2012 Georgia WIC procedures manual & Georgia state plan [2012]

2012 GEORGIA WIC PROCEDURES MANUAL
& STATE PLAN
ga
GEORGIA DEPARTMENT OF PUBLIC HEALTH

GEORGIA WIC 2012 PROCEDURES MANUAL

Introduction

TABLE OF CONTENTS

Page

I.

Purpose/Mission........................................................................................................ IN-1

II.

Scope ........................................................................................................................ IN-1

III.

References ................................................................................................................ IN-1

IV.

Prior Approval............................................................................................................ IN-1

V.

Policy/Action 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-5

G. Nutrition Education (NE)...................................................................................... IN-5

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

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

J. Food Delivery (FD) .............................................................................................. IN-6

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

L. Monitoring (MO) .................................................................................................. IN-7

M. Breastfeeding (BF) .............................................................................................. IN-7

N. Emergency Plan (EP).......................................................................................... IN-7

O. Georgia WIC Glossary ........................................................................................ IN-7

P. Statewide Standard List (Abbreviations, Acronyms and Symbols............................................................................................................... IN-7

GEORGIA WIC 2012 PROCEDURES MANUAL

Introduction

VII.

Administration ........................................................................................................... IN-8

A. Food and Nutrition Services (FNS)/USDA .......................................................... IN-8

B. State Agency ....................................................................................................... IN-8

VIII. Addresses ................................................................................................................. IN-8

A. Local Agencies .................................................................................................... IN-8

B. State Agency ..................................................................................................... IN-16



GEORGIA WIC 2012 PROCEDURES MANUAL

Introduction

I.

PURPOSE/MISSION

The purpose of the Georgia WIC Procedures Manual is to provide local agency staff with a guide to Georgia WIC. The information in this manual is to be used in the delivery of services to Georgia WIC applicants and participants in the State of Georgia.

The mission of the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) is to improve the health of low-income women, infants and children up to age five (5) years who are at nutritional risk by providing nutritious foods to supplement diets, information on healthy eating and referrals to health care. The mission of WIC is to provide policy direction and technical assistance to ensure continuity in program administration, operations, and compliance with program regulations, policies and procedures. The intent of the Grant-In-Aid is to support the efforts of local agencies to provide WIC services.

II. SCOPE
The information in the Georgia WIC Procedures Manual applies to all Department of Public Health agencies, including district health units and non-DPH agencies that contract with DPH to administer and operate Georgia WIC. WIC 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 Georgia WIC Federal Register be filed with the Georgia WIC 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/ACTION MEMOS
Georgia WIC policy/action memos, distributed throughout the year, reflect current policies in Georgia WIC. Policy/action memos must not be re-written by district and/or local staff. Policy/action memos are posted on the Georgia WIC website www.WIC.ga.gov under District Resources Page. These memos must be saved on the employee desktop/laptop. These policies must be kept at the district and clinic levels wherever there is a Georgia WIC Procedures Manual. Policy/action memos must be accessible to all staff that work with Georgia WIC. During monthly/quarterly meetings held with Georgia WIC and non-WIC staff,

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GEORGIA WIC 2012 PROCEDURES MANUAL

Introduction

policy/action memos and changes must be discussed to keep staff abreast of current procedures. Policy/action memos must be made available to Georgia WIC staff during onsite monitoring visits. During the fourth quarter of each year, the Georgia WIC Procedures Manual will be completely revised and reprinted, and all policy/action memos from the previous year will be incorporated.

VI. SECTIONS
Georgia WIC Policy and 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 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 16. Ineligibility Procedures (Notification Requirements) 17. Transfer of Certification 18. WIC Overseas Program

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GEORGIA WIC 2012 PROCEDURES MANUAL
19. Correcting Official WIC Documents 20. Late Entry Correction on Health Records 21. Documentation Procedures 22. Waiting List 23. System Information Management 24. Immunization Coverage Assessment 25. Complaint Procedures 26. Special Certification Conditions (Home Certifications) 27. Special Certification Conditions (Hospital Certifications) 28. Client Staff Ratio 29. PNSS Data Collection 30. WIC Interview Script
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 10. Pre-Approval/Pre-Award Review
D. Administrative (AD) Section includes: Section One Financial Management 1. State Operations 2. Local Agency Operations 3. Financial Procedures 4. Funding Requirements 5. Equipment Inventory 6. Retroactive Benefits and Reimbursements 7. Local Agency Collections
Section Two Statewide Cost Allocation Plan 1. Introduction to WIC Statewide Cost Allocation Plan 2. Basic Cost Principles/WIC Allowable Costs 3. Method for Charging the Cost of Wages and Salaries 4. Guidelines for local Agency Cost Allocation Methodology
Section Three Program Administration
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Introduction

GEORGIA WIC 2012 PROCEDURES MANUAL

Introduction

1. Retention of Records 2. WIC Acronym and Logo 3. Lobbying Restrictions 4. Confidentiality 5. E-Mail and Faxing Confidential Information 6. WIC Volunteers and Confidentiality 7. Health Insurance Portability and Accountability Act 8. Retroactive Benefits and Reimbursements 9. Mandatory No-Smoking Policy 10. Subpoenas 11. Search Warrants 12. WIC Participation 13. Establishing New Clinics/Clinic changes 14. Clinic Closings 15. Reporting Systems Problems 16. Request for Financial and/or Statistical Data 17. Identification Cards and Food List Order 18. Client/Staff Ratio 19. Nutrition Services Director Job Description 20. Compliance Reviews 21. Medical Nutrition Therapy 22. Registered and/or Licensed Dietitian Credentialing Policy for DPH 23. Conflict of Interest 24. Renovations 25. Inter/Intra Agency Agreement 26. Patient Flow Analysis 27. State Plan 28. Local Agency Application, Disqualification and Administrative Review 29. Special Project Program 30. Request Form for a New Facility 31. Participant Characteristics Minimum Data Set (MDS) 32. Local Agency Funding Allocation for Information on Funding Allocations
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

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GEORGIA WIC 2012 PROCEDURES MANUAL

Introduction

7. High Risk Identification System 8. Prohibition Against Certain Vendors-Consolidated Appropriations Act 2005 9. Vendor Cost Containment 10. Routine Monitoring 11. Vendor Sanction System 12. Administrative Review 13. Coordination with Supplemental Nutrition Assistance Program (SNAP) 14. Staff Training in Vendor Management
F. Food Package (FP) Section includes: 1. Authorization of Foods 2. Prescribing Foods - General 3. Infants 4. Women, Children and Infants with Qualifying Medical Conditions 5. Children 1-5 years 6. Women 7. Homelessness, Migrancy, and Disaster Situation 8. Medical Documentation 9. Formula Distribution/Tracking Guidelines 10. Office of Nutrition Special Formula Orders 11. Emory Genetics
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

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GEORGIA WIC 2012 PROCEDURES MANUAL

Introduction

I.

Outreach (OR)

Section includes:

1. General

2. Methods of Outreach

3. Agencies to Contact for Outreach

4. Public Notification

5. Public Comments Period

6. Outreach During A Waiting List

7. Program Costs

8. Coordination/Integration of Services

J. Food Delivery (FD) Section includes: 1. General 2. Types of WIC Vouchers 3. Voucher Issuance - General 4. 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. Prorated Vouchers 9. Late Pick-up of Vouchers 10. Coordination of Health Services and Voucher Issuance 11. Lost, Stolen or Damaged Vouchers 12. Borrowed Vouchers 13. Critical Errors 14. Cumulative Unmatched Redemption Report (CUR) 15. Unmatched Redemption Report 16. Reconciliation of WIC Reports and Daily Program Operations
K. Compliance Analysis (CA) Section includes: 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

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GEORGIA WIC 2012 PROCEDURES MANUAL
9. Disqualified Vendor/Participant Access 10. Investigation of Missing Vouchers/VOC Cards 11. Security of Issuance Material 12. Voucher Issuance Security

Introduction

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GEORGIA WIC 2012 PROCEDURES MANUAL

Introduction

L. Monitoring (MO) Section Includes: 1. State Agency Monitoring 2. Quality Assurance Self-Reviews
M. Breastfeeding (BF) Section includes: 1. Introduction 2. Definitions 3. State Agency 4. Local Agency 5. Participant Education 6. Participant Referral 7. Breastfeeding Materials and Resources 8. Allowable Cost for the Promotion and Support of Breastfeeding 9. Documentation of Breastfeeding Rates
N. Emergency Plan (EP) Section includes: 1. Introduction 2. Policies 3. Assessing Impact of Disaster 4. Concept of Operation 5. Responsibilities 6. Resource Requirement 7. Types of Emergencies 8. Manual Certification with VPOD or Manual Voucher Issuance 9. Nutrition Education, Food Package Change or other Manual Certification Changes with VPOD or Manual Voucher Issuance 10. VPOD or Manual Voucher Issuance Only 11. Replacing Lost Vouchers 12. Voucher Ordering, Receipt, and Close-Out of APD contractor Printed Vouchers 13. Mailing Paper TADs to ADP contractor 14. Tips for Operating a Manual System
O. Georgia WIC Glossary
P. Statewide Standard List (Abbreviations, Acronyms and Symbols)



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GEORGIA WIC 2012 PROCEDURES MANUAL

Introduction


VII. ADMINISTRATION
A. Food and Nutrition Services (FNS)/USDA
FNS/USDA administers WIC nationwide and provides grants to state health agencies.
B. State Agency
In Georgia, the Department 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 Medical Center, Inc., and Grady Health System, contract with DPH to administer and operate Georgia WIC.

VIII. ADDRESSES
A. Local Agencies
The following table lists all local agencies, their address, counties served, and the number of clinic sites.

DISTRICT/ADDRESS
District 1, Unit 1 (Rome)
C. Wade Sellers, M.D., M.P.H. District Health Director Margaret Bean, BSN, M.S., R.N. Program Manager Rhonda Tankersley RD, LD, CLC Nutrition Services Director Northwest Georgia Regional Hospital 1309 Redmond Road, Bldg. 614 Rome, GA 30165 (706) 295-6660/FAX (706) 295-6015

COUNTIES SERVED

# OF WIC CLINIC SITES

Dade, Walker,

11

Catoosa, Polk,

Chattooga, Gordon,

Floyd, Bartow,

Paulding, Haralson

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GEORGIA WIC 2012 PROCEDURES MANUAL

Introduction

DISTRICT/ADDRESS

COUNTIES SERVED

District 1, Unit 2 (Dalton)
Harold W. Pitts, M.D. District Health Director Louise Hamrick, MSN, MBA, RNCS, FNP Program Manager Karen Rutledge, RD, LD, CLC Nutrition Services Director 100 W. Walnut Avenue - Suite 92 Dalton, GA 30720 (706) 272-2991/FAX (706) 272-2223
District 2 (Gainesville)
David Westfall, M.D., CPE District Health Director Edith Parsons, PhD, MEd Program Manger Charlene Thompson, LD Nutrition Services Director 1280 Athens Street Gainesville, GA 30507 (770) 535-5743/ FAX (770) 535-5958

Whitfield, Murray, Gilmer, Fannin, Pickens, Cherokee
Banks, Dawson, Forsyth, Franklin, Habersham, Hall, Hart, Lumpkin, Rabun, Towns, Stephens, Union, White

# OF WIC CLINIC SITES
8
14

District 3, Unit 1 (Cobb)

Cobb, Douglas

8

John Kennedy, MD, MBA District Health Director Lisa Crossman, M.S. Program Manager Barbara Stahnke, MS, RD,LD Nutrition Services Director 1650 County Services Pkwy. Marietta, GA 30008 (770) 514-2453/FAX (770) 514-2419

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GEORGIA WIC 2012 PROCEDURES MANUAL

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DISTRICT/ADDRESS District 3, Unit 2 (Fulton)

COUNTIES SERVED
Fulton

Patrice Harris, MD, MA District Health Director Contact Persons: Michelle Broussard, LD,RD Lew Oliver Fulton County Health Department and Wellness 515 Fairburn Road Suite #350 Atlanta, GA 30331 (404) 505-6754/FAX (404) 893-1899

# OF WIC CLINIC SITES
8

District 3, Unit 3 (Clayton)

Clayton

2

Alpha Bryan, M.D. District Health Director Dianne Banister Program Manager Glenn Pryor, RD, LD Nutrition Services Director Clayton County Health Department 1117 Battle Creek Road Jonesboro, GA 30236 (678) 610-7639/ FAX (404) 603-4872

District 3, Unit 4 (Gwinnett)

Gwinnett, Rockdale,

6

Newton

Lloyd M. Hofer, M.D., M.P.H.

District Health Director

Connie Russell

Program Director

Diane Shelton, RD, LD,CLC

Nutrition Services Director

P.O. Box 897

2570 Riverside Parkway

Lawrenceville, GA 30046

(678) 442-6885 / FAX (770) 963-6322

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DISTRICT/ADDRESS District 3, Unit 5 (DeKalb)

COUNTIES SERVED
DeKalb

Sandra Elizabeth Ford, MD, MBA District Health Director Katrina Green, MBA Program Manager Gregory French, RD,LD,CPT Nutrition Services Director 395 Glendale Road Scottdale, Georgia 30079 (404) 297-7204 / FAX (404) 508-6089

# OF WIC CLINIC SITES
5

District 4 (LaGrange)

Fayette, Heard,

14

Henry, Butts,

Nicole Haynes, MD, MPH

Carroll, Coweta,

District Health Director

Lamar, Pike,

John G. Darden

Meriwether, Troup,

Program Manger

Spalding, Upson

Blanche DeLoach Moreman, RD, LD

Nutrition Services Director

122 Gordon Commercial Drive

Section B Bldg Suite A

LaGrange, Georgia 30240

(706) 298-6099/FAX (706) 845-4309

District 5, Unit 1 (Dublin)

Bleckley, Dodge,

12

Laurens,

Lawton Davis, M.D.

Montgomery,

District Health Director

Pulaski, Telfair,

Bruce Evans, M.S.

Treutlen, Wilcox,

Program Manager

Wheeler, Johnson

Brent Gibbs, R.D., L.D.

Nutrition Services Director

South Central Health District

2121-B Bellevue Road

Dublin, GA 31021

(478) 275-6545/ FAX (478) 275-6575

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GEORGIA WIC 2012 PROCEDURES MANUAL

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DISTRICT/ADDRESS
District 5, Unit 2 (Macon)
David N. Harvey, M.D. District Health Director Roy Moore Program Manager Nancy Jeffery, MPH, RD, LD Nutrition Services Director 5191 Columbus Road, Suite B Macon, Georgia 31206 (478) 471-5300/ FAX (478) 445-1139

COUNTIES SERVED
Hancock, Houston, Jasper, Baldwin, Bibb, Crawford, Jones, Monroe, Peach, Putnam, Twiggs, Washington, Wilkinson

# OF WIC CLINIC SITES
17

District 6 (Augusta)

Burke, Columbia,

19

Emanuel, Glascock,

Ketty M. Gonzales, M.D.

Jefferson, Wilkes,

District Health Director

Warren, Jenkins,

John Nolan

Lincoln, McDuffie,

Program Manager

Richmond, Screven,

Dorothy Hart, RD,LD

Taliaferro

Interim Nutrition Services Director

East Central Health District Office

1916 North Leg Road

Augusta, GA 30909

(706) 667-4287/ FAX (706) 667-4667

Contact Person:

Dorothy Hart RD, LD

Nutrition Manager

Richmond County Health Department

(706) 721-5828

District 7 (Columbus)

Harris, Talbot,

17

Dooly, Quitman,

Beverly Townsend, MD, MBA, FAAFP Taylor, Marion,

District Health Director

Macon, Crisp,

J. Edward Saidla

Sumter, Clay,

Program Manager

Schley, Webster,

Brenda Forman, Med, RD, LD,

Randolph, Stewart,

Nutrition Services Director

Muscogee,

West Central Health District Office

Chattahoochee

2100 Comer Avenue

P.O. Box 2299

Columbus, GA 31902

(706) 321-6281/FAX (706) 321-6295

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GEORGIA WIC 2012 PROCEDURES MANUAL

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DISTRICT/ADDRESS
District 8, Unit 1 (Valdosta)
William Grow, MD,FACP District Health Director Elsie Napier Program Manager Holly Rountree, RD,LD Nutrition Services Director Lowndes County Health Department 312 North Patterson Street Valdosta, GA 31603 (229) 333-7829/ FAX (229) 333-7822

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

# OF WIC CLINIC SITES
12

District 8, Unit 2 (Albany)

Baker, Lee,

15

Calhoun, Miller,

Jacqueline Grant, M.D.

Colquitt, Mitchell,

District Health Director

Decatur, Seminole,

Brenda Greene, RN,BSN,MPA

Dougherty, Terrell,

Program Manager

Early, Thomas,

Teresa Graham MPA, RD, LD, CLC Grady, Worth

Nutrition Services Director

Southwest Health District Office

1109 North Jackson Street

Albany, GA 31701

(229) 430-4111/FAX (229) 430-3866

District 9, Unit 1 (Coastal)

Bryan

16

Camden

W. Douglas Skelton, M.D.

Chatham

District Health Director

Effingham

Saroyi Morris

Glynn

Program Manager

Liberty

Tonya Scott, MBA, RD, LD,CLC

Long

Nutrition Services Director

McIntosh

Coastal Health District Office

150 Scanton Connector

Brunswick, GA 31525

(912) 262-3003/ (912) 262-3332

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DISTRICT/ADDRESS
District 9, Unit 2 (Waycross)
Rosemarie Parks, M.D., M.P.H District Health Director Derek Jones Program Manager(Acting) Heather Peebles, RD, LD District Nutrition Services Director Southeast Health District 1115-B Church Street Waycross,GA 31501 (912) 285-6110/ FAX (912) 287-6521

COUNTIES SERVED
Appling, Atkinson, Bacon, Jeff Davis, Brantley, Ware, Bulloch, Candler, Clinch, Charlton, Evans, Coffee, Wayne, Pierce, Toombs, Tattnall

# OF WIC CLINIC SITES
18

District 10 (Athens)

Barrow, Clarke,

11

Elbert, Green,

Claude A. Burnett, M.D.

Jackson, Madison,

District Health Director

Morgan, Oconee,

Louis Kudon, PhD.

Walton, Oglethorpe

Program Manager

Vicky Moody, M.P.H., L.D.

Nutrition Services Director

189 Paradise Blvd

Athens, GA 30607

(706) 583-2859 / FAX (706) 543-2034

Ann Sears, MED

Nutrition Services Director

345 N. Harris Street

Athens, GA

(706) 593-2860 / FAX (706) 543-2034

Grady Health System

ALL

5

Rondell Jaggers, Pharm.D. Interim Executive Director of Pharmacy & Clinical Nutrition Bernadine Joubert Director of Nutrition Services Divya Patel, RD,LD Nutrition Services Director Grady Health System 80 Jesse Hill Jr. Drive, SE Atlanta, GA 30303 (404) 616-5401/ FAX (404) 616-2422


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GEORGIA WIC 2012 PROCEDURES MANUAL

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B. State Agency
State agency agrees: 1. For technical assistance regarding all areas, except nutrition-related topics,
contact Georgia WIC. 2. To allocate Nutrition Services Administration (NSA) funds to the local agency for
use in meeting reimbursed allowable WIC administrative, nutrition education, breastfeeding and client service expenses of the local agency. 3. To pay cost for food vouchers issued by the local agency and redeemed by participating authorized vendors for eligible participants. 4. To monitor and evaluate the local agency to insure maximum effectiveness and efficiency to provide technical assistance, consultation and training to improve performance. 5. To provide specific manuals, forms, and nutrition education material required for operation of WIC. 6. To conduct independent verification and validation that local WIC data system modifications are performing as expected and/or to ensure system modifications are in place and are operating in accordance with federal and state program regulations and guidelines.
Georgia Department of Public Health
Georgia WIC Two Peachtree Street, N.E. 10th Floor, Suite 10-476 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 Services Unit.
Georgia Department of Public Health Nutrition Services Unit Maternal and Child Health Program Two Peachtree Street, N.E. 11th Floor, Suite 11-267 Atlanta, Georgia 30303 (404) 657-2884
FAX (404) 657-2886

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GEORGIA WIC 2012 PROCEDURES MANUAL

TABLE OF CONTENTS

Certification

Page

I.

General ....................................................................................................................... CT-1

II. Eligibility Requirements............................................................................................... CT-1
A. Category .......................................................................................................... CT-1 B. Physical Presence........................................................................................... CT-2 C. Residency........................................................................................................ CT-2 D. Income............................................................................................................. CT-4 E. Nutritional Risk ................................................................................................ CT-4 F. Requirements to Copy Identification, Residency and
Income Proofs ................................................................................................. CT-4
III. Initial Application ......................................................................................................... CT-5

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

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

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

VII. Proxies ...................................................................................................................... CT-10 A. Reasons for Proxies ...................................................................................... CT-11 B. Authorization ................................................................................................. CT-11 C. Voucher Pick Up, Issuance, and Use............................................................ CT-11 D. Restrictions.................................................................................................... CT-11 E. Participant Instructions .................................................................................. CT-12 F. Guardianship ................................................................................................. CT-12

VIII. Income Eligibility ....................................................................................................... CT-14 A. Procedures .................................................................................................... CT-14 B. Adjunctive (Automatic) Eligibility ................................................................... CT-15 C. Computing Income ........................................................................................ CT-17 D. Documented Proof of Income........................................................................ CT-28

GEORGIA WIC 2012 PROCEDURES MANUAL


Certification

E. Applicants with Zero (0) Income .................................................................... CT-29

F. Verification of Income.................................................................................... CT-29

IX. Nutritional Risk Determination................................................................................... CT-30

A. Required Data ............................................................................................... CT-30

B. Referral Data ................................................................................................. CT-31

C. Medical Data ................................................................................................. CT-31

X. Nutrition Risk Criteria ................................................................................................ CT-33

XI. Nutrition Risk Priority System.................................................................................... CT-34 A. General Priorities I -VI ................................................................................ CT-34 B. Special Considerations.................................................................................. CT-35 C. Specific.......................................................................................................... CT-35 D. Assignment.................................................................................................... CT-36

XII. Changes within a Valid Certification Period ............................................................. CT-36 A. Women Who Cease Breastfeeding ............................................................... CT-36 B. Upgrading a Priority....................................................................................... CT-36

XIII. Certification Periods .................................................................................................. CT-36

XIV. Infant Mid-Certification Nutrition Assessment ........................................................... CT-37

XV. WIC Assessment/Certification Form ......................................................................... CT-38 A. General.......................................................................................................... CT-38 B. Completion .................................................................................................... CT-38

XVI. Ineligibility Procedures (Notification Requirements).................................................. CT-49 A. Written Notification ........................................................................................ CT-50 B. Completion of Notice of Termination/Ineligibility/Waiting List Form............... CT-50 C. Ineligibility File .............................................................................................. CT-51

XVII. Transfer of Certification............................................................................................. CT-51 A. Clinic Staff ..................................................................................................... CT-52 B. Out of State Transfer ..................................................................................... CT-53 C. In-State Transfer ........................................................................................... CT-52 D. Release of Information/Original Certification Form........................................ CT-53 E. Two Methods for Transfer ............................................................................. CT-54 F. Ordering VOC Cards ..................................................................................... CT-56 G. Inventories ..................................................................................................... CT-56

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H. Issuance ........................................................................................................ CT-57

I.

Security ......................................................................................................... CT-58

J. Lost/Stolen/Destroyed EVOC or VOC Cards ................................................ CT-59

XVIII. WIC Overseas Program ............................................................................................ CT-59 A. General.......................................................................................................... CT-59 B. Impact on USDA's WIC Programs................................................................. CT-59 C. New EVOC or VOC Card Requirements ....................................................... CT-60 D. Completion of the EVOC or VOC Card ......................................................... CT-60 E. Acceptance of WIC Overseas Program EVOC or VOC Cards...................... CT-60

XIX. Correcting Official WIC Documents .......................................................................... CT-61

XX. Late Entry Correction of Health Records .................................................................. CT-61

XXI. Documentation Procedures....................................................................................... CT-61

XXII. Waiting List................................................................................................................ CT-61 A. Procedures for Maintaining a Waiting List..................................................... CT-62 B. Procedures for Removal from the Waiting List .............................................. CT-62

XXIII. System Information Management ............................................................................. CT-63

XXIV. Immunization Coverage Assessment........................................................................ CT-63

XXV. Complaint Procedures............................................................................................... CT-63 A. Procedures for Processing a Complaint or Incident ...................................... CT-63 B. How to File a Complaint (Flyer) ..................................................................... CT-64

XXVI. Special Certification Conditions (Home Visits).......................................................... CT-64 A. General.......................................................................................................... CT-64 B. Certification for Home Visits .......................................................................... CT-65 C. Procedures .................................................................................................... CT-65

XXVII. Special Certification Conditions ................................................................................ CT-66 A. General.......................................................................................................... CT-66 B. Separation of Duty......................................................................................... CT-66 C. Certification Procedure (with use of medical records) ................................... CT-67 D. Certification Procedure (without use of medical records) .............................. CT-67 E. 90-Day Blood Work Policy............................................................................. CT-68 F. Voter Registration Policy ............................................................................... CT-68

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G. Transfers/Caseload Count ............................................................................ CT-68

H. Identification (ID) Number Assignment.......................................................... CT-68

I.

Thirty (30) Day Policy .................................................................................. CT-69

J. Agreement between the District and Hospital ............................................... CT-69

K. Prior Approval................................................................................................ CT-69

L. File Maintenance in the Hospital ................................................................... CT-69

M. Voucher Security ........................................................................................... CT-69

N. Certification Process in the Hospital.............................................................. CT-69

O. Required Components of a Hospital Certification ......................................... CT-69

P. Two Types of Hospital Clinics ....................................................................... CT-71

XXVIII. Client Staff Ratio....................................................................................................... CT-72

XXIX. PNSS Data Collection .............................................................................................. CT-72

XXX. WIC Interview Script ................................................................................................. CT-72

Attachments: CT-1 WIC Assessment/Certification Form Prenatal Woman........................................... CT-73 CT-2 WIC Assessment/Certification Form Post Partum Breastfeeding .......................... CT-76 CT-3 WIC Assessment/Certification Form Post Partum Non Breastfeeding................... CT-79 CT-4 WIC Assessment/Certification Form Infant ............................................................ CT-82 CT-5 WIC Assessment/Certification Form Child ............................................................. CT-85 CT-6 FFY 2012 Nutrition Risk Criteria Handbook .............................................................. CT-88 CT-7 Nutrition Questionnaire ........................................................................................... CT-220 CT-8 Equipment Maintenance ......................................................................................... CT-232 CT-9 Participant Transfer Log.......................................................................................... CT-234 CT-10 Prenatal Weight Gain Grid Multifetal Pregnancy..................................................... CT-235 CT-11 Prenatal Weight Gain Grid Singleton Pregnancy .................................................... CT-238 CT-12 Signed Statement of Income, Residency and Identification (English)..................... CT-240 CT-13 WIC Income Eligible Guidelines.............................................................................. CT-241 CT-14 Notice of Termination/Ineligibility/Waiting List Form (English) ................................ CT-242

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CT-15 Notice of Termination/Ineligibility/Waiting List Form (Spanish) ............................... CT-243

CT-16 Paper Verification of Certification (VOC) Card......................................................... CT-244

CT-17 Electronic Verification of Certification (EVOC) Card ................................................ CT-245

CT-18 Electronic VOC Card Report (Example).................................................................. CT-246

CT-19 VOC Card Inventory Log (Clinic)............................................................................. CT-247

CT-20 VOC Card Inventory Log (Local Agency) ................................................................ CT-248

CT-21 VOC Card Agreement ............................................................................................. CT-249

CT-22 VOC Card Form ...................................................................................................... CT-250

CT-23 Women, Infant and Children (WIC) Ordering Form................................................. CT-251

CT-24 State/District/Clinic Transmittal Form...................................................................... CT-252

CT-25 Medicaid Right From the Start ................................................................................ CT-253

CT-26 THERE IS NO CHARGE (Flyer).............................................................................. CT-254

CT-27 Verification of Residency and/or Income Form ....................................................... CT-255

CT-28 No Proof Form......................................................................................................... CT-256

CT-29 Family Plus Medicaid Card ...................................................................................... CT-257

CT-30 Disclosure Statement Employees and Relatives ................................................. CT-258

CT-31 Income Calculation Form ........................................................................................ CT-259

CT-32 Identification, Residency and Income Proof List (English)....................................... CT-260

CT-33 Identification, Residency and Income Proof list (Spanish)....................................... CT-261

CT-34 Thirty (30) - Day Certification/Termination Form ..................................................... CT-263

CT-35 Department of Defense WIC Overseas Program VOC Card .................................. CT-264

CT-36 WIC Overseas Program Contacts ........................................................................... CT-265

CT-37 Proof of Residency Form for Applicants with P.O. Box Address............................. CT-266

CT-38 Income Verification Letter ....................................................................................... CT-267

CT-39 Incident/Complaint Form ......................................................................................... CT-268

CT-40 How to File a Complaint (Flyer) ............................................................................... CT-269

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CT-41 Request for WIC Services Log................................................................................. CT-270

CT-42 WIC Interview Script ................................................................................................ CT-271

CT-43 Separation of Duties Form ....................................................................................... CT-272

CT-44 Military Income Inclusions and Exclusions............................................................... CT-273

CT-45 Proxy Letter.............................................................................................................. CT-274

GEORGIA WIC 2012 PROCEDURES MANUAL


I.

GENERAL

Certification

Certification is the process whereby an individual is evaluated to determine eligibility for Georgia WIC. All persons wishing to participate in Georgia WIC must have their eligibility determined except those persons transferring within a valid certification period with proper verification (Refer to XVII). If eligible funds are available, the individual will be enrolled in Georgia WIC and will be issued supplemental food vouchers, when applicable. Supplemental food is defined as those WIC foods that promote health as indicated by relevant nutrition science, public health concerns, and that contain nutrients determined to be beneficial for pregnant, breastfeeding, and postpartum women, infants, and children. Cultural eating patterns are also taken into consideration in the supplemental foods offered. Eligible participants 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 Georgia WIC until the end of the certification period or the end of categorical eligibility, whichever occurs first, as long as the person complies with Georgia WIC's 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 Charge for WIC Services" flyer must be placed in an area where it is immediately seen by applicants/participants. During program reviews, the "No Charge for WIC Services" flyer (Attachment CT-26) will be monitored for compliance by the review team.

II. ELIGIBILITY REQUIREMENTS

The local agency may not establish any eligibility criteria for Georgia WIC participation other than those established by the State agency.

To be eligible and certified for Georgia WIC participation, an individual must meet all of the following requirements:

A. Category
To meet this eligibility requirement, an applicant must be: 1. A pregnant woman; OR 2. A postpartum, breastfeeding woman within twelve (12) months of the
end of a pregnancy; OR 3. A postpartum, non-breastfeeding woman within six (6) months of the
end of a pregnancy; OR 4. An infant up to one (1) year of age; OR 5. A child up to five (5) years of age.

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* The end of a pregnancy is the date the pregnancy terminates (e.g., date of delivery, spontaneous miscarriage or elective abortion). When a participant no longer meets the definition of pregnant woman, breastfeeding woman, postpartum, non-breastfeeding woman, infant, or child, he/she becomes categorically ineligible for Georgia WIC (see Ineligibility Procedures CT-XVI). Refer to "A Woman 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. Georgia WIC 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 the clinic/health department for each WIC Certification. If the applicant is not present, the reason for the exception must be documented in the comment section of the certification form or progress notes. If the applicant is not present at certification/recertification, the staff collecting proof of income must have written approval from the Nutrition Services Director or Designee to conduct WIC services. See XV.19 of the Certification Section of the Procedures Manual for exceptions to physical presence.

The following people may determine if special considerations are required to conduct WIC services:

a. Doctor b. Nurse c. Nutritionist, Registered Dietitian, or Licensed Dietitian d. Physician Assistant e. Competent Professional Authority (CPA) f. Nutrition Services Director or Designee
A child or an infant must accompany the parent/guardian/caregiver/spouse/alternate parent 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 the only address that an applicant/participant has, the Proof of Residency Form for Applicants with a P.O. Box Address (see Attachment CT-37) must be completed by the applicant/participant. File the

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completed form in the applicant/participant's health record. The Proof of Residency Form for Applicants with a P.O. Box Address may be used for multiple certifications if the following applies:

1. No change in P.O. Box; and 2. Same physical address.

Residency shall be determined from an item that is on a list of acceptable proof of residency that is established in the applicant's name (see list below). In cases of a minor applicant or applicants who reside with parents/guardians with no evidence of presumptive Medicaid eligibility, the Verification of Residency and/or Income Form (see Attachment CT-27), 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, e.g., electric bill. A date stamped copy of the proof of residency must be kept in the medical record. The information on the Verification of Residency and/or 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/Medicaid Internet Site address only if it
appears on the screen. (Presumptive Medicaid is unacceptable) 9. Signed letter from the person who is providing food or shelter 10. 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 (see CT-VIII. C. 3.).

Homeless Individuals and Migrants - 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 (see Attachment CT-28) must be completed by the applicant.

Migrant Farm workers - Migrant farm workers are considered "residents" of the local agency service area in which they apply for WIC benefits. Migrants are not required to show proof of residency. The No Proof Form must be completed.

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 or where the WIC participant lives 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

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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 does not exist, use the No Proof Form (see Attachment CT-28).

E. Nutritional Risk
Applicants must have a nutritional risk, as determined through a nutritional risk assessment, to be eligible for WIC benefits. If no nutritional risks are evident, applicants who are otherwise eligible based on income, residency, identification, and category may be presumed to be at nutritional risk and assigned Risk Code 401 (Other Dietary Risk) except for infants who are less than four (4) months of age. Infants less than four (4) months of age cannot use Risk Code 401 to establish their nutritional risk.
F. Requirements to Copy Identification, Residency and Income Proofs
All local agencies must place a date stamped copy of the identification, residency and income proofs used to determine eligibility in the applicant's medical record.
Copies of proofs to be placed in the records are: x Proof of Identification for transfers, thirty (30)-day adjustments, initial and subsequent certifications. x Proof of Residency for transfers, thirty (30)-day adjustments, initial and subsequent certifications. x Proof of Income for unresolved thirty-day transfer only, thirty-day adjustments, initial and subsequent certifications.
Exceptions of Proofs: x There are two exceptions for not having to copy proof for the medical record. The two exceptions are listed below: 1. Medical records in a Hospital do not have to be copied. 2. Medical records in clinics do not have to be copied. Additionally, medical records may only be used as proof if the applicant does not have any other proof. Excessive use of medical records as proof will be monitored on self reviews and State audits. Medical records may not be used as a standard proof for daily operations.
Location of proofs: x Copies of proofs must be placed behind the current certification documentation. The exception to this rule will be based on standing

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District policy for the location of documents. x Scanned or copied version of proofs must be date stamped. Copying Proofs: x All three proofs may be copied on one sheet of paper.

Certification

Note: New proofs must be obtained for each proof of identification for transfer, thirty (30)-day adjustments, initial and subsequent certifications. No proofs should be over two months old such as electric bills, etc. All proof must be date stamped to match the certification date.

Georgia WIC can not use any Voter Registration card (in State, out-of- State or out-of-country) as proof of identification.

III. INITIAL APPLICATION

Initial contact date is defined as the date the individual first requests WIC benefits face-to-face or by telephone. Written or e-mail inquiries are not used to establish an initial contact date. An individual's initial contact date will remain the same unless there is a break in enrollment. A break in enrollment is the period or lapse of time between a valid certification period and the subsequent certification. When a person fails to keep an appointment and requests a new appointment, the initial contact date is the new date that the participant requests.

The following items must be recorded when an individual first contacts the clinic during office hours and specifically requests WIC benefits (face to face or by telephone) and benefits are not provided.

1. Applicant's Name and Address 2. Category, e.g., pregnant, postpartum, infant, child, migrant 3. Initial Contact Date (date services were requested) 4. Appointment Date (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 abovenumbered items 1-6 as long as it is implemented in a consistent manner. Suggested methods of documentation include, but are not limited to, a personal visit log, an appointment book or the WIC Certification/Assessment Form (see Attachments CT-1 thru CT-5).

If the applicant does not reside within the jurisdiction of the state, ineligibility procedures will be followed (see Ineligibility Procedures CT-XVI).

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

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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.

Employees must never certify, recertify, or issue vouchers to family members or blood relatives, e.g., their children, spouse, cousins, other blood-related persons or those persons related by marriage, nor to 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 Nutrition Services Director. 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 (see Attachment CT-30) must be completed annually by all clinic employees who perform WIC services to inform District staff of their family participation on Georgia WIC. This form must be completed by the local agency and returned to the Nutrition Services Director by September 30th of each year. A copy of this form must also remain in the county health department / WIC clinic site for audit purposes (i.e., one copy at the clinic plus one copy at the District). Procedures for completing the Disclosure Statement:
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 Georgia WIC. 5. If yes, fill in the name and relationship of those relatives and their date
of certification on this form.
When reviewing the records of employees on Georgia WIC, use the Record Review Form located in the Monitoring Section of the Procedure Manual, Employee Relative Record Review Form (Form 3).
Note: Staff must not evaluate their own income, residency or identification information, certify themselves or family members or issue vouchers to themselves or family members.

Special provisions must be made for scheduling employed, rural and migrant participants. In the event normal working hours are not convenient, early morning, late evening, 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 lunch hours.

Each local agency shall attempt at least one contact for a pregnant woman who misses her first appointment to apply for WIC services. In order to reschedule

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the appointment, the local agency must have an address and telephone number on file where the pregnant woman can be reached.

1. With Medical Record Documentation of the contact(s) must be noted in the client's record. Documentation must specify if the participant was contacted by phone or mailed an appointment. The staff must sign or initial their attempt.
2. No Medical Record If the client does not have a record, documentation is still required. It is up to the local agency to keep this documentation manually or in the computer and have it on file for the State to review. The documentation will consist of: a. The name of the client. b. Appointment date. c. Date of second appointment. d. Documentation of whether second appointment was made by phone. e. The initials of the staff member who made the appointment.

Note: Failure to maintain this documentation will result in a corrective action.

IV. PROCESSING STANDARDS

A. Timeframes
Processing standard timeframes begin when the applicant requests WIC benefits face-to-face or by telephone, e.g., initial contact date. Processing standards must be met when an applicant requests services face-to-face or by telephone. If the local agency has issues meeting processing standards, the local agency should request an extension. Pregnant and breastfeeding 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 Georgia WIC benefits. All other applicants will be notified of their eligibility or ineligibility within twenty (20) calendar days of their initial contact date. If a line forms at any clinic site for WIC services, and any applicants/participants cannot be seen that day, provide each person who was not served with an appointment prior to their leaving the clinic.

A Request for WIC Services Log has been developed to document processing standards (see Attachment CT-41). If your District is already using a log to document processing standards, the State will review it. However, if your District does not have a log, the WIC Services Log must be put into use immediately.

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.) must be documented. A clinic that does not routinely schedule appointments shall schedule appointments for employed adult applicants/participants who are applying or reapplying for WIC for themselves or on behalf of others to minimize the time these applicants/participants are absent from the workplace.

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C. Request for Extension On an annual basis, the State agency may grant an extension of a maximum of 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 that includes justification to the State agency by October 1 of each year. Include in your justification an assessment of your current staffing standards ratio and Planning and Resources Section (PARS) documentation. 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 presented, checked and documented for both the applicant/participant and parent/guardian/caregiver/spouse/alternate parent (in the case of infant and child applicants/participants) at initial and subsequent certifications. The identification must be documented before issuance of benefits at a certification. (For person picking up vouchers See Food Delivery Section.) Clinic staff may not personally identify an applicant/participant even if they know the identity. Other records which clinic staff considers adequate to establish identity may be used if approved by the District Nutrition Services Director 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. Birth Certificate/Confirmation of Birth Letter 2. State ID 3. Driver's License 4. Military ID 5. Work or School ID 6. Social Security Card 7. WIC ID (for Voucher Issuance Only) 8. Hospital ID Bracelets (mother & baby) 9. EVOC/VOC Card (with additional ID)
10. Immunization Record (presented by applicant) 11. Passport or Passport Card 12. Health/Medical Record (presented by the applicant; already exists in
the clinic or the record if transferred) 13. Other (with explanation/description)
Note: As of January 2010, WIC applicants and participants can use expired picture identification as a form of Proof of Identification only.

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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 may be utilized and must be completed by the applicant (see Attachment CT-28). 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 IDENTIFICATION (ID) CARD

General

During the certification appointment, a WIC identification (ID) card (see the Food Delivery Section) must be completed and issued to any person who is enrolled in Georgia WIC. A WIC 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 one WIC 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 Georgia WIC before issuing an ID card. English and Spanish WIC ID cards are mailed bi-annually to each district based on participant caseload/ID card distribution calculation.

The Georgia WIC ID card or another form of identification must be presented by the participant/parent/guardian/caregiver/spouse/alternate parent and documented each time vouchers are picked up at the clinic. A proxy must present a valid identification with the WIC ID card when picking up vouchers. If a participant/parent/guardian/caregiver/spouse or alternate parent 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 for certification, it must be documented. The same verification codes used for certification must be used 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.

A. Required Data

All items on the front must be completed before issuing the WIC ID card.

FRONT: 1. Participant's name 2. WIC ID number 3. Date certification period expires 4. Participant/parent/guardian/caregiver/spouse/alternate parent's

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signature 5. Food Package # 6. Signature of proxy (ies), if the participant designates one:
a. Refer to Food Delivery Section if the participant/parent/guardian/caregiver/ spouse/alternate parent or proxy is unable to write.
b. This may be accomplished by the participant/parent/guardian/caregiver/ spouse/alternate parent after he/she has left the clinic.
7. Signature of clinic WIC official 8. Date card was issued 9. Georgia WIC Stamp (must appear in the designated box)

Certification

Note: Do not pre-stamp stock of Georgia WIC ID cards.

It is required that all of the information on the back of the WIC ID card also be completed.

BACK: 1. Appointment information 2. Date of last voucher issued 3. Voucher pickup code 4. Voucher interval code 5. Comments when needed 6. Clinic identifying information 7. Clinic telephone number 8. Clinic fax number 9. 30 day proof (if applicable)

B. Participant Instructions

Participant/parent/guardian/caregiver/spouse/alternate parent must be instructed on the purpose and use of the WIC 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 WIC ID card is to identify you as an authorized WIC participant when picking up and/or redeeming vouchers. You should keep vouchers with the WIC ID card. You must have your WIC ID card when picking up vouchers, at certifications and when redeeming vouchers at the grocery store. A proxy must have the WIC ID card to pick up or redeem vouchers. Refer to the section below for more information regarding proxies.
2. Notify the clinic if the WIC 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 (e.g., review allowable items, importance
of separating foods, etc.). VII. PROXIES

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General 1. 2. 3.
4 5. 6.
7.

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. A person who is certified for Georgia WIC and issued a Georgia WIC ID card may designate up to two (2) persons to act as a proxy(ies). A proxy should be a responsible person who the participant/ parent/guardian/spouse/caregiver/alternate parent trusts and, whenever possible, should be another person in the same household as the participant. Issue a proxy letter to all proxies explaining proxy responsibilities (see Attachment CT-45). A proxy should be limited to picking up vouchers for two (2) families statewide. If a proxy picks up vouchers or brings a child in for subsequent certification, WIC clinic staff must ensure that adequate measures are taken for the provision of nutrition education and health services to the participant. Documentation of proxies must be recorded on the Georgia WIC ID card and on either of the following:
x Certification form x Computer x 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/parent/guardian/spouse/ caregiver /alternate parent. When a proxy is designated, the participant /parent/guardian/spouse/caregiver/ alternate parent must have the proxy sign his/her name in the designated space on the WIC ID card in their presence (refer to the Food Delivery Section if a proxy is unable to write). The parent/guardian/spouse/caregiver /alternate parent should be listed in the health record whenever possible. Without this documentation, local agencies have no proof of who has legal responsibility for a WIC participant and health services may be denied.

C. Voucher Pick Up, Issuance, and Use

In order to pick up WIC vouchers, a proxy must bring the participant's WIC ID card along with the proxy's own ID.

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During issuance, the proxy will sign his/her own name on the VPOD receipt, voucher register, 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 Nutrition Services Director or designated Competent Professional Authority (CPA). Approval must be documented in the participant's health record.
2. Staff State, District Health Department, and local staff, including volunteers working for the local health department or WIC clinic may not act as proxies for participants.
3. Vendors Vendors must not be used as a proxy.

E. Participant Instructions

When an individual is certified for Georgia WIC, 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, SNAP), residency and ID must be signed and dated by the child's parent/guardian/spouse/caregiver /alternate parent. A form for this purpose has been developed by the State (see Attachment CT-12). Use of this form is required at each recertification.
2. Proxy's ID 3. WIC ID card 4. Knowledge of the child's medical history and nutritional habits/normal
nutritional intake. 5. ID of the child 6. Proof of residency of the child

Note: The proxy should have the same knowledge regarding the above as you would expect the parent to have.

F. Guardianship
Definition of Spouse: Legal husband/wife of the primary parent of the participant.
Definition of Guardian: Legal or court-appointed custodian/caregiver of the child.
Definition of Alternate Parent: Alternate parent is the other parent of the child.

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A spouse and the biological parent can be an alternate parent.

Certification

In some instances, the spouse of the parent/guardian applying for WIC benefits for a child may not be the child's parent, e.g., a step-parent. The parent/guardian applying for services may, at the time of certification, specify that person as a spouse. That person's name will be documented in the child's record and the spouse will sign the WIC ID card on the second (parent/guardian/caregiver/spouse/alternate parent) signature line. In this case, the spouse is not a proxy and no additional identification is necessary for voucher pick-up. When the parent/guardian/spouse/caregiver /alternate parent is applying for WIC benefits on behalf of the child (re-certification), WIC staff must verify that he/she is the designated alternate person named in the client record.

Caseworker as a Guardian Another type of guardianship is a caseworker who is certified by the State's Department of Family and Children Services (DFCS) to act as the State appointed guardian or a proxy for foster care children in temporary custody. The caseworker must have all the documentation that indicates that DFCS has legal custody of the child/children from the state courts.
The caseworker may also request information on a child with a Release of Information and an official court order. When this request is made by a DFCS caseworker, please have your District's attorney verify the court order prior to releasing the official WIC portion of the records. The attached forms must be used for the Release of Information.

Grandparents as Guardians There are many situations where the grandparents serve as temporary or even become permanent guardians for children on Georgia WIC. If the grandparent has the proper legal documentation, e.g., guardianship papers, identification for the child, proof of residency, etc., he/she may have the right to act on behalf of the WIC participant. These situations may arise due to an applicant/participant/guardian/caregiver/spouse/ alternate parent not being able to come for WIC services for a short period of time. In these cases, the grandparent will serve as the guardian or proxy.

Joint Custody
In joint legal custody, both parents share the ability to have access to educational, health, and other records and have equal decision-making status where the welfare of the child is concern. Each parent's information must be documented in the medical record along with all legal documentation from court.

Other Legal Custody Georgia WIC could never list all of the possible guardianship situations or persons who may have temporary and permanent custody of a child. As long as the proper legal documentation is presented, the individual presenting the legal documents may serve as the guardian for certification, voucher pick up and nutrition education services.
In the event that none of the above has all of the documentation, treat them

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as if they were regular WIC participants. However, in the above situations, some legal documentation must be shown prior to placing the child on Georgia WIC (birth certificate, court documents from a judge or documentation from a parent, DFCS documentation ,etc.). Copy and file the documentation in the participant's chart. Place the child(ren) on Georgia WIC and only give thirty (30) days' worth of vouchers until all the information is received by the health department/WIC clinic.

VIII. INCOME ELIGIBILITY
To be eligible for Georgia WIC, 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.
The Healthy Meals for Healthy Americans Act of 1994, P.L. 103-448, provides regulations for conducting Georgia WIC income assessment/determination for pregnant women. According to the act, a pregnant woman who does not meet income eligibility requirements for Georgia WIC 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 Georgia WIC, 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 Georgia WIC applicants/participants:
1. Pre-screening by telephone - Pre-screening for income over the phone is a local agency/clinic option. If an appointment is made based on the pre-screening call, this is considered the initial contact date. This applies only for the first application. However, the formal application for WIC begins when the applicant/participant visits the clinic. Income eligibility must be assessed at that time.
2. Confidentiality/Privacy - Clinic personnel who interview applicants for Georgia WIC must determine the family size 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

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allowed for that family size (see Attachment CT-13). Income eligibility must be determined before nutritional risk eligibility. When determining the income of the WIC applicant, the Income Calculation Form must be completed if the applicant does not qualify for adjunctive or presumptive eligibility and if the applicant has more than one income to calculate (see Attachment CT-31). 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 (see Attachment CT-31). If the applicant does not qualify for adjunctive eligibility and has more than one income to calculate, income calculation may also be done in the computer system. Each system will be reviewed on a monitoring visit to determine compliance. When completing this form:
1. Write/type in the WIC 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, e.g., PS 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/bi-weekly, monthly/yearly.
b) Total the amount of all income earned. Circle if the amount earned is weekly/bi-weekly, monthly/yearly.
c) Answer the question, "Is the applicant income eligible?" YES or NO?
d) Transfer this total to the Certification Form. e) Have applicant read their Right and Obligations. f) Have the applicant sign this form. g) Signature & date of staff accepting income.
B. Adjunctive (Automatic) Eligibility
"Adjunctive" or automatic income eligibility for WIC applicants/ participants is mandated for the following individuals: - Recipients of Supplemental Nutrition Assistance Program (SNAP) and
members of a household currently participating in SNAP. - Recipients of Temporary Assistance for Needy Families (TANF) and
family members.

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- Recipients of Medicaid or members of families in which a pregnant woman or infant who 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 Georgia WIC, her infant and children income qualify for WIC.
2. If an infant qualifies for Medicaid, his/her pregnant, breastfeeding or postpartum/non-breastfeeding mother may be placed on Georgia WIC using the infant's Medicaid number.
3. 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 for medical/nutritional risk to qualify for the program.

Acceptable Proof of Eligibility The WIC applicant may present one of the following as acceptable proof of income eligibility.

1. Medicaid: The participant enrolled in Medicaid will be issued a Medicaid identification 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 using the Medicaid web portal. Active status on the printout will indicate current Medicaid eligibility. If the participant's address appears on the printout, 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 Medicaid web portal.

Infants are issued a Medicaid number at the time of birth. Should a Medicaid eligible infant come 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 Interactive Voice Response (IVR) may be used to provide it by dialing 770-570-3373 or 1-866-211-0950. Place the twelve-digit number in the field provided for Medicaid numbers. Follow the above procedures on using the Medicaid web portal.

2. SNAP: Must present a notification letter. A copy of the notification letter must be copied, date stamped and placed in the medical record.

Either the SNAP ID card number or a copy of the actual card must be placed in the health record as appropriate documentation.

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Electronic Benefit Transfer (EBT) Card: EBT cards are currently being used for the SNAP and Temporary Assistance for Needy Families (TANF) Programs. The EBT card can not be used as proof of eligibility for SNAP or TANF. 3. Temporary Assistance for Needy Families (TANF): Must present a notification letter (with dates of eligibility). A copy of the notification letter must be date stamped and placed in the health records as appropriate documentation.

4. PeachCare: All PeachCare clients must be assessed for WIC income eligibility.
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 to nearest whole number.
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, e.g., lottery winnings. d. Quarterly payments are divided by 3 to get a monthly rate.
Converting to and calculating annual income: All income sources may be converted to annual income and added to reach the total annual income for the household. Actual amounts as

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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 return to determine income:

Look for the "total income" line item on the income tax return. 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.

The Economic Stimulus Rebate: The economic stimulus rebate is a lump sum payment and it is to be excluded when calculating income for potential WIC families.

To comply with the Tax Relief, Unemployment Insurance Reauthorization and Job Creation Act of 2010, exclude the federal tax refund when taking income from WIC applicants through December 31, 2012.

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 Alternate Parent - A child is counted in the family size of the parent, guardian or alternate parent with whom the child lives, with the exception of the foster child (see paragraph "b" below). 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 are considered to be the income of that foster child. In most situation, all foster care children are income eligible.

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.

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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 Georgia WIC on the basis of her current family size shall be reassessed for eligibility based on a family size increased by one or the number of expected infant(s).

f. Absent Spouse (excluding military families) - A household where the spouse is away and maintains a separate residence due to job related assignments shall be considered a separate economic unit without the inclusion of the spouse. Only income received by the household would be used to determine eligibility.

g. Students (1) College students who maintain a separate residence at school but who are supported by parents/guardians must be counted in the household of the parent/guardian. Students who maintain a separate residence and are self-supported must be counted as a separate household. Any regular cash supplements received from parents or guardians must be included in the student's total income. (2) If a student receives financial assistance from any program funded under Title IV (e.g., the Pell Grant, Supplemental Educational Opportunity Grant, Byrd Scholarship, Student Incentive Grant, National Direct Student Loan, PLUS, (College Work Study, etc.) the following guidelines must be followed: (a) The portion of federally-funded student aid that is used by the student for books, materials, tuition, feeds, supplies and transportation will not be counted as income. (b) 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 WICauthorizing legislation nor the Federal WIC regulations require citizenship or make aliens categorically ineligible for Georgia WIC. 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 with whom the child(ren) is/are living. 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. Add all applicable income inclusions (for a complete list (see Attachment CT-44) x Career Sea Pay x HFP (Hazardous Fire Pay)
3. Subtract all applicable income exclusions (for a complete list (see Attachment CT-44) x BAH (Basic Allowance Housing) x BAQ (Basic Allowance Quarters) if any apply x LQA (Living Quarters Allowance) x VHA (Variable Housing Allowance) x OCONUS COLA (Overseas Continental United States Cost of Living Allowance) x FSH (Family Separate Housing)
4. 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: x Hazardous or foreign duty x Back pay or combat pay x Family separation x 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
$2,140 per month for four (4) people

The LES contains: Individual's name and Social Security number

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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. **Combat Pay for WIC Income Eligibility Determination: A combat zone is any area that the President of the United States designates by Executive Order as an area in which the U.S. Armed Forces are engaging or have engaged in combat. Combat pay received by the service members is normally reflected in the entitlements column of the military LES. Combat pay is excluded for the following reason:
x If received in addition to the service member's basic pay
x If received as a result of the service member's deployment to or service in an area that has been designated as a combat zone, and
x If not received by the service member prior to his/her deployment to or service in the designated combat zone.

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 as a child 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 The Verification of Residency and/or Income Form is to be given to any potential applicant to assist them in collecting necessary documentation from other members of the family (economic unit) to determine income eligibility under Georgia WIC. Clinics are encouraged to determine presumptive Medicaid eligibility prior to issuing the Verification of Residency and /or Income form to any potential applicant who does not qualify (see Attachment CT-27).

Procedures for Completing the Verification of Residency and/or 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

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date given to the WIC participant. (3) Complete or fill in the date that the form must be delivered
back to the clinic. (4) Once the form 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, they must give their income verbally and the No Proof Form must be signed (see Attachment CT-28). 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.
m. No Proof Form The No Proof Form is to be used when the applicant can not provide proof of ID, residency or income. 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. Migrant Status 5. Homelessness 6. Employer who refuses to write a letter for employee when employee is paid in cash (day workers, domestic, etc) 7. An applicant whose spouse or partner refuses to give income information.

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 and must be filed in the health record (see Attachment CT- 28).

The applicant or adult applying on 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 selfdeclares an income for family size that exceeds the WIC income guidelines. A No Proof Form can be used only during certification. A No Proof Form can not be used when participant brings back proof.

Clinics are required to maintain a No Proof file. The No Proof file must contain a copy of the completed No Proof Form or a list of the participants. This file will be monitored for compliance by the review team during District Program Reviews.

n. Temporary Thirty (30)-Day Certification

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This policy applies to clients who meet all other eligibility requirements and do have proof of identity, income and/or residency but fail to bring it to the WIC clinic for the certification visit. The Identification, Residency and Income Proof List should be routinely given to the client to clearly communicate the kinds of information they will need to bring for certification visits (see Attachments CT-32 and 33). Clinic procedures for issuing Thirty (30)-day certification are as follows (see Attachment CT-34):

1. Procedures for Thirty (30)-Day Certification When an applicant/participant arrives in the WIC clinic without proof of residency, income or identification: (a) Place the applicant on Georgia WIC 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 copies of the form in the Medical Record and the thirty (30)-day file. (d) The computer system will update for the thirty (30)-day eligibility. When a month has 28-31 days, the system must be fixed to accommodate the number of days per month. If your District is using hand written forms, your District must use the same procedures located in your District Computer System for calculating days.

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 and submit an updated Turn Around Document (TAD) to include the new information. The "up ____" field has been added as a reminder to update the information on the hard copy of the Certification Form only once the participant returns to the clinic with the required information. The "up: ______" is found in the following sections of the Certification Form: x Proof of residency x Current ID x Gross income x Source of income code x Staff initials x Date Utilize the "up____" field as follows: (a) Update your computer system and submit an updated TAD. (b) When one or more of the fields are updated, the staff must initial and date the back of the form (hard copy only). (c) When income is updated, the amount and source must be updated.

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(d) If the applicant/participant is found to be over income, provide a termination letter or thirty (30)-day certification/termination form, (see Attachment CT-34), stating that he/she is being terminated from Georgia WIC due to over income.
(e) The applicant/participant must return with the information. A proxy may not provide the necessary documentation to complete the thirty (30)-day certification process.

3. Procedures when applicant/participant fails to bring back proof: It is the responsibility of the clinic to terminate participants who fail to bring back proof to the clinic within thirty (30) days of certification.

If the participant fails to return within thirty (30) days, the clinic must terminate the participant using the term code "L" (Failure to return with proof on the thirty (30)- day certification). Georgia WIC contractor will automatically terminate the participant if an update is not received. A Termination Report is generated and the terminations must be entered into the computer system.

(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. The original clinic must notify the new clinic about the client's thirty (30)-day status. 2. Vouchers must never be issued if the participant has not brought back the necessary information.

3. Procedures when applicant/participant is overincome: (a) Document on the thirty (30)-day form that participant is terminated from Georgia WIC (b) Staff must sign and date the thirty (30)-day form in the thirty (30)-day file and medical record (c) Give the participant a termination notice or the thirty (30)-day form from the thirty (30)-day file (d) Make thirty (30)-day adjustment on the Certification Form (e) Copies of the income proof used must be made, date stamped and placed in medical record

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(f) Participant is terminated in the computer system

o. 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.

p. 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 indicating what their income is. Ask for documentation first (see Attachment CT- 28).

q. Zero Income Applicants Complete applicable questions on back of assessment form. See "Income Eligibility Applicants with Zero (0) Income" at 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.

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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) Food and Nutrition Act of 2008 (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 - BAH (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 WIC Regulations at 7 C.F.R. Part 246.
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, AtRisk 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 Georgia WIC 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 saleable 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 (1) 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.

8. Incarcerated Parent/Guardian Children residing with a caregiver are counted in the family size of the caregiver with whom they live. Ideally legal custody is required. However, a signed note from the parent giving permission to the caregiver, e.g., grandmother, is acceptable and must be placed in the health record.

D. Documented Proof of Income

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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) from previous year up until April 15th of the current year (e.g., 2009 W-2 can be accepted up until April 15, 2011). 4. On-going financial records (for self-employed only). 5. Unemployment notice. 6. Other (see List of Income Inclusions).

Note: All proof of income should not be more than sixty days (60) old with the exception of the most recent tax return.
For additional sources of income, see Income Inclusions (VIII.C.3.q.1.).

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 on the Certification Form. Check "Yes" if the client is income eligible. This does not apply to applicants with adjunctive income eligibility documents.
Record zero (0) as the current income amount and "ZI" (zero income) as the income source.

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.

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3. A conflict of information is found between Georgia WIC 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, WIC clinic staff may also request that the participant/parent/spouse/guardian/caregiver/or alternate parent bring proof of income back to the clinic. In the event clinic staff request proof, from the participant/ parent/ spouse/alternate parent/ guardian/ or caregiver the Income Verification Letter may be used (see Attachment CT-38).

Failure of the participant/parent/spouse/guardian/caregiver/or alternate parent to return to the clinic within thirty (30) days with proper documentation would result in the following:

1. Termination from Georgia WIC 2. Re-payment to Georgia WIC for vouchers issued over one-hundred
dollars ($100.00) Note: Information concerning payment to Georgia WIC can be found in the
Compliance Analysis Section of the Georgia WIC Procedures Manual.

IX. NUTRITIONAL RISK DETERMINATION

To be eligible for WIC benefits, an applicant/participant must have a nutritional risk, as determined through a nutritional risk assessment. If no nutritional risks are evident, applicants who are otherwise eligible based on income, residency, identification, and category may be presumed to be at nutritional risk and assigned Risk Code 401 (Other Dietary Risk) except for infants who are fewer than four (4) months of age. Nutritional risk is identified through the assessment of required medical data (length/height, weight, hematocrit/hemoglobin), nutritional practices, and the individual's medical history. The data are 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 who has been trained by the State or local agency to perform WIC assessments.

WIC applicants may not under any circumstances be charged for services or tests, e.g., blood work, anthropometric measurements, etc., which are used to determine WIC 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 WIC eligibility may be suspended by Georgia WIC. The applicant cannot be required to obtain such data at their own expense.

A. Required Data

1. Women Assessment/Certification Form 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

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women must be taken during the current pregnancy. Proof of pregnancy is not required as a condition of eligibility for Georgia WIC. 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 (see Attachments CT-1, CT-2, and CT-3).

2. Infants Assessment/Certification Form lists required assessment data and documentation requirements for all infants by age. This data must be collected and documented for each assessment (see Attachment CT-4).

3. Children Assessment/Certification Form 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 (see Attachment CT-5).

B. Referral Data

Identification of nutritional risk can be based on referral data submitted by a CPA or health care provider not on staff at the clinic. Referral data must then be evaluated by a CPA on staff at the clinic. Local agencies should make the authorized referral form available to area health care providers in order to facilitate entry into Georgia WIC and the certification process. Local agencies must accept the Georgia WIC Referral Form and Medical Documentation for Special Food Substitutions Form #2, in the Food Package Section (see Attachment FP-42), and may not develop their own referral form.

Local agencies must accept referral forms from a private provider, provided that the entire minimum required referral data/information has been completed properly, as described below. The data/information must be documented on official letterhead.
All private provider referral forms must contain, at a minimum, the following information:
I. Demographic Data a. Applicant's first and last name b. Applicant's date of birth

II. Medical Referral Data, as appropriate* a. Length/Height b. Weight

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c. Hematocrit/Hemoglobin d. Date(s) measurements were taken * If missing, the clinic can perform measurements themselves.

III. Referral Agency Information a. Original signature and title of health care provider b. Date the referral was completed c. Agency address d. Agency telephone and fax numbers

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. Anthropometric data required for certification (length/height and weight) may precede the date of certification by up to sixty (60) days. 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 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. 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's/participant's eligibility is based on other criteria.

Note: Hematological data for postpartum and breastfeeding women must be obtained after delivery.

Georgia WIC has elected to use a special code to be entered into the hematological data field when hemoglobin is not determined. Please use the following code 88.8.

CSC Covansys is set up to accept this value 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 nine (9) months of age, unless there is a medical reason. In most cases, infants

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will have blood work performed around twelve (12) months of age (infant status blood work) and then six (6) months later (child status blood work). If the child's blood work is normal, blood work does not have to be performed for one (1) 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. If the hemoglobin becomes normal during a certification assessment, it does not have to be assessed for another year (the subsequent certification visit closest to that year without exceeding twelve [12] months between hematological measurements).

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. For a child, if 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 without exceeding twelve [12] months between hematological measurements).

Blood work within the normal range is valid for children for twelve (12) months beginning at eighteen (18) months of age. If a child is certified within seven (7) months of the previous certification, blood work does not need to be repeated if it was found to be within a normal range at the last certification (e.g., within thirty [30] days of the last certification due date).

Example: A 24-month old child missed its certification appointment on the 7th of the month and is terminated. When the child returns on the 15th of the month a new initial contact date is assigned and the child is
recertified. The hematological data from the previous certification can
be used for this certification since it was found to be within a normal
range. Document the hematological measurement as 88.8.

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

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 (if blood work is unavailable): 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 up to two (2)
month of vouchers and follow District's procedures for obtaining

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blood work by the next voucher issuance.

Certification

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 Services Unit 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, nutritional deficiencies that impair or endanger health, or conditions that predispose persons to inadequate nutritional patterns or nutritionally related conditions. If no nutritional risks are evident, applicants who are otherwise eligible based on income, residency, identification, and category may be presumed to be at nutritional risk and assigned Risk Code 401 (Other Dietary Risk) except for infants who are fewer than four (4) months of age.

Nutrition risk criteria, risk factor codes and priority designations used for Georgia WIC certification are listed in Attachment CT-6.

The nutrition risk criteria are listed by applicant/participant category 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.B. for information regarding completion of the WIC Assessment/Certification Form.

XI. NUTRITION RISK PRIORITY SYSTEM

A. General Priorities I -VI

Each nutrition risk criterion is assigned a specific priority. Statewide priorities are set in accordance with the following guidelines:

1. Priority I: Pregnant women, breastfeeding women, and infants with nutritional need. This need is determined by measuring length/height, weight, hemoglobin/hematocrit and assessing nutrition status and nutrition related medical history.

2. Priority II: Breastfeeding women who do not qualify under Priority I, but are breastfeeding Priority II infants.

Infants up to six (6) months of age whose mothers were WIC participants during their pregnancy. Infants up to six (6) months of age whose mothers were not WIC participants during pregnancy but had a documented nutritional need.

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3. Priority III: Children (under age of five (5) years) 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 their being 18 years and 10 months of age.

4. Priority IV: Pregnant women, breastfeeding women, and infants with a nutritional need because of inappropriate nutrition practices, other dietary risk, or homeless/migrancy status.
5. Priority V: Children with a nutritional need because of inappropriate nutrition practices, other dietary risk, or homeless/ migrancy status.

6. Priority VI: Postpartum, non-breastfeeding women with a nutritional need because of inappropriate nutrition practices, other dietary risk, or homeless/migrancy status.
B. Special Considerations

Reciprocal Risk - A breastfeeding mother and her infant shall be placed in the highest priority for which either is qualified.

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, 304, 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, 502,904

Priority IV:

400, 401,502, 801, 802, 901, 902

2. Breastfeeding Women

Priority I:

101, 111, 133, 201, 211, 303, 304, 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, 363, 371, 372, 373, 381, 502, 601, 602, 904

Priority II:

502, 601

Priority IV:

400, 401, 502, 601, 801, 802, 901, 902

3. Postpartum, Non-Breastfeeding Women

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Priority III:

331, 502

Certification

Priority VI:
4. Infants Priority I: Priority II:

101, 111, 133, 201, 211, 303, 304, 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, 363, 371, 372, 373, 381, 400, 401, 502, 801, 802, 901, 902
103, 121, 134, 135, 141, 142, 153, 201, 211, 341, 342, 343, 344, 345, 346, 347, 348, 349, 351, 352, 353, 354, 355, 356, 357, 359, 360, 362, 381, 382, 502, 603, 702, 703, 904 502, 701, 702

Priority IV:

400, 401, 502, 702, 801, 802, 901, 902

5. Children

Priority III:

103, 113, 114, 121, 134, 135, 141, 142, 201, 211, 341, 342, 343, 344, 345, 346, 347, 348, 349, 351, 352, 353, 354, 355, 356, 357, 359, 360, 361, 362, 381, 382, 502,904

Priority V:

400, 401, 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 WIC 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 Georgia WIC 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, non-breastfeeding woman to continue benefits. The woman's status, priority, and food package must be updated. If no nutrition risks are evident, Risk Code 401 (Other Dietary Risk / Failure To Meet Dietary Guidelines) can be used for the woman to continue to receive WIC benefits as a postpartum, non-breastfeeding woman until six (6) months from the delivery date. All information must

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be documented in the participant's health record and entered into the automated system.

B. Upgrading a Priority

New data that have been collected and assessed during the certification period can be used to place a participant in a higher priority. A priority cannot be downgraded during a participant's certification period (with the exception of a breastfeeding woman changing status to a postpartum non-breastfeeding woman).

XIII. CERTIFICATION PERIODS

Certification periods are:

Pregnant Women: for the duration of their pregnancy and for up to six (6) weeks postpartum. There is no extension granted beyond the six (6) week postpartum cutoff.

Breastfeeding Women: for six (6) months from the date of initial and/or subsequent certification as a postpartum, breastfeeding woman. Eligibility ends when the certification period is over, when the breastfed infant turns one (1) year old 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 woman 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: certified at age six (6) months or younger: until their first birthday.

Infants: certified at age greater than six (>6) months: 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.

Vouchers may only be issued to participants who are in a valid certification period. The certification period always begins with the date of certification and ends on the categorically ineligible termination date (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. Vouchers can be issued for the one month extension. Please use this as the exception and not the rule. Document in the participant's health record the reason for the extension and issue only one month of vouchers.

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XIV. INFANT MID-CERTIFICATION NUTRITION ASSESSMENT

Certification

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 (only if mid-certification nutrition
assessment is performed between nine to eleven [9-11] months of age). d. Recording, summarizing, and evaluating inappropriate nutrition practices. e. Assessing nutrition risk criteria. f. Assigning the highest priority for which the infant is eligible, 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 the 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 fewer than five (5) months of age must be scheduled for a mid-certification nutrition assessment. WIC benefits may not be withheld from a participant for failing the mid-certification nutrition assessment appointment(s). Missed appointments should be documented in the participant's health record. If the infant misses the mid-certification appointment, a secondary nutrition education contact should still be conducted with the person who is picking up the infant's vouchers.

Note: Proof of identification, residency and income are not required during the midcertification assessment. However, if during the mid-certification a participant reveals that their income is above the income guidelines, the participant and ineligible household members will be terminated from Georgia WIC.

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

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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 agency 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
The following are instructions for 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, ethnic origin, race, migrant status, county of residency, proof of residence, proof of identification (for applicant/participant and, if applicable, for a parent/guardian/caregiver/spouse/alternate parent), clinic number, family ID number, foster care information, WIC ID number, and, in the case of infants and children, the full name of the parent or guardian/caregiver/alternate parent must be filled in on each form used. All legally responsible persons making application for Georgia WIC must be documented in the health record (e.g., name of father, guardian, caregiver, etc.).
The local agency representative must ask the applicant to make a self-declaration of their ethnic origin, race and migrant status and use the WIC Interview Script to collect demographic data. Unknown cannot be used to identify race for Georgia WIC. If the client refuses to answer, WIC staff must make the determination to the best of their ability.
2. Breastfeeding Information - Complete each line in this section, using the following information:
Infant's and Children's Forms through age two (2) years at each certification:
a. Breastfed Now (1) On Infant's Form, check "Yes" if this infant is currently breastfeeding.

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(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 using a paper Certification Form and the infant/child is currently or ever breastfed, record the number of weeks up to a maximum of ninety-nine (99) weeks (two [2] years of age). (see Attachment BF-9 in the Breastfeeding Section for the key for entering weeks breastfed.) If using direct entry of information into the computer system, the computer will automatically calculate weeks breastfed.

d. Date of Most Recent Breastfeeding Response - Record the date on which you asked the participant/guardian/alternate parent about breastfeeding.

Women's Form: a. Postpartum Breastfeeding Assessment/Certification Form (Breastfeeding an Infant Less than one (1) Year of Age): (1) If using a paper Certification Form, enter the weeks breastfed in the "Weeks" column. (see Attachment BF-9 in the Breastfeeding Section for the key for entering weeks breastfed). If using direct entry of information into the computer system, the computer will automatically calculate weeks breastfed. (2) Update the information at time of termination and submit to Covansys.

b. Postpartum Non-Breastfeeding Assessment/Certification form (Less than 6 Months Postpartum): (1) If the woman is not currently breastfeeding but has breastfed, check "Yes" to Breastfed Ever. (2) If using a paper certification form, and 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.) If using direct entry of information into the computer system, the computer will automatically calculate weeks breastfed. (3) If using a paper certification form, and if the response to Breastfed Ever is "No", enter "0" in the "Weeks" Column. If using direct entry of information into the computer system, the computer will automatically calculate weeks breastfed.

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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".)

x Initial Contact Type Select type of Initial Contact x W Walk-in x T Telephone x O Other (explain in notes)

4 Foster Care Enter Yes or No if the applicant is in Foster Care.

5. Medical Data Date - See the Nutritional Risk Determination CT-IX for the definition of required medical data. Enter the date anthropometric measurements were taken for certification purposes.

6. Length/Height - Enter the length/height to the nearest eighth of an inch (for infants and children only).

7. Weight - Enter the weight in pounds and ounces (for infants and children only).

8. Hematological Data Date - Enter the date the hematological measurement was taken for certification purposes. Hematological data date must be within d 90 days prior to certification for infants 9-12 months of age, children and women. Hematological data date must also be after the delivery or pregnancy termination for postpartum and breastfeeding women.

9. Hematocrit/Hemoglobin - Enter the hematocrit and/or the hemoglobin value(s) in the appropriate field. Values must be rounded to one decimal place.

10. 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 criteria marked with an asterisk (*).
This section of the form must be completed by a CPA during each certification appointment and at the infant's midcertification nutrition assessment.

11. High Risk - Check "Yes" when at least one nutrition risk meets the High Risk Criteria (see Attachment NE-1 and NE-2, Nutrition Education Section).

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12. Eligible for WIC - Check "Yes" when all of the following criteria are met: a. The applicant resides within the State of Georgia, and b. The applicant is income eligible, and c. The applicant is an infant, child, pregnant, postpartum or breastfeeding woman, and d. At least one (1) nutritional risk criterion is checked "Yes." There must always be at least one nutritional risk checked "Yes" for all participants / applicants. CPAs may assign Risk Code 401 (Other Dietary Risk) when no other nutritional risk factors have been identified for participants who are at least four (4) months of age. Check "No" when one or more of any of the criteria from the above list are not met (see Ineligibility Procedures CT-XVI).

13. Priority - Enter correct priority (I - VI). Refer to the Nutritional Risk Priority System CT-XI for risk factor codes and priorities.

14. Food Package - Enter the appropriate food package code (see Section FP, Food Packages Section).

15. Services - Enter referrals and/or enrollments to other health services and programs using codes listed on the WIC Assessment/Certification form. See Nutrition Education Section for more information regarding required referrals. Enrollment in or Referral to TANF, SNAP and Medicaid MUST be documented at least one time while a participant is receiving WIC. However, it is a best practice to assess enrollment at every certification. Simply asking if an applicant receives these other health services does not constitute making a referral; the applicant must be provided with information about the other services or programs, such as information about how or where to apply in their area. 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.

16. Today's Date - Enter the date the assessment is completed.

17. Signature/Title - Enter signature (first name and last name) and title (Nutr., R.D., L.D., R.N., M.D., etc.). An appropriate signature consists of first name, last name and title. The local WIC CPA signature confirms the nutritional risk.

18. Income Assessment

a. Date - Fill in the date the income screening was completed

b. Number in Family - Fill in according to Income Eligibility CTVIII.

c. Gross Income/Month

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1. Medicaid Recipients (See "Acceptable Proof of EligibilityAdjunctive Eligibility" at (CT-VIII.B.1) Mark "yes" (Y) if Medicaid participation has been confirmed. Medicaid recipients must self declare income.
2. PeachCare Recipients (See "Acceptable Proof of EligibilityAdjunctive Eligibility" at (CT-VIII.B.4.) All PeachCare clients must be assessed for WIC income eligibility.
3. SNAP Recipients (See "Acceptable Proof of Eligibility Adjunctive Eligibility" at CT-VIII.B.2) Mark "yes" (Y) if SNAP participation has been confirmed.
4. Temporary Assistance for Needy Families (TANF) - (See "Acceptable Proof of Eligibility-Adjunctive Eligibility" at (CTVIII.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 SNAP, Medicaid, or TANF Complete according to "Computing Income" at CT-VIII.C.
6. Income Eligibility - Check "Yes" or "No" to indicate applicant's income status. Transfer the total from the Income Calculation form to the section of the Certification form. 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 qualify for Medicaid, SNAP or TANF. Record current annual or monthly income.
Note: Income must be recorded for all applicants, including applicants who receive Medicaid, SNAP and TANF.
7. Income Source - Record, document and review for proof of income.
d. Staff Initial The staff person who confirms income, residency and ID maybe different from the person who signs the Certification Form. Therefore, the staff that collected this information must enter his/her initials.
e. Staff Signature(s) - The local WIC official signature confirms the income, residency 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 and title of person verifying income and witnessing the participant's signature.
f. Date - The date must be completed by the participant, their

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authorized representative or the attending staff person.

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g. Applicant/Participant Signature - The participant/parent/spouse/guardian/caregiver/ alternate parent 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):

WIC CERTIFICATION STATEMENT

RIGHTS AND OBLIGATIONS I have been advised of my rights and obligations for participation in Georgia's WIC. I certify
that the information I will provide, or have provided, is correct to the best of my knowledge. The income information that I have provided 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. Georgia's WIC 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 to Georgia's WIC, 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. NOTICE OF DISCLOSURE I understand that the chief state health officer for Georgia may authorize the disclosure of information about my participation in the WIC program for non-WIC purposes. This information will be used by Georgia WIC, its local WIC agencies and certain public organizations. These organizations include but are not limited to the Immunization Program, Pregnancy Risk Assessment Monitoring Systems (PRAMS), Epidemiology and other Maternal and Child Health Programs, Emergency Preparedness, Environmental Health and Medicaid. I understand that Georgia WIC, its local agencies and the public organizations can only use my information in the administration of their programs that serve persons eligible for WIC. The public organizations that receive my information must assure that it will not disclose my information to another organization or person without my permission.

I further understand that information about my participation in WIC may be used by the organizations that receive it only to:

1. Determine my eligibility for programs that the organization administers 2. Conduct outreach for such programs 3. Enhance the health, education, or well-being of WIC applicants and participants who are currently enrolled in those programs 4. Streamline administrative procedures to ease the burdens on WIC staff and participants 5. Assess the responsiveness of the state's health system to participants' health care needs and health care outcomes.

I have been advised that the decision to share my information is not a condition for eligibility

for WIC, and if I decide not to share my information, this will not affect my application or

participation in Georgia WIC.

_____________________________ ________ _____________________ _____

Name of WIC Applicant/Participant/Guardian/ Date

Name of WIC Official (please print)

Date

Caregivers/Spouse/Alternate Parent (please print) ___________

UP:

_________________________________________ __________ _____________________________ _______

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Signature of WIC Applicant/Participant/Guardian/ Date Caregivers/Spouse/Alternate Parent

Certification

Signature of WIC Official

Date

Please initial below to indicate your preference:

___In applying for WIC services, I AUTHORIZE DISCLOSURE of my WIC applicant or participant information for the purposes referenced above. I understand that my refusal to allow such disclosure does not affect my application for or participation in WIC or my eligibility for WIC services. ___In applying for WIC services, I DO NOT AUTHORIZE DISCLOSURE of my WIC applicant or participant information for the purposes referenced above. I understand that my refusal to allow such disclosure does not affect my application for or participation in WIC or my eligibility for WIC services.

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 WIC staff person will print the person's name next to the mark, and initial and date the mark to indicate that it has been witnessed.

19. Physical Presence (Certification Form (Back) Physical Presence
Physical Presence is mandatory for each applicant/participant at each WIC certification. (Refer to Section II.B. of Certification Section for additional information and documentation procedures.) If the response is "NO" to the Physical presence question, then N, D, R or W must be selected: x (N) Newborn Infants under age 8 weeks who are born to a mother who was on WIC during her pregnancy or was eligible to participate but was not certified. Medical or high risk condition is not required. Infants greater than or equal to age 8 weeks ( 8 weeks) cannot be
certified using this reason for physical presence exemption.
x (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 caregivers 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.
x (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 physical presence requirements by the local agency, if unreasonable barriers exist.
x (W) Working Parent or Caregivers The local agency may exempt an infant or child from the physical presence requirements if

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all 3 of the following criteria are met: a. If the infant/child was present for his/her initial WIC
certification, and 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
parent(s)/guardian(s) whose working status presents a barrier to bringing the infant/child into the WIC clinic.

20. Immunization Status

Infant and Children Form:

The immunization status is required during Initial and Subsequent certifications for infants over six (6) months of age and children.

(1) Record Screened/Requested Yes ( ) Requested ( )

(2) Adequate for Age/Referred? Yes ( ) Doctor ( ) Health Dept ( )

21. Data Needed for Pregnancy Surveillance

Infant's 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, e.g., 0=married, 1=not married, 9=unknown.
(2) Years of Education Completed - Enter a two-digit number to indicate years of education completed, e.g., 01=1st grade, 02=2nd grade, 14=2 years of college, 99=unknown.
(3) Month of Gestation at Time of First Prenatal Exam - Enter a one-digit code to indicate the month of gestation at the first prenatal exam, e.g., 0=No Prenatal Care, 1=1st Month, 8=8th or 9th month, 9=unknown
(4) Delivery - Enter the last weight taken prior to delivery, rounded to the nearest whole pound, e.g. 165.6 = 166.
(5) Parity A two-position field indicating the number of times a
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woman has been pregnant for 20 or more weeks gestation, regardless of whether the infant was alive or dead (stillbirth, miscarriage, induced or spontaneous abortion) at birth, e.g., 00=None, 01-29=Number of previous births.

(6) Date Last Pregnancy Ended A six-position field indicating the date when the previous pregnancy of at least 20 weeks or more ended, whether by normal delivery, stillbirth, induced or spontaneous abortion (miscarriage) excluding current pregnancy, e.g., 000000= No Previous Pregnancies, Month/Year=01-12 and All four digits.
(7) Diabetes During Pregnancy Postpartum Visit - A oneposition field indicating the presence of diabetes during this current pregnancy, as diagnosed by a physician and selfreported by the postpartum woman or as reported or documented by a physician or someone working under a physician's orders, e.g., 1=No, never had diabetes of any type. 2= Yes, told by a doctor I had diabetes before the most recent pregnancy, when not pregnant (diabetes mellitus). 3=Yes, told by a doctor I had diabetes before the most recent pregnancy, but only when pregnant (gestational diabetes in both past and most recent pregnancies). 4=Yes, told by a doctor I had diabetes for the first time during the most recent pregnancy (gestational diabetes in the current pregnancy only).

(8) Hypertension During Pregnancy Postpartum Visit - A one-position field indicating the presence of hypertension during pregnancy as diagnosed by a physician or someone working under a physician's orders and self-reported by a woman, e.g., 1=No, never had high blood pressure before the most recent pregnancy, when not pregnant (chronic hypertension). 2= Yes, told by a doctor I had high blood pressure before the most recent pregnancy, when not pregnant (chronic hypertension). 3= Yes, told by a doctor I had high blood pressure before the most recent pregnancy, but only when pregnant (pregnancy-induced hypertension in both past and most recent pregnancies). 4= Yes, told by a doctor I had high blood pressure for the first time during the most recent pregnancy (pregnancy-induced hypertension in the current pregnancy only).

(9) Multi/Prenatal Vitamin Consumption Prior to Pregnancy A one-position field indicating an average of how many times per week a woman took a multi/prenatal vitamin in the month before pregnancy, e.g., 0=Less than once per week , 1-7= Times per week, 8= Eight or more times a week, 9=unknown.

(10) Multi/Prenatal Vitamin Consumption During Pregnancy A one- position field indicating if a pregnant woman has taken multi/prenatal vitamins and/or minerals in the past month, e.g.,1=Yes, 2=No and 9=Unknown.

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(11) Cigarettes/Day 3 Months Prior to Pregnancy A twoposition field indicating the average number of cigarettes the woman smoked per day during the three (3) months before she became pregnant, e.g., 00=Did not smoke, 01-96=Number of cigarettes smoked per day, 97=97 cigarettes per day or more, 98=Smoked, but quantity unknown, 99=Unknown or refused.
(12) Cigarettes per Day Prenatal Visit - A two-position field indicating the average number of cigarettes the woman currently smoked per day at her prenatal visit, e.g., 00=Did not smoke, 01-96=Number of cigarettes smoked per day, 97=97 cigarettes per day or more, 98=Smoked, but quantity unknown, 99=Unknown or refused.
(13) Cigarettes per Day Postpartum Visit A two -position field indicating the average number of cigarettes the woman currently smoked per day at her postpartum visit, e.g., 00=Did not smoke, 01-96=Number of cigarettes smoked per day, 97=97 cigarettes per day or more, 98=Smoked, but quantity unknown, 99=Unknown or refused.
(14) Cigarettes/Day Last 3 Months of Pregnancy A twoposition field indicating that average number of cigarettes the woman smoked during the last three (3) months of her current or most recent pregnancy. This is reported at the postpartum visit only, e.g. 00=Did not smoke, 01-96=number of cigarettes smoked per day, 97 = 97 or more, 98 = smoked but quantity unknown, 99=Unknown or refused.
(15) Household Smoking Prenatal Visit A one-position field indicating whether anyone in the household other than the pregnant or postpartum women currently smokes inside the home, e.g., 1=Yes, someone else smoke inside the home, 9=Unknown. 2= No, no one else smokes inside the home.
(16) Household Smoking Postpartum Visit A one-position field indicating whether anyone in the household other than the pregnant or postpartum women currently smokes inside the home, e.g.,1=Yes, someone else smokes inside the home, 2No, no one else smokes inside the home, 9=Unknown.
(17) Drinks/Week 3 Months Prior to Pregnancy A two position field indicating the average number of drinks per week of beer, wine or liquor the woman consumed during the three (3) months before her current or most recent pregnancy, e.g., 00=Did not drink, 01= 1 drink per week or less, 02-20=number of drinks per week, 21=21 or more drinks per week, 98=Drank, but quality unknown, 99=Unknown or refused.
(18) Drink/Week Last 3 months of Pregnancy A two-position

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field indicating the average number of drinks per week or beer, wine, or liquor the woman consumed during the last three (3) months of her current or most recent pregnancy. This is reported at the postpartum visit only, e.g., 00=Did not drink, 01=1 drink per week or less, 02-20=Number of drinks per week, 21=21 or more drinks per week, 98=Drank, but quantity unknown, 99=Unknown or refused.

22. Comments (Proxy 1/Proxy 2) This section may be used to maintain a record of proxy names authorized by participants or parents/alternate parent/spouse at certification. Review names prior to voucher issuance.

23. Questions added to the Certification forms (P,N,B,I and C):

Breastfeeding The "Food Package" row has been expanded to include space to record the infant's food package code. If the infant has not yet been certified or if the mother has delivered multiple infants (e.g., twins, triplets, etc.), the CPA should enter "AAA" in this box on the Certification Form or in the computer system. The purpose of this field is for the computer to perform a cross-check between the mother's and infant's food package codes to ensure the mother is receiving an allowed food package.

Woman's Feeding Method (E, M, S). The CPA is to identify whether the breastfeeding woman is classified as Exclusively, Mostly, or Some breastfeeding.

Non-Breastfeeding, Breastfeeding, Infant and Children Date of last time of breastfeeding and/or pumping (MMDDYYY) Children Recumbent/Standing (R or S). The CPA is required to identify whether a child was measured in a recumbent (R) or standing (S) position.

Infant Infant Feeding Type (E, M or F). The CPA is to identify whether the infant is receiving an Exclusively Breastfed, Mostly Breastfed, or Fully Formula Fed food package.

Infant and Children 1. Medical Home (Y or N). If yes, enter name of physician or
practice. 2. PeachCare (Y or N)

Prenatal, Non-Breastfeeding, Breastfeeding, and Children 1. Fruit Intake (D, S or N). The CPA is to indicate whether the
applicant / participant consumes fruit daily, some days of the week, or never. 2. Vegetable Intake (D, S or N). The CPA is to indicate whether the applicant or participant consumes vegetables daily, some

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days of the week, or never. 3. Usual Daily Activity (V, S or N). The CPA is to indicate whether
the applicant / participant is very physically active, somewhat active, or not active. 4. Dairy Intake (D, S or N). The CPA is to indicate whether the applicant or participant consumes dairy products daily, some days of the week, or never. 5. Screen Time (Hours in 00-24). The CPA is to indicate the amount of time in hours per day that the applicant or participant spends watching television, playing video games and/or playing on a computer.

Prenatal, Non-Breastfeeding, Breastfeeding, Infant and Children Family Number

XVI. INELIGIBILITY PROCEDURES (NOTIFICATION REQUIREMENTS)

Persons may be ineligible or disqualified for Georgia WIC benefits on the basis of residency, category, income or nutritional risk; however, infants fewer than four (4) months of age are the only participants/applicants who potentially can be disqualified based solely on the lack of nutritional risk (due to the introduction of Risk Code 401, which can be used to document presumed nutritional risk for all otherwise eligible persons who are age four [4] months or older). All applicants/participants who do not meet Georgia WIC 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 (see Attachment CT-14 or CT-15). When applicants/participants are ineligible or terminated from Georgia WIC and a NTIWL is issued, they must be informed of their right to a fair hearing. A fair hearing may be requested when Georgia WIC participation is denied or a participant is disqualified for benefits (see Fair Hearing Section in Rights and Obligations). Local agencies must follow Georgia WIC 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 Georgia WIC 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 (3) years plus current year. A copy of the form will be filed in the individual's health record and/or the Ineligibility file.

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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 fifteen (15) days before the expiration of their certification eligibility period that it is about to expire. Homeless participants will be notified at least thirty (30) days before the expiration of their certification period.

3. Disqualification - A participant who is about to be disqualified from Georgia WIC 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.

4. Termination Notification - Notification does not need to be provided to persons terminated for failing to pick up vouchers for two (2) 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 Georgia WIC. The Fair Hearing Section must be completed when using this form. If a stamp is used for this purpose, all copies must be stamped. The form must be signed by the parent/guardian/caregiver/spouse/ guardian/alternate parent and the WIC representative. Appropriate documentation and termination procedures must be followed. A written notice of termination must be given for each member of the family on Georgia WIC.

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

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guidelines are followed:

Certification

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 filled out with signatures, dates and the Fair Hearing Section); c. The date the ineligibility action was taken. d. WIC Assessment/Certification Form (Complete all sections on the WIC Assessment/Certification Form when an applicant is not eligible for Georgia WIC. This includes income documentation, date, signature of the participant or applying parent/guardian/caregiver/spouse/guardian/alternate parent of the participant and the signature of the person who collected income information). e. All supporting documentation, e.g., nutritional assessment, 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. Paper and electronic Verification of Certification (VOC) cards are the official documents for validating WIC certification nationwide (see Attachment CT-16 and 17). VOC cards (paper and electronic) are negotiable instruments used to validate WIC certification. These cards allow WIC participants to transfer certification from one clinic, city or state to another. Local agencies must maintain accurate records of issuance, security and receipt from participants.

A. Clinic Staff
Clinic staff must:
1. Inform all WIC participants that they should request a VOC Card if relocating anytime during their eligibility period. All migrant farm workers must be issued VOC cards upon arrival in the clinic. For nonmigrant participants transferring within the State of Georgia only, issue a VOC/EVOC card. However, original records must be retained at the initial clinic site.
2. Instruct the participant on the use of the VOC card. 3. Do not issue an EVOC/VOC card to a proxy.
When an applicant transfers in with a VOC card, the parent, guardian, or caregiver is not required to bring the infant or child.

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4. When transferring from one clinic to another (in-state or out-of-state), the participant or parent/guardian/caregiver/spouse/ guardian/alternate parent must present the VOC card, proof of identity, and residency documents. The Thirty (30)-Day Form can be used for missing proof information.

Note: A Notice of Termination Waiting List (NTIWL) form must be issued on site, when a VOC card is issued to a participant, with the exception of a migrant participant (see Attachment CT-14 or CT-15).

B. Out-of-State Transfer/Incomplete VOC Cards

Out-of-state participants with a valid VOC card must be placed on Georgia WIC even if they do not meet Georgia WIC 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. Transfer with valid VOC cards or other valid signed certification evidence (e.g., certification record, valid proof of identification and residency) must be enrolled immediately. The Thirty (30)-Day Form can be used for missing proof information. If information is missing, contact the clinic and ask the staff to fax or e-mail the required information as soon as possible. Proxies cannot present VOC or transfer information for the participant. 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 certification expires and (3) the name and address of the certifying agency. The participant must also present proof of identification and residency. The VOC card must be placed in the participant's file/record. Participants who are transferring Out-of-State and are in a Thirty (30)-day period status, please document "Thirty Day", the Thirty Day return date and the missing proof information on the VOC/EVOC cards.

C. In-State Transfer
If WIC clinic staff is unable to obtain the necessary information by phone for a Georgia participant, 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. All transfer certification information must be in the participant record within two (2) weeks of the transfer. The phone call and all information obtained must be documented in the participant's health record. The call must be followed with written documentation from the clinic.
It is recommended that each District establish procedures to make it easy for other WIC clinics to obtain the information needed to complete a transfer. This could include a staff member assigned to handle all transfer requests. Also if the clinic uses automatic phone transfers to have the voice message indicate to

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which extension transfer request should be routed.

Certification

D. Release of Information/Original Certification Form (In-State/Out-of- State)

The United States Department of Agriculture (USDA) approved the release of participants' WIC records from one WIC clinic to another WIC clinic without completion of a Release of Information form. The original WIC Assessment/Certification form must be retained in the District/Clinic where the participant was certified. Below are some scenarios for transferring a WIC participant's records:

Intra-State (within the state of Georgia): When transferring a participant from one Georgia WIC clinic to another Georgia WIC clinic, a Release of Information form is not required. The WIC staff of the receiving clinic should call the original clinic and obtain all necessary information required to complete the transfer process. The original clinic must verify that the receiving clinic is a genuine clinic and provide the participant's information. In addition, the original clinic must send a signed copy of the current Certification form to the receiving clinic as soon as possible, preferably by fax.
Out-of-State Transfer: When transferring a participant from out of state, the Release of Information form is not required. The above (in-state) policy applies to the out-of-state participants as well.
Transferring a WIC record for a non-WIC purpose: (Parent of the Child or Private Doctors) A Release of Information form (see Attachment AD-4) must be completed and signed by the participant or parent of the participant before releasing any WIC information to any other agency/program other than WIC. The WIC staff must keep the original record/document in the original clinic. If a mother wants to transfer her child to another WIC clinic and wants to take the WIC record with her (hard copy), the mother must sign the Release of Information form.
If another health program, such as Immunization, private doctors and DFCS, wants the WIC record, a Release of Information form (see Attachment AD-4) must be completed before releasing any confidential WIC information.
If a WIC staff is releasing any medical/health information other than WIC information, a Release of Information form must be filled out and signed.
Transferring a Foster Child: When transferring a foster child from one WIC clinic to another WIC clinic, intrastate policy also applies. If a foster child is placed in a different home during the valid certification period, the foster parent must present all legal documentation. The new foster parents should sign a Release of Information Form (see Attachment AD-4).
Note: Any time a clinic refuses to send information without a completed Release of Information form, the requesting clinic must advise the Policy Unit at

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the Georgia WIC of the name of the employee, clinic, and date the information was requested. However, the participant must not suffer; in this situation, please send a Release of Information form to the receiving clinic to serve the participant.

The use of the Participant Transfer Log is optional for all clinics. This form was developed in an effort to remind WIC clinic staff of the status of Transfer information from one WIC clinic to another. Documentation of Transfer will be reviewed (see Attachment CT-9).

E. Two Methods for Transfer

Georgia WIC has two (2) methods for VOC cards. They are electronic and paper VOC cards issuance.
1. The Electronic VOC Card System
a. The Electronic EVOC card system automatically: 1. Prints the card 2. Completes the inventory 3. Conducts a physical inventory 4. Prints your initials 5. Gives Clinic Manager and Nutrition Services Director access for security reasons
b. The Electronic VOC card system procedure requires: 1. Logging into the VOC card computer system 2. Entering your password 3. Entering necessary data in your VOC card system 4. Printing two copies of the EVOC Card x The first signed copy is to be given to the participant x The second copy must be placed in the medical record or EVOC card file
If the printing system is linked in GWIS or the GWIS.net, clinic staff is only required to enter the WIC ID number and the required fields will be populated automatically. If the system is not linked to GWIS.net, all required fields on the computer screen must be completed.
c. Quarterly Report for Electronic VOC Card & Paper VOC Cards On the last working day of the months of December, March, June and September of each year, WIC clinic staff is required to print a copy of their EVOC card inventory and place it in a file for audit purposes. Additionally, each Nutrition Services Director and designee will have permission to view the EVOC card files at any time for security purposes.
d. Printing Electronic VOC Cards EVOC card information is to be printed on regular white

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8 x 11 paper. However, an official EVOC card must be stamped with the Georgia WIC stamp using BLACK INK.

e. Termination Notices Once the EVOC card information is entered, a Notice of Termination/Waiting List form will be generated automatically stating the participant has moved out of the area. The only exception to printing a Notice of Termination/Waiting List form is when a card is issued to a Migrant.

f. Migrant Transfer When a migrant visits your clinic, automatically issue an EVOC card. However, you must not issue a Notice of Termination/Waiting List Form unless their certification is ending.

g. Required Data on the EVOC and Paper VOC cards Required data on the EVOC and Paper VOC cards is as follows: 1. Clinic # 2. Participant/Parent/Guardian/Spouse/Caregiver Alternate Parent 3. Telephone 4. Address 5. ID # 6. Date of Birth 7. Participant's Name 8. Telephone 9. Participant Address 10. Certification Date 11. Height 12. Date Certification Expires 13. Medical Data Date 14. HGB or 15. HCT 16. Weight 17. Food Package 18. Priority 19. EDC Date 20. Migrant (must be checked "yes/no") 21. Nutritional Risk Code (use national risk codes) 22. Intended City/State moving to 23. Date of Latest Income Eligibility 24. Last Date Vouchers Issued

The signature of the WIC official as well as the WIC applicant is required on the EVOC card. Remember: A VOC card must not be issued to a proxy.

h. Physical Inventory No physical inventory is required for the EVOC system.

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2. The Manual VOC Inventory System
The Manual VOC Card Inventory System is a backup system in the event the computer system crashes. This system requires:
a. Security of VOC cards b. Quarterly or monthly physical inventory c. Issuance d. Counting of cards quarterly or monthly e. Signature of person who conducted the inventory and the
initials of the person verifying the inventory
F. Ordering VOC Cards
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 Nutrition Services Director must submit a VOC Card Agreement and a VOC Card form (see Attachment CT-21 and CT-22). These two forms must be completed, signed and forwarded to Georgia WIC at the address below. No orders will be accepted from any clinic unless these forms have been received.
The VOC Agreement must be completed by the Nutrition Services Director who must indicate which clinic representative is responsible for requesting VOC cards from the State (see Attachment CT-21). NO PHONE CALL REQUESTS WILL BE HONORED.
When ordering VOC cards directly from the State, an order form must be completed and mailed to: Georgia WIC, Policy Unit, Suite 10-476, 2 Peachtree Street, NE, Atlanta, Georgia 30303. A minimum of five (5) paper cards must be on hand (see Attachment CT-23).

G. Inventories
All local agencies and clinics are responsible for maintaining an inventory of all VOC cards. The State VOC Card Inventory Logs must be used by all local agencies and clinics (see Attachments CT-19 and CT-20). When VOC cards are received, the following must be recorded on the inventory log: 1. The date. 2. The number 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.

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The EVOC Card Inventory should be printed and filed quarterly on the last working day of December, March, June and September of each year.

VOC Card Inventory (Paper)

Districts have the option to conduct VOC card physical inventory monthly or quarterly. If monthly is chosen, the physical inventory should be conducted on the last working day of each month. This monthly inventory must be continued for the entire fiscal year. If the District chooses to conduct inventory quarterly, the physical inventory should be conducted on the last working day of December, March, June and September of each year.

The following must be recorded on the inventory log: 1. The date 2. The number series must be recorded in the beginning/ending number
columns. 3. Document "Physical Inventory Conducted". 4. Total number of cards on hand. 5. Signature of staff person conducting the physical inventory. 6. Initials of staff person verifying the physical inventory. 7. All VOC cards must be accounted for and the log must accurately
reflect the disposition of each VOC card.

H. 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-19): 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/Spouse/Caregiver/Alternate Parent/ (A
proxy cannot pick up a VOC card). 6. Name/City/State participant is moving to. 7. Number of cards on hand. 8. Signature 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-20): 1. Date. 2. VOC card number 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. Signature of staff person conducting the physical inventory. 8. Signature of the staff person issuing the card.

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I.

Security

VOC cards are negotiable instruments; therefore, the security of the cards and the accompanying inventory log is imperative. VOC cards, the 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.
When the State office mandates that old stock of VOC cards are replaced with revised ones, complete the Lost/Stolen/Destroyed/Voided Vouchers Report with following (see Attachment FD-18):
a. Current Date. b. VOC Card number series (beginning/ending numbers). c. Quantity. d. Status.

Retain a copy in the clinic and forward a copy to Georgia WIC, Policy Unit, Suite 10-476, 2 Peachtree Street, NE, Atlanta, Georgia 30303. Document the destroyed VOC cards on the VOC card Inventory Log with the following:
a. Current date b. VOC card number series (beginning/ending numbers) c. Document "Destroyed" d. Number on hand e. Initials of staff person destroying VOC cards f. Initials of staff person verifying that the VOC cards were
destroyed

J. Lost/Stolen/Destroyed EVOC or VOC Cards

In the event an EVOC or VOC card is lost, stolen or destroyed, contact the Policy Unit immediately and complete the Lost/Stolen/Destroyed/Voided Voucher Report. This report is located in the Food Delivery Section. Anytime an EVOC or VOC Card is lost, stolen, destroyed, an Action Memo will be sent to all local agencies by Georgia WIC so that you are aware of the status of the card.
EVOC or VOC Cards must not be reissued to WIC participants within a certification period. If an EVOC or 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 PublicHealth.
When there are any discrepancies in the EVOC card system noted an investigation will automatically take place.

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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 locations include: 1. Lakenheath, England (Air Force) 2. Yokosuka, Japan (Navy) 3. Baumholder, Germany (Army) 4. Okinawa, Japan (Marines and Air Force) 5. Guantanamo Bay, Cuba (Navy)
Additional WIC Overseas Programs will be phased in at other locations where WIC Overseas Program services and benefits can be provided. Information about DOD's WIC Overseas Programs can be found on the TRICARE Website at: http://www.tricare.osd.mil.
B. Impact on USDA's WIC Programs
Legislation limits eligibility in the WIC Overseas Program to: 1. Members of the armed forces (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) (e.g., 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 the USDA's WIC requirements. Therefore, DOD guidelines provide that WIC 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 (see Attachment CT-35).
Note: A "dependent" includes a spouse and "U.S. national" 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.

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C. New EVOC or VOC Card Requirements
State and local agencies must begin to issue WIC EVOC or VOC Cards to WIC participants affiliated with the military who will be transferred overseas. WIC participants issued EVOC or 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 (as defined in Section B above) are eligible for the WIC Overseas Program.
3. Issuance of a WIC EVOC or VOC card does not guarantee continued eligibility and participation in the WIC Overseas Program. Eligibility for the overseas program will be assessed at the overseas WIC service site.
D. Completion of the EVOC or VOC Card
When completing the EVOC or VOC card for a transfer overseas, please follow the same procedures outlined in CT-XVII. E.g. 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 EVOC or 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. TRANSFER OF CERTIFICATION SECTION (Out of State Transfer).
If questions arise about the VOC card presented, a current list of WIC Overseas Program contacts is attached (see Attachment CT-36). 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 regulations and policies.

XIX. CORRECTING OFFICIAL WIC DOCUMENTS A. Correcting Mistakes The following procedure must be followed when a mistake is made on an official WIC document:
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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).
B. Adding Information
The following procedure must be followed when it is necessary to write additional information on an official WIC document: 1. Write new information 2. Initial 3. Date
XX. LATE ENTRY CORRECTION OF HEALTH RECORDS
Upon receipt of WIC records from another clinic, review the record for missing information. If information is missing, the receiving WIC 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 non-erasable ink.
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. WAITING LIST
When the local agency is serving it maximum caseload, the state must notified the local agency that a waiting list must be maintained on individuals who visit the clinic to express interest in receiving program benefits and who are likely to be served. However, in no case must an applicant who request placement on the waiting list be denied inclusion.
A waiting list must not begin until the state contacts the United States Department of

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Agriculture for approval. Once the waiting list is approved by USDA, the state will contact the local agency by sending out an Action memo outlining the procedures for a waiting list.

The state agency may establish a policy which permits or requires local agencies to accept telephone request for placement on the waiting list. Below are additional procedures for maintaining a waiting list.

A. Procedures for Maintaining a Waiting List
1. A waiting list shall be maintained for individuals who qualify and express an interest in receiving Georgia WIC 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 available:
a. Applicant's name b. Date applicant was placed on the waiting list. c. Applicant's address and telephone number. d. Applicant's status (e.g., pregnant, breastfeeding, age of
applicant, etc.). e. Applicant's priority.
Applicants must be notified of their placement on the waiting list within 20 days after they visit the local agency during clinic office hours to request benefits. If the state is approved for establishing procedures to accept telephone requests for applicant's placement on a waiting list, applicants must be notified of their placement on a waiting list within 20 days after contacting the local agency by telephone.
Before a waiting list is instituted, the Competent Professional Authority at the state must apply the applicant's priority system and ensure that the highest priority applicants is processed first to become a program participants when a caseload slots become available B. Procedures for Removal from the Waiting List
The state will notify the local agency when a waiting list ends and the procedures for removal from the waiting list.
The Nutrition Services Director 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

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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.

Note: The Notice of Termination/Eligibility/Waiting List form will be used to notify applicants on the status of the waiting list when the certification expires.

XXIII. SYSTEM INFORMATION MANAGEMENT

All clinics are now able to utilize the Electronic Verification of Certification program via GWIS.net or GWIS. Additionally, the WIC Monitoring Tool is being updated to an electronic version for State and local agency staff to use. The Policy Unit placed all clerical and administrative staff forms on the www.WIC.ga.gov website under the "District WIC Resources" page.

XXIV. IMMUNIZATION COVERAGE ASSESSMENT

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 C. F. R. Section 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. Georgia WIC 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 birth.

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: Is there a documented immunization record; the response is (Y) for yes an immunization record is viewed or (R) for the record requested (record was not available). If the prior response was (Y), then the next response should be (Y) the child is adequate for age or (D) referred to doctor or (H) referred to health department. 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 immunization records are assessed and that referrals are being made according to local agency policy. See the Monitoring Section for the tool on which the local agency will be reviewed.

XXV. COMPLAINT PROCEDURES
A. 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-four (24) hours. The Incident/Complaint Form should be used to assure that all required information is captured (see Attachment CT-39).

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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 Georgia WIC 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 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 resolution date.
If it is necessary for the incident/complaint to be forwarded to Georgia WIC, the above procedure will apply for state staff. The name of the Georgia WIC Customer Service Coordinator or designee and date of follow-up must be documented. This form will be kept on file for three (3) years plus current year.
B. How to File a Complaint (Flyer)
It is required that the "How to File a Complaint" Flyer be displayed and visible from all WIC service delivery points in the clinic (see Attachment CT-40). This flyer must be offered to all applicants/participants at initial certification, recertification and mid-certification. Please refer to Rights and Obligations Section IV. E and F regarding complaint procedures.
Note: For a family of two or more, only one flyer is required to be distributed.

XXVI. SPECIAL CERTIFICATION CONDITIONS (HOME VISITS)
A. General
A home certification may be done for WIC applicants/participants unable to visit the clinic for an extended period of time due to the following conditions: Recent child birth, prenatal on bed rest, disabilities that inhibit movement from place to place, medical equipment that is difficult to transport or health conditions that would be exacerbated by coming into a WIC clinic.
Districts must receive approval from Georgia WIC as mandated by Federal regulations prior to implementing the routine practice of home certifications. Charges for in-home WIC services are forbidden.

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B. Certification for Home Visits
Certification requires all information to be completed on the Certification Form and vouchers issued at the time of certification in order to complete the process. When only one person completes a certification, a copy of the completed Certification Form, voucher receipt(s) and any other documentation must be submitted to the District Nutrition Services Directors or their designee within three (3) days of certification to comply with separation of duties. Separation of Duties means more than one employee is required to complete the WIC application process of issuing vouchers and conducting the WIC Certification process. However, a form has been created to document the absence of Separation of Duties (see Attachment CT-43) if only one person is completing the entire voucher issuance and WIC certification process. The Separation of Duties form must be:
x Maintained on file at the District office for review. x Maintained on file for three (3) years plus current year. x Completed within three (3) days of certification. x Used anytime one (1) person completes the certification process
alone.
C. Procedures
When making a home visit to certify all applicants for Georgia WIC, the following procedures must be followed:
1. Staff will communicate with client by phone; obtain as much information over the phone as possible (establish time and date of visit).
2. Clinic staff must take a laptop or paper Certification Form to the client's home. Clinic staff must request ID, residency and income and documents using established codes. When using a paper Certification Form, place the signed copy of the form in the patient's file. The certifying information must be entered into the computer. However the, unsigned computer printout must not be included in the patient record.
3. VPOD vouchers must be created prior to leaving the WIC clinic. The client then signs the voucher receipt or voucher register if blank manual vouchers are used. The signed receipt or register must be filed and maintained according to standard operating procedures.
4. Clinic staff may use the mother's Medicaid number as proof for the first sixty (60) days to place an infant on Georgia WIC. Medicaid card verification must be done or a thirty (30)-day certification may be used. If the thirty (30)-day certification is used, the established procedures must be followed.
5. An Ineligibility Notice must be issued if the client is determined to be ineligible at that time.

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6. If, after completing the certification process, Voter Registration has been offered according to the requirements of the National Voter Registration Act of 1993, Rights and Obligations and How to File a Complaint flyer have been given, and the applicant/participant is eligible, then vouchers and a WIC ID card must be issued.
7. WIC clinic staff must return the Certification Form, signed copies of Blank Manual Vouchers and other paperwork to clinic for filing.
8. WIC clinic staff must enter the information into the computer and mail copies of the Blank Manual Vouchers (if used) to CSC Covansys.
9. Nutrition assessment/education Based on the data collected from the WIC Assessment and Certification Forms (e.g., client's available anthropometric, biochemical, nutritional information and health history), a nutrition assessment shall be done and nutrition counseling provided. The client-centered counseling shall include information on the applicant's nutritional risks identified, food package prescribed, information about Georgia WIC and any referrals for services needed. The nutrition education and related forms shall be documented and filed in the participant's chart upon return to the clinic.
XXVII. SPECIAL CERTIFICATION CONDITIONS
A. General
The certification process for Newborn/Postpartum certification in the hospital is listed below. This includes but is not limited to the certification and transfer process of WIC participants statewide.
Hospital newborns/Postpartum WIC Clinics may be transit or stationary clinic sites. The hospital clinics presently serve:
x Newborns delivered on site x Postpartum women x Postpartum women already served by clinics during their prenatal period
B. Separation of Duty
When only one (1) person completes any certification process alone, a copy of the completed Certification Form, voucher receipt(s) and any other documentation must be submitted to the Nutrition Services Director or their designee within three (3) days of certification to comply with separation of duties. A form has been created to document the absence of Separation of Duties (see Attachment CT-43). The Separation of Duties form must be:
x Maintained on file at the District office for review. x Maintained on file for three (3) years plus current year. x Completed within three (3) days of certification. x Used any time one (1) person completes the certification process alone.

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C. Certification Procedure (with use of medical records)

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The procedures for certification at a hospital with use of medical records are as follows:
x A list of daily deliveries is given to WIC Staff to make rounds on the OB wards.
x WIC staff visits the OB ward and review the medical records, nurse kardex/a list and lab data, which facilitate the certification process.
x The medical records contain the identification (ID), residency, Medicaid documentation, weight, heights and hemoglobin.
x Record Medical Record (MR) for proofs obtained by the hospital medical records. Stamped dated copies are required for proofs received from the applicant/participant or the thirty (30)-day procedure should be used.
x A Certification form is completed. Voter Registration is offered, according to the requirements of the National Voter Registration Act of 1993, Rights and Obligation and How to File a Complaint flyer are given and one (1) to three (3) months of vouchers are issued depending on client risk and follow-up needed.
x The participant is transferred to the clinic of their choice. This includes all health districts and the two contracted agencies.
x Vouchers are taken on the ward stored in a locked container until issued. x The participant is given a follow-up appointment with the name and
phone number of the WIC clinic to contact. x WIC staff maintains a daily running list of patients enrolled on Georgia
WIC to ensure that duplication does not occur.

Note: High-risk participants Certifying WIC staff must use professional judgment in determining the number of months of vouchers that are issued to high-risk participants.

D. Certification Procedures (without use of the Medical Record)

When only one person completes any certification process, a copy of the completed Certification Form, voucher receipt(s) and any other documentation must be submitted to the Nutrition Services Director or their designee within three (3) days of certification to comply with separation of duties.

The procedures for certification at a hospital without permission to use Medical Records are as follows:
x WIC staff is given a list (daily) of patients that are on the OB ward. This list contains information that will determine the status of each patient (e.g., name, age, lab data, etc., that facilitates the certification process).
x This list may also contain the identification (ID), residency, Medicaid documentation, weight, heights and hemoglobin.
x Identification, residency and income information (if adjunctive eligibility documentation is not found) is brought to the hospital or the Thirty (30)Day procedure should be used).
x The WIC employee verifies the list prior to making rounds on the on the

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OB wards. This will determine if the patient needs to be seen. Additionally, information must be asked of the applicant to determine eligibility (e.g., income, etc.). x WIC staff maintains a daily running list of patients enrolled on Georgia WIC to ensure that duplication does not occur. x A Certification form is completed. Voter Registration is offered, according to the requirements of the National Voter Registration Act of 1993, Rights and Obligations and How to File a Complaint flyer are given and one (1) to three (3) months of vouchers are issued. x The participant is transferred to the clinic of their choice. This includes all county clinics and the two contracted agencies. x Vouchers are taken on the ward stored in a locked container until issued. x The participant is given a follow-up appointment with the name and phone number of the clinic to contact. Note: High-risk participants Certifying WIC staff must use professional
judgment in determining the number months of vouchers that are issued to high-risk participants.

E. 90-Day Blood Work Policy

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 Services Unit prior to implementation. Written approval must be kept on file in the District Office.

F. Voter Registration Policy

WIC applicants/participants are offered the opportunity to register to vote at the time of all application, renewal, recertification and change of address transactions according to the requirements of the National Voter Registration Act of 1993. Follow all the requirements set forth in the Rights and Obligation Section at National Voters Registration Act.

G. Transfers/Caseload Count
Hospital clinics must not maintain any WIC participant from another District for more than three (3) months. In fact, all participants certified for Georgia WIC must be given a copy of their Certification Form to enroll into the clinic/county of their choice.

When clinic staff completes the certification documentation, the information is entered into the computer and transmitted daily to the State contractor. VOC cards are one method of transfers that are being used. Other clinics are using the three-ply certification form maintaining one copy for the clinic; the second copy is mailed to the receiving clinic and the third copy is given to the participant to carry to the clinic.

H. Identification (ID) Number Assignment

WIC participant ID numbers are assigned based on District policy.

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Thirty (30) -Day Policy

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The Thirty (30) -Day Policy may be used in the hospital. However, only one month of vouchers may be issued and the receiving clinic must collect the missing documentation. Please remember to identify the missing documentation on the WIC ID card. Send a copy of the Thirty (30)-Day form along with a copy of the Certification Form to the new clinic site.

J. Agreement between the District and Hospital
All hospital-based clinics must have a Memorandum of Understanding or agreement in place with District prior to opening. This agreement must be forwarded to Georgia WIC upon approval.

K. Prior Approval
Written approval must be given by Georgia WIC prior to opening any new WIC clinics (see the Administrative section of the Georgia WIC Procedures Manual).
L. File Maintenance in the Hospital
Files for all hospital sites must be kept separate and apart from other records for audit purposes.

M. Voucher Security
All vouchers must be kept secure and follow the procedures outlined in the Georgia WIC Procedures Manual.

N. Certification Process in the Hospital
Only one Certification Form is required per certification. If a paper Certification Form is used for certification, file it in the WIC record. Once the certification information is entered into the computer, do not print an additional computer certification form.
O. Required Components of a Hospital Certification
1. The name, address and income of the WIC applicants must be acquired from the Medical Record or by requesting the information on site from the applicant.
2. The initial contact date is the date the applicant is being certified and vouchers are issued at the hospital.
3. Physical Presence Status Answer Yes - The applicant is on site during the certification.

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4. Residency Proof The documentation in the Medical Record, the documentation the applicant shows you on site or the Thirty (30)-Day form may be used as proof of residency.

5. Identity Proof The documentation in the medical record, the documentation that the applicant shows you on site or the Thirty (30)Day form may be used as proof of identification.
6. Date of Certification and Date the Nutritional Risk data was taken This is the date the documentation was taken on site.

7. Height for Postpartum Women and Length for Infants

Women - Breastfeeding and Non Breastfeeding Post Partum a. Use height from the prenatal certification or the hospital record. b. If no documented height is available, then use a self-reported height.
Infants Use birth length from the hospital for infants (in Medical Record or on the crib card).

8. Weight for Postpartum Women and Infants

Women-Breastfeeding and Non-Breastfeeding Post Partum a. Pre-Pregnancy Weight - Pre-pregnancy weight from health record; self reported if not available from record. b. Current Weight Before Delivery - Required; self reported if not available from record.
Infants Weight for Infants Use birth weight from the hospital (Medical Record or the crib card).

9. Hematological Data Document post-partum hematological data when available or use the ninety (90)-day hematological policy.

Blood work may be available for postpartum women prior to discharge from the hospital. When postpartum breastfeeding and nonbreastfeeding women are certified in the hospital, and hematological data is not available, follow these procedures: ninety (90)-day Hematological Policy

a. Enter the Date of Certification in the Hematological Date field. b. Enter the value 88.8 in the Hemoglobin field. c. If the applicant is assessed WIC eligible, issue up to two (2)
months 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 nonbreastfeeding women certified in the hospital. This procedure

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must be approved by the Nutrition Services Unit prior to implementation. Written approval must be kept on file in the District office.

10. Risk Factor Assessment and Documentation - The documentation may come from the Medical Record or by speaking with the WIC applicant.

Women (Breastfeeding and Non-Breastfeeding Postpartum) Evaluation of Inappropriate Nutrition Practices. Infants a. Evaluation of Inappropriate Nutrition Practices and completion
of Growth Chart are both optional (hospitals only) b. Risk Factor Assessment Required

11. Primary Nutrition Education and Referrals - Primary nutrition education and appropriate referrals must be documented for all hospital certifications.

12. Signatures and Title of the Competent Professional Authority making the determination and signature and title of person making income determination. Signature of the applicant/ participant/caregiver or parent Date Applicant is seen.

13. The Statement advising participants of their Rights and Obligations while on Georgia WIC - This information is already on the Certification Form.

14. If information is shared with other Programs, Disclosure Statement is required on the Certification form.

15. Notification of the participant's Rights and Obligations Must be given on site to the participant (handout).

16. Explanation on how the Local Food Delivery System Works - Must be given on site to the participant (handout).

17. Advise in writing of the Ineligibility/Suspension or Disqualification Not necessary unless ineligible during the initial certification.

18. Voter Registration - Must be offered during the certification process according to the requirements of the National Voter Registration Act of 1993.
19. How to File a Complaint Flyer Must be given on site to the participant (handout).

P. Two Types of Hospital Clinics There are two types of hospital clinics. The types are listed below:

A transit clinic is a site where WIC staff does not have an office in the hospital but

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GEORGIA WIC 2012 PROCEDURES MANUAL


Certification

make rounds for eligible Georgia WIC applicants. Transit clinic must bring documents, vouchers, etc., to the hospital. These clinics do not store records on site. Transit clinics must have WIC records stored at a location separate and apart from other WIC records for audit purposes. A stationary clinic is a site where WIC staff has a permanent office in the hospital. Stationary clinics have documents, vouchers, etc., housed on site. WIC records are maintained separate and apart from hospital records for WIC audit purposes.

Each site must have its own clinic number regardless if it is a stationary site or voucher issuance site. Additionally, WIC records must be attainable for audits by District/State or USDA.

XXVIII.CLIENT STAFF RATIO

Client-to-staff ratios are listed in the Administrative section of the Georgia WIC Procedures Manual for administrative purposes.

XXIX. PNSS DATA COLLECTION

Georgia WIC Certification Forms (PNBIC) incorporate the Pregnancy Nutrition Surveillance
Systems (PNSS) data collection fields. The new PNSS data is locatedon the back of the
Prenatal, Breastfeeding and Non- breastfeeding Certification forms. PNSS is a program based public health surveillance system that monitors risk factors associated with infant mortality and poor birth outcomes among low-income pregnant.

The Pediatric Nutrition Surveillance System (PedNSS) is a child based public health surveillance system that monitors the nutritional status of low income U.S. children who attend federally-funded maternal and child health and nutrition programs.

XXX. WIC INTERVIEW SCRIPT

The WIC Interview Script provides WIC applicants/participants with general WIC information. The WIC Interview Script must be presented to all WIC applicants/participants during the initial certification, re-certification and mid-certification process so they will have the opportunity to select their ethnicity, migrancy status and all racial categories that applies. However, during the re-certification or mid-certification process, it is not necessary to use this script if you ask the following question: "Has anything changed since the last visit, e.g., address, telephone number, migrant status, ethnic origin or race?" Please document change(s) if necessary.

The WIC Interview Script will be a part of the WIC Programmatic Review (see Attachment CT-42).

CT-73

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT-1

FFF CLINIC

NAME

LAST

WIC ASSESSMENT/CERTIFICATION FORM
PRENATAL WOMAN
FAMILY NUMBER FFFFFFFFFFF
FIRST

WIC ID NUMBER FFF FFF FFF FF

MIDDLE INITIAL

BIRTHDATE

ADDRESS

CITY

ZIP CODE

(

)

COUNTY OF RESIDENCY

TELEPHONE PROOF OF RESIDENCY

HISPANIC/LATINO

F YES

F NO

PROOF OF I.D.

F1

RACE (check all that applies)

F2

F3

F4

F5

FOSTER CARE

FFF

UP:

UP:

INITIAL CONTACT DATE: DATE OF FIRST VISIT REQUESTING WIC SERVICES (Must change date if certifications are not consecutive)

F F YES

NO

MEDICAL DATA DATE (Enter date height and weight measurements were taken)
Height

Weight in.

Pregravid Weight

lbs.

lbs.

Hematological Data Date: Hematocrit/Hemoglobin (Value must be d 90 days)
Select appropriate risk criteria per State guidelines (See Risk Criteria Handbook for definitions) Low Hgb/Hct Underweight

[HR]

201

[HR]

101

Overweight

[HR?]

111

Low Maternal Weight Gain

[HR]

131

* Gestational Weight Loss During Pregnancy

High Maternal Weight Gain

* Elevated Blood Lead Level (Blood Lead Level t 10 g/dl)

* Hyperemesis Gravidarum

* Gestational Diabtes

* History of Gestational Diabetes

* History of Preeclampsia

* History of Preterm Delivery (Enter delivery date(s) and weeks gestation:

)

* History of Low Birth Weight Infant(s) (Enter birth weight(s) and birth date(s):

)

* History of Fetal/Neonatal Death (Enter date(s) and weeks gestation:

)

Pregnancy at a Young Age (Age of EDC)

* Closely Spaced Pregnancies (Enter termination date of last pregnancy:

)

* High Parity and Young Age (Enter delivery dates of previous pregnancies:

)

* Lack of, or inadequate Prenatal Care [Prenatal care beginning after 1st Trimester (0-13 wks.)]

* Multi-Fetal Gestation

* Fetal Growth Restriction

* History of Birth of a Large for Gestational Age Infant (Enter birth weight(s):

)

[HR?]

132

133

[HR]

211

[HR]

301

[HR]

302

303

304

311

312

[HR?]

321

331

332

333

334

[HR]

335

336

337

Pregnant Woman Currently Breastfeeding

* History of Birth with Nutrition Related Congenital or Birth Defect(s):

)

* Nutrition Related Medical Conditions (List code(s):

)

338 339
[HR?]

* Smoking (Any smoking of cigarettes, pipes or cigars)

(Enter number of cigarettes or cigars smoked or number of times pipe smoked (#/day:

)

371

* Environmental Tobacco Smoke Exposure

904

* Alcohol Use: Circle type: Routine (Enter oz./wk:

), Binge drinker, Heavy drinker

372

* Street Drug Use (Enter type of drug(s):

)

373

* Dental Problems

381

* Inappropriate Nutrition Practices

400

Homelessness

801

Migrancy

802

* Recipient of Abuse

901

* Woman with Limited Ability to make Feeding Decisions and/or Prepare Food

902

Transfer of Certification

502

Other Dietary Risk (Failure to Meet Dietary Guidelines)

401

HIGH RISK (Yes or No)

ELIGIBLE FOR WIC

PRIORITY: 1= (201, 101, 111, 131, 132, 133, 211, 301, 302, 303, 304, 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, 904) 4= (400, 401, 502, 801, 802, 901, 902)
FOOD PACKAGE: (Specify Tailoring Instructions)

MIGRANT

F YES

F NO

ENTER EDC DATE

Date:

Type:

HCT
YES

.HGB
NO

CT-73

(Rev. 07/10) (1 of 3)

GEORGIA WIC 2012 PROCEDURES MANUAL


Attachment CT-1 (cont'd)

SERVICES: CH (A), Health Check (B), CMS (C), Women's Health (D), PCM (E), PRS (F), Immun (G), Lead Screen (H), Dental Health (I), STD (J), Private MD (K), SNAP (L), Medicaid (M), TANF (N), Mental Health (O), Head Start (P), NA/None (Q), Refused (R), Community Health Center (S), Children 1st (T), Other-Specify (U), Dietitian (V), Breastfeeding (W), Breastfeeding Peer Counselor (X)
TODAY'S DATE

Enrolled In: Referred To:

SIGNATURE AND TITLE OF HEALTH PROFESSIONAL

*Additional Documentation Required

INCOME DETERMINATION (income must be documented)

DATE

PHYSICAL PRESENCE
Y( ) N( )*
*N ( ) R( ) D ( ) W( )

MEDICAID CURRENT Y/N/U

Y( ) N( )

U( )

UP ( )

MEDICAID I.D. NUMBER VERIFY

TANF Y/N/U
COPY AND FILE Y( ) U( ) N( )

SNAP Y/N/U
Y( ) U( ) N( )

UP ( )

UP ( )

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 __________________ Other ____________________ (Write in type)

UP: _________________

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 ( )

_________________ Staff Initials

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

UP: _________________ Staff Initials

DATA NEEDED FOR PREGNANCY SURVEILLANCE

Marital Status (O=Married 1=Not Married 9=Unknown) Years of Education completed (e.g. 1st grade = 01, 2yrs. College = 14, Unknown = 99) Month of gestation at time of first prenatal exam (0=o Prenatal Care, 1=1st. mo., 8=8th or 9th mo., 9=Unknown)

Parity (00= None 01-29 = Number of previous births)

Date last pregnancy ended (000000 = No Previous Pregnancy 01-12 (all four digits) = Month/Year)

Multi / Prenatal Vitamin Consumption During Pregnancy (1=Yes, 2=No, 9 = Unknown)

Multi / Prenatal Vitamin Consumption Prior to Pregnancy (0=less than once a week, 1-8=number per week, 9-Unknown)

Cigarettes/Day 3 mos prior to Pregnancy 00=no, 01-96=#cigs/day, 97=97 or more, 98=quantity unknown, 99=refused)

Cigarettes/Day Prenatal Visit (00=no, 01-96=#cigs/day, 97=97 or more, 98=unknown, 99=refused)

Household Smoking Prenatal Visit (1=Yes, someone smokes, 2=No, no one smokes, 9=unknown)

Drinks/week 3 mos prior (00=No, 01=1 drink, 02-20=drinks, 21=21 or more, 98=quantity unknown, 99=refused)

Fruit Intake.

D=Daily

S=Some Days

N=Never

Vegetable Intake.

D=Daily

S=Some Days

N=Never

Dairy Intake.

D=Daily

S=Some Days

N=Never

Daily Activity.

V=Very Active S=Active Some of the Time N-Not Active

Screen time.

Hours = 00 through 24

CT-74

(Rev. 07/10) (2 of 3)

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT-1 (cont'd)


Comments :( Date/Sign/Title):_________________________________________________________________________________________________________

Proxy 1 _________________________________________________________ Proxy 2 ______________________________________________________

WIC CERTIFICATION STATEMENT
RIGHTS AND OBLIGATIONS I have been advised of my rights and obligations for participation in Georgia's WIC. I certify that the information I will provide, or have provided, is correct
to the best of my knowledge. The income information that I have provided 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. Georgia's WIC 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 to Georgia's WIC, 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.
NOTICE OF DISCLOSURE I understand that the chief state health officer for Georgia may authorize the disclosure of information about my participation in the WIC program for non-WIC purposes. This information will be used by Georgia WIC, its local WIC agencies and certain public organizations. These organizations include but are not limited to the Immunization Program, Pregnancy Risk Assessment Monitoring Systems (PRAMS), Epidemiology and other Maternal and Child Heath Programs, Emergency Preparedness, Environmental Health and Medicaid. I understand that Georgia WIC, its local agencies and the public organizations can only use my information in the administration of their programs that serve person eligible for WIC. The public organizations that receive my information must assure that it will not disclose my information to another organization or person without my permission.
I further understand that information about my participation in WIC may be used by the organizations that receive it only to:
1. Determine my eligibility for programs that the organization administers 2. Conduct outreach for such programs 3. Enhance the health, education, or well-being of WIC applicants and participants who are currently enrolled in those programs 4. Streamline administrative procedures to ease the burdens on WIC staff and participants 5. Assess the responsiveness of the state's health system to participants' health care needs and health care outcomes.
I have been advised that the decision to share my information is not a condition for eligibility for WIC, and if I decide not to share my information, this will not affect my application or participation in Georgia WIC.

___________________________________________ Name of WIC Applicant/Participant/Guardian/ Caregiver/Spouse/Alternate Parent (please print)
___________________________________________ Signature of WIC Applicant/Participant/Guardian/ Caregiver/Spouse/Alternate Parent

__________ Date __________ UP: __________ Date

________________________________ _____________

Name of WIC Official (please print)

Date

________________________________ _____________

Signature of WIC Official

Date

Please initial below to indicate your preference:
___In applying for WIC services, I AUTHORIZE DISCLOSURE of my WIC applicant or participant information for the purposes referenced above. I understand that my refusal to allow such disclosure does not affect my application for or participation in WIC or my eligibility for WIC services.
___ In applying for WIC services, I DO NOT AUTHORIZE DISCLOSURE of my WIC applicant or participant information for the purposes referenced above. I understand that my refusal to allow such disclosure does not affect my application for or participation in WIC or my eligibility for WIC services.

Rev. 07/10) (3 of 3)

CT-75

GEORGIA WIC 2012 PROCEDURES MANUAL
WIC ASSESSMENT/CERTIFICATION FORM POSTPARTUM BREASTFEEDING WOMAN

Attachment CT-2

FFF CLINIC

FAMILY NUMBER FFFFFFFFFFF

WIC ID NUMBER FFF FFF FFF FF

NAME

LAST

FIRST

MIDDLE INITIAL

BIRTHDATE

ADDRESS

CITY

ZIP CODE

TELEPHONE

(

)

1 COUNTY OF RESIDENCY PROOF OF RESIDENCY

HISPANIC/LATINO

F YES

F NO

F1

PROOF OF I.D.

RACE (check all that applies)

F2

F3

F4

F5

FFF
2 COUNTY OF RESIDENCY

UP: PROOF OF RESIDENCY

UP: PROOF OF I.D.

FFF

UP:

UP:

INITIAL CONTACT DATE: DATE OF FIRST VISIT REQUESTING WIC SERVICES (Must change date if certifications are not consecutive)

Date:

Type:

WOMEN'S FEEDING METHOD:
E= Exclusively Breastfeeding M= Mostly Breastfeeding S= Some Breastfeeding

E

M

S

(Circle One)

BREASTFEEDING AN INFANT LESS THAN 1 YEAR OF AGE

(Enter Delivery Date:

) (Birthweight:

lbs.

ozs.) (00= 0-6 days, 01= 7-13 days, 02= 14-20 days, 03= 21-27 days, etc.)

Wks

MEDICAL DATA DATE (Enter date height and weight measurement taken)

Height

Pregravid Weight

in.

lbs.

lbs.

Hematological Data Date: Hematocrit/Hemoglobin (Value must be d 90 days)
Select appropriate risk criteria per State guidelines (See Risk Criteria Handbook for definitions)

Low Hgb/Hct

Underweight (< 6 mo. postpartum, based on pregravid or current wt., t 6 mo. postpartum, based on current wt.)

Overweight (< 6 mo. postpartum, based on pregravid or current wt., t 6 mo. postpartum, based on current wt.)

High Maternal Weight Gain (most recent pregnancy)

* Elevated Blood Lead Level (Blood Lead Level t 10 g/dl)

* History of Gestational Diabetes

* History of Preeclampsia

* Delivery of Preterm Infant(s) (most recent pregnancy) (enter weeks gestation:

)

* Delivery of Low Birth Weight Infant(s) (most recent pregnancy) (Enter birth weight(s) and birth date(s):

)

* Fetal/Neonatal Death (most recent pregnancy) (Enter date(s) of death and weeks gestation:

)

Pregnancy at a Young Age (most recent pregnancy)

* Closely Spaced Pregnancies (most recent pregnancy) (Enter termination dates of last (2) pregnancies:

)

* High Parity and Young Age (Enter delivery date(s) of previous pregnancies:

)

* Multi-Fetal Gestation (most recent pregnancy)

* History of Large for Gestational Age Infant (Birth weight(s): t 9 lbs. enter birth weight(s):

)

* Birth with Nutrition Related Congenital or Birth Defect(s) (most recent pregnancy) (specify defect(s):

)

* Nutrition Related Medical Conditions (List code(s):

)

* Smoking (Any smoking of cigarettes, pipes or cigars)

(Enter number of cigarettes or cigars smoked or number of times pipe smoked (# cig./day:

)

* Environmental Tobacco Smoke Exposure

* Alcohol Use: Circle type: Routine (Enter oz./wk:

), Binge drinker, Heavy drinker

* Street Drug Use (Enter type of drug(s):

)

* Dental Problems

* Inappropriate Nutrition Practices

* Breastfeeding Mother of an Infant(s) at Nutritional Risk (enter infants risk factors:

)

* Breastfeeding Complications or Potential Complications

Homelessness

Migrancy

* Recipient of Abuse

* Woman with Limited Ability to make Feeding Decisions and/or Prepare Food

Transfer of Certification

Other Dietary Risk (Failure to Meet Dietary Guidelines)

HIGH RISK (Yes or No)

ELIGIBLE FOR WIC

[HR] [HR] [HR?] [HR] [HR]
[HR?] [HR] [HR?]
[HR]

HCT
YES
201 101 111 133 211 303 304 311 312 321 331 332 333 335 337 339
371 904 372 373 381 400 601 602 801 802 901 902 502 401

HGB
NO

PRIORITY: 1= (201, 101, 111,133, 211, 303, 304, 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, 502, 601, 602, 904) 2= (502, 601) 4= (400, 401, 502,

601, 801, 802, 901, 902)

FOOD PACKAGE: (If unable to complete infant certification at this time,

WOMAN'S FOOD PACKAGE:

enter code AAA for infant food package and describe reason below.)

INFANT'S FOOD PACKAGE:

MIGRANT

F YES

F NO

ENTER EDC DATE

Date:

FOSTER CARE

F F YES

NO

FOSTER CARE

F F YES

NO

Type:

E

M

S

Wks

ht.
HCT
YES

wt.
HGB
NO

(Rev. 07/10) (1 of 3)

CT-76

GEORGIA WIC 2012 PROCEDURES MANUAL
SERVICES: CH (A), Health Check (B), CMS (C), Women's Health (D), PCM (E), PRS (F), Immun (G), Lead Screen (H), Dental Health (I), STD (J), Private MD (K), SNAP (L), Medicaid (M), TANF (N), Mental Health (O), Head Start (P), NA/None (Q), Refused (R), Community Health Center (S), Children 1st (T), Other-Specify (U), Dietitian (V), Breastfeeding (W), Breastfeeding Peer Counselor (X)
TODAY'S DATE SIGNATURE AND TITLE OF HEALTH PROFESSIONAL
*Additional Documentation Required

Enrolled In: Referred To:

INCOME DETERMINATION (income must be documented)

Attachment CT-2 (cont'd)
Enrolled In: Referred To:

FIRST CERTIFICATION

DATE

PHYSICAL PRESENCE

Y( ) N( )*

MEDICAID CURRENT Y/N/U

Y( ) N( )

U( )

*N ( ) R( ) D ( ) W( )

UP ( )

MEDICAID I.D. NUMBER VERIFY

TANF Y/N/U
COPY AND FILE Y( ) U( ) N( )
UP ( )

SNAP Y/N/U
Y( ) U( ) N( )
UP ( )

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 __________________ Other ____________________ (Write in type)

UP: _________________

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 ( )

_________________ Staff Initials

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

UP: _________________ Staff Initials

SECOND CERTIFICATION

DATE

PHYSICAL PRESENCE

MEDICAID CURRENT Y/N/U

Y( ) N( )*

Y( ) N( )

U( )

*N ( ) R( ) D ( ) W( )

MEDICAID I.D. NUMBER VERIFY

TANF Y/N/U
COPY AND FILE Y( ) U( ) N( )

SNAP Y/N/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 __________________ Other ____________________ (Write in type)

UP: _________________

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 ( )

_________________ Staff Initials

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

UP: _________________ Staff Initials

DATA NEEDED FOR PREGNANCY SURVEILLANCE

Marital Status (O=Married 1=Not Married 9=Unknown) Years of Education completed (e.g. 1st grade = 01, 2yrs. College = 14, Unknown = 99) Month of gestation at time of first prenatal exam (0=o Prenatal Care, 1=1st. mo., 8=8th or 9th mo., 9=Unknown) Last weight prior to delivery (Round to the nearest pound) Parity (00= None 01-29 = Number of previous births) Date last pregnancy ended (000000 = No Previous Pregnancy 01-12 (all four digits) = Month/Year) Diabetes Postpartum visit (1=No, 2= Yes, most recent, 3=Yes, past and most recent, 4=Yes, first time) Hypertension Postpartum visit (1=No, 2= Yes, most recent, 3=Yes, past and most recent, 4=Yes, first time) Multi / Prenatal Vitamin Consumption Prior to Pregnancy (0=less than once a week, 1-8=number per week, 9-Unknown) Cigarettes/Day 3 mos prior to Pregnancy 00=no, 01-96=#cigs/day, 97=97 or more, 98=quantity unknown, 99=refused) Cigarettes/Day Postpartum Visit (00=no, 01-96=#cigs/day, 97=97 or more, 98=unknown, 99=refused)

(Rev. 07/10) (2 of 3)

CT-77

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT-2 (cont'd)

Cigarettes/Day Last 3 mos of Pregnancy 00=no, 01-96=#cigs/day, 97=97 or more, 98=quantity unknown, 99=refused)

Household Smoking Postpartum Visit (1=Yes, someone smokes, 2=No, no one smokes, 9=unknown)

Drinks/week 3 mos prior (00=No, 01=1 drink, 02-20=drinks, 21=21 or more, 98=quantity unknown, 99=refused)

Drinks/week Last 3 mos Postpartum (00=No, 01=1 drink, 02-20=drinks, 21=21 or more, 98=quantity unknown, 99=refused)

Date breastfeeding began

(MM/DD/YYYY)

Date of last time of breastfeeding and/or pumping

(MM/DD/YYYY)

Fruit Intake.

D=Daily

S=Some Days

N=Never

Vegetable Intake.

D=Daily

S=Some Days

N=Never

Dairy Intake.

D=Daily

S=Some Days

N=Never

Daily Activity.

V=Very Active S=Active Some of the Time N-Not Active

Screen time.

Hours = 00 through 24

Comments:(Date/Sign/Title):_________________________________________________________________________________________________________
Proxy 1 _________________________________________________________ Proxy2 ______________________________________________________
WIC CERTIFICATION STATEMENT RIGHTS AND OBLIGATIONS
I have been advised of my rights and obligations for participation in Georgia's WIC. I certify that the information I will provide, or have provided, is correct to the best of my knowledge. The income information that I have provided 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. Georgia's WIC 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 to Georgia's WIC, 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.
NOTICE OF DISCLOSURE I understand that the chief state health officer for Georgia may authorize the disclosure of information about my participation in the WIC program for non-WIC purposes. This information will be used by Georgia WIC, its local WIC agencies and certain public organizations. These organizations include but are not limited to the Immunization Program, Pregnancy Risk Assessment Monitoring Systems (PRAMS), Epidemiology and other Maternal and Child Heath Programs, Emergency Preparedness, Environmental Health and Medicaid. I understand that Georgia WIC, its local agencies and the public organizations can only use my information in the administration of their programs that serve person eligible for WIC. The public organizations that receive my information must assure that it will not disclose my information to another organization or person without my permission.
I further understand that information about my participation in WIC may be used by the organizations that receive it only to:
1. Determine my eligibility for programs that the organization administers 2. Conduct outreach for such programs 3. Enhance the health, education, or well-being of WIC applicants and participants who are currently enrolled in those programs 4. Streamline administrative procedures to ease the burdens on WIC staff and participants 5. Assess the responsiveness of the state's health system to participants' health care needs and health care outcomes.
I have been advised that the decision to share my information is not a condition for eligibility for WIC, and if I decide not to share my information, this will not affect
my application or participation in Georgia WIC.

FIRST CERTIFICATION

___________________________________________

________________

__________________________________

______________

Name of WIC Applicant/Participant/Guardian/

Date

Name of WIC Official (please print)

Date

Caregiver/Spouse/Alternate Parent (please print)

________________

UP:

___________________________________________

________________

__________________________________

______________

Signature of WIC Applicant/Participant/Guardian/

Date

Signature of WIC Official

Date

Caregiver/Spouse/Alternate Parent

Please initial below to indicate your preference:

___In applying for WIC services, I AUTHORIZE DISCLOSURE of my WIC applicant or participant information for the purposes referenced above. I

understand that my refusal to allow such disclosure does not affect my application for or participation in WIC or my eligibility for WIC services.

___ In applying for WIC services, I DO NOT AUTHORIZE DISCLOSURE of my WIC applicant or participant information for the purposes referenced above. I understand that my refusal to allow such disclosure does not affect my application for or participation in WIC or my eligibility for WIC services.

SECOND CERTIFICATION

___________________________________________

________________

__________________________________

______________

Name of WIC Applicant/Participant/Guardian/

Date

Name of WIC Official (please print)

Date

Caregiver/Spouse/Alternate Parent (please print)

________________

UP:

___________________________________________

________________

__________________________________

______________

Signature of WIC Applicant/Participant/Guardian/

Date

Signature of WIC Official

Date

Caregiver/Spouse/Alternate Parent

Please initial below to indicate your preference:

___In applying for WIC services, I AUTHORIZE DISCLOSURE of my WIC applicant or participant information for the purposes referenced above. I

understand that my refusal to allow such disclosure does not affect my application for or participation in WIC or my eligibility for WIC services.

___ In applying for WIC services, I DO NOT AUTHORIZE DISCLOSURE of my WIC applicant or participant information for the purposes referenced above. I understand that my refusal to allow such disclosure does not affect my application for or participation in WIC or my eligibility for WIC services.
(Rev. 07/10) (3 of 3)

CT-78

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT-3

FFF CLINIC

NAME

LAST

WIC ASSESSMENT/CERTIFICATION FORM POSTPARTUM / NON-BREASTFEEDING WOMAN

FAMILY NUMBER FFFFFFFFFFF

WIC ID NUMBER FFF FFF FFF FF

FIRST

MIDDLE INITIAL

BIRTHDATE

ADDRESS

CITY

ZIP CODE

(

)

COUNTY OF RESIDENCY

TELEPHONE PROOF OF RESIDENCY

HISPANIC/LATINO

F YES

F NO

PROOF OF I.D.

F1

RACE (check all that applies)

F2

F3

F4

F5

FOSTER CARE

FFF UP:

INITIAL CONTACT DATE: DATE OF FIRST VISIT REQUESTING WIC SERVICES (Must change date if certifications are not consecutive) NON-BREASTFEEDING, LESS THAN 6 MONTHS POSTPARTUM

(Enter Delivery Date:

) (Birthweight:

MEDICAL DATA DATE (Enter date height and weight measurements were taken)

lbs.

ozs.)

Height

Weight in.

UP: Date:

F EVER BREASTFED?

YES

F NO

Pregravid Weight lbs.

F F YES

NO

lbs.

Hematological Data Date: Hematocrit/Hemoglobin (Value must be d 90 days)
Select appropriate risk criteria per State guidelines (See Risk Criteria Handbook for definitions) Low Hgb/Hct Underweight (Based on pregravid weight or current weight)

[HR]

201

[HR]

101

Overweight (Based on pregravid weight )

[HR?]

111

High Maternal Weight Gain (most recent pregnancy)

* Elevated Blood Lead Level (Blood Lead Level t 10 g/dl)

* History of Gestational Diabetes

* History of Preeclampsia

* Delivery of Preterm Infant(s) (most recent pregnancy) (Enter weeks gestation:

)

* Delivery of Low Birth Weight Infant(s) (most recent pregnancy) (Enter birth weight(s) and delivery date(s):

* Fetal/Neonatal Death (most recent pregnancy) (Enter date(s) of death and weeks gestation:

Pregnancy at a Young Age (most recent pregnancy)

* Closely Spaced Pregnancies (most recent pregnancy) (Enter termination dates of last (2) pregnancies:

* High Parity and Young Age (Enter delivery dates of previous pregnancies:

* Multi-Fetal Gestation (most recent pregnancy)

133

[HR]

211

303

304

311

)

312

)

321

[HR?]

331

)

332

)

333

[HR]

335

* History of Large for Gestational Age Infant (Birth weight t 9lbs.) (Enter birth weight(s):

)

* Birth with Nutrition Related Congenital or Birth Defect(s) (most recent pregnancy) (Specify defect(s):

* Nutrition Related Medical Conditions (List code(s):

)

* Smoking (Any smoking of cigarettes, pipes or cigars)

* Environmental Tobacco Smoke Exposure

* Alcohol Use: Circle type: Routine (Enter oz./wk:

), Binge drinker, Heavy drinker

* Street Drug Use (Enter type of drug(s):

)

* Dental Problems

* Inappropriate Nutrition Practices

337

)

339

[HR?]

371

904

372

373

381

400

Homelessness

801

Migrancy

802

* Recipient of Abuse

901

* Woman with Limited Ability to make Feeding Decisions and/or Prepare Food

902

Transfer of Certification

502

Other Dietary Risk (Failure to Meet Dietary Guidelines)

401

HIGH RISK (Yes or No)

ELIGIBLE FOR WIC

PRIORITY: 3= (331, 502) 6= (201, 101, 111, 133, 211, 303, 304, 311, 312, 321, 331, 332, 333, 335, 336, 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, 400, 401, 502, 801, 802, 901, 902, 904)
FOOD PACKAGE: (Specify Tailoring Instructions)

SERVICES: CH (A), Health Check (B), CMS (C), Women's Health (D), PCM (E), PRS (F), Immun (G), Lead Screen (H), Dental Health (I), STD (J), Private MD (K), SNAP (L), Medicaid (M), TANF (N), Mental Health (O), Head Start (P), NA/None (Q), Refused (R), Community Health Center (S), Children 1st (T), Other-Specify (U), Dietitian (V), Breastfeeding (W), Breastfeeding Peer Counselor (X)

TODAY'S DATE

SIGNATURE AND TITLE OF HEALTH PROFESSIONAL

*Additional Documentation Required

MIGRANT

F YES

F NO

ENTER EDC DATE

Type: Weeks Breastfed:

HCT
YES

.HGB
NO

Enrolled In: Referred To:
(Rev. 07/10) (1 of 3)

CT-79

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT-3(cont'd)

INCOME DETERMINATION (income must be documented)

DATE

PHYSICAL PRESENCE
Y( ) N( )*
*N ( ) R( ) D ( ) W( )

MEDICAID CURRENT Y/N/U

Y( ) N( )

U( )

UP ( )

MEDICAID I.D. NUMBER VERIFY

TANF Y/N/U
COPY AND FILE Y( ) U( ) N( )

SNAP Y/N/U
Y( ) U( ) N( )

UP ( )

UP ( )

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 __________________ Other ____________________ (Write in type)

UP: _________________

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 ( )

_________________ Staff Initials

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

UP: _________________ Staff Initials

DATA NEEDED FOR PREGNANCY SURVEILLANCE

Marital Status (O=Married 1=Not Married 9=Unknown) Years of Education completed (e.g. 1st grade = 01, 2yrs. 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)

Parity (00= None 01-29 = Number of previous births)

Date last pregnancy ended (000000 = No Previous Pregnancy 01-12 (all four digits) = Month/Year)

Diabetes Postpartum visit (1=No, 2= Yes, most recent, 3=Yes, past and most recent, 4=Yes, first time)

Hypertension Postpartum visit (1=No, 2= Yes, most recent, 3=Yes, past and most recent, 4=Yes, first time)

Multi / Prenatal Vitamin Consumption Prior to Pregnancy (0=less than once a week, 1-8=number per week, 9-Unknown)

Cigarettes/Day 3 mos prior to Pregnancy 00=no, 01-96=#cigs/day, 97=97 or more, 98=quantity unknown, 99=refused)

Cigarettes/Day Postpartum Visit (00=no, 01-96=#cigs/day, 97=97 or more, 98=unknown, 99=refused)

Cigarettes/Day Last 3 mos of Pregnancy 00=no, 01-96=#cigs/day, 97=97 or more, 98=quantity unknown, 99=refused)

Household Smoking Postpartum Visit (1=Yes, someone smokes, 2=No, no one smokes, 9=unknown)

Drinks/week 3 mos prior (00=No, 01=1 drink, 02-20=drinks, 21=21 or more, 98=quantity unknown, 99=refused)

Drinks/week Last 3 mos Postpartum (00=No, 01=1 drink, 02-20=drinks, 21=21 or more, 98=quantity unknown, 99=refused)

Date breastfeeding began

(MM/DD/YYYY)

Date of last time of breastfeeding and/or pumping

(MM/DD/YYYY)

Fruit Intake.

D=Daily

S=Some Days

N=Never

Vegetables Intake.

D=Daily

S=Some Days

N=Never

Dairy Intake.

D=Daily

S=Some Days

N=Never

Daily Activity.

V=Very Active S=Active Some of the Time N-Not Active

Screen time.

Hours = 00 through 24

Comments :( Date/Sign/Title):_________________________________________________________________________________________________________
Proxy 1 _________________________________________________________ Proxy2 ______________________________________________________
(Rev. 07/10) (2 of 3)
.
CT-80

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT-3(cont'd)

WIC CERTIFICATION STATEMENT
RIGHTS AND OBLIGATIONS I have been advised of my rights and obligations for participation in Georgia's WIC. I certify that the information I will provide, or have provided, is correct
to the best of my knowledge. The income information that I have provided 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. Georgia's WIC 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 to Georgia's WIC, 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.
NOTICE OF DISCLOSURE I understand that the chief state health officer for Georgia may authorize the disclosure of information about my participation in the WIC program for non-WIC purposes. This information will be used by Georgia WIC, its local WIC agencies and certain public organizations. These organizations include but are not limited to the Immunization Program, Pregnancy Risk Assessment Monitoring Systems (PRAMS), Epidemiology and other Maternal and Child Heath Programs, Emergency Preparedness, Environmental Health and Medicaid. I understand that Georgia WIC, its local agencies and the public organizations can only use my information in the administration of their programs that serve person eligible for WIC. The public organizations that receive my information must assure that it will not disclose my information to another organization or person without my permission.
I further understand that information about my participation in WIC may be used by the organizations that receive it only to:
1. Determine my eligibility for programs that the organization administers 2. Conduct outreach for such programs 3. Enhance the health, education, or well-being of WIC applicants and participants who are currently enrolled in those programs 4. Streamline administrative procedures to ease the burdens on WIC staff and participants 5. Assess the responsiveness of the state's health system to participants' health care needs and health care outcomes.
I have been advised that the decision to share my information is not a condition for eligibility for WIC, and if I decide not to share my information, this will not affect my application or participation in Georgia WIC.

___________________________________________ Name of WIC Applicant/Participant/Guardian/ Caregiver/Spouse/Alternate Parent (please print)
___________________________________________ Signature of WIC Applicant/Participant/Guardian/ Caregiver/Spouse/Alternate Parent

__________ Date __________ UP: __________ Date

________________________________ _____________

Name of WIC Official (please print)

Date

________________________________ _____________

Signature of WIC Official

Date

Please initial below to indicate your preference:
___In applying for WIC services, I AUTHORIZE DISCLOSURE of my WIC applicant or participant information for the purposes referenced above. I understand that my refusal to allow such disclosure does not affect my application for or participation in WIC or my eligibility for WIC services.
___ In applying for WIC services, I DO NOT AUTHORIZE DISCLOSURE of my WIC applicant or participant information for the purposes referenced above. I understand that my refusal to allow such disclosure does not affect my application for or participation in WIC or my eligibility for WIC services.

(Rev. 07/10) (3 of 3)

CT-81

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 4

FFF CLINIC

NAME

LAST

WIC ASSESSMENT/CERTIFICATION FORM
INFANT
FAMILY NUMBER FFFFFFFFFFF
FIRST

WIC ID NUMBER FFF FFF FFF FF

MIDDLE INITIAL

BIRTHDATE

ADDRESS

(

)

TELEPHONE

CITY

GENDER

F MALE

F FEMALE

HISPANIC/LATINO

F YES

F NO

ZIP CODE
F1

MIGRANT

F YES

F NO

RACE (check all that applies)

F2

F3

F4

F5

COUNTY OF RESIDENCY
FFF

PROOF OF RESIDENCY UP:

PARENT/GUARDIAN PROOF OF IDENTIFICATION UP:

INFANT PROOF OF IDENTIFICATION UP:

PARENT/GUARDIAN/CAREGIVER/SPOUSE/ALTERNATE PARENT NAME

FOSTER CARE:

F YES

F NO

FOSTER CARE:

F YES

F NO

MOTHER'S WIC ID# INITIAL CONTACT DATE OF FIRST VISIT REQUESTING WIC SERVICES

LAST WEIGHT BEFORE DELIVERY: Date:

Type:

lbs. EDC DATE: Date:

Type:

INFANT FEEDING METHOD:

E= Exclusively Breastfeeding M= Mostly Breastfeeding F= Fully Formula Fed

Check Each Question Yes or No or Write N/A (per state guidelines)

BREAST FED NOW

BREASTFED EVER

RECORD THE NUMBER OF WEEKS INFANT BREASTFED
(00= 0-6 days, 01= 7-13 days, 02= 14-20 days, 03= 21-27 days, etc.)
DATE OF MOST RECENT BREASTFEEDING RESPONSE

MEDICAL DATA DATE (Enter date length/weight measurements were taken) Length:

Weight (Enter Birth weight

lbs

ozs

)

Hematological Data Date:

Hematocrit/Hemoglobin (Value must be d 90 days)

Select appropriate risk criteria per State guidelines (See Risk Criteria Handbook for definitions)

Low Hgb/Hct

Underweight (less than or equal to 10%)

Short Stature d 10% (if < 38 weeks gestation use adjusted age)

* Failure to Thrive

Inadequate Growth

* Low Birth Weight (Birth weight d 5 lbs. or d 2500 gms)

* Prematurity (Enter weeks gestation:

)

[HR]

201

[HR?]

103

[HR?]

121

[HR]

134

[HR]

135

[HR]

141

142

* Large for Gestational Age [Birth weight t 9 lbs. (4000 gms)] * Elevated Blood Lead Level (Blood Lead Level t 10 g/dl) * Nutrition Related Medical Conditions (List code(s):

153

[HR]

211

) [HR?]

* Dental Problems * Environmental Tobacco Smoke Exposure * Fetal Alcohol Syndrome * Inappropriate Nutrition Practices * Breastfeeding Complications or Potential Complications
Infants (up to 6 months old) of a WIC Mother or a woman who would have been eligible during pregnancy * Breastfeeding Infant of a Woman at Nutritional Risk (Enter mother's risk factors: * Infants born to Mother with Mental Retardation, or Alcohol or Drug Abuse During Most Recent Pregnancy Homelessness Migrancy * Recipient of Abuse * Primary Caregiver with Limited Ability to make Feeding Decisions and/or Prepare Food Transfer of Certification * Other Dietary Risk (Risk of Inappropriate Complimentary Feeding Practices) [t 4 months and d 12 months] HIGH RISK (Yes or No)

381

904

[HR]

382

400

[HR]

603

701

)

702

703
801 802 901 902 502 401

ELIGIBLE FOR WIC

PRIORITY: 1= (201, 103, 121, 134, 135, 141, 142, 153, 211, 341, 342, 343, 344, 345, 346, 347, 348, 349, 350, 351, 352, 353, 354, 355, 356, 357, 359, 360, 362, 381, 382, 502, 603, 702, 703, 904)
2= (502, 701, 702) 4= (400, 401, 502, 702, 801, 802, 901, 902)

YES

(Circle One) NO

E

M

F

YES

NO

wks lbs. YES

in

ozs.

lbs.

HCT

NO

YES

in ozs.
HGB
NO

(NEVER DOWNGRADE INFANTS PRIORITY) (Rev. 07/10) (1 of 3)

CT-82

GEORGIA WIC 2012 PROCEDURES MANUAL
FOOD PACKAGE: (Specify Tailoring Instructions)
SERVICES: CH (A), Health Check (B), CMS (C), Immun (G), Lead Screen (H), Dental Health (I), STD (J), Private MD (K), SNAP (L), Medicaid
(M), TANF (N), Mental Health (O), Head Start (P), NA/None (Q), Refused (R), Community Health Center (S), Children 1st (T), Other-Specify (U), Dietitian (V), Breastfeeding (W), Breastfeeding Peer Counselor (X)
TODAY'S DATE
SIGNATURE AND TITLE OF HEALTH PROFESSIONAL

*Additional Documentation Required
Do you have a medical home?

Yes

No

M.D. Name

Enrolled In: Referred To:

Attachment CT- 4 (cont'd)
Enrolled In: Referred To:

INCOME DETERMINATION (income must be documented)

DATE

PHYSICAL PRESENCE
Y( ) N( )*
*N ( ) R( ) D ( ) W( )

MEDICAID CURRENT Y/N/U

Y( ) N( )

U( )

UP ( )

MEDICAID I.D. NUMBER VERIFY

TANF Y/N/U
COPY AND FILE Y( ) U( ) N( )

SNAP Y/N/U
Y( ) U( ) N( )

UP ( )

UP ( )

NO. IN

GROSS INCOME

FAMILY (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 __________________ Other ____________________ (Write in type)
UP: _________________

No Proof ( )

How is food, shelter, clothing and Medical Care obtained?_____________________________________________________________________________________

____________________________________________________________________________________________________________________________

_________________ Staff Initials

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

Check Here if Only One Income Reported ( )

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

UP: _________________ Staff Initials

Peachcare Date breastfeeding began Date of last time of breastfeeding and/or pumping

Y=Yes
(MM/DD/YYYY) (MM/DD/YYYY)

N=No

IMMUNIZATION STATUS Record Screened/Requested? Yes ( ) Requested ( )
Adequate for Age/Referred: Yes ( ) Doctor ( ) Health Dept. ( )

IMMUNIZATION STATUS Record Screened/Requested? Yes ( ) Requested ( )
Adequate for Age/Referred: Yes ( ) Doctor ( ) Health Dept. ( )

Comments:(Date/Sign/Title):_________________________________________________________________________________________________________

Proxy 1 _________________________________________________________ Proxy 2 ______________________________________________________
(Rev. 07/10) (2 of 3)



CT-83

GEORGIA WIC 2012 PROCEDURE MANUAL

Attachment CT- 4 (cont'd)

WIC CERTIFICATION STATEMENT
RIGHTS AND OBLIGATIONS I have been advised of my rights and obligations for participation in Georgia's WIC. I certify that the information I will provide, or have provided, is correct
to the best of my knowledge. The income information that I have provided 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. Georgia's WIC 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 to Georgia's WIC, 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.
NOTICE OF DISCLOSURE I understand that the chief state health officer for Georgia may authorize the disclosure of information about my participation in the WIC program for non-WIC purposes. This information will be used by Georgia WIC, its local WIC agencies and certain public organizations. These organizations include but are not limited to the Immunization Program, Pregnancy Risk Assessment Monitoring Systems (PRAMS), Epidemiology and other Maternal and Child Heath Programs, Emergency Preparedness, Environmental Health and Medicaid. I understand that Georgia WIC, its local agencies and the public organizations can only use my information in the administration of their programs that serve person eligible for WIC. The public organizations that receive my information must assure that it will not disclose my information to another organization or person without my permission.
I further understand that information about my participation in WIC may be used by the organizations that receive it only to:
1. Determine my eligibility for programs that the organization administers 2. Conduct outreach for such programs 3. Enhance the health, education, or well-being of WIC applicants and participants who are currently enrolled in those programs 4. Streamline administrative procedures to ease the burdens on WIC staff and participants 5. Assess the responsiveness of the state's health system to participants' health care needs and health care outcomes.
I have been advised that the decision to share my information is not a condition for eligibility for WIC, and if I decide not to share my information, this will not affect my application or participation in Georgia WIC.

___________________________________________ Name of WIC Applicant/Participant/Guardian/ Caregiver/Spouse/Alternate Parent (please print)
___________________________________________ Signature of WIC Applicant/Participant/Guardian/ Caregiver/Spouse/Alternate Parent

__________ Date __________ UP: __________ Date

________________________________ _____________

Name of WIC Official (please print)

Date

________________________________ _____________

Signature of WIC Official

Date

Please initial below to indicate your preference:
___In applying for WIC services, I AUTHORIZE DISCLOSURE of my WIC applicant or participant information for the purposes referenced above. I understand that my refusal to allow such disclosure does not affect my application for or participation in WIC or my eligibility for WIC services.
___ In applying for WIC services, I DO NOT AUTHORIZE DISCLOSURE of my WIC applicant or participant information for the purposes referenced above. I understand that my refusal to allow such disclosure does not affect my application for or participation in WIC or my eligibility for WIC services.

(Rev. 07/10) (3 of 3)

CT-84

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT-5

FFF CLINIC

NAME

LAST

WIC ASSESSMENT/CERTIFICATION FORM
CHILD

FAMILY NUMBER FFFFFFFFFFF

FFF WIC ID NUMBER FFF FFF FF

FIRST

MIDDLE INITIAL

BIRTHDATE

ADDRESS

TELEPHONE

(

)

1 COUNTY OF RESIDENCY
FFF

PROOF OF RESIDENCY UP:

CITY

GENDER

F MALE

F FEMALE

HISPANIC/LATINO

F YES

F NO

PARENT/GUARDIAN PROOF OF IDENTIFICATION

UP:

ZIP CODE

MIGRANT

F YES

F NO

F1

RACE (check all that applies)

F2

F3

F4

F5

CHILD PROOF OF IDENTIFICATION

UP:

2 COUNTY OF RESIDENCY
FFF

PROOF OF RESIDENCY UP:

PARENT/GUARDIAN PROOF OF IDENTIFICATION UP:

CHILD PROOF OF IDENTIFICATION UP:

EDC DATE:

FOSTER CARE INFORMATION

FOSTER CARE:

F YES

F NO

FOSTER CARE:

F YES

F NO

PARENT/GUARDIAN/CAREGIVER/SPOUSE/ALTERNATE PARENT NAME:

INITIAL CONTACT DATE OF FIRST VISIT REQUESTING WIC SERVICES (Must change date if certifications are not consecutive)

Check Each Question Yes or No or Write N/A (per state guidelines)

BREAST FED NOW

BREASTFED EVER

RECORD THE NUMBER OF WEEKS CHILD BREASTFED
(00= 0-6 days, 01= 7-13 days, 02= 14-20 days, 03= 21-27 days, etc.)
DATE OF MOST RECENT BREASTFEEDING RESPONSE

MEDICAL DATA DATE (Enter date length/weight measurements were taken)

Length/Height:

Recumbent (R) or Standing (S)

Weight (Enter Birth weight

lbs

oz

)

Circle One

Hematocrit/Hemoglobin (Value must be d 90 days)

Hematological Data Date:

Select appropriate risk criteria per State guidelines (See Risk Criteria Handbook for definitions)

Low Hgb/Hct

[HR]

201

Underweight (less than or equal to 10%)

[HR?]

103

Overweight (BMI t 95%, t 24 months, standing height)

[HR]

113

At Risk of Becoming Overweight (BMI t 85% and < 95%, t 24 months, standing height)

114

Short Stature d 10% (if < 24 months of age and < 38 weeks gestation, use adjusted age)
* Failure to Thrive

[HR?]

121

[HR]

134

Inadequate Growth

[HR]

135

* Low Birth Weight (Children < 24 months of age)

141

* Prematurity (Children < 24 months of age) (Enter weeks gestation:

)

142

* Elevated Blood Lead Level (Blood Lead Level t 10 g/dl)

[HR]

211

* Nutrition Related Medical Conditions (List code(s):

) [HR]

* Dental Problems

381

* Environmental Tobacco Smoke Exposure

904

* Fetal Alcohol Syndrome

[HR]

382

* Inappropriate Nutrition Practices

400

Homelessness

801

Migrancy

802

* Recipient of Abuse

901

* Primary Caregiver with Limited Ability to make Feeding Decisions and/or Prepare Food

902

Transfer of Certification

502

Other Dietary Risk

401

-(Risk of Inappropriate Complementary Feeding Practices) [12 months to 23 months]

-(Failure to meet Dietary Guidelines) [t 2 years of age]

HIGH RISK (Yes or No)

ELIGIBLE FOR WIC

PRIORITY: 3= (201, 103, 113, 114, 121, 134, 135, 141, 142, 211, 341, 342, 343, 344, 345, 346, 347, 348, 349, 351, 352, 353, 354, 355, 356, 357, 359, 360, 361, 362, 381, 382, 502, 904)
5= (400, 401, 502, 801, 802, 901, 902)
FOOD PACKAGE: (Specify Tailoring Instructions)

Date:
YES
wks
in.
lbs. HCT
YES

Type:
NO
RS
ozs HGB
NO

Date:
YES

Type:
NO

wks

in.
lbs. HCT
YES

RS
ozs
HGB
NO

(NEVER DOWNGRADE INFANTS PRIORITY)

SERVICES: CH (A), Health Check (B), CMS (C), Immun (G), Lead Screen (H), Dental Health (I), STD (J), Private MD (K), SNAP (L), Medicaid
(M), TANF (N), Mental Health (O), Head Start (P), NA/None (Q), Refused (R), Community Health Center (S), Children 1st (T), Other-Specify (U), Dietitian (V), Breastfeeding (W), Breastfeeding Peer Counselor (X)

TODAY'S DATE SIGNATURE AND TITLE OF HEALTH PROFESSIONAL *Additional Documentation Required

CT-85

Enrolled In: Referred To:

Enrolled In: Referred To:
Rev. 07/10) (1 of 3)

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT-5 (cont'd)

Do you have a medical home?

Yes

No

M.D. Name

INCOME DETERMINATION (income must be documented)

FIRST CERTIFICATION

DATE

PHYSICAL PRESENCE

Y( ) N( )*

MEDICAID CURRENT Y/N/U

Y( ) N( )

U( )

*N ( ) R( ) D ( ) W( )

UP ( )

MEDICAID I.D. NUMBER VERIFY

TANF Y/N/U
COPY AND FILE Y( ) U( ) N( )

SNAP Y/N/U
Y( ) U( ) N( )

UP ( )

UP ( )

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 __________________ Other ____________________ (Write in type)
UP: _________________

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 ( )

_________________ Staff Initials

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

UP: __________________ Staff Initial

______________________________________________________________________________________

SECOND CERTIFICATION

DATE

PHYSICAL PRESENCE

MEDICAID CURRENT Y/N/U

MEDICAID I.D. NUMBER VERIFY

TANF Y/N/U COPY AND FILE

SNAP Y/N/U

NO. IN FAMILY

GROSS INCOME (CURRENT/ANNUAL

Y( ) N( )*

Y( ) N( )

U( )

Y( ) U( ) N( )

Y( ) U( ) N( )

C () A () UP ( )

*N ( ) R( ) D ( ) W( )

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

Source of Income Code __________________ Other ____________________ (Write in type)
UP: _________________

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 ( )

_________________ Staff Initials

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

UP: _________________ Staff Initials

Peachcare

Y=Yes

N=No

Date breastfeeding began.

(MM/DD/YYYY)

Date of last time of breastfeeding and/or pumping

(MM/DD/YYYY)

Fruit Intake.

D=Daily

S=Some Days

N=Never

Vegetable Intake.

D=Daily

S=Some Days

N=Never

Dairy Intake.

D=Daily

S=Some Days

N=Never

Daily Activity.

V=Very Active S=Active Some of the Time

N-Not Active

Screen Time.

Hours = 00 through 24

______________________________________________________________________________________

IMMUNIZATION STATUS

IMMUNIZATION STATUS

Record Screened/Requested? Yes ( ) Requested ( )

Record Screened/Requested? Yes ( ) Requested ( )

Adequate for Age/Referred: Yes ( ) Doctor ( ) Health Dept. ( )

Adequate for Age/Referred: Yes ( ) Doctor ( ) Health Dept. ( )

CT-86

(Rev. 07/10) (2 of 3)

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT-5 (cont'd)

Comments:(Date/Sign/Title):_________________________________________________________________________________________________________ Proxy 1 _________________________________________________________ Proxy2 ______________________________________________________

WIC CERTIFICATION STATEMENT RIGHTS AND OBLIGATIONS
I have been advised of my rights and obligations for participation in Georgia's WIC. I certify that the information I will provide, or have provided, is correct to the best of my knowledge. The income information that I have provided 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. Georgia's WIC 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 to Georgia's WIC, 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.
NOTICE OF DISCLOSURE I understand that the chief state health officer for Georgia may authorize the disclosure of information about my participation in the WIC program for non-WIC purposes. This information will be used by Georgia WIC, its local WIC agencies and certain public organizations. These organizations include but are not limited to the Immunization Program, Pregnancy Risk Assessment Monitoring Systems (PRAMS), Epidemiology and other Maternal and Child Heath Programs, Emergency Preparedness, Environmental Health and Medicaid. I understand that Georgia WIC, its local agencies and the public organizations can only use my information in the administration of their programs that serve person eligible for WIC. The public organizations that receive my information must assure that it will not disclose my information to another organization or person without my permission.
I further understand that information about my participation in WIC may be used by the organizations that receive it only to:
1. Determine my eligibility for programs that the organization administers 2. Conduct outreach for such programs 3. Enhance the health, education, or well-being of WIC applicants and participants who are currently enrolled in those programs 4. Streamline administrative procedures to ease the burdens on WIC staff and participants 5. Assess the responsiveness of the state's health system to participants' health care needs and health care outcomes.
I have been advised that the decision to share my information is not a condition for eligibility for WIC, and if I decide not to share my information, this will not affect my application or participation in Georgia WIC.

FIRST CERTIFICATION

___________________________________________ Name of WIC Applicant/Participant/Guardian/ Caregiver/Spouse/Alternate Parent (please print)
___________________________________________ Signature of WIC Applicant/Participant/Guardian/ Caregiver/Spouse/Alternate Parent

________________ Date ________________ UP: ________________ Date

__________________________________ Name of WIC Official (please print)
__________________________________ Signature of WIC Official

______________ Date
______________ Date

Please initial below to indicate your preference:

___In applying for WIC services, I AUTHORIZE DISCLOSURE of my WIC applicant or participant information for the purposes referenced above. I understand that my refusal to allow such disclosure does not affect my application for or participation in WIC or my eligibility for WIC services.

___ In applying for WIC services, I DO NOT AUTHORIZE DISCLOSURE of my WIC applicant or participant information for the purposes referenced above. I understand that my refusal to allow such disclosure does not affect my application for or participation in WIC or my eligibility for WIC services.

SECOND CERTIFICATION

___________________________________________ Name of WIC Applicant/Participant/Guardian/ Caregiver/Spouse/Alternate Parent (please print)
___________________________________________ Signature of WIC Applicant/Participant/Guardian/ Caregiver/Spouse/Alternate Parent

________________ Date ________________ UP: ________________ Date

__________________________________ Name of WIC Official (please print)
__________________________________ Signature of WIC Official

______________ Date
______________ Date

Please initial below to indicate your preference:

___In applying for WIC services, I AUTHORIZE DISCLOSURE of my WIC applicant or participant information for the purposes referenced above. I understand that my refusal to allow such disclosure does not affect my application for or participation in WIC or my eligibility for WIC services.

___ In applying for WIC services, I DO NOT AUTHORIZE DISCLOSURE of my WIC applicant or participant information for the purposes referenced above. I understand that my refusal to allow such disclosure does not affect my application for or participation in WIC or my eligibility for WIC services.
(Rev. 07/10) (3 of 3)

CT-87

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6

DATA AND DOCUMENTATION REQUIRED FOR WIC ASSESSMENT/CERTIFICATION
PRENATAL WOMEN

Data
Height Pre-Pregnancy Weight
Current Weight Hematocrit or Hemoglobin Prenatal Weight Grid Plotted Evaluation of Inappropriate Nutrition Practices Risk Factor Assessment

Prenatal Women
Required Required Required Required Required Required Required

CT-88

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

NUTRITION RISK CRITERIA PREGNANT WOMEN

NOTE: High Risk Criteria, as defined below, are to be used for referral purposes, not certification (See Appendix A-1)

CODE

PREGNANT WOMEN

201

LOW HEMOGLOBIN/HEMATOCRIT

1st Trimester (0-13 wks):

Hemoglobin

Hematocrit

Non-Smokers Smokers

10.9 gm or lower 11.2 gm or lower

32.9% or lower 33.9% or lower

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

10.4 gm or lower 10.7 gm or lower

31.9% or lower 32.9% or lower

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

10.9 gm or lower 11.2 gm or lower

32.9% or lower 33.9% or lower

PRIORITY I

101

UNDERWEIGHT

I

Pre-pregnancy weight is equal to a Body Mass Index (BMI) of <18.5. Refer to BMI Table, Appendix C-1.

High Risk: Pre-pregnancy BMI <18.5

111

OVERWEIGHT

I

Pre-pregnancy weight is equal to a Body Mass Index of >25. Refer to BMI Table, Appendix C-1.

High Risk: Pre-pregnancy BMI >29.9

131

LOW MATERNAL WEIGHT GAIN

I

Low weight gain at any point in pregnancy, such that a pregnant woman's weight plots at any point beneath the bottom line of the appropriate weight gain range for her respective prepregnancy weight category.

Refer to Appendix C-2.

High Risk: Low Maternal Weight Gain

CT-89

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE

PREGNANT WOMEN

PRIORITY

132

GESTATIONAL WEIGHT LOSS DURING PREGNANCY

I

x During first (0-13 weeks) trimester, any weight loss below pregravid weight; based on pregravid weight and current weight.
OR x During second and third trimesters (14-40 weeks gestation), >2 lbs 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 lbs in the second and third trimesters

133

HIGH MATERNAL WEIGHT GAIN

I

High maternal weight gain at any point in pregnancy, such that a pregnant woman's weight plots at any point above the top line of the appropriate weight gain range for her respective prepregnancy weight category.

211

ELEVATED BLOOD LEAD LEVELS

I

Blood lead level of >10 Pg/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 Pg/deciliter

CT-90

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE 301

PREGNANT WOMEN

PRIORITY

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

Gestational diabetes mellitus (GDM) is defined as any degree of glucose/carbohydrate intolerance.

Presence of gestational diabetes diagnosed by a physician as self-reported by applicant/participant/caregiver; or as reported or documented by physician, or someone working under physician's orders.

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

High Risk: Diagnosed gestational diabetes

303

HISTORY OF GESTATIONAL DIABETES

I

History of diagnosed gestational diabetes mellitus (GDM)

Presence of condition diagnosed by a physician as self-reported by applicant/participant/caregiver; or as reported or documented by physician, or someone working under physician's orders.

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

CT-91

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE

PREGNANT WOMEN

304

HISTORY OF Preeclampsia

History of diagnosed preeclampsia

Presence of condition diagnosed by a physician as self-reported by applicant/participant/caregiver; or as reported or documented by physician, or someone working under physician's orders

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

PRIORITY I

311

HISTORY OF PRETERM DELIVERY

Any history of infant(s) born at 37 weeks gestation or less

I

Document: Delivery date(s) 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 lb 8 oz (2500 gms) or less.

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

321

HISTORY OF FETAL OR NEONATAL DEATH

I

Any fetal death(s) (death >20 weeks gestation) or neonatal death(s) (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.

CT-92

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE

PREGNANT WOMEN

331

PREGNANCY AT A YOUNG AGE

For current pregnancy, EDC at less than 18 years and 10 months of age.

Document: Expected date of delivery (EDC) on the WIC Assessment/ Certification Form

High Risk: EDC at less than 17 years of age

PRIORITY I

332

CLOSELY SPACED PREGNANCIES

I

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

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

CT-93

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE 335

PREGNANT WOMEN
MULTI-FETAL GESTATION

More than one (>1) fetus in a current pregnancy.

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

High Risk: Multi-fetal gestation

PRIORITY I

336

FETAL GROWTH RESTRICTION

I

Fetal Growth Restriction (FGR) must be diagnosed by a physician or a health professional acting under standing 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 (1) or more infants with a birth weight of 9 pounds (4000 gm) or more, OR infant(s) diagnosed as large for gestational age by a physician or a health professional acting under standing 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 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 BIRTH

DEFECT(S)

I

A prenatal woman with any history of giving 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).

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

CT-94

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

PREGNANT WOMEN
CODE NUTRITION RELATED MEDICAL CONDITIONS

341

NUTRIENT DEFICIENCY DISEASES

PRIORITY I

Diagnosis of clinical signs of nutritional deficiencies or a disease caused by insufficient dietary intake of macro or micronutrients. Diseases include, but not limited to: protein energy malnutrition, hypocalcemia, cheilosis, scurvy, osteomalacia, menkes disease, rickets, Vitamin K deficiency, xerothalmia, beriberi, and pellagra. (See Appendix D)

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 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 nutrient deficiency disease

342

GASTRO-INTESTINAL DISORDERS:

I

Diseases or conditions that interfere with the intake, digestion, and or absorption of nutrients. The diseases and/or conditions include, but are not limited to: x Gastroesophageal reflux disease (GERD) x Peptic ulcer x Post-bariatric surgery x Short bowel syndrome x Inflammatory bowel disease, including ulcerative colitis or Crohn's disease x Liver disease x Pancreatitis x Biliary tract disease

The presence of gastro-intestinal disorders as diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or someone working under physician's orders.

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-95

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE

PREGNANT WOMEN

PRIORITY

343

DIABETES MELLITUS

I

The presence of diabetes mellitus diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or someone working under physician's orders.

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

High Risk: Diagnosed diabetes mellitus

344

THYROID DISORDERS

I

Hypothyroidism or hyperthyroidism: Presence of thyroid 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 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

I

Presence of hypertension or prehypertension diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or someone working under physician's orders.

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

High Risk: Diagnosed hypertension

CT-96

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE 346

PREGNANT WOMEN
RENAL DISEASE
Any renal disease including pyelonephritis and persistent proteinuria, but EXCLUDING urinary tract infections (UTI) involving the bladder. Presence of renal disease diagnosed by a physician as self reported by 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 name of the physician that is treating this condition in the participant's health record.
High Risk: Diagnosed renal disease

PRIORITY I

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 standing orders of a physician.

Document: Description of how the 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 cancer

348

CENTRAL NERVOUS SYSTEM DISORDERS

I

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

Presence of a central nervous system disorder(s) 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 central nervous system disorder

CT-97

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE

PREGNANT WOMEN

PRIORITY

349

GENETIC AND CONGENITAL DISORDERS

I

Hereditary or congenital condition at birth that causes physical or metabolic abnormality, or both. May include, but 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 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 genetic/congenital disorder

351

INBORN ERRORS OF METABOLISM

I

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

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

CT-98

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE

PREGNANT WOMEN

PRIORITY

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 be present within 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 standing orders of a physician.

Document: Diagnosis, appropriate dates of each occurrence, and name of physician treating condition in the participant's health record. When using HIV/AIDS positive status as a Nutritionally Related Medical Condition, write "See Medical Record" for documentation purpose.

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 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 food allergy.

354

CELIAC DISEASE

I

Also known as celiac sprue, gluten enteropathy, or non-tropical sprue.

Presence of celiac 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 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 Celiac Disease

CT-99

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE

PREGNANT WOMEN

PRIORITY

355

LACTOSE INTOLERANCE

I

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

Document: Diagnosis and the 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.

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 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 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 the 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-100

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE

PREGNANT WOMEN

PRIORITY

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 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 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 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 past 2 months

360

OTHER MEDICAL CONDITIONS

I

Diseases or conditions with nutritional implications that are not included in any

of the other medical conditions. The current condition, or treatment for the

condition, MUST be severe enough to affect nutritional status. Including, but not

limited to: juvenile rheumatoid arthritis (JRA), lupus erythematosus, cardio-

respiratory diseases, heart disease, cystic fibrosis; moderate, persistent or

severe asthma.

Presence of other medical conditions diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or health care provider working under the orders of a physician.

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

High Risk: Diagnosed medical condition severe enough to compromise

CT-101

GEORGIA WIC 2012 PROCEDURES MANUAL nutritional status

Attachment CT- 6 (cont'd)

CT-102

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE

PREGNANT WOMEN

361

DEPRESSION

Presence of depression diagnosed by a physician or psychologist as self reported by applicant/participant/caregiver; or as reported or documented by a physician, psychologist or health care provider working under the orders of a physician.

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

PRIORITY I

362

DEVELOPMENTAL, SENSORY OR MOTOR DELAYS INTERFERING WITH

I

THE ABILITY TO EAT

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

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

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

371

MATERNAL SMOKING

I

Any smoking of cigarettes, pipes or cigars.

Document: Number of cigarettes or cigars smoked, or number of times pipe smoked, on WIC Assessment/Certification Form. See Appendix E-1 for documentation codes.

904

ENVIRONMENTAL TOBACCO SMOKE EXPOSURE

I

Environmental tobacco smoke (ETS) exposure is defined as exposure to smoke from tobacco products inside the home.

CT-103

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE

PREGNANT WOMEN

372

ALCOHOL USE

Any alcohol use:

A serving of standard sized drink (1 ounce of alcohol) is:

x 1 can of beer (12 fluid oz) x 5 oz wine x 1 fluid oz 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 oz of alcohol/per week intake on WIC Assessment/Certification Form. See Appendix E-1 for documentation codes.

