, 2=Black, 3=Hispanic, 4=Native American, and 5=Asian, Pacific Islands and 6=Multiracial.

Presumptive Eligibility - Individual presumed eligible for medicaid, benefits based upon information presented.
Priority I - Pregnant women, breast-feeding women, and infants at nutritional need determined by measuring height/weight, taking a blood test and medical history.
Priority II (Breast-feeding women) - Women who do not qualify under priority I, but are breast-feeding Priority 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.

Reason for Certification - A participant's nutritional need for the WIC Program, based on the medical/nutritional data collected at the time of certification.
Redemption - The exchange of WIC vouchers for supplemental foods at participating grocery stores. Only authorized foods (listed on the face of the voucher) may be purchased.
Refugee - Someone who flees his or her native country due to persecution or well-founded fear of persecution because of race, religion, nationality, political opinion, or membership.
Residency - Determined by using the applicants documented proof of address.

Priority III (Children) - Children with a nutritional need. This need is determined by measuring height/weight, taking a blood test and medical history.

Residual Funds - Funds remaining available for allocation to State agencies after every State agency has received the amount allocable to it as stability finds.

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.
Priority V - Children with a nutritional need because of poor diet

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.
Seasonal Farmworker - A worker employed in agriculture occupation whose residence is not temporary for the purpose of such work.

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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 years Program operating level.

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 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.

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.

Thirty (30) Day Issuance The issuance of vouchers to
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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 High Risk by the State WIC Branch through the use of VAMP, complaints, or request for investigation forms received from the districts.
Vendor Registry Update a form used to update information regarding approved WIC vendors.
Vendor Materials a list of resources available through the Georgia WIC Branch that pertain to vendor management.
Vendor Monitoring an overt compliance activity that is conducted on- site by WIC Program representatives.
Vendor Profile - A summary of information about a vendor designed to show their overall standing with the program.
Vendors Review Form a tool that is used to document a vendor's shelf prices and inventory of WIC approved foods.
Vendor Sanctions Penalties that are assessed to a WIC vendor for violating program policy and/or regulations that may lead to disqualification.
Vendor Stamp a uniquely numbered instrument that is used by vendors to prepare vouchers for payment.
Vendor Training Checklist -A form that lists topics which are covered during a training session .
Vendor Training Sign-In Sheet A form used to document attendance at a training session.

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

VIPS (Vendor Integrity Profile System ) - a computerized data base that contain information on all vendors in Georgia.
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
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