GA WIC 2005 procedures manual, GA state plan

GA WIC 2005 PROCEDURES MANUAL

Introduction

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-5

H. Special Population (SP) .....................................................................................IN-5

I. Outreach (OR).....................................................................................................IN-5

J. Food Delivery (FD) ............................................................................................IN-5

K. Compliance Analysis (CA) ...............................................................................IN-6

L. Monitoring (MO)................................................................................................IN-6

M. Breastfeeding (BF) ..............................................................................................IN-6

N. Disaster Plan (DP) ..............................................................................................IN-7

O. WIC Procedures Manual Glossary ..................................................................IN-7

GA WIC 2005 PROCEDURES MANUAL

Introduction

VII. VIII.

Administration .........................................................................................................IN-7 A. Food and Nutrition Service (FNS)/USDA .....................................................IN-7 B. State Agency .......................................................................................................IN-7 Addresses ..................................................................................................................IN-8 A. Local Agencies....................................................................................................IN-8 B. State Agency .....................................................................................................IN-14

GA WIC 2005 PROCEDURES MANUAL

Introduction

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
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GA WIC 2005 PROCEDURES MANUAL

Introduction

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 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. Georgia WIC Program Identification (ID) Card 7. Proxies 8. Income Eligibility 9. Nutritional Risk Determination 10. Nutrition Risk Criteria 11. Nutrition Risk Priority System 12. Changes Within a Valid Certification Period 13. Certification Periods 14. Infant Mid-Certifications Nutrition Assessment 15. WIC Assessment/Certification Form

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GA WIC 2005 PROCEDURES MANUAL

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16. Ineligibility Procedures (Notification Requirements) 17. Transfer of Certification 18. WIC Overseas Program 19. Correcting Mistakes 20. Late Entry Correction on Health Records 21. Documentation Procedures 22. Certified Waiting List 23. Patient Flow Analysis 24. System Information Management 25. Immunization Coverage Assessment 26. Procedures for Processing Complaint Incidents
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. Equipment Inventory 7. Allocation of Nutrition Services & Administration Funds 8. Program Income
Section II 1. Retention of Records

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2. WIC Acronym & Logo 3. Lobbying Restrictions 4. Confidentiality 5. E-mail and Faxing Confidentiality Information 6. WIC Volunteer and Confidentiality 7. Health Insurance Portability and Accountability Act 8. Retroactive Benefits and Reimbursement 9. Mandatory No Smoking Policy in Local WIC Clinics 10. Subpoenas 11. Search Warrants 12. Program Participation 13. Establishing New Clinics/Clinic changes 14. Clinic Closings 15. Damaged Formula Report 16. Reporting Systems Problems 17. Request for Financial and/or Statistical Data 18. Identification Cards and Food List Order Referral Form

E. Vendor (VN) Section includes: 1. Number and Distribution of Authorized Vendors 2. Vendor Applications Periods 3. Vendor Selection and Authorization 4. Peer Groups 5. Vendor Agreements 6. Vendor Training 7. High Risk Identification System 8. Routine Monitoring 9. Vendor Sanction System 10. Administrative Review 11. Coordination With Food Stamp Program 12. Staff Training in Vendor Management

F. Food Package (FP) Section includes: 1. Authorization of Foods 2. Prescribing Foods - General 3. Infants

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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 9. Free Trade Formula
G. Nutrition Education (NE) Section includes: 1. Purpose 2. Definition 3. Goals 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

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4. Vouchers Printed on Demand (VPOD Vouchers and Computer Printed Voucher)
5. Manual Vouchers (Blank and Standard) 6. VPOD Procedures 7. Mailing/Delivery of WIC Vouchers 8. Voided Vouchers 9. Prorated Vouchers 10. Late Pick-up of Vouchers 11. Coordination of Health Services and Voucher Issuance 12. Lost, Stolen or Damaged Vouchers 13. Borrowed Vouchers 14. Cumulative Unmatched Redemption Report (CUR) 15. Reconciliation of WIC Reports and Daily Program Operations

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. Financial Review 4. Establish New Clinic Procedures

M. Breastfeeding (BF) Section includes: 1. Introduction

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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 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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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 # OF WIC CLINIC SITES

District 1, Unit 1 (Rome)
C. Wade Sellers, M.D., M.P.H. District Health Director Margaret Bean, BSN, M.S., R.N. Program Manager Rhonda Landrum, R.D., 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

Dade, Walker, Catoosa, 17

Polk,

Chattooga,

Gordon, Floyd, Bartow,

Paulding, Haralson

District 1, Unit 2 (Dalton)

Whitfield, Murray, 7

Thomas Chester, M.D., M.P.H. District Health Director

Gilmer,

Fannin,

Pickens, Cherokee

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 Charlene Thompson, L.D. District WIC Coordinator DHR Health District 2 Office 1280 Athens Street Gainesville, GA 30507 (770) 535-5743/GIST 261-5743

Banks,

Dawson, 13

Forsyth, Franklin,

Habersham, Hall, Hart,

Lumpkin, Rabun,

Towns,

Stephens,

Union, White

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DISTRICT/ADDRESS District 3, Unit 1 (Cobb)

COUNTIES SERVED # OF WIC CLINIC SITES

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 Shenica 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

Steven Katkowsky, M.D., M.P.H. District Health Director Vacant Deputy Director for Personal and Population Health and Clinical Services Arlene Murell Nutrition Services Manager Fulton County Health Department 75 Piedmont Avenue Suite #362 Atlanta, GA 30303 (404) 730-4050

District 3, Unit 3 (Clayton)

Clayton

3

Stephen Morgan, M.D. District Health Director Glenda Keith, RN 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

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DISTRICT/ADDRESS
District 3, Unit 4 (Gwinnett)
Lloyd M. Hofer, M.D., M.P.H. District Health Director Brenda Etheridge 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 678-442-6895 District 3, Unit 5 (DeKalb)

COUNTIES SERVED # OF WIC CLINIC SITES
Gwinnett, Rockdale, 6 Newton

DeKalb

5

Stewart Brown, M.D. Interim 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 or Noreen O'Neil, R.N. Director 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

Betty Neal, RN, M.P.H. DeKalb - Atlanta- Health Center 30 Warren Street Atlanta, GA 30317 Contact: Sharon Joseph, (404) 370-4666

Robert V. Taylor Director North Dekalb Health Centers 1954 Airport Road Suite #150 Chamblee, GA 30341-4953

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GA WIC 2005 PROCEDURES MANUAL
DISTRICT/ADDRESS
Contact: Dan Bacon L.D. (770) 454-1144
Wanza Bacon, R.N. Director South DeKalb Health Center 3110 Clifton Springs Road, SuiteD Decatur, GA 30034 Contact:: Debra McElmont (404) 244-2210 District 4 (LaGrange)
Michael Brackett, M.D., F.A.A., F.P. Interim District Health Director Carl Knapp, M.P.A. 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 Brent Gibbs, R.D., L.D. District WIC Coordinator 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 Nancy Jeffery Nutrition Services Director 187 Robertson Mill Rd., Suite 103 Milledgeville, GA 31061 (478) 445-1137 Fax (478) 445-1139

Introduction
COUNTIES SERVED # OF WIC CLINIC SITES

Fayette, Heard, Henry, 17

Butts, Carroll, Coweta,

Lamar,

Pike,

Meriwether, Troup,

Spalding, Upson

Bleckley,

Dodge, 10

Laurens, Montgomery,

Pulaski,

Telfair,

Treutlen,

Wilcox,

Wheeler, Johnson

Hancock, Houston, 21

Jasper, Baldwin, Bibb,

Crawford,

Jones,

Monroe,

Peach,

Putnam,

Twiggs,

Washington, Wilkinson

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GA WIC 2005 PROCEDURES MANUAL
DISTRICT/ADDRESS
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 Deputy Health Director Frances Wilkinson, M.S., R.D., L.D. District WIC Coordinator East Central Health District Office 1916 North Leg Road Augusta, GA 30909 (706) 667-4287 District 7 (Columbus)
Zsolt Kippanyi, M.D. District Health Director Dorothy (Dee) Cantrell Program Manager Jackie Miller, R.D., L.D., M.S.P.H District WIC Coordinator West Central Health District Office 2100 Comer Avenue P.O. Box 2299 Columbus, GA 31902 (706) 321-6300/FAX (706) 321-6126 District 8, Unit 1 (Valdosta)
Lynne D. Feldman, M.D., 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