373

STREET DRUG USE

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

Document: Type of drug(s) being used. See Appendix E-2 for documentation codes.

PRIORITY I
I

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. Including but 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 in adequate quality or quantity.

Document: In the participant's health record, a description of how the dental problem interferes with mastication and/or has other nutritionally related health problems.

CT-104

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE

PREGNANT WOMEN

400

INAPPROPRIATE NUTRITION PRACTICES

Routine nutrition practices that may result in impaired nutrient status, disease, or health problems. (Appendix G)

Document: Inappropriate Nutrition Practice(s) in the participant's health record.

PRIORITY IV

801

HOMELESSNESS

IV

Homelessness as defined in the Special Populations Section of the Georgia WIC Program Procedure 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 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 AND/OR PREPARE FOOD

Woman who is assessed to have limited ability to make appropriate feeding decisions and/or prepare food. Examples may include:

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

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

CT-105

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CT-106

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE 502

PREGNANT WOMEN TRANSFER OF CERTIFICATION

PRIORITY I, IV

Person with a current valid Verification of Certification (VOC) document from another state or local agency. The VOC is valid until the certification period expires, and shall be accepted as proof of eligibility for Program benefits. If the receiving local agency has waiting lists 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.

401

OTHER DIETARY RISK (FAILURE TO MEET DIETARY GUIDELINES)

IV

A woman who meets eligibility requirements based on category, income, and residency but who does not have any other identified nutritional risk factor may be presumed to be at nutritional risk based on failure to meet the Dietary Guidelines for Americans.

(This risk factor may be assigned only when a woman does not qualify for risk 400 or for any other risk factor.)

CT-107

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

DATA AND DOCUMENTATION REQUIRED FOR WIC ASSESSMENT/CERTIFICATION

BREASTFEEDING WOMEN

Data

Breastfeeding and Non-Breastfeeding Woman Certified in
Hospital Prior to Initial Discharge

Woman Certified in Clinic

Breastfeeding Woman Certified in
Clinic >6 Months Postpartum

Height

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

Pre-Pregnancy Weight

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

Current Weight

If available

Last Weight Before Delivery

Required

Hemoglobin or Hematocrit

Required (Apply 90-day rule when not available)

Evaluation of Inappropriate Nutrition Practices

Required

Risk Factor Assessment

Required

Required
Required Required Required Required Required Required

Required
Required Required Required Optional Required Required

CT-108

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

NUTRITION RISK CRITERIA

BREASTFEEDING WOMEN

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

certification (See Appendix A-1)

BREASTFEEDING WOMEN

CODE

PRIORITY

201

LOW HEMOGLOBIN/HEMATOCRIT

I

Non-Smokers:

Hemoglobin:

11.9 gm or lower (> 15 years of age)

11.7 gm or lower (< 15 years of age)

Hematocrit:

35.8% or lower

Smokers:

Hemoglobin:

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 (Appendix B-1)

101

UNDERWEIGHT

I

< 6 months Postpartum: Pre-pregnancy or current weight is equal to a Body Mass Index (BMI) of <18.5. Refer to BMI Table, Appendix C-1.

6 months Postpartum: Current weight is equal to a Body Mass Index (BMI) of <18.5. Refer to BMI Table, Appendix C-1.

High Risk: Current BMI <18.5

111

OVERWEIGHT

I

<6 months Postpartum: Pre-pregnancy weight is equal to a Body Mass Index (BMI) of >25. Refer to BMI Table, Appendix C-1.

6 months Postpartum: Current weight is equal to a Body Mass Index (BMI) of >25. Refer to BMI Table, Appendix C-1.

High Risk: Current BMI >29.9

CT-107

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE

BREASTFEEDING WOMEN

PRIORITY

133

HIGH MATERNAL WEIGHT GAIN

I

Breastfeeding (most recent pregnancy only): total gestational weight gain exceeding the upper limit of the recommended range based on Body Mass Index (BMI), as follows:

Prepregnancy Weight Group

Definition (BMI)

Cut-off Value (Singleton)

Cut-off Value (Multi-Fetal)

Underweight

< 18.5

>40 lbs

*

Normal Weight

18.5 to 24.9

>35 lbs

>54 lbs

Overweight

25.0 to 29.9

>25 lbs

>50 lbs

Obese

> 30.0

>20 lbs

>42 lbs

*There are no provisional guidelines for an underweight woman with multiple

fetuses. (Appendix C-2)

Document: Pre-gravid weight and last weight before delivery

211

ELEVATED BLOOD LEAD LEVELS

I

Blood lead level of >10 Pg/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 Pg/deciliter

303

HISTORY OF GESTATIONAL DIABETES

I

History of diagnosed gestational diabetes mellitus (GDM)

Presence of condition diagnosed by a physician as self-reported by applicant/participant/caregiver; or as reported or documented by physician, or someone working under physician's orders.

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

CT-108

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE

BREASTFEEDING WOMEN

304 HISTORY OF PREECLAMPSIA

History of diagnosed preeclampsia

PRIORITY I

Presence of condition diagnosed by a physician as self-reported by applicant/participant/caregiver; or as reported or documented by physician, or someone working under physician's orders

Document: Diagnosis and name of the physician that is treating this condition 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 lb 8 oz (2500 gms) 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 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.

CT-109

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE
331

BREASTFEEDING WOMEN
PREGNANCY AT A YOUNG AGE

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

PRIORITY I

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

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 is under age 20 at date of conception 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

MULTI FETAL GESTATION

I

More than one (>1) fetus in the most recent pregnancy

High Risk: Multi-fetal gestation

337

HISTORY OF A LARGE FOR GESTATIONAL AGE INFANT

I

Birth of an infant with a birth weight of 9 pounds or more, OR infant diagnosed as large for gestational age by a physician or a health professional acting under orders of a physician.

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

CT-110

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE

BREASTFEEDING WOMEN

PRIORITY

339

BIRTH WITH NUTRITION RELATED CONGENITAL OR BIRTH DEFECT(S)

I

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

NUTRITION RELATED MEDICAL CONDITIONS

I

341

NUTRIENT DEFICIENCY DISEASES

Diagnosis of clinical signs of nutritional deficiencies or a disease caused by insufficient dietary intake of macro or micro nutrients. Diseases include, but not limited to: protein energy malnutrition, hypocalcemia, cheilosis, scurvy, osteomalacia, menkes disease, rickets, Vitamin K deficiency, xerothalmia, beriberi, and pellagra. (See Appendix D)

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 standing orders of a physician.

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

High Risk: Diagnosed nutrient deficiency disease

CT-111

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE

BREASTFEEDING WOMEN

PRIORITY

342

GASTRO-INTESTINAL DISORDERS

I

Diseases or conditions that interfere with the intake, digestion, and or absorption of nutrients. The diseases and/or conditions include, but are not limited to: x Gastroesophageal reflux disease (GERD) x Peptic ulcer x Post-bariatric surgery x Short bowel syndrome x Inflammatory bowel disease, including ulcerative colitis or Crohn's
disease x Liver disease x Pancreatitis x Biliary tract disease

The presence of gastro-intestinal disorders as diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or someone working under physician's orders.

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

The presence of diabetes mellitus diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or someone working under physician's orders.

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

High Risk: Diagnosed diabetes mellitus

CT-112

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE

BREASTFEEDING WOMEN

PRIORITY

344

THYROID DISORDERS

I

Hypothyroidism or hyperthyroidism: Presence of thyroid 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 standing orders of a physician.

Document: Diagnosis and name of the physician that is treating this condition in participant's health record.
High Risk: Diagnosed thyroid disorder

345

HYPERTENSION

I

Presence of hypertension or prehypertension diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or someone working under physician's orders.

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 standing orders of a physician.

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

High Risk: Diagnosed renal disease

CT-113

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE

BREASTFEEDING WOMEN

PRIORITY

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 standing orders of a physician.

Document: Description of how the condition or treatment affects nutritional status and the name of the physician that is treating the condition in the participant's health record.

High Risk: Diagnosed cancer

348

CENTRAL NERVOUS SYSTEM DISORDERS

I

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

Presence of a central nervous system disorder(s) 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 name of the physician that is treating this condition in participant's health record.

High Risk: Diagnosed central nervous system disorder

CT-114

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE

BREASTFEEDING WOMEN

PRIORITY

349

GENETIC AND CONGENITAL DISORDERS

I

Hereditary or congenital condition at birth that causes physical or metabolic abnormality, or both. May include, but 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 standing orders of a physician.

Document: Diagnosis and name of the physician that is treating this condition in participant's health record.
High Risk: Diagnosed genetic/congenital disorder

351

INBORN ERRORS OF METABOLISM

I

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

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

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

High Risk: Diagnosed inborn error of metabolism

CT-115

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE

BREASTFEEDING WOMEN

PRIORITY

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 be present within 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 standing orders of a physician.

Document: Diagnosis, appropriate dates of each occurrence, and name of physician treating this condition in the participant's health record. When using HIV/AIDS positive status as a Nutritionally Related Medical Condition, write "See Medical Record" for documentation purpose.

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 standing orders of a physician.

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

High Risk: Diagnosed food allergy

CT-116

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE

BREASTFEEDING WOMEN

PRIORITY

354

CELIAC DISEASE

I

Also known as celiac sprue, gluten enteropathy, non-tropical sprue.

Presence of celiac 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 standing orders of a physician.

Document: Diagnosis and name of the physician that is treating this condition in 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 standing orders of a physician; OR symptoms must be well documented by the competent professional authority.

Document: Diagnosis and the 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.

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 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 hypoglycemia

CT-117

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE

BREASTFEEDING WOMEN

PRIORITY

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 the participant's health record.

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

358

EATING DISORDERS

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 standing orders of a physician.

Document: Diagnosis and name of the physician that is treating this condition in 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 professional acting under the standing 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-118

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE

BREASTFEEDING WOMEN

PRIORITY

360

OTHER MEDICAL CONDITIONS

I

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

Presence of other medical conditions diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or health care provider working under the standing orders of a physician.

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

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

361

DEPRESSION

I

Presence of depression diagnosed by a physician or psychologist as self reported by applicant/participant/caregiver; or as reported or documented by a physician, psychologist or health care provider working under the orders of a physician.

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

CT-119

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE

BREASTFEEDING WOMEN

PRIORITY

362

DEVELOPMENTAL, SENSORY OR MOTOR DELAYS INTERFERING WITH

I

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 the delay and how it interferes with the ability to eat and the name of the physician that is treating this condition in the participant's health record.

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

I

363

PRE-DIABETES

Presence of pre-diabetes 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 name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed pre-diabetes

371

MATERNAL SMOKING

I

Any smoking of cigarettes, pipes or cigars.

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

904

ENVIRONMENTAL TOBACCO SMOKE EXPOSURE

I

Environmental tobacco smoke (ETS) exposure is defined as exposure to smoke from tobacco products inside the home.

CT-120

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE

BREASTFEEDING WOMEN

PRIORITY

372

ALCOHOL USE

I

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

A serving of standard sized drink (1 ounce of alcohol) is: x 1 can of beer (12 fluid oz) x 5 oz wine x 1 fluid oz liquor, OR

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

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 oz of alcohol/week intake on WIC Assessment/Certification Form. See Appendix E-1 for documentation codes.

373

STREET DRUG USE

I

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

Document: Type of drug(s) being used. See Appendix E-2 for documentation codes.

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. Including but not limited to: tooth decay, periodontal disease, and tooth loss and/or ineffectively replaced teeth which impair the ability to ingest food in adequate quality or quantity.

Document: In the participant's health record, a description of how the dental problem interferes with mastication and/or has other nutritionally related health problems.

CT-121

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE

BREASTFEEDING WOMEN

PRIORITY

400

INAPPROPRIATE NUTRITION PRACTICES

IV

Routine nutrition practices that may result in impaired nutrient status, disease, or health problems. (Appendix G)

Document: Inappropriate Nutrition Practice(s) in the participant's health record.

601

BREASTFEEDING AN INFANT AT NUTRITIONAL RISK

I, II, IV

A breastfeeding woman whose breastfed 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 COMPLICATIONS

I

A breastfeeding woman with any of the following complications or potential complications for breastfeeding.

a. severe breast engorgement b. recurrent plugged ducts c. mastitis d. flat or inverted nipples e. cracked, bleeding or severely sore nipples f. age > 40 years g. failure of milk to come in by 4 days postpartum h. tandem nursing (nursing two siblings who are not twins)

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

High Risk: Refer to or provide the mother with appropriate breastfeeding counseling.

801 HOMELESSNESS

IV

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

CT-122

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE

BREASTFEEDING WOMEN

PRIORITY

802 MIGRANCY

IV

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

901

RECIPIENT OF ABUSE

IV

Battering within 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 FEEDING

IV

DECISIONS AND/OR PREPARE FOOD

Woman who is assessed to have limited ability to make appropriate feeding decisions and/or prepare food. Examples may include:

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

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

CT-123

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE

BREASTFEEDING WOMEN

PRIORITY

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 is valid until the certification period expires, and shall be accepted as proof of eligibility for Program benefits. If the receiving local agency has waiting lists 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.

401

OTHER DIETARY RISK (FAILURE TO MEET DIETARY GUIDELINES)

IV

A woman who meets eligibility requirements based on category, income, and residency but who does not have any other identified nutritional risk factor may be presumed to be at nutritional risk based on failure to meet the Dietary Guidelines for Americans.

(This risk factor may be assigned only when a woman does not qualify for risk 400 or for any other risk factor.)

CT-124

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

DATA AND DOCUMENTATION REQUIRED FOR WIC ASSESSMENT/CERTIFICATION
POSTPARTUM NON-BREASTFEEDING WOMEN

Data
Height
Pre-Pregnancy Weight Current Weight Last Weight Before Delivery Hemoglobin or Hematocrit Evaluation of Inappropriate Nutrition Practices Risk Factor Assessment

Woman Certified in Hospital Prior to Initial
Discharge
Pre-pregnancy height from health record; self reported if
not available from record
Pre-pregnancy weight from health record; self reported if
not available from record
If available
Required
Required (Apply 90-day rule when not
available)
Required
Required

Woman Certified in Clinic
Required
Required Required Required Required
Required Required

CT-125

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

NUTRITION RISK CRITERIA

POSTPARTUM, NON- BREASTFEEDING WOMEN

NOTE: High Risk Criteria, as defined below, are to be used for referral purposes, not certification (See Appendix A-1)

POSTPARTUM NON-BREASTFEEDING WOMEN

CODE

PRIORITY

201

LOW HEMOGLOBIN/HEMATOCRIT

VI

NonSmokers:

Hemoglobin: Hematocrit:

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

Smokers:

Hemoglobin: Hematocrit:

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

High Risk: Hemoglobin OR hematocrit at treatment level (Appendix B-1)

101

UNDERWEIGHT

VI

Pre-pregnancy or current weight is equal to a Body Mass Index (BMI) of <18.5. Refer to BMI Table, Appendix C-1.

High Risk: Pre-pregnancy or current BMI <18.5

111

OVERWEIGHT

VI

Pre-pregnancy weight is equal to a Body Mass Index (BMI) of >25. Refer to BMI Table, Appendix C-1.

High Risk: Pre-pregnancy BMI >29.9

CT-126

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE

POSTPARTUM NON-BREASTFEEDING WOMEN

PRIORITY

133 HIGH MATERNAL WEIGHT GAIN

VI

Non-Breastfeeding (most recent pregnancy only): total gestational weight gain exceeding the upper limit of the recommended range based on Body Mass Index (BMI), as follows:

Prepregnancy Weight Group

Definition (BMI)

Cut-off Value (Singleton)

Cut-off Value (Multi-Fetal)

Underweight Normal Weight
Overweight Obese

< 18.5 18.5 to 24.9 25.0 to 29.9
> 30.0

>40 lbs >35 lbs >25 lbs >20 lbs

* >54 lbs >50 lbs >42 lbs

*There are no provisional guidelines for an underweight woman with multiple fetuses. (Appendix C-2)
Document: Pre-gravid weight and last weight before delivery

211

ELEVATED BLOOD LEAD LEVELS

VI

Blood lead level of >10 Pg/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 Pg/deciliter

303

HISTORY OF GESTATIONAL DIABETES

VI

History of diagnosed gestational diabetes mellitus (GDM)

Presence of condition diagnosed by a physician as self-reported by applicant/participant/caregiver; or as reported or documented by physician, or someone working under physician's orders.

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

CT-127

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE 304

POSTPARTUM NON-BREASTFEEDING WOMEN
HISTORY OF PREECLAMPSIA

PRIORITY VI

History of diagnosed preeclampsia

Presence of condition diagnosed by a physician as self-reported by applicant/participant/caregiver; or as reported or documented by physician, or someone working under physician's orders

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

311

DELIVERY OF PREMATURE INFANT(S)

VI

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

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

312

DELIVERY OF LOW BIRTH WEIGHT INFANT(S)

VI

Woman has delivered one (1) or more infants with a birth weight of 5 lb 8 oz (2500 gms) 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.

CT-128

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE

POSTPARTUM NON-BREASTFEEDING WOMEN

PRIORITY

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

332

CLOSELY SPACED PREGNANCIES

Delivery date for most recent pregnancy occurred less than 25 months after the

VI

termination of the previous pregnancy.

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

333

HIGH PARITY AND YOUNG AGE

VI

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 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

MULTI FETAL GESTATION

VI

More than one (>1) fetus in the most recent pregnancy

High Risk: Multi-fetal gestation

CT-129

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE

POSTPARTUM NON-BREASTFEEDING WOMEN

337

HISTORY OF A LARGE FOR GESTATIONAL AGE INFANT

PRIORITY VI

Birth of an infant with a birth weight of 9 pounds or more, OR infant diagnosed as large for gestational age by a physician or a health professional acting under standing orders of a physician.
Document: Birth weight(s) and/or diagnosis in the participant's health record.

339

BIRTH WITH NUTRITION RELATED CONGENITAL OR BIRTH DEFECT(S)

VI

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 the participant's health record.

NUTRITION RELATED MEDICAL CONDITIONS

VI

341

NUTRIENT DEFICIENCY DISEASES

Diagnosis of clinical signs of nutritional deficiencies or a disease caused by insufficient dietary intake of macro or micro nutrients. Diseases include, but not limited to: protein energy malnutrition, hypocalcemia, cheilosis, scurvy, osteomalacia, menkes disease, rickets, Vitamin K deficiency, xerothalmia, beriberi, and pellagra. (See Appendix D)

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 standing orders of a physician.

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

High Risk: Diagnosed nutrient deficiency disease

CT-130

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE

POSTPARTUM NON-BREASTFEEDING WOMEN

PRIORITY

342

GASTRO-INTESTINAL DISORDERS

VI

Diseases or conditions that interfere with the intake, digestion, and or absorption of nutrients. The diseases and/or conditions include, but are not limited to: x Gastroesophageal reflux disease (GERD) x Peptic ulcer x Post-bariatric surgery x Short bowel syndrome x Inflammatory bowel disease, including ulcerative colitis or Crohn's disease x Liver disease x Pancreatitis x Biliary tract disease

The presence of gastro-intestinal disorders as diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or someone working under physician's orders.

Document: Diagnosis and name of the physician that is treating this condition in the participant's health record.
High Risk: Diagnosed gastro-intestinal disorder

343

DIABETES MELLITUS

VI

The presence of diabetes mellitus diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or someone working under physician's orders.
Document: Diagnosis and name of the physician that is treating this condition in the participant's health record.
High Risk: Diagnosed diabetes mellitus

CT-131

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE

POSTPARTUM NON-BREASTFEEDING WOMEN

PRIORITY

344

THYROID DISORDERS

VI

Hypothyroidism or hyperthyroidism: Presence of thyroid 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 standing orders of a physician.

Document: Diagnosis and the name of the physician that is treating this condition in participant's health record.
High Risk: Diagnosed thyroid disorder

345

HYPERTENSION

VI

Presence of hypertension or prehypertension diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or someone working under physician's orders.

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 standing orders of a physician.

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

High Risk: Diagnosed renal disease

CT-132

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE

POSTPARTUM NON-BREASTFEEDING WOMEN

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 standing orders of a physician.

Document: Description of how the condition or treatment affects nutritional status and the 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 central nervous system disorder(s) 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 participant's health record.

High Risk: Diagnosed central nervous system disorder

CT-133

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE

POSTPARTUM NON-BREASTFEEDING WOMEN

PRIORITY

349

GENETIC AND CONGENITAL DISORDERS

VI

Hereditary or congenital condition at birth that causes physical or metabolic abnormality, or both. May include, but 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 standing orders of a physician.

Document: Diagnosis and the name of the physician that is treating this condition in participant's health record.
High Risk: Diagnosed genetic/congenital disorder

351

INBORN ERRORS OF METABOLISM

VI

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

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

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

High Risk: Diagnosed inborn error of metabolism

CT-134

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE

POSTPARTUM NON-BREASTFEEDING WOMEN

PRIORITY

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 be present within 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 standing orders of a physician.

Document: Diagnosis, appropriate dates of each occurrence, and name of physician treating condition in the participant's health record. When using HIV/AIDS positive status as a Nutritionally Related Medical Condition, write "See Medical Record" for documentation purpose.
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 standing orders of a physician.

Document: Diagnosis and the name of the physician that is treating this condition.

High Risk: Diagnosed food allergy

CT-135

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE

POSTPARTUM NON-BREASTFEEDING WOMEN

PRIORITY

354

CELIAC DISEASE

VI

Also known as celiac sprue, gluten enteropathy, non-tropical sprue.

Presence of celiac 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 standing orders of a physician.

Document: Diagnosis and the name of the physician that is treating this condition.

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 standing orders of a physician; OR symptoms must be well documented by the competent professional authority.

Document: Diagnosis and the 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.

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 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 hypoglycemia

CT-136

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE

POSTPARTUM NON-BREASTFEEDING WOMEN

PRIORITY

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 the participant's health record.

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

358

EATING DISORDERS

VI

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

Document: Diagnosis and the name of the physician that is treating this condition.

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 the standing 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-137

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE

POSTPARTUM NON-BREASTFEEDING WOMEN

PRIORITY

360

OTHER MEDICAL CONDITIONS

VI

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

Presence of other medical conditions diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or health care provider working under the standing orders of a physician.

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

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

361

DEPRESSION

VI

Presence of depression diagnosed by a physician or psychologist as self reported by applicant/participant/caregiver; or as reported or documented by a physician, psychologist or health care provider working under the orders of a physician.

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

CT-138

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE

POSTPARTUM NON-BREASTFEEDING WOMEN

PRIORITY

362

DEVELOPMENTAL, SENSORY OR MOTOR DELAYS INTERFERING WITH

VI

THE ABILITY TO EAT

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

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

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

363

PRE-DIABETES

VI

Presence of pre-diabetes 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 name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed pre-diabetes

371

MATERNAL SMOKING

VI

Any smoking of cigarettes, pipes or cigars.

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

904

ENVIRONMENTAL TOBACCO SMOKE EXPOSURE

VI

Environmental tobacco smoke (ETS) exposure is defined as exposure to smoke from tobacco products inside the home.

CT-139

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE

POSTPARTUM NON-BREASTFEEDING WOMEN

PRIORITY

372

ALCOHOL USE

VI

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

A serving of standard sized drink (1 ounce of alcohol) is: x 1 can of beer (12 fluid oz) x 5 oz wine x 1 fluid oz liquor, OR

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

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 oz of alcohol/per week intake on WIC Assessment/Certification Form. See Appendix E-1 for documentation codes.

373

STREET DRUG USE

VI

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

Document: Type of drug(s) being used. See Appendix E-2 for documentation codes.

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. Including but not limited to: tooth decay, periodontal disease, and tooth loss and/or ineffectively replaced teeth which impair the ability to ingest food in adequate quality or quantity.

Document: In the participant's health record, a description of how the dental problem interferes with mastication and/or has other nutritionally related health problems.

CT-140

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE

POSTPARTUM NON-BREASTFEEDING WOMEN

PRIORITY

400

INAPPROPRIATE NUTRITION PRACTICES

VI

Routine nutrition practices that may result in impaired nutrient status, disease, or health problems. (Appendix G)

Document: Inappropriate Nutrition Practice(s) in the participant's health record.

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 within 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-141

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE

POSTPARTUM NON-BREASTFEEDING WOMEN

PRIORITY

902

POSTPARTUM, NON-BREASTFEEDING WOMAN WITH LIMITED ABILITY

IV

TO MAKE FEEDING DECISIONS AND/OR PREPARE FOOD

Woman who is assessed to have limited ability to make appropriate feeding decisions and/or prepare food. Examples may include:

x mental disability / delay and/or mental illness such as clinical depression (diagnosed by a physician or licensed psychologist)
x physical disability which restricts or limits food preparation abilities x current use of or history of abusing alcohol or other drugs
Document: The women's specific limited abilities in the participant's health record.

502

TRANSFER OF CERTIFICATION

III, VI

Person with a current valid Verification of Certification (VOC) document from another state or local agency. The VOC is valid until the certification period expires, and shall be accepted as proof of eligibility for Program benefits. If the receiving local agency has waiting lists 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.

401

OTHER DIETARY RISK (FAILURE TO MEET DIETARY GUIDELINES)

VI

A woman who meets eligibility requirements based on category, income, and residency but who does not have any other identified nutritional risk factor may be presumed to be at nutritional risk based on failure to meet the Dietary Guidelines for Americans.

(This risk factor may be assigned only when a woman does not qualify for risk 400 or for any other risk factor.)

CT-142

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

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
Evaluation of Inappropriate Nutrition Practices
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

Required

Optional

Required

Optional

Required

Optional Required

Required Required

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

CT-143

GEORGIA WIC 2012 PROCEDURES MANUAL
NUTRITION RISK CRITERIA INFANTS

Attachment CT- 6 (cont'd)

NOTE: High Risk Criteria, as defined below, are to be used for referral purposes, not certification (See Appendix A-2)
INFANTS

CODE

PRIORITY

201

LOW HEMOGLOBIN/HEMATOCRIT

I

Hemoglobin: 10.9 gm or lower (6-11 month old) Hematocrit: 32.8% or lower (6-11 month old)

High Risk: Hemoglobin OR Hematocrit at treatment level (Appendix B-2)

103

UNDERWEIGHT

I

Less than or equal to the 10th percentile weight for length, based on the 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. (if < 38 weeks gestation use adjusted age)
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-144

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE

INFANTS

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:
Not back to birth weight by 2 weeks of age A gain of less than 19 ounces by 1 month of age
Infants being certified during period from 1 to 5 months of age:
This method (explained in Appendix C-3) is optional, if an infant 1 to 5 months of age qualifies for WIC based on any other risk criterion. If there is no other reason to qualify the infant, use this method to determine eligibility.

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 lbs 8 oz (< 2500 g)

Document: Birth weight in participant's health record

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

CT-145

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE

INFANTS

PRIORITY

142

PREMATURITY

I

Infant born at < 37 weeks gestation

Document: Weeks gestation in participant's health record

153

LARGE FOR GESTATIONAL AGE

I

Birth weight > 9 lbs or presence of large for gestational age diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or health care professional working under standing orders of a physician.

Document: Weight(s) of infant in participant's health record.

211

ELEVATED BLOOD LEAD LEVELS

I

Blood lead level of > 10 Pg/deciliter.

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

High Risk: Blood lead level of > 10 Pg/deciliter

CT-146

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE

INFANTS

NUTRITION RELATED MEDICAL CONDITIONS

341

NUTRIENT DEFICIENCY DISEASES

Diagnosis of clinical signs of nutritional deficiencies or a disease caused by insufficient dietary intake of macro or micro nutrients. Diseases include, but not limited to: protein energy malnutrition, hypocalcemia, cheilosis, scurvy, osteomalacia, menkes disease, rickets, Vitamin K deficiency, xerothalmia, beriberi, and pellagra. (See Appendix D)

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

PRIORITY I

High Risk: Diagnosed nutrient deficiency disease

342

GASTRO-INTESTINAL DISORDERS

I

Diseases or conditions that interfere with the intake, digestion, and or absorption of nutrients. The diseases and/or conditions include, but are not limited to: x Gastroesophageal reflux disease (GERD) x Peptic ulcer x Post-bariatric surgery x Short bowel syndrome x Inflammatory bowel disease, including ulcerative colitis or
Crohn's disease x Liver disease x Pancreatitis x Biliary tract disease

The presence of gastro-intestinal disorders as diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or someone working under physician's orders.

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-147

GEORGIA WIC 2012 PROCEDURES MANUAL

CODE

INFANTS

343

DIABETES MELLITUS

Attachment CT- 6 (cont'd)
PRIORITY I

The presence of diabetes mellitus diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or someone working under physician's orders.
Document: Diagnosis and name of the physician that is treating this condition in the participant's health record.
High Risk: Diagnosed diabetes mellitus

344

THYROID DISORDERS

I

Hypothyroidism or hyperthyroidism: Presence of thyroid disorders diagnosed by a 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 the 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 or prehypertension diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or someone working under physician's orders.

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

CT-148

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE 346

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

PRIORITY I

Document: Diagnosis and the 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 standing orders of a physician.

Document: Description of how the condition or treatment affects nutritional status and the name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed cancer

348

CENTRAL NERVOUS SYSTEM DISORDERS

I

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

Presence of a central nervous system disorder(s) diagnosed by a 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 the name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed central nervous system disorder

CT-149

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE

INFANTS

PRIORITY

349

GENETIC AND CONGENITAL DISORDERS

I

Hereditary or congenital condition at birth that causes physical or metabolic abnormality, or both. May include, but 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 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 genetic and congenital disorder

351

INBORN ERRORS OF METABOLISM

I

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

Presence of inborn errors of metabolism diagnosed by a physician as self reported by caregiver; or as reported or documented by a physician, or 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 inborn error of metabolism

CT-150

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE 352

INFANTS
INFECTIOUS DISEASES
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 be present within 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 standing orders of a physician.
Document: Diagnosis, appropriate dates of each occurrence, and name of physician treating condition in the participant's health record. When using HIV/AIDS positive status as a Nutritionally Related Medical Condition, write "See Medical Record" for documentation purpose.
High Risk: Diagnosed infectious disease, as described above.

PRIORITY I

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 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 food allergy

354

CELIAC DISEASE

I

Also known as celiac sprue, gluten enteropathy, non-tropical sprue.

Presence of celiac disease diagnosed by a 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 the name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed Celiac Disease

CT-151

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE

INFANTS

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 standing orders of a physician; OR symptoms described by caregiver must be well documented by the competent professional authority

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

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 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 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 the 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-152

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE

INFANTS

PRIORITY

359

RECENT MAJOR SURGERY, TRAUMA, 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 professional acting under standing 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 affect 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 other medical conditions. The current condition, or treatment for the condition, MUST be severe enough to affect nutritional status. Including, but 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 standing orders of a physician.

Document: Specific medical condition; a description of how the disease, condition or treatment affects nutritional status and the 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-153

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE

INFANTS

PRIORITY

362

DEVELOPMENTAL, SENSORY OR MOTOR DELAYS

I

INTERFERING WITH 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 standing orders of a physician.

Document: Specific condition/ description of delays and how these interfere with the ability to eat and the 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 the orders of a physician or adequate documentation by the competent professional authority. Including but not limited to:

x Presence of nursing bottle caries x Smooth surface decay of the maxillary anterior and the primary
molars

Document: Description of how the dental problem interferes with mastication and/or has other nutritionally related health problems in the participant's health record.

CT-154

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE

INFANTS

PRIORITY

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 standing orders of a physician.

Document: Diagnosis and name of physician treating the condition in the participant's health record.
High Risk: Diagnosed fetal alcohol syndrome

400

INAPPROPRIATE NUTRITION PRACTICES

IV

Routine nutrition practices that may result in impaired nutrient status, disease, or health problems. (Appendix G)

Document: Inappropriate Nutrition Practice(s) in the participant's health record.

603

BREASTFEEDING COMPLICATIONS OR POTENTIAL

I

COMPLICATIONS

Any of the following are considered complications or potential complications of breastfeeding:

x Breastfed infant with jaundice x Breastfed infant with weak or ineffective suck x Breastfed infant with difficulty latching onto mother's breast x Breastfed infant with inadequate stooling for age (as determined
by a physician or other health care provider) x Breastfed infant who wets diaper less than 6 times per day

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

High Risk: Refer to or provide the infant's mother with appropriate breastfeeding counseling.

CT-155

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE

INFANTS

PRIORITY

701

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

II

WOMAN WHO WOULD HAVE BEEN ELIGIBLE DURING

PREGNANCY

x An infant under 6 months of age whose mother was a WIC Program participant during pregnancy, OR
x An infant whose mother's medical 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 breastfed infant whose breastfeeding mother has been determined to be at nutritional risk.

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

703

INFANT BORN TO MOTHER WITH MENTAL RETARDATION, OR

ALCOHOL OR DRUG ABUSE DURING MOST RECENT

PREGNANCY

x Infant born of a woman diagnosed with mental retardation by a physician or psychologist as self-reported by caregiver; or as reported by a physician, psychologist, or someone working under physician's orders; OR
x Documentation or self-report of any use of alcohol or illegal drugs during most recent pregnancy.

801

HOMELESSNESS

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

802

MIGRANCY

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

I, II, IV I
IV IV

CT-156

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE

901

RECIPIENT OF ABUSE

INFANTS

Child abuse/neglect within past 6 months 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:

PRIORITY IV

x Imminent risk or serious harm x Serious physical or emotional harm x Sexual abuse or exploitation of an infant or child by a parent
or caretaker.
Georgia State law requires that medical and child service organization personnel, having reasonable cause to suspect child abuse, report these suspicions to the authority designated by the health district/organization.

902

PRIMARY CAREGIVER WITH LIMITED ABILITY TO MAKE

FEEDING DECISIONS AND/OR PREPARE FOOD

IV

Infant whose primary caregiver is assessed to have limited ability to make appropriate feeding decisions and/or prepare food. Examples may include:

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

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

904

ENVIRONMENTAL TOBACCO SMOKE EXPOSURE

I

Environmental tobacco smoke (ETS) exposure is defined as exposure to smoke from tobacco products inside the home.

CT-157

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE

INFANTS

PRIORITY

502

TRANSFER OF CERTIFICATION

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

This criterion would 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 State agency.

I, II, IV

401 OTHER DIETARY RISK

IV

RISK OF INAPPROPRIATE COMPLEMENTARY FEEDING PRACTICES > 4 MONTHS. (4 months through <12 months)

An infant 4 months of age who has begun to or is expected to begin to do any of the following practices is considered to be at risk of inappropriate complementary feeding:

1) consume complementary foods and beverages, or 2) eat independently, or 3) be weaned from breast milk or infant formula, or 4) transition from a diet based on infant/toddler foods to one based on the Dietary Guidelines for Americans.

(This risk factor may be assigned only when an infant > 4 months of age does not qualify for risk 400 or for any other risk factor.)

CT-158

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

DATA AND DOCUMENTATION REQUIRED FOR

WIC ASSESSMENT/CERTIFICATION

CHILDREN

Data
Length or Height Weight Hemoglobin or Hematocrit Weight/Age Plotted Length or Height/Age Plotted Weight/Length or BMI for Age Plotted Evaluation of Inappropriate Nutrition Practices Risk Factor Assessment

Documentation
Required Required Required Required Required Required Required Required

CT-159

GEORGIA WIC 2012 PROCEDURES MANUAL
NUTRITION RISK CRITERIA CHILDREN

Attachment CT- 6 (cont'd)

NOTE: High Risk Criteria, as defined below, are to be used for referral purposes, not certification (See Appendix A-2)

CODE

CHILDREN

PRIORITY

201

LOW HEMOGLOBIN/HEMATOCRIT

III

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

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

High Risk: Hemoglobin OR Hematocrit at treatment level (Appendix B-2)

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

III

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 the CDC age/sex specific growth charts. Can only be used if
standing height is taken.

CT-160

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE

CHILDREN

PRIORITY

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. (if < 24 months of age and <

38 weeks gestation use adjusted age)

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

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

Weight Gain in previous 6-month interval*

12 months >12 - 60 months

< 3 pounds < 1 pound

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

High Risk: Inadequate growth

141

LOW BIRTH WEIGHT (children < 24 months of age)

III

Birth weight < 5 lbs 8 oz (< 2500 g)

Document: Birth weight of participant in health record.

142

PREMATURITY (Children < 24 months of age)

III Born at 37 weeks gestation or less

Document: Weeks gestation in participant's health record.

CT-161

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE

CHILDREN

PRIORITY

211

ELEVATED BLOOD LEAD LEVELS

III

Blood lead level of >10 Pg/deciliter

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

High Risk: Blood lead level of >10 Pg/deciliter

NUTRITION RELATED MEDICAL CONDITIONS

III

341

NUTRIENT DEFICIENCY DISEASES

Diagnosis of clinical signs of nutritional deficiencies or a disease caused by insufficient dietary intake of macro or micronutrients. Diseases include, but not limited to: protein energy malnutrition, hypocalcemia, cheilosis, scurvy, osteomalacia, menkes disease, rickets, Vitamin K deficiency, xerothalmia, beriberi, and pellagra. (See Appendix D)

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 standing orders of a physician.

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

High Risk: Diagnosed nutrient deficiency disease

CT-162

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE

CHILDREN

PRIORITY

342

GASTRO-INTESTINAL DISORDERS

III

Diseases or conditions that interfere with the intake, digestion, and or absorption of nutrients. The diseases and/or conditions include, but are not limited to: x Gastroesophageal reflux disease (GERD) x Peptic ulcer x Post-bariatric surgery x Short bowel syndrome x Inflammatory bowel disease, including ulcerative colitis or
Crohn's disease x Liver disease x Pancreatitis x Biliary tract disease

The presence of gastro-intestinal disorders as diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or someone working under physician's orders.

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

The presence of diabetes mellitus diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or someone working under physician's orders.
Document: Diagnosis and name of the physician that is treating this condition in the participant's health record.
High Risk: Diagnosed diabetes mellitus

CT-163

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE

CHILDREN

PRIORITY

344

THYROID DISORDERS

III Hypothyroidism or hyperthyroidism: Presence of thyroid disorders diagnosed by a 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 participant's health record.

High Risk: Diagnosed thyroid disorder

345

HYPERTENSION

III Presence of hypertension or prehypertension diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or someone working under physician's orders.

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

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 standing orders of a physician.

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

High Risk: Diagnosed renal disease

CT-164

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE

CHILDREN

PRIORITY

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 standing orders of a physician.

Document: Description of how the 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 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, cerebal palsy (CP), and neural tube defects (NTD) such as spina bifida and myelomeningocele.

Presence of a central nervous system disorder(s) diagnosed by a 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 central nervous system disorder

CT-165

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE

CHILDREN

PRIORITY

349

GENETIC AND CONGENITAL DISORDERS

III

Hereditary or congenital condition at birth that causes physical or metabolic abnormality, or both. May include, but 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 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 genetic and congenital disorder

351

INBORN ERRORS OF METABOLISM

III

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

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

CT-166

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE

CHILDREN

PRIORITY

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 be present within 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 standing orders of a physician.

Document: Diagnosis, and approximate dates of each occurrence, and name of the physician that is treating this condition in the participant's health record. When using HIV/AIDS positive status as a Nutritionally Related Medical Condition, write "See Medical Record" for documentation purpose.

High Risk: Diagnosed infectious disease, as described above.

353

FOOD ALLERGIES

III

Presence of food allergy diagnosed by a 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 food allergy

354

CELIAC DISEASE

III

Also known as celiac sprue, gluten enteropathy, non-tropical sprue.

Presence of celiac disease diagnosed by a 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 Celiac Disease

CT-167

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE

CHILDREN

PRIORITY

355

LACTOSE INTOLERANCE

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

Document: Diagnosis and the name of the physician that is treating this condition in the participant's health record; OR list of symptoms described by caregiver/participant (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.

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 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 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 the participant's health record.

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

CT-168

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE

CHILDREN

PRIORITY

359

RECENT MAJOR SURGERY, TRAUMA, 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 professional acting under standing 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 other medical conditions. The current condition, or treatment for the condition, MUST be severe enough to affect nutritional status. Including, but 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 standing orders of a physician.

Document: 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-169

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE
361

DEPRESSION

CHILDREN

Presence of depression diagnosed by a physician or psychologist as self reported by applicant/participant/caregiver; or as reported or documented by a physician, psychologist or health care provider working under the orders of a physician.

PRIORITY III

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

362

DEVELOPMENTAL, SENSORY OR MOTOR DELAYS

III

INTERFERING WITH 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 standing orders of a physician.

Document: Specific condition/description of the delay and how it interferes with the ability to eat, and the name of the physician that is treating this condition in the participant's health record.

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 professional working under standing orders of a physician or adequate documentation by the competent professional authority. Including but not limited to:

x Presence of nursing bottle caries x Smooth surface decay of the maxillary anterior and the primary
molars

Document: In the participant's health record, a description of how the dental problem interferes with mastication and/or has other nutritionally related health problems.

CT-170

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE

CHILDREN

PRIORITY

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 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 fetal alcohol syndrome

400

INAPPROPRIATE NUTRITION PRACTICES

V

Routine nutrition practices that may result in impaired nutrient status, disease, or health problems. (Appendix G)

Document: Inappropriate Nutrition Practice(s) in the participant's health record.

801

HOMELESSNESS

V Homelessness as defined in the Special Population Section of the Georgia WIC Procedures Manual.

802

MIGRANCY

V

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

CT-171

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE

CHILDREN

PRIORITY

901

RECIPIENT OF ABUSE

V Child abuse/neglect within past 6 months 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:

x

Imminent risk or serious harm

x

Serious physical or emotional harm

x

Sexual abuse or exploitation of an infant or child by a

parent or caretaker.

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

902

PRIMARY CAREGIVER WITH LIMITED ABILITY TO MAKE

V

FEEDING DECISIONS AND/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:

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

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

904

ENVIRONMENTAL TOBACCO SMOKE EXPOSURE

III

Environmental tobacco smoke (ETS) exposure is defined as exposure to smoke from tobacco products inside the home.

CT-172

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

CODE

CHILDREN

PRIORITY

502

TRANSFER OF CERTIFICATION

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

This criterion would 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 State agency.

III, V

401

OTHER DIETARY RISK

V

RISK OF INAPPROPRIATE COMPLEMENTARY FEEDING PRACTICES < 24 MONTHS OF AGE (12 months through <24 months) A child who has begun to or is expected to begin to do any of the following practices is considered to be at risk of inappropriate complementary feeding:

1) consume complementary foods and beverages, or 2) eat independently, or 3) be weaned from breast milk or infant formula, or 4) transition from a diet based on infant/toddler foods to one based on the Dietary Guidelines for Americans.
OR
FAILURE TO MEET DIETARY GUIDELINES > 24 MONTHS OF AGE
A child who meets eligibility requirements based on category, income, and residency but who does not have any other identified nutritional risk factor may be presumed to be at nutritional risk based on failure to meet the Dietary Guidelines for Americans.

(This risk factor may be assigned only when a child does not qualify for risk 400 or for any other risk factor.)

CT-173

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

TABLE OF APPENDICES

APPENDICES REFERENCED IN RISK CRITERIA SECTION

Appendix

Page

A-1

WIC Maternal High Risk Criteria..................................................

91

A-2

WIC High Risk Criteria for Infants and Children..............................

92

B-1

Women's Health Recommended Guidelines for Iron

Supplementation, Based on Treatment Values...............................

93

B-2

Child Health Recommended Guidelines for Iron Supplementation,

Based on Treatment Values.......................................................

94

C-1

Body Mass Index (BMI) Table for Determining Weight

Classification for Women...........................................................

95

C-2

Definition of Maternal Weight Gain (Low, High, and Multi-Fetal).........

96

C-3

Definition of Inadequate Growth for Infants 1-6 Months of Age...........

97

D

Physical Signs Suggestive of Nutrient Deficiencies..........................

98

E-1

Alcohol and Cigarettes............................................................... 100

E-2

Common Names of Illegal (Street) Drugs/Drugs of Abuse.................................................................................... 101

F

Recommended Food Intake Patterns........................................... 102

G

Inappropriate Nutrition Practices................................................

103

H

Products Containing Caffeine...................................................... 108

I

Clear Liquids........................................................................... 110

J

Instructions for Use of the Prenatal Weight Gain Grid......................

111

K-1

Measuring Length..................................................................... 112

K-2

Measuring Weight ("Infant" Scale)................................................ 113

K-3

Measuring Height...................................................................... 114

CT-174

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

K-4

Measuring Weight (Standing)...................................................... 115

L

Instructions for Use of the Growth Charts.....................................

116

M

Use and Interpretation of the Growth Charts.................................. 120

APPENDICES PROVIDED FOR SUPPLEMENTAL INFORMATION

Appendix

Page

N

Food Sources of Vitamin A......................................................... 121

O

Food Sources of Vitamin C......................................................... 122

P

Food Sources of Folate............................................................. 123

Q

Food Sources of Iron................................................................. 124

R

Food Source of Calcium............................................................ 125

S

Herbs: Their Use and Potential Risks........................................... 126

T

Key for Entering Weeks Breastfed............................................... 127

U

Infant Formula Preparation......................................................... 128

V-1

Conversion Tables and Equivalents............................................. 131

V-2

Approximate Metric and Imperial Equivalents................................. 132

CT-175

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

Appendix A-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 tailored to the participants' desired health outcomes, following VENA principles. 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

Risk Code 201

Underweight

Prenatal Women: Body Mass Index <18.5

101

Postpartum Women: Body Mass Index <18.5

Overweight

Prenatal Women: Body Mass Index >25

111

Postpartum Women: Body Mass Index > 25

Low maternal weight gain

131

Weight loss during pregnancy

132

Nutrition-related medical conditions; presence of any disease or condition affecting nutritional status that requires a therapeutic diet as ordered by a physician or health professional acting under standing orders of a physician
EDC or delivery prior to 17th birthday

341-349; 351-354; 356-360;
362
331

Blood lead level > 10 Pg/dl

211

Breastfeeding complications; referral to appropriate BF counselor must be made

602

Hyperemesis Gravidarum

301

Gestational diabetes

302

Multifetal gestation

335

Any condition deemed by the competent professional authority to place the woman at high risk for compromised nutritional status; adequate documentation required

Appendix B-1
C-1 Body Mass Index Tables
C-1 Body Mass Index Tables
C-2

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Attachment CT- 6 (cont'd)
Appendix A-2

WIC HIGH RISK CRITERIA FOR INFANTS AND CHILDREN

WIC infants and children who have the following high-risk factors must receive nutrition counseling tailored to the participants' desired health outcomes, following VENA principles. 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
Underweight (weight for length or Body Mass Index for age <5th %)
Overweight (Body Mass Index for age >95th %)
Short stature (length/height for age <5th %)
Failure to thrive
Inadequate growth
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
Low birthweight infant (infant weighing 2500 grams [5 pounds] or less at birth). May only be used for infants as high risk criteria.
Blood lead level > 10Pg/dl
Breastfeeding complications; infants only; referral to appropriate BF counselor must be made
Fetal Alcohol Syndrome (child only)
Any condition deemed by the competent professional authority to place the infant/child at high risk for compromised nutritional status; adequate documentation required

Risk Code 201

Appendix B-2

103

113

121

134

135

341-354;
356, 357, 359, 360, 362; 382

141

211

603 382

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Attachment CT- 6 (cont'd)
Appendix B-1

WOMEN'S HEALTH RECOMMENDED GUIDELINES FOR IRON SUPPLEMENTATION
BASED ON TREATMENT VALUES

Hemoglobin

Hematocrit

Treatment Value

Treatment Value

NonSmokers

Smokers

NonSmokers

Smokers

Prenatal Woman 1st Trimester 3rd Trimester

10.9 gm or lower

11.2 gm or lower

32.9% or lower 33.9% or lower

Prenatal Woman 2nd Trimester

10.4 gm or lower

10.7 gm or lower

31.9% or lower 32.9% or lower

Non-Pregnant and/or Lactating Woman (<15 years of age)

11.7 gm or lower

12.0 gm or lower

35.8% or lower 36.8% or lower

Non-Pregnant and/or Lactating Woman (>15 years of age)

11.9 gm or lower

12.2 gm or lower

35.8% or lower 36.8% or lower

For Prenatal Women: Begin routine supplementation of a prenatal vitamin and mineral supplement to include 27-30 mg/day of elemental iron for all pregnant women at the 1st prenatal visit. For women with hemoglobin/hematocrit levels within the treatment value, treat anemia with a therapeutic dose of 60-120 mg of elemental iron/day.

NOTE: If a woman is taking a prenatal or other multi-vitamin and mineral supplement with iron, the prenatal or multivitamin and mineral supplement + iron supplement should equal a total of 60-120 mg elemental iron/day. When the hemoglobin/hematocrit reaches the acceptable value for the specific stage pregnancy, decrease iron dosage to 30 mg/day

PHYSICIAN REFERRAL: Hemoglobin less than 9.0 g/dL or hematocrit less than 27.0% Hemoglobin more than 15.0 g/dL or hematocrit more than 45.0% (2nd and 3rd trimester) If after 4 weeks the hemoglobin does not increase by 1 g/dL or hematocrit by 3%, despite compliance with iron
supplementation regimen and the absence of acute illness

For Non-Pregnant/Lactating Women: For women with hemoglobin/hematocrit levels within the treatment value, treat anemia with a therapeutic dose of 60120 mg of elemental iron/day.

NOTE: If a woman is taking a prenatal or other multi-vitamin and mineral supplement with iron, the prenatal or multi-vitamin and mineral supplement + iron supplement should equal a total of 60-120 mg elemental iron/day.

PHYSICIAN REFERRAL: Hemoglobin less than 9.0 g/dL or hematocrit less than 27.0% If after 4 weeks the hemoglobin does not increase by 1 g/dL or hematocrit by 3%, despite compliance with iron
supplementation regimen and the absence of acute illness

After 4 weeks, if the hemoglobin increases > 1g/dl or if the hematocrit increases > 3 %, continue treatment for 2-3 more months.
Reference: CDC/MMWR: April 3, 1998. Recommendations to Prevent and Control Iron Deficiency in the United States

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Attachment CT- 6 (cont'd)
Appendix B-2

CHILD HEALTH RECOMMENDED GUIDELINES FOR IRON SUPPLEMENTATION BASED ON TREATMENT VALUES

Hemoglobin Treatment
Value

Hematocrit Treatment
Value

Treatment Regimen

Infant 6 through 11 months

10.9 gm or lower

Dosage: 0.6 cc Ferrous Sulfate 32.8% or lower Drops BID
Mg Elemental Iron: 15 mg BID

Child 12 through 23 months

10.9 gm or lower

Dosage: 0.6 cc Ferrous Sulfate 32.8% or lower Drops BID
Mg Elemental Iron: 15 mg BID

Child 2 through 5 years

11.0 gm or lower

Dosage: 1.2 cc Ferrous Sulfate 32.9% or lower Drops BID
Mg Elemental Iron: 30mg BID

x Premature and low birth weight infants, infants of multiple births, and infants with suspected blood losses should be screened before 6 months of age, preferably at 6-8 weeks postnatal.
x Routine screening for iron deficiency anemia is not recommended in the first 6 months of life. x Treatment of iron deficiency anemia is 3 mg per kilogram per day. x Refer to the package insert of iron preparation to correctly calculate the appropriate dosage of
elemental iron. Most pediatric chewable preparations (i.e., Feostat, 100 mg) contain 33 mg elemental iron per tablet as ferrous fumarate. Non-chewable preparations for older patients (i.e., Feosol, 300 mg) contain 60-65 mg per tablet or capsule elemental iron as ferrous sulfate.

Sources: Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report, April 3, 1998/Vol.47/No. RR-3.
Nutrition Guidelines for Practice: A Manual for Providing Quality Nutrition Services. Nutrition Section, 1997.

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Attachment CT- 6 (cont'd)
Appendix C-1

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

Height Underweight Normal Weight Overweight

(Inches)

BMI <18.5

BMI 18.5-24.9 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 Institute 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.

*These calculations are based on estimated height and weights; your system will calculate a more exact BMI based on actual height and weights including fractional ounces and inches.

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Attachment CT- 6 (cont'd)
Appendix C-2

Definition of Weight Gain (Women)
Total Weight Gain Range (lbs)

Prepregnancy Weight Groups
Underweight Normal Weight
Overweight Obese

Singleton Pregnancy

Definition Low Maternal Recommended High Maternal

(BMI)

Weight Gain Weight Gain Weight Gain

< 18.5

<28

18.5 to 24.9

<25

25.0 to 29.9

<15

> 30.0

<11

28-40 25-35 15-25 11-20

> 40 > 35 > 25 > 20

Prepregnancy Weight Groups
Underweight
Normal Weight Overweight Obese

Multi-Fetal Weight Gain

Definition Low Maternal Recommended High Maternal

(BMI)

Weight Gain Weight Gain Weight Gain

< 18.5
18.5 to 24.9 25.0 to 29.9
> 30.0

There was insufficient information for the IOM committee to develop provisional guidelines for underweight woman
with multiple fetuses.
<37
<31
<25

1.5lbs/week during 2nd and 3rd trimesters
37-54 31-50 25-42

There was insufficient information for the IOM committee to develop provisional guidelines for underweight woman with multiple fetuses.
> 54 > 50 > 42

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Attachment CT- 6 (cont'd)
Appendix C-3

Definition of Inadequate Growth for Infants 1-6 Months of Age

Inadequate growth for infants between 1 and 6 months of age is based on two weight measurements taken at least 1 month (4.3 weeks) apart, using the following guidelines:

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

Minimum Acceptable Weight Gain
19 oz 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)

Example:

Date of Measurement 09/13/98 (birth) 10/26/98 (6 weeks, 1 day old)

Weight 7 lbs 6 oz 9 lbs 3 oz

1. Calculate infant's age:

98 - 98

10

26

09 13

01 mo 13 days = 1 month + 1 week + 6 days = about 1 mo + 2 wks

2. Calculate minimum acceptable weight gain:
1st month minimum acceptable weight = 19 oz 1-2 months minimum acceptable weight/wk = 6 oz (2x 6 = 12 oz) Total acceptable weight = 19 oz + 12 oz = 31 oz = 1 lb 15 oz

3. Compare actual weight gain (1 lb 13 oz) to acceptable minimum (1 lb 15 oz). This infant's weight gain is below acceptable minimum, so you can apply the criterion for inadequate growth.

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Attachment CT- 6 (cont'd)
Appendix D

PHYSICAL SIGNS SUGGESTIVE OF NUTRIENT DEFICIENCIES

Body Area Hair Eyes
Lips
Gums Tongue
Face and Neck

Normal Appearance

Signs Suggestive of Nutrient Deficiency(ies)

Nutrient Consideration(s)

shiny; firm; not easily plucked
bright; clear; shiny; no sores at corners of eyelids;

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

inadequate protein and calories
anemia (inadequate iron, folacin, or vitamin B-12)

membranes healthy pink and moist; no prominent blood vessels

Bitot's spots; red membranes; dryness of membranes; dull appearance of cornea (cornea xerosis); softening of cornea (keratomalacia);

inadequate Vitamin A

smooth; not chapped or swollen
healthy, red; do not bleed; not swollen deep red; not swollen or smooth

redness and fissuring of eyelid corners

inadequate riboflavin, Vitamin B-6, and niacin

redness or 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

spongy; bleeding; receding

inadequate ascorbic acid

scarlet; raw; edematous (glossitis)

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

purplish color (magenta);

inadequate riboflavin

smooth; pale; slick; atrophied taste buds (papillae)

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

diffuse depigmentation; darkening of skin over cheeks and under eyes;

inadequate folacin, Vitamin B-12, iron and niacin
inadequate protein
inadequate calories and niacin

scaling of skin around nostrils (nasolabial seborrhea)

inadequate riboflavin, niacin, and Vitamin B-6

swollen (moon) face;

inadequate protein

front of neck swollen (thyroid enlargement);

inadequate protein; inadequate iodine

swollen cheeks (bilateral parotid enlargement)

inadequate protein

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Attachment CT- 6 (cont'd)
Appendix D (cont.)

PHYSICAL SIGNS SUGGESTIVE OF NUTRIENT DEFICIENCIES

Body Area Skin
Teeth
Head / Neck Nails Muscular and Skeletal Systems

Normal Appearance no signs of swelling rashes, dark or light spots
no cavities, no pain, bright
face not swollen firm, pink good muscle tone; some fat under skin; can walk or run without pain

Signs Suggestive of Nutrient Deficiency(ies)

Nutrient Consideration(s)

dry and scaly (xerosis); sandpaper-like feel (follicular hyperkeratosis);

Inadequate Vitamin A or Essential fatty acids

pinhead-size purplish skin hemorrhages (petechiae);

Inadequate Vitamin C

excessive bruising;

Inadequate Vitamin K

red, swollen pigmentation of areas exposed to sunlight (pellagrous dermatitis);

Inadequate niacin and Tryptophan

extensive lightness and darkness of skin (flaky, pressure sores(decubiti)

Inadequate protein, Vitamin C, and zinc

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 and Vitamin A

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

Inadequate iodine; inadequate protein

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

Inadequate iron; Vitamin A toxicity

muscles have "wasted" appearance; baby's skull bones are thin and soft (craniotabes); round swelling of front and side of head (frontal and parietal bossing); 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 (musculoskeletal hemorrhages); person cannot get up or walk properly

Inadequate protein Inadequate thiamin Inadequate Vitamin D

Sources: 1. American Journal of Public Health, Supplement, November 1973, p. 19. 2. Georgia Dietetic Association Diet Manual, 1992.

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Attachment CT- 6 (cont'd)
Appendix E-1

ALCOHOL AND CIGARETTES

Alcohol Equivalents:

One serving of alcohol

=

12 ounces of beer (light or regular);

12 ounces of wine cooler;

5 ounces of wine (light or regular);

1 1/2 ounces of liquor.

Key for Entering Ounces of Alcohol/Week: On the WIC Assessment/Certification Form enter the amount of alcohol in ounces per week using the above equivalent chart.

Key: 00 ounces/week = no alcohol intake

01 ounces/week = greater than 0 and up to 1 1/2 ounce/week

02-98 ounces week = amount of intake

99 ounces/week = greater than 98 ounces/week

Binge drinking: drinks 5 or more (>5) drinks on the same occasion on at least one day in the past 30 days.

Heavy drinking: drinks 5 or more (>5) drinks on the same occasion on five or more days in the previous 30 days.

Key for Entering Number of Cigarettes/Cigars/Pipes Smoked: On the WIC Assessment/Certification Form record the average number of cigarettes/cigars/pipes smoked per day. If the client reports smoking on average less than once per day, record the average number of cigarettes/cigars/pipes smoked per week. If the client reports smoking on average less than once per week, record the average number of cigarettes/cigars/pipes smoked per month.

Key: 01-98/day = average number of cigarettes/cigars/pipes smoked per day

99/day = greater than 98 cigarettes/cigars/pipes smoked per day

01-06/week = average number of cigarettes/cigars/pipes smoked per week

01-03/month = average number of cigarettes/cigars/pipes smoked per month

Note: The usual number of cigarettes in a pack is equal to 20. This number may vary.

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Attachment CT- 6 (cont'd)
Appendix E-2

COMMON NAMES FOR ILLEGAL (STREET) DRUGS/DRUGS OF ABUSE

Controlled Substances Cannabis:

Common Names

Marijuana
Tetrahydrocannabinol Hashish, Hashish Oil

Acapulco Gold, Grass, Pot, Reefer, Sinsemilla, Thai Sticks
Marinol, THC
Hash, Hash Oil

Hallucinogens:

LSD (lysergic acid diethylamide) Mescaline, Peyote Amphetamine Variants
Phencyclidine and Analogs

Acid, Microdot
Buttons, Cactus, Mescal
2,5-DMA, DOB, DOM, Ecstasy, MDA, MDMA, STP
Angel Dust, Hog, Loveboat, PCE, PCP, PCPy, TCP

Narcotics:

Heroin

Diacetylmorphine, Horse, Smack

Stimulants:

Cocaine

Coke, Crack, Flake, Snow, Rock

Source: Drugs of Abuse. Drug Enforcement Administration and The National Guard. Arlington, VA, 1997.

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Attachment CT- 6 (cont'd)

Appendix F

RECOMMENDED FOOD INTAKE PATTERNS

Food Group

Birth to 5/6 Months

5/6 Months to 12 months

1 Year

2-3 Years

4-6 Years

Pregnant Teen/ Pregnant Adult

Breastfeeding Teen/ Breastfeeding Adult

Teen Postpartum/ Adult Postpartum

Milk, Yogurt & Cheese

Breast milk, every 2-3 hrs or Iron fortified formula, 2.5 oz/lb (18-35 ozs)

Breast milk, every 2-4 hrs or Iron fortified formula, 2.5 oz/lb (24-35 ozs)

2 cups1

2 cups

2 cups

3 cups

3 cups

3 cups

Meat, Poultry, Dry Beans, Eggs, Nuts Group

None

Add after 6 months and before 9 months

2 ounces

2 ounces

3-4 ounces

6- 6 ounces

6 ounces

5- 5 ounces

Fruit Group

None

Vegetable Group

None

Add after 6 months and before 9 months
Add after 6 months and before 9 months

1 cup2 1 cup

1 cup2 1 cup

1- 1 cups

2 cups

1 cups

3 cups

2-2 cups 3-3 cups

1 -2 cups 2 cups

Grain Group

None

Add iron Fortified cereal at 6 months

3 oz equivalent s

3 oz equivalents

4- 5 oz equivalents

7- 8 oz equivalents

7- 8 oz equivalents

6 oz equivalents

Discretionary Calorie Allowance3

None

None

165

165

171

290- 362

362- 410

195-267

1 AAP recommends whole milk for children until 2 years old 2 AAP recommends no more than 6 ounces of juice per day for children 3 Discretionary Calorie Allowance is the remaining amount of calories in a food intake pattern after accounting for the calories

needed

for all food groups- preferably using forms of foods that are fat-free or low-fat and with no added sugars.

Milk, Yogurt & Cheese Group:

Fruit Group:

Most milk group choices should be fat-free or low-fat for those over 1 cup equivalent from this group=

the age of 2 years.

1 cup equivalent from this group =

1 medium fruit

1 cup freshly cut canned or frozen fruit

1 cup milk/yogurt

cup dried fruit

1 ounces natural cheese (i.e. cheddar, Colby, longhorn)

1 cup 100% fruit juice

2 ounces processed cheese (i.e. American, Swiss)

2 cups cottage cheese

Vegetable Group:

1 serving =

Meat, Poultry, Dry Beans, Eggs, Nuts Group:

1 ounce equivalent from this group=

1 cup cooked or chopped

2 cups raw leafy salad greens

1 ounce lean meat, poultry or fish

1 cup 100% vegetable juice

1 egg

ounce nuts or seeds

Grain Group:

cup cooked dry beans or tofu

At least half of all grains consumed should be whole grains

1 tablespoon peanut butter

1ounce equivalent from this group =

1 slice of Bread , Hamburger Bun, 1 small muffin cup cooked cereal, rice or pasta 1 cup ready to eat cereal flakes All information provided courtesy of MyPyramid.gov For more information http://download.journals.elsevierhealth.com/pdfs/journals/1499-4046/PIIS1499404606005628.pdf

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Attachment CT- 6
Appendix G

Inappropriate Nutrition Practices for Women

Inappropriate Nutrition Practices for Women

Examples of Inappropriate Nutrition Practices (Including but not limited to)

Potentially Harmful Dietary Supplements
Consuming Dietary Supplements with potentially harmful consequences. Restrictive Diet
Consuming a diet very low in calories and/or essential nutrients; or impaired caloric intake or absorption of essential nutrients following bariatric surgery. Routine ingestion of non-food items (pica)
Compulsively ingesting non-food items (pica).
Inadequate vitamin/mineral supplementation recognized as essential by national public health policy.
Pregnant Women Potentially unsafe food consumption
Pregnant woman ingesting foods that could be contaminated with pathogenic microorganisms.

Examples of Dietary supplements which when ingested in excess of recommended dosages, may be toxic or have harmful consequences:
x Single or multiple vitamins x Mineral supplements; and x Herbal or botanical supplements/remedies/teas. x Strict vegan diet; x Low-carbohydrate, high-protein diet; x Macrobiotic diet; and x Any other diet restricting calories and/or essential nutrients.

Non-food items:

x Ashes;

x Clay;

x Baking soda;

x Dust;

x Burnt matches;

x Large quantities of ice

x Carpet fibers;

x Paint chips;

x Chalk;

x Soil; and

x Cigarettes;

x Starch (laundry and cornstarch)

x Consumption of less than 27 mg of supplemental iron per day by

pregnant women

x Consumption of less than 150 g of supplemental iodine per day by

pregnant and breastfeeding women

x Consumption of less than 400 mcg of folic acid from fortified foods

and/or supplements daily by non-pregnant women

Potentially harmful foods: x Raw fish or shellfish, including oysters, clams, mussels, and scallops; x Refrigerated smoked seafood, unless it is an ingredient in a cooked dish, such as a casserole; x Raw or undercooked meat or poultry; x Hot dogs, luncheon meat (cold cuts), fermented and fry sausage and other deli-style meat or poultry unless reheated until steaming hot; x Refrigerated pt or meat spreads; x Unpasteurized milk or foods containing unpasteurized milk; x Soft cheese such as feta, Brie, Camembert, blue-veined cheeses and Mexican style cheese such as queso blanco, queso fresco, or Panela unless labeled as "made with pasteurized milk"; x Raw or undercooked eggs or foods containing raw or lightly cooked eggs including certain salad dressings, cookie and cake batters, sauces, and beverages such as unpasteurized eggnog; x Raw sprouts (alfalfa, clover, and radish); or x Unpasteurized fruit or vegetable juices.

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Attachment CT- 6
Appendix G (cont.)

Inappropriate Nutrition Practices for Children

Inappropriate Nutrition Practices for Children

Examples of Inappropriate Nutrition Practices (Including but not limited to)

Routinely feeding inappropriate beverages as the primary milk source.

Examples of inappropriate beverages as primary milk source: x Non-fat or reduced-fat milks (between 12 and 24 months of age only) or sweetened condensed milk; and x Imitation or substitutes milks (such as inadequately or unfortified rice- or soy-based beverages, non-dairy creamer), or other "homemade concoctions."

Routinely feeding a child any sugarcontaining fluids.
Routinely using nursing bottle, cups, or pacifiers improperly.

Examples of sugar-containing fluids:

x Soda/soft drinks;

x Corn syrup solutions; and

x Gelatin water;

x Sweetened tea.

x Using a bottle to feed:

Fruit juice, or

Diluted cereal or other solid foods.

x Allowing the child to fall asleep or be put to bed with a

bottle at naps or bedtime.

x Allowing the child to use the bottle without restriction (e.g.,

walking around with a bottle) or as a pacifier.

x Using a bottle for feeding or drinking beyond 14 months of

age.

x Using a pacifier dipped in sweet agents such as sugar,

honey, or syrups.

x Allowing a child to carry around and drink, throughout the

day, from covered or training cups.

Routinely using feeding practices that disregard the developmental needs or stages of the child.

x Inability to recognize, insensitivity to, or disregarding the child's cues for hunger and satiety (e.g., forcing a child to eat a certain type and/or amount of food or beverage or ignoring a hungry child's request for appropriate foods).
x Feeding foods of inappropriate consistency, size, or shape that put children at risk of choking.
x Not supporting a child's need for growing independence with self-feeding (e.g.; solely spoon-feeding a child who is able and ready to finger-feed and/or try self-feeding with appropriate utensils).
x Feeding a child with an inappropriate texture based on his/her developmental stage (e.g., feeding primarily purees or liquid food when the child is read and capable of eating mashed, chopped, or appropriate finger food).

Potentially unsafe food consumption. Examples of potentially harmful foods for a child: x Unpasteurized fruit or vegetable juices.

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Attachment CT- 6

(cont'd)

Inappropriate Nutrition Practices

Examples of Inappropriate Nutrition Practices

for Children

(Including but not limited to)

Feeding foods to a child that could be contaminated with harmful microorganisms.

x Unpasteurized dairy products or soft cheese such as feta, Brie, Camembert, blue-veined cheeses and Mexican style cheese such as queso blanco, queso fresco, or Panela unless labeled as "made with pasteurized milk
x Raw or undercooked meat, fish, poultry, or eggs x Raw sprouts (alfalfa, clover, and radish) x Hot dogs, luncheon meat (cold cuts), fermented and fry
sausage and other deli-style meat or poultry unless reheated until steaming hot;

Routinely feeding a diet very low in calories and/or essential nutrients.

Examples: x Vegan Diet; x Macrobiotic diet; and x Other diets very low in calories and/or essential nutrients.

Feeding dietary supplements with potentially harmful consequences

Examples of dietary supplements which when feed in excess of recommended dosages, may be toxic or have harmful consequences:
x Single or multiple vitamins x Mineral supplements; and x Herbal or botanical supplements/remedies/teas

Routinely not providing dietary supplements as recognized as essential by national public health policy when a child's diet alone cannot meet nutrient requirements.

x Providing children under 36 months of age less than 0.25 mg of fluoride daily when the water supply contains less than 0.3 ppm fluoride.
x Providing children 36-60 months of age less than 0.50 mg of fluoride daily when the water contains less than 0.3 ppm fluoride.
x Not providing 400 IU of vitamin D if a child consumes less than 1 liter (or 1 quart) of vitamin D fortified milk or formula.

Routine ingestion of non-food items (pica)

x Ashes; x Carpet fibers; x Cigarettes or cigarette butts; x Clay; x Dust; x Foam Rubber x Paint chips; x Soil; and x Starch (laundry and cornstarch)

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Attachment CT- 6 (cont'd)
Appendix G (cont.)

Inappropriate Nutrition Practices for Infants

Inappropriate Nutrition Practices for Infants

Examples of Inappropriate Nutrition Practices (Including but not limited to)

Breast-milk or Formula Substitute Routinely using a substitute(s) for breast milk or FDA approved ironfortified formula as the primary source during the first year of life.
Inappropriate use of bottles or Sugar-Containing Fluids. Routinely using nursing bottles or cups improperly
Inappropriate Introduction of Solid Foods Routinely offering complementary foods* or other substances that are inappropriate in type or timing.
Feeding Practices not Developmentally Appropriate Routinely using feeding practices that disregard the developmental needs or stages of the child.

Examples of substitutes: x Low iron formula without iron supplementation; x Cow's milk, goat milk, or sheep milk (whole, reduced-fat low-fat, skim) canned evaporated sweetened condensed milk; and x Imitation or substitutes milks (such as inadequately or unfortified rice- or soy-based beverages, non-dairy creamer), or other "homemade concoctions." x Using a bottle to feed fruit juice x Adding any food (cereal or other solid foods) to the infant's bottle. x Feeding any sugar-containing fluids such as, soda/soft drinks; gelatin water; corn syrup solutions; and sweetened tea. x Allowing the child to fall asleep or be put to bed with a bottle at naps or bedtime. x Allowing the child to use the bottle without restriction (e.g., walking around with a bottle) or as a pacifier. x Propping the bottle when feeding. x Allowing a child to carry around and drink, throughout the day, from covered or training cups. x Adding sweet agents such as sugar, honey, or syrups to any beverage (including water) or prepared food, or used on a pacifier; or x Introduction of any food other than breast milk or iron-fortified infant formula before 4 months of age.
*Complementary foods are any foods or beverages other than breast milk or infant formula. x Inability to recognize, insensitivity to, or disregarding the child's cues for hunger and satiety (e.g., forcing an infant to eat a certain type and/or amount of food or beverage or ignoring a hungry infant's hunger cues). x Feeding foods of inappropriate consistency, size, or shape that put infants at risk of choking. x Not supporting an infant's need for growing independence with self-feeding (e.g.; solely spoon-feeding an infant who is able and ready to finger-feed and/or try self-feeding with appropriate utensils). x Feeding an infant with an inappropriate texture based on his/her developmental stage (e.g., feeding primarily purees or liquid food when the child is read and capable of eating mashed, chopped, or appropriate finger food).

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Attachment CT- 6 (cont'd)

Inappropriate Nutrition Practices

Examples of Inappropriate Nutrition Practices

for Infants

(Including but not limited to)

Potentially unsafe food consumption
Feeding foods to a child that could be contaminated with harmful microorganisms or toxins.
Inappropriate Formula Preparation. Routinely feeding inappropriately diluted formula Restrictive Nursing. Routinely limiting the frequency of nursing of the exclusively breastfeed infant when breast milk is the sole source of nutrients. Restrictive Diet
Routinely feeding a diet very low in calories and/or essential nutrients Lack of proper Sanitation. Routinely using inappropriate sanitation in preparation, handling, and storage of expressed breast milk or formula.
Potentially Harmful Dietary Supplements. Feeding dietary supplements with potentially harmful consequences
Lack of Essential Dietary Supplements.
Routinely not providing dietary supplements as recognized as essential by national public health policy when an Infant's diet alone

Examples of potentially harmful foods for a child: x Unpasteurized fruit or vegetable juices. x Unpasteurized dairy products or soft cheese such as feta, Brie, Camembert, blue-veined cheeses and Mexican style cheese such as queso blanco, queso fresco, or Panela unless labeled as "made with pasteurized milk x Honey (added to liquids or solid food, used in cooking, as part of processed foods, on pacifier, etc.); x Raw or undercooked meat, fish, poultry, or eggs x Raw vegetable sprouts (alfalfa, clover, bean and radish) x Hot dogs, luncheon meat (cold cuts), fermented and fry sausage and other deli-style meat or poultry unless reheated until steaming hot;
x Failure to follow manufacturer's dilution instructions (to include stretching formula for household economic reasons).
x Failure to follow specific instructions accompanying a prescription.
Examples of inappropriate frequency of nursing: x Scheduled feedings instead of demand feedings; x Less than 8 feedings in a 24 hours if less than 2 months of age; and x Less than 6 feedings in 24 hours if between 2-6 months of age.
Examples: x Vegan Diet; x Macrobiotic diet; and x Other diets very low in calories and/or essential nutrients
Examples of inappropriate sanitation: x Limited or no access to a: Safe water supply (documented by appropriate officials) Heat source for sterilization, and/or; Refrigerator or freezer storage. x Failure to properly prepare, handle, and store bottles or storage containers of expressed breast milk or formula.
Examples of Dietary supplements which when feed in excess of recommended dosages, may be toxic or have harmful consequences:
x Single or multiple vitamins x Mineral supplements; and x Herbal or botanical supplements/remedies/teas x Infants who are 6 months of age or older who are ingesting less
than 0.25 mg of fluoride daily when the water supply contains less than 0.3 ppm fluoride. x Infants who are exclusively breastfed, or are ingesting less than 1 liter (or 1 quart) per day of vitamin D-fortified formula, and are not taking a supplement of 400 IU of vitamin D. x Non-breastfed infants who are ingesting less than 1 liter (or 1

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Attachment CT- 6 (cont'd)

Inappropriate Nutrition Practices

Examples of Inappropriate Nutrition Practices

for Infants

(Including but not limited to)

cannot meet nutrient requirements.

quart) per day of vitamin D-fortified formula, and are not taking a supplement of 400 IU of vitamin D.

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Attachment CT- 6 (cont'd)

Appendix H

PRODUCTS CONTAINING CAFFEINE

PRODUCT

AVERAGE CAFFEINE CONTENT (mg)

CAFFEINE RANGE (mg)

Coffee (5-oz cup)

Brewed, drip

115

Brewed, percolator

80

Instant

65

Decaffeinated, brewed

3

Decaffeinated, instant

2

Tea

Brewed, major US brands (5-oz)

40

Brewed, imported brand (5-oz)

60

Instant (5-oz)

30

Iced (12-oz)

70

Chocolate Beverages

Cocoa beverage (5-oz)

4

Chocolate milk (8-oz)

5

Milk chocolate (1-oz)

6

Dark choc, semi-sweet (1 oz)

20

Baker's chocolate (1 oz)

26

Chocolate-flavored syrup (1 oz)

4

60-180 40-170 30-120
2-5 1-5
20-90 25-110 25-50 67-76
2-20 2-7 1-15 5-35 26 4

PRODUCT
Energy Drinks (16-oz) Monster Energy Rock Star Energy Drink Red Bull Full Throttle 5 Hour Energy (2-oz)
Soft Drinks (12-oz) Mountain Dew Mello Yellow TAB Coca-Cola Diet Coke Mr. PIBB Dr. Pepper Pepsi Cola Diet Pepsi

CAFFEINE CONTENT (mg)
160.0 160.0 160.0 144.0 138.0
54.0 52.8 46.8 45.6 44.4 39.6 39.6 38.0 36.0

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Attachment CT- 6 (cont'd)
Appendix H (cont.)

PRODUCTS CONTAINING CAFFEINE

PRODUCT

MILLIGRAMS CAFFEINE/DOSE

Diet Plan Non-Prescription Drugs

Caltrim Tablets

100

Caffeine-Free Dexatrim w/ Vitamin C

0

Dexatrim

200

X-tra Strength Dexatrim

200

Gold Medal

100

Odrinex

Pain Relievers Anacin and X-tra Strength Capron Capsules Tri Pain Caplets BC Tablet BC Powder Arthritis Strength BC Doan's Pills Duradyne Excedrin X-tra Strength Goody's Powder Goody's X-tra Strength Meadache Trigesic Vanquish Caplet Prolamine Capsules

32 32.4 16.2 16 32 36 32 15 65 32.5 16.25 32 30 33 140

Menstrual Relief

Aqua Ban

100

Midol

32.4

Midol Max Strength, Multi-Symptom

60

Sources: 1American Pharmaceutical Association and The National Professional Society of Pharmacists. (8th Ed.).
(1986). Handbook of Nonprescription Drugs.

2American Dietetic Association (ADA). (1992). Manual of Clinical Dietetics (4th ed.). Chicago, IL: Chicago Dietetic Association.

3Georgia Dietetic Association (GDA). (1992). Georgia Dietetic Association Diet Manual (4th ed.). Duluth, GA.

4Medical Economics Data Production Company. (15th Ed.). (1994). Physician's Desk Reference for Nonprescription Drugs, Montvale, N.J.

5U.S. Pharmacopeial Convention, Inc. (13th Ed.). (1993). Drug Information for the Health Care Professional USP DI.

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CLEAR LIQUIDS

Attachment CT- 6 (cont'd)
Appendix I

The following foods are considered clear liquids: All strained clear juices (apple, grape, cranberry) Carbonated beverages Clear broths Coffee Decaffeinated coffee Fruit ices Gelatin, plain Kool-Aid and other clear juice drinks Lemonade Popsicles Teas Water

Source:

Georgia Dietetic Association Diet Manual. Georgia Dietetic Association, Inc. Fourth edition, 1992.

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(cont'd)

Attachment CT-6

Appendix J

INSTRUCTIONS FOR USE OF PRENATAL WEIGHT GAIN GRID

1. Record applicant/participant's name.
2. Use "Body Mass Index Table" (Attachment CT-6) to determine if the applicant is Normal Weight, Underweight for Height, Overweight for Height, or Obese for Height using pre-pregnancy weight. Select the weight curve, which represents the prenatal woman's weight status. If she is pregnant with more than one fetus, use the Multifetal Pregnancy chart based on her appropriate 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 prepregnancy weight is unknown, or if the weight she gives seems disproportionate to her current weight use professional judgment to select A, B, C, or D range. Next, plot the midpoint of the selected range for the number of weeks pregnant to obtain the Expected Weight Gain. Then use this equation:

[Current Weight]- [Expected Weight Gain] = Estimated Prepregnancy Weight

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

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Attachment CT- 6 (cont'd)
Appendix K-1

Age:

MEASURING LENGTH

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:

An accurate lengthboard for measuring infants is dedicated to length measurement. It has a firm, flat horizontal surface with a measuring tape in 1 mm (0.1 cm) or 1/8 inch increments, an immovable headpiece at a right angle to the tape, and a smoothly moveable footpiece, perpendicular to the tape.

Two (2) people required

Procedure:

1. Check to be sure that moveable foot piece slides easily and the headboard is at the zero (0) mark.

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

3. With the child positioned so that the shoulders, back and buttocks are flat along the center of the board, the measurer should hold the child's knees together, gently pushing them down against the board with one (1) hand to fully extend the child. With the other hand the measurer should slide the footboard to the child's feet until both heels touch the foot piece. Toes should be pointing directly upward.

4. Recheck head placement. Immediately remove the child's feet from contact with the footboard with one (1) hand, while holding the footboard securely in place with the other hand.

5. Measure length in inches to the nearest 1/8-inch. Repeat the measurement by sliding footboard away and starting again until two (2) readings agree within 1/4 inch.

6. Record the second reading promptly.

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Attachment CT- 6 (cont'd)
Appendix K-2

MEASURING WEIGHT ("INFANT" SCALE)

Age:

Infants and very young children up to 35 pounds

Materials/Equipment:
Scales with beam balance and non-detachable weights or electronic, with a maximum weight of 40 lbs and weigh in ounce increments.

Scales must be calibrated yearly.

Procedure:

1. Check scales at zero (0) position. With weights in zero (0) position, indicator should point at zero (0). If not, use the adjustment screws to move adjustable zeroing weight until the beam is in zero (0) balance.

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

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

4. Move the weight on the main beam away from the zero (0) position (left to right) until the indicator shows excess weight, then move the weight back (right to left) towards the zero (0) position until too little weight has been obtained.

5. Move the weight on the fractional beam away from the zero (0) position (left to right) until the indicator is centered and stationary. (Record weight)

6. Repeat the measurements by moving the fractional beam until two (2) readings agree within -ounce.

7. Record the second reading promptly.

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Attachment CT- 6 (cont'd)
Appendix K-3

MEASURING HEIGHT

Age:

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

Adults

NOTE: Once measurements are started with child standing, all subsequent measurements must be done standing.

Material/Equipment:

An accurate stadiometer for stature measurements is designed for and dedicated to stature measurement. It can be wall mounted or portable. An appropriate stadiometer requires a vertical board with an attached metric rule and a horizontal headpiece (right angle headboard) that can be brought into contact with the most superior part of the head. The stadiometer should be able to read to 0.1 cm or 1/8 in.

Procedure:
1. Remove all bulky clothing, head and footwear.
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. Read the stature to the nearest 1/8-inch.
6. Repeat the adjustment of the headboard and re-measure until two (2) readings agree within 1/4 inch.
7. Record the second reading promptly.

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GEORGIA WIC 2012 PROCEDURES MANUAL
(cont'd)

Attachment CT- 6

Appendix K-4

Age:

MEASURING WEIGHT (STANDING)

Adults, and children 2 years of age or older who can stand unattended by an adult

Materials/Equipment:

Standard electronic scale or platform beam scale with non-detachable weights that weighs in at least 1/4 pound or 100 gram increments.
Scales must be calibrated yearly

Procedure:
1. Check scales at zero (0) position. With weights in zero (0) position indicator should point at zero (0). If not, use adjustment screws to move the adjustable zeroing weight until the beam is in zero (0) balance.

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

3. Have child/adult stand in the center of the platform, arms hanging naturally. The child/adult must be free standing.
4. Move the weight on the main beam away from zero (0) until the indicator shows that excess weight has been added, then move the weight back towards the zero (0) position (right to left) until just barely too much weight has been removed.

5. Move the weight on the fractional beam away from the zero (0) position (left to right) until the indicator is centered.
6. Make sure the child/adult is still not holding on, then record to the nearest 1/4 lb.

7. Have the child/adult step off scale and return weight to zero (0). Repeat until two (2) readings agree within 1/4 pound.
8. Record the second reading promptly.

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

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Attachment CT- 6 (cont'd)

Appendix L

INSTRUCTIONS FOR USE OF THE CHILD 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

Date of Birth

-1997

-8

-10

Child's Age

4y

8

11

or 4 yrs 8 mos
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. Plot growth measurements by using the Interpolation Method.

Plotting Interpolation Method:

a. Birth - 36 Month Growth Chart - Calculate exact age (to nearest week) and plot measurement into the space at the point nearest to the age.
b. 2 - 18 Years Growth Chart - Calculate exact age (to nearest month) and plot measurement into space at the point nearest to the age.

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.

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GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

Appendix L (cont.)

6. To plot the length or height/weight chart:

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 Body Mass Index (BMI) for age:

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

b. Using a straight-edge, line up as closely as possibly the measured BMI and mark the point where the two (2) lines intersect.

8. 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.

9. Calculating Gestation-Adjusted Age:

a. Document the infant's gestational age in weeks. (Mother/caregiver can self report, or referral information from the medical provider may be used.)

b. Subtract the child's gestational age in weeks from 40 weeks (gestational age of term infant) to determine the adjustment for prematurity in weeks.

c. Subtract the adjustment for prematurity in weeks from the child's chronological postnatal age in weeks to determine the child's gestation-adjusted age.

d. For WIC nutrition risk determination, adjustment for gestational age should be calculated for all premature infants for the first 2 years of life.

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GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

Appendix L (cont.)

Example: Randy was born prematurely on March 19, 2001. His gestational age at birth was determined to be 30 weeks based on ultrasonographic examination. At the time of the June 11, 2001 clinic visit, his chronological postnatal age is 12 weeks. What is his gestation-adjusted age?

30 = gestational age in weeks 40 30 = 10 weeks adjustment for prematurity 12 10 = 2 weeks gestation-adjusted age

Measurements would be plotted on a growth chart as a 2-week-old infant.

10. Plotting for Prematurity:

For all premature infants and children <24 months plot adjusted and actual age.

a. Infant Plot- (weight/age, Length/age, length/weight)

b. Child Plot- (weight/age, height/age, BMI)

11. The formula for calculating BMI for age is:

[weight (lb.) y height (in.) y 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.

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

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GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT- 6 (cont'd)

Guidance for Rounding to One Decimal Point:

Appendix L (cont.)

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

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Attachment CT- 6 (cont'd)

Appendix M

USE AND INTERPRETATION OF THE CHILD GROWTH CHARTS

PLOTTING
1. Standing height and weight must be plotted on the 2-18 Years growth charts. 2. Recumbent length and weight must be plotted on the 0-36 Months growth charts. 3. When a measurement cannot be plotted, a notation to this effect must be noted in the
health record or on the growth chart. This measurement may not be used as a risk criterion. See the following example:
Standing height is measured on a 26-month old child. The child is 34 7/8 inches tall. Two options may be taken:
a. Re-measure the child on the recumbent board, and plot length on the 0-36 months growth chart; OR
b. Make a notation in the health record that the height of the child cannot be plotted on the 2-18 years growth chart.

INTERPRETATION
1. Pattern of growth can only be interpreted when two sets of measurements are plotted on the same growth grid. If one set of measurements are plotted on the 0-36 months growth charts and the next set of measurements on the 2-18 years growth charts, these measurements cannot be used to interpret the pattern of growth of the child.

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Attachment CT- 6 (cont'd)

Food Source Apricots
canned dried raw
Bok Choy
Broccoli cooked raw
Carrots cooked raw
Cantaloupe, cubed
Endive, raw
Greens, fresh, cooked beet collards kale turnip spinach
Liver, beef
Mango, raw
Papaya, raw
Parsley, chopped
Peaches canned, juice pack raw dried
Persimmon, raw
Pumpkin, canned
Sweet Potato, baked
Watercress, raw Winter Squash, baked

FOOD SOURCES OF VITAMIN A

Appendix N

Serving Size

Vitamin A (mcg Retinol)*

3 halves

140

10 halves

250

3 medium

280

1 cup

110

1 cup

110

1 cup

680

1cup 1 medium
1 cup
1cup

1920 2030
520
50

1cup 1cup 1cup 1cup 1cup
3 ounces
1 medium
1 medium
1cup

370 350 480 400 740
10,600
810
620
160

1 cup 1 medium 10 halves
1 medium
1cup
1 medium
1cup 1cup

100 50 280
360
2690
2490
80 240

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GEORGIA WIC 2012 PROCEDURES MANUAL
*Micrograms of retinol equivalent: rounded to the nearest 10

FOOD SOURCES OF VITAMIN C

Food Source

Serving Size

Broccoli, chopped cooked raw

1/2 cup 1/2 cup

Cantaloupe, raw

1 cup, pieces

Green Pepper

1/2 medium

Grapefruit juice**, from concentrate raw

1/2 cup 1/2 medium

Mango, raw

1 medium

Orange juice**, from concentrate raw (navel)

1/2 cup 1 medium

Strawberries, raw

1 cup

Tomato, raw
*Milligrams Vitamin C: rounded to nearest 10 **Items distributed through Georgia WIC.

1 medium

Attachment CT- 6 (cont'd)
Appendix O
Vitamin C (mg)*
60 40 70 40
40 50 60
50 80 90 20

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Attachment CT- 6 (cont'd)

Selected Food Sources of Folate and Folic Acid

Food Source / Serving Size

Micrograms (g)

*Breakfast cereals fortified with 100% of the DV, cup

400

Beef liver, cooked, braised, 3 ounces

185

Cowpeas (blackeyes), immature, cooked, boiled, cup

105

*Breakfast cereals, fortified with 25% of the DV, cup

100

Spinach, frozen, cooked, boiled, cup

100

Great Northern beans, boiled, cup

90

Asparagus, boiled, 4 spears

85

*Rice, white, long-grain, parboiled, enriched, cooked, cup

65

Vegetarian baked beans, canned, 1 cup

60

Spinach, raw, 1 cup

60

Green peas, frozen, boiled, cup

50

Broccoli, chopped, frozen, cooked, cup

50

*Egg noodles, cooked, enriched, cup

50

Broccoli, raw, 2 spears (each 5 inches long)

45

Avocado, raw, all varieties, sliced, cup sliced

45

Peanuts, all types, dry roasted, 1 ounce

40

Lettuce, Romaine, shredded, cup

40

Wheat germ, crude, 2 Tablespoons

40

Tomato Juice, canned, 6 ounces

35

Orange juice, chilled, includes concentrate, cup

35

Turnip greens, frozen, cooked, boiled, cup

30

Orange, all commercial varieties, fresh, 1 small

30

*Bread, white, 1 slice

25

*Bread, whole wheat, 1 slice

25

Egg, whole, raw, fresh, 1 large

25

Cantaloupe, raw, medium

25

Papaya, raw, cup cubes

25

Banana, raw, 1 medium

20

Appendix P
% DV^ 100 45 25 25 25 20 20 15 15 15 15 15 15 10 10 10 10 10 10 10 8 8 6 6 6 6 6 6

* Items marked with an asterisk (*) are fortified with folic acid as part of the Folate Fortification Program. ^ DV = Daily Value. DVs are reference numbers developed by the Food and Drug Administration (FDA) to help consumers determine if a food contains a lot or a little of a specific nutrient. The DV for folate is 400 micrograms (g). Most food labels do not list a food's magnesium content. The percent DV (%DV) listed on the table indicates the percentage of the DV provided in one serving. A food providing 5% of the DV or less is a low source while a food that provides 10-19% of the DV is a good source. A food that provides 20% or more of the DV is high in that nutrient. It is important to remember that foods that provide lower percentages of the DV also contribute to a healthful diet. For foods not listed in this table, please refer to the U.S. Department of Agriculture's Nutrient Database Web site: http://www.nal.usda.gov/fnic/cgi-bin/nut_search.pl.

Sources: U.S. Department of Agriculture, Agricultural Research Service. 2003. USDA National Nutrient
Database for Standard Reference, Release 16. Nutrient Data Laboratory Home Page, http://www.nal.usda.gov/fnic/cgi-bin/nut_search.pl

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FOOD SOURCES OF IRON

Food Source Iron Fortified Breakfast Cereal* Canned Clams Cooked Oysters Blackstrap Molasses Liver Baked Beans Spinach Red Meat Prunes Raisins Pork Turkey Baked Potato with skin Ham Legumes, cooked* Raw Shrimp Baked Winter Squash Berries Turnip or Collard Greens Liverwurst Chicken Fish Prune Juice
*Items distributed through Georgia WIC.

Serving Size
cup
1/3 cup 3 oz
1 Tbsp. 2 ounces
1 cup 1 cup 3 ounces 10 large 1/2 cup 3 ounces 3 ounces
1 3 ounces 1/2 cup 3 ounces
1 cup 1 cup 1 cup 1 slice 3 ounces 3 ounces 1/3 cup

Attachment CT- 6 (cont'd)
Appendix Q
Iron (mg) 8-18
11 7 5 5 5 4 3 3 3 3 3 3 2 2 2 2 1.5 2 1.5 1 1 1 1

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Attachment CT- 6 (cont'd)
Appendix R

MILK GROUP

FOOD SOURCES OF CALCIUM

250 mg

150-249 mg

75-149 mg

Milks - 1 cup Whole - 291 mg 1% lowfat - 300 mg 2% lowfat 297 mg Skim - 302 mg Buttermilk - 285 mg Chocolate 284 mg Malted - 348 mg
Swiss Cheeses 272 mg Ricotta, part skim, c - 337 mg Milkshakes - 1 cup
Chocolate 397 mg Vanilla 457 mg Yogurt, lowfat - 1 cup Plain 415 mg Flavored 380 mg Fruit 345 mg

Cheeses - 1 oz. American, processed, 174 mg Blue 150 mg Brick 191 mg Caraway 204 mg Cheddar 204 mg Colby 194 mg Edam 207 mg Monterey 212 mg Mozzarella, part skim 183 mg Muenster 203 mg
Cheese food American, processed, 163 mg Swiss, processed 205 mg

Cottage Cheese, 2% Lowfat, c, 75 mg Frozen desserts c
Ice cream 88 mg Ice milk, hardened, 88 mg Ice Milk, soft serve, 137 mg Pudding, 133 mg

MEAT/PROTEIN GROUP

Sardines, with bones, 3 oz, 372 mg Tofu, firm processed with calcium- sulfate, 4 oz, 250-765 mg

Salmon, with bones 167 mg. - 3 oz Sesame seeds 2 TB, 176 mg.

Beans, dried, cooked, 90 mg. - 1 c Oysters, 7-9, 113 mg Shrimp, canned, 3 oz, 100 mg Tofu, soft, c, 145 mg Tahini (sesame butter) 2 TB, 128 mg. Soybeans, 8 oz, 64 mg Soy beverage, 8 oz, 64 mg Almonds, 1 oz, 75 mg

VEGETABLE GROUP

Cooked, 1 cup Collards, 357 mg Rhubarb, 348 mg Spinach, 278 mg Bok Choy, 252 mg

Cooked, 1 cup Kale, 200 mg Mustard greens, 200 mg Turnip greens, 249 mg

Cooked, 1 cup Okra, 176 mg Broccoli, 90 mg

FRUIT

Figs, dried or fresh 5 med, 135 mg. Papaya, raw 1 med, 72 mg. Sapote, raw 1 med, 88 mg. Tamarind, raw - 1 c, 89 mg.

GRAIN GROUP

Waffle, 7" diameter, 179 mg

Cornbread, 2" square , 94 mg Pancakes, 2-4" diameter, 116 mg

"OTHERS" Category fats, sweets, alcohol

Molasses, Blackstrap, 2 Tbsp., 274 mg

COMBINATION FOODS: Foods made with ingredients from more than one food group

Cheese pizza, of 14" pie, 332 mg

Macaroni and cheese, c c, 181 mg Soups made with milk - 1 c
Cream of mushroom , 191 mg Cream of tomato, 168 mg Taco, beef, 174 mg

Chili con carne with beans, 1 c, 82 mg Custard, baked, c, 148 mg Spaghetti, meatballs, tomato sauce, and cheese, 1 c, 124 mg

Sources: (1) Pennington, JAT. Bowes & Church's Food Values of Portions Commonly Used. 16th edition. Philadelphia, PA: J.B. Lippincott Co.; 1994. (2) Georgia Dietetic Association Diet Manual. Georgia Dietetic Association, Inc. Fourth edition, 1992. (3) National Osteoporosis Foundation 1991.

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Attachment CT- 6 (cont'd)
Appendix S

Herbs
Chamomile
Ginseng Mandrake Pennyroyal oil
Sassafras Tonka beans, melilot, sweet woodruff (tea) Devil's claw root
Ginger root tea

HERBS: THEIR USE AND POTENTIAL RISKS

Use

Risks

Relaxant

May cause allergic reaction (up to anaphylactic shock in allergic individuals).

Health food remedy

Painful, swollen breasts

Sold falsely as Ginseng

Contains scopolamine

Abortifacient

Toxicity, teratogenesis, increased risk of medical abortion, hepatotoxin, coma death

Tonic for a variety of unsubstantiated uses

Possible carcinogenesis

Seasonal tonic

Hemorrhage

Abortifacient Morning sickness remedy

Sodium and water retention, hypokalemia, hypertension, cardiac failure/arrest
Unknown - very large doses may cause depression of CNS, and cardiac arrhythmias.

There is insufficient information on many herbs that women may want to use during pregnancy and lactation. Herbs have been used as remedies for years and in many cases some may be beneficial. The problems that might arise may be dose related, which could affect the fetus and growing infant. A safe level or dangerous level is generally not known for use in pregnancy and lactation; avoidance of most herbs is usually the best practice. In addition to the herbs listed above, the following herbs are recommended NOT to be used during pregnancy and lactation:

Angelica Black Cohosh Blessed Thistle Calendula Dong Quai

Elecampane Gotu kola Juniper Berries Motherwart Myrrh

Sources:

Dimperio, Diane: Florida Department of Health and Rehabilitative Services, Florida's Guide to Maternal Nutrition, 1986.
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Attachment CT- 6 (cont'd)

Tenney, Louise: Today's Herbal Health, 3rd Edition, Woodland Books, Utah, 1992.

Tyler, Varro E.: The Honest Herbal, 3rd Edition, Pharmaceutical Products Press, New York, 1993.

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Attachment CT- 6 (cont'd)

Appendix T

KEY FOR ENTERING WEEKS BREASTFED

The number of weeks breastfed must be manually entered when completing paper WIC Assessment/Certification Forms and paper Turnaround Documents for:

- Breastfeeding women: initial and six month certification visits - Postpartum, non-breastfeeding women: certification visit - Infants: initial certification and mid-certification nutrition assessments - Children: initial certification and subsequent certification, until the answer is "No"

Length of time breastfed must be entered in weeks (two-digit). When the answer to the question "How long have you breastfed this infant?" OR "How long has this infant 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

Convert Days to Weeks

Fewer than 7 days

= 00 weeks

7 - 13 days

= 01 week

14 20 days

= 02 weeks

21 27 days

= 03 weeks

28 34 days

= 04 weeks

35 41 days

= 05 weeks

42 48 days

= 06 weeks

Source:

Georgia WIC Branch ETAD Change Number 08-12b, 2008.

II. Codes to Enter When Breastfeeding is Given in Months

1 month 2 months 3 months 4 Months 5 Months 6 Months 7 Months 8 Months 9 Months 10 Months 11 Months

= 04 weeks = 08 weeks = 13 weeks = 17 weeks = 22 weeks = 26 weeks = 30 weeks = 35 weeks = 39 weeks = 43 weeks = 48 weeks

12 Months 13 Months 14 Months 15 Months 16 Months 17 Months 18 Months 19 Months 20 Months 21 Months 22 Months 22.5 Months +

= 52 weeks = 56 weeks = 61 weeks = 65 weeks = 69 weeks = 74 weeks = 78 weeks = 82 weeks = 87 weeks = 91 weeks = 96 weeks = 98 weeks or more

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. February 2000.

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Attachment CT- 6 (cont'd)
Appendix U

Infant Formula Preparation
GENERAL INFORMATION
1. Before starting, wash hands with soap and water. Rinse well.
2. Wash bottles and nipples using brushes made for bottles and nipples. Wash caps, rings and preparation utensils such as spoons, pitchers, etc. Use hot soapy water. Rinse well.
3. Squeeze clean water through the nipple holes to be sure they are open.
4. Put the bottles, nipples, caps and rings and other utensils in a pot and cover with water. Heat on the stove, bring to a boil; boil for 5 minutes. Remove from heat and let cool. OR Put all items in a properly functioning dishwasher and run it at the normal temperature (not the low or economy temperature setting).
5. The most important time to boil bottles, nipples and formula preparation items for the infant is through 3 months of age. Also, the most important time to boil the water used in formula preparation is through 3 months of age. If there is any doubt about the safety of the water supply or the cleanliness of the home, then continue to sterilize the equipment and to boil the water used in formula preparation.
6. Boil water for 2 minutes before using to prepare formula. Prolonged boiling of water (greater than 5-6 minutes) is not recommended because some trace contaminates in the water such as lead, nitrates, or even trace minerals may concentrate in the boiled water as the liquid water is reduced.
7. Do not feed an infant a bottle left out of the refrigerator for more than 1 hour.
8. For infants who prefer a warmed bottle, hold the bottle under warm running tap water. Shake well and test the temperature before giving to the infant. Do not use microwave oven to prepare or to warm formula. Formula heated in the microwave may result in serious burns to the infant.
9. When using formula:
x Check the formula's expiration date prior to use. Do not use if the date has passed. x Avoid using cans of infant formula that have dents, leaks, bulges or puffed ends or rust
spots. x Store cans of infant formula in a cool place, indoors. Do not store in vehicles, garages or
outdoors. x For more information, see the following references:
i Infant formula cans - commercial brands. i United States Dept. of Agriculture, Food and Nutrition Service. Infant Nutrition
and Feeding, a Reference Handbook for Nutritional Health Counselors in the WIC and CSF Programs. FNS-288, September 1993. USDA, FNS, Alexandria,

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Attachment CT- 6 (cont'd)

Virginia 22302-1594. (U.S. Gov. Printing Office: 1994-0-360-395 QL.3).

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Attachment CT- 6 (cont'd)
Appendix U (cont.)

Infant Formula Preparation

PREPARATION FROM CONCENTRATED LIQUID FORMULA

1. Boil for 5 minutes all bottles, nipples, rings and utensils to be used; let cool. 2. Heat water for formula on stove to a rolling boil for 2 minutes; let cool. 3. Wash top of the can with soap and water; rinse well. Wash the can opener. 4. Shake can well before opening. 5. Open can and pour formula into a clean bottle using ounce markings to measure amount of
formula. Add an equal amount of the cooled boiled water. Example: For 4 ounces of concentrated formula poured into the bottle, add 4 ounces of water. Shake or stir again. 6. To store: cover container or bottles and refrigerate. Use within 48 hours. If more than one bottle is prepared, put the nipples in upside down on each bottle. Cover the nipple with a cap and screw on the ring. 7. After feeding, throw away any formula left in bottle or cup, as this can contain germs.

Note:

Do not use microwave oven to prepare or to warm formula. Formula heated in the microwave may result in burns.

PREPARATION OF READY-TO-FEED FORMULA

1. Boil for 5 minutes all bottles, nipples, rings and utensils to be used; let cool. 2. Wash top of the can with soap and water; rinse well. Wash the can opener. 3. Shake can very well. Open with a clean punch-type can opener. 4. Pour the amount of ready-to-feed formula for one feeding into a clean bottle.

Note:

Do not add water or any other liquid to this formula.

5. Attach nipple and cap. Shake well again and feed infant.

6. If more than one bottle is prepared, put the nipples in upside down on each bottle. Cover the nipple with a cap and screw on the ring. Refrigerate. If formula is left in opened can, cover and refrigerate. Use within 48 hours. Shake can again before pouring; or shake bottles before serving.

Note:

Do not use microwave oven to prepare or to warm formula. Formula heated in the microwave may result in burns.

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Attachment CT- 6 (cont'd)
Appendix U (cont.)

Infant Formula Preparation

Preparation from Powdered Formula

1. Boil for 5 minutes all bottles, nipples, rings and utensils to be used; let cool. 2. Heat water for formula on stove to a rolling boil for 2 minutes; let cool to a warm temperature. 3. Remove plastic lid from can; wipe it off if dusty. Wash top of can with soap and water; rinse
well and dry it. Wash can opener. Do not let water get into the can. 4. Pour the warm water into the bottle(s). Use only the scoop that comes with the formula can
(8.7 gm). The scoop should be totally dry before scooping out the powdered formula. Add 1 level scoop of the powdered formula for each 2 oz of warm water in the bottle(s). Example: If 8 ounces of water is poured in the bottle, then 4 level scoops of formula should be added. 5. Put nipples and rings on bottle and shake well. If feeding immediately, check temperature and then feed. After feeding, throw away formula left in bottle or cup, as this can contain germs. 6. Store filled bottles in refrigerator and use within 24 hours. Put a clean nipple upside down on each bottle. Cover the nipple with a cap and screw on the ring. 7. Do not store can containing the dry powdered formula in the refrigerator. Keep it covered and store in a cool, dry place; avoid temperature extremes. Use can within one month after opening.

Note:

Do not use microwave oven to prepare or to warm formula. Formula heated in the microwave may result in burns.

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Attachment CT- 6 (cont'd)
Appendix V-1

CONVERSION TABLES AND EQUIVALENTS

I. TABLE OF EQUIVALENTS
3 teaspoon (tsp.) 2 Tbsp. 8 oz. 16 Tbsp. 2 c. 2 pts. 4 c. 4 qts.
II. METRIC SYSTEM

= 1 Tablespoon (Tbsp.)
= 1 ounce (oz)
= 1 cup (c.)
= 1 c. = 1 pint (pt.) = 1 quart (qt.) = 1 qt. = 1 gallon (gal.) = 128 oz.

A.

APPROXIMATE WEIGHTS/MEASURES

20 drops 1 ml. 1 ml. 1 tsp. 1 Tbsp. 1 oz., fluid 1 cup, fluid 1 oz., weight 1 c., weight 1 pound (lb.) 2.2 lbs. 33 oz. 1.1 qts.

= 1 milliliter (ml.)
= 1 gram (g.)
= 1 cubic centimeter (cc)
= 5 ml. = 5 cc = 5 g. = 15 ml. = 15 cc = 15 g. = 29.57 ml. = 30 cc = 240 ml. = 28.35 g. (approx 30) = 240 g. = 453.6 g. = 1 kilogram (kg.) = 1 liter (L.) = 1000 ml = 1 liter

B.

WEIGHTS

1 milligram 1 gram (g) 1 kilogram

= 1000 micrograms (mcg) = 1000 mg. = 1000 g.

C.

CONVERSIONS

To convert ounces to grams multiply by 30. To convert grams to ounces divide by 30. To convert pounds to kilograms divide by 2.2. To convert kilograms to pounds multiply by 2.2. To convert inches to centimeters multiply by 2.54.

References: Georgia Dietetic Association, Inc., Diet Manual, 4th edition, 1992.

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Attachment CT- 6 (cont'd)
Appendix V-2

APPROXIMATE METRIC AND IMPERIAL EQUIVALENTS

Useful approximate metric and imperial equivalents

1 cm = 0.39 in 1 meter = 1.1 yd.

1 in = 2.54 cm 1 ft = 30.48 cm

To convert centimeters to inches Divide the length in centimeters by 2.54. Example: The average newborn infant measures 50.89 cm:
50.89 cm: 2.54 cm/in = 20 in To convert inches to centimeters Multiply the length in inches by 2.54 Example: The average newborn infant measures 20 in:
20 in x 2.54 cm/in = 50.8 cm

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Attachment CT-7

Infant Nutrition Questionnaire English (page 1)

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GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT-7 (cont'd)

Infant Nutrition Questionnaire English (page 2)

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Attachment CT-7 (cont'd)

Infant Nutrition Questionnaire Spanish (page 1)

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GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT-7 (cont'd)

Infant Nutrition Questionnaire Spanish (page 2)

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Attachment CT-7 (cont'd)

Child Nutrition Questionnaire English (page 1)

CT-224

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT-7 (cont'd)

Child Nutrition Questionnaire English (page 2)

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GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT-7 (cont'd)

Child Nutrition Questionnaire Spanish (page 1)

CT-226

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT-7 (cont'd)

Child Nutrition Questionnaire Spanish (page 2)

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GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT-7 (cont'd)

Woman Nutrition Questionnaire English (page 1)

CT-228

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT-7 (cont'd)

Woman Nutrition Questionnaire English (page 2)

CT-229

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT-7 (cont'd)

Woman Nutrition Questionnaire Spanish (page 1)

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GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT-7 (cont'd)

Woman Nutrition Questionnaire Spanish (page 2)

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GEORGIA WIC 2012 PROCEDURES MANUAL


Attachment CT-8

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 Office of Nutrition 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.

Georgia's WIC 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.

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

Covansys 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.

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, it must be re-checked at each subsequent certification until it becomes normal.

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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Attachment CT-8 (cont'd)

It is recommended that hematological equipment be checked for accuracy (balanced/calibrated) according to a regular schedule, based on usage. Follow the manufacturer's instructions for regular calibration of the equipment for machines that do not perform routine/daily self-calibration tests.



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Participant Transfer Log (Optional)
District __ Unit__ Clinic____

Participant Name


Date

Date

Record Record

Requested Received









































































CT-234

Agency Contact Information

Attachment CT-9
Received Yes/No


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT-10



CT-235

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT-10 (cont'd)





CT-236

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT-10 (cont'd)





CT-237

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT-11

CT-238

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT-11 (cont'd)


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GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT-12

SIGNED STATEMENT OF INCOME, RESIDENCY AND IDENTIFICATION PROXY LETTER
I (Parent/guardian) _____________________________, cannot come in to apply for WIC services for my child (ren) _______________________________________. I have given permission to (name of proxy) _____________________________ to apply for WIC for my child (ren). The number of people in my family is ___________ ("Family" means related or non-related individuals living together), and the monthly household income is _____________. The requested documentation listed below is attached.

Parent/guardian signature

Date

The proxy must provide the following documentation for recertification appointments:
1. Proxy Form 2. The Participant's WIC ID card 3. Participant's ID (Birth Certificate, Immunization record, e.g.) 4. Parent/Guardian or Participant's current Medicaid, SNAP (formally Food Stamps)
Letter or TANF Letter 5. If there is no proof of Medicaid, please provide proof of income (Pay Stubs,
Alimony, Social Security, Child Support, Current Year Income Tax, e.g.) 6. Proof of Residency 7. Proxy Identification (Current) 8. Knowledge of child(ren) health and diet 9. Knowledge of proxy responsibilities
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.
To file a complaint of discrimination, write USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call toll free (866) 6329992 (Voice). Individuals who are hearing impaired or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish)." USDA is an equal opportunity provider and employer.
Revised 3/11
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Attachment CT-13

Georgia Special Supplemental Nutrition Program for Women, Infants and Children (WIC) INCOME ELIGIBLE GUIDELINES
(Effective from July 1, 2009 to June 30, 2012)
Reduced Price Meals 185% of Federal Poverty Guidelines 48 Contiguous States

Household Size 1................ 2................ 3................ 4................ 5................ 6................ 7................. 8................. 9................. 10................ 11................ 12................ 13................ 14................ 15................ 16................
Each Add'l Family Member, add

Annual $20,147 27,214 34,281 41,348 48,415 55,482 62,549 69,616 76,683 83,750 90,817 97,884 104,951 112,018 119,085 126,152
+$7,067

Monthly $1,679 2,268 2,857 3,446 4,035 4,624 5,213 5,802 6,391 6,980 7,569 8,157 8,746 9,335 9,924 10,513
+$589

Twice-monthly $840 1,134 1,429 1,723 2,018 2,312 2,607 2,901 3,196 3,490 3,785 4,079 4,373 4,668 4,962 5,257
+$295

Bi-weekly $775 1,047 1,319 1,591 1,863 2,134 2,406 2,678 2,950 3,222 3,493 3,765 4,037 4,309 4,581 4,852
+$272

Weekly $388 524 660 796 932 1,067 1,203 1,339 1,475 1,611 1,747 1,883 2,019 2,155 2,291 2,426
+$136

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Attachment CT-14

GEORGIA WIC NOTICE OF TERMINATION / INELIGIBILITY / WAITING LIST

NAME:

DATE: _______________________________ DATE OF BIRTH:

ADDRESS:

CITY/ZIP CODE:

PHONE NUMBER:

TERMINATION/INELIGIBILITY SECTION:
You are not eligible for Georgia WIC because you:
You are being terminated from Georgia WIC because you:
______ have an income that is too high for Georgia WIC ______ do not live in the area served by Georgia WIC. ______ 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 Georgia WIC for three (3) months because you broke the following Georgia WIC 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___________________.
x You may still receive nutritional education and other services provided by the Health Department. x If you need information or would like to discuss this decision, please contact Georgia WIC 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:

___________________________________________________________________

Georgia WIC

___________________________________________________________________________

ADDRESS

_____________________________________________/______________________________

CITY/ZIP CODE

PHONE NUMBER

________________________________________________________________________

SIGNATURE/PARENT/CAREGIVER/GUARDIAN

WIC RESPRENTATIVE SIGNATURE/TITLE



"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.

To file a complaint of discrimination, write USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call toll free (866) 632-9992 (Voice). Individuals who are hearing impaired or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish)." USDA is an equal opportunity provider and employer.

Revised 3/11

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Attachment CT-15

EL PROGRAMA WIC DE GEORGIA NOTICIA DE DECONTINUACIN / INELIGIBILIDAD /LISTA DE ESPERA

NOMBRE:

Fecha: ______________________ FECHA DE NACIMIENTO:

DIRECCION:

CIUDAD / CODIGO POSTAL

NUMERO DE TELFONO:

SECCIN DE DESCONTINUACION / DESCUALIFICACION:
Usted no es seleccionada para el programa WIC porque:
Usted ha sido descualificada del programa WIC porque:
_______ Tiene un ingresso muy alto para el Programa WIC _______ No vive en el area servida por el Programa WIC _______ No es una mujer embarazada, acaba de dar a luz, esta dando pecho a su bebe; o tiene un
nio (a) menor de (5) os de edad. _______ No tiene problemas de salud o nutricin _______ No regreso a la clinica para su cita de qualificacin el _______________________ (fecha). _______ No recogi sus cupones para comida por 2 meses. Usted ser descualificada el _______ ____________________________ (fecha).
Otro _________ los fondos no son disponible para servir a mujeres desups del parto no amamantando.

SECCIN DE SUSPENCION:

Usted ha sido suspendida del Programa WIC por tres (3) meses porque rompio la(s) siguiente(s) regla(s)

SECCIN DE LISTA DE ESPERA:

Usted ha sido puesta en la lista de espera. No hay fondos disponibles para servir la prioridad
____________________. Usted esta en la proirdad ________________________________ x Usted puedo recibir education nutritiva y otros servicios provistos por el Departamento
de Salud. x Si necesita ms informacin o quisiera discutir esta decision, por favor llame a la oficina del
Programa WIC a la direccin abajo:

SECCIN DE JUICIO IMPARCIAL:

Usted tiene derecho a un juicio imparcial si no esta de acuerdo con la razon para la seleccin de su

puesto en al Noticia de Decontinuacin / Ineligibilidad / Lista de Espera. La peticin para un juicio

imparcial tiene que hacerce por escrito antes de 60 das a partir de la fecha de esta notificacin. La

peticin debe ser dirigida a:

_______________________________________________________________

PROGRAMA WIC

_______________________________________________________________

DIRECCION

_______________________________________________________________

CIUDAD / CODIGO POSTAL

# DE TELEFONO

_______________________________________

_________________________________

Firma del Participante / Padre o Madre

Firma del Representante

"En concordancia con la Ley Federal y con las Polticas del Departamento de Agricultura de los E.E.U.U., esta institucin

tiene prohibido el discriminar en base a raza, color, nacionalidad, sexo, edad o discapacidad.

Para iniciar una queja por discriminacin, escriba a USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW,

Washington, D.C. 20250-9410 o llame sin cargos al (866) 632-9992 (voz). Individuos con discapacidad auditiva o

discapacidad del habla pueden contactar al USDA a travs del Servicio de Relevo Federal (Federal Relay Service) al (800)

977-8339; o al (800) 845-6136 (espaol)."

USDA es un proveedor y empleador de igualdad de oportunidades.

Revised 3/11



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Attachment CT-16

CT-244

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT-17

CT-245

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT-18

CT-246

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT-19

DISTRICT

Date Beginning Ending

No.

Card

No.

No. Received No.

Issued

CLINIC VOC CARD INVENTORY LOG
GEORGIA WIC
VOC CARD INVENTORY LOG

CLINIC

Participants Name (Print)

WIC ID Number

Signature of Parent, Guardian or Caregiver

City State*

Total No. of Cards
on Hand

Staff Signature

Staff Initials

Note: A Physical Inventory of VOC cards must be performed by the local agency and clinics quarterly. One staff member must conduct the inventory (sign the Log) and a second member must verify the accuracy of the inventory (initial the Log).
* 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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GEORGIA WIC 2012 PROCEDURES MANUAL


DISTRICT

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

Date Beginning Ending

No.

No.

No.

No. Received Issued

Clinic Name (Print)

Name of Clinic Representative

Total No. of Cards
on Hand

Attachment CT-20

Staff Signature

Staff Initials

Note: A Physical Inventory of VOC cards must be performed by the local agency and clinics quarterly. One staff member must conduct the inventory (sign the Log) and a second member must verify the accuracy of the inventory (initial the Log).
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Attachment CT-21

GEORGIA WIC
VOC CARD AGREEMENT
District ______, Unit ______ would like to have a clinic representative order VOC Cards directly from Georgia WIC.
In order to accommodate this request, please complete the VOC CARD FORM, located in the Certification Section of the Georgia WIC Procedure Manual.

Signed________________________________ Nutrition Services Director

Date_____________

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

CT-249

GEORGIA WIC 2012 PROCEDURES MANUAL
GEORGIA WIC
VOC CARD FORM

Attachment CT-22

District ____, Unit ____
In an effort to begin sending VOC cards directly to the clinic from Georgia WIC, the following form must be on record at Georgia WIC.
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-250

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT-23

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-251

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT-24

GEORGIA WIC STATE/DISTRICT/CLINIC TRANSMITTAL FORM
The State/District Clinic Transmittal Form is a three (3) part form used to transmit VOC Cards from Georgia WIC to the Clinic. This Form must be signed by clinic staff within five (5) days of Receipt then returned to sender. Georgia WIC 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

CT-252

GEORGIA WIC 2012 PROCEDURES MANUAL

MEDICAID INFORMATION

Attachment CT-25

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 nontraditional 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-253

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT-26

THERE IS NO CHARGE FOR WIC SERVICES

GEORGIA WIC

PROMOTING HEALTHLY NUTRITION FOR WOMEN, INFANTS AND CHILDREN
SINCE 1974

1-800-228-9173

"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.

To file a complaint of discrimination, write USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call toll free (866) 6329992 (Voice). Individuals who are hearing impaired or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish)." USDA is an equal opportunity provider and employer.

Revised 3/11

CT-254

GEORGIA WIC 2012 PROCEDURES MANUAL


Attachment CT-27

Georgia WIC
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 Georgia WIC. 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. "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.
To file a complaint of discrimination, write USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call toll free (866) 6329992 (Voice). Individuals who are hearing impaired or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish)." USDA is an equal opportunity provider and employer.
Revised 3/11

CT-255

GEORGIA WIC 2012 PROCEDURES MANUAL

GEORGIA WIC NO PROOF FORM

Attachment CT-28

Georgia WIC requires each applicant to show documentation of identification, residence (address), and income to be eligible for Georgia WIC. This form is to be completed by those who cannot 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: Identification (circle the appropriate proof (s))

Income

Address

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)

"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.
To file a complaint of discrimination, write USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call toll free (866) 632-9992 (Voice). Individuals who are hearing impaired or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish)." USDA is an equal opportunity provider and employer.
Revised 3/11
CT-256

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT-29

FAMILYPLUSMEDICAIDCARD

BENEFIT DESCRIPTION

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

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

CO-PAY

FamilyPlus*

MEMBER # 403967045P

EFF DATE 02/01/98

GROUP# M00101 BIRTH

MEDICAID OF GA 06/03/94 F (404) 525-0600

*CALL YOUR PCP TO COORDINATE NETWORK

*ATLANTA CHILDREN'S HEALTH

*ALL OF YOUR HEALTHCARE NEED

*The family of health plans that fits.



CT-257

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT-30

GEORGIA WIC DISCLOSURE STATEMENT

All Health Department Staff who performs WIC services 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 Georgia's WIC?

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

_________Yes

__________No

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

"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.
To file a complaint of discrimination, write USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call toll free (866) 632-9992 (Voice). Individuals who are hearing impaired or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish)." USDA is an equal opportunity provider and employer.

Revised 3/11

CT-258

GEORGIA WIC 2012 PROCEDURES MANUAL


Attachment CT-31

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

Last

First

Middle Initial

Date of Birth

NAME

___________________________________________________________________________________________________________

City

Zip Code

ADDRESS__________________________________________________________________________________________________

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

First Certification
Relationship and Name
__________________________ __________________________ __________________________ __________________________ __________________________

Income Source
__________ __________ __________ __________ __________

Use This Section to Calculate Income Date_______________________
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
__________________________ __________________________ __________________________ __________________________ __________________________

Income Source
__________ __________ __________ __________ __________

Use This Section to Calculate Income Date_______________________
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/CAREGIVER SIGNATURE

DATE

SIGNATURE OF WIC OFFICIAL (Who assessed income)

Please place this form in the Client's Medical Record behind the Certification Form
"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. To file a complaint of discrimination, write USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call toll free (866) 632-9992 (Voice). Individuals who are hearing impaired or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish)." USDA is an equal opportunity provider and employer. Revised 3/11



CT-259

GEORGIA WIC 2012 PROCEDURES MANUAL


Attachment CT-32

IDENTIFICATION, RESIDENCY & INCOME PROOF LIST
Help WIC help you!
"Proof of ID, residency and income is needed for each applicant/participant/guardian/caregiver and infant/child". Please call your local WIC department for any questions you may have. Whenever your child, infant or you need be certified for WIC, you must present proof of each of the following categories:
Proof of Identifications (One form of proof required)

Infant: Birth Certificate Confirmation of birth letter Hospital ID bracelet (mom & baby) Immunization Record Military ID Health Records Social Security Card Discharge of hospital papers EVOC/VOC Card (with Additional ID) Passport Card/Passport

Child:

Women:

Birth Certificate

Birth Certificate

Immunization Record

Driver's License

Health Records

Immunization Record

Social Security Card

Military ID

Military ID

Health Records

EVOC/VOC Card (with

Hospital ID bracelet (mom &

Additional ID)

baby)

Passport Card/Passport

Social Security Card

State ID/School ID

EVOC/VOC Card (with Additional

ID)

WIC ID (Voucher Pick Up Only)

Work ID

Passport Card/Passport

Proof of Residency (Address)

(One form of proof required)

Cable TV Bill

Gas Bill

Telephone Bill

Electric Bill

Water Bill

Rent/Mortgage Receipt

Medicaid (address must be visible during swipe or internet access) Health Record

(P.O. Box address is not acceptable)

Proof of Income (Bring proof of Income for each household member)

Alimony Pay Stub Annuities Pensions Basic Allowance from Private Pensions Child Support Payments Public Assistance/Welfare Payments (TANF) Contribution from people Current Tax Return

Rental Income (Net) Dividends or Interest on Bonds Self Employment (Net Income) Estate Income Social Security Financial Records Supplemental Social Security Supplement Nutrition Assistance Program (SNAP) Trust

Government Retirement Unemployment Compensation Letter from your Employer Unemployment Notice Medicaid Military Retirement Veteran's Payment Monetary Compensation Net Royalties

"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. To file a complaint of discrimination, write USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call toll free (866) 632-9992 (Voice). Individuals who are hearing impaired or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish)." USDA is an equal opportunity provider and employer. Revised 3/11

CT-260

GEORGIA WIC 2012 PROCEDURES MANUAL


Attachment CT-33

LISTA DE IDENTIFICACIN, RESIDENCIA Y COMPROBANTE DE INGRESOS
Ayude a que WIC le ayude!

"Comprobantes de identidad, residencia e ingresos son necesarios para cada solicitante, participante, representante legal, proveerdor de cuidados y para nios y bebs". Favor de llamara a su oficina local de WIC en caso de tener alguna pregunta. Cada vez que su nio(a), infante o usted necesite certificarse para WIC, usted debe presentar comprobantes de cada una de las siguientes categoras:

Comprobantes de Identificacin

(Se requiere un tipo de comprobante)

Infante:

Nio(a):

Mujeres:

Certificado de nacimiento Certificado de nacimiento Certificado de nacimiento

Carta de confirmacin de Historial de inmunizaciones Licencia de conducir

nacimiento

Bracelete de identificacin Historial de salud

Historial de inmunizaciones

del hospital (madre y beb)

Historial de inmunizaciones Tarjeta de Seguro Social Identificacin militar

Identificacin militar

Identificacin militar

Historial de salud

Historial de salud

Tarjetas EVOC/VOC (con Bracelete de identificacin

identificacin adicional)

del hospital (madre y beb)

Tarjeta de Seguro Social Tarjeta de

Tarjeta de Seguro Social

pasaporte/pasaporte

Documentos de dada de alta del hospital Tarjetas EVOC/VOC (con identificacin adicional) Tarjeta de pasaporte/pasaporte

Identificacin estatal, identificacin escolar Tarjetas EVOC/VOC (con identificacin adicional) Identificacin de WIC (slo para recoger el taln)

Identificacin laboral Tarjeta de pasaporte/pasaporte

Comprobantes de Residencia (Direccin)

(Se requiere un tipo de comprobante)

Recibo de televisin por

Recibo de gas

Recibo de telfono

cable

Recibo de electricidad

Recibo de agua

Recibo de alquiler / pago

de hipoteca

Medicaid (la direccin debe

Historial de salud

ser visible en la corrida o

acceso por internet)

(No se aceptan direcciones a cajas postales o P.O. Box)

Comprobantes de Ingresos

(Traiga comprobantes de ingresos para cada miembro del hogar)

Pensin alimentaria entre Ingresos por renta (neto) Retiro gubernamental

cnyuges

Talones de pago

Dividendos o intereses por Compensacin por

bonos

desempleo

CT-261

GEORGIA'S WIC 2012 PROCEDURES MANUAL


Anualidades
Pensiones Contribucin bsica proveniente de pensiones privadas Pagos de manutencin infantil Asistencia pblica/bienestar
Pagos (TANF)
Contribuciones provenientes de personas Declaracin actual de impuestos

Empleo Independiente (Ingreso Neto) Ingreso estatal Seguro Social
Historial financiero
Seguro Social suplementario Documentacin Suplemento Nutricin Asistencia Programa (SNAP) Fideicomiso

Attachment CT-33 (cont'd)
Carta del empleador Notificacin de desempleo Medicaid
Retiro militar Pago de Veterano Compensacin monetaria
Regalas netas

"En concordancia con la Ley Federal y con las Polticas del Departamento de Agricultura de los E.E.U.U., esta institucin tiene prohibido el discriminar en base a raza, color, nacionalidad, sexo, edad o discapacidad.
Para iniciar una queja por discriminacin, escriba a USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 o llame sin cargos al (866) 6329992 (voz). Individuos con discapacidad auditiva o discapacidad del habla pueden contactar al USDA a travs del Servicio de Relevo Federal (Federal Relay Service) al (800) 977-8339; o al (800) 845-6136 (espaol)." USDA es un proveedor y empleador de igualdad de oportunidades.
Revised 3/11

CT-262

GEORGIA WIC 2012 PROCEDURES MANUAL


Attachment CT-34

GEORGIA WIC Thirty (30) Day Certification/Termination Form
This Thirty (30) Day Certification Form allows you to be on Georgia WIC 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: ADDRESS: CITY/ZIPCODE:

DATE OF BIRTH: PHONE NUMBER:

_____ You will be terminated from Georgia WIC if you fail to bring in the following information by ______________. (date)
Proof of: _____ Family Income or _____Medicaid, TANF or Supplemental Nutrition Assistance Program (SNAP) Documentation (check one)

_____ Identification Client ____ Identification Parent/Guardian

________ Residency

WIC Representative _________________________________ Date__________________________
FAILURE TO BRING THIS DOCUMENTATION TO THE HEALTH DEPARTMENT ON OR BEFORE THE ABOVE DATE WILL RESULT IN TERMINATION FROM GEORGIA WIC

_____ You are being terminated from Georgia WIC because you have been found to be over income.

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:

_______________________________________________

Georgia WIC

_______________________________________________

Address

_______________________________________________

City/Zip Code

Phone Number

__________________________________________________________________________________

Participant Signature/Parent/Caregiver/Guardian

WIC Representative Signature/Title

"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.

To file a complaint of discrimination, write USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call toll free (866) 632-9992 (Voice). Individuals who are hearing impaired or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish)." USDA is an equal opportunity provider and employer. Revised 3/11



CT-263

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT-35

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-264

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT-36

WIC OVERSEAS PROGRAM CONTACTS
(as of April 2001)

x Lakenheath, England x Yokosuka, Japan x Baumholder, Germany
x Guantanamo Bay, Cuba

-- Nancy Czarzasty nancy.czarzasty@lakenheath.af.mil
-- Yokosuka Naval Hospital, Honshu, Japan Gina Gagui gaguig@nhyoko.med.navy.mil
-- 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
-- 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-265

GEORGIA WIC 2012 PROCEDURES MANUAL
PROOF OF RESIDENCY FORM FOR
APPLICANTS WITH P.O. BOX ADDRESS

Attachment CT-37

The WIC applicant must complete this form when giving a post office box address:

Directions to House

Participant Signature

Date

Participant Signature

Date

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

Date

"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.
To file a complaint of discrimination, write USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call toll free (866) 6329992 (Voice). Individuals who are hearing impaired or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish)." USDA is an equal opportunity provider and employer.
Revised 3/11
CT-266

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT-38

INCOME VERIFICATION LETTER

Date

Dear Mr/Ms:
It has been brought to the attention of Georgia WIC that the income reported in the clinic may not be accurate. In order to qualify for Georgia WIC, you must meet the income guidelines of Georgia WIC.
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 Georgia WIC, an investigation 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, sex, age or disability.
To file a complaint of discrimination, write USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call toll free (866) 6329992 (Voice). Individuals who are hearing impaired or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish)." USDA is an equal opportunity provider and employer.
Revised 3/11



CT-267

GEORGIA WIC 2012 PROCEDURES MANUAL

DEPARTMENT OF HEALTH GEORGIA OFFICE OF NUTRITION AND WIC
INCIDENT/COMPLAINT FORM

District/Unit/Clinic: Date of Incident:
Follow-up Date:

County: Date Reported:

Type of Complaint: Participant Vendor Civil Rights Local Agency/State WIC Branch Staff Other:

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:

State Office of Nutrition and WIC Resolution/Comments:
Follow-up Report: Office of Nutrition and WIC, Customer Service Coordinator: FORM 3772 Revised 05/10

CT-268

Attachment CT-39
Wait time Customer Service Transfer Appointment Formula
Local Agency/State Office of Nutrition and WIC Information Staff Name: Phone:
Can Complaint be Closed at Local Agency? Yes No Signature and Title: Date:
Can Complaint be Closed at State Office of Nutrition and WIC? Yes No Signature and Title:
Date:

GEORGIA WIC 2012 PROCEDURES MANUAL

GEORGIA WIC How to File a Complaint

Attachment CT-40

If you feel you have been treated unfairly, please let us know by using the information listed below. Georgia WIC will assist you as well as notify the proper authorities if necessary.
ANY COMPLAINT You may call Georgia WIC about any complaints at the toll free phone number: 1-800-228-9173 and/or write about your complaint to the address below:
Georgia WIC Policy Unit 2 Peachtree Street, Suite 10-293
Atlanta, GA 30303
DISCRIMINATION AND/OR CIVIL RIGHTS If you feel that you have been discriminated against or that your civil rights have been violated, you may contact Georgia WIC by calling the toll free number 1800-228-9173, and/or write about your complaint to the address below:
Georgia WIC Policy Unit 2 Peachtree Street, Suite 10-293
Atlanta, GA 30303
And/or you may contact the Federal Office of Adjudication directly by calling the phone number below:
1-866-632-9992 and/or you may write the Office of Adjudication at the address below:
Office of Adjudication 1400 Independence Avenue, SW
Washington, DC 20250-9140
"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.
To file a complaint of discrimination, write USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call toll free (866) 6329992 (Voice). Individuals who are hearing impaired or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish)." USDA is an equal opportunity provider and employer.
CT- 269

GEORGIA WIC 2012 PROCEDURES MANUAL

Revised 3/11

Attachment CT-40

CT- 270

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT-41

GEORGIA WIC REQUEST FOR WIC SERVICES LOG
PHONE CALLS/WALK-INS

NAME

ADDRESS

P/B/PP Infant/ Child

Date Service Requested

Date of Appointment

Prenatal ReAppointments

Telephone Number

CT-270

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT-42



Georgia WIC

Interview Script

Georgia WIC is a nutrition program for Women, Infants and Children who have nutritional needs and are

income eligible. Eligible program enrollees receive:

Nutrition assessment

Nutrition education

Healthy foods (milk, eggs, cheese, juice, cereal, peanut butter, dried beans or peas, carrots,

tuna and infant formula)

Support for breastfeeding moms

Referral to other health and social services

You may qualify for WIC if you:

are pregnant, just had a baby, is breastfeeding a baby, or have small children under age 5;

have a moderately low family income, even if you work; and

have a documented nutrition-related medical need:

and live in the State of Georgia.

The following information is being asked for statistical purposes and the answers will have no effect

on the receipt of WIC services

Are you a Migrant Farmworker*?

_________Yes

_________ No

*A Migrant Farmworker is an individual whose principal employment is in agriculture on a seasonal

basis, who has been employed within the last twenty-four (24) months and who establish for the

purpose of such, a temporary abode.

Are you Hispanic/Latino?

_________Yes

_________ No

(Yes = A person of Cuban, Mexican, Puerto Rican, South or Central America or other Spanish culture or

origin, regardless of race.)

What is your RACE ?

You may choose more than one race or all that apply.

1._____ White A person having origins in any of the original people of Europe, the Middle East of North Africa.

2._____ Black or African American A person having origins in any of the Black racial groups of Africa.

3._____ Asian A person having origins in any of the original people of the Far East, Southeast Asia, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam.

4._____ American Indian/Alaska Native A person having origins in any of the original people of North and South America (including Central America), and who maintain tribal affiliation or community attachment.

5._____ Native Hawaiian or Other Pacific Islander A person having origins in any of the original people of Hawaii, Guam, Samoa, or other Pacific Islands.

"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.
To file a complaint of discrimination, write USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call toll free (866) 632-9992 (Voice). Individuals who are hearing impaired or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish)." USDA is an equal opportunity provider and employer.

Revised 3/11

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GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT-43

Separation of Duty Form/District Office

Type of Certification (Home, Hospital, etc.)

Date of
Certification





Was Any Information Missing?
(Cert. , Voucher Receipt, Nutrition Information)


Name of Person who performed
Certification


Nutrition Services Director or
Designee's Name


Approved or
Disapproved































































































































































(This form must be kept on file for 3 years plus current year)

Completion Date


CT-272

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT-44

MILITARY INCOME INCLUSIONS AND EXCLUSIONS

BAH BAS BASE CAREER SEA PAY CLOTHING
COLA FLPP
FLY FSSA
FSP HDP HFP JUMP SDP SEB
SEP SPEC SRB
TDY REBATE TLA FSH OLA SAVE CMAI
UEA

BASIC HOUSING SEPARATE RATIONS BASE PAY CAREER SEA PAY CLOTHING ALLOWANCE
COST OF LIVING ALLOWANCE FOREIGN LANGUAGE PROFICIENCY PAY FLY PAY FAMILY SUBSISTANCE SUPPLEMENTAL ALLOWANCE FAMILY SEPARATION PAY HAZARDOUS DUTY PAY HAZARDOUS FIRE PAY JUMP PAY SPECIAL DUTY PAY SERVICE MEMBER ENLISTMENT BONUS SEPARATION PAY SPECIAL FORCES STANDARD REENLISTMENT BONUS
TEMPORARY DUTY REBATE TEMPORARY LODGING ALLOWANCE FAMILY SEPARATE HOUSING OVERSEAS LIVING ALLOWANCE FOREIGN DUTY PAY CIV CLOTHING MAINT ALLOWANCE
ONE TIME CLOTHING ALLOWANCE FOR WI

DO NOT COUNT TO BE COUNTED TO BE COUNTED TO BE COUNTED TO BE COUNTED (DIVIDE BY 12) DO NOT COUNT TO BE COUNTED
TO BE COUNTED TO BE COUNTED
TO BE COUNTED TO BE COUNTED TO BE COUNTED TO BE COUNTED TO BE COUNTED TO BE COUNTED (DIVIDE BY 12) TO BE COUNTED TO BE COUNTED TO BE COUNTED (DIVIDE BY 12) TO BE COUNTED DO NOT COUNT DO NOT COUNT DO NOT COUNT DO NOT COUNT TO BE COUNTED TO BE COUNTED (DIVIDE BY 12) TO BE COUNTED (DIVIDE BY 12)

CT-273

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CT-45

Dear WIC Proxy:
The Georgia WIC Program appreciates your help, respects your time and effort in assisting Georgia WIC participants. As a proxy, it is vital that you follow the rules below:
1. A proxy is a person who acts on behalf of the participant. Authorized proxies may pick-up and/or redeem vouchers and may bring a child in for subsequent certifications in restricted situation.
2. A proxy is a person who is named by the WIC participant and given the participants WIC ID card when redeeming WIC Approved food item at the grocery store.
3. A proxy is a responsible person who the participant/parent/guardian/spouse/ caregiver/alternate parent depends on.
4. If a proxy picks up vouchers or brings a child in for subsequent certification, the proxy may sometimes have to remain for nutrition education classes and be able to provide health information for the participant(s).
5. A proxy must be at least sixteen (16) years old unless prior approval is obtained from the WIC staff.
6. A proxy must not pick up vouchers for more than two (2) families in the state of Georgia.
Documentation of proxy is recorded on the Georgia WIC ID card. The name of the proxy is placed in the WIC participants file. The local agency will notify the WIC participant if the proxy is not listed within the WIC participants file.
Please contact the WIC participant if you can no longer serve as a proxy. The WIC participant must notify the WIC clinic of this change. If you have any questions pertaining to your new role, please ask the person who asked you to serve as a proxy.
Thank you in advance for what you will do to help the Georgia WIC program.
Sincerely,

Georgia WIC Staff

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Rights and Obligations





TABLE OF CONTENTS



Page

I.

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

II. Non-discrimination Clause ......................................................................................... RO-3

III. Public Notification....................................................................................................... RO-4

IV. Civil Rights ................................................................................................................. RO-4

A. "And Justice for All"- Poster............................................................................ RO-4

B. Training .......................................................................................................... RO-5

C. Self Identification of Race, Ethnicity, Migrant and Homeless Status .............. RO-5

D. Collection of Racial/Ethnic Data ..................................................................... RO-5

E. Discrimination Complaints .............................................................................. RO-6

1. Written Complaints ................................................................................... RO-6

2. Verbal Complaints .................................................................................... RO-7

F. Handling Complaints at the Service Delivery Point ........................................ RO-7

V. Fair Hearing Procedures - WIC Applicants/Participants ............................................ RO-7

A. Hearing Official............................................................................................... RO-8

B. Request(s) for Hearing ................................................................................... RO-8

C. Georgia WIC Record Summary Form ............................................................ RO-9

D. Document and Record Disclosure Prior to the Hearing.................................. RO-9

E. Adjusting Local Agency Decisions Regarding Eligibility............................... RO-10

F. Continuation of Benefits ............................................................................... RO-10

G. Denial or Dismissal of a Request for a Hearing ........................................... RO-10

H. Notification of the Hearing ............................................................................ RO-11

I.

Conduct of the Hearing and the Appellant's Rights...................................... RO-11

J. The Hearing Record ..................................................................................... RO-12

K. The Hearing Decision................................................................................... RO-12



GEORGIA WIC 2012 PROCEDURES MANUAL


Rights and Obligations

L. Notification of the Hearing Decision ............................................................. RO-12

M. Post-Hearing Appeal Rights of the Appellant ............................................... RO-13

N. State Rules of Procedure ............................................................................. RO-13

O. Participant Complaint ................................................................................... RO-13

VI. Fair Hearing Procedures - Migrants ......................................................................... RO-13

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

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

IX. Pre-Approval/PreAward Review............................................................................. RO-15

Attachments: RO-1 Rights and Obligations (English).............................................................................. RO-16 RO-1A Rights and Obligations (Spanish) ............................................................................ RO-18 RO-2 Appellant's Georgia WIC Record Summary ............................................................. RO-20 RO-3 OSAH Form 1 ........................................................................................................... RO-23



GEORGIA WIC 2012 PROCEDURES MANUAL


Rights and Obligations

I.

RIGHTS AND OBLIGATIONS OF WIC APPLICANTS/PARTICIPANTS

WIC applicants/participants have certain rights including, but not limited to the following: protection against discrimination, the right to a fair hearing when benefits are denied, and the right to receive information in a language other than English. Translations of material in a language other than English are based on the size and the concentration of a population. All participants must have Dual Participation explained to them at the initial certification. WIC applicants/participants are obligated to provide true information and follow program requirements.

At each certification, the participant or parent/caregiver/guardian/spouse or alternate parent 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:

RIGHTS AND OBLIGATIONS I have been advised of my rights and obligations for participation in Georgia's WIC. I certify that the information I will provide, or have provided, is correct to the best of my knowledge. The income information that I have provided 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. Georgia's WIC 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 to Georgia's WIC, 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.

NOTICE OF DISCLOSURE I understand that the chief state health officer for Georgia may authorize the disclosure of information about my participation in the WIC program for non-WIC purposes. This information will be used by Georgia WIC, its local WIC agencies and certain public organizations. These organizations include but are not limited to the Immunization Program, Pregnancy Risk Assessment Monitoring Systems (PRAMS), Epidemiology and other Maternal and Child Health Programs, Emergency Preparedness, Environmental Health and Medicaid. I understand that Georgia WIC, its local agencies and the public organizations can only use my information in the administration of their programs that serve persons eligible for WIC. The public organizations that receive my information must assure that it will not disclose my information to another organization or person without my permission.

I further understand that information about my participation in WIC may be used by the organizations that receive it only to:

1. Determine my eligibility for programs that the organization administers 2. Conduct outreach for such programs 3. Enhance the health, education, or well-being of WIC applicants and participants who
are currently enrolled in those programs 4. Streamline administrative procedures to ease the burdens on WIC staff and
participants 5. Assess the responsiveness of the state's health system to participants' health care
needs and health care outcomes.

RO-1

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Rights and Obligations

I have been advised that the decision to share my information is not a condition for

eligibility for WIC, and if I decide not to share my information, this will not affect my

application or participation in Georgia WIC.







___________________________________________ __________________________________________ ______

Name of WIC Applicant/Participant/Guardian/

Date

Name of WIC Official (please print) Date

Caregiver/Spouse/Alternate Parent (please print) ________













UP:

___________________________________________ ________

_____________________________________

Signature of WIC Applicant/Participant/Guardian/ Date

Signature of WIC Official

Date

Caregiver/Spouse/Alternate Parent





Please initial below to indicate your preference:

___In applying for WIC services, I AUTHORIZE DISCLOSURE of my WIC applicant or participant information for the purposes referenced above. I understand that my refusal to allow such disclosure does not affect my application for or participation in WIC or my eligibility for WIC services.

___In applying for WIC services, I DO NOT AUTHORIZE DISCLOSURE of my WIC applicant or participant information for the purposes referenced above. I understand that my refusal to allow such disclosure does not affect my application for or participation in WIC or my eligibility for WIC services.

During the certification process, the participant must receive an explanation of the following: 1. Reason for Certification 2. Program Benefits 3. Reasons for Ineligibility 4. Items that can and cannot be purchased 5. How to file a complaint 6. Nutrition Education Requirements 7. Illegality and consequences of Dual Participation

In addition to the Rights and Obligations stated on the I.D. Card (see Attachment RO-1 and RO-1A), the applicant/participant must not be charged for any WIC service, e.g., copying of WIC records, laboratory tests.

Each participant in Georgia WIC has the right to be treated with courtesy while in either the Health Department WIC clinic 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 violates WIC's nondiscrimination policy.

Participants/applicants will be informed that the Policy Unit and/or the Vendor Management Unit will investigate reports of discrimination made to Georgia WIC

RO-2

GEORGIA WIC 2012 PROCEDURES MANUAL


Rights and Obligations

II. NONDISCRIMINATION CLAUSE
Georgia WIC is required to send out Public Notification 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 Georgia WIC 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 have the nondiscrimination clause include, but are not limited to:
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 Georgia WIC 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.
The current nondiscrimination statement is:
English
"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.
To file a complaint of discrimination, write USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call toll free (866) 6329992 (Voice). Individuals who are hearing impaired or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish)." USDA is an equal opportunity provider and employer.
Spanish
"En concordancia con la Ley Federal y con las Polticas del Departamento de Agricultura de los E.E.U.U., esta institucin tiene prohibido el discriminar en base a raza, color, nacionalidad, sexo, edad o discapacidad.
Para iniciar una queja por discriminacin, escriba a USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 o llame sin cargos al (866) 632-9992 (voz). Individuos con discapacidad auditiva o discapacidad del habla pueden contactar al USDA a travs del Servicio de Relevo Federal (Federal Relay Service) al (800) 977-8339; o al (800) 845-6136 (espaol)." USDA es un proveedor y empleador de igualdad de oportunidades.

RO-3

GEORGIA WIC 2012 PROCEDURES MANUAL


Rights and Obligations

III. PUBLIC NOTIFICATION
When the Nutrition Services Directors give interviews to local media, the Nondiscrimination statement should be included in verbal statements and on written documents. Any public or media discussions of WIC by local agency staff should be documented for review by the State agency monitoring staff. The Office of Communication prepares a news release annually to publicize the availability of WIC benefits. The news release is distributed to newspapers statewide.
Georgia' WIC regulations and guidelines must be made available to the public on request. These documents include WIC components of the relevant Code of Federal Regulations at 7 C.F.R. Part 246, Rules of the Department of Public Health at Chapter 111-9, Georgia WIC State Plan, and the Georgia WIC Procedures Manual. Georgia WIC Income Guidelines are part of the Procedures Manual and must be given to the public upon request.
There are three elements of Public Notifications:
1. Program Availability Inform applicants, participants, and potentially eligible persons of their rights and responsibilities and the steps necessary for WIC participation.
2. Complaint Information
Advise applicants and participants at the service delivery point of their rights to file a complaint, how to file a complaint, and the complaint procedures. Upon receipt of a complaint, WIC clinic staff must complete and submit a Complaint Form (see Attachment CT-39) to the Georgia WIC office within 24 (twenty-four) hours of the complaint. All complaints must be processed and closed within 90 (ninety) days upon receipt. All discrimination complaints must go to USDA within 24 (twenty-four) hours of receiving the complaint(s).
3. Nondiscrimination Statement
All information materials and sources, including web sites, used by FNS, State agencies, local agencies, or other sub-recipients to inform the public about FNS programs must contain a nondiscrimination statement. The statement is not required to be included on every page of Georgia WIC web site. At a minimum the nondiscrimination statement or a link to it must be included on the home page of the website.
IV. CIVIL RIGHTS
A. "And Justice for All" Poster
The "And Justice for All" poster must be displayed in a visible and/ or accessible
RO-4

GEORGIA WIC 2012 PROCEDURES MANUAL


Rights and Obligations

location in each WIC clinic. The poster should have the Non-discrimination statement in both English and Spanish and can be ordered from Georgia WIC.

B. Training

Civil Rights training must be provided annually or as requested for all local agency staff that have contact with WIC applicants/participants. This training must be provided to State agency and District staff annually. New staff must have Civil Rights training prior to working in WIC 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/meeting, it is required that District/WIC Clinic and State agency staff ask if anyone needs any special accommodations.

WIC staff must be trained in the specific area matter required, but not limited to: 1. Collection and use of data; 2. Effective public notification systems; 3. Complaint procedures; 4. Compliance review techniques; 5. Resolution of noncompliance; 6. Requirements for reasonable accommodation of persons with
disabilities; 7. Requirements for language assistance; 8. Conflict resolution; 9. Customer service; and 10. Investigator's training.

C. Self Identification of Race, Ethnicity, Migrant and Homeless Status

Each applicant/participant must be coded in the WIC computer system to identify race, ethnic group, migrant and homeless status. In order to do this, local agency staff must: 1. Give each applicant the opportunity to select one or more racial
designations by using the Interview Script (see Attachment CT- 42).
2. 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 without their consent. If the applicant refuses to self identify, WIC staff will make its own identification for the applicant.
3. Accept race information provided by applicants without disputing their description regarding their race.

D. Collection of Racial/Ethnic Data

RO-5

GEORGIA WIC 2012 PROCEDURES MANUAL


Rights and Obligations

In collecting the Racial/Ethnic Data, the ethnicity data must be collected first. Ask the client if he/she is of Spanish origin. The terms Hispanic or Latino may also be used. The applicant must then be given the option to select one or more racial designations (See the Certification Section, WIC Assessment form for racial and ethnic categories).

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 allow access to authorized personnel. Georgia WIC 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.

Georgia WIC is obligated to safeguard confidential WIC information including identifying WIC applicant/participant information. In many local agencies, charts have the participant's name and birth date on the outside label. In this instance, please remove the birth date or situate your files in a manner, which ensures that confidential WIC participant information will not be exposed to the general public. This may be accomplished (as done in many hospitals) by turning the files to face away from the public's view. (For reference, see the Summary of the HIPAA Privacy rules. Plus review "What Information is Protected", pages 3-4 and "End Notes", page 19, number 15. Also see, Federal WIC regulations concerning confidentiality of WIC participant information at 7 C.F.R. 246.26(d)).

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 USDA, Office of Adjudication, 1400 Independence Avenue, SW, Washington D.C. 20250-9410 or call toll free (866) 632-9992 (Voice). Individuals who are hearing impaired or have speech disabilities may contact USDA through the Federal Relay Service at (800) 8778339; or (800) 845-6136 (Spanish)."
If the District office or a WIC clinic receives a discrimination complaint or an applicant/ participant feels discrimination has occurred, forward a copy of the complaint to Georgia WIC, Policy Unit, Two Peachtree Street, Suite 10-293, Atlanta GA 30303. USDA is an equal opportunity provider and employer. [SEP Regional Letter 290-7, Rev .2]
1. Written Complaints

Persons seeking to file discrimination complaints may file their complaint with USDA, the State agency or the local agency. A copy

RO-6

GEORGIA WIC 2012 PROCEDURES MANUAL


Rights and Obligations

must be sent to Georgia WIC will send the complaint to USDA to process. Do not try to process any discrimination complaint. Please send the complaints directly to Georgia WIC.
Complaints should include the name of the agency and/or the individual(s) whom the complaint addresses and a description of the alleged violation. Anonymous complaints will be handled in the same manner as any other complaints.

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(s) 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. g. Signature of the person recording the complaint.

F.

Handling Complaints at the Service Delivery Point

Advise applicants and participants at the service delivery point of their right to file a complaint, how to file a complaint and the complaint procedures. Display the "How to File a Complaint" flyer at the service delivery point. Clinic staff must also offer the flyer to all applicants/participants at certification, re-certification and midcertification.

V. FAIR HEARING PROCEDURES WIC APPLICANTS/PARTICIPANTS
WIC Federal regulations require the State agency to establish hearing procedures that will guarantee the right to appeal a decision or action to deny participation and/or suspend or terminate participation from the program. The applicant/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 WIC funding
2. The priority system
3. Waiting list

RO-7

GEORGIA WIC 2012 PROCEDURES MANUAL

4. Reasons for the denial of benefits or termination from WIC

Rights and Obligations

At the time of fair hearing request, the District Nutrition Services Director will need to conduct a preliminary conference with the applicant/participant. This conference may resolve the issues, particularly if the individual misunderstood WIC policy or was not aware that certain procedures are required by Federal regulations. The State agency will also conduct a preliminary conference with the applicant/participant prior to the actual hearing. The applicant/participant should receive information on fair hearing procedures and their rights and responsibilities concerning the hearing process. Included will be a description of the role of the Administrative Law Judge, the time frame for issuance of fair hearing decisions, and any other pertinent information.

In the event a WIC participant timely requests a fair hearing within fifteen days of the termination date, WIC benefits will continue until the Administrative Law Judge reaches a decision or the certification period expires, whichever occurs first.

The following are Georgia WIC Fair Hearing Procedures:

A. Hearing Official

The Office of State Administrative Hearings (OSAH) is responsible for conducting a fair hearing when requested by a WIC applicant/participant. OSAH, as the impartial administrative tribunal for the State of Georgia, is vested with full authority to conduct the fair hearing. OSAH is responsible for conducting hearings in accordance with the Georgia Administrative Procedures Act and the Rules of the Office of State Administrative Hearings, and 7 C.F.R., Part 246.

The Administrative Law Judge shall:

1. Administer oaths and affirmations; 2. Ensure that all relevant issues are considered; 3. Request, receive and make part of the hearing record all evidence
determined necessary to decide the issue(s) being raised; 4. Regulate the conduct and course of the hearing consistent with due process
to ensure an orderly hearing; 5. Order, where relevant and necessary, an independent medical assessment
or professional evaluation from a source mutually satisfactory to the appellant and the State agency; and 6. Render a fair hearing decision which will resolve the dispute.

B. Request(s) for Hearing

A request for hearing is defined as any clear expression by the applicant/participant or that individual's parent/guardian/caregiver 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 freedom of a WIC applicant/participant to request a hearing.

The applicant/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

RO-8

GEORGIA WIC 2012 PROCEDURES MANUAL


Rights and Obligations

terminate benefits. Fair hearing requests shall be submitted to Georgia WIC, 10th Floor, 10-293 Policy Unit, Two Peachtree Street, Atlanta, Georgia 30303.

A fair hearing request shall be effective upon timely receipt of a verbal or written request. A verbal request received within the sixty (60) days shall be considered timely. The forty-five (45) day period allowed for rendering a hearing decision shall begin on the day of receipt of the fair hearing request.

Upon request, the local agency shall assist an applicant/participant in submitting a request for fair hearing. The local agency shall provide contact information for legal services that may be available to represent an appellant (an applicant/participant who requests a fair hearing to contest an adverse action).

C. Georgia WIC Record Summary Form
The local agency shall prepare a Georgia WIC Record Summary Form (Attachment RO-2) and OSAH Form 1 (Attachment RO-3). Within three (3) business days from the receipt of the fair hearing request, the completed forms, notice of adverse actions, and written hearing request shall be submitted to Georgia' WIC, 10th Floor, 10-293 Policy Unit, Two Peachtree Street, Atlanta, Georgia 30303. A copy of the form shall be sent to Georgia WIC. If the hearing request is filed initially with the State WIC agency, a copy will be immediately forwarded to the local agency.
The local agency has the responsibility of maintaining contact with the appellant once the hearing is requested and must report promptly to the State WIC agency any change in appellant's circumstances, including changes in mailing address. As soon as the local agency receives notification that a hearing has been scheduled, the local agency Nutrition Services Directors shall immediately review the record to:
1. Re-examine the action of the local agency and the circumstances of the appellants to determine if an adjustment can be made.
2. Review appellant's eligibility on all points other than the point at issue.

All hearing requests, whether timely or not, must be submitted to Georgia WIC. The local agency will secure any additional evidence necessary for the hearing.

D. Document and Record Disclosure Prior to the Hearing
All documents and records to be used in the hearing will be available for examination by the appellant and/designated representative prior to the fair hearing. Such examination shall be made at the local agency. "Designated representative" means an attorney or friend, or personal counselor, of the appellant. Upon request, the local agency shall make available, without charge, the specific materials necessary for an appellant or designated representative to determine whether a hearing should be requested or to prepare for a hearing. The appellant and/or designated representative will be given an opportunity to

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GEORGIA WIC 2012 PROCEDURES MANUAL


Rights and Obligations

copy any materials in the file, which are relevant to the fair hearing. Documents and records that do not support the adverse action for which the fair hearing was requested 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 WIC staff will operate the equipment. When reproduction equipment is not available, the appellant or designated representative may make longhand notes.

E. Adjusting Local Agency Decisions Regarding Eligibility

The local agency has the responsibility of taking proper action in adjusting its decisions against WIC applicants/participants regarding their eligibility. If an applicant/participant is dissatisfied with a local agency decision, the local agency shall review the individual's status with him/her. If the applicant/participant who is appealing the local agency decision so desires, the local agency shall assist with the filing of the fair hearing request. If, after the appeal for fair hearing is filed, the appellant and local agency reaches a mutually satisfactory resolution prior to the fair hearing, the appellant may withdraw the request for hearing.

The local agency may amend or reverse its decision regarding WIC applicant/participant eligibility at any time prior to the actual hearing, regardless of whether an appellant withdraws the request for fair hearing. In the event of withdrawal, amendment or reversal, the local agency shall notify the State WIC agency immediately by attaching a copy of the withdrawal, amendment or reversal with a summary supporting the adjustment action taken by the local agency. If time does not permit notification to the State WIC agency, verbal notification to it should be immediately followed with written notification.

F. Continuation of Benefits

Participants who appeal the termination of benefits within fifteen (15) days from date of notification of adverse action shall continue to receive WIC benefits until the Administrative Law Judge reaches a decision or the certification period expires, whichever occurs first. Benefits will be terminated for participants who make a timely appeal after the fifteenth day from the date of notification.

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. Georgia WIC will discontinue all program benefits to categorically ineligible applicants/participants while awaiting appeal decision.

G. Denial or Dismissal of a Request for a Hearing

A request for a fair hearing shall not be denied or dismissed unless: 1. The request for hearing is not timely received within the sixty (60) day
time limit.

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Rights and Obligations

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 WIC participation by a previous hearing and cannot provide evidence that circumstances relevant to WIC eligibility have changed in such a way as to justify a hearing. (See Attachment RO-2 for timeframes.)

H. Notification of the Hearing
The hearing shall be conducted within twenty-one (21) days from the date the State receives 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 of hearing shall contain the following: 1. A statement of the time, place, and nature of the hearing. 2. A statement of the legal authority and jurisdiction under which the
hearing is to be held. 3. A reference to the statutes and regulations involved. 4. A short statement of the complaint. If the agency or other party is
unable to state the complaint in detail, the notice may be limited to a statement of the issues involved. 5. A statement that the State will dismiss the hearing request if the individual or his/her representative fails to appear at the hearing without good cause. 6. A statement that the participant/designated representative may examine the case files prior to the hearing. 7. Advisement that appellant may be assisted or represented by an attorney or other persons.
The Administrative Law Judge may change the time and place of the hearing upon his own motion or upon motion either or both 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 appellant shall be given at least ten (10) days advance notice of such action.

I.

Conduct of the Hearing and the Appellant'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.

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Rights and Obligations

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. The Hearing Record
The Administrative Law Judge shall keep the official hearing record that includes: 1. The OSAH Form 1 and related attachments as the mandatory formal
request for fair hearing. 2. All pleadings, motions, documents and papers filed by the parties. 3. All intermediate rulings made and issued by the Administrative Law
Judge. 4. The sworn testimony of all witnesses, with a recording of all oral
testimony or an official report containing the substance of what transpired at the hearing. 5. All exhibit evidence offered and all exhibit evidence admitted into evidence that was considered by the Administrative Law Judge. 6. The decision issued by the Administrative Law Judge. 7. Written transcript, if made, of any oral testimony.
Requests for a copy of any recording of oral testimony must be made to the Administrative Law Judge pursuant to the Rules of the Office of State Administrative Hearings. The State or local WIC agency shall retain the hearing record in accordance with the relevant Federal WIC Regulations (7 C.F.R. Section 246.25) and make the hearing record available for copying and inspection to the appellant or representative at any reasonable time.

K. The Hearing Decision
Decisions of the Administrative Law Judge shall be based on the application of relevant law, rules, regulations and policy as related to the facts of the case as established in the hearing record. An initial 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 relevant regulations or policy. The decision shall be come part of the hearing record.
L. Notification of the Hearing Decision
Within forty-five (45) days of the receipt of the request for fair hearing, the appellant and/or his/her representative shall be notified in writing of the

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Rights and Obligations

Administrative Law Judge's initial decision. In addition, the initial decision will inform the appellant of any right to appeal known to the Administrative Law Judge.

M. Post-Hearing Appeal Rights of the Appellant

When an initial decision is adverse to the appellant, he/she has the right to appeal to a DPH Appeals Reviewer for a final agency decision. The DPH Appeals Reviewer shall allow the appellant thirty (30) days to request review of the Administrative Law Judge's initial decision. The DPH Appeals Reviewer shall have all the powers and delegated authority of the DPH Commissioner to make a final decision. The Appeals Reviewer shall review the entire record and may take additional testimony or remand the case to the Administrative Law Judge for such purpose. The final decision shall affirm, reverse or modify the initial decision to assure full compliance with State and Federal law, rules, regulations and policy.

The appellant and his/her representative shall be notified, in writing, of the final decision of the DPH Appeals Reviewer who shall advise the appellant and his/her representative of any right to judicial review should the appellant be dissatisfied with the final decision of the DPH Appeals Reviewer.

N. State Rules of Procedure

The State agency shall provide and distribute upon request, to any interested party, that portion of Georgia WIC Procedures Manual that outlines the Fair Hearing Procedures.

O. 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 (see Attachment CT-39).

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 service area and should convey this information to the State WIC agency.

VII. 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.
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GEORGIA WIC 2012 PROCEDURES MANUAL


Rights and Obligations

VIII. NATIONAL VOTER REGISTRATION ACT
The National Voter Registration Act of 1993 (also known as "NVRA" and the "Motor Voter Act") requires states to provide voter registration through designated governmental agencies that provide public assistance, including SNAP, WIC, TANF, SCHIP and Medicaid. To meet the requirements of the NVRA as a designated agency, Georgia WIC must: distribute voter registration application forms; provide a preference/declination form that contains information on the voter registration process; provide the same level of assistance to all WIC applicants/participants in completing the voter registration application form; accept completed voter registration application forms from the applicant/participant; and transmit each completed application form to the Georgia Office of Secretary of State (SOS) within the prescribed time frame.
Georgia WIC must offer applicants/participants the opportunity to register to vote at the time of all application, renewal, recertification and change of address transactions. If Georgia WIC were to offer any of the above transactions to be completed by mail or telephone or through the internet, opportunity to register to vote must still be offered. A preference/declination form must be provided to each WIC applicant/participant, which is separate from the State of Georgia voter registration form. The preference/declination form must include the following information: 1) the question, "If you are not registered to vote where you live now, would you like to apply to register to vote here today?"; 2) "Applying to register or declining to register to vote will not affect the amount of assistance that you will be provided by this agency"; 3) boxes to be checked indicating whether the individual would like to register to vote or declines with a statement in close proximity to the boxes in prominent type that reads, "IF YOU DO NOT CHECK EITHER YOU WILL BE CONSIDERED TO HAVE DECIDED NOT TO REGISTER TO VOTE AT THIS TIME."; 4) the statement, "If you would like help in filling out the voter registration application form, we will help you. The decision whether to seek or accept help is yours. You may fill out the application form in private."; and 5) the statement, "If you believe that someone has interfered with your right to register or to decline to register to vote, your right to privacy in deciding whether to register or in applying to register to vote, or your right to choose your own political party or other political preference, you may file a complaint with the Secretary of State at 1104 West Tower, 2 Martin Luther King Jr. Drive, S.E. Atlanta, Georgia 30334 or by calling 404-656-2871." The blank should be completed with the name, address and phone number of the appropriate official at the SOS to whom such a complaint should be addressed.
The State of Georgia voter registration application may be used by Georgia WIC to register a WIC applicant/participant to vote in Georgia, and it includes a separate preference/declination form (FORM DS-07, "Declaration Statement"), which conforms to the requirements of the NVRA regarding the preference/declination form. The State of Georgia voter registration application can be ordered by contacting the SOS at 404/6562871 or at http://www.sos.ga.gov/electroniconnection. No information relating to a declination to register to vote may be used for any purpose other than voter registration. Georgia WIC shall retain the State of Georgia Declaration Statement as the required preference/declination form for twenty-four (24) months.
Georgia WIC must offer each WIC applicant/participant the same degree of assistance in completing a voter registration application and the same degree of assistance offered
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GEORGIA WIC 2012 PROCEDURES MANUAL


Rights and Obligations

in completing WIC forms. WIC staff who offer such assistance are prohibited from: 1) seeking to influence an individual's political preference or party registration; 2) displaying any political preference or party allegiance; 3) taking any action or making any statement to an individual to discourage interest in registering to vote; or 4) taking any action or making any statement that may lead the individual to believe that a decision to register or not to register has any bearing on the availability of or eligibility for WIC services.

The State agency and/or local agency must accept completed voter registration applications and transmit them to the SOS weekly. Completed voter registration applications received within fifteen (15) days before the last day to register to vote in an election must be transmitted to the SOS daily. (The State of Georgia requires an individual to be registered thirty days before any election in which voting is to occur.)

Following these procedures ensures that Georgia WIC is complying with Federal law and USDA guidelines. Please note that, according to USDA guidelines, a WIC applicant/participant need not be a United States citizen. However, the WIC applicant/participant must be a United States citizen to register to vote. The SOS prepares a quarterly WIC Voter Registration Report to determine local agency compliance. Failure to comply with the NVRA requirements could result in monetary penalties against an out-of-compliance local agency and the State of Georgia. Failure to comply could also result in enforcement action by the United States Department of Justice.

IX. PRE-APPROVAL / PRE-AWARD REVIEW
A new WIC clinic site must not open until a Pre-Approval/Pre-Award Review is conducted by the State agency. For procedures on opening a new WIC clinic site, see the Administrative Section of the WIC Procedures Manual at "Establishing New Clinics/Clinic Changes".

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GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment RO-1

Georgia Department of Public Health Georgia WIC
Rights and Obligations

RIGHTS AND OBLIGATIONS
1. The rules for signing up and taking part in Georgia WIC are the same for everyone, regardless of race, color, national origin, sex, age, or disability.
2. You may appeal any decision made by the WIC clinic about your eligibility for WIC or disqualification from WIC by asking for a fair hearing.
3. The WIC clinic will give you information about food that is healthy 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 WIC services and tell us how many people are on WIC.
5. The food you get from WIC is only for WIC participant(s).
6. You may be taken off WIC if:
x You do not tell the truth about eligibility criteria. x You get vouchers from more than one (1) WIC clinic at the same time. x You do not keep your certification appointments. (Rescheduling WIC
appointments may take from 7 to 20 days depending on the clinic schedule). x You do not get your vouchers for two (2) months in a row. x You sell or trade your WIC vouchers or WIC food for money or any product, good, or service not authorized by Georgia WIC. x You use your vouchers to buy food that is not on the authorized WIC food list. x You exchange your WIC food items after purchase for any item(s) not listed on the voucher. x You use abusive language with WIC clinic staff, store clerks, or managers. x You are physically violent with WIC clinic staff, other WIC clients, or store personnel. 7. If you do not keep your appointments, the number of vouchers issued to you or your child(ren) will be reduced. 8. A proxy cannot provide services for more than two families. 9. Lost and destroyed/stolen vouchers will not be replaced.

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GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment RO-1

VOUCHER INFORMATION
x Failure to keep appointments will reduce the number of vouchers you receive.
x The fruit and vegetable/cash value voucher can not be prorated. It must always be issued and must be issued in full value (e.g., $6, $10, $15).
x Food packages will be prorated based on the total number of vouchers in the package.

"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.
To file a complaint of discrimination, write USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call toll free (866) 6329992 (Voice). Individuals who are hearing impaired or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish). USDA is an equal opportunity provider and employer."

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GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment RO-1A

Departamento de Salud Pblica Programa WIC de Georgia Derechos Y Obligaciones

DERECHOS Y OBLIGACIONES
1. Las reglas para inscribirse y participar en el programa WIC de Georgia son las mismas para todos, sin distincin de raza, color de piel, nacionalidad de origen, sexo, edad o discapacidad.
2. Usted puede apelar cualquier decisin tomada por la clnica de WIC acerca de su elegibilidad para el programa WIC o descalificacin de WIC pidiendo una audiencia imparcial.
3. La clnica de WIC le dar informacin acerca de los alimentos que son saludables para usted. Tambin hay a su disposicin referencias de servicios de salud. La clnica desea que usted use dichos servicios.
4. La informacin en el formulario de WIC ser utilizada para revisar los servicios de WIC y decirnos cuntas personas estn en el programa WIC.
5. Los alimentos que recibe de WIC son solamente para quienes participan en WIC.
6. Usted puede ser suspendido del programa WIC si:
x No dice la verdad acerca de los criterios de elegibilidad. x Recibe cupones de ms de una (1) clnica de WIC al mismo tiempo. x No acude a las citas de certificacin. (Cambiar las citas de WIC puede
tardar de 7 a 20 das, dependiendo del horario de la clnica). x No obtiene sus cupones por dos (2) meses consecutivos. x Vende o intercambia sus cupones de WIC o alimentos de WIC por dinero o
algn producto, bien o servicio no autorizado por el programa WIC de Georgia. x Utiliza sus cupones para comprar alimentos que no est en la lista de alimentos autorizados por WIC. x Intercambia sus alimentos de WIC despus de comprarlos por algn(os) artculo(s) que no figura(n) en el cupn. x Utiliza un lenguaje abusivo con el personal de la clnica de WIC, los dependientes de las tiendas o los gerentes. x Emplea violencia fsica contra el personal de la clnica de WIC, otros clientes de WIC o el personal de las tiendas. 7. Si no mantiene sus citas, se reducir el nmero de cupones que se emitan para usted o su(s) nio(s). 8. Un apoderado no puede prestar servicios para ms de dos familias. 9. Los cupones extraviados, destruidos o robados no sern reemplazados.

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GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment RO-1A

INFORMACIN DEL CUPN
- No acudir a las citas reducir la cantidad de cupones que usted reciba.
- El valor en efectivo del cupn de frutas y vegetales no se puede prorratear. Siempre se debe emitir y emitirse por su valor completo (p. ej., $6, $10,$15).
- Los paquetes de alimentos se pueden prorratear segn la cantidad total de cupones que haya en el paquete.

"En concordancia con la Ley Federal y con las Polticas del Departamento de Agricultura de los E.E.U.U., esta institucin tiene prohibido el discriminar en base a raza, color, nacionalidad, sexo, edad o discapacidad.
Para iniciar una queja por discriminacin, escriba a USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 o llame sin cargos al (866) 632-9992 (voz). Individuos con discapacidad auditiva o discapacidad del habla pueden contactar al USDA a travs del Servicio de Relevo Federal (Federal Relay Service) al (800) 977-8339; o al (800) 845-6136 (espaol)." USDA es un proveedor y empleador de igualdad de oportunidades.

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GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment RO-2



Georgia Department of Public Health Office of Nutrition and WIC (Georgia WIC) APPELLANT'S GEORGIA WIC RECORD SUMMARY


SECTION I - IDENTIFICATION

District/Unit

WIC ID #

Applicant/Participant:

Appellant (if different from above):

Address:

Street Number and Name

City

State

Zip Code

Phone Number:

Representative:

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

Ethnicity: (1) Hispanic or Latino (2) Non Hispanic or Latino

Sex: (1) Male (2) Female

Race: (1) American Indian or Alaskan Native (2) Asian (3) Black or African-American (4) Native Hawaiian or Other Pacific Islander (5) White

County:

Date of Request:

Date of Appointment:

Date of Notification:

FOR STATE OFFICE USE ONLY: Request number:

Date request filed:

Time limits Hearing shall be held within three (3) weeks from the date the State or local agency receives the request for hearing 7 C.F.R Section 246.9(j). The fair hearing decision shall issue within 45 (forty-five) days (7 C.F.R. Section 246.9 (k)(3)) of the date the request for hearing was received by the State or local agency.

SECTION II - TYPE OF AGENCY ACTION OR INACTION

A. Agency Action (Circle item number)

Participation denied/terminated because WIC applicant/participant:

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GEORGIA WIC 2012 PROCEDURES MANUAL


Attachment RO-2 (cont'd)

1. Is not income eligible.
2. Does not live in local WIC service area.
3. Has reached expiration of regulatory eligibility.
4. Is not pregnant, postpartum, breastfeeding woman or an 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 WIC rules and was suspended for three

(3) months for:

.

9. Is in Priority and WIC has funds to serve

only Priority(ies)

.

10. Other

.

B. Agency Inaction (Circle item number):

__________ Date __________ Date __________ Date
__________ Date
__________ Date __________ Date

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

2. Other:

(specify)

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________ ___________________________________________________________________

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GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment RO-2 (cont'd)



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

________________________________ Name

________________________________ Address

___________________________________

City

State

Zip Code

_________________________________ Telephone Number

"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. To file a complaint of discrimination, write USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call toll free (866) 632-9992 (Voice). Individuals who are hearing impaired or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish)." USDA is an equal opportunity provider and employer.
Revised 3/11

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GEORGIA WIC 2012 PROCEDURE MANUAL RO-3
OSAH FORM 1
This form is available online at http://www.osah.ga.gov/ or by telephone request at (404) 657-2800.

Attachment

OSAH USE ONLY DOCKET NUMBER:

AGENCY
DCH

CASE TYPE DOCKET NUMBER
GEORGIA DEPARTMENT OF PUBLIC HEALTH
PUBLIC HEALTH CASES

COUNTY

JUDGE

Non-Agency Party County of Residence:

Date Request for Hearing Filed with Agency:

Agency Case Number:

Check Here if an Application Was Denied:

Check Only One in This Box:

ASL (Ambulatory Service License) BCW (Babies Can't Wait) CT (Cardiac Technician License) EMS (Emergency Medical Service) EMT (Emergency Medical Technician License) EMTI (Emergency Medical Technician Instructor License)

FSEP (Food Service Establishment Permit, If Issued by DCH) MFR (Medical First Response Service License) NT (Neonatal Transport Service License) PI (Paramedic Instructor License) SSM (Sewage Management) WICV (WIC Vendor)

CONTACT PERSON IN AGENCY
NAME
CURRENT ADDRESS INCLUDING ZIP CODE ON HEARING REQUEST

TEL NO POSITION

FAX NO EMAIL

NON-AGENCY PARTY
NAME CURRENT ADDRESS INCLUDING ZIP CODE
ATTORNEY PERSONAL REPRESENTATIVE NAME (IF APPLICABLE) ADDRESS INCLUDING ZIP CODE
AGENCY PARTY
NAME AND TITLE OF CONTACT IN OFFICE CURRENT ADDRESS INCLUDING ZIP CODE
ATTORNEY NAME (IF APPLICABLE)
ADDRESS INCLUDING ZIP CODE

TEL NO
TEL NO GEORGIA BAR NO
DIRECT TEL NO EMAIL TEL NO EMAIL

FAX NO EMAIL FAX NO EMAIL
FAX NO
FAX NO GEORGIA BAR NO

RO-23
2012_RO_3 Attachment_OSAH FORM 1(26).doc (web-version) Revised 2/7/12

GEORGIA WIC 2012 PROCEDURES MANUAL

Administrative

TABLE OF CONTENTS

SECTION ONE - FINANCIAL MANAGEMENT

Page

I.

State Operations ........................................................................................................AD-1

A. General .................................................................................................................AD-1

B. Cost Allocation Plan .............................................................................................AD-1

C. Food Funds Management / Nutrition Services Administration.......................AD-1

D. Local Level Requirements ....................................................................................AD-2

E. Property Management and Procurement .............................................................AD-3

F. Caseload Management/Food Cost .......................................................................AD-4

II. Local Agency Operations ...........................................................................................AD-5

III. Financial Procedures .................................................................................................AD-6

A. District Health Agencies ........................................................................................AD-6

B. Non-profit Agencies ..............................................................................................AD-6

C. Unliquidated Obligations .......................................................................................AD-6

D. Year End Funds Obligations ................................................................................AD-6

IV. Funding Requirement..................................................................................................AD-6

V. Equipment Inventory ...................................................................................................AD-8

A. Acquisition..........................................................................................................AD-8

B. Status Change...................................................................................................AD-8

VI. Retroactive Benefits and Reimbursements .................................................................AD-9

A. Revenue ............................................................................................................AD-9

B. Misuse of Funds ................................................................................................AD-9

VII. Local Agency Collections ............................................................................................AD-9

GEORGIA WIC 2012 PROCEDURES MANUAL

Administrative

SECTION TWO STATEWIDE COST ALLOCATION PLAN

I.

Introduction to WIC Statewide Cost Allocation Plan .................................................AD-10

Purpose ..................................................................................................................... AD-10

Authority ....................................................................................................................AD-10

Background ...............................................................................................................AD-10

Public Health Grant-In-Aid Program..........................................................................AD-11

Cost Distribution........................................................................................................AD-11

Composition of Cost..................................................................................................AD-11

II. Basic Cost Principles/WIC Allowable Costs ..............................................................AD-11

General Requirements ..............................................................................................AD-11

Components of Federal WIC Grant...........................................................................AD-12

Nutrition Service Administration (NSA) Cost - General .............................................AD-12

Food Cost..................................................................................................................AD-12

NSA Costs for Clinic Activities ..................................................................................AD-13

NSA Costs for Program Management Activities........................................................AD-14

Unallowable Costs ....................................................................................................AD-14

Distribution of Funds to States ..................................................................................AD-14

Distribution of Funds to Local Agencies ....................................................................AD-19

Participation Cost Adjustment ...................................................................................AD-19

Performance Standard ..............................................................................................AD-20

Cost-Related Compliance Requirements ..................................................................AD-20

III. Method for Charging the Cost of Wages and Salaries ..............................................AD-22

Authority ....................................................................................................................AD-22

Personal Activity Report System (PARS)..................................................................AD-22

Rules for PARS .........................................................................................................AD-22

GEORGIA WIC 2012 PROCEDURES MANUAL

Administrative

Special Reports.........................................................................................................AD-22 Personnel Activity Report Systems (PARS) Access .................................................AD-23 Frequently Asked Questions .....................................................................................AD-50 IV. Guidelines For Local Agency Cost Allocation Methodology......................................AD-51 Overview ...................................................................................................................AD-51 Lead County Cost Allocation Plan.............................................................................AD-52 Central Cost Allocation Plan for Counties .................................................................AD-52 Bases for Distributing Shared Services.....................................................................AD-52 Inequitable Methods of Cost Allocations ...................................................................AD-53 Expensing Equipment Purchases .............................................................................AD-54

SECTION THREE - PROGRAM ADMINISTRATION

I.

Retention of Records ................................................................................................AD-55

A. Definition of Records ...........................................................................................AD-55

B. Records and Reports - Accessibility of Records .................................................AD-55

C. Retention Schedule .............................................................................................AD-55

D. Prior Approval/Duplication of WIC Records ........................................................AD-56

II. WIC Acronym and Logo ............................................................................................AD-58

A. Authority ..............................................................................................................AD-58

B. Official Use ..........................................................................................................AD-58

C. Special Use .........................................................................................................AD-58

D. WIC Food Vendors..............................................................................................AD-59

E. Unauthorized Use................................................................................................AD-59

III. Lobbying Restrictions................................................................................................AD-59

IV. Confidentiality............................................................................................................AD-59

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A. Confidential Information ......................................................................................AD-59 B. Restrictions on Disclosure of Confidential Information........................................AD-60 C. Exceptions to Restrictions on Disclosure of Confidential Information .................AD-60 V. E-Mail and Faxing Confidential Information ..............................................................AD-62 VI. WIC Volunteers and Confidentiality ......................................................................... AD-63 VII. Health Insurance Portability and Accountability Act (HIPPA)....................................AD-63 VIII. Retroactive Benefits and Reimbursements ...............................................................AD-64 IX. Mandatory No-Smoking Policy..................................................................................AD-64 X. Subpoenas ................................................................................................................AD-64 A. Subpoenas ..........................................................................................................AD-64 B. Procedures for Responding to a Subpoena ........................................................AD-64 XI. Search Warrants .......................................................................................................AD-65 A. Search Warrants .................................................................................................AD-65 B. Procedures for Responding to a Search Warrant ...............................................AD-65 XII. WIC Participation ......................................................................................................AD-65 XIII. Establishing New Clinics/Clinic Changes ..................................................................AD-66 XIV. Clinic Closings...........................................................................................................AD-67 XV. Reporting Systems Problems....................................................................................AD-68 XVI. Request for Financial and/or Statistical Data ............................................................AD-68 XVII. Identification Cards and Food List Orders.................................................................AD-68 XVIII. Clinic/Staff Ratio........................................................................................................AD-68 XIX. Nutrition Service Director Job Description ................................................................AD-68 XX. Compliance Reviews.................................................................................................AD-68 XXI. Medical Nutrition Therapy .........................................................................................AD-69 XXII. Registered and/or Licensed Dietitian Credentialing Policy for the Department of Public Health .....................................................................................AD-70 XXIII. Conflict of Interest .....................................................................................................AD-71

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XXIV. Renovations .............................................................................................................AD-71 XXV. Inter/Intra Agency Agreement ...................................................................................AD-71 XXVI. Patient Flow Analysis .................................................................................................AD-71 XXVII. State Plan ..................................................................................................................AD-76
A. Description............................................................................................................AD-76 B. Format and Reporting...........................................................................................AD-76 C. Annual Update of the Clinic Listing ......................................................................AD-77 XXVIII. Local Agency Application, Disqualification and Administrative Review ....................AD-77 A. Local Agency Application Process........................................................................AD-77 B. Local Agency Disqualification Process .................................................................AD-79 C. Local Agency Administrative Review....................................................................AD-80 XXIX. Special Project Program ...........................................................................................AD-81 A. Introduction ..........................................................................................................AD-81 B. Overview of Local Agency Special Project (LASP) Grants ...................................AD-81 C. Proposal Process .................................................................................................AD-82 D. Grant Management...............................................................................................AD-83 XXX. Request Form for a New Facility ..............................................................................AD-84 XXXI. Participant Characteristics Minimum Data Set (MDS) .............................................AD-84 XXXII. Local Agency Funding Allocation for Information on Funding Allocation ....................................................................................................AD-84

ATTACHMENTS AD-1. FFY 2012 Georgia WIC Master Agreement.............................................................AD-85 AD-2. Property Transfer Form ...........................................................................................AD-88 AD-3. Agreement for Disclosure of WIC Information .........................................................AD-89 AD-4. Release of Information Form ...................................................................................AD-93

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AD-5. Request to Establish New Clinics/Clinic Changes...................................................AD-94 AD-6. Computer System Issues and Problem Report Form ..............................................AD-95 AD-7. New Site Permission Form ......................................................................................AD-96 AD-8. Data Request Form .................................................................................................AD-97 AD-9. New Clinic Evaluation Report ..................................................................................AD-98 AD-10. Nutrition Services Director Job Description ...........................................................AD-104 AD-11. Patient Flow Analysis.............................................................................................AD-107
A. Option I ............................................................................................................AD-107 B. Option II............................................................................................................AD-111 AD-12. Inter/Intra Agency Agreement................................................................................AD-118 Option I ..................................................................................................................AD-119
A. Planned Budget for SFY ...........................................................................AD-124 B. Central Cost Allocation Plan (643)............................................................AD-125 Option II .................................................................................................................AD-126 A. Planned Budget for SFY ...........................................................................AD-130 B. Central Cost Allocation Plan (643)............................................................AD-131 AD-13. Local Agency NSA Funding Allocation .................................................................AD-132 AD-14. Local Agency Application......................................................................... AD-133 AD-15. Disqualification/Not Accepting an Application Form ..............................................AD-139 AD-16. Participant Characteristics Minimum Data Set (MDS).......................................AD-140 AD-17. Georgia WIC Clinic Listing (Instructions) .............................................................AD-151 AD-18. Request Form for a New Facility ...........................................................................AD-153 AD-19. Release of Information Form (court order).............................................................AD-155

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SECTION ONE - FINANCIAL MANAGEMENT

I.

STATE OPERATIONS

A.

General

The Office of Financial Services (OFS) of DPH maintains the financial records in a manner that reflects separate accountability for each activity administered by DPH, utilizing disbursement classifications as required by the state auditor and the various federal agencies. The financial system uses a combination of both data processing and manual entries. The process of writing checks, preparing check registers and other mass detail work, is performed by data processing systems. The records kept in the county Health Departments are subsidiary or supplemental. County departments submit monthly reports to the Office of Financial Services according to prescribed uniform reporting procedures. These reports cover the financial operations that will be reimbursed by the Department of Public Health. Supporting data for other county department administrative expenditures are not submitted directly to OFS; they are retained in the county department finance offices. County Health Departments' contract with Certified Public Account (CPA) firms to audit their records.

The State of Georgia Department of Audits performs both financial and program audits. State law mandates that the State Auditors perform a financial audit of the books and accounts of the Department of Public Health each fiscal year. The state auditors perform programmatic audits of specific programs as deemed necessary.

B. Cost Allocation Plan
The Department of Public Health is in the process of securing the Department of Health and Human Services approval for the Cost Allocation Plan.
C. Food Funds Management / Nutrition Services Administration
The Office of Financial Services functions as cash manager for the Department of Public Health. Federal funds are drawn from the Office of Treasury and Fiscal Services based upon the reimbursement of actual expenditures. A control disbursement account is used for WIC food redemption. Federal funds are requested and drawn through the electronic funds (Automated Standard Application for Payments system ASAP) transfer process and transferred into WIC Federal Funds Holding Account. All transfers of federal funds are drawn in accordance with regulations of the United States Department of the Treasury, Cash Management Improvement Act (CMIA), agreements with the Treasury and other cash management policies and procedures as designated by the United States Department of Agriculture (USDA). Monthly cash draws are reconciled and balanced with actual expenditures. Each grant award is recorded, balanced, and reported quarterly as designated. Actual expenditures are tracked through the Budget Cost Comparison Report.
When rebate funds are received from the formula contractor, those funds are used first to pay food expenditures. Federal food funds are not utilized until the rebate deposit is depleted. The cashier records the payment against the

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receivable by customer number and by invoice number. The cash manager takes the amount of the rebate into consideration before making any future draws on the Letter of Credit.
The Department accounts for transactions on a modified accrual accounting basis to record WIC expenditures and federal revenues. PeopleSoft Accounting System controls and records expenditures to assure expenses are within budget limits. PeopleSoft Accounting System ensures that withdrawals from the LOC are not in excess of immediate cash needs and are in compliance with the Cash Management Improvement ACT (CMIA). As rebates are received in the state office, the actual food expenditures presented by the WIC Banking system are paid against rebate balances first. The PeopleSoft Accounting System provides for accurate, current and complete disclosure of the financial status of the program, including a procedure which enables prompt and accurate payment of allowable costs. The Uniform Accounting System (UAS) is the subsidiary budget and expenditure control system in which the Department allocates and tracks local agency WIC administrative funding. Local agencies are allocated their administrative funding through allotment which they budget in UAS. These budgets are used as control budgets upon which local agencies may expend. Each month, local agencies report their expenditures against those budgets and request reimbursement for those expenditures through the Monthly Income and Expenditure Reports (MIERS) component of UAS. Upon close out of each month's MIERS, the Department's general ledger system (People Soft) is updated by UAS and the monthly local agency expenditures are recorded.

D.

Local Level Requirements

The local level requirements are as follows:

1. The Master Agreement for the Department of Public Health requires that local agencies maintain their Financial Management Systems in accordance with 45 CFR Parts 74.60 and 74.61 (Subpart H) and Official Code of Georgia Annotated (OCGA), Section 31-3-8. A copy of the Master Agreement for Public Health may be obtained from the Financial Management Section of Georgia WIC.

The DPH Administrative Policy and Procedures Manual and the DPH Grants to Counties Manual give specific instructions on the operation of a financial management system at the local level.
2. Each month local agencies must submit a Monthly Income and Expenditure Report (MIER) to the Public Health Grant-In-Aid office. Georgia WIC staff and/or Financial Management staff monitor these reports against approved budgets. During program reviews, equipment and computer inventories are reviewed to ensure program compliance.

3. The Public Health Master Agreement requires an annual audit of all local agencies. The DPH Office of Audits is responsible for overseeing this requirement. Non-compliance results in the immediate suspension of payments to the delinquent agency. The financial management staff of

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each local agency, in keeping with state agency requirements, is charged with oversight and accountability for WIC Program budgets and expenditures according to DPH and USDA Food and Nutrition Services (FNS) guidelines and instructions.
4. The allocation of Nutrition Service and Administration (NSA) Grant funds is based on methodology developed by Georgia WIC and the WIC Allocation Advisory Committee, with final approval from the Director of the Department of Public Health. Funds available for allocation to local agencies are determined by subtracting the cost of operations of the WIC Program, the Office of Nutrition and WIC and the centralized costs for management of the food grant, from the total NSA grant received from USDA. The balance is allocated to local agencies based on participation.
5. The WIC Allocation Advisory Committee is charged with assisting the Program and the Department of Public Health with developing an acceptable methodology for allocating federal grant funds to local agencies. Georgia WIC approved funding formula has been well accepted by local agencies due to its accuracy and fairness. Additionally, the Georgia WIC Allocation Advisory Committee makes recommendations to the WIC Program concerning caseload management strategies. A district heath director chairs the committee.
6. Operational and administrative funds are distributed to local agencies by contractual agreements. WIC funding to Georgia eighteen lead counties is part of the DPH Public Health Master Agreement. Funding to two nonprofit organizations is made through a standard DPH contract.
7. Budgets for local agencies are changed by means of contractual amendments.
E. Property Management and Procurement
1. See paragraph #204 of the DPH Public Health Master Agreement for property management requirements.
2. All purchases are made in accordance with laws governing purchases, OCGA, 50-5-50 through 50-5-124 and the Rules and Regulations of the Georgia Department of Administrative Services, Purchasing Division. Consultants and certain other contracts in excess of $250,000 must be approved by the State Office of Planning and Budget with exemptions to this requirement as stated in the Department of Administrative Services (DOAS) Georgia Procurement Manual, Chapter 2, and Section 3. A copy can be obtained from the WIC Program Financial Management Section.

F. Caseload Management/Food Cost Food Cost may come from three sources. A description of each source is listed below:
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1. CSC Covansys (the State's Data Processing and Banking Contractor) compiles a monthly Reconciliation Report (EWRR860G) report using a series of four reports: x Monthly Report of Food Expenditures x Bank Exception x Unmatched Redemption x Bank Listing
This data is based on the issue month of the voucher.
The State's Office of Financial Services enters the information from the Reconciliation Report (EWRR860G) into the state's financial system (People Soft).
2. The Vendor Section authorizes administrative payments to Vendors for returned vouchers. Vouchers may be returned for the following reasons: x Post and Stale date x Signature of participant missing x Exceeded maximum amount allowed x Altered vouchers x Missing Vendor stamp
Post and Stale dated vouchers are not approved for payment. Once these vouchers have been individually researched and payment has been authorized, the information is entered into People Soft. The Office of Financial Services will then release payment.
3. Orders for Special Formula are placed by clinics through the State Nutrition Services Unit.
These orders are reviewed for approval prior to the purchase of formula. Once approved, the formula is ordered and the information placed into People Soft for Office of Financial Services to process.

4. Once the Office of Financial Services has received all of the information, the final cost of redeemed month is entered into the FNA-798 Report.
5. Monthly Food expenditures as reported on the 798 report are recorded by issue month.
6. Projected participation is determined by the local agency assigned caseload in accordance to the state funding formula. The monthly projections are distributed using a three year trend analysis of closeout caseload.
7. Closeout Participation means the sum of:
a.) The number of persons who received supplemental foods instruments during the reporting period.
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b.) The number of infants who did not receive supplemental foods or food instruments but whose breastfeeding mother received supplemental foods or food instruments during the report period; and
c.) The number of breastfeeding women who did not receive supplemental foods or food instruments but whose infant received supplemental foods or food instruments during the report period.

8. Rebate is post by month received and is expended prior to the draw down of federal dollars.
9. Gross Obligation and Outlays are the unliquidated obligation and ongoing monthly operation cost.
II. LOCAL AGENCY OPERATIONS

Prior to July 1 of each year, all local agencies operating Georgia WIC, excluding contracted local agencies, must sign a copy of DPH Master Agreement which included Annex I and submit to the Budget Office (See Attachment AD-1). District staff receiving WIC funds must:
1. Provide services in accordance with the Child Nutrition Act of 1966, as amended by P. L. 108, for the delivery of services for the Special Supplemental Nutrition Program for Women, Infants and Children (WIC). This provider agreement is made pursuant to the Department of Public Health (DPH) Administration Policy and Procedures Manual, Part II A.I, the United Stated Department of Agriculture/Food and Nutrition Services (USDA/FNS) regulations at 7 C.F.R. Part 246, the Georgia WIC Procedures Manual, the Georgia Nutrition and State Plan, the Georgia WIC Guidance for Local Agency Planning, and all administered memos. (The aforementioned documents are hereinafter incorporated into the Master Agreement.)
2. Collect and submit accurate client data for WIC participants for the purpose of monitoring program performance. Comply with all Federal and state requirements in the collection of program data and make modifications as appropriate or requested within a specified time.
3. Employ appropriate staff to adequately perform WIC responsibilities in accordance with WIC staffing and processing standards, certification requirements, program integrity, and voucher accountability and security.
4. Participate in development of Georgia WIC State Plan that is annually submitted to USDA. Submit a local agency program plan to Georgia WIC by March 31st, unless another date has been designated as the due date for that year for inclusion in the annual State Plan.
5. When local agencies provide WIC Farmer's Market Nutrition Program services, they must provide WIC Farmer's Market Nutrition Program services according to the Federal regulations at 7 C.F.R. Part 248 and the Georgia WIC Farmer's Market Handbook.

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Reporting Requirements: 1. Submit an annual report by March 31 and October 31, unless another date has been
designated as the due date for that year for the previous Federal fiscal year (October thru September).
III. 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 Public Health. Title 7 Code of Federal Regulations Part 246 (7 C.F.R. Part 246)
B. Non-profit Agencies Adhere to the tenets of the negotiated contract and prescribed policies and procedures established by Georgia WIC and Department of Public Health, and by the Federal WIC regulations at 7 C.F.R. Part 246.
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.

IV. FUNDING REQUIREMENT
THE LOCAL AGENCY MUST:
1. Implement management controls to track and ensure accountability of program funds, assets and property, in accordance with WIC regulations. A penalty of up to $25,000 may be charged for the misuse or illegal use of program funds, assets or property. This applies to individuals that embezzle, willfully misapply, steal or obtain by fraud, assets or property, whether received directly or indirectly from USDA.
2. Have a central cost allocation plan that has prior approval from DPH, Office of Financial Services.
3. Ensure that the local agency staff complies with guidelines and procedures for

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requesting and expending funds awarded to the local agency for special projects. As an addendum to this annex, Georgia WIC shall outline project specific requirements in the "Local Agency Special Projects Terms and Conditions". Grant funds awarded for special projects shall not be used to supplant existing programs. All equipment purchases made with special projects funds are the property of Georgia WIC and shall be transferred back to the state at the termination of the project.
4. Maintain complete and accurate documentation of allocated funds received and expended by employing General Accepted Accounting Principles (GAAP) and making these records available for audit upon request of Georgia WIC or the Federal Agency.
5. In case of an audit exception, the local agency may be required to repay the Department from the local agency's non-participating funds.
6. Federal regulations require Georgia WIC to spend 97% (ninety-seven percent) 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 determined by the federal caseload mandate.
7. Request and obtain, through Georgia WIC, prior approval for the purchase of computers and /or related hardware and software regardless of cost and for any expenditure over $5,000 (five thousand dollars).
8. Complete all monthly Bank Exceptions Reports and Cumulative Unmatched Redemption (CUR) Reports received from the State EIC Branch or the Data Processing Contractor and return within the specified time. Local agencies will monitor clinics for compliance. Failure to correct the errors on the CUR Report when moved to Part Two of the report will require a monetary payback to Georgia WIC when the total amount of the redeemed vouchers exceeds $1,000.00 (one thousand dollars) monthly.
9. Place all employees who are paid entirely by WIC funds into the 301 cost pool.
10. Ensure that no WIC funds are expended toward a computer system unless the computer system has prior written approval by USDA.
11. The local agency that participates in Using Loving Support to Manage Peer Counseling agrees to the development, operation and evaluation of supervisory clinic staff and Peer Counselors (PC) as prescribed in guidance developed by Best Start Social Marketing. All peer counseling grant funds will be available as grant-in-aid under Program #329. A Peer Counselor must be a current or former WIC participant and must have breastfed for at least six (6) months. Preferred candidates should have six (6) months of personal breastfeeding experience. The actual number of peer counselors employed may be determined by the Health Director, as long as the individual Peer Counselor hours do not exceed thirty (30) hours a week. A Peer Counselor must be paid a minimum of ten dollars ($10.00) per hour.
A Peer Counselor must be reimbursed for all approved work related expenses as stated in the Department of Public Health Travel Regulations. The local contractors must have available an equal number of additional alternate Peer Counselors. The purpose of alternate Peer Counselors is to have trained replacements immediately available, in event of a Peer Counselor position

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vacancy. The grant award will include additional funds of ten dollars ($10.00) per hour for the training of the alternate Peer Counselors. Funds from this grant must not be used to supplant existing WIC financial resources. 12. Comply with the Georgia DPH Administrative Policy and Procedures and DPH Grants-to Counties Policies for administration of funds.
V. 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 Georgia WIC Inventory Database are required whenever new non-ADP equipment over $1,000 (one thousand dollars) or new ADP equipment for any dollar amount has been acquired. Equipment that is transferred, surplused, destroyed or reported stolen or missing also requires an 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 state office 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 state office 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 the Property Transfer Form (See Attachment AD-2) with appropriate fields marked to reflect that change. Forward the completed form to Georgia WIC electronically or by regular mail. Changes to the master file are then made by 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 DPH Real and Personal Property Management Manual Regulations.
2. Equipment without Value
Equipment that is no longer valuable and/or usable and is scheduled for destruction must be noted on Attachment AD-2. Also attach a Destruction of Surplus Property Affidavit, which must be signed by the

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appropriate state authority and returned to the district prior to their taking any action.
3. Missing Equipment and Stolen Equipment
Districts are to complete the Property Transfer Form (see Attachment AD-2) which gives a brief explanation of the circumstances leading to equipment disappearance. Attach a Police report to this attachment. If the equipment is recovered, complete the Property Transfer Form (see Attachment AD-2); attach an explanation for the equipment reappearance. Forward all forms to Georgia WIC.
VI. RETROACTIVE BENEFITS AND REIMBURSEMENTS
A. Revenue
Any revenue generated as a result of administering Georgia WIC is considered as governmental and/or program income and must be used to further program objectives in accordance with Federal WIC regulations at 7 C.F.R. Part 3016.
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 at $100.00 (one hundred dollars) or more will have to pay a penalty of $25,000 (twentyfive thousand dollars). SFP Regional letter, #250-04, March 8, 2004.

VII. LOCAL AGENCY COLLECTIONS
Local agency collections are funds recovered through the collection of local agency claims. The state agency is responsible for monitoring local agency operations including financial management systems (7 C.F.S. Section 246.19(b)). If any food or NSA funding provided to a local agency is misused, diverted from program purposes, or lost as a result of thefts, embezzlements, or unexplained causes, the state agency should assess a claim against the local agency, as well as require the local agency to submit a corrective action plan.

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SECTION TWO STATEWIDE COST ALLOCATION PLAN

I.

INTRODUCTION TO WIC STATEWIDE COST ALLOCATION PLAN

PURPOSE

The statewide cost allocation plan describes methods for assigning costs to a state or local agency's WIC grant or sub-grant. State and local agencies shall use this guide in assigning costs to WIC, except where other documents, such as an Advance Planning Document (APD), statewide cost allocation plan, indirect cost rate agreement, etc., prescribe other methods.

AUTHORITY
The WIC authorizing statute at 42 U.S.C. 17(h)(1)(A) provides that FNS shall allocate Federal WIC funds to States each fiscal year "for costs incurred by State and local agencies for nutrition services and administration for such year." The Federal cost principles stated in OMB Circular A-87 (Cost Principles for State, Local, and Indian Tribal Governments), OMB Circular A-122 (Cost Principles for Nonprofit Organizations), and 31 CFR Part 74, Appendix E (Principles for Determining Costs Applicable to Research and Development Under Grants and Contracts With Hospitals) provide general rules for use by the respective types of organizations to which they apply in charging costs to Federal programs for reimbursement by Federal awarding agencies. Program-specific allowable cost rules are found at 7 CFR 246.14 and in written guidance issued by Food and Nutrition Services. This plan implements these authoritative documents with respect to Georgia WIC.

BACKGROUND
The Congress created the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) to serve as an adjunct to good health care for low-income women, infants, and children. Its primary mission is to provide nutritious supplemental foods and nutrition education for such persons during critical times of growth and development.
As important as nutrition is to overall health and well-being, the Congress also recognized that nutritional services without other primary health care and related social services are simply halfmeasures. Therefore, WIC is also tasked with operating as a front-line health screening and risk assessment program and serving as a linkage or gateway to health care and social services. WIC accomplishes this by performing an aggressive information and referral function.
Many costs incurred by state or local agencies are directly attributable to WIC; these are known as direct costs. However, the delivery of WIC benefits has great potential to overlap the health service parameters of a number of other state and federal public health and public assistance programs. Examples of such programs include those funded under Title V of the Maternal and Child Health Block Grant, Community and Migrant Health Centers, Medicaid (especially its Early and Periodic Screening, Diagnostic and Treatment (EPSDT) component), Immunization, Head Start, and the WIC Farmers' Market Nutrition Program. The same costs that benefit WIC often benefit these and other programs as well. Such shared costs must be assigned to programs through a process of allocation.
This is particularly true in cases where state and local agencies have integrated the delivery of program services in order to make them available to clients in a "one-stop shopping" mode. While this operating method minimizes duplication of effort between programs, it results in different programs sharing many costs. The trend toward the integration of health service

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delivery magnifies the need for cost allocation systems sophisticated enough to assign WIC its fair share of costs, but not so complex as to create administrative burdens that discourage "one-stop shopping".

PUBLIC HEALTH GRANT-IN-AID PROGRAM
Georgia county public health departments are the service-delivery arm of the Department of Public Health. While they are independent legal entities, through the means of a contract, they work with the Division to provide public health services to the citizens of the state. WIC funds are allocated to the lead county health department as part of the Department's Grant-in-Aid Program and, as such, are recorded into the department's (Uniform Accounting System) UAS computer system. UAS then interfaces with the department's financial records. This allows for the reimbursement to the lead county health department for expenditures and for the preparation of financial reports.
COST DISTRIBUTION
Programs that are part of public health's Grant-in-Aid to counties (GIA) may have some of their costs direct charged. All of the costs that are direct should be directly charged to a program. The remainder should be allocated. Costs are collected monthly by the UAS and updated to PeopleSoft. When the update to PeopleSoft occurs, the direct charged programs are posted to their funding sources.
COMPOSITION OF COST
Direct Costs are those that can be identified specifically with a particular cost objective. All WIC expenditures are direct cost including all employees 100% paid by WIC and non WIC paid employees who occasionally perform WIC services.

II. BASIC COST PRINCIPLES/WIC ALLOWABLE COSTS
GENERAL REQUIREMENTS
The basic guidelines for identifying costs which may be charged to a Federal grant are found in OMB Circular A-87 for state agencies and governmental local agencies, and in A-122 for nongovernmental, nonprofit local agencies. These circulars are implemented by departmental regulations at 7 C.F.R. Parts 3016 and 3019. To be deemed an allowable charge to a Federal grant under these guidelines, a cost must:
A. Be reasonable and necessary to administration of WIC services. B. Be treated consistently. This means that costs incurred for the same purpose in like
circumstances must be consistently charged to a Federal grant as either direct costs or indirect costs. C. Be consistent with and allowable under federal, state and local laws, regulations and policies. D. Be determined in accordance with generally accepted accounting principles (except where the applicable Federal cost principles expressly provide otherwise) and
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adequately documented.
E. Be net of applicable credits.
F. Be charged to the correct accounting period.
G. Not be charged to more than one Federal grant or used to meet a matching or cost sharing requirement for more than one Federal grant, either in the current or a prior accounting period.
H. Be allocable. A cost is allocable to the Federal grant only to the extent that it benefits the grant's objective.
I. Costs must be allocated equitably in terms of the benefit derived. To accomplish this requirement, the relative benefit must be approximated through the use of a reasonable method.

A cost is considered reasonable if, in nature and amount, it does not exceed what a prudent person would spend for a like item or activity to achieve the program's objectives. Costs incurred to carry out essential WIC functions, and which cannot be avoided without adversely impacting WIC operations, will be considered necessary. Costs determined to be reasonable and necessary to meet WIC objectives are allowable charges to the Federal WIC grant, provided these costs meet the other requirements for allow ability. Since the WIC grant is limited in amount, the priority of the expenditure in relation to other demands on available resources must also be considered.
Activities considered necessary to achieve WIC objectives are discussed in this chapter. They may be performed solely for the benefit of meeting WIC objectives, or to meet objectives of both WIC and non-WIC programs. Further, these activities may be performed by WIC-only or multiple-program employees. The costs of the activities are allocable to WIC grant to the extent that the activities are performed to benefit WIC.

COMPONENTS OF FEDERAL WIC GRANT
WIC's authorizing statute, the Child Nutrition Act of 1966, as amended, provides that a state agency's Federal WIC grant will consist of two components: one for the cost of supplemental food benefits and one for the costs of nutrition services and administration (NSA). Costs necessary to fulfill Program objectives e.g., costs to provide WIC participants with supplemental foods, nutrition education, breastfeeding promotion and support and referral to related health services, are allowable charges to the applicable component of the WIC grant.

NUTRITION SERVICE ADMINISTRATION (NSA) COSTS - GENERAL
A state or local agency must perform the following functions in order to meet WIC objectives: nutrition education, breastfeeding promotion and support, participant certification and caseload management, food delivery, screenings for and referrals to other social and medical service providers and general programs management. Therefore, the costs associated with these functions are allowable charges to the NSA component of the Federal WIC grant, provided these costs meet the other requirements for allowability.

FOOD COST The WIC food delivery system is managed by Georgia WIC.
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NSA COSTS FOR CLINIC ACTIVITIES

The following activities performed in WIC clinics are considered necessary to meet WIC objectives. Therefore, provided all other requirements for allowability are satisfied, the direct and indirect costs associated with performing these activities are allowable charges to the WIC NSA grant.

A. Participant Certification/Case Management

1. Data Collection and Risk Assessment for Eligibility Determination

i)

obtain application data and assess for eligibility -

name, income, residency, etc.

ii) anthropometric screening (heights, weights) and blood work (hematocrit or hemoglobin)

iii) obtain and/or score nutritional practices

iv) screening for other medical conditions which affect the participant's nutritional status and needs such as substance abuse, food allergies, diabetes, etc. (no laboratory analysis)

2. Case Management

i)

Nutrition care plan development

ii) Maintenance of participant manual or automated charts/records
iii) Appointment scheduling, reminders, and reviewing certification/recertification information needed with applicant/participant
iv) Participation in public health needs assessment/surveillance activities related broadly to maternal and child health as long as WIC has access to information gathered

B. Nutrition Education

i)

Preparing, scheduling, providing group or individual nutrition

education

ii) Preparing nutrition education materials iii) Providing High risk nutrition counseling C. Breastfeeding Promotion and Support
1. Preparing, scheduling, providing group or individual breastfeeding
promotion and support.
2. Preparing breastfeeding promotion and support materials.

D. Food Delivery 1. Development and assignment of WIC food packages. 2. Issuing food instruments and accounting for food instrument issuances.

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E. Health Care Referrals
The costs of some screening (excluding laboratory tests), referrals for other medical/social services such as immunizations, prenatal care, well child care and/or family planning, and follow-up on participants referred for such services, may be charged to the WIC grant. However, the cost of the services performed by the other health care/social service provider to which the participant has been referred shall not be charged to the WIC grant.
A hematological test for anemia such as a hemoglobin, hematocrit, or free erythrocyte protoporphyrin test is the only laboratory test required to determine a person's eligibility for WIC. As such, the cost of a hematological test for anemia is the only laboratory cost that may be charged to the WIC grant. Laboratory tests to screen for other health conditions including, but not limited to, pregnancy, lead and diabetes are not allowable charges to the WIC grant. When WIC operates in a clinic which requires complete blood samples for more complex blood tests, WIC will only pay an agreed upon amount that approximates the cost that WIC would have incurred if it had conducted its own blood tests (hemoglobin, hematocrit or free erythrocyte protoporphyrin tests) for WIC eligibility.

NSA COSTS FOR PROGRAM MANAGEMENT ACTIVITIES
The following program management activities are considered necessary to meet Georgia WIC objectives; and therefore, the costs associated with conducting these activities are allowable charges to the WIC Nutrition Service Administration grant component.
A. Maintaining accounting records
B. Audits
C. Budgeting
D. Food instrument reconciliation, monitoring and payment
E. Vendor Monitoring
F. Outreach
UNALLOWABLE COSTS
Under no circumstances may the Federal WIC grant be charged in full or in part for the costs of services which are demonstrably outside the scope of WIC's authorizing statute. For example, the WIC grant may be charged to screen WIC participants for immunizations and refer and follow-up on WIC participant immunizations, but WIC may not be charged for the cost to administer the shot, the vaccine or vaccine-related equipment. Further, costs which are specifically disallowed by applicable Federal cost principles may not be charged to the WIC grant.

DISTRIBUTION OF FUNDS TO STATES Below are the official Regulations for Distribution of Funds to the States: (7 C.F.R. Section 246.16)

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"b) Distribution and application of grant funds to State agencies. Notwithstanding any other provision of law, funds made available to the State agencies for the Program in any fiscal year will be managed and distributed as follows:
(1) The State agency shall ensure that all Program funds are used only for Program purposes. As a prerequisite to the receipt of funds, the State agency shall have executed an agreement with the Department and shall have received approval of its State Plan.
(2) Notwithstanding any other provision of law, all funds not made available to the Secretary in accordance with paragraph (a)(6) of this section shall be distributed to State agencies on the basis of funding formulas which allocate funds to all State agencies for food costs and NSA costs incurred during the fiscal year for which the funds had been made available to the Department. Final State agency grant levels as determined by the funding formula and State agency breastfeeding promotion and support expenditure targets will be issued in a timely manner.
(i) Back spend authority. The State agency may back spend into the prior fiscal year up to an amount equal to one percent of its current year food grant and one percent of its current year NSA grant. Food funds spent back may be used only for food costs incurred during the prior fiscal year. NSA funds spent back may be used for either food or NSA costs incurred during the prior fiscal year. With prior FNS approval, the State agency may also back spend food funds up to an amount equal to three percent of its current year food grant in a fiscal year for food costs incurred in the prior fiscal year. FNS will approve such a request only if FNS determines there has been a significant reduction in infant formula cost containment savings that affected the State agency's ability to maintain its participation level.
(ii) Spend forward authority. (A) The State agency may spend forward NSA funds up to an amount equal to three (3) percent of its total grant (NSA plus food grants) in any fiscal year. These NSA funds spent forward may be used only for NSA costs incurred in the next fiscal year. Any food funds that the State agency converts to NSA funds pursuant to paragraph (f) of this section (based on projected or actual participation increases during a fiscal year) may not be spent forward into the next fiscal year. With prior FNS approval, the State agency may spend forward additional NSA funds up to an amount equal to one-half of one percent of its total grant. These funds are to be used in the next fiscal year for the development of a management information system, including an electronic benefit transfer system.
(B) Funds spent forward will not affect the amount of funds allocated to the State agency for any fiscal year. Funds spent forward must be the first funds expended by the State agency for costs incurred in the next fiscal year.
(iii) Reporting requirements. In addition to obtaining prior FNS approval for certain spend forward/back spending options, the State agency must report to FNS the amount of all funds it already has or intends to back spend and spend forward. The spending options must be reported at closeout.
(c) Allocation formula. State agencies shall receive grant allocations according to the formulas described in this paragraph. To accomplish the distribution of funds under the allocation formulas, State agencies shall furnish the Department with any necessary financial and Program data.
(1) Use of participation data in the formula. Wherever the formula set forth in paragraphs (c)(2) and (c)(3) of this section require the use of participation data, the Department shall use participation data reported by State agencies according to 246.25(b).

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(2) The funds available for allocation to State agencies for NSA for each fiscal year must be sufficient to guarantee a national average per participant NSA grant, adjusted for inflation. The amount of the national average per participant grant for NSA for any fiscal year will be an amount equal to the national average per participant grant for NSA issued for the preceding fiscal year, adjusted for inflation. The inflation adjustment will be equal to the percentage change between two values. The first is the value of the index for State and local government purchases, as published by the Bureau of Economic Analysis of the Department of Commerce, for the 12-month period ending June 30 of the second preceding fiscal year. The second is the best estimate that is available at the start of the fiscal year of the value of such index for the 12month period ending June 30 of the previous fiscal year. Funds for NSA costs will be allocated according to the following procedure:
(i) Fair share target funding level determination. For each State agency, FNS will establish, using all available NSA funds, an NSA fair share target funding level which is based on each State agency's average monthly participation level for the fiscal year for which grants are being calculated, as projected by FNS. Each State agency receives an adjustment to account for the higher per participant costs associated with small participation levels and differential salary levels relative to a national average salary level. The formula shall be adjusted to account for these cost factors in the following manner: 90 percent of available funds shall provide compensation based on rates which are proportionately higher for the first 15,000 or fewer participants, as projected by FNS, and 10 percent of available funds shall provide compensation based on differential salary levels, as determined by FNS.
(ii) Base funding level. To the extent funds are available and subject to the provisions of paragraph (c)(2)(iv) of this section, each State agency shall receive an amount equal to 100 percent of the final formula-calculated NSA grant of the preceding fiscal year, prior to any operational adjustment funding allocations made under paragraph (c)(2)(iv) of this section. If funds are not available to provide all State agencies with their base funding level, all State agencies shall have their base funding level reduced by a pro-rata share as required by the shortfall of available funds.
(iii) Fair share allocation. Any funds remaining available for allocation for NSA after the base funding level required by paragraph (c)(2)(ii) of this section has been completed and subject to the provisions of paragraph (c)(2)(iv) of this section shall be allocated to bring each State agency closer to its NSA fair share target funding level. FNS shall make fair share allocation funds available to each State agency based on the difference between the NSA fair share target funding level and the base funding level, which are determined in accordance with paragraphs (c)(2)(i) and (c)(2)(ii) of this section, respectively. Each State agency's difference shall be divided by the sum of the differences for all State agencies, to determine the percent share of the available fair share allocation funds each State agency shall receive.
(iv) Operational adjustment funds. Each State agency's final NSA grant shall be reduced by up to 10 percent, and these funds shall be aggregated for all State agencies within each FNS region to form an operational adjustment fund. The Regions shall allocate these funds to State agencies according to national guidelines and shall consider the varying needs of State agencies within the region.
(v) Operational level. The sum of each State agency's stability, residual and operational adjustment funds shall constitute the State agency's operational level. This operational level shall remain unchanged for such year even if the number of Federally-supported participants in the program at such State agency is lower than the Federally-projected participation level. However, if the provisions of paragraph (e)(2)(ii) of this section are applicable, a State agency will have its operational level for NSA reduced in the immediately succeeding fiscal year.

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(3) Allocation of food benefit funds. In any fiscal year, any amounts remaining from amounts appropriated for such fiscal year and amounts appropriated from the preceding fiscal year after making allocations under paragraph (a)(6) of this section and allocations for nutrition services and administration (NSA) as required by paragraph (c)(2) of this section shall be made available for food costs. Allocations to State agencies for food costs will be determined according to the following procedure:
(i) Fair share target funding level determination. (A) For each State agency, FNS will establish a fair share target funding level which shall be an amount of funds proportionate to the State agency's share of the national aggregate population of persons who are income eligible to participate in the Program based on the 185 percent of poverty criterion. The Department will determine each State agency's population of persons categorically eligible for WIC which are at or below 185% of poverty, through the best available, nationally uniform, indicators as determined by the Department. If the Commodity Supplemental Food Program (CSFP) also operates in the area served by the WIC State agency, the number of participants in such area participating in the CSFP but otherwise eligible to participate in the WIC Program, as determined by FNS, shall be deducted from the WIC State agency's population of income eligible persons. If the State agency chooses to exercise the option in 246.7(c)(2) to limit program participation to U.S. citizens, nationals, and qualified aliens, FNS will reduce the State agency's population of income eligible persons to reflect the number of aliens the State agency declares no longer eligible.
(B) The Department may adjust the respective amounts of food funds that would be allocated to a State agency which is outside the 48 contiguous states and the District of Columbia when the State agency can document that economic conditions result in higher food costs for the State agency. Prior to any such adjustment, the State agency must demonstrate that it has successfully implemented voluntary cost containment measures, such as improved vendor management practices, participation in multi-state agency infant formula rebate contracts or other cost containment efforts. The Department may use the Thrifty Food Plan amounts used in SNAP, or other available data, to formulate adjustment factors for such State agencies.
(ii) Prior year grant level allocation. To the extent funds are available, each State agency shall receive a prior year grant allocation equal to its final authorized grant level as of September 30 of the prior fiscal year. If funds are not available to provide all State agencies with their full prior year grant level allocation, all State agencies shall have their full prior year grant level allocation reduced by a pro-rata share as required by the shortfall of available funds.
(iii) Inflation/fair share allocation. (A) If funds remain available after the allocation of funds under paragraph (c)(3)(ii) of this section, the funds shall be allocated as provided in this paragraph (c)(3)(iii). First, FNS will calculate a target inflation allowance by applying the anticipated rate of food cost inflation, as determined by the Department, to the prior year grant funding level. Second, FNS will allocate 80 percent of the available funds to all State agencies in proportionate shares to meet the target inflation allowance. Third, FNS will allocate 20 percent of the available funds to each State agency which has a prior year grant level allocation, as determined in paragraph (c)(3)(ii) of this section and adjusted for inflation as determined in this paragraph (c)(3)(iii), which is still less than its fair share target funding level. The amount of funds allocated to each State agency shall be based on the difference between its prior year grant level allocation plus target inflation funds and the fair share funding target level. Each State agency's difference shall be divided by the sum of the differences for all such State agencies, to determine the percentage share of the 20 percent of available funds each State agency shall receive. In the event a State agency declines any of its allocation under either this paragraph (c)(3)(iii) or paragraph (c)(3)(ii) of this section, the declined funds shall be reallocated in the percentages and manner described in this paragraph (c)(3)(iii). Once all State agencies

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receive allocations equal to their full target inflation allowance, any remaining funds shall be allocated or reallocated, in the manner described in this paragraph (c)(3)(iii), to those State agencies still under their fair share target funding level.
(B) In the event funds still remain after completing the distribution in paragraph (c)(3)(iii)(A) of this section, these funds shall be allocated to all State agencies including those with a stability allocation at, or greater than, their fair share allocation. Each State agency which can document the need for additional funds shall receive additional funds based on the difference between its prior year grant level and its fair share allocation. State agencies closest to their fair share allocation shall receive first consideration.
(d) Distribution of funds to local agencies. The State agency shall provide to local agencies all funds made available by the Department, except those funds necessary for allowable State agency NSA costs and food costs paid directly by the State agency. The State agency shall distribute the funds based on claims submitted at least quarterly by the local agency. Where the State agency advances funds to local agencies, the State agency shall ensure that each local agency has funds to cover immediate disbursement needs, and the State agency shall offset the advances made against incoming claims as they are submitted to ensure that funding levels reflect the actual expenditures reported by the local agency. Upon receipt of Program funds from the Department, the State agency shall take the following actions:
(1) Distribute funds to cover expected food cost expenditures and/or distribute caseload targets to each local agency which are used to project food cost expenditures.
(2) Allocate funds to cover expected local agency NSA costs in a manner which takes into consideration each local agency's needs. For the allocation of NSA funds, the State agency shall develop an NSA funding procedure, in cooperation with representative local agencies, which takes into account the varying needs of the local agencies. The State agency shall consider the views of local agencies, but the final decision as to the funding procedure remains with the State agency. The State agency shall take into account factors it deems appropriate to further proper, efficient and effective administration of the program, such as local agency staffing needs, density of population, number of persons served, and availability of administrative support from other sources.
(3) The State agency may provide in advance to any local agency any amount of funds for NSA deemed necessary for the successful commencement or significant expansion of program operations during a reasonable period following approval of a new local agency, a new cost containment measure, or a significant change in an existing cost containment measure.
(e) Recovery and reallocation of funds. (1) Funds may be recovered from a State agency at any time the Department determines, based on State agency reports of expenditures and operations, that the State agency is not expending funds at a rate commensurate with the amount of funds distributed or provided for expenditures under the Program. Recovery of funds may be either voluntary or involuntary in nature. Such funds shall be reallocated by the Department through application of appropriate formulas set forth in paragraph (c) of this section.
(2) Performance standards. The following standards shall govern expenditure performance.
(i) The amount allocated to any State agency for food benefits in the current fiscal year shall be reduced if such State agency's food expenditures for the preceding fiscal year do not equal or exceed 97 percent of the amount allocated to the State agency for such costs. Such reduction shall equal the difference between the State agency's preceding year food expenditures and the performance expenditure standard amount. For purposes of determining the amount of such reduction, the amount allocated to the State agency for food benefits for the preceding fiscal year shall not include food funds expended for food costs incurred under the spendback
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provision in paragraph (b)(3)(i) of this section or conversion authority in paragraph (g) of this section. Temporary waivers of the performance standard may be granted at the discretion of the Department.
(ii) Reduction of NSA grant. FNS will reduce the State agency's NSA grant for the next fiscal year if the State agency's current fiscal year per participant NSA expenditure is more than 10 percent higher than it's per participant NSA grant. To avoid a reduction to its NSA grant level, the State agency may submit a "good cause" justification explaining why it exceeded the applicable limit on excess NSA expenditures. This justification must be submitted at the same time as the close-out report for the applicable fiscal year. Good cause may include dramatic and unforeseen increases in food costs, which would prevent a State agency from meeting its projected participation level."

DISTRIBUTION OF FUNDS TO LOCAL AGENCIES
7 C.F.R. Part 246 requires each state that receives Food and Nutrition Services Administration (NSA) Funds must be assigned an initial caseload target.
The Georgia WIC Local Agency Funding Front-end Methodology is patterned after the Federal funding formula. The formula is designed to provide greater initial funding, but includes a reward for those local agencies that exceed the initial assigned caseload. The methodology discussed below as Option A allows those local agencies that are experiencing growth to receive a larger share of NSA funds on the front-end. Agencies failing to meet caseload are assigned Option B for funding.
Funding Options:
A. Local agencies that meet or exceed caseload targets using the current Federal fiscal year four-month closeout, one month (30) day and one month (issued) will be assigned a new target using the highest one-month participation.
B. Local agencies that do not meet caseload targets using the current Federal fiscal year four-month closeout, one month-30 day and one month (issue) will be assigned a six-month average caseload target.
Each Federal fiscal year WIC management establishes the amount of NSA funds to be made available to the local agency. The local agency funding formula is established by using two (2) formulas:
1. Initial funding dollars y statewide caseload y 12 months = Rate.
2. Caseload x Rate x 12 months = Local Agency Allocation.
Occasionally, additional NSA funds become available for local agency allocations. The additional funds are allocated using the funding formula, but with no increase in assigned caseload.
PARTICIPATION COST ADJUSTMENT
A. Participant Cost Adjustment will be accessed to Local Agencies that are not averaging their assigned caseload for the current federal fiscal year. The adjustment will be based upon the first four (4) months closeout, the issue month and the Thirty-Day report (October through AD-19

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March). The monetary adjustment will be based upon six (6) months average participation times the original funding rate.
1. Current federal fiscal year initial funding rate x current 6 month average participation x 12 months = Participant Cost Adjustment.
B. Participate Cost Adjustment will be allocated in the next federal fiscal year to the Local Agencies that exceed their prior year assigned caseload. This allocation will be made based upon the availability of NSA funds and State Management discretion. The Participant Cost Adjustment funding formula is as follows:
1. Prior federal fiscal year initial funding rate x participant(s) that exceeds caseload x 12 months = Participant Cost Adjustment.

PERFORMANCE STANDARD
WIC Management may establish performance standards that may increase participation over and above the assigned caseload formula.
COST- RELATED COMPLIANCE REQUIREMENTS
WIC's authorizing statute and program regulations at 7 CFR, section 246.14(c) require a State to incur a stated level of cost for each of two functions, nutrition education, breastfeeding promotion and support.
During each fiscal year, each state agency shall expend, for nutrition education activities and breastfeeding promotion and support activities, an aggregate amount that is not less than the sum of one-sixth of the amount expended by the state agency for costs of NSA and an amount equal to its proportionate share of the national minimum expenditure for breastfeeding promotion and support activities. The amount to be spent on nutrition education shall be computed by taking one-sixth of the total fiscal year NSA expenditures. The amount to be spent by a state agency on breastfeeding promotion and support activities shall be an amount that is equal to at least its proportionate share of the national minimum breastfeeding promotion expenditure as specified in paragraph (c)(1) of this section. The national minimum expenditure for breastfeeding promotion and support activities shall be equal to $21 multiplied by the number of pregnant and breastfeeding women in the Program, based on the average of the last three months for which the Department has final data. On October 1, 1996 and each October 1 thereafter, the $21 will be adjusted annually using the same inflation percentage used to determine the national administrative grant per person. If the state agency's total reported nutrition education and breastfeeding promotion and support expenditures are less than the required amount of expenditures, FNS will issue a claim for the difference. The state agency may request prior written permission from FNS to spend less than the required portions of its NSA grant for either nutrition education or for breastfeeding promotion and support activities. FNS will grant such permission if the state agency has sufficiently documented that other resources, including in-kind resources, will be used to conduct these activities at a level commensurate with the requirements of this paragraph (c)(1). However, food costs used to purchase or rent breast pumps may not be used for this purpose. Nutrition education costs are limited to activities which are distinct and separate efforts to help participants understand the importance of nutrition to health. The cost of dietary assessments for the purpose of certification, the cost of prescribing and issuing supplemental foods, the cost of screening for drug and other harmful substance use and making referrals to drug and other harmful substance abuse services, and the cost of other health-related screening shall not be applied to the expenditure requirement for nutrition education and breastfeeding promotion and support
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activities. The Department shall advise state agencies regarding methods for minimizing documentation of the nutrition education and breastfeeding promotion and support expenditure requirement. Costs to be applied to the one-sixth minimum amount required to be spent on nutrition education and the target share of funds required to be spent on breastfeeding promotion and support include, but need not be limited to:
(i) Salary and other costs for time spent on nutrition education and breastfeeding promotion and support consultations whether with an individual or group;
(ii) The cost of procuring and producing nutrition education and breastfeeding promotion and support materials including handouts, flip charts, filmstrips, projectors, food models or other teaching aids, and the cost of mailing nutrition education or breastfeeding promotion and support materials to participants;
(iii) The cost of training nutrition or breastfeeding promotion and support educators, including costs related to conducting training sessions and purchasing and producing training materials;
(iv) The cost of conducting evaluations of nutrition education or breastfeeding promotion and support activities, including evaluations conducted by contractors;
(v) Salary and other costs incurred in developing the nutrition education and breastfeeding promotion and support portion of the State Plan and local agency nutrition education and breastfeeding promotion and support plans; and
(vi) The cost of monitoring nutrition education and breastfeeding promotion and support activities.
(2) The cost of Program certification, nutrition assessment and procedures and equipment used to determine nutritional risk, including the following:
(i) Laboratory fees incurred for up to two hematological tests for anemia per individual per certification period. The first test shall be to determine anemia status. The second test may be performed only in follow up to a finding of anemia when deemed necessary for health monitoring as determined by the WIC state agency;
(ii) Expendable medical supplies;
(iii) Medical equipment used for taking anthropometric measurements, such as scales, measuring boards, and skin fold calipers; and for blood analysis to detect anemia, such as spectrophotometers, hematofluorometers and centrifuges; and
(iv) Salary and other costs for time spent on nutrition assessment and certification.
(3) The cost of outreach services.
(4) The cost of administering the food delivery system, including the cost of transporting food.
(5) The cost of translators for materials and interpreters.
(6) The cost of fair hearings, including the cost of an independent medical assessment of the appellant, if necessary.
(7) The cost of transporting participants to clinics when prior approval for using Program funds to provide transportation has been granted by the state agency and documentation that such service is considered essential to assure Program access has been filed at the state agency. Direct reimbursement to participants for transportation cost is not an allowable cost.
(8) The cost of monitoring and reviewing Program operations.

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(9) The cost, exclusive of laboratory tests, of screening for drug and other harmful substance use and making referrals for counseling and treatment services.
(10) The cost of breastfeeding aids which directly support the initiation and continuation of breastfeeding."
Each health district is responsible for expending 22% (twenty-two percent) of its total expenditures towards Nutrition Education and 9% (nine percent) of its total expenditures toward Breastfeeding Education and Promotion. Failure to expend the required amount will result in the following Federal fiscal year allocation being reduced by the difference.

III. METHOD FOR CHARGING THE COST OF WAGES AND SALARIES
AUTHORITY A state or local agency must record data on WIC employees and non WIC paid employees that perform WIC services. Time and effort of employees engaged in WIC cost objectives must provide documentation supporting the distribution of time and effort. The recording of employees compensated time to WIC must be supported by a Personnel Activity Record System (PARS). This documentation should reflect a real time recording of the actual activity performed (2 CFR 225 Appendix B, paragraph 11.h (1) - (2); 2 CFR 230 Appendix B, paragraph 7.m (1); 45 CFR Part 92, Appendix E, paragraph 1X, B, 7, C).
PERSONNEL ACTIVITY REPORT SYSTEM (PARS) Personnel Activity Report System (PARS) is a time keeping system that allows you to post time for WIC services. This document will illustrate a step by step method of recording time spent for Programs and Activities.
RULES FOR PARS x All 100% WIC paid employees must record a full day work by Program and Activity using PARS x All non WIC paid employees that perform any WIC services must record a full day of work by Program and Activity using PARS. x Non WIC paid employees that do not perform any WIC services are not required to use PARS x WIC dollars will not be allocated to paid non WIC staff for paid time off (breaks, sick, vacation, etc.) unless the non WIC paid employees record all Programs and Activities for a full work day on a daily basis using PARS x If a non WIC paid employee records a full days work by Program and Activity, WIC's fair share may be allocated using PARS for charges distributed across all Programs for paid time off x WIC cannot be charged for employees that are paid via Local Agency's State Approved Cost Allocation Plan (Indirect cost) x WIC cannot be charged for employees that are paid via County's Approved Central Services Cost Allocation Plan

SPECIAL REPORTS The district will be able to create ad hoc district specific reports using the limited data elements used for the Georgia State Reports (line lists can be obtained via CSV files). Reports cannot be created if the data elements are not currently captured.

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PERSONNEL ACTIVITY REPORT SYSTEMS (PARS) ACCESS

Locate the PARs icon

then double click to open the application

Enter your Employee ID- numeric field that must be at least 6 characters in length.

Enter Password- Passwords must be at least 4 characters in length. Input can be alpha or

numeric or a combination.

If you have forgotten your password, click on the "Forget Your Password?" located at the bottom of the PARs Login window. The below window will appear. You will need to contact the Help Desk at (800)796-1850 for a reset. Please provide the Help Desk with your Employee ID and Full Name.

Once the application has been launched the following screen displays. PARs displays with tabs for easy access. The PARs tab is for time entry and the Reports tab displays the reports available to you based on the permissions assigned to your login. Every user will have a reports tab that will include at least one report that allows you to monitor your daily time entry.
PROGRAM / ACTIVITIES
There are multiple Programs and Activities to choose from. Selecting a Program on the right will display the Activities associated with that program below. Break have been added for time entry to all Programs. Paid Time Off is currently only associated with the WIC Program. You will notice the WIC Program is the default upon entry into PARs.
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x Clinic Choose the Clinic where services are being provided from the drop down. x Date - The Date defaults to today's date, but can be modified if posting time for a
previous date up to 14 calendar days. If a date is entered older than 14 calendar days the following message will display. You will need to correct the date field before proceeding.
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Note: If the date field is modified, that date will remain on all entries until a new date is added.

Next to the date field is an ellipses

by clicking on this button a calendar will

display.

You can click on a specific day in the calendar which will populate the Date on the time entry

screen.

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x WIC ID Enter a valid WIC ID for the WIC client in which services have been provided.

x Time You can select the amount of time spent providing the service by clicking the up/down arrows to the right of the field. The time may also be manually entered in minutes.
NOTE: If 1 hour 15 minutes was spent on an activity the time must be entered as 75 minutes. The screen clip gives you an example of how the Time entry should appear. The time will be entered in minutes, notice below the Time Entry field that the hour and minute displays for you to verify that the time entered is correct.
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x Activity Choose from the list the type of service being provided. There are now sixteen options to choose from under the WIC Program: a) Voucher Issuance b) Intake c) Individual Nutrition Ed. d) Nutrition Ed. VICS e) Group Nutrition Ed. f) Non-Client Nutrition Ed. g) BF Ed. h) BF Ed. VICS i) Group BF Ed. j) Non-Client BF Ed. No WIC ID Required k) Client Services l) Non-Client WIC Services No WIC ID Required m) Client Ineligible for Service No WIC ID Required n) WIC Administration No WIC ID Required o) PTO Paid Time Off No WIC ID Required p) Break No WIC ID Required

x WIC client based services that must include the WIC ID number are:
a. Client Services
Height and weight measurements done by non CPA staff, hemoglobin done by non CPA staff, interpreter services that are not specifically nutrition education or breastfeeding, certification procedures that are not specifically nutrition education or breastfeeding. Phone calls that can be tied to a WIC ID number and is easily accessible.
2. Individual Nutrition Education
Nutrition education provided by CPA's at certification, recertification, voucher pickup, infant mid assessment, or secondary contact (Low or high risk follow up).
Low risk secondary education provided by a Nutrition Assistant (NA). Language interpretation for nutrition education.
3. Group Nutrition Education.
Group setting nutrition education provided by CPA or NA. Language interpretation for group nutrition education. Group nutrition education documentation will require multiple WIC ID
numbers. You will enter each WIC ID number and the total number of minutes for the class. The system will calculate time per participant based on the total time and total number of participants.

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4. Nutrition Education VICS
Individual nutrition education provided to clients by CPA'S via VICS at certification, recertification, voucher pick up, infant mid assessment or secondary contact
Low risk secondary education provided by CPA or NA via VICS Language interpretation for nutrition education provided via VICS
5. Individual Breast Feeding Education.
Nutrition education related to breastfeeding provided by CPA's at certification, recertification, infant mid assessment, or secondary contact (low or high risk follow up).
Low risk secondary education provided by a Nutrition Assistant (NA). Language interpretation for individual breastfeeding education.
6. Group Breastfeeding Education
Group setting breastfeeding nutrition education provided by CPA or NA Language interpretation for group breastfeeding education. Group breastfeeding education documentation will require multiple WIC ID
numbers. You will enter each WIC ID number and the total number of minutes for the class. The system will calculate time per participant based on the total time and total number of participants.
7. Breastfeeding Education VICS
Individual breastfeeding education provided to clients by CPAS via VICS at certification, recertification, voucher pick up, infant mid assessment or secondary contact
Low risk secondary breastfeeding education provide by CPA or NA via VICS Language interpretation for breastfeeding education provided via VICS
8. Voucher Issuance
Vouchers issued to clients at certification, recertification, infant mid assessment, or secondary contact (Low or high risk follow up).
Language interpretation for voucher issuance
9. Intake
At certification and recertification when income, ID, residency and demographics are collected and financial eligibility is determined.
Language interpretation at intake process. 10. Nutrition Education VICS
Nutrition education as during certification and recertification, or delivery of secondary and high risk nutrition education when used via VICS- (Video Conferencing)

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11. Breastfeeding Education VICS
Breastfeeding education as during certification and recertification, or delivery of secondary and high risk nutrition education when used via VICS- (Video Conferencing)
x WIC client based services that are not tied to a WIC ID number are:
1. Non client WIC services
WIC services that are provided to benefit WIC or potential WIC clients Examples include phone calls, appointments without ID number, reports,
chart audits, batching, equipment maintenance, creating client schedules, inventories, ordering medical supplies, making copies, , staff meeting, and language interpretation for any of the above.
2. Client ineligible for service
Time spent on intake and client cannot be assigned WIC ID # due to ineligibility.
3. Non client Nutrition Education
Time spent on non client nutrition education such as nutrition education displays, bulletin boards, class prep, and nutrition education material creation, and annual nutrition education plan, procurement of nutrition education supplies, continuing nutrition education for staff, language interpretation for any of the above.
4. Non client Breastfeeding Education
Time spent on non client breastfeeding education such as breastfeeding coordinator activities, preparing breastfeeding classes, breastfeeding displays, bulletin boards, breastfeeding education material creation, procurement of breastfeeding supplies, breastfeeding continuing education for staff, language interpretation for any of the above.
5. WIC Administration
Any paid personnel time spent to the benefit of the WIC program that cannot be tied to another activity or cost objective. Example, personnel management (performance management plan), preparing/reviewing reports such as participation, processing standards, etc.
6. WIC PTO (Paid Time Off)
Staff paid from the 301 cost pool budget would put their annual and sick leave in this category
Staff paid from the 001 county budgets can only count a proportion of their time to this category based on the percentage of time they work on WIC services if they do continuous time reporting, i.e. record every minute of every day they work. Example, they must record their full day on the days they work in the WIC program and the days they don't do any work in the WIC program.
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7. Break WIC
Staff paid from 301 cost pool budget would put any paid break time in this category. Note, lunch is non paid time and should not be entered into the Break WIC category.
Staff paid from the 001 county budgets can only enter a proportion of their time in this category based on the percentage of time that they perform WIC services if they do continuous time reporting, i.e. record every minute of every day they work. Example, they must record their full day on the days they work in the WIC program and the days they don't do any work in the WIC program.
Once the information has been input, click the Save button. The information will immediately be sent to CSC via WebServices. You will need to ensure the computer has internet access. If a Client has had multiple services provided, you can choose each one individually and enter a line for each service provided and amount of time spent NOTE: The ID number will remain for additional activities until a new ID is entered. PTO (Paid Time Off) is a new activity. This is the only activity within PARs that allows you to post date time to the system. Your entries can be entered for up to 17 days in advance. PARs will display the following message if you exceed the date range. The error message also displays the date that cannot be exceeded for your convenience. This date is calculated 17 days out from today's date.

The following is a list of Programs and Activities, available in PARs for time entry. WIC
x Voucher Issuance x Intake x Individual Nutrition Ed. x Nutrition Ed. VICS x Group Nutrition Ed. x Non-Client Nutrition Ed. - No WIC ID Required x BF Ed. x BF Ed. VICS x Group BF Ed.
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x Non-Client BF Ed. - No WIC ID Required x Client Services x Non-Client WIC Services - No WIC ID Required x Client Ineligible for Service - No WIC ID Required x WIC Administration - No WIC ID Required x PTO Paid Time Off x Break-WIC Adolescent and Adult Health Promotion
x Adolescent Health and Youth Development x Cancer Screening and Prevention x Family Planning x Health Promotion x Tobacco Use Prevention x Break-Adolescent and Adult Health Promotion
Adult Essential Health Treatment Services x Cancer State Aid x Hypertension Management x Refugee Health Services x Break Adult Essential Health Treatment Services
Emergency Preparedness-Trauma System x Emergency Medical Services x Preparedness Coordination for Emergencies x Trauma System x Injury Prevention x Break Emergency Preparedness- Trauma System
Epidemiology x Epidemiology x Laboratory Services-Health Info & Assessment x Break Epidemiology
Immunization x Immunization x Break Immunization
Infant & Child Essential Health Treatment Services x Babies Born Healthy AD-31

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x Babies Can't Wait x Children's Medical Services x Genetics/Sickle Cell x Infant & Child Oral Health x Prenatal/Maternal Health x Regional Tertiary Care Centers x Break Infant & Child Essential Health Treatment
Infant & Child Health Promotions x Comprehensive Child Health x ICHP Lab Services x Nutrition-Woman, Infants and Children x Break - Infant & Child Health Promotions
Infectious Disease Control x HIV/Aids x Laboratory-Infectious Disease x Sexually Transmitted Disease Treatment and Control x Tuberculosis Treatment and Control x Break - Infectious Disease Control
Inspections and Environmental Hazard Control x Environmental Health x Laboratory - Environmental Health x Break - Inspections and Environmental Hazard
County Services x County Services x Break - County Services

Administrative

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GROUP ACTIVITY When entering any type of group education classes in the activity box, a pop up screen will appear, that allows you to enter the number of clients participating in the class, up to 100. The screen defaults to 10 available spaces for ID numbers. Enter the number of clients attending the class in the specified box. This will expand the number of ID boxes available for entry. See the example below.

Enter the ID#'s in the spaces provided then enter the time in minutes for the length of the class. Upon Save you will be taken back to the main PARs screen, the information will display in the Grid.
The ID#'s displayed in the Grid are the beginning ID # of each set of 10. To edit a specific group make the selection in the Grid then select Edit to make the appropriate changes. The time
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entered will automatically break down accordingly, based on the number of participants attending and the length of the class for the group.
By monitoring the Grid, it identifies whether CSC received your entry successfully or if there was a problem with the record. The Grid will display entries in, Green, Blue or Red.
Green Successful record has been sent to CSC.
Blue If a record displays in Blue in the Grid once Save has been pressed, this means that the record has not yet been sent to CSC. You should check and verify if you are able to access the internet, if not, the record will be sent once connection is restored. If you find you are able to access the internet successfully, but the record is still not sending, please contact the CSC help desk at (800)796-1850 for assistance.
Red - If a record is displayed in red verify the information input is correct. The Entry Status box, displays the information that needs verification. If this is one of the Group Activities, and an invalid ID(s) display in the Entry Status field, you will need to select the appropriate entry from the Grid and click the edit button to display the Group WIC ID's assigned to the activity. If the participant was terminated and is coming back onto the program, or if they are a new participant the ID# will not yet be on file. If you determine that all information is correct leave the record as is, then once the ID# is in the CSC database the record will update when Save is selected. NOTE: If the record returns as Green nothing will appear in the Entry Status Box. To Edit, select the record in the Grid by clicking in the gray box to the left of the ID#, this will place an arrow next to the record, then press Edit. This places the information at the top of the time entry window where corrections can be made. Editing cannot be done within the Grid. Once the corrections have been made, press Save to update the information. If you determine you have selected the incorrect record in the Grid or the record does not need editing, you may click the Undo button. This will take you back to the point before Edit was pressed.

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PARs EMPLOYEE EDITS
PARs, has an Administrative function that allows you as an Administrator to Add/Edit Employee information. CSC still maintains the Administrator setup for PARs, but once setup, the Administrator can maintain employee information within their district.
This document will step you through the procedures of adding, editing or deactivating an employee.
To access the Employee screen, click on the Employee Edits tab.

Note: This tab is only available if an Employee has been granted Administrative access to PARs.
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Since this is an Administrative function you will be required to re-enter your password to gain access. Below is an example of the password screen.

Once you have entered your password, press <Enter>. If you have entered an invalid password you will receive the following message.
Click Ok. This will take you back to the PARs screen, click Employee Edits tab again to be prompted to enter the password. Then press the <Enter> on your keyboard.
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Once you have entered the correct password, you will then be taken into the Employee screen.

Enter the Employee number, if this is a new Employee, you will need to enter the First Name, Last Name and the Pay Rate with Fringe. This will be the employee's hourly rate of pay. You will need to key the decimal between the dollars and cents. NOTE: The rate of pay will display with asterisks until you place the cursor within this field. Choose the Employee WIC Type from the drop down. The options available are 100% WIC or Non-WIC.
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Place a check mark in the box next to reports if the employee should be granted permissions to run All PARs reports. Do not place a check mark in this box for the employee to access their personal Daily activity report. All employees have permissions to access their personal time entry report.
Select the clinic on the left side of the window, the employee is to be assigned to, then click the Add To button to add that clinic to the grid on the right side of the window. If they are to be assigned to more than one clinic select the next clinic, then the Add to button again for each clinic. If the employee needs to be assigned to all clinics within the district then choose the "Add all Clinics in DU to ID".
NOTE: The clinic selection is limited to the Clinics within your district unit.
Once the clinic(s) is selected and added to the Grid a check mark will be placed in the Active box located next to the clinic in the Grid. See the screen clip below to see how the window will appear.

If you have selected an incorrect clinic from the list, you can click in the column labeled Active to remove the check mark, next to that clinic.
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Click Save this will add the employee information to the employee database, stored at CSC.

To search for an employee click on the ellipses next to the employee ID.

This

activates the Search window,

A search can be defined by District/Unit, Clinic First Name or Last name, then click Find It. If available the employees information will display in the Grid. To select the employee click in the Gray box to the left of the employee ID this will place an arrow next to the employee, click Select.
The Undo button will allow you to remove information that was keyed, if Save has not yet been selected, it will not remove an employee.
Deactivate Emp ID: Enter the employee ID and select the Deactivate Emp ID Button, this removes the check mark from Emp_active status field within the grid. This will remove the check marks from all clinics they have been assigned to. If they only need to be deactivated from certain clinics, in this case, you would only need to click on the check box to remove the check mark from that specific clinic assignment so they will not be able to add time for that clinic. Once you have completed this step, click Save.
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To Edit an Employees record, such as changing their rate of pay or correcting the spelling of a name. Access employee edit as above, then enter the Employee ID, this will populate the fields with the employee's information. To Edit the Rate of Pay click in that field and change the pay rate. NOTE: The rate of pay will display with asterisks until you place the cursor within this field. Click Save.

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PARs REPORTS
PARs reports are accessible through the PARs time keeping system. The ability to run PARs reports is available to employees who have been given rights by their PARs Administrator within the District.
Note: The PARs Report tab is available to all users so that they may monitor their daily time entry input.
From the PARs time keeping screen click on the Reports tab.

This document is an overview of the catalog of reports available in PARs. x You may select a report by double clicking on a report name or by clicking on a report name then choosing the select button in the lower left portion of the screen.
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Administrative

Each selection criteria screen contains a description of the report. The criterion shown depends on the report selected. Each selection criteria window contains the following radio button options.
x Screen This allows you to display the report on screen instead of printing.
x Printer Sends the selected report to the default printer.
x File Allows printing to a designated file on your local computer or a network drive.
x CSV - By selecting to print to CSV creates a CSV folder in the C:\Program Files\PARs folder. The CSV report is saved in an Excel Spreadsheet format.

Reports Available in PARs

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x Activity Count Summary By District/Unit/Clinic Provides total counts of each activity by specified date range.
x Activity Summary By District/Unit/Clinic Provides activity counts by specified date range. By selecting specific criteria this allows printing for single or multiple clinics. To achieve gathering of all clinics information within a district only input a date range in the Selection Criteria screen.
x Activity Summary By Employee Provides activity information for employees by date range. Selection Criteria allows to report on and individual employee number, or by selecting the radio button options of Active employees only, Inactive employees only, or to print for All Active and Inactive employees.
x Daily Employee Activity - Lists detailed entry information based on the currently logged in employee ID, within a specified date range.
x Detailed District/Unit/Clinic Activity Lists employee activities information by District for all clinics or Individual Clinic, by specified date range.
x Detailed Employee Activity Lists detailed employee information by activities performed within a specified date range. Allows criteria reporting of a single employee ID, or by selecting the radio button options of Active employees only, Inactive employees only, or to print for All Active and Inactive employees.
x Employee Summary Activity Summary total of employee activities for specified date range. Sort by single employee ID, or by selecting the radio button options of Active employees only, Inactive employees only, or to print for All Active and Inactive employees.
x Employee Summary by District/Unit/Clinic Activity Summary total of employee activities for a specified date range. Sort by Clinic or multiple clinic selections. To report for all clinics within a District, only input a date range in the Selection Criteria screen.
x Nutrition Ed Summary by District/Unit/Clinic Summary count of Nutrition Education activity by selected date range. Sort order by District/Unit/Clinic.

Reports

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GEORGIA WIC 2012 PROCEDURES MANUAL To access Reports, click on the Reports tab.

Administrative

If you do not have permissions to run reports, only one report will display in the list. To access this report you may either double click or click the select button. The following selection criteria will display.
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Specify a date range for the report. Make a selection to how you would like to view the report by clicking on one of the radio buttons next to Screen, Printer, File or CSV.
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Manually Apply Updates PARs allows electronic updates, which means you are no longer required to download updates manually from GWISnet. On occasion CSC may need to make a change to the PARs.EXE, which will take some user interaction to apply, but the update will be sent to your computer through the self update. If CSC has sent an update that needs to be applied manually, you will see the following message,

Click OK to clear the message, PARs will then load. Exit the application and go to the C:\Program Files\PARs\Updates folder. Highlight the PARs.exe then right click and Cut, then go up a folder to the C:\Program files\PARs and select Paste. You will then be asked to overwrite the existing file, click Yes. You are now ready to access PARs.
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DEFINITIONS OF COST CATEGORIES

Duty

PAR Category

Add/ Update Immunizations Add/ Update Record in Central Registry

client svc Intake

Add/ Update WIC client in WIC screen 1 (clerical intake or update 30 day) Answering phone (checking on clients appointment times, hours of operation, giving directions to clinic, etc) Answering questions (or calls) about how to use WIC vouchers or WIC approved foods Auditing charts
Batching TADs and voucher files Calibrating equipment (scales, height/length boards, Hemocue machines, etc) Checking GWIS for dual participation Checking Medicaid/ Updating Medicaid screen Classes (preparing) for NE or BF Classes (teaching) for NE/BF Client referrals
Collecting anthropometrical data (weight & length/height) Collecting lab values (Hgb) Computer work for clients transferring in Creating class (objectives, curriculum, handouts, etc) Creating client schedules Data input for certification Document Secondary Nutrition Education Document Update Immunizations Document/ Update Record in Central Registry Fixing critical errors Follow up on breastfeeding progress Follow up phone call on issued breastpumps GWISnet request forms Health Fairs
Home visits to breastfeeding mothers
Hospital visits for breastfeeding mothers

Intake
client svc if know ID#, non client svc if no ID # client svc if know ID#, non client svc if no ID # non client svc, non client NE or BF if done for nutrition QA review non client svc non client svc
client svc Intake Non client NE or BF NE or BF client svc, NE if done by CPA as part of cert/re-cert client svc, NE if done by CPA client svc, NE if done by CPA client svc NE or BF non client svc client svc individual Nutr Ed client svc Intake client svc individual bf ed individual bf ed non client svc Non client svc, Non client NE or non client BF Individual bf ed (PARS not entered by Peer Counselor) individual bf ed (PARS not entered by Peer Counselor)

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Interpretation Services
Inventorying breast pumps Inventorying manual vouchers Inventorying VPOD Issuing breastpump Mailing out supplies/ inventory/ materials/ equipment to the clinics

Individual NE or BF if interpreting for CPA or NA. Client svc for intake, etc. Non client BF non client svc non client svc individual bf ed WIC admin

Maintaining relationship with community partnership

NE or BF

Make/ Change Appointment Making copies of materials (i.e. "How to file a complaint form")

client svc if know ID#, non client svc if no ID #
non client svc

Ordering & Inventorying formula in stock Ordering Breastpumps Ordering nutrition education or breastfeeding materials and supplies Ordering medical or office supplies Outreach Paperwork/ phone calls to give transfer information Paperwork/ phone calls to request transfer information Phone calls to doctors Preparing requisition for purchases of nutrition education and breastfeeding supplies

non client svc Non client BF NE or BF
Non client svc non client svc client svc Intake client svc NE or BF

Preparing requisition for purchases of medical and office supplies
Printing VOC and EVOC reports Printing/ voiding vouchers Providing clinic with alphabetic master file list (printing and mailing) Reporting computer problems with SWO & M&M Retroactive Reconciliation Report Reviewing clients rights, obligations, and how to file a complaint Self-reviews (full audit) Sending out memos (action, information, policy) Staff leave reports, meetings, PMF's, trainings, time reports Staff Meetings (preparing) Staff Meetings (attending) with or without NE content Teaching classes Training (attending or preparing) specific to NE or BF Training (attending) not specific to NE/BF Training (Preparing) not specific to NE/BF

non client svc client svc voucher issuance non client svc
non client svc non client svc client svc non client svc or non client NE/BF WIC admin WIC admin WIC Admin Non Client WIC or Non-client NE/ BF Group nutr ed or group bf ed Non client NE or BF Non-Client WIC WIC Admin

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Training requests specific to NE/BF Unmatched redemption report (CUR part 1 and 2) Update TAD (i.e. food package change) Update WIC screen 2-4 for certification Vendor training, visits Verifying over-income clients Voter registration Voucher issuance WIC equipment inventory Working on WIC budget Working the Bank Exception Report Working the batch acknowledgement report

Administrative
Non client NE or BF non client svc non client svc client svc non client svc client ineligible for svc Intake voucher issuance WIC admin WIC admin non client svc non client svc

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FREQUENTLY ASKED QUESTIONS

How do we log our time if you make an appointment for a client who doesn't have a WIC ID # yet? Answer- It would be logged under non-client WIC services.
Is a voucher pick-up listed under non client WIC services? Answer- No, it would be coded under voucher issuance.
How about when reports are done or someone doing a white envelope. These things can take time. Is it necessary to report these activities? For example, I am doing a white envelope and I review each paper TAD to see if any information needs to be entered. Answer- First, assuming you fall under the category for county paid WIC staff, it is very important to account for any WIC time. This example would be coded under non-client WIC services.
When we add a new baby or a recertification on someone who has not been on in a while, the number comes up red. Because they won't show up at Covansys for several days, my question is: Do we need to go back when that batch shows rec'd and edit that line or will it send auto? Answer- No, you do not need to do anything else. The system will eventually link this ID number to a WIC active participant.
When we do our terminations, do we put each individual ID# in PARs? Answer- No, you would not need to put each individual ID number into PARs. This would need to be coded under non-client WIC services.
I don't see anything that allows me to make changes after I have entered time into this system? Answer- Yes, you can make edits after the information has been entered: 1. Click the entry to be edited in the history grid. 2. Click the edit button. 3. Make changes as needed on the top row (not on the history grid). 4. Click the save button.
When I see a client, I enter them in and then when the nutritionist gets through, and I print vouchers and see them again do I do another entry? Or does the one entry cover all? Answer- You can enter the data either way. You could track your total time with the client and enter it after all services have been completed or you can enter at the time you are doing each service. However it is important to break the services out. For instance one client will require multiple entries by multiple staff. For instance- An NA staff may perform 15 minutes of individual nutrition education, 15 minutes of intake, 3 minutes of voucher issuance. CPA staff may perform 5 minutes of client service, 10 minutes of individual nutrition education, and 5 minutes of breastfeeding education. The bottom line is the client number and the total time needs to be documented.
Can a successful transmission be edited? Example an active ID is put in but it is the wrong ID? Answer- Yes, click the record in question in the history grid, click the edit button, change the field(s) as needed at the top, then click save.
Can info be deleted? Example: an invalid ID is entered. This will not let the transmission go through but it won't let us delete the incorrect ID? Answer- No, but as above, the line can be edited. If not needed, instead of adding a new record, select it, click edit and just type over it with good information. If effect, turn it into a good record.

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What about entering ID for new babies and people who have been termed when they are certified? A TAD would not have been created yet so the ID number we give them won't be valid and our time won't transmit? Answer- The system will keep trying to validate any record that is red. Once the information makes it from your front end system, and we have access to it from the PARs backend system, the fields will turn green if valid. It might take a couple of days, up to 5 days, but it will eventually validate. If the entry turns red or green it has been transmitted to us, it stays blue if it has not been transmitted, but you will get a message on the screen informing you why it is still blue.

IV. GUIDELINES FOR LOCAL AGENCY COST ALLOCATION METHODOLOGY

OVERVIEW

The fundamental principle for assigning non-salary costs to cost objectives is the same as for salary costs: a state or local agency assigns a cost item incurred solely for a single cost objective to that cost objective; a cost incurred for multiple cost objectives must be distributed to such cost objectives such that each bears a portion of the cost commensurate with the benefit received from it. When allocating shared non-salary costs to several different programs or other cost objectives, it is important to group pools of costs to be allocated and select bases for allocating such costs in a manner which will produce equitable and reasonable charges to each cost objective.

Most government units provide certain services, such as motor pools, computer centers, purchasing, accounting, etc., to operating agencies on a centralized basis. Since federally-supported awards are performed within the individual operating agencies, there needs to be a process whereby these central service costs can be identified and assigned to benefitted activities on a reasonable and consistent basis. The central service cost allocation plan provides that process. All cost and other data used to distribute the costs included in the plan should be supported by formal accounting and other records that will support the propriety of the costs assigned to Federal awards.

Guidelines and illustrations of central service cost allocation plans are provided in a brochure published by the Department of Health and Human Services entitled "A Guide for State and Local Government Agencies (ASMB - C10): Cost Principles and Procedures for Establishing Cost Allocation Plans and Indirect Cost Rates for Grants and Contracts for the Federal Government." A copy of this brochure may be obtained from the Superintendent of Documents, U.S. Government Printing Office.

A.

Definitions

1. "Billed central services" means central services that are billed to
benefitted agencies and/or programs on an individual fee-for-service or similar basis. Typical examples of billed central services include computer services, transportation services, insurance, and fringe benefits.

2. "Allocated central services" means central services that benefit operating
agencies but are not billed to the agencies on a fee-for-service or similar basis. These costs are allocated to benefitted agencies on some reasonable basis. Examples of such services might include general accounting, personnel administration, purchasing, etc.

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3. "Agency or operating agency" means an organizational unit or
subdivision within a governmental unit that is responsible for the performance or administration of awards or activities of the governmental unit.

B.

Scope of the Central Service Cost Allocation Plans

The central service cost allocation plan will include all central services costs that will be claimed (either as a billed or an allocated cost) under Federal awards and will be documented as described in OMB Circular A-87, Section E. Costs of central services omitted from the plan will not be reimbursed.

LEAD COUNTY COST ALLOCATION PLAN
All lead counties claiming central service costs must develop a plan in accordance with the requirements described in OMB Circular A-87 and maintain the plan and related supporting documentation for audit. Since lead counties receive funds as a subrecipient, the State will be responsible for negotiating indirect cost rates and/or monitoring the sub-recipient's plan. The health district must submit a Central Cost Allocation to the Department for approval.

CENTRAL COST ALLOCATION PLAN FOR COUNTIES
The lead county may allow the counties within its district to charge a central cost allocation to their WIC funding. A central cost allocation are those costs that are common to all programs, such as gas, electric, water, maintenance, security expenses and other approved cost. All programs must be charged based on an equitable methodology, such as occupied space or number of employees. For a county to charge a central cost allocation, the county must submit a Central Cost Allocation Plan for review and approval to the lead county. The lead county must provide at least annually a review, approval, monitoring and oversight of the Plan. A copy of the county approved Plan must be maintained on sight at the lead county office and available upon the request of auditors. A copy of the Plan must be provided to the State WIC office.
BASES FOR DISTRIBUTING SHARED SERVICES
The following table lists suggested bases for distributing shared costs. The suggested bases are not mandatory for use. Any base which produces an equitable distribution of cost may be used. These bases may be used to distribute and directly charge nonsalary costs not covered in an indirect cost agreement approved by the cognizant agency or to negotiate an indirect cost agreement with the cognizant agency.

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TYPE OF SERVICE

SUGGESTED BASES FOR ALLOCATION

Accounting Budgeting
Buildings lease management Data processing Disbursing service Employees retirement system administration Insurance management service Legal services Mail and messenger service
Motor pool costs including automotive management Office machines and equipment maintenance Office space use and related costs (heat, light, janitor services, etc.) Organization and management services Payroll services Personnel administration Printing and reproduction Procurement service Local telephone Health services Fidelity bonding program

Number of transactions processed. Direct hours of identifiable services of employees of central budget. Number of leases. System usage. Number of checks or warrants issued. Number of employees contributing.
Direct hours. Direct hours. Number of documents handled or employees served. Miles driven and/or days used.
Direct hours.
Square foot of space occupied.
Direct hours.
Number of employees. Number of employees. Direct hours, job basis, pages printed, etc. Number of transactions processed. Number of telephone instruments. Number of employees. Employees subject to bond or penalty amounts.

INEQUITABLE METHODS OF COST ALLOCATION
If a cost allocation method produces an inequitable distribution of costs, this may result in questioned or disallowed costs during a subsequent audit. The incidence of inequitable allocation of non-salary costs to WIC occurs much less frequently than the incidence of inequitable allocation of salary costs to WIC. However, the following are just a few examples that have been documented in recent audit reports:
A. Facility expenses (building use, janitorial services, utilities, etc.) had been allocated on the basis of the number of employees rather than the square footage occupied. This resulted in a disproportionate share of the total cost allocated to WIC. A tour of the facility revealed that the per-employee space was not consistent among programs. Typically, other programs that were co-located

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with WIC had much more space per employee than did WIC. Therefore, square footage occupied generally provides a more reasonable and equitable distribution of this cost.
B. Allocating professional liability insurance coverage to WIC based on the number of patient visits without regard to the risk involved in each visit produced inequitable charges to WIC. When contacted, the insurance company stated that WIC had been included in the insurance coverage at no additional charge due to its low risk. An equitable method for allocating malpractice insurance to WIC would consider the amount of the professional's time spent on WIC operations and the relatively low risk of the certification process.
C. Supplies as a pool of costs allocated to WIC included supplies not used by nor allowable for WIC, such as popcorn and toothbrushes for a health fair and flowers for an employee on sick leave. When allocating a pool of costs, the pool should consist of only allowable costs.

EXPENSING EQUIPMENT PURCHASES
The preferred method of recovering the cost of a capital asset, such as equipment, is to claim depreciation expense or use allowance under OMB Circular A-87, Attachment B, paragraph 15 or OMB Circular A-122, Attachment B, paragraph 11, as applicable. However, a state or local agency may seek prior approval to charge the entire acquisition cost of the equipment to the Federal grant or subgrant for the fiscal year in which the purchase is made, (meaning to "expense" it). If more than a negligible portion of the "expensed" equipment's use is expected to benefit programs other than WIC, then WIC cannot bear the entire acquisition cost. Rather, the state or local agency must allocate the acquisition cost among programs on the basis of their anticipated respective benefit from the equipment's use.

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SECTION THREE - 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 C.F.R. Section 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 `06 Policy Memos may be destroyed once the FFY `07 Procedures Manual has been received.

B. Records and Reports - Accessibility of Records

Food Nutrition Services (FNS) may require the state or local agencies to supply medical data and other information collected for WIC in a form that does not identify particular individuals, yet enable the state agencies to evaluate the effect of food intervention upon low-income individuals determined to be at nutritional risk.

C. Retention Schedule

1. The following documents must be retained for five (5) years plus current Federal fiscal year:
(1) WIC Assessment/Certification Forms (2) Nutrition Questionnaires and All Secondary Nutrition Education
Contacts (3) Growth Charts/Weight Gain Grids (4) VOC Card Inventories (5) Medical Records (6) WIC Termination/Ineligibility/Waiting List Forms (7) Vendor Monitoring Reports (8) Computer Generated Voucher Registers/Voucher Printing On
Demand (VPOD) Receipts (9) Manual Voucher Inventory Records (10) Budgets and Expenditure Reports (11) Contracts (12) Indirect Cost Plan (13) Shared Costs Documentation (14) Fair hearing and civil rights complaints and all related
documentation (15) Federal, State, District, County Audit reports (16) Copies of manual vouchers (17) Vouchers Activity Report (18) Dual participation Reports*

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(19) Cumulative Unmatched Redemptions Part 1* (not matched to issuance record
(20) Cumulative Unmatched Redemptions Part 2* (not matched to a valid certification record)
(21) Batch Control Report (22) Batch Control Form and Module (23) Critical Error Report (24) Canceled Food Instruments (25) Lost/Stolen/Destroyed/Voided Voucher Report (26) Separation of Duty Form/ District office (27) Request for WIC Services Log (28) Personnel Documentation (29) District Self Reviews (30) Waiting List
2. The following documents must be kept for two (2) years: (1) Voter Registration Documentation (2) Master List
3. The following documents must be retained for one (1) year plus the current year: (1) Voucher Packing List/VPOD Confirmation Notice (2) TAD's
*The original copy of these reports with their manual reconciliation must be sent to the Georgia WIC prior to being destroyed. Georgia WIC 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 WIC office forms, e.g., pamphlets, flyers. Please forward revised, reformatted or modified forms to Georgia WIC Nutrition Services Unit for prior approval before distribution.
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 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

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6. Medicaid-Percentage of Poverty Income by Type and Age Categories
7. Medicaid-Priority Counts by Percentage by Poverty Income Level
8. Numeric Master File Listing 9. Percentage of Poverty Level Income Level by Type and Age
Categories 10. Priority Counts by Percentage of Poverty Income Level 11. Trimester Analysis Report 12. Unduplicated Participation Report, State Fiscal Year 13. Unduplicated Participation Report, Federal Fiscal Year 14. Waiting List Report 15. WIC Status (Type) by Reason Certified
b. Monthly Reconciliation
1. Bank Exception Report 2. Bank Listing 3. Closeout Reconciliation Report 4. Cumulative Unmatched Redemptions Over 30 Days-Based on
CUR-Part 1 5. Cumulative Unmatched Redemption Over 30 Days-Based on
CUR-Part 2 6. District Unit/County Compliance Summary 7. Dual Participation Report-Part 1 8. Ethnic Enrollment and Participation by Priority (Issue 30 Day)
and Closeout 9. Ethnic Participation Summary 10. Financial and Program Status 11. Food Cost Allocation (Projection) 12. Food Package Create Report 13. Food Package Expenditures Report 14. Infant Formula Rebate Report Concentrated, Powder, Ready
To Feed 15. Infant Rebate County Summary 16. Infant Rebate District Unit Summary 17. Migrant Participation Summary 18. Migrant Enrollment and Participation by Priority (Issue 30 Day)
and Closeout 19. Monthly Report of Food Expenditures Summary (Issue 30 Day)
and Closeout 20. Monthly Report of Food Expenditures by Vouchers Code (Issue
30-Day Closeout) 21. Participant Totals 22. Participation Summary by District/Unit 23. Previously Unmatched Redemptions, Which Were Matched 24. Unmatched Redemption's Report 25. EVOC Card Information
c. Monthly Reconciliation - Vendor Cycle
1. Cumulative Vendor Totals

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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

Administrative

II. WIC ACRONYM AND LOGO

A. Authority

The acronym "WIC" was registered with the U.S. Patent and Trademark Office on 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 on April 16, 1991. Regulations authorizing the use of the WIC acronym and logo are provided in 42 U.S.C. Section 1786, 15 U.S.C. Section 1051 et seq., and 7 C.F.R. 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

The WIC logo and acronym shall be used for official use only. FNS reserved the

right to approve and use of the logo and acronym. Georgia WIC may use the

logo or acronym on the items below:

Brochures

Leaflets

Bulletins

Letters

Business Cards (for employees) Manuals

Cups

Newspapers

Directories

Posters

Food Instruments

Radio and T.V. Announcements

Forms (i.e., Cert. forms)

Reports

Guides

Studies

Immunizations Initiatives

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. 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

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public service and will contribute to public information and education concerning Georgia WIC. Non-profit 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 Georgia WIC in writing. The written request must include a copy/sample of the way in which the acronym or logo will be used. Georgia WIC must respond in writing as to whether such use is authorized.
D. WIC Food Vendors
At the discretion of Georgia WIC, 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. 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 as to whether such use is authorized.
E. Unauthorized Use
Any person who uses the WIC acronym or the WIC logo in an unauthorized manner, including close facsimiles thereof, in total or in part, may be subject to injunction and the payment of damages. Any person who is aware of such violations should provide the information to FNS.

III. LOBBYING RESTRICTIONS
The state /local agencies must not use Federal funds for the lobbying of specific Federal awards. Recipients of any Federal grants, contracts, loans, or cooperative agreements are required to disclose expenditures made with their own funds for such purpose.
IV. CONFIDENTIALITY
The state and local agencies must restrict disclosure of confidential identifying WIC applicant/participant information (see Attachment AD-3).
A. Confidential Information
Confidential WIC applicant and participant information is any information about an applicant or participant, whether it is obtained from the individual, another source, or generated as a result of WIC application, certification, participation, that individually identifies an applicant or participant and/or family member(s). Applicant or participant information is confidential, regardless of the original
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source and exclusive of previously applicable confidentiality provided in accordance with other federal, state or local law.

B. Restrictions on Disclosure of Confidential Information

The state agency must restrict the use and disclosure of confidential applicant/participant information to persons directly connected with the administration or enforcement of WIC whom the state agency determines has a need to know the information for WIC purposes.

These persons may include, but are not limited to:

1.

Official requests from personnel from local agencies and other

WIC state or local agencies

2.

Persons under contract with the state agency to perform

research regarding WIC

3.

Persons investigating or prosecuting WIC violations under

federal, state or local law

C. Exceptions to Restrictions on Disclosure of Confidential Information

1. State and local agency staff that is required by State law to report known or suspected child abuse or neglect may disclose confidential WIC applicant/participant information without their consent to the extent necessary to comply with such law.

2. Any state or local agency may use confidential WIC applicant/participant information in the administration of its other programs that serve persons eligible for WIC provided the prescribed steps are followed pursuant to the Federal WIC regulations:

a. The state or local agency must enter into a written agreement with the public organization for use of confidential WIC information in the administration of their programs that serve persons eligible for WIC.
b. The public organization must agree to not disclose the confidential WIC information to third parties.
c. The Chief of State Health Officer must designate in writing the permitted non-WIC uses of all information and the names of the organizations to which such information may be disclosed.
d. The following public organizations are designated: MCH Perinatal Hepatitis B Prevention Newborn Hearing Screening Newborn Metabolic Screening Children 1st Babies Can't Wait Children Medical Services Oral Health Family Planning Babies Born Healthy

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MCH Director's Office
Infectious Disease & Immunization Immunization
Epidemiology PRAMS OASIS/OHIP
Environmental Health Lead
Health Promotion and Disease Prevention Tobacco Obesity Adolescent Health
DEPARTMENT OF PUBLIC HEALTH
Medicaid Medicaid Peachcare for Kids
State Health Benefit Plan
Emergency Preparedness & Response Injury Prevention Department of Human Resources Division of Family and Children Services
e. The applicants/participants must be notified that the Chief State Health Officer may authorize the use and disclosures of information about their participation in the WIC Program for non-WIC purposes.
3. A state or local agency may disclose confidential WIC applicant/participant information if the affected WIC applicant/participant signs a release form authorizing the disclosure and specifying the parties to which the information may be disclosed (see Attachment AD-4). The state or local agency must permit the affected applicant/participant to refuse to sign the release form and must notify them that signing the release form is not a condition of eligibility and refusing to sign will not affect their participation in WIC. Release forms authorizing disclosure to private physicians or other health care providers may be included as part of the WIC application or certification process. All other requests for applicants and participants to sign voluntary release forms must occur after the application and certification process is completed.
4. Release forms include an Authorization for Release of Information form 5459R (see Attachment AD-19) that has been signed by a DFCS case
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manager when a court has granted legal custody of a WIC applicant/participant to the Georgia Department of Human Services.
a. The form must specify the parties to which information may be released.
b. The court order must be attached.
c. The WIC Legal Services Officer has reviewed and approved the form and court order.
d. Release the information if approved.
5. A state or local agency must provide applicants/participants with access to all information they have provided to WIC. If the applicant/participant is an infant or child, access may be provided to the parent or guardian of the infant or child, assuming that any issues regarding custody have been settled. The state or local agency need not provide access to any other information in the WIC file or records, for example, documentation of income provided by third parties and staff assessments of the participant's condition or behavior unless required by federal, state or local law or policy, or unless the information supports a fair hearing appeal.
6. Representatives from the USDA and the Comptroller General of the United States may inspect, audit, and copy all records that include information pertaining to certification, nutrition education, civil rights and fair hearing procedures, as well as food delivery systems and food instrument issuance and redemption. Reports or other documents resulting from such inspection, audit and copying that are publicly released may not include confidential identifying WIC applicant/participant information.
Note: Information about the use of drugs and alcohol by a WIC applicant/participant must not be shared.

V. E-MAIL AND FAXING CONFIDENTIAL INFORMATION
Districts that transmit confidential information by e-mail or facsimile transmission should incorporate the confidentiality provision statement into the 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 attorney-client communication and, as such is, privileged and confidential. If the
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reader of this message is not 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.

VI. WIC VOLUNTEERS AND CONFIDENTIALITY
In order to prevent a breach of confidentiality, Georgia WIC must exercise discretion in screening and selecting capable volunteers who will handle confidential information. It is therefore the responsibility of the state and local agencies to ensure that volunteers who are given access to WIC applicant/participant information are well trained and knowledgeable about the restrictions in disclosure of WIC information.
The following action steps must be taken in order to protect confidential identifying WIC applicant/participant information:
A. Once volunteers are selected, specific confidentiality requirements governing Georgia WIC must be covered in their orientation or training.
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 identifying WIC applicant/participant information.

C. The state or local agencies may have volunteers sign an agreement acknowledging restrictions on the disclosure of confidential identifying WIC applicant/participant information. By signing such a form, the volunteer would agree to keep this information confidential or forfeit the volunteer assignment. Such an agreement would reinforce the importance of maintaining confidential information.
D. If a volunteer does not appear to be a good candidate for keeping information confidential, assign the volunteer to other activities related to administration of WIC services.
VII. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)
By law, all identifying WIC applicant/participant information must remain confidential except where disclosure is authorized by law (see 45 C.F.R. Parts 160 and 164). This is a HIPAA requirement.
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The privacy practices of WIC are in compliance with the HIPAA laws. State-to-State transfers are allowable. A request for release of information is advised.

VIII. RETROACTIVE BENEFITS AND REIMBURSEMENTS

Federal 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
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, or clinics that are open 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 WICspecific "No Smoking" sign.

X. SUBPOENAS
A. Subpoenas A subpoena is an order directed to an individual or entity to compel the court appearance of a witness to give testimony or to compel the production of documents and other exhibits as evidence.
B. Procedures for Responding to a Subpoena
1. Upon receiving the subpoena the local agency must immediately notify its state agency.
2. State or local agencies must determine, based on the content of the subpoena and the requested information, whether to comply with the subpoena and release the information as requested or to attempt to quash the subpoena. In making the determination, state or local agencies must consult with legal counsel determine whether the information is confidential and prohibited from disclosure under the Federal WIC regulations (7 C.F.R. Section 246.26(i)(1)).
3. Determinations to disclose confidential WIC information requested by a subpoena or to attempt to quash a subpoena must be based on the
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relevant Federal WIC regulations and state laws, and FNS Instruction 8001. The determination to disclose confidential WIC information without attempting to quash the subpoena should be made only infrequently.
4. Receipt of a subpoena shall be reported to Georgia WIC and the WIC Legal Services Officer. Because subpoenas must be complied with by a date, certain information must be specified in the subpoena and must be reported to Georgia WIC and the WIC Legal Services Officer immediately.
5. If confidential WIC information is disclosed pursuant to a subpoena, inform the court or receiving party that the information is confidential and seek to limit disclosure by:
a. Providing only the specific information requested in the subpoena and no other information; and
b. Limiting to the greatest extent possible the public access to the confidential information disclosed.

XI. SEARCH WARRANTS
A. Search Warrants
Search warrants can be used by law enforcement to seek disclosure of confidential WIC applicant/participant information. State and local agencies must comply with search warrants to avoid possible incarceration.
B. Procedures for Responding to a Search Warrant
1. Upon receiving a search warrant, the state agency and WIC Legal Services Officer must be notified immediately. Legal counsel for the local agency should also be notified.
2. Individuals serving the search warrant should be notified that the information being sought is confidential. The state or local agency should seek to limit disclosure by:
a. Providing only the specific information requested in the search warrant and no other information; and
b. Limiting to the greatest extent possible the public access to the confidential information disclosed.

XII. WIC PARTICIPATION
The definition of a WIC participant and enrollee is listed below:
Participant: A participants is a pregnant woman, breastfeeding woman, postpartum woman, infant or child who is receiving nutrition education and supplemental foods or food instruments under WIC, and the exclusively breastfed infant of a participating exclusively breastfeeding woman. A participant is a client who has been issued at least
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one voucher during the reporting month. The exclusively breastfed infant is issued a voucher message but no formula is issued. Likewise, the some breastfeeding woman is issued a voucher message but no supplemental foods beyond six (6) months postpartum.
Enrollee: A WIC 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 new WIC clinics must have completed a PreApproval - Pre-Award Compliance Review before the new clinic can open.
Prior to establishing and opening a new WIC clinic, the district staff must complete and send to the Policy Unit the following information:
Note: Please note that a new clinic applicant is the entity applying for WIC funding to serve WIC participants.
1. Demographics of the population to be served in order to evaluate WIC applicant/participant access racial makeup of the area you will be serving and who will be attending the clinic. A public health website that may be used to collect this information is: http://oasis.state.ga.us/.
2. Data collected regarding WIC employment, including use of bilingual public contact employees serving LEP (Limited English Speaking) beneficiaries of the programs Racial ethnic data of the employees that will be working at the new clinic.
3. Evaluation of the location of existing or proposed facilities connected with WIC and whether access would be difficult or impossible because of locale Is there anyone who would be denied services due to the clinic's location and racial makeup of the clinic.
4. Review of the composition of the planning or advisory board for the new WIC clinic racial makeup of the new facility.
5. Analysis of civil rights impact, if relocation of the clinic is involved provide an analysis of the new location. This only applies when the WIC clinic is relocating.
6. A written assurance by any new WIC clinic applicant that it will compile and maintain records required by the Food Nutrition Service (FNS) guidelines or other directives.
7. The manner in which WIC services are or will be provided by the new clinic applicant and related data necessary for determining whether any persons are or will be denied WIC services on the basis of prohibited discrimination.
8. A statement from the new WIC clinic applicant as prompt notification to (FNS) Food Nutrition Service of any lawsuit or complaint filed against the applicant that alleges discrimination on the basis of race, color, or national origin. The new WIC clinic applicant's statement should also provide a brief description of any pending application to other Federal agencies for assistance, and of Federal assistance being provided at time of application or requested report.
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9. A statement or description of previous civil rights reviews conducted on behalf of the new WIC clinic applicant during the two years prior to applying, as well as any information about the agency or organization performing the review and any periodic statements by the new WIC clinic applicant regarding such reviews.
Once the analysis is completed and approved by the state, the Program Review Team will complete the New Clinic Evaluation Report (see Attachment AD-9).

Additionally, the Program Review Team will:



Visit the potential new WIC clinic



Observe and determine compliance according to the WIC regulations using

Attachment AD-9



Mail a report indicating one or more of the following:

a. Approval by completing the New Site Permission Request Form (see Attachment AD-7)

b. Approval with a list of changes needed prior to the establishment of the new clinic

c. Disapproval of the establishment of the new clinic

After the new clinic is approved, district staff can complete the Request to Establish New Clinics/Clinic Change form (see Attachment AD-5). The Georgia WIC Systems staff will verify collection, processing, and submission of the information and forward this form to the data processing contractor (CSC Covansys) within five (5) days. The data processing contractor assigns a number for the new clinic. If the district selects its own number, the data processing contractor must verify and approve the number before it may be considered a valid number. The data processing contractor mails the new clinic the supplies necessary to start processing operations, e.g., TADs, vouchers.
Once your district receives an approved clinic number, you may begin to enroll WIC participants. Georgia WIC will provide technical assistance, consultation and training to the local agency in the start up procedures of a new clinic, if needed.
A WIC clinic is a facility where WIC business is conducted. Each clinic that operates in the state must have its own number. This requirement applies to, but not limited to the following:
x All hospitals locations x DFCS locations x Health Departments x 330 Community Health Organizations x Health Centers x Migrant Clinics
Failure to comply to list all of the clinic sites and locations in your district may result in a financial penalty for the district. These penalties may include refunding monies for vouchers issued from the date the clinic sites opened. A financial penalty letter will be sent to your district if the Program Review Team finds clinic sites either a) operating and not on the WIC Clinic Listing or b) not having a unique clinic number.

XIV. CLINIC CLOSINGS

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In the event a clinic will be closed temporarily due to an emergency, please notify the Policy Unit at Georgia WIC as early as possible. This will enable the state /local agency staff to better serve WIC 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 Policy Unit (see Attachment AD-5).
XV. REPORTING SYSTEMS PROBLEMS
Local WIC agencies must immediately report any CSC Covansys and/or front-end systems discrepancies to the Systems Information Unit of Georgia WIC. 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 Computer Systems Issues and Problem Report Form (see Attachment AD-6) to Georgia WIC. In addition, the clinic should notify the District Nutrition Services Director and Management Information System's staff at the district office.
XVI. REQUEST FOR FINANCIAL AND/OR STATISTICAL DATA
Request for financial and/or statistical data or reports must be made in writing by completing the Data Request Form (see Attachment AD-8). Fax the Data Request Forms to Georgia WIC, (404) 657-2910, attention Systems Information Unit.
XVII. 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 at the beginning of each quarter (January, April, July and October). If the amount received needs to be adjusted based on an increase or decrease in caseload, please contact Georgia WIC.
XVIII. CLINIC/STAFF RATIO
Clinic staff ratio is listed below for administrative purposes: A. One (1) CPA per every 1,000 participants served. B. One (1) administrative support staff per every 800 clients served. C. One (1) RD/LD per every 5,000 clients served.
XIX. NUTRITION SERVICE DIRECTOR JOB DESCRIPTION
The Nutrition Services Director's position is an administrative position. Attached is a copy of the current job description, which describes the responsibilities (See Attachment AD-10).
XX. COMPLIANCE REVIEWS
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A. There are three (3) types of compliance reviews: x Pre-Approval or Pre-Award x Post-Award or Routine x Special
B. Definitions
Pre-Approval or Pre-Award Review is a review that must be conducted prior to the approval of a clinic opening. No Federal funds can be awarded to a state or local agency until a pre-award compliance review has been conducted and the applicant is determined to be in compliance with civil right rules. This review may be a desk or on-site review. The results of the review must be in writing.
Prior to creating a new clinic site, the following must be reviewed for compliance: Demographics of the population to evaluate program access Data collection regarding covered employment, including use of
bilingual public-contact employees serving LEP beneficiaries of the programs Location of existing or proposed facilities connected with WIC and whether access would be unnecessarily denied because of locale Makeup of planning or advisory board Civil Rights Impact analysis conducted if relocation is involved
Post Award or Routine Review is a regular review or self-review in which civil rights compliance is checked.
When conducting a post review or routine review, look for the number of discrimination complaints filed, information from grass roots and advocacy groups, individuals, state officials and unresolved findings from previous civil rights reviews.
Special Review is a review conducted due to reported alleged noncompliance. Prior to this review, check patterns of complaints of discrimination through reviewing documentation at the state and district level.
XXI. MEDICAL NUTRITION THERAPY
Below are the policies regarding medical nutrition therapy and Medicaid. 1. 100% paid WIC employees (full time or part-time) may not provide medical
nutrition therapy which is a Medicaid reimbursed service. Any nurse, dietitian or other nutrition staff paid by WIC or any Federal program may not bill Medicaid for medical nutrition therapy provided within or outside of the WIC clinics. This includes WIC certifications conducted as part of a home visit by non-WIC staff.
Example of inappropriate billing procedures:
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a. Non-WIC paid nurse making home visits, completing a WIC certification, and billing Georgia WIC
b. Any WIC paid staff in the 301 Cost Pool must not participate in Medicaid reimbursement

XXII. REGISTERED AND/OR LICENSED DIETITIAN CREDENTIALING POLICY FOR THE DEPARTMENT OF PUBLIC HEALTH
It is the policy of the Department of Public Health, that those registered and or licensed professionals providing medical nutrition therapy in public health practice meet all standards and guidelines outlined in the credentialing expectations document. All licensed professionals participating in reimbursable services must be credentialed by June 1, 2006. The District Nutrition Service Directors are responsible for monitoring the credentials and competence of county professionally licensed dietitians in their districts.

I.

Professional Licensure

a. Each professional dietitian shall, at all times, maintain current licenses

received by the Georgia Board of Examiners of Licensed Dietitians.

b. Verification of licensure may be obtained via the internet

(www.sos.state.ga.us).

II. Professional Registration a. Each professional with the designation of Registered Dietitian shall, at all times, maintain current registration by the Commission on Dietetic Registration of the American Dietetic Association. b. Verification of registration may be via internet (www.cdrnet.org).

III. Initial Practice a. Academic preparation i. Licensed Dietitian copy of current license issued by the Georgia Board of Examiners of Licensed Dietitians. ii. Registered/Licensed Dietitian copy of current registration card from the Commission on Dietetic Registration of the American Dietetic Association and copy of current license issued by the Georgia Board of Examiners of Licensed Dietitians. iii. Provisionally Licensed Dietitian copy of verification statement from an American Dietetic Association accredited dietetic internship program and copy of provisional license. The Provisional License only lasts for ONE year. If the Dietitian does not pass the RD exam within that time the Provisional License expires, which means they can not function as a Licensed Dietitian in the State of Georgia until they pass the Registration exam. Once the exam is passed, the Dietitian can submit the proper paperwork to the ADA and the Secretary of State to become a RD and LD. b. Authority and Scope of Practice i. ADA Code of Ethics prior to the practice of medical

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ii. Nutrition therapy- all credentialed professionals will read and agree to abide by the Code of Ethics set forth by the American Dietetic Association.
iii. DPH Policy all credentialed professionals will read and agree to abide by DPH policy regarding other employment.

XXIII. CONFLICT OF INTEREST
Georgia WIC does not support conflict of interest at the state, district or local level. Based on DPH policy, all employees must report outside employment to their immediate supervisor. A determination will be made whether this employment opportunity is a conflict. A definitive time frame for employment will be agreed upon between the employee and his/her immediate supervisor. This will be documented in the employee's personnel file.
The state and local agency must prohibit the following certification practices or provide alternative policies and procedures when such prohibition is not possible:
(1) Certifying oneself (2) Certifying relatives or close friends or (3) An employee determining eligibility for all certification criteria and issuing food
instruments for some participants. (See Food Delivery Section III. F and Certification Section III. E. for the current procedures).

XXIV. RENOVATIONS
Any capital improvements exceeding $4,999 must have prior approval from Georgia WIC and USDA. (Capital improvements are any improvements that can be depreciated, such as buildings, renovations, etc.).

XXV. INTER/INTRA AGENCY AGREEMENT
The Inter/Intra Agency Agreement is an agreement that must be used by all multi-county health district with each of their counties. Your district may add additional terms but must not delete or change any of the existing terms (see Attachment AD-12).

XXVI 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 services 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.
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5. Whether clients are seen in the order of appointments. 6. Whether participants are scheduled at a rate appropriate for services received
and staff availability. 7. Whether staff has down times for any staff? 8. Whether appropriate staff is present for first morning appointments. 9. Number of appointments and no-shows.

(See Attachment AD11 for the PFA options)
Procedures for the Patient Flow Analysis consist of the following two options:
OPTION I Option I contains four (4) forms which include: 1) Patient Flow Analysis (PFA) Sign-In Sheet 2) Patient Flow Analysis (PFA) Form 3) Employee Time Log 4) 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 alphabetically and each staff person is keeping his/her own Sign In form.
2. Clinic - Name of the clinic where the analysis is being conducted.
3. Patient # - Number that is assigned on the Patient Flow Analysis Sign-In Form.
4. Name - Name of the applicant/participant.
5. Date Seen - Actual date the Patient Flow Analysis is taking place.
6. WIC Type P __ N __ B __ I __ C Check mark which identifies whether the applicant/participant is a pregnant (P), postpartum (N) or breastfeeding women (B), an infant (I) or a child (C).

7. Reason for Visit - Reason the applicant/ participant made a visit to the WIC

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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 - Appointment time of the applicant/participant.

9. Time Started - Actual time that the clinic staff begins to work with the WIC participant.

10. Time Finished - Actual time that staff finishes working with the applicant/participant.

11. Staff Initials - Staff that serves the WIC applicant/participant.
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 - Time the applicant completes all WIC services and is leaving the clinic.

14. Total Time in Clinic - Amount of time from arrival to departure for applicant/participant to receive WIC services.

15. Food Package Change (FPC)/Formula Type (optional) - FPC or formula type, if applicable, for district use.

16. Special Services Provided/Comments - Special services or circumstances which may cause additional time to be taken with the applicant/participant.

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FORM III Employee Time Log
The Employee Time Log documents the following:
1. Name and Title of Employee Employee who is providing services must document their name and official title.
2. Work Hours - Employee must document their schedule work hours including the time spent servicing a client doing the clinical work, administrative work and clerical work. In addition, if an employee is working in the clinic and providing other services that does not require face to face work with the client, that time must be documented. For example, an employee working at the file room or making/receiving work related phone calls or doing administrative work.
3. Miscellaneous Any other duties the employee performed during the day of Patient Flow Analysis.
4. Lunch/ Break Employee must document the time taken for lunch or break during the day of Patient Flow Analysis.
FORM IV - QUESTIONS TO ANSWER FROM THE MODIFIED PFA
Questions from the modified PFA are listed on this form to indicate the type of information you can expect to receive from the PFA.
OPTION II
Option II contains seven (7) forms 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) Employee Time Log 7) Questions to Answer from the Modified PFA Form
(See Attachment AD-11 for PFA options)

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.

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FORM II - PERSONNEL IDENTIFICATION CODE FORM
The Personnel Identification Code is used to identify clinic staff/title involved, i.e., R.N., in the PFA. A letter from the alphabet must be assigned to each employee before the PFA begins. This form must be completed at the beginning of the Patient Flow Analysis so that each clinic staff is aware of what code is assigned to them to use for the PFA.
FORM III - REASON FOR VISIT CODES
The Reason for Visit Code is used to identify the type of services being rendered to the WIC applicant/participant.
FORM IV PATIENT CATEGORY FORM
The client category identifies the codes you must use to identify the type of clients who are being served 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 (it 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 (should be the same as what is recorded on the sign in sheet). 5. Time of clinic appointment (should be the same as what is recorded on the 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 EMPLOYEE TIME LOG
The Employee Time Log form documents the following:
1. Name and Title of Employee Employee who is providing services must
document their name and official title.
2. Work Hours - Employee must document their scheduled work hours, including
the time spent servicing a client or doing the clinical work, administrative work and clerical work. In addition, if an employee is working in the clinic and providing other services that do not require face- to-face work with the client, that
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time must be documented. For example, an employee working at the file room or making/receiving work related phone calls or doing administrative work.
3. Miscellaneous Any other duties the employee performed during the day of
Patient Flow Analysis.
4. Lunch/ Break Employee must document the time taken for lunch or break
during the day of Patient Flow Analysis.

FORM VII - 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.

XXVII. STATE PLAN
A. Description
1. The FFY annual State Plan has three major chapters: State Overview; State Office Overview; and Goals and Objectives. The Plan covers all aspects of WIC services from administration to certification, to nutrition education.
a. The State Overview includes a description of the Department's and Division's Capacity and structure; Program capacity and structure at the State and local agency levels, and public comments.
b. The State Office Overview includes a narrative that describes each Section and its responsibilities at the State level.
c. The Goals and Objectives chapter includes accomplishments at both the State and local agency levels for the FFY that is two years prior to the current State Plan year and goals and objectives for the upcoming year. For example, the FFY 2012 plan includes accomplishments for FFY 2010 and the goals and objectives for FFY 2012.

B. Format and Reporting
1. Annually, the state plan format, goals and objectives, and any other information needed will be reviewed and revised as needed. Instructions will be developed and finalized no later than March of each year.
2. The District or local agency annual plan will be due by May 31, unless another date has been designated as the due date for that year.

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3. In addition to the District or local agency annual plan, a Breast- feeding Peer Counselor plan is due from those Districts or local agencies who have received designated Breastfeeding Peer Counselor funds. More details, instructions, and the due date for this plan are included in the Breastfeeding Section, BF.
4. The District or local agency mid-year report will be due by October 31, unless another date has been designated as the due date for that year.
5. The State Plan is due to USDA no later than August 15 of each year.

C. Annual Update of the Clinic Listing
The clinic listing should be reviewed and updated at least annually by March 31 so that the clinic locations, contact numbers, addresses, clinic type and types of services are accurate. Instructions for updating the clinic listing are included as Attachment AD-17.

XXVIII. LOCAL AGENCIES: APPLICATION, DISQUALIFICATION AND ADMINISTRATIVE REVIEW
A. LOCAL AGENCY APPLICATION PROCESS
Local agencies are public or private health or human services agencies as defined at 7 C.F.R. Section 246.2. A local agency applicant must demonstrate its ability to provide WIC services according to state policies (see Attachment AD-14) and in compliance with Federal WIC regulations.
Georgia WIC operates in all 159 counties within the state via local public health departments and two Atlanta-based contracted agencies (Grady Health System and Southside Medical Center). Since FFY 04, Georgia WIC has expanded WIC services into non-public health agencies/providers, such as migrant health centers, health maintenance organizations, community health centers, schools and/or private provider offices.
Applications for expansion of WIC services in an area or special population already being served or for initiation of WIC services in a new area or special population shall be considered based on need as measured by participant priority (see 7 C.F.R. Section 246.7) and the Affirmative Action Plan (see 7 C.F.R. Section 246.4 (a)(5)). The state agency shall establish standards for selection of new local agencies based on considerations set forth at 7 C.F.R. Section 246.5 (d).
Upon request from a local agency interested in operating Georgia WIC, the state agency will supply, within fifteen (15) days of inquiry, a pre-application information package containing of the following documents:

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1. A cover letter explaining, at minimum, the overall application process, time frames involved, criteria for selecting agencies and information concerning the appeal process in the event that the application is denied.
2. A copy of Federal WIC regulations (7 C.F.R. Part 246).
3. A list of basic requirements to be included in the local agency's application to operate Georgia WIC including staffing and equipment requirements, as well as clinical and nutritional regulatory mandates.
4. A listing of state and local agency resources.
5. A copy of the Memorandum of Understanding between the state agency and the local agency (the Memorandum of Understanding is included in the Administration Section of the WIC Procedures Manual).
6. A copy of the most current State Plan, Procedures Manual and Georgia WIC Information Packet.
7. Examples of nutrition education materials and participant training tapes.
Selection criteria for local agencies will be consistent with the requirements of 7 C.F.R. Section 246.5. Applications will also be reviewed for assurance that, at minimum:
1. The local agency has corrected all past substantiated civil rights problems and/or non-compliance situations.
2. The Civil Rights Assurance is included in the state /local agency Georgia WIC Agreement.
3. Civil Rights complaints are being handled in accordance with procedures outlined in the Rights and Obligations Section of the WIC Procedures Manual.
4. Clinic sites, certification offices, vendors and other food distribution sites do not deny access to any person because of his/her race, color, national origin, language, sex, age, or disability.
5. Appropriate staff, volunteers and/or other translation resources is available in areas where a significant proportion of non-English or limited English-Speaking persons reside.
6. A description of the racial/ethnic makeup of the service area is included in the application.
7. The local agency has the ability to provide appropriate WIC services to applicants and participants in accordance with USDA and Georgia WIC regulations and policies.
8. The local agency's space availability is adequate to provide WIC services.

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9. The local agency demonstrates the ability to manage financial obligations in accordance with USDA and state regulations and policies.
10. The local agency will demonstrate the ability to ensure the security of WIC vouchers at all times.
11. The local agency agrees to have all agency staff attend any required meetings and training programs.
12. The local agency agrees to comply with all USDA and Georgia WIC reporting and documentation requirements.
13. The local agency demonstrates the ability to comply with all Georgia WIC Automated Data Processing requirements.
14. The local agency agrees to make all documents and records available for review and audits
15. A facility serving homeless participants agrees to ensure that the homeless facility :
a. Does not accrue financial or in-kind benefits from a resident's participation in WIC.
b. Does not subsume foods provided by Georgia WIC into a communal food service; WIC foods must only be available to the WIC participant.
c. Does not allow the homeless facility to place constraints on the ability of the WIC participant to partake of the supplemental foods and nutritional education available through WIC.
16. The local agency agrees to contact the facility that serves the homeless periodically to ensure continued compliance with these conditions.
17. The local agency requires the facility that serves the homeless to notify the state or local agency if it ceases to meet any of these conditions.

B. LOCAL AGENCY - DISQUALIFICATION PROCESS
1. The state agency may disqualify a local agency for the following:
- Non-compliance with Federal WIC regulations - State WIC funds are insufficient to support the continued operation of all its existing local agencies at the current participation level - A determination by the state agency following a review of local agency credentials in accordance with 7 C.F.R. Section 246.5(f) that another local agency can provide WIC services more effectively and efficiently
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2. When disqualifying a local agency, the state agency must ensure the action is not in conflict with any existing written agreements between the state and local agency, and provide the affected local agency with written notice of not fewer than 60 (sixty) days in advance of the pending disqualification (see Attachment AD-15).
3. The written notice must include an explanation of the reasons for disqualification, the date of disqualification, and, except in cases of the expiration of a local agency's agreement, the local agency's right to administrative review as set forth in 7 C.F.R. Section 246.18.
C. LOCAL AGENCY - ADMINISTRATIVE REVIEW
1. The state agency shall give 60 (sixty) days advance notice of an adverse action against a local agency and must provide full administrative review to local agencies.
Actions Subject to Administrative Review The state agency must provide administrative review for the following:
- Denial of local agency's application - Disqualification of a local agency - Any other adverse action that affects a local agency's participation
Actions Not Subject to Administrative Review The state agency may not provide administrative review for the following:
- Expiration of the local agency's agreement - Denial of a local agency's application if the state agency's local
agency selection is subject to the procurement procedures of the Department of Public Health
2. Effective Date of Adverse Action Against Local Agency
Any denial of a local agency application shall be effective immediately. Adverse actions subject to administrative review shall be effective on the date the local agency receives the review decision. All other adverse actions are effective 60 (sixty) days after the date of adverse action.
3. Administrative Review Requests
The local agency must submit a written request for administrative review to the state agency within 15 (fifteen) days from the date of its receipt of notification of the adverse action the local agency is appealing. The state agency shall immediately refer the local agency's request for administrative review to the Office of State Administrative Hearings (OSAH). The referral should be made within one business day and in a way that allows the state agency to track receipt of the referral by OSAH, e.g., UPS, etc.
The Administrative Law Judge (ALJ) from OSAH who is assigned to the administrative review shall provide adequate notice of the administrative review
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to the parties. Georgia WIC, which, pursuant to Federal WIC regulations, may set the number of days required for notice of the review, has established that notice should be given 15 (fifteen) days in advance. The ALJ must issue a written review decision within 60 (sixty) days of receipt of the local agency's request for administrative review. A local agency may reschedule a review one (1) time. The state agency should indicate this information on the OSAH Form One as the mandatory referral form.
The ALJ is an impartial decision maker whose determination is based solely on evidence presented at the hearing review as to whether the state agency correctly applied federal and state statutes, regulations, policies and procedures governing WIC when taking the adverse action against the local agency. The DPH appeals reviewer shall review the ALJ's decision on behalf of the state agency to ensure it conforms to approved policies and procedures. If the review decision upholds the adverse action against the local agency, the state agency must inform the local agency that it may be able to pursue judicial review of the decision. The adverse action is effective upon the local agency's receipt of the review decision.
At the administrative review before the ALJ, the local agency shall have the opportunity to cross examine adverse witnesses and be represented by counsel at its expense. Prior to the review, the local agency may examine the evidence upon which the state agency's adverse action is based. The local agency is responsible for continued compliance with the terms of any written agreement with the state agency pending receipt of the ALJ's written review decision.

XXIX. SPECIAL PROJECT PROGRAM

A.

INTRODUCTION

New ideas and concepts that stimulate growth, collaborative partnerships and program effectiveness are the foundational principles that guide Georgia WIC Special Project Program (GWSPP). In fiscal year 1999, Georgia WIC initiated special funding for new interventions developed by local WIC agencies. The GWSPP offers financial support to local agencies desiring to explore non-traditional means of providing WIC benefits to eligible participants. Resources are available to the local agencies in the form of Local Agency Special Project (LASP) grants. When funds are available, Georgia WIC sets aside Nutrition Service Administration funds to distribute as LASP grant awards.

This section of the project outlines the purpose and processes for local agencies wishing to participate in GWSPP. In instances where grant processes are linked to routine procedures, the related procedures are referenced and must be followed.

B.

OVERVIEW OF LOCAL AGENCY SPECIAL PROJECT (LASP) GRANTS

Project Purpose and Priority

LASP grants provide financial support to local agencies endeavoring to implement new program enhancements. The primary intent of the LASP grant is to support the efforts of

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local agencies to plan, design and implement innovative initiatives that will improve access to WIC benefits, and ultimately increase statewide participation.
Priority is given to projects proposing new concepts that can be replicated, are sustainable after the initial funding, can be implemented and completed within twelve months, and demonstrates collaborative partnerships. The focus areas for new program enhancements include:
1. Non-traditional service delivery sites and collaborative partnerships. 2. Special outreach to hard to reach clients. 3. Breastfeeding initiation and duration. 4. Linguistically and culturally appropriated nutrition education. 5. Efficiency measures for staff and participants.
Project Period
The LASP grant is a twelve-month non-renewable award. Applicants are encouraged to consider the grant period when deciding the complexity and scope of the project. Project proposals selected for funding must illustrate the potential to complete implementation within twelve months. LASP grant funds must be expended by September 30 of the Federal fiscal year in which grant is awarded. Georgia WIC plans to award grants to selected local agencies by October 1.
C. PROPOSAL PROCESS

All interested local agencies must submit a LASP grant proposal. Grants are awarded to an individual local agency or to a consortium of local agencies. Local agencies are encouraged to consider collaborating with other WIC agencies on proposals. A local agency may submit only one proposal per fiscal year. If an agency submits a project proposal as part of a consortium of agencies, it may not submit a separate individual application.
Request for Proposal
Georgia WIC conducts an annual solicitation for LASP grant proposals to give local agencies the opportunity to propose new Program initiatives for the upcoming fiscal year. The Request for Proposal (RFP) outlining funding requirements and deadlines is distributed to all WIC local agencies in April of each year.
The RFP package includes the following: 1. Application procedures 2. Proposal requirements 3. Project criteria 4. Proposal format 5. Focus areas 6. Proposal Evaluation criteria and weights 7. Application checklist

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Completed LASP grant proposals must be received by Georgia WIC by August 1 of each year.
Proposal Review Process
It is the intent of Georgia WIC to select LASP grant proposals that offer new and innovative concepts that address one of the focus areas, and have the best chance to continue beyond the initial funding period. Each proposal is reviewed and ranked by a proposal review committee. The committee is comprised of representatives from Georgia WIC, the Maternal and Child Health Program, WIC Nutrition Services Directors who did not submit an application, and a representative from a non-WIC public health program.
After reviewing and ranking proposals, Georgia WIC representatives may interview agencies on site before making selection decisions to: 1. clarify questionable concerns identified in the application review process; and 2. to collect information that validates the agency's capacity to successfully implement the proposed project.
Selected LASP grant proposals have two funding possibilities: GWSPP funds or USDA infrastructure grant funds. The state submits USDA applications on behalf of local agencies. State staff will provide technical assistance to local agencies to enable full development of proposals to meet USDA requirements. Both funding possibilities are subject to the availability of USDA funds.
D. GRANT MANAGEMENT
The Health Director of local agencies awarded LASP grants, must sign the terms and conditions of the DPH Master Agreement Addendum to Annex 2 with the Director of Georgia WIC agreeing to implement the project and to use the funds as described in the proposal. Special stipulations or instructions are stated in the Agreement. The LASP grant funds will transfer to local agencies as grant-in-aid funds that will not be transferred until the Agreement has been signed.
Reports
General administration of these LASP grants includes quarterly reports of expenditures, performance progress, a final closeout summarizing LASP outcomes and financial reconciliation. Local agencies are required to submit quarterly financial status reports on a Standard Form 269A. The due dates for quarterly reports are as follows:
January 15 May 15 September 15 December 31 (Final report)
The final summary of project accomplishments and a final Standard Form 269A must be submitted to Georgia WIC no later than ninety (90) days after the last day of the Federal fiscal year to close out the project. Additionally, grantees are required to submit copies of educational curricula, videos or other tangible products produced with LASP grant funds with the final report.

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Monitoring
Georgia WIC will monitor grantees as specified in the Agreement. Upon creation of a WIC new service delivery site, the Policy Unit will conduct a monitoring visit. In addition, the Systems Information Unit must assign a unique clinic number. Once the grantee receives permission to proceed with operational plans, a monitoring visit will be conducted. Before the monitoring visit, the local agency is required to complete and submit an inventory of the Georgia WIC LASP grant purchases.
XXX. REQUEST FORM FOR A NEW FACILITY
A request form for a new facility must be completed by the state when/if the district requests to move into a new facility (see Attachment AD-18).
XXXI. PARTICIPANT CHARACTERISTICS MINIMUM DATA SET (MDS)
The Participant Characteristics Minimum Data Set (MDS) contains data items that are reported to FCS electronically by state agencies for one report month on all or a sample of participants (see Attachment AD-16).

XXXII. LOCAL AGENCY FUNDING ALLOCATION FOR INFORMATION ON FUNDING ALLOCATION
The current Nutrition Services Administration (NSA) funding formula allows growth district s to receive their fair share of funding on the front-end. The combined caseload target is based on the current five (5) months participation closeout October-February and one month March (30 day) and the projected availability of federal food funds (see Attachment AD-13).

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Attachment AD-1

Annex 2

FY 2012 PUBLIC HEALTH MASTER AGREEMENT ANNEX PROGRAMMATIC REPORTING REQUIREMENTS

PROGRAM NAME: Georgia WIC, WIC Farmer's Market Nutrition Program, WIC Breastfeeding
PROGRAM CODES: 07, 09, 643, 301
FUNDING REQUIREMENTS:
Restrictions:
Funds may be used for:
Providing services to improve the health of low-income women, infants and children up to age five years who are at nutritional risk by providing nutritious foods to supplement diets, information on healthy eating and referrals to health care. The intent of the Grant In-Aid is to support the efforts of local agencies to provide WIC services.
Funds may not be used for:
Administrative costs unless the Department of Public Health (DCH) Financial Services has approved a cost allocation plan.
Statement of allowable costs/expenses:
Those costs that is reasonable and necessary in accordance with 7 C.F.R. Parts 246 and 3016.
Deliverables:
1. Provide services in accordance with the Child Nutrition Act of 1966, as amended by P.L. 108, the delivery of services for the Special Supplemental Nutrition Program for Women, Infants and Children (WIC). This provider agreement is made pursuant to the Georgia Department of Public Health (DCH) policies and procedures, and the referenced United States Department of Agriculture/Food and Nutrition Services (USDA/FNS) regulations, the Georgia WIC Procedures Manual, the Georgia WIC State Plan, and all administrative memos (i.e. informational, action, policy). The aforementioned documents are hereinafter incorporated into this Annex.
2. Collect client data for participants for the purpose of monitoring and performance. Comply with all Federal and State requirements in the collection of data and make modifications as appropriate or requested within a specified time.
3. Employ appropriate staff to adequately perform responsibilities in accordance with staffing and processing standards, certification requirements, program integrity, and voucher accountability and security.
4. Participate in the annual development of the Georgia WIC State Plan and Georgia WIC Procedures Manual.
5. Participate in state trainings and meetings.
6. Provide WIC Farmer's Market Nutrition Program services according to the Federal regulations at 7 C.F.R. Parts 248 and Georgia WIC Farmer Market Handbook if funded to do so.
7. Ensure that no individual is discriminated against on the basis of disability in the full and equal enjoyment of services and facilities or accommodations of any place that provides such services as expressed in the Americans with Disabilities Act of 1990, as amended (ADA)(42 U.S.C. Section 12101 et seq.), including changes made by the ADA Amendments Act of 2008 (ADAAA)(42 U.S.C. Section 12182).

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Attachment AD-1 (cont'd)

8. Shall hire a Nutrition Services Director and/or WIC Coordinator position using the State Personnel Administration's job specifications for job title, MG1: Nutrition, and job code #10027.

9. Notify the Office of Nutrition and WIC of termination of this agreement, any county intragency agreements, or closure of a clinic location at least ninety days in advance.

PERFORMANCE MEASURES: 1. Increase average monthly participation to 318,624 statewide. 2. Increase average monthly prenatal participation to 24,615 statewide 3. Increase average monthly infant participation to 81,018 statewide. 4. Increase percentage of prenatal women enrolled in the first trimester to 60% 5. Increase percentage of infants enrolled in the first six weeks to 90% 6. Increase percentage of infants who initiate breastfeeding to 60% 7. Increase percentage of infants who breastfeed for at least six months to 40% 8. Increase percentage of children two to five years old who are within normal weight to 80% 9. Increase percentage of participants who received nutrition education to 90% 10. Increase percentage of high risk participants who received high risk nutrition education to 90%

Federal Fund Source Requirements:
1. Assure that nutrition education expenditures account for at least 22% of all Nutrition Services and Administration (NSA) total expenditures. If the minimum threshold is not met regarding NSA total expenditures, next year's allocation may be negatively adjusted.
2. Assure that breastfeeding education and promotion expenditures account for at least 9% of all Nutrition Services and Administration (NSA) total expenditures. If the minimum threshold is not met regarding NSA total expenditures, next year's allocation may be negatively adjusted.
3. Reimburse the Office of Nutrition and WIC with non-WIC funds in the amount of $1,000 per clinic that failed to batch and submit electronically participant and or vouchers issuance data to the WIC data processing contractor, Computer Science Corporation, on a daily basis or when clinic activity occurred for each occurrence over three in a quarter.

REPORTING REQUIREMENTS:
1. Submit electronically accurate and complete participant data to the WIC data processing contractor, Computer Science Corporation, on a daily basis or when clinic activity has occurred for the purpose of monitoring and performance.
2. Submit electronically an annual report identifying the status of the previous year's accomplishments and challenges, and a plan for the next year's activities to be included in Georgia WIC State Plan using the provided format by May 31, 2012.
Annual report is to be sent to the Programmatic Contact at the address listed below:
Georgia Department of Public Health Maternal and Child Health Program Office of Nutrition and WIC ATTN: Candace Jones, Planning Specialist 2 Peachtree Street, N.W., Suite 10.204 Atlanta, Georgia 30303-3142 Phone: (404) 657-8754
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Attachment AD-1 (cont'd)

E-mail Address: cjones2@dhr.ga.us
3. Submit electronically and by mail signed copies of annual budget and county intragency agreements using provided format by June 30, 2011.

Annual budget and county intragency agreements are to be sent to the WIC Financial contact at the address listed below:
Georgia Department of Public Health Finance and Budget ATTN: Samuel Sims 2 Peachtree Street, N.W., Suite 15.233 Atlanta, Georgia 30303-3142 Phone: (404) 657-2758 E-mail Address: sxsims@dhr.state.ga.us
PROGRAMMATIC CONTACT:
Georgia Department of Public Health Brian Castrucci, MA Program Director Maternal and Child Health Program 2 Peachtree Street, N.W., Suite 11.415 Atlanta, Georgia 30303-3142 Phone: (404) 657-2850 E-mail Address: bccastrucci@dhr.state.ga.us

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Attachment AD-2

Georgia Department of Administrative Services Surplus Property Division 2072 N. Bibb Drive Tucker, GA 30084-6233

Page 1 of __

*Transfer from Agency: *Unit:
*Address 1: *Address 2: *Point of Contact:
*Email: l
*Phone:

Fields with * are required
* Transfer to Agency: * Unit: * Address 1:
* Address 2: * Point of Contact: * Email: * Phone:

Property Transfer Form
Date:
DOAS Use:
Transaction #

Action Requested:
*Line *Quantity
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Intra Agency Transfer

Surplus Center Transfer

Destruction

*Description
(Model, Serial #, Inventory #, etc.)

On-Site Sale

Vendor Return

*Condition
Select Select Select Select Select Select Select Select Select Select Select Select Select Select Select Select Select Select Select Select

*Funding Information
(Funded or Non-Funded)
Make Selection Make Selection Make Selection Make Selection Make Selection Make Selection Make Selection Make Selection Make Selection Make Selection Make Selection Make Selection Make Selection Make Selection Make Selection Make Selection Make Selection Make Selection Make Selection Make Selection

DNS
*Final Disposition
(DOAS use only)

DOAS Surplus Representative Signature

Property Release Signature

Property Receipt Signature

Title

Title

Title

Date

Date

Date

Releasing signature certifies that ORIGINAL asset funding is accurate and that all software and data have been removed from all computers prior to their transfer.

"I hereby declare that the item(s) purchased through the Surplus Property Section, DOAS, shall not be resold within one (1) year of such transfer without the written consent of the Surplus Property Section, and the Surplus Property Section shall have the right which shall be exercised at their discretion, to supervise the resale of such property at public outcry to the highest responsible bidder is such property is within one (1) year after such transfer. All proceeds derived from that sale of such transferred item will revert to the State of Georgia through the Surplus Property Section."

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DOAS-2563E (9/07) PROPTRF-W

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment AD-3

STATE OF GEORGIA AGREEMENT FOR THE DISCLOSURE OF WIC INFORMATION
BETWEEN
DEPARTMENT OF PUBLIC HEALTH MATERNAL AND CHILD HEALTH PROGRAM
OFFICE OF NUTRITION AND WIC
AND
_____________________________________________________ _____________________________________________________ _____________________________________________________

I. Parties to the Agreement
This Agreement for the disclosure of WIC information (hereinafter, the "Agreement") is entered into between the Department of Public Health, Maternal and Child Health Program, Office of Nutrition and WIC (hereinafter, "WIC") and ______________________________________________ _______________________________________________________________________ (hereinafter, "Receiving Organization").
II. Purpose of the Agreement
Applicant and participant information for individuals participating in Georgia's Special Supplemental Nutrition Program for Women, Infants and Children (WIC) that individually identifies an applicant or participant and/or family members is confidential. Georgia WIC may disclose confidential WIC applicant and participant information to public organizations for use in the administration of their programs that serve persons eligible for Georgia WIC only for the purposes specified in the paragraph referenced immediately below, and only with the consent and authorization of the WIC applicant or participant. 7 C.F.R. 246.26(d).
The purpose of the Agreement is to allow for the disclosure of identifying WIC applicant and participant information (current and historical) for the sole purpose of: 1) establishing eligibility of WIC applicants or participants for the programs that the Receiving Organization administers; 2) conducting outreach to WIC applicants and participants for such programs; 3) enhancing the health, education or well-being of WIC applicants or participants who are currently enrolled in such programs; 4) streamlining administrative procedures in order to minimize burdens on staff, applicants, or participants in either the receiving program or WIC; and/ or 5) assessing and evaluating the responsiveness of a state's health system to participants' health care needs and health care outcomes. 7 C.F.R. 246.26(d).
III. Restrictions on Use
The Parties to the Agreement shall treat all information that is obtained or viewed by them or through their staff and subcontractors as confidential information and shall not use any

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GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment AD-3 (cont'd)

information so obtained in any manner, except for the purposes of disclosure stated in the paragraph above.
Criminal penalties, including fine or imprisonment or both, may apply upon disclosures of protected health information that are not authorized by regulation or Federal law. Criminal penalties under the HIPAA Privacy Rule (45 C.F.F. Part 164) may apply if it is determined that any employee (full time or part-time), agent, third-party vendor or subcontractor knowingly and willfully obtained protected health information of a WIC applicant or participant under false pretenses. Criminal penalties may be imposed under the HIPAA Privacy Rule if it is determined that any employee (full time or part-time), agent, third-party vendor or subcontractor has taken or converted to his or her own use protected health information knowing that it was stolen or converted.
IV. Responsibilities of the Parties
Georgia WIC agrees: 1) To provide the following WIC applicant or participant information on the WIC Assessment/Certification Form or in the WIC computer, including, but not limited to, an individual's name, address, phone number, ethnic origin and date of birth. The information will be provided to the Receiving Organization as needed, only with the consent and authorization of the WIC applicant or participant.
2) To provide no medical data or protected health information.
Receiving Organization agrees: 1) For the duration of the Agreement, to use identifying WIC applicant and participant information only for the purposes specified in this Agreement, pursuant to 7 C.F.R. 246.26(d), and to assure that it shall not disclose information provided by Georgia WIC under this Agreement to a third party and shall resist efforts made by others to obtain the information; 2) Upon termination of the Agreement, to cease all use of identifying WIC applicant and participant information and to assure that it shall not disclose information provided by Georgia WIC under the Agreement to a third party and shall resist efforts made by others to obtain the information after termination of the Agreement; and
3) For the duration of the Agreement, and upon its termination, to establish at all times appropriate administrative, technical, and physical safeguards to protect confidentiality of the identifying WIC applicant and participant information and to prevent unauthorized use of or access to the information. The safeguards shall provide a level and scope of security that is not less than that established by the Office of Management and Budget (OMB) in: OMB Circular No. A-130, Appendix III Security of Federal Automated Information Systems (http://www.whitehouse.gov/omb/circulars/a130/a130.html).

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Attachment AD-3 (cont'd)

V. Effective Date and Duration
The Agreement shall become effective upon signing by the Georgia WIC representative. The Agreement shall extend from that date of signing until termination. The Agreement may be canceled or terminated by either party with at least thirty (30) days' written notice of such intent. Georgia WIC shall have the sole discretion whether to amend the Agreement.
Upon the termination of the Agreement, Georgia WIC shall cease to provide and Receiving Organization shall cease to use all identifying WIC applicant and participant information and shall not disclose information provided by Georgia WIC under the Agreement to a third party. . VI. Notices
All notices, correspondence, directives, documents and other advisements shall be directed as follows to the parties:
GEORGIA WIC
Attention: Director, Office of Nutrition and WIC Maternal and Child Health Program Department of Public Health 2 Peachtree Street, NW Suite 10-476 Atlanta, Georgia 30303 (404) 657-2900

RECEIVING ORGANIZATION
Attention: ___________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________
VII. Entire Agreement
The Agreement contains the entire agreement between the parties with regard to the sharing of identifying WIC applicant and participant information and supersedes all other prior and contemporaneous statements, agreements, and understandings between the parties regarding the subject matter of the Agreement. Only a signed writing of equal dignity may amend the Agreement if Georgia WIC utilizes its sole discretion to amend the Agreement.
The Agreement is binding up on all employees (full time and part-time), agents, thirdparty vendors and subcontractors of the parties. The Agreement shall bind the respective heirs, executors, administrators, legal representatives, successors and assigns of each party.

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GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment AD-3 (cont'd)

VIII. Signatures

Signatures of the parties' duly authorized officers or agents are affixed as follows:

----Signatures appear on the following page.---IN WITNESS WHEREOF, the undersigned duly authorized officers or agents of each party affix their signatures on the day and year so indicated.

OFFICE OF NUTRITION AND WIC

___________________________________

Date: __________________

Deputy Director, Public Health Programs and Services

Department of Public Health

RECEIVING ORGANIZATION
___________________________________ Name
___________________________________ Title
___________________________________ Program
___________________________________ Department

Date: __________________

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GEORGIA WIC 2012 PROCEDURES MANUAL
GEORGIA DEPARTMENT OF PUBLIC HEALTH

Attachment AD-4
NAME OF INDIVIDUAL/CONSUMER/PATIENT/APPLICANT DATE OF BIRTH

Requesting Agency ID #

Releasing Agency ID #

AUTHORIZATION TO RELEASE INFORMATION

I hereby request and authorize:

(Name of Person or Agency Requesting Information)

to obtain from:

(Address) (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:

I understand that the federal Privacy Rule (HIPAA) does not protect the privacy of information if redisclosed, and therefore request that all information obtained from this person or agency be held strictly confidential and not be further released by the recipient. I further understand that my eligibility for benefits, treatment or payment is not conditioned upon my provision of this authorization. I intend this document to be a valid authorization conforming to all requirements of the Privacy Rule and understand that my authorization will remain in effect for: (PLEASE CHECK ONE)
ninety (90) days unless I specify an earlier expiration date here: one (1) year the period necessary to complete all transactions on matters related to services provide to me. I understand that unless otherwise limited by state or federal regulations, and except to the extent that action has been taken based upon it, I may withdraw this authorization at any time.

(Date)

(Signature of Individual/Consumer/Patient/Applicant)

(Date)

(Signature of Parent or other legally Authorized Representative, where applicable)

(Signature of Witness)

(Title or Relationship to Individual)

USE THIS SPACE ONLY IF AUTHORIZATION IS WITHDRAWN

(Date this authorization is revoked by Individual)

(Signature of Individual or legally authorized Representative) Form Effective 7/1/2011
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GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment AD-5

GEORGIA WIC

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) ____________________________________________________________________________
CSC COVANSYS 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 GEORGIA WIC USE

APPROVED

DISAPPROVED

FOR CSC COVANSYS USE

NEW CLINIC # ASSIGNED

____________________________________________________

EFFECTIVE DATE

____________________________________________________

COMPLETED BY

____________________________________________________

SYSTEM MAINTENANCE REPORT #

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GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment AD-6

Date submitted:

GEORGIA WIC COMPUTER SYSTEM ISSUES and PROBLEMS REPORT
Date problem discovered:

Clinic number:

District/unit number:

Name of person reporting issue:

Position:

Telephone number:

Email:

Name of person experiencing issue: Telephone number:

Position: Email:

Directions: Type an X next to selections and email to the Systems Information Unit or fax to (404) 6572910.

Severity of problem (select one)
Extremely critical
Critical
Major

Problem type: (select one and describe below)

Batching problem Provide Batch number Incorrect information in system
Equipment malfunction

Voided voucher numbers (list)
Multiple copies of same voucher printed ( ) times Voucher number error

Average

Printer problem

Same voucher number(s) given to different client(s)

Minor

System down (failure)

Vouchers did not print

Enhancement

System slow

Voucher format error

Farmer's Market

Update system information needed Computer virus (type)

Vouchers printed to wrong destination Other

Describe the issue and proposed solution (include voucher numbers if applicable):

Did staff report this issue to anyone? Yes____ No____

If yes, provide name and telephone number: _________________

Status since report (circle): Resolved

Unresolved

Computer report potentially affected: (e.g. CUR) _________

Reason for reporting to state WIC Office (circle): FYI only

Pending Take Action

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GEORGIA WIC 2012 PROCEDURES MANUAL


NEW SITE PERMISSION FORM

TO: FROM: DATE: RE:

District Health Directors Chief, Office of Nutrition and WIC XX XX, 20_ _ Permission to Open a New WIC Site.

Georgia WIC Review Team has completed the site(s) visit located at:

Attachment AD-7

Based on this visit the district site(s) listed above: May Open: ____________________ May Not Open: ________________
If you have any questions, please contact the Policy Unit at (404) 657-2900.

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Attachment AD-8

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Attachment AD-9

_NEW CLINIC EVALUATION REPORT_
Health District: Clinic: Date:
Satisfactory = S Unsatisfactory = U Recommendation = R Not Applicable = NA Satisfactory, Needs Improvement = SN
This New Clinic Evaluation Report will be used to ensure uniformed adherence to clinic set up specifications. A written summary of activities must be submitted and approved before the clinic in question can officially be opened.

NEW CLINIC SITE
PART I PROGRAMMATIC A. Location of Records Are participant records kept on file?

S U R NA SN

B. Documentation of Transfer Methods How are participants transferred?

C. Security (ID Card, WIC Stamp, VOC Cards, VOC Card Log) Are security procedures being followed?

D. Equipment in Place with Inventory Numbers Is WIC purchased equipment accurately identified?

E. Policy/Action Memos Does the new clinic have a copy of all policy memos on file?

F. Procedures Manual Is a current Procedures Manual located in the clinic?

G. Poster (No Smoking, Civil Rights, LEP, How to File a Complaint and No Charge) Are required posters displayed in the clinic?

H. Certification Form Are current certification forms available?

I. Certification Process Are policies and procedures followed during the certification process?

J. Processing Standards Are staff aware of WIC processing standards timeframes?

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GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment AD-9 (cont'd)

NEW CLINIC SITE

S

K. Adequate Space for Intake
Is the space provided adequate for patient confidentiality during the intake process?

L. Copy Machine
Is a copy machine available to copy required residency, identification and income proofs?

M. Clinic Hours of Operation (after hours one day a week) What are the clinic's hours of operation?

N. Agreement with the State Georgia WIC /District/Hospital Does the Coordinator/District Office/Georgia WIC have a signed copy of the agreement on file?

O. Civil Rights Has staff been trained in the area of Civil Rights?
Note: 1. Demographics of the population to be served in order to evaluate program access Racial makeup of the area you will be serving and who will be attending the clinic. A public health website that may be used to collect this information is http://oasis.state.ga.us/. 2. Data collected regarding covered employment including use of bilingual public-contact employees serving LEP (Limited English Speaking) beneficiaries of the programs Racial ethnic data of the employees that will be working at the new clinic. 3. Evaluation of the location of existing or proposed facilities connected with the program and whether access would be difficult or impossible because of locale Is there anyone who would be denied services due to the facility and racial makeup of the clinic. 4. Review of the composition of the planning or advisory board Racial makeup of the new facility. 5. Analysis of civil rights impact, if relocation of the clinic is involved Provide an analysis of the new location. This only applies when the clinic is relocating. 6. A written assurance by any program applicant or recipient that it will compile and maintain records required by the (FNS) Food Nutrition Service guidelines or other directives. 7. The manner in which services are or will be provided by the program in question, and related data necessary for determining whether any persons are or will be denied such services on the basis of prohibited discrimination. 8. A statement of notification from the program applicant or recipient to promptly notify (FNS) Food Nutrition Service of any lawsuit filed against the program applicant or recipient or sub recipient alleging discrimination on the basis of race, color, or national

U R NA SN

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GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment AD-9 (cont'd)

NEW CLINIC SITE

S

origin and that each recipient notify (FNS) Food Nutrition Service of any complaints filed against the recipient alleging such discrimination; and that each program applicant or recipient provide a brief description of any pending application to other Federal agencies for assistance, and of Federal assistance being provided at time of application or requested report . 9. A statement or description of previous civil rights reviews regarding the program applicant two years prior to applying as well as any information about the agency or organization performing the review and any periodic statements by the recipient regarding such reviews.

* Please note that a program applicant or recipient is the entity applying for program funding to serve WIC participants.

U R NA SN

P. Voter Registration Are WIC participants given the opportunity to vote and is documentation batched? Are declaration forms kept on file? Q. Prenatal Logs Is documentation available to review rescheduled missed appointments for prenatal applicants? R. Separation of Duties If one person conducts certification and issues vouchers, is the documentation sent to the District office to review for approval? S. Interview Script Is the applicant/participant given the opportunity to chose race, migrant and Hispanic/Latino status? T. Request for Services Log Is the Request for Services Log used in the clinic? If not, what method is used to document processing standards, e.g., appointment book, computer. U. Access to VOC/EVOC Cards Are VOC cards located in the clinic? Is staff using the electronic EVOC card system? Part II COMPLIANCE ANALYSIS A. Voucher Inventory The VPOD and Manual inventory must be conducted for all vouchers issued to participants.
B. Voucher Security Vouchers must be stored in a safe and secure location at all times.
C. Printer Security

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Attachment AD-9 (cont'd)

NEW CLINIC SITE Printers must not be accessible to participants or any unauthorized personnel.
D. Transported Vouchers Vouchers in a hospital setting can be transported in a locked clipboard, lockbox or locked briefcase.
E. Issuance Space Adequate space for issuing vouchers to participant with security of vouchers maintained.
PART III NUTRITION SECTION A. Anthropometrics
1. Height Board Meeting Standards? 2. Length Board Meeting Standards? 3. Adult Scales Meeting Standards/Certified within Last Year? 4. Infant Scales Meeting Standards/Certified within Last Year? B. Growth Charts 1. Birth-36 months and 2-20 Years for Boys and Girls? 2. Prenatal Weight Gain Grid? C. Certification 1. Hemoglobin/Hematocrit Procedures for Evaluation? 2. Dietary Assessment Sheets? 3. Certification Forms? 4. Computer Certification? D. Staff Interviews 1. Nutritionist 2. Clerk 3. Nurse 4. Nutrition Assistant E. Staff Training 1. Nutritionist 2. Clerk 3. Nurse 4. Nutrition Assistant F. Breastfeeding Promotion and Support (friendly environment)?
G. Adequate Space to Work?

S U R NA SN

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Attachment AD-9 (cont'd)

NEW CLINIC SITE H. Adequate Space for Counseling?
I. Adequate Space for Voucher Issuance/Waiting Room?
J. Patient Confidentiality?
K. Clinic Flow?
L. Resources 1. Nutrition Education Materials (provide list of materials available at clinic site)? 2. Nutrition Education Materials Ordering Catalog (describe process for ordering nutrition education materials)? 3. Nutrition Guidelines for Practice? 4. Risk Criteria Handbook? 5. Calculator?
PART IV SYSTEMS INFORMATION A. Clinic Information
1. Clinic Number 2. Full VPOD 3. WIC Computers 4. Clinic Staff Authorized to Use WIC System 5. Clinic Supervisors Listed 6. Current Authorized Users Kept on a List 7. Non-clinic Staff Authorized to Use WIC System Listed 8. Terminated or Transferred Staff Still on the List B. Physical Security 1. Computer, Printer and Voucher Stock in a Safe Area 2. Computer is Locked in a Safe Area when Clinic is Closed C. Program Security 1. System Backed Up Daily? 2. Provisions for Storing Backup Files in Case of Fire or Other
Disasters? 3. Users No Longer Employed by WIC Deleted from the
System? 4. List of Users and their Passwords Kept in the Clinic (No
such list should be kept anywhere)? 5. Clinic Maintains a Supply of Both Blank and Pre-numbered

S U R NA SN

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GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment AD-9 (cont'd)

NEW CLINIC SITE Paper TADs for Use in Emergencies?

S U R NA SN

6. Clinic Maintains a Supply of Blank Manual Vouchers for Use in Emergencies?

7. Clinic Maintains a Supply of Blank Standard Vouchers for All WIC Types as well as Blank Manual (999 series) Vouchers for Use in Emergencies?

8. Acknowledgement Dates for ETAD and Voucher Batches are Posted?

Comments/Observed Strengths and Weaknesses:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

_________________________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

_____________________________

______________ _______________________

Nutrition Services Director/Clinic ManagerDate Completed Date Submitted to the State

For State Agency Use Only _____________________________ State Staff Receiving Signature

_______________________ Date Received by the State

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GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment AD-10

Nutrition Services Director Job Description

Under broad supervision of the District Health Director and/or the District Program Manager, plans, implements, monitors, and evaluates the nutrition services of a Public Health District and WIC services to include certification section, rights and obligations section, administrative section, vendor section, food package section, nutrition education section, special population section, outreach section, food delivery section, compliance section, monitoring section, breastfeeding section, computer system section and disaster plan section.

Job Responsibilities and Performance Standards:

I.

Advises and collaborates with the agency health official, senior policy makers,

administrators and legislators who have a significant impact on the mission, programs

and policies in the District Health Agency. (Performed by all incumbents)

1. Participates in the development of health policies as a member of the health

agency's management team.

2. Reviews and comments on proposed legislation, regulations, and guidelines

promulgated by federal, state and local legislative bodies and regulator agencies and

evaluates potential impact on health agency performance and environment.

3. Participates in development, implementation and compliance with nutrition standards

of care and quality assurance throughout health agency.

4. Collaborates with community agencies or groups and provide nutrition outreach and

educational information as needed.

II. Develops long and short term goals for the health agency and participates in the agency's strategic and operational planning. (Performed by all incumbents) 1. Identifies programs and services to be implemented. 2. Conducts agency and community assessments. Uses health and management information databases in decision making. 3. Identifies available and needed nutrition resources for the target population. Plans future directions by coordinating and writing the State Administrative/Nutrition Education Plans. 4. Approves the district's nutrition plan within established time frames.

III. Prepares the agency's multi-million dollar nutrition services budget (i.e., WIC, Medicaid, other third party reimbursements and contract funds) and prepares grant proposals and contracts to obtain funds for expansion of nutrition services. (Performed by all incumbents) 1. Budgets multiple source nutrition funding, (i.e., WIC, Medicaid, other third party reimbursements, grant and contract funds) in compliance with federal, state and local standards. 2. Monitors expenditures to ensure conformity to budget category allowance. Identifies potential cost overruns. 3. Administers grants and contracts for nutrition services according to applicable laws and guidelines.

IV. Participates as an active member of the agency management team and recommends health program utilization and implementation strategies. (Performed by all incumbents) 1. Accurately determines staffing, facility and equipment needs. Coordinates staff activities, assign work and set priorities and deadlines for staff.

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GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment AD-10 (cont'd)

2. Provides appropriate input in the design and implementation of the agency management information system.
3. Thoroughly evaluates and monitors nutrition services outcomes for budget justification and for program compliance.
4. Conducts self-reviews annually using the "Georgia WIC Local Agency Monitoring Tool" to evaluate operations and to document findings for usage at the State level and Local level.
5. Participates as a member of the District Health Emergency Assistance and Resource Team (DHEART).
V. Provides expert nutrition information on technical application of nutrition expertise to agency and community administrators, policy makers and advocacy groups. (Performed by all incumbents) 1. Provides timely responses to inquiries regarding nutrition information by human service professionals, related community volunteer agencies and/or educators or academic. 2. Provides nutrition policy analysis and interpretation to administrators, legislators and/or corporate/industry inquiries as needed. 3. Collaborates as agency representative in community advocacy or volunteer agencies, providing nutrition and health educational information and agency support. 4. Responsible for researching and providing training opportunities to nutrition competency for nutritionists, public health nurses and other health care workers. 5. Responsible for overseeing breastfeeding trainings and to attend biannual coalition meetings.
VI. Creates and maintains a high performance environment characterized by positive leadership and a strong team orientation. (Performed by all incumbents) 1. Define 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 required results are not met.
3. Confers regularly with staff and supervision to review employee relation's 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 celebrate accomplishments. 6. Motivates staff to improve quantity and quality of work performed and provides
training and development opportunities as appropriate.
VII. Manages human resource and employee relation's functions. (Performed by all incumbents) 1. Interviews applicants or employees to fill vacancies or promotional positions according to applicable laws, rules and policies. 2. Selects or promotes the appropriate number of individuals who possess the skills needed to perform required work.

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Attachment AD-10 (cont'd)

3. Provides orientation to new employees. Identifies training needs and ensure that necessary job-related instruction is provided to all staff.
4. Discusses potential grievance-related concerns with employees in order to identify options or resolve issues prior to the formal filing of a grievance.
5. Advises employees of established grievance procedures. 6. Recommends or initiates disciplinary actions according to applicable rules and
policies.
VIII. Maintains responsibility for personal professional continuing education to enable application of current professional practice. (Performed by all incumbents) 1. Participates in professional workshops, seminars, nutrition staff meetings and other in-services as scheduled. Summarizes relevant information received in the training sessions and shares with other staff either in verbal or written form. 2. Remains knowledgeable and up-to-date in the field of nutrition through reading nutrition and medical journals and textbooks. 3. Maintains CPR certification and proficiency by renewing certification bi-annually.















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Attachment AD-11

FORM I

PATIENT FLOW ANALYSIS (PFA) SIGN IN

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 Administration section of the Procedures Manual)

FORM II

OPTION I

Patient Flow Analysis (PFA) Form

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GEORGIA WIC 2012 PROCEDURES MANUAL
Room #: _________________ (If Applicable) Clinic: ________________________________________ Patient #: ______________________________________ Name: ________________________________________ Date Sent: _____________________________________ Reason for Visit: ________________________________ WIC Type: P _____ N _____ B _____I ______ C________ Appointment Time: ______________________________

Attachment AD-11 (cont'd)

Time

Time Started

Time

Staff

Finished Initials

Patient Arrived:

____

Initiate Worker:

____

____

____

Clerk:

____

____

____

Lab Worker:

____

____

____

Nurse:

____

____

____

Nutritionist:

____

____

____

Clerk:

____

____

____

Time Patient Left:

____

Total Time in Clinic:

____

FPC/Formula Type: (Optional) __________________________________________________

Special Services Provided/Comments: _____________________________________________

____________________________________________________________________________

Note: 1. 2.

A record of staff initials must be kept on file for audit purposes. Each applicant/participant must have her/his own PFA Form.

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GEORGIA WIC 2012 PROCEDURES MANUAL
FORM III

Attachment AD-11 (cont'd) OPTION I

Patient Flow Analysis: Employee Time Log

Name & Title of Employee

_________________________

Work Hours (Serving Participant in the Clinic):

Clinical:

_________________________

Administrative:

_________________________

Clerical:

__________________________

Work Hours (Serving Participant outside of Clinic, ie phone/appt/Dr. office):

Clinical:

_________________________

Administrative:

_________________________

Clerical:

__________________________

Miscellaneous (any other duties perform):

__________________________

Lunch/ Break:

__________________________

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Attachment AD-11 (cont'd)

FORM IV

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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GEORGIA WIC 2012 PROCEDURES MANUAL
FORM I

Attachment AD-11 (cont'd) OPTION II

PATIENT FLOW ANALYSIS (PFA) SIGN IN

Clinic _______________ Date ___________ Start Time ___________

Patient Number 1

Name

Arrival Time

Appt. Time

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)

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Attachment AD-11 (cont'd)

FORM 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

PERSONNEL IDENTIFICATION CODES

OPTION II

NAME

OFFICIAL FUNCTION

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GEORGIA WIC 2012 PROCEDURES MANUAL
FORM III

Attachment AD-11 (cont'd) OPTION II

REASON FOR VISIT CODES

Code A. B. C. D. E. F. G. H. I.

Definition Initial Certification Recertification (Subsequent) Incomplete Certification (i.e. - Client left without completing certification process) Reinstate Transfer Education (with or without vouchers) Special Formula or Formula Change Vouchers only (no nutritional education) Other (please specify)

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GEORGIA WIC 2012 PROCEDURES MANUAL
FORM IV

Attachment AD-11 (cont'd) OPTION II

PATIENT CATEGORY

A.

Pregnant Woman

B.

Postpartum Woman

C.

Breastfeeding Woman

D.

Infant

E.

Child

F.

Family (use only when a combination of family members receives WIC services)

G.

Other (specify)

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GEORGIA WIC 2012 PROCEDURES MANUAL
FORM V
PATIENT REGISTER

Attachment AD-11 (cont'd) 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 ID Code

Start Time

End Time

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 ________



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GEORGIA WIC 2012 PROCEDURES MANUAL
FORM VI

Attachment AD-11 (cont'd) OPTION II

Patient Flow Analysis: Employee Time Log

Name & Title of Employee

__________________________

Work Hours (Serving Participant in the Clinic):

Clinical:

__________________________

Administrative:

__________________________

Clerical:

__________________________

Work Hours (Serving Participant outside of Clinic, ie phone/appt/Dr. office):

Clinical:

__________________________

Administrative:

__________________________

Clerical:

__________________________

Miscellaneous (any other duties performed): __________________________

Lunch/ Break:

__________________________

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GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment AD-11 (cont'd)

FORM VII

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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GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment AD-12

INTER/INTRA AGENCY AGREEMENT

x Use Option that fits District model
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GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment AD-12 OPTION I

INTRA-AGENCY AGREEMENT FOR
THE SPECIAL SUPPLEMENTAL NUTRITION PROGRAM FOR WOMEN, INFANTS AND CHILDREN (WIC) SFY _______

I.

Introduction

This contract (hereinafter, "the Contract") is between the _________________County Board of Health (hereinafter, "Lead County") and the _______________County Board of Health (hereinafter, "Non-Lead County") in accordance with the Child Nutrition Act of 1966, as amended, for the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) in Georgia (hereinafter, "Georgia WIC").

II. Purpose

The Contract is made pursuant to regulations of the United States Department of Agriculture, Food and Nutrition Services (USDA/FNS) at 7 C.F.R. Section 246, the Georgia Department of Public Health (DPH) Policies and Procedures Manual, the Georgia WIC Procedures Manual, the Georgia WIC State Plan of operation, the Master Agreement and Annex J, the Georgia WIC Plan for Local Agency Planning, the WIC Financial Management and Statewide Cost Allocation Plan, and all relevant administrative memos. The aforementioned documents are hereinafter incorporated into the Contract.

Pursuant to the Contract, the Lead County agrees to distribute WIC Nutrition Services Administrative (NSA) funds to the Non-Lead County based upon an assigned caseload target. To receive these funds, the Non-Lead County must perform the following functions in order to meet Georgia WIC objectives: nutrition education, breastfeeding promotion and support, participant certification, caseload management, food delivery, screenings for and referrals to other social and medical service providers, and general WIC management.

III. General Agreement

Both the Lead County and the Non-Lead County agree to:

1. Adhere to the WIC Statewide Cost Allocation Plan.

2. Maintain complete and accurate records of WIC funds received and expended by employing Generally Accepted Accounting Principles (GAAP) and reconciling WIC expenditures to WIC revenue.

3. Make these records available for audit upon request of Georgia WIC, the DPH Office of Audits, the DPH Office of Investigative Services and/or the USDA.

In case of an audit exception in performance, the Non-Lead County may be responsible for payment to Georgia WIC from that County's non-participating funds.

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GEORGIA WIC 2012 PROCEDURES MANUAL IV. Lead County Agreement

Attachment AD-12

The Lead County agrees to:

1. Provide $___________ of NSA funding for the reimbursement of non-WIC paid staff for salary and fringe benefits only with an assigned caseload target of _________ to the Non-Lead County.

2. Disburse contracted NSA funds to the Non-Lead County in the first and second quarter of the State fiscal year, and amend the Contract using Attachment 1-A when and if additional NSA funds become available.

3. Reimburse non-WIC paid staff for all WIC approved per diem/travel.

4. Provide medical/supplies, office supplies, equipment and any items required to perform service delivery to WIC clients.

5. Provide manuals, forms and nutrition education materials required for WIC service delivery as specified in the Georgia WIC Procedures Manual and the Georgia WIC State Plan of operation.

6. Monitor, evaluate and provide technical assistance and training for the Non-Lead County agency staff regarding the delivery of WIC services on a routine basis and/or as requested.

7. Reimburse the Non-Lead County for approved Central Services Cost Allocation expenditures in County Health Departments using Attachment 1-B.

V. Non-Lead County Agreement
The Non-Lead County agrees to:
1. Accept $___________ of NSA funding with an assigned WIC caseload target of______ from ________ County Board of Health. A local agency must perform the following functions in order to meet WIC's objectives: nutrition education, breastfeeding promotion and support, participant certification, caseload management, food delivery, screenings for and referrals to other social and medical service providers, and general WIC management.
2. Expend twenty-two (22) percent of NSA funds expended toward nutrition education.
3. Expend nine (9) percent of NSA funds expended towards breastfeeding education and promotion.
4. Accept an allocation adjustment if total reported nutrition education and breastfeeding promotion and support expenditures are less than the required amount of expenditures. The State WIC office will reduce the following federal fiscal years' allocation by the difference.

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GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment AD-12

5. Record all WIC transactions for non-WIC paid employees using the Personnel Activity Report System (PARS), which will be the official record for tracking nutrition education and breastfeeding education and promotion.
6. Submit a projected line item budget to Lead County within thirty (30) days of the acceptance of the Contract and resubmit the Contract using Attachment 1-A when additional funds are allocated to the County.

7. Have appropriate staff adequately perform WIC responsibilities in accordance with WIC staffing and processing standards, certification requirements, WIC services integrity, and voucher accountability and security.
8. Collect client data for WIC participants for the purpose of monitoring WIC services performance and comply with all Federal and State requirements in the collection of WIC data and modify as appropriate or requested within a specified time.

9. Comply with all the fiscal and operational requirements prescribed by Georgia WIC pursuant to: 7 C.F.R. Part 3016, the debarment and suspension requirements of 7 C.F.R. Part 3017 (if applicable), the lobbying restrictions of 7 C.F.R. Part 3018, and FNS guidelines and instructions; provide on a timely basis to Georgia WIC all required information regarding fiscal and WIC services information.

10. Prohibit smoking in the space used to perform WIC services during times of service delivery.

11. Comply with non-discrimination laws by not discriminating against persons on the grounds of race, color, national origin, age, sex or handicap, and compile data, maintain records, and submit reports as required to permit effective enforcement of non-discrimination laws.

12. Maintain on file and have available for review and audit all certification criteria used to determine WIC eligibility.

13. Make available all appropriate health services to WIC participants, whether directly or through referral services; inform WIC applicants and participants about these services; and provide nutrition educational services to WIC participants in compliance with WIC Federal regulations and FNS guidelines and instructions.

14. Maintain complete, accurate, documented and current accounting of all WIC funds received and expended.

15. Provide the Lead County, Georgia WIC, and the DPH Office of Audits immediate and complete access to all WIC clinics and all records maintained by WIC clinics within the County.

16. Obtain prior approval from the Lead County for any Central Services Cost Allocation Plan, and adhere to the WIC Cost Allocation Guidelines using Attachment 1-B.

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GEORGIA WIC 2012 PROCEDURES MANUAL VI. Notice

Attachment AD-12

All notices under this Contract shall be deemed duly given upon delivery, if delivery by hand, or three (3) calendar days after posting, if sent by registered or certified mail, return receipt requested, to a party listed at the addresses below or otherwise designated by notice pursuant to this paragraph:

LEAD COUNTY

Name: _______________________________________ Title: _______________________________________ Address: _______________________________________
_______________________________________ _______________________________________ _______________________________________

NON-LEAD COUNTY

Name: ________________________________________ Title: ________________________________________ Address: ________________________________________
________________________________________ ________________________________________ ________________________________________

VII. Entire Agreement

The Contract constitutes the entire agreement between the Lead County and Non-Lead County with respect to the subject matter hereof and supersedes all prior negotiations, representations, or contracts. No written or oral agreements, representations, statements, negotiations, understandings, or discussions that are not set out, referenced, or specifically incorporated in this Contract shall in any way be binding on or of effect between the Lead County and Non-Lead County.

Any section, subsection, paragraph, term, condition, provision, or other part of the Contract that is judged, held, found or declared to be voidable, void, invalid, illegal or otherwise not fully enforceable shall not affect any other part of the Contract, and the remainder of the Contract shall continue to be of full force and effect as set out herein.

VIII. Term and Termination
The Contract shall be effective for the ____ State Fiscal Year beginning on July 1st and ending on June 30th of the given State Fiscal Year.
The Contract is binding on the Lead County and Non-Lead County, and its successors, transferees, and assignees, so long as the County receives assistance or retains possession of any assistance from Georgia WIC. Either party, upon sixty (60) days' written notice, may terminate the Contract.

AD-122

GEORGIA WIC 2012 PROCEDURES MANUAL IX. Amendment

Attachment AD-12

No amendment, waiver, termination or discharge of this Contract, or any of the terms or provisions hereof, shall be binding upon either the Lead County or the NonLead County unless confirmed in writing. Nothing may be modified or amended, except in writing executed by both the Lead County and the Non-Lead County.

X. Confidentiality Requirements

The Lead County and Non-Lead County shall not use any information obtained or viewed in performance of the Contract in any manner except as necessary for the proper discharge of their respective obligations under the Contract.

The Lead County and Non-Lead County shall adhere to the confidentiality provisions of the Federal WIC regulations found at 7 C.F.R. Section 246.26(d) concerning confidential WIC applicant and participant information.

XI. Signatures

IN WITNESS WHEREOF, the undersigned duly authorized officers or agents of each party affix their signatures on the day and year so indicated.

DISTRICT HEALTH DIRECTOR

_____________________________ Name

________________________ Date

LEAD COUNTY

_____________________________ Name Title

________________________ Date

NON-LEAD COUNTY

_____________________________ Name Title

_________________________ Date

AD-123

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment AD-12 Option 1-A

PLANNED BUDGET FOR SFY _____
______________________ COUNTY BOARD OF HEALTH FOR
THE SPECIAL SUPPLEMENT NUTRITION PROGRAM FOR WOMEN, INFANTS AND CHILDREN (WIC)

A. Personnel Services B. Central Cost Allocation Plan

$_______________ $_______________

TOTAL COSTS:

$______________

Prepared by:
______________________________________ Contractor Signature
___________________________________ Contractor Typed Name and Title
___________________________________ Date

AD-124

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment AD-12 Option 1-B

Central Cost Allocation Plan (643) SFY _____

______________________ COUNTY BOARD OF HEALTH FOR
THE SPECIAL SUPPLEMENT NUTRITION PROGRAM FOR WOMEN, INFANTS AND CHILDREN (WIC)

Purpose: The purpose of this Central Cost Allocation Plan is to arrive at an equitable distribution of WIC common expenses reimbursable from the ______________ County Board of Health ("Lead County") to the __________________County Board of Health ("Non-Lead County") based on square footage of floor space.

Shared Cost: This Central Cost Allocation Plan includes reimbursement for actual costs common to WIC.

Expenses: Expenses will be based on a percentage of the actual cost and will include the following:

Percentage of Common Space allotted to WIC (Identify Space): ____________ Total square footage of building: ________________

Common Costs: x Utilities (% of actual cost based on utility bill) x Cleaning/maintenance/supplies/paper products (% of actual cost) x Annual Electric Record Room File Maintenance (%of actual cost) x Toilet paper/paper towels (% of actual cost) x A/C & Heating Repairs/Maintenance/Insurance (% of actual cost) x Garbage (% of actual cost) x Pest control (% of actual cost) x Scale Calibration (% of actual cost) x Telephone and Fax (per Phone bill) x Use of Copy Machine/Supplies (% of actual cost) x Medical Waste (% of actual cost)

Invoices must be submitted by the fifth day of the current month for expenses incurred during the previous month. Reimbursement is based on WIC funding and is not guaranteed if funding is not available.

_________________________________ _________________________________

Chair, Lead County Board of Health

Chair, Non-Lead County Board of Health

__________________________________ District Health Director

AD-125

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment AD-12

OPTION II
INTRA-AGENCY AGREEMENT FOR
THE SPECIAL SUPPLEMENTAL NUTRITION PROGRAM FOR WOMEN, INFANTS AND CHILDREN (WIC) SFY ______
IV. Introduction
This contract (hereinafter, "the Contract") is between the __________________ County Board of Health (hereinafter, "Lead County") and the _______________County Board of Health (hereinafter, "Non-Lead County") in accordance with the Child Nutrition Act of 1966, as amended, for the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) in Georgia (hereinafter, "Georgia WIC").
V. Purpose
The Contract is made pursuant to regulations of the United States Department of Agriculture, Food and Nutrition Services (USDA/FNS) at 7 C.F.R. Section 246, the Georgia Department of Public Health (DPH) Policies and Procedures Manual, the Georgia WIC Procedures Manual, the Georgia WIC State Plan of operation, the Master Agreement and Annex J, the Georgia WIC Plan for Local Agency Planning, the WIC Financial Management and Statewide Cost Allocation Plan, and all relevant administrative memos. The aforementioned documents are hereinafter incorporated into the Contract.
III. Lead County Agreement
The Lead County agrees to:
1. Provide $___________ of NSA funding for the payment of approved Central Services Costs upon prior approval of any Central Services Cost Allocation Plan with adherence to the Statewide Cost Allocation Plan.
2. Maintain complete, accurate, documented and current accounting of all WIC funds received from USDA/FNS and provided to the Non-Lead County.
IV. Non-Lead County Agreement
The Non-Lead County agrees to:
1. Accept $___________ of NSA funding for the payment of approved Central Services Costs upon prior approval of any Central Services Cost Allocation Plan with adherence to the Statewide Cost Allocation Plan.
2. Collect client data for WIC participants for the purpose of monitoring WIC services performance and comply with all Federal and State requirements in the collection of WIC data and modify as appropriate or requested within a specified time.

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GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment AD-12

3. Comply with all the fiscal and operational requirements prescribed by Georgia WIC pursuant to: 7 C.F.R. Part 3016, the debarment and suspension requirements of 7 C.F.R. Part 3017 (if applicable), the lobbying restrictions of 7 C.F.R. Part 3018, and FNS guidelines and instructions; provide on a timely basis to Georgia WIC all required information regarding fiscal and WIC services information.

4. Prohibit smoking in the space used to perform WIC services during times of service delivery.

5. Comply with non-discrimination laws by not discriminating against persons on the grounds of race, color, national origin, age, sex or handicap, and compile data, maintain records, and submit reports as required to permit effective enforcement of non-discrimination laws.

6. Maintain on file and have available for review and audit all certification criteria used to determine WIC eligibility.

7. Make available all appropriate health services to WIC participants, whether directly or through referral services, and inform WIC applicants and participants about these services.

8. Maintain complete, accurate, documented and current accounting of all WIC funds received and expended.

9. Provide the Lead County, Georgia WIC, and the DPH Office of Audits immediate and complete access to all WIC clinics within the County and their WIC records.

V. Notice

All notices under this Contract shall be deemed duly given upon delivery, if delivery by hand, or three (3) calendar days after posting, if sent by registered or certified mail, return receipt requested, to a party listed at the addresses below or otherwise designated by notice pursuant to this paragraph:

LEAD COUNTY

Name: _______________________________________ Title: _______________________________________ Address: _______________________________________
_______________________________________ _______________________________________ _______________________________________

NON-LEAD COUNTY

Name: ________________________________________ Title: ________________________________________ Address: ________________________________________
________________________________________ ________________________________________ ________________________________________

AD-127

GEORGIA WIC 2012 PROCEDURES MANUAL VI. Entire Agreement

Attachment AD-12

The Contract constitutes the entire agreement between the Lead County and Non-Lead County with respect to the subject matter hereof and supersedes all prior negotiations, representations, or contracts. No written or oral agreements, representations, statements, negotiations, understandings, or discussions that are not set out, referenced, or specifically incorporated in this Contract shall in any way be binding on or of effect between the Lead County and Non-Lead County.

Any section, subsection, paragraph, term, condition, provision, or other part of the Contract that is judged, held, found or declared to be voidable, void, invalid, illegal or otherwise not fully enforceable shall not affect any other part of the Contract, and the remainder of the Contract shall continue to be of full force and effect as set out herein.

VII. Term and Termination

The Contract shall be effective for the _____ State Fiscal Year beginning on July 1st and ending on June 30th of the given State Fiscal Year.

The Contract is binding on the Lead County and Non-Lead County, and its successors, transferees, and assignees, so long as the County receives assistance or retains possession of any assistance from Georgia WIC. Either party, upon sixty (60) days' written notice, may terminate the Contract.

VIII. Amendment

No amendment, waiver, termination or discharge of this Contract, or any of the terms or provisions hereof, shall be binding upon either the Lead County or the NonLead County unless confirmed in writing. Nothing may be modified or amended, except in writing executed by both the Lead County and the Non-Lead County.

IX. Confidentiality Requirements

The Lead County and Non-Lead County shall not use any information obtained or viewed in performance of the Contract in any manner except as necessary for the proper discharge of their respective obligations under the Contract.

The Lead County and Non-Lead County shall adhere to the confidentiality provisions of the Federal WIC regulations found at 7 C.F.R. Section 246.26(d) concerning confidential WIC applicant and participant information.

AD-128

GEORGIA WIC 2012 PROCEDURES MANUAL X. Signatures

Attachment AD-12

IN WITNESS WHEREOF, the undersigned duly authorized officers or agents of each party affix their signatures on the day and year so indicated.

DISTRICT HEALTH DIRECTOR

_______________________________ Name

________________________ Date

LEAD COUNTY

_______________________________ Name Title

________________________ Date

NON-LEAD COUNTY

_______________________________ Name Title

_______________________ Date

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GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment AD-12 Option II-A

PLANNED BUDGET FOR SFY _____
______________________ COUNTY BOARD OF HEALTH FOR
THE SPECIAL SUPPLEMENT NUTRITION PROGRAM FOR WOMEN, INFANTS AND CHILDREN (WIC)

A. Personnel Services B. Central Cost Allocation Plan

$______________ $______________

TOTAL COSTS:

$______________

Prepared by:
______________________________________ Contractor Signature
___________________________________ Contractor Typed Name and Title
______________________________________ Date

AD-130

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment AD-12 Option II-B

Central Cost Allocation Plan (643) SFY _____

______________________ COUNTY BOARD OF HEALTH FOR
THE SPECIAL SUPPLEMENT NUTRITION PROGRAM FOR WOMEN, INFANTS AND CHILDREN (WIC)

Purpose: The purpose of this Central Cost Allocation Plan is to arrive at an equitable distribution of WIC common expenses reimbursable from the ______________ County Board of Health ("Lead County") to the __________________County Board of Health ("Non-Lead County") based on square footage of floor space.

Shared Cost: This Central Cost Allocation Plan includes reimbursement for actual costs common to WIC.

Expenses: Expenses will be based on a percentage of the actual cost and will include the following:

Percentage of Common Space allotted to WIC (Identify Space): ____________ Total square footage of building: ________________

Common Costs: x Utilities (% of actual cost based on utility bill) x Cleaning/maintenance/supplies/paper products (% of actual cost) x Annual Electric Record Room File Maintenance (%of actual cost) x Toilet paper/paper towels (% of actual cost) x A/C & Heating Repairs/Maintenance/Insurance (% of actual cost) x Garbage (% of actual cost) x Pest control (% of actual cost) x Scale Calibration (% of actual cost) x Telephone and Fax (per Phone bill) x Use of Copy Machine/Supplies (% of actual cost) x Medical Waste (% of actual cost)

Invoices must be submitted by the fifth day of the current month for expenses incurred during the previous month. Reimbursement is based on WIC funding and is not guaranteed if funding is not available.

________________________________ Chair, Lead County Board of Health

________________________________ Chair, Non-Lead County Board of Health

________________________________ District Health Director

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GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment AD-13

LOCAL AGENCY NSA FUNDING ALLOCATON
The current Nutrition Services Administration (NSA) funding formula allows growth Districts to receive their fair share of funding on the front-end. The combined caseload target is based on the current five (5) months participation closeout October-February and one month March (30 day) and the projected availability of federal food funds.
1. Caseload targets are assigned using two (2) factors.
a. Local agencies that meet or exceed caseload targets using the current
federal fiscal year five-month closeout and one month (30 day) will be assigned a new target using the highest one-month participation.
b. Local agencies that do not meet caseload targets using the current
federal fiscal year five-month closeout and one month (30 day) will be assigned a six-month average caseload target.
PROGRAM PARTICIPATION
The definition of a participant 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 exclusive breastfed infant is issued a voucher message but no formula is issued.
PARTICIPANT COST ADJUSTMENT
Participant Cost Adjustment will be allocated in the next federal fiscal year to the Local Agencies that exceeded their prior year assigned caseload. This allocation will be made based upon the availability of NSA funds and State Management discretion. The Participant Cost Adjustment funding formula is as follows:
a. Number of participant that exceeded caseload.
b. Prior Federal Fiscal year funding rate per participant or participant times
funding rate times 12 months, equals Participant Cost Adjustment.

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Attachment AD-14

LOCAL AGENCY APPLICATION FOR

CONSIDERATION AS A PROVIDER

OF

SERVICES FOR THE

SPECIAL SUPPLEMENTAL NUTRITIONAL PROGRAM

FOR

WOMEN, INFANTS AND CHILDREN (WIC)

Purpose
The purpose of this application is to provide information to Georgia WIC regarding the applicant's desire, qualifications and capacity to deliver Georgia WIC services to eligible clients/patients. Upon review of the completed application, Georgia WIC staff will make an initial determination of the agencies suitability for participation in the program. Final determinations will be made pending decisions regarding coordination with existing service providers.
Initial approval will be based on the following factors:
1. The need for WIC services within the service area. 2. An estimate of the number of individuals to be served by the applicant. 3. The capacity of the agency to deliver quality services. 4. The availability of staff required meeting federal guidelines for WIC service
providers.
AGENCY NAME
ADDRESS
CITY, STATE & ZIPCODE
TELEPHONE NUMBER
CONTACT PERSON
ALTERNATE # _________________________________________________________
NAME OF CEO ____________________________________________________



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GEORGIA WIC 2012 PROCEDURES MANUAL
LOCAL AGENCY APPLICATION Page 2

Attachment AD-14 (cont'd)

Identify whether the agency is nonprofit, federally funded, Physician Sponsor Plan (PSP), HMO, clinic plan, local health department, private practice, community health center, etc.
TYPE OF AGENCY AGENCY NAME

Describe your service area including geographic area (counties), demographics of the population served, and percent of patients on Medicaid:

Number of pregnant women served: Number of hours for obstetric (OB) services: __________________ Number of hours for pediatric services: __________________ Number of hours for general services: __________________

AGENCY STAFFING

Number of physicians by specialty:

__________________

Do you have a registered dietitian (RD) on staff? _________________

Number of hours per week an RD is available: __________________

Number of registered dietitians on staff: __________________



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GEORGIA WIC 2012 PROCEDURES MANUAL
LOCAL AGENCY APPLICATION Page 3

Attachment AD-14 (cont'd)

Number of Nutritionists with a B.S. in nutrition and/or Dietetic Technician Registered: Number of registered nurses (RN) on staff: _________ Number of staff to weigh and measure and perform hemoglobin and hematocrits: _________
CLINIC/FACILITY CAPACITY How many clinic locations do you operate? List the name and location of each clinic to provide WIC services:

AGENCY NAME:
Describe the discussions with your county WIC agency regarding provision of WIC services by your agency.



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GEORGIA WIC 2012 PROCEDURES MANUAL
LOCAL AGENCY APPLICATION Page 4

Attachment AD-14 (cont'd)

PROPOSED WIC SERVICES AND ESTIMATE OF NEED FOR WIC SERVICES WIC Program eligibility is prescribed in the Code of the Federal Register (CFR) Title 7 Part 246. To be eligible for participation in Georgia WIC, clients/patients must meet income and categorical eligibility requirements. Eligible clients include Women, Infants and Children to age five (5) years who are at or below 185% of the federal poverty level and have a medical or nutritional risk. Residents and Migrants meeting these requirements can be offered program benefits.
How many WIC eligible clients reside in your service area? Number of WIC eligible clients served by your agency/clinic: Number of pregnant women currently being served: Number of WIC clients you will serve in the first year: Maximum number of persons you can/will serve after the first year:
What is the date and source of the information provided above (census data; actual count, etc.)?
SOURCE AGENCY:



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GEORGIA WIC 2012 PROCEDURES MANUAL
LOCAL AGENCY APPLICATION Page 5

Attachment AD-14 (cont'd)

CLINIC/FACILITY CAPACITY
How much space do you plan to designate for WIC service delivery in each clinic location?

Can you perform required Laboratory procedures at each location?
Do you have equipment available to perform Anthropometric (weight, height/length and hematocrit/hemoglobin) Measurements?
What other health-related services do you provide at each clinic location?



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GEORGIA WIC 2012 PROCEDURES MANUAL
LOCAL AGENCY APPLICATION Page 6

Attachment AD-14 cont'd

BUDGET ESTIMATE

Number of WIC clients you will serve in the first year. First year costs of serving eligible WIC clients. Monthly per client cost for year two and beyond.

_______ Signature of Chief Executive Officer (CEO) or Contact Person
For additional information, contact Samuel Sims at (404) 657-2900. Please return completed form with documents required to:
Department of Public Health Georgia WIC
Two Peachtree Street, Suite 10- 495 Atlanta, GA 30303-3182

Date



AD-138

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment AD-15

Department of Public Health Georgia WIC
Two Peachtree Street, NW Atlanta, Georgia 30303
Disqualification/Not Accepting an Application Form

Georgia WIC is disqualifying / not accepting an application from (Circle One)
________________________________ for the following reason(s): Local Agency Name

1. ________________________________________________________________ ________________________________________________________________

2. ________________________________________________________________ ________________________________________________________________

3. ________________________________________________________________ ________________________________________________________________

4. ________________________________________________________________ ________________________________________________________________

___________________________________ Chief, Office of Nutrition and WIC

______________ Date



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GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment AD-16

PARTICIPANT CHARACTERISTICS MINIMUM DATA SET (MDS)
The Participant Characteristics Minimum Data Set (MDS) contains data items that are reported to FCS electronically by state agencies for one report month on all or a sample of participants. The MDS has required data items that must be collected and reported. The Supplemental Data Set Specifications (SDS) comprised of optional data items that state agencies may collect and report. Please check those data items the state agency currently collects in its Management Information Systems and those data items it is planning to collect within the next two years.
REQUIRED: Participant Characteristics Minimum Data Set
State Agency MIS: Collects

X

State agency ID. A unique number that permits linkage to the WIC state agency where

the participant was certified.

X

Local agency ID. A unique number that permits linkage to the local agency where the participant was certified as eligible for WIC benefits.

X

Service Site ID. A unique number that permits linkage to the service site where certified.

Either local agency ID or service site ID may be reported according to the level the state

agency feels appropriate. At a minimum, state agencies must provide agency names

and addresses for each ID provided on their files.

X

Case ID. A unique record number for each participant that maintains individual privacy

at the national level.

General Instructions: Participant or Case IDs for each participant should continue to maintain individual privacy at the national level. States are requested to generate these IDs in the same manner that was applied for PC92 to allow longitudinal tracking of participant characteristics. This task can be accomplished by applying the PC92 algorithm to construction of PC98 participant IDs.

X

Client Date of Birth: Month, day and year of participant's birth reported in MMDDYYYY

format.

Client Race/Ethnicity: The classification of the participant into one of the five (5)

racial/ethnic categories: white; black; Hispanic; American Indian or Alaskan Native; or

Asian or Pacific Islander. The ethnic categories, white and black, include only those

X

persons who are not of Hispanic origin.





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Attachment AD-16 (cont'd)

MANAGEMENT INFORMATION SYSTEM WIC SYSTEMS FUNCTIONAL REQUIREMENTS CHECKLIST

State Agency Performs

State Agency Plans Function/Capabilities

NUTRITION EDUCATION AND HEALTH SURVEILLANCE

Maintain Nutrition Education Data

X

Maintain appointment schedules for enrollees that are to receive nutrition

education

X

Maintain appointment schedule of available nutrition education sessions

X

Provide appointment notice to enrollee

X Track participation in education

X Track types of nutrition education provided

Perform Individual Client Health Monitoring

X

Capture and monitor changes in individual client health status

X

Provide individual client data to other health agencies

Perform individual client nutrition education and diet monitoring

Capture and monitor changes in individual client dietary behavior

Perform Analysis of WIC Population Nutrition Education and Health

Surveillance

Monitor changes in WIC participant population health status

X Monitor clients' views of WIC program services

Monitor changes in WIC participant population dietary behavior

Provide WIC health statistics to other health agencies

X

Provide WIC participant population data to other state health agencies

X

Provide WIC participant population data to Centers for Disease Control

FOOD INSTRUMENT PRODUCTON

Maintain Food Package Database

X

Record list of approved foods and food package data

X

Record food package variations and food instrument types

X

Prorating food quantities for clients with late pick-up

Print Food Instruments on Demand

X

Print regular food instruments for participants on demand

X

Print food instruments for multiple months

Print Vendor-specific food instruments

X

Print prorated food instruments

X

Print custom-tailored food instruments

MANAGEMENT INFORMATION SYSTEM

WIC SYSTEMS FUNCTIONAL REQUIREMENTS CHECKLIST

Print and Distribute Food Instruments in Advance of Pick-Up

X

Print food instruments in advance of participant pick-up

X

Print food instruments for multiple months

Print Vendor-specific food instrument





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GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment AD-16 (cont'd)

Monitor Food Instrument Stock

X

Record stock receipt, shipment and usage of food instruments

FOOD INSTRUMENT PAYMENT AND RECONCILIATION

Void Unissued and Unredeemed Food Instruments

X

Void unissued and unredeemed food instruments produced on demand

X

Void unissued and unredeemed food instruments printed in advance

Reconcile Redeemed Food Instruments

X

Process food instruments redeemed by Vendors

X

Produce rejection reports for food instruments not paid to Vendors

X

Check for valid Vendors on redeemed food instruments

X

Check for redeemed but unissued food instruments

Produce Vendor Payment Detail

X

Produce payment detail for checks (where applicable)

X

Produce payment detail for vouchers (where applicable)

CASELOAD MANAGEMENT

Allocate Caseload

X

Determine maximum state caseload which could be served with available funds

X

Prepare Local agency caseload allocation estimates

X

Record caseload allocations assigned to local agencies

Monitor Caseload

X

Track actual participation against caseload levels

X

Produce FNS reports on participation

VENDOR MANAGEMENT

Support Vendor authorizations

X

Capture and maintain data on authorized Vendors

X

Produce Vendor history information on individual Vendors

X

Track Vendor authorization process

Determine High-Risk Vendors

X

Determine High-Risk Vendors using basic statistical analysis (e.g. low

variance, high mean)

Determine High-Risk Vendors by using additional analysis tools



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GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment AD-16 (cont'd)

MANAGEMENT INFORMATION SYSTEM WIC SYSTEMS FUNCTIONAL REQUIREMENTS CHECKLIST

Monitor Vendor Education

X

Record Vendor education sessions scheduled for each Vendor

X

Record attendance at Vendor education sessions by Vendor

Track Investigations and Routine Monitoring

X

Capture compliance buys and routine monitoring data performed on Vendors

X

Support constructing a sampling of Vendors for investigation

Support record audits with data needed to evaluate Vendor inventory of WIC

X

foods

Monitor Compliance Cases and Sanctions

X

Maintain data for in-state Vendor investigation cases and sanctions applied

Maintain compliance data for abusive out-of-state Vendors

X

Accumulate sanction points for Vendor abuse

Coordinate With Food Stamps Program

X

Maintain FSP violation data on WIC Vendors

X

Report WIC sanctions to Food Stamps Program

Support Vendor Communications

X

Produce Vendor lists and labels

X

Produce Vendor correspondence

OPERATIONS MANAGEMENT

Monitor Administrative Operations Maintain staffing, client load and operational characteristics on local agencies and clinics

X

Produce client and food instrument activity reports on local agencies and clinics

Maintain Client Outreach Maintain client lists for local agencies to use for Outreach

X

Track referrals of WIC participants to other health and social services

FINANCIAL MANAGEMENT

Record Grants and Budgets

X

Record nutrition services, administration and food grants for State agency

X

Maintain local agency budget information

X

Maintain state agency budget information





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GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment AD-16 (cont'd)

MANAGEMENT INFORMATION SYSTEM WIC SYSTEMS FUNCTIONAL REQUIREMENTS CHECKLIST

Monitor Expenditure

X

Monitor nutrition services, administration and food obligations and

expenditures

X

Monitor cash flow

X

Produce FNS 498 Report

Process Manufacturer Rebates

X

Estimate total annual rebates

X

Bill manufacturer(s) for rebate

X

Monitor rebate collections from manufacturer(s)

SYSTEM ADMINISTRATION

Maintain System Data Tables

X

Maintain system data tables

Administer System Security

X

Maintain user identification

X

Maintain user capabilities

X

Monitor unauthorized access

Archive System Data

X

Archive and restore historical data

X

Purge unnecessary data





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GEORGIA WIC 2012 PROCEDURES MANUAL
MANAGEMENT INFORMATION SYSTEM PARTICIPATION CHARACTERISTICS
State Agency MIS: Collects

Attachment AD-16 (cont'd)

X

Certification category. One of five (5) possible categories--under which a person is

certified as eligible for WIC benefits: pregnant woman; breastfeeding woman;

postpartum woman (not breastfeeding); infant (under twelve (12) months); or child

(12-59 months).

X

Expected date of delivery or week's gestation. For pregnant women, the projected

date of delivery (MMDDYYYY format) or the number of weeks since the last

menstrual period as determined at WIC Program certification.

X

Date of certification. The date the person was declared eligible for the most current

WIC Program certification as of April 1998. Month, day and year should be reported

in MMDDYYYY format.

X

Sex. For infants and children, male or female.

X

Priority level. Participant priority level for WIC Program certification at the time of the

most recent WIC Program certification as of April 1998.

X

Participation in TANF/AFDC, Food Stamps, Medicaid. The participant's reported

participation in each of these programs at the time of the most recent WIC Program

certification as of April 1998.

X

Migrant status. Participant migrant status according to the federal WIC Program

definition of a migrant farm worker (currently counted in the FNS 498 report).

X

Number in family or economic unit. The number of persons in the family or economic

unit upon which WIC income eligibility was based.

A self-declared number in the family or economic unit may be reported for participants whose income was not required to be determined as part of the WIC certification process. These participants are adjunctively income-eligible due to TANF/AFDC, Food Stamps Program, or Medicaid participation or are deemed income eligible under optional procedures available to the state agency in Federal WIC Regulations, Section 246.7(d)(2)(vi-viii). This means tested programs identified by the state for automatic WIC Program income eligibility, such as income eligibility of Indian and in-stream migrant farmworker applicants.



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GEORGIA WIC 2012 PROCEDURES MANUAL
MANAGEMENT INFORMATION SYSTEM PARTICIPATION CHARACTERISTICS
State Agency MIS: Collects

Attachment AD-16 (cont'd)

X

Family or economic unit income

For persons for whom income is determined during the certification process, the income amount that was determined to qualify them for the WIC Program during the most recent certification as of April 1998.

FNS will convert income expressed in different measures (weekly, monthly, yearly, etc.) to annual amounts.

For descriptive purposes only, participants whose income was not required to be determined as part of the WIC Program certification process use the self-reported income at the time of certification. These participants include adjunctively incomeeligible participants and those persons deemed eligible under optional procedures available to the state agency in Federal WIC Regulations, Section 246.7(d) (2) (viviii).

Zero should not be used to indicate income values that are missing or not available. Zero should indicate only an actual value of zero.

X

Nutritional risks present at certification. The three highest priority nutritional risks

present at the WIC Program certification current in April 1998.

X

Hemoglobin or hematocrit. That value for the measure of iron status that applies to

the WIC Program certification. It is assumed that the measure was collected within

sixty (60) days of the certification date.

X

Weight. The participant's weight measured according to the CDC nutrition

surveillance program standards [nearest one-quarter (1/4) pound]. If weight is not

collected in pounds and quarter pounds, weight may be reported in grams.

X

Height. The participant's height (or length) measured according to the CDC nutrition

surveillance program standards [nearest one-eight (1/8) inch]. If height is not

collected in inches and eighth inches, height may be reported in centimeters.

X

Date of height and weight measures. The date of the height and weight measures

that were used during the most recent WIC Program certification period as of April

2002 in MMDDYYYY format.

X

Currently breastfed. For infant participants between the ages of seven and eleven

months, whether or not the participant is currently receiving breast milk.

Ever breastfed. For infants between the ages of seven and eleven months, whether

X

or not the infant was ever breastfed.



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GEORGIA WIC 2012 PROCEDURES MANUAL
MANAGEMENT INFORMATION SYSTEM PARTICIPATION CHARACTERISTICS
State Agency MIS: Collects

Attachment AD-16 (cont'd)

X Length of time breastfed. For infants between the ages of seven and eleven months, the number of weeks the infant received breast milk.

X Date breastfeeding data collected. For infants between the ages of seven and eleven months, the date on which breastfeeding status was reported in MMDDYYY format.
Food packages. The food package code(s) for the WIC food package or for all food X instruments prescribed for the participant during the month.





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GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment AD-16 (cont'd)

MANAGEMENT INFORMATION SYSTEM PARTICIPATION CHARACTERISTICS

State Agency Collects

MIS Plans to Collect Supplemental Data Set (OPTIONAL)

X

Date of first WIC certification: Date the participant was first certified

for the WIC Program in MMDDYYYY format. For pregnant,

breastfeeding and postpartum women, this applies to the

current/most recent pregnancy and not to prior pregnancies.

X

Educational level: For pregnant, breastfeeding and postpartum

women, the highest grade or year of school completed. For infants

and children, the highest grade or year of school completed by

mother or primary caregiver.

X

Number in household on WIC: The number of people in the

participant's household receiving WIC benefits.

Source of prenatal care: For pregnant, breastfeeding and postpartum women, source of care for current/most recent pregnancy.

X

Date when prenatal care began: For pregnant, breastfeeding and

postpartum women, the date when prenatal care began for the most

recent pregnancy in MMDDYYYY format.

Date previous pregnancy ended: For pregnant women, the date previous pregnancy ended in MMDDYYYY format.

Total number of pregnancies: For pregnant women, the total number of times the woman has been pregnant, including this pregnancy, all live births and any pregnancies resulting in miscarriage, abortion or stillbirth.

Total number of live births: For pregnant women, the total number of babies born alive to this woman, including those who may have died shortly after birth.

Pre-pregnancy weight: For pregnant women only, the participant's

X

weight immediately before pregnancy. Pre-pregnancy weight may be reported either in pounds and ounces or in grams.





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GEORGIA WIC 2012 PROCEDURES MANUAL
MANAGEMENT INFORMATION SYSTEM PARTICIPATION CHARACTERISTICS

Attachment AD-16 (cont'd)

State Agency Collects

MIS Plans to Collect Supplemental Data Set (OPTIONAL)
Weight gain during pregnancy: For breastfeeding and postpartum women, the participants weight gain during pregnancy as taken immediately at or before. Weight gain during pregnancy may be reported in both pounds and ounces or in grams.

X

Birth weight: For infants and children, the participant's weight at

birth measured according to the CDC nutrition surveillance program

standards (lbs./ounces). Birth weight may be reported in either

pounds or ounces or in grams.

X

Birth length: For infants and children, the participant's length

measured according to the CDC nutrition surveillance program

standards (1/8 inches). Birth length may be reported in either inches

or eighth inches or in centimeters.

X

Date of last routine check-up or immunization: Month, day, and year

of the last routine check-up or immunization for infants and children

reported in MMDDYYYY format.

Length of time mother on WIC during pregnancy: For infant participants, the length of time mother was on WIC during this infant's prenatal period.

Individual States may report the following items at their discretion.
Erythrocyte protoporphyrin. That value for the measure of iron status that applies to the WIC Program certification current in April 1998.
Participation in the Food Distribution on Indian Reservations Program. The participant's reported participation in this program at the time of the most recent WIC Program certification as of April 1998.





AD-149

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment AD-16 (cont'd)

MANAGEMENT INFORMATION SYSTEM WIC SYSTEMS FUNCTIONAL REQUIREMENTS CHECKLIST

The following checklists were taken from the WIC Functional Requirements Document (FRD), which was provided as guidance to state agencies on functions they should consider incorporating in their Management Information Systems. Please check those functions/capabilities, which the state agency system currently performs or plans to perform within the next two years.

State

State

Agency Performs

Agency Planned

Function/Capabilities

CERTIFICATION
X X
X
X
X X
X X
X X

Determine Basic Eligibility of Applicant Capture basic eligibility characteristics on persons applying for WIC Maintain appointment schedule availability and produce daily appointment schedules
Provide appointment notice to applicant
Determine Nutritional Risk of Client Capture required client nutrition and health characteristics needed for certification Capture additional client nutrition and health characteristics Assign the nutritional risk of the client
Certify Eligible Applicants Capture and maintain enrollee data on certified clients Issue identification card to client
Food Package Issuance/Data Prescribe enrollee food package Maintain appointment schedule for enrollee food instrument pick-up

Select and record enrollee Vendor selection

Check for Dual Participation/Process Transfers

X

List dual enrollees

X

List dual participants

X

Process transfer of enrollee

Capture Investigator Data Capture enrollee record for compliance investigators



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GEORGIA WIC 2012 PROCEDURE MANUAL

Attachment AD-17

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GEORGIA WIC 2012 PROCEDURE MANUAL

Attachment AD-17 (cont'd)

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GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment AD-18

REQUEST FORM FOR A NEW FACILITY

NOTE: When a District requests space in a new facility, the following form will be used to determine approval of the space by the State WIC Office.

COMMENT

SATIFACTORY

UNSATISFACTORY

1. Building

a. Hours of building operations

b. Level of security

c. Number of Entrances

d. Building Management

2. Parking

a. Staff

b. Clients

c. Availability of free client parking

3. Proximity

a. Public Transportation

4. Space

a. Training room

b. Staff

c. Interview and Evaluation

d. Waiting Area(s)

e. Breastfeeding room

f. Conference rooms

g. Meeting rooms

h. Location within building

i. Possibility to expand square footage initially under lease

j. Any non-removable glass doors, walls and partitions

k. Noise level of building and WIC space

5. Storage

a. Closets

b. Cupboards

6. Safety features:

a. "Exit" Signs

b. Water Sprinklers

c. Fire Alarms

d. Smoke Alarms

e. Fire Extinguishers

f. Power Surge Protectors

7. Air Conditioner and Heating

8. Lighting a. Electrical outlets b. Cable TV outlets c. Computer Cable outlets d. WIFI
9. Condition of Building

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GEORGIA WIC 2012 PROCEDURES MANUAL
10. Flooring a. Carpet b. Tile
11. Elevators a. Escalators b. Stairs
12. ADA Complaint a. Building entrance b. WIC space c. Bathroom d. Counters
13. Plumbing a. Sinks b. Waste disposal
14. Drinking fountains

REQUEST FORM FOR A NEW FACILITY
COMMENT

15. Janitorial Services

16. Amenities a. Nearby shops b. Pharmacies c. Food stores d. Food establishments
17. Mail a. Chute b. Mail c. FedEX d. UPS drops
18. Lease a. Duration b. Renewability c. Cost per square footage d. Reconfiguration cost per square foot
19. Landlord and Tenants a. Tenants with who WIC would have conflict of interest b. Landlords acceptance of WIC clients and nature of WIC services c. Acceptance of WIC clients and services by other tenants
20. Presence and/or proximity of other government agencies and services
21. Comfort level to WIC clients a. Similarity of other building tenants and guests

AD-154

Attachment AD-18 (cont'd)

SATIFACTORY

UNSATISFACTORY

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment AD-19

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GEORGIA WIC 2012 PROCEDURES MANUAL

Vendor Management

TABLE OF CONTENTS

Page

I.

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

II.

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

III.

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

IV.

Peer Groups ............................................................................................................ VM-2

V.

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

VI.

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

VII.

High Risk Identification System............................................................................... VM-3

VIII. Prohibition Against Certain Vendors - Consolidated Appropriations Act 2005 .......................................................................................... VM-4

IX.

Vendor Cost Containment ....................................................................................... VM-5

X.

Routine Monitoring .................................................................................................. VM-5

XI.

Vendor Sanction System......................................................................................... VM-5

XII.

Administrative Review ............................................................................................. VM-5

XIII. Coordination with Supplemental Nutrition Assistance Program (SNAP) .................................................................................................................... VM-6

XIV. Staff Training on Vendor Management ................................................................... VM-6

Attachments:

VM-1 Application for Vendor Authorization ...................................................................... VM-7

VM-2 Selection Criteria for Vendor Authorization ........................................................... VM-21

VM-3 Georgia`s WIC Vendor Handbook ......................................................................... VM-27

VM-4 WIC Non-Corporate Vendor Agreement (3 Year) ................................................. VM-81

VM-5 WIC Corporate Vendor Agreement (3 Year) ......................................................... VM-95

VM-6 Corporate Attachment Form................................................................................ VM-109

VM-7 Vendor Training Checklist ................................................................................... VM-116

VM-8 Corporate Vendor Training Checklist .................................................................. VM-117



GEORGIA WIC 2012 PROCEDURES MANUAL

Vendor Management

VM-9 WIC Incident/Complaint Form ............................................................................. VM-118 VM-10 Vendor Review Form.................................................................................... VM-119-123 VM-11 Vendor Non-Notification for 1st Violation ............................................................. VM-124 VM-12 Above 50% Verification Form...................................................................VM-125



GEORGIA WIC 2012 PROCEDURES MANUAL

Vendor Management

I.

NUMBER AND DISTRIBUTION OF AUTHORIZED VENDORS

Any legitimate retailer, pharmacy or military commissary within Georgia and no greater than ten (10) miles outside of the Georgia border may apply to become an authorized vendor.

II. VENDOR APPLICATION PERIODS

Georgia WIC vendor applications are currently accepted year round, on an ongoing basis. (See attachment VM-1, Application for Vendor Authorization, VM-2 Selection Criteria).

III. VENDOR SELECTION AND AUTHORIZATION
A. Selection Criteria
All applicants must meet the established criteria to become an authorized Georgia's WIC vendor and maintain WIC authorization. The vendor must comply with the selection criteria (e.g. SNAP authorization, business integrity, minimum inventory, store operating hours, etc.) throughout the agreement period including any changes to the criteria. Using the current vendor selection criteria, Georgia's WIC may reassess the vendor at any time during the agreement period. Georgia's WIC will terminate the Vendor Agreement if the vendor fails to meet the current vendor selection criteria at any time during the agreement period. (See attachment VM-2, Selection Criteria for Vendor Authorization). When a potential vendor applicant requests an application, the vendor is directed to the Georgia's WIC Vendor Management website at http://wic.ga.gov/vendorinfo.asp to retrieve the application packet, which includes the selection criteria for vendor authorization.
B. On-Site Visit and Authorization
On-site visits are conducted on each vendor applicant prior to initial 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 on-site pre-approval visit, the application will be denied for a period of six (6) months.
When a vendor meets all authorization criteria and has received interactive training, a vendor agreement is signed by the State agency official and mailed to the vendor or to the corporate vendor's authorized representative.
Vendors are required to submit food sales information within six (6) months of becoming an authorized WIC vendor.

VM-1

GEORGIA WIC 2012 PROCEDURES MANUAL

Vendor Management

IV. PEER GROUPS
Authorized vendors are classified into eight (8) different peer groups depending on square footage of the store, number of stores in a chain, and potential or actually above 50% status. (See attachment VM-3, Georgia's WIC Vendor Handbook-Vendor authorization).
Vendors found to be above 50% or potentially above 50% are reassigned to Peer Group G.

V. VENDOR AGREEMENTS
Georgia's WIC enters into three (3) year agreements with food retailers, pharmacies and military commissaries. (See attachments VM-4 and VM-5) Corporate vendors will sign a new agreement prior to September 30, 2011. This agreement will expire in two years. All agreements will expire September 30, 2013. After September 30, 2013, all agreements will once again be for a period of three years.
Food retailers with the same Federal Employer Identification Number (FEIN) and a corporate home office, or a single owner business entity that serves as a parent company, may sign one single agreement. This vendor is classified as a corporate vendor. Vendors wishing to participate as a corporate vendor must apply for all the stores in the chain seeking WIC authorization on a Corporate Attachment Form. This form becomes a legal addendum to the Corporate Vendor Agreement. (See attachment VM-6, Corporate Attachment Form). If one store in the chain violates Georgia's WIC regulations and is disqualified, the remaining stores are not affected.

VI. VENDOR TRAINING
Vendors are provided WIC authorization training sessions in an interactive format prior to authorization. The training sessions are conducted by the State agency with noncorporate vendors and by the corporate representative for vendors who are classified as corporate vendors. At the end of the three (3) 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, e.g. newsletters, interactive. Vendors who have received authorization and annual training must sign corresponding forms as documentation of their training. (See attachment VM-3, Georgia's WIC Vendor Handbook, Vendor Training; attachment VM-7, Vendor Training Checklist and attachment VM-8, Corporate Vendor Training Checklist).

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GEORGIA WIC 2012 PROCEDURES MANUAL

Vendor Management

VII. HIGH RISK IDENTIFICATION SYSTEMS
A. VENDOR COMPLAINTS
Georgia's WIC provides a toll-free customer service hotline (1-866-814-5468) that WIC vendors and participants may call to report complaints/incidents or to make inquires. The 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-9, Complaint Form) and begin the resolution process on all complaints from a WIC participant about a vendor. Once a complaint/incident is resolved at the local level, the form should be sent to the State WIC office for additional processing, e.g. covert or overt visit, warning letters and entry into the vendor's record.
Resolution, at the State agency, will be initiated within twenty-four (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.
B. 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; E) Large percent of High Priced Food Instruments.
Complaints and incidents that are reported to the Georgia's WIC about vendors also place them in a high risk category and may lead to a covert investigation of that vendor.
If more than 5% of all vendors are identified as high risk, they must be prioritized so that compliance investigations and/or inventory audits are conducted on those that pose the greatest risk to program compliance.
High risk vendors will be prioritized based on high risk scores and volume of WIC redemption. Those with the highest sores and the highest volume of WIC redemption will be audited first.
C. NOTIFICATION OF VENDOR VIOLATIONS
During an investigation, if a violation is found that requires a pattern of violative incidences, the vendor may receive a courtesy notice informing them of the violation. Vouchers received during the covert investigation must be cashed in order to qualify for the courtesy notice of any violation. Vendors who receive courtesy notices will be given an opportunity to correct the behavior causing the
VM-3

GEORGIA WIC 2012 PROCEDURES MANUAL

Vendor Management

violation, including training of any personnel involved in WIC transactions. The courtesy notice may include sanctions for violations that occurred which do not require a pattern (see Categories I, II, III under "Sanctions"). The vendor will be notified if a subsequent violation occurs and will be sanctioned accordingly. Effective October 1, 2004, during a covert compliance investigation, the Georgia's WIC is required to notify the vendor of an initial violation, for violations requiring a pattern of incidences in order to impose a sanction, prior to documenting another violation, unless the Georgia's WIC determines that notifying the vendor would compromise an investigation. Therefore, Georgia's WIC will send the vendor a written notice of an initial violation during a covert compliance investigation for which a pattern of violative incidences must be established in order to impose a sanction, except when conditions 1 through 8 listed below exist.
1. Your vendor status is considered high-risk consistent with Section 246.12(j) (3) of the WIC federal regulations.
2. Violation(s) outlined in category VI, and category VII of the Georgia WIC Vendor Sanction System for which no pattern is required.
3. Georgia's WIC became aware of violations taking place during the course of an on-going investigation, during which time other vendors were found to be in violation of Georgia's WIC regulations, prompting further investigation.
4. Georgia's WIC received complaint(s) against vendor.
5. Georgia's WIC investigator's identity may be in jeopardy.
6. Threatening conduct or security factors that may occur during the course of a covert/compliance investigation.
7. Covert sting operation by WIC, or in conjunction with other Local, State or Federal agencies.
8. More than one violation occurred during the initial compliance visit.
Vendors will receive notification of all results including violations after the investigation is considered closed by Georgia's WIC representatives.
When notices of violations are not sent to a vendor, Attachment VM-11 will be placed in the vendor's file.

VIII. PROHIBITION AGAINST CERTAIN VENDORS - CONSOLIDATED APPROPRIATIONS ACT 2005
A new for profit vendor will be authorized and placed into peer group G if that vendor is expected to derive more than 50 percent of its annual food sales revenue from WIC food instruments (see Attachment VM-12). Once vendors are authorized, an assessment of WIC redemption to food sales will be conducted within six (6) months of authorization. All current vendors are assessed via the annual assessment as well as during reauthorization. All vendors are required to submit food sales data upon request in order to monitor compliance with the above-50 percent criterion. If it is subsequently determined that a vendor does not meet the above-50 percent criterion, they will be placed into peer group G.

VM-4

GEORGIA WIC 2012 PROCEDURES MANUAL

Vendor Management

IX. VENDOR COST CONTAINMENT
Vendor Cost Containment is intended to assist State agencies in achieving compliance with section 17(h)(11) of the Child Nutrition Act of 1966, as amended by (42 U.S.C. 1786).
The new requirements underscore the State agency's responsibility to ensure that WIC pays all vendors competitive prices for supplemental foods. Georgia's WIC implemented a cost containment plan to identify and manage vendors who derive more than fifty (50) percent of their annual food revenue from WIC food instruments.
By June 30th of each year the Georgia's WIC will assess each vendor to determine if the vendor derives more than fifty (50) percent of it's food revenue from WIC food instruments annually. New vendors will be assessed six (6) months after enrollment.
X. ROUTINE MONITORING
On-site, overt monitoring is performed on a minimum of five (5) percent of the total active vendors statewide on an annual basis using a standardized monitoring instrument (see Attachment VM-10, 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 FFY 2006 and no later than 2009; 3) a current list of vendors who are suspected of being potential above 50 percent vendors or fraudulent vendors; and in addition, 4) requests from investigators as a result of their findings during a covert visit; 5) if Georgia's WIC has reason to believe that the vendor is participating in fraudulent activity at anytime during the vendor agreement period; and 6) new vendors within 2 (two) months of authorization will be selected for routine monitoring visits. Vendors receive written notification of the results and copies are sent to the vendor's corporate office, when applicable. (See Attachment VM-3, Georgia's WIC Vendor Handbook, Overt Monitoring).
XI. VENDOR SANCTION SYSTEM
When any authorized vendor is found to be in violation of federal regulations and/or State rules, 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's WIC Vendor Handbook, Sanction System).
XII. ADMINISTRATIVE REVIEW
Georgia's WIC must provide administrative reviews in accordance with Federal WIC regulations at 246.18. Information on adverse actions the vendor may appeal, adverse actions that are not subject to administrative review, as well as Georgia WIC's administrative review procedures are found in the Section 111-9-.06 of the Rules and
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GEORGIA WIC 2012 PROCEDURES MANUAL

Vendor Management

Regulations of the State of Georgia and the most recent publication of the Vendor Handbook. The vendor agrees to abide by said provisions if requesting review of an adverse action.

XIII. COORDINATION WITH SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP)
A reciprocal agreement between the Georgia's WIC and the Food and Nutrition Services Supplemental Nutrition Assistance Program (SNAP) is on file at the State WIC office.
All vendors must be licensed as a (SNAP) retail provider. Vendors who withdraw from SNAP, are disqualified from SNAP, or are terminated from SNAP due to non-redemption will be terminated from Georgia WIC. Unless necessary to ensure adequate participant access, Georgia WIC will not authorize an applicant that is currently disqualified from SNAP, or that has been assessed a SNAP civil money penalty (CMP) for hardship and the disqualification period that would otherwise have been imposed has not expired.
Georgia's WIC Compliance Analysis Unit routinely coordinates investigative activities with their SNAP counterparts on high-risk WIC vendors. All authorized Georgia WIC Vendors must be also be SNAP authorized at the time of WIC authorization and at all times during the vendor agreement period.

XIV. STAFF TRAINING ON VENDOR MANAGEMENT
New employees receive orientation and on the job training on the following Vendor Management topics:
1. Application process (selection and authorization) 2. Vendor training 3. Routine monitoring 4. Compliance investigations 5. Inventory audits (when applicable) 6. Sanctions 7. Vendor appeals/Administrative reviews 8. Federal and State WIC regulations 9. High Risk vendor identification 10. GWIS (Georgia's WIC Information System) and other internal vendor databases
such as VIPS and STARS

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GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment VM-1

GEORGIA WIC APPLICATION FOR VENDOR AUTHORIZATION AND INSTRUCTIONS
Please print or type legibly. Follow the attached instructions, starting on page 8, carefully. Incomplete forms and attachments will be returned unprocessed.
FOR GEORGIA WIC (GW) USE ONLY

District/Unit

Vendor Number

Peer Group

Date Received in VMU Return Date

Received By Date Received

Pre-screened By Return Date

Returned By Date Received

Return Date

Date Received

Return Date

Date Received

Date Placed in bin for Pick-up Date Approved
Date Denied
Reason Denied

OAS: QAS:

Date Reviewer

Received

VM:

VD:

VM:

VD:

Date Stamp Sent Date Denial Letter Sent

Processed By

Check one

Re-Application (Enter current vendor number) _______________________

Initial Application

(New Vendor must provide food sales data within six months of authorization.)

A. Will this store participate as a corporate vendor?

Yes

No

B. Is this store expected to derive more than 50% of its annual food sales

from the sale of WIC approved foods?

Yes

No

C. Is this application submitted as a result of a change in the store's

Yes

No

location?

D. Will this store sell medical formula and special medical foods only?

Yes

No

PART I - STORE IDENTIFICATION

1. Full Legal Name of Store

Store Number

Full Legal Name of Corporation (if applicable) Registered Agent

Manager's Name

Business Telephone Number

-

-

Area Code

E-mail Address (Required)

Fax Number

-

-

Area Code

2. Physical Location

Street Address/Rural Route

City

County

State

Zip +4

Mailing Address (if different from above. P.O. Box must be accompanied by a physical mailing address as well)

Street Address

City

State

Zip + 4

P.O.

Box

City

State

Zip + 4

3. Square Footage of Store (excluding storage area)

VM -7

GEORGIA WIC 2012 PROCEDURES MANUAL
4. Food Sales Establishment License Number 5. Does this store now participate in the SNAP (formerly the Food
Stamp Program)? Indicate the SNAP Authorization Number

Attachment VM-1 (cont'd)

Yes

No

6. Type of Business - Check Only One Independent
Chain

Commissary Pharmacy

7. Federal Employer Identification Number (FEIN)

or

Owner's SSN#

8.

A. Is this store dependent upon receiving WIC Authorization before it can

open for business?

Yes

-

-

No

B. What date did (or will) the store open for business under the applying owner(s)?

/

/

Month

Day

Year

C. What date will the store have the required minimum inventory of approved WIC foods in stock?

/

/

Month

Day

Year

9.

A. Are you related to previous owner(s) by blood or marriage?

If YES, what is the relationship?

Yes

No

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

Program? If YES, list stores below. Attach additional paper if necessary.

Yes

No

1.
STORE NAME
2.
STORE NAME

VENDOR NUMBER VENDOR NUMBER

C. Has this store ever operated under another name in Georgia or states that are 25

Yes

No

miles outside of the Georgia border?

If YES, indicate name.

PART II - STORE OWNERSHIP AND MANAGEMENT

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

Privately owned corporation Publicly owned corporation Government owned Non-profit

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GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment VM-1 (cont'd)

11. List the full name (NO INITIALS) of every owner with five percent (5%) or more financial interest in the company.

If the type of ownership listed above is a publicly owned corporation or government owned, DO NOT completes this

section. Attach additional sheets if needed. Shortened versions of a name are not acceptable.

A.

1.

First Name

Middle Name

Last Name

SSN#

Date of Birth
2. First Name
Date of Birth
3. First Name

Middle Name Middle Name

Last Name Last Name

SSN# SSN#

Date of Birth B.
Name of Registered Agent
Address of Registered Agent
12. 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 disqualification or assessment of a Civil Money Penalty? If YES, attach an explanation identifying the person, business name, location and nature of violation.

B. Including this store, has the current owner(s), officer(s) or manager(s) ever owned or managed a business that violated the SNAP regulations, receiving a warning letter or was withdrawn, disqualified or assessed a Civil Money Penalty?
If YES, attach an explanation identifying the person, business name and nature of violation.
C. Has the current owners, officers or managers ever been convicted of or had a civil judgment for fraud, antitrust violations, embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, receiving stolen property, making false claims or obstruction of justice?

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

PART III A OPERATIONS AND SALES

13. Hours of Business Check here if opened 24 hours each day
Sunday

Thursday

Monday

Friday

Tuesday

Saturday

VM -9

Yes Yes Yes

No No No

GEORGIA WIC 2012 PROCEDURES MANUAL

14.

A. Number of Cash Registers

B. Number of Scanners

C. Can Scanners detect WIC eligible foods?

D. Does your store have a Point of Sale Device?

Attachment VM-1 (cont'd)

Yes

No

Yes

No

E. Please check the forms of payment your store Cash EBT Debit will be accepting.

Credit Checks

15. Bank Information Enter information pertaining to where you will deposit all WIC food instruments and cash value vouchers.
Bank __________________________________________________________
Account Number ______________________________
Street ____________________________________________________
City State Zip _________________________________________
Telephone Number: Area Code ________________ Number _______________________________________
PART III B - OPERATIONS AND SALES VENDOR COST CONTAINMENT
Applicant vendors must submit purchase invoice receipts, bills of lading or recent invoices which depict the purchase of all items intended for sale in their stores upon request. This includes WIC food items, non-WIC food items, household products, miscellaneous items, etc. Failure to submit the requested documentation within 10 (ten) days of the request will result in denial of the vendor application.
16. A. What is the estimated percent of annual food sales you anticipate deriving from the following types of payment? Total must equal 100%
Cash/Personal Checks ______% Debit/Credit Cards _____% Food Stamps ______% WIC Food Instruments ______%
Total 100%
B. CHECK APPROPRIATE BOX PLEASE GIVE YEARLY (NOT MONTHLY) AMOUNT: Check the sales figure you are providing (Actual or Estimated). If giving estimated sales, you must provide a dollar amount for one year that is equal to one month times 12 (1month X12). However, report estimated sales only if you do not have actual sales figures for the most recent tax year. You may be required to provide updated information when actual sales figures are available.
__ Actual Gross Sales $ ________________________________ For tax year ____________
__ Estimated Gross Sales $______________________________ For tax year ____________
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GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment VM-1 (cont'd)

STAPLE FOODS CATEGORIES CARRIED IN STOCK: All vendors (pharmacies excluded) must carry food items other than WIC Approved Foods. These items are considered non-WIC inventory. This includes dried, frozen, canned/jar, boxed, fresh, refrigerated, etc. (Staple foods do not include any prepared foods or accessory foods such as candy, condiments, spices, tea, coffee, or carbonated and un-carbonated drinks.)

17. What percentage of each item does this store carry from the following food groups? The total percentage must equal one-hundred percent (100%).

A. Meats, Poultry and/or Seafoods (refrigerated) B. Dairy (milk, cheese, yogurt, etc.) C. Shelf Staples (e.g., flour, sugar, pasta, pudding mix, etc.) D. Cans, Jars, Bottled Goods (i.e. mayo, ketchup, relish, etc) E. Beverages F. Breads and Cereal Products

18. A. Does the current owner(s), officer(s) or manager(s) currently or previously own(ed) or manage (d) a business whereby more than fifty percent (50%) of the total annual food sales is derived from the sale of WIC approved foods?

Yes

No

B. If YES, identify the name of the store, identification number (ID), city and state. Include stores nationwide, and Georgia.

1. Store Name City

ID State

2. Store Name City

ID State

3. Store Name City

ID State

19. A. Was all infant formula that will be used to redeem WIC vouchers, purchased from suppliers listed on the Approved Infant Formula Supplier list? (see www.health.state.ga.us/programs/WIC/vendorinfo.asp)

Yes

No

Note: Records of all infant formula purchases must be maintained according to the terms of the WIC Vendor Agreement, III, I.3.

B. If yes, indicate the name of the supplier, address, city and State. (Attach additional paper if necessary.)

Supplier

Address

City

State

Supplier City

Address State

Supplier City

VM-11

Address State

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment VM-1 (cont'd)

20. Has this store ever been denied or disqualified from SNAP? __ YES __ NO.

IF YES, attach a written explanation, giving the date denied or disqualified, and the reasons.

Has this store ever been placed on probation or received a Civil Money Penalty from SNAP? __ YES __ NO.

IF YES, attach a written explanation including the probation period or amount of Civil Money Penalty.

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GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment VM-1 (cont'd)

PART IV - INVENTORY AND PRICE LIST

Food Item

Brand Name

Size

Highest Price or On-Site

Least Expensive Price

where indicated

21.

Juice

22.

Cereal

23.

Peas/Beans

Peas/Beans

24.

Peanut Butter

Infant Cereal

25.

Rice

Gerber Good Start Gentle

26.

Gerber Good Start Soy

Gerber Good Start Gentle

27.

Gerber Good Start Soy

46-48 oz. bottle
64 oz. plastic bottle
11 to 13 oz box Size ____
1 pound bag 14-16 oz cans
18 oz. jar
8 oz. box 13 oz. can concentrate 13 oz. can concentrate 12.7 oz. can powdered 12.9 oz. can powdered

Whole Pasteurized

28.

Milk

29.

2%, 1% or Skim Milk

30.

Dry Milk

31.

Cheese

32.

Eggs (Large Only)

33.

Fresh Fruit

34.

Fresh Vegetables

35.

Bread

Fish - Tuna

or

36.

Salmon

Baby Food Fruits

37.

and vegetables

Baby Food

38.

Meats

1 gallon container (Least Expensive) 1 gallon container (Least Expensive) Makes 3 quarts
1 pound package (Least Expensive) 1 dozen carton (Least Expensive) 10 pounds 10 pounds 16 oz. loaf
5 oz. can 7.5 or 14.75 oz. can Product __________
Size______
4 oz. jar
2.5 oz. jar
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GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment VM-1 (cont'd)

Please ensure that you have the following inventory, as well as a substantial amount of non-WIC inventory, in stock by the date you specified in question 8C. Failure to do so will result in denial of the
application.

Food Item

Brands (B)

Types (T)

Size

39. Juice 40. Juice 41. Cereal
(2 types must be Whole Grain)
42. Dried Peas/Beans 43. Canned Peas/Beans 44. Peanut Butter 45. Infant Cereal
(1 type must be rice)
46. Gerber Good Start Gentle 47. Gerber Good Start Soy 48.
Gerber Good Start Gentle 49.
Gerber Good Start Soy 50. Pasteurized Milk - whole 51. Pasteurized Milk 2%, 1% or
skim 52. Dry Milk non-fat
OR
Evaporated
53. Cheese 54. Eggs (Large Only) 55. Bread 56. Fruit (fresh and canned or frozen) 57. Vegetables (fresh and canned or
frozen)
58. Fish Tuna Salmon
59. Baby Food Fruits
60. Baby Food Vegetable
61. Baby Food Meat

2 (T) 2 (T) 4 (T)

46 oz. 64 oz. 11 to 36 oz.

2 (T) 2 (T) 2 (B) 2 (T)

1 lb. pkg. 14-16 oz.
18 oz. 8 oz.

1 (B) 1 (B) 1 (B) 1 (B) 1 (B) 1 (B) 1 (B)
1 (B) 2 (T) 1 (B) 1 (B) 4 (T) 4 (T) 1 (T)
2 (T)
2 (T)
2 (T)

13 oz.
13 oz.
12.7 oz. (powder) 12.9 oz. (powder) 1 gallon 1 gallon
Makes 3 qt.
12 oz 1 pound 1 dozen 16 oz. loaf 10 pounds 10 pounds
5 oz can 7.5 -14.75 oz. can
4 oz. or twin pack (2 x 3.5 oz.
plastic) 4 oz. or twin pack (2 x 3.5 oz.
plastic) 2.5 oz

Minimum Quantity 12 12 24
5 18 6 12
30 20 50
20
8 12
3 boxes
12 cans 8 8 6
10 lbs. 10 lbs.
18 combined
96 combined
31

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GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment VM-1 (cont'd)

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 n the WIC Program, monitor compliance with program regulations and for program management. The provision of the requested information, including he Federal Employer Identifier Number or Social Security Number, is voluntary. However, failure to provide information may result in the denial or ermination 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.
I authorize Georgia WIC to investigate my background for purposes of evaluating my vendor application. I understand that I may withhold my permission, and that in such case, no background check will be done and my vendor application will not be processed further.

SIGNATURE

(no initials)

First
PRINT NAME

Middle

(no initials)

First

Middle

DATE
Last
Last

TITLE

"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.
To file a complaint of discrimination, write USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call toll free (866) 632-9992 (Voice). Individuals who are hearing impaired or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish). USDA is an equal opportunity provider and employer."

Return application to: DO NOT FAX
DO NOT HAND DELIVER

Georgia WIC Program Vendor Management Unit 2 Peachtree Street, NW Suite 10-476 Atlanta, Georgia 30303-3142 Toll free 1-866-814-5468

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GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment VM-1 (cont'd)

Instructions for Completing the Vendor Application

Check appropriate box to indicate if application is a re-application or initial application. If application is a Re-application, please enter the current vendor number in the space provided.

A. Answer "yes" or "no" if your store will participate as a corporate vendor.

B. Answer "yes" or "no" if your store expects to derive more than 50% of its annual food sales from the sale of WIC approved foods.

C. Answer "yes" or "no" if application submitted as a result of a change in store's location?

D. Answer "yes" or "no" if you will be selling medical formula (formula other than the contract formula) and special medical foods only.

PART I - STORE IDENTIFICATION

1. FULL LEGAL NAME OF STORE. Enter the name of the store. Include the store number, if applicable. Corporate Vendors with two or more locations, enter CA (Corporate Attachment Form). FULL LEGAL NAME OF CORPORATION (if applicable). Enter the legal name of the corporation under which the store(s) is licensed. Include the name for public-owned and private-owned corporations. If the corporation has a division or department that is dedicated to handling WIC issues, enter the name of the division or department after the name. MANAGER'S NAME. Enter the name of the person responsible for this store location. Corporate vendors, enter "CA". BUSINESS TELEPHONE NUMBER. Enter the main telephone number located at the store. DO NOT LIST CELLULAR TELEPHONE NUMBERS. Corporate vendors enter the main telephone number for the corporation. If the corporation has a division or department dedicated to handling WIC issues, enter the number of the division or department. FAX NUMBER. Enter the fax number for the store entered above. Corporate vendors enter the main fax number for the corporation. If the corporation has a division or department dedicated to handling WIC issues, enter the fax number of the division or department. E-MAIL ADDRESS. Enter the e-mail address for the manager listed above. Corporate vendors enter the main e-mail for the company.

2

Physical Location

STREET ADDRESS. Enter the street name and number of the store.

Corporate vendors enter "CA". DO NOT enter a post office box address here.

CITY. Enter the name of the city.

COUNTY. Enter the county where the business is located.

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

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

Mailing Address STREET ADDRESS. Enter the street name and number for the store where mail is to be delivered for the location above. DO NOT enter a post office box address in this space unless you are also including a physical mailing address. Corporate vendors enter the street address of the home office of the corporation. If the corporation has a division or department dedicated to handling WIC issues, include the floor/suite of the department or division. CITY. Enter the name of the city. Corporate vendors enter the city of the home office. STATE. Enter the name of the state. Corporate vendors enter the state of the home office. ZIP+4. Enter the postal code plus the four digit locator code.

3. SQUARE FOOTAGE. Enter the store's total square footage, excluding storage area. Corporate vendors enter CA.

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GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment VM-1 (cont'd)

4. FOOD SALES ESTABLISHMENT LICENSE 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. Some pharmacies and military commissaries may not be required to have this license and should enter Not Applicable (N/A). Corporate vendors enter "CA".
5. Answer "yes" or "no". Does this store participate in the Supplement Nutrition Assistance Program (SNAP: formerly the Food Stamp Program)? If yes, enter the authorization number for this location. Corporate vendors should answer this question based on the answer that applies to the majority of the stores.
6. TYPE OF BUSINESS. Check the box that best fits the type of business for your store or corporation: Independent - A store independently owned by a person or group. Chain - A business entity that has multiple locations throughout one or more states. Commissary - A military outlet providing goods and services for military personnel and their families. Commissaries receive exemptions through the 1983 Memorandum of Understanding between the Food and Nutrition Service and the United States Department of Defense. Pharmacy - A "drug" store applying to redeem exempt and/or special infant formulas, including medical foods. No contract brand infant formula or other standard WIC approved food sales are allowed for pharmacies
7. FEDERAL EMPLOYER IDENTIFICATION NUMBER. Enter the Federal Employer Identification Number (FEIN) assigned to the store by the Internal Revenue Service (IRS). If the owner is a sole proprietor and does not have a FEIN, enter the owner's Social Security Number (SSN). If a FEIN is entered, DO NOT enter the SSN. Corporate Vendors, enter "CA".
8. Answer the question regarding minimum inventory and opening date A. Answer "yes" or "no" whether this store is dependent upon WIC authorization before it can open for business. B. OPENING DATE - Enter the specific month, day and year that the store will open under the applying owner(s). If the store is currently open for business at the time of application, enter the official date the store opened or the date a change of ownership became effective. Enter Not Applicable (N/A) if the store is currently authorized as a WIC vendor and is re-applying for authorization. C. MINIMUM INVENTORY - Enter the specific month, day and year that ALL required quantity and variety of WIC approved foods and non-WIC food items (including perishables) will be in stock and ready for inspection. See Selection Criteria for Vendor Authorization for exact quantities. Enter "Not Applicable" (N/A) if the store is currently authorized as a WIC vendor and is re-applying for authorization.
9. Answer the questions regarding ownership history. A. RELATION TO OWNER. Check "yes" or "no" to indicate if you are related to the previous owner by blood or marriage. If yes, indicate the relationship. B. OTHER WIC-AUTHORIZED STORES. Check yes or no to indicate if any owner(s) also own other WIC authorized stores. If the owner(s) listed in question 11 have additional stores that are WIC authorized, list the name of the store in the space provided. Include the WIC vendor number. Attach additional paper if necessary. Corporate vendors enter "CA". C. OPERATION UNDER ANOTHER NAME. Check "yes" or "no" to indicate if the store has ever operated under another name. If yes, indicate the name.
Part II STORE OWNERSHIP AND MANAGEMENT
10. TYPE OF OWNERSHIP. Check the one type that closely represents your business: Sole proprietorship. A business owned by a single individual. Partnership. A business owned by two or more individuals. Limited Liability Company (LLC). A business combining both corporations and partnerships

VM-17

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment VM-1 (cont'd)

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 nor available for purchase by the general public. Publicly owned corporation. For purposes of this application, a publicly owned corporation is one which has shares or stocks 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 commissaries, pharmacies or clinics owned and operated by county, state or federal government agencies. Nonprofit. A business entity that has been granted nonprofit, tax exempt status from the Internal Revenue Service.
11. NAMES OF OWNERS.
A. Enter the information for all owners with a 5% or more interest in the store. List the full name (first, middle and last) for each owner. Also list the social security number and the date of birth for each owner. Attach additional paper if necessary. Initials or shortened versions of a name are not acceptable. Do not complete if the store is government owned or publicly owned.
B. Enter the corporation information. List the full name of the registered agent. Also list the mailing address of the registered agent.
12. OWNERSHIP HISTORY
A. PREVIOUS GEORGIA WIC VIOLATIONS. Check "yes" or "no" to indicate 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 name and address, and nature of the violation.
B. SNAP (Supplemental Nutrition Assistant Program formerly Food Stamps) VIOLATIONS. Check "yes" or "no" to indicate if the current owners, officers or managers have ever violated the SNAP Program by receiving a warning, disqualification, or have been assessed a civil money penalty. If yes, attach an explanation identifying the date, person, store name and address, and nature of the violation.
C. CONVICTIONS/JUDGEMENTS. Check "yes" or "no" to indicate if the owner, current officers, or manager ever had a civil judgment involving 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
13. HOURS OF BUSINESS. Enter the hours the store is actually open for business each day. Corporate vendors, enter the hours that the majority of the stores are actually open for business.
14. A. NUMBER OF CASH REGISTERS. Enter number of cash registers in the store. Corporate vendors, enter the average number of cash registers per store. Corporate vendors must enter the exact number of cash registers per store on the Corporate Attachment Form.

B. NUMBER OF SCANNERS. Enter the number of scanners in the store. Corporate vendors must enter the average number of scanners per store on the vendor application but must enter the exact number of scanners per store on the Corporate Attachment Form.

C. OPTICAL SCANNERS. Check "yes" or "no" if the scanner(s) can detect WIC eligible products.

VM-18

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment VM-1 (cont'd)

D. POINT OF SALE (POS) DEVICES. Check "yes" or "no" if there is a Point of Sale device at each register. (The POS device is the machine used to swipe credit or debit cards at each checkout.)
E. Check all the types of payment your store will/does accept.

15. Banking Information Enter the banking institution where WIC food instruments and cash values vouchers will be deposited.

PART III B OPERATIONS AND SALES VENDOR COST CONTAINMENT
16. Enter the percentage of sales you anticipate being made per each type of payment, e.g. of all food being purchased by your customers, what percentage do you anticipate will purchase items using cash/checks, what percentage do you anticipate will purchase items using debit/credit, what percentage do you anticipate will purchase items using SNAP, what percentage do you anticipate will purchase items using WIC.
B. Enter the amount you have actually made in food sales to date for the year or enter the amount you anticipate making for the year in food sales.
17. Enter the percentage of what you carry next to each category of food. Percentage totals must equal one hundred percent (100%). If your store is new and/or there is no history of food sales, enter the percentage of foods in each category you anticipate carrying.
18. A. Answer "yes" or "no" if any owners or managers of this store owns or manages a currently WIC authorized store(s) that derives more than fifty percent (50%) of its total annual food sales from WIC voucher transactions.
B. If yes, enter the name, ID number assigned by the authorizing WIC agency, city and state.
19. A. Answer yes or no whether all infant formula purchases, which will be used with WIC vouchers, were purchased from the approved list. (This excludes medical foods and specialized infant formula).
B. If yes, enter the suppliers name, address, city and state.
20. Answer yes or no if the applying store is or has ever been disqualified from SNAP. If yes attach a written explanation including date denied or disqualified and the reason. Answer yes or no if the applying store has ever been placed on probation or received a Civil Money Penalty from SNAP. If yes attach a written explanation including the probationary period and the amount of the Civil Money Penalty.
PART IV STORE PRICE LIST AND INVENTORY
21-38. Enter the brand name and highest price or least expensive price of each approved WIC food item in the sizes listed. Use the current WIC-Approved Foods List to complete this section. Do not complete the shaded area.
Corporate vendors: List the brand and highest price or least expensive price that exists among all the stores in the chain.
Pharmacy Vendors: Do not complete Items 19-36.
39-61 Please ensure that you have the following inventory, as well as a substantial amount of non-
WIC inventory (minimum of one hundred (100) items in each of the designated categories) in stock by the date you specified in question 8C. (All stores must be fully functioning grocery stores and must carry enough food items which constitute them as being such. Please refer to the most current copy of the Georgia WIC Vendor handbook for specific brands, types and sizes. Pharmacies are exempt.) Corporate vendors: Please ensure that all stores which are added to the current agreement

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Attachment VM-1 (cont'd)

carry the WIC minimum inventory as well as a substantial amount of non-WIC inventory. Pharmacy Vendors: N/A

Review the Privacy Act Statement, Warning Statement and Certification.

An owner or authorized representative must sign, print name and date the application. Initials or a shortened version of a name is not acceptable.

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Attachment VM-2

Selection Criteria for Vendor Authorization

All applicants must meet the following criteria at the time of application and sustain the criteria throughout the entire agreement period. Georgia WIC will deny the application or terminate the Vendor Agreement if it is determined that the applicant provided false information in connection with the application.
It is a violation of Federal law to accept WIC vouchers without authorization from the appropriate agency. If it is determined that an applicant has accepted WIC vouchers prior to authorization, they will be subject to criminal prosecution and reimbursement for the unauthorized transactions. In addition, their application will be denied for a twelve month period.
Changes mandated by the USDA may occur to the selection criteria after an application has been submitted. When this happens, applicants will be notified regarding the changes, and must comply with the changes in order to become authorized. If an applicant is denied for failure to meet any of the selection criteria below, the application will be denied for a sixmonth period. Applicants may re-apply after their denial period has expired.
All requested information must be provided in order to process the application. This includes, but is not limited to, Bill of Sale, Articles of Incorporation, Driver's License or State issued ID card, Social Security card, food sales, etc. Applications will not be processed until all information is received by Georgia WIC. Vendor applications that are held pending receipt of additional information will expire ten days after the date of the written request for information.
1. Minimum Inventory of WIC-Approved Foods. Each vendor is required to stock and maintain daily the minimum inventory of approved WIC foods as well as a substantial amount of non-WIC foods. The inventory must be in the store or the store's stockroom. Expired foods do not count towards minimum inventory; all WIC minimum inventory must be within the expiration dates during the application process, including the preauthorization visit. Pharmacies and military commissaries are exempt from minimum inventory requirements. The vendor must carry other foods outside of the WIC minimum inventory and WIC approved foods.
The minimum inventory requirements are listed on the following pages.

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Attachment VM-2 (cont'd)

Food Item
MILK Least Expensive
Brand of type selected/allowed
CHEESE Least Expensive
Brand of type selected/allowed
EGGS Least Expensive
Brand
PEANUT BUTTER
BEANS / PEAS / LENTILS
JUICE
WHOLE GRAINBREAD
CEREAL Whole Grain
FISH Least Expensive of
type selected
INFANT FORMULA

Georgia WIC Program

Minimum Inventory Requirements

Effective October 24 , 2011

Types/Brands

Size

Whole Milk

Gallon

Fat free/Skim, Low-fat (1%), Reduced Fat (2%)
Milk

Gallon

Dry powdered milk OR Evaporated milk

Makes 3 quarts 12 oz.

One pound package

16 oz. (1 pound)

Grade A Large
Any brand Creamy, Crunchy, or Extra Crunchy (Regular or
Low-salt)
Dried Beans / Peas / Lentils
Canned Beans / Peas / Lentils
Ready to Serve Container
Ready to Serve Container
Whole Grain Bread
WIC Approved Cereal Brands and Types (see WIC Approved Foods List)
Tuna
Pink Salmon
Milk Based Gerber Good Start Gentle
PLUS Soy Based Gerber Good Start Soy
Plus

1 Dozen carton
16-18 oz
1 pound packages 14 to 16 oz cans
46-48 oz 64 oz
16 oz loaf
11-36 oz 5 oz Can 7.5 oz or 14.75 oz
13 oz Concentrate

Minimum Inventory ;

8 Gallons



12 Gallons



(Can be Combined)

3 Boxes



12 cans

8 1 lb packages

8 1 Dozen



6 - 16-18 oz

Containers 2



types

5 Packages - 2 types
18 Cans - 2 types

12 Containers - 2 types



12 Containers - 2 types



6 Loaves



24 Boxes - 4 types,

2 must be whole

grain,



2 must be in 11 to

14 oz size

18 Cans Combined

Milk Based - 30 Soy Based - 20

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Attachment VM-2 (cont'd)

Food Item
INFANT CEREAL INFANT FRUIT &
VEGETABLES INFANT MEATS
FRUITS &VEGETABLES

Georgia WIC Program

Minimum Inventory Requirements

Effective October 24 , 2011

Types/Brands

Size

Milk Based

Gerber Good Start Gentle PLUS

12.7 oz Powder

Soy Based
Gerber Good Start Soy Plus

12.9 oz Powder

Dry cereal in

8 oz box

Fruit and /or Vegetable Meats in Gravy Fruits
Vegetables

4 oz Jars
2.5 oz Jars 10 Pounds Combined (fresh, frozen or canned) 10 Pounds Combined (fresh, frozen or canned)

Minimum Inventory ;

Milk Based -50 Soy Based - 20

12 Boxes - 2 types, 1 must be rice



96 Jars Combined

31 Meat



4 types must be fresh



4 types must be fresh



Non-WIC Inventory Requirement

Food Item

Type

Meats, Poultry and/or Seafood (refrigerated or

NON-WIC

frozen)

Breads and Cereal Products

NON-WIC

Dairy (e.g. milk, cheese, yogurt, etc.)

NON-WIC

Shelf Staples (e.g. flour, sugar, pasta, pudding

NON-WIC

mix, etc.)

Cans, Jars, Bottled Goods (e.g. mayo, ketchup,

NON-WIC

relish, etc.)

Beverages (e.g. soda, water, powdered drinks,

NON-WIC

etc.)

Snack Foods (e.g. crackers, granola bars, etc.)

NON-WIC

Minimum in each category 200 200 200 200
200
200 200

2. Pre-Approval Visit. Only those vendor applicants that pass initial screening will receive an announced on-site pre-approval visit from Georgia WIC representatives to verify the information listed on the application and items A & B above. For non-corporate vendors, pre-approval visits will not be conducted until a vendor has attended training and passed the evaluation with a score of 80 or above. For corporate vendors, only one authorized representative from the store is required to attend training. Georgia WIC will conduct the visit based on the date the vendor states they will have the required minimum inventory of WIC approved foods in stock (question 8C on the application). If the vendor will not have the inventory by the date stated on the application, the vendor must contact our office IMMEDIATELY to prevent denial of the application by calling 1866-814-5468 or (404) 657-2900. The vendor will only be allowed to change this date once within 30 days from the application date. Applications from vendors unable to acquire the necessary inventory for authorization will expire 30 days from date the applicant declared they will have the minimum inventory, and the applications will be denied.
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Attachment VM-2 (cont'd)

3. Non-Profit Vendor. Non-profit vendors are not authorized in Georgia.
4. Adequate Access for Participants. The store must be open for business at least eight hours per day, six days per week, and must be open during the hours specified on the Vendor Application (exceptions may be granted for pharmacies at the State agency's discretion). There should be no barriers to participant entry to the store during opening hours (e.g. required store membership or controlled access or entry to the store).
5. Suitable Store Location. Stores must contain at least 3,000 square feet of retail food sales space open to the public excluding administrative and storage space. New vendors applying to Georgia WIC for the first time must meet this requirement at the time of application. Vendors already participating in Georgia WIC as of December 1, 2011 will have until October 1, 2012 to comply with this requirement. There must be a store sign to identify the store with the name of the business clearly marked. The store must not be located inside of another facility that is not food retail in nature (e.g. a suite on the upper floors of an office building, inside a community center, daycare, floral shop, etc.) The applicant must provide proof of a lease for at least a three-year period, or proof of ownership of the store location.
6. Licensed by 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 that are on the border of Georgia and another state must have a comparable food sales establishment license from that other state's Department of Agriculture.
7. Competitive Prices with Similar Stores. Georgia WIC will establish procedures to ensure that an applicant vendor whose prices exceed maximum allowable prices for food items will not be authorized. Georgia WIC will establish procedures to ensure that a vendor selected for participation in the program will not, subsequent to selection, increase prices to levels that would make the vendor ineligible for authorization. Prices are compared with other stores within the vendor's peer group, except for above 50% vendors, whose prices are based on the statewide average of all regular vendors. Maximum allowable prices for food items are determined using the vendor-submitted shelf pricing by peer group. Any applicant or existing vendor who exceeds the maximum allowable price as determined using a standard methodology for more than 10% of all food items listed on the shelf pricing survey will not be authorized.
8. Compliance with the Supplemental Nutrition Assistance Program (SNAP) Regulations. All vendors must be licensed as a SNAP retail provider. Vendors who withdraw from SNAP, are disqualified from SNAP, or are terminated from SNAP due to non-redemption will be terminated from Georgia WIC. Unless necessary to ensure adequate participant access, Georgia WIC will not authorize an applicant that is currently disqualified from SNAP, or that has been assessed a SNAP civil money penalty (CMP) for hardship and the disqualification period that would otherwise have been imposed has not expired.
9. Compliance with Georgia WIC Program Policies and Procedures. For existing vendors, any violations found during the re-authorization process may result in denial of the application for re-authorization. Vendors and applicants will be required to comply with all federal and state WIC policies.
10. Business Integrity/ Background Checks. All new applicant vendors will be subject to background checks to determine the applicant's business integrity as a part of the pre-
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Attachment VM-2 (cont'd)

screening process. Any vendor that has a history of fraud, embezzlement or trafficking, or has engaged in any activity that Georgia WIC deems to be indicative of a lack of business integrity will be denied. Unless necessary to ensure adequate participant access, Georgia WIC will not authorize an applicant that does not meet the business integrity criteria, and may rely upon its own investigation as well as 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 against the applicant, the applicant's owners, officers or managers 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, obstruction of justice or any crime of moral turpitude.
b. Official records of removal from other federal, state or local programs will also be considered.
11. Store Acquisition. Georgia WIC will not approve a store location or entity that was sold or assigned to transfer the ownership of a disqualified vendor or his/ her partners, members, owners, officers, directors, employees, relatives by blood or marriage, heirs or assigns. If it is later determined that the applicant failed to abide by this provision, the vendor will be subject to civil liability, fines, and penalties.
12. 50% Criterion. All vendors are required to submit food sales data, purchase invoice receipts, and any other records requested to validate food sales upon request for Georgia WIC to monitor whether the vendor derives more than 50% of its annual foods sales revenue from WIC food instruments. Vendors and applicants found to be actual or potential above 50% vendors at application, the six-month assessment, annual assessment or re-authorization will be assigned to peer group G.
13. Infant Formula Suppliers. All vendor applicants are required to purchase infant formula, solely from a list of suppliers selected and approved by Georgia WIC. The list can be obtained via the Internet at www.wic.ga.gov/vendorinfo.asp , (click on "Approved Infant Formula Suppliers"). If a supplier is not listed, a vendor may call 866-814-5468 to inquire about adding the supplier to the list. After the vendor has requested the addition, the vendor must ensure that Georgia WIC has authorized the supplier, prior to purchasing any infant formula from that supplier. Records of the infant formula purchase must be maintained for the three previous years plus the current year or until any pending investigations are closed, if longer.
14. WIC Acronym and Logo. A WIC vendor or applicant may not use the WIC acronym,
the WIC logo, or close facsimiles thereof, in total or in part, either in the official name in which the vendor is registered or in the name in which it does business. The WIC vendor or applicant may not use the WIC acronym, the WIC logo or close facsimiles thereof, in total or in part, in an unauthorized manner on packages, product labels, proprietary materials including pamphlets and brochures, or in any form of marketing, promotional material or advertisement of the store.
15. Purchase Invoice Receipts. Vendor applicant vendors must submit upon request purchase invoice receipts, bills of lading or recent invoices that show the purchase of items intended for sale in their stores. Failure to submit the requested documentation within the time frame stated in the request will result in denial of the vendor application.
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Attachment VM-2 (cont'd)

16. Automatic Clearing House (ACH) Application. Vendors who are authorized for participation in Georgia WIC will receive an ACH enrollment form. Vendors will have five business days from the date of receipt of the form to enroll. Failure to enroll in ACH within the allotted timeframe will result in termination of the vendor agreement.

17. Provision of Incentive Items. Georgia WIC will not authorize or continue authorization of a vendor that advertises, promises, provides, or indicates an intention to provide prohibited incentive items to customers. Incentives include, but are not limited to free or complimentary gifts, home delivery of goods, store memberships, and other free or discounted services that are offered to WIC customers to entice them to transact food instruments.

18. Pharmacies. A pharmacy vendor shall redeem only exempt or special infant formulas, including medical foods.

19. Acceptance of WIC Vouchers prior to Authorization It is a violation of Federal law to accept WIC vouchers without authorization from the appropriate agency. If it is determined that an applicant has accepted WIC vouchers prior to authorization, they will be subject to criminal prosecution and reimbursement for the unauthorized transactions. In addition, their application will be denied for a twelve (12) month period.

20. Denial of Vendor Authorization If an applicant has been denied because they have accepted WIC vouchers prior to authorization, then the application will be denied for a period of twelve months. If an applicant is denied for failure to meet the selection criteria above, the application will be denied for a period of six months. A current vendor will be terminated if it fails to meet the selection criteria during a re-assessment. Vendors may re-apply after their denial period has expired.

The vendor may appeal certain denials of vendor authorization through the administrative review process. For more information on actions that may be appealed and the administrative review process, please refer to page 41 of the Vendor Handbook.

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Attachment VM-3

GEORGIA WIC PROGRAM

VENDOR HANDBOOK

Effective December 1, 2011
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GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment VM-3 (cont'd)

TABLE OF CONTENTS

INTRODUCTION

30

The Vendor Handbook

30

Georgia WIC

30

WIC ACRONYM AND LOGO, ADVERTISEMENTS AND INCENTIVES

31

Use of the WIC Acronym and Logo

31

Advertisements, Shelf Talkers, Channel Strips, and Posters

31

Incentives

32

VENDOR AUTHORIZATION AND PARTICIPATION

33

Vendor Authorization Process for Authorization

33

Invoice Assessment

36

Peer Groups

37

RESPONSIBILITIES AND PROCEDURES FOR SELECTED VENDOR TYPES

38

Corporate Vendors (Multiple Locations and a Single FEIN)

38

Pharmacy Vendors

38

Corporations

38

Release of State Tax Information

39

VENDOR TRAINING

40

Pre-Authorization and Re-Authorization Training

40

Annual Training

40

Customized Training

41

WIC APPROVED FOODS

42

List of Infant Formula Wholesalers, Distributors, Retailers, and

Manufacturers

42

Non-WIC Inventory Requirement

42

Minimum WIC Food Inventory Requirements

43

THE WIC FOOD INSTRUMENT

45

Food Instrument Types and Descriptions

45

Processing WIC Food Instruments Including Cash Value Vouchers

49

Important Notes about the WIC Customer for Cashiers and Store Managers

51

Food Instrument Payment Procedures

53

Redemption Assessment

54

USDA's Rule on Vendor Cost Containment

55

Important Notes About The Vendor Stamp

55

CHANGES IN VENDOR INFORMATION

56

Changes in Store Location or Information

56

Changes in Ownership and Cessation of Operation

56

Reporting and Changing Shelf Prices

57

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GEORGIA WIC 2012 PROCEDURES MANUAL
PERFORMANCE COMPLIANCE Covert Compliance Investigation Overt Monitoring Audits Programmatic Reports and Database High Risk Identification
TERMINATION OF THE VENDOR AGREEMENT Summary Termination Termination upon Notice
SANCTIONS AND THE SANCTION SYSTEM Sanctions Disqualification The Sanction System Additional Notes on Violations Civil Monetary Penalties (CMP) CMP Methodology for State Agency Sanctions CMP Methodology for Mandatory Sanctions
ADMINISTRATIVE REVIEW AND APPEAL PROCEDURES
WHERE TO GET MORE INFORMATION
GLOSSARY

Attachment VM-3 (cont'd)
58 58 58 58 59 59
60 60 60
62 62 62 63 67 67 67 69
70
75
76

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GEORGIA WIC 2012 PROCEDURES MANUAL
INTRODUCTION

Attachment VM-3 (cont'd)

The Vendor Handbook
The Georgia Special Supplemental Nutrition Program for Women, Infants and Children (Georgia WIC) Vendor Handbook is an addendum to and incorporated into the Vendor Agreement. Vendors, pharmacy vendors and military commissaries must adhere to all information provided in the most recent edition of the Vendor Handbook to ensure compliance with federal and state regulations, rules, policies, and procedures. The vendor's role is important to the success of Georgia WIC. 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 Georgia WIC to maximize services to its citizens. Authorized WIC vendors redeemed approximately $250,174,551 in WIC food vouchers during federal fiscal year 2010.
Georgia WIC
WIC is a federally funded special supplemental food program intended to provide supplemental foods, nutrition education, and nutrition counseling to Georgia's citizens. WIC saves lives and improves the health of nutritionally at-risk women, infants, and children. Since its 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.
A list of some of the positive health outcomes associated with WIC participation follows.
x Reduces fetal deaths and infant mortality x Reductions in the rate of low birth weight infants x Increases in pregnancy duration x Improves the growth of nutritionally at-risk infants and children x Decreases in the incidence of iron deficiency anemia in children x Improves the dietary intake of pregnant and postpartum women and improves weight gain in
pregnant women x Increases early initiation into prenatal care x Increases the number of children who have a regular source of medical care x Helps children get ready to start school x Improves intellectual development x Improves children's diets
Georgia's health professionals determine who is eligible to participate in the WIC program according to criteria established by federal regulations. These health professionals also provide nutrition education, counseling and prescribe nutritious foods. Instruments used to obtain the supplemental foods are called WIC food instruments, which are redeemed through WIC authorized vendors statewide.

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Attachment VM-3 (cont'd)

WIC ACRONYM AND LOGO, ADVERTISEMENTS AND INCENTIVES

Use of the WIC Acronym and Logo
A WIC vendor must not use the acronym "WIC", the WIC logo, or close facsimiles thereof, in total or in part, either in the vendor's official registered name or in the name under which it does business.
A WIC authorized vendor shall not use the WIC acronym, the WIC logo, or close facsimiles thereof, in total or in part, in an unauthorized manner on packages, product labels, proprietary materials including pamphlets and brochures, or in any form of marketing, promotional material or advertisement of the store.
Any person who uses the acronym "WIC" or the WIC logo in an unauthorized 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.
Georgia WIC will terminate the Vendor Agreement for misuse or unauthorized use of the WIC acronym or the WIC logo. If a vendor applicant misuses the WIC acronym or the WIC logo prior to or at application, the Vendor Application will be denied.
Advertisements, Shelf Talkers, Channel Strips, and Posters
Channel Strips and Shelf Talker, and "We Welcome WIC" posters
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 contains WIC approved foods. These items have been developed by Georgia WIC and are available upon request. Vendors who wish to develop their own shelf talkers or channel strips must obtain written permission from Georgia WIC by submitting a copy or sample of the final version for approval prior to use.
To identify the retailer as an authorized WIC vendor, vendors are required to prominently display in plain sight a poster or decal provided by Georgia WIC which states that the store accepts WIC.
Payment Posters
A WIC vendor must accept at least two other forms of payment other than WIC and EBT (Electronic Benefit Transfer.) If a payment poster is displayed all forms of payment accepted by a vendor must be listed so as not to solicit the WIC customer. Payment posters cannot imply that the vendor only takes WIC or EBT. EBT or WIC cannot be more pronounced on the poster than other forms of payment (e.g. EBT and WIC should not be in a larger or different font, or in boldface.)

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Attachment VM-3 (cont'd)

Bread Manufacturers
Bread manufacturers are allowed to create their own shelf talkers and channel strips. Final artwork must be submitted to the Georgia WIC office for approval or revision prior to implementation.
It is the responsibility of the vendor to ensure that the labels used by bread manufacturers have been approved by Georgia WIC. Should a non-approved label be used, the vendor will be subject to sanctions (see page 34, `State Agency Sanctions- Category II'). Please contact Georgia WIC prior to allowing a bread manufacturer to label your shelves to ensure that their labels are approved.
Incentives
Georgia WIC prohibits any vendor from using incentives to solicit the patronage of WIC participants. Vendors who use advertisements to solicit the business of WIC participants, or who offer incentives or delivery services to participants, will be subject to sanctions as explained in the Vendor Agreement and this handbook. Incentives are defined as any item, service, or gimmick used to solicit the patronage of a WIC participant. Incentives include, but are not limited to, free or complimentary gifts, home delivery of foods, store memberships, and other free or discounted services that are offered to WIC customers to entice them to transact food instruments.

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GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment VM-3 (cont'd)

VENDOR AUTHORIZATION AND PARTICIPATION

Vendor Authorization Process for Authorization
WIC Vendor Applications are accepted year round. All applicants must meet the Georgia WIC selection criteria at the time of application. After authorization, the vendor must continue to comply with all selection criteria throughout the agreement period including any changes to the criteria. Georgia WIC may reassess any authorized vendor at any time during the vendor's agreement period using the selection criteria in effect at the time of reassessment, and must terminate the agreement of any vendors that fail to meet the current criteria. Georgia WIC will deny an application or terminate the vendor agreement if it is determined that the applicant provided false information in connection with the application. During the application process, Georgia WIC may request additional information that must be provided within the time period specified in the request.
All requested information must be provided in order to process the application. This includes, but is not limited to, Bill of Sale; Articles of Incorporation, Driver's License or State issued ID card, Social Security card, food sales, etc. Applications will not be processed until all information is received by Georgia WIC. Vendor applications that are held pending receipt of additional information will expire ten days after the date of the written request for information.
It is a violation of Federal law to accept WIC vouchers without authorization from the appropriate agency. If it is determined that an applicant has accepted WIC vouchers prior to authorization, they will be subject to criminal prosecution and reimbursement for the unauthorized transactions. In addition, their application will be denied for a twelve (12) month period.
If an applicant is denied for failure to meet the selection criteria below, the application will be denied for a period of six months. Applicants may re-apply after their denial period has expired.
1. Minimum Inventory of WIC-Approved Foods. Each vendor is required to stock and maintain daily the minimum inventory of approved WIC foods as well as a substantial amount of non-WIC foods. The inventory must be in the store or the store's stockroom. Expired foods do not count towards minimum inventory; all WIC minimum inventory must be within the expiration dates during the application process, including the preauthorization visit. The minimum inventory requirements are listed in the charts on pages 14 through 15 of this handbook. Pharmacies and military commissaries are exempt from minimum inventory requirements. The vendor must carry other foods outside of the WIC minimum inventory and WIC approved foods.
2. Pre-Approval Visit. Only those vendor applicants that pass initial screening will receive an announced on-site pre-approval visit from Georgia WIC representatives to verify the information listed on the application and items A and B above. For non-corporate vendors, pre-approval visits will not be conducted until the vendor has attended training and passed the evaluation with a score of 80 or above. For corporate vendors, only one authorized representative from the store is required to attend training (see page 11.) Georgia WIC will conduct the visit based on the date the vendor states that they will have the required minimum inventory of WIC approved foods in stock (question 8C on the application.) If the

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GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment VM-3 (cont'd)

vendor will not have the inventory by the date stated on the application, the vendor must contact our office IMMEDIATELY to prevent denial of the application by calling 1-866-8145468 or (404) 657-2900. The vendor will only be allowed to change this date once within 30 days from the application date. Applications from vendors unable to acquire the necessary inventory for authorization will expire thirty days from date the applicant declared they will have the minimum inventory, and the applications will be denied.

3. Non-Profit Vendor. Non-profit vendors are not authorized in Georgia.

4. Adequate Access for Participants. The store (with the exception of military commissaries and pharmacies) must be open for business at least eight hours per day, six days per week, and must be open during the hours specified on the Vendor Application. Military commissaries and pharmacies must be open for business at least five hours per day, five days per week. There should be no barriers to participant entry to the store during opening hours (e.g. required store membership or controlled access or entry to the store.)

5. Suitable Store Location. Stores must contain at least 3,000 square feet of retail food sales space open to the public, excluding administrative and storage space. New vendors applying to Georgia WIC for the first time must meet this requirement at the time of application. Vendors already participating in the program as of December 1, 2011 will have until October 1, 2012 to comply with this requirement. There must be a store sign to identify the store with the name of the business clearly marked. The store must not be located inside of another facility that is not food retail in nature (e.g. a suite on the upper floors of an office building, inside a community center, daycare, floral shop, etc.) The applicant must provide proof of a lease for at least a three-year period, or proof of ownership of the store location.

6. Licensed by 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 that are on the border of Georgia and another state must have a comparable food sales establishment license from that other state's Department of Agriculture.

7. Competitive Prices with Similar Stores. Georgia WIC will establish procedures to ensure that an applicant vendor whose prices exceed maximum allowable prices for food items will not be authorized. Georgia WIC will establish procedures to ensure that a vendor selected for participation in the program will not, subsequent to selection, increase prices to levels that would make the vendor ineligible for authorization. Prices are compared with other stores within the vendor's peer group, except for above 50% vendors, whose prices are based on the statewide average of all regular vendors. Maximum allowable prices for food items are determined using the vendor-submitted shelf pricing by peer group. Any applicant or existing vendor who exceeds the maximum allowable price as determined using a standard methodology for more than 10% of all food items listed on the shelf pricing survey will not be authorized.

8. Compliance with the Supplemental Nutrition Assistance Program (SNAP) Regulations. All vendors must be licensed as a SNAP retail provider. Vendors who withdraw from SNAP, are disqualified from SNAP, or are terminated from SNAP due to non-redemption will be terminated from Georgia WIC. Unless necessary to ensure adequate participant access,

VM - 34

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment VM-3 (cont'd)

Georgia WIC will not authorize an applicant that is currently disqualified from SNAP, or that has been assessed a SNAP civil money penalty (CMP) for hardship and the disqualification period that would otherwise have been imposed has not expired.

9. Compliance with Georgia WIC Program Policies and Procedures. For existing vendors, any violations found during the re-authorization process may result in denial of the application for re-authorization. Vendors and applicants will be required to comply with all federal and state WIC policies.

10. Business Integrity/ Background Checks. All new applicant vendors will be subject to background checks to determine the applicant's business integrity as a part of the prescreening process. Any vendor that has a history of fraud, embezzlement or trafficking, or has engaged in any activity that Georgia WIC deems to be indicative of a lack of business integrity will be denied. Unless necessary to ensure adequate participant access, Georgia WIC will not authorize an applicant that does not meet the business integrity criteria, and may rely upon its own investigation as well as 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 against the applicant, the applicant's owners, officers or managers 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, obstruction of justice, or any crime of moral turpitude.

b. Official records of removal from other federal, state or local programs will also be considered.

11. Store Acquisition. Georgia WIC will not approve a store location or entity that was sold or assigned to transfer the ownership of a disqualified vendor or his/ her partners, members, owners, officers, directors, employees, relatives by blood or marriage, heirs or assigns. If it is later determined that the applicant failed to abide by this provision, the vendor will be subject to civil liability, fines, and penalties.

12. 50% Criterion. All vendors are required to submit food sales data, purchase invoice receipts, and any other records requested to validate food sales upon request for Georgia WIC to monitor whether the vendor derives more than 50% of its annual food sales revenue from WIC food instruments. Vendors and applicants found to be actual or potential above 50% vendors at application, the six-month assessment, annual assessment or re-authorization will be assigned to peer group G.

13. Infant Formula Suppliers. All vendor applicants are required to purchase infant formula solely from a list of suppliers selected and approved by Georgia WIC. The list can be obtained via the Internet at www.wic.ga.gov/vendorinfo.asp (click on "Approved Infant Formula Suppliers"). If a supplier is not listed, the vendor may call 866-814-5468 to inquire about adding the supplier to the list. After the vendor has requested the addition, the vendor must ensure that Georgia WIC has authorized the supplier prior to purchasing any infant formula from that supplier. Records of the infant formula purchase must be maintained for the three previous years plus the current year or until any pending investigations are closed, if longer.

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Attachment VM-3 (cont'd)

14. WIC Acronym and Logo. A WIC vendor or applicant may not use the WIC acronym, the WIC logo, or close facsimiles thereof, in total or in part, either in the official name in which the vendor is registered or in the name in which it does business. The WIC vendor or applicant may not use the WIC acronym, the WIC logo, or close facsimiles thereof, in total or in part, in an unauthorized manner on packages, product labels, proprietary materials including pamphlets and brochures, or in any form of marketing, promotional material or advertisement of the store (see page 2).
15. Purchase Invoice Receipts. Vendor Applicants must submit upon request purchase invoice receipts, bills of lading or recent invoices that show the purchase of items intended for sale in their stores. Failure to submit the requested documentation within the time frame stated in the request will result in denial of the vendor application.
16. Automatic Clearing House (ACH) Application. Vendors who are authorized for participation in Georgia WIC will receive an ACH enrollment form. Vendors will have five business days from the date of receipt of the form to enroll. Failure to enroll in ACH within the allotted timeframe will result in termination of the vendor agreement.
17. Provision of Incentive Items. Georgia WIC will not authorize or continue the authorization of a vendor that advertises, promises, provides, or indicates an intention to provide prohibited incentive items to customers. Incentives include, but are not limited to, free or complimentary gifts, home delivery of foods, store memberships, and other free or discounted services (see page 3).
18. Pharmacies. A pharmacy vendor shall redeem only exempt or special infant formulas, including medical foods.
Invoice Assessment
Vendor applicants must submit upon request purchase invoice receipts, bills of lading or recent invoices which show the purchase of all items intended for sale in their stores. This includes WIC food items, non-WIC food items, household products, and miscellaneous items. Purchase invoices must reflect the name and address of the wholesaler or supplier, date of the purchase, list of the items purchased, size, stock number, quantity, unit price and total dollar amount for the quantity purchased. Itemized cash receipts must include the name and address of the store or a code number by which the store can be identified, the date of purchase, description of the items purchased, unit price and total purchase price. Itemized cash receipts that do not completely describe the item should have a computer code that can be verified by calling the store manager. Affidavits or oral statements are not acceptable as proof of inventory.
Failure to submit the requested documentation within the time specified will result in denial of the vendor application.

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Attachment VM-3 (cont'd)

Peer Groups
Authorized vendors are classified into eight different peer groups depending on square footage of the store (excluding administrative and storage space), number of stores in the chain, and potential or actual 50% status.

Peer Group A B C D
E F
G

Type Small Medium Chain Large Independent
Military Commissary Pharmacy
Above 50%

Description
3,000 to 10,000 Square Feet
10,001 to 15,000 Square Feet
15,001 or more Square Feet and 20 or more locations
15,001 or more Square Feet and less than 20 locations
Located on Military Bases serving military personnel only Pharmacy Redeem exempt and/or special infant formulas only including medical foods. No contract formula stated infant formula or other standard WIC foods are allowed for this peer group. Vendors and applicants found to be actual or potential above 50% vendors at application, the sixmonth assessment, annual assessment or reauthorization will be assigned to peer group G.

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Attachment VM-3 (cont'd)

RESPONSIBILITIES AND PROCEDURES FOR SELECTED VENDOR TYPES

Corporate Vendors (Multiple Locations and a Single FEIN)
A business entity having two 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" by Georgia WIC for program purposes. An authorized representative of the business entity shall sign one agreement and list required information about each store that is an authorized vendor on Corporate Attachment Form 3771A. 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.
The Corporate Attachment Form is an addendum to the Corporate Vendor Agreement. The attachment serves as verification that the location listed is the authorized location in which WIC vouchers are to be redeemed. Vendors are not permitted to redeem vouchers in a location other than the authorized location listed in the Vendor Agreement or Corporate Attachment. The location listed on the Corporate Attachment Form will correspond to the Vendor Number that has been assigned to the store.
Pharmacy Vendors
Pharmacy vendors may redeem exempt and special infant formula only, including medical foods. No contract formula (i.e. contract infant formula listed on a standard food instrument) or other standard WIC foods listed on a food instrument may be redeemed by this peer group. 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 exempt infant formula food instruments. 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. Pharmacy vendors shall not accept food instruments through the mail, nor mail any approved formula/medical foods directly to the WIC customer. Doing so will result in termination of the vendor agreement.
Corporations
New vendors who are incorporated will be required to complete the corporation information on the application including the name of their corporation and registered agent. Current vendors will be asked to download a corporate information form from the Georgia WIC website, and complete and submit it to the Georgia WIC office to update the vendor file. The form can be found at www.wic.ga.gov/vendorinfo.asp. Error! Hyperlink reference not valid.

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Attachment VM-3 (cont'd)

Release of State Tax Information
Vendors are required to sign and submit to Georgia WIC and the Georgia Department of Revenue (DOR), upon request, a form authorizing DOR to release certain sales and use tax information to Georgia WIC, for use in determining if the vendor derives more than fifty percent of its annual food sales revenue from WIC food instruments. At the time that vendors submit their Sales and Use Tax Return (ST3 Form) to DOR, vendors are also required to submit the Georgia WIC ST3 Addendum to DOR. Both the authorization and the Georgia WIC ST3 Addendum are available at www.wic.ga.gov/vendorinfo.asp.

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Attachment VM-3 (cont'd)

VENDOR TRAINING

Vendor training will be conducted to ensure that all vendors are familiar with Georgia WIC program policies and procedures. Training will be offered in one of the following formats: newsletters, videos, videoconferences, or interactive training sessions. A score of eighty points or higher on the training evaluation is required before a pre-approval visit will occur.
Vendors must register to attend training and must attend on the date they have elected. If the vendor is unable to attend training on the date selected, they must alert Georgia WIC with an alternate date. For authorization training, vendors will be required to show a government issued picture ID before they will be admitted.

Pre-Authorization and Re-Authorization Training

Georgia WIC will provide an initial training session in an interactive format prior to, or at the time of authorization, and at least once every three years thereafter at the time of vendor reauthorization. Georgia WIC will provide vendors with at least one alternative date on which to attend interactive training. Attendance at training will be documented, a checklist of items discussed must be signed by the vendor and a Post Vendor Training Evaluation test will be given. A passing score of eighty points or higher is required to become authorized. Vendor applicants cannot attend the initial authorization training session until an application for authorization has been submitted and the vendor has registered to attend.
For corporate vendors, a representative of the corporate vendor must initially complete the authorized training session and receive a passing score of eighty points or higher. After completing and passing the training session, the 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. The corporate vendor must conduct authorization training for existing and new locations. The representative must ensure that all training topics are provided to a management representative in each authorized store.
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 vendor agreement that is signed by both parties and the receipt of a vendor stamp constitutes authorization.

Annual Training

Georgia WIC will conduct annual training for vendors regarding changes and updates to policies and procedures. Annual training may be conducted in a variety of formats including newsletters, videos and interactive training. Authorized vendors must provide documentation of participation in annual training by the deadline specified. In addition, corporate vendors must ensure that each store listed in the current Vendor Agreement receives annual training by the deadline specified. Failure to do so will result in termination of the Vendor Agreement. Failure to provide documentation that each store participated in annual training will result in termination of the store(s).

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Attachment VM-3 (cont'd)

Customized Training

Georgia WIC representatives may conduct training for employees of WIC vendors at their request. Training requests should be made in writing to Georgia WIC, Vendor Management Unit, 2 Peachtree Street, Suite 10-476, Atlanta, Georgia, 30303. Please specify the desired training topics and the type and number of employees who will attend. Georgia WIC and the WIC vendor will mutually agree upon location and dates for the training.

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Attachment VM-3 (cont'd)

WIC APPROVED FOODS

The WIC Approved Foods posted on the WIC Vendor Management website at www.wic.ga.gov/vendorinfo.asp are foods that are available to the WIC customer. ONLY these foods may be purchased by the participant or proxy using the WIC food instrument.
Because the brand names and types of infant formula as well as special medical foods are too numerous to list, approved foods will be printed directly on the front of the WIC food instrument. 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 food instrument. Do not allow the WIC customer to purchase infant formula or medical food that is NOT listed on the food instrument.
The vendor will receive an updated list of approved foods as changes are made, and can always check the WIC Vendor Management website for current information. Vendors will periodically receive pamphlets and posters of WIC approved food items that can be used as displays or as a training resource.

List of Infant Formula Wholesalers, Distributors, Retailers, and Manufacturers

All currently authorized WIC vendors and all stores applying for WIC authorization are required to purchase infant formula solely from a list of suppliers selected and approved by Georgia WIC. The list is located at www.wic.ga.gov/vendorinfo.asp (click on "Approved Infant Formula Suppliers"). If a supplier is not listed, a vendor may call 866-814-5468 or 404-657-2900 to inquire about adding them to the list. After the vendor has requested the addition, the vendor must ensure that Georgia WIC has authorized the supplier, prior to purchasing any infant formula from that supplier. Records of the infant formula purchase must be maintained according to the terms of the WIC Vendor Agreement.

Non-WIC Inventory Requirement

All vendors except pharmacies are required to carry foods other than WIC approved foods. These food items must consist of qualifying food items approved by SNAP in addition to the WIC minimum inventory and WIC-approved foods, and foods that are intended for home preparation and consumption, such as meat, fish, and poultry bread and cereal products dairy products, fruits, and vegetables. Items such as condiments and spices, coffee, tea, cocoa, carbonated and noncarbonated beverages are included in food sales only when offered for sale along with foods in the four primary categories. Non-food items, alcoholic beverages, hot foods, or food that will be eaten on the store premises are not considered a part of USDA's definition of eligible foods.
At least two hundred items in each of the following categories must be in stock at all times.

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Food Item Meats, Poultry and/or Seafood (refrigerated or frozen)
Breads and Cereal Products Dairy (e.g. milk, cheese, yogurt, etc.) Shelf Staples (e.g. flour, sugar, pasta, pudding mix, etc.) Cans, Jars, Bottled Goods (e.g. mayo, ketchup, relish, etc.) Beverages (e.g. soda, water, powdered drinks, etc.) Snack Foods (e.g. crackers, granola bars, etc.)

Attachment VM-3 (cont'd)
Minimum in each category 200 200 200 200 200 200 200

Minimum WIC Food Inventory Requirements

Vendors are REQUIRED to maintain in stock a minimum variety and quantity of the WIC foods as described in the chart below. An on-site inventory audit of the below mentioned food items (WICapproved and non-WIC) is a component to the pre-approval and routine monitoring visits.

Food Item
MILK Least Expensive
Brand of type selected/allowed
CHEESE Least Expensive
Brand of type selected/allowed
EGGS Least Expensive
Brand
PEANUT BUTTER
BEANS / PEAS / LENTILS
JUICE

Georgia WIC Program Minimum Inventory Requirements
Effective October 24, 2011

Types/Brands

Size

Whole Milk Fat free/Skim, Low-fat (1%), Reduced Fat (2%)
Milk Dry powdered milk OR
Evaporated milk

Gallon Gallon
Makes 3 quarts 12 oz

One pound package

16 oz. (1 pound)

Grade A Large
Any brand Creamy, Crunchy, or Extra Crunchy (Regular or Low-
salt) Dried Beans / Peas /
Lentils Canned Beans / Peas /
Lentils Ready to Serve Container Ready to Serve Container

1 Dozen carton
16-18 oz
1 pound packages 14 to 16 oz cans
46-48 oz 64 oz

Minimum Inventory 8 Gallons 12 Gallons (Can be Combined) 3 Boxes 12 cans 8 1 lb packages 2 types
8 1 Dozen
6 - 16-18 oz Containers 2 brands 5 Packages - 2 types
18 Cans - 2 types 12 Containers - 2 types 12 Containers - 2 types

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Attachment VM-3 (cont'd)

Food Item WHOLE GRAIN-
BREAD CEREAL Whole Grain
FISH Least Expensive of
type selected
INFANT FORMULA
INFANT CEREAL INFANT FRUIT &
VEGETABLES INFANT MEATS
FRUITS &VEGETABLES

Georgia WIC Program Minimum Inventory Requirements
Effective October 24, 2011

Types/Brands

Size

Whole Grain Bread
WIC Approved Cereal Brands and Types
(see WIC Approved Foods List) Tuna
Pink Salmon
Milk Based
Gerber Good Start Gentle
Soy Based
Gerber Good Start Soy
Milk Based
Gerber Good Start Gentle
Soy Based
Gerber Good Start Soy
Dry cereal in

16 oz loaf
11-36 oz 5 oz Can 7.5 oz or 14.75 oz
13 oz Concentrate
12.7 oz Powder 12.9 oz Powder
8 oz box

Fruit and /or Vegetable

4 oz Jars

Meats in Gravy Fruits
Vegetables

2.5 oz Jars 10 Pounds Combined 10 Pounds Combined

Minimum Inventory
6 Loaves 24 Boxes - 4 types, 2 must be whole grain, 2 must be in 11 to 14 oz size
18 Cans Combined
Milk Based - 30 Soy Based - 20
Milk Based -50
Soy Based - 20 12 Boxes - 2 types, 1 must be rice 96 Jars Combined
31 Meat 4 types fresh 4 types fresh

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Attachment VM-3 (cont'd)

THE WIC FOOD INSTRUMENT
The WIC food instrument is similar to a check. A vendor must accept all valid food instruments, with the exception of a pharmacy vendor, who may only redeem food instruments for exempt and special infant formula, including medical foods. The vendor shall not accept counterfeit or altered food instruments.
When food instruments are properly redeemed, the vendor will receive credit for the amount of the purchase by depositing the food instrument into the specific account number provided to Georgia WIC by the vendor for deposit of all WIC food instruments at the vendor's bank.
Food instruments are not transferable and cannot be sold. They must only be redeemed and deposited to the account of the vendor that corresponds with the WIC vendor stamp and location listed on the Vendor Agreement or Corporate Attachment Form. Vendors who commit fraud or abuse in the program are subject to criminal prosecution. Those who have willfully misapplied, stolen or fraudulently obtained program funds will be subject to a fine of not more than $25,000 or imprisonment for not more than five years, or both, if the value of the funds is $100 or more. If the value is less than $100, the penalties are fines of not more than $1000 or imprisonment for not more than one year, or both.
Food Instrument Types and Descriptions
There are five types of WIC food instruments: laser-printed, blank manual, standard manual, computer generated and cash value vouchers. Descriptions and pictures of the food instruments are below.
Laser Printed Food Instruments. The laser-printed food instrument is printed at the clinic site at the time of the participant, parent's, caretaker's and/or proxy's visit.

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Attachment VM-3 (cont'd)

Blank Manual/Handwritten Food Instruments. All information on the food instrument 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 are no numbers. This helps to eliminate any possible unauthorized alterations on the food instrument. There are two types of Blank Manual/ Handwritten Food Instruments, which are shown below.

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Attachment VM-3 (cont'd)

Blank Standard Manual Food Instruments. Blank standard manual vouchers have the WIC approved foods preprinted on the vouchers. The top portion of the voucher is completed (handwritten) by the clinic staff. These vouchers have two signature boxes.

Emergency Computer Generated Food Instruments. These food instruments are used in case of emergencies. All information on the food instrument is computer printed.

Cash Value/Fruit and Vegetable Vouchers (CVV). A CVV is issued for fruits and vegetables.
x CVVs are used to purchase approved fresh, frozen, and canned fruits and vegetables. x CVVs have a maximum amount listed (e.g. $6, $7, $8 or $10.) x The WIC participant will be allowed to pay the difference when the cost of their produce
exceeds the price stated on the CVV. The amount over the CVV maximum is be subject to tax, when applicable. The WIC participant is responsible for paying the difference plus the applicable sales tax. x The vendor may need to adjust its current procedures to allow for WIC clients to use payment methods such as Food Stamps EBT cards, cash, credit cards, or debit cards to complete the CVV transaction.
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GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment VM-3 (cont'd)

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Attachment VM-3 (cont'd)

Processing WIC Food Instruments Including Cash Value Vouchers
The vendor's bank should be informed that WIC food instruments are negotiable instruments that must be processed through the Federal Reserve Bank. Georgia WIC will provide each vendor a stamp that is embossed with a unique WIC identification number. All food instruments accepted by the vendor must be stamped with this number in preparation for a bank deposit. Only food instruments stamped with an authorized vendor stamp that is issued by Georgia WIC will be paid. The stamp should be fully depressed onto the WIC food instrument so that it is clearly recognizable on the food instrument. Lost, stolen or damaged stamps must be reported to Georgia WIC immediately. DO NOT REPRODUCE THE VENDOR STAMP. Food Instruments stamped with an unauthorized vendor stamp will not be paid (see section entitled `Vendor Stamp' on page 25 for further instructions on the vendor stamp). Payment on any voucher rejected by the WIC banking system is at the sole discretion of Georgia WIC.
Minimum Requirements for Payment
x Food instruments must be issued by Georgia WIC or its authorized local agencies, printed on official Georgia WIC paper, and unaltered.
x Food instruments are accepted on the "First Day to Use" date through the "Last Day to Use" date.
x An authorized WIC vendor stamp appears on the food instrument, is legible, and the food instrument is deposited to the single account provided to Georgia WIC by the vendor.
x Deposited within sixty days of the "First Day to Use" date. x The amount of purchase is entered in the "PAY EXACTLY SPACE" in ink. x A signature is obtained from the participant, in ink, at the time of purchase. x For cash value vouchers, the vendor must not issue change to a WIC customer for
purchases that are less than the total value of the cash value voucher. x For cash value vouchers, the WIC customer may use his/ her own funds for purchase
amounts in excess of the monetary limit for his/her cash value voucher.
WIC Customer Transactions at the Store
WIC food instruments may be presented at authorized vendor locations by WIC participants, parents, caretakers or proxies (WIC customer). WIC customers are required to take their WIC ID folder to each visit to the store. Vendors must 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 food instrument.
WIC foods must be separated from other food purchases prior to the WIC transaction. When approved supplemental food is being purchased with a WIC food instrument, the cashier must complete each food instrument separately and do the following:
Steps to Follow When Accepting WIC Food Instruments

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Attachment VM-3 (cont'd)

1. Check the participant's WIC ID card/folder. The WIC customer's name must be listed on the ID card/folder. If the WIC customer does not present a WIC ID card, then the food instruments cannot be redeemed.

2. For manual vouchers that contain two signature boxes, make sure that the "Sign here at WIC office" signature box contains a signature.

3. Check the dates on the food instrument. Food Instruments cannot be used before the "First Day to Use" or after the "Last Day to Use" dates.

4. Ring up the current shelf price of the food for each food instrument. Make sure that the exact types and amounts of approved WIC foods are being purchased.

5. Print in ink the amount of the WIC purchase in the "Pay Exactly" space on the food instrument in the presence of the WIC customer. Complete this step for one food instrument prior to moving on to the next food instrument.

6. Obtain a signature from the WIC customer, which must match the signature on the WIC ID card.

7. WIC customers must not be given credit or cash in exchange for WIC food instruments.

8. If the cashier makes a mistake entering the price on the food instrument, the incorrect price should be marked through and the correct price written above the error. The cashier must initial the correction as verification.

9. 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 food instruments.

10. The cashier must provide the WIC customer with a receipt and keep a copy of the receipt for the vendor's records.

Steps to Follow When Accepting Cash Value Vouchers (CVV)

1. Check the participant's WIC ID card/ folder. The WIC customer's name must be listed on the ID card/ folder. If the WIC customer does not present a WIC ID card, then the food instruments cannot be redeemed.
2. For manual vouchers that contain two signature boxes, make sure that the "Sign here at WIC office" signature box contains a signature.
3. Check the date on the face of the food instrument. CVVs cannot be used before the "First Day to Use" date or after the "Last day to Use" date.
4. Check the food items. They must be fruits and vegetables that cannot be purchased with the regular WIC food instrument.

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GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment VM-3 (cont'd)

5. Weigh the fruits or vegetables and/or ring up the current shelf price of the food for each item chosen. Make sure that the exact types of approved WIC foods (fruits and vegetables) are being purchased.

6. Check the value of the CVV. CVVs will be in $6, $7, $8 or $10 amounts.

7. Ring up price of the purchase

8. Write the price of the purchase in the "Pay Exactly" space in ink in the presence of the WIC Customer. Complete this step for one CVV before moving on to the next CVV.

9. Obtain a signature from the WIC customer, which must match the signature on the WIC ID card.

10. If the purchase amount is over the max price listed on the face of the CVV, the participant may pay cash or check, credit or EBT for the amount over the max price on the CVV.

11. Include tax for the amount over the maximum on the face of the CVV, if applicable. This amount in not a part of the WIC transaction. Give change for any amount over the face of the CVV. This is not a part of the WIC transaction. Change is not permitted for purchases that are less than the max price listed on the CVV.

12. WIC customers must not be given credit or cash in exchange for CVVs.

13. If the cashier makes a mistake entering the price on the CVV, the incorrect price should be marked through and the correct price written above the error. The cashier must initial the correction.

14. If the cash register does not automatically print "WIC" on the receipt, cashiers must write "WIC" vertically on all receipts for WIC food purchases.

15. The cashier must provide the WIC customer with a receipt, and keep a copy for the vendor's records.

If the amount of the CVV is less than the maximum amount on the face of the food instrument, do not give change and do not charge sales tax. If the price of the purchase is over the amount on the face of the CVV, charge the maximum amount of the purchase to the CVV. Your store will be responsible for collecting any difference over the maximum amount of the CVV. Tax can be charged for the amount over the maximum on the face of the food instrument. The WIC customer can pay the amount over the maximum in cash, credit, debit, EBT, or check. Change can be given for cash payment for any difference over the amount of the maximum for the CVV. That amount is not a part of the WIC transaction.

Important Notes about the WIC Customer for Cashiers and Store Managers
The WIC customer.

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Attachment VM-3 (cont'd)

1. Must present a WIC ID card to redeem food instruments.

2. Must sign the food instrument at the time of purchase.

3. May not use a WIC food instrument to purchase items not listed on the food instrument.

4. Must never be required to pay cash for items purchased except for items purchased with the cash value/ fruit and vegetable food instrument, in excess of the amount on the food instrument.

5. Must be allowed to purchase all foods listed on the food or CVV, regardless of price.

6. Must be afforded the same courtesies given to other store customers.

7. Must be permitted to purchase eligible food items without making other purchases.

8. Must be charged the same shelf prices as other customers.

9. Must not be charged sales tax, except on the purchase amount that is in excess of the amount on the cash value/ fruit and vegetable voucher, if applicable.

10. Must be reported to Georgia WIC immediately if they attempt to purchase foods that are not approved or create other problems in the store.

11. Must not be required to purchase every item on the food instrument.

12. Must not be contacted regarding restitution, payment or to obtain a missing signature. More Important Notes.

1. WIC approved foods purchased with a WIC food instrument cannot be returned for a cash refund.

2. WIC food instruments from other states must not be accepted.

3. If a manager is called to approve a WIC food instruments 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.

4. Separate checkout lines for the WIC customer are prohibited. Signs such as "WIC food instruments not allowed in this line" or "No Checks-No WIC" cannot be displayed. 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.

5. Every store must check 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 food

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GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment VM-3 (cont'd)

instruments. Food Instruments cannot be redeemed without the WIC ID card which shows the name of the person redeeming the food instruments.

6. Whenever food instruments are lost or stolen from a WIC health facility, Georgia WIC will notify area vendors that a stop payment has been placed on the food instruments. Vendors will be provided the food instrument numbers and informed not to accept the food instruments for redemption. These food instruments will not be paid.

7. The vendor must not provide refunds or permit exchanges for authorized supplemental foods obtained with food instruments except for exchanges of the same brand and size of 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.

8. The WIC customer must be allowed to participate in in-store or manufacturer promotions that are available to all other customers, and that include WIC approved food items. This includes `buy one get one or more free' promotions.

9. The WIC authorized vendor, its paid or unpaid owners, officers, managers, agents and employees shall not engage in any activity with the WIC participant, proxy, or caretaker that would create a conflict of interest, as determined by Georgia WIC. Authorized WIC vendors are not permitted to act as a proxy for a WIC participant.

10. The vendor is not permitted to provide transportation for the WIC customer to or from the vendor's premises.

11. The vendor is not permitted to deliver WIC approved foods to the WIC customer's residence.

12. The vendor shall not take back items purchased by the participant nor shall a vendor ask about obtaining food items that the participant chooses not to buy with the WIC food instrument.

13. The vendor must not provide unauthorized food or non-food items, cash, credit (including "rain checks") in exchange for food instruments.

14. Georgia WIC will review food instruments submitted for redemption to ensure compliance with price limitations and to detect suspected vendor overcharges and other errors.

15. Georgia WIC may require reimbursement for the full price of the food instrument that contains a vendor overcharge or other error detected as a result of compliance investigations, food instrument reviews, or other reviews or investigations of a vendor's operations.

Food Instrument Payment Procedures

All authorized vendors are required to enroll in the Automated Clearing House (ACH) for payment of WIC food instruments that exceed the maximum allowable price. At the time of authorization and re-authorization, vendors are also required to provide a single account number to which the

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vendor will deposit all WIC food instruments. If this account number changes, the vendor must notify Georgia WIC in writing within two business days. Upon authorization the ACH Enrollment Form is sent with the Vendor Stamp. The form must be completed and submitted immediately to the address indicated on the form. Vendors will have five business days from the date of receipt of the ACH Enrollment Form to enroll. Failure to enroll within the allotted timeframe will result in termination of the vendor agreement.

Approved payments will be posted to the vendor's bank account immediately. Vendors will be able to view their ACH statements on-line at any time on the WIC Banking website at www.wicbanking.com by entering their personal User ID and Password.

User ID and Passwords will be provided by Georgia WIC once the ACH enrollment form has been completed and forwarded to the WIC data processing contractor indicated on the form. Users are urged to change their password when entering the system for the first time. Assistance with changing passwords may be obtained from Georgia WIC, Systems Information Unit at 404-6572900 or toll free at 1-800-228-9173.

Return Food Instrument Payment Procedure

x If the purchase price on a food instrument exceeds the maximum allowable price for the food instrument, it will be returned from the bank and stamped "Amount Exceeds Limit Paid via ACH Do Not Resubmit". The food instrument will be paid at a rate equal to the average redeemed price for that food instrument code for the vendor's peer group.
x Food instruments returned by the vendor's bank stamped "invalid vendor stamp," "unreadable vendor stamp," "missing vendor stamp," or "encoding error" should be corrected and resubmitted for payment through the vendor's bank of deposit. Once a submitted food instrument has been rejected for any of the above reasons, the vendor has 45 days to resubmit the food instrument before it will be considered stale and unredeemable.
x If the redeposit is unsuccessful, or for food instruments returned by the vendor's bank for reasons other than those listed above, send the returned food instruments along with an explanation of why they were returned to Georgia WIC, Vendor Management Unit, 2 Peachtree Street, Suite 10-476, Atlanta, Georgia, 30303, for review and payment consideration.
x Food Instrument returned by the vendor's bank stamped "stale date," "post date" "altered" or "signature missing will not be paid.

Redemption Assessment

Any vendor with less than $2,000 in annual WIC redemption will be terminated from the program for a period of one year. Food Instrument redemption data on all vendors will be reviewed on a monthly basis. A vendor must remain price-competitive throughout the agreement period. Noncompetitive pricing occurs when the amount paid per food instrument by Georgia WIC to a vendor for a month's payment for all food instruments except cash value food instruments, exempt infant formulas, and medical foods exceeds the statewide average amount paid per food instrument

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redeemed within the peer group by more than 50%. If a vendor is found to be non-competitive during an assessment, the vendor will receive written notice. If the vendor is identified as noncompetitive for three additional assessments, the vendor agreement will be terminated for a period of twelve months.

USDA's Rule on Vendor Cost Containment

The dollar amount that a store will be paid for each WIC food instrument will be calculated pursuant to the terms and conditions prescribed and approved by USDA. (See USDA website at http://www.fns.usda.gov/wic/regspublished/vendorccinterim.pdf). Food Instruments that are deposited in the vendor's bank, and that contain a dollar amount in the "pay exactly box" that exceeds the statewide and/or peer group Maximum Allowable Reimbursement Level (MARL) will be returned by the bank.
By June 30 of each year, Georgia WIC will conduct an annual assessment of each current vendor to determine if they derive more than fifty percent of their food revenue from WIC food instruments. New vendors will be assessed six months after enrollment to determine if they derive more than fifty percent of their food revenue from WIC food instruments.
Georgia WIC uses vendor reported shelf prices to determine the Maximum Allowable Prices for food items and the Maximum Allowable Reimbursable Limit for food instruments redeemed monthly. Food instruments submitted by vendors in peer groups A through F are paid according to the MARL for their peer group. The WIC vendor agrees to accept an adjustment in the dollar amount written in the `pay exactly' box of the WIC food instrument if the dollar amount exceeds the statewide average and/or peer group MARL. Vendors who exceed the MARL will be paid based upon the average shelf price, which will be based on the average shelf prices for all comparable stores in the same peer group and/or the statewide average for a given time period. Above 50% vendors will be paid the statewide average across peer groups A through F.

Important Notes About The Vendor Stamp

x Lost, stolen, or damaged stamps must be reported to Georgia WIC immediately. x The vendor stamp must be kept in a secure location at all times. x Vendors are NOT permitted to reproduce the vendor stamp. Vendors who redeem food
instruments stamped with a reproduced stamp may be subject to investigation for fraud and a claim for restitution. x Vendors will be held responsible for the unauthorized use of the vendor stamp by their paid or unpaid owners, officers, managers, agents, and employees. x If the inkpad dries out, it is the vendor's responsibility to replenish the removable pad. Use only black liquid ink that is specifically designed for stamping mechanisms. x The vendor stamp is not transferable to another location or individual. x Food instruments stamped with an unauthorized vendor stamp will not be paid.

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CHANGES IN VENDOR INFORMATION
Any changes to the information provided on the vendor application must be communicated to Georgia WIC. Georgia WIC requires the vendor to provide advance written notice of any changes in vendor information including ownership, store location or cessation of operations.
Changes in Store Location or Information
The vendor must provide Georgia WIC with at least twenty-one days advance written notice of any changes in location or other information including, but not limited to, the name of store and telephone number. Each store is authorized based on the ownership and street address that exists at the time of authorization, and authorization is not transferable to another location. Therefore, if a change in location is ten 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 miles from the original store location, the vendor must only complete and submit an updated application or corporate attachment form.
If Georgia WIC discovers that a change in location has occurred before notice is received, then the vendor authorization number will be immediately terminated. All food instruments submitted for payment will be returned unpaid and Georgia WIC will establish a claim for reimbursement of redemptions.
Changes in Ownership and Cessation of Operation
The vendor must provide Georgia WIC with at least twenty-one days advance written notice of any change in ownership or cessation of business and the effective date. Georgia WIC will acknowledge the receipt of this information. Upon the effective date, the vendor authorization number will be terminated. Any food instruments 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.
If Georgia WIC discovers that a change in ownership has occurred before notice is received, then the vendor authorization number will be immediately terminated. All food instruments submitted for payment will be returned unpaid and Georgia WIC will establish a claim for reimbursement of redemptions.
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 be considered for authorization as a WIC vendor. If the new owner submits a Vendor Application, then the new owner will be required to provide proof of purchase of the store from the previous WIC vendor.
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If a vendor is disqualified from Georgia WIC, the vendor shall not continue operating as a Georgia WIC vendor by selling, assigning or otherwise transferring ownership to the vendor's partners, members, owners, officers, directors, employees, relatives by blood or marriage, heirs or assigns. Similarly, upon or after the assessment of a sanction, the vendor may not withdraw from the program, close the store or transfer ownership of the store to the vendor's partners, members, owners, officers, directors, employees, relatives by blood or marriage, heirs or assigns. Failure to abide by this provision may subject the vendor to civil liability, fines, and penalties.
Reporting and Changing Shelf Prices
Each vendor is required to submit the shelf prices for WIC food items carried in each store. Georgia WIC collects mandatory shelf prices quarterly, but reserves the right to collect shelf prices outside of that time frame at its discretion. Georgia WIC may request shelf prices for as many or as few items as it desires. Should an authorized Georgia WIC vendor change prices subsequent to authorization, the vendor is requested to inform Georgia WIC of such changes within forty-eight hours of implementing the new prices. The vendor should make the changes at https://sendss.state.ga.us/wicpricing. To access the database, please use the password provided in the notice for shelf price collection. In the event the vendor fails to update Georgia WIC of such changes, WIC may rely on the latest submission of shelf prices by the vendor in determining its current shelf prices. Collection of shelf prices is neither approval nor denial by Georgia WIC of the actual shelf prices that the vendor charges WIC participants.

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PERFORMANCE COMPLIANCE

A vendor is subject to compliance performance activities. Any violations that are found may result in sanctions (See Sanction System). Compliance with Georgia WIC policies and procedures is determined using the following methods:
1. Covert (undercover) compliance investigations
2. Overt unannounced monitoring visits
3. Inventory audits
4. Research of programmatic reports and database

Covert Compliance Investigation

Vendors will not receive prior notice when a covert investigation has been scheduled. A vendor will not be advised of any violation that is discovered while the investigation is ongoing unless the violation requires proof of a pattern. In such cases, the vendor will receive written notice of the violation prior to documenting a second violation, unless Georgia WIC determines that notifying the vendor would compromise the investigation.
Vendors will receive notification of all results including violations after the investigation is considered closed by the WIC Program representatives.
Vendors may be identified for covert compliance investigations via:
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; or
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 must be available for review by the representative of the agency upon request.

Audits

Georgia WIC may conduct record or inventory 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 WIC customers the quantities specified on food instruments redeemed by the vendor during a given period of time.

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Purchase invoices should reflect the name and address of the wholesaler or supplier, date of the purchase, list of the items purchased, size, stock number, quantity, unit price and total dollar amount for the quantity purchased. Itemized cash receipts must include the name and address of the store or a code number by which the store can be identified, the date of purchase, description of the items purchased, unit price and total purchase price. Itemized cash receipts that do not completely describe the item should have a computer code that can be verified by calling the store manager. Affidavits or oral statements are not acceptable as proof of inventory. During an audit, the vendor must supply Georgia WIC or its representative with documentation of pertinent records upon request. Vendors must retain copies of all invoices relating to the purchase of WIC food items for the three previous years plus the current year.

Programmatic Reports and Database

The WIC Program will review 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 the vendor to provide an opportunity to reimburse Georgia WIC for the excess amount charged. Failure to repay will result in a program sanction (see "Sanction System").
Programmatic reports will also be generated to determine if a pharmacy vendor is accepting food instruments other than those for exempt or special infant formulas, including medical foods. Failure to comply shall result in termination of the vendor agreement for cause.
Programmatic reports, such as the Vendor Profile report, also will be generated. 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.

High Risk Identification

Georgia WIC must identify high-risk vendors at least once a year using criteria developed by the USDA or other criteria developed by Georgia WIC. Compliance investigations will be conducted on vendors identified as high-risk. Vendors found to be high-risk may receive notice indicating that they qualify as high-risk.

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TERMINATION OF THE VENDOR AGREEMENT

Summary Termination
Georgia WIC will immediately terminate this agreement if it determines that the vendor provided false information or made a material omission in connection with its application for authorization or re-authorization.
Termination upon Notice
Georgia WIC may terminate the vendor agreement for cause after providing at least fifteen days advance written notice. Use of the vendor stamp shall be discontinued fifteen days after the date of the termination notice. Any vouchers submitted for payment after fifteen days of the date of the termination notice will not be paid. All terminations shall remain in effect during the administrative review process. Reasons for termination may include, but are not limited to, the following:
1. Voluntary withdrawal from the WIC program.
2. The decision to sell the store.
3. Civil Money Penalty imposed by SNAP in lieu of disqualification.
4. Use of the WIC acronym, WIC logo, or close facsimiles thereof, in total or in part, in a manner that violates the provisions of this vendor handbook.
5. Accepting food instruments through the mail or mailing any approved formula/medical foods directly to the WIC customer.
6. Failure to complete and submit documentation for annual training by the deadline specified by Georgia WIC.
7. Failure to provide Georgia WIC with written notice of a change in the vendor's business within at least twenty-one days in advance of the change (including but is not limited to a change in ownership, name, location, corporate structure, sale or transfer of the business, or cessation of operation.)
8. Two failed attempts by Georgia WIC to contact the vendor during business hours at the vendor's reported address and telephone number.
9. Determination that the vendor's SNAP license is invalid or not current.
10. Intentionally providing false information or vendor records, other than information or records provided in connection with a vendor application for authorization or reauthorization.

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11. Failure to provide food instruments, inventory records, food sales or tax information upon request.

12. Failure to allow monitoring by WIC representatives, or harassing or threatening any WIC representative.

13. Forging a participant's signature on a WIC food instrument.

14. Reproducing the WIC vendor stamp.

15. Identification by Georgia WIC of a conflict of interest as defined by applicable state laws, regulations, and policies, between the vendor and Georgia WIC or its local agencies.

16. Failure to enroll in ACH within the time specified.

17. Four failed assessments for non-competitive prices within a 12-month period or less.

18. Providing prohibited incentive items as part of a WIC transaction, in a manner that violates the provisions of this handbook.

19. Failure to meet the selection criteria (see pages 4-7) in effect at the time of assessment at any time throughout the agreement period.

20. Less than $2,000 in annual WIC redemptions or not redeeming any WIC food instruments in sixty days.

21. Violation of any federal or state law or regulation, or terms of the WIC Vendor Agreement or Vendor Handbook not otherwise covered by the sanction system.

After being terminated from the Georgia WIC Program, the vendor will not be automatically reinstated as an authorized WIC vendor. The vendor may re-apply no sooner than one year after being terminated from Georgia WIC. To re-apply, the vendor must complete the application process in its entirety.

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SANCTIONS AND THE SANCTION SYSTEM

Sanctions
Any authorized WIC vendor found to be in violation of federal regulations or Georgia WIC 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 paid or unpaid owners, officers, managers, agents or 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.
There are seven categories of sanctions: three categories of state agency sanctions and four categories of federal mandatory sanctions. State agency sanctions are established by Georgia WIC program representatives and have been approved by the United States Department of Agriculture (USDA) prior to implementation. State agency sanctions include disqualification, and civil money penalties assessed in lieu of disqualification in the event of inadequate participant access. Federal mandatory sanctions are established by the USDA. Both state agency and federal mandatory sanctions must be enforced when violations occur.
Violations are categorized by the nature and severity of the violation. Each category has a prescribed period of disqualification. Sanctions shall be assessed as follows:
1. In the event of multiple violations, the highest sanction assessed to a vendor shall determine the period of disqualification.
2. All State agency sanctions assessed are retained in the vendor's file for a period of one year and will roll off at the end of that period.
3. If both mandatory and state agency sanctions result from a single investigation, and the disqualification for a mandatory sanction is not upheld during the administrative review process, then Georgia WIC may impose the state agency sanction.
Georgia WIC will notify a vendor in writing when an investigation reveals an initial incidence of a program violation for which a pattern of incidences must be established to impose a sanction before another violation is documented, unless Georgia WIC determines that notifying the vendor would compromise an investigation.
Disqualification
A vendor will be disqualified from Georgia WIC for committing certain program violations. The actual disqualification period is determined using the same criteria for every vendor.
1. Georgia WIC will not accept voluntary withdrawal as an alternative to disqualification. 2. A vendor that has been disqualified from SNAP will be disqualified from WIC for the same
period of time. If a vendor has been assessed a CMP in lieu of disqualification for a SNAP violation, the vendor agreement will be terminated.

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3. Disqualification from the WIC Program may also result in a civil money penalty or disqualification from SNAP. Such disqualification may not be subject to administrative or judicial review under SNAP.

4. If a vendor is disqualified or assessed a civil money penalty (CMP) for a federal mandatory sanction from the WIC Program in another state (see federal mandatory sanctions on pages 35-36), the vendor will be disqualified from the Georgia WIC Program for the same period of time.

5. A vendor may be assessed (CMP) in lieu of disqualification, if the disqualification will result in inadequate participant access. Upon assessment of a CMP, the disqualification period will 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.

Effective Date of Adverse Actions

Denials of vendor authorization and permanent disqualifications are effective on the date of receipt of the notice of the adverse action, at which time the vendor stamp will be discontinued. All other adverse actions against a vendor are effective fifteen days after the date of the notice of the adverse action. For those adverse actions resulting in disqualification (other than denials of vendor authorization and permanent disqualifications), use of the vendor stamp shall be discontinued fifteen days after the date of the notice of the adverse action. Any vouchers submitted for payment after fifteen days of the date of the notice of the adverse action will not be paid. All adverse actions shall remain in effect during the administrative review process.

The Sanction System

Below is a description of the Georgia WIC sanction system and how it works. For those violations that require a pattern, a pattern is established when the same violation occurs twice. Enforcement of all sanctions is required when violations have been committed.
State Agency Sanctions

If a violation occurs in Category I, the vendor will receive written warning for the first offense. If the same violation occurs a second time, the vendor will receive another warning for the second offense. If the same violation occurs a third time, the vendor will be required to complete training. If the violation occurs again after training, the vendor will be disqualified for the time period specified for that category (six months.)
If a violation occurs in Category II, the vendor will receive written warning for the first offense. If the same violation occurs a second time, the vendor will receive another warning for the second offense. If the same violation occurs a third time, the vendor will be disqualified for the time period specified for that category (eight months.)
If a violation occurs in Category III, the vendor will receive written warning for the first offense. If the same violation occurs again after receiving the first warning, the vendor will be disqualified for the time period specified for that category (ten months).

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If a vendor receives a warning letter and desires further explanation, the vendor may call Georgia WIC and speak with the Vendor Management Unit Manager or submit a written request for further explanation to Georgia WIC.
State Agency Sanctions Category I - Disqualification for six months on fourth violation
1. Stocking one or more WIC food items outside of manufacturer's expiration date.
2. Failure to allow in-store or manufacturers' promotional or free item with a WIC purchase.
3. Failure to submit or return requested documentation, other than food instruments or inventory records, food sales, tax information, or documentation for annual training, by the stated deadline.
4. Failure to stock the required inventory of contract formula.
5. Failure to stock the required inventory of any WIC food items other than contract formula.
6. WIC redemptions in excess of SNAP redemptions.

State Agency Sanctions Category II - Disqualification for eight months on third violation 1. Allowing the purchase of WIC foods in unauthorized container sizes.

2. Requiring WIC participants to show any identification other than the WIC identification card.

3. Use of a non-approved label by a bread manufacturer in the vendor's store. State Agency Sanctions Category III - Disqualification for ten months on second violation
1. Failure to ring up a sale of WIC purchases. 2. Failure to write the price on a food instrument before the participant signs in plain sight of
the participant during the WIC transaction. 3. Refusing to accept a valid WIC food instrument from a participant. 4. Allowing the substitution of one WIC approved food item listed on the food instrument for
another WIC approved food item not listed on the food instrument. 5. Failure to repay charges within thirty days.

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6. Contacting WIC participants for any reason regarding a WIC transaction.

7. Requiring participant to pay cash to redeem WIC food instruments, except for personal payments for amounts over the maximum amount of a Cash Value/Fruit and Vegetable Food Instrument.

8. Allowing the purchase of any formula other than the one specified on the front of the food instrument.

9. Failing to provide a WIC participant with the same courtesies as other customers
10. Prices not marked clearly on or near a WIC food item.
11. Allowing WIC food items to exceed the quantity specified on the food instrument (except for manufacturers' or in-store promotional or free items that are offered to all customers.)
12. Failure to allow the purchase of any WIC food item.
13. Issuing a "rain check"/IOU for WIC approved foods.
14. Charging sales tax on a WIC food item other than on the amount that exceeds the value of the Cash Value Fruit and Vegetable Voucher.
15. Failure to provide WIC participants with a receipt.
16. Failure to check a WIC customer's WIC ID card/folder.
Federal Mandatory Sanctions
If a pattern is required but not established for a Category IV or V violation, then one occurrence of a violation during a covert compliance investigation will be treated as a Category III sanction.
If a vendor previously has been assessed a Mandatory Sanction for any of the violations carrying one, three or six year disqualifications, and receives another sanction for any of these violations, then the second sanction will be doubled. If a civil money penalty is imposed in lieu of disqualification, then the amount of that penalty will be doubled up to the maximum limits per violation.
If a vendor previously has been assessed two or more sanctions for any of the violations carrying one, three or six year disqualifications, and receives another sanction for any of these violations, then the third sanction and all subsequent sanctions will be doubled. Civil money penalties shall not be imposed in lieu of disqualification for third or subsequent sanctions.
Federal Mandatory Sanctions Category IV - Disqualification for one year

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1. A pattern of providing unauthorized food items in exchange for food instruments or cash value vouchers, including charging for supplemental foods provided in excess of those listed on the food instrument.

2. A pattern of an above-50-percent vendor providing prohibited incentive items to customers.

Federal Mandatory Sanctions Category V - Disqualification for three years

1. A pattern of receiving, transacting, or redeeming food instruments or cash-value vouchers outside of authorized channels, such as at locations different from the authorized location listed on the Vendor Agreement, or the use of an unauthorized vendor or an unauthorized person. This includes but is not limited to delivering WIC food items to WIC participants or collecting WIC food instruments prior to completing the WIC transaction.
2. A pattern of providing credit or non-food items (other than alcohol, alcoholic beverages, tobacco products, cash, firearms, ammunition, explosives or controlled substances) in exchange for WIC food instruments or cash-value vouchers.
3. A pattern of vendor overcharges.
4. A pattern of charging for supplemental food not received by the participant. This includes but is not limited to vendor representatives receiving WIC foods not received by the participants. The WIC participant does not have the authority to give WIC foods to vendor or its representatives and neither does the vendor or its representatives have the authority to accept such WIC food items.
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 providing alcohol or alcoholic beverages or tobacco products in exchange for WIC food instruments or cash-value vouchers.
Federal Mandatory Sanctions Category VI - Disqualification for six years

1. One incidence of buying or selling WIC food instruments or cash value vouchers for cash (trafficking).
2. One incidence of selling firearms, ammunition, explosives, or controlled substances, in exchange for food instruments or cash-value vouchers.
Federal Mandatory Sanctions Category VII - Permanent disqualification

1. Conviction for trafficking in food instruments or cash-value vouchers
2. Conviction for selling firearms, ammunition, explosives, or controlled substances in exchange for food instruments or cash value vouchers.

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Additional Notes on Violations

Vendors who commit fraud or abuse in the program are subject to criminal prosecution. Those who have willfully misapplied, stolen or fraudulently obtained program funds will be subject to a fine of not more than $25,000 or imprisonment for not more than five years, or both, if the value of the funds is $100 or more. If the value is less than $100, the penalties are fines of not more than $1,000 or imprisonment for not more than one year, or both. Georgia WIC will refer all criminal activity including theft and fraud to law enforcement.
When Georgia WIC determines that a vendor has committed a vendor violation that affects payment to the vendor, Georgia WIC will delay payment and establish a claim. In addition to delaying payment and asserting a claim, Georgia WIC may sanction the vendor for vendor overcharges or other errors in accordance with the sanction schedule. Payment of food instruments submitted through the banking system by the vendor will be suspended as of the date of the notice of adverse action pending review by Georgia WIC. The vendor will be instructed to submit all outstanding food instruments to Georgia WIC for review and payment consideration.

Civil Monetary Penalties (CMP)

Prior to disqualifying a vendor for any mandatory or state agency violations, Georgia WIC must determine if disqualification of the vendor will result in inadequate participant access. Inadequate participant access occurs when there is not another authorized WIC vendor within ten miles of the vendor who has committed the violation. Only when Georgia WIC determines and documents that disqualification of the vendor would result in inadequate participant access, a civil money penalty must be imposed in lieu of disqualification. CMPs will only be assessed for both state and mandatory sanctions in the event of inadequate participant access, as determined by Georgia WIC. The CMP shall not exceed $11,000 per violation, or $44,000 for multiple violations occurring during a single investigation.
CMPs must be paid within thirty days of the notice of approval. Installments may be considered up to a maximum of six months. If a vendor does not pay, partially pays, or fails to pay a CMP assessed in lieu of disqualification on time, the Georgia WIC Program will disqualify the vendor for the length of the disqualification corresponding to the to the violation for which the CMP was assessed.

CMP Methodology for State Agency Sanctions

CMPs will be assessed in lieu of disqualification for State Agency sanctions based on the chart below.

Civil Money Penalty Formula for State Agency Sanctions Based on Six Month WIC Redemption

Category
Category I Category II Category III

For $0 to $11,000 in Redemptions (CMP Base
Rate) $500 $1,000 $1,500

For Redemption Amount Above $11,000 (CMP= Base Rate + % of Total Redemption over
$11,000) $500 + 1% of redemption over $11,000 $1,000 + 2% of redemption over $11,000 $1500 + 3% of redemption over $11,000

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For State agency Sanctions, the first CMP will be reduced by fifty percent 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.
CMPs cannot exceed $11,000 per violation or $44,000 per investigation. If more than one violation is detected during a compliance investigation, a CMP must be imposed for each violation (up to the $11,000/$44,000 limits.) Only two CMPs can be assessed against a vendor. CMPs cannot be imposed in lieu of disqualification for third and subsequent sanctions in these categories.

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CMP Methodology for Mandatory Sanctions
For a violation that warrants permanent disqualification, the amount of the CMP shall be $11,000 for each violation.
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 six months ending immediately preceding the month during which the notice of the adverse action is dated.
2. Multiply the average monthly redemptions figure by ten percent. 3. Multiply the amount from step 2 above 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 $11,000 per violation. The total amount of the CMP assessed for violations that occur during a single investigation may not exceed $44,000.
If a vendor who received a Categories IV, V or VI sanction receives a second sanction in any of these categories, the second sanction must be doubled. However, CMPs can only be doubled up to the limits stated above. CMPs cannot be imposed in lieu of disqualification for third and subsequent sanctions in these categories.

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ADMINISTRATIVE REVIEW AND APPEAL PROCEDURES

A vendor may appeal certain adverse action(s) imposed by Georgia WIC. Adverse actions a vendor may appeal, as well as Georgia WIC's administrative review procedures are detailed below. Vendors are required to adhere to these procedures if requesting review of an adverse action.
If reimbursement is owed to Georgia WIC by the vendor as a result of the adverse action being affirmed after administrative review, neither the vendor nor its affiliates shall be eligible to participate as an authorized WIC vendor until the reimbursement is paid in full. The vendor may not circumvent reimbursement by selling or otherwise making any changes or amendments to its corporate structure that was in place since the time of its initial authorization.

Procedures for Vendor Administrative Review, Hearings and Appeals
(1) Effective Date of Adverse Actions Unless a later date is specified in the notice of adverse action against a vendor by the State agency, all adverse actions (except denials of vendor authorization and permanent disqualifications which are effective on the date of receipt of the notice) shall be effective fifteen days after the date of the notice of the adverse action. All adverse actions shall remain in effect during the administrative appeal process.
(2) Full Administrative Review
(a) The following adverse actions shall be subject to full administrative review upon timely request by the vendor:
(i) denial of authorization based on the application of the vendor selection criteria for minimum variety and quantity of authorized supplemental foods, or on a determination that the vendor is operating a store sold by its previous owner in an attempt to circumvent a sanction, as stated in 7 C.F.R. 246.12(g)(7) ;
(ii) termination of an agreement for cause;
(iii) disqualification; and
(iv) imposition of a fine or a civil money penalty in lieu of disqualification.
(b) These procedures shall be followed in cases meriting full administrative review:
(i) The State agency shall give written notice to the vendor of the adverse action, the procedures to follow to obtain full administrative review, the causes for and the effective date of the action. When a vendor is disqualified due in whole or in part for any of the violations listed in 7 C.F.R 246.12(l)(1), the notice shall include the following statement: "This disqualification from WIC may result in disqualification as a retailer in SNAP. Such disqualification is not subject to administrative or judicial review under SNAP."

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(ii) A vendor seeking review must send a written request for review to the Commissioner of the State agency within fifteen days from the date of the notice of adverse action, with a copy of the decision to be reviewed;

(iii) Upon receiving a timely request for review, the Commissioner shall refer the case to the Office of State Administrative Hearings (OSAH) for initial decision.

(iv) The hearing before OSAH shall be conducted in accordance with the Georgia Administrative Procedures Act and the rules of OSAH. In addition, the Administrative Law Judge (ALJ) shall ensure that the vendor is given:

(A) Adequate advance notice of the time and place of the administrative

review to provide all parties involved sufficient time to prepare for the

review;

(B) The opportunity to present its case and at least one opportunity to

reschedule the administrative review date upon specific request;

(C) The opportunity to cross-examine adverse witnesses. When necessary to

protect the identity of WIC Program investigators, such examination may be

conducted behind a protective screen or other device to conceal the

investigator's

face

and

body;

(D) The opportunity to be represented by counsel; and

(E) The opportunity to examine prior to the hearing the evidence upon which

the State agency's action is based.

(v) The ALJ's determination shall be based solely on whether the State agency has correctly applied Federal and State statutes, regulations, policies, and procedures governing the WIC Program, according to the evidence presented at the review.

(vi) The Commissioner shall appoint an attorney from the Office of General Counsel as a reviewing official to review the ALJ's initial decision at the request of either party within ten days of the date of the ALJ's initial decision, to ensure that it conforms to approved policies and procedures, and to render the final agency decision in accordance with O.C.G.A. 50-13-41. If neither party requests that the ALJ's decision be reviewed, then the ALJ's decision shall become the final agency decision thirty days after it was entered.

(vii) When the ALJ's decision is reviewed at the request of either party, the reviewing official shall provide written notification of the final agency decision, including the basis for the decision, and the vendor's right to seek judicial review pursuant to O.C.G.A. 50-13-19, within the time period prescribed by O.C.G.A. 50-13-41. If the adverse action under review has not already taken effect, the review official's decision shall be effective on the date of receipt by the vendor.

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(3) Abbreviated Administrative Review

(a) The following adverse actions shall be subject to abbreviated administrative review upon timely request by the vendor:
(i) denial of authorization based on the vendor selection criteria for business integrity or for a current SNAP disqualification or civil money penalty for hardship;
(ii) denial of authorization based on the application of the vendor selection criteria for competitive price;
(iii) the application of the State agency's vendor peer group criteria and the criteria used to identify vendors that are above-50-percent vendors or comparable to above-50-percent vendors;
(iv) denial of authorization based on a State agency-established vendor selection criterion if the basis of the denial is a WIC vendor sanction or a SNAP withdrawal of authorization or disqualification;
(v) denial of authorization based on the State agency's vendor limiting criteria;
(vi) denial of authorization because a vendor submitted its application outside the timeframes during which applications are being accepted and processed as established by the State agency;
(vii) termination of an agreement because of a change in ownership or location or cessation of operations;
(viii) disqualification based on a trafficking conviction;
(ix) disqualification based on the imposition of a SNAP civil money penalty for hardship;
(x) disqualification or a civil money penalty imposed in lieu of disqualification based on a mandatory sanction imposed by another WIC State agency;
(xi) a civil money penalty imposed in lieu of disqualification based on a SNAP disqualification; and
(xii) denial of an application based on a determination of whether an applicant vendor is currently authorized by SNAP.

(b) These procedures shall be followed in cases meriting abbreviated administrative review:

(i) The State agency shall give written notice to the vendor of the adverse action, the procedures to follow to obtain an abbreviated administrative review, the causes for and the effective date of the action;
(ii) A vendor seeking review must send a written request for review to the Commissioner of the State agency within fifteen days from the date of the notice of adverse action, with a copy of the decision to be reviewed and any

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documents, argument, or information that the vendor contends would justify reversal; (iii) Upon receiving a timely request for review, the Commissioner shall appoint a decision-maker who is someone other than the person who rendered the initial decision on the action to review the information provided to the vendor concerning the causes for the adverse action and the vendor's response, and to make a determination based solely on whether the State agency has correctly applied Federal and State statutes, regulations, policies, and procedures governing the Program; (iv) The decision-maker shall provide written notification of the final agency decision, including the basis for the decision, and the vendor's right to seek judicial review pursuant to O.C.G.A. 50-13-19, within 90 days of the date of receipt of the request for an administrative review. If the adverse action under review has not already taken effect, the decision-maker's ruling shall be effective on the date of receipt by the vendor.

(4) Actions not Subject to Administrative Review
The following adverse actions are not subject to administrative review: (a) The validity or appropriateness of the State agency's vendor limiting criteria or
vendor selection criteria for minimum variety and quantity of supplemental foods, business integrity, and current SNAP disqualification or civil money penalty for hardship; (b) The validity or appropriateness of the State agency's selection criteria for competitive price, including, but not limited to, vendor peer group criteria and the criteria used to identify vendors that are above-50-percent vendors or comparable to above-50-percent vendors; (c) The validity or appropriateness of the State agency's participant access criteria and the State agency's participant access determinations; (d) The State agency's determination to include or exclude an infant formula manufacturer, wholesaler, distributor, or retailer from the list required pursuant to 246.12(g)(11); (e) The validity or appropriateness of the State agency's prohibition of incentive items and the State agency's denial of an above-50-percent vendor's request to provide an incentive item to customers pursuant to 246.12(h)(8); (f) The State agency's determination whether to notify a vendor in writing when an investigation reveals an initial violation for which a pattern of violations must be established in order to impose a sanction, pursuant to 246.12(l)(3); (g) The State agency's determination whether a vendor had an effective policy and 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; (h) Denial of authorization if the State agency's vendor authorization is subject to the procurement procedures applicable to the State agency; (i) The expiration of a vendor's agreement; (j) Disputes regarding food instrument or cash-value voucher payments and vendor claims (other than the opportunity to justify or correct a vendor overcharge or other error, as permitted by 246.12(k)(3); and (k) Disqualification of a vendor as a result of disqualification from SNAP.

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WHERE TO GET MORE INFORMATION
Georgia WIC 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 4:30 PM Eastern Standard Time (EST). After 4:30 PM and during periods of high volume calling, please leave a voice message.
Georgia WIC Vendor Management Unit 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)
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.
To file a complaint of discrimination, write, U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington D.C. 20250-9410 or call toll free (866) 632-9992 (Voice) or (202) 260-1026 (local).
TTY users can contact USDA through local relay or the Federal Relay at (800) 877-8339 (TTY) or (866) 377-8642 (relay voice users). USDA is an equal opportunity provider and employer.

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Attachment VM-3 (cont'd)

GLOSSARY

Above-50 percent vendors A vendor that derives more than fifty percent of its annual food sales revenue from WIC food instruments, and new vendor applicants expected to meet this criterion under guidelines approved by FNS. New vendors will be assessed within six months of authorization, and all vendors will be assessed annually to determine if they are an above-50% vendor.
Automatic Clearing House (ACH) An electronic funds transfer network which enables participating financial institutions to distribute electronic credit and debit entries to bank accounts and to settle such entries.
Administrative Review A review process offered to vendors attempting to challenge decisions made by the program. Such decisions include, but are not limited to, denial of authorization, disqualification, and termination of the vendor agreement.
Affiliates Any partner, member, owner, officer, director, employee, relative by blood or marriage, heirs, or assigns.
Annual Training A yearly mandatory training session for all vendors to receive program updates and reminders, and to ensure their understanding of program updates and reminders.
Authorized Supplemental Foods Those supplemental foods authorized by Georgia WIC for issuance to a particular participant.
Cash-Value/Fruit and Vegetable Voucher (CVV) A fixed-dollar amount check, voucher, electronic benefit transfer (EBT) card or other document which is used by a participant to obtain authorized fruits and vegetables.
Civil Money Penalty A monetary penalty that can be assessed in lieu of a sanction.
Contracted Brand Infant Formula All infant formulas (except EXEMPT INFANT FORMULAS) produced by the manufacturer awarded the infant formula cost containment contract.
Corporate Vendor A WIC authorized vendor that has the more than one store with the same FEIN. The term does not mean that the vendor is an incorporated entity.
Covert Compliance Investigation or Compliance Buy An undercover, onsite investigation in which a representative of the WIC Program poses as a participant, parent, or caretaker of an infant or child participant, or proxy, transacts one or more food instruments, and does not reveal during the visit that he or she is a program representative.
Customized Training Training that vendors can request to suit their specific training needs.
Days Calendar days, unless otherwise noted.
Delivery The act of transferring a product from a seller to its buyer outside the confines of the retail food establishment.

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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 (e.g. termination of vendors from Georgia WIC for program violations.)
Documentation The presentation of written documents which substantiate statements made by a WIC applicant or participant or a person applying on behalf of an applicant.
Exempt Infant Formula An infant formula that meets the requirements for an exempt infant formula under section 412(h) of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 350a(h)) and the regulations at 21 C.F.R. parts 106 and 107.
Federal Mandatory Vendor Sanction A sanction required by federal law for a vendor's violation of the WIC Vendor Agreement or the laws, regulations, rules, and policies governing the WIC program, imposed pursuant to 7 C.F.R. 246.12(l) (1).
First date of use The first date on which the food instrument may be used to obtain supplemental foods.
Food Instrument A voucher, check, electronic benefits transfer (EBT) card, coupon or other document which is used by a participant to obtain supplemental foods.
Food Sales Sales of all Supplemental Nutrition Assistance Program (SNAP) - eligible foods intended for home preparation and consumption, including meat, fish, and poultry; bread and cereal products; dairy products; fruits and vegetables. Food items such as condiments and spices, coffee, tea, cocoa, and carbonated and noncarbonated drinks may be included in food sales when offered for sale along with foods in the categories identified above. Food sales do not include sales of any items that cannot be purchased with SNAP benefits, such as hot foods or food that will be eaten in the store.
Food Sales Establishment License A license granted by the Georgia Department of Agriculture which permits the retail food vendor to sell food items.
High-Risk Vendor A vendor identified as having a high probability of committing a vendor violation through application of the criteria established in 246.12(j)(3) and any additional criteria established by Georgia WIC.
Inadequate Participant Access Not another WIC authorized vendor within ten miles of another WIC authorized vendor.
Inventory Supplemental foods in stock, received, and issued.
Inventory audit 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 the quantities specified on food instruments redeemed by the vendor during a given period of time.
Last Date of Use The last date on which the food instrument may be used to obtain authorized supplemental foods.

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Minimum Inventory Required inventory that all vendors must carry everyday at all times, including, but not limited to, fruits and vegetables, and whole grains. Pharmacies are exempt from keeping minimum inventory.

Non-Contract Brand Infant Formula All infant formula, including exempt infant formula, that is not covered by an infant formula cost containment contract awarded by that State agency.

Non-Corporate Vendor A WIC authorized vendor that has only one store or a vendor with more than one store, each with a different FEIN. The term does not mean that the vendor is not an incorporated entity.

Non-WIC Inventory Food items that are not a part of the WIC minimum inventory or the WIC Approved Foods List.

Participants Persons who are receiving supplemental foods or food instruments under the WIC Program, such as pregnant women, breastfeeding women, postpartum women, infants and children, and the breastfed infants of participant breastfeeding women.

Pharmacy Vendor A WIC authorized vendor that is allowed to only redeem vouchers for exempt and special infant formulas, including medical foods. No contract formula or other standard WIC food sales are allowed for these vendors.

Pre Approval Visit An on-site visit to a vendor's retail food establishment to verify location, inventory, and all other information submitted on the vendor application.

Price Adjustment An adjustment made by Georgia WIC, in accordance with the vendor agreement, to the purchase price on a food instrument after it has been submitted by a vendor for redemption to ensure that the payment to the vendor for the food instrument complies with Georgia WIC's price limitations.

Proxy Any person designated by a woman WIC participant, or by a parent or caretaker of an infant or child WIC participant, to obtain and transact food instruments or to obtain supplemental foods on behalf of a WIC participant.

Purchase price A space for the purchase price to be entered on the WIC food instrument.

Offense or Violation An act against the programs rules, regulation, policies or procedure.

Routine Monitoring Overt, on-site monitoring during which program representatives identify themselves to vendor personnel.

Redemption The act of cashing the WIC voucher according to WIC banking standards.

Redemption period The date by which the vendor must submit the food instrument for redemption. This date must be no more than sixty days from the first date on which the food instrument may be used.

Sanction A penalty that is imposed when WIC program rules, regulations, policies or procedures are violated.

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Sign or Signature A handwritten signature on paper or an electronic signature.
State agency The health department or comparable agency of each state. In this instance, the Georgia Department of Public Health, Maternal and Child Health Program, Office of Nutrition and WIC.
Supplemental Nutrition Assistance Program (SNAP) SNAP is the new name for the federal Food Stamp Program.
Termination Discontinuance of vendor participation in the Georgia WIC program.
Vendor A sole proprietorship, partnership, cooperative association, corporation, or other business entity operating one or more stores authorized by Georgia WIC to provide authorized supplemental foods to participants under a retail food delivery system. Each store operated by a business entity is considered to be a separate vendor and must be authorized separately from other stores operated by the business entity. Each store must have a single, fixed location. Mobile stores are authorized in Georgia only when necessary to meet the special needs described in the Georgia WIC State Plan in accordance with 246.4(a)(14)(xiv).
Vendor Authorization The process by which Georgia WIC assesses, selects, and enters into agreements with stores that apply or subsequently reapply to be authorized as vendors.
Vendor Number A unique four digit number that is used to identify each vendor authorized to provide WIC food items. Redemption activity must be identified by the vendor that submitted the food instrument, using the vendor number. Each vendor operated by a single business entity must be identified separately.
Vendor Peer Group System A classification of authorized vendors into groups based on common characteristics or criteria that affect food prices, for the purpose of applying appropriate competitive price criteria to vendors at authorization and limiting payments for food to competitive levels.
Vendor Overcharge Intentionally or unintentionally charging Georgia WIC more for authorized supplemental foods than is permitted under the vendor agreement. It is not a vendor overcharge when a vendor submits a food instrument for redemption and Georgia WIC makes a price adjustment to the food instrument.
Vendor Selection Criteria The criteria established by Georgia WIC to select individual vendors for authorization consistent with the requirements in 246.12(g)(3) and (g)(4).
Vendor Training The procedures Georgia WIC will use to train vendors in accordance with 7 C.F.R 246.12(i). Georgia WIC will provide training annually to at least one representative from each vendor. Vendor Applicants will receive training at the time of authorization. Participating Vendors will receive re-authorization training at least once every three years in an interactive format.
Vendor Violation Any intentional or unintentional action of a vendor's paid or unpaid owners, officers, managers, agents, or employees (with or without the knowledge of management) that

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violates the vendor agreement or Federal or State statutes, regulations, policies, or procedures governing the Program.

WIC The Special Supplemental Nutrition Program for Women, Infants and Children (WIC) authorized by section 17 of the Child Nutrition Act of 1966, as amended (42 U.S.C. 1786).

WIC-eligible medical foods Certain enteral products that are specifically formulated to provide nutritional support for individuals with a qualifying condition, when the use of conventional foods is precluded, restricted, or inadequate. Such WIC eligible medical foods must serve the purpose of a food, meal or diet (may be nutritionally complete or incomplete) and provide a source of calories and one or more nutrients; be designed for enteral digestion via an oral or tube feeding; and may not be a conventional food , drug, flavoring, or enzyme. WIC eligible medical foods include many, but not all, products that meet the definition of medical food in Section 5 (b)(3) of the Orphan Drug Act (21 U.S.C 360ee(b)(3)).

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GEORGIA

Attachment VM-4

Full Legal Name of Store or Corporation
Doing Business As (If applicable)
Street Address
Store location or corporate home office
City
Business Telephone
Mailing Address
(If different from above)

(Area Code)

State
Number

City
Email Address
Fax Number
Federal Employer Identification Number
Registered Agent
(If applicable)
Mailing Address

State

City

State

NOTE: All communications, i.e. disqualifications, sanctions, addendums, annual training, etc. will be mailed to all listed addresses

DO NOT WRITE BELOW THIS LINE
GEORGIA'S WIC USE ONLY
WIC VENDOR AGREEMENT WIC VENDOR NUMBER
(Non-corporate vendors only)

Zip County
Zip
Zip

This Agreement is by and between the Georgia Special Supplemental Nutrition Program for Women, Infant and Children ("Georgia WIC " or the "Program") having a mailing address of Two Peachtree Street NW, Suite 10-476, Atlanta, Georgia, 30303-3142, and the above-named business entity ("the Vendor"). This agreement is effective for the period beginning ______________________________ and ending September 30, 2013.
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Attachment VM-4 (cont'd)

I.

PURPOSE

The purpose of this agreement is to establish the terms and conditions for an authorized vendor to sell prescribed supplemental foods under the Georgia WIC program, in accordance with federal and state laws and regulations.

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. Military commissaries and pharmacies do not have to be licensed by the Georgia Department of Agriculture.

B. An eligible vendor is a business entity that is 1) registered and licensed by the United States Department of Agriculture Food & Nutrition Service as a retail participant in the Supplemental Nutrition Assistance Program or SNAP (formally the Food Stamp Program) and 2) is in good standing without debarment or suspension from the United States Department of Agriculture or the SNAP program. Military commissaries and pharmacies do not have to be SNAP participants.
C. An eligible vendor must have a fixed location with an official physical address.
D. For corporate vendors owning two (2) or more locations, the requested information for each location must be listed on the Corporate Attachment (Form 3771A) and made part of the agreement. The corporate attachment form is an addendum to the corporate vendor agreement. The attachment form serves as verification that the location listed is the authorized location at which WIC vouchers are to be redeemed. Vendors are not permitted to redeem vouchers in a location other than the authorized location listed in the vendor agreement or corporate attachment.

E. An eligible vendor must meet all requirements as described in the most recent version of the Georgia WIC Vendor Handbook and all addendums.
F. The vendor must comply with the selection criteria (including any changes to those criteria, throughout the agreement period. Georgia WIC may reassess any authorized vendor at any time during the vendor agreement period using the current vendor selection criteria, and will terminate the agreement if the vendor fails to meet those criteria.
G. A vendor authorized as a military commissary, pharmacy or corporate vendor will be given certain exceptions to this agreement. The exceptions are outlined in this Agreement and the Georgia WIC Vendor Handbook.

III. RESPONSIBILITIES VENDOR
The Vendor agrees to comply with the provisions of this agreement and all federal and state laws, policies, procedures, rules and regulations, including

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those contained in the most recent publication of the Vendor Handbook and

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 Georgia WIC during the agreement period. This

Agreement will be interpreted according to 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, including any vendor violations committed by such persons.
2. To abide by the rules, policies and procedures as outlined in the most recent publication of Georgia WIC Vendor Handbook and all addendums, and all federal and state laws and regulations.
3. To not solicit the WIC customer on the premises of WIC clinics. 4. To only purchase infant formula, that will be redeemed for WIC
vouchers, from the Approved Infant Formula Supplier list. If a supplier is not listed, a vendor may call 866-814-5468 or 404-657-2900 to inquire about adding that supplier to the list. The vendor must ensure that the requested supplier has been authorized by Georgia WIC, prior to purchasing any infant formula from that supplier. Records of the infant formula purchase must be maintained according to Section III.J.3 of this Agreement. 5. To submit total food sales and gross sales revenue records, and any other records needed to validate total food sales and gross sales, as requested by Georgia WIC, and to complete and submit upon request, the specified Sales and Use Tax Report Form ST-3 for Georgia WIC vendors. 6. To not use the WIC acronym, the WIC logo or close facsimiles thereof, in total or in part, either in the official name in which the vendor is registered or under the name in which it does business; or in any unauthorized manner on packages, product labels, proprietary materials including pamphlets and brochures, or in any form of marketing, promotional material or advertisement of the store. 7. To carry a substantial amount of non-WIC food inventory at all times. The vendor must carry the minimum amount of items in each category as specified in the Vendor Handbook. 8. To comply with the vendor selection criteria throughout the agreement period, including any changes to the criteria. 9. To not offer, advertise, promise or indicate an intention to provide incentives to WIC participants. Vendors who use advertisements or incentives to solicit the business of WIC participants, or offer incentives or delivery services will be subject to sanctions as explained in this Vendor Agreement and the Vendor Handbook. Incentives include but are not limited to free or complimentary gifts, home delivery of foods, store memberships, and free or discounted services. 10. To prominently display in plain sight the poster provided by Georgia WIC indicating that the store welcomes or accepts WIC.

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B. VENDOR TRAINING

Attachment VM-4 (cont'd)

Prior to accepting WIC vouchers, the vendor or his authorized representative must receive interactive authorized training. The vendor must also participate in annual training on changes and updates on Georgia WIC policies and procedures. Georgia WIC will provide the date, time and location of the training, and will provide vendors with at least one alternative date on which to attend interactive training. The vendor may submit a written request for Georgia WIC to provide subsequent customized training to store personnel at any time after both parties have signed the agreement.

The vendor agrees and covenants:
1. To participate in all required training, including annual training. 2. To provide training on the requirements of the WIC program to paid
and unpaid employees, agents and all personnel involved in WIC transactions. 3. To not participate in Georgia WIC until Authorized Training has been completed and a vendor stamp has been issued. 4. To not participate in Georgia WIC until the vendor has received a passing score of eighty points or higher on the Post Vendor Training Evaluation. 5. For vendors with multiple locations that have separately been authorized to participate in the WIC program, to provide documentation that a management representative(s) from each authorized store location has been trained on the required topics as listed on the Corporate Vendor Training Checklist (Form 3757A), (Corporate vendors only).

C. NO SUBSTITUTIONS, CASH, REFUNDS, OR EXCHANGES
The vendor agrees and covenants:
1. To only charge for authorized supplemental foods selected by the WIC customer as listed on the food instrument or cash value/fruit and vegetable voucher, and not charge for WIC approved items that are not received by the WIC customer.
2. To not provide unauthorized food items, non-food items, cash or credit (including rain checks) in exchange for food instruments or cash value/fruit and vegetable vouchers.
3. To not provide refunds or permit exchanges for authorized supplemental foods obtained with food instruments or cash-value vouchers, except for exchanges of the same brand and size when the original authorized supplemental food item is defective, spoiled, recalled or has exceeded its "sell by" or "best if used by" or other date limiting the sale or use of the food item.
4. To provide only the authorized infant formula which the vendor has obtained pursuant to paragraph III A (4) of this agreement, to participants in exchange for food instruments for infant formula.

D. FOOD VOUCHER TRANSACTIONS The vendor agrees and covenants:

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1. To accept food instruments and cash-value vouchers only from WIC

participants, parents or caretakers of infants and child participants or

proxies (the "WIC customer).

2. To ensure that WIC food instrument transactions are processed in
accordance with the procedures set forth in the most recent

publication of the Georgia WIC Vendor Handbook and all addendums.

3. To not demand that a WIC customer purchase every eligible WIC food

item listed on the voucher.

4. To allow WIC customers the right to purchase the eligible foods of

their choice as listed on the WIC food instrument, cash value voucher

and the approved food list.

5. To ensure that the purchase price is entered on food instruments and

cash-value vouchers in accordance with the procedures governing the

processing of WIC food instruments in the most recent publication of

the Vendor Handbook. The purchase price must include only the

authorized supplemental food items actually provided and must be

entered on the food instrument or cash-value voucher in plain sight of

the WIC customer during the WIC transaction.

6. To ensure that the WIC customer signs the food instrument or cash-

value voucher in the presence of the cashier.

7. To only allow the purchase of supplemental foods listed on the food

instrument and cash value/fruit and vegetable voucher.

8. To offer the WIC customer the same courtesies offered to all other

customers.

9. To ensure that all information including the identity of the WIC

customer is kept confidential, in accordance with federal and state law

and regulation.

10. To ensure that Georgia WIC is not being charged for foods not

received by the participant.

11. To not charge the WIC customer for authorized supplemental foods

obtained with food instruments or cash-value vouchers.

12. To not contact or seek restitution from the WIC customer for WIC food

vouchers not paid or partially paid by Georgia WIC.

13. To not request cash from the WIC customer for any WIC transaction

except for transactions involving the cash value/fruit and vegetable vouchers, for which the total amount of the transaction exceeds the

amount on the voucher.

14. To not provide the WIC customer with unauthorized food or non-credit

food items, rain checks/IOUs, credit slips, due bills or other similar

receipts for WIC foods not obtained at the time of the purchase.

15. To allow the WIC customer to participate in in-store and/or

manufacturer promotions that include WIC approved food items. This

includes `buy one, get one or more free' promotions.

16. To not collect sales tax on authorized WIC food purchases, except on

the purchase amount that is in excess of the amount on a cash value/

fruit and vegetable voucher, if applicable.

17. To not charge the WIC customer or Georgia WIC for bank fees or

other fees related to food instrument redemption.

18. To allow the WIC customer to use their own funds in excess of the

monetary limits for their cash value/fruit and vegetable voucher.

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Attachment VM-4 (cont'd)



19. To not issue cash change to a WIC customer for purchases less than

the total value of the cash value/fruit and vegetable voucher.

20. To only use the cash value/fruit and vegetable voucher for fruit and

vegetable purchases.

21. To enroll in the Automatic Clearing House upon authorization for the

payment of WIC vouchers that exceeds the maximum allowable price.

22. To provide a single account number to which all WIC vouchers will be

deposited.

E. PRICING
The vendor agrees and covenants:
1. To clearly mark the price of WIC foods on the item, container, shelf or sign near the WIC food item.
2. To provide each WIC food item at or below the current shelf price. 3. To not accept WIC food instruments or cash value/fruit and vegetable
vouchers before the "First Date to Use" or after the "Last Date to Use" as printed on the food instrument. 4. To submit vouchers to the bank for payment within sixty days from the "First Date to Use" as indicated on each food instrument. 5. To submit food instruments and cash-value vouchers for redemption in accordance with the redemption and voucher payment procedures outlined in the most recent version of the Vendor Handbook. 6. To accept an adjustment in the amount written in the "pay exactly" box of the WIC food instrument submitted for redemption if the amount exceeds the statewide and/ or peer group Maximum Allowable Reimbursement Level. The amount to be paid will be based upon the average shelf price, which will be based on the average shelf prices for all comparable stores in the same peer group or the statewide average for above 50% vendors for a given time period. 7. To remain price-competitive throughout the agreement period. Noncompetitive pricing occurs when the amount paid per food instrument by Georgia WIC to the vendor for a month's payment for all food instruments except cash value vouchers, exempt infant formulas and medical foods exceeds the statewide average amount paid per food instrument within the peer group by more than 50%. If the vendor is found to be non-competitive during an assessment, the vendor will receive written notice. If the vendor is identified as non-competitive for three additional assessments for a total of four (4) failed assessments within a twelve-month period or less, the vendor agreement will be terminated.

F. OVERCHARGING
The vendor agrees and covenants:
To not overcharge the WIC customer or Georgia WIC by charging more than the vendor's current shelf price for a WIC approved food item(s), or charging a WIC participant more for food than a non WIC customer.

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GEORGIA WIC 2012 PROCEDURES MANUAL

G. VENDOR COST CONTAINMENT

Attachment VM-4 (cont'd)

Georgia WIC is responsible for ensuring that the WIC program pays all vendors competitive prices for supplemental foods. Georgia WIC Program implemented a cost containment plan to identify and manage vendors who derive more than 50 percent of their annual food revenue from WIC food instruments.

By June 30th of each year Georgia WIC will conduct an annual assessment of each current vendor to determine if they derive more than 50 percent of their food revenue from WIC food instruments. New vendors will be assessed six months after enrollment to determine if they derive more than 50 percent of their food revenue from WIC food instruments. The State WIC Program utilizes a methodology that uses shelf prices to determine the maximum allowable reimbursement levels (MARL) for food instruments. If Georgia WIC determines that the vendor derived more than 50 percent of its food revenue from WIC, the vendor will be assigned to peer group G.

If upon reassessment Georgia WIC reassigns a vendor to a peer group offering a lower level of reimbursement in error, and on appeal the vendor is restored to their original peer group, damages to the vendor will be limited to the difference between the reimbursement they should have the received, and the reimbursement actually received.

H. NON-DISCRIMINATION
In accordance with federal law and U.S. Department of Agriculture (USDA) policy, all organizations that participate in the WIC program are prohibited from discriminating or denying benefits or participation to any person on the grounds of race, color, national origin, age, sex or handicap.
I. CHANGE OF OWNERSHIP, LOCATION OR CESSATION OF OPERATION
The vendor agrees and covenants: 1. To submit, upon request, to Georgia WIC proof of ownership,
identity and any other requested documents, (e.g. articles of incorporation, bill of sale, partnership declaration, evidence of sole proprietorship, social security card, driver's license, etc.) 2. To notify Georgia WIC in writing at least twenty-one days in advance of any change in location or other information (including but not limited to the name of the store and telephone number), change in ownership or cessation of business operations.
J. PERFORMANCE COMPLIANCE AND CONFLICT OF INTEREST
The vendor agrees and covenants: 1. To be monitored for compliance with program requirements.

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Attachment VM-4 (cont'd)



2. To permit unannounced visits by federal or state agency

representatives to review adherence to federal and state laws and

Georgia WIC policies and procedures.

3. To provide access to WIC food instruments and cash value/fruit and

vegetable vouchers on hand, inventory records (invoices) and any

other business records during a monitoring visit or inventory audit by

any authorized federal or state agency representative.

4. To maintain records used for federal tax reporting purposes,

inventory records including purchase and sales invoices and

receipts, and all other records related to WIC transactions and

participation in the WIC program for the three previous years and the

current year, or until pending investigations are completed, if longer.

5. To disclose any potential or actual conflict of interest between the

vendor and Georgia WIC or its employees.

6. To not engage in any activity with the WIC customer that would

create a conflict of interest, as determined by Georgia WIC. This

includes, but is not limited, acting as a proxy for the WIC customer.

7. To not attempt to circumvent a sanction(s) by selling, assigning or

otherwise transferring ownership to any person including the

vendor's partners, members, owners, officers, directors, employees,

relatives by blood or marriage, heirs or assigns.

8. To not use the WIC acronym, the WIC logo or close facsimiles

thereof, in total or in part, either in the official name in which the

vendor is registered or under the name in which it does business; or

in any unauthorized manner on packages, product labels, proprietary

materials including pamphlets and brochures, or in any form of

marketing, promotional material or advertisement of the store.

K. VENDOR SANCTION SYSTEM AND VENDOR CLAIMS
The vendor agrees and covenants:
1. To pay any claim assessed by Georgia WIC if Georgia WIC determines that vendor has committed a violation affecting payment to the vendor (such as overcharging), and delays payment or assesses a claim.
2. To pay claims and penalties levied for audit citations and for sanctions levied pursuant to this agreement and the most recent publication of Georgia WIC Vendor Handbook and all addendums.

L. STATE PROPERTY
The vendor agrees and covenants:
1. To return the vendor stamp(s) to Georgia WIC upon termination, change of ownership or disqualification.
2. To report lost, stolen or damaged vendor stamps to Georgia WIC immediately.
3. To not reproduce the vendor stamp.

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GEORGIA WIC 2012 PROCEDURES MANUAL

IV. RESPONSIBILITIES GEORGIA WIC PROGRAM

Attachment VM-4 (cont'd)

Georgia WIC agrees to adhere to federal and state laws, policies, procedures, rules and regulations, including the most recent publication of the Vendor Handbook and all addendums.

Any subsequent revisions to the policies, procedures, laws, rules and regulations that relate to Georgia WIC issued by the federal government are hereby made a part of this agreement.

Georgia WIC further agrees:

A. To provide the vendor with the most recent publication of the Georgia

WIC Vendor Handbook and all addendums.

B. To ensure that WIC customers are informed of the proper food instrument

redemption procedures and the correct use of WIC food instruments.

C. To notify the vendor of new program requirements set forth by the U.S.

Department of Agriculture regulations and Georgia WIC.

D. To provide training for the vendor on policies and procedures of Georgia

WIC, at a time, place and in a manner prescribed by Georgia WIC.

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

rules, regulations, policies or procedures.

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

through a system of claims, penalties, and/or sanctions as described in

the most recent publication of the Georgia WIC Vendor Handbook and all

addendums.

G. To provide appropriate written notice of intent or reason(s) to terminate

this agreement.

H. To notify the vendor of the right to appeal those adverse actions that are

appealable.

I.

To provide payment for food instruments validly redeemed and submitted

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

Georgia WIC Vendor Handbook and all addendums.

J. To deny payment for food instruments that are fraudulent or improperly

completed, redeemed or submitted.

K. To delay payment or establish a claim when it determines the vendor has

committed a vendor violation that affects payment to the vendor.

L. To notify vendor of stolen vouchers. Stolen vouchers may not be

redeemed.

M. To maintain an up-to-date listing of Approved Infant Formula retailers,

wholesalers, manufactures and distributors that authorized vendors must

use to purchase infant formula, and to consider approval of additional

suppliers upon request.

V. TERMINATION OF THE VENDOR AGREEMENT

Summary Termination. Georgia WIC will immediately terminate this agreement if it determines that the vendor provided false information or made a material omission in connection with its application for authorization or re-authorization.

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Attachment VM-4 (cont'd)



Termination Upon Notice. Georgia WIC may terminate the vendor agreement

for cause after providing at least 15 days advance written notice. Reasons for

termination may include, but are not limited to, the following:

1. Voluntary withdrawal from the WIC program. 2. The decision to sell the store. 3. Expiration of the agreement without a new application being submitted. 4. Civil Money Penalty imposed by SNAP in lieu of disqualification. 5. Use of the WIC acronym, WIC logo, or close facsimiles thereof, in total or in
part, in a manner that violates the provisions of this agreement and the vendor handbook. 6. Accepting food instruments through the mail or mailing any approved formula/medical foods directly to the WIC customer. 7. Failure to complete and submit documentation for annual training by the deadline specified by Georgia WIC. 8. Failure to provide Georgia WIC with written notice of a change in the vendor's business within at least twenty-one days in advance of the change (including but is not limited to a change in ownership, name, location, corporate structure, sale or transfer of the business, or cessation of operation.) 9. Two failed attempts by Georgia WIC to contact the vendor during business hours at the vendor's reported address and telephone number. 10. Determination that the vendor's SNAP license is invalid or not current. 11. Intentionally providing false information or vendor records, other than information or records provided in connection with a vendor application for authorization or re-authorization. 12. Failure to provide food instruments, inventory records, food sales or tax information upon request. 13. Failure to allow monitoring by WIC representatives, or harassing or threatening any WIC representative. 14. Forging a participant's signature on a WIC food instrument. 15. Reproducing the WIC vendor stamp. 16. Identification by Georgia WIC of a conflict of interest as defined by applicable state laws, regulations, and policies, between the vendor and Georgia WIC or its local agencies. 17. Failure to enroll in ACH within the time specified. 18. Four failed assessments for non-competitive prices within a 12-month period or less. 19. Providing prohibited incentive items as part of a WIC transaction, in a manner that violates the provisions of this agreement and the vendor handbook. 20. Failure to meet the selection criteria in effect at the time of assessment at any time throughout the agreement period. 21. Less than $2,000 in annual WIC redemptions or failure to redeem any WIC food instruments in sixty days. 22. Violation of any federal or state law or regulation, or terms of the WIC Vendor Agreement or Vendor Handbook not otherwise covered by the sanction system.

After being terminated from the Georgia WIC Program, the vendor will not be automatically reinstated as an authorized WIC vendor. The vendor may re-apply no sooner than one year after being terminated from Georgia WIC. To re-apply, the vendor must complete the application process in its entirety.

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Attachment VM-4 (cont'd)

In the event a termination is overturned on appeal, Georgia WIC shall not be liable for consequential damages, including but not limited to lost profits and attorney's fees. VI. SANCTIONS

Any authorized WIC vendor found to be in violation of federal regulations or Georgia WIC policy will be assessed a sanction consistent with the severity and nature of the violation, in accordance with Georgia WIC's sanction schedule. 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.

There are seven categories of sanctions, three categories of State agency sanctions and four categories of federal mandatory sanctions. State agency sanctions are established by Georgia WIC program representatives and have been approved by the United States Department of Agriculture (USDA) prior to implementation. State agency sanctions include disqualification, and civil money penalties assessed in lieu of disqualification in the event of inadequate participant access. Federal mandatory sanctions are established by the USDA. Both State agency and Federal mandatory sanctions must be enforced when violations occur.
The vendor is required to abide by the provisions of the current Georgia WIC Vendor Handbook, as amended, including the sanction schedule outlined therein. The vendor will be sanctioned for program violations according to the version of the handbook and all amendments in effect at the time the violation occurs.
Georgia WIC will notify the vendor in writing when an investigation reveals an initial incidence of a violation for which a pattern of incidences must be established in order to impose a sanction, before another such incidence is documented, unless Georgia WIC determines, in its sole discretion, on a case by case basis, that notifying the vendor would compromise the investigation.
If there is credible evidence that the vendor has committed fraud or abuse in excess of $1000 or other major criminal activity has occurred, Georgia WIC will immediately advise the USDA Food and Nutrition Service Regional Office, which will refer the case to the appropriate USDA Office of the Inspector General Regional Office.

Disqualification from the WIC program may result in disqualification as a retailer in the Supplemental Nutrition Assistance Program. Such disqualification may not be subject to administrative or judicial review under SNAP.

VII. SANCTIONS/VIOLATIONS FROM PREVIOUS AGREEMENT PERIODS
Sanctions - any sanction(s) that are in the vendor's record at the time of reauthorization will remain on the vendor's record for the period of time specified when the sanction was issued. Prior year's sanctions may result in a denial of

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Attachment VM-4 (cont'd)



the authorization of the application and/or additional sanctions up to and

including disqualification, in accordance with the most recent Georgia WIC

Program Vendor Handbook and all addendums.

Violations - Pending and/or potential violations, that exists at the time of reauthorization will accrue and may result in sanctions up to and including disqualification, in accordance with the most recent Georgia WIC Program Vendor Handbook and all addendums.
VIII. CRIMINAL PENALTIES
The vendor will be subject to criminal prosecution under applicable federal, state or local law for fraud or abuse in the program (including but not limited to redeeming vouchers prior to becoming an authorized vendor or without being an authorized vendor). Those who have willfully misapplied, stolen or fraudulently obtained program funds will be subject to a fine of not more than twenty-five thousand dollars or imprisonment for not more than five years, or both, if the value of the funds is one hundred dollars or more. If the value is less than one hundred dollars, the penalties are fines of not more than one thousand dollars or imprisonment for not more than one year, or both. Georgia WIC will refer all criminal activity including theft, fraud and embezzlement to local law enforcement.
IX. ADVERSE ACTIONS AND REVIEW PROCEDURES
Information on adverse actions the vendor may appeal, adverse actions that are not subject to administrative review, as well as Georgia WIC's administrative review procedures are found in the Section 111-9-.06 of the Rules and Regulations of the State of Georgia and the most recent publication of the Vendor Handbook. The vendor agrees to abide by said provisions if requesting review of an adverse action.
X. SEVERABILITY
If any one 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. RENEWABILITY
This agreement is not renewable. If the vendor wishes to continue to be authorized beyond the current agreement period, the vendor must re-apply for authorization.
XII. NON TRANSFERABILITY
This agreement is not transferable.
XIII. MISCELLANEOUS

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Attachment VM-4 (cont'd)



The vendor certifies, through the signature of the owner, or an authorized

representative below, that he or she understands and accepts all terms of this

agreement. The individual signing this agreement certifies 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 Georgia WIC and upon receipt, by the vendor, of an executed copy along with vendor stamps for each authorized location.

This agreement does not constitute a license or property interest. If the vendor wishes to continue to be authorized beyond the period of this agreement, the vendor must apply for re-authorization. If the vendor is disqualified, Georgia WIC will terminate this agreement, and the vendor will have to re-apply to be authorized after the disqualification period is over. The vendor's new application will be subject to the vendor selection criteria and any vendor limiting criteria in effect at the time of re-application.

The Georgia WIC Vendor Handbook is part of this agreement, and is incorporated by reference.

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GEORGIA WIC 2012 PROCEDURES MANUAL
VENDOR SIGNATURE

Attachment VM-4 (cont'd)

Signature of Authorized

First

Representative (no initials)

Authorized Representative First (Type or Print) (no initials)

Title (Type or Print)

Middle

Last

Middle

Last

DO NOT WRITE BELOW THIS LINE GEORGIA WIC PROGRAM USE ONLY GEORGIA WIC PROGRAM SIGNATURE

Date Date

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

Date

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GEORGIA WIC 2012 PROCEDURES MANUAL

GEORGIA WIC VENDOR AGREEMENT
Full Legal Name of Store or Corporation
Doing Business As (If applicable)
Street Address
Store location or corporate home office

City Business Telephone
Mailing Address
(If different from above)

(Area Code)

State
Number

Attachment VM-5
Zip County

City

State

Zip

Email Address

Fax Number

Federal Employer Identification Number

Registered Agent
(if applicable)
Mailing Address

City

State

Zip

NOTE: All communications, i.e. disqualifications, sanctions, addendums, annual training, etc. will be mailed to all listed addresses

DO NOT WRITE BELOW THIS LINE
GEORGIA'S WIC USE ONLY
WIC VENDOR NUMBER (Corporate vendors only)
See Attached Spreadsheet

This Agreement is by and between the Georgia Special Supplemental Nutrition Program for Women, Infant and Children ("Georgia WIC " or the "Program") having a mailing address of Two Peachtree Street NW, Suite 10-476, Atlanta, Georgia, 30303-3142, and the above-named business entity ("the Vendor"). This agreement is effective for the period beginning ______________________________ and ending September 30, 2013.

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GEORGIA WIC 2012 PROCEDURES MANUAL


Attachment VM-5 (cont'd)

I.

PURPOSE

The purpose of this agreement is to establish the terms and conditions for an authorized vendor to sell prescribed supplemental foods under the Georgia WIC program, in accordance with federal and state laws and regulations.

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. Military commissaries and pharmacies do not have to be licensed by the Georgia Department of Agriculture.

B. An eligible vendor is a business entity that is 1) registered and licensed by the United States Department of Agriculture Food & Nutrition Service as a retail participant in the Supplemental Nutrition Assistance Program or SNAP (formally the Food Stamp Program) and 2) is in good standing without debarment or suspension from the United States Department of Agriculture or the SNAP program. Military commissaries and pharmacies do not have to be SNAP participants.
C. An eligible vendor must have a fixed location with an official physical address.
D. For corporate vendors owning two (2) or more locations, the requested information for each location must be listed on the Corporate Attachment (Form 3771A) and made part of the agreement. The corporate attachment form is an addendum to the corporate vendor agreement. The attachment form serves as verification that the location listed is the authorized location at which WIC vouchers are to be redeemed. Vendors are not permitted to redeem vouchers in a location other than the authorized location listed in the vendor agreement or corporate attachment.

E. An eligible vendor must meet all requirements as described in the most recent version of the Georgia WIC Vendor Handbook and all addendums.
F. The vendor must comply with the selection criteria (including any changes to those criteria, throughout the agreement period. Georgia WIC may reassess any authorized vendor at any time during the vendor agreement period using the current vendor selection criteria, and will terminate the agreement if the vendor fails to meet those criteria.
G. A vendor authorized as a military commissary, pharmacy or corporate vendor will be given certain exceptions to this agreement. The exceptions are outlined in this Agreement and the Georgia WIC Vendor Handbook.

III. RESPONSIBILITIES VENDOR
The Vendor agrees to comply with the provisions of this agreement and all federal and state laws, policies, procedures, rules and regulations, including

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Attachment VM-5 (cont'd)



those contained in the most recent publication of the Vendor Handbook and

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 Georgia WIC during the agreement period. This

Agreement will be interpreted according to 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, including any vendor violations committed by such persons. 2. To abide by the rules, policies and procedures as outlined in the most recent publication of Georgia WIC Vendor Handbook and all addendums, and all federal and state laws and regulations. 3. To not solicit the WIC customer on the premises of WIC clinics. 4. To only purchase infant formula, that will be redeemed for WIC vouchers, from the Approved Infant Formula Supplier list. If a supplier is not listed, a vendor may call 866-814-5468 or 404-657-2900 to inquire about adding that supplier to the list. The vendor must ensure that the requested supplier has been authorized by Georgia WIC, prior to purchasing any infant formula from that supplier. Records of the infant formula purchase must be maintained according to Section III.J.3 of this Agreement. 5. To submit total food sales and gross sales revenue records, and any other records needed to validate total food sales and gross sales, as requested by Georgia WIC, and to complete and submit upon request, the specified Sales and Use Tax Report Form ST-3 for Georgia WIC vendors. 6. To not use the WIC acronym, the WIC logo or close facsimiles thereof, in total or in part, either in the official name in which the vendor is registered or under the name in which it does business; or in any unauthorized manner on packages, product labels, proprietary materials including pamphlets and brochures, or in any form of marketing, promotional material or advertisement of the store. 7. To carry a substantial amount of non-WIC food inventory at all times. The vendor must carry the minimum amount of items in each category as specified in the Vendor Handbook. 8. To comply with the vendor selection criteria throughout the agreement period, including any changes to the criteria. 9. To not offer, advertise, promise or indicate an intention to provide incentives to WIC participants. Vendors who use advertisements or incentives to solicit the business of WIC participants, or offer incentives or delivery services will be subject to sanctions as explained in this Vendor Agreement and the Vendor Handbook. Incentives include but are not limited to free or complimentary gifts, home delivery of foods, store memberships, and free or discounted services. 10. To prominently display in plain sight the poster provided by Georgia WIC indicating that the store welcomes or accepts WIC.

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GEORGIA WIC 2012 PROCEDURES MANUAL

B. VENDOR TRAINING

Attachment VM-5 (cont'd)

Prior to accepting WIC vouchers, the vendor or his authorized representative must receive interactive authorized training. The vendor must also participate in annual training on changes and updates on Georgia WIC policies and procedures. Georgia WIC will provide the date, time and location of the training, and will provide vendors with at least one alternative date on which to attend interactive training. The vendor may submit a written request for Georgia WIC to provide subsequent customized training to store personnel at any time after both parties have signed the agreement.

The vendor agrees and covenants:
1. To participate in all required training, including annual training. 2. To provide training on the requirements of the WIC program to paid
and unpaid employees, agents and all personnel involved in WIC transactions. 3. To not participate in Georgia WIC until Authorized Training has been completed and a vendor stamp has been issued. 4. To not participate in Georgia WIC until the vendor has received a passing score of eighty points or higher on the Post Vendor Training Evaluation. 5. For vendors with multiple locations that have separately been authorized to participate in the WIC program, to provide documentation that a management representative(s) from each authorized store location has been trained on the required topics as listed on the Corporate Vendor Training Checklist (Form 3757A), (Corporate vendors only).

C. NO SUBSTITUTIONS, CASH, REFUNDS, OR EXCHANGES
The vendor agrees and covenants:
1. To only charge for authorized supplemental foods selected by the WIC customer as listed on the food instrument or cash value/fruit and vegetable voucher, and not charge for WIC approved items that are not received by the WIC customer.
2. To not provide unauthorized food items, non-food items, cash or credit (including rain checks) in exchange for food instruments or cash value/fruit and vegetable vouchers.
3. To not provide refunds or permit exchanges for authorized supplemental foods obtained with food instruments or cash-value vouchers, except for exchanges of the same brand and size when the original authorized supplemental food item is defective, spoiled, recalled or has exceeded its "sell by" or "best if used by" or other date limiting the sale or use of the food item.

4. To provide only the authorized infant formula which the vendor has obtained pursuant to paragraph III A (4) of this agreement, to participants in exchange for food instruments for infant formula.

D. FOOD VOUCHER TRANSACTIONS The vendor agrees and covenants:

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GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment VM-5 (cont'd)



1. To accept food instruments and cash-value vouchers only from WIC

participants, parents or caretakers of infants and child participants or

proxies (the "WIC customer.)

2. To ensure that WIC food instrument transactions are processed in
accordance with the procedures set forth in the most recent

publication of the Georgia WIC Vendor Handbook and all addendums.

3. To not demand that a WIC customer purchase every eligible WIC food

item listed on the voucher.

4. To allow WIC customers the right to purchase the eligible foods of

their choice as listed on the WIC food instrument, cash value voucher

and the approved food list.

5. To ensure that the purchase price is entered on food instruments and

cash-value vouchers in accordance with the procedures governing the

processing of WIC food instruments in the most recent publication of

the Vendor Handbook. The purchase price must include only the

authorized supplemental food items actually provided and must be

entered on the food instrument or cash-value voucher in plain sight of

the WIC customer during the WIC transaction.

6. To ensure that the WIC customer signs the food instrument or cash-

value voucher in the presence of the cashier.

7. To only allow the purchase of supplemental foods listed on the food

instrument and cash value/fruit and vegetable voucher.

8. To offer the WIC customer the same courtesies offered to all other

customers.

9. To ensure that all information including the identity of the WIC

customer is kept confidential, in accordance with federal and state law

and regulation.

10. To ensure that Georgia WIC is not being charged for foods not

received by the participant.

11. To not charge the WIC customer for authorized supplemental foods

obtained with food instruments or cash-value vouchers.

12. To not contact or seek restitution from the WIC customer for WIC food

vouchers not paid or partially paid by Georgia WIC.

13. To not request cash from the WIC customer for any WIC transaction

except for transactions involving the cash value/fruit and vegetable vouchers, for which the total amount of the transaction exceeds the

amount on the voucher.

14. To not provide the WIC customer with unauthorized food or non-credit

food items, rain checks/IOUs, credit slips, due bills or other similar

receipts for WIC foods not obtained at the time of the purchase.

15. To allow the WIC customer to participate in in-store and/or

manufacturer promotions that include WIC approved food items. This

includes `buy one, get one or more free' promotions.

16. To not collect sales tax on authorized WIC food purchases, except on

the purchase amount that is in excess of the amount on a cash value/

fruit and vegetable voucher, if applicable.

17. To not charge the WIC customer or Georgia WIC for bank fees or

other fees related to food instrument redemption.

18. To allow the WIC customer to use their own funds in excess of the

monetary limits for their cash value/fruit and vegetable voucher.

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GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment VM-5 (cont'd)



19. To not issue cash change to a WIC customer for purchases less than

the total value of the cash value/fruit and vegetable voucher.

20. To only use the cash value/fruit and vegetable voucher for fruit and

vegetable purchases.

21. To enroll in the Automatic Clearing House upon authorization for the

payment of WIC vouchers that exceed the maximum allowable price.

22. To provide a single account number to which all WIC vouchers will be

deposited.

E. PRICING
The vendor agrees and covenants:
1. To clearly mark the price of WIC foods on the item, container, shelf or sign near the WIC food item.
2. To provide each WIC food item at or below the current shelf price. 3. To not accept WIC food instruments or cash value/fruit and vegetable
vouchers before the "First Date to Use" or after the "Last Date to Use" as printed on the food instrument. 4. To submit vouchers to the bank for payment within sixty days from the "First Date to Use" as indicated on each food instrument. 5. To submit food instruments and cash-value vouchers for redemption in accordance with the redemption and voucher payment procedures outlined in the most recent version of the Vendor Handbook. 6. To accept an adjustment in the amount written in the "pay exactly" box of the WIC food instrument submitted for redemption if the amount exceeds the statewide and/ or peer group Maximum Allowable Reimbursement Level. The amount to be paid will be based upon the average shelf price, which will be based on the average shelf prices for all comparable stores in the same peer group or the statewide average for above 50% vendors for a given time period. 7. To remain price-competitive throughout the agreement period. Noncompetitive pricing occurs when the amount paid per food instrument by Georgia WIC to the vendor for a month's payment for all food instruments except cash value vouchers, exempt infant formulas and medical foods exceeds the statewide average amount paid per food instrument within the peer group by more than 50%. If the vendor is found to be non-competitive during an assessment, the vendor will receive written notice. If the vendor is identified as non-competitive for three additional assessments for a total of four (4) failed assessments within a twelve-month period or less, the vendor agreement will be terminated.

F. OVERCHARGING
The vendor agrees and covenants:
To not overcharge the WIC customer or Georgia WIC by charging more than the vendor's current shelf price for a WIC approved food item(s), or charging a WIC participant more for food than a non WIC customer.

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GEORGIA WIC 2012 PROCEDURES MANUAL

G. VENDOR COST CONTAINMENT

Attachment VM-5 (cont'd)

Georgia WIC is responsible for ensuring that the WIC program pays all vendors competitive prices for supplemental foods. Georgia WIC Program implemented a cost containment plan to identify and manage vendors who derive more than 50 percent of their annual food revenue from WIC food instruments.
By June 30th of each year Georgia WIC will conduct an annual assessment of each current vendor to determine if they derive more than 50 percent of their food revenue from WIC food instruments. New vendors will be assessed six months after enrollment to determine if they derive more than 50 percent of their food revenue from WIC food instruments. The State WIC Program utilizes a methodology that uses shelf prices to determine the maximum allowable reimbursement levels (MARL) for food instruments. If Georgia WIC determines that the vendor derived more than 50 percent of its food revenue from WIC, the vendor will be assigned to peer group G.
If upon reassessment Georgia WIC reassigns a vendor to a peer group offering a lower level of reimbursement in error, and on appeal the vendor is restored to their original peer group, damages to the vendor will be limited to the difference between the reimbursement they should have the received, and the reimbursement actually received.

H. NON-DISCRIMINATION
In accordance with federal law and U.S. Department of Agriculture (USDA) policy, all organizations that participate in the WIC program are prohibited from discriminating or denying benefits or participation to any person on the grounds of race, color, national origin, age, sex or handicap.
I. CHANGE OF OWNERSHIP, LOCATION OR CESSATION OF OPERATION
The vendor agrees and covenants: 1. To submit, upon request, to Georgia WIC proof of ownership,
identity and any other requested documents, (e.g. articles of incorporation, bill of sale, partnership declaration, evidence of sole proprietorship, social security card, driver's license, etc.) 2. To notify Georgia WIC in writing at least twenty-one days in advance of any change in location or other information (including but not limited to the name of the store and telephone number), change in ownership or cessation of business operations.
J. PERFORMANCE COMPLIANCE AND CONFLICT OF INTEREST
The vendor agrees and covenants: 1. To be monitored for compliance with program requirements.

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GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment VM-5 (cont'd)



2. To permit unannounced visits by federal or state agency

representatives to review adherence to federal and state laws and

Georgia WIC policies and procedures.

3. To provide access to WIC food instruments and cash value/fruit and

vegetable vouchers on hand, inventory records (invoices) and any

other business records during a monitoring visit or inventory audit by

any authorized federal or state agency representative.

4. To maintain records used for federal tax reporting purposes,

inventory records including purchase and sales invoices and

receipts, and all other records related to WIC transactions and

participation in the WIC program for the three previous years and the

current year, or until pending investigations are completed, if longer.

5. To disclose any potential or actual conflict of interest between the

vendor and Georgia WIC or its employees.

6. To not engage in any activity with the WIC customer that would

create a conflict of interest, as determined by Georgia WIC. This

includes, but is not limited, acting as a proxy for the WIC customer.

7. To not attempt to circumvent a sanction(s) by selling, assigning or

otherwise transferring ownership to any person including the

vendor's partners, members, owners, officers, directors, employees,

relatives by blood or marriage, heirs or assigns.

8. To not use the WIC acronym, the WIC logo or close facsimiles

thereof, in total or in part, either in the official name in which the

vendor is registered or under the name in which it does business; or

in any unauthorized manner on packages, product labels, proprietary

materials including pamphlets and brochures, or in any form of

marketing, promotional material or advertisement of the store.

K. VENDOR SANCTION SYSTEM AND VENDOR CLAIMS
The vendor agrees and covenants: 1. To pay any claim assessed by Georgia WIC if Georgia WIC
determines that vendor has committed a violation affecting payment to the vendor (such as overcharging), and delays payment or assesses a claim. 2. To pay claims and penalties levied for audit citations and for sanctions levied pursuant to this agreement and the most recent publication of Georgia WIC Vendor Handbook and all addendums.
L. STATE PROPERTY
The vendor agrees and covenants: 1. To return the vendor stamp(s) to Georgia WIC upon termination,
Change of ownership or disqualification. 2. To report lost, stolen or damaged vendor stamps to Georgia WIC
immediately 3. To not reproduce the vendor stamp.

VM- 102

GEORGIA WIC 2012 PROCEDURES MANUAL

IV. RESPONSIBILITIES GEORGIA WIC PROGRAM

Attachment VM-5 (cont'd)

Georgia WIC agrees to adhere to federal and state laws, policies, procedures, rules and regulations, including the most recent publication of the Vendor Handbook and all addendums.

Any subsequent revisions to the policies, procedures, laws, rules and regulations that relate to Georgia WIC issued by the federal government are hereby made a part of this agreement.

Georgia WIC further agrees:

A. To provide the vendor with the most recent publication of the Georgia

WIC Vendor Handbook and all addendums.

B. To ensure that WIC customers are informed of the proper food instrument

redemption procedures and the correct use of WIC food instruments.

C. To notify the vendor of new program requirements set forth by the U.S.

Department of Agriculture regulations and Georgia WIC.

D. To provide training for the vendor on policies and procedures of Georgia

WIC, at a time, place and in a manner prescribed by Georgia WIC.

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

rules, regulations, policies or procedures.

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

through a system of claims, penalties, and/or sanctions as described in

the most recent publication of the Georgia WIC Vendor Handbook and all

addendums.

G. To provide appropriate written notice of intent or reason(s) to terminate

this agreement.

H. To notify the vendor of the right to appeal those adverse actions that are

appealable.

I.

To provide payment for food instruments validly redeemed and submitted

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

Georgia WIC Vendor Handbook and all addendums.

J. To deny payment for food instruments that are fraudulent or improperly

completed, redeemed or submitted.

K. To delay payment or establish a claim when it determines the vendor has

committed a vendor violation that affects payment to the vendor.

L. To notify vendor of stolen vouchers. Stolen vouchers may not be

redeemed.

M. To maintain an up-to-date listing of Approved Infant Formula retailers,

wholesalers, manufactures and distributors that authorized vendors must

use to purchase infant formula, and to consider approval of additional

suppliers upon request.

V. TERMINATION OF THE VENDOR AGREEMENT

Summary Termination. Georgia WIC will immediately terminate this agreement if it determines that the vendor provided false information or made a material omission in connection with its application for authorization or re-authorization.

VM- 103

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment VM-5 (cont'd)



Termination Upon Notice. Georgia WIC may terminate the vendor agreement

for cause after providing at least 15 days advance written notice. Reasons for

termination may include, but are not limited to, the following:

1. Voluntary withdrawal from the WIC program. 2. The decision to sell the store. 3. Expiration of the agreement without a new application being submitted. 4. Civil Money Penalty imposed by SNAP in lieu of disqualification. 5. Use of the WIC acronym, WIC logo, or close facsimiles thereof, in total or in
part, in a manner that violates the provisions of this agreement and the vendor handbook. 6. Accepting food instruments through the mail or mailing any approved formula/medical foods directly to the WIC customer. 7. Failure to complete and submit documentation for annual training by the deadline specified by Georgia WIC. 8. Failure to provide Georgia WIC with written notice of a change in the vendor's business within at least twenty-one days in advance of the change (including but is not limited to a change in ownership, name, location, corporate structure, sale or transfer of the business, or cessation of operation.) 9. Two failed attempts by Georgia WIC to contact the vendor during business hours at the vendor's reported address and telephone number. 10. Determination that the vendor's SNAP license is invalid or not current. 11. Intentionally providing false information or vendor records, other than information or records provided in connection with a vendor application for authorization or re-authorization. 12. Failure to provide food instruments, inventory records, food sales or tax information upon request. 13. Failure to allow monitoring by WIC representatives, or harassing or threatening any WIC representative. 14. Forging a participant's signature on a WIC food instrument. 15. Reproducing the WIC vendor stamp. 16. Identification by Georgia WIC of a conflict of interest as defined by applicable state laws, regulations, and policies, between the vendor and Georgia WIC or its local agencies. 17. Failure to enroll in ACH within the time specified. 18. Four failed assessments for non-competitive prices within a 12-month period or less. 19. Providing prohibited incentive items as part of a WIC transaction, in a manner that violates the provisions of this agreement and the vendor handbook. 20. Failure to meet the selection criteria in effect at the time of assessment at any time throughout the agreement period. 21. Less than $2,000 in annual WIC redemptions or failure to redeem any WIC food instruments in sixty days. 22. Violation of any federal or state law or regulation, or terms of the WIC Vendor Agreement or Vendor Handbook not otherwise covered by the sanction system.

After being terminated from the Georgia WIC Program, the vendor will not be automatically reinstated as an authorized WIC vendor. The vendor may re-apply no sooner than one year after being terminated from Georgia WIC. To re-apply, the vendor must complete the application process in its entirety.

VM- 104

GEORGIA WIC 2012 PROCEDURES MANUAL


Attachment VM-5 (cont'd)

In the event a termination is overturned on appeal, Georgia WIC shall not be liable for consequential damages, including but not limited to lost profits and attorney's fees.

VI. SANCTIONS

Any authorized WIC vendor found to be in violation of federal regulations or Georgia WIC policy will be assessed a sanction consistent with the severity and nature of the violation, in accordance with Georgia WIC's sanction schedule. 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.

There are seven categories of sanctions, three categories of State agency sanctions and four categories of federal mandatory sanctions. State agency sanctions are established by Georgia WIC program representatives and have been approved by the United States Department of Agriculture (USDA) prior to implementation. State agency sanctions include disqualification, and civil money penalties assessed in lieu of disqualification in the event of inadequate participant access. Federal mandatory sanctions are established by the USDA. Both State agency and Federal mandatory sanctions must be enforced when violations occur.

The vendor is required to abide by the provisions of the current Georgia WIC Vendor Handbook, as amended, including the sanction schedule outlined therein. The vendor will be sanctioned for program violations according to the version of the handbook and all amendments in effect at the time the violation occurs.

Georgia WIC will notify the vendor in writing when an investigation reveals an initial incidence of a violation for which a pattern of incidences must be established in order to impose a sanction, before another such incidence is documented, unless Georgia WIC determines, in its sole discretion, on a case by case basis, that notifying the vendor would compromise the investigation.

If there is credible evidence that the vendor has committed fraud or abuse in excess of $1000 or other major criminal activity has occurred, Georgia WIC will immediately advise the USDA Food and Nutrition Service Regional Office, which will refer the case to the appropriate USDA Office of the Inspector General Regional Office.

Disqualification from the WIC program may result in disqualification as a retailer in the Supplemental Nutrition Assistance Program. Such disqualification may not be subject to administrative or judicial review under SNAP.

VII. SANCTIONS/VIOLATIONS FROM PREVIOUS AGREEMENT PERIODS

Sanctions - any sanction(s) that are in the vendor's record at the time of reauthorization will remain on the vendor's record for the period of time specified

VM- 105

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment VM-5 (cont'd)



when the sanction was issued. Prior year's sanctions may result in a denial of

the authorization of the application and/or additional sanctions up to and

including disqualification, in accordance with the most recent Georgia WIC

Program Vendor Handbook and all addendums.

Violations - Pending and/or potential violations, that exists at the time of reauthorization will accrue and may result in sanctions up to and including disqualification, in accordance with the most recent Georgia WIC Program Vendor Handbook and all addendums.
VIII. CRIMINAL PENALTIES
The vendor will be subject to criminal prosecution under applicable federal, state or local law for fraud or abuse in the program (including but not limited to redeeming vouchers prior to becoming an authorized vendor or without being an authorized vendor). Those who have willfully misapplied, stolen or fraudulently obtained program funds will be subject to a fine of not more than twenty-five thousand dollars or imprisonment for not more than five years, or both, if the value of the funds is one hundred dollars or more. If the value is less than one hundred dollars, the penalties are fines of not more than one thousand dollars or imprisonment for not more than one year, or both. Georgia WIC will refer all criminal activity including theft, fraud and embezzlement to local law enforcement.
IX. ADVERSE ACTIONS AND REVIEW PROCEDURES
Information on adverse actions the vendor may appeal, adverse actions that are not subject to administrative review, as well as Georgia WIC's administrative review procedures are found in the Section 111-9-.06 of the Rules and Regulations of the State of Georgia and the most recent publication of the Vendor Handbook. The vendor agrees to abide by said provisions if requesting review of an adverse action.
X. SEVERABILITY
If any one 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. RENEWABILITY
This agreement is not renewable. If the vendor wishes to continue to be authorized beyond the current agreement period, the vendor must re-apply for authorization.
XII. NON TRANSFERABILITY
This agreement is not transferable.

VM- 106

GEORGIA WIC 2012 PROCEDURES MANUAL

XIII. MISCELLANEOUS

Attachment VM-5 (cont'd)

The vendor certifies, through the signature of the owner, or an authorized representative below, that he or she understands and accepts all terms of this agreement. The individual signing this agreement certifies 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 Georgia WIC and upon receipt, by the vendor, of an executed copy along with vendor stamps for each authorized location.

This agreement does not constitute a license or property interest. If the vendor wishes to continue to be authorized beyond the period of this agreement, the vendor must apply for re-authorization. If the vendor is disqualified, Georgia WIC will terminate this agreement, and the vendor will have to re-apply to be authorized after the disqualification period is over. The vendor's new application will be subject to the vendor selection criteria and any vendor limiting criteria in effect at the time of re-application.

The Georgia WIC Vendor Handbook is part of this agreement, and is incorporated by reference.

VM- 107

GEORGIA WIC 2012 PROCEDURES MANUAL
VENDOR SIGNATURE

Attachment VM-5 (cont'd)

Signature of Authorized

First

Representative (no initials)

Authorized Representative First (Type or Print) (no initials)

Title (Type or Print)

Middle

Last

Middle

Last

DO NOT WRITE BELOW THIS LINE GEORGIA WIC PROGRAM USE ONLY GEORGIA WIC PROGRAM SIGNATURE

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

Date

Date Date

VM- 108


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment VM-6

GEORGIA WIC CORPORATE ATTACHMENT FORM

FOR GEORGIA WIC (GW) USE ONLY

District/Unit

Date Received

Date Approved QAS:

Date Denied

QAS:

Reason Denied

Processed By

Vendor Number

VM:

VD:

VM:

VD:

Peer Group

A. Is this store expected to derive more than 50% of its annual food sales from the sale of WIC approved foods? (Food sales mean foods that are eligible items under SNAP.)

Yes

No

B. Is this form submitted due to a change in the store's location?

Yes

No

Full Legal Name of Corporation Full Legal Name of Store

STORE IDENTIFICATION
Store Number

WIC Vendor No.

Address

County

City

State

Zip

Business Telephone
Mailing Address
(If Different From Above)

(Area Code)

Number

Fax County

(Area Code) Number

City

State

Zip

Store Contact and Title
E-mail Address (Required)

Name LICENSING

Title
Square Footage of Store
(excluding storage and administrative area)

Federal Employer Identification Number (FEIN)

Food Stamp Authorization Number (Required For Approval)

Food Sales Establishment License Number

Date store representative received WIC Authorization Training (Form #3757A Corporate Training Checklist is required as documentation.)

VM-109

FORM 3771A (03/2011)


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment VM-6 (cont'd)

COST CONTAINMENT, INVENTORY, AND PRICE LIST

Applicant vendors must submit purchase invoice receipts, bills of lading or recent invoices which depict the purchase of all items intended for sale in their stores upon request. This includes WIC food items, non-WIC food items, household products, miscellaneous items, etc. Failure to submit the requested documentation within 10 (ten) days of the request will result in denial of the vendor application.
A. What is the estimated percent of annual food sales you anticipate deriving from the following types of payment? Total must equal 100%
Cash/Personal Checks ______% Debit/Credit Cards _____% Food Stamps ______% WIC Food Instruments ______%
Total 100%

B. CHECK APPROPRIATE BOX PLEASE GIVE YEARLY (NOT MONTHLY) AMOUNT: Check the sales figure you are providing (Actual or Estimated). If giving estimated sales, you must provide a dollar amount for one year that is equal to one month times 12 (1month X12). However, report estimated sales only if you do not have actual sales figures for the most recent tax year. You may be required to provide updated information when actual sales figures are available.
__ Actual Gross Sales $ ________________________________ For tax year ____________
__ Estimated Gross Sales $______________________________ For tax year ____________

STAPLE FOODS CATEGORIES CARRIED IN STOCK: All vendors (pharmacies excluded) must carry food items other than WIC Approved Foods. These items are considered non-WIC inventory. This includes dried, frozen, canned/jar, boxed, fresh, refrigerated, etc. (Staple foods do not include any prepared foods or accessory foods such as candy, condiments, spices, tea, coffee, or carbonated and un-carbonated drinks.)
What percentage of each item does this store carry from the following food groups? The total percentage must equal one-hundred percent (100%).

A. Meats, Poultry and/or Seafoods (refrigerated) B. Dairy (milk, cheese, yogurt, etc.) C. Shelf Staples (e.g., flour, sugar, pasta, pudding mix, etc.) D. Cans, Jars, Bottled Goods (i.e. mayo, ketchup, relish, etc) E. Beverages F. Breads and Cereal Products

VM-110

FORM 3771A (11/2011)


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment VM-6 (cont'd)

Does the current owner(s), officer(s) or manager(s) currently or previously own(ed) or

Yes

No

manage(d) a business whereby more than fifty percent (50%) of the total annual food

sales is derived from the sale of WIC approved foods?

If YES, identify the name of the store, identification number (ID), city and state. Include stores nationwide, and Georgia.

1. Store Name City

ID State

2. Store Name City

ID State

3. Store Name City

ID State

INFANT FORMULA SUPPLIER

1

A Were all infant formula, that will be used to redeem WIC vouchers, purchased

from suppliers listed on the Approved Infant Formula Supplier list?

(see www.health.state.ga.us/programs/WIC/vendorinfo.asp)

Yes

N

o

Note: Records of all infant formula purchases must be maintained according to the terms of the WIC Vendor Agreement, III, I.3.

B If yes, indicate the name of the supplier, address, city and State. (Attach additional paper if necessary.)

Supplier City

Address State

Supplier City

Address State

Supplier City

Address State

SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP)
A. Has this store ever been denied or disqualified from SNAP? __ YES __ NO.
IF YES, attach a written explanation, giving the date denied or disqualified, and the reasons.
B. Has this store ever been placed on probation or received a Civil Money Penalty from SNAP? __ YES __ NO.

VM-111

FORM 3771A (03/2011)


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment VM-6 (cont'd)

IF YES, attach a written explanation including the probation period or amount of Civil Money Penalty.

OPERATIONAL AND BANKING INFORMATION

Enter information pertaining to where you will deposit all WIC food instruments and cash value vouchers. Bank __________________________________________________________ Account Number ______________________________ Street ____________________________________________________ City State Zip _________________________________________ Telephone Number: Area Code ________________ Number _______________________________________

INVENTORY AND PRICES

Date store will open(ed)

Date store will have minimum and non-WIC inventory in stock

Number of Cash Registers

Number or Scanners

Can scanners detect WIC eligible foods?

Yes

No

Does this store have a point of sale device?

Yes

No

VM-112

FORM 3771A (11/2011)


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment VM-6 (cont'd)

Food Item

1.

Juice

Brand Name

2.

Cereal

3.

Peas/Beans

Peas/Beans

4.

Peanut Butter

Infant Cereal

5.

Rice

6.

Gerber Good Start Gentle

Gerber Good Start Soy

7.

Gerber Good Start Gentle

Gerber Good Start Soy

Whole Pasteurized

8.

Milk

9.

2%, 1% or Skim Milk

10.

Dry Milk

11.

Cheese

12.

Eggs (Large Only)

13.

Fresh Fruit

14.

Fresh Vegetables

15.

Bread

Fish Tuna or

16.

Salmon

17.

Baby Food Fruits and vegetables

18.

Baby Food Meats

Size
46-48 oz. bottle
64 oz. plastic bottle
11-36 oz. box Size _____
1 pound bag 14-16 oz cans
16-18 oz. jar
8 oz. container 13 oz. can concentrate
13 oz. can concentrate 12.7 oz. can powdered 12.9 oz. can powdered 1 gallon container (Least Expensive) 1 gallon container (Least Expensive) Makes 3 quarts
1 pound package (Least Expensive) 1 dozen carton (Least Expensive) 10 pounds 10 pounds 16 oz. loaf

Highest Price or Least Expensive where indicated

5 oz. can 7.5 or 14.75 oz can Product_________ Size____________
4 oz. jar or twin pack (2 x 3.5 oz. plastic)
2.5 oz. jar

On-Site Price

VM-113

FORM 3771A (03/2011)


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment VM-6 (cont'd)

Please ensure that this store location has the following inventory, as well as a substantial amount of nonWIC inventory, in stock by the date you specified above. Failure to do so will result in denial of the application.

Food Item
19. Juice 20. Juice
Cereal 21. (2 types must be Whole Grain)
22. Dried Peas/Beans 23. Canned Peas/Beans
24. Peanut Butter Infant Cereal
25. (1 type must be rice)
26. Gerber Good Start Gentle 27. Gerber Good Start Soy
28. Gerber Good Start Gentle 29.
Gerber Good Start Soy 30. Pasteurized Milk - whole 31. Pasteurized Milk 2%, 1% or
skim 32. Dry Milk non-fat
OR Evaporated 33. Cheese 34. Eggs (Large Only) 35. Bread 36. Fruit (fresh and canned or frozen) 37. Vegetables (fresh and canned or frozen) 38. Fish Tuna Salmon 39. Baby Food Fruits
40. Baby Food Vegetable
41. Baby Food Meat

Brands (B)
Types (T)
2 (T) 2 (T)

Size
46-48 oz. 64 oz.

4 (T)

11 to 36 oz.

2 (T) 2 (T)

1 lb. pkg. 14-16 oz.

2 (B)

16-18 oz.

2 (T)

8 oz.

1 (B) 1 (B)

13 oz. 13 oz.

1 (B)
1 (B) 1 (B)

12.7 oz. (powder) 12.9 oz. (powder) 1 gallon

1 (B) 1 (B)

1 gallon Makes 3 qt.

1 (B) 2 (T)
1 (B) 1 (B)

12 oz 1 pound
1 dozen 16 oz. loaf

4 (T)

10 pounds

4 (T) 1 (T)

10 pounds 5 oz can 7.5 -14.75 oz. can

2 (T) 2 (T) 2 (T)

4 oz. or twin pack (2 x 3.5 oz. plastic)
4 oz. or twin pack (2 x 3.5 oz. plastic) 2.5 oz.

Minimum Quantity
12 12
24
5 18
6
12
30 20
50
20 8
12 3 boxes
12 cans 8 8 6
10 lbs.
10 lbs. 18
combined
96 combined
31

VM-114

FORM 3771A (11/2011)


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment VM-6 (cont'd)

STORE OPERATIONS

Hours of Business Sunday Monday Tuesday Wednesday

Open 24 Hours

Thursday Friday Saturday

Signature of Authorized Representative Authorized Representative (Type or Print)
Telephone Number

Date Title (Type or Print)

VM-115

FORM 3771A (03/2011)

GEORGIA WIC 2012 PROCEDURES MANUAL

Please print all information.
STORE NAME & NUMBER or
PARENT/CORPORATE OFFICE
(Provide Parent Office or Corporation information if this
is initial or re-authorization training for WIC corporate
vendor status)
I have been trained on and I understand:

GEORGIA WIC PROGRAM VENDOR TRAINING CHECKLIST
AUTHORIZED TRAINING

Attachment VM-7
VENDOR NUMBER (if applicable)

1.

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

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.

I understand the vendor's responsibility for adhering to the selection criteria throughout the agreement period. This

includes but is not limited to:

a. Stocking a minimum quantity and variety of approved WIC foods daily

b. Stocking at least 200 items in each category of non-WIC food inventory daily

c. Maintaining prices that are compatible to stores in same peer group

d. Compliance with Supplemental Nutrition Assistance Program (SNAP - formally the Food Stamp Program)

regulations

e. Maintaining a favorable business integrity

f. The prohibition of the unauthorized use of the WIC acronym and logo

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 and non-WIC food items on a daily basis.

6.

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

7.

The requirement to purchase infant formula from an approved list of infant formula suppliers and how to obtain the

Georgia WIC Approved Infant Formula Supplier List.

8.

The procedures for redeeming Georgia WIC vouchers/Cash Value Fruit and Vegetable Vouchers (CVFVV), the use

of the vendor stamp, and the requirement to enroll in the Automatic Clearing House (ACH) following authorization to

the Georgia WIC Program.

9.

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

10.

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.

11.

The Georgia WIC Program's vendor complaint process.

12.

The Vendor Sanction System and violations of program, including the federally mandated sanctions (including

incentive item violations), disqualification periods, vendor claims, and civil money penalties. Disqualifications from

the Georgia WIC Program may result in disqualification from SNAP.

13.

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 VERSION OF GEORGIA'S WIC VENDOR HANDBOOK.

Signature of Store/Corporate Representative

Date

Print Name
Form 3757 (Rev. 08-11)

Title
VM-116

GEORGIA WIC 2012 PROCEDURES MANUAL
GEORGIA WIC PROGRAM CORPORATE VENDOR TRAINING CHECKLIST
Complete for each store under the Corporate Agreement.

Attachment VM-8

CORPORATE VENDOR NAME
STORE NAME & NUMBER

VENDOR NUMBER (if applicable)

A representative from my company has trained me and I understand:

1. The purpose of the Georgia WIC Program and how to contact Georgia WIC.
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. I understand the vendor's responsibility for adhering to the selection criteria throughout the agreement period. This includes but is not limited to: a. Stocking a minimum quantity and variety of approved WIC foods daily b. Stocking at least 200 items in each category of non-WIC food inventory daily c. Maintaining prices that are compatible to stores in same peer group d. Compliance with Supplemental Nutrition Assistance Program (SNAP - formally the Food Stamp Program) regulations e. Maintaining a favorable business integrity f. The prohibition of the unauthorized use of the WIC acronym and logo
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 and non-WIC food items on a daily basis.

6. The requirement to purchase infant formula from an approved list of infant formula suppliers and how to obtain the Georgia WIC Approved Infant Formula Supplier List.
7. The types of valid WIC vouchers, the procedures for transacting Georgia WIC vouchers

8. The procedures for redeeming Georgia WIC vouchers/Cash Value Fruit and Vegetable Vouchers (CVFVV), the use of the vendor stamp, and the requirement to enroll in the Automatic Clearing House (ACH) following authorization to the Georgia WIC Program.
9. Returned voucher payment procedures and the provision for Georgia WIC to make price adjustments.
10. 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.

11. The Georgia WIC Program's vendor complaint process.
12. The Vendor Sanction System and violations of program, including state agency sanctions, federally mandated sanctions (including incentive item violations), disqualification periods, vendor claims, and civil money penalties. Disqualifications from the Georgia WIC Program may result in disqualification from SNAP.
13. 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 VERSION OF GEORGIA'S WIC VENDOR HANDBOOK.

Signature of Store/Corporate Representative

Date

Print Name

Title

VM-117

GEORGIA WIC 2012 PROCEDURE MANUAL

DEPARTMENT OF HEALTH GEORGIA OFFICE OF NUTRITION AND WIC
INCIDENT/COMPLAINT FORM

District/Unit/Clinic: Date of Incident:
Follow-up Date:

County: Date Reported:

Type of Complaint: Participant Vendor Civil Rights Local Agency/State WIC Branch Staff Other:

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:

State Office of Nutrition and WIC Resolution/Comments: Follow-up Report: Office of Nutrition and WIC, Customer Service Coordinator:

VM-118

Attachment VM-9
Wait time Customer Service Transfer Appointment Formula
Local Agency/State Office of Nutrition and WIC Information Staff Name: Phone:
Can Complaint be Closed at Local Agency? Yes No Signature and Title: Date:
Can Complaint be Closed at State Office of Nutrition and WIC? Yes No Signature and Title:
Date:

GEORGIA WIC 2012 PROCEDURES MANAUL

Attachment VM-10

VM-119

GEORGIA WIC 2012 PROCEDURES MANAUL

Attachment VM-10 (cont'd)

VM-120

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment VM-10 (cont'd)

VM-121

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment VM-10 (cont'd)

VM-122

GEORGIA WIC 2012 PROCEDURES MANUAL _

Attachment VM-10 (cont'd)

VM-123

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment VM-11



VM-124

GEORGIA WIC 2012 PROCEDURES MANUAL

Vendor Management VM-12

Above 50% Application Verification Date: ___________________________________________ QAS: ____________________________________________ Store Name: ______________________________________ Vendor Number, if applicable: _________________________

The assessment of this vendor's potential to be an above 50% vendor has revealed the following:
_____ The vendor is dependent upon the authorization of WIC before it can open for business
_____ The vendor carries mostly WIC approved food items and is deficient in the nonWIC food item categorized by USDA as food
_____ The dollar amount assessment of WIC food items to all food items purchased for sell denotes that the applicant vendor has the potential to be an above 50% vendor.
_____ The applicant will not accept more than 3 types of payment for food items and as such will be expected to accept WIC food instruments as the primary source of payment for supplemental food items
_____ The vendor currently has at least one authorized WIC location that has been categorized as an above 50% vendor
_____ Vendor failed to submit requested documentation by the stated deadline
_____ The vendor is not expected to derive more than 50% of it's total food sales form the sale of WIC food items.

Summary of Findings:_______________________________________________________________ ______________________________________________________________________ ______________________________________________________________________
________ Application is approved
________ Application is denied for meeting the above 50% criterion

Verified by Vendor Relations Manager (Initial) ________ Date ____________

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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 Package Categories .................................................................................... FP-3 C. Food Packages ..................................................................................................... FP-4 D. Required Documentation.................................. ............................................. FP-5
III. Infants ......................................................................................................................... FP-6 A. Tailoring................................................................................................................. FP-7 B. Feeding Type Assignment..................................................................................... FP-8 C. Food Package Assignment ................................................................................... FP-9 D. Matching Mother/Baby Food Packages................................................... FP-11 E. Manual Food Packages....................................................................................... FP-11 F. Rounding Infant Age............................................................................................ FP-12 G. Request for Additional Formula........................................................................... FP-12 H. Physical Form ..................................................................................................... FP-13
IV. Women, Children and Infants with Qualifying Medical Conditions ............................ FP-13 A. Qualifications for Food Package III Issuance ...................................................... FP-14 B. Disqualifications for Food Package III Issuance.................................................. FP-14 C. Food Package ..................................................................................................... FP-15 D. Tailoring............................................................................................................... FP-15 E. Food Package Assignment ................................................................................. FP-15 F. Manual Food Package ........................................................................................ FP-17 G. WIC Foods ......................................................................................................... FP-17 H. Responsibilities .................................................................................................. FP-18 I. Maximum Amounts .............................................................................................. FP-18
V. Children 1 to 5 Years ................................................................................................ FP-18 A. Tailoring............................................................................................................... FP-19 B. Food Package Assignment ................................................................................. FP-19 C. Manual Food Package ........................................................................................ FP-19 D. WIC Foods ......................................................................................................... FP-19 E. Milk Alternative .................................................................................................... FP-21 F. Additional Documentation .................................................................................. FP-21

GEORGIA WIC 2012 PROCEDURES MANUAL

Food Package

VI. Women...................................................................................................................... FP-22 A. Food Package V.................................................................................................. FP-22 B. Food Package VI................................................................................................. FP-22 C. Food Package VII................................................................................................ FP-22 D. Tailoring............................................................................................................... FP-23 E. Food Package Assignment ................................................................................. FP-23 F. Manual Food Package ........................................................................................ FP-23 G. WIC Foods ......................................................................................................... FP-24 H. Milk Alternatives ................................................................................................. FP-25 I. Additional Documentation ..................................................................................... FP-26
VII. Homelessness, Migrancy, and Disaster Situations ................................................... FP-26 A. Alternate Food Package Assignment .................................................................. FP-26 B. Food Package Assignment ................................................................................. FP-26 C. Manual Food Package ....................................................................................... FP-27 D. Assignment of Food Package Code.................................................................... FP-27
VIII. Medical Documentation............................................................................................. FP-28 A. Situations Requiring Medical Documentation ..................................................... FP-28 B. Acceptable and Unacceptable Forms of Documentation .................................... FP-29 C. Required Medical Documentation Components ................................................ FP-30 D. Verbal Orders ..................................................................................................... FP-31 E. Frequency and Records ..................................................................................... FP-32 F. Issuance of Ready-to-Feed Products ................................................................. FP-33 G. Medical Diagnoses ............................................................................................. FP-34
IX. Formula Distribution/Tracking Guidelines ................................................................. FP-36 A. Reasons to Issue Formula .................................................................................. FP-36 B. Maximum Amount to be Issued........................................................................... FP-36 C. Documentation .................................................................................................... FP-36 D. Disposal of Expired Formula ............................................................................... FP-37 E. Staff Resonsiblity...................................................................................FP-37
X. Nutrition Services Unit Special Formula Orders........................................................ FP-37 A. Ordering ............................................................................................................. FP-37 B. Tracking Log ....................................................................................................... FP-37 C. Amount to Order ................................................................................................. FP-38 D. Special Formula Order Form............................................................................... FP-38 E. Frequency .......................................................................................................... FP-38



GEORGIA WIC 2012 PROCEDURES MANUAL

Food Package

F. Medical Documentation ...................................................................................... FP-39 G. Printing Tracking Voucher .................................................................................. FP-39 H. Flavor ................................................................................................................. FP-39 I. Processing the Order ......................................................................................... FP-39 XI. Emory Genetics......................................................................................................... FP-40 A. Emory Genetics Prescriptions ............................................................................. FP-40 B. Provision of Formula and WIC Foods .................................................................. FP-41 C. Breastfeeding ...................................................................................................... FP-41 XII. Creating 999 Food Packages.......................................................................FP-41

Attachments: FP-1 Formula Summary: Standard Formulas for Infants and Children ........................... FP-43 FP-2 Contract Formula Food Packages for Fully Formula Fed Infant.............................. FP-46 FP-3 Food Packages for Exclusively Breastfed Infant ..................................................... FP-54 FP-4 Contract Formula Packages for Mostly Breastfed Infant ......................................... FP-55 FP-5 Contract Infant Formula Packages for Children .............................................FP-62 FP-6 Formula Summary: Non-Contract Standard Formulas..................................... FP-64 FP-7 Non-Contract Standard Formula Food Packages for Fully Formula Fed
Infant....................................................................................................................... FP-68 FP-8 Non-Contract Standard formula Food packages for Mostly Breast Fed Infant........FP-76 FP-9 Non-Contract Standard Formula Food Packages for Children ................................ FP-86 FP-10 Summary of Food Packages for Women and Children .......................................... FP-88 FP-11 Prenatal/Mostly Breastfeeding Woman ................................................................... FP-91 FP-12 Non-Breastfeeding Postpartum /Some Breastfeeding Woman ............................. FP-105 FP-13 Exclusively Breastfeeding Single Infant/Prenatal Pregnant with Multiples ........... .FP-118 FP-14 Exclusively Breastfeeding Multiples...................................................................... FP-133 FP-15 Children 12 23 months........................................................................................ FP-155 FP-16 Children 2 5 years............................................................................................... FP-165 FP-17 Special Formula Summary (Food Package III) ..................................................... FP-178 FP-18 Special Formulas for Fully Formula Fed Infants (Food Package III) ..................... FP-186 FP-19 Food Package III - Special Infant Formulas for Children ....................................... FP-218 FP-20 Food Package III - Special Formulas for Children........................ ..................FP-226 FP-21 Food Package III - Special Formulas for Women .................................................. FP-243 FP-22 Tracking Food Packages ...................................................................................... FP-252


GEORGIA WIC 2012 PROCEDURES MANUAL

Food Package

FP-23 Special Formula Packages for 6 11 Month Old Infants unable to Eat Solids .................................................................................................................... FP-254
FP-24 Maximum Monthly Amounts Authorized - Fully Formula Fed Infant ...................... FP-264 FP-25 Maximum Monthly Amounts Authorized - Mostly Breastfed Infant ........................ FP-266 FP-26 Maximum Monthly Amounts Authorized - Infant Foods ......................................... FP-268 FP-27 Voucher Codes for Special Formula Packages for Mostly Breastfeeding
Infants Maximum Amounts....................................................................FP-269 FP-28 Supplemental Formula Conversion Table - Modulars ........................................... FP-274 FP-29 Maximum Monthly Amounts of Formula Authorized for
Children and Women with Qualifying Conditions Food Package III ...................... FP-275 FP-30 Maximum Monthly Amounts of WIC Foods Authorized for Children...................... FP-276 FP-31 Maximum Monthly Amounts of WIC Foods Authorized for Women ...................... FP-277 FP-32 Maximum Monthly Amounts for WIC Foods Authorized for
Alternate Food Packages ..................................................................................... FP-279 FP-33 How to Convert Breastfeeding Packages .............................................................. FP-282 FP-34 Infant Formula Sequencing Exceptions ................................................................. FP-285 FP-35 WIC-Approved Formulas/Medical Foods .............................................................. FP-286 FP-36 Formula Manufacturer's Contact Information ....................................................... FP-291 FP-37 Special Formula Order Form ................................................................................. FP-292 FP-38 Special Formula Order Tracking Form .................................................................. FP-293 FP-39 Milk/Cheese/Tofu Substitution Tables ................................................................... FP-294 FP-40 Instructions for Medical Documentation Form (Form 1) ........................................ FP-296 FP-41 Medical Documentation Form (Form 1) ................................................................. FP-303 FP-42 Instructions for Medical Documentation Referral Form / Special Food Substitutions
(Form 2) ................................................................................................................ FP-305 FP-43 Referral Form and Medical Documentation /Special Food Substitutions (Form 2) FP-310 FP-44 Georgia WIC-Approved Foods List, Criteria to Evaluate an
Eligible Food Item ... ............................................................................................. FP-312 FP-45 WIC-Approved Foods List October 2011............................................................... FP-316 FP-46 Formula Tracking Log............................................................................................ FP-321 FP-47 Calcium Fortified Juices / Guidelines, Procedures & Recommendations.............. FP-322
FP-48 List of Single Item or Special Vouchers for 999 Food Packages .......................... FP-323



GEORGIA WIC 2012 PROCEDURES MANUAL

I. AUTHORIZATION OF FOODS

Food Package

A Competent Professional Authority (CPA)* shall prescribe the categories of authorized supplemental foods in quantities that do not exceed the regulatory maximum and are appropriate for the participant, taking into consideration the participant's age, nutritional needs, and feeding type. The provision of less than the maximum monthly allowances of supplemental foods to an individual WIC participant is appropriate only when:

1. Medically or nutritionally warranted (e.g., eliminate a food due to an allergy);

2. A participant refuses or cannot use the maximum monthly allowances.

The amounts of supplemental foods shall not exceed the maximum quantities specified in this Section. All participants/caregivers should be instructed on how to select WIC-approved foods to receive their maximum allowance.

*A CPA is a nutritionist, Registered Dietitian, Licensed Dietitian, Registered Nurse, Licensed Practical Nurse, physician, or Physician Assistant who has been trained by the State or local agency to perform WIC assessments.

II. PRESCRIBING FOODS, GENERAL

A. Contract Versus Non-Contract Formula

The State of Georgia has entered into a contract with Nestl Nutrition / Gerber (effective date: October 1, 2010 through September 30, 2013), to provide formula for WIC participants. All infants participating in Georgia WIC will be provided with vouchers for a contract formula. The contract infant formulas are Gerber Good Start Gentle (milk-based), Gerber Good Start Soy (soy-based), Gerber Good Start 2 Gentle and Gerber Good Start 2 Soy. This contract also covers children and women who require a contract infant formula as a source of nutrition. The contract currently provides a rebate on each container of Gerber Good Start Gentle, Gerber Good Start Soy, Gerber Good Start 2 Gentle, and Gerber Good Start 2 Soy purchased.
Contract formulas not requiring medical documentation for infants:
Gerber Good Start Gentle Gerber Good Start Soy Gerber Good Start 2 Gentle * Gerber Good Start 2 Soy *
*For infants ages nine (9) through 11 (eleven) months only. Children require medical documentation to receive any formula products.
1. Milk-Based Formula:

All participants who receive a milk-based infant formula will receive the contract formula Gerber Good Start Gentle.

FP-1


GEORGIA WIC 2012 PROCEDURES MANUAL


Food Package

Georgia WIC does NOT APPROVE the following non-contract milkbased infant formulas for distribution for which medical documentation will NOT be accepted:
Gerber Good Start Protect Gerber Good Start 2 Protect Enfamil LIPIL 24 w/Iron Enfamil RestFull Enfamil PREMIUM Infant Enfagrow PREMIUM Next Step or Enfagrow PREMIUM Toddler Enfagrow PREMIUM Toddler Chocolate Enfagrow PREMUIM Toddler Vanilla Parent's Choice (milk-based) Similac Advance EarlyShield Similac Go & Grow EarlyShield Milk-Based Store brand milk-based infant formulas Organic formula (Any Type)

2. Soy-Based Formula:
All participants who receive a soy-based infant formula will receive the contract formula Gerber Good Start Soy.

Georgia WIC does NOT APPROVE the following non-contract soybased infant formulas for distribution for which medical documentation will NOT be accepted:
Enfagrow Soy Next Step or Enfagrow Soy Toddler Enfamil ProSobee Parent's Choice Soy Similac Go & Grow EarlyShield Soy-Based Similac Sensitive Isomil Soy or Similac Soy Isomil Store brand soy-based formulas that are USDA approved
3. Lactose-Reduced and Rice-Added Formula:
Participants requiring a milk-based, standard lactose-free, lactose-reduced, and/or rice-added infant formula may receive the following non-contract formulas with valid medical documentation of qualifying medical conditions:

Enfamil Gentlease Enfagrow Gentlease Next Step or Enfagrow Gentlease Toddler (age 9
months or older only) Enfamil A.R.
FP-2


GEORGIA WIC 2012 PROCEDURES MANUAL


Food Package

Similac Sensitive Similac Sensitive for Spit Up They may also receive store brand milk-based lactose-free, lactose-
reduced, and/or rice-added formulas approved by USDA (e.g., Parent's Choice Added Rice Starch).

4. Formula Changes:
Whenever medical condition(s)/diagnosis(es) warrant a change from the contract formula, WIC may provide the infant another approved formula upon receipt of proper medical documentation. Vouchers will specify the prescribed formula. Refer to Section VIII (Medical Documentation) for information regarding the required medical documentation for qualifying medical conditions.
B. Food Package Categories
There are seven (7) food package categories authorized by Federal WIC regulations. Each group is specified according to age, condition, and/or formula type (in the case of Food Package III). The groups are:

Food Package Name from the Federal WIC Regulations Food Package IA
Food Package IB
Food Package II

Age/Condition
Fully Formula Fed (FFF) infants ages 0 through 3 months Mostly Breastfed (MBF) infants ages 0 through 1 month Mostly Breastfed (MBF) infants ages 1 through 3 months
Exclusively Breastfed (EBF) infants ages 0 through 5 months
Fully Formula Fed (FFF) infants ages 4 through 5 months Mostly Breastfed (MBF) infants ages 4 through 5 months
Fully Formula Fed (FFF) infants ages 6 through 11 months Mostly Breastfed (MBF) infants ages 6 through 11 months Exclusively Breastfed (EBF) infants ages 6 through 11 months

Food Package Series Number
(Internal) A00-A99
E02 E60, E70 E99
E02 E60, E70 E99 F00 F99, J00 J99, K00 K99 E00
B00 B99
G00 G99 E00 E99, J00 J99, K00 K99 (D00 D99)
(H00 H99), (L00 L99), (M00 M99), (N00 N99) (E01)

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GEORGIA WIC 2012 PROCEDURES MANUAL


Food Package III
Food Package IV Food Package V Food Package VI Food Package VII

Medically fragile women, infants, and children with qualifying medical conditions receiving special formulas/medical foods
Children ages 1 through 4 years
Pregnant women Mostly breastfeeding women
Non-breastfeeding women Women breastfeeding some
Exclusively breastfeeding women Women pregnant with multiple fetuses Women mostly breastfeeding multiples

Food Package
R00 R99, (S00 S99), (T00 T99) X00 X99, Z00 Z99 C00 C99 W01 W19
W20 W39
W40 W79 (V60 V79)

C. Food Packages
Food Packages are foods from the Georgia WIC-Approved Foods List in combinations and amounts to meet USDA Federal regulations for WIC participants by WIC type.
Food packages translate the foods authorized in each food package category group into allowed amounts of Georgia WIC-approved foods. Food packages include standard food packages and packages to meet special nutritional needs (e.g., lactose intolerance). (See Attachments FP-1 to FP-22.)
All formulas, medical foods and supplemental foods that are authorized for distribution through WIC must first be determined WIC-eligible by the Food and Nutrition Service, United States Department of Agriculture. The Nutrition Services Unit may then approve distribution of the product through Georgia WIC.
1. Tailoring: Available state-created food packages contain the maximum amounts of allowed foods. This is called the "full nutritional benefit." Any food grouping that includes maximum amounts of allowed foods may be prescribed. (See Attachments FP-1 to FP-22 for a list of numbered food packages.)
No matter how many family members are participating in WIC, each participant's nutritional needs must be given individual consideration.
Participants or their caretaker should be advised that the supplemental foods issued are only for their personal use. However, the supplemental foods are not authorized for participant use while hospitalized on an inpatient basis. In addition, supplemental foods are not authorized for use in the preparation of meals served in a communal food service. This restriction does not preclude the provision or use of supplemental foods for
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GEORGIA WIC 2012 PROCEDURES MANUAL


Food Package

individual participants in a nonresidential setting (e.g., child care facility, family day care home, school, or other educational program); a homeless facility or a residential institution (e.g., home for pregnant teens, prison, or residential drug treatment center) that allows for individuals to store their WIC foods for their personal use apart from community prepared foods.

2. Assignment of CPA Food Package Code (CPA FPC): CPA FPC is the "umbrella" code assigned to a WIC participant that reflects the types and quantities of foods to be issued over a certification period. Each CPA FPC may be subcategorized into multiple internal food package codes based on the participant's age at voucher issuance and in the case of infants feeding type. The CPA assigns the CPA FPC that coincides with the types of foods desired based on the participant's category. If a state-created food package that meets the needs of the participant is not available, the CPA specifies the quantities/items desired and assigns a District/clinic-created 999 food package (i.e., food package in the 900-999 number series). A 999 food package may include any allowed food combination, up to the maximum allowed. Allowable foods and maximum quantities will vary depending on participant category. (Refer to Attachments FP-23 to FP-31 for maximum monthly amounts authorized; see Attachment FP-47 for voucher codes for single food items and small quantity vouchers.)

3. Assignment Method: The CPA must evaluate and assign food packages:

a. At each WIC assessment/certification

b. Upon receipt of medical documentation prescribing a new food/foods

c. At the request of the participant

Only WIC CPA staff is authorized to assign food packages.

D. Required Documentation

1. General Documentation:

a. During the WIC assessment/certification, the CPA must enter the CPA Food Package Code in the "Food Package" space provided on the WIC Assessment/ Certification Form or directly into the applicable field in the front-end computer system. Specific foods or voucher codes to be issued 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. Food package changes occurring within a valid WIC certification period must be documented 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

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GEORGIA WIC 2012 PROCEDURES MANUAL


Food Package

is not acceptable. Secondary nutrition education provided with food package changes must be documented in the medical record.

2. Medical Documentation:

Documentation from a health care provider is required for the following situations:
a. All lactose-reduced, lactose-free, and/or rice-added standard infant formulas (e.g., Enfamil Gentlease, Enfagrow Gentlease Next Step or Enfagrow Gentlease Toddler, Enfamil A.R., Similac Sensitive, Similac Sensitive for Spit Up, Parent's Choice Added Rice Starch, or other store brand milk-based lactose-free, lactose-reduced, and/or rice-added formulas approved by USDA).
b. Authorized non-contract infant formulas for infants, any infant formulas for children or women, any exempt infant formulas, and any medical foods (e.g., as indicated for chronic diseases or medical conditions).
c. Women and children who require more than one pound of cheese per month or women receiving Food Package VII who require more than three pounds of cheese per month.
d. Children who require any amount of tofu or soy milk.
e. Women who require more than four pounds of tofu or women receiving Food Package VII who require more than six pounds of tofu.
3. CPA documentation is required for:
a. Issuance of ready-to-feed formulas, unless ready-to-feed is the only available form of the product.
b. Disaster situations.
c. Issuing less than the maximum monthly allowance of supplemental foods (e.g., to omit a food due to a food allergy).
III. INFANTS
Food Package I is for infants 0 through five (5) months of age and consists only of ironfortified infant formula that is not an exempt infant formula. Food Package II is for infants six (6) through 11 (eleven) months of age and consists of iron-fortified infant formula, iron-fortified infant cereal, and infant fruits and vegetables. Infant cereal and infant fruits and vegetables may not be assigned to an infant less than 6 months old. Exclusively breastfed infants six (6) through 11 (eleven) months of age also receive infant meats. Food Packages I and II are designed for issuance to infants who do not have a medical condition qualifying them to receive Food Package III. Infant formula is the only category of formula authorized in this food package. Exempt infant formulas and WIC-eligible medical foods are authorized only in Food Package III.
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GEORGIA WIC 2012 PROCEDURES MANUAL


Food Package

Cow's milk and goat's milk are not authorized for infants in the first 12 (twelve) months of life.
Infant Formula: A nutritionally complete, iron-fortified standard or slightly modified (e.g., reduced-lactose or rice-added) formula for use in full-term infants. Infant formulas provide 20 (twenty) calories per fluid ounce at standard reconstitution. Examples include Gerber Good Start Gentle, Gerber Good Start Soy, Similac Sensitive, Similac Sensitive for Spit Up, Enfamil A.R., Enfagrow Gentlease Toddler, and Gerber Good Start 2 Soy.
Exempt Infant Formula: An infant formula designed for infants with medical conditions (e.g., prematurity, low birth weight, metabolic disorders, etc.). Some exempt infant formulas are also classified as medical foods. Examples of exempt infant formulas include EleCare for Infants, Nutramigen with Enflora LGG, premature infant formulas (such as Similac Expert Care NeoSure, Similac Special Care products, Enfamil Premature LIPIL 20, and Gerber Good Start Premature 24), Cyclinex-1, Similac Expert Care Alimentum, Enfaport LIPIL, Similac Expert Care for Diarrhea (formerly Isomil DF), Pregestimil LIPIL, and Neocate Infant.
Medical Foods: A WIC-eligible medical food refers to certain enteral products that are specifically formulated to provide nutritional support for individuals with a diagnosed medical condition when the use of conventional foods is precluded, restricted, or inadequate. Such WIC-eligible medical foods may be nutritionally complete or incomplete, but they must serve the purpose of a food, provide a source of calories and one or more nutrients, and be designed for enteral digestion via oral or tube feeding. WIC-eligible medical foods include many, but not all, products that meet the definition of medical foods. Examples of medical foods include PediaSure, EO28 Splash, Nutren 2.0, KetoCal 4:1, Boost, Pediasure Peptide, Peptamen Jr., Polycose, Boost Kid Essentials, Cyclinex-1, Portagen, and human milk fortifier.
To determine if a product is an infant formula, an exempt infant formula, or a medical food, visit the WIC Works Formula Database at the following website: http://riley.nal.usda.gov/wicworks/formulas/FormulaSearch.php .
A. Tailoring
1. Breastfed Infants: To fully establish the maternal milk supply, it is best if no formula is offered to infants prior to four (4) to six (6) weeks of age. If the mother requests it and the CPA deems it appropriate, one can of powder formula may be issued during the first month of life. However, large cans of powder formula (e.g., 22-25.7 oz. cans) cannot be issued as they exceed the maximum number of reconstituted fluid ounces (104 fluid oz.) allowed to be issued.
If a mother chooses to both breastfeed and formula feed her infant, powder formula is recommended. However, liquid concentrate formula is allowed if there is no powder version available. The CPA should assign a food package with only the amount of formula the infant requires (e.g., one can, two cans, or three cans powder). The CPA should reassess the infant's needs any time the mother requests more formula. Any problems with
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GEORGIA WIC 2012 PROCEDURES MANUAL


Food Package

breastfeeding should be addressed at this time. Requests for increases in the amount of formula should not be honored without assessment and counseling of the mother/baby dyad. Refer to Attachment BF-5 in the Breastfeeding Section for a chart to assist CPAs in determining the approximate amount of formula needed based on the infant's usual formula intake.

2. Formula Fed Infants: When the participant is not breastfed, a contract infant formula should be prescribed unless appropriate medical documentation is provided. The amount of formula provided varies with age and feeding type.

The issuance of any contract brand or non-contract brand infant formula that contains less than ten (10) milligrams of iron per liter at standard dilution (i.e., approximately 20 (twenty) kilocalories per fluid ounce of prepared formula) is prohibited.
3. Cereal: Cereal is not authorized for the infant 0 through five (5) months of age. Infants six (6) to 11 (eleven) months old will receive the full nutritional benefit of twenty-four (24) ounces of infant cereal per month.
4. Infant Fruits and Vegetables: Infant fruits and vegetables are containers of baby food in either 4 oz or 7 oz twin packs. They may be single ingredient or mixtures. Infant fruits and vegetables are not authorized for the infant 0 through five (5) months of age. The full nutritional benefit for Fully Formula Fed (FFF) and Mostly Breastfed (MBF) infants is 128 ounces (32 4 oz jars) of infant fruits and/or vegetables. Exclusively Breastfed (EBF) infants receive 256 ounces (64 4 oz jars or 18 7 oz) of infant fruits and/or vegetables. Georgia WIC authorizes only Stage 2 (2nd Foods) or Stage 2 1/2 infant fruits and vegetables.
5. Infant Meats: Infant meats are jars of baby food containing single-ingredient meats (e.g., baby food beef and beef broth or chicken and chicken gravy). Infant meat is not authorized for the infant 0 through five (5) months of age. The full nutritional benefit is 77.5 ounces (31 2.5 oz jars) of infant meat. No meat mixtures are allowed. Infant meat is only authorized for Exclusively Breastfed (EBF) infants six (6) through 11 (eleven) months of age.
B. Feeding Type Assignment

Three infant feeding options are available Exclusively Breastfed (EBF), Mostly Breastfed (MBF), or Fully Formula Fed (FFF).
1. Exclusively Breastfed (EBF) infants receive no formula from WIC.
2. Mostly Breastfed (MBF) infants receive formula in amounts that do not exceed the maximum allowed for mostly breastfed infants in the federal regulations (approximately half [50%] of the full formula package issued to FFF infants).
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GEORGIA WIC 2012 PROCEDURES MANUAL


Food Package

3. Fully Formula Fed (FFF) infants receive formula in excess of the amount allowed for mostly breastfed infants in the federal regulations. This feeding type assignment applies even if they are receiving some breast milk in addition to the formula.
C. Food Package Assignment
1. For Fully Formula Fed (FFF) infants each CPA Food Package Code (CPA FPC) represents three or more packages one for each infant age group (0 through three [3] months, four [4] through five [5] months, and six [6] through 11 [eleven] months). A different amount of formula is allowed for each age group. Infants age four (4) through five (5) months receive slightly more formula than do infants age 0 through three (3) months. Infants six (6) through 11 (eleven) months old receive less formula and the addition of baby cereal and infant food fruits and vegetables.
Georgia WIC computer systems are automated to progress the infant through these three age groups. The CPA FPCs for FFF infant packages start with an "A." The computer will issue internal system food packages beginning with an "A" to FFF infants ages 0 through three (3) months old, a "B" package to FFF infants ages four (4) through five (5) months old, and a "D" package to FFF infants ages six (6) through 11 (eleven) months old. However, the CPA FPC assigned by the CPA that began with an "A" and remains unchanged throughout the entire transition from birth through eleven (11) months of age, unless there is a food package change. The WIC computer system will automatically sequence the formula quantities and add the cereal and baby food to the food packages at the appropriate age.
2. Mostly Breastfed (MBF) infants are infants who receive formula from WIC in amounts that do not exceed the maximum allowed for mostly breastfed infants (approximately half [50%] of the full formula package issued to FFF infants).
a. Food Packages
Food packages containing the maximum formula allowed for a MBF infant begin with an "F." The computer will issue food packages beginning with an "F" to MBF infants ages one (1) month through three (3) months old, a "G" package to MBF infants ages four (4) through five (5) months old, and an "H" package to MBF infants ages six (6) through 11 (eleven) months old for the Mostly Breastfed maximum formula food package. Food packages for MBF infants needing only one (1) can, two (2) cans or three (3) cans of powder formula per month begin with "E," "K," and "J," respectively. The WIC computer system will automatically add the cereal and baby food to the food packages when the infant is six (6) months old.

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Food Package Code Begins With: F G H E K J L M N

Infant Age
1-3 months 4-5 months 6-11 months 0-5 months 1-5 months 1-5 months 6-11 months 6-11 months 6-11 months

Food Package
Formula Amount
Maximum MBF Maximum MBF Maximum MBF 1 can powder 2 cans powder 3 cans powder 1 can powder 2 cans powder 3 cans powder

b.

First Month

During the first month of life, the Mostly Breastfed (MBF) infant may not receive more than 104 reconstituted fluid ounces of formula from WIC (approximately one [1] can of powder formula). Formulas that are only available in large powder container sizes (e.g., 22-25.7 oz) cannot be issued to a MBF infant during the first month of life since their reconstituted yield exceeds the maximum allowed. CPAs must verify the formula yield per can prior to issuance of a 999 food package to a MBF infant during the first month of life. Infant formula issuance is limited during this time period to support the successful establishment of breastfeeding.

When an infant's initial certification is during the first month of life, the CPA will assign the CPA FPC that provides the amount of formula that should be issued after the first month. After entering the CPA FPC in the computer system, a second box will appear for the CPA to enter the FPC for the first month. From 0 to 20 (twenty) days of age this can either be E00 (no formula) or the appropriate FPC for one (1) can of powder formula (i.e., E17 for Gerber Good Start Gentle).

From 21 (twenty-one) days to one (1) month of age, the CPA is allowed a third choice for the first month's food package. Since the infant is almost one (1) month old, the CPA can assign the same package as the CPA FPC or the full amount of formula being prescribed after the first month. For example, entering F17 in the second box would provide the maximum formula amount of five (5) cans allowed for ages one (1) to three (3) months. This option is only available at the initial certification.

For additional formula to be issued during the first 30 days of life both mother and baby must be switched to some breastfeeding or fully formula feeding.

3. Exclusively Breastfed (EBF) infants receive no formula from WIC. At six (6) months of age, EBF infants receive infant cereal, infant fruits and vegetables, and infant meats. EBF infant food package codes are E00 and
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Food Package

E01. The computer will automatically advance the food package at age six (6) months from E00 to E01.

D.

Matching Mother/Baby Packages

"Mother/baby dyad" refers to the process of thinking of a mother and her infant as a unit or pair rather than as two individuals. The mother/baby dyad food packages must agree. For instance, the mother of an infant assigned a food package for an Exclusively Breastfed (EBF) infant must be issued a food package for an Exclusively Breastfeeding (EBF) woman. The table below matches the appropriate mother's food package to her infant's food package. The infant's food package should be assigned first since the mother's food package is based on the amount of formula her infant receives from WIC.

If Infant Receives: Exclusively Breastfed (EBF) food package (receives no formula from WIC) Mostly Breastfed (MBF) food package (does not exceed monthly formula allowance for Mostly Breastfed infant)
Formula in an amount that exceeds the monthly allowance for a Mostly Breastfed infant (e.g., a Fully Formula Fed [FFF] food package) and breast milk
Fully Formula Fed (FFF) food package and no breast milk

Then Mother Receives:

Federal Terminology:

Exclusively Breastfeeding (EBF) Fully Breastfed infant and Fully

woman food package

Breastfeeding Woman

Mostly Breastfeeding (MBF) woman food package
If less than 6 months postpartum: a Some Breastfeeding (SBF) woman food package If greater than 6 months postpartum: Some Breastfeeding (SBF) woman food package W80 (with no foods) If less than 6 months postpartum: Non-Breastfeeding woman food package

Partially Breastfed Infant and Partially Breastfeeding Woman where a singleton infant receives formula from the WIC program in amounts that does not exceed the maximum allowances for FP I-BF/FF A, B, C or II-BF/FF Partially Breastfed Infant and Partially Breastfeeding Woman where a singleton infant receives formula from the WIC program in amounts that exceeds the maximum allowances for FP IBF/FF A, B, C or II-BF/FF
Fully Formula Fed

If greater than 6 months postpartum: mother is no longer WIC eligible

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E.

Manual Food Package

Food Package

When Voucher Printing on Demand (VPOD) is not available, a manual food package for age or equivalent (i.e., concentrate or powder) should be issued to infants. Manual vouchers are available for Gerber Good Start Gentle for food packages A17, B17, and D17. If a manual food package is not available for the type and/or the amount of formula the infant receives, the food package should be issued on a blank voucher(s). When using blank vouchers for state-created food packages, the CPA FPC, the age-appropriate internal food package code (FPC), and the voucher code (VC) must be listed on the blank voucher. For example, a FFF four (4)-month-old infant on powder Similac Sensitive would be issued two vouchers each with the following codes: CPA FPC A31, FPC B31, and VC 353.

F.

Rounding Infant Age for Manual Food Package Issuance

"First Day to Use" date is the date the WIC participant is first allowed to cash their WIC voucher. When calculating infant's age to determine which food package to issue when using manual or blank vouchers, round as follows:

x If the infant's age on the "First Day to Use" date for the voucher is 0 to 15 (fifteen) days old, round down to nearest month.

x If the infant's age on the "First Day to Use" date for the voucher is 16 (sixteen) 30 (thirty) days old, round up to nearest month.

The WIC computer system will normally make this age determination. The WIC staff only have to calculate age when the WIC computer system is unavailable.

G.

Requests for Additional Formula for Mostly Breastfed (MBF) Infants

To promote breastfeeding, the infant should be issued the smallest amount of formula needed. Additional formula can be issued as long as the infant does not exceed the maximum monthly allowance for Mostly Breastfed (MBF) infants.

At no time should a mostly breastfed receive additional formula during the first 30 days of life after the initial certification. To receive more than one can of formula for the first month they most change feeding types to fully formula fed.

If the infant's needs exceed the maximum monthly allowance for Mostly Breastfed (MBF) infants and the mother has used some of her vouchers for that month, use the instructions in Attachment FP-32 to calculate whether a food package change can be made for the current month. The standard
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Food Package

woman's MBF food package W01 cannot be changed to food package W21 during the same month if voucher code W02 or both voucher codes 041 and 040 have already been spent by the mother. The women can be issued any foods allowed in the new food package that she has not already received by cashing a voucher from her old food package. State-created vouchers have been designed for use in converting the standard Mostly Breastfeeding package (W01) to the standard Some Breastfeeding or Non-Breastfeeding package (W21). See Attachment FP-32 on how to use voucher codes A34 and W71 to make this transition. If the infant's needs exceed the maximum monthly allowance for Mostly Breastfed (MBF) infants and the mother has used vouchers for that month which would result in her food package not being able to be converted to the new food package, then the food package change for both the infant and mother would be effective the following month.

If the mother has not used any of her vouchers for that month, then the clinic may void the current vouchers for the mother and re-issued the new food package. When reissuing the infant's vouchers take into consideration which, if any, of the infant vouchers have already been cashed. Subtract any formula already issued from the amount being reissued.

H.

Physical Form

Local agencies must issue all WIC formulas (infant formula, exempt infant formula and WIC-eligible medical foods) in concentrated liquid or powder physical forms. Ready-to-feed WIC formulas may be authorized when the CPA determines and documents that:

(1) The participant's household has an unsanitary or restricted water supply or poor refrigeration;

(2) The person caring for the participant may have difficulty in correctly diluting concentrated or powder forms; or

(3) The formula is only available in a ready-to-feed form.

In addition, participants with qualifying medical conditions who are assigned to Food Package III can also be issued ready-to-feed formulas for the additional reasons below:
(4) If the ready-to-feed form better accommodates the participant's medical condition (Food Package III clients only); or
(5) If the ready-to-feed form improves the participant's compliance in consuming the prescribed formula (Food Package III clients only).

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Food Package

IV. WOMEN, CHILDREN AND INFANTS WITH QUALIFYING MEDICAL CONDITIONS

Food Package III is reserved for issuance to women, infants and children who have a documented qualifying medical condition(s) that requires the use of a WIC formula (infant formula [children & women only], exempt infant formula or WIC-eligible medical food) because the use of conventional foods is precluded, restricted, or inadequate to address their special nutritional needs. Medical documentation must meet the requirements described in Section VI of the Food Package (FP) Section.

A. Qualifications for Food Package III Issuance 1. Food Package III requires two components: (a) Diagnosis of one or more qualifying medical conditions and (b) The prescription of: (1) An exempt infant formula or medical food for an infant, or (2) A medical food, infant formula, or an exempt infant formula for a woman or child

2. Qualifying medical conditions must be diagnosed by a health care professional licensed to write medical prescriptions in the State of Georgia. Qualifying medical conditions include, but are not limited to, premature birth, low birth weight, failure to thrive, inborn errors of metabolism and metabolic disorders, gastrointestinal disorders, malabsorption syndromes, immune system disorders, severe food allergies that require an elemental formula, and life threatening disorders, diseases and medical conditions that impair ingestion, digestion, absorption or the utilization of nutrients that could adversely affect the participant's nutrition status. Food Package III may not be issued solely for the purpose of enhancing nutrient intake or managing body weight (e.g., to treat "weight loss" or "poor weight gain").

B. Disqualifications for Food Package III

1. Food Package III is not authorized for infants whose only condition is:

a.

A diagnosed formula intolerance or food allergy to lactose,

sucrose, milk protein or soy protein that does not require the use

of an exempt infant formula; or

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b. A non-specific formula or food intolerance.

Food Package

2. Other participants who do not qualify for Food Package III include:
a. Infants receiving non-contract standard infant formulas.
b. Infants receiving standard infant formula via tube-feeding due to a medical condition.
c. Children or women diagnosed with a medical condition that does not require the use of a formula or medical food.

C. Food Packages
1. Infant food packages in Food Package III only consist of exempt infant formula or medical food(s) plus infant cereal and infant fruits and vegetables as allowed for age, if appropriate for the medical condition. Infant meats are not authorized for issuance in Food Package III since Exclusively Breastfed (EBF) infants by definition do not receive any formula from WIC and therefore could not be receiving exempt infant formula or medical food(s) as required for Food Package III.
2. Child and woman food packages in Food Package III may consist of infant formula, exempt infant formula, and/or medical food(s) and any of the foods in the standard children or women packages (cereal, juice, milk, cheese, whole grain bread or alternatives, beans, peanut butter, eggs, and fruits and vegetables). Children and women in Food Package III are also allowed to receive infant cereal, if appropriate for their medical condition(s).
D. Tailoring
Due to the varying ages and medical conditions, tailoring for Food Package III must be carefully individualized. Georgia WIC Medical Documentation Form for WIC Special Formulas and Approved WIC Foods (Form #1) allows the health care provider to list the name of the special formula prescribed and indicate which authorized supplemental foods, if any, are not allowed due to the participant's medical condition. (See section VIII of this Food Package [FP] Section of the manual for medical documentation procedures.)
E. Food Package Assignment
1. Infant
Each infant CPA Food Package Code (FPC) represents three packages one for each infant age group (0 through three [3] months, four [4] through five [5] months, and six [6] through 11 [eleven] months). A different amount of formula is allowed for each
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Food Package

age group. Infants four (4) through five (5) months of age receive slightly more formula than the 0 through three (3) month-old infant. Infants six (6) through 11 (eleven) months of age receive less formula, but with the addition of baby cereal and baby food fruits and vegetables. Infant CPA FPCs for exempt infant formulas begin with an "R." The computer will automatically sequence the infant through the "S" (four [4] through five [5] months) and "T" packages (six [6] through 11 [eleven] months).

Infants ages six (6) through 11 (eleven) months old who are unable to consume solid foods due to their qualifying medical condition(s) and who are assigned to Food Package III are eligible to receive formula at the higher maximum allowance rate allowed for infants ages four (4) through five (5) months old (based on their feeding method). If the infant age six (6) through 11 (eleven) months old is unable to eat any solid foods as indicated on the medical documentation form, the CPA can assign a CPA FPC code beginning with an "S" so that the infant can receive additional formula in place of the supplemental foods. Although used differently, the internal "S" food package is identical to the CPA FPC "S" package.

Exceptions there are a few powder exempt infant formulas that do not follow the standard sequencing described in the preceding paragraphs. The state-created food packages for powder Similac Expert Care Alimentum, Nutramigen AA LIPIL, and Pregestimil LIPIL have special sequencing patterns to avoid over or under issuance. (See Attachment FP-33 to view the sequencing patterns for these formulas.)
2. Women and Children
The food package codes for special formulas for women and children begin with an "X" or "Z." When the CPA assigns a special formula package beginning with an "X" or "Z," a second food package field will be enabled in the computer system to allow the CPA to enter a food package for the appropriate supplemental foods based on the medical documentation provided. The food package could be a child or woman's state-created food package or a 999 food package if none of the standard state-created food packages meet the medical food prescription. The special formula food package (food package beginning with an "X" or "Z") must be entered into the computer as the first food package code to enable the second field.
If the WIC participant only needs the "X" or "Z" package, enter "000" in the second food package field to indicate that supplemental foods do not need to be issued.
If none of the state-created formula food packages meet the prescription needs of the participant, a 999 food package can be assigned in the first box to allow the CPA to design an individualized package.
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Food Package

F. Manual Food Package
There is no standard manual food package for Food Package III. Each package is tailored to meet the participant's needs. If manual vouchers are needed, use blank vouchers.
G. WIC Foods
1. Children may receive any infant formula, pediatric formula or medical food on Georgia WIC-approved formula list. Women may receive any adult formula or medical food on Georgia WIC-approved formula list. (See Attachment FP-34 or visit Georgia WIC website at http://www.wic.ga.gov/wicformula.asp.)
2. The maximum amount of formula or medical food allowed is based on reconstituted fluid ounces of the product. To determine the maximum number of containers allowed, see Attachments FP-23, FP-24, and FP28. If the product does not have standard mixing instructions (e.g., many metabolic formulas), then the formula should be issued by weight. (See Attachments FP-23, FP-22, and FP-25.) If the prescribed product reconstitutes to an amount not listed or if the container size (if calculating by weight) is not on the tables, then call the Nutrition Services Unit for assistance.
Women and children may receive up to the maximum quantities allowed for their WIC category of the juice, milk, cereal, eggs, fruits and vegetables, whole wheat bread or alternative, peanut butter and beans/peas as prescribed by their health provider on the Medical Documentation Form (Form #1). No supplemental foods may be issued to a Food Package III participant without appropriate medical documentation. (See maximum food quantities for children on Attachment FP-29 and women on Attachment FP-30.)
Cereal: Infant cereal may be issued in place of adult cereals to children or women in Food Package III, if appropriate. Up to 32 ounces of infant cereal may be substituted for the 36 ounces of adult cereal for a woman or child in Food Package III if deemed appropriate by either the prescribing health care provider or by the CPA.
Infant Fruits and Vegetables: Jars of infant food fruits and vegetables cannot be issued to women or children on their WIC vouchers, even in Food Package III. However, women or children can use their cash value fruit and vegetable produce voucher to purchase baby food fruits and vegetables, if needed.
For a Food Package III participant, if the prescribing authority requests whole milk on the medical documentation form (Form #1 only), whole

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Food Package

milk may be issued to women and children over age two (2) years in Food Package III.

H. Responsibilities
Due to the nature of the health conditions of participants who are issued supplemental foods that require medical documentation, close medical supervision is essential for each participant's nutritional management. Per Federal regulations, this responsibility remains with the participant's health care provider for this medical oversight and instruction. This responsibility cannot be assumed by personnel at the WIC State or local agency. However, it is the responsibility of the local WIC agency to ensure that only the amounts of supplemental foods prescribed by the participant's health care provider are issued in the participant's food package. CPAs should provide high risk counseling according to WIC procedures.
Medical documentation and/or prescriptions signed by dietitians cannot be accepted. Dietitians do not have prescriptive authority as outlined in the laws of the State of Georgia. However, a Registered or Licensed Dietitian or CPA may:

a. Recommend to a physician, certified nurse practitioner, or physician assistant a suitable alternative formula, or

b. Refer a participant to a physician, certified nurse practitioner, or physician assistant for evaluation.

I.

Maximum Amounts:

(See Attachment FP-28 for maximum amounts of formula authorized for women and children.) The maximum amounts of formula, cereal, and infant food fruits and vegetables authorized for infants is the same as infants in Food Packages I and II. (See Attachments FP-23 to FP-25.) The maximum amount of supplemental foods for women and children is the same as the amounts they would have received had they not qualified for Food Package III. (See Attachments FP-29 to FP-30.)

V. CHILDREN AGES 1 through 4 YEARS
Food Package IV is for children 1 through 4 years of age. This food group consists of milk, cheese, cereal, juice, eggs, whole grain bread or alternative, fruits and/or vegetables, and beans/peas or peanut butter.

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A. Tailoring

Food Package

It is federally mandated that a food package be prescribed that provides the maximum monthly allowance of supplemental foods. This applies even when there are two (2) or more family members participating on WIC.
The CPA can assign a standard package or a package with an alternative dairy option such as lactose reduced milk or goat's milk.

B. Food Package Assignment

The food packages for children ages one (1) to five (5) years are listed in Attachments FP-14 and FP-15. Food package codes for children ages 12 through 23 months are C01 C13 and ages two (2) through five (5) years old are C21 C33. Refer to Attachments FP-29 for the maximum amounts of each food item allowed per month.
Children ages 24 months and older in Food Package IV are required by federal regulations to be issued only low-fat milk. Younger children (ages 12 through 23 months old) are only authorized to receive whole milk from WIC. The computer system will automatically transition a child from the whole milk food package to the low-fat milk food package on the first set of vouchers printed with a "First Day to Use" date on or after the child is age 23 months, 16 days old.

C. Manual Food Package

When Voucher Printing on Demand (VPOD) is not available, a manual food package should be issued. If a manual food package is not available for the food package the child receives, then the food package should be issued using blank vouchers.

Manual vouchers are available for the standard food packages for children: C01 for children ages 12 through 23 months and C21 for children 2 through 5 years old.

D. WIC Foods

1. Juice: Children will be issued single strength juice in 64 oz bottles.
2. Milk: Children greater than 23 months 15 days of age will have a choice between two standard food packages C21 (with 1 pound of cheese substituted for part of the milk) or C28 (with all milk and no cheese). Food package C21 does include one box of dry powder milk or four 12-oz cans of evaporated milk in order to provide the full nutritional benefit mandated by federal regulation. If the participant does not want the dry powder/evaporated milk, the clinic can issue food package C28 with no cheese instead.
Participants who prefer evaporated milk can be issued the state created
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Food Package

evaporated milk food package C12 (12-23 months) or C32 (2 through 5 years).

The standard package for children 12 through 23 months of age contains whole milk and no cheese. A 999 food package can be used to issue cheese to this age group. Federal regulations prohibit issuance of low-fat milk by WIC to children ages 12 through 23 months old. Therefore, prescriptions for low-fat milk cannot be accepted for any reason for children in this age group. Children ages 12 through 23 months old with a medically indicated need to reduce their fat or caloric intake should be instead provided appropriate nutritional counseling according to standard high risk education procedures.

Children ages 24 months and older will receive low-fat milk. Prescriptions for whole milk cannot be accepted for any reason for children ages 24 months or older receiving Food Package IV. (Note: Only children ages 24 months or older receiving a formula or medical food due to a qualifying medical condition [in Food Package III] can be issued whole milk if the medical documentation provided allows milk issuance.)

3. Cheese: The standard food package for children 12 through 23 months old does not include cheese. However, a 999 food package containing cheese can be created for children.

For children 2 through 5 years of age, the CPA may assign a food package with or without cheese substituted for a portion of the milk allowance. The food package containing cheese has some of the milk given in the dry powder form.

Additional cheese may be issued in place of milk to children with medical documentation. When "extra cheese" is prescribed, any remaining milk allotment must be issued in full. This may require the issuance of either dry powder milk or evaporated milk for a portion of the milk allowance. (See Attachment FP-38 for a chart listing the amount of fluid and dry powder milk to be issued based on the amount of cheese prescribed.) Issuing greater than one (1) pound of cheese per month to a child requires medical documentation.

4. Fruits and Vegetables: The fruit and vegetable voucher cannot be counted when prorating vouchers. If a participant is eligible to receive any voucher for the month, the participant must be issued the fruit and vegetable voucher.

5. Peanut Butter: The food packages for children ages 12 through 23 months old do not contain peanut butter because of the risk of choking.

6. Cereal: Infant cereal cannot be issued to children ages 1 through 5 years in Food Package IV. Only children with qualifying medical conditions who are receiving formulas or medical foods in Food Package III are eligible to receive infant cereal in place of adult cereal.

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Food Package

7. Jars of infant food fruits and vegetables cannot be issued to children on their WIC vouchers. However, children can use their cash value fruit and vegetable produce voucher to purchase baby food fruits and vegetables, if needed.

8. Other WIC Foods: For information on package sizes and restrictions see Georgia WIC-Approved Food List (Attachment FP-43).

E. Milk Alternatives

For children, cheese, calcium-set tofu, or soy milk may be substituted for milk as described below. The issuance of any soy milk, any tofu, or extra cheese (greater than 1 pound per month) to children requires medical documentation to ensure that the medical provider is aware that the child is receiving a cow's milk substitution. Medical documentation can include religious and cultural reasons (e.g., vegan or vegetarian) as acceptable reasons to issue soy milk and tofu.
Cheese: Cheese may be substituted for milk at the rate of 1 pound of cheese per 3 quarts of milk. A maximum of 1 pound of cheese can be substituted in this manner without requiring medical documentation. With medical documentation of a qualifying medical condition such as lactose intolerance, additional amounts of cheese may be substituted up to the maximum of four (4) pounds of cheese.
Soy Milk: Soy milk may be substituted for cow's milk at the rate of 1 quart of soy milk for 1 quart of milk, up to the total maximum monthly allowance of milk (16 quarts). Children must have medical documentation of a qualifying medical condition to receive any amount of soy milk.
Tofu: Calcium-set tofu may be substituted for milk at the rate of 1 pound of tofu per 1 quart of milk, up to a maximum of 8 pounds of tofu per month. Children must have medical documentation for a qualifying medical condition to receive any amount of tofu.

F. Additional Documentation

CPAs must thoroughly document any situation in which less than the full maximum allotment of a supplemental food is issued to a participant (e.g., at the participant's request, due to a food allergy, etc.).
Medical documentation is required in the following situations:
1. Any authorized soy milk or tofu issued to children.

2. Any authorized cheese issued to children that exceeds the maximum substitution rate of one (1) pound per month.

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VI. WOMEN

Food Package

Women participating in WIC and who do not have a medical condition qualifying them for Food Package III are categorized into three Federal Food Packages: V, VI, and VII. Each Federal Food Package consists of different quantities of supplemental foods, different allowed supplement foods, and/or different eligibility periods and requirements.

A. Food Package V is for two categories of women:

(1) Women with a singleton pregnancy ("Prenatal")

(2) Women who are mostly breastfeeding up to one year postpartum ("Mostly Breastfeeding Women") and whose Mostly Breastfed (MBF) infants receive formula from Georgia WIC in amounts that do not exceed the maximum allowances for Mostly Breastfed infants.

Food Package V consists of milk, cheese, cereal, juice, eggs, whole grain bread or alternative, fruits and/or vegetables, beans/peas or peanut butter.

B. Food Package VI is for two categories of women:

(1) Women up to six months postpartum who are not breastfeeding their infants ("Non-Breastfeeding/Fully Formula Feeding Women"). At six months postpartum, the non-breastfeeding postpartum women are no longer eligible for WIC.

(2) Breastfeeding women ("Some Breastfeeding") accepting formula for their infants in amounts that exceed the maximum monthly allowance for Mostly Breastfed (MBF) infants. At six months postpartum, the breastfeeding women in Food Package VI will no longer be issued supplemental foods in their food package (CPA FPC W80) but do remain eligible for WIC. Such women may remain on WIC as breastfeeding participants and receive nutrition education and breastfeeding support if in a current certification (up until they discontinue breastfeeding or their infants reach age 12 months, whichever happens first).

Food Package VI consists of milk, cheese, cereal, juice, eggs, fruits and/or vegetables, beans/peas or peanut butter. Refer to Attachment FP-30 for the authorized foods and the maximum amounts allowed per month for women.

C. Food Package VII is for four categories of women:

(1) Breastfeeding women up to one year postpartum whose infants do not receive any formula or medical foods from WIC ("Exclusively Breastfeeding Women"). These women are assumed to be exclusively breastfeeding their infants.

(2) Women who are pregnant with two or more fetuses ("Prenatal with Multiples").

(3) Women who are mostly breastfeeding multiple infants ("Mostly Breastfeeding Multiples") from the same pregnancy.

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Food Package

(4) Food Package VII also includes a "super" food package for women exclusively breastfeeding multiple infants ("Exclusively Breastfeeding Multiples") from the same pregnancy. None of the infants of a woman in this classification can receive any formula or medical foods from WIC in order for the woman to qualify for this "super" food package. This package contains 1.5 times the amount of foods in the standard Food Package VII. Each of these "super" food packages consists of two monthly packages that are issued in alternating months. The rotation is done automatically by the computer system.

Food Package VII consists of milk, cheese, cereal, juice, eggs, whole grain bread or alternative, fruits and/or vegetables, beans/peas, peanut butter and fish. Refer to Attachment FP-30 for the authorized foods and the maximum amounts allowed per month for women.

D. Tailoring
It is federally mandated that the maximum monthly allowance be prescribed. This applies even where there are two (2) or more family members participating on WIC.

The CPA can assign a standard package or a package with an alternative dairy option such as goat milk, tofu, or soy milk.

E. Food Package Assignment

The food packages for women are listed on Attachments FP-10 to FP-13. The Food Package Codes (FPCs) for Prenatal and Mostly Breastfeeding Women are W00 W13. The FPCs for Postpartum Non-Breastfeeding/Fully Formula Feeding and Some Breastfeeding Women are W20 W33 plus W80 for Some Breastfeeding women greater than 6 months postpartum. The FPCs for Exclusively Breastfeeding Women are W40 W79.

The food package assigned to a breastfeeding mother is determined by the food package her infant(s) is receiving. If at any time the mother requests an additional amount of formula, the CPA should reassess the mother/baby pair to determine what changes need to be made to both the mother's and the infant's food package and feeding type. CPAs must change both the food package of the mother and infant(s) to reflect any changes in their joint status; for example, transitioning from Exclusively Breastfeeding to Mostly Breastfeeding or from Mostly Breastfeeding to Some Breastfeeding. Refer to Attachment FP-30 for the authorized foods and the maximum amounts allowed per month for women.
F. Manual Food Package
When Voucher Printing on Demand (VPOD) is not available, a manual food package should be issued. If a manual food package is not available for the food package the woman receives, then a food package should be issued using blank vouchers.

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Food Package

The standard food package for Prenatal and Mostly Breastfeeding Women is W01. For Non-Breastfeeding/Fully Formula Feeding Women and Some Breastfeeding Women the standard food package is W21. It is W41 for Exclusively Breastfeeding Women.

G. WIC Foods
1. Juice Women have a choice of three forms of juice frozen concentrate, pourable concentrate, or 46 to 48 oz containers of single strength juice.
2. Milk
Only low-fat milk is allowed for women. Women in Food Package V or VII have a choice of two standard packages one with cheese and one without cheese. The package containing cheese also contains one box of dry powder milk or four 12-oz cans of evaporated milk in order to provide the full nutritional benefit mandated by federal regulations. If the participant does not want the dry powder milk/evaporated milk the clinic can issue the food package without cheese (all milk).
Participants who prefer evaporated milk can be issued the state created evaporated milk food packages.
The standard food package for women in Food Package VII contains cheese.
3. Fish
Women receiving Food Package VII receive 30 ounces of fish (tuna or salmon). Women in Food Package V or VI are not authorized to receive fish.
4. Beans/Peas and Peanut Butter
Canned beans/peas may be substituted for dried beans/peas at the rate of 64 oz. of canned for one (1) pound of dried beans/peas. Issuance of additional combinations of dried or canned beans/peas and peanut butter is authorized as listed below:
(a) 1 pound of dried plus 64 oz. of canned beans/peas (and no peanut butter)
(b) 2 pounds of dried beans/peas (and no peanut butter)
(c) 128 oz. of canned beans/peas (and no peanut butter)
(d) 2 containers (16-18 oz. each) of peanut butter (and no beans/peas)
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Food Package

6. Fruits and Vegetables: The fruit and vegetable voucher cannot be counted when prorating vouchers. If the participant receives any voucher for the month, she must receive the fruit and vegetable voucher.
7. Cereal: Infant cereal cannot be issued to women in Food Packages V, VI, or VII. Only women with qualifying medical conditions who are receiving formulas or medical foods in Food Package III are eligible to receive infant cereal in place of adult cereal.
8. Jars of infant food fruits and vegetables cannot be issued to women on their WIC vouchers. However, women can use their cash value fruit and vegetable produce voucher to purchase baby food fruits and vegetables, if needed.
9. Other WIC Foods: For information on package sizes and restrictions see Georgia WIC-Approved Foods List (Attachment FP-44).

H. Milk Alternatives
For women, cheese, calcium-set tofu, or soy milk may be substituted for milk as described below.
Cheese: Cheese may be substituted for milk at the rate of one (1) pound of cheese for 3 quarts of milk. A maximum of one (1) pound of cheese may be substituted in this manner without medical documentation of a qualifying medical condition for Food Packages V and VI. No more than two (2) pounds of cheese may be substituted for milk for Food Package VII recipients. With medical documentation women receiving Food Package VI may receive up to four (4) pounds of cheese and women receiving Food Package V and VII may receive up to six (6) pounds of cheese.
Soy Milk: Soy milk may be substituted for milk at the rate of 1 quart of soy milk for 1 quart of milk up to the total maximum monthly allowance of milk. Women are not required to have medical documentation in order to receive soy milk. Please note, soy-based beverages are not recommended for women with breast cancer.
Tofu: Calcium-set tofu may be substituted for milk at a rate of one (1) pound of tofu for 1 quart of milk. Medical documentation is required for women to receive more than four (4) pounds or six (6) pounds of tofu per month, depending on their category, feeding method and number of infants being carried or breastfed. With medical documentation women may receive up to 12 pounds of tofu. There are state-created vouchers containing tofu. If a different amount of tofu is needed, then a 999 food package will need to be developed using state-created vouchers.

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I.

Additional Documentation

Food Package

CPAs must thoroughly document any situation in which less than the full maximum allotment of a supplemental food is issued to a participant (e.g., at the participant's request, due to a food allergy, etc.).

Medical documentation is required in the following situation:
Any authorized cheese or tofu issued to women that exceeds the maximum substitution rate.

VII. HOMELESSNESS, MIGRANCY, AND DISASTER SITUATIONS
A. Alternative Food Package Assignment
Local agencies have the option to convert participants to an alternative 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 designed 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.
4. In disaster situations such as floods, tornadoes, etc., that temporarily displace participants from their normal residences or that result in an unsafe water supply.
B. Food Package Assignment
The CPA must reevaluate and assign appropriate food packages when the participant locates a permanent residence with adequate refrigeration and/or a safe water supply.

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C. Manual Food Package

Food Package

When Voucher Printing on Demand (VPOD) is not available, a manual food package should be issued when possible. If a manual food package is not available that will meet the participant's needs, then a food package should be issued using blank voucher(s).

D. Assignment of Food Package Codes
1. Infants
a. Alternative food packages for infants consist of 8.45 oz containers of ready-to-feed formula.
(1) Contract milk-based formula: CPA FPC is A09.
(2) There is no contract soy-based alternative formula package.
b. Each infant CPA Food Package Code (FPC) represents three packages - one for each infant age group (0 through 3 months, 4 through 5 months, and 6 through 11 months.) A different amount of formula is allowed for each age group. Infants 4 through 5 months receive slightly more formula than do the infants 0 through 3 months old. Infants 6 through 11 months old receive less formula and the addition of baby cereal and infant food fruits and vegetables.
Georgia computer systems are automated to progress the infant through these three age groups. The CPA FPCs for Fully Formula Fed (FFF) infant packages start with an "A." The computer will issue internal food packages beginning with a "B" to infants ages 4 through 5 months, and packages beginning with "D" to infants ages 6 through 11 months. For maximum amounts see Attachment FP-25 for infant food and Attachment FP-31 for alternative formula.
2. Children 1 To 5 Years

Alternative food packages for this group consist of ultra high temperature (UHT) milk, iron fortified cereal, vitamin C fortified juice, fruits and vegetables, whole grain bread or alternative and canned beans or peanut butter. The food package codes for children's alternative packages are C10 and C30. For maximum amounts see Attachment FP-29.
3. Pregnant and Breastfeeding Women

Food packages for this group consist of ultra high temperature (UHT) milk, iron fortified cereal, and 100% vitamin C fortified juice,
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Food Package

fruits and vegetables, whole grain bread or alternative, canned beans and/or peanut butter. Food package W10 may be assigned to pregnant and Mostly Breastfeeding women. The alternative package for Exclusively Breastfeeding women is W50. For maximum amounts see Attachment FP-30.

4. Non-Breastfeeding Women

Food packages for this group consist of ultra high temperature (UHT) milk, iron fortified cereal, 100% vitamin C fortified juice, fruits and vegetables, canned beans and/or peanut butter. The alternative package for women Breastfeeding Some (SBF) and NonBreastfeeding women is W30. For Maximum amounts see Attachment FP-30.

VIII. MEDICAL DOCUMENTATION
No medical foods, formulas requiring a prescription, supplemental foods (for clients in Food Package III), or special milk substitutions requiring medical documentation may be issued to a participant without appropriate medical documentation, as outlined below. Participants with expired medical documentation cannot be issued any vouchers until either verbal or written medical authorization is obtained.
WIC-approved formulas designed for enteral feeding (i.e., tube feeding) may be authorized. However, WIC does not authorize distribution of formulas designed for parenteral (i.e., intravenous) infusion. All apparatus, equipment, or devices (e.g., enteral feeding tubes, bags and pumps) designed to administer WIC formulas are not allowable WIC costs.

A. Situations Requiring Medical Documentation
1. Infants:
a) Issuance of Georgia WIC-approved non-contract brand infant formula.
b) Issuance of any Georgia WIC-approved exempt infant formula or medical food.
2. Children:
a) Issuance of any Georgia WIC-approved infant formula, exempt infant formula, or medical food.
b) Issuance of any quantity of soy milk or tofu.
c) Issuance of more than one (1) pound of cheese per month.
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3. Women:

Food Package

a) Issuance of any Georgia WIC-approved formula, exempt formula, or medical food.

b) Issuance of more than one or two (1 or 2) pounds of cheese per month.*

c) Issuance of more than four or six (4 or 6) pounds of tofu per month.*

*Note: The exact quantity depends upon a woman participant's category, the number of infants she is pregnant with or has just delivered, and her infant feeding method.

B. Acceptable & Unacceptable Forms of Documentation
1. Clinics may accept medical documentation in the form of an original written document, an electronic document, or medical documentation received by facsimile or telephone. Verbal orders received by telephone to a CPA must be followed with written documentation (original, electronic, or faxed) within two (2) weeks of the original verbal order. Please refer to Section D below for verbal order procedures.
2. Medical documentation must be written on a physician's prescription pad, private medical office letterhead, District/County letterhead, or on one of the two Georgia WIC forms described below.
3. Clinics are encouraged to promote the use of Georgia WIC medical documentation forms to reduce the likelihood of missing information when other forms are used. It is not mandatory for the health care providers to use Georgia WIC medical documentation forms, but other forms described in #2 above must contain all of the required information described in this section. Georgia WIC medical documentation forms are:
a) Medical Documentation Form for WIC Special Formula and Approved WIC Foods (Form #1). This form is for prescribing formulas and medical foods. Please refer to Attachments FP-39 and FP-40 for a copy of the form and complete instructions on form use.
b) Referral Form and Medical Documentation for Special Food Substitutions (Form #2). This form is for providing referral data and for authorizing special milk substitutions requiring medical documentation (e.g., tofu, extra cheese, soy milk). Please refer to Attachments FP-41 and FP-42 for a copy of the form and complete instructions on form use.

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4. Georgia WIC clinics may not accept the following forms:

Food Package

a) Prescription forms or prescription pads which are pre-printed or prestamped with a formula requiring a prescription.

b) Forms or prescription pads containing formula advertising.

c) Prescription pads or forms that include a pre-printed list of formulas from which the healthcare provider is expected to choose are not allowed. For example, a prescription form that lists ten (10) common special formulas and one (1) blank "other" formula option with a check box next to each is unacceptable. The prescription pad or form must not contain any pre-printed or "suggested" formulas.

C. Required Medical Documentation Components
1. The complete brand name of the authorized WIC formula prescribed and the amount of formula needed per day in reconstituted fluid ounces.
2. The authorized supplemental food(s) appropriate for the qualifying medical condition(s) and any restrictions. This section (Section 3 of Medical Documentation Form #1) must be completed before supplemental foods are issued to women, infants, and children.
3. The length of time the prescribed WIC formula is required by the participant.
4. The qualifying medical condition(s) requiring the issuance of the authorized WIC formula.
5. The original signature, date, and contact information of the authorized prescribing health care provider.
a) Medical documentation must contain the original signature of a health care professional licensed by the State of Georgia to write prescriptions in accordance with state laws. Stamped, electronic, or pre-printed signatures will not be accepted. Medical documentation for Georgia WIC may only be signed by the following healthcare providers:
x Physicians (e.g., MD, DO)
x Nurse Practitioners (e.g., APRN, NP, CPNP, CNP, PNP, CNNP, FNP)
x Physician Assistants (e.g., PA, PA-C)
b) Prescriptions signed by any other health professionals cannot be accepted. Registered Dietitians (RDs), including those with advanced certifications such as certified nutrition support dietitians
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Food Package

(CNSDs) and dietitians who are board certified specialists in pediatric nutrition (e.g., CSPs), cannot sign prescriptions for WIC. Although such dietitians are experts in their respective areas of specialization, they do not have prescriptive authority in the State of Georgia and therefore cannot sign prescriptions for use in Georgia WIC as outlined by Federal regulations.

D. Verbal Orders
1. For Participants Without Any Medical Documentation
a) Written medical documentation or a verbal order from an authorized healthcare provider is required prior to food package assignment by the WIC CPA.
b) Verbal orders must only be received and documented by a CPA.
c) The CPA must promptly document the verbal order. Document the details of the verbal order in the participant's paper or electronic WIC record (including all medical documentation components required in Section C above) and sign/date the information. The complete name and credentials (e.g., MD or NP) of the authorized prescribing health care provider is to be recorded in place of his/her original signature.
d) Confirmation of a verbal order must be requested from the health care provider and must be received within two (2) weeks of the initial verbal order.
e) Only one (1) month of vouchers may be issued to a participant when a verbal order is received. Do not issue a second month of vouchers until the written documentation is received by the clinic. Medical documentation must be written and may be provided as an original written document, an electronic document, or by facsimile.
f) All medical documentation must be kept on file at the local clinic.
2. For Participants With Incomplete Medical Documentation
a) Verbal orders also may be accepted by a CPA to complete minor missing or incomplete information on Form #1 or Form #2. For example:
1. A missing ICD-9 code (when the name of the diagnosis is already recorded on the form), if the ICD-9 code would help to better clarify the participant's condition

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Food Package

2. To clarify the full formula product name (e.g., did "Neocate" mean Neocate Infant, Neocate Infant DHA + ARA, or Neocate Junior?)

3. A missing product form (powder, concentrate, or ready-tofeed)

4. A missing "planned length of use"

5. A missing zip code, phone number, or fax number

6. Incorrectly documented amount of formula prescribed per day (e.g., prescribed amount was written as the number of cans required per day instead of the number of reconstituted fluid ounces required per day)

b) The CPA must document the missing information on the form, initial and date each change, and record the name and credentials of the
physician, physician assistant, nurse practitioner, or nurse
(relayingtheinformationonbehalfoftheprovider)whogave the verbal clarification by each change who gave the verbal
clarification by each change. A new medical documentation form does not need to be completed.

1. If extensive information is missing or if any information needs to be corrected or revised, the health care provider must complete a new form.

2. If the health care provider's signature is missing, was completed using a "signature stamp," or if the form was signed by an unauthorized provider, a new form must be completed.

3. This process cannot be used in place of the "verbal order" procedures outlined above for use when no medical documentation exists (i.e., instead of getting written medical documentation from a health care provider). This process must only be used to add minor missing information to an existing form.

c) In this instance, the participant may be issued the full set of vouchers once the missing/incomplete information is obtained and fully documented by the CPA.

E. Frequency & Records
1. Current medical documentation is required, at a minimum, every six (6) months, with any change in the order, and at every recertification/subcertification/mid-certification* for the prescription of special formulas and medical foods on Form #1.
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Food Package

2. Current medical documentation is required, at a minimum, every six (6) months, with any change in the order, and at every recertification/subcertification/mid-certification* for the prescription of special milk substitutions on Form #2.

*Note: If the medical documentation on file was signed and dated by the health care provider more than 30 (thirty) days prior to the date of the recertification / sub-certification / mid-certification, then new medical documentation must be provided by the client.

3. Current medical documentation is defined as medical documentation that was signed and dated by the health care provider less than or equal to 30 (thirty) days of being processed by the WIC staff (i.e., within the past 30 [thirty] days prior to certification or food package change).

4. All medical documentation must be kept on file at the local clinic.

F. Issuance of Ready-To-Feed Products
Local agencies must issue all WIC formulas (all infant formula, exempt infant formula and WIC-eligible medical foods) in concentrated liquid or powder physical forms. Ready-to-feed WIC products may be authorized when the CPA determines and documents that:
1. The participant's household has an unsanitary or restricted water supply or poor refrigeration;
2. The person caring for the participant may have difficulty in correctly diluting concentrated or powder forms; or
3. The formula is only available in a ready-to-feed form.
4. In addition, participants with qualifying medical conditions who are assigned to Food Package III can also be issued ready-to-feed formulas for the additional reasons below:
x If the ready-to-feed form better accommodates the participant's medical condition (Food Package III clients only); or
x If the ready-to-feed form improves the participant's compliance in consuming the prescribed formula (Food Package III clients only).
Use of either of these two additional reasons must be clearly documented by the CPA in the participant's paper or electronic WIC record. These two reasons are only applicable for participants who have medical documentation on Form #1 and who meet the below criteria:
a) Infants must be prescribed an exempt infant formula or medical food on Form #1. Infants who are receiving a standard non-contract
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Food Package

infant formula requiring a prescription are not eligible for Food Package III, and therefore are not eligible to receive ready-to-feed products for the above two additional reasons. Examples of ineligible products include Enfagrow Gentlease Toddler, Enfamil Gentlease, Similac Sensitive, Similac Sensitive for Spit Up, and Enfamil A.R.

b) Children or women may be prescribed any infant formula, exempt infant formula, or medical food on Form #1 to qualify for the two (2) additional ready-to-feed options.

G. Medical Diagnoses

1. Non-specific, general medical diagnoses are not sufficient for the purpose of WIC prescriptions. The below list of unacceptable diagnoses is not allinclusive. WIC clients with prescriptions containing the below diagnoses may need additional documentation or a more specific diagnosis. Please contact the prescribing health care professional for a more specific, updated prescription. If a prescription includes more than one diagnosis (including one of those listed below), the other listed diagnosis(es) may be sufficient for approval. CPAs should use their professional judgment or contact their Nutrition Manager for guidance. The below diagnoses are not permitted for use as the sole diagnosis on WIC prescriptions:

x "Milk intolerance" or "formula intolerance" (e.g., sometimes ICD-9 code 579.8 is used)

x "Severe milk allergy" or "milk allergy"

x "Multiple food allergies"

x "Feeding difficulties" or "feeding problems" (e.g., 783.3, 779.3)

x "Colic," "fussiness," "constipation," "gas," or "cramps" (e.g., 787.3, 789.0, 780.91, 780.92)

x "Spitting up"

x "Digestive disturbances"

x "Picky eater," "poor appetite," or "inadequate/poor intake"

Insufficient Diagnosis "783.3" "Feeding problems" "Spitting up" "Formula intolerance"

Sample Acceptable Alternative Diagnosis/Diagnoses "Feeding problems (783.3), CP, NG-tube" "Oral-motor feeding disorder 783.40" "GERD/reflux 530.81" "Cow's milk protein intolerance" or "malabsorption syndrome NOS" (e.g., 558.3, 579.8, 579.9, 693.1)

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GEORGIA WIC 2012 PROCEDURES MANUAL


Food Package

2. The following diagnoses require an underlying medical condition be present and documented:

a) "Underweight" or "inadequate/poor weight gain"

b) "Feeding disorder"

c) "Inadequate/poor growth"

Georgia WIC cannot accept these diagnoses alone a more specific, primary medical condition must be present and listed among the diagnoses (e.g., Cerebral Palsy, Failure-to-Thrive, Oral-Motor Feeding Disorder, Prematurity, Dysphagia, etc.).

3. Medical diagnoses must be consistent with the participant's anthropometric data (e.g., length/height, weight, BMI). CPAs should use their professional judgment and, if needed, seek additional guidance from their Nutrition Managers or Nutrition Services Directors. For example:

a) A diagnosis of "Failure to Thrive/FTT" for a child whose BMI is at the 75th percentile or above should be questioned.

b) A diagnosis of "Food Aversion" for a child whose BMI is above the 50th percentile and whose caregiver reports that the child eats chips,
candy, junk food, and sweets all day but refuses healthier foods
should be questioned.

c) A diagnosis of "Food Aversion" for a child whose BMI is below the 25th percentile and who is receiving therapy (e.g., speech, physical,
or occupational therapy) need not be questioned.

4. Medical diagnoses must be consistent with the formula or medical food prescribed. CPAs should use their professional judgment and, if needed, seek additional guidance from their Nutrition Managers or Nutrition Services Directors. For example:

a) "Lactose intolerance" should not be accepted as a diagnosis if the product prescribed contains lactose.

b) A diagnosis of "GERD" is not an appropriate diagnosis for the issuance of PediaSure or Boost Kid Essentials.

c) "Milk protein allergy" is not an appropriate diagnosis for the issuance of a milk-based formula or medical food.

5. A "suspected" diagnosis is allowable as long as it still meets the other diagnostic criteria (e.g., "suspected milk protein allergy").

6. See Attachments FP-40 and FP-42 for Medical Documentation Form (Form 1) and Referral Form (Form 2).

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IX.

FORMULA DISTRIBUTION/TRACKING GUIDELINES

Food Package

Local agency procedures for tracking formula returned to the clinic for various reasons and tracking formula received and distributed related to special formula ordered through the Office of Nutrition (see Attachment FP-45).

A. Reasons to Issue Formula. See the Formula Distribution / Tracking Guidelines table below for guidance on allowable and non-allowable reasons for issuing formula.

Formula Distribution / Tracking Guidelines (Returned Formula)

Allowable reasons to issue Formula:

Non-allowable reasons to issue Formula:

x Trading formula- 1 for 1 trade of returned formula (based on equivalent quantity of reconstituted formula). Issuance may include a combination of vouchers and formula.
x Food Package Change
x Error in purchase
x Damaged Formula
x Clinic error with appointment given
x Adjusting pick up code for family
x Disaster situations: Fire, flood etc.
x Partial or full issuance as Food Package

x Pre-certification issuance of formula to last until scheduled appointment
x Client missed recertification appointment
x For client to try out another formula to determine if it is better tolerated
x Participant reporting lost or stolen vouchers
x Client running out of formula
x Distribution to non-WIC clients

*Document returned formula on the Formula Tracking Log (Attachment FP-45). All formula must be accounted for when issued to a client or destroyed.

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-45). When applicable, also document issuance in the client's health record.
a. Formula Tracking Log: Formula issued to a WIC client or destroyed must be documented on the Formula Tracking Log (Attachment FP-45).
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.
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Food Package

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.
E. Staff Responsibaility. It is the responsibility of a CPA to complete all duties related to the Formula Tracking Log. These duties including formula documentation; acceptance, issuance, and destruction of formula; signing the Formula Tracking Log for each transaction completed; ensuring that formula on hand is not expired or damaged; calculating the correct quantity of formula for exchanges based on the fluid ounces of formula returned (as both formula containers returned & formula on returned vouchers); and conducting quarterly inventories."

X. NUTRITION SERVICES UNIT SPECIAL FORMULA ORDERS
When ordering special formulas through the Nutrition Services Unit the "Special Formula Order Form" (Attachment FP-36) should be used. A fillable version of the "Special Formula Order Form" is also available on Georgia WIC website listed below. The fillable order form can be completed online, saved, printed, signed, and then faxed to Nutrition Services Unit (404-657-2886) along with the client's medical documentation. Also calling to alert staff of the in-coming fax is helpful. In addition, the link contains a copy of the ordering procedures and a copy of the current WIC-Approved Formulas/Medical Foods List.
Web resources for special formula ordering: http://www.wic.ga.gov/wicformula.asp (under "Procurement of Special Formula")
A. Ordering
The Nutrition Services Unit can only order special formula in whole case quantities. This will often result in the District/clinic receiving more formula than was ordered and more formula than is allowed to be issued to a client. When a District/clinic receives a formula order, issue only the prescribed amount of formula to the client (up to the maximum allowed). Do not automatically give a client all of the formula that was delivered, since that will usually result in overissuance.
B. Tracking Log
Districts/clinics are responsible for tracking the additional partial cases of formula received in the appropriate Formula Tracking Log. Such leftover formula must be taken into consideration when determining how much special formula to request on subsequent special formula orders. Leftover formula one month indicates that less formula will need to be requested from the Nutrition Services Unit the following month. Document request for formula and distribution in participant's health record.
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C. Amount to Order

Food Package

When completing the "Special Formula Order Form," Districts/clinics must specify in Line #6 the exact number of cans/containers of special formula needed for that client for that issue month (taking into consideration any leftover formula on hand, the prescribed quantity, the maximum allowed for the client category [infant, child, woman], the maximum allowed for infants [if applicable] based on infant age and infant feeding type, and the product type [powder, concentrate, ready-to-feed]). The Nutrition Services Unit will convert the number of cans/containers to case quantities for the order. Please do not simply write "max. allowed," "9 cases," or enter the same quantity of formula each month (e.g., "10 cans"). Districts/clinics are encouraged to maintain a spreadsheet(s) to track the special formula orders submitted for their participants in addition to tracking leftover partial cases of formula in the applicable Formula Tracking Log. Please refer to Attachment FP-37 for a sample tracking document.

For infant participants, please enter the infant's age on the "Special Formula Order Form" as of the "First Day To Use" date on the vouchers for the current issuance month. The infant's age must be documented in months and days to ensure that the correct amount of formula is being requested based on the infant's age. For child and women participants you need not calculate the age.

Remember to use the correct charts to determine maximum formula allowed if you are ordering formula for an infant who is also being breastfed.

D. Special Formula Order Form

Districts/clinics should complete and submit the "Special Formula Order Form" each month for each client allowing for realistic shipping time. Orders can be shipped overnight, if necessary, for new clients. However, ongoing orders for existing special formula clients should be submitted at least seven (7) to ten (10) business days prior to the date the formula is needed for pick-up by the client to ensure sufficient processing time. Special formula orders should not routinely be requested for "rush" delivery due to the additional fees often charged for expedited delivery. All efforts will be made by state staff to ensure timely delivery of special formula for WIC clients. However, since WIC is a supplemental program, caregivers may need to purchase some formula in the interim. Under routine circumstances, an order should be received within five (5) business days of placing the order.

E. Frequency

The Nutrition Services Unit only accepts orders for a one-month supply of any special formula(s) at a time for a client. Please do not submit requests for multiple months' worth of formula on one order form or submit several orders covering several months at one time. Many clients on special formulas frequently change formulas and/or food packages.

F. Medical Documentation

Districts/clinics must include current medical documentation with each special
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GEORGIA WIC 2012 PROCEDURES MANUAL

formula order submitted each month.

Food Package

G. Printing Tracking Voucher

Clinics must print a CPA FPC 199 each month a client is issued formula that is ordered through the Nutrition Services Unit. The tracking voucher in this food package allows the client to be counted in the clinic caseload. Failure to do so underreports your District caseload. In addition, USDA requires monthly reconciliation of state-ordered formulas with their tracking vouchers so that formula expenditures can be matched to active WIC participants.

H. Flavor

Specify product flavor(s), when applicable, on the Special Formula Order Form every month.

I.

Processing the Order

After the order is received and verified as correct and complete the packing slip should be signed and dated. The special order packing slip should then be returned to the Nutrition Services Unit by mail or fax:

Mail: 2 Peachtree Street NW, Suite 11-222, Atlanta, GA, 30303-3142

Fax: 404-657-2886

Notify the Nutrition Services Unit immediately if an incorrect order is delivered or if there is a change in the formula order.

The CPA FPC for all WIC types for special formulas ordered through Nutrition Services Unit is 199. When the CPA assigns food package 199 a second field will be enabled in the computer system to allow the CPA to select a food package for the appropriate supplemental foods or additional formula based on the medical documentation provided. The food package could be a child or woman's state-created food package or a 999 food package if none of the standard state-created food packages meet the medical food prescription. The special formula food package must be entered into the computer as the first food package code to enable the second field.

If the WIC participant only needs the "199" food package, enter "000" in the second food package box to indicate that additional foods do not need to be issued.

For infants receiving a "199" food package needing to be issued infant fruits and vegetables and/or cereal enter "999" in the second box and select appropriate voucher codes.

Add a section on need to prorate if client is late picking up (as long as it was not due to the clinic error).

XI.

EMORY GENETIC WIC CLIENTS

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Food Package

Under the State of Georgia's Newborn Screening Program, all infants are screened for specific metabolic and genetic conditions. The Emory Genetics program is responsible for following up on all infants who have positive screenings. In most cases Emory Genetics also provides ongoing medical services including highly specialized nutritional management to those individuals with diagnosed metabolic or genetic disorders.
Georgia WIC has an agreement with Emory University that permits Emory Genetics to provide WIC-approved formulas and medical foods to active WIC clients. Georgia WIC food package system allows a WIC clinic to issue a special "Emory Genetics food package" or food package 099 to active WIC clients who are under the medical care of Emory Genetics, which provides the prescribed formula or combination of formulas to each of their WIC clients on a monthly basis. Emory Genetics then submits a report to Georgia WIC requesting reimbursement for the formulas provided (up to the maximum monthly formula amounts authorized per client according to Federal WIC regulations).
A. Emory Genetics Prescriptions
When active WIC clients present Emory Genetics medical documentation to their WIC clinics, special precautions must be taken to eliminate the possibility of duplicate issuance of formula.
Emory Genetics clients who are active WIC clients should be issued a CPA FPC 099 to cover the formula issued by Emory Genetics. The 099 food package only contains tracking vouchers (no formula or supplemental food vouchers). Emory Genetics will provide the WIC clinic with medical documentation on which, if any, supplemental foods are allowed for the participant.
The WIC clinic must print the Emory Genetics food package for each issuance month based on the active WIC client's pick-up code. Follow the instructions on each voucher. Effective October 1, 2010, food package 099 contains four (4) vouchers instead of three (3). Have the active WIC client sign the voucher receipt(s).
The WIC clinic will then fax the two (2) "Emory Genetics Copy" vouchers (voucher code #299) for each month to the fax number listed on the voucher. Do not complete the "Formula Name" or "Cost" lines on the voucher; those lines are for Emory Genetics use. Retain the "Emory Genetics Copy and "Chart Copy" vouchers in the client's medical record or WIC chart. Provide the "Client Copy" to the client/caregiver.

B. Provision of Formula and WIC Foods
WIC clinics do not issue any formula to an Emory Genetics WIC client. WIC clinics should not print any vouchers containing formula or provide any formula from stock on hand to an Emory Genetics WIC client. Emory Genetics provides all of the formula to the WIC client and then invoices the state for the allowable amount of formula based on WIC policies. Clinics that issue any formula to their
FP-40


GEORGIA WIC 2012 PROCEDURES MANUAL


Food Package

Emory Genetics WIC clients risk formula over-issuance. Districts will be held financially responsible for repaying Georgia WIC for such duplicate formula issuance errors. Any exceptions identified will be reported to the state's contracted financial auditor. The Auditor will be notified to immediately conduct a financial desk audit of the District in question. If substantiated by the contracted auditor, funds will be recouped from subsequent grant in aid.

The clinic will issue any supplemental foods Emory Genetics has prescribed. If supplemental foods are authorized, enter the appropriate state-created special food package code on the 2nd FPC field in the computer system. If none of the State-created food packages match the participant's prescription, enter "999" and create a 999 food package using state-created vouchers for individual supplemental foods. If the client is not approved to receive any supplemental foods enter "000" in the second food package box.

C. Breastfeeding

If an infant receiving formula from Emory Genetics is also being breastfed, be sure the medical documentation includes enough information for you to assign the correct feeding type for the infant and its mother.

XII. Creating 999 Food Packages
Districts are allowed to create food packages for formulas and combinations of foods not available in state created food packages. These food packages are referred to as 999 food packages. Each District must maintain a record of all District created food packages which include a description of the package, food package code, voucher codes, and amounts and types of formula/food allowed. The description should include WIC type, age group and feeding type as applicable.
It is recommended that one person in each District be responsible for creating and/or approving all 999 food packages.
Each package must provide the full nutritional benefit for each food category as allowed for WIC Type based on age and feeding type. Documentation is required for the issuance of less than the full nutritional benefit. However, remember that children and women prescribed special formulas and medical foods are only to be issued the formula quantity prescribed, up to the maximum allowed.
State created voucher codes must be used for all food categories (i.e., milk and whole grains). The District is allowed to create voucher codes for WIC approved formulas and medical food when no state created vouchers are available for these products.
Attachments FP-23 through FP-31 contain the maximum monthly allowed tables; Attachment FP-38 provides information on milk/cheese/tofu substitutions; and Attachment FP-47 is a list of commonly used voucher codes for single foods or small amounts of formulas. These resources are provided to help in the creation of 999 food packages.
FP-41


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-1

Formula Summary: Standard Formulas for Infants and Children

CPA FPC A18
F18
X18 A17
F17
E17 K17 J17 Z17 A19
F19

Status / Age
FFF 0-3 m FFF 4-5 m FFF 6-11 m MB 1-3 m MB 4-5 m MB 6-11 m
Child
FFF 0-3 m FFF 4-5 m FFF 6-11 m MB 1-3 m MB 4-5 m MB 6-11 m
MB 0-5 MB 6-11 m MB 1-5 m MB 6-11 m MB 1-5 m MB 6-11 m
Child
FFF 0-3 m
FFF 4-5 m FFF 6-11 m
MB 1-3 m
MB 4-5 m
MB 6-11 m

System FPC
A18 B18 D18
F18 G18 H18
X18
A17 B17 D17
F17 G17 H17
E17 L17
K17 M17
J17 N17
Z17
A19
B19
D19
F19
G19
H19

Formula
Gerber Good Start Gentle Concentrate 31-13 oz or 34-12.1 oz concentrate Gerber Good Start Gentle
34-13 oz or 37-12.1 oz concentrate Gerber Good Start Gentle
24-13 oz or 26-12.1 oz concentrate Gerber Good Start Gentle 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 14-13 oz or 15-12.1 oz concentrate Gerber Good Start Gentle 17-13 oz or 18-12.1 oz concentrate Gerber Good Start Gentle 12-13 oz or 13-12.1 oz concentrate Gerber Good Start Gentle 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 35-13 oz or 37-12.1 oz concentrate Gerber Good Start Gentle
Gerber Good Start Gentle Powder 9-12.7 oz cans powder Gerber Good Start Gentle
10-12.7 oz cans powder Gerber Good Start Gentle
7-12.7 oz cans powder Gerber Good Start Gentle 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 4-12.7 oz cans powder Gerber Good Start Gentle 5-12.7 oz cans powder Gerber Good Start Gentle 4-12.7 oz cans powder Gerber Good Start Gentle 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 1-12.7 oz can powder Gerber Good Start Gentle 1-12.7 oz can powder Gerber Good Start Gentle 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 2-12.7 oz cans powder Gerber Good Start Gentle 2-12.7 oz cans powder Gerber Good Start Gentle 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 3-12.7 oz cans powder Gerber Good Start Gentle 3-12.7 oz cans powder Gerber Good Start Gentle 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 10-12.7 oz cans powder Gerber Good Start Gentle
Gerber Good Start Gentle RTF 26-32 oz RTF containers or 25-33.8 oz (4-packs) Gerber Good Start Gentle 28-32 oz RTF containers or 27-33.8 oz (4-packs)Gerber Good Start Gentle 20-32 oz RTF containers or 19-33.8 oz (4-packs)Gerber Good Start Gentle 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 12-32 oz RTF containers or 12-33.8 oz (4-packs)Gerber Good Start Gentle 14-32 oz RTF containers or 14-33.8 oz (4-packs)Gerber Good Start Gentle 10-32 oz RTF containers or 10-33.8 oz (4-packs)Gerber Good Start Gentle 32 jars baby fruit/vegetable, 3-8 oz box infant cereal

FP-42


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP 1

CPA FPC X19 A09
Z09 A28
F28
X28 A27
F27
E27 K27 J27 X27 A29

Status / Age Child
FFF 0-3 m FFF 4-5 m FFF 6-11 m
Child
FFF 0-3 m FFF 4-5 m FFF 6-11 m MB 1-3 m MB 4-5 m MB 6-11 m
Child
FFF 0-3 m FFF 4-5 m FFF 6-11 m MB 1-3 m MB 4-5 m MB 6-11 m
MB 0-5 MB 6-11 m MB 1-5 m MB 6-11 m MB 1-5 m MB 6-11 m
Child
FFF 0-3 m
FFF 4-5 m FFF 6-11 m

System FPC X19
A09 B09 D09
Z09
A28 B28 D28
F28 G28 H28
X28
A27 B27 D27
F27 G27 H27
E27 L27
K27 M27
J27 N27
X27
A29
B29
D29

Formula
28-32 oz RTF containers or 26-33.8 oz (4-packs)Gerber Good Start Gentle
Gerber Good Start Gentle Alternative RTF 98-8.45 oz RTF containers Gerber Good Start Gentle
106-8.45 oz RTF containers Gerber Good Start Gentle
75-8.45 oz RTF containers Gerber Good Start Gentle 32 jars baby fruit/vegetable, 3-8 oz box infant cereal
107-8.45 oz RTF container Gerber Good Start Gentle Gerber Good Start Soy Concentrate
31-13 oz cans or 34-12.1 oz concentrate Gerber Good Start Soy
34-13 oz cans or 37-12.1 oz concentrate Gerber Good Start Soy
24-13 oz cans or 26-12.1 oz concentrate Gerber Good Start Soy 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 14-13 oz cans or 15-12.1 oz concentrate Gerber Good Start Soy 17-13 oz cans or 18-12.1 oz concentrate Gerber Good Start Soy 12-13 oz cans or 13-12.1 oz concentrate Gerber Good Start Soy 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 35-13 oz cans or 37-12.1 oz concentrate Gerber Good Start Soy
Gerber Good Start Soy Powder 9-12.9 oz cans powder Gerber Good Start Soy
10-12.9 oz cans powder Gerber Good Start Soy
7-12.9 oz cans powder Gerber Good Start Soy 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 4-12.9 oz cans powder Gerber Good Start Soy 5-12.9 oz cans powder Gerber Good Start Soy 4-12.9 oz cans powder Gerber Good Start Soy 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 1-12.9 oz can powder Gerber Good Start Soy 1-12.9 oz can powder Gerber Good Start Soy 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 2-12.9 oz cans powder Gerber Good Start Soy 2-12.9 oz cans powder Gerber Good Start Soy 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 3-12.9 oz cans powder Gerber Good Start Soy 3-12.9 oz cans powder Gerber Good Start Soy 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 10-12.9 oz cans powder Gerber Good Start Soy
Gerber Good Start Soy RTF 26-32 oz RTF containers or 25-33.8 oz (4-packs) Gerber Good Start Soy 28-32 oz RTF containers or 27-33.8 oz (4-packs)Gerber Good Start Soy 20-32 oz RTF containers or 19-33.8 oz (4-packs)Gerber Good Start Soy 32 jars baby fruit/vegetable, 3-8 oz box infant cereal

FP-43


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP 1

CPA FPC F29
X29
D67 F67 Z67 D77 F77 Z77

Status / Age MB 1-3 m MB 4-5 m MB 6-11 m Child
FFF 9- 11 m MB 9-11 m
Child FFF 9- 11 m MB 9-11 m
Child

System FPC F29 G29 H29
X29
D67 F67 Z67
D77 F77 Z77

Formula
12-32 oz RTF containers or 12-33.8 oz (4-packs)Gerber Good Start Soy 14-32 oz RTF containers or 14-33.8 oz (4-packs)Gerber Good Start Soy 10-32 oz RTF containers or 10-33.8 oz (4-packs)Gerber Good Start Soy 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 28-32 oz RTF container or 26-33.8 oz (4-packs)Gerber Good Start Soy
Gerber Good Start 2 Gentle Powder 4-22 oz cans powder Gerber Good Start 2 Gentle 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 2-22 oz cans powder Gerber Good Start 2 Gentle 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 5-22 oz cans powder Gerber Good Start 2 Gentle
Gerber Good Start 2 Soy Powder 4-24 oz cans powder Gerber Good Start 2 Soy 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 2-24 oz cans powder Gerber Good Start 2 Soy 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 5-24 oz cans powder Gerber Good Start 2 Soy

FP-44


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-2

Contract Formula Food Packages Fully Formula Fed Infant 0 3 months

Gerber Good Start Gentle Food Package Code A17 9-12.7 oz powder Gerber Good Start Gentle

Rank VC 2 G04
4 G05

A18 31-13 oz or 34-12.1 oz concentrate Gerber Good Start Gentle

2 G14 4 G17

A19

4 G19

26-32 oz or 25-33.8 oz

ready to feed Gerber Good

Start Gentle

2 G48

A09 98-8.45 oz or 25-33.8 oz ready to feed Gerber Good Start Gentle

2 G21 2 G21 4 G21 4 G21 4 G50

Voucher Message Formula: 4-12.7 oz cans powder Gerber Good
Start Gentle Formula: 5-12.7 oz cans powder Gerber Good
Start Gentle

Formula: Formula:

14-13 oz or 16-12.1 oz containers concentrate Gerber Good Start Gentle 17-13 oz or 18-12.1 oz containers concentrate Gerber Good Start Gentle

Formula:
Formula:
Formula: Formula: Formula: Formula: Formula:

12-32 oz containers or 12-33.8 oz (4packs) ready to feed Gerber Good Start Gentle 14-32 oz containers or 13-33.8 oz (4packs) ready to feed Gerber Good Start Gentle 24-8.45 oz containers ready to feed Gerber Good Start Gentle (1 case) 24-8.45 oz containers ready to feed Gerber Good Start Gentle (1 case) 24-8.45 oz containers ready to feed Gerber Good Start Gentle (1 case) 24-8.45 oz containers ready to feed Gerber Good Start Gentle (1 case) 4-8.45 oz containers or 1-33.8 oz (4pack) ready to feed Gerber Good Start

FP-45


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP 2

Gerber Good Start Soy Food Package Code A27 9-12.9 oz powder Gerber Good Start Soy
A28 31-13 oz or 34-12.1 oz concentrate Gerber Good Start Soy A29 26-32 oz or 25-33.8 oz ready to feed Gerber Good Start Soy

Rank VC 2 N40 4 N41 2 N36 4 N37 2 N44
4 G54

Voucher Message Formula: 4-12.9 oz cans powder Gerber Good
Start Soy Formula: 5-12.9 oz cans powder Gerber Good
Start Soy

Formula: Formula: Formula:
Formula:

15-13 oz or 18-12.1 oz containers concentrate Gerber Good Start Soy 16-13 oz cans or 16-12.1 oz concentrate Gerber Good Start Soy 13-32 oz containers or 13-33.8 oz (4packs) ready to feed Gerber Good Start Soy 13-32 oz containers or 12-33.8 oz (4packs) ready to feed Gerber Good Start Soy

FP-46


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP 2

Contract Infant Formula Fully Formula Fed 4 5 months

Gerber Good Start Gentle Food Package Code B17 (Assign A17) 10-12.7 oz powder Gerber Good Start Gentle

Rank VC 2 G04
4 G06

B18 (Assign A18) 34-13 oz or 37-12.1 oz concentrate Gerber Good Start Gentle

2 G17 4 G51

B19 (Assign A19)

2 G13

28-32 oz or 27-33.8 oz

ready to feed Gerber Good

Start Gentle

4 G48

B09 (Assign A09) 106-8.45 oz or 27-33.8 oz ready to feed Gerber Good Start Gentle

2 G21 2 G21 4 G21 4 G21 4 G50

4 G50

4 G50

Voucher Message Formula: 4-12.7 oz cans powder Gerber Good
Start Gentle Formula: 6-12.7 oz. cans powder Gerber Good
Start Gentle

Formula: Formula:

17-13 oz or 18-12.1 oz containers concentrate Gerber Good Start Gentle 17-13 oz or 19-12.1 oz containers concentrate Gerber Good Start

Formula:
Formula:
Formula: Formula: Formula: Formula: Formula:
Formula:
Formula:

14-32 oz containers or 14-33.8 oz (4packs) ready to feed Gerber Good Start Gentle 14-32 oz containers or 13-33.8 oz (4packs) ready to feed Gerber Good Start Gentle 24-8.45 oz containers ready to feed Gerber Good Start Gentle (1 case) 24-8.45 oz containers ready to feed Gerber Good Start Gentle (1 case) 24-8.45 oz containers ready to feed Gerber Good Start Gentle (1 case) 24-8.45 oz containers ready to feed Gerber Good Start Gentle (1 case) 4-8.45 oz containers or 1-33.8 oz (4pack) ready to feed Gerber Good Start Gentle 4-8.45 oz containers or 1-33.8 oz (4pack) ready to feed Gerber Good Start Gentle 4-8.45 oz containers or 1-33.8 oz (4pack) ready to feed Gerber Good Start Gentle

FP-47


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP 2

Gerber Good Start Soy Food Package Code B27 (Assign A27) 10-12.9 oz powder Gerber Good Start Soy

Rank VC 2 N41
4 N41

B28 (Assign A28)

2 N36

34-13 oz or 37-12.1 oz

concentrate Gerber Good

4 N38

Start Soy

B29 (Assign A29)

2 N45

28-32 oz or 27-33.8 oz

ready to feed Gerber Good

Start Soy

4 G53

Voucher Message Formula: 5-12.9 oz cans powder Gerber Good
Start Soy Formula: 5-12.9 oz cans powder Gerber Good
Start Soy

Formula: Formula: Formula:
Formula:

15-13 oz or 18-12.1 oz containers concentrate Gerber Good Start Soy 19-13 oz or 19-12.1 oz containers concentrate Gerber Good Start Soy 14-32 oz containers or 14-33.8 oz (4packs) ready to feed Gerber Good Start Soy 14-32 oz containers or 13-33.8 oz (4pack) ready to feed Gerber Good Start Soy

FP-48


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP 2

Contract Infant Formula Infant Fully formula Fed
6-11 months

Gerber Good Start Gentle Food Package Code D17 (Assign A17) 7-12.7 oz powder Gerber Good Start Gentle 32 jars baby fruit/vegetable 3-8 oz box infant cereal
D18 (Assign A18) 24-13 oz or 26-12.1 oz concentrate Gerber Good Start Gentle 32 jars baby fruit/vegetable 3-8 oz box infant cereal
D19 (Assign A19) 20-32 oz or 19-33.8 oz ready to feed Gerber Good Start Gentle 32 jars baby fruit/vegetable 3-8 oz box infant cereal

Rank VC 2 G03 4 G04 4 N01
2 N26 2 G12 4 G12 4 N01
2 N26 2 G10 4 G49 4 N01
2 N26

Voucher Message Formula: 3-12.7 oz cans powder Gerber Good
Start Gentle Formula: 4-12.7 oz cans powder Gerber Good
Start Gentle

Infant foods:
Infant cereal: Infant foods:
Formula:
Formula:

16-4 oz OR 9-7 oz (twin pack) containers baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods)
3-8 oz containers 16-4 oz OR 9-7 oz (twin pack) containers baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods) 12-13 oz or 13-12.1 oz containers concentrate Gerber Good Start Gentle 12-13 oz or 13-12.1 oz containers concentrate Gerber Good Start Gentle

Infant foods:
Infant cereal: Infant foods:
Formula:
Formula:
Infant foods:
Infant cereal: Infant foods:

16-4 oz OR 9-7 oz (twin pack) containers baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods)
3-8 oz containers 16-4 oz OR 9-7 oz (twin pack) containers baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods) 10-32 oz containers or 10-33.8 oz (4packs) ready to feed Gerber Good Start Gentle 10-32 oz containers or 9-33.8 oz (4packs) ready to feed Gerber Good Start Gentle 16-4 oz OR 9-7 oz (twin pack) containers baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods)
3-8 oz containers 16-4 oz OR 9-7 oz (twin pack) containers baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods)

FP-49


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP 2

Food Package Code D09 (Assign A09) 75-8.45 oz or 19-33.8 oz ready to feed Gerber Good Start Gentle
32 jars baby fruit/vegetable
3-8 oz box infant cereal

Rank VC 2 G21 4 G21 4 G21 2 G50
4 N01
2 N26

Voucher Message

Formula: 24-8.45 oz containers ready to feed

Gerber Good Start Gentle (1 case)

Formula: 24-8.45 oz containers ready to feed

Gerber Good Start Gentle (1 case)

Formula: 24-8.45 oz containers ready to feed

Gerber Good Start Gentle (1 case)

Formula: 4-8.45 oz containers or 1-33.8 oz (4-

pack) ready to feed Gerber Good Start

Gentle

Infant

16-4 oz OR 9-7 oz (twin pack) containers

foods:

baby food fruit and/or vegetable (Stage

2, Stage 2 1/2 or 2nd foods)

Infant

cereal: 3-8 oz containers

Infant

16-4 oz OR 9-7 oz (twin pack) containers

foods:

baby food fruit and/or vegetable (Stage

2, Stage 2 1/2 or 2nd foods)

FP-50


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP 2

Gerber Good Start Soy Food Package Code D27 (Assign A27) 7-12.9 oz powder Gerber Good Start Soy

Rank VC 4 N40
2 N55

32 jars baby fruit/vegetable 4 N01

3-8 oz box infant cereal

2 N26

D28 (Assign A28) 24-13 oz or 26-12.1 oz concentrate Gerber Good Start Soy
32 jars baby fruit/vegetable
3-8 oz box infant cereal

2 N39 4 N39 4 N01
2 N26

D29 (Assign A29) 20-32 oz or 19-33.8 oz ready to feed Gerber Good Start Soy
32 jars baby fruit/vegetable
3-8 oz box infant cereal

2 N46 4 G52 4 N01

2 N26

Voucher Message

Formula: 4-12.9 oz cans powder Gerber Good

Start Soy

Formula: 3-12.9 oz cans powder Gerber Good

Start Soy

Infant

16-4 oz OR 9-7 oz (twin pack) containers

foods:

baby food fruit and/or vegetable (Stage

2, Stage 2 1/2 or 2nd foods)

Infant

cereal: 3-8 oz containers

Infant

16-4 oz OR 9-7 oz (twin pack) containers

foods:

baby food fruit and/or vegetable (Stage

2, Stage 2 1/2 or 2nd foods)

Formula: 12-13 oz or 13-12.1 oz containers cans

concentrate Gerber Good Start Soy

Formula:
Infant foods:
Infant cereal: Infant foods:

12-13 oz or 13-12.1 oz containers cans concentrate Gerber Good Start Soy 16-4 oz OR 9-7 oz (twin pack) containers baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods)
3-8 oz containers 16-4 oz OR 9-7 oz (twin pack) containers baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods)

Formula:
Formula:
Infant foods:
Infant cereal: Infant foods:

10-32 oz containers or 10-33.8 oz (4packs) ready to feed Gerber Good Start Soy 10-32 oz containers or 9-33.8 oz (4packs) ready to feed Gerber Good Start Soy 16-4 oz OR 9-7 oz (twin pack) containers baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods)
3-8 oz containers 16-4 oz OR 9-7 oz (twin pack) containers baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods)

FP-51


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP 2

Contract Toddler Formula 9 to 12 months only

Powder Gerber Good Start 2 Gentle

Food Package Code

Rank VC

D67

2 G42

4-24 oz powder

Gerber Good Start 2 Gentle 4 G42

32 jars baby fruit/vegetable 3-8 oz box infant cereal

4 N01

2 N26

Voucher Message Formula: 2-24 oz cans powder Gerber Good Start
2 Gentle Formula: 2-24 oz cans powder Gerber Good Start
2 Gentle

Infant foods:
Infant cereal: Infant foods:

16-4 oz OR 9-7 oz (twin pack) containers baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods)
3-8 oz containers 16-4 oz OR 9-7 oz (twin pack) containers baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods)

Powder Gerber Good Start 2 Soy

Food Package Code

Rank VC

D77

2 G44

4-22 oz powder Gerber

Good Start 2 Soy

4 G44

32 jars baby fruit/vegetable 3-8 oz box infant cereal

4 N01

2 N26

Voucher Message

Formula: 2-22 oz cans powder Gerber Good Start 2 Soy

Formula: 2-22 oz cans powder Gerber Good Start 2 Soy

Infant

16-4 oz OR 9-7 oz (twin pack) containers

foods:
Infant cereal:

baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods)
3-8 oz containers

Infant foods:

16-4 oz OR 9-7 oz (twin pack) containers baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods)

FP-52


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-3

Food Packages for Exclusively Breastfed Infant

Food Package Code E00 Breastfeeding message

Rank VC 9 059

Voucher Message

Message Nurse your baby often. The more you

only

breastfeed the more milk you will have

for your baby.

E01 (Assign E00) Breastfeeding message
64-4 oz infant food
3-8 oz cereal
31-2.5 oz infant meat

This does voucher has no cash value

Grocers should not accept this

voucher

9 059 Message Nurse your baby often. The more you

only

breastfeed the more milk you will have

for your baby

2 N26 Infant foods:
4 N26 Infant foods:
2 N26 Infant foods:
4 N01 Infant foods:
Infant cereal:
4 N52 Infant foods:

Grocers do not accept this voucher 16-4 oz OR 9-7 oz (twin pack) containers baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods) 16-4 oz OR 9-7 oz (twin pack) containers baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods) 16-4 oz OR 9-7 oz (twin pack) containers baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods) 16-4 oz OR 9-7 oz (twin pack) containers baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods)
3-8 oz containers 31-2.5 oz containers baby food meat (Stage 1 or 2nd foods only)

FP-53


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-4

Contract Formula Packages for Mostly Breastfed Infant 1 3 months Maximum

Gerber Good Start Gentle

Food Package Code

Rank VC

F17

4 G04

4-12.7 oz powder Gerber

Good Start Gentle

F18

4 G55

14-13 oz or 15-12.1 oz

concentrate Gerber Good

Start Gentle

F19

4 G19

12-32 oz or 12-33.8 oz

ready to feed Gerber Good

Start Gentle

Voucher Message Formula: 4-12.7 oz ocans powder Gerber Good
Start Gentle
Formula: 14-13 oz or 15-12.1 oz cans concentrate Gerber Good Start Gentle

Formula:

12-32 oz containers or or 12-33.8 oz (4packs) ready to feed Gerber Good Start Gentle

Gerber Good Start Soy

Food Package Code

Rank VC

F27

4 N40

4-12.9 oz powder Gerber

Good Start Soy

F28

4 G26

14-13 oz or 15-12.1 oz

concentrate Gerber Good

Start Soy

F29

4 G56

12-32 oz or 12-33.8 oz

ready to feed Gerber Good

Start Soy

Voucher Message Formula: 4-12.9 oz cans powder Gerber Good
Start Soy
Formula: 14-13 oz or 15-12.1 oz containers concentrate Gerber Good Start Soy

Formula:

12-32 oz containers or or 12-33.8 oz (4packs) ready to feed Gerber Good Start Soy

FP-54


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-4

Contract Infant Formula Mostly Breastfed
4 5 months Maximum

Gerber Good Start Gentle Food Package Code G17 (Assign F17) 5-12.7 oz powder Gerber Good Start Gentle G18 (Assign F18) 17-13 oz or 18-12.1 oz concentrate Gerber Good Start Gentle G19 (Assign F19) 14-32 oz or 33.8 oz ready to feed Gerber Good Start Gentle

Rank VC 4 G05 4 G17
4 G13

Voucher Message Formula: 5-12.7 oz cans powder Gerber Good
Start Gentle
Formula: 17-13 oz or 18-12.1 containers concentrate Gerber Good Start Gentle

Formula:

14-32 oz containers or or 14-33.8 oz (4packs) ready to feed Gerber Good Start Gentle

Gerber Good Start Soy

Food Package Code

Rank VC

G27 (Assign F27)

4 N41

5-12.9 oz powder Gerber

Good Start Soy

G28 (Assign F28)

4 G27

17-13 oz or 18-12.1 oz

concentrate Gerber Good

Start Soy

G29 (Assign F29)

4 N45

14-32 oz or 14-33.8 oz

ready to feed Gerber Good

Start Soy

Voucher Message Formula: 5-12.9 oz cans powder Gerber Good
Start Soy
Formula: 17-13 oz or 18-12.1 oz containers concentrate Gerber Good Start Soy

Formula:

14-32 oz containers Soy or 14-33.8 oz (4-packs) ready to feed Gerber Good Start Soy

FP-55


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-4

Contract Infant Formula 6 11 months Maximum

Gerber Good Start Gentle Food Package Code H17 (Assign F17) 4-12.7 oz powder Gerber Good Start Gentle

Rank VC 4 G04
4 N01

32 jars baby fruit/vegetable

3-8 oz box infant cereal

2 N26

H18 (Assign F18) 12-13 oz or 13-12.1 oz concentrate Gerber Good Start Gentle
32 jars baby fruit/vegetable
3-8 oz box infant cereal

4 G12 4 N01
2 N26

H19 (Assign F19)

4 G10

10-32 oz or 10-33.8 oz

ready to feed Gerber Good

Start Gentle

4 N01

32 jars baby fruit/vegetable

3-8 oz box infant cereal

2 N26

Voucher Message

Formula: 4-12.7 oz cans powder Gerber Good

Start Gentle

Infant

16-4 oz OR 9-7 oz (twin pack) containers

foods:

baby food fruit and/or vegetable (Stage

2, Stage 2 1/2 or 2nd foods)

Infant

cereal: 3-8 oz containers

Infant

16-4 oz OR 9-7 oz (twin pack) containers

foods:

baby food fruit and/or vegetable (Stage

2, Stage 2 1/2 or 2nd foods)

Formula: 12-13 oz or 13-12.1 oz containers

concentrate Gerber Good Start Gentle

Infant

16-4 oz OR 9-7 oz (twin pack) containers

foods:

baby food fruit and/or vegetable (Stage

2, Stage 2 1/2 or 2nd foods)

Infant

cereal: 3-8 oz containers

Infant

16-4 oz OR 9-7 oz (twin pack) containers

foods:

baby food fruit and/or vegetable (Stage

2, Stage 2 1/2 or 2nd foods)

Formula: 10-32 oz containers or 10-33.8 oz (4-

packs) ready to feed Gerber Good Start

Gentle

Infant

16-4 oz OR 9-7 oz (twin pack) containers

foods:

baby food fruit and/or vegetable (Stage

2, Stage 2 1/2 or 2nd foods)

Infant

cereal: 3-8 oz containers

Infant

16-4 oz OR 9-7 oz (twin pack) containers

foods:

baby food fruit and/or vegetable (Stage

2, Stage 2 1/2 or 2nd foods)

FP-56


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-4

Gerber Good Start Soy Food Package Code H27 (Assign F27) 4-12.9 oz powder Gerber Good Start Soy

Rank VC 4 N40
4 N01

32 jars baby fruit/vegetable

3-8 oz box infant cereal

2 N26

H28 (Assign F28) 12-13 oz or 13-12.1 oz concentrate Gerber Good Start Soy
32 jars baby fruit/vegetable
3-8 oz box infant cereal

4 N39 4 N01
2 N26

H29 (Assign F29)

4 N46

10-32 oz or 10-33.8 oz

ready to feed Gerber Good

Start Soy

4 N01

32 jars baby fruit/vegetable

3-8 oz box infant cereal

2 N26

Voucher Message

Formula: 4-12.9 oz cans powder Gerber Good

Start Soy

Infant

16-4 oz OR 9-7 oz (twin pack) containers

foods:

baby food fruit and/or vegetable (Stage

2, Stage 2 1/2 or 2nd foods)

Infant

cereal: 3-8 oz containers

Infant

16-4 oz OR 9-7 oz (twin pack) containers

foods:

baby food fruit and/or vegetable (Stage

2, Stage 2 1/2 or 2nd foods)

Formula: 12-13 oz or 13-12.1 oz containers

concentrate Gerber Good Start Soy

Infant

16-4 oz OR 9-7 oz (twin pack) containers

foods:

baby food fruit and/or vegetable (Stage

2, Stage 2 1/2 or 2nd foods)

Infant

cereal: 3-8 oz containers

Infant

16-4 oz OR 9-7 oz (twin pack) containers

foods:

baby food fruit and/or vegetable (Stage

2, Stage 2 1/2 or 2nd foods)

Formula: 10-32 oz containers or 10-33.8 oz (4-

packs) ready to feed Gerber Good Start

Soy

Infant

16-4 oz OR 9-7 oz (twin pack) containers

foods:

baby food fruit and/or vegetable (Stage

2, Stage 2 1/2 or 2nd foods)

Infant

cereal: 3-8 oz containers

Infant

16-4 oz OR 9-7 oz (twin pack) containers

foods:

baby food fruit and/or vegetable (Stage

2, Stage 2 1/2 or 2nd foods)

FP-57


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-4

Contract Infant Formula 9 to 12 months only

Powder Gerber Good Start 2 Gentle

Food Package Code

Rank VC

F67

4 G42

2-22 oz powder

Gerber Good Start 2 Gentle 4 N01

32 jars baby fruit/vegetable

3-8 oz box infant cereal

2 N26

Voucher Message

Formula: 2-22 oz cans powder Gerber Good Start

2 Gentle

Infant

16-4 oz OR 9-7 oz (twin pack) containers

foods:

baby food fruit and/or vegetable (Stage

2, Stage 2 1/2 or 2nd foods)

Infant

cereal: 3-8 oz containers

Infant

16-4 oz OR 9-7 oz (twin pack) containers

foods:

baby food fruit and/or vegetable (Stage

2, Stage 2 1/2 or 2nd foods)

Powder Gerber Good Start 2 Soy

Food Package Code

Rank VC

F77

4 G44

2-24 oz powder Gerber

Good Start 2 Soy

4 N01

32 jars baby fruit/vegetable

3-8 oz box infant cereal

2 N26

Voucher Message

Formula: 2-24 oz cans powder Gerber Good Start

2 Soy

Infant

16-4 oz OR 9-7 oz (twin pack) containers

foods:

baby food fruit and/or vegetable (Stage

2, Stage 2 1/2 or 2nd foods)

Infant

cereal: 3-8 oz containers

Infant

16-4 oz OR 9-7 oz (twin pack) containers

foods:

baby food fruit and/or vegetable (Stage

2, Stage 2 1/2 or 2nd foods)

FP-58


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-4

Contract Infant Formula Mostly Breastfed Infant
1- 3 cans per month

Gerber Good Start Gentle

Food Package Code

Rank VC VC

E17

4 G01 Formula:

1-12.7 oz powder Gerber

Good Start Gentle

L17 (Assign E17)

4 G01 Formula:

1-12.7 oz powder Gerber

Good Start Gentle

4 N01 Infant

foods:

32 jars baby

fruit/vegetable

Infant

3-8 oz box infant cereal

cereal:

2 N26 Infant

foods:

K17 2-12.7 oz powder Gerber Good Start Gentle M17 (Assign K17) 2-12.7 oz powder Gerber Good Start Gentle
32 jars baby fruit/vegetable
3-8 oz box infant cereal

4 G02 Formula:
4 G02 Formula:
4 N01 Infant foods:
Infant cereal: 2 N26 Infant foods:

J17 3-12.7 oz powder Gerber Good Start Gentle N17 (Assign J17) 3-12.7 oz powder Gerber Good Start Gentle
32 jars baby fruit/vegetable
3-8 oz box infant cereal

4 G03 Formula:
4 G03 Formula:
4 N01 Infant foods:
Infant cereal: 2 N26 Infant foods:

Voucher Message 1-12.7 oz can powder Gerber Good Start Gentle
1-12.7 oz can powder Gerber Good Start Gentle 16-4 oz OR 9-7 oz (twin pack) containers baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods)
3-8 oz containers 16-4 oz OR 9-7 oz (twin pack) containers baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods) 2-12.7 oz can powder Gerber Good Start Gentle
2-12.7 oz can powder Gerber Good Start Gentle 16-4 oz OR 9-7 oz (twin pack) containers baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods)
3-8 oz containers 16-4 oz OR 9-7 oz (twin pack) containers baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods) 3-12.7 oz can powder Gerber Good Start Gentle
3-12.7 oz can powder Gerber Good Start Gentle
16-4 oz OR 9-7 oz (twin pack) containers baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods) -8 oz containers 16-4 oz OR 9-7 oz (twin pack) containers baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods)

FP-59


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-4

Gerber Good Start Soy Food Package Code E27 1-12.9 oz powder Gerber Good Start Soy L27 (Assign E27) 1-12.9 oz powder Gerber Good Start Soy
32 jars baby fruit/vegetable
3-8 oz box infant cereal
K27 2-12.9 oz powder Gerber Good Start Soy M27 (Assign K27) 2-12.9 oz powder Gerber Good Start Soy
32 jars baby fruit/vegetable
3-8 oz box infant cereal
J27 3-12.9 oz powder Gerber Good Start Soy N27 (Assign J27) 3-12.9 oz powder Gerber Good Start Soy
32 jars baby fruit/vegetable
3-8 oz box infant cereal

Rank VC 4 476 4 476 4 N01
2 N26 4 G22 4 G22 4 N01
2 N26 4 N55 4 N55 4 N01
2 N26

Voucher Message Formula: 1-12.9 oz can powder Gerber Good Start
Soy

Formula:
Infant foods:
Infant cereal: Infant foods:
Formula:

1-12.9 oz can powder Gerber Good Start Soy 16-4 oz OR 9-7 oz (twin pack) containers baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods)
3-8 oz containers 16-4 oz OR 9-7 oz (twin pack) containers baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods) 2-12.9 oz cans powder Gerber Good Start Soy

Formula:
Infant foods:
Infant cereal: Infant foods:
Formula:

2-12.9 oz cans powder Gerber Good Start Soy 16-4 oz OR 9-7 oz (twin pack) containers baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods)
3-8 oz containers 16-4 oz OR 9-7 oz (twin pack) containers baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods) 3-12.9 oz cans powder Gerber Good Start Soy

Formula:
Infant foods:
Infant cereal: Infant foods:

3-12.9 oz cans powder Gerber Good Start Soy 16-4 oz OR 9-7 oz (twin pack) containers baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods)
3-8 oz containers 16-4 oz OR 9-7 oz (twin pack) containers baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods)

FP-60


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-5

Contract Infant Formula Packages for Children

Gerber Good Start Gentle Food Package Code Z17 10-12.7 oz powder Gerber Good Start Gentle
Medical Documentation Required X18 35-13 oz or 37- 12.1 oz concentrate Gerber Good Start Gentle

Rank VC 2 G05 4 G05
4 G18 2 G17

Voucher Message Formula: 5-12.7 oz cans powder Gerber Good
Start Gentle Formula: 5-12.7 oz cans powder Gerber Good
Start Gentle

Formula: Formula:

18-13 oz or 19-12.1 oz containers concentrate Gerber Good Start Gentle 17-13 oz or 18-12.1 oz containers concentrate Gerber Good Start Gentle

Medical Documentation Required X19 28-32 oz or 26-33.8 ready to feed Gerber Good Start Gentle
Medical Documentation Required Z09 107-8.45 oz ready to feed Gerber Good Start Gentle
Medical Documentation Required

2 G48 Formula: 14-32 oz containers or 13-33.8 oz (4packs) ready to feed Gerber Good Start Gentle
4 G48 Formula: 14-32 oz containers or 13-33.8 oz (4packs) ready to feed Gerber Good Start Gentle
2 G21 Formula 24-8.45 oz containers ready to feed Gerber Good Start Gentle (1 case)
2 G21 Formula 24-8.45 oz containers ready to feed Gerber Good Start Gentle (1 case)
4 G21 Formula 24-8.45 oz containers ready to feed Gerber Good Start Gentle (1 case)
4 G21 Formula 24-8.45 oz containers ready to feed Gerber Good Start Gentle (1 case)
4 G32 Formula: 11-8.45 oz containers or 2-33.8 oz (4packs) ready to feed Gerber Good Start Gentle

FP-61


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-5

Gerber Good Start Soy Food Package Code X27 10-12.9 oz powder Gerber Good Start Soy
Medical Documentation Required X28 35-13 oz or 37-12.1 oz concentrate Gerber Good Start Soy

Rank VC 2 N41
4 N41

Voucher Message Formula 5-12.9 oz cans powder Gerber Good
Start Soy Formula 5-12.9 oz cans powder Gerber Good
Start Soy

4 N38 Formula 19-13 oz or 19-12.1 oz cans concentrate Gerber Good Start Soy
2 N37 Formula 16-13 oz or 16-12.1 oz cans concentrate Gerber Good Start Soy

Medical Documentation Required X29 28-32 oz or 26-33.8 oz ready to feed Gerber Good Start Soy
Medical Documentation Required

2 G53 Formula 14-32 oz containers or 13-33.8 oz (4packs) ready to feed Gerber Good Start Soy
4 G53 Formula 14-32 oz containers or 13-33.8 oz (4packs) ready to feed Gerber Good Start Soy

Powder Gerber Good Start 2 Gentle

Food Package Code

Rank VC

Z67

2 G42

5-22 oz powder

Gerber Good Start 2 Gentle 4 G42

Medical Documentation Required

4 G41

Voucher Message Formula: 2-22 oz cans powder Gerber Good Start
2 Gentle Formula: 2-22 oz cans powder Gerber Good Start
2 Gentle
Formula: 1-22 oz cans powder Gerber Good Start 2 Gentle

Powder Gerber Good Start 2 Soy

Food Package Code

Rank VC

Z77

2 G44

5-24 oz powder Gerber

Good Start 2 Soy

4 G44

Medical Documentation Required

4 G43

Voucher Message Formula: 2-24 oz cans powder Gerber Good Start
2 Soy Formula: 2-24 oz cans powder Gerber Good Start
2 Soy
Formula: 1-24 oz can powder Gerber Good Start 2 Soy

FP-62


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-6

Formula Summary Non-Contract Infant Formula Summary Medical Documentation Required

CPA FPC A44
F44
E44 K44 J44 X44 A46
F46
X46 A34
F34
E34

Status / Age
FFF 0-3 m FFF 4-5 m FFF 6-11 m MB 1-3 m MB 4-5 m MB 6-11 m
MB 0-5 MB 6-11 m MB 1-5 m MB 6-11 m MB 1-5 m MB 6-11 m
Child
FFF 0-3 m FFF 4-5 m FFF 6-11 m MB 1-3 m MB 4-5 m MB 6-11 m
Child
FFF 0-3 m FFF 4-5 m FFF 6-11 m MB 1-3 m MB 4-5 m MB 6-11 m
MB 0-5
MB 6-11 m

System FPC
A44 B44 D44
F44 G44 H44
E44 L44
K44 M44
J44 N44
X44
A46 B46 D46
F46 G46 H46
X46
A34 B34 D34
F34 G34 H34
E34 L34

Formula
Enfamil AR Powder 9-12.9 oz cans powder Enfamil AR 10-12.9 oz cans powder Enfamil AR 7-12.9 oz cans powder Enfamil AR, 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 4-12.9 oz cans powder Enfamil AR 5-12.9 oz cans powder Enfamil AR 4-12.9 oz cans powder Enfamil AR 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 1-12.9 oz can powder Enfamil AR 1-12.9 oz can powder Enfamil AR 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 2-12.9 oz cans powder Enfamil AR 2-12.9 oz cans powder Enfamil AR 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 3-12.9 oz cans powder Enfamil AR 3-12.9 oz cans powder Enfamil AR 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 912.9 oz cans powder Enfamil AR
Enfamil AR RTF
26-quart cans RTF Enfamil AR 28-quart cans RTF Enfamil AR 20-quart cans RTF Enfamil AR 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 12-32 oz RTF containers Enfamil AR 14-32 oz RTF containers Enfamil AR 10-32 oz RTF containers Enfamil AR 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 2832 oz cans RTF Enfamil AR
Enfamil Gentlease Powder 10-12 oz OR 9-12.4 oz cans powder Enfamil Gentlease 11-12 oz OR 10-12.4 oz cans powder Enfamil Gentlease 8-12 oz OR 7-12.4 oz cans powder Enfamil Gentlease 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 5-12 oz OR 4-12.4 oz cans powder Enfamil Gentlease 6-12 oz OR 5-12.4 oz powder Enfamil Gentlease 4-12 oz OR 4-12.4 oz cans powder Enfamil Gentlease 32 jars baby fruit/vegetable, 3-8 oz box infant cereal
1-12 oz OR 1-12.4 oz can powder Enfamil Gentlease 1-12 oz OR 1-12.4 oz can powder Enfamil Gentlease 32 jars baby fruit/vegetable, 3-8 oz box infant cereal

FP-63


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-6

CPA FPC K34 J34 Z34 A36
F36
Z36 A32
F32
X32 A31
F31
E31 K31 J31

Status / Age
MB 1-5 m MB 6-11 m MB 1-5 m MB 6-11 m
Child
FFF 0-3 m FFF 4-5 m FFF 6-11 m MB 1-3 m MB 4-5 m MB 6-11 m
Child
FFF 0-3 m FFF 4-5 m FFF 6-11 m MB 1-3 m MB 4-5 m MB 6-11 m
Child
FFF 0-3 m FFF 4-5 m FFF 6-11 m MB 1-3 m MB 4-5 m MB 6-11 m
MB 0-5 MB 6-11 m MB 1-5 m MB 6-11 m MB 1-5 m

System FPC K34 M34
J34 N34
Z34
A36 B36 D36
F36 G36 H36
Z36
A32 B32 D32
F32 G32 H32
X32
A31 B31 D31
F31 G31 H31
E31 L31
K31 M31
J31

Formula
2-12 oz OR 2-12.4 oz cans powder Enfamil Gentlease 2-12 oz OR 2-12.4 oz cans powder Enfamil Gentlease 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 3-12 oz OR 3-12.4 oz cans powder Enfamil Gentlease 3-12 oz OR 3-12.4 oz cans powder Enfamil Gentlease 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 10-12 oz or 10-12.4 oz cans powder Enfamil Gentlease
Enfamil Gentlease RTF 26-32 oz containers RTF Enfamil Gentlease 28-32 oz containers RTF Enfamil Gentlease 20-32 oz containers RTF Enfamil Gentlease 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 12-32 oz containers RTF Enfamil Gentlease 14-32 oz containers RTF Enfamil Gentlease 10-32 oz containers RTF Enfamil Gentlease 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 28-32 oz containers RTF Enfamil Gentlease
Similac Sensitive Concentrate
31-13 oz cans concentrate Similac Sensitive
34-13 oz cans concentrate Similac Sensitive
24-13 oz cans concentrate Similac Sensitive , 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 14-13 oz cans concentrate Similac Sensitive
17-13 oz cans concentrate Similac Sensitive
12-13 oz cans concentrate Similac Sensitive 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 35-13 oz cans concentrate Similac Sensitive
Similac Sensitive Powder
9-12.6 oz (or 12.6 oz)cans powder Similac Sensitive
10-12.6 oz (or 12.6 oz)cans powder Similac Sensitive
7-12.6 oz (or 12.6 oz)cans powder Similac Sensitive 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 4-12.6 oz cans powder Similac Sensitive
5-12.6 oz cans powder Similac Sensitive
4-12.6 oz cans powder Similac Sensitive 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 1-12.6 oz powder Similac Sensitive
1-12.9 oz powder Similac Sensitive 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 2-12.6 oz powder Similac Sensitive
2-12.6 oz powder Similac Sensitive 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 3-12.6 oz powder Similac Sensitive

FP-64


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-6

CPA FPC X31 A33
F33
X33 A41
F41
E41 K41 J41 X41 A43
F43

Status / Age
MB 6-11 m Child
FFF 0-3 m FFF 4-5 m FFF 6-11 m MB 1-3 m MB 4-5 m MB 6-11 m
Child
FFF 0-3 m FFF 4-5 m FFF 6-11 m MB 1-3 m MB 4-5 m MB 6-11 m
MB 0-5 MB 6-11 m MB 1-5 m MB 6-11 m MB 1-5 m MB 6-11 m
Child
FFF 0-3 m FFF 4-5 m FFF 6-11 m MB 1-3 m MB 4-5 m MB 6-11 m

System FPC N31
X31
A33 B33 D33
F33 G33 H33
X33
A41 B41 D41
F41 G41 H41
E41 L41
K41 M41
J41 N41
X41
A43 B43 D43
F43 G43 H43

Formula
3-12.6 oz powder Similac Sensitive 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 9-12.6 oz (or 12.6 oz)cans powder Similac Sensitive
Similac Sensitive RTF
26-32 oz RTF container Similac Sensitive
28-32 oz RTF container Similac Sensitive
20-32 oz RTF container Similac Sensitive 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 12-32 oz RTF container Similac Sensitive
14-32 oz RTF container Similac Sensitive
10-32 oz RTF container Similac Sensitive 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 28-32 oz RTF container Similac Sensitive
Similac Sensitive for Spit Up Powder
9-12.3 oz cans powder Similac Sensitive for Spit Up
10-12.3 oz cans powder Similac Sensitive for Spit Up
7-12.3 oz cans powder Similac Sensitive for Spit Up 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 4-12.3 oz cans powder Similac Sensitive for Spit Up
5-12.3 oz cans powder Similac Sensitive for Spit Up
4-12.3 oz cans powder Similac Sensitive for Spit Up 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 1-12.3 oz powder Similac Sensitive for Spit Up
1-12.3 oz powder Similac Sensitive for Spit Up 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 2-12.3 oz powder Similac Sensitive for Spit Up
2-12.3 oz powder Similac Sensitive for Spit Up 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 3-12.3oz powder Similac Sensitive for Spit Up
3-12.3 oz powder Similac Sensitive for Spit Up 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 9-12.3 oz cans powder Similac Sensitive for Spit Up
Similac Sensitive for Spit Up RTF
26- quart RTF container Similac Sensitive for Spit Up
28- quart RTF container Similac Sensitive for Spit Up
20- quart RTF container Similac Sensitive for Spit Up 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 12-quart RTF container Similac Sensitive for Spit Up
14-quart RTF container Similac Sensitive for Spit Up
10-quart RTF container Similac Sensitive for Spit Up 32 jars baby fruit/vegetable, 3-8 oz box infant cereal

FP-65


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-6

CPA FPC X43

Status / Age System FPC

Formula

Child

X43 28-quart RTF container Similac Sensitive for Spit Up

FP-66


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-7

Non-Contract Standard Formula Food Packages for Fully Formula Fed Infant

Enfamil AR Food Package Code A44 9-12.9 oz powder Enfamil AR

0 3 months

Rank VC 2 N33 4 168

Voucher Message Formula 4-12.9 oz cans powder Enfamil AR Formula 5-12.9 oz cans powder Enfamil AR

Medical Documentation Required A46 26-1 quart ready to feed Enfamil AR
Medical Documentation Required

2 169 Formula 13-1 quart containers ready to feed Enfamil AR
4 169 Formula 13-1 quart containers ready to feed Enfamil AR

Enfamil Gentlease Food Package Code A34 9-12.4 oz powder Enfamil Gentlease
Medical Documentation Required A36 2632 oz cans RTF Enfamil Gentlease
Medical Documentation Required

Rank VC 2 M01 4 M40
4 M07 2 M12

Voucher Message Formula 5-12 oz cans OR 4-12.4 oz cans powder
Enfamil Gentlease Formula 5-12 oz OR 5-12.4 oz cans powder
Enfamil Gentlease

Formula Formula

14-1 quart containers ready to feed Enfamil Gentlease
12-1 quart containers ready to feed Enfamil Gentlease

FP-67


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-7

Similac Sensitive Food Package Code A31 9-12.6 oz powder Similac Sensitive
Medical Documentation Required A32 31-13 oz concentrate Similac Sensitive
Medical Documentation Required A33 26-32 oz ready to feed Similac Sensitive
Medical Documentation Required

VC Voucher Message 353 Formula 5-12.6 oz cans powder Similac Sensitive
(orange and white label) N03 Formula 4-12.6 oz cans powder Similac Sensitive
(orange and white label)
364 Formula 15-13 oz cans concentrate Similac Sensitive (orange and white label)
365 Formula 16-13 oz cans concentrate Similac Sensitive (orange and white label)
103 Formula 13-32 oz containers ready to feed Similac Sensitive (orange and white label)
103 Formula 13-32 oz containers ready to feed Similac Sensitive (orange and white label)

Similac Sensitive for Spit Up

Food Package Code

VC

A41

N60

9-12.3 oz powder Similac

Sensitive for Spit Up

N61 Medical Documentation Required

A43

137

26-32 oz ready to feed

Similac Sensitive for Spit Up

137

Medical Documentation

Required

Voucher Message Formula 5-12.3 oz cans powder
Similac Sensitive for Spit Up (green and white label)

Formula 4-12.3 oz cans powder Similac Sensitive for Spit Up (green and white label)

Formula Formula

13-quart containers ready to feed Similac Sensitive for Spit Up (green and white label) 13-quart containers ready to feed Similac Sensitive for Spit Up (green and white label)

FP-68


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-7

Non-Contract Formulas Infant Fully formula Fed
4-5 months

Enfamil AR Food Package Code B44 (Assign A44) 10-12.9 oz Enfamil AR
Medical Documentation Required B46 (Assign A46) 28-1 quart ready to feed Enfamil AR
Medical Documentation Required

Rank VC 2 168 4 168

Voucher Message Formula 5-12.9 oz cans powder Enfamil AR Formula 5-12.9 oz cans powder Enfamil AR

2 309 Formula 14-1 quart containers ready to feed Enfamil AR
4 309 Formula 14-1 quart containers ready to feed Enfamil AR

Enfamil Gentlease Food Package Code B34 (Assign A34) 10-12.4 oz powder Enfamil Gentlease
Medical Documentation Required B36 (Assign B36) 2832 oz cans RTF Enfamil Gentlease
Medical Documentation Required

Rank VC 4 M02 2 M40
2 M07 4 M07

Voucher Message Formula 6-12 oz OR 5-12.4 oz cans powder
Enfamil Gentlease Formula 5-12 oz OR 12.4 oz cans powder Enfamil
Gentlease

Formula Formula

14-1 quart containers ready to feed Gentlease 14-1 quart containers ready to feed Gentlease

FP-69


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-7 (cont'd)

Similac Sensitive Food Package Code B31 (Assign A31) 10-12.9 oz powder Similac Sensitive
Medical Documentation Required B32 (Assign A32) 34-13 oz concentrate Similac Sensitive
Medical Documentation Required B33 (Assign A33) 28-32 oz ready to feed Similac Sensitive
Medical Documentation Required

Rank VC 2 353 4 353
2 364 4 386 2 132 4 132

Voucher Message Formula 5-12.6 oz cans powder Similac
Sensitive (orange and white label) Formula 5-12.6 oz cans powder Similac
Sensitive (orange and white label)

Formula Formula Formula Formula

15-13 oz cans concentrate Similac Sensitive (orange and white label) 19-13 oz cans concentrate Similac Sensitive (orange and white label) 14-32 oz containers ready to feed Similac Sensitive (orange and white label) 14-32 oz containers ready to feed Similac Sensitive (orange and white label)

Similac Sensitive RS or Similac Sensitive for Spit Up

Food Package Code

Rank VC Voucher Message

B41 (Assign A41)

2 N60 Formula 5-12.3 oz cans powder Similac

10-12.3 oz powder Similac

Sensitive for Spit Up (green and white

Sensitive for Spit Up

label)

Medical Documentation Required

4 N60 Formula 5-12.3 oz cans powder Similac Sensitive for Spit Up (green and white label)

B43 (Assign A43) 28-32 oz ready to feed Similac Sensitive for Spit Up
Medical Documentation Required

2 139 Formula 14- quart containers ready to feed Similac Sensitive for Spit Up (green and white label)
4 139 Formula 14- quart containers ready to feed Similac Sensitive for Spit Up (green and white label)

FP-70


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-7 (cont'd)

Non-Contract Formulas Infant Fully formula Fed
6-11 months

Enfamil AR Food Package Code D44 (Assign A44) 7-12.9 oz Enfamil AR
32 jars baby fruit/vegetable
3-8 oz box infant cereal
Medical Documentation Required
D46 (Assign A46) 20-1 quart ready to feed Enfamil AR 32 jars baby fruit/vegetable
3-8 oz box infant cereal
Medical Documentation Required

Rank VC 4 N33 2 N34 4 N01
2 N26
2 N35 4 N35 4 N01
2 N26

Voucher Message

Formula 4-12.9 oz cans powder Enfamil AR

Formula 3-12.9 oz cans powder Enfamil AR

Infant

16-4 oz OR 9-7 oz (twin pack) containers

foods: baby food fruit and/or vegetable (Stage 2,

Stage 2 1/2 or 2nd foods)

Infant

cereal: 3-8 oz containers

Infant

16-4 oz OR 9-7 oz (twin pack) containers

foods: baby food fruit and/or vegetable (Stage 2,

Stage 2 1/2 or 2nd foods)

Formula 10-1 quart containers ready to feed

Enfamil AR

Formula 10-1 quart containers ready to feed

Enfamil AR

Infant

16-4 oz OR 9-7 oz (twin pack) containers

foods: baby food fruit and/or vegetable (Stage 2,

Stage 2 1/2 or 2nd foods)

Infant

cereal: 3-8 oz containers

Infant

16-4 oz OR 9-7 oz (twin pack) containers

foods: baby food fruit and/or vegetable (Stage 2,

Stage 2 1/2 or 2nd foods)

FP-71


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-7 (cont'd)

Enfamil Gentlease Food Package Code D34 (Assign A34) 7-12 oz powder Enfamil Gentlease
32-4 oz infant food
3-8 oz cereal
Medical Documentation Required
D36 (Assign A36) 2032 oz cans RTF Enfamil Gentlease
32-4 oz infant food
3-8 oz cereal

Rank VC 2 M03 4 M39 2 N26
4 N01
2 M08 4 M08 2 N26
4 N01

Voucher Message

Formula 4-12 oz OR 3-12.4 oz cans powder

Enfamil Gentlease

Formula 4-12 oz OR 12.4 oz cans powder Enfamil

Gentlease

Infant

16-4 oz OR 9-7 oz (twin pack) containers

foods: baby food fruit and/or vegetable (Stage 2,

Stage 2 1/2 or 2nd foods)

Infant

16-4 oz OR 9-7 oz (twin pack) containers

foods: baby food fruit and/or vegetable (Stage 2,

Stage 2 1/2 or 2nd foods)

Infant

cereal: 3-8 oz containers

Formula 10-1 quart containers ready to feed

Enfamil Gentlease

Formula 10-1 quart containers ready to feed

Enfamil Gentlease

Infant foods:
Infant foods:
Infant cereal:

16-4 oz OR 9-7 oz (twin pack) containers baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods) 16-4 oz OR 9-7 oz (twin pack) containers baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods)
3-8 oz containers

FP-72


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-7 (cont'd)

Similac Sensitive Food Package Code D31 (Assign A31) 7-12.6 oz powder Similac Sensitive 32-4 oz infant food 3-8 oz cereal Medical Documentation Required
D32 (Assign A32) 24-13 oz concentrate Similac Sensitive 32-4 oz infant food 3-8 oz cereal Medical Documentation Required
D33 (Assign A33) 20-32 oz ready to feed Similac Sensitive 32-4 oz infant food 3-8 oz cereal Medical Documentation Required

Rank VC 4 N03 2 N09 2 N26 4 N01
2 371 4 371 2 N26 4 N01
2 N10 4 N10 2 N26 4 N01

Voucher Message Formula 4-12.6 oz cans powder Similac
Sensitive (orange and white label) Formula 3-12.6 oz cans powder Similac
Sensitive (orange and white label) Infant 16-4 oz OR 9-7 oz (twin pack) foods: containers baby food fruit and/or
vegetable (Stage 2, Stage 2 1/2 or 2nd foods) Infant 16-4 oz OR 9-7 oz (twin pack) foods: containers baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods) Infant cereal: 3-8 oz containers Formula 12-13 oz cans concentrate Similac Sensitive (orange and white label) Formula 12-13 oz cans concentrate Similac Sensitive (orange and white label) Infant 16-4 oz OR 9-7 oz (twin pack) foods: containers baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods) Infant 16-4 oz OR 9-7 oz (twin pack) foods: containers baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd Infant foods) cereal: 3-8 oz containers Formula 10-32 oz containers ready to feed Similac Sensitive (orange and white label) Formula 10-32 oz containers ready to feed Similac Sensitive (orange and white label) Infant 16-4 oz OR 9-7 oz (twin pack) foods: containers baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods) Infant 16-4 oz OR 9-7 oz (twin pack) foods: containers baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd Infant foods) cereal: 3-8 oz containers

FP-73


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-7 (cont'd)

Similac Sensitive RS or Similac Sensitive for Spit Up

Food Package Code

Rank VC Voucher Message

D41 (Assign A41)

4 N61 Formula 4-12.3 oz cans powder Similac

7-12.3 oz cans powder

Sensitive for Spit Up (green and white

Similac Sensitive for Spit

label)

Up

2 N62 Formula 3-12.3 oz cans powder Similac

Sensitive for Spit Up (green and white

32-4 oz infant food

label)

2 N26 Infant

16-4 oz OR 9-7 oz (twin pack)

3-8 oz cereal

foods: containers baby food fruit and/or

vegetable (Stage 2, Stage 2 1/2 or 2nd

Medical Documentation

foods)

Required

4 N01 Infant

16-4 oz OR 9-7 oz (twin pack)

foods: containers baby food fruit and/or

vegetable (Stage 2, Stage 2 1/2 or 2nd

foods)

Infant

cereal: 3-8 oz containers

D43 (Assign A43)

2 N11 Formula 10- quart containers ready to feed

20-32 oz ready to feed

Similac Sensitive for Spit Up (green and

Similac Sensitive for Spit

white label)

Up

4 N11 Formula 10- quart containers ready to feed

Similac Sensitive for Spit Up (green and

32-4 oz infant food

white label)

2 N26 Infant

16-4 oz OR 9-7 oz (twin pack)

3-8 oz cereal

foods: containers baby food fruit and/or

vegetable (Stage 2, Stage 2 1/2 or 2nd

Medical Documentation

foods)

Required

4 N01 Infant

16-4 oz OR 9-7 oz (twin pack)

foods: containers baby food fruit and/or

vegetable (Stage 2, Stage 2 1/2 or 2nd

Infant

foods)

cereal:

3-8 oz containers

FP-74


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-8

Non-Contract Infant Formula Mostly Breastfed Infant Maximum 1-3 months Mostly Breastfeeding Max

Enfamil AR Food Package Code F44 4-12.9 oz powder Enfamil AR
F46 12-32 oz ready to feed Enfamil AR

Rank VC Voucher Message 4 N33 Formula 4-12.9 oz cans powder Enfamil AR
4 M43 Formula 12-1 quart containers ready to feed Enfamil AR

4-5 months Mostly Breastfeeding Max

Enfamil AR

Food Package Code

Rank VC Voucher Message

G44 (Assign F44)

4 168 Formula 5-12.9 oz cans powder Enfamil AR

5-12.9 oz powder Enfamil

AR

G46 14-32 oz ready to feed Enfamil AR

4 309 Formula 14-1 quart containers ready to feed Enfamil AR

6-11 months Mostly Breastfeeding Max

Enfamil AR

Food Package Code

Rank VC Voucher Message

H44 (Assign F44)

4 N33 Formula 4-12.9 oz cans powder Enfamil AR

4-12.9 oz powder Enfamil

2 N26 Infant

16-4 oz OR 9-7 oz (twin pack) containers

AR

foods: baby food fruit and/or vegetable (Stage 2,

Stage 2 1/2 or 2nd foods)

32-4 oz infant food

4 N01 Infant

16-4 oz OR 9-7 oz (twin pack) containers

3-8 oz cereal

foods:

baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods)

Infant

cereal: 3-8 oz containers

H46 (Assign F46)

4 N35 Formula 10-1 quart ready to feed Enfamil AR

10-32 oz ready to feed

Enfamil AR

2 N26 Infant

16-4 oz OR 9-7 oz (twin pack) containers

32-4 oz infant food

foods:

baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods)

3-8 oz cereal

4 N01 Infant foods:
Infant cereal:

16-4 oz OR 9-7 oz (twin pack) containers baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods)
3-8 oz containers

FP-75


GEORGIA WIC 2011 PROCEDURES MANUAL

Attachment FP-8

1-3 months Mostly Breastfeeding Max

Enfamil Gentlease

Food Package Code

Rank VC Voucher Message

F34

4 M01 Formula 5-12 oz OR 4-12.4 oz cans powder

4-12.4 oz powder Enfamil

Enfamil Gentlease

Gentlease

F36

4 M12 Formula 12-1 quart containers ready to feed

12-32 oz ready to feed

Enfamil Gentlease

Enfamil Gentlease

Enfamil Gentlease

4-5 months Mostly Breastfeeding Max

Food Package Code

Rank VC Voucher Message

G34 (Assign F34) 5-12.4 oz powder Enfamil Gentlease

4 M02 Formula 6-12 oz or 5- 12.4 cans powder Enfamil Gentlease

G36 (Assign F36) 14-32 oz ready to feed Enfamil Gentlease

4 M07 Formula 14-1 quart containers ready to feed Enfamil Gentlease

6-11 months Mostly Breastfeeding Max

Enfamil Gentlease

Food Package Code

Rank VC Voucher Message

H34 (Assign F34)

4 M39 Formula 4-12 oz or 4-12.4 oz cans powder Enfamil

4-12.4 oz powder Enfamil

Gentlease

Gentlease

2 N26 Infant

16-4 oz OR 9-7 oz (twin pack) containers

32-4 oz infant food

foods:

baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods)

3-8 oz cereal
H36 (Assign F36) 10-32 oz ready to feed Enfamil Gentlease 32-4 oz infant food

4 N01 Infant

16-4 oz OR 9-7 oz (twin pack) containers

foods: baby food fruit and/or vegetable (Stage 2,

Stage 2 1/2 or 2nd foods)

Infant

cereal: 3-8 oz containers

4 M08 Formula 10-1 quart containers ready to feed

Enfamil Gentlease

2 N26 Infant

16-4 oz OR 9-7 oz (twin pack) containers

foods: baby food fruit and/or vegetable (Stage 2,

Stage 2 1/2 or 2nd foods)

3-8 oz cereal

4 N01 Infant foods:
Infant cereal:

16-4 oz OR 9-7 oz (twin pack) containers baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods)
3-8 oz containers

FP-76


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-8 cont'd)

Similac Sensitive Food Package Code F31 4-12.9 oz powder Similac Sensitive
Medical Documentation Required F32 14-13 oz concentrate Similac Sensitive
Medical Documentation Required F33 12-32 oz ready to feed Similac Sensitive
Medical Documentation Required
Similac Sensitive Food Package Code G31 (Assign F31) 5-12.9 oz powder Similac Sensitive
Medical Documentation Required G32 (Assign F32) 17-13 oz concentrate Similac Sensitive
Medical Documentation Required G33 (Assign F33) 14-32 oz ready to feed Similac Sensitive
Medical Documentation Required

Mostly Breastfed Infant 1-3 months - Maximum VC Voucher Message N03 Formula 4-12.9 oz cans powder Similac Sensitive
(orange and white label)
N21 Formula 14-13 oz cans concentrate Similac Sensitive (orange and white label)
102 Formula 12-32 oz containers ready to feed Similac Sensitive (orange and white label)
Mostly Breastfed Infant 4-5 months - Maximum VC Voucher Message 353 Formula 5-12.9 oz cans powder Similac Sensitive
(orange and white label)
N22 Formula 17-13 oz cans concentrate Similac Sensitive (orange and white label)
132 Formula 14-32 oz containers ready to feed Similac Sensitive (orange and white label)

FP-77


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-8 cont'd)

Similac Sensitive Food Package Code H31 (Assign F31) 4-12.9 oz powder Similac Sensitive
32-4 oz infant food
3-8 oz cereal
Medical Documentation Required H32 (Assign F32) 12-13 oz concentrate Similac Sensitive
32-4 oz infant food
3-8 oz cereal
Medical Documentation Required H33 (Assign F33) 10-32 oz ready to feed Similac Sensitive
32-4 oz infant food
3-8 oz cereal
Medical Documentation Required

Mostly Breastfed Infant 6-11 months - Maximum
VC Voucher Message N03 Formula 4-12.9 oz cans powder Similac Sensitive
(orange and white label) N26 Infant 16-4 oz OR 9-7 oz (twin pack) containers
foods: baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods)
N01 Infant 16-4 oz OR 9-7 oz (twin pack) containers foods: baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods) Infant cereal: 3-8 oz containers
371 Formula 12-13 oz cans concentrate Similac Sensitive (orange and white label)
N26 Infant 16-4 oz OR 9-7 oz (twin pack) containers foods: baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods)
N01 Infant 16-4 oz OR 9-7 oz (twin pack) containers foods: baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods) Infant cereal: 3-8 oz containers
N10 Formula 10-32 oz containers ready to feed Similac Sensitive (orange and white label)
N26 Infant 16-4 oz OR 9-7 oz (twin pack) containers foods: baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods)
N01 Infant 16-4 oz OR 9-7 oz (twin pack) containers foods: baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods) Infant cereal: 3-8 oz containers

FP-78


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-8 cont'd)

Mostly Breastfed Infant

1-3 months - Maximum

Similac Sensitive for Spit Up

Food Package Code

VC Voucher Message

F41

N61 Formula 4-12.9 oz cans powder

4-12.9 oz powder Similac

Similac Sensitive for Spit Up (green and

Sensitive for Spit Up

white label)

Medical Documentation

Required

F43

136

12-32 oz ready to feed

Similac Sensitive for Spit Up

Formula 12-32 oz containers ready to feed Similac Sensitive for Spit Up (green and white label)

Medical Documentation Required

Mostly Breastfed Infant

4-5 months - Maximum

Similac Sensitive for Spit Up

Food Package Code

VC Voucher Message

G41 (Assign F41)

N60 Formula 5-12.9 oz cans powder

5-12.9 oz powder Similac

Similac Sensitive for Spit Up (green and

Sensitive for Spit Up

white label)

Medical Documentation

Required

G43 (Assign F43)

139

14-32 oz ready to feed

Similac Sensitive for Spit Up

Formula 14-32 oz containers ready to feed Similac Sensitive for Spit Up (green and white label)

Medical Documentation Required

FP-79


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-8 cont'd)

Similac Sensitive RS Food Package Code H41 (Assign F41) 4-12.9 oz powder Similac Sensitive for Spit Up 32-4 oz infant food
3-8 oz cereal
Medical Documentation Required
H43 (Assign F43) 10-32 oz ready to feed Similac Sensitive for Spit Up
32-4 oz infant food
3-8 oz cereal
Medical Documentation Required

Mostly Breastfed Infant 6-11 months - Maximum
VC Voucher Message N61 Formula 4-12.9 oz cans powder
Similac Sensitive for Spit Up (green and white label) N26 Infant 16-4 oz OR 9-7 oz (twin pack) containers foods: baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods) N01 Infant 16-4 oz OR 9-7 oz (twin pack) containers foods: baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods) Infant cereal: 3-8 oz containers N11 Formula 10-32 oz containers ready to feed Similac Sensitive for Spit Up (green and white label) N26 Infant 16-4 oz OR 9-7 oz (twin pack) containers foods: baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods) N01 Infant 16-4 oz OR 9-7 oz (twin pack) containers foods: baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods) Infant cereal: 3-8 oz containers

FP-80


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-8 cont'd)

Non-Contract Infant Formula Mostly Breastfed Infant 1- 3 cans per month

Enfamil AR Food Package Code E44 1-12.9 oz powder Enfamil AR L44 (Assign E44) 1-12.9 oz powder Enfamil AR
32-4 oz infant food
3-8 oz cereal
Medical Documentation Required K44 2-12.9 oz powder Enfamil AR M44 (Assign K44) 2-12.9 oz powder Enfamil AR
32-4 oz infant food
3-8 oz cereal
Medical Documentation Required J44 3-12.9 oz powder Enfamil AR
Medical Documentation Required N44 (Assign J44) 3-12.9 oz powder Enfamil AR
32-4 oz infant food
3-8 oz cereal
Medical Documentation Required

Rank VC Voucher Message 4 307 Formula 1-12.9 oz can powder Enfamil AR

4 307 Formula 1-12.9 oz can powder Enfamil AR

2 N26 Infant

16-4 oz OR 9-7 oz (twin pack) containers

foods: baby food fruit and/or vegetable (Stage 2,

Stage 2 1/2 or 2nd foods)

4 N01 Infant

16-4 oz OR 9-7 oz (twin pack) containers

foods: baby food fruit and/or vegetable (Stage 2,

Stage 2 1/2 or 2nd foods)

Infant

cereal: 3-8 oz containers

4 M42 Formula 2-12.9 oz cans powder Enfamil AR

4 M42 Formula 2-12.9 oz cans powder Enfamil AR

2 N26 Infant

16-4 oz OR 9-7 oz (twin pack) containers

foods: baby food fruit and/or vegetable (Stage 2,

Stage 2 1/2 or 2nd foods)

4 N01 Infant

16-4 oz OR 9-7 oz (twin pack) containers

foods: baby food fruit and/or vegetable (Stage 2,

Stage 2 1/2 or 2nd foods)

Infant

cereal: 3-8 oz containers

4 N34 Formula 3-12.9 oz cans powder Enfamil AR

4 N34 Formula 3-12.9 oz cans powder Enfamil AR

2 N26 Infant foods:
4 N01 Infant foods:
Infant cereal:

16-4 oz OR 9-7 oz (twin pack) containers baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods) 16-4 oz OR 9-7 oz (twin pack) containers baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods)
3-8 oz containers

FP-81


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-8 cont'd)

Enfamil Gentlease Food Package Code E34 1-12.4 oz powder Enfamil Gentlease
Medical Documentation Required L34 (Assign E34) 1-12.4 oz powder Enfamil Gentlease
32-4 oz infant food
3-8 oz cereal
Medical Documentation Required K34 2-12.4 oz powder Enfamil Gentlease M34 (Assign K34) 2-12 oz powder Enfamil Gentlease
32-4 oz infant food
3-8 oz cereal
Medical Documentation Required J34 3-12.4 oz powder Enfamil Gentlease
Medical Documentation Required N34 (Assign J34) 3-12.4 oz powder Enfamil Gentlease
32-4 oz infant food
3-8 oz cereal
Medical Documentation Required

Rank VC Voucher Message 4 M36 Formula 1-12 oz OR 1-12.4 oz can powder Enfamil Gentlease

4 M36 Formula 1-12 oz OR 1-12.4 oz can powder

Enfamil Gentlease

2 N26 Infant

16-4 oz OR 9-7 oz (twin pack) containers

foods: baby food fruit and/or vegetable (Stage 2,

Stage 2 1/2 or 2nd foods)

4 N01 Infant

16-4 oz OR 9-7 oz (twin pack) containers

foods: baby food fruit and/or vegetable (Stage 2,

Stage 2 1/2 or 2nd foods)

Infant

cereal: 3-8 oz containers

4 M37 Formula 2-12 oz OR 2.12.4 oz cans powder

Enfamil Gentlease

4 M37 Formula 2-12 oz OR 2.12.4 oz cans powder

Enfamil Gentlease

2 N26 Infant

16-4 oz OR 9-7 oz (twin pack) containers

foods: baby food fruit and/or vegetable (Stage 2,

Stage 2 1/2 or 2nd foods)

4 N01 Infant

16-4 oz OR 9-7 oz (twin pack) containers

foods: baby food fruit and/or vegetable (Stage 2,

Stage 2 1/2 or 2nd foods)

Infant

cereal: 3-8 oz containers

4 M38 Formula 3-12 oz OR 12.4 oz cans powder Enfamil

Gentlease

4 M38 Formula 3-12 oz OR 12.4 oz cans powder Enfamil

Gentlease

2 N26 Infant

16-4 oz OR 9-7 oz (twin pack) containers

foods: baby food fruit and/or vegetable (Stage 2,

Stage 2 1/2 or 2nd foods)

4 N01 Infant

16-4 oz OR 9-7 oz (twin pack) containers

foods: baby food fruit and/or vegetable (Stage 2,

Stage 2 1/2 or 2nd foods)

Infant

cereal: 3-8 oz containers

FP-82


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-8 cont'd)

Similac Sensitive Food Package Code E31 1-12.6 oz powder Similac Sensitive
Medical Documentation Required L31 (Assign E31) 1-12.6 oz powder Similac Sensitive
32-4 oz infant food
3-8 oz cereal
Medical Documentation Required K31 2-12.6 oz powder Similac Sensitive
Medical Documentation Required M31 (Assign K31) 2-12.6 oz powder Similac Sensitive
32-4 oz infant food
3-8 oz cereal
Medical Documentation Required J31 3-12.6 oz powder Similac Sensitive
Medical Documentation Required N31 (Assign J31) 3-12.6 oz powder Similac Sensitive
32-4 oz infant food
3-8 oz cereal
Medical Documentation Required

VC Voucher Message 374 Formula 1-12.6 oz can powder Similac Sensitive
(orange and white label)
374 Formula 1-12.6 oz can powder Similac Sensitive (orange and white label)
N26 Infant 16-4 oz OR 9-7 oz (twin pack) containers foods: baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods)
N01 Infant 16-4 oz OR 9-7 oz (twin pack) containers foods: baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods) Infant cereal: 3-8 oz containers
N23 Formula 2-12.6 oz cans powder Similac Sensitive (orange and white label)
N23 Formula 2-12.6 oz cans powder Similac Sensitive (orange and white label)
N26 Infant 16-4 oz OR 9-7 oz (twin pack) containers foods: baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods)
N01 Infant 16-4 oz OR 9-7 oz (twin pack) containers foods: baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods) Infant cereal: 3-8 oz containers
N24 Formula 3-12.6 oz cans powder Similac Sensitive (orange and white label)
N24 Formula 3-12.6 oz cans powder Similac Sensitive (orange and white label)
N26 Infant 16-4 oz OR 9-7 oz (twin pack) containers foods: baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods)
N01 Infant 16-4 oz OR 9-7 oz (twin pack) containers foods: baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods) Infant cereal: 3-8 oz containers
FP-83


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-8 cont'd)

Similac Sensitive for Spit Up

Food Package Code

VC

E41

111

1-12.6 oz powder Similac

Sensitive for Spit Up

Voucher Message Formula 1-12.6 oz can powder Similac Sensitive
for Spit Up (green and white label)

Medical Documentation Required L41 (Assign E41) 1-12.6 oz powder Similac Sensitive for Spit Up
32-4 oz infant food
3-8 oz cereal
Medical Documentation Required K41 2-12.6 oz powder Similac Sensitive for Spit Up

111 Formula 1-12.6 oz can powder Similac Sensitive for Spit Up (green and white label)
N26 Infant 16-4 oz OR 9-7 oz (twin pack) containers foods: baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods)
N01 Infant 16-4 oz OR 9-7 oz (twin pack) containers foods: baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods) Infant cereal: 3-8 oz containers
N64 Formula 2-12.6 oz cans powder Similac Sensitive for Spit Up (green and white label)

Medical Documentation Required M41 (Assign K41) 2-12.6 oz powder Similac Sensitive for Spit Up
32-4 oz infant food
3-8 oz cereal
Medical Documentation Required J41 3-12.6 oz powder Similac Sensitive for Spit Up

N64 Formula 2-12.6 oz cans powder Similac Sensitive for Spit Up (green and white label)
N26 Infant 16-4 oz OR 9-7 oz (twin pack) containers foods: baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods)
N01 Infant 16-4 oz OR 9-7 oz (twin pack) containers foods: baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods) Infant cereal: 3-8 oz containers
N65 Formula 3-12.6 oz cans powder Similac Sensitive for Spit Up (green and white label)

Medical Documentation Required N41 (Assign J41) 3-12.6 oz powder Similac Sensitive for Spit Up
32-4 oz infant food
3-8 oz cereal
Medical Documentation Required

N65 Formula 3-12.6 oz cans powder Similac Sensitive for Spit Up (green and white label)
N26 Infant 16-4 oz OR 9-7 oz (twin pack) containers foods: baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods)
N01 Infant 16-4 oz OR 9-7 oz (twin pack) containers foods: baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods) Infant cereal: 3-8 oz containers

FP-84


GEORGIA WIC 2011 PROCEDURES MANUAL

Attachment FP-9

Non-Contract Standard Infant Formula for Children

Enfamil AR Food Package Code X44 9-12.9 oz powder Enfamil AR

Rank VC 2 N33 4 168

Voucher Message Formula 4-12.9 oz cans powder Enfamil AR Formula 5-12.9 oz cans powder Enfamil AR

Medical Documentation Required X46 28-1 quart ready to feed Enfamil AR
Medical Documentation Required

2 309 Formula 14-1 quart containers ready to feed Enfamil AR
4 309 Formula 14-1 quart containers ready to feed Enfamil AR

Enfamil Gentlease Food Package Code Z34 10-12.4 oz powder Enfamil Gentlease
Medical Documentation Required Z36 28-32 oz ready to feed Enfamil Gentlease
Medical Documentation Required

Rank VC 2 M40
4 M40

Voucher Message Formula 5-12 oz OR 5-12.4 oz cans powder
Enfamil Gentlease Formula 5-12 oz OR 5-12.4 oz cans powder
Enfamil Gentlease

2 M07 Formula 14-1 quart containers ready to feed Enfamil Gentlease
4 M07 Formula 14-1 quart containers ready to feed Enfamil Gentlease

FP-85


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-9 cont'd)

Similac Sensitive Food Package Code X31 9-12.6 oz powder Similac Sensitive
Medical Documentation Required X32 35-13 oz concentrate Similac Sensitive
Medical Documentation Required X33 28-32 oz ready to feed Similac Sensitive
Medical Documentation Required

Rank VC 4 353
2 N03

Voucher Message Formula 5-12.6 oz cans powder Similac
Sensitive (orange and white label) Formula 4-12.6 oz cans powder Similac
Sensitive (orange and white label)

4 386 Formula 19-13 oz cans concentrate Similac Sensitive (orange and white label)
2 365 Formula 16-13 oz cans concentrate Similac Sensitive (orange and white label)
2 132 Formula 14-32 oz containers ready to feed Similac Sensitive (orange and white label)
4 132 Formula 14-32 oz containers ready to feed Similac Sensitive (orange and white label)

Similac Sensitive for Spit Up

Food Package Code

Rank VC

X41

2 N61

9-12.3 oz cans powder

Similac Sensitive for Spit

Up 4 N60

Medical Documentation

Required

X43 Similac Sensitive for Spit Up
Medical Documentation Required

2 139 4 139

Voucher Message Formula 4-12.3 oz cans powder Similac
Sensitive for Spit Up (green and white label)

Formula Formula Formula

5-12.3 oz cans powder Similac Sensitive for Spit Up (green and white label)
14- quart containers ready to feed Similac Sensitive for Spit Up (green and white label) 14- quart containers ready to feed Similac Sensitive for Spit Up (green and white label)

FP-86


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-10

W01 W02 W03 W04
W05 W06
W07
W08 W09
W10 W11 W12 W13
W21 W22 W23 W24
W25 W26
W27
W28 W29
W30 W31 W32 W33 W80

Summary of Food Packages for Women and Children
Women Food Packages:
Prenatal/Mostly Breastfeeding W00 W19
Standard Prenatal/Mostly Breastfeeding Women Lactose Intolerant Prenatal/Mostly Breastfeeding Women Goat Milk for Prenatal/Mostly Breastfeeding Women Extra Cheese for Prenatal/Mostly Breastfeeding Women MEDICAL DOCUMENTATION REQUIRED Limited Tofu for Prenatal/Mostly Breastfeeding Women Extra Tofu for Prenatal/Mostly Breastfeeding Women MEDICAL DOCUMENTATION NEEDED Whole Milk Prenatal/Mostly Breastfeeding Women MEDICAL DOCUMENTATION REQUIRED No Cheese for Prenatal/Mostly Breastfeeding Women No Milk for Prenatal/Mostly Breastfeeding Women MEDICAL DOCUMENTATION REQUIRED Prenatal/Mostly Breastfeeding Women Alternative Package Soy Milk for Prenatal/Mostly Breastfeeding Women Evaporated Milk for Prenatal/Mostly Breastfeeding Women Soy Milk with Tofu for Prenatal/Mostly Breastfeeding Women
Postpartum Non-Breastfeeding/Some Breastfeeding W20 W39, W80
Standard Postpartum Women Lactose Intolerant Postpartum Women Goat Milk for Postpartum Women Extra Cheese for Postpartum Women MEDICAL DOCUMENTATION REQUIRED Limited Tofu for Postpartum Women Extra Tofu for Postpartum Women Extra Tofu MEDICAL DOCUMENTATION REQUIRED Whole Milk for Postpartum Women MEDICAL DOCUMENTATION REQUIRED No Cheese for Postpartum Women No Milk for Postpartum Women MEDICAL DOCUMENTATION REQUIRED Postpartum Women Alternative Package Soy Milk for Postpartum Women Evaporated Milk for Postpartum Women Soy Milk with Tofu for Postpartum Women Some Breastfeeding >6 months Postpartum

FP-87


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-10 (cont'd)

Exclusively Breastfeeding Woman Single Infant/Prenatal with Multiples /Mostly Breastfeeding Multiples W40 W59

W41 W42 W43 W44 W45 W46
W47
W49
W50 W51 W52 W53

Standard Exclusively Breastfeeding/Prenatal with Multiples Lactose Intolerant Exclusively Breastfeeding/Prenatal with Multiples Goat Milk for Exclusively Breastfeeding/Prenatal with Multiples More Cheese for Exclusively Breastfeeding/Prenatal with Multiples Limited Tofu for Exclusively Breastfeeding/Prenatal with Multiples Extra Tofu for Exclusively Breastfeeding/Prenatal with Multiples
MEDICAL DOCUMENTATION NEEDED Whole Milk for Exclusively Breastfeeding/Prenatal with Multiples MEDICAL DOCUMENTATION REQUIRED No Milk for Exclusively Breastfeeding/Prenatal with Multiples
MEDICAL DOCUMENTAION REQUIRED Exclusively Breastfeeding/Prenatal with Multiples Alternative Package Soy Milk for Exclusively Breastfeeding/Prenatal with Multiples Evaporated Milk for Exclusively Breastfeeding/Prenatal with Multiples Soy Milk with Tofu for Exclusively Breastfeeding/Prenatal with Multiples

Exclusively Breastfeeding Multiples W60 W79 (V60 V79)

W61 V61 W62 V62 W63 V63 W65 V65 W69
V69
W71 V71

Standard Exclusively Breastfeeding Multiples Package A Standard Exclusively Breastfeeding Multiples Package B Lactose Intolerant Exclusively Breastfeeding Multiples Package A Lactose Intolerant Exclusively Breastfeeding Multiples Package B Goat Milk for Exclusively Breastfeeding Multiples Package A Goat Milk for Exclusively Breastfeeding Multiples Package B Tofu for Exclusively Breastfeeding Multiples Package A Tofu for Exclusively Breastfeeding Multiples Package B No milk for Exclusively Breastfeeding Multiples Package A MEDICAL DOCUMENTATION REQUIRED No milk for Exclusively Breastfeeding Multiples Package B MEDICAL DOCUMENTATION REQUIRED Soy Milk for Exclusively Breastfeeding Multiples Package A Soy Milk for Exclusively Breastfeeding Multiples Package A

FP-88


GEORGIA WIC 2012 PROCEDURES MANUAL
Child Food Packages:
12 23 Month Old Child C00 C19
C01 Standard Child 1-2 years old C02 Lactose Intolerant 1-2 year old C03 Goat Milk for 1 -2 year old C05 Limited Tofu for 1-2 yr old
MEDICAL DOCUMENTATION REQUIRED C06 Extra Tofu for 1-2 year old
MEDICAL DOCUMENTATION REQUIRED C09 No milk for 1-2 year old
MEDICAL DOCUMENTAION NEEDED C10 1-2 year old Alternative Package C11 Soy Milk for 1-2 years old
MEDICAL DOCUMENTATION REQUIRED C12 Evaporated Milk for 1-2 year old C13 Soy Milk with Tofu for 1-2 years old
MEDICAL DOCUMENTATION REQUIRED
2 - 5 Year Old Child C20 C39
C21 Standard 2-5 year old C22 Lactose Intolerant 2- 5 year old C23 Goat Milk for 2-5 year old C24 Extra Cheese for 2-5 yr old child
MEDICAL DOCUMENTATION REQUIRED C25 Limited Tofu for 2-5 yr child
MEDICAL DOCUMENTATION REQUIRED C26 Extra Tofu for 2-5 yr child
MEDICAL DOCUMENTATION REQUIRED C27 Whole Milk for 2 -5 year old
MEDICAL DOCUMENTATION REQUIRED C28 No Cheese for 2-5 year old C29 No milk for 2-5 year old
MEDICAL DOCUMENTATION REQUIRED C30 2-5 year old Alternative Package C31 Soy Milk for 2-5 year old
MEDICAL DOCUMENTATION REQUIRED C32 Evaporated Milk for 2-5 year old C33 Soy Milk for 2-5 year old
MEDICAL DOCUMENTATION REQUIRED

Attachment FP-10 (cont'd)

FP-89


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-11

Prenatal/Mostly Breastfeeding Women Packages W00-W13

Food Package Number W01 Standard Prenatal/Mostly Breastfeeding Women
$10 fruit and vegetable
4 gallons of milk
1-3 qt box dry milk
1 lb cheese
3-48 oz cans of juice
1 dozen eggs
36 oz cereal
16 oz whole grains
1 container of peanut butter (16-18 oz.)
1 lb dried beans

Rank 9 3
2
4

VC P02 041
W01
W02

Voucher Message

Produce: $10 for fresh, frozen, or canned fruit and

vegetables

No potatoes-except for sweet potatoes or

yams. No products with added sugar,

seasonings, fat, or oils. No creamed

vegetables. No stewed tomatoes.

Milk:

1 gallon low-fat (fat-free, 1%, 2%)

No whole milk. Least expensive brand

Eggs: 1 dozen

Juice: 2 containers (46 to 48 oz) OR 2-12 oz cans

frozen OR 2-11.5 oz cans pourable

concentrate

Cereal: No more than 36 oz.

Milk:

1 gallon low-fat (fat-free, 1%, 2%)

No whole milk. Least expensive brand

Dry Milk: 1- 3 quart container non-fat dry powder OR

4-12 oz cans low-fat (fat-free, skimmed,

2%) evaporated

Cheese: 1-16 oz package

Peanut

butter: 1 container (16 to 18 oz)

Milk:

1 gallon low-fat (fat-free, 1%, 2%)

No whole milk. Least expensive brand

Whole Grain:

Pick 1: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns

Beans: 1 lb dried OR 4 cans (14 to 16 oz)

1 040 Milk:

1 gallon low-fat (fat-free, 1%, 2%)

No whole milk. Least expensive brand

Juice:

1 container (46-48 oz) OR 1-12 oz can frozen OR 1-11.5 oz can pourable concentrate

FP-90


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-11 (cont'd)

Food Package number W02 Lactose Intolerant Prenatal/Mostly Breastfeeding Women
$10 fruit and vegetable
19 qt lactose reduced milk
1 lb cheese
3-48 oz juice
1 dozen eggs
36 oz cereal
16 oz whole grain
1 container of peanut butter (16-18 oz.)

Rank VC 9 P02
2 034
2 024

VC Message

Produce: $10 for fresh, frozen, or canned fruit

and vegetables

No potatoes-except for sweet potatoes

or yams. No products with added

sugar, seasonings, fat, or oils. No

creamed vegetables. No stewed

tomatoes.

Milk:

1 gallon OR 4 quarts OR 2 half gallons

low- fat (fat-free, 1%, 2%) Lactose

free, OR Acidophilus, OR Acidophilus

and Bifidum. No whole milk.

Least expensive brand

Juice:

2 containers (46 to 48 oz) OR 2-12 oz

cans frozen OR 2-11.5 oz cans

pourable concentrate

Milk:

1 gallon OR 4 quarts OR 2 half gallons

low- fat (fat-free, 1%, 2%) Lactose

free, OR Acidophilus, OR Acidophilus

and Bifidum. No whole milk. Least

expensive brand

1 lb dried beans

Beans: 3 033 Milk:

1 lb dried OR 4 cans (14 to 16 oz) 1 gallon OR 4 quarts OR 2 half gallons low- fat (fat-free, 1%, 2%) Lactose free, OR Acidophilus, OR Acidophilus and Bifidum. No whole milk. Least expensive brand

Cereal: No more than 36 oz

1 501 Milk:

1 gallon OR 4 quarts OR 2 half gallons

low- fat (fat-free, 1%, 2%) Lactose

free, OR Acidophilus, OR Acidophilus

and Bifidum. No whole milk. Least

expensive brand

Juice:

1 container (46-48 oz) OR 1-12 oz can frozen OR 1-11.5 oz can pourable concentrate

FP-91


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-11 (cont'd)

4 W07 Milk:

1-3 quart (96 oz) container OR 1-half gallon low-fat (fat-free, 1%, 2%) Lactose-free, OR Acidophilus, OR Acidophilus and Bifidum No whole milk. Least expensive brand

Cheese: 1-16 oz package

4 W80 Eggs:

1 dozen

Whole Pick 1: 16 oz loaf of bread; 16 oz pkg

grain:

brown rice; 16 oz pkg tortillas; 14 to 16

oz pkg buns

Peanut butter:

1 container (16 to 18 oz)

FP-92


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-11 (cont'd)

Food Package W03 Goat Milk for Prenatal/Mostly Breastfeeding Women
$10 fruit and vegetable
19 quarts goat milk
1 lb cheese
3-48 oz juice
1 dozen eggs
36 oz cereal
16 oz whole grains
1 container of peanut butter (16-18 oz.)
1 lb dried beans

Rank 9
4

VC P02
W11

Voucher Message

Produce: $10 for fresh, frozen, or canned fruit

and vegetables

No potatoes-except for sweet potatoes

or yams. No products with added

sugar, seasonings, fat, or oils. No

creamed vegetables. No stewed

tomatoes.

Goat

3 quarts low-fat goat milk. No whole

milk:

Milk.

Cheese: 1-16 oz package

Peanut

butter: 1 container (16 to 18 oz)

4 W12 Goat

4 quarts low-fat goat milk. No whole

milk:

Milk.

Juice:

2 containers (46 to 48 oz) OR 2-12 oz cans frozen OR 2-11.5 oz cans pourable concentrate

Whole grain:
1 W13 Goat milk:

Pick 1: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns 4 quarts low-fat goat milk. No whole milk.

Beans: 2 W14 Goat
milk:

1 lb dried OR 4 cans (14 to 16 oz) 4 quarts low-fat goat milk. No whole milk.

Juice:
Eggs: 3 W15 Goat
milk:

1 container (46-48 oz) OR 1-12 oz can frozen OR 1-11.5 oz can pourable concentrate 1 dozen 4 quarts low-fat goat milk. No whole milk.

Cereal: No more than 36 oz

FP-93


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-11 (cont'd)

Food Package Number W04 Extra Cheese for Prenatal/Mostly Breastfeeding Women
MEDICAL DOCUMENTATION REQUIRED
$10 fruit and vegetable
4 gallon milk
2 lb cheese

Rank VC 9 P02
2 041

Voucher Message

Produce: $10 for fresh, frozen, or canned fruit

and vegetables

No potatoes-except for sweet potatoes

or yams. No products with added

sugar, seasonings, fat, or oils. No

creamed vegetables. No stewed

tomatoes.

Milk:

1 gallon low-fat (fat-free, 1%, 2%)

No whole milk. Least expensive

brand

Juice:

2 containers (46 to 48 oz) OR 2-12 oz

cans frozen OR 2-11.5 oz cans

pourable concentrate

3-48 oz juice 1 dozen eggs 36 oz cereal

Eggs:

1 dozen

Cereal: No more than 36 oz.

3 W45 Milk:

1 gallon low-fat (fat-free, 1%, 2%)

No whole milk. Least expensive

brand

16 oz whole grain

Cheese: 1-16 oz package

Peanut

1 container of peanut butter

butter: 1 container (16 to 18 oz)

(16-18 oz.)

4 W02 Milk:

1gallon low-fat (fat-free, 1%, 2%)

No whole milk. Least expensive

1 lb dried bean

brand

Whole Grain:
Beans: 1 031 Milk:

Pick 1: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns 1 lb dried OR 4 cans (14 to 16 oz) 1 gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Juice: Cheese:

1 container (46-48 oz) OR 1-12 oz can frozen OR 1-11.5 oz can pourable concentrate 1-16 oz package

FP-94


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-11 (cont'd)

Food Package Number W05 Limited Tofu for Prenatal/Mostly Breastfeeding Women
$10 fruit and vegetable
5 gallons of milk
2 lb of tofu
3-48 oz juice
1 dozen eggs
36 oz cereal
16 oz whole grain
1 container of peanut butter (16-18 oz.)
1 lb dried beans

Rank VC 9 P02
2 041

Voucher Message

Produce: $10 for fresh, frozen, or canned fruit

and vegetables

No potatoes-except for sweet potatoes

or yams. No products with added

sugar, seasonings, fat, or oils. No

creamed vegetables. No stewed

tomatoes.

Milk:

1 gallon low-fat (fat-free, 1%, 2%)

No whole milk. Least expensive brand

Juice:

2 containers (46 to 48 oz) OR 2-12 oz cans frozen OR 2-11.5 oz cans pourable concentrate

Eggs:

1 dozen

Cereal: No more than 36 oz.

3 W37 Milk:

1 gallon low-fat (fat-free, 1%, 2%)

No whole milk. Least expensive brand

Cheese: 1-16 oz package

Tofu:

No more than 2 pounds

Peanut

butter: 1 container (16 to 18 oz)

4 W02 Milk:

1gallon low-fat (fat-free, 1%, 2%)

No whole milk. Least expensive brand

Whole Grain:

Pick 1: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns

Beans: 1 051 Milk:

1 lb dried OR 4 cans (14 to 16 oz) 2 gallons low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Juice:

1 container (46-48 oz) OR 1-12 oz can frozen OR 1-11.5 oz can pourable concentrate

FP-95


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-11 (cont'd)

Food Package Number W06 Extra Tofu for Prenatal/Mostly Breastfeeding Women
MEDICAL DOCUMENTATION NEEDED
$10 fruit and vegetable
3 gallon milk
10 lb tofu
3-48 oz juice
1 dozen eggs
36 oz cereal

Rank VC 9 P02
2 041
3 W37

Voucher Message

Produce: $10 for fresh, frozen, or canned fruit

and vegetables

No potatoes-except for sweet potatoes

or yams. No products with added

sugar, seasonings, fat, or oils. No

creamed vegetables. No stewed

tomatoes.

Milk:

1 gallon low-fat (fat-free, 1%, 2%)

No whole milk. Least expensive

brand

Juice:

2 containers (46 to 48 oz) OR 2-12 oz

cans frozen OR 2-11.5 oz cans

pourable concentrate

Eggs:

1 dozen

Cereal: No more than 36 oz.

Milk:

1 gallon low-fat (fat-free, 1%, 2%)

No whole milk. Least expensive

brand

Cheese: 1-16 oz package

16 oz whole grain

Tofu:

No more than 2 pounds

Peanut

1 container of peanut butter

butter: 1 container (16 to 18 oz)

(16-18 oz.)

4 W38 Tofu:

No more than 4 pounds

1 lb dried beans

Whole Grain:
Beans: 1 W43 Milk:

Pick 1: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns 1 lb dried OR 4 cans (14 to 16 oz) 1 gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Tofu:

No more than 4 pounds

Juice:

1 container (46-48 oz) OR 1-12 oz can frozen OR 1-11.5 oz can pourable concentrate

FP-96


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-11 (cont'd)

Food Package Number W07 Whole Milk for Prenatal/Mostly Breastfeeding Women
Can only be given with food package III
MEDICAL DOCUMENTATION REQUIRED
$10 fruit and vegetable
5 gallon whole milk
3-48 oz juice
1 dozen eggs
36 oz cereal
16 oz whole grain
1 container of peanut butter (16-18 oz.)
1 lb dried beans

Rank VC 9 P02
1 046 3 C04 4 W47 4 W48

Voucher Message

Produce: $10 for fresh, frozen, or canned fruit

and vegetables

No potatoes-except for sweet potatoes

or yams. No products with added

sugar, seasonings, fat, or oils. No

creamed vegetables. No stewed

tomatoes.

Milk:

1 gallon Whole milk only

Least expensive brand

Juice: Milk:

1 container (46-48 oz) OR 1-12 oz can frozen OR 1-11.5 oz can pourable concentrate 1 gallon Whole milk only Least expensive brand

Cereal: No more than 36 oz

Eggs: Milk:

1 dozen 2 gallons Whole milk only Least expensive brand

Juice: Milk:

2 containers (46 to 48 oz) OR 2-12 oz cans frozen OR 2-11.5 oz cans pourable concentrate 1 gallon Whole milk only Least expensive brand

Whole Grains:

Pick 1: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns

Beans: 1 lb dried OR 4 cans (14 to 16 oz)

2 W49 Milk:

1 half gallon whole milk only

Least expensive brand

Peanut

butter: 1 container (16 to 18 oz)

FP-97


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-11 (cont'd)

Food Package W08 No Cheese for Prenatal/Mostly Breastfeeding Women
$10 fruit and vegetable
5 gallon milk
3-48 oz juice
1 dozen eggs
36 oz cereal
16 oz whole grain
1 container of peanut butter (16-18 oz.)
1 lb dried beans

Rank VC 9 P02
3 039
4 W02

Voucher Message

Produce: $10 for fresh, frozen, or canned fruit

and vegetables

No potatoes-except for sweet potatoes

or yams. No products with added

sugar, seasonings, fat, or oils. No

creamed vegetables. No stewed

tomatoes.

Milk:

1 gallon low-fat (fat-free, 1%, 2%)

No whole milk. Least expensive

brand

Juice:

1 container (46-48 oz) OR 1-12 oz can

frozen OR 1-11.5 oz can pourable

concentrate

Eggs:

1 dozen

Milk:

1gallon low-fat (fat-free, 1%, 2%)

No whole milk. Least expensive

brand

Whole Grain:
Beans: 1 040 Milk:

Pick 1: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns 1 lb dried OR 4 cans (14 to 16 oz) 1 gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Juice: 2 029 Milk:

1 container (46-48 oz) OR 1-12 oz can frozen OR 1-11.5 oz can pourable concentrate 2 gallons low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Juice: 4 W20 Milk:

1 container (46-48 oz) OR 1-12 oz can frozen OR 1-11.5 oz can pourable concentrate 1-half gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Cereal: No more than 36 oz

Peanut Butter:

1 container (16-18 oz)

FP-98


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-11 (cont'd)

Food Package W09 No Milk for Prenatal/Mostly Breastfeeding Women
MEDICAL DOCUMENTATION REQUIRED
Can only be given with food package III

Rank 9
2

VC P02
W54

Voucher Message Produce: $10 for fresh, frozen, or canned fruit
and vegetables No potatoes-except for sweet potatoes or yams. No products with added sugar, seasonings, fat, or oils. No creamed vegetables. No stewed or diced tomatoes. Cheese: 1-16 oz package

Eggs:

1 dozen

$10 Fruit and vegetable 1 lb cheese 3-48 oz juice 1 dozen eggs

Cereal: No more than 36 oz

4 W55 Juice:

1 container (46-48 oz) OR 1-12 oz can

frozen OR 1-11.5 oz can pourable

concentrate

Whole Pick 1: 16 oz loaf of bread; 16 oz pkg

Grain: brown rice; 16 oz pkg tortillas; 14 to 16

oz pkg buns

36 oz cereal

Beans: 1 lb dried OR 4 cans (14 to 16 oz)

3 W56 Juice:

2 containers (46 to 48 oz) OR 2-12 oz

16 oz whole grain

cans frozen OR 2-11.5 oz cans

pourable concentrate

1 container of peanut butter

Peanut

(16-18 oz.)

Butter: 1 container (16-18 oz)

1 lb dried beans

FP-99


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-11 (cont'd)

Food Package Number W10 Prenatal/Mostly Breastfeeding Women Alternative Package
$10 fruit and vegetable
88-8 oz UHT milk
24-6oz cans juice
36 oz cereal
16 oz whole grains
2 containers of peanut butter (16-18 oz. each)

Rank VC 9 P02
3 H14

Voucher Message

Produce: $10 for fresh, frozen, or canned fruit

and vegetables

No potatoes-except for sweet potatoes

or yams. No products with added

sugar, seasonings, fat, or oils. No

creamed vegetables. No stewed

tomatoes.

Milk:

12-8 oz OR half pint boxes low-fat (fat-

free, 1%, 2%) UHT. No whole milk.

Juice: 2 H15 Milk:

6 cans (5.5 to 6 oz) 12-8 oz OR half pint boxes low-fat (fat-free, 1%, 2%) UHT. No whole milk.

Juice:

6 cans (5.5 to 6 oz)

Peanut butter: 4 H15 Milk:

1 container (16 to 18 oz)
12-8 oz OR half pint boxes low-fat (fatfree, 1%, 2%) UHT. No whole milk.

Juice:

6 cans (5.5 to 6 oz)

Peanut butter: 2 H13 Milk:

1 container (16 to 18 oz)
12-8 oz OR half pint boxes low-fat (fatfree, 1%, 2%) UHT. No whole milk.

Cereal: No more than 18 oz

3 H13 Milk:

12-8 oz OR half pint boxes low-fat (fat-

free, 1%, 2%) UHT. No whole milk.

Cereal: No more than 18 oz

1 H14 Milk:

12-8 oz OR half pint boxes low-fat

(fat-free, 1%, 2%) UHT. No whole milk.

Juice: 4 H01 Milk:

6 cans (5.5 to 6 oz)
16-8 oz OR half pint boxes low-fat (fatfree, 1%, 2%) UHT. No whole milk.

Whole Grain:

Pick 1: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns

FP-100


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-11 (cont'd)

Food Package W11 Soy Milk for Prenatal/Mostly Breastfeeding Women
$10 fruit and vegetable
5 gallons soy milk
3-48 oz juice
1 dozen eggs
36 oz cereal
16 oz whole grains
1 container of peanut butter (16-18 oz.)
1 lb dried beans

Rank VC 9 P02
3 W28 4 W30

Voucher Message

Produce: $10 for fresh, frozen, or canned fruit

and vegetables

No potatoes-except for sweet potatoes

or yams. No products with added

sugar, seasonings, fat, or oils. No

creamed vegetables. No stewed

tomatoes.

Soy Milk: 3 half gallons 8th Continent

(Original OR Vanilla flavors only)

Peanut

butter: 1 container (16 to 18 oz)

Soy milk: 2 half gallons 8th Continent

(Original OR Vanilla flavors only)

Juice:

2 containers (46 to 48 oz) OR 2-12 oz

cans frozen OR 2-11.5 oz cans

pourable concentrate

Whole Pick 1: 16 oz loaf of bread; 16 oz pkg

grain:

brown rice; 16 oz pkg tortillas; 14 to 16

oz pkg buns

1 W57 Soy milk: 2 half gallons 8th Continent

(Original OR Vanilla flavors only)

Beans: 1 lb dried OR 4 cans (14 to 16 oz) 2 W69 Soy milk: 2 half gallons 8th Continent
(Original OR Vanilla flavors only)

Juice:

1 container (46-48 oz) OR 1-12 oz can frozen OR 1-11.5 oz can pourable concentrate

Eggs:

1 dozen

4 W70 Soy milk: 2 half gallons 8th Continent

(Original OR Vanilla flavors only)

Cereal: No more than 36 oz

FP-101


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-11 (cont'd)

Food Package W12 - Evaporated Milk for Prenatal/Mostly Breastfeeding
$10 fruit and vegetable
1 gallon of milk
20-12 oz cans evaporated milk

Rank 9
4

VC P02
W83

Voucher Message

Produce $10 for fresh, frozen, or canned fruit

and vegetables

No potatoes-except for sweet potatoes

or yams. No products with added

sugar, seasonings, fat, or oils. No

creamed vegetables. No stewed

tomatoes.

Milk:

4-12 ounce cans low-fat (fat-free,

skimmed, 2%) evaporated

Least expensive brand

1 lb cheese

Eggs: 1 dozen

3-48 oz cans of juice 1 dozen eggs 36 oz cereal 16 oz whole grains 1 container of peanut butter (16-18 oz.)

Cereal: No more than 36 oz

4 W55 Juice: 1 container (46-48 oz) OR 1-12 oz can

frozen OR 1-11.5 oz can pourable

concentrate

Whole Pick 1: 16 oz loaf of bread; 16 oz pkg

Grain: brown rice; 16 oz pkg tortillas; 14 to 16

oz pkg buns

Beans: 1 lb dried OR 4 cans (14 to 16 oz)

1 W41 Milk:

1 gallon low-fat (fat-free, 1%, 2%)

No whole milk. Least expensive brand

1 lb dried beans

Juice: 2 W84 Milk:

2 containers (46 to 48 oz) OR 2-12 oz cans frozen OR 2-11.5 oz cans pourable concentrate 8-12 ounce cans low-fat (fat-free, skimmed, 2%) evaporated Least expensive brand

Peanut

Butter: 1 container (16-18 oz)

3 W85 Milk:

8-12 ounce cans low-fat (fat-free,

skimmed, 2%) evaporated

Least expensive brand

Cheese: 1-16 oz package

FP-102


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-11 (cont'd)

Food Package W13 Soy Milk with Tofu for Prenatal/Mostly Breastfeeding Women
$10 fruit and vegetable
4 gallons soy milk
4 lbs tofu
3-48 oz juice
1 dozen eggs
36 oz cereal

Rank 9
2 4

VC P02
W28 W30

Voucher Message

Produce: $10 for fresh, frozen, or canned fruit and

vegetables

No potatoes-except for sweet potatoes or

yams. No products with added sugar,

seasonings, fat, or oils. No creamed

vegetables. No stewed tomatoes.

Soy Milk: 3 half gallons 8th Continent

(Original OR Vanilla flavors only)

Peanut

butter: 1 container (16 to 18 oz)

Soy milk: 2 half gallons 8th Continent

Juice:

(Original OR Vanilla flavors only)

2 containers (46 to 48 oz) OR 2-12 oz

cans frozen OR 2-11.5 oz cans pourable

concentrate

16 oz whole grains
1 container of peanut butter (16-18 oz.)
1 lb dried beans

Whole Pick 1: 16 oz loaf of bread; 16 oz pkg

grain:

brown rice; 16 oz pkg tortillas; 14 to 16 oz

pkg buns

1 W57 Soy milk: 2 half gallons 8th Continent

(Original OR Vanilla flavors only)

Beans: 1 lb dried OR 4 cans (14 to 16 oz) 3 W69 Soy milk: 2 half gallons 8th Continent
(Original OR Vanilla flavors only)

Juice:
Eggs: 4 W91 Tofu:

1 container (46-48 oz) OR 1-12 oz can frozen OR 1-11.5 oz can pourable concentrate 1 dozen No more than 4 pounds tofu

Cereal: No more than 36 oz

FP-103


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-12

Non-Breastfeeding Postpartum /Some Breastfeeding Woman W20 - W39

Food Package Number W21 Standard Postpartum/Some Breastfeeding Women
$10 fruit and vegetable
2 gallon milk
1-3 qt box dry milk
2-48 oz juice
1 lb cheese
1 dozen eggs
36 oz cereal
1 lb dried beans or 1 container of peanut butter (16-18 oz.)

Rank 9
3

VC P02
W41

Voucher Message

Produce $10 for fresh, frozen, or canned fruit and

:

vegetables

No potatoes-except for sweet potatoes or

yams. No products with added sugar,

seasonings, fat, or oils. No creamed

vegetables. No stewed tomatoes.

Milk:

1 gallon low-fat (fat-free, 1%, 2%)

No whole milk. Least expensive brand

Juice: 2 W04 Milk:

2 containers (46 to 48 oz) OR 2-12 oz cans frozen OR 2-11.5 oz cans pourable concentrate 1 half gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Cheese: 1-16 oz package

4 W05 Milk:

1 gallon low-fat (fat-free, 1%, 2%)

No whole milk. Least expensive brand

Eggs: 1 dozen

Cereal: No more than 36 oz. 1 W06 Dry milk: 1- 3 quart container non-fat dry powder
OR 4-12 oz cans low-fat (fat-free, skimmed, 2%) evaporated

Beans/ peanut butter:

1 lb dried OR 4 cans (14 to 16 oz) beans OR 1 container (16 to 18 oz) peanut butter

FP-104


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-12 (cont'd)

Food Package W22 Lactose Intolerant Postpartum/Some Breastfeeding Women

Rank VC 9 P02

$10 fruit and vegetable

13 quarts of lactose reduced milk

2 034

1 lb cheese

2-48 oz juice

1 dozen eggs

36 oz cereal
1 lb dried bean or 1 container of peanut butter (16-18 oz.)

3 W92

1 045

4 W90

Voucher Message

Produce $10 for fresh, frozen, or canned fruit and

:

vegetables

No potatoes-except for sweet potatoes

or yams. No products with added sugar,

seasonings, fat, or oils. No creamed

vegetables. No stewed tomatoes.

Milk:

1 gallon OR 4 quarts OR 2 half gallons

low- fat (fat-free, 1%, 2%) Lactose free,

Acidophilus, OR Acidophilus and

Bifidum. No whole milk. Least

expensive brand

Juice: Milk:

2 containers (46 to 48 oz) OR 2-12 oz cans frozen OR 211.5 oz cans pourable concentrate 1-half gallon low- fat (fat-free, 1%, 2%) Lactose free, OR Acidophilus, OR Acidophilus and Bifidum. No whole milk. Least expensive brand

Cereal: Milk:

No more than 36 oz 1 gallon OR 4 quarts or 2 half gallons low- fat (fat-free, 1%, 2%) Lactose free, OR Acidophilus, OR Acidophilus and Bifidum. No whole milk. Least expensive brand

Beans/ peanut butter: Milk:
Cheese: Eggs:

1 lb dried OR 4 cans (14 to 16 oz) beans OR 1 container (16 to 18 oz) peanut butter 1-3 quart (96 oz) container low-fat (fatfree, 1%, 2%) Lactose free, OR Acidophilus, OR Acidophilus and Bifidum No whole milk. Least expensive brand
1-16 oz package
1 dozen

FP-105


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-12 (cont'd)

Food Package W23 Goat Milk for Postpartum/Some Breastfeeding Women
$10 fruit and vegetable
13 quarts goat milk
1 lb cheese
2-48 oz juice
1 dozen eggs
36 oz cereal
1 lb dried beans or 1 container of peanut butter (16-18 oz.)

Rank VC 9 P02
2 W14

Voucher Message

Produce: $10 for fresh, frozen, or canned fruit

and vegetables

No potatoes except for sweet potatoes

or yams. No products with added

sugar, seasonings, fat, or oils. No

creamed vegetables. No stewed

tomatoes.

Goat

4 quarts low-fat goat milk. No whole

milk:

milk.

Juice:

1 container (46-48 oz) OR 1-12 oz can frozen OR 1-11.5 oz can pourable concentrate

Eggs: 4 W15 Goat
milk:

1 dozen 4 quarts low-fat goat milk. No whole milk.

Cereal: No more than 36 oz

1 W18 Goat

4 quarts low-fat goat milk. No whole

milk:

Milk.

Juice:
3 W19 Goat milk:

1 container (46-48 oz) OR 1-12 oz can frozen OR 1-11.5 oz can pourable concentrate 1 quart low-fat goat milk. No whole Milk.

Cheese: 1-16 oz package

Beans/ peanut butter

1 lb dried OR 4 cans (14 to 16 oz) beans OR 1 container (16 to 18 oz) peanut butter

FP-106


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-12 (cont'd)

Food Package Number W24 Extra Cheese for Postpartum/Some Breastfeeding Women
MEDICAL DOCUMENTATION REQUIRED
$10 Fruit and vegetable
2 gallon milk
2 lb cheese
2-48 oz juice
1 dozen eggs
36 oz cereal
1 lb dried bean or 1 container of peanut butter (16-18 oz.)

Rank VC 9 P02
1 040

Voucher Message

Produce: $10 for fresh, frozen, or canned fruit

and vegetables

No potatoes-except for sweet potatoes

or yams. No products with added

sugar, seasonings, fat, or oils. No

creamed vegetables. No stewed

tomatoes.

Milk:

1 gallon low-fat (fat-free, 1%, 2%)

No whole milk. Least expensive

brand

Juice: 2 W04 Milk:

1 container (46-48 oz) OR 1-12 oz can frozen OR 1-11.5 oz can pourable concentrate 1 half gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Cheese: 1-16 oz package

3 W05 Milk:

1 gallon low-fat (fat-free, 1%, 2%)

No whole milk. Least expensive brand

Eggs:

1 dozen

Cereal: No more than 36 oz

4 W46 Juice:

1 container (46-48 oz) OR 1-12 oz can

frozen OR 1-11.5 oz can pourable

concentrate

Cheese: 1-16 oz package

Beans/ Peanut butter:

1 lb dried OR 4 cans (14 to 16 oz) beans OR 1 container (16 to 18 oz) peanut butter

FP-107


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-12 (cont'd)

Food Package Number W25 Limited Tofu for Postpartum/Some Breastfeeding Women
$10 fruit and vegetable
3 gallon of milk
4 lb tofu
2-48 oz juice
1 dozen eggs
36 oz cereal
1 lb dried beans or 1 container of peanut butter (16-18 oz.)

Rank VC 9 P02
1 040

Voucher Message

Produce: $10 for fresh, frozen, or canned fruit

and vegetables

No potatoes-except for sweet potatoes

or yams. No products with added

sugar, seasonings, fat, or oils. No

creamed vegetables. No stewed

tomatoes.

Milk:

1 gallon only low-fat (fat-free, 1%, 2%)

No whole milk. Least expensive

brand

Juice: 2 040 Milk:

1 container (46-48 oz) OR 1-12 oz can frozen OR 1-11.5 oz can pourable concentrate 1 gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Juice: 3 W05 Milk:

1 container (46-48 oz) OR 1-12 oz can frozen OR 1-11.5 oz can pourable concentrate 1 gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Eggs:

1 dozen

Cereal 4 W42 Tofu:

No more than 36 oz. No more than 4 pounds

Beans/ Peanut butter:

1 lb dried OR 4 cans (14 to 16 oz) beans OR 1 container (16 to 18 oz) peanut butter

FP-108


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-12 (cont'd)

Food Package Number W26 Extra Tofu for Postpartum/Some Breastfeeding Women
MEDICAL DOCUMENTATION REQUIRED
$10 Fruit and vegetable
2 gallon milk
8 lb tofu
2-48 oz juice
1 dozen eggs
36 oz cereal
1 lb dried beans or 1 container of peanut butter (16-18 oz.)

Rank VC 9 P02
1 040

Voucher Message

Produce: $10 for fresh, frozen, or canned fruit

and vegetables

No potatoes-except for sweet potatoes

or yams. No products with added

sugar, seasonings, fat, or oils. No

creamed vegetables. No stewed

tomatoes.

Milk:

1 gallon low-fat (fat-free, 1%, 2%)

No whole milk. Least expensive

brand

Juice: 3 W05 Milk:

1 container (46-48 oz) OR 1-12 oz can frozen OR 1-11.5 oz can pourable concentrate 1 gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Eggs: Cereal 4 W42 Tofu:

1 dozen No more than 36 oz. No more than 4 pounds

Beans or 1 lb dried OR 4 cans (14 to 16 oz)

Peanut beans OR 1 container (16 to 18 oz)

butter: peanut butter

2 W39 Tofu:

No more than 4 pounds

Juice:

1 container (46-48 oz) OR 1-12 oz can frozen OR 1-11.5 oz can pourable concentrate

FP-109


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-12 (cont'd)

Food Package Number W27 Whole Milk for Postpartum/Some Breastfeeding Women
Can only be given with food package III
MEDICAL DOCUMENTATION REQUIRED
$10 fruit and vegetable
4 gallons whole milk
2-48 oz juice
1 dozen eggs
36 oz cereal
1 dried beans or 1 container of peanut butter (16-18 oz.)

Rank VC 9 P02
1 046

Voucher Message

Produce: $10 for fresh, frozen, or canned fruit and

vegetables

No potatoes-except for sweet potatoes

or yams. No products with added sugar,

seasonings, fat, or oils. No creamed

vegetables. No stewed tomatoes.

Milk:

1 gallon Whole milk only

Least expensive brand

Juice: 4 C04 Milk:

1 container (46-48 oz) OR 1-12 oz can frozen OR 1-11.5 oz can pourable concentrate 1 gallon Whole milk only Least expensive brand

Cereal: No more than 36 oz

Eggs:

1 dozen

3 046 Milk:

1 gallon Whole milk only

Least expensive brand

Juice: 2 W52 Milk:

1 container (46-48 oz) OR 1-12 oz can frozen OR 1-11.5 oz can pourable concentrate 1 gallon whole milk only Least expensive brand

Beans/ peanut butter:

1 lb dried OR 4 cans (14 to 16 oz) beans OR 1 container (16 to 18 oz) peanut butter

FP-110


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-12 (cont'd)

Food Package W28 No Cheese for Postpartum/Some Breastfeeding Women
$10 fruit and vegetable
4 gallon milk
2-48 oz juice
1 dozen eggs
36 oz cereal
1 lb dried beans or 1 container of peanut butter (16-18 oz.)

Rank 9 4
1 3

VC P02 039
040 W21

Voucher Message

Produce: $10 for fresh, frozen, or canned fruit and

vegetables

No potatoes-except for sweet potatoes or

yams. No products with added sugar,

seasonings, fat, or oils. No creamed

vegetables. No stewed tomatoes.

Milk:

1 gallon low-fat (fat-free, 1%, 2%)

No whole milk. Least expensive brand

Juice:
Eggs: Milk:

1 container (46-48 oz) OR 1-12 oz can frozen OR 1-11.5 oz can pourable concentrate 1 dozen 1 gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Juice: Milk:

1 container (46-48 oz) OR 1-12 oz can frozen OR 1-11.5 oz can pourable concentrate 1 gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Cereal: 2 W22 Milk:

No more than 36 oz 1 gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Beans/ Peanut butter:

1 lb dried OR 4 cans (14 to 16 oz) beans OR 1 container (16 to 18 oz) peanut butter

FP-111


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-12 (cont'd)

Food Package W29 No Milk for Postpartum/Some Breastfeeding Women
MEDICAL DOCUMENTATION REQUIRED
Can only be given with food package III
$10 fruit and vegetable

Rank 9
2

VC P02
W46

Voucher Message Produce: $10 for fresh, frozen, or canned fruit
and vegetables No potatoes-except for sweet potatoes or yams. No products with added sugar, seasonings, fat, or oils. No creamed vegetables. No stewed tomatoes. Cheese: 1-16 oz package

Juice:

1 container (46-48 oz) OR 1-12 oz can frozen OR 1-11.5 oz can pourable concentrate

1 lb cheese 2-48 oz juice 1 dozen eggs 36 oz cereal

Beans/ Peanut butter: 4 W71 Juice:
Eggs:

1 lb dried OR 4 cans (14 to 16 oz) beans OR 1 container (16 to 18 oz) peanut butter 1 container (46 to 48 oz) OR 1-12 oz can frozen OR 1-11.5 oz can pourable concentrate 1 dozen

1 lb dried beans or 1 container of peanut butter (16-18 oz.)

Cereal: No more than 36 oz

FP-112


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-12 (cont'd)

Food Package

Rank VC

W30

9 P02

Postpartum/Some

Breastfeeding Women

Alternative Package

$10 fruit and vegetable 64- 8 oz UHT milk

4 H15

Voucher Message

Produce: $10 for fresh, frozen, or canned fruit

and vegetables

No potatoes-except for sweet potatoes

or yams. No products with added sugar,

seasonings, fat, or oils. No creamed

vegetables. No stewed tomatoes.

Milk:

12-8 oz OR half pint boxes low-fat (fat-

free, 1%, 2%) UHT. No whole milk.

16-6 oz juice

Juice:

6 cans (5.5 to 6 oz)

36 oz cereal
1 container of peanut butter (16-18 oz.)

Peanut butter: 1 H14 Milk:

1 container (16 to 18 oz)
12-8 oz OR half pint boxes low-fat (fatfree, 1%, 2%) UHT. No whole milk.

Juice: 4 H13 Milk:

6 cans (5.5 to 6 oz ) 12-84oz OR half pint boxes low-fat (fatfree, 1%, 2%) UHT. No whole milk.

Cereal: 2 H13 Milk:

Not more than 18 oz 12-8 oz OR half pint boxes low-fat (fatfree, 1%, 2%) UHT. No whole milk.

Cereal: 3 H02 Milk:

Not more than 18 oz 16-8 oz OR half pint boxes low-fat (fatfree, 1%, 2%) UHT. No whole milk.

Juice:

4 cans (5.5 to 6 oz)

FP-113


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-12 (cont'd)

Food Package W31 Soy Milk for Postpartum/Some Breastfeeding Women
$10 fruit and vegetable
4 gallons soy milk
2-48 oz juice
1 dozen eggs
36 oz cereal
1 lb dried beans or 1 container of peanut butter (16-18 oz.)

Rank VC 9 P02
4 W69

Voucher Message

Produce: $10 for fresh, frozen, or canned fruit

and vegetables

No potatoes except for sweet potatoes

or yams. No products with added

sugar, seasonings, fat, or oils. No

creamed vegetables. No stewed

tomatoes.

Soy

2 half gallons 8th Continent

milk:

(Original OR Vanilla flavors only)

Juice:
Eggs: 3 W70 Soy
milk:

1 container (46-48 oz) OR 1-12 oz can frozen OR 1-11.5 oz can pourable concentrate 1 dozen 2 half gallons 8th Continent (Original OR Vanilla flavors only)

Cereal: No more than 36 oz 1 W72 Soy milk: 2 half gallons 8th Continent
(Original OR Vanilla flavors only)

Juice:

1 container (46-48 oz) OR 1-12 oz can

frozen OR 1-11.5 oz can pourable

concentrate

2 W73 Soy milk: 2 half gallons 8th Continent

(Original OR Vanilla flavors only)

Beans/ peanut butter:

1 lb dried OR 4 cans (14 to 16 oz) beans OR 1 container (16 to 18 oz) peanut butter

FP-114


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-12 (cont'd)

Food Package

Rank VC Voucher Message

W32 - Evaporated Milk for 9 Postpartum/ Some Breastfeeding Women

P02 Produce:

$10 fruit and vegetable

1 gallon milk

4 W86 Milk:

12-12 oz cans evaporated milk

Eggs:

$10 for fresh, frozen, or canned fruit and vegetables No potatoes-except for sweet potatoes or yams. No products with added sugar, seasonings, fat, or oils. No creamed vegetables. No stewed tomatoes.
8-12 ounce cans low-fat (fat-free, skimmed, 2%) evaporated Least expensive brand 1 dozen

2-48 oz juice
1 lb cheese
1 dozen eggs
36 oz cereal
1 lb dried beans or 1 container of peanut butter (16-18 oz)

Cereal: 3 W87 Juice:
Beans/ Peanut butter: 1 W41 Milk:

No more than 36 oz. 1 container (46-48 oz) OR 1-12 oz can frozen or 1-11.5 oz can pourable concentrate
1 lb dried OR 4 cans (14 to 16 oz) beans OR 1 container (16 to 18 oz) peanut butter 1 gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Juice 2 W85 Milk:

1-46 oz container OR 1-12 oz can frozen or 11.5 oz can pourable 4-12 ounce cans low-fat (fat-free, skimmed, 2%) evaporated Least expensive brand

Cheese: 1-16 oz package

FP-115


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-12 (cont'd)

Food Package W33 Soy Milk with Tofu for Postpartum/Some Breastfeeding Women
$10 fruit and vegetable
3 gallons soy milk
4 lb tofu

Rank VC 9 P02
3 W69

Voucher Message

Produce: $10 for fresh, frozen, or canned fruit

and vegetables

No potatoes except for sweet potatoes

or yams. No products with added

sugar, seasonings, fat, or oils. No

creamed vegetables. No stewed

tomatoes.

Soy

2 half gallons 8th Continent

milk:

(Original OR Vanilla flavors only)

2-48 oz juice 1 dozen eggs

Juice:

1 container (46-48 oz) OR 1-12 oz can frozen OR 1-11.5 oz can pourable concentrate

36 oz cereal
1 lb dried beans or 1 container of peanut butter (16-18 oz.)

Eggs: 4 W91 Tofu:

1 dozen No more than 4 pounds tofu

Cereal: No more than 36 oz 1 W72 Soy milk: 2 half gallons 8th Continent
(Original OR Vanilla flavors only)

Juice:

1 container (46-48 oz) OR 1-12 oz can

frozen OR 1-11.5 oz can pourable

concentrate

2 W73 Soy milk: 2 half gallons 8th Continent

(Original OR Vanilla flavors only)

Beans/ peanut butter:

1 lb dried OR 4 cans (14 to 16 oz) beans OR 1 container (16 to 18 oz) peanut butter

Food Package Number W80 Some Breastfeeding >6 months postpartum and <50% of the time

Rank 9

VC W60

Voucher Message Good Job! Keep breastfeeding to provide your baby with the BEST milk.

FP-116


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-13

Exclusively Breastfeeding Single Infant/Prenatal Woman Pregnant with Multiples W40W59

Food package Number W41 Standard Exclusively Breastfeeding/Prenatal Women with Multiples Package/MBF Multiples

Rank VC 9 P02

$10 fruit and vegetable 6 gallons milk

4 W82

1 lb cheese

3-48 oz juice

2 dozen eggs 36 oz cereal

1 039

16 oz whole grain

1 container of peanut butter (16-18 oz.)

1 lb dried beans

2 W02

30 oz fish

Voucher message

Produce: $10 for fresh, frozen, or canned fruit

and vegetables

No potatoes-except for sweet potatoes

or yams. No products with added

sugar, seasonings, fat, or oils. No

creamed vegetables. No stewed

tomatoes.

Milk:

2 gallons low-fat (fat-free, 1%, 2%)

No whole milk. Least expensive

brand

Juice:

2 containers (46 to 48 oz) OR 2-12 oz

cans frozen OR 2-11.5 oz cans

pourable concentrate

Eggs:

1 dozen

Cereal: No more than 36 oz

Milk:

1 gallon low-fat (fat-free, 1%, 2%)

No whole milk. Least expensive

brand

Juice:
Eggs: Milk:

1 container (46 to 48 oz) OR 1-12 oz can frozen OR 1-11.5 oz can pourable concentrate 1 dozen 1gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Whole Pick 1: 16 oz loaf of bread; 16 oz pkg

Grain: brown rice; 16 oz pkg tortillas; 14 to 16

oz pkg buns

Beans: 1 lb dried OR 4 cans (14 to 16 oz)

3 W03 Milk:

2 gallons low-fat (fat-free, 1%, 2%)

No whole milk. Least expensive

brand

Cheese: 1-16 oz package

Peanut

Butter: 1 container (16 to 18 oz)

Fish:

No more than 30 oz (canned tuna or canned salmon)

FP-117


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-13 (cont'd)

Food Package number W42 Lactose Intolerant Exclusively Breastfeeding/ Prenatal women with Multiples/ MBF Multiples
$10 fruit and vegetable
24 qt lactose reduced milk
1 lb cheese
3-48 oz juice
2 dozen eggs
36 oz cereal
16 oz whole grain
1 container of peanut butter (16-18 oz.)
1 lb dried beans
30 oz fish

Rank VC 9 P02 4 034
2 024 3 033

VC Message

Produce: $10 for fresh, frozen, or canned fruit

and vegetables

No potatoes-except for sweet potatoes

or yams. No products with added

sugar, seasonings, fat, or oils. No

creamed vegetables. No stewed

tomatoes.

Milk:

1 gallon OR 4 quarts OR 2 half gallons

low- fat (fat-free, 1%, 2%) Lactose

free, OR Acidophilus, OR Acidophilus

and Bifidum. No whole milk. Least

expensive brand

Juice: Milk:

2 containers (46 to 48 oz) OR 2-12 oz cans frozen OR 2-11.5 oz cans pourable concentrate 1 gallon OR 4 quarts OR 2 half gallons low- fat (fat-free, 1%, 2%) Lactose free, OR Acidophilus, OR Acidophilus and Bifidum. No whole milk. Least expensive brand

Beans: Milk:

1 lb dried OR 4 cans (14 to 16 oz) 1 gallon OR 4 quarts OR 2 half gallons low- fat (fat-free, 1%, 2%) Lactose free, OR Acidophilus, OR Acidophilus and Bifidum. No whole milk. Least expensive brand

Cereal: No more than 36 oz

1 501 Milk:

1 gallon OR 4 quarts OR 2 half gallons

low- fat (fat-free, 1%, 2%) Lactose

free, OR Acidophilus, OR Acidophilus

and Bifidum. No whole milk. Least

expensive brand

Juice:

1 container (46-48 oz) OR 1-12 oz can frozen OR 1-11.5 oz can pourable concentrate

FP-118


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-13 (cont'd)

3 W09 Milk:

2 gallon OR 8 quarts OR 4 half gallons low- fat (fat-free, 1%, 2%) Lactosefree, OR Acidophilus, OR Acidophilus and Bifidum No whole milk. Least expensive brand

Cheese: 1-16 oz package

Eggs: 4 W08 Eggs:

1 dozen 1 dozen

Whole Grain:
Peanut butter:

Pick 1: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns
1 container (16 to 18 oz)

Fish:

No more than 30 ounces (canned tuna or canned salmon)

FP-119


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-13 (cont'd)

Food Package W43 Goat Milk for Exclusively Breastfeeding/ Prenatal Women with Multiples/ MBF Multiples $10 fruit and vegetable
24 quarts goat milk
1 lb cheese
3-48 oz juice
2 dozen eggs
36 oz cereal
16 oz whole grain
1 container of peanut butter (16-18 oz.)
1 lb dried beans
30 oz fish

Rank VC 9 P02
3 W12

Voucher Message

Produce: $10 for fresh, frozen, or canned fruit

and vegetables

No potatoes-except for sweet potatoes

or yams. No products with added

sugar, seasonings, fat, or oils. No

creamed vegetables. No stewed

tomatoes.

Goat

4 quarts low-fat goat milk. No whole

Milk:

Milk.

Juice:

2 containers (46 to 48 oz) OR 2-12 oz cans frozen OR 2-11.5 oz cans pourable concentrate

Whole Grain:
4 W17 Goat Milk:

Pick 1: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns 6 quarts low-fat goat milk. No whole milk.

Beans: 1 lb dried OR 4 cans (14 to 16 oz)

Eggs: 1 W14 Goat
Milk:

1 dozen 4 quarts low-fat goat milk. No whole milk.

Juice:

1 container (46 to 48 oz) OR 1-12 oz can frozen OR 1-11.5 oz can pourable concentrate

Eggs: 2 W15 Goat
Milk:

1 dozen 4 quarts low-fat goat milk. No whole milk.

Cereal 4 W16 Goat
Milk:

No more than 36 oz 6 quarts low-fat goat milk. No whole milk.

Cheese: 1-16 oz package

Peanut Butter:

1 container (16 to 18 oz)

Fish:

No more than 30 oz (canned tuna or canned salmon)

FP-120


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-13 (cont'd)

Food Package Number W44 More cheese for Exclusively Breastfeeding/ Prenatal Women with Multiples/MBF Multiples
$10 Fruit and Vegetable
4 gallon milk
3 lb cheese
3-48 oz juice
2 dozen eggs
36 oz cereal
16 oz whole grain

Rank VC 9 P02
4 041

Voucher Message

Produce: $10 for fresh, frozen, or canned fruit

and vegetables

No potatoes-except for sweet potatoes

or yams. No products with added

sugar, seasonings, fat, or oils. No

creamed vegetables. No stewed

tomatoes.

Milk:

1 gallon low-fat (fat-free, 1%, 2%)

No whole milk. Least expensive

brand

Juice:

2 containers (46 to 48 oz) OR 2-12 oz

cans frozen OR 2-11.5 oz cans

pourable concentrate

Eggs:

1 dozen

Cereal: No more than 36 oz.

2 039 Milk:

1 gallon low-fat (fat-free, 1%, 2%)

No whole milk. Least expensive

brand

1 container of peanut butter (16-18 oz.)

Juice:

1 lb dried beans 30 oz fish

Eggs: 4 W03 Milk:

1 container (46-48 oz) OR 1-12 oz can frozen OR 1-11.5 oz can pourable concentrate 1 dozen 2 gallons low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Cheese: 1-16 oz package

Peanut Butter:

1 container (16 to 18 oz)

Fish:

No more than 30 oz (canned tuna or canned salmon)

FP-121


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-13 (cont'd)

1 W04 Milk:

1 half gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Cheese: 1-16 oz package 3 W44 Cheese: 1-16 oz package

Whole Grain:

Pick 1: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns

Beans: 1 lb dried OR 4 cans (14 to 16 oz)

FP-122


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-13 (cont'd)

Food Package Number W45 Limited Tofu for Exclusively Breastfeeding/ Prenatal Women with Multiples/MBF Multiples
$10 fruit and vegetables
5 gallons milk
1 lb cheese
4 lb tofu
3-48 oz cans juice

Rank 9
3

VC P02
W82

Voucher Message

Produce: $10 for fresh, frozen, or canned fruit

and vegetables

No potatoes-except for sweet potatoes

or yams. No products with added

sugar, seasonings, fat, or oils. No

creamed vegetables. No stewed

tomatoes.

Milk:

2 gallon low-fat (fat-free, 1%, 2%)

No whole milk. Least expensive

brand

Juice: Eggs:

2 containers (46 to 48 oz) OR 2-12 oz cans frozen OR 2-11.5 oz cans pourable concentrate 1 dozen

2 dozen eggs

Cereal: No more than 36 oz.

1 039 Milk:

1 gallon only low-fat (fat-free, 1%, 2%)

36 oz cereal

No whole milk. Least expensive

brand

16 oz whole grain

Juice:

1 container (46 to 48 oz) OR 1-12 oz

1 container of peanut butter

can frozen OR 1-11.5 oz can pourable

(16-18 oz.)

concentrate

Eggs:

1 dozen

1 lb dried Beans

4 W38 Tofu:

No more than 4 pounds

30 oz fish

Whole Grain:

Pick 1: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns

Beans 2 W03 Milk:

1 lb dried OR 4 cans (14 to 16 oz) 2 gallons low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Cheese: 1-16 oz package

Peanut Butter:

1 container (16 to 18 oz)

Fish:

No more than 30 oz (canned tuna or canned salmon)

FP-123


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-13 (cont'd)

Food Package Number W46 Extra Tofu for Exclusively Breastfeeding/ Prenatal Women with Multiples/ MBF Multiples
MEDICAL DOCUMENTATION REQUIRED
$10 fruit and vegetable
3 gallons milk
1 lb cheese
12 lb tofu
3-48 oz juice
2 dozen eggs
36 oz cereal
16 oz whole grain
1 container of peanut butter (16-18 oz.)
1 lb dried beans
30 oz fish

Rank VC 9 P02 4 W38 2 039
4 050
3 W39 3 W40
1 A11

Voucher Message

Produce: $10 for fresh, frozen, or canned fruit

and vegetables

No potatoes-except for sweet potatoes

or yams. No products with added

sugar, seasonings, fat, or oils. No

creamed vegetables. No stewed

tomatoes.

Tofu:

No more than 4 pounds

Whole Grain:

Pick 1: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns

Beans Milk:

1 lb dried OR 4 cans (14 to 16 oz) 1 gallon only low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Eggs:

1 dozen

Juice: Milk:

1 container (46 to 48 oz) OR 1-12 oz can frozen OR 1-11.5 oz can pourable concentrate 1 gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Juice:

1 container (46 to 48 oz) OR 1-12 oz can frozen OR 1-11.5 oz can pourable concentrate

Eggs

1 dozen

Cereal: Tofu:

No more than 36 oz No more than 4 pounds

Juice: Milk:

1-12 oz can frozen OR 1-46 oz container OR 1-11.5 oz can pourable concentrate 1 gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Cheese: 1-16 oz package

Peanut Butter:

1 container (16 to 18 oz)

Fish: Tofu:

No more than 30 oz (canned tuna or canned salmon) No more than 4 pounds

FP-124


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-13 (cont'd)

Food Package Number W47 Whole Milk for Exclusively breastfeeding/ Prenatal Women with Multiples/MBF Multiples
Can only be given with food package III
MEDICAL DOCUMENTATION REQUIRED
$10 fruit and vegetable
6 gallons whole milk

Rank 9
1

VC P02
W51

Voucher Message

Produce: $10 for fresh, frozen, or canned fruit

and vegetables

No potatoes-except for sweet potatoes

or yams. No products with added

sugar, seasonings, fat, or oils. No

creamed vegetables. No stewed

tomatoes.

Milk:

1 gallon Whole milk only

Least expensive brand

Juice:
Fish: 4 C04 Milk:

1 container (46 to 48 oz) OR 1-12 oz can frozen OR 1-11.5 oz can pourable concentrate No more than 30 oz (canned tuna or canned salmon) 1 gallon Whole milk only Least expensive brand

1 lb cheese

Cereal: No more than 36 oz

3-48 oz juice 2 dozen eggs

Eggs: 2 W47 Milk:

1 dozen 2 gallons Whole milk only Least expensive brand

36 oz cereal 16 oz whole grain 1 container of peanut butter (16-18 oz.) 1 lb dried beans 30 oz fish

Juice:
4 W48 Milk:
Whole Grains:
Beans: 3 W50 Milk:

2 containers (46 to 48 oz) OR 2-12 oz cans frozen OR 2-11.5 oz cans pourable concentrate 1 gallon Whole milk only Least expensive brand
Pick 1: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns
1 lb dried OR 4 cans (14 to 16 oz) 1 gallon Whole milk only Least expensive brand

Cheese: 1-16 oz package

Eggs:

1 dozen

Peanut Butter:

1 container (16 to 18 oz)

FP-125


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-13 (cont'd)

Food Package W49 No milk Exclusively Breastfeeding/ Prenatal with Multiples/ MBF Multiples
MEDICAL DOCUMENTAION REQUIRED Can only be given with food package III
$10 fruit and vegetable
1 lb cheese

Rank 9
4

VC P02
W44

Voucher Message Produce: $10 for fresh, frozen, or canned fruit
and vegetables No potatoes-except for sweet potatoes or yams. No products with added sugar, seasonings, fat, or oils. No creamed vegetables. No stewed tomatoes. Cheese: 1-16 oz package

Whole Grain:

Pick 1: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns

Beans: 2 W58 Eggs:

1 lb dried OR 4 cans (14 to 16 oz) 1 dozen

3-48 oz juice 2 dozen eggs 36 oz cereal 16 oz whole grain 1 container of peanut butter (16-18 oz.)

Cereal: 1 W59 Juice:
Fish: 3 W61 Juice:

No more than 36 oz 1 container (46 to 48 oz) OR 1-12 oz can frozen OR 1-11.5 oz can pourable concentrate
No more than 30 oz (canned tuna or canned salmon) 2 containers (46 to 48 oz) OR 2-12 oz cans frozen OR 2-11.5 oz cans pourable concentrate

1 lb dried beans

Eggs:

1 dozen

30 oz fish

Peanut Butter:

1 container (16 to 18 oz)

FP-126


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-13 (cont'd)

Food Package W50 Exclusively Breastfeeding/Prenatal with Multiples/MBF Multiples Alternative Package
$10 fruit and vegetable
96-8 oz UHT milk
16 oz cheese
24-6 oz juice
36 oz cereal
16 oz whole grain
2 containers of peanut butter (16-18 oz. each)
8-16 oz cans beans
30 oz fish

Rank VC 9 P02
1 H14 3 H20
4 H20
4 H03 2 H04 3 H14

Voucher Message

Produce: $10 for fresh, frozen, or canned fruit

and vegetables

No potatoes-except for sweet potatoes

or yams. No products with added

sugar, seasonings, fat, or oils. No

creamed vegetables. No stewed

tomatoes.

Milk:

12-8 oz OR half pint boxes low-fat (fat-

free, 1%, 2%) UHT. No whole milk.

Juice: Milk:

6 cans (5.5 to 6 oz )
15-8 oz OR half pint boxes low-fat (fat-free, 1%, 2%) UHT. No whole milk.

Cereal: Not more than 18 oz

Juice:

6 cans (5.5 to 6 oz)

Peanut butter: Milk:

1 container (16 to 18 oz) 15-8 oz OR half pint boxes low-fat (fatfree, 1%, 2%) UHT. No whole milk.

Cereal: Juice:

Not more than 18 oz 6 cans (5.5 to 6 oz)

Peanut butter: Milk:

1 container (16 to 18 oz)
15-8 oz OR half pint boxes low-fat (fatfree, 1%, 2%) UHT. No whole milk.

Cheese:
Whole grain: Milk:

1-16 oz package
Pick 1: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns 15-8 oz OR half pint boxes low-fat (fatfree, 1%, 2%) UHT. No whole milk.

Beans: Milk:

4 cans (14 to 16 oz)
12-8 oz OR half pint boxes low-fat (fatfree, 1%, 2%) UHT. No whole milk.

Juice:

6 cans (5.5 to 6 oz)

FP-127


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-13 (cont'd)

CONTINUED W50

2 H05 Milk:
Beans: Fish:

12-8 oz OR half pint boxes low-fat (fatfree, 1%, 2%) UHT. No whole milk.
4 cans (14 to16 oz)
No more than 30 ounces (canned tuna or canned salmon)

FP-128


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-13 (cont'd)

Food Package W51 Soy Milk for Exclusively Breastfeeding/ Prenatal Women with Multiples/ MBF Multiples
$10 fruit and vegetable
6 gallons soy milk
1 lb cheese
3-48 oz juice
2 dozen eggs
36 oz cereal
16 oz whole grain
1 container of peanut butter (16-18 oz.)
1 lb dried beans
30 oz fish

Rank 9
4

VC P02
W30

Voucher Message
Produce: $10 for fresh, frozen, or canned fruit and vegetables No potatoes-except for sweet potatoes or yams. No products with added sugar, seasonings, fat, or oils. No creamed vegetables. No stewed tomatoes.
Soy Milk: 2 half gallons 8th Continent (Original OR Vanilla flavors only)
Juice: 2 containers (46 to 48 oz) OR 2-12 oz cans frozen OR 2-11.5 oz cans pourable concentrate

Whole Pick 1: 16 oz loaf of bread; 16 oz pkg Grain: brown rice; 16 oz pkg tortillas; 14 to 16
oz pkg buns 3 W74 Soy Milk: 4 half gallons 8th Continent
(Original OR Vanilla flavors only)

Eggs:

1 dozen

Beans: 1 lb dried OR 4 cans (14 to 16 oz) 1 W69 Soy Milk: 2 half gallons 8th Continent
(Original OR Vanilla flavors only)

Juice:

1 container (46 to 48 oz) OR 1-12 oz can frozen OR 1-11.5 oz can pourable concentrate

Eggs:

1 dozen

2 W70 Soy Milk: 2 half gallons 8th Continent

(Original OR Vanilla flavors only)

Cereal No more than 36 oz 4 W75 Soy Milk: 2 half gallons 8th Continent
(Original OR Vanilla flavors only)

Cheese: 1-16 oz package

Peanut Butter: 1 container (16 to 18 oz)

Fish:

No more than 30 oz (canned tuna or canned salmon)

FP-129


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-13 (cont'd)

Food Package W52-Evaporated Milk for Exclusively Breastfeeding/Prenatal Women with Multiples Package/MBF Multiples
$10 fruit and vegetable
28-12 oz cans evaporated milk
2 lb cheese
3-48 oz juice
2 dozen eggs
36 oz cereal
16 oz whole grain

Rank VC 9 P02 Produce:
4 W44 Cheese:

Voucher Message $10 for fresh, frozen, or canned fruit and vegetables No potatoes-except for sweet potatoes or yams. No products with added sugar, seasonings, fat, or oils. No creamed vegetables. No stewed tomatoes. 1-16 oz package

Whole Grain:
Beans: 4 W86 Milk:
Eggs:

Pick 1: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns 1 lb dried OR 4 cans (14 to 16 oz) 8-12 ounce cans low-fat (fat-free, skimmed, 2%) evaporated Least expensive brand 1 dozen

Cereal: 3 W66 Eggs:

No more than 36 oz 1 dozen

1 container of peanut butter (16-18 oz.)

Peanut Butter:

1 container (16-18 oz)

1 lb dried beans 30 oz fish

Fish: 1 W88 Milk:

No more than 30 oz (canned tuna OR canned salmon) 4-12 ounce cans low-fat (fat-free, skimmed, 2%) evaporated Least expensive brand

Juice: 2 W89 Milk

2 containers (46 to 48 oz) OR 2-12 oz cans frozen OR 2-11.5 oz cans pourable 8-12 ounce cans low-fat (fat-free, skimmed, 2%) evaporated Least expensive brand

Juice:

1 container (46 to 48 oz) OR 1-12 oz

cans frozen OR 1-11.5 oz cans

pourable

2 W85 Milk

8-12 ounce cans low-fat (fat-free,

skimmed, 2%) evaporated

Least expensive brand

Cheese 1-16 oz package

FP-130


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-13 (cont'd)

Food Package W53 Soy Milk with Tofu for Exclusively Breastfeeding/ Prenatal Women with Multiples/ MBF Multiples
$10 fruit and vegetable
5 gallons soy milk

Rank 9
4

VC P02
W30

Voucher Message
Produce: $10 for fresh, frozen, or canned fruit and vegetables No potatoes-except for sweet potatoes or yams. No products with added sugar, seasonings, fat, or oils. No creamed vegetables. No stewed tomatoes.
Soy Milk: 2 half gallons 8th Continent (Original OR Vanilla flavors only)

4 lb tofu 1 lb cheese

Juice:

2 containers (46 to 48 oz) OR 2-12 oz cans frozen OR 2-11.5 oz cans pourable concentrate

3-48 oz juice 2 dozen eggs 36 oz cereal

Whole Pick 1: 16 oz loaf of bread; 16 oz pkg Grain: brown rice; 16 oz pkg tortillas; 14 to 16
oz pkg buns 2 W74 Soy Milk: 4 half gallons 8th Continent
(Original OR Vanilla flavors only)

16 oz whole grain

Eggs:

1 dozen

1 container of peanut butter (16-18 oz.)
1 lb dried beans
30 oz fish

Beans: 1 lb dried OR 4 cans (14 to 16 oz) 1 W69 Soy Milk: 2 half gallons 8th Continent
(Original OR Vanilla flavors only)

Juice:

1 container (46 to 48 oz) OR 1-12 oz can frozen OR 1-11.5 oz can pourable concentrate

Eggs: 4 W91 Tofu:

1 dozen No more than 4 pounds

Cereal: No more than 36 oz 3 W75 Soy Milk: 2 half gallons 8th Continent
(Original OR Vanilla flavors only)

Cheese: Peanut Butter:

1-16 oz package 1 container (16 to 18 oz)

Fish:

No more than 30 oz (canned tuna or canned salmon)

FP-131


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-14

Exclusively Breastfeeding Multiples W60 W79 (V60 V79)

Food Package

Rank VC Voucher Message

W61 Exclusively

9 P01 Produce: $8 for fresh, frozen, or canned fruit and

Breastfeeding Multiples -

vegetables

Standard Package A

No potatoes-except for sweet potatoes

or yams. No products with added

$15 fruit and vegetable

sugar, seasonings, fat, or oils. No

creamed vegetables. No stewed

9 gallon milk

tomatoes.

9 P07 Produce: $7 for fresh, frozen, or canned fruit and

2 lb cheese

vegetables

No potatoes-except for sweet potatoes

4-48 oz juice

or yams. No products with added

sugar, seasonings, fat, or oils. No

3 dozen eggs

creamed vegetables. No stewed

tomatoes.

54 oz cereal

4 W82 Milk:

2 gallon low-fat (fat-free, 1%, 2%)

No whole milk. Least expensive

16 oz whole grain

brand

1 container of peanut butter (16-18 oz.)
2 lb dried beans
45 oz fish

Juice:

2 containers (46 to 48 oz) OR 2-12 oz cans frozen OR 2-11.5 oz cans pourable concentrate

Eggs:: 1 dozen

Cereal: No more than 36 oz.

4 W03 Milk:

2 gallons low-fat (fat-free, 1%, 2%)

No whole milk. Least expensive

brand

Cheese: 1-16 oz package

Peanut butter:

1 container (16 to 18 oz)

Fish: 1 029 Milk:

No more than 30 ounces (canned tuna or canned salmon) 2 gallons low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Juice:

1 container (46 to 48 oz) OR 1-12 oz can frozen OR 1-11.5 oz can pourable concentrate

FP-132


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-14 (cont'd)

2 031 Milk:

1 gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Juice:

1 container (46 to 48 oz) OR 1-12 oz can frozen OR 1-11.5 oz can pourable concentrate

Cheese: 1-16 oz package

3 W23 Milk:

1 gallon low-fat (fat-free, 1%, 2%)

No whole milk. Least expensive

brand

Eggs:

1 dozen

Cereal:

No more than 18 oz

3 W02 Milk:

1gallon low-fat (fat-free, 1%, 2%)

No whole milk. Least expensive

brand

Whole Grain:
Beans:
2 W24 Eggs:

Pick 1: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns
1 lb dried OR 4 cans (14 to 16 oz) 1 dozen

Beans: 1 lb dried OR 4 cans (14 to 16 oz)

Fish:

No more than 15 oz (canned tuna or canned salmon)

FP-133


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-14 (cont'd)

Food Package V61 (Assign W61) Exclusively Breastfeeding Multiples Standard Package B
$15 fruit and vegetables
9 gallons of milk
1 lb cheese
5-48 oz juice
3 dozen eggs
54 oz cereal
32 oz whole grains
2 container of peanut butter (16-18 oz. each)
1 lb dried beans
45 oz fish

Rank VC 9 P01
9 P07
4 W82
2 W03

Voucher Message

Produce: $8 for fresh, frozen, or canned fruit and

vegetables

No potatoes-except for sweet potatoes

or yams. No products with added

sugar, seasonings, fat, or oils. No

creamed vegetables. No stewed

tomatoes.

Produce: $7 for fresh, frozen, or canned fruit and

vegetables

No potatoes-except for sweet potatoes

or yams. No products with added

sugar, seasonings, fat, or oils. No

creamed vegetables. No stewed

tomatoes.

Milk:

2 gallons low-fat (fat-free, 1%, 2%)

No whole milk. Least expensive brand

Juice:

2 containers (46 to 48 oz) OR 2-12 oz

cans frozen OR 2-11.5 oz cans

pourable concentrate

Eggs:

1 dozen

Cereal: No more than 36 oz

Milk:

2 gallons low-fat (fat-free, 1%, 2%)

No whole milk. Least expensive brand

Cheese: 1-16 oz package

Peanut 1 container (16 to 18 oz)

Butter: No more than 30 oz (canned tuna OR

Fish:

canned salmon)

1 029 Milk:

2 gallons low-fat (fat-free, 1%, 2%)

No whole milk. Least expensive brand

Juice:

1 container (46-48 oz) OR 1-12 oz can

frozen OR 1-11.5 oz can pourable

concentrate

3 W23 Milk:

1 gallon low-fat (fat-free, 1%, 2%)

No whole milk. Least expensive brand

Eggs:

1 dozen

Cereal: No more than 18 oz

4 W53 Eggs:

1 dozen

Whole Pick 2: 16 oz loaf of bread; 16 oz pkg

Grain: brown rice; 16 oz pkg tortillas; 14 to 16

oz pkg buns

Fish:

No more than 15 oz (canned tuna OR

canned salmon)

FP-134


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-14 (cont'd)

3 W26 Milk:

2 gallons low-fat (fat-free, 1%, 2%)

No whole milk. Least expensive brand

Juice:

2 containers (46 to 48 oz) OR 2-12 oz

cans frozen OR 2-11.5 oz cans

pourable concentrate

Peanut

butter: 1 container (16 to 18 oz)

Beans: 1 lb dried OR 4 cans (14 to 16 oz)

FP-135


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-14 (cont'd)

Food Package W62 Lactose Intolerant Exclusively Breastfeeding Multiples Package A
$15 fruit and vegetables
36 quarts lactose reduced milk
2 lb cheese
4-48 oz cans juice
3 dozen eggs
54 oz cereal
16 oz whole grain

Rank VC 9 P01
9 P07
2 W27

Voucher Message

Produce: $8 for fresh, frozen, or canned fruit and

vegetables

No potatoes-except for sweet potatoes

or yams. No products with added

sugar, seasonings, fat, or oils. No

creamed vegetables. No stewed

tomatoes.

Produce: $7 for fresh, frozen, or canned fruit and

vegetables

No potatoes-except for sweet potatoes

or yams. No products with added

sugar, seasonings, fat, or oils. No

creamed vegetables. No stewed

tomatoes.

Milk:

2 gallons OR 8 quarts or 4 half gallons

low- fat (fat-free, 1%, 2%) Lactose

free, OR Acidophilus, OR Acidophilus

and Bifidum No whole milk. Least

expensive brand

1 container of peanut butter (16-18 oz.)
2 lb dried beans
45 oz fish

Juice:
Eggs: 2 W09 Milk:

2 containers (46 to 48 oz) OR 2-12 oz cans frozen OR 2-11.5 oz cans pourable concentrate
1 dozen 2 gallons OR 8 quarts OR 4 half gallons low-fat (fat-free, 1%, 2%) Lactose free, OR Acidophilus, OR Acidophilus and Bifidum No whole milk. Least expensive brand

Cheese: 1-16 oz package

Eggs: 3 024 Milk:

1 dozen 1 gallon OR 4 quarts OR 2 half gallons low- fat (fat-free, 1%, 2%) Lactose free, OR Acidophilus, or Acidophilus and Bifidum No whole milk. Least expensive brand

Beans: 1 lb dried OR 4 cans (14 to 16 oz)

FP-136


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-14 (cont'd)

1 034 Milk:

1 gallon OR 4 quarts OR 2 half gallons low- fat (fat-free, 1%, 2%) Lactose free, OR Acidophilus, OR Acidophilus and Bifidum No whole milk. Least expensive brand

Juice: 3 033 Milk:

2 containers (46 to 48 oz) OR 2-12 oz cans frozen OR 2-11.5 oz cans pourable concentrate 1 gallon OR 4 quarts OR 2 half gallons low- fat (fat-free, 1%, 2%) Lactose free, OR Acidophilus, OR Acidophilus and Bifidum No whole milk. Least expensive brand

Cereal: No more than 36 oz

4 W29 Milk:

1 gallon OR 4 quarts OR 2 half gallons

low- fat (fat-free, 1%, 2%) Lactose free,

OR Acidophilus, OR Acidophilus and

Bifidum No whole milk. Least

expensive brand

Cheese: 1-16 oz package

Cereal: No more than 18 oz

Fish: 4 W08 Eggs:

No more than 15 oz (canned tuna OR canned salmon) 1 dozen

Whole Grain:
Peanut Butter:

Pick 1: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns
1 container (16-18 oz)

Fish: 3 024 Milk:

No more than 30 oz (canned tuna OR canned salmon) 1 gallon OR 4 quarts OR 2 half gallons low- fat (fat-free, 1%, 2%) Lactose free, OR Acidophilus, OR Acidophilus and Bifidum No whole milk. Least expensive brand

Beans: 1 lb dried OR 4 cans (14 to 16 oz)

FP-137


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-14 (cont'd)

Food Package V62 (Assign W62) Lactose Intolerant Exclusively Breastfeeding Multiples Package B
$15 fruits and vegetables
36 quarts lactose reduced milk
1 lb cheese
5-48 oz juice
3 dozen eggs
54 oz cereal
32 oz whole grains
2 container of peanut butter (16-18 oz. each)

Rank VC 9 P01
9 P07
4 W27

Voucher message

Produce: $8 for fresh, frozen, or canned fruit and

vegetables

No potatoes-except for sweet potatoes

or yams. No products with added

sugar, seasonings, fat, or oils. No

creamed vegetables. No stewed

tomatoes.

Produce: $7 for fresh, frozen, or canned fruit and

vegetables

No potatoes-except for sweet potatoes

or yams. No products with added

sugar, seasonings, fat, or oils. No

creamed vegetables. No stewed

tomatoes.

Milk:

2 gallons OR 8 quarts OR 4 half

gallons low- fat (fat-free, 1%, 2%)

Lactose free, OR Acidophilus, OR

Acidophilus and Bifidum No whole milk.

Least expensive brand

Juice:

2 containers (46 to 48 oz) OR 2-12 oz cans frozen OR 2-11.5 oz cans pourable concentrate

1 lb dried beans 45 oz fish

Eggs: 2 W09 Milk:

1 dozen 2 gallons OR 8 quarts OR 4 half gallons low- fat (fat-free, 1%, 2%) Lactose free, OR Acidophilus, OR Acidophilus and Bifidum No whole milk. Least expensive brand

Cheese: 1-16 oz package

Eggs: 1 024 Milk:

1 dozen 1 gallon OR 4 quarts OR 2 half gallons low- fat (fat-free, 1%, 2%) Lactose free, OR Acidophilus, OR Acidophilus and Bifidum No whole milk. Least expensive brand

Beans: 1 lb dried OR 4 cans (14 to 16 oz)

FP-138


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-14 (cont'd)

2 034 Milk:
Juice: 3 033 Milk:
Cereal: 1 501 Milk:
Juice: 3 W31 Milk:
Peanut Butter: Fish: 4 W25 Eggs: Cereal: Whole Grain: Fish:

1 gallon OR 4 quarts OR 2 half gallons low- fat (fat-free, 1%, 2%) Lactose free, OR Acidophilus, OR Acidophilus and Bifidum No whole milk. Least expensive brand
2 containers (46 to 48 oz) OR 2-12 oz cans frozen OR 2-11.5 oz cans pourable concentrate 1 gallon OR 4 quarts OR 2 half gallons low- fat (fat-free, 1%, 2%) Lactose free OR Acidophilus OR Acidophilus and Bifidum No whole milk. Least expensive brand
No more than 36 oz. 1 gallon OR 4 quarts OR 2 half gallons low- fat (fat-free, 1%, 2%) Lactose free OR Acidophilus OR Acidophilus and Bifidum No whole milk. Least expensive brand
1 container (46-48 oz) OR 1-12 oz can frozen OR 1-11.5 oz can pourable concentrate 1 gallon OR 4 quarts OR 2 half gallons low- fat (fat-free, 1%, 2%) Lactose free, OR Acidophilus, OR Acidophilus and Bifidum No whole milk. Least expensive brand
2-containers (16 to 18 oz) peanut butter
No more than 30 oz (canned tuna OR canned salmon) 1 dozen No more than 18 oz
Pick 2: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns No more than 15 oz (canned tuna OR canned salmon)

FP-139


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-14 (cont'd)

Food Package W63 Goat Milk for Exclusively Breastfeeding Multiples Package A
$15 fruits and vegetables
36 quarts of goat milk
2 lb cheese
4-48 oz juice
3 dozen eggs
54 oz cereal
16 oz whole grain
1 container of peanut butter (16-18 oz.)
2 lb dried beans
45 oz fish

Rank VC 9 P01
9 P07
3 W17

Voucher message

Produce: $8 for fresh, frozen, or canned fruit and

vegetables

No potatoes-except for sweet potatoes

or yams. No products with added

sugar, seasonings, fat, or oils. No

creamed vegetables. No stewed

tomatoes.

Produce: $7 for fresh, frozen, or canned fruit and

vegetables

No potatoes-except for sweet potatoes

or yams. No products with added

sugar, seasonings, fat, or oils. No

creamed vegetables. No stewed

tomatoes.

Goat

6 quarts low-fat goat milk. No whole

Milk:

milk.

Eggs:

1 dozen

Beans: 4 W16 Goat
Milk:

1 lb dried OR 4 cans (14 to 16 oz) 6 quarts low-fat goat milk. No whole milk.

Cheese: 1-16 oz package

Peanut Butter:

1 container (16 to 18 oz)

Fish:
2 W14 Goat Milk:

No more than 30 oz (canned tuna OR canned salmon) 4 quarts low-fat goat milk. No whole milk.

Juice:

1 container (46-48 oz) OR 1-12 oz can frozen OR 1-11.5 oz can pourable concentrate

Eggs: 3 W32 Goat
Milk:

1 dozen 8 quarts low-fat goat milk. No whole milk.

Cheese: 1-16 oz package

Juice:

2 containers (46 to 48 oz) OR 2-12 oz cans frozen OR 2-11.5 oz cans pourable concentrate

FP-140


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-14 (cont'd)

2 W33 Goat Milk:

6 quarts low-fat goat milk. No whole milk.

Juice:

1-46 oz container OR 1-12 oz can frozen OR 1-11.5 oz can pourable concentrate

Cereal: No more than 36 oz

4 W34 Goat

6 quarts low-fat goat milk. No whole

Milk:

milk.

Cereal: No more than 18 oz

Whole Grain:
1 W24 Eggs:

Pick 1: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns 1 dozen

Beans: 1 lb dried OR 4 cans (14 to 16 oz)

Fish:

No more than 15 oz (canned tuna OR canned salmon)

FP-141


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-14 (cont'd)

Food Package V63 (Assign W63) Goat Milk for Exclusively Breastfeeding Multiples Package B
$15 fruits and vegetables
36 qt goat milk
1 lb cheese
5-48 oz juice
3 dozen eggs
54 oz cereal

Rank VC 9 P01
9 P07
3 W17

Voucher message

Produce: $8 for fresh, frozen, or canned fruit and

vegetables

No potatoes-except for sweet potatoes

or yams. No products with added

sugar, seasonings, fat, or oils. No

creamed vegetables. No stewed

tomatoes.

Produce: $7 for fresh, frozen, or canned fruit and

vegetables

No potatoes-except for sweet potatoes

or yams. No products with added

sugar, seasonings, fat, or oils. No

creamed vegetables. No stewed

tomatoes.

Goat

6 quarts low-fat goat milk. No whole

milk:

milk.

32 oz whole grain

Eggs:

1 dozen

2 containers of peanut butter (16-18 oz. each)
1 lb dried beans
45 oz fish

Beans: 4 W16 Goat
milk:

1 lb dried OR 4 cans (14 to 16 oz) 6 quarts low-fat goat milk. No whole milk.

Cheese: 1-16 oz package

Peanut butter:

1 container (16 to 18 oz)

Fish:
1 W14 Goat milk:

No more than 30 oz (canned tuna OR canned salmon) 4 quarts low-fat goat milk. No whole milk.

Juice:
Eggs: 3 W33 Goat
milk:

1 container (46-48 oz) OR 1-12 oz can frozen OR 1-11.5 oz can pourable concentrate 1 dozen 6 quarts low-fat goat milk. No whole milk.

Juice:

1 container (46-48 oz) OR 1-12 oz can frozen OR 1-11.5 oz can pourable concentrate

Cereal: No more than 36 oz

FP-142


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-14 (cont'd)

2 W35 Goat milk:

6 quarts low-fat goat milk. No whole milk.

Juice:
2 W36 Goat milk:

2 containers (46 to 48 oz) OR 2-12 oz cans frozen OR 2-11.5 oz cans pourable concentrate 8 quarts low-fat goat milk. No whole milk.

Juice:

1 container (46-48 oz) OR 1-12 oz can

frozen OR 1-11.5 oz can pourable

concentrate

Peanut

butter: 1 container (16 to 18 oz)

4 W25 Eggs:

1 dozen

Cereal: No more than 18 oz

Whole grain:

Pick 2: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns

Fish:

No more than 15 oz (canned tuna OR canned salmon)

FP-143


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-14 (cont'd)

Food Package Number W65 Tofu for Exclusively Breastfeeding Multiples Package A
$15 fruit and vegetable
8 gallon milk
2 lb cheese
4 lb tofu
4-48 oz juice
3 dozen eggs
54 oz cereal
16 oz whole grain
1 container of peanut butter (16-18 oz.)
2 lb dried beans
45 oz fish

Rank 9
9
4

VC P01
P07
W82

Voucher Message

Produce: $8 for fresh, frozen, or canned fruit and

vegetables

No potatoes-except for sweet potatoes

or yams. No products with added sugar,

seasonings, fat, or oils. No creamed

vegetables. No stewed tomatoes.

Produce: $7 for fresh, frozen, or canned fruit and

vegetables

No potatoes-except for sweet potatoes

or yams. No products with added sugar,

seasonings, fat, or oils. No creamed

vegetables. No stewed tomatoes.

Milk:

2 gallons only low-fat (fat-free, 1%, 2%)

No whole milk.

Least expensive brand

Juice

2 containers (46 to 48 oz) OR 2-12 oz cans frozen OR 2-11.5 oz cans pourable concentrate

Eggs:

1 dozen

Cereal: No more than 36 oz.

3 W03 Milk:

2 gallons only low-fat (fat-free, 1%, 2%)

No whole milk.

Least expensive brand

Cheese: 1-16 oz package

Peanut butter:

1 container (16 to 18 oz)

Fish: 2 029 Milk:

No more than 30 oz (canned tuna OR canned salmon) 2 gallons only low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Juice:

1 container (46-48 oz) OR 1-12 oz can frozen OR 1-11.5 oz can pourable concentrate

FP-144


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-14 (cont'd)

3 031 Milk:

1 gallon only low-fat (fat-free, 1%, 2%) No whole milk Least expensive brand

Juice: 1 container (46-48 oz) OR 1-12 oz can

frozen OR 1-11.5 oz can pourable

concentrate

Cheese: 1-16 oz package

2 W23 Milk:

1 gallon only low-fat (fat-free, 1%, 2%)

No whole milk.

Least expensive brand

Eggs: 1 dozen

Cereal: No more than 18 oz.

4 W38 Tofu:

No more than 4 pounds

Whole Grain:

Pick 1: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns

Beans 1 lb dried OR 4 cans (14 to 16 oz) 1 W24 Eggs: 1 dozen eggs

Beans: 1 lb dried or 4 cans (14 to 16 oz)

Fish:

No more than 15 oz (canned tuna OR canned salmon)

FP-145


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-14 (cont'd)

Food Package Number V65 (Assign W65) Tofu for Exclusively Breastfeeding Multiples Package B

Rank VC 9 P01

$15 fruit and vegetables 8 gallons of milk

9 P07

1 lb cheese

4 lb tofu 5-48 oz juice

3 050

Voucher Message

Produce: $8 for fresh, frozen, or canned fruit and

vegetables

No potatoes-except for sweet potatoes

or yams. No products with added sugar,

seasonings, fat, or oils. No creamed

vegetables. No stewed tomatoes.

Produce: $7 for fresh, frozen, or canned fruit and

vegetables

No potatoes-except for sweet potatoes

or yams. No products with added sugar,

seasonings, fat, or oils. No creamed

vegetables. No stewed tomatoes.

Milk:

1 gallon low-fat (fat-free, 1%, 2%)

No whole milk. Least expensive brand

3 dozen eggs
54 oz cereal
32 oz whole grains
2 containers of peanut butter (16-18 oz. each)

1 container (46-48 oz) OR 1-12 oz can

Juice: frozen OR 1-11.5 oz can pourable

concentrate

1 dozen

Eggs: No more than 36 oz

Cereal

2 W03 Milk:

2 gallons low-fat (fat-free, 1%, 2%)

No whole milk. Least expensive brand

1 lb dried beans

Cheese: 1-16 oz package

45 oz fish

Peanut butter: 1 container (16 to 18 oz)

Fish: 1 029 Milk:

No more than 30 oz (canned tuna OR canned salmon) 2 gallons low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Juice: 2 W23 Milk:
Eggs:

1 container (46-48 oz) OR 1-12 oz can frozen OR 1-11.5 oz can pourable concentrate 1 gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand 1 dozen

Cereal: No more than 18 oz

FP-146


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-14 (cont'd)

3 W53 Eggs: 1 dozen

Whole Grain:

Pick 2: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns

Fish 4 W26 Milk:

No more than 15 oz (canned tuna OR canned salmon) 2 gallons low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Juice:
Peanut butter:

2 containers (46 to 48 oz) OR 2-12 oz cans frozen OR 2-11.5 oz cans pourable concentrate
1 container (16 to 18 oz)

Beans: 1 lb dried OR 4 cans (14 to 16 oz)

4 W39 Tofu:

No more than 4 pounds

Juice:

1 container (46-48 oz) OR 1-12 oz can frozen OR 1-11.5 oz can pourable concentrate

FP-147


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-14 (cont'd)

Food Package Number W69 No milk for Exclusively Breastfeeding Multiples Package A
MEDICAL DOCUMENTATION REQUIRED
Can only be given with food package III
$15 fruit and vegetables
2 lb cheese

Rank VC 9 P01
9 P07
2 W62

Voucher Message Produce: $8 for fresh, frozen, or canned fruit and
vegetables No potatoes-except for sweet potatoes or yams. No products with added sugar, seasonings, fat, or oils. No creamed vegetables. No stewed tomatoes. Produce: $7 for fresh, frozen, or canned fruit and vegetables No potatoes-except for sweet potatoes or yams. No products with added sugar, seasonings, fat, or oils. No creamed vegetables. No stewed tomatoes. Cheese: 1-16 oz package

4-48 oz cans juice

Juice:

2 containers (46 to 48 oz) OR 2-12 oz

cans frozen OR 2-11.5 oz cans

3 dozen eggs

pourable concentrate

4 W08 Eggs:

1 dozen

54 oz cereal

Whole Pick 1: 16 oz loaf of bread; 16 oz pkg

16 oz whole grain

Grain: brown rice; 16 oz pkg tortillas; 14 to 16

oz pkg buns

1 container of peanut butter (16-18 oz.)

Peanut Butter:

1 container (16-18 oz)

2 lb dried beans 45 oz fish

Fish: 1 W24 Eggs:

No more than 30 oz (canned tuna OR canned salmon) 1 dozen

Beans: 1 lb dried OR 4 cans (14 to 16 oz)

Fish:

No more than 15 oz (canned tuna OR

canned salmon)

4 W54 Cheese: 1-16 oz package

Eggs:

1 dozen

Cereal: No more than 36 oz

3 W63 Juice

2 containers (46 to 48 oz) OR 2-12 oz

cans frozen OR 2-11.5 oz cans

pourable concentrate

Beans: 1 lb dried OR 4 cans (14 to 16 oz)

Cereal: No more than 18 oz

FP-148


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-14 (cont'd)

Food Package number V69 (Assign W69)No Milk for Exclusively Breastfeeding Multiples Package B
MEDICAL DOCUMENTATION REQUIRED
Can only be given with food package III
$15 fruit and vegetable
1 lb cheese
5-48 oz juice
3 dozen eggs
54 oz cereal
32 oz whole grains
2 containers of peanut butter (16-18 oz. each)
1 lb dried beans
45 oz fish

Rank VC 9 P01
9 P07
1 W62

Voucher Message Produce: $8 for fresh, frozen, or canned fruit and
vegetables No potatoes-except for sweet potatoes or yams. No products with added sugar, seasonings, fat, or oils. No creamed vegetables. No stewed tomatoes. Produce: $7 for fresh, frozen, or canned fruit and vegetables No potatoes-except for sweet potatoes or yams. No products with added sugar, seasonings, fat, or oils. No creamed vegetables. No stewed tomatoes. Cheese: 1-16 oz package

Juice: 2 W66 Eggs:

2 containers (46 to 48 oz) OR 2-12 oz cans frozen OR 2-11.5 oz cans pourable concentrate 1 dozen

Peanut Butter:

1 container (16-18 oz)

Fish:

No more than 30 oz (canned tuna OR

canned salmon)

3 W64 Juice:

2 containers (46 to 48 oz) OR 2-12 oz

cans frozen OR 2-11.5 oz cans

pourable concentrate

Peanut

butter: 1 container (16 to 18 oz)

Beans: 4 W65 Juice:

1 lb dried OR 4 cans (14 to 16 oz) 1 container (46-48 oz) OR 1-12 oz can frozen OR 1-11.5 oz can pourable concentrate

Eggs:

1 dozen

Cereal: No more than 36 oz

4 W25 Eggs:

1 dozen

Cereal: No more than 18 oz

Whole grain:
Fish:

Pick 2: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns No more than 15 oz (canned tuna OR canned salmon)

FP-149


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-14 (cont'd)

Food Package W71 Soy milk for Exclusively Breastfeeding Multiples Package A
$15 fruits and vegetables
9 gallons soy milk
2 lb cheese
4-48 oz juice
3 dozen eggs
54 oz cereal
16 oz whole grain
1 container of peanut butter (16-18 oz.)
2 lb dried beans
45 oz fish

Rank VC 9 P01
9 P07
1 W74

Voucher message

Produce: $8 for fresh, frozen, or canned fruit and

vegetables

No potatoes-except for sweet potatoes

or yams. No products with added sugar,

seasonings, fat, or oils. No creamed

vegetables. No stewed tomatoes.

Produce: $7 for fresh, frozen, or canned fruit and

vegetables

No potatoes-except for sweet potatoes

or yams. No products with added sugar,

seasonings, fat, or oils. No creamed

vegetables. No stewed tomatoes.

Soy

4 half gallons 8th Continent

Milk:

(Original OR Vanilla flavors only)

1 dozen

Eggs:

1 lb dried OR 4 cans (14 to 16 oz)

Beans:

3 W75 Soy

2 half gallons 8th Continent

Milk:

(Original OR Vanilla flavors only)

1-16 oz package Cheese:

Peanut 1 container (16 to 18 oz)

Butter:

No more than 30 oz (canned tuna OR

Fish:

canned salmon)

2 W69 Soy

2 half gallons 8th Continent

Milk:

(Original OR Vanilla flavors only)

Juice:
Eggs: 2 W76 Soy
Milk:

1 container (46-48 oz) OR 1-12 oz can frozen OR 1-11.5 oz can pourable concentrate 1 dozen
4 half gallons 8th Continent (Original OR Vanilla flavors only)

Cheese: 1-16 oz package Cereal: No more than 18 oz

FP-150


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-14 (cont'd)

4 W77 Soy Milk:

2 half gallons 8th Continent (Original OR Vanilla flavors only)

Juice:

1 container (46-48 oz) OR 1-12 oz can frozen OR 1-11.5 oz can pourable concentrate

Cereal: No more than 36 oz

4 W30 Soy

2 half gallons 8th Continent

Milk:

(Original OR Vanilla flavors only)

Juice:

2 containers (46 to 48 oz) OR 2-12 oz cans frozen OR 2-11.5 oz cans pourable concentrate

Whole Grain: 3 W78 Soy milk:

Pick 1: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns 2 half gallons 8th Continent (Original OR Vanilla flavors only)

Eggs: 1 dozen

Beans: 1 lb dried OR 4 cans (14 to 16 oz)

Fish:

No more than 15 oz (canned tuna OR canned salmon)

FP-151


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-14 (cont'd)

Food Package V71 (Assign W71) Soy Milk for women Exclusively Breastfeeding Multiples Package B
$15 fruits and vegetables
9 gallons soy milk
1 lb cheese
5-48 oz juice
3 dozen eggs
54 oz cereal
32 oz whole grain
2 containers of peanut butter (16-18 oz. each)
1 lb dried beans
45 oz fish

Rank VC 9 P01
9 P07
3 W74

Voucher message Produce: $8 for fresh, frozen, or canned fruit and
vegetables No potatoes-except for sweet potatoes or yams. No products with added sugar, seasonings, fat, or oils. No creamed vegetables. No stewed tomatoes. Produce: $7 for fresh, frozen, or canned fruit and vegetables No potatoes-except for sweet potatoes or yams. No products with added sugar, seasonings, fat, or oils. No creamed vegetables. No stewed tomatoes. Soy milk: 4 half gallons 8th Continent (Original OR Vanilla flavors only)

Eggs:

1 dozen

Beans: 1 lb dried OR 4 cans (14 to 16 oz) 4 W75 Soy milk: 2 half gallons 8th Continent
(Original OR Vanilla flavors only)

Cheese: 1-16 oz package

Peanut butter:

1 container (16 to 18 oz)

Fish:

No more than 30 oz (canned tuna OR

canned salmon)

1 W69 Soy milk: 2 half gallons 8th Continent

(Original OR Vanilla flavors only)

Juice:

1 container (46-48 oz) OR 1-12 oz can

frozen OR 1-11.5 oz can pourable

concentrate

Eggs:

1 dozen

3 W77 Soy milk: 2 half gallons 8th Continent

(Original OR Vanilla flavors only)

Juice:

1 container (46-48 oz) OR 1-12 oz can frozen OR 1-11.5 oz can pourable concentrate

Cereal: No more than 36 oz

FP-152


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-14 (cont'd)

2 W79 Soy milk: 4 half gallons 8th Continent (Original OR Vanilla flavors only)

Juice:

2 containers (46 to 48 oz) OR 2-12 oz

cans frozen OR 2-11.5 oz cans

pourable concentrate

2 W81 Soy milk: 4 half gallons 8th Continent

(Original OR Vanilla flavors only)

Juice:
Peanut butter: 4 W25 Eggs:

1-46 oz container OR 1-12 oz can frozen OR 1-11.5 oz can pourable concentrate
1 container (16 to 18 oz) 1 dozen

Cereal: No more than 18 oz

Whole grain:

Pick 2: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns

Fish:

No more than 15 oz (canned tuna OR canned salmon)

FP-153


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-15

Children 12 23 Month (C00-C19)

Food Package number C01 - Standard Child 1-2 years old
$6 fruit and vegetables
4 gallon whole milk
2-64 oz juice

Rank VC 9 P03
1 C03

Voucher Message

Produce: $6 for fresh, frozen, or canned fruit and

vegetables

No potatoes-except for sweet potatoes

or yams. No products with added sugar,

seasonings, fat, or oils. No creamed

vegetables. No stewed tomatoes.

Milk:

1 gallon Whole milk only

Least expensive brand

1 dozen eggs 36 oz cereal

Juice: 2 C04 Milk:

1-64 oz container 1 gallon Whole milk only Least expensive brand

32 oz whole grain

Cereal: No more than 36 oz

1 lb beans

Eggs: 3 C03 Milk:

1 dozen 1 gallon Whole milk only Least expensive brand

Juice: 4 C05 Milk:

1-64 oz container 1 gallon Whole milk only Least expensive brand

Whole Grains:

Pick 2: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns

Beans: 1 lb dried OR 4 cans (14 to 16 oz)

FP-154


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-15 ( cont'd)

Food Package C02 Lactose Intolerant 1-2 year old
$6 fruit and vegetable
16 quarts lactose reduced whole milk
2-64 oz juice
1 dozen eggs
36 oz cereal
32 oz whole grains
1 lb beans

Rank VC 9 P03 1 C08
3 C09

Voucher Message

Produce: $6 for fresh, frozen, or canned fruit and

vegetables

(No potatoes-except for sweet potatoes

or yams. No products with added sugar,

seasonings, fat, or oils. No creamed

vegetables. No stewed tomatoes.

Milk:

1 gallon OR 4 quarts OR 2 half gallons

whole lactose free, OR Acidophilus,

OR Acidophilus and Bifidum No low-fat

milk. Least expensive brand

Juice:

1-64 oz container

Eggs: Milk:

1 dozen 1 gallon OR 4 quarts OR 2 half gallons whole lactose free, OR Acidophilus, OR Acidophilus and Bifidum No low-fat milk. Least expensive brand

Juice:

1-64 oz container

Cereal: No more than 36 oz

2 C10 Milk:

1 gallon OR 4 quarts OR 2 half gallons

whole lactose free, OR Acidophilus,

OR Acidophilus and Bifidum No low-fat

milk. Least expensive brand

Beans: 4 C12 Milk:

1 lb dried OR 4 cans (14 to 16 oz) 1 gallon OR 4 quarts OR 2 half gallons whole lactose free, OR Acidophilus, OR Acidophilus and Bifidum No low-fat milk. Least expensive brand

Whole Grain:

Pick 2: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns

FP-155


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-15 ( cont'd)

Food Package C03 Goat Milk for 1-2 year old
$6 fruit and vegetable
16 quarts of whole goat milk or 21 quarts evaporated goat milk
2-64 oz juice
1 dozen eggs
36 oz cereal
32 oz whole grain
1 lb dried beans

Rank VC 9 P03
4 C15

Voucher Message

Produce: $6 for fresh, frozen, or canned fruit and

vegetables

No potatoes-except for sweet potatoes

or yams. No products with added

sugar, seasonings, fat, or oils. No

creamed vegetables. No stewed

tomatoes.

Goat

3 quarts whole goat milk OR 4-12 oz

Milk:

cans evaporated goat milk No low-fat

milk.

Cereal: No more than 36 oz

2 C18 Goat

3 quarts whole goat milk OR 4-12 oz

Milk:

cans evaporated goat milk No low-fat

milk.

Beans: 3 C16 Goat
Milk:

1 lb dried OR 4 cans (14 to 16 oz) 3 quarts whole goat milk OR 4-12 oz cans evaporated goat milk No low-fat milk.

Juice:

1-64 oz container

Eggs: 4 C17 Goat
Milk:

1 dozen 3 quarts whole goat milk OR 4-12 oz cans evaporated goat milk No low-fat milk.

Juice:

1-64 oz container

Whole grain:
1 A25 Goat Milk:

Pick 2: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns 4 quarts whole goat milk OR 5-12 oz cans evaporated goat milk. No low-fat milk.

FP-156


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-15 ( cont'd)

Food Package Number

Rank VC

C05 Limited Tofu for 1-2 9 P03

yr old

MEDICAL DOCUMENTATION REQUIRED

$6 Fruit and vegetable

1 C03

3 gallon whole milk 4 lb tofu

2 C04

Voucher Message

Produce: $6 for fresh, frozen, or canned fruit and

vegetables

No potatoes-except for sweet potatoes

or yams. No products with added

sugar, seasonings, fat, or oils. No

creamed vegetables. No stewed

tomatoes.

Milk:

1 gallon Whole milk only

Least expensive brand

Juice:

1-64 oz container

Milk:

1 gallon Whole milk only

Least expensive brand only

2-64 oz juice

Cereal: No more than 36 oz

1 dozen eggs 36 oz cereal 32 oz whole grains 1 lb dried beans

Eggs: 3 C20 Tofu:

1 dozen No more than 4 pounds

Juice: 4 C05 Milk:

1-64 oz container 1 gallon Whole milk only Least expensive brand

Whole Grains:

Pick 2: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns

Beans: 1 lb dried OR 4 cans (14 to 16 oz)

FP-157


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-15 ( cont'd)

Food Package Number C06 Extra Tofu for 1-2 year old
MEDICAL DOCUMENTATION REQUIRED
$6 fruit and vegetable
2 gallon whole milk
8 lb tofu
2-64 oz juice
1 dozen eggs
36 oz cereal
32 oz whole grain
1 lb dried beans

Rank VC 9 P03
1 C20

Voucher Message

Produce: $6 for fresh, frozen, or canned fruit and

vegetables

No potatoes-except for sweet potatoes

or yams. No products with added

sugar, seasonings, fat, or oils. No

creamed vegetables. No stewed

tomatoes.

Tofu:

4 pounds

Juice: 2 C04 Milk:

1-64 oz container 1 gallon Whole milk only Least expensive brand

Cereal: No more than 36 oz

Eggs: 3 C20 Tofu:

1 dozen 4 pounds

Juice: 4 C05 Milk:

1-64 oz container 1 gallon Whole milk only Least expensive brand

Whole Grains:

Pick 2: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns

Beans: 1 lb dried OR 4 cans (14 to 16 oz)

FP-158


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-15 ( cont'd)

Food Package C09 No Milk 1-2 year old
MEDICAL DOCUMENTAION REQUIRED
Can only be given with Food Package III
$6 fruit and vegetable
2-64 oz juice
1 dozen eggs
36 oz cereal
32 oz whole grain
1 lb beans

Rank VC 9 P03
2 C23

Voucher Message

Produce: $6 for fresh, frozen, or canned fruit and

vegetables

No potatoes-except for sweet potatoes

or yams. No products with added

sugar, seasonings, fat, or oils. No

creamed vegetables. No stewed

tomatoes.

Juice:

1-64 oz container

Eggs:

1 dozen

Cereal: No more than 36 oz

4 C24 Juice:

1-64 oz container

Whole grain:

Pick 2: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns

Beans: 1 lb dried OR 4 cans (14 to 16 oz)

FP-159


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-15 ( cont'd)

Food Package C10 1-2 year old Alternative Package $6 fruits and vegetables
64-8 oz UHT whole milk
21-6 oz juice
36 oz cereal
32 oz whole grain
4-16 oz cans beans

Rank VC 9 P03
4 H06

Voucher Message

Produce: $6 for fresh, frozen, or canned fruit and

vegetables

No potatoes-except for sweet potatoes

or yams. No products with added

sugar, seasonings, fat, or oils. No

creamed vegetables. No stewed

tomatoes.

Milk:

12-8 oz OR half pint boxes whole UHT

Juice:

6 cans (5.5 to 6 oz)

Cereal: No more than 18 oz

1 H07 Milk:

12-8 oz OR half pint boxes whole UHT

Juice: 3 H07 Milk:

6 cans (5.5 to 6 oz) 12-8 oz OR half pint boxes whole UHT

Juice: 2 H10 Milk:

6 cans (5.5 to 6 oz) 12-8 oz OR half pint boxes whole UHT

Cereal: Not more than 18 oz

4 H08 Milk:

16-8 oz OR half pint boxes whole UHT

Juice:

3 cans (5.5 to 6 oz)

Whole grain:

Pick 2: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns

Beans: 4 cans (14 to 16 oz)

FP-160


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-15 ( cont'd)

Food Package C11 Soy Milk for 1 -2 year old
MEDICAL DOCUMENTATION REQUIRED
$6 fruit and vegetable
4 gallons soy milk
2-64 oz juice
1 dozen eggs
36 oz cereal
32 oz whole grain
1 lb dried beans

Rank VC 9 P03
3 W70

Voucher Message
Produce: $6 for fresh, frozen, or canned fruit and vegetables No potatoes-except for sweet potatoes or yams. No products with added sugar, seasonings, fat, or oils. No creamed vegetables. No stewed tomatoes.
Soy Milk: 2 half gallons 8th Continent (Original OR Vanilla flavors only)

Cereal: No more than 36 oz

1 W57 Soy

2 half gallons 8th Continent

Milk:

(Original OR Vanilla flavors only)

Beans: 2 C28 Soy
Milk:

1 lb dried OR 4 cans (14 to 16 oz) 2 half gallons 8th Continent
(Original OR Vanilla flavors only)

Juice:

1-64 oz container

Eggs:

1 dozen

4 C29 Soy Milk: 2 half gallons 8th Continent

(Original OR Vanilla flavors only)

Juice:

1-64 oz container

Whole grain:

Pick 2: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns

FP-161


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-15 ( cont'd)

Food Package

Rank VC Voucher Message

C12 - Evaporated Milk for 9 P03 Produce: $6 for fresh, frozen, or canned fruit and

Standard 1-2 year old -

vegetables

evaporated

No potatoes-except for sweet potato or

yams. No products with added sugar,

$6 fruit and vegetable

seasonings, fat, or oils. No creamed

vegetables. No stewed tomatoes.

1 gallon whole milk

3 C33 Milk:

4-12 ounce cans evaporated (whole)

Least expensive brand

16-12 oz cans evaporated

milk

Eggs:

1 dozen

264 oz juice 1 dozen eggs

Cereal 2 C31 Milk:

No more than 36 oz 8-12 ounce cans evaporated (whole) Least expensive brand

36 oz cereal

Cheese: 1-16 oz package

32 oz whole grain 1 lb dried beans

Juice: 1 C32 Milk

1-64 oz container 4-12 ounce cans evaporated (whole) Least expensive brand

Juice: 4 C05 Milk:

1-64 oz container 1 gallon Whole milk only Least expensive brand

Whole Grains:

Pick 2: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns

Beans: 1 lb dried OR 4 cans (14 to 16 oz)

FP-162


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-15 ( cont'd)

Food Package C13 Soy Milk with Tofu for 1 -2 year old
MEDICAL DOCUMENTATION REQUIRED
$6 fruit and vegetable

Rank 9
4

VC P03
W91

Voucher Message

Produce: $6 for fresh, frozen, or canned fruit and

vegetables

No potatoes-except for sweet potatoes

or yams. No products with added

sugar, seasonings, fat, or oils. No

creamed vegetables. No stewed

tomatoes.

Tofu:

No more than 4 pounds tofu

3 gallons soy milk 4 lb tofu

Cereal: No more than 36 oz

1 W57 Soy

2 half gallons 8th Continent

Milk:

(Original OR Vanilla flavors only)

2-64 oz juice 1 dozen eggs

Beans: 2 C28 Soy
Milk:

1 lb dried OR 4 cans (14 to 16 oz) 2 half gallons 8th Continent
(Original OR Vanilla flavors only)

36 oz cereal

Juice:

1-64 oz container

32 oz whole grain 1 lb dried beans

Eggs:

1 dozen

3 C29 Soy Milk: 2 half gallons 8th Continent

(Original OR Vanilla flavors only)

Juice:

1-64 oz container

Whole grain:

Pick 2: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns

FP-163


GEORGIA WIC 2012 PROCEDURES MANUAL Children 2 -5 Years (C20-C39)

Attachment FP-16

Food Package C21 Standard 2-5 year old
$6 fruit and vegetable
2 gallons milk
1-3 qt dry milk
1 lb cheese
264 oz juice
1 dozen eggs
36 oz cereal
32 oz whole grain
1 lb dried beans or 1 container of peanut butter (16-18 oz.)

Rank VC 9 P03
1 C01

Voucher Message

Produce: $6 for fresh, frozen, or canned fruit and

vegetables

No potatoes-except for sweet potato or

yams. No products with added sugar,

seasonings, fat, or oils. No creamed

vegetables. No stewed tomatoes.

Milk:

1 gallon low-fat (fat-free, 1%, 2%) No

whole milk. Least expensive brand

Juice: 2 W04 Milk:

2-64 oz containers 1 half gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Cheese: 1-16 oz package

3 W05 Milk:

1 gallon low-fat (fat-free, 1%, 2%)

No whole milk. Least expensive brand

Eggs:

1 dozen

Cereal No more than 36 oz 4 C02 Dry milk: 1-3 quart container non-fat dry powder
OR 4-12 oz cans low-fat (fat-free, skimmed, 2%) evaporated

Whole Grain:

Pick 2: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns

Beans/ peanut butter:

1 lb dried OR 4 cans (14 to 16 oz) beans OR 1 container (16 to 18 oz) peanut butter

FP-164


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-16 (cont'd)

Food Package C22- Lactose Intolerant 2-5 year old
$6 fruit and vegetable
13 quarts of lactose reduced milk
1 lb cheese
2-64 oz juice
1 dozen eggs
36 oz cereal
32 oz whole grain
1 lb dried beans or 1 container of peanut butter (16-18 oz.)

Rank VC 9 P03
2 C11

Voucher Message

Produce: $6 for fresh, frozen, or canned fruit and

vegetables

No potatoes except for sweet potatoes

or yams. No products with added sugar,

seasonings, fat, or oils. No creamed

vegetables. No stewed tomatoes.

Milk:

1 gallon OR 4 quarts OR 2 half gallons

low- fat (fat-free, 1%, 2%) Lactose free,

OR Acidophilus, OR Acidophilus and

Bifidum. No whole milk. Least

expensive brand

Cheese: 1-16 oz package

Juice: 3 W92 Milk:

2-64 oz containers 1-half gallons low- fat (fat-free, 1%, 2%) Lactose free, OR Acidophilus, OR Acidophilus and Bifidum. No whole milk. Least expensive brand

Cereal: 1 045 Milk:

No more than 36 oz 1 gallon OR 4 quarts OR 2 half gallons low- fat (fat-free, 1%, 2%) Lactose free, OR Acidophilus, OR Acidophilus and Bifidum. No whole milk. Least expensive brand

Beans/ peanut butter: 4 C35 Milk:

1 lb dried OR 4 cans (14 to 16 oz) beans OR 1 container (16 to 18 oz) peanut butter 1-3 quart (96 oz) low-fat (fat-free, 1%, 2%) Lactose free, OR Acidophilus, OR Acidophilus and Bifidum. No whole milk. Least expensive brand

Eggs:

1 dozen

Whole Grain:

Pick 2: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns

FP-165


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-16 (cont'd)

Food Package C23 Goat Milk for 2-5 year old
$6 fruit and vegetable 13 quarts of goat milk 1 lb cheese

Rank VC 9 P03
2 W15

Voucher Message

Produce: $6 for fresh, frozen, or canned fruit and

vegetables

No potatoes-except for sweet potatoes

or yams. No products with added sugar,

seasonings, fat, or oils. No creamed

vegetables. No stewed tomatoes.

Goat

4 quarts low-fat goat milk. No whole

milk:

milk.

2-64 oz juice
1 dozen eggs
36 oz cereal
32 oz whole grains
1 lb dried beans or 1 container of peanut butter (16-18 oz.)

Cereal: No more than 36 oz

3 W19 Goat

1 quart low-fat goat milk. No whole Milk.

milk:

1-16 oz package

Cheese:

1 lb dried OR 4 cans (14 to 16 oz)

Beans/ beans OR 1 container (16 to 18 oz)

Peanut peanut butter

butter:

1 C13 Goat

4 quarts low-fat goat milk. No whole

milk:

milk.

Juice:

1-64 oz container

Eggs: 4 C14 Goat
Milk:

1 dozen 4 quarts low-fat goat milk. No whole milk.

Juice:

1-64 oz container

Whole Grain:

Pick 2: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns

FP-166


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-16 (cont'd)

Food Package Number C24 Extra Cheese for 2-5 year old child
MEDICAL DOCUMENTATION REQUIRED
$6 Fruit and vegetable
2 gallon milk
2 lb cheese
2-64 oz juice
1 dozen eggs
36 oz cereal
32 oz whole grain
1 lb dried beans or 1 container of peanut butter (16-18 oz.)

Rank VC 9 P03
1 C01

Voucher Message

Produce: $6 for fresh, frozen, or canned fruit and

vegetables

No potatoes-except for sweet potatoes

or yams. No products with added sugar,

seasonings, fat, or oils. No creamed

vegetables. No stewed tomatoes.

Milk:

1 gallon low-fat (fat-free, 1%, 2%)

No whole milk. Least expensive brand

Juice: 2 W04 Milk:

2-64 oz containers 1 half gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Cheese: 1-16 oz package

3 W05 Milk:

1 gallon low-fat (fat-free, 1%, 2%)

No whole milk. Least expensive brand

Eggs:

1 dozen

Cereal 4 C21 Beans/
peanut butter:

No more than 36 oz. 1 lb dried OR 4 cans (14 to 16 oz) beans OR 1 container (16 to 18 oz) peanut butter

Whole Grain:

Pick 2: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns

Cheese: 1-16 oz package

FP-167


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-16 (cont'd)

Food Package Number C25- Limited Tofu for 2-5 year old child
MEDICAL DOCUMENTATION REQUIRED
$6 Fruit and vegetable
3 gallon milk
4 lb tofu
2-64 oz juice
1 dozen eggs
36 oz cereal
32 oz whole grain
1 lb dried beans or 1 container of peanut butter (16-18 oz.)

Rank VC 9 P03
1 C01

Voucher Message

Produce: $6 for fresh, frozen, or canned fruit and

vegetables

No potatoes-except for sweet potatoes

or yams. No products with added

sugar, seasonings, fat, or oils. No

creamed vegetables. No stewed

tomatoes.

Milk:

1 gallon low-fat (fat-free, 1%, 2%)

No whole milk. Least expensive

brand

Juice: 2 C19 Milk:

2-64 oz containers 1 gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Whole Grain:
4 W05 Milk:

Pick 2: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns 1 gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Eggs:

1 dozen

Cereal: No more than 36 oz

3 W42 Tofu:

No more than 4 pounds

Bean/ Peanut butter:

1 lb dried OR 4 cans (14 to 16 oz) beans OR 1 container (16 to 18 oz) peanut butter

FP-168


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-16 (cont'd)

Food Package Number C26 Extra Tofu for 2-5 year old child
MEDICAL DOCUMENTATION REQUIRED
$6 fruit and vegetable
2 gallon milk
8 lb tofu
2-64 oz juice
1 dozen eggs
36 oz cereal
32 oz whole grain
1 lb dried beans or 1 container of peanut butter (16-18 oz.)

Rank VC 9 P03
1 C06

Voucher Message

Produce: $6 for fresh, frozen, or canned fruit and

vegetables

No potatoes-except for sweet potatoes

or yams. No products with added

sugar, seasonings, fat, or oils. No

creamed vegetables. No stewed

tomatoes.

Tofu:

No more than 4 pounds

Juice: 4 C19 Milk:

2-64 oz containers 1 gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Whole Grain:
2 W05 Milk:

Pick 2: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns 1 gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Eggs:

1 dozen

Cereal: No more than 36 oz.

3 W42 Tofu:

No more than 4 pounds

Beans/ Peanut butter:

1 lb dried OR 4 cans (14 to 16 oz) beans OR 1 container (16 to 18 oz) peanut butter

FP-169


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-16 (cont'd)

Food Package Number C27 Whole Milk for 2 -5 year old
MEDICAL DOCUMENTATION REQUIRED
Can only be given with food package III
$6 fruit and vegetable
4 gallon milk
2-64 oz juice
1 dozen eggs
36 oz cereal
32 oz whole grain
1 lb dried beans or 1 container of peanut butter (16-18 oz.)

Rank VC 9 P03
1 C03

Voucher Message

Produce: $6 for fresh, frozen, or canned fruit and

vegetables

No potatoes-except for sweet potatoes

or yams. No products with added

sugar, seasonings, fat, or oils. No

creamed vegetables. No stewed

tomatoes.

Milk:

1 gallon Whole milk only

Least expensive brand

Juice: 2 C04 Milk:

1-64 oz container 1 gallon Whole milk only Least expensive brand

Cereal: No more than 36 oz

Eggs: 3 C03 Milk:

1 dozen 1 gallon Whole milk only Least expensive brand

Juice: 4 C22 Milk:

1-64 oz container 1 gallon Whole milk only Least expensive brand

Whole Grains:

Pick 2: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns

Beans/ peanut Butter:

1 lb dried OR 4 cans (14 to 16 oz) beans OR 1 container (16 to 18 oz) peanut butter

FP-170


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-16 (cont'd)

Food Package C28 No Cheese for 2-5 year old
$6 fruit and vegetable
4 gallon milk
2-64 oz juice

Rank VC 9 P03
1 C01

Voucher Message

Produce: $6 for fresh, frozen, or canned fruit and

vegetables

No potatoes-except for sweet potatoes

or yams. No products with added sugar,

seasonings, fat, or oils. No creamed

vegetables. No stewed tomatoes.

Milk:

1 gallon low-fat (fat-free, 1%, 2%)

No whole milk. Least expensive brand

1 dozen eggs 36 oz cereal

Juice: 3 W05 Milk:

2-64 oz containers 1 gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

32 oz whole grain

Eggs:

1 dozen

1 lb dried beans or 1 container of peanut butter (16-18 oz.)

Cereal: No more than 36 oz

2 W22 Milk:

1 gallon low-fat (fat-free, 1%, 2%)

No whole milk. Least expensive brand

Beans/ peanut butter: 4 C19 Milk:

1 lb dried OR 4 cans (14 to 16 oz) beans OR 1 container (16 to 18 oz) peanut butter 1 gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand

Whole Grain:

Pick 2: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns

FP-171


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-16 (cont'd)

Food Package C29 No Milk for 2-5 year old
MEDICAL DOCUMENTATION REQUIRED
Can only be given with Food Package III
$6 fruit and vegetable
1 lb cheese
2-64 oz juice

Rank VC 9 P03
2 C27
4 C26

Voucher Message Produce: $6 for fresh, frozen, or canned fruit and
vegetables No potatoes-except for sweet potatoes or yams. No products with added sugar, seasonings, fat, or oils. No creamed vegetables. No stewed tomatoes. Cheese: 1-16 oz package

Juice:

1-64 oz container

Eggs:

1 dozen

Cereal: Juice:

No more than 36 oz 1-64 oz container

1 dozen eggs 36 oz cereal

Whole grain:

Pick 2: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns

32 oz whole grain
1 lb beans or 1 container of peanut butter (16-18 oz.)

Beans/ peanut butter:

1 lb dried OR 4 cans (14 to 16 oz) beans OR 1 container (16 to 18 oz) peanut butter

FP-172


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-16 (cont'd)

Food Package C30 2-5 year old Alternative Package
$6 fruit and vegetable
64-8 oz UHT milk
21-6 oz juice
36 oz cereal
32 oz whole grain
1 container of peanut butter (16-18 oz.)
4 cans beans

Rank VC 9 P03
3 H12

Voucher Message

Produce: $6 for fresh, frozen, or canned fruit and

vegetables

No potatoes-except for sweet potatoes

or yams. No products with added

sugar, seasonings, fat, or oils. No

creamed vegetables. No stewed

tomatoes.

Milk:

12-8 oz OR half pint boxes low-fat

(fat-free, 1%, 2%) UHT. No whole milk.

6 cans (5.5 to 6 oz)

Juice:

No more than 18 oz

Cereal:

4 H15 Milk:

12-8 oz OR half pint boxes low-fat (fat-

free, 1%, 2%) UHT. No whole milk.

Juice:

6 cans (5.5 to 6 oz)

Peanut 1 container (16 to 18 oz)

butter:

1 H11 Milk:

12-8 oz OR half pint boxes low-fat (fat-

free, 1%, 2%) UHT. No whole milk.

Juice:

6 cans (5.5 to 6 oz)

Beans: 2 H13 Milk:

4 cans (14 to 16 oz) 12-8 oz OR half pint boxes low-fat (fat-free, 1%, 2%) UHT. No whole milk.

Not more than 18 oz

Cereal:

4 H09 Milk:

16-8 oz OR half pint boxes low-fat (fat-

free, 1%, 2%) UHT. No whole milk.

Juice:

3 cans (5.5 to 6 oz)

Whole grain:

Pick 2: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns

FP-173


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-16 (cont'd)

Food Package C31 Soy Milk for 2 -5 year old
MEDICAL DOCUMENTATION REQUIRED
$6 fruit and vegetable
4 gallons soy milk
2-64 oz juice
1 dozen eggs
36 oz cereal
32 oz whole grain
1 lb dried beans or 1 container of peanut butter (16-18 oz.)

Rank 9
3 1

VC P03
W70 W73

Voucher Message

Produce: $6 for fresh, frozen, or canned fruit and

vegetables

No potatoes-except for sweet potatoes

or yams. No products with added

sugar, seasonings, fat, or oils. No

creamed vegetables. No stewed

tomatoes.

Soy Milk: 2 half gallons 8th Continent

(Original OR Vanilla flavors only)

Cereal:

No more than 36 oz

Soy

2 half gallons 8th Continent

Milk:

(Original OR Vanilla flavors only)

Beans/ peanut butter: 2 C28 Soy Milk:

1 lb dried OR 4 cans (14 to 16 oz) beans OR 1 container (16 to 18 oz) peanut butter 2 half gallons 8th Continent (Original OR Vanilla flavors only)

Juice:

1-64 oz container

Eggs: 4 C29 Soy
Milk:

1 dozen 2 half gallons 8th Continent
(Original OR Vanilla flavors only)

Juice:

1-64 oz container

Whole grain:

Pick 2: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns

FP-174


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-16 (cont'd)

Description C32 - Evaporated Milk for Standard 2-5 year old
$6 fruit and vegetable
1 gallon milk
12-12 oz cans evaporated milk
1 lb cheese
264 oz juice
1 dozen eggs
36 oz cereal

Rank VC Category 9 P03 Produce:
2 W05 Milk:
Eggs: Cereal 3 C25 Milk:

Message $6 for fresh, frozen, or canned fruit and vegetables No potatoes-except for sweet potato or yams. No products with added sugar, seasonings, fat, or oils. No creamed vegetables. No stewed tomatoes. 1 gallon low-fat (fat-free, 1%, 2%) No whole milk. Least expensive brand
1 dozen
No more than 36 oz 8-12 ounce cans low-fat (fat-free, skimmed, 2%) evaporated Least expensive brand

32 oz whole grain
1 lb dried beans or 1 container of peanut butter (16-18 oz.)

Juice: 1 C34 Milk
Juice: 4 C21 Beans/
peanut butter:
Whole Grain:

1-64 oz container 4-12 ounce cans low-fat (fat-free, skimmed, 2%) evaporated Least expensive brand
1-64 oz container 1 lb dried OR 4 cans (14 to 16 oz) beans OR 1 container (16 to 18 oz) peanut butter Pick 2: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns

Cheese: 1-16 oz package

FP-175


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-16 (cont'd)

Food Package C33 Soy Milk with tofu for 2 -5 year old
MEDICAL DOCUMENTATION REQUIRED
$6 fruit and vegetable
3 gallons soy milk
4 lb tofu
2-64 oz juice
1 dozen eggs
36 oz cereal
32 oz whole grain
1 lb dried beans or 1 container of peanut butter (16-18 oz.)

Rank 9
4

VC P03
W91

Voucher Message

Produce: $6 for fresh, frozen, or canned fruit and

vegetables

No potatoes-except for sweet potatoes

or yams. No products with added

sugar, seasonings, fat, or oils. No

creamed vegetables. No stewed

tomatoes.

Tofu:

No more than 4 pounds tofu

Cereal: No more than 36 oz

1 W73 Soy

2 half gallons 8th Continent

Milk:

(Original OR Vanilla flavors only)

Beans/ peanut butter: 2 C28 Soy Milk:

1 lb dried OR 4 cans (14 to 16 oz) beans OR 1 container (16 to 18 oz) peanut butter 2 half gallons 8th Continent (Original OR Vanilla flavors only)

Juice:

1-64 oz container

Eggs: 3 C29 Soy
Milk:

1 dozen 2 half gallons 8th Continent
(Original OR Vanilla flavors only)

Juice:

1-64 oz container

Whole grain:

Pick 2: 16 oz loaf of bread; 16 oz pkg brown rice; 16 oz pkg tortillas; 14 to 16 oz pkg buns

FP-176


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-17

CPA FPC
R01 R01 R01
S01 X01
R03 R03 R03
S03 X03
X39 X40 X02 X42
X07 X08 X09 X16
X90 X93 X94 X95
X96 X97 X98 X99
X86 X34 X35 X36
Z31 Z32 Z33 Z35

Special Formula Summary

Status / Age
FFF 0-2 m FFF 3-5 m FFF 6-11 m
FFF 6-11 m Child
FFF 0-3 m FFF 4-5 m FFF 6-11 m
FFF 6-11 m Child
Women Women Women Women
Child Child Child Child
Child Child Child Child
Child Child Child Child
Child Child Child Child
Child Child Child Child

System FPC
R01 S01 T01
S01 X01
R03 S03 T03
S03 X03
X39 X40 X02 X42
X07 X08 X09 X16
X90 X93 X94 X95
X96 X97 X98 X99
X86 X34 X35 X36
Z31 Z32 Z33 Z35

Formula
Similac Expert Care Alimentum Powder 7-16 oz cans powder Similac Expert Care Alimentum
8-16 oz cans powder Similac Expert Care Alimentum
6-16 oz cans powder Similac Expert Care Alimentum 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 8-16 oz cans powder Similac Expert Care Alimentum
7-16 oz cans powder Similac Expert Care Alimentum Similac Expert Care Alimentum RTF
26-32 oz cans RTF Similac Expert Care Alimentum 28-32 oz cans RTF Similac Expert Care Alimentum 20-32 oz cans RTF Similac Expert Care Alimentum 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 28-32 oz cans RTF Similac Expert Care Alimentum 28-32 oz cans RTF Similac Expert Care Alimentum
Boost 30-8 oz containers Boost 60-8 oz containers Boost 90-8 oz containers Boost 112-8 oz containers Boost
Boost Kid Essentials (Retail) 30-8.25 oz containers ready to feed Boost Kid Essentials 60-8.25 oz containers ready to feed Boost Kid Essentials 90- .25 oz containers ready to feed Boost Kid Essentials 110-8.25 oz containers ready to feed Boost Kid Essentials
Boost Kid Essentials 1.5 30-8 oz containers ready to feed Boost Kid Essentials 1.5 608 oz containers ready to feed Boost Kid Essentials 1.5 908 oz containers ready to feed Boost Kid Essentials 1.5 1138 oz containers ready to feed Boost Kid Essentials 1.5
Boost Kid Essentials 1.5 With Fiber 30-8 oz containers ready to feed Boost Kid Essentials 1.5 With Fiber 608 oz containers ready to feed Boost Kid Essentials 1.5 With Fiber 908 oz containers ready to feed Boost Kid Essentials 1.5 With Fiber 1138 oz containers ready to feed Boost Kid Essentials 1.5 With Fiber
Bright Beginnings Soy Pediatric Drink 30-8 oz containers Bright Beginnings Soy Pediatric Drink 60-8 oz containers Bright Beginnings Soy Pediatric Drink 90-8 oz containers Bright Beginnings Soy Pediatric Drink 108-8 oz containers Bright Beginnings Soy Pediatric Drink
Compleat Pediatric 30-250 ml containers Compleat Pediatric
60-250 ml containers Compleat Pediatric
90-250 ml containers Compleat Pediatric
107-250 ml containers Compleat Pediatric

FP-177


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-17 (cont'd)

CPA FPC
X89
R41 R41 R41
S41
R24 R24 R24
S24
R26 R26 R26
S26
R20 R20 R20
S20
R30 R30 R30
S30
R40 R40 R40
S40
R12

Status / Age
Child FFF 0-3 m FFF 4-5 m FFF 6-11 m
FFF 6-11 m
FFF 0-3 m FFF 4-5 m FFF 6-11 m
FFF 6-11 m
FFF 0-3 m FFF 4-5 m FFF 6-11 m
FFF 6-11 m FFF 0-3 m FFF 4-5 m FFF 6-11 m
FFF 6-11 m FFF 0-3 m FFF 4-5 m FFF 6-11 m
FFF 6-11 m FFF 0-3 m FFF 4-5 m FFF 6-11 m
FFF 6-11 m FFF 0-3 m

System FPC
X89
R41 S41 T41
S41
R24 S24 T24
S24
R26 S26 T26
S26
R20 S20 T20
S20
R30 S30 T30
S30
R40 S40 T40
S40
R12

Formula
EleCare Jr Powder 9-14.1 oz cans powder EleCare Jr
EleCare for Infants Powder 9-14.1 oz cans powder EleCare for Infants 10-14.1 oz cans powder EleCare for Infants 7-14.1 oz cans powder EleCare for Infants 32 jars baby fruit/vegetable 3-8 oz box infant cereal 10-14.1 oz cans powder EleCare for Infants
Enfamil EnfaCare Powder 10-12.8 oz cans powder Enfamil EnfaCare
11-12.8 oz cans powder Enfamil EnfaCare
8-12.8 oz cans powder Enfamil EnfaCare 32 jars baby fruit/vegetable 3-8 oz box infant cereal 11-12.8 oz oz cans powder Enfamil EnfaCare
Enfamil EnfaCare RTF 26-32 oz cans RTF Enfamil EnfaCare 28-32 oz cans RTF Enfamil EnfaCare 20-32 oz cans RTF Enfamil EnfaCare 32 jars baby fruit/vegetable 3-8 oz box infant cereal 28-32 oz cans RTF Enfamil EnfaCare
Enfamil EnfaCare RTF 414-2 oz cans RTF Enfamil EnfaCare 444-2 oz cans RTF Enfamil EnfaCare 318-2 oz cans RTF Enfamil EnfaCare 32 jars baby fruit/vegetable 3-8 oz box infant cereal 444-2 oz cans RTF Enfamil EnfaCare
Enfamil Premature LIPIL 20 RTF 414-2 oz cans RTF Enfamil Premature LIPIL 20 444-2 oz cans RTF Enfamil Premature LIPIL 20 318-2 oz cans RTF Enfamil Premature LIPIL 20 32 jars baby fruit/vegetable 3-8 oz box infant cereal 444-2 oz cans RTF Enfamil Premature LIPIL 20
Enfamil Premature LIPIL 24 RTF 414-2 oz cans RTF Enfamil Premature LIPIL 24 444-2 oz cans RTF Enfamil Premature LIPIL 24 318-2 oz cans RTF Enfamil Premature LIPIL 24 32 jars baby fruit/vegetable 3-8 oz box infant cereal 444-2 oz cans RTF Enfamil Premature LIPIL 24
Enfaport LIPIL 102-8 oz cans Enfaport LIPIL

FP-178


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-17 (cont'd)

CPA FPC R12 R12
S12 Z49 Z50 Z51 Z52
X06 X38 X45 X15
X47 X48 X49 X50
X51 X52 X53
R02 R02 R02
S02
R51 R51 R51
S51
R61 R61 R61
S61

Status / Age FFF 4-5 m FFF 6-11 m
FFF 6-11 m Child Child Child Child
Women Women Women Women
Women Women Women Women
Child Child Child
FFF 0-3 m FFF 4-5 m FFF 6-11 m
FFF 6-11 m
FFF 0-3 m FFF 4-5 m FFF 6-11 m
FFF 6-11 m
FFF 0-3 m FFF 4-5 m FFF 6-11 m
FFF 6-11 m

System FPC S12 T12
S12 Z49 Z50 Z51 Z52
X06 X38 X45 X15
X47 X48 X49 X50
X51 X52 X53
R02 S02 T02
S02
R51 S51 T51
S51
R61 S61 T61
S61

Formula
112-8 oz cans Enfaport LIPIL
78-8 oz cans Enfaport LIPIL
32 jars baby fruit/vegetable 3-8 oz box infant cereal
112-8 oz cans Enfaport LIPIL
30-8 oz cans Enfaport LIPIL
60-8 oz cans Enfaport LIPIL
90-8 oz cans Enfaport LIPIL
113-8 oz cans Enfaport LIPIL
Ensure 30-8 oz containers Ensure 60-8 oz containers Ensure 90-8 oz containers Ensure 108-8 oz containers Ensure
Ensure Fiber 30-8 oz containers Ensure Fiber 60-8 oz containers Ensure Fiber 90-8 oz containers Ensure Fiber 108-8 oz containers Ensure Fiber
EO28 Splash 31-237 ml containers EO28 Splash 62-237 ml containers EO28 Splash 113-237 ml containers EO28 Splash
Gerber Good Start Premature 24 272-3 oz containers RTF feed Gerber Good Start Premature 24
296-3 oz containers RTF feed Gerber Good Start Premature 24 208-3 oz containers RTF feed Gerber Good Start Premature 24 32 jars baby fruit/vegetable 3-8 oz box infant cereal 296-3 oz containers RTF feed Gerber Good Start Premature 24
Neocate Infant Powder 10-400 grams (14.1 oz) cans powder Neocate Infant 11-400 grams (14.1 oz) cans powder Neocate Infant 8-400 grams (14.1 oz) cans powder Neocate Infant 32 jars baby fruit/vegetable 3-8 oz box infant cereal 11-400 grams (14.1 oz) cans powder Neocate Infant
Neocate Infant DHA & ARA Powder 10-400 grams (14.1 oz) cans powder Neocate Infant DHA & ARA 11-400 grams (14.1 oz) cans powder Neocate Infant DHA & ARA 8-400 grams (14.1 oz) cans powder Neocate Infant DHA & ARA 32 jars baby fruit/vegetable 3-8 oz box infant cereal 11-400 grams (14.1 oz) cans powder Neocate Infant DHA & ARA

FP-179


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-17 (cont'd)

CPA FPC X75
R71 R71 R71
S71 X92
R73 R73 R73
S73 X73 R70 R70 R70
S70
Z41 Z42 Z43 Z44
R81 R81 R81
S81 X81

Status / Age
Child FFF 0-3 m FFF 4-5 m FFF 6-11 m
FFF 6-11 m Child
FFF 0-3 m FFF 4-5 m FFF 6-11 m
FFF 6-11 m Child
FFF 0-3 m FFF 4-5 m FFF 6-11 m
FFF 6-11 m
Child Child Child Child
FFF 0-3 m FFF 4-5 m FFF 6-11 m
FFF 6-11 m Child

System FPC X75
R71 S71 T71
S71 X92
R73 S73 T73
S73 X73 R70 S70 T70
S70
Z41 Z42 Z43 Z44
R81 S81 T81
S81 X81

Formula
Neocate Junior Powder 14-400 grams (14.1 oz) cans powder Neocate Junior
Similac NeoSure or Similac Expert Care Neosure Powder 10-12.8 oz cans powder Similac NeoSure or 10-13.1 oz Similac Expert Care NeoSure 11-12.8 oz cans powder Similac NeoSure or 11-13.1 oz Similac Expert Care NeoSure 8-12.8 oz cans powder Similac NeoSure or 8-13.1 oz Similac Expert Care NeoSure 32 jars baby fruit/vegetable 3-8 oz box infant cereal 11-12.8 oz cans powder Similac NeoSure or 11-13.1 oz Similac Expert Care NeoSure 10-12.8 oz cans powder Similac NeoSure or 10-13.1 oz Similac Expert Care NeoSure
Similac NeoSure or Similac Expert Care NeoSure 32 oz RTF 26-32 oz cans RTF Similac NeoSure or Similac Expert Care NeoSure 28-32 oz cans RTF Similac NeoSure or Similac Expert Care NeoSure 20-32 oz cans RTF Similac NeoSure or Similac Expert Care NeoSure 32 jars baby fruit/vegetable 3-8 oz box infant cereal 28-32 oz cans RTF Similac NeoSure or Similac Expert Care NeoSure 28-32 oz cans RTF Similac NeoSure or Similac Expert Care NeoSure
Similac NeoSure or Similac Expert Care NeoSure 2 oz RTF 416-2 oz cans RTF Similac NeoSure or Similac Expert Care NeoSure 448-2 oz cans RTF Similac NeoSure or Similac Expert Care NeoSure 320-2 oz cans RTF Similac NeoSure or Similac Expert Care NeoSure 32 jars baby fruit/vegetable 3-8 oz box infant cereal
448-2 oz cans RTF Similac NeoSure or Similac Expert Care NeoSure
Nepro RTF
30-8 oz cans Nepro
60-8 oz cans Nepro
90-8 oz cans Nepro
112-8 oz cans Nepro
Nutramigen LIPIL with Enflora LGG Powder 10-12.6 oz cans powder Nutramigen LIPIL with Enflora IGG 11-12.6 oz cans powder Nutramigen LIPIL with Enflora LGG 8-12.6 oz cans powder Nutramigen LIPIL with Enflora LGG 32 jars baby fruit/vegetable 3-8 oz box infant cereal 11-12.6 oz cans powder Nutramigen LIPIL with Enflora LGG 10-12.6 oz cans powder Nutramigen LIPIL with Enflora LGG
Nutramigen LIPIL Concentrate

FP-180


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-17 (cont'd)

CPA FPC R82 R82
R82
S82 X82
R83 R83 R83
S83 X83
R91 R91 R91
S91
Z45 Z46 Z47 Z48
X54 X55 X56
X57 X58 X59
X60 X37 X62
X84 X30 X87 X88

Status / Age
FFF 0-3 m FFF 4-5 m

System FPC R82 S82

Formula
31-13 oz cans concentrate Nutramigen LIPIL 34-13 oz cans concentrate Nutramigen LIPIL

FFF 6-11 m
FFF 6-11 m Child
FFF 0-3 m FFF 4-5 m FFF 6-11 m
FFF 6-11 m Child
FFF 0-2 m FFF 3-5 m FFF 6-11 m
FFF 6-11 m
Women Women Women Women
Women Women Women
Child Child Child
Child Child Child
Child Child Child Child

T82 24-13 oz cans concentrate Nutramigen LIPIL 32 jars baby fruit/vegetable 3-8 oz box infant cereal
S82 34-13 oz cans concentrate Nutramigen LIPIL X82 35-13 oz cans concentrate Nutramigen LIPIL
Nutramigen LIPIL 32 oz RTF R83 26-32 oz cans RTF Nutramigen LIPIL S83 28-32 oz cans RTF Nutramigen LIPIL T83 20-32 oz cans RTF Nutramigen LIPIL
32 jars baby fruit/vegetable 3-8 oz box infant cereal S83 28-32 oz cans RTF Nutramigen LIPIL X83 28-32 oz cans RTF Nutramigen LIPIL
Nutramigen AA LIPIL Powder R91 8-400 gram (14.1 oz) cans powder Nutramigen AA LIPIL
S91 9-400 gram (14.1 oz) cans powder Nutramigen AA LIPIL
T91 7-400 gram (14.1 oz) cans powder Nutramigen AA LIPIL 32 jars baby fruit/vegetable 3-8 oz box infant cereal
S91 9-400 gram (14.1 oz) cans powder Nutramigen AA LIPIL
Nutren 1.5
Z45 30-250 ml containers Nutren 1.5
Z46 60-250 ml containers Nutren 1.5
Z47 90-250 ml containers Nutren 1.5
Z48 107-250 ml containers Nutren 1.5
Nutren 2.0 X54 35-250 ml containers Nutren 2.0 X55 59-250 ml containers Nutren 2.0 X56 107-250 ml containers Nutren 2.0
Nutren Junior X57 35-250 ml containers Nutren Junior X58 59-250 ml containers Nutren Junior X59 107-250 ml containers Nutren Junior
Nutren Junior Fiber X60 35-250 ml containers Nutren Junior Fiber X37 59-250 ml containers Nutren Junior Fiber X62 107-250 ml containers Nutren Junior Fiber
PediaSure Ready to Feed X84 30-8 oz containers PediaSure X30 60-8 oz containers PediaSure X87 90-8 oz containers PediaSure X88 108-8 oz containers PediaSure

FP-181


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-17 (cont'd)

CPA FPC
Z53 Z54 Z55 Z56
Z57 Z58 Z59 Z60
Z27 Z28 Z29 Z30
Z37 Z38 Z39 Z40
X76 X85 X78 X79
X63 X64 X65
X66 X67 X68
Z05 Z06 Z07 Z08
X69 X70 X05

Status / Age
Child Child Child Child
Child Child Child Child
Child Child Child Child
Child Child Child Child
Child Child Child Child
Women Women Women
Child Child Child
Child Child Child Child
Child Child Child

System FPC
Z53 Z54 Z55 Z56
Z57 Z58 Z59 Z60
Z27 Z28 Z29 Z30
Z37 Z38 Z39 Z40
X76 X85 X78 X79
X63 X64 X65
X66 X67 X68
Z05 Z06 Z07 Z08
X69 X70 X05

Formula
PediaSure 1.5 Cal 30-8 oz containers PediaSure 1.5 Cal
60-8 oz containers PediaSure 1.5 Cal
90-8 oz containers PediaSure 1.5 Cal
113-8 oz containers PediaSure 1.5 Cal
PediaSure 1.5 Cal with fiber
30-8 oz containers PediaSure 1.5 Cal with fiber
60-8 oz containers PediaSure 1.5 Cal with fiber
90-8 oz containers PediaSure 1.5 Cal with fiber
113-8 oz containers PediaSure 1.5 Cal with fiber
PediaSure Enteral 30-8 oz containers PediaSure Enteral
60-8 oz containers PediaSure Enteral
90-8 oz containers PediaSure Enteral
113-8 oz containers PediaSure Enteral
PediaSure Enteral with Fiber and scFOS 30-8 oz containers PediaSure Enteral with Fiber and scFOS
60-8 oz containers PediaSure Enteral with Fiber and scFOS
90-8 oz containers PediaSure Enteral with Fiber and scFOS
113-8 oz containers PediaSure Enteral with Fiber and scFOS
PediaSure with Fiber Ready to Feed 30-8 oz containers PediaSure with Fiber 60-8 oz containers PediaSure with Fiber 90-8 oz containers PediaSure with Fiber 108-8 oz containers PediaSure with Fiber
Peptamen 35-250 ml containers Peptamen 59-250 ml containers Peptamen 107-250 ml containers Peptamen
Peptamen Junior 35-250 ml containers Peptamen Junior 59-250 ml containers Peptamen Junior 107-250 ml containers Peptamen Junior
Peptamen Junior Fiber 30-250 ml containers Peptamen Junior Fiber 60-250 ml containers Peptamen Junior Fiber 90-250 ml containers Peptamen Junior Fiber 107-250 ml containers Peptamen Junior Fiber
Peptamen Junior with Prebio 35-250 ml containers Peptamen Junior with Prebio 59-250 ml containers Peptamen Junior with Prebio 107-250 ml containers Peptamen Junior with Prebio
Peptamen Junior 1.5

FP-182


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-17 (cont'd)

CPA FPC Z01 Z02 Z03 Z04
X20
R04 R04 R04
S04 X04
R05 R05 R05
S05
R06 R06 R06
S06
Z19 Z20 Z21 Z22
R14 R14 R14
R14

Status / Age Child Child Child Child
Child
FFF 0-2 m FFF 3-5 m FFF 6-11 m
FFF 6-11 m Child
FFF 0-2 m

System FPC Z01 Z02 Z03 Z04
X20
R04 S04 T04
S04 X04
R05

Formula
30-250 ml containers Peptamen Junior 1.5 60-250 ml containers Peptamen Junior 1.5 90-250 ml containers Peptamen Junior 1.5 107-250 ml containers Peptamen Junior 1.5
Portagen Powder 13-1 lb cans powder Portagen
Pregestimil Powder 7-16 oz cans powder Pregestimil 8-16 oz cans powder Pregestimil 6-16 oz cans powder Pregestimil 32 jars baby fruit/vegetable 3-8 oz box infant cereal 8-16 oz cans powder Pregestimil 8-16 oz cans powder Pregestimil
Pregestimil LIPIL 20 cal RTF 414- 2 oz containers ready to feed Pregestimil LIPIL 20 Calorie

FFF 3-5 m FFF 6-11 m
FFF 6-11 m
FFF 0-2 m FFF 3-5 m FFF 6-11 m
FFF 6-11 m
Child Child Child Child
FFF 0-3 m FFF 4-5 m FFF 6 m
FFF 7-11 m

S05 444-2 oz containers ready to feed Pregestimil LIPIL 20 Calorie
T05 318- 2 oz containers ready to feed Pregestimil LIPIL 20 Calorie 32 jars baby fruit/vegetable 3-8 oz box infant cereal
S05 444- 2 oz containers ready to feed Pregestimil LIPIL 20 Calorie
Pregestimil LIPIL 24 cal RTF R06 414- 2 oz containers ready to feed Pregestimil LIPIL 24 Calorie
S06 444-2 oz containers ready to feed Pregestimil LIPIL 24 Calorie
T06 318- 2 oz containers ready to feed Pregestimil LIPIL 24 Calorie 32 jars baby fruit/vegetable 3-8 oz box infant cereal
S06 444- 2 oz containers ready to feed Pregestimil LIPIL 24 Calorie
Resource Breeze
Z19 30-8 oz containers ready to feed Resource Breeze
Z20 60-8 oz containers ready to feed Resource Breeze
Z21 90-8 oz containers ready to feed Resource Breeze
Z22 113-8 oz containers ready to feed Resource Breeze
Similac PM 60/40 Powder R14 8-14.1 oz cans powder Similac PM 60/40 S14 9-14.1 oz cans powder Similac PM 60/40 V14 7-14.1 oz cans powder Similac PM 60/40
32 jars baby fruit/vegetable 3-8 oz box infant cereal T14 6-14.1 oz cans powder Similac PM 60/40 32 jars baby fruit/vegetable 3-8 oz box infant cereal

FP-183


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-17 (cont'd)

CPA FPC S14 X14
R10 R10 R10
S10
R50 R50 R50
S50
R60 R60 R60
S60
Z14 Z15 Z16 Z18
Z10 Z11 Z12 Z13
Z23 Z24 Z25 Z26
099 197 199

Status / Age FFF 6-11 m
Child
FFF 0-3 m FFF 4-5 m FFF 6-11 m
FFF 6-11 m
FFF 0-3 m FFF 4-5 m FFF 6-11 m
FFF 6-11 m
FFF 0-3 m FFF 4-5 m FFF 6-11 m
FFF 6-11 m
Child Child Child Child
Child Child Child Child
Child Child Child Child
All All All

System FPC S14 X14
R10 S10 T10
S10
R50 S50 T50
S50
R60 S60 T60
S60
Z14 Z15 Z16 Z18
Z10 Z11 Z12 Z13
Z23 Z24 Z25 Z26
099 197 199

Formula
9-14.1 oz cans powder Similac PM 60/40 8-14.1 oz cans powder Similac PM 60/40
Similac Special Care 20 2 oz RTF 416-2 oz cans RTF Similac Special Care 20 448-2 oz cans RTF Similac Special Care 20 320-2 oz cans RTF Similac Special Care 20 32 jars baby fruit/vegetable 3-8 oz box infant cereal
448-2 oz cans RTF Similac Special Care 20 Similac Special Care 24 2 oz RTF
416-2 oz cans RTF Similac Special Care 24 448-2 oz cans RTF Similac Special Care 24 320-2 oz cans RTF Similac Special Care 24 32 jars baby fruit/vegetable 3-8 oz box infant cereal 448-2 oz cans RTF Similac Special Care 24
Similac Special Care 30 2 oz RTF 416-2 oz cans RTF Similac Special Care 30 448-2 oz cans RTF Similac Special Care 30 320-2 oz cans RTF Similac Special Care 30 32 jars baby fruit/vegetable 3-8 oz box infant cereal 448-2 oz cans RTF Similac Special Care 30
Suplena 30-8 oz containers ready to feed Suplena
60-8 oz containers ready to feed Suplena
90-8 oz containers ready to feed Suplena
113-8 oz containers ready to feed Suplena
Vital jr or Pediasure Peptide 1.0 Cal 30-8 oz containers ready to feed Vital jr. or Pediasure Peptide 1.0 Cal
60-8 oz containers ready to feed Vital jr or Pediasure Peptide 1.0 Cal 90-8 oz containers ready to feed Vital jr or Pediasure Peptide 1.0 Cal 113-8 oz containers ready to feed Vital jr or Pediasure Peptide 1.0 Cal
Vivonex Pediatric 30-1.7 oz packets powder Vivonex Pediatric
60-1.7 oz packets powder Vivonex Pediatric
90-1.7 oz packets powder Vivonex Pediatric
102-1.7 oz packets powder Vivonex Pediatric
Tracking Vouchers Emory Genetics tracking voucher Formula Provided from stock on hand Formula ordered from office of Nutrition

FP-184


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-18

Special Formulas for Fully Formula Fed Infants

Similac Expert Care Alimentum

Food Package Code

Rank VC

R01

4 360

7-16 oz cans powder

Similac Expert Care

2 S01

Alimentum

Voucher Message Formula 4-16 oz cans powder Similac Expert
Care Alimentum Formula 3-16 oz cans powder Similac Expert
Care Alimentum

Medical Documentation Required S01 (Assign R01) 8-16 oz cans powder Similac Expert Care Alimentum

2 360 Formula 4-16 oz cans powder Similac Expert Care Alimentum
4 360 Formula 4-16 oz cans powder Similac Expert Care Alimentum

Medical Documentation Required
T01 (Assign R01) 6-16 oz cans powder Similac Expert Care Alimentum
32-4 oz infant food
3-8 oz infant cereal
Medical Documentation Required
R03 26-32 oz containers ready to feed Similac Expert Care Alimentum

2 S01 Formula 3-16 oz cans powder Similac Expert

Care Alimentum

4 S01 Formula 3-16 oz cans powder Similac Expert

Care Alimentum

2 N26 Infant

16-4 oz OR 9-7 oz (twin pack)

foods:

containers baby food fruit and/or

vegetable (Stage 2, Stage 2 1/2 or 2nd

foods)

4 N01 Infant

16-4 oz OR 9-7 oz (twin pack)

foods:

containers baby food fruit and/or

vegetable (Stage 2, Stage 2 1/2 or 2nd

Infant

foods)

cereal:

3-8 oz containers

2 130 Formula 13-32 oz containers ready to feed

Similac Expert Care Alimentum

4 130 Formula 13-32 oz containers ready to feed

Similac Expert Care Alimentum

Medical Documentation Required

FP-185


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-18 (cont'd)

Food Package Code

Rank VC

S03 (Assign R03)

2 150

28-32 oz containers ready

to feed Similac Expert Care 4 150

Alimentum

Voucher Message Formula 14-32 oz containers ready to feed
Similac Expert Care Alimentum Formula 14-32 oz containers ready to feed
Similac Expert Care Alimentum

Medical Documentation Required

T03 (Assign R03)

2 N05 Formula 10-32 oz containers ready to feed

20-32 oz containers ready

Similac Expert Care Alimentum

to feed Similac Expert Care 4 N05 Formula 10-32 oz containers ready to feed

Alimentum

Similac Expert Care Alimentum

2 N26 Infant

16-4 oz OR 9-7 oz (twin pack)

32-4 oz infant food

foods:

containers baby food fruit and/or

vegetable (Stage 2, Stage 2 1/2 or 2nd

3-8 oz infant cereal

foods)

Medical Documentation Required

4 N01 Infant foods:

16-4 oz OR 9-7 oz (twin pack) containers baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd

Infant

foods)

cereal:

3-8 oz containers

FP-186


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-18 (cont'd)

EleCare for Infants Food Package Code R41 9-14.1 oz cans powder EleCare for Infants
Medical Documentation Required S41 (Assign R41) 10-14.1 oz cans powder EleCare for Infants
Medical Documentation Required T41 (Assign R41) 7-14.1 oz cans powder EleCare for Infants
32-4 oz infant food
3-8 oz infant cereal
Medical Documentation Required

Rank VC 4 S33
2 S34

Voucher Message Formula 6-14.1 oz cans powder EleCare DHA
and ARA or EleCare for Infants (1 case)
Formula 3-14.1 oz cans powder EleCare with DHA and ARA or EleCare for Infants

4 S33 Formula 6-14.1 oz cans powder EleCare with DHA and ARA or EleCare for Infants (1 case)
2 S35 Formula 4-14.1 oz cans powder EleCare with DHA and ARA or EleCare for Infants

4 S33 Formula 6-14.1 oz cans powder EleCare with

DHA and ARA or EleCare for Infants (1

case)

2 S36 Formula 1-14.1 oz can powder EleCare with

DHA and ARA or EleCare for Infants

2 N26 Infant

16-4 oz OR 9-7 oz (twin pack)

foods:

containers baby food fruit and/or

vegetable (Stage 2, Stage 2 1/2 or 2nd

foods)

4 N01 Infant

16-4 oz OR 9-7 oz (twin pack)

foods:

containers baby food fruit and/or

vegetable (Stage 2, Stage 2 1/2 or 2nd

Infant

foods)

cereal:

3-8 oz containers

FP-187


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-18 (cont'd)

Enfamil EnfaCare Food Package Code R24 10-12.8 oz cans powder Enfamil EnfaCare
Medical Documentation Required S24 (Assign R24) 11-12.8 oz cans powder Enfamil EnfaCare
Medical Documentation Required
T24 (Assign R24) 8-12.1 oz cans powder Enfamil EnfaCare LIPIL or Enfamil EnfaCare
32-4 oz infant food
3-8 oz infant cereal
Medical Documentation Required
R26 26-32 oz containers ready to feed Enfamil EnfaCare
Medical Documentation Required
S26 (Assign R26) 28-32 oz containers ready to feed Enfamil EnfaCare
Medical Documentation Required

Rank VC 4 541 2 542
4 541 2 S11
2 542 4 542 2 N26
4 N01
2 543 2 543 4 543 4 543 4 S13 2 543 2 543 4 543 4 543 2 S12

Voucher Message Formula 6-12.8 oz cans powder Enfamil
EnfaCare Formula 4-12.8 oz cans powder Enfamil
EnfaCare

Formula Formula

6-12.8 oz cans powder Enfamil EnfaCare 5-12.8 oz cans powder Enfamil EnfaCare

Formula Formula Infant foods:
Infant foods: Infant cereal: Formula Formula Formula Formula Formula Formula Formula Formula Formula Formula

4-12.8 oz cans powder Enfamil EnfaCare 4-12.8 oz cans powder Enfamil EnfaCare 16-4 oz OR 9-7 oz (twin pack) containers baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods) 16-4 oz OR 9-7 oz (twin pack) containers baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods)
3-8 oz containers 6-32 oz containers ready to feed Enfamil EnfaCare (1 case) 6-32 oz containers ready to feed Enfamil EnfaCare (1 case) 6-32 oz containers ready to feed Enfamil EnfaCare (1 case) 6-32 oz containers ready to feed Enfamil EnfaCare (1 case) 2-32 oz containers ready to feed Enfamil EnfaCare 6-32 oz containers ready to feed Enfamil EnfaCare (1 case) 6-32 oz containers ready to feed Enfamil EnfaCare (1 case) 6-32 oz containers ready to feed Enfamil EnfaCare (1 case) 6-32 oz containers ready to feed Enfamil EnfaCare (1 case) 4-32 oz containers ready to feed Enfamil EnfaCare

FP-188


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-18 (cont'd)

Food Package Code

Rank VC Voucher Message

T26 (Assign R26) 20-32 oz containers ready to feed Enfamil EnfaCare 32-4 oz infant food
3-8 oz infant cereal
Medical Documentation Required

2 543 Formula 6-32 oz containers ready to feed

Enfamil EnfaCare (1 case)

4 543 Formula 6-32 oz containers ready to feed

Enfamil EnfaCare (1 case)

4 543 Formula 6-32 oz containers ready to feed

Enfamil EnfaCare (1 case)

2 S13 Formula 2-32 oz containers ready to feed

Enfamil EnfaCare

2 N26 Infant

16-4 oz OR 9-7 oz (twin pack)

foods:

containers baby food fruit and/or

vegetable (Stage 2, Stage 2 1/2 or 2nd

foods)

4 N01 Infant

16-4 oz OR 9-7 oz (twin pack)

foods:

containers baby food fruit and/or

vegetable (Stage 2, Stage 2 1/2 or 2nd

Infant

foods)

cereal:

3-8 oz containers

FP-189


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-18 (cont'd)

Food Package Code R20 414-2 oz containers ready to feed Enfamil EnfaCare Medical Documentation Required
S20 (Assign R20) 444-2 oz containers ready to feed Enfamil EnfaCare Medical Documentation Required
T20 (Assign R20) 318-2 oz containers ready to feed Enfamil EnfaCare 32-4 oz infant food 3-8 oz infant cereal Medical Documentation Required

Rank VC 2 589 2 589 4 589 4 589 4 540 2 S20 2 589 2 589 4 589 4 589 4 539 2 S20 2 589 4 589 4 589 2 540 2 S20 2 N26
4 N01

Voucher Message

Formula 96-2 oz containers ready to feed

Enfamil EnfaCare (2 cases)

Formula 96-2 oz containers ready to feed

Enfamil EnfaCare (2 cases)

Formula 96-2 oz containers ready to feed

Enfamil EnfaCare (2 cases)

Formula 96-2 oz containers ready to feed

Enfamil EnfaCare (1 case)

Formula 18-2 oz containers ready to feed

Enfamil EnfaCare

Formula 12-2 oz containers ready to feed

Enfamil EnfaCare

Formula 96-2 oz containers ready to feed

Enfamil EnfaCare (2 cases)

Formula 96-2 oz containers ready to feed

Enfamil EnfaCare (2 cases)

Formula 96-2 oz containers ready to feed

Enfamil EnfaCare (2 cases)

Formula 96-2 oz containers ready to feed

Enfamil EnfaCare (2 case)

Formula 48-2 oz containers ready to feed

Enfamil EnfaCare (1 case)

Formula 12-2 oz containers ready to feed

Enfamil EnfaCare

Formula 96-2 oz containers ready to feed

Enfamil EnfaCare (2 cases)

Formula 96-2 oz containers ready to feed

Enfamil EnfaCare (2 cases)

Formula 96-2 oz containers ready to feed

Enfamil EnfaCare (2 cases)

Formula 18-2 oz containers ready to feed

Enfamil EnfaCare

Formula 12-2 oz containers ready to feed

Enfamil EnfaCare

Infant

16-4 oz OR 9-7 oz (twin pack)

foods:

containers baby food fruit and/or

vegetable (Stage 2, Stage 2 1/2 or 2nd

foods)

Infant

16-4 oz OR 9-7 oz (twin pack)

foods:

containers baby food fruit and/or

vegetable (Stage 2, Stage 2 1/2 or 2nd

Infant

foods)

cereal:

3-8 oz containers

FP-190


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-18 (cont'd)

Enfamil Premature LIPIL 20

Food Package Code

Rank VC

R30

2 595

414-2 oz containers ready

to feed iron fortified

Enfamil Premature LIPIL

2 595

20

Medical Documentation Required

4 595

4 595

S30 (Assign R30) 444-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 20
Medical Documentation Required

4 546 2 S21 2 595 2 595 4 595 4 595

4 545

2 S21

Voucher Message Formula 96-2 oz containers ready to feed iron
fortified Enfamil Premature LIPIL 20 (2 cases) Formula 96-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 20 2 cases) Formula 96-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 20 (2 cases) Formula 96-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL20 (2 cases) Formula 18-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 20 Formula 12-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 20 Formula 96-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 20 (2 cases) Formula 96-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 20 (2 cases) Formula 96-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 20 (2 cases) Formula 96-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL20 (2 cases) Formula 48-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 20 (1 case) Formula 12-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 20

FP-191


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-18 (cont'd)

Food Package Code T30 (Assign R30) 318-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 20
32-4 oz infant food
3-8 oz infant cereal
Medical Documentation Required

Rank VC 2 595 4 595 4 595 2 546 2 S21

Voucher Message Formula 96-2 oz containers ready to feed iron
fortified Enfamil Premature LIPIL 20 (2 cases) Formula 96-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 20 (2 cases) Formula 96-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 20 (2 cases) Formula 18-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 20

Formula

12-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 20

2 N26 Infant foods:
4 N01 Infant foods:
Infant cereal:

16-4 oz OR 9-7 oz (twin pack) containers baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods) 16-4 oz OR 9-7 oz (twin pack) containers baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods)
3-8 oz containers

FP-192


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-18 (cont'd)

Enfamil Premature 24

Food Package Code

Rank VC

R40

2 597

414-2 oz containers ready

to feed iron fortified

Enfamil Premature LIPIL

2 597

24

Medical Documentation Required

4 597

4 597

S40 (Assign R40) 444-2 oz containers ready to feed Enfamil Premature LIPIL 24

2 548 4 S22 2 597
1 597

Medical Documentation Required

4 597 4 597

4 547

2 S22

Voucher Message Formula 96-2 oz containers ready to feed iron
fortified Enfamil Premature LIPIL 24 (2 case) Formula 96-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 24 (2 cases) Formula 96-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 24
(2 cases) Formula 96-2 oz containers ready to feed iron
fortified Enfamil Premature LIPIL 24 (2 cases) Formula 18-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 24 Formula 12-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 24 Formula 96-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 24 (2 cases) Formula 96-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 24 (2 cases) Formula 96-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 24 (2 cases) Formula 96-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 24 (2 cases) Formula 48-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 24 (1 case) Formula 12-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 24

FP-193


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-18 (cont'd)

Food Package Code T40 (Assign R40) 318-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 24
32-4 oz infant food
3-8 oz infant cereal
Medical Documentation Required

Rank VC 2 597 4 597
4 597 2 S22 2 548 2 N26
4 N01

Voucher Message Formula 96-2 oz containers ready to feed iron
fortified Enfamil Premature LIPIL 24 (2 cases) Formula 96-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 24 (2 cases)

Formula
Formula Formula Infant foods:
Infant foods: Infant cereal:

96-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 24 (2 cases) 12-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 24 18-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 24 16-4 oz OR 9-7 oz (twin pack) containers baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods) 16-4 oz OR 9-7 oz (twin pack) containers baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods)
3-8 oz containers

FP-194


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-18 (cont'd)

Enfaport LIPIL Food Package Code R12
102-8 oz cans ready to feed Enfaport LIPIL

Rank 2
4

Medical Documentation

4

Required

4

S12 (Assign R12)

4

112-8 oz cans ready to

feed Enfaport LIPIL

2

Medical Documentation

Required

2

4

2

T12 (Assign R12)

4

78-8 oz cans ready to feed

Enfaport LIPIL

2

32-4 oz infant food

2

3-8 oz boxes infant cereal 2

Medical Documentation Required

4

VC N90 N91 N91 N93 N90 N91 N91 N92 N96 N90 N91 N93 N26
N01

Voucher Message Formula 48-8 oz cans ready to feed Enfaport
LIPIL (2 cases)

Formula

24-8 oz cans ready to feed Enfaport LIPIL (1 case)

Formula

24-8 oz cans ready to feed Enfaport LIPIL (1 case)

Formula

6-8 oz cans ready to feed Enfaport LIPIL (one 6-pack)

Formula

48-8 oz cans ready to feed Enfaport LIPIL (2 cases)

Formula

24-8 oz cans ready to feed Enfaport LIPIL (1 case)

Formula

24-8 oz cans ready to feed Enfaport LIPIL (1 case)

Formula

12-8 oz cans ready to feed Enfaport LIPIL (two 6-packs)

Formula

4-8 oz cans ready to feed Enfaport LIPIL

Formula
Formula
Formula
Infant foods:
Infant foods: Infant cereal:

48-8 oz cans ready to feed Enfaport LIPIL (2 cases)
24-8 oz cans ready to feed Enfaport LIPIL (1 case)
6-8 oz cans ready to feed Enfaport LIPIL (one 6-pack) 16-4 oz OR 9-7 oz (twin pack) containers baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods) 16-4 oz OR 9-7 oz (twin pack) containers baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods)
3-8 oz containers

FP-195


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-18 (cont'd)

Gerber Good Start Premature 24

Food Package Code

Rank

R02

2

272 - 3 oz containers

ready to feed Gerber

4

Good Start Premature 24

4 Medical Documentation Required
2

S02 (Assign R01)

2

296 - 3 oz containers

ready to feed Gerber

4

Good Start Premature 24

4 Medical Documentation Required
2

4

T02 (Assign R01)

4

208 - 3 oz containers

ready to feed Gerber

2

Good Start Premature 24

2 32-4 oz infant food 3-8 oz boxes infant cereal
4

Medical Documentation

Required

4

VC S38 S38 S39 S40 S38 S38 S39 S39 S41 S38 S39 S39 S42 N01
N26

Voucher Message

Formula Formula Formula Formula

96-3 oz containers ready to feed Gerber Good Start Premature 24 (2 cases)
96-3 oz containers ready to feed Gerber Good Start Premature 24 (2 cases)
48-3 oz containers ready to feed Gerber Good Start Premature 24 (1 case)
32-3 oz containers ready to feed Gerber Good Start Premature 24 (four 8-packs)

Formula Formula Formula Formula Formula Formula Formula Formula

96-3 oz containers ready to feed Gerber Good Start Premature 24 (2 cases)
96-3 oz containers ready to feed Gerber Good Start Premature 24 (2 cases)
48-3 oz containers ready to feed Gerber Good Start Premature 24 (1 case)
48-3 oz containers ready to feed Gerber Good Start Premature 24 (1 case)
8-3 oz containers ready to feed Gerber Good Start Premature 24 (one 8-pack)
96-3 oz containers ready to feed Gerber Good Start Premature 24 (2 cases)
48-3 oz containers ready to feed Gerber Good Start Premature 24 (1 case)
48-3 oz containers ready to feed Gerber Good Start Premature 24 (1 case)

Formula

16-3 oz containers ready to feed Gerber Good Start Premature 24 (two 8-packs)

Infant foods:
Infant cereal:
Infant foods:

16-4 oz OR 9-7 oz (twin pack) containers baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods)
3-8 oz containers 16-4 oz OR 9-7 oz (twin pack) containers baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods)

FP-196


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-18 (cont'd)

Neocate Infant Food Package Code R51 10-400 gram (14.1 oz) cans powder Neocate Infant
Medical Documentation Required
S51 (Assign R51) 11-400 gram (14.1 oz) cans powder Neocate Infant
Medical Documentation Required
T51 (Assign R51) 8-400 gram (14.1 oz) cans powder Neocate Infant
32-4 oz infant food
3-8 oz infant cereal
Medical Documentation Required

Rank VC 2 506 4 506 2 507 4 507 2 506 4 506 2 507 4 507 4 507 2 506 4 506 2 N26
4 N01

Voucher Message

Formula 4-400 gram (14.1 oz) cans powder Neocate

Infant

Formula 4-400 gram (14.1 oz) cans powder Neocate

Infant

Formula 1-400 gram (14.1 oz) can powder Neocate

Infant

Formula 1-400 gram (14.1 oz) can powder Neocate

Infant

Formula 4-400 gram (14.1 oz) cans powder Neocate

Infant

Formula 4-400 gram (14.1 oz) cans powder Neocate

Infant

Formula 1-400 gram (14.1 oz) can powder Neocate

Infant

Formula 1-400 gram (14.1 oz) can powder Neocate

Infant

Formula 1-400 gram (14.1 oz) can powder Neocate

Infant

Formula 4-400 gram (14.1 oz) cans powder Neocate

Infant

Formula 4-400 gram (14.1 oz) cans powder Neocate

Infant

Infant

16-4 oz OR 9-7 oz (twin pack) containers

foods:

baby food fruit and/or vegetable (Stage 2,

Stage 2 1/2 or 2nd foods)

Infant

16-4 oz OR 9-7 oz (twin pack) containers

foods:

baby food fruit and/or vegetable (Stage 2,

Stage 2 1/2 or 2nd foods)

Infant

cereal:

3-8 oz containers

FP-197


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-18 (cont'd)

Neocate Infant DHA & ARA

Food Package Code

Rank VC

R61

2 500

10-400 gram (14.1 oz)

cans powder Neocate

4 500

Infant DHA & ARA

2 505

Medical Documentation

Required

4 505

S61 (Assign R61)

2 500

11-400 gram (14.1 oz) cans powder Neocate Infant DHA & ARA

4 500 2 505

Medical Documentation Required

4 505 4 505

T61 (Assign R61) 8-400 gram (14.1 oz) cans powder Neocate Infant DHA & ARA
32-4 oz infant food

2 500 4 500 2 N26

3-8 oz infant cereal
Medical Documentation Required

4 N01

Voucher Message

Formula 4-400 gram (14.1 oz) cans powder

Neocate Infant DHA & ARA

Formula 4-400 gram (14.1 oz) cans powder

Neocate Infant DHA & ARA

Formula 1-400 gram (14.1 oz) can powder

Neocate Infant DHA & ARA

Formula 1-400 gram (14.1 oz) can powder

Neocate Infant DHA & ARA

Formula 4-400 gram (14.1 oz) cans powder

Neocate Infant DHA & ARA

Formula 4-400 gram (14.1 oz) cans powder

Neocate Infant DHA & ARA

Formula 1-400 gram (14.1 oz) can powder

Neocate Infant DHA & ARA

Formula 1-400 gram (14.1 oz) can powder

Neocate Infant DHA & ARA

Formula 1-400 gram (14.1 oz) can powder

Neocate Infant DHA & ARA

Formula 4-400 gram (14.1 oz) cans powder

Neocate Infant DHA & ARA

Formula 4-400 gram (14.1 oz) cans powder

Neocate Infant DHA & ARA

Infant

16-4 oz OR 9-7 oz (twin pack)

foods:

containers baby food fruit and/or

vegetable (Stage 2, Stage 2 1/2 or 2nd

foods)

Infant

16-4 oz OR 9-7 oz (twin pack)

foods:

containers baby food fruit and/or

vegetable (Stage 2, Stage 2 1/2 or 2nd

Infant

foods)

cereal:

3-8 oz containers

FP-198


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-18 (cont'd)

Similac NeoSure or Similac Expert Care Neosure

Food Package Code

Rank VC Voucher Message

R71

4 519 Formula 6-12.8 oz cans powder Similac

10-12.8 oz cans powder

NeoSure OR 6-13.1 oz cans Similac

Similac NeoSure or 10-

Expert Care NeoSure (1 case)

13.1 oz Similac Expert

2 520 Formula 4-12.8 oz cans powder Similac

Care Neosure

NeoSure OR 4-13.1 oz cans Similac

Expert Care NeoSure

Medical Documentation

Required

S71 (Assign R71)

4 519 Formula 6-12.8 oz cans powder Similac

11-12.8 oz cans powder

NeoSure OR 6-13.1 oz cans Similac

Similac NeoSure or 11-

Expert Care NeoSure (1 case)

13.1 oz Similac Expert

2 S25 Formula 5-12.8 oz cans powder Similac

Care Neosure

NeoSure OR 5-13.1 oz cans Similac

Expert Care NeoSure

Medical Documentation

Required

T71 (Assign R71)

2 520 Formula 4-12.8 oz cans powder Similac

8-12.8 oz cans powder

NeoSure OR 4-13.1 oz cans Similac

Similac NeoSure or 8-13.1

Expert Care NeoSure

oz Similac Expert Care

4 520 Formula 4-12.8 oz cans powder Similac

Neosure

NeoSure OR 4-13.1 oz cans Similac

Expert Care NeoSure

32-4 oz infant food

2 N26 Infant

16-4 oz OR 9-7 oz (twin pack)

foods:

containers baby food fruit and/or

3-8 oz infant cereal

vegetable (Stage 2, Stage 2 1/2 or 2nd

foods)

Medical Documentation

4 N01 Infant

16-4 oz OR 9-7 oz (twin pack)

Required

foods:

containers baby food fruit and/or

vegetable (Stage 2, Stage 2 1/2 or 2nd

Infant

foods)

cereal:

3-8 oz containers

FP-199


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-18 (cont'd)

Food Package Code

Rank VC

R73

2 517

26-32 oz containers ready

to feed Similac NeoSure or

Similac Expert Care

2 517

NeoSure

Medical Documentation Required

4 517

4 517

4 S10

S73 (Assign R73)

2 517

28-32 oz containers ready

to feed Similac NeoSure or

Similac Expert Care

NeoSure

4 517

Medical Documentation Required

4 517

2 517

2 S09

Voucher Message Formula 6-32 oz containers ready to feed
Similac NeoSure OR Similac Expert Care NeoSure (1 case) Formula 6-32 oz containers ready to feed Similac NeoSure or Similac Expert Care NeoSure (1 case) Formula 6-32 oz containers ready to feed Similac NeoSure or Similac Expert Care NeoSure (1 case) Formula 6-32 oz containers ready to feed Similac NeoSure or Similac Expert Care NeoSure (1 case) Formula 2-32 oz containers ready to feed Similac NeoSure or Similac Expert Care NeoSure Formula 6-32 oz containers ready to feed Similac NeoSure or Similac Expert Care NeoSure (1 case) Formula 6-32 oz containers ready to feed Similac NeoSure or Similac Expert Care NeoSure (1 case) Formula 6-32 oz containers ready to feed Similac NeoSure or Similac Expert Care NeoSure (1 case) Formula 6-32 oz containers ready to feed Similac NeoSure or Similac Expert Care NeoSure (1 case) Formula 4-32 oz containers ready to feed Similac NeoSure or Similac Expert Care NeoSure

FP-200


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-18 (cont'd)

Food Package Code

Rank VC

T73 (Assign R73)

2 517

20-32 oz containers ready

to feed Similac NeoSure or

Similac Expert Care

NeoSure

4 517

32-4 oz infant food

3-8 oz infant cereal
Medical Documentation Required

4 517

2 S10

2 N26

4 N01

Voucher Message

Formula 6-32 oz containers ready to feed

Similac NeoSure or Similac Expert Care

NeoSure

(1 case)

Formula 6-32 oz containers ready to feed

Similac NeoSure or Similac Expert Care

NeoSure

(1 case)

Formula 6-32 oz containers ready to feed

Similac NeoSure or Similac Expert Care

NeoSure

(1 case)

Formula 2-32 oz containers ready to feed

Similac NeoSure or Similac Expert Care

NeoSure

Infant

16-4 oz OR 9-7 oz (twin pack)

foods:

containers baby food fruit and/or

vegetable (Stage 2, Stage 2 1/2 or 2nd

foods)

Infant

16-4 oz OR 9-7 oz (twin pack)

foods:

containers baby food fruit and/or

Infant

vegetable (Stage 2, Stage 2 1/2 or 2nd

cereal:

foods)

3-8 oz containers

R70

2 596 Formula 96-2 oz containers ready to feed

416-2 oz containers ready

Similac NeoSure or Similac Expert Care

to feed Similac NeoSure or

NeoSure (2 cases)

Similac Expert Care

2 596 Formula 96-2 oz containers ready to feed

NeoSure

Similac NeoSure or Similac Expert Care

NeoSure (2 cases)

Medical Documentation

4 596 Formula 96-2 oz containers ready to feed

Required

Similac NeoSure or Similac Expert Care

NeoSure (2 cases)

4 596 Formula 96-2 oz containers ready to feed

Similac NeoSure or Similac Expert Care

NeoSure (2 cases)

2 516 Formula 16-2 oz containers ready to feed

Similac NeoSure or Similac Expert Care

NeoSure

4 516 Formula 16-2 oz containers ready to feed

Similac NeoSure or Similac Expert Care

NeoSure

FP-201


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-18 (cont'd)

Food Package Code

Rank VC

S70 (Assign R70)

2 596

448-2 oz containers ready

to feed Similac NeoSure or

Similac Expert Care

2 596

NeoSure

Medical Documentation Required

4 596

4 596

4 515

2 516

T70 (Assign R70)

2 596

320-2 oz containers ready

to feed Similac NeoSure or

Similac Expert Care

4 596

NeoSure

32-4 oz infant food

4 596

3-8 oz infant cereal
Medical Documentation Required

2 516 2 516

2 N26

2 N01

Voucher Message

Formula 96-2 oz containers ready to feed

Similac NeoSure or Similac Expert Care

NeoSure (2 cases)

Formula 96-2 oz containers ready to feed

Similac NeoSure or Similac Expert Care

NeoSure (2 cases)

Formula 96-2 oz containers ready to feed

Similac NeoSure or Similac Expert Care

NeoSure (2 cases)

Formula 96-2 oz containers ready to feed

Similac NeoSure or Similac Expert

Care NeoSure (2 cases)

Formula 48-2 oz containers ready to feed

Similac NeoSure or Similac Expert Care

NeoSure (1 case)

Formula 16-2 oz containers ready to feed

Similac NeoSure or Similac Expert Care

NeoSure

Formula 96-2 oz containers ready to feed

Similac NeoSure or Similac Expert Care

NeoSure (2 cases)

Formula 96-2 oz containers ready to feed

Similac NeoSure or Similac Expert Care

NeoSure (2 cases)

Formula 96-2 oz containers ready to feed

Similac NeoSure or Similac Expert Care

NeoSure (2 cases)

Formula 16-2 oz containers ready to feed

Similac NeoSure or Similac Expert Care

NeoSure

Formula 16-2 oz containers ready to feed

Similac NeoSure or Similac Expert

Care NeoSure

Infant

16-4 oz OR 9-7 oz (twin pack)

foods:

containers baby food fruit and/or

vegetable (Stage 2, Stage 2 1/2 or 2nd

foods)

Infant

16-4 oz OR 9-7 oz (twin pack)

foods:

containers baby food fruit and/or

vegetable (Stage 2, Stage 2 1/2 or 2nd

foods)

Infant

cereal:

3-8 oz containers

FP-202


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-18 (cont'd)

Nutramigen LIPIL Food Package Code R82 31-13 oz cans concentrate Nutramigen LIPIL
Medical Documentation Required S82 (Assign R82) 34-13 oz cans concentrate Nutramigen LIPIL
Medical Documentation Required T82 (Assign R82) 24-13 oz cans concentrate Nutramigen LIPIL
32-4 oz infant food
3-8 oz infant cereal
Medical Documentation Required
R81 1012.6 oz cans powder Nutramigen LIPIL with Enflora LGG

Rank VC 2 N08 4 N67
2 N08 4 N57
2 163 4 163 2 N26
4 N01
2 156 4 156

Voucher Message Formula 15-13 oz cans concentrate Nutramigen
LIPIL Formula 16-13 oz cans concentrate Nutramigen
LIPIL

Formula Formula

15-13 oz cans concentrate Nutramigen LIPIL 19-13 oz cans concentrate Nutramigen LIPIL

Formula Formula Infant foods:
Infant foods: Infant cereal: Formula Formula

12-13 oz cans concentrate Nutramigen LIPIL 12-13 oz cans concentrate Nutramigen LIPIL 16-4 oz OR 9-7 oz (twin pack) containers baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods) 16-4 oz OR 9-7 oz (twin pack) containers baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods)
3-8 oz containers 5-12.6 oz cans powder Nutramigen LIPIL with Enflora LGG 5-12.6 oz cans powder Nutramigen LIPIL with Enflora LGG

Medical Documentation Required S81 (Assign R81) 11-12.6 oz cans powder Nutramigen LIPIL with Enflora LGG

2 156 Formula 5-12.6 oz cans powder Nutramigen LIPIL with Enflora LGG
4 155 Formula 6-12.6 oz cans powder Nutramigen LIPIL with Enflora LGG

Medical Documentation Required

FP-203


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-18 (cont'd)

Food Package Code T81 (Assign R81) 8-12.6 oz cans powder Nutramigen LIPIL with Enflora LGG
32-4 oz infant food
3-8 oz infant cereal
Medical Documentation Required
R83 26-32 oz containers ready to feed Nutramigen LIPIL
Medical Documentation Required S83 (Assign R83) 28-32 oz containers ready to feed Nutramigen LIPIL
Medical Documentation Required T83 (Assign R83) 20-32 oz containers ready to feed Nutramigen LIPIL
32-4 oz infant food
3-8 oz infant cereal
Medical Documentation Required

Rank VC 4 156 2 S32 2 N26
4 N01
2 S30 4 S30
2 S03 4 S03
2 S29 4 S29 2 N26
4 N01

Voucher Message

Formula 5-12.6 oz cans powder Nutramigen

LIPIL with Enflora LGG

Formula 3-12.6 oz cans powder Nutramigen

LIPIL with Enflora LGG

Infant

16-4 oz OR 9-7 oz (twin pack)

foods:

containers baby food fruit and/or

vegetable (Stage 2, Stage 2 1/2 or 2nd

foods)

Infant

16-4 oz OR 9-7 oz (twin pack)

foods:

containers baby food fruit and/or

vegetable (Stage 2, Stage 2 1/2 or 2nd

Infant

foods)

cereal:

3-8 oz containers

Formula 13-32 oz containers ready to feed

Nutramigen LIPIL

Formula 13-32 oz containers ready to feed

Nutramigen LIPIL

Formula Formula

14-32 oz containers ready to feed Nutramigen LIPIL 14-32 oz containers ready to feed Nutramigen LIPIL

Formula
Formula
Infant foods:
Infant foods:
Infant cereal:

10-32 oz containers ready to feed Nutramigen LIPIL 10-32 oz containers ready to feed Nutramigen LIPIL 16-4 oz OR 9-7 oz (twin pack) containers baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods) 16-4 oz OR 9-7 oz (twin pack) containers baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods)
3-8 oz containers

FP-204


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-18 (cont'd)

Nutramigen AA LIPIL Food Package Code R91 8-14.1 oz cans powder Nutramigen AA LIPIL
Medical Documentation Required S91 (Assign R91) 9-14.1 oz cans powder Nutramigen AA LIPIL
Medical Documentation Required T91 (Assign R91) 7-14.1 oz cans powder Nutramigen AA LIPIL
32-4 oz infant food
3-8 oz infant cereal
Medical Documentation Required

Rank VC 2 706
4 706

Voucher Message Formula 4-400 gram (14.1 oz) cans powder
Nutramigen AA LIPIL Formula 4-400 gram (14.1 oz) cans powder
Nutramigen AA LIPIL

2 706 Formula 4-400 gram (14.1 oz) cans powder

Nutramigen AA LIPIL

4 706 Formula 4-400 gram (14.1 oz) cans powder

Nutramigen AA LIPIL

4 707 Formula 1-400 gram (14.1 oz) can powder

Nutramigen AA LIPIL

4 706 Formula 4-400 gram (14.1 oz) cans powder

Nutramigen AA LIPIL

2 S14 Formula 3-400 gram (14.1 oz) cans powder

Nutramigen AA LIPIL

2 N26 Infant

16-4 oz OR 9-7 oz (twin pack)

foods:

containers baby food fruit and/or

vegetable (Stage 2, Stage 2 1/2 or 2nd

foods)

4 N01 Infant

16-4 oz OR 9-7 oz (twin pack)

Foods:

containers baby food fruit and/or

vegetable (Stage 2, Stage 2 1/2 or 2nd

Infant

foods)

Cereal:

3-8 oz containers

FP-205


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-18 (cont'd)

Pregestimil Food Package Code R04 7-16 oz cans powder Pregestimil LIPIL
Medical Documentation Required S04 (Assign R04) 8-16 oz cans powder Pregestimil LIPIL
Medical Documentation Required T04 (Assign R04) 6-16 oz cans powder Pregestimil LIPIL
32-4 oz infant food
3-8 oz infant cereal
Medical Documentation Required

Rank VC Voucher Message 4 140 Formula 4-16 oz cans powder Pregestimil LIPIL 2 S08 Formula 3-16 oz cans powder Pregestimil LIPIL

2 140 Formula 4-16 oz cans powder Pregestimil LIPIL 4 140 Formula 4-16 oz cans powder Pregestimil LIPIL

2 S08 Formula 3-16 oz cans powder Pregestimil LIPIL

4 S08 Formula 3-16 oz cans powder Pregestimil LIPIL

2 N26 Infant foods:
4 N01 Infant foods:
Infant cereal:

16-4 oz OR 9-7 oz (twin pack) containers baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods) 16-4 oz OR 9-7 oz (twin pack) containers baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods)
3-8 oz containers

FP-206


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-18 (cont'd)

Pregestimil LIPIL 20 Calorie

Food Package Code

Rank

R05

2

414-2 oz containers ready to feed Pregestimil LIPIL

2

20 Calorie

4

Medical Documentation

Required

4

4

S05 (Assign R05)

2

444-2 oz containers ready

to feed Pregestimil LIPIL

2

20 Calorie

4

Medical Documentation

4

Required

4

2

T05 (Assign R05)

4

318-2 oz containers ready

to feed Pregestimil LIPIL

4

20 Calorie

2

32-4 oz infant food

2

3-8 oz boxes infant cereal

Medical Documentation

2

Required

4

VC S61 S61 S61 S61 S62
S61 S61 S61 S61 S63 S64
S61 S61 S61 S62 N26
N01

Voucher Message Formula 96-2 oz containers ready to feed
Pregestimil LIPIL 20 Calorie (2 cases)

Formula

96-2 oz containers ready to feed Pregestimil LIPIL 20 Calorie (2 cases)

Formula

96-2 oz containers ready to feed Pregestimil LIPIL 20 Calorie (2 cases)

Formula

96-2 oz containers ready to feed Pregestimil LIPIL 20 Calorie (2 cases)

Formula

30-2 oz containers ready to feed Pregestimil LIPIL 20 Calorie (five 6packs)

Formula

96-2 oz containers ready to feed Pregestimil LIPIL 20 Calorie (2 cases)

Formula

96-2 oz containers ready to feed Pregestimil LIPIL 20 Calorie (2 cases)

Formula

96-2 oz containers ready to feed Pregestimil LIPIL 20 Calorie (2 cases)

Formula

96-2 oz containers ready to feed Pregestimil LIPIL 20 Calorie (2 cases)

Formula

48-2 oz containers ready to feed Pregestimil LIPIL 20 Calorie (1 case)

Formula

12-2 oz containers ready to feed Pregestimil LIPIL 20 Calorie (two 6packs)

Formula Formula Formula Formula
Infant foods:
Infant foods: Infant cereal:

96-2 oz containers ready to feed Pregestimil LIPIL 20 Calorie (2 cases)
96-2 oz containers ready to feed Pregestimil LIPIL 20 Calorie (2 cases)
96-2 oz containers ready to feed Pregestimil LIPIL 20 Calorie (2 cases)
30-2 oz containers ready to feed Pregestimil LIPIL 20 Calorie (five 6packs) 16-4 oz OR 9-7 oz (twin pack) containers baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods) 16-4 oz OR 9-7 oz (twin pack) containers baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods)
3-8 oz containers

FP-207


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-18 (cont'd)

Pregestimil LIPIL 24 Calorie

Food Package Code

Rank

R06

2

414-2 oz containers ready to feed Pregestimil LIPIL

2

24 Calorie

4

Medical Documentation

Required

4

4

S06 (Assign R06)

2

444-2 oz containers ready

to feed Pregestimil LIPIL

2

24 Calorie

4

Medical Documentation

4

Required

4

2

T06 (Assign R06)

4

318-2 oz containers ready

to feed Pregestimil LIPIL

4

24 Calorie

2

32-4 oz infant food

2

3-8 oz boxes infant cereal 2

Medical Documentation Required

4

VC S65 S65 S65 S65 S66
S65 S65 S65 S65 S67 S68
S65 S65 S65 S66 N26
N01

Voucher Message Formula 96- oz containers ready to feed
Pregestimil LIPIL 24 Calorie (2 cases)

Formula

96-2 oz containers ready to feed Pregestimil LIPIL 24 Calorie (2 cases)

Formula

96-2 oz containers ready to feed Pregestimil LIPIL 24 Calorie (2 cases)

Formula

96-2 oz containers ready to feed Pregestimil LIPIL 24 Calorie (2 cases)

Formula

30-2 oz containers ready to feed Pregestimil LIPIL 24 Calorie (five 6packs)

Formula

96-2 oz containers ready to feed Pregestimil LIPIL 24 Calorie (2 cases)

Formula

96-2 oz containers ready to feed Pregestimil LIPIL 24 Calorie (2 cases)

Formula

96-2 oz containers ready to feed Pregestimil LIPIL 24 Calorie (2 cases)

Formula

96-2 oz containers ready to feed Pregestimil LIPIL 24 Calorie (2 cases)

Formula

48-2 oz containers ready to feed Pregestimil LIPIL 24 Calorie (1 case)

Formula

12-2 oz containers ready to feed Pregestimil LIPIL 24 Calorie (two 6packs)

Formula

96-2 oz containers ready to feed Pregestimil LIPIL 24 Calorie (2 cases)

Formula

96-2 oz containers ready to feed Pregestimil LIPIL 24 Calorie (2 cases)

Formula

96-2 oz containers ready to feed Pregestimil LIPIL 24 Calorie (2 cases)

Formula

96-2 oz containers ready to feed Pregestimil LIPIL 24 Calorie (2 cases)

Infant foods:
Infant foods:
Infant cereal:

16-4 oz OR 9-7 oz (twin pack) containers baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods) 16-4 oz OR 9-7 oz (twin pack) containers baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods)
3-8 oz containers

FP-208


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-18 (cont'd)

Similac PM 60/40 Food Package Code R14 8-14.1 oz cans powder Similac PM 60/40
Medical Documentation Required S14 (Assign R14) 9-14.1 oz cans powder Similac PM 60/40
Medical Documentation Required V14 (Assign R14) 7-14.1 oz cans powder Similac PM 60/40 (special package given at six months of age for one month)
32-4 oz jars infant fruit and vegetables
3-8 oz infant cereal
Medical Documentation Required T14 (assign R14) 6-14.1 oz cans powder Similac PM 60/40
32-4 oz infant food
3-8 oz infant cereal
Medical Documentation Required

Rank VC 2 529 4 529
4 527 2 528
4 529 2 528 4 N01
2 N26
2 528 4 528 2 N26
4 N01

Voucher Message Formula 4-14.1 oz cans powder Similac PM
60/40 Formula 4-14.1 oz cans powder Similac PM
60/40

Formula Formula

6-14.1 oz cans powder Similac PM 60/40
3-14.1 oz cans powder Similac PM 60/40

Formula Formula Infant foods:
Infant foods: Infant cereal: Formula Formula Infant foods:
Infant foods:
Infant cereal:

4-14.1 oz cans powder Similac PM 60/40 3-14.1 oz cans powder Similac PM 60/40 16-4 oz OR 9-7 oz (twin pack) containers baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods)
3-8 oz containers 16-4 oz OR 9-7 oz (twin pack) containers baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods) 3-14.1 oz cans powder Similac PM 60/40 3-14.1 oz cans powder Similac PM 60/40 16-4 oz OR 9-7 oz (twin pack) containers baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods) 16-4 oz OR 9-7 oz (twin pack) containers baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods)
3-8 oz containers

FP-209


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-18 (cont'd)

Similac Special Care 20 Food Package Code R10 416-2 oz containers ready to feed Similac Special Care 20 With Iron Medical Documentation Required
S10 (Assign R10) 448-2 oz containers ready to feed Similac Special Care 20 With Iron Medical Documentation Required

Rank VC 2 598 2 598 4 598 4 598 2 522 4 522 2 598 2 598 4 598 4 598 4 521 2 522

Voucher Message Formula 96-2 oz containers ready to feed
Similac Special Care 20 With Iron (2 cases) Formula 96-2 oz containers ready to feed Similac Special Care 20 With Iron (2 cases) Formula 96-2 oz containers ready to feed Similac Special Care 20 With Iron (2 cases) Formula 96-2 oz containers ready to feed Similac Special Care 20 With Iron (2 cases) Formula 16-2 oz containers ready to feed Similac Special Care 20 With Iron Formula 16-2 oz containers ready to feed Similac Special Care 20 With Iron Formula 96-2 oz containers ready to feed Similac Special Care 20 With Iron (2 cases) Formula 96-2 oz containers ready to feed Similac Special Care 20 With Iron (2 cases) Formula 96-2 oz containers ready to feed Similac Special Care 20 With Iron (2 cases) Formula 96-2 oz containers ready to feed Similac Special Care 20 With Iron (2 cases) Formula 48-2 oz containers ready to feed Similac Special Care 20 With Iron Formula 16-2 oz containers ready to feed Similac Special Care 20 With Iron

FP-210


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-18 (cont'd)

Food Package Code T10 (Assign R10) 320-2 oz containers ready to feed Similac Special Care 20 With Iron
32-4 oz infant food
3-8 oz infant cereal
Medical Documentation Required

Rank VC 2 598 4 598 4 598 2 522 4 522 2 N26
4 N01

Voucher Message

Formula 96-2 oz containers ready to feed

Similac Special Care 20 With Iron

(2 cases)

Formula 96-2 oz containers ready to feed

Similac Special Care 20 With Iron

(2 cases)

Formula 96-2 oz containers ready to feed

Similac Special Care 20 With Iron

(2 cases)

Formula 16-2 oz containers ready to feed

Similac Special Care 20 With Iron

Formula 16-2 oz containers ready to feed

Similac Special Care 20 With Iron

Infant

16-4 oz OR 9-7 oz (twin pack)

foods:

containers baby food fruit and/or

vegetable (Stage 2, Stage 2 1/2 or 2nd

foods)

Infant

16-4 oz OR 9-7 oz (twin pack)

foods:

containers baby food fruit and/or

vegetable (Stage 2, Stage 2 1/2 or 2nd

Infant

foods)

cereal:

3-8 oz containers

FP-211


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-18 (cont'd)

Similac Special Care 24 Food Package Code R50 416-2 oz containers ready to feed Similac Special Care 24 With Iron
Medical Documentation Required

Rank VC 2 594
2 594
4 594

4 594

S50 (Assign R50) 448- 2 oz containers ready to feed Similac Special Care 24 With Iron
Medical Documentation Required

2 524 4 524 2 594
2 594
2 594

4 594

4 523

2 524

Voucher Message Formula 96-2 oz containers ready to feed
Similac Special Care 24 With Iron (2 cases) Formula 96-2 oz containers ready to feed Similac Special Care 24 With Iron (2 cases) Formula 96-2 oz containers ready to feed Similac Special Care 24 With Iron (2 cases) Formula 96-2 oz containers ready to feed Similac Special Care 24 With Iron (2 cases) Formula 16-2 oz containers ready to feed Similac Special Care 24 With Iron Formula 16-2 oz containers ready to feed Similac Special Care 24 With Iron Formula 96-2 oz containers ready to feed Similac Special Care 24 With Iron (2 cases) Formula 96-2 oz containers ready to feed Similac Special Care 24 With Iron (2 cases) Formula 96-2 oz containers ready to feed Similac Special Care 24 With Iron (2 cases) Formula 96-2 oz containers ready to feed Similac Special Care 24 With Iron (2 cases) Formula 48-2 oz containers ready to feed Similac Special Care 24 With Iron (1 case) Formula 16-2 oz containers ready to feed Similac Special Care 24 With Iron

FP-212


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-18 (cont'd)

Food Package Code T50 (Assign R50) 320-2 oz containers ready to feed Similac Special Care 24 With Iron
32-4 oz infant food
3-8 oz infant cereal
Medical Documentation Required

Rank VC 2 594 4 594
4 594 2 524 2 524 2 N26
4 N01

Voucher Message Formula 96-2 oz containers ready to feed
Similac Special Care 24 With Iron (2 cases) Formula 96-2 oz containers ready to feed Similac Special Care 24 With Iron (2 cases)

Formula
Formula Formula Infant foods:
Infant foods: Infant cereal:

96-2 oz containers ready to feed Similac Special Care 24 With Iron (2 cases) 16-2 oz containers ready to feed Similac Special Care 24 With Iron 16-2 oz containers ready to feed Similac Special Care 24 With Iron 16-4 oz OR 9-7 oz (twin pack) containers baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods) 16-4 oz OR 9-7 oz (twin pack) containers baby food fruit and/or vegetable (Stage 2, Stage 2 1/2 or 2nd foods)
3-8 oz containers

FP-213


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-18 (cont'd)

Similac Special Care 30 Food Package Code R60 416-2 oz containers ready to feed Similac Special Care 30 With Iron Medical Documentation Required
S60 (Assign R60) 448-2 oz containers ready to feed Similac Special Care 30 With Iron Medical Documentation Required

Rank VC 2 585 2 585 4 585 4 585 2 526 4 526 2 585 2 585 4 585 4 585 4 525 2 526

Voucher Message Formula 96-2 oz containers ready to feed
Similac Special Care 30 With Iron (2 cases) Formula 96-2 oz containers ready to feed Similac Special Care 30 With Iron (2 cases) Formula 96-2 oz containers ready to feed Similac Special Care 30 With Iron (2 cases) Formula 96-2 oz containers ready to feed Similac Special Care 30 With Iron (2 cases) Formula 16-2 oz containers ready to feed Similac Special Care 30 With Iron Formula 16-2 oz containers ready to feed Similac Special Care 30 With Iron Formula 96-2 oz containers ready to feed Similac Special Care 30 With Iron (2 cases) Formula 96-2 oz containers ready to feed Similac Special Care 30 With Iron (2 cases) Formula 96-2 oz containers ready to feed Similac Special Care 30 With Iron (2 cases) Formula 96-2 oz containers ready to feed Similac Special Care 30 With Iron (2 cases) Formula 48-2 oz containers ready to feed Similac Special Care 30 With Iron (1 case) Formula 16-2 oz containers ready to feed Similac Special Care 30 With Iron

FP-214


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-18 (cont'd)

Food Package Code T60 (Assign) 320-2 oz containers ready to feed Similac Special Care 30 With Iron
32-4 oz infant food
3-8 oz infant cereal
Medical Documentation Required

Rank VC 2 585 4 585 4 585 2 526 2 526 2 N26
2 N01

Voucher Message

Formula 96-2 oz containers ready to feed

Similac Special Care 30 With Iron

(2 cases)

Formula 96-2 oz containers ready to feed

Similac Special Care 30 With Iron

(2 cases)

Formula 96-2 oz containers ready to feed

Similac Special Care 30 With Iron

(2 cases)

Formula 16-2 oz containers ready to feed

Similac Special Care 30 With Iron

Formula 16-2 oz containers ready to feed

Similac Special Care 30 With Iron

Infant

16-4 oz OR 9-7 oz (twin pack)

foods:

containers baby food fruit and/or

vegetable (Stage 2, Stage 2 1/2 or 2nd

foods)

Infant

16-4 oz OR 9-7 oz (twin pack)

foods:

containers baby food fruit and/or

Infant

vegetable (Stage 2, Stage 2 1/2 or 2nd

cereal:

foods)

3-8 oz containers

FP-215


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-19

Food Package III - Special Infant Formulas for Children

Similac Expert Care Alimentum

Food Package Code

Rank VC

X01

4 360

7-1 lb cans powder Similac

Expert Care Alimentum

2 S01

Medical Documentation Required X03 28-32 oz containers ready to feed Similac Expert Care Alimentum

2 150 4 150

Voucher Message Formula 4-1 lb cans powder Similac Expert Care
Alimentum Formula 3-1 lb cans powder Similac Expert Care
Alimentum

Formula Formula

14-32 oz containers ready to feed Similac Expert Care Alimentum 14-32 oz containers ready to feed Similac Expert Care Alimentum

Medical Documentation Required

FP-216


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-19 (cont'd)

Boost Kid Essentials Food Package Code X07 30-8.25 oz containers ready to feed Boost Kid Essentials
Medical Documentation Required X08 60-8.25 oz containers ready to feed Boost Kid Essentials
Medical Documentation Required X09 90-8.25 oz containers ready to feed Boost Kid Essentials
Medical Documentation Required
X16 110-8.25 oz containers ready to feed Boost Kid Essentials
Medical Documentation Required

Rank 4 2 2 4 2 2 4 2 3 1 1 4 3 2 1 1

VC S02 S04 S07 S05 S02 S04 S05 S05 S02 S06 S07 S05 S05 S05 S04 S07

Voucher Message Formula 16 - 8.25 oz containers ready to feed
Boost Kid Essentials (1 case)

Formula

12 - 8.25 oz containers ready to feed Boost Kid Essentials (three 4-packs)

Formula

2 - 8.25 oz containers ready to feed Boost Kid Essentials

Formula

32-8.25 oz containers ready to feed Boost Kid Essentials (2 cases)

Formula

16-8.25 oz containers ready to feed Boost Kid Essentials (1 case)

Formula

12-8.25 oz containers ready to feed Boost Kid Essentials (three 4-packs)

Formula

32-8.25 oz containers ready to feed Boost Kid Essentials (2 cases)

Formula

32-8.25 oz containers ready to feed Boost Kid Essentials (2 cases)

Formula

16-8.25 oz containers ready to feed Boost Kid Essentials (1 case)

Formula

8-8.25 oz containers ready to feed Boost Kid Essentials (two 4-packs)

Formula

2-8.25 oz containers ready to feed Boost Kid Essentials

Formula

32-8.25 oz containers ready to feed Boost Kid Essentials (2 cases)

Formula

32-8.25 oz containers ready to feed Boost Kid Essentials (2 cases)

Formula

32-8.25 oz containers ready to feed Boost Kid Essentials (2 cases)

Formula

12-8.25 oz containers ready to feed Boost Kid Essentials (three 4-packs)

Formula

2-8.25 oz containers ready to feed Boost Kid Essentials

FP-217


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-19 (cont'd)

Boost Kid Essentials 1.5 Food Package Code X90 30 - 8 oz containers ready to feed Boost Kid Essentials 1.5
Medical Documentation Required
X93 60 - 8 oz containers ready to feed Boost Kid Essentials 1.5
Medical Documentation Required
X94 90 - 8 oz containers ready to feed Boost Kid Essentials 1.5
Medical Documentation Required X95 113 - 8 oz containers ready to feed Boost Kid Essentials 1.5
Medical Documentation Required

Rank 4
2

VC S15
S17

Voucher Message Formula 27 - 8 oz containers ready to feed Boost
Kid Essentials 1.5 (1 case)

Formula

3 - 8 oz containers ready to feed Boost Kid Essentials 1.5

4

S15 Formula 27 - 8 oz containers ready to feed Boost

Kid Essentials 1.5 (1 case)

2

S15 Formula 27 - 8 oz containers ready to feed Boost

Kid Essentials 1.5 (1 case)

4

S18 Formula 6 - 8 oz containers ready to feed Boost

Kid Essentials 1.5

4

S16 Formula 54 - 8 oz containers ready to feed Boost

Kid Essentials 1.5 (2 cases)

2

S15 Formula 27 - 8 oz containers ready to feed Boost

Kid Essentials 1.5 (1 case)

2

S19 Formula 9 - 8 oz containers ready to feed Boost

Kid Essentials 1.5

4

S16 Formula 54 - 8 oz containers ready to feed Boost

Kid Essentials 1.5 (2 cases)

2

S15 Formula 27 - 8 oz containers ready to feed Boost

Kid Essentials 1.5 (1 case)

1

S15 Formula 27 - 8 oz containers ready to feed Boost

Kid Essentials 1.5 (1 case)

3

S23 Formula 5 - 8 oz containers ready to feed Boost

Kid Essentials 1.5

FP-218


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-19 (cont'd)

Boost Kid Essentials 1.5 With Fiber

Food Package Code

Rank VC

X96

4

S24

30-8 oz containers ready to feed Boost Kid Essentials 1.5 With Fiber

2

S26

Voucher Message Formula 27-8 oz containers ready to feed Boost
Kid Essentials 1.5 With Fiber (1 case)

Formula

3-8 oz containers ready to feed Boost Kid Essentials 1.5 With Fiber

Medical Documentation Required

X97
60-8 oz containers ready to feed Boost Kid Essentials 1.5 With Fiber

4

S24 Formula 27-8 oz containers ready to feed Boost

Kid Essentials 1.5 With Fiber (1 case)

2

S24 Formula 27-8 oz containers ready to feed Boost

Kid Essentials 1.5 With Fiber (1 case)

Medical Documentation Required

4

S27 Formula 6-8 oz containers ready to feed Boost

Kid Essentials 1.5 With Fiber

X98

4

S28 Formula 54-8 oz containers ready to feed Boost

90- oz containers ready to

Kid Essentials 1.5 With Fiber (2 cases)

feed Boost Kid Essentials 1.5 With Fiber

2

S24 Formula 27-8 oz containers ready to feed Boost

Kid Essentials 1.5 With Fiber (1 case)

Medical Documentation Required

2

S31 Formula 9-8 oz containers ready to feed Boost

Kid Essentials 1.5 With Fiber

X99

4

S28 Formula 54-8 oz containers ready to feed Boost

113-8 oz containers ready

Kid Essentials 1.5 With Fiber (2 cases)

to feed Boost Kid Essentials 1.5 With Fiber

2

S24 Formula 27-8 oz containers ready to feed Boost

Kid Essentials 1.5 With Fiber (1 case)

Medical Documentation Required

1

S24 Formula 27-8 oz containers ready to feed Boost

Kid Essentials 1.5 With Fiber (1 case)

3

S37 Formula 5-8 oz containers ready to feed Boost

Kid Essentials 1.5 With Fiber

FP-219


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-19 (cont'd)

EleCare Jr Food Package Code X89 9-14.1 oz cans powder EleCare Jr
Medical Documentation Required

Rank VC 4 532
2 533

Voucher Message Formula 6-14.1 oz cans powder Elecare or
EleCare Jr (1 case) Formula 3-14.1 oz cans powder EleCare or
EleCare Jr

Enfaport LIPIL Food Package Code Z49 30-8 oz cans ready to feed Enfaport LIPIL
Medical Documentation Required Z50 60-8 oz cans ready to feed Enfaport LIPIL
Medical Documentation Required Z51 90-8 oz cans ready to feed Enfaport LIPIL
Medical Documentation Required
Z52 113-8 oz cans ready to feed Enfaport LIPIL
Medical Documentation Required

Rank VC

4

N91

2

N93

2

N91

4

N91

4

N92

4

N90

2

N91

1 N92

3 N93

4

N90

2

N91

1

N91

3

N92

3

N96

3

A64

Voucher Message Formula 24-8 oz cans ready to feed Enfaport
LIPIL (1 case)
Formula 6-8 oz cans ready to feed Enfaport LIPIL (one 6-pack)

Formula Formula Formula Formula Formula Formula Formula Formula Formula Formula Formula Formula Formula

24-8 oz cans ready to feed Enfaport LIPIL (1 case)
24-8 oz cans ready to feed Enfaport LIPIL (1 case)
12-8 oz cans ready to feed Enfaport LIPIL (two 6-packs)
48-8 oz cans ready to feed Enfaport LIPIL (2 cases)
24-8 oz cans ready to feed Enfaport LIPIL (1 case)
12-8 oz cans ready to feed Enfaport LIPIL (two 6-packs)
6-8 oz cans ready to feed Enfaport LIPIL (one 6-pack)
48-8 oz cans ready to feed Enfaport LIPIL (2 cases)
24-8 oz cans ready to feed Enfaport LIPIL (1 case)
24-8 oz cans ready to feed Enfaport LIPIL (1 case)
12-8 oz cans ready to feed Enfaport LIPIL (two 6-packs)
4-8 oz cans ready to feed Enfaport LIPIL
1-8 oz can ready to feed Enfaport LIPIL

FP-220


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-19 (cont'd)

Similac NeoSure or Similac Expert Care Neosure

Food Package Code

Rank VC Voucher Message

X92

4 519 Formula 6-12.8 oz cans powder Similac

1012.8 oz cans powder

NeoSure OR 6-13.1 oz cans Similac

Similac NeoSure or 10-

Expert Care NeoSure

13.1 oz Similac Expert

(1 case)

Care Neosure

2 520 Formula 4-12.8 oz cans powder Similac

NeoSure OR 4-13.1 oz cans Similac

Expert Care NeoSure

Medical Documentation

Required

X73

1 517 Formula 6-32 oz containers ready to feed

28-32 oz containers ready

Similac NeoSure or Similac Expert

to feed Similac NeoSure or

Care NeoSure (1 case)

Similac Expert Care

2 517 Formula 6-32 oz containers ready to feed

NeoSure

Similac NeoSure or Similac Expert Care

NeoSure (1 case)

Medical Documentation

3 517 Formula 6-32 oz containers ready to feed

Required

Similac NeoSure or Similac Expert Care

NeoSure (1 case)

4 517 Formula 6-32 oz containers ready to feed

Similac NeoSure or Similac Expert Care

NeoSure (1 case)

4 S09 Formula 4-32 oz containers ready to feed

Similac NeoSure or Similac Expert Care

NeoSure

FP-221


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-19 (cont'd)

Nutramigen LIPIL Food Package Code X81 10-12.6 oz cans powder Nutramigen LIPIL with Enflora LGG

Rank VC 2 156
4 156

Voucher Message Formula 5-12.6 oz cans powder Nutramigen
LIPIL with Enflora LGG Formula 5-12.6 oz cans powder Nutramigen
LIPIL with Enflora LGG

Medical Documentation Required X82 35-13 oz cans concentrate Nutramigen LIPIL
Medical Documentation Required X83 28-32 oz containers ready to feed Nutramigen LIPIL
Medical Documentation Required

2 N67 Formula 16-13 oz cans concentrate Nutramigen LIPIL
4 N57 Formula 19-13 oz cans concentrate Nutramigen LIPIL
1 S03 Formula 14-32 oz containers ready to feed Nutramigen LIPIL
1 S03 Formula 14-32 oz containers ready to feed Nutramigen LIPIL

Pregestimil Food Package Code X04 8-1 lb cans powder Pregestimil LIPIL

Rank VC 2 140 4 140

Voucher Message Formula 4-1 lb cans powder Pregestimil LIPIL Formula 4-1 lb cans powder Pregestimil LIPIL

Medical Documentation Required

Portagen Food Package Code X20 13-1 lb cans powder Portagen
Medical Documentation Required

Rank VC 3 060 4 060 2 260

Voucher Message Formula 4-1 lb cans powder Portagen Formula 4-1 lb cans powder Portagen Formula 5-1 lb cans powder Portagen

FP-222


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-19 (cont'd)

Similac PM 60/40 Food Package Code X14 8-14.1 oz cans powder Similac PM 60/40
Medical Documentation Required

Rank VC 2 529
4 529

Voucher Message Formula 4-14.1 oz cans powder Similac PM
60/40 Formula 4-14.1 oz cans powder Similac PM
60/40

FP-223


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-20

Food Package III - Special Formulas for Children

Bright Beginnings Soy Pediatric Drink

Food Package Code

Rank VC

X86

4 330

30-8 oz containers ready

to feed Bright Beginnings

Soy Pediatric Drink

Voucher Message Formula 30-8 oz containers ready to feed Bright
Beginnings Soy Pediatric Drink

Medical Documentation Required X34 60-8 oz containers ready to feed Bright Beginnings Soy Pediatric Drink
Medical Documentation Required X35 90-8 oz containers ready to feed Bright Beginnings Soy Pediatric Drink
Medical Documentation Required X36 108-8 oz containers ready to feed Bright Beginnings Soy Pediatric Drink
Medical Documentation Required

2 330 Formula 30-8 oz containers ready to feed Bright Beginnings Soy Pediatric Drink
4 330 Formula 30-8 oz containers ready to feed Bright Beginnings Soy Pediatric Drink
2 330 Formula 30-8 oz containers ready to feed Bright Beginnings Soy Pediatric Drink
3 330 Formula 30-8 oz containers ready to feed Bright Beginnings Soy Pediatric Drink
4 330 Formula 30-8 oz containers ready to feed Bright Beginnings Soy Pediatric Drink
4 330 Formula 30-8 oz containers ready to feed Bright Beginnings Soy Pediatric Drink
3 330 Formula 30-8 oz containers ready to feed Bright Beginnings Soy Pediatric Drink
2 330 Formula 30-8 oz containers ready to feed Bright Beginnings Soy Pediatric Drink
1 118 Formula 18-8 oz containers ready to feed Bright Beginnings Soy Pediatric Drink

FP-224


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-20 (cont'd)

Compleat Pediatric Food Package Code Z31 30-50 ml containers ready to feed Compleat Pediatric
Medical Documentation Required
Z32 60-250 ml containers ready to feed Compleat Pediatric
Medical Documentation Required
Z33 90-250 ml containers ready to feed Compleat Pediatric
Medical Documentation Required
Z35 107-250 ml containers ready to feed Compleat Pediatric
Medical Documentation Required

Rank 4

VC N68

Voucher Message Formula 24-250 ml containers ready to feed
Compleat Pediatric (1 case)

2

N70 Formula 6-50 ml containers ready to feed

Compleat Pediatric

2

N68 Formula 24-250 ml containers ready to feed

Compleat Pediatric (1 case)

4

N68 Formula 24-250 ml containers ready to feed

Compleat Pediatric (1 case)

4

N71 Formula 12-250 ml containers ready to feed

Compleat Pediatric

4

N69 Formula 48-250 ml containers ready to feed

Compleat Pediatric (2 cases)

2

N68 Formula 24-250 ml containers ready to feed

Compleat Pediatric (1 case)

3 N70 Formula 6-250 ml containers ready to feed Compleat Pediatric

1 N71 Formula 12-250 ml containers ready to feed

Compleat Pediatric

4

N69 Formula 48-250 ml containers ready to feed

Compleat Pediatric (2 cases)

1

N68 Formula 24-250 ml containers ready to feed

Compleat Pediatric (1 case)

2

N68 Formula 24-250 ml containers ready to feed

Compleat Pediatric (1 case)

3

N73 Formula 11-250 ml containers ready to feed

Compleat Pediatric

FP-225


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-20 (cont'd)

EO28 Splash

Food Package Code

Rank VC

X51

4 513

31-237 ml containers

ready to feed EO28 Splash

Medical Documentation required

2 514

2 513

X52

62-237 ml containers

4 513

ready to feed EO28 Splash

1 514

Medical Documentation

Required

3 514

X53

1 513

113-237 ml containers

ready to feed EO28 Splash 2 513

Medical Documentation Required

3 513 4 513

4 514

4 310

Voucher Message Formula 27-237 ml containers ready to feed
EO28 Splash (1 case)

Formula

4-237 ml containers ready to feed EO28 Splash (1-4 pack)

Formula Formula Formula Formula Formula Formula Formula Formula Formula Formula

27-237 ml containers ready to feed EO28 Splash (1 case) 27-237 ml containers ready to feed EO28 Splash (1 case) 4-237 ml containers ready to feed EO28 Splash (1-4 pack) 4-237 ml containers ready to feed EO28 Splash (1-4 pack) 27-237 ml containers ready to feed EO28 Splash (1 case) 27-237 ml containers ready to feed EO28 Splash (1 case) 27-237 ml containers ready to feed EO28 Splash (1 case) 27-237 ml containers ready to feed EO28 Splash (1 case) 4-237 ml containers ready to feed EO28 Splash (one 4-pack) 1-237 ml container ready to feed EO28 Splash

Neocate Junior Food Package Code X75 14-400 gram (14.1 oz) cans powder Neocate Junior
Medical Documentation required

Rank VC 2 508
3 508 4 508 1 509

Voucher Message Formula 4-400 gram (14.1 oz) cans powder
Neocate Junior

Formula Formula Formula

4-400 gram (14.1 oz) cans powder Neocate Junior
4-400 gram (14.1 oz) cans powder Neocate Junior 2-400 gram (14.1 oz) cans powder Neocate Junior

FP-226


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-20 (cont'd)

Nutren Junior Food Package Code X57 35-250 ml containers ready to feed Nutren Junior
Medical Documentation required X58 59-250 ml containers ready to feed Nutren Junior
Medical Documentation Required X59 107-250 ml containers ready to feed Nutren Junior
Medical Documentation Required

Rank VC 4 559

Voucher Message Formula 24-250 ml containers ready to feed
Nutren Junior (1 case)

2 560 Formula 11-250 ml containers ready to feed Nutren Junior

2 559 Formula 24-250 ml containers ready to feed Nutren Junior (1 case)
4 559 Formula 24-250 ml containers ready to feed Nutren Junior (1 case)
3 560 Formula 11-250 ml containers ready to feed Nutren Junior
1 559 Formula 24-250 ml containers ready to feed Nutren Junior (1 case)
2 559 Formula 24-250 ml containers ready to feed Nutren Junior (1 case)
3 559 Formula 24-250 ml containers ready to feed Nutren Junior (1 case)
4 559 Formula 24-250 ml containers ready to feed Nutren Junior (1 case)
4 560 Formula 11-250 ml containers ready to feed Nutren Junior

FP-227


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-20 (cont'd)

Nutren Junior Fiber Food Package Code X60 35-250 ml containers ready to feed Nutren Junior Fiber
Medical Documentation required X37 59-250 ml containers ready to feed Nutren Junior Fiber
Medical Documentation Required X62 107-250 ml containers ready to feed Nutren Junior Fiber
Medical Documentation Required

Rank VC 4 561

Voucher Message Formula 24-250 ml containers ready to feed
Nutren Junior Fiber (1 case)

2 562 Formula 11-250 ml containers ready to feed Nutren Junior Fiber

2 561 Formula 24-250 ml containers ready to feed Nutren Junior Fiber (1 case)
4 561 Formula 24-250 ml containers ready to feed Nutren Junior Fiber (1 case)
3 562 Formula 11-250 ml containers ready to feed Nutren Junior Fiber
1 561 Formula 24-250 ml containers ready to feed Nutren Junior Fiber (1 case)
2 561 Formula 24-250 ml containers ready to feed Nutren Junior Fiber (1 case)
3 561 Formula 24-250 ml containers ready to feed Nutren Junior Fiber (1 case)
4 561 Formula 24-250 ml containers ready to feed Nutren Junior Fiber (1 case)
4 562 Formula 11-250 ml containers ready to feed Nutren Junior Fiber

FP-228


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-20 (cont'd)

PediaSure Food Package Code X84 30-8 oz containers ready to feed PediaSure
Medical Documentation required X30 60-8 oz containers ready to feed PediaSure
Medical Documentation Required X87 90-8 oz containers ready to feed PediaSure
Medical Documentation Required X88 108-8 oz containers ready to feed PediaSure
Medical Documentation Required

Rank VC 4 730
2 730 4 730
2 730 3 730 4 730 2 730 3 730 4 730 1 718

Voucher Message Formula 30-8 oz containers ready to
feed PediaSure

Formula Formula

30-8 oz containers ready to feed PediaSure 30-8 oz containers ready to feed PediaSure

Formula Formula Formula Formula Formula Formula Formula

30-8 oz containers ready to feed PediaSure 30-8 oz containers ready to feed PediaSure 30-8 oz containers ready to feed PediaSure 30-8 oz containers ready to feed PediaSure 30-8 oz containers ready to feed PediaSure 30-8 oz containers ready to feed PediaSure 18-8 oz containers ready to feed PediaSure (three 6-packs)

FP-229


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-20 (cont'd)

PediaSure 1.5 Food Package Code Z53 30-8 oz containers ready to feed PediaSure 1.5 Cal
Medical Documentation Required Z54 60-8 oz containers ready to feed PediaSure 1.5 Cal
Medical Documentation Required
Z55 90-8 oz containers ready to feed PediaSure 1.5 Cal
Medical Documentation Required
Z56 113-8 oz containers ready to feed PediaSure 1.5 Cal
Medical Documentation Required

Rank 4

VC N97

Voucher Message Formula 24-8 oz containers ready to
feed PediaSure 1.5 Cal (1 case)

2

N98 Formula 6-8 oz containers ready to feed

PediaSure 1.5 Cal

2

N97 Formula 24-8 oz containers ready to

feed PediaSure 1.5 Cal (1 case)

4

N97 Formula 24-8 oz containers ready to

feed PediaSure 1.5 Cal (1 case)

4

N99 Formula 12-8 oz containers ready to

feed PediaSure 1.5 Cal

4

R01 Formula 48-8 oz containers ready to

feed PediaSure 1.5 Cal (2

cases)

2

N97 Formula 24-8 oz containers ready to

feed PediaSure 1.5 Cal (1 case)

3 N98 Formula 6 - 8 oz containers ready to

feed PediaSure 1.5 Cal

1 N99 Formula 12-8 oz containers ready to

feed PediaSure 1.5 Cal

4

R01 Formula 48-8 oz containers ready to

feed PediaSure 1.5 Cal (2

cases)

2

N97 Formula 24-8 oz containers ready to

feed PediaSure 1.5 Cal (1 case)

1

N97 Formula 24-8 oz containers ready to

feed PediaSure 1.5 Cal (1 case)

3

R03 Formula 17-8 oz containers ready to

feed PediaSure 1.5 Cal

FP-230


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-20 (cont'd)

PediaSure 1.5 with fiber Food Package Code Z57 30-8 oz containers ready to feed PediaSure 1.5 Cal with fiber
Medical Documentation Required Z58 60-8 oz containers ready to feed PediaSure 1.5 Cal with fiber
Medical Documentation Required
Z59 90-8 oz containers ready to feed PediaSure 1.5 Cal with fiber
Medical Documentation Required
Z60 113 - 8 oz containers ready to feed PediaSure 1.5 Cal with fiber
Medical Documentation Required

Rank 4
2

VC R04
R05

Voucher Message Formula 24-8 oz containers ready to
feed PediaSure 1.5 Cal with fiber

(1 case)

Formula

6-8 oz containers ready to feed PediaSure 1.5 Cal with fiber

2

R04 Formula

24-8 oz containers ready to feed PediaSure 1.5 Cal with

fiber (1 case)

4

R04 Formula

24-8 oz containers ready to feed PediaSure 1.5 Cal with

fiber (1 case)

4

R06 Formula

12-8 oz containers ready to feed PediaSure 1.5 Cal with

fiber

4

R07 Formula

48-8 oz containers ready to feed PediaSure 1.5 Cal with

fiber (2 cases)

2

R04 Formula

24-8 oz containers ready to feed PediaSure 1.5 Cal with

fiber (1 case)

3 R05 Formula 6-8 oz containers ready to feed

PediaSure 1.5 Cal with fiber

1 R06 Formula 12-8 oz containers ready to

feed PediaSure 1.5 Cal with

fiber

4

R07 Formula

48-8 oz containers ready to feed PediaSure 1.5 Cal with

fiber (2 cases)

2

R04 Formula

24-8 oz containers ready to feed PediaSure 1.5 Cal with

fiber (1 case)

1

R04 Formula

24-8 oz containers ready to feed PediaSure 1.5 Cal with

fiber (1 case)

3

R09 Formula

17-8 oz containers ready to feed PediaSure 1.5 Cal with

fiber

FP-231


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-20 (cont'd)

Food Package Code Z27 30-8 oz containers ready to feed PediaSure Enteral
Medical Documentation Required Z28 60-8 oz containers ready to feed PediaSure Enteral
Medical Documentation Required
Z29 90-8 oz containers ready to feed PediaSure Enteral
Medical Documentation Required
Z30 113-8 oz containers ready to feed PediaSure Enteral
Medical Documentation Required

Rank 4

PediaSure Enteral VC Voucher Message S94 Formula 24-8 oz containers ready to
feed PediaSure Enteral (1 case)

2

S96 Formula 6-8 oz containers ready to feed

PediaSure Enteral

2

S94 Formula 24-8 oz containers ready to

feed PediaSure Enteral (1 case)

4

S94 Formula 24-8 oz containers ready to

feed PediaSure Enteral (1 case)

4

S97 Formula 12-8 oz containers ready to

feed PediaSure Enteral

4

S95 Formula 48-8 oz containers ready to

feed PediaSure Enteral (2

cases)

2

S94 Formula 24-8 oz containers ready to

feed PediaSure Enteral (1 case)

3 S86 Formula 6-8 oz containers ready to feed

PediaSure Enteral

1 S97 Formula 12-8 oz containers ready to

feed PediaSure Enteral

4

S95 Formula 48-8 oz containers ready to

feed PediaSure Enteral (2

cases)

2

S94 Formula 24-8 oz containers ready to

feed PediaSure Enteral (1 case)

1

S94 Formula 24-8 oz containers ready to

feed PediaSure Enteral (1 case)

3

S99 Formula 17-8 oz containers ready to

feed PediaSure Enteral

FP-232


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-20 (cont'd)

PediaSure Enteral with Fiber and scFOS

Food Package Code

Rank VC

Z37

4

N20

30-8 oz containers ready to feed PediaSure Enteral with Fiber and scFOS

2

N27

Medical Documentation Required
Z38 60-8 oz containers ready to feed PediaSure Enteral with Fiber and scFOS

2

N20

4

N20

Medical Documentation Required

4

N47

Z39 90-8 oz containers ready to feed PediaSure Enteral with Fiber and scFOS
Medical Documentation Required

4

N50

2

N20

3 N27

1 N47

Z40

4

N50

113-8 oz containers ready

to feed PediaSure Enteral

with Fiber and scFOS

2

N20

Medical Documentation Required

1

N20

3

N63

Voucher Message Formula 24-8 oz containers ready to
feed PediaSure Enteral with Fiber and scFOS (1 case)

Formula

6-8 oz containers ready to feed PediaSure Enteral with Fiber and scFOS

Formula Formula Formula Formula Formula Formula Formula Formula Formula Formula Formula

24-8 oz containers ready to feed PediaSure Enteral with Fiber and scFOS (1 case)
24-8 oz containers ready to feed PediaSure Enteral with Fiber and scFOS (1 case)
12-8 oz containers ready to feed PediaSure Enteral with Fiber and scFOS
48 - 8 oz containers ready to feed PediaSure Enteral with Fiber and scFOS (2 cases)
24 - 8 oz containers ready to feed PediaSure Enteral with Fiber and scFOS (1 case) 6-8 oz containers ready to feed PediaSure Enteral with Fiber and scFOS 12-8 oz containers ready to feed PediaSure Enteral with Fiber and scFOS
48 - 8 oz containers ready to feed PediaSure Enteral with Fiber and scFOS (2 cases)
24 - 8 oz containers ready to feed PediaSure Enteral with Fiber and scFOS (1 case)
24 - 8 oz containers ready to feed PediaSure Enteral with Fiber and scFOS (1 case)
17 - 8 oz containers ready to feed PediaSure Enteral with Fiber and scFOS

FP-233


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-20 (cont'd)

PediaSure with Fiber Food Package Code X76 30-8 oz containers ready to feed PediaSure With Fiber
Medical Documentation required X85 60-8 oz containers ready to feed PediaSure With Fiber
Medical Documentation Required X78 90-8 oz containers ready to feed PediaSure With Fiber
Medical Documentation Required X79 108-8 oz containers ready to feed PediaSure With Fiber
Medical Documentation Required

Rank VC 4 731
2 731 4 731
2 731 3 731 4 731 4 731 3 731 2 731 1 719

Voucher Message Formula 30-8 oz containers ready to feed
PediaSure With Fiber

Formula Formula

30-8 oz containers ready to feed PediaSure With Fiber 30-8 oz containers ready to feed PediaSure With Fiber

Formula Formula Formula
Formula Formula Formula Formula

30-8 oz containers ready to feed PediaSure With Fiber 30-8 oz containers ready to feed PediaSure With Fiber 30-8 oz containers ready to feed PediaSure With Fiber
30-8 oz containers ready to feed PediaSure With Fiber 30-8 oz containers ready to feed PediaSure With Fiber
30-8 oz containers ready to feed PediaSure With Fiber 18-8 oz containers ready to feed PediaSure With Fiber (three 6-packs)

FP-234


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-20 (cont'd)

Peptamen Junior Food Package Code X66 35-250 ml containers ready to feed Peptamen Junior
Medical Documentation required X67 59-250 ml containers ready to feed Peptamen Junior
Medical Documentation Required X68 107-250 ml containers ready to feed Peptamen Junior
Medical Documentation Required

Rank VC 4 571

Voucher Message Formula 24-250 ml containers ready to feed
Peptamen Junior (1 case)

2 572 Formula 11-250 ml containers ready to feed Peptamen Junior

2 571 Formula 24-250 ml containers ready to feed Peptamen Junior (1 case)
4 571 Formula 24-250 ml containers ready to feed Peptamen Junior (1 case)
3 572 Formula 11-250 ml containers ready to feed Peptamen Junior
1 571 Formula 24-250 ml containers ready to feed Peptamen Junior (1 case)
2 571 Formula 24-250 ml containers ready to feed Peptamen Junior (1 case)
3 571 Formula 24-250 ml containers ready to feed Peptamen Junior (1 case)
4 571 Formula 24-250 ml containers ready to feed Peptamen Junior (1 case)
4 572 Formula 11-250 ml containers ready to feed Peptamen Junior

FP-235


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-20 (cont'd)

Peptamen Junior Fiber Food Package Code Z05 30-250 ml containers ready to feed Peptamen Junior Fiber
Medical Documentation Required
Z06 60-250 ml containers ready to feed Peptamen Junior Fiber
Medical Documentation Required
Z07 90-250 ml containers ready to feed Peptamen Junior Fiber
Medical Documentation Required
Z08 90-250 ml containers ready to feed Peptamen Junior Fiber
Medical Documentation Required

Rank VC Voucher Message

4

S49 Formula

24-250 ml containers ready to feed Peptamen Junior Fiber (1 case)

2

S51 Formula

6-250 ml containers ready to feed Peptamen Junior Fiber

4

S49 Formula

24-250 ml containers ready to feed Peptamen Junior Fiber (1 case)

2

S49 Formula

24-250 ml containers ready to feed Peptamen Junior Fiber (1 case)

4

S52 Formula

12-250 ml containers ready to feed Peptamen Junior Fiber

4

S50 Formula

48-250 ml containers ready to feed Peptamen Junior Fiber (2 cases)

2

S49 Formula

24-250 ml containers ready to feed Peptamen Junior Fiber (1 case)

3

S51 Formula

6-250 ml containers ready to feed Peptamen Junior Fiber

1 S52 Formula 12-250 ml containers ready to feed Peptamen Junior Fiber

4

S50 Formula

48-250 ml containers ready to feed Peptamen Junior Fiber (2 cases)

1

S49 Formula

24-250 ml containers ready to feed Peptamen Junior Fiber (1 case)

2

S49 Formula

24-250 ml containers ready to feed Peptamen Junior Fiber (1 case)

3

S54 Formula

11-250 ml containers ready to feed Peptamen Junior Fiber

FP-236


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-20 (cont'd)

Peptamen Junior with Prebio

Food Package Code

Rank VC

X69

4 576

35-250 ml containers

ready to feed Peptamen

Junior with Prebio

2 577

Medical Documentation required X70 59-250 ml containers ready to feed Peptamen Junior with Prebio

4 576 2 576

Medical Documentation Required X05 107-250 ml containers ready to feed Peptamen Junior with Prebio
Medical Documentation Required

3 577 1 576 2 576 3 576 4 576

4 577

Voucher Message Formula 24-250 ml containers ready to feed
Peptamen Junior with Prebio (1 case)

Formula

11-250 ml containers ready to feed Peptamen Junior with Prebio

Formula
Formula Formula Formula Formula Formula Formula Formula

24-250 ml containers ready to feed Peptamen Junior with Prebio (1 case)
24-250 ml containers ready to feed Peptamen Junior with Prebio (1 case) 11-250 ml containers ready to feed Peptamen with Prebio
24-250 ml containers ready to feed Peptamen Junior with Prebio (1 case) 24-250 ml containers ready to feed Peptamen Junior with Prebio (1 case) 24-250 ml containers ready to feed Peptamen Junior with Prebio (1 case) 24-250 ml containers ready to feed Peptamen Junior with Prebio (1 case) 11-250 ml containers ready to feed Peptamen Junior with Prebio

FP-237


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-20 (cont'd)

Peptamen Junior 1.5 Food Package Code Z01 30-250 ml containers ready to feed Peptamen Junior 1.5
Medical Documentation Required
Z02 60-250 ml containers ready to feed Peptamen Junior 1.5
Medical Documentation Required
Z03 90- 50 ml containers ready to feed Peptamen Junior 1.5
Medical Documentation Required
Z04 107-250 ml containers ready to feed Peptamen Junior 1.5
Medical Documentation Required

Rank VC

4

S43

2

S45

4

S43

2

S43

4

S46

4

S44

2

S43

3

S45

1 S46

4

S44

2

S43

1

S43

3

S48

Voucher Message Formula 24- 50 ml containers ready to feed
Peptamen Junior 1.5 (1 case)

Formula

6-250 ml containers ready to feed Peptamen Junior 1.5

Formula Formula Formula Formula Formula Formula Formula Formula Formula Formula Formula

24-250 ml containers ready to feed Peptamen Junior 1.5 (1 case)
24-250 ml containers ready to feed Peptamen Junior 1.5 (1 case)
12-250 ml containers ready to feed Peptamen Junior 1.5
48-250 ml containers ready to feed Peptamen Junior 1.5 (2 cases)
24-250 ml containers ready to feed Peptamen Junior 1.5 (1 case)
6-250 ml containers ready to feed Peptamen Junior 1.5 12-250 ml containers ready to feed Peptamen Junior 1.5
48-250 ml containers ready to feed Peptamen Junior 1.5 (2 cases)
24-250 ml containers ready to feed Peptamen Junior 1.5 (1 case)
24-250 ml containers ready to feed Peptamen Junior 1.5 (1 case)
11-250 ml containers ready to feed Peptamen Junior 1.5

FP-238


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-20 (cont'd)

Vital jr. or Pediasure Peptide 1.0 Cal

Food Package Code

Rank VC

Z10

4

S55

30-8 oz containers ready

to feed Vital jr. or

Pediasure Peptide 1.0 Cal

2

S57

Medical Documentation Required

Z11

4

S55

60-8 oz containers ready

to feed Vital jr. or Pediasure Peptide 1.0 Cal

2

S55

Medical Documentation Required

4

S58

Z12 90-8 oz containers ready

4

S56

to feed Vital jr. or Pediasure Peptide 1.0 Cal

2

S55

Medical Documentation Required
Z13 113-8 oz containers ready to feed Vital jr. or Pediasure Peptide 1.0 Cal

3 S57

1 S58

4

S56

1

S55

Medical Documentation

2

S55

3

S60

Voucher Message Formula 24-8 oz containers ready to feed Vital jr.
or Pediasure Peptide 1.0 Cal (1 case)

Formula

6-8 oz containers ready to feed Vital jr. or Pediasure Peptide 1.0 Cal

Formula Formula Formula Formula Formula Formula Formula Formula Formula Formula Formula

24-8 oz containers ready to feed Vital jr or Pediasure Peptide 1.0 Cal. (1 case)
24-8 oz containers ready to feed Vital jr. or Pediasure Peptide 1.0 Cal (1 case)
12-8 oz containers ready to feed Vital jr. or Pediasure Peptide 1.0 Cal
48-8 oz containers ready to feed Vital jr. or Pediasure Peptide 1.0 Cal (2 cases)
24-8 oz containers ready to feed Vital jr. or Pediasure Peptide 1.0 Cal (1 case) 6-8 oz containers ready to feed Vital jr. or Pediasure Peptide 1.0 Cal 12-8 oz containers ready to feed Vital jr. or Pediasure Peptide 1.0 Cal
48-8 oz containers ready to feed Vital jr. or Pediasure Peptide 1.0 Cal (2 cases)
24-8 oz containers ready to feed Vital jr. or Pediasure Peptide 1.0 Cal (1 case)
24-8 oz containers ready to feed Vital jr or Pediasure Peptide 1.0 Cal. (1 case)
17-8 oz containers ready to feed Vital jr. or Pediasure Peptide 1.0 Cal

FP-239


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-20 (cont'd)

Vivonex Pediatric Food Package Code
Z23 30-1.7 oz packets powder Vivonex Pediatric

Rank 4

VC S82

Voucher Message Formula 30-1.7 oz packets powder Vivonex
Pediatric (five boxes, 6 packets each)

Medical Documentation Required

Z24

4

60-1.7 oz packets powder

Vivonex Pediatric

2

Medical Documentation Required

Z25

4

90-1.7 oz packets powder

Vivonex Pediatric

2

Medical Documentation

4

Required

Z26

4

102-1.7 oz packets powder

Vivonex Pediatric

2

Medical Documentation

Required

4

S81 Formula S83 Formula

36-1.7 oz packets powder Vivonex Pediatric (1 case)
24-1.7 oz packets powder Vivonex Pediatric (four boxes, 6 packets each)

S81 Formula S81 Formula S84 Formula S81 Formula S81 Formula S82 Formula

36-1.7 oz packets powder Vivonex Pediatric (1 case)
36-1.7 oz packets powder Vivonex Pediatric (1 case)
18-1.7 oz packets powder Vivonex Pediatric (three boxes, 6 packets each)
36-1.7 oz packets powder Vivonex Pediatric (1 case)
36-1.7 oz packets powder Vivonex Pediatric (1 case)
30-1.7 oz packets powder Vivonex Pediatric (five boxes, 6 packets each)

FP-240


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-21

Food Package III - Special Formulas for Women

Boost Food Package Code X39 30-8 oz containers ready to feed Boost
Medical Documentation required
X40 60-8 oz containers ready to feed Boost
Medical Documentation Required
X02 90-8 oz containers ready to feed Boost
Medical Documentation Required
X42 112-8 oz containers ready to feed Boost
Medical Documentation Required

Rank VC 4 555
2 554
2 555 4 555 1 554 3 554 2 555 3 555 4 555 1 554 1 554 1 554 1 555 2 555 3 555 4 555 4 556

Voucher Message Formula 24-8 oz containers ready to feed
Boost (1 case)

Formula

6-8 oz containers ready to feed Boost (one 6-pack)

Formula Formula Formula Formula Formula Formula Formula Formula Formula Formula Formula Formula
Formula Formula Formula

24-8 oz containers ready to feed Boost (1 case) 24-8 oz containers ready to feed Boost (1 case) 6-8 oz containers ready to feed Boost (one 6-pack) 6-8 oz containers ready to feed Boost (one 6-pack) 24-8 oz containers ready to feed Boost (1 case) 24-8 oz containers ready to feed Boost (1 case) 24-8 oz containers ready to feed Boost (1 case) 6-8 oz containers ready to feed Boost (one 6-pack) 6-8 oz containers ready to feed Boost (one 6-pack) 6-8 oz containers ready to feed Boost (one 6-pack) 24-8 oz containers ready to feed Boost (1 case) 24-8 oz containers ready to feed Boost (1 case)
24-8 oz containers ready to feed Boost (1 case) 24-8 oz containers ready to feed Boost (1 case) 16-8 oz containers ready to feed Boost

FP-241


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-21 (cont'd)

Ensure Food Package Code X06 30-8 oz containers ready to feed Ensure
Medical Documentation required
X38 60-8 oz containers ready to feed Ensure
Medical Documentation Required X45 90-8 oz containers ready to feed Ensure
Medical Documentation Required
X15 108-8 oz containers ready to feed Ensure
Medical Documentation Required

Rank VC 4 537
2 302
2 537 4 537 3 538
4 537 3 537 2 537 1 538 1 302 1 537 2 537 3 537 4 537 4 538

Voucher Message Formula 24-8 oz containers ready to feed
Ensure (1 case)

Formula

6-8 oz containers ready to feed Ensure (one 6-pack)

Formula Formula Formula
Formula Formula Formula Formula Formula Formula Formula Formula Formula Formula

24-8 oz containers ready to feed Ensure (1 case) 24-8 oz containers ready to feed Ensure (1 case) 12-8 oz containers ready to feed Ensure (two 6-pack)
24-8 oz containers ready to feed Ensure (1 case) 24-8 oz containers ready to feed Ensure (1 case) 24-8 oz containers ready to feed Ensure (1 case) 12-8 oz containers ready to feed Ensure (2-6 pack) 6-8 oz containers ready to feed Ensure (one 6-pack) 24-8 oz containers ready to feed Ensure (1 case) 24-8 oz containers ready to feed Ensure (1 case)
24-8 oz containers ready to feed Ensure (1 case) 24-8 oz containers ready to feed Ensure (1 case) 12-8 oz containers ready to feed Ensure (two 6-pack)

FP-242


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-21 (cont'd)

Ensure Fiber Food Package Code X47 30-8 oz containers ready to feed Ensure Fiber
Medical Documentation Required
X48 60-8 oz containers ready to feed Ensure Fiber
Medical Documentation Required X49 90-8 oz containers ready to feed Ensure Fiber
Medical Documentation Required
X50 108-8 oz containers ready to feed Ensure Fiber
Medical Documentation Required

Rank VC 4 579
2 304
2 579 4 579 3 580
2 579 3 579 4 579 1 580 1 304 1 579 2 579 4 579 3 579 4 580

Voucher Message Formula 24-8 oz containers ready to feed
Ensure Fiber (1 case)

Formula

6-8 oz containers ready to feed Ensure Fiber (one 6-pack)

Formula Formula Formula
Formula Formula Formula Formula Formula Formula Formula Formula Formula Formula

24-8 oz containers ready to feed Ensure Fiber (1 case) 24-8 oz containers ready to feed Ensure Fiber (1 case) 12-8 oz containers ready to feed Ensure Fiber (two 6-pack)
24-8 oz containers ready to feed Ensure (Fiber 1 case) 24-8 oz containers ready to feed Ensure Fiber (1 case) 24-8 oz containers ready to feed Ensure Fiber (1 case) 12-8 oz containers ready to feed Ensure Fiber (two 6-pack) 6-8 oz containers ready to feed Ensure Fiber (one 6-pack) 24-8 oz containers ready to feed Ensure Fiber (1 case) 24-8 oz containers ready to feed Ensure Fiber (1 case)
24-8 oz containers ready to feed Ensure Fiber (1 case) 24-8 oz containers ready to feed Ensure Fiber (1 case) 12-8 oz containers ready to feed Ensure Fiber (two 6-pack)

FP-243


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-21 (cont'd)

Nepro Food Package Code Z41 30-8 oz cans ready to feed Nepro
Documentation Required
Z42 60-8 oz cans ready to feed Nepro
Medical Documentation Required
Z43 90-8 oz cans ready to feed Nepro
Medical Documentation Required
Z44 112-8 oz cans ready to feed Nepro
Medical Documentation Required

Rank VC

4

N78

2

N79

2

N80

4

N78

2

N78

2

N77

4

N81

2

N78

1 N94

3 N80

2

N81

4

N81

4

N94

Voucher Message Formula 24-8 oz cans ready to feed Nepro
(1 case)

Formula

4-8 oz cans ready to feed Nepro (one 4-pack)

Formula Formula Formula Formula Formula Formula Formula Formula Formula Formula Formula

2-8 oz cans ready to feed Nepro
24-8 oz cans ready to feed Nepro (1 case)
24-8 oz cans ready to feed Nepro (1 case)
12-8 oz cans ready to feed Nepro (three 4-packs)
48-8 oz cans ready to feed Nepro (2 cases)
24-8 oz cans ready to feed Nepro (1 case)
16-8 oz cans ready to feed Nepro (four 4-packs)
2-8 oz cans ready to feed Nepro
48-8 oz cans ready to feed Nepro (2 cases)
48-8 oz cans ready to feed Nepro (2 cases)
16-8 oz cans ready to feed Nepro (four 4-packs)

FP-244


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-21 (cont'd)

Nutren 1.5 Food Package Code Z45 30-250 ml containers ready to feed Nutren 1.5
Medical Documentation Required Z46 60-250 ml containers ready to feed Nutren 1.5
Medical Documentation Required
Z47 90-250 ml containers ready to feed Nutren 1.5
Medical Documentation Required
Z48 107-250 ml containers ready to feed Nutren 1.5
Medical Documentation Required

Rank 4

VC N84

Voucher Message Formula 24-250 ml containers ready to feed
Nutren 1.5 (1 case)

2

N85 Formula 6-250 ml containers ready to feed

Nutren 1.5

2

N84 Formula 24-250 ml containers ready to feed

Nutren 1.5 (1 case)

4

N84 Formula 24-250 ml containers ready to feed

Nutren 1.5 (1 case)

4

N86 Formula 12-250 ml containers ready to feed

Nutren 1.5

4

N87 Formula 48 - 250 ml containers ready to feed

Nutren 1.5 (2 cases)

2

N84 Formula 24 - 250 ml containers ready to feed

Nutren 1.5 (1 case)

3 N85 Formula 6-250 ml containers ready to feed

Nutren 1.5

1 N86 Formula 12-250 ml containers ready to feed

Nutren 1.5

4

N87 Formula 48 - 250 ml containers ready to feed

Nutren 1.5 (2 cases)

1

N84 Formula 24 - 250 ml containers ready to feed

Nutren 1.5 (1 case)

2

N84 Formula 24 - 250 ml containers ready to feed

Nutren 1.5 (1 case)

3

N89 Formula 11 - 250 ml containers ready to feed

Nutren 1.5

FP-245


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-21 (cont'd)

Nutren 2.0 Food Package Code X54 35-250 ml containers ready to feed Nutren 2.0
Medical Documentation required
X55 59-250 ml containers ready to feed Nutren 2.0
Medical Documentation Required X56 107-250 ml containers ready to feed Nutren 2.0
Medical Documentation Required

Rank VC 4 567

Voucher Message Formula 24-250 ml containers ready to feed
Nutren 2.0 (1 case)

2 568 Formula 11-250 ml containers ready to feed Nutren 2.0

2 567 Formula 24-250 ml containers ready to feed Nutren 2.0 (1 case)
4 567 Formula 24-250 ml containers ready to feed Nutren 2.0 (1 case)
3 568 Formula 11-250 ml containers ready to feed Nutren 2.0
1 567 Formula 24-250 ml containers ready to feed Nutren 2.0 (1 case)
2 567 Formula 24-250 ml containers ready to feed Nutren 2.0 (1 case)
3 567 Formula 24-250 ml containers ready to feed Nutren 2.0 (1 case)
4 567 Formula 24-250 ml containers ready to feed Nutren 2.0 (1 case)
4 568 Formula 11-250 ml containers ready to feed Nutren 2.0

FP-246


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-21 (cont'd)

Peptamen Food Package Code X63 35-250 ml containers ready to feed Peptamen
Medical Documentation required
X64 59-250 ml containers ready to feed Peptamen
Medical Documentation Required X65 107-250 ml containers ready to feed Peptamen
Medical Documentation Required

Rank VC 4 569

Voucher Message Formula 24-250 ml containers ready to feed
Peptamen (1 case)

2 570 Formula 11-250 ml containers ready to feed Peptamen

2 569 Formula 24-250 ml containers ready to feed Peptamen (1 case)
4 569 Formula 24-250 ml containers ready to feed Peptamen (1 case)
3 570 Formula 11-250 ml containers ready to feed Peptamen
1 569 Formula 24-250 ml containers ready to feed Peptamen (1 case)
2 569 Formula 24-250 ml containers ready to feed Peptamen (1 case)
3 569 Formula 24-250 ml containers ready to feed Peptamen (1 case)
4 569 Formula 24-250 ml containers ready to feed Peptamen (1 case)
4 570 Formula 11-250 ml containers ready to feed Peptamen

FP-247


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-21 (cont'd)

Resource Breeze Food Package Code Z19 30-8 oz containers ready to feed Resource Breeze
Medical Documentation Required Z20 60-8 oz containers ready to feed Resource Breeze
Medical Documentation Required
Z21 90-8 oz containers ready to feed Resource Breeze
Medical Documentation Required
Z22 113-8 oz containers ready to feed Resource Breeze
Medical Documentation Required

Rank 4

VC S75

Voucher Message Formula 27-8 oz containers ready to feed
Resource Breeze (1 case)

2

S77 Formula 3-8 oz containers ready to feed

Resource Breeze

4

S75 Formula 27-8 oz containers ready to feed

Resource Breeze (1 case)

2

S75 Formula 27-8 oz containers ready to feed

Resource Breeze (1 case)

4

S78 Formula 6-8 oz containers ready to feed

Resource Breeze

4

S76 Formula 54-8 oz containers ready to feed

Resource Breeze (2 cases)

2

S75 Formula 27-8 oz containers ready to feed

Resource Breeze (1 case)

3

S77 Formula 3-8 oz containers ready to feed

Resource Breeze

1 S78 Formula 6-8 oz containers ready to feed

Resource Breeze

4

S76 Formula 54-8 oz containers ready to feed

Resource Breeze (2 cases)

2

S75 Formula 27-8 oz containers ready to feed

Resource Breeze (1 case)

1

S75 Formula 27-8 oz containers ready to feed

Resource Breeze (1 case)

3

S80 Formula 5-8 oz containers ready to feed

Resource Breeze

FP-248


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-21 (cont'd)

Suplena Food Package Code Z14 30-8 oz containers ready to feed Suplena
Medical Documentation Required Z15 60-8 oz containers ready to feed Suplena
Medical Documentation Required
Z16 90 - 8 oz containers ready to feed Suplena
Medical Documentation Required
Z18 113 - 8 oz containers ready to feed Suplena
Medical Documentation Required

Rank 4

VC S69

Voucher Message Formula 24-8 oz containers ready to feed
Suplena (1 case)

2

S71 Formula 6-8 oz containers ready to feed Suplena

4

S69 Formula 24-8 oz containers ready to feed

Suplena (1 case)

2

S69 Formula 24-8 oz containers ready to feed

Suplena (1 case)

4

S72 Formula 12-8 oz containers ready to feed

Suplena

4

S70 Formula 48 - 8 oz containers ready to feed

Suplena (2 cases)

2

S69 Formula 24 - 8 oz containers ready to feed

Suplena (1 case)

1 S72 Formula 12-8 oz containers ready to feed Suplena

3 S71 Formula 6-8 oz containers ready to feed Suplena

4

S70 Formula 48 - 8 oz containers ready to feed

Suplena (2 cases)

1

S69 Formula 24 - 8 oz containers ready to feed

Suplena (1 case)

2

S69 Formula 24 - 8 oz containers ready to feed

Suplena (1 case)

3

S74 Formula 17 - 8 oz containers ready to feed

Suplena

FP-249


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-22

Tracking Food Packages

The tracking packages can be given to women, children or infants.

Emory Genetics Food Package Code 099
Medical Documentation Required

Rank VC 9 099
9 299
9 299
9 399

Voucher Message Formula This voucher has no cash value
Grocers should not accept this voucher
Client copy: Formula Provided by Emory Genetics. Emory Genetics 404-778-8519 Georgia WIC 800-228-9173 This voucher has no cash value. Grocers should not accept this voucher Emory Genetics Copy : Formula provided by Emory Genetics Fax to Emory Genetics: 404-778-8562 Formula Name: _______ Cost: ________ This voucher has no cash value. Grocers should not accept this voucher Emory Genetics Copy : Formula provided by Emory Genetics Fax to Emory Genetics: 404-778-8562 Formula Name: _______ Cost: ________
This voucher has no cash value Grocers should not accept this voucher Chart Copy : / File in participants health record: Formula provided by Emory Genetics Contact Information: Emory Genetics- 404-778-8519 / Georgia WIC- 800-228-9173

FP-250


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-22 (cont'd)

Formula Provided from Stock on Hand

Food Package Code

Rank VC

197

9 197

Voucher Message Formula This voucher has no cash value
Grocers should not accept this voucher

Formula provided from stock on hand. Document formula quantity and type issued in client's medical record and Formula Tracking Log

Formula Ordered from Nutrition Section

Food Package Code

Rank VC

199

9 199

Voucher Message Formula This voucher has no cash value
Grocers should not accept this voucher Formula ordered from the Office of Nutrition Document formula quantity and type issued in client's medical record and Formula Tracking Log

FP-251


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-23

Special Formula Packages for Infants Age 6-11 Months Unable to Eat Solid Foods

Alimentum Food Package Code
S01 (Assign S01) 8-16 oz cans powder Similac Expert Care Alimentum

Rank VC 2 360 4 360

Voucher Message

Formula Formula

4-16 oz cans powder Similac Expert Care Alimentum 4-16 oz cans powder Similac Expert Care Alimentum

Medical Documentation Required S03 (Assign S03) 28-32 oz containers ready to feed Similac Expert Care Alimentum

2 150 Formula 14-32 oz containers ready to feed Similac Expert Care Alimentum
4 150 Formula 14-32 oz containers ready to feed Similac Expert Care Alimentum

Medical Documentation Required

EleCare for Infants Food Package Code
S41 (Assign S41) 10-14.1 oz cans powder EleCare with DHA and ARA or EleCare for Infants
Medical Documentation Required

Rank VC 4 S33
2 S35

Voucher Message

Formula Formula

6-14.1 oz cans powder EleCare with DHA and ARA or EleCare for Infants (1 case) 4-14.1 oz cans powder EleCare with DHA and ARA or EleCare for Infants

FP-252


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-23 (cont'd)

Enfamil EnfaCare Food Package Code
S24 (Assign S24) 11-12.8 oz cans powder Enfamil EnfaCare
Medical Documentation Required S26 (Assign S26) 28-32 oz containers ready to feed Enfamil EnfaCare
Medical Documentation Required
S20 (Assign S20) 444-2 oz containers ready to feed Enfamil EnfaCare
Medical Documentation Required

Rank VC 4 541 2 S11
2 543 2 543 4 543 4 543 4 S12 2 589 2 589 4 589 4 589 4 539 2 S20

Voucher Message

Formula Formula

6-12.8 oz cans powder Enfamil Enfamil EnfaCare 5-12.8 oz cans powder Enfamil EnfaCare

Formula Formula Formula Formula Formula Formula Formula Formula Formula Formula Formula

6-32 oz containers ready to feed Enfamil EnfaCare (1 case) 6-32 oz containers ready to feed Enfamil EnfaCare (1 case) 6-32 oz containers ready to feed Enfamil EnfaCare (1 case) 6-32 oz containers ready to feed Enfamil EnfaCare (1 case) 4-32 oz containers ready to feed Enfamil EnfaCare 96-2 oz containers ready to feed Enfamil EnfaCare (2 cases) 96-2 oz containers ready to feed Enfamil EnfaCare (2 cases) 96-2 oz containers ready to feed Enfamil EnfaCare (2 cases) 96-2 oz containers ready to feed Enfamil EnfaCare (2 case) 48-2 oz containers ready to feed Enfamil EnfaCare (1 case) 12-2 oz containers ready to feed Enfamil EnfaCare

FP-253


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-23 (cont'd)

Enfamil Premature LIPIL 20

Food Package Code

Rank VC

S30 (Assign S30)

2 595

444-2 oz containers ready

to feed iron fortified

Enfamil Premature LIPIL

2 595

20

Medical Documentation Required

4 595 4 595

4 545

2 S21

Voucher Message Formula 96-2 oz containers ready to feed iron
fortified Enfamil Premature LIPIL 20 (2 cases) Formula 96-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 20 (2 cases) Formula 96-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 20 (2 cases) Formula 96-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL20 (2 cases) Formula 48-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 20 (1 case) Formula 12-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 20

Enfamil Premature LIPIL 24

Food Package Code

Rank VC

S40 (Assign S40) 444-2 oz containers ready to feed Enfamil Premature LIPIL 24

2 597 2 597

Medical Documentation Required

4 597 4 597

4 547

2 S22

Voucher Message

Formula Formula Formula Formula Formula Formula

96-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 24 (2 cases) 96-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 24 (2 cases) 96-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 24 (2 cases) 96-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 24 (2 cases) 48-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 24 (1 case) 12-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 24

FP-254


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-23 (cont'd)

Enfaport LIPIL Food Package Code S12 (Assign S12) 112-8 oz cans ready to feed Enfaport LIPIL
Medical Documentation Required

Rank 4 2 2 4 2

VC N90 N91 N91 N92 N96

Voucher Message Formula 48-8 oz cans ready to feed Enfaport
LIPIL (2 cases)

Formula

24-8 oz cans ready to feed Enfaport LIPIL (1 case)

Formula

24-8 oz cans ready to feed Enfaport LIPIL (1 case)

Formula

12-8 oz cans ready to feed Enfaport LIPIL (two 6-packs)

Formula

4-8 oz cans ready to feed Enfaport LIPIL

Gerber Good Start Premature 24

Food Package Code

Rank

S02 (Assign S02)

4

296 - 3 oz containers

ready to feed Gerber Good

Start Premature 24

2

Medical Documentation

4

Required

2

4

VC S38
S38 S39 S39 S41

Voucher Message Formula 96-3 oz containers ready to feed Gerber
Good Start Premature 24

(2 cases)

Formula

96-3 oz containers ready to feed Gerber Good Start Premature 24 (2 cases)

Formula

48-3 oz containers ready to feed Gerber Good Start Premature 24 (1 case)

Formula

48-3 oz containers ready to feed Gerber Good Start Premature 24 (1 case)

Formula

8-3 oz containers ready to feed Gerber Good Start Premature 24 (one 8-pack)

Neocate Infant Food Package Code
S51 (Assign S51) 11-400 gram (14.1 oz) cans powder Neocate Infant
Medical Documentation Required

Rank VC 2 506 4 506 2 507 4 507 4 507

Voucher Message

Formula Formula Formula Formula Formula

4-400 gram (14.1 oz) cans powder Neocate Infant 4-400 gram (14.1 oz) cans powder Neocate Infant 1-400 gram (14.1 oz) can powder Neocate Infant 1-400 gram (14.1 oz) can powder Neocate Infant 1-400 gram (14.1 oz) can powder Neocate Infant

FP-255


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-23 (cont'd)

Neocate Infant DHA & ARA

Food Package Code

Rank VC

S61 (Assign S61)

4 500

11-400 gram (14.1 oz) cans powder Neocate Infant DHA & ARA

2 500 4 505

Medical Documentation Required

4 505 2 505

Voucher Message

Formula Formula Formula Formula Formula

4-400 gram (14.1 oz) cans powder Neocate Infant DHA & ARA 4-400 gram (14.1 oz) cans powder Neocate Infant DHA & ARA 1-400 gram (14.1 oz) can powder Neocate Infant DHA & ARA 1-400 gram (14.1 oz) can powder Neocate Infant DHA & ARA 1-400 gram (14.1 oz) can powder Neocate Infant DHA & ARA

FP-256


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-23 (cont'd)

NeoSure or Similac Expert Care Neosure

Food Package Code

Rank VC Voucher Message

S71 (Assign S71)

4 519 Formula 6-12.8 oz cans powder Similac

11-12.8 oz cans powder

NeoSure or 6-13.1 oz cans Similac

Similac NeoSure or 11-

Expert Care Neosure (1 case)

13.1 oz Similac Expert

2 S25 Formula 5-12.8 oz cans powder Similac

Care Neosure

NeoSure or 5-13.1 oz cans Similac

Expert Care Neosure

Medical Documentation

Required

S73 (Assign S73)

4 517 Formula 6-32 oz containers ready to feed

28-32 oz containers ready

Similac NeoSure or Similac Expert Care

to feed Similac NeoSure or

NeoSure (1 case)

Similac Expert Care

4 517 Formula 6-32 oz containers ready to feed

NeoSure

Similac NeoSure or Similac Expert Care

NeoSure (1 case)

2 517 Formula 6-32 oz containers ready to feed

Medical Documentation

Similac NeoSure or Similac Expert Care

Required

NeoSure (1 case)

2 517 Formula 6-32 oz containers ready to feed

Similac NeoSure or Similac Expert Care

NeoSure (1 case)

4 S09 Formula 4-32 oz containers ready to feed

Similac NeoSure or Similac Expert Care

NeoSure

S70 (Assign S70)

2 596 Formula 96-2 oz containers ready to feed

448-2 oz containers ready

Similac NeoSure or Similac Expert Care

to feed Similac NeoSure or

NeoSure (2 cases)

Similac Expert Care

2 596 Formula 96-2 oz containers ready to feed

NeoSure

Similac NeoSure or Similac Expert Care

NeoSure (2 cases)

Medical Documentation

4 596 Formula 96-2 oz containers ready to feed

Required

Similac NeoSure or Similac Expert Care

NeoSure (2 cases)

4 596 Formula 96-2 oz containers ready to feed

Similac NeoSure or Similac Expert Care

NeoSure (2 cases)

4 515 Formula 48-2 oz containers ready to feed

Similac NeoSure or Similac Expert Care

NeoSure (1 case)

2 516 Formula 16-2 oz containers ready to feed

Similac NeoSure or Similac Expert Care

NeoSure

FP-257


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-23 (cont'd)

Nutramigen LIPIL Food Package Code S82 (Assign S82)
34-13 oz cans concentrate Nutramigen LIPIL

Rank VC 2 N08
4 N57

Voucher Message Formula 15-13 oz cans concentrate Nutramigen
LIPIL Formula 19-13 oz cans concentrate Nutramigen
LIPIL

Medical Documentation Required S81 (Assign S81) 11-12.6 oz cans powder Nutramigen LIPIL with Enflora LGG

2 156 Formula 5-12.6 oz cans powder Nutramigen LIPIL with Enflora LGG
4 155 Formula 6-12.6 oz cans powder Nutramigen LIPIL with Enflora LGG

Medical Documentation Required

S83 (Assign S83) 28-32 oz containers ready to feed Nutramigen LIPIL
Medical Documentation Required

2 S03 Formula 14-32 oz containers ready to feed Nutramigen LIPIL
4 S03 Formula 14-32 oz containers ready to feed Nutramigen LIPIL

Nutramigen AA LIPIL Food Package Code
S91 (Assign S91) 9-14.1 oz cans powder Nutramigen AA LIPIL
Medical Documentation Required

Rank VC 4 706 2 706 4 707

Voucher Message

Formula Formula Formula

4-400 gram (14.1 oz) cans powder Nutramigen AA LIPIL 4-400 gram (14.1 oz) cans powder Nutramigen AA LIPIL 1-400 gram (14.1 oz) can powder Nutramigen AA LIPIL

Pregestimil LIPIL Food Package Code S04 (Assign S04) 8-16 oz cans powder Pregestimil LIPIL
Medical Documentation Required

Rank VC 2 140
4 140

Voucher Message Formula 4-16 oz cans powder Pregestimil LIPIL
Formula 4-16 oz cans powder Pregestimil LIPIL

FP-258


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-23 (cont'd)

Pregestimil LIPIL 20 Calorie

Food Package Code

Rank

S05 (Assign S05)

2

444-2 oz containers ready

to feed Pregestimil LIPIL

2

20 Calorie

4

Medical Documentation

4

Required

4

2

VC S61 S61 S61 S61 S63 S64

Voucher Message Formula 96-2 oz containers ready to feed
Pregestimil LIPIL 20 Calorie (2 cases)

Formula

96-2 oz containers ready to feed Pregestimil LIPIL 20 Calorie (2 cases)

Formula

96-2 oz containers ready to feed Pregestimil LIPIL 20 Calorie (2 cases)

Formula

96-2 oz containers ready to feed Pregestimil LIPIL 20 Calorie (2 cases)

Formula

48-2 oz containers ready to feed Pregestimil LIPIL 20 Calorie (1 case)

Formula

12-2 oz containers ready to feed Pregestimil LIPIL 20 Calorie (two 6packs)

Pregestimil LIPIL 24 Calorie

Food Package Code

Rank

S06 (Assign S06)

2

444-2 oz containers ready

to feed Pregestimil LIPIL

2

24 Calorie

4

Medical Documentation

4

Required

4

2

VC S65 S65 S65 S65 S67 S68

Voucher Message Formula 96-2 oz containers ready to feed
Pregestimil LIPIL 24 Calorie (2 cases)

Formula

96-2 oz containers ready to feed Pregestimil LIPIL 24 Calorie (2 cases)

Formula

96-2 oz containers ready to feed Pregestimil LIPIL 24 Calorie (2 cases)

Formula

96-2 oz containers ready to feed Pregestimil LIPIL 24 Calorie (2 cases)

Formula

48-2 oz containers ready to feed Pregestimil LIPIL 24 Calorie (1 case)

Formula

12-2 oz containers ready to feed Pregestimil LIPIL 24 Calorie (two 6packs)

Similac PM 60/40 Food Package Code S14 (assign S14) 9-14.1 oz cans powder Similac PM 60/40
Medical Documentation Required

Rank VC 4 527
2 528

Voucher Message

Formula

6-14.1 oz cans powder Similac PM 60/40

(1 case)

Formula

3-14.1 oz cans powder Similac PM 60/40

FP-259


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-23 (cont'd)

Similac Special Care 20 Food Package Code
S10 (Assign S10) 448-2 oz containers ready to feed Similac Special Care 20 With Iron
Medical Documentation Required

Rank VC 4 598 2 598 4 598 2 598 4 521 2 522

Voucher Message

Formula Formula Formula Formula Formula Formula

96-2 oz containers ready to feed Similac Special Care 20 With Iron (2 cases) 96-2 oz containers ready to feed Similac Special Care 20 With Iron (2 cases) 96-2 oz containers ready to feed Similac Special Care 20 With Iron (2 cases) 96-2 oz containers ready to feed Similac Special Care 20 With Iron (2 cases) 48-2 oz containers ready to feed Similac Special Care 20 With Iron (1 case) 16-2 oz containers ready to feed Similac Special Care 20 With Iron

Similac Special Care 24 Food Package Code S50 (Assign S50) 448- 2 oz containers ready to feed Similac Special Care 24 With Iron

Rank VC 2 594
2 594

Medical Documentation Required

4 594

4 594

4 523

2 524

Voucher Message Formula 96-2 oz containers ready to feed
Similac Special Care 24 With Iron (2 cases) Formula 96-2 oz containers ready to feed Similac Special Care 24 With Iron (2 cases) Formula 96-2 oz containers ready to feed Similac Special Care 24 With Iron (2 cases) Formula 96-2 oz containers ready to feed Similac Special Care 24 With Iron (2 cases) Formula 48-2 oz containers ready to feed Similac Special Care 24 With Iron (1 case) Formula 16-2 oz containers ready to feed Similac Special Care 24 With Iron

FP-260


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-23 (cont'd)

Similac Special Care 30 Food Package Code S60 (Assign S60) 448-2 oz containers ready to feed Similac Special Care 30 With Iron
Medical Documentation Required

Rank VC 2 585 2 585 4 585 4 585 4 525 2 526

Voucher Message Formula 96-2 oz containers ready to feed
Similac Special Care 30 With Iron (2 cases) Formula 96-2 oz containers ready to feed Similac Special Care 30 With Iron (2 cases) Formula 96-2 oz containers ready to feed Similac Special Care 30 With Iron (2 cases) Formula 96-2 oz containers ready to feed Similac Special Care 30 With Iron (2 cases) Formula 48-2 oz containers ready to feed Similac Special Care 30 With Iron (1 case) Formula 16-2 oz containers ready to feed Similac Special Care 30 With Iron

FP-261


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-24

MAXIMUM MONTHLY AMOUNTS AUTHORIZED Fully Formula Fed FORMULA TYPES, SIZES, AND MAXIMUM AMOUNTS

FFF: Table for Concentrate Formula

TYPE1

Container SIZE2

MAXIMUM AMOUNTS3 (By Infant Age)

Age 0-3 Months

Age 4-5 Months

Age 6-11 Months

Concentrate

13 ounces

31 cans or

34 cans or

24 cans or

Maximum listed in reconstituted fluid ounces

403 oz concentrate or 806 oz reconstituted or 26.9 oz per day

264 oz concentrate 312 oz concentrate

or

or

884 oz reconstituted 624 oz reconstituted

or

or

29.5 oz per day

20.8 oz per day

Maximum Allowed

806 fl oz

884 fl oz

624 fl oz

FFF: Table for Ready-To-Feed Formula

TYPE1

Container SIZE2

MAXIMUM AMOUNTS3 (By Infant Age)

Age 0-3 Months

Age 4-5 Months

Ready-To-Feed 32 ounces

26 cans

28 cans

2 ounces

416 bottles

448 bottles

3 ounces

277 bottles

298 bottles

4 ounces

208 bottles

224 bottles

8 ounces

104 cans

112 cans

Maximum Allowed

832 fl oz

896 fl oz

1 For each type listed, the most economical size is recommended. 2 Sizes listed are not all-inclusive. 3 Maximum amounts are listed for each age group for each form.

Age 6-11 Months 20 cans 320 bottles 213 bottles 160 bottles 80 cans 640 fl oz

FP-262


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-24 (cont'd)

FFF: Table for Powder Formulas with Standard Mixing Instructions4

TYPE1

MAXIMUM AMOUNTS3 (By Infant Age in # of Cans of Powder)

Powdered Reconstituted

4

fluid ounces

per container

Age 0-2 months

Age 3 months

Age 4-5 months

Age

Age

6 months 7-11 months

82-87

10

10

11

8

8

90-96

9

9

10

7

7

98-99

8

9

9

7

7

101-103

8

8

9

7

6

111-115

7

8

8

6

6

Maximum

870 fl oz

870 fl oz

960 fl oz

696 fl oz

696 fl oz

Allowed

4 Formula yield per container based on standard mixing instructions (reconstituted). Refer to

product label or manufacturer's website for reconstitution. If fluid ounce yield is not listed on

label ask for assistance from Office of Nutrition.

FFF: Table for Exempt Infant Formula and Medical Foods Without Standard

Reconstitution Instructions

TYPE1

Container SIZE2

MAXIMUM AMOUNTS5 (By Infant Age in # of Cans of Powder)

Powdered
5

Age 0-3 Months (128 oz maximum by can weight)

Age 4-5 Months (141 oz Age 6-11 Months (102 maximum by can weight) oz maximum by can
weight)

12 ounces 10 cans (120 oz)

11 cans

8 cans

12.8 ounces 10 cans- (128 oz)

11 cans

7 cans

12.9 ounces 9 cans- (116.1 oz)

10 cans

7 cans

14.1 ounces 9 cans- (126.9 oz)

10 cans

7 cans

14.3 ounces 8 cans- (114.4 oz)

9 cans

7 cans

16 ounces 8 cans- (128 oz)

8 cans

6 cans

24 ounces 5 cans- (120 oz)

5 cans

4 cans

25.7 ounces 4 cans- (102.8 oz)

5 cans

3 cans

Exempt infant formulas are those designed for low birth weight infants or infants with an inborn error of metabolism, or other medical or nutritional problem. To determine if a formula is exempt visit the WIC formula database at: http://grande.nal.usda.gov/wicworks/formulas/FormulaSearch.php .
Each formula is categorized as an infant formula or an exempt infant formula. 5 Use this table only for exempt infant formulas and medical foods that do not have standard instructions for reconstitution, such as metabolic formulas.

FP-263


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-25

MAXIMUM MONTHLY AMOUNTS AUTHORIZED Mostly Breastfed

FORMULA TYPES, SIZES, AND MAXIMUM AMOUNTS

MBF: Table for Concentrate Formula

TYPE1

Container MAXIMUM AMOUNTS3 (By Infant Age) SIZE2

Age 0-1 Month Age 1-3 Months Age 4-5 Months Age 6-11 Months

Concentrate 13 ounces

Maximum

listed

in

reconstituted

fluid ounces

4 cans or

14 cans or

52 oz concentrate 182

or

concentrate

104

oz 364

reconstituted

reconstituted

3.5 oz per day

12 oz per day

17 cans or

12 cans or

oz 221 oz concentrate 156

oz

442

oz concentrate

oz reconstituted

312

oz

14.5 oz per day reconstituted

10.4 oz per day

Max. oz

104 fl oz

364 fl oz

442 fl oz

312 fl oz

MBF: Table for Ready-To-Feed Formula

TYPE1

Container MAXIMUM AMOUNTS3 (By Infant Age in # of Cans of Powder) SIZE2

Age 0-1 Month Age 1-3 Months Age 4-5 Months Age 6-11 Months

Ready-ToFeed

32 ounces 3 cans

12 cans

14 cans

10 cans

2 ounces 52 bottles

192 bottles

224 bottles

160 bottles

3 ounces 34 bottles

128 bottles

149 bottles

106 bottles

4 ounces 26 bottles

96 bottles

112 bottles

80 bottles

8 ounces 13 cans

48 cans

56 cans

40 cans

Max. oz

104 fl oz

384 fl oz

448 fl oz

320 fl oz

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.

FP-264


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-25 (cont'd)

MBF: Table for Powder Formulas with Standard Mixing Instructions

TYPE1

Container SIZE2

MAXIMUM AMOUNTS3 (By Infant Age in # of Cans of Powder)

Powdered4 Reconstitute Age 0-1

Age 1-2

Age 3

Age 4-5

d fluid ounces per

Month

Months

Months

Months

container

Age 6-11 Months

82-87

1

5

5

6

4

90-96

1

4

4

5

4

98-99

1

4

4

5

3

101-103

1

4

4

5

3

111-115

1

3

4

4

3

Max oz

104 fl oz

435 fl oz

435 fl oz

522 fl oz

384 fl oz

4 Formula yield per container based on standard mixing instructions (reconstituted). Refer to

product label or manufacturer's website for reconstitution. If fluid ounce yield is not listed on

label ask for assistance from Office of Nutrition.

MBF: Table for Exempt Infant Formula and Medical Foods Without Standard Reconstitution Instructions

TYPE1

Container MAXIMUM AMOUNTS3 (By Infant Age in # of Cans of Powder) SIZE2

Powdered
5

Age 0-3 Months (64 oz 4-5 months (77 oz

6-11 months (56 oz

maximum by can weight) maximum by can weight) maximum by can weight)

12 ounces 5 cans (60 oz)

6 cans

4 cans

12.8 ounces 5 cans- (64 oz)

5 cans

4 cans

12.9 ounces 4 cans- (51.6 oz)

5 cans

4 cans

14.1 ounces 4 cans- (56.4 oz)

5 cans

3 cans

14.3 ounces 4 cans- (57.2 oz)

5 cans

3 cans

16 ounces 4 cans- (64 oz)

4 cans

3 cans

24 ounces 2 cans- (48 oz)

3 cans

2 cans

25.7 ounces 2 cans- (51.4 oz)

2 cans

2 cans

Exempt infant formulas are those designed for low birth weight infants or infants with an inborn error of metabolism, or other medical or nutritional problem. To determine if a formula is exempt visit the WIC formula database at: http://grande.nal.usda.gov/wicworks/formulas/FormulaSearch.php .
Each formula is categorized as an infant formula or an exempt infant formula. 5 Use this table only for powdered products that do not have standard instructions for reconstitution, such as metabolic formulas.

FP-265


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-26

FORMULA TYPES, SIZES, AND MAXIMUM AMOUNTS - INFANT FOODS MAXIMUM MONTHLY AMOUNTS

(For Infants 6 through 11 Months)

INFANT FOOD

SIZE

Infant Cereal Infant Fruit and Vegetable Infant Meats

8 ounces 4 ounces 2.5 ounces

MAXIMUM AMOUNTS

FFF MBF

Exclusively Breastfed

24 oz

24 oz

128 oz (32 jars)

256 oz (64 jars)

N/A

77.5 oz (31 jars)

FP-266


GEORGIA WIC 2011 PROCEDURES MANUAL

Attachment FP-27

Voucher Codes for Special Formula Packages for Mostly Breastfeeding Infants

Maximum Amounts

Formula Name

Age

Max Allowed

Voucher Code

Amount

Similac Expert

0-1

1-powder

358

1 can

Care Alimentum

1-2

3-powder

S01

3 cans

3

4 powder

360

4 cans

4-5

4-powder

360

4 cans

6-11

3-powder

S01

3 cans

N01

16 jars

baby foods

N26

16 jars

cereal

3 boxes

Similac Expert

0-1

Care Alimentum

3-RTF

359

1 can

359

1 can

359

1 can

1-2

12-RTF

359

1 can

359

1 can

N05

10 cans

3

12-RTF

359

1 can

359

1 can

N05

10 cans

4-5

14-RTF

150

14 cans

6-11

10-RTF

N05

10 cans

N01

16 jars

baby foods

N26

16 jars

cereal

3 boxes

EleCare for

0-1

1-powder

S36

1 can

Infants

1-2

4-powder

S35

4 cans

3

4-powder

S35

4 cans

4-5

5-powder

S35

4 cans

S36

1 can

6-11

4-powder

S35

4 cans

N01

16 jars

baby foods

N26

16 jars

cereal

1 boxes

EnfaCare

0-1

1-powder

591

1 can

1-2

5-12.8 powder

4 or 5 cans

S11

3

5-12.8 powder

S11

4 or 5 cans

4-5

6-12.8 powder

541

5 or 6 cans

6-11

4-powder

542

4 can

N01

16 jars

FP-267


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-27 (cont'd)

Voucher Codes for Special Formula Packages for Mostly Breastfeeding Infants

Maximum Amounts

Formula Name

Age

Max Allowed

Voucher Code

Amount

EnfaCare

0-1 1-3 4-5 6-11

Enfamil

0-1

Premature LIPIL

1-3

20

4-5

baby foods cereal 3-RTF
12-RTF 14-RTF
10-RTF baby foods
cereal 48-2 oz 192-2 oz 222-2 oz

6-11

Enfamil

0-1

Premature LIPIL

1-3

24

4-5

156-2 oz
baby foods cereal
48-2 oz 192-2 oz 222-2 oz

6-11

156-2 oz baby foods

N26

16 jars

3 boxes

544

1 can

544

1 can

544

1 can

543

6 cans

543

6 cans

543

6 cans

543

6 cans

S13

2 cans

543

6 cans

S12

4 cans

N01

16 jars

N26

16 jars

3 boxes

545

1 case

595

2 cases

595

2 cases

595

2 cases

595

2 cases

546

18 bottles

S21

12 bottles

595

2 cases

545

1 case

S21

12 bottles

N01

16 jars

N26

16 jars

3 boxes

547

1 case

597

2 cases

597

2 cases

597

2 cases

597

2 cases

548

18 bottles

S22

12 bottles

597

2 cases

547

1 case

S22

12 bottles

N01

16 jars

FP-268


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-27 (cont'd)

Voucher Codes for Special Formula Packages for Mostly Breastfeeding Infants

Maximum Amounts

Formula Name

Age

Max Allowed

Voucher Code

Amount

cereal

N26

16 jars

3 boxes

Enfamil AR

0-1

1-powder

307

1 can

1-3

4-powder

N33

4 cans

4-5

5-powder

168

5 cans

6-11

4-powder

N33

4 cans

baby foods

N01

16 jars

cereal

N26

16 jars

3 boxes

Neocate Infant

0-1

1-powder

507

1 can

1-3

5-powder

507

1 can

506

4 cans

4-5

6-powder

507

507

506

6-11

4-powder

506

baby foods

N01

cereal

N26

Neocate Infant

0-1

1-powder

505

DHA & ARA

1-3

5-powder

505

500

4-5

6-powder

505

505

500

6-11

4-powder

500

baby foods

N01

cereal

N26

Nutramigen LIPIL

0-1

1-powder

157

with Enflora LGG

1-3

5-powder

156

4-5

6-powder

155

6-11

4-powder

S32

157

baby foods

N01

cereal

N26

FP-269


1 can 1 can 4 cans 4 cans 16 jars 16 jars 3 boxes 1 can 1 can 4 cans 1 can 1 can 4 cans 4 cans 16 jars 16 jars 3 boxes 1 can 5 cans 6 cans 3 cans 1 can 16 jars 16 jars 3 boxes

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-27 (cont'd)

Voucher Codes for Special Formula Packages for Mostly Breastfeeding Infants

Maximum Amounts

Formula Name

Age

Max Allowed

Voucher Code

Amount

Nutramigen AA

0-1

1-powder

707

1 can

LIPIL

1-3

4-powder

706

4cans

4-5

5-powder

707

1 can

706

4cans

6-11

3-powder

S14

3 cans

baby foods

N01

16 jars

cereal

N26

16 jars

3 boxes

Pregestimil

0-1

1-powder

141

1 can

1-2

3-powder

S08

3 cans

3

4-powder

140

4 cans

4-5

4-powder

140

4 cans

6-11

3-powder

S08

3 cans

N01

16 jars

N26

16 jars

3 boxes

Similac Expert

0-1

1-powder

482

Care Neosure

1 can

1-3 4-5 6-11

Similac PM 60/40

0-1 1-3 4-5
6-11

Similac Special

0-1

Care 20

1-3

4-5

5-powder 6-powder 4-powder
baby foods cereal
1-powder 4-powder
5
3
baby foods cereal 48-2 oz
192-2 oz
224-2 oz

S25

5 cans

519

6 cans

520

4 cans

N01

16 jars

N26

16 jars

3 boxes

483

1 can

529

4 cans

483

1 can

529

4 cans

528

3 cans

N01

16 jars

N26

16 jars

3 boxes

521

1 case

598

2 cases

598

2 cases

598

2 cases

598

2 cases

522

16 bottles

FP-270


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-27 (cont'd)

Voucher Codes for Special Formula Packages for Mostly Breastfeeding Infants

Maximum Amounts

Formula Name

Age

Max Allowed

Voucher Code

Amount

6-11

160-2 oz

baby foods cereal

522

16 bottles

521

1 case

598

2 cases

522

16 bottles

N01

16 jars

N26

16 jars

3 boxes

Similac Special

0-1

Care 24

1-3

4-5

48-2 oz 192-2 oz
224-2 oz

6-11

160-2 oz

baby foods cereal

523

1 case

594

2 cases

594

2 cases

594

2 cases

594

2 cases

524

16 bottles

524

16 bottles

523

1 case

594

2 cases

524

16 bottles

N01

16 jars

N26

16 jars

3 boxes

FP-271


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-27 (cont'd)

Formula

Age

Similac Special

0-1

Care 30

1-3

4-5

6-11

Max Allowed 48-2 oz 192-2 oz 224-2 oz
160-2 oz
baby foods cereal

Voucher Code 525 585 585 585 585 526 526 525 585 526 526 N01
N26

Amount 1 case 2 cases 2 cases 2 cases 2 cases 16 bottles 16 bottles 1 case 2 cases 16 bottles 16 jars 16 jars 3 boxes 1 case

FP-272


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-28

SUPPLEMENTAL FORMULA CONVERSION TABLE - MODULARS Displacement Method

Monthly RX

Concentrate
One 13 oz
13 *Duocal (14.1 oz powder)

1 can

4

2 cans

8

3 cans

12

4 cans

16

Amount of Formula Replaced

Powder12 - 16 oz

Powder22- 24 oz

1

1

2

1

3

2

4

2

Ready-to-Feed 32 oz
4 7 10 13

** Polycose (12.3 oz powder)

1 can

4

1

1

4

2 cans

8

2

1

7

3 cans

12

3

2

10

4 cans

16

4

2

13

*** MCT Oil (32 fl oz bottle)

1 bottle

3

1

1

3

2 bottles

6

2

1

3

*

Duocal powder: 1 can contains 42 TBSP/1968 Calories

**

Polycose powder: 1 can contains 59 TBSP/1330 Calories

***

MCT Oil: 1 bottle contains 960 cc/64 TBSP/7392 Calories

3 teaspoons = 1 TBSP 1 fl oz = 30 cc

FP-273


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-29

MAXIMUM MONTHLY AMOUNTS of FORMULA AUTHORIZED for CHILDREN & WOMEN WITH QUALIFYING MEDICAL CONDITIONS FOOD PACKAGE III
See Also Children and Women Maximum Amounts Attachments FP-29 & FP-30

FORMULA TYPES, SIZES AND ADDITIONAL AMOUNTS

Formula Type: Child Max

ConcentrateRTFPowder-

455 fluid ounces 910 fluid ounces 910 fluid ounces reconstituted or 144 oz (if no standard dilution)

TYPE Concentrate
Ready-To-Feed

CAN SIZE 13 ounces
32 ounces

Children & Women Maximum Amounts
35 cans or 455 ounces maximum concentrate or 910 fluid ounces reconstituted 28 cans or 910 fluid ounces

Table for Powder Formulas With Standard Mixing Instructions

Powdered4

Reconstituted fluid ounces per container

Maximum Number of Cans Allowed

66-70

13

71-75

12

76-82

11

83-91

10

92-101

9

102-113

8

114-130

7

Maximum Allowed 4 Refer to product label or manufacturer's website for reconstitution.

910 fl oz

Table for Powder Exempt Formulas and Medical Foods Without Standard Reconstitution Instructions for Children and Women

Powdered5

144 ounces Maximum by can weight

Maximum Number of Cans Allowed Per Month

12 ounces

12 cans

12.8 ounces

11 cans

12.9 ounces

11 cans

14.1 ounces

10 cans

14.3 ounces

10 cans

16 ounces

9 cans

24 ounces

6 cans

25.7 ounces

5 cans

5Use this table only for powdered products that do not have standard instructions for

reconstitution, such as metabolic formulas.

FP-274


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-30

MAXIMUM MONTHLY AMOUNTS OF WIC FOODS AUTHORIZED FOR CHILDREN

FOOD Milk1

Food Package IV MAXIMUM AMOUNT PER MONTH
16 quart equivalents2

Cheese Tofu Eggs Juice

4 pounds3 8 pounds8
1 dozen
2-64 ounce containers

Cereal

36 ounces (Maximum of 32 oz infant cereal)

Beans/Peas OR Peanut Butter

1 pound bag dried or 4 cans (14-16 ounces) OR 1 container (16-18 oz)

Fruits and Vegetables

$6.00

Whole Grain Bread or alternative

32 ounces

1 May substitute up to 16 quarts of lactose reduced milk for up to 4 gallons of milk.

2 Substitution amounts for fluid milk include:

ITEM

FLUID MILK EQUIVALENTS

Cheese, 1 pound

3 quarts3

Evaporated milk, whole or skim , 12 ounces 4 cans equal 3 quarts4,5

Nonfat or low-fat dry milk

1-3 quart container equal to 3 quarts6,7

Tofu, 1 pound

1 quart8

3 Subtract from monthly milk allotment. A maximum of one (1) pound of cheese per month is

allowed without medical documentation and a maximum of four (4) pounds with medical

documentation of a qualifying condition. 4 If no cheese is issued, a maximum of 12 quarts of milk may be substituted with evaporated

milk (16 cans). This leaves one gallon of fluid milk in the food package. 5 If one pound of cheese is issued, a maximum of 9 quarts of milk may be issued with
evaporated milk (12 cans). This leaves one gallon of fluid milk in the food package. 6 If no cheese is issued, a maximum of 12 quarts of milk may be substituted with dry powder
milk. This leaves one gallon of fluid milk in the food package. 7 If one pound of cheese is issued a maximum of 9 quarts of milk may be substituted with dry
powder milk. This leaves one gallon of fluid milk in the food package. 8 Subtract from monthly milk allotment. Medical documentation required for a child to receive
any tofu.

See Attachment FP-38 for more information on milk substitutions

FP-275


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-31

MAXIMUM MONTHLY AMOUNTS OF WIC FOODS AUTHORIZED FOR WOMEN

FOOD

PREGNANT (Singleton), MOSTLY
BREASTFEEDING

EXCLUSIVELY BREASTFEEDING11,
PREGNANT WITH MULTIPLE
FETUSES, MOSTLY BREASTFEEDING
MULTIPLES7

NONBREASTFEEDING,
SOME BREASTFEEDING

Milk2

Food Package V 22 quart equivalents 3

Food Package VII 24 quart equivalents3

Food Package VI 16 quart equivalents3

Cheese Tofu8

6 pounds 4,5 12 pounds

6 pounds4,5,6 12 pounds

4 pounds4,5 12 pounds

Eggs

1 dozen

2 dozen

1 dozen

Juice

3 (46-48 oz) containers or 3-12 oz cans frozen or 3-11.5 oz cans pourable

3 (46-48 oz) containers or 3-12 oz cans frozen or 3-11.5 oz cans pourable

2 (46-48 oz) containers or 2-12 oz cans frozen or 2-11.5 oz cans pourable

Cereal

36 ounces

36 ounces

36 ounces

Beans/Peas and/or
Peanut Butter

1 pound bag dried or 4 (14-16 oz) cans and 1 container (16-18 oz)

1 pound bag dried or 4 (14-16 oz) cans and 1 container (16-18 oz)

1 pound bag dried or 4 (14-16 oz) cans OR 1 container (16-18 oz)

Fruit and Vegetable

$10.00

$10.00

$10.00

Whole

16 oz

16 oz

N/A

Grain or

Alternative

Fish1

N/A

30 oz

N/A

1 Additional item authorized for Food Package VII only. 2 May substitute up to maximum quart equivalents of lactose reduced milk for milk. 3 Substitution amounts for fluids milk include:

ITEM Cheese, 1 pound Evaporated milk, non-fat (12 oz) Nonfat or low-fat dry milk Tofu, 1 pound

FLUID MILK EQUIVALENTS 3 quarts4,5 4 cans equal 3 quarts9 1-3 quart container equal to 3 quarts10 1 quart8

4 Subtract from monthly milk allotment. A maximum of one (1) pound of cheese per month is allowed without medical documentation of a qualifying condition. Women in Food Package VII are allowed up to a total of three (3) pounds of cheese per month without medical documentation.

FP-276


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-31 (cont'd)

5 Substitute up to six (6) pounds of cheese with medical documentation for Food Package V and VII and up to four (4) pounds of cheese for Food Package VI with medical documentation. 6 The standard package includes one (1) pound of cheese; staff may substitute up to an additional five (5) pounds of cheese with medical documentation for a total of six (6) pounds. 7 Women exclusively breastfeeding multiples can receive 1.5 times the amounts listed. 8 One (1) pound of tofu can be substituted for 1 quart of milk. Subtract from monthly milk allotment. Medical documentation must be on file to receive more than four (4) pounds of tofu for Food Packages V and VI and to receive more than six (6) pounds for Food Package VII. 9 For postpartum women not receiving cheese, a maximum of 12 quarts of milk may be substituted with evaporated milk or 9 quarts when one (1) pound of cheese is issued. In both cases this leaves one gallon of fluid milk. For pregnant and breastfeeding women not receiving cheese, a maximum of 18 quarts of milk may substituted with evaporated milk or 15 quarts when one (1) pound of cheese is issued. In both cases, one gallon of fluid milk is left. For exclusively breastfeeding women 21 quarts of milk may be substituted with evaporated milk. They would receive two (2) pounds of cheese with this package. 10 For postpartum women not receiving cheese a maximum of 12 quarts of milk may be substituted with dry powder milk or 9 quarts with one (1) pounds of cheese. In both cases one gallon of fluid milk is left. For pregnant and breastfeeding women not receiving cheese, a maximum of 18 quarts of milk may substituted with dry powder milk or 15 quarts when one (1) pound of cheese is issued. In both cases one gallon of fluid milk is left. For exclusively breastfeeding women 21 quarts of milk of milk may be substituted with dry powder milk. They would receive two (2) pounds of cheese with this package. 11Women exclusively breastfeeding multiple infants receive 1.5 times the amounts of food listed in the table for women exclusively breastfeeding women. Items not in full packages can be averaged over two months (e.g., 1.5 jars of peanut butter with one jar being issued one month and two jars to next month).

FP-277


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-32

MAXIMUM MONTHLY AMOUNTS OF WIC FOODS AUTHORIZED FOR ALTERNATIVE FOOD PACKAGES
FOR FULLY FORMULA FED INFANTS (0-3 MONTHS)
Contract Standard Formulas

TYPE Ready-To-Feed

SIZE 104-8 oz containers

MAXIMUM AMOUNT 832 fluid ounces

This food package consists of five vouchers per month.

FOR FULLY FORMULA FED INFANTS (4-5 MONTHS) Contract Standard Formulas

TYPE

SIZE

MAXIMUM AMOUNT

Ready-To-Feed

112-8 oz containers

896 fluid ounces

This food package consists of five vouchers per month.

FOR FULLY FORMULA FED INFANTS (6-11 MONTHS) Contract Standard Formulas

TYPE Ready-To-Feed Cereal, Infant

SIZE 80-8 oz containers 3-8 oz boxes, dry

MAXIMUM AMOUNT 640 fluid ounces 24 ounces

Infant fruit and vegetables

32-4 oz jars

128 ounces

This food package consists of six (6) vouchers per month.

FP-278


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-32 (cont'd)

FOR CHILDREN AND WOMEN WITH QUALIFYING MEDICAL CONDITIONS: MAXIMUM MONTHLY AMOUNTS AUTHORIZED FOR FORMULAS

FOOD Ready-To-Feed Formula

SIZE 113-8 oz containers

MAXIMUM AM0UNTS 910 fluid ounces

ALTERNATIVE FOOD PACKAGES FOR CHILDREN AGES 1 TRHOUGH 5 YEARS MAXIMUM MONTHLY AMOUNTS AUTHORIZED

FOOD UHT Milk

SIZE
64-8 ounce OR half pint boxes

MAXIMUM AMOUNTS 512 fluid ounces

Cereal

3-12 oz boxes

36 ounces

Juice

21 (5.5 to 6 oz) cans

128 fluid ounces

Peanut Butter

1 container (16-18 oz)

Whole Grain Bread or alternative

2-16 oz loaves

This food package consists of six (6) vouchers.

18 ounces 32 oz

FP-279


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-32 (cont'd)

FOR PREGNANT AND MOSTLY BREASTFEEDING WOMEN MAXIMUM MONTHLY AMOUNTS AUTHORIZED

FOOD

PREGNANT AND
MOSTLY BREASTFEEDING Food Package V

EXCLUSIVELY BREASTFEEDING,
MOSTLY BREASTFEEDING MULTIPLES, AND PREGNANT WITH MULTIPLE FETUSES
Food Package VII

UHT Milk, lowfat
Cheese
Whole grains or Alternative

88 - 8 ounce OR half pint boxes
16 oz

96 - 8 ounce OR half pint boxes
1 lb cheese 16 oz

Cereal

3 - 12 oz boxes

3 - 12 oz boxes

Juice Peanut Butter
Beans/Peas

24 (5.5 to 6 oz) cans
2 containers (16-18 oz each)
N/A

24 (5.5 to 6 oz) cans
1 container (16-18 oz) and 4 (14-16 oz) cans

Fish

N/A

6 5 oz cans

SOME BREASTFEEDING AND
NON-BREASTFEEDING Food Package VI
64 8 ounce OR half pint boxes
N/A 3 - 12 oz boxes 16 (5.5 to 6 oz) cans 1 container (16-18 oz) N/A N/A

Fruit and

$10

$10

$10

vegetable

Note* These food packages consist of 6-8 vouchers

FP-280


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-33

How to Convert Breastfeeding Packages

Step1: List food allowed in smaller package Step 2: Subtract amounts of foods on vouchers already cashed Step 3: Issue remaining foods using a 999 voucher

Sample: Mostly to Some for Standard Food Packages

Can not be done mid-month if: 1) Voucher code W02 cashed or 2) Voucher codes 041 and 040 both have been cashed or 3) Three (3) or more regular vouchers have been cashed

W01 to W21

(Mom returns voucher codes W02 and 040)

Milk

Dry milk Juice Cheese Eggs Cereal

Allowed 2 gal

1 pkg

2

1

1

36

041

1 gal

2

1

36

Remaining 1 gal

1 pkg

0

1

0

0

W01

1 gal

1

1

Issue

gal

0

0

0

0

0

Issue VC A34. Client may keep P02 voucher. Mom would return W02 and 040.

Beans/PB F/veg 1 or 1 $10

1 or 1 $10

1 PB

0

$10

Allowed 040 Remaining W01 Issue

Milk 2 gal 1 gal 1 gal 1 gal gal

W01 to W21

(Mom returns voucher codes W02 and 041)

Dry milk Juice Cheese Eggs Cereal

1 pkg

2

1

1

36

1

1 pkg

1

1

1

36

1

1

1

0

1

0

1

36

Beans/PB F/veg 1 or 1 $10

1 or 1 $10

1 PB

0

$10

It's okay if P02 has been cashed.

Issue VC A34 and W71. Client may keep P02voucher.

If only VC 041 has been used she keeps W01 and P02. You issue VC A34.

If only VC 040 has been used She keeps W01 and P02. You issue VC A34 and W71.

If only VC W01 has been used She keeps 041 and P02. You issue VC A34.

Sample: Exclusively to Mostly Breastfeeding
Can not be done mid-month if: 1) Voucher code W03 has been cashed or 2) Voucher codes W82 and 039 has been cashed
FP-281


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-33 (cont'd)

W41 to W01 (mom returns voucher codes 039, W03) Milk Dry milk Juice Cheese Eggs Cereal Beans/PB

Allowed 4 1

3

1

1

W82

2

2

1

Remaining 2 1

1

1

0

W02

1

Remaining 1 1

1

1

0

Issue VC 040 and A35. Mom returns 039, W03.

36 oz 36 0
0

1 and 1
1 and 1 1 beans 1 PB

Whole Grain 16 oz
16 16 0

F/veg $10 $10 $10

W41 to W01 (mom returns voucher codes W82, W03) Milk Dry milk Juice Cheese Eggs Cereal Beans/PB

Allowed 4 1

3

1

1

36 oz

039

1

1

1

Remaining 3 1

2

1

0

36

W02

1

Remaining 2 1

2

1

0

36

Issue VC 040, 040, 780, and A35. Mom returns W82 and W03.

1 and 1
1 and 1 1 beans 1 PB

Whole Grain 16 oz
16 16 0

F/veg $10 $10 $10

If only VC W82 has been used - she keeps W02. You issue VC 040 and A35.

If only VC 039 has been used She keeps W02. You issue VC 040, 780, 040 and A35.

If only VC W02 has been used she keeps W82. You issue VC 040 and A35.

FP-282


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-33 (cont'd)

Special Voucher Codes Used in Converting Standard Food Packages

A34 Milk: 1 half gallon low-fat (fat-free, 1%, 2%) No whole milk. Least

expensive brand

A35

Dry 1-3 quart container non-fat dry powder or 4-12 oz cans low-

Milk: fat (fat-free, skimmed, 2%) evaporated

Cheese: 1-16 oz package

Peanut

Butter: 1 container (16-18 oz)

040 Milk:

1 gallon low fat (fat-free, 1%, 2%) No whole milk Least

expensive brand

Juice: W71 Juice:

1-46 oz container or 1-12 oz can frozen or 1-11.5 oz can pourable concentrate 1 container (46 to 48 oz) or 1-12 oz can frozen or 1-11.5 oz can pourable concentrate

Eggs: 1 dozen

Cereal: No more than 36 oz

FP-283


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-34

Infant Formulas with Sequencing Exceptions

Similac Special Care Alimentum, Pregestimil LIPIL

Age at Issuance

Package Assigned

Package Issued

Amount Issued

0 2 month 15 days

R**

R**

7 powder

2 month 16 days 5 months 15 days

S**

8 powder

5 months 16 days 11 months 15 days

T**

6 powder +

*5 months 16 days 11 months 15 days

S**

S**

8 powder

* Alternative package for infants unable to eat solids foods ** Insert package number for type of formula being issued + Receives infant cereal and infant fruits and vegetables in addition to formula

Nutramigen AA LIPIL

Age at Issuance

Package Assigned

Package Issued

Amount Issued

0 2 month 15 days

R**

R**

8 powder

2 month 16 days 5 months 15 days

S**

9 powder

5 months 16 days 11 months 15 days

T**

7 powder +

*5 months 16 days 11 months 15 days

S**

S**

9 powder

* Alternative package for infants unable to eat solids foods ** Insert package number for type of formula being issued + Receives infant cereal and infant fruits and vegetables in addition to formula

Similac PM 60/40 Age at Issuance
0 3 month 15 days 3 month 16 days 5 months 15 days 5 months 16 days 6 months 15 days

Package Assigned
R14

Package Issued
R14 S14 V14

Amount Issued 8 powder 9 powder 7 powder+

6 months 16 days 11 months 15 days

T14

6 powder+

*6 months 16 days 11 months 15 days

S

S14

9 powder

* Alternative package for infants unable to eat solids foods

+Receives infant cereal and infant fruits and vegetables in addition to formula

FP-284


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-35

WIC Approved Formulas/Medical Foods

Contract Infant Formula: a,b

Gerber Good Start Gentle

Nestl HealthCare Nutrition

Gerber Good Start Soy

Nestl HealthCare Nutrition

Gerber Good Start 2 Gentle (age 9-11 months) Nestl HealthCare Nutrition

Gerber Good Start 2 Soy (age 9-11 months) Nestl HealthCare Nutrition

Non-Contract Formulas/Medical Foods Requiring Medical Documentation: a,b,c

Formula
A-Soy
Acerflex Add-Ins
Advera
AlitraQ
Boost Boost Glucose Control Boost High Protein Boost Kid Essentials Boost Kid Essentials 1.5 Boost Kid Essentials 1.5 w / fiber Boost Plus Boost Pudding Bright Beginnings Pediatric Nutritional Drink Bright Beginnings Pediatric Nutritional Drink w/Fiber

Manufacturer PBM Products Nutricia Nutricia Ross Products Ross Products Nestl
Nestl
Nestl
Nestl
Nestl
Nestl
Nestl Nestl
PBM Products
PBM Products

Formula Bright Beginnings Soy Pediatric Nutritional Drink
Calcilo XD
Carnation Instant Breakfast Essentials Carnation Instant Breakfast Essentials, No Sugar Added Carnation Instant Breakfast Lactose Free Carnation Instant Breakfast Lactose Free Plus Carnation Instant Breakfast Lactose Free VHC Compleat Compleat Pediatric

Manufacturer PBM Products Ross Products Nestl
Nestl
Nestl
Nestl
Nestl Nestl Nestl

Formula Manufacturer

Complex MSUD Amino Acid Bars

Applied Nutrition Corporation

Crucial

Nestl

Cyclinex 1

Ross Products

Cyclinex 2

Ross Products

Duocal

Nutricia

EO28 Splash

Nutricia

EleCare Jr

Ross Products

EleCare for Ross

Infants

Products

EnfaCare

Mead Johnson

Enfagrow

Gentlease

Next Step Mead

or Enfagrow Johnson

Gentlease

Toddler

Enfamil

Mead

A.R.

Johnson

Enfamil Human Milk Fortifier

Mead Johnson

Enfamil Human Milk Fortifier with iron

Mead Johnson

FP-285


GEORGIA WIC 2012 PROCEDURES MANUAL

Enfamil

Mead

Gentlease Johnson

Enfamil Premature LIPIL 20

Mead Johnson

Enfamil Premature LIPIL 20 with iron

Mead Johnson

Enfamil Premature LIPIL 24

Mead Johnson

Enfamil

Premature Mead

LIPIL 24 Johnson

with iron

Enfaport Mead

LIPIL

Johnson

Enlive

Ross Products

Ensure

Ross Products

Ensure with Ross

Fiber

Products

Ensure High Protein

Ross Products

Ensure Plus

Ross Products

Ensure Plus Ross

HN

Products

Ensure

Ross

Pudding Products

Fiber Source HN

Nestl

Forta Drink

Ross Products

Forta

Ross

Shake

Products

Gerber

Good Start Premature

Nestl

24

Glucerna

Ross Products

Glutarex-1

Ross Products

Glutarex-2
Hominex-1
Hominex-2
Introlite
IsoSource 1.5 IsoSource HN
I-Valex-1
I-Valex-2
Jevity
KetoCal 3:1 KetoCal 4:1
Ketonex-1
Ketonex-2
KetoVolve
L-Emental
L-Emental Hepatic L-Emental Pediatric Lipistart
Lo*Pro
MCT Oil Methionaid Microlipid Monogen MSUD Analog MSUD Maxamaid MSUD Maxamum MSUD-1 MSUD-2 Neocate Infant

Ross Products Ross Products Ross Products Ross Products
Nestl
Nestl
Ross Products Ross Products Ross Products Nutricia Nutricia Ross Products Ross Products Solace Nutrition Hormel Health Labs Hormel Health Labs Hormel Health Labs Vitaflow Med-Diet Labs Nestl Nutricia Nestl Nutricia
Nutricia
Nutricia
Nutricia
Nutricia Nutricia
Nutricia

FP-286


Attachment FP-35

Neocate Infant DHA & ARA Neocate Junior Neocate Junior with Prebiotics Neocate Nutra
Nepro
Nitro-Pro
NovaSourc e Renal Nutramigen AA LIPIL Nutramigen LIPIL Nutramigen LIPIL with Enflora LGG Nutren 1.0 Nutren 1.0 with Fiber Nutren 1.5 Nutren 2.0 Nutren Glytrol Nutren Junior Nutren Junior Fiber Nutren Pulmonary Nutren Replete with Fiber NutriHep NutriVent
Osmolite
Osmolite HN Plus

Nutricia
Nutricia
Nutricia
Nutricia Ross Products Hormel Health Labs
Nestl
Mead Johnson Mead Johnson
Mead Johnson
Nestl Nestl Nestl Nestl Nestl
Nestl
Nestl
Nestl
Nestl
Nestl Nestl Ross Products Ross Products

GEORGIA WIC 2012 PROCEDURES MANUAL

Parent's Choice Added Rice Starch Parent's Choice Sensitivity
PediaSure
PediaSure w/Fiber PediaSure 1.5 Cal PediaSure 1.5 Cal with fiber PediaSure Enteral PediaSure Enteral w/Fiber and scFOS Pepdite Junior Pediasure Peptide Peptamen Peptamen 1.5 Peptamen AF Peptamen Junior Peptamen Junior Fiber Peptamen Junior 1.5 Peptamen Junior with Prebio Peptamen OS (formerly Peptinex 1.0)

PBM Products
PBM Products Ross Products Ross Products Ross Products Ross Products Ross Products
Ross Products
Nutricia
Ross Nestl Nestl
Nestl
Nestl
Nestl
Nestl
Nestl
Nestl

Peptamen OS 1.5 (formerly Peptinex 1.5)
Perative
Periflex Advance Periflex Infant Periflex Junior
Phenex-1
Phenex-2
PhenylAde 40Drink Mix
PhenylAde 60Drink Mix
PhenylAde Amino Acid Bars PhenylAde Amino Acid Blend
PhenylAde Drink Mixes
PhenylAde Essential Drink PhenylAde MTE Amino Acid Blend PhenylFree 2 PhenylFree 2HP Phlexy 10 Bar Phlexy 10 Capsules Phlexy 10 Drink Mix PKUExpress

Nestl
Ross Products
Nutricia
Nutricia North America
Nutricia
Ross Products Ross Products Applied Nutrition Corporation Applied Nutrition Corporation Applied Nutrition Corporation Applied Nutrition Corporation Applied Nutrition Corporation Applied Nutrition Corporation Applied Nutrition Corporation Mead Johnson Mead Johnson
Nutricia
Nutricia
Nutricia
Vitaflo Limited

FP-287


Attachment FP-35

PKU-Gel
Polycal
Polycose
Portagen
Pregestimil LIPIL Pregestimil LIPIL 24 ProBalance Product 3200AB Product 3232 A Product 80056
ProMod
Promote
Pro-Peptide
Pro-Peptide for Kids Pro-Peptide VHN
Pro-Phree
Propimex-1
Propimex-2
Protifar
ProViMin
Pulmocare
RE/GEN
Renalcal Resource 2.0 Resource Benecalorie Resource Benefiber

Vitaflo Limited Nutricia Ross Products Mead Johnson Mead Johnson Mead Johnson Nestl Mead Johnson Mead Johnson Mead Johnson Ross Products Ross Products Hormel Health Labs Hormel Health Labs Hormel Health Labs Ross Products Ross Products Ross Products Nutricia North America Ross Products Ross Products Nutra/ Balance Nestl
Nestl
Nestl
Nestl

GEORGIA WIC 2012 PROCEDURES MANUAL

Resource Beneprotein

Nestl

Resource Breeze

Nestl

Ross CHO Ross

Free (RCF) Products

Scandical

Calorie

Scandipharm

Booster

Scandishak e

Scandipharm

Scandishak

e Lactose Scandipharm

Free

Scandishak

e Sugar

Scandipharm

Free

Similac Expert Care Alimentum

Ross Products

Similac Expert Care for Diarrhea

Ross Products

Similac Expert Care NeoSure

Ross Products

Similac

Human Milk Ross

Fortifier

Products

with iron

Similac PM Ross

60/40

Products

Similac

Ross

Sensitive Products

Similac Sensitive for Spit Up

Ross Products

Similac Special Care 20

Ross Products

Similac Special Care with Iron 20

Ross Products

Similac Special Care 24

Ross Products

Similac Special Care with Iron 24
Similac Special Care with Iron 30
Suplena
Tolerex
TwoCal HN
Tyrex-1
Tyrex-2
UCD-2 Vital High Nitrogen Vivonex Pediatric Vivonex Plus Vivonex T.E.N. XLeu Analog XLeu Maxamaid XLeu Maxamum XLYS, XTrp Analog XLys, XTrp Maxamaid XLys, XTrp Maxamum XMet Analog XMet Maxamaid XMet Maxamum XMTVI Analog XMTVI Maxamaid

Ross Products
Ross Products
Ross Products Nestl Ross Products Ross Products Ross Products Nutricia Ross Products
Nestl
Nestl
Nestl
Nutricia
Nutricia
Nutricia
Nutricia
Nutricia
Nutricia
Nutricia
Nutricia
Nutricia
Nutricia

FP-288


Attachment FP-35

XMTVI Maxamum

Nutricia

XPhe , XTyr Maxamaid

Nutricia

XPhe Maxamaid

Nutricia

XPhe Maxamum

Nutricia

XPhe

Maxamum Nutricia

Drink

XPHE, XTyr Analog

Nutricia

XPTM Analog

Nutricia

Nutricia

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-35

a. 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. (4) For participants in Food Package III with a qualifying medical condition and who are receiving exempt infant formulas or medical foods (a) if the ready-to-feed form better accommodates the participant's medical condition or (b) if the ready-to-feed form improves the participant's compliance in consuming the prescribed formula.
b. If a health care provider with prescriptive authority orders a product that is not on this list, contact the Nutrition Services Unit to determine whether the product is authorized for distribution through Georgia WIC.
c. Special formulas may be acquired through the Nutrition Services Unit. See Georgia WIC Procedures Manual, Food Package Section for appropriate procedure and forms.

FP-289


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-36

Formula Manufacturers

Hormel Health Labs 3000 Tremont Road Savannah, Georgia 31405 (800) 866-7757

PBM Products 204 N. Main St. Gordonsville, VA 22942 (800) 485-9969

Mead Johnson Nutritional Group 2400 W. Lloyd Expressway Evansville, Indiana 47721-0001 (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 Nutrition 12 Vreeland Road, 2nd Floor Florham Park, New Jersey 07932 (973) 593-7500 FAX (973) 593-7718
Nutra/Balance Products 7155 Wadsworth Way Indianapolis, Indiana 46219 (800) 432-3134
Nutricia North America 9900 Belward Campus Drive, Ste. 100 Rockville, MD 20850 (800) 365-7354 FAX (301) 795-2301

Ross Products Division, Abbott Nutrition 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
Solace Nutrition One Research Court , Suite 450 Rockville, MD 20850 (888) 876-5223 FAX (401) 633-6066
Vitaflo Limited Distributed Through:
Transitional Service and Operation 123 East Neck Road Huntington, New York 11743 (631) 547-5984

FP-290


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-37

SPECIAL FORMULA ORDER FORM

I. TO BE COMPLETED BY DISTRICT/LOCAL STAFF

Date Faxed:

Rush Delivery: YES NO

Nutrition Services Unit called or emailed and notified of incoming fax.

Written medical documentation with medical diagnosis attached.

Returned packing slip to the Nutrition Services Unit when formula was received.

1. Name of WIC client & WIC ID Number

2. Birth Date

x "First Day To Use" date on vouchers for current issuance month

x Infant age (in months & days) as of "First Day To Use" date

3. Diagnosis(es)

4. Name of formula requested

x Formula flavor (if applicable)

5. Product number/manufacturer of formula

6. Amount of formula needed for current month (number of cans / containers)

x Amount of formula prescribed per month (total # of cans / containers)

x Amount of formula on hand (number of cans / containers)

7. Type of formula: ready to feed, concentrate, powder, single use bottle, etc. (Provide justification for RTF formula)

8. Estimated time on formula

9. Formula issue month (based on voucher "First Day To Use" date) __________________

10. Clinic name, contact person, and phone no.

11. Address/telephone number to ship formula

12. Prescribing Physician 13. District contact person 14. WIC/Nutrition Coordinator's signature or designee
II. TO BE COMPLETED BY NUTRITION SERVICES UNIT
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. State Nutrition Program Consultant's signature & date
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 _________________________________________________________________________________ NUTRITION SERVICES UNIT, PHONE: (404) 657-2884, FAX: (404) 657-2886 or (404) 657-2910
FP-291


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-38

Special Formula Order Tracking Form Sample
Clients Name: _________________

Next Rx P/U Due Date Code

Next Pick Up Date

Date Order Faxed to State

Amt of Formula Ordered

Amt of

Date

Formula Order

Received Received

Date Packing
Slip Faxed to
State

Date Client Picked Up

Amt. of Formula Issued

3/1/2009

9/29/200

12 cans 10/3/200 10/3/200

2A4 10/13/2008

8

9 cans (3 cases)

8

8

10/14/2008 9 cans

10/31/20

8 cans (2 11/6/200 11/6/200

11/10/2008

08

6 cans cases)

8

8

11/11/2008 9 cans

11/24/20

8 cans (2 12/3/200 12/4/200

12/8/2008

08

7 cans cases)

8

8

12/10/2008 9 cans

12/29/20

8 cans (2

1/12/2009

08

8 cans cases) 1/6/2009 1/7/2009 1/9/2009 9 cans

1/30/200

12 cans

2/9/2009

9

9 cans (3 cases) 2/5/2009 2/5/2009 2/9/2009 9 cans

FP-292


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-39

Table: Cheese and Tofu Substitution
Note: When milk substitutions are provided, the full maximum monthly fluid milk allowance must be provided.

Children/Non-Breastfeeding and Some Breastfeeding Women:

Standard Milk Allotment 16 quarts

Cheese Substitution

For this amount of Give this amount of fluid

cheese (lb)

milk (gallon)

Plus this amount of powder milk OR evaporated

milk "CHOOSE ONE"

Powder Milk (3qt)

Evaporated Milk (12 oz)

0

4

0

0

1

3

1

4

2

2

0

0

3

1

1

4

4*

1

0

0

Tofu Substitution

For this amount of tofu (lb)

Give this amount of fluid milk (gallon)

0

4

2

3

4

3

6

2

8**

2

*Maximum amount of cheese which is allowed to be substituted for milk ** Maximum amount of tofu which is allowed to be substituted for milk

Pregnant and Mostly Breastfeeding Women:

Standard Milk Allotment 22 quarts

Cheese Substitution

For this amount of cheese (lb)

Give this amount of fluid milk (gallon)

Plus this amount of powder milk OR evaporated

milk "CHOOSE ONE"

Powder Milk (3qt)

Evaporated Milk (12 oz)

0

5

0

0

1

4

1

4

2

4

0

0

3

2

1

4

4

2

0

0

5

1

1

4

6*

1

0

0

FP-293


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-39

Tofu Substitution

For this amount of tofu (lb)

Give this amount of fluid milk (gallon)

0

5

2

5

4

4

6

4

8

3

10

3

12**

2

*Maximum amount of cheese which is allowed to be substituted for milk ** Maximum amount of tofu which is allowed to be substituted for milk

Exclusively Breastfeeding Women:

Standard Allotment 24 quarts of milk and one (1) pound of cheese

Cheese Substitution

For this amount of cheese Give this amount of

(lb)

fluid milk (gallon)

Plus this amount of powder milk OR evaporated

milk "CHOOSE ONE"

Powder Milk (3qt)

Evaporated Milk (12 oz)

0

6

0

0

1

4

1

4

2

4

0

0

3

2

1

4

4

2

0

0

5

1

1

4

6*

1

0

0

Tofu Substitution

For this amount of tofu (lb)

Give this amount of fluid milk (gallon)

0

6

2

5

4

5

6

4

8

4

10

3

12**

3

*Maximum amount of cheese which is allowed to be substituted for milk ** Maximum amount of tofu which is allowed to be substituted for milk ***The amount is in addition to the standard one (1) pound of cheese issued to all exclusively

breastfeeding women.

FP-294


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-40

Form #1 Instructions Medical Documentation Form for WIC Special Formulas and Approved WIC Foods
A. Form Explanation
1. The Medical Documentation Form for WIC Special Formulas and Approved WIC Foods is designated as "Form #1," as identified by the "1" in the box in the upper right corner on both the first and second page of the form.
2. The Medical Documentation Form for WIC Special Formulas and Approved WIC Foods (Form #1) is used to prescribe any formula/medical food requiring a prescription for issuance by Georgia WIC. These formulas/medical foods are outlined below:
a) Any exempt infant formula for an infant (e.g., Similac Expert Care NeoSure)
b) Any medical food prescribed for infants, children, or women (e.g., PediaSure, Hominex-1, Nutren Junior, Similac Special Care 24)
c) Any infant formula or exempt infant formula prescribed for children or women (e.g., Gerber Good Start Gentle, Gerber Good Start 2 Soy, EleCare for Infants)
3. The Medical Documentation Form for WIC Special Formulas and Approved WIC Foods (Form #1) cannot be used solely to provide medical documentation for issuance of food substitutions such as soy milk, tofu, or extra cheese. Please refer to Form #2 (Referral Form and Medical Documentation for Special Food Substitutions) for food substitutions.
4. The Medical Documentation Form for WIC Special Formulas and Approved WIC Foods (Form #1) consists of five parts WIC participant information at the top of the form followed by four (4) sections for documentation of diagnoses, the prescribed formula/medical foods, the allowed WIC supplemental foods, and the provider's information. All four (4) sections plus the participant information must be completed on the form in order for the form to be accepted by the WIC clinic. If information is missing or incomplete, the CPA should attempt to contact the prescribing medical office/clinic to obtain a verbal order and follow the instructions in Section VIII (Medical Documentation) of the Food Package Section for documenting verbal orders and obtaining necessary verification.
5. Formula products requiring a prescription, medical foods, and supplemental foods cannot be issued to WIC clients with qualifying medical conditions unless complete, up-to-date written medical documentation or a verbal order is present and documented. It is unacceptable and against program policy to issue formula, medical foods, or supplemental foods for one month until the client can provide the required documentation. Documentation must be present prior to issuance, except in the case of transfers whose medical documentation cannot be obtained at the time of Transfer In; such participants may only receive 1 month of vouchers until documentation is received. (Refer to the Certification Section.)
6. Health care providers are not required to use the Medical Documentation Form for WIC Special Formulas and Approved WIC Foods (Form #1) for the
FP-295


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Attachment FP-40 (cont'd)

prescription of formulas and medical foods, but its use is strongly encouraged to reduce the likelihood of missing information when other forms are used. However, medical documentation can also be provided on a physician's prescription pad, private medical office letterhead, or District/County letterhead, as long as all of the required information is present.
7. The completed medical documentation may be faxed to the clinic, sent electronically, delivered in person, or mailed.
8. The Medical Documentation Form for WIC Special Formulas and Approved WIC Foods (Form #1) is available on Georgia WIC website at: http://wic.ga.gov/wicformula.asp.
B. Form Components
1. WIC Participant Information: The WIC participant's first and last name, date of birth, and (for infants/children) the parent/caregiver's name must be listed at the top of the form.
2. Section #1: Qualifying Medical Conditions
a) This section is where the medical diagnosis(es) is documented that justifies the need for the special formula or medical food.
b) Both the name of the medical condition and the applicable ICD9/ICD-10 code must be listed.
c) Resources for ICD-9/ICD-10 codes can be found at: x http://www.who.int/classifications/icd/en/ x http://www.cdc.gov/nchs/about/major/dvs/icd9des.htm x http://en.wikipedia.org/wiki/List_of_ICD-9_codes x http://en.wikipedia.org/wiki/ICD-10 x http://icd9cm.chrisendres.com/
3. Section #2: Special Formula Requested
a) This section is where the brand name of the prescribed special formula or medical food is listed. The full name of the prescribed product should be listed (e.g., "Neocate Infant" or "Neocate Junior" rather than "Neocate") to avoid confusion. If the full product name is not specified, the CPA must call the prescribing health care provider for clarification and document the complete information on the form. The updated information must be signed and dated by the CPA.
b) The amount of the product must be listed in fluid ounces per day, unless there is no standard dilution (e.g., many metabolic formulas). If there is no standard dilution, the provider may list the amount prescribed per day in another form based on the patient's individualized mixing instructions (e.g., grams of powder per day). If the prescribed product is in concentrate or powdered form, the amount per day is listed in reconstituted fluid ounces (i.e., after preparation with water) based on standard dilution. Formula is

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GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-40 (cont'd)

issued based on standard reconstitution directions for making 20 calorie/oz. formula. c) The prescribing health care provider must identify the form of the product by checking the "powder," "concentrate," or "ready-tofeed" box. If "ready-to-feed" is selected, the CPA must determine if the participant meets WIC ready-to-feed issuance requirements and must document those reasons in the participant's record. See page FP-14 for more details. d) The prescribing health care provider must indicate the intended length of time the participant will need to use the special formula/medical food product based on the participant's condition. This is only an estimate. However, if the planned length of use is less than 6 months (e.g., 1 or 2 months), the participant must provide the WIC clinic with an updated medical documentation form to continue on the special formula/medical food beyond the 1 month or 2 months initially indicated. Clinics cannot issue vouchers beyond the period of time listed in the "planned length of use" in Section #2. For example, if an infant has medical documentation to receive EleCare for Infants for 2 months, the clinic may only issue 2 months worth of vouchers. New medical documentation must be presented to the clinic at the end of the 2-month time period in order for the infant to continue receiving EleCare for Infants.
4. Section #3: WIC Foods
a) This section is where the prescribing health care provider indicates which WIC supplemental foods the participant can or cannot receive based on the participant's medical condition.
b) The provider must complete either "A" or "B" of this section. c) If the participant is allowed to consume all supplemental foods, the
provider must initial the line in section "A." d) If the participant cannot eat certain foods due to the medical
condition, the provider must check all applicable boxes in section "B" to indicate which foods cannot be issued. e) The provider can list any special comments in the "Comments" box on the table. This area can be used to indicate special situations (e.g., the participant can only drink soy milk or goat milk). f) If the formula is to replace milk in the diet, then milk should be checked on the contraindicated supplemental food box.
5. Section #4: Health Care Provider Information
a) This section is where the prescription date is recorded and the prescribing health care provider's name, signature, credentials, and contact information are documented.
b) All five boxes must be completed. c) The form can only be signed by the types of providers listed. d) The medical office/clinic contact information can be stamped. e) The provider's signature cannot be a stamped signature.

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GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-40 (cont'd)

6. Page 2: The back of the form contains information for completing the form, definitions, examples, and the non-discrimination statement.

C. Evaluation of Medical Documentation
1. The CPA must carefully evaluate the diagnosis, formula/medical food prescribed, supplemental foods allowed, and the WIC participant's existing anthropometric data and nutrition/health history.
2. The CPA must determine whether or not the prescription can be approved for WIC use based on WIC policies and procedures. Please refer to Section VIII (Medical Documentation) of the Food Package Section for additional guidance. CPAs must take into consideration:
a) Which formulas and medical foods are approved for issuance by Georgia WIC,
b) The maximum allowed quantities of special formulas and medical foods based on participant category (infant, child, or woman), age, feeding method, and product form,
c) The intended use of the formula or medical food, d) The appropriateness of the diagnosis for the prescribed formula or
medical food, e) Non-specific diagnoses that are not acceptable for WIC
prescriptions and diagnoses requiring additional information (see page 2 of the form), f) The participant's age and existing health data.
3. The CPA must determine whether an appropriate state-created food package exists to meet the participant's needs or whether a 999 food package must be developed using state-created and/or District-created voucher codes.
4. The CPA must determine when the participant is required to bring updated medical documentation back to the clinic. a) If section #2 of the form indicates a time period of less than 6 months, new documentation is required at the end of that time period (e.g., 1 or 2 months after the date in section #4) or at the next certification, whichever comes first. b) If section #2 of the form indicates a time period of 6 or more months, new documentation is required in 6 months from the date listed in section #4 or at the next certification, whichever comes first.
5. Districts are encouraged to designate a contact person (e.g., Nutrition Manager, Nutrition Services Director) for CPAs to call when medical documentation questions arise.
6. Additional clarifying information can always be requested from the provider, if necessary, prior to the denial of a prescription.

D. Special Situations
1. Infants (ages 6-11 months) receiving exempt infant formulas or medical foods and who cannot tolerate any supplemental foods are eligible to receive formula at
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GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-40 (cont'd)

the higher maximum rate allowed for a 4-5 month old infant in place of the supplemental foods.
a) The infant must be age 6-11 months old. b) The infant must be receiving an exempt infant formula or a medical
food. Infants receiving standard infant formulas requiring medical documentation are not eligible to receive the higher maximum formula rate in place of the infant foods, even if the infant is unable to consume those foods. The ineligible formulas are Similac Sensitive, Similac Sensitive for Spit Up, Enfamil A.R., Enfagrow Gentlease Next Step or Enfagrow Gentlease Toddler, Enfamil Gentlease, and any store brand milk-based lactose-free, lactosereduced, and/or rice-added formulas approved by USDA (e.g., Parent's Choice Added Rice Starch). c) The provider must indicate under section #3 (WIC Foods) on the medical documentation form that the infant cannot consume both "infant cereal" and "baby food fruits and vegetables" by checking both boxes. If the infant cannot tolerate just one of the supplemental foods, the infant is not eligible to receive the additional formula quantity.
2. Ready-to-Feed Products a) Infants with medical documentation who are receiving exempt infant formulas or medical foods are eligible for two additional reasons to be issued the ready-to-feed form of a product: x If the ready-to-feed product better accommodates the participant's medical condition x If the ready-to-feed product improves the participant's compliance in consuming the prescribed product. b) Infants with medical documentation who are receiving the following formulas are not eligible for the additional two reasons listed above to issue the ready-to-feed version of a product: Similac Sensitive, Similac Sensitive for Spit Up, Enfamil A.R., Enfagrow Gentlease Next Step or Enfagrow Gentlease Toddler, Enfamil Gentlease, and any store brand milk-based lactose-free, lactose-reduced, and/or rice-added formulas approved by USDA (e.g., Parent's Choice Added Rice Starch). c) The reason for issuance of a ready-to-feed product must be clearly documented in the participant's WIC record.
3. Milk Issuance
a) Children and women with medical documentation who are receiving any formula or medical food and who have a qualifying medical condition (i.e., are in Food Package III) are eligible to receive whole milk. Milk must be allowed per the provider's medical documentation (i.e., the "milk" box must not be checked as contraindicated in section #3). If milk is allowed, children/women can be issued whole milk at the CPA's professional discretion if it is appropriate for the participant's medical condition (e.g., Failure To Thrive).
b) If milk is allowed, children ages 12-23 months old cannot be issued low-fat milk for any reason, even with medical documentation.
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GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-40 (cont'd)

c) Tofu, soy milk, goat milk, lactose-reduced milk, or extra cheese can be substituted for milk for clients who are providing other medical documentation (Food Package III) by following the procedures for milk substitutions previously outlined by participant category in the Food Package Section.
4. Children and Women Needing Infant Cereal a) Children and women with medical documentation who are receiving any formula or medical food and who have a qualifying medical condition (Food Package III) can be issued infant cereal in place of adult cereal. b) Children and women who, for example, have developmental delays or swallowing disorders may be issued up to 32 ounces of infant cereal in place of 36 ounces of adult cereal. c) The CPA can make this determination or the provider can make the substitution request in the comments section on the medical documentation form in section #3 (WIC Foods).
E. Formula Quantity To Issue 1. As stated on page 2 of the medical documentation form, infant WIC participants are to be issued the full maximum quantity of formula allowed per month regardless of the quantity prescribed per day under section #2 of the form. This ensures that the infants receive the full nutritional benefit. The full maximum quantity allowed depends upon the infant's age, feeding method (Mostly Breastfed or Fully Formula Fed), the product form (powder, concentrate, or ready-to-feed), and the product package size. 2. Child and woman WIC participants are to be issued the quantity of formula or medical food prescribed, up to the maximum quantity allowed by WIC regulations, under section #2 of the form.

F. Valid Dates
1. New medical documentation (Form #1) of a prescribed special formula or medical food is required every six (6) months, at a minimum, and at every recertification/certification / mid-certification (if the medical documentation on file was signed and dated by the health care provider more than 30 days prior to the recertification/certification / mid-certification). For example, if the caregiver of an infant client provides medical documentation on Form #1 when the infant is age 5 months 2 days old, a new, updated copy of the medical documentation must also be provided at the time of the mid-certification if it occurs when the infant is more than 6 months 2 days old. Likewise, if the caregiver of a child participant provides medical documentation for a prescribed formula/medical food using Form #1 at age 22 months 25 days, a new, updated copy of the medical documentation must also be provided at the next subcert, if that recertification occurs more than 30 days after the medical documentation was signed by the provider (e.g., when the child is age 24 months old).
2. Each time new medical documentation (Form #1) is submitted by a WIC participant, it must include all required information and must be signed and dated by the health care provider no more than 30 days ago. Clinics cannot accept
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GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-40 (cont'd)

medical documentation (Form #1) where the date under section #4 has simply had a line drawn through it and a new date added. A new form must be submitted.

FP-301


GEORGIA WIC 2012 PROCEDURES MANUAL
Page 1 of Medical Documentation Form (Form #1)

Attachment FP-41

FP-302


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-41(cont'd)

Page 2 of Medical Documentation Form (Form #1)

FP-303


GEORGIA WIC 2011 PROCEDURES MANUAL

Attachment FP-42

Form #2 Instructions Referral Form and Medical Documentation for Special Food Substitutions
A. Form Explanation
1. The Referral Form and Medical Documentation for Special Food Substitutions is designated as "Form #2," as identified by the "2" in the box in the upper right corner on both the first and second page of the form.
2. The Referral Form and Medical Documentation for Special Food Substitutions (Form #2) is used for two primary purposes to provide medical referral data on a WIC participant/applicant and to provide the required medical documentation needed to authorize special food substitutions in place of all or part of the milk allowance for women and children. The form may be used to provide referral data only, to authorize a special food substitution only, or for both.
3. The Referral Form and Medical Documentation for Special Food Substitutions (Form #2) cannot be used to prescribe any formula/medical food requiring a prescription for issuance by Georgia WIC. Please refer to Form #1 (Medical Documentation Form for WIC Special Formulas and Approved WIC Foods) for prescribing special formulas or medical foods.
4. The Referral Form and Medical Documentation for Special Food Substitutions (Form #2) consists of four parts WIC participant information and medical office contact information at the top of the form followed by three (3) sections for documentation of medical referral data, the prescription of milk substitutions for children, and the prescription of milk substitutions for women. Only the WIC participant information and the medical office contact information is required to be completed on every form. The applicable section(s) should be completed for each participant depending upon whether the form is being used for medical referral data only, for the prescription of special food substitutions only, or for both. If a special food substitution is being prescribed and any information is missing or incomplete in the applicable section, the CPA should attempt to contact the prescribing medical office/clinic to obtain a verbal order and follow the instructions in Section VIII (Medical Documentation) of the Food Package Section for documenting verbal orders and obtaining necessary verification.
5. Special food substitutions requiring medical documentation cannot be issued to WIC clients unless complete, up-to-date written medical documentation or a verbal order is present and documented. It is unacceptable and against program policy to issue special food substitutions for one month until the client can provide the required documentation. Documentation must be present prior to issuance except in the case of transfers whose medical documentation cannot be obtained at the time of Transfer In; such participants may only receive 1 month of vouchers until documentation is received. (Refer to the Certification Section.)
6. Health care providers are not required to use the Referral Form and Medical Documentation for Special Food Substitutions (Form #2) for the provision of medical referral data or for the prescription of special food substitutions for women and children, but its use is strongly encouraged to reduce the likelihood of missing information when other forms are used. However, referral data and
FP-304


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-42 (cont'd)

medical documentation for special food substitutions can also be provided on a physician's prescription pad, private medical office letterhead, or District/County letterhead, as long as all of the required information is present.
7. The completed referral form (Form #2) may be faxed to the clinic, sent electronically, delivered in person, or mailed.
8. The Referral Form and Medical Documentation for Special Food Substitutions (Form #2) is available on Georgia WIC website at: http://wic.ga.gov/wicformula.asp.
B. Form Components
1. WIC Participant Information & Medical Office Contact Information: The WIC participant's first and last name, date of birth, and (for infants/children) the parent/caregiver's name must be listed at the top of the form along with the medical office/clinic contact information. This information must be completed on all referral forms regardless of what other information is being provided on the form (e.g., referral data only or prescription of special food substitutions or both).
2. Referral Data
a) This section is where the medical referral data are reported. Only applicable spaces should be completed based upon the WIC participant category (e.g., infant, child, or woman).
b) It is not mandatory to complete this section if prescribing a special food substitution.
c) If only referral data are being provided, the health professional who collected the data should sign the "Referral Data Provided By:" line and enter the date the form was completed.

3. Authorization of Special Food Substitutions for Children
a) This section is where special food substitutions are prescribed in place of all or part of the milk allowance for children ages 12 months and older. If a food substitution is prescribed, all parts of this section must be completed in full.
b) The diagnosed medical condition justifying the special food substitution is required. The diagnosis (e.g., lactose intolerance, vegan/vegetarian, milk protein allergy, etc.) should be consistent with the food substitution prescribed as outlined in Section VIII (Medical Documentation) of the Food Package Section.
c) The prescribing health care provider must check the box identifying which food substitution is being authorized. Federal regulations mandate that child WIC participants are required to have medical documentation authorizing the issuance of any quantity of soy milk, any quantity of tofu, or more than one (1) pound of cheese per month.
d) The exact quantity of the food substitution issued is determined by the CPA in conjunction with the participant or parent/caregiver. In
FP-305


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-42 (cont'd)

some instances, only part of the milk allowance will be replaced with the special food substitution, depending upon the participant's medical needs and the substitution rates. When providing food substitutions for milk, the full nutritional benefit must be provided, which may require the issuance of some powdered, evaporated milk, or fluid milk. See Attachment FP-38 for more information on how to calculate milk substitutions and the maximum amounts of milk allowed to be substituted. e) The prescribing health care provider must indicate the intended length of time the participant will need to use the special food substitution based on the participant's condition. This is only an estimate. However, if the planned length of use is less than 6 months (e.g., 4 months), the participant must provide the WIC clinic with an updated referral form (Form #2) containing medical documentation to continue on the special food substitution beyond the number of months initially indicated. Clinics cannot issue vouchers containing special food substitutions beyond the period of time listed in the "Planned Length of Use." For example, if a child has medical documentation to receive extra cheese for 2 months, the clinic may only issue 2 months worth of vouchers. New medical documentation must be presented to the clinic at the end of the 2month time period in order for the child to continue receiving extra cheese.
4. Authorization of Special Food Substitutions for Women
a) This section is where special food substitutions are prescribed in place of all or part of the milk allowance for women participants. If a food substitution is prescribed, all parts of this section must be completed.
b) The diagnosed medical condition justifying the special food substitution is required. The diagnosis (e.g., lactose intolerance, vegan/vegetarian, milk protein allergy, etc.) should be consistent with the food substitution prescribed as outlined in Section VIII (Medical Documentation) of the Food Package Section.
c) The prescribing health care provider must check the box identifying which food substitution is being authorized. Federal regulations mandate that women WIC participants are required to have medical documentation authorizing the issuance of extra tofu or extra cheese. Women are not required to have medical documentation in order to receive soy milk.
d) Extra tofu is defined for women participants as the issuance of: a. More than four (4) pounds of tofu per month for pregnant women and for postpartum women classified as NonBreastfeeding, Some Breastfeeding, Mostly Breastfeeding. b. More than six (6) pounds of tofu per month for women classified as Exclusively Breastfeeding (one or more infants), Pregnant with Multiples (e.g., twins, triplets, etc.), Mostly Breastfeeding Multiples.
e) Extra cheese is defined for women participants as the issuance of:

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GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-42 (cont'd)

a. More than one (1) pound of cheese per month for women who are pregnant with only one fetus and for postpartum women classified as Non-Breastfeeding, Some Breastfeeding, or Mostly Breastfeeding.
b. More than three (3) pounds of cheese per month for women who are classified as Exclusively Breastfeeding (one or more infants) or who are pregnant with multiple fetuses (e.g., twins, triplets, etc.) or Mostly Breastfeeding Multiples.
f) The exact quantity of the food substitution issued is determined by the CPA in conjunction with the participant. In some instances, only part of the milk allowance will be replaced with the special food substitution, depending upon the participant's medical needs and the substitution rates. When providing food substitutions for milk, the full nutritional benefit must be provided, which may require the issuance of some powdered, evaporated, or fluid milk. See Attachment FP-38 for more information on how to calculate milk substitutions and the maximum amounts of milk allowed to be substituted.
g) The prescribing health care provider must indicate the intended length of time the participant will need to use the special food substitution based on the participant's condition. This is only an estimate. However, if the planned length of use is less than 6 months (e.g., 4 months), the participant must provide the WIC clinic with an updated referral form containing medical documentation to continue on the special food substitution beyond the number of months initially indicated. Clinics cannot issue vouchers containing special food substitutions beyond the period of time listed in the "Planned Length of Use." For example, if a woman has medical documentation to receive extra cheese for 2 months, the clinic may only issue 2 months worth of vouchers. New medical documentation must be presented to the clinic at the end of the 2-month time period in order for the woman to continue receiving extra cheese.
5. Page 2: The back of the form contains information for completing the form, WIC policies, examples, and the non-discrimination statement.

C. Evaluation of Medical Documentation
1. The CPA must carefully evaluate the diagnosis, the food substitution authorized, and the WIC participant's existing anthropometric data and nutrition/health history.
2. The CPA must determine whether or not the prescription can be approved for WIC use based on WIC policies and procedures. Please refer to Section VIII (Medical Documentation) of the Food Package Section for additional guidance.
3. The CPA must determine whether an appropriate state-created food package exists to meet the participant's needs or whether a 999 food package must be developed using state-created and/or District-created voucher codes.
4. The CPA must determine when the participant is required to bring updated medical documentation back to the clinic.
FP-307


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-42 (cont'd)

c) If the form indicates a "planned length of use" of less than 6 months, new documentation is required at the end of that time period (e.g., 1 or 2 months after the form date) or at the next certification, whichever comes first.
d) If the form indicates a "planned length of use" of 6 months, new documentation is required 6 months from the date listed on the form or at the next certification, whichever comes first.
5. Districts are encouraged to designate a contact person (e.g., Nutrition Manager, Nutrition Services Director) for CPAs to call when medical documentation questions arise.
6. Additional clarifying information can always be requested from the provider, if necessary, prior to the denial of a prescription.

D. Food Substitution Quantity to Issue 1. CPAs must use professional judgment to determine the amount of food substitution to be issued. 2. See Attachment FP-38 for the allowed maximum amounts of milk to be substituted. The amounts vary based on product being substituted, and WIC category and feeding type.
E. Valid Dates 1. New medical documentation for special food substitutions (Form #2) is required every six (6) months, at a minimum, and at every recertification/certification (if the medical documentation on file was signed and dated by the health care provider more than 30 days prior to the recertification/certification). For example, if the caregiver of a child participant provides medical documentation for the use of soy milk on Form #2 when the child is age 28 months 25 days old, a new, updated copy of Form #2 must also be provided at the time of the next recertification, even if the next recertification is due at age 30 months.
2. Each time new medical documentation for special food substitutions (Form #2) is submitted by a WIC participant, it must include all required information and must have been signed and dated by the health care provider no more than 30 days ago. Clinics cannot accept special food substitution prescriptions on Form #2 where the date has simply had a line drawn through it and a new date added. A new form must be submitted.

FP-308


GEORGIA WIC 2012 PROCEDURES MANUAL Page 1 of Referral Form (Form #2)

Attachment FP-43

FP-309


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-43 (cont'd)

Page 2 of Referral Form (Form #2)

FP-310


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-44

GEORGIA WIC-APPROVED FOOD LIST CRITERIA TO EVALUATE AN ELIGIBLE FOOD ITEM

I.

Administrative Adjustments

A. A food company interested in participating in Georgia WIC should submit product statewide availability, package size, unit cost per ounce and nutrient composition information to the Office of Nutrition* by October 1st of each year.

*Address: Office of Nutrition, 2 Peachtree Street NW, Suite 11-222, Atlanta, GA 303033142.

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. Fish

6. Cheese 7. Juice 8. Dried Beans/Peas and Peanut Butter 9. Fruits and Vegetables 10. Whole Grains (bread, rice, tortillas)

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 grams of sucrose and other sugars per 100 grams of dry cereal (less than 6 grams of sucrose and other sugars per ounce). At least one-half of the total number of approved cereals must have whole grain as the primary ingredient and meet labeling requirements for making a health claim as a "whole grain food with moderate fat content." 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
FP-311


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-44 (cont'd)

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 Domestic Cheese (pasteurized, processed American, Monterey Jack, Colby, Natural Cheddar, Mozzarella, Swiss) Sliced Cheese (American, Cheddar, Swiss) String Cheese (Mozzarella String Cheese)

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- 46 for distribution guidelines. 5. No infant juices allowed.

G. Eggs Whole, large, grade A.

H. Fish Tuna or Salmon 100% tuna, water packed only. No albacore.

I.

Fruit and vegetables

Fresh, frozen or canned

Any variety of fresh whole or cut fruit without added sugar or artificial sweeteners Any variety of fresh whole or cut vegetable, except white potatoes without added, sugars, fats, and oils Any variety of canned fruits, including applesauce; juice-pack or water pack without added sugars, fats, oils, or salt Any variety of frozen fruits without added sugar Any variety of canned or frozen vegetable, except white potatoes, without added sugars, fats, oils

J. Whole Grains 100% whole wheat bread or hamburger buns, brown rice, whole wheat or corn tortillas

FP-312


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-44 (cont'd)

K. Soy milk -

1.

276 mg calcium per cup

2.

8 grams protein per cup

3.

500 IU vitamin A per cup

4.

100 IU vitamin D per cup

5.

24 mg magnesium per cup

6.

222 mg phosphorous per cup

7.

349 mg potassium per cup

8.

0.44 mg riboflavin per cup

9.

1.1 mcg vitamin B12 per cup

III. Packaging
A. Food must be prepackaged, no bins except for fresh fruits and vegetables.
B. Cereal (adult and infant) 1. No single serving containers. 2. Adult cereal weight must be in whole numbers, minimum of 11 ounces, not to exceed 36 ounces. 3. Infant cereal only in eight (8) ounce packages.
C. Cheese 1. Brick or sliced cheese only, no shredded. 2. Cheese from the dairy case only, no deli cheese. 3. Plain cheese only, no additions of products such as jalapeno peppers. 4. 16 ounce package only
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 or forty-eight (46-48) ounce containers, 64 ounce containers, 12 ounce frozen cans, 12 ounce cans concentrate, or 11.5 oz pourable cans or 5.5 to 6 ounce can.
E. Eggs One dozen size carton only.
F. Milk- (Cow) 1. Half gallon and one gallon size: Whole, Reduced Fat (2%), Low-fat (1%), Lite (0.5%), Skim (Non-Fat). 2. Quart size containers only for Lactose Reduced and goat milk. 3. Twelve ounce cans only for Evaporated milk and goat milk. 4. Three quart boxes for Powder milk. 5. 8 ounce or half-pint box for ultra high temperature (UHT) milk.
Milk - (Meyenberg Goat Milk) Twelve ounce cans evaporated or quart
FP-313


GEORGIA WIC 2012 PROCEDURES MANUAL

G. Tuna 5 ounce can only.

H. Salmon 6 oz or 14.75 oz only

I.

Peanut Butter

16 to 18 ounce container only.

J. Dried Beans/Peas One pound bag or 14 to 16 ounce can.

Attachment FP-44 (cont'd)

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-314


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-45

FP-315


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-45 (cont'd)

FP-316


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-45 (cont'd)

FP-317


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-45 (cont'd)

FP-318


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-45 (cont'd)

FP-319


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-46

Formula Type: ___________________________

Formula Tracking Log

Date:

Action Taken
Received "R"
Issued "I"
Destroyed "D"
Balance Forward RID

*Number of Cans Powder Concentrate RTF

Returned / Exchanged Formula

Client's Name AND / OR
Client's WIC ID #

Reason for Receiving, Issuing or Discarding
Formula

RID

RID

RID

RID

RID

RID

RID

Inventory Total

Notes:

*Cases must be converted to cans **Inventory verification must be completed at least quarterly.
FP-320


Signature & Title of CPA

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-47

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 calciumfortified 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 calcium-fortified juice in the food package, that client can be instructed to purchase calcium-fortified juices. The vendor manual and training will indicate 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.

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.

FP-321


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-48

999 Single Item Voucher Codes

W5 = Prenatal/Mostly Breastfeeding Women W6 = Non-Breastfeeding Postpartum/Some Breastfeeding Woman
W7 = Exclusively Breastfeeding Women/Prenatal with Multiples/ Mostly Breastfeeding Multiples C1 = Child 12-23 months old C2 = Child >23 months old I = Infant

Voucher code 775 703 778
273
A02
A03 A04 779 780 A05 782 A07
781
A08
A09
783
A10
772
771
774

Eggs: Eggs: Juice
Juice:
Juice:
Juice: Juice: Cereal: Cereal: Cereal: Beans: Peanut Butter: Beans or peanut butter Whole Grains: Whole Grains: Fish:
Fish:
Milk:
Milk:
Cheese:

Supplemental Foods Voucher message 2 dozen Least expensive brand 1 dozen Least expensive brand 1-46 oz container or 1-12 oz can frozen or 11.5 oz can pourable 2 containers (46 to 48 oz) or 2-12 oz cans frozen or 2-11.5 oz cans pourable 3 containers (46 to 48 oz) or 3-12 oz cans frozen or 3-11.5 oz cans pourable 2-64 oz containers 1-64 oz container No more than 24 oz No more than 36 oz No more than 18 oz 1 lb dried or 4 cans (14 to 16 oz) 1 container (16-18 oz)
1 lb dried or 4 cans (14 to 16 oz) beans or 1 container (16 to 18 oz) peanut butter
Pick 2: 16 oz bread; 16 oz brown rice; 16 oz tortilla; or 14 to 16 oz bun Pick 1: 16 oz (bread, or brown rice or whole grain tortilla) or 14 to 16 oz bun No more than 30 ounces (canned tuna OR canned salmon) No more than 15 ounces (canned tuna OR canned salmon) 1 gallon low-fat (fat-free, 1%, 2%) No whole milk Least expensive brand 2 gallons low-fat (fat-free, 1%, 2%) No whole milk Least expensive brand 1-16 oz package

Allowed Category W7
W5, W6, W7, C1, C2 W5, W6, W7
W5, W6, W7
W5, W7
C1, C2 C1,C2 W5, W6, W7, C1, C2 W5, W6, W7, C1, C2 W5, W6, W7, C1, C2 W5, W6, W7, C1, C2 W5, W6, W7, C2
W6, C2
C1, C2
W5, W6, C1, C2
W7
W7
W5, W6, W7, C2
W5, W6, W7, C2
W5, W6, W7, C1, C2

FP-322


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-48 (cont'd)

786

Milk: 1 gallon or 4 quarts or 2 half gallons low-

W5, W6, W7, C2

fat (fat-free, 1%, 2%) Lactose free,

Acidophilus, or Acidophilus and Bifidum.

No whole milk Least expensive brand

785

Milk: 2 quarts or 1 half gallon low-fat (fat-free,

W5, W6, W7, C2

1%, 2%) Lactose free, Acidophilus, or

Acidophilus and Bifidum. No whole milk

Least expensive brand

A11

Tofu: No more than 4 pounds

W5, W6, W7, C1, C2

A12

Tofu: 1 pound

W5, W6, W7, C1, C2

205

Infant 1-8 oz container

I, C1, C2

Cereal:

A13

Infant 3-8 oz containers

I, C1, C2

Cereal:

A14

Dry

1-3 quart container box non-fat dry

W5, W6, W7, C2

Milk

powder

Least expensive brand

A15

Dry

2-3 quart containers non-fat dry powder

W5, W6, W7, C2

Milk

Least expensive brand

A16

Dry

3-3 quart containers non-fat dry powder

W5, W6, W7, C2

Milk

Least expensive brand

A17

Milk

4-12 ounce cans low-fat (fat-free,

W5, W6, W7, C2

skimmed, 2%) evaporated

Least expensive brand

A18

Milk

1-12 ounce cans low-fat (fat-free,

W5, W6, W7, C2

skimmed, 2%) evaporated

Least expensive brand

A19

Milk

4-12 ounce cans evaporated (whole)

W5, W6, W7, C1, C2

Least expensive brand

A20

Milk

1-12 ounce cans evaporated (whole)

W5, W6, W7, C1, C2

Least expensive brand

773

Cheese 2-16 oz packages

W5, W6, W7, C1, C2

776

Juice 4 containers (46 to 48 oz) or 4-12 oz

W7 (EBF twins only)

cans frozen or 4-11.5 oz cans pourable

A01

Milk

1 gallon Whole milk Only

W5, W6, W7, C1, C2

Least expensive brand

A21

Milk

2 gallons Whole milk Only

W5, W6, W7, C1, C2

Least expensive brand

A34

Milk

1 half gallon low-fat (fat-free, 1%, 2%) No

W5, W6, W7, C2

whole milk.

Least expensive brand

A22

Goat Milk 4 quarts low-fat goat milk No whole milk

W5, W6, W7, C2

A23

Goat Milk 8 quarts low-fat goat milk No whole milk

W5, W6, W7, C2

A24

Goat Milk 1 quart low-fat goat milk No whole milk

W5, W6, W7, C2

A25

Goat Milk 4 quarts whole goat milk or 5-12 oz cans W5, W6, W7, C1, C2

evaporated goat milk No low-fat milk

A26

Goat Milk 1 quart whole goat milk or 1-12 oz can

W5, W6, W7, C1, C2

FP-323


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-48 (cont'd)

A27
A28
A30 Prenatal Conversion to an Exclusively Breastfeeding Package
A37 A33 A38
A39 A41

Milk Milk Milk:

evaporated goat milk No low-fat milk 1 quart low-fat (fat-free, 1%, 2%) Lactose free, Acidophilus, or Acidophilus and Bifidum. No whole milk Least expensive brand 1 quart Whole Lactose free, Acidophilus, or Acidophilus and Bifidum. Least expensive brand 1 half gallon low-fat (fat-free, 1%, 2%) No whole milk Least expensive brand

Eggs:
Fish: Infant Cereal: Soy milk:
Milk:
Milk
Soy milk

1 dozen No more than 30 oz (canned tuna OR canned salmon) 4-8 oz container
2 half gallons 8th Continent (Original OR Vanilla flavors only) 8-12 ounce cans low-fat (fat-free, skimmed, 2%) evaporated Least expensive brand 8-12 ounce cans evaporated (whole) Least expensive brand 1 half gallons 8th Continent (Original OR Vanilla flavors only)

W5, W6, W7, C2
W5, W6, W7, C1, C2 W7
C1, C2 W5, W6, W7, C1, C2
W5, W6, W7, C2 C1, C2, W5, W6, W7 W5, W6, W7, C1, C2

FP-324


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-48 (cont'd)

Voucher code A43 A44 A45 A46 A60 A64 A56 A57 374 518 544 707 874 358 359 553 116 117 300 307 308 590 591 305

Infant/Special Formulas Voucher message
Formula 1-8.25 oz container ready to feed Boost Kid Essentials
Formula 4-8.25 oz containers ready to feed Boost Kid Essentials (one 4-pack)
Formula 1-8 oz container ready to feed Boost Kid Essentials 1.5
Formula 1-8 oz container ready to feed Boost Kid Essentials 1.5 With Fiber
Formula 1-250 ml container ready to feed Compleat Pediatric
Formula 1-8 oz can ready to feed Enfaport LIPIL Formula 1-32 oz container ready to feed Isomil DF
OR Similac Expert Care for Diarrhea Formula 1-8 oz container ready to feed Isomil DF
OR Similac Expert Care for Diarrhea Formula 1-12.9 oz can or 1-12.6 oz can powder
Similac Sensitive Formula 1-32 oz container ready to feed Similac
NeoSure or Similac Expert Care NeoSure Formula 1-32 oz container ready to feed
Enfamil EnfaCare Formula 1-400 gram (14.1oz) can powder
Nutramigen AA LIPIL Formula 1-12.9 oz can or 1-12.4 oz can powder
Similac Advance EarlyShield Formula 1-1 lb can powder Similac Expert Care
Alimentum Formula 1-32 oz container ready to feed Similac
Expert Care Alimentum Formula 1-8 oz container ready to feed Boost Formula 1-8 oz container ready to feed Bright
Beginnings Soy Pediatric Drink Formula 6-8 oz containers ready to feed Bright
Beginnings Soy Pediatric Drink Formula 1-14.1 oz can powder EleCare OR
EleCare Jr Formula 1-12.9 oz can powder Enfamil AR LIPIL
or Enfamil AR Formula 1-1 quart container ready to feed
Enfamil AR LIPIL or Enfamil AR Formula 6-2 oz containers ready to feed Enfamil
EnfaCare Formula 1-12.8 oz can powder Enfamil EnfaCare Formula 6-2 oz containers ready to feed iron
fortified Enfamil Premature LIPIL 20 (1-6 pack)

FP-325


Allowed Category C1, C2 C1, C2 C1, C2 C1, C2 C1, C2 I, C1, C2 I I I, C1, C2 I, C1, C2 I, C1, C2 I, C1, C2 I, C1, C2 I, C1, C2 I, C1, C2
W5, W6, W7 C1, C2 C1, C2 C1, C2 I, C1, C2 I, C1, C2 I, C1, C2 I, C1, C2 I, C1, C2

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-48 (cont'd)

Voucher code 306
301 303 310 474 476 477 A62 157 159 A63 563
557 558 716 717 A65 A66 A58 A59 720 721 479 480 A47 A48

Infant/Special Formulas Voucher message
Formula 6-2 oz containers ready to feed iron fortified Enfamil Premature LIPIL 24 (1-6 pack)
Formula 1-8 oz container ready to feed Ensure Formula 1-8 oz container ready to feed
Ensure Fiber Formula 1-237 ml container EO28 Splash Formula 1-400 gram (14.1 oz) can powder
Neocate Junior Formula 1-12.9 oz can powder Gerber Good Start
Gerber Good Start Soy Formula 1-13 oz or 1-12.1 oz container
concentrate Gerber Good Start Soy Formula 1-8 oz can ready to feed Nepro Formula 1-12.6 oz can powder Nutramigen LIPIL
with Enflora LGG Formula 1-13 oz can concentrate Nutramigen
LIPIL Formula 1-250 ml container ready to feed
Nutren 1.5 Formula 1-250 ml container ready to feed
Nutren 2.0

Formula Formula Formula Formula Formula Formula Formula Formula Formula Formula Formula Formula Formula Formula

1-250 ml container ready to feed Nutren Junior 1-250 ml container ready to feed Nutren Junior Fiber 1-8 oz container ready to feed Pediasure 6-8 oz container ready to feed Pediasure 1-8 oz containers ready to feed PediaSure 1.5 Cal 1-8 oz containers ready to feed PediaSure 1.5 Cal with fiber 1-8 oz container ready to feed PediaSure Enteral 1-8 oz container ready to feed PediaSure Enteral with Fiber and scFOS 1-8 oz container ready to feed Pediasure with Fiber 6-8 oz container ready to feed Pediasure with Fiber 1-250 ml container ready to feed Peptamen 1-250 ml container ready to feed Peptamen Junior 1-250 ml container ready to feed Peptamen Junior 1.5 1-250 ml container ready to feed

FP-326


Allowed Category I, C1, C2
W5, W6, W7 W5, W6, W7
C1, C2 C1, C2 I, C1, C2 I, C1, C2 C1, C2, W5, W6, W7 I, C1, C2 I, C1, C2 W5, W6, W7 W5, W6, W7
C1, C2 C1, C2 C1, C2 C1, C2 C1, C2 C1, C2 C1, C2 C1, C2 C1, C2 C1, C2 W5, W6, W7 C1, C2 C1, C2 C1, C2

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-48 (cont'd)

Voucher code 578 259 141 A50
A51
A53 A61 N74 S87
S91
481
482
483 101
363 484
588
587
586
A52

Infant/Special Formulas Voucher message
Peptamen Junior Fiber Formula 1-250 ml container ready to feed
Peptamen Junior with Prebio Formula 1-1 lb can powder Portagen Formula 1-1 lb can powder Pregestimil LIPIL Formula 6-2 oz containers ready to feed
Pregestimil LIPIL 20 Calorie (one 6-pack) Formula 6-2 oz containers ready to feed Pregestimil LIPIL 24 Calorie (one 6-pack) Formula 1-8 oz container ready to feed Resource Breeze Formula 1-13 oz container concentrate RCF

Formula Formula Formula Formula Formula Formula Formula Formula Formula Formula Formula Formula Formula

12-13 oz containers concentrate RCF (1 case) 6-32 oz containers ready to feed Similac Expert Care for Diarrhea OR Isomil DF (1 case) 24-8 oz containers ready to feed Similac Expert Care for Diarrhea OR Isomil DF (1 case) 4-2 oz containers ready to feed Similac NeoSure or Similac Expert Care NeoSure (1-4 pack) 1-12.8 oz can powder Similac NeoSure or 1-13.1 oz can powder Similac Expert Care Neosure 1-14.1 oz can powder Similac PM 60/40 1-32 oz container ready to feed Similac Sensitive (orange and white label) 1-13 oz can concentrate Similac Sensitive (orange and white label) 1-32 oz container ready to feed Similac Sensitive RS or Similac Sensitive for Spit Up (green and white label) 4-2 oz containers ready to feed iron fortified Similac Special Care 20 (1-4 pack) 4-2 oz containers ready to feed iron fortified Similac Special Care 24 (1-4 pack) 4-2 oz containers ready to feed iron fortified Similac Special Care 30 (1-4 pack) 1-8 oz container ready to feed Suplena

Allowed Category C1, C2 I, C1, C2 I, C1, C2 I, C1, C2
I, C1, C2
C1, C2, W5, W6, W7 I I I
I
I, C1, C2
I, C1, C2
I, C1, C2 I, C1, C2
I, C1, C2 I, C1, C2
I, C1, C2
I, C1, C2
I, C1, C2
W5, W6, W7

FP-327


GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-48 (cont'd)

Voucher code G11 G20 G07 G08 G09 G01 476 G41 G23 G24 G29 G28 G43 A49 A54 A55

Infant/Special Formulas Voucher message
Formula 1-32 oz container or 1-33.8 oz (4-packs) ready to feed Gerber Good Start Gentle
Formula 2-32 oz containers or 2-33.8 oz (4-packs) ready to feed Gerber Good Start Gentle
Formula 1-13 oz or 1-12.1 oz container concentrate Gerber Good Start Gentle
Formula 2-13 oz or 2-12.1 oz containers concentrate Gerber Good Start Gentle
Formula 3-13 oz or 3-12.1 oz containers concentrate Gerber Good Start Gentle
Formula 12.7 oz can powder Gerber Good Start Gentle
Formula 1-12.9 oz cans powder Gerber Good Start Soy
Formula 1-24 oz cans powder Gerber Good Start 2 Gentle
Formula 2-13 oz or 2-12.1 oz containers concentrate Gerber Good Start Soy
Formula 3-13 oz or 3-12.1 oz container concentrate Gerber Good Start Soy
Formula 2-32 oz containers or 2-33.8 oz (4-packs) ready to feed Gerber Good Start Soy
Formula 1-32 oz container or 1-33.8 oz (4-pack) ready to feed Gerber Good Start Soy
Formula 1-24 oz cans powder Gerber Good Start 2 Soy
Formula 1-8 oz container ready to feed Vital jr. or Pediasure Peptide 1.0 Cal
Formula 1-1.7 oz packet powder Vivonex Pediatric Formula 6-1.7 oz packets powder Vivonex
Pediatric (one box, 6 packets each)

Allowed Category I, C1, C2 I, C1, C2 I, C1, C2 I, C1, C2 I, C1, C2 I, C1, C2 I, C1, C2 I, C1, C2 I, C1, C2 I, C1, C2 I, C1, C2 I, C1, C2 I, C1, C2 C1, C2 C1, C2 C1, C2

Voucher code 511 512 530 531 535

Modulars Voucher message
Formula 1-400 gram (14.1 oz) can powder Duocal
Formula 4-400 gram (14.1 oz) cans powder Duocal
Formula 1 carton (50 packs per carton) Similac Human Milk Fortifier
Formula 1 case (150 packs per case) Similac Human Milk Fortifier
Formula 1-12.3 oz can Polycose
FP-328


Allowed Category All All
C1, I C1, I
All

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FP-48 (cont'd)

Voucher code 536 551
552
N75
582 583

Modulars
Voucher message Formula 6-12.3 oz cans Polycose (1 case) Formula 1 carton (100-0.71 gram sachets per carton) Enfamil Human Milk Fortifier Formula 1 case (200-0.71 gram sachets per carton) Enfamil Human Milk Fortifier Formula 1 carton (100 vials, 25 pouches with 4 5ml vials per pouch) Enfamil Human Milk Fortifier Acidified Liquid Formula 1-32 oz container MCT Oil Formula 6-32 oz containers MCT Oil (1 case)

Allowed Category All
I, C1
I, C1
I, C1
All All

FP-329


GEORGIA WIC 2012 PROCEDURES MANUAL

Nutrition Education

TABLE OF CONTENTS

Page

I.

Purpose ....................................................................................................................NE-1

II.

Definitions ................................................................................................................NE-1

III.

Goals ........................................................................................................................NE-1

IV.

State Agency................. ...........................................................................................NE-2

A. State Nutrition Staff ............................................................................................NE-2

B. State Nutrition Education Responsibilities..........................................................NE-2

V.

Local Agency............................................................................................................NE-3

A. Local Nutrition Staff ............................................................................................NE-3

B. Local Nutrition Education Responsibilities .........................................................NE-4

C. Training ..............................................................................................................NE-5

VI.

Participant Nutrition Education .................................................................................NE-7

A. Participant Nutrition Education Requirements....................................................NE-7

B. Documentation of Nutrition Education................................................................NE-9

VII.

Participant Referral to Other Agencies...................................................................NE-10

A. Participant Referrals.........................................................................................NE-10

B. Participant Documentation ...............................................................................NE-11

VIII. Nutrition Education Materials .................................................................................NE-11

A. Criteria for Development and Use ....................................................................NE-11

Attachments: 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-19 NE-5 Material Evaluation Form .......................................................................................NE-20

GEORGIA WIC 2012 PROCEDURES MANUAL

Nutrition Education

NE-6 NE-7

WIC Local Agency Continuing Education Documentation Log ..............................NE-25 WIC CPA Orientation Checklist..............................................................................NE-26

GEORGIA WIC 2012 PROCEDURES MANUAL

Nutrition Education

I.

PURPOSE

A. This section of Georgia WIC Procedures Manual defines the concept of nutrition education; states the goals for nutrition education; explains the requirements for providing nutrition education to WIC participants; outlines the criteria for developing nutrition education materials; and outlines guidelines for referring participants to other health care services.

B. Nutrition education shall be considered a Georgia WIC benefit, and made available at no cost to all participants.

II. DEFINITIONS
A. "Nutrition Education" is a dynamic process delivered through individual or group sessions and the provision of materials by which participants 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 participant's interests and designed based on ethnic, cultural, and geographic preferences with consideration for language, educational, environmental factors, and nutritional risks.
B. "Value Enhanced Nutrition Assessment" (VENA) is an initiative designed to improve nutrition services in Georgia WIC. VENA reaffirms the necessity to conduct a complete nutrition assessment. VENA introduces an emphasis on a more qualitative rather than quantitative dietary assessment by promoting a participant-centered, positive approach to nutrition assessment one that is based on desired health outcomes rather than deficiency findings. This shift allows for individualized strategies rather than establishing broad and general requirements. VENA serves to enhance existing WIC nutrition services. (Adapted from: http://apha.confex.com/apha/135am/techprogram/session_21855.htm.)
VENA makes the nutrition education process more effective for both participants and Competent Professional Authorities (CPAs) by providing more opportunities for participant-centered dialogue. The intent of VENA is to complement nutrition assessment, education and counseling, which will lead to a more measurable method of client-centered goal setting. Additional information on VENA is available at the USDA WIC Works website (http://www.nal.usda.gov/wicworks/). The entire VENA manual can be downloaded as a PDF file at the following link:
http://www.nal.usda.gov/wicworks/Learning_Center/VENA/VENA_Guidance.pdf

III. GOALS
Nutrition education and counseling 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)

NE-1

GEORGIA WIC 2012 PROCEDURES MANUAL

Nutrition Education

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. State Nutrition Staff
The delegation of WIC nutrition education activities is vested within the Georgia Department of Public Health, Maternal and Child Health Program, Office of Nutrition and WIC and the Nutrition Services Unit.
Nutrition Program Consultants in the Nutrition Services Unit are available to local agencies 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 Services Unit.
B. State Nutrition Education Responsibilities
The state agency responsibilities for nutrition education: 1. Develop, implement, and evaluate the State Nutrition Education Plan.
Periodically review, 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 annual reporting.
4. Evaluate the nutrition services of all local agencies.
5. Maintain 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. Provide, as available, resources and committee leadership for obtaining or developing nutrition education materials.
7. Coordinate WIC nutrition education activities with related programs and professional groups such as the Cooperative Extension Service,

NE-2

GEORGIA WIC 2012 PROCEDURES MANUAL

Nutrition Education

Supplemental Nutrition Assistance Program (SNAP, formerly Food Stamps), professional organizations, advisory committees, etc.
8. Develop and implement procedures to assure that nutrition education is provided to all adult participants, to parents or caregivers of infant or child participants and, when appropriate, to child participants.
9. Perform and document evaluation of nutrition education activities on an annual basis. The evaluation shall include an assessment of participants' views concerning the usefulness of the nutrition education they received.
10. Establish standards for participants' education contacts that ensure the provision of adequate nutrition education (Refer to the nutrition portion of the State Agency Monitoring [MO] Section for standards).
11. Monitor local agency activities to ensure compliance with defined local agency responsibilities and participant nutrition education contacts.
V. LOCAL AGENCY
A. Local Nutrition Staff
1. Each of the WIC districts or contract agencies (Grady and Southside) must be staffed with a District Nutrition Services Director who must be at minimum a (1) full-time equivalent (FTE) public health nutritionist, (2) a Licensed Dietitian (LD) in the state of Georgia and (3) be employed in either the class of Nutrition Services Director, Nutrition Program Manager, or Nutrition Manager. Duties include: planning, organizing, implementing, and evaluating the nutrition service component of WIC. This encompasses leadership in the development and approval of nutrition education materials, development of the nutrition education plan, and implementation of nutrition risk criteria and food package delivery.
2. Each WIC local agency must be staffed with a minimum of one (1) fulltime equivalent (FTE) Competent Professional Authority (CPA) for every one thousand (1,000) participants, and one (1) full-time equivalent (FTE) Registered and Licensed Dietitian (RD, LD) or Licensed Dietitian (LD) for every five thousand (5,000) participants. District staff can only be counted towards these requirements when they provide direct services.
3. Nutrition positions should be appropriately classified according to the State Personnel Agency class specifications for nutrition personnel. The State Personnel Agency 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.

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4. The class specifications for nutrition personnel and qualifications and compensation levels are to be according to State Personnel Agency and are available at http://www.spa.ga.gov/jobdescriptionsapp/jobsalaryinfo.asp.
B. Local Nutrition Education Responsibilities The local agencies shall perform the following activities in carrying out their nutrition education responsibilities:
PARTICIPANT (this section moved from below) 1. Provide nutrition education to all adult participants, parents or caregivers
of infant or child participants and, whenever appropriate, to child participants. WIC participants may be encouraged to participate in facilitative discussion. 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. Develop a system and/or utilize annual public comment responses 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 that is due to the Nutrition Services Unit (end of March).
3. Online Nutrition Education
A local agency shall offer participants the option of completing a second nutrition education contact online using www.gawiconline.org. Participants completing online education must be offered an opportunity to speak with a CPA to answer any questions at voucher pick up. Highrisk participants who complete online education must still receive an individual contact. The High Risk Nutrition Education contact must include a care plan.
Internet Secondary Contact: When participants choose online education staff will:
a. Provide first time users with a www.GAWIConline.com User's Guide b. Review the procedure and requirements for completing online education
with the participant c. Verify completion of the online contact at voucher pick up through a
review of the printed certificate or other documentation of online verification. Verify the participants WIC ID/Household ID and date of contact, which must be within the current certification period d. Offer participants opportunity to speak with a CPA, if they have questions. e. Document an individual contact in the nutrition education contact screen of your WIC system and select the appropriate online topic code f. Offer a group or individual contact to participants

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4. Develop a system and/or utilize annual public comment responses 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 that is due to the Nutrition Services Unit (end of March).
STAFF/CPAs 1. Provide in-service training and technical assistance for competent
professional authorities (CPAs) and nutrition assistants at local clinics.
2. Local WIC Agency shall develop a Nutrition Education Plan consistent with the nutrition education goals and objectives related to the provision of training that covers secondary nutrition education to Participants and nutrition education for High Risk Participants Format should be similar and included goals, SMART objectives (Specific, Measureable, Achievable, Realistic and with targeted Time frame) and specific performance measures. NE Plan is to be finalized and submitted to the Nutrition Services Unit no later than March 31st of each year.
C. Training
1. Orientation
a. Districts must use the CPA Orientation Checklist for training all CPAs hired on or after 9/1/2008. The Orientation Checklist must be completed within thirty days of the employee providing WIC services. Refer to Attachment NE-7 for a copy of the Orientation Checklist.
b. The WIC CPA must also receive competency based nutrition training within twenty-four months of employment. This training should cover skills outside of the basic competencies required for holding CPA position, such as VENA competency skills or other competencies for special populations.
2. Continuing Education
a. All WIC CPA and Nutrition Assistant (NA) staff, whether they work full time or part time, must receive at least twelve (12) hours of nutrition specific continuing education each year. Training must be approved by the local agency Nutrition Services Director (or designee). The twelve hours of nutrition specific continuing education can be met in the following ways: (1) Through participation at local, state, or national workshops or meetings to develop and update skills and knowledge in nutrition and lactation management;

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(2) Through completion of Internet based or home study nutrition related educational courses (developed and/or approved by a nationally recognized professional organization);
(3) Through establishment of a staff Nutrition Journal Club, where peer reviewed nutrition related research articles are shared, reviewed and discussed. A maximum of one (1) credit hour (or clock hour) will be allowed per meeting time. Examples of approved peer reviewed research journals include: Journal of the American Dietetic Association, the American Journal of Public Health and Journal of Nutrition Education and Behavior, etc.
(4) Special Note: Since the implementation of the Value Enhanced Nutrition Assessment (VENA) process, continuing education training received annually by the CPAs and other WIC staff should address their self-identified training needs and in addition must include one or more of the following areas: i. Competency-based trainings in nutrition assessment, education and counseling (including critical thinking, motivational interviewing, reflective listening, rapport building, and goal setting) and breastfeeding education. ii. In addition, updated trainings on WIC programmatic content areas (e.g., risk criteria, food package/approved foods, etc.) should be included.
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.

(1) Acceptable documents are: roster with signatures and/or certificates, agenda for training activities.
c. The hours of continuing education required may be pro-rated for new hires, staff who terminate prior to the end of the reporting period, and in special circumstances (e.g., staff on medical leave). For example, a staff member who works in WIC for six months would be expected to have accumulated approximately six hours of continued education. However, the number of continuing education hours required per year cannot be adjusted based upon the percent of time the employee performs WIC duties (e.g., employee only performs WIC duties 50% of the time).
3. Reporting and Monitoring
a. The WIC Local Agency Continuing Education Documentation Log (Attachment NE-6) should reflect training obtained by all CPAs in the local agency, be maintained in the local agency files, and must be available for review by State Nutrition Unit staff during the WIC program review. Districts are not mandated to use the state's log; this log is only an example.

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However, districts must track and be able to produce the same continuing education information required as outlined in the attached log.
b. The file should include the following at a minimum for each CPA in the local agency: (1) CPA name and title (2) Clinic number(s) (3) Yearly total of continuing education hours received (4) Hire and termination date.
c. Local agency training provided must include at a minimum: (1) Training topics (2) Agendas (3) Speaker(s) vitae (must show evidence of training in the area which they are presenting) (4) Staff trained (e.g. all CPA staff, Nutritionists only, etc.) (5) Sign-in roster

VI. PARTICIPANT NUTRITION EDUCATION
A. Participant Nutrition Education Requirements
1. All adult participants and caregivers 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/caregivers 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. Document "no shows" with the date the participant was scheduled to receive the nutrition education contact but failed to appear for the contact. Participants who fail to keep their appointments must be offered a nutrition education contact at their next voucher pick up.
3. The nutrition education contacts shall be made available through individual or group sessions, which are appropriate to the individual participant's nutritional needs.
4. Printed and audio-visual materials may be used to support the educational messages. Use of the following reinforcements alone is not considered to be effective and can not be counted as a nutrition education contact: publications, pamphlets, take-home activities,

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newsletters, videotapes, posters, bulletin boards, displays, health fairs, public service announcements, radio, and TV advertisements.
5. A local agency must submit proposals for the development of new nutrition education projects and must contact the Nutrition Services Unit 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 Services Unit staff will review the proposed nutrition education program/strategy and provide the local agency with initial feed back within thirty (30) days. Nutrition Services Unit approval of proposed special projects will be provided to the Office of Nutrition and WIC within sixty (60) days of receipt of the final local agency proposal. If USDA approval is required, the Office of Nutrition and WIC will assist the local agency in obtaining the approval.
6. All participants shall receive at least one (1) nutrition education contact during each certification period which relates to their own (or their child's) dietary practices, as assessed by the CPA, from the state approved Nutrition Assessment Questionnaire. Visual aids, such as food models or measuring cups, should be used to obtain a good assessment of nutritional practices and to help the participant learn about portion sizes.
7. Counseling with regard 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 increase physical activity and decrease screen time should be provided.
8. 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. The High Risk Nutrition Education contact must include a care plan. Refer to Attachment NE4 for the documentation components of the care plan.
9. All women participants must receive exit counseling by the final nutrition education contact of the postpartum period (i.e., counseling at least one (1) time on each of the below topics between the initial prenatal certification and when the postpartum woman is terminated as a participant for the current pregnancy). Exit counseling is defined as counseling which includes the following topics which are to be discussed within the valid certification period: a. Importance of folic acid intake
b. Health risks of using alcohol, tobacco, and other drugs

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c. Breastfeeding as the preferred method of infant feeding or continued breastfeeding as the preferred method of infant feeding for those women who are currently breastfeeding
d. Importance of up-to-date immunizations
10. Parents or caregivers of WIC infants and children must also be provided with exit counseling /preventative information about abuse of drugs and other harmful substances at least one time while the infant/child is enrolled in WIC. However, it is a best practice to provide this preventative information at the initial visit and on a more frequent basis, where applicable.
11. Each local agency must have an established nutrition reference guide available. Examples of approved nutrition reference guides include, but are not limited to:
a. ADA Nutrition Care Manual b. Georgia Dietetic Association Nutrition Manual
12. Nutrition education contacts must be provided by a nutritionist, Registered and Licensed Dietitian (RD, LD), Licensed Dietitian (LD), or other Competent Professional Authority (CPA) that has been trained by the state or local agency. Nutrition Assistants (NAs) can provide lowrisk nutrition education contacts when appropriate nutrition education training has been received. The Nutrition Services Unit 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. A class outline must be developed when group-facilitated classes are used to provide the nutrition education contact. The class outline must include learning objective(s). Class outlines must be kept at the clinic site for use by clinic staff and provided to the Nutrition Services Unit at the time of program reviews.
14. If the participant/caregiver is unable to receive services at the clinic for an extended period of time, providing the nutrition education contact to the proxy at the time of voucher issuance is 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 for the topics

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discussed (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 (Subjective Objective Assessment Plan) 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 must be documented in the participant's health record. The name and credentials of the staff member conducting the group-facilitated class must also be documented in the participant's health record.
3. Documentation of secondary nutrition education contacts must be completed in the participant's electronic record and include the date, topic(s), care plan (if high risk), the title of the person providing the nutrition education, and method by which the nutrition education contact was provided (e.g., class, kiosk, individual counseling, etc.). Electronic documentation of all nutrition education contacts is required.
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. Failed, missed, and refused secondary nutrition education appointments do not count as having provided secondary nutrition education.

VII. PARTICIPANT REFERRAL TO OTHER AGENCIES
Participants must be assessed for referrals during each certification appointment.
A. Participant Referrals
1. While receiving Georgia WIC, participants must be referred to the Supplemental Nutrition Assistance Program (SNAP; formerly Food Stamps), Medicaid and Temporary Assistance for Needy Families (TANF) at least one time. 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), Head Start, Pre-K, and other programs.
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
Supplemental Nutrition Assistance Program (SNAP, formerly Food Stamps) Medicaid Right from the Start Temporary Assistance for
Needy Families (TANF) Head Start

Child Health Programs
Children 1st Children's Medical Services Immunization Program Lead Screening Program Health Check Dental Health Program Vision Screening 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. General breastfeeding referrals should be documented as "W," while referrals to breastfeeding peer counselors should be documented as "X."

5. Any participant identified as high risk should be referred to a nutritionist or Registered Dietitian ("V") if one is not available in the clinic.

B. Participant 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; reasons for not referring or participant's refusal should be included in documentation.

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:
a. Approved by the District Nutrition Service Director or designee. b. Submitted to the Nutrition Services Unit for DPH approval prior
to distribution. c. Must have current non discrimination statement based on current
Federal requirement.

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See Materials Evaluation Form for guidance (Attachment NE-5). The Nutrition Services Unit is available for consultation and technical assistance to review nutrition education materials.
2. Sample copies of all nutrition education materials used by the local agency must be made available to the Nutrition Services Unit 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 prenatal, breastfeeding, postpartum women, infants, and children less than five, and when applicable, migrant farm workers and homeless persons. Consideration must be given to the reading level as well as to the cultural and language needs of clients.
5. The Nutrition Services Unit 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 Unit 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 tailored to the participants' desired health outcomes, following VENA principles. 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

Risk Code 201

Appendix B-1

Underweight Prenatal Women: Body Mass Index <18.5 Postpartum Women: Body Mass Index <18.5
Overweight Prenatal Women: Body Mass Index >25 Postpartum Women: Body Mass Index > 25

C-1

101

Body Mass

Index Tables

C-1

111

Body Mass Index Tables

Low maternal weight gain

131

C-2

Weight loss during pregnancy

132

Nutrition-related medical conditions; presence of any disease or condition affecting nutritional status that requires a therapeutic diet as ordered by a physician or health professional acting under standing orders of a physician
EDC or delivery prior to 17th birthday

341-349; 351-354; 356-360;
362
331

Blood lead level > 10 Pg/dl

211

Breastfeeding complications; referral to appropriate BF counselor must be made

602

Hyperemesis Gravidarum

301

Gestational diabetes

302

Multifetal gestation

335

Any condition deemed by the competent professional authority to place the woman at high risk for compromised nutritional status; adequate documentation required

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Attachment NE-2

WIC HIGH-RISK CRITERIA FOR INFANTS AND CHILDREN
WIC infants and children who have the following high-risk factors must receive nutrition counseling tailored to the participants' desired health outcomes, following VENA principles. 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
Underweight (weight for length/height <5th %)
Overweight (weight for length/height > 95th %). May only be used for children as high-risk criteria.
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

341-354;
356, 357, 359, 360, 362; 382

Low birth weight infant [infant weighing 2500 grams (5

141

pounds) or less at birth]. May only be used for infants only

as high-risk criteria.

Blood lead level > 10Pg/dl

211

Fetal Alcohol Syndrome

382

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 to provide services to participants:

A. WIC clerical staff and health services technicians.

B. Expanded Food and Nutrition Education Program (EFNEP) agents.

C. Volunteers with a background in Home Economics, Nutrition, Medical Science, and Health Education.

D. Nursing students who have taken at least one (1) nutrition course.

E. University students who have done nutrition/health course work.

II. Who can provide Nutrition Assistant Training
A nutritionist, Registered and Licensed Dietitian (RD, LD), Licensed Dietitian (LD), or other Competent Professional Authority (CPA) that has been trained by the state or local agency. Certified Nutrition Assistants may assist the facilitator to provide peer experiences and support.

III. Competencies for Nutrition Assistants
A. Basic Georgia WIC Knowledge. The WIC Nutrition Assistant will be able to:
1. Describe the basic goals of Georgia WIC.
2. List eligibility requirements for Georgia WIC.
3. Name the State and Federal agencies that fund and administer Georgia WIC.
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) USDA rules and regulations or Georgia WIC Procedures Manual policies relating to supplemental foods and nutrition education.

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Attachment NE-3 (cont'd)

6. Describe the process of how a WIC participant obtains WIC foods and list the various WIC approved foods.
7. Demonstrate a thorough knowledge for any topic for which they will be providing of individual counseling or leading classes. The Nutrition Assistant should score ninety (90) percent or above on the written test.
8. Demonstrate ability to apply VENA counseling skills during nutrition nutrition counseling.
B. Communication Skills. The Nutrition Assistant will be able to: 1. Demonstrate each of the following skills during a participant interview or group-facilitated class: - Introduce him/her and make introductions among participants - Provide a clear explanation for the purpose of class/contact - Conduct the activity within a given time frame - Use Reflective Listening - Use open-ended questions - Conduct activities in a non-judgmental manner - Communicate using simple language - Convey sincere interest - Convey positive body language and attitude
2. Identify problems, during the individual contact or group-facilitated classes, that are WIC, health, or staff-participant relationship oriented.
C. Referral Skills. The Nutrition Assistant will be able to: 1. Refer participant for needs encountered during the group-facilitated class/individual contact to appropriate personnel.
2. Refer participant with medical and nutrition related needs to the appropriate professional, as written in the class outlines.
3. Refer any questions they were unable to address to the appropriate professional.

IV. Requirements for Nutrition Assistant Training/Continuing Education
Nutrition Assistants may provide low-risk secondary nutrition education contacts only if the following competencies have been met:
A. A training session related to the nutrition topic is successfully completed.
1. A test and clinic observation is completed for each nutrition topic area. 2. The Nutrition Assistant can only provide information to participants that
have been covered in their training sessions.
B. Nutrition Assistants must receive at least twelve (12) hours of nutrition-specific

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Attachment NE-3 (cont'd)

continuing education per year. Training must be approved by the local Nutrition Services Director (or designee). These hours can be attained through: 1. Participation in local agency Nutrition Assistant trainings
2. Other nutrition conferences/workshops/training

V. Parameters for Nutrition Assistants Conducting Low Risk Secondary Nutrition Education Contacts
Nutrition Assistants (NAs) will be trained to provide very specific nutrition information to WIC participants. Nutrition Assistants will only be permitted to provide information covered in completed training(s). Referrals by the NA to a nutritionist or CPA will be made based on guidance in class outlines and/or the training manual, and/or for questions beyond the scope of the training received by the Nutrition Assistant.
VI. Evaluation of the Nutrition Assistant
Competencies that will be evaluated include the following:
A. The Nutrition Assistant must score 90% or above on a test for each topic area, before being able to proceed to the next topic.
B. The Nutrition Assistant must observe a professional providing low-risk secondary nutrition education contacts for at least one (1) clinic day, before being allowed to provide any participants with secondary nutrition education contacts.
C. The Nutrition Assistant must be observed conducting at least three (3) low-risk secondary nutrition education contacts before being allowed to provide any unaccompanied secondary nutrition education contacts on a routine basis. Observation criteria: to include at minimum: basic competencies for which NA has been trained to provide nutrition education for low risk participants, appropriate and accurate documentation, VENA principles, accurate content during nutrition education sessions and follows course outline when providing group education.
D. The immediate supervisor (or designee) must be readily accessible to assist the Nutrition Assistant with problems.
E. The Nutrition Services Director (or designee) will conduct quarterly record reviews and observe the Nutrition Assistant providing low-risk secondary nutrition education contacts. These quarterly record reviews and observations will be documented and made available for Nutrition Services Unit staff during WIC program reviews.
F. The Nutrition Services Director (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:

____ Class Outlines 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 low-risk secondary nutrition contacts.

____ Plan for Nutrition Service Director (or designee) to observe Nutrition Assistant(s) providing low-risk secondary nutrition education contacts.

____

Plan to conduct quarterly chart reviews, where applicable, and quarterly observations of Nutrition Assistant(s).
Record review to include the following: Documentation of nutrition education is completed and accurate Identification data completed accurately Error corrections done to policy All dates, signatures, title documented

____ Class Outlines for use by Nutrition Assistant(s) in providing low-risk secondary nutrition education contacts (group-facilitated classes 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 need to be communicated to other health professionals. The use of the SOAP Note format is an excellent way of conveying this nutritional information. The data gathered during the nutrition assessment can be incorporated into the SOAP Note in the following manner:
S- Subjective Data: - Statement of the individual's thoughts and feelings - Individual complaints, "quotable" significant information, individual's description of his or her problem, individual's statement of needs - Information gained from talking with the individual, from others working with the individual, or from the individual's relatives - Dietary intake and reported nutritional practices
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 the participant chooses as a goal in order to address their individual nutritional status, need, or situation - 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 ACCEPTABL

ADEQUATE

E

SUPERIOR

CONTENT
Complete non-discrimination clause present (refer to RO Section for wording)

Accurate and up-to-date

Learning Objectives
x No more than 3 objectives
x Should not promote undesirable behavior

x Summary of learning objective matched with activities provided in the material

Scope x Topics deemed necessary x Useful and relevant to target audience

x Appropriate for target audiences' lives and environments

Purpose of material clearly stated

Organization
x Main topic or ideas are clearly identified
x Progression of information easy to follow

Learning Activities x Provides for learner involvement x Is appropriate for knowledge/skill level x Suggestions made for further learning

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Attachment NE-5

EVALUATION CRITERIA opportunities

MINIMALLY ACCEPTABL

ADEQUATE

E

SUPERIOR

References are accurate, up-to-date, and available for use.

LANGUAGE USAGE
Reading level appropriate for audience present (determined with SMOG)

If technical terms are used, definitions are provided.

Style x Personalized x Few instances of negative wording x Respectful x Sentences simple, short, specific x Use of wording is consistent

STEREOTYPING Appropriate role models
Minority representation are: x Presented in a factual manner x Presented in a variety of roles,
occupations, values
Lifestyle and cultural differences are illustrated

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Attachment NE-5 (cont'd)

EVALUATION CRITERIA FORMAT

MINIMALLY ACCEPTABLE

ADEQUATE

Paper quality is acceptable for intended use

Print/Font x Style acceptable x Size appropriate

Topic headings/typographic cueing

Line width and spacing

Placement and use of illustrations

Placement and use of charts, table, graphs

Color
x Appropriate colors per DPH Stylebook guidelines and colors that are easy to read
x Good quality per DPH Stylebook guidelines

Pages x Appropriate length

Overall visual appearance is pleasing

Quality of sound track is good

SUPERIOR

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Attachment NE-5 (cont'd)

Other Areas to be considered Prior to Purchase/Development:

EVALUATION CRITERIA
COST Original x Material cost x Shipping/handling x Discount for multiples x Easy to obtain x Time to obtain

MINIMALLY ACCEPTABLE

ADEQUATE

Replacement x Reasonable work life (durability) x Predisposed to obsolescence x Ease of repair (include
shipping/handling) x Cost of replacement

Duplication x Allowable/legal x Cost of duplication

SUPERIOR

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Attachment NE-5 (cont'd)

EVALUATION CRITERIA

MINIMALLY ACCEPTABLE

VIEWING/USAGE

Space

x Appropriate for existing available space for viewing or use of materials

x Adequate space available for storage

ADEQUATE

Easy to Use By: x Staff x Audience/participant

Targets x Group classes x Individual counseling/use x Waiting room use

Is there an easier, more efficient way to stimulate learning?

RECOMMENDATIONS:

SUPERIOR

SIGNATURE/TITLE OF EVALUATOR:

DATE:

Adapted from: E.M.P.O.W.E.R. (Evaluate Materials to Promote Optimal Use of WIC Education Resources), Massachusetts WIC Program, Department of Public Health, April 1985.

NE-24

GEORGIA WIC 2012 PROCEDURES MANUAL WIC LOCAL AGENCY CONTINUING EDUCATION DOCUMENTATION LOG
District _________________________ CPA Staff: Minimum Requirement 12 Hours Yearly Year Reviewed: __________________

Name EX: Jane Doe

Title Nutritionist

Clinic 625

Training Type Clinical Skills

Training Date 8/25/2007

Training Hours 10 hours
documented

Attachment NE-6

Start Date 1/1/2008

Total Hours

10 hours

Comments: _____________________________________________________________________________

Nutrition Assistants: Minimum Yearly Requirement 12 Hours Yearly Year Reviewed: __________________

Name EX: Nancy Drew

Title Nutrition Assistant

Clinic 625

Start Date 1/1/2008

Training Type Stress Free Feeding

Training Date 1/1/2008

Training Hours 5 hours
documented

Total Hours

5 hours

*Quarterly Clinic Observations Documented
1/1/2008 by TES 4/17/2008 by TRS 7/7/2008 by TES 10/21/2008 by TRS

Comments: _____________________________________________________________________________

Note: Total CPAs/Nutrition Assistants with adequate documentation divided by Total CPAs evaluated = % of CPAs with adequate documentation. * Documentation of Nutrition Assistant Clinic Observations must include the dates and signatures of the Nutrition Services Director or designees conducting the observations.

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GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment NE-7



Name ____________________________ Hire Date: __________________________

District: __________________________ County/Clinic: ______________________

Orientation Items
Job Description/Expectations WIC Overview Computer System Overview Data Entry Customer Service Civil rights Cultural competency WIC Procedure's Manual Nutrition Reference Guides
- Nutrition Care Manual - Other as approved by the
Nutrition Services Unit
BREASTFEEDING State/District Breastfeeding Policy

Date

Employee Trainer

Reviewed Initials Initials

Comments

Breastfeeding Advantages - Infants, Mother, Society
WIC Approved Educational Materials Breast Pumps and Accessories
- Assembly instructions - Issuing/Tracking Logs - Care, Cleaning, Safety - Accessory information and
Instructions - Issuing/Tracking Logs Common Concerns/Potential Issues Infants: - Normal eating patterns/habit - Weight Gain - Adequate intake assessment - Fussy baby - Normal stools/frequency - Gas - Other: Mothers
- Dietary Needs/fluids - Smoking/Drugs - Working/Time away from
infant - Other:

NE-26

GEORGIA WIC 2012 PROCEDURES MANUAL 7(cont'd)

Referrals for complications: - Sore breasts/nipples - Jaundice - Inadequate weight gain - Constipation - Diarrhea - Poor latch - Mastitis - Clogged ducts - Other:
Referrals for support: - Peer Counselors - Breastfeeding Coordinator - Designated clinic CPA
Approved Reference Books: - Breastfeeding Answer Book - Medications and Mother's Milk - Other:
WIC Hotline Clinic/District/Community Resources Other:
Nutrition Risk Criteria Women: Prenatal Women: Breastfeeding Women: Postpartum Infants Children Priority Assignment per category
Food Packages WIC Approved Foods Tailoring Special Formulas/Metabolic Foods 999 Procedures
- Documentation - Follow up Infant formulas: - Contract - Exempt
Laboratory Data Anthropometrical Procedures
- Measuring weight - Measuring length/height - Head circumference (if
applicable) - Calculations: BMI, wt/length,
prenatal weight gain - Plotting Hemoglobin/Hematocrit Procedures
Counseling Skills / VENA
NE-27

Attachment NE-

GEORGIA WIC 2012 PROCEDURES MANUAL 7(cont'd)

VENA SKILLS: Establishing Rapport Critical Thinking Motivational Interviewing
- uses open ended questions
Guides participant in goal setting Invites participant questions, concerns, interests
Reflects/Summarizes participant concerns Sensitive to participant's cultural beliefs/practices
Documentation Use of SOAP format Writes measurable goals Error Correction procedures Makes appropriate referrals- how and when
- Medicaid - Food Stamps - TANF - Children's 1st - BCW - RD - CMS - Housing Authority - Head Start - Food Bank
Other: Online Nutrition Education GA WIC online
Nutrition Related Continuing Education
- Discuss requirements with each staff
- 12 hours required annually
Cultural Competency
Additional:
Employee Signature: __________________________
Supervisor Signature: _________________________
NE-28

Attachment NE-

GEORGIA WIC 2012 PROCEDURES MANUAL
7(cont'd)


Attachment NE-

Note: All criteria listed above are not intended to be an exhaustive list. Districts may include additional WIC related topics to their checklists as they see necessary. All competencies listed must be reviewed with the new employee, checked and signed within 30 days of the employee providing WIC services.

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GEORGIA WIC 2012 PROCEDURES MANUAL


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-2

II.

Individuals Residing in Non-Traditional Housing or Institutions ............................... SP-2

A. Definitions........................................................................................................... SP-3
B. Services for Applicants or Participants Residing in Temporary Housing............................................................................................ SP-3

C. Meals in Institutions and Temporary Housing .................................................... SP-5

III.

Other Special Populations........................................................................................ SP-6

A. Definitions........................................................................................................... SP-6 B. Limited English Proficient (LEP) Population....................................................... SP-6

C. Refugees ............................................................................................................ SP-7

D. Native Americans ............................................................................................... SP-8

E. Persons with Disabilities................................................................................... ..SP-8

F. Proposed Language for the Low Literacy and Limited English Proficiency..............................................................................................................SP-8

IV.

Referral and Outreach to Special Populations ......................................................... SP-8

Attachments

SP-1 SP-2
SP-3

Georgia Farm Worker Health Program .................................................................. SP-10
Telamon Corporation (Migrant and Seasonal Farm Worker Association, Inc.).................................................................................................... SP-11
Translation Interpretative Services ........................................................................ SP-13



GEORGIA WIC 2012 PROCEDURES MANUAL


Special Population

SP-4 Assurance Statement ............................................................................................. SP-16

SP-5 Notice of Free Interpretation Services.................................................................... SP-17

SP-6 Waiver of Rights to Free Interpreter Services ....................................................... SP-18



GEORGIA WIC 2012 PROCEDURES MANUAL

Special Population

I.

INTRODUCTION

This section of the manual outlines procedures for assuring access to WIC services and minimizing hardship for the segment of the population that requires non-traditional services. Federal 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 People, Native Americans and persons with disabilities. Local Georgia WIC clinics are responsible for ensuring accessibility to WIC services for these populations.

A. Definitions

1. Migrant Farm Workers are individuals (and family members) employed seasonally in agriculture occupations, who establish temporary residence for the purpose of such employment, and have been employed in such occupation within the last twenty-four (24) months.

2. Loggers are individuals whose principal employment is seasonal harvesting of trees, who have been employed in this activity within the last twenty-four (24) months and for such employment established a temporary abode.

3. Seasonal Farm Workers are individuals employed in agriculture occupations who do not move from place to place establishing temporary residence for the purpose of work. THEY ARE NOT migrant farm workers as defined by Georgia WIC.

B. Certification
The process for certifying migrant farm workers must comply with standard certification procedures (see Certification Section). The local agency must issue an Electronic Verification of Certification (EVOC)/Verification of Certification (VOC) card to every migrant at the time of certification. A valid EVOC/VOC card helps migrant farm workers access WIC services (see Certification Section - Transfer of Certification). The VOC card is valid until the certification period expires.
WIC certification must be documented with an EVOC/VOC card or a copy of the Georgia WIC assessment form. In lieu of a VOC card, the receiving WIC clinic must verify the current certification information. Vouchers must only be issued for thirty (30) days if WIC clinic staff cannot verify certification information with the

SP-1

GEORGIA WIC 2012 PROCEDURES MANUAL

Special Population

originating clinic.
C. Food Delivery
Migrants frequently remain in a local area for a very short period. 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 in which the vouchers originated. The local agency must forward the voided vouchers to the appropriate state agency. If a migrant presents vouchers from another WIC 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, the local agencies are required to make special effort to reach out and serve this population. The local agency should decide whether evening WIC clinics or certifications at migrant camps are necessary. This decision should be based on migrant outreach efforts and consultation with organizations serving migrants as well as other migrant activities in the service area. All services necessary to serve migrant populations should be implemented. Special outreach and referral efforts implemented by a local agency to provide access to health services for the migrants and their families should be documented.
E. Reporting and Monitoring
The number of migrants participating in Georgia WIC is reported on the Racial/Ethnic Participation Report generated by the WIC 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 Interview Script must be used to allow the applicant/participant to self declare (see Certification Section). If necessary, WIC's definition of a migrant should be explained to the applicant/participant.
Migrant activity is reported monthly on the Migrant Participation Report found in GWIS.net. 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 Procedures 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

SP-2

GEORGIA WIC 2012 PROCEDURES MANUAL

Special Population

Local agencies must continue to serve and enroll eligible participants and applicants living in non-traditional housing environments. Georgia WIC 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 residence of another person), and special drug rehabilitation homes for pregnant women. Both applicant/participant and non-traditional housing representatives must comply with WIC 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-4). The signed copy of this agreement, in accordance with USDA Federal Register, Volume 54, No. 239, must be on file with Georgia WIC before participants may be served.
A. Definitions
WIC services benefits must be tailored to meet the special needs of individuals defined in these groups.

Institution is any residential accommodation, which provides meals and sleeping accommodations to a special group of people, or a facility designated as a residence for individuals intended to be in a controlled environment. Excluded are private residences and homeless facilities.
Homeless facility is a public or private supervised facility, which provides temporary living accommodations and meal services for individuals who lack a fixed and regular night time residence.
Homeless Individual means a woman, infant or child: a. Who lacks a fixed and regular night time residence.
b. Whose primary night time 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.

SP-3

GEORGIA WIC 2012 PROCEDURES MANUAL

Special Population

B. Services for Applicants or Participants Residing in Temporary Housing
Local Georgia WIC clinics are responsible for ensuring accessibility to WIC services for individuals who have lost their usual (or primary) place of residence or who may be residing in temporary housing. Individuals who reside in temporary housing represent a high-risk population due to their compromised health and nutrition status and high levels of anxiety and stress. Sensitivity should be displayed with these individuals when gathering application and certification information. WIC procedures should be explained thoroughly. Applicants and participants must be provided services in accordance with the regulations and requirements of Georgia WIC (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 result of a disaster (see Emergency Plan Section).
Local agencies should make every effort to certify these applicants immediately, e.g., during the initial clinic visit. Local agencies should be flexible when issuing vouchers. If a participant is no longer residing in the WIC clinic service area where they last received vouchers, the vouchers should be issued and the participant transferred to the nearest WIC clinic. Employees of institutions may not serve as proxies for the residents.
Due to the nature of 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 powdered 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 a four (4) week period.

SP-4

GEORGIA WIC 2012 PROCEDURES MANUAL

Special Population

2. Offer information on food storage and sanitation, when applicable.

C. Meals in Institutions and Temporary Housing
Applicants/participants who reside in institutions or temporary housing, which serve meals, may participate in Georgia WIC. This may be a permanent or temporary residence such as a homeless shelter, group home, shelter for battered women, rehabilitation facility, etc.
When determining eligibility for participation in Georgia WIC, the institution or temporary housing facility and participant/applicant 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 or facility.
2. The institution or facility must not accrue financial or in-kind benefit from a person's participation in WIC. For example, the institution or facility may not transfer WIC foods to its general inventories or reduce 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 participant's diet and nutritional needs. If WIC foods are used in the communal food supply, the intent of providing supplemental foods to eligible individuals is not fulfilled.
4. No institutional constraints may be placed on the WIC participant's ability to partake of the supplemental foods and WIC related services and benefits. Participants must have full, free, and direct access to all WIC benefits and services available.
The above conditions have been established to ensure that: a. Participants, rather than the institution or facility, benefit from
Georgia WIC. b. All eligible persons participate in WIC in the same manner and
to the same degree as persons without institutional or facility 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 or facility 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.
SP-5

GEORGIA WIC 2012 PROCEDURES MANUAL

Special Population

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 Georgia WIC seeks to serve include, but are not limited to, individuals who may experience barriers to WIC 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 inhabitant of America.
Non-English speaking refers to an individual whose primary language is not English or an individual who speaks little or no English.
Vision Impaired refers to an individual with limited ability or the inability to see.
Refugee refers to someone who flees his or her country to another country to seek protection or relief from persecution because of race, religion, nationality, 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 (see Attachments SP-3).
In areas where a substantial number of persons have Limited English Proficiency, local agencies must carry out outreach activities to ensure that eligible members of such populations participate in WIC. Contact should be made with other agencies and community organizations serving LEP persons. A variety of nutrition education and breastfeeding materials should be available in Spanish through the Nutrition Services Unit.
If there is a need for materials in other languages, the local agency should

SP-6

GEORGIA WIC 2012 PROCEDURES MANUAL

Special Population

contact Georgia WIC or the Nutrition Services Unit for assistance. The Refugee Health Program has developed and compiled a library of translated health education materials. These materials are distributed, upon request, to organizations and individuals (see Attachment SP-3).
Local agencies may contract with translators or interpreters as needed. However, local agencies are encouraged to first hire multilingual staff in their programs to provide these services. Limited language interpretation services are available through the State Refugee Health Program. Specific areas of the state have also identified available interpreters (see Attachment SP-3). The Nutrition Services Unit 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 Georgia WIC to provide interpreters for WIC applicants and participants. Free interpreter services are available through agencies of the Georgia Department of Public Health. Although free interpreter services are available, an applicant or a participant may choose his or her own interpreter, such as a family member or friend who may not be a qualified or certified interpreter to attend the WIC appointment. In this instance, the applicant or participant must sign the "Client Waiver of Rights to Free Interpreter Services" form (see Attachment SP-6).
The local agency staff must inform a WIC applicant or a participant of the availability of qualified or 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's or participant's record.
Federal WIC regulations state 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. (7 C.F.R. Section 246.14(c) (5) ).
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 WIC services are available in other languages at no charge to them upon request. The displaying of this sign will be monitored on program and self reviews (see Attachment SP-5).
C. Refugees
A refugee is someone who flees his or her country due to persecution or a wellfounded fear of persecution because of race, religion, nationality, political opinion, or membership in a social group. With the significant number of

SP-7

GEORGIA WIC 2012 PROCEDURES MANUAL

Special Population

refugees coming to the State, every effort will be made to ensure that services are extended to this population (see Attachment SP-3). Aliens (legal and illegal) are eligible to apply for WIC on the same basis as United States citizens.
Staff of the Division of Public Health's, Refugee Health Program includes interpreters who speak Amharic, Bosnian, Cambodian, Russian, Somali, Tigrinya, and Vietnamese. WIC interpreters help refugees access health care by making appointments, arranging transportation, and providing interpretation at appointments.
D. Native Americans
Georgia WIC should make every effort to locate and enroll all eligible Native Americans residing within a local agency service area.
E. Persons with Disabilities
Georgia WIC is required to make services accessible to individuals covered by the Americans with Disabilities Act. Local agencies are responsible for ensuring that individuals with disabilities are accommodated in Georgia WIC. All facilities where WIC and related services are provided must be physically accessible from the outside as well as on the inside. The local agencies are required to 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-3).
F. Proposed Language for the Low Literacy and Limited English Proficiency
The United States Congress passed the National Literacy Act in 1991 that defined literacy as "an individual's ability to read, write, and speak in English, and compute and solve problems at levels of proficiency necessary to function on the job and in society, to achieve one's goals, and develop one's knowledge and potential". In the state of Georgia, the low literacy rate is 20 percent to 30 percent. Materials must be prepared to meet needs of the specific population group to be served, including migrant farm workers and homeless persons. When developing educational materials, Georgia WIC should assess its audience for literacy levels, language and culture. Attention should be paid to reading and/or writing abilities of individuals and assistance with even these adapted materials should be provided in a way that does not embarrass or bring attention to the WIC participant or applicant.

IV. REFERRAL AND OUTREACH TO SPECIAL POPULATIONS
Local agencies must develop a network for coordinating activities with local organizations and persons serving and providing resources to special population groups and minority populations. Local agencies should advise Georgia WIC 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 Georgia WIC agency will compile a

SP-8

GEORGIA WIC 2012 PROCEDURES MANUAL

Special Population

statewide listing for persons and organizations serving migrants and other minorities (see Attachments SP-1, SP-2, and SP-3). Local agencies should contact and distribute outreach materials to other agencies offering services to persons who reside in temporary locations. Health care may not be accessible to individuals who reside in temporary locations. Therefore, these individuals should be referred to any and all health services provided by local agencies. These high-risk individuals must be referred to appropriate local health and human service agencies such as: 1. Temporary Assistance for Needy Families (TANF) and client assistance services 2. Food pantries and meal programs 3. Local shelters 4. Supplemental Nutrition Assistance program (SNAP) 5. Legal services
Other pertinent outreach and referral procedures may be found in the Outreach Section of the Georgia WIC Procedures Manual.

SP-9

GEORGIA WIC 2012 PROCEDURES MANUAL

Georgia Farm Worker Health Program Cordele, GA 31010-0310
Phone: (229) 401-3096 Fax: (229) 401-3077

Attachment SP-1

Isiah C. Lineberry, Executive Director, Office of Rural Health Services, Email: ilineberry@dch.state.ga.us Tony Brown, Migrant Health Coordinator, Office of Rural Health Services, Email: tbrown@dch.state.ga.us Ted Meisner, Field Data Consultant, 478-746-9659, Email: laermita@asburyusa.net FAX: 630-929-1364

Project Sites

Migrant Program Staff

Telephone/Fax

Ellaville Ellenton

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
Blainette Hanson, FNP Dana Reddick, Nurse Manager Marisela Resendiz, Nurse's Aid Kathy French, Data Entry Jose Palomares, ORW Celines Quinones, ORW

Tel: (229) 937-5321 Fax: (229) 937-2232
Tel: (229) 324-2845 Fax: (229) 324-3383

Jody Horne, Cost Reports Tel: (229) 891-7100

Barbara Jackson, District

Tel: (229) 430-4575

Contact

Fax: (229) 912-430-

Mary Ann Bland, Accounting 5143

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

Ellenton Clinic 103 Baker Street P.O. Box 312 Ellenton, GA 31747

Colquitt Tift Cook Brooks

Colquitt Health Department Moultrie, GA
1109 N. Jackson Street Albany, GA 31701-2022


SP-10

GEORGIA WIC 2012 PROCEDURES MANUAL


Attachment SP-2



TELAMON CORPORATION (Migrant and Seasonal Farmworker Association, Inc.)

Field Offices

Offices
Lyons Office 120 East Liberty Avenue Lyons, GA 30436 (912) 526-3094 (912) 526-5906 (FAX)
Dublin Office 112 East Johnson Street Dublin, GA 31021 (478) 275-0127 (478) 275-7548 (FAX)
Statesboro Office 105 Elm Street P.O. Box 645 Statesboro, GA 30358 (912) 764-6169 (912) 489-6516 (FAX)

Supervisors Elmira Reynolds Employment and Training Specialist
Barbara Mosley Employment and Training Specialist
Elsie Trethaway Employment and Training Specialist

SP-11

GEORGIA WIC 2012 PROCEDURES MANUAL


Attachment SP-2 (cont'd)



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

KIDDIE KASTLE II

111 Oliver Lane

Glennville, GA 30427

(912) 654-2182

(912) 654-2190 (FAX)

3)

Ms. Gloria Sandoval, Director

KIDDIE KASTLE III

133 Serena Drive

Norman Park, GA 31771

(229) 769-3627

(229) 761-3182 (FAX)


SP-12

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment SP-3

SP-13

GEORGIA WIC 2012 PROCEDURES MANUAL


Attachment SP-3 (cont'd)











SP-14

GEORGIA WIC 2012 PROCEDURES MANUAL


Attachment SP-3 (cont'd)


SP-15

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment SP-4

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 Georgia WIC 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 Georgia WIC 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 Georgia WIC benefits such as is available to participants not associated with an institution.
Georgia WIC 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 Georgia WIC until such time as the shelter/facility notifies Georgia WIC that it no longer wishes to participate according to the ascribed conditions and/or it is determined by Georgia WIC 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) Title

Date

Please return completed and signed statement to:
Georgia WIC
Georgia Department of Public Health Two Peachtree Street, NW 10th Floor, Suite 10-476 Atlanta GA 30303

SP-16

GEORGIA WIC 2012 PROCEDURES MANUAL


Attachment SP-5

SP-17

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment SP-6

GEORGIA DEPARTMENT OF PUBLIC HEALTH WAIVER OF RIGHTS TO FREE INTERPRETER SERVICES
Free interpreter services are available through agencies or programs of the Georgia Department of Public Health (DPH). DPH 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, DPH or its representative agencies will not authorize payment for interpreter services not secured or approved by DPH.
I, __________________________, have been informed of my right to receive free interpretive
(Client Name)
services from ____________________________________. I understand that I am entitled to
(Agency or Program)
interpretive services at no cost to myself or to other family members, but do not wish to receive

DPH's free services at this time. I choose _________________________________to act as my
(Interpreter's Name)

interpreter from ___________________________ until ______________________________ .

(Start Date)

(End 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 ________________________________________________
(DPH Agency or Program)
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)

(Date)

(Staff Person's Signature)
SP- 18


(Date)

GEORGIA WIC 2012 PROCEDURES MANUAL

Outreach


TABLE OF CONTENTS

Page

I.

General ..................................................................................................................... OR-1

II. Methods of Outreach ................................................................................................. OR-1

III. Agencies to Contact for Outreach .............................................................................. OR-2

IV. Public Notification....................................................................................................... OR-3

V. Public Comment Period ............................................................................................. OR-3

VI. Outreach During a Waiting List ................................................................................. OR-3

A.

Outreach........................................................................................................ OR-3

B.

Coordination with Government Entitlement Program .................................... OR-4

VII. Program Costs ........................................................................................................... OR-4 VIII. Coordination/Integration of Services .......................................................................... OR-4
A. Outreach......................................................................................................... OR-4 B. WIC/Medicaid Coordination............................................................................ OR-4 C. WIC Coordination Strategies .......................................................................... OR-4 D. WIC Works Resources Center ....................................................................... OR-5 E. Georgia WIC Fact Sheet ................................................................................ OR-5

Attachments:
OR-1 BPHC Service Delivery Sites ..................................................................................... OR-8 OR-2 Georgia Association for Primary Health Care, Inc ................................................... OR-19 OR-3 Georgia Farm Worker Health Program Migrant Health Clinics Sites ....................... OR-24 OR-4 District Map .............................................................................................................. OR-25

GEORGIA WIC 2012 PROCEDURES MANUAL

Outreach

I.

GENERAL

Outreach activities are those promotional efforts designed to encourage and/or increase participation in Georgia WIC. The purpose of outreach is to:

1. Increase public awareness of the benefits of Georgia WIC. 2. Inform potentially eligible persons about Georgia WIC in order to encourage and
promote their participation in WIC. 3. Inform health and social service agencies about WIC eligibility criteria for
participation and to encourage referrals. 4. Ensure cooperation and coordination between WIC and other health- related and
public assistance programs to benefit WIC applicants and participants. 5. Promote a positive image of Georgia WIC.

Each local agency must conduct outreach and referral activities to coordinate Georgia WIC with other health-related and public assistance programs that can serve potential WIC applicants. The outreach activities conducted must be documented and kept on file for three (3) prior years plus the current year. An Outreach Plan may be requested during a fiscal year according to need.
When funds are available, Georgia WIC will develop and provide general outreach materials for use by other programs.

II. METHODS OF OUTREACH
Outreach activities should be aimed directly at potentially eligible persons through the use of informational posters, brochures, displays in public places, presentations at meetings and clubs, and advertisements through local newspapers, radio, or television. If a local agency serves a significant number of applicants/participants 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, the National Association for the Advancement of Colored People (NAACP), or churches to provide outreach information. All outreach materials must include the USDA full nondiscrimination statement as follows:
"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.
To file a complaint of discrimination, write USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call toll free (866) 6329992 (Voice). Individuals who are hearing impaired or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish)." USDA is an equal opportunity provider and employer.

OR-1

GEORGIA WIC 2012 PROCEDURES MANUAL

Outreach

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 direct access to Georgia WIC at no cost. This toll-free number, 1-800-228-9173, is available on printed materials and is provided during radio and television interviews about WIC.
The eighteen (18) Georgia Public Health Districts and two contracted WIC agencies are encouraged to communicate regularly with other agencies that also provide 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 Georgia WIC applicants and participants, or their designated proxies, with information on other health-related and public assistance programs, and when appropriate, shall refer WIC applicants and participants to such programs.
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 Offices 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. Head Start Programs

OR-2

GEORGIA WIC 2012 PROCEDURES MANUAL

Outreach

IV. PUBLIC NOTIFICATION
The State Agency, through the Department of Public Health Office of Communication, will distribute outreach information to every newspaper and radio station in Georgia, at least annually. All outreach materials must include the USDA full non-discrimination statement as follows:
"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.
To file a complaint of discrimination, write USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call toll free (866) 6329992 (Voice). Individuals who are hearing impaired or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish)." USDA is an equal opportunity provider and employer.

V. PUBLIC COMMENT PERIOD
Georgia WIC has developed a website (on the Public Health Website) where all WIC advocates, applicants/participants, vendors and the general public have an opportunity to make comments on the operation of Georgia WIC. This site will be open all year for general comments. Additionally, to ensure that everyone has access to the website address, all information, pamphlets, letters, etc. given to health department staff, WIC advocates, applicants, participants, vendors and the general public will reference the website www.wic.ga.gov which contains a link to the public comment survey.
During the comment period, which is now open throughout the year, Georgia WIC regulations and guidelines will be made available to the public upon request. This includes Federal Regulations, the State Plan, the Procedures Manual and the Income Guidelines.
Once a year, the Office of Communications prepares News Releases to notify the general public of Georgia WIC benefits and notices soliciting public comments on WIC operations. The news releases are sent to newspapers statewide annually.

VI. OUTREACH DURING A WAITING LIST
When a local agency is serving its maximum caseload of WIC participants, the local agency shall maintain a waiting list of individuals who express interest in receiving WIC and are likely to be served.
A. Outreach
The USDA and DPH are fully committed to the principle of integrating WIC and health and social services while protecting an individual's right to privacy.

OR-3

GEORGIA WIC 2012 PROCEDURES MANUAL

Outreach

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 programs, e.g., Medicaid, Peachcare, Food Stamps/SNAP and Temporary Assistance for Needy Families (TANF).
VII. PROGRAM COSTS
Costs of promotional efforts designed to encourage and increase participation in Georgia WIC are reimbursable to the local agencies. Outreach efforts should be consistent with the health-oriented nature of WIC.
VIII. COORDINATION/INTEGRATION OF SERVICES
A. Outreach
Integration of WIC services with other health clinic services has been a major thrust for Georgia WIC and the Department of Public Health. All districts have taken positive steps toward decentralization and the corresponding integration of WIC with existing services (see Attachment OR-1).
B. WIC/Medicaid Coordination
To date, several measures have been implemented statewide to address the coordination of Georgia WIC and Medicaid Programs. They include:
1. The WIC Certification process now uses the WEB portal for adjunctive eligibility. The toll free number for Georgia WIC is 1-800-228-9173.
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 toll free number for Georgia Medicaid Program is 1800-809-7276.
3. Community-based health centers supported by the Georgia Association for Primary Health Care Inc., provide health and nutrition services, including WIC services in some areas
(see Attachment OR-2).
C. WIC 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).

OR-4

GEORGIA WIC 2012 PROCEDURES MANUAL

Outreach

This project was one of a number of activities undertaken in response to the 1994 legislative mandate for enhanced coordination between WIC and healthrelated services. The legislation, the Healthy Meals for Healthy Americans Act of 1994 (P. L. 103-448), stipulated that the Secretaries of the U.S. Departments 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) (see Attachment OR-3) and improve coordination of WIC services with Indian Health Services (HIS) facilities. This publication can be found online at: http://www.fns.usda.gov/wic/resources/strategies.htm
D. WIC Works Resources Center
The WIC Works Resources Center is a USDA-sponsored site in which states share state-developed materials and best practices. This information can be accessed online at: http://wickworks.nal.usda.gov
The site consists of:

WIC Learning Online- a series of 18 online learning modules designed for all levels of staff working in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) WIC Database WIC Sharing Center WIC Learning Center WIC Topics A-Z WIC Talk
E. Georgia WIC 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 healthcare for infants is key to preventing babies from dying or becoming ill. Low-income women in Georgia who receive both WIC and Medicaid have a
significantly lower infant mortality rate than 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 healthcare costs, according to a national study.
Who Gets WIC?
To be certified as eligible for WIC, infants, children, and pregnant, postpartum, and breastfeeding women must meet all of the following eligibility requirements:
x Categorical x Residential x Income

OR-5

GEORGIA WIC 2012 PROCEDURES MANUAL

Outreach

x Nutrition Risk
Categorical Requirement
The following individuals are considered categorically eligible for WIC: prenatal women; breastfeeding women for up to one years' time; post-partum women for up to 6 months' time; children ages 1-5 years, and infants ages 0-12 months.
Residential Requirement
Applicants must live in Georgia (see Attachment OR-4). Applicants served in areas where WIC is administered by an Indian Tribal Organization (ITO) must meet residency requirements established by the ITO. 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.
Income Requirement
To be eligible for WIC, applicants and re-certifying participants must have income at or below an income level or standard set by the federal agency or be determined automatically income-eligible based on participation in other designated programs, (e.g., Medicaid, SNAP or TANF).
Nutrition Risk Requirement
Applicants must be seen by a health professional, such as a physician, nurse, or nutritionist, who must determine the individual's nutritional risk. This is done in the WIC clinic at no cost to the applicant. In addition, health referral 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, but are not limited to, anemia (low blood levels), underweight, or history of poor pregnancy outcomes. A dietary-based condition includes, but is not limited to, inappropriate nutritional practices.
At a minimum, the applicant's height and weight must be measured and blood taken to check for anemia as part of the eligibility determination. An applicant must have at least one of the medical or nutritional conditions on the State's list of WIC nutrition risk criteria. When no nutritional risks are evident, applicants who are otherwise eligible based on income, residency, identification, and category may be presumed to be at nutritional risk and assigned Risk Code 401 (Other Dietary Risk) except for infants who are less than four (4) months of age. Infants less than four (4) months of age cannot use Risk Code 401 to establish their nutritional risk.
Georgia residents 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 the Grady Health System and Southside Medical Center.

OR-6

GEORGIA WIC 2012 PROCEDURES MANUAL

Outreach

Income Eligibility Guidelines effective July 1, 2011 to June 30, 2012

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

Yearly Income $20,147
27,214 34,281 41,348 48,415 55,482 62,549 69,616 +$ 7,067

Length of Participation
WIC is a supplemental food program that provides nutrition education, and referrals to enhance the nutritional and health status of women, infants, and children. A certification period is the length of time for which a WIC participant is determined to be eligible to receive benefits. 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 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 notify Georgia WIC. In most cases, WIC staff will give the participant a Verification of Certification (VOC) Card, which enables the participant to continue receiving benefits at a new location. When the individual moves, they can call the WIC office in their new area or location for an appointment and take the VOC card to the WIC appointment for benefits.
Waiting List / Priority System
Sometimes WIC agencies do not have enough money to serve everyone who needs WIC or wishes 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 first get WIC benefits when more participants 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 low hemoglobin/hematocrit, underweight, breastfeeding women, or women with problems during pregnancy. 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 served first when the WIC agency can serve more individuals.

OR-7

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment OR-1

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

Phone

Notes

Service Types

BPHC Supported Programs

Albany Area Primary 204 N. Westover Albany, GA

Health Care, Inc

Boulevard

31707

(229) 888-6559

Admin Only

Primary Medical Care

CHC, ISDI

Clinics

East Albany Medical Center

1712-A East Broad Avenue

Albany, GA 31705

(229) 639-3100

Year round

East Albany Pediatric & Adolescent Center

1712-C East Broad Avenue

Albany, GA 31705

(229) 639-3103

Year round

Rural HIV Model

2202 East Oglethorpe Boulevard

Albany, GA 31705

(229) 431-1423

Year round

Dawson Medical 420 Johnson

Center

Street, S.E.

Dawson, GA 39842-1523

(229) 995-2990

Year round

Edison Medical Center

19519 West Hartford Street

Edison, GA 31746-0849

(229) 835-2238

Year round

Lee Medical Arts Center

235 Walnut Street

Leesburg, GA 31705

(229) 759-6508

Year round

Baker County Primary Health Care Center

100 Sunset Boulevard

Newton, GA 39870

(229) 734-5250

Year round

Dooly County Community Health Center

1212 E. Union Street

Vienna, GA 31092

(229) 268-8865

Year round

OR-8

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment OR-1 (cont'd)

Main Site

Address

City, State, ZIP

Phone

Notes Service Types

BPHC Supported Programs

Southside Medical Center, Inc

1046 Ridge Avenue, Southwest

Atlanta, GA 30315

(404) 688-1350

Admin/ Clinic

Dental Care

Services, Enabling

Services, Mental

Health/Substance

Abuse Services,

Obstetrical and Gynecological Care,

CHC

Other Professional

Services, Primary

Medical Care,

Specialty Medical

Care

Clinics

Southside Medical Center, Inc - Atlanta

1660 Lakewood Avenue

Atlanta, GA 30315

(404) 627-1385

Year round

Southside Medical Center, Inc -

2578 Gresham Road

Gresham

Atlanta, GA 30316

(404)

Year

241-2336 round

OR-9

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment OR-1 (cont'd)

Main Site

Address

City, State, ZIP

Phone

Notes

West End Medical Centers, Inc

868 York Atlanta, Avenue, GA Southwest 30310

(404) 756-8732

Admin/ Clinic

Clinics

West End Medical Center

868 York Avenue, SW

Atlanta, GA 30318

(404) 752-1400

Year round

Service Types

BPHC Supported Programs

Dental Care Services, Enabling Services, Obstetrical and Gynecological Care, Other Professional Services, Primary Medical Care, Specialty Medical Care

CHC, PH

OR-10

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment OR-1 (cont'd)

Main Site

Address

City, State, ZIP

Phone

Notes

Service Types

BPHC Supported Programs

Med-Link Georgia

11 Charlie Morris Road PO Box 459

Colbert, GA 30628

(706) 788-3234

Admin/ Clinic

Primary Medical CHC Care

Clinics

Med-Link Bowman Medical Center

206 East Church Street PO Box 430

Bowman, GA 30624

(706) 245-7361

Year round

Med-Link Gainesville Medical Center

1211 Sherwood Park Drive, NE

Gainesville, GA 30501

(770) 287-0290

Year round

Med-Link Hartwell Medical Center

63 West Gibson Street

Hartwell, GA 30643

(706) 376-6100

Year round

Med-link

247 Union Point

Oglethorpe Medical Street

Center

PO Box 264

Lexington, GA 30648

(706) 743-8171

Year round

Med-Link Washington

123 B Gordan Street

Washington, GA 30673

(706) 678-1411

Year round

Med-Link Winder

563 Jefferson Highway

Winder, GA 30680

(706) 867-6633

Year round

Med-Link Royston

625 Cook Street

Royston, GA 30662

(706) 245-5050

Year round

Med-Link Rabun

896 Hwy 441 South

Clayten, GA 30525

(706) 782-5991

Year round

Med-Link Banks

1244 Historic Horner Highway

Horner, GA 30547

(706) 677-4568

Year round

OR-11

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment OR-1 (cont'd)

Main Site

Address

City, State, ZIP

Phone

Valley Healthcare System, Inc

Building No 120 1440 Benning Drive

1315 Delaunay Suite 201 Columbus, GA 31901

Columbus, GA 31903

(706) 3229456

Clinics
Valley Healthcare System, Inc

3473 N. Lumpkin Bldg C

Columbus, GA 31903

Notes
Admin/ Clinic
Year round

Service Types

BPHC Supported Programs

Dental Care Services, Enabling Services, Mental Health/Substance Abuse Services, Obstetrical and Gynecological Care, Other Professional Services, Primary Medical Care, Specialty Medical Care

CHC

Main Site

Address

City, State, ZIP

Phone

Notes

Service Types

BPHC Supported Programs

Georgia Highlands Medical Services, Inc

260 Elm Street PO Box 307

Cumming, GA 30028

(770) 887-1668

Admin/Clinic

Primary Medical Care

CHC

Clinics

OR-12

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment OR-1 (cont'd)

Main Site

Address

City, State, ZIP

Phone

Notes

Service Types

BPHC Supported Programs

Palmetto Health Council, Inc

Suite 200 547 Ponce de Leon Ave

Atlanta, GA (404) 929- Admin

30308-1880 8824

Only

Enabling Services, Obstetrical and Gynecological Care, Primary Medical Care

CHC

Clinics

Community Medical Center of Barnesville

Suite 1 101 Commerce Place

Barnesville, (770) 358- Year

GA 30204 4408

round

Community Medical Center of Hogansville

200 N Hwy 29

Hogansville, (706) 675- Year

GA 30230 3481

round

Community Medical 507 Park Palmetto, (770) 463- Year

Center of Palmetto Street

GA 30268 4644

round

Community Medical Center of Zebulon

1601 Barnesville Street

Zebulon, GA 30295

(770) 567- Year

3323

round

Community Medical Center of Carrollton

115 Ambulance Drive

Carrollton, GA 30117

(770) 8342255

Main Site

Address

Tendercare Clinic Clinics

803 South Main Street

City, State, ZIP

Phone Notes

Service Types

BPHC Supported Programs

Greensboro, GA 30642

(706) 4531201

Admin/Clinic

CHC, CHC

OR-13

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment OR-1 (cont'd)

Main Site

Address

City, State, ZIP

Phone

Notes

Georgia Mountains 75 Bypass Road Health Services, Inc PO Box 540

Morganton, (706) 374- Admin/

GA 30560 6898

Clinic

Clinics

Georgia Mountains Health Services, Inc

Suite 101 526 Maddox Drive

Ellijay, GA 30540

(706) 6356898

Year round

Service Types

BPHC Supported Programs

Primary Medical CHC Care

Main Site
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

Address

City, State, ZIP

Phone

Notes

BPHC
Service Types Supported
Programs

2016 Ocilla Rd

Douglas, (912)

Year

GA 31533 384-2252 round

200 South Cherry Ocilla, GA (229)

Year

Street

31774

468-5911 round

202 South Cherry Ocilla, GA (229)

Year

Street

31774

468-7762 round

105 Fleet Wood Avenue

Willacooch ee, GA 31650

(912) 534-5993

Year round

OR-14

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment OR-1 (cont'd)

Main Site

Address

City, State, ZIP

Phone

Notes Service Types

BPHC Supported Programs

Stewart Webster Rural Health, Inc

220 Alston Street PO Box 357

Richland, GA (229) 887-

31825

3324

Admin/ Clinic

Dental Care Services, Enabling Services, Mental Health/Substance Abuse Services, Obstetrical and Gynecological Care, Primary Medical Care

CHC

Clinics

Quitman Health Care

41 Old School Road

Georgetown, (229) 334- Year

GA 39874 9353

round

Plains Medical Center

107 Main Street PO Box 389

Plains, GA 31780

(229) 824- Year

7757

round

OR-15

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment OR-1 (cont'd)

Main Site

Address

Oakhurst Medical 770 Village Square

Centers, Inc

Drive

Clinics

Decatur Medical Office

1760 Candler Road

City, State, ZIP

Phone Notes

Service Types

BPHC Supported Programs

Stone Mountain, GA 300833380

(404) 2988998

Primary Admin/Clinic Medical CHC
Care

Decatur, GA 30032

(404) 2862215

Year round

Main Site Address
East Georgia 316 North Main Healthcare Street Center, Inc PO Box 807
Clinics

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, Primary Medical Care

CHC, MHC

Main Site

Address

Primary Health Care 13570 North Main Center of Dade, Inc Street
Clinics

City, State, ZIP

Phone

Notes

Service Types

BPHC Supported Programs

Trenton, GA 30752

(706) 6577575

Primary Admin/Clinic Medical CHC
Care

OR-16

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment OR-1 (cont'd)

Main Site

Address

City, State, ZIP

Phone

Tri-County Health 1008 Atlanta Warrenton,

System, Inc

Highway

GA 30828

(706) 4653253

Clinics

Tri-County Health System, Inc

156 Alexander Street

Crawfordville, (706) 456-

GA 30631

2925

Tri-County Health System, Inc

437-C East Main Street

Gibson, GA 30810

(706) 5983359

Hancock County 323 Hamilton

Primary Health Street

Care

PO Drawer J

Sparta, GA 31087

(706) 4445241

Notes

Service Types

BPHC Supported Programs

Admin/ Clinic

Dental Care Services, Obstetrical and Gynecological Care, Primary Medical Care

CHC

Year round
Year round
Year round

Main Site

Address

City, State, ZIP

Phone

McKinney Community Health Center, Inc

218 Quarterman Street PO Box 1902

Waycross, GA 315013547

(912) 2870301

Clinics

McKinney Community Health Center, Inc

122 North Main Street

Nahunta, GA 31553

McKinney Community Outreach Center

935 McDonald Waycross,

Street

GA 31501

(912) 4626222
(912) 2855080

Notes

Service Types

BPHC Supported Programs

Admin/ Clinic

Dental Care Services, Enabling Services, Other Profession al Services, Primary Medical Care

CHC, MHC

Year round
Year round

OR-17

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment OR-1 (cont'd)

Main Site
Community Health Care Systems, Inc
Clinics Tennille Community Health Center

Address

City, State, ZIP

508 West Elm Street PO Box 371

Wrightsville, GA 31096

116 Smith Street

Tennille, GA 31096

Phone

Notes

BPHC
Service Types Supported
Programs

(478)

Admin/

864-2600 Clinic

Obstetrical and Gynecological Care, Primary Medical Care

CHC

(478)

Year

552-7384 round

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)

Revised 3/11

OR-18

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment OR-2

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 Practices
Albany Area Primary Health Care, Inc.
204 N. Westover Blvd. Albany, GA 31707 (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 420 Johnson Street Dawson, GA 39842 (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 19159 West Hartford Street/P.O. Box 849 Edison, GA 31746-0849 (229) 835-2238 (229) 835-3032/FAX Calhoun County

Lee Medical Arts Center 235 Walnut Street Leesburg, GA 31763 (229) 759-6508 (229) 759-9950/FAX Lee County
Rural HIV Model 2202 E. Oglethorpe Blvd. Albany, GA 31705 (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
Tennille Community Health Center 116 Smith Street Tennille, GA 31089 (478) 552-7384 (478) 552-1198/FAX Washington County
East Georgia Healthcare Center, Inc.
316 North Main Street/P.O. Box 807 Swainsboro, GA 30401 (478) 237-2638 (478) 237-9138/FAX

OR-19

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment OR-2 (cont'd)



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

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
GA Mountains Health Services at Ellijay 526 Maddox Drive, Suite 101 Ellijay, GA 30540 (706) 635-6898 (706) 635-6888/FAX Gilmer 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 Ola Smith, CEO Mukesh Agarwal, M.D., Medical Director Ware County

(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
Colbert Medical Center 11 Charlie Morris Road./P.O. Box 609 Colbert, GA 30628 (706) 788-2127 (706) 788-2815/FAX Madison County
Georgia Pines Medical Center 212 Hospital Drive Washington, GA 30673 (706) 678-1411 (706) 678-3620/FAX Wilkes County
Hartwell Medical Center 127 West Gibson Street Hartwell, GA 30643 (706) 376-6100 (706) 376-3394/FAX Hart County

McKinney Community Outreach Center 935 McDonald Street Waycross, GA 31501 (912) 285-5080 Ware County

Oglethorpe Medical Center 247 Union Point Street/P.O. Box 264 Lexington, GA 30648 (706) 743-8171 (706) 743-3000/FAX Oglethorpe County

McKinney Community Health Center, Inc. 122 North Main Street Nahunta, GA 31553 (912) 462-6222

Greater Hall Community Health Center 810 Pine Street, SW/P.O. Box 445 Gainesville, GA 30503 (770) 287-0290

OR-20

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment OR-2 (cont'd)



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



(770) 287-7597/FAX

(706) 675-3481

Hall County

(706) 675-8253/FAX

Heard County

Oakhurst Medical Centers, Inc.
770 Village Square Stone Mountain, GA 30083 (404) 298-8998 (404) 298-7658/FAX

Community Medical Center of Carrollton 115 Ambulance Drive Carrollton, GA 30117-3855 (770) 834-2255

William A. Murrain, JD, Chief Executive Officer Doa Harris, M.D., Medical Director

Primary Health Care Center of Dade

Dekalb County

13570 North Main Street

Trenton, GA 30752

Oakhurst Medical Center at Candler and

(706) 657-7575

Glenwood

(706) 657-5885/FAX

1760 Candler Road

Diana Allen, LCSW, Chief Executive Officer

Decatur, GA 30032

Pamela C. Ventra, M.D., Medical Director

(404) 286-2215

Dade County

Dekalb County

South Central Primary Care Center

Palmetto Health Council, Inc.
Corporate Office 547 Ponce de Leon Avenue, Suite 200 Atlanta, GA 30308-1880 (404) 929-8824

200 Cherry Street Ocilla, GA 31774 (229) 468-5911/ (229) 468-4247/FAX (229) 468-7762/(229) 468-9302/FAX Irwin County

(404) 929-9769 Jon Wollenzien, Jr., D.B.A., Chief Executive

South Central Primary Care Center 101 Bowens Mill Road

Community Medical Center of Palmetto 507 Park Street/P.O. Box 469 Palmetto, GA 30268 (770) 463-4644

Douglas, GA 31533 (229) 384-2252 (229) 384-8888/FAX Coffee County

(770) 463-9885/FAX Fulton County

South Central Primary Care Center Fleetwood Avenue

Community Medical Center of Zebulon 1601 Barnesville Street/P.O. Box 561 Zebulon, GA 30295 (770) 567-3323

Willacoochee, GA 31650 (912) 534-5993 (912) 534-5703/FAX Atkinson County

(770) 567-0332/FAX Pike County

South Columbus, Inc., Community

Community Medical Center of Barnesville 101 Commerce Place, Suite 1 Barnesville, GA 30204 (770) 358-4408 (770) 358-0002/FAX Lamar County

Health Center of
1315 DeLaunay Avenue, Suite 201 Columbus, GA 31901 (706) 322-9599 (706) 322-8332/FAX Sarah Lang, Chief Executive Officer & Medical Director

Community Medical Center of Hogansville

Muscogee County

200 N Hwy 29 Hogansville, GA 30230-1142

South Columbus Community Health Center 1440 Benning Drive - Building 120

OR-21

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment OR-2 (cont'd)



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



Columbus, GA 31903

5139 Jimmy Carter Boulevard, Suite 205

(706) 689-1331

Norcross, GA 30093

(706) 689-4340/FAX

(770) 613-0070

Muscogee County

Gwinnett 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
SMC Substance Abuse Treatment Center 1660 Lakewood Avenue, SW Atlanta, GA 30316 (404) 627-1385 (404) 622-9769/FAX Fulton County
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 Atlanta, GA 30315 (404) 622-0727 (404) 627-8420/FAX Fulton County
SMC Clinica de la Mama
1046 Ridge Avenue, SW Atlanta, GA 30315 (404) 688-1350 Fulton County
Clinica de la Mama Austell 1680 Mulkey Road, Suite E Austell, GA 30106 (770) 732-1880 Cobb County
Clinica de la Mama Norcross

Clinica de la Mama South Atlanta/Cleveland 2685 Metropolitan Parkway, Suite C Atlanta, GA 30048 (404) 684-1250 Fulton 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
Plains Medical Center 107 Main Street/P.O. Box 389 Plains, GA 31780 (229) 824-7757 (229) 824-3497/FAX Sumter County
Tender Care Clinic, Inc.
803 South Main Street Greensboro, GA 30642 (706) 453-1201 (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 Warrenton, GA 30828 (706) 465-3253 (706) 465-3256/FAX Donna Newsome, Chief Executive Officer Debra Crawley, M.D., Medical Director Warren County
Tri-County Family Medical Center 156 Alexander Street/P.O. Box 205 Crawfordville, GA 30631 (706) 456-2925 (706) 456-2224/FAX Taliaferro County

OR-22

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment OR-2 (cont'd)



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



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
West End Medical Centers, Inc.
868 York Avenue Atlanta, GA 30310 (404) 752-1400/(404) 755-8295/FAX (404) 756-8732 (CEO)/(404) 752-7296/FAX CEO) Daisy S. Harris, Chief Executive Officer Linda J. Cannon, M.D., Medical Director Fulton County

West End Medical Group 361 North Marietta Pkwy Marietta, GA 30062 (770) 919- 0025 (678) 569-0228/FAX Cobb County

OR-23

GEORGIA WIC 2012 PROCEDURE MANUAL

Attachment OR-3

Georgia Farmworker Health Program Migrant Health Clinic Sites

Project Site & Address
Decatur County Health Department 928 West Street PO Bos 417 Bainbridge, Georgia 39818

Project Coordinator
Sherrie Hutchins, RN, Director

Ellaville Primary Medicine Clinic 103 Broad Street PO Box 65 Ellaville, Georgia 31806-9428

Mary Anne Shepherd, RN-C, FNP

Ellenton Clinic 185 Baker Street PO Box 312 Ellenton, Georgia 31747

Cynthia Hernandez

Rochelle Healthcare Center 636 2nd Avenue SW PO Box 481 Rochelle, Georgia 31079

H. Scott Jobe, MBA, CMPE

Reidsville East Georgia Healthcare Center 222 Soth Main Street Main Street Reidsville, Georgia 30453

Sandra Durrence, FNP

Contact Information Tel: 229-248-3055 Fax: 229-248-3010 slhutchins@dhr.state.ga.us
Tel: 229-937-3748 Fax: 229-937-2232 mshepherd@sumterregional.o rg
Tel: 229-324-2845 Fax: 229-324-3383 cyhernandez@dhr.state.ga.us
Tel: 229-365-2570 (Clinic) Fax: 229-365-2571 (Clinic) Scott Jobe: Tel: 229-2714676 hsjobe@crispregional.org
Tel: 912-557-3300 Fax: 912-557-3328 smdurrence@gdph.state.ga.us

Office of Rural Health Services
OR- 24

GEORGIA WIC 2012 PROCEDURES MANUAL
District Map

Attachment OR-4

OR-25

GEORGIA WIC 2012 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. Vegetable and Fruit Voucher.............................................................................. FD-2

E. WIC Farmers Market Nutrition Program (FMNP) ............................................... FD-2

F. Senior Farmers Market Nutrition Program (SFMNP).......................................... FD-3

III.

Voucher Issuance General.................................................................................... FD-3

A. Valid Certification Period .................................................................................... FD-3 B. Identification of Person Picking Up Vouchers .................................................... FD-4

C. Corrections ......................................................................................................... FD-4

D. Issuance ............................................................................................................. FD-4

E. Categorically Ineligible ....................................................................................... FD-5

F. Issuance of Vouchers to Family Members ......................................................... FD-6

IV.

Voucher Printed on Demand (VPOD) and Computer Generated

Vouchers .................................................................................................................. FD-6

A. Data Elements.................................................................................................... FD-6

B. Voucher Cycles ................................................................................................. FD-7

C. Voucher Packaging ............................................................................................ FD-7

D. Voucher Issuance............................................................................................... FD-7 E. Transporting VPOD Vouchers from a Site within a Site ..................................... FD-9

F. Ordering VPOD Vouchers .................................................................................. FD-9

V.

Manual Vouchers (Blank and Standard) .................................................................. FD-9

A. Blank Manual Vouchers ................................................................................... FD-10



GEORGIA WIC 2012 PROCEDURES MANUAL


Food Delivery

B. Preprinted Manual Vouchers............................................................................ FD-10

C. Ordering Manual Vouchers .............................................................................. FD-10

D. Receipt of Manual Vouchers ............................................................................ FD-10

E. Inventory Control of Manual Vouchers ............................................................. FD-11

F. Issuance of Manual Vouchers .......................................................................... FD-11

G. Distribution of Manual Voucher Copies ............................................................ FD-12

H. Voided Manual Vouchers ................................................................................. FD-13

VI.

VPOD Procedures.................................................................................................. FD-13

A. General............................................................................................................. FD-13

B. Issuing VPOD Vouchers................................................................................... FD-14

C. Voucher Reconciliation..................................................................................... FD-14

D. Voiding VPOD Vouchers .................................................................................. FD-15

E. VPOD Inventory Log Sheets ............................................................................ FD-15

F. Corrective Actions for VPOD............................................................................ FD-15

VII.

Mailing/Delivery of WIC Vouchers.......................................................................... FD-16

A. Conditions for Mailing/Delivering Vouchers...................................................... FD-16

B. Acceptable Reasons for Mailing/Delivering Vouchers...................................... FD-16

C. Mailing/Delivery Procedures............................................................................. FD-16

D. Voucher Mailing Process.................................................................................. FD-17

E. Returned Vouchers .......................................................................................... FD-17

VIII. Prorated Vouchers................................................................................................... FD-18

IX.

Late Pick-Up of Vouchers ...................................................................................... FD-19

X.

Coordination of Health Services and Vouchers Issuance ...................................... FD-20

XI.

Lost, Stolen or Damaged Vouchers ....................................................................... FD-20

A. Replacement of Vouchers ................................................................................ FD-20

B. Replacement Vouchers Due to a Declared Emergency .................................. FD-20



GEORGIA WIC 2012 PROCEDURES MANUAL


Food Delivery

C. Lost/Stolen/Destroyed/Voided Voucher Report................................................ FD-21

D. Vouchers Lost, Stolen, or Destroyed Prior to Issuance.................................... FD-22

E. Change of Formula Order/Formula Purchased In Error ................................... FD-23

XII.

Borrowed Vouchers................................................................................................ FD-23

XIII. Critical Errors ......................................................................................................... FD-24

XIV. Cumulative Unmatched Redemption (CUR) Report .............................................. FD-24

A. Introduction....................................................................................................... FD-24

B. Procedures for Reconciliation .......................................................................... FD-25

C. Manually Reconciling CUR Part 1 .................................................................... FD-26

D. Manually Reconciling CUR Part 2 .................................................................... FD-28

E. Procedures for Both Reports............................................................................ FD-28

XV. Unmatched Redemption Report............................................................................. FD-28

XVI. Reconciliation of WIC Reports and Daily Program Operations .............................. FD-29

A. Daily Verifications............................................................................................. FD-29

B. Monthly Verifications ........................................................................................ FD-29

Attachments: FD-1 Preprinted Standard Manual Voucher .................................................................... FD-30 FD-2 Blank Manual Voucher ........................................................................................... FD-31 FD-3 Voucher Printed On Demand (VPOD) Voucher ..................................................... FD-32 FD-4 WIC Farmer Market Nutrition Program Check ...................................................... FD-33 FD-5 Senior Farmers Market Nutrition Program Check .................................................. FD-34 FD-6 Voucher Cycle Packing List ................................................................................... FD-35 FD-7 Form and Manual Voucher (Supply Order Form)................................................... FD-36 FD-8 Manual Voucher Inventory Log .............................................................................. FD-37 FD-9 Voucher Printed On Demand Log Sheet................................................................ FD-38 FD-10 Batch Control Form ................................................................................................ FD-39



GEORGIA WIC 2012 PROCEDURES MANUAL


Food Delivery

FD-11 Batch Control Exception Report ............................................................................. FD-40

FD-12 Georgia WIC Identification Card............................................................................. FD-41

FD-13 Daily Roster/Monthly Mailed Voucher Report ........................................................ FD-43

FD-14 Borrowed Voucher Report Form ............................................................................ FD-44

FD-15 Cumulative Unmatched Redemptions Part I .......................................................... FD-45

FD-16 Cumulative Unmatched Redemptions Part II ......................................................... FD-46

FD-17 Unmatched Redemption Report............................................................................. FD-47

FD-18 Lost, Stolen, Destroyed, Voided Voucher Report................................................... FD-48

FD-19 Vouchers Printed on Demand (VPOD) Receipt ..................................................... FD-49

FD-20 Infant Blank Manual or Vegetable and Fruit Voucher............................................. FD-50



GEORGIA WIC 2012 PROCEDURES MANUAL


I.

GENERAL

Food Delivery

Georgia WIC uses a uniform retail food delivery system. Participants are issued Food Instruments (FI) in the form of 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. Georgia WIC contracts with a third party data processing firm, CSC Covansys. CSC Covansys maintains the participant master file, produces a wide range of monthly and quarterly reports, and performs reconciliation of all issued food
instruments. Local agencies mustelectronically transmit WIC voucher issuance records
to CSC Covansys daily.

Participants redeem the vouchers for specified types and quantities of foods at authorized vendors. Vendors deposit redeemed vouchers into their local bank accounts just as they would any other check. 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 returned to the bank of first deposit and the vendor's account is reduced by the value of the vouchers. Vendors may request payment for returned vouchers by submitting them along with a completed Returned Voucher Payment log to Georgia WIC. Vouchers paid, but flagged as suspect, are investigated by the state agency.

In February 2008, Georgia WIC initiated the mandatory Automated Clearing House (ACH) process for making payments for vouchers presented with a requested value over the maximum allowable cost.

When such a voucher reaches the bank, it will be paid at a rate equal to the average for the vendor's peer group.

While those vouchers must still be returned to the bank of first deposit and a return check fee imposed, ACH greatly reduces the time and expense involved in paying over the maximum rejected vouchers.

CSC Covansys reconciles individually issued and redeemed vouchers as required by federal regulations and maintains a voucher master file that tracks the status of all vouchers. CSC Covansys 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 eight (8) types of Standard Manual Vouchers, and two (2) types of Blank Manual Vouchers that may be issued to WIC participants:
A. Vouchers Printed On Demand (VPOD)
Vouchers Printed On Demand (VPOD) are produced on site by the clinic's automated system for each qualified participant (see Attachment FD-3). The receipts generated from printing these vouchers are maintained by the clinic. VPOD serial numbers must be entered into the VPOD inventory log within three

FD-1

GEORGIA WIC 2012 PROCEDURES MANUAL

(3) days of receipt (see Attachment FD-9). B. Blank Manual Vouchers

Food Delivery

Blank Manual Vouchers may be issued in cases when automated systems are inoperable or otherwise unavailable. These vouchers may be completed for:

1.) New or transferring WIC participants; 2.) To replace voided computer printed vouchers; 3.) To adjust a food package in the event of late pick up by a participant; 4.) To supplement the preprinted manual voucher food package (see FD-V.,
Manual Vouchers and FD-V.,-F. Issuance of Manual Vouchers for procedures). The district/unit/clinic identification number is preprinted on blank manual vouchers (see Attachment FD-2 and FD-20). These vouchers must be stored in a secure location and must be logged in the Manual Inventory Log within three (3) days of receipt (see Attachment FD-8).

C. Preprinted Standard Manual Vouchers

Standard Manual Vouchers are produced by CSC Covansys in separated sets of eight (8) food package types. These vouchers contain a preprinted standard food package (see Attachment FD-1). Standard manual voucher sets must not be broken to issue single vouchers. Use a blank manual voucher(s) when a partial food package needs to be issued. These vouchers must be stored in a secured location and must be logged in the Manual Inventory Log within three (3) days of receipt (see Attachment FD-8). The five types of food packages are:

1. Infants (Food Package A17, B17, D17). 2. Pregnant and Mostly Breastfeeding Women (Food Package W01). 3. Postpartum, Non-Breastfeeding Women (Food Package W21). 4. Children (Food Package C01, C21). 5. Exclusively Breastfeeding Women and Prenatal Women Pregnant with
Multiples (Food Package W41).

D. Vegetable and Fruit Voucher

Vegetable and Fruit Vouchers are part of the expanded food packages that became effective on October 1, 2009. The vouchers may be redeemed for fresh, frozen, or canned vegetables and fruit. A child or woman participant will receive a Vegetable and Fruit Voucher in the amount of $6, $10, or $15. If the purchase amount exceeds the amount of the voucher, the participant will be allowed to use cash or other accepted forms of payment to make up the difference.

E. WIC Farmers Market Nutrition Program (FMNP)

FMNP coupons are printed in the WIC clinic and issued to participants to allow them to purchase fresh fruit and vegetables from participating Farmers

FD-2

GEORGIA WIC 2012 PROCEDURES MANUAL


Food Delivery

Markets. Coupons Printed On Demand (CPOD) differs from Vegetable and Fruit Vouchers in appearance, value and redemption process (see Attachment FD-4). CPOD coupons may only be redeemed during the FMNP season which runs from approximately May to October of each year. They may not be used in grocery stores.

F. Senior Farmers Market Nutrition Program (SFMNP)
SFMNP coupons are either printed at the WIC clinic or may be pre-printed depending on the clinic's situation (see Attachment FD-5). SFMNP coupons are issued to Senior Citizens over the age of 60 years. This Program is run jointly with the Georgia Department of Aging.

III. VOUCHER ISSUANCE - GENERAL

A. Valid Certification Period

Vouchers may only be issued to participants who are within a valid certification period.

Valid Certification Periods Category
Pregnant Post Partum Breast feeding
Children Infants (< six (6) months)
Infants (> six (6) months)

Valid Certification Period From the date of certification until six (6) weeks after delivery From the actual date of delivery until six (6) months after delivery From the date of certification until six months, then until the infant's First (1) birthday or breastfeeding is discontinued. From the date of certification then every six (6) months until five (5) years of age From the date of certification until First (1) birthday For a six (6) month period starting from the date of certification.

Vouchers must not be issued past the end of the certification period. The issuance period is six (6) months of vouchers for women and children and up to twelve (12) months of vouchers for infants, e.g., if a participant is certified on January 15 and receives a 3b pickup code, (see Edit's Manual for pick-up codes, Field 58) he/she is entitled to receive vouchers through the month of June because he/she has received six (6) months of vouchers, January through June. An issuance month is defined as vouchers issued to a participant during the month regardless of the number vouchers.
Postpartum women who are due for recertification are often being over issued vouchers. This situation occurs when women are issued vouchers during the prenatal period for two or three month increments that extend beyond their pregnancy period. When they are subsequently recertified as a postpartum

FD-3

GEORGIA WIC 2012 PROCEDURES MANUAL


Food Delivery

woman, vouchers must not be issued for the postpartum period without first checking the last voucher issuance date. Women must not be issued two sets of vouchers for the same month. This will prevent the woman from being over issued vouchers at the postpartum period.

B. Identification of Person Picking Up Vouchers
ID cards must be checked for signatures of participants/proxies (see Attachment FD-12):
x If a proxy is picking up vouchers. x 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/caregiver, giving him/her the authority to pick up vouchers for the participant.
The proxy/authorized representative must also present acceptable form of identification and the WIC ID Card to verify that he/she is the person authorized
by the participant to pick up vouchers. (See Edits Manual, Table 31 for proof of
identification.)
If a participant/ parent/guardian /caregiver does not possess, or has lost his/her WIC ID card, other identification may be accepted as verification and a new ID card issued.
A proxy may not be issued WIC ID Card.
A proxy must be at least 16 years old.
If a child is placed in foster care, the Foster parent must bring in guardianship papers from DFACS to confirm the child has been placed in their care before a
new WIC ID card or vouchers can be issued. (See Edits Manual, Table 33 for
proof of identification for Parent/Guardian/Caregiver.)
Documentation of ID for Voucher Pickup
Document the types of ID presented by the person picking up the vouchers, not the ID of the participant for whom the vouchers were issued.

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 on WIC clinic copy only.

C. Corrections
Vouchers must not be corrected or altered. If an error is made during issuance, the voucher(s) must be voided. Correction fluid ("white-out") must not be used on vouchers for any reason.

FD-4

GEORGIA WIC 2012 PROCEDURES MANUAL


Food Delivery

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, WIC 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 WIC client is no longer in a valid certification period and, therefore, is not 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 or equal to six ( 6) months postpartum or up to 12 months postpartum.
Benefit issuance periods are measured by month, one week at a time, starting with the first date of certification and ending with the last date of eligibility, i.e., the termination date. If the termination date occurs before a full week ends, the participant is eligible for benefits for that entire week. For example: If a participant is eligible for vouchers for one or more days within the week, the participants should receive vouchers for that entire week.
When a participant becomes categorically ineligible before the end of the month, they will only receive vouchers up to the categorical term date. For example, If a participant's category term date is January 15 and his/her pick-up is January 2, the participant will only receive two vouchers. If the participant's pick-up date is after the categorical term date the participant will receive no vouchers. Vouchers must not be issued past the month of categorical eligibility. The categorical ineligible message will appear on the voucher receipt for the last set of vouchers one month prior to the termination date.

Category Postpartum NonBreastfeeding Women Mostly and Exclusively Breastfeeding Women
Some Breastfeeding (SBF) Women
Children

Categorical Eligibility Six (6) months postpartum from delivery date
Twelve (12) months postpartum or greater than six (6) months postpartum if breastfeeding stops. Twelve (12) months postpartum or greater than six (6) months postpartum if breastfeeding stops.
Fifth (5) Birthday

Last Voucher Issuance Up to week that includes the categorical termination date. Up to week that includes the categorical termination date.
Receives a SBF Woman food package up to the week that she becomes 6 months postpartum. Then she receives a tracking food package (CPA FPC W80) without foods up to the week she becomes 12 months postpartum. Up to the end of the month

FD-5

GEORGIA WIC 2012 PROCEDURES MANUAL


Food Delivery

that the child turns five (5). Note: Children due to be recertified in the month of their fifth birthday must be recertified. Certification must be done prior to the date of the fifth birthday, and vouchers issuedto the end of the month only. Vouchers must be prorated to last only through the end of the month in which the child turns age 5 years. For example, if there are only 2 weeks remaining in the month, the child is only allowed to be issued half of their food package (e.g., usually 2 vouchers plus the produce/fruit & vegetable voucher). Vouchers can not be issued if the pickup code is after the birthdate.
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:

1. Children 2. Grandchildren 3. Sisters 4. Brothers 5. Nieces 6. Nephews 7. Aunts

8. Uncles 9. Parents 10. Spouses 11. First Cousins 12. In-laws 13. Grandparents 14. Individuals related by marriage

IV. VOUCHER PRINTED ON DEMAND (VPOD) AND COMPUTER GENERATED VOUCHERS

A. Data Elements

The following data elements appear on the face of the vouchers:
1. District/Unit/Clinic. The district is represented by a two-digit number, the unit by a one-digit number, and the clinic by a three-digit number.
2. WIC ID Number. The participant's unique nine (9) digit identification number that corresponds to the number on the TurnAround 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.

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6. Voucher Number. A unique eight (8)-digit serial number printed on each voucher.
7. Voucher Message. A description of the food items and the quantities that may be purchased. Also, the food package and voucher codes are printed here.
8. WIC Vendor Stamp. Stamped by the vendor prior to deposit.
9. Sign Here At Grocery Store. The participant/proxy signs his/her name in this space when the voucher is redeemed at a WIC vendor.
10. The reverse side of the vouchers contains an area for endorsement by the authorized WIC vendor location.
11. Food Package Code 12. Rank

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 more than 30 days, CSC Covansys has the capability of producing vouchers. In cases of emergency clinic closing due to natural or man-made disasters, vouchers will be delivered to identified sites by overnight or ground postal delivery.

Computer printed vouchers are received by the clinic in alphabetical order of the last name of the lead family member within each Sort Code. The lead family member is the one with WIC type P, N, or B or 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 The (2-ply) Packing list provides the specific beginning and ending voucher numbers for all the computer printed and manual vouchers for the clinic. Two copies of the packing list are provided. The clinic must retain one copy and send one signed copy to the district office as acknowledgement/proof of
receipt of the vouchers (see Attachment FD-6).

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

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Vouchers," for procedures. Record the ID proof for the person picking up the vouchers in the appropriate place.
2. Vouchers Issuance. Vouchers are only to be issued to participants who are in a valid certification period. (See FD-III. A. "Valid Certification Period").
The serial numbers on the VPOD vouchers must match the serial numbers on the VPOD receipt. The name on the vouchers and the receipt must be identical.
The following items must be completed on the VPOD receipt 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
(2) If a participant or proxy leaves the clinic without signing the
receipt,voucher copy, or voucher register,clinic staff must
document the issuance by writing "Failed To Sign". "Failed To Sign" must not be abbreviated.
(3) During a monitoring review, if one (1%) percent or more "Failed To Sign" notations appear on the VPOD receipts 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 every time.
(4) If the participant or proxy is unable to write, he/she must enter his/her mark in lieu of a signature. Clinic staff will print the person's name next to the mark and initial and date the mark to indicate that it has been witnessed.
3. Voucher Participant/Proxy Signature. The participant or proxy must sign only manual vouchers in the left signature space, in the presence of the issuing staff person.

4. When VPOD vouchers are printed, the printer produces a receipt along with the vouchers. The receipt contains the following information:

a. Client's WIC ID number b. Name c. Issue date d. First date to use e. Food package number

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f. Voucher code g. Voucher number(s) h. Any appropriate message i. Signature line for the client/proxy to sign j. Initials of issuing clerk or user ID

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The receipt takes the place of the voucher register. The client signs the receipt(s) and only then is handed the vouchers. The receipt must then be immediately filed in numerical order. All receipts must be reconciled with the daily activity report. Any voucher numbers that are missing must have an explanation. "Failed To Print" is not an acceptable explanation. Documentation for missing voucher numbers must include the reason the numbers are missing, i.e. vouchers voided before printing, computer error, vouchers printed on wrong paper.

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 and voided in the system prior to batching for that day. (See transporting procedures in the Compliance Analysis Section of the Procedures Manual).
F. Ordering VPOD Vouchers
VPOD voucher numbers are received in the clinic from the ADP contractor CSC Covansys. 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 CSC Covansys will take the place of the Packing list but must be maintained in the same manner as the Packing list (see Receipt of Manual Vouchers FD-V., D). The Packing list must be signed, dated and a copy sent to the district office within the proper timeframe. Voucher ranges or numbers not issued within thirteen (13) months of receipt will be automatically voided by the system.

V. MANUAL VOUCHERS (Blank and Standard)
Manual vouchers are different from VPOD vouchers in the following ways:
1. Manual vouchers are three (3) part forms. The parts are color-coded for distribution as follows:
a. First copy (blue) - Participant. b. Second copy (red) - ADP contractor (or clinic copy if automated transfer
is used.)

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c. Third copy (black) Serves as clinic proof of issuance.

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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 for those items not assigned.

A. Blank 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 vouchers that have been destroyed or damaged (see Lost, Stolen or Damaged Vouchers FD-XI.A.2.).
3. In the event of system failure, loss of power at the clinic or other condition when the clinic system is not available.

B. Preprinted Manual Vouchers
Preprinted Manual Vouchers are issued for the following reasons:
1. To provide vouchers for standard food packages 2. In the event of system failure, loss of power at the clinic or other
condition when the clinic system is not available

C. Ordering Manual Vouchers
Local agencies must order manual vouchers from the ADP contractor. Orders must be made using the "Form and Manual Voucher Orders" Form (see Attachment FD-7) and must be received by the ADP contractor by the 10th or 25th of each month. The ADP contractor will fill manual voucher orders twice a month and will ship them with each cycle of computer printed vouchers.
D. 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 Georgia WIC 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

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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 Georgia WIC. All packing lists received by the district must be reconciled with the clinic's copy, and the district's copy must be signed and dated.
E. Inventory Control of Manual Vouchers
When manual vouchers are received, the serial numbers must be recorded in the "Received" column of the "Manual Voucher Inventory" Log (see Attachment FD8). The numbers must be recorded exactly as is stated on the packing list. 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)
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 (see Attachment FD-8). If vouchers are issued during the month, a perpetual inventory must be conducted weekly. If no manual vouchers are issued, only a physical inventory is required. All columns of the log must be completed accurately, legibly, and initialed, by a responsible staff member. Always record the voucher numbers immediately after receiving them from the ADP contractor on the Log Sheet.
2. Physical Inventory (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 Nutrition Services Director. Manual Voucher Inventory Logs must be retained for three (3) years plus the current Federal Fiscal Year. Inventories must be completed in black or blue ink.

F. Issuance of Manual Vouchers

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Manual vouchers must be issued in complete sets, in consecutive order. When preparing manual vouchers, all items must be printed clearly and legibly, using a black or blue 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 check digit and participant
code.
2. Participant's name (last, first).
3. First Day to Use (MMDDYY).
4. Last Day to Use (MMDDYY), which is thirty (30) days from the "First Day to Use."
5. Vendor must deposit by (MMDDYY) which is sixty (60) days from the "First Day to Use."
6. CPA Food Package Code (FPC) internal (system), Food Package
Code and Voucher Code. If blank manual vouchers are issued to replace damaged computer printed vouchers, the CPA Food Package Code (FPC), internal (system) 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.

G. 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 (see Attachment FD-10). 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

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"Batch Control Exception Report "(see Attachment FD-11), describing the discrepancy. Discrepancies should be resolved by recounting vouchers, and contacting the ADP contractor to resolve count differences by WIC ID if necessary.
When the signed Batch Control Form is returned to the clinic, the copy of the Batch Control Form may be discarded. Voucher copies must be organized by type and stored neatly in serial number order. It is recommended that voucher copies be stored in binding materials such as vinyl lined binders, post binders, or expanding file folders in order to maintain them.
Voucher copies must be retained for three (3) years plus the current Federal Fiscal Year.

H. Voided Manual Vouchers
Vouchers marked VOID must be returned to the Contract Bank. Package the vouchers securely to prevent breakage and ensure that they arrive at the Contract Bank by noon of the fifth (5th) workday of the following month.
Voided Manual Vouchers Manual vouchers, blank vouchers, or preprinted vouchers must be voided if:
x The participant's name is misspelled x Any of the participant information is entered incorrectly x Damage during issuance x Any voucher(s) returned unused by participant x There is a food package change
1. Voided Manual Vouchers that were reported to the ADP contractor as Issued. The system contains an issuance record that must be voided. To accomplish this, 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 issuance 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 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". Complete a Batch Control Form and return the original and the second copy to the ADP contractor. Please refer to Section FD-V.G. for information on batching manual voucher copies.
Although there are no issuance records on these vouchers, the ADP contractor will input this voided information into the system to identify the disposition of the vouchers. All Voided and Destroyed vouchers must be reported to the ADP contractor's Bank. Do not send out- of- date vouchers back to the bank, (only those vouchers that are voided due to package changes, formula changes, etc). The ADP contractor will provide addressed envelopes or labels to be used when

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returning vouchers.

VI. VPOD PROCEDURES

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A. General

Vouchers Printed on Demand (VPOD) are generated on site by the WIC clinic's automated system for participants on Georgia WIC. The receipt generated as part of the printing process becomes the voucher register. When serial numbers are received from the ADP contractor, each clinic must log all numbers on the VPOD Inventory Log and in the computer the same day that they are received but no more than three (3) days after receipt. A computer screen must be printed and stapled to the corresponding packing slip to show date of entrance. 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; that the food package code is correct and that the correct number of vouchers will be printed
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 as it appears on the vouchers
4. The client must sign the receipt before receiving the VPOD vouchers. Vouchers must not be issued until after the participant/proxy/parent/guardian signs the receipt
5. The receipt must be filed in numerical order immediately after issuing the vouchers

C. Voucher Reconciliation
At the end of each day, the WIC clinic staff must print a Daily Activity Report that includes:
1. Voucher numbers 2. Participant's name

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3. Issue date 4. Initials of issuing clerk 5. Status of voucher (Issued or Voided)

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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. Clinic staff must staple or paperclip the voided vouchers to the back of the receipt. If the voucher does not print or the receipt is lost, use a blank voucher receipt to write those numbers, the date, the
participant's name, theparticipants WIC ID number and the clerk's initials on the
receipt. The Activity Report must be signed and dated to verify reconciliation each day.

D. Voiding VPOD Vouchers
If it becomes necessary to void VPOD vouchers, the vouchers in question must be voided in the computer system. The information will be transmitted to CSC Covansys during the daily batching routine.

DO NOT send the voided copies of those vouchers to the WIC banking center for further processing. Doing so will create a bank exception of PREVIOUSLY VOID.

If the VPOD vouchers have been voided in the system before batching, paper copies do not need to be sent to the banking facility. If the VPOD vouchers have been voided after the batch has been transmitted, the paper copies of the VPOD vouchers must be sent the banking facility.

E. VPOD Inventory Log Sheets

The VPOD inventorylog sheet must be completed daily or at a minimum weekly
(only for those clinics who are open less than two days a week: all others must complete the log sheet daily). The log is used to keep track of the voucher numbers issued, voided or not printed. Always record the voucher numbers received from the ADP contractor on the log sheet. The top of the log sheet must reflect the packing list beginning and ending number for the series of vouchers being used. Separate log sheets can be used for each batch, but they must be kept in the inventory logbook. 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 initials.

F. Corrective Actions for VPOD

1. Any missing receipt 2. Incomplete log sheets 3. More than one percent "Fail to Sign" on receipts

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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 9. Missing participant signatures

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 done so on a temporary/short-term basis. There is no standard, on-going reason to mail vouchers (i.e., permanent difficulty accessing the clinic(s).

2. Vouchers must not be mailed or delivered in the following situations: a. Participant is due for re-certification b. Participant is due for nutrition education c. Participant is unable to offer a current address, e.g., 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
3. Environmental crisis as a result of a tornado, hurricane, flood, snowstorm, ice storm or other natural disaster
4. Closure of clinic due to structural damage, relocation, etc... 5. Other special circumstances approved by the Nutrition Services
Director

C. Mailing/Delivery Procedures
The procedures to be followed when mailing vouchers are as follows:
1. Prior to mailing/delivering vouchers, the issuing professional must obtain approval from the District Nutrition Services Director or a designated Competent Professional Authority (CPA). Written approval must be maintained on file in the form of a local agency policy memorandum

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When delivering vouchers, the participant must sign a copy of the voucher receipt. Once the receipt is signed by the participant, it must be returned to the clinic to be filed
Original copies of the receipt must not be taken from the clinic; a copy of the receipt must be taken to the participant to sign
Upon returning to the clinic, the copy must be attached to the original receipt
2. The hardship condition and the District Nutrition Services Director 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 a staff person other than the one who prepared the vouchers for mailing. The envelope must specify, "Do Not Forward, Return to Sender", and a return receipt must be requested on all vouchers sent by certified mail

7. A staff person other than the one 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 FD13)

The procedures for delivering a voucher(s) are as follows:
x The VPOD vouchers and receipts (when transporting vouchers) must be copied
x The original receipt must be left in the clinic x Once the participant signs the copied page, the copy must be
attached to the original VPOD receipt
x The original VPOD receipt must have the statement "See Attachment" on the receipt
D. Voucher Mailing Process

x When mailing vouchers, the VPOD receipt, or voucher copy must be documented with the disposition of the vouchers
x The WIC official must document the signature line(s) with the statement "mailed vouchers" or "delivered vouchers"
x The reason(s) for mailing, the date mailed, and the signature of the person preparing vouchers for mailing

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x Vouchers must be mailed via certified mail with return receipt x 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 must
attempt to contact the participant in an effort to issue. The attempt to contact must be recorded on the voucher receipt. If the local agency is unable to contact the participant, "VOID" the voucher(s) immediately, and retain them on site until the time that they are scheduled to be mailed to the bank (non-VPOD vouchers only). The only exception is for manual vouchers that are returned to Data Processing. If a record of manual vouchers has been sent to the ADP contractor, those vouchers must be voided and sent to the bank 2. If the vouchers have expired, they must be stamped "VOID". Note on the receipt, "returned by postal service" next to the corresponding voucher numbers and retain them on site until the scheduled to be mailed to the bank (non-VPOD vouchers only). Voucher(s) must be stamped "VOID" immediately and processed in accordance with the procedures described above
VIII. PRORATED VOUCHERS
The objective of prorated vouchers is to ensure that participants receive benefits only during a valid certification period. Vouchers are issued based on the number of weeks within a valid redemption time period. A voucher is only valid for thirty (30) days from
the date of issuance.
Prorating is the issuance of partial food packages by eliminating one or more vouchers from the designated food package. Vouchers must be prorated when: (1) A participant is late picking up vouchers (procedures for voiding vouchers must
be followed as outlined in FD-IX - Late Pickup of Vouchers) (2) Vouchers are being replaced if they are damaged as a result of agency error.
(3) A participant is categorically ineligible (see FD-III.-E.-Categorically Ineligible)
Note: The procedures in Section FD-XI. A must be followed when replacing vouchers.

Number of Days Late Less than 7 days late 7-13 days late

Women & Children
full package
Vouchers issued = 3/4 package plus Produce

Infants full package full package

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Number of Days Late

Women & Children

Infants

(Fruit/Vegetables) voucher

14-20 days late

Vouchers issued = 1/2 package plus Produce (Fruit/Vegetables) voucher

(1/2) package (deduct one(1) half of formula vouchers plus one food voucher)

21-31 days late

Vouchers issued = 1/4 package plus Produce (Fruit/Vegetables) voucher

(1/2) package (deduct one(1) half of formula vouchers plus one food voucher)

*Note: Cash Value Vouchers (Fruit/Vegetables) cannot be prorated. They must always be issued for the full value (e.g., $6, $10 or $15) if the participant is eligible to receive any vouchers for that month.
Vouchers should be prorated following the rank order system in the Food Package Section. A voucher with a rank of "1" in a food package should be removed first. A voucher with a rank of "9" is never prorated; if the participant is eligible for any vouchers that month, a voucher with a rank of "9" must be issued. Cash Value/Produce (Fruit/vegetable) vouchers all have a rank of "9."
Ranks of 1-4 correspond to the week of the month, with "1" representing the voucher(s) to be prorated after the participant is late by 7-13 days, "2" representing the voucher(s) to be prorated (in addition to the rank "1" vouchers) after the participant is late by 14-20 days, and so on. Food packages containing more than 5 vouchers will have more than 1 voucher with the same rank; all vouchers with the same rank must be prorated at the same time. For example, if a participant is 2 weeks late, then all vouchers with ranks of "1" and "2" must be prorated and not issued, regardless of how many vouchers there are with ranks of "1" or "2." The vouchers were ranked based on the contents of the voucher to ensure as even a distribution of formula and/or foods removed per week as possible.
IX. 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-VIII.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

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The appointment date must be documented on the receipt in addition to the required pickup date.

Change pickup interval code

When a participant is late picking up vouchers, the pickup code must not be changed to avoid prorating vouchers. When it becomes necessary to change the pickup 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. WIC clinic staff are not encouraged to change pickup codes because of the affects doing so may have on 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 codes will be based on district policy. To change the participant's pickup code the clinic staff must: 1. Document the appointment date changes on the voucher receipt. 2. Complete an update TAD to change the pickup code and submit to the data-
processing contractor.
3. Immediately stamp or write "VOID" on the voucher(s).
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 code.

X. 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. (7C.F.R. 246.12(d); 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 (7C.F.R. 246.11 (a) (2)) Participants/caregivers have the right to refuse other health services, but we have the responsibility to frequently offer and strongly encourage the use of all available health services (7 C.F.R. 246.6 (6) (3) and (5); 246.7(j)(2)(iii); 246.12(S)(7) and (8).)

XI. LOST, STOLEN OR DAMAGED VOUCHERS

A. Replacement of Vouchers

1. Lost or Stolen vouchers will not be replaced.

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2. Damaged Vouchers - When a participant/parent/guardian/caregiver 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. Replacement Vouchers Due to a Declared Emergency

Policy allows the reissuance of lost vouchers for those participants who live in a emergency declared area. Below is the procedure that must be followed:

1. Determine if the participant resides in an area that has been designated as an area affected by a Declared Emergency:
2. Determine which vouchers the participant has lost and need replacement.
3. Call the CSC Help Desk to determine which lost vouchers have been cashed and processed by the bank. Listed below is the information that staff will need to provide to CSC:
1. Voucher numbers 2. Participant ID number 3. Name of participant 4. Clinic, County and District number 5. Name of staff member requesting the information
a. Phone number is 1-800-796-1850.
b. Hours of operation are from 7:30 am to 5:00 pm, Eastern Standard Time (EST).
4. After receiving the verification information of lost vouchers that have been cashed or not cashed from the CSC Help Desk, document the voucher information for lost vouchers that have NOT BEEN CASHED on the Lost/Stolen/Destroyed Voided Voucher Report, per family/participant (see Attachment FD-18). Use as many pages as necessary to document information.
5. Replacement vouchers will only be issued for vouchers that have NOT BEEN CASHED by the participant and document on all voucher receipts, "Replacement Vouchers-Declared Emergency."
6. Make and distribute up to four copies of the Lost/Stolen/Destroyed Voided Voucher Report: a. Place original in the participant's file. b. Place one copy in the Lost/Stolen/Destroyed Voided Voucher file.

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c. Send one copy to your district office for their Lost/Stolen/Destroyed file. d. Send one copy to the State WIC Office to the Compliance Unit. e. Send one copy to the clinic that originally issued the vouchers if the participant picked up replacement vouchers at a different clinic.

7. Void all copies of previously issued vouchers that have been replaced (vouchers that have NOT BEEN CASHED) in the computer system.

C. Lost/Stolen/Destroyed/Voided Voucher Report

When vouchers are reported as lost, stolen, or destroyed, complete the Lost/Stolen /Destroyed/ Voided Voucher Report (see Attachment FD-18) with the following items:
1. District/Unit/Clinic 2. Current Date 3. Beginning Voucher Number in Range* 4. Ending Voucher Number in Range* 5. Quantity of Vouchers in Range 6. Participant's WIC ID Number 7. Participant's Status Code 8. 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 Georgia WIC State Office-System Unit, and a copy to the district office. 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.

Georgia WIC cannot initiate "stop payments" on lost/stolen/destroyed vouchers. 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 Voucher Investigation Log (see Attachment CA-2) to the Compliance Analysis Unit (see Compliance Analysis Section, X).

D. 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:

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1. Complete the Lost/Stolen/Destroyed Voided Voucher Report (see Attachment FD-18) 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 district office and Georgia WIC, System Information Unit, 2 Peachtree Street, Suite 10.476 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 and Bank Exception report to identify potential fraud and refer findings to the Compliance Analysis Unit. The Compliance Analysis Unit will work in conjunction with the local agency to investigate potential fraud, when a block of 25 or more vouchers are missing (see "Compliance Analysis" at Section X).

E. Change of Formula Order/Formula Purchased In 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 if the original vouchers and/or incorrect formula purchased are returned. 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 in reconstituted fluid ounces and vouchers voided for the current issuance period. Supplemental vouchers are issued on a reconstituted fluid ounce for a reconstituted fluid ounce basis. 4. Document the amount, type, and disposition of formula returned on the "Formula Tracking Log" located in the Food Package section of the WIC Procedures Manual.
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:

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1. Issue supplemental vouchers equal to the reconstituted fluid ounces of formula returned in the issuance period.
2. Document the amount, type, and disposition of formula returned to the clinic on the Voucher Receipt or on the WIC 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 by the Nutrition Services Unit for accuracy during District Program Reviews conducted by the state.

XII. BORROWED VOUCHERS
Vouchers may be borrowed within a district by a WIC clinic whose current stock is depleted (see Attachment FD-14) from another WIC clinic. This applies to manual vouchers only. VPOD numbers cannot be borrowed by one clinic from 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.

XIII. CRITICAL ERRORS
If a TAD or ETAD is submitted to the ADP contractor with a critical error, the system rejects the file and does not update the client master file. This can cause voucher(s) issued to that participant to show up on the Unmatched Redemption Report followed the next month by the Cumulative Unmatched Redemption (CUR) report if not corrected. Clinic staff must correct the error and re-submit the TAD or ETAD immediately. Failure to correct critical errors and unmatched redemptions may result in loss of funding to the district.
WIC clinic staff is encouraged to review critical error reports and batch rejection reports in GWISnet daily and resubmit a corrected TAD transaction or voucher issuance record as appropriate.

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XIV. CUMULATIVE UNMATCHED REDEMPTION (CUR) REPORT

A. Introduction

The Cumulative Unmatched Redemption (CUR) report identifies redeemed VPOD and manual vouchers that have not matched a valid client or issuance record. Local agencies are required to review the redeemed manual vouchers appearing on the CUR Report monthly. The vouchers must be reconciled with the ADP contractor or a manual reconciliation must be performed with Georgia WIC, depending on how much time has elapsed since the voucher was redeemed. The CUR Report has two parts:

Part 1: Part 2:

A cumulative list of 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-15).
A cumulative list of vouchers issued by the clinics and cashed by the participants, which have not matched to a valid WIC ID number or participant certification record on the ADP contractor's mainframe computer system (see Attachment FD-16).

The local agency may correct a CUR that is over thirty (30) days old with the ADP contractor. The second month the item appears on the CUR Report, the local agency must manually reconcile the items described below. These manually reconciled items must 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: Provides an example of vouchers that are not matched to an issuance record (see Attachment FD-15).

x Column 1: Voucher Number. This is the serial number of the voucher in question.
x Column 2: <Month> Amount. This column contains the redeemed amount for vouchers that are now in their 30-Day Month. Vouchers in this column can still be reconciled with the ADP contractor.
x Column 3: <Month> Amount. This column contains the redeemed amount for vouchers that are now in their Close-Out Month. Vouchers in this column have been purged from the ADP contractor's system and can only be manually reconciled with the state office.
To reconcile vouchers in the second column:

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1. Look in the Clinic Feedback - Batch Rejection Section of GWISnet to confirm that the batch containing vouchers appearing in Column 2 had not been rejected by the ADP contractor.
2. If the batch is not showing as having been rejected, look in the Clinic Feedback Batch Acknowledgement Section of GWISnet. If there is no acknowledgment from the ADP contractor that the batch was received, resubmit the entire batch to the ADP contractor.
3. If there is acknowledgement that the ADP contractor received the batch, the vouchers may have contained an error or been processed incorrectly by the bank. (For manual vouchers, 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 Column 1 with the ADP Contractor.
The ADP contractor must receive corrections and resubmitted batches by the end of the month cut-off which is the seventh working day of the month following the month in which the report was received. For paper vouchers: 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 those vouchers to Georgia WIC.
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 Georgia WIC. The CUR Report should always be submitted to Georgia WIC in its entirety. Do not send copies of vouchers to Georgia WIC.
Cumulative Unmatched Redemptions that have not matched to a valid certification record:
Cumulative Unmatched Redemptions that have not been matched to a valid certification record or valid WIC ID number:

CUR Part 2: Provides an example of a cumulative unmatched redemption that is not matched to a valid certification record or valid WIC ID number (see Attachment FD-16).

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x Column 1: Voucher Number. This is the serial number of the voucher in question.
x Column 2: Issue Date. Date on which the voucher was printed. Usually coincides with the "First day to use" date on the voucher use.
x Column 3, 4, 5: WIC ID. Col 3: Family WIC ID number, Col 4: Check digit, Col 5: Participant number.
x Column 6: <Month> Amount. This column contains the redeemed amount for vouchers that are now in their 30-Day Month. Vouchers in this column can still be reconciled with the ADP contractor.
x Column 7: <Month> Amount. This column contains the redeemed amount for vouchers that are now in their Close-Out Month. Vouchers in this column have been purged from the ADP contractor's system and can only be manually reconciled with the state office.
x Column 8: Reconciliations. Provides space for clinic staff to indicate how the voucher was reconciled. This is only for vouchers appearing in the Close-Out Month.
x Column 9: Reason: Indicates the reason that the vouchers appeared on the CUR Part 2. This information is provided by the ADP contractor.
x Column 10: Total. Provides a count of the total number of vouchers (30-Day + Close-Out) that appear on the CUR Part 2 report.

To reconcile vouchers in the sixth column:
1. Refer to the Reason in Column 9. This will indicate why the voucher appeared on the report and will give the clinic staff a starting point for research.
2. If the reason for appearing on the report is "Issued After Term" check the Clinic Feedback Batch Acknowledgement Section in GWISnet. If the batch containing the voucher(s) in question does not appear, go to the Batch Reject Section. If the batch is not located in either section re-submit the batch to the ADP contractor.
3. If the batch appears in the rejected section look to determine the reason. If possible, correct the error and re-submit the batch.
4. In the case where the batch appears in the Acknowledgement Section review the critical errors for the time that the batch was sent. If the client's ETAD transaction appears, correct the error and resubmit only that transaction. Re-submitting the entire batch will result in numerous critical errors.
5. Verify that the issue date and/or the ID number are 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

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correct issue date and/or ID number for the entire set of vouchers listed. Mail the top copy of the form to the ADP contractor. Retain the bottom copy for your files. Do not submit a copy of the CUR Part 2 Correction Form to Georgia WIC.
6. When the issue date and the ID number on the voucher(s) and the CUR Part 2 Report are correct:

x Verify that the participant was in a valid certification period on the date the voucher was issuance. 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.
x 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 (see above). If there is no batch acknowledgment, resubmit the entire batch to the ADP contractor.
x 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.
x Correct only those voucher(s) listed in the 30-Day column (Column 4) on the report with the ADP contractor. The ADP contractor must receive corrections and resubmitted batches by the end of the month cut-off which is the 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 seventh column have expired and cannot be corrected through the ADP contractor. These vouchers must be manually reconciled to Georgia WIC.

x Locate the copy of the voucher receipt and check the ID number, name, and issue date. If the issuance date or the ID number on the receipt or the CUR Part 2 report is erroneous, record only the corrected information on the dotted line adjacent to the voucher number on the CUR Part 2 report.
x If the issuance date and the ID number on the CUR Part 2 are correct, record briefly the reason the voucher(s) were issued.
x The first voucher of a set of vouchers issued to a participant appearing in the seventh column must be manually reconciled with Georgia WIC (see Attachment FD-16).
x Sign and date the completed report and submit to Georgia WIC. If there are no vouchers on the report to be manually

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reconciled, the CUR Report should still be forwarded to Georgia WIC in its entirety. Do not send CUR Reports to the ADP contractor.
E. Procedures for Both Reports

1. Clinics must submit the completed reports to the district office and the district office will submit all the reports in one batch to Georgia WIC by the 22nd of the month following the report's run date month (i.e., if the run date is 2/18/08, the manually reconciled CUR Report is due to Georgia WIC by 3/22/08). Clinics must not submit their reports directly to the state office.
2. If you are unable to locate a copy of a specific voucher or vouchers, send a memo to Georgia WIC requesting a copy of the voucher(s). Please include the redemption month along with the voucher number(s).

XV. UNMATCHED REDEMPTION REPORT
In order to reduce the cases of CUR's, Georgia WIC began issuing the Unmatched Redemption Report (see Attachment FD-19). This report acts as an issue month CUR. Vouchers appearing without a participant's name have been cashed but no issue record has been received. These are potential CUR Part 1 vouchers. Vouchers with client information are potential CUR Part 2.
The Unmatched Redemption Report must be corrected monthly in the same manner as the CUR Reports.

XVI. RECONCILIATION OF WIC REPORTS AND DAILY PROGRAM OPERATIONS
Nutrition Services Directors and Clinic Managers are responsible for ensuring daily verification, daily reconciliation of WIC reports and daily program operations for accuracy. Districts must immediately report discrepancies to Georgia WIC Systems Information Unit. Reconciliation includes, but is not limited to, conducting the following daily and monthly verifications.
A. Daily Verifications 1. Verify vouchers issued. 2. Match numbers on the computer with vouchers 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. If a number(s) is skipped, document the number on activity log and in the VOIDED section of the inventory log. 6. Verify that duplicate numbers have not been issued. 7. Batching must be done daily or on any day when vouchers have been issued. 8. Review and correct critical errors.

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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 Unmatched and CUR Reports and reasons indicated. 3. Assure voucher redemption reports are verified and resubmitted in the
required time frame.

Clinic managers should report all discrepancies to the District Nutrition Services Director immediately. In addition, it is the responsibility of the District Nutrition Services Director to conduct periodic self-reviews as well as review any discrepancies or problems reported by the clinic manger.

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Attachment FD-1

PREPRINTEDSTANDARDMANUALVOUCHER

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BLANKMANUALVOUCHER

Attachment FD-2

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GEORGIA WIC 2012 PROCEDURE MANUAL

Attachment FD-3

VOUCHERPRINTEDONDEMAND (VPODVOUCHER)

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GEORGIA WIC 2012 PROCEDURES MANUAL
WIC FMNP Check

Attachment FD-4

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GEORGIA WIC 2012 PROCEDURES MANUAL
Senior FMNP Check

Attachment FD-5

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GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FD-6

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 CSC COVANSYS - WIC IMMEDIATELY. TELEPHONE 1-800-899-7913 CONTENTS VERIFICATION

______________________________________ ________________

WIC REPRESENTATIVE SIGNATURE

DATE

COMMENTS

CSC Covansys SHIPPING USE NUMBER OF PIECES FOR THIS DISTRICT/UNIT CSC QUALITY CONTROL INITIALS

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Attachment FD-7

GEORGIA WIC
FORM AND MANUAL VOUCHER SUPPLY ORDER FORM

Return to:

CSC Covansys 1499 Windhorst Way, Suite 240 P.O. Box 2507 Greenwood, Indiana 46142

Your District/Unit:

Clinic name:

Address:

Phone 1-800-899-7913
FAX: 1-317-859-7150 This order is for clinic #:

Contact person:______________________ Phone:

Date :

Mailed/Faxed__________________

Note: CSC processes Georgia WIC orders weekly. All orders received at CSC by the end of the business day on Friday will be processed and shipped the following week.
Manual Voucher Order

Blank Manual Vouchers for Hand Completion
Blank Manual Vouchers for WIC Foods Blank Manual Vouchers for Formula, Infant Foods, and Produce

GAC9-EE GAC9-FIP

Preprinted Manual Voucher Package Sets for Hand Completion

GAC6

Sets of Prenatal/Mostly Breastfeeding Woman Package (W01)

P, B

Sets of Postpartum/None Breastfeeding Woman Package (W21)

N, B

Sets of Exclusively Breastfeeding/Prenatal with Multiples

Woman package (W41)

B, P

Sets of Infant Birth - 3 Months Old Fully Formula Fed Package (A17) I

Sets of Infants 4 5 Months Old Fully Formula Fed Package (B17) I

Sets of Infant 6 11 Months Old Fully Formula Fed Package (D17) I

Sets of Child 1 2 Years Old Package (C01)

C

Sets of Child 2 5 Years Old Package (C21)

C

Certification Form (TAD) Order

Blank TAD (with no preprinted ID number) Prenumbered TAD (with preprinted ID number)

Other Forms

Form and Manual Voucher Supply Order Forms Lost/Stolen/Destroyed/Voided Voucher Report Form CSC Return Envelopes (for mailing voided vouchers only) Borrowed Voucher Report Forms

VPOD Supplies

Boxes of Paper Stock Voucher Serial Numbers

Revised 3/11

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MANUAL VOUCHER INVENTORY LOG

Attachment FD-8

STANDARD MANUAL___________ CLINIC___________

BALANCE BROUGHT FORWARD_________________

DATE BEGINNING NO. ENDING NO. NO.RECEIVED NO. ISSUED NO. VOID NO. ON HAND INITIALS INITIALS


Revised 3/11

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GEORGIA WIC 2012 PROCEDURES MANUAL
VOUCHER PRINTED ON DEMAND LOG SHEET

Attachment FD-9

DATE RECEIVED #_________

BEGINNING #_____________

ENDING #____________ TOTAL # REC'D___________

DATE (when vouchers were printed.)

BEGINNING (the number of the first voucher printed for that day.)

ENDING (the number of the last voucher printed for that day.)

ISSUED (the number of vouchers issued for that day.)

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.)

Revised 3/11

GRAND TOTAL OF NUMBERS REMAINING IN STOCK. (After completing this form.)

REMAINING STOCK

______________

INITIALS

______________

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Attachment FD-10

BATCH CONTROL FORM

GEORGIA WIC

DISTRICT/UNIT

CLINIC

BATCH CONTROL FORM

DATE

NUMBER

//

//

INSTRUCTIONS
CSC COVANSYS INPUT SECTION COMMENTS:

1. USE THIS FORM AS A COVER SHEET TO FORWARD ALL TADS (CERTIFICATIONS, UPDATES, TRANSFERS AND TERMINATIONS) AND ISSUED/VOIDED MANUAL VOUCHERS.
2. DO NOT BATCH TADS WITH MANUAL VOUCHERS
3. SUBMIT THIS FORM WITH THE TADS AND ISSUED MANUAL VOUCHERS TO:
CSC COVANSYS P.O. BOX 2507 GREENWOOD, IN 46142
SUBMIT THIS FORM WITH THE VOIDED MANUAL VOUCHERS TO:
CSC COVANSYS 1000 COBB PLACE BLVD BUILDING 100, SUITE 190 KENNESAW, GEORGIA 30144

4. RETAIN A COPY OF THIS FORM IN THE CLINIC WITH COPIES OF THE TADS, ISSUED MANUAL VOUCHERS OR VOIDED MANUAL VOUCHERS, CREATING A BATCH CONTROL MODULE.

TYPE OF DOCUMENT
TURNAROUND

NUMBER IN BATCH

ISSUED MANUAL VOUCHERS

VOIDED MANUAL VOUCHERS

DATE SENT BY DISTRICT/UNIT
DATE RECEIVED AT CSC COVANSYS
DATE ENTERED AT CSC COVANSYS
Revised 3/11

PREPARER'S SIGNATURE SIGNATURE SIGNATURE

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GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FD-11

BATCH CONTROL EXCEPTION REPORT

GEORGIA WIC

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.

CSC COVANSYS
INPUT SECTION

TYPE OF DOCUMENT ISSUED MANUAL VOUCHERS VOIDED MANUAL VOUCHERS

APPROXIMATE NUMBER IN BATCH

DATE BATCH RECEIVED AT: FD-40

GEORGIA WIC 2012 PROCEDURE MANUAL Georgia WIC Identification Card
BRING THIS FOLDER FOR EACH VISIT TO THE GROCERY STORE AND CLINIC

Attachment FD-12
NOT VALID WITHOUT
WIC PROGRAM
STAMP

APPOINTMENTS

APPT. DATE

TIME

VOUCHER PICK-UP/ NUTR. ED.

SUBSEQUENT CERTIFICATION
BRING YOUR CHILD(REN), PROOF OF I.D. PARENT/CHILD, RESIDENCY &
CURRENT MEDICAID CARD
OR INCOME

DATE OF LAST
ISSUED VOUCHERS

THIRTY DAY
PROOF MISSING
EXP. DATE

Department of Public Health Georgia WIC Program 1-800-228-9173

WIC PROGRAM IDENTIFICATION CARD
PARTICIPANTS ID# & NAME

EXP. EXP. DATE DATE

ID# & NAME

ID# & NAME

ID# & NAME

ID# & NAME

ID# & NAME

AUTHORIZED PERSON: Cashier must enter price before you sign your voucher(s)

PICK UP CODE: _________ VOUCHER INTERVAL CODE: ____________ COMMENTS:______________________________________________________ __________________________________________________________________
LOCAL AGENCY/CLINIC NAME: ADDRESS: PHONE: FAX:

*_______________________________________________________________ PARTICIPANT/PARENT/GUARDIAN SIGNATURE

*_______________________________________________________________ SPOUSE/ALTERNATE PARENT/GUARDIAN SIGNATURE
Others authorized to pick up vouchers and food: *It is the responsibility of the participant to educate proxies on the proper use of WIC vouchers.

1._____________________________________________________ PROXY SIGNATURE: Must be 16 years or older

2._____________________________________________________ PROXY SIGNATURE: Must be 16 years or older

_________________________________________________________________

SIGNATURE OF WIC OFFICIAL

ISSUE DATE

BRING THIS FOLDER FOR EACH VISIT TO THE GROCERY STORE AND CLINIC

FD-41

GEORGIA WIC 2012 PROCEDURE MANUAL Georgia WIC Identification Card

Attachment FD-12 (cont'd)

Department of Public Health Georgia WIC Program
RIGHTS AND OBLIGATIONS
1. The rules for signing up and taking part in Georgia WIC are the same for everyone, regardless of race, color, national origin, sex, age, or disability.
2. You may appeal any decision made by the WIC clinic about your eligibility for WIC or disqualification from WIC by asking for a fair hearing.
3. The WIC clinic will give you information about food that is healthy 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 WIC services and tell us how many people are on WIC.
5. The food you get from WIC is only for WIC participant(s).
6. You may be taken off WIC if:
x You do not tell the truth about eligibility criteria. x You get vouchers from more than one (1) WIC
clinic at the same time. x You do not keep your certification appointments.
(Rescheduling WIC appointments may take from 7 to 20 days depending on the clinic schedule). x You do not get your vouchers for two (2) months in a row. x You sell or trade your WIC vouchers or WIC food for money or any product, good, or service not authorized by Georgia WIC. x You use your vouchers to buy food that is not on the authorized WIC food list. x You exchange your WIC food items after purchase for any item(s) not listed on the voucher. x You use abusive language with WIC clinic staff, store clerks, or managers. x You are physically violent with WIC clinic staff, other WIC clients, or store personnel. x If you do not keep your appointments, the number of vouchers issued to you or your child(ren) will be reduced. 8. A proxy cannot provide services for more than two families. 9. Lost and destroyed/stolen vouchers will not be replaced.

How to File a Complaint
If you feel you have been treated unfairly, please let us know by using the information listed below. Georgia WIC will assist you as well as notify the proper authorities if necessary.
ANY COMPLAINT You may call Georgia WIC about any complaints at the toll free phone number below:
1-800-228-9173 and/or write about your complaint to the address below:
Georgia WIC Policy Unit 2 Peachtree Street, Suite 10-293
Atlanta, GA 30303
DISCRIMINATION AND/OR CIVIL RIGHTS If you feel that you have been discriminated against or that your civil rights have been violated, you may contact Georgia WIC by calling the toll free number 1-800-228-9173, and/or write about your complaint to the address below:
Georgia WIC Policy Unit 2 Peachtree Street, Suite 10-293
Atlanta, GA 30303
And/or you may contact the Federal Office of Adjudication directly by calling the phone numbers below:
1-866-632-9992 and/or you may write the Office of Adjudication
at the address below:
Office of Adjudication 1400 Independence Avenue, SW
Washington, DC 20250-9140
"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. To file a complaint of discrimination, write USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call toll free (866) 632-9992 (Voice). Individuals who are hearing impaired or have speech disabilities may contact USDA through the Federal Relay Service at (800) 8778339; or (800) 845-6136 (Spanish). USDA is an equal opportunity provider and employer."

VOUCHER INFORMATION

Verification of Certification (VOC) Card

x Failure to keep appointments will reduce the number of

Please go by the local clinic and ask for a VOC Card if you are:

vouchers you receive.

x Moving out-of-state

x The fruit and vegetable/cash value voucher can not be

x A Migrant Farm Worker

prorated. It must always be issued and must be issued in

full value (e.g., $6, $10, $15).

The WIC Program is a Special Supplemental Nutrition Program for

Women, Infants and Children (WIC) which improves the health and

x Food packages will be prorated based on the total number nutritional status of low-income, pregnant, breastfeeding and

of vouchers in the package.

postpartum women, infants, and children up to age five (5).

FD-42

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FD-13


D A I L Y
End of Month Totals Date:

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









































































































































































Total # of Participants:

Total # Issued:

Total # Returned:

Total # Replaced:

Redemption Value of Lost
Vouchers
Total Redemption Value: $

*Redemption Rate must be completed by the District Office.

FD-43

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FD-14

BORROWEDVOUCHERREPORTFORM


GEORGIA WIC

BORROWEDVOUCHER REPORT

BORROWINGDISTRICT/UNIT: ____

CLINIC: ____

DATE:________________________

INSTRUCTIONS

x x x

x

USEFORMTOREPORTMANUALVOUCHERSBORROWEDFROMANOTHERCLINIC RETURNTOCSCCOVANSYSASSOONASPOSSIBLE. MAILTO: CSCCOVANSYS
GEORGIAWICUNIT 1000N.MADISONAVENUE,SUITE GREENWOOD,IN48142 ORFAXTO:(317)8899485

DISTRICT(S)

CLINIC(S)

____ ____







____ ____







____ ____







____ ____







____ ____







____ ____







____ ____







____ ____







____ ____







____ ____







____ ____







____ ____









REASON(S):





INSUFFICIENTQUANTITY











BEGINNINGVOUCHER NO.



ENDINGVOUCHER



QUANTITY

________ ________ ______













________ ________ ______













________ ________ ______













________ ________ ______













________ ________ ______













________ ________ ______













________ ________ ______













________ ________ ______













________ ________ ______













________ ________ ______













________ ________ ______













________ ________ ______













ORDEREDLATE







ORDERNOTRECEIVED FROMCSC

OTHER

COMMENTS: _____________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________

FD-44

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FD-14

DISTRICTOFFICEAPPROVALDATE:





CSCCOVANSYSWHITECOPYSWOYELLOWCOPY DISTRICTOFFICEPINKCOPY



Revised3/11

CLINICGOLDCOPY

FD-44

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FD-15

CUMULATIVE UNMATCHED REDEMPTIONS
PART I

PAGE

7

REPORT EWRR350G DALTON

STATE OF GEORGIA WIC SYSTEM CUMULATIVE UNMATCHED REDEMPTIONS FOR THE MONTH OF

FEBRUARY 2008

VOUCHER JANUARY DECEMBER

NUMBER S AMOUNT S AMOUNT

23377883 R 11.92

23378827 R 10.53

23382633 R 11.74

23384228 R 10.53

23385118 R 11.92

23391403

R 72.45

23393798 R 7.90 CLINIC PAGE 1 D/U/CL 01-2-061 RUN DATE 03/13/08



FD-45

GEORGIA WIC 2012 PROCEDURES MANUAL


Attachment FD-15

FD-45

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FD-16

CUMULATIVE UNMATCHED REDEMPTIONS PART II



PAGE

6

REPORT EWRR351G

DALTON

STATE OF GEORGIA

WIC SYSTEM

CUMULATIVE UNMATCHED

REDEMPTIONS

FOR THE MONTH OF FEBRUARY

2008

PART 2 NOT MATCHED TO VALID CERTIFICATION RECORD

VOUCHE R
NUMBER

ISSUE WIC ID

JANUARY DECEMBER

DATE

FAMIL Y

C P

S AMOUNT

S AMOUNT

RECONCILIATIONS

31223935 01/01/08

105012196 1

9

V

31223936 01/01/08 31223938 01/01/08 31223939 01/01/08 31223940 02/01/08 31223941 02/01/08 31223942 02/01/08 31223943 02/01/08 31223944 02/01/08

105012196 1

9

V

105012196 1

9

V

105012196 1

9

V

105012196 1

9

V

105012196 1

9

V

105012196 1

9

V

105012196 1

9

V

105012196 1

9

V

31224978 12/04/07

155308830 1 2


R 12.09 .........................
....

31224979 12/04/07

155308830 1 2

R 14.85 .............................

31224980

12/04/07

155308830 1 2

R 16.90 .............................

31224981 12/04/07

155308830 1 2

R 15.45 .............................

31224982

01/01/08

105012275 1

1

R

14.09

31224983

01/01/08

105012275 1

1

R

14.86

31224984 01/01/08

105012275 1

1

R

19.66

31224985 01/01/08

105012275 1

1

R

16.23









CLINIC PAGE

1

D/U/CL 01-2-105

RUN DATE 03/13/08

REASON TOTAL

NO MASTER RECORD
NO MASTER RECORD
NO MASTER RECORD
NO MASTER RECORD
NO MASTER RECORD
NO MASTER RECORD
NO MASTER RECORD
NO MASTER RECORD
NO MASTER RECORD

ISSUED AFTER

TERM

ISSUED AFTER

TERM

ISSUED AFTER

TERM

ISSUED AFTER

TERM

ISSUED BEFORE

CERT

ISSUED BEFORE

CERT

ISSUED BEFORE

CERT

ISSUED BEFORE

CERT

FD-46

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FD-17

PAGE REPORT
ROME

2 EWRR300G

VOUCHER

ISSUE

NUMBER DATE
19955351
19957683 19957686 19957713 19958770 19958772 19960920 22705948 22706194 22707346 22707347 22707356 22708545 22711805 22711810 22712915 22718917 02/01/08 22718918 02/01/08 22718919 02/01/08 22718920 02/01/08 22718921 02/01/08 27561122 27561126 27567877 02/01/08 27567878 02/01/08 27567879 02/01/08 27567880 02/01/08 27570243 02/01/08 27570244 02/01/08 27570247 02/01/08 27570452 02/01/08 27570453 02/01/08 27570454 02/01/08 27570455 02/01/08 27570456 02/01/08
30556834 02/21/08

TOTALS

NO MATCHING ISSUE NO VALID CERT

UNMATCHEDREDEMPTIONREPORT

STATE OF GEORGIA WIC SYSTEM UNMATCHED REDEMPTION REPORT
FEBRUARY 2008

CLINIC PAGE

1

D/U/CL 01-1-023

RUN DATE 03/13/08

WIC ID

FAMILY

C

P

146010279 9 1 146010279 9 1 146010279 9 1 146010279 9 1 146010279 9 1

023006381 0 1

023006381 0 1

023006381 0 1

023006381 0 1

023010507 4

1

023010507 4 1

023010507 4 1

023010027 3 1

023010027 3

1

023010027 3 1

023010027 3

1

023010027 3

1

023005374 6 1

DATE
REDEEMED
02/29/08 02/29/08 02/29/08 02/29/08 02/29/08 02/29/08 02/29/08 02/29/08 02/29/08 02/29/08 02/29/08 02/29/08 02/29/08 02/29/08 02/29/08 02/29/08 02/26/08 02/26/08 02/26/08 02/05/08 02/14/08 02/29/08 02/29/08 02/14/08 02/07/08 02/22/08 02/27/08 02/05/08 02/05/08 02/20/08 02/06/08 02/26/08 02/06/08 02/12/08 02/22/08
02/25/08

AMOUNT
78.65
12.76 16.26 12.76 8.48 12.27 8.68 78.63 13 .46 10.17 10.17 13 .16 78.63 76.04 8.48 15.75 9.93 17.65 11.21 10.45 11.52 76.17 80.82 15.89 11.86 11.22 16.59 17.17 21.21 16.56 11.59 10.73 16.24 11.32 9.21
11.39

STATUS
REDEEMED
REDEEMED REDEEMED REDEEMED REDEEMED REDEEMED REDEEMED REDEEMED REDEEMED REDEEMED REDEEMED REDEEMED REDEEMED REDEEMED REDEEMED REDEEMED
REDEEMED-NO CERT REDEEMED-NO CERT REDEEMED-NO CERT REDEEMED-NO CERT REDEEMED-NO CERT REDEEMED REDEEMED REDEEMED-NO CERT REDEEMED-NO CERT REDEEMED-NO CERT REDEEMED-NO CERT REDEEMED-NO CERT REDEEMED-NO CERT REDEEMED-NO CERT REDEEMED-NO CERT REDEEMED-NO CERT REDEEMED-NO CERT REDEEMED-NO CERT REDEEMED-NO CERT
REDEEMED-NO CERT

VOUCHERS
18 18

AMOUNT 611.34 241.74


REDEEMED
18 18

VOm/UNCL
0 0

FD-47

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment FD-18

LOST/STOLEN/DESTROYED VOIDEDVOUCHERREPORT

GEORGIA WIC

LOST/STOLEN/DESTROYED VOIDEDVOUCHERREPORT

DISTRICT/UNIT/CLINIC:

INSTRUCTIONS

x USE THIS FORM TO REPORT VOUCHERS (COMPUTER OR MANUAL) WHICH HAVE BEEN LOST, STOLEN, OR DESTROYED BY EITHER THE PARTICIPANT OR THE CLINIC.
x SUBMIT AT LEAST MONTHLY. x MAIL TO: CSC COVANSYS
x GEORGIA WIC UNIT x P.O. BOX 2504 x GREENWOOD, IN 46142-25041:

BEGINNING VOUCHER NO.

ENDING

QUANTITY

VOUCHER NO.

WIC I.D. NUMBER

STATUS

DATE: STATUS CODES
LOST/STOLEN/DESTROYED - 2 VOIDED - 3
COMMENTS

TOTAL VOUCHERS:
Revised 3/11

FD-48

GEORGIA WIC 2012 PROCEDURE MANUAL
Voucher Printed on Demand (VPOD) Receipt

Attachment FD-19

FD-49

GEORGIA WIC 2012 PROCEDURE MANUAL

Attachment FD-20

INFANT BLANK MANUAL or
VEGETABLE AND FRUIT VOUCHER

FD-50

GEORGIA WIC 2012 PROCEDURES MANUAL

Compliance Analysis



TABLE OF CONTENTS

Page

I.

Introduction .................................................................................................................CA-1

II. Monitoring ...................................................................................................................CA-1

III. Participant Abuse ........................................................................................................CA-2

A. Dual Participation ............................................................................................CA-2

B. Duplicate Participation Verification Form ........................................................CA-3

C. Detecting Dual Participation Along Bordering States ......................................CA-3

D. Participant Abuses and Sanctions...................................................................CA-3

IV. Procedures for Repayment of WIC Funds .................................................................CA-7

V. Guidelines for Investigating Employee Abuse............................................................ CA-8

VI. Procedures to Request an Employee Investigation ....................................................CA-9

VII. Vendor Compliance Investigation ...............................................................................CA-9

VIII. Compliance Investigation Food Purchases.................................................................CA-9

IX. Disqualified Vendor/Participant Access ....................................................................CA-10

X. Investigation of Missing Vouchers/Verification of Certification

Cards (VOC) .............................................................................................................CA-10

A. Manual Voucher Inventory.............................................................................CA-11

B. Georgia WIC Voucher Investigation Log .......................................................CA-11

C. Stop Payment of WIC Vouchers....................................................................CA-11

XI. Security of Issuance Materials ..................................................................................CA-11

A. Georgia WIC Stamps.....................................................................................CA-11

B. VOC Cards ...................................................................................................CA-12

C. Georgia WIC ID Cards...................................................................................CA-12

XII. Voucher Issuance Security .......................................................................................CA-12

A. WIC Vouchers ...............................................................................................CA-12

B. Voucher Security ...........................................................................................CA-13

C. Voucher Storage ...........................................................................................CA-13

D. Voucher Printing on Demand (VPOD)..........................................................CA-13

E. Transporting Georgia WIC Vouchers ............................................................CA-13

Attachments: CA-1 Closeout Reconciliation Report.................................................................................CA-14 CA-2 Georgia WIC Voucher Investigation Log...................................................................CA-15

GEORGIA WIC 2012 PROCEDURES MANUAL

Compliance Analysis


CA-3 Dual Participation Sample Warning Letter ................................................................CA-16

CA-4 Participant Fraud Sample Warning Letter .................................................................CA-17

CA-5 Request for Investigation Form .................................................................................CA-18

CA-6 Georgia WIC Transaction Report..............................................................................CA-19

CA-7 Participant Access Verification Form ........................................................................CA-20

CA-8 Georgia WIC Food Donation List ..............................................................................CA-21

CA-9 Notification Summary of Missing Vouchers/VOC Cards ...........................................CA-24

CA-10 Duplicate Participation Verification Form ..................................................................CA-25

CA-11 Participant Repayment Sample Letter ......................................................................CA-26

CA-12 Participant Repayment Schedule Sample Letter ......................................................CA-27

CA-13 Dual Participation Report Investigation Form ............................................................CA-28

CA-14 Georgia WIC Abuse Claims Payment Report ............................................................CA-29

GEORGIA WIC 2012 PROCEDURES MANUAL



I.

INTRODUCTION

Compliance Analysis

The Compliance Analysis Unit (CAU) assesses programmatic compliance for approximately 1600 retail grocery stores that are authorized WIC Vendors in Georgia. CAU performs covert investigations to deter potential abuse and to ensure the appropriate delivery of Georgia WIC approved food items.

The CAU is responsible for the investigation of vouchers reported missing or stolen from WIC clinics. Clinic investigations are performed in conjunction with the Office of Inspector General.

The Unit also investigates participant and employee fraud associated with Georgia WIC clinics. Report analysis is performed 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 District Nutrition Services Director or designee will visit each WIC clinic for the purpose of reviewing clinical procedures, as outlined in the Self Review Monitoring Tool.
2. If the review of vouchers/voucher-related materials causes suspicion, and the District Nutrition Services Director determines that an investigation is needed, the District Nutrition Services Director shall notify the Director of the Georgia Office of Nutrition and WIC and proceed with the investigation. Georgia WIC may notify USDA-Food and Nutrition Services (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 computer-printed vouchers. This report should be used to monitor the disposition of any vouchers that have a questionable status, e.g., voids, fail to sign, etc. If findings lead to suspicion and the District Nutrition Services Director determines an investigation is needed, the District Nutrition Services Director shall notify Georgia WIC and proceed with the investigation.
4. Georgia WIC shall retrieve voucher copies when the District Nutrition Services Director determines the need during an investigation. These vouchers will be reviewed by Georgia WIC for compliance prior to being forwarded to the local agency. A Georgia WIC Voucher Investigation Log should be used when requesting voucher copies from Georgia WIC (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 Georgia WIC, 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-1

GEORGIA WIC 2012 PROCEDURES MANUAL

III. PARTICIPANT ABUSE

Compliance Analysis

Report Analysis: The CAU conducts monthly reviews of Dual Participation Reports that may lead to the investigation of WIC 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 a participant concurrently receives services from one or more WIC clinics. The WIC automated data system generates a monthly "Dual Participation Report." This 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 downloads a Composite Dual Participation Report monthly to Georgia WIC and to each local agency. The local agency must investigate and reconcile each possible dual enrollment. The reconciled report must be submitted to Georgia WIC within fifteen (15) days from the run date of the report. The report must include the status of the participant (active or terminated), last voucher pickup date, participant's mother, guardian's or caregiver's name, and termination date, if applicable. The Dual Participation Report must be signed and dated by the person completing the report. The Dual Participation Report Investigation Form must be used (see Attachment CA-13) and attached to the Dual Participation Report. Upon receipt of these completed reports, Georgia WIC 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(s) enrolled in the same local agency at the same clinic site.

Investigate to determine if there is any difference in the spelling of the first name. If so, twins may be enrolled. If the first names are spelled exactly the same, then investigate clinical records to determine if it is the same participant or 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.

CA-2

GEORGIA WIC 2012 PROCEDURES MANUAL


Compliance Analysis

2. Participant (s) 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 (TAD's) 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 Georgia WIC 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 and sent to Georgia WIC.
B. Duplicate Participation Verification Form

The Duplicate Participation Verification Form (see Attachment CA-10) 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, pink copy-district Office, gold copy-WIC Clinic.
C. Detecting Dual Participation Along Bordering States
Georgia WIC has an agreement with states bordering Georgia to detect Dual Participation; these states are Alabama, Florida, North Carolina, South Carolina, and Tennessee. Georgia WIC will compare lists of WIC participants who live near the state line who may receive benefits from the program in both states. Georgia WIC will routinely exchange list of program participants in an electronic file format and coordinate punitive action against any individual who are determined to be dual participating in compliance with federal WIC regulations. This list will be exchanged quarterly.

D. Participant Abuses and Sanctions

CA-3

GEORGIA WIC 2012 PROCEDURES MANUAL


Compliance Analysis

Georgia WIC will assess claims and penalties against a participant when the participant has abused WIC 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 Georgia WIC, the participant must receive notice of suspension or termination. The Notice of Termination /Ineligibility/Waiting Form (see Attachment CT-14) must be completed. The specific WIC 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 WIC, the local agency may warn a participant (see Attachment CA-3) or decide not to impose a mandatory sanction if: 1. Within thirty (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
eighteen (18) years, the local agency approves the designation of a proxy.

Terminations
The local agency may permit a participant to reapply for WIC 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 of
eighteen (18) years, the 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 should refer participants who violate WIC requirements to federal, state, or local authorities for prosecution under applicable statues.
1. ABUSE: Dual Participation participation in more than one Georgia WIC clinic simultaneously
SANCTION: When dual participation is suspected, the state or local agency must take follow up action within one hundred twenty (120) days of detecting instances of suspected dual participation.

CA-4

GEORGIA WIC 2012 PROCEDURES MANUAL


Compliance Analysis

The local agency shall notify the state agency of any suspected dual participation, including dual participation resulting from a WIC participant's intentional misrepresentation to obtain improperly issued WIC benefits. All facts must be documented in writing. The local agency shall provide the state agency with the following information in writing:

a. Copy of the front and back sides of the WIC Assessment/Certification Form signed by the WIC participant or authorized representative.
b. The serial number of all WIC vouchers issued manually or by computer to the WIC participant or authorized representative within the certification period.
c. Copy of all documentation used to certify the WIC participant, e.g., participant's ID, parent/guardian's ID, proof of residency and income, etc.
d. A written summary of comparison between information that was provided by the WIC participant or authorized representative and what the actual information is believed to be, along with a statement from the Nutrition Services Director as to whether intentional misrepresentation is suspected.

Based upon information provided by the local agency, the state agency shall make a determination of dual participation and a determination of whether the WIC participant intentionally misrepresented information to participate in more than one WIC clinic simultaneously in order to obtain improperly issued WIC benefits.

If the state agency determines a violation of dual participation has occurred, a WIC participant who is otherwise eligible will be immediately terminated from participation in all but one WIC clinic. An individual who is not otherwise eligible for WIC benefits will be immediately terminated from participation in any WIC clinic.

If the state agency determines that dual participation results from intentional misrepresentation, a claim shall be established against the WIC participant for the full value of improperly obtained WIC benefits, and the WIC participant shall be disqualified from participation in all WIC clinics for one (1) year if otherwise eligible to receive WIC benefits. An individual who is not otherwise eligible will be immediately terminated from WIC.

If the state agency determines that WIC benefits were improperly obtained as the result of a participant violation, such as dual participation, including intentional misrepresentation to participate in more than one WIC clinic simultaneously to obtain improperly issued WIC benefits, the state agency must establish a claim against the WIC participant for the full value of such benefits. To establish a claim, the state agency shall determine the total value of the cashed WIC vouchers from the contract bank and/or WIC banking and advise the local agency accordingly. The Nutrition Services Director will be held accountable for recouping funds from dual participants. After 90 days of non-payment the Georgia WIC

CA-5

GEORGIA WIC 2012 PROCEDURES MANUAL

Compliance Analysis


Legal Officer will solicit the professional assistance of a debt collector to seek recoupment of participant fee assessment.

Within seven (7) days of advisement from the state agency as to the dollar amount of any dual participation, the local agency shall issue a letter by certified mail advising the WIC participant of the determination of dual participation and any intentional misrepresentation; the dollar amount of the improperly obtained WIC benefits; and a demand for repayment of the total dollar amount (see Attachment CA-11 and CA-12 for Sample Letters). The letter shall include advisement as to disqualification or denial/termination of WIC participation and as to the WIC participant's right to a fair hearing. In no instance will repayment arrangements be extended beyond ninety (90) days from the date of notification to the WIC participant.

The state agency shall maintain all records of WIC participant fraud or abuse, regardless of dollar amount. A list of dual participants will be distributed to Nutrition Services Directors monthly. The Nutrition Services Directors must distribute the list to their local agencies, which must review the list for all certified WIC participants to ensure they will not be enrolled in the local agency's WIC clinics.

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 Georgia WIC, 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 Georgia WIC of the special formula provided through the Nutrition Services Unit.
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 (see Attachment CA-4) Subsequent abuse will result in disqualification from WIC for a period not to exceed one (1) year. The participant must be notified of his/her right to a fair hearing (see Rights and Obligation Section Fair Hearing Procedures). If the total value of benefits is one hundred dollars ($100) or greater, the repayment procedures outlined above (Sanction #2C4) 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.

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Compliance Analysis


SANCTION: When proof of abuse has been established, the participant will be suspended from WIC for a period not to exceed one (1) year. The participant must be notified of his/her right to a fair hearing (see Rights and Obligation Section-Fair Hearing Procedures).
If the total value of benefits is $100 or greater, the repayment procedures outlined above (Sanction #2C4) will be implemented.
Georgia WIC 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 WIC 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 law enforcement authorities and may also suspend the participant(s) from WIC 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: DPH/ Georgia WIC.
1. The local agency will immediately forward all repayments received to the Georgia WIC for processing.
2. If total payment is not made within the ninety (90) day timeframe, the local agency will notify Georgia WIC, which will in turn, proceed with recovery actions prescribed under Georgia Statute. When appropriate, Georgia WIC must refer participants who violate Georgia WIC requirements to federal, state or local authorities for prosecution under applicable statutes (7 C.F.R. 246.12(ii) (5).

3. Georgia WIC shall continue collection procedures until it determines it is no longer cost effective. Georgia WIC Abuse Claims Payment Report will be used to document repayment of funds (see Attachment CA-14).
4. Georgia WIC will maintain records of all participant abuse regardless of dollar amount.
B. Collection of claims for repayment of benefits is suspended if an appeal for a fair

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GEORGIA WIC 2012 PROCEDURES MANUAL

Compliance Analysis


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 Public Health Policy 1201 Standard Code of Conduct states that any employee who violates WIC policies and procedures will be terminated required paying back funds to the agency, and facing 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 Georgia WIC, and may require a Department of Public Health Office of Inspector General (DPH-OIG) investigation.
Intentional abuse is a deliberate effort to defraud Georgia WIC (for example: illegally taking WIC vouchers; giving false/misleading information in order to become certified for WIC; etc). A. Employees participating in Georgia WIC 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 Georgia WIC shall adhere to the rules and regulations for WIC participation and job responsibilities.

C. A DPH-OIG investigation shall be handled in conjunction with the local agency.
D. Action to be taken as a result of DPH-OIG investigation findings shall 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 Georgia WIC and Georgia WIC shall notify USDA-FNS.
F. Georgia WIC recommends that any employee found to be abusing Georgia WIC should be removed promptly from issuing or processing WIC vouchers, without reappointment rights.
G. Georgia WIC shall inform USDA of any investigations of WIC related employee fraud.

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GEORGIA WIC 2012 PROCEDURES MANUAL

Compliance Analysis


H. Georgia WIC will maintain all records of employee abuse regardless of dollar amount.

VI. PROCEDURES TO REQUEST AN EMPLOYEE INVESTIGATION
A. The District Health Director shall forward a letter requesting an investigation directly to the DPH-OIG and a copy of the letter must be forwarded to the Department of Public Health Director's Office and Georgia WIC.
B. Contract agencies requesting an employee investigation shall submit their letter to the Department of Public Health Director's Office and a copy to Georgia WIC. The Director's Office shall then forward the request for investigation along with a cover letter to DPH-OIG.
C. DPH-OIG investigation results will be forwarded to the office, which initiates the request. The initiating agency shall submit the results to the Nutrition Services Director, Program Manager, Health Director and a copy to Georgia WIC.
VII. VENDOR COMPLIANCE INVESTIGATION
Compliance investigations will be initiated by Georgia WIC.
Investigations will occur at stores that have been identified as "High Risk" by Georgia WIC through the use of ADP system reports, complaints, the Request for Investigation Forms received from the districts and random selection.
A Request for Investigation Form (see Attachment CA-5) 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 Georgia WIC for action. (see "Complaints Against Vendors" in the Vendor Procedures section of this manual).
Vouchers to be used by Georgia WIC in compliance investigations will be generated by Georgia WIC and from the local agencies designated personnel. Investigations will be documented using a WIC Transaction Report (WTR) (see Attachment CA-6).
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

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GEORGIA WIC 2012 PROCEDURES MANUAL

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

Compliance Analysis

The compliance investigator must complete a Food Donation List (see Attachment CA-8) and submit 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 Georgia WIC policies and Federal WIC regulations following 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 Georgia WIC 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 Handbook-Terminations/Disqualification Section.
To assess inadequate participant access in obtaining WIC foods as the result of a vendor disqualification, Georgia WIC will initiate the verification process by completing the Participant Access Form (see Attachment CA-7). 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.
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 CAU. Investigating agencies may include the DPH Office of Inspector General and the local police department. Local agencies may be subject to corrective action(s) and/or financial penalties if WIC 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 (see Attachment CA-9) must be completed. However, if five (5) or fewer cards are reported missing again from the same clinic, state WIC office staff will make a special site visit. When vouchers/VOC cards are discovered missing, immediately notify the supervisor, District Nutrition Services

CA-10

GEORGIA WIC 2012 PROCEDURES MANUAL

Compliance Analysis


Director, and the local law enforcement. The assigned detective shall be given the name of either the District Nutrition Services Director or their designee as a contact person while conducting their investigation. The District Nutrition Services Director/designee shall report details of investigation to the Compliance Analysis Unit.

The Nutrition Services Director or designee must submit the Notification Summary to Georgia WIC within three (3) working days of the discovery of missing vouchers/VOC cards. Immediately following initial contact from the local agency, Georgia WIC 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 (see Attachment CA-2) with the following: a. District/Unit b. Current date c. Reason for investigation (suspected fraud, etc.) d. List voucher numbers e. Issue date (date missing if manual voucher) f. Clinic number g. Sign and date.
This form should be completed whenever any voucher copies are being requested.
2. Mail the completed Georgia WIC Investigation Log to Georgia WIC, Compliance Analysis Unit, along with the Lost/Stolen/Destroyed/Voided Voucher Report. The CAU 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 exists, and to notify the CAU if further review or an investigation is required, within thirty (30) days of receipt.
4. The local agency shall work in conjunction with Georgia WIC during an investigation of missing vouchers. When a determination has been made that potential employee fraud exist, the DPH-OIG must be contacted (see Compliance Analysis Section V. and VI.).

C.

STOP PAYMENT OF WIC VOUCHERS

Georgia WIC will immediately upon notification, place a stop payment on

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GEORGIA WIC 2012 PROCEDURES MANUAL

Compliance Analysis


WIC manual vouchers reported stolen from WIC clinics by notifying the contract bank to stop payment.

XI. SECURITY OF ISSUANCE MATERIALS

A. Georgia WIC Stamps
1. Georgia WIC 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. Georgia WIC stamps must be stored in a location separate from WIC vouchers, ID 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 separate and secure location.
2. VOC cards must be stored separately from the VOC card inventory log.

C. Georgia WIC ID Cards
1. ID 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 separate and secure location.
2. ID cards must be stored separately from VOC cards, WIC vouchers, and Georgia WIC stamps.

Note: ID cards must not be pre-stamped for usage in the clinic.
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. Georgia WIC and the local agency have the responsibility to maintain control and provide accountability for the receipt and issuance of supplemental foods and food instruments. Georgia WIC and the 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, with the key stored in a secure location (change location of keys occasionally).
2. When issuing vouchers from a computer, the clerk must log out before leaving the workstation.

CA-12

GEORGIA WIC 2012 PROCEDURES MANUAL

Compliance Analysis


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 ninety (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 used by or accessed by the employee. c. Change key to voucher security door (when applicable). d. Change location of all security keys.
6. Only authorized persons may be given access to WIC vouchers.
B. Voucher Security

Voucher stock must not be accessible to participants or other unauthorized persons. Except for the vouchers issued to the participant being 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 WIC 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 Georgia WIC Vouchers

When transporting WIC vouchers, Georgia WIC stamps, and VOC cards, to a clinic site, they must be secured in a locked box or locked briefcase (see Food

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GEORGIA WIC 2012 PROCEDURES MANUAL

Compliance Analysis


Delivery Section FD.IV.E). When vouchers are being delivered to a client in a hospital setting, the vouchers must be kept in a locked box, locked clipboard or locked brief case.

CA-14

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CA-1

D/U #:

CLOSEOUT RECONCILIATION REPORT CL #:

PAGE 20634 REPORT EWRR840G GRADY MATL & INFANT CARE

STATE OF GEORGIA WIC SYSTEM CLOSEOUT RECONCILIATION REPORT FOR THE CLOSEOUT MONTH OF JUNE 1995

WIC ID

PARTICIPANT NAME

VOUCHER REFERENCE FAMILY C P NUMBER NUMBER

25709399 55236263

999054588 2 1

LAST

FIRST

VCHR TYPE
055

REDMO AMT 10.61

26499328 48629635

697012089 2 1 -

047

12.14

26488329 26488330 26488331 25709404 25709405 25709406 25709407 25709412 25709413 25709414 25709415 25709420 25709421 25709422 25709423 26488336 26488337 26488338 26488339 26488344 26488345 26488346 26488347 26488352 26488353 25709428 25709429 25709430 25709431 25488356 26488357 26488358 26488359 26488364 26488365 26488366 26488367 25709436 25709437

48629615 48629626 63771576 63771588 63771592 63771629 63771624 63771617 63771570 63771616 52185535 52185541 52185557 52185542 63851783 67212999 63851787 67213000 67212970 42701052 63778323 67212998 63851800 63851799 63867366 63867371 63867382 63857574 42501104 68637805 42502548 68637825 42501097 68637806 42502547 68637826 63827114 63827113

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

025

9.82

039

6.33

028

8.20

031

8.92

037

14.54

054

12.26

047

12.14

039

6.33

025

9.82

039

6.33

047

12.22

039

6.13

025

10.37

039

6.13

031

8.92

037

13.71

039

6.33

055

9.10

028

7.18

031

7.23

037

14.54

054

8.37

068

58.87

072

51.40

031

8.92

037

14.54

039

6.33

055

9.91

031

8.92

037

14.54

039

6.33

055

9.91

031

8.92

037

14.54

039

6.33

055

9.91

031

6.87

037

6.95

CLINIC PAGE 9 D/U/CL 09-1-259 RUN DATE 07/13/95

DATE ISSUED 04/06/95 04/14/95
04/14/95 04/14/95 04/14/95 04/06/95 04/06/95 04/05/95 04/06/95 04/06/95 04/06/95 04/06/95 04/06/95 04/12/95 04/12/95 04/12/95 04/12/95 04/11/95 04/11/95 04/11/95 04/11/95 04/06/95 04/06/95 04/06/95 04/06/95 04/11/.95 04/11/95 04/11/95 04/11/95 04/11/95 04/11/95 04/11/95 04/11/95 04/11/95 04/11/95 04/10/95 04/10/95 04/10/95 04/10/95 04/06/95 04/06/95

STATUS DATE
05/10/95 04/18/95
04/14/95 04/18/95 04/10/95 04/10/95 04/10/95 04/10/95 04/10/95 04/10/95 04/10/95 04/10/95 04/19/95 04/19/95 04/19/95 04/12/95 04/13/95 05/01/95 04/13/95 05/01/95 05/01/95 05/26/95 04/10/95 05/01/95 04/13/95 04/13/95 04/13/95 04/13/95 04/13/95 04/13/95 05/12/95 05/05/95 05/12/95 05/05/95 05/12/95 05/05/95 05/12/95 05/05/95 04/10/95 04/10/95

CMNTS
EXP 04/18/95
VOID
VOID

TOTAL VOUCHERS CASHED TOTAL VOUCHERS EXPIRED TOTAL UNMATCHED TO CERT RECORDS TOTAL VOUCHERS ISSUED VOIDED UNCLAIMED TOTAL VOUCHERS CREATED

CLINIC TOTALS VOUCHERS
805 73 0
878 135
0 1,013

AMOUNT 11,199.66
.00 11,199.66
11,199.66

(TOTAL OF CASHED AND EXPIRED) (COMPUTED AND MANUAL VOUCHERS)

CA-14

GEORGIA WIC 2012 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 Program, Yellow - Local Agency

Revised 3/11

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GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CA-3

Dual Participation Sample Warning Letter

Dear Participant: Our records show that you have participated on two Georgia WIC. You were certified and enrolled on ___________________ Georgia WIC on (date) __________, and you were also certified and enrolled on _________________Georgia WIC on (date) __________. As indicated on your Georgia WIC ID card, participating on more that one Georgia WIC violates programs regulations. Information concerning this will be forwarded to the Compliance Analysis Unit of Georgia WIC to determine if you will be required to pay money back to Georgia WIC. Should you have any questions, contact me at _________________________________.
Sincerely,
District Nutrition Services Director

"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.
To file a complaint of discrimination, write USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call toll free (866) 632-9992 (Voice). Individuals who are hearing impaired or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish)." USDA is an equal opportunity provider and employer.
Revised 3/11
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GEORGIA WIC 2012 PROCEDURES MANUAL
Participant Fraud Sample Warning Letter

Attachment CA-4

Dear Participant: It has come to my attention that you sold food that was purchased utilizing your Georgia WIC vouchers. This is against Federal WIC regulations. The WIC foods are provided to your child to improve their nutrition status and overall health. The food must be given to the qualified child and not used for any other purpose. If you continue to sell your WIC food after this warning, your child may be denied WIC services for up to three (3) months. If you have any questions, please call me at __________________________________.
Sincerely,
District Nutrition Services Director

"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. To file a complaint of discrimination, write USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call toll free (866) 632-9992 (Voice). Individuals who are hearing impaired or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish)." USDA is an equal opportunity provider and employer.
Revised 3/11
CA-17

GEORGIA WIC 2012 PROCEDURES MANUAL
REQUEST FOR INVESTIGATION FORM

Attachment CA-5

GEORGIA WIC WIC REQUEST FOR INVESTIGATION

TO:

FROM:

DATE:

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)

Revised 3/11

CA-18

GEORGIA WIC 2012 PROCEDURES MANUAL

Voucher Number Number
Store Name and Address:-

Georgia Department of Public Health
Georgia WIC
WIC TRANSACTION REPORT (WTR)
WTR Returned to WIC Agency:

Attachment CA-6
Vendor

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

Y/N
Rang up Sale

Y/N
Adequate Supply of WIC Foods on Shelf

Recorded Price on Voucher

Checked ID Cards

Gave Receipt to Investigator

4. Comments

5.

Description of Clerk (Approximate)

SEX

RACE

AGE

6. Other Identifying Information: 7. Identified During Transaction as (Title/Name):

ELIGIBLE ITEMS SUMMARY OF PURCHASE

QUANTITY

BRAND NAME

HEIGHT

WEIGHT

HAIR COLOR

ITEM

PRICE

INELIGIBLE ITEMS
QUANTITY

ITEM

PRICE

ITEMS REFUSED
QUANTITY

ITEM

I

, an investigator of Georgia WIC and the Department of Public Health,

makes the above statement freely and voluntarily knowing that this statement may be used as evidence.

Name: Title:

Date: Investigator Signature:

Form3773(6/99)

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GEORGIA WIC 2012 PROCEDURE MANUAL

Attachment CA-7

GEORGIA WIC

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 ________________________
________________________________
Distance in Miles____________

List any Geographical Barriers _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________

Comments______________________ _______________________________ _______________________________ _______________________________ _______________________________

Investigator's Signature______________________________ Date____________

CA-20

GEORGIA WIC 2012 PROCEDURE MANUAL

Attachment CA-8

GEORGIA DEPARTMENT OF PUBLIC HEALTH GEORGIA WIC
FOOD DONATION LIST

Vendor Number:

Date:

Milk

Type Brand

Quantity/Size

Comment

Cereal

Type Brand

Quantity/Size

Comment

Beans
Frozen Canned Fresh Cheese

Type Brand

Quantity/Size

Comment

Type Brand

Quantity/Size

Comment

Juice
Canned/ Bottle Frozen Pourable
Bread
Loaf Buns Tortilla
Non-WIC Foods
Type

Type Brand

Quantity/Size

Comment

Type Brand

Quantity/Size

Comment

Brand Quantity/Size

Comment

Tuna/Salmon
Type

Brand Quantity/Size

Comment

CA-21

GEORGIA WIC 2012 PROCEDURE MANUAL

Eggs

Type Brand

Attachment CA-8 (cont'd)

Quantity/Size

Comment

Baby Foods
Foods Formula Cereal
Peanut Butter

Type Brand

Quantity/Size

Comment

Type Brand

Quantity/Size

Comment

Fresh
Fruits Vegetables

Type Brand

Quantity/Size

Comment

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GEORGIA WIC 2012 PROCEDURE MANUAL

Attachment CA-8 (cont'd)

GEORGIA WIC DONATION LIST
Organization Name:
Organization Representative Signature: ________________________________________________________________
Phone#:_____________________ Address:_____________________________________
City:___________________ Zip Code:_____________
WIC Representative: ____________________________________________________

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GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CA-9

Please use Ink Georgia WIC 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; Nutrition Services Director; 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 #

Ending #

VOC CARD'S Beginning #

Ending #

SECTION IV

Complete a detailed summary of how vouchers/VOC cards were discovered missing: __________ ______________________________________________________________________________
Use additional sheets of paper if needed, and attach

SECTION V
List any additional information that would apply to this case. _____________________________________________________________________________

Use additional sheets of paper if needed, and attach

SECTION VI

Signature of person completing report:

______________________________________________________________________________

____________________

(Submit completed report to the District Nutrition Services Director/Person in charge)

Person receiving the report:

Title:

Date:

(This signature is to verify receipt of this report, not to verify information on report)

District Nutrition Services Director or designee shall submit a copy of this report to the State WIC Office within three (3) working days.

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.

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GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CA-10

GEORGIA WIC

Duplicate Participation Verification Form

DISTRICT/UNIT: | | | | | CLINIC: | | | | | DATE: | | | | | | |

INSTRUCTIONS

- USE THIS FORM TO REMOVE PARTICIPANTS FROM THE DUPLICATE PARTICIPATION REPORT
- RETURN TO COVANSYS AS SOON AS POSSIBLE. - MAIL TO: COVANSYS COMPUTING, INC.
GEORGIA WIC Unit 1499 WINDHORST WAY, SUITE 240 GREENWOOD, IN 46142 - OR FAX TO: (317) 889-9485

THE FOLLOWING CLIENT(S) LISTED BELOW ARE LEGITIMATE PARTICIPANTS. PLEASE REMOVE THEM FROM SUBSEQUENT DUAL PARTICPATION REPORTS

PARTICIPANT ID NUMBER

PARTICIPANT NAME

Revised 3/11 CA-25

GEORGIA WIC 2012 PROCEDURES MANUAL
Participant Repayment SAMPLE LETTER

Attachment CA-11

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 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 Georgia WIC work effectively.

Please call me at _____________ (your #) if you have any questions or need to establish a repayment schedule.

Sincerely,

District Nutrition Services Director's Name Address

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GEORGIA WIC 2012 PROCEDURES MANUAL
Participant Repayment Schedule SAMPLE LETTER
Date
CERTIFIED MAIL RETURN RECEIPT REQUESTED Ms.

Attachment CA-12

Dear Ms.

:

This letter confirms your proposal to repay $______ to Georgia WIC 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 Georgia WIC and mail it to the following address:
Georgia WIC Your address
If you have any questions, please call me at ________________.
Sincerely,
District Nutrition Services Director's Name Address

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GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CA-13

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:

Birth date:

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)

Termination Date:

Term code:

Has the client transferred into your area recently?

(If yes, give date; ___________________________)

Date of last certification:

Social Security number:

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GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment CA-14

Georgia WIC Abuse Claims Payment Report

Name of Participant:__________________________ ID#_______________DU#____________

Name of Vendor_____________________________ Vendor #_______________DU#________

Reason for claim:_______________________________________________________________

Amount of claim:________________________________________________________________

Date of notification to participant:____________ Date fair hearing requested:_____________

Date of final disposition of fair hearing/court mandate: _______________________________

Repayment Schedule Agreement
Due Date:____________ Amount Due:___________ Payment to be submitted by : Clerk of Court [ ] Participant [ ] Vendor [ ]

Date Paid: Amount Paid: Balance Due:

Initials

COLLECTED FUNDS ARE DEPOSITED IN A GENERAL ACCOUNT FOR FARMER'S MARKET MATCH FUND

Collection ceased due to:

[ ] No longer cost effective [ ] Unable to locate participant [ ] Other_________________

Date:__________________ Date:__________________ Date:__________________

Initials__________ Initials__________ Initials__________

Was In-kind Service performed: YES [ ]

NO [ ]

If yes explain:___________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

Revised 3/11

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GEORGIA WIC 2012 PROCEDURES MANUAL

TABLE OF CONTENTS

State Agency Monitoring

MO-1 Local Agency 2011 Monitoring Section

Page

I.

State Agency Monitoring ............................................................................................ MO-1

A. Introduction ....................................................................................................... MO-1

B. Monitoring Schedule.......................................................................................... MO-1

C. Clinic and Health Record Selection................................................................... MO-1

D. Pre-Review Activities......................................................................................... MO-3

E. Files................................................................................................................... MO-4

F. Timeframes ....................................................................................................... MO-5

G. On-Site WIC Review Visits................................................................................ MO-5

1. Entrance Conference................................................................................ MO-6

2. Point Assignment ..................................................................................... MO-6

3. Exit Conference........................................................................................ MO-7

H. Revisit - WIC Review......................................................................................... MO-7

I. Special Site Visits.............................................................................................. MO-8

J. Written Reports ................................................................................................. MO-9

K. Close-Out Report ............................................................................................ MO-10

L. Establish New Clinic Procedures .................................................................... MO-10

II. Quality Assurance Self-Reviews .............................................................................. MO-11

A. Purpose ........................................................................................................... MO-11

B. Conducting Self-Reviews ................................................................................ MO-11

Attachments: MO-1 Local Agency 2011 Monitoring Tool .......................................................................... MO-12
Management Evaluