GA WIC 2005 procedures manual, GA state plan [2005]

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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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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Introduction

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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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

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?

Staff Initial

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

Check Here if Only One Income Reported ( )

UP:

Staff Initial

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

SECOND CERTIFICATION

PHYSICAL

MEDICAID

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

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.

SIGNATURE OF WIC OFFICIAL

PARENT/GUARDIAN/CAREGIVER SIGNATURE

DATE

UP:

UP:

DATA NEEDED FOR PREGNANCY SURVEILLANCE

Marital Status

(0=Married 1=Not Married

9=Unknown)

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

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

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

Comments: (Date/Sign/Title):

Proxy 1_______________________________________________
Form 3296B (Rev. 3-04)

Proxy 2___________________________________________
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Attachment CT-3

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

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Attachment CT-3 (cont'd)

WIC ASSESSMENT/CERTIFICATION FORM POST PARTUM NON BREASTFEEDING (BACK)

INCOME DETERMINATION (income must be documented)

FIRST CERTIFICATION
PHYSICAL DATE PRESENCE
Y( ) N( )* *N ( ) R ( ) D ( ) 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?

Staff Initial

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

Check Here if Only One Income Reported ( )

UP:

Staff Initial

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

I have been advised of my rights and obligations under the Program. I certify that the information I will provide, or have provided is correct, to the best of my knowledge. The income I have given is my total gross household income (all cash income before deductions). This certification form is being submitted in connection with the receipt of Federal assistance. Program officials may verify information on this form. I understand that intentionally making a false or misleading statement or intentionally misrepresenting, concealing, or 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 SURVEILLANCE

Marital Status

(0=Married 1=Not Married

9=Unknown)

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

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

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

Comments: (Date/Sign/Title):
Proxy 1 _____________________________________
Form 3296N (Rev. 3-04)

Proxy 2 ______________________________________
CT-75

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-4

WIC ASSESSMENT/CERTIFICATION FORM INFANT (FRONT)

CT-76

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-4 (cont'd)

WIC ASSESSMENT/CERTIFICATION FORM INFANT (BACK)

INCOME DETERMINATION (income must be documented)

DATE

PHYSICAL PRESENCE

Y( )

N( )*

*N ( ) D( )

R( ) W( )

MEDICAID CURRENT Y/N/U

Y( )

U( )

N( )

MEDICAID I.D. NUMBER VERIFY

TANF
Y( ) N( )

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

COPY AND FILE

U( ) Y( )

U( )

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:

IMMUNIZATION STATUS

Record Screened ( )

No Record ( ) Record Requested ( )

Adequate for age Date ________________________________________ Referred to __________________________________ Referred for follow-up _________________________ (Subsequent visit date)__________________________

Comments: (Date/Sign/Title):

Proxy 1 ______________________________________________
Form 3299 (Rev. 3-04)

Proxy 2 _______________________________________

CT-77

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-5

WIC ASSESSMENT/CERTIFICATION FORM CHILDREN (FRONT)

CT-78

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-5 (cont'd)

WIC ASSESSMENT/CERTIFICATION FORM CHILDREN (BACK)

CT-79

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-6

SIGNED STATEMENT OF INCOME, RESIDENCY AND IDENTIFICATION

I,
Parent/Guardian

, cannot come in to apply for WIC for my

child(ren)

Name(s)

. I have given permission to

Proxy Name

to file my application.

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

("Family"

Parent, Guardian or Caretaker's Signature

_______________________________
Date

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

"This institution is an equal opportunity provider."

CT-80

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-7

DATA AND DOCUMENTATION REQUIRED FOR WIC ASSESSMENT AND CERTIFICATION

WOMEN

Data
Height
Pre-Pregnancy Weight Current Weight Last Weight Before Delivery

Prenatal Women
Required
Required Required
N/A

Woman Certified in Hospital Prior to Initial Discharge

Breastfeeding and Non-
Breastfeeding Postpartum
Women Certified in Clinic

Pre-pregnancy height from health
record; self reported if not available from
record Pre-pregnancy weight required from health record; self reported if not available from
record
If available

Required
Required Required

Required

Required

Breastfeeding Woman
Certified in Clinic >6 months
Postpartum
Required
Required
Required Required

Hematocrit or Hemoglobin

Required

Required
(apply 90-day rule when not available)

Required

Optional

Prenatal Weight Grid

Required

N/A

N/A

N/A

Dietary Intake and Summary

Required

Required

Required

Required

Dietary Evaluation
Risk Factor Assessment

Required Required

Required Required

Required Required

Required Required

Note:

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

CT-81

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-8

DATA AND DOCUMENTATION REQUIRED FOR WIC ASSESSMENT/CERTIFICATION

INFANTS

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

Infant Certified in Hospital Prior to Initial Discharge
Birth Data or other measurement
Birth Data or other measurement
N/A

Documentation
Infant 0-6 Months Required
Required
Optional

Optional Optional Optional Optional Optional Required

Required Required Required Required Required Required

Infant 6-12 Months
Required
Required
Required (9-12 months)
Required
Required
Required
Required
Required Required

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

CT-82

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-9

DATA AND DOCUMENTATION REQUIRED FOR WIC ASSESSMENT/CERTIFICATION

CHILDREN

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

Documentation Required Required Required Required Required Required
Required Required Required

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

CT-83

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-10

NUTRITION RISK CRITERIA PRENATAL WOMEN

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

CODE

201 LOW HGB/HCT

1st Trimester (0-13 weeks): Non-Smokers Smokers

Hemoglobin
10.9 gm or lower 11.2 gm or lower

Hematocrit
32.9% or lower 33.9% or lower

PRIORITY I

2nd Trimester (14-26 weeks):

Non-Smokers

10.4 gm or lower

Smokers

10.7 gm or lower

31.9% or lower 32.9% or lower

3rd Trimester (27-40 weeks):

Non-Smokers

10.9 gm or lower

Smokers

11.2 gm or lower

32.9% or lower 33.9% or lower

High Risk: Hemoglobin OR hematocrit at treatment level

101 PRE-PREGNANCY UNDERWEIGHT

I

Pre-pregnancy Body Mass Index (BMI) is <19.8. Refer to BMI Table, Attachment CT-29.

High Risk: Pre-pregnancy BMI <19.8.

111 PRE-PREGNANCY OVERWEIGHT

I

Pre-pregnancy BMI is >26. Refer to BMI Table, Attachment CT-29.

High Risk: Pre-pregnancy BMI >29.

CT-84

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-10 (cont'd)

CODE

PRIORITY

131 LOW GESTATIONAL WEIGHT GAIN

I

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

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

132 GESTATIONAL WEIGHT LOSS DURING PREGNANCY

I

During first trimester (0-13 weeks), any weight loss below prepregnancy weight; based on pre-pregnancy weight and current weight.

OR

During second and third trimesters (14-40 weeks gestation), >2 pounds weight loss; based on two weight measures recorded at 14 weeks gestation or later.

Document: Two weight measures, as specified above.

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

133 HIGH GESTATIONAL WEIGHT GAIN

I

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

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

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

current weight - previous weight x 4.3

# weeks between the two weights

211 ELEVATED BLOOD LEAD LEVELS

I

Blood lead level 10 g/

Document: Date of blood test and blood lead level in the participant's health record. Must be within the past 6 months

High Risk: Blood lead level 10 g/deciliter.

CT-85

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-10 (cont'd)

CODE

PRIORITY

301 HYPEREMESIS GRAVIDARUM

I

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

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

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

High Risk: Diagnosed hyperemesis gravidarum.

302 GESTATIONAL DIABETES

I

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

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

High Risk: Diagnosed gestational diabetes.

303 HISTORY OF GESTATIONAL DIABETES

I

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

Document: Pregnancy or pregnancies when gestational diabetes was diagnosed.

311 DELIVERY OF PREMATURE INFANT(S)

I

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

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

312 HISTORY OF LOW BIRTH WEIGHT INFANT(S)

I

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

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

CT-86

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-10 (cont'd)

CODE

PRIORITY

321 HISTORY OF FETAL OR NEONATAL DEATH

I

Any fetal deaths (death >20 weeks gestation) or neonatal deaths (death occurring from 0-28 days of life.

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

331 PREGNANCY AT A YOUNG AGE

I

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

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

High Risk: EDC at less than 17 years of age.

332 CLOSELY SPACED PREGNANCIES

I

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

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

333 HIGH PARITY AND YOUNG AGE

I

The following two (2) conditions must both apply:

1. The woman is under age 20 at date of conception, AND

2. She has had 3 or more previous pregnancies of at least 20 weeks duration, regardless of birth outcome.

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

334 LACK OF, OR INADEQUATE PRENATAL CARE

I

Prenatal care beginning after the 1st trimester (0 13 weeks gestation).

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

335 MULTI-FETAL GESTATION

I

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

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

High Risk: Multi-fetal gestation.

336 FETAL GROWTH RESTRICTION

I

CT-87

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-10 (cont'd)

CODE

PRIORITY

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

Document: Diagnosis in participant's health record.

337 HISTORY OF BIRTH OF A LARGE FOR GESTATIONAL AGE INFANT

I

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

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

338 PREGNANT WOMAN CURRENTLY BREASTFEEDING

I

Breastfeeding woman who is now pregnant.

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

339 HISTORY OF BIRTH WITH NUTRITION RELATED CONGENITAL OR

I

BIRTH DEFECT(S)

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

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

341 NUTRIENT DEFICIENCY DISEASES

I

Diagnosis of clinical signs of nutrient deficiencies or a disease caused by insufficient dietary intake of macro- and micro-nutrients. Diseases include, but are not limited to, protein energy malnutrition, scurvy, rickets, beriberi, hypocalcemia, osteomalacia, vitamin K deficiency, pellagra, cheilosis, menkes disease, xerothalmia. (See Attachment CT-31)

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

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

High Risk: Diagnosed nutrient deficiency disease.

342 GASTRO-INTESTINAL DISORDERS

I

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

CT-88

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-10 (cont'd)

CODE bowel disease (including ulcerative colitis and Crohn's disease).

PRIORITY

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

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

High Risk: Diagnosed gastro-intestinal disorder.

343 DIABETES MELLITUS

I

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

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

High Risk: Diagnosed diabetes mellitus.

344 THYROID DISORDERS

I

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

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

High Risk: Diagnosed thyroid disorder.

345 HYPERTENSION

I

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

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

High Risk: Diagnosed hypertension.

346 RENAL DISEASE

I

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

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

CT-89

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-10 (cont'd)

CODE

PRIORITY

High Risk: Diagnosed renal disease.

347 CANCER

I

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

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

High Risk: Diagnosed cancer.

348 CENTRAL NERVOUS SYSTEM DISORDERS

I

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

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

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

High Risk: Diagnosed central nervous system disorder.

349 GENETIC AND CONGENITAL DISORDERS

I

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

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

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

High Risk: Diagnosed genetic/congenital disorder.

CT-90

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-10 (cont'd)

CODE

PRIORITY

351 INBORN ERRORS OF METABOLISM

I

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

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

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

High Risk: Diagnosed inborn error of metabolism.

352 INFECTIOUS DISEASES

I

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

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

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

High Risk: Diagnosed infectious disease, as described above.

353 FOOD ALLERGIES

I

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

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

High Risk: Diagnosed food allergy.

CT-91

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-10 (cont'd)

CODE

PRIORITY

354 CELIAC DISEASE

I

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

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

High Risk: Diagnosed celiac disease.

355 LACTOSE INTOLERANCE

I

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

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

High Risk: Lactose intolerance.

356 HYPOGLYCEMIA

I

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

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

High Risk: Diagnosed hypoglycemia.

357 DRUG NUTRIENT INTERACTIONS

I

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

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

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

358 EATING DISORDERS

I

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

CT-92

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-10 (cont'd)

CODE

PRIORITY

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

High Risk: Diagnosed eating disorder.

359 RECENT MAJOR SURGERY, TRAUMA OR BURNS

I

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

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

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

360 OTHER MEDICAL CONDITIONS

I

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

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

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

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

361 DEPRESSION

I

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

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

CT-93

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-10 (cont'd)

CODE

PRIORITY

362 DEVELOPMENTAL, SENSORY OR MOTOR DELAYS INTERFERING

I

WITH THE ABILITY TO EAT

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

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

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

371 MATERNAL SMOKING

I

Daily smoking of cigarettes, pipes or cigars.

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

372 ALCOHOL USE

I

Any alcohol use:

A standard serving of a drink containing alcohol (12 ounces of alcohol) is: 1 can or bottle of beer (12 fluid ounces) 5 ounces of wine 1 2 fluid ounces of liquor

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

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

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

373 STREET DRUG USE

I

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

Document: Type of drug(s) being used.

CT-94

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-10 (cont'd)

CODE

PRIORITY

381 DENTAL PROBLEMS

I

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

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

422 INADEQUATE DIETARY PATTERN

IV

1. Any food group missing, based on the Recommended Daily Servings Chart (Attachment CT-32).
2. Failure to meet the recommended number of servings from two (2) food groups.
3. Practice of two (2) inappropriate food practices, based on the Inappropriate Food Practices List (Attachment CT-33).
4. The practice of one (1) inappropriate food practice and the failure to meet the recommended number of servings from one (1) food group.

801 HOMELESSNESS

IV

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

802 MIGRANCY

IV

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

901 RECIPIENT OF ABUSE

IV

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

Battering refers to violent assaults on women.

902 PRENATAL WOMAN WITH LIMITED ABILITY TO MAKE FEEDING

IV

DECISIONS AN/OR PREPARE FOOD

Woman who is assessed to have limited ability to make appropriate feeding decisions and/or prepare food. Examples may include:
mental disability/delay, and/or a mental illness such as clinical depression (diagnosed by a physician or licensed psychologist).
physical disability which restricts or limits food preparation abilities
current use of or history of abusing alcohol or other drugs.

Document: The woman's specific limited abilities; in the participant's health record.
CT-95

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-10 (cont'd)

CODE

PRIORITY

502 TRANSFER OF CERTIFICATION

IV

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

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

CT-96

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-11

NUTRITION RISK CRITERIA POSTPARTUM, BREASTFEEDING WOMEN

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

201 LOW HGB/HCT Non-Smokers:

CODE

PRIORITY

I

Hemoglobin: 11.9 gm or lower (> 15 years of age) 11.7 gm or lower (< 15 years of age)
Hematocrit: 35.8% or lower

Smokers:

Hemoglobin: 12.2 gm or lower (> 15 years of age) 12.0 gm or lower (< 15 years of age)
Hematocrit: 36.8% or lower

High Risk: Hemoglobin OR hematocrit at treatment level.

101 UNDERWEIGHT

I

< 6 months Postpartum:

Pre-pregnancy Body Mass Index (BMI) is <18.5. Refer to BMI Table Attachment CT-30.

High Risk: Pre-pregnancy BMI <18.5

> 6 months Postpartum:

Current Body Mass Index (BMI) is <18.5. Refer to BMI Table Attachment CT-30.

High Risk: Current BMI <18.5

111 OVERWEIGHT

I

< 6 months Postpartum:

Pre-pregnancy Body Mass Index (BMI) is >24.9. Refer to BMI Table Attachment CT-30.

High Risk: Pre-pregnancy BMI >29

> 6 months Postpartum:

Current Body Mass Index (BMI) is >24.9. Refer to BMI Table Attachment CT-30.

High Risk: Current BMI >29.9.

CT-97

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-11 (cont'd)

CODE

PRIORITY

133 HIGH GESTATIONAL WEIGHT GAIN

I

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

Pre-Pregnancy Weight Group

Cut-Off Value

Underweight Normal Weight Overweight Obese

(BMI <19.8) (BMI 19.8 - 26.0) (BMI 26.1 29.0) (BMI >29.0)

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

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

211 ELEVATED BLOOD LEAD LEVELS

I

Blood lead level 10 g/

Document: Date of blood test and blood lead level in the participant's health record. Must be within the past 6 months.

High Risk: Blood lead level 10 g/deciliter.

303 GESTATIONAL DIABETES (Most Recent Pregnancy)

I

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

Document: Diagnosis in the participant's health record.

311 DELIVERY OF PREMATURE INFANT(S)

I

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

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

312 DELIVERY OF LOW BIRTH WEIGHT INFANT(S)

I

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

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

321 FETAL OR NEONATAL DEATH

I

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

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

CT-98

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-11 (cont'd)

CODE

PRIORITY

331 PREGNANCY AT A YOUNG AGE

I

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

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

332 CLOSELY SPACED PREGNANCIES

I

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

Document: Termination dates of last two pregnancies in the participant's health record.

333 HIGH PARITY AND YOUNG AGE

I

The following two (2) conditions must both apply:

1. The woman was under age 20 at date of conception for most recent pregnancy, AND

2. She has had 3 or more pregnancies of at least 20 weeks duration (regardless of birth outcome), previous to the most recent pregnancy

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

335 MULTIFETAL GESTATION

I

Had greater than one fetus in most recent pregnancy.

High Risk: Multi-fetal gestation.

337 BIRTH OF A LARGE FOR GESTATIONAL AGE INFANT

I

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

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

339 BIRTH OF INFANT WITH NUTRITION RELATED CONGENITAL OR

I

BIRTH DEFECT(S)

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

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

CT-99

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-11 (cont'd)

CODE

PRIORITY

341 NUTRIENT DEFICIENCY DISEASES

I

Diagnosis of clinical signs of nutrient deficiencies or a disease caused by insufficient dietary intake of macro- and micro-nutrients. Diseases include, but are not limited to, protein energy malnutrition, scurvy, rickets, beriberi, hypocalcemia, osteomalacia, vitamin K deficiency, pellagra, cheilosis, menkes disease, xerothalmia. (See Attachment CT-31).

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

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

High Risk: Diagnosed nutrient deficiency disease.

342 GASTRO-INTESTINAL DISORDERS

I

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

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

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

High Risk: Diagnosed gastro-intestinal disorder.

343 DIABETES MELLITUS

I

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

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

High Risk: Diagnosed diabetes mellitus.

CT-100

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-11 (cont'd)

CODE

PRIORITY

344 THYROID DISORDERS

I

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

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

High Risk: Diagnosed thyroid disorder.

345 HYPERTENSION

I

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

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

High Risk: Diagnosed hypertension.

346 RENAL DISEASE

I

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

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

High Risk: Diagnosed renal disease.

347 CANCER

I

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

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

High Risk: Diagnosed cancer.

CT-101

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-11 (cont'd)

CODE

PRIORITY

348 CENTRAL NERVOUS SYSTEM DISORDERS

I

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

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

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

High Risk: Diagnosed central nervous system disorder.

349 GENETIC AND CONGENITAL DISORDERS

I

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

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

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

High Risk: Diagnosed genetic/congenital disorder.

351 INBORN ERRORS OF METABOLISM

I

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

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

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

High Risk: Diagnosed inborn error of metabolism.

CT-102

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-11 (cont'd)

CODE

PRIORITY

352 INFECTIOUS DISEASES

I

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

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

High Risk: Diagnosed infectious disease, as described above.

353 FOOD ALLERGIES

I

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

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

High Risk: Diagnosed food allergy.

354 CELIAC DISEASE

I

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

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

High Risk: Diagnosed celiac disease.

355 LACTOSE INTOLERANCE

I

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

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

High Risk: Lactose intolerance.

CT-103

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-11 (cont'd)

CODE

PRIORITY

356 HYPOGLYCEMIA

I

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

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

High Risk: Diagnosed hypoglycemia.

357 DRUG NUTRIENT INTERACTIONS

I

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

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

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

358 EATING DISORDERS

I

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

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

High Risk: Diagnosed eating disorder.

359 RECENT MAJOR SURGERY, TRAUMA OR BURNS

I

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

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

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

CT-104

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-11 (cont'd)

CODE

PRIORITY

360 OTHER MEDICAL CONDITIONS

I

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

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

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

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

361 DEPRESSION

I

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

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

362 DEVELOPMENTAL, SENSORY OR MOTOR DELAYS INTERFERING

I

WITH THE ABILITY TO EAT

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

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

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

371 MATERNAL SMOKING

I

Daily smoking of cigarettes, pipes or cigars.

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

CT-105

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-11 (cont'd)

CODE

PRIORITY

372 ALCOHOL USE

I

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

A standard serving of a drink containing alcohol (1 2 ounces of alcohol) is: 1 can or bottle of beer (12 fluid ounces) 5 ounces of wine 1 2 fluid ounces of liquor

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

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

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

373 STREET DRUG USE

I

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

Document: Type of drug(s) being used.

381 DENTAL PROBLEMS

I

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

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

422 INADEQUATE DIETARY PATTERN

IV

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

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

3. Practice of two (2) inappropriate food practices, based on the Inappropriate Food Practices List (Attachment CT-33).

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

CT-106

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-11 (cont'd)

CODE

PRIORITY

501 POSSIBILITY OF REGRESSION

I, IV

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

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

Regression cannot be used for the initial certification period.

601 BREASTFEEDING AN INFANT AT NUTRITIONAL RISK

I, II, IV

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

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

602 BREASTFEEDING COMPLICATIONS OR POTENTIAL

I

COMPLICATIONS

A breastfeeding woman with any of the following complications or potential Complications for breastfeeding:
Severe breast engorgement Recurrent plugged ducts Mastitis Flat or inverted nipples Cracked, bleeding or severely sore nipples Age >40 years Failure of milk to come in by 4 days postpartum Tandem nursing (nursing two siblings who are not twins)

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

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

801 HOMELESSNESS

IV

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

802 MIGRANCY

IV

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

CT-107

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-11 (cont'd)

CODE

PRIORITY

901 RECIPIENT OF ABUSE

IV

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

Battering refers to violent assaults on women.

902 BREASTFEEDING WOMAN WITH LIMITED ABILITY TO MAKE

IV

FEEDING DECISIONS AN/OR PREPARE FOOD

Woman who is assessed to have limited ability to make appropriate feeding decisions and/or prepare food. Examples may include:
mental disability/delay, and/or a mental illness such as clinical depression (diagnosed by a physician or licensed psychologist).
physical disability which restricts or limits food preparation abilities
current use of or history of abusing alcohol or other drugs.

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

502 TRANSFER OF CERTIFICATION

IV

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

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

CT-108

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-12

NUTRITIONAL RISK CRITERIA POSTPARTUM, NON-BREASTFEEDING WOMEN

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

201 LOW HGB/HCT Non-Smokers:
Smokers:

CODE

Hemoglobin: Hematocrit: Hemoglobin: Hematocrit:

11.9 gm or lower (> 15 years of age) 11.7 gm or lower (< 15 years of age) 35.8% or lower
12.2 gm or lower (> 15 years of age) 12.0 gm or lower (< 15 years of age) 36.8% or lower

PRIORITY VI

High Risk: Hemoglobin OR hematocrit at treatment level

101 UNDERWEIGHT

VI

Pre-pregnancy Body Mass Index (BMI) is <18.5. Refer to BMI Table Attachment CT-30.

High Risk: Pre-pregnancy BMI <18.5

111 OVERWEIGHT

VI

Pre-pregnancy Body Mass Index (BMI) is >24.9. Refer to BMI Table Attachment CT-30.

High Risk: Pre-pregnancy BMI >29.9

133 HIGH GESTATIONAL WEIGHT GAIN

VI

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

Pre-Pregnancy Weight Group

Cut-Off Value

Underweight Normal Weight Overweight Obese

(BMI <19.8) (BMI 19.8 - 26.0) (BMI 26.1 29.0) (BMI >29.0)

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

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

303 GESTATIONAL DIABETES (Most Recent Pregnancy)

VI

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

Document: Diagnosis in the participant's health record.

CT-109

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-12 (cont'd)

CODE

PRIORITY

311 DELIVERY OF PREMATURE INFANT(S)

VI

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

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

312 DELIVERY OF LOW BIRTH WEIGHT INFANT(S)

VI

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

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

321 FETAL OR NEONATAL DEATH

VI

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

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

331 PREGNANCY AT A YOUNG AGE

III

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

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

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

333 HIGH PARITY AND YOUNG AGE

VI

The following two (2) conditions must both apply:

1. The woman was under age 20 at date of conception for most recent pregnancy, AND

2. She has had 3 or more pregnancies of at least 20 weeks duration (regardless of birth outcome), previous to the most recent pregnancy

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

335 MULTIFETAL GESTATION

VI

Had greater than one fetus in most recent pregnancy.

High Risk: Multi-fetal gestation.

CT-110

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-12 (cont'd)

CODE

PRIORITY

337 BIRTH OF A LARGE FOR GESTATIONAL AGE INFANT

VI

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

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

339 BIRTH OF INFANT WITH NUTRITION RELATED CONGENITAL OR

VI

BIRTH DEFECT(S)

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

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

341 NUTRIENT DEFICIENCY DISEASES

VI

Diagnosis of clinical signs of nutrient deficiencies or a disease caused by insufficient dietary intake of macro- and micronutrients. Diseases include, but are not limited to, protein energy malnutrition, scurvy, rickets, beriberi, hypocalcemia, osteomalacia, vitamin K deficiency, pellagra, cheilosis, menkes disease, xerothalmia. (See Attachment CT-31)

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

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

High Risk: Diagnosed nutrient deficiency disease.

342 GASTRO-INTESTINAL DISORDERS

VI

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

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

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

High Risk: Diagnosed gastro-intestinal disorder.

CT-111

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-12 (cont'd)

CODE

PRIORITY

343 DIABETES MELLITUS

VI

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

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

High Risk: Diagnosed diabetes mellitus.

344 THYROID DISORDERS

VI

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

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

High Risk: Diagnosed thyroid disorder.

345 HYPERTENSION

VI

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

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

High Risk: Diagnosed hypertension.

346 RENAL DISEASE

VI

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

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

High Risk: Diagnosed renal disease.

CT-112

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-12 (cont'd)

CODE

PRIORITY

347 CANCER

VI

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

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

High Risk: Diagnosed cancer.

348 CENTRAL NERVOUS SYSTEM DISORDERS

VI

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

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

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

High Risk: Diagnosed central nervous system disorder.

349 GENETIC AND CONGENITAL DISORDERS

VI

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

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

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

High Risk: Diagnosed genetic/congenital disorder.

CT-113

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-12 (cont'd)

CODE

PRIORITY

351 INBORN ERRORS OF METABOLISM

VI

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

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

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

High Risk: Diagnosed inborn error of metabolism.

352 INFECTIOUS DISEASES

VI

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

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

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

High Risk: Diagnosed infectious disease, as described above.

353 FOOD ALLERGIES

VI

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

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

High Risk: Diagnosed food allergy.

CT-114

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-12 (cont'd)

CODE

PRIORITY

354 CELIAC DISEASE

VI

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

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

High Risk: Diagnosed celiac disease.

355 LACTOSE INTOLERANCE

VI

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

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

High Risk: Lactose intolerance.

356 HYPOGLYCEMIA

VI

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

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

High Risk: Diagnosed hypoglycemia.

357 DRUG NUTRIENT INTERACTIONS

VI

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

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

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

CT-115

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-12 (cont'd)

CODE

PRIORITY

358 EATING DISORDERS

VI

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

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

High Risk: Diagnosed eating disorder.

359 RECENT MAJOR SURGERY, TRAUMA OR BURNS

VI

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

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

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

360 OTHER MEDICAL CONDITIONS

VI

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

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

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

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

CT-116

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-12 (cont'd)

CODE

PRIORITY

361 DEPRESSION

VI

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

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

362 DEVELOPMENTAL, SENSORY OR MOTOR DELAYS INTERFERING

VI

WITH THE ABILITY TO EAT

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

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

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

372 ALCOHOL USE

VI

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

A standard serving of a drink containing alcohol (1 2 ounces of alcohol) is: 1 can or bottle of beer (12 fluid ounces) 5 ounces of wine 1 2 fluid ounces of liquor

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

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

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

373 STREET DRUG USE

VI

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

Document: Type of drug(s) being used.

CT-117

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-12 (cont'd)

CODE

PRIORITY

381 DENTAL PROBLEMS

VI

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

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

422 INADEQUATE DIETARY PATTERN

VI

1. Any food group missing, based on the Recommended Daily Servings Chart (Attachment CT-32).
2. Failure to meet the recommended number of servings from two (2) food groups.
3. Practice of two (2) inappropriate food practices, based on the Inappropriate Food Practices List (Attachment CT-33).
4. The practice of one (1) inappropriate food practice and the failure to meet the recommended number of servings from one (1) food group.

501 POSSIBILITY OF REGRESSION

VI

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

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

Regression cannot be used for the initial certification period.

801 HOMELESSNESS

VI

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

802 MIGRANCY

VI

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

901 RECIPIENT OF ABUSE

VI

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

Battering refers to violent assaults on women.

CT-118

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-12 (cont'd)

CODE

PRIORITY

902 POSTPARTUM, NON-BREASTFEEDING WOMAN WITH LIMITED

VI

ABILITY TO MAKE FEEDING DECISIONS AN/OR PREPARE FOOD

Woman who is assessed to have limited ability to make appropriate feeding decisions and/or prepare food. Examples may include:
mental disability/delay, and/or a mental illness such as clinical depression (diagnosed by a physician or licensed psychologist).
physical disability which restricts or limits food preparation abilities
current use of or history of abusing alcohol or other drugs.

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

502 TRANSFER OF CERTIFICATION

VI

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

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

CT-119

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-13

NUTRITIONAL RISK CRITERIA INFANT

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

CODE

PRIORITY

201 LOW HGB/HCT

I

Hemoglobin: 10.9 gm or lower (6-11 month old)

Hematocrit: 32.8% or lower (6-11 month old)

High Risk: Hematocrit/Hemoglobin at treatment level

103 UNDERWEIGHT

I

Less than or equal to the 10th percentile weight for length, based on Centers for Disease Control and Prevention (CDC) age/sex specific growth charts.

High Risk: Weight for length < 5th percentile

121 SHORT STATURE

I

Less than or equal to the 10th percentile length for age based on CDC age/sex specific growth charts.

High Risk: Length for age < 5th percentile

134 FAILURE TO THRIVE

I

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

Document: Diagnosis in the participant's health record

High Risk: Diagnosed failure to thrive

CT-120

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-13 (cont'd)

CODE

PRIORITY

135 INADEQUATE GROWTH

I

An inadequate rate of weight gain as defined below:

Infants being certified during period from birth to 1 month of age: Excessive weight loss after birth: in the first week of life, weight loss of greater than pound OR >8% (below birth weight) Percent Weight Loss = (birth weight current weight) birth weight x 100 Not back to birth weight by 2 weeks of age A gain of less than 19 ounces by 1 month of age

Note: The average infant should, at minimum, regain birth weight by 2 weeks of age, then gain 4 ounces per week in the next two weeks.

Infants being certified during period from 1 to 5 months of age:

This assessment is optional, if an infant who is >1 month but <5 months of age qualifies for WIC based on any other risk factor.
If there is no other reason to qualify the infant, use the following information to determine eligibility:

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

Minimum Acceptable Weight Gain
19 ounces 27 oz/month (6 oz/wk) 19 oz/month (4 oz/wk) 17 oz/month (4 oz/wk) 15 oz/month (3 oz/wk) 13 oz/month (3 oz/wk)

Infants 6 months to 12 months of age:

Age in Months at Certification 5 mos - 6 mos > 6 mos - 9 mos > 9 mos - 12 mos

Weight Gain per 6-Month Interval*
< 7 lbs < 5 lbs < 3 lbs

*Note: Use this chart only for infants who are > 5 months 2 weeks of age. Use only for an interval of 6 months +/- 2 weeks.

High Risk: Inadequate growth.

141 LOW BIRTH WEIGHT

I

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

Document: Birth weight in participant's health record.

High Risk: Birth weight < 5 lbs 8 oz (< 2500 gms).

142 PREMATURITY

I

Infant born at 37 weeks gestation or less

Document: Weeks gestation in participant's health record.

CT-121

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-13 (cont'd)

CODE

PRIORITY

153 LARGE FOR GESTATIONAL AGE

I

Greater than or equal to 90th percentile weight for gestational age at birth, OR > 9 pounds, OR large for gestational age diagnosed by a physician as self-reported by caregiver; or as reported or documented by a physician, or health care professional working under orders of a physician.

Document: Weight of infant OR diagnosis; in participant's health record.

211 ELEVATED BLOOD LEAD LEVELS

I

Blood lead level of >10 g/deciliter

Document: Date of blood test and blood lead level in the participant's health record. Must be within the past 6 months.

High Risk: Blood lead level of >10 g/deciliter.

NUTRITION RELATED MEDICAL CONDITIONS

I

341 NUTRIENT DEFICIENCY DISEASES

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

The presence of nutrient deficiency diseases diagnosed by a physician, as self-reported by caregiver; or as reported or documented by a physician, or health professional acting under orders of a physician.

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

High Risk: Diagnosed nutrient deficiency disease.

342 GASTRO-INTESTINAL DISORDERS

I

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

The presence of gastro-intestinal disorders The presence of nutrient deficiency diseases diagnosed by a physician, as self-reported by caregiver; or as reported or documented by a physician, or health professional acting under orders of a physician.

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

High Risk: Diagnosed gastro-intestinal disorder.

CT-122

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-13 (cont'd)

CODE

PRIORITY

343 DIABETES MELLITUS

I

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

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

High Risk: Diagnosed diabetes mellitus.

344 THYROID DISORDERS

I

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

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

High Risk: Diagnosed thyroid disorder.

345 HYPERTENSION

I

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

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

High Risk: Diagnosed hypertension.

346 RENAL DISEASE

I

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

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

High Risk: Diagnosed renal disease.

347 CANCER

I

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

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

High Risk: Diagnosed cancer.

CT-123

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-13 (cont'd)

CODE

PRIORITY

348 CENTRAL NERVOUS SYSTEM DISORDERS

I

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

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

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

High Risk: Diagnosed central nervous system disorder.

349 GENETIC AND CONGENITAL DISORDERS

I

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

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

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

High Risk: Diagnosed genetic/congenital disorder.

350 PYLORIC STENOSIS

I

Gastrointestinal obstruction with abnormal gastrointestinal function, affecting nutritional status.

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

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

High Risk: Diagnosed pyloric stenosis.

CT-124

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-13 (cont'd)

CODE

PRIORITY

351 INBORN ERRORS OF METABOLISM

I

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

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

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

High Risk: Diagnosed inborn error of metabolism.

352 INFECTIOUS DISEASES

I

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

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

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

High Risk: Diagnosed infectious disease, as described above.

353 FOOD ALLERGIES

I

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

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

High Risk: Diagnosed food allergy.

354 CELIAC DISEASE

I

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

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

High Risk: Diagnosed celiac disease.

CT-125

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-13 (cont'd)

CODE

PRIORITY

355 LACTOSE INTOLERANCE

I

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

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

High Risk: Lactose intolerance.

356 HYPOGLYCEMIA

I

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

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

High Risk: Diagnosed hypoglycemia.

357 DRUG NUTRIENT INTERACTIONS

I

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

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

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

359 RECENT MAJOR SURGERY, TRAUMA OR BURNS

I

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

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

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

360 OTHER MEDICAL CONDITIONS

I

Diseases or conditions with nutritional implications that are not included in any of the above medical conditions. The current condition, or treatment for the condition, MUST be severe enough to affect nutritional status.

CT-126

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-13 (cont'd)

CODE
Includes, but is not limited to: juvenile rheumatoid arthritis (JRA), lupus erythematosus, cardiorespiratory diseases, heart disease, cystic fibrosis, moderate persistent or severe asthma.

PRIORITY

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

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

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

362 DEVELOPMENTAL, SENSORY OR MOTOR DELAYS INTERFERING

I

WITH THE ABILITY TO EAT

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

Presence of developmental, sensory or motor delay diagnosed by a physician, as self reported by caregiver; or as reported or documented by a physician, or health professional acting under orders of a physician.

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

High Risk: Developmental, sensory or motor delay interfering with ability to eat.

381 DENTAL PROBLEMS

I

Diagnosis of dental problems by a physician or health care provider working under orders of a physician, or adequate documentation by the competent professional authority. Includes, but is not limited to:
Presence of nursing bottle caries
Smooth surface decay of the maxillary anterior and the primary molars

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

382 FETAL ALCOHOL SYNDROME

I

Fetal alcohol syndrome (FAS) is based on the presence of retarded growth, a pattern of facial abnormalities and abnormalities of the central nervous system, including mental retardation.

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

CT-127

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-13 (cont'd)

CODE

PRIORITY

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

High Risk: Diagnosed fetal alcohol syndrome.

422 INADEQUATE DIETARY PATTERN

IV

1. Any food group missing, based on the Recommended Daily Servings Chart (Attachment CT-32).
2. Failure to meet the recommended number of servings from two (2) food groups.
3. Practice of two (2) inappropriate food practices, based on the Inappropriate Food Practices List (Attachment CT-33).
4. The practice of one (1) inappropriate food practice and the failure to meet the recommended number of servings from one (1) food group.
5. Consuming less than the recommended amount of iron-fortified or prescription formula for infants, or consuming a low-iron
formula without a prescription and appropriate diagnosis.

603 BREASTFEEDING COMPLICATIONS OR POTENTIAL

I

COMPLICATIONS

Any of the following are considered complications or potential complications of breastfeeding:
Breastfed infant with jaundice

Breastfed infant with weak or ineffective suck

Breastfed infant with difficulty latching on to mother's breast

Breastfed infant with inadequate stooling for age (as determined by a physician or other health care provider)

Breastfed infant who wets diaper less than 6 times per day

Document: Breastfeeding complications or potential complications in the participant's health record.
High Risk: Breastfeeding complications or potential complications. Refer for, or provide infant's mother with appropriate breastfeeding counseling.

701 INFANT UP TO 6 MONTHS OLD OF A WIC MOTHER, OR OF A

II

WOMAN WHO WOULD HAVE BEEN ELIGIBLE DURING

PREGNANCY

An infant under 6 months of age whose mother was a WIC Program participant during pregnancy, OR

An infant whose mother's health records document that the woman was at nutritional risk during pregnancy because of detrimental or abnormal nutrition conditions detectable by biochemical or anthropometric measurements or other documented nutritionally related medical conditions.

702 BREASTFEEDING INFANT OF A WOMAN AT NUTRITIONAL RISK
A breastfeeding infant whose breastfeeding mother has been determined to be at nutritional risk.

I, II, IV

CT-128

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-13 (cont'd)

CODE

PRIORITY

Document: Mother's risks on infant's WIC Assessment/Certification Form.

703 INFANT BORN TO MOTHER WITH MENTAL RETARDATION, OR

I

ALCOHOL OR DRUG ABUSE DURING MOST RECENT

PREGNANCY

Infant born of a woman diagnosed with mental retardation by a physician or psychologist as self-reported by woman/woman's caregiver; or as reported by a physician, psychologist, or someone working under physician's orders; OR

Documentation or self-report of any use of alcohol or illegal drugs during most recent pregnancy

Document: Diagnosis of mental retardation, OR reported use of alcohol or illegal drugs during most recent pregnancy.

801 HOMELESSNESS

IV

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

802 MIGRANCY

IV

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

901 RECIPIENT OF ABUSE

IV

Child abuse/neglect within past 6 months or as self reported by the caregiver, or as documented by a social worker, health care provider or on other appropriate documents; or as reported through consultation with a social worker, health care provider or other appropriate personnel.

Child abuse/neglect refers to any recent act, or failure to act, resulting in: Imminent risk or serious harm Serious physical or emotional harm Sexual abuse or exploitation of an infant or child by a parent or caretaker

Georgia State law requires that medical and child service organizations personnel, having reasonable cause to suspect child abuse, report these suspicions to the authority designated by the health district/organization.

CT-129

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-13 (cont'd)

CODE

PRIORITY

902 PRIMARY CAREGIVER WITH LIMITED ABILITY TO MAKE

IV

FEEDING DECISIONS AN/OR PREPARE FOOD

Infant whose primary caregiver is assessed to have limited ability to make appropriate feeding decisions and/or prepare food. Examples may include:
mental disability/delay, and/or a mental illness such as clinical depression (diagnosed by a physician or licensed psychologist).
physical disability which restricts or limits food preparation abilities
current use of or history of abusing alcohol or other drugs.

Document: The caregiver's limited abilities in the participant's health record.

502 TRANSFER OF CERTIFICATION

I, II, IV

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

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

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Attachment CT-14

NUTRITIONAL RISK CRITERIA CHILDREN

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

CODE

PRIORITY

201 LOW HGB/HCT

III

12-23 months of age: Hemoglobin: 10.9 gm or lower Hematocrit: 32.8% or lower

24 months-5 years of age: Hemoglobin: 11.0 gm or lower Hematocrit: 32.9% or lower

High Risk: Hematocrit/Hemoglobin at treatment level

103 UNDERWEIGHT

III

Less than or equal to the 10th percentile weight for length or Body Mass Index (BMI) for age based on Centers for Disease Control and Prevention (CDC) age/sex specific growth charts.

High Risk: Weight for length or BMI for age <5th percentile

113 OVERWEIGHT

III

Greater than or equal to 24 months old and BMI for age greater than or equal to the 95th percentile based on CDC age/sex specific growth charts. Can only be used if standing height is taken.

High Risk: BMI for age >95th percentile

114 AT RISK OF BECOMING OVERWEIGHT

Greater than or equal to 24 months old and BMI for age greater than or equal to the 85th percentile and less than the 95th percentile based on CDC age/sex specific growth charts. Can only be used if standing height is taken.

121 SHORT STATURE

III

Less than or equal to the 10th percentile length or height for age based on CDC age/sex specific growth charts.

High Risk: Length or height for age <5th percentile

134 FAILURE TO THRIVE

III

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

Document: Diagnosis in participant's health record.

High Risk: Diagnosed failure to thrive.

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GA WIC 2005 PROCEDURES MANUAL

Attachment CT-14 (cont'd)

CODE

PRIORITY

135 INADEQUATE GROWTH

III

A low rate of weight gain over a six-month period, as defined by the following chart:

Age in Months at Certification 12 months >12 - 60 months

Weight Gain in Previous 6-Month Interval*
< 3 pounds < 1 pound

*Note: Use only for an interval of 6 months +/- 2 weeks

High Risk: Inadequate growth.

141 LOW BIRTH WEIGHT (Children < 24 months of age)

III

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

Document: Birth weight in participant's health record.

211 ELEVATED BLOOD LEAD LEVELS

III

Blood lead level of >10 g/deciliter

Document: Date of blood test and blood lead level in the participant=s health record. Must be within the past 6 months.

High Risk: Blood lead level of >10 g/deciliter.

NUTRITION RELATED MEDICAL CONDITIONS

III

341 NUTRIENT DEFICIENCY DISEASES

Diagnosis of clinical signs of nutrient deficiencies or a disease caused by insufficient dietary intake of macro- and micro-nutrients. Diseases include, but are not limited to, protein energy malnutrition, scurvy, rickets, beriberi, hypocalcemia, osteomalacia, vitamin K deficiency, pellagra, cheilosis, menkes disease, xerothalmia. (See Attachment CT-31)

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

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

High Risk: Diagnosed nutrient deficiency disease.

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Attachment CT-14 (cont'd)

CODE

PRIORITY

342 GASTRO-INTESTINAL DISORDERS

III

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

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

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

High Risk: Diagnosed gastro-intestinal disorder.

343 DIABETES MELLITUS

III

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

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

High Risk: Diagnosed diabetes mellitus.

344 THYROID DISORDERS

III

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

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

High Risk: Diagnosed thyroid disorder.

345 HYPERTENSION

III

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

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

High Risk: Diagnosed hypertension.

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Attachment CT-14 (cont'd)

CODE

PRIORITY

346 RENAL DISEASE

III

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

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

High Risk: Diagnosed renal disease.

347 CANCER

III

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

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

High Risk: Diagnosed cancer.

348 CENTRAL NERVOUS SYSTEM DISORDERS

III

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

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

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

High Risk: Diagnosed central nervous system disorder.

349 GENETIC AND CONGENITAL DISORDERS

III

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

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

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

High Risk: Diagnosed genetic/congenital disorder.

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Attachment CT-14 (cont'd)

CODE

PRIORITY

351 INBORN ERRORS OF METABOLISM

II

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

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

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

High Risk: Diagnosed inborn error of metabolism.

352 INFECTIOUS DISEASES

III

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

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

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

High Risk: Diagnosed infectious disease, as described above.

353 FOOD ALLERGIES

III

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

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

High Risk: Diagnosed food allergy.

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GA WIC 2005 PROCEDURES MANUAL

Attachment CT-14 (cont'd)

CODE

PRIORITY

354 CELIAC DISEASE

III

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

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

High Risk: Diagnosed celiac disease.

355 LACTOSE INTOLERANCE

Presence of lactose intolerance diagnosed by a physician, as self reported

III

by caregiver; or as reported or documented by a physician, or health

professional acting under orders of a physician; OR symptoms must be

well documented by the competent professional authority.

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

High Risk: Lactose intolerance.

356 HYPOGLYCEMIA

III

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

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

High Risk: Diagnosed hypoglycemia.

357 DRUG NUTRIENT INTERACTIONS

III

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

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

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

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GA WIC 2005 PROCEDURES MANUAL

Attachment CT-14 (cont'd)

CODE

PRIORITY

359 RECENT MAJOR SURGERY, TRAUMA OR BURNS

III

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

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

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

360 OTHER MEDICAL CONDITIONS

III

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

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

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

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

361 DEPRESSION

III

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

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

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GA WIC 2005 PROCEDURES MANUAL

Attachment CT-14 (cont'd)

CODE

PRIORITY

362 DEVELOPMENTAL, SENSORY OR MOTOR DELAYS INTERFERING

III

WITH THE ABILITY TO EAT

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

Presence of developmental, sensory or motor delay diagnosed by a physician, as self reported by caregiver; or as reported or documented by a physician, or health professional acting under orders of a physician.

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

High Risk: Developmental, sensory or motor delay interfering with ability to eat.

381 DENTAL PROBLEMS

III

Diagnosis of dental problems by a physician or health care provider working under orders of a physician, or adequate documentation by the competent professional authority. Includes, but is not limited to:
Presence of nursing bottle caries
Smooth surface decay of the maxillary anterior and the primary molars

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

382 FETAL ALCOHOL SYNDROME

III

Fetal alcohol syndrome (FAS) is based on the presence of retarded growth, a pattern of facial abnormalities and abnormalities of the central nervous system, including mental retardation.

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

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

High Risk: Diagnosed fetal alcohol syndrome.

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GA WIC 2005 PROCEDURES MANUAL

Attachment CT-14 (cont'd)

CODE

PRIORITY

422 INADEQUATE DIETARY PATTERN

V

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

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

3. Practice of two (2) inappropriate food practices, based on the Inappropriate Food Practices List (Attachment CT - 33).

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

5. Consuming less than the recommended amount of formula prescribed.

501 POSSIBILITY OF REGRESSION

III

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

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

Regression cannot be used for the initial certification period.

801 HOMELESSNESS

V

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

802 MIGRANCY

V

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

901 RECIPIENT OF ABUSE

V

Child abuse/neglect within past 6 months or as self reported by the caregiver, or as documented by a social worker, health care provider or on other appropriate documents; or as reported through consultation with a social worker, health care provider or other appropriate personnel.

Child abuse/neglect refers to any recent act, or failure to act, resulting in: Imminent risk or serious harm Serious physical or emotional harm Sexual abuse or exploitation of an infant or child by a parent or caretaker

Georgia State law requires that medical and child service organizations personnel, having reasonable cause to suspect child abuse, report these suspicions to the authority designated by the health district/organization.

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Attachment CT-14 (cont'd)

CODE

PRIORITY

902 PRIMARY CAREGIVER WITH LIMITED ABILITY TO MAKE FEEDING

V

DECISIONS AN/OR PREPARE FOOD

Child whose primary caregiver is assessed to have limited ability to make appropriate feeding decisions and/or prepare food. Examples may include:
mental disability/delay, and/or a mental illness such as clinical depression (diagnosed by a physician or licensed psychologist)
physical disability which restricts or limits food preparation abilities
current use of or history of abusing alcohol or other drugs.

Document: The caregivers limited abilities in the participant's health record.

502 TRANSFER OF CERTIFICATION

III, V

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

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

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GA WIC 2005 PROCEDURES MANUAL

Attachment CT-15

NOTICE OF TERMINATION/INELIGIBILITY/WAITING LIST FORM

DHR GEORGIA DEPARTMENT OF HUMAN RESOURCES
NAME:

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

ADDRESS:

CITY/ZIP CODE:

PHONE NUMBER:

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

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

WAITING LIST SECTION:

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

FAIR HEARING SECTION:

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

___________________________________________________________________________

WIC PROGRAM

___________________________________________________________________________

ADDRESS

_____________________________________________/______________________________

CITY/ZIP CODE

PHONE NUMBER

___________________________________
PARTICIPANT SIGNATURE/PARENT/CARETAKER/GUARDIAN

___________________________________
WIC RESPRENTATIVE SIGNATURE/TITLE

This Institution is an Equal Opportunity Provider. If you believe you have been discriminated against because of race, color, national origin, age, sex or handicap, write immediately to the Secretary of Agriculture, Washington, D.C. 20250

Form 3293 (Rev.8-04)

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Attachment CT-16

VERIFICATION OF CERTIFICATION (VOC) CARD

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

PARTICIPANT/PARENT/ GUARDIAN SIGNATURE:
SIGNATURE OF WIC OFFICIAL

COUNTY/CLINICTELEPHONE NUMBER

CLINIC ADDRESS

This card must be accepted by all state and local agencies as a WIC Program Verification of Certification until expiration date.

PARTICIPANT RIGHTS

USDA prohibits discrimination in the administration of its program.

You may appeal any decision made by the local agency regarding your participation in the program.

The local agency will make health services and nutrition education available to you and you are encouraged to participate in these services.

DERECHOS DE PARTICIPANTES

USDA prohibe la discriminacin de su programa.

Usted puedo apelar la decision tomada por la agencia local con respecto a su participation en el Programa.

La agencia local arreglar papa useted la disponibilidad de services de salud y de educatin en asuntos de nutricin y se recomienda que Ud. Haga uso de estos servicios.

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

WEIGHT PRIORITY

FORM 3292 (REV. 8-98)

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GA WIC 2005 PROCEDURES MANUAL
CLINIC VOC CARD INVENTORY LOG

GEORGIA WIC PROGRAM VOC CARD INVENTORY LOG

DISTRICT

CLINIC

Date Beginning Ending No.

Card

No.

No. Received No.

Issued

Participants Name (Print)

WIC ID Number

Signature of Parent, Guardian or Caretaker

Attachment CT-17
City Total No. Staff Staff State* of Cards Initials Initials
on Hand

Note: A Physical Inventory of VOC cards must be performed by the local agency and clinics monthly. One staff member must conduct the inventory (initial the Log) and a second member must verify the accuracy of the inventory (initial the Log also).
* If a migrant is issued a VOC card and is not moving, please place "Not Moving" in the column marked City/State.
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GA WIC 2005 PROCEDURES MANUAL

DISTRICT

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

Date Beginning Ending

No.

No.

No.

No. Received Issued

Clinic Name (Print)

Name of Clinic Representative

Attachment CT-18
Total No. Staff Staff of Cards Initials Initials on Hand

Note: A Physical Inventory of VOC cards must be performed by the local agency and clinics monthly. One staff member must conduct the inventory (initial the Log) and a second member must verify the accuracy of the inventory (initial the Log also).
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Attachment CT-19

MEASURING LENGTH

Age:

Birth to 24 months. 24-36 months, if proper position to measure stature cannot be achieved or with children less
than 32 inches in stature.

Material/Equipment:

Recumbent length board with fixed headboard and movable footboard, both at right angles; marked in increments of 1/8 inch.
Two (2) people required.

Procedure:

1. Check to be sure that moveable foot piece slides easily and the headboard is at the zero mark.

2. Remove headgear, shoes and bulky clothing. Instruct caretaker to apply gentle traction to ensure that the child's head is firmly against the headboard so that the eyes are pointing directly upward.

3. With the child positioned so that the shoulders, back and buttocks are flat along the center of the board, the measurer should hold the child's knees together, gently pushing them down against the board with one hand to fully extend the child. With the other hand the measurer should slide the footboard to the child's feet until both heels touch the foot piece. Toes should be pointing directly upward.

4. Recheck head placement. Immediately remove the child's feet from contact with the footboard with one hand, while holding the footboard securely in place with the other hand.

5. Measure length in inches to the nearest 1/8 inch. Repeat the measurement sliding footboard away and starting again until two readings agree within 1/4 inch.

6. Record the second reading promptly.

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GA WIC 2005 PROCEDURES MANUAL

Attachment CT-20

MEASURING HEIGHT

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

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

Material/Equipment:
Wall mounted or portable stadiometer or metal measuring tape mounted on wall. A right angle headboard marked in increments of 1/8 inch.

Procedure:

1. Remove all bulky clothing, head and foot wear.

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

3. Make sure the child/adult stands flat footed with feet slightly apart and knees extended; then check for three (3) contact points: (a) shoulders, (b) buttocks, and (c) the back of the heels.

4. Lower the moveable headboard until it firmly touches the crown of the head. The child/adult should be looking straight ahead, not upward or down at the floor.

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

6. Repeat the adjustment of the headboard and re-measure until two readings agree within 1/4 inch.

7. Record the second reading promptly.

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GA WIC 2005 PROCEDURES MANUAL

Attachment CT-21

MEASURING WEIGHT

Age:

Infants. Young children up to 35 pounds.

Materials/Equipment:

Scales with beam balance and non-detachable weights. Scales must be calibrated yearly (see Attachment CT-23).

Procedure:
1. Check scales at zero position. With weights in zero position, indicator should point to zero. If not, use the adjustment screws to move adjustable zeroing weight until the beam is in zero balance.

2. Remove shoes and clothes. Remove diaper if wet.

3. Place infant/child in center of scale (may be done sitting or lying down).

4. Move the weight on the main beam away from the zero position (left to right) until the indicator shows excess weight, then move the weight back (right to left) towards the zero position until too little weight has been obtained.

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

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

8. Record the second reading promptly.

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GA WIC 2005 PROCEDURES MANUAL MEASURING WEIGHT-STANDING

Attachment CT-22

Age:

Children who can stand unattended by an adult. Adults.

Materials/Equipment:

Standard platform beam scale with non-detachable weights; marked in increments of at least 1/4 pound or 100 grams.
Scales must be calibrated yearly (see Attachment CT-23).

Procedure:

1. Check scales at zero position. With weights in zero position indicator should point to zero. If not, use adjustment screws to move the adjustable zeroing weight until the beam is in zero balance.

2. Should be wearing minimal indoor clothing. Remove shoes, heavy clothing, belts, and heavy jewelry. Be sure pockets are empty.

3. Have child/adult stand in the center of the platform, arms hanging naturally. The child/adult must be free standing.

4. Move the weight on the main beam away from zero until the indicator shows that excess weight has been added, then move the weight back towards the zero position (right to left) until just barely too much weight has been removed.

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

6. Make sure the child/adult is still not holding on, then record to the nearest 1/4 pound.

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

8. Record the second reading promptly.

Sources:

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

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GA WIC 2005 PROCEDURES MANUAL

Attachment CT-23

EQUIPMENT MAINTENANCE

1. A yearly calibration of scales is required for proper usage. To arrange for your equipment to be calibrated, please contact a scale company licensed by the Georgia Department of Agriculture for service or each local agency/clinic may calibrate its scales by using the Procedures for Testing Scales developed by the Georgia Department of Agriculture.

Georgia Department of Agriculture Fuel and Measures Division Agriculture Building, Room 321 Capitol Square Atlanta, Georgia 30334 (404) 656-3605

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

2. A yearly calibration of centrifuges and other hematological equipment used to determine anemia status of WIC applicants/participants is recommended. There is no State agency that is responsible for this procedure. Calibration of hematological equipment should follow manufacturer recommendations. Each local agency/clinic should establish a calibration procedure.

The Georgia WIC Program has elected to use special codes to be entered into the hematological data field, when hemoglobin is not determined. Please use the following codes, based on the computer systems in your district.

ATAVS: 88:8 Mitchell & McCormick (M&M): 88.8 Athens System: 88:8 DeKalb System: 88:8 HOST: 88:8 Aegis: 88:8

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

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

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GA WIC 2005 PROCEDURES MANUAL

Attachment CT-23 (cont'd)

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

a. For infants and children receiving their health care through the health department, follow the protocol for treatment of low hemoglobin, and submit to Viking each hemoglobin value determined as part of the follow-up. Once the hemoglobin become normal, it does not have to be determined for another year (the subsequent certification visit closest to that year).

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

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

3. It is recommended that hematological equipment be checked for accuracy (balanced) according to a regular schedule, based on usage. Several methods are available for checking equipment. These methods include:

a. Spinning one sample of blood twice:

1. Obtain a blood sample and centrifuge it. 2. Read the hematocrit value. 3. Spin the same blood sample a second time. 4. Read the hematocrit value. 5. If the two value readings are the same, the centrifuge is packing/spinning
the red blood cells sufficiently and the centrifuge is calibrated. 6. If the two values are different, the centrifuge is not calibrated and needs
to be serviced.

b. Spinning two tubes of blood collected from the same person, and centrifuging both samples at the same time. Values obtained should be approximately the same.

c. Running a standard solution and obtaining an acceptable reading for that solution.

CT-150

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-24

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

1. Record applicant/participant's name.

2. Use "Body Mass Index Table" (Attachments CT-29, 30) to determine if the applicant is Normal Weight, Underweight for Height or Overweight for Height, using pre-pregnancy weight. Select the weight curve, which represents the prenatal woman's weight status. If she is pregnant with twins, use the "Twins" chart regardless of her weight status.

3. Enter height in inches without shoes, if not recorded in participant's health record.

4. Use Weight History chart, if information is not recorded in participant's health record.

5. Enter pre-pregnancy weight as indicated. Enter date and weight at each visit.

6. Plot today's weight using the following steps:

a. Record the pre-pregnancy weight at the initial point of the selected weight curve, which is located on the left side of the grid at zero point. From the chart or gestation calculator, determine the completed weeks of gestation.
b. Using the gain (or loss) in weight from the pre-pregnancy weight baseline and the completed gestational weeks (this visit) place an X on the point at which these two lines meet.
c. If the patient does not know her pre-pregnancy weight, or if the weight she gives seems disproportionate to her current weight, place an X on the dotted line for the calculated completed gestational week. Let this be a beginning point to plot future weights. Indicate that this weight is an estimate by writing "estimate" vertically on the grid next to the X. Use the "Normal" weight curve unless it is very obvious that the prenatal woman was overweight or underweight prior to gestation. Document this observation in the health record.
d. At the second and each subsequent visit, the weight gain for completed weeks of gestation should be plotted on the grid.

CT-151

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-25

PRENATAL WEIGHT GRID FOR NORMAL WEIGHT AND TWINS

CT-152

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-26

PRENATAL WEIGHT GRID FOR UNDERWEIGHT AND OVERWEIGHT

CT-153

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-27

DIETARY ASSESSMENT

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

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

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

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

3. A method for documenting inappropriate food practices (see Attachment CT-33).

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

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

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

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

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GA WIC 2005 PROCEDURES MANUAL

Attachment CT-28

INSTRUCTIONS FOR USE OF THE GROWTH CHARTS

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

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

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

Year

Month

Day

Date of Measurement

2002

4

21

Birth date

-1997

-8

-10

Child's Age

4y

8m

11

days

or 5-2/3 years

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

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

Interpolation Method:

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

2-120 Years Growth Chart - Calculate exact age (to nearest month) and plot measurement into space at the point nearest to the age.

Rounding Method:

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

2-5 Years Growth Chart - Calculate age to the nearest 1/4 year and plot on the corresponding line.

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GA WIC 2005 PROCEDURES MANUAL

Attachment CT-28 (cont'd)

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

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

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

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

a. Follow a vertical line at the appropriate age. b. Using a straight-edge, line up as closely as possible to the measured length or height
and weight and mark the point where the two (2) lines intersect. c. Write the date above the point.

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

a. Follow a vertical line at the point of the correct length or height. b. Using a straight-edge, line up as closely as possible to the weight and mark the point
where the two (2) lines intersect. c. Write the date on the point.

7. To plot an infant's head circumference:

a. Follow a vertical line as near as possible to the appropriate age.
b. Using a straight-edge, line up as closely as possible the measured head circumference and mark the point where the two (2) lines intersect.

8. See the Nutrition Guidelines for Practice, Infant Section, III. d. for instructions on adjusting for prematurely. Use measurements plotted at actual age to determine WIC eligibility.

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

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

CT-156

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-28 (cont'd)

Reference for Converting Fractions to Decimals

1/8 = .125

2/8 or = .25

3/8 = .375

4/8 or = .5

5/8 = .625

6/8 or = .75

7/8 = .875

Guidance for Rounding to One Decimal Point

When calculating Body Mass Index (BMI) round the final answer to one decimal point. To do this you will round up to the next number if the second number past the decimal point is five or greater and you will round down if the second number past the decimal point is four or less.

Example:

If the final BMI calculation equals 17.158829, the BMI would be 17.2

If the final BMI calculation equals 17.14829, the BMI would be 17.1

CT-157

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-29

Body Mass Index (BMI) Table for Determining Weight Classification for Pregnant Women 1

Height
(Inches)

Underweight Normal Weight

BMI <19.8

BMI 19.8-26.0

Overweight
BMI 26.1-29.0

Obese
BMI >29.0

58"

<95

95-124

125-138

>138

59"

<98

98-128

129-143

>143

60"

<102

102-133

134-148

>148

61"

<105

105-137

138-153

>153

62"

<108

108-142

143-158

>158

63"

<112

112-146

147-163

>163

64"

<116

116-151

152-169

>169

65"

<119

119-156

157-174

>174

66"

<123

123-161

162-179

>179

67"

<127

127-166

167-185

>185

68"

<130

130-171

172-190

>190

69"

<134

134-176

177-196

>196

70"

<138

138-181

182-202

>202

71"

<142

142-186

187-208

>208

72"

<146

146-191

192-213

>213

1Adapted from the Institute of Medicine: Nutrition During Pregnancy, National Academy Press;1990.

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GA WIC 2005 PROCEDURES MANUAL

Attachment CT-30

Body Mass Index (BMI) Table for Determining Weight Classification for Non-Pregnant Women 1

Height
(Inches)

Underweight Normal Weight

BMI <18.5

BMI 18.5-24.9

Overweight
BMI 25.0-29.9

Obese
BMI >29.9

58"

<89

89-118

119-142

>142

59"

<92

92-123

124-147

>147

60"

<95

95-127

128-152

>152

61"

<98

98-131

132-157

>157

62"

<101

101-135

136-163

>163

63"

<105

105-140

141-168

>168

64"

<108

108-144

145-173

>173

65"

<111

111-149

150-179

>179

66"

<115

115-154

155-185

>185

67"

<118

118-158

159-190

>190

68"

<122

122-163

164-196

>196

69"

<125

125-168

169-202

>202

70"

<129

129-173

174-208

>208

71"

<133

133-178

179-214

>214

72"

<137

137-183

184-220

>220

1Adapted from Clinical Guidelines on the Identification, Evaluation and Treatment of Overweight and Obesity in Adults. National Heart, Lung and Blood Institute (NHLBI), National Institutes of Health (NIH). NIH Publication No. 98-4083.

CT-159

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-31

Body Area Hair Eyes
Lips Gums Tongue
Face and Neck
Skin
Teeth Glands

PHYSICAL SIGNS SUGGESTIVE OF NUTRIENT DEFICIENCIES

Normal Appearance

Signs Suggestive of Nutrient Deficiency (ies)

Nutrient Consideration(s)

shiny; firm; not easily plucked

lack of natural shine; dull; dry; thin; loss of curl; color changes (flag sign); easily plucked

inadequate protein and calories

bright; clear; shiny; no sores at corners of eyelids; membranes healthy pink and moist; no prominent blood vessels

eye membranes pale;
Bitot's spots; red membranes; dryness of membranes dull appearance of cornea (cornmeal xerosis); softening of cornea (keratomalacia);
redness and fissuring of eyelid corners

anemia (inadequate iron, folacin, or Vitamin B-12)
inadequate Vitamin A
inadequate riboflavin, Vitamin B-6, and niacin

smooth; not chapped or swollen

redness of swelling of mouth or lips (cheilosis);
bilateral cracks, white or pink lesions at corners of mouth (angular stomatitis) and/or scars

inadequate niacin and riboflavin inadequate riboflavin, niacin, iron and Vitamin B-6

healthy; red; do not bleed; not swollen

spongy; bleeding; receding

inadequate ascorbic acid

deep red; not swollen or smooth

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

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

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

diffuse depigmentation;
darkening of skin over cheeks and under eyes; scaling of skin around nostrils (nasolabial seborrhea)

inadequate protein inadequate calories and niacin inadequate riboflavin, niacin, and Vitamin B-6

swollen (moon) face; front of neck swollen (thyroid enlargement) swollen cheeks (bilateral parotid enlargement)

inadequate protein inadequate protein inadequate iodine inadequate protein

no signs of swelling, rashes, dark or light spots

dry and scaly (xerosis); sandpaper-like feel (follicular hyperkeratosis); pinhead-size purplish skin hemorrhages (petechiae); excessive bruising; red, swollen pigmentation of areas exposed to sunlight (pellagrous dermatitis); extensive lightness and darkness of skin (flaky, pressure sores (decubiti)

inadequate Vitamin A or essential fatty acids inadequate Vitamin C
inadequate Vitamin K inadequate niacin and tryptophan inadequate protein, Vitamin C, and zinc

no cavities, no pain, bright

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

inadequate Vitamin D inadequate Vitamin A

face not swollen

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

inadequate iodine inadequate protein

CT-160

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-31 (cont'd)

Body Area Nails
Muscular and skeletal systems

Normal Appearance firm, pink
good muscle tone; some fat under skin; can walk or run without pain

Signs Suggestive of Nutrient Deficiency (ies)

Nutrient Consideration(s)

nails are spoon-shaped (koilonychia); brittle, ridged nails, pale nail beds

inadequate iron Vitamin A toxicity

muscles have "wasted" appearance; baby's skull bones inadequate protein

are thin and soft (craniotabes); round swelling of

inadequate thiamin

front and side of head (frontal and parietal bossing); inadequate Vitamin D

swelling of ends of bones (epiphyseal enlargement);

small bumps on both sides of chest wall (on ribs) -

beading of ribs; baby's soft spot on head does not

harden at proper time (persistently open anterior fontanelle);

knock-knees or bow-legs; bleeding into muscle (muscular-

skeletal hemorrhages); person cannot get up or walk properly

*As stated under nutritional risk criterion "I. Clinical Manifestations of Malnutrition, Dental Problems, Lead Poisoning."
Adapted from American Journal of Public Health, Supplement, November 1973, p. 19. and 1992 Georgia Dietetic Association Diet Manual.

CT-161

GA WIC 2005 PROCEDURES MANUAL RECOMMENDED DAILY SERVINGS CHART

Attachment CT-32

Food Group

Birth to 5/6 Months

5/6 Months to 1 Year

1-3 Years old1

4-6 Years old4

Pregnant Teen/ Pregnant Adult4

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

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

Breastmilk, every 2-4 hrs or Iron fortified formula, 2.5 oz/lb (24-35 ozs)
Add after 6 months and before 9 months
Add after 6 months and before 9 months

Vegetable Group

None

Add after 6 months and before 9 months

Bread, Cereal, Rice & Pasta Group

None

Add iron Fortified cereal at 5-6 months

Other

None

None

1 Portion size is reduced by approximately 1/3rd, except for milk 2 Pregnant and breastfeeding teenagers need 4 servings 3 Women 24 years and under need 3 servings 4 Recommended serving sizes: 5 AAP recommends no more than 6 ounces of juice per day
Milk, Yogurt & Cheese Group: 1 Serving =
1 cup milk/yogurt 1 ounces natural cheese(i.e. cheddar, colby, longhorn) 2 ounces processed cheese(i.e. American, Swiss) 1 cup ice cream 2 cups cottage cheese
Meat, Poultry, Dry Beans, Eggs, Nuts Group: Other foods from this group count as 1 ounce of lean meat 1 serving =
1 egg 1/3 cup nuts cup cooked dry beans 2 tablespoons peanut butter

2 servings (16 ounces total)

2 servings (16 ounces total)

3-4 servings2

3 ounces

5 ounces

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

2 servings

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

3 servings

6 servings
1 serving = slice or cup cooked c dry cereal

6 servings

As needed to meet RDA for energy

6 ounces 3 servings 4 servings 9 servings

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

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

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

CT-162

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-33

INAPPROPRIATE FOOD PRACTICES

Inappropriate Food Practices for Women, Infants, and Children:

1. Use of nutritional supplement(s) in excess of 100% of the RDA's other than those prescribed by physician. (1)

2. Any practice of pica. (1)

Additional Inappropriate Food Practices for Prenatal Women:

1. Intake of more than 300 mg of caffeine per day. (1, 4, 5, 6, 7)

2. Intake of less than 8 cups of clear liquids per 24 hours. (1)

Additional Inappropriate Food Practices for Breastfeeding Women:

1. Intake of 300 mg or more of caffeine per day.(10)

Additional Inappropriate Food Practices for Infants:

1. Use of an infant feeder. (1)

2. Routinely drinking from bottle while lying down. (1)

3. Liquids and/or food in the bottle except for formula, breast milk or water. (1)

4. Inappropriate formula preparation. (1)

5. Introduction of solids prior to 5 months of age. (1, 2)

6. Food consistently used as a pacifier or reward for the infant. (1)

7. Introduction of mixed food groups prior to the introduction of the ingredients singly. (2)

8. Not offering unflavored water daily, once diet intake includes anything other than breastmilk/infant formula. (1)

9. Feeding any amount of honey to infants under 1 year of age (added to liquids or solid foods, used in cooking, as part of processed foods, on a pacifier, etc.). (11)

Additional Inappropriate Food Practices for Children:

1. Food consistently used as a pacifier or reward. (1)

2. Unflavored water not offered daily. (1)

3. Drinking from the bottle after one year of age, unless medically indicated. (7)

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

CT-163

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-33 (cont'd)

References for Inappropriate Food Practices

(1) Office of Nutrition, Division of Public Health, Georgia Department of Human Resources: Nutrition Guidelines for Practice. 1997.

(2) Committee on Nutrition: Pediatric Nutrition Handbook. American Academy of Pediatrics, 1993.

(3) American Dietetic Association: Meal Time! Happy Time! A Guide for Parents. Chicago, Illinois.

(4) National Academy of Sciences, Institute of Medicine: Nutrition During Pregnancy. Washington, D.C., 1990.

(5) Berger, Alvin: Effects of Caffeine Consumption on Pregnancy Outcome. Journal of Reproduction Medicine, 33 (12):945-956, 1988.

(6) Martin, T.R., Bracken, M.B.: The Association Between Low Birth Weight and Caffeine Consumption During Pregnancy. American Journal of Epidemiology, 126:813-821, 1987.

(7) Watkinson, B., Fried, P.A.: Maternal Caffeine Use Before, During and After Pregnancy and Effects Upon Offspring. Neuro-behavioral Toxicology and Teratology, 7:9-17, 1985.

(8) Georgia Dietetic Association, Inc., Diet Manual, Fourth Edition, 1992.

(9) United States Department of Agriculture and United States Department of Health and Human Services: Home and Garden Bulletin No. 232, 1985.

(10) United States Department of Agriculture and United States Department of Health and Human Services: Home and & Garden Bulletin No. 232, 1986.

(11) National Academy of Sciences, Institute of Medicine: Nutrition During Lactation. Washington, D.C., 1991.

(12) United States Department of Agriculture and United States Department of Health and Human Services: Home and Garden Bulletin No. 232, 1986.

CT-164

GA WIC 2005 PROCEDURES MANUAL

Attachment CT- 34

Georgia WIC Program Referral Form
Name: Address:

GEORGIA WIC PROGRAM REFERRAL FORM
"This institution is an equal opportunity provider" Date of Birth: Telephone Number:_______________________________

Date Measurements Obtained:

Current Height:

Current Weight:

Any nutritionally related medical conditions?

Yes

If yes, specify:

Hematological Data Date: Hematocrit: Hemoglobin: No

Any clinical manifestations of malnutrition?

Yes

No

If yes, specify:

Any dental problems severe enough to interfere with mastication?

Yes

No

If yes, specify:

Any evidence of lead poisoning?

Yes

No

If yes, specify:

WOMEN ONLY EDC/Delivery Date: Blood Pressure: Number of Previous Pregnancies: _________

Live Births: _________

INFANTS ONLY Breastfeeding: Birth weight: Weeks Gestation:

Yes

No

_____________________________

HEALTH PROFESSIONAL Signature/Title: Agency Address:

Currently Breastfeeding:

Yes

No

Date Taken:

Miscarriages, Abortions: ________ Pregravid Weight

Birth length:

Agency Telephone:

CT-165

GA WIC 2005 PROCEDURES MANUAL

Attachment CT- 35

GEORGIA WIC PROGRAM INCOME ELIGIBILITY GUIDELINES (Effective from April 15, 2004 to April 15, 2005) 48 CONTIGUOUS UNITED STATES, DISTRICT OF COLUMBIA, GUAM
AND TERRITORIES

Reduced Price Miles 185% Federal Poverty Guidelines

Household Size

Annually

Monthly

TwiceMonthly

Bi-Weekly

Weekly

1 2 3 4 5 6 7 8
Each Additional Member Add

17,224 23,107 28,990 34,873 40,756 46,639 52,522 58,405
+5,883

1,436 1,926 2,416 2,907 3,397 3,887 4,377 4,868
+491

718 963 1,208 1,454 1,699 1,944 2,189 2,434
+246

663 889 1,115 1,342 1,568 1,794 2,021 2,247
+227

332 445 558 671 784 897 1,011 1,124
+114

CT-166

GA WIC 2005 PROCEDURES MANUAL GEORGIA WIC PROGRAM

Attachment CT- 36

VOC CARD AGREEMENT

District ______, Unit ______ would like to have a clinic representative order VOC Cards directly from the Georgia WIC Branch.

In order to accommodate this request, the attached form (Attachment CT-37) must be completed.

Signed________________________________
WIC Program Coordinator

Date_____________

IN SIGNING THIS FORM, I REALIZE THAT IF THE CLINIC REPRESENTATIVE CHANGES, I MUST CONTACT THE GEORGIA WIC BRANCH TO INFORM THEM OF THE CHANGE.

CT-167

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-37

VOC CARD FORM

District ____, Unit ____

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

1. Please list the information requested below:

CLINIC NAME/#

# OF VOC CARDS ISSUED
(Three Month Period)

STAFF PERSON
Clinic Representative

2. How many cards do you currently have on hand at the District Office? CT-168

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-38

WOMEN INFANT AND CHILDREN (WIC) ORDERING FORM

SEND TO:________________________________________________________________

(NAME OF OFFICE)

_________________________________________________________________

(STREET ADDRESS)

_________________________________________________________________

(CITY)

(STATE)

(ZIP CODE)

COUNTY:________________________________
(NAME)
DATE:________________________

__________________________
(NUMBER)

STATUS BOX

BO

BACKORDER DO NOT REORDER

C

QUANTITY CUT

N

NOT STORED AT THE STATE

V VOID PREVIOUSLY SHIPPED M MUST BE PRINTED BY DISTRICT D DISCONTINUED

Name of Form

Form #

Quantity

Description

COMMENTS SECTION: ______________________________________ ______________________________________
ORDERED BY:_____________________________________________ TELEPHONE: ______________________________________________ SIGNATURE OF STATE REPRESENTATIVE: ________________________ DATE: _______________
CT-169

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-39

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

Clinic Use Only
Date VOC Card(s) Received:___________________________
Date
# of Card(s) Received:_________________________________

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

Form 3699 (12-95)

White Copy - Georgia WIC Branch

Canary Clinic

Pink - District

CT-170

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-40

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

DHR
Georgia Department of Human Resources

CT-171

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-41

THERE IS NO CHARGE FOR WIC SERVICES

Georgia WIC Program Promoting healthy nutrition for Women,
Infants and Children since 1974 1-800-228-9173
"This is an Equal Opportunity Program. If you believe you have been discriminated against because of race, color, national origin, sex, age, or handicap, write immediately to the Secretary of Agriculture, Washington, D.C. 20250."
CT-172

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-42

Georgia WIC Program VERIFICATION OF RESIDENCY AND/OR INCOME

Household Section:

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

Name of WIC Applicant(s): ________________________________

Address: __________________________________

________________________________

__________________________________

Including the applicant(s) listed above, I have ___________of people in my family. ("Family" means related or non-related individuals living together.)

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

___________________________________________________________________________________

Signature

Date

Address:_________________________________________

City:_______________________________State:_________________Zip Code:________________

Telephone No.:_______________________________

Clinic Section:

This form must be returned on_____________________to_______________________________

______________________________________________________________________________________

WIC Official

Date

_______________________________________________________________________________

WIC Official

Date Received

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

CT-173

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-43

GEORGIA WIC PROGRAM NO PROOF FORM

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

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

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

Income

Address

Identification

2. Who do you work for?

How much did you make last month?

$

List working family members:

How much did they make last month?

$

$

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

3. Reason for No Documentation:

List family members applying for WIC:

(Signature of Applicant)

(Date)

(Signature of Clinic Staff)

(Date)

"This institution is an equal opportunity provider."

CT-174

GA WIC 2005 PROCEDURES MANUAL FAMILY PLUS MEDICAID CARD

Attachment CT-44

BENEFIT DESCRIPTION

CO-PAY

FamilyPlus*

COPAYS ------------------OV $0 SP $0 ER $0 UC $0 RX $0 AFD

RX USE ONLY ---------------------------
| BIN # 600426 | PCN #6F | 1 (800) 433-4893 | | |

MEMBER # 403967045P

EFF DATE 02/01/98

GROUP# M00101 MEDICAID OF GA (404) 525-0600

BIRTH SEX 06/03/94 F

*CALL YOUR PCP TO COORDINATE

*ATLANTA CHILDREN'S HEALTH NETWORK

*ALL OF YOUR HEALTHCARE NEED

*The family of health plans that fits.

CT-175

GA WIC 2005 PROCEDURES MANUAL THE DISCLOSURE STATEMENT

Attachment CT-45

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

County_______________________

Name (Please print)___________________________, Title_______________________

Are you a WIC Participant? ________Yes ________No

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

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

_________Yes

__________No

If you answered "Yes" to either of the above questions, please complete the form below.

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

(If more space is needed, list on back)
I Certify that the above information is correct.
_______________________________________
Signature/Title

_______________________
Date

CT-176

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-46

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

NAME ___________________________________________________________________________________________________________

Last

First

Middle Initial

Date of Birth

ADDRESS__________________________________________________________________________________________________________

City

Zip Code

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

First Certification
Relationship and Name
__________________________ __________________________ __________________________ __________________________ __________________________

Use This Section to Calculate Income

Date_______________________

Income

Source

What Is Each Family Member's Income?

(circle one)

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

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

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

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

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

Other Income Is there other regular income or contributions received by the family (i.e., unemployment, child support)?
__________________________ __________ $______________________ Weekly/Bi-Weekly/Monthly/Yearly __________________________ __________ $______________________ Weekly/Bi-Weekly/Monthly/Yearly

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

No. In Family_____

IS THE CLIENT INCOME ELIGIBLE? YES

NO

(Transfer total to the Certification Form)

First Certification
Relationship and Name
__________________________ __________________________ __________________________ __________________________ __________________________

Use This Section to Calculate Income

Date_______________________

Income

Source

What Is Each Family Member's Income?

(circle one)

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

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

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

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

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

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

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

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

No. In Family_____

IS THE CLIENT INCOME ELIGIBLE? YES

NO

(Transfer total to the Certification Form)

I have been advised of my rights and obligations under the Program. I certify that the information I will provide, or have provided is correct, to the best of my knowledge. The income I have given is my total gross income (all cash income before deductions). This certification form is being submitted in connection with the receipt of Federal assistance. Program officials may verify information on this form. I understand that intentionally making a false statement or intentionally misrepresenting, concealing, or withholding facts may result in paying the State agency, in cash, the value of the food benefits improperly issued to me and may subject me to civil or criminal prosecution under State and Federal law. I understand that the WIC Program may give my certification information to other health or public assistance agencies to see if my family is eligible for their services. I understand that these agencies may contact me, but they may not give my information to anyone else without asking my permission.

PARENT/GUARDIAN/CARETAKER SIGNATURE

DATE

SIGNATURE OF WIC OFFICIAL (Who assessed income)

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

CT-177

IDENTIFICATION, RESIDENCY & INCOME PROOF LIST

Help WIC help you!

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

PROOF OF IDENTIFICATION

Birth Certificate/Confirmation of Birth Letter

Social Security Card

Driver's License

State ID/School ID

Hospital ID Bracelet (Mom & Baby)

VOC Card (with Additional ID)

Birth Record (Infants Only)

Voter Registration Card

Immunization Record

WIC ID (Voucher Pick Up Only)

Military ID

Work ID

Health Record

Cable TV Bill Electric Bill Gas Bill Water Bill

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

PROOF OF INCOME (Bring proof of income for each household member)

Alimony Annuities Basic Allowance from Subsistence Child Support Payments Contribution from people Current Tax Return Form Dividends or Interest on Bonds Estate Income Financial Records Food Stamps Documentation Government Retirement Letter from your Employer Military Retirement Monetary Compensation Net Royalties

Pay Stub Pensions Private Pensions Public Assistance/Welfare Payments (TANF) Rental Income (Net) Self Employment (Net Income) Social Security Supplemental Social Security Trust Unemployment Compensation Unemployment Notice Veteran's Payment

"Proof of ID, residency and income is needed for each applicant/participant/guardian/caretaker and infant/child. The Medicaid information can be used to establish adjunctive eligibility when verified by swipe machine, interactive voice response or internet. During the verification process proof of residency can be established using the internet. The print out from the swipe machine can only be used of the address appears when the card is swiped."

"This institution is an equal opportunity provider."

CT-178

MANUAL DE PROCEDIMIENTOS WIC 2005 GEORGIA

Anexo CT-47B

LISTA DE DOCUMENTOS DE IDENTIDAD Y COMPROBANTES DE DOMICILIO E INGRESOS
Ayude a WIC para que pueda ayudarlo! Cada vez que usted recibe la certificacin de WIC, usted debe presentar un documento de identidad o comprobante de cada una de las siguientes categoras:

DOCUMENTOS DE IDENTIDAD

Certificado de nacimiento/carta de

Tarjeta del Seguro Social

confirmacin de nacimiento

Licencia de conducir

Identificacin del estado/escolar

Pulsera de identificacin del hospital

Tarjeta VOC (con identificacin adicional)

(madre/beb)

Registro de nacimiento (slo para infantes)

Tarjeta de inscripcin como votante

Registro de vacunas

Identificacin de WIC (solo comprobante)

Cdula militar

Credencial del trabajo

Historial mdico

COMPROBANTES DE DOMICILIO (DIRECCIN)

(Se requiere un comprobante solamente.)

Factura de televisin por cable

Historial mdico

Factura de electricidad

Recibo de la renta/hipoteca

Factura de gas

Factura de telfono

Factura del servicio de agua Los nmeros de las casillas de correo no son aceptables.

COMPROBANTES DE INGRESOS (Traiga un comprobante de ingresos para cada uno de los miembros del grupo familiar.)

Pensin alimenticia Anualidades Asistencia de otras personas Carta de su empleador Dividendos o intereses sobre bonos Documentacin del programa de estampillas para alimentos Formulario de impuesto a las ganancias corriente Indemnizacin monetaria Ingresos de acervo hereditario Pagos de manutencin Asignacin bsica de subsistencia Registros financieros Retiro de empleados pblicos Retiro de la actividad militar

Pensiones Taln del cheque de pago Asistencia pblica/Bienestar social Seguro de desempleo Ingreso (neto) de rentas Seguridad de ingreso suplementario
Pagos (Asistencia Temporaria para Familias Indigentes o TANF, por sus siglas en ingls) Subsidio para veteranos Trabajo autnomo (ingreso neto) Retiro privado Regalas netas Seguro social Fideicomiso Notificacin de desempleo

Se necesita un documento de identidad y un comprobante de domicilio/ingresos para cada solicitante/participante, padre/tutor/persona encargada del cuidado de los nios e infante/nio. La informacin de Medicaid se puede utilizar para probar que usted rene los requisitos en forma complementaria cuando ella es verificada al pasar la tarjeta, grabar un mensaje de voz interactivo o usar el Internet. Durante el proceso de verificacin, se puede constatar el comprobante de domicilio usando el Internet. El recibo impreso del lector de la tarjeta se puede utilizar solamente para la direccin indicada cuando se pasa la tarjeta.

"Esta institucin practica una poltica de igualdad de oportunidades."

CT-179

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-48

GEORGIA WIC PROGRAM
Thirty (30) Day Certification/Termination Form

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

NAME:

DATE OF BIRTH:

ADDRESS: CITY/ZIPCODE:

PHONE NUMBER:

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

_____Identification

________Residency

WIC Representative

Date

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

FAIR HEARING SECTION:

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

_______________________________________________

WIC Program

_______________________________________________

Address

_______________________________________________

City/Zip Code

Phone Number

Participant Signature/Parent/Caretaker/Guardian

WIC Representative Signature/Title

"This institution is an equal opportunity provider"

CT-180

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-49

Session Date:

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

Address 1:

Gender:

DOB:

Marital:

Participant ID:

Spouse/Parent Guardian Name:

Address 1:

Annual Income:

Sponsor Name:

Sponsor Address 1:

Relationship:

Authorized Proxy:

Encounter Type:

Height:

Weight: BMI:

Nutrition Risks:

Nutrition Education:

Food Prescription ID:

FI One: xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxx

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

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

Food Instrument Issued for Dates:

Participant Rights and Obligations:
I have been advised of my rights and obligations under the program. I certify that the information I have provided for my eligibility determination is correct, to the best of my knowledge. I understand I have a right to appeal any decision which I am aggrieved. This certification form is being submitted in connection with the receipt of Federal funds. Program officials may verify information on this form. I understand that intentionally making a false or misleading statement or intentionally misrepresenting, concealing or withholding facts may result in paying the State agency, in cash, the value of the food benefits improperly issued to me and may subject me to civil or criminal prosecution under State and federal law. I hereby certify that I am not currently enrolled in any other WICO or WIC Program. I understand that to do so would be deliberate misuse of program benefits and could result in the loss of these benefits.

Participant or Parent/Guardian Signature:

Date:

Competent Professional Authority:

Print Name:

CT-181

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-50

WIC OVERSEAS PROGRAM CONTACTS (as of April 2001)

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

Yokosuka, Japan

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

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

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

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

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

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

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

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

CT-182

GA WIC 2005 PROCEDURES MANUAL

Attachment CT-51

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

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

Date Date Date

CT-183

GA WIC 2005 PROCEDURES MANUAL INCOME VERIFICATION LETTER

Attachment CT-52

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

__________________ Title
c:

"In accordance with Federal law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color national origin, age, sex, or disability". To file a complaint of discrimination, write to: USDA, Office of Civil Rights, Room 326-W, Whitten Building, 1400 Independence Avenue, SW, Washington, DC 20250-9410 or call (202) 720-5964 (voice and TDD). USDA is an equal opportunity provider and employee.
CT-184

GA WIC 2005 PROCEDURES MANUAL
District/Unit/Clinic: County: Date of Incident: Date Reported: Follow-up Date:

GEORGIA DEPARTMENT OF HUMAN RESOURCES
WIC PROGRAM
INCIDENT/COMPLAINT FORM

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

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

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

Attachment CT-53
Type of Complaint: Participant [] Vendor []
Civil Rights [] Local Agency/State WIC Branch Staff []
Local Agency/State WIC Information
Staff Name: Phone: ()

Local Agency Resolution:

State WIC Branch Resolution/Comments:

Follow-up Report:
SWB Customer Service Coordinator: FORM 3772 Revised 12/01

Routing: Original-State WIC Branch, Yellow-District WIC Office, Pink-WIC Clinic
CT-185

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

GA WIC 2005 PROCEDURES MANUAL

Rights and Obligations

TABLE OF CONTENTS

Page

I.

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

II.

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

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

IV. Civil Rights.............................................................................................................. RO-4

A. "And Justice for All" ....................................................................................... RO-4

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

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

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

E. Discrimination Complaints ............................................................................ RO-5

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

2. Verbal Complaints .................................................................................. RO-6

V.

Fair Hearing Procedures - Participants............................................................... RO-6

A. Hearing Official................................................................................................ RO-7

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

C. Claimant's WIC Program Record Summary Form ..................................... RO-8

D. Case Record Disclosure Prior to the Hearing .............................................. RO-9

E. Adjusting Complaints ..................................................................................... RO-9

F. Continuation of Benefits ................................................................................. RO-9

G. Denial or Dismissal of a Request for a Hearing......................................... RO-10

H. Notification of the Hearing........................................................................... RO-10

I. Conduct of the Hearing and the Claimant's Right.................................... RO-11

GA WIC 2005 PROCEDURES MANUAL

Rights and Obligations

VI. VII. VIII. IX.

J. Attendance at the Hearing............................................................................ RO-11 K. The Hearing Record....................................................................................... RO-12 L. The Hearing Decision .................................................................................... RO-12 M. Notification of the Hearing Decision .......................................................... RO-12 N. Appeal Rights of the Claimant..................................................................... RO-13 O. State Rules of Procedure ............................................................................... RO-13 P. Participant Complaint ................................................................................... RO-13 Fair Hearing Procedures - Migrants.................................................................. RO-14 Administrative Appeals Participant - Local Agency ...................................... RO-14 Availability of Hearing Records ........................................................................ RO-15 National Voter Registration Act ........................................................................ RO-15

Attachments:

RO-1 Rights and Obligations........................................................................................ RO-16 RO-2 Claimants WIC Program Record Summary..................................................... RO-18 RO-3 Order Form for Voter Registration Supplies........................................RO-21

GA WIC 2005 PROCEDURES MANUAL

Rights and Obligations

I. RIGHTS AND OBLIGATIONS OF WIC APPLICANTS/PARTICIPANTS
WIC applicants/participants are entitled to certain rights including, but not limited to the following: protection against discrimination, the right to a fair hearing when benefits are denied, the right to receive information in a language other than English, considering the size and concentration of the population, nutrition education, referrals to health services, policies on disqualification for dual participation and for not picking up food instruments. WIC applicants/participants are obligated to provide true information and follow program requirements.
At each certification, the participant or parent/caretaker/guardian must sign the certification statement on the WIC Assessment Certification Form. Prior to signing, the applicant must read (or have read to them) the certification statement on the WIC Assessment Certification Form. See the statement below:
I have been advised of my rights and obligations under the Program. I certify that the information I will provide, or have provided, is correct to the best of my knowledge. The income that I have given is my total gross household income (all cash income before deductions). This certification form is being submitted in connection with the receipt of Federal assistance. Program officials may verify information on this form. I understand that intentionally making a false or misleading statement or intentionally misrepresenting, concealing or withholding facts may result in my paying the State agency, in cash, the value of the food benefit improperly issued to me and may subject me to civil or criminal prosecution under State and Federal law. I authorize the WIC Program to share my certification information with other health care and/or public assistance programs to see if my family is eligible for their services. I understand that other agencies may contact me, but they may not share my certification information with any person or agency without asking my permission.
After signing the certification form the participant must receive an explanation of the following:
1. Reason for Certification. 2. Program Benefits 3. Reasons for Ineligibility 5. Items that can and cannot be purchased 6. Illegality of dual participation

RO-1

GA WIC 2005 PROCEDURES MANUAL

Rights and Obligations

In addition to the rights and obligations stated on the I.D. Card, the applicant/participant also must not be charged for any WIC service (i.e. copying of WIC records).
Each participant on the WIC Program is entitled to be treated with courtesy while in either the health department or an authorized WIC vendor's store. A WIC participant must never be singled out in a grocery store by the use of intercom systems or coding systems that would draw attention to the fact that they are WIC participants. The use of intercom systems or coding systems in this manner is discriminatory.
The Policy Management and Training Section and/or the Vendor Management Unit will handle the type of discrimination described above, when reported to the WIC Branch.

II. NONDISCRIMINATION CLAUSE
The Georgia WIC Branch is required to implement a public notification period to inform participants, applicants and the potentially eligible population of their rights and responsibilities, protection against discrimination, and the procedures for filing a complaint. Therefore, any materials that provide information about WIC Program benefits and eligibility, regardless of the intent, design, or source, must contain the nondiscrimination statement. These materials include brochures, posters, visuals, and any other literature produced by vendors or other interested parties. Examples of materials that are required to include the nondiscrimination clause are:
1. Notices of warning or adverse action to applicants/participants, local agencies, vendors, and employees or employment applicants. This includes items such as notices of ineligibility or disqualification, fair hearing procedures, and cards or letters for missed appointments.
2. All outreach and referral materials.
3. Participant Identification (ID) Folder or food lists for participants and vendors that describe the WIC Program's participation requirements and benefits.
4. Letters of invitation to participate in the public comment process that are sent to vendors, health department staff, advocates, organizations, other interested parties, and media announcements of public hearings.
5. Newsletters that convey WIC benefits and participation requirements.

RO-2

GA WIC 2005 PROCEDURES MANUAL

Rights and Obligations

The current nondiscrimination statement is:
"In accordance with Federal law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. (Not all prohibited bases apply to all programs).
To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call (202) 720-5964 (voice and TDD). USDA is an equal opportunity provider and employer."
The USDA "And Justice for All" poster should be used.
The nondiscrimination statement is not required on promotional items like cups, buttons, magnets, and pens that identify the WIC Program. In addition, the nondiscrimination statement does not have to be read on radio and television public service announcements. Instead, a statement such as "This institution is an equal opportunity provider" is sufficient to meet the nondiscrimination requirement if space is not adequate. Finally, promotion and nutrition education materials that solely provide a nutrition message, without mentioning the program, are not required to contain the nondiscrimination statement.
III. PUBLIC NOTIFICATION
When WIC program coordinators give interviews to the local media, the nondiscrimination statement should be included in verbal statements and on written documents. Any public or media discussions of WIC by local program staff should be documented for review by the state agency monitoring staff. The Office of Communications of the Georgia Department of Human Resources prepares a news release annually to publicize the availability of WIC benefits. The news release is distributed to newspapers statewide.
WIC Program regulations and guidelines must be made available to the public on request. These documents include WIC components of the Federal Register, the Georgia WIC Program State Plan, and the Georgia WIC Program Procedures Manual. Income Guidelines are parts of the Procedures Manual and must be given to the public upon request.

RO-3

GA WIC 2005 PROCEDURES MANUAL

Rights and Obligations

IV. CIVIL RIGHTS
A. "And Justice for All"
The "And Justice for All" poster must be displayed in a conspicuous location in each WIC clinic. The poster's nondiscrimination message is in both English and Spanish and it may be ordered from the WIC Branch.
B. Training
Civil Rights training must be provided annually or as requested for all local staff that have contact with WIC applicants/participants. This training must be provided to State and District staff annually. New staff must have Civil Rights Training prior to working in clinics. A list of participants and an agenda for each training session must be documented and kept on file for three (3) years plus the current year.
Note: When conducting any training, it is required that District/Clinic and State staff asks if anyone needs any special accommodations.
C. Self Identification of Race, Ethnicity, Migrant and Homeless Status
Each applicant/participant must be coded in the computer system to identify race, ethnic group, migrant and homeless status. In order to do this, local agency staff must:
Request that the applicant make a self-identification. When selfidentification is made, the interviewer should make it clear to the applicant that the information is for statistical use only and that no other use will be made of the information. Accept race information provided by applicants without disputing their description.
D. Collecting of Racial/Ethnic Data
Collecting and reporting racial and ethnic participation data are requirements of Title VI of the Civil Rights Act of 1964. The "Ethnic Participation Summary Report" provides information on client participation by ethnic status and priority. The report records data by local clinic and summarizes the data by district/unit and state. This report should be reviewed and maintained in district/unit files. Data must be maintained for four (4) years under safeguards, which will only

RO-4

GA WIC 2005 PROCEDURES MANUAL

Rights and Obligations

allow access to authorized personnel. The Georgia WIC Program does not allow any coding system on the outside of medical records, tickler cards, appointment or any other WIC documents which can openly distinguish applicants/participants by race, color, national origin, sex, age, and/or disability.
E. Discrimination Complaints
All written or verbal discrimination complaints must be filed as soon as the alleged discriminatory action is known. No applicant/participant should be discouraged from filing a complaint directly to the USDA, Office of Civil Rights, Room 326-W, Whitten Building, 1400 Independence Avenue, SW, Washington, DC 20250-9410 or by calling (202) 720-5964 (voice and TDD), or the State of Georgia anti-discrimination agency. Please identify and provide contact information. If an applicant or participant feels discrimination has occurred, a copy of the complaint may also be sent to the WIC Branch, Technical Assistance and Management Evaluation Section, Two Peachtree Street, Suite 10-394, Atlanta GA 30303. The USDA is an equal opportunity provider and employer. [SEP Regional Letter 290-7, Rev .2]
The status of each applicant must be identified and coded in the WIC computer system (i.e. ethic status, migrancy and if homeless).
1. Written Complaints
Persons seeking to file discrimination complaints may file their complaint at the same address. A copy must be sent to the WIC Branch. The Food Nutrition Service (FNS) must receive all complaints immediately. The WIC Branch will send a copy of the discrimination complaint to the USDA Regional Office.
Complaints should include the name of the agency and/or the individual to whom the complaint addresses and a description of the alleged violation. Anonymous complaints will be handled in the same manner as any other complaints.

RO-5

GA WIC 2005 PROCEDURES MANUAL

Rights and Obligations

2. Verbal Complaints
In the event a complainant makes verbal allegations and cannot place such allegations in writing, the person to whom the allegations are made will write up the elements of the complaint for the complainant. The documentation must include the following:
a. Name, address, and telephone number of the complainant.
b. The specific location and name of the local agency and person delivering WIC services.
c. The nature of the incident or action that led to the complaint.
d. The basis on which the complainant feels discrimination exists (e.g. race, color, national origin, sex, age, or disability).
e. The names, titles, and addresses of persons who may have witnessed the discriminatory action.
f. The date(s) during which the alleged discriminatory action occurred.

V. FAIR HEARING PROCEDURES - PARTICIPANTS
WIC Federal Regulations require the State agency to establish hearing procedures that will guaranteed the right to appeal a decision or action to deny participation, to suspend or to terminate participation from the program. The participant must be informed in writing of his/her right to a fair hearing and of the method by which a hearing may be requested.
In the event of denial of benefits followed by a request for a fair hearing, the following should be discussed with the participant:
1. Limited funding of program. 2. The priority system. 3. Waiting list 4. Reasons for the denial of benefits or termination from the program.
At the time of Fair Hearing request, the WIC Coordinator will need to conduct a preliminary conference with the applicant. This conference may resolve the issues, particularly when the individual may misunderstand a program policy or not be aware that certain procedures are required by regulations. The State Agency must
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also conduct a preliminary conference with the applicant/participant prior to the actual hearing. In the event a Fair Hearing is still requested, the State Agency will try, when possible, to hold group-hearing procedures on the same day. The applicant could receive information on fair hearing procedures and their rights and responsibilities concerning the hearing process. Included will be the role of the Administrative Law Judge, the time frame for final decisions and any other pertinent information. Cases can then be heard on an individual basis with the specifics of each case being separately discussed.
In the event, a participant requests a fair hearing, (within fifteen days of the termination date) program benefits will continue until the final administrative decision.
The following are the Georgia WIC Fair Hearing Procedures:
A. Hearing Official
The Office of State and Administrative Hearings (OSAH) are responsible for action on each fair hearing request. OSAH, an impartial party, is vested with full authority in conducting the hearing process. This includes the conduct of hearings, keeping all files and records, and furnishing information for proper reports. OSAH is fully responsible for conducting hearings properly and promptly in accordance with the rules and regulations established by the State. OSAH shall have the authority to do the following:
1. Administer oaths or affirmations. 2. Request, receive, and make a part of the hearing record, all
evidence determined necessary to decide the issues being raised. 3. Regulate the conduct, in the course of the hearing, consistent
with due process to insure an orderly hearing. 4. Render a hearing decision based exclusively on the hearing
record and matters officially noticed.

B. Request(s) for Hearing
A request for hearing is defined as any clear expression by the individual or the individual's parent/guardian/caretaker or other representative, that an opportunity to present his/her case to a higher authority is desired. The State and local agency shall not limit or interfere with the individual's freedom to request a hearing.

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The participant must request the hearing within sixty (60) days from the date the local agency issues the notice of adverse action to deny, suspend, or terminate benefits. Fair hearing requests shall be submitted to the DHR Legal Services Office (LSO), 29th Floor, Two Peachtree Street, Atlanta, Georgia 30303.
A hearing request shall be effective upon receipt of a verbal or written request. A verbal request received within the sixty (60) days shall be accepted. The forty-five (45) day period allowed for rendering a hearing decision shall begin on the day the fair hearing request is received by the local agency.
Upon request, the local agency shall assist the claimant in submitting a request for a fair hearing. The claimant shall be advised by the local agency of any legal services available that can provide representation at the hearing.
C. Claimant's WIC Program Record Summary Form
The local agency shall prepare the Claimant's WIC Program Record Summary Form (Attachment RO-2). Within three (3) working days, the completed form and written request shall be submitted to the DHR Legal Services Office (LSO), 2 Peachtree Street, Atlanta, Georgia 30303. A copy of the form shall be sent to the WIC Branch. If the hearing request is filed initially with the DHR LSO, a copy will be immediately forwarded to the local agency.
The local agency has the responsibility of maintaining contact with the claimant and must report promptly to the LSO any change in circumstances, including changes in mailing address. As soon as the local agency receives notification that a hearing has been scheduled, the local agency WIC Program Coordinator shall immediately review the record to:
1. Re-examine the action of the local agency and the circumstances of the claimant to determine if an adjustment can be made.

2. Review claimant eligibility on all points other than the point at issue. All hearing requests, whether timely or not, must be submitted to the LSO. The local agency will secure any additional evidence necessary for the hearing.

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D. Case Record Disclosure Prior to the Hearing
All documents and records to be used in the hearing will be available for examination by the claimant and/or his/her designated representative prior to the fair hearing. Such examination shall be made at the local agency. "Designated representative" is understood to mean an attorney, friend, or personal counselor of the claimant. Upon request, the local agency shall make available, without charge, the specific materials necessary for a claimant or his/her representative to determine whether a hearing should be requested or to prepare for a hearing. The claimant and/or his/her representative will be given an opportunity to copy any materials in the file, which are relevant to the appeal. Confidential materials, which cannot be released to the claimant or his/her representative, shall be removed from the file prior to such copying and will not be used at the hearing. When local agency reproduction equipment and supplies are available, the agency staff will operate the equipment. When reproduction equipment is not available, the claimant or his/her representative may make longhand notes.
E. Adjusting Complaints
The local agency has the responsibility of taking proper action in adjusting all complaints. If an applicant/participant is dissatisfied, the local agency shall review their status with them. If the claimant so desires, the local agency shall assist him/her in filing the hearing request and preparing for the hearing. If the local agency and the claimant arrive at a mutually satisfactory decision prior to the hearing, the claimant may withdraw his/her request for the hearing in accordance with the withdrawal procedures. The local agency may amend or reverse its decision at any time prior to a hearing, regardless of the claimant's decision on withdrawal. In the case of withdrawal, amendment, or reversal, the local agency shall notify the LSO immediately, attaching a copy of the withdrawal or new notification and a summary supporting the corrective action taken by the local agency. If time does not permit written notification, the LSO shall be notified verbally with immediate follow-up in writing.
F. Continuation of Benefits
Participants who appeal the termination of benefits within fifteen (15) days from date of notification shall continue to receive program benefits
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until the final administrative decision.
Applicants who are denied benefits at initial certification or at subsequent certifications may appeal the denial, but shall not receive benefits while awaiting the hearing.
The local agency shall promptly inform the individual, in writing, if participation status changes, pending the hearing decision.
G. Denial or Dismissal of a Request for a Hearing by LSO or OSAH
A request for a hearing shall not be denied or dismissed unless: 1. The request for hearing is not received within the sixty (60) day
time limit. 2. The request is withdrawn in writing by the appellant or a
representative. 3. The appellant or representative fails, without good cause, to
appear at the scheduled hearing. 4. The appellant has been denied participation by a previous
hearing and cannot provide evidence that circumstances relevant to program eligibility have changed in such a way as to justify a hearing.

H. Notification of the Hearing
The hearing shall be conducted within twenty-one (21) days from the date the State received the hearing request. A time and place shall be arranged in order for the hearing to be accessible to the participant/designated representative. At least ten (10) days prior to the hearing, the Office of State and Administrative Hearings shall provide written notice to all parties involved to permit adequate preparation of the case. The notice shall contain the following: 1. A statement of the time, place, and nature of the hearing. 2. A statement of the legal authority and jurisdiction under which
the hearing is to be held. 3. A reference to the statutes and regulations involved. 4. A short statement of the complaint. If the agency or other party
is unable to state the complaint in detail, the notice may be limited to a statement of the issues involved.

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5. A statement that the State will dismiss the hearing request if the individual or his/her representative fails to appear at the hearing without good cause.
6. A statement that the participant/designated representative may examine the case files prior to the hearing.
The Administrative Law Judge may change the time and place of the hearing upon his own motion or that by the parties. The Administrative Law Judge may adjourn, postpone, or reopen the hearing upon receipt of additional information at any time prior to mailing the hearing decision. Should the Administrative Law Judge exercise the option of rescheduling the hearing, the claimant shall be given at least ten (10) days advance notice of such action.

I. Conduct of the Hearing and the Claimant's Rights
If, at the hearing, it becomes evident that the issue involved is different from the one on which the hearing was requested, the Administrative Law Judge shall exercise discretion and may conduct the hearing on the newly emerged issue. In such instances, the hearing may be continued so all concerned may prepare additional evidence.
The claimant/designated representative shall be provided with an opportunity to:
1. Bring witnesses. 2. Advance arguments without undue interference. 3. Question or refute any testimony or evidence, including an
opportunity to confront and cross-examine adverse witnesses. 4. Submit evidence to establish all pertinent facts and circumstances
in the case.
The local agency shall have the same opportunities listed above.
J. Attendance at the Hearing
The Administrative hearing shall be attended by a representative of the agency that initiated the action being contested and may be attended by the individual and/or his/her representative. Other local agency staff may attend and participate in the hearing process at the discretion of the Administrative Law Judge. Friends and relatives of the claimant may also

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attend the hearing if the claimant so chooses.
K. The Hearing Record
The Administrative Law Judge shall compile the official hearing record that covers all points of eligibility dealing with the issues directly related to the action being appealed. The record shall include:
1. All pleadings, motions, and intermediate rulings. 2. A summary of the oral testimony and all other evidence received
or considered, except that oral proceedings and any part thereof, shall be transcribed or recorded upon request. Upon written request, a transcript or tape of such oral proceedings, or any part thereof, shall be furnished to any party to the proceedings. 3. A statement of matters officially noted. 4. Questions of matters officially noted. 5. The decision by the Hearing Officer. 6. All staff memoranda and dates submitted to the Hearing Officer in connection with the case.

L. The Hearing Decision
Decisions of the Administrative Law Judge shall comply with State and Federal law, rules, regulations and policy and shall be based on the hearing record. The Administrative Law Judge's decision shall take into consideration only those issues directly related to the action being appealed and shall be based exclusively on evidence and other material introduced at the hearing. A decision by the Administrative Law Judge shall be binding on the local agency and shall summarize the facts of the case, specify the reasons for the decision, and identify the supporting evidence and the pertinent regulation(s) or policy. The decision shall become a part of the record.
M. Notification of the Hearing Decision
Within forty-five (45) days of the receipt of the request for a hearing, the claimant and/or his/her representative shall be notified in writing of the decision. If the decision is in favor of the claimant and participation was denied or discontinued, benefits shall begin immediately.
If the decision is in favor of the agency, as soon as administratively

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feasible, any continued benefits shall be terminated as decided by the Administrative Law Judge and efforts will be made to collect the claims.

In addition, the decision will inform the claimant of any right to appeal known to the Administrative Law Judge and shall advise that an appeal request may result in a reversal of the decision.
N. Appeal Rights of the Claimant
When a decision is adverse to the claimant, he/she has the right to appeal to a DHR Appeal Reviewer. The DHR Appeal Reviewer shall allow the claimant thirty (30) days to request review of the decision. The DHR Appeal Reviewer shall have all the powers and delegated authority of the Commissioner to make a decision. He/she may take additional testimony or remand the case to the Administrative Law Judge for such purpose. The decision will be based upon the record from the original hearing as presented before the Appeal Reviewer and shall either affirm, reverse, or modify the original decision to assure full compliance with State and Federal law, rules, regulations, and policy.
If the claimant requests review of the Administrative Law Judge's decision, the usual standard of promptness is automatically waived. The claimant and his/her legal representative shall be notified, in writing, of the decision of the Appeal Reviewer and of his/her right to judicial review. If the claimant is dissatisfied with the decision of the Appeal Reviewer, he/she has the right to pursue judicial review (e.g., civil court).
O. State Rules of Procedure
The State agency shall provide and distribute upon request, to any interested party, that portion of the Georgia WIC Program Procedures Manual that outlines the Fair Hearing Procedures.
P. Participant Complaint
The WIC participant may file a complaint (written or oral) regarding staff or clinic treatment (unrelated to discrimination or ineligibility/disqualification). Documentation of this complaint may be written on the Incident/Complaint Form.

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VI. FAIR HEARING PROCEDURES - MIGRANTS
Because migrant farm workers and their families may leave a program area after a very short time, it is important that fair hearing procedures for migrants be expedited, by contacting them immediately for the hearing process. When a local agency receives a fair hearing request from a migrant, they should attempt to find out how long the migrant will be in the program area and should convey this information to the DHR Legal Services Office and WIC Branch.
VII. ADMINISTRATIVE APPEALS PARTICIPANT - LOCAL AGENCY
An entity such as a doctor, hospital or HMO, applying to become a WIC provider, can appeal a decision of the state or local agency if the decision resulted in the denial of that application.
The appeal must be filed within thirty (30) days of the adverse action and the fair hearing must be scheduled within thirty (30) days of the filing of the appeal. Fifteen (15) days advance notice of the hearing date will be given to the applying entity with an option to reschedule one (1) time with just cause.
The applying entity will have ample opportunity to present its case at the hearing, including the opportunity to confront and cross-examine witnesses. Counsel may represent the applying entity if desired. The applying entity may review the case file prior to the hearing.
The local agency will have ample opportunity to present its case at the hearing, including the opportunity to confront and cross-examine adverse witnesses. Counsel may represent the local agency, if desired. The local agency may review the case file prior to the hearing.
In the event of a hearing, an administrative hearing panel will be appointed by the Director of the WIC Branch to hear local agency appeals. This panel will consist of one (1) local agency WIC Program Coordinator and two (2) representatives from the Division of Public Health. This panel will be an impartial decision maker with no personal interest or involvement in the outcome of the hearing or the statutory and regulatory provisions governing the program. The basis of the decision shall be stated in writing, though it need not amount to a full opinion or contain formal findings of fact and conclusions of law. The local agency will be notified of the decision within sixty (60) days from the date of the request. If a State decision is rendered against the local agency, the local agency may pursue judicial review of the decision.

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VIII. AVAILABILITY OF HEARING RECORDS
The State and local agencies shall make all hearing records and decisions available for public inspection and copying; however, the names and addresses of the participants and other members of the public must be kept confidential.
IX. NATIONAL VOTER REGISTRATION ACT
The National Voter Registration Act of 1993 (NVRA) requires states to provide voter registration through designated agencies. WIC is a designated agency. At the time of program certification applicants or participants must be offered a opportunity to register to vote.
Individuals wishing to register must be given a voter registration application and any assistance needed to complete the form. WIC Staff should collect the form when it is completed and submit to the Secretary of State.
To order additional forms, you may either (1) complete and mail the order form provided to you in your User Guide; 2) Fax the order form to the attention of Carol Fuller at (404) 651-9531 with the number of applications needed (100 to a package); or email Ms. Fuller at cfuller@sos.state.ga.us (See Attachment AD-3).
An applicant/participant who is already registered or does not wish to register must complete a declination statement. Submit appropriate documentation to the Secretary of State.
Acting in this manner ensures that the Georgia WIC Program complies with federal regulations and USDA guidelines. Please note, according to USDA guidelines, an applicant does not need to be a citizen of the United States to receive WIC.
The Secretary of State prepares a WIC Voter Registration Report quarterly to determine local agency compliance. Failure to comply with Motor Voter Registration requirements could result in monetary penalties for your local agency and the State of Georgia. It may also lead to intervention by the United States Department of Justice.

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Attachment RO-1

Georgia Department of Human Resources Division of Public Health/Georgia WIC Program
RIGHTS AND OBLIGATIONS
1. The rules for signing up and taking part in the WIC Program are the same for everyone regardless of race, color, national origin, sex, age, or disability.
2. You may appeal any decision made by the clinic about your eligibility for WIC by asking for a fair hearing.
3. The clinic will give you information about food that is good for you. Health service referrals are also available to you. The clinic would like you to use these services.
4. Information on your WIC form will be used to review the program and tell us how many people are on WIC.
5. The WIC Program may disclose specific applicant information to designated health or welfare agencies for the purpose of determining eligibility and conducting outreach to WIC applicants and participants.
6. The food you get from WIC is only for you or your children.
7. You may be taken off WIC if: You do not tell the truth. You get vouchers from more than one (1) WIC program at the same time. You do not keep your certification appointments. (Rescheduling WIC appointments may take from 7 to 20 days depending on the clinic schedule). You do not get your vouchers for two (2) months in a row. You sell or trade your WIC vouchers or WIC food for money or anything not authorized by the WIC Program. You use your vouchers to buy food that is not on the authorized WIC food list. You exchange your WIC food items after purchase for any item(s) not listed on the voucher. You use abusive language with clinic staff, store clerks, or managers. You are physically violent with clinic staff, other WIC clients, or store personnel.
8. If you do not keep your appointments, the number of vouchers issued to you or your child will be reduced.

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Attachment RO-1 (cont'd)

SCHEDULE FOR PICKING UP VOUCHERS LATE Failure to keep appointments will reduce the number of vouchers you receive.
LATE PICK-UP

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

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

Infants Full package Full package 1 voucher issued 1 voucher issued

If you have any questions about this form, you may ask for help or call the clinic. LATE PICK-UP SCHEDULE ADDITIONAL/ALTERNATE FOOD PACKAGES

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

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

Infants full package full package 1 voucher issued 1 voucher issued

Form 3768 (Rev.)

"This institution is an equal opportunity provider."

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Attachment RO-2

GEORGIA DEPARTMENT OF HUMAN RESOURCES
CLAIMANT'S WIC PROGRAM RECORD SUMMARY
SECTION I - IDENTIFICATION

District/Unit

WIC ID #

Applicant/Participant:

Claimant (if different from above):

Address:

Street Number and Name

City

State

Zip Code

Phone Number:

Representative:

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

1. white male

2. white female

3. nonwhite male

4. nonwhite female

County:

Date of Request:

Date of Appointment:

Date of Notification:

FOR STATE OFFICE USE ONLY:

Request number:

Date request filed:

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

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Attachment RO2 (cont'd)

SECTION II - TYPE OF AGENCY ACTION OR INACTION

A. Agency Action (Circle item number)

Participation denied/terminated because client:

1. Is not income eligible.
2. Does not live in local program area.
3. Has reached expiration of regulatory eligibility.
4. Is not pregnant, postpartum, breastfeeding or infant/child under five (5) years old.

__________ Date __________ Date __________ Date __________ Date

5. Does not meet nutritional risk criteria.

6. Failed certification appointment on: ____________________.

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

8. Violated program rules and was suspended for three

(3) months for:

.

9. Is in Priority and program has funds to serve

only Priority(ies)

.

10. Other

.

B. Agency Inaction (Circle item number):

__________ Date __________ Date __________ Date
__________ Date
__________ Date __________ Date

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

2. Other: (specify) ________________________________________________________

_____________________________________________________________________

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Attachment RO2 (cont'd)

SECTION III - NARRATIVE SUMMARY OF AGENCY'S ACTION OR INACTION AND PRINCIPAL ISSUES INVOLVED IN THE REQUEST FOR HEARING
A. Basis for local agency's action or inaction (specify briefly):

B. WIC regulations applied by local agency:

C. Participant's income eligibility information:

_______________________________ Signature/Title of WIC Personnel

_______________________________ Signature of WIC Coordinator

________________________________ Program Name

________________________________ Address

________________________________

City

State

Zip Code

_________________________________ Telephone Number

Prepare in triplicate Original - DHR Legal Services Office File Copy - Georgia WIC Branch File Copy - District/Local Agency

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Attachment RO-3

ORDER FORM FOR VOTER REGISTRATION SUPPLIES

TO:

Office of Secretary of State

Elections Division

1104 West Tower, #2 Martin Luther King Jr. Dr., SE

Atlanta, GA 30334

OR: FAX to Carol Fuller 404/651-9531 Email: cfuller@sos.state.ga.us Call: 404/657-5367

FROM:

__________________________________________ Agency/Library Name

__________________________________________ Street Address

__________________________________________

City

Zip Code

__________________________________________

Contact Person

Area Code/Telephone

DATE:

__________________________________________

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

______

AENV

Agency Pre-addressed Postage Paid Return Envelope Package of 100

______

DS

Declaration Statement (used for declinations)

Pads of 100

______

ATF

Agency Daily Transmittal forms (Recaps) Packages of 250

______

VRA

Mail Voter Registration Applications Packages of 100

______

GUIDE

Training Manual

NOTE: YOU MAY INCLUDE ORDER FORM IN WITH MAILING OF COMPLETED VOTER REGISTRATION APPLICATIONS OR FAX TO 404/651-9531

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Administrative

TABLE OF CONTENTS SECTION ONE - FINANCIAL MANAGEMENT

Page

I. Agreement with State Agency ............................................................................... AD-1

II. Financial Procedures ................................................................................................ AD-1

A. District Health Agencies ................................................................................. AD-1

B. Non-profit Agencies ....................................................................................... AD-1

C. Unliquidated Obligations ............................................................................... AD-1

D. Year End Funds Obligations .......................................................................... AD-1

III. Nutrition Services and Administration Cost Categories .................................... AD-2

A. Cost Pool............................................................................................................ AD-2

B. Nutrition Education Costs............................................................................. AD-2

C. Breastfeeding Costs.......................................................................................... AD-2

D. Direct Costs ....................................................................................................... AD-3

IV. Random Moment Sample Study (RMSS) .............................................................. AD-3

V. Expense Categories ................................................................................................... AD-4

A. Capital Expenditures...................................................................................... AD-4

B. Automated Data Processing (ADP) Equipment.......................................... AD-4

VI. Equipment Inventory .............................................................................................. AD-4

A. Acquisition .............................................................................AD-4

B. Status Change .........................................................................AD-4

VII. Allocation of Nutrition Services and Administration Funds ............................. AD-5

VIII. Program Income ....................................................................................................... AD-6

A. Revenue.................................................................................AD-6 B. Misuse of Funds.......................................................................AD-6

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SECTION TWO - PROGRAM ADMINISTRATION I. Retention of Records................................................................................................. AD-6
A. Definition of Records....................................................................................... AD-6 B. Records and Reports - Accessibility of Records .......................................... AD-6 C. Retention Schedule .......................................................................................... AD-7 D. Prior Approval/Duplication of WIC Records............................................. AD-8 II. WIC Acronym and Logo........................................................................................ AD-10 A. Authority ......................................................................................................... AD-10 B. Official Use...................................................................................................... AD-10 C. Special Use ...................................................................................................... AD-11 D. WIC Food Vendors ........................................................................................ AD-11 E. Unauthorized Use .......................................................................................... AD-12 III. Lobbying Restrictions............................................................................................. AD-12 IV. Confidentiality......................................................................................................... AD-12 V. E-Mail and Faxing Confidential Information ..................................................... AD-13 VI. WIC Volunteers and Confidentiality .................................................................. AD-14 VII. Health Insurance Portability and Accountability Act ....................................... AD-14 VIII. Retroactive Benefits and Reimbursements.......................................................... AD-15 IX. Mandatory No-Smoking Policy in Local WIC Clinic......................................... AD-15 X. Subpoenas ................................................................................................................ AD-15 XI. Search Warrants ...................................................................................................... AD-17 XII. Program Participation............................................................................................ AD-17 XIII. Establishing New Clinics/Clinic Changes.......................................................... AD-17 XIV. Clinic Closings......................................................................................................... AD-19 XV. Damage Formula Report........................................................................................ AD-19

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XVI. Reporting Systems Problems................................................................................. AD-19 XVII. Request for Financial and/or Statistical Data .......................................AD-20 XVIII. Identification Cards, and Food List Orders Referral Form.......................AD-20

Attachments: AD-1. FFY 2002 Georgia WIC Branch Agreement ....................................................... AD-21 AD-2. Equipment Status Change Form/Transfer Form & Invoice ........................... AD-24 AD-3. Agreement for Disclosure of Information.......................................................... AD-25 AD-4. Release of Information Form................................................................................ AD-26 AD-5. Request to Establish New Clinic/Clinic Changes ............................................ AD-27 AD-6. System Problem Report Form............................................................................. AD-28 AD-7. New Site Permission Request Form.................................................................... AD-29 AD-8. Data Request Form ........................................................................AD-30

GA WIC 2005 PROCEDURES MANUAL

Administrative

SECTION ONE - FINANCIAL MANAGEMENT
I. AGREEMENT WITH STATE AGENCY Prior to July 1 of each year, all District Health agencies operating a WIC Program, excluding contract local agencies, must sign a copy of the Master Agreement which includes Annex I and submit to the Budget Office. (See Attachment AD-1).

II. FINANCIAL PROCEDURES
A. District Health Agencies
Adhere to:
Georgia WIC Procedures Manual USDA FNS Instruction 808-1 OMB Circular A-87 and A-102 Grant-in-Aid Policy & Procedure Manual, Parts III.E, Attachment 1 and IX.A,B., from the Department of Human Resources. Title 7 Code of Federal Regulations Part 246 (7 CFR 246)
B. Non-profit Agencies Adhere to the tenets of the negotiated contract and prescribed policies and procedures established by USDA, (7 CFR 246), the WIC Branch (Division of Public Health) and DHR.

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

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Administrative

III. NUTRITION SERVICES AND ADMINISTRATION COST CATEGORIES

A. Cost Pool (301)

1. All Salaries.

2. Purchases not 100% WIC.

3. Travel and training costs not 100% WIC.

4. All Inter/Intra Agency Agreements between Health District WIC Programs and County Boards of Health for WIC services.

B. Nutrition Education Costs (007)
Federal regulations require that each WIC State agency spend one-sixth of its NSA Grant for Nutrition Education.
The cost of activities directed toward helping participants understand the importance of nutrition in relation to health, is allowed as nutrition education expense.
C. Breastfeeding Costs (009)
A local agency is required to spend WIC breastfeeding funds for breastfeeding related costs and activities. The following breastfeeding costs are allowable: 1. Travel and training costs of staff associated with breastfeeding
promotion and support activities.
2. Contracts for services of breastfeeding specialist.
3. Breastfeeding aids, such as breast pumps, breast shells, nursing supplements, nursing bras and nursing pads, which directly support the initiation and continuation of breastfeeding. A quarterly report listing breast pump expenditures including quantity and dollar amount should be submitted to the State WIC Financial Section by the 15th of the month following the end of the quarter.
4. Items used for training and demonstration purposes to promote breastfeeding or assist participants in using breastfeeding aids. Such

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items may include models to illustrate the use of various breastfeeding aids, dolls used to illustrate nursing, etc.
5. Development, procurement and distribution of materials, instructional curricula, etc., related to breastfeeding promotion and support.
6. Developing and updating the biennial Breastfeeding Promotion and Support Plan.
7. Payments for interpreters and the translation of breastfeeding materials.
8. The costs of agreements with other individuals or organizations, whether public or private, to provide breastfeeding training and direct service delivery to WIC participants.
D. Direct Costs (643)
Allowable administrative and operational costs are those costs necessary to fulfill program objectives.
1. 100% WIC expenses that do not qualify under Nutrition Education or Breastfeeding activities such as, office supplies, WIC forms, rent, telecommunication, maintenance, postage, travel, contracts, promotion items, outreach activities specific to WIC.
2. All pre-approved equipment and computer purchases.
3. No Inter/Intra Agency Contracts can be charged to WIC Direct Cost Category.

IV. RANDOM MOMENT SAMPLE STUDY (RMSS)
The Random Moment Sample Study (RMSS) is a statewide method of measuring time worked per program by employees. This method uses a statistically valid sample to determine the time employees expend on individual programs. The results of the RMSS for a quarter are used as a basis for the distribution of each quarter's cost. A comprehensive and detailed procedural methodology of this process is included in Appendix B of the Cost Allocation Plan. A copy of the Cost Allocation Plan can be obtained from the Georgia Department of Human Resources, Office of Financial Services.

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V. EXPENSE CATEGORIES

A. Capital Expenditures

Approval for capital expenditures in excess of $4,999.99 for a single item must be requested in writing by the local agency. The Georgia WIC Branch will review the request and in consultation with USDA will approve or deny the request in writing.

B. Automated Data Processing (ADP) Equipment.

All computers and computer related equipment and software is prohibited without prior approval of the Georgia WIC Branch regardless of cost.

VI. EQUIPMENT INVENTORY
Maintenance of a complete and accurate inventory of all equipment leased or purchased with WIC funds is an ongoing district responsibility. Updates to the Georgia WIC Inventory Database are required whenever new non-ADP equipment over $1,000 or new (any dollar amount) ADP equipment has been acquired. Equipment that is transferred, surplused, destroyed or reported stolen or missing also requires and immediate update to the database.
Updating the database falls into one of the two categories, acquisition and status change. It is understood that districts will provide the branch with appropriate and immediate notification of their equipment acquisitions and status changes as follows:
A. Acquisition
Acquisition of a new item requires the districts to complete a new record in the database and send a copy of the newly written database, electronically to the state office. The branch will then overwrite (save) the appropriate copy in its master file.
B. Status Change
Change in the status of an item requires the districts to complete DHR Form 5086 (AD-2) with appropriate fields marked to reflect that change. Form 5086 is then forwarded to the WIC Branch by mail and approved by

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the proper authority. Changes in the master file are then made by the WIC Personnel and a copy of the new district portion of the database is electronically mailed back to the district. The district must then overwrite (save) that copy in their database directory. This will ensure that both the district portion and the state master file are in agreement and fully updated. Instructions for each status change are listed below:
1. Surplus Equipment
Surplus Equipment according to DHR Real and Personal Property Management Manual Regulations.
2. Equipment Without Value
Equipment that is no longer valuable and/or usable and is schedule for destruction must be noted on DHR Form 5086. Also attach a Destruction of Surplus Property Affidavit, which must be signed by the appropriate state authority and returned to the district prior to their taking any action.
3. Stolen Equipment
Complete DHR Form 5086 and attach a police report.
4. Missing Equipment
Districts are to complete DHR Form 5086 and attach a brief explanation of the circumstances leading to equipment disappearance. Should equipment be recovered, complete another DHR Form 5086, attach an explanation for equipment reappearance. Forward all forms to the branch.

VII. ALLOCATION OF NUTRITION SERVICES AND ADMINISTRATION FUNDS
The WIC Allocation Advisory Committee was established for the purpose of advising the WIC Branch and the Division of Public Health regarding the development of an acceptable methodology for allocating federal grant funds to local agencies. The current WIC approved funding formula recommendations were approved by the Advisory Committee in 2001. A District Health Director chairs the committee.

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VIII. PROGRAM INCOME
A. Revenue Any revenue generated as a result of administering the WIC Program is considered as governmental and/or program income and will be used to further program objectives in accordance with the Code of Federal Regulati ons (CFR), Title 7, and Section 3016.25.
B. Misuse of Funds Any vendor, local agency or state agency and/or individual(s) that embezzle willfully misapply, steal or obtain by fraud any funds, assets or property provided (whether received directly or indirectly from USDA) valued of $100.00 or more will have to pay a penalty of $25,000. SFP Regional letter, #250-04, March 8, 2004.
SECTION TWO - PROGRAM ADMINISTRATION
I. RETENTION OF RECORDS
A. Definition of Records
Federal regulations state: "Records shall include, but not be limited to, information pertaining to financial operations, food delivery systems, food instrument issuance and inventory, certification, nutrition education, civil rights and fair hearing procedures" [7 CFR 246.25(a)(1)].
State policy memos from the previous year may be destroyed once the new Procedures Manual has been received, unless otherwise instructed. For example, FFY `01 Policy Memos may be destroyed once the FFY `02 Procedures Manual has been received.
B. Records and Reports - Accessibility of Records
The WIC Branch, Federal Office of the Inspector General (OIG) as well as Investigative Agencies of the State and Federal Government have been given total access to WIC Program Records since that Office has overall authority and responsibility for the examination of the Food and Nutrition Service Program. The WIC Certification file is part of the documentation for determining food cost charge. Therefore, certification records when requested must be made available to the WIC Branch and OIG.

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If a certification file does not contain the required information, local agency personnel are required to make available to the OIG a medical case record or other documentation which will substantiate that the cost incurred by serving the participant is a proper charge to the WIC Program.
In cases where the OIG finds that certification data is insufficient, and is denied access to the medical record or other documentation is not made available, a claim will result against the State Agency.
C. Retention Schedule
1. The following documents must be retained for five (5) years, as stated in the DHR Record Retention Policy, issued November 12, 1986: (1) WIC Assessment/Certification Forms (2) Diet Histories (3) Growth Charts/Weight Gain Grids (4) VOC Card Inventories (5) Medical Records
2. The following documents must be retained for three (3) years plus the current Federal Fiscal Year: (1) Vendor Monitoring Reports (2) Computer Generated Voucher Registers/Voucher Printing On Demand (VPOD) Receipts (3) Manual Voucher Inventory Records (4) Budgets and Expenditure Reports (5) Contracts (6) Indirect Cost Plan (7) Shared Costs Documentation (8) Fair hearing and civil rights complaints and all related documentation (9) Federal, State, District, County Audit reports (10) Copies of manual vouchers (11) TAD's (12) Vouchers Activity Report (13) Dual participation Report* (14) Cumulative unmatched Redemptions (15) Part 1* (not matched to issuance record) (16) Cumulative Unmatched Redemptions, (17) Part 2* (not matched to a valid certification record)
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(18) Batch Control Report (19) Batch Control Form and Module (20) Critical Error Report (21) Canceled food instruments
3. The following documents must be retained for one (1) year plus the current year: (1) Waiting List (2) Voucher Packing List/VPOD Confirmation Notice

*The original copy of these reports with their manual reconciliation must be sent to the Georgia WIC Branch prior to being destroyed. The Georgia WIC Branch will maintain these reports for four (4) years.
D. Prior Approval/Duplication of WIC Records
Local Agencies must request prior approval for the reformatting or modification of any office WIC forms.
If the Local Agency duplicates an official WIC form, the Local Agency is responsible for ensuring that the form contains the exact information as its original.
The following documents are available through the Georgia WIC Information System (GWIS). GWIS documents are accessible via the web for a period of three (3) years plus the current Federal Fiscal Year.
a. Monthly Reconciliation - Enrollment Cycle 1. Alphabetic Master File Listing 2. Critical Error Report 3. Enrollee Income by Household Size 4. Grady Hospital Enrollee Distribution 5. Medicaid-Enrollee Income by Household Size 6. Medicaid-Percentage of Poverty Income by Type and Age Categories 7. Medicaid-Priority Counts by Percentage by Poverty Income Level 8. Numeric Master File Listing 9. Percentage of Poverty Level Income Level by Type and Age Categories
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10. Priority Counts by Percentage of Poverty Income Level 11. Trimester Analysis Report 12. Unduplicated Participation Report, State Fiscal Year 13. Unduplicated Participation Report, Federal Fiscal Year 14. Waiting List Report 15. WIC Status (Type) by Reason Certified

b. Monthly Reconciliation
1. Bank Exception Report 2. Bank Listing 3. Closeout Reconciliation Report 4. Cumulative Unmatched Redemptions Over 30 Days-
Based on CUR-Part 1 5. Cumulative Unmatched Redemption Over 30 Days-Based
on CUR-Part 2 6. District Unit/County Compliance Summary
(Concentrated Powder Ready To Feed). 7. Dual Participation Report-Part 1 8. Ethnic Enrollment and Participation by Priority (Issue 30
Day) and Closeout 9. Ethnic Participation Summary 10. Financial and Program Status 11. Food Cost Allocation (Projection) 12. Food Package Create Report 13. Food Package Expenditures Report 14. Infant Formula Rebate Report Concentrated Powder
Ready To Feed 15. Infant Rebate County Summary 16. Infant Rebate District Unit Summary 17. Migrant Participation Summary 18. Migrant Enrollment and Participation by Priority (Issue 30
Day) and Closeout 19. Monthly Report of Food Expenditures Summary (Issue 30
Day) and Closeout 20. Monthly Report of Food Expenditures by Vouchers Code
(Issue 30 Day Closeout 21. Participant Totals 22. Participation Summary by District/Unit 23. Previously Unmatched Redemptions Which Were
Matched 25. Unmatched Redemption's Report

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c. Monthly Reconciliation - Vendor Cycle
1. Cumulative Vendor Totals 2. Detailed Flagged Voucher Listing 3. Flagged Voucher by Vendor per Peer Average 4. Maximum Amount Input Update 5. Statistics File for Vouchers 6. Vendor Exception Report 7. Vendor Listing 8. Vendor Update Listing 9. Vendor Voucher Deviation Report 10. Voucher Redemption Fluctuation Report 11. Voucher Variation Report 12. Voucher by Day Cashed 13. Vouchers Cashed by Clinics 14. Financial Records

II. WIC ACRONYM AND LOGO
A. Authority
The acronym "WIC" was registered with the U.S. Patent and Trademark Office January 1, 1991 the WIC logo, a stylized representation of a woman holding an infant in her arms and a child by the hand, was registered April 16, 1991. Regulations authorizing the use of the WIC acronym and logo are provided in 42 U.S.C. 1786, 15 U.S.C. 1051 et seq., and 7 CFR Part 246.
It is an on-going policy to discourage the industrial use of the WIC acronym and logo on products to avoid certain difficulties that may be encountered.

B. Official Use

Use of the acronym "WIC" and the WIC logo is reserved for the official use of national, instructions and policies restrict use to purposes consistent with the WIC Program regulations. Materials, which display WIC identifiers will be used primarily for identification, public notification, and outreach purposes. Below is a list of the possible uses of the WIC acronym and logo. This list is not inclusive and there may be other WIC ideas. FNS reserve the right to approve any use of the WIC acronym or logo.

Brochures

Leaflets

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

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

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

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E. Unauthorized Use
Any person who uses the acronym "WIC" or the WIC logo in an unauthorized manner, including close facsimiles thereof, in total of in part, may be subject of injunction and the payment of damages. Any person who is aware of violators should provide the information to the Food and Nutrition Services (FNS) Office.
III. LOBBYING RESTRICTIONS
The State/Local Agencies must not use federal funds for lobbying for specific federal awards and requires recipients of any federal grants, contracts, loans, and cooperative agreements to disclose expenditures made with their own funds for such purpose.
IV. CONFIDENTIALITY
The State/local agencies are required to restrict the disclosure of information obtained from any program applicant/participant (See Attachment AD-3).
Effective FFY2003, Georgia WIC monthly reports are issued on CD to WIC Coordinators. At the discretion of the WIC Coordinators, other authorized staff may use the CD's. These CD's must be stored in a secure locked location. Password access must be used if the CD is installed. Sharing of CD contents is strictly prohibited.
WIC program information must not be released except in the following situations: A. The WIC applicant/participant signs a release of information (See
Attachment AD-4).
B. The State or local agencies enter into a written agreement with an organization (i.e. immunization program). The Director of Public Health must sign this agreement. In the event an agreement is entered into with the organization and the Director of Public Health, a release of information would not need to be signed by the WIC applicant/participant. Information shared with that agency however, is restricted (See Attachment AD-3). Note: The WIC Certification Form and
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Rights and Obligations Form have been revised to meet these requirements.

C. For the Comptroller General of the U.S. for audit and examinations authorized by law. Disclosure of information with other organizations may be used for the sole purpose of:
1. Determining eligibility for programs administered by the recipient organization.
2. Conducting outreach for the program.
Note: Information on the use of drugs and alcohol must not be shared.
V. E-MAIL AND FAXING CONFIDENTIAL INFORMATION
Districts that decide to fax or e-mail confidential information should incorporate a confidentiality provision statement into your fax cover sheet information. If the information contained on the fax or in the e-mail is considered Private Health Information (PHI) then the (HIPAA) regulations governing the release of such information applies. The following represents an example of such a statement:
CONFIDENTIALITY NOTE
The information contained in this fax/e-mail message is intended only for the personal and confidential use of the designated recipients named above. This message may involve and attorney-client communication, and as such is privileged and confidential. If the reader of this message is not of the intended recipient or an agent responsible for delivering it to the intended recipient, you are hereby notified that you have received this document in error and any review, dissemination, distribution or copying of this message is strictly prohibited. If you have received this communication in error, please notify us immediately by telephone and return the original message to us by mail. Our number is (404) 657-2900, and the fax number is (404) 657-2910
THANK YOU.

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VI. WIC VOLUNTEERS AND CONFIDENTIALITY
In order to prevent a breach of confidentiality, the Georgia WIC Program must exercise discretion in screening and selecting capable volunteers who will handle confidential information. It is therefore the responsibility of the local agency to ensure that volunteers who are given access to client information are well trained and knowledgeable of the restrictions in disclosure of patient information.
The following action steps must be taken in order to protect participant information: A. Once volunteers are selected, specific confidentiality requirements
governing the WIC Program must be covered in the orientation or training of volunteers.

B. Follow-up training must be conducted periodically to remind volunteers, as well as paid staff, of the importance of maintaining the confidential nature of participant information.

C. The selecting agency may have volunteers sign an agreement acknowledging restrictions on the disclosure of confidential information. By signing such a form, the volunteer would agree to keep information confidential or forfeit the volunteer assignment. Such an agreement would reinforce the importance of maintaining confidential participant information.

D. If a volunteer does not appear to be a good candidate for keeping information confidential, assign the volunteer to other activities in the program.

VII. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)
By law, the WIC Program is exempt from HIPAA. However, HIPAA compliance may be required because of WIC's unique contract and referral practices.
The privacy practices of WIC are in compliance with the HIPAA laws. State-toState transfers are allowable. A request for release of information is advised.

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VIII. RETROACTIVE BENEFITS AND REIMBURSEMENTS
WIC regulations do not provide for retroactive benefits and reimbursement. The WIC Food Packages are designed to be consumed within a specified time period when participants are experiencing critical growth and development.

IX. MANDATORY NO-SMOKING POLICY IN LOCAL WIC CLINICS
Public Law 103-111 prohibits the allocation of Administrative Funds to any clinic providing WIC services if that clinic allows smoking within the space used to perform program functions. In order to avoid administrative penalties, Local Health Department or WIC Clinics must display a No Smoking Sign. These signs must be visible somewhere in the clinic.
The prohibition against smoking applies only during the hours of actual WIC operations. In the event the clinics for voucher issuance are being held at a satellite clinic (i.e. church, public housing, clinic site, community health center only once or twice per week) then the no-smoking policy would only be in effect during WIC operation hours. If the health department is a no-smoking facility, and such signs are displayed throughout the health department, then there is no need to display a WIC specific no-smoking sign.

X. SUBPOENAS
A. Subpoenas
A subpoena is a request for information issued by a clerk of a court in response to a request by an attorney representing a party. A subpoena may be directed to an individual or an entity. In the event, the local agency receives a subpoena, please follow the instructions below. Also, please contact the Georgia WIC Branch for legal advice.
B. Procedures for Responding to a Subpoena
1. State or local agencies, in consultation with their legal counsel, must make a determination based on the content of the subpoena and the requested information whether or not to comply with the subpoena and release the information as requested or to attempt to quash the subpoena. In making the determination, State or

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local agencies must determine whether the information is protected under 7 CFR 246.26(d) of the WIC regulations.
2. Decisions to release WIC information as requested by a subpoena or to attempt to quash a subpoena must be based on the requirements and restrictions set forth in 7 CFR 246.26(d) of the WIC regulations, any pertinent State laws, FNS Instruction 800-1, and WIC Policy Memorandum 94-3. Any conflicts identified between Federal and State requirements should be referred to the DHR Legal Services Office where appropriate.
3. If the court denies the motion to quash the subpoena and requires the WIC State or local agency to release the requested information, the State or local agency or legal counsel acting on its behalf shall attempt to: a. consider the appropriateness of an appeal of the decision
b. ensure that the information produced is only what is essential to respond to the subpoena (i.e. provide related documents reflecting only the requested WIC information)
c. attempt to negotiate the extent to which the WIC information actually produced becomes public information (i.e. reviewed in camera by the court, limited entry into the public record)
4. If the motion to quash the subpoena is denied by the court, we recommend that legal counsel acting on behalf of the State or local agency request the parties reduce to writing the terms of the release of the subpoenaed information so that all parties are in accord as to the use of such information. Ideally, counsel should seek a warrant of attachment or similar court order. A warrant of attachment is a written order by the Court based on State law, which orders a law enforcement officer to seize specific documents and deliver them to the court, essentially forcing the State or local agency to comply. In this way, there is a record that WIC State or local officials disregarded the Federal law protecting the confidentiality of WIC records only after having been compelled to do so by a court.

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5. State/Local agencies must advise legal counsel of any formal complaints that may result in litigation. Receipt of a subpoena or search warrant must also be reported to the WIC Branch and legal counsel.
6. In some instances, a State or local agency maybe required to release confidential information in response to a subpoena or search warrant. However, if the release of such information is made pursuant to and in keeping with WIC Program regulations, instruction, and policy, that release will not result in FNS or its agents taking adverse action against the State and local agency or any individuals acting on their behalf.
XI. SEARCH WARRANTS
In addition to the issuance of subpoenas, search warrants have been used by police investigators to obtain WIC applicant and participant information. State and local agencies must comply with search warrants. A search warrant differs from a subpoena in which a time frame is established to either comply with the subpoena or attempt to quash the request. Failure to fully comply with a search warrant at the time it is served could result in the incarceration of WIC State and local agency staff.

XII. PROGRAM PARTICIPATION
The definition of a participant and enrollee is listed below:
Participant: Participants means pregnant women, breastfeeding women, postpartum women, infants and children who are receiving supplemental foods or food instruments under the program and the breastfed infants of participant breastfeeding women. A participant is a client who has been issued at least one voucher during the reporting month. The exclusively breastfeed infant is issued a voucher message, no formula is issued.

Enrollee: A client who is active, during a valid certification period, but did not receive vouchers during the reporting month. XIII. ESTABLISHING NEW CLINICS/CLINIC CHANGES
All local agencies must submit clinic changes to the Georgia WIC Branch within thirty (30) days of the date the change occurs. No clinic may open in the State of

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Georgia without written approval from the Georgia WIC Branch. Additionally, all clinics must have a clinic number, sort numbers must no longer be used.
Clinic changes are reported using the Request for Establishing New Clinic/Clinic Changes Form (Attachment AD-5). The form must be completed and forwarded to the Georgia WIC Branch when there is a change in clinic address or a request to establish a new clinic site.
All Local Agencies must utilize the following procedures to establish new clinic sites: 1. A Local Agency wishing to establish a new clinic must contact the Georgia
WIC Branch in writing.

2. The Georgia WIC Branch Systems Information Unit will forward to the requesting agency a Request to Establish New Clinic /Clinic Changes Form within five (5) days from the date of the request.

3. The Local Agency completes the form (See Attachment AD-5) and returns it to the Georgia WIC Branch.

4. Upon receipt of the completed form, the Systems Information Unit verifies the information and forwards the form to the data processing contractor within five (5) days from the date of receipt.

5. The data processing contractor assigns a number for the new clinic site. If the Local Agency selects its own new number, the data processing contractor must verify and approve the number before it may be considered a valid number.

6. The data processing contractor mails the new clinic the supplies necessary to start clinic operations (i.e., TAD, Vouchers, etc.).

7. The Georgia WIC Branch will provide technical assistance, consultation, and training to the Local Agency in the start up procedures of a new clinic. Attachment AD-7 (New Site Permission Request Form) will be forwarded to each clinic once the state approves the clinic.

8. Any District/local agency that opens a clinic without following the above procedures will be in violation of these requirements and vouchers will not be delivered to clinics that so not have a clinic number

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XIV. CLINIC CLOSINGS In the event a clinic is going to be closed temporarily due to an emergency, please notify the Policy Unit at the Georgia WIC Branch as early as possible. This will enable the local/state staff to better serve the applicants/participants and clinic staff.

Closing of clinics causes participants/applicants hardship when they are not notified in writing or in advance.
If your district plans to close a WIC clinic permanently, please complete the Clinic Change form and mail it to the WIC Branch System Unit (See Attachment AD-5).
XV. DAMAGED FORMULA REPORT
The Formula Tracking Log (See Food Package Section) must be used to report free trade formula that is damaged on receipt.
When a formula shipment is sent damaged, complete the section of the form indicating the formula was discarded and the reason the formula was discarded and fax this form to the System Unit attention at the Georgia WIC Branch. The Fax Number (404) 657-2910.
XVI. REPORTING SYSTEMS PROBLEM
Local WIC Agencies must immediately report any Covansys and/or front-end systems discrepancies to the Systems and Information Section of the Georgia WIC Branch. Systems discrepancies may include, but are not limited to the following; duplicate vouchers, duplicate voucher numbers, inaccurate voucher numbers, vouchers without a number, or any action which causes an unmatched redemption. Fax the completed System Problem Report Form, (Attachment AD6) to the State WIC Branch. In addition, the clinic should notify the WIC Coordinator and Management Information Systems staff at the District Office.

XVII. REQUEST FOR FINANCIAL AND/OR STATISTICAL DATA
Request for financial and/or statistical data or reports must be made in writing (Data Request Form AD-30). Fax data request forms to the State WIC Branch, (404) 657-2910, Attention Systems Information Section.

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XVIII. IDENTIFICATION CARDS AND FOOD LIST ORDERS
The WIC ID Cards, Food List and Referral Form will be mailed to your District Office from the contracted printer quarterly (Jan., April, July and Oct.) each year. If the amount received needs to be adjusted based on an increase or decrease in caseload, please contact the State WIC Branch.

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Attachment AD-1

SFY 2005
ANNEX I STATE OF GEORGIA DEPARTMENT OF HUMAN RESOURCES PUBLIC HEALTH AGREEMENT
FOR THE SPECIAL SUPPLEMENTAL NUTRITION PROGRAM
FOR WOMEN, INFANTS AND CHILDREN (WIC)

This provider agreement is made pursuant to the Georgia Department of Human Resources (DHR) Administrative Policy and Procedures Manual, Part II A.l., and United State Department of Agriculture/Food and Nutrition Services (USDA/FNS) regulations being 7CFR 246. This agreement is between the Georgia Department of Human Resources, Division of Public Health (hereinafter referred to as the WIC Branch) and the Board (hereinafter referred to as the Local Agency). This agreement is effective the first day of July, 2003 and shall continue for one (1) year unless revised or terminated as provided herein.

THE STATE AGENCY AGREES:
To allocate administrative funds to the Local Agency for their use in meeting all allowable administrative, nutrition education, breastfeeding and client service expenses of the Local Agency.
To pay cost of food vouchers issued by the Local Agency and redeemed by retailers for eligible participants.
To monitor and evaluate the Local Agency to insure maximum effectiveness and efficiency; to provide technical assistance and consultation; and to provide training for Local Agency staff on a routine basis and as requested.
To provide specific manuals, forms, and nutrition education materials required for operation of the Local Agency WIC Program as specified in the WIC Branch Policy and Procedures Manual and the WIC Branch State Plan for Program Operation.
To conduct independent verification and validation that local WIC data system modifications are performing as expected and/or to recommend modifications as required to meet federal and state program regulations and guidelines.

THE LOCAL AGENCY AGREES:
That administrative costs may not be charged to WIC unless a cost allocation plan has been approved by the Department's Office of Financial Services.
To comply with USDA program regulations 7 CFR 246 and state policies and procedures as outlined in the WIC Branch State Plan for Program Operation and the WIC Branch Policy and Procedures Manual.
To comply with the Georgia DHR Administrative Policy and Procedures and DHR Grants-to-Counties Policies for administration of funds.
To submit the program plan or plan update for the upcoming federal fiscal year to the WIC Branch by May 15th of the fiscal year.

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To submit quarterly reports regarding local agency accomplishments relative to program objectives as stated in the District Program Plan by the 15th of the month following the end of the quarter.
To submit a quarterly breast pump expense report by the 15th of the month following the end of the quarter. The breast pump reports must include quantity and dollar amount expended.
To maintain complete and accurate documentation of allocated funds received and expended, employing General Accepted Accounting Principles (GAAP) and to make these records available for audit upon request of the WIC Branch or the Federal Agency. To establish budgets for Random Moment Sample Study (RMSS) Cost Pool (301) expenses, direct nutrition education (007) expenses, direct breastfeeding (009) expenses and 100% direct WIC administrative (643) expenses.
In case of an audit exception, the Local Agency may be required to repay the Department from the Local Agency's non-participating funds.
Federal regulations require the WIC Branch to spend 97% of its food grant dollars. Failure to meet this mandate may result in the imposition of a penalty. To be consistent with the federal mandate each Local Agency will be expected to serve a minimum number of WIC participants as determine by the federal caseload mandate.
To request and obtain through the WIC Branch prior approval for all computer hardware regardless of cost and for any capital expenditure over $5,000.
To provide the WIC Branch immediate and complete access to all clinics and all records maintained by WIC clinics within the District.
To implement a security system for unissued food instruments (vouchers) which will protect and reduce the risk of on-site lost/stolen vouchers. In the event unissued vouchers are lost or stolen resulting in USDA sanctions, the Local Agency may be responsible for repaying the WIC Branch for the value of those food instruments. In the event of over issuance of food instruments, the local agency is responsible for payment to the WIC Branch.
To develop an action plan to guard and protect all automated systems and data elements in the event of a disaster or emergency affecting the operation of a local agency (or agencies) and to have a disaster recovery plan available for WIC Branch review.
To perform full system backups on a daily basis of all WIC transactions detailing the enrollment of WIC applicants and the issuance of vouchers.
To submit documentation to include user's manuals and/or other teaching guides that help users to better understand the operation of the WIC enrollment/certification and voucher issuance processes.
To ensure that WIC approved edits, as determined by State and Federal authorities, are properly programmed and operating on the chosen data processing system.
For agencies that use non-state front-end data collection and processing systems, a copy of the "Report on Controls Placed in Operation and Tests of Operating Effectiveness in Accordance with Statement of Auditing Standards No. 70 (SAS 70 Report)" must be secured from the contractor and submitted to the WIC Branch.
To develop a plan and timetable for all systems modifications and submit the plan to the WIC Branch prior to implementation.
To test all system modifications in a test environment prior to placing such modifications into production.
To submit signed copies of all Inter/Intra Agency Agreements for WIC Services between the Local Agency and its County Boards of Health and sub-contracts that relate to the delivery of WIC services. The Inter/Intra Agency

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Attachment AD-1

Agreements must be submitted by September 30th of the fiscal year. All sub-contracts must be submitted within 45 days of the date of consummation.

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Attachment AD-1

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

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GA WIC 2005 PROCEDURES MANUAL

Attachment AD-2

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GA WIC 2005 PROCEDURES MANUAL

Attachment AD-3

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

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

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

______________________________
Director
__________________________________ Receiving Organization
__________________________________ DATE

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GA WIC 2005 PROCEDURES MANUAL

Attachment AD-4

RELEASE OF INFORMATION FORM

Georgia Department of Human Resources

________________________________________
Name of Client/Patient/Applicant

________________________________________
Date of Birth

IF AVAILABLE:

__________________
ID Number Used by
Requesting Agency

______________
ID Number used by
Releasing Agency

AUTHORIZATION FOR RELEASE OF INFORMATION

I hereby request and authorize: ______________________________________________________________
(Name of Person or Agency Requesting Information)
________________________________________________________________________________________
(Address)
to obtain from:____________________________________________________________________________
(Name of Person or Agency Holding the Information)
________________________________________________________________________________________
(Address)
the following type(s) of information from my records (and any specific portion thereof): ________________________________________________________________________________________
________________________________________________________________________________________
for the purpose of: _______________________________________________________________________
________________________________________________________________________________________

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

[ ] the period necessary to complete all transactions on accounts related to services provided to me.
I understand that unless otherwise limited by state or federal regulation, and except to the extent that action has been taken which was based on my consent, I may withdraw this consent at any time.

______________________________________
(Date)

____________________________________
(Signature of Client/Patient/Applicant)

______________________________________
(Signature of Witness) (Title or relationship to Client)

____________________________________

(Signature of Parent or Authorized

(Date)

Representative, where applicable)

USE THIS SPACE ONLY IF CLIENT WITHDRAWS CONSENT

_____________________________________
(Date this consent is revoked by client)

________________________________
(Signature of Client)

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GA WIC 2005 PROCEDURES MANUAL

Attachment AD-5

REQUEST TO ESTABLISH NEW CLINICS/CLINIC CHANGE

PURPOSE OF REQUEST: EST. NEW CLINIC EFFECTIVE DATE OF CHANGE

CLINIC CHANGE CLINIC NUMBER

TYPE OF CHANGE

DIST/UNIT

DATE SUBMITTED

COUNTY#

COORDINATOR

CONTRACT # (IF LOCATED OUTSIDE OF HEALTH DEPT.)

CONTACT PERSON

NEW CLINIC NAME

MAILING ADDRESS (not a Post Office Box)

PHONE#

ATTENTION:

CLINIC DAYS AND HOURS OF OPERATION

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

Other (specify)

SCHEDULE OF VOUCHER ISSUANCE (circle) monthly

bi-monthly odd

bi-monthly even

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

VOUCHER ORDERS SPECIAL VOUCHERS
BLANK VOUCHERS

TAD ORDERS BLANK TADS ________________________________
PREPRINTED TADS ______________________________

PREPRINTED VOUCHER PACKAGES

WOMEN (P&B) INFANTS

________________ PACKAGES ________________ PACKAGES

WOMEN (N) CHILDREN

_______________ PACKAGES _______________ PACKAGES

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

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

TO 100 PACKAGES FOR WOMEN, 100 PACKAGES FOR INFANTS AND 100 PACKAGES FOR CHILDREN. IF YOU WISH TO

INCREASE THIS NUMBER, PLEASE INDICATE: YES

NO

FOR STATE WIC BRANCH USE

APPROVED

DISAPPROVED

FOR COVANSYS USE

NEW CLINIC # ASSIGNED

__________________________________________________________

EFFECTIVE DATE

__________________________________________________________

COMPLETED BY

__________________________________________________________

SYSTEM MAINTENANCE REPORT #

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GA WIC 2005 PROCEDURES MANUAL

Attachment AD-6

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GA WIC 2005 PROCEDURES MANUAL

Attachment AD-7

NEW SITE PERMISSION REQUEST FORM

TO: FROM:
DATE: RE:

District Health Directors
Alwin K. Peterson Georgia WIC Director XX XX, 200_
Permission To Open A New WIC Site.

The WIC Branch Review Team has completed the site(s) visit located at:

Based on this visit the District site(s) listed above: May Open: ____________________ May Not Open: ________________
If you have any questions, please call the Director or the Manager of the Management Evaluation Unit at (404) 657-2900

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GA WIC 2005 PROCEDURES MANUAL

Attachment AD-8

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GA WIC 2005 PROCEDURES MANUAL

Vendor Management

I. II. III. IV. V. VI. VII. VIII. IX. X. XI. XII.

TABLE OF CONTENTS
Page
Number and Distribution of Authorized Vendors ...........................................VM-1 Vendor Application Periods.................................................................................VM-1 Vendor Selection and Authorization ..................................................................VM-1 Peer Groups ............................................................................................................VM-2 Vendor Agreements...............................................................................................VM-2 Vendor Training .....................................................................................................VM-2 High Risk Identification System ..........................................................................VM-2 Routine Monitoring ...............................................................................................VM-3 Vendor Sanction System .......................................................................................VM-3 Administrative Review .........................................................................................VM-4 Coordination With Food Stamp Program ..........................................................VM-4 Staff Training in Vendor Management ...............................................................VM-4

Attachments: VM-1 Application for Vendor Authorization VM-2 Selection Criteria for Vendor Authorization VM-3 Georgia WIC Program Vendor Handbook VM-4 WIC Vendor Agreement (2 and 3 years) VM-5 Corporate Attachment Form VM-6 Vendor Training Checklist VM-7 Corporate Vendor Training Checklist VM-8 WIC Incident/Complaint Form

GA WIC 2005 PROCEDURES MANUAL
VM-9 Vendor Review Form VM-10 Cooperative Agreement Between the Georgia WIC
Program and FNS Field Office

Vendor Management

GA WIC 2005 PROCEDURES MANUAL VENDOR MANAGEMENT

Vendor Management

I. NUMBER AND DISTRIBUTION OF AUTHORIZED VENDORS
The Georgia WIC Branch does not use limiting criteria to limit the number of vendors it authorizes. Any legitimate retailer, pharmacy or military commissary within Georgia and no greater than 10 miles outside of the Georgia border may apply to become an authorized vendor.

II. VENDOR APPLICATION PERIODS
Applications are accepted year round on an ongoing basis, except sixty (60) days prior to the expiration of the two (2) and three (3) year agreement period. The two and three year agreement expires September 30, 2006 and 2007 respectively. (See Attachment VM-1, Application for Vendor Authorization).

III. VENDOR SELECTION AND AUTHORIZATION
A. Selection Criteria
All applicants must meet the established criteria to become and maintain WIC program authorization. (See attachment VM-3, Selection Criteria for Vendor Authorization). When a potential vendor or applicant requests an application, the Selection Criteria for Vendor Authorization is mailed in the application package.
B. On Site Visit and Authorization
On-site visits are conducted on each vendor applicant prior to authorization to verify the information that is received during the application process, including minimum variety and quantity of WIC approved foods as well as the current shelf price. If a vendor does not have the correct quantity of approved foods on hand at the time of the pre-approval visit, the application will be denied for a period of ninety days.
When a vendor meets all authorization criteria and has received interactive training, an agreement is signed by the state agency official and mailed to the vendor or to the corporate vendor's authorized representative.
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GA WIC 2005 PROCEDURES MANUAL

Vendor Management

IV. PEER GROUPS
Authorized vendors are classified into seven different peer groups depending on square footage or the type of business. (See Attachment VM-3, Georgia WIC Program Vendor Handbook- Vendor authorization).
V. VENDOR AGREEMENTS
The Georgia WIC Branch enters into two (2) year and three (3) year agreements with food retailers, pharmacies and military commissaries (See Attachment VM4).
Food retailers with the same federal employment identification number and a corporate home office or a single owner business entity that serves as a parent company may sign a single agreement. This vendor is classified as a corporate vendor and must submit a list of all the stores in the chain on a corporate attachment form. This forms becomes a legal addendum to the Agreement. (See attachment VM-5, Corporate Attachment Form ). If one store in the chain violates the program and is disqualified, the remaining stores are not affected.
VI. VENDOR TRAINING
Vendors are provided authorization training sessions prior to authorization in an interactive format. The training sessions are conducted by the WIC Branch representatives for the non corporate vendor and by the corporate representative for vendors who are classified as corporate vendors. At the end of the two or three year agreement period, authorization training is once again provided to vendors who are re-applying.
Annual training is provided once every year using a variety of formats, i.e. newsletters. Vendors who have received authorization training must sign certain forms as documentation. (See Attachment VM-3 Georgia WIC Program Vendor Handbook, Vendor Training; Attachment VM-6, Vendor Training Checklist and Attachment VM-7, Corporate Vendor Training Checklist).
VII. HIGH RISK IDENTIFICATION SYSTEMS
VENDOR COMPLAINTS
Vendors and participants are given a toll free customer service hotline that can be used to report complaints/incidents or make inquiries @ 1-866-814-5468. The
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GA WIC 2005 PROCEDURES MANUAL

Vendor Management

participant may also contact their local WIC clinic to voice their complaint/incident. The local agency must complete a complaint/incident form (See Attachment VM-8, Complaint Form) and attempt resolution. If a complaint/incident is not resolved at the local level, the form is sent to the State for resolution. All forms are forwarded to the state agency agency whether they are resolved at the local level or not.
Resolution, at the state level, will be initiated within 24 hours of receipt. The local agency will receive notification regarding how and when the complaint/incident was resolved
A vendor may be investigated when a complaint/incident appears to be a sanctionable offense.
IDENTIFYING HIGH-RISK VENDORS
Programmatic reports, including but not limited to the Vendor Profile report, are used to identify high risk vendors. The indicators listed on the Profile are: A) Small Amount of Price Variance, B) Large percent of food instruments redeemed at the same price, H) Vendor has large percent of total area redemption, M) Large percent of participants outside vendor area. To keep vendors apprised of their level of risk, the Vendor Profile is mailed to each active vendor annually.
Complaints and incidences that are reported to the WIC Branch about vendors also place them in a high risk category and may cause them to receive a covert investigation.
VIII. ROUTINE MONITORING
On site, overt monitoring is performed on a minimum of five percent of the total active vendors statewide on an annual basis using a standardized monitoring instrument (See Attachment VM-9, Vendor Review Form). Vendors statewide (except commissaries and pharmacies are selected for routine monitoring visits based on : 1) complaints/incidents regarding a specific vendor 2) a current list of vendors that have been on the program the longest and have not received a routine monitoring visit prior to FY2000 and 3) request from investigators as a result of their findings following a covert visit. Vendors receive written notification of the results and copies are sent to the vendor's corporate office, when applicable. (See Attachment VM-3, Georgia WIC Program Vendor Handbook, Overt Monitoring)

VM-3

GA WIC 2005 PROCEDURES MANUAL

Vendor Management

IX. VENDOR SANCTION SYSTEM
When any authorized vendor is found to be in violation of federal regulations and/or state policies and procedures, the vendor will be assessed a sanction consistent with the severity and nature of the violation. Sanctions may include disqualification or a civil money penalty. (See Attachment VM-3, Georgia WIC Program Vendor Handbook, Sanction System.

X. ADMINISTRATIVE REVIEW
The Georgia WIC Branch conducts only full Administrative Reviews. Adverse actions that are mandated under the abbreviated review process are addressed under full Administrative Reviews. For administrative review procedures (See Attachment VM-3, Georgia WIC Program Vendor Handbook, Administrative Review Procedures).

XI. COORDINATION WITH FOOD STAMP PROGRAM
A reciprocal agreement between the Georgia WIC Branch and the Food and Nutrition Service Food Stamp Program is on file at the State Agency. (see attachment VM-10 Cooperative Agreement Between the Georgia WIC Program and FNS Field Office). Prior to terminating a vendor from WIC due to a food stamp disqualification, inadequate participant access is determined and documented. Geographic barriers are considered in the determination.
The Georgia WIC Branch's Compliance Analyses Section routinely coordinates their investigative activities with their Food Stamp Program counterparts when investigating high-risk WIC vendors.

XII. STAFF TRAINING IN VENDOR MANAGEMENT
New employees receive orientation and on the job training on the following Vendor Management topics:
1. The application process (selection and authorization) 2. Vendor Training 3. Routine Monitoring 4. Compliance Investigations 5. Inventory Audits (when applicable)

VM-4

GA WIC 2005 PROCEDURES MANUAL

Vendor Management

6. Sanctions 7. Vendor Appeals/Administrative Reviews 8. Federal and State WIC regulations 9. High Risk Vendor Identification 10. GWIS (Georgia WIC Information System) other internal vendor database
such as WIC and STARS

VM-5

GA WIC 2005 PROCEDURES MANUAL

Attachment VM-1

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

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

District/Unit
Date Received Date Approved Date Denied

Vendor Number
F/P F/P F/P

Cost Cost
Cost

Peer Group

Maximum Maximum
Maximum

Reason Denied

Processed By

Check one
Re-Application (Enter current vendor number) ____________________

Initial Application

Will this store participate as a corporate vendor?

Yes

No

PART I - STORE IDENTIFICATION

1. Store Name

Manager's Name

Business Telephone Number

-

Area Code

E-mail Address

2. Physical Location

Street Address/Rural Route

City

State Mailing Address

-

Fax Number

-

-

Area Code

County Zip + 4

Street Address/P. O. Box City

State

Zip + 4

3. Square Footage of Store (including storage area)

4. Food Sales Establishment License Number 5. Does this store now participate in the Food Stamp Program? Yes
If yes, indicate the Food Stamp Authorization Number

No

6. Type of Business - Check Only One Independent
Chain

Commissary Pharmacy

Page 1 of 9

GA WIC 2005 PROCEDURES MANUAL
7. Federal Employer Identification Number
8. A. What date will the store have the required minimum inventory of approved WIC food items in stock?
B. What date did (or will) the store open under the applying ownership?

or Owner's SSN
Month
Month

Attachment VM-1

-

-

Day
/
Day

Year
/
Year

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

Yes

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

WIC Program?

Yes

If YES, attach a list of stores.

C. How long has this store been in business?
D. Has this store ever operated under another name in Georgia? If YES, indicate name.

Yes

PART II - STORE OWNERSHIP AND MANAGEMENT

No No No

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

Name

Title

Street Address/Rural Route

City Business Telephone
E-mail address

-

-

Area Code

State

Fax

-

Number
Area Code

Zip+ 4 -

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

Privately owned corporation Publicly owned corporation Government owned

12. Names and Titles of Owner(s)

Name

Title

Name

Title

Name

Title

13. Ownership History
A. Including this store, has the current owner(s), officer(s) or manager(s) ever owned or managed a business that violated the Georgia WIC Program, receiving a warning letter, probation, disqualification or assessment of a Civil Money Penalty? Page 2 of 9

GA WIC 2005 PROCEDURES MANUAL

Attachment VM-1

assessment of a Civil Money Penalty? If YES, attach an explanation identifying the person, business name, location and nature of violation.

Yes

No

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

ever owned or managed a business that violated the Food Stamp

Program, receiving a warning letter or was withdrawn, disqualified or assessed a Civil Money Penalty?

Yes

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

violation.

No

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

had a civil judgment for fraud, antitrust violations, embezzlement, theft,

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

Yes

of justice?

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

violation.

No

PART III OPERATIONS AND SALES

14. Hours of Business Sunday Monday Tuesday Wednesda y
15. A. Number of scanners
B. Can the scanner detect WIC eligible foods?
C. Does your store have a Point of Sale device?

Thursday Friday Saturday

16. Bank Information Name of Bank Street Address City

State

Zip

Yes Yes

No No

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GA WIC 2005 PROCEDURES MANUAL

Attachment VM-1

PART IV STORE PRICE LIST AND INVENTORY

Food Item 17. Juice

Brand Name

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

Size

Highest Price

46 oz. can 46 oz. plastic bottle

12 oz. box

1 pound bag

18 oz. jar

8 oz. box

13 oz. can 13 oz. can

1 gallon container 1 pound package 1 dozen carton

FOR GWB USE ONLY

Negotiated On-Site

Price

Price

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GA WIC 2005 PROCEDURES MANUAL

Attachment VM-1

Food Item 27. Juice

Brands (B) Types (T)
2 (T)

Size 46 oz.

Item In Stock? Minimum Quantity In Stock? Yes No 24 Yes No

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

4 (T) 9 to 24 oz. Yes No 30 Yes No

29. Dried Peas/Beans 30. Peanut Butter

2 (T) 1 lb. pkg. Yes No 8 Yes No 2 (B) 18 oz. Yes No 8 Yes No

31. Infant Cereal (1 type must be rice)

2 (T) 8 oz.

Yes No 12 Yes No

32. Contract Formula Milk based

1 (B) 13 oz. Yes No 138 Yes No

33. Contract Formula Soy based
34. Pasteurized Milk

1 (B) 13 oz. Yes No 32 Yes No 1 (B) 1 gallon Yes No 20 Yes No

35. Cheese

2 (T) 1 pound Yes No 16 Yes No

36. Eggs

1 (B) 1 dozen Yes No 16 Yes No

PART V STATEMENTS AND CERTIFICATION

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

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

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

SIGNATURE

DATE

PRINT NAME

TITLE

DAYTIME NUMBER

-

-

Area Code

E-MAIL ADDRESS

FAX NUMBER

-

-

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

Return application to: DO NOT FAX

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

Page 5 of 9

GA WIC 2005 PROCEDURES MANUAL Instructions for Completing the Vendor Application

Attachment VM-1

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

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

PART I - STORE IDENTIFICATION

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

2

Enter the information regarding the addressof the store.

Physical Location STREET ADDRESS. Enter the street name and number for the store (or corporation) listed above. DO NOT enter a Post Office Box for this location. CITY. Enter the name of the city. COUNTY. Enter the name of the county. STATE. Enter the name of the state in which the business is located. ZIP+4. Enter the postal code + the four digit locator code. Mailing Address STREET ADDRESS. Enter the street name and number for the store (or corporation) where mail is delivered to the location above. A Post Office Box may be entered in this space. CITY. Enter the name of the city. STATE. Enter the name of the state in which the business is located. ZIP+4. Enter the postal code + the four digit locator code.

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

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

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

6. TYPE OF BUSINESS. Check the box that best fits the type of business for your store. Independent A store independently owned by a person or group. Page 6 of 9

GA WIC 2005 PROCEDURES MANUAL

Attachment VM-1

Chain. A business entity that has multiple locations throughout one or more states. Commissary. A military outlet providing goods and services for military personnel and their families. Commissaries receive exemptions through the 1983 Memorandum of Understanding between the Food and Nutrition Service and the United States Department of Defense. Pharmacy. A "drug" store redeeming infant formula and WIC-eligible medical foods only.
7. TAXPAYER IDENTIFICATION NUMBER. Enter the Federal Employer Identification Number (FEIN) assigned to the store by the Internal Revenue Service. If the owner is a sole proprietor, enter the owner's Social Security Number (SSN). If a FEIN is entered, the SSN is not required.
8. Answer the question regarding minimum inventory and opening date A. MINIMUM INVENTORY. Enter the specific month, day and year that ALL required quantity and variety of WIC approved food items (including perishables) will be in stock and ready for inspection? Enter Not Applicable (N/A) if the store is currently authorized as a WIC vendor. B. OPENING DATE. Enter the specific month, day and year that the store will open under the applying ownership. If the store is currently open for business at the time of application, enter the official date the store opened or the date the change of ownership became effective. Enter Not Applicable (N/A) if the store is currently authorized as a WIC vendor.
9. Answer the questions regarding ownership history.
A. RELATION TO OWNER. Check yes or no if the vendor applicant is related to the previous owner by blood or marriage. If yes, indicate the relationship. A vendor applicant cannot be related to the seller by blood or marriage if it is determined that the store is being sold to circumvent a WIC sanction.
B. OTHER WIC AUTHORIZED STORES BY OWNER. Check yes or no if the vendor applicant also owns other WIC authorized stores. Attach a list of stores and addresses to the application.
C. OPERATION UNDER ANOTHER NAME. Check yes or no if your store has operated under another name. If yes, indicate the name.

Part II STORE OWNERSHIP AND MANAGEMENT

10. AUTHORIZED REPRESENTATIVE. Provide the information for the person designated to be responsible for the authorization of your business entity. A corporate vendor may list a person other than the owner(s) or officer(s). Complete each space. Enter Not Applicable (N/A) if there is not a fax number or e-mail address for the individual. Enter "same as #1" if the authorized representative is the same person listed on line 1 (one).
11. TYPE OF OWNERSHIP. Check the one type that closely represents your business. Sole proprietorship. A business owned by a single individual who has total control of the business. Partnership. A business owned by two or more individuals who share the management of the business. Limited Liability Company (LLC). A business combining both corporations and partnerships in that the business is required to register with the Secretary of State but do not have the same filing and record maintenance as a corporation. Privately owned corporation. For purposes of this application, a privately owned corporation is one which has shares or stock that are not traded on a stock exchange or available for purchase by the general public.

Page 7 of 9

GA WIC 2005 PROCEDURES MANUAL

Attachment VM-1

Publicly owned corporation. For purposes of this application, a publicly owned corporation is one which has shares or stock that are traded on a stock exchange and are available for purchase by the general public. Government owned entity. A business entity that may include pharmacies or clinics owned and operated by county, state or federal government agencies.
12. NAMES OF OWNERS/OFFICERS. Supply the names of all owners with equal to or greater than 5% interest/ownership in the store (attach additional sheet with additional names if necessary). For corporations, supply the names and titles of the primary officers of the corporation. Provide the name of the President, Vice-President, Secretary or Treasurer of the corporation.
13. OWNERSHIP HISTORY
A. PREVIOUS GEORGIA WIC VIOLATIONS. Check yes or no if the current owners, officers or managers have ever violated Georgia WIC Program by receiving a warning, probation, disqualification, or have been assessed a civil money penalty. If yes, attach an explanation identifying the date, the person, store and nature of the violation.
B. FOOD STAMP VIOLATIONS. Check yes or no if the current owners, officers or managers have ever violated the Food Stamp Program by receiving a warning, disqualification, or have been assessed a civil money penalty. If yes, attach an explanation identifying the date, person, store and nature of the violation.
C. CONVICTIONS/JUDGEMENTS. Check yes or no if the owner, current officers, or manager everhad a civil judgment involving civil judgment for fraud, antitrust violations, embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, receiving stolen property, making false claims or obstruction of justice? If yes, attach an explanation identifying the person, date and nature of the violation.

PART III OPERATIONS AND SALES
14. HOURS OF BUSINESS. Enter the hours the store is actually open for business each day. Corporate vendors, enter the hours that the ma jority of the stores are actually open for business.
15. A. NUMBER OF SCANNERS. Enter the number of scanners in the store. Corporate vendors, enter the average number of scanners per store. B. OPTICAL SCANNERS. Check yes or no if the register(s) can detect WIC eligible products. C. POINT OF SALE (POS) DEVICES. Check yes or no if there is a Point of Sale (POS) device at each register. This is the machine used to swipe credit or debit cards at each checkout.
16. BANK. Enter the name, address and telephone number of the bank where WIC vouchers will be deposited. Corporate vendors, if more than one bank is used, enter the information about your primary bank.

PART IV STORE PRICE LIST AND INVENTORY

Enter the brand name and highest price of each approved WIC food item in the sizes listed on the application. Use the October 1, 2004 WIC Approved Foods List to complete this section. Do not complete the shaded area.

17. Juice

18. Cereal

19. Dried peas or beans

20. Peanut butter

21. Infant cereal - rice

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22. Contract formula milk based 23. Contract formula soy based 24. Pasteurized cow's milk 25. Cheese 26. Eggs Check yes or no if the number (#) of brands and if the required quantity of inventory items of approved WIC foods are in your current inventory. Corporate vendors must assure the required quantity is in stock at each location. 27. Juice 28. Cereal 29. Dried peas or beans 30. Peanut butter 31. Infant cereal 1 type must be rice 32. Contract formula milk based 33. Contract formula soy based 34. Pasteurized cow's milk 35. Cheese 36. Eggs

Review the Privacy Act Statement, Warning Statement and Certification. The applying owner or authorized representative must sign this application. Indicate the daytime number and e-mail
address (if available).

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Selection Criteria for Vendor Authorization

All applicants must meet the following criteria at the time of application and sustain the criteria throughout the agreement period. The Georgia WIC Program will terminate the agreement if it is determined that the applicant provided false information in conjunction with the application.

1. Additional Required Information. All requested information must be provided, upon request, that is needed to process the application. This includes but is not limited to the bill of sale, articles of incorporation, gross sales, etc.

2. Minimum Inventory of WIC Approved Foods (see chart below). Stores are required to stock and daily maintain the minimum inventory of approved WIC foods. A. The inventory must be in the store or the store's stockroom. B. Expired foods do not count towards minimum inventory. (Note: All WIC approved foods currently in stock, including the minimum amounts, must be within the expiration dates at the time of application). C. Pharmacies are exempt from minimum inventory requirements. D. Commissaries are exempt from the minimum requirement under the 1983 Memorandum of Understanding between the United States Department of Agriculture, Food and Nutrition Service and the United States Department of Defense.
All applicants will receive an on-site pre-approval visit from State representatives to verify the information listed on the application and items A & B above. The Georgia WIC Branch will contact the applicant to confirm that the date listed on line eight (A) and that all minimum inventory items (including perishables items) are in stock and all WIC approved foods are within expiration date(s). The applicant should provide a 48-hour minimum notice for any date changes by calling 1-866-814-5468 or (404) 657-2900. The application will be denied for a 90 (ninety) day period if the required minimum inventory is not in stock and/or if any WIC approved food item is outside of the manufacturer's expiration date when the State representative(s) arrives at the store.

FOOD ITEM
Pasteurized Milk Whole, Skim, 2%or 1% Cheese

MINIMUM INVENTORY REQUIREMENTS

QUANTITY

SIZE

TYPES/BRANDS

20

1 gallon

1brand

16

1 pound package

2 types

Eggs

16

Grade A Large

1 dozen carton

1 brand

Juice
Cereal
Peas/Beans Peanut Butter Infant Cereal
Infant Formula w/ Iron* Low iron cans do not meet minimum requirement

24

30

8 8 12
170 TOTAL

138 Milk Based

32

Soy Based

46 oz. cans or plastic bottles 9 to 24 oz. box
1 pound package 18 ounce jar 8 ounce box
13 ounce can

2 types
4 types 2 types in 12 oz. boxes 2 types 2 brands 2 types 1 type must be rice 1 brand contract brand of formula only

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Selection Criteria Page 2
3. Provide Adequate Access for Participants. The store must be open for business at least 8 hours per day, six days per week. (Exceptions may be granted at the States discretion)
4. Compliance With the Georgia Department of Agriculture. Each store must have a valid Retail Food Sales Establishment License in the current owner's name. Pharmacies and military commissaries are exempt from this requirement. Stores in bordering states must have a comparable license.
5. Compatible Prices With Similar Stores The prices listed on the application will be compared with the State's pre-established baseline prices. An applicant whose prices exceed current food package voucher maximum amounts will not be authorized. The Georgia WIC Branch may negotiate prices with the applicant prior to the on-site pre-approval visit for compliance with criteria. The application will be denied for a 90 (ninety) day period if the food package maximums exceed the maximums amount allowed when the State representative(s) arrives at the store. The Georgia WIC Branch may review store prices at any time during the agreement period.
6. Compliance With Food Stamp Program (FSP) Regulations. Unless necessary to ensure adequate participant access, the Georgia WIC Program will not authorize an applicant that is currently disqualified from the Food Stamp Program or that has been assessed a civil money penalty (CMP) for hardship and the disqualification period has not expired.
7. Compliance With Georgia WIC Program Policies and Procedures (This item does not apply to applicants who have never been an authorized vendor). A. Sanctions - any sanction(s) that are in the vendor's record at the time of re-authorization will remain on the vendor's record. Prior year's sanctions may result in denial of application and/or additional sanctions up to and including disqualification, in accordance with the 2004 Georgia WIC Program Vendor Handbook and all addendums.
B. Violations - Pending and/or potential violations, that exists at the time of re-authorization will accrue and will result in sanctions up to and including disqualification, in accordance with the 2004 Georgia WIC Program Vendor Handbook and all addendums.
C. If it is determined that an applicant is attempting to circumvent a period of disqualification from the Georgia WIC Program, the application will denied until the disqualification period has expired.
D. An application will be denied if there is evidence of disqualification after exhaustion of all administrative appeals.
8. Business Integrity Unless necessary to ensure adequate participant access, the Georgia WIC Program will not authorize an applicant that does not meet the business integrity criteria based on facts already known and information provided on the application. This includes but is not limited to the following: A. Criminal conviction or civil judgments during the past six years among the applicant's owner's, officer(s) or manager(s) for any activity indicating a lack of business integrity such as fraud, antitrust violations embezzlement, theft, forgery bribery, falsification or destruction of records, making false statements, receiving stolen property, making false claims and obstruction of justice. B. Official records of removal from other federal, state or local programs.

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Selection Criteria Page 3
Requests for an Administrative Review
The validity or appropriateness of the Georgia WIC Program's selection criteria is not subject to administrative review. An applicant may request an administrative review if the application is denied for the following reasons:
1. Denial of authorization based on the vendor selection criteria for competitive price or for minimum variety and quantity of authorized supplemental foods.
2. Denial of authorization based on the Georgia WIC Program's determination that the vendor is attempting to circumvent a sanction.
3. Denial of authorization based on the selection criteria for business integrity. 4. Denial of authorization based on a current Food Stamp Program disqualification or civil
money penalty for hardship. 5. Denial because an applicant submitted its application outside of the timeframe during which
applications were being accepted and processed as established by the Georgia WIC Program, (August 1 September 30, 2006 and August 1 September 30, 2007).
A request for review must be submitted in writing within twenty-one (21) days of the date of the denial notice. Submit the request to:
Vendor Management Section Administrative Review Request Georgia WIC Branch 2 Peachtree Street NW, Suite 10-476 Atlanta, Georgia 30303-3142
The procedures for an administrative review include the following: 1. Written notification of the adverse action. 2. The opportunity to appeal the action. 3. Adequate advance notice of the time and place of the administrative review. 4. The opportunity to present its case and at least one opportunity to reschedule. 5. The opportunity to cross-examine adverse witnesses (When necessary to protect the identity of
WIC Program investigators, such examinations may be conducted behind a protective screen or other device). 6. The opportunity to be represented by counsel. 7. The opportunity to examine prior to the review the evidence upon which the action is based. 8. An impartial decision-maker, whose determination is based solely on whether the Georgia WIC Program has correctly applied Federal and State statutes, regulations, policies and procedures governing the Program, according to the evidence presented at the review. 9. Written notification of the review decision, including the basis for the decision, within 90 days from the date of the receipt of a vendor's request for an administrative review.

Form 3746 (Revised 03/2004)
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Georgia WIC Program Vendor Handbook
Effective October 1, 2004

WIC WORKS WONDERS with PARTNERS

GA WIC 2005 RPOCEDURES MANUAL

Attachment VM-3

Table of Contents
The Vendor Handbook ........................................................................................................................ 1
The Georgia Women, Infants and Children (WIC) Program....................................................................1
WIC Acronym and Logo ......................................................................................................................2
Authorized Vendors ............................................................................................................................ 2
Vendor Authorization ..........................................................................................................................2
Responsibilities and Procedures for Selected Vendor Types Corporate Vendors .......................................................................................................................... 3 Pharmacy Vendors .......................................................................................................................... 3
Vendor Training Authorization Training Non Corporate Vendors ............................................................................... 3 Authorization Training Corporate Vendors ...................................................................................... 3 Annual Training Non Corporate Vendors ........................................................................................ 4 Annual Training Corporate Vendors ............................................................................................... 4 Customized Training ........................................................................................................................ 4
WIC Approved Foods .......................................................................................................................... 4
Minimum Inventory Requirements........................................................................................................9
Policy for Granting Waivers ................................................................................................................. 9
The WIC Voucher ............................................................................................................................. 10
Voucher Descriptions ........................................................................................................................ 10
Processing WIC Vouchers ................................................................................................................. 11 WIC Customer Transactions at the Store ........................................................................................ 12 Important Notes about the WIC Customer for Cashiers and Store Managers ..................................... 12 Return Voucher Payment Procedure............................................................................................... 13 The Vendor Stamp ........................................................................................................................ 13
Changes in Vendor Information Changes in Store Location ............................................................................................................. 13 Changes in Ownership and Cessation of Operations ....................................................................... 14
Performance Compliance Covert Compliance Investigations ................................................................................................... 14 Overt Monitoring............................................................................................................................ 14 Audits ........................................................................................................................................... 14 Programmatic Reports ................................................................................................................... 14
Termination ...................................................................................................................................... 15
High Risk Identification...................................................................................................................... 15
Sanctions ......................................................................................................................................... 15
Sanction System............................................................................................................................... 16
Disqualification ................................................................................................................................. 17
Administrative Reviews and Appeal Procedures Actions Subject to Administrative Review........................................................................................ 18 Actions Not Subject to Administrative Review .................................................................................. 18 Administrative Review Procedures .................................................................................................. 18
Inadequate Participant Access Cases ................................................................................................ 19
CMP Methodology for Mandatory Sanctions ....................................................................................... 19

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Attachment VM-3

THE VENDOR HANDBOOK

The Georgia WIC Program Vendor Handbook is intended to serve as a reference and is considered an addendum to the Vendor Agreement. Food retailers (hereafter called vendors), pharmacies and military commissaries should adhere to all the information provided in this book to assure compliance with federal regulations, state policies and procedures.
The vendor's role is important to the success of the Georgia WIC program. Vendors must assure that the participant, parent, caretaker and/or proxy, also known as the WIC customer, purchase only the prescribed foods.
Prices charged by the vendor must be reasonable and competitive. Competitive prices will enable the Georgia WIC program to maximize services to its citizens. Authorized WIC vendors redeemed approximately $158 million in WIC food vouchers during federal fiscal year 2003.

THE GEORGIA WIC PROGRAM

WIC (Women, Infants and Children) special supplemental food program, is a federally funded program that provides supplemental foods, nutrition education and counseling to Georgia's citizens.

WIC saves lives and improves the health of nutritionally at-risk women, infants and children.

Since it's beginning in 1974, the WIC program has earned the reputation of being one of the most successful federally funded programs in the United States. Collective findings of studies, reviews and reports illustrate that the WIC program is cost-effective in protecting and improving the nutritional status of low-income women, infants and children.

Improved outcomes attributed to WIC:
WIC reduces fetal deaths and infant mortality. WIC reduces low birthweight rates and increases the duration of pregnancy. WIC improves the growth of nutritionally at-risk infants and children. WIC decreases the incidence of iron deficiency anemia in children. WIC improves the dietary intake of pregnant and postpartum women and improves weight gain in pregnant
women. Pregnant women participating in WIC receive prenatal care earlier. Children enrolled in WIC are more likely to have a regular source of medical care and have more up to date
immunizations. WIC helps children get ready to start school; children who receive WIC benefits demonstrate improved
intellectual development.
WIC significantly improve children's diets.

Georgia's health professionals determine who is eligible to participate in the WIC program. They also provide nutrition education, counseling and prescribe nutritious foods. Instruments used to obtain the supplemental foods are called vouchers, which are redeemed through authorized food retailers statewide.

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WIC ACRONYM AND LOGO
A WIC vendor is not permitted to use either the acronym "WIC" or the WIC logo pictured above, including close facsimiles thereof, in total or in part, either in the official name in which the vendor is registered or in the name under which it does business, if different.
Any person who uses the acronym "WIC" or the WIC logo in a non-authorized manner, including close facsimiles thereof, in total or in part, may be subject to injunction by the United States Department of Agriculture and the payment of damages.
The WIC authorized vendor is not permitted to use the WIC acronym, or the WIC logo including close facsimiles thereof in any form of marketing or advertisement of the store that gives an impression that the business is owned, operated, approved, favored or endorsed by the Georgia WIC Program, including wording such as "WIC Only". The state agency will solely make a determination and notify the vendor if misuse is determined. If a vendor fails to discontinue the use of the WIC acronym or the WIC logo including close facsimiles thereof, in total or in part, after misuse is determined, the Vendor Agreement will be terminated, for cause, as allowed in CFR246.12 (h)(3)(xvi).
The Vendor is permitted to use shelf talkers or channel strips stating "WIC approved or WIC eligible" on grocery shelves at the exact spot that contain WIC approved foods. These items have been developed by the WIC Program and are available upon request. Vendors who wish to develop their own shelf talkers or channel strips must obtain written permission by submitting a copy or sample of the final version prior to use.
AUTHORIZED VENDORS
An authorized vendor is a sole proprietorship, partnership, cooperative association, corporation or other business entity operating one or more vendors. A vendor is authorized to provide approved supplemental foods to participants, parents, caretakers and/or proxies. The program is operated in accordance with federal laws and regulations, the Georgia State Plan of Program Operations and Administration and the policies and procedures of the Special Supplemental Nutrition Program for Women, Infants and Children (WIC), pursuant to the laws of the State of Georgia and the Child Nutrition Act (CNA) of 1966 as amended.
VENDOR AUTHORIZATION
To become or continue as an authorized vendor the criteria used to select the vendor must be maintained throughout the agreement period. The selection criteria are the same for vendors statewide with the exception of commissary and pharmacy vendors.
The criteria include but are not limited to: 1) Competitive prices 2) Minimum variety and quantity of supplemental foods 3) Business integrity 4) Absence of current Food Stamp Program disqualification or civil money penalty for hardship
Vendors are placed into peer groups (see below) based on the type and/or square footage of the store including storage areas and the number of stores in the chain.

Peer Group 1 2 3 4 5 6 7

Type

Description

SMALL

0 to 5,000 Square Feet

AVERAGE

5,001 to 10,000 Square Feet

MEDIUM

10,001 to 15,000 Square Feet

CHAIN

>15,001 Square Feet and 20 or more locations

MILITARY COMMISSARY Located on Military Bases serving military personnel only

PHARMACY

Redeem infant formula only, including special infant formula and medical foods

LARGE INDEPENDENT >15,001 Square Feet and less than 20 locations
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RESPONSIBILITIES AND PROCEDURES FOR SELECTED VENDOR TYPES
Corporate Vendors
A business entity having two (2) or more stores operating under the same Federal Employer Identification Number (FEIN) and a corporate/home office or single owner/business entity that serves as the parent, shall be classified as a corporate vendor. An authorized representative of the corporate office shall sign one agreement and list pertinent information about each store on Corporate Attachment Form 3771A. Corporate vendors must send a representative(s) to the Authorized Training session and afterwards ensure that all training topics are provided to a management representative(s) in each store. The Corporate Training Checklist Form 3757A must be completed and returned to the Georgia WIC Branch, documenting that training has occurred in each store. Signature of the store's management representative is required on this form.
To add a new store, the corporate vendor must first amend their agreement by submitting the corporate Attachment Form 3771A that includes required information about the new location and a corporate Vendor Training Checklist. The new store shall not begin to accept vouchers until a vendor stamp has been received.
Pharmacy Vendors
Pharmacy vendors are authorized to provide infant formula and WIC-eligible medical foods. Pharmacy vendors are exempt from maintaining minimum inventory requirements. Programmatic reports will be used to verify performance compliance, such as whether a pharmacy vendor is redeeming only infant formula vouchers. If authorized pharmacy vendors wish to change their classification to allow for the redemption of all WIC approved foods, a new application must be submitted. Note: Pharmacy vendors shall not accept vouchers through the mail, nor mail any approved formula/medical foods directly to the WIC customer. Termination for cause may occur if this is violated, as allowed in CFR246.12(h)(3)(xvi).
VENDOR TRAINING
Vendor training, including annual training, will be conducted to inform vendors of the appropriate program policies and procedures in one of the following formats: newsletters, videos, videoconferences, or interactive training sessions.
Authorization Training for Non Corporate Vendors
The Georgia WIC Program will provide an authorized training session in an interactive format prior to, or at the time of authorization. Attendance at training will be documented, a checklist of items discussed will be signed and a Post Vendor Training Evaluation (multiple choice test) will be given. A passing score of seventy (70) is required to become authorized.
Attendance at a training session, prior to becoming an authorized vendor, does not grant the right to begin accepting WIC vouchers. Only a fully executed agreement, signed by both parties and the receipt of a vendor stamp constitutes authorization.
Authorization Training for Corporate Vendors
A representative of the Corporate Vendor must initially complete the authorized training session and receive a passing score of seventy (70) or above. After completing and passing the training session, a corporate vendor is allowed to conduct Authorization Training for 1) existing authorized stores at the time of re-application and 2) new unauthorized stores that will be added to an existing Vendor Agreement. Any corporate vendor must subsequently conduct authorization training for existing and new locations.
The corporate vendor shall submit documentation (Corporate Vendor Training Checklist) verifying that a management representative of each store has completed authorization training that includes the required training topics that are listed on the Corporate Vendor Training Checklist. Note: The corporate vendor has the option to allow any of their store representatives to attend the authorized training sessions conducted by WIC Program Representatives.
Corporate Vendor Training conducted prior to becoming an authorized vendor does not grant the right to begin accepting WIC vouchers. Only receipt of the vendor stamp (for corporate vendors only) constitutes authorization.

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Annual Training for Non Corporate Vendors
The WIC Branch will conduct training annually to all vendors regarding changes and updates to policies and procedures. Annual training may be conducted in a variety of formats including newsletters and addendums. Authorized vendors must document participation in annual training by the deadline specified. Failure to do so will result in termination of the Vendor Agreement by giving a 21day advance notice.
Annual Training Corporate Vendors
The WIC Branch will conduct training annually to inform corporate vendors of changes and updates to policies and procedures. Annual training may be conducted in a variety of formats including newsletters and addendums. Corporate vendors must first document their participation in annual training by the deadline specified. In addition, the corporate vendor must ensure that each store listed in the current Vendor Agreement receives annual training by the deadline specified. Failure to provide documentation that each store participated in Annual Training will result in termination of the store(s), after a 21day notice.
Customized Training
The Georgia WIC Program Representatives may conduct training for employees of WIC vendors at their request. Training should be requested in writing to the Georgia WIC Program, Vendor Management Section, 2 Peachtree Street, Suite 10-476, Atlanta, Georgia, 30303. Please specify the desired training topic(s) and the type and number of employees who will attend. Both parties will mutually agree upon location and dates.
WIC APPROVED FOODS
The WIC Approved Foods listed in the following chart are foods that are available to the WIC customer. ONLY these foods are allowed to be purchased. Brand names and types of infant formula as well as special medical foods are too numerous to list on the chart. Instead, they will be printed directly on the front of the voucher. The WIC customer is allowed to purchase the brand, type and size of infant formula or medical food that is printed on the front of the voucher. Do not allow the WIC customer to purchase infant formula or medical food that is NOT listed on the voucher.
The vendor will receive an updated list of approved foods any time changes are made. Vendors will periodically receive pamphlets and posters of WIC approved food items that can be used as marketing displays or as a training resource.

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FOOD ITEM MILK
PASTEURIZED
MEYENBERG GOAT MILK

WIC Approved Foods List Effective October 1, 2004
Only the following list of foods may be purchased with WIC vouchers

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

CONTAINER/PACKAGE SIZE
One Gallon ONLY
Makes 3 Quarts Makes 5 Quarts
12 oz. Can 8 oz. or Half-Pint Box
One Gallon Gallon
1 Quart Carton
1 Quart Carton 12 oz. Can
(makes 3 quarts) 12 oz. Can
1 Quart Carton

NOT ALLOWED
Flavored Milk Buttermilk Soy Milk Rice Milk Raw Milk (non-
pasteurized milk)

CHEESE Fat Free, Low Fat or 2% Allowed

Slices Any Brand
(Wrapped or unwrapped)

Block Any Brand

American Swiss Cheddar
American Cheddar Colby Monterey Jack Mozzarella Swiss
(Combinations allowed i.e. Colby/Jack)

Minimum Package Size is 9 oz

Cheese Product Flavored Cheese Cheese Food Shredded
Cheese Cheese Slices from
Delicatessen 8 oz. Package Two 8 oz.
Packages to equal 16 oz.

EGGS
DRIED PEAS/BEANS

Least Expensive Brand Only
Any Brand without Flavoring

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

CANNED PEAS/BEANS (Legumes Only)

Any Brand (If Listed on the Voucher)

14 to16 oz. Can ONLY

PEANUT BUTTER Any Brand Creamy, Crunchy or Extra Crunchy 18 oz. Jar ONLY (Regular, Natural, Low-Salt or Reduced Fat)

Any other size or quantity
Any other size or quantity
Flavored Peas Flavored Beans
Any other size or quantity
Flavored Peas Flavored Beans
Any other size or quantity
Marshmallow Added
Chocolate Added Honey Spread Jelly Added
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WIC Approved Foods List Effective October 1, 2004 Continued
The following list of foods may be purchased with WIC vouchers.

FOOD ITEM

BRAND OR TYPE

INFANT FORMULA
INFANT CEREAL (Boxes Only)

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

TUNA

Any Brand - Water Packed Only

CONTAINER/PACKAGE SIZE
As listed on the front of the voucher Dry Cereal in 8 oz. or 16 oz. Box
6 oz. Can ONLY

NOT ALLOWED
Formula not listed on the voucher
Baby Cereal in Jars Dry Cereal w/ Fruit
added Dry Cereal w/
Formula added
Tuna packed in oil

CARROTS

Any Brand - Fresh (Whole)
Any Brand - Canned (Sliced, Medium-Cut) (If Listed on the Voucher)

1 lb Pre-sealed Plastic Bag 14 to 16 oz. Can

Bulk, frozen, shredded or baby carrots

C

Brand Name General Mills

Type

9 oz. Box or above, not to

CheeriosWhole Grain exceed the maximum

8 oz. Box or less Flavored Oatmeal

Oat

amount listed on the

Flavored Grits

CheeriosMulti Grain voucher.

Any type, brand or

Corn Chex

variety of cereal

Country Corn Flakes

other than the ones

Kix

Can mix and match sizes

listed.

E

Multi-Brand Chex Rice Chex

and types.

Total Corn Flakes

Wheat Chex

Wheaties

Whole Grain Total

R

Jim Dandy

Quick Grits - Iron Fortified

Kellogg's
E
A

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

Malt-O-Meal

Crispy Rice

Frosted Mini Spooners

Original Hot Wheat

2 Minute

Toasty O's

L

Nabisco

Cream of Wheat

Regular flavor

10 minutes

2 minutes

1 minute Instant

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WIC Approved Foods List Effective October 1, 2004 Continued
The following list of foods may be purchased with WIC vouchers.

FOOD ITEM

BRAND OR TYPE

CONTAINER/PACKAGE SIZE

NOT ALLOWED

C

Brand Name Post

Type Banana Nut Crunch

9 oz. Box or above, not to exceed the maximum

8 oz. Box or less Flavored Oatmeal

Bran Flakes

amount listed on the

Flavored Grits

Grape Nuts

voucher.

Any type, brand or

Grape Nut Flakes

variety of cereal

Honey Bunches of

other than the ones

Oats-Almond

Can mix and match sizes

listed.

E

Honey Bunches of

and types.

Oats-Honey Roasted

Quaker

Crunchy Corn Bran

Instant Grits

Instant Oatmeal

Regular

R

King Vitamin Life-plain

Oat Bran Ready to Eat

Quaker Squares

Crunchy Oatmeal w/

Brown Sugar

Only the 18 brands of cereal on the left can be

E

purchased in any of the types on the right.

American Fare (K -mart) Bran Flakes-enriched

Bi-Lo

wheat or high fiber

Flavorite

Corn Flakes

Food Lion

Crispy Corn Puffs

Great Value (Wal-Mart) Crispy Rice or Crisp

Hy-Top

Rice

A

IGA Kroger

Crunchy Nuggets GritsInstant, regular

Laura Lynn

Multigrain Flakes

Our Family

Nature's Grain

Piggly Wiggly

Nutty Nuggets

Price Wise

Oat O's

Publix

Oatmealregular

L

Ralston

Save-A-Lot

flavor-Instant Shredded Wheat-

Shurfine

(unflavored) frosted or

Southern Home

bite size

Winn Dixie

Silly Spheres

Tasteeos

Toasted Oat or

Toasted Oats

Whole Grain 100

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WIC Approved Foods List Effective October 1, 2004 Continued
The following list of foods may be purchased with WIC vouchers.

FOOD ITEM
J
U
I
C
E
100% Juice Vitamin C Fortified
and/or Calcium Fortified

BRAND OR TYPE

Least Expensive Brand Only
Great Value Hy-Top Kroger Lucky Leaf Seneca (Red Label) Shurfine Thrifty Maid White House Welch's Seneca Old Orchard

Orange Pineapple Grapefruit Tomato 100% Vegetable Juice
or 100% Vegetable Juice Cocktail Apple
Apple Apple Apple Apple Apple Apple Apple Grape White Grape Grape White Grape All Flavors

Libby's Juicy Juice

All Flavors

Welch's (Blends)
Dole Libby's Juicy Juice Welch's

White-Grape-Raspberry White-Grape-Cranberry White-Grape-Peach White-Grape-Pear
Pineapple Orange Pine-Orange Banana
All flavors
All flavors

CONTAINER/PACKAGE SIZE
46 oz. Ready to Serve Cans
46 oz. Ready to Serve Plastic Bottles
11.5 oz. or 12 oz. Frozen Concentrate (5.5 oz. and 6 oz. CAN IS ALLOWED ONLY IF LISTED ON VOUCHER)
12 oz. Frozen Concentrate ONLY 46 oz. Cans 46 oz. Plastic Bottles 11.5 oz. Frozen Concentrate
12 oz. Frozen Concentrate
11.5 oz. Non-frozen pourable concentrate

NOT ALLOWED
Juice drink Fresh squeezed
juice Infant juice Juice with sugar
added Sports drink Cartons of Juice Single Serving
Size V-8 Splash

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GA WIC 2005 PROCEDURES MANUAL

Attachment VM-3

MINIMUM INVENTORY REQUIREMENTS
The WIC customer may receive vouchers for specific kinds of highly nutritious foods. Vendors are REQUIRED to maintain in stock, a minimum variety and quantity of the WIC foods below.

WIC Minimum Inventory Requirements*

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

FOOD ITEM

QUANTITY

SIZE

TYPES/BRANDS

Pasteurized Milk Skim, 1%, 2% or Whole

20

Cheese

16

1 Gallon 1 Pound

1 Brand 2 Types

Eggs Grade A Large
Juice

16

1 Dozen

1 Brand

24

46 oz. Can or Plastic Bottle

2 Types

Cereal

4 Types

30

9 to 24 oz. Box

(2 types must be in

12 oz. boxes)

Peas/Beans

8

1 Pound

2 Types

Peanut Butter

8

18 oz.

2 Brands

Infant Cereal

12

8 oz.

2 Types

(1 type must be rice)

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

170 TOTAL
138 Milk-Based 32 Soy-Based

13 oz.

Contract Brand of Formula Only

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

POLICY FOR GRANTING WAIVERS
If a vendor has been authorized for a period of at least one year, a waiver to reduce the minimum inventory requirement for an approved food may be requested by writing the Georgia WIC Branch. Waivers will be granted solely at the discretion of the WIC Branch after reviewing the vendors' data and records.
Please specify the following information in the correspondence:
1) Name of the food item(s). 2) New amount that is desired to be considered as minimum inventory. 3) Reason for requesting the waiver.

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GA WIC 2005 PROCEDURES MANUAL THE WIC VOUCHER

Attachment VM-3

The WIC voucher is similar to a check. A vendor must accept all valid vouchers, with the exception of a pharmacy vendor, who is authorized to accept vouchers that contain only infant formula or specialized medical foods. The vendor should not accept altered vouchers.

When vouchers are properly redeemed, the vendor will receive credit for the amount of purchase by depositing the voucher into the bank. However, no voucher will be redeemed by the bank for more than the maximum amount printed on the face of each voucher. Information regarding redeeming vouchers whose purchase amount is more than the maximum amount can be found under Returned Voucher Payment Procedures.

VOUCHER DESCRIPTIONS
There are four (4) types of WIC vouchers: laser printed, blank manual, standard manual and computer generated.

Laser Printed Vouchers: The laser printed voucher is printed at the clinic site at the time of the participant, parent's, caretaker's and/or proxy's visit.

Blank Manual Vouchers: All information on the voucher is either handwritten or typed. Redeem only for the amount of food indicated. Only one (1) number should appear in each box. X's are placed in all boxes where there is no number. This helps to eliminate any possible unauthorized alterations on the voucher.

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GA WIC 2005 PROCEDURES MANUAL

Attachment VM-3

Standard Manual Vouchers: All information on the voucher is written or typed by the staff at the clinic.

Computer Generated Vouchers: All information on voucher is computer printed.
PROCESSING WIC VOUCHERS
The vendor's bank should be informed that vouchers are negotiable instruments that must be processed through the Federal Reserve Bank. The Georgia WIC Program will provide each vendor a stamp that is embossed with a unique WIC identification number. All vouchers accepted by the vendor must be stamped with this number in preparation for a bank deposit. Lost, stolen or damaged stamps must be reported to the WIC Branch immediately. DO NOT REPRODUCE THE VENDOR STAMP. Payment will be assured if:
Voucher(s) are accepted on the "First Day to Use" date through the "Last Day to Use" date. An authorized WIC vendor stamp appears on the voucher. Deposited within sixty (60) days of the "First Day to Use" date. A signature is obtained, in ink, at the time of purchase. The amount of purchase is entered in the "PAY EXACTLY SPACE", in ink.
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GA WIC 2005 PROCEDURES MANUAL
WIC Customer Transactions at the Store

Attachment VM-3

WIC participants, parents, caretakers and/or proxies (WIC Customer), redeem WIC vouchers at authorized vendor locations. WIC customers are required to take the WIC ID folder upon each visit to the store. However, it is the option of each vendor to request the WIC customer to present the WIC ID folder at the time of the transaction. WIC vendors shall NOT request any other form of identification from WIC customers in order to transact a WIC voucher(s).

WIC foods should be separated from other food purchases prior to the WIC transaction. When approved supplemental food is being purchased with a WIC voucher, the cashier must complete each voucher separately and do the following:
1) For vouchers that contain two signature boxes, check to see if the "Sign here at WIC office" signature box contains a signature.
2) Check the dates on the voucher. Vouchers cannot be used before the "First Day to Use" or after the "Last Day to Use" dates.
3) Ring up the current shelf price of the food for each voucher. Make sure that the exact types and amounts of approved WIC foods are being purchased. Do not include sales tax.
4) Print the amount of the WIC purchase in ink, in the "Pay Exactly" space on the voucher in the presence of the WIC customer. Complete this step for one voucher prior to moving on to the next voucher.
5) If the amount of the transaction is less than the maximum amount listed on the voucher, the cashier must not give change.
6) Credit must not be given to WIC customers in exchange for WIC vouchers. 7) If the cashier makes a mistake entering the price on the voucher, the incorrect price should be marked
through and the correct price written above the error. The cashier must initial the correction as verification. 8) If the cash registers do not automatically imprint "WIC" on the receipt, cashiers must write "WIC" vertically on
all receipts for food purchased with WIC vouchers.

Important notes about the WIC Customer for Cashiers and Store Managers
The WIC customer:
1. Must sign the voucher at the time of purchase. 2. May not use a WIC voucher to purchase items not listed on the voucher. 3. Must never be required to pay cash for items purchased. 4. Must be allowed to purchase all foods listed on the voucher, regardless of price. 5. Must be afforded the same courtesy given to other store customers. 6. Must be permitted to purchase eligible food items without making other purchases. 7. Must be charged the same shelf prices as other customers. 8. Must not be charged sales tax. 9. Must be reported to the Georgia WIC Program immediately if they attempt to purchase foods that are not
approved or create other problems in the store. 10. Must not be required to purchase every item on the voucher. 11. May not be contacted regarding restitution, payment or to obtain a missing signature.
More Important Notes
1. If the amount entered on the Pay Exactly space on the WIC voucher exceeds the maximum purchase price listed on the voucher, the Georgia WIC Program may make price adjustments when these vouchers are sent via a Return Voucher Payment Log.
2. WIC approved foods purchased with a WIC voucher cannot be returned for a cash refund. 3. WIC vouchers must not be accepted from other states. 4. If a manager is called to approve a WIC voucher transaction, it is imperative that the customer is not
identified as a WIC participant, parent, caretaker and/or proxy. Every effort must be made to protect confidentiality and discussion of the transaction should be kept at a conversational level. 5. Separate checkout lines for the WIC customer are prohibited. Signs such as "WIC vouchers not allowed in this line" or "No Checks-No WIC" cannot be displayed since they are considered discriminatory. However, vendors who wish to ensure that the WIC customer does not enter certain lines, such as express lines, may post "Cash Only" signs in those lines.

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GA WIC 2005 PROCEDURES MANUAL

Attachment VM-3

6. Every store has the option of checking the customer's WIC identification card for the proper WIC ID

number and authorized signature(s). WIC customers have been instructed about the importance of

carrying the WIC ID card to the grocery store when using WIC vouchers.

7. Vendors with self-check out lines must take appropriate steps to verify that the items purchased are WIC

approved foods and in the appropriate sizes.

8. Whenever vouchers are lost or stolen from a WIC health facility, the Georgia WIC Program will notify area

vendors that a stop payment has been placed on the vouchers. Vendors will be provided the voucher

numbers and informed not to accept the vouchers for redemption. These vouchers will not be paid.

9. The vendor must not provide refunds or permit exchanges for authorized supplemental foods obtained

with food vouchers except for exchanges of an identical authorized supplemental food item when the

original authorized supplemental food item is defective, recalled, spoiled, or has exceeded its "sell by" or

"best if used by," or other date limiting the sale or use of the food item.

10. The WIC customer must be allowed to participate in both in-store and/or manufacturer promotions that

include WIC approved food items. This includes buy one, get one or more free promotions.

Returned Voucher Payment Procedure

If the purchase price on the voucher exceeds the maximum purchase price, it will be returned from the bank and stamped "Amount Exceeds Limit - Do Not Resubmit". To be redeemed, the original vouchers should be sent to the Georgia WIC Branch, attached to a fully completed Return Voucher Payment Log
(RVPL). Voucher(s) mailed in without the RVPL attached will be returned unprocessed. Vendors must attach a proof of purchase (receipt) for each infant formula and special medical food
voucher submitted that contains food package code (FPC) 999 OR voucher codes (VC) 900 thru 999.
These two codes can be found on the face of the voucher. Vouchers that are mailed without the required receipt will be returned unprocessed. If it is a vendor's first time submitting vouchers via RVPL, a completed W-9 Form must be included when the vouchers are mailed in. Voucher(s) sent in without a W-9 Form cannot be paid. A W-9 form is an Internal Revenue Service document that collects taxpayer identification number and certification. A copy of the W-9 Form can be found on the last page of this handbook.
The vendor should retain the last copy of the RVPL for their records. If a voucher(s) is approved for payment, a copy of the RVPL, along with the payment is forwarded to the
vendor. Price adjustments may be made in the amount that the vendor will be paid. If a voucher(s) is denied, a copy of the RVPL and the original voucher(s) is returned to the vendor with an
explanation for the denial. Voucher(s) returned by the vendor's bank stamped "stale date", "post date" "altered" or "signature missing
will not be paid.

The Vendor Stamp

Lost, stolen or damaged stamps must be reported to the WIC Branch immediately. Do not reproduce the vendor stamp. If the inkpad dries out, it is the vendors responsibility to replenish the removable pad. Use black liquid ink
only that is specifically designed for stamping mechanisms. The vendor stamp is not transferable to another location or individual.
CHANGES IN VENDOR INFORMATION

Changes to the information provided on the vendor application must be communicated to the Georgia WIC Branch. This information will be used to update files as necessary. The Georgia WIC Branch requires the vendor to provide a 21 day advance written notification of any changes in ownership, store location or cessation of operations.

Changes in Store Location

The vendor must provide the Georgia WIC Branch with at least twenty-one (21) days advance notification of any changes in location. Each store is authorized based on the ownership and street address that exists at the time of authorization and is not transferable to another location. Therefore, if a change in location is ten (10) miles or more from the original store location, the vendor must complete and submit an updated application (non corporate vendor) or corporate attachment form (corporate vendor) and sign a new agreement. If the change in location is less than ten (10) miles from the original store location, the vendor must only complete and submit an updated application or corporate attachment form.

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GA WIC 2005 PROCEDURES MANUAL
Changes in Ownership and Cessation of Operation

Attachment VM-3

The vendor must submit a notice to the Georgia WIC Branch within twenty-one (21) days of any change in ownership or cessation of business (closure) and the effective date. The Georgia WIC Branch will acknowledge the receipt of this information. Upon the effective date, the vendor authorization number will be terminated. Any vouchers submitted for payment after the effective date will be returned unpaid. If the vendor wishes to change the effective date, a written notification is required. Otherwise, the vendor authorization number will be terminated, as originally confirmed. Once termination occurs, a vendor must submit a new application and meet all current selection criteria. New owners must submit an application, since WIC vendor agreements are not transferable.

Should the Georgia WIC Branch discover that a change in ownership has already occurred, the vendor authorization number will be immediately terminated. All vouchers submitted for payment will be returned unpaid.

Upon the sale of the store, the authorized WIC vendor should inform the new owner that the Georgia WIC Vendor Agreement is non-transferable and that the new owner must submit an application to obtain authorization.

PERFORMANCE COMPLIANCE
A vendor, with the exception of a military commissary vendor, is subject to compliance performance activities. Any violations that are found may result in sanctions (See Sanction System). Compliance with the Georgia WIC Branch policies and procedures is determined using the following methods:
1) Covert (undercover) compliance investigations (military commissary and pharmacy vendors exempt) 2) Overt unannounced monitoring visits (military commissary and pharmacy vendors exempt) 3) Inventory audits (military commissary and pharmacy vendors exempt) 4) Research of programmatic reports and database
Covert Compliance Investigation
Vendors will not receive prior notice when an investigation has been scheduled. A vendor will not be told of any violation(s) that is discovered while the investigation is ongoing. Vendors will receive notification of all results including violations after the investigation is considered closed by the WIC Program representatives.
Vendors will be identified for covert compliance investigations as follows:
1) Research of programmatic reports and vendor database, including but not limited to the Vendor Score section of the Vendor Profile report
2) Vendors who have been reported for potentially violating program policies 3) Random selection
Overt Monitoring
Representatives of the federal or state agencies may conduct unannounced overt monitoring visits any time that the store is open for business. All records pertinent to this monitoring visit must be available for review by the representative of the agency upon request.
Audits
The Georgia WIC Program may conduct record audits on any vendor at any time. Inventory audits will include the examination of food invoices or other proofs of purchase to determine whether a vendor has purchased sufficient quantities of supplemental foods to provide participants, parents, caretakers and/or proxies the quantities specified on food vouchers redeemed by the vendor during a given period of time. During an audit, the vendor must supply the WIC representative with documentation of pertinent records upon request. Vendors must retain copies of all invoices relating to the purchase of WIC food items for a period of three (3) years, plus current year.
Programmatic Reports and Database
The WIC Program will research/collect data from specific programmatic reports or databases to identify vendors who may be out of compliance.
If a vendor is out of compliance because of overpricing based on a programmatic report, notification will be given to provide an opportunity to reimburse the Georgia WIC program for the excess amount. Failure to repay will result in a program sanction(s), (see Sanction System).
Programmatic reports will also be generated to determine if a pharmacy vendor is accepting voucher(s) other than infant formula or WIC-eligible medical foods. If a pharmacy vendor is out of compliance, the Vendor Agreement may be terminated after notifying the vendor.
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GA WIC 2005 PROCEDURES MANUAL

Attachment VM-3

Programmatic reports, such as the Vendor Profile report will be generated also. If a vendor's score causes a flag

in any category, the vendor will be considered high risk and may receive a covert compliance investigation.

TERMINATION

Termination is the ending, by either party, of the agreement between the Georgia WIC Program and the authorized vendor. A written notification of the termination shall be mailed to the affected party at least twentyone (21) calendar days in advance. Reasons for termination, by either party, may include but are not limited to:

1) Voluntary withdrawal from the WIC program. 2) The decision to sell the store. 3) Failure to notify the Georgia WIC Program of a change in ownership. 4) Expiration of the agreement without a new application being submitted. 5) Food Stamp Program (FSP) Disqualification or Civil Money Penalty imposed by FSP in lieu of
disqualification. 6) Georgia WIC Branch disqualification. 7) Failure to participate in and submit documentation of participation in Annual Vendor Training. 8) Termination for cause, including but not limited to the violation of any federal regulation or terms of the WIC
vendor agreement not otherwise covered by the sanction system.

HIGH RISK IDENTIFICATION
There are four indicators and scores that will identify a vendor as high risk.
A = 80 or higher (small amount of price variation) B = 80 or higher (large % of food instruments redeemed at same price) H = 7 or higher (vendor has large % of total area redemption) M = 40 or higher (large % of participants outside vendor area)
The four high risk indicators and scores are found in the Vendor Score section of the Vendor Profile report and flagged with an asterisk (*). The report will be mailed annually to keep a vendor apprised of their high risk status.
SANCTIONS
Any WIC vendor found to be in violation of federal regulations and/or Georgia WIC Program policy will be assessed a sanction consistent with the severity and nature of the violation. Vendor violations means any intentional or unintentional action of a vendor's current owners, officers, managers, agents or paid or unpaid employees (with or without the knowledge of management) that violates the WIC Vendor Agreement or Federal or State statutes, regulations, policies or procedures governing the Program. Sanctions may include a warning letter, probation, disqualification or a civil money penalty. There are two types of sanctions, State Agency and Mandatory. State Agency sanctions are developed by WIC Program representatives and have obtained approval from United States Department of Agriculture (USDA) prior to implementation. Mandatory sanctions are developed by USDA. Implementation is required and cannot be omitted from the sanction system. Both State Agency and Mandatory Sanctions must be enforced when violation exists.

Violations are categorized by the nature and severity of the violation and shall determine which sanction will be assessed, the duration of the probationary period, and/or the period of disqualification. Each category has a prescribed period of disqualification, probation or warning assessed. Therefore, sanctions shall be assessed as follows:
1) The highest sanction assessed to a vendor shall determine the period of probation or disqualification. 2) All State Agency Sanctions and warnings assessed are retained in the vendor's file for a period of one year
and will roll off in one year. 3) Probationary periods are not subject to an Administrative Review. Vendors will continue to operate their
business during the probationary period. A vendor found to be in violation of WIC policies and procedures during the probationary period will be disqualified for the full probationary period. 4) If a disqualification for a mandatory sanction is not upheld during the administrative review process, then the remaining State Agency Sanction(s) if any, will remain on the vendor's record for one year.
If a vendor receives a warning letter and decides to dispute it, the vendor may request to be heard by the Georgia WIC Branch. To have the decision reviewed, the vendor may select from the following options:
- Call the Georgia WIC Branch and speak with the Vendor Management Section Director. - Submit written correspondence to the Georgia WIC Branch. - Request in writing a consultation with the Georgia WIC Branch, to be held with the vendor and/or the
vendor's advisor(s).
15

GA WIC 2005 PROCEDURES MANUAL SANCTION SYSTEM

Attachment VM-3

Following is a description of the Georgia WIC Program Sanction System and how it works. Civil Money Penalties (CMP) may be assessed in Categories I-V in lieu of disqualification for State Agency sanctions only. However, CMP shall only be assessed in lieu of disqualification for mandatory sanctions if the disqualification results in inadequate participant access. Enforcement of all sanctions are required when violations have been committed.

A. Any violation from Category I, II or III may be assessed a CMP in lieu of disqualification.
Category I - Warning on first and second offense, third offense probation for six (6) months. While on probation if a violation occurs in Categories I, II or III the vendor will be disqualified for six (6) months.
State Agency Sanctions Violations: 1. Stocking a WIC food item(s) outside of manufacturer's expiration date(s). 2. Prices not marked clearly on WIC food items or near WIC food items. 3. Allowing WIC food items to exceed the quantity specified on the voucher. (Except for promotional or free
items) 4. Failure to allow the purchase of any WIC food item(s). 5. Charging sales tax on WIC food item(s). 6. Failure to allow in-store or manufacturers' promotional or free item(s) with a WIC purchase.
Category II - Warning on first offense, second offense -probation for eight (8) months. While on probation if a violation occurs in Categories I, II or III the vendor will be disqualified for eight (8) months.
State Agency Sanctions Violations: 1. Failure to ring up sales of WIC purchases or failure to write the price on voucher before the participant
signs. 2. Failure to stock the required inventory of contracted formula or failure to stock the required inventory of
two or more WIC food items. 3. Refusing to accept valid WIC vouchers from participants in exchange for WIC food items. 4. Allowing the substitution of one WIC approved food item listed on the voucher for another WIC approved
food item not listed on the voucher, or allowing the purchase of WIC foods in unauthorized container sizes. 5. Failure to remain open for business at least eight hours per day, six days per week. 6. Failure to repay charges within thirty (30) days.
Category III - Warning on first offense, second offense - probation for ten (10) months. While on probation if a violation occurs in Categories I, II or III the vendor will be disqualified for ten (10) months.
State Agency Sanctions Violations: 1. Issuing rain checks/IOU's for WIC approved foods. 2. Contacting WIC participants for any reason regarding a WIC transaction. 3. Requiring participant to pay cash to redeem WIC vouchers. 4. Allowing the purchase of any formula other than the one specified on the front of the voucher. 5. Failure to allow purchase of all WIC approved food items listed on the face of the voucher regardless of
the price on the voucher. 6. Providing incentive items as part of the WIC transaction. 7. One occurrence during a compliance investigation of a violation in Category IV, violations 1-2. 8. One occurrence during a compliance investigation of a violation in Category V, violations 1-5. 9. Requiring WIC Participants to show any identification other than the WIC Identification Card.

B. Any violation from category IV or V that occurs at any time will result in immediate disqualification for the period specified in each category. No warning will be given prior to the completion of a covert compliance investigation. A pattern is established when the same violation occurs twice during a covert compliance investigation. When a pattern is not established, one occurrence during a compliance investigation will result in a Category III sanction.
Category IV - Immediate disqualification for one (1) year (twelve months) for each violation.
Mandatory Sanctions Violations: 1. A pattern of providing unauthorized food items in exchange for WIC vouchers. 2. A pattern of charging for supplemental foods provided in excess of those listed on the voucher.

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GA WIC 2005 PROCEDURES MANUAL
State Agency Sanctions Violations: 3. Intentionally providing false information on vendor records. 4. Discrimination. 5. Failure to provide vouchers or inventory records upon request. 6. Failure to allow monitoring by WIC representatives.

Attachment VM-3

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

Mandatory Sanctions Violations: 1. A pattern of receiving, transacting, and/or redeeming food vouchers in locations different from the
authorized location listed on the Agreement including the use of an unauthorized vendor and/or an unauthorized person. 2. A pattern of providing credit or non-food items in exchange for WIC vouchers. 3. A pattern of overcharging on WIC vouchers (charging a WIC participant more than the current shelf price or charging a WIC participant more for food than a non-WIC customer) during a compliance investigation. 4. A pattern of charging for supplemental food not received by the participant. 5. A pattern of claiming reimbursement for the sale of an amount of a specific supplemental food item which exceeds the store's documented inventory of that supplemental food item for a specific period of time. 6. One incidence of the sale of alcohol or alcoholic beverages or tobacco products in exchange for WIC vouchers.

C. Any violation from category VI or VII that occurs at any time will result in immediate disqualification for the period specified in category VI & VII (No warning will be given prior to the completion of the overt compliance investigation).
Category VI - Disqualification for six (6) years (seventy-two months) for each violation.
Mandatory Sanctions Violations: 1. One incidence of buying or selling WIC vouchers for cash. 2. One incidence of exchanging WIC vouchers for firearms. 3. One incidence of exchanging WIC vouchers for ammunition. 4. One incidence of exchanging WIC vouchers for explosives. 5. One incidence of exchanging WIC vouchers for controlled substances.
Category VII - Permanent disqualification for a conviction of each violation [Conviction refers to an action by a criminal court as defined in section 102 of the Controlled Substances Act (21 U.S.C. 802)].
Mandatory Sanctions Violations: 1. Conviction for buying or selling WIC vouchers for cash. 2. Conviction for buying or selling WIC vouchers for firearms. 3. Conviction for buying or selling WIC vouchers for ammunition. 4. Conviction for buying or selling WIC vouchers for explosives. 5. Conviction for buying or selling WIC vouchers for controlled substances.
DISQUALIFICATION

When a vendor accumulates the maximum number of sanctions, the store shall be disqualified from the WIC program. An exception may be granted when inadequate participant access exists. The disqualification period is determined by the severity and nature of the violation, the number of violations and past
disqualifications. Therefore, the highest sanctions assessed to a vendor shall determine the period of probation or disqualification. The actual disqualification period is determined using the same criteria for every vendor. The Georgia WIC Branch will not accept voluntary withdrawal as an alternative to disqualification.
Disqualification from the WIC Program could also result in a civil money penalty or disqualification from the Food Stamp Program.
If a vendor is disqualified or assessed a CMP for a mandatory sanction from the WIC Program in another state, the vendor may be disqualified from the Georgia WIC Program for the same period of time.
A vendor may be granted a Civil Money Penalty (CMP) in lieu of disqualification when prescribed procedures are met (see Civil Money Penalties and Sanction System). Upon the Georgia WIC Branch approval of a CMP, the disqualification period may be waived. Subsequent visits may be conducted during a waived
disqualification period. If violations occur during a subsequent visit, the vendor will be disqualified for a period equal to the period that the CMP was assessed or a second CMP may be imposed. If a vendor is disqualified from the Food Stamp Program or assessed a civil money penalty, the vendor shall be disqualified from the WIC Program for the same period of time. (Refer to Food Stamp Federal Regulations 7 CFR; Part 278)

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GA WIC 2005 PROCEDURES MANUAL ADMINISTRATIVE REVIEW AND APPEAL PROCEDURES

Attachment VM-3

Actions Subject to Administrative Review

If the vendor disagrees with an adverse action(s), an administrative review may be requested. Vendors may request an administrative review for the following reason(s):

1) Denial of authorization based on the vendor selection criteria for competitive price or for minimum variety and quantity of authorized supplemental foods or the determination that the vendor is attempting to circumvent a sanction.
2) Termination for cause including but not limited to change in ownership, location (more than 10 miles) or cessation of operations.
3) Disqualification. 4) Imposition of a civil money penalty in lieu of disqualification. 5) Denial of authorization based on the vendor selection criteria for business integrity or for a current Food
Stamp Program disqualification or civil money penalty for hardship. 6) Denial of authorization because a vendor submitted its application outside the established timeframes. 7) Disqualification based on a trafficking conviction. 8) Disqualification based on the imposition of a Food Stamp Program civil money penalty for hardship in lieu of
disqualification.

Actions Not Subject to Administrative Review
The following actions are not subject to administrative review:
1) The validity or appropriateness of the vendor selection criteria. 2) The validity or appropriateness of the participant access criteria and participant access determinations. 3) The determination whether a vendor had an effective policy or program in effect to prevent trafficking and
that the ownership of the vendor was not aware of, did not approve of, and was not involved in the conduct of the violation. 4) The expiration of a vendor's agreement. 5) Disputes regarding food instrument payment and vendor claims (other than the opportunity to justify or correct a vendor overcharge or other error). 6) Disqualification of a vendor as a result of disqualification from the Food Stamp Program.

Vendors requesting an Administrative Review must contact the Georgia WIC Program in writing within twenty-one (21) days of the adverse action. Vendors may choose to be represented by legal counsel. An Administrative Review shall be scheduled only in Atlanta, Georgia at the Office of State Administrative Hearings.

Administrative Review Procedures
The administrative review process includes the following:
1) Written notification of the adverse action. 2) The opportunity to appeal the action. 3) Adequate advance notice of the time and place of the administrative review. 4) The opportunity to present a case and at least one opportunity to reschedule. 5) The opportunity to cross-examine adverse witnesses (When necessary to protect the identity of WIC
Program investigators, such examinations may be conducted behind a protective screen or other device). 6) The opportunity to be represented by legal counsel. 7) The opportunity to examine prior to the review the evidence upon which the action is based. 8) An impartial decision-maker, whose determination is based solely on whether the Georgia WIC Program has
correctly applied Federal and State statutes, regulations, policies and procedures governing the Program, according to the evidence presented. 9) Written notification of the decision, including the basis for the decision, within 90 days from the date of the receipt of a vendor's request for an administrative review.

When the initial decision of a review is ruled in the State's favor, the vendor may file a motion for reconsideration to the administrative law judge within the time provided by law. When such motions are filed with the Administrative Law Judge, the vendor must also notify the Georgia WIC Branch, in writing, within ten (10) days of the initial decision date.

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GA WIC 2005 PROCEDURES MANUAL

Attachment VM-3

When the initial decision of the review is ruled in the State's favor, the vendor may choose to request a

departmental appeal within the time provided by law. When such an appeal has been requested, the vendor must

notify the Georgia WIC Branch in writing that the motion has been filed, within thirty (30) days of the initial

decision date.

Prior to the Administrative Review date, if a vendor would like to review their WIC records, contact the Georgia WIC Branch in writing for an appointment. The request must be made within the allowable time frames as detailed in the code of Federal Regulations 7 CFR 246.18. The Georgia WIC Branch will determine the location for the record review. The vendor may have a legal representative present. In the event an appointment cannot be negotiated, a conference call may be scheduled. The Georgia WIC Branch will mail all the records pertaining to the adverse action prior to the conference call. The conference call will be documented.

INADEQUATE PARTICIPANT ACCESS
Inadequate participant access is granted only when there is not an authorized WIC vendor within 10 miles of the violating vendor. Geographical barriers will be considered. The validity or appropriateness of the participant access criteria and participant access determinations are not subject to administrative review.

If the State Agency determines that disqualifying a vendor causes inadequate participant access, the State Agency must impose a Civil Money Penalty (CMP) in lieu of disqualification in Categories I-VII. The State Agency may not impose a CMP in lieu of disqualification either as a result of a Food Stamp Program/Civil Money Penalty or for a third or subsequent sanction as specified in 7 CFR 246.12(l)(1)(vi).

CIVIL MONEY PENALTIES (CMP)
CMPs may be assessed in lieu of disqualification for State Agency sanctions based on the methodology outlined in the chart below.

Civil Money Penalty Formula for State Agency Sanctions Based on a Six Month WIC Redemption Total

Category

$0-10,000 (Base Rate)

Amount Above $10,000 (Base Rate + % of Total Redemption over $10,000)

Category I $500

$500 + 1% of redemption over $10,000

Category II $1000

$1000 + 2% of redemption over $10,000

Category III $1500

$1500 + 3% of redemption over $10,000

If a CMP is not requested in the specified time period, all rights to a CMP are forfeited. For State Agency Sanctions, the first CMP will be reduced by 50% if the vendor presents documented proof that they had an effective training program in place. The vendor must also submit documentation listing the names of the personnel trained and the date of training. This training date must be during the fiscal year and before the disqualification notification.
Civil Money Penalties cannot exceed $10,000 per violation and/or $40,000 per investigation. If more than one violation is detected during a compliance investigation, a CMP must be imposed for each violation (up to the $10,000/$40,000 limits). Only two CMPs can be granted within a waived disqualification period.
CMPs must be paid within 30 days of the notice of approval. Installments may be considered up to a maximum of six months. When a CMP is approved, the waived disqualification period will begin as outlined in the disqualification notice. If a vendor fails to pay the CMP, the State Agency must disqualify the vendor for a period equal to the violation for which the CMP was assessed.
CMP Methodology for Mandatory Sanctions
CMPs may only be assessed for mandatory sanctions if the disqualification would result in inadequate participant access. The CMP formula for mandatory sanctions shall be based on 7 CFR 246.12 (l)(1)(x). For a violation that warrants permanent disqualification, the amount of the CMP shall be $10,000.

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For each violation subject to a mandatory sanction, the following formula will be used to calculate the amount of

the CMP imposed in lieu of disqualification.

1) Determine the vendor's average monthly redemptions for at least the 6 month period ending with the month immediately preceding the month during which the notice of the adverse action is dated.
2) Multiply the average monthly redemptions figure by ten percent (.10). 3) Multiply the product from the figure in the above statement by the number of months for which the store
would have been disqualified. This is the amount of the civil money penalty, provided that the civil money penalty shall not exceed $10,000 per violation. The total amount of the CMP assessed for violations that occur during a single investigation may not exceed $40,000.

When a vendor, who previously has been assessed any mandatory sanction, receives another identical mandatory sanction, the second CMP amount must be doubled. CMPs may only be doubled up to the maximum limits. When a vendor has previously been assessed two or more identical mandatory sanctions, receives a subsequent, yet different mandatory sanction, the CMP amount of this third identical sanction and all subsequent sanctions must be doubled. Civil money penalties may not be imposed in lieu of disqualification for third or subsequent mandatory sanctions.

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WHERE TO GET MORE INFORMATION
The Georgia WIC Branch has a vendor customer service hotline (toll free in Georgia) available to assist Georgia WIC vendors with any aspect of the WIC Program. The hotline is available Monday through Friday, except State holidays, from 8:00 AM - 5:00 PM Eastern Standard Time (EST). After 5:00 PM and during periods of high volume calling, please leave a voice message. Contact us at: Georgia WIC Branch Vendor Management Section 2 Peachtree Street, NW Suite 10-476 Atlanta, Georgia 30303-3142 404-657-2900 Customer service hotline 1-866-814-5468 (toll free within Georgia) The United States Department of Agriculture (USDA) prohibits discrimination in its program and activities on the basis of race, color, national origin, sex, age or disability. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information (Braille, larger print, audiotape, etc.) should contact USDA's Target Center at (202) 720-5964 (voice and TDD). To file a complaint, of discrimination, write USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 14th and Independence Avenue, SW, Washington, DC 20250-9410 or call (202) 720-5964 (voice and TDD). USDA is an equal opportunity provider and employer.
Form No. 3783 (Rev. 3/2004)

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

Legal Name of Vendor

Vendor Address

City

Business Telephone Mailing Address
If different from above

(Area Code)

State
Number

City

State

Business Telephone
(Area Code)
Federal Employer Identification Number

Number

WIC VENDOR NUMBER

Zip County
Zip

This Agreement is by and between the Georgia Department of Human Resources, Division of Public Health, WIC Branch, hereinafter known as the "Georgia WIC Program," having a mailing address of Two Peachtree Street NW, 10th Floor, Suite 476, Atlanta, Georgia, 303033142, and the above named vendor hereinafter known as "the Vendor." This agreement is effective for the period beginning _______________________________________________ I. PURPOSE
The purpose of this agreement is to establish the terms and conditions for an authorized vendor to sell prescribed nutritious supplemental foods in accordance with federal laws and regulations and the Georgia Nutrition Program for Women, Infants and Children (WIC) pursuant to the laws of the State of Georgia and the Child Nutrition Act (CNA) of 1966 as amended.
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II. VENDOR ELIGIBILITY AND LOCATION

A. An eligible vendor is a business entity that is 1) licensed by the Georgia Department of Agriculture and, 2) without a debarment or suspension from United States Department of Agriculture. Pharmacies and military commissaries do not have to be licensed by the Georgia Department of Agriculture.
B. An eligible vendor must be identified as a fixed location with an official physical address. For corporate vendors owning two (2) or more locations, the following information for each location must be listed on the Corporate Attachment (Form 3771A) and made part of the agreement: 1. vendor name 2. vendor number 3. bank name 4. Food Stamp Program authorization number 5. Georgia Department of Agriculture number 6. physical address 7. city, state and zip code 8. authorized contact person(store manager) 9. telephone number 10. Federal Employer Identification Number

C. An eligible vendor must meet all requirements as described in the 2002 Georgia WIC Program Vendor Handbook and all addendums.

D. The vendor must comply with the selection criteria throughout the agreement period including any changes to the criteria. Using the current vendor selection criteria, the Georgia WIC Program may reassess the vendor at any time during the agreement. The Georgia WIC Program will terminate the vendor agreement if the vendor fails to meet the current vendor selection criteria.

E. An eligible vendor, authorized as a military commissary, pharmacy or
corporate vendor will be given certain exceptions to this agreement. The exceptions are outlined in the 2002 Georgia WIC Program Vendor Handbook and all addendums.

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III. RESPONSIBILITIES VENDOR
The Vendor agrees to adhere to all federal and state laws, policies, procedures, rules and regulations, including the most recent State Plan of Program Operation and Administration and any subsequent revisions to the policies, procedures, laws, rules and regulations issued by the federal government and/or the Georgia WIC Program. This agreement will be interpreted based on the laws of the State of Georgia.
A. The vendor agrees and covenants: 1. To be fully accountable for the actions of its paid or unpaid owners, officers, managers, agents and employees. 2. To abide by the rules, policies and procedures as outlined in the most recent publication of the Georgia WIC Program Vendor Handbook and all addendums. 3. To provide training to paid and unpaid employees, agents and all personnel involved in WIC transactions. 4. To not solicit WIC participants, parents, caretakers and/or proxies on the premises of WIC clinics.
B. VENDOR TRAINING
Prior to accepting WIC vouchers, the vendor or his authorized representative must receive interactive authorized training. The Georgia WIC Program will provide the date, time and location of the training. The vendor may submit a written request, for the Georgia WIC Program to provide subsequent training to store personnel at anytime after both parties have signed the agreement.
The vendor agrees and covenants: 1. To not participate in the Georgia WIC Program until Authorized
Training has been completed and a vendor stamp has been issued. 2. To not participate until the vendor has received a passing score of
seventy (70) points or above on the Post Vendor Training Evaluation. 3. To provide documentation that a management representative(s) from
each location has been trained on the required topics as listed on the Corporate Vendor Training Checklist (form 3757A).

C. NO SUBSTITUTIONS, CASH, REFUNDS, OR EXCHANGES
The vendor agrees and covenants: 1. To only charge for authorized supplemental foods listed on the food
voucher.

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2. To not provide unauthorized food items, non-food items or cash in exchange for food vouchers.
3. To not provide refunds or permit exchanges for authorized supplemental food vouchers except for exchanges of an identical authorized supplemental food item when the original authorized supplemental food item is defective, spoiled or has exceeded its "sell by" or "best if used by" or other date limiting the sale or use of the food item.
D. FOOD VOUCHER TRANSACTIONS
The vendor agrees and covenants: 1. To not accept WIC food vouchers before the "First Date to Use" or after
the "Last Date to Use" as printed on the voucher. 2. To submit vouchers to the bank for payment within sixty (60) days
from the "First Date to Use" as indicated on each voucher. 3. To assure that WIC food voucher transactions are processed in
accordance with the procedures set forth in the 2002 Georgia WIC Program Vendor Handbook and all addendums. 4. To not demand that a WIC participant, parent, caretaker and/or proxy purchase every eligible WIC food item listed on the voucher. 5. To allow participants, parent, caretakers and/or proxies the right to purchase the eligible foods of their choice as listed on the WIC food voucher and the approved food list. 6. To not transfer Georgia WIC Program vouchers from vendor to vendor or to not accept Georgia WIC Program vouchers from another vendor for payment or to not accept WIC vouchers in an unauthorized location for payment in an authorized location. 7. To not contact or seek restitution from participants, parents, caretakers and/or proxies for WIC food vouchers not paid or partially paid by the Georgia WIC Program. 8. To not request cash from the WIC participant, parents, caretakers or proxies for any WIC transaction. 9. To not provide WIC participants, parents, caretakers and/or proxies with rain checks/IOU's, credit slips, due bills or other similar receipts for WIC foods not obtained at the time of the purchase. 10. To allow WIC participants, parents, and caretakers and/or proxies to participate in both or either in -store and/or manufacturer promotions that include WIC approved food items. 11. To not collect sales tax on prescribed WIC food purchases. 12. To not charge the participant, parents, caretaker, and/or proxy or the WIC Program for bank fees or other fees related to voucher redemption. 13. To advise participants, parents, caretakers and/or proxies that the Georgia WIC Program is not responsible for the home delivery of food items or any other in-store promotions. 14. To insert, in ink the actual cost of the WIC foods on the WIC voucher face at the time of purchase in the presence of the customer.

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E. PRICING
The vendor agrees and covenants: 1. To clearly mark the price of WIC foods on the item, container, shelf or
sign. 2. To provide each WIC food item at or below the current shelf price. 3. To accept an adjustment if the price on the voucher(s) submitted for
payment exceeds the maximum price printed on the voucher.
F. OVERCHARGING
The vendor agrees and covenants: 1. To not overcharge the WIC participant, parent, caretaker and/or proxy,
or the Georgia WIC Program by charging more than the vendor's current shelf price for a WIC approved food item(s). (Overcharging is considered a violation and will result in sanction(s) if it occurs during a covert investigation).
G. CIVIL RIGHTS
The vendor agrees and covenants: 1. To abide by the United States Civil Rights Act and the United States
Civil Rights Policy Statement and to assure that discrimination is prohibited towards WIC Program participants, caretakers, parents or proxies and all related activities, on the basis of race, color, national origin, sex, religion, age, disability, political beliefs, sexual orientation or marital status. 2. To offer WIC participants, parents, caretakers and/or proxies the same courtesies offered to other customers. 3. To display the "We Welcome WIC'' decal on the door glass or other prominent place. 4. To assure that all information, including the identity of the WIC participant, parent, caretaker and/or proxy is kept confidential in accordance with state and federal law.
H. CHANGE OF OWNERSHIP, LOCATION OR CESSATION OF OPERATION
The vendor agrees and covenants: 1. To submit, upon request, to the Georgia WIC Program a copy of all
acceptable proof of ownership and related documents, (e.g. articles of incorporation, bill of sale and partnership declaration and evidence of sole proprietorship, etc). 2. To notify the Georgia WIC Program in writing at least twenty-one (21) days in advance if the vendor plans to cease business operation, change
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ownership and/or when the vendor plans to move from the authorized location.

I.

COMPLIANCE AND MONITORING

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

J.

VENDOR SANCTION SYSTEM AND VENDOR CLAIMS

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

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

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IV. RESPONSIBILITIES GEORGIA WIC PROGRAM

The Georgia WIC Program agrees to adhere to federal and/or state laws, policies, procedures, rules and regulations, including the most recent State Plan of Program Operation and Administration.

Any subsequent revisions to the policies, procedures, laws, rules and regulations that relate to the Georgia WIC Program issued by the federal government are hereby made a part of this agreement.

The Georgia WIC Program further agrees to the following:

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

and all addendums.

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

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

WIC vouchers.

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

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

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

procedures.

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

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

the Georgia WIC Program.

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

Program rules, regulations, policies or procedures.

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

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

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

Vendor Handbook and all addendums.

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

agreement.

I.

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

J.

To provide payment for vouchers validly redeemed and submitted to the

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

Georgia WIC Vendor Handbook and all addendums.

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

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

Vendor Handbook and all addendums.

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

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

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

redeemed.

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V. RENEWABILITY

This agreement is not renewable. If the vendor wishes to continue to be authorized beyond the period of its current agreement, the vendor must reapply for authorization.

VI. NON TRANSFERABILITY
This agreement is not transferable.
VII. EXPIRATION, TERMINATION AND DISQUALIFICATION
A. Expiration of this agreement is not subject to appeal by the vendor.
B. Either party may terminate the agreement.
C. The Georgia WIC Program may terminate for cause, after providing a twentyone (21) day advance written notice. Vendors have the right to request an Administrative Review.
D. Disqualification is an adverse action taken by the Georgia WIC Program and is based on the sanction system outlined in the 2002 Georgia WIC Program Vendor Handbook and all addendums.

VIII. ADVERSE ACTIONS AND REVIEW PROCEDURES
A vendor may request an Administrative Review for the following: A. Denial of authorization based on the vendor selection criteria for competitive
price or for minimum variety and quantity of authorized supplemental foods or on a determination that the vendor is attempting to circumvent a sanction. B. Termination for cause, including but not limited to change in ownership, location (more than mile) or cessation of operations. C. Disqualification. D. Imposition of a civil money penalty in lieu of disqualification. E. Denial of authorization based on the vendor selection criteria for business integrity or for a current Food Stamp Program disqualification or civil money penalty for hardship. F. Denial of authorization because a vendor submitted its application outside the established timeframes. G. Disqualification based on a trafficking conviction. H. Disqualification based on the imposition of a Food Stamp Program civil money penalty for hardship.

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Administrative Review Procedures are outlined in the most recent Georgia Vendor Handbook.
IX. PENALTIES
A. The Georgia WIC Program may penalize the vendor by issuing sanctions in accordance with the procedures prescribed in the most recent publication of the Georgia WIC Vendor Handbook and all addendums.
The Georgia WIC Program sanctions may include disqualification, warnings, probation and civil money penalties in lieu of disqualification. The State agency does not have to provide the vendor with prior warning about those violations before imposing such sanctions (7CFR 246.12 XVIII).
B. A vendor maybe subject to criminal penalties as a result of a violation of the Georgia WIC Program in additional to civil money penalties described above. Vendors who have willfully misapplied, stolen or fraudulently obtained WIC funds shall be subject to a fine of not more than $25,000.00 imprisonment for not more than five (5) years or both. If the value of the funds is less than $100.00 then the penalties may be a fine of not more than $1,000.00, imprisonment for not more than one (1) year or both.
X. SEVERABILITY
If any provision of this agreement or form attached to or incorporated by reference is waived or held to be invalid, such waiver or invalidity shall not affect other provisions of this agreement.
XI. SANCTIONS/VIOLATIONS FROM PREVIOUS AGREEMENT PERIODS
A. Sanctions - any sanction(s) that are in the vendor's record at the time of reauthorization will remain on the vendor's record. Prior year's sanctions may result in denial of application and/or additional sanctions up to and including disqualification, in accordance with the 2002 Georgia WIC Program Vendor Handbook and all addendums.
B. Violations - Pending and/or potential violations, that exists at the time of reauthorization will accrue and will result in sanctions up to and including disqualification, in accordance with the 2002 Georgia WIC Program Vendor Handbook and all addendums.

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

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

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State Agency Sanctions Violations: 3. Intentionally providing false information on vendor records.
4. Discrimination. 5. Failure to provide vouchers or inventory records upon request. 6. Failure to allow monitoring by WIC representatives.

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

Mandatory Sanctions Violations:

1.

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

locations different from the authorized locations listed on the

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

unauthorized person.

2.

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

vouchers.

3.

A pattern of overcharging on WIC vouchers (charging a WIC

participant more than the current shelf price or charging a WIC

participant more for food than a non-WIC customer) during a

compliance investigation.

4.

A pattern of charging for supplemental food not received by the

participant.

5.

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

specific supplemental food item which exceeds the store's documented

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

6.

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

products in exchange for WIC vouchers.

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

Category VI - Disqualification for six (6) years (seventy-two months) for each violation.
Mandatory Sanctions Violations: 1. One incidence of buying or selling of WIC vouchers for cash. 2. One incidence of exchanging WIC vouchers for firearms. 3. One incidence of exchanging WIC vouchers for ammunition. 4. One incidence of exchanging WIC vouchers for explosives. 5. One incidence of exchanging WIC vouchers for controlled substances.
Category VII -Permanent disqualification for a conviction of each violation [Conviction refers to an action by a criminal court as defined in section 102 of the Controlled Substances Act (21 U.S.C. 8020)]

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Mandatory Sanctions Violations: 1. Conviction for buying or selling WIC vouchers for cash. 2. Conviction for exchanging WIC vouchers for firearms. 3. Conviction for exchanging WIC vouchers for ammunition. 4. Conviction for exchanging WIC vouchers for explosives. 5. Conviction for exchanging WIC vouchers for controlled substances.
XIII. SPECIAL CERTIFICATION
The vendor acknowledges through the signature of the owner, or an authorized representative, that he or she understands and accepts all terms of this agreement. The individuals signing this agreement certify that they are authorized to sign the agreement on behalf of the vendor.
This agreement becomes valid only upon the signature of an authorized representative of the Georgia WIC Program and upon receipt, by the vendor, of an executed copy along with vendor stamps for each authorized location.

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Signature of Authorized Representative

Date

Authorized Representative (Type or Print)

Title (Type or Print)

GEORGIA WIC PROGRAM SIGNATURE

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

Date

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

Store Name and Number

WIC Vendor Number

Store Address

City

State

Zip

Business Telephone

(Area Code)

Number

County

Store Contact or Manager

Federal Employer Identification Number

Food Stamp Authorization Number

Georgia Department of Agriculture License Number
Date store representative received Authorized Training (Include Form #3757A Corporate Training
Checklist.) Date WIC minimum inventory will be in store (For locations opening after October 1, 2004) Date store will open (For locations opening after October 1, 2004)

Signature of Authorized Representative Authorized Representative (Type or Print) Title (Type or Print) Name of Company (Type or Print)
Form 3771A (03/04)

Date

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Instructions: Please print all information. STORE NAME
STAFF PRESENT 1. 2. 3. 4.

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

VENDOR NUMBER

Check items reviewed, discussed and explained to vendor.

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

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

SIGNATURE

TITLE

DATE

PRINT NAME

Form 3757 (Rev. 03-04)

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

Please print all information. CORPORATE VENDOR NAME
STORE NAME & NUMBER

VENDOR NUMBER

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

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

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

I ACKNOWLEDGE THAT I HAVE BEEN TRAINED ON THE ITEMS LISTED ABOVE AND RECEIVED A CURRENT GEORGIA WIC VENDOR HANDBOOK.

Signature of Store Representative

Date

Print Name

Title

Form 3757A (Rev. 03-04)

GA WIC 2005 PROCEDURES MANUAL
District/Unit/Clinic: County: Date of Incident: Date Reported: Follow-up Date:

GEORGIA DEPARTMENT OF HUMAN RESOURCES
WIC PROGRAM
INCIDENT/COMPLAINT FORM

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

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

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

Local Agency Resolution:
Georgia WIC Branch Resolution/Comments:
Follow-up Report: GWB Customer Service Coordinator: FORM 3772 Revised 3/02

Attachment VM-8
Type of Complaint: Participant [ ] Vendor [ ] Civil Rights [ ]
Local Agency/GA WIC Branch Staff [ ] Local Agency/State WIC Information Staff Name: Phone: ( )
Can Complaint be Closed at Local Agency? Yes [] No [] Signature and Title: Date: Can Complaint be Closed at GA WIC Branch? Yes [] No [] Signature and Title: Date:

GA WIC 2005 PROCEDURES MANUAL

Attachment VM-9

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

Vendor Number

District/Unit Date of Visit

/
Month

/

Day

Year

Store Owner

Store Manager

Store Address

City

County

State

Zip

Review Type - Check One Pre-Approval Monitoring

Follow-Up Complaint

Inventory Type - Check One Regular Inventory
Waived Inventory

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

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

YES

NO

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

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

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

YES

NO

YES

NO

Peanut Butter

YES

NO

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

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

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

Infant Cereal At least one type must be rice

YES

NO

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

2. Is rice cereal in stock?

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

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

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

GA WIC 2005 PROCEDURES MANUAL

Attachment VM-9

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

YES

NO

YES

NO

YES

NO

YES

NO

General Observations and Questions

N/A YES

NO

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

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

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

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

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

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

Signature of Vendor Representative

Date

Print Name of Vendor Representative

Title

Comments:

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

Signature of WIC Representative

Date

Comments:

Print Name of WIC Representative

GA WIC 2005 PROCEDURES MANUAL

Attachment VM-10

COOPERATIVE AGREEMENT BETWEEN THE GEORGIA WIC PROGRAM AND FNS FIELD OFFICE

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

I. Responsibilities of the FNS Field Office

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

Name/Title:

Rosie V. Daugherty, Officer In Charge

Address: Atlanta Field Office

61 Forsyth Street SW, Suite 8T25

Atlanta, Georgia 30303

Telephone: (404) 562- 7060

Fax: (404) 562 -7120

E-mail: rosie.daugherty@fns.usda.gov

Provide the WIC State agency with general information on the process of authorizing FSP retailers.