Introduction

COUNTIES SERVED # OF WIC CLINIC SITES

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

Ben Hill, Berrien, 12 Brooks, Cook, Echols, Irwin, Tift, Turner, Lanier, Lowndes

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GA WIC 2005 PROCEDURES MANUAL
DISTRICT/ADDRESS
District 8, Unit 2 (Albany)
J. Paul Newell, M.D. District Health Director Barbara Jackson Program Manager Susan Miller District WIC Coordinator Southwest Health District Office 231 Tift Avenue Albany, GA 31701 (229) 430-4111 District 9, Unit 1 (Savannah)
W. Douglas Skelton, M.D District Health Director Kathryn Martin, M.P.H. 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 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

Introduction

COUNTIES SERVED # OF WIC CLINIC SITES

Terrell, Lee, Calhoun, 15

Worth,

Early,

Dougherty, Baker,

Grady,

Mitchell,

Colquitt,

Miller,

Thomas, Seminole,

Decatur

Chatham, Effingham 10

Appling, Atkinson, 21

Bacon, Jeff Davis,

Brantley,

Ware,

Bulloch,

Candler,

Clinch,

Charlton,

Evans, Coffee, Wayne,

Pierce,

Toombs,

Tattnall

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GA WIC 2005 PROCEDURES MANUAL
DISTRICT/ADDRESS
District 9, Unit 3 (Brunswick)
W. Douglas Skelton, M.D. Interim District Health Director Randy McCall Program Manager Jo Bishop Manning, L.D. District WIC Coordinator Coastal Health District Office 777 Gloucester Street, Suite 301 Brunswick, GA 31520 (912) 262-2300 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

Introduction
COUNTIES SERVED # OF WIC CLINIC SITES
Bryan, Liberty, Long, 15 McIntosh, Camden, Glynn

Barrow, Clarke, Elbert, 17

Green,

Jackson,

Madison, Morgan,

Oconee,

Walton,

Oglethorpe

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DISTRICT/ADDRESS
Southside Medical Center
David Williams, M.D. Director Vacant Program Manager Laverne Montgomery, M.A., R.D., L.D. District WIC Coordinator Southside Medical Center 1039 Ridge Avenue, S.W. Atlanta, Ga 30315 (404) 688-1350, Ext. 97 Grady Maternal & Infant Care Project

COUNTIES SERVED # OF WIC CLINIC SITES
Portions of Fulton and 3 Dekalb Counties

ALL

6

Douglas E. Miller, Pharm.D.

Asst. Vice President for Pharmacy & Drug

Information

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

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.

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GA WIC 2005 PROCEDURES MANUAL
Georgia Department of Human Resources Division of Public Health Family Health Section Nutrition Section Two Peachtree Street, N.E. 11th Floor Atlanta, Georgia 30303 (404) 657-2884 FAX (404) 657-2884

Introduction

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Certification

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-5 E. Nutritional Risk..............................................................................................CT-5

III. Initial Application ......................................................................................................CT-5

IV. Processing Standards.................................................................................................CT-8 A. Timeframes .....................................................................................................CT-7 B. Walk-in Clinics ...............................................................................................CT-7 C. Request for Extension....................................................................................CT-8

V. Participant Identification ..........................................................................................CT-8

VI. Georgia WIC Program Identification (ID) Card ....................................................CT-9 A. Required Data...............................................................................................CT-10 B. Participant Instructions ...............................................................................CT-11

VII. Proxies .......................................................................................................................CT-12 A. Reasons for Proxies......................................................................................CT-12 B. Authorization ...............................................................................................CT-12 C. Voucher Pick Up, Issuance, and Use.........................................................CT-13 D. Restrictions....................................................................................................CT-13 E. Participant Instructions ...............................................................................CT-13

VIII. Income Eligibility .....................................................................................................CT-14 A. Procedures.....................................................................................................CT-14 B. Adjunctive (Automatic) Eligibility ............................................................CT-16 C. Computing Income ......................................................................................CT-18

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D. Documented Proof of Income ....................................................................CT-30 E. Applicants with Zero (0) Income ...............................................................CT-30 F. Verification of Income .................................................................................CT-31
IX. Nutritional Risk Determination .............................................................................CT-32 A. Required Data...............................................................................................CT-32 B. Referral Data .................................................................................................CT-33 C. Medical Data.................................................................................................CT-34
X. Nutrition Risk Criteria ............................................................................................CT-36 XI. Nutrition Risk Priority System...............................................................................CT-36
A. General Priorities I -VI..............................................................................CT-36 B. Special Considerations ................................................................................CT-37 C. Specific...........................................................................................................CT-38 D. Assignment ...................................................................................................CT-39
XII. Changes Within a Valid Certification Period......................................................CT-39 A. Women Who Cease Breastfeeding ............................................................CT-39 B. Upgrading a Priority ...................................................................................CT-40
XIII. Certification Periods ................................................................................................CT-40 XIV. Infant Mid-Certification Nutrition Assessment ..................................................CT-41 XV. WIC Assessment/Certification Form ...................................................................CT-42
A. General...........................................................................................................CT-42 B. Completion....................................................................................................CT-42
XVI. Ineligibility Procedures (Notification Requirements) ........................................CT-50 A. Written Notification.....................................................................................CT-51 B. Completion of Notice of Termination/Ineligibility/ Waiting List Form ........................................................................................CT-52 C. Ineligibility File ............................................................................................CT-52
XVII. Transfer of Certification ..........................................................................................CT-53

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A. Verification of Certification (VOC) Card..................................................CT-53 B. Other Methods of Verification ...................................................................CT-54 C. Instructions for VOC Card Use..................................................................CT-56 D. Orders ............................................................................................................CT-56 E. Inventories.....................................................................................................CT-57 F. Issuance .........................................................................................................CT-57 G. Security ..........................................................................................................CT-58 H. Lost/Stolen/Misplaced VOC Cards .........................................................CT-58
XVIII. WIC Overseas Program...........................................................................................CT-59 A. General...........................................................................................................CT-59 B. Impact on USDA's WIC Program..............................................................CT-59 C. New VOC Card Requirements...................................................................CT-60 D. Completion of the VOC Card.....................................................................CT-60 E. Acceptance of WIC Overseas Program VOC Cards ...............................CT-61
XIX. Correcting Mistakes.................................................................................................CT-61 XX. Late Entry Correction on Health Records ............................................................CT-61 XXI Documentation Procedures ....................................................................................CT-62 XXII. Certified Waiting List ..............................................................................................CT-62
A. Procedures for Maintaining a Waiting List ..............................................CT-62 B. Procedures for Removal from the Waiting List.......................................CT-63
XXIII. Patient Flow Analysis..............................................................................................CT-63 XXIV. System Information Management .........................................................................CT-67 XXV. Immunization Coverage Assessment ...................................................................CT-67 XXVI. Procedures for Processing Complaint/Incidents ...................................CT68

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Attachments: CT-1 WIC Assessment/Certification Form - Pregnant Women .................................CT-70 CT-2 WIC Assessment/Certification Form - Post Partum Breastfeeding ................CT-72 CT-3 WIC Assessment/Certification Form - Post Partum Non
Breastfeeding ...........................................................................................................CT-74 CT-4 WIC Assessment/Certification Form - Infants....................................................CT-76 CT-5 WIC Assessment/Certification Form - Children ................................................CT-78 CT-6 Signed Statement of Income ...................................................................................CT-80 CT-7 Data and Documentation Required for WIC
Assessment/Certification - Women......................................................................CT-81 CT-8 Data and Documentation Required for WIC
Assessment/Certification - Infants .......................................................................CT-82 CT-9 Data and Documentation Required for WIC
Assessment/Certification - Children ....................................................................CT-83 CT-10 Nutritional Risk Criteria - Prenatal Women ........................................................CT-84 CT-11 Nutritional Risk Criteria - Postpartum, Breastfeeding Women........................CT-97 CT-12 Nutritional Risk Criteria - Postpartum, Non-Breastfeeding Women.............CT-109 CT-13 Nutritional Risk Criteria - Infants........................................................................CT-120 CT-14 Nutritional Risk Criteria - Children ....................................................................CT-131 CT-15 Notice of Termination/Ineligibility/Waiting List Form..................................CT-141 CT-16 Verification of Certification (VOC) Card............................................................CT-142 CT-17 VOC Card Inventory Log (Clinic) .......................................................................CT-143 CT-18 VOC Card Inventory Log (Local Agency)..........................................................CT-144 CT-19 Measuring Length..................................................................................................CT-145 CT-20 Measuring Height .................................................................................................CT-146 CT-21 Measuring Weight ................................................................................................CT-147

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CT-22 Measuring Weight Standing ................................................................................CT-148 CT-23 Equipment Maintenance .......................................................................................CT-149 CT-24 Instructions for Use of Prenatal Weight Gain Grid (Form #3059) ..................CT-151 CT-25 Prenatal Weight Grid for Normal Weight and Twins .....................................CT-152 CT-26 Prenatal Weight Grid for Underweight and Overweight ................................CT-153 CT-27 Dietary Assessment ...............................................................................................CT-154 CT-28 Instructions for Use of the Growth Charts .........................................................CT-155 CT-29 Body Mass Index (BMI) Table for Determining Weight
Classification for Pregnant Women 1..................................................................CT-158 CT-30 Weight for Height Table for Women, Based on the Body Mass
Index (BMI) .............................................................................................................CT-159 CT-31 Physical Signs Suggestive of Nutrient Deficiencies ..........................................CT-160 CT-32 Recommended Daily Servings Chart..................................................................CT-162 CT-33 Inappropriate Food Practices ...............................................................................CT-163 CT-34 Georgia WIC Program Referral Form ................................................................CT-165 CT-35 WIC Income Poverty Guidelines ........................................................................ CT-166 CT-36 VOC Card Agreement .......................................................................................... CT-167 CT-37 VOC Card Form .....................................................................................................CT-168 CT-38 Women, Infant and Children (WIC) Ordering Form........................................CT-169 CT-39 State/District/Clinic Transmittal Form..............................................................CT-170 CT-40 Medicaid Right From the Start.............................................................................CT-171 CT-41 No Cost Flyer..........................................................................................................CT-172 CT-42 Verification of Residency and/or Income Form ...............................................CT-173 CT-43 Georgia WIC Program No Proof Form ..............................................................CT-174 CT-44 Family Plus Medicaid Card ..................................................................................CT-175

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CT-45 Disclosure Statement Employees and Relatives ............................................CT-176 CT-46 Income Calculation Form......................................................................................CT-177 CT-47 Identification, Residency and Income Proof List...............................................CT-178 CT-47B Identification, Residency and Income Proof list (Spanish)......................CT-179 CT-48 Thirty (30) Day Certification/Termination Form..............................................CT-180 CT-49 Department of Defense WIC Overseas Program VOC Card...........................CT-181 CT-50 WIC Overseas Program Contacts ........................................................................CT-182 CT-51 Proof of Residency Form for Applicants with P.O. Box Address ...................CT-183 CT-52 Income Verification Letter ....................................................................................CT-184 CT-53 Incident/Complaint Form ............................................................... CT-185

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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 Program, must have their eligibility determined except those persons transferring within a valid certification period with proper verification (Refer to XVII). If eligible and funds are available, the individual will enroll in the program and be issued with supplemental food vouchers. A participant shall be issued vouchers at the time they are notified of their eligibility. If the client is certified in the home, vouchers must be issued at that time. 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 (See Ineligibility Procedures CT-XVI).
Applicants who do not meet the income requirement for WIC eligibility may be referred to the area food pantries or other food assistance programs.
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 for compliance 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
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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 or miscarriage. When a participant no longer meets the definition of pregnant woman; breastfeeding woman; postpartum, nonbreastfeeding 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 WIC Program is exempt from any restrictions in regard to aliens, refugees, and immigrants.
B. Physical Presence
All applicants (women, infants and children) must 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. Newborn infants who are born to a mother who was on WIC during her pregnancy or was eligible to participate but was not certified. The infant must be brought into the clinic prior to two (2) months of age to avoid termination. Medical or high risk condition may not be present.
2. 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 into the WIC clinic.
3. Receiving Ongoing Health Care An infant or child who was
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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 exempt from physical presence requirements by the local agency, if unreasonable barriers exist.
4. Working parents or caretakers The local agency may exempt an infant or child from the physical presence requirements: a. If the infant/child was present for his/her initial WIC certification b. If the infant/child was present at a WIC certification within the last year and determined eligible. c. If the infant/child is under the care of working parents/guardian whose working status presents a barrier to bringing the infant/child into the WIC clinic.
The following people may determine if special considerations are required:
a. Doctor b. Nurse c. Nutritionist d. Physician Assistant e. Competent Professional Authority (CPA) f. WIC Coordinator or Designee
Physical presence is required unless a participant qualifies for an exemption as stated above. 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 CT- 51 may be used for
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multiple certifications if the following applies:
1. No change in P.O. Box; and 2. 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 a minor applicant 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 proof of residency includes: 1. Electric bill 2. Gas bill 3. Telephone Service bill 4. Water bill 5. Cable TV bill 6. Rent Receipt 7. Health Record (not a bill) 8. Medicaid Swipe Machine address only if it appear on the screen 9. 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 Farm workers - Migrants farm workers 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.
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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, MUST present proof of income or adjunctive income eligibility. If proof of income is not available, use the No Proof Form (See Migrants CT-VIII.C.l.).
E. Nutritional Risk
Applicants must have an identifiable nutritional risk, as determined through a nutritional risk assessment, to be eligible for benefits.
III. INITIAL APPLICATION
A. Initial contact date is defined as the date the individual first visits the clinic during office hours and requests WIC benefits, orally or in writing. An individual's initial contact date will remain the same unless there is a break in enrollment. A break in enrollment is defined as missing a certification appointment after the current certification expires, a lapse in eligibility, or the participant is terminated and not reinstated during a valid certification period.
B. The following items must be recorded when an individual first visits the clinic during office hours and specifically requests WIC benefits (orally or in writing) and benefits are not provided.
1. Applicant's Name and Address 2. Category (i.e. pregnant, postpartum, infant, child, migrant) 3. Initial Contact Date (date services were requested in person)
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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 16 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 CTXVI).

D. An income eligibility assessment should be made either prior to rendering WIC nutrition 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 in stream migrant farm workers and their families for a period of twelve (12) months. The income determination can occur either in the migrant's home base area before the migrant has entered the stream, or in an in stream area during the agricultural season.
E. Employees must never certify, recertify, or issue vouchers to family members or blood relatives (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 Competent 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 Disclosure Statement (Attachment CT-45) must be completed by clinic staff annually to inform District staff of their family participation on the WIC Program. This form must be completed by the local agency and returned to the WIC Coordinator by September 30th of each year. A copy
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of this form must also remain in the Health Department for audit purposes.
Procedures for completing the Disclosure Statement (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 Program, use the Record Review Form located in the Monitoring Section of the Procedure Manual.
Note: Staff must 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, late evenings, and weekend clinics must be held or an appointment given to meet the needs of the applicants/participants. Clinics must make provisions to provide service for those applicants/participants that need to pick up vouchers during the lunch hours.
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 timeframes 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

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women, infants and members of migrant farm worker families must be notified of their eligibility or ineligibility within ten (10) calendar days of their initial contact date for program benefits. All other applicants will be notified of their eligibility or ineligibility within twenty (20) calendar days of their initial contact date for program benefits.
B. Walk-in Clinics
Walk-in clinics are an excellent way to meet processing standards. The six (6) items collected at the time of the initial application (See CT-III.B) must be documented. A clinic that does not routinely schedule appointments shall schedule appointments for employed adult applicants/participants to apply or reapply for participation in the WIC Program for themselves or on behalf of others, to minimize the time these applicants/participants are absent from the workplace.
C. Request for Extension
On an annual basis the State agency may grant an extension of ten (10) to fifteen (15) days to local agencies experiencing difficulty in meeting processing standards. Those local agencies in need of an extension are required to submit a written request, including justification, to the State agency by October 1 of each year. Justifiable reasons for granting an extension include, but are not limited to:
1. Rural or satellite clinics unable to provide services more than twice per month.
2. Agencies with a high migrant participation population. 3. Agencies experiencing a continuous backlog in appointments
reflecting ongoing difficulty in scheduling clients for prenatal/well-child appointments.

V. PARTICIPANT IDENTIFICATION
General
Identification must be checked and documented for both the applicant/ participant and parent/guardian/caretaker at initial and subsequent certification. The identification must be documented before issuing of benefits to 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
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establish identity may be used if approved by the Georgia WIC Program Coordinator or designated CPA. Other records used for identification purposes that have been approved by the district, must be documented on the Certification Form.
Acceptable Documentation: 1. Immunization Record (Presented by applicant) 2. Health/Medical Record (Presented by applicant) 3. Birth Certification/Confirmation of Birth Letter 4. State ID 5. Driver's License 6. Military ID 7. Work or School ID 8. Social Security Card 9. Voter Registration Card (must match residency address) 10. WIC ID (For Voucher Issuance Only) 11. Hospital ID Bracelets (Mother & Baby) 12. VOC Card (with additional ID) 13. Other
For a categorical list of acceptable proofs of identification that must be used for women, infants or children see the Monitoring Section.
Immigrants, Migrant Farm workers or individuals who have experienced theft, loss or disaster may not be able to provide an acceptable proof of identification. In limited and special situations the No-Proof Form (Attachment CT-43) may be utilized and must be completed by the applicant. A police report maybe required for individuals claiming theft or loss.
Note: Only one (1) piece of identification is required per applicant.

VI. GEORGIA WIC PROGRAM IDENTIFICATION (ID) CARD
General
During the certification appointment, a Georgia WIC Branch Identification (ID) card (See the Food Delivery Section) must be completed and issued 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.

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Effective January, 2004, English and Spanish WIC ID cards will be mailed quarterly to each district based on participant caseload/ID card distribution calculation.
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:
1. Manual vouchers Document on the manual voucher copy under the date.
2. Voucher Printed on Demand (VPOD) Document on the receipt under User's ID.
3. Voucher Register Document on the left side of the voucher register under the WIC ID number.
A. Required Data
All items on the front must be completed, before issuing the ID Card.
FRONT: 1. Participant's name 2. WIC ID number 3. Date certification period expires 4. Participant/parent/guardian/caretaker's signature 5. 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.

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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 be instructed 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 for eligibility screening. 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 who 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 on either of the following: 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 clinic 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).

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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.
C. Voucher Pick Up, Issuance, and Use
In order to pick up WIC vouchers, the proxy must have the participant's WIC ID card.
During issuance, the proxy will sign the voucher register, VPOD receipt or manual vouchers (refer to Food Delivery Section if a proxy is unable to write).
D. Restrictions
1. Age - A proxy must be at least sixteen (16) years old, unless prior approval is obtained from the District WIC Coordinator or designated Competent Professional Authority (CPA). Approval must be documented in the participant's health record.
2. Staff - Health Department staff and volunteers working for the health department may not act as proxies for participants (See Proxies CT-VII).
3. Vendors Vendors must not be used as a proxy.
E. Participant Instructions
When an individual is certified for the WIC Program, explanation of the following must be provided: proxy use and function, the importance of choosing responsible proxies, how to authorize a proxy, and the participant's responsibility for instructing proxies on the proper procedures of voucher redemption.
The proxy must have or be able to provide the following information in order to certify a child: 1. 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.
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2. Proxy's ID 3. Knowledge of the child's medical history and dietary
habits/normal nutritional intake.
Note: The proxy should have the same knowledge regarding the above as you would expect the parent to have.
VIII. INCOME ELIGIBILITY
To be eligible for the WIC Program, an applicant/participant must present proof of gross annual family income equal to or less than 185% of the Federal Poverty Level. Income is defined as gross cash income before deductions. Georgia WIC income guidelines are implemented simultaneously with the Medicaid program income guidelines.
Public Law 103-438, the Healthy Meals for Healthy Americans Act, provides new regulations for conducting the WIC Program income assessment/determination for pregnant women. 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. This is considered the initial contact date.
2. Confidentiality/Privacy - Clinic personnel who interview applicants for the WIC Program must determine the family size
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and income eligibility with as much confidentiality and privacy as possible.
3. Determining Family Size/Income Eligibility - Family size must be determined first (See Income Eligibility CT-VIII). Then, the income for that family must be calculated and compared to the maximum income allowed for that family size (See Attachment CT-35). Income eligibility must be determined before nutritional risk eligibility. When determining the income of the WIC applicant, the Income Calculation Form must be completed (See Attachment CT-46), if the applicant does not qualify for adjunctive or presumptive eligibility and if the applicant has more than one income to calculate. If only one income was reported place a check in the designated space behind the statement "check here if only one income reported".
Procedures for completing the Income Calculation Form:
All local agencies must complete the Income Calculation Form if the applicant does not qualify for adjunctive eligibility and has more than one income to calculate. When completing this form:
1. Write/type in the ID Number if applicable (the ID number is an eleven-digit number).
2. Write/type name of the WIC applicant.
3. Write/type the address of the WIC applicant.
4. Complete the Income Calculation by filling in the following: a) Date b) Relationship and name of the person whose income is being given. c) Income source. (which is a two-digit alphabet, i.e., P.S. for pay stub) d) 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/biweekly, monthly/yearly. b) Total the amount of all income earned. Circle if the amount earned is weekly/bi-weekly, monthly/yearly.
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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 receives 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 qualifies for Medicaid, other categorically eligible family member(s) income qualifies for the program.
4. A child on Medicaid can not income qualify his/her mother or a sibling.
When an applicant qualifies for adjunctive eligibility, document the Program for which the applicant is eligible.
Note: Persons who are adjunctively income eligible for WIC must also be categorically eligible and assessed 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
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of income eligibility.
1. Medicaid: The participant enrolled in Medicaid will be issued a swipe card. This card will contain the participant's name, identification number, date of issue and the primary care provider. Current eligibility may be verified by swiping the Medicaid card through the magnetic swipe machine. "Status 1" on the print out will indicate current Medicaid eligibility. If the participant's address appears on the print out, it may be used to verify residency.
A participant who is enrolled in Medicaid but does not have a card at the time of certification may have eligibility verified by keying the name and date of birth into the magnetic swipe machine or logging onto the internet. The Interactive Voice Response (IVR) may also be used to verify the eligibility status by dialing 770-570-3373 or 1-866-211-0950.
Infants are issued a Medicaid number at the time of birth. Should a Medicaid eligible infant comes to clinic for the first time without the Medicaid card, ask the mother if the hospital issued a temporary Multi Health Network (MHN) number for the infant. If the mother does not have one, the IVR can provide it. Place the twelve digit number in the field provided for Medicaid numbers.
2. PeachCare All PeachCare participants must be screened for WIC income eligibility. The PeachCare participant who is also Medicaid eligible is being phased out. That participant population will diminish with time.
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 or TANF. Continue to use the Food Stamp ID card/number or TANF ID card/number for proof of income.
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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. Verify income eligibility for those participants/applicants who do not have proof of participation on TANF.
C. Computing Income
1. Current vs. Annual In determining income, clinic staff 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 on a case by case basis.
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. a. 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. b. Annual income is divided by 12. c. A lump sum payment should be divided by 12 to estimate a monthly income (i.e. Lottery winnings). d. Quarterly payments are divided by 3 to get a monthly rate.
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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). a. Hourly: hourly rate x hours per week x 52 b. Daily: daily rate x 5 (or number of workdays per week) x
52 c. Twice a month: Pay rate x 24 d. Every two weeks: pay rate x 26 e. Monthly: pay rate x 12 f. Quarterly: pay rate x 4 g. 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. Total income should reflect current circumstances.
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
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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.
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
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parent temporarily move in with friends or relatives, choose one of the following options: (a) Count absent parents and exclude current caregivers.
(b) 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.
(c) Count children as members of the caregiver's household. Determine family size based on the family 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 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) OCONUS COLA (Overseas Continental United
State Cost of Living 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
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The LES contains: - Individual'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. Verification of Residency and/or Income Form - (See Attachment CT-42) The verification form is to be given to any potential applicant to assist them in collecting necessary documentation from other members of the family (economic unit) to determine income eligibility under the program.
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.
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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 CT43).
The applicant or adult applying in behalf of an infant/child applicant, must self-declare income and family size, and write and sign a statement explaining why they are unable to obtain proof of family income. Do not accept an incomplete No Proof Form. Do not certify and issue benefits to an applicant who self-declares an income for family size that exceeds the WIC income guidelines.
m. Temporary Thirty (30) Day Certification
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
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client to clearly communicate the kinds of information they will need to bring for certification visits. Clinic procedures for issuing thirty (30) day certification are as follows (See Attachment CT-48):
Procedures for Thirty (30) Days Certification
1. When an applicant/participant arrives in the clinic without proof of residency, income or identification: (a) Place the applicant on the program using the Thirty (30) Day rule. (b) Proof that is not available on site must be entered as "NO" in the appropriate field on the computer. (c) Complete the Thirty (30) Day form. Give the client the original copy and place a copy of the form in the Medical Record. (d) The computer system will update for the Thirty-Day eligibility.
2. Procedures when applicant/participant brings back required proof:
If the participant returns with proof of residency, income or identification prior to the thirty (30) day period, generate an updated Turn Around Document (TAD) to include the new information. The "up____" has been added as a reminder to update the information on the paper form only once the participant returns to the clinic with the required information.
The "up:______" is found in the following sections of the back of the certification form.
Gross Income see "up_____" Source of income Code see "up______" Staff initials see "up_____" Data see "up______"
Utilize the "up____" field as follows: (a) Update your computer screen as needed for 30 day. (b) When one or more of the fields are updated, the staff must initial and date the back of the form (paper form only). (c) When income is updated, the amount and source must be updated.
(d) The applicant/participant must return with the information. A proxy may not provide the necessary documentation to complete the Thirty (30) Day Certification process.
(e) When using the computer TAD and updating the screen, use an
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"update".
3. Procedures when applicant/participant fails to bring back proof:
If the participant fails to return within thirty (30) days, the clinic must terminate the participant using the term code L. Convansys will automatically terminate the participants if an update is not received.
(a) Reversing Terminations:
If the applicant returns after the Thirty (30) Day grace period a reversal can be made for any participant in a valid certification period. The updated information must be entered in the term reversal Electronic Turn Around Document (ETAD).
(b) Procedure for Participant Transfers
1. When a participant transfers to another district, the receiving clinic must call the original clinic to determine the client's Thirty (30) Day status.
2. Vouchers must never be issued if the participant has not brought back the necessary information
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. Ask them to complete the No Proof Form (Attachment CT- 43) indicating what their income is. Ask for documentation first.

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p. Zero Income Applicants Complete applicable questions on back of assessment form.
See Income Eligibility Applicants with Zero (0) Income (CT-VIII. E.).
1. Income Inclusions a. Monetary compensation for services, including wages, salary, commissions, or fees b. Net income from farm and non-farm self employment c. Social Security benefits and/or Supplemental Security Income (SSI) d. Dividends or interest on savings or bonds, income from estates or trusts, or net rental income e. Public assistance or welfare payments f. Unemployment compensation g. Government civilian employee or military retirement, pensions, or veterans' payments h. Private pensions or annuities i. Alimony or child support payments j. Regular contributions from persons not living in the household k. Basic Allowance for Subsistence (BAS) is cash payment added to base pay and is counted as part of all cash income for military families l. Net royalties m. Other cash income. This includes, but is not limited to, cash amounts received or withdrawn from any source including savings, investments, trust accounts, and other resources which are available to the family (e.g. money from friends and relatives).
2. Income Exclusions
a. The value of in-kind housing and other in-kind benefits. An in-kind benefit is anything of value, which is not provided in the form of cash.
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
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(3) Job Training Partnership Act (4) Home Energy Assistance Act of 1980 (5) National Older Americans Volunteer Program (6) Domestic Volunteer Service Act of 1973 (VISTA, Foster
Grandparents, Retired Senior Volunteers Program, Senior Companions Program) (7) Child Nutrition Act of 1966 (8) Small Business Act (9) Uniform Relocation Assistance and Real Property Acquisitions Policies Act of 1970 (10) Military Housing - BAQ (11) Title IV Student Financial Assistance.
c. Bank loans, other payments or benefits provided under certain federal programs or acts to be excluded may be found in the Federal Regulations governing WIC 7 CFR Part 246.7(d)(2)(iv).
d. Child care benefits provided under grant programs to states shall not be treated as income in federal programs such as WIC. 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.
e. 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.
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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 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.

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Reimbursement payment(s) represents money received for loss of assets or injuries to real or personal property. Reimbursement lump sum payment(s) should not be counted as income for WIC eligibility purposes.
Examples include but are not limited to insurance reimbursement, payment on specified household expenses or medical expenses.
New Money is money received as gifts, inheritances, lottery winnings, workman's compensation for lost wages, or severance pay. Lump sum payments that represent new money intended to be used, as income should be considered as "Other Cash Income".
The lump sum payment must not be counted for one month of current income. Rather, the lump sum payment should be counted as annual income, or be divided by 12 to estimate a monthly income.
Some lump sum payments may not be easily classified into either of the two categories, reimbursement or new money; but may represent both. In such instances treat the lump sum payment in a way that most accurately reflects the economic situation of the household. Examples of such payment include legal or medical settlements that provide reimbursement for lost property and medical expenses, as 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.
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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 any source. Some pay stubs will not have a name but will have a Social Security Number. Ask for the Social Security Card. 2. A statement from employers for all people in your household. Attach non-letterhead statements from employers to the No Proof Form and file in the health record. 3. Current tax return (W-2 or 1040). 4. On-going financial records (for self-employed only). 5. Unemployment Notice. 6. Other (See List of Income Inclusions).
For additional sources of income, see Income Inclusions (CT-VIII. P.2.).
E. Applicants with Zero (0) Income
When an applicant declares that they have no income (zero) except applicants that adjunctively income qualify, 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 record your initials (Staff initials) on the
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Certification Form. Check "Yes" the client is income eligible. This does not apply to applicants with adjunctive income eligibility documents.

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 public assistance 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 Compliance Analysis Section of the Procedures Manual.

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IX. NUTRITIONAL RISK DETERMINATION
To be eligible for the WIC benefits, an applicant/participant must have an identifiable nutritional risk, as determined through a nutritional risk assessment. Nutritional risk is identified through the assessment of required medical data (length/height, weight, hematocrit/hemoglobin), dietary information, and the individual's medical history. The 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, or physician's assistant, that has been trained by the State or local agency.
WIC 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 assess program eligibility may be suspended by the State WIC Branch. The applicant cannot be required to obtain such data at their 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.
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2. Infants - Attachment CT-8 lists required assessment data and documentation requirements for all infants by age. This data must be collected and documented for each assessment.
3. Children - Attachment CT-9 lists the required assessment data and documentation requirements for all children. This data must be collected and documented for each assessment. All required medical data used to determine nutritional risk must be reflective of the applicant's status at the time of certification.
B. Referral Data
Identification 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.
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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 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. The Hematological Data Date documented on the WIC Assessment/Certification form must be the same as the date the hematological data were taken". 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: a. ATVS: 88.8 b. Mitchell & McCormick (M&M): 88.8 c. Athens System: 88.8 d. Dekalb System: 88.8 e. Host: 88.8 f. Aegis: 88.8
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Convansys is set up to accept these values to indicate that no blood work has been performed for any reason, 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 of age, unless there is a medical reason.
In most cases, infants will have blood work performed around 12 months of 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 submit to Convansys each hemoglobin value determined as part of the followup. Once the hemoglobin becomes normal, it does not have to be assessed 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 closest to that year).
Blood work within the normal range is valid for children for one year; however, if the child participant is terminated from the program and re-applies for WIC benefits, blood work will have to be performed again. When a new initial contact date is assigned to the participant, blood work as well as anthropometrics must be taken in the clinic or from referral data to assess for eligibility.
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.
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Blood work 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: a. Enter the Date of Certification in the Hematological Data
Date field. b. Enter the value 88.8 in the Hemoglobin field. c. If the applicant is assessed WIC eligible, issue one month
of vouchers and follow District procedures for obtaining blood work, by the next voucher issuance.
Note: Each District must develop a written procedure to be used in obtaining blood work 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.
XI. NUTRITION RISK PRIORITY SYSTEM
A. General
Each nutrition risk criterion is assigned a specific priority. Statewide
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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 whose mothers were program participants during their pregnancy.
Infants up to six (6) months of age whose mothers were not Program participants during pregnancy but had a documented nutritional need.
3. Priority III: Children (under age 5) with a nutritional need. This need is assessed 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 breast milk 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.
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2. Possibility of Regression - If it has been determined that the only applicable risk criterion is "Possibility of Regression" the priority from the previous certification is retained.

During periods of caseload management when it is necessary to limit the number of priorities being served and a waiting list is being maintained, "Possibility of Regression" cannot be used as a reason for certification.

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:

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

Priority IV: 422, 502, 801, 802, 901, 902

2. Breastfeeding Women

Priority I:

101, 111, 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:

101, 111, 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

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4. Infants

Priority I:

103, 121, 134, 135, 141, 142, 153, 201, 211, 341, 342, 343, 344, 345, 346, 347, 348, 349, 350, 351, 352, 353, 354, 355, 356, 357, 359, 360, 362, 381, 382, 502, 603, 702, 703

Priority II: 502, 701, 702

Priority IV: 422, 502, 702, 801, 802, 901, 902

5. Children

Priority III:

103, 113, 114, 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

Priority V: 422, 502, 801, 802, 901, 902

D. Assignment

At the time of certification, the CPA must assign a priority based on the identified 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, reassessment of nutrition risk is required. The woman must qualify for WIC based on the risk criteria for a postpartum, nonbreastfeeding woman to continue benefits. If there is a nutrition risk reason, the woman's status, priority, and food package must
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be changed. If no nutrition risks are evident, new certification information must be collected to assess if the woman could continue to receive WIC benefits as a postpartum, nonbreastfeeding 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 nonbreastfeeding woman).
XIII. CERTIFICATION PERIODS
Certification periods are:
Pregnant Women: for the duration of their pregnancy and for up to six (6) weeks postpartum. There is no extension granted beyond the six (6) week postpartum cutoff.
Breastfeeding Women: for six (6) months from the date of initial and/or subsequent certification as a postpartum, breastfeeding woman. Eligibility ends when the certification period is over, when the breastfed infant turns one (1) or when breastfeeding is discontinued, whichever comes first.
Note: The certification period for the breastfeeding woman is six (6) months, however, she is eligible to be recertified as a breastfeeding postpartum women if she is still breastfeeding an infant less than 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 each certification may continue eligibility until they reach their fifth birthday, if assessed at nutritional risk.

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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 III-E).
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 completed:
1. The initial certification of the infant less than six (6) months of age will follow the standard procedures. The infant shall be assigned the highest priority for which he/she is eligible.
2. The mid-certification nutrition assessment must consist of: a. Measuring length and weight. b. Plotting weight for length, length for age, and weight for age. c. Measuring hemoglobin or hematocrit (if mid-certification nutrition assessment is performed between 9-12 months of age). d. Recording, summarizing, and evaluating dietary intake. e. Assessing nutrition risk criteria. f. Assigning the highest priority for which the infant is eligible, and 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 if using paper 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. All infants certified at <6 months of age must be scheduled for a midcertification nutrition assessment. Program benefits may not be withheld
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from a participant for failing the mid-certification 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.

B. Completion
All items on the WIC Assessment/Certification form must be completed as follows:
1. Identification Information - Applicant's name, birth date, address, telephone number, social security number (optional),
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ethnic origin, race and migrant status, county of residency, proof of residence and proof of identification (for applicant/participant and if applicable parent/guardian/caretaker), clinic number, WIC ID number and parent or guardian/caretaker's full 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 self-declaration of their ethnic origin, race and migrant status. Unknown cannot be used to identify race for the WIC Program.
2. Breastfeeding Information - Complete each line in this section, using the following information:
Infant's and Children's Forms through age 2 at each certification:
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 Infant's Form, check "Yes" if this infant was ever breastfed (even if currently not breastfeeding) (2) On Children's Form, check "Yes" if this child was ever breastfed (even if currently not breastfeeding) (3) If the answer is "No", two times for an infant or one time for a child, this question does not need to be asked again.
c. Record the Number of Weeks Infant/Child Breastfed - If the infant/child is currently or ever breastfed, record the number of weeks up to a maximum of 99 weeks (2 years of age). (See the key for entering weeks breastfed in Attachment BF-9, Breastfeeding Section)
d. Date of Most Recent Breastfeeding Response - Record the date on which you asked the participant/guardian/ caregiver about breastfeeding.
Women's Form:
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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). (2) Update the information at time of termination and submit to Convansys.
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 CTIX 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 (for infants and children only).
6. Weight - Enter the weight in pounds and ounces (for infants and children only).
7. Hematological Data Date - Enter the date hematological measurement was taken for certification purposes. Hematological data date must be within 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 field. Values must be
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rounded to one decimal place.
9. Nutrition Risk Criteria - Complete each line in this section using the following procedure: a. Check "Yes" when the nutrition risk criterion is present. b. Check "No" when the risk criterion is not present. c. Write "N/A" when the risk criterion does not apply or was not assessed. d. Record additional documentation for risk criterion. Mark with (*).
This section of the form must be completed by a CPA during each certification appointment and at the infant's mid-certification nutrition assessment.
10. High Risk - Check "Yes" when at least one nutrition risk meets the High Risk Criteria (See Attachment NE-7, Nutrition Education Section).
11. Eligible for WIC - Check "Yes" when all of the following criteria are met:
a. The applicant resides within the State of Georgia b. The applicant is income eligible c. At least one (1) nutrition risk criterion is checked "Yes" d. The applicant is 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.

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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 Assessment
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 Medicaid participation has been confirmed. Medicaid recipients must self declare income.
2. PeachCare Recipients All PeachCare clients must be assessed for WIC income eligibility.
3. Food Stamp Recipients - {See Acceptable Proof of Eligibility-Adjunctive Eligibility (CT-VIII.B.2)} Mark yes (Y) if Food Stamp participation has been confirmed.
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. Computing Income.

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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. Indicate the total number in the family. The Income Calculation Form must be used to determine income eligibility, if the applicant has more than one source of income and does not quality for Medicaid, Food Stamps or TANF. Record current annual income.
Note: Income must be recorded for all applicants, including Medicaid and Food Stamps.
d. Staff Initial The staff person who confirms income, residency and ID maybe different from the person who is signs the form. Therefore the staff who collected this information must enter his/her initials.
e. Staff Signature(s) - The local WIC official signature confirms the income, residency, nutrition medical risk and family size are correct as stated by the applicant/participant. The signature also verifies/witnesses the participant's signature. An appropriate signature consists of first and last name; title of person verifying income.
f. Date - The date must be completed by either the participant, their authorized representative or the attending staff person.
g. Applicant/Participant Signature - The participant, parent/guardian/caretaker, or proxy must be asked to read and sign the following statement each time they are certified (if unable to read, must have it read to them):
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

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intentionally misrepresenting, concealing, or withholding facts may result in paying the State agency, in cash, the value of the food benefits improperly issued to me and may subject me to civil or criminal prosecution under State and Federal law. I understand that the WIC Program may give my certification information to other public health assistance programs to see if my family is eligible for their services. I understand that these agencies may contact me, but they may not give my information to anyone else without asking my permission.
h. 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
Certification Form (Back) Physical Presence If the response is "NO", N, D, R or W must be selected:
(N) Newborn-Infants who are born to a mother who was on WIC during her pregnancy or was eligible to participate but was not certified. The infant must be brought into the clinic prior to two (2) months of age to avoid termination. Medical or high risk condition may not be present.
(D) 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 that meet this standard. Examples of such situations include: a. A medical condition that necessitates the use of medical equipment that is not easily transported. b. A medical condition that requires confinement to bed rest; and c. A serious illness that may be exacerbated by coming into the WIC clinic.
( R) 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 exempt from

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physical presence requirements by the local agency, if unreasonable barriers exist. (W) Working parent or caretakers The local agency may exempt an infant or child from the physical presence requirements:
a. If the infant/child was present for his/her initial WIC certification;
b. If the infant/child was present at a WIC certification within the last year and determined eligible; and
c. If the infant/child is under the care of working parents/guardian whose status presents a barrier to bringing the infant/child into the WIC clinic.
19. Data Needed for Pregnancy Surveillance
Infants' Form:
(1) Mother's WIC ID# - Enter the full 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 = 165.
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 onedigit code to indicate the month of gestation at the first prenatal exam, e.g., 0=No Prenatal Care, 1=1st month, 8=8th or 9th month, 9=unknown.
(4) Last Weight Prior to Delivery - Enter the last weight taken prior to delivery, rounded to the nearest whole pound, e.g. 165 = 166.
20. Verification of Certification (VOC) Card Information (Required)

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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 issuing 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 accepting the card.
VOC Card (Issued within the State) (1) Enter the number of the VOC Card being issued. (2) Issued/Received Box - Place an "I" in the box. (3) Date - Enter the date the card is issued. (4) Signature of WIC Official - The signature of the WIC official issuing the card.

21. Comments (Proxy 1/Proxy 2) This section may be used to maintain a record of proxy names authorized by participants or parents/caretakers at certification. Review names 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 assessed to be ineligible or disqualified for WIC benefits must be notified of ineligibility, in writing. 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).

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When applicants/participants are ineligible or terminated from the program and a NTIWL is issued, they must be informed of their right to a fair hearing. A fair hearing may be requested when program participation is denied or a participant is disqualified for benefits (See Fair Hearing Section in Rights and Obligations).
Local agencies must follow program procedures for "written notification" and "processing standards" whenever an ineligibility/termination decision is made. All procedures followed must be documented in the health record or agency file.
The following notifications shall be made in writing and comply with programmatic time frames:
A. Written Notification
1. Ineligibility - An applicant/participant determined to be ineligible for program benefits on the basis of residence, income, or nutrition risk will receive a Notice of Termination/ Ineligibility/Waiting List Form on site, which states the reason(s) for ineligibility. If the applicant/participant is assessed over the income limits, a copy of the document viewed must be placed in the ineligibility file. These files must be maintained for three years plus current year. A copy of the form will be filed in the individual's health record and/or the ineligibility file (See Attachment CT-15).
Note: Completion of the Fair Hearing Section of the Notice of Termination/ Ineligibility/Waiting List (NTIWL) Form is required.
2. Expiration of Certification Period - Each participant will be notified at least (15) days before the expiration of their certification eligibility period that it 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 benefits end. Reasons for this action and of the right to a fair hearing must be provided. 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 NTIWL Form must be issued to the participant. A copy of this form must be filed in the individual's health record.
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4. Termination Notification - Notification does not need to be provided to persons terminated for failing to pick up vouchers for two consecutive months and failing to return for subsequent certification provided the participant has been given or read the Rights and Obligations.
5. Interim Income Change (Reassessment of Income Eligibility) Individuals will be disqualified at any time during the certification period when family income exceeds eligibility requirements. A fifteen (15) day notice must be issued.
B. Completion of Notice of Termination/Ineligibility/Waiting List Form
1. Fill in applicant's name and the date at the top of the form including the date of birth, phone number, and address.
2. Mark the box with the correct option and check the reason for termination.
3. Complete the information at the bottom of the form regarding the name and address of the WIC Program. The Fair Hearing Section must be completed when using this form. If a stamp is used for this purpose, all copies must be stamped. Appropriate documentation and termination procedures must be followed. A written notice of termination must be given for each member of the family on the program.
C. Ineligibility File
Clinics are required to maintain an ineligibility file. The five items listed below are critical and must be presented when a fair hearing is requested by an applicant or other persons acting 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 NTIWL 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
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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 collected income information). 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 NTIWL Form must be kept in the ineligibility file. If a copy of their NTIWL Form is filed in the ineligibility file, it does not also need to be filed in the health record.

XVII. TRANSFER OF CERTIFICATION
WIC certification is transferable during a valid certification period. A Verification of Certification (VOC) card is the official document for validating WIC certification nationwide. This card allows WIC participants to transfer certification from one clinic, city or state to another.
VOC cards are honored during a waiting list period regardless of priority.
A. Verification of Certification (VOC) Card
The Verification of Certification card is a negotiable instrument used to validate WIC certification. Local agencies must maintain accurate records of issuance, security, and receipt from participants. Local agencies and clinics are responsible for maintaining an inventory of all VOC cards (See Inventory CT-XVII.E.).
Out-of-state participants with a valid VOC card must be placed on the program even if they do not meet Georgia's eligibility criteria. Local agencies must be aware that some states use the combination WIC ID/VOC card and must read all VOC cards carefully. Under no circumstances should a WIC participant transferring into a clinic with a valid VOC card be denied WIC benefits or reassessed for eligibility. Transfers with valid VOC cards or other valid certification evidence (i.e. certification record) must be enrolled immediately. Proxies can not present
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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 additional ID. However, the receiving clinic must verify the documentation with the originating clinic by telephone or written correspondence. The type 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, use the current log, 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 must be written (Do not include codes) 5. Expiration date of certification 6. Printed/typed name of the issuing clerk 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 confirming eligibility 3. Certification date
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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 assessed (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 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. Medical data. 4. Nutrition risk factors. 5. Priority. 6. Assigned food package. 7. Date vouchers were last issued. 8. Date income eligibility was last assessed (migrant farm
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workers only). 9. WIC ID number (Georgia transfers only). 10. Signature of certifying local agency/clinic official. A
signed certification form.
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 they should request a VOC Card if relocating anytime during their eligibility period. All migrant farm workers should 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 NTIWL form must be issued on site, whenever a VOC Card is issued to a participant, with the exception of a migrant participant.
D. Orders
VOC cards can be ordered by the clinic directly from the State or District Office. The District Office shall determine how/when 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

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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 Order Form (Attachment CT-38) must be completed and mailed to: Georgia WIC 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 CT17 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 numbers series must be recorded in the beginning/ending
number columns. 3. The number of VOC cards received. 4. Total number of VOC cards on hand. 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 a 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: 1. The date. 2. The numbers series must be recorded in the beginning/ending
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number columns. 3. Document "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 VOC Cards are issued to the local agency, the following information must be documented (See Attachment CT-18): 1. Date. 2. VOC card numbers series issued (beginning/ending number
columns). 3. Number of cards issued. 4. Name of receiving clinic. 5. Name of clinic representative at the receiving clinic. 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 overseas similar to WIC. 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.
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B. Impact on USDA's WIC Programs

Legislation limits eligibility in the WIC Overseas Program to:
1. Members of the armed forces (and their dependents) on duty at stations outside the U.S. and their dependents
2. Civilians who are employees of a military department (and their dependents) (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.
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Eligibility for the overseas program will be assessed 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.

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. LATE ENTRY CORRECTION OF HEALTH RECORD
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Upon receipt of WIC records from another clinic, review the record for missing information. If information is missing, the receiving clinic may add the missing documentation according to the following procedure:
1. Write the words LATE ENTRY (in caps) in the space where the correction needs to be made.
2. Make the necessary adjustments. 3. Sign your initials and date the change. 4. Any other corrections should be made according to the procedure which
is currently outlined in the Georgia WIC procedures Manual.

XXI. DOCUMENTATION PROCEDURES
1. All WIC documentation must be typed or completed in blue or black nonerasable 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. Do not, under any circumstances, alter WIC vouchers.
"Official WIC documents" include, but are not limited to: WIC Assessment/Certification Forms, ID cards, VOC cards, voucher registers, inventory logs, vouchers, voucher receipts and health records.

XXII. 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.
A. Procedures for Maintaining a Waiting List
1. A waiting list shall be maintained for 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. The waiting list must include the following information to facilitate contacting the applicant when caseload space becomes
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available: 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 CT15).
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 re-established:
1. Only those individuals who are still categorically eligible need to be contacted. All others can be periodically purged from the list.
2. Those persons on the waiting list who are still in a current certification period will be contacted to come to the clinic immediately to receive vouchers. All others will be informed that current medical data is required and must be evaluated before certification will be possible.
3. Applicants will be contacted by phone or letter.

XXIII. PATIENT FLOW ANALYSIS
A Patient Flow Analysis (PFA) is optional and is a tool to analyze the following: 1. The range of time for certification of clients from sign-in to first face-to-face visit where service provided. 2. The range of time for certification of clients from sign-in to exit. 3. The range of time for clients scheduled for issuance of vouchers. 4. Clinic bottlenecks. 5. Whether clients are seen in the order of appointments? 6. Are clients scheduled at a rate appropriate for services received and staff availability? 7. Are there down times for any staff? 8. Are the appropriate staff present for first a.m. appointments?
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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 sign-in 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 (P), postpartum (N) or
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breastfeeding women (B), infant (I) or child (C).
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
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services.
15. Food Package Change (FPC)/Formula Type (optional) Document the FPC or formula type if applicable for District use.
16. Special Services Provided/Comments - Documents any special services or circumstances which may cause you to take additional time with the applicant/participant.
FORM III - QUESTIONS TO ANSWER FROM THE MODIFIED PFA
Questions from the modified PFA are listed on this form to indicate the type of information you can expect to receive from the PFA.
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.

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FORM IV PATIENT CATEGORY FORM
The client category identifies the codes you must use to identify the type of clients you are serving during the PFA.
FORM V - PATIENT REGISTER FORM
The Patient Register Form is to be placed on the record of each participant as they sign in, unless the participant is in the clinic for voucher pick-up only and the record is not routinely pulled. The Patient Register Form documents the following:
1. Patient Number (Should match the number on the sign in sheet). 2. Reason for visit (See Reason for Visit Codes). 3. Patient Category (See Form IV, Patient Category Form). 4. Time of Arrival (Same as sign in sheet). 5. Time of clinic appointment (Same as sign in sheet). 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). 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.
XXIV. SYSTEM INFORMATION MANAGEMENT
One of the goals of the Systems Information Section is to implement a fully integrated health department environment be replacing the WIC Automated TAD and Voucher System (ATVS) with Aegis.
All district/units will at that time, have an integrated system. DHR-IT plans to convert all ATVS and HOST sites to Aegis by late 2003 or early 2004.
Fulton County and Grady M & I will be converted to Aegis in the near future.
XXV. IMMUNIZATION COVERAGE ASSESSMENT

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All WIC agencies are required to coordinate with and refer participants to a variety of allied nutrition and primary health care services including immunization [7 CFR 246.4(a)(8)]. As with all program coordination efforts, the method by which WIC and immunization services are coordinated is a local agency decision. The Georgia WIC 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 level of immunization compliance for infants and children zero (0) to thirty-six (36) months of age. Screening for immunization status begins at two months of age. Currently there are no required immunizations for an infant younger than (2) months old. Hospital certifications are not required to screen for immunization if an assessment is done on an infant younger than two months.
WIC is under federal mandate to screen every child for immunization status at each certification. The immunization status must be recorded in the medical record and/or the computer. The following information must be recorded: was there a documented immunization record; did you request the client to bring in a documented record; is client adequately immunized for age. If the client is not adequately immunized a referral must be made to the health department (H) or to the doctor/ private care provider (D). Clients who fail to bring immunization records to clinic for two (2) consecutive certification visits must be referred to the district immunization coordinator or designee for tracking and follow-up. Local agencies will be routinely monitored to assure documented immunization records are assessed, referrals are being made according to recommendation and that local agencies have an established referral system which minimizes barriers to adequate immunizations. See the Monitoring tool for the tool local agencies will be review on.
XXVI. PROCEDURES FOR PROCESSING A COMPLAINT OR INCIDENT
It is required that all complaints be systematically documented. Every effort should be made to resolve an incident or complaint within twenty hours. Form 3772 (Attachment CT-53) should be used to assure that all required information is captured.

Complete the top left hand portion of the form. This section will capture the District/Unit/Clinic and the county in which the incident occurred. Complete the date of the incident and the date the incident was reported. The follow-up date will be completed later when follow-up is done. If the complaint is identified as a Civil Rights Complaint, refer immediately to the State WIC Office Civil Rights Coordinator.
The top right hand portion of the form is designed to capture the type of complaint. If a participant files a complaint, check participant and complete the
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Person Filing Complaint and Participant Information section. Proceed with the complaint . If a vendor calls with a complaint, check vendor and complete the Vendor Information section on the form and document the complaint.

When recording the incident/complaint, get as much information about the situation as possible. In the absence of electronic signatures type the name of the person taking the incident/complaint. It is necessary for the local agency to document the resolution of the incident/complaint and indicate if the complaint can be closed at the local level. Record the name and title of the person resolving the complaint and the date of the resolution.
If it is necessary for the incident/complaint to be forwarded to State WIC Office the above procedure will apply for state staff. The name of the State WIC Office Customer Service Coordinator or designee and date of follow-up must be documented. This form will be kept on file for three years and the current year.

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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)

DATE

PHYSICAL PRESENCE

Y( ) N( )*

*N ( ) D( )

R( ) W( )

MEDICAID CURRENT Y/N/U

Y( ) N( )

U( )

MEDICAID I.D. NUMBER VERIFY

TANF Y/N/U FOOD STAMPS Y/N/U

COPY AND FILE

Y( ) U( ) Y( )

U( )

N( )

N( )

NO. IN FAMILY

GROSS INCOME (CURRENT/ANNUAL)
C( ) A( ) UP ( )

* See Procedures Manual (CT - Physical Presence) for a list of applicable reasons. (MUST Document in Health Record)

Source of Income Code
UP:

Other (Write in type)

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

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.

Staff Initial
UP: Staff Initial

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 witholding 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 the Immunization Program and 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

UP:

DATA NEEDED FOR PREGNANCY SURVEILLLANCE

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)

Comments: (Date/Sign/Title):

Proxy 1_______________________________________________ Proxy 2___________________________________________
Form 3296P (Rev. 3-04)

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Attachment CT-2

WIC ASSESSMENT/CERTIFICATION FORM POST PARTUM BREASTFEEDING (FRONT)

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Attachment CT-2

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

FIRST CERTIFICATION

PHYSICAL

MEDICAID

DATE PRESENCE

CURRENT Y/N/U

Y( )

Y( )

U( )

N( )*

N( )

*N ( ) R ( )

D ( ) W( )

MEDICAID I.D. NUMBER VERIFY

TANF Y/N/U FOOD STAMPS Y/N/U

COPY AND FILE

Y( ) U( ) Y( )

U( )

N( )

N( )

NO. IN FAMILY