Provide the WIC State agency, upon request, with a list of all FSP authorized retailers statewide.

Provide WIC State agency investigative staff with training on FSP compliance investigation techniques. Such training will be scheduled to the extent to which resources are available.

Provide the WIC State agency with the following:

Final summary report of letters of determination after all appeal rights have been exhausted by the 10th of each month

Provide the WIC State agency with the above letters and notices:

No later than 45 days after a retailer's opportunity to appeal a FSP sanction has either expired or been exhausted.

Include the statement "Disqualification from the Food Stamp Program may also result in a WIC Program disqualification which is not subject to administrative or judicial review under the WIC Program. A civil money penalty from the Food Stamp Program may also result in a WIC Program disqualification, but such disqualification would be subject to administrative and/or judicial review under the WIC Program"-- on the following letters and notices:

1

GA WIC 2005 PROCEDURES MANUAL

Attachment VM-10

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

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

III. Responsibilities of the WIC State agency.
Provide the FNS Field Office with the name, title, and address of the WIC State agency office where all information on abusive FSP retailers should be sent.
Name/Title: Alwin K. Peterson, Program Director Name/Title: Vera Green, Director, Vendor Management Section
Address: Georgia WIC Branch 2 Peachtree Street NW. Suite 10-476 Atlanta, Georgia 30303-3186
Telephone: (404) 657-2900 Fax (404) 657-2910
E mail: alpeterson@dhr.state.ga.us vmgreen@dhr.state.ga.us
Provide FNS Field Office with general information on the process of authorizing WIC vendors.
Provide the FNS Field Office, no later than 15 days after a vendor's opportunity to appeal a WIC sanction has either expired or been exhausted, a copy of all

2

GA WIC 2005 PROCEDURES MANUAL

Attachment VM-10

notices of administrative action for the mandatory sanctions set forth in section 46.12(k)(1)(i) through (k)(1)(vi) of the federal WIC regulations. Such notice must include the name, address, and FSP retailer identification number of the vendor, the type(s) of violation(s), and the length of disqualification or the length of the disqualification corresponding to the violation for which a civil money penalty was assessed.
Provide ongoing written notice of all Judicial Appeal results, i.e. stay of stamp, etc.
Include on all disqualification notices to WIC vendors the following statement: "This disqualification from WIC may result in disqualification as a retailer in the Food Stamp Program per section 278.6(e)(8) of the federal Food Stamp Program regulations. Such disqualification may not be subject to administrative or judicial review under the Food Stamp Program."
Provide the FNS Field Office, upon request, a copy of all notices of administrative action for the State agency established sanctions authorized by section 246.12(k)(2) of the federal WIC regulations, or letters of warning for any such violation.
Provide the FNS Field Office, upon request; information on specific WIC authorized vendors.
Submit to the Supplemental Nutrition Program, all requests for training on FNS compliance investigation techniques.

IV. The undersigned parties further mutually agree that:
Information exchanged in accordance with this agreement must be disclosed and used only in direct connection with the administration and enforcement of WIC and FSP regulations and procedures, except that such information must be disclosed to the Comptroller General of the United States and other authorized officials for audit and examination authorized by law. Under no circumstances should such information be disclosed to any State personnel who are not directly involved in the management of vendors in the WIC Program, other public or private agencies, or to private citizens or enterprises not directly involved in State agency vendor management. The protected information includes all information exchanged about retailers/vendors, as well as about investigations of retailers/vendors, such as the identities of investigators and investigative aides.
Information exchanged in accordance with this agreement is not subject to the Federal and State freedom of information laws and regulations.

3

GA WIC 2005 PROCEDURES MANUAL

Attachment VM-10

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

Regional Director Supplemental Nutrition Programs

Date

Director WIC State Agency

Date

Officer In Charge Field Office

Date

Regional Director Field Operations

Date

4

GA WIC 2005 PROCEDURES MANUAL

Food Package

TABLE OF CONTENTS
Page I. Authorization of Foods ..............................................................................................FP-1 II. Prescribing Foods, General........................................................................................FP-1
A. Contract Versus Non-Contract Formula ...........................................................FP-1 B. Food Groups ..........................................................................................................FP-5 C. Food Packages .......................................................................................................FP-6 D. Required Documentation.....................................................................................FP-8 III. Infants ...........................................................................................................................FP-9 A. Tailoring .................................................................................................................FP-9 B. Infants 0 Through 4 Months ..............................................................................FP-11 C. Infants 5 Through 12 Months ............................................................................FP-14 IV. Children and Women with Special Dietary Needs..............................................FP-18 A. Tailoring ...............................................................................................................FP-18 B. Food Package Assignment.................................................................................FP-18 C. Standard Manual Food Package .......................................................................FP-18 D. Additional Documentation................................................................................FP-19 V. Children 1 to 5 Years ................................................................................................FP-21 A. Tailoring ...............................................................................................................FP-21 B. Food Package Assignment.................................................................................FP-22 C. Standard Manual Food Package .......................................................................FP-22 D. Additional Documentation................................................................................FP-22 VI. Pregnant and Breastfeeding Women .....................................................................FP-23 A. Tailoring ...............................................................................................................FP-23 B. Food Package Assignment.................................................................................FP-24

FP-i

GA WIC 2005 PROCEDURES MANUAL

Food Package

C. Standard Manual Food Package .......................................................................FP-24 D. Additional Documentation................................................................................FP-24 VII. Postpartum, Non-Breastfeeding Women ..............................................................FP-25 A. Tailoring ...............................................................................................................FP-25 B. Food Package Assignment.................................................................................FP-26 C. Additional Documentation................................................................................FP-26 VIII. Homelessness, Migrancy, And Disaster Situations .............................................FP-27 A. Alternate Food Package Assignment ...............................................................FP-27 B. Method for Food Package Assignment............................................................FP-27 C. Assignment of Food Package Number ............................................................FP-27 D. Documentation Requirements ..........................................................................FP-28 E. Alternate Food Packages....................................................................................FP-29 IX. Formula Tracking Guidelines .................................................................................FP-32 A. Formula Distribution Guidelines......................................................................FP-32 B. Maximum Amount to be Issued .......................................................................FP-32 C. Documentation ....................................................................................................FP-32 D. Disposal of expired formula..............................................................................FP-33

Attachments:
FP-1 Infant Food Packages, Maximum Monthly Amounts Authorized....................FP-34 FP-2 Infant Food Packages, Contract Formula ..............................................................FP-35 FP-3 Infant Food Packages, Contract Special Formulas ...............................................FP-47 FP-4 Infant Food Packages, Non-Contract Special Formulas......................................FP-57 FP-5 Infant Food Packages, Non-Contract Soy Formulas............................................FP-60
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GA WIC 2005 PROCEDURES MANUAL

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FP-6 Alternate Food Package for Infants (0-4 Months), Maximum Monthly Amounts Authorized, Contract Formula .............................................FP-63
FP-7 Alternate Food Package for Infants (0-4 Months), Contract Formula ......................................................................................................................FP-64
FP-8 Alternate Food Package for Infants (5-12 Months), Maximum Monthly Amounts Authorized, Contract Formula..............................................FP-65
FP-9 Alternate Food Package for Infants (5-12 Months), Contract Formula ......................................................................................................................FP-66
FP-10 Food Packages for Children and Women with Special Dietary Needs, Maximum Monthly Amounts Authorized ................................FP-67
FP-11 Children's and Women's Packages, Contract Special Formulas, Prescription Required............................................................................FP-68
FP-12 Children's and Women's Packages, Non-Contract Contract Special Formulas, Prescription Required ..............................................................FP-84
FP-13 Alternate Food Packages for Children and Women with Special Dietary Needs, Maximum Monthly Amounts Authorized .................................................................................................................FP-95
FP-14 Alternate Food Packages For Children and Women with Special Dietary Needs ..............................................................................................FP-96
FP-15 Children's Food Packages, Maximum Monthly Amounts Authorized .................................................................................................................FP-97
FP-16 Children's Food Packages ........................................................................................FP-98
FP-17 Alternate Food Packages for Children 1 Through 5 Years, Maximum Monthly Amounts Authorized..........................................................FP-108
FP-18 Alternate Food Packages for Children 1 Through 5 Years ...............................FP-109
FP-19 Pregnant and Breastfeeding Women's Food Packages, Maximum Monthly Amounts Authorized..........................................................FP-110
FP-20 Pregnant and Breastfeeding Women's Food Packages......................................FP-111
FP-21 Exclusively Breastfeeding Food Packages...........................................................FP-120

FP-iii

GA WIC 2005 PROCEDURES MANUAL

Food Package

FP-22 Alternate Food Packages for Pregnant and Breastfeeding Women, Maximum Monthly Amounts Authorized..........................................FP-122
FP-23 Alternate Food Packages for Pregnant and Breastfeeding Women......................................................................................................................FP-123
FP-24 Postpartum, Non-Breastfeeding Women's Food Packages, Maximum Monthly Amounts Authorized..........................................................FP-125
FP-25 Postpartum, Non-Breastfeeding Women's Food Packages ..............................FP-126
FP-26 Alternate Food Packages for Postpartum, Non-Breastfeeding Women, Maximum Monthly Amounts Authorized..........................................FP-131
FP-27 Alternate Food Package for Postpartum, Non-Breastfeeding Women......................................................................................................................FP-132
FP-28 Georgia WIC Program Formula Referral Form ..................................................FP-133
FP-29 Georgia WIC Approved Food List, Criteria to Evaluate an Eligible Food Item ...................................................................................................FP-134
FP-30 Georgia WIC Program, WIC Approved Food List.............................................FP-137
FP-31 WIC Approved Formulas/Medical Foods..........................................................FP-142
FP-32 Procurement of Special Formula .........................................................................FP-148
FP-33 Special Formula Order Form.................................................................................FP-149
FP-34 Supplemental Formula Conversion Table...........................................................FP-150
FP-35 Formula Food Package Index Reference Pages ..................................................FP-151
FP-36 Calcium Fortified Juices / Guidelines, Procedures & Recommendations...................................................................................................FP-156
FP-37 Free Trade Formula Tracking Log........................................................................FP-157

FP-iv

GA WIC 2005 PROCEDURES MANUAL

Food Package

I. AUTHORIZATION OF FOODS
The State food package tailoring policy is:
A competent professional authority (CPA)* shall prescribe types of supplemental foods and the food package in quantities appropriate for each participant, taking into consideration the participant's age and dietary needs. The amounts of supplemental foods may equal, but shall not exceed, the maximum quantities specified in this Section.
There will be NO deviation from the State food package tailoring policy.
*A CPA is a nutritionist, registered dietitian, licensed dietitian, registered or licensed practical nurse, physician, or physician's assistant.
II. PRESCRIBING FOODS, GENERAL
A. Contract Versus Non-Contract Formula
The State of Georgia has entered into a contract with Mead Johnson Nutritionals (effective date: October 1, 2002 through September 30, 2005), to provide formula for WIC participants. All infants participating in the Georgia WIC Program will be provided with vouchers for a contract formula. The contract infant formulas are Enfamil with Iron & Enfamil Lipil with Iron Infant Formula (milk-based), ProSobee with Iron & ProSobee Lipil with Iron (soy based) and Enfamil LactoFree with iron & Enfamil LactoFree Lipil with Iron (milk-based lactose free). This contract also covers children and women who require a contract formula as a source of nutrition. The contract currently provides the following rebate on each can of Enfamil with Iron, Enfamil ProSobee, Enfamil Lipil, Enfamil ProSobee Lipil, Enfamil Next StepLipil, Enfamil Next Step ProSobee Lipil, Enfamil Low Iron Lipil, Enfamil LactoFree Lipil or Enfamil AR Lipil purchased. Numbers rounded to the nearest whole cent.

FP-1

GA WIC 2005 PROCEDURES MANUAL

Food Package

Enfamil

Concentrate (13 ounces):

$3.19

Powder (14.3 ounces):

$10.77

Ready-To-Feed (32 ounces): $3.88

Enfamil ProSobee

Concentrate (13 ounces):

$3.34

Powder (14.3 ounces):

$11.22

Ready-To-Feed (32 ounces): DISCONTINUED

Enfamil Lipil

Concentrate (13 ounces):

$3.41

Powder (12.9 ounces):

$10.53

Ready-To-Feed (32 ounces): $4.12

Enfamil ProSobee Lipil

Concentrate (13 ounces):

$3.45

Powder (12.9 ounces):

$10.64

Ready-To-Feed (32 ounces): $4.18

Enfamil Next Step Lipil (Replaced Enfamil Next Step)

Powder (12 ounces):

$8.71

Enfamil Next Step ProSobee Lipil (Replaced Enfamil Next Step Soy)

Powder (12 ounces):

$8.71

Enfamil Low Iron Lipil (Replaced Enfamil Low Iron)

Concentrate (13 ounces):

Discontinued

Powder (14.3 ounces):

$10.53

Ready-To-Feed (32 ounces): $4.12

Enfamil LactoFree Lipil (Replaced LactoFree Lipil)

Concentrate (13 ounces):

$3.45

Powder (12.9 ounces):

$10.64

Ready-To-Feed (32 ounces): $4.18

Enfamil AR Lipil (Replaced Enfamil AR)

Powder (12.9 ounces):

$10.65

Ready-To-Feed (32 ounces): $3.93

When Mead Johnson's wholesale formula price increases, the amount of Georgia's rebate increases cent for cent beginning the month in which the increase goes into effect.

Contract formulas not requiring a prescription:

Enfamil with Iron

Enfamil ProSobee with Iron

Enfamil Lipil with Iron Enfamil ProSobee Lipil with Iron

All other formulas must be documented appropriately. Refer to pages FP-9 through FP-19 for information regarding the required documentation

FP-2

GA WIC 2005 PROCEDURES MANUAL

Food Package

for a diagnosis and prescription. 1. Milk-based Formula:
All participants who receive a milk-based formula, will receive the contract formula Enfamil With Iron OR Enfamil Lipil with Iron.
The Georgia WIC Program does NOT APPROVE the following non-contract milk-based formulas for distribution.
Prescriptions will not be accepted for:

Nestl Good Start Supreme (Replaced Carnation Good Start) Nestl Good Start Supreme DHA & ARA Nestl Good Start 2 Supreme DHA & ARA Nestl Good Start Essentials Nestl Good Start 2 Essentials (Replaced Carnation Follow-Up) Nestl NAN Similac Similac Advance Similac 2 Similac 2 Advance Parent's Choice Store Brand milk-based infant formulas

Whenever medical condition(s) /diagnosis warrants a change from the contract milk-based formula (Enfamil with Iron or Enfamil Lipil with Iron), the WIC program may provide the infant another approved formula with proper documentation. Vouchers will specify the prescribed formula. Refer to pages FP7 through FP-21 for information regarding the required documentation for a diagnosis and prescription.
2. Soy Based Formula:
All participants who receive a soy-based formula will receive the contract formula ProSobee with Iron OR ProSobee Lipil with Iron.

FP-3

GA WIC 2005 PROCEDURES MANUAL

Food Package

Whenever medical condition(s) /diagnosis warrants a change from the contract soy-based formula (ProSobee with Iron or ProSobee Lipil with Iron), the WIC program may provide the infant another approved formula with proper documentation. Vouchers will specify the prescribed formula. Refer to pages FP7 through FP-21 for information regarding the required documentation for a diagnosis and prescription. Vouchers will specify the prescribed formula. Refer to pages FP-9 through FP19 for information regarding the required documentation for a diagnosis and prescription.
The following non-contract soy based formulas ARE APPROVED for distribution by the Georgia WIC Program with a valid written prescription with medical condition(s) /diagnosis:
Nestl Good Start Supreme Soy DHA & ARA Nestl Good Start 2 Essentials Soy (Replaced Carnation FollowUp Soy with iron) Isomil with Iron Isomil Advance Isomil 2 Advance Parent's Choice Soy Store Brand soy based formulas that are USDA approved
3. Lactose Free Formula:
All participants who receive a milk-based, lactose free formula will receive the contract formula Enfamil LactoFree or Enfamil LactoFree Lipil. Enfamil LactoFree or Enfamil LactoFree Lipil can only be distributed by the Georgia WIC Program with a valid written medical condition(s) /diagnosis and prescription. Refer to pages FP-9 through FP-19 for information regarding the required documentation for a diagnosis and prescription.

The Georgia WIC Program does NOT APPROVE Similac Lactose Free for distribution. Prescriptions will not be accepted for Similac Lactose Free.

Whenever medical condition(s) /diagnosis warrants a change from the contract lactose free formula (Enfamil LactoFree or

FP-4

GA WIC 2005 PROCEDURES MANUAL

Food Package

Enfamil LactoFree Lipil), the WIC program may provide the infant another approved formula with proper documentation. Vouchers will specify the prescribed formula. Refer to pages FP7 through FP-21 for information regarding the required documentation for a diagnosis and prescription.

B. Food Groups
There are seven (7) food groups authorized by Federal WIC Regulations. Each group is specified according to age and/or condition. The groups are:

Food Group from the Federal WIC Regulations

Age/Condition

Computer Food Package Series Number

I

Infants 0 Through 3 Months 113, 216, 123, 222, 223, 112, 013, 813,

(0 through 4 months in the 023, 043, 063, 823, 033, 299, 199, 999,

Georgia WIC Program)

103, 206, 233, 208, 203, 102, 210, 010,

242, 042, 219, 019, 134, 108, 201, 109,

121, 151, 161, 211, 111, 143, 193, 194,

230, 140

II

Infants 4 Through 12

116, 117, 118, 217, 126, 224, 225, 115,

Months (5 through 12

016, 816, 026, 046, 066, 826, 036, 221,

months in the Georgia WIC 106, 128, 107, 207, 276, 204, 205, 105,

Program)

215, 015, 259, 059, 289, 089, 137, 168,

251, 169, 131, 191, 171, 214, 114, 146,

196, 195, 232, 141

III

Children/Women with

319, 312, 316, 317, 313, 329, 322, 323,

Special Dietary Needs

326, 327, 304, 314, 339, 332, 336, 337,

333, 347, 346, 342, 343, 374, 334, 399,

309, 389, 349, 368, 308, 361, 351, 360,

350, 335, 375, 345, 305, 365, 355, 368,

308, 389, 349, 393, 396, 320, 300, 310,

318, 382, 383, 340, 330, 328, 348, 338,

378, 341, 301, 325, 381, 315, 730, 760,

790, 798, 731, 761, 791, 799, 370, 999

IV

Children 1 to 5 Years

600-607, 613, 614, 610, 615, 999

V

Pregnant and Breastfeeding 401- 407, 414, 416, 410, 999

Women

VI

Postpartum, Non-

501-504, 512, 510, 999

fd

FP-5

GA WIC 2005 PROCEDURES MANUAL

Food Package

Food Group from the Federal WIC Regulations

Age/Condition Breastfeeding Women

VII

Exclusively Breastfeeding

Women

Computer Food Package Series Number
408, 418, 411, 999

C. Food Packages

Food Packages translate the foods authorized in each food group into varying quantities, within the maximum amounts allowed. See Attachments FP-1, FP-6, FP-8, FP-10, FP-13, FP-15, FP-17, FP-19, FP-22, FP24, and FP-26.
1. Tailoring. Food packages are designed to meet individual participants' nutritional needs and food preferences. Available computer food packages include maximum amounts of food allowed, reduced amounts and/or the elimination of specific food items. Any food grouping that includes allowed foods within the maximum amounts may be prescribed. Attachments FP-2, FP-3, FP4, FP-5, FP-7, FP-9, FP-11, FP-12, FP-14, FP-16, FP-18, FP-20, FP-21, FP-23, FP-25, and FP-27 list numbered food packages.
No matter how many family members are participating in the WIC Program, each participant's nutritional needs must be given individual consideration.
2. Assignment of Food Package Number. The CPA assigns the computer food package number that coincides with the quantity/items desired. If a pre-established food package that meets the needs of the participant is not available, the CPA specifies the quantities/items desired and assigns a food package 999. A food package 999 may include any allowed food combination, within the maximum allowed. Allowable foods and maximum quantities will vary depending on participant category. Refer to FP-29, FP-56, FP58, FP-60, FP-89, FP-101, FP-101, FP-116, FP-119, & FP-124 for maximum monthly amounts authorized.

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3. Assignment Method. The CPA must evaluate and assign food packages:
a. At each WIC assessment/certification
b. When medically necessary
c. At the request of the participant
Only CPA staff are authorized to assign food packages.
D. Required Documentation
1. General Documentation
a. During the WIC assessment/certification, the CPA must enter the food package number in the "Food Package" space provided on the WIC Assessment/Certification Form. Specific tailoring instructions for food package 999 must be documented on the WIC Assessment/Certification Form or in the progress notes of the participant's health record.
b. Between WIC assessments/certifications, the CPA must document food package changes on the WIC Assessment/Certification Form. The date of the food package change and the CPA's signature and title must be included in the documentation. The use of a signature stamp is not acceptable.
2. Additional Documentation. Additional documentation is required for:
a. Contract formulas requiring a prescription (Enfamil LactoFree Lipil, Enfamil Next Step Lipil, Enfamil Next Step ProSobee Lipil, Enfamil Low Iron Lipil, or Enfamil AR Lipil)
b. Non-contract formula requiring a prescription (e.g., as indicated for chronic diseases or medical conditions)
c. Ready-to-feed formulas

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d. Lactose intolerant women and children who require more than two (2) pounds of cheese per month
e. Low iron formulas (e.g., as indicated for conditions such as hemochromatosis)
f. Hospital-based formulas
g. Disaster situations

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III. INFANTS
Food Group I is for infants 0 through 4 months of age and consists only of ironfortified formula. Food Group II is for infants 5 through 12 months of age and consists of iron fortified formula, iron-fortified cereal, and juice. In the Georgia WIC Program, iron-fortified cereal and juice may not be assigned to an infant until at least 5 months of age.
Cow's and goat's milk are not authorized for infants in the first 12 months of life.
A. Tailoring
1. Breastfed Infants. The best food for most infants is breastmilk. Until the maternal milk supply is well established at 4-6 weeks of lactation, no formula should be offered. Infant formula should not be provided, through food package assignment or free samples, to breastfeeding participants who do not want or need it. Breastfeeding is defined as feeding a mother's breastmilk to her infant(s) at least once a day.

If a mother chooses to both breastfeed and formula feed her infant, powdered formula is recommended. However, liquid concentrated formula is available. The CPA may assign the maximum amount of formula to breastfed infants. The need for the maximum allowance must be thoroughly documented in the infant's health record.
2. Formula fed Infants. When the participant is not breastfeeding, iron-fortified formula is the recommended formula for healthy infants. The definition of iron-fortified formula is: A complete formula requiring only the addition of water prior to being served in a liquid state that contains at least ten (10) milligrams of iron per liter of formula at standard dilution and supplies sixty-seven (67) kilocalories per one-hundred (100) milliliters, i.e., approximately twenty (20) kilocalories per fluid ounce of formula at standard dilution.
All formulas and medical foods authorized for distribution through the WIC Program must first be determined WIC-eligible by the Food and Nutrition Service, United States Department of Agriculture. The Nutrition Section may then approve

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distribution of the product through the Georgia WIC Program. For a list of Georgia WIC Program approved infant formulas see Attachment FP-32.
WIC approved non-contract formulas and medical foods designed for enteral feeding may be authorized when a physician determines that the infant has a medical condition/diagnosis, which contraindicates the use of the contract infant formulas. These condition(s) /diagnosis include, but are not limited to, preterm infant, metabolic disorders, inborn errors of metabolism, gastrointestinal disorders, malabsorption syndrome, allergies and hematological disorders. Examples of additional acceptable medical condition(s) / diagnosis can be found in the ICD-9-CM publication, International Classification of Diseases, 10th Revision; Clinical Modification. Low-calorie formulas are not authorized solely for the purpose of managing the body weight of infants. The WIC Program does not authorize formulas designed for parenteral infusion.
For guidance in assessing infant formula tolerance consult the Department of Human Resources Protocol For Infant Formula Intolerance and the Nutrition Section, Nutrition Guidelines for Practice.
The amount of formula required (including calorie and protein needs) is based on the infant's total body weight. Infants require approximately fifty (50) calories per pound of body weight. A general recommendation is to provide 2.5 ounces of iron-fortified formula per pound of body weight, or 5.5 ounces per kilogram of body weight, when formula is the only source of nutrition.
The Nutrition Section, Nutrition Guidelines for Practice recommends the introduction of solid foods when the infant is 56 months of age and is developmentally ready. For maximum formula amounts, see Attachments FP-1, FP-6, and FP-8. The adjusted age is to be used with premature infants.
3. Cereal. Cereal is not authorized for the infant 0 through 4 months of age. The Nutrition Section, Nutrition Guidelines for Practice recommends that cereal be introduced when the infant is 5-6 months of age and developmentally ready. A maximum of twenty-four (24) ounces of cereal per month is authorized.

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4. Juice. Juice is not authorized for the infant 0 through 4 months of age. The Nutrition Section, Nutrition Guidelines for Practice recommends that juice not be offered until the infant can drink from a cup to help prevent "nursing bottle caries." A maximum of ninety-two (92) fluid ounces of single strength juice per month is authorized.
B. Infants 0 Through 4 Months
Food Group I consists only of formula. No cereal or juice is authorized for this food group.
1. Food Package Assignment. The food packages for infants 0 through 4 months of age are listed on Attachments FP-2, FP-3, FP-4, FP-5, FP-7, and FP-9. The use of a contract formula not requiring a prescription is required unless a medical condition/diagnosis warrant a change to a formula requiring a prescription. The food package numbers are:
a. No formula: 299
b. Contract formula (Enfamil with Iron, ProSobee with Iron, Enfamil Lipil with Iron, or Enfamil ProSobee Lipil with Iron): 113, 216, 123, 222, 223, 112, 013, 813, 023, 043, 063, 823, 033, and 999
c. Contract formulas requiring a prescription (Enfamil LactoFree Lipil, Enfamil Next Step Lipil, Enfamil Next Step ProSobee Lipil, Enfamil Low Iron Lipil, or Enfamil AR Lipil): 103, 206, 233, 208, 203, 102, 210, 010, 242, 042, 219, 019, 133, 134, 108, 201, 109 and 999
d. Non-contract formula requiring a prescription: 121, 151, 161, 211, 111, 143, 193, 230, and 999
2. Standard Manual Food Package. Where Voucher Printing on Demand (VPOD) is not available the CPA will assign a food package to the participant upon certification and enter the food package number on the WIC Assessment/Certification Form. The standard manual food package for infants (food package 113) will be issued for all infants until the computer vouchers for the
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assigned food package are generated. The CPA may require the assigned food package be given to the participant. The CPA must state this in on the WIC Assessment/Certification Form. The actual assigned food package must then be issued instead of the standard manual.
3. Additional Documentation. Additional documentation is required in the participant's health record whenever medical conditions/diagnosis warrant a change to a formula requiring a prescription.
a. Contract formula requiring a prescription or Non-contract formula requiring a prescription
(1) All changes from the contract formula not requiring a prescription to a formula requiring a prescription must be written on a prescription pad, private medical office letterhead, district/county letterhead or the Georgia WIC Formula Referral Form, stating the name of the alternative formula and the medical condition/diagnosis. Orders must have an original signature of the physician or licensed/certified health professional working under standing orders. Prescription pads that are pre-printed or pre-stamped with a formula requiring a prescription will not be accepted.
(2) A physician's written or verbal order is required prior to food package assignment by the WIC Competent Professional Authority (CPA). When a written order is not present, confirmation of a verbal order must be requested from the physician. The verbal order and the request for confirmation must be documented in the patient's health record.
(3) A current order is required at initial and subsequent certification, mid-certification nutrition assessment, and with any change in the order.
(4) Certified nurse practitioners/midwives/specialists working under the Public Health Nurse Protocols may order a contract formula requiring a prescription or noncontract formula requiring a prescription (excluding low iron formula and hospital-based formula). The nurse's

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order must be documented in the participant's health record. When a written order is not present, confirmation of a verbal order must be documented in the participant's health record.
(5) A Registered or Licensed Dietitian or other qualified WIC Competent Professional Authority (CPA) following the Department of Human Resources Protocol on Infant Formula Intolerance may: (a) Recommend to a physician or certified nurse practitioner/midwife/specialist a suitable alternative formula, or (b) Refer a participant to a physician or certified nurse practitioner/midwife/specialist for evaluation.
b. Ready-to-feed formula
The CPA must document in the participant's health record that there is an unsanitary or restricted water supply, poor refrigeration, or that the person who is caring for the infant has difficulty in diluting concentrated or powdered formula.
c. Low iron formula
(1) Low iron or no iron formula may be indicated for infants with hemochromatosis, hemosiderosis, neonatal iron storage disease, polycythemia, thalassemia major, hyperferremia, sickle cell anemia, liver disease, pancreatic insufficiency, cardiac defects with cyanosis, and those infants requiring frequent transfusions.
(2) Low iron formula is NOT authorized for: colic, spitting up, vomiting, cramps, constipation, diarrhea, or fussiness nor is it authorized for healthy partially breastfed infants.
d. Hospital-based formula
Hospital-based infant formulas may be ordered (only by a physician) to meet the nutrition needs of preterm infants and children with special health care needs. Generally, these products are designed for use in a hospital setting

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and are not available for retail sale. County health departments may acquire these products through a system established by the Nutrition Section or through a local pharmacy that is a WIC Vendor. See Attachment FP33 for procedures and Attachment FP-34 for the order form to use when acquiring a product through the Nutrition Section. The following requirements must be met before a Special formula can be ordered or issued:
(1) A physician's written or verbal order is required prior to food package assignment by the WIC Competent Professional Authority (CPA). A current order is required at least every three (3) months.
(2) Orders must be written on a prescription pad, a private physician's letterhead, district/county letterhead, or Georgia WIC Formula Referral Form stating the name of the formula, the diagnosis (physical condition) and the expiration date of the order.
C. Infants 5 Through 12 Months
Food Group II consists of formula, iron-fortified cereal, and juice.
1. Food Package Assignment. The food packages for infants 5 through 12 months of age are listed on Attachments FP-2, FP-3, FP-4, FP-5, FP-7, and FP-9. The use of a contract formula not requiring a prescription is required unless a medical condition/diagnosis warrant a change to a formula requiring a prescription. The food package numbers are:
a. No formula: 221 and 299
b. Contract formula: (Enfamil with Iron, ProSobee with Iron, Enfamil Lipil with Iron, or Enfamil ProSobee Lipil with Iron): 116, 117, 118, 217, 126, 224, 225, 115, 016, 816, 026, 046, 066, 826, 036, 806, and 999
c. Contract formula requiring a prescription (Enfamil LactoFree Lipil, Enfamil Next Step Lipil, Enfamil Next Step ProSobee Lipil, Enfamil Low Iron Lipil, or Enfamil AR Lipil): 106, 128, 107, 207, 276, 204, 205, 105, 215, 015, 259, 059, 289, 089, 136, 137, 168, 251, 169, and 999

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d. Non-contract formula requiring a prescription 131, 191, 171, 214, 114, 146, 196, 232, and 999
2. Standard Manual Food Package. The CPA will assign a food package upon certification and the computer food package number that matches the assigned food package will be given to the participant. The standard manual food package for infants is food package 113. The standard manual will be issued for all infants until the computer vouchers for the assigned food package are generated. The CPA may require the assigned food package to be given to the participant at the time of certification. The CPA must state this on the WIC Assessment/ Certification Form. The actual assigned food package must then be issued instead of the standard manual.
3. Additional Documentation. Additional documentation is required in the participant's health record whenever medical conditions/diagnosis warrant a change from a contract formula not requiring a prescription to a formula requiring a prescription.
a. Contract formula requiring a prescription or Non-contract formula requiring a prescription
(1) All changes from the contract formula not requiring a prescription to a formula requiring a prescription must be written on a prescription pad, private medical office letterhead, district/county letterhead or the Georgia WIC Formula Referral Form, stating the name of the alternative formula and the medical condition/diagnosis. Orders must have an original signature of the physician or licensed/certified health professional working under standing orders. Prescription pads that are pre-printed or pre-stamped with a formula requiring a prescription will not be accepted.
(2) A physician's written or verbal order is required prior to food package assignment by the WIC Competent Professional Authority (CPA). When a written order is not present, confirmation of a verbal order must be requested from the physician. The verbal order and the request for confirmation must be documented in the patient's health record.
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(3) A current order is required at initial and subsequent certification, mid-certification nutrition assessment, and with any change in the order.
(4) Certified nurse practitioners/midwives/specialists working under the Public Health Nurse Protocols may order a contract formula requiring a prescription or noncontract formula requiring a prescription (excluding low iron formula and hospital-based formula). The nurse's order must be documented in the participant's health record. When a written order is not present, confirmation of a verbal order must be documented in the participant's health record.
(5) A Registered or Licensed Dietitian or other qualified WIC Competent Professional Authority (CPA) following the Department of Human Resources Protocol on Infant Formula Intolerance may: (a) Recommend to a physician or certified nurse practitioner/midwife/specialist a suitable alternative formula, or (b) Refer a participant to a physician or certified nurse practitioner/midwife/specialist for evaluation.
b. Ready-to-feed formula
The CPA must document in the participant's health record that there is an unsanitary or restricted water supply, poor refrigeration, or that the person who is caring for the infant has difficulty in diluting concentrated or powdered formula.
c. Low iron formula
(1) Low iron or no iron formula may be indicated for infants with hemochromatosis, hemosiderosis, neonatal iron storage disease, polycythemia, thalassemia major, hyperferremia, sickle cell anemia, liver disease, pancreatic insufficiency, cardiac defects with cyanosis, and those infants requiring frequent transfusions.

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(2) Low iron formula is NOT authorized for: colic, spitting up, vomiting, cramps, constipation, diarrhea, or fussiness nor is it authorized for healthy partially breast-fed infants.
d. Hospital-based formula
Hospital-based infant formulas may be ordered (only by a physician) to meet the nutrition needs of preterm infants and children with special health care needs. Generally, these products are designed for use in a hospital setting and are not available for retail sale. County health departments may acquire these products through a system established by the Nutrition Section or through a local pharmacy that is a WIC Vendor. See Attachment FP33 for procedures and Attachment FP-34 for the order form to use when acquiring a product through the Nutrition Section. The following requirements must be met before a hospital-based formula can be ordered or issued:
(1) A physician's written or verbal order is required prior to food package assignment by the WIC Competent Professional Authority (CPA). A current order is required at least every three (3) months.
(2) Orders must be written on a prescription pad, a private physician's letterhead, district/county letterhead, or Georgia WIC Formula Referral Form stating the name of the formula, the diagnosis (physical condition), and the expiration date of the order.

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IV. CHILDREN AND WOMEN WITH SPECIAL DIETARY NEEDS
Food Group III consists of formula, iron-fortified cereal, and single strength juice.
A. Tailoring
Due to the varying ages and conditions, tailoring for this package must be carefully individualized.
1. Formula. WIC-approved formulas designed for enteral feeding (tube feeding) and prescribed by a physician may be authorized. The WIC Program does not authorize distribution of formulas designed for parenteral infusion. Formula may not be authorized solely for the purpose of enhancing nutrient intake or managing body weight of children and women participants. For a list of Georgia WIC Program approved formulas see Attachment FP-32.
2. Cereal. A maximum of thirty-six (36) ounces of cereal per month is authorized.
3. Juice. A maximum of one hundred thirty-eight (138) ounces of single strength juice per month is authorized.

B. Food Package Assignment
The food packages for children and women with special dietary needs are listed on Attachments FP-11, FP-12, and FP-14. The food package numbers are 319, 312, 316, 317, 313, 329, 322, 323, 326, 327, 304, 314, 339, 332, 336, 337, 333, 347, 346, 342, 343, 374, 334, 399, 309, 389, 349, 368, 308, 361, 351, 360, 350, 335, 375, 345, 305, 365, 355, 368, 308, 389, 349, 393, 396, 300, 310, 318, 382, 383, 340, 330, 328, 348, 338, 378, 341, 301, 325, 381, 315, 730, 760, 790, 798, 731, 761, 791, 799, 370, and 999. Formula types, sizes, and amounts as well as, amounts for cereal and juice are included in Attachments FP-10 and FP-13.
C. Standard Manual Food Package
There is no standard manual food package for Food Group III.

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D. Additional Documentation
Additional documentation is required in the participant's health record whenever medical conditions/diagnosis warrant a change from a contract formula not requiring a prescription to a formula requiring a prescription.
1. Contract formula requiring a prescription or Non-contract formula requiring a prescription
a. All changes from the contract formula not requiring a prescription to a formula requiring a prescription must be written on a prescription pad, private medical office letterhead, district/county letterhead or the Georgia WIC Formula Referral Form, stating the name of the alternative formula and the medical condition/diagnosis. Orders must have an original signature of the physician or licensed/certified health professional working under standing orders. Prescription pads that are pre-printed or pre-stamped with a formula requiring a prescription will not be accepted.
b. A physician's written or verbal order is required prior to food package assignment by the WIC Competent Professional Authority (CPA). When a written order is not present, confirmation of a verbal order must be requested from the physician. The verbal order and the request for confirmation must be documented in the patient's health record.
c. A current order is required at initial and subsequent certification, and with any change in the order.
2. Certified Nurse Practitioners/Midwives/Specialists working under Public Health Nurse Protocol may order a contract formula requiring a prescription or non-contract formula requiring a prescription (excluding low iron formulas, and hospital-based formulas). The nurse's order must be documented in the participant's health record. When a written order is not present, confirmation of a verbal order must be documented in the participant's health record.

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3. A Registered or Licensed Dietitian or other qualified WIC Competent Professional Authority (CPA) following the Department of Human Resources Protocol on Infant Feeding Problems may:
a. Recommend to a physician or certified nurse practitioner/midwife/ specialist a suitable alternative formula, or
b. Refer a participant to a physician or certified nurse practitioner/ midwife/specialist for evaluation.
4. Ready-to-feed Formula.
The CPA must document in the participant's health record that there is an unsanitary or restricted water supply, poor refrigeration, or that the person who is caring for the infant has difficulty in diluting concentrated or powdered formula.
5. Low Iron Formula
a. Low iron or no iron formula may be indicated for clients with hemochromatosis, hemosiderosis, iron storage disease, polycythemia, thalassemia major, hyperferremia, sickle cell anemia, liver disease, pancreatic insufficiency, cardiac defects with cyanosis and those participants requiring frequent transfusions.
b. Low Iron formula is NOT authorized for colic, spitting up, vomiting, cramps, constipation, diarrhea or fussiness nor is it authorized for healthy partially breastfed children.
6. Hospital-based Formula
Hospital-based infant formulas may be ordered (only by a physician) to meet the nutrition needs of preterm infants and children with special health care needs. Generally, these products are designed for use in a hospital setting and are not available for retail sale. County health departments may acquire these products through a system established by the Nutrition Section or through a local pharmacy that is a WIC Vendor. See

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Attachment FP-33 for procedures and Attachment FP-34 for the order form to use when acquiring a product through the Nutrition Section. The following requirements must be met before a hospital-based formula can be ordered or issued:
a. A physician's written or verbal order is required prior to food package assignment by the WIC Competent Professional Authority (CPA). A current order is required at least every three (3) months.
b. Orders must be written on a prescription pad, a private physician's letterhead, district/county letterhead, or Georgia WIC Formula Referral Form stating the name of the formula, the diagnosis (physical condition), and the expiration date of the order.
7. Additional Formula.

The need for additional formula above the maximum for children and women must be documented by the CPA in the participant's health record. See Attachments FP-10 and FP-13 for maximum formula amounts.

V. CHILDREN 1 TO 5 YEARS
Food Group IV is for children 1 to 5 years of age. This food group consists of milk, cheese, cereal, juice, eggs, and dried beans/peas or peanut butter.
A. Tailoring
General nutrient requirements for children vary with age, nutritional risk, and stage of development. From ages 1 to 3, nutrient requirements are about half those of adults with the exception of vitamin C, calcium, and iron. The requirements for these nutrients are approximately the same. It is important that an adequate food package be prescribed for the child's individual needs. This applies even where there are two (2) or more family members participating on the WIC Program.
1. Increased Need. Very active, rapidly growing, and/or underweight children need more nutrients for energy, and optimum physical and mental growth and development.
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Chronic diseases and/or repeated infections also increase requirements. To meet the nutrient needs of these children, food packages containing larger amounts of foods are recommended.
2. Decreased Need. The very young child or the inactive child may not require the maximum amounts of foods allowed, therefore a food package containing reduced amounts of food may be prescribed.
3. Modified Food Packages. A tailored food package may be created by the CPA to include modified foods, i.e., lower fat cheese, low fat milk, etc.

B. Food Package Assignment
The food packages for children ages 1 to 5 years are listed on Attachments FP-16 and FP-18. The food package numbers are 600-607, 613, 614, 610 and 999. Refer to Attachments FP-15 and FP-17 for the maximum amounts of each food item allowed per month.
C. Standard Manual Food Package
The CPA will assign a food package upon certification and the computer food package number which matches the assigned food package will be given to the participant. The standard manual food package for children is food package 603. The standard manual food package will be issued for all children until the computer vouchers for the assigned food packages are generated. The CPA may require the assigned food package be given to the participant at the time of certification. The CPA must state this on the WIC Assessment/Certification Form. The actual assigned food package must then be issued instead of the standard manual food package.
D. Additional Documentation
Additional documentation is required in the following situations:
1. When a diagnosis of chronic renal disease, cerebral palsy, cardiac disease, cystic fibrosis, thyroid disorders, inborn errors of metabolism, or any medical condition that interferes with the ingestion, absorption or utilization of nutrients is made that requires a therapeutic diet, and a special food package. Examples

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of additional acceptable medical condition(s) /diagnosis can be found in the ICD-9-CM publication, International Classification of Diseases, 9th Revision; Clinical Modification. A current prescription from a physician is required prior to issuance of a special food package.
2. When cheese is increased to greater than two (2) pounds per month. Additional cheese may be issued on an individual basis in cases of lactose intolerance, provided the need is documented in the participant's health record by the CPA.
3. When a food package is tailored by the CPA to give less food than listed in the moderate food packages (i.e., 603/604) and/or to modify the type of food (i.e., low fat milk) given to the participant.
VI. PREGNANT AND BREASTFEEDING WOMEN
Food Group V consists of milk, cheese, cereal, juice, eggs, dried beans/peas or peanut butter.
Food Group VII consists of milk, cheese, cereal, juice, eggs and dried beans/peas, peanut butter, tuna, and carrots. This food group is limited to use with breastfeeding women who receive no infant formula/medical food from the WIC Program.
A. Tailoring
Increased nutrient requirements due to pregnancy and lactation determine the importance of assuring an adequate food package for the participant.
1. Increased Need. The pregnant adolescent has dual demands for nutrients for both her developing body and her developing fetus. The underweight pregnant or lactating woman also has increased nutrient needs. Pregnant adolescents, underweight prenatal women, and lactating women need to be issued the maximum amount of the allowed foods that they will consume.
2. Decreased need. The need for protein, energy, calcium, and other nutrients are the same for the overweight prenatal woman as for the normal weight prenatal woman. Therefore, if the CPA

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assigns a food package that provides less than the standard (404) food package, reasons for doing so must be thoroughly documented in the participant's health record.
3. Modified Food Packages. A tailored food package may be created by the CPA to include modified foods, i.e. lower fat cheese, lowfat milk, etc.

B. Food Package Assignment
The food packages for prenatal and breastfeeding women are listed on Attachments FP-20, FP-21, and FP-23. The food package numbers are 401408, 414, 416, 418, 410, 411, and 999. Food package 408 may be assigned to all women who are exclusively breastfeeding infants (defined as those women who do not receive any infant formula from the WIC Program). If at any time the mother requests formula supplementation, the CPA should change the food package of the mother and infant to reflect the change in their status. Refer to Attachments FP-19 and FP-22 for the authorized foods and the maximum amounts allowed per month.
C. Standard Manual Food Package
The CPA will assign a food package upon certification and the computer food package number that matches the assigned food package will be given to the participant. The standard manual food package for prenatal and breastfeeding women is food package 404. The standard manual food package will be issued for all prenatal and breastfeeding women until the computer vouchers for the assigned food packages are generated. The CPA may require the assigned food package be given to the participant at the time of certification. The CPA must state this in the "Comments" section of the WIC Assessment/Certification Form. The actual assigned food package must then be issued instead of the standard manual food package.
D. Additional Documentation
Additional documentation is required in the following situations:
1. When a diagnosis of chronic renal disease, cerebral palsy, cardiac disease, cystic fibrosis, thyroid disorders, inborn errors of metabolism, or any medical condition that interferes with the ingestion, absorption or utilization of nutrients is made which

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requires a therapeutic diet and a special food package. Examples of additional acceptable medical condition(s)/diagnosis can be found in the ICD-9-CM publication, International Classification of Diseases, 9th Revision; Clinical Modification. A current prescription from a physician is required prior to issuance of a special food package.
2. When cheese is increased to greater than two (2) pounds per month. Additional cheese may be issued on an individual basis in cases of lactose intolerance, provided the need is documented in the participant's health record by the CPA.
3. When a food package is tailored by the CPA to give less food than listed in a moderate food package (i.e., 404) and/or to modify the type of food (i.e., low fat milk) given to the participant.

VII. POSTPARTUM, NON-BREASTFEEDING WOMEN
Food Group VI consists of milk, cheese, cereal, juice, and eggs.
A. Tailoring
Generally, this group of participants does not have the increased nutrient needs of the prenatal and breastfeeding women. Therefore, the maximum amounts allowed for each food group are reduced.
1. Increased Need. Adolescents have a higher need for calcium than the adult woman. Caloric needs may also be higher, thus the maximum amounts are recommended. Underweight women may also need the maximum amounts of foods allowed.
2. Decreased Need. The inactive individual may not require the maximum amount of food allowed, therefore a food package containing reduced amounts of food may be prescribed. However, if a food package is assigned which contains less than the moderate (502) food package, reasons for this must be thoroughly documented in the participant's health record.

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3. Modified Food Packages. A tailored food package may be designed by the CPA to include modified foods, i.e., lower fat cheese, low fat milk, etc.

B. Food Package Assignment
The food packages for postpartum, non-breastfeeding women are listed on Attachments FP-25 and FP-27. The food package numbers are 501-504, 512, 510 and 999. A postpartum, non-breastfeeding food package must be issued to the participant no later than six (6) weeks postpartum. Refer to Attachments FP-24 and FP-26 for the foods and maximum amounts allowed.
C. Additional Documentation
Additional documentation is required in the following situations:
1. When a diagnosis of chronic renal disease, cerebral palsy, cardiac disease, cystic fibrosis, thyroid disorders, inborn errors of metabolism, or any medical condition that interferes with the ingestion, absorption or utilization of nutrients is made that requires a therapeutic diet and a special food package. Examples of additional acceptable medical condition(s) /diagnosis can be found in the ICD-9-CM publication, International Classification of Diseases, 9th Revision; Clinical Modification. A current prescription from a physician is required prior to issuance of a special food package.
2. When cheese is increased to greater than two (2) pounds per month. Additional cheese may be issued on an individual basis in cases of lactose intolerance, provided the need is documented in the participant's health record by the CPA.
3. When a food package is tailored by the CPA to give less food than listed in the moderate food package (i.e., 502) and/or to modify the type of food (i.e., low fat cheese) given to a participant.

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VIII. HOMELESSNESS, MIGRANCY, AND DISASTER SITUATIONS
A. Alternate Food Package Assignment
Local agencies have the option to convert participants to an alternate food package under the following circumstances: 1. A participant lacks a fixed and regular nighttime residence.
2. A participant's primary nighttime residence is:
a. A publicly or privately operated shelter designated to provide temporary living accommodations.
b. A temporary accommodation in the residence of another individual.
c. A public or private place not designed for or ordinarily used as a regular sleeping accommodation.
3. A participant's primary residence lacks refrigeration and/or contains a contaminated or limited water supply.
B. Method for Food Package Assignment The CPA must evaluate and assign food packages as follows: 1. At each WIC assessment/certification visit.
2. When medically necessary.
3. At the request of the participant.
4. When the participant locates a permanent residence with adequate refrigeration and/or a safe water supply.
Only CPA staff are authorized to assign food packages.

C. Assignment of Food Package Number The CPA may assign the computer food package number that coincides

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with the quantity/items desired. If a computer food package is unable to meet the needs of the participant, the CPA specifies the quantities/items desired and assigns a food package 999. A food package 999 should not exceed the maximum monthly amount per item or include unapproved combinations of WIC foods. If retail purchase is not an option, direct distribution measures will be considered. The local agency, State WIC Branch and the Nutrition Section should be consulted to discuss this option.
D. Documentation Requirements
1. General Documentation
a. During the WIC assessment/certification, the CPA must write the food package number in the space provided on the WIC Assessment/Certification Form. If a food package 999 is assigned, document specific tailoring instructions on the WIC Assessment/Certification form or in the progress notes of the participant's health record.
b. Between WIC Assessments/Certifications, the CPA must document food package changes on the WIC Assessment/Certification form. The CPA must date and sign (include title) any changes. The use of a signature stamp is not acceptable.
2. Additional Documentation. Additional documentation is required in the participant's health record for the following:
a. Contract formula requiring a prescription (Enfamil LactoFree Lipil, Enfamil Next Step Lipil, Enfamil Next Step ProSobee Lipil, Enfamil Low Iron Lipil, or Enfamil AR Lipil)
b. Non-contract formula requiring a prescription
c. Low iron formula
d. Hospital-based formula
e. Disaster situations

FP-28

GA WIC 2005 PROCEDURES MANUAL

Food Package

E. Alternate Food Packages

1. Infants 0 Through 4 Months

a. Food packages for this age group consists of ready-to-feed formula only. No cereal or juice is authorized for this age group. The food packages for these infants are listed on Attachment FP-7. Breast milk is the best food for the normal infant. Infant formula should not be provided to breastfeeding participants unless requested. If a mother chooses to supplement her breastfeeding with infant formula, powdered formula is recommended. However ready-to-feed is available. The use of a contract formula not requiring a prescription is required unless a medical condition/diagnosis warrant a change to a formula requiring a prescription. The food package numbers are:

(1) No formula:

299

(2) Contract formula:

140

(3) Contract formula requiring a prescription or Non-

contract formula requiring a prescription:

999

b. Additional documentation is required in the participant's health record whenever medical conditions/diagnosis warrant a change from a contract formula not requiring a prescription to a formula requiring a prescription. See FP9 through FP-12 for specific documentation requirements.

2. Infants 5 Through 12 Months

a. Food packages for this age group consists of ready-to-feed formula, iron fortified infant cereal and 100%, vitamin C fortified juice. The food packages for these infants are listed on Attachment FP-9. Breast milk is the best food for most infants. Infant formula should not be provided unless requested. If a mother chooses to supplement her breastfeeding with infant formula, powdered formula is recommended. However, ready-to-feed formula is also available. The use of a contract formula not requiring a prescription is required unless a medical

FP-29

GA WIC 2005 PROCEDURES MANUAL

Food Package

condition/diagnosis warrant a change to a formula requiring a prescription. The food package numbers are:

(1) No formula:

299

(2) Contract standard formula:

141

(3) Contract formula requiring a prescription or Non-

contract formula requiring a prescription:

999

b. Additional documentation is required in the participant's health record whenever medical conditions/diagnosis warrant a change from a contract formula not requiring a prescription to a formula requiring a prescription. See FP14 through FP-17 for specific documentation requirements.

3. Children and Women with Special Dietary Needs

a. Food packages for this group consist of formula/medical foods, iron fortified cereal, and 100% vitamin C fortified juice. The food packages for these participants are listed on Attachment FP-11, FP-12, and FP-14. Due to the varying ages and conditions, food packages must be carefully individualized to meet the participant's nutritional needs and food preferences. The food package numbers are 370 and 999.
b. Additional documentation is required in the participant's health record. See FP-18 through FP-21 for specific documentation requirements.
4. Children 1 To 5 Years

a. Food packages for this group consist of ultra high temperature (UHT) milk, iron fortified cereal, 100% vitamin C fortified juice, and peanut butter. The food packages for these participants are listed on Attachment FP-18. General nutrient requirements for children vary with age, nutrition risk, and stage of development. Food packages must be assigned based on individual needs. The food package numbers are 610 and 999.

FP-30

GA WIC 2005 PROCEDURES MANUAL

Food Package

b. Additional documentation is required with a diagnosis of a chronic disease, developmental disability/congenital defect, inborn error of metabolism or any medical condition that interferes with the ingestion, absorption or utilization of nutrients that requires a therapeutic diet. See FP-21 through FP-23 for specific documentation requirements.
5. Pregnant and Breastfeeding Women
a. Food packages for this group consist of ultra high temperature (UHT) milk, iron fortified cereal, 100%, vitamin C fortified juice, and peanut butter. Food package 410 may be assigned to pregnant and breastfeeding women. Exclusively breastfeeding women (defined as women receiving no infant formula from the WIC Program) receive additional items such as canned tuna, canned beans/peas, and canned carrots. The food packages for these participants are listed on Attachment FP-20. Food package 408 may be assigned to all women who are breastfeeding infants who do not receive any infant formula from the WIC program. If at any time the mother request formula supplementation, the CPA should change the food package of the mother and infant to reflect the change in their status. The food package numbers are 410, 411 and 999.
b. Additional documentation is required with the diagnosis of a chronic disease, developmental disability/congenital defect, inborn errors of metabolism, or any medical condition that interferes with the ingestion, absorption, or utilization of nutrients that requires a therapeutic diet. See FP-23 and FP-25 for specific documentation requirements.
6. Postpartum, Non-Breastfeeding Women
a. Food packages for this group consist of ultra high temperature (UHT) milk, iron fortified cereal, 100% vitamin C fortified juice, and peanut butter. Food packages for these participants are listed on Attachment FP-27. These food packages are issued to participants

FP-31

GA WIC 2005 PROCEDURES MANUAL

Food Package

who are greater than or equal to six (6) weeks postpartum. The food package numbers are 510 and 999.
b. Additional documentation is required with the diagnosis of a chronic disease, developmental disability/congenital defect, inborn error of metabolism, or any medical condition that interferes with the ingestion, absorption, or utilization of nutrients that requires a therapeutic diet. See FP-25 through FP-26 for specific documentation requirements.

IX. Formula Tracking Guidelines

Local Agency Procedures for tracking Free Trade Formula and/or formula returned to the clinic for various reasons.

A. Acceptable Reasons to Issue Formula. See the Formula Distribution Guidelines table below for guidance on allowable and non-allowable reasons for issuing formula.

Formula Distribution Guidelines

(Returned Formula and Free Trade Formula)

Allowable reasons to issue Formula:

Non-allowable reasons to issue Formula:

Transition from one formula to another (Maximum of 3 cans)

Pre-certification issuance of formula to last until scheduled appointment

Clinic error when scheduling an appointment

Participant reporting lost or stolen vouchers

Adjusting pick up code for family

Client running out of formula

Disaster situations: Fire, flood etc.

Distribution to non-WIC clients

Trading formula 1 for 1 that was purchased in error

*Document returned formula on the Formula Tracking Log (Attachment FP-37). All formula must be accounted for when issued to a client or destroyed.

FP-32

GA WIC 2005 PROCEDURES MANUAL

Food Package

B. Maximum Amount to be Issued. Not to exceed the maximum monthly amounts authorized for the participant category in question.
C. Documentation. Documentation of issuance must be written on the Formula Tracking Log (Attachment FP-37). When applicable, document issuance in the client's health record.
a. Formula tracking log: Formula issued to a WIC client or discarded must be documented on the Formula Tracking Log (Attachment FP-37).
b. WIC client's health record: If a detailed medical explanation is needed (i.e. transition from one formula to another), document the quantity of formula issued, type of formula, reason for issuance and signature of individual issuing the formula.
D. Disposal of Expired Formula. Expired formula should be opened and disposed of properly. Document expired formula that was disposed of on the Formula Tracking Log.

FP-33

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-1

INFANT FOOD PACKAGES MAXIMUM MONTHLY AMOUNTS AUTHORIZED

A. FORMULA TYPES, SIZES, AND MAXIMUM AMOUNTS
(Contract and Non-Contract)

TYPE1
Concentrate

SIZE2
13 ounces

MAXIMUM AMOUNTS3
31 cans, 403 ounces concentrate or 806 ounces reconstituted, 26.9 ounces per day

Ready-To-Feed Powdered4

32 ounces 2 ounces 3 ounces 4 ounces 8 ounces 16 ounces (1 pound) 12 ounces 12.8 ounces 12.9 ounces 14 ounces 14.1 ounces 14.3 ounces 16 ounces 30 ounces

Maximum number of cans / bottles

25 cans

806 ounces Maximum

403 bottles

268 bottles

201 bottles

100 cans

8 cans

128 ounces Maximum

10 cans

10 cans

9 cans

9 cans

9 cans

8 cans

8 cans

4 cans

1 For each type listed, the most economical size is recommended. 2 Sizes listed are not inclusive. 3 Maximum amounts are listed for each type. 4 Powdered size listed by can weight. Reconstituted amounts vary. Refer to product label for specific
reconstitution instruction.

B. CEREAL AND JUICE MAXIMUM MONTHLY AMOUNTS
(For Infants 5 Through 12 Months)

FOOD
Infant Cereal Single Strength Juice OR Frozen Concentrated Juice OR Pourable Concentrated Juice

SIZE
8 ounces 46 fluid ounces OR 12 fluid ounces OR 11.5 fluid ounces

MAXIMUM AMOUNTS
24 ounces 92 fluid ounces OR 96 fluid ounces, reconstituted OR 92 fluid ounces, reconstituted

FP-34

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-2

INFANT FOOD PACKAGES CONTRACT STANDARD FORMULA (ENFAMIL, PROSOBEE & ENFAMIL LIPIL, PROSOBEE LIPIL)

FOOD PACKAGE NUMBER 113 *
31 - 13 OZ CANS CONCENTRATE IRON FORTIFIED ENFAMIL OR PROSOBEE * STANDARD PACKAGE
116 31 - 13 OZ CANS CONCENTRATE IRON FORTIFIED ENFAMIL OR PROSOBEE 2 CANS JUICE 24 OZ INFANT CEREAL
117 31 - 13 OZ CANS CONCENTRATE IRON FORTIFIED ENFAMIL OR PROSOBEE 2 CANS JUICE

VOUCHER CODE

VOUCHER MESSAGE

064

FORMULA:

15-13 OZ CANS CONCENTRATE

ENFAMIL OR PROSOBEE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

065

FORMULA:

16-13 OZ CANS CONCENTRATE ENFAMIL

OR PROSOBEE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

064

FORMULA:

15-13 OZ CANS CONCENTRATE

ENFAMIL OR PROSOBEE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

065

FORMULA:

16-13 OZ CANS CONCENTRATE ENFAMIL

OR PROSOBEE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

073

JUICE:

CEREAL:

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

064

FORMULA:

15-13 OZ CANS CONCENTRATE

ENFAMIL OR PROSOBEE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

065

FORMULA:

16-13 OZ CANS CONCENTRATE ENFAMIL

OR PROSOBEE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

273

JUICE:

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

FP-35

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-2 (cont'd)

FOOD PACKAGE NUMBER 118
31 - 13 OZ CANS CONCENTRATE IRON FORTIFIED ENFAMIL OR PROSOBEE 2 CANS JUICE 16 OZ INFANT CEREAL
216 13 - 13 OZ CANS CONCENTRATE IRON FORTIFIED ENFAMIL OR PROSOBEE

VOUCHER CODE

VOUCHER MESSAGE

064

FORMULA:

15-13 OZ CANS CONCENTRATE

ENFAMIL OR PROSOBEE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

065

FORMULA:

16-13 OZ CANS CONCENTRATE ENFAMIL

OR PROSOBEE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

173

JUICE:

CEREAL:

2-12 OZ CANS FROZEN OR 2-46 OZ CANS OR 2-46 OZ PLASTIC BOTTLES OR 2-11.5 OZ CANS POURABLE
UP TO 16 OZ INFANT CEREAL

092

FORMULA:

13-13 OZ CANS CONCENTRATE ENFAMIL

OR PROSOBEE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

217 13 - 13 OZ CANS CONCENTRATE IRON FORTIFIED ENFAMIL OR PROSOBEE
2 CANS JUICE 24 OZ INFANT CEREAL

092

FORMULA:

13-13 OZ CANS CONCENTRATE ENFAMIL

OR PROSOBEE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

073

JUICE:

CEREAL:

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

123

091

FORMULA:

4-14.3 OZ CANS POWDER ENFAMIL OR

8 - 14.3 OZ CANS POWDER

PROSOBEE

IRON FORTIFIED ENFAMIL OR PROSOBEE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

091

FORMULA:

4-14.3 OZ CANS POWDER ENFAMIL OR

PROSOBEE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FP-36

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-2 (cont'd)

FOOD PACKAGE NUMBER

VOUCHER CODE

VOUCHER MESSAGE

126

091

FORMULA:

4-14.3 OZ CANS POWDER ENFAMIL OR

8 - 14.3 OZ CANS POWDER

PROSOBEE

IRON FORTIFIED

ENFAMIL OR PROSOBEE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

2 CANS JUICE 24 OZ INFANT CEREAL

091

FORMULA:

4-14.3 OZ CANS POWDER ENFAMIL OR

PROSOBEE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

073

JUICE:

CEREAL:

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

222 1 - 14.3 OZ CAN POWDER IRON FORTIFIED ENFAMIL OR PROSOBEE

074

FORMULA:

1-14.3 OZ CAN POWDER ENFAMIL OR

PROSOBEE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

224 1 - 14.3 OZ CAN POWDER IRON FORTIFIED ENFAMIL OR PROSOBEE
2 CANS JUICE 24 OZ INFANT CEREAL

074

FORMULA:

1-14.3 OZ CAN POWDER ENFAMIL OR

PROSOBEE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

073

JUICE:

CEREAL:

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

223

091

FORMULA:

4-14.3 OZ CANS POWDER ENFAMIL OR

4 - 14.3 OZ CANS POWDER

PROSOBEE

IRON FORTIFIED ENFAMIL OR PROSOBEE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

225

091

FORMULA:

4-14.3 OZ CANS POWDER ENFAMIL OR

4 - 14.3 OZ CANS POWDER

PROSOBEE

IRON FORTIFIED ENFAMIL OR PROSOBEE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

2 CANS JUICE 24 OZ INFANT CEREAL

073

JUICE:

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

CEREAL:

UP TO 24 OZ INFANT CEREAL

FP-37

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-2 (cont'd)

FOOD PACKAGE NUMBER

VOUCHER CODE

VOUCHER MESSAGE

112 25 - 1 QT (ML 986) CANS READY TO FEED IRON FORTIFIED ENFAMIL
RTF ProSobee no longer produced

062

FORMULA:

12-1 QT (ML 986) CANS READY TO FEED

ENFAMIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

063

FORMULA:

13-1 QT (ML 986) CANS READY TO FEED

ENFAMIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

115 25 - 1 QT (ML 986) CANS READY TO FEED IRON FORTIFIED ENFAMIL

062

FORMULA:

12-1 QT (ML 986) CANS READY TO FEED

ENFAMIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

RTF ProSobee no longer produced

063

FORMULA:

13-1 QT (ML 986) CANS READY TO FEED

ENFAMIL

2 CANS JUICE 24 OZ INFANT CEREAL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

073

JUICE:

CEREAL:

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

013

864

FORMULA:

15-13 OZ CANS CONCENTRATE ENFAMIL

31 - 13 OZ CANS

LIPIL OR PROSOBEE LIPIL

CONCENTRATE IRON FORTIFIED ENFAMIL

IRON FORTIFIED

LIPIL OR PROSOBEE LIPIL

NO LOW IRON FORMULA ALLOWED

865

FORMULA:

16-13 OZ CANS CONCENTRATE ENFAMIL

LIPIL OR PROSOBEE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FP-38

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-2 (cont'd)

FOOD PACKAGE NUMBER

VOUCHER CODE

VOUCHER MESSAGE

016

864

FORMULA:

15-13 OZ CANS CONCENTRATE ENFAMIL

31 - 13 OZ CANS

LIPIL OR PROSOBEE LIPIL

CONCENTRATE IRON FORTIFIED ENFAMIL

IRON FORTIFIED

LIPIL OR PROSOBEE LIPIL

NO LOW IRON FORMULA ALLOWED

2 CANS JUICE 24 OZ INFANT CEREAL

865

FORMULA:

16-13 OZ CANS CONCENTRATE ENFAMIL

LIPIL OR PROSOBEE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

073

JUICE:

CEREAL:

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

813

863

FORMULA:

13-13 OZ CANS CONCENTRATE ENFAMIL

13 - 13 OZ CANS

LIPIL OR PROSOBEE LIPIL

CONCENTRATE IRON FORTIFIED ENFAMIL LIPIL OR PROSOBEE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

816

863

FORMULA:

13-13 OZ CANS CONCENTRATE ENFAMIL

13 - 13 OZ CANS

LIPIL OR PROSOBEE LIPIL

CONCENTRATE IRON FORTIFIED ENFAMIL LIPIL OR PROSOBEE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

2 CANS JUICE 24 OZ INFANT CEREAL

073

JUICE:

CEREAL:

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

023

854

FORMULA:

4 - 12.9 OZ CANS POWDER ENFAMIL LIPIL

9 - 12.9 OZ CANS POWDER

OR PROSOBEE LIPIL

IRON FORTIFIED ENFAMIL LIPIL OR PROSOBEE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

855

FORMULA:

5 - 12.9 OZ CANS POWDER ENFAMIL LIPIL

OR PROSOBEE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FP-39

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-2 (cont'd)

FOOD PACKAGE NUMBER

VOUCHER CODE

VOUCHER MESSAGE

026

854

FORMULA:

4 - 12.9 OZ CANS POWDER ENFAMIL LIPIL

9 - 12.9 OZ CANS POWDER

OR PROSOBEE LIPIL

IRON FORTIFIED ENFAMIL LIPIL OR PROSOBEE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

2 CANS JUICE 24 OZ INFANT CEREAL

855

FORMULA:

5 - 12.9 OZ CANS POWDER ENFAMIL LIPIL

OR PROSOBEE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

073

JUICE:

CEREAL:

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

043 1 - 12.9 OZ CAN POWDER IRON FORTIFIED ENFAMIL LIPIL OR PROSOBEE LIPIL

844

FORMULA:

1 - 12.9 OZ CAN POWDER ENFAMIL LIPIL

OR PROSOBEE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

046 1 - 12.9 OZ CAN POWDER IRON FORTIFIED ENFAMIL LIPIL OR PROSOBEE LIPIL
2 CANS JUICE 24 OZ INFANT CEREAL

844

FORMULA:

1 - 12.9 OZ CAN POWDER ENFAMIL LIPIL

OR PROSOBEE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

073

JUICE:

CEREAL:

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

063

845

FORMULA:

3 - 12.9 OZ CANS POWDER ENFAMIL LIPIL

3 - 12.9 OZ CANS POWDER

OR PROSOBEE LIPIL

IRON FORTIFIED ENFAMIL LIPIL OR PROSOBEE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

066

845

FORMULA:

3 - 12.9 OZ CANS POWDER ENFAMIL LIPIL

3 - 12.9 OZ CANS POWDER

OR PROSOBEE LIPIL

IRON FORTIFIED ENFAMIL LIPIL OR PROSOBEE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

2 CANS JUICE 24 OZ INFANT CEREAL

073

JUICE:

CEREAL:

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

FP-40

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-2 (cont'd)

FOOD PACKAGE NUMBER

VOUCHER CODE

VOUCHER MESSAGE

823

855

FORMULA:

5 - 12.9 OZ CANS POWDER ENFAMIL LIPIL

5 - 12.9 OZ CANS POWDER

OR PROSOBEE LIPIL

IRON FORTIFIED ENFAMIL LIPIL OR PROSOBEE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

826

855

FORMULA:

5 - 12.9 OZ CANS POWDER ENFAMIL LIPIL

5 - 12.9 OZ CANS POWDER

OR PROSOBEE LIPIL

IRON FORTIFIED ENFAMIL LIPIL OR PROSOBEE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

2 CANS JUICE 24 OZ INFANT CEREAL

073

JUICE:

CEREAL:

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

033

872

FORMULA:

12 - 32 OZ CANS READY TO FEED

25 - 32 OZ CANS READY

ENFAMIL LIPIL OR PROSOBEE LIPIL

TO FEED IRON FORTIFIED ENFAMIL LIPIL OR PROSOBEE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

873

FORMULA:

13 - 32 OZ CANS READY TO FEED

ENFAMIL LIPIL OR PROSOBEE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

036

872

FORMULA: 12 - 32 OZ CANS READY TO FEED ENFAMIL

25 - 32 OZ CANS READY

LIPIL OR PROSOBEE LIPIL

TO FEED IRON FORTIFIED ENFAMIL LIPIL OR PROSOBEE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

873

FORMULA: 13 - 32 OZ CANS READY TO FEED ENFAMIL

2 CANS JUICE

LIPIL OR PROSOBEE LIPIL

24 OZ INFANT CEREAL

IRON FORTIFIED

NO LOW IRON FORMULA ALLOWED

073

JUICE:

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

CEREAL:

UP TO 24 OZ INFANT CEREAL

FP-41

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-2 (cont'd)

FOOD PACKAGE NUMBER
XXXXXXXXXXXXXXXXX Package Discontinued
XXXXXXXXXXXXXXXXX 053
31 - 13 OZ CANS CONCENTRATE IRON FORTIFIED ENFAMIL PROSOBEE LIPIL
XXXXXXXXXXXXXXXXX Package Discontinued
XXXXXXXXXXXXXXXXX 056
31 - 13 OZ CANS CONCENTRATE IRON FORTIFIED ENFAMIL PROSOBEE LIPIL
2 CANS JUICE 24 OZ INFANT CEREAL
XXXXXXXXXXXXXXXXX Package Discontinued
XXXXXXXXXXXXXXXXX 073
13 - 13 OZ CANS CONCENTRATE IRON FORTIFIED ENFAMIL PROSOBEE LIPIL
XXXXXXXXXXXXXXXXX Package Discontinued
XXXXXXXXXXXXXXXXX 076
13 - 13 OZ CANS CONCENTRATE IRON FORTIFIED ENFAMIL PROSOBEE LIPIL
2 CANS JUICE 24 OZ INFANT CEREAL

VOUCHER CODE

VOUCHER MESSAGE

804

FORMULA: 15-13 OZ CANS CONCENTRATE ENFAMIL

PROSOBEE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

805

FORMULA: 16-13 OZ CANS CONCENTRATE ENFAMIL

PROSOBEE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

804

FORMULA: 15-13 OZ CANS CONCENTRATE ENFAMIL

PROSOBEE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

805

FORMULA: 16-13 OZ CANS CONCENTRATE ENFAMIL

PROSOBEE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

073

JUICE:

2-12 OZ CANS FROZEN OR 2-46 OZ CANS OR 246 OZ PLASTIC BOTTLES OR 2-11.5 OZ CANS POURABLE

CEREAL:

UP TO 24 OZ INFANT CEREAL

803

FORMULA: 13-13 OZ CANS CONCENTRATE ENFAMIL

PROSOBEE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

803

FORMULA: 13-13 OZ CANS CONCENTRATE ENFAMIL

PROSOBEE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

073

JUICE:

2-12 OZ CANS FROZEN OR 2-46 OZ CANS OR 246 OZ PLASTIC BOTTLES OR 2-11.5 OZ CANS POURABLE

CEREAL:

UP TO 24 OZ INFANT CEREAL

FP-42

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-2 (cont'd)

FOOD PACKAGE NUMBER

VOUCHER CODE

VOUCHER MESSAGE

XXXXXXXXXXXXXXXXX Package Discontinued

824

FORMULA: 4 - 12.9 OZ CANS POWDER ENFAMIL

PROSOBEE LIPIL

XXXXXXXXXXXXXXXXX

IRON FORTIFIED

003

NO LOW IRON FORMULA ALLOWED

9 - 12.9 OZ CANS POWDER

IRON FORTIFIED

825

FORMULA: 5 - 12.9 OZ CANS POWDER ENFAMIL

ENFAMIL PROSOBEE

PROSOBEE LIPIL

LIPIL

IRON FORTIFIED

NO LOW IRON FORMULA ALLOWED

XXXXXXXXXXXXXXXXX Package Discontinued

824

FORMULA: 4 - 12.9 OZ CANS POWDER ENFAMIL

PROSOBEE LIPIL

XXXXXXXXXXXXXXXXX 006

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

9 - 12.9 OZ CANS POWDER

IRON FORTIFIED

825

FORMULA: 5 - 12.9 OZ CANS POWDER ENFAMIL

ENFAMIL PROSOBEE

PROSOBEE LIPIL

LIPIL

IRON FORTIFIED

2 CANS JUICE 24 OZ INFANT CEREAL

NO LOW IRON FORMULA ALLOWED

073

JUICE:

2-12 OZ CANS FROZEN OR 2-46 OZ CANS OR 246 OZ PLASTIC BOTTLES OR 2-11.5 OZ CANS

POURABLE

CEREAL:

UP TO 24 OZ INFANT CEREAL

XXXXXXXXXXXXXXXXX
Package Discontinued
XXXXXXXXXXXXXXXXX
083
1 - 12.9 OZ CAN POWDER IRON FORTIFIED ENFAMIL PROSOBEE LIPIL

814

FORMULA: 1 - 12.9 OZ CAN POWDER ENFAMIL PROSOBEE

LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

XXXXXXXXXXXXXXXXX Package Discontinued
XXXXXXXXXXXXXXXXX 086
1 - 12.9 OZ CAN POWDER IRON FORTIFIED ENFAMIL PROSOBEE LIPIL
2 CANS JUICE 24 OZ INFANT CEREAL

814

FORMULA: 1 - 12.9 OZ CAN POWDER ENFAMIL PROSOBEE

LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

073

JUICE:

2-12 OZ CANS FROZEN OR 2-46 OZ CANS OR 246 OZ PLASTIC BOTTLES OR 2-11.5 OZ CANS POURABLE

CEREAL:

UP TO 24 OZ INFANT CEREAL

FP-43

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-2 (cont'd)

FOOD PACKAGE NUMBER

VOUCHER CODE

VOUCHER MESSAGE

XXXXXXXXXXXXXXXXX Package Discontinued

815

FORMULA: 3 - 12.9 OZ CANS POWDER ENFAMIL

PROSOBEE LIPIL

XXXXXXXXXXXXXXXXX 093

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

3 - 12.9 OZ CANS POWDER IRON FORTIFIED ENFAMIL PROSOBEE LIPIL

XXXXXXXXXXXXXXXXX Package Discontinued

815

FORMULA: 3 - 12.9 OZ CANS POWDER ENFAMIL

PROSOBEE LIPIL

XXXXXXXXXXXXXXXXX 096

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

3 - 12.9 OZ CANS POWDER

IRON FORTIFIED

073

JUICE:

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

ENFAMIL PROSOBEE

46 OZ PLASTIC BOTTLES OR 2-11.5 OZ CANS

LIPIL

POURABLE

CEREAL:

UP TO 24 OZ INFANT CEREAL

2 CANS JUICE 24 OZ INFANT CEREAL

XXXXXXXXXXXXXXXXX Package Discontinued

825

FORMULA: 5 - 12.9 OZ CANS POWDER ENFAMIL

PROSOBEE LIPIL

XXXXXXXXXXXXXXXXX 833
5 - 12.9 OZ CANS POWDER IRON FORTIFIED ENFAMIL PROSOBEE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

XXXXXXXXXXXXXXXXX Package Discontinued

825

FORMULA: 5 - 12.9 OZ CANS POWDER ENFAMIL

PROSOBEE LIPIL

XXXXXXXXXXXXXXXXX

IRON FORTIFIED

836

NO LOW IRON FORMULA ALLOWED

5 - 12.9 OZ CANS POWDER

IRON FORTIFIED

073

JUICE:

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

ENFAMIL PROSOBEE

46 OZ PLASTIC BOTTLES OR 2-11.5 OZ CANS

LIPIL

POURABLE

CEREAL:

UP TO 24 OZ INFANT CEREAL

2 CANS JUICE 24 OZ INFANT CEREAL

FP-44

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-2 (cont'd)

FOOD PACKAGE NUMBER

VOUCHER CODE

VOUCHER MESSAGE

XXXXXXXXXXXXXXXXX Package Discontinued

822

FORMULA: 12 - 32 OZ CANS READY TO FEED ENFAMIL

PROSOBEE LIPIL

XXXXXXXXXXXXXXXXX

IRON FORTIFIED

803

NO LOW IRON FORMULA ALLOWED

25 - 32 OZ CANS READY

TO FEED IRON FORTIFIED

823

FORMULA: 13 - 32 OZ CANS READY TO FEED ENFAMIL

ENFAMIL PROSOBEE

PROSOBEE LIPIL

LIPIL

IRON FORTIFIED

NO LOW IRON FORMULA ALLOWED

XXXXXXXXXXXXXXXXX Package Discontinued

822

FORMULA: 12 - 32 OZ CANS READY TO FEED ENFAMIL

PROSOBEE LIPIL

XXXXXXXXXXXXXXXXX

IRON FORTIFIED

806

NO LOW IRON FORMULA ALLOWED

25 - 32 OZ CANS READY

TO FEED IRON FORTIFIED

823

FORMULA: 13 - 32 OZ CANS READY TO FEED ENFAMIL

ENFAMIL PROSOBEE

PROSOBEE LIPIL

LIPIL

IRON FORTIFIED

NO LOW IRON FORMULA ALLOWED

2 CANS JUICE 24 OZ INFANT CEREAL

073

JUICE:

2-12 OZ CANS FROZEN OR 2-46 OZ CANS OR 246 OZ PLASTIC BOTTLES OR 2-11.5 OZ CANS POURABLE

CEREAL:

UP TO 24 OZ INFANT CEREAL

221 2 CANS JUICE 24 OZ INFANT CEREAL
299 BREASTFEEDING
MESSAGE

073

JUICE:

2-12 OZ CANS FROZEN OR 2-46 OZ CANS OR 246 OZ PLASTIC BOTTLES OR 2-11.5 OZ CANS POURABLE

CEREAL:

UP TO 24 OZ INFANT CEREAL

059

NURSE YOUR BABY OFTEN

THE MORE YOU BREASTFEED, THE MORE MILK YOU WILL

HAVE FOR YOUR BABY

BREASTFEEDING QUESTIONS 1-800-822-2539

199

199

PARTICIPANT TRACKING

VOUCHER

FORMULA ORDERED FROM THE NUTRITION SECTION. NO VALUE IS PLACED ON THIS VOUCHER

FP-45

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-2 (cont'd)

FOOD PACKAGE NUMBER

VOUCHER CODE

VOUCHER MESSAGE

999 FORMULA AS ORDERED BY A PHYSICIAN FORMULA MAY NOT EXCEED 128 OZ POWDER OR 403 OZ CONCENTRATE OR 800 OZ READY TO FEED

999

AS PRESCRIBED

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

JUICE: 2-12 OZ CANS FROZEN OR 2-46 OZ CANS OR 2-46 OZ PLASTIC BOTTLES OR 211.5 OZ CANS POURABLE CEREAL: 24 OZ INFANT CEREAL FORMULA ONLY MAY BE PRESCRIBED

FP-46

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-3

INFANT FOOD PACKAGES CONTRACT SPECIAL FORMULA- (LACTOFREE LIPIL, ENFAMIL NEXT STEP LIPIL, ENFAMIL NEXT STEP PROSOBEE LIPIL, ENFAMIL LOW IRON LIPIL &
ENFAMIL AR LIPIL) Prescription Required

FOOD PACKAGE NUMBER
103 31 - 13 OZ CANS CONCENTRATE IRON FORTIFIED ENFAMIL LACTOFREE OR ENFAMIL LACTOFREE LIPIL
106 31 - 13 OZ CANS CONCENTRATE IRON FORTIFIED ENFAMIL LACTOFREE OR ENFAMIL LACTOFREE LIPIL
2 CANS JUICE 24 OZ INFANT CEREAL

VOUCHER CODE

VOUCHER MESSAGE

264

FORMULA: 15-13 OZ CANS CONCENTRATE ENFAMIL

LACTOFREE OR ENFAMIL LACTOFREE

LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

265

FORMULA: 16-13 OZ CANS CONCENTRATE ENFAMIL

LACTOFREE OR ENFAMIL LACTOFREE

LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

264

FORMULA: 15-13 OZ CANS CONCENTRATE ENFAMIL

LACTOFREE OR ENFAMIL LACTOFREE

LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

265

FORMULA: 16-13 OZ CANS CONCENTRATE ENFAMIL

LACTOFREE OR ENFAMIL LACTOFREE

LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

073

JUICE:

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

OR 2-46 OZ PLASTIC BOTTLES OR 2-11.5

OZ CANS POURABLE

CEREAL:

UP TO 24 OZ INFANT CEREAL

FP-47

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-3 (cont'd)

FOOD PACKAGE NUMBER 128
31 - 13 OZ CANS CONCENTRATE IRON FORTIFIED ENFAMIL LACTOFREE OR ENFAMIL LACTOFREE LIPIL 2 CANS JUICE 16 OZ INFANT CEREAL
107 31 - 13 OZ CANS CONCENTRATE IRON FORTIFIED ENFAMIL LACTOFREE OR ENFAMIL LACTOFREE LIPIL 2 CANS JUICE
206 13 - 13 OZ CANS CONCENTRATE IRON FORTIFIED ENFAMIL LACTOFREE OR ENFAMIL LACTOFREE LIPIL
207 13 - 13 OZ CANS CONCENTRATE IRON FORTIFIED ENFAMIL LACTOFREE OR ENFAMIL LACTOFREE LIPIL 2 CANS JUICE 24 OZ INFANT CEREAL

VOUCHER CODE 264
265
173 264
265
273 292

VOUCHER MESSAGE

FORMULA:

15-13 OZ CANS CONCENTRATE ENFAMIL LACTOFREE OR ENFAMIL LACTOFREE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA:

16-13 OZ CANS CONCENTRATE ENFAMIL LACTOFREE OR ENFAMIL LACTOFREE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE:
CEREAL: FORMULA:

2-12 OZ CANS FROZEN OR 2-46 OZ CANS OR 2-46 OZ PLASTIC BOTTLES OR 2-11.5 OZ CANS POURABLE
UP TO 16 OZ INFANT CEREAL
15-13 OZ CANS CONCENTRATE ENFAMIL LACTOFREE OR ENFAMIL LACTOFREE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA:

16-13 OZ CANS CONCENTRATE ENFAMIL LACTOFREE OR ENFAMIL LACTOFREE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE: FORMULA:

2-12 OZ CANS FROZEN OR 2-46 OZ CANS OR 2-46 OZ PLASTIC BOTTLES OR 2-11.5 OZ CANS POURABLE
13-13 OZ CANS CONCENTRATE ENFAMIL LACTOFREE OR ENFAMIL LACTOFREE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

292

FORMULA: 13-13 OZ CANS CONCENTRATE ENFAMIL

LACTOFREE OR ENFAMIL LACTOFREE

LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

073

JUICE:

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

OR 2-46 OZ PLASTIC BOTTLES OR 2-11.5

OZ CANS POURABLE

CEREAL:

UP TO 24 OZ INFANT CEREAL

FP-48

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-3 (cont'd)

FOOD PACKAGE NUMBER 233
8 - 14.3 OZ CANS POWDER IRON FORTIFIED ENFAMIL LACTOFREE OR 9 - 12.9 OZ CANS IRON FORTIFIED ENFAMIL LACTOFREE LIPIL
276 8 - 14.3 OZ CANS POWDER IRON FORTIFIED ENFAMIL LACTOFREE OR 9 - 12.9 OZ CANS IRON FORTIFIED ENFAMIL LACTOFREE LIPIL 2 CANS JUICE 24 OZ INFANT CEREAL
208 1 - 14.3 OZ CAN POWDER IRON FORTIFIED ENFAMIL LACTOFREE OR 1 - 12.9 OZ CAN IRON FORTIFIED ENFAMIL LACTOFREE LIPIL
204 1 - 14.3 OZ CAN POWDER IRON FORTIFIED ENFAMIL LACTOFREE OR 1 - 12.9 OZ CAN IRON FORTIFIED ENFAMIL LACTOFREE LIPIL
2 CANS JUICE 24 OZ INFANT CEREAL

VOUCHER CODE 375
373
375 373 073 274
274
073

VOUCHER MESSAGE

FORMULA:

4-14.3 OZ CANS POWDER ENFAMIL LACTOFREE OR 5 - 12.9 OZ CANS IRON FORTIFIED ENFAMIL LACTOFREE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA:

4-14.3 OZ CANS POWDER ENFAMIL LACTOFREE OR 4 - 12.9 OZ CANS IRON FORTIFIED ENFAMIL LACTOFREE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA:

4-14.3 OZ CANS POWDER ENFAMIL LACTOFREE OR 5 - 12.9 OZ CANS IRON FORTIFIED ENFAMIL LACTOFREE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA:

4-14.3 OZ CANS POWDER ENFAMIL LACTOFREE OR 4 - 12.9 OZ CANS IRON FORTIFIED ENFAMIL LACTOFREE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE: CEREAL:

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

FORMULA:

1-14.3 OZ CAN POWDER ENFAMIL LACTOFREE OR 1 - 12.9 OZ CAN IRON FORTIFIED ENFAMIL LACTOFREE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA:

1-14.3 OZ CAN POWDER ENFAMIL LACTOFREE OR 1 - 12.9 OZ CAN IRON FORTIFIED ENFAMIL LACTOFREE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE: CEREAL:

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

FP-49

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-3 (cont'd)

FOOD PACKAGE NUMBER
203 3 - 14.3 OZ CANS POWDER IRON FORTIFIED ENFAMIL LACTOFREE OR 4 - 12.9 OZ CANS IRON FORTIFIED ENFAMIL LACTOFREE LIPIL
205 3 - 14.3 OZ CANS POWDER IRON FORTIFIED ENFAMIL LACTOFREE OR 4 - 12.9 OZ CANS IRON FORTIFIED ENFAMIL LACTOFREE LIPIL
2 CANS JUICE 24 OZ INFANT CEREAL
102 25 - 1 QT (ML 986) CANS READY TO FEED IRON FORTIFIED ENFAMIL LACTOFREE OR ENFAMIL LACTOFREE LIPIL
105 25 - 1 QT (ML 986) CANS READY TO FEED IRON FORTIFIED ENFAMIL LACTOFREE OR ENFAMIL LACTOFREE LIPIL
2 CANS JUICE 24 OZ INFANT CEREAL

VOUCHER CODE 275
275
073 262
263
262
263
073

VOUCHER MESSAGE

FORMULA:

3-14.3 OZ CANS POWDER ENFAMIL LACTOFREE OR 4 - 12.9 OZ CANS IRON FORTIFIED ENFAMIL LACTOFREE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA:

3-14.3 OZ CANS POWDER ENFAMIL LACTOFREE OR 4 - 12.9 OZ CANS IRON FORTIFIED ENFAMIL LACTOFREE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE: CEREAL:

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

FORMULA:

12-1 QT (ML 986) CANS READY TO FEED ENFAMIL LACTOFREE OR ENFAMIL LACTOFREE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA:

13-1 QT (ML 986) CANS READY TO FEED ENFAMIL LACTOFREE OR ENFAMIL LACTOFREE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA:

12-1 QT (ML 986) CANS READY TO FEED ENFAMIL LACTOFREE OR ENFAMIL LACTOFREE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA:

13-1 QT (ML 986) CANS READY TO FEED ENFAMIL LACTOFREE OR ENFAMIL LACTOFREE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE: CEREAL:

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

FP-50

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-3 (cont'd)

FOOD PACKAGE NUMBER
210 10 - 12 OZ OR 5 - 24 OZ CANS POWDER IRON FORTIFIED ENFAMIL NEXT STEP OR ENFAMIL NEXT STEP LIPIL
215 10 - 12 OZ OR 5 - 24 OZ CANS POWDER IRON FORTIFIED ENFAMIL NEXT STEP OR ENFAMIL NEXT STEP LIPIL
2 CANS JUICE 24 OZ INFANT CEREAL
242 1 - 12 OZ CAN POWDER IRON FORTIFIED ENFAMIL NEXT STEP OR ENFAMIL NEXT STEP LIPIL
259 1 - 12 OZ CAN POWDER IRON FORTIFIED ENFAMIL NEXT STEP OR ENFAMIL NEXT STEP LIPIL 2 CANS JUICE 24 OZ INFANT CEREAL

VOUCHER CODE
128

VOUCHER MESSAGE

FORMULA:

10-12 OZ OR 5-24 OZ CANS POWDER IRON FORTIFIED ENFAMIL NEXT STEP OR ENFAMIL NEXT STEP LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

128

FORMULA: 10-12 OZ OR 5-24 OZ CANS POWDER IRON

FORTIFIED ENFAMIL NEXT STEP OR

ENFAMIL NEXT STEP LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

073

JUICE:

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

OR 2-46 OZ PLASTIC BOTTLES OR 2-11.5

OZ CANS POURABLE

CEREAL:

UP TO 24 OZ INFANT CEREAL

097

FORMULA: 1 - 12 OZ CAN POWDER IRON FORTIFIED

ENFAMIL NEXT STEP OR ENFAMIL NEXT

STEP LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

097

FORMULA: 1 - 12 OZ CAN POWDER IRON FORTIFIED

ENFAMIL NEXT STEP OR ENFAMIL NEXT

STEP LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

073

JUICE:

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

OR 2-46 OZ PLASTIC BOTTLES OR 2-11.5

OZ CANS POURABLE

CEREAL:

UP TO 24 OZ INFANT CEREAL

FP-51

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-3 (cont'd)

FOOD PACKAGE NUMBER
219 5 - 12 OZ CANS POWDER IRON FORTIFIED ENFAMIL NEXT STEP OR ENFAMIL NEXT STEP LIPIL
289 5 - 12 OZ CANS POWDER IRON FORTIFIED ENFAMIL NEXT STEP OR ENFAMIL NEXT STEP LIPIL 2 CANS JUICE 24 OZ INFANT CEREAL
010 10 - 12 OZ OR 5 - 24 OZ CANS POWDER IRON FORTIFIED ENFAMIL NEXT STEP SOY OR ENFAMIL NEXT STEP PROSOBEE LIPIL
015 10 - 12 OZ OR 5 - 24 OZ CANS POWDER IRON FORTIFIED ENFAMIL NEXT STEP SOY OR ENFAMIL NEXT STEP PROSOBEE LIPIL
2 CANS JUICE 24 OZ INFANT CEREAL

VOUCHER CODE 138
138
073 828
828 073

VOUCHER MESSAGE

FORMULA:

5 - 12 OZ CANS POWDER IRON FORTIFIED ENFAMIL NEXT STEP OR ENFAMIL NEXT STEP LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA:

5 - 12 OZ CANS POWDER IRON FORTIFIED ENFAMIL NEXT STEP OR ENFAMIL NEXT STEP LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE: CEREAL:

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

FORMULA:

10-12 OZ OR 5-24 OZ CANS POWDER IRON FORTIFIED ENFAMIL NEXT STEP SOY OR ENFAMIL NEXT STEP PROSOBEE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA:

10-12 OZ OR 5-24 OZ CANS POWDER IRON FORTIFIED ENFAMIL NEXT STEP SOY OR ENFAMIL NEXT STEP PROSOBEE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE: CEREAL:

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

FP-52

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-3 (cont'd)

FOOD PACKAGE NUMBER
042 1 - 12 OZ CAN POWDER IRON FORTIFIED ENFAMIL NEXT STEP SOY OR ENFAMIL NEXT STEP PROSOBEE LIPIL

VOUCHER CODE
897

VOUCHER MESSAGE

FORMULA:

1 - 12 OZ CAN POWDER IRON FORTIFIED ENFAMIL NEXT STEP SOY OR ENFAMIL NEXT STEP PROSOBEE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

059 1 - 12 OZ CAN POWDER IRON FORTIFIED ENFAMIL NEXT STEP SOY OR ENFAMIL NEXT STEP PROSOBEE LIPIL 2 CANS JUICE 24 OZ INFANT CEREAL
019 5 - 12 OZ CANS POWDER IRON FORTIFIED ENFAMIL NEXT STEP SOY OR ENFAMIL NEXT STEP PROSOBEE LIPIL
089 5 - 12 OZ CANS POWDER IRON FORTIFIED ENFAMIL NEXT STEP SOY OR ENFAMIL NEXT STEP PROSOBEE LIPIL 2 CANS JUICE 24 OZ INFANT CEREAL
XXXXXXXXXXXXXXXXX Package Discontinued
XXXXXXXXXXXXXXXXX 133
31 - 13 OZ CANS CONCENTRATE ENFAMIL LOW IRON

897

FORMULA: 1 - 12 OZ CAN POWDER IRON FORTIFIED

ENFAMIL NEXT STEP SOY OR ENFAMIL

NEXT STEP PROSOBEE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

073

JUICE:

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

OR 2-46 OZ PLASTIC BOTTLES OR 2-11.5

OZ CANS POURABLE

CEREAL:

UP TO 24 OZ INFANT CEREAL

838

FORMULA: 5 - 12 OZ CANS POWDER IRON FORTIFIED

ENFAMIL NEXT STEP SOY OR ENFAMIL

NEXT STEP PROSOBEE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

838

FORMULA: 5 - 12 OZ CANS POWDER IRON FORTIFIED

ENFAMIL NEXT STEP SOY OR ENFAMIL

NEXT STEP PROSOBEE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

073

JUICE:

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

OR 2-46 OZ PLASTIC BOTTLES OR 2-11.5

OZ CANS POURABLE

CEREAL:

UP TO 24 OZ INFANT CEREAL

094

FORMULA: 15-13 OZ CANS CONCENTRATE ENFAMIL

LOW IRON

LOW IRON FORMULA ALLOWED

095

FORMULA: 16-13 OZ CANS CONCENTRATE ENFAMIL

LOW IRON

LOW IRON FORMULA ALLOWED

FP-53

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-3 (cont'd)

FOOD PACKAGE NUMBER
XXXXXXXXXXXXXXXXX Package Discontinued
XXXXXXXXXXXXXXXXX 136
31 - 13 OZ CANS CONCENTRATE ENFAMIL LOW IRON
2 CANS JUICE 24 OZ INFANT CEREAL
134 8 - 14.3 OZ CANS POWDER ENFAMIL LOW IRON OR 9 - 12.9 OZ CANS POWDER ENFAMIL LOW IRON LIPIL
137 8-14.3 OZ CANS POWDER ENFAMIL LOW IRON OR 9 - 12.9 OZ CANS POWDER ENFAMIL LOW IRON LIPIL
2 CANS JUICE 24 OZ INFANT CEREAL
108 9 - 12.9 OZ CANS POWDER IRON FORTIFIED ENFAMIL AR LIPIL

VOUCHER CODE 094
095
073
194

VOUCHER MESSAGE

FORMULA: 15-13 OZ CANS CONCENTRATE ENFAMIL LOW IRON

LOW IRON FORMULA ALLOWED

FORMULA: 16-13 OZ CANS CONCENTRATE ENFAMIL LOW IRON

LOW IRON FORMULA ALLOWED

JUICE: CEREAL:

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

FORMULA:

4-14.3 OZ CANS POWDER ENFAMIL LOW IRON OR 4-12.9 OZ CANS POWDER ENFAMIL LOW IRON LIPIL

LOW IRON FORMULA ALLOWED

196

FORMULA: 4-14.3 OZ CANS POWDER ENFAMIL LOW

IRON OR 5-12.9 OZ CANS POWDER

ENFAMIL LOW IRON LIPIL

LOW IRON FORMULA ALLOWED

194

FORMULA: 4-14.3 OZ CANS POWDER ENFAMIL LOW

IRON OR 4-12.9 OZ CANS POWDER

ENFAMIL LOW IRON LIPIL

LOW IRON FORMULA ALLOWED

196

FORMULA 4-14.3 OZ CANS POWDER ENFAMIL LOW

IRON OR 5-12.9 OZ CANS POWDER

ENFAMIL LOW IRON LIPIL

LOW IRON FORMULA ALLOWED

073

JUICE:

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

OR 2-46 OZ PLASTIC BOTTLES OR 2-11.5

OZ CANS POURABLE

CEREAL:

UP TO 24 OZ INFANT CEREAL

108

FORMULA: 4 - 12.9 OZ CANS POWDER ENFAMIL AR

LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

168

FORMULA: 5 - 12.9 OZ CANS POWDER ENFAMIL AR

LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FP-54

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-3 (cont'd)

FOOD PACKAGE NUMBER 168
9 - 12.9 OZ CANS POWDER IRON FORTIFIED ENFAMIL AR LIPIL
2 CANS JUICE 24 OZ INFANT CEREAL
201 5 - 12.9 OZ CANS POWDER IRON FORTIFIED ENFAMIL AR LIPIL
251 5 12.9 OZ CANS POWDER IRON FORTIFIED ENFAMIL AR LIPIL 2 CANS JUICE 24 OZ INFANT CEREAL
109 25 - 32 OZ CANS READY TO FEED IRON FORTIFIED ENFAMIL AR OR ENFAMIL AR LIPIL

VOUCHER CODE 108
168
073 168
168
073 109 169

VOUCHER MESSAGE

FORMULA: 4 - 12.9 OZ CANS POWDER ENFAMIL AR LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA: 5 - 12.9 OZ CANS POWDER ENFAMIL AR LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE:
CEREAL: FORMULA:

2-12 OZ CANS FROZEN OR 2-46 OZ CANS OR 2-46 OZ PLASTIC BOTTLES OR 2-11.5 OZ CANS POURABLE UP TO 24 OZ INFANT CEREAL
5 12.9 OZ CANS POWDER ENFAMIL AR LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED
FORMULA: 5 - 12.9 OZ CANS POWDER ENFAMIL AR LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE: CEREAL:

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

FORMULA: 12 - 32 OZ CANS READY TO FEED ENFAMIL AR OR ENFAMIL AR LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA: 13 - 32 OZ CANS READY TO FEED ENFAMIL AR OR ENFAMIL AR LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FP-55

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-3 (cont'd)

FOOD PACKAGE NUMBER
169 25 - 32 OZ CANS READY TO FEED IRON FORTIFIED ENFAMIL AR OR ENFAMIL AR LIPIL
2 CANS JUICE 24 OZ INFANT CEREAL
999 FORMULA AS ORDERED BY A PHYSICIAN FORMULA MAY NOT EXCEED 128 OZ POWDER OR 403 OZ CONCENTRATE OR 800 OZ READY TO FEED
JUICE: 2-12 OZ CANS FROZEN OR 2-46 OZ CANS OR 2-46 OZ PLASTIC BOTTLES OR 2-11.5 OZ CANS POURABLE CEREAL: 24 OZ INFANT CEREAL FORMULA ONLY MAY BE PRESCRIBED

VOUCHER CODE 109
169
073
999

VOUCHER MESSAGE

FORMULA: 12 - 32 OZ CANS READY TO FEED ENFAMIL AR OR ENFAMIL AR LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA: 13 - 32 OZ CANS READY TO FEED ENFAMIL AR OR ENFAMIL AR LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE: CEREAL:

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

AS PRESCRIBED

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

FP-56

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-4

INFANT FOOD PACKAGES NON-CONTRACT SPECIAL FORMULA (NUTRAMIGEN LIPIL, ALIMENTUM,
ALIMENTUM ADVANCE, PREGESTIMIL, PORTAGEN) PERSCRIPTION REQUIRED

FOOD PACKAGE NUMBER 121
8 - 1LB CANS POWDER OR 31 - 13 OZ CANS CONCENTRATE NUTRAMIGEN OR NUTRAMIGEN LIPIL
131 8 - 1LB CANS POWDER OR 31 - 13 OZ CANS CONCENTRATE NUTRAMIGEN OR NUTRAMIGEN LIPIL 2 CANS JUICE 24 OZ INFANT CEREAL
151 8 - 1LB CANS POWDER ALIMENTUM OR ALIMENTUM ADVANCE

VOUCHER CODE 160
161
160
161
073 360 360

VOUCHER MESSAGE

FORMULA:

4-1LB CANS POWDER OR 15-13 OZ CANS CONCENTRATE NUTRAMIGEN OR NUTRAMIGEN LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA:

4-1LB OZ CANS POWDER OR 16-13 OZ CANS CONCENTRATE NUTRAMIGEN OR NUTRAMIGEN LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA:

4-1LB OZ CANS POWDER OR 15-13 OZ CANS CONCENTRATE NUTRAMIGEN OR NUTRAMIGEN LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA:

4-1LB OZ CANS POWDER OR 16-13 OZ CANS CONCENTRATE NUTRAMIGEN OR NUTRAMIGEN LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE: CEREAL:

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

FORMULA: 4-1 LB CANS POWDER ALIMENTUM OR ALIMENTUM ADVANCE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA: 4-1 LB CANS POWDER ALIMENTUM OR ALIMENTUM ADVANCE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FP-57

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-4 (cont'd)

FOOD PACKAGE NUMBER 191
8 - 1LB CANS POWDER ALIMENTUM OR ALIMENTUM ADVANCE
2 CANS JUICE 24 OZ INFANT CEREAL
161 25 - 1 QT CANS READY TO FEED ALIMENTUM OR 25 32 OZ PLASTIC BOTTLES READY TO FEED ALIMENTUM ADVANCE
171 25 - 1 QT CANS READY TO FEED ALIMENTUM OR 25 32 OZ PLASTIC BOTTLES READY TO FEED ALIMENTUM ADVANCE 2 CANS JUICE 24 OZ INFANT CEREAL

VOUCHER CODE 360 360 073 190
191
190
191
073

VOUCHER MESSAGE

FORMULA: 4-1 LB CANS POWDER ALIMENTUM OR ALIMENTUM ADVANCE
IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA: 4-1 LB CANS POWDER ALIMENTUM OR ALIMENTUM ADVANCE
IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE:
CEREAL: FORMULA:

2-12 OZ CANS FROZEN OR 2-46 OZ CANS OR 2-46 OZ PLASTIC BOTTLES OR 2-11.5 OZ CANS POURABLE
UP TO 24 OZ INFANT CEREAL
12-1 QT CANS READY TO FEED ALIMENTUM OR 12-32 OZ PLASTIC BOTTLES READY TO FEED ALIMENTUM ADVANCE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA:

13-1 QT CANS READY TO FEED ALIMENTUM OR 13-32 OZ PLASTIC BOTTLES READY TO FEED ALIMENTUM ADVANCE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA:

12-1 QT CANS READY TO FEED ALIMENTUM OR 12-32 OZ PLASTIC BOTTLES READY TO FEED ALIMENTUM ADVANCE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA:

13-1 QT CANS READY TO FEED ALIMENTUM OR 13-32 OZ PLASTIC BOTTLES READY TO FEED ALIMENTUM ADVANCE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE: CEREAL:

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

FP-58

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-4 (cont'd)

FOOD PACKAGE NUMBER

VOUCHER CODE

VOUCHER MESSAGE

211
8 - 1LB CANS POWDER PREGESTIMIL

140

FORMULA: 4-1 LB CANS POWDER PREGESTIMIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

214 8 - 1LB CANS POWDER PREGESTIMIL
2 CANS JUICE 24 OZ INFANT CEREAL

140

FORMULA 4-1 LB CANS POWDER PREGESTIMIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

140

FORMULA: 4-1 LB CANS POWDER PREGESTIMIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

140

FORMULA: 4-1 LB CANS POWDER PREGESTIMIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

073

JUICE:

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

OR 2-46 OZ PLASTIC BOTTLES OR 2-11.5

OZ CANS POURABLE

CEREAL:

UP TO 24 OZ INFANT CEREAL

Portagen is no longer approved for issuance to an infant without prior approval from the state Nutrition Section. Chylothorax is the most common condition that may necessitate issuance of Portagen to an infant.

111 8 - 1LB CANS POWDER PORTAGEN

060

FORMULA: 4-1 LB CANS POWDER PORTAGEN

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

060

FORMULA: 4-1 LB CANS POWDER PORTAGEN

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

114 8 - 1LB CANS POWDER PORTAGEN
2 CANS JUICE 24 OZ INFANT CEREAL

060

FORMULA: 4-1 LB CANS POWDER PORTAGEN

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

060

FORMULA: 4-1 LB CANS POWDER PORTAGEN

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

073

JUICE:

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

OR 2-46 OZ PLASTIC BOTTLES OR 2-11.5

OZ CANS POURABLE

CEREAL:

UP TO 24 OZ INFANT CEREAL

FP-59

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-5

INFANT FOOD PACKAGES NON-CONTRACT SOY FORMULA
Prescription Required

FOOD PACKAGE NUMBER
143 31 - 13 OZ CANS CONCENTRATE IRON FORTIFIED NONCONTRACT SOY FORMULA: ISOMIL OR ISOMIL ADVANCE OR CARNATION ALSOY OR NESTLE GOOD START ESSENTIALS SOY OR NESTLE GOOD START SUPREME SOY DHA & ARA
146 31 - 13 OZ CANS CONCENTRATE IRON FORTIFIED NONCONTRACT SOY FORMULA: ISOMIL OR ISOMIL ADVANCE OR CARNATION ALSOY OR NESTLE GOOD START ESSENTIALS SOY OR NESTLE GOOD START SUPREME SOY DHA & ARA
2 CANS JUICE 24 OZ INFANT CEREAL

VOUCHER CODE 257
258
257
258
073

VOUCHER MESSAGE

FORMULA:

15-13 OZ CANS CONCENTRATE ISOMIL OR ISOMIL ADVANCE OR CARNATION ALSOY OR NESTLE GOOD START ESSENTIALS SOY OR NESTLE GOOD START SUPREME SOY DHA & ARA

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA:

16-13 OZ CANS CONCENTRATE ISOMIL OR ISOMIL ADVANCE OR CARNATION ALSOY OR NESTLE GOOD START ESSENTIALS SOY OR NESTLE GOOD START SUPREME SOY DHA & ARA

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA:

15-13 OZ CANS CONCENTRATE ISOMIL OR ISOMIL ADVANCE OR CARNATION ALSOY OR NESTLE GOOD START ESSENTIALS SOY OR NESTLE GOOD START SUPREME SOY DHA & ARA

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA:

16-13 OZ CANS CONCENTRATE ISOMIL OR ISOMIL ADVANCE OR CARNATION ALSOY OR NESTLE GOOD START ESSENTIALS SOY OR NESTLE GOOD START SUPREME SOY DHA & ARA

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE: CEREAL:

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

FP-60

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-5 (cont'd)

FOOD PACKAGE NUMBER
193 9 - 14 OZ CANS POWDER IRON FORTIFIED NONCONTRACT SOY FORMULA: CARNATION ALSOY OR NESTLE GOOD START ESSENTIALS SOY OR 9 - 12.9 OZ CANS POWDER NESTLE GOOD START SUPREME SOY DHA & ARA
196 9 - 14 OZ CANS POWDER IRON FORTIFIED NONCONTRACT SOY FORMULA: CARNATION ALSOY OR NESTLE GOOD START ESSENTIALS SOY OR 9 - 12.9 OZ CANS POWDER NESTLE GOOD START SUPREME SOY DHA & ARA
2 CANS JUICE 24 OZ INFANT CEREAL
194 9 - 14 OZ CANS POWDER IRON FORTIFIED NONCONTRACT SOY FORMULA: ISOMIL OR 9 - 12.9 OZ CANS POWDER NON-CONTRACT SOY FORMULA: ISOMIL OR ISOMIL ADVANCE

VOUCHER CODE 457
458
457
458
073 891 889

VOUCHER MESSAGE

FORMULA:

4-14 OZ CANS POWDER CARNATION ALSOY OR NESTLE GOOD START ESSENTIALS SOY OR 4-12.9 OZ CANS POWDER NESTLE GOOD START SUPREME SOY DHA & ARA

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA:

5-14 OZ CANS POWDER CARNATION ALSOY OR NESTLE GOOD START ESSENTIALS SOY OR 5-12.9 OZ CANS POWDER NESTLE GOOD START SUPREME SOY DHA & ARA

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA:

4-14 OZ CANS POWDER CARNATION ALSOY OR NESTLE GOOD START ESSENTIALS SOY OR 4-12.9 OZ CANS POWDER NESTLE GOOD START SUPREME SOY DHA & ARA

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA:

5-14 OZ CANS POWDER CARNATION ALSOY OR NESTLE GOOD START ESSENTIALS SOY OR 5-12.9 OZ CANS POWDER NESTLE GOOD START SUPREME SOY DHA & ARA

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE:
CEREAL: FORMULA:

2-12 OZ CANS FROZEN OR 2-46 OZ CANS OR 2-46 OZ PLASTIC BOTTLES OR 2-11.5 OZ CANS POURABLE UP TO 24 OZ INFANT CEREAL
4-14 OZ CANS POWDER ISOMIL OR 4-12.9 OZ CANS POWDER ISOMIL OR ISOMILADVANCE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA:

5-14 OZ CANS POWDER ISOMIL OR
5-12.9 OZ CANS POWDER ISOMIL OR ISOMILADVANCE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FP-61

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-5 (cont'd)

FOOD PACKAGE NUMBER
195 9 - 14 OZ CANS POWDER IRON FORTIFIED NONCONTRACT SOY FORMULA: ISOMIL OR 9 - 12.9 OZ CANS POWDER NON-CONTRACT SOY FORMULA: ISOMIL OR ISOMIL ADVANCE
2 CANS JUICE 24 OZ INFANT CEREAL
230 IRON FORTIFIED NONCONTRACT SOY FORMULA: 9 - 14 OZ OR 4 - 30 OZ ISOMIL 2 OR 9 12.9 OZ CANS POWDER ISOMIL 2 ADVANCE
232 IRON FORTIFIED NONCONTRACT SOY FORMULA: 9 - 14 OZ OR 4 - 30 OZ ISOMIL 2 OR 9 12.9 OZ CANS POWDER ISOMIL 2 ADVANCE
2 CANS JUICE 24 OZ INFANT CEREAL

VOUCHER CODE 891
889
073 788
888 788 888 073

VOUCHER MESSAGE

FORMULA:

4-14 OZ CANS POWDER ISOMIL OR
4-12.9 OZ CANS POWDER ISOMIL OR ISOMILADVANCE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA:

5-14 OZ CANS POWDER ISOMIL OR
5-12.9 OZ CANS POWDER ISOMIL OR ISOMILADVANCE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE:
CEREAL: FORMULA:

2-12 OZ CANS FROZEN OR 2-46 OZ CANS OR 2-46 OZ PLASTIC BOTTLES OR 2-11.5 OZ CANS POURABLE
UP TO 24 OZ INFANT CEREAL
4-14 OZ OR 2-30 OZ CANS POWDER IRON FORTIFIED ISOMIL 2 OR 4-12.9 OZ CANS POWDER ISOMIL 2 ADVANCE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA:

5-14 OZ OR 2-30 OZ CANS POWDER IRON FORTIFIED ISOMIL 2 OR 5-12.9 OZ CANS POWDER ISOMIL 2 ADVANCE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA:

4-14 OZ OR 2-30 OZ CANS POWDER IRON FORTIFIED ISOMIL 2 OR 4-12.9 OZ CANS POWDER ISOMIL 2 ADVANCE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA:

5-14 OZ OR 2-30 OZ CANS POWDER IRON FORTIFIED ISOMIL 2 OR 5-12.9 OZ CANS POWDER ISOMIL 2 ADVANCE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE: CEREAL:

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

FP-62

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-6

ALTERNATE FOOD PACKAGE FOR INFANTS (0-4 MONTHS)
Maximum Monthly Amounts Contract Standard Formulas

TYPE Ready-To-Feed

SIZE 100-8 fluid oz cans

MAXIMUM AMOUNT 800 fluid ounces

This food package consists of eight (8) vouchers per month.

FP-63

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-7

ALTERNATE FOOD PACKAGE FOR INFANTS (0-4 MONTHS) Contract Standard Formulas

FOOD PACKAGE NUMBER
140
100 - 8 OZ CANS READY TO FEED IRON FORTIFIED ENFAMIL LIPIL OR PROSOBEE LIPIL

VOUCHER CODE 240 240 240 240 241 241 241 241

VOUCHER MESSAGE
FORMULA: 12-8 OZ CANS READY TO FEED ENFAMIL LIPIL OR PROSOBEE LIPIL
IRON FORTIFIED NO LOW IRON FORMULA ALLOWED
FORMULA: 12-8 OZ CANS READY TO FEED ENFAMIL LIPIL OR PROSOBEE LIPIL
IRON FORTIFIED NO LOW IRON FORMULA ALLOWED
FORMULA: 12-8 OZ CANS READY TO FEED ENFAMIL LIPIL OR PROSOBEE LIPIL
IRON FORTIFIED NO LOW IRON FORMULA ALLOWED
FORMULA: 12-8 OZ CANS READY TO FEED ENFAMIL LIPIL OR PROSOBEE LIPIL
IRON FORTIFIED NO LOW IRON FORMULA ALLOWED
FORMULA: 13-8 OZ CANS READY TO FEED ENFAMIL LIPIL OR PROSOBEE LIPIL
IRON FORTIFIED NO LOW IRON FORMULA ALLOWED
FORMULA: 13-8 OZ CANS READY TO FEED ENFAMIL LIPIL OR PROSOBEE LIPIL
IRON FORTIFIED NO LOW IRON FORMULA ALLOWED
FORMULA: 13-8 OZ CANS READY TO FEED ENFAMIL LIPIL OR PROSOBEE LIPIL
IRON FORTIFIED NO LOW IRON FORMULA ALLOWED
FORMULA: 13-8 OZ CANS READY TO FEED ENFAMIL LIPIL OR PROSOBEE LIPIL
IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FP-64

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-8

ALTERNATE FOOD PACKAGE FOR INFANTS (5-12 MONTHS)
Maximum Monthly Amounts Contract Standard Formulas

TYPE

SIZE

Ready-To-Feed

100-8 fluid ounces

Cereal, Infants

3-8 boxes, dry

Juice

12-5.5 to 6 oz cans

This food package consists of eight (8) vouchers.

MAXIMUM AMOUNT 800 fluid ounces 24 ounces 72 ounces

FP-65

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-9

ALTERNATE FOOD PACKAGE FOR INFANTS (5-12 MONTHS)

FOOD PACKAGE NUMBER
141
100 -8 OZ CANS READY TO FEED IRON FORTIFIED ENFAMIL LIPIL OR PROSOBEE LIPIL
3-8 OZ BOXES OF INFANT CEREAL 12-5.5 to 6 OZ CANS JUICE

VOUCHER CODE
240 240 240 240 240 242
242
243

VOUCHER MESSAGE

FORMULA:

12-8 OZ CANS READY TO FEED ENFAMIL LIPIL OR PROSOBEE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA:

12-8 OZ CANS READY TO FEED ENFAMIL LIPIL OR PROSOBEE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA:

12-8 OZ CANS READY TO FEED ENFAMIL LIPIL OR PROSOBEE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA:

12-8 OZ CANS READY TO FEED ENFAMIL LIPIL OR PROSOBEE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA:

12-8 OZ CANS READY TO FEED ENFAMIL LIPIL OR PROSOBEE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA:

13-8 OZ CANS READY TO FEED ENFAMIL LIPIL OR PROSOBEE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

INFANT CEREAL:

1-8 OZ BOX, DRY

JUICE:

6-5.5 to 6 OZ CANS

FORMULA:

13-8 OZ CANS READY TO FEED ENFAMIL LIPIL OR PROSOBEE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

INFANT CEREAL:

1-8 OZ BOX, DRY

JUICE:

6-5.5 to 6 OZ CANS

FORMULA:

14-8 OZ CAN READY TO FEED ENFAMIL LIPIL OR PROSOBEE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

INFANT CEREAL:

1-8 OZ BOX, DRY

FP-66

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-10

FOOD PACKAGES FOR CHILDREN AND WOMEN WITH SPECIAL DIETARY NEEDS
MAXIMUM MONTHLY AMOUNTS AUTHORIZED

A. FORMULA TYPES, SIZES AND ADDITIONAL AMOUNTS

Formula Type: Concentrate-

Infant Max
403 oz.

Child Max
455 oz.

RTF-

806 oz. 910 oz.

Powder-

128 oz. 144 oz.

TYPE

CAN SIZE

MAXIMUM AMOUNTS- Infant

ADDITIONAL AMOUNTS- Children & Women

Concentrate

13 ounces

31 cans (403 oz concentrate or 806 oz reconstituted)

4 can (52 oz concentrate or 104 oz reconstituted)
455 ounces maximum

Ready-To-Feed 32 ounces

Powder

16 ounces

25 cans (800 oz) 8 cans (128 oz)

12 ounces 12.8 ounces 12.9 ounces 14 ounces 14.1 ounces 14.3 ounces 16 ounces 30 ounces

3 cans (96 oz)
910 ounces maximum
1 can (16 oz)
144 ounces maximum
Total Cans by Size 12 total cans 11 total cans 11 total cans 10 total cans 10 total cans 10 total cans 9 total cans 4 total cans

B. CEREAL AND JUICE MAXIMUM MONTHLY AMOUNTS

FOOD
Cereal
Single Strength Juice
Frozen concentrated Juice Pourable Concentrated Juice

SIZE
9 ounces and above
46 fluid ounces
OR
12 fluid ounces
OR
11.5 fluid ounces

MAXIMUM AMOUNT 36 ounces 138 fluid ounces 144 fluid ounces
144 fluid ounces

FP-67

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-11

CHILDREN'S AND WOMEN'S PACKAGES CONTRACT SPECIAL FORMULAS (ENFAMIL, PROSOBEE, ENFAMIL LACTOFREE LIPIL, ENFAIL LIPIL, PROSOBEE LIPIL, ENFAMIL NEXT STEP LIPIL, ENFAMIL NEXT STEP PROSOBEE LIPIL,
ENFAMIL AR LIPIL) Prescription Required

FOOD PACKAGE NUMBER
319 35 - 13 OZ CANS CONCENTRATE IRON FORTIFIED ENFAMIL OR PROSOBEE
3 CANS JUICE 36 OZ CEREAL (CHILD MAX)
312 31 - 13 OZ CANS CONCENTRATE IRON FORTIFIED ENFAMIL OR PROSOBEE

VOUCHER CODE 065
085
070
064
065

VOUCHER MESSAGE

FORMULA: 16-13 OZ CANS CONCENTRATE ENFAMIL OR PROSOBEE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA: 19-13 OZ CANS CONCENTRATE ENFAMIL OR PROSOBEE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE: CEREAL:

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

FORMULA: 15-13 OZ CANS CONCENTRATE ENFAMIL OR PROSOBEE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA: 16-13 OZ CANS CONCENTRATE ENFAMIL OR PROSOBEE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FP-68

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-11 (cont'd)

FOOD PACKAGE NUMBER 316
31 - 13 OZ CANS CONCENTRATE IRON FORTIFIED ENFAMIL OR PROSOBEE 2 CANS JUICE 24 OZ CEREAL
317 31 - 13 OZ CANS CONCENTRATE IRON FORTIFIED ENFAMIL OR PROSOBEE 2 CANS JUICE 36 OZ CEREAL
313 25 - 13 OZ CANS CONCENTRATE IRON FORTIFIED ENFAMIL OR PROSOBEE 2 CANS JUICE 24 OZ CEREAL

VOUCHER CODE 064 065 573 064 065 473 078 092 573

VOUCHER MESSAGE

FORMULA: 15-13 OZ CANS CONCENTRATE ENFAMIL OR PROSOBEE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA: 16-13 OZ CANS CONCENTRATE ENFAMIL OR PROSOBEE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE: CEREAL:

2-12 OZ CANS FROZEN OR 2-46 OZ CANS OR 2-46 OZ PLASTIC BOTTLES OR 2-11.5 OZ CANS POURABLE
UP TO 24 OUNCES CEREAL

FORMULA: 15-13 OZ CANS CONCENTRATE ENFAMIL OR PROSOBEE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA: 16-13 OZ CANS CONCENTRATE ENFAMIL OR PROSOBEE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE: CEREAL

2-12 OZ CANS FROZEN OR 2-46 OZ CANS OR 2-46 OZ PLASTIC BOTTLES OR 2-11.5 OZ CANS POURABLE
UP TO 36 OUNCES CEREAL

FORMULA: 12-13 OZ CANS CONCENTRATE ENFAMIL OR PROSOBEE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA: 13-13 OZ CANS CONCENTRATE ENFAMIL OR PROSOBEE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE: CEREAL:

2-12 OZ CANS FROZEN OR 2-46 OZ CANS OR 2-46 OZ PLASTIC BOTTLES OR 2-11.5 OZ CANS POURABLE
UP TO 24 OUNCES CEREAL

FP-69

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-11 (cont'd)

FOOD PACKAGE NUMBER 329
10 - 14.3 OZ CANS POWDER IRON FORTIFIED ENFAMIL OR PROSOBEE 3 CANS JUICE 36 OZ CEREAL (CHILD MAX)
322 8 - 14.3 OZ CANS POWDER IRON FORTIFIED ENFAMIL OR PROSOBEE
323 8 - 14.3 OZ CANS POWDER IRON FORTIFIED ENFAMIL OR PROSOBEE 3 CANS JUICE 24 OZ CEREAL

VOUCHER CODE 093 093 070 091
091
091
091 066

VOUCHER MESSAGE

FORMULA: 5-14.3 OZ CANS POWDER ENFAMIL OR PROSOBEE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA: 5-14.3 OZ CANS POWDER ENFAMIL OR PROSOBEE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE: CEREAL:

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

FORMULA: 4-14.3 OZ CANS POWDER ENFAMIL OR PROSOBEE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA: 4-14.3 OZ CANS POWDER ENFAMIL OR PROSOBEE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA: 4-14.3 OZ CANS POWDER ENFAMIL OR PROSOBEE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA: 4-14.3 OZ CANS POWDER ENFAMIL OR PROSOBEE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE: CEREAL:

3-12 OZ CANS FROZEN OR 3-46 OZ CANS OR 3-46 OZ PLASTIC BOTTLES OR 3-11.5 OZ CANS POURABLE
UP TO 24 OUNCES CEREAL

FP-70

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-11 (cont'd)

FOOD PACKAGE NUMBER 326
9 - 14.3 OZ CANS POWDER IRON FORTIFIED ENFAMIL OR PROSOBEE 3 CANS JUICE 24 OZ CEREAL
327 8 - 14.3 OZ CANS POWDER IRON FORTIFIED ENFAMIL OR PROSOBEE 3 CANS JUICE 36 OZ CEREAL
304 28 - 1 QT (ML 986) CANS READY TO FEED IRON FORTIFIED ENFAMIL RTF ProSobee no longer produced 3 CANS JUICE 36 OZ CEREAL
(CHILD MAX)

VOUCHER CODE 091 093 066 091 091 070 061
061
070

VOUCHER MESSAGE

FORMULA: 4-14.3 OZ CANS POWDER ENFAMIL OR PROSOBEE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED
FORMULA: 5-14.3 OZ CANS POWDER ENFAMIL OR PROSOBEE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE: CEREAL:

3-12 OZ CANS FROZEN OR 3-46 OZ CANS OR 3-46 OZ PLASTIC BOTTLES OR 3-11.5 OZ CANS POURABLE
UP TO 24 OUNCES CEREAL

FORMULA: 4-14.3 OZ CANS POWDER ENFAMIL OR PROSOBEE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA: 4-14.3 OZ CANS POWDER ENFAMIL OR PROSOBEE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE: CEREAL:

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

FORMULA: 14-1 QT (ML 986) CANS READY TO FEED ENFAMIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA: 14-1 QT (ML 986) CANS READY TO FEED ENFAMIL
IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE: CEREAL:

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

FP-71

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-11 (cont'd)

FOOD PACKAGE NUMBER 314
25 - 1 QT (ML 986) CANS READY TO FEED IRON FORTIFIED ENFAMIL RTF ProSobee no longer produced 2 CANS JUICE 24 OZ CEREAL
339 35 - 13 OZ CANS CONCENTRATE IRON FORTIFIED ENFAMIL LACTOFREE OR ENFAMIL LACTOFREE LIPIL 3 CANS JUICE 36 OZ CEREAL
(CHILD MAX)
332 31 - 13 OZ CANS CONCENTRATE IRON FORTIFIED ENFAMIL LACTOFREE OR ENFAMIL LACTOFREE LIPIL

VOUCHER CODE 062 063 573 265
295
070 264
265

VOUCHER MESSAGE

FORMULA: 12-1 QT (ML 986) CANS READY TO FEED ENFAMIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA: 13-1 QT (ML 986) CANS READY TO FEED ENFAMIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE: CEREAL:

2-12 OZ CANS FROZEN OR 2-46 OZ CANS OR 2-46 OZ PLASTIC BOTTLES OR 2-11.5 OZ CANS POURABLE
UP TO 24 OUNCES CEREAL

FORMULA:

16-13 OZ CANS CONCENTRATE ENFAMIL LACTOFREE OR ENFAMIL LACTOFREE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA:

19-13 OZ CANS CONCENTRATE ENFAMIL LACTOFREE OR ENFAMIL LACTOFREE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE: CEREAL:

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

FORMULA:

15-13 OZ CANS CONCENTRATE ENFAMIL LACTOFREE OR ENFAMIL LACTOFREE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA:

16-13 OZ CANS CONCENTRATE ENFAMIL LACTOFREE OR ENFAMIL LACTOFREE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FP-72

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-11 (cont'd)

FOOD PACKAGE NUMBER
336 31 - 13 OZ CANS CONCENTRATE IRON FORTIFIED ENFAMIL LACTOFREE OR ENFAMIL LACTOFREE LIPIL
2 CANS JUICE 24 OZ CEREAL
337 31 - 13 OZ CANS CONCENTRATE IRON FORTIFIED ENFAMIL LACTOFREE OR ENFAMIL LACTOFREE LIPIL
2 CANS JUICE 36 OZ CEREAL

VOUCHER CODE 264
265
573 264
265
473

VOUCHER MESSAGE

FORMULA:

15-13 OZ CANS CONCENTRATE ENFAMIL LACTOFREE OR ENFAMIL LACTOFREE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA:

16-13 OZ CANS CONCENTRATE ENFAMIL LACTOFREE OR ENFAMIL LACTOFREE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE:
CEREAL: FORMULA:

2-12 OZ CANS FROZEN OR 2-46 OZ CANS OR 2-46 OZ PLASTIC BOTTLES OR 2-11.5 OZ CANS POURABLE
UP TO 24 OUNCES CEREAL
15-13 OZ CANS CONCENTRATE ENFAMIL LACTOFREE OR ENFAMIL LACTOFREE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA:

16-13 OZ CANS CONCENTRATE ENFAMIL LACTOFREE OR ENFAMIL LACTOFREE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE: CEREAL:

2-12 OZ CANS FROZEN OR 2-46 OZ CANS OR 2-46 OZ PLASTIC BOTTLES OR 2-11.5 OZ CANS POURABLE
UP TO 36 OUNCES CEREAL

FP-73

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-11 (cont'd)

FOOD PACKAGE NUMBER 333
25 13 OZ CANS CONCENTRATE IRON FORTIFIED ENFAMIL LACTOFREE OR ENFAMIL LACTOFREE LIPIL
2 CANS JUICE 24 OZ CEREAL
347 10 - 14.3 OZ CANS POWDER IRON FORTIFIED ENFAMIL LACTOFREE OR 11 - 12.9 OZ CANS IRON FORTIFIED ENFAMIL LACTOFREE LIPIL 3 CANS JUICE 36 OZ CEREAL
(CHILD MAX)

VOUCHER CODE 278
292
573 291
290
070

VOUCHER MESSAGE

FORMULA:

12-13 OZ CANS CONCENTRATE ENFAMIL LACTOFREE OR ENFAMIL LACTOFREE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA:

13-13 OZ CANS CONCENTRATE ENFAMIL LACTOFREE OR ENFAMIL LACTOFREE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE: CEREAL:

2-12 OZ CANS FROZEN OR 2-46 OZ CANS OR 2-46 OZ PLASTIC BOTTLES OR 2-11.5 OZ CANS POURABLE
UP TO 24 OUNCES CEREAL

FORMULA:

5-14.3 OZ CANS POWDER ENFAMIL LACTOFREE OR 6 - 12.9 OZ CANS IRON FORTIFIED ENFAMIL LACTOFREE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA:

5-14.3 OZ CANS POWDER ENFAMIL LACTOFREE OR 5 - 12.9 OZ CANS IRON FORTIFIED ENFAMIL LACTOFREE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE: CEREAL:

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

FP-74

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-11 (cont'd)

FOOD PACKAGE NUMBER 346
10 - 14.3 OZ CANS POWDER IRON FORTIFIED ENFAMIL LACTOFREE OR 11 - 12.9 OZ CANS IRON FORTIFIED ENFAMIL LACTOFREE LIPIL 3 CANS JUICE 24 OZ CEREAL
342 8 - 14.3 OZ CANS POWDER IRON FORTIFIED ENFAMIL LACTOFREE OR 9 - 12.9 OZ CANS IRON FORTIFIED ENFAMIL LACTOFREE LIPIL

VOUCHER CODE 291
290
066 375
373

VOUCHER MESSAGE

FORMULA:

5-14.3 OZ CANS POWDER ENFAMIL LACTOFREE OR 6 - 12.9 OZ CANS IRON FORTIFIED ENFAMIL LACTOFREE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA:

5-14.3 OZ CANS POWDER ENFAMIL LACTOFREE OR 5 - 12.9 OZ CANS IRON FORTIFIED ENFAMIL LACTOFREE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE: CEREAL:

3-12 OZ CANS FROZEN OR 3-46 OZ CANS OR 3-46 OZ PLASTIC BOTTLES OR 3-11.5 OZ CANS POURABLE
UP TO 24 OUNCES CEREAL

FORMULA

4-14.3 OZ CANS POWDER ENFAMIL LACTOFREE OR 5 - 12.9 OZ CANS IRON FORTIFIED ENFAMIL LACTOFREE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA:

4-14.3 OZ CANS POWDER ENFAMIL LACTOFREE OR 4 - 12.9 OZ CANS IRON FORTIFIED ENFAMIL LACTOFREE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FP-75

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-11 (cont'd)

FOOD PACKAGE NUMBER 343
8 - 14.3 OZ CANS POWDER IRON FORTIFIED ENFAMIL LACTOFREE OR 9 - 12.9 OZ CANS IRON FORTIFIED ENFAMIL LACTOFREE LIPIL 3 CANS JUICE 24 OZ CEREAL
374 28 - 1 QT (ML 986) CANS READY TO FEED IRON FORTIFIED ENFAMIL LACTOFREE OR ENFAMIL LACTOFREE LIPIL 3 CANS JUICE 36 OZ CEREAL
(CHILD MAX)

VOUCHER CODE 375
373
066 261
261
070

VOUCHER MESSAGE

FORMULA:

4-14.3 OZ CANS POWDER ENFAMIL LACTOFREE OR 5 - 12.9 OZ CANS IRON FORTIFIED ENFAMIL LACTOFREE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA:

4-14.3 OZ CANS POWDER ENFAMIL LACTOFREE OR 4 - 12.9 OZ CANS IRON FORTIFIED ENFAMIL LACTOFREE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE: CEREAL:

3-12 OZ CANS FROZEN OR 3-46 OZ CANS OR 3-46 OZ PLASTIC BOTTLES OR 3-11.5 OZ CANS POURABLE
UP TO 24 OUNCES CEREAL

FORMULA:

14-1 QT (ML 986) CANS READY TO FEED ENFAMIL LACTOFREE OR ENFAMIL LACTOFREE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA:

14-1 QT (ML 986) CANS READY TO FEED ENFAMIL LACTOFREE OR ENFAMIL LACTOFREE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE: CEREAL:

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

FP-76

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-11 (cont'd)

FOOD PACKAGE NUMBER 334
25 - 1 QT (ML 986) CANS READY TO FEED IRON FORTIFIED ENFAMIL LACTOFREE OR ENFAMIL LACTOFREE LIPIL 2 CANS JUICE 24 OZ CEREAL
399 35 - 13 OZ CANS CONCENTRATE IRON FORTIFIED ENFAMIL LIPIL OR PROSOBEE LIPIL
3 CANS JUICE 36 OZ CEREAL
(CHILD MAX)
309 35 - 13 OZ CANS CONCENTRATE IRON FORTIFIED ENFAMIL LIPIL OR PROSOBEE LIPIL

VOUCHER CODE 262
263
573 865
885 070

VOUCHER MESSAGE

FORMULA:

12-1 QT (ML 986) CANS READY TO FEED ENFAMIL LACTOFREE OR ENFAMIL LACTOFREE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA:

13-1 QT (ML 986) CANS READY TO FEED ENFAMIL LACTOFREE OR ENFAMIL LACTOFREE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE: CEREAL:

2-12 OZ CANS FROZEN OR 2-46 OZ CANS OR 2-46 OZ PLASTIC BOTTLES OR 2-11.5 OZ CANS POURABLE
UP TO 24 OUNCES CEREAL

FORMULA 16-13 OZ CANS CONCENTRATE ENFAMIL LIPIL OR PROSOBEE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA 19-13 OZ CANS CONCENTRATE ENFAMIL LIPIL OR PROSOBEE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE: CEREAL:

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

865

FORMULA 16-13 OZ CANS CONCENTRATE

ENFAMIL LIPIL OR PROSOBEE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

885

FORMULA 19-13 OZ CANS CONCENTRATE

ENFAMIL LIPIL OR PROSOBEE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FP-77

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-11 (cont'd)

FOOD PACKAGE NUMBER 361
11 - 12.9 OZ CANS POWDER IRON FORTIFIED ENFAMIL LIPIL OR PROSOBEE LIPIL
3 CANS JUICE 36 OZ CEREAL
(CHILD MAX)
351 11 - 12.9 OZ CANS POWDER IRON FORTIFIED ENFAMIL LIPIL OR PROSOBEE LIPIL
360 28 - 32 OZ CANS READY TO FEED IRON FORTIFIED ENFAMIL LIPIL OR PROSOBEE LIPIL
3 CANS JUICE 36 OZ CEREAL
(CHILD MAX)

VOUCHER CODE 855
875
070 855
875
860 860 070

VOUCHER MESSAGE

FORMULA: 5 - 12.9 OZ CANS POWDER ENFAMIL LIPIL OR PROSOBEE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED
FORMULA: 6 - 12.9 OZ CANS POWDER ENFAMIL LIPIL OR PROSOBEE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE: CEREAL:

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

FORMULA: 5 - 12.9 OZ CANS POWDER ENFAMIL LIPIL OR PROSOBEE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED
FORMULA: 6 - 12.9 OZ CANS POWDER ENFAMIL LIPIL OR PROSOBEE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA: 14 - 32 OZ CANS READY TO FEED ENFAMIL LIPIL OR PROSOBEE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA: 14 - 32 OZ CANS READY TO FEED ENFAMIL LIPIL OR PROSOBEE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE: CEREAL:

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

350 28 - 32 OZ CANS READY TO FEED IRON FORTIFIED ENFAMIL LIPIL OR PROSOBEE LIPIL

860

FORMULA: 14 - 32 OZ CANS READY TO FEED

ENFAMIL LIPIL OR PROSOBEE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

860

FORMULA: 14 - 32 OZ CANS READY TO FEED

ENFAMIL LIPIL OR PROSOBEE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FP-78

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-11 (cont'd)

FOOD PACKAGE NUMBER
XXXXXXXXXXXXXXXXX Package Discontinued
XXXXXXXXXXXXXXXXX 306
35 - 13 OZ CANS CONCENTRATE IRON FORTIFIED ENFAMIL PROSOBEE LIPIL
3 CANS JUICE 36 OZ CEREAL
(CHILD MAX)

VOUCHER CODE 805
806
070

VOUCHER MESSAGE

FORMULA 16-13 OZ CANS CONCENTRATE ENFAMIL PROSOBEE LIPIL
IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA 19-13 OZ CANS CONCENTRATE ENFAMIL PROSOBEE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE: CEREAL:

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

XXXXXXXXXXXXXXXXX Package Discontinued
XXXXXXXXXXXXXXXXX 302
35 - 13 OZ CANS CONCENTRATE IRON FORTIFIED ENFAMIL PROSOBEE LIPIL
XXXXXXXXXXXXXXXXX Package Discontinued
XXXXXXXXXXXXXXXXX 386
11 - 12.9 OZ CANS POWDER IRON FORTIFIED ENFAMIL PROSOBEE LIPIL
3 CANS JUICE 36 OZ CEREAL
(CHILD MAX)
XXXXXXXXXXXXXXXXX Package Discontinued
XXXXXXXXXXXXXXXXX 380
11 - 12.9 OZ CANS POWDER IRON FORTIFIED ENFAMIL PROSOBEE LIPIL

805

FORMULA 16-13 OZ CANS CONCENTRATE

ENFAMIL PROSOBEE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

806

FORMULA 19-13 OZ CANS CONCENTRATE

ENFAMIL PROSOBEE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

825

FORMULA: 5 - 12.9 OZ CANS POWDER ENFAMIL

PROSOBEE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

826

FORMULA: 6 - 12.9 OZ CANS POWDER ENFAMIL

PROSOBEE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

070

JUICE:

3-12 OZ CANS FROZEN OR 3-46 OZ

CANS OR 3-46 OZ PLASTIC BOTTLES

OR 3-11.5 OZ CANS POURABLE

CEREAL:

UP TO 36 OUNCES CEREAL

825

FORMULA: 5 - 12.9 OZ CANS POWDER ENFAMIL

PROSOBEE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

826

FORMULA: 6 - 12.9 OZ CANS POWDER ENFAMIL

PROSOBEE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FP-79

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-11 (cont'd)

FOOD PACKAGE NUMBER
XXXXXXXXXXXXXXXXX Package Discontinued
XXXXXXXXXXXXXXXXX 394
28 - 32 OZ CANS READY TO FEED IRON FORTIFIED ENFAMIL PROSOBEE LIPIL
3 CANS JUICE 36 OZ CEREAL
(CHILD MAX)

VOUCHER CODE 834
834
070

VOUCHER MESSAGE

FORMULA: 14 - 32 OZ CANS READY TO FEED ENFAMIL PROSOBEE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA: 14 - 32 OZ CANS READY TO FEED ENFAMIL PROSOBEE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE: CEREAL:

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

XXXXXXXXXXXXXXXXX Package Discontinued
XXXXXXXXXXXXXXXXX 391
28 - 32 OZ CANS READY TO FEED IRON FORTIFIED ENFAMIL PROSOBEE LIPIL
335 12 - 12 OZ OR 6 - 24 OZ CANS POWDER IRON FORTIFIED ENFAMIL NEXT STEP OR ENFAMIL NEXT STEP LIPIL
3 CANS JUICE 36 OZ CEREAL
(CHILD MAX)

834

FORMULA: 14 - 32 OZ CANS READY TO FEED

ENFAMIL PROSOBEE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

834

FORMULA: 14 - 32 OZ CANS READY TO FEED

ENFAMIL PROSOBEE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

148

FORMULA: 12-12 OZ OR 6-24 OZ CANS POWDER

IRON FORTIFIED ENFAMIL NEXT

STEP OR ENFAMIL NEXT STEP LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

070

JUICE:

3-12 OZ CANS FROZEN OR 3-46 OZ

CANS OR 3-46 OZ PLASTIC BOTTLES

OR 3-11.5 OZ CANS POURABLE

CEREAL:

UP TO 36 OUNCES CEREAL

FP-80

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-11 (cont'd)

FOOD PACKAGE NUMBER
345 10 - 12 OZ OR 5 - 24 OZ CANS POWDER IRON FORTIFIED ENFAMIL NEXT STEP OR ENFAMIL NEXT STEP LIPIL
3 CANS JUICE 24 OZ CEREAL
365 12 - 12 OZ OR 6 - 24 OZ CANS POWDER IRON FORTIFIED ENFAMIL NEXT STEP OR ENFAMIL NEXT STEP LIPIL
375 12 - 12 OZ OR 6 - 24 OZ CANS POWDER IRON FORTIFIED ENFAMIL NEXT STEP SOY OR ENFAMIL NEXT STEP PROSOBEE LIPIL
3 CANS JUICE 36 OZ CEREAL
(CHILD MAX)
305 10 - 12 OZ OR 5 - 24 OZ CANS POWDER IRON FORTIFIED ENFAMIL NEXT STEP SOY OR ENFAMIL NEXT STEP PROSOBEE LIPIL
3 CANS JUICE 24 OZ CEREAL

VOUCHER CODE 128
066 148
158
070 828
066

VOUCHER MESSAGE

FORMULA:

10-12 OZ OR 5-24 OZ CANS POWDER IRON FORTIFIED ENFAMIL NEXT STEP OR ENFAMIL NEXT STEP LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE: CEREAL:

3-12 OZ CANS FROZEN OR 3-46 OZ CANS OR 3-46 OZ PLASTIC BOTTLES OR 3-11.5 OZ CANS POURABLE
UP TO 24 OUNCES CEREAL

FORMULA:

12-12 OZ OR 6-24 OZ CANS POWDER IRON FORTIFIED ENFAMIL NEXT STEP OR ENFAMIL NEXT STEP LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA:

12-12 OZ OR 6-24 OZ CANS POWDER IRON FORTIFIED ENFAMIL NEXT STEP SOY OR ENFAMIL NEXT STEP PROSOBEE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE: CEREAL:

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

FORMULA:

10-12 OZ OR 5-24 OZ CANS POWDER IRON FORTIFIED ENFAMIL NEXT STEP SOY OR ENFAMIL NEXT STEP PROSOBEE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE: CEREAL:

3-12 OZ CANS FROZEN OR 3-46 OZ CANS OR 3-46 OZ PLASTIC BOTTLES OR 3-11.5 OZ CANS POURABLE
UP TO 24 OUNCES CEREAL

FP-81

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-11 (cont'd)

FOOD PACKAGE NUMBER
355 12 - 12 OZ OR 6 - 24 OZ CANS POWDER IRON FORTIFIED ENFAMIL NEXT STEP SOY OR ENFAMIL NEXT STEP PROSOBEE LIPIL
368 11 - 12.9 OZ CANS POWDER IRON FORTIFIED ENFAMIL AR LIPIL
3 CANS JUICE 36 OZ CEREAL
(CHILD MAX)

VOUCHER CODE 158
168
167
070

VOUCHER MESSAGE

FORMULA:

12-12 OZ OR 6-24 OZ CANS POWDER IRON FORTIFIED ENFAMIL NEXT STEP SOY OR ENFAMIL NEXT STEP PROSOBEE LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA: 5 - 12.9 OZ CANS POWDER ENFAMIL AR LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED
FORMULA: 6 - 12.9 OZ CANS POWDER ENFAMIL AR LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE: CEREAL:

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

FP-82

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-11 (cont'd)

FOOD PACKAGE NUMBER 308
11 - 12.9 OZ CANS POWDER IRON FORTIFIED ENFAMIL AR LIPIL
389 28 - 32 OZ CANS READY TO FEED IRON FORTIFIED ENFAMIL AR OR ENFAMIL AR LIPIL
3 CANS JUICE 36 OZ CEREAL
(CHILD MAX)
349 28 - 32 OZ CANS READY TO FEED IRON FORTIFIED ENFAMIL AR OR ENFAMIL AR LIPIL

VOUCHER CODE 168
167
309 309 070
309 309

VOUCHER MESSAGE

FORMULA: 5 - 12.9 OZ CANS POWDER ENFAMIL AR

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED
FORMULA: 6 - 12.9 OZ CANS POWDER ENFAMIL AR

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA: 14 - 32 OZ CANS READY TO FEED ENFAMIL AR OR ENFAMIL AR LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA: 14 - 32 OZ CANS READY TO FEED ENFAMIL AR OR ENFAMIL AR LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE: CEREAL:

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

FORMULA: 14 - 32 OZ CANS READY TO FEED ENFAMIL AR OR ENFAMIL AR LIPIL
IRON FORTIFIED NO LOW IRON FORMULA ALLOWED
FORMULA: 14 - 32 OZ CANS READY TO FEED ENFAMIL AR OR ENFAMIL AR LIPIL
IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FP-83

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-12

CHILDREN'S AND WOMEN'S PACKAGES
NON-CONTRACT SPECIAL FORMULAS (ISOMIL, ISOMIL ADVANCE, CARNATION ALSOY, NESTL GOOD START SUPREME SOY DHA & ARA, ISOMIL 2, NUTRAMIGEN LIPIL, ALIMENTUM, ALIMENTUM
ADVANCE, PREGESTIMIL, PORTAGEN, PEDIASURE, PEDIASURE w/FIBER)
Prescription Required

FOOD PACKAGE NUMBER
393 35 - 13 OZ CANS CONCENTRATE IRON FORTIFIED NONCONTRACT SOY FORMULA: ISOMIL OR ISOMIL ADVANCE OR CARNATION ALSOY OR NESTLE GOOD START ESSENTIALS SOY OR NESTLE GOOD START SUPREME SOY DHA & ARA
3 CANS JUICE 36 OZ CEREAL
(CHILD MAX)
396 10 - 14 OZ CANS POWDER IRON FORTIFIED NONCONTRACT SOY FORMULA: CARNATION ALSOY OR NESTLE GOOD START ESSENTIALS SOY OR 10 - 12.9 OZ CANS POWDER NESTLE GOOD START SUPREME SOY DHA & ARA
3 CANS JUICE 36 OZ CEREAL
(CHILD MAX)

VOUCHER CODE 258
268
070 458
658
070

VOUCHER MESSAGE

FORMULA:

16-13 OZ CANS CONCENTRATE ISOMIL OR ISOMIL ADVANCE OR CARNATION ALSOY OR NESTLE GOOD START ESSENTIALS SOY OR NESTLE GOOD START SUPREME SOY DHA & ARA

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA:

19-13 OZ CANS CONCENTRATE ISOMIL OR ISOMIL ADVANCE OR CARNATION ALSOY OR NESTLE GOOD START ESSENTIALS SOY OR NESTLE GOOD START SUPREME SOY DHA & ARA

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE: CEREAL:

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

FORMULA:

5-14 OZ CANS POWDER CARNATION ALSOY OR NESTLE GOOD START ESSENTIALS SOY OR 5-12.9 OZ CANS POWDER NESTLE GOOD START SUPREME SOY DHA & ARA

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA:

5-14 OZ CANS POWDER CARNATION ALSOY OR NESTLE GOOD START ESSENTIALS SOY OR 6-12.9 OZ CANS POWDER NESTLE GOOD START SUPREME SOY DHA & ARA

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE: CEREAL:

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

FP-84

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-12 (cont'd)

FOOD PACKAGE NUMBER
320 10 - 14 OZ CANS POWDER IRON FORTIFIED NONCONTRACT SOY FORMULA: ISOMIL OR 11 - 12.9 OZ CANS POWDER NON-CONTRACT SOY FORMULA: ISOMIL OR ISOMIL ADVANCE
3 CANS JUICE 36 OZ CEREAL
(CHILD MAX)
300 IRON FORTIFIED NONCONTRACT SOY FORMULA: 10 - 14 OZ OR 4 - 30 OZ ISOMIL 2 OR 11 12.9 OZ CANS POWDER ISOMIL 2 ADVANCE
310 IRON FORTIFIED NONCONTRACT SOY FORMULA: 10 - 14 OZ OR 4 - 30 OZ ISOMIL 2 OR 11 12.9 OZ CANS POWDER ISOMIL 2 ADVANCE
3 CANS JUICE 36 OZ CEREAL
(CHILD MAX)

VOUCHER CODE 889
890
070 888 898 888
898 070

VOUCHER MESSAGE

FORMULA:

5-14 OZ CANS POWDER ISOMIL OR
5-12.9 OZ CANS POWDER ISOMIL OR ISOMILADVANCE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA:

5-14 OZ CANS POWDER ISOMIL OR
6-12.9 OZ CANS POWDER ISOMIL OR ISOMILADVANCE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE: CEREAL:

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

FORMULA:

5-14 OZ OR 2-30 OZ CANS POWDER IRON FORTIFIED ISOMIL 2 OR 5-12.9 OZ CANS POWDER ISOMIL 2 ADVANCE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA:

5-14 OZ OR 2-30 OZ CANS POWDER IRON FORTIFIED ISOMIL 2 OR 6-12.9 OZ CANS POWDER ISOMIL 2 ADVANCE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA:

5-14 OZ OR 2-30 OZ CANS POWDER IRON FORTIFIED ISOMIL 2 OR 5-12.9 OZ CANS POWDER ISOMIL 2 ADVANCE
IRON FORTIFIED

NO LOW IRON FORMULA ALLOWED

FORMULA:

5-14 OZ OR 2-30 OZ CANS POWDER IRON FORTIFIED ISOMIL 2 OR 6-12.9 OZ CANS POWDER ISOMIL 2 ADVANCE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE: CEREAL:

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

FP-85

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-12 (cont'd)

FOOD PACKAGE NUMBER 318
9 - 1 LB CANS POWDER OR 35 - 13 OZ CANS CONCENTRATE NUTRAMIGEN OR NUTRAMIGEN LIPIL 3 CANS JUICE 36 OZ CEREAL
(CHILD MAX)
382 8 - 1 LB CANS POWDER OR 31 - 13 OZ CANS CONCENTRATE NUTRAMIGEN OR NUTRAMIGEN LIPIL

VOUCHER CODE 170
171
070 182
183

VOUCHER MESSAGE

FORMULA:

4-1 LB CANS POWDER OR 16-13 OZ CANS CONCENTRATE NUTRAMIGEN OR NUTRAMIGEN LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA:

5-1 LB CANS POWDER OR 19-13 OZ CANS CONCENTRATE NUTRAMIGEN OR NUTRAMIGEN LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE: CEREAL:

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

FORMULA:

4-1 LB CANS POWDER OR 15-13 OZ CANS CONCENTRATE NUTRAMIGEN OR NUTRAMIGEN LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA:

4-1 LB CANS POWDER OR 16-13 OZ CANS CONCENTRATE NUTRAMIGEN OR NUTRAMIGEN LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FP-86

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-12 (cont'd)

FOOD PACKAGE NUMBER 383
8 - 1 LB CANS POWDER OR 31 - 13 OZ CANS CONCENTRATE NUTRAMIGEN OR NUTRAMIGEN LIPIL 3 CANS JUICE 24 OZ CEREAL
340 9 - 1 LB CANS POWDER ALIMENTUM OR ALIMENTUM ADVANCE 3 CANS JUICE 36 OZ CEREAL (CHILD MAX)
330 9 - 1 LB CANS POWDER ALIMENTUM OR ALIMENTUM ADVANCE

VOUCHER CODE 182
183
066 360 361 070 360 361

VOUCHER MESSAGE

FORMULA:

4-1 LB CANS POWDER OR 15-13 OZ CANS CONCENTRATE NUTRAMIGEN OR NUTRAMIGEN LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA:

4-1 LB CANS POWDER OR 16-13 OZ CANS CONCENTRATE NUTRAMIGEN OR NUTRAMIGEN LIPIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE: CEREAL:

3-12 OZ CANS FROZEN OR 3-46 OZ CANS OR 3-46 OZ PLASTIC BOTTLES OR 3-11.5 OZ CANS POURABLE
UP TO 24 OUNCES CEREAL

FORMULA: 4-1 LB CANS POWDER ALIMENTUM OR ALIMENTUM ADVANCE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA: 5-1 LB CANS POWDER ALIMENTUM OR ALIMENTUM ADVANCE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE: CEREAL:

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

FORMULA: 4-1 LB CANS POWDER ALIMENTUM OR ALIMENTUM ADVANCE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA: 5-1 LB CANS POWDER ALIMENTUM OR ALIMENTUM ADVANCE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FP-87

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-12 (cont'd)

FOOD PACKAGE NUMBER 328
28 - 1 QT CANS READY TO FEED ALIMENTUM OR 28 32 OZ PLASTIC BOTTLES READY TO FEED ALIMENTUM ADVANCE 3 CANS JUICE 36 OZ CEREAL
(CHILD MAX)
348 28 - 1 QT CANS READY TO FEED ALIMENTUM OR 28 32 OZ PLASTIC BOTTLES READY TO FEED ALIMENTUM ADVANCE
338 25 - 1 QT CANS READY TO FEED ALIMENTUM OR 25 32 OZ PLASTIC BOTTLES READY TO FEED ALIMENTUM ADVANCE

VOUCHER CODE 150
150
070 150
150
130
131

VOUCHER MESSAGE

FORMULA:

14-1 QT CANS READY TO FEED ALIMENTUM OR 14-32 OZ PLASTIC BOTTLES READY TO FEED ALIMENTUM ADVANCE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA:

14-1 QT CANS READY TO FEED ALIMENTUM OR 14-32 OZ PLASTIC BOTTLES READY TO FEED ALIMENTUM ADVANCE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE: CEREAL:

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

FORMULA:

14-1 QT CANS READY TO FEED ALIMENTUM OR 14-32 OZ PLASTIC BOTTLES READY TO FEED ALIMENTUM ADVANCE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA:

14-1 QT CANS READY TO FEED ALIMENTUM OR 14-32 OZ PLASTIC BOTTLES READY TO FEED ALIMENTUM ADVANCE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA:

13 - 1 QT CANS READY TO FEED ALIMENTUM OR 13-32 OZ PLASTIC BOTTLES READY TO FEED ALIMENTUM ADVANCE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA:

12 - 1 QT CANS READY TO FEED ALIMENTUM OR 12-32 OZ PLASTIC BOTTLES READY TO FEED ALIMENTUM ADVANCE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FP-88

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-12 (cont'd)

FOOD PACKAGE NUMBER 378
25 - 1 QT CANS READY TO FEED ALIMENTUM OR 25 32 OZ PLASTIC BOTTLES READY TO FEED ALIMENTUM ADVANCE 3 CANS JUICE 24 OZ CEREAL
341 9-1 LB CANS POWDER PREGESTIMIL 3 CANS JUICE 36 OZ CEREAL (CHILD MAX)
301 8 - 1 LB CANS POWDER PREGESTIMIL

VOUCHER CODE 130
131
066 140 181 070 140

VOUCHER MESSAGE

FORMULA:

13 - 1 QT CANS READY TO FEED ALIMENTUM OR 13-32 OZ PLASTIC BOTTLES READY TO FEED ALIMENTUM ADVANCE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA:

12 - 1 QT CANS READY TO FEED ALIMENTUM OR 12-32 OZ PLASTIC BOTTLES READY TO FEED ALIMENTUM ADVANCE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE: CEREAL:

3-12 OZ CANS FROZEN OR 3-46 OZ CANS OR 3-46 OZ PLASTIC BOTTLES OR 3-11.5 OZ CANS POURABLE
UP TO 24 OUNCES CEREAL

FORMULA: 4-1 LB CANS POWDER PREGESTIMIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED
FORMULA: 5-1 LB CANS POWDER PREGESTIMIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE: CEREAL:

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

FORMULA: 4-1 LB CANS POWDER PREGESTIMIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

140

FORMULA: 4-1 LB CANS POWDER PREGESTIMIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FP-89

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-12 (cont'd)

FOOD PACKAGE NUMBER 325
8 - 1 LB CANS POWDER PREGESTIMIL 3 CANS JUICE 24 OZ CEREAL
381 9 - 1 LB CANS POWDER PORTAGEN 3 CANS JUICE 36 OZ CEREAL (CHILD MAX)
315 8 - 1 LB CANS POWDER PORTAGEN 3 CANS JUICE 24 OZ CEREAL
730 30 - 8 OZ CANS READY TO FEED PEDIASURE 3 CANS JUICE 36 OZ CEREAL

VOUCHER CODE 140 140 066
060 260 070
060 060 066
730
070

VOUCHER MESSAGE

FORMULA: 4-1 LB CANS POWDER PREGESTIMIL
IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA: 4-1 LB CANS POWDER PREGESTIMIL

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE: CEREAL:

3-12 OZ CANS FROZEN OR 3-46 OZ CANS OR 3-46 OZ PLASTIC BOTTLES OR 3-11.5 OZ CANS POURABLE
UP TO 24 OUNCES CEREAL

FORMULA: 4 - 1 LB CANS POWDER PORTAGEN

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA: 5 - 1 LB CANS POWDER PORTAGEN

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE: CEREAL:

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

FORMULA: 4 - 1 LB CANS POWDER PORTAGEN

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED
FORMULA: 4 - 1 LB CANS POWDER PORTAGEN

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE: CEREAL:

3-12 OZ CANS FROZEN OR 3-46 OZ CANS OR 3-46 OZ PLASTIC BOTTLES OR 3-11.5 OZ CANS POURABLE
UP TO 24 OUNCES CEREAL

FORMULA: 30-8 OZ CANS READY TO FEED PEDIASURE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE: CEREAL:

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

FP-90

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-12 (cont'd)

FOOD PACKAGE NUMBER 760
60 - 8 OZ CANS READY TO FEED PEDIASURE 3 CANS JUICE 36 OZ CEREAL
790 90 - 8 OZ CANS READY TO FEED PEDIASURE 3 CANS JUICE 36 OZ CEREAL

VOUCHER CODE 730
730
070 730
730
730
070

VOUCHER MESSAGE

FORMULA: 30-8 OZ CANS READY TO FEED PEDIASURE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA: 30-8 OZ CANS READY TO FEED PEDIASURE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE: CEREAL:

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

FORMULA: 30-8 OZ CANS READY TO FEED PEDIASURE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA: 30-8 OZ CANS READY TO FEED PEDIASURE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA: 30-8 OZ CANS READY TO FEED PEDIASURE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE: CEREAL:

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

FP-91

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-12 (cont'd)

FOOD PACKAGE NUMBER 798
108 - 8 OZ CANS READY TO FEED PEDIASURE 3 CANS JUICE 36 OZ CEREAL (CHILD MAX)
731 30 - 8 OZ CANS READY TO FEED PEDIASURE WITH FIBER 3 CANS JUICE 36 OZ CEREAL

VOUCHER CODE 718
730
730
730
070 731
070

VOUCHER MESSAGE

FORMULA: 18-8 OZ CANS READY TO FEED PEDIASURE
IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA: 30-8 OZ CANS READY TO FEED PEDIASURE
IRON FORTIFIED NO LOW IRON FORMULA ALLOWED
FORMULA: 30-8 OZ CANS READY TO FEED PEDIASURE
IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA: 30-8 OZ CANS READY TO FEED PEDIASURE

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE: CEREAL:

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

FORMULA: 30-8 OZ CANS READY TO FEED PEDIASURE WITH FIBER

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE: CEREAL:

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

FP-92

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-12 (cont'd)

FOOD PACKAGE NUMBER 761
60 - 8 OZ CANS READY TO FEED PEDIASURE WITH FIBER 3 CANS JUICE 36 OZ CEREAL
791 90 - 8 OZ CANS READY TO FEED PEDIASURE WITH FIBER 3 CANS JUICE 36 OZ CEREAL

VOUCHER CODE 731
731
070 731
731
731
070

VOUCHER MESSAGE

FORMULA: 30-8 OZ CANS READY TO FEED PEDIASURE WITH FIBER

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA: 30-8 OZ CANS READY TO FEED PEDIASURE WITH FIBER

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE: CEREAL:

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

FORMULA: 30-8 OZ CANS READY TO FEED PEDIASURE WITH FIBER

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA: 30-8 OZ CANS READY TO FEED PEDIASURE WITH FIBER

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA: 30-8 OZ CANS READY TO FEED PEDIASURE WITH FIBER

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE: CEREAL:

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

FP-93

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-12 (cont'd)

FOOD PACKAGE NUMBER 799
108 - 8 OZ CANS READY TO FEED PEDIASURE WITH FIBER 3 CANS JUICE 36 OZ CEREAL
(CHILD MAX)
999 FORMULA AS ORDERED BY A PHYSICIAN FORMULA MAY NOT EXCEED 144 OZ POWDER OR 403-455 OZ CONCENTRATE OR 800-910 OZ READY TO FEED JUICE: 3-12 OZ CANS FROZEN OR 3-46 OZ CANS OR 3-46 OZ PLASTIC BOTTLES OR 3-11.5 OZ CANS POURABLE CEREAL: 36 OZ CEREAL FORMULA ONLY MAY BE PRESCRIBED

VOUCHER CODE 719
731
731
731
070 999

VOUCHER MESSAGE

FORMULA: 18-8 OZ CANS READY TO FEED PEDIASURE WITH FIBER
IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA: 30-8 OZ CANS READY TO FEED PEDIASURE WITH FIBER
IRON FORTIFIED NO LOW IRON FORMULA ALLOWED
FORMULA: 30-8 OZ CANS READY TO FEED PEDIASURE WITH FIBER
IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

FORMULA: 30-8 OZ CANS READY TO FEED PEDIASURE WITH FIBER

IRON FORTIFIED NO LOW IRON FORMULA ALLOWED

JUICE: CEREAL:

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

AS PRESCRIBED

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

FP-94

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-13

ALTERNATE FOOD PACKAGES FOR CHILDREN AND WOMEN WITH SPECIAL DIETARY NEEDS
MAXIMUM MONTHLY AMOUNTS AUTHORIZED

FOOD

SIZE

MAXIMUM MONTHLY AM0UNTS

ADDITIONAL AMOUNTS

Ready-To-Feed Formula

100-8 oz cans

800 ounces

13-8 oz cans (104 ounces)

Cereal

4-9 oz boxes

36 ounces

---

Juice

23-5.5 to 6 oz

138 ounces

---

cans

This food package consists of eight (8) vouchers

FP-95

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-14

ALTERNATE FOOD PACKAGES FOR CHILDREN AND WOMEN WITH SPECIAL DIETARY NEEDS

FOOD PACKAGE NUMBER

VOUCHER CODE

VOUCHER MESSAGE

370
100 - 8 OZ CANS READY TO FEED IRON FORTIFIED ENFAMIL LIPIL OR PROSOBEE LIPIL
4 - 9 OZ BOXES CEREAL 18- 5.5 to 6 OZ CANS JUICE

240

FORMULA: 12-8 OZ CANS READY TO FEED

ENFAMIL LIPIL OR PROSOBEE LIPIL

IRON FORTIFIED

240

FORMULA: 12-8 OZ CANS READY TO FEED

ENFAMIL LIPIL OR PROSOBEE LIPIL

IRON FORTIFIED

342

FORMULA: 14-8 OZ CANS READY TO FEED

ENFAMIL LIPIL OR PROSOBEE LIPIL

IRON FORTIFIED

CEREAL:

1-9 OZ BOX

JUICE:

6-5.5 to 6 OZ CANS

343

FORMULA: 14-8 OZ CANS READY TO FEED

ENFAMIL LIPIL OR PROSOBEE LIPIL

IRON FORTIFIED

CEREAL:

1-9 OZ BOX

344

FORMULA: 12-8 OZ CANS READY TO FEED

ENFAMIL LIPIL OR PROSOBEE LIPIL

IRON FORTIFIED

CEREAL:

1-9 OZ BOX

344

FORMULA: 12-8 OZ CANS READY TO FEED

ENFAMIL LIPIL OR PROSOBEE LIPIL

IRON FORTIFIED

CEREAL

1-9 OZ BOX

345

FORMULA: 12-8 OZ CANS READY TO FEED

ENFAMIL LIPIL OR PROSOBEE LIPIL

JUICE:

IRON FORTIFIED 6-5.5 to 6 OZ CANS

345

FORMULA: 12-8 OZ CANS READY TO FEED

ENFAMIL LIPIL OR PROSOBEE LIPIL

JUICE:

IRON FORTIFIED 6-5.5 to 6 OZ CANS

FP-96

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-15

CHILDREN'S FOOD PACKAGES MAXIMUM MONTHLY AMOUNTS AUTHORIZED

FOOD

MAXIMUM AMOUNT PER MONTH

Milk1

24 quart equivalents2

Cheese

4 pounds3

Eggs

2 dozen

Juice Cereal

6-46 ounce cans OR 6-46 ounce plastic bottles OR 6-12 ounce frozen OR 6-11.5 ounce pourable
36 ounces

Dried Beans/Peas OR Peanut Butter

1 pound bags OR 18 ounce jar

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

ITEM

FLUID MILK EQUIVALENTS

Cheese, 1 pound Evaporated milk, whole or skim , 13 ounces Dry whole milk, 1 pound Nonfat or low fat dry milk, 1 pound

3 quarts 1 quart 3 quarts 5 quarts

3 Subtract from monthly milk allotment. A maximum of two (2) pounds of cheese per month is recommended except for those with lactose intolerance.

FP-97

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-16

FOOD PACKAGE NUMBER
MINIMUM 600
2 GALS MILK 1 LB CHEESE 1 DOZ EGGS 18 OZ CEREAL 4 CANS JUICE

CHILDREN'S FOOD PACKAGES

VOUCHER CODE
042

CHEESE: JUICE:

040

MILK:

JUICE

039

MILK:

EGGS: JUICE:

049

JUICE:

CEREAL:

VOUCHER MESSAGE
UP TO 1 LB 1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-46 OZ PLASTIC BOTTLE OR 1-11.5 OZ CAN POURABLE
1 GAL OR 4-12 OZ CANS EVAP OR 1-5 QT BOX 1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-46 OZ PLASTIC BOTTLE OR 1-11.5 OZ CAN POURABLE
1 GAL OR 4-12 OZ CANS EVAP OR 1-5 QT BOX 1 DOZEN 1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-46 OZ PLASTIC BOTTLE OR 1-11.5 OZ CAN POURABLE
1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-46 OZ PLASTIC BOTTLE OR 1-11.5 OZ CAN POURABLE UP TO 18 OUNCES

FP-98

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-16 (cont'd)

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

VOUCHER CODE 040
039
040
037

MILK: JUICE:
MILK: EGGS: JUICE:
MILK: JUICE:
MILK: JUICE:
CEREAL: BEANS/PEAS/ PEANUT BUTTER:

VOUCHER MESSAGE
1 GAL OR 4-12 OZ CANS EVAP OR 1-5 QT BOX 1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-46 OZ PLASTIC BOTTLE OR 1-11.5 OZ CAN POURABLE
1 GAL OR 4-12 OZ CANS EVAP OR 1-5 QT BOX 1 DOZEN 1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-46 OZ PLASTIC BOTTLE OR 1-11.5 OZ CAN POURABLE
1 GAL OR 4-12 OZ CANS EVAP OR 1-5 QT BOX 1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-46 OZ PLASTIC BOTTLE OR 1-11.5 OZ CAN POURABLE
1 GAL OR 4-12 OZ CANS EVAP OR 1-5 QT BOX 1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-46 OZ PLASTIC BOTTLE OR 1-11.5 OZ CAN POURABLE UP TO 24 OUNCES 1 LB DRIED BEANS/PEAS OR 18 OZ PEANUT BUTTER

FP-99

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-16 (cont'd)

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

VOUCHER CODE
042

CHEESE: JUICE:

043

CHEESE:

JUICE:

BEANS/PEAS OR PEANUT BUTTER:

048

MILK:

EGGS: JUICE:

CEREAL:

039

MILK:

EGGS: JUICE:

VOUCHER MESSAGE
UP TO 1 LB 1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-46 OZ PLASTIC BOTTLE OR 1-11.5 OZ CAN POURABLE
UP TO 1 LB 1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-46 OZ PLASTIC BOTTLE OR 1-11.5 OZ CAN POURABLE
1 LB DRIED BEANS/PEAS OR 18 OZ PEANUT BUTTER
1 GAL OR 4-12 OZ CANS EVAP OR 1-5 QT BOX 1 DOZEN 1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-46 OZ PLASTIC BOTTLE OR 1-11.5 OZ CAN POURABLE UP TO 24 OUNCES
1 GAL OR 4-12 OZ CANS EVAP OR 1-5 QT BOX 1 DOZEN 1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-46 OZ PLASTIC BOTTLE OR 1-11.5 OZ CAN POURABLE

FP-100

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-16 (cont'd)

FOOD PACKAGE NUMBER
MODERATE 603*
4 GALS MILK 1 LB CHEESE 2 DOZEN EGGS 4 CANS JUICE 24 OZ CEREAL 1 LB BEANS/PEAS
* STANDARD MANUAL

VOUCHER CODE
047

MILK:

JUICE:

CEREAL:

039

MILK:

EGGS: JUICE:

025

MILK:

CHEESE: JUICE:

BEANS/PEAS

039

MILK:

EGGS: JUICE:

VOUCHER MESSAGE
1 GAL OR 4-12 OZ CANS EVAP OR 1-5 QT BOX 1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-46 OZ PLASTIC BOTTLE OR 1-11.5 OZ CAN POURABLE UP TO 24 OUNCES
1 GAL OR 4-12 OZ CANS EVAP OR 1-5 QT BOX 1 DOZEN 1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-46 OZ PLASTIC BOTTLE OR 1-11.5 OZ CAN POURABLE
1 GAL OR 4-12 OZ CANS EVAP OR 1-5 QT BOX UP TO 1 LB 1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-46 OZ PLASTIC BOTTLE OR 1-11.5 OZ CAN POURABLE 1 LB DRIED BEANS/PEAS
1 GAL OR 4-12 OZ CANS EVAP OR 1-5 QT BOX 1 DOZEN 1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-46 OZ PLASTIC BOTTLE OR 1-11.5 OZ CAN POURABLE

FP-101

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-16 (cont'd)

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

VOUCHER CODE 031
037
039
055

VOUCHER MESSAGE

MILK: CHEESE: JUICE:
MILK: JUICE:
CEREAL: BEANS/PEAS/ PEANUT BUTTER: MILK: EGGS: JUICE:
MILK: CHEESE: EGGS: JUICE:

1 GAL OR 4-12 OZ CANS EVAP OR 1-5 QT BOX UP TO 1 LB 1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-46 OZ PLASTIC BOTTLE OR 1-11.5 OZ CAN POURABLE
1 GAL OR 4-12 OZ CANS EVAP OR 1-5 QT BOX 1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-46 OZ PLASTIC BOTTLE OR 1-11.5 OZ CAN POURABLE UP TO 24 OUNCES 1 LB DRIED BEANS/PEAS OR 18 OZ PEANUT BUTTER
1 GAL OR 4-12 OZ CANS EVAP OR 1-5 QT BOX 1 DOZEN 1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-46 OZ PLASTIC BOTTLE OR 1-11.5 OZ CAN POURABLE
1 GAL OR 4-12 OZ CANS EVAP OR 1-5 QT BOX UP TO 1 LB 1 DOZEN 1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-46 OZ PLASTIC BOTTLE OR 1-11.5 OZ CAN POURABLE

FP-102

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-16 (cont'd)

FOOD PACKAGE NUMBER
605
LACTOSE REDUCED MILK LACTOSE INTOLERANT 16 QTS LACTOSE REDUCED MILK 2 LBS CHEESE 2 DOZ EGGS 6 CANS JUICE 24 OZ CEREAL 1 LB BEANS/PEAS OR 18 OZ JAR PEANUT BUTTER

VOUCHER CODE 044
034
045
034

VOUCHER MESSAGE

MILK:
CHEESE: JUICE:
CEREAL: MILK:
EGGS: JUICE:
MILK:
CHEESE: JUICE:
BEANS/PEAS/ PEANUT BUTTER: MILK:
EGGS: JUICE:

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

FP-103

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-16 (cont'd)

FOOD PACKAGE NUMBER
615
LACTOSE REDUCED MILK LACTOSE INTOLERANT 16 QTS LACTOSE REDUCED MILK 2 LBS CHEESE 2 DOZ EGGS 6 CANS JUICE 24 OZ CEREAL 1 LB BEANS/PEAS

VOUCHER CODE
044

MILK:

CHEESE: JUICE:

CEREAL:

034

MILK:

EGGS: JUICE:

024

MILK:

CHEESE: JUICE:

BEANS/PEAS

034

MILK:

EGGS: JUICE:

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

FP-104

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-16 (cont'd)

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

VOUCHER CODE
028
031
055
056

VOUCHER MESSAGE

MILK:
EGGS: JUICE:

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

MILK:
CHEESE: JUICE:

1 GAL OR 4-12 OZ CANS EVAP OR 1-5 QT BOX
UP TO 1 LB
1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 146 OZ PLASTIC BOTTLE OR 1-11.5 OZ CAN POURABLE

MILK:
CHEESE: EGGS: JUICE:

1 GAL OR 4-12 OZ CANS EVAP OR 1-5 QT BOX
UP TO 1 LB
1 DOZEN
1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 146 OZ PLASTIC BOTTLE OR 1-11.5 OZ CAN POURABLE

MILK: JUICE:
CEREAL: BEANS/PEAS/ PEANUT BUTTER:

1 GAL OR 4-12 OZ CANS EVAP OR 1-5 QT BOX 2-12 OZ CANS FROZEN OR 2-46 OZ CANS OR 2-46 OZ PLASTIC BOTTLES OR 2-11.5 OZ CANS POURABLE
UP TO 36 OUNCES 1 LB DRIED BEANS/PEAS OR 18 OZ PEANUT BUTTER

FP-105

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-16 (cont'd)

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

VOUCHER CODE
027
028
032
046

VOUCHER MESSAGE

MILK:
JUICE:
CEREAL: BEANS/PEAS/ PEANUT BUTTER:

2 GAL OR 8-12 OZ CANS EVAP OR 2-3 QT BOX
1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 146 OZ PLASTIC BOTTLE OR 1-11.5 OZ CAN POURABLE
UP TO 36 OUNCES
1 LB DRIED BEANS/PEAS OR
18 OZ PEANUT BUTTER

MILK:
EGGS: JUICE:

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

MILK: EGGS: JUICE:
MILK: JUICE:

2 GAL OR 8-12 OZ CANS EVAP OR 2-3 QT BOXES
1 DOZEN 2-12 OZ CANS FROZEN OR 2-46 OZ CANS OR 2-46 OZ PLASTIC BOTTLES OR 2-11.5 OZ CANS POURABLE
1 GAL OR 4-12 OZ CANS EVAP OR 1-5 QT BOX 1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 146 OZ PLASTIC BOTTLE OR 1-11.5 OZ CAN POURABLE

FP-106

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-16 (cont'd)

FOOD PACKAGE NUMBER
613
16 QUARTS MEYENBERG GOAT MILK 1 LB CHEESE 2 DOZEN EGGS 4 CANS JUICE 24 OZ CEREAL 1 LB BEANS/PEAS
(Package similar to 603)

VOUCHER CODE
647

MEYENBERG GOAT MILK:

JUICE:

639

MEYENBERG

GOAT MILK:

CHEESE:

VOUCHER MESSAGE
4 QUARTS OR 4-12 OZ CANS EVAP OR 2-12 OZ CANS POWDER
2-12 OZ CAN FROZEN OR 2-46 OZ CAN OR 2-46 OZ PLASTIC BOTTLE OR 2-11.5 OZ CAN POURABLE
4 QUARTS OR 4-12 OZ CANS EVAP OR 1-12 OZ CAN POWDER
UP TO 1 LB

EGGS:

1 DOZEN

625

MEYENBERG

4 QUARTS OR 4-12 OZ CANS EVAP

GOAT MILK:

OR 1-12 OZ CAN POWDER

JUICE:

2-12 OZ CAN FROZEN OR 2-46 OZ CAN OR 2-46 OZ PLASTIC BOTTLE OR 2-11.5 OZ CAN POURABLE

681

MEYENBERG

4 QUARTS OR 4-12 OZ CANS EVAP

GOAT MILK:

OR 1-12 OZ CAN POWDER

EGGS:

1 DOZEN

651

CEREAL:

UP TO 24 OUNCES

BEANS/PEAS 1 LB DRIED BEANS/PEAS

FP-107

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-16 (cont'd)

FOOD PACKAGE NUMBER
614
16 QUARTS MEYENBERG GOAT MILK 2 LBS CHEESE 2 DOZEN EGGS 4 CANS JUICE 24 OZ CEREAL 1 LB DRIED BEANS/PEAS OR 18 OZ PEANUT BUTTER
(Package similar to 604)

VOUCHER CODE
647

MEYENBERG GOAT MILK:
JUICE:

639

MEYENBERG

GOAT MILK:

CHEESE: EGGS:

625

MEYENBERG

GOAT MILK:

JUICE:

639

MEYENBERG

GOAT MILK:

VOUCHER MESSAGE
4 QUARTS OR 4-12 OZ CANS EVAP OR 2-12 OZ CANS POWDER
2-12 OZ CAN FROZEN OR 2-46 OZ CAN OR 2-46 OZ PLASTIC BOTTLE OR 2-11.5 OZ CAN POURABLE
4 QUARTS OR 4-12 OZ CANS EVAP OR 1-12 OZ CAN POWDER
UP TO 1 LB 1 DOZEN
4 QUARTS OR 4-12 OZ CANS EVAP OR 1-12 OZ CAN POWDER
2-12 OZ CAN FROZEN OR 2-46 OZ CAN OR 2-46 OZ PLASTIC BOTTLE OR 2-11.5 OZ CAN POURABLE
4 QUARTS OR 4-12 OZ CANS EVAP OR 1-12 OZ CAN POWDER

CHEESE: EGGS:

UP TO 1 LB 1 DOZEN

637

CEREAL:

UP TO 24 OUNCES

BEANS/PEAS/ PEANUT BUTTER:

1 LB DRIED BEANS/PEAS OR 18 OZ PEANUT BUTTER

999*

999

AS PRESCRIBED

6 GALS OR 24 QTS MILK 4 LBS CHEESE 2 DOZEN EGGS 6 CANS JUICE 36 OZ CEREAL 1 LB BEANS/PEAS OR 18 OZ PEANUT BUTTER

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

*A maximum of 2 pounds of cheese per month is recommended except for those with lactose intolerance

FP-108

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-17

ALTERNATE FOOD PACKAGES FOR CHILDREN 1 TRHOUGH 5 YEARS MAXIMUM MONTHLY AMOUNTS AUTHORIZED

FOOD UHT Milk OR Lactose Reduced Milk
Cereal

SIZE 96-8 ounce OR half pint boxes
24 quarts or 12-1/2 gallons 4-9 oz boxes

MAXIMUM AMOUNTS 768 ounces
768 ounces 36 ounces

Juice

42-5.5 to 6 oz cans

252 ounces

Peanut Butter

2-18 oz jars

36 ounces

This food package consists of eight (8) vouchers.

FP-109

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-18

ALTERNATE FOOD PACKAGES FOR CHILDREN 1 THROUGH 5 YEARS

FOOD PACKAGE NUMBER
610
96- 8 OZ OR HALF PINT BOXES UHT MILK OR 22 QTS OR 11 1/2 GALLONS LACTOSE REDUCED MILK 4-9 BOXES CEREAL 42-5.5 to 6 OZ CANS JUICE 2-18 OZ JARS PEANUT BUTTER

VOUCHER

CODE

VOUCHER MESSAGE

610

MILK:

12-8 OZ OR HALF PINT BOXES UHT OR 4

QTS OR 2-1/2 GAL LACTOSE REDUCED

CEREAL: 1-9 OZ BOX

JUICE:

6-5.5 to 6 OZ CANS

PEANUT BUTTER:

1-18 OZ JAR

611

MILK:

12-8 OZ OR HALF PINT BOXES UHT OR 2

QTS OR 1-1/2 GAL LACTOSE REDUCED

JUICE:

6-5.5 to 6 OZ CANS

611

MILK:

12-8 OZ OR HALF PINT BOXES UHT OR 2

QTS OR 1-1/2 GAL LACTOSE REDUCED

JUICE:

6-5.5 to 6 OZ CANS

611

MILK:

12-8 OZ OR HALF PINT BOXES UHT OR 2

QTS OR 1-1/2 GAL LACTOSE REDUCED

JUICE:

6-5.5 to 6 OZ CANS

612

MILK:

12-8 OZ OR HALF PINT BOXES UHT OR 2

QTS OR 1-1/2 GAL LACTOSE REDUCED

CEREAL: 1-9 OZ BOX

JUICE:

6-5.5 to 6 OZ CANS

613

MILK:

12-8 OZ OR HALF PINT BOXES UHT OR 2

QTS OR 1 - 1/2 GAL LACTOSE REDUCED

CEREAL: 1-9 OZ BOX

614

MILK:

12 - 8 OZ OR HALF PINT BOXES UHT OR

4 QTS OR 2 -1/2 GAL LACTOSE REDUCED

CEREAL: 1-9 OZ BOX

JUICE:

6-5.5 to 6 OZ CANS

615

MILK:

12-8 OZ OR HALF PINT BOXES UHT OR 4

QTS OR 2 - 1/2 GAL LACTOSE REDUCED

PEANUT

BUTTER: 1-18 OZ JAR

JUICE:

6-5.5 to 6 OZ CANS

FP-110

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-19

WOMEN'S FOOD PACKAGES MAXIMUM MONTHLY AMOUNTS AUTHORIZED

FOOD

PREGNANT, BREASTFEEDING

EXCLUSIVELY BREASTFEEDING 1

Milk2

28 quart equivalents 3

28 quart equivalents

Cheese

4 pounds 4,5

1 pound

Eggs

2 dozen

2 dozen

Juice

6-46 oz cans or 6-46 oz plastic bottles 6-12 oz cans frozen or 6-11.5 oz cans pourable

7-46 oz cans or 7-46 oz plastic bottles 7-12 oz cans frozen or 6-11.5 oz cans pourable

Cereal

36 ounces

36 ounces

Dried Beans/Peas or Peanut Butter

1 pound bag or 1-18 oz jar

1 lb. bag or 18 oz jar plus an additional 1 lb. bag

Carrots1

NA

2 pounds, fresh, whole

Tuna1

NA

4-6 oz cans

1 Additional items authorized for exclusively breastfeeding women only. 2 Substitute up to 28 quarts of reduced milk for up to 7 gallons of milk. 3 Substitution amounts for fluids milk include:

ITEM
Cheese, 1 pound
Evaporated milk whole or skim (13 oz)
Dry whole milk 1 pound
Nonfat or low fat dry milk, 1 pound

FLUID MILK EQUIVALENTS
3 quarts
1 quart
3 quarts
5 quarts

4 Subtract from monthly milk allotment. A maximum of two (2) pounds of cheese per month is recommended except for those with lactose intolerance. 5 Substitute up to 4 lbs cheese for up to 7 gallons of milk.

FP-111

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-20

PREGNANT AND BREASTFEEDING WOMEN'S FOOD PACKAGES

FOOD PACKAGE NUMBER
MINIMUM 401
4 GALS MILK 1 DOZ EGGS 4 CANS JUICE 24 OZ CEREAL 1 LB BEANS/PEAS OR 18 OZ PEANUT BUTTER

VOUCHER CODE 040 039
037
040

VOUCHER MESSAGE

MILK: JUICE:

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

MILK:
EGGS: JUICE:

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

MILK:
JUICE:
CEREAL: BEANS/PEAS/ PEANUT BUTTER:

1 GAL OR 4-12 OZ CANS EVAP OR 1-5 QT BOX
1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-46 OZ PLASTIC BOTTLE OR 1-11.5 OZ CAN POURABLE
UP TO 24 OUNCES
1 LB DRIED BEANS/PEAS OR
18 OZ PEANUT BUTTER

MILK: JUICE:

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

FP-112

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-20 (cont'd)

FOOD PACKAGE NUMBER
402 LIMITED MILK LACTOSE INTOLERANT
2 GALS MILK 2 LBS CHEESE 2 DOZ EGGS 6 CANS JUICE 36 OZ CEREAL 1 LB BEANS/PEAS OR 18 OZ PEANUT BUTTER

VOUCHER CODE 041
042 028
043

VOUCHER MESSAGE

MILK: EGGS: JUICE:
CEREAL:

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

CHEESE: JUICE:

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

MILK:
EGGS: JUICE:

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

CHEESE: JUICE:
BEANS/PEAS/ PEANUT BUTTER:

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

FP-113

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-20 (cont'd)

FOOD PACKAGE NUMBER
403
4 GALS MILK 1 LB CHEESE 1 DOZ EGGS 4 CANS JUICE 24 OZ CEREAL 1 LB BEANS/PEAS OR 18 OZ PEANUT BUTTER

VOUCHER CODE 037
039
031
040

VOUCHER MESSAGE

MILK:
JUICE:
CEREAL: BEANS/PEAS/ PEANUT BUTTER:

1 GAL OR 4-12 OZ CANS EVAP OR 1-5 QT BOX
1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-46 OZ PLASTIC BOTTLE OR 1-11.5 OZ CAN POURABLE
UP TO 24 OUNCES
1 LB DRIED BEANS/PEAS OR 18 OZ PEANUT BUTTER

MILK:
EGGS: JUICE:

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

MILK: CHEESE: JUICE:
MILK: JUICE:

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

FP-114

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-20 (cont'd)

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

VOUCHER CODE 028
031
037
054

VOUCHER MESSAGE

MILK:
EGGS: JUICE:

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

MILK:
CHEESE: JUICE:

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

MILK:
JUICE:
CEREAL: BEANS/PEAS/ PEANUT BUTTER:

1 GAL OR 4-12 OZ CANS EVAP OR 1-5 QT BOX 1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-46 OZ PLASTIC BOTTLE OR 1-11.5 OZ CAN POURABLE
UP TO 24 OUNCES
1 LB DRIED BEANS/PEAS OR 18 OZ PEANUT BUTTER

MILK:
CHEESE: EGGS: JUICE:

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

FP-115

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-20 (cont'd)

FOOD PACKAGE NUMBER
405
LACTOSE REDUCED MILK
LACTOSE INTOLERANT
12 QTS LACTOSE REDUCED MILK 3 LBS CHEESE 2 DOZ EGGS 6 CANS JUICE 36 OZ CEREAL 1 LB BEANS/PEAS OR 18 OZ PEANUT BUTTER

VOUCHER CODE 033
034
035
036

VOUCHER MESSAGE

MILK:
CHEESE: JUICE:
CEREAL: MILK:
EGGS: JUICE:
MILK:
CHEESE: JUICE:
BEANS/PEAS/ PEANUT BUTTER: MILK:
CHEESE: EGGS: JUICE:

4 QTS OR 2-1/2 GAL ACIDOPHILUS OR ENJOY OR LACTAID OR LACTAID 100 OR NUTRISH OR DAIRY EASE UP TO 1 LB 1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-46 OZ PLASTIC BOTTLE OR 1-11.5 OZ CAN POURABLE UP TO 36 OUNCES
4 QTS OR 2-1/2 GAL ACIDOPHILUS OR ENJOY OR LACTAID OR LACTAID 100 OR NUTRISH OR DAIRY EASE 1 DOZEN 2-12 OZ CANS FROZEN OR 2-46 OZ CANS OR 2-46 OZ PLASTIC BOTTLES OR 2-11.5 OZ CANS POURABLE
2 QTS OR 1/2 GAL ACIDOPHILUS OR ENJOY OR LACTAID OR LACTAID 100 OR NUTRISH OR DAIRY EASE UP TO 1 LB 2-12 OZ CANS FROZEN OR 2-46 OZ CANS OR 2-46 OZ PLASTIC BOTTLES OR 2-11.5 OZ CANS POURABLE 1 LB DRIED BEANS/PEAS OR 18 OZ PEANUT BUTTER
2 QTS OR 1/2 GAL ACIDOPHILUS OR ENJOY OR LACTAID OR LACTAID 100 OR NUTRISH OR DAIRY EASE UP TO 1 LB 1 DOZEN 1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-46 OZ PLASTIC BOTTLE OR 1-11.5 OZ CAN POURABLE

FP-116

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-20 (cont'd)

FOOD PACKAGE NUMBER
406
5 GALS MILK 2 LBS CHEESE 2 DOZEN EGGS 6 CANS JUICE 36 OZ CEREAL 1 LB BEANS/PEAS OR 18 OZ PEANUT BUTTER

VOUCHER CODE 027
028
031
054

VOUCHER MESSAGE

MILK:
JUICE:
CEREAL: BEANS/PEAS/ PEANUT BUTTER:

2 GAL OR 8-12 OZ CANS EVAP OR 2-3 QT BOX
1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-46 OZ PLASTIC BOTTLE OR 1-11.5 OZ CAN POURABLE
UP TO 36 OUNCES
1 LB DRIED BEANS/PEAS OR 18 OZ PEANUT BUTTER

MILK:
EGGS: JUICE:

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

MILK:
CHEESE: JUICE:

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

MILK:
CHEESE: EGGS: JUICE:

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

FP-117

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-20 (cont'd)

FOOD PACKAGE NUMBER
MAXIMUM 407
7 GALS MILK 2 DOZEN EGGS 6 CANS JUICE 36 OZ CEREAL 1 LB BEANS/PEAS OR 18 OZ PEANUT BUTTER

VOUCHER CODE 027
028
029 030

VOUCHER MESSAGE

MILK: JUICE:
CEREAL: BEANS/PEAS/ PEANUT BUTTER:

2 GAL OR 8-12 OZ CANS EVAP OR 2-3 QT BOX
1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-46 OZ PLASTIC BOTTLE OR 1-11.5 OZ CAN POURABLE
UP TO 36 OUNCES
1 LB DRIED BEANS/PEAS OR 18 OZ PEANUT BUTTER

MILK:
EGGS: JUICE:

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

MILK: JUICE:
MILK: EGGS: JUICE:

2 GAL OR 8-12 OZ CANS EVAP OR 2-5 QT BOXES 1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-46 OZ PLASTIC BOTTLE OR 1-11.5 OZ CAN POURABLE
2 GAL OR 8-12 OZ CANS EVAP OR 2-5 QT BOX
1 DOZEN
2-12 OZ CANS FROZEN OR 2-46 OZ CANS OR 2-46 OZ PLASTIC BOTTLES OR 2-11.5 OZ CANS POURABLE

FP-118

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-20 (cont'd)

FOOD PACKAGE NUMBER
414
16 QUARTS MEYENBERG GOAT MILK 2 LBS CHEESE 2 DOZ EGGS 6 CANS JUICE 24 OZ CEREAL 1 LB BEANS/PEAS OR 18 OZ PEANUT BUTTER
(Package Similar to 404)

VOUCHER CODE 655
639
638
639
637

VOUCHER MESSAGE

MEYENBERG GOAT MILK:
JUICE:
MEYENBERG GOAT MILK: CHEESE: EGGS: MEYENBERG GOAT MILK: JUICE:
MEYENBERG GOAT MILK: CHEESE: EGGS: CEREAL:

4 QUARTS OR 4-12 OZ CANS EVAP OR 2-12 OZ CANS POWDER
3-12 OZ CANS FROZEN OR 3-46 OZ CANS OR 3-46 OZ PLASTIC BOTTLES OR 3-11.5 OZ CANS POURABLE
4 QUARTS OR 4-12 OZ CANS EVAP OR 1-12 OZ CAN POWDER
UP TO 1 LB 1 DOZEN
4 QUARTS OR 4-12 OZ CANS EVAP OR 1-12 OZ CAN POWDER
3-12 OZ CAN FROZEN OR 3-46 OZ CAN OR 3-46 OZ PLASTIC BOTTLE OR 3-11.5 OZ CAN POURABLE
4 QUARTS OR 4-12 OZ CANS EVAP OR 1-12 OZ CAN POWDER
UP TO 1 LB 1 DOZEN
UP TO 24 OUNCES

BEANS/PEAS/
PEANUT BUTTER:

1 LB DRIED BEANS/PEAS OR 18 OZ PEANUT BUTTER

FP-119

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-20 (cont'd)

FOOD PACKAGE NUMBER
416
20 QUARTS MEYENBERG GOAT MILK 2 LBS CHEESE 2 DOZEN EGGS 6 CANS JUICE 36 OZ CEREAL 1 LB BEANS/PEAS OR 18 OZ PEANUT BUTTER
(Package Similar to 406)

VOUCHER CODE 654
657
654
657 661

VOUCHER MESSAGE

MEYENBERG GOAT MILK:
JUICE:
MEYENBERG GOAT MILK:
CHEESE: EGGS: MEYENBERG GOAT MILK:

5 QUARTS OR 5-12 OZ CANS EVAP OR 2-12 OZ CANS POWDER
3-12 OZ CAN FROZEN OR 3-46 OZ CAN OR 3-46 OZ PLASTIC BOTTLE OR 3-11.5 OZ CAN POURABLE
5 QUARTS OR 5-12 OZ CANS EVAP OR 1-12 OZ CANS POWDER
UP TO 1 LB 1 DOZEN
5 QUARTS OR 5-12 OZ CANS EVAP OR 2-12 OZ CANS POWDER

JUICE:
MEYENBERG GOAT MILK:
CHEESE: EGGS: CEREAL:

3-12 OZ CAN FROZEN OR 3-46 OZ CAN OR 3-46 OZ PLASTIC BOTTLE OR 3-11.5 OZ CAN POURABLE
5 QUARTS OR 5-12 OZ CANS EVAP OR 1-12 OZ CANS POWDER
UP TO 1 LB 1 DOZEN
UP TO 36 OUNCES

BEANS/PEAS/
PEANUT BUTTER:

1 LB DRIED BEANS/PEAS OR 18 OZ PEANUT BUTTER

FP-120

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-21

EXCLUSIVELY BREASTFEEDING FOOD PACKAGES*

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

VOUCHER CODE 001
027
028
029 054

VOUCHER MESSAGE

CHEESE: JUICE:
CARROTS: TUNA: BEANS/PEAS: MILK:
JUICE:
CEREAL: BEANS/PEAS/ PEANUT BUTTER: MILK:
EGGS: JUICE:
MILK:
JUICE:

UP TO 1 LB 1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-46 OZ PLASTIC BOTTLE OR 1-11.5 OZ CAN POURABLE 2-1 LB SEALED PLASTIC BAGS 4-6 OZ CANS 1 LB DRIED BEANS OR PEAS
2 GAL OR 8-12 OZ CANS EVAP OR 2-3 QT BOX 1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-46 OZ PLASTIC BOTTLE OR 1-11.5 OZ CAN POURABLE UP TO 36 OUNCES 1 LB DRIED BEANS/PEAS OR 18 OZ PEANUT BUTTER
1 GAL OR 4-12 OZ CANS EVAP OR 1-5 QT BOX 1 DOZEN 2-12 OZ CANS FROZEN OR 2-46 OZ CANS OR 2-46 OZ PLASTIC BOTTLES OR 2-11.5 OZ CANS POURABLE
2 GAL OR 8-12 OZ CANS EVAP OR 2-5 QT BOXES 1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-46 OZ PLASTIC BOTTLE OR 1-11.5 OZ CAN POURABLE

MILK:
CHEESE: EGGS: JUICE:

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

FP-121

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-21 (cont'd)

FOOD PACKAGE NUMBER 418
EXCLUSIVELY BREASTFEEDING
25 QUARTS MEYENBERG GOAT MILK 2 LBS CHEESE 2 DOZEN EGGS 7 CANS JUICE 36 OZ CEREAL 1 LB BEANS/PEAS OR 1-18 OZ PEANUT BUTTER PLUS 1 LB BEANS/PEAS 2 LBS CARROTS 4 CANS TUNA
(Package Similar to 408)
999 7 GALS OR 28 QTS MILK 4 LBS CHEESE 2 DOZ EGGS 7 CANS JUICE 36 OZ CEREAL 1 LB BEANS/PEAS OR 18 OZ PEANUT BUTTER

VOUCHER CODE 682 657 654
683
678
661 999

VOUCHER MESSAGE

MEYENBERG GOAT MILK: CARROTS: TUNA: MEYENBERG GOAT MILK: CHEESE: EGGS: MEYENBERG GOAT MILK: JUICE:
MEYENBERG GOAT MILK: CHEESE: EGGS: BEANS/PEAS MEYENBERG GOAT MILK: JUICE:
CEREAL: BEANS/PEAS/ PEANUT BUTTER: AS PRESCRIBED

5 QUARTS OR 5-12 OZ CANS EVAP OR 2-12 OZ CANS POWDER
2-1 LB SEALED PLASTIC BAGS 4-6 OZ CANS
5 QUARTS OR 5-12 OZ CANS EVAP OR 1-12 OZ CANS POWDER UP TO 1 LB 1 DOZEN
5 QUARTS OR 5-12 OZ CANS EVAP OR 2-12 OZ CANS POWDER
3-12 OZ CANS FROZEN OR 3-46 OZ CANS OR 3-46 OZ PLASTIC BOTTLES OR 3-11.5 OZ CANS POURABLE
5 QUARTS OR 5-12 OZ CANS EVAP OR 2-12 OZ CANS POWDER UP TO 1 LB 1 DOZEN
1 LB DRIED BEANS/PEAS
5 QUARTS OR 5-12 OZ CANS EVAP OR 1-12 OZ CANS POWDER
4-12 OZ CANS FROZEN OR 4-46 OZ CANS OR 4-46 OZ PLASTIC BOTTLES OR 4-11.5 OZ CANS POURABLE
UP TO 36 OUNCES
1 LB DRIED BEANS/PEAS OR 18 OZ PEANUT BUTTER

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

* These food packages may be issued to breastfeeding women who are not receiving formula from the WIC Program, for their infants (defined here as exclusively breastfeeding).
**a. Food package 408 can be issued to the mother immediately after delivery. Food package 999, voucher code 999, may be tailored for exclusively breastfeeding women not to exceed the maximum amounts listed in package 408.
b. Substitution for food package 408 only: 1. 5 gallons of milk and 2 lbs. cheese to replace 7 gallons of milk 2. 4 lbs cheese to replace 7 gallons of milk
c. A maximum of 2 pounds of cheese per month is recommended except for those with lactose intolerance.

FP-122

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-22

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

FOOD UHT Milk

PREGNANT, AND BREASTFEEDING
112 - 8 ounce OR half pint boxes

EXCLUSIVELY REASTFEEDING*
124 - 8 ounce OR half pint boxes

Lactose Reduced Milk Cereal

OR
28 quarts or 14 1/2 gallons
4-9 oz boxes

OR 31 quarts or 15 1/2 gallons
4-9 oz boxes

Juice

42 - 5.5 to 6 oz cans

56-5.5 to 6 oz cans

Peanut Butter Beans/Peas Tuna Carrots

2-18 oz jars ------------------------

3-18 oz jars 4- 14 to 16 oz can 6-6 oz cans 2- 14 to 16 oz can

This food package consists of 8-9 vouchers
*Exclusively breastfeeding is defined here as receiving no formula from the WIC Program, for their infants.

FP-123

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-23

ALTERNATE FOOD PACKAGES FOR PREGNANT AND BREASTFEEDING WOMEN

FOOD PACKAGE NUMBER
410 (PREGNANT AND BREASTFEEDING)
111 - 8 OZ OR HALF PINT BOXES UHT MILK OR 16 QT OR 8 1/2 GAL LACTOSE REDUCED MILK 4-9 OZ BOXES CEREAL 42-5.5 to 6 OZ CANS JUICE 2-18 OZ JARS PEANUT BUTTER

VOUCHER CODE

620

MILK:

CEREAL: JUICE: PEANUT BUTTER:

621

MILK:

JUICE:

621

MILK:

JUICE:

621

MILK:

JUICE:

622

MILK:

CEREAL: JUICE:

622

MILK:

CEREAL: JUICE:

623

MILK:

CEREAL:

624

MILK:

JUICE:
PEANUT BUTTER:

VOUCHER MESSAGE
15-8 OZ OR HALF PINT BOXES UHT OR 2 QTS OR 1-1/2 GAL LACTOSE REDUCED 1-9 OZ BOX 6-5.5 to 6 OZ CANS
1-18 OZ JAR
15-8 OZ OR HALF PINT BOXES UHT OR 2 QTS OR 1-1/2 GAL LACTOSE REDUCED 6-5.5 to 6 OZ CANS
15-8 OZ OR HALF PINT BOXES UHT OR 2 QTS OR 1-1/2 GAL LACTOSE REDUCED 6-5.5 to 6 OZ CANS
15-8 OZ OR HALF PINT BOXES UHT OR 2 QTS OR 1 -1/2 GAL LACTOSE REDUCED 6-5.5 to 6 OZ CANS
15-8 OZ OR HALF PINT BOXES UHT OR 2 QTS OR 1-1/2 GAL LACTOSE REDUCED 1-9 OZ BOX 6-5.5 to 6 OZ CANS
15-8 OZ OR HALF PINT BOXES UHT OR 2 QTS OR 1-1/2 GAL LACTOSE REDUCED 1-9 OZ BOX 6-5.5 to 6 OZ CANS
9-8 OZ OR HALF PINT BOXES UHT OR 2 QTS OR 1-1/2 GAL LACTOSE REDUCED 1-9 OZ BOX
12-8 OZ OR HALF PINT BOXES UHT OR 2 QTS OR 1-1/2 GAL LACTOSE REDUCED 6-5.5 to 6 OZ CANS
1-18 OZ JAR

FP-124

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-23 (cont'd)

FOOD PACKAGE NUMBER
411 (EXCLUSIVELY BREAST FEEDING)
123-8 OZ OR HALF PINT BOXES UHT MILK 31 QUARTS OR 15-1/2 GAL LACTOSE REDUCED MILK 36 OZ CEREAL 54-5.5 to 6 OZ CANS JUICE 3-18 OZ JAR PEANUT BUTTER 6-6 OZ CANS TUNA 4-14 to 16 OZ CANS BEANS/PEAS 2-14 to 16 OZ CANS CARROTS

VOUCHER CODE

VOUCHER MESSAGE

630

MILK:

15-8 OZ OR HALF PINT BOXES UHT OR 4

QTS OR 2-1/2 GAL LACTOSE REDUCED

CEREAL: 1-9 OZ BOX

JUICE:
PEANUT BUTTER:
BEANS/ PEAS: CARROTS:

12-5.5 to 6 OZ CANS
1-18 OZ JAR 1-14 to 16 OZ CAN 1-14 to 16 OZ CAN

631

MILK:

15-8 OZ OR HALF PINT BOXES UHT OR 4

QTS OR 2-1/2 GAL LACTOSE REDUCED

JUICE:

6-5.5 to 6 OZ CANS

TUNA:

2-6 OZ CANS

631

MILK:

15-8 OZ OR HALF PINT BOXES UHT OR 4

QTS OR 2-1/2 GAL LACTOSE REDUCED

JUICE:

6-5.5 to 6 OZ CANS

TUNA:

2-6 OZ CANS

632

MILK:

15-8 OZ OR HALF PINT BOXES UHT OR 4

QTS OR 2-1/2 GAL LACTOSE REDUCED

CEREAL: 1-9 OZ BOX

JUICE:

6-5.5 to 6 OZ CANS

PEANUT

BUTTER: 1-18 OZ JAR

634

MILK:

15-8 OZ OR HALF PINT BOXES UHT OR 4

QTS OR 2-1/2 GAL LACTOSE REDUCED

JUICE:

6-5.5 to 6 OZ CANS

PEANUT

BUTTER: 1-18 OZ JAR

635

MILK:

15-8 OZ OR HALF PINT BOXES UHT OR 4

QTS OR 2-1/2 GAL LACTOSE REDUCED

CEREAL: 1-9 OZ BOX

JUICE:

6-5.5 to 6 OZ CANS

BEANS/

PEAS:

1-14 to 16 OZ CAN

CARROTS: 1-14 to 16 OZ CAN

636

MILK:

18-8 OZ OR HALF PINT BOXES UHT OR 4

QTS OR 2-1/2 GAL LACTOSE REDUCED

JUICE:

6-5.5 to 6 OZ CANS

BEANS/

PEAS:

1-14 to 16 OZ CAN

CEREAL: 1-9 OZ BOX

633

MILK:

15-8 OZ OR HALF PINT BOXES UHT OR 3 QTS OR

1-1/2 GAL LACTOSE REDUCED

JUICE:

6-5.5 to 6 OZ CANS

BEANS/

PEAS:

1-14 to 16 OZ CAN

TUNA:

2-6 OZ CANS

FP-125

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-24

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

FOOD

MAXIMUM AMOUNT PER MONTH

Milk1

24 quart equivalents2

Cheese

4 pounds3

Eggs

2 dozen

Juice Cereal

4-46 oz cans or 4-46 oz plastic bottles or 412 oz frozen or 4-11.5 oz pourable
36 ounces

1Substitute up to 24 quarts of lactose reduced milk to replace up to 6 gallons of milk. 2Substitution amounts for fluid milk include: ITEM FLUID MILK EQUIVALENTS
Cheese, 1 pound 3 quarts
Evaporated milk, whole or skim (13 oz) 1 quart
Dry whole milk, 1 pound 3 quarts
Nonfat or low fat dry milk, 1 pound 5 quarts
3Subtract from monthly milk allotment. A maximum of two (2) pounds of cheese per month is recommended except for those with lactose intolerance.

FP-126

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-25

POSTPARTUM, NON-BREASTFEEDING WOMEN'S FOOD PACKAGES

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

VOUCHER CODE

040

MILK:

JUICE:

040

MILK:

JUICE:

053

MILK:

CEREAL:

052

JUICE:

EGGS:

040

MILK:

JUICE:

042

CHEESE:

JUICE:

047

MILK:

JUICE:

CEREAL:

055

MILK:

CHEESE: EGGS: JUICE:

VOUCHER MESSAGE
1 GAL OR 4-12 OZ CANS EVAP OR 1-5 QT BOX 1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-46 OZ PLASTIC BOTTLE OR 1-11.5 OZ CAN POURABLE
1 GAL OR 4-12 OZ CANS EVAP OR 1-5 QT BOX 1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-46 OZ PLASTIC BOTTLE OR 1-11.5 OZ CAN POURABLE
1 GAL OR 4-12 OZ CANS EVAP OR 1-5 QT BOX UP TO 18 OUNCES
1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-46 OZ PLASTIC BOTTLE OR 1-11.5 OZ CAN POURABLE 1 DOZEN
1 GAL OR 4-12 OZ CANS EVAP OR 1-5 QT BOX 1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-46 OZ PLASTIC BOTTLE OR 1-11.5 OZ CAN POURABLE
UP TO 1 LB 1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-46 OZ PLASTIC BOTTLE OR 1-11.5 OZ CAN POURABLE
1 GAL OR 4-12 OZ CANS EVAP OR 1-5 QT BOX 1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-46 OZ PLASTIC BOTTLE OR 1-11.5 OZ CAN POURABLE UP TO 24 OUNCES
1 GAL OR 4-12 OZ CANS EVAP OR 1-5 QT BOX UP TO 1 LB 1 DOZEN 1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-46 OZ PLASTIC BOTTLE OR 1-11.5 OZ CAN POURABLE

FP-127

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-25 (cont'd)

FOOD PACKAGE NUMBER
MAXIMUM 503
6 GALS MILK 2 DOZEN EGGS 4 CANS JUICE 36 OZ CEREAL

VOUCHER CODE

050

MILK:

JUICE:

CEREAL: EGGS:

051

MILK:

JUICE:

039

MILK:

EGGS: JUICE:

051

MILK:

JUICE:

VOUCHER MESSAGE
1 GAL OR 4-12 OZ CANS EVAP OR 1-5 QT BOX 1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-46 OZ PLASTIC BOTTLE OR 1-11.5 OZ CAN POURABLE UP TO 36 OUNCES 1 DOZEN
2 GALS OR 8-12 OZ CANS EVAP OR 2-5 QT BOX 1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-46 OZ PLASTIC BOTTLE OR 1-11.5 OZ CAN POURABLE
1 GAL OR 4-12 OZ CANS EVAP OR 1-5 QT BOX 1 DOZEN 1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-46 OZ PLASTIC BOTTLE OR 1-11.5 OZ CAN POURABLE
2 GALS OR 8-12 OZ CANS EVAP OR 2-5 QT BOX 1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-46 OZ PLASTIC BOTTLE OR 1-11.5 OZ CAN POURABLE

FP-128

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-25 (cont'd)

FOOD PACKAGE NUMBER
504
LACTOSE REDUCED MILK
LACTOSE INTOLERANT 12 QTS MILK 2 LBS CHEESE 1 DOZEN EGGS 4 CANS JUICE 24 OZ CEREAL

VOUCHER VOUCHER MESSAGE CODE

501

MILK:

4 QTS OR 2-1/2 GAL ACIDOPHILUS OR

ENJOY OR LACTAID OR LACTAID 100

NUTRISH OR DAIRY EASE-

CHEESE:

UP TO 1 LB

JUICE:

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

OR 1-46 OZ PLASTIC BOTTLE OR 1-11.5

OZ CAN POURABLE

502

MILK:

EGGS; JUICE:

4 QTS OR 2-1/2 GAL ACIDOPHILUS OR ENJOY OR LACTAID OR LACTAID 100 NUTRISH OR DAIRY EASE1 DOZEN 1-12 OZ CAN FROZEN OR 1-46 OZ CAN OR 1-46 OZ PLASTIC BOTTLE OR 1-11.5 OZ CAN POURABLE

503

MILK:

2 QTS OR 1-1/2 GAL ACIDOPHILUS OR

ENJOY OR LACTAID OR LACTAID 100

NUTRISH OR DAIRY EASE

CHEESE:

UP TO 1 LB

JUICE:

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

OR 1-46 OZ PLASTIC BOTTLE OR 1-11.5

OZ CAN POURABLE

504

MILK:

2 QTS OR 1-1/2 GAL ACIDOPHILUS OR

ENJOY OR LACTAID OR LACTAID 100

NUTRISH OR DAIRY EASE

JUICE:

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

OR 1-46 OZ PLASTIC BOTTLE OR 1-11.5

OZ CAN POURABLE

CEREAL:

OR 1-11.5 OZ CAN POURABLE UP TO 24 OUNCES

FP-129

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-25 (cont'd)

FOOD PACKAGE NUMBER 512
12 QUARTS MEYENBERG GOAT MILK 2 LBS CHEESE 1 DOZ EGGS` 4 CANS JUICE 24 OZ CEREAL
(Package Similar to 502)
999* 6 GALS OR 24 QTS MILK SUBSTITUTE 1 LB CHEESE FOR 3 QTS MILK 2 DOZEN EGGS 4 CANS JUICE 36 OZ CEREAL

VOUCHER VOUCHER MESSAGE CODE

647

MEYENBERG 4 QUARTS OR 4-12 OZ CANS EVAP

GOAT MILK: OR 2-12 OZ CANS POWDER

JUICE:

2-12 OZ CAN FROZEN OR 2-46 OZ CAN OR 2-46 OZ PLASTIC BOTTLE OR 2-11.5 OZ CAN POURABLE

679

CEREAL:

UP TO 24 OUNCES

CHEESE:

UP TO 1 LB

625

MEYENBERG 4 QUARTS OR 4-12 OZ CANS EVAP

GOAT MILK: OR 1-12 OZ CAN POWDER

JUICE:

2-12 OZ CAN FROZEN OR 2-46 OZ CAN OR 2-46 OZ PLASTIC BOTTLE OR 2-11.5 OZ CAN POURABLE

639

MEYENBERG 4 QUARTS OR 4-12 OZ CANS EVAP

GOAT MILK: OR 1-12 OZ CAN POWDER

CHEESE: EGGS:

UP TO 1 LB 1 DOZEN

999

AS PRESCRIBED

A TAILORED PACKAGE DESIGNED BY THE CPA

MUST NOT EXCEED THE MAXIMUM QUANTITY OF

SUPPLEMENTAL FOODS FOR THE PARTICIPANT'S

CATEGORY

FP-130

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-26

ALTERNATE FOOD PACKAGES FOR POSTPARTUM, NON-BREASTFEEDING WOMEN
MAXIMUM MONTHLY AMOUNTS AUTHORIZED

FOOD UHT Milk
OR Lactose Reduced Milk

SIZE
96-8 ounce OR half pint boxes
24 quarts OR 12-1/2 gallons

MAXIMUM AMOUNT 768 ounces

Cereal

4-9 ounce boxes

36 ounces

Juice

30-5.5 to 6 ounce cans

184 ounces

Peanut Butter

1-18 ounce jar

18 ounces

This food package consists of eight (8) vouchers.

FP-131

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-27

ALTERNATE FOOD PACKAGE FOR POSTPARTUM, NON-BREASTFEEDING WOMEN

FOOD PACKAGE NUMBER
510
72 - 8 OZ BOXES OR HALF PINT UHT MILK 18 QTS OR 9-1/2 GAL LACTOSE REDUCED MILK 4-9 OZ BOXES CEREAL 30-5.5 to 6 OZ CANS JUICE 1-18 OZ JAR PEANUT BUTTER

VOUCHER CODE

642

MILK:

CEREAL: JUICE:

645

MILK:

PEANUT BUTTER:
JUICE:

642

MILK:

CEREAL: JUICE:

641

MILK:

642

MILK:

CEREAL: JUICE:

641

MILK:

641

MILK:

642

MILK:

CEREAL: JUICE:

VOUCHER MESSAGE
9-8 OZ OR HALF PINT BOXES UHT OR 2 QTS OR 1-1/2 GAL LACTOSE REDUCED 1-9 OZ BOX 6-5.5 to 6 OZ CANS
9-8 OZ OR HALF PINT BOXES UHT OR 4 QTS OR 2-1/2 GAL LACTOSE REDUCED
1-18 OZ JAR 6-5.5 to 6 OZ CANS
9-8 OZ OR HALF PINT BOXES UHT OR 2 QTS OR 1-1/2 GAL LACTOSE REDUCED 1-9 OZ BOX 6-5.5 to 6 OZ CANS
9-8 OZ OR HALF PINT BOXES UHT OR 2 QTS OR 1-1/2 GAL LACTOSE REDUCED
9-8 OZ OR HALF PINT BOXES UHT OR 2 QTS OR 1-1/2 GAL LACTOSE REDUCED 1-9 OZ BOX 6-5.5 to 6 OZ CANS
9-8 OZ OR HALF PINT BOXES UHT OR 2 QTS OR 1-1/2 GAL LACTOSE REDUCED
9-8 OZ OR HALF PINT BOXES UHT OR 2 QTS OR 1-1/2 GAL LACTOSE REDUCED
9-8 OZ OR HALF PINT BOXES UHT OR 2 QTS OR 1-1/2 GAL LACTOSE REDUCED 1-9 OZ BOX 6-5.5 to 6 OZ CANS

FP-132

GA WIC 2005 PROCEDURES MANUAL

DATE: TO:
FROM:
PHONE #:

GEORGIA WIC PROGRAM FORMULA REFERRAL FORM (To Be Completed By Referral Agency)
WIC PROGRAM
Signature/Title (Physician) Health Facility - Location

Attachment FP-28

1. ____________________________________________ is a resident of _________________________.

(NAME)

(COUNTY)

He/She receives treatment for _____________________________________. His/Her local physician
(DIAGNOSIS)

is __________________________________________. Please provide _____________ ounces of

(NAME)

(AMOUNT)

(NAME)

formula monthly. I estimate he/she will need this formula for _________ months.

(NUMBER)

2. Check the correct statement:

This client has been assessed for the WIC Program. A WIC Program Assessment/Certification is attached.

Please assess this client for the WIC Program. The following information was collected on .
(DATE)

Length/Height* _________

Weight* _________

Hematocrit/Hemoglobin* __________

3. Diet Order: Please list other WIC approved foods allowed and any follow-up diet instructions. The WIC Program authorizes the following distribution to infants and children: Infants, 5-12 months old up to 92 ounces of fruit juice and 24 ounces of infant cereal. Children - up to 138 ounces of single strength juice & 36 ounces of cereal.

*Please include this information, if available.

[SAMPLE FORM. MAY BE ADAPTED FOR LOCAL AGENCY USE] FP-133

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-29

GEORGIA WIC APPROVED FOOD LIST CRITERIA TO EVALUATE AN ELIGIBLE FOOD ITEM

I.

Administrative Adjustments

A. A food company interested in participating in the Georgia WIC Program should submit product statewide availability, package size, unit cost per ounce and nutrient composition information to the Nutrition Section* by October 1st of each year.

*Address: Nutrition Section, 2 Peachtree Street NW, Suite 11-222, Atlanta, GA 30303-3142.

B.

A review of potentially new food items shall be conducted biennially. Consequently, the

WIC Approved Food List shall be printed biennially only. Biennial review of the WIC Food

List does not necessarily constitute a change in the food list. Changes to the WIC Approved

Food List shall occur more frequently only to accommodate Federal mandates.

C.

A product must be commercially available as a brand name, or a store brand, for a minimum

of twelve (12) consecutive months prior to October 1st of each year.

D. The food item cost cannot exceed 10 percent (10%) of the State average cost per ounce for that food group. Food groups include:

1.

Milk

2.

Eggs

3.

Cereal

4.

Infant Cereal

5.

Tuna

6.

Cheese

7.

Juice

8.

Dried Beans/Peas and Peanut Butter

9.

Carrots

E.

The food item must be acceptable to participants.

II. Nutrition Quality

A. Cereal - Adult

1.

Contains a minimum of 28 mg of iron per 100 gm of dry cereal.

2.

Contains not more than 21.1 gm of sucrose and other sugars per 100 gm of dry

cereal (less than 6 gm per ounce). High fiber cereals (5 gm or more) must not

contain more than 6 gm of total sugar per 100 gm of dry cereal.

3.

Contains not more than 500 mg of sodium per 1 ounce of dry cereal.

4.

Contains no artificial or non-nutritive sweeteners.

B.

Cereal - Infant

1.

Contains a minimum of 45 mg of iron per 100 gm of dry cereal.

2.

Contains no added sugar.

3.

Contains no added fruit.

4.

Contains no added formula

C.

Milk

1.

Contains 400 IU vitamin D per quart.

2.

Contains 2,000 IU vitamin A per quart.

3.

Contains no added sugar or flavorings.

4.

No Buttermilk

D. Cheese

FP-134

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-29 (cont'd)

Domestic Cheese (pasteurized, processed American, Monterey Jack, Colby, Natural Cheddar, Mozzarella, Swiss) Sliced Cheese (American, Cheddar, Swiss)

E.

Peanut Butter and Canned/ Dried Beans and Peas

1.

Including, but not limited to: black, navy, kidney, garbanzo, soy, pinto, great

northern, red, white, lima, black, broad, fava, cranberry, roman, and mung beans;

crowder, cow, split, black-eyed and pigeon peas, chickpeas, and lentils.

2.

No flavored beans/peas allowed.

3.

No peanut butter and jelly, honey, marshmallow, or chocolate combinations.

F.

Juice

1.

Single strength or frozen concentrate or canned concentrate or pourable, 100% fruit

juice

2.

30 mg vitamin C per 100 ml of reconstituted juice, minimum.

3.

Contains no added sugar.

4.

Calcium fortified juice allowed with counseling and CPA approval. See Attachment

FP- 36 for distribution guidelines.

5.

No infant juices allowed.

G. Eggs Whole, large, grade A.

H. Carrots Mature, raw or canned, packaged in water only.

I.

Tuna

100% tuna, water packed only.

III. Packaging

A. Food must be prepackaged, no bins.

B.

Cereal (adult and infant)

1.

No single serving containers.

2.

Adult cereal weight must be in whole numbers, minimum of 9 ounces, not to exceed

36 ounces.

3.

Infant cereal only in eight (8) or sixteen (16) ounce packages.

C.

Cheese

1.

Brick or sliced cheese only, no shredded.

2.

Cheese from the dairy case only, no deli cheese.

3.

Plain cheese only, no additions of products such as jalapeno peppers.

4.

A minimum of 9 ounces, not to exceed 16 ounces.

D. Juice

1.

No single serving containers.

2.

No fresh squeezed.

3.

Containers must be easily and clearly identified as fortified with 30 mg of vitamin C

per 100 ml of juice, except orange juice and grapefruit juice.

4.

Forty-six (46) ounce cans or plastic bottles, 12 ounce frozen cans, 12 ounce cans

concentrate, or 11.5 oz pourable cans or 5.5 to 6 ounce can.

E.

Eggs

FP-135

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-29 (cont'd)

One dozen size carton only.

F.

Milk- (Cow)

G. 1. One gallon size: Whole, Reduced Fat (2%), Low fat (1%), Lite ( %), Skim (Non-Fat). 2. One-half gallon or quart size containers only for Lactose Reduced milk. 3. Twelve ounce cans only for Evaporated milk. 4. Three or 5 quart boxes for Powdered milk. 5. 8 ounce box for ultra high temperature (UHT) milk.

Milk - (Meyenberg Goat Milk) 1. Quart size: Low Fat or Whole Goat Milk 2. Twelve ounce cans Evaporated or Powdered Goat milk. 3. Quart size: ultra high temperature (UHT) Goat milk.

H. Carrots One pound plastic bag, pre-packaged with wire or adhesive tape or 14 to 16 ounce can.

I.

Tuna

6 ounce can only.

J.

Peanut Butter

18 ounce jar only.

K.

Dried Beans/Peas

One pound bag or 14 to 16 ounce can.

IV. Formula

A. Complete Formula

1.

Iron fortified infant formula that contains at least 10 mg iron per liter of formula at

standard dilution.

2.

67 kcal per milliliter (approximately 20 kcal per fluid ounce at standard dilution).

B.

Formula Not Meeting the Requirements for a Complete Formula

1.

Formula intended for use as an oral feeding and prescribed by a physician when the

participant has a medical condition that precludes the use of conventional formula

or food.

2.

Allow supplements to be used in conjunction with an appropriate prorated food

package. Substitute a specified amount of supplement per quart or can of milk or

formula.

FP-136

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-30

WIC Approved Foods List Effective October 1, 2004 Only the following list of foods may be purchased with WIC vouchers

FOOD ITEM MILK
PASTEURIZED
MEYENBERG GOAT MILK

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

CONTAINER/PACKAGE SIZE
One Gallon ONLY

NOT ALLOWED

Makes 3 Quarts Makes 5 Quarts
12 oz. Can
8 oz. or Half-Pint Box

Flavored Milk Buttermilk Soy Milk Rice Milk Raw Milk (non-
pasteurized milk)

One Gallon Gallon
1 Quart Carton
1 Quart Carton
12 oz. Can (makes 3 quarts)

Evaporated Milk (If listed on voucher)

12 oz. Can

CHEESE
Fat Free, Low Fat or 2% Allowed

UHT Milk (If listed on voucher)

1 Quart Carton

Slices Any Brand (Wrapped or unwrapped)
Block Any Brand

American Swiss Cheddar
American Cheddar Colby Monterey Jack Mozzarella Swiss (Combinations allowed i.e. Colby/Jack)

Minimum Package Size is 9 oz.

Cheese Product Flavored Cheese Cheese Food Shredded
Cheese Cheese Slices from
Delicatessen 8 oz. Package Two 8 oz.
Packages to equal 16 oz.

FP-137

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-30 (cont'd)

FOOD ITEM
EGGS
DRIED PEAS/BEANS
CANNED PEAS/BEANS (Legumes Only)

BRAND OR TYPE
Least Expensive Brand Only
Any Brand without Flavoring
Any Brand (If Listed on the Voucher)

PEANUT BUTTER

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

INFANT FORMULA

As listed on front of the voucher

INFANT CEREAL Brands: Beech Nut, Gerber or Del Monte Types: Rice, Barley, Oatmeal, Mixed
(Boxes Only)

TUNA

Any Brand - Water Packed Only

CONTAINER/PACKAGE SIZE
1 Dozen Carton Grade A Large ONLY 1 lb. Package ONLY
14 to 16 oz. Can ONLY
18 oz. Jar ONLY
As listed on the front of the voucher
Dry Cereal in 8 oz. or 16 oz. Box
6 oz. Can ONLY

NOT ALLOWED
Any other size or quantity
Any other size or quantity
Flavored Peas Flavored Beans Any other size or
quantity Flavored Peas Flavored Beans Any other size or
quantity Marshmallow
Added Chocolate Added Honey Spread Jelly Added
Formula not listed on the voucher
Baby Cereal in Jars Dry Cereal w/ Fruit
added Dry Cereal w/
Formula added
Tuna packed in oil

CARROTS
C E R E A L

Any Brand - Fresh (Whole)

Any Brand - Canned (Sliced, Medium-Cut) (If Listed on the Voucher)

Brand Name General Mills

Type CheeriosWhole Grain Oat CheeriosMulti Grain Corn Chex Country Corn Flakes Kix Multi-Brand Chex Rice Chex Total Corn Flakes Wheat Chex Wheaties Whole Grain Total

1 lb Pre-sealed Plastic Bag 14 to 16 oz. Can

Bulk, frozen, shredded or baby carrots

9 oz. Box or above, not to exceed the maximum amount listed on the voucher.
Can mix and match sizes and types.

8 oz. box or less Flavored Oatmeal Flavored Grits Any type, brand or
variety of cereal other than the ones listed.

FP-138

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-30 (cont'd)

FOOD ITEM
C E R E

BRAND OR TYPE

Brand Name

Type

CONTAINER/PACKAGE SIZE

NOT ALLOWED

Jim Dandy Kellogg's

Quick Grits - Iron Fortified
Complete Oat Bran Flakes Complete Wheat Bran Flakes Corn Flakes Crispix Mini Wheats- Frosted Bite-size or Big Bite Mini Wheats Raisin Mini Wheats
Strawberry Product 19 Special K

9 oz. Box or above, not to exceed the maximum amount listed on the voucher.
Can mix and match sizes and types.

8 oz. Box or less Flavored Oatmeal Flavored Grits Any type, brand or
variety of cereal other than the ones listed.

Malt-O-Meal

Crispy Rice Frosted Mini Spooners Original Hot Wheat
2 Minute Toasty O's

A

Nabisco

L
Post

Cream of Wheat Regular flavor 10 minutes 2 minutes 1 minute Instant
Banana Nut Crunch Bran Flakes Grape Nuts or Grape Honey Bunches of Honey Bunches of

Quaker

Crunchy Corn Bran Instant Grits Instant Oatmeal King Vitamin Life-plain Oat Bran Ready to Eat Quaker Squares
Crunchy Oatmeal w/ Brown Sugar

FP-139

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-30 (cont'd)

FOOD ITEM
C E R E A L

BRAND OR TYPE
Only the 18 brands of cereal on the left can be purchased in any of the types on the right.

American Fare (K-mart) Bi-Lo Flavorite Food Lion Great Value (Wal-Mart) Hy-Top IGA Kroger Laura Lynn Our Family Piggly Wiggy Price Wise Publix Ralston Save-A-Lot Shurfine Southern Home Winn Dixie

Bran Flakesenriched wheat or high fiber Corn Flakes
Crispy Corn Puffs Crispy Rice or
Crisp Rice Crunchy Nuggets GritsInstant,
regular Multigrain Flakes Nature's Grain Nutty Nuggets Oat O's Oatmealregular
flavor-Instant Shredded Wheat-
frosted or bite size Silly Spheres Tasteeos Toasted Oat or
Toasted Oats Whole Grain 100

CONTAINER/PACKAGE SIZE

NOT ALLOWED

9 oz. Box or above, not to exceed the maximum amount listed on the voucher.
Can mix and match sizes and types.

8 oz. Box or less Flavored Oatmeal Flavored Grits Any type, brand or
variety of cereal other than the ones listed.

FP-140

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-30 (cont'd)

FOOD ITEM

BRAND OR TYPE

Brand Name

J

Least Expensive Brand Only

U
Great Value

Hy-Top

I

Kroger

Lucky Leaf

Seneca (Red Label)

Shurfine

C

Thrifty Maid

White House

Welch's

E
100% Juice Vitamin C Fortified
and/or Calcium Fortified

Seneca Old Orchard Libby's Juicy Juice

Type Orange Pineapple Grapefruit Tomato 100% Vegetable
Juice or 100% Vegetable Juice Cocktail Apple
Apple Apple Apple Apple Apple Apple Apple Grape White Grape Grape White Grape All Flavors
All Flavors

Welch's (Blends)
Dole
Libby's Juicy Juice
Welch's

White-GrapeRaspberry
White-GrapeCranberry
White-Grape-Peach White-Grape-Pear
Pineapple Orange Pine-Orange
Banana
All flavors
All flavors

CONTAINER/PACKAGE SIZE

NOT ALLOWED

46 oz. Ready to Serve Cans
46 oz. Ready to Serve Plastic Bottles
11.5 oz. or 12 oz. Frozen Concentrate
(5.5 oz. and 6 oz. CAN IS ALLOWED ONLY IF
LISTED ON VOUCHER)

Juice drink Fresh squeezed
juice Infant juice Juice with sugar
added Sports drink Cartons of Juice Single Serving Size V-8 Splash

12 oz. Frozen Concentrate ONLY 46 oz. Cans 46 oz. Plastic Bottles 11.5 oz. Frozen Concentrate
12 oz. Frozen Concentrate
11.5 oz. Non-frozen pourable concentrate

FP-141

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-31

WIC Approved Formulas/Medical Foods

Contract Infant Formula: a,b
Enfamil with Iron ProSobee with Iron Enfamil Lipil with Iron ProSobee Lipil with Iron

Mead Johnson Nutritionals Mead Johnson Nutritionals Mead Johnson Nutritionals Mead Johnson Nutritionals

Contract Infant Formula Prescription Required: a,b

Enfamil LactoFree Lipil

Mead Johnson Nutritionals

Enfamil Next Step Lipil

Mead Johnson Nutritionals

Enfamil Next Step ProSobee Lipil

Mead Johnson Nutritionals

Enfamil Low Iron Lipil

Mead Johnson Nutritionals

Enfamil AR Lipil

Mead Johnson Nutritionals

Non-Contract Formulas/Medical Foods Requiring a Prescription and Diagnosis: a,d,c

FP-142

GA WIC 2005 PROCEDURES MANUAL

Formula Acerflex
Advera Alimentum Alimentum Advance AlitraQ Analog MSUD Analog XLEU Analog XLYS,TRY Analog XMET Analog XMTVI Analog XP Analog XPHEN,TRY Analog XPTM Boost
Boost Breeze
Boost Fiber
Boost High Protein Boost Plus
Boost Pudding Casec
Choice d.m.
Citrisource Compleat Modified Compleat Pediatric Compleat Regular Complex MSUD Amino Acid Bars

Manufacturer Scientific Hospital Supplies Ross Products Ross Products Ross Products
Ross Products SHS
SHS
SHS
SHS
SHS
SHS SHS
SHS
Mead Johnson Mead Johnson Mead Johnson Mead Johnson Mead Johnson Mead Johnson Mead Johnson Mead Johnson Novartis Novartis
Novartis
Novartis
Applied Nutrition Corporation

Formula Criticare HN
Crucial Ctrotein Cyclinex 1 Cyclinex 2 Deliver 2.0
Discontinued Similac 24

Manufacturer Mead Johnson Nestle Novartis Ross Products Ross Products Mead Johnson Ross Products

Discontinued Ross Products Similac 24 with iron

Discontinued Sustacal Discontinued Sustacal Plus Discontinued Sustacal Pudding Discontinued Sustacal with Fiber Duocal E028 Extra Elecare Elementra EnfaCare Lipil Enfamil 24

Mead Johnson Mead Johnson Mead Johnson
Mead Johnson
SHS SHS Ross Nestle Mead Johnson Mead Johnson

Enfamil 24 with iron

Mead Johnson

Enfamil AR
Enfamil Human Milk Fortifier

Mead Johnson Mead Johnson

Enfamil Human Milk Fortifier with iron

Mead Johnson

Enfamil Next Mead

Step Soy

Johnson

Enfamil Premature Lipil 20

Mead Johnson

FP-143

Attachment FP-31 (cont'd)

Formula Enfamil Premature Lipil 20 with iron

Manufacturer Mead Johnson

Enfamil Premature Lipil 24 Enfamil Premature Lipil 24 with iron Enlive Ensure Ensure High Protein Ensure Plus Ensure Plus HN Ensure Pudding Ensure with Fiber Entrition 0.5 Entrition HN EO28 Pediatric Fiber Pro Fiber Source Fiber Source HN Forta Drink Forta Shake Glucerna Gluco-Pro
Glytrol Hominex-1 Hominex-2 Introlite Isocal
Isomil Isomil 2 Advance Isomil Advance Isomil DF IsoPro

Mead Johnson
Mead Johnson
Ross Products Ross Products Ross Products
Ross Products Ross Products
Ross Products
Ross Products
Nestl Nestl SHS
Novartis Novartis Novartis
Ross Products Ross Products Ross Products Nutrition Medical Nestle Ross Products Ross Products Ross Products Mead Johnson Ross Products Ross Products
Ross Products
Ross Products Nutrition Medical

GA WIC 2005 PROCEDURES MANUAL

Formula IsoSource 1.5 Isosource HN Isosource Standard I-Valex-1 I-Valex-2 Jevity KetoCal Ketonex-1 Ketonex-2 Kindercal
L-Elemental
L-Elemental Hepatic L-Elemental Plus L-Elemental Pediatric Lipisorb
Lo*Pro
Lofenalac
Magnacal Renal Maxamaid UCD Maxamaid XMTVI Maxamaid MSUD Maxamaid XMET Maxamaid XP Maxamaid XPHEN,TYR Maxamum XMET Maxamum XMTVI Maxamum MSUD Maxamum XLEU

Manufacturer Novartis Novartis
Novartis
Ross Products Ross Products Ross Products SHS Ross Products Ross Products Mead Johnson Nutrition Medical Nutrition Medical Nutrition Medical Nutrition Medical Mead Johnson Med-Diet Labs Mead Johnson Mead Johnson SHS
SHS
SHS
SHS
SHS
SHS
SHS
SHS
SHS
SHS

Formula

Manufacturer

Maxamum SHS

XLYS,TRY

Maxamum SHS

XP

MCT Oil

Mead

Johnson

Meritene

Novartis

Methionaid SHS

Microlipids Mead

Johnson

Moducal

Mead

Johnson

MSUD AID SHS

Neocate

SHS

Neocate

SHS

Junior

Neocate

SHS

Junior

Tropical

Fruit

NeocateOne+ SHS

NeoSure

Ross Products

Advance

Nepro

Ross Products

Nestl Good Nestl

Start 2

Essentials

Soy (was

Carnation

Follow-up

Soy)

Nestl Good Nestl

Start Essen-

tials Soy (was DISCONTINUED

Carnation

ITEM

Alsoy)

Nestl Good Nestl

Start

Supreme Soy

DHA & ARA

Nitro-Pro Nutrition

Medical

NovaSource Novartis

Renal

NuBasics

Nestl

NuBasics 2.0 Nestl

NuBasics

Nestl

Juice Drink

NuBasics

Nestl

Plus

FP-144

Attachment FP-31 (cont'd)

Formula NuBasics VHP Nutramigen
Nutren 1.0 Nutren 1.0 with Fiber Nutren 2.0 Nutren Junior Nutren Junior with Fiber Nutren1.5 NutriHep NutriRenal NutriVent Osmolite Osmolite HN Plus Parents Choice Soy Pediasure Pediasure w/Fiber Peptinex Oral Pediatric Peptinex DT Pediatric Peptinex DT w/Fiber Pepdite One+ Peptamen Peptamen Junior Peptamen Junior Oral Peptamen VHP Peptamen VHP Oral Peptide Perative Periflex Phenex 1 Phenex 2

Manufacturer Nestl
Mead Johnson Nestl Nestl
Nestl Nestl
Nestl
Nestl Nestl Nestl Nestle Ross Products Ross Products
Wyeth Nutrition Ross Products Ross Products
Novartis
Novartis
Novartis
SHS
Nestl Nestl
Nestl
Nestl
Nestl
Novartis Ross Products SHS Ross Products Ross Products

GA WIC 2005 PROCEDURES MANUAL

Formula PhenylAde Amino Acid Bars PhenylAde Amino Acid Blend PhenylAde Drink Mixes
PhenylAde MTE Amino Acid Blend Phenyl-Free 2 Phenyl-Free 2HP Phlexy 10 Bar Phlexy 10 Capsules Phlexy 10 Drink Mix PKU-Express
PKU-Gel
Polycose Portagen
Pregestimil 20 Pregestimil 24 ProBalance Product 3200AB Product 3232 A Product 80056 ProMod Promote Pro-Pepetide for Kids Pro-Peptide
Pro-Peptide VHN Pro-Phree Propimex-1

Manufacturer Applied Nutrition Corporation Applied Nutrition Corporation Applied Nutrition Corporation Applied Nutrition Corporation Mead Johnson Mead Johnson SHS
SHS
SHS
Vitaflo Limited Vitaflo Limited Ross Products Mead Johnson Mead Johnson Mead Johnson Nestle Mead Johnson Mead Johnson Mead Johnson Ross Products Ross Products Nutrition Medical Nutrition Medical Nutrition Medical Ross Products Ross Products

Formula

Manufacturer

Propimex-2 Ross Products

Prosobee

Mead

Johnson

ProViMin Ross Products

Pulmocare Ross Products

RCF

Ross Products

RE/Neph Nutra/Balanc

HP/HC

e

RE/Neph Nutra/Balanc

LP/HC

e

Reabilan

Nestl

Reabilan HN Nestl

Renalcal Diet Nestl

Replete

Nestl

Replete with Nestl

Fiber

Resource

Novartis

Benecalorie

Resource

Novartis

Diabetic

Resource

Novartis

Fruit

Beverage

Resource Just Novartis

for Kids

Resource Just Novartis

for Kids with

Fiber

Resource

Novartis

Plus

Resource

Novartis

Standard

Respalor

Mead

Johnson

Ross CHO Ross Products

Free

Scandical

Scandipharm

Calorie

Booster

Scandishake Scandipharm

Scandishake Scandipharm

Lactose Free

Scandishake Scandipharm

Sugar Free

Similac

Ross Products

Human Milk

Fortifier with

iron

FP-145

Attachment FP-31 (cont'd)

Formula

Manufacturer

Similac

Ross Products

Natural Care

Similac PM 60/40 Similac Special Care Advance 20

Ross Products Ross Products

Similac Special Care Advance 24

Ross Products

Similac Special Care Advance with Iron 20

Ross Products

Similac Special Care Advance with Iron 24

Ross Products

Subdue
Suplena Tolorex
TraumaCal
TwoCal HN Ultracal
Ultra-Pro
Vital High Nitrogen Vivonex Pediatric Vivonex Plus Vivonex T.E.N.

Mead Johnson Ross Products Mead Johnson Mead Johnson Ross Products Mead Johnson Nutrition Medical Ross Products
Novartis
Novartis Novartis

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-31 (cont'd)

a. Low iron formula may be indicated only for limited conditions. Low iron formulas may be indicated for participants with hemochromatosis, hemosiderosis, neonatal iron storage disease, polycythemia, thalassemia, hyperferremia, sickle cell anemia, liver disease, pancreatic insufficiency, cardiac defects with cyanosis, and those participants requiring frequent transfusions. Low iron formula is not authorized for colic, spitting up, vomiting, cramps, constipation, diarrhea, fussiness, or for partially breastfed infants/children.
b. Ready-to-feed formula may be indicated in limited documented cases, such as: (1) Unsanitary or restricted water supply (2) Inadequate refrigeration (3) Caregiver has a documented condition which inhibits the proper dilution of concentrated or powder formula.
c. If a physician orders a product that is not on this list, contact the Nutrition Section to determine whether the product is authorized for distribution through the WIC Program.
d. Special formulas may be acquired through the Nutrition Section. See the Georgia WIC Program Procedures Manual, Food Package Section for appropriate procedure and forms.

FP-146

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-31 (cont'd)

Formula Manufacturers

Carnation Nutritional Products
800 No. Brand Boulevard Glendale, California 91203 (800) 628-BABY [2229]

Nutra/Balance Products
7155 Wadsworth Way Indianapolis, Indiana 46219 (800) 432-3134

Foodtec Manufacturing Company
273 Franklin Road Randolph, New Jersey 07869 (201) 361-7004

Nutrition Medical
308 12th Avenue, South Buffalo, Minnesota 55313 (800) 569-7828

Mead Johnson Nutritional Group 2400 W. Lloyd Expressway Evansville, Indiana 47721 (800) 247-7893 - Adult Products (800) BABY-123 [222-9123] - Pediatric Products
Med-Diet Laboratories, Inc. 3050 Ranchview Lane Plymouth, Minnesota 55447 (612) 550-2020; FAX (612) 550-2022 (800) 633-3438: Consumer Telephone Number
Nestl Clinical Nutrition (formerly Clintec Nutrition) Three Parkway North, Suite 500 P.O. box 760 Deerfield, Illinois 60015-3186 (708) 317-2800; FAX (708) 317-3186 (800) 422-ASK2 [2752]: Infolink
Novartis Nutrition (formerly Sandoz Nutrition) 5320 W. Twenty-third St. St. Louis Park, Minnesota 55416 (800) 333-3785

Ross Products Division 625 Cleveland Avenue Columbus, Ohio 43216 (800) 551-5838 (800) 227-5767: Consumer Information
Scandipharm, Inc. 2200 Inverness Center Parkway Suite 310 Birmingham, Alabama 35242 (800) 950-8085
Scientific Hospital Supplies, Inc. (SHS) P.O. Box 117 Gaithersburg, Maryland 20884 (800) 365-7354 or (301) 840-0408 FAX (301) 963-7026
Vitaflo Limited Distributed Through: Transitional Service and Operation 123 East Neck Road Huntington, New York 11743 (631) 547-5984

FP-147

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-32

PROCUREMENT OF SPECIAL FORMULA
Hospital-based infant formulas may be ordered (only by a physician) to meet the nutritional needs of pre-term infants and children with special health care needs.
Generally these products are designed for use in a hospital setting and are not available for retail sale. County health departments may acquire these products through a system established by the Nutrition Section or in rare instances through a local pharmacy (WIC Vendor). When acquiring a product through the Nutrition Section use the following procedure:
1. District WIC Coordinator or designated staff will fax to the Procurement of Special Formula form complete with the following information (see Attachment FP-33): a. Date b. Name of client c. Birth date d. Diagnosis e. Name of formula f. Manufacturer's name g. Amount of formula requested, list as number of cases or total fluid ounces h. Type of formula, list as ready-to-feed, concentrate, powder i. Estimated time on formula j. Formula issue month k. Prescribing physician l. Hospital discharged form m. Clinic contact person/telephone number n. District contact person/signature
2. Call the Nutrition Section to notify of incoming fax.
3. Document request for formula and distribution in participant's health record.
4. Verify that the order meets requested specifications, then complete and sign the shipping receipt form. Also complete and sign the DHR Receiving Report and return to the address provided on the form.
Submit order(s) monthly. The total fluid ounces per order must not exceed the maximum monthly allowance. County health departments should receive shipment within 5 working days.
Notify the Nutrition Section immediately if an incorrect order is delivered, or if there is a change in the formula order.
Note: For accounting purposes return the special order packing slip to the Nutrition Section, 2 Peachtree Street NW, Suite 11-222, Atlanta, GA 30303-3142.
Only a complete case(s) may be returned by the Nutrition Section to the formula company for credit.

FP-148

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-33

SPECIAL FORMULA ORDER FORM

I. TO BE COMPLETED BY DISTRICT/LOCAL STAFF

Date:

Nutrition Section called and notified of incoming fax. Written prescription with medical diagnosis attached. Returned packing slip to the Nutrition section when formula was received.

1. Name of WIC client 2. Birth date 3. Diagnosis 4. Name of formula requested 5. Product number/manufacturer of formula 6. Amount of formula requested 7. Type of formula: ready to feed, concentrate, powder, single
use bottle, etc. 8. Estimated time on formula 9. Formula issue month 10. Clinic contact person/phone no. 11. Address/telephone number to ship formula 12. Prescribing Physician 13. Hospital discharged from 14. District contact person 15. WIC/Nutrition Coordinator's signature
II. TO BE COMPLETED BY NUTRITION SECTION 1. Formula Cost of this order (including price per case) 2. Date order placed to formula company 3. Clinic/District's account number 4. Contact person at formula company/phone no. 5. Anticipated date of delivery 6. Nutrition Section Nutrition Consultant's signature
III. TO BE COMPLETED BY STATE WIC BUDGET OFFICER 1. Purchasing authorization number/initial date 2. Field Purchase Order # / initial date 3. WIC Financial Director's signature

CALL THE NUTRITION SECTION AND FAX TO FRANCES COOK, NUTRITION SECTION PHONE: (404) 657-2884 FAX: (404) 657-2886

FP-149

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-34

SUPPLEMENTAL FORMULA CONVERSION TABLE
Caloric Displacement Method

Monthly RX *Moducal (13 oz powder)

Maximum Cans of Formula Allowed

Infant

Child/Woman

Concentrate- Powder- Concentrate-

Powder-

31 cans

8 - 16 oz

35 cans

9 - 16 oz

1 can

28

7

32

8

2 cans

25

6

29

7

3 cans

23

5

27

6

4 cans

20

5

24

6

** Polycose (12 oz powder)

1 can

28

7

32

8

2 cans

25

6

29

7

3 cans

23

5

27

6

4 cans

20

5

24

6

*** MCT Oil (32 fl oz bottle)

1 bottle 2 bottles

17

4

21

5

3

1

7

2

Infant is allowed a maximum of 403 fl oz of concentrated formula per month.

Child/Woman is allowed a maximum of 455 fl oz of concentrated formula per month.

*

Moducal powder: 1 can contains 46 TBSP/1400 Calories

**

Polycose powder: 1 can contains 59 TBSP/1330 Calories

***

MCT Oil: 1 bottle contains 960 cc/64 TBSP/7300 Calories

3 teaspoons = 1 TBSP 1 fl oz = 30 cc 13 oz can standard concentrated contract formula = 40 Cal/fl oz 13 oz can standard reconstituted contract formula = 20 cal/fl oz

FP-150

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-36

Formula Food Package Index Reference Pages 1
199
Participant Tracking Voucher ............................................................................................................................45
2
221
2 cans juice, 24 oz infant cereal...........................................................................................................................45
299
Breastfeeding Message ........................................................................................................................................45
A
ALIMENTUM OR ALIMENTUM ADVANCE
25-1 qt cans OR 25-32 oz plastic bottles RTF....................................................................................................58 25-1 qt cans OR 25-32 oz plastic bottles RTF, 2 cans juice, 24 oz infant cereal ............................................58 8-1 pound cans powder.......................................................................................................................................57 8-1 pound cans powder, 2 cans juice, 24 oz infant cereal ...............................................................................58
ALIMENTUM OR ALIMENTUM ADVANCE CHILD
25-1 qt cans OR 25-32 oz plastic bottles RTF....................................................................................................88 25-1 qt cans OR 25-32 oz plastic bottles RTF, 3 cans juice, 24 oz cereal........................................................89 28-1 qt cans OR 28-32 oz plastic bottles RTF....................................................................................................88 28-1 qt cans OR 28-32 oz plastic bottles RTF, 3 cans juice, 36 oz cereal........................................................88 9-1 pound cans powder.......................................................................................................................................87 9-1 pound cans powder, 3 cans juice, 36 oz cereal...........................................................................................87
E
ENFAMIL
25-1 qt cans RTF ...................................................................................................................................................38 25-1 qt cans RTF, 2 cans juice, 24 oz infant cereal............................................................................................38
ENFAMIL AR LIPIL
25-32 oz cans RTF ....................................................................................................................................................55 25-32 oz cans RTF, 2 cans juice, 24 oz infant cereal..................................................................................................56 5-12.9 oz cans powder .............................................................................................................................................55 5-12.9 oz cans powder, 2 cans juice, 24 oz infant cereal ...........................................................................................55 9-12.9 oz cans powder .............................................................................................................................................54 9-12.9 oz cans powder, 2 cans juice, 24 oz infant cereal ...........................................................................................55
ENFAMIL AR LIPIL CHILD
11-12.9 oz cans powder .......................................................................................................................................83 11-12.9 oz cans powder, 3 cans juice, 36 oz cereal ...........................................................................................82 28-32 oz cans RTF,................................................................................................................................................83 28-32 oz cans RTF, 3 cans juice, 36 oz cereal.....................................................................................................83
ENFAMIL CHILD
25-1 qt cans RTF, 2 cans juice, 24 oz cereal...............................................................................................................72 25-1 qt cans RTF, 3 cans juice, 36 oz cereal...............................................................................................................71
ENFAMIL LIPIL OR PROSOBEE LIPIL
100-8 oz cans RTF.................................................................................................................................................64 100-8 oz cans RTF, 12-5.5 to 6 oz cans juice, 3-8 oz boxes of infant cereal ................................................................66 1-12.9 oz can powder ...........................................................................................................................................40 1-12.9 oz can powder, 2 cans juice, 24 oz infant cereal ...................................................................................40 13-13 oz cans concentrate....................................................................................................................................39 13-13 oz cans concentrate, 2 cans juice, 24 oz infant cereal ............................................................................39 25-32 oz cans RTF.................................................................................................................................................41 25-32 oz cans RTF, 2 cans juice, 24 oz infant cereal .........................................................................................41 31-13 oz cans concentrate....................................................................................................................................38 31-13 oz cans concentrate, 2 cans juice, 24 oz infant cereal ............................................................................39

FP-156

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-35 (cont'd)

3-12.9 oz cans powder .........................................................................................................................................40 3-12.9 oz cans powder, 2 cans juice, 24 oz infant cereal..................................................................................40 5-12.9 oz cans powder .........................................................................................................................................41 5-12.9 oz cans powder, 2 cans juice, 24 oz infant cereal..................................................................................41 9-12.9 oz cans powder .........................................................................................................................................39 9-12.9 oz cans powder, 2 cans juice, 24 oz infant cereal..................................................................................40
ENFAMIL LIPIL OR PROSOBEE LIPIL CHILD
100-8 oz cans RTF, 23-5.5 to 6 oz cans juice, 4-9 oz boxes cereal ...................................................................96 11-12.9 oz cans powder .......................................................................................................................................78 11-12.9 oz cans powder, 3 cans juice, 36 oz cereal ...........................................................................................78 28-32 oz cans RTF.................................................................................................................................................78 28-32 oz cans RTF, 3 cans juice, 36 oz cereal.....................................................................................................78 35-13 oz cans concentrate....................................................................................................................................77 35-13 oz cans concentrate, 3 cans juice, 36 oz cereal........................................................................................77
ENFAMIL LOW IRON LIPIL
8-14.3 oz cans powder .............................................................................................................................................54 8-14.3 oz cans powder, 2 cans juice, 24 oz infant cereal ...........................................................................................54
ENFAMIL NEXT STEP OR ENFAMIL NEXT STEP LIPIL
10-12 oz OR 5-24 oz cans powder ............................................................................................................................51 10-12 oz OR 5-24 oz cans powder, 2 cans juice, 24 oz infant cereal ..........................................................................51 1-12 oz can powder .................................................................................................................................................51 1-12 oz can powder, 2 cans juice, 24 oz infant cereal ...............................................................................................51 5-12 oz cans powder................................................................................................................................................52 5-12 oz cans powder, 2 cans juice, 24 oz infant cereal..............................................................................................52
ENFAMIL NEXT STEP OR ENFAMIL NEXT STEP LIPIL CHILD
10-12 oz OR 5-24 oz cans powder, 3 cans juice, 24 oz cereal ..........................................................................81 12-12 oz OR 6-24 oz cans powder ......................................................................................................................81 12-12 oz OR 6-24 oz cans powder, 3 cans juice, 36 oz cereal ..........................................................................80
ENFAMIL NEXT STEP SOY OR ENFAMIL NEXT STEP PROSOBEE LIPIL
10-12 oz OR 5-24 oz cans powder ............................................................................................................................52 10-12 oz OR 5-24 oz cans powder, 2 cans juice, 24 oz infant cereal ..........................................................................52 1-12 oz can powder .................................................................................................................................................53 1-12 oz can powder, 2 cans juice, 24 oz infant cereal ...............................................................................................53 5-12 oz cans powder................................................................................................................................................53 5-12 oz cans powder, 2 cans juice, 24 oz infant cereal..............................................................................................53
ENFAMIL NEXT STEP SOY OR ENFAMIL NEXT STEP PROSOBEE LIPIL CHILD
10-12 oz OR 5-24 oz cans powder, 3 cans juice, 24 oz cereal ..........................................................................81 12-12 oz OR 5-24 oz cans powder ......................................................................................................................82 12-12 oz OR 6-24 oz cans powder, 3 cans juice, 36 oz cereal ..........................................................................81
ENFAMIL OR PROSOBEE
1-14.3 oz can powder ...........................................................................................................................................37 1-14.3 oz can powder, 2 cans juice, 24 oz infant cereal ...................................................................................37 13-13 oz cans concentrate....................................................................................................................................36 13-13 oz cans concentrate, 2 cans juice, 24 oz infant cereal ............................................................................36 31-13 oz cans concentrate....................................................................................................................................35 31-13 oz cans concentrate, 2 cans juice ..............................................................................................................35 31-13 oz cans concentrate, 2 cans juice, 16 oz infant cereal ............................................................................36 31-13 oz cans concentrate, 2 cans juice, 24 oz infant cereal ............................................................................35 4-14.3 oz cans powder .........................................................................................................................................37 4-14.3 oz cans powder, 2 cans juice, 24 oz infant cereal..................................................................................37 8-14.3 oz cans powder .........................................................................................................................................36 8-14.3 oz cans powder, 2 cans juice, 24 oz infant cereal..................................................................................37

FP-152

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-35 (cont'd)

ENFAMIL OR PROSOBEE CHILD
10-14.3 oz cans powder, 3 cans juice, 36 oz cereal ...........................................................................................70 25-13 oz cans concentrate, 2 cans juice, 24 oz cereal........................................................................................69 31-13 oz cans concentrate....................................................................................................................................68 31-13 oz cans concentrate, 2 cans juice, 24 oz cereal........................................................................................69 31-13 oz cans concentrate, 2 cans juice, 36 oz cereal........................................................................................69 35-13 oz cans concentrate, 3 cans juice, 36 oz cereal........................................................................................68 8-14.3 oz cans powder .........................................................................................................................................70 8-14.3 oz cans powder, 3 cans juice, 24 oz cereal .............................................................................................70 8-14.3 oz cans powder, 3 cans juice, 36 oz cereal .............................................................................................71 9-14.3 oz cans powder, 3 cans juice, 24 oz cereal .............................................................................................71
L
LACTOFREE OR ENFAMIL LACTOFREE LIPIL........................................................................................................48 1-14.3 OR 1-12.9 oz can powder...............................................................................................................................49 1-14.3 OR 1-12.9 oz can powder, 2 cans juice, 24 oz infant cereal.............................................................................49 13-13 oz cans concentrate, 2 cans juice, 24 oz infant cereal ......................................................................................48 25-1 qt cans RTF ......................................................................................................................................................50 25-1 qt cans RTF, 2 cans juice, 24 oz infant cereal ....................................................................................................50 31-13 oz cans concentrate ........................................................................................................................................47 31-13 oz cans concentrate, 2 cans juice.....................................................................................................................48 31-13 oz cans concentrate, 2 cans juice 24 oz infant cereal .......................................................................................47 31-13 oz cans concentrate, 2 cans juice, 16 oz infant cereal ......................................................................................48 3-14.3 OR 4-12.9 oz cans powder .............................................................................................................................50 3-14.3 OR 4-12.9 oz cans powder, 2 cans juice, 24 oz infant cereal ...........................................................................50 8-14.3 OR 9-12.9 oz cans powder .............................................................................................................................49 8-14.3 OR 9-12.9 oz cans powder, 2 cans juice, 24 oz infant cereal ...........................................................................49
LACTOFREE OR ENFAMIL LACTOFREE LIPIL CHILD
10-14.3 OR 11-12.9 oz cans powder, 3 cans juice, 24 oz cereal .......................................................................75 10-14.3 OR 11-12.9 oz cans powder, 3 cans juice, 36 oz cereal .......................................................................74 25-1 qt cans RTF, 2 cans juice, 24 oz cereal .......................................................................................................77 25-13 oz cans concentrate, 2 cans juice, 24 oz cereal........................................................................................74 28-1 qt cans RTF, 3 cans juice, 36 oz cereal .......................................................................................................76 31-13 oz cans concentrate....................................................................................................................................72 31-13 oz cans concentrate, 2 cans juice, 24 oz cereal........................................................................................73 31-13 oz cans concentrate, 2 cans juice, 36 oz cereal........................................................................................73 35-13 oz cans concentrate, 3 cans juice, 36 oz cereal........................................................................................72 8-14.3 OR 9-12.9 oz cans powder .......................................................................................................................75 8-14.3 OR 9-12.9 oz cans powder, 3 cans juice, 24 oz cereal ...........................................................................76
LOW IRON ENFAMIL DISCONTINUED
31-13 oz cans concentrate ........................................................................................................................................53 31-13 oz cans concentrate, 2 cans juice, 24 oz infant cereal ......................................................................................54
N
NON-CONTRACT SOY FORMULA: CARNATION ALSOY OR NESTLE GOOD START ESSENTIALS SOY
9-14 oz cans powder OR 9 - 12.9 OZ CANS POWDER NESTLE GOOD START SUPREME SOY DHA & ARA..61 9-14 oz cans powder OR 9 - 12.9 OZ CANS POWDER NESTLE GOOD START SUPREME SOY DHA & ARA, 2
cans juice, 24 oz infant cereal.........................................................................................................................61
NON-CONTRACT SOY FORMULA: CARNATION ALSOY OR NESTLE GOOD START ESSENTIALS SOY OR 10 12.9 OZ CANS POWDER NESTLE GOOD START SUPREME SOY DHA & ARA CHILD
10-14 oz cans powder, 3 cans juice, 36 oz cereal ......................................................................................................84
NON-CONTRACT SOY FORMULA: ISOMIL 2
9-14 oz cans or 4-30 oz cans powder........................................................................................................................62 9-14 oz cans or 4-30 oz cans powder, 2 cans juice, 24 oz infant cereal..........................................................62

FP-153

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-35 (cont'd)

NON-CONTRACT SOY FORMULA: ISOMIL 2 CHILD
10-14 oz OR 4-30 oz powder OR 11-12.9 oz powder Isomil 2 Advance .......................................................85 10-14 oz OR 4-30 oz powder OR 11-12.9 oz powder Isomil 2 Advance, 3 cans juice, 36 oz cereal ...........85 NON-CONTRACT SOY FORMULA: ISOMIL OR ISOMIL ADVANCE 9-12.9 OR 9-14 oz cans powder ..........................................................................................................................61 9-12.9 OR 9-14 oz cans powder, 2 cans juice, 24 oz infant cereal...................................................................62 NON-CONTRACT SOY FORMULA: ISOMIL OR ISOMIL ADVANCE CHILD 11-12.9 OR 10-14 oz cans powder, 3 cans juice, 36 oz infant cereal...............................................................85
NON-CONTRACT SOY FORMULA: ISOMIL OR ISOMIL ADVANCE OR CARNATION ALSOY OR NESTLE GOOD START ESSENTIALS SOY OR NESTLE GOOD START SUPREME SOY DHA & ARA
31-13 oz cans concentrate....................................................................................................................................60 31-13 oz cans concentrate, 2 cans juice, 24 oz infant cereal ............................................................................60
NON-CONTRACT SOY FORMULA: ISOMIL OR ISOMIL ADVANCE OR CARNATION ALSOY OR NESTLE GOOD START ESSENTIALS SOY OR NESTLE GOOD START SUPREME SOY DHA & ARA CHILD
35-13 oz cans concentrate, 3 cans juice, 36 oz cereal........................................................................................84
NUTRAMIGEN LIPIL
8-1 pound cans powder or 31-13 oz cans concentrate.....................................................................................57 8-1 pound cans powder or 31-13 oz cans concentrate, 2 cans juice, 24 oz infant cereal .............................57
NUTRAMIGEN LIPIL CHILD
8-1 pound cans powder OR 31-13 oz cans concentrate...................................................................................86 8-1 pound cans powder OR 31-13 oz cans concentrate, 3 cans juice, 24 oz cereal ......................................87 9-1 pound cans powder OR 35-13 oz cans concentrate, 3 cans juice, 36 oz cereal ......................................86
P
PEDIASURE CHILD
108-8 oz cans RTF, 3 cans juice, 36 oz cereal.....................................................................................................92 60-8 oz cans RTF, 3 cans juice, 36 oz cereal.......................................................................................................91 90-8 oz cans RTF, 3 cans juice, 36 oz cereal.......................................................................................................91
PEDIASURE WITH FIBER CHILD
108-8 oz cans RTF, 3 cans juice, 36 oz cereal.....................................................................................................94 30-8 oz cans RTF, 3 cans juice, 36 oz cereal.......................................................................................................92 60-8 oz cans RTF, 3 cans juice, 36 oz cereal.......................................................................................................93 90-8 oz cans RTF, 3 cans juice, 36 oz cereal.......................................................................................................93 PORTAGEN 8-1 pound cans powder.......................................................................................................................................59 8-1 pound cans powder, 2 cans juice, 24 oz infant cereal ...............................................................................59
PORTAGEN CHILD
8-1 pound cans powder, 3 cans juice, 24 oz cereal...........................................................................................90 9-1 pound cans powder, 3 cans juice, 36 oz cereal...........................................................................................90
PREGESTIMIL
8-1 pound cans powder.......................................................................................................................................59 8-1 pound cans powder, 2 cans juice, 24 oz infant cereal ...............................................................................59
PREGESTIMIL CHILD
8-1 pound cans powder.......................................................................................................................................89 8-1 pound cans powder, 3 cans juice, 24 oz cereal...........................................................................................90 9-1 pound cans powder, 3 cans juice, 36 oz cereal...........................................................................................89
PROSOBEE LIPIL CHILD FOOD PACKAGE DISCONTINUED...SEE ENFAMIL LIPIL OR PROSOBEE LIPIL
11-12.9 oz cans powder .......................................................................................................................................79 11-12.9 oz cans powder, 3 cans juice, 36 oz cereal ...........................................................................................79 28-32 oz cans RTF.................................................................................................................................................80 28-32 oz cans RTF, 3 cans juice, 36 oz cereal.....................................................................................................80 35-13 oz cans concentrate....................................................................................................................................79 35-13 oz cans concentrate, 3 cans juice, 36 oz cereal........................................................................................79
PROSOBEE LIPIL FOOD PACKAGE DISCONTINUED...SEE ENFAMIL LIPIL OR PROSOBEE LIPIL

FP-154

GA WIC 2005 PROCEDURES MANUAL

Attachment FP-35 (cont'd)

1-12.9 oz can powder ...........................................................................................................................................43 1-12.9 oz can powder, 2 cans juice, 24 oz infant cereal ...................................................................................43 13-13 oz cans concentrate....................................................................................................................................42 13-13 oz cans concentrate, 2 cans juice, 24 oz infant cereal ............................................................................42 25-32 oz cans RTF.................................................................................................................................................45 25-32 oz cans RTF, 2 cans juice, 24 oz infant cereal .........................................................................................45 31-13 oz cans concentrate....................................................................................................................................42 31-13 oz cans concentrate, 2 cans juice, 24 oz infant cereal ............................................................................42 3-12.9 oz can powder ...........................................................................................................................................44 3-12.9 oz can powder, 2 cans juice, 24 oz infant cereal ...................................................................................44 5-12.9 oz cans powder .........................................................................................................................................44 5-12.9 oz cans powder, 2 cans juice, 24 oz infant cereal..................................................................................44 9-12.9 oz cans powder .........................................................................................................................................43 9-12.9 oz cans powder, 2 cans juice, 24 oz infant cereal..................................................................................43

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Attachment FP-36

Calcium Fortified Juices
Calcium-fortified Juices Guidelines, Procedures & Recommendations Calcium-fortified juice that meets the minimum Federal requirements for a WIC-eligible juice (100 percent fruit/vegetable juice that contains 30 milligrams of vitamin C per 100 milliliters of juice) is WIC-eligible. It may be used for the fruit/vegetable juice component of the WIC food packages up to the maximum quantities for juice. WIC State agencies have the option of approving calcium-fortified juice for inclusion on their lists of approved WIC juices, as they do with other WIC-eligible foods. State agencies are encouraged to develop policies and procedures for local agencies to follow when issuing calcium-fortified juice.
Juice, including calcium-fortified juice, cannot be prescribed as a substitute for the dairy products in WIC Food Packages. Calcium-fortified juice also should not be offered routinely to all WIC women and children participants. It should be prescribed only to address specific nutritional need of individuals whose dietary intake of calcium-rich food products is low due to reasons such as cultural food preferences, dislike of milk, or lactose intolerance.
The 2004-2006 Georgia WIC Approved Food List will remove calcium-fortified juice from the INELIGIBLE ITEMS. But it will additionally not be highlighted as a juice on the approved food list. If the CPA determines a possible benefit to include calciumfortified juice in the food package, that client can be instructed to purchase calciumfortified juices. The vendor manual and training will indicate that calcium-fortified juices that meet federal regulation above may be included in any food package (types, least expensive where appropriate, and container sizes all apply). Calcium-fortified juices are currently available in limited flavors and package sizes.

Counseling Recommendations: 1. If clients have never tried calcium-fortified juices, recommend they try just one container of calcium-fortified juice to see if they like the taste. Some have found this to be bitter compared to the `regular' juices. 2. Provide counseling on other sources of calcium as part of the nutrition education session along with handouts. 3. The calcium-fortified juices can be purchased with any of the existing child and adult packages, but this is to be recommended secondary to the client assessment. We are not promoting this as a dairy alternative, but merely making it available as an option as deemed appropriate.

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Attachment FP-37

Date:
SAMPLE 6/11/04

*Number of Cans
Received "R" Issued "I"
Destroyed "D"
5 cans / I D
R I D

Formula Name & Size of
Container
Enfamil Lipil 12.9 oz Powder

Formula Tracking Log Returned formula & Free Trade Formula

Client's Name

Client's WIC ID #

Reason for Receiving, Issuing or Discarding Formula

Smith, John

000-000-000-00

Food Package change to Lacto Free, client returned unused formula.

Signature of WIC Staff
Todd R. Stormant RD, LD

R I D

R I D

R I D

R I D

R I D

R I D

R I D

R I D

R I D

R I D

R I D

R I D

*Cases must be converted to cans

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GA WIC 2005 PROCEDURES MANUAL

Nutrition Education

I. II. III. IV.
V.
VI.
VII.
VIII.

TABLE OF CONTENTS

Page

Purpose.................................................................................................................... NE-1

Definition................................................................................................................. NE-1

Goals ........................................................................................................................ NE-1

State Agency ........................................................................................................... NE-1

A. Nutrition Staff................................................................................................... NE-1

B. Nutrition Education Responsibilities............................................................ NE-2

Local Agency .......................................................................................................... NE-3

A. Nutrition Staff................................................................................................... NE-3

B. Nutrition Education Responsibilities............................................................ NE-4

C. Training ............................................................................................................. NE-5

D. Nutrition Education Plan................................................................................ NE-5

Participant Nutrition Education .......................................................................... NE-7

A. Participant Nutrition Education Requirements........................................... NE-7

B. Documentation of Nutrition Education........................................................ NE-9

Participant Referral to Other Agencies ............................................................. NE-10

A. Referrals........................................................................................................... NE-10

B. Documentation ............................................................................................... NE-11

Nutrition Education Materials ........................................................................... NE-11

A. Criteria for Development and Use .............................................................. NE-11

NE-1

GA WIC 2005 PROCEDURES MANUAL

Nutrition Education

Attachments:

Page

NE-1 WIC Maternal High Risk Criteria ...................................................................... NE-13

NE-2 WIC High Risk Criteria for Infants and Children ........................................... NE-14

NE-3 Guidelines for Nutrition Assistant Training.................................................... NE-15

NE-4 SOAP Note Documentation Format.................................................................. NE-20

NE-5 Material Evaluation Form................................................................................... NE-21

NE-2

GA WIC 2005 PROCEDURES MANUAL

Nutrition Education

I. PURPOSE
This section of the Georgia WIC Program Procedures Manual defines the concept of nutrition education; states the goals for nutrition education; and explains the requirements for providing nutrition education to WIC participants.

II. DEFINITION
"Nutrition Education" is a dynamic process by which individuals gain the understanding, skills, and motivation necessary to promote and protect their nutritional well being through their food, physical activity, and behavioral choices. Nutrition education shall be focused on the client's interests and designed based on ethnic, cultural, and geographic preferences and with consideration for language, educational, and environmental factors.

III. GOALS
Nutrition education for WIC participants is designed to achieve two broad goals:
A. Emphasize the relationship between proper nutrition, physical activity, and good health, with emphasis on the nutritional needs of pregnant, breastfeeding and postpartum non-breastfeeding women, infants, and children less than five (5) years of age.
B. Assist the individual who is at nutritional risk in achieving positive changes in food and physical activity behaviors, in order to improve nutritional status and to prevent nutrition-related problems, through the optimal use of supplemental foods and other nutritious foods.

IV. STATE AGENCY
A. Nutrition Staff
The delegation of WIC nutrition education activities is vested within the Georgia Department of Human Resources, Division of Public Health, Family Health Branch, Nutrition Section.
The nutrition education component of the WIC Program is carried out under the direction of a qualified nutritionist (M.A., M.S. or M.P.H., and a

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registered dietitian, or eligible for registration as a dietitian). The responsibilities of this person are to plan, direct, and coordinate the nutrition education component of the WIC Program.
Nutrition program consultants in the Nutrition Section are available to districts/units as a resource in order to facilitate the State's efforts to strengthen and integrate Maternal and Child Health services (MCH) and WIC nutrition services. Current staff assignments are available from the Nutrition Section.
B. Nutrition Education Responsibilities
The State agency responsibilities for nutrition education:
1. Develop, implement, and evaluate the State Nutrition Education Plan. Periodically review, and evaluate, and make appropriate revisions as necessary.
2. Develop guidelines for local agency Nutrition Education Plan development. Review each plan and provide feedback.
3. Monitor the progress of local agency Nutrition Education Plans on a periodic basis through on-site visits and reports.
4. Evaluate the nutrition services of all local agencies.
5. Develop and implement a plan for providing training and technical assistance for WIC competent professional authorities (CPA's) and nutrition assistant staff at local clinics. Training and technical assistance provides WIC competent professional authorities with current information on the nutritional management of normal and high-risk participants, special problems, and emerging issues in nutrition.
6. Identify and develop resource and education materials for use at local agencies. Provide materials in languages other than English in areas where a substantial number of persons are non-English speaking.
7. Coordinate WIC nutrition education activities with related programs and professional groups such as the Cooperative

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Nutrition Education

Extension Service, Food Stamp Program, professional organizations, advisory committees, etc.
8. Develop and implement procedures to assure that nutrition education is offered to all adult participants, child participants whenever possible, and to parents or caretakers of infant or child participants.
9. Perform and document evaluation of nutrition education activities on an annual basis. The evaluation shall include an assessment of participant's views concerning the effectiveness of the nutrition education they received.
10. Establish standards for participant contacts that ensure adequate nutrition education.
11. Monitor local agency activities to ensure compliance with defined local agency responsibilities and participant nutrition education contacts.

V. LOCAL AGENCY
A. Nutrition Staff
1. Each of the WIC local agencies must be staffed with a minimum of one (1) public health nutritionist in the class of Nutrition Services Director, Nutrition Program Manager, or Nutrition Manager. This nutritionist will be designated as the District Nutrition Coordinator. Duties include: planning, organizing, implementing, and evaluating the nutrition service component of the WIC Program. This encompasses development and approval of nutrition education materials, development of the nutrition education plan, and implementation of nutrition risk criteria.
2. Each WIC local agency must be staffed with a minimum of one (1) nutritionist for every one thousand (1,000) high-risk participants. The ability of each local WIC agency to meet this requirement will be assessed in FFY 2005-2006. Based on the findings, the requirement will be fully implemented in FFY 2007.

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Nutrition Education

3. Nutrition positions should be appropriately classified according to the Performance Plus class specifications for nutrition personnel. The Performance Plus Nutritionist class specifications should be used for nutritionists providing direct client nutrition services, and these nutritionists should receive supervision from a higher level public health nutritionist.
4. The Performance Plus class specifications for nutrition personnel and qualifications and compensation levels are available on request from the Georgia Merit System of Personnel Administration.

B. Nutrition Education Responsibilities
The local agencies shall perform the following activities in carrying out their nutrition education responsibilities:
1. Provide nutrition education to all adult participants, parents or caretakers of infant or child participants, and whenever possible, to child participants. Program participants may be encouraged to assist in providing nutrition education to other participants (e.g. the use of a breastfeeding participant to talk with participants who are interested in breastfeeding). Individual or group sessions and/or education materials designed for program participants may be utilized for the delivery of nutrition education services to non-participating women, infants, and children who take part in other local agency health services.
2. Provide in-service training and technical assistance for competent professional authorities (CPA's) and nutrition assistants at local clinics.
3. Develop a Nutrition Education Plan consistent with the nutrition education portion of the State Plan.
4. Develop a system for the regular assessment of participant views on nutrition education and breastfeeding promotion, at least on an annual basis. This data shall be used in the development and revision of the Nutrition Education Plan. The findings shall be reported annually in the Nutrition Education Plan Update that is due to the Nutrition Section three times a year (end of February, June, and October).

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Nutrition Education

C. Training
1. Orientation
The WIC CPA must receive training on anthropometric and hematological measurements, nutrition risk assessment, and food package assignments prior to being assigned to certify WIC participants.
The WIC CPA must also receive competency based nutrition skills within 24 months of employment. This training should cover nutritional management of normal and high-risk perinatal women, infants, children, and adolescents; and breastfeeding management in normal and special situations.
2. Continuing Education
a. The CPA must receive at least four (4) hours of nutrition training each year. All CPA's are encouraged to attend local, state, or national workshops or meetings to develop and update skills and knowledge in nutrition and lactation management.
b. All nutrition training and continuing education activities conducted or attended by the local staff must be recorded and kept on file by the local agency. The file should include the name and title of the participant and the title and date of the workshop.
D. Nutrition Education Plan
1. Triennial Nutrition Education Plan
A Nutrition Education Plan must be submitted to the Nutrition Section by April 15, 2005. The time-span is planned to align with the 2010 Goals for the Nation. This Plan should be incorporated in the local agency strategic plan for WIC and nutrition services, and must be integrated with the overall WIC plan that is due to the Georgia WIC Branch on the same date.
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GA WIC 2005 PROCEDURES MANUAL

Nutrition Education

a. The local agency Nutrition Education Plan must include:
(1) The local agency GOAL for Nutrition education; (2) OBJECTIVES to reach the stated goal; (3) STRATEGIES to achieve the objective; (4) ACTION STEPS for activities/methods for each
strategy; (5) PERSON RESPONSIBLE for each action step; (6) TIME FRAME to complete action steps; (7) RESOURCES NEEDED to accomplish each step; (8) STATUS of implementation or completion of action
steps.
b. Plans must relate to nutrition education services.
c. The Nutrition Education Plan should address at a minimum: nutrition education contacts, nutrition materials, local and state goals.
d. Format and form Local agencies must submit the plan, using the format developed by the State Agency.
2. Nutrition Education Plan Report
a. The Nutritional Education Plan Report must be submitted to the Nutrition Section three (3) times a year by the following deadlines: February 28th, covering the period from October through December. June 30th, covering the period from February through May. October 31st, covering the period from June through September.
b. The reporting form/format will be sent to the local agencies by the beginning of FFY 2004.

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Nutrition Education

VI. PARTICIPANT NUTRITION EDUCATION
A. Participant Nutrition Education Requirements
1. All adult participants and caretakers of child participants must be provided with two (2) nutrition education contacts (must receive nutrition education on two different occasions) during each six (6) month certification period, but not within the same day/clinic visit. For prenatal women and parents/caretakers of infant participants certified for a period in excess of six (6) months, nutrition education contacts shall be made available at a quarterly rate, but not necessarily taking place within each quarter. Participants must be encouraged to attend and participate in nutrition education activities, but cannot be denied supplemental foods for failure to attend or participate in the provided activities.
2. The nutrition education contacts shall be made available through individual or group sessions, which are appropriate to the individual participant's nutritional needs.

3. A local agency must contact the Nutrition Section for technical assistance prior to initiating the implementation of a nutrition education program or strategy that is not conducted through individual or group, face-to-face sessions. Any non-direct nutrition education session, for example Internet, self-direct computer module, etc. must be approved prior to implementation. Upon receipt of the local agency request, the Nutrition Section staff will review the proposed nutrition education program/strategy and provide the local agency with initial feed back within thirty (30) days. If USDA approval is required the Nutrition Section and the WIC Branch will assist the local agency in obtaining the approval.
4. All participants shall receive nutrition education contacts, which relate to their particular nutrition risk condition and the need for a well balanced diet. As much as is reasonably possible, nutrition education sessions should focus on the participant's nutritional interests.
5. All participants shall receive at least one nutrition education contact during each certification period which relates to their own (or their child's) dietary intake, as assessed by the CPA.

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Nutrition Education

Visual aids, such as food models or measuring cups, should be used to obtain a good assessment of dietary intake and to help the participant learn about portion sizes.

6. Counseling in regards to the need for regular physical activity may be documented as nutrition education, since physical activity relates to energy balance, and thus contributes to nutritional status. Encouragement to decrease physical inactivity should be provided.

7. All high-risk WIC participants (as defined in Attachment NE-1 and NE-2) must be scheduled to receive a high-risk nutrition education contact during the current certification period. If someone provides the high-risk contact other than a nutritionist, adequate documentation must be provided.

8. All women participants must receive exit counseling by the final nutrition education contact of the postpartum period. Exit counseling is defined as counseling which includes the following topics which are to be discussed by the final nutrition education contact:
a. Importance of folic acid intake
b. Health risks of using alcohol, tobacco, and other drugs
c. Continued breastfeeding as the preferred method of infant feeding (for those women who are breastfeeding)
9. Importance of up-to-date immunizations.
10. Parents or caretakers of WIC infants and children must also be provided with information about abuse of drugs and other harmful substances.
11. The Nutrition Guidelines for Practice is the established guide for nutrition education contacts.
12. Nutrition education contacts must be provided by a nutritionist, registered dietitian, registered and licensed practical nurses, physician, physician's assistant, or other certified health

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Nutrition Education

professional that has been trained by the State or local agency. Nutrition assistants can provide nutrition education contacts when appropriate nutrition education training has been received. The Nutrition Section must approve the training plan. (See Attachment NE-3 for the Guidelines for Nutrition Assistant Training and list of items to be submitted for approval.)
13. An individual nutrition care plan should be developed for a participant, based on need, as determined by the CPA. The Nutrition Care Plan should be written using the SOAP (Subjective Objective Assessment Plan) note format. (See Attachment NE-4 for the SOAP Note Documentation Format).
14. A lesson plan must be developed when group classes are used to provide the nutrition education contact. Lesson plans must be kept at the clinic site for use by clinic staff and provided to the Nutrition Section at the time of program reviews.
15. If the participant/caregiver is unable to receive services at the clinic for an extended period of time, home visits are the recommended method for providing secondary nutrition education contacts.

B. Documentation of Nutrition Education
1. All individual nutrition education services and contacts received by participants must be documented in the participant's health record.
a. In order to facilitate continuity of care, specific aspects of nutrition counseling must be documented (e.g., introduction of solids; portion sizes for the 2-3 year old; ways to increase fluid intake).
b. The POMR (Problem Oriented Medical Record)/SOAP note format is the recommended method of documentation. A flow sheet may be used as long as it contains all components of a SOAP note.
2. Group nutrition education contacts may be documented with the participant's signature on a class attendance sheet, voucher register (or VPOD receipt) and a class roster which contains the

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Nutrition Education

lesson objective(s) and the original signature of the staff conducting the class. A description of the district's method of documentation must be submitted for approval prior to implementation.
3. Documentation of nutrition education contacts must include the date, topic, and method by which the nutrition education contact was provided (e.g., class, kiosk, individual counseling, etc.).
4. Missed appointments for nutrition education contacts and the refusal of a participant/caregiver to receive nutrition education must be documented in the participant's health record.

VII. PARTICIPANT REFERRAL TO OTHER AGENCIES
Participants must be assessed for referrals during each certification appointment.
A. Referrals
1. Participants must be referred to the Food Stamp Program, Medicaid and Temporary Assistance for Needy Families (TANF). Participants shall be informed of these programs and, if needed, be provided with the addresses and telephone numbers of local/State offices.
2. Local agencies are encouraged to coordinate with and refer participants to the Cooperative Extension Service, Expanded Food and Nutrition Education Program (EFNEP).
3. Local agencies should refer participants to other health services offered within the health department system and other agencies and services. These include, but are not limited to:

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Maternal Health Programs
High Risk Pregnancy Program Family Planning Program Sexually Transmitted Disease
Assistance Programs
Food Stamps Medicaid Right from the Start Temporary Assistance for
Needy Families (TANF) Headstart

Child Health Programs
Children's Medical Services Immunization Program Lead Screening Program Health Check Dental Health Program
Community Resources
AIDS Program Private Physician Mental Health and Substance Abuse Program

4. Prenatal or breastfeeding participants needing additional breastfeeding information, assistance or support should be referred to the appropriate person(s) designated through the local agency breastfeeding program.

B. Documentation
Referrals to and enrollment in other health services and programs must be documented in the participant's health record. A decision not to refer or a refusal by the participant must also be documented.

VIII. NUTRITION EDUCATION MATERIALS
A. Criteria for Development and Use
1. All nutrition education materials and forms used and developed locally for WIC participants must be approved by the District Nutrition Coordinator or designee. See Materials Evaluation Form for guidance (Attachment NE-5). The Nutrition Section is available for consultation and technical assistance to review nutrition education materials.

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2. Sample copies of all nutrition education materials used by the local agency, must be made available to the Nutrition Section during the program review.
3. All nutrition education materials used must accurately reflect current documented scientific knowledge of nutrition.
4. Materials must be prepared to meet needs of the specific population group to be served, including migrant farm workers, and homeless persons. Consideration must be given to the reading level as well as to cultural and language needs of clients.
5. The Nutrition Section reserves the right to disapprove the use of nutrition education materials if it determines them to be inappropriate.
6. If a local agency develops materials that are applicable statewide, the Nutrition Section may seek approval from the local agency to duplicate these materials.

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Attachment NE-1

WIC MATERNAL HIGH RISK CRITERIA
Any WIC prenatal, breastfeeding, or non-breastfeeding woman who has the following high risk factors must receive nutrition counseling specific to their nutritional condition and to the nutritional problems identified in their diet, as reflected in an individual care plan. In most instances, a nutritionist should provide this counseling. However, if the CPA determines that some other intervention or referral would be more appropriate, adequate documentation must be provided.

High Risk Criteria
Hemoglobin or hematocrit at treatment level
Pre-pregnancy/postpartum underweight (>10% below midpoint of normal weight for height range OR Body Mass Index <19.8)

Risk Code 201
101, 102

Pre-pregnancy/postpartum obesity (>36% above mid-point of normal weight for height range OR Body Mass Index >29)

111, 112

Low maternal weight gain or weight loss during pregnancy
Nutrition-related medical conditions; presence of any disease or condition affecting nutritional status that requires a therapeutic diet as ordered by a physician or health professional acting under standing orders of a physician
EDC or delivery prior to 17th birthday
Blood lead level > 10 g/dl
Breastfeeding (BF) complications; referral to appropriate BF counselor must be made
Hyperemesis Gravidarum
Gestational diabetes or history of gestational diabetes
Multifetal gestation
Any condition deemed by the competent professional authority to place the woman at high risk for compromised nutritional status; adequate documentation required

131, 132 341-349
and 351-362
331 211 602
301 302, 303
335

Appendix
B-1
C-1 Weight for
Height Table;
C-2 Body Mass Index Table; C-3 BMI Chart
C-1 Weight for Height Table; C-2 Body Mass Index Table; C-3 BMI Chart

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Attachment NE-2

WIC HIGH RISK CRITERIA FOR INFANTS AND CHILDREN
WIC infants and children who have the following high risk factors must receive nutrition counseling specific to their nutritional condition and to the nutritional problems identified in their diet, as reflected in an individual care plan. In most instances, this counseling should be provided by a nutritionist. However, if the CPA determines that some other intervention or referral would be more appropriate, adequate documentation must be provided.

High Risk Criteria Hemoglobin or hematocrit at treatment level Underweight (weight for length/height <5th %) Obesity (weight for length/height > 95th %) Short stature (length/height for age <5th %)

Risk Code 201 103 113 121

Failure to thrive; inadequate growth

134 and/or 135

Nutrition-related medical conditions; presence of any disease or condition affecting nutritional status that requires a therapeutic diet or special prescribed formula as ordered by a physician or health professional acting under standing orders of a physician

341-360; 362; 382

Low birth weight infant [infant weighing 2500 grams (5

141

pounds) or less at birth]. May be used for infants only as

high-risk criteria.

Blood lead level > 10g/dl

211

Breastfeeding complications; infants only; referral to

603

appropriate breastfeeding counselor must be made

Any condition deemed by the competent professional authority to place the infant/child at high risk for compromised nutritional status; adequate documentation required

Appendix B-2

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Attachment NE-3

GUIDELINES FOR NUTRITION ASSISTANT TRAINING
I. Qualifications for Nutrition Assistants: Who can be trained: A. WIC clerical staff and health services technicians.

B. Expanded Food and Nutrition Education Program (EFNEP) agents.

C. Volunteers with a background in Home Economics, Nutrition, Medical Science, and Health Education.

D. Nursing students who have taken at least one (1) nutrition course.

E. University students who have done nutrition/health course work.

F. Dietetic interns.

II. Competencies for Nutrition Assistants
A. Basic WIC Program Knowledge. The WIC Nutrition Assistant will be able to:
1. Describe the basic goal of the WIC Program.
2. List eligibility requirements for the WIC Program.
3. Name the State and Federal agencies that fund and administer the WIC Program.
4. Identify the district WIC staff, including the Nutrition Services Director or the Nutrition Program Manager, and where to locate the district WIC office (address and phone number).
5. Locate: (a) the local WIC clinic policies and procedures; (b) list of local area WIC vendors; (c) personal reference book (if one is developed); and (d) USDA rules and regulations or Georgia WIC Program Procedures Manual policies relating to supplemental foods and nutrition education.

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Attachment NE-3

6. Describe the process of how a WIC participant obtains WIC foods.
7. List the various WIC approved foods.
8. List notification requirements.
9. Demonstrate a thorough knowledge of individual lesson plans and content, as outlined by the district nutrition coordinator/designee. The nutrition assistant should score ninety percent or above on the written test.
B. Communication Skills. The Nutrition Assistant will be able to:
1. Demonstrate each of the following factors in a participant interview or group class:
- Making introductions - Explaining purpose of class/contact - Working within a given time frame - Listening - Using open-ended questions - Being non-judgmental - Using simple language - Conveying sincere interest - Conveying positive body language and attitude
2. Identify problems, during the individual contact or class, which are WIC, health, or staff-participant relationship oriented.
C. Referral Skills. The Nutrition Assistant will be able to:
1. Refer problems encountered during the class/individual contact to appropriate personnel.
2. Refer medical and nutrition related problems to the appropriate professional, as written in the lesson plans.
III. Requirements for Training/Continuing Education
Secondary nutrition education contacts can be provided within the following parameters:
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Attachment NE-3 (cont'd)

A. A training session must be completed,
B. The test and clinic observation must be completed for each topic area, and
C. Nutrition information given to participants must be limited to that received in the training sessions (topic area) by the nutrition assistant.
Nutrition Assistants must receive at least 12 hours of continuing education per year. These hours can be attained through:
1. Participation in the annual Competency Based Skills Workshop for nutrition assistants, provided by the Nutrition Section
2. Other nutrition conferences/workshops
3. Other health conferences with a nutrition component, covering at least two (2) hours of nutrition information.
IV. Parameters for Nutrition Assistants
Nutrition Assistants will be trained to provide very specific and limited nutrition information to WIC participants. Information will be limited to that learned in training. Referrals to the nutritionist will be made based on guidance in lesson plans and/or the training manual, and/or for questions beyond the scope of the training received by the nutrition assistant.
V. Evaluation Component
Evaluation of the nutrition assistant includes the following:
A. The nutrition assistant must score the required percentage on a test for each topic area, before being able to proceed to the next step.
B. The nutrition assistant must observe a professional providing secondary nutrition education contacts for at least one (1) clinic day, before being able to provide these her/himself.
C. The nutrition assistant must be observed conducting at least three (3) secondary nutrition education contacts before being able to do so
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GA WIC 2004 PROCEDURES MANUAL

Attachment NE-3 (cont'd)

routinely.
D. The immediate supervisor must be readily accessible to assist the nutrition assistant with problems.
E. The district nutrition coordinator (or designee) will conduct quarterly record reviews and observe the nutrition assistant providing secondary nutrition education contacts.

F. The district nutrition coordinator (or designee) will be available to provide technical supervision and to act as a resource.

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Attachment NE-3 (cont'd)

NUTRITION ASSISTANT TRAINING PLAN CHECKLIST FOR ITEMS TO SUBMIT FOR APPROVAL
Training Plan:
Lesson Plans for use in training nutrition assistants, including post-tests.
Note: These may be submitted on an on-going basis.
Evaluation Component
Plan for nutrition assistant to observe professional(s) providing secondary nutrition contacts.
Plan for nutrition coordinator (or designee) to observe nutrition assistant(s) providing secondary nutrition education contacts.
Plan to conduct quarterly chart reviews and observation of nutrition assistant(s).
Lesson Plans for use by nutrition assistant(s) in providing secondary nutrition education contacts - group class or individual counseling.
Documentation Procedures to be used by nutrition assistants.

Additional Information: Name(s) of nutrition assistant(s) being trained, and clinic(s) in which trainee is working.
Name(s) of direct supervisor(s).
Name of district nutritionist designated to provide technical assistance.

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Attachment NE-4

SOAP NOTE DOCUMENTATION FORMAT

Once the nutritional status of an individual has been determined, the assessment of the problem and intervention plans needs to be communicated to other health professionals. The use of the SOAP Note format is an excellent way of conveying this nutritional information. The data gathered during the nutrition assessment can be incorporated into the SOAP Note in the following manner:

S- Subjective Data:

-

statement of the individual's thoughts and feelings

-

individual complaints, "quotable" significant information, individual's description

of his or her problem, individual's statement of needs

-

information gained from talking with the individual, from others working with the

individual, or from the individual's relatives

-

dietary intake and reported food habits

O- Objective Data:

-

facts, tangible findings, clinical observations, documented information

-

physical findings, signs, symptoms

-

anthropometric data

-

laboratory data

-

factual information regarding background, history

-

environment, progress or problems

A- Assessment:

-

your assessment or impression of the individual's nutritional status, needs,

problems; assessment of the overall situation

-

summary and evaluation of dietary intake

-

meaning, value of the information presented

-

information still needed

-

problem definition, interpretation

P- Plan:

-

what you plan to do to obtain more information and/or educate and treat the

individual

-

referrals

-

recommendations and plans for follow-up visits

-

educational materials used and given to the individual

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Attachment NE-5

MATERIAL EVALUATION FORM

Material Name/Title:

Type:

Obtained from:

Date Received:

By:

EVALUATION CRITERIA
SPONSOR BIAS OR PROMOTION Product name not visible

MINIMALLY ACCEPTABLE

ADEQUATE

CONTENT Non-discrimination clause present

Accurate and up-to-date

Outcome no more than 3 objectives does not promote undesirable behavior

Scope topics deemed necessary useful and relevant to target audience

Appropriate for target audience's lives and environment

Clear purpose of material

Organization main ideas are clear smooth flow of material

Learning experiences seeks learner involvement appropriate knowledge/skill level suggests further learning

Summarization of ideas

References are accurate, up-to-date and usable

SUPERIOR

NE-21

GA WIC 2004 PROCEDURES MANUAL

Attachment NE-5 cont'd

EVALUATION CRITERIA

MINIMALLY ACCEPTABLE

LANGUAGE USAGE

Reading level appropriate for audience present (use SMOG)

ADEQUATE

Few technical terms used with definitions provided

Style personal few instances of negative wording respectful, non-condescending tone sentences simple, short, specific

Use of words is consistent

STEREOTYPING Appropriate role models

Minority representation presented in a factual manner variety in roles, occupation, values

Lifestyle/cultural differences are reflected

SUPERIOR

NE-22

GA WIC 2004 PROCEDURES MANUAL

Attachment NE-5 cont'd

EVALUATION CRITERIA FORMAT

MINIMALLY ACCEPTABLE

ADEQUATE

Paper quality is acceptable for intended use

Print style acceptable size appropriate

Topic headings/typographic cueing

Line width and spacing

Placement and use of illustrations

Placement and use of charts, table, graphs

Color good choice good quality

Pages appropriate length face to face

Overall visual appearance is pleasing

Quality of sound track is good

SUPERIOR

NE-23

GA WIC 2004 PROCEDURES MANUAL

Attachment NE-5 cont'd

Other Areas to be considered Prior to Purchase:

EVALUATION CRITERIA
COST Original material cost shipping/handling discount for multiples easy to obtain time to obtain

MINIMALLY ACCEPTABLE

ADEQUATE

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

Duplication allowable/legal cost of duplication

SUPERIOR

NE-24

GA WIC 2004 PROCEDURES MANUAL

Attachment NE-5 cont'd

EVALUATION CRITERIA
VIEWING/USAGE Space available for viewing/use of materials available for storage

MINIMALLY ACCEPTABLE

ADEQUATE

Easy to Use staff audience/client

Geared for group classes individual counseling/use waiting room use

Is there an easier, more efficient way to stimulate the same behavior?

RECOMMENDATIONS:

SUPERIOR

SIGNATURE/TITLE OF EVALUATOR:

DATE:

Adapted from: E.M.P.O.W.E.R. (Evaluate Materials to Promote Optimal Use of WIC Education Resources), Massachusetts WIC Program, Department of Public Health, April 1985.

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Special Population

TABLE OF CONTENTS

Page

I.

Introduction ..............................................................................................................SP-1

A. Definitions...........................................................................................................SP-1

B. Certification ........................................................................................................SP-1

C. Food Delivery .....................................................................................................SP-2

D. Outreach and Referral .......................................................................................SP-2

E. Reporting and Monitoring................................................................................SP-3

II.

Individuals Residing in Non-Traditional Housing or

Institutions ................................................................................................................SP-3

A. Definitions...........................................................................................................SP-3

B. Services for Applicants/Participants Residing In Temporary Housing....SP-4

C. Meals in Institutions and Temporary Housing .............................................SP-6

III. Other Special Populations ......................................................................................SP-7

A. Definitions...........................................................................................................SP-7

B. Limited English Proficient Population............................................................SP-8

C. Refugees ..............................................................................................................SP-9

D. Native Americans ............................................................................................SP-10

E. Persons With Disabilities ................................................................................SP-10

IV. Referral and Outreach to Special Populations...................................................SP-10

GA WIC 2005 PROCEDURES MANUAL

Special Population

Attachments:

Page

SP-1 Georgia Farm Worker Health Program ..............................................................SP-12

SP-2 Migrant Education Staff/Four Regional Offices ...............................................SP-14

SP-3 Telamon Corporation (Migrant and Seasonal Farm worker Association, Inc.) ....................................................................................................SP-15

SP-4 Interpreter Services ...............................................................................................SP-17

SP-5 Assurance Statement .............................................................................................SP-19

SP-6 Notice of Interpretation Service Sign ..................................................................SP-21

SP-7 Directory of Spanish Translators and Interpreters............................................SP-22

SP-8 Foreign Language Services for Africa, Asia and Europe ................................SP-25

SP-9 Waiver of Rights to Free Interpreter Services ....................................... SP-26

GA WIC 2005 PROCEDURES MANUAL

Special Population

I. INTRODUCTION
This section of the manual outlines program procedures for assuring access to WIC services and minimizing hardship for the segment of the population that requires non- traditional services. The program regulations require that all eligible and potentially eligible individuals have equal access to WIC benefits and services. Therefore, the local agency must make every effort to identify and reduce barriers that prohibit enrollment and service to eligible and potentially eligible clients.
WIC defines a special population as a group of persons with common needs that require special assistance and/or specific services to access and participate in WIC related services. Special population groups referenced in this section are: migrants, loggers, applicants/participants residing in institutions, homeless people, Limited English Proficient refugees, Native Americans and persons with disabilities. Local WIC Programs are responsible for ensuring accessability to WIC services for these populations.
A. Definitions
1. Migrant Farm Workers are individuals (and family members) employed seasonally in agriculture occupations, who establish temporary residence for the purpose of such employment, and have been employed in such occupation within the last twentyfour (24) months.
2. Loggers are individuals whose principal employment is seasonal harvesting of trees, who have been employed in this activity within the last twenty-four (24) months and for such employment established a temporary abode.
3. Seasonal Farm Workers are individuals employed in agriculture occupations who do not move from place to place establishing temporary residence for the purpose of work ARE NOT migrant farm workers as defined by the WIC Program.
B. Certification
The process for certifying migrant farm workers must comply with standard program procedures (see Certification Section). The local agency must issue a Verification of Certification (VOC) card to every migrant at the time of certification. A valid VOC card helps migrant
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farm workers access WIC services (See Certification Section - Transfer of Certification). The VOC card is valid until the certification period expires.
WIC certification must be documented with a VOC card or a copy of the Georgia WIC assessment form. In lieu of a VOC card, a Georgia WIC Identification (ID) card is acceptable. However, the receiving clinic must verify the information on the Georgia WIC ID Card. Vouchers must only be issued for thirty (30) days if clinic staff cannot verify certification information with the originating clinic.
C. Food Delivery
Migrants frequently remain in a local area for very short periods. It is essential that migrant certification, transfer of eligibility, and receipt of WIC foods are received as expeditiously as possible. Vouchers must be issued on the same day the migrant participant is certified.
When a migrant presents WIC vouchers from another state, the certifying clinic should void the vouchers and issue Georgia WIC vouchers as replacements. The certifying clinic must send the voided vouchers back to the state that the vouchers originated. The local agency must forward the voided vouchers to the appropriate state agency. If a migrant presents vouchers from another clinic in Georgia, the clinic staff should instruct the migrant to redeem them if they have a valid issue date (See Food Delivery Section).
D. Outreach and Referral
In geographical areas where there is significant movement of migrants' dwellings, the local agencies are required to make special effort to reach out and serve this population. The local agency should decide whether evening clinics or certifications at migrant camps are necessary. This decision should be based on migrant outreach efforts and consultation with organizations serving migrants as well as other migrant activities in the service area. All services necessary to serve migrant populations should be implemented. Special outreach and referral efforts implemented by a local agency to provide access to health services for the migrants and their families should be documented.

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Special Population

E. Reporting and Monitoring
The number of migrants participating in the Georgia WIC Program is reported on the Racial/Ethnic Participation Report generated by the Automated Data Processing (ADP) Contractor each month. Migrant information on the Turnaround Document (TAD) is completed with a Yes (Y) or No (N). To accurately determine the migrant status of an applicant or a participant, the following question must be asked, "Are you a migrant"? If necessary, WIC's definition of a migrant should be explained to the applicant/participant.
Migrant activity and expenditures are also reported on the Quarterly Status Report. The state agency is responsible for monitoring migrant services provided by local agencies. Migrant activities will be monitored according to the procedures outlined in the Monitoring Section of the Georgia WIC Procedure Manual. Local agencies with significant migrant populations, as outlined in the Monitoring Section, must conduct migrant specific outreach.

II. INDIVIDUALS RESIDING IN NON-TRADITIONAL HOUSING OR INSTITUTIONS
Local agencies must continue to serve and enroll eligible participants and applicants living in non-traditional housing environments. The Georgia WIC Program defines non-traditional housing as living accommodations where individuals or families reside for a particular purpose or need. These accommodations include, but are not limited to, private and public institutions, homeless shelters, temporary housing, (including the residences of another person), and special drug rehabilitation homes for pregnant women. Both applicant/participant and non-traditional housing representatives must comply with program procedures and policies as outlined in Section SP-II, C.
Non-traditional housing representatives who provide accommodations for WIC participants must sign an Assurance Statement (Attachment SP-5). The signed copy of this agreement, in accordance with USDA Federal Register, Volume 54, No. 239, must be on file with the Georgia WIC Branch before clients may be served.
A. Definitions
Services and program benefits must be tailored to meet the special needs of individuals defined in these groups.

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Institution is any residential accommodation, which provides meals and sleeping accommodations to a special group of people, or a facility designated as a residence for individuals intended to be in a controlled environment. Excluded are private residences and homeless facilities.
Homeless facility is a public or private supervised facility, which provides temporary living accommodations and meal services for individuals who lack a fixed and regular nighttime residence.
Homeless Individual means a woman, infant or child: a. Who lacks a fixed and regular nighttime residence. b. Whose primary nighttime residence is:
1. A supervised publicly or privately operated shelter (including a welfare hotel, a congregate shelter, or a shelter for victims of domestic violence) designated to provide temporary living accommodations.
2. An institution that provides a temporary residence for individuals intended to be institutionalized.
3. A temporary accommodation of not more than 365 days in the residence of another individual.
4. A public or private place not designed for, or ordinarily used as, a regular sleeping accommodation for human beings.
Temporary Housing refers to a residential facility or home for individuals who have lost their primary place of residence and relocate to a short term lodging facility in a private or public residence. Individuals in this category include, but are not limited to: battered women and their children in temporary shelters; homeless persons; pregnant teenagers in group homes; and individuals whose primary residence is lost as the result of a disaster.
B. Services for Applicants or Participants Residing in Temporary Housing
Local WIC Programs are responsible for ensuring accessibility to WIC services for individuals who have lost their usual (or primary) place of residence or who may be residing in temporary housing. Individuals who reside in temporary housing represent a high-risk population due to their compromised health and nutrition status and high levels of anxiety and stress. Sensitivity should be displayed with these individuals when gathering application and certification information. WIC procedures should be explained thoroughly. Applicants and participants must be

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GA WIC 2005 PROCEDURES MANUAL

Special Population

provided services in accordance with the regulations and requirements of the Georgia WIC Program (See Certification Section for Program Policies).
Individuals in this category include, but are not limited to: battered women and their children, homeless persons who may be residing in vehicles, parks, hallways, doorsteps, sidewalks, abandoned buildings, temporary shelters, hotels, motels, etc.; pregnant women residing in drug rehabilitation facilities and pregnant teenagers in a group home. Also included are individuals whose primary residence is lost as the results of a disaster (See Disaster Section).
Local agencies should make every effort to certify these applicants immediately, i.e., during the initial clinic visit. Local agencies should be flexible when issuing vouchers. If a participant is no longer residing in the clinic service area where they last received vouchers, the vouchers should be issued and the participant transferred to the nearest clinic. Employees of institutions may not serve as proxies for the residents.
Due to the nature of their temporary residence, cooking facilities, refrigeration, and acceptable storage areas may not be available. Therefore, special consideration must be given to the issuance of supplemental food packages in order to meet the participant's nutritional needs. The types of supplemental foods prescribed must take into account the cooking and storage facilities available to the participant. The food package should be tailored using alternative food packages or manual vouchers to:
1. Offer smaller amounts of more perishable foods and larger amounts of less perishable foods (amounts not to exceed Federal Regulations).
2. Offer canned evaporated milk and/or dry powder milk.
3. Offer ready-to-feed and/or powdered formula when sanitation or storage is a problem.
Education related to the use and storage of food is very important for WIC participants who reside in temporary residences. The educational information should include the following:
1. Discuss spreading out redemption of vouchers over the 4-week period.

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Special Population

2. Offer information on food storage and sanitation, when applicable.
C. Meals in Institutions and Temporary Housing
WIC Program applicants/participants who reside in institutions or temporary housing, which serve meals, may participate in the Georgia WIC Program. This may be a permanent or temporary residence such as a homeless shelter, group home, and shelter for battered women, rehabilitation facility, etc.
When determining eligibility for participation in the Georgia WIC Program, the institution and participant must adhere to the following requirements.
1. When determining income eligibility and family size of the individual(s) residing in temporary housing accommodations, do not include other residents of the institution or the temporary housing facility. The applicant's income is also separate from the general revenues of the institution.
2. The residential facility must not accrue financial or in-kind benefit from a person(s) participation in WIC. For example, transferring WIC foods to the general inventories of the facility or reducing the quantity of food provided to WIC participants.
3. Food items purchased with WIC vouchers must not be used in communal feedings. WIC foods are supplemental foods intended to enhance the participants diet and nutritional needs. If these foods are used in the communal food supply, the intent of the supplemental foods is not fulfilled.
4. No institutional constraints may be placed on the WIC participant's ability to partake of the supplemental foods and WIC associated services and benefits. Participants must have full, free, and direct access to all program benefits and services available.
The above conditions have been established to ensure that:

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Special Population

a. Participants, rather than the institution, benefit from the WIC program.
b. All eligible persons participate in WIC in the same manner and to the same degree as persons without institutional affiliation. It is vital that adequate documentation regarding these applicants/ participants is included in the medical record. This documentation includes, but is not limited to:
1. The institution where the applicant/participant resides.
2. The above conditions addressed in Section II C. 2, 3, and 4 were discussed and are understood by the applicant/participant.
3. Each applicant/participant has been informed of their rights and obligations, both verbally and in writing.

III. OTHER SPECIAL POPULATIONS
The local agencies must make every effort to alleviate barriers to WIC services for all eligible and potentially eligible individuals during critical times of growth and development. Other special population groups that the Georgia WIC Program seeks to serve include, but are not limited to individuals who may experience barriers to program services due to physical conditions, language, vision and hearing impairment, and cultural differences.
A. Definitions
The following definitions define groups identified in this section as other special population groups.
Hearing impaired refers to a person who cannot hear or has limited ability to hear.
Multilingual means the person speaks two or more languages fluently.
Native American is used to designate an American Indian or original inhabitants of America.
Non-English speaking refers to an individual whose primary language is not English or an individual who speaks little or no English.

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Special Population

Vision Impaired refers to an individual with limited ability or the inability to see.
Refugee refers to someone who flees his or her country to another country to seek protection or relief from persecution because of race, religion, nationality, their political opinion, or membership in a social group.
B. Limited English Proficient (LEP) Population
Individuals whose primary language is not English, and who do not read or speak English well enough to have access to WIC services and benefits provided in local clinics may be considered members of the Limited English Proficient population. The local agencies are responsible for ensuring that multilingual staff, volunteers, or other translation resources are available to serve Limited English Proficient (LEP) participants or LEP applicants.
In areas where a substantial number of persons have Limited English Proficiency, local agencies must carry out outreach activities to insure that eligible members of such populations participate in the program. Contact should be made with other agencies and community organizations serving LEP persons. A variety of nutrition education and breastfeeding materials are available in Spanish through the Nutrition Section.
If there is a need for materials in other languages, the local agency should contact the WIC Branch or the Nutrition Section for assistance. The Refugee Health Program has developed and compiled a library of translated health education materials. These materials are distributed, upon request, to organizations and individuals (See Attachment SP-4).
Local agencies may contract with translators or interpreters as needed. However, local agencies are encouraged to first hire multilingual staff in their programs to provide these services. Limited language interpretation services are available through the State Refugee Health Program. Specific areas of the state have identified available interpreters (See Attachment SP-4). The Nutrition Section will assist local agencies in identifying multilingual translators or interpreters.
WIC applicants or participants shall not be denied WIC services or benefits because they did not bring an interpreter to their appointment. It is the responsibility of the WIC Program to provide interpreters for WIC Services. Free interpreter services are available through agencies of the
SP-8

GA WIC 2005 PROCEDURES MANUAL

Special Population

Georgia Department of Human Resources. Although free interpreter services are available, an applicant or a participant may choose his or her interpreter, such as a family member or friend who may not be a qualified or certified interpreter. In instances when an interpreter attends a WIC visit as the client's interpreter, the applicant or participant must sign the "Client Waiver of Rights to Free Interpreter Service" form. (Attachment SP-9)
The Local agency staff must inform an applicant or a participant of the availability of qualified certified interpreter at no cost. After the information is communicated and the applicant or participant makes an informed choice to use the interpreter of his or her choice, the signed "Client Waiver of Rights to Free interpreter Services" documents that choice.
The client's interpreter will sign an acknowledgement of his or her responsibility and provide an oral translation of the informed choices statement to the WIC applicant or participant. Documentation of the actions along with a copy of the signed document must be retained in the applicant or participants record.
Federal Regulations, Section 7CFR, 246.14 (c) (5) states that the cost of translators for materials and interpreters are allowable costs. Therefore, these services are allowable and WIC funds may be used to secure these services.
The local agency must post the Notice of Interpretation Services Sign in the waiting room, front office or voucher issuance area for WIC applicants. The purpose of this sign is to indicate to the applicant that services are available at no charge to them in other languages upon request. The displaying of this sign will be monitored on program and self reviews (See Attachment SP-6).
C. Refugees
A refugee is someone who flees his or her country due to persecution or a well-founded fear of persecution because of race, religion, nationality, political opinion, or membership in a social group. With the significant number of refugees, such as Cuban, Haitian, Asians, and Vietnamese, in Georgia, every effort will be made to ensure that services are extended to these populations (See Attachment SP-4). Aliens (legal and illegal) are eligible to apply for WIC on the same basis as United States citizens.

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Special Population

The Division of Public Health, Refugee Health Program staff includes interpreters who speak Amharic, Bosnian, Cambodian, Russian, Somali, Tigtinya and Vietnamese. Program interpreters help refugees' access health care by making appointments, arranging transportation, and providing interpretation at appointments.
D. Native Americans
The WIC Program should make every effort to locate and enroll all eligible Native Americans residing within a local agencies service area.
E. Persons with Disabilities
The Georgia WIC Program is required to make program services accessible to individuals covered by the Americans With Disabilities Act. Local agencies are responsible for ensuring that individuals with disabilities are accommodated in the WIC Program. All facilities where WIC and related services are provided must be physically accessible from the outside as well as on the inside. The local programs should provide capabilities for communicating with vision and hearing impaired participants and applicants. Interpreters for the hearing impaired, are available through the State Rehabilitation Program (See Attachment SP-4).
IV. REFERRAL AND OUTREACH TO SPECIAL POPULATIONS
Local agencies must develop a network for coordinating activities with local organizations and person serving and providing resources to special population groups and minority populations. Local agencies should advise the Georgia WIC Branch of organizations and resources available in their local service area in order to maintain a current listing of statewide resources and services for migrants and special populations. Using updated information provided by the local agencies, the state agency will compile a statewide listing for persons and organizations serving migrants and other minorities (See Attachments SP-1, SP-2, SP-3 and SP-4). Local agencies should contact and distribute outreach materials to other agencies offering services to persons who reside in temporary locations. Health care may not be accessible to individuals who reside in temporary locations. Therefore, these individuals should be referred to any and all health services provided by local agencies. These high risk individuals must be referred to appropriate local health and human service agencies such as:
1. Public assistance and Temporary Assistance to Needy Families (TANF) client assistance services

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Special Population

2. Food pantries and meal programs 3. Local shelters 4. Food stamps 5. Legal services Other pertinent outreach and referral procedures may be found in the Outreach Section of the Procedures Manual.

SP-11

GA WIC 2005 PROCEDURES MANUAL

Attachment SP-1

Georgia Farm Worker Health Program P.O. Box 310
Cordele, GA 31010-0310 Phone: (229) 401-3086 Fax: (229) 401-3077

Isiah C. Lineberry, Executive Director, Office of Rural Health Services, Email: ilineberry@dch.state.ga.us Tony Brown, Migrant Health Coordinator, Office of Rural Health Services, Email: tbrown@dch.state.ga.us
Ted Meisner, Field Data Consultant, 478-746-9659, Email: laermita@asburyusa.net FAX: 630-929-1364

Project Sites Ellaville
Glennville
Coffee

Migrant Program Staff Telephone/Fax

Mary Anne Shepherd, FNP, P/Coordinator Shelby Clark, RN. Angelica Carranza, ORW Angie McIllrath, ORW Rosa Cazares, ORW Shirley Jones, Office Manager Michelle Doggett, Accounting
Christy Pike, FNP, P/Coordinator Linda Baxter, Data Entry/Secretary Manuela Galvan, ORW Jean Ulbrick, ORW Lydia Villalobos, ORW Maria Contreras, ORW Juanita Johnson, ORW

Tel: (229) 937-5321 Fax: (229) 937-2232
Tel: (912) 654-5300 Fax: (912) 654-5303 Tel: (912) 685-5765 Tel: (912) 526-8108

Sue Scaffe, District Office, Waycross

Josie Haklin, RN, P/Coordinator Kaye Hulett, Accounting Clerk Sherrill Carver, Cost Report Angelica Gomez, ORW

Tel: (912) 389-4450 Fax: (912) 389-4326

Address
Ellaville Primary Medicine Clinic 103 Broad Street P.O. Box 65 Ellaville GA 31806-9428
E-Mail: mshepherd@sumterregional.org

Counties Served
6/27/01
Schley Sumter Macon Taylor Crisp

Tattnall County Health Department 1001 N. Downing Musgrove Hwy Glennville GA 30427 E-mail: fwhealth@pineland.net
Candler County Health Department P.O. Box 205 Metter GA 30439

Tattnall Candler Toombs

Toombs County Health Department P.O. Box 191 Lyons GA 30426

6/27/01

Coffee County Health Department Atkinson

1111 West Baker Highway

Coffee

Douglas GA 31533-4920

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GA WIC 2005 PROCEDURES MANUAL

Attachment SP-1 (cont'd)

Project Sites

Migrant Program Staff Telephone/Fax

Address

Ellenton Valdosta

Blainette Hanson, FNP Dana Reddick, Nurse Manager Marisela Resendiz, Nurse's Aid Kathy French, Data Entry Jose Palomares, ORW Celines Quinones, ORW
Jody Horne, Cost Reports
Barbara Jackson, District Contact Mary Ann Bland, Accounting Steve Graham, President/CEO Dr. Manual Tovar, MD Janie McGhin, ANP-C Lydia Naylor, RN Julissa (Julie) Clapp, ORW Tomi McCain, Receptionist, ORW Dr. Antonio Gracia, MD

Tel: (229) 324-2845 Fax: (229) 324-3383
Tel: (229) 891-7100
Tel: (229) 430-4575 Fax: (229) 912-4305143
Tel and Fax: (229) 559-9910 Steve Graham's Fax: (229) 242-0490

Ellenton Clinic 103 Baker Street P.O. Box 312 Ellenton GA 31747
Colquitt Health Department Moultrie GA 1109 N. Jackson Street Albany GA 31701-2022
Airport Medical Clinic Culpepper Road P.O. Box 889 Lake Park GA 31636

Counties Served 6/27/01 Colquitt Tift Cook Brooks
Echols Lowndes

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GA WIC 2005 PROCEDURES MANUAL
MIGRANT EDUCATION STAFF Mary Jo Crawford, Director
Georgia Migrant Education Program Georgia Department of Education 1854 Twin Towers East Atlanta, GA 30334 (404) 656-2030

Attachment SP-2

REGIONAL OFFICES
Chattahoochee Flint Regional Education Service Agency P.O. Box 588
Americus, GA 31709 (229) 937-5341

Migrant Education Association Live Oak
P.O. Box 780 Brooklet, GA 30415
(912) 424-5400

Piedmont Migrant Education Association 3536 East Hall Road Gainesville, GA 30507 (770) 536-5717

Southern Pine Migrant Education Association P.O. Drawer 745
Nashville, GA 31639 (229) 686-2053

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Attachment SP-3

TELAMON CORPORATION (Migrant and Seasonal Farmworker Association, Inc.)

Herbert Williams, State Director 2720 Sheraton Dr., Suite 140D Macon, GA 31204-1167 (478) 873-6575

Field Offices

Offices Valdosta Office 200 East Mary Street Valdosta, GA 31601 (229) 244-4920

Supervisors Carmen Wilkinson Program Coordinator

Lyons Office 120 East Liberty Avenue 1020 Lyons, GA 30436 (912) 526-3094 (912) 526-5906 (FAX)

Elmira Reynolds Employment and Training Specialist

Dublin Office 112 East Johnson Street Dublin, GA 31021 (478) 275-0127 (478) 275-7548 (FAX)

Barbara Mosley Employment and Training Specialist

Douglas Office 613 West Baker Hwy. P.O. Box 966 Douglas, GA 31533 (478) 384-8856 (478) 384-8929 (FAX)

Myrtice Moore Employment and Training Specialist

Statesboro Office 105 Elm Street P.O. Box 645 Statesboro, GA 30358 (912) 764-6169 (912) 489-6516 (FAX)

Elsie Trethaway Employment and Training Specialist

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Attachment SP-3

Offices

Supervisors

Moultrie Office 19 First Street S.E. Moultrie GA 31776 (229) 985-7507 (229) 985-7305 (FAX)

Beverly Scretchen Employment and Training Specialist

Blackshear Office 3351 West Highway 84 P.O. Box 413 Blackshear GA 31516 (912) 449-3016 (912) 449-4579 (FAX)

Sharon Moody Deputy Director

MIGRANT HEAD START PROGRAMS

1)

Ms. Sandra Adams, Director

KIDDIE KASTLE I

684 N. Washington Street

Lyons GA 30445

(912) 526-9556

(912) 526-3434 (FAX)

2)

Ms. Betty Mincey, Director

KIDDLE KASTLE II

111 Oliver Lane

Glennville GA 30427

(912) 654-2182

(912) 654-2190 (FAX)

3)

Ms. Gloria Sandoval, Director

KIDDLE KASTLE III

133 Serena Drive

Norman Park GA 31771

(229) 769-3627

(229) 761-3182 (FAX)

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GA WIC 2005 PROCEDURES MANUAL

Attachment SP-4

INTERPRETER SERVICES

STATE REFUGEE HEALTH PROGRAM INTERPRETERS

Alice Long, Director

(404) 679-3031

Below are lists of interpreters available in specific areas of the State. For interpreter services not listed below, or for general information regarding health services for refugees, call the State Refugee Health Program at (404) 657-2550.

Greater Atlanta

REFUGEE HEALTH INTERPRETERS

Sabina Brovic Chanthary Chea Bay Ngyun Zyan Amedi Siya Kim Margarita Tselesin Halema Hasashi

Bosian Cambodian, Vietnamese Vietnamese Kurdish Cambodian Russian Somalia

(404) 294-3816 (404) 508-7785 (404) 657-2552 (404) 294-3816 (404) 657-2563 (404) 657-2641 (404) 657-6716

Gainesville

Anita Gougelmann Vietnamese

(770 ) 531-5600 GIST 261-5600

DFCS STATE REFUGEE COORDINATOR

Barbara Burham

(404) 657-3428

Two Peachtree ST NW

19th Floor

Atlanta, GA 30303

GEORGIA INTERPRETER SERVICES FOR THE HEARING IMPAIRED

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

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

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Attachment SP-4 (cont'd)

LIST OF INTERPRETER SERVICES

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

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Attachment SP-5

ASSURANCE STATEMENT In accordance with the Federal Register, Vol. 54, No. 239, regarding the homeless and provision of the Special Supplemental Nutrition Program for Women, Infants and Children (WIC),
(Name of shelter/facility)
...assures the Georgia WIC Branch that it will adhere to the following conditions:

1. The facility will not accrue financial or in-kind benefits from resident's participating in WIC. For example, the facility may not transfer WIC foods to its own general inventories or reduce the quantity of food that would have otherwise been provided to the WIC participant.
2. Food items purchased by the WIC Branch will not be used in communal feedings. WIC provides specific supplemental food intended to meet the individual needs of participants in crucial stages of growth and development. If WIC foods were used in communal feedings, they would not enhance the WIC participant's diet to the degree intended.
3. The facility places no constraints on the ability of the WIC participant to partake of supplemental foods and all associated WIC services made available to participants by the local WIC agency. The participant must be given free, full and direct access to all WIC program benefits such as are available to participants not associated with an institution.

The Georgia WIC Program or the local WIC agency may at it discretion, make site visits to monitor compliance to the above conditions and/or investigate complaints.

The "Assurance Statement" will remain on file in the Georgia WIC Branch until such time as the shelter/facility notifies the Georgia WIC Branch that it no longer wishes to participate according to the ascribed conditions and/or it is determined by the Georgia WIC Branch that the agency is not in compliance.

The undersigned agrees to the conditions stated and declares that he/she is the duly authorized representative of the named shelter/facility, and as such, is authorized to enter into the agreement:

(Name of shelter/facility)

(Street address or P.O. Box)

(City, State, Zip County)

(Area code-telephone number)

(Hours of telephone coverage am to pm)

Signature (Authorized Representative)

Date

Title

SP-19

GA WIC 2005 PROCEDURES MANUAL

Attachment SP-5 (cont'd)

Please return completed and signed statement to:
WIC Branch Division of Public Health Georgia Department of Human Resources Two Peachtree Street, NW
10th Floor, Suite 10-476 Atlanta GA 30303

SP-20

GA WIC 2005 PROCEDURES MANUAL

Attachment SP-6

NOTICE OF INTERPRETATION SERVICES SIGN

SP-21

GA WIC 2005 PROCEDURES MANUAL

Attachment SP-7

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

SP-22

GA WIC 2005 PROCEDURES MANUAL

Attachment SP-7

Judy R. Palmer (Freelance translator, interpreter, editor, proofreader in Spanish) 879 Springdale Road, Atlanta, GA 30306 Contact: Judy R. Palmer (404) 373-9621 Fax: (404) 479-6260 E-mail: Jurepal@mindspring.com
Elena N. Treto (Freelance translator in Spanish) Post Office Box 13623, Atlanta, GA 30324 Tel: (404) 633-7290 Fax: (404) 248-9645 E-mail: entreto@mindspring.com
Claudia Mendez Porter (Spanish translator and interpreter) Tel: (770) 736-2994 Fax: (770) 609-5242 E-mail: cmp@avana.net
Cathy McCabe (Spanish interpreter and translator) E-mail: cathspan@mindspring.com
Joaquin J. Coello (Certified Mediator and Arbitrator) 479 Wall Street, Marietta, GA 30068 Tel: (770) 973-5094 Fax: (770) 973-5094? E-mail: jcoello@csi.com
Clara Marcela Lievano (Spanish translator and interpreter services for legal/medical) 246 Ennisbrook Drive, Smyrna, GA 30082 Tel: (770) 803-0093 Work #(404) 250-2877 E-mail: clievano@mindspring.com
Ligia Mejia (English-Spanish translator) Tel: (770) 345-1251 E-mail: Lsrey@bellsouth.net
Maria Luisa Saucedo (Spanish translator) Tel: (340) 713-1584 E-mail: marilu85@go.com
Daniel G. Saavedra (Spanish translator and interpreter) 2772 Hawk Trace Court, Marietta, GA 30066-1535 Tel: (770) 982-8216 Fax: (770) 924-4707 E-mail: dansaav@mindspring.com
LW Translation Service 7185 Amberleigh Way, Duluth, GA 30097 Tel: (770) 622-4176 E-mail: lourdeswyly@mediaone.net

SP-23

GA WIC 2005 PROCEDURES MANUAL

Attachment SP-7

Lingo Link (Professor of Spanish language and small business owner) Contact: Bunderlai Souto Duhham Tel: (770) 753-8882 Fax: (770) 442-6040 E-mail: Bunderlai@mindspring,com
Bilingual Crosscultural Communications (Spanish translation, voice talent, writer) 2519 Gravey Drive NE, Atlanta, GA 30345 Contact: Yvonne de Wright Tel: (770) 493-6518 Fax: (770) 934-6996 E-mail: ydwright@aol.com
Annie Lidback Castro (Spanish, Portuguese and Italian translation services) E-mail: TransAL@alo.com
Velasco Language Services (Spanish translation of immigrant documents, etc.) 5715 Sunset Maple drive, Alpharetta, GA 30005 Contact: Pablo Velasco Tel: (770) 663-4042 E-mail: pvelasco@worldnet.att.net
Susie Maratorell (Spanish translations of medical, legal and government policies) 1006 Clifton Road, Atlanta, GA 30307 Tel: (404) 931-6619 E-mail: susy@mindspring.com
Workplace Spanish, Inc. (Full services Spanish translations and classes) Contact: Tom Sutula Tel: (770) 993-4075 Fax: (770) 992-0390 E-mail: tom@workplaceSpaish.com

SP-24

GA WIC 2005 PROCEDURES MANUAL

Attachment SP-8

Foreign Language Services for Africa, Asia and Europe

Georgia Mutual Assistance Association Consortium (GMAAC) 4151 Memorial Drive, Suite 200-D, Decatur, GA 30032 Contact: Fatana Pirzad or Marge Flaherty Tel: (404) 296-5400 Fax: (404) 296-0036
GMAAC is a non-profit organization that provides social adjustment, case management, and other services to refugees and immigrants in the greater Atlanta area. GMAAC was organized in 1984 by refugees and has served the refugee and immigrant community for over 16 years. The staff at Georgia Mutual Assistance Association Consortium speak 11 different languages and provides interpretation and translation services for medical and legal issues in Somali, Serbo-Croatian, Amharic, Farsi, Vietnamese, Cambodian, Russian, Albanian, Arabic, Laotian, Korean, French, Gujarti, Hindi, German, Italian, and Spanish. Community interpreter services charges a fee of $35.00 per hour and requests 7 to 10 days prior notice before appointments are scheduled. GMAAC also operates youth programs for refugee children in Clarkston, Stone Mountain and South Atlanta.

Vietnamese English Interpreters P.O. Box 941694, Atlanta, GA 30041 Contact: Y n Tran Tel: (404) 277-4644 A volunteer group that helps the Vietnamese community with free medical and legal translation and interpreter services at no charge.

SP-25

GA WIC 2005 PROCEDURES MANUAL

Attachment SP-9

Waiver of Rights to Free Interpreter Services

Free interpreter services are available through agencies of the Georgia Department of Human Resources (DHR). DHR will call an interpreter after identifying the primary language in which you are able to communicate. You are entitled to bring your own interpreter, however, DHR or its representative agencies will not authorize payment for interpreter services not previously secured or approved by DHR.

I, __________________________, have been informed of my right to receive free interpretive (Client Name)

services from ____________________________________. I understand that I am entitled to (Agency)

interpretive services at no cost to myself or to other family members, but do not wish to receive

DHR's free services at this time. I choose _________________________________to act as my (Interpreter's Name)

interpreter from ___________________________ until ______________________________ .

(Date)

(Date)

I understand that I may withdraw this waiver at any time and request the services of an

interpreter, which will be paid for by ________________________________________________ (DHR Agency)

To the best of my knowledge, the person I am using to act as my own interpreter is over the age of 18. I understand that this waiver pertains to interpreter services only and does not entitle my interpreter to act as my Authorized Representative. I also understand that the service agency may secure a qualified or certified interpreter to observe the interpreter of my choice during the interpreting session to ensure the accuracy of the communication and follow-up instructions.

The interpreter indicated below orally translated this form to me.

(Client's Signature)

(Date)

(Interpreter's Signature)

(Date)

(Interpreter Printed or Typed Name and Signature) (Date)

(Staff Person Signature)

(Date)

SP-26

GA WIC 2005 PROCEDURES MANUAL

Outreach

I. II. III. IV. V. VI. VII. VIII.

TABLE OF CONTENTS Page
General..................................................................................................................... OR-1 Methods of Outreach............................................................................................. OR-1 Agencies to Contact for Outreach........................................................................ OR-2 Public Notification ................................................................................................. OR-3 Public Comments Period ...................................................................................... OR-3 Outreach During a Waiting List .......................................................................... OR-3 Program Costs ........................................................................................................ OR-4 Coordination/Integration of Services................................................................. OR-4 A. Outreach ............................................................................................................ OR-4 B. WIC/Medicaid Coordination......................................................................... OR-4 C. WIC Coordination Strategies ......................................................................... OR-5 D. WIC Works Resource Center.......................................................................... OR-5

Attachments:
OR-1 Georgia WIC Program Fact Sheet........................................................................ OR-6 OR-2 BPHC Service Delivery Sites .............................................................OR-9 OR-3 Georgia Association for Primary Health Care, Inc.................................OR-19 OR-4 Georgia Farm Worker Health Program Sites..........................................OR-25 OR-5 District Map..................................................................................OR-26

GA WIC 2005 PROCEDURES MANUAL

Outreach

I. GENERAL
Outreach activities are those promotional efforts designed to encourage and/or increase participation in the WIC Program. The purpose of outreach is to:
1. Increase public awareness of the benefits of the WIC Program.
2. Inform potentially eligible persons about the WIC Program in order to encourage and promote their participation in the program.
3. Inform health and social service agencies of the WIC Program's eligibility criteria for participation and to encourage referrals.
4. Ensure cooperation and coordination between WIC benefits and other related services and programs for participants.
5. Promote a positive image of the WIC program.
6. Generate additional outreach material in other languages as appropriate.
Each local agency must conduct outreach and referral activities to coordinate the WIC Program with other programs and services, which serve potential WIC applicants. The outreach activities conducted must be documented and kept on file for four (4) years.
When funds are available, the Georgia WIC Branch will develop and provide general outreach materials for use by local programs.
II. METHODS OF OUTREACH
Outreach activities should be aimed directly at potentially eligible persons through the use of informational posters, brochures, displays in public places, presentations at meetings and clubs, advertisements through local newspapers, radio, or television. If a local agency serves a significant number of persons whose primary language is not English, the local agency must make outreach materials available to this population in their language. Additionally, The state and local agencies must contact grass root organizations such as the Latin American Association, NAACP, or churches.
The WIC HOTLINE continues to be available for information on WIC services. The WIC HOTLINE was established to give vendors, clients, staff, and the general public
OR-1

GA WIC 2005 PROCEDURES MANUAL

Outreach

direct access to the State WIC Branch at no cost. This toll-free number, 1-800-2289173, is available on printed materials and is provided during radio and television interviews.
The twenty-one (21) local WIC agencies are encouraged to communicate regularly with agencies providing services to families. These agencies are inclusive of governmental, quasi-governmental, private not-for-profit organizations, and citizen participation groups.
III. AGENCIES TO CONTACT FOR OUTREACH
State and local agencies shall provide WIC Program applicants and participants or their designated proxies with information on other healthrelated and public assistance programs, and when appropriate, shall refer applicants and participants to such programs. (CFR 246.7 Subpart C.b)
Examples of agencies, offices, and organizations that should be contacted regarding outreach, referral, and coordination of services include: 1. Alcohol/Drug Abuse Counseling and Treatment Centers 2. Family Planning Programs 3. Child Abuse Counseling Centers 4. Physicians, Obstetricians, Pediatricians, Family Practitioners, Nurses and
Nurse Practitioners 5. Health and Medical Organizations, Hospitals, Community Centers and
Clinics 6. Pharmacies 7. Public Assistance Office 8. Unemployment Offices 9. Social Service Agencies 10. Religious and Community Organizations 11. Agencies offering services for Homeless Families and Individuals 12. Housing Authorities 13. School-Based Health Clinics 14. Migrant Health Centers, Migrant Offices, Logging and Agricultural
Communities 15. Military Bases 16. Retail Stores 17. Day Care Centers 18. Charitable Organizations (Goodwill, Salvation Army, etc.) 19. Headstart Programs

OR - 2

GA WIC 2005 PROCEDURES MANUAL

Outreach

20. Division of Family and Children Services (DFCS) Offices IV. PUBLIC NOTIFICATION
The State Agency, through the Office of Public Information, will distribute outreach information to every newspaper and radio station in Georgia, at least annually. All outreach materials must include the USDA non-discrimination statement.

V. PUBLIC COMMENTS PERIOD
Each spring, the Georgia WIC Program solicits public comments regarding the State Plan of Operation and Administration through a public comment period. Public comments on the quality of WIC service delivery are also welcomed throughout the year. A letter announcing the public comment period is mailed to boards of health, district health directors, district program managers, community health centers, WIC nutrition coordinators, vendors, economic opportunity authorities, community action agencies, migrant and seasonal farm workers associations, March of Dimes, Division of Family and Children Services, Legal Aid Societies, Head Start Programs, unemployment offices, hospitals, elected officials, associations of elected officials, religious groups, special interest health groups, minority groups, grassroots organizations, retail vendors, and grocers associations. Comment boxes are also placed within local WIC offices to collect responses from participants and other patrons.
WIC Program regulations and guidelines are made available to the public upon request. This includes the USDA Federal Regulations, the Georgia State Plan, Georgia Operations Procedures Manual, and the income guidelines. The Georgia Department of Human Resources, Office of Public Affairs prepares news releases to notify the public of WIC benefits and notices soliciting public comments on WIC operations. The news releases are sent to statewide newspapers annually.

VI. OUTREACH DURING A WAITING LIST
When a waiting list is instituted by the state, a local agency cannot decide to not have a waiting list within their district due to caseload problems.
A. Outreach The USDA and DPH are fully committed to the principle of integrating WIC and health and social services while protecting the individual's right to privacy.

OR - 3

GA WIC 2005 PROCEDURES MANUAL

Attachment OR-1

B. Coordination With Government Entitlement Program
During the WIC application and certification process, WIC staff refers families as appropriate and collects data on participation in other governmental entitlement programs, e.g. Medicaid, Food Stamps and Temporary Assistance for Needy Families (TANF).
VII. PROGRAM COSTS
Costs of promotional efforts designed to encourage and increase participation in the WIC Program are reimbursable. Outreach efforts should be consistent with the health-oriented nature of the WIC Program.
VIII. COORDINATION/INTERGRATION OF SERVICES
A. Outreach
Integration of WIC services with other health clinic services has been a major thrust for the State WIC Branch and the Division of Public Health. All districts have taken positive steps toward decentralization and the integration of WIC with existing services.
B. WIC/Medicaid Coordination
To date several measures have been implemented statewide to address the coordination of the WIC and Medicaid Programs. They include:
1. The WIC Certification process now includes swipe card verification for adjunctive eligibility.
2. The State of Georgia "Right From The Start Medicaid (RSM)" program provides medical assistance to pregnant women and children ages 0 through 18 years.
The Child Nutrition and WIC Re-authorization Act of 1989 (P.L. 101-147) requires state agencies to provide information about and referrals to Medicaid at the time of initial application and reapplication of such individuals who appear to be Medicaid eligible but are not participating.

OR - 4

GA WIC 2005 PROCEDURES MANUAL

Attachment OR-1

C. Coordination Strategies
Coordination Strategies Handbook- A Guide for WIC and Primary Care Professionals, development of this handbook was funded through a grant from the Food and Nutrition Service (FNS), U. S. Department of Agriculture, for the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). This project was one of a number of activities undertaken in response to the 1994 legislative mandate for enhanced coordination between the WIC Program and health services. The legislation, the Healthy Meals for Healthy Americans Act (Public Law 103448), stipulated that the Secretaries of Agriculture and Health and Human Services jointly establish and carry out initiatives to provide WIC services at substantially more Community and Migrant Health Centers (C/MHCS) and improve coordination of WIC services with Indian Health Service (IHS) facilities. This publication can be found online at: http://www.fns.usda.gov/WIC/resoures/coordinationstrategies.htm.
D. WIC Works Resources Center
WIC Resources Center is a USDA sponsored site in which states share State developed materials. This information can be accessed online at: http://www.nal.usda.gov/wicworks/.
The site consist of:
WIC Learning Online, a series of 12 online learning modules designed for all leaves of staff working in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). WIC Database, online, searchable database of materials developed for WIC audiences. WIC Sharing Center WIC Learning Center WIC Topics A-Z WIC Talk

OR - 5

GA WIC 2005 PROCEDURES MANUAL

Attachment OR-1

GEORGIA WIC PROGRAM FACT SHEET
Why is WIC Important?
Georgia has one of the highest infant mortality rates in the nation. Good nutrition and regular prenatal care during pregnancy, and good nutrition and preventive health care for infants are key to preventing babies from dying or becoming disabled.
Low-income women in Georgia who receive both WIC and Medicaid health insurance have a significantly lower infant mortality rate than do other low-income women in the state. They are more likely to get prenatal care early in their pregnancy and to seek preventive care, such as immunizations, for their children.
Every dollar spent on WIC saves up to three dollars in health care costs, according to a national study.
Who Gets WIC?
To be certified as eligible for the Program, infants, children, and pregnant, postpartum, and breastfeeding women must meet all of the following eligibility requirements:
Categorical Residential Income Nutrition Risk
Categorical Requirement
The WIC Program is designed to serve certain categories of women, infants, and children. Therefore, the following individuals are considered categorically eligible for WIC:
Residential Requirement
Applicants must live in Georgia. Applicants served in areas where WIC is administered by an Indian Tribal Organization (ITO) must meet residency requirements established by the ITO. As a State agency option, applicants may be required to live in a local service area and apply at a WIC clinic that serves that area. Applicants are not required to live in the State or local service area for a certain amount of time in order to meet the WIC residency requirement.

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GA WIC 2005 PROCEDURES MANUAL

Attachment OR-1

Income Requirement
To be eligible for WIC, applicants must have income at or below an income level or standard set by the State agency or be determined automatically income-eligible based on participation in certain programs.

Nutrition Risk Requirement
Applicants must be seen by a health professional such as a physician, nurse, or nutritionist who must determine whether the individual is at nutritional risk. In many cases, this is done in the WIC clinic at no cost to the applicant. However, this information can be obtained from another health professional such as the applicant's physician.

"Nutrition risk" means that an individual has medical-based or dietary-based conditions. Examples of medical-based conditions include anemia (low blood levels), underweight, or history of poor pregnancy outcomes. A dietary-based condition includes, for example, a poor diet.

At a minimum, the applicant's height and weight must be measured and blood work taken to check for anemia.

An applicant must have at least one of the medical or dietary conditions on the State's list of WIC nutrition risk criteria.

Women wishing to apply for WIC benefits for themselves or their children should contact their local health departments. In Atlanta, WIC applicants may also apply at Grady Hospital and Southside Healthcare, Inc.

For FFY05 income of 185 percent of the federal poverty level equals:

Family Size 1 2 3 4 5 6 7 8
Each Additional Member Add

Yearly Income 17,224 23,107 28,990 34,873 40,756 46,639 52,522 58,405 +5,883

OR - 7

GA WIC 2005 PROCEDURES MANUAL

Attachment OR-1

Length of Participation
WIC is a short-term program. Therefore, a participant will "graduate" at the end of one or more certification periods. A certification period is the length of time a WIC participant is eligible to receive benefits. Depending on whether the individual is pregnant, postpartum, breastfeeding, an infant, or a child, an eligible individual usually receives WIC benefits from 6 months to a year, at which time she/he must reapply.

Moving
WIC participants who move from one area of the State to another are placed at the top of a waiting list when they move and are also served first when the WIC agency can serve more individuals. WIC participants who move can continue to receive WIC benefits until their certification period expires as long as there is proof that the individual received WIC benefits in another area or State. Before a participant moves, they should tell the WIC office. In most cases, WIC staff will give the participant a special card, which proves that the individual participated in the WIC Program. When the individual moves, they can call the new WIC office for an appointment and take the special card to the WIC appointment in the new area or State.
Waiting List/Priority System
Sometimes WIC agencies do not have enough money to serve everyone who needs WIC or calls to apply. When this happens, WIC agencies must keep a list, called a waiting list, of individuals who want to apply and are likely to be served. WIC agencies then use a special system, called a Priority System, to determine who will get WIC benefits first when more people can be served. The purpose of the priority system is to make sure that WIC services and benefits are provided first to participants with the most serious health conditions such as anemia (low blood levels), underweight, history of problems during pregnancy.

OR - 8

GA WIC 2005 PROCEDURES MANUAL

Attachment OR-2

IMPORTANT: Clinics vary in range of services provided. Please contact the main site or the clinic(s) in which you are interested to verify the type of services offered as well as location and hours of operation.

Main Site

Address

City, State, ZIP

Albany Area Primary Health Care, Inc
Clinics
East Albany Medical Center

804 14th Avenue
1712-A East Broad Avenue

Albany, GA 31701-1304
Albany, GA 31705

East Albany Pediatric & 1712-C East Broad

Adolescent Center

Avenue

Albany, GA 31703-0098

Rural HIV Model

Suite C-1

Albany, GA

1120 West Broad Avenue 31707-4308

Dawson Medical Center

475 Cinderella Lane, Southeast

Dawson, GA 39842-0391

Edison Medical Center

129 West Hartford Street

Edison, GA 39846-0855

Lee Medical Arts Center

235 Walnut Street

Leesburg, GA 31705

Baker County Primary Health Care Center

100 Sunset Boulevard

Newton, GA 31705

Phone Notes

Service Types

BPHC Supported Programs

(229) 8886559

Admin Only

Primary Medical Care

CHC, ISDI

(229) 6393100

Year round

(229) 6393103

Year round

(229) 4311423

Year round

(229) 9952990

Year round

(229) 8352238

Year round

(229) 7596508

Year round

(229) 7345250

Year round

OR-9

GA WIC 2005 PROCEDURES MANUAL

Attachment OR-2 (con't)

Main Site

Address

City, State, ZIP

Phone Notes

Service Types

BPHC Supported Programs

Southside Medical Center, Inc

1039 Ridge Avenue, Southwest

Atlanta, GA 30315

(404) 6881350

Admin/Clinic

Dental Care Services, Enabling Services, Mental Health/Substance Abuse Services, Obstetrical and Gynecological Care, Other Professional Services, Primary Medical Care, Specialty Medical Care

CHC

Clinics

Southside Medical 1660 Lakewood Center, Inc - Atlanta Avenue

Atlanta, (404)

GA

627- Year round

30315 1385

Southside Medical Center, Inc Thomasville Heights Satellite Clinic

Apartment 143-144 Atlanta, (404)

1178 Henry

GA

622-

Thomas Drive

30315 0727

Year round

Southside Medical 2578 Gresham Center, Inc - Gresham Road

Atlanta, (404)

GA

241- Year round

30316 2336

OR-9

GA WIC 2005 PROCEDURES MANUAL

Attachment OR-2 (con't)

Main Site

Address

City, State, ZIP Phone

Notes

Service Types

BPHC Supported Programs

West End Medical Centers, Inc

868 York Avenue, Southwest

Atlanta, GA 30310

(404) 756-8732 Admin/Clinic

Dental Care Services, Enabling Services, Obstetrical and Gynecological Care, Other Professional Services, Primary Medical Care, Specialty Medical Care

CHC, PH

Clinics

Bowen Homes

950 Wilkes Atlanta, GA

Circle

30318

(404) 794-0851 Year round

Herndon Homes

511 Johns Street

Atlanta, GA 30318

(404) 572-5850 Year round

West End Medical Center

868 York Atlanta, GA Avenue, SW 30318

(404) 752-1400 Year round

West End Medical Center at West Lake

319 West Lake Avenue, NW

Atlanta, GA 30318

(404) 752-1450 Year round

West End Medical Center at John O Chiles

456 Ashby Atlanta, GA

Street

30310

(404) 753-1970 Part time

Main Site

Address

City, State, ZIP

Phone

Notes

Service Types

BPHC Supported Programs

Southside Medical Center, Inc

1039 Ridge Avenue, Southwest

Atlanta, GA 30315

(404) 6881350

Admin/Clinic

Dental Care Services, Enabling Services, Mental Health/Substance Abuse Services, Obstetrical and Gynecological Care, Other Professional Services, Primary Medical Care, Specialty Medical Care

CHC

OR-10

GA WIC 2005 PROCEDURES MANUAL

Attachment OR-2 (con't)

Clinics Southside Medical Center, Inc Norcross Bowman Medical Center
Gainesville Medical Center
Hartwell Medical Center

5139 Jimmy Carter Boulevard 206 East Church Street PO Box 430
810 Pine Street
127 West Gibson Street

Norcross, GA 30093- (770) 613-

1638

0070

Bowman, GA 30624

(706) 2457361

Gainesville, GA 30503

(770) 2870290

Hartwell, GA 30643

(706) 3766100

Year round
Year round
Year round
Year round

Main Site

Address

City, State, ZIP

Phone Notes

Service Types

BPHC Supported Programs

Northeast Health Systems, Inc

11 Charlie Morris Road Colbert, GA

PO Box 459

30628

(706) 7883234

Primary Admin/Clinic Medical CHC
Care

Clinics

Bowman Medical Center

206 East Church Street Bowman,

PO Box 430

GA 30624

(706) 245- Year round 7361

Gainesville Medical Center

810 Pine Street

Gainesville, GA 30503

(770) 287- Year round 0290

Hartwell Medical Center

127 West Gibson Street

Hartwell, GA 30643

(706) 3766100

Year round

Lavonia Medical Center

12134 Augusta Road PO Box 749

Lavonia, GA 30673

(706) 3562223

Year round

Oglethorpe Medical 247 Union Point Street Lexington,

Center

PO Box 264

GA 30648

(706) 743- Year round 8171

Georgia Pines Medical Center

123 Gordan Street

Washington, GA 30673

(706) 6781411

Year round

OR-11

GA WIC 2005 PROCEDURES MANUAL

Attachment OR-2 (con't)

Main Site
Valley Healthcare System, Inc
Clinics Martin Luther King, Jr Elementary School Clinic Benning Drive Clinic

Address

City, State, ZIP

Phone

Notes

Service Types

BPHC Supported Programs

Building No 120 1440 Benning Drive

Columbus, GA 31903

(706) 3229456

Admin/Clinic

Dental Care Services, Enabling Services, Mental Health/Substance Abuse Services, Obstetrical and Gynecological Care, Other Professional Services, Primary Medical Care, Specialty Medical Care

CHC

3050 30th Avenue

Columbus, GA 31903

(706) 6837816

Seasonal

Building #120 1440 Benning Drive

Columbus, GA 31903

(706) 6891331

Year round

Main Site

Address

Georgia Highlands Medical Services, Inc
Clinics

260 Elm Street PO Box 307

City, State, ZIP
Cumming, GA 30028

Phone Notes

Service Types

BPHC Supported Programs

(770)

Primary

887- Admin/Clinic Medical CHC

1668

Care

OR-12

GA WIC 2005 PROCEDURES MANUAL

Attachment OR-2 (con't)

Main Site
Palmetto Health Council, Inc
Clinics Community Medical Center of Barnesville
Community Medical Center of Franklin Community Medical Center of Palmetto Community Medical Center of Zebulon

Address
Suite 300 1201 Clairmont Road

Decatur, GA 30030

City, State, ZIP

Phone

Notes

Service Types

(404) 9298824

Admin Only

Enabling Services, Obstetrical and Gynecological Care, Primary Medical Care

BPHC Supported Programs
CHC

408-B Thomaston Street

Barnesville, GA 30204

(770) 3584408

7699 US Highway 27

Franklin, (706) 675GA 30217 3481

507 Park Palmetto, (770) 463-

Street

GA 30268 4644

230 Barnesville Street

Zebulon, GA 30295

(770) 5673323

Year round
Year round
Year round
Year round

Main Site Tendercare Clinic Clinics

Address 803 South Main Street

City, State, ZIP
Greensboro, GA 30642

Phone Notes

Service Types

BPHC Supported Programs

(706) 453- Admin/Clinic 1200

CHC, CHC

Main Site

Address

Georgia Mountains Health Services, Inc
Clinics

75 Bypass Road PO Box 540

City, State, ZIP
Morganton, GA 30560

Phone Notes

Service Types

BPHC Supported Programs

(706)

Primary

374- Admin/Clinic Medical CHC

6898

Care

Georgia Mountains Health Services

Suite 101

Ellijay GA

OR-13

(706) 635-

Year

GA WIC 2005 PROCEDURES MANUAL

Inc

572 Maddox

30540

Drive

Attachment OR-2 (con't)

6898

round

Main Site

Address

South Central Primary 357 Cargile Road

Care Center No 1

PO Box 749

Clinics
South Central Primary Care Center, Inc
South Central Primary Care Center No 3
South Central Primary Care Center No 2
South Central Primary Care Center

2016 Ocilla Rd
200 South Cherry Street
202 South Cherry Street
105 Fleet Wood Avenue

City, State, ZIP
Ocilla, GA 31774

Phone Notes

Service Types

BPHC Supported Programs

(229) 4689160

Admin/Clinic

Obstetrical and Gynecological Care, Primary Medical Care, Specialty Medical Care

CHC

Douglas, GA 31533

(912) 3842252

Year round

Ocilla, GA 31774

(229) 468- Year round 5911

Ocilla, GA 31774

(229) 468- Year round 7762

Willacoochee, GA 31650

(912) 5345993

Year round

Main Site

Address

Stewart Webster 220 Alston Street Rural Health, Inc PO Box 357
Clinics

City, State, ZIP

Phone Notes

Service Types

BPHC Supported Programs

Richland, GA 31825

(229) 8873324

Admin/Clinic

Dental Care Services, Enabling Services, Mental Health/Substance Abuse Services, Obstetrical and Gynecological Care, Primary Medical Care

CHC

OR-14

GA WIC 2005 PROCEDURES MANUAL

Attachment OR-2 (con't)

Quitman Health Care One Harrison Street Georgetown, GA 31754 (229) 334-9353 Year round

Lumpkin Health Care

102 Cotton Street PO Box 488

Lumpkin, GA 31815

(229) 838-4150 Year round

Plains Medical Center

107 Main Street PO Box 389

Plains, GA 31780

(229) 824-7757 Year round

Main Site

Address

Westside-Urban Health 115 East York Street

Center, Inc

PO Box 2024

Clinics

Westside-Urban Health Center, Inc

Two Roberts Street

City, State, ZIP
Savannah, GA 314022024

Phone Notes

Service Types

BPHC Supported Programs

(912)

Primary

944- Admin/Clinic Medical CHC, PH

6088

Care

Savannah, GA 31408

(912) 966- Year round 2922

Main Site
Oakhurst Medical Centers, Inc
Clinics
Decatur Medical Office

Address

City, State, ZIP

Phone Notes

Service Types

BPHC Supported Programs

Stone

(404)

Primary

770 Village Square Drive Mountain, GA 298- Admin/Clinic Medical CHC

30083-3380 8998

Care

1760 Candler Road

Decatur, GA 30032

(404) 286- Year round 2215

Main Site

Address

East Georgia Healthcare Center, Inc

316 North Main Street PO Box 807

City, State, ZIP

Phone Notes

Service Types

BPHC Supported Programs

Swainsboro, GA 30401

(478) 2372638

Admin/Clinic

Dental Care Services, Mental Health/Substance Abuse Services

CHC, MHC

OR-16

GA WIC 2005 PROCEDURES MANUAL
Clinics

Attachment OR-2 (con't)
Primary Medical Care

Main Site

Address

Primary Health Care Center of Dade, Inc
Clinics

13570 North Main Street

City, State, ZIP

Phone Notes

Service Types

BPHC Supported Programs

Trenton, GA 30752

(706) 6572510

Primary Admin/Clinic Medical CHC
Care

Main Site

Address

City, State, ZIP

Phone Notes

Service Types

BPHC Supported Programs

Tri-County Health System, Inc

140 Norwood Road Warrenton,

PO Box 312

GA 30828

(706) 4653253

Admin/Clinic

Dental Care Services, Obstetrical and Gynecological Care, Primary Medical Care

CHC

Clinics

Tri-County Health System, Inc

156 Alexander Street

Crawfordville, GA 30631

(706) 4562925

Year round

Tri-County Health System, Inc

437-C East Main Street

Gibson, GA 30810

(706) 598- Year round 3359

Hancock County Primary Health Care

323 Hamilton Street Sparta, GA

PO Drawer J

31087

(706) 444- Year round 5241

OR-16

GA WIC 2005 PROCEDURES MANUAL

Attachment OR-2 (con't)

Main Site

Address

City, State, ZIP

Phone

Notes

Service Types

BPHC Supported Programs

McKinney Community Health Center, Inc

218 Quarterman Street PO Box 1902

Waycross, GA 315013547

(912) 2870301

Admin/Clinic

Dental Care Services, Enabling Services, Other Professional Services, Primary Medical Care

CHC, MHC

Clinics

McKinney Community Health Center, Inc

122 North Main Street

Nahunta, GA 31553

(912) 462- Year round 6222

McKinney Community Outreach Center

935 McDonald Street

Waycross, GA 31501

(912) 285- Year round 5080

Main Site
Community Health Care Systems, Inc
Clinics Tennille Community Health Center

Address

City, State, ZIP

Phone Notes

Service Types

BPHC Supported Programs

508 West Elm Street PO Box 371

Wrightsville, GA 31096

(478) 8642600

Admin/Clinic

Obstetrical and Gynecological Care, Primary Medical Care

CHC

116 Smith Street

Tennille, GA 31096

(478) 552- Year round 7384

Related Primary Care References Go to Bureau of Primary Health Care (BPHC) Go to Health and Human Services (HHS) | Go to Health Resources and Services Administration (HRSA)
Last revised 09-Mar-04
OR-18

GA WIC 2005 PROCEDURES MANUAL

Attachment OR-3

GEORGIA ASSOCIATION FOR PRIMARY HEALTH CARE, INC.
The Grant Building 44 Broad Street, N.W. Suite 410 Atlanta, GA 30303
404.659.2861/Phone 404.659.2801/fax

Georgia's Community Based Health Center
Albany Area Primary Health Care, Inc.
804 Fourteenth Avenue Albany, GA 31701 (229) 888-6559 (229) 436-4107/FAX Tary L. Brown, CEO Linda Leeson, COO Bernard Scoggins, M.D., Medical Director Dougherty County
Baker County Health Center 100 Sunset Boulevard./P.O. Box 130 Newton, GA 31770 (229) 734-5250 (229) 734-5606/FAX Baker County
Dawson Medical Center 475 Cinderella Lane, SE/P.O. Box 391 Dawson, GA 31742 (229) 995-2990 (229) 995-2993/FAX Terrell County
East Albany Medical Center 1712-A East Broad Avenue/ P.O. Box 50098 Albany, GA 31705/31703 (229) 639-3100 (229) 888-6516/FAX Dougherty County
East Albany Pediatric & Adolescent Center 1712-C East Broad Avenue/P.O. Box 50098 Albany, GA 31705/31703 (229) 639-3103 (229) 888-8935 Dougherty County

Edison Medical Center 129 West Hartford Street/P.O. Box 849 Edison, GA 31746-0849 (229) 835-2238
(229) 835-3032/FAX Calhoun County
Lee Medical Arts Center Highway 19 North/P.O. Box 542 Leesburg, GA 31763 (229) 759-6508 (229) 759-9950/FAX Lee County
Rural HIV Model 1120 West Broad Avenue, #C-1 Albany, GA 31701 (229) 431-1423 (229) 438-0738/FAX Dougherty County
Athens Neighborhood Health Center 675 College Avenue/P.O. Box 147 Athens, GA 30603 (706) 546-5526 (706) 546-5687/FAX Diane Dunston, M.D., Chief Executive Officer & Medical Director Clarke County
East Athens Satellite 402 McKinley Drive/ P.O. Box 81102 Athens, GA 30603/30608 (706) 543-1145 Clarke County
Community Health Care Systems, Inc. 508 West Elm Street/P.O. Box 371 Wrightsville, GA 31096 (478) 864-2600 (478) 864-2244/FAX Carla Belcher, Chief Executive Officer Dale Brown, M.D., Medical Director Johnson County

OR-19

GA WIC 2005 PROCEDURES MANUAL

Attachment OR-3 (con't)

GEORGIA ASSOCIATION FOR PRIMARY HEALTH CARE, INC.

Washington County

The Grant Building 44 Broad Street, N.W. Suite 410 Atlanta, GA 30303
404.659.2861/Phone 404.659.2801/fax Ola Smith, CEO
Mukesh Agarwal, M.D., Medical Director Ware County

East Georgia Healthcare Center, Inc. 316 North Main Street/P.O. Box 807 Swainsboro, GA 30401 (478) 237-2638 (478) 237-9138/FAX Jennie Wren Denmark, Chief Executive Officer Sanjay Serrao, M.D., Medical Director Emanuel County
Georgia Highlands Medical Services, Inc. 260 Elm Street/P.O. Box 307 Cumming, GA 30040/30028 (770) 887-1668 (770) 781-9937/FAX Carlos Stapleton, Chief Executive Officer Ellie Campbell, D.O., Medical Director Forsyth County
Georgia Mountains Health Services, Inc. GA Mountains Health Services at Morganton 75 ByPass Road, P.O. Box 540 Morganton, GA 30560 (706) 374-6806 (706) 374-5006/FAX Bruce Whyte, M.D., Chief Executive Officer Lajos Toth, M.D., Medical Director Fannin County

McKinney Community Outreach Center 935 McDonald Street Waycross, GA 31501 (912) 285-5080 Ware County McKinney Community Health Center, Inc. 122 North Main Street Nahunta, GA 31553 (912) 462-6222 (912) 462-6803/FAX Brantley County
Northeast Health Systems, Inc. Corporate Office 11 Charlie Morris Road./P.O. Box 459 Colbert, GA 30628 (706) 788-3234 (706) 788-2936/FAX Jackie Griffin, D.P.A., Chief Executive Officer Paul Raber, D.O., Medical Director
Bowman Medical Center 206 East Church Street/P.O. Box 430 Bowman, GA 30624 (706) 245-7361 (706) 245-4054/FAX Elbert County

GA Mountains Health Services at Ellijay 572 Maddox Drive, Suite 101 Ellijay, GA 30540 (706) 635-6898 (706) 635-6888/FAX Gilmer County

Colbert Medical Center 11 Charlie Morris Road./P.O. Box 609 Colbert, GA 30628 (706) 788-2127 (706) 788-2815/FAX Madison County

McKinney Community Health Center 218 Quarterman Street/ P.O. Box 1902 Waycross, GA 31502 (912) 287-9140 (912) 287-0301 (CEO) (912) 287-1059/FAX

Georgia Pines Medical Center 212 Hospital Drive Washington, GA 30673 (706) 678-1411 (706) 678-3620/FAX Wilkes County

OR-20

GA WIC 2005 PROCEDURES MANUAL

Attachment OR-3 (con't)

GEORGIA ASSOCIATION FOR PRIMARY HEALTH CARE, INC.

The Grant Building

44 Broad Street, N.W. Suite 410 Atlanta, GA 30303

404.659.2861/Phone 404.659.2801/fax

(404) 929-9769

Lavonia Medical Center

Jon Wollenzien, Jr., D.B.A., Chief Executive Officer

11909 Augusta Road, Suite 8/P.O. Box 749

Louis Anderson, M.D., Medical Director

Lavonia, GA 30553

(706) 356-2223

Community Medical Center of Palmetto

(706) 356-2959/FAX Franklin County

507 Park Street/P.O. Box 469 Palmetto, GA 30268

(770) 463-4644

(770) 463-9885/FAX Fulton County

Oglethorpe Medical Center 247 Union Point Street/P.O. Box 264 Lexington, GA 30648 (706) 743-8171 (706) 743-3000/FAX Oglethorpe County

Community Medical Center of Zebulon 230 Barnesville Street/P.O. Box 561 Zebulon, GA 30295 (770) 567-3323 (770) 567-0332/FAX Pike County

Greater Hall Community Health Center 810 Pine Street, SW/P.O. Box 445 Gainesville, GA 30503 (770) 287-0290 (770) 287-7597/FAX Hall County
Oakhurst Medical Centers, Inc. 770 Village Square Stone Mountain, GA 30083 (404) 298-8998 (404) 298-7658/FAX William A. Murrain, JD, Chief Executive Officer Doa Harris, M.D., Medical Director Dekalb County
Oakhurst Medical Center at Candler and Glenwood 1760 Candler Road Decatur, GA 30032 (404) 286-2215 Dekalb County
Palmetto Health Council, Inc. Corporate Office 1201 Clairmont Road, Suite 300 Decatur, GA 30030 (404) 929-8824

Community Medical Center of Barnesville 408B Thomaston Street Barnesville, GA 30204 (770) 358-4408 (770) 358-0002/FAX Lamar County
Community Medical Center of Franklin 7699 Highway 27 Franklin, GA 30217 (706) 675-3481 (706) 675-8253/FAX Heard County
Primary Health Care Center of Dade 13570 North Main Street Trenton, GA 30752 (706) 657-7575 (706) 657-5885/FAX Diana Allen, LCSW, Chief Executive Officer Pamela C. Ventra, M.D., Medical Director Dade County
Saint Joseph's Mercy Care Services 60 11th Street, NE Atlanta, GA 30309 (404) 249-8600 (404) 249-8941/FAX

OR-21

GA WIC 2005 PROCEDURES MANUAL

Attachment OR-3 (con't)

GEORGIA ASSOCIATION FOR PRIMARY HEALTH CARE, INC.

The Grant Building

44 Broad Street, N.W. Suite 410 Atlanta, GA 30303

404.659.2861/Phone 404.659.2801/fax

(706) 322-9599

201 Washington Street

(706) 322-8332/FAX

Atlanta, GA 30303

Sarah Lang, Chief Executive Officer

(404) 659-0117
(404) 221-3692/FAX Fulton County

& Medical Director Muscogee County

South Central Primary Care Center, Inc. 357 Cargile Road/P.O. Box 749 Ocilla, GA 31774 (229) 468-9160 (229) 468-5526/FAX

South Columbus Community Health Center 1440 Benning Drive - Building 120 Columbus, GA 31903 (706) 689-1331 (706) 689-4340/FAX Muscogee County

Delane Roberts, Chief Executive Officer

Saiyed Ashfaq, M.D., Medical Director Irwin County

MLK School-based Clinic 305 30th Avenue

Columbus, GA 31903

(706) 683-7816 Muscogee County

South Central Primary Care Center 200 Cherry Street Ocilla, GA 31774 (229) 468-5911 (229) 468-4247/FAX
and (229) 468-7762 (229) 468-9302/FAX Irwin County

Southside Medical Centers, Inc. 1039 Ridge Avenue, SW Atlanta, GA 30315 (404) 688-1350 (404) 688-2962/FAX David M. Williams, M.D., Chief Executive Officer Dominic Mack, M.D., Medical Director Fulton County

South Central Primary Care Center 101 Bowens Mill Road Douglas, GA 31533 (229) 384-2252 (229) 384-8888/FAX Coffee County

SMC Substance Abuse Treatment Center 1660 Lakewood Avenue, SW Atlanta, GA 30316 (404) 627-1385 (404) 622-9769/FAX Fulton County

South Central Primary Care Center Fleetwood Avenue Willacoochee, GA 31650 (912) 534-5993 (912) 534-5703/FAX Atkinson County
South Columbus, Inc., Community Health Center of 1315 DeLaunay Avenue, Suite 201 Columbus, GA 31901

Southside Medical Center Gresham/DeKalb Office 2578 Gresham Road Atlanta, GA 30316 (404) 241-2336 (404) 241-6256/FAX DeKalb County
Southside Medical Center Thomasville Office 1178 Henry Thomas Drive Apt# 143 and Apt# 144

OR-22

GA WIC 2005 PROCEDURES MANUAL

Attachment OR-3 (con't)

GEORGIA ASSOCIATION FOR PRIMARY HEALTH CARE, INC.

The Grant Building

44 Broad Street, N.W. Suite 410 Atlanta, GA 30303

SMC Clinica de la Mama 1039 Ridge Avenue, SW Atlanta, GA 30315 (404) 688-1350 Fulton County

404.659.2861/Phone 404.659.2801/fax Sumter County
Quitman Health Care 1 Harrison Street/ P.O. Box 584 Georgetown, GA 31754 (912) 334-9353 Quitman County

Clinica de la Mama Austell 1680 Mulkey Road, Suite E

TenderCare Clinic, Inc.

Austell, GA 30106

803 South Main Street

(770) 732-1880 Cobb County

Greensboro, GA 30642 (706) 453-1201

Clinica de la Mama Norcross 5139 Jimmy Carter Boulevard, Suite 205 Norcross, GA 30093 (770) 613-0070 Gwinnett County

(706) 453-1205/FAX Lisa Brown, R.N., Executive Director Medical Director Greene County
Tri-County Health System, Inc. 140 Norwood Road/P.O. Drawer 312

Clinica de la Mama South Atlanta/Cleveland 2685 Metropolitan Parkway, Suite C Atlanta, GA 30048 (404) 684-1250 Fulton County

Warrenton, GA 30828 (706) 465-3253 (706) 465-3256/FAX Donna Newsome, Chief Executive Officer Debra Crawley, M.D., Medical Director Warren County

Stewart-Webster Rural Health, Inc. 220 Alston Street Richland, GA 31825 (229) 887-3324 (229) 887-2559/FAX Sarah Richardson, Chief Executive Officer George Ellard M.D., Medical Director Stewart County
Lumpkin Health Care 102 Cotton Street/P.O. Box 488 Lumpkin, GA 31815 (229) 838-4150 (229) 838-4156/FAX Stewart County
Plains Medical Center 107 Main Street/P.O. Box 389 Plains, GA 31780 (229) 824-7757 (229) 824-3497/FAX

Tri-County Family Medical Center 156 Alexander Street/P.O. Box 205 Crawfordville, GA 30631 (706) 456-2925 (706) 456-2224/FAX Taliaferro County
Tri-County Family Medical Center 437 East Main Street/P.O. Box 234 Gibson, GA 30810 (706) 598-3359 (706) 598-3403/FAX Glascock County
Hancock County Primary Health Care Center 323 Hamilton Street/P.O. Box J Sparta, GA 31087 (706) 444-5241 (706) 444-7302/FAX Hancock County

OR-23

GA WIC 2005 PROCEDURES MANUAL

Attachment OR-3 (con't)

GEORGIA ASSOCIATION FOR PRIMARY HEALTH CARE, INC.

The Grant Building

44 Broad Street, N.W. Suite 410 Atlanta, GA 30303

404.659.2861/Phone 404.659.2801/fax

(912) 966-2922

and (404) 756-8732 (CEO)

(912) 966-2921/FAX Chatham County

(404) 752-7296/FAX (CEO)

Daisy S. Harris, Chief Executive Officer
Linda J. Cannon, M.D., Medical Director Fulton County

Westside-Urban Health Center Robert Hitch Village 840 Hitch Drive

Savannah, GA 31401

West Lake Medical Group 319 West Lake Avenue, N.W.

(912) 232-9696 Chatham County

Atlanta, GA 30318

(404) 752-1450

(404) 752-1479/FAX Fulton County

West End Medical Centers at Bowen Homes 950 Wilkes Circle, N.W. Atlanta, GA 30318 (404) 799-0851
(404) 794-4798/FAX
Fulton County
West End Medical Centers at Herndon Homes 511 John Street Atlanta, GA 30318 (404) 572-5850 (404) 880-9071/FAX Fulton County

Westside-Urban Health Centers 115 East York Street/P.O. Box 2024 Savannah, GA 31401 (912) 944-6080 (912) 944-6087/FAX (912) 231-2783/FAX Edward G. Miller, Chief Executive Officer Khaishoon Basrai, M.D., Medical Director Chatham County
Westside-Urban Health Center Two Roberts Street Savannah, GA 31408

OR-24

GA WIC 2005 PROCEDURE MANUAL

Attachment OR-4

Project Site & Address

Georgia Farmworker Health Program Migrant Health Clinic Sites

Project Coordinator

Contact Information

Coffee County Health Department 1111 West Baker Highway Douglas, Georgia 31533-4920
Decatur County Health Department 928 West Street PO Bos 417 Bainbridge, Georgia 39818
Ellaville Primary Medicine Clinic 103 Broad Street PO Box 65 Ellaville, Georgia 31806-9428
Ellenton Clinic 185 Baker Street PO Box 312 Ellenton, Georgia 31747
Georgia Farmworker Clinic J. Frank Culpepper Road PO Box 889 Lake Park, Georgia 31636
Rochelle Healthcare Center 636 2nd Avenue SW PO Box 481 Rochelle, Georgia 31079
Tattnall County Health Department 1001 N. Downing Musgrove Highway Glennville, Georgia 30427

Josie Haklin, RN Charles Taylor, MSN, FNP-C Mary Anne Shepherd, RN-C, FNP Cynthia Hernandez Steve Graham, President/CEO H. Scott Jobe, MBA, CMPE Sandra Durrence, FNP

Tel: 912-389-4458 Fax: 912-389-4326 kkhulett@gdph.state.ga.us
Tel: 229-248-3055 Fax: 229-248-3010 crtaylor@gdph.state.ga.us
Tel: 229-937-5321 Fax: 229-937-2232 mshepherd@sumterregional.org
Tel: 229-324-2845 Fax: 229-324-3383 cyhernandez@gdph.state.ga.us
Tel: 229-242-9003 Fax: 229-242-0490 stgraham@mchsi.com
Tel: 229-365-2570 (Clinic) Fax: 229-365-2571 (Clinic) Scott Jobe: Tel: 229-271-4676 hsjobe@crispregional.org
Tel: 912-654-5300 Fax: 912-654-5303 smdurrence@gdph.state.ga.us

Office of Rural Health Services 11/5/03

OR-25

GA WIC 2005 PROCEDURES MANUAL

Attachment OR-5

OR-26

GA WIC 2005 PROCEDURES MANUAL

Food Delivery

TABLE OF CONTENTS

Page

I.

General...................................................................................................................... FD-1

II.

Types of WIC Vouchers ........................................................................................FD-1

A. Vouchers Printed On Demand (VPOD).........................................................FD-1

B. Blank Manual Vouchers ...................................................................................FD-2

C. Preprinted Standard Manual Vouchers.........................................................FD-2

D. Computer Printed Vouchers ..........................................................................FD-2

E. Automated Special Manual Voucher .............................................................FD-3

III. Voucher Issuance General ..................................................................................FD-3 A. Valid Certification Period ................................................................................FD-3

B. Identification of Person Picking Up Vouchers..............................................FD-3

C. Corrections .........................................................................................................FD-4

D. Issuance ..............................................................................................................FD-4

E. Categorically Ineligible ....................................................................................FD-4

F. Issuance of Vouchers to Family Members.....................................................FD-5

IV. Voucher Printed on Demand (VPOD) Vouchers and Computer Generated Vouchers ............................................................................FD-5
A. Data Elements....................................................................................................FD-5

B. Voucher Cycles .................................................................................................FD-6

C. Voucher Packaging ...........................................................................................FD-6

D. Voucher Issuance ............................................................................................FD-10

GA WIC 2005 PROCEDURES MANUAL

Food Delivery

E. Transporting VPOD Vouchers from a Site within a Site...........................FD-11

F. Ordering VPOD Vouchers.............................................................................FD-12

V.

Manual Vouchers (Blank and Standard) ..........................................................FD-12

A. Blank Manual and Preprinted Manual Vouchers ......................................FD-12

B. Ordering Manual Vouchers...........................................................................FD-12

C. Receipt of Manual Vouchers .........................................................................FD-13

D. Inventory Control of Manual Vouchers.......................................................FD-13

E. Issuance of Manual Vouchers .......................................................................FD-14

F. Distribution of Manual Voucher Copies .....................................................FD-15

VI. VPOD Procedures .................................................................................................FD-16 A. General..............................................................................................................FD-16

B. Issuing VPOD Vouchers ................................................................................FD-16

C. Voucher Reconciliation ..................................................................................FD-17

D. VPOD Inventory Log Sheets .........................................................................FD-17

E. Corrective Action for VPOD .........................................................................FD-17

VII. Mailing/Delivery of WIC Vouchers ..................................................................FD-18 A. Conditions for Mailing/Delivering Vouchers ............................................FD-18

B. Acceptable Reasons for Mailing/Delivering Vouchers.............................FD-18

C. Mailing/Delivery Procedures .......................................................................FD-19

D. Voucher Mailing Process ...............................................................................FD-20

E. Returned Vouchers .........................................................................................FD-20

GA WIC 2005 PROCEDURES MANUAL

Food Delivery

VIII. IX. X. XI. XII.

Voided Vouchers...................................................................................................FD-21 Prorated Vouchers ................................................................................................FD-22 Late Pick-Up of Vouchers ....................................................................................FD-23 Coordination of Health Services and Vouchers Issuance ...............................FD-24 Lost, Stolen or Damaged Vouchers ....................................................................FD-26 A. Replacement of Vouchers ..............................................................................FD-26

B. Lost/Stolen/Destroyed/Voided Voucher Report .....................................FD-26

C. Vouchers Lost, Stolen, or Destroyed Prior to Issuance .............................FD-27

D. Change of Formula Order..............................................................................FD-28

XIII. Borrowed Voucher................................................................................................FD-29

XIV. Cumulative Unmatched Redemption Report (CUR)......................................FD-29

A. Introduction .....................................................................................................FD-29

B. Procedures for Reconciliation .......................................................................FD-30

C. Manually Reconciliation CUR Part 1 ...........................................................FD-31

D. Manually Reconciliation CUR Part 2 ...........................................................FD-32
E. Procedures for Both Reports .........................................................................FD-33
XV. Reconciliation of WIC Reports and Daily Program Operations .............................................................................................................. FD-33
Attachments: FD-1 Preprinted Standard Manual Voucher...............................................................FD-35 FD-2 Blank Manual Voucher.........................................................................................FD-36 FD-3 Computer Printed Voucher .................................................................................FD-37 FD-4 Automated Special Manual Voucher .................................................................FD-38

GA WIC 2005 PROCEDURES MANUAL

Food Delivery

FD-5 Voucher Printed On Demand (VPOD) Voucher ..............................................FD-39 FD-6 Voucher Creation Calendar.................................................................................FD-40 FD-7 Voucher Cycle Packing List.................................................................................FD-41 FD-8 Computer Printed Voucher Register..................................................................FD-42 FD-9 Voucher Register Summary Page .......................................................................FD-43 FD-10 Transmittal Form ..................................................................................................FD-44 FD-11 Form and Manual Voucher (Order Supply Form) ...........................................FD-45 FD-12 Manual Voucher Inventory .................................................................................FD-46 FD-13 Voucher Printed On Demand Log Sheet ...........................................................FD-47 FD-14 Batch Control Form...............................................................................................FD-48 FD-15 Batch Control Exception Report .........................................................................FD-49 FD-16 Georgia WIC Program Identification Card .......................................................FD-50 FD-17 Daily Roster/Monthly Mailed Voucher Report ...............................................FD-51 FD-18 Borrowed Voucher Report Form ........................................................................FD-52 FD-19 Cumulative Unmatched Redemptions Part I....................................................FD-53 FD-20 Cumulative Unmatched Redemptions Part II ..................................................FD-54 FD-21 Lost, Stolen, Destroyed, Voided Voucher Report ............................................FD-55 FD-22 Vouchers Printed On Demand (VPOD) Receipt ..............................................FD-56

GA WIC 2005 PROCEDURES MANUAL

Food Delivery

I. GENERAL
The Georgia WIC Program uses a uniform retail food delivery system. Participants are issued food instruments (vouchers) which are redeemed at authorized vendors for WIC foods. Clinics issue vouchers to participants, or their proxies, on a one, two, or three-month interval. Georgia has a fully automated food delivery and management information system. The Georgia WIC Program contracts with a third party data processing firm to operate and maintain a participant master file via the back-end system.
Local agencies have the capability of electronically transmitting WIC vouchers issuance data.
Participants redeem the vouchers for specific types and quantities of foods at authorized vendors. Vendors deposit the redeemed vouchers into the local bank accounts. The vouchers proceed through the banking system to a central clearing bank where they are edited for missing or invalid information. Vouchers that are not paid are sent back to the appropriate local bank and the vendor's account is reduced by the value of the vouchers. Vendors may appeal this process by submitting the vouchers to the Georgia WIC Branch. Vouchers paid, but flagged as suspect, are investigated by the State agency.
The Automated Data Processing (ADP) Contractor reconciles individually issued and redeemed vouchers as required by federal regulations and maintains a voucher master file that tracks the status of all vouchers. The ADP Contractor also produces participation, financial, vendor, and other management reports at regular intervals for use by State and local agencies.

II. TYPES OF WIC VOUCHERS
There are five (5) types of WIC vouchers that may be issued to participants:
A. Vouchers Printed On Demand (VPOD)
Vouchers Printed On Demand (VPOD) are generated on site by the clinic's automated system for each qualified participant for the WIC Program. The receipts generated from printing these vouchers are maintained by the clinic. VPOD numbers must be logged on the VPOD inventory log within three (3) days of receipt.

FD-1

GA WIC 2005 PROCEDURES MANUAL

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B. Blank Manual Vouchers
These vouchers maybe issued if or when automated systems are inoperable. These vouchers may be completed for (1) new or transferring participants; (2) to replace voided computer printed vouchers; (3) to adjust a food package in the event of late pick up by a participant, or (4) to supplement the preprinted manual voucher food package. (See FD-V., A. Manual Vouchers and FD-V.,-E. Issuance of Manual Vouchers for procedures). The clinic identification number is preprinted on blank manual vouchers (Attachment FD-2). These vouchers must be stored in a secure location and must be logged in the Manual Inventory Log within three (3) days of receipt.
C. Preprinted Standard Manual Vouchers
Standard manual vouchers are in separated sets of four (4) food package types. These vouchers contain a preprinted standard food package (Attachment FD-3). Standard voucher sets must not be broken to issue single standard vouchers. These vouchers must be stored in a secured location and must be logged in the Manual Inventory log within three (3) days. The four (4) types of food packages are: 1. Infants (Food Package 113). Provides formula only. 2. Pregnant and Breastfeeding Women (Food Package 404).
Provides food for pregnant and breastfeeding women. 3. Postpartum, Non-Breastfeeding Women (Food Package 502).
Provides a food for postpartum, non-breastfeeding women. 4. Children (Food Package 603). Provides food for children.

D. Computer Printed Vouchers
These vouchers contain a specific food package, individually tailored for each participant's nutritional needs. Computer printed vouchers are produced by the ADP Contractor and contain information based on the Turn Around Document (TAD) submitted by the clinics. District/clinic identification numbers are also printed on the vouchers. These vouchers must be kept in a secure location.

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E. Automated Special Manual Voucher
Automated Special Manual Vouchers are similar to Preprinted Standard Manual Vouchers except the food messages are blank on the automated forms. Automated clinics use these forms to prepare manual vouchers for any food package. These vouchers must be stored in a secured location and must be logged in the Manual Inventory Log within three (3) days. When clinics convert to VPOD, these vouchers must be purged from the system and destroyed. A lost/ stolen/ destroyed report must be sent to the APD contractor and the State WIC Branch.

III. VOUCHER ISSUANCE - GENERAL

A. Valid Certification Period

Vouchers must not be issued to participants outside of a valid certification period.

Valid Certification Periods

Category

Valid Certification Period

Pregnant

Til six (6) weeks after delivery

Post Partum

Til six (6) months after delivery

Children

Every six (6) months till five (5)

years of age

Infants (< six (6) months)

Til First (1) birthday

Infants (> six (6) months)

For a six (6) month period

B. Identification of Person Picking Up Vouchers
ID cards must be checked for signatures of participants/proxies before vouchers are issued. If a proxy is picking up vouchers, his/her signature must be on the ID card. If a participant has not previously had a proxy sign their ID card, the proxy must have a dated note, signed by the participant/parent/ guardian/caretaker, giving him/her the authority to pick up vouchers for the participant. The proxy/authorized representative must also present some form of identification to verify that he/she is the person authorized by the participant to pick up vouchers. If a participant/parent/guardian/caretaker does not possess, or has lost his/her ID card, other identification may be accepted as verification and a new ID card issued. Proxies may not be issued a new WIC ID card. A
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proxy must be at least 16 years old.
Documentation of ID for Voucher Pickup Document the ID of the person picking up the vouchers, not of the participant who receives the vouchers. 1. Voucher Printed on Demand (VPOD) - Document the proof code
on the voucher receipt under the user's ID. 2. Manual Vouchers - Document the proof code on the manual
voucher under the date the vendor must deposit by. 3. Voucher Registers - Document the proof code on the left side of
the voucher register.

C. Corrections
Vouchers must not be corrected or altered. If an error is made during issuance, the voucher(s) must be voided (See FD-VIII Voided Vouchers). Correction fluid ("white-out") must not be used on vouchers for any reason.
D. Issuance
Local agencies have the option to issue vouchers to participants' at a one, two, or three-month interval. With two or three- month issuance, clinic staff must explain to participants, not to use vouchers prior to the "First Day to Use" date on the vouchers.
E. Categorically Ineligible
Categorically ineligible refers to the period of time a client is no longer eligible to receive WIC benefits. Participants who are categorically ineligible are postpartum women at six months postpartum, children who have reached their fifth (5th) birthday, and breastfeeding women who stop breastfeeding and are greater than six (6) months postpartum or 1 year postpartum.
When a participant becomes categorically ineligible before the end of the month, eligibility is extended until the end of the month. The participant will receive the last full set of vouchers for the month of categorical eligibility. Vouchers must not be issued past the month of categorical eligibility. The categorically ineligible message will appear on the voucher receipt for the last set of vouchers prior to the termination date.

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F. Issuance of Vouchers to Family Members

An employee must never issue vouchers to family members or other

persons residing in their household. Family members include but are not

limited to:

1. Children

7. Aunts 13. Grandparents

2. Grandchildren 8. Uncles 14. Individuals related by marriage

3. Sisters

9. Parents

4. Brothers

10. Spouses

5. Nieces

11. First Cousins

6. Nephews

12. In-laws

IV. VOUCHER PRINTED ON DEMAND (VPOD) AND COMPUTER GENERATED VOUCHERS
A. Data Elements
The following data elements appear on the face of the vouchers: 1. District/Unit/Clinic. The district is represented by a two-digit
number, the unit by a one-digit number, and the clinic by a threedigit number. 2. WIC ID Number. The participant's unique eleven (11) identification number that corresponds to the number on the Turn-Around Document (TAD). Self-Check Digit. Calculated by the ADP Contractor or front end system. Participant Number (P). This is a one-digit number that specifies an individual family member in a multi-WIC participant family. 3. Participant's Name. The full name of the participant (last name, first name, middle initial). 4. First Day to Use (MMDDYY). The first valid date when the voucher may be used to purchase foods. 5. Last Day to Use (MMDDYY). The last valid date, after which the voucher can no longer be used by the participant. The voucher may be used on this date, but not after this date. 6. Vendor Must Deposit by (MMDDYY). The date by which the vendor must deposit the voucher is sixty (60) days after the first day of use. Vouchers not deposited by this date are considered stale and will not be paid by the Contract Bank.
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7. Voucher Number. A unique serial number printed on each voucher.
8. Quantity Only. A description of the food items and the quantities that may be purchased. Also, the food package and voucher codes are printed here.
9. Maximum Purchase Price. The actual purchase price may not exceed the maximum amount that appears on the voucher.
10. Pay Exactly. This space is left blank for the vendor to enter the actual cost of the WIC foods purchased.
11. WIC Vendor Stamp. Stamped by the vendor prior to deposit. 12. Sign Here At Grocery Store. The participant/proxy signs his/her
name in this space when the voucher is redeemed at a WIC vendor. 13. The reverse side of the vouchers contains an area for endorsement by the authorized WIC vendor location.
B. Voucher Cycles
The clinic staff and participant determine the voucher pickup day. This day is entered as a Pickup Code on the TAD.
Voucher interval codes are entered on the TAD (1= monthly; 2= two months even; 3 = two months odd; 4 = three months).
C. Voucher Packaging

In emergency situations where clinics are unable to print vouchers for a period of time, the ADP contractor has the capability of producing vouchers.
Computer printed vouchers are delivered to the clinic in alphabetical order based on the last name of the lead family member within each Site Code. The lead family member is the one with WIC type P, N, or B or the one with the lowest Participant ID Number (usually #1).
1. The following items will be transmitted to each clinic (or clinic package #1 if there is more than one [1]). a. Voucher Cycle Packing List This (2-ply) packing list provides the specific beginning and ending voucher numbers for all the computer printed vouchers, manual vouchers when appropriate, and VPOD serial numbers for the clinic. It also lists the appropriate

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pages of the Computer Voucher register that accompany the clinic's computer printed vouchers. Two copies of the packing list are provided. The clinic must retain one copy and send one signed copy to the district/unit as acknowledgement of receipt of the vouchers. b. Computer Voucher Register: Used only for vouchers produced by ADP contractor in emergencies. Purpose To provide a listing of participants that have computer generated vouchers produced during a cycle and to provide a signature space for verification of receipt of vouchers. The register is organized in the same order as the computer-generated vouchers.

Distribution Clinic District/Unit State

1 copy 1 copy, summary 1 microfiche copy

Frequency twice each month, at each voucher printing cycle. Sequence District/Unit, clinic, alphabetic by name of lead family member.

Register Description: Line 1

WIC ID: The WIC ID number of each participant.

PARTICIPANT NAME: The name of the participant in the family having the lowest Participant ID Number. The register is in sequence by this name, and all other family members, regardless of their last name, fall in sequence by WIC ID/ Participant Number.

MI: Middle Initial

MEDICAID REFERRAL: Code to indicate Medicaid Program participant or income as a percent of the Federal Poverty Guidelines.

M: If the client is enrolled in Medicaid.

TYPE: WIC type P, N, B, I, C

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PR: Priority
SIGNATURE OF PARTICIPANT: Space for participant/ proxy signature. The participant must sign here before receiving the vouchers.
DATE: Space for the date vouchers were issued. The participant/guardian/caretaker/proxy or the issuing authority must fill in the date. NOTE: The issue date appears under this line.
CLERK INITIAL (CLK INIT): The staff person must initial here when vouchers are issued or voided.
Line 2
TELEPHONE NUMBER: Phone number of participant.
VOUCHER NUMBERS: The voucher numbers are listed across the four (4) columns below the name.
TOTAL: The number of vouchers produced for the participant.
MESSAGE: Applicable messages regarding participant's need for subsequent certification, no show, automatic changes, etc. The following is a complete list of messages. The due date follows the messages.
NUTRITIONAL ASSESSMENT- MMDDYY: For infants who are certified prior to six (6) months of age, the infant's six (6) month anniversary is printed.
RECERT DUE- MMDDYY: Subsequent certification is due in the same month as the voucher issue month. For breastfeeding women and children, the date is the certification date plus six (6) months.
RECERT DUE (P)- MMDDYY: Subsequent certification is due in the same month as voucher issue month. For pregnant women, the date is forty-five (45) days from the Expected Date of Confinement (EDC).

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RECERT OVDUE- MMDDYY: For breastfeeding women and children, subsequent certification is overdue based on the certification date plus six (6) months.
RECERT OVDUE (P) MMDDYY: For pregnant women, subsequent certification is overdue based on the EDC plus forty-five (45) days.
1ST B'DATE-MMDDYY: Infant's birth date is in the month after the voucher issue month. The date printed is the birth date.
CATEG TERM-MMDDYY: The participant is categorically ineligible in the month after voucher issuance month. A message accompanies the last set of vouchers. The date printed is the categorical termination date.
FOR N- Delivery date plus 6 months
FOR B- Delivery date plus 12 months
FOR C- At 5th birth date
ISSUE DATE- The date of issue printed on the vouchers
The District/Unit (clinic) receives the following items with each voucher shipment: a. Voucher Cycle Packing List b. Voucher Register Summary Page
This summary page includes: 1. Total participants who received computer generated
vouchers. 2. Total vouchers for the District/Unit (clinic). 3. Total number of messages by message type. 4. Signature line and certifying statement of persons
closing out the voucher register. Two signatures are required to closeout the register. [The signatures must be for each month by two different staff members.]

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D. Voucher Issuance
The following procedures must be followed when issuing vouchers: 1. Identification. Verify the identity of the person picking up the
vouchers. Please refer to FD-III.B. "Identification of Person Picking Up Vouchers," for procedures. Record ID proof of person picking up the vouchers in the appropriate place.
2. Vouchers Issuance. Vouchers can only be issued to participants in a valid certification period (See FD-3).
The serial numbers on the VPOD vouchers must match the serial numbers on the VPOD receipt. The name on the vouchers and the receipt must be identical.
The following items must be completed on the VPOD receipt and voucher register each time vouchers are issued:
a. Signature of Participant or Proxy. The participant or proxy must sign his/her name on the signature line to indicate that the proper person has received those specific vouchers. This signature must match the signature of the participant or proxy on the ID card. (1) Vouchers must not be issued until after the participant/proxy signs the receipt/voucher register. (2) If a participant or proxy leaves the clinic without signing the receipt/voucher register, clinic staff must document the issuance. The issuing staff person must write, "failed to sign" and initial and date the appropriate line(s). "Failed to sign" must not be abbreviated. (3) During a monitoring review, if one (1) percent or more "fail to sign" notations appear on the VPOD receipts/voucher register in a clinic, a corrective action will be issued to the clinic. Therefore, clinic staff must be extremely careful to ensure that participants sign the VPOD receipt/voucher register. (4) If the participant or proxy is unable to write, he/she will enter his/her mark in lieu of a signature. Clinic staff will print the person's name next to the mark and initial the mark to indicate that it has been witnessed. (5) When receiving vouchers for multiple participants the participant must sign the first line and initial subsequent lines. Line drawn across multiple lines and ditto marks are unacceptable.

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3. Voucher Participant/Proxy Signature. The participant or proxy must sign only manual vouchers in the left signature space, in the presence of the issuing staff person.
4. When VPOD vouchers are printed, the printer produces the food packages along with a receipt. The receipt contains the clients' WIC ID number, name, issue date, last date to use, food package number, voucher code, voucher number, any appropriate message and a place for the client/proxy to sign. The receipt takes the place of the voucher register. The client signs the receipt and then is handed the vouchers. The receipt must then be immediately filed in numerical order if possible. All receipts must be reconciled with the daily activity report. Any voucher numbers that are missing must have an explanation.
5. Food Package Change. Food items on computer printed vouchers may not be crossed out in order to reduce the participant's food package unless prior authorization is received from the Georgia WIC Branch. Computer printed voucher(s) must be voided and replaced with manually issued vouchers if the food package is changed.

E. Transporting VPOD Vouchers From a Site within a Site
When VPOD vouchers are transported to a site that has no printer (voucher issuance clinic only), the vouchers must be printed the afternoon prior to going to the clinic or printed the day of the clinic visit.
Vouchers not issued on site must be voided immediately.
See transporting procedures in the Compliance Analysis Section of the Procedures Manual.

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F. Ordering VPOD Serial Numbers
Voucher Printing On Demand (VPOD) voucher numbers are received in the clinic from the ADP Contractor. All numbers must be entered on the VPOD inventory log within three (3) days of receipt as with other manual vouchers. For VPOD vouchers, the confirmation notice of voucher numbers sent from ADP contractor will take the place of the packing list and must be maintained in the same manner as the packing list (See Receipt of Manual Vouchers FD-V., C.). The packing list must be signed and dated and a copy sent to the District office.

V. MANUAL VOUCHERS (Blank and Standard)
Manual vouchers are different from VPOD vouchers. The primary differences are: 1. Manual vouchers are three (3) part forms. The parts are colorcoded for distribution as follows: a. First copy (blue) participant. b. Second copy (red) - ADP Contractor or clinic copy if automated transfer is used. c. Third copy (black) retain in clinic or may be destroyed if automated transfer is used. 2. All manual vouchers require completion of participant and issuance data. 3. Blank manual vouchers require entry of food quantities. All blocks must be filled in with a number or an X.
A. Blank Manual and Preprinted Manual Vouchers
Blank manual vouchers are issued for the following reasons: 1. To provide vouchers for a food package other than those
provided by the preprinted manual vouchers. 2. To replace one or more VPOD vouchers that have been destroyed
or damaged. (See Compliance Analysis CA-X). B. Ordering Manual Vouchers
Local agencies must order manual vouchers from the ADP Contractor. Orders must be made using the "Form and Manual Voucher Orders" Form (Attachment FD-11) and must be received by the ADP Contractor by the 10th or 25th of each month. The ADP Contractor will fill manual voucher orders twice a month and will ship them with each cycle of computer

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printed vouchers. C. Receipt of Manual Vouchers
1. Clinic Clinics will compare beginning and ending voucher numbers to those on the Clinic Voucher Cycle Packing List. Any discrepancies must be reported to the ADP Contractor and the Georgia WIC Branch immediately. The packing list must be signed and dated to verify receipt. A copy of the signed/dated packing list must be mailed to the local agency/district office within five (5) days of receipt of the vouchers. The original must be retained by the clinic for one (1) year plus the current Federal Fiscal Year.
2. District/Unit The District/Unit receives a copy of each detailed clinic packing list for control, and a summary copy showing total vouchers received from the District/Unit. Any discrepancies must be reported to the ADP Contractor immediately. Missing shipments must also be reported to the Georgia WIC Branch. All packing list received by the District must be reconciled with the clinic's copy and the District's copy must be signed and dated.

D. Inventory Control of Manual Vouchers
When manual vouchers are received, the serial numbers must be recorded in the "Received" column of the "Manual Voucher Inventory" log (See Attachment FD-12). This documentation must be completed the same day the vouchers are received by the responsible WIC staff person. Vouchers must be used in the order in which they were received; first in, first out. All vouchers must be used in sequential order until depleted. Do not use two voucher batches at the same time; complete one batch before using another.
1. Perpetual Inventory (Weekly) (Manual Vouchers & VPOD Vouchers)
The perpetual inventory accounts for the voucher numbers issued, voided, and on hand. The perpetual inventory should be conducted daily, and must be done at a minimum weekly and documented on the Manual Voucher Inventory Log Sheet or the VPOD Inventory Log Sheet (Attachment FD-12). All columns of

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the log must be completed accurately, legibly, and initialed, by a responsible staff member. Always record the voucher numbers immediately after receiving them from the ADP contractor on the Log Sheet.
2. Physical Inventory (Monthly -Blank and Standard Manual Vouchers)
A monthly physical inventory of all manual vouchers must be conducted. Another staff person must verify the inventory and initial the inventory log. Physical inventory documentation must include the serial numbers of the vouchers and the total number of vouchers on hand. The physical inventory must be documented on the "Manual Voucher Inventory Log" and labeled "Physical Inventory Conducted and Verified by." Two staff members must initial and date the physical inventory. When discrepancies are discovered during a manual voucher inventory, they must be reported to the District WIC Coordinator immediately. Manual Voucher Inventory logs must be retained for three (3) years plus the current Federal Fiscal Year. Inventories must be completed in black or blue ink.

E. Issuance of Manual Vouchers Manual vouchers will be issued in complete sets, in consecutive order. When preparing manual vouchers, all items will be printed clearly and legibly, using a ballpoint pen. If an error is made on a voucher, void the voucher and issue a blank manual voucher.
The pickup code is generally the same day as the day on which vouchers are issued. The dates on the second and third set of vouchers must correspond to the pick-up code of the first set of vouchers.
Pre-printed standard/ blank manual vouchers must include the following information: 1. The participant's WIC ID number, including self-check and
participant code. 2. Participant's name (last, first). 3. First Day to Use (MMDDYY). 4. Last Day to Use (MMDDYY) which is thirty (30) days from the
"First Day to Use."

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5. Vendor must deposit by (MMDDYY) which is sixty (60) days from the "First Day to Use."
6. Food Package Code and Voucher Code. If blank manual vouchers are issued to replace damaged computer printed vouchers, the Food Package Code and Voucher Code from the damaged VPOD vouchers must be written on the manual voucher to retain the original information.
On a blank manual voucher, the following additional information must be completed:
Food Prescription Data blocks. Enter quantities for appropriate foods; enter an "X" in all unassigned blocks.

F. Distribution of Manual Voucher Copies (Only when Handwriting Vouchers)
1. The red copy must be counted in numerical order, and mailed to the ADP Contractor using a Batch Control Form (Attachment FD14). Do not separate or fold the red copies. DO NOT BATCH VOUCHER COPIES WITH TADs. They may be mailed together, but must be batched separately. When sending via Express Mail, do not use a Post Office Box. The clinic address must be used for this process.

2. When a batch is mailed to the ADP Contractor, the black copy of the Manual Vouchers must be retained by the clinic and attached to a copy of the Batch Control Form, creating a Batch Control Module (BCM). BCM's must remain intact until they are reconciled. Upon receipt of a manual voucher BCM, the ADP Contractor will send an acknowledgement receipt to the clinic on a monthly basis (with a TAD shipment).
If there are discrepancies, the ADP Contractor will send the clinic a form referred to as "Batch Control Exception Report (Attachment FD-15)," describing the discrepancy. Discrepancies should be resolved by recounting vouchers, and contacting the ADP Contractor to resolve count differences by WIC ID if necessary.
When the signed Batch Control Form is returned to the clinic, the copy of the Batch Control Form may be discarded. Voucher

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copies must be organized by type and stored neatly in serial number order. It is recommended that voucher copies be stored in binding materials such as vinyl lined binders, post binders, or expanding file folders in order to maintain them.
Voucher copies must be retained for three (3) years plus the current Federal Year.

VI. VPOD PROCEDURES
A. General
Vouchers printed on demand (VPOD) are generated on site by the clinic's automated system for each participant on the WIC Program. The receipt generated from printing these vouchers becomes the voucher register.
When serial numbers are received from ADP contractor, each clinic must log all numbers on the VPOD Inventory Log and in the computer. The confirmation notice must be signed and dated and a copy sent to the district office to be kept on file. The confirmation notice must also be kept on file in the clinics in the same manner as the packing list. The retention period is also the same.
B. Issuing VPOD Vouchers
The following procedures must be followed when issuing VPOD Vouchers:
1. Identification - Verify the identity of the person picking up the vouchers.
2. Issuance - Before vouchers are printed, the clerk must check the client's WIC History to determine if the participant is in a valid certification period, has a nutrition education appointment, or any other follow-up appointments the client may have.
3. The serial numbers on the VPOD vouchers must match the serial numbers on the VPOD receipt. The name of the participant will be compared to the participant's name on the WIC ID card and the computer.

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4. The client must sign the receipt before receiving the VPOD vouchers. Vouchers must not be issued until after the participant/proxy signs the receipt.

C. Voucher Reconciliation
At the end of each day, the clinic staff must print a daily activity report that includes: 1. Voucher numbers 2. Participant's name 3. Issue date 4. Initials of issuing clerk .
All receipts must be reconciled with the daily activity report. The receipts must be filed in numerical order. Each clinic must maintain a file for the activity reports and keep it in the clinic. If vouchers are voided, they must be stamped void before filing them with the receipts. If the voucher does not print, use a blank voucher receipt to write those numbers, the date, the participant's name, and the clerk's initials on the receipt.
D. VPOD Inventory Log Sheets
The VPOD log sheet must be completed daily or at a minimum weekly (only for those clinics who are open less than two days a week, everyone else must complete the log sheet daily). The log will be used to keep track of the voucher numbers issued, voided or not printed. Always record the voucher numbers received from ADP contractor immediately on the log sheet. Separate log sheets can be used for each batch, but they must be kept in the inventory log book. The confirmation notice of numbers sent will take the place of the voucher-packing list and should be maintained in the same manner. All columns of the log sheet must be completed accurately, legibly, and initialed by a responsible staff member. The bottom of the VPOD log must be completed with the remaining stock and clerk signature.
E. Corrective Actions for VPOD
1. Any missing receipt.
2. Incomplete log sheets.

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3. More than one percent "fail to sign" on receipts.
4. Vouchers issued during an invalid certification period.
5. Any missing daily activity reports.
6. Any vouchers filed with receipts that do not have void stamped or written on them.
7. Voucher printing problems that are not documented properly.
8. Voucher numbers that did not print, and are not voided in the computer.

VII. MAILING/DELIVERY OF WIC VOUCHERS
A. Conditions for Mailing/Delivering Vouchers
1. Vouchers may be mailed or otherwise delivered to participants on an individual hardship basis or, in special circumstances, may be mailed in mass. If vouchers are mailed to a participant for hardship reasons, they will be mailed/delivered on a temporary/short-term basis. There should not be a standard, ongoing reason to mail vouchers (i.e. permanent difficulty accessing the clinic(s) for mailing/delivering vouchers to participants).
2. Vouchers must not be mailed in the following situations: a. Participant due for re-certification. b. Participant due for nutrition education. c. Participant unable to offer a current address (i.e., homeless shelter participant).
B. Acceptable Reasons for Mailing/Delivering Vouchers
1. Difficulties of the participant and his/her proxy in obtaining vouchers for reasons such as illness.
2. Imminent or recent childbirth requiring bed rest and no proxy is available.

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3. Environmental crisis as a result of a tornado, hurricane, flood, snow-storm, or ice storm.
4. Closure of clinic due to structural damage, relocation, etc.
5. Other special circumstances approved by the WIC Coordinator.
NOTE: *If the Food Stamp Program has discontinued or does not routinely mail Food Stamp Coupons to a geographical location, WIC Vouchers can not be mailed to this area.

C. Mailing/Delivery Procedures
The procedures for mailing vouchers are as follows:
1. Prior to mailing/delivering vouchers, the issuing professional must obtain approval from the WIC Coordinator or a designated Competent Professional Authority (CPA). Written approval must be on file in the form of a local agency policy memorandum. Prior to mailing/delivering vouchers to a participant, the issuing person must obtain approval from the WIC Coordinator. When delivering vouchers, the participant must sign a copy of the voucher register or receipt. Once the receipt or register page is signed by the participant, it must be returned to the clinic to be filed.
2. The hardship condition and the WIC Coordinator approval must be documented in the participant's health record. Once the initial hardship has been resolved, the mailing or delivery of WIC Vouchers must be discontinued and the action documented.

3. Confirm valid certification.
4. Confirm the mailing address.
5. Give the participant their next appointment.
6. Each district or local agency must have a post office box as well as a return address for all vouchers mailed. The "return to sender name" on the mailing envelope must be someone other than the staff person who prepared the vouchers for mailing.

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7. Someone other than the staff person(s) who prepared and mailed the vouchers must pick-up returned vouchers from the post office box; and must note on the mail roster the participant's name, identification number and sequence of voucher numbers returned in the mail and a full signature of the person documenting this information.
8. A roster must be maintained on a weekly basis by the local office noting all vouchers mailed and participant names and identification numbers. This roster should be mailed to the District Office (See Attachment FD-17).
The procedures for delivering a voucher (s) are as follows:
The VPOD vouchers and receipts, or voucher register (when transporting vouchers) must be copied. The original receipt or voucher register must be left in the clinic. Once the participant signs the copied page, the copy must be attached to the original VPOD receipt or voucher register. The original VPOD receipt or voucher register must have the statement "See Attachment" on the receipt.

D. Voucher Mailing Process
When mailing vouchers, the VPOD receipt, voucher register, or voucher copy must be documented with the disposition of the vouchers. The WIC official must document the signature line(s) with the statement "mailed vouchers" or "delivered vouchers," the reason(s) for mailing, the date mailed, and the signature of the person preparing vouchers for mailing. Vouchers must be mailed via certified mail; mailed vouchers will not be replaced.
E. Returned Vouchers
When vouchers are returned by the postal service, the following steps must be followed: 1. If the voucher(s) are still valid for redemption, the local agency
will attempt to contact the participant in an effort to issue. This contact must be recorded on the voucher register or receipt. If the local agency is unable to contact the participant, "void" the voucher(s) immediately, and maintain on site until the scheduled time that they are mailed to the bank, except for manual vouchers that are returned to Data Processing. If a record of manual

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vouchers have been sent to the ADP Contractor, manual vouchers must be voided and sent to the bank. 2. If the vouchers are out of date, stamp the word "void" on the food instrument. Note on the Voucher register or receipt, "returned by postal service" at the corresponding voucher numbers and maintain on site until the scheduled time that they are mailed to the bank. Voucher(s) should be "voided" immediately and processed as customary. VIII. VOIDED VOUCHERS
Voided vouchers should be marked "void" if the participant is ineligible for the vouchers, if they are replaced with manual vouchers, or if a participant does not pick up their vouchers by the last day of the month. Vouchers marked VOID must be returned to the Contract Bank. Package the vouchers securely to prevent breakage and send them to arrive at the Contract Bank by noon of the fifth (5th) workday of the following month.
Voided Manual Vouchers and VPOD Vouchers
Manual vouchers, blank vouchers, VPOD vouchers, or preprinted vouchers must be voided if the participant's name is misspelled; when any of the participant information is entered incorrectly; when there is damage during issuance; or if a voucher(s) is returned unused by participant; when there is a food package change.
1. Voided Manual/ VPOD Vouchers That Were Reported to the ADP Contractor as Issued. The system contains an issue record that must be voided. To accomplish this void, the clinic must return the original voucher (s) if possible to the contract bank stamped "VOID." The ADP Contractor will input this voided voucher information into the system to void the issue record. If the original is not available, the Lost/Stolen/ Destroyed Voided Form must be used to report the void to the ADP Contractor.
2. Voided Manual/ VPOD Vouchers That Were Not Reported to the ADP Contractor as Issued. These voids are due to errors made while completing the voucher, which prevent the voucher from being issued. All three (3) manual voucher copies must be marked "VOID". Use a Batch Control Form and return the original and the second copy to the ADP Contractor. Please refer to Section FD-V.F. for information on batching manual voucher copies.
Although there are no issue records on these vouchers, the ADP

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Contractor will input this voided information into the system to identify the disposition of the vouchers. All voided and destroyed vouchers must be reported to the ADP Contractor's Bank. Do not send out- of- date vouchers back to the bank, (only those vouchers that are voided due to package changes, formula changes, etc). The ADP Contractor will provide addressed envelopes or labels to be used when returning vouchers.
IX. PRORATED VOUCHERS
The objective of prorated vouchers is to ensure that participants receive benefits for which they are entitled during a valid time frame. Vouchers are issued based on the number of weeks within a valid redemption time period. A voucher is valid for only 30 days from the date of issuance. When it is determined that a participant cannot redeem vouchers within the valid time frame, the number of vouchers issued must be prorated.
Prorating is the partial issuance of vouchers by retrieving one or more vouchers from the designated voucher series. Vouchers must be prorated when:

(1) A participant is late picking up vouchers (procedures for voiding vouchers must be followed as outlined in FD-X - Late Pickup of Vouchers).
(2) Vouchers are replaced when they are damaged or there is a change in the prescribed food package or agency error.
Note: The procedures in Section FD-XII.A must be followed when replacing vouchers.
To ensure consistency when prorating vouchers, the guidelines below must be followed:

Number of Days Late Women & Children

Infants

Less than 7 days late

full package

full package

7-13 days late

3 vouchers issued (3/4 full package package)

14-20 days late

2 vouchers issued (1/2 package)

1 voucher issued (1/2) package (deduct formula vouchers only)

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21-31 days late

1 voucher issued (1/4 package)

1 voucher issued (1/2) package (deduct formula vouchers only)

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a) ALTERNATE FOOD PACKAGES

Number of Days Late Women & Children

Infants

Less than 7 days late

full package

full package

7 - 13 days late

6 vouchers issued (3/4 package)

full package

14-20 days late

4 vouchers issued (1/2 package)

1 voucher issued (1/2 package, deduct
formula only)

21-31 days late

2 vouchers issued (1/4 package)

1 voucher issued (1/2 package deduct
formula only)

Note: If a scheduling error is made by the clinic, which results in the loss of vouchers, by the participant, there are two options. These options are: either to issue the entire food package and follow procedures noted above, or change the pickup codes and submit to the ADP Contractor.

X. LATE PICK-UP OF VOUCHERS
Participants who are late picking up their vouchers must be issued a prorated food package based on the schedule in FD-IX. If participants come in for their vouchers after they have been "VOIDED", they must be issued manual vouchers that bear the issue date and other dates as they appeared on the computer printed vouchers. The food package must be prorated to reflect the period of time left until the participant's next scheduled pickup date.
To determine the number of days that a participant is late for pickup, the following guidelines must be followed: 1. Count calendar days, including weekends. 2. If the participant's scheduled pickup day was before the "First Day to Use"
on the vouchers, begin counting days late from the "First Day to Use" date. 3. If the participant's scheduled pickup day was after the "First Day to Use" on
the vouchers, begin counting days late from the appointment date. The appointment date must be documented on the voucher register in addition to the required pickup date.
Change pickup interval code
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When a participant is late picking up vouchers, the pickup interval code must not be changed to avoid prorating vouchers. When it is necessary to change the pickup interval code, the code is changed to the date the vouchers are picked up, and a full set of vouchers are issued with the current date. We do not encourage staff to change pickup interval codes because it affects participation.
There are two reasons when pickup codes should be changed during a valid certification period: 1. Adding a new family member 2. A change in circumstances such as a change in job or working hours that
results in a hardship on the participant.
The decision to change pickup interval code will be the responsibility of the clinic supervisor.
To change the participant's pickup interval code the clinic staff must: 1. Document the appointment date changes on the voucher receipt or
voucher register. 2. Complete a TAD to change the pickup interval code and submit to the
data-processing contractor. 3. Stamp the voucher "void" immediately. 4. Give the participant an appointment for next month's pickup with the
new pickup date. 5. Document in participant's record the reason for change in pickup interval
code.
XI. COORDINATION OF HEALTH SERVICES AND VOUCHER ISSUANCE
Every effort must be made to coordinate the issuance of WIC vouchers with the delivery of health services. [CFR 246.12(d); CFR 246.11(a)(1) and (2)]. Efforts must be made to provide health services so that the patients/families will not have to return more than once a month. However, vouchers may be issued for one month, if the participant/caregiver is to return for services at that time (This is the exception not the rule).
Under no circumstances are vouchers to be withheld or denied nor are any services to be forced upon participant/caregiver [CFR 246.11(a)(2)]. Participants/caregivers have the right to refuse other health services, but we have the responsibility to frequently offer and strongly encourage the use of all

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available health services [CFR 246.6(b)(3)(4)(5); CFR 246.7(I)(2)(iii); CFR 246.12(s)(7) (8)].

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XII. LOST, STOLEN OR DAMAGED VOUCHERS
A. Replacement of Vouchers 1. Lost or Stolen vouchers will not be replaced. 2. Damaged Vouchers - When a participant/parent/guardian/ caretaker reports that their vouchers have been damaged the following procedure may be implemented: a. If vouchers are damaged, any pieces of the vouchers that can be salvaged should be brought to clinic. Vouchers that can be identified by voucher numbers may be replaced. b. Vouchers destroyed due to fire will be replaced with a copy of the fire report.
B. Lost/Stolen/Destroyed/Voided Voucher Report
When vouchers are reported as lost, stolen, or destroyed, complete the Lost/Stolen /Destroyed/ Voided Voucher Report (Attachment FD-21) with the following items: a. District/Unit/Clinic b. Current Date c. Beginning Voucher Number in Range* d. Ending Voucher Number in Range* e. Quantity of Vouchers in Range f. Participant's WIC ID Number g. Participant's Status Code h. Participant's Last Name and Replacement Voucher Numbers in
the "Comments" block. *If a participant reports that part of a voucher package was lost/stolen/destroyed and the other portion was cashed, but cannot determine which voucher serial numbers were lost/stolen/destroyed, include all of the voucher serial numbers on the form. Note in the comment section of the Lost/Stolen Destroyed Voided Voucher Report that between 1-4 vouchers may have been cashed.
Mail the completed Lost/Stolen/Destroyed Voided Voucher Report to the ADP Contractor, retain a copy in the clinic, and forward a copy to the Georgia WIC Branch, System Information Unit. Upon receipt of the Report, the ADP Contractor will enter this information into the system. If the contract bank subsequently pays the vouchers, they will be identified on the Bank Exception Report during the monthly reporting process.
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The Georgia WIC Branch cannot initiate "stop payments" on lost/stolen/destroyed vouchers issued to WIC participants. When fraud is suspected, the local agency should notify the Compliance Analysis Unit to request assistance with an investigation. To obtain copies of suspect vouchers, the Local Agency must submit a Georgia WIC Program Voucher Investigation Log (Attachment CA-2) to the Compliance Analysis Section (See Section X of CA Section of the Georgia WIC Procedures Manual).
C. Vouchers Lost, Stolen, or Destroyed Prior to Issuance
When a clinic determines that vouchers have been lost, stolen, or destroyed prior to issuance, the following procedure must be implemented: 1. Complete the Lost/Stolen/Destroyed Voided Voucher Report
(Attachment FD-21) with the following items:
a. District/Unit/Clinic b. Current Date c. Beginning Voucher Number in Range d. Ending Voucher Number in Range e. Quantity of Vouchers in Range.
2. Mail the completed Lost/Stolen/Destroyed Voided Voucher Report to the ADP Contractor, retain a copy in the clinic, and forward a copy to the Georgia WIC Branch, System Information Unit, 2 Peachtree Street Atlanta, GA 30303. Upon receipt of the Report, the ADP Contractor will enter this information into the system. If the contract bank subsequently pays the vouchers, they will be identified on the Bank Exception Report during the monthly reporting process.
The System Information Unit will review Lost, Stolen, or Destroyed voucher reports in conjunction with the Cumulative Unmatched Redemption (CUR) report to identify potential fraud and refer findings to the Compliance Analysis Section. The Compliance Analysis Section will work in conjunction with the Local Agency to investigate potential fraud. When a block of 25 or more vouchers are missing (See Section CA-X, Investigation of Missing Vouchers).

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D. Change of Formula Order / Formula Purchased I Error
In the event that a formula order is changed after a participant has been issued vouchers for an original formula order, or formula was purchased in error, replacement vouchers must be issued. When vouchers are replaced within the same month of original issuance, the following procedures must be implemented:

Standard Formula, Special Formula
1. Participants must return unused formula to the clinic if available, and/or
2. Return unredeemed voucher(s) to the clinic for voiding. 3. Supplemental vouchers issued must equal the amount of unused
formula returned and vouchers voided for the current issuance period. Supplemental vouchers are issued on a can for can basis. 4. Document the amount, type, and disposition of formula returned to clinic on the voucher receipt or the clinic's copy of the manual voucher. 5. Document returned formula on the "Formula Tracking Log" located in the Food Package section of the WIC Procedures Manual. All returned formula must be accounted for when issued to another client or destroyed. The "Formula Tracking Log" will be monitored for accuracy during District Program Reviews conducted by the state.
Hospital Based Formula If a physician changes a formula, the participant must return all
unopened cans of formula to the clinic. The Clinic must then: 1. Issue supplemental vouchers equal to the amount of formula
returned in the issuance period. 2. Document the amount, type, and disposition of formula returned
to clinic on the Voucher Receipt or on the clinic's copy of the manual voucher. 3. Document formula change and receipt of an updated written or verbal order from the physician in the participant's health record. 4. Document returned formula on the "Formula Tracking Log" located in the Food Package section of the WIC Procedures Manual. All returned formula must be accounted for when issued to another client, destroyed or returned to the manufacturer. The "Formula Tracking Log" will be monitored

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for accuracy during District Program Reviews conducted by the state. 5. If the formula is ordered by the Nutrition Section, all unopened cases of formula should be returned to the company. Notify the Nutrition Section so that a refund may be obtained from the company.
XIII. BORROWED VOUCHERS
Vouchers may be borrowed within a District from one clinic by a clinic whose current stock is depleted (See Attachment FD-18). This applies to manual vouchers only. VPOD numbers cannot be borrowed from one clinic to another.
Submitting the form in a timely manner is important. The ADP contractor must be notified of all manual voucher reassignments as soon as possible. Any borrowed voucher reassignments not received by the ADP contractor before reconciliation (usually around the eighth working day of the month) may result in new check issues received from clinics being rejected because the issue clinic fails to match the check issue master file. Accordingly, any of these vouchers that were cashed would result in unmatched redemption the first month and would be listed on the Cumulative Unmatched Redemptions Report if not corrected by the second month.
Those borrowed voucher reassignments that fail the required edits will also be subject to the unmatched redemption process described in the previous paragraph. If a borrowed voucher reassignment does fail the edits, the districts will be contacted to correct the discrepancy for the next reconciliation.
The ADP contractor will accept the new Borrowed Voucher Report input form from the districts, edit the required fields for validity, and reassign clinic numbers on the check issue master file on a monthly basis before reconciliation. Instructions for the use of borrowed vouchers may be found as Attachment FD-18 of the Food Delivery Section.
XIV. CUMULATIVE UNMATCHED REDEMPTION REPORT (CUR)
A. Introduction
The Cumulative Unmatched Redemption (CUR) Report identifies redeemed manual vouchers that have not matched a valid client record. Local Agencies are required to review the redeemed manual vouchers appearing on the CUR report. The vouchers should be reconciled with the ADP contractor or a manual reconciliation should be performed with the Georgia WIC Branch, depending on how much time has elapsed since the voucher was redeemed. The CUR Report has two parts:

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Part 1: Part 2:

A cumulative list of manual vouchers issued by clinics and cashed by the participant, when there is no record that the voucher was issued on the ADP Contractor's mainframe computer system (See Attachment FD-19).
A cumulative list of manual vouchers issued by the clinics and cashed by the participants, which have not matched to a valid WIC ID number, issue date, or participant certification record on the ADP Contractor's mainframe computer system (See Attachment FD-20).

The Local Agency may correct an unmatched redemption list that is over 30 days old. The second month the item appears, the Local Agency must manually reconcile the items described below. These manually reconciled items should not be submitted to the ADP Contractor since the items are purged from the system after they are listed the second time.

B. Procedures for Reconciliation

Cumulative Unmatched Redemptions that have not matched to an issuance record.
CUR Part 1: Attachment FD-19 provides an example of cumulative unmatched redemption that is not matched to an issuance record. The third and fourth columns on the CUR Part 1 have the dollar amount of the redeemed voucher(s).

If the voucher appears in the third column or the 1st dollar amount column, confirm the batch of vouchers appearing in the 1st dollar amount column was sent to the ADP Contractor.
1. If there is no acknowledgment from the ADP Contractor that the batch was received, resubmit to the ADP Contractor.

2. If there is acknowledgement that the ADP Contractor received the vouchers appearing in the 1st dollar amount column, the vouchers may have contained an error or been processed incorrectly by the bank. Photocopy the entire set of vouchers that were issued to that participant even if all the vouchers are not listed on the report, and make the necessary corrections on the photocopy. Correct only those voucher(s) listed in the 1st dollar amount column with the ADP Contractor.

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The ADP Contractor must receive corrections and resubmitted batches by the end of the month cut-off (seventh working day of the month following the month in which the report was received). Complete a Batch Control Form. Batch and submit to the ADP Contractor. Do not submit copies of the CUR report to the ADP Contractor and do not send copies of vouchers to the GWB.
C. Manually Reconciling CUR Part 1
Those voucher(s) listed in the second dollar amount column are too old to correct through the ADP Contractor and must be manually reconciled by the clinic.
1. Locate a copy of the voucher(s) listed in the second dollar amount column.
2. Record the issue date only of the voucher (the actual date as it appears on the voucher) on the dotted line adjacent to the voucher number on the CUR Part 1 report, sign and date the report. If there are no vouchers appearing on the CUR Part 1 report that have to be manually reconciled, the report should still be forwarded to the GWB. The CUR Report should always be submitted to the GWB in its entirety. Do not send copies of vouchers to the Georgia WIC Branch.
Cumulative Unmatched Redemption that have not matched to a valid certification record:
CUR Part 2: Attachment FD-20 provides an example of cumulative unmatched redemption that is not matched to a valid certification record. The fifth and sixth columns on the CUR Part 2 have the dollar amount of the redeemed voucher. Verify that the issue date and/or the ID number is correct as it appears on the voucher and the CUR report. If both or either the issue date or the ID number is incorrect, complete only the appropriate column of the CUR Part 2 Correction Form with the correct issue date and/or ID number for the entire set of vouchers listed. Mail the top copy of the form to the ADP Contractor.

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GA WIC 2005 PROCEDURES MANUAL

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Retain the bottom copy for your files. Do not submit a copy of the CUR Part 2 Correction Form to the GWB.

When the issue date and the ID number on the voucher(s) and the CUR

Part 2 report are correct:

1.

Verify that the participant was in a valid certification

period as of the voucher issue date. If the participant

was not within a valid certification period when the

voucher was issued, there is no correction to be made

and the voucher will appear on the next CUR report.

Briefly document on the dotted line adjacent to the

voucher number on the CUR report why the vouchers

were issued outside of a valid certification period.

2.

If the vouchers were issued within a valid certification

period, verify whether the TAD transaction creating the

valid certification was batched and submitted to the

ADP Contractor. If there is no batch acknowledgment,

resubmit the entire batch to the ADP Contractor.

3.

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

have contained a critical error. Review critical error

reports and resubmit a corrected TAD transaction as

appropriate.

Correct only those voucher(s) listed in the last dollar amount column on the report with the ADP Contractor. The ADP Contractor must receive corrections and resubmitted batches by the end of the month cut-off (seventh working day of the month following the month in which the report was received).

D. Manually Reconciling CUR Part 2
Vouchers listed in the second dollar amount column (sixth column) are too old to correct through the ADP Contractor. Those vouchers must be manually reconciled by the clinic. A note in the last column explains why the vouchers appear on the CUR Part 2.
1. Locate the copy of the voucher(s) and check the ID number, name, and issue date.
2. If the issue date or the ID number on the voucher(s) or the CUR Part 2 report is erroneous, record only the corrected information

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on the dotted line adjacent to the voucher number on the CUR Part 2 report.
3. If the issue date and the ID number on the CUR Part 2 are correct, record briefly the reason the voucher(s) were issued.
4. The first voucher of a set of vouchers issued to a participant appearing in the second dollar amount column must be manually reconciled. (See Attachment FD-20)
5. Sign and date the completed report and submit to the Georgia WIC Branch. If there are no vouchers on the report to be manually reconciled, the CUR report should still be forwarded to the GWB in its entirety. Do not send CUR reports to the ADP Contractor.
E. Procedures for Both Reports
1. Submit the completed reports to the District Office and the District Office will submit all the reports from each clinic in a batch to the Georgia WIC Branch by the 22nd of the month following the report's run date month (i.e., if the run date is 2/18/94, the manually reconciled CUR report is due to the Georgia WIC Branch by 3/22/94).
2. If you are unable to locate a copy of a specific voucher(s), send a memo to the Georgia WIC Branch requesting a copy of the vouchers. Please include the redemption month along with the voucher number(s).
Note: The vouchers in the second dollar amount columns on Part 1 and Part 2 can no longer be reconciled by the ADP Contractor and must be manually reconciled by the clinic.
XV. Reconciliation of WIC Reports and Daily Program Operations
WIC Coordinators and Clinic Managers are responsible for ensuring daily verification and daily reconciliation of WIC reports and daily program operations for accuracy. Districts must immediately report discrepancies to the Georgia WIC Branch Systems and Information Section. Reconciliation includes, but is not limited to, conducting the following daily and monthly verifications.
A. Daily Verifications:
1. Verify vouchers issued.

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2. Match number on the computer with voucher issued. 3. Ensure all vouchers contain required voucher numbers. 4. Ensure that numbers received are properly entered into the system. 5. Ensure that vouchers do not skip numbers. 6. Verify that duplicate numbers have not been issued to different participants. 7. Verify that duplicate numbers have not been issued to the same participant. 8. Batching must be done daily.
B. Monthly Verifications:
1. Ensure that all vouchers are appropriately issued and/or voided. "Did not print" is not an acceptable voucher status. 2. Review voucher redemption reports and reasons indicated. 3. Assure voucher redemption report is done verified.
Clinic managers should report all discrepancies to the District WIC Coordinator immediately. In addition, it is the responsibility of the WIC Coordinator to conduct periodic self-reviews as well as review any discrepancies or problems reported by the clinic manger.

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GA WIC 2005 PROCEDURES MANUAL

Attachment FD-1

PREPRINTED STANDARD MANUAL VOUCHER

FD-34

GA WIC 2005 PROCEDURES MANUAL BLANK MANUAL VOUCHER

Attachment FD-2

FD-35

GA WIC 2005 PROCEDURES MANUAL COMPUTER PRINTED VOUCHER

Attachment FD-3

FD-36

GA WIC 2005 PROCEDURES MANUAL Automated Special Manual Voucher

Attachment FD-4

FD-37

GA WIC 2005 PROCEDURES MAMUAL

Attachment FD-5

VOUCHER PRINTED ON DEMAND (VPOD VOUCHER)

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GA WIC 2005 PROCEDURES MANUAL

Attachment FD-6

VOUCHER CREATION CALENDAR

1999

2000

JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC JAN

1

2

3

4

5

HOL

6

HOL

7

5

5

5

5

5

5

5

5

5

8

5

5

5

9

6

6

6

5

6

6

10

6

6

6

6

6

11 6

6

HOL HOL

12

6

13

1

14

1

15 1

1

1

1

1

1

1

1

1

16

17

18 HOL

19

20

21

22 2

2

2

2

2

2

2

2

2

2

23

2

24 3

3

3

2

3

3

3

3

2

25

3

HOL

26 3

4

HOL

3

3

3

HOL

3

27

3

HOL

28

4

29 4

4

30

4

4

4

4

4

4

31

4

HOL

4

HOL

4

CYCLE 1 1st - 14th
CYCLE 2 15th - Month end

1 - Cycle 1 TAD INPUT CUTOFF (15th) 2 - Date Federal Express shipped VOUCHERS ARRIVE at D/U (22nd) 3 - ESTIMATED date UPS shipped VOUCHERS ARRIVE at Clinic
4 - Cycle 2 TAD INPUT CUTOFF (last workday of each month) 5 - Date Federal Express shipped VOUCHERS ARRIVE at D/U (7th) 6 - ESTIMATED date UPS shipped VOUCHERS ARRIVE at Clinic

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GA WIC 2005 PROCEDURES MANUAL

Attachment FD-7

PAGE 60 REPORT ENCR2006
DISTRIBUTION:

VOUCHER CYCLE PACKING LIST

STATE OF GEORGIA WIC SYSTEM VOUCHER CYCLE PACKING LIST (CLINIC)
FOR THE SECOND CYCLE OF JULY

CLINIC PAGE 2 D/U/CL

CLINIC KEEPS TOP COPY

CLINIC RETURN SECOND COPY TO DISTRICT/UNIT

(

)

VOUCHER REGISTER PGS 1508 1566

(

)

COMPUTER PRINTED VOUCHER FROM 1006547 TO 1008499

IF THE ACTUAL CONTENTS OF THIS SHIPMENT DIFFER FROM THIS PACKING SLIP. CONTACT EDS - WIC IMMEDIATELY. TELEPHONE 1-800-221-9182. CONTENTS VERIFICATION

________________________________________ __________________

WIC REPRESENTATIVE SIGNATURE

DATE

COMMENTS

EDS SHIPPING USE NUMBER OF PIECES FOR THIS DISTRICT/UNIT EDS QUALITY CONTROL INITIALS

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GA WIC 2005 PROCEDURES MANUAL

Attachment FD-8

COMPUTER PRINTED VOUCHER REGISTER

PAGE

6570

REPORT EWCR201G

COASTAL HEALTH

STATE OF GEORGIA WIC SYSTEM

CLINIC PAGE 34

COMPUTER GENERATED VOUCHER REGISTER

D/U/CL 09-03-632

RUN DATE: 3/19/99

INPUT CUTOFF DATE: 03/15/99

WIC ID FAMILY

C P

LAST

FIRST I M Y R

SIGNATURE OF PARTICIPANT

DATE CLK

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GA WIC 2005 PROCEDURES MANUAL

Attachment FD-9

VOUCHER REGISTER SUMMARY PAGE

PAGE 708 REPORT EWCR201G

STATE OF GEORGIA WIC SYSTEM COMPUTER GENERATED VOUCHER REGISTER

DIST/UT 01-1 RUN DATE __/__/__ INPUT CUTOFF DATE __/__/__

D/U -01-1
MESSAGE TOTALS

TOTAL OF 3,639 PARTICIPANTS RECEIVING TOTAL OF 3,374 PARTICIPANTS RECEIVING

12,809 VOUCHERS FOR 01/92 11,913 VOUCHERS FOR 01/92

1496 RECERT DUE MM/DD/YY

214

CATG TERM MM/DD/YY

919

NUTRITIONAL ASSESSMENT -

MM/DD/YY

(DUE FOR RECERT -SEE CERT -DUE) (CATEGORICAL TERM DUE ON DATE SHOWN) (NUTRITIONAL ASSESSMENT DUE-DATE SHOWN)

162

1ST BDATE-MM/DD/YY

(INFANT TO CHOLD CHANGE IN DATE SHOWN)

226

RECERT DUE (P)-MM/DD/YY

(PASSED CERT -DUE DATE)

0

NO-SHOW PRIOR NO-MM

(CLIENT DID NOT PICK UP VOUCHER IN MONTH)

72

RECERT OVERDUE (P)-MM/DD/YY (PASSED CERT -DUE-DATE P)

0

RECERT OVERDUE (F2)-MM/DD/YY ([PASSED CERT DUE DATE PRIORITY 2)

0

RECERT DUE (PRI2)-MM/DD/YY

(DUE FOR RECERT (PRI -W) SEE CERT DUE)

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GA WIC 2005 PROCEDURES MANUAL

TRANSMITTAL FORM
Verification Receipt of WIC Vouchers
Client's Name ____________________________ Clinic This is to certify that I received the following WIC vouchers:

# _______________________________________

# _______________________________________

________________________________________

Participant/Proxy

Date

# #
Staff/Initials

Verification Receipt of WIC Vouchers

Client's Name ____________________________ Clinic This is to certify that I received the following WIC vouchers:

# _______________________________________

# _______________________________________

________________________________________

Participant/Proxy

Date

# #
Staff/Initials

Verification Receipt of WIC Vouchers

Client's Name ____________________________ Clinic This is to certify that I received the following WIC vouchers:

# _______________________________________

# _______________________________________

________________________________________

Participant/Proxy

Date

# #
Staff/Initials

Verification Receipt of WIC Vouchers

Client's Name ____________________________ Clinic This is to certify that I received the following WIC vouchers:

# _______________________________________

# _______________________________________

________________________________________

Participant/Proxy

Date

# #
Staff/Initials

Verification Receipt of WIC Vouchers
Client's Name ____________________________ Clinic This is to certify that I received the following WIC vouchers:

# _______________________________________

# _______________________________________

________________________________________

Participant/Proxy

Date

# #
Staff/Initials

FD-43

Attachment FD-10
Date Date Date Date Date

GA WIC 2005 PROCEDURES MANUAL

Attachment FD-11

FORM AND VOUCHER ORDERS

GEORGIA WIC PROGRAM FORM AND MANUAL VOUCHER SUPPLY ORDER FORM (REV 1/95)

Return to:

Covansys 1499 Windhorst Way, Suite 240 Greenwood, Indiana 46142

Your District/Unit:

Clinic name:

Address:

Phone 1-800-899-7913
FAX: 1-317-889-9485 This order is for clinic #:

Contact person:

Phone:

Date Mailed:

NOTE: Viking processes Georgia WIC Program orders twice a month. Orders received at Viking by the 10th of the month are processed so that the order is delivered by the 25th of the month. Orders received at Viking by the 25th of the month are processed so that the order is delivered by the 10th of the following month. If the 10th or 25th fall on the weekend or on a holiday, the cut-off is the workday before.
MANUAL VOUCHER ORDER

BLANK MANUAL VOUCHERS FOR HAND COMPLETION
Blank manual voucher (no tuna or carrots) 408 (blank manual voucher with tuna and carrots)
PREPRINTED MANUAL VOUCHER PACKAGE SETS FOR HAND COMPLETION
Sets of prenatal/breastfeeding women package 404 Sets of postpartum non-breastfeeding women package 502 Sets of infant package 113 Sets of child package 603
SPECIAL MANUAL VOUCHERS FOR USE ON COMPUTER
Special manual vouchers for use on computer (ATVS, MVS, M&M, or other State approved system)
CERTIFICATION FORM (TAD) ORDER
Blank TAD (no preprinted ID number) Pre-numbered TAD (preprinted ID number)
OTHER FORMS
Form and Manual Voucher Supply Order forms Lost/Stolen/Destroyed voided Voucher Report forms Vendor Input Form

VPOD SUPPLIES

_______ Paper (cases) _______ VPOD Number

FD-44

GA WIC 2005 PROCEDURES MANUAL

Attachment FD-12

MANUAL VOUCHER INVENTORY

STANDARD MANUAL___________ CLINIC___________

BALANCE BROUGHT FORWARD_________________

DATE BEGINNING NO. ENDING NO. NO.RECEIVED NO. ISSUED NO. VOID NO. ON HAND INITIALS INITIALS

FD-45

GA WIC 2005 PROCEDURES MANUAL
VOUCHER DEMAND LOG SHEET

Attachment FD-13

BATCH #_____________

BEGINNING #__________________________ ENDING #__________________

DATE (when vouchers were printed.)

BEGINNING (the number of the first voucher printed for that day.) (A)

ENDING (the number of the last voucher printed for that day.) (B)

NUMBER REC'D

ISSUED (the number of vouchers issued for that day.) (B-A= total)

VOIDED (the number of vouchers that were voided for that day.)

ON HAND (total amount of numbers on hand)

INITIALS (always sign your initials for that day.)

GRAND TOTAL OF NUMBERS REMAINING IN STOCK. (After completing this form.)

REMAINING STOCK INITIALS

______________ ______________

FD-46

GA WIC 2005 PROCEDURES MANUAL

Attachment FD-14

BATCH CONTROL FORM

GEORGIA DEPARTMENT OF HUMAN RESOURCES WIC PROGRAM

DISTRICT/UNIT

CLINIC

BATCH CONTROL FORM

DATE

NUMBER

/ /

/ /

1. USE THIS FORM AS A COVER SHEET TO FORWARD ALL TADS (CERTIFICATIONS, UPDATES, TRANSFERS AND TERMINATIONS) AND ISSUED/VOIDED MANUAL VOUCHERS.

2. DO NOT BATCH TADS WITH MANUAL VOUCHERS

INSTRUCTIONS

3. DO NOT SUBMIT VOIDED/UNCLAIMED COMPUTER VOUCHERS TO VIKING.
4. SUBMIT THE 1ST AND 2ND COPIES OF THIS FORM AND ACCOMPANYING MATERIALS TO:
COVANSYS P.O. BOX 2507 GREENWOOD, IN 46142-2504
5. RETAIN THE 3RD COPY OF THIS FORM IN THE CLINIC WITH COPIES OF THE TADS OR MANUAL VOUCHERS, CREATING A BATCH CONTROL MODULE.

COVANSYS INPUT SECTION

TYPE OF DOCUMENT
TURNAROUND ISSUED MANUAL VOUCHERS

NUMBER IN BATCH

VOIDED MANUAL VOUCHERS

COMMENTS:

DATE SENT BY DISTRICT/UNIT DATE RECEIVED AT VIKING DATE ENTERED AT VIKING
FORM 3762 (REV.02-92)

PREPARER'S SIGNATURE SIGNATURE SIGNATURE
FD-47

GA WIC 2005 PROCEDURES MANUAL

Attachment FD-15

BATCH CONTROL EXCEPTION REPORT

GEORGIA DEPARTMENT OF HUMAN RESOURCES WIC PROGRAM

DISTRICT/UNIT

CLINIC

VOUCHER BATCH EXCEPTION FORM

DATE

NUMBER

THIS FORM HAS BEEN GENERATED AS A RESULT OF:
THE QUANTITY ON THE CLINIC COMPLETED BATCH CONTROL FORM DOES NOT AGREE WITH THE ACTUAL QUANTITY RECEIVED.
THE VOUCHERS WERE RECEIVED IN A BATCH OF TADS.
ONLY ONE (1) COPY OF THE BATCH CONTROL FORM WAS RECEIVED WITH THE VOUCHERS.
NO BATCH CONTROL FORM WAS RECEIVED WITH THE VOUCHERS.

COVANSYS INPUT
SECTION

TYPE OF DOCUMENT ISSUED MANUAL VOUCHERS VOIDED MANUAL VOUCHERS

APPROXIMATE NUMBER IN BATCH

DATE BATCH RECEIVED AT:
FD-48

GA WIC 2005 PROCEDURES MANUAL

Attachment FD-16

GEORGIA WIC PROGRAM IDENTIFICATION CARD

FD-49

GA WIC 2005 PROCEDURES MANUAL

Attachment FD-17

DAILY ROSTER/MONTHLY MAILED VOUCHER REPORT

Participant's Name

I.D. Number

Voucher Number (Range)

Number of
Vouchers Returned

Signature of CPA

Date Returned

Replaced Voucher Numbers Lost/Stolen

Redemption Value of Lost
Vouchers

D A I L Y

End of Month Totals Date:

Total # of Participants:

Total # Issued:

Total # Returned:

*Redemption Rate must be completed by the District Office.

Total # Replaced:

Total Redemption Value:
$

FD-50

GA WIC 2005 PROCEDURES MANUAL

Attachment FD-18

BORROWED VOUCHER REPORT FORM

GEORGIA DEPARTMENT OF HUMAN RESOURCES WIC PROGRAM

BORROWED VOUCHER REPORT

BORROWING DISTRICT/UNIT: | | | |

CLINIC: | | | |

DATE: ________________

INSTRUCTIONS
DISTRICT(S)
|| ||

USE FORM TO REPORT MANUAL VOUCHERS BORROWED FROM ANOTHER CLINIC RETURN TO COVANSYS AS SOON AS POSSIBLE. MAIL TO: COVANSYS
GEORGIA WIC UNIT 1000 N. MADISON AVENUE, SUITE GREENWOOD, IN 48142
OR FAX TO: (317)889-9485

CLINIC(S)

BEGINNING VOUCHER NO.

ENDING VOUCHER

QUANTITY

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REASON(S):

INSUFFICIENT QUANTITY

ORDERED LATE

ORDER NOT RECEIVED FROM VIKING

OTHER

COMMENTS: _______________________________________________________________________________________________________

__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________ DISTRICT OFFICE APPROVAL DATE

VIKING WHITE COPY

SWO YELLOW COPY

DISTRICT OFFICE PINK COPY

CLINIC GOLD COPY

FD-51

GA WIC 2005 PROCEDURES MANUAL

Attachment FD-19

CUMULATIVE UNMATCHED REDEMPTIONS PART I EXAMPLE

PAGE 1 REPORT EWRR350G COOSA VALLEY HEALTH

STATE OF GEORGIA WIC SYSTEM CUMULATIVE UNMATCHED REDEMPTIONS FOR THE MONTH OF ___________ 20____

CLINIC PAGE 1 D/U/CL 01-1-008 RUN DATE __/__/__

VOUCHER REFERENCE NUMBER NUMBER

PART 1 NOT MATCHED TO ISSUANCE RECORD

FEBRUARY

JANUARY

S AMOUNT S AMOUNT

ISSUE DATE

TOTAL

74622188 74623694 74623736 74623812

36698524 36614713 55658120 36551839

R

66.36

R

39.75

R

36.15

R

4.77

TOTAL *****STATUS*****

147.03

147.03

VOID

REDEEMED

4

4

TOTAL

4

4

FD-52

GA WIC 2005 PROCEDURES MANUAL

Attachment FD-20

CUMULATIVE UNMATCHED REDEMPTIONS PART II EXAMPLE

PAGE 1 REPORT EWRR351G COOSA VALLEY HEALTH

STATE OF GEORGIA WIC SYSTEM CUMULATIVE UNMATCHED REDEMPTIONS FOR THE MONTH OF ___________ 20____

CLINIC PAGE 1 D/U/CL 01-1-008 RUN DATE __/__ /__

PART 2 NOT MATCHED TO ISSUANCE RECORD

VOUCHER REFERENCE ISSUE

NUMBER NUMBER

DATE

WIC ID

FEBRUARY JANUARY

FAMILY C P S AMOUNT S AMOUNT

RECONCILIATIONS TOTAL

74620912 74620913 74620914 74620915 74621454 74621455

15692612 11454716 11454717 34537674 36190860 55336318

01/12/96 008007741 5 1 01/12/96 008007741 5 1 01/12/96 008007741 5 1 01/12/96 008007741 5 1 02/05/96 008008287 8 1 02/05/96 008008287 8 1

R 4.14
R 7.17 R 4.17

R 5.13 R 11.06 R 8.27

............................................ ............................................ ............................................

74621456 7462145 7 74621502 74621504 74621505 74621506 74621507 74621509 74621755 74621818 74621820 74621821 74621822 74621823

36163633 36163632 60056231 34792625 60056230 32816278 36598558 36332739 36698773 36698562 15835402 55637585 36593568 42729901

02/05/96 008008287 8 1 02/05/96 008007096 8 1 01/02/96 008007096 4 2 01/02/96 008007096 4 2 01/02/96 008007096 4 2 02/06/96 008007096 4 2 02/06/96 008007096 4 2 02/06/96 008007096 4 2 02/13/96 440134495 9 2 02/13/96 008008171 4 1 02/13/96 008008171 4 1 02/13/96 008008171 4 1 01/09/96 008006036 1 2 01/09/96 008006036 1 2

R 6.47 R 4.17
R 8.48 R 4.45 R 4.46 R 8.85 R 3.48 R 7.97 R 8.31 R 9.10

R 9.00 R 7.52 R 4.30
R 4.40

............................................ ............................................ ............................................
..............................................................................

FD-53

GA WIC 2005 PROCEDURES MANUAL LOST/STOLEN/DESTROYED VOIDED VOUCHER REPORT

Attachment FD-21

GEORGIA DEPARTMENT OF HUMAN RESOURCES WIC PROGRAM

LOST/STOLEN/DESTROYED VOIDED VOUCHER REPORT

DISTRICT/UNIT/CLINIC:

INSTRUCTIONS
BEGINNING VOUCHER NO.

USE THIS FORM TO REPORT VOUCHERS (COMPUTER OR MANUAL) WHICH HAVE BEEN LOST, STOLEN, OR DESTROYED BY
EITHER THE PARTICIPANT OR THE CLINIC.

SUBMIT AT LEAST MONTHLY.

MAIL TO

COVANSYS

GEORGIA WIC UNIT

P.O. BOX 2504

GREENWOOD, IN 46142 -25041:

ENDING

QUANTITY

VOUCHER NO.

WIC I.D. NUMBER

STATUS

DATE:
STATUS CODES LOST/STOLEN/DESTROYED - 2
VOIDED - 3
COMMENTS

TOTAL VOUCHERS:
FD-54

GA WIC 2005 PROCEDURES MANUAL Voucher Printed on Demand (VPOD) Receipt

Attachment FD-22

DP-55

GA WIC 2005 PROCEDURES MANUAL

Compliance Analysis

TABLE OF CONTENTS Page
I. Introduction ............................................................................................................... CA-1 II. Monitoring ................................................................................................................. CA-1 III. Participant Abuse...................................................................................................... CA-3
A. Dual Participation ......................................................................................... CA-3 B. Duplicate Participation Verification Form ................................................ CA-5 C. Participant Abuses and Sanctions .............................................................. CA-5 IV. Procedures for Repayment of WIC Funds ........................................................... CA-9 V. Guidelines for Investigating Employee Abuse.................................................. CA-10 VI. Procedures to Request an Employee Investigation............................................ CA-11 VII. Vendor Compliance Investigation........................................................................ CA-11 VIII. Compliance Investigation Food Purchases ......................................................... CA-12 IX. Disqualified Vendor/Participant Access............................................................. CA-12 X. Investigation of Missing Vouchers/Verification of Certification Cards (VOC) ............................................................................................................ CA-14 A. Manual Voucher Inventory ....................................................................... CA-14 B. Georgia WIC Voucher Investigation Log ................................................ CA-14 C. Stop Payment of WIC Vouchers ............................................................... CA-15 XI. Security of Issuance Materials............................................................................... CA-15 A. WIC Program Stamps................................................................................. CA-15 B. VOC Cards .................................................................................................. CA-15 XII. Voucher Issuance Security..................................................................................... CA-16 A. WIC Vouchers.............................................................................................. CA-16 B. Voucher Security ......................................................................................... CA-17 C. Voucher Storage .......................................................................................... CA-17 D. Voucher Printing on Demand (VPOD) ................................................... CA-17 E. Transporting WIC Vouchers ..................................................................... CA-17

GA WIC 2005 PROCEDURES MANUAL

Compliance Analysis

Attachments:
CA-1 Closeout Reconciliation Report............................................................................. CA-18 CA-2 Georgia WIC Voucher Investigation Log ............................................................ CA-19 CA-3 Participant Sample Warning Letter...................................................................... CA-20 CA-4 Request for Investigation Form............................................................................. CA-21 CA-5 WIC Transaction Report ........................................................................................ CA-22 CA-6 Participant Access Verification Form................................................................... CA-23 CA-7 WIC Program Vendor Donation List ................................................................... CA-24 CA-8 Notification Summary of Missing Vouchers/VOC Cards................................ CA-25 CA-9 Duplicate Participation Verification Form .......................................................... CA-26 CA-10 Participant Repayment Sample Letter ................................................................. CA-27 CA-11 Participant Repayment Schedule Sample Letter ................................................ CA-28 CA-12 Dual Participation Report Investigation Form ................................................... CA-29

GA WIC 2005 PROCEDURES MANUAL

Compliance Analysis

I. INTRODUCTION
The Compliance Analysis Section (CAS) assesses programmatic compliance for over 1800 retail grocery stores (WIC Vendors). CAS performs covert investigations to deter potential abuse and to ensure the appropriate delivery of WIC approved food items
The section is responsible for the investigation of vouchers reported missing or stolen from WIC clinics. Clinic investigations are performed in conjunction with the Office of Investigative Services.
The Section also investigates participant and employee fraud associated with WIC clinics. Report analysis is preformed to determine dual participation and system related fraud and abuse.
II. MONITORING
Clinic reviews are conducted to assess the security of WIC vouchers, and voucher issuance materials in WIC clinics during issuance, staff breaks, and at the close of business.
1. Annually, the local WIC Program Coordinator or designee will visit each clinic for the purpose of reviewing clinical procedures, as outlined in the Self Reviews, Monitoring Tool.
2. If the review of vouchers/voucher-related materials causes suspicion, and the Coordinator determines that an investigation is needed, the Coordinator shall notify the Georgia WIC Branch and proceed with the investigation. The Georgia WIC Branch may notify USDA-Food Nutrition Service (FNS) of the impending investigation and keep them informed of case progress on a periodic basis or as requested.
3. The Closeout Reconciliation Report (see Attachment CA-1) is generated for the local agency and indicates the final disposition of all computerprinted vouchers. This report should be used to monitor the disposition of any vouchers that have a questionable status ( i.e., voids, fail to sign, etc). If findings lead to suspicion and the Coordinator determines an investigation is needed, the Coordinator shall notify the Georgia WIC Branch and proceed with the investigation.
4. The Georgia WIC Branch shall retrieve voucher copies when the Coordinator determines the need during an investigation. These vouchers will be reviewed by the Georgia WIC Branch for compliance prior to being forwarded to the Local Agency. A Georgia WIC Voucher Investigation Log should be used when requesting voucher copies from the Georgia

CA-1

GA WIC 2005 PROCEDURES MANUAL

Compliance Analysis

WIC Branch (see Attachment CA-2).
5. Investigations may include but are not limited to review of the voucher inventory, cashed vouchers, certification records, employee/relative participation in the WIC Program, and if necessary, contacting WIC participants to verify that vouchers were picked up.
6. Investigative/Monitoring clinical reviews will be conducted in conjunction with the monitoring team, and when deemed necessary.

CA-2

GA WIC 2005 PROCEDURES MANUAL

Compliance Analysis

III. PARTICIPANT ABUSE
Reports Analysis: The unit conducts quarterly reviews of Dual Participation Reports that may lead to the investigation of program participants. Financial penalties may be assessed to participants found guilty of violations. Other system reports, including system generated reports, manual reports, and ad hoc reports are also analyzed.
A. Dual Participation
Dual participation occurs when individuals concurrently participate in one or more WIC clinics. The WIC Program's automated data system generates a quarterly "Dual Participation Report." The report specifies possible duplicate enrollment in alphabetic sequence, (See Georgia WIC Reports on GWIS for details). The report data is compiled into a composite state report as well as a report for each local agency.
The ADP Contractor mails a Composite Dual Participation Report quarterly to the WIC Branch and to each local agency. The local agency must investigate and reconcile each possible dual enrollment. The reconciled report must be submitted to the WIC Branch within sixty (60) days from the run date of the report. The report should include the status of the participant (active or terminated), last voucher pickup date, participant's mother, guardian or caretaker's name, and termination date if applicable. Please use the Dual Participation Investigation Form (See Attachment CA-12) and attach it to the Dual Participation Report. Upon receipt of these completed reports, the WIC Branch will eliminate obvious false duplicates by:

1. Transferring all actions taken by local agencies onto the Statewide or composite report.
2. Notifying local agencies that have participants whose enrollment has not been reconciled.
The local agency must conduct further investigation until all alleged dual participation is resolved.
The following are examples of possible dual participation situations and the procedures for reconciliation.

1. Participant enrolled in the same local agency at the same clinic site.

CA-3

GA WIC 2005 PROCEDURES MANUAL

Compliance Analysis

Investigate to determine if there is any difference in the spelling of the first name. If so, twins may be enrolled. If the first names are spelled exactly the same, then investigate clinical records to determine if it is the same participant or a different participants. Document dual participation information obtained and the final action taken on each case in the participant's health and issuance records.
The current TAD field code #54 allows the system to identify multiple births. This should reduce, if not eliminate, twins from appearing on the dual participation report.
2. Participant Enrolled in the Same Local Agency at Different Clinic Sites.
Investigate to determine if the participant has received vouchers at both clinic sites. If not, it is possible that two turnaround documents (TADs) were inadvertently printed. The TAD that is incorrect (based on the clinic site the participant is attending) must be deleted. If the participant has picked up vouchers in both sites for the same month, a possible case of participant abuse exists. Refer to the "Participant Abuses and Sanctions" section below for procedures regarding this type of abuse. Documentation must be forwarded to the WIC Branch as a part of the Dual Participation Report, and a copy of the same documentation must be placed in the participant's clinic file.
3. Participant Enrolled in Different Local Agencies
Contact the other local agency and together investigate the possibility of dual participation. Each local agency should review health and issuance records. If the participant has moved, the local agency from which the participant moved must terminate the participant. If dual participation and/or intentional fraud is involved refer to the section on Participant Abuses and Sanctions for procedures regarding how to proceed with this type of abuse. Documentation of dual participation information and final action on each case must become a part of the participant's clinic file.

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GA WIC 2005 PROCEDURES MANUAL

Compliance Analysis

B. Duplicate Participation Verification Form
The Duplicate Participation Verification Form (Attachment CA-9) is printed and distributed by the ADP Contractor. The local agencies will use this form to notify the ADP contractor to terminate a dual participant from the specified clinic.
The Duplicate Participation Verification Form must be completed when dual participation has been verified by the local agency. The form should be mailed to the ADP contractor as soon as dual participation has been verified. Route the form as follows: white copy-ADP Contractor, yellow copy-Georgia WIC Branch, pink copy-District Office, gold copy-WIC Clinic.
C. Participant Abuses and Sanctions
The Georgia WIC Program may assess claims and penalties against a WIC participant when the participant has abused program guidelines. All actions taken as a result of participant abuse must be documented in the participant's health record. This includes, but is not limited to, verbal warnings, written warnings, suspensions, and terminations.
In all cases of suspension or termination from the program, the participant must receive notice of suspension or termination. The Notice of Termination /Ineligibility/Waiting Form must be completed. The specific program abuse must be entered in the appropriate space. A copy of the form must be filed in the participant's health record.
Exceptions
Before disqualifying a participant from the program, the local agency may warn a participant (see Attachment CA-3) or decide not to impose a mandatory sanction if: 1. Within 30 days of receipt of the letter demanding repayment, full
restitution is made by the participant. 2. A repayment schedule is agreed upon. 3. Or in the case of an infant, child, or participant under the age of
18, the state/local agency approves the designation of a proxy.

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GA WIC 2005 PROCEDURES MANUAL

Compliance Analysis

Terminations
The local agency may permit a participant to reapply for the program before the end of a mandatory disqualification period if: 1. Full restitution is made. 2. Repayment schedule is agreed upon. 3. In the case of a participant who is an infant, child or under age
18, the state or local agency approves the designation of a proxy.
At the time of disqualification, the local agency must advise the participant of the procedure to follow to obtain a fair hearing (See Rights and Obligations Fair Hearing Section).
When appropriate, the local agency must refer participants who violate program requirements to Federal, State, or local authorities for prosecution under applicable statues.
1. ABUSE: Participating in more than one WIC Program simultaneously (dual participation). SANCTION: When dual participation is discovered, the participant must be removed from one (1) program. The local agencies involved must agree on which program will terminate the participant. The participant must be given a warning in writing, that simultaneous participation in more than one (1) program is in violation of WIC regulations (See Abuse #2 for further sanction procedures). If the same individual is found to be a dual participant on a subsequent occasion, he/she must be disqualified for one (1) year (See Abuse #2 for further sanction procedures).
2. ABUSE: Intentionally making a false or misleading statement or intentionally misrepresenting, concealing, or withholding facts. This includes, but is not limited to, information concerning income, family size, personal ID, residence, diet intake, and medical history. SANCTION: The participant may be required to pay the State Agency, in cash, the value of benefits improperly issued to them. The "value of benefits" is the dollar amount of WIC vouchers which were issued and cashed or the cost to the WIC Program of
CA-6

GA WIC 2005 PROCEDURES MANUAL

Compliance Analysis

the special formula provided through office of Nutrition. Any benefits received through fraudulent information will be pursued administratively.
When it is suspected that intentional misrepresentation may have occurred, the local agency is to notify the state agency of such occurrence. Based upon the information received from the local agency, the state agency will make a determination as to whether the misrepresentation or falsification was intentional. All facts must be documented in writing.
Prior to the State Agency determination, the local agency shall provide the state agency, in writing, with the following information: a. Copy of the front and back of the WIC Assessment/
Certification Form signed by the participant or authorized representative. b. The serial number of all WIC vouchers, manual and computer, issued to the participant or authorized representative within the certification period. c. A written summary specifying what information was supplied by the participant or authorized representative, what the actual information is suspected to be, and a statement as to whether it is suspected that the falsification was intentional.
Based on the information received from the local agency, the state agency will make a determination as to whether falsification and/or intentional misrepresentation has occurred. If the misrepresentation or falsification is determined to be intentional, the state agency will proceed as follows: a. Secure the vouchers cashed by the participant from the
contract bank and/or WIC banking. b. Determine the total value of the cashed vouchers. c. Make a recommendation that the local agency take the
following actions within seven (7) days: (1) Notify the participant of the findings. If the investigation
findings determine the participant is eligible for program benefits, a sanction will be imposed for a disqualification period of one (1) year. The participant will be notified, by certified mail, of his/her disqualification and right to a fair hearing. (2) If the investigation findings establish that the participant is ineligible for program benefits, the participant will be

CA-7

GA WIC 2005 PROCEDURES MANUAL

Compliance Analysis

immediately terminated from the program. The participant will be sent, by certified mail, a Notice of Termination Form, which includes notification of their right to a fair hearing.
(3) If the total value of benefits issued is less than $100, it will be documented in the participant's health record. No recovery action will be initiated the first time, however, (1) and (2) above still apply. If the same offense occurs a second time, steps will be taken to recover all of the misappropriated benefits.
(4) If the total value of benefits issued is $100 or more, the local agency will notify the participant of the dollar value of WIC vouchers cashed and request repayment (See Attachment CA-10 and CA-11 for Sample Letters). In no instance will repayment arrangements be extended beyond ninety (90) days from the date notification is provided to the participant.

3. ABUSE: Sale or exchange of vouchers or WIC food items with other individuals or parties. SANCTION: When proof of abuse has been established, the participant may receive a first offense warning in writing. Subsequent abuse will result in disqualification from the program for a period not to exceed one (1) year. The participant must be notified of his/her right to a fair hearing (See RO-Section Fair Hearing Procedures).
If the total value of benefits is $100 or greater, the repayment procedures outlined above (Sanction #2d) will be implemented.
4. ABUSE: Receiving cash for vouchers from food vendors, or credit toward purchase of unauthorized food or other items of value in place of approved WIC foods. SANCTION: When proof of abuse has been established, the participant will be suspended from the program for a period not to exceed one (1) year. The participant must be notified of his/her right to a fair hearing (See RO-Section-Fair Hearing Procedures).
If the total value of benefits is $100 or greater, the repayment procedures outlined above (Sanction #2d) will be implemented.

CA-8

GA WIC 2005 PROCEDURES MANUAL

Compliance Analysis

The Georgia WIC Branch must be notified if this abuse is occurring in order for appropriate action to be taken with the vendor.

5. ABUSE: Speaking to clinic staff, vendor personnel, and/or other WIC participants in an obnoxious, threatening, obscene or derogatory manner.
SANCTION: The participant should be warned, in writing, of the inappropriate behavior and the action that will be taken if the problem continues.
If the problem does continue, the participant may be suspended from the program for a period not to exceed one (1) year.

6. ABUSE: Physically hurting, pushing, or inappropriate physical handling of clinic staff, vendor personnel or property, and/or other WIC participants in the clinic/store.
SANCTION: If local agency staff determines that the abuse is extensive and/or detrimental to clinic staff, the local agency may contact the local authorities, i.e. police, and may also suspend the participant(s) from the program for a period not to exceed one (1) year

IV. PROCEDURES FOR REPAYMENT OF WIC FUNDS
A. Repayments will be submitted to the local agency and must be in the form of a cashier's check or money order payable to: DHR/WIC Program.
1. The local agency will immediately forward all repayments received to the State agency for processing.
2. If total payment is not made within the ninety (90) day timeframe, the local agency will notify the state agency, which will in turn proceed with recovery actions prescribed under the Georgia Statute. "When appropriate the state agency must refer participants who violate program requirements to Federal, State or Local authorities for prosecution under applicable statutes[(7 c FR246.12(u) (5)].
3. The State agency shall continue collection procedures until it determines it is no longer cost effective.
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GA WIC 2005 PROCEDURES MANUAL

Compliance Analysis

B. Collection of claims for repayment of benefits is suspended if an appeal for a fair hearing is requested.
1. The suspension remains in effect until a fair hearing decision is rendered.
2. If a fair hearing decision at the local level is rendered in favor of the local agency, efforts to collect repayment must be resumed.
3. Repayment efforts must be resumed even if the local level decision is being appealed to the next level.
V. GUIDELINES FOR INVESTIGATING EMPLOYEE ABUSE
Department of Human Resources Policy 1201 Standard Code of Conduct states that any employee that violates WIC policies and procedures will be terminated, required to pay back funds to the agency, and face possible prosecution.
When intentional employee abuse is found, it may be considered employee misconduct. Suspected intentional abuse shall be investigated by the local agency with assistance from the WIC Branch, and may require a Department of Human Resource Office of Investigative Services (DHR-OIS) investigation.
Intentional abuse is a deliberate effort to defraud the WIC program (example: illegally taking WIC vouchers; giving false/misleading information in order to become certified for WIC, etc).
A. Employees participating in the WIC Program shall have the same rights and obligations as any other WIC participant, however, employees are not allowed to issue vouchers or certify themselves or family members.
B. Employees participating in the WIC Program shall adhere to the rules and regulations for program participation and job responsibilities.
C. A DHR-OIS investigation shall be handled in conjunction with the local agency.
D. Action to be taken as a result of DHR-OIS investigation findings shall
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GA WIC 2005 PROCEDURES MANUAL

Compliance Analysis

depend on local agency personnel policy and procedures concerning the employee misconduct.

E. Prosecution shall be processed through the District Attorney's Office. The local agency requesting an order of prosecution, shall notify the WIC Branch and the WIC Branch shall notify USDA-FNS.
F. The WIC Branch recommends that any employee found to be abusing the WIC Program should be removed promptly from issuing or processing WIC vouchers, without reappointment rights.
G. The WIC Branch shall inform USDA of any investigations of WIC related employee fraud.

VI. PROCEDURES TO REQUEST AN EMPLOYEE INVESTIGATION
A. The District Health Officer shall forward a letter requesting an investigation directly to the DHR-OIS and a copy of the letter must be forwarded to the Division of Public Health Director's Office and the Georgia WIC Branch.
B. Contract agencies requesting an employee investigation shall submit their letter to the Division of Public Health Director's Office and a copy to the Georgia WIC Branch. The Director's Office shall then forward the request for investigation along with a cover letter to DHR-OIS.
C. DHR-OIS investigation results will be forwarded to the office, which initiates the request. The initiating agency shall submit the results to the District WIC Coordinator, Program Manager, District Health Director and a copy to the Georgia WIC Branch.

VII. VENDOR COMPLIANCE INVESTIGATION
Compliance investigations will be initiated by the WIC Branch.
Investigations will occur at stores that have been identified as "High Risk" by the WIC Branch through the use of ADP system reports, complaints, the Request for Investigation Forms received from the districts and random selection.

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GA WIC 2005 PROCEDURES MANUAL

Compliance Analysis

A Request for Investigation Form (Attachment CA-4) should be completed on any store the local agency has reason to believe is violating WIC procedures. A copy of the Request for Investigation Form should be mailed as soon as possible to the WIC Branch for action. (See Complaints Against Vendors, in the Vendor Procedures section of this manual).
Vouchers to be used by the WIC Branch in compliance investigations will be generated by authorized WIC staff.

VIII. COMPLIANCE INVESTIGATION FOOD PURCHASES
WIC foods and other food items purchased as a result of compliance investigations must be donated to non-profit organizations. Such non-profit organizations include but are not limited to:
1. City and County Fire Department(s) 2. City and County Police Department(s) 3. Retirement Homes 4. Battered Women Shelters 5. Church Organizations 6. Homeless Shelters 7. Salvation Army 8. Food Pantry (Bank) 9. Head Start Program 10. Boy Scouts 11. Girl Scouts
The compliance investigator must complete a Food Donation List (See Attachment CA-7) and submits it to a non-profit organization for verification. A representative of the non-profit organization must sign the donation list to confirm the receipt of foods, and may obtain a copy of the list for their records.

IX. DISQUALIFIED VENDOR/PARTICIPANT ACCESS
If a vendor is found in violation of program policies and federal regulations following a compliance investigation(s), the vendor will be assessed sanctions for violations occurring during each investigative visit. If a vendor accumulates the maximum allowable sanctions, the store shall be disqualified from WIC Program

CA-12

GA WIC 2005 PROCEDURES MANUAL

Compliance Analysis

participation (See Vendor Sanctions-Vendor Section of the Procedure Manual). In the event a vendor disqualification creates inadequate participant access for WIC participants, procedures outlined in the Vendor Handbook (inadequate participant access cases) will be implemented. Procedures and guidelines for vendor disqualification, as a result of an investigation, are found in the Vendor HandbookTerminations/Disqualification Section.
To assess inadequate participant access in obtaining WIC foods as the result of a vendor disqualification, the WIC Branch will initiate the verification process by completing the Participant Access Form (Attachment CA-6). The purpose of the "Access Form" is: (a) to verify if a disqualified vendor's absence will create inadequate access for WIC participants; and/or (b) to verify that there is adequate participant access. Verification of inadequate participant access will be in accordance with Inadequate Participant Access Procedures as stated in the Vendor Section.

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GA WIC 2005 PROCEDURES MANUAL

Compliance Analysis

X. INVESTIGATION OF MISSING VOUCHERS/VERIFICATION OF CERTIFICATION CARDS (VOC)
Vouchers/VOC cards reported missing or stolen from WIC clinics will be investigated by local agencies in conjunction with the Compliance Analysis Section of the WIC Branch. Investigating agencies may include the DHR Office of Investigative Services and the local police department. Local agencies may be subject to corrective action(s) and/or financial penalties if program regulations are violated.
When twenty-five (25) or more WIC vouchers or five (5) or more VOC Cards are missing, the Notification Summary of Missing Vouchers/VOC Cards (Attachment CA-8) must be completed. However, if five (5) or less cards are reported missing again from the same clinic, state staff will make a special site visit. When vouchers/VOC cards are discovered missing, immediately notify the supervisor, WIC Coordinator, and the Police. The assigned detective shall be given the name of either the WIC Coordinator or their designee as a contact person while conducting their investigation. The coordinator/designee shall report details of investigation to the Compliance Analysis Section .
The WIC Coordinator or designee must submit the Notification Summary to the WIC Branch within three (3) working days of the discovery of missing vouchers/VOC cards. Immediately following initial contact from the local agency, the WIC Branch will notify WIC vendors and instruct the contract bank to place a stop payment on the missing vouchers. For additional instructions on VOC cards, refer to the Certification Section of the Procedures Manual.
A. MANUAL VOUCHER INVENTORY
Document the serial numbers of the vouchers that are lost or stolen on the manual voucher inventory.
B. GEORGIA WIC VOUCHER INVESTIGATION LOG

1. To request WIC voucher copies, complete the Georgia WIC Voucher Investigation Log (Attachment CA-2) with the following: a. District/Unit b. Current date c. Reason for investigation (suspected fraud, etc.) d. List voucher numbers e. Issue date (date missing if manual voucher)

CA-14

GA WIC 2005 PROCEDURES MANUAL

Compliance Analysis

f. Clinic number g. Sign and date.
This form should be completed whenever any voucher copies are being requested.
2. Mail the completed Georgia WIC Investigation Log to the WIC Branch, Compliance Analysis Section, along with the Lost/Stolen/Destroyed/Voided Voucher Report. The Compliance Analysis Section will follow up with the local agency immediately on reports that indicate potential fraud.
3. Upon receipt of special request voucher copies, the local agency should conduct a review to determine if potential fraud exist, and to notify the Compliance Analysis Section if further review or an investigation is required, within thirty (30) days of receipt.
4. The local agency shall work in conjunction with the WIC Branch during an investigation of missing vouchers. When a determination has been made that potential employee fraud exist, the DHR Investigative Services must be contacted (See V. and VI. of the CA Section).
C. STOP PAYMENT OF WIC VOUCHERS
The Georgia WIC Branch will immediately upon notification, place a stop payment on WIC vouchers reported stolen from WIC clinics.

XI. SECURITY OF ISSUANCE MATERIALS
A. WIC Program Stamps 1. WIC Program stamps must be stored in a locked desk, cabinet, or closet. The key which locks the desk, cabinet, or closet must be stored in a secure location. 2. WIC Program stamps must be stored in a location separate from WIC vouchers, I.D. cards, and VOC cards.
B. VOC Cards 1. VOC cards must be stored in a locked desk, cabinet, or closet. The key that locks the desk, cabinet, or closet must be stored in a secure location.

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GA WIC 2005 PROCEDURES MANUAL

Compliance Analysis

2. VOC cards must be stored separately from the VOC card inventory.
XII. VOUCHER ISSUANCE SECURITY
A. WIC Vouchers
WIC vouchers are food instruments (checks, coupons, etc.) that are used by a participant to obtain supplemental foods. The State and local agency have the responsibility to maintain control and provide accountability for the receipt and issuance of supplemental foods and food instruments. The state and local agency must also ensure that there is secure transportation and storage of un-issued food instruments.
In the event that unused vouchers are lost or stolen as a result of failure to follow security regulations, the local agency may be issued a repayment letter for the value of the lost or stolen vouchers in question.

1. All vouchers must be stored in a locked cabinet, desk, or closet when not being issued. The key which locks the cabinet, desk, or closet must be stored in a secure location (change location of keys occasionally).
2. When issuing manual vouchers from a computer, the clerk must log out before leaving the work station.
3. When more than one person is using the same terminal, each person must log out upon completion of their printing job.
4. Passwords must be changed every 90 days at a minimum.
5. When a voucher issuance employee resigns or is no longer authorized to issue vouchers, the following procedures should be implemented: a. Within three (3) business days, delete employee's name from the system. b. Change all passwords that the employee had access to. c. Change key to voucher security door (when applicable). d. Change location of all security keys.
6. Only authorized persons may be given access to WIC vouchers.

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GA WIC 2005 PROCEDURES MANUAL

Compliance Analysis

B. Voucher Security
WIC voucher stock must not be accessible to participants or other unauthorized persons. Except for the vouchers issued to the participant served, multiple vouchers must not be placed on top of the issuance counter. One of the following methods must be used to assure at least minimum security for voucher issuance station(s): 1. Service Delivery Counter which will provide a shield between
the issuance clerk and the participant; 2. Half Door may be used in a small clinic with only one clerk; 3. Vouchers must be kept three (3) feet out of the reach of the
participants, or there must be a physical barrier between the vouchers and the participant.

C. Voucher Storage
At a minimum, when clinics are closed, districts must utilize at least one of the following voucher storage methods: 1. If vouchers are locked in a standard cabinet, the cabinet must be
in a locked room, within a locked building; 2. A locked cabinet in a locked building with an alarm system; 3. A fire proof insulated security file cabinet with combination lock,
securely attached to the floor, in a locked building; 4. A safe securely attached to the floor in a locked building; 5. A vault in a locked building.

D. Voucher Printing on Demand (VPOD)
VPOD Printers must not be accessible to participants or other unauthorized personnel. The printers must be in a secure location and exclusively used to print VPOD vouchers.
E. Transporting WIC Vouchers
When transporting WIC vouchers, program stamps, and VOC cards, to a clinic site, they must be secured in a locked box or locked briefcase (See Attachment FD-8). When vouchers are being delivered to a client in a hospital setting, the vouchers must be kept in a locked box, locked clipboard or lock brief case.

CA-17

GA WIC 2005 PROCEDURE MANUAL

Attachment CA-1

CLOSEOUT RECONCILIATION REPORT

D/U #:

CL #:

PAGE 20634 REPORT EWRR840G GRADY MATL & INFANT CARE

WIC ID

STATE OF GEORGIA WIC SYSTEM CLOSEOUT RECONCILIATION REPORT FOR THE CLOSEOUT MONTH OF JUNE 1995
PARTICIPANT NAM E

VOUCHER REFERENCE

NUMBER

NUMBER

25709399 55236263

FAMILY C P 999054588 2 1

LAST

FIRST

VCHR TYPE
055

REDMO AMT 10.61

26499328 48629635

697012089 2 1 -

047

12.14

CLINIC PAGE

9

D/U/CL 09-1-259

RUN DATE 07/13/95

DATE ISSUED 04/06/95
04/14/95

STATUS DATE
05/10/95
04/18/95

CMNTS

26488329 26488330 26488331 25709404 25709405 25709406 25709407 25709412 25709413 25709414 25709415 257094 2 0 25709421 25709422 25709423 2648833 6 26488337 26488338 26488339 26488344 26488345 26488346 26488347 26488352 26488353 25709428 25709429 25709430 25709431 25488356 26488357 26488358 26488359 26488364 26488365 26488366 26488367 25709436 25709437

48629615 48629626 63771576 63771588 63771592 63771629 63771624 63771617 63771570 63771616 52185535 52185541 52185557 52185542 63851783 67212999 63851787 67213000 67212970 42701052 63778323 67212998 63851800 63851799 63867366 63867371 63867382 63857574 42501104 68637805 4250254 8 68637825 42501097 68637806 42502547 68637826 63827114 63827113

697012089 2 1 697012089 2 1 697012089 2 1 699126861 3 1 699126861 3 1 699126861 3 1 699126861 3 1 999043937 5 1 999043937 5 1 999043937 5 1 999043937 5 1 697010260 1 1 697010260 1 1 697010260 1 1 697010260 1 1 697008023 7 1 697008023 7 1 697008023 7 1 697008023 7 1 699148954 0 1 699148954 0 1 699148954 0 1 699148954 0 1 695100454 5 1 695100454 5 1 697004511 5 1 697004511 5 1 697004511 5 1 697004511 5 1 999051530 7 1 999051530 7 1 999051530 7 1 999051530 7 1 697009847 8 1 697009847 8 1 697009847 8 1 697009847 8 1 999047451 3 1 999047451 3 1

039

.00

04/14/95

EXP

025

9.82

04/14/95 04/14/95 04/18/95

039

6.33

04/14/95 04/18/95

VOID

028

8.20

04/06/95 04/10/95

031

8.92

04/06/95 04/10/95

037

14.54

04/05/95 04/10/95

VOID

054

12.26

04/06/95 04/10/95

047

12.14

04/06/95 04/10/95

039

6.33

04/06/95 04/10/95

025

9.82

04/06/95 04/10/95

039

6.33

04/06/95 04/10/95

047

12.22

04/12/95 04/19/95

039

6.13

04/12/95 04/19/95

025

10.37

04/12/95 04/19/95

039

6.13

04/12/95 04/12/95

031

8.92

04/11/95 04/13/95

037

13.71

04/11/95 05/01/95

039

6.33

04/11/95 04/13/95

055

9.10

04/11/95 05/01/95

028

7.18

04/06/95 05/01/95

031

7.23

04/06/95 05/26/95

037

14.54

04/06/95 04/10/95

054

8.37

04/06/95 05/01/95

068

58.87

04/11/.95 04/13/95

072

51.40

04/11/95 04/13/95

031

8.92

04/11/95 04/13/95

037

14.54

04/11/95 04/13/95

039

6.33

04/11/95 04/13/95

055

9.91

04/11/95 04/13/95

031

8.92

04/11/95 05/12/95

037

14.54

04/11/95 05/05/95

039

6.33

04/11/95 05/12/95

055

9.91

04/11/95 05/05/95

031

8.92

04/10/95 05/12/95

037

14.54

04/10/95 05/05/95

039

6.33

04/10/95 05/12/95

055

9.91

04/10/95 05/05/95

031

6.87

04/06/95 04/10/95

037

6.95

04/06/95 04/10/95

TOTAL VOUCHERS CASHED TOTAL VOUCHERS EXPIRED TOTAL UNMATCHED TO CERT RECORDS TOTAL VOUCHERS ISSUED VOIDED UNCLAIMED TOTAL VOUCHERS CREATED

CLINIC TOTALS VOUCHERS
805 73 0
878 135
0 1,013

AMOUNT 11,199.66
.00 11,199.66
11,199.66

(TOTAL OF CASHED AND EXPIRED) (COMPUTED AND MANUAL VOUCHERS)

CA-18

GA WIC 2005 PROCEDURES MANUAL GEORGIA WIC
VOUCHER INVESTIGATION LOG

Attachment CA-2

DISTRICT/UNIT: ___________________DATE:____________________________________

REASON FOR INVESTIGATION:

VOUCHER NUMBER

ISSUE DATE

CLINIC BOX

#

#

STATE WIC OFFICE USE ONLY

PAID YES/NO

COMMENTS

COMPLETED BY:

DATE: ___________________________
Routing : White Copy - State WIC Branch, Yellow - Local Agency

Form 3789 (5-99)

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GA WIC 2005 PROCEDURES MANUAL

Attachment CA-3

PARTICIPANT SAMPLE WARNING LETTER

Dear Participant,

It has come to my attention that you sold food that was purchased utilizing your WIC vouchers. This is against WIC Program regulations.

The WIC foods are provided to your child so that he/she can become healthy. The food must be given to him/her and not sold or given to anyone else.

If you continue to sell your WIC food after this warning, your child may be taken off of the WIC Program for up to three (3) months.

If you have any questions, please call me at

.

Sincerely,

WIC Program Coordinator

CA-20

GA WIC 2005 PROCEDURES MANUAL

Attachment CA-4

REQUEST FOR INVESTIGATION FORM

Georgia Department of Human Resources

DATE

WIC REQUEST FOR INVESTIGATION

TO:

FROM:

NAME AND ADDRESS OF STORE (INCLUDE STREET, CITY, STATE AND COUNTY)

VENDOR NUMBER

NAME OF OWNER OR MANAGER ETHNIC MAKEUP OF STORE'S CLIENTELE

HAS STORE BEEN PREVIOUSLY INVESTIGATED?

YES

NO

ARE THERE OTHER STORES UNDER THE SAME OWNERSHIP WHICH ARE AUTHORIZED FOR PARTICIPATION?

YES

NO

If Yes, fill in their names and address.

TYPES OF ABUSES FOR WHICH INVESTIGATION IS REQUESTED. OTHER INFORMATION USEFUL TO THE INVESTIGATOR (PROVIDE ADDITIONAL SHEETS IF NECESSARY)

Form 3775 (3-97)

CA-21

GA WIC 2005 PROCEDURES MANUAL

Voucher Number

Georgia Department of Human Resources Division of Public Health
WIC Program WIC TRANSACTION REPORT (WTR)

Store Name and Address:

WTR Returned to WIC Agency:

Attachment CA-5 Vendor Number

1. At the Check-out counter there (was/were) person(s) in line ahead of me. On

, at about . I entered the subject's store. I selected the item(s) specified below. The food instrument indicated above

was used for this transaction. The clerk sold the item(s) below at a total cost of (if available) $

. During checkout, the voucher was in plain view of the clerk who served the investigator. The price of the

items(s) were marked on the item(s) or shelf, for item(s) not marked, they were verified by:

2.

Time Entered Store:

Time Approached Checkout:

Time Left Store:

3. Check List

Y / N

Prices Marked on Foods or Shelf

Rang up Sale

Y / N

Adequate Supply of WIC Foods on Shelf

Y / N

Recorded Price on Voucher

Checked ID Cards

Gave Receipt to Investigator

4. Comments

5.

Description of Clerk (Approximate)

SEX

RACE

AGE

6. Other Identifying Information:

7. Identified During Transaction as (Title/Name):

ELIGIBLE ITEMS

SUMMARY OF PURCHASE

QUANTITY

BRAND NAME

HEIGHT

WEIGHT

ITEM

HAIR COLOR PRIC E

INELIGIBLE ITEMS
QUANTITY

ITEM

PRICE

ITEMS REFUSED
QUANTITY

ITEM

I

, an investigator of the Georgia WIC Program, Department of Human Resources,

make the above statement freely andvoluntarily knowing that this statement may be used as evidence.

Name:

Date:

Title:

Investigator Signature:

Form 3773 (6/99)

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GA WIC 2005 PROCEDURES MANUAL

Attachment CA-6

GEORGIA WIC PROGRAM
PARTICIPANT ACCESS VERIFICATION FORM

District/Unit____________________________ Vendor Number ________________

Name of Vendor under Investigation Address (Street/Hwy)

___________________________________ ___________________________________ ___________________________________

WIC Vendor(s) within ten (10) miles of Investigated Vendor

Vendor Name ___________________ Address ___________________ _______________________________

Vendor Name _____________________

Address

_____________________

__________________________________

Distance In Miles _____________ Distances In Miles ________________

Longitude ____ _______ Latitude ______

Longitude ____ __ _________________

_

Latitude__________________________

List any Geographical Barriers _______________________________ _______________________________ _______________________________ Explain the following observations

List any Geographical Barriers __________________________________ __________________________________ __________________________________ Explain the following observations

Sidewalks _______________________ _______________________________ Crosswalks ______________________ _______________________________ Traffic Lights____________________ _______________________________ Busy Highway(s)__________________ _______________________________ Concrete Medians _________________ _______________________________ Public Transportation_____________

Sidewalks __________________________ __________________________________ Crosswalks _________________________ __________________________________ Traffic Lights_______________________ __________________________________ Busy Highway(s)_____________________ __________________________________ Concrete Medians ____________________ __________________________________ Public Transportation________________

Comments ______________________ _______________________________ _______________________________

Comments _________________________ __________________________________ __________________________________

Investigator's Signature ______________________________ Date____________

CA-23

GA WIC 2005 PROCEDURES MANUAL

Attachment CA-7

Product Type Milk

Brand

GEORGIA DEPARTMENT OF HUMAN RESOURCES
STATE WIC PROGRAM DONATION LIST

Quant./ C.B. Date Vendor # Size

Non WIC Foods Items

Items Purchased

Type

Brand

Quant./ Size

CB Date

Vendor #

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

Other WIC Approved Items:
Comments: Organization Name: Organization Representative: Phone #: Address: City: WIC Representative: Date:
CA-24

Zip Code:

GA WIC 2005 PROCEDURES MANUAL

Attachment CA-8

PLEASE USE INK
Georgia Department of Human Resources WIC Program
NOTIFICATION SUMMARY OF MISSING VOUCHERS/VOC CARDS
COMPLETE : When 25 or more WIC vouchers; 5 or more VOC cards; are missing. (A lost/stolen/voucher report must be completed for all missing vouchers) IMMEDIATELY: Notify Supervisor; WIC Coordinator; and the Police.
Complete the following information: (ALL SECTIONS MUST BE COMPLETED)
SECTION I

Name of person who discovered the vouchers/VOC cards missing

D/U/C

Name of person completing this form, if different from above _____________________________________________________________________________
SECTION II

Name of person(s), who is responsible for vouchers/VOC cards at this clinic. __________________________________________________ __________________________________________________
SECTION III

______________________________________________ ______________________________________________

Number of Missing Voucher(s)

Number of Missing VOC Cards

NOTE: A separate form must be completed if both Vouchers and VOC cards are missing

Discovered missing: Date

Time

am

pm

Supervisor notified: Date

Time

am

pm

Coordinator notified: Date

Time

am

pm

VOUCHER'S Beginning # VOC CARDS Beginning #

Ending # Ending #

SECTION IV

Com plete a detailed summary of how vouchers/VOC cards were discovered missing. ________________________________________________________________ ________________________________________________________________________________________________________________________________

Use additional sheets of paper if needed, and attach
SECTION V

List any additional information that would apply to this case. ___________________________________________________________________________________________________________________________________________

SECTION VI

Use additional sheets of paper if needed, a nd attach

Signature of person completing report:

__________________________________________________________________________________________________

(Submit completed report to WIC Coordinator/Person in charge)

Person receiving the report:

Title:

(This signature is to verify receipt of this report, not to verify information on report)

Date:

WIC Coordinator or designee, shall submit a copy of this report to the State WIC Office within three (3) working days.

Routing: White Copy-SWO

Pink Copy-District

Yellow Copy- Clinic

Note:

In the event that unused vouchers are lost or stolen as a result of an unsecured food instrument environment, thus resulting in USDA sanctions to repay the value of the lost or stolen vouchers in question, the Local Agency will be responsible for repaying the value of those food instruments.

Form 3827 (2-96)

CA-25

GA WIC 2005 PROCEDURES MANUAL

Attachment CA-9

GEORGIA DEPARTMENT OF HUMAN RESOURCES WIC PROGRAM

DISTRICT/UNIT

CLINIC:

Duplicate Participation Verification Form
DATE:

INSTRUCTIONS

- USE THIS FORM TO REMOVE PARTICIPANTS FROM THE DUPLICATE

PARTICIPATION REPORT

- RETURN TO VIKING AS SOON AS POSSIBLE.

- MAIL TO:

VIKING COMPUTING, INC.

GEORGIA WIC UNIT

1000 N. MADISON AVENUE, SUITE S-3

GREENWOOD, IN 46142

- OR FAX TO: (317) 889-9485

THE FOLLOWING CLIENT(S) LISTED BELOW ARE LEGITIMATE PARTICIPANTS. PLEASE REMOVE THEM FROM SUBSEQUENT DUAL PARTICIPATION REPORTS

PARTICIPANT ID NUMBER

PARTICIPANT NAME

VIKING WHITE COPY SWO YELLOW COPY

DISTRICT OFFICE PINK COPY

CLINIC GOLD COPY

CA-26

GA WIC 2005 PROCEDURES MANUAL Participant Repayment SAMPLE LETTER

Attachment CA-10

CERTIFIED MAIL RETURN RECEIPT REQUESTED Ms.

Date:

Dear Ms. :
We read an advertisement that you placed in the Swapper Newspaper selling 48 cans of Similac infant formula for $______ per can. Formula provided by WIC must not be sold by our participants.
Please return all 48 cans of formula to the health department or remit $______ to us by check or money order. This is the amount we paid for the formula.
If you are unable to make a full payment of $______, please contact your Local Health Department for a payment plan. The payment plan cannot extend more than 90 days from the date of this letter.
Please send a cashier's check or money order payable to:
Georgia WIC Program Your address
We are a service organization, and it is our intent to be of assistance to our participants. We expect your cooperation to help make the WIC Program work effectively.
Please call me at _____________(your #) if you have any questions or need to establish a repayment schedule.
Sincerely,

WIC Coordinator's Name Address

CA-27

GA WIC 2005 PROCEDURES MANUAL Participant Repayment Schedule SAMPLE LETTER

Attachment CA-11

CERTIFIED MAIL RETURN RECEIPT REQUESTED Ms.

Date

Dear Ms.

:

This letter confirms your proposal to repay $______ to the Georgia WIC Program in monthly installments of $_______. If you fail to make payments on time, the full amount will be due immediately. The following is the payment schedule that we will require you to follow until the full amount is recovered:

DATE

AMOUNT

DATE

AMOUNT

Total Please send a cashier's check or money order payable to the Georgia WIC Program and mail it to the following address:
Georgia WIC Program Your address
If you have any questions, please call me at ________________. Sincerely,
WIC Coordinator's Name Address

CA-28

GA WIC 2005 PROCEDURE MANUAL

Attachment CA-12

DUAL PARTICIPATION REPORT INVESTIGATION FORM

Please complete and return the following information listed below. Please send the information to the requesting clinic as soon as possible.

DU/Clinic: _____________________________________________ Name: ________________________________________________ WIC ID: ______________________________________________ Birthdate: _____________________________________________ Mother's Name: ________________________________________ Date of last voucher pickup: ______________________________ Date of Issue: __________________________________________ Is this client active or terminated? _________________________ (If terminated, indicate term date and term code) Has the client transferred into your area recently? ___________ (If yes, give date; ___________________________) Date of last certification: _________________________________ Social Security number: _________________________________

CA-29

GA WIC 2005 PROCEDURES MANUAL

Attachment MO-1

STATE OF GEORGIA
Department of Human Resources Division of Public Health
WIC Branch

LOCAL AGENCY FFY 2005
MONITORING TOOL

GA WIC 2005 PROCEDURES MANUAL

Attachment MO-1

PURPOSE: Federal Regulations require state agencies to establish procedures for reviewing local program operations. The "Local Agency Monitoring Tool" was designed as the instrument to be used in completing this review.
GENERAL INSTRUCTIONS: Local agencies are encouraged to use this tool as a guide in preparing for the State agency review. Monitoring efforts will ensure compliance as well as emphasize quality assurance. The format of the monitoring tool has been designed to enable local agency responses to be recorded in a narrative form.
SPECIFIC INSTRUCTIONS: The monitoring tool is divided into six (6) parts as follows:
I. Administrative Section
II. Civil Rights
III. Clinic Review
IV. Forms For Administrative Review
V. Food Instrument Accountability
VI. Nutrition Certification, Education / Breastfeeding Section

1

GA WIC 2005 PROCEDURES MANUAL DISTRICT/CLINICS REVIEWED

Attachment MO-1

A. Name of District/Local Agency:

B. Clinic(s) to be reviewed: (Attach a copy of the District Clinic Listing)

1. __________________________ Clinic #/Clinic Name

2. __________________________ Clinic #/Clinic Name

3. __________________________ Clinic #/Clinic Name

4. __________________________ Clinic #/Clinic Name

5. _________________________ Clinic #/Clinic Name

C. Attach a Copy of the Review Schedule

Entrance Conference:

Date:

Time:

Place:

Exit Conference:

Date:

Time:

Place:

2

GA WIC 2005 PROCEDURES MANUAL

State Agency Monitoring

TABLE OF CONTENTS Page
I. State Agency Monitoring ........................................................................................ MO-1 A. Introduction ........................................................................................................ MO-1 B. Monitoring Schedule ......................................................................................... MO-1 C. Clinic and Health Record Selection................................................................. MO-2 D. Pre-Review Activities ........................................................................................ MO-3 E. Files ...................................................................................................................... MO-3 F. Timeframes ......................................................................................................... MO-4 G. On-Site Visit ........................................................................................................ MO-5 1. Entrance Conference.................................................................................... MO-5 2. Exit Conference ............................................................................................ MO-5 H. Special Site Visits................................................................................................ MO-6 I. Written Reports .................................................................................................. MO-7 J. Close-Out Report ............................................................................................... MO-8
II. Quality Assurance Self-Review ............................................................................. MO-8 A. Purpose................................................................................................................ MO-9 B. Conducting Self Reviews .................................................................................. MO-9
III. Financial Review .................................................................................................... MO-10 A. Reports............................................................................................................... MO-10 B. Financial Self Review....................................................................................... MO-11 C. Single Audits Act ............................................................................................. MO-11 D. Technical Assistance...................................................................MO-11
IV. Establish New Clinic Procedures......................................................................... MO-11

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V. Financial Timeframes.....................................................................MO-11 Attachments: MO-1 Local Agency Monitoring Tool Part I Administration Section ............................................................................................03 Part II Civil Rights.................................................................................................................10 Part III Clinic Review Section ...............................................................................................11 Part IV Forms Section.............................................................................................................30 Part V Food Instrument Accountability.............................................................................58 Part VI Nutrition Certification, Education/Breastfeeding Section .................................80 Part VII Staffing Patterns......................................................................... ...109

MO-2 Financial Review Section Policy 1244...................................................................................................01 Procedure 1244....................................................................................... ......03 Financial Review Form....................................................................................09

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I. STATE AGENCY MONITORING
A. Introduction
The State agency will conduct an on-site monitoring visit every two (2) years at each of the twenty-one (21) local agencies, for the purpose of reviewing local WIC agency operation. Local agencies that are not monitored for the year will receive priority for on-site technical assistance. The purpose of the monitoring visit is to ensure local agency compliance with State policies and Federal WIC regulations. The review will consist of an evaluation of program administration, staff training, voucher issuance, certification, food package assignment, nutrition education, and breastfeeding.
In order for the above areas to be thoroughly evaluated, it is necessary for the monitoring team to observe at least three (3) clinics in full operation. A minimum of three (3) certifications/subsequent certifications must be observed (one per clinic). If the monitoring team is unable to make these observations, they must reschedule that part of the review. The review cannot be closed until the clinic observations have been completed.
The monitoring team from the WIC Branch and the Nutrition Section will complete the on-site visit. Every effort will be made to conduct all portions (Programmatic, Compliance Analysis, Nutrition, and Breastfeeding, Fiscal) of the review during the same time period.
District reviews may be conducted yearly for clinics with specific problems (See page MO-6, H. Special Site Visits).

B. Monitoring Schedule
A schedule of on-site monitoring visits will be developed and coordinated by the WIC Branch and the Nutrition Section, prior to the start of each Federal Fiscal Year (FFY). A statewide schedule containing the dates and monitoring teams for each review will be sent to all local agencies.
The WIC Coordinator will be notified by phone, approximately one (1) month prior to the review, of the specific clinics (clinics and health records are randomly selected) to be monitored. A letter will then be sent to the WIC Coordinator and the District Health Officer to confirm the clinic selection, the dates of the review, the time and place for the entrance and exit conferences, etc. Additional information that will be requested for the review (by the State) will be included in the letter sent to the WIC Coordinator.
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C. Clinic and Health Record Selection
1. Clinic Site Every two (2) years, twenty percent (20%) of the total number of clinics in the local agency are randomly selected for program monitoring. The largest clinic in each local agency will be monitored during each program review. a. Each local agency may have a maximum of five (5) clinics selected for review. If more than five (5) clinics are randomly selected, those in excess will be eliminated from the selection. b. Clinics that have not been reviewed for at least four (4) years may be selected in place of randomly selected clinics, to ensure regular reviews of all clinics.
2. Record Selection Health records monitored during the program reviews will be randomly selected. The following constraints will be applied to the random selection: a. Two (2) records will be randomly selected for each 100 participants enrolled in a clinic, up to one thousand participants. If a clinic has more than one thousand participants, an additional two (2) records will be selected for each five hundred (500) participants above one thousand. Note: a minimum of six (6) records will be reviewed in each clinic. b. Fifty percent (50%) of the records selected must be women's records. The remaining fifty percent (50%) will include infants and children. Note: If a record selected for review cannot be located in the clinic during the review process, the Local Agency will be cited for a corrective action.
3. Migrant Health Records The State must review migrant health records during a local agency program review visit. The WIC Branch will randomly select Migrant health records for review. a. Where there is at least one clinic site with a minimum of twenty-five (25) migrants participating in the WIC Program, records are randomly selected according to the clinic and health record selection procedures (page MO-2). b. If a clinic site serving a significant number of migrants is not selected for program review, migrant health records
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will be selected and reviewed according to the clinic and health record selection procedures (page MO-2). c. If a significant number of the migrant population is in a local agency service area and is not participating in the WIC Program, the State must evaluate the local agency's outreach efforts related to migrants. Prior to a review the WIC Branch will review the migrant report.
D. Pre-Review Activities
Prior to the on-site visit, State staff will review local agency reports and files in the State office. The WIC Coordinator will be contacted about materials that need to be made available during the on-site review.

E. Files
Documentation and files to be considered during an on-site review include, but are not limited to, the following areas: 1. Past Program Review Reports and Responses 2. Quality Assurance Self-Reviews 3. Health Department Employee WIC Participation Form 4. Ethnic Enrollment Participation Report 5. Clinic Schedules 6. Outreach Activities 7. Waiting List(s) 8. Georgia WIC Program Procedures Manual 9. WIC Policy Memorandums 10. Federal WIC Regulations 11. Fair Hearing and Civil Rights Complaints 12. Participant Abuse Reports 13. Manual Voucher Inventories 14. Verification of Certification (VOC) Cards and Inventory 15. Batch Control Modules 16. Completed Computer Voucher Registers 17. Voucher Packing Lists 18. Copies of Manual Vouchers 19. Daily Activity Reports 20. Demographic Information 21. Vouchers Printed On Demand (VPOD) Receipts
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22. Ineligibility Files 23. District Specific Policies and Procedures 24. Local Agency Nutrition Education and Breastfeeding Plan 25. Nutrition Education Materials 26. Breastfeeding Education Materials 27. Lesson Plans 28. Staff Training Files 29. Equipment Inventory (current year) 30. Voter's Registration Files 31. Agreements With Other Agencies (other than Health
Departments) Where WIC Programs Are Located. 32. Temporary Thirty (30) Day Certification Files 33. Free Trade Formula Tracking 34. No Proof File

F. Timeframes

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

ACTIVITY

TIMEFRAME

Notification of intent to conduct a review,

The WIC Branch contacts the Local

30 days prior to the scheduled date

Agency to discuss possible review dates

The WIC Branch prepares and submits a report of program observation and review to the Local Agency after the site visit/exit interview
The Local Agency submits a corrective action report to the WIC Branch

Within 60 days of the exit interviews
Within 60 days of the date of receipt of program review report is received

The WIC Branch submits a written response to the Local Agency report

Within 30 days of the receipt of Local Agency response

The Local Agency submits a written response to the WIC Branch's requests for additional information
Program review closed

Within 30 days of the date of the written request
Within 180 days of the exit interview, unless an extension was negotiated

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NOTE: Failure to resolve any outstanding deficiency found during the review could result in a delay of funding for the next fiscal year.

G. On-Site Visit
During the on-site visit, the local agency will make accessible all reports, forms, and files requested. Local agency staff will be asked to respond to questions asked by State staff. Staff must be available to answer questions during the clinic visit. The average review for a district will take three (3) to five (5) days.
1. Entrance Conference
An entrance conference may be requested by the district to officially begin the review. The District Health Director, Program Manager, WIC Coordinator, and any other pertinent staff are invited to participate in the entrance conference. During this conference, District staff will have the opportunity to provide an overview of their district and ask questions of the State monitoring team. State staff will:
a. Make introductions b. Explain the purpose of the visit c. Review the district specific monitoring schedule d. Briefly explain what will take place during the review e. Discuss pertinent district specific information/data
2. Exit Conference An exit conference with clinic staff may be held in each clinic monitored to review the specific clinic findings. Upon completion of the on-site District Review, the monitoring team will meet privately to prepare for the exit conference. State staff will then meet with the District Health Director, Program Manager, WIC Coordinator, and other local agency staff as designated by the District Health Director for the exit conference. Findings reported by the reviewers at the exit conference are preliminary. The final report will be forwarded to the local agency within 60 days. The following will be discussed at this conference: a. Areas deserving commendation b. Achievements c. Corrective actions d. Recommendations

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NOTE:

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

H. Special Site Visits

The WIC Branch, in accordance with federal requirements, may make special site visits at any time.

Special Site Visit Procedures:
In the event of a special site visit by the WIC Branch or Local Agency Coordinator, Health Director or Program Manager, the following procedures must be followed:
1. The WIC Branch may contact the WIC Coordinator prior to the visit.
2. After careful observation and investigation, a report will be generated and mailed to the District WIC Coordinator within thirty (30) days of the site visit.
3. Upon receipt of the report from the State WIC Branch, the WIC Coordinator must respond in writing to the WIC Branch within thirty (30) days of receipt. All district responses must address a resolution to the exiting problem. Supporting documentation must also be included in the plan:
a. Submit an agenda with dates of training and a list of staff that have attended the training.
b. Submit copies of all the memorandums sent out to local agency staff by the WIC Coordinator addressing problems found during the special site visit.
c. Copies of any information that could not be located during the special site visit that relate to the specific corrective actions must be forwarded to the site.
d. The WIC Coordinator using the Procedures Manual for each local agency involved must conduct training to close a special site visit. The WIC Coordinator may also contact the Staff Development Training Coordinator for technical assistance.

NOTE: The review will not be closed until all corrective actions have been completed.

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Once the State agency has received the local agency response to the written report, it may elect to do one or more of the following, based on the action plan:
a. Close the review after another site visit within thirty (30) days.
b. Request additional information. This information will be due within thirty (30) days from the date of the request.
c. Make all the follow-up monitoring visits within fifteen (15) days of the exit conference.
d. Offer technical assistance to help develop a corrective plan or train local agency staff.

The local agency will receive written notification of the above from the State agency, within fifteen (15) days from the receipt of the action plan.

I. Written Reports
The State will send a written report of the review to the District Health Director within sixty (60) days of the exit conference. The report will address areas of special achievement, recommendations, and corrective actions. The district will respond to all corrective actions within sixty (60) days from the date of the State agency report (See page MO-4, F. Timeframes).

A written plan of action must be developed for all program deficiencies identified during the program review. A District-Wide Correction Plan is due to the WIC Branch if two (2) or more clinics fail to meet standards. If one clinic fails to meet standards, a Correction Action Plan must be conducted at that clinic site only. The plan must ensure that the questions Who? What? When? Where? and How? are addressed. For example: who will be trained, what will the training be on, when will they be trained, where will the training be held, and how will the training be conducted?

NOTE:

All training must be performed within ninety (90) days from the date the Program Review Report is received by the district. Contact the Staff Development Training Coordinator for technical assistance in conducting trainings.

All supporting documentation must be included in this plan. Supporting documentation includes:

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1. An agenda, dates of training and a list of staff that have attended the training.
2. A copy of all the memorandums sent out to local agency staff by the WIC Coordinator addressing problems found during the program review.
3. Copies of information that could not be located during the on-site monitoring visit that relate to specific corrective actions.
NOTE: The review will not be closed until all planned trainings have been conducted.
Once the State agency has received the local agency response to the written report, it may elect to do one or more of the following, based on the action plan:
1. Close the review. 2. Request additional information. This information will be due
fifteen (15) days from the date of the request. 3. Make a follow-up-monitoring visit within six (6) months of the
exit conference. 4. Offer technical assistance to help develop a corrective action plan
or train local agency staff.

The local agency will receive written notification of the above from the State agency, within fifteen (15) days from the receipt of the action plan. J. Close-Out Report
A written close-out report will be sent to the local agency upon the satisfactory resolution of all corrective actions. The close-out report is written documentation that the corrective action plan has been accepted and the program review is closed. All program reviews must be closed within 180 days of the exit interview.
II. QUALITY ASSURANCE SELF-REVIEWS
A. Purpose
The purpose of Self-Reviews is to improve the quality of Local Agency program operations. Self-Reviews allow local agencies to assess compliance of program operations with WIC policies and procedures. Early identification and resolution of non-compliance improves the quality and strengthens the operations of the local agency.
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B. Conducting Self-Reviews
The local agency must conduct an internal self-review annually by September 30th. Half of the District Clinics must be reviewed one year and all other clinics must be reviewed the following year. A schedule of review dates and clinics, as well as, documentation including the completed tool used, training agendas, and sign-in sheets must be submitted to the WIC Branch by September 30th of each year. The assessment will include all phases of the program operations. The "State of Georgia WIC Branch Local Agency Monitoring Tool" may be utilized to evaluate operations of each clinic in the district.
NOTE: Guidelines marked as a "recommendation" throughout the monitoring tool are not required in completing self-reviews. Columns marked "NA" stands for Not Applicable.
In instances where the local agency has developed an evaluation tool, the local agency's internal review must include at a minimum:
1. Outreach and Referrals 2. Processing Standards 3. Certification Procedures 4. Chart Audit 5. Accountability of Food Instrument and Issuance Materials 6. Nutrition Services 7. Breastfeeding Promotion and Support Services 8. Civil Rights Compliance 9. Participant Complaints 10. Fair Hearing 11. Review Certification/Voucher Issuance Records for employees
and their relatives 12. Temporary Thirty (30) Day Certification Purging of Files 13. Voter Registration 14. Equipment Inventory 15. Ineligibility File 16. No Proof File 17. Trimester Enrollment 18. Financial Management/ Reports 19. Financial Self Review Tool
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Note: The Financial Monitoring Tool must be used. In addition Policy 1244 is a part of the Financial Monitoring Tool. This policy must be used by the contractor and district financial staff to conduct reviews.

At the time of the local agency program review, the State review team will review all documentation pertaining to the self-reviews. If repeated errors are found when conducting self-reviews, the District must conduct additional monitoring reviews and one-on-one training (i.e. errors in issuance of VOC Cards or the prorating of vouchers). Special attention must be given in the area of voucher registers and VPOD receipts. This is an area where the coordinator could detect potential fraud. The District must submit documentation used in the completion of all self-reviews to the Policy Unit by September 30th. USDA recommends that a nutritionist be a member of the Local Agency Quality-Assurance team conducting self-reviews. A list of sites that will be reviewed, the dates of the reviews, and the name of person conducting the reviews must be submitted to the WIC Branch by September 30th of each year. Self-reviews are not required on clinic sites that are monitored by the State.

NOTE:

The District WIC Coordinator must request the names of employees and family members enrolled on the WIC Program for internal audit purposes. This information is confidential and must be seen by the WIC Coordinator only. In addition, the District WIC Coordinator must send in a list of all WIC employees by September 30th of each federal fiscal year.

III. FINANCIAL REVIEW

The State auditors perform programmatic audits of specific programs as deemed necessary. The WIC Branch also contracts with outside professional service providers to review at least ten (10) district WIC programs annually. The State agency and/or the contractor will contact the local agency as to the date and time of the audit prior to the review. See V. Financial Timeframe at the end of this section.

A. Reports

The State agency in agreement with the contractors will submit the audit report to the District Health Director and WIC Coordinator within ninety (90) days of the acceptance of findings. All findings will be shared with the Division of Public Health and the Office of Financial Services.

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B. Financial Self-Review
The district is responsible for conducting annual self-reviews by June 30 of each year using the financial section of the monitoring tool. A summary of that review must be kept on file and will be monitored by the contractor on audits yearly.
C. Single Audits Act
A copy of the Single Audit (once finalized) must be forwarded to the WIC Branch. The WIC Branch will follow up any non-financial WIC findings.
D. Technical Assistance
Technical assistance will be made available by the State agency to all local agencies on an ongoing basis as requested or deemed necessary.

IV. ESTABLISH NEW CLINIC PROCEDURES
Any district considering opening a new WIC clinic, must contact the WIC Branch (See Administrative Section).

V. FINANCIAL TIMEFRAMES

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

ACTIVITY

TIMEFRAME

Notification of intent to conduct a review. The contractor contacts the district office 30 days prior to the scheduled date to discuss possible review dates

Contractor prepares and submits a report of the findings to the WIC Branch. Once the WIC Branch approves the findings the WIC Branch will submit the final report to the district office.

Within 14 days

District office submits a corrective action report to the WIC Branch

Once a written response is received from

the district office; the WIC Branch

b it th

t t th DHR MO-11

Within 30 days of the date of receipt of program review report is received

Within 30 days of the receipt of

district office response, the WIC

B h ill d th i

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submits the report to the DHR Department of Audits for monitoring and evaluation. The programmatic findings will be handled by the WIC Branch.

Branch will send the review and response to department of audits. Appropriate action will be taken by the DHR Department of Audits. The Department of Audits will submit a letter of closure the WIC Branch.

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Attachment MO-1

PART I ADMINISTRATIVE SECTION (DISTRICT ONLY)

GUIDELINES
Corrective Action

AREAS OF REVIEW
I. ADMINISTRATION A. Internal Communication
1. Are new policies and State memos sent to staff? Are staff meetings held regularly? Date of the last meeting: ___________

YES NO

NA COMMENTS

Corrective Action

Looking for: Whether or not all staff are informed on all new policies.
2. Is there a planned method of communication between WIC staff and non-WIC staff? (i.e. staff meeting)

Corrective Action

Looking for: Ensure that if staff meetings are not held, communication is taking place with non-WIC staff.
3. Is in-service training conducted regularly for WIC and non-WIC staff providing WIC services? Date of the last meeting: _____________

Corrective Action

Looking for: Whether or not staff members are updated regularly? 4. Does the District Office have a copy of all policy Memorandums on file?

Corrective Action

Looking for: Up to date Manual. Policy is in place. Staff understanding policy.
5. Is a signed copy of the Memorandum of Agreement on file?

Looking for: Whether or not the Coordinator has a copy.

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PART I ADMINISTRATIVE SECTION (DISTRICT ONLY)

GUIDELINES
Corrective Action

AREAS OF REVIEW
6. Is a copy of the Procedures Manual located at the District Office?

YES NO NA COMMENTS

Corrective Action

Looking for: Manual if in place in the event of questions. Services are delivered according to the manual.
7. Did the District Office submit a copy of the Local agency contract(s) to the SWB by September 30th?

Corrective Action

Looking for: Copy of each agreement with the Local Agency.
B. Caseload Management (must have approval from State).
1. Has the District implemented a waiting list since the last review?

Corrective Action

Looking for: Ensure that Clinic/District does not begin its own waiting list.
2. Is there a current waiting list? If yes, what priorities are being served?

Recommendation

Looking for: Whether or not correct priorities are being served.
3. What percent of the district's caseload falls into the following categories (prenatal only)?

First Trimester: ________________ Second Trimester: ________________ Third Trimester: ________________
Looking for: At what point in pregnancy are women enrolling in the program?

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Attachment MO-1

PART I ADMINISTRATIVE SECTION (DISTRICT ONLY)

GUIDELINES
Corrective Action

AREAS OF REVIEW

YES NO NA COMMENTS

C. System Maintenance Indicators
(Review reports prior to the monitoring review)
1. Are System Maintenance Indicators in compliance with State standards? In the event a district's/local agencies rate is 10% or above, a technical assistance visit and/or plan must be submitted to the WIC Branch.

Corrective Action

Looking for: Federal requirements met for participation. The state-determined rate was met.
2. Is at least 60% of the prenatal caseload enrolled in the first trimester?

Corrective Action

Looking for: Sixty percent (60% ) of prenatal women are enrolled during their first trimester.
D. Fair Hearing/Participant Complaints
(Review district files prior to the monitoring review) 1. Is documentation on file for any Fair
Hearing? Is it available for review at the District and State Office?

Corrective Action

Looking for: Is documentation on file at the State Office? Were proper procedures followed?
2. Were Fair Hearing/Participant Complaints handled/resolved according to program procedures? If no, please explain (in comments section)

Looking for: Check documentation of compliance.

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PART I ADMINISTRATIVE SECTION (DISTRICT ONLY)

GUIDELINES
Corrective Action

AREAS OF REVIEW
E. Quality Assurance/Self Review 1. Does the District conduct Self Reviews? (Attach a copy of the Review Schedule)

YES NO NA COMMENTS

Looking for: Copy of Monitoring tool of all sites reviewed Copy of Review Schedule.
2. Is there a list of deficiencies identified for each clinic?

Looking for: Types of deficiencies found. Corrective action given. Plan in place for correction.
3. Were repeated errors found?

Looking for: If repeated errors are made, is training being conducted?
4. If yes, were additional monitoring visits made or training conducted?

Looking for: Documentation for training(s) is available from the clinic.

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Attachment MO-1

PART I ADMINISTRATIVE SECTION (DISTRICT ONLY)

GUIDELINES
Corrective Action

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

YES NO NA COMMENTS

Corrective Action

Looking for: A Record Review of Employee and their Relative(s). Check the Voucher Registers for ID Proof Waiting List Outreach and Referral Record Review (Income, Residency and Identification) Whether or not all the areas reviewed in the event the Monitoring Tool is not used Voter Registration Trimester Enrollment
6. Have any special initiative efforts been implemented as a result of the internal monitoring?
F. Outreach 1. Does the District have a plan for developing and conducting outreach activities pertinent to local service area? Are grassroots organizations included (churches, Boys and Girls Clubs, ethnic organizations)? 2. If yes, are outreach activities documented and available for review? 3. If no, explain how WIC information is disseminated to applicants/participants and local communities.

Corrective Action

Looking for: Plan for reaching potential WIC applicants. 4. Has the district or local clinic conducted outreach activities within the last 12 months?

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PART I ADMINISTRATIVE SECTION (DISTRICT ONLY)

GUIDELINES

AREAS OF REVIEW
5. Are all outreach activities documented and available for review? (See Outreach File)

YES NO NA COMMENTS

Corrective Action

Looking for: Documentation that outreach activities were conducted yearly.
6. Have special provisions been made for scheduling the following applicants? Please explain your answer.

Participants Who Work

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

Rural Participants

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

Migrants

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

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

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Attachment MO-1

PART I ADMINISTRATIVE SECTION (DISTRICT ONLY)

GUIDELINES
Corrective Action

AREAS OF REVIEW

YES NO NA COMMENTS

7. What are your hours of operation? Are the clinics throughout the district open during lunch, after five o'clock, and on weekends?

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

Corrective Action

Looking for:
Alternative clinic operating hours.
G. Processing Standards 1. Has the District requested an extension for processing standards? If yes, is the written approval of extension on file and available for review?

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

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Attachment MO-1

PART II CIVIL RIGHTS

GUIDELINES

AREAS OF REVIEW

YES NO NA COMMENTS

Corrective Action

I. CIVIL RIGHTS
A. Civil Rights Training 1. Is Civil Rights training conducted annually for local WIC staff? (District)

When? ____________________

By Whom? ________________

Corrective Action

Looking for: Whether or not all staff received Civil Rights training. Ensure that all staff knows what to do in the event of a complaint.
2. Is Civil Rights training a part of new employee orientation? (Review list of new employees and documentation of Civil Rights Training).

Corrective Action

Looking for: Documentation of training.
B. Civil Rights Complaint 1. Are Civil Rights complaints handled in accordance with established program procedures? (Review Complaint File Number of Complaints).

Looking for: Was the Civil Rights complaint handled according to procedures?

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Attachment MO-1

GUIDELINES
Corrective Action

AREAS OF REVIEW
I. PROGRAM MANAGEMENT (Clinical Review)
A. Waiting List 1. Does the clinic have a waiting list?

YES NO NA COMMENTS

Corrective Action

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

Recommendation

Looking for: Clinic staff follows proper procedures if waiting list is implemented and correct priorities are served.
B. Coordination and Integration 1. Are WIC services coordinated or integrated with other health department services?

Recommendation

Looking for: Verification.
2. How is this coordinated? (records, appointment, clinics, etc.)

Corrective Action

Looking for: Documentation in SOAP notes, computer records, or clinic schedulers, etc. verifying integration/coordination of services.
3. Does the clinic have an outreach plan?

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

Looking for: Current clinic plans.

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Attachment MO-1

GUIDELINES
Corrective Action

AREAS OF REVIEW
4. Are initial contact dates documented and available to review?

YES NO NA COMMENTS

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________
Clinic ___________________

Corrective Action

Looking for: Is the clinic meeting processing standards?
5. Are initial contacts dates documented and available for review?

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

Corrective Action

Looking for: Is the clinic meeting processing standards?
6. When a prenatal applicant misses an appointment, are they contacted to reschedule and by whom?

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

Looking for: Attempts by the clinic to reschedule prenatal participants who miss appointments. Documentation in the computer or in the participant's medical record.

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Attachment MO-1

GUIDELINES
Corrective Action

AREAS OF REVIEW
7. If postcards are mailed to participants for any reason, are they in compliance with HIPAA regulations? (View postcards or other documents mailed)

YES NO NA COMMENTS

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

Corrective Action

Looking for: HIPAA compliance for confidentiality. No visible program identification.
8. When is the next available appointment for a walk-in applicant requesting WIC benefits?

Clinic ___________________ Women(P) ________ Infant________ Women(B) ________ Child________ Women(PP) ________

Clinic ___________________ Women(P) ________ Infant________ Women(B) ________ Child________ Women(PP) ________

Clinic ___________________ Women(P) ________ Infant________ Women(B) ________ Child________ Women(PP) ________

Clinic ___________________ Women(P) ________ Infant________ Women(B) ________ Child________ Women(PP) ________

Clinic ___________________ Women(P) ________ Infant________ Women(B) ________ Child________ Women(PP) ________

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Attachment MO-1

GUIDELINES
Corrective Action

AREAS OF REVIEW

9. Ask clinic staff the processing standards

time frames for each category below.

Times Frames

Clinic (1) _____________________

Prenatal

___________________

Breastfeeding ___________________

Postpartum ___________________

Infants

___________________

Children

___________________

Migrants

___________________

Clinic (2) _____________________

Prenatal

___________________

Breastfeeding ___________________

Postpartum ___________________

Infants

___________________

Children

___________________

Migrants

___________________

Clinic (3) _____________________

Prenatal

___________________

Breastfeeding ___________________

Postpartum ___________________

Infants

___________________

Children

___________________

Migrants

___________________

Clinic (4) __________________

Prenatal

___________________

Breastfeeding ___________________

Postpartum ___________________

Infants

___________________

Children

___________________

Migrants

___________________

Clinic (5) __________________

Prenatal

___________________

Breastfeeding ___________________

Postpartum ___________________

Infants

___________________

Children

___________________

Migrants

___________________

Looking for: Ensure that staff members are knowledgeable about processing time frames.

YES NO NA COMMENTS

14

GA WIC 2005 PROCEDURES MANUAL PART III CLINIC REVIEW

Attachment MO-1

GUIDELINES
Corrective Action

AREAS OF REVIEW
C. Income Assessment 1. Is income taken before or after the certification process?

YES NO NA COMMENTS

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

Corrective Action

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

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

Corrective Action

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

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

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

15

GA WIC 2005 PROCEDURES MANUAL PART III CLINIC REVIEW

Attachment MO-1

GUIDELINES
Corrective Action

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

YES NO NA COMMENTS

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

Corrective Action

Looking for: Is the WIC staff aware of the proper procedures for determining income eligibility?
5. Does the clinic determine an applicant to be income-eligible based on presumptive eligibility requirements? Where is it documented?

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

Corrective Action

Looking for: Is the WIC staff aware of the proper procedures for determining income eligibility?
6. Is income status taken when a participant is determined adjunctively eligible for the program?

Looking for: Income documentation.

16

GA WIC 2005 PROCEDURES MANUAL PART III CLINIC REVIEW

Attachment MO-1

GUIDELINES
Corrective Action

AREAS OF REVIEW

YES NO NA COMMENTS

7. If an applicant is adjunctively eligible for services, when are they referred to the WIC program? When is an appointment provided?

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

Corrective Action

Looking for: No delay for an applicant to receive WIC services.
D. Participant I.D. 1. What form of participant identification do you accept?

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

Corrective Action

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

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

Looking for: To ensure that participants are given appropriate notification prior to the expiration of certification.

17

GA WIC 2005 PROCEDURES MANUAL PART III CLINIC REVIEW

Attachment MO-1

GUIDELINES
Corrective Action

AREAS OF REVIEW
3. How are participants notified and is the notification documented?

YES NO NA COMMENTS

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

Corrective Action

Looking for: Is the clinic staff documenting and/or notifying the participants?
4. Are participants who are terminated during a valid certification period notified prior to termination?

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

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

18

GA WIC 2005 PROCEDURES MANUAL PART III CLINIC REVIEW

Attachment MO-1

GUIDELINES
Corrective Action

AREAS OF REVIEW
5. Certification Periods Is the staff knowledgeable of certification periods? (Staff interviews)

YES NO NA COMMENTS

Time Frames

Time Periods

Clinic ___________________ Women(P) ________ Infant________ Women(B) ________ Child________ Women(PP) ________

Clinic ___________________ Women(P) ________ Infant________ Women(B) ________ Child________ Women(PP) ________

Clinic ___________________ Women(P) ________ Infant________ Women(B) ________ Child________ Women(PP) ________

Clinic ___________________ Women(P) ________ Infant________ Women(B) ________ Child________ Women(PP) ________

Clinic ___________________ Women(P) ________ Infant________ Women(B) ________ Child________ Women(PP) ________

Looking for: To ensure that WIC staff members are aware of certification periods for each type of WIC participant so that vouchers are issued only during a valid certification.

19

GA WIC 2005 PROCEDURES MANUAL PART III CLINIC REVIEW

Attachment MO-1

GUIDELINES
Corrective Action

AREAS OF REVIEW

YES NO NA COMMENTS

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

Corrective Period

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

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

Corrective Action

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

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

Looking for: Accountability of all issued and voided VOC cards.

20

GA WIC 2005 PROCEDURES MANUAL PART III CLINIC REVIEW

Attachment MO-1

GUIDELINES
Corrective Action

AREAS OF REVIEW

YES NO NA COMMENTS

9. Is the inventory of VOC cards conducted monthly according to program procedures? (Review physical inventory of VOC card log)

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

Corrective Action

Looking for: Maintenance and accurate issuance of VOC cards. Procedures conducted monthly for security purposes.
10. Are two initials of Local Agency Staff on the VOC card Inventory monthly?

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

Corrective Action

Looking for: Two initials of staff verifying that physical inventory is being conducted.
E. Voter Registration 1. Is each participant offered an opportunity to complete a Voter Registration Application?

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

Looking for: Declaration File.

21

GA WIC 2005 PROCEDURES MANUAL PART III CLINIC REVIEW

Attachment MO-1

GUIDELINES
Corrective Action

AREAS OF REVIEW

YES NO NA COMMENTS

F. Policy Memos/Procedures Manuals 1. Is there a Procedures Manual located in the clinic?

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

Corrective Action

Looking for: Is Procedures Manual paper or on disk.
2. Are current federal fiscal year Policy Memos on file?

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

Corrective Action

Looking for: Policy memos on file for the current federal fiscal year.
G. Special Population 1. Does the local population include migrants? If so, are they being served? If not, why?

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

Looking for: Clinics that serve migrants.

22

GA WIC 2005 PROCEDURES MANUAL PART III CLINIC REVIEW

Attachment MO-1

GUIDELINES
Corrective Action

AREAS OF REVIEW

YES NO NA COMMENTS

2. Is the staff knowledgeable of procedures to complete migrant certification?

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

Corrective Action

Looking for: Knowledge of the staff on proper procedures for ensuring accessibility to WIC services for the migrant population.
3. Does the population include Limited English Proficient (LEP) persons?

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

Corrective Action

Looking for: Whether the clinic serves non-English speaking participants.
4. Are interpreters or bilingual staff available for the LEP clients, if applicable?

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

Looking for: Local agencies are responsible for ensuring that multilingual staff, volunteers or other interpreters are available.

23

GA WIC 2005 PROCEDURES MANUAL PART III CLINIC REVIEW

Attachment MO-1

GUIDELINES
Corrective Action

AREAS OF REVIEW
5. Is the local agency in compliance with program policy regarding racial or ethic coding and filing of participants' records? (Review Clinic Medical Records)

YES NO

NA COMMENTS

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

Corrective Action

Looking for: Ensure that records are not coded or filed by racial/ethnic origin.
6. Are the current race codes being utilized?

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

Looking for: Clinic computer systems are updated. Compliance with federal regulations.

7. Is a waiver completed when the applicant or participants bring their own interpreters?
Yes ___________ No ___________
If no, why not? ____________________ ____________________________________ ____________________________________

24

GA WIC 2005 PROCEDURES MANUAL

PART III CLINIC REVIEW

Corrective Action

H. Complaint Handling 1. Is the staff knowledgeable of proper procedures for handling Civil Rights complaints? (Discrimination)

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

Looking for: Staff is knowledgeable of the process and time frame for filing Civil Rights Complaints. Notification of proper person. Ability to identify a civil right/discrimination complaint based on race, color, national origin, etc.

Corrective Action

2. How is the race of a participant determined?

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

Corrective Action

Looking for: Participant self-identification
I. Home Visits 1. Do employees complete WIC certifications or Referral forms with a home visit?

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________
Looking for: Participation in home visits. Approval of the procedures by the district and the state.

25

Attachment MO-1

GA WIC 2005 PROCEDURES MANUAL

Attachment MO-1

PART III CLINIC REVIEW

GUIDELINES

AREAS OF REVIEW

YES NO NA COMMENTS

2. If vouchers are issued to participants in the home, how are they delivered?

Corrective Action

Looking for: VPOD vs. manual vouchers. Separation of duties.
II. STORAGE AND SECURITY A. Were the old stock of VOC cards securely destroyed in the event VOC cards are revised?

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

Corrective Action

Looking for: A destroyed report stating the date, series #, amount and staff initials for security destroyed VOC cards.
B. Are the following items stored in a separate, secure location?

1. Program Stamp 2. VOC Cards 3. VOC Card Inventory

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

Looking for: Security of Programs Stamp and VOC/Cards.

26

GA WIC 2005 PROCEDURES MANUAL

Attachment MO-1

PART III CLINIC REVIEW

GUIDELINES
Corrective Action

AREAS OF REVIEW
III. TRANSFER OF CERTIFICATION A. Describe the process of accepting an out-ofstate transfer.

YES NO

NA COMMENTS

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

Looking for: Immediate acceptance of VOC card information and/or verification of undocumented required information.

Corrective Action

B. When a VOC Card is received, what clinic staff has to process the transaction?

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

Looking for: Unnecessary delays in processing a VOC card transfer.

Corrective Action

C. Are vouchers issued the same day of the transfer or would the client need to return at another time?

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________
Looking for: Unnecessary delays in processing a VOC card transfer. Circumstances that would cause a client to leave the facility without services.

27

GA WIC 2005 PROCEDURES MANUAL

Attachment MO-1

PART III CLINIC REVIEW

GUIDELINES
Corrective Action

AREAS OF REVIEW
IV. RECORD REVIEW Complete Record Review Work Sheet. Copy additional sheets as needed. (See Form 4)

YES NO NA COMMENTS

Corrective Action

Looking for: Monitoring clinic records to make certain WIC guidelines are being followed and certification is being processed properly.
V. CLINIC OBSERVATION (See Form 5)

Corrective Action

Looking for: Monitoring procedures for participant certification.
VI. EQUIPMENT INVENTORY (See Form 6)

Recommendation

Looking for: Checking equipment purchased with WIC Administrative funds.
VII. NO PROOF MONITORING FORM (See Form 7)

Corrective Action

Looking for: Proper use of form Improper use of this form Reason for use Too much use
VIII. PROOF OF IDENTITY OBSERVATION FORM (See Form 8)

Looking for: Use of correct identification Identification for proxies

28

GA WIC 2005 PROCEDURES MANUAL

PART III CLINIC REVIEW

GUIDELINES
Corrective Action

AREAS OF REVIEW
IX. NOTICE OF TERMINATION/ INELIGIBILITY/WAITING LIST FORM (See Form 9)

Corrective Action

Looking for: Proper use of form Documentation accuracy Copies of documentation
X. TEMPORARY THIRTY (30) DAY CERTIFICATION RECORD REVIEW FORM (See Form 10)

Recommendation

Looking for: Proper use of the form Documentation at clinic Over issuance of voucher
XI. PATIENT FLOW ANALYSIS
(See Forms 11 and 12)

Looking for: Bottlenecks Long waiting period Need for additional staff Need for interpreters
XI. IMMUNIZATION REVIEW (STATE USE ONLY)
(See Form 13)

Looking for: Documentation that the immunization record was reviewed or requested.
If reviewed, was the child adequately immunized for age or referred to an immunization provider.

.

Attachment MO-1 YES NO NA COMMENTS

29

GA WIC 2005 PROCEDURES MANUAL

Forms Section MO-1

PART IV FORMS FOR ADMINISTRATIVE REVIEW
Form 1 ..........................Ineligible Certification Work Sheet Form 2 ..........................Re-cert Overdue Form 3A.......................District/Clinic Issued VOC Cards Form 3B........................VOC Card Security Report Form 4 ..........................Record Review Form 5 ..........................Clinic Observation Form 6 ..........................Equipment Inventory Form 7 ..........................No Proof Monitoring Form Form 8 ..........................Proof of Identity for Women, Infants and
Children Observation Form Form 9 ..........................Notice of Termination/Ineligibility/Waiting
List Form Users' Checklist Form 10 ........................Temporary Thirty (30) Day Certification
Record Review Form 11 ........................Option I Form I Patient Flow Analysis (PFA) Form 12 ........................Option II Form I Patient Flow Analysis (PFA) Form 13 ........................Immunization Review Form

30

GA WIC 2005 PROCEDURES MANUAL

Form 1

INELIGIBLE CERTIFICATION WORK SHEET

Review three (3) records in each clinic of individuals found ineligible at the time of certification and/or of individuals who were terminated from the Program within the last year. Note: This information may be retrieved from your ineligible file.

District:

Clinic

Name

Reason for Ineligibility or Termination

If reason for ineligibility is "A", was the income section of the Certification Form completed, dated and signed.

Was Notice of Fair Hearing
given or a Release of Information
Form received?

Completed Signature & Date of Person Determining Eligibility.

Certification Termination

Form

Form

31

GA WIC 2005 PROCEDURES MANUAL

Form 2

RE-CERT OVERDUE
Select a random sample of at least three (3) records for which the following message "RECERT OVERDUE MMDDYY" appears and to whom vouchers were issued. It is important that six-week postpartum women be in the sample.

District _____________________________

Clinic Name

Participant Name

WIC Status

Delivery Date or
EDC Date

Re-cert Due Date

Re-cert Date

Voucher Issuance
Date

Were Vouchers Validly Issued?

32

GA WIC 2005 PROCEDURES MANUAL
DISTRICT/CLINIC ISSUED VOC CARDS

Form 3A

District/Clinic Name

State/District Issued VOC Cards Beg # End #

Amount Issued

Date Issued

On Site Issued VOC Cards
Beg # End #

# of Cards on Hand

Requested Cards Accounted For?
YES NO

Is Inventory Accurate?
YES NO

2 Staff District & Clinic

Initials?

#'s Match?

YES NO YES NO

33

GA WIC 2005 PROCEDURES MANUAL

Form 3B

VOC CARD SECURITY REPORT

Pull five (5) records in each clinic from the VOC Card Log.

Clinic Name

Participant's Name

Date Issued

Signature of Parent/Guardian/
Caretaker Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___

Signatures Match
Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___

Migrant
Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___

Issued Termination Notice
Yes___ No___ N/A___ Yes___ No___ N/A___ Yes___ No___ N/A___ Yes___ No___ N/A___ Yes___ No___ N/A___ Yes___ No___ N/A___ Yes___ No___ N/A___ Yes___ No___ N/A___ Yes___ No___ N/A___ Yes___ No___ N/A___ Yes___ No___ N/A___ Yes___ No___ N/A___ Yes___ No___ N/A___ Yes___ No___ N/A___ Yes___ No___ N/A___ Yes___ No___ N/A___ Yes___ No___ N/A___ Yes___ No___ N/A___ Yes___ No___ N/A___ Yes___ No___ N/A___ Yes___ No___ N/A___ Yes___ No___ N/A___ Yes___ No___ N/A___ Yes___ No___ N/A___ Yes___ No___ N/A___ Yes___ No___ N/A___ Yes___ No___ N/A___

34

GA WIC 2005 PROCEDURES MANUAL
RECORD REVIEW
Review the following criteria in the records randomly selected CLINIC_______________________
CRITERIA TO REVIEW: Was the Name, Address (Demographics) completed? Was the correct initial contact date recorded? Were processing standards met? Was proof of residency recorded? Was proof of identification recorded? Was participant categorically eligible? Was the signature/title of person collecting income/residence/I.D. data recorded? Was the participant's signature/date recorded? Was participant physically present? If no to the above, was the exempt reason documented in the record? Was Medicaid eligibility documented? Was Medicaid number documented? Was TANF documented? Was the TANF verification present? Was Food Stamps documented? Was the Food Stamps verification present? Was the number in family recorded? Was income information documented? Was the income source documented? Was the date of recorded income information documented? Were staff initials recorded for residency, identification and income verification? Was it documented that participant was income eligible/ineligible?
35

Form 4

GA WIC 2005 PROCEDURES MANUAL

Form 4

Was the error correction procedure used?
Was the form for Applicants with a P.O. Box completed and filed in health record? Was documentation for immunizations present?
Was the certification a home visit?
OTHER CRITERIA TO MONITOR:
Was the No Proof Form used?
Was zero income accepted?
If yes to the above, was the following question answered? How do you obtain food, shelter, clothing and medical care?
Note: Make copies of this form for Record Review. Must have 100% compliance.

36

GA WIC 2005 PROCEDURES MANUAL

Form 5

CLINIC OBSERVATION

ENVIRONMENT

1. Are WIC facilities accessible to persons with special needs?

2. "And Justice For All Poster" Displayed in a visible location in each clinic site.

3. Is the "No Charge for WIC Services" sign posted in the clinic?

Clinic

Yes

No Clinic

Yes

No

Clinic

Yes

No

______________ ______ ___ _____________ ______ ____

______________ ______ ____

______________ ______ ___ _____________ ______ ____

______________ ______ ____

______________ ______ ___ _____________ ______ ____

______________ ______ ____

______________ ______ ___ _____________ ______ ____

______________ ______ ____

______________ ______ ___ _____________ ______ ____

______________ ______ ____

4. Are "No Smoking" signs posted?

(N/A if a DHR Building)

Clinic

Yes

No

______________ ______ ___

______________ ______ ___

______________ ______ ___

______________ ______ ___

______________ ______ ___

5. Was the "Interpreter" sign posted 6. Was the applicant receiving

in a visible place?

WIC benefits present?

Clinic

Yes

_____________ ______

_____________ ______

_____________ ______

_____________ ______

_____________ ______

No ____ ____ ____ ____ ____

Clinic

Yes

______________ ______

______________ ______

______________ ______

______________ ______

______________ ______

No ____ ____ ____ ____ ____

7. Were clinic participants waiting for long periods of time?

Clinic

Yes

No

______________ ______ ___

______________ ______ ___

______________ ______ ___

______________ ______ ___

______________ ______ ___

8. Does the clinic offer privacy for health screening and counseling?

9. Does the reviewer observe any practices that could be considered discriminating?

Clinic

Yes

No

Clinic

Yes

No

_____________ ______ ____

______________ ______ ____

_____________ ______ ____

______________ ______ ____

_____________ ______ ____

______________ ______ ____

_____________ ______ ____

______________ ______ ____

_____________ ______ ____

______________ ______ ____

37

GA WIC 2005 PROCEDURES MANUAL

Form 5

CERTIFICATION

1. Was Medicaid/Food Stamps/PeachCare verified?

Clinic

Yes

No

______________ ______ ___

______________ ______ ___

______________ ______ ___

______________ ______ ___

______________ ______ ___

CLINIC OBSERVATION

2. Is there a place for documentation for proxy(s)?

3. Is income determined prior to nutritional risk assessment?

Clinic

Yes

No

______________ ______ ___

______________ ______ ___

______________ ______ ___

______________ ______ ___

______________ ______ ___

Clinic

Yes

_____________ ______

_____________ ______

_____________ ______

_____________ ______

_____________ ______

No ____ ____ ____ ____ ____

4. Was the correct form used for income?

Clinic

Yes

No

______________ ______ ___

______________ ______ ___

______________ ______ ___

______________ ______ ___

______________ ______ ___

5. Was the Income Calculation Form used accurately?

Clinic

Yes

No

______________ ______ ___

______________ ______ ___

______________ ______ ___

______________ ______ ___

______________ ______ ___

6. Were the right questions asked for income?

Clinic

Yes

No

_____________ ______ ____

_____________ ______ ____

_____________ ______ ____

_____________ ______ ____

_____________ ______ ____

7. Was proof of income verified at certification/re-certification.

Clinic

Yes

______________ ______

______________ ______

______________ ______

______________ ______

______________ ______

No ___ ___ ___ ___ ___

8. Was proof of residence required at certification/re-certification.

9. Was proof of ID requested at and
required for certification/recertification and pickup (Form 8)?

Clinic

Yes

No Clinic

Yes

No

______________ ______ ___

_____________ ______ ____

______________ ______ ___

_____________ ______ ____

______________ ______ ___

_____________ ______ ____

______________ ______ ___

_____________ ______ ____

______________ ______ ___

_____________ ______ ____

38

GA WIC 2005 PROCEDURES MANUAL

Form 5

CLINIC OBSERVATION

10. Were participants informed of their rights and obligations?

Clinic

Yes

______________ ______

______________ ______

______________ ______

______________ ______

______________ ______

No ___ ___ ___ ___ ___

11. Was the No Proof form used appropriately (Form 10) if applicable?

Clinic

Yes No

______________ ______ ___

______________ ______ ___

______________ ______ ___

______________ ______ ___

______________ ______ ___

12. Was the 30 Day Form used appropriately, if applicable?

Clinic

Yes

_____________ ______

_____________ ______

_____________ ______

_____________ ______

_____________ ______

No ____ ____ ____ ____ ____

13. Was the applicant asked to read the certification statement before signing?

Clinic

Yes

No

______________ ______ ___

______________ ______ ___

______________ ______ ___

______________ ______ ___

______________ ______ ___

14. Was proper use of ID card explained?

Clinic

Yes No

______________ ______ ___

______________ ______ ___

______________ ______ ___

______________ ______ ___

______________ ______ ___

39

GA WIC 2005 PROCEDURES MANUAL

Form 6

EQUIPMENT INVENTORY

Was the equipment inventory sent in by October 1 of the new fiscal year?

Yes ______ No ______

Can all the equipment be located as documented on the inventory?

Clinic (Write in name)

Equipment Number

Located

Comment

Yes_____ No_____

Yes_____ No_____

Yes_____ No_____

Yes_____ No_____

Yes_____ No_____

Yes_____ No_____

Yes_____ No_____

Yes_____ No_____

Yes_____ No_____

Yes_____ No_____

Yes_____ No_____

Yes_____ No_____

Yes_____ No_____

Yes_____ No_____

Yes_____ No_____

Yes_____ No_____

Yes_____ No_____

Yes_____ No_____

Yes_____ No_____

Yes_____ No_____

Yes_____ No_____

Yes_____ No_____

Yes_____ No_____
Note: Any piece of equipment not located at the assigned clinic as documented on the inventory will automatically constitute a corrective action.

40

GA WIC 2005 PROCEDURES MANUAL

Form 7

NO PROOF MONITORING FORM
In each clinic randomly select five (5) records, from the No Proof file, to review the following criteria:
CLINIC: __________________________________________

CRITERIA TO REVIEW

PARTICIPANT NAME

Was the missing proof documented?
Was the income information recorded?
Was self-declaration allowed and documented on the Certification form if income was the missing proof?
Was the reason for no documentation recorded?
Was the applicant's signature recorded?
Was the form dated?
Was the WIC representative's signature recorded?
Was the form completely filled out?
Was the No Proof form used correctly?

41

GA WIC 2005 PROCEDURES MANUAL

Form 8

PROOF OF IDENTITY OBSERVATION FORM
The following proofs of identities are acceptable and can be used for a woman (participant, guardian or caretaker), infant, child and proxy. Use this form to document the identification proof shown at certification/subsequent certification and voucher issuance.
CLINIC NAME: _______________________________________________________________ (Use one form per clinic)

Identification Proof

Initial/Subsequent Voucher Certification Issuance

Infant

Birth Certificates/Confirmation of Birth Letter

Hospital Identification Bracelet (Mom and Baby)

Immunization Record (only if the record already exists in the clinic or a transferred record) Medical Record (Hospital record or a transferred record) Social Security Card

VOC Card (with addition ID)

Child

Birth Certificate/Confirmation of Birth Letter

Immunization Record (only if the record already exists in the clinic or a transferred record) Medical Record (only if that record already exists in the clinic or a transferred record) Social Security Card

VOC Card (with addition ID)

WOMAN (participant) Birth Certificate

Driver's License

Military ID

Medical Record (only if the record already exists in the clinic or a transferred record) Social Security Card

State ID/School Identification

VOC Card (with addition ID)

Voter Registration

WIC ID (Voucher Pick Up Only)

PROXY (parent/guardian/
caretaker)

Birth Certificate Driver's License

Military ID

Medical Record (only if the record already exists in the clinic or a transferred record) Social Security Card

State ID/School Identification

Voter Registration

Work ID

Note: Proxy must show identification in addition to the ID card.

42

GA WIC 2005 PROCEDURES MANUAL

Form 9

NOTICE OF TERMINATION/INELIGIBILITY/WAITING LIST FORM USERS' CHECKLIST
CLINIC: _________________________

REMEMBER TO

YES NO

TERMINATION/INELIGIBILITY SECTION
Did you write in the date form is completed? Did you fill in the name, address, phone number and age of the client? Did you check "You are not eligible for the WIC Program because you"? Or did you check "You are being terminated from the WIC Program because you..."? Did you give the dates where necessary? Did you make a copy of the income documentation and place it in the file? Did you complete a Certification form?
SUSPENSION SECTION
Did you write in the rules that the participant violated?
WAITING LIST SECTION
Did you give the priority(ies) you have funds to serve? Did you tell the participant what priority he/she is? Did you inform the participant that he/she may still continue to receive nutrition education and other services provided by the Health Department? Did you notify the participant that he/she may get additional information or discuss this decision by contacting the WIC Program?
FAIR HEARING SECTION
Did you give the complete name, address and phone number? (If you use a rubber stamp make certain all pages are stamped.) Did you have the parent/guardian/caretaker sign? Did you sign as the WIC representative and give your title?

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GA WIC 2005 PROCEDURES MANUAL

Form 10

TEMPORARY THIRTY (30) DAY CERTIFICATION RECORD REVIEW
(Use one form per clinic)
In each clinic randomly select three to five records, from the Temporary Thirty (30) Day Certification Report, to review the following criteria:
CLINIC _____________________________________
Participant's Name
Criteria required when applicant/participant is temporarily certified for thirty (30) days:
Is the date recorded? Is the name, date of birth, address and telephone number completed? Is "You will be terminated from the WIC Program..." checked? Is the date (that information is due back to the clinic) recorded? Is the type of proof(s) client is to bring back to the clinic checked? Are the date and the WIC Representative's signature completed? Is the Fair Hearing Section completed? Is the participant or parent/guardian/caretaker's signature completed? Is the WIC Representative's signature/title completed? Is "NO" placed in the missing proof(s) field? If income was the missing proof, is self-declared income documented on the WIC assessment form? Did the participant or parent/guardian/caretaker sign the WIC assessment form? Did the WIC Representative sign and date the WIC assessment form? Was the participant issued more than thirty (30) days of vouchers?
Criteria required when the participant or parent/guardian/caretaker returns with the missing proof(s):
If the participant or parent/guardian/caretaker returned with the missing proof(s), is the actual document presented recorded in the "UP" field? If income documentation was the missing proof, is the adjustment made on the WIC assessment form? Did the WIC Representative date and initial the updated adjustment? Was the adjustment entered into the computer? If the participant is income ineligible, was "You are being terminated from the WIC Program..." checked? Are the date and the WIC Representative's signature completed?
Criteria required if the participant or parent/guardian/caretaker did not return with the missing proof(s)
If the participant or parent/guardian/caretaker did not return with the missing proof(s), was the participant terminated? Was the temporary thirty (30) day certification extended and participant issued more vouchers?
Note: Make copies of this form for review of the Temporary Thirty (30) Day Certification Report.

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GA WIC 2005 PROCEDURES MANUAL

Form 11

FORM I

OPTION I

Patient Flow Analysis Sign In Form Procedures

The Patient Flow Analysis Sign In Form is designed to have all WIC applicants/participants sign in at the time of arrival. Each applicant/participant must:

1. Sign In 2. Document the arrival time

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GA WIC 2005 PROCEDURES MANUAL

FORM II

PATIENT FLOW ANALYSIS (PFA) SIGN IN

Form 11 OPTION I

Clinic

Date ____________ Start Time ___________

Patient Number

Name

Arrival Time

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20 (See instructions for PFA in the Certification section of the Procedures Manual)

46

GA WIC 2005 PROCEDURES MANUAL

Form 11

FORM III

PROCEDURES FOR COMPLETION

OPTION I

Clinic Flow Analysis Form (is completed by clinic staff)

The Clinic Flow Analysis form documents the following:

1.

Room #

(If applicable) - room # is completed in the event a clinic is

divided by alphabets and each staff person is keeping her/his own Sign-

In Form (FORM I).

2.

Clinic - List the name of the clinic that the analysis is being conducted.

3.

Patient # - Document the number that is assigned on the Patient Flow

Analysis Sign-In Form.

4.

Name - Document the name of the applicant/participant.

5.

Date Seen - Document the actual date the Patient Flow Analysis is

taking place.

6.

Reason For Visit - Document the reason the applicant/participant made

a visit to the WIC clinic.

Reason for Visit Code Definitions Initial Certification Recertification (Subsequent) Incomplete Certification (i.e. - Client left without completing certification process) Reinstate Transfer Education (with or without vouchers) Special Formula or Formula Change Vouchers only (no nutritional education)

7.

WIC Type - P

N B I C

Place a check mark by the category that identifies whether the

applicant/participant is a pregnant, post-partum or breastfeeding

woman, infant, or child.

8.

Appointment Time - Document appointment time of the

applicant/participant.

47

GA WIC 2005 PROCEDURES

FORM 11

9.

Time Started - Document the actual time that the clinic staff begins to

work with WIC

applicant/participant.

10. Time finished - Document the actual time that staff finished working with the applicant/participant.

11. Staff initials - List the initials of the staff that serve the WIC applicant/participant.

Note: 1. A record of the staff person's initials must be placed with the actual Patient Flow Analysis documentation for audit purposes.

2. Each applicant/participant must have his/her own Patient Flow Analysis Form. Each family member must have his/her own form

12. Patient Arrival - Actual time that participant signed in the clinic.

13. Time Patient Left - Documents the applicant completed all WIC services and is leaving the clinic.

14. Total Time in Clinic - Documents the amount of time from arrival to departure for applicant/participant to receive WIC services.

15. Food Package Change (FPC)/Formula Type (optional) - Document the FPC or formula type if applicable for District Use.

16. Special Service Provided/Comments - Documents any special services or circumstances which may cause you to take additional time with the applicant/participant.

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GA WIC 2005 PROCEDURES

FORM 11

FORM IV Patient Flow Analysis (PFA) Form

OPTION I

Room #: __________________ (If Applicable) Clinic: _________________________________________ Patient #: _______________________________________ Name: _________________________________________ Date Sent:_______________________________________ Reason for Visit: ________________________________ WIC Type: _____ P______ N_____B _____ I _______ C Appointment Time: _____________________________

Patient Arrived: Initiate Worker: Clerk: Lab Worker: Nurse: Nutritionist:

Time

Time Started
____ ____ ____ ____ ____

Time Finished
_____ _____ _____ _____ _____

Staff Initials
____ ____ ____ ____ ____ ____

Clerk:

____

_____

____

Time Patient Left:

____

Total Time in Clinic:

____

FPC/Formula Type: (Optional) ________________________________________________

Special Services Provided/Comments: ___________________________________________

______________________________________________________________________________

Note: 1. 2.

A record of staff initials must be kept on file for audit purposes. Each applicant/participant must have her/his own PFA Form.

49

GA WIC 2005 PROCEDURES

FORM 11

FORM V

OPTION I

Questions to Answers for Option I

1.

What was the length of time that a client waited from sign-in to first

clinic staff contact?

2.

What was the range of time for certification clients from sign-in to exit?

For clients scheduled for issuance?

3.

Were there any clinic bottlenecks?

4.

Are clients seen by order of appointment?

5.

Are clients scheduled at a rate appropriate for services received and staff

availability?

6.

Are there down times for any staff?

7.

Are the appropriate staff present for first morning appointments?

8.

How many appointments were there? Number of no-shows?

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GA WIC 2005 PROCEDURES MANUAL

Form 12

FORM I

PATIENT FLOW ANALYSIS (PFA) SIGN IN

Clinic _______________ Date ___________ Start Time ___________

Patient Number
1
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Name

Arrival Time

OPTION Appt. Time

(See instructions for PFA in the Certification section of the Procedures Manual)

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GA WIC 2005 PROCEDURES MANUAL

Form 12

FORM II

PERSONNEL IDENTIFICATION CODES

OPTION II

CODES A B C D E F G H I J K L M N O P Q R S T U V W

NAME

OFFICIAL FUNCTION

52

GA WIC 2005 PROCEDURES MANUAL

Form 12

FORM III

REASON FOR VISIT CODES

Code A.

Definition
Initial Certification

OPTION II

B.

Recertification (Subsequent)

C.

Incomplete Certification (i.e. - Client left without completing certification process)

D.

Reinstate

E.

Transfer

F.

Education (with or without vouchers)

G.

Special Formula or Formula Change

H.

Vouchers only (no nutritional education)

I.

Other (please specify)

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GA WIC 2005 PROCEDURES MANUAL

FORM IV

PATIENT CATEGORY

Form 12 OPTION II

A. Pregnant Woman B. Postpartum Woman C. Breastfeeding Woman D. Infant E. Child F. Family (use only when a combination of family members receive WIC services) G. Other (specify)

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GA WIC 2005 PROCEDURES MANUAL

Form 12

FORM V

PATIENT REGISTER

OPTION II

Patient Number: ____________________________________ (from sign-in sheet) Reason for Visit: ____________________________________

Patient Category: ____________________________________

Time of Arrival: ____________________________________

(from sign-in sheet)

Time of Clinic:

____________________________________

Appointment

Patient Service Time

Contact # Personnel Start Time End Time ID Code

Service Provided *

1.

______

______

______

_______________________

2.

______

______

______

_______________________

3.

______

______

______

_______________________

4.

______

______

______

_______________________

5.

______

______

______

_______________________

6.

______

______

______

_______________________

7.

______

______

______

_______________________

8.

______

______

______

_______________________

*Note: Service Provided If anything out of the ordinary occurs while serving the participant, please write in the Service Provided Column one of the items listed below that apply.

Computer Problems Food Package Change Multiple Family No.____ Telephone Call Customer Complaint

Interpreter Transfer Need Re-cert New WIC ID Card Verification of ID

Client Left Clinic Address Change Immunization Other _______

55

GA WIC 2005 PROCEDURES MANUAL

Form 12

FORM VI

OPTION II

Questions to Answer from the Modified PFA

1. What was the length of time that a client waited from sign-in to first clinic staff contact?

2. What was the range of time for certification clients from sign-in to exit?

For clients scheduled for issuance?

3. Were there any clinic bottlenecks?

4. Are clients seen by order of appointment?

5. Are clients scheduled at a rate appropriate for services received and staff availability?

6. Are there down times for any staff?

7. Are the appropriate staff present for first morning appointments?

8. How many appointments were there? Number of no-shows?

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GA WIC 2005 PROCEDURES MANUAL
IMMUNIZATION REVIEW
District: ______________ Clinic: _____________
Criteria to Review:
Was child screened for immunization status? Does WIC do immunization screening? If No, are the participants referred? Is the child adequately immunized for age? Are WIC/Immunization services coordinated? Do you give immunizations on site? Do you refer participants who have no immunization record? Do you refer all children who cannot get shots at your location? Does the WIC participant have an immunization record, but failed to bring it? Are participants who are not up-to-date on immunizations, and refuse to take time to get them referred the immunization coordinator for tracking and follow up? Do you have a policy on withholding vouchers? Do you verify immunization records with private physicians' offices?

Form 13

57

GA WIC 2005 PROCEDURES MANUAL

Attachment MO-1

PART V - FOOD INSTRUMENT ACCOUNTABILITY (LOCAL AGENCY ONLY)

GUIDELINES

AREAS OF REVIEW

YES NO NA COMMENTS

Corrective Action Corrective Action

I. FOOD INSTRUMENT ACCOUNTABILITY (DISTRICT REVIEW)
A. Packing List/Confirmation Notice 1. Is a copy of the voucher packing list/ confirmation notice received by the District within five days of clinic verification?
Looking for: Packing slips in the District Office within 5 days of receipt with signature. 2. Are packing lists signed, dated and reconciled with the clinic copy?

Corrective Action

Looking for: All packing slips are signed, dated and reconciled at the district office.
B. Voucher Issuance Employees/Family Members 1. Does the Local Agency have a policy for issuing vouchers to eligible WIC employees and their family members?

Corrective Action

Looking for: District policy that is different from the procedures manual.
2. Are any local agency staff receiving WIC benefits at the clinic site where they work?

Corrective Action

Looking for: Staff receiving benefits at the site where they are located and review file?
3. Are any family members of WIC staff receiving benefits at the local clinic where the staff is employed?

Looking for: Documentation of family members of staff receiving benefits where the staff is employed.

58

GA WIC 2005 PROCEDURES MANUAL

Attachment MO-1

PART V - FOOD INSTRUMENT ACCOUNTABILITY (LOCAL AGENCY ONLY)

GUIDELINES
Corrective Action

AREAS OF REVIEW
4. Are staff members at the clinic allowed to issue vouchers or process certification for family members?

YES NO

NA COMMENTS

Corrective Action

Looking for: District awareness of the policy on family certification and voucher issuance.
5. Does the district maintain a file of all employees and relatives of employees receiving WIC benefits?

Corrective Action

Looking for:
Is the Health Department Employee Form completed and on file at the district office.
C. Participant Abuse 1. Has the District received any reports of program abuse by the participants since the last Program Review?

Corrective Action

Looking for: Reports of participant abuse and the nature of the abuse and review. 2. Was the report of abuse investigated?

Corrective Action

Looking for: Proper procedure being followed for processing report
3. Was the report sent to the Georgia WIC Branch?

Looking for: Reports at the local level that were not forwarded to the Georgia WIC Branch.

59

GA WIC 2005 PROCEDURES MANUAL

Attachment MO-1

PART V - FOOD INSTRUMENT ACCOUNTABILITY (LOCAL AGENCY ONLY)

GUIDELINES
Corrective Action

AREAS OF REVIEW
D. Dual Participation 1. Have there been any cases of intentional dual participation since the last monitoring review?

YES NO NA COMMENTS

Looking for: Dual participation

Corrective Action

2. Was the report sent to the Georgia WIC Branch?

Corrective Action

Looking for: Documentation of what was investigated and findings sent to Georgia WIC Branch.
E. Missing Voucher/VPOD Receipt 1. Has the District Office received notice of any missing vouchers/VPOD receipts from any WIC clinic since the last Program Review?

Corrective Action

Looking for: Clinic report of any missing vouchers to the District office.
2. Was the report investigated?

Corrective Action

Looking for: Proper procedures when vouchers/VPOD receipts are missing.
3. Was the report sent to the State WIC Branch?

Looking for: District notification to the State WIC Branch of any missing vouchers/VPOD receipts.

60

GA WIC 2005 PROCEDURES MANUAL

Attachment MO-1

PART V - FOOD INSTRUMENT ACCOUNTABILITY (LOCAL AGENCY ONLY)

GUIDELINES
Corrective Action

AREAS OF REVIEW
A. Manual Voucher Inventory Log 1. Is the log being completed on all vouchers?

YES NO NA COMMENTS

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

Looking for: Assurance that all vouchers are recorded on the Manual Inventory Log (both standard preprinted and special blank manuals).

Corrective Action

2. Are packing lists recorded on manual inventory logs within three days of receipt?

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

Corrective Action

Looking for: Assurance that packing lists are recorded on inventory logs within three days. 3. Are clerk initials present on the Manual Inventory Log?

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

Looking for: Assurance that clerk's initials are present to verify accurate entries.

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GA WIC 2005 PROCEDURES MANUAL

Attachment MO-1

PART V - FOOD INSTRUMENT ACCOUNTABILITY (LOCAL AGENCY ONLY)

GUIDELINES
Corrective Action

AREAS OF REVIEW
4. Does Manual Inventory Log contain second verifying signature for physical inventory?

YES NO NA COMMENTS

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

Looking for: Assurance that monthly inventory is conducted by two staff persons.

Corrective Action B. VPOD Inventory 1. Is the VPOD inventory log completed on all VPOD vouchers?
Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________
Looking for: Assurance that the inventory is kept on VPOD vouchers on a daily basis. 2. Is the VPOD inventory complete and accurate?
Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________
Looking for: Assurance that all columns of the log are completed accurately?
62

GA WIC 2005 PROCEDURES MANUAL

Attachment MO-1

PART V - FOOD INSTRUMENT ACCOUNTABILITY (LOCAL AGENCY ONLY)

GUIDELINES
Corrective Action

AREAS OF REVIEW
3. Are VPOD numbers recorded accurately on the VPOD inventory within three (3) days of receipt?

YES NO NA COMMENTS

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

Looking for:
Assurance that VPOD serial numbers are recorded on the inventory log in a timely manner.

Corrective Action C. Manual Voucher Physical Inventory 1. Are any vouchers missing?

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

Corrective Action

Looking for: A complete and actual physical inventory to ensure that all vouchers are accounted for.
2. Does physical inventory match the inventory log?

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

Looking for: Assurance that the actual physical inventory matches the inventory log.

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GA WIC 2005 PROCEDURES MANUAL

Attachment MO-1

PART V - FOOD INSTRUMENT ACCOUNTABILITY (LOCAL AGENCY ONLY)

GUIDELINES
Corrective Action

AREAS OF REVIEW
3. Is a physical inventory conducted and verified monthly?

YES NO NA COMMENTS

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

Corrective Action

Looking for: Documentation on the inventory log that a physical count of all vouchers was completed and verified each month.
D. Vouchers Printed On Demand (VPOD Vouchers) Receipts 1. Are receipts filed in serial number order?

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

Corrective Action

Looking for: Assurance that all voucher receipts are stored neatly and in order by serial number.
2. Are any receipts missing or misfiled?
Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

Looking for: Assurance that all vouchers are accounted for.

64

GA WIC 2005 PROCEDURES MANUAL

Attachment MO-1

PART V - FOOD INSTRUMENT ACCOUNTABILITY (LOCAL AGENCY ONLY)

GUIDELINES
Corrective Action

AREAS OF REVIEW
3. Are daily activity reports maintained correctly? Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

YES NO NA COMMENTS

Looking for: Assurance that daily activity reports are kept in a folder or with the receipts.

Corrective Action

4. Are there any gaps or missing numbers on the activity report?
Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

Corrective Action

Looking For:
Assurance that all serial numbers are accounted for and printed on the activity report to show disposition of voucher number.
5. Does receipt contain the correct ID proof codes?

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

Looking for: Assurance the correct ID is collected for

65

GA WIC 2005 PROCEDURES MANUAL

Attachment MO-1

PART V - FOOD INSTRUMENT ACCOUNTABILITY (LOCAL AGENCY ONLY)

GUIDELINES
Corrective Action

AREAS OF REVIEW
voucher issuance. 6. Are any participant's signatures missing
on the receipts?

YES NO

NA COMMENTS

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

Looking for: Missing participant's signature.

Corrective Action

7. Does the VPOD receipts contain the entry "Failed to Sign" more than 1% for the entire month.

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

Corrective Action

Looking for: More than 1% "Failed to Sign" entries on the VPOD receipts.
8. Are voided vouchers stamped "void" and attached to the receipts?

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________
Looking for: Voided vouchers filed without void or stamped written on them.

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GA WIC 2005 PROCEDURES MANUAL

Attachment MO-1

PART V - FOOD INSTRUMENT ACCOUNTABILITY (LOCAL AGENCY ONLY)

GUIDELINES

AREAS OF REVIEW

YES NO NA COMMENTS

Corrective Action

E. Manual Voucher Copies 1. Are manual voucher copies filed in serial number order? Clinic ___________________ Clinic ___________________

Clinic ___________________

Clinic ___________________

Clinic ___________________

Looking for: Assurance that all manual vouchers are stored neatly and in serial number order.

Corrective Action

2. Are any manual vouchers missing?

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

Corrective Action

Looking for: Assurance that all manual vouchers are accounted for. 3. Have vouchers been altered with write overs or scratch-outs?

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

Looking for: Unauthorized corrections or alterations

67

GA WIC 2005 PROCEDURES MANUAL

Attachment MO-1

PART V - FOOD INSTRUMENT ACCOUNTABILITY (LOCAL AGENCY ONLY)

GUIDELINES
Corrective Action

AREAS OF REVIEW
4. Are manual vouchers completed accurately?

YES NO NA COMMENTS

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

Looking for: Assurance that manual vouchers are completed with name, WIC ID number, dates, clerk initials and reason.

Corrective Action

5. Are all boxes completed on blank manual vouchers?

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

Looking for: Assurance that all boxes contain numbers or an X.
F. Reconciled Packing List/Confirmation Notices 1. Is the Packing List/Confirmation Notice verified, signed, and dated?

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

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GA WIC 2005 PROCEDURES MANUAL

Attachment MO-1

PART V - FOOD INSTRUMENT ACCOUNTABILITY (LOCAL AGENCY ONLY)

GUIDELINES

AREAS OF REVIEW

YES NO NA COMMENTS

Corrective Action

Looking for: Packing list/ signed and dated confirmation notices. 2. Are vouchers accurately recorded on the VPOD Log Sheet or the Manual Inventory Log?

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________
Looking for: Assurances that serial numbers received are recorded accurately on the manual voucher inventory/VPOD log.

Corrective Action

3. Are copies of packing list/confirmation notice sent to the District Office?

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

Corrective Action

Looking for: Assurance that a copy of the signed/dated packing/confirmation notice is in all the District Offices within five days of receipt of the vouchers. 4. Are any packing lists missing?

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

69

GA WIC 2005 PROCEDURES MANUAL

Attachment MO-1

PART V - FOOD INSTRUMENT ACCOUNTABILITY (LOCAL AGENCY ONLY)

GUIDELINES

AREAS OF REVIEW

YES NO NA COMMENTS

Corrective Action

Looking for:
Assurance that all packing lists are accounted for.
G. Voucher Registers 1. Are all lines completed on the voucher register?

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

Looking for: Assurance that all lines on the vouchers register is completed.

Corrective Action

2. Are any participant's signatures missing on the voucher register?

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

Corrective Action

Looking for The participant or proxy's signature. 3. Does the voucher register contain the entry "fail to sign" more than one percent for the entire month?

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

70

GA WIC 2005 PROCEDURES MANUAL

Attachment MO-1

PART V - FOOD INSTRUMENT ACCOUNTABILITY (LOCAL AGENCY ONLY)

GUIDELINES
Corrective Action

AREAS OF REVIEW
Looking for: More than one percent "fail to sign" on the voucher register. 4. Are any clerk initials or dates missing?

YES NO NA COMMENTS

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

Looking for: Missing clerk initials and/or dates.

Corrective Action

5. Does voucher register contain required closeout signatures and dates?

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

Corrective Action

Looking for: Signature/date for employee that closed the register and signature/date for employee that verified the closed register.
6. Are correct ID proof codes documented on the voucher register?

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

71

GA WIC 2005 PROCEDURES MANUAL

Attachment MO-1

PART V - FOOD INSTRUMENT ACCOUNTABILITY (LOCAL AGENCY ONLY)

GUIDELINES

AREAS OF REVIEW
Clinic ___________________

YES NO NA COMMENTS

Corrective Action

Looking For: Assurance that the correct ID is accepted for voucher pickup.
H. Voucher Security 1. During office hours, are vouchers securely stored or in the possession of authorized staff?

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

Looking for: Proper voucher security

Corrective Action

2. Are vouchers properly secured overnight?

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

Corrective Action

Looking for: Proper voucher security procedure when the clinic is closed. 3. Are vouchers securely stored separately from ID cards and voucher registers?

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

72

GA WIC 2005 PROCEDURES MANUAL

Attachment MO-1

PART V - FOOD INSTRUMENT ACCOUNTABILITY (LOCAL AGENCY ONLY)

GUIDELINES
Corrective Action

AREAS OF REVIEW
Looking for: Are Vouchers and WIC program stamps stored in a location separately from WIC vouchers, ID cards and VOC cards. 4. Are WIC ID cards stored separately from the Program Stamp?

YES NO NA COMMENTS

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

Looking for: WIC ID cards stored in a separate location from the vouchers, registers, and the program stamp?

Corrective Action

5. What security measures are taken when an employee resigns or is no longer authorized to issue voucher(s)?

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

Corrective Action

Looking for: Assure that unauthorized personnel do not have access to secure area? 6. Is the key properly secured only with authorized personnel?

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

73

GA WIC 2005 PROCEDURES MANUAL

Attachment MO-1

PART V - FOOD INSTRUMENT ACCOUNTABILITY (LOCAL AGENCY ONLY)

GUIDELINES

AREAS OF REVIEW

YES NO NA COMMENTS

Corrective Action

Looking for: Make sure the key to the locked storage space is secure and in the possession of authorized personnel. 7. What security measures are currently in place to prevent voucher theft by participants?

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________
Looking for: Assurance that vouchers are not easily assessable to clients.

Corrective Action I. Prorating (Voucher Issuance) 1. Is staff knowledgeable of the proper procedures for prorating?

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

Corrective Action

Looking for: The proper procedures for prorating are performed. 2. Is prorating consistently performed?

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

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GA WIC 2005 PROCEDURES MANUAL

Attachment MO-1

PART V - FOOD INSTRUMENT ACCOUNTABILITY (LOCAL AGENCY ONLY)

GUIDELINES
Corrective Action

AREAS OF REVIEW
Looking for:
Assurance the vouchers are prorated for late pickup.
3. Are vouchers transported from one site to another?

YES NO NA COMMENTS

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

Looking for: Clinics that transport vouchers to other clinic sites.

Corrective Action

4. When vouchers are transported, are they in a locked container (lock box, briefcase)?

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

Corrective Action

Looking for: Assurance that Vouchers are transported in locked briefcase or lockbox.
J. Local Agency Policies 1. Does the local agency have a policy for issuing vouchers to employees/family members?

Clinic ___________________ Clinic ___________________ Clinic ___________________

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GA WIC 2005 PROCEDURES MANUAL

Attachment MO-1

PART V - FOOD INSTRUMENT ACCOUNTABILITY (LOCAL AGENCY ONLY)

GUIDELINES

AREAS OF REVIEW
Clinic ___________________ Clinic ___________________

YES NO NA COMMENTS

Corrective Action

Looking for: Assurance that clinic employees are knowledgeable of district policy. 2. Do any employees of this clinic receive WIC benefits?

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

Looking for: Assurance that employees are not certifying or issuing vouchers to family members.

Corrective Action

3. Are family members of staff receiving WIC benefits at these locations?

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

Corrective Action

Looking for: Assurance that employees are not certifying or issuing vouchers to family members. 4. Is clinic staff allowed to issue vouchers or to certify family members?

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

76

GA WIC 2005 PROCEDURES MANUAL

Attachment MO-1

PART V - FOOD INSTRUMENT ACCOUNTABILITY (LOCAL AGENCY ONLY)

GUIDELINES

AREAS OF REVIEW

YES NO NA COMMENTS

Corrective Action

Looking for: Check medical records of family members of staff to determine if the staff certified their family members. 5. Is the District aware of all staff/family members enrolled on the WIC Program?

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________
Looking for: District awareness of any staff or family members participating on the program.

Corrective Action

K. Participant Abuse 1. Has the clinic had any problems with participant abuse since the last program review?

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

Corrective Action

Looking for: Problems with participants (verbal abuse, misconduct, dual participation, etc). 2. Was the coordinator notified?

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

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PART V - FOOD INSTRUMENT ACCOUNTABILITY (LOCAL AGENCY ONLY)

GUIDELINES

AREAS OF REVIEW
Clinic ___________________

YES NO NA COMMENTS

Looking for: If participant abuse identified, was coordinator informed about abuse? 3. To your knowledge, was there an investigation?

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

Looking for: The outcome of the situation.

Recommendation L. Dual Participation 1. Has the clinic followed up on each dual participation case received at the clinic?

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

Corrective Action

Looking for: Make sure the clinics are completing the dual participation reports and handling any cases of dual participation.
M. Missing Vouchers 1. Have any vouchers been reported missing during the last twelve months?

Clinic ___________________ Clinic ___________________ Clinic ___________________

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PART V - FOOD INSTRUMENT ACCOUNTABILITY (LOCAL AGENCY ONLY)

GUIDELINES

AREAS OF REVIEW
Clinic ___________________ Clinic ___________________

YES NO NA COMMENTS

Corrective Action

Looking for: Make sure all vouchers were accounted for, and record if the clinic was aware of any missing vouchers. 2. Was a Lost, Stolen, Destroyed Voucher Report sent to the Georgia WIC Branch?

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

Looking for: Make sure the proper procedures and forms were completed when vouchers were reported missing.

Corrective Action

3. Was supervisor/coordinator notified of the missing vouchers?

Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________ Clinic ___________________

Looking for: If the coordinator was made aware of any missing vouchers.

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PART VI NUTRITION CERTIFICATION, EDUCATION/ BREASTFEEDING SECTION

GUIDELINES
Corrective Action

AREAS OF REVIEW
I. FOOD PACKAGE ASSIGNMENT A. List title(s) of competent professional authorities (CPA's) who assign food packages for participants:

YES NO NA COMMENTS

Corrective Action

Looking for: Compliance with Federal requirements and State policy that only CPA's can assign/tailor food packages.
B. Is there a protocol for infant food package changes from the contract formula to the noncontract formula? If yes, which of the following do you use? State Protocol: _______ Local Agency Policy: _______ (Please provide a copy to the reviewer)

Corrective Action

Looking for: Compliance with, and consistent application of State policies and procedures regarding food package changes.
C. What guidelines are used for food package tailoring? (Please provide reviewer with any written communications to clinic staff on food package tailoring.)

Recommendation

Looking for: Compliance with Federal requirements and State policy.
D. What procedures are used for obtaining and tracking the use of prescription formulas/metabolic foods, and providing follow-up for participants on special formulas/metabolic foods?

Looking for: Consistency among clinic staff in methods used to assign, obtain and track the use of prescription formulas/metabolic foods. Whether or not participants receive followup from the appropriate source, (i.e., private M.D., health department). Whether FFY 2004 food packages comply with federal regulations.
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PART VI NUTRITION CERTIFICATION, EDUCATION/ BREASTFEEDING SECTION

GUIDELINES
Corrective Action

AREAS OF REVIEW
II. NUTRITION EDUCATION A. Training 1. At the time of the program review, please provide the reviewer with a summary of all nutrition training attended by local staff since the last review. List provided?

YES NO NA COMMENTS

Recommendation

Looking for: Whether or not all staff providing WIC services receive adequate training as required by State policy. 2. How are training needs assessed?

Recommendation

Looking for: Adequacy of continuing education of all staff providing WIC services. 3. How do you assess the effectiveness of the training over time?

Corrective Action

Looking for: Monitor adequacy of continuing education for all staff providing WIC services.
B. Nutrition Assistants (NAs) 1. Are NAs used to certify participants?

Corrective Action

Looking for: Ensure that NAs are not certifying participants. 2. Are NAs used to provide secondary nutrition education contacts?

Corrective Action

Looking for: Ensure that NAs are not being used without State approval. 3. Are NAs used to provide secondary nutrition education contacts?

Looking for: Ensure that NAs are not being used without State approval.

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PART VI NUTRITION CERTIFICATION, EDUCATION/ BREASTFEEDING SECTION

GUIDELINES
Corrective Action

AREAS OF REVIEW
4. Has the training plan for NAs been approved by the Nutrition Section? If yes, the date: __________

YES NO NA COMMENTS

Corrective Action

Looking for: Whether or not a training plan approved by the Nutrition Section has been implemented.
5. Have all lesson plans for training NAs been submitted to the Nutrition Section for approval? If no, please provide reviewer with lesson plans at the time of review.

Corrective Action

Looking for: Ensure that the Nutrition Section has all lesson plans on file, and all plans have been approved.
5. Has the district submitted to the Nutrition Section, a list of NA staff who provides secondary nutrition education contacts? If yes, date provided: ______ If no, please provide the reviewer a list at the time of review.

Corrective Action

Looking for: A current list of approved NA staff on file in the Nutrition Section.
C. Nutrition Education Plan 1. Was a three-year Nutrition Education Plan received by the Nutrition Section by September 1? If yes, date: __________ If no, date received: __________ Not received: __________

Looking for: Compliance with Federal requirements that a local plan be developed that is consistent with the State plan.

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PART VI NUTRITION CERTIFICATION, EDUCATION/ BREASTFEEDING SECTION

GUIDELINES
Corrective Action

AREAS OF REVIEW

YES NO NA COMMENTS

2. Was an annual progress report received by

the Nutrition Section by November 30?

If yes, date: _____

If no, date received: _______

Not received: ______

Corrective Action

Looking for: Compliance with the Federal requirement for development of an annual local agency plan.
D. Participant Nutrition Education Contacts 1. If the district provides group Nutrition Education, please provide the reviewer with a copy of the lesson plans developed since last review.

Recommendation

Looking for: Compliance with Federal requirements and State policy that standards for nutrition education are followed. Compliance with State policy that only approved materials are used for the provision of nutrition education.
2. Describe the system used to provide two (2) nutrition education contacts for each six (6) month certification period or quarterly for certification greater than 6 months.

Recommendation

Looking for: Adequacy of system to provide education contacts. Potential problems in the system, that can be identified and corrected.
3. What method is used to document secondary nutrition education contacts?

Looking for: Compliance with Federal requirements and State policy.

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PART VI NUTRITION CERTIFICATION, EDUCATION/ BREASTFEEDING SECTION

GUIDELINES
Corrective Action

AREAS OF REVIEW
4. Are missed nutrition education appointments documented? If yes, describe the method used:

YES NO NA COMMENTS

Recommendation

Looking for: Compliance with Federal requirements and State policy. Identify and correct potential problems with the system in place.
5. How are the Nutrition Guidelines for Practice being used?

Corrective Action

Looking for: Whether or not the Guidelines have been implemented at the clinic level.
6. Do you have a system in place to assure the provision of high risk nutrition education contacts? Describe the method:

Corrective Action

Looking for: Compliance with Federal requirements for appropriate nutrition education contacts, and State policy regarding development of care plans for high risk participants.
E. Nutrition Education Materials 1. Who approves nutrition education materials and forms not provided by the State?

Recommendation

Looking for: A qualified designated nutritionist. 2. What method(s) is (are) used to evaluate nutrition education materials?

Looking for: Whether or not materials are evaluated on a regular basis using consistent methods. Compliance with Federal regulation for educational materials appropriate for participant use.

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PART VI NUTRITION CERTIFICATION, EDUCATION/ BREASTFEEDING SECTION

GUIDELINES
Corrective Action

AREAS OF REVIEW

YES NO NA COMMENTS

3. A list of all approved nutrition education

materials and a copy of those not

available through Central Supply are to be

provided to the Nutrition Section. List

provided? (New materials only since last

review.

Corrective Action

Looking for: Compliance with Federal requirements for education materials appropriate for participant use. 4. Are materials provided which meet the needs of specific population groups?

Corrective Action

Looking for: Compliance with Federal requirements for education materials appropriate for participant use. 5. Are inappropriate nutrition education materials available for participant use?

Corrective Action for No Breastfeeding Coordinator

Looking for: Compliance with Federal requirements for education materials appropriate for participant use.
III. BREASTFEEDING PROMOTION AND SUPPORT This section should be addressed with both the WIC coordinator and the local agency breastfeeding coordinator.
A. Breastfeeding Coordinator 1. What are the names and credentials/qualifications of the breastfeeding coordinator?

Looking for: Compliance with Federal requirements.

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PART VI NUTRITION CERTIFICATION, EDUCATION/ BREASTFEEDING SECTION

GUIDELINES
Recommendation

AREAS OF REVIEW
2. How many hours per week/month does the Breastfeeding Coordinator spend on breastfeeding promotion and support activities?

YES NO NA COMMENTS

Recommendation

Looking for: Adequate time provided to the breastfeeding coordinator to comply with federal requirements. 3. Is the breastfeeding coordinator position permanent or a contract?

Corrective Action

Looking for: Services provided by Breastfeeding Coordinator: cost factors, duties performed based on how hired.
4. Does the breastfeeding coordinator conduct activities agency-wide or primarily in one location?

Recommendation

Looking for: Ability of Breastfeeding Coordinator to meet Federal requirements throughout the local agency.
5. Describe the major responsibilities and activities of the Breastfeeding Coordinator.

Looking for: Ability of the Breastfeeding Coordinator to conduct activities designed to comply with Federal requirements and State policy.

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PART VI NUTRITION CERTIFICATION, EDUCATION/ BREASTFEEDING SECTION

GUIDELINES
Recommendation

AREAS OF REVIEW
6. How are Breastfeeding Coordinator activities documented (i.e., counseling, classes)? _____ Central File _____ Participant health record _____ Other (please specify)

YES NO NA COMMENTS

Recommendation

Looking for: Complete documentation of all breastfeeding services provided. Identification, for follow-up and monitoring purposes, of location of documentation.
7. For individual counseling done, describe the process for documentation including the time lag between counseling and documentation.

Corrective Action

Looking for: Complete documentation of all breastfeeding services provided. Location of documentation for follow-up and monitoring purposes.
B. Encouragement to Breastfeed 1. How is breastfeeding encouraged during the prenatal period? _____Individual Contact _____Prenatal/Breastfeeding Class _____Other (Please specify):

Recommendation

Looking for: Compliance with Federal requirements for prenatal education. 2. Describe the process for individual contacts that are provided (when, by whom, documentation).

Looking for: Activities performed by the Breastfeeding Coordinator and other clinic staff to monitor and assess the system for

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PART VI NUTRITION CERTIFICATION, EDUCATION/ BREASTFEEDING SECTION

GUIDELINES
Recommendation

education contacts as well as the variety of staff able to perform the required functions.
AREAS OF REVIEW
3. Describe the process for the provision of prenatal classes to include breastfeeding (when, by whom, documentation).

YES NO NA COMMENTS

Recommendation

Looking for: Activities performed by the Breastfeeding Coordinator and other clinic staff to monitor and assess the system for education contacts as well as the variety of staff able to perform these required functions.
C. Training 1. Please provide, at the time of the review, a list of: _____ Trainings attended by the Breastfeeding Coordinator. _____ Trainings provided by the Breastfeeding Coordinator.

Corrective Action

Looking for: Compliance with Federal requirements for training of new staff. Adequacy of continuing education for all staff providing WIC services.
2. Describe how you assure that clinic staff are knowledgeable about current breastfeeding issues.

Looking for Compliance with Federal requirement for training of new staff. Adequacy of continuing education for all staff providing WIC services.

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PART VI NUTRITION CERTIFICATION, EDUCATION/ BREASTFEEDING SECTION

GUIDELINES
Corrective Action

AREAS OF REVIEW
3. Do you have a referral system for participants who request additional support/information or require more indepth counseling /assistance on breastfeeding? If yes, describe how this is done and who provides the support, information, and in-depth counseling.

YES NO NA COMMENTS

Corrective Action

Looking for: Compliance with the Federal requirements for assuring adequate breastfeeding support for participants.
4. Describe what the local agency is doing to create a clinic atmosphere that is supportive of breastfeeding.

Recommendation

Looking for: Compliance with Federal requirements regarding a clinic atmosphere that promotes and supports breastfeeding.
5. Other Please describe any breastfeeding activities not addressed above (e.g., peer counseling, special projects, media exposure, etc.).

For Office of Nutrition Use
For Office of Nutrition Use

Looking for: Activities that go beyond the Federal requirements, but serve to promote, educate, and support breastfeeding.
IV. SPECIAL PROJECTS, INITIATIVES, AND ACCOMPLISHMENTS IN THE PROVISION OF NUTRITION SERVICES (OPTIONAL)
A. What Public Health Nutrition services are available in your Local Agency?
B. Describe the special projects, initiatives, and/or accomplishments in the area of breastfeeding, nutrition education, and

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PART VI NUTRITION CERTIFICATION, EDUCATION/ BREASTFEEDING SECTION

nutrition materials being implemented in the Local Agency.

For Office of Nutrition Use

C. What requests does the District/Local Agency have of the Nutrition Section staff to assist in implementing Nutrition Education and Breastfeeding Plans and providing nutrition services?

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PART VI NUTRITION CERTIFICATION, EDUCATION/ BREASTFEEDING SECTION

CLINIC OBSERVATION: INDIVIDUAL NUTRITION EDUCATION SESSION

DATE: ___________________CLINIC:____________________________

REVIEWER:_____________________________

Participant status: P B N I C

Participant priority:

I II III IV V VI

Participant risk factors:____________________________

Time estimated for total contact: _______________________

Time estimated for NE contact: ________________________

GUIDELINES
Corrective Action

AREAS OF REVIEW
A. Nutrition Education (NE) 1. Is diet evaluated according to Georgia WIC standards (intake, summary, food practices, evaluation)?

YES NO NA COMMENTS

Corrective Action

Looking for: Compliance with Federal requirements and State policy. 2. Does NE relate to participant status?

Corrective Action

Looking for: Compliance with Federal requirements and State policy. 3. Does NE relate to participant risk factors?

Corrective Action

Looking for: Compliance with Federal requirements and State policy. 4. Does NE relate to diet recall/assessment?

Corrective Action

Looking for: Compliance with Federal requirements and State policy. 5. Does NE include WIC foods and their relationship to participant risk?

Looking for: Compliance with Federal requirements and State policy.

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PART VI NUTRITION CERTIFICATION, EDUCATION/ BREASTFEEDING SECTION

GUIDELINES
Corrective Action

AREAS OF REVIEW
6. Does NE include total food intake and its relationship to participant risk?

YES NO NA COMMENTS

Corrective Action

Looking for: Compliance with Federal requirements and State policy. 7. Does NE follow Nutrition Guidelines for Practice?

Recommendation

Looking for: Compliance with Federal requirements and State policy.
B. Communication 1. Does counselor invite questions?

Recommendation

Looking for: Appropriate counseling skills Need for additional training. 2. Does the participant ask questions?

Recommendation

Looking for: Appropriate counseling skills. Need for additional training. 3. Is session conducted in a language the participant speaks/understands?

Recommendation

Looking for: Compliance with Federal requirements and State policy.
C. Materials (includes posters, flip charts, food models, pamphlets, etc.) 1. Are materials in participant's primary language?

Corrective Action

Looking for: Compliance with Federal requirements and State policy. 2. Do materials relate to risk factor?

Looking for: Compliance with Federal requirements and State policy.

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PART VI NUTRITION CERTIFICATION, EDUCATION/ BREASTFEEDING SECTION

GUIDELINES
Corrective Action

AREAS OF REVIEW
3. Do materials relate to counseling session?

YES NO NA COMMENTS

Recommendation

Looking for: Compliance with Federal requirements and State policy.
D. Space 1. Is space private?

Recommendation

Looking for: Appropriate counseling skills. Need for additional training. Clinic limitations. 2. Is there seating for the counselor?

Recommendation

Looking for: Appropriate counseling skills. Need for additional training. Clinic limitations. 3. Is there seating for the participant and others in the session?

Recommendation

Looking for: Appropriate counseling skills. Need for additional training. Clinic limitations. 4. Is space quiet enough to talk normally?

Recommendation

Looking for: Appropriate counseling skills. Need for additional training. Clinic limitations.
5. Is the view of the participant/counselor obstructed by materials on the desk or by the seating arrangement?

Looking for: Appropriate counseling skills. Needs for additional training.
Clinic limitations.

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PART VI NUTRITION CERTIFICATION, EDUCATION/ BREASTFEEDING SECTION

CLINIC OBSERVATION: GROUP

NUTRITION EDUCATION SESSION

DATE: __________________________ CLINIC: __________________________

REVIEWER: ___________________________

Topic: ________________________________

Composition of Group (prenatal, breastfeeding mothers, care givers of infants, etc.):

______________________

______________________________________________

Expected Attendance: __________________

Actual Attendance: _________________

No show rate (calculate percent): ______________%

Time Estimate for NE Contact: _______________

GUIDELINES

AREAS OF REVIEW

YES NO NA COMMENTS

Recommendation

A. Integration

Session conducted in connection with:

Certification: ___________

Voucher Pickup: ___________

Other Appointment: ___________

Specify: ______________________

Corrective Action

Looking for: Clinic flow. Efficiency in delivery of nutrition services in conjunction with other clinic services.
B. Nutrition Education 1. Does NE include WIC foods and their relationship to nutritional status?

Recommendation

Looking for: Compliance with Federal requirements and State policy. 2. Does NE include total food intake and its relationship to nutritional status?

Corrective Action

Looking for: Appropriate counseling skills. Need for additional training. 3. Does NE follow Nutrition Guidelines for Practices?

Looking for: Compliance with State policy.

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PART VI NUTRITION CERTIFICATION, EDUCATION/ BREASTFEEDING SECTION

GUIDELINES
Recommendation

AREAS OF REVIEW
C. Communication 1. Does instructor invite questions?

YES NO NA COMMENTS

Recommendation

Looking for: Appropriate counseling skills. Need for additional training of staff. 2. Do participants ask questions?

Recommendation

Looking for: Appropriate counseling skills. Need for additional training of staff. 3. Does instructor respond to questions?

Recommendation

Looking for: Appropriate counseling skills. Need for additional training of staff.
D. Materials/Media 1. Is the session conducted in a language(s) participants speak/understand?

Recommendation

Looking for: Compliance with Federal requirements and State policy. 2. Are materials/media in the participant(s) primary language?

Recommendation

Looking for: Compliance with Federal requirements and State policy.
3. Media used: Film/Filmstrip________ Slide/Tape Show________ Video Tape________ Poster/Flip Chart________ Food Models ________ Pamphlets________ Other________ Specify: ________________________

Looking for: Appropriate counseling skills. Need for additional training of staff.

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PART VI NUTRITION CERTIFICATION, EDUCATION/ BREASTFEEDING SECTION

GUIDELINES
Recommendation

AREAS OF REVIEW
4. Are printed materials related to information covered during session?

YES NO NA COMMENTS

Corrective Action

Looking for: Appropriate counseling skills. Need for additional training of staff.
E. Staff Session conducted by: Nurse: _________ Nutritionist: _________ Nutrition Assistant: _________ Other: _________ Specify: ____________________________

Recommendation

Looking for: Compliance with Federal requirements and State policy.
F. Evaluation of Knowledge and Satisfaction 1. Is there any evaluation of the participant's nutritional knowledge base?

Recommendation

Looking for: Appropriate counseling skills. Need for additional training of staff. 2. Is there any evaluation of the knowledge gained in the session?

Recommendation

Looking for: Appropriate counseling skills. Need for additional training of staff. 3. Is there any evaluation of the participants' attitudes about nutrition and diet?

Recommendation

Looking for: Appropriate counseling skills. Need for additional training of staff. 4. Is participant satisfaction evaluated? If yes, how?

Looking for: Appropriate counseling skills.

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PART VI NUTRITION CERTIFICATION, EDUCATION/ BREASTFEEDING SECTION

Need for additional training of staff.

GUIDELINES
Recommendation

AREAS OF REVIEW
G. Space 1. How is the room arranged?

YES NO NA COMMENTS

Recommendation

Looking for: Appropriate counseling skills. Need for additional training of staff. Clinic limitations.
2. Where is the session conducted? Waiting room_______ Private room_______ Other_______ Specify: ______________________

Recommendation

Looking for: Appropriate counseling skills. Need for additional training of staff. Clinic limitations. 3. Is there seating for the participants?

Recommendation

Looking for: Appropriate counseling skills. Need for additional training of staff. Clinic limitations. 4. Can participants see the instructor?

Recommendation

Looking for: Appropriate counseling skills. Need for additional training of staff. Clinic limitations. 5. Can participants hear the instructor?

Recommendation

Looking for: Appropriate counseling skills. Need for additional training of staff. Clinic limitations. 6. Can participants see video, film, or other visual aids?

Looking for: Appropriate counseling skills. Need for additional training of staff.
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PART VI NUTRITION CERTIFICATION, EDUCATION/ BREASTFEEDING SECTION

Clinic limitations.

GUIDELINES
Recommendation

AREAS OF REVIEW
7. Can participants hear any audio aids?

Looking for: Appropriate counseling skills. Need for additional training of staff. Clinic limitations.
H. Additional Comments

YES NO NA COMMENTS

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PART VI NUTRITION CERTIFICATION, EDUCATION/ BREASTFEEDING SECTION

CLINIC OBSERVATION: QUESTIONS FOR CLINIC STAFF

(Must be completed in at least one (1) clinic).

Date: ___________________ Clinic: _________________________ Reviewer:

____________________________________

Staff person interviewed: Nurse: ______

Nutritionist: _______

Paraprofessional: _______

GUIDELINES

AREAS OF REVIEW

YES NO NA

Recommendation A. How do you use the Nutrition Guidelines for

Practice? Give some examples.

COMMENTS

Recommendation

Looking for: Staff knowledge. Need for additional training.
B. How do you encourage breastfeeding?

Recommendation

Looking for: Staff knowledge. Need for additional training.
C. Who assigns food packages in the clinic?

Recommendation

Looking for: Staff knowledge. Need for additional training.
D. How do you decide which food package to assign to a participant?

Looking for: Staff knowledge. Need for additional training.

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PART VI NUTRITION CERTIFICATION, EDUCATION/ BREASTFEEDING SECTION

ANTHROPOMETRIC EQUIPMENT

Date_____________Clinic___________Reviewer___________________________________

OBSERVATIONS

1. Length Board:

a. Moveable foot piece at

90% angle that slides

easily

b. Foot piece at a 90%

angle

c.

Fixed headboard

2. Height Board: a. Fixed measuring device (fixed to vertical flat surface, no skirting) b. Right angle head board
3. Standing Scales: a. Calibrated in last 12 months (use scale test report or sticker) b. Beam scale

4. Infant Scale: a. Calibrated in last 12 months (use scale test report or sticker) b. Beam Scale

S-Satisfactory U-Unsatisfactory #1 #2 #3

COMMENTS

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HEMATOLOGIC EQUIPMENT

Date_____________Clinic___________Reviewer____________________________________

A. Type of equipment used (brand/model) for hemoglobin or hematocrit

B. Balancing/Checking Accuracy

1.

How is equipment balanced or checked for accuracy?

2.

Who balances/checks the equipment?

3.

How often is the equipment balanced/checked?

4.

How is the balancing/checking of equipment documented?

C. Calibration

1.

How is equipment calibrated?

2.

Who calibrates the equipment?

3.

How often is the equipment calibrated?

4.

How is calibration documented?

D. Does staff person use universal precautions when obtaining blood sample?

Date_____________Clinic___________Reviewer__________________________________ Observe at least one (1) standing height, standing weight, recumbent length, and infant scale weight.

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ANTHROPEMETRIC MEASUREMENTS Woman Status:

Child Age:

Woman/Child (Standing Height) 1. Participant measured without shoes 2. Proper stance used for reading measurement 3. Headboard is level, touches top of head 4. Correct angle used for measurement 5. Measurement taken to nearest 1/8 inch 6. Two (2) measurements taken Woman/Child (Standing Weight) 1. Participant dressed in minimal clothing 2. Scale zeroed prior to measurement 3. Correct angle used for reading measurement 4. Weight measured to nearest 1/4 pound 5. Two (2) measurements taken
Infant/Child (Recumbent Length)
1. Participant measured with minimal clothing

Yes

No

Yes

No

Infant Age:

Yes

No

Yes

No

Yes

No

Child Age:

Yes

No

2. Body straight, lined up with measuring board 3. Head is against headboard throughout
measurement 4. Footboard resting firmly against heels

5. Correct angle used for reading measurement

6. Measurement read to nearest 1/8 inch

7. Two (2) measurements taken

Infant/Child (Infant Scale Weight) 1. Participant dressed in minimal clothing
(without wet diaper)
2. Scale zeroed, prior to measurement

Yes

No

Yes

No

3. Correct angle used for reading measurement

4. Weight measured to nearest 1/2 ounce

5. Two (2) measurements taken

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PART VI NUTRITION CERTIFICATION, EDUCATION/ BREASTFEEDING SECTION

RECORD REVIEW (Acceptable Level of Compliance 90% Records Satisfactory)

RECORD REVIEW

T

District _______________

O

Clinic ________________

T

Date _________________

A

L

1. EDC Date

2. Medical Data Date

3. Length/Height Recorded

4. Weight Recorded

5. Hct/Hgb Recorded

6. Age Recorded

7. Length/Height Plotted

8. Weight Plotted

9. BMI or Prenatal weight gain plotted

10. Diet Intake Recorded

11. Diet Summary Completed

12. Food Practices Evaluated

13. Diet Evaluation Documented

14. Date Signature & Title (Diet Form)

15. All Nutritional Risks Checked

16. All Nutritional Risks Documented

17. Priority Correct

18. Food Pkg. Assigned

19. Food Pkg. Number

20. Referrals/Enrollment Documented

21. Today's Date

22. Professional's Signatures & Titles

(Certification Form)

23. Primary NE Contact, Current

Certification

24. Secondary NE Contact, Current or

Prior Certification

25. Breastfeeding Encouraged

26. High Risk Follow-up Documented

27. Exit Counseling Documented

(Women)

28. Breastfeeding Data Collected

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RECORD REVIEW: INTERPRETATION

Areas on the record review are classified S (Satisfactory), U (Unsatisfactory), or NA (not applicable). Corrective action must be taken for an area of review when the percentage of S's is less than 90% for the applicable records reviewed. The satisfactory percentage is calculated for each individual area below, with the following exceptions: "satisfactory percentage" for Plotting is calculated after averaging numbers 6-9; for Diet Evaluation, after averaging numbers 10-14; for Documentation of Nutrition Risks, after averaging numbers 15-16; and for Nutrition Education, after averaging numbers 23-24.

1. Participant Status Recorded (Women Only) [Certification Section, IX. C. X.] The correct status must be checked on the WIC Assessment/Certification Form (prenatal; postpartum, breastfeeding; or postpartum, non-breastfeeding).

2. Medical Data Date [Certification Section, VII.C, XIII.4.] The date must be recorded by mm/dd/yy. The date recorded must be when the required anthropometric measurements (height/length, weight) were determined. The date must not be more than 60 days prior to certification date. The data must be reflective of the applicant's status at the time of the application.

3. Length/Height Recorded [Certification Section, XIII.5.] Length or Height must be entered to the nearest 1/8 of an inch.

4. Weight Recorded [Certification Section, XIII.6.] Weight must be entered in pounds and ounces.

5. Hematocrit/Hemoglobin Recorded [Certification Section, XIII. 7.] Hematocrit/hemoglobin must be entered to one decimal place. The date of the hematological measurement, if different than the medical data date, must be documented in the health record. The date must not be more than 90 days prior to certification date. For women, the data must be reflective of the applicant's status at the time of the application.

6. Age Recorded [Certification Section, Attachment CT-28] The participant's birth date must be recorded on the WIC Assessment/Certification Form. Age calculation must be based on the birth date. A woman's age need not be recorded. Infant's and children's ages must be documented in their health records, preferably on the appropriate growth grids. An infant's age may be entered in days, in months and days, or rounded appropriately. A child's age may be entered in years, months and days, or rounded appropriately.

7. Length/Height Plotted [Certification Section, Attachments CT-7, 8, 9, 28] The length/height for age must be plotted accurately, either by rounding the age appropriately or plotting

104

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PART VI NUTRITION CERTIFICATION, EDUCATION/ BREASTFEEDING SECTION

as closely as possible to the exact age. Length/height values must be plotted as accurately as possible. On each growth grid, one method of plotting age must be used consistently.

8. Weight Plotted [Certification Section, Attachments CT-6, 7, 8, 22] Weight for age must be plotted accurately, either by rounding age appropriately or plotting as closely as possible to the exact age. Weight values must be plotted as accurately as possible. Weight for gestational age must be plotted to the nearest completed week of gestation and nearest half pound.

9. Weight for Length/Height Plotted [Certification Section, Attachments CT-7, 8, 22] Weight for length/height must be plotted as accurately as possible.

10. Diet Intake Recorded [Certification Section, XIII.8., Attachments CT-7, 8, 9, 32, 33] Diet intake must be recorded on an approved form. Food frequency, 24-hour recall or food record should be used. Evidence of amounts being assessed must be present when a 24-hour recall or food record is being used. Evidence of frequency of intake being assessed must be present when a food frequency is being used.

11. Diet Summary Completed [Certification Section, XIII.9.; Attachments CT-6, 7, 8, 21, 26] Total servings in each food group must be recorded on an approved form.

12. Food Practices Evaluated [Certification Section, XIII.9.; Attachments CT-6, 7, 8, 21, 26] If inappropriate food practices are present, these must be identified on the approved diet form. If no inappropriate food practices are present, this fact must be documented on the approved diet form.

13. Diet Evaluation Documented [Certification Section, XIII.9.; Attachments CT-6, 7, 8, 21, 25, 26] The definition of Poor Dietary Pattern must be applied to the diet and inappropriate food practices available.

14. Date, Signature and Title (Diet Form) [Certification Section, XIII.9.; Attachments CT-6, 7, 8] The date of the diet assessment must be documented on the approved form. The signature and title of the assessing professional must be entered accurately on the approved diet form. An appropriate signature consists of first initial and last name or first and last names.

15. All Nutritional Risks Checked [Certification Section, XIII.9.] All applicable nutritional risks must be evaluated during each certification appointment and at the infant's mid-certification nutrition assessment. All evident nutritional risks must be checked YES on the WIC Assessment/Certification Form. If a nutritional risk is not present, the risk category must be checked NO on the WIC Assessment/Certification Form (except for systems in which only risks present are printed). If a nutritional risk is not assessed/not applicable, a NA must be written/entered by the appropriate risk

105

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PART VI NUTRITION CERTIFICATION, EDUCATION/ BREASTFEEDING SECTION

category on the WIC Assessment/Certification Form (except for systems in which only risks present are printed). If documentation for a nutritional risk is found in the health record, the risk must be checked on the WIC Assessment/Certification Form.

16. All Nutritional Risks Documented [Certification Section, XIII.9.] All nutritional risk criteria checked on the WIC Assessment/Certification Form must be supported by the appropriate documentation.

17. Priority Correct [ Certification Section, XIII.12.] The correct priority must be assigned according to a participant's status and nutritional risks. A priority is determined to be incorrectly assigned if nutritional risks are present that would change the priority, even if these are not checked on the WIC Assessment/Certification Form.

18. Food Package Assigned [Certification Section, XIII.13.] A food package must be assigned in a series that is appropriate to the participant's status. Appropriate documentation and prescriptions must be in the health record, for those food packages and nutritional conditions requiring them.

19. Food Package Number [Certification Section, XIII.13.] The reviewer will record the food package number assigned to each participant whose health record is being reviewed. A compilation of these numbers will then be used, in conjunction with the Food Package Distribution Report and clinic observation, to assess whether food packages are being tailored in the clinic.
20. Referrals/Enrollment Documented [Certification Section, XIII.14.] All applicants to the WIC Program must be screened for referral to the Food Stamp Program, Medicaid and/or TANF. Applicants should also be referred to other appropriate health and social services. Referrals to other programs or services, current enrollment in other programs or services and/or a decision not to refer must be documented in the applicant's health record.

21. Today's Date [Certification Section, XIII.15.] Today's Date corresponds to the date the certification process is completed. Today's Date must be the same as or no more than 60 days later than the Medical Data Date.
22. Professional's Signature and Title [Certification Section, XIII.16.] The signature and title of the person completing the certification must be recorded An appropriate signature consists of first and last names, or first initial and last name.
23. Primary Nutrition Education Contact, Current Certification [Nutrition Education Section, VI.A., B.] Individual nutrition education contacts must be documented in the participant's health record. Documentation of group classes may consist of a participant's signature on a class attendance sheet, voucher register or class roster which contains the lesson objective(s) and the original signature of the staff person conducting the class. The method used must have the approval of the Office of Nutrition. The education must be appropriate to the individual participants' individual or group needs.

106

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PART VI NUTRITION CERTIFICATION, EDUCATION/ BREASTFEEDING SECTION

The primary nutrition education contact must be provided by a competent professional authority (CPA), not by a paraprofessional/nutrition assistant. Specific aspects of nutrition counseling must be documented (not "Nutrition education provided"). Missed appointments or refusal of nutrition education must be documented in the health record. The nutrition education must follow the Nutrition Guidelines for Practice.

24. Secondary Nutrition Education Contact, Current or Prior Certification [Nutrition Education Section, VI. A., B.] If a secondary contact is not documented for the current certification period, documentation must be present for a secondary contact provided during the previous period (infants, children, postpartum breastfeeding and non-breastfeeding women). For infants, the mid-certification nutrition assessment will be equivalent to a certification visit for the purpose of evaluation of secondary contacts. At least one secondary contact must be provided during each six-month certification period. For certification periods that exceed six months (prenatal women), secondary contacts must be provided at a quarterly rate (i.e., a prenatal woman who is on the Program for greater than six months would have to receive a minimum of two secondary contacts) but not necessarily within each quarter. Secondary contacts for prenatal women will be assessed when the expected date of confinement (EDC) has
been reached or a delivery date has been recorded.
Individual nutrition education contacts must be documented in the participant's health record.
Documentation of group classes may consist of a participant's signature on a class attendance sheet, voucher
register or class roster which contains the lesson objective(s) and the original signature of the staff person
conducting the class.
The education must be appropriate to the individual participant's health needs.
Nutrition education must be provided by a competent professional authority (CPA). Paraprofessional staff can
provide these contacts when nutrition education training approved by the Office of Nutrition has been
received. The method used must have the approval of the Office of Nutrition.
Missed appointments or refusal of nutrition education must be documented in the health record.
Specific aspects of nutrition counseling must be documented (not "Nutrition education provided").
The nutrition education must follow the Nutrition Guidelines for Practice.

25. Breastfeeding Encouraged [Nutrition Education Section VI.A., B.; Breastfeeding Section, V.A., B.] All pregnant participants must be encouraged to breastfeed unless contraindicated for health reasons. If a pregnant participant is not encouraged to breastfeed based on health reasons or the refusal of the participant to receive nutrition education, the reason(s) must be documented in the participant's health record. It is not acceptable to not encourage a woman to breastfeed based simply on her answering no to whether she plans to breastfeed or is interested in breastfeeding. Documentation must include all aspects of breastfeeding discussed (not, "Breastfeeding encouraged"). The breastfeeding education must follow the Nutrition Guidelines for Practice.

26. High Risk Follow-Up Documented [Certification Section, XIII.10.; Nutrition Education Section, VI. A. 4., 9.] A WIC participant who has any of the risk factors identified in the Procedures Manual must receive an individual care plan. Documentation must indicate nutrition counseling specific to their nutritional condition and problems

107

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PART VI NUTRITION CERTIFICATION, EDUCATION/ BREASTFEEDING SECTION

identified in their diet.

27. Exit Counseling Documented From the prenatal through the postpartum (breastfeeding or non-breastfeeding) period, a woman participant must receive education on the following topics: a. Importance of folic acid intake b. Health risks of using alcohol, tobacco and other drugs c. Continued breastfeeding as the preferred method of infant feeding d. Importance of up-to-date immunizations

28. Breastfeeding Data Collected The questions Ever Breastfed, Currently Breastfeeding, and Weeks Breastfed must be completed as follows: a. Breastfeeding women: initial and six-month certification visit (the weeks breastfed at six months after the initial certification must be more than the weeks breastfed at certification). b. Postpartum, non-breastfeeding women: certification visit. c. Infants: initial certification and mid-certification assessment visits (the weeks breastfed at midcertification must be the same or more than the weeks breastfed at certification). d. Children: one year of age certification (11-16 months of age).

108

GA WIC 2005 PROCEDURES MANUAL PART VII STAFFING PATTERNS

Attachment MO-3

VII. STAFFING PATTERNS

List the number of types of staff located in your District who work with the WIC Program:

Staff

How many

Nutritionist LPN (WIC) Lactation Consultants Administrative Staff Health Techs Clerks Para professions Health Associates Registered Nurse (RN) Lab Technicians Program Assistants Nutrition Assistants Breastfeeding Coordinator WIC Coordinator Others ____________
write in title

___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________

Looking for: The number and types of staff that administers the WIC Program in each District.

MO-109

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Attachment MO-2

STATE OF GEORGIA
Department of Human Resources Division of Public Health
Georgia WIC Branch
LOCAL AGENCY FFY 2005
MONITORING TOOL FINANCIAL REVIEW SECTION

GA WIC 2005 PROCEDURES MANUAL

Attachment MO-2

Department of Human Resources Directives Information System

Index: POL1244 Effective: 10/13/1999 Review: 07/01/2004 Page 1 of 2

SUBJECT: External Entities Audit Standards and Sanctions
POLICY
The policy of the Department of Human Resources is to ensure that those non-federal entities which receive funds from the Department conform to the standards and requirements imposed by federal and state law and by DHR Contracts. Sanctions are imposed on those entities that do not comply with the standards and/or audit requirements.
A. Authority O.C.G.A. 50-20-1 through 50-20-8 as amended, 1998 Legislative Session Single Audit Act Amendments of 1996 (PL 104-156)
B. References OMB Circular A-133 CFR Title 45, Part 74.60 et seq of CFR CFR Title 7, Part 277.17 entitled "Audit Requirements" Standards for Audit of Governmental Organizations, Programs, Activities and Functions
C. Applicability All of the Department of Human Resources
D. Definitions 1. Non-Federal Entity: A state, local government, or a nonprofit organization. 2. Sanctions: Penalties imposed by the Department on those fund recipients who do not abide by their contract requirements for audit reports and fail to comply with state law regarding timeliness. Sanctions may include: reimbursements being withheld,
1

GA WIC 2005 PROCEDURES MANUAL

Attachment MO-2

contracts being canceled, recoupment of funds, and denial of further contracts with the Department for a period of 12 months.

E. Responsibilities The Director of the Department of Human Resources' Office of Audits is responsible for issuing and updating procedures to implement this policy. The procedures are indexed at PRO1244.

F. History Replaces Department of Human Resources Administrative Policy and Procedures Manual, Part V. A. 4., "Auditing/Reporting/Sanctions for Nonprofit Organizations Required by the Governor's Executive Order Dated May 27, 1997," effective July 1, 1997, and Part V. A. 5., "Standards for Audits Purchased by DHR Agencies and Local Entities as Required by the Single Audit Act Amendments of 1996," effective July 1, 1997.
G. Evaluation none
H. Authentication

(signed by Audrey W. Horne) Commissioner

10/13/1999 Date

2

GA WIC 2005 PROCEDURES MANUAL

Attachment MO-2

Department of Human Resources Directives Information System

Index: Revised: Review: Page

PRO1244 07/01/2002 07/01/2004 1 of 6

SUBJECT: External Entities Audit Standards
PROCEDURE Entities that contract with the Department must meet certain financial reporting requirements. These requirements are defined in: the Single Audit Act Amendment of 1996; OMB Circular A-133; Contract Provisions; DHR Policy; and Title 50, Chapter 20, Sections 1 through 8 of the Official Code of Georgia Annotated. The requirements vary according to the dollar amount expended by the entity during its accounting year. The Office of Audits and the DHR Programmatic Division have certain responsibilities that are delineated below. Several words and phrases are used in these procedures that may have meaning that is special to these procedures. These words and phrases are defined below.
The address for the DHR Office of Audits is: DHR Office of Audits Two Peachtree Street, NW Suite 26.425 Atlanta, Georgia 30303-3142
The address for the State Department of Audits is: State Department of Audits and Accounts Professional Practices Division - Suite 214 254 Washington Street SW Atlanta, Georgia 30334-8400
1. Definitions Budget Category: A numbering system used for budget and accounting purposes that corresponds to a specific program name. Numbers reduce chances of confusion with similar program names.
Contractor's Fiscal Year: The 12-month accounting period established by the entity as its business year, which is on file with the U.S. Internal Revenue Service as the basis for filing required tax and Tax Exempt Status Returns.
3

GA WIC 2005 PROCEDURES MANUAL

Attachment MO-2

Entity: An organization receiving funds from DHR exclusive of DHR field offices.
Expense Category: A numbering system corresponding to a list of specific services within a Budget Category, where the amount of funds used to pay for the service are recorded for accounting purposes.
Independent Auditor: - A Certified Public Accountant (CPA); or - A Registered Public Accountant (RPA) licensed on or before December 31, 1970; or - A government Auditor located outside the staff or line management function of the unit under audit
To be independent, the auditor's relationships with the auditee is of such an "arm's length" nature so as to preclude any appearance of bias, or any obligation to or interest in the auditee, its management or its owners. Relationships or combinations of relationships with the auditee must not create any conflict of interest that impairs the auditor's integrity and objectivity with respect to the audit engagement. It is inappropriate in some circumstances for auditors to perform both audit and non-audit services for the same client.
Major Program: A federally funded program determined by the auditor to be a major program in accordance with OMB circular A-133, Section_.520 or a program defined as a major program by a federal agency or pass-through entity in accordance with Section_.215(c).
Nonprofit Organization: Any corporation, trust, association, cooperative, or other organization that is operated primarily for scientific, educational, service, charitable, or similar purposes in the public interest; is not organized primarily for profit; and uses its net proceeds to maintain, improve, or expand its operations.
Program: A grouping of activities and resources to accomplish a mission with specific goals and objectives. Some programs have names, some have numbers, and some have both. Usually programs are budgeted by number for ease of tracking and to reduce potential confusion. Budget categories can and are considered to be programs. Federal programs are considered to be those activities that are or can be assigned a single number in the Catalog of Federal Domestic Assistance (CFDA). When no CFDA number is assigned, all federal awards from the same agency made for the same purpose are to be combined and considered one program. Throughout this procedure, the term "program" refers either to a named activity or an activity that is numbered.

4

GA WIC 2005 PROCEDURES MANUAL

Attachment MO-2

Public Entity: Includes, but is not limited to: state and local governments and their instrumentalities; authorities; county Boards of Health; Community Service Boards; and District Attorneys (judicial circuits) operating Child Support Enforcement programs through contracts with DHR.
Schedule of State Awards Expended: A schedule arranged by state program name and contract number that reflects revenues, expenditures, or expenses and amounts owed to and due from each state organization. Amounts listed for each program should include federal funds that pass through state organizations to the entity.
2. Requirements Prior to Contract Prior to executing a contract between the DHR and a non-profit organization, the organization furnishes a previous year's audit. If the entity has been in existence for less than a year, then they furnish unaudited financial statements. If no audit or unaudited financial statements are on record with DHR, the following procedure is followed: - The contracting division or Office of DHR requests such audit or financial statements as part of its negotiation or solicitation process. - The entity furnishes an audit report (or unaudited financial statements, if appropriate) to the DHR Office of Financial Services, Contract Section, as a part of its contract package. - When it is received, the financial information is forwarded to the Office of Audits for a compliance review. The Division of Mental Health, Mental Retardation, and Substance Abuses' Regional Boards submit requested financial audits and statements directly to the Office of Audits for compliance review. - The Office of Audits reviews the information and determines compliance with O.C.G.A. Section 50-20-1 through 50-20-8, as amended, 1998 Legislative Session. - The Office of Audits notifies the Contracts Section of the Office of Financial Services or the Regional Board of the results of its review. For instances of noncompliance with requirements, the omitted items are specified.
3. Requirements of Contractors The financial reporting requirements vary depending on the amount of state and/or federal funds expended by the entity during its fiscal year.
3.1. Entities expending $500,000 or more in federal funds All entities expending $500,000 or more in federal funds during their fiscal year comply with: the provisions of the Single Audit Act Amendments of 1996 and their implementing regulation - OMB Circular A-133; with contract provisions; and with DHR Policy. Non-profit organizations also comply with the provisions of the O.C.G.A. Annotated, Section 50-20-1 through 50-20-8, as amended, 1998 Legislative Session. Audits of nonprofit organizations also include a "Schedule of State Awards Expended."

5

GA WIC 2005 PROCEDURES MANUAL

Attachment MO-2

These entities obtain a single entity-wide audit of their financial records performed by an independent auditor. The audit covers all financial activities for the fiscal year and is conducted in accordance with Generally Accepted Government Auditing Standards issued by the Comptroller General of the United States.
Audits for public entities include, for those contracts that were completed during the audit period, a "Statement of Revenues and Expenditures Compared to Budget," presented by program name or contract name and number. This statement is presented by contract name and number for the entire contract period. Audits of public entities also include a "Schedule of State Awards Expended."
The entity files two copies of the independent auditor's report with the Director, DHR Office of Audits, within 180 days after the end of the organization's fiscal year. Additionally, private nonprofit organizations submit one copy of the report to the State Department of Audits and Accounts within the same time period. If an extension of the time period is desired, the State Department of Audits (for private nonprofit entities) or the DHR Office of Audits (for public entities) may waive the requirement for completion if a request is made that shows good cause. The waiver is for an additional period of not more than 90 days, and no such waiver is granted for more than two successive years to the same entity. A plan of corrective action for all deficiencies disclosed in the audit report is submitted with the audit report.
3.2. Entities expending $100,000 or more in state funds All entities expending $100,000 or more in state funds during their fiscal year comply with contract provisions and DHR policy. Nonprofit organizations also comply with the provisions of the O.C.G.A. Annotated, Section 50-20-1 through 5020-8, as amended, 1998 Legislative Session. Audits of nonprofit organizations also include a "Schedule of State Awards Expended."
These entities obtain an entity-wide audit of their financial records performed by an independent auditor. The audit is conducted in accordance with Generally Accepted Auditing Standards issued by the American Institute of Certified Public Accountants and the financial statements are prepared in accordance with generally accepted accounting principles. Audits for public entities include, for those contracts that were completed during the audit period, a "Statement of Revenues and Expenditures Compared to Budget," presented by program name or contract name and number. This statement is presented by contract name and number for the entire contract period. Audits of public entities also include a "Schedule of State Awards Expended."
The entity files two copies of the independent auditor's report with the Director, DHR Office of Audits, within 180 days after the end of the organization's fiscal
6

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Attachment MO-2

year. Additionally, private nonprofit organizations submit one copy of the report to the State Department of Audits and Accounts within the same time period. If an extension of the time period is desired, the State Department of Audits (for private nonprofit entities) or the DHR Office of Audits (for public entities) may waive the requirement for completion if a request is made that shows good cause. The waiver is for an additional period of not more than 90 days, and no such waiver is granted for more than two successive years to the same entity. A plan of corrective action for all deficiencies disclosed in the audit report is submitted with the audit report.
3.3. Entities expending between $25,000 and $100,000 in state funds All entities expending at least $25,000 but less than $100,000 in state funds during their fiscal year comply with contract provisions and DHR policy by submitting audited or unaudited financial statements. Nonprofit organizations are also required to comply with the provisions of the O.C.G.A. Annotated, Section 50-20-1through 50-20-8, as amended, 1998 Legislative Session. Audits or financial statements of nonprofit organizations also include a "Schedule of State Awards Expended."
Financial statements that have been audited include the auditor's report on the financial statements. Audits for public entities include, for those contracts that were completed during the audit period, a "Statement of Revenues and Expenditures Compared to Budget," presented by program name or contract name and number. This statement is presented by contract name and number for the entire contract period. Audits or financial statements of public entities also include a "Schedule of State Awards Expended."
Financial statements that have not been audited include a statement from the president or other responsible official of the organization which states that:
- The financial statements are presented in accordance with generally accepted accounting principles and, if not, the basis used for their presentation;
- The financial statements are prepared on a basis consistent with that of the preceding year, and if not, the respects in which they differ from the preceding year;
- The financial statements of public entities include for those contracts that were completed during the audit period, a "Statement of Revenues and Expenditures Compared to Budget," presented by program name or contract name and number. This statement is presented by contract name and number for the entire contract period. The financial statements of public entities also include a "Schedule of State Awards Expended."
The entity files two copies of the audit or financial statements with the Director, DHR Office of Audits, within 180 days after the end of the organization's fiscal year. Additionally, private nonprofit organizations submit one copy of the report to

7

GA WIC 2005 PROCEDURES MANUAL

Attachment MO-2

the State Department of Audits and Accounts within the same time period. If an extension of the time period is desired, the State Department of Audits (for private nonprofit entities) or the DHR Office of Audits (for public entities) may waive the requirement for completion if a request is made that shows good cause. The waiver is for an additional period of not more than 90 days, and no such waiver is granted for more than two successive years to the same entity. A plan of corrective action for all deficiencies disclosed in the audit report is submitted with the audit report.
4. Role of the DHR Office of Audits The DHR office of Audits: - Requests the required audit or financial statements from those entities that have failed to provide them; - Reviews the audit reports for financial settlement amounts, questioned costs, and findings and recommendations; - Communicates the dollar amounts of financial settlements to the DHR Office of Financial Services for settlement; - Requests corrective action plans to preclude recurrence of findings from those entities that have failed to provide them; - Forwards one copy of the audit report or financial statements to the programmatic Division(s) or Office(s); and - Notifies the appropriate DHR programmatic Division(s) or Offices(s) of those entities which have not complied with the filing requirements of this policy as well as the DHR Office of Financial Services that will impose the appropriate sanctions.
5. Role of the Programmatic Division(s) or Office(s) The programmatic Division(s) or Office(s): - Insures that appropriate programmatic corrective actions are implemented when required by an audit report; - Reviews audits for compliance with programmatic performance goals; - Enforces corrective action on repeat findings; and - Approves or disapproves budget and spending variances.
A. History Replaces Department of Human Resources Administrative Policy and Procedures Manual, Part V. A. 4., "Auditing/Reporting/Sanctions for Nonprofit Organizations Required by the Governor's Executive Order Dated May 27, 1997", effective July 1, 1997, and Part V. A. 5., "Standards for Audits Purchased by DHR Agencies and Local Entities as Required by the Single Audit Act Amendments of 1996", effective July 1, 1997.
B. Proponency Office of Audits

8

GA WIC 2005 PROCEDURES MANUAL GEORGIA WIC PROGRAM FINANCIAL REVIEW FORM
GA WIC 2005 PROCEDURES MANUAL

GEORGIA WIC PROGRAM FINANCIAL REVIEW FORM

AREAS OF REVIEW

YES

NO

A. Review of Previous Audit Findings

1. Has an audit been performed recently by an independent accounting firm?

2. Were any findings noted? (If yes, attach a copy of the audit containing the findings.)

B. General Accounting Practices

1. Are accounting records maintained by WIC paid staff or by the district accounting personnel?
2. Does the local agency maintain a separate account for WIC funds?
3. If not, is adequate documentation maintained to identify revenues and disbursements for the WIC Program?

4. Are revenues for the WIC Program deposited in an interest bearing account?

5. Are hard copies of all accounting transactions printed and maintained for reference?

6. Is there a separation of duties for the various accounting tasks?
7. Is the bank reconciliation performed by an employee who is independent of cash disbursements or receipts and general ledger maintenance?

8. Is the signing of checks independent from the approval of invoices?
9. Is the preparation of checks independent from the approval of invoices?
10. Are the receiving duties independent of the purchasing function?

11. Is there a limitation on the dollar amount for checks which only require one signature?

12. Are invoices and supporting documentation examined at the time of signing and marked "paid" to prevent duplication of payment?

13. Are records maintained for the required length

of time? (3years plus current)

WIC Review Form 101 (Revised 07.03)

9

Attachment MO-2 ATTACHMENT MO-2

NA

COMMENTS

GA WIC 2005 PROCEDURES MANUAL GEORGIA WIC PROGRAM FINANCIAL REVIEW FORM

AREAS OF REVIEW

YES

NO

NA

C. OPERATIONAL COST

1. Does the WIC Program pay a share of Administrative position salaries to a District budget through an Intra/Inter Agency Agreement?

2. Are administrative costs based on a logically developed cost allocation plan or methodology which provides fair and equable distribution of applicable costs?

3. Does the District have a Cost Allocation Plan on file that has been approved by DHR within the last two years?

4. Does the District have a contract for WIC eligibility and enrollment processing?

5. What is the contract cost to WIC for computer services for enrollment and eligibility determination?

6. How is WIC's share of the cost determined?

D. EXPENDITURES

1. General Review

A. Are all WIC costs allowable under USDA standards?

B. Are there any incorrect charges?

C. Did any expenditures require prior approval of the State WIC Branch, i e.; 1. Capital expenditure over $5,000; 2. Computer expenditure; 3. Capital improvements
D. If yes, is there documentation of State WIC approval?
E. Do all payments include adequate supporting documentation including: Nature of expenditure Amount Date service was provided Payee Date of Invoice
F. Are unliquidated obligations being posted on MEIR each month?
G. Have any MIERs been revised? Why?
H. If applicable, is Program Income (i.e., interest) properly accounted for?

WIC Review Form 101 (Revised 07.03)

10

Attachment MO-2
COMMENTS

GA WIC 2005 PROCEDURES MANUAL GEORGIA WIC PROGRAM FINANCIAL REVIEW FORM

AREAS OF REVIEW 2. 301 - Cost Pool Budget

YES

NO

NA

A. Are all salary expenses being charged to this budget?

B. Are all Intra/Inter Agency Agreements being charged to this budget?

C. Are copies of all Intra/Inter Agency Agreements on file?

D. Are other expenses being charged to this budget?

E. If yes, are these expenses a direct benefit to multiple programs other than WIC?

3. 643 - Direct WIC Budget

A. Are costs that are a direct benefit to WIC being charged?

B. Are such items as rent, telecom and equipment being charged?

4. 007 - Nutrition Education

A. Are costs that are a direct benefit to WIC NE being charged?

5. 009 - Breastfeeding

A. Are costs that are a direct benefit to WIC Breastfeeding being charged?

B. Is a Breast Pump report being sent to the State WIC Program as required?

6. Self Review

A. Was a financial self review conducted by June 30th?

B. By whom was the review conducted?

C. Was a corrrective action plan required and developed?

Attachment MO-2
COMMENTS

WIC Review Form 101 (Revised 07.03)

11

GA WIC 2005 PROCEDURES MANUAL

Breastfeeding

TABLE OF CONTENTS Page
I. Introduction ................................................................................................................BF-1 II. Definitions....................................................................................................................BF-1 III. State Agency ................................................................................................................BF-2
A. Breastfeeding Coordinator ............................................................................BF-2 B. Breastfeeding Promotion, Education and Support Responsibilities .......BF-2 IV. Local Agency ..............................................................................................................BF-4 A. Breastfeeding Coordinator ............................................................................BF-4 B. Breastfeeding Promotion, Education and Support Responsibilities .......BF-5 C. Training ...........................................................................................................BF-6 D. Breastfeeding Promotion, Education and Support Plan ..........................BF-7 V. Participant Education ................................................................................................BF-8 A. Participant Education Requirements ..........................................................BF-8 B. Documentation of Breastfeeding Services ................................................BF-10 VI. Participant Referral ..................................................................................................BF-11 A. Referrals .........................................................................................................BF-11 B. Documentation .............................................................................................BF-11 VII. Breastfeeding Materials and Resources ................................................................BF-12 A. Printed and Audio-Visual Materials ........................................................BF-12 B. Breastfeeding Equipment and Supplies ...................................................BF-12

GA WIC 2005 PROCEDURES MANUAL

Breastfeeding

Page VIII. Allowable Costs for the Promotion and Support of Breastfeeding ...................BF-14
A. Minimum Expenditure Requirement.........................................................BF-14 B. Allowable Breastfeeding Promotion and Support Costs ........................BF-15 C. Documentation of Costs...............................................................................BF-16 IX. Documentation of Breastfeeding Rates..................................................................BF-17 A. Documentation of WIC Type ......................................................................BF-17 B. Documentation of Weeks Breastfed ...........................................................BF-18 Attachments BF-1 Position Paper on Breastfeeding .............................................................................BF-19 BF-2 Sample Job Description: Senior Public Health Educator - Lactation Consultant........................................BF-21 BF-3 Georgia Gain Proposed Job Description: Breastfeeding Coordinator...............BF-23 BF-4 Guidelines for Breastfeeding Promotion and Support in the WIC Program..................................................................................................BF-26 BF-5 Breastfeeding Resources Recommended by the Nutrition Section ...................BF-38 BF-6 Allowable and Unallowable Costs for the Promotion and Support of Breastfeeding.........................................................................................................BF-41 BF-7 Issues to Consider When Providing Breast Pumps .............................................BF-42 BF-8 Status Change from Prenatal to Breastfeeding and Assignment of Priority to Breastfeeding Mother and Infant.........................................................BF-45 BF-9 Key for Entering Weeks Breastfed..........................................................................BF-48

GA WIC 2005 PROCEDURES MANUAL

Breastfeeding

I. INTRODUCTION
This section of the Procedures Manual defines the concept of breastfeeding promotion, education and support; and explains the requirements for providing lactation services to WIC Program participants.
Health professionals recognize that, in almost all circumstances, breastfeeding is the optimal method for ensuring proper infant nutrition, while simultaneously benefiting the lactating mother. The advantages of breastfeeding range from biochemical, immunological, and endocrinologic to psychosocial, developmental, sanitary, and economic. Human milk contains the ideal balance of nutrients, enzymes, immunoglobulins, anti-infective agents, anti-allergic substances, hormones, and growth factors. Further, breastmilk changes to match the changing needs of the infant. Breastfeeding provides a time of intense maternal-infant interaction. Lactation also facilitates the physiologic return to the pre-pregnant state for the mother. 1
Public Health staff have a responsibility to provide services designed to optimize the health of their clients. Through the WIC Program they have a unique opportunity to influence decisions on infant feeding. As stated in the Division of Public Health Position Paper on Breastfeeding (Attachment BF-1) a sound program of information and support is necessary to promote the successful establishment and maintenance of breastfeeding. Such a program should be integrated into the health care system and should encompass both the prenatal and postpartum periods.

II. DEFINITIONS
Breastfeeding promotion, education and support are components of a process through which individuals gain the understanding, skills and motivation necessary to be able to select breastfeeding as the preferred method of feeding, as well as to initiate and maintain breastfeeding for a significant period of time.
Federal Regulations define a woman as breastfeeding if she either feeds breastmilk to her infant(s), on the average, at least once every 24 hours; or expresses breastmilk with the intention to breastfeed, on the average, at least once every 24 hours.

1 Healthy People 2000: National Health Promotion and Disease Prevention Objectives, U.S. Department of Health and Human Services, 1990.
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Re-lactation/induced lactation after a period of not breastfeeding, or by a woman who is not the biological mother of the infant, also qualifies the woman as breastfeeding.

III. STATE AGENCY
A. Breastfeeding Coordinator
The responsibility for coordination of statewide WIC breastfeeding activities is vested within the Georgia Department of Human Resources, Division of Public Health, Family Health Branch, Nutrition Section.
A qualified nutritionist (Master's degree and Registered Dietitian, or eligible for registration) is designated as the State Breastfeeding Coordinator. The responsibilities of this person are to plan, direct and coordinate the breastfeeding promotion, education and support component of the WIC Program.
B. Breastfeeding Promotion, Education and Support Responsibilities
The following are the State Agency responsibilities for breastfeeding promotion, education and support:
1. Develop, implement and evaluate the State breastfeeding promotion, education and support plan. Periodically review and evaluate the plan, and make appropriate revisions as necessary.
2. Develop guidelines for local agency breastfeeding promotion, education and support plan development. Review each plan and provide feedback.
3. Monitor the progress of local agency breastfeeding promotion, education and support plans on a periodic basis through on-site visits and reports.
4. Evaluate breastfeeding promotion, education and support services of all local agencies.
5. Develop and implement a plan for providing training and technical assistance for Competent Professional Authorities (CPAs), paraprofessional staff, and clerical staff at local clinics.

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Training and technical assistance provide CPAs with current information on the management of normal breastfeeding issues and special problems in lactation. It provides all staff with an understanding of the importance of promoting, and ways to promote, breastfeeding in a clinic setting.
6. Identify and develop resource and education materials for use by local agencies. Provide materials in languages other than English in areas where a substantial proportion of the population needs the information in a language other than English, considering the size and concentration of such population and, where possible, the reading level of the participants.
7. Coordinate WIC breastfeeding promotion, education and support activities with related programs and professional groups such as hospitals, private medical organizations, the Cooperative Extension Service, professional organizations, advisory committees, La Leche League, and other breastfeeding support and advocacy groups, private lactation consultants, etc.
8. Develop and implement procedures to assure that encouragement to breastfeed is offered to all prenatal participants, unless medically contraindicated.
9. Perform and document evaluation of breastfeeding promotion, education and support activities for each local agency on an annual basis. The evaluations shall include an assessment of the participant's views concerning the effectiveness of the education they received.
10. Establish standards for participant contact that ensure adequate breastfeeding education.
11. Monitor local agency activities to ensure compliance with defined local agency responsibilities and participant breastfeeding education contacts.
12. Establish breastfeeding promotion, education and support standards that include, at a minimum, the following:
a. A policy that creates a positive clinic environment which endorses breastfeeding as the preferred method of infant feeding.

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b. A requirement that each local agency designate a staff person to coordinate the breastfeeding promotion and support activities.
c. A requirement that each local agency incorporate taskappropriate breastfeeding promotion and support training into orientation programs for new staff involved in direct contact with WIC clients.
d. A plan to ensure that women have access to breastfeeding promotion, education, and support activities during the prenatal and postpartum periods.
IV. LOCAL AGENCY
A. Breastfeeding Coordinator
1. Each local agency must designate a staff person to coordinate breastfeeding promotion, education and support activities. The breastfeeding coordinator position may be a qualified nutritionist, nurse, health educator or certified lactation consultant. Attachment BF-2 lists a job description for Health Educator Senior, which may be used to assure an individual is qualified to fill this position. A Georgia Gain job classification, entitled Breastfeeding Coordinator, specific to nutritionists can be found in Attachment BF-3.
2. It is recommended that this position be designated as a full-time position in order to facilitate coordinating services throughout the local agency and across program lines and to adequately meet Federal requirements.
3. It is recommended that the breastfeeding coordinator be, or work towards becoming, a certified lactation consultant. At a minimum, the breastfeeding coordinator should complete the Lactation Specialist Self Study Series, which has been provided to each local agency by the Nutrition Section.
4. It is recommended that the breastfeeding coordinator work across program lines to provide breastfeeding services, thus increasing opportunities for all current and potential WIC
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participants to be reached. This will also serve to integrate services, and assure that all clinic staff receive appropriate training and deliver consistent information on breastfeeding.
B. Breastfeeding Promotion, Education and Support Responsibilities
The Georgia WIC Program is committed to the implementation of the Guidelines for Breastfeeding Promotion and Support in the WIC Program, developed by the National WIC Association (NWA) Breastfeeding Promotion Committee (Attachment BF-4). The local agencies are encouraged to use the Guidelines in carrying out the following breastfeeding responsibilities:
1. Establish and maintain a positive clinic environment that clearly endorses and supports breastfeeding as the preferred method of infant feeding (NWA Guidelines #2, #4).
a. It is important to assure that relevant education materials available to participants portray breastfeeding as the preferred infant feeding method. The following items must be free of formula product names: print and audiovisual materials; and office supplies such as cups, pens and note-pads.
b. Staff should be careful not to communicate overt or subtle endorsements of formula. Such messages may influence a mother's decision about infant feeding or her breastfeeding pattern. Once a mother initiates infant feeding, staff should support her decision, and provide appropriate information.
c. The local agency must minimize the visibility of formula and bottle-feeding equipment through storing supplies of formula, baby bottles and nipples out of view of participants.
d. Staff must not accept formula from formula manufacturer representatives for personal use.
e. Staff should make every effort to provide a supportive environment in which women feel comfortable breastfeeding their infants. The clinic waiting area can be used advantageously to motivate women to recognize

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breastfeeding as the "norm" rather than the exception. The clinic area can also be used to provide worksite support for staff who are breastfeeding.
2. Incorporate task-appropriate breastfeeding promotion and support training into orientation programs for new staff involved in direct contact with WIC participants (NWA Guideline #1).
3. Develop a plan to ensure that women have access to breastfeeding promotion and support activities during the prenatal and postpartum periods (NWA Guidelines #3, #5-9).
4. Submit, on an annual basis, a local agency plan of activities (See IV. D., below).
C. Training
1. Orientation
All staff that interact with WIC applicants and participants must receive basic information on breastfeeding, during their orientation to the WIC Program.
a. Clerical and other non-CPA staff must receive training on maintaining a positive clinic environment, a positive and supportive attitude towards breastfeeding, and what they can do to promote and support breastfeeding in the clinic.
b. CPA's must receive, in addition to the above information, training on basic skills in getting women started with breastfeeding, assessment, problem solving, and follow-up and referrals.
2. Continuing Education
a. All staff are encouraged to attend local, State or National workshops for the purpose of developing and updating skills and knowledge in lactation management.
b. All breastfeeding training and continuing education activities conducted or attended by local staff must be recorded and kept on file by the local agency. The file should include the names and titles of the workshop participants, and the titles and dates of the workshops

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(see Attachments NE-2 and NE-3 for recommended forms).
D. Breastfeeding Promotion, Education and Support Plan
1. Annual Plan of Activities
The State Agency develops an annual Breastfeeding Promotion, Education and Support Plan which incorporates both Federal Regulations and objectives/activities requested by the local agencies. In order to integrate efforts being conducted at both the State and the local levels, local agencies shall submit to the State, a Plan of Activities based on the State Plan objectives, and recommendations for additions or changes to the State Plan. A Breastfeeding Promotion, Education and Support Plan must be submitted to the WIC Branch by April 15, 2005. This Plan should be incorporated in the local agency strategic plan for WIC and nutrition services.
a. The local agency Breastfeeding Plan must include:
1) The local agency GOAL for breastfeeding promotion, education and support;
2) OBJECTIVES to reach the stated goal; 3) STRATEGIES under each objective; 4) ACTION STEPS for each strategy; 5) PERSON RESPONSIBLE for each action step; 6) TIME FRAME for each action step; 7) RESOURCES NEEDED to accomplish each action step; 8) STATUS of each action step (this should be completed as
each action step is accomplished).
b. The local agency Plan must address, at a minimum, the Federal requirements:
1. establishing and maintaining a local agency breastfeeding coordinator position;
2. prenatal encouragement to breastfeed; 3. establishing a positive clinic atmosphere; 4. incorporating breastfeeding training into staff
orientation;

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5. ensuring that women have access to breastfeeding promotion and support during the prenatal and postpartum periods.
2. Breastfeeding Plan Report
The Breastfeeding Plan Report must be submitted to the Nutrition Section three (3) times a year in conjunction with the Nutrition Education Plan Report.
V. PARTICIPANT EDUCATION
A. Participant Education Requirements
1. The Nutrition Guidelines for Practice are the established guide for breastfeeding education. Nutrition Guidelines for Practice manuals are located in each health department and with each local agency nutrition coordinator.
2. All pregnant participants must be encouraged to breastfeed unless contraindicated for health reasons. As recommended in the Nutrition Guidelines for Practice, encouragement to breastfeed should continue throughout the prenatal period.
As stated in the Healthy People 2000 National Health Promotion and Disease Prevention objectives for breastfeeding, breastfeeding is not appropriate for infants whose mothers use drugs illicitly, or who receive certain therapeutic or diagnostic agents such as radioactive elements and cancer chemotherapy.2 Women who are HIV positive, according to the Centers for Disease Control and Prevention guidelines, should also avoid breastfeeding.
3. As part of the prenatal breastfeeding education, the following information must be offered on WIC benefits for breastfeeding women:
a. Breastfeeding women are at a higher level in the priority system than non-breastfeeding postpartum women, and

2 Healthy People 2000: National Health Promotion and Disease Prevention Objectives, U.S. Department of Health and Human Services, 1990.

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are more likely to be served than these women when local agencies do not have the resources to serve all qualified individuals.
b. Breastfeeding women may receive WIC benefits for up to one (1) year postpartum, while non-breastfeeding women are eligible for only six (6) months postpartum.
c. The WIC Program offers a greater variety and quantity of food to breastfeeding participants than to nonbreastfeeding, postpartum participants.
4. Breastfeeding women should be taught hand expression of breastmilk. All CPA's, breastfeeding counselors and nutrition assistants should be trained to teach hand expression of breastmilk. However, if a staff person is not skilled in this area, a referral should be made to trained staff or the local agency breastfeeding coordinator.
5. Breastfeeding women must be taught signs of adequate intake by the breastfed infant. Signs of adequate intake are:
1. baby is nursing 8-12 times per 24 hours 2. baby wets diaper at least six (6) or more times per 24
hours 3. baby has three (3) or more stools per 24 hours, in first
month 4. baby has visible and audible signs of swallowing 5. mother's breasts feel softer after feeding 6. baby has adequate weight gain over time (for infants who
are presented for weight checks).
6. It is recommended that adequate intake be assessed during the diet assessment, and documented on the diet assessment form. See Certification Section, Dietary Assessment attachment.
7. Breastfeeding education contacts must be provided by a nutritionist, registered dietitian, registered nurse, licensed practical nurse, physician, physician's assistant; or other certified health professional, peer counselor or nutrition assistant that has been trained by the State or local agency.
8. Local agencies are encouraged to use peer counselors trained by

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the State or local agency to provide encouragement, education, and support to prenatal and breastfeeding women.
9. Nutrition assistants can also provide breastfeeding education and support when appropriate training has been received. The Nutrition Section must approve the training plan. See Attachment NE-3 for the Guidelines for Nutrition Assistant Training and list of items to be submitted for approval.
10. An individual care plan should be developed for a participant based on the need, as determined by the competent professional authority. The Care Plan should be written in the progress notes, preferably using the SOAP (Subjective - Objective - Assessment Plan) note format.
11. Lesson plans must be developed when group classes are used to provide the breastfeeding education contact. Lesson plans must be kept at the clinic site for use by clinic staff, and provided to the Nutrition Section at the time of program reviews.
12. If the participant/caregiver is unable to receive services at the clinic for an extended period of time, home visits are the recommended method for providing breastfeeding education contacts.
13. Local agencies are also encouraged to provide ongoing lactation support for prenatal and breastfeeding women by telephone. If possible, a breastfeeding hot line should be established to facilitate access to information and support services.
B. Documentation of Breastfeeding Services
1. All breastfeeding education and support contacts received by participants must be documented in the participant's health record.
a. In order to facilitate continuity of care, documentation of encouragement to breastfeed should include all aspects of breastfeeding discussed with the participant (e.g., barriers to breastfeeding, emotional/nutritional advantages, positioning).
b. The POMR (Problem Oriented Medical Record)/SOAP

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note format is the recommended method of documentation. A flow sheet may be used as long as it contains all components of a SOAP note.
c. Group breastfeeding education contacts may be documented with the participant's signature on a class attendance sheet or voucher register. There must also be a class description with date, lesson objective(s) and original signature of the staff person conducting the class.
2. Missed appointments for breastfeeding education contacts and the refusal of a participant/caregiver to receive breastfeeding education must be documented in the participant's health record. Documenting missed appointments and refusal to receive education are important for the purpose of monitoring and further education efforts.

VI. PARTICIPANT REFERRAL
A. Referrals
1. Prenatal or breastfeeding participants needing additional breastfeeding information, assistance or support should be referred to the appropriate person(s) designated through the local agency breastfeeding program.
2. Local agencies are encouraged to identify and develop a list of breastfeeding resources for prenatal and breastfeeding women. This list may include hospital staff, physicians, local support groups (both informal and organized, such as La Leche League), public health staff with expertise in handling breastfeeding questions, sources for breastfeeding pumps, peer counselors, etc.
B. Documentation
Referrals to and enrollment in other health services and programs must be documented in the participant's health record. A decision not to refer or a refusal by the participant must also be documented.

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VII. BREASTFEEDING MATERIALS AND RESOURCES
A. Printed and Audio-Visual Materials
Standards for the development and use of printed and audio-visual breastfeeding materials are the same as those used for Nutrition Education materials (See VIII. in the Nutrition Education Section for information). In addition:
a. It is important to assure that relevant educational materials available to participants portray breastfeeding as the preferred infant feeding method.
b. The following items must be free of formula product names: print and audiovisual materials, and office supplies such as cups, pens and note-pads. Staff should be careful not to communicate overt or subtle endorsements of formula. Such messages may influence a mother's decision about infant feeding or her breastfeeding pattern.
c. The local agency must minimize the visibility of formula and bottle-feeding equipment through storing supplies of formula, baby bottles and nipples out of view of participants.
Attachment BF-5 provides a list of resources that are recommended for use by the Nutrition Section.
B. Breastfeeding Equipment and Supplies
1. Allowable Costs
Local agencies are encouraged to assess the need for breastfeeding equipment and supplies. Providing equipment and supplies should not generally be the primary means by which the State and local agencies meet their breastfeeding promotion and support target expenditures. Breastfeeding aids should be used in conjunction with appropriate counseling, education, and follow-up provided by trained staff.
Breast pumps and other breastfeeding aids may not be provided
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to all pregnant or breastfeeding women solely as an inducement to consider or to continue breastfeeding.
The policy on allowable costs for the promotion and support of breastfeeding is explained in VIII. below, and in the Administrative Responsibilities section of the Procedures Manual. Attachment BF-6 provides a list of allowable and unallowable costs, as specified in the Federal Regulations.
2. Breast Pumps
Local agencies are encouraged to have a supply of manually operated and electric pumps on hand for situations that merit their use. It is neither necessary nor desirable to give breast pumps to every breastfeeding or potential breastfeeding mother. Some situations in which availability of a breast pump may be necessary to assure continuation of milk production are:
a. Mothers who have temporary breastfeeding problems, such as engorgement. These are situations in which hand expression or a manual pump may be all that is needed.
b. Mothers who are having difficulty in establishing or maintaining an adequate milk supply due to maternal illness or a premature/sick infant.
c. Mothers with inverted/flat nipples who are having latchon problems.
d. Mothers attempting to build their milk supply for any reason.
e. Mothers choosing to express breastmilk for missed feedings due to work, school or maternal hospitalization, or if temporary weaning is necessary.
Breast pumps are not a direct program benefit that State agencies are required to provide but rather are aids that may be offered to certain WIC participants to facilitate breastfeeding. The pumps may be offered free or at cost to WIC participants. Issues to consider when providing breast pumps are explained in Attachment BF-7.

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3. Instructions for Breast Pump Use
Local agencies with breast pump loan and give-away programs must establish written policy and procedures regarding appropriate use, and instructions to be provided to breast pump recipients. The following must be included in the policy and procedures:
a. A trained, designated staff person is to provide instructions to the breastpump recipient on the proper use, assembly and cleaning of the breast pump.
b. The participant receiving the breast pump should be able to demonstrate the proper usage of the breast pump before leaving the issuing facility.
c. Follow-up within a 24-hour period is recommended, to assure that the pump is operating correctly and that the mother is using it properly.
4. Equipment and Supplies Inventory
Local agencies should maintain an inventory of all breastfeeding equipment and supplies. It is recommended that the inventory be updated on a quarterly basis. An inventory of breast pumps and attachment kits must be submitted to the Nutrition Section by October 31st and March 31st of every year.

VIII. ALLOWABLE COSTS FOR THE PROMOTION AND SUPPORT OF BREASTFEEDING
A. Minimum Expenditure Requirement
The State Agency's Breastfeeding Promotion and Support (BFPS) minimum expenditure requirement is equal to $21 (starting in FFY '91), adjusted for inflation as of October 1st of every year, multiplied by the average number of pregnant and breastfeeding women participating in the program in the months of July through September of the previous federal fiscal year.

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B. Allowable Breastfeeding Promotion and Support Costs
State WIC Program expenditures that are classified and reported as breastfeeding promotion and support, and may count toward the BFPS spending requirement include, but are not limited to, the following:
Salaries:
1. Salary and other costs for time, including preparation and travel time, spent on BFPS training and consultations, both individual and group.
2. Salary and other costs, for staff to organize volunteers and community groups to support breastfeeding WIC participants.
3. Salary and benefit expenses of peer counselors and individuals hired to undertake home visits and other actions intended to assist women to continue breastfeeding.
4. Salary and other costs incurred in developing the BFPS portion of the State Plan and local agencies' BFPS action plans.
5. Interpreter or translator services to facilitate breastfeeding promotion and support.
Training:
6. Costs of training BFPS educators, including costs related to conducting training sessions and purchasing and producing training materials.
Space and Facilities:
7. Costs of clinic space devoted to BFPS education and training activities, including space set aside for breastfeeding WIC infants.
Materials and Equipment:
8. Costs of procuring and producing BFPS materials and equipment.
9. Breastfeeding aids which directly support the initiation and continuation of breastfeeding. See Attachment BF-6 for a list of

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allowable and unallowable breastfeeding aids.
Monitoring and Evaluation:
10. Costs of documenting, monitoring, and/or evaluating BFPS staff, activities, methods and materials. This includes the cost of collecting, analyzing and evaluating data concerning WIC participants' opinions on the effectiveness of the BFPS they received and the incidence and duration of breastfeeding for WIC participants, to assess the effectiveness of breastfeeding promotion, education and support efforts.
Travel:
11. Travel and related expenses incurred by WIC staff to conduct any BFPS activity.
Other Sources:
12. Costs of reimbursable agreements with other organizations, public or private, to undertake training and direct service delivery to WIC participants concerning breastfeeding promotion and support.
C. Documentation of Costs
The State and local agencies must document all Federal WIC grant funds expended to meet the minimum BFPS requirement. Documentation is necessary so that the WIC State Agency can clearly demonstrate the expenditure requirement has been satisfied. Salary costs identified and reported as being for BFPS activities must be supported with employee payroll and time distribution records. Costs such as equipment purchases and travel must be supported with accounting records, including source documents such as invoices and travel statements.

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IX. DOCUMENTATION OF BREASTFEEDING RATES
The Georgia WIC Program documents breastfeeding rates by two different methods: percentage of women who are certified as breastfeeding (WIC Type B), and selfreported information on weeks breastfeed (initiation). It is important that documentation be accurate in both instances since they have a major impact on administration of the WIC Program. These two methods are described below:
A. Documentation of WIC Type
The State agency must have breastfeeding promotion and support expenditures which are based on the number of prenatal (WIC Type P) and breastfeeding women (WIC Type B) on the WIC Program. In addition, the Southeast Regional Office of USDA monitors changes in breastfeeding rates based on the number of women who are listed as breastfeeding (Type B on the WIC System). Breastfeeding women should be entered into the system in the following ways:
1. Status Change from Prenatal (P) to Breastfeeding (B) During Subsequent Certification: A prenatal woman gives birth and is being certified as breastfeeding, within six weeks postpartum.
2. Status Change from Prenatal (P) to Breastfeeding (B) Without a Subsequent Certification: When a prenatal participant delivers her infant(s) and initiates breastfeeding, the local agency is encouraged to change the participant's status from that of Prenatal (P) to Breastfeeding (B) through an Update to the system. This should occur as soon as the local agency is made aware of the participant's change in status, as it will enable the program to capture those women who initiate breastfeeding, but may discontinue breastfeeding by their subsequent certification. A subsequent certification is not required in order to simply change the participant's status from P to B, as long as she is less than six (6) weeks postpartum.
Note: This action does not exclude the participant from the required postpartum subsequent certification. See Attachment BF-8 for instructions on making the status change.
3. Assignment of Breastfeeding Status During Certification: A woman was not on the program while she was pregnant but is being certified as a breastfeeding woman.

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Note: A woman and her infant can be certified as breastfeeding as long as the definition of breastfeeding is met, i.e., the infant is offered breastmilk, on the average, once a day (See II.).
B. Documentation of Weeks Breastfed
The State agency uses this information to monitor changes in breastfeeding initiation and duration rates by State, local agency and individual clinic sites. This information is very useful in program planning and targeting of resources. The Infant Breastfeeding Characteristics Report, which includes this information, is sent to the local agencies on a monthly basis.
It is critical that all staff who complete the WIC Assessment/Certification Forms and the Turnaround Documents be instructed on the importance of, and the process for, accurate documentation of weeks breastfed.
It is a requirement that the weeks breastfed be completed on the WIC Assessment/Certification Form and the Turnaround Document for:
1. Breastfeeding women: initial and six-month certification visits
2. Postpartum, non-breastfeeding women: certification visit
3. Infants: initial certification and mid-certification assessment visits
4. Children: one year of age subsequent certification visit (11 - 16 months of age), if they participated as infants at initial certification (any age), if they did not participate as infants
Participants/caregivers should be asked about weeks breastfed, using the following, or similar words: "How long have you breastfed this baby/child?" or "How long has this baby/child been breastfed?" The length of time breastfed must be entered in weeks. When the answer to the question is given in days or months, this information must be converted to weeks. See Attachment BF-9 for appropriate codes to use for weeks breastfed.

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Attachment BF-1

POSITION PAPER ON BREASTFEEDING
If the children of Georgia are to be healthy and strong, it is essential that they receive the best possible nutrition when they are infants. Breast milk is the ideal first food for the human infant. In addition to the nutritional benefits for the infant, this method of feeding offers unique physiological and psychological advantages to both the mother and the infant. Every infant, therefore, should receive the benefits of this ideal choice for infant feeding. This paper presents the recommendations of the State of Georgia for encouraging breastfeeding and defines the advantages of breastfeeding for the health of mothers and infants.
No formula, no matter how "humanized", can take the place of human milk. Decreased infant mortality and optimum infant health are the most important goals of the Division of Public Health. Breastfeeding can contribute significantly to the achievement of these goals because:
breast milk provides an ideal balance of nutrients for the human infant. the nutrients in breast milk are easily absorbed and digested. breast milk contains immune factors and anti-infective properties that protect against
infections. breastfeeding allows the satiety mechanism in the infant to develop naturally. infants who are breastfed have fewer allergies. breastfeeding permits increased bonding between mother and infant. breast milk is safe, sanitary food.
A sound program of information and support is necessary to promote the successful establishment and maintenance of breastfeeding. Such a program should be integrated into the health care system and should encompass both the prenatal and postpartum periods. Based on the World Health Organization/United Nations International Children's Fund (WHO/UNICEF) 1979 meeting on Infant and Young Child Feeding, the WHO 1981 Resolution and the recommendation of the American Academy of Pediatrics Committee on Nutrition, the Georgia Department of Human Resources recommends that:
breast milk be the "house formula" in all hospitals in Georgia where maternity services are offered
all expectant parents be informed of the numerous advantages (both to infant and mother) of breastfeeding.
every expectant mother receive practical information on how to initiate and maintain lactation.
obstetrical procedures and practices be consistent with the policy of promoting breastfeeding.
breastfeeding be initiated as soon as possible, preferably during the first hour after birth. every hospital permit and encourage rooming-in and on-demand feeding of breastfed
infants. infant formulas not be marketed or distributed in ways that may interfere with the
protection and promotion of breastfeeding. places of business, including government offices, facilitate the maintenance of lactation
through liberalized policies that would promote breastfeeding.

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Attachment BF-1

All the available knowledge indicates that breastfeeding is the best choice for infant feeding and should be promoted for mothers and infants of the State. Breast milk as this choice for infant nutrition will promote optimum health for future generations of Georgians.

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Attachment BF-2

SAMPLE JOB DESCRIPTION SENIOR PUBLIC HEALTH EDUCATOR - LACTATION CONSULTANT

The examples of work given are illustrative of the duties assigned to positions of this class. No attempt is made to be exhaustive. The intent of the listed examples is to give a general indication of the levels of difficulty and responsibility common to all positions of this class.

The standards for training and experience express the minimum background necessary as evidence of an applicant's ability to qualify for positions of this class. Unless otherwise stated, the Applicant Services division may allow substitution of appropriate education or experience for the training and experience minimum listed.

DEFINITION

Under direction, performs work of moderate difficulty in planning and implementing breastfeeding education activities related to public health programs; and performs related work as required.

EXAMPLES OF DUTIES

I.

Coordinates breastfeeding promotion project. Writes, revises, and evaluates the district's

breastfeeding services.

A. Establishes relationships with community health centers and/or hospital staff to provide breastfeeding services.

B. Provides in-service education material and/or needed equipment on breastfeeding for staff development.

C. Responsible for keeping daily communication sheets regarding telephone calls, correspondence, patients seen, meetings, and work related to breastfeeding funds.

II. Promotes breastfeeding services as an integral part of perinatal care.

A. Encourages all prenatal women, on their initial visit, to breastfeed by providing an array of educational material and counseling.

B. Provides additional breastfeeding counseling to prospective breastfeeding women during the last trimester through breastfeeding classes and/or individual counseling.

C. Provides postpartum assessment of breastfeeding dyad, education, and assistance in resolving problems upon request. Provides adequate documentation of services and makes appropriate referrals for continuity of care.

D. Develops and implements continuing education and support networks through a variety of methods, such as support groups, peer counselors, etc.

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Attachment BF-2

E. Supervises and trains peer counselors. F. Has ability to communicate effectively in writing, including grant proposals.

III. Evaluates effectiveness of breastfeeding program activities.
A. Produces reports to determine breastfeeding rate and duration.
B. Assists WIC Nutrition Coordinator in writing the breastfeeding promotion plan and annual update of breastfeeding activities.
C. Shares reports at local district meetings and Statewide breastfeeding conferences.

IV. Attends in-service education programs and annual Statewide breastfeeding conferences.

V. Other miscellaneous duties, activities and responsibilities as program needs develop and change, and as assigned.
MINIMUM QUALIFICATIONS: NECESSARY KNOWLEDGE, SKILLS, AND ABILITIES
Considerable ability to assess the effectiveness and needs of a lactation education program and to plan and implement appropriate changes and improvement; and to assess and counsel an individual.
Considerable skill in the organization and preparation of lactation literature and visual aids; in making oral presentations of instructional programs to the general public and to other health specialists.
Good knowledge of educational program development and implementation as related to the preparation of health education displays, lectures, written material, and classroom programs; of data collection and evaluation techniques appropriate to the assessment of the breastfeeding program.
Good working skills in communicating effectively with the professional staff, general public and para-professionals; in use of educational literature and visual aids; in making oral presentations of instructional programs; in making recommendations for equipment needs; and in ability to budget.
TRAINING AND EXPERIENCE
Completion of a masters degree in public health education, education, nursing, home economics or a field directly related to public health activities. Has successfully completed the State certification or equivalent.

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Attachment BF-3

GEORGIA GAIN PROPOSED JOB DESCRIPTION
JOB CODE: E0707% JOB TITLE: BREASTFEEDING COORDINATOR
GENERAL SUMMARY Under general supervision, plans, develops, implements and evaluates strategies for promoting and supporting breastfeeding among the high risk, low income population, especially prenatal/breastfeeding women and infants.
RESPONSIBILITIES AND STANDARDS
Responsibility Number 1 (All) Develops long and short-term goals for breastfeeding promotion and supports activities for the district.
STANDARDS:
1. Works closely with the supervisor to develop an appropriate District Breastfeeding Promotion and Support Plan.
2. Coordinates breastfeeding services among all clinic sites to ensure efficiency of services provided.
3. Accurately interprets federal/state regulations to ensure adherence to these.
4. Makes sound and defensible recommendations to the supervisor regarding the breastfeeding budget.
5. Develops continuing education, support networks for mothers and networks for professionals in breastfeeding promotion and support.
Responsibility Number 2 (Some) Implements breastfeeding promotion and support plans, to include staff development, community networks and services to clients.
STANDARDS:
1. Provides in-service education, materials and/or needed equipment for staff development in a timely manner.
2. Establishes a good working relationship with community health centers and/or hospital staff to assure continuity of breastfeeding services to clients.
3. Serves as the District's primary resource person regarding breastfeeding education and support by providing prompt responses to inquiries.

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4. Provides direct services to clients through prenatal classes, individual instruction, referral for appropriate case, telephone consultations according to established laws and guidelines.
5. Coordinates pump loan program to ensure maximum usage of available pumps and instructs both staff and clients on use of breast pumps as needed.
6. Serves as primary resource person to health department staff regarding current recommendations and information in breastfeeding management.
Responsibility Number 3 (All)
Works closely with the supervisor to evaluate the effectiveness of breastfeeding program activities.
STANDARDS:
1. Monitors reports to accurately determine breastfeeding rates by county, district, and state.
2. Writes the annual progress report on the breastfeeding promotion and support plan by providing appropriate input in a timely manner.
3. Maintains necessary reports and data for the purpose of documenting incidence and duration of breastfeeding, client-centered activities, activities conducted with other agencies, community groups and local hospitals, and training conducted.
Responsibility Number 4 (All) Creates and maintains a high performance environment characterized by positive leadership and a strong team orientation.
STANDARDS:
1. Defines goals and/or required results at beginning of performance period and gains acceptance of ideas by creating a shared vision.
2. Communicates regularly with staff on progress toward defined goals and/or required results, providing specific feedback and initiating corrective action when defined goals and/or results are met.
3. Confers regularly with staff to review employee relations climate, specific problem areas and actions necessary for improvement.
4. Evaluates employees at scheduled intervals, obtains and considers all relevant information in evaluations and supports staff by giving praise and constructive criticism.
5. Recognizes contributions and celebrates accomplishments.
6. Motivates staff to improve quantity and quality of work performed and provides training

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and development opportunities as appropriate.

Responsibility Number 5 (All)
Maintains responsibility for personal professional continuing education to enable application of current practice.

STANDARDS:

1. Participates in professional workshops, seminars, staff meetings and other in-services as scheduled. Summarizes relevant information received in training sessions; shares with other staff either in verbal or written form.

2.

Remains knowledgeable and up-to-date in the field of nutrition through reading nutrition and

medical journals and textbooks.

3.

Maintains CPR certification and proficiency by renewing certification bi-annually.

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POSITION PAPER NATIONAL WIC ASSOCIATION
April 1994
Guidelines for Breastfeeding Promotion and Support in the WIC Program
These guidelines were developed to assist local and state WIC agencies initiate and strengthen breastfeeding promotion and support programs. The guidelines address training, clinic environment, coordinated efforts, program evaluation, breastfeeding education and support, and the food packages for breastfed infants and breastfeeding women. The guidelines are numbered for easy reference and are listed in random order. Therefore, the numbering system does not reflect rank order or priority.
GUIDELINE #1 Breastfeeding promotion and support are enhanced when local agency WIC staff receive orientation and task-appropriate training on breastfeeding as the preferred method of infant feeding.
GUIDELINE #2 Breastfeeding promotion and support are enhanced when policies encourage a positive clinic environment and endorse breastfeeding as the preferred method of infant feeding.
GUIDELINE #3 Breastfeeding promotion and support are enhanced when WIC agencies coordinate with the private and public health care systems, educational systems, and community organizations.
GUIDELINE #4 Breastfeeding promotion and support are enhanced when positive breastfeeding messages are incorporated in relevant educational activities, materials, and outreach efforts.
GUIDELINE #5 Breastfeeding promotion and support are enhanced when activities are evaluated on an annual basis.
GUIDELINE #6 Breastfeeding promotion and support are enhanced when appropriate breastfeeding education and support is offered to all pregnant WIC participants.
GUIDELINE #7 Breastfeeding promotion and support are enhanced when policies allow breastfeeding women to receive all WIC services regardless of their breastfeeding patterns.

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GUIDELINE #8 Breastfeeding promotion and support are enhanced when policies allow breastfeeding infants to receive a food package consistent with their nutritional needs.
GUIDELINE #9 Breastfeeding promotion and support are enhanced when breastfeeding support and assistance is provided throughout the postpartum period, particularly at critical times when the mother is most likely to need assistance.
SUGGESTIONS FOR IMPLEMENTATION
GUIDELINE #1 Breastfeeding promotion and support are enhanced when local agency WIC staff receive orientation and task-appropriate training on breastfeeding promotion and support.
Suggestions for Implementation
1. It is important to develop orientation guidelines for new WIC employees that address: clinic environment policies program goals and philosophy regarding breastfeeding task-appropriate information
Rationale: All new employees (support staff, paraprofessionals and professionals) must be familiar with program policies, goals and philosophy regarding breastfeeding. When all program staff project a positive attitude about breastfeeding, clients will be more comfortable discussing their breastfeeding questions and concerns.
2. It is important that the state agency develop guidelines for on-going training that address: culturally appropriate breastfeeding promotion strategies current breastfeeding management techniques to encourage and support the breastfeeding mother and infant appropriate use of breastfeeding education materials identification of individual needs and concerns about breastfeeding
Rationale: Ongoing training for staff providing breastfeeding education is needed because information about breastfeeding education continues to evolve. Addressing specific ethnic and culturally based needs fosters appropriately targeted messages in print and audiovisual materials.
3. It is important that local agency staff participate in breastfeeding training such as:

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statewide and local conferences and workshops events sponsored by other agencies and organizations
Rationale: Local agencies' participation in breastfeeding training is essential to successful implementation of breastfeeding promotion programs.
4. It is important that the local agency and state agency appoint a breastfeeding coordinator.
Rationale: Appointing a breastfeeding coordinator helps ensure that breastfeeding promotion and support activities are integrated into WIC program operations. The specific responsibilities and tasks of breastfeeding coordinators will vary from agency to agency based on their breastfeeding promotion and support activities. Breastfeeding coordinators should participate in training opportunities related to their job responsibilities.
GUIDELINE #2 Breastfeeding promotion and support are enhanced when policies encourage a positive clinic environment and breastfeeding as the preferred method of infant feeding.
Suggestions for Implementation
1. It is important to assure that relevant educational materials available to participants portray breastfeeding as the preferred infant feeding method. Consider: print and audiovisual materials free of formula product names office supplies such as cups, pens, and note-pads free of formula product names
Rationale: Use of materials with product names sends a mixed message to clients and staff and might unconsciously put up barriers to breastfeeding.
2. It is important to establish a positive attitude toward breastfeeding in WIC clinics.
Rationale: Health care workers should be careful not to communicate overt or subtle endorsements of formula. Such messages may influence a mother's decision about infant feeding or her breastfeeding pattern. Once a mother initiates infant feeding, WIC staff should support her decision.
3. It is important that the local agency minimize the visibility of formula and bottlefeeding equipment. Consider: storing supplies of formula out of view of participants storing baby bottles and nipples out of view of participants

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Rationale: Formula and bottle-feeding equipment in clear view of participants may influence a mother's decision on infant feeding.
4. It is important that staff not accept formula from formula manufacturer representatives for personal use.
Rationale: Acceptance of formula for personal use may influence staff to endorse a particular product, either consciously or unconsciously. Acceptance of formula also conflicts with the program's breastfeeding promotion and support activities.
5. It is important that the local agency try to provide a supportive environment in which women feel comfortable breastfeeding their infants. Consider: chairs with arms a breastfeeding area away from the entrance
Rationale: The clinic waiting area can be used advantageously to motivate women to recognize breastfeeding as the "norm" rather than the exception. The clinic area can also be used to provide worksite support for breastfeeding WIC staff.
6. It is important that the state agency assist local agencies in obtaining culturally sensitive and appropriate and translated breastfeeding education materials.
Rationale: The language and pictures in breastfeeding education materials should be relevant to the target population served by the program.
GUIDELINE #3 Breastfeeding promotion and support are enhanced when WIC agencies coordinate with the private and public health care systems, educational systems, and community organizations providing care and support for women, infants and children.
Suggestions for Implementation
1. It is important for local and state agencies to participate in and support coordinated activities with appropriate groups such as: task forces, networks, or steering committees to exchange information and strategies professional health organizations to secure resources and expertise and assure communication with health professionals serving pregnant and breastfeeding women existing peer support groups to facilitate local exchange of breastfeeding information across the state community leaders and citizen groups who support breastfeeding

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the Breastfeeding Promotion Consortium and its efforts, including a national breastfeeding promotion campaign
Rationale: A collaborative approach to breastfeeding promotion can create a strong supportive climate and help ensure more effective use of all available resources.
2. It is important that the state agency disseminate information such as the NAWD position paper, Breastfeeding Promotion in the WIC Program and the Guidelines for Breastfeeding Promotion in the WIC Program to state and local affiliates of groups such as: American Academy of Pediatrics American Academy of Family Physicians American college of Nurse Midwives American College of Obstetricians and Gynecologists American Dietetic Association American Hospital Association American Nurses Association American Public Health Association Association of Pediatric Nurse Practitioners Association of Women's Health and Obstetrics Nurses Healthy Mothers, Healthy Babies Coalitions International Lactation Consultants Association La Leche League International Maternal and Child Health Directors Medicaid Directors National Association of Pediatric Nurse Associates and Practitioners
Rationale: Serving as an adjunct to health care is a vital component of the WIC Program. Therefore, it is important that the program's health-related policies be shared with appropriate health care programs and professional organization. such interaction encourages a strong cooperative working relationship with the health community to accomplish mutual goals.
3. It is important for local and state WIC agencies to participate in and support coordinated breastfeeding promotion and support activities such as:
co-sponsoring training and continuing education programs sharing breastfeeding education materials for clients developing local or state documents such as position statements, policies, model
hospital policies and counseling and referral protocols

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GUIDELINE #4 Breastfeeding promotion and support are enhanced when positive breastfeeding messages are incorporated in relevant educational activities, materials and outreach efforts. Suggestions for Implementation
It is important that positive breastfeeding messages are used in: participant orientation programs and materials printed and audiovisual materials for professional audiences printed, audiovisual, and display materials for potential clients
Rationale: Including positive breastfeeding messages promotes breastfeeding as the preferred infant feeding choice and reinforces WIC's position on breastfeeding.
GUIDELINE #5 Breastfeeding promotion and support are enhanced when activities are evaluated on an annual basis.
Suggestions for Implementation
1. It is important that evaluation include measures of incidence and duration such as: incorporation of data collection into current WIC systems periodic sample surveys of program participants Centers for Disease Control and Prevention surveillance systems state surveillance systems birth certificate information
Rationale: Since few data are available, data collection will help identify and direct further breastfeeding promotion efforts for this population. Assessment of successful strategies will help agencies measure progress toward meeting the health objectives for the nation.
2. If more in-depth information on the incidence and duration of breastfeeding is desired, it is important that information be collected on at least the following categories: exclusive breastfeeding patterns of combined breastfeeding and formula feeding, e.g.: mostly breastfeeding equal parts breastfeeding and formula feeding mostly formula feeding exclusive formula feeding
Rationale: Collecting data on breastfeeding patterns gives a better picture of the WIC population's infant feeding practices. This will help states better focus their

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breastfeeding promotion activities. 3. It is important that questions regarding breastfeeding attitudes, infant feeding
decisions, and the WIC program's breastfeeding support activities are included in the annual participant survey.
Rationale: Collecting data on breastfeeding attitudes, infant feeding practices and WIC-related promotion activities about breastfeeding assists state and local agencies design more effective breastfeeding promotion program components.
4. It is important that the state agency management evaluation process reviews local agency breastfeeding promotion and support activities such as: participant orientation and education materials policies regarding formula samples and food package tailoring for breastfeeding mothers and infants clinic environment, including display materials and posters, and visibility of formula supplies staff interaction with participants regarding the infant feeding decision and breastfeeding support local agency linkages with other community programs providing services to breastfeeding women staff training plans
Rationale: Guidelines and policies must be implemented in order to affect breastfeeding initiation and duration rates of WIC participants.
GUIDELINE #6 Breastfeeding promotion and support are enhanced when appropriate breastfeeding education and support is offered to all pregnant WIC participants.
Suggestions for Implementation
1. It is important that a breastfeeding protocol is established to: integrate breastfeeding promotion into the continuum of prenatal nutrition education include an initial assessment of participant knowledge, concerns and attitudes related to breastfeeding provide breastfeeding education and support sessions to each prenatal participant based on the above assessment define the roles of all staff in the promotion of breastfeeding define situations when breastfeeding is contraindicated establish referral criteria

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Rationale: Making informed choices regarding the best methods of infant feeding is, in part, dependent on staff's ability and efforts to address women's needs and concerns throughout the prenatal period.
2. It is important to develop a mechanism to incorporate positive peer influence into the prenatal period, such as: peer counselors an honor roll of successful breastfeeding WIC participants an opportunity to watch other WIC participants breastfeed classes with currently breastfeeding WIC participants talking about their experiences
Rationale: Positive peer influence has been shown to be a factor in a woman's decision to breastfeed.
3. It is important to include the participant's family and friends in breastfeeding education and support sessions.
Rationale: Assistance and emotional support from family and friends are helpful to a woman's initiation and continuation of breastfeeding.
4. It is important to encourage the mother to communicate her decision to breastfeed to appropriate hospital staff and physicians.
Rationale: To overcome potential barriers due to hospital and physician practices, women should be aware of the need to request the services that will facilitate successful breastfeeding, e.g., baby put to the breast soon after delivery.
5. It is important for the local WIC agency to coordinate prenatal breastfeeding education activities with primary care providers by: discussing WIC's position about breastfeeding as optimal for most women and infants encouraging the sharing of educational materials between WIC and primary care providers identifying the breastfeeding promotion and support services available in the community and referring participants as needed
Rationale: Coordinating activities in the community increases the likelihood of women and families receiving consistent messages and information about breastfeeding.
6. It is important that the local WIC agency know the breastfeeding practices of their community hospitals and primary health care providers.

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Rationale: Local agency WIC staff should be part of the prenatal care team preparing women for their early breastfeeding experiences. Positive breastfeeding practices and policies facilitate successful breastfeeding.
GUIDELINE #7 Breastfeeding promotion and support are enhanced when policies allow breastfeeding women to receive all WIC services regardless of their breastfeeding patterns.
Suggestions for Implementation
1. It is important that eligible women who meet the definition of breastfeeding (the practice of feeding a mother's breast milk to her infant(s) on the average of at least once a day) be certified to the extent that caseload management permits.
Rationale: Breastfeeding women are among the highest priority groups of WIC participants.
2. It is important that breastfeeding women receive a food package consistent with their nutritional need.
Rationale: Breastfeeding women have the highest nutritional needs of any category of women participants and should receive a food package to meet those needs.
3. It is important that breastfeeding women receive support and assistance in order to maintain or increase breastfeeding.
Rationale: All breastfeeding women, regardless of their breastfeeding pattern, need ongoing support so that they feel positive about their breastfeeding experience.
GUIDELINE #8 Breastfeeding promotion and support are enhanced when policies allow breastfeeding infants to receive a food package consistent with their nutritional needs.
Suggestions for Implementation
1. It is important that the use of supplemental formula for breastfed infants be minimized.
Rationale: Support that encourages breastfeeding is more effective than offering more formula than the baby is currently using. Clear support which continues to build confidence includes praise and encouragement for her current level of
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breastfeeding.
2. It is important that vouchers with infant formula are not issued to exclusively breastfed infants. If a food instrument must be distributed to enroll the infant, consider printing a positive breastfeeding message on the voucher.
Rationale: A blank voucher emphasizes that the breastfeeding dyad may not be receiving as much food as the formula-feeding dyad and makes the mother feel as though she is missing out on some of the food available to her. A voucher with even a small amount of formula on it sends a message to the mother that she is expected to supplement. A positive breastfeeding message will reinforce the importance of breastfeeding.
3. It is important to encourage the issuance of vouchers for powdered formula to breastfeeding mothers who wish to supplement.
Rationale: Powdered formula can be prepared in as small a quantity as needed. However, the minimum amount of the concentrated fluid formula that can be prepared is 26 ounces. This amount must be used within 48 hours, which could encourage more supplementation than originally intended.
4. It is important that breastfeeding women receive information about the potential impact of formula on lactation and breastfeeding before formula is given.
Rationale: Breastfeeding mothers may not fully understand the impact formula supplementation has on breastmilk supply. This is especially important during the first few critical weeks when the milk supply is being established.
5. It is important that formula vouchers or samples be given only when specifically requested.
Rationale: Offering formula to a breastfeeding woman undermines her confidence that she can breastfeed successfully, particularly in the first few weeks. She also may find it difficult to refuse the free formula even though she had not planned to use it.
GUIDELINE #9 Breastfeeding promotion and support are enhanced when breastfeeding support and assistance is provided throughout the postpartum period, particularly at critical times when the mother is most likely to need assistance.

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Suggestions for Implementation
1. It is important to develop a plan to provide women with access to locally available breastfeeding support programs, making sure support is available early in the postpartum period and throughout lactation to: a. Include professional support, such as management of lactation problems, hotline contacts and telephone counselors b. include peer support, such as peer counselors and resource mothers
Rationale: Professional support programs assist the mother experiencing lactation problems to resolve questions and problems with lactation management. Peer support programs use individuals who have successfully breastfed an infant and who express a positive, enthusiastic viewpoint of breastfeeding.
2. It is important to provide or identify education and support for breastfeeding women in special situations. Consider: a. mothers returning to paid employment or school; mothers separated from their infants due to hospitalization or illness; mothers of multiples; infants with special needs b. support program at times in keeping with the mother's schedule
Rationale: Breastfeeding mothers who are separated from their infants need support programs which include situation-specific information and support.
3. It is important that postpartum contacts with breastfeeding women provide positive reinforcement for the continuation of breastfeeding. Consider: a. using appropriate posters and messages placed in the clinic waiting and nutrition education areas b. including a special breastfeeding message, on vouchers, encouraging the continuation of breastfeeding
Rationale: Encouragement from professional staff and peers can provide motivation to succeed at breastfeeding.
4. It is important to coordinate breastfeeding support with other health care programs and providers, such as: a. Maternal and Child Health b. Family Planning c. hospitals d. Indian Health Service e. community health providers

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Rationale: Collaborative relationships result in consistent messages supporting breastfeeding, more efficient services and decreased lactation problems; and reach a larger number of women. These efforts will have a more far-reaching effect as the incidence of breastfeeding increases.
5. It is important that the state agency develop a protocol or guidelines regarding the distribution of breastfeeding aids, including:
a. circumstances when the breastfeeding aid might be provided b. guidelines for participant instruction about using the breastfeeding aid
Rationale: Many women have successful breastfeeding experiences without using breastfeeding aids. Breastfeeding aids can enhance breastfeeding success when their distribution is based on individual need and when instruction about the aid is provided.

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BREASTFEEDING RESOURCES RECOMMENDED BY THE NUTRITION SECTION
PAMPHLETS
Breastfeeding Basics: Collecting and Storing Your Milk (#3850) Breastfeeding Basics: Common Problems (#3848) Breastfeeding Basics: The First Six Weeks (#3849) Breastfeeding: Getting Started in Five Easy Steps - English, (#4002) Breastfeeding: Getting Started in Five Easy Steps - Spanish, (#4003) Good Nutrition for Breastfeeding (#4004) Breastfeeding: A Time for Good Food Choices (#4019) Working and Breastfeeding (#4020)
BOOKS AND MANUALS
Breastfeeding: A Guide for the Medical Profession, by Ruth Lawrence C.V. Mosby Co., St. Louis, MO, 1999.
Breastfeeding: A Parent's Guide, by Amy Spangler Amy Spangler/Daddy, Mommy and Me, Atlanta, GA, 2000.
Breastfeeding: A Problem-Solving Manual, by Stephen Saunders, et. al. Essential Medical Information Systems, Inc., Dallas, TX, 1990.
Breastfeeding & Human Lactation, by Jan Riordan and Kathleen Auerbach Jones & Bartlett, Publishers, Boston, MA, 1999.
The Breastfeeding Answer Book, by La Leche League International La Leche League International, Franklin Park, IL, 1997.
Breastfeeding Triage Tool, by Sandra Jolley Breastfeeding Promotion Project, Seattle-King County Public Health, Seattle, WA, 1990.
Counseling the Nursing Mother: A Reference Handbook for Health Care Providers and Lay Counselors, by Judith Lauwers and Candace Woesner. Avery Publishing Group, New York, NY, 1983.
Evidence-Based Guidelines for Breastfeeding Management during the First Fourteen Days, International Lactation Consultant Association, April 1999.
Medication and Mothers' Milk, by Thomas Hale Pharmasoft Medical Publishing, Amarillo, TX, 2002.
Nursing Mother's Companion, by Kathleen Huggins Harvard Common Press, Boston, MA, 1990.
Nutrition During Lactation, by the Institute of Medicine, National Academy of Sciences National Academy Press, Washington, D.C., 1991
Nutrition Guidelines for Practice, by the Nutrition Section Nutrition Section, Family Health Branch, Division of Public Health, Georgia Department of Human Resources, Atlanta, GA, 1995.

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The Pediatric Clinics of North America: Breastfeeding 2001, Part I (The Evidence for Breastfeeding) and Part II (The Management of Breastfeeding), W.B. Saunders Company, Philadelphia, PA, 2001.
Pocket Guide to Breastfeeding and Human Lactation, Second Edition, by Jan Riordan and Kathleen G. Auerbach, Jones and Bartlett Publishers, Sudbury, MA, 2001.
Womanly Art of Breastfeeding, by La Leche League International La Leche League International, Franklin Park, IL.
VIDEOTAPES
Best Start: For All the Right Reasons, (also available in Spanish), Best Start, Inc., Tampa, FL.
Best Start: Training Program, Best Start, Inc., Tampa, FL. Breastfeeding Your Baby, The Nutrition Section, 1994. Yes, You Can Breastfeed, (also available in Spanish), Texas Public Health.
Available from Metro Post, Attn: Ecko, 501 N. IH 35, Austin, TX 28273; (512) 476-3876.
TEACHING TOOLS
Breast Model Childbirth Graphics Ltd., P.O. Box 20540, Rochester, NY, 14602
Flip Chart Childbirth Graphics Ltd., P.O. Box 20540, Rochester, NY, 14602
Baby Model Childbirth Graphics Ltd., P.O. Box 20540, Rochester, NY, 14602
TELEPHONE INFORMATION SERVICES FOR HEALTH PROFESSIONALS
Georgia Poison Control Center Grady Memorial Hospital, Atlanta, GA (404) 616-9000 or (800) 282-5846 Service Provided: Answers to questions on Drugs and Lactation Charge: There is no cost for this service
Breastfeeding and Human Lactation Study Center University of Rochester School of Medicine & Dentistry, Box 777, Rochester, New York, 14642 (716) 275-0088. Service Provided: Database to assist with questions about pharmaceutical drugs and breastfeeding. Provides bibliographies on breastfeeding and lactation. Charge: None, beyond cost of telephone call
The Lactation Program

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1719 E. 19th Avenue, Denver, CO, 80218 (303) 869-1881 Service Provided: Phone consultation with lactation consultants for difficult breastfeeding questions. Charge: None, beyond cost of telephone call

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ALLOWABLE AND UNALLOWABLE COSTS OF BREASTFEEDING AIDS USED FOR
THE PROMOTION AND SUPPORT OF BREASTFEEDING
The cost of breastfeeding aids that directly support the initiation and continuation of breastfeeding are allowable WIC nutrition services and administration (NSA) expenses. Such expenses can be applied to the State agency's breastfeeding spending target and/or its overall nutrition education expenditures.
Breastfeeding aids which are allowable NSA costs include: Breast pumps Breast shells Nursing supplementers Nursing bras Nursing pads Costs associated with the purchase and availability of breastfeeding aids through the WIC Program, such as insurance and service fees in providing breast pumps Items used for training and demonstration purposes to promote breastfeeding or assist participants in using breastfeeding aids. For example: breast models, breastfeeding aids, dolls to illustrate nursing, etc. Other items which can be shown to directly support the initiation and continuation of breastfeeding.
UNALLOWABLE COSTS
Breastfeeding aids that do not directly support the initiation and continuation of breastfeeding and are not within the scope of the WIC Program cannot be purchased with NSA funds. Such items include, for example: topical creams, ointments, Vitamin E, other medicinals, foot stools, infant pillows or nursing blouses.

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ISSUES TO CONSIDER WHEN PROVIDING BREAST PUMPS
WIC State agencies are currently making breast pumps available to WIC participants in a variety of ways, including:
a. giving away manual breast pumps or electric pump attachment kits; b. selling manual breast pumps or electric pump attachment kits for a
nominal charge; c. loaning manual or electric breast pumps; d. contracting with a third party to provide manual or electric breast pumps
to WIC participants; and e. referring WIC participants to providers who rent breast pumps directly to
them for a fee.
While all of the above options are available to the Georgia WIC Program, the following issues should be considered in reference to each:
Giving Away Breast Pumps
Local agencies may give away breast pumps without any reimbursement from participants. This option applies to inexpensive manual breast pumps, small electric pumps, or electric pump attachment kits which do not represent a significant investment of program resources.
Selling Breast Pumps
Local agencies may provide breast pumps by charging a fee to WIC participants (i.e., the purchase price or a portion of the cost to the WIC Program), to partially or totally offset their cost. Since breast pumps are not a direct program benefit, they are not subject to the legislative requirement that WIC benefits must be provided at no cost to participants. Such a plan must be submitted to the Nutrition Section for approval. A local agency that sells breast pumps to WIC participants must treat the receipts as an "applicable credit" against expenditures for program costs. As applicable credits, these receipts must be used to offset or reduce charges made to the Federal grant for such cost. Applicable credits against expenditures for program costs are discussed in Office of Management and Budget Circulars A-87, Attachment A, paragraph C.3., and A-122, Attachment A, paragraph A.5.
Loaning Breast Pumps and Liability Issues
Manual breast pumps, attachment kits for electric pumps and small electric or battery operated pumps should not be reused, due to the possibility of cross-contamination from improper sterilization. The possible liability cost is high when compared to the cost for a

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one-person use of a manual pump. In addition, the small electric/battery-operated pumps are often not durable enough to be used repeatedly and their cost is minimal.
Since large electric breast pumps represent a significant investment of WIC resources, loaning them is the only option. However, under this option, local agencies that directly purchase breast pumps for loan to participants may incur the financial liability of lost or damaged breast pumps. These pumps should be loaned in combination with some means to insure against loss or damage, such as:
a. establishing procedures to ensure that participants fully understand their rights and responsibilities when signing liability release forms;
b. developing an agreement between the program and the participant which stipulates the participant's responsibility to reimburse the program for the value of a lost or damaged pump;
c. monitoring through periodic visual inspection, frequent inventory counts and records, and telephone check-ins; or
d. limiting pump loans only to special circumstances, e.g., after a minimum duration of breastfeeding or for certain medical conditions; and
e. charging a refundable deposit. This deposit must not present a barrier to the participant that would prevent her from being able to borrow the pump. While a lower deposit is encouraged, it must not exceed $20.00, for a hospital-grade pump.
Participants may not be terminated or suspended for unreimbursed loss or damage to loaned pumps. While a financial penalty, if included in the original agreement, could be imposed on a participant for failure to return or damage to a pump, the State WIC Program recommends that this approach not be taken. The resources required to recover the cost of the lost or damaged breast pump could easily exceed the value of the pump itself. Building a relationship of trust with WIC participants may minimize the risk of the participant not fulfilling the obligation to return the pump.
If it provides breast pumps, the WIC Program may also be liable for injury to a WIC participant resulting from improper breast pump use, even when there is a signed release of liability. This is true whether pumps are given, sold, or loaned. All participants provided with breast pumps by the WIC Program must be instructed on proper pump use.
Contracting with a Third Party
Local agencies may contract with a third party, such as a breast pump manufacturer, hospital pharmacy, or private lactation consultant, to loan or provide breast pumps to WIC participants. WIC employees must not be affiliated with the third party with whom they are contracting.

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A major advantage to contracting with a third party is that it transfers liability for equipment loss or damage from the WIC Program to the third party provider, for example, through a loss or damage waiver or insurance fee.
Referrals
A local agency may opt to refer WIC participants to providers who rent breast pumps directly to participants at a fee, such as breast pump manufacturers, hospital pharmacies, and private lactation consultants. This option avoids the liability and financial issues for the program. However, it is likely to pose a financial barrier to WIC participants. In the Georgia WIC Program, this does not meet the requirement for the provision of support to breastfeeding women.
Medicaid Reimbursement
The cost of manual pump purchase and electric pump rentals are generally not covered as a separate benefit under the Medicaid Program. However, in Georgia, the State Medicaid Program does cover the rental of an electric pump and the price of an attachment kit in some cases. Coverage is based on the mother's Medicaid eligibility and so is limited by the period of time the mother is covered by Medicaid in the postpartum period. In addition, coverage is provided for those cases in which the mother and infant are separated by hospitalization, i.e., premature birth.
The electric breast pump and attachment kit must be obtained by a Medicaid Durable Goods provider. It does not require that the provider give instructions to the client on proper use, maintenance and cleaning of the equipment. In these cases, the local agency staff should provide the necessary information and follow-up to the WIC participant.

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STATUS CHANGE FROM PRENATAL TO BREASTFEEDING AND ASSIGNMENT OF PRIORITY TO BREASTFEEDING MOTHER AND INFANT
I. Status Change from Prenatal (P) to Breastfeeding (B) Without a Subsequent Certification:
When a prenatal participant delivers her infant(s) and initiates breastfeeding, the local agency is encouraged to change the participant's status from that of Prenatal (P) to Breastfeeding (B) through an update to the system. This should occur as soon as the local agency is made aware of the participant's change in status. A subsequent certification is not required in order to simply change the participant's status, as long as she is less than six (6) weeks postpartum. Note: This action does not exclude the participant from the required subsequent certification, in order to continue on the program past the six weeks postpartum.
Listed below are examples of situations in which the simple status change from Prenatal to Breastfeeding might occur:
A woman calls the clinic to state she has delivered her infant and is breastfeeding.
A parent of a newborn breastfeeding infant comes to the clinic to enroll the infant in the program.
A local agency does in-hospital certification of infants only. A breastfeeding peer counselor notifies the clinic that a participant has
delivered her infant and is breastfeeding.
Follow the steps listed below to change the status of a prenatal women, prior to her subsequent certification:
A. Change TYPE from P to B, since subsequent certification may not take place until 6 weeks postpartum.

B. Change/add the following: DELIVERY DATE, PREGNANCY OUTCOME, and NUMBER OF WEEKS BREASTFED.

C. Change the following if determined to be appropriate (these are optional changes):
1. PRIORITY. A breastfeeding woman's priority can be upgraded if one or more breastfeeding risk factors are identified. The risk factor(s) must be documented in the participant's health record. See II. Assignment of Priority to Breastfeeding Dyad, below.

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Attachment BF-8

2. FOOD PACKAGE. If the Competent Professional Authority (CPA) determines that a food package change is needed, assign a new food package. Participants who are exclusively breastfeeding (receiving no infant formula through WIC) should be assigned Food Package 408. If this participant has already picked up the current month's prenatal vouchers, you may print a single "001" voucher for her. This voucher includes the additional beans/peas or peanut butter, carrots and juice which are part of the 408 food package.
II. Assignment of Priority to Breastfeeding Dyad
When a participant's status is changed from Prenatal (P) to Breastfeeding (B), prior to her postpartum certification, it may not be possible to assign the same priority to both mother and infant at this time. Please follow these steps in assigning the priorities:
A. When a participant's status is changed from Prenatal (P) to Breastfeeding (B) through a systems update, her priority may be upgraded if there is appropriate documentation. This is optional, however, and she can maintain her Prenatal priority until the subsequent certification.
B. When a breastfeeding infant is certified for, and enrolled in, the WIC Program prior to its mother being subsequently certified, the infant may be assigned one of the following priorities:
1. If the infant has a risk factor of its own that would result in it's being a Priority I, the infant must be assigned a Priority I.
2. If the infant has only nutritional risk factor 701 (Infant of a WIC Mother or Mother with Nutritional Risk During Pregnancy), assign a Priority II. It may be helpful to "flag" the infant's name/record through an internal tracking system (tickler card, computer, voucher register, etc.) to alert staff to the need to re-evaluate the infant=s priority at the mother's postpartum certification.
3. If the infant's mother was assigned a Priority I based on documented postpartum breastfeeding risk factors, assign a Priority I to the infant.
C. When the mother of a breastfeeding infant is certified at a later time than the infant, one of the following actions must be taken:

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Attachment BF-8

1. If the mother is no longer breastfeeding, she must be assessed as a non-breastfeeding postpartum woman (status is changed from P to N), and she must be assigned the appropriate priority based on the assessment. Her infant retains the priority assigned at its enrollment.
2. If the mother is still breastfeeding, she must be assessed as a breastfeeding woman (status is changed from P to B). The highest priority of either the mother or her infant(s) must be assigned to both mother and infant(s). This priority and the supportive risk criteria must be documented in the health record of both the mother and her infant(s).

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Attachment BF-9

KEY FOR ENTERING WEEKS BREASTFED
The number of weeks breastfed must be entered on the WIC Assessment/Certification Form and Turnaround Document for:
Breastfeeding Women: initial and six-month certification visits Postpartum, non-breastfeeding women: certification visit Infants: initial certification and mid-certification nutrition assessment visits Children: one-year of age certification visit (11 to 16 months of age)
Length of time breastfed must be entered in weeks (two-digit). When the answer to the question "how long have you breastfed this baby/child?" or "how long has this baby/ child been breastfed?" is given in days or months, use the following key to determine appropriate codes:
I. Codes to Enter When Breastfeeding is Given in Days
00 = Never breastfed to 3 days 01 (weeks) = 4 to 10 days 02 (weeks) = 11 to 17 days 03 (weeks) = 18 to 24 days 04 (weeks) = 25 to 31 days 05 (weeks) = 32 to 38 days 06 (weeks) = 39 to 45 days 07 (weeks) = 46 to 52 days 08 (weeks) = 53 to 59 days ETC.
II. Codes to Enter When Breastfeeding is Given in Months
If the length of breastfeeding is given in months, simply multiply by 4.3 to calculate the number of weeks breastfed.
Example: A woman stated she breastfed her infant for 4 months. Calculate weeks breastfed as follows:
4 x 4.3 = 17.2 weeks
Enter 17 on the in the appropriate space for Weeks Breastfed, on the WIC Assessment/Certification Form and the Turnaround Document.
Source: Enhanced Pregnancy Nutrition Surveillance System User's Manual. Division of Nutrition, Center for Chronic Disease Prevention & Health Promotion, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, Public Health Service. November 1989.

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GA WIC 2005 PROCEDURES MANUAL TABLE OF CONTENTS

Disaster Plan

I. Introduction..........................................................................DP-1 A. Purpose.......................................................................DP-1 B. Scope..........................................................................DP-1
II. Policies................................................................................DP-2 III. Assessing Impact of Disaster....................................................DP-3 IV. Concept of Operation.............................................................DP-4
A. General......................................................................DP-4 B. Organization (WIC Director Responsibilities State
Level Responsibilities, State and Local Agencies)................DP-4 C. Notification.................................................................DP-6 V. Responsibilities.....................................................................DP-7 A. Facilities.....................................................................DP-7 B. Issuance.....................................................................DP-7 C. Certification..............................................................DP-10 D. Nutrition Education Contacts........................................DP-10 VI. Resource Requirements........................................................DP-11 A. Staff Requirements.....................................................DP-11 B. Infant Formula...........................................................DP-11 C. Food Vouchers...........................................................DP-12 D. Transportation...........................................................DP-12

GA WIC 2005 PROCEDURES MANUAL

Disaster Plan

Attachments: DP-1 Staff Availability Form............................................................DP-13 DP-2 Personnel Time Tracking Form................................................DP-14 DP-3 Communications Log............................................................DP-15 DP-4 American Red Cross Listing....................................................DP-16 DP-5A Disaster Daily Work Activity Log............................................DP-18 DP-5B Disaster Projections and Planning Assumptions.........................DP-19 DP-6 Division Mutual Aid Agreement..............................................DP-20 DP-7 WIC Disaster Plan.................................................................DP-24

GA WIC 2005 PROCEDURES MANUAL

Disaster Plan

I. INTRODUCTION
The following information is provided to the districts for incorporation into the district Disaster Plan. In contrast to commodity distribution of food stamps, WIC is a limited grant supplemental food program that serves a specific population with special nutritional needs. WIC is not designed or funded to meet the basic nutritional needs of disaster victims who would not otherwise be eligible for the program. Unlike the distribution of commodities or the emergency issuance of food stamps, there is no legislatively mandated role for WIC in disaster relief, nor is there legislative authority for using WIC food funds for purposes other than providing allowable food benefits to categorically eligible participants. Finally, no additional WIC funds are designated by law for WIC disaster relief, and WIC must operate in disaster situation within its current program context and funding. For these reasons, WIC is not to be considered a first responder or first line provider of infant formula or the nutritional needs of disaster victims. The State WIC Branch may briefly suspend WIC operations during some instances and rely entirely on other disaster relief feeding operations (e.g. American Red Cross, Salvation Army, churches, etc.) until it is feasible to operate a direct distribution system or until retail distribution returns to normal conditions.
A. Purpose
The Purpose of this Disaster Plan is to:
1. Restore WIC services to current participants as soon as possible.
2. Expand services to the eligible population in disaster-affected areas.
3. Respond in a manner consistent with the Georgia Department of Human Resources, Division of Public Health.
B. Scope
These guidelines incorporate the Georgia Department of Human Resources, Division of Public Health, Public Health Emergency Response Plan (PHERP), Georgia Division of Public Health Internal Operating Procedures Volume I, and the State WIC Branch Operating Plan. These plan should be followed in the event of a disaster or emergency that disrupts service delivery at local
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agency(ies). The actions of local agency WIC staff should be guided by the procedures developed within their respective county public health departments. Private agencies, that contract to provide WIC services, should follow the disaster plans consistent with those policies that have been developed by their parent agencies. State WIC Branch guidelines will reflect the purpose, authority, and responsibilities developed by Georgia department of Human Resources, Division of Public Health, Public Health.
The State WIC Branch and local agency(ies) must also make an initial and on-going assessment as to the feasibility of distributing ready-tofeed infant formula. The decision to use ready-to-feed infant formula will be made on a day-by-day assessment of the situation and type of disaster.
The emergency numbers for contacting the American Red Cross are also attached to this plan (See Attachment DP-4). The contact person as well as a fax number is also available in (Attachment DP-4).
II. POLICIES
Concept of Operations: Operations will be conducted in three phases that may overlap as outlined in the Georgia Department of Human Resources, Public Health Emergency Response Plan (PHERP). Phase One is Detection and Investigation. Phase Two is Assessment of Magnitude. Phase Three is Response to the Emergency. In all three phases, the order of preference for voice communications is landline, radio, and cellular communications. Voice communications may be supplemented by complementary and redundant e-mail, Internet, or fax. When none of these are available, satellite communications or amateur radio systems may provide redundancy. Each agency is to provide an accurate and complete accounting of costs associated with the incident.
Phase One begins when a suspected or possible emergency having withstood clinical review, is reported to the Director of the Division of Public Health or detected by the public health system in Georgia. The Division of Public Health will contact and or assist the Health District(s) in determining the nature of the emergency. Phase One is complete when the appropriate state or federal agency either confirms or refutes the emergency. For a natural disaster, Phase One will be complete when a determination is made of health consequences associated with the disaster. The Office of the Director, Division of Public Health, will provide direction for public health assets involved in any investigation. District Health

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Directors are responsible for ensuring that the efforts of district and provider resources are managed effectively in the detection and investigation of the possible health emergency.
Phase Two begins with confirmation of the incident. It may begin before identification of the source or agent of the outbreak or incident. County, District and State Public Health with support from health provider organizations and others, will determine the potential scope of the emergency. The assessment will include determining the availability of facilities, staff and equipment. The local County Health Departments will determine local responses status, needs and priorities. District and State Public Health Officials will do likewise for their respective levels. This phase will require close coordination between County, District and State Public Health, health care providers, mental health care providers and other.
Phase Three begins with allocation of additional resources (i.e. personnel, supplemental foods, and other resources). Phase Three will be complete when the emergency is contained and the community begins to return to normal functions as determined by local, district and state officials.
The WIC Coordinator or designee, serves as the local lead and is responsible for coordinating local WIC responses to an emergency.
Specific decisions concerning State WIC Branch actions during a disaster depend upon the duration and magnitude of the disaster, and upon specific directions from the WIC Branch Director. The focus of State WIC Agency activity is to support local agency service delivery. These guidelines primarily reflect State WIC Branch responsibilities in the event of disruption of services in one local agency. In the event of an emergency at the State WIC Branch, State WIC Branch personnel will follow the rules developed by the State Health Director. In the event of a disaster or emergency involving both local and State agencies, the initial focus of the State WIC Branch will be to estimate the impact and determine the measures needed to support the restoration of services by the local agency. The state and local agencies will develop provisional operational policies following a disaster that respond to the specific needs created by the disaster.
III. ASSESSING IMPACT OF DISASTER
The extent of damage caused by the disaster must be assessed by the local agency. To determine if delivery of services is feasible, the following questions should be answered:

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1. What type of assistance does the local agency need?
2. Are the issuance sites operational? How many participants are affected? Can participants reach food instrument issuance sites?
3. How many grocery stores are closed due to the disaster? Is retail purchase still feasible?
4. Are electric, water, communication, and/or transportation services disrupted?
5. How long will services be disrupted?
6. How best can the State WIC Branch assist with aiding the health district?
7. Has the area been declared a federal disaster?
IV. CONCEPT OF OPERATION
A. General
The State WIC Branch Director or designee and the Director of the Nutrition Section shall keep a Disaster Plan folder. The Disaster Plan folder provides the current telephone numbers for selected State WIC Branch and Nutrition Section staff, the Regional Food Nutrition Services Offices, County Public health Unit Disaster Coordinators, State Health office Disaster Coordinators, statewide and local chapters of the American Red Cross, U.S. Department of Agriculture Food Distribution Program, and other non-profit and private programs. Home addresses and telephone numbers are confidential and will be used only in an emergency.
B. Organization
WIC Director Responsibilities
1. Contact the Division of Public Health Emergency Coordinator.
2. Contact the formula manufacturers to secure ready to feed (RTF) formula with nipples and bottles.
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i. Follow through on receipt and delivery of formula ii. Visit area to make on-site assessment of support staff,
etc.
State Level Responsibilities
Various staff members have responsibilities in the WIC and Nutrition Services Disaster Plan. The overall responsibilities for implementation and reporting on WIC's response to the disaster lies with the Directors of WIC and Nutrition Services or a designee. WIC section managers and consultants will be responsible for coordinating staff and analyzing the disaster as follows: The Systems Information Section Manager (in conjunction with local WIC program coordinators) will be responsible for ensuring that infant formula contracts contain a clause addressing alternative measures for acquisition and distribution of infant formula in the case of a disaster, coordinating mass shipment of supplies, storage, and coordinating the issuance food vouchers to participants, including remote printing, equipment issues and emergency procurement of vouchers. The Financial Unit will be responsible for tacking and reconciling disaster related costs. The Compliance Analysis Section Manager will be responsible for documenting the use of the vouchers, ensuring that inventories are used appropriately, and ensuring that manual vouchers are available. The Vendor Section Manager will be responsible for informing local agency(ies) of authorized WIC vendors open for business. The Nutrition Section Consultants will be responsible for assisting in certification and food package issuance, nutrition education, food safety preparation, and breastfeeding education support information. Staff will be assigned to serve locations according to availability and needs.
State and Local Agencies
The state and local agencies will coordinate efforts to determine the appropriate assignments of staff to assist the local agency in need. Staff may be assigned from within the county, from another county, from another district or from the State WIC Branch to meet a specific county's needs during a disaster.
The state and local agencies may be asked to assign staff to designated disaster assistance locations (not always a health
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Disaster Plan

department facility) in order to provide WIC services more expediently.
When a disaster causes state or local agency offices to be closed, staff should contact one of their supervisors as soon as possible to report their situation and availability for duty. If none of the local agency's immediate supervisors can be reached, local agency staff can call the State WIC Branch at 1-800-228-9173 to report their status and phone number where they can be reached. Attachment DP-1 is a form designed to collect data for this purpose.
Staff Documentation Requirements:
1. Any office that has staff working on disaster activities must maintain a Staff Availability Form (Attachment DP-1), Disaster Personnel Time Tracking Form (Attachment DP-2), and a Communication Log (Attachment DP-3). One log per office should be maintained per day period and kept on file.
2. The Staff Availability Form (Attachment DP-1) must show which employees are available for emergency operations and when they were notified.
3. Each employee should maintain and retain a Disaster Personnel Time Tracking Form (Attachment DP-2) to document hours worked during a disaster. If the Federal Emergency Management Agency (FEMA) or other funding sources become available, the Disaster Daily Work Activity Logs will be used to help documents hours worked (Attachment DP-5).
4. The Communication Log (Attachment DP-3) should show the communication made with respect to and during the documented emergency.
C. Notification
Lines of communication during a disaster begin with WIC offices contacting the main local agency office. Local agencies would contact their WIC Coordinator, who will contact the district disaster coordinators. The State WIC Branch Disaster Plan will be implemented following notification from the local WIC Coordinator, who has cleared these plans with his or her District Disaster

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Coordinators. The State WIC Branch would contact the State Health Office Disaster Coordinator and appropriate WIC retail vendors.
V. RESPONSIBILITIES
A. Facilities
During a disaster, it is imperative that the safety of staff and participants be considered. Therefore, it may be necessary to move to another location. In the event of a move, an immediate survey should be taken of all state buildings and offices in the affected area(s) to identify damage or the nature of the incident.
Necessary emergency action should be taken to protect the WIC Program property where state buildings or offices have been damaged. This may include, but is not limited to, moving contents and equipment files, acquiring security services, securing buildings, or the other necessary activities.
The records and invoices of any damage to facilities, equipment, supplies, repair or replacement should identify the site location address and identification numbers of the item(s) to assist in filing insurance claims. This information must be reported to the State WIC Financial Management Section, within seventy-two (72) hours after the disaster area returns to normal.
The State WIC Branch will cooperate with the local agency to identify buildings, equipment, medical services, general supplies, and any other resources required to continue service delivery. This will include assisting in finding potential locations for direct distribution of infant formula and food that are most accessible to participants. Whenever possible, the State WIC Branch will coordinate communications and services with other state program offices, such as Maternal and Child Health, TANF, Food Stamps, and Disaster Assistance Centers.
B. Issuance
During periods of emergency or disaster, every effort will be made to continue issuance of food vouchers to participants. When adverse circumstances persist, such as the lack of

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available facilities, records or food instrument supplies, the State WIC Branch will coordinate efforts with the local agency to ensure that a minimum supply of food or food vouchers are available for participants if such action is necessary. Securing formula for WIC infants effected by the disaster is the top priority of any State WIC Branch disaster relief plan. Readyto-feed formula may be necessary if the areas water supply is contaminated and/or electrical power is disrupted. State government and local agencies will collaborate daily (or as needed) to determine the most appropriate food distribution method. In the event that ready-to-feed infant formula is required, efforts will be made to order appropriate amounts (along with disposable nipples and bottles). As soon as the disaster area returns to normal or if another agency accepts responsibility for formula (i.e. American Red Cross), distribution of ready-to-feed formula will be discontinued. Adult and child participants will be directed to emergency food centers in the event that direct distribution is necessary.
1. Retail Grocery Stores: The state and local agency will establish and maintain a list of retail grocery stores that remain in operation following the disaster, their operating, and their available stock of WIC approved foods. The state and local agency will coordinate efforts foods. The state and local agency will coordinate efforts to share this information with the participants.
2. Direct Distribution: If retail purchase is not viable, then direct distribution measures will be considered. The local agency, state staff, and disaster coordinator will determine that retail purchase is not viable when a significant number of clients are unable to purchase WIC approved foods. This could be due to the closure of many retail stores, the inability on many clients to get to a retail store, or disruption of the supply of food to stores.
State and local agencies will coordinate efforts to contact the Red Cross and other relief agencies to arrange for methods of food distribution to current participants and to newly eligible participants. The State WIC Branch will arrange for the supply and distribution of food items and/or food vouchers

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to the local agency in need. For those local agencies in close proximity to the State WIC Branch, the State WIC Branch may become directly involved with the distribution. If the district office is closer in proximity, efforts will be made by the State Branch to coordinate distribution to the local agency through the district office. When district offices are affected by the disaster, the State WIC Branch may elect to take other appropriate measures to supply the local agency with infant formula, other food, i.e. alternate food packages or food vouchers. Ready-to-feed formula will be used if the water supply is contaminated or limited.
All contracts for formula procurement by Georgia WIC and nutrition services will contain a clause addressing alternative measures for acquisition and distribution of infant formula in the case of a disaster.
3. Special formula/Hospital Based Formula: The State WIC Branch and local agency(ies) will estimate the quantity of special formula and hospital based formula needed to sustain services until normal operations are restored. The State WIC Branch will then take measures to ensure that affected local agencies have supplies in the types and quantities needed. This may include State WIC Branch contracts with manufactures, wholesalers, suppliers, retailers, and other local agencies. Procurement, shipment, and local storage of infant formula will be the responsibility of the State WIC Branch.
4. Food Vouchers: Local agencies should maintain at all times a minimum back up supply of preprinted manual food vouchers. These manual food vouchers should be secured in such a way that they will be safe and accessible during emergencies. Based on the local agency needs, the State WIC Branch will help to sustain the local agency's inventory of food vouchers. Local agency staff must complete an inventory of vouchers, at the end of each day, to account for usage.
5. Food Package: The WIC Competent Professional Authority (CPA) determines the type of food package to be issued consistent with the Food Package Section

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of the WIC Program Procedures Manual (See alternative food package section.) Local agencies have the option of converting participants to a special food package (i.e. homeless package) under any of the following circumstances: a. The participant does not have refrigeration. b. Lacks food preparation facilities (e.g. living in a
shelter, motel, etc.).

C. Certification

Depending on the duration and severity of the disaster,

appropriate measures will be taken by the State WIC

Branch to minimize the disruption of certification

services at the local agency. When facilities medical

services, equipment, general supplies and staff are

available, the State WIC Branch will assist local

agencies maintain services. When specific facilities,

medical services, or staff are needed, the State WIC

Branch will enact measures to meet those needs

through other local agency or State WIC Branch

resources.

Special provisions for expedited

certifications may be authorized with approval from

the State WIC Branch. The State WIC Branch gives

local agencies the right to extend the length of

certification of applicants when no proof of residency

or identity exists (such as when a applicant or an

applicant's parent is a victim of theft, loss, or disaster, a

homeless individual, or a migrant farm worker). In

these cases, the State or local agency must require the

applicant to confirm in writing his/her residency or

identity.

D. Nutrition Education Contacts

Nutrition education may be provided in group or individual settings during certification and voucher issuance during crisis situations.

Nutrition education during a crisis should address: 1. Food safety 2. Meal planning 3. Food preparation

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4. Nutrition needs of the individual 5. Safe water supply 6. General sanitation 7. Relocation shelters for emergency purposes
VI. RESOURCES REQUIREMENTS
The requirements for providing services to WIC participants during a disaster include providing: staff, infant formula, manual vouchers, and transportation. See the information below:
A. Staff Requirements
1. Analyzing the needs caused by the disaster as well as monitoring and controlling the response.
3. Coordinating WIC staff and nutrition volunteers from around the state.
4. Scheduling shifts for volunteers and helping to obtain lodging at the disaster site.
5. Scheduling and coordinating staff at the local office and the State WIC Branch.
6. Coordinating with local agency financial staff, monitoring and tracking all disaster recovery related costs.
B. Infant Formula
1. Obtain storage facilities near the affected disaster area for storing an extra supply of infant formula. Obtain manpower to move formula from trucks to storage to shelter.
2. There must be a plan to procure, ship, store and distribute infant formula and food to disaster areas.
3. Protocol of agency to contact distribution personnel (i.e., helicopters, airplanes, over land all terrain trucks).

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C. Food Vouchers
1. Obtain a supply of blank food vouchers for state office remote printing.
2. Printing and shipment of pre-printed food vouchers to the disaster area.
D. Transportation
1. Arrange transportation for volunteer staff.
2. Arrange transportation for local distribution of infant formula.

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GA WIC 2005 PROCEDURES MANUAL

Date

Time Call Received

District/Unit Clinic

Staff Availability

Staff Name

Staff Telephone

Attachment DP-1

Return to Return to Work Date Work Time

Closure of Issue

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GA WIC 2005 PROCEDURES MANUAL

Attachment DP-2

Disaster Personnel Time Tracking Form Summarize incident related activities:

Affected district/county(ies):

Federal Disaster Declaration:

Name SSN

Dates

Location Deployed District/Unit/Clinic

Total Hours

Total Form completed by: Date
Retain to document future federal disaster relief claims
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GA WIC 2005 PROCEDURES MANUAL

Communications Log

Date

Time

Name of Communicator

Message

Person Receiving Communication

Action Taken

Attachment DP-3

Lead Person

Closure of Issue

DP-15

GA WIC 2005 PROCEDURES MANUAL AMERICAN RED CROSS LISTING

Attachment DP-4

CHAPTER
Albany Cluster I Coverage: Clay, Dougherty, Lee, Randolph, Terrell
Americus Cluster V Coverage: Sumter
Augusta Cluster II Coverage: Burke, Columbia, Glascock, Jefferson, Jenkins, Lincoln, McDuffie, Richmond, Screven, Taliaferro, Warren, Wilkes Baldwin County Cluster VI Coverage: Baldwin, Putnam, Washington, Wilkinson
Bartow County Cluster VII Coverage: Bartow
Bulloch County Cluster III Coverage: Bulloch, Candler, Emanuel

AMERICAN RED CROSS CONTACT
Deborah Blanton 2421 N Slappey Blvd. Albany, GA 31701 (912) 436-4845 Fax:(912) 434-9610
Joan Mason P.O. Box 214 Americus, GA 31709 (912) 924-2026 Fax:(912) 931-0811
Carolyn Maund 811 12th Street Augusta, GA 30901 (706) 826-4463 Fax: (706) 826-4507
Olsen Rogers P.O. Box 516 Milledgeville, GA 31061 (912) 454-2675 Fax:(912) 451-5376
Beth Kennedy 105 North Bartow Street Cartersville, GA 30120 (404) 382-0981 Fax:(404) 606-1600
Vacant P.O. Box 843 Statesboro, GA 30458 (912) 767-4468

Fort Gordon Dwight D. Eisenhower Army Medical Center
Fort McPherson
Fort Stewart Winn Army Community Hospital
Metropolitan Atlanta Cluster VIII Coverage: Fulton, DeKalb, Gwinnett, Cobb, Cherokee, Paulding, Fayette, Butts, Henry, Clayton, Douglas, Rockdale

Rick Tuchscherer P.O. Box 7266 Fort Gordon, GA 30905 (706) 791-3169/6341 After Hours:(706) 791-4517 Fax:(706) 790-4822
Kathy Staten Bldg. 536 Ft. McPherson, Ga 30330 (404) 753-8315
Lynn Dowling Bldg. 8401 P.O. Box 3280 Fort Stewart, Ga 31314 (912) 767-8857/2197 After Hours:(912) 767-2197/8666 Fax:(912) 368-6353
Martha W. Ferguson 1955 Monroe Drive, N.E. Atlanta, Georgia 30324 (404) 881-9800 Fax: (404) 874-2993

CHAPTER Hunter Army Airfield
Marine Corp Supply School Covered by: Albany Chapter

AMERICAN RED CROSS CONTACT
Mark Stall Building 401 Hunter Army Airfield, GA 31409 (912) 352-5410 After Hours:(912) 651-5310

Moody Air Force Base Naval Air Station, Albany

John Lukens 5124 Austin Ellipse Moody AFB, GA 31699 (912) 244-3570 Fax:(912) 333-3114

Georgia Low Country
Cluster III Coverage: Liberty, Long, Tattnalli, Wayne

Kenny Murphy P.O. Box 242 Hinesville, GA 31313 (912) 876-3975

Glynn County Cluster III Coverage: Appling, Glynn,
Gordon County Cluster VII Coverge: Gordon

McIntoshBeth VanDerbeck P.O. Box 1436 Brunswick, GA 31521 (912) 265-6467/1695 Fax:(912) 261-1443
Mary Thomas P.O. Box 342 Calhoun, GA 30703-0342 (706) 629-4510

Griffin Cluster VIII Coverage: Spalding
Houston-Middle Georgia Cluster VI Coverage: Bleckley, Dooly, Hancock, Houston, Lamar, Macon, Pulaski, Taylor, Wilcox

Brenda Hoard 100 South Hill Street Griffin, Ga 30244 (404) 227-3145
Sam Register 346 Corder Warner Robbins, GA 31088 (912) 923-6332 Fax:(912) 922-8858

Toombs County Cluster III Coverage: Montgomery, Toombs, Treutlen, Wheeler

Stan Bazemore P.O. Box 49 Lyons, Georgia 30436 (912) 526-3150

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GA WIC 2005 PROCEUDRES MANUAL

Attachment DP-4 (con't)

CHAPTER
Murray County Cluster VII Coverage: Murray
Newton County Cluster II Coverage: Newton
Northeast Geor gia Cluster I Coverage: Dawson, Fannin, Forsyth, Gilmer, Habersham, Hall, Lumpkin, Pickens, Rabun, Stephens, Towns, Union, White Rome-Floyd County Cluster VII Coverage: Chattooga, Dade, Floyd, Polk
Savannah Chapter Cluster III Coverage: Bryan, Chatham, Effingham
Southeast Georgia Cluster III Coverage: Atkinson, Bacon, Brantley, Clinch, Coffee, Jeff Davis, Pierce, Telfair, Ware Thomas County Cluster IV Coverage: Decatur, Grady, Seminole, Thomas
Tift County Cluster IV Coverage: Ben Hill, Irwin, Tift, Turner, Worth Troup County Cluster V Coverage: Troup
Upson County Cluster VI Coverage: Pike, Upson
Dobbins Air Force Base Covered by: Fort McPherson

AMERICAN RED CROSS CONTACT
Annette Patton P.O. Box 1301 Chatsworth, Ga 30705 (706) 695-7605

Laura Bertram 7144 Floyd Street Covington, GA 30209 (404) 786-2018 Fax: (404) 287-1236
Pamela Watts 425 Bradford Street, N.W. Gainesville, GA 30501 (404) 532-8453 (800) 282-1722 (in GA)

Jean Lambert 311 Turner McCall Blvd. Suite A Rome, GA 31065-2733 (706) 291-6648 Fax:(706) 235-2842
Angela Viney 422 Habersham Street Savannah, GA 31401 (912) 651-5300/5310/5385 Fax:(912) 651-5329

Ossie Andrews 809 Isabella Street Waycross, Georgia 31501 (912) 283-7846/4639

Gardiner Hasty P.O. Box 1135 Thomasville, Georgia (912) 226-2181

31799-1135

Maxine Franks P.O. Drawer 70770 Tifton, Georgia 31793 (912) 382-3133
Barbara Hudson 411 South Greenwood St. Suite #B LaGrange, Georgia 30240 (706) 884-5818 Fax: (706) 882-4364
Jeanne Hinson 310 North Church Street Thomaston, Georgia 30286 (706) 647-3023

CHAPTER
Valdosta Cluster IV Coverage: Berrien, Brooks, Echols
Walker County Cluster VII Coverage: Walker
Naval Air Station Atlanta Covered by: Fort McPherson
Ranger School Covered by: Ft. Benning
Robins Air Force Base/ Robins AFB Hospital
Walton County Cluster II Coverage: Walton
West Central Georgia Cluster V Coverage: Calhoun, Chattahoochee, Harris, Marion, Meriwether, Muscogee, Putnam, Quitman, Stewart, Talbot, Webster West Georgia Cluster VII Coverage: Carroll, Clay, Harralson, Randolph, Schley Wilkes County Cluster II Coverage Wilkes
Fort Gillem Covered by: Fort McPherson
Fort Benning/Martin Army Hospital

AMERICAN RED CROSS CONTACT
Stephen Coyne 707 North Patterson Street Valdosta, Georgia 31601 (912) 242-7404 Fax: (912) 242-1553 Jerry Lipps P.O. Box 372 Lafayette, Georgia 30728 (706) 638-2546
Chris Miller Family Support Center 825 9th Street, Suite #109 Robins AFB, GA 31098 (912) 926-5493 After Hours: (912) 923-6332 Don Shedd 2499 Pannell Road, S.E. Monroe, GA 30655-9611 (404) 267-3534 Fax: (404) 207-4338 Jean Kent 3940 Rosemont Drive Columbus, Georgia 31904 (706) 323-5614 Fax: (706) 322-2495
Marianne Chance 401 Bradley Street Carrollton, Georgia 30117 (404) 832-6112 Sniggy Eskew P.O. Box 774 Washington, GA 30673 (706) 678-4650 Fax: (706) 678-3752
Station Manager P.O. Box 51945 Fort Benning, GA 31995 (706) 545-5194 Fax: (706) 545-5118

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GA WIC 2005 PROCEDURES MANUAL

Attachment DP-5A

PAGE

OF

DISASTER DAILY WORK ACTIVITY LOG

DATE:

/

/

NAME: DISTRICT:

OFFICE:

SSN:

NEW ACTIVITY TIME: :
ACTIVITY LOCATION: Activity Description:

AM

AM

PM to :

PM BLDG:

OTHER:

NEW ACTIVITY TIME: :
ACTIVITY LOCATION: Activity Description:

AM

AM

PM to :

PM BLDG:

OTHER:

NEW ACTIVITY TIME: :
ACTIVITY LOCATION: Activity Description:

AM

AM

PM to :

PM BLDG:

OTHER:

SIGNATURE:

DATE:

Note: MUST ATTACH TO DISASTER EMPLOYEE LOG.

RETAIN COMPLETED LOG FOR USE IN DOCUMENTING FUTURE FEDERAL CLAIMS

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GA WIC 2005 PROCEDURES MANUAL

Attachment DP-5B

DP-19

GA WIC 2005 PROCEDURES MANUAL Division Mutual Aid Agreement

Attachment DP-6

MEMORANDUM AMERICAN RED CROSS AND GEORGIA DEPARTMENT OF PUBLIC HEALTH

TO:

DATE: July 17, 1995

FROM: Patrick J. Meehan, M.D., Dir. Division of Public Health Carol Rittenhouse, RN American Red Cross General Manager, Field Services

RE: The New Partnership between Health, The American Red Cross, and Public Health Nursing

We are excited about sharing with you the progress made to date by the new partnership between the American Red Cross and Public Health Nursing. Soon after the flood of 1994, the need for this new collaborative effort was determined. During the past several months, representatives of the American Red Cross and Public Health Nursing have jointly agreed upon an approach to use for maximizing the community's response to meet disaster health needs.

This approach calls for: 1. Strong and ongoing collaboration between chapters and public health agencies at
the local level to make disaster health decisions. 2. Establishment and/or expansion of Disaster Health Services Committees to
include representatives from many community partners.

Essential to the success of this partnership is the recruitment, training, and retention of a large pool of nursing volunteers. A major priority is the recruitment of local nurses from all available community sources.
An outline of the new partnership is attached for your further understanding of our current collaborative efforts. In accordance with this new agreement, the partnership is in the process of scheduling joint ARC/PHN meetings with you and your staff in your area. We are asking for your support and participation in this effort.

If you have questions or need further information, please call: Carol Robinson, DPH, 404-657-2700, GIST 294-2700, Susan Adkins, ARC, 404-881-0668 Ext. 593.

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GA WIC 2004 PROCEDURES MANUAL

Attachment DP-6 (cont'd)

THE NEW PARTNERSHIP AMERICAN RED CROSS AND PUBLIC HEALTH NURSING
PURPOSE:

The purpose of the new partnership between the American Red Cross and the Department of Public Health Nursing is to build and maintain resources necessary to respond to and prepare for health needs related to local disaster.
PROCEDURE:

1. The cluster resource chapter manager and corresponding district public health nursing coordinator will be asked to convene a meeting of: All chapters' disaster health committees/volunteers. All public health nursing coordinators within the cluster area. District public health officials: EMS, Environmental Services, Epidemiology. Emergency Management Agency Representatives within cluster.

Representatives of the following agencies are also suggested as invitees:

Home Health Agencies

Schools of Nursing

Hospitals

School Nurses

Occupational Health Nurses

Adult and Technical Education

Medical/Nursing

Long Term Care Facilities

2. The purpose of the cluster meeting will be to:

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GA WIC 2004 PROCEDURES MANUAL

Attachment DP-6 (cont'd)

A. Discuss the importance of collaboration among agencies preparing for and responding to disaster health needs.

B. Review the roles and responsibilities (current and potential) of each agency in disaster health.

C. Provide a forum for establishing partnerships among agencies in order to develop and strengthen local chapter disaster health committees.

D. Plan strategies for recruiting nurses in the community for disaster response training.

E. Share the process and criteria for Red Cross Instructor Training in Disaster Health.

TIMELINE:

Cluster meetings will be scheduled August through November of 1995. The following order of cluster meetings is anticipated.

Cluster 3 - Savannah, Brunswick Cluster 4 Albany Cluster 6 Macon Cluster 8 Atlanta Cluster 7 Rome Cluster 1 Gainesville Cluster 5 Columbus Cluster 2 Augusta

August September October October October November November November

RESULT:

Meetings among disaster health involved groups should result in the formation or enlargement of a Disaster Health Committee in each chapter. The DHS Committee will develop a disaster health plan that includes the following:

A. An assessment of the vulnerability of the community to a disaster and of the disaster's potential health risks.

B. The development and maintenance of a roster of prepared and available health personnel.

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GA WIC 2004 PROCEDURES MANUAL

Attachment DP-6 (cont'd)

C. The development of cooperative agreements with hospitals and health agencies.
D. The development of a standard price list for replacement of health aids, e.g. glasses.
E. A written plan for mobilizing resources in the event of a disaster.
F. A list of all nursing homes and hospitals in the chapter jurisdiction. The list should identify the contact person and should be updated annually.

DP-23

GA WIC 2005 PROCEDURES MANUAL

Attachment DP-7

WIC Disaster Plan

ESF#6
DEPARTMENT OF HUMAN RESOURCES DIVISION OF FAMILY AND CHILDREN SERVICES MASS CARE AND SHELTER STANDING OPERATING PROCEDURES (August 1995)
The Department of Human Resources/Division of Family and Children and Services, by executive Order of the Governor, will support any emergency of disaster as directed: Emergency Management Act of 1981, O.C.G.A. 38.3.1.

I. Purpose
1. The purpose of these procedures is to provide the basis for a comprehensive emergency management program that will enable the designated staff to respond quickly and effectively to an emergency or disaster.

2. Emergency management coupled with disaster preparedness is designed to minimize loss of life and property in an affected area.

II. General
The Department of Human Resources/Division of Family and Children Services (DFCS) has been designated primary responsibility for (1) coordinating mass and shelter services, (2) administering the Individual and Family Grant (IFG) Program and (3) administering and issuing disaster food stamps in the implementation of the State's overall emergency response plan. DFCS will:
A. Identify mass care and shelter facilities with support from Emergency Management directors and staff of the Division of Public Health, the American Red Cross, and other public and private agencies assigned support roles in this function.
B. Administer and implement the Individual and Family Grant (IFG) Program in the event of a major federal disaster is declared by the President to assist individuals and families who, as a result of a catastrophic occurrence, are unable to meet disaster-related expenses or

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GA WIC 2004 PROCEDURES MANUAL

Attachment DP-7 (cont'd)

serious needs.

C. Distribute USDA food stamps when the disaster results in individuals and families being unable to meet their food and nutrition needs. This requires the approval of the USDA Secretary on a county by county basis.

D. Cooperate with state/local emergency management teams and assist with duties and responsibilities at the state and community levels as set forth in emergency operation plans.

III. Local Responsibilities
A. Pre-disaster mass care planning
Develop and maintain current listing of facilities that will be available and suitable to provide mass care within each county. This included facilities that would host evacuees from at risk Counties and facilities to meet local shelter needs.
Mass Care encompasses shelter, feedings and emergency first aid. Red Cross with the Assistance of Public Health usually administers the emergency first aid within the first 48 hours of an emergency or disaster.
B. Coordinate local mass care and shelters
At the request of the local Emergency Management director operationalize mass care shelter in coordination with the American Red Cross (ARC) and local community agencies or group with which memorandums of understanding have been developed. The American Red Cross will assume primary responsibility for implementing the mass care and shelter function at ARC-approved sites. DFCS may be needed to staff sites at the onset of their openings for the first 48 hours.

DP-25

GA WIC 2004 PROCEDURES MANUAL

Attachment DP-7 (cont'd)

C. Staff the ARC Service Center
Local DFCS staffs help provide information and referral services to disaster victims, provide information regarding individuals within the affected area to family members outside of the affected area and distribute emergency relief items. These services may be provided at a service center established by ARC in the affected community.
D. Staff the Disaster Assistance Center (DAC)
Provide at least one staff person from the affected area to provide information and referral services at the Georgia Telephone Registration Assistant Center (GTAC) established by GEMA or Disaster Assistance Center (DAC) Established by the Federal Emergency Management Agency (FEMA).
E. Disaster Food Stamp Program
Gather date required to apply for the Disaster Food Stamp program or to request waivers to regular State Food Stamp Program. After the USDA Secretary grants the disaster program and or waivers, DFCS will manage and staff the certification for and issuance of food stamps to eligible individuals and families of a disaster.
F. Grievances
As provided for in applicable DFCS procedures, inform individuals and families of their rights to appeal actions taken by the agency. The Commissioner's Office of Policy and Governmental Services Office, Legal Services office to the Office of State Administrative Hearing, will forward individual grievances.
G. Reports
Provide requested information and status reports to The Department of Human Resources Emergency Manager for submission to GEMA and in turn, FEMA as well as designated others. All local reports are submitted through the State Office of the Division of Family and Children Services.

DP-26

GA WIC 2004 PROCEDURES MANUAL

Attachment DP-7 (cont'd)

IV. Procedures

A. The GEMA Director or designee will notify DHR of a disaster. The DHR Emergency Crisis Team Manager will provide guidance and support to the DFCS Emergency Management Coordinator to help local DFCS staff meet the "responsibilities in Section III of this document".

B. Staff ARC-approved shelters for not more than 48 hours when requested by ARC.

C. DFCS will offer support to American Red Cross in the delivery of services at the ARC Service Center(s).

D. In the event of a Presidentially declared disaster, FEMA may open a DAC in the affected area. FEMA will announce Hotline (1-800) tale-registration number and take applications for the IFG program by telephone. FEMA will also provide referral service information to callers.

E. DHR/DFCS will execute the assigned roles as required to assist the affected community area(s).

F. State and county DFCS staff will participate in emergency management training and exercise.

G. Each county DFCS director or designee will participate in the development of the local Emergency Management Plan. The local team will review the pan annually and update it as new or changed resources or procedures are identified.

H. Each county DFCS director or designee will take lead responsibility for developing suitable locations for providing mass care in conjunction with the local County Emergency Manager and American Red Cross.

Potential sites are evaluated by ARC, Public Health environmentalist and Rehabilitation Service community service specialists. A shelter requires Public Health approval. ARC approval is desirable, but is not required where Chapters are not available.
If the site is not approved by ARC but is approved by a Public Health environmentalist, the county director will develop a memorandum of understanding with the owner or other appropriate person(s) to use the facility for mass care. The facility arranges for staff and food, which may be provided by a volunteer group at the facility. (For

DP-27

GA WIC 2004 PROCEDURES MANUAL

Attachment DP-7 (cont'd)

example, a church recreation hall may serve as a shelter. Church Members or a community volunteer group may provide staff end meals.

V. State Responsibilities
A. The DHR Emergency Management Crisis Team Manager is the official liaison with GEMA and upon GEMA request with FEMA and coordinates services between the divisions of the Department.

B. The DHR office of Financial Services, in coordination with DFCS Planning, Budgeting and Reporting staff, manages the draw down of Federal funds foe disasters and the issuance of the IEG benefits, and prepares final fiscal figures for closing the IFG Program.
C. DFCS Emergency Management Coordinator staffs and oversees all disaster planning, mitigation, response and recovery efforts and programs within the Division, and works closely with the DHR Emergency Management Crisis Team Manager.
D. The DFCS Disaster Recovery and Mitigation Unit Manager coordinates DFCS service delivery at the GTAC and DAC with affected local county directors; oversees submits requires reports in a timely manner; supervises unit staff and-services as needed as liaison to local partner agencies; directs timely annual revisions to the State IFG Plan; and defines the expectations of staff and development internal procedure for accomplishing the goals of the unit.
E. The DFCS Emergency Management Coordinator and the DFCS Disaster Recovery and Mitigation Unit Manage completes closure of Program. Final reports are submitted through the DHR Emergency Management Crisis Team Manager to the GEMA Executive Director for close-out with FEMA.
F. Final reports of the Disaster Food Stamp Program are submitted the USDA Food and Consumer Service with copier to the DHR Emergency Crisis Team manager for GEMA Executive Director.

DP-28

Georgia WIC Program Procedures Manual GLOSSARY 2005

GA WIC 2005 PROCEDURES MANUAL
Acceptable Proof - Documentation reviewed by clinic staff to determine the qualification or disqualification of a WIC participant.
Adjunctive Eligibility - Automatic income eligibility for WIC applicants.
Administrative and Program Service Costs - Direct and indirect costs, exclusive of food costs, which State and local agencies determine to be necessary to support Program operations.
Adopted Child - A child that lives with a family who has accepted legal responsibility.
Affirmative Action Plan - Portion of the State Plan which describes how the Program will be initiated and expanded within the State's jurisdiction.
Agricultural Occupation - Employment related to the production, growth, and harvesting of commodities grown in or on land, or an adjunct to a part of a commodity grown in or on land.
Allocation of Funds - The allocation of funds is based on a methodology that includes an analysis of the district's participation at the beginning of the fiscal year by WIC type, within priority. The projected amount to be spent for the total fiscal year is then calculated and, based on priorities, the Allocation Advisory Committee determines which types will be served. The allocation of administrative funds is based on an average cost per participant and is distributed to the local agencies after state administrative costs have been deducted.
Alphabetic Client Master file - An enrollment report which lists selected participant information for all active participants.
And Justice For All Poster - Poster which must be displayed in a conspicuous location in each WIC Clinic site indicating the WIC non-discriminatory clause.
Applicants - Pregnant women, breastfeeding women, postpartum women, infants, and children who are applying to receive WIC benefits, and the breastfed infants of applicant breastfeeding women. Applicants include individuals who are currently participating in the program but are re-applying because their certification period is about to expire.
ARMIS - Automated Reports Management Information System. Provides quick and accurate retrieval of WIC data at the State, D/U, and Clinic level without resorting to the

Glossary
time consuming effort of viewing paper or microfiche reports.
Automated Termination Action - The system which automatically terminates a participant when a child reaches his/her fifth birthday, a non-breast-feeding woman at 6 months, a breast-feeding woman at 12 months from delivery, failure to pickup vouchers for 2 full consecutive months, transfer out of clinic or district/unit, terminated from waiting list, pregnant woman at EDC + 75 days, or overdue for certification.
Automated TAD/Voucher System (ATVS) - Computer system developed by the WIC Branch to create vouchers and prepare automated turnaround documents (TADs). The vouchers and TADs are submitted to the ADP contractor via modem or diskette.
Automatic Update of Infant to Child - The system automatically updates an infant to a child when the infant reaches his/her first birthday.
BAQ - Basis Allowance for Quarters Housing allowance for military families living on base.
BASD - Basic Active Service Date for someone in the military.
Batch Control Form - A 3 ply form which is completed for each transmitted batch of TADs sent to Viking. This form is ordered from DOAS Central Supply through the WIC Branch. A completed form contains the date the batch was assembled, and a four digit sequence number assigned to this batch (can not be duplicated within the same date). The date and the sequence number combined is the Batch Control Number. This number is printed on the computer printed TAD. The district/unit code, clinic code, the number of TADs or Vouchers in the batch (do not mix TADs and vouchers in a batch), the person who prepares the batch should sign and date the Batch Control form upon completion. The top copy of the form goes to the ADP contractor. The second and third copies are retained by the clinic.
Blank Manual Vouchers - Vouchers that require manual entry of certain information by the clinic prior to issuance. It is commonly used for issuance when replacing only a part of a participant's computer generated voucher package, to a newly certified participant or transferring participants when a standard manual voucher package is inappropriate, or to supplement the preprinted manual voucher food package.
Breastfeeding Women - Women up to one year postpartum who are breastfeeding their infants.

Glossary-2

GA WIC 2005 PROCEDURES MANUAL
Budget - An itemized summary of probable expenditures and income for a given period.
Calendar Year - The period of time between January 1st and December 31st.
Cash Income - Applicants/participants who are paid money on site for services rendered.
Categorical Termination - Child who has reached his/her fifth birthday, Postpartum non-breast-feeding woman 6 months after delivery, Postpartum breast-feeding woman 12 months after delivery.
Categorical Eligibility - Woman, Infant or Child who meet the definitions of pregnant women, breastfeeding women, postpartum women, or infants or children.
Certification - The implementation of criteria and procedures to assess and document each applicant's eligibility for the Program.
Children - Child who have had their first birthday but have not yet attained their fifth birthday.
Civil Money Penalty (CMP) - May be assessed in lieu of disqualification. The amount of the penalty will be established using a standard formula. CMP's cannot exceed $10,000 per violation or $40,000 per investigation.
Clinic - A facility where applicants are certified.
Closeout Month - The third month (sixty days) after vouchers were issued.
Closeout Reconciliation Report - Report generated at the clinic level to give the final disposition of all computerprinted vouchers.
Coding of Records - Documenting special codes on record for special treatment for applicants/participants.
Collections - Repayment of WIC funds that were received fraudulently and must be made by cashiers check or money order.
Communal Feeding - Group meals or food supplies.
Competent Professional Authority - An individual on the staff of the local agency authorized to determine nutritional risk and prescribe supplemental foods. The following persons are the only persons the State agency may authorize to serve as a competent professional authority: Physicians, nutritionists, (Bachelors or Masters

Glossary
Degree in Nutritional Sciences, Community Nutrition, Clinical Nutrition, Dietetics, Public Health Nutrition or Home Economics with emphasis in Nutrition), dietitians, registered nurses, physicians assistants (certified by the National Committee on Certification of Physicians Assistants or certified by the State medical certifying authority), or State or local medically trained health officials. This definition also applies to an individual who is not on the staff of the local agency but who is qualified to provide data upon which nutritional risk determinations are made by a competent professional authority on the staff of the local agency.
Computer Generated Vouchers - These vouchers contain a specific food package, individually tailored for each participant's nutritional needs. These vouchers are produced by the ADP contractor and contain information based on the TAD submitted by the clinic. District/Clinic identification numbers are also printed on the vouchers.
Computer Printed Voucher Register - A listing of participants that have computer generated vouchers produced during a cycle and to provide a signature space for verification of receipt of vouchers.
Computing Income - Review documents (i.e. Check Stubs, IRS forms, etc.) to determine the income eligibility of the WIC participant.
Confidentiality - The WIC Program may give the participants certification information to other Health Public Assistance programs to determine if the participant is eligible for their services. These agencies may contact the applicant, but they may not give any information to anyone else without obtaining the participants permission.
Cost Containment Measure - A competitive bidding, rebate or direct distribution implemented by a State agency as described in its approved State Plan of operation and administration.
CSFP - The Commodity Supplemental Food Program administered by USDA.
Cumulative Unmatched Redemption - Identifies redeemed manual vouchers, which have not matched a valid client record. Local Agencies are required to review the redeemed manual vouchers appearing on the CUR report. The vouchers should be reconciled or a manual reconciliation should be done, depending on how much time has elapsed since the voucher was redeemed.
CUR Part 1 - Cumulative Unmatched Redemptions which have not matched to an issuance record.

Glossary-3

GA WIC 2005 PROCEDURES MANUAL
CUR Part 2 - Cumulative Unmatched Redemptions which have not matched to a valid certification record.
Day Worker - Individual who contracts for labor or services on a daily basis.
Declination Statement Forms - A form used to document refusal to want to register to vote.
Delivery Date - Indicates the date of actual delivery of an infant (or the date the pregnancy ended) for a postpartum woman.
Disability - A physical incapacitated or disabling condition which prevents or restricts normal accessibility or activity included are visual and hearing impaired individuals.
Disqualification - The act of ending the program participation of a participant, authorized food vendor, or authorized State or local agency, whether as a punitive sanction or for administrative reasons.
Disqualified Vendors - Vendors that are found to be in violation of program policies and regulations through compliance investigation. Vendors will be assessed sanction points for violations occurring in each investigation visit.
DOD - Department of Defense
Donations - WIC foods and other food items purchased as a result of the compliance investigations. These items are donated to non-profit organizations within the city(ies) where the purchases are made by the investigator.
Dual Participation Report - This report specifies possible dual participants in alphabetic sequence, which must be investigated by the local agency and submitted to the WIC Branch.
Dual Participation - WIC participants who receive benefits twice in the same clinic, or from more than one clinic.
EBT - Electronic Benefit Transfer.
EDC (Estimated Date of Confinement) - Indicates the date of expected delivery for a pregnant woman.
Education Level - Indicates the highest level or grade completed, for women participants only.

Glossary
Enrollee - A client who is active and in a valid certification period, but did not receive vouchers during the reporting month.
Ethnicity of Participant 1=Yes, Hispanic/Latino, 2=No, Not Hispanic/Latino.
Equipment Inventory - A detailed listing of all property purchased with WIC funds and valued at a minimum of $1000.00.
Fair Hearings - Procedures under which a person or his/her guardian will be guaranteed the right to appeal a decision or action by the State or local agency which results in the individuals denial of participation, suspension, or termination from the program.
Family - A group of related or non-related individuals who are living together as one economic unit, except that residents of a homeless facility or an institution shall not all be considered as members of a single family.
Family and Children Services - Government agency responsible for the welfare of children.
Family Size - Identifies the total number of individuals in a household.
Fiscal Year - The WIC Program operates under the constraints of both the federal fiscal year (October 1 through September 30) and the state fiscal year (July 1 through June 30).
FNS - The Food and Nutrition Service of the United States Department of Agriculture.
Food Delivery System - The method used by State and local agencies to provide supplemental foods to participants.
Food Costs - The costs of supplemental foods.
Food Instrument - A voucher, check, coupon or other document, which is used by a participant to obtain supplemental foods.
Fraud - Intentional deception.
Grant Award (Formula Grant/Grant Allocation) - Total (food and administrative) dollars allocated to the State for the federal fiscal year based on funding formula.
Health Services - Ongoing, routine pediatric and obstetric care (such as infant and childcare and prenatal and postpartum examinations) or referral for treatment.

Glossary-4

GA WIC 2005 PROCEDURES MANUAL
Height - The vertical length (depending on the age) of a participant to the nearest eighth inch.
Hematocrit - Medical criteria required to assess nutritional risk.
Hemoglobin - Medical criteria required to assess nutritional risk.
Homeless - A woman, infant or child who does not have regular fixed night time residence, or resides in a temporary public or private shelter.
Homeless Individual - A woman, infant or child who lacks a fixed and regular night time residence; or whose primary night time residence is: A supervised publicly or privately operated shelter (including a welfare hotel, a congregate shelter, or a shelter for victims of domestic violence) designated to provide temporary living accommodation; an institution that provides a temporary residence for individuals intended to be institutionalized; a temporary accommodation in the residence of another individual; or a public or private place not designed for, or ordinarily used as, a regular sleeping accommodation for human beings.
Homeless Facility - A supervised publicly or privately operated shelter (including a welfare hotel or congregate shelter) designed to provide temporary living accommodations; a facility that provides a temporary residence for individuals intended to be institutionalized; or a public or private place not designed for, or normally used as, a regular sleeping accommodation for human beings.
Hospital Certification - Reviewing hospital documentation for eligibility of applicants/participants for the WIC program.
HOST - Health Outcomes Services Tracking System.
Identification - Valid picture ID or other valid ID such as Drivers License, Birth Certificate, Immunization record, etc.
Inadequate Participant Access - A condition that exists when the nearest authorized WIC vendor is ten (10) miles or more away from another authorized WIC vendor.
Incident/Complaint Form - Form #3772 titled Incident/Complaint Form. This form is used to document complaints from participants, vendors, USDA, etc.

Glossary
Income - Gross cash income before deductions for income taxes, employee's social security taxes, insurance premiums, bonds, etc.
Income Exclusion - Income or benefits received that are not counted as income.
Income Inclusion - Monetary compensation for service including wage, salary, commissions or fees that are counted as income.
Income Tax Form - Legal Statement of earnings and deduction as prescribed by the IRS Tax Codes.
Infant Mid-Certification Nutrition Assessment - The assessment to be completed between five and seven months of age for an infant. The infants weight, height, hemoglobin or hematocrit, diet, nutritional risk, and food package needs are evaluated during this assessment. This assessment ensures accessibility to quality health care services.
Initial Contact Date - The date an applicant first visits the WIC clinic during office hours and requests WIC benefits, orally or in writing.
Institution - Any residential facility designed to provide meals and living accommodations for individuals intended to be institutionalized but excludes private residences or homeless facilities.
Institutionalize - To reside in, by choice or otherwise, an established residential facility that provides accommodations and meals.
Inventory - A detailed list of all goods and materials on hand.
Issue Month - The month in which vouchers were issued.
Joint Custody - A child who resides in more than one home as a result of a joint custody situation shall be considered part of the household of the parent who is applying on behalf of the child.
LQA - Living Quarter Allowance for military applicant/participant living off base.
Leave and Earnings Statement (LES) - Paycheck stub for the military.
Legal Custody - Court ordered custody of a person.
LEP - Limited English Proficient.

Glossary-5

GA WIC 2005 PROCEDURES MANUAL
Letter of Household Income - Statement attesting to household income by wage earner(s).
Local Agency - A public or private, nonprofit health or human service agency, which provides health services, either directly or through contract.
Logger - An individual whose primary employment is the harvesting of trees seasonally; and for such work the person establishes temporary residence.
Manual Voucher Inventory Log - Documentation that vouchers are inventoried on a weekly and monthly basis.
Medical Care Start Date - Indicates which month of the pregnancy the woman began receiving prenatal care.
Members of Populations - Persons with a common special need who do not necessarily reside in a specific geographic area, such as off-reservation Indians or migrant farm workers and their families.
Memorandum of Agreement - Written operation agreement between the State of Georgia and the Health District or agency where WIC services are delivered.
MIER (Monthly Income and Expense Report) - An itemized summary of all WIC expenditures reported monthly by each Local Agency.
Migrant Farm Workers - An individual whose principal employment is in agriculture on a seasonal basis, who has been so employed within the last 24 months, and who establishes, for the purposes of such employment, a temporary abode.
Migrant - A seasonal farm or agricultural worker or family member who travels from place to place for the purpose of work and such work requires the establishment of temporary residence.
Minimum Inventory Requirement Waiver - This waiver is granted to reduce the minimum inventory when a WIC vendor has difficulty selling WIC food items.
Motor Voter Act - An act that mandates the WIC Programs obligation to offer voter registration opportunities to anyone entering a clinic for WIC benefits.
Motor Voter Forms - A form issued to applicants that wish to register to vote.
Native American - The original inhabitants of America; an American Indian.

Glossary
No-Proof Form - Form used when an applicant for WIC cannot provide documented proof of identification, residence or income. Non-Participation - Participants in a valid certification period who do not pick up (manual or computer) are counted as a non-participant.
Non-Breast-feeding - Postpartum woman who is not breast-feeding an infant.
Non-English Speaking - Individual whose primary language is not English or speaks little English.
Nonprofit Agency - A private agency which is exempt from income tax under the Internal Revenue Code of 1954, as amended.
Numeric Client Master file - An enrollment report, which list all active participants. This report is a cross reference for the Alphabetic Client Master file. It provides the client names by ID number.
Nutrition Education - Individual or group education sessions and the provision of information and educational materials designed to improve health status, achieve positive change in dietary habits, and emphasize relationships between nutrition and health.
Nutritional Assessment - Contains medical data obtained and evaluated by a CPA, which determines a participant's nutritional risk.
Nutritional Risk - Detrimental or abnormal nutritional conditions detectable by biochemical or anthropometric measurements; other documented nutritionally related medical conditions; dietary deficiencies that impair or endanger health; or conditions that predispose persons to inadequate nutritional patterns or nutritionally related medical conditions.
OIG - The USDA Office of the Inspector General.
Overseas WIC Program - A program similar to the USDA operated program that qualifies military persons, their dependents and government civilians for WIC benefits overseas.
Participant - A participant is a client who has been issued at least one voucher during the reporting period.
Participation - The sum of the number of persons who have received supplemental foods or food instruments during the reporting period and the number of infants breast-fed by participant breastfeeding women (and

Glossary-6

GA WIC 2005 PROCEDURES MANUAL
receiving no supplemental foods or food instruments) during the reporting period.
Patient Flow Analysis - A tool to analyze the ranges of time of a certification period form entry until exit. It also analysis voucher issuance time, bottlenecks and appointments.
Patient Flow Form - Tools used to measure the examination of patient flow.
Paid Cash - Applicant/Participant is paid in cash for work or services rendered.
Pay Stub - Statement of paid income earned.
PedNSS - The Pediatric Nutrition Surveillance System (PedNSS) is a national nutrition surveillance system administered by CDC.
Physical Presence - Applicant for WIC services must be present in the clinic to request WIC services.
PNNS Data - The Pregnancy Nutrition Surveillance System (PNSS) is a national nutrition surveillance system administered by CDC.
P.O. Box - Post Office Box.
Post Vendor Training Evaluation - A test pertaining to WIC vendor requirements given to all vendors when attending the initial and annual vendor training.
Postpartum Women - Women up to six months after termination of pregnancy.
Poverty Income Guidelines - The poverty income guidelines prescribed by the Department of Health and Human Services. These guidelines are adjusted annually by the Department of Health and Human Services, with each annual adjustment effective July 1 of each year.
Pregnancy Outcome - The results of the just ended pregnancy for the postpartum woman participant.
Pregnant Women - Women determined to have one or more embryos or fetuses in uterus.
Prenatal Women - Pregnant female between the ages of 10 and 55 years.
Prenatal Weight - Prenatal woman's weight prior to delivery.

Glossary
Presumptive Eligibility - Individual presumed eligible for Medicaid, benefits based upon information presented.
Priority I - Pregnant women, breast-feeding women, and infants at nutritional need determined by measuring height/weight, taking a blood test and medical history.
Priority II (Breast-feeding women) - Women who do not qualify under priority I, but are breast-feeding Priority II infants.
Priority II (Infants) - Infants up to six months of age born to women who were WIC Program participants during their pregnancy, or infants born to women who were not WIC Program participants during their pregnancy but had a nutritional need.
Priority III (Children) - Children with a nutritional need. This need is determined by measuring height/weight, taking a blood test and medical history.
Priority III (Postpartum) - Postpartum teenagers who are not breast-feeding.
Priority IV - Pregnant women, breast-feeding women, and infants with a nutritional need because of poor diet or homeless/migrancy status.
Priority V - Children with a nutritional need because of poor diet or homeless/migrancy status.
Priority VI - Postpartum, non-breast-feeding women with a nutritional need, or homeless/migrancy status and homeless/migrant postpartum non-breast-feeding teenagers.
Procedures Manual - A document that lists federal and state regulations for the WIC Program.
Processing Standards - Period of time an applicant requests WIC services in person to the time he/she receives services.
Program - The Special Supplemental Food Program for Women, Infants and Children (WIC) authorized by section 17 of the Child Nutrition Act of 1966, as amended.
Prorate - The partial issuance of vouchers. The most common cause for the partial issuance of vouchers is missed appointments for voucher pick up. The number of vouchers withheld depends on the number of days the participants are late picking up their vouchers.
Protective Services - A program design to protect the rights of children.

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Glossary

Proxy - Responsible person whom the participant/ parent/guardian/caretaker chooses to act on his/her behalf. A participant may designate up to 2 persons to act as proxy. The proxies must sign the space on the participant's WIC ID card. An authorized proxy may pick up or redeem vouchers and may bring the child in for subsequent certifications, in restricted situations.
Racial Group of Participant - 1=White, 2=Black/African American, 3=Asian, 4=American Indian/Alaska Native, 5=Native Hawaiian/Other Pacific Islander, and 6=Multiracial.
Reason for Certification - A participant's nutritional need for the WIC Program, based on the medical/nutritional data collected at the time of certification.
Redemption - The exchange of WIC vouchers for supplemental foods at participating grocery stores. Only authorized foods (listed on the face of the voucher) may be purchased.
Refugee - Someone who flees his or her native country due to persecution or well-founded fear of persecution because of race, religion, nationality, political opinion, or membership.
Residency - Determined by using the applicants documented proof of address.
Residual Funds - Funds remaining available for allocation to State agencies after every State agency has received the amount allocable to it as stability finds.
Return Voucher Payment Form - Form #3760 titled Return Voucher Payment Log. Vendors use this form used by Vendor when sending vouchers, that have been returned to them from the bank, to the State WIC Office for payment.
Seasonal Farmworker - A worker employed in agriculture occupation whose residence is not temporary for the purpose of such work.
Secretary - The Secretary of Agriculture.
SFPD - The Supplemental Food Programs Division of the Food and Nutrition Service of the United States Department of Agriculture.
Special Formula - Formula that is not the standard contract formula. This formula is approved when a written prescription from a medical doctor with the diagnosis included is given to the participant.

Special Population - An Individual or a group of individuals with common needs who require special assistance or service to access and participate in WIC related services.
Special Site Visit - An official district/clinic visit requested by the State WIC Branch due to various clinic problems. A district/clinic may be called one day on a site visit may take place the next day due to the severity of the problem identified.
Stability Funds - Funds allocated to any State agency for the purpose of maintaining its preceding years Program operating level.
Staff Signature - The WIC Official signature verifies the income residency, identification and family size are correct as stated by the participant. The Staff signature also verifies/witness the participant signature and the participant has been advised to read (or have read to them) their rights and obligations.
Standard Formula - A particular type of formula provided by the State. All infants participating in the Georgia WIC Program will be provided with vouchers for the formula the program is under contract to use.
State - Any of the 50 States, the District of Columbia, the Commonwealth of Puerto Rico, the Virgin Islands, Guam, American Samoa, the Northern Marinas Islands and the Trust Territory of the Pacific Islands.
State Agency - The health department or comparable agency of each State; an Indian tribe, band or group recognized by the Department of the Interior.
State Plan - A plan of program operation and administration that describe the manner in which the State agency intends to implement and operate all aspects of program administration within its jurisdiction.
Supplemental Foods - Those WIC foods containing nutrients determined to be beneficial for pregnant, breastfeeding, and postpartum women, infants and children.
TANF - Temporary Assistance for Needy Families Program.
Temporary Accommodation - A public or private shelter or the residence of another person used for temporary living and sleeping accommodation.

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Temporary Relocation - The establishment of a temporary residence for individuals whose primary place of residence is lost as the result of disaster, or other privation.
Thirty (30) Day Issuance - The issuance of vouchers to participants for thirty (30) days until documentation is received.
Transfers: Into - This transaction is used to transfer a participant already assigned an ID number on the computer system from one Georgia WIC Clinic to another. The transaction code is (X).
Turnaround Documents (TADs), Blank - A TAD which only has the Clinic Code field preprinted on it. This TAD is used for enrolling any additional family members onto the computer system through the use of either an Initial Certification, Waiting List, or Out of State Transfer input transaction. This TAD may also be used to complete an in-state transfer or any time a Computer Printed TAD is not available.
Turnaround Documents (TADs), Prenumbered - A TAD has the clinic code field and the complete WIC ID number field (with participant code 1) preprinted on it. The remainder of the form is blank. This TAD is used for enrolling the first member of a family onto the computer system through the use of either an Initial Certification, Waiting List, or Out of State Transfer input transaction.
Unemployed - Individual who is not currently being paid for labor or services.
Update/Infant Assessment - This transaction is used to change, correct, or update information for a participant already assigned an ID number on the computer system. This transaction is also used to enter the mid-certification nutritional assessment information for an infant already on the computer system. The transaction code is (U).
USDA - The United States Department of Agriculture.
VPOD - Vouchers printed on demand/on-site.
VHA - Variable Housing Allowance.
Vendor Compliance Investigation - Vendors that have been identified as "High Risk" by the State WIC Branch through the use of VAMP, complaints, or request for investigation forms received from the districts.
Vendor Registry Update - A form used to update information regarding approved WIC vendors.

Glossary
Vendor Materials - A list of resources available through the Georgia WIC Branch that pertains to vendor management.
Vendor Monitoring - An overt compliance activity that is conducted on site by WIC Program representatives.
Vendor Profile - A summary of information about a vendor designed to show their overall standing with the program.
Vendors Review Form - A tool that is used to document a vendor's shelf prices and inventory of WIC approved foods.
Vendor Sanctions - Penalties that are assessed to a WIC vendor for violating program policy and/or regulations that may lead to disqualification.
Vendor Stamp - A uniquely numbered instrument that is used by vendors to prepare vouchers for payment.
Vendor Training Checklist -A form that lists topics which are covered during a training session .
Vendor Training Sign-In Sheet - A form used to document attendance at a training session.
VIPS (Vendor Integrity Profile System ) - A computerized data base that contain information on all vendors in Georgia.
VOC - Verification of certification confirming that all requirements for WIC participation have been met.
VOC Card - A certification card from a WIC clinic verifying that the named person is a valid WIC participant entitling that individual to transfer certification to a new clinic.
Voided Vouchers - Both computer generated and manual vouchers may be voided for a variety of reasons. There are three different categories of voids: Voided Computer Generated Vouchers, Voided but issued manual vouchers, and Voided but Unissued Manual Vouchers.
Vouchers Printed On Demand - Vouchers are printed as the participant appears in the clinic.
Voucher Security - WIC vouchers are negotiable items which are presented to the bank as a check for cash reimbursement. Therefore all vouchers must be securely protected as checks or cash in order to help prevent voucher theft, and deter program fraud.

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Voucher Number - The serial numbers of the vouchers produced for a participant.
Weight - Total weight in pounds and ounces of a participant.
Weight, Prior to Delivery - Indicates the woman's final weight immediately prior to delivery.
WIC ID Number - Uniquely identifies the participant. It consists of 3 data elements: A 9-digit family identification number, a 1-digit check digit, and a 1-digit participant code. All members of a family should be assigned the same family identification number to facilitate voucher distribution.
WIC Type - Classifies WIC participants i.e., P=Pregnant Woman (Prenatal), N=Non-breastfeeding postpartum woman, B=Breastfeeding postpartum woman, I=Infant, and C=Child.
Zero Income - Applicant/Participant receives no monies from work, services or any entitlement programs

Glossary

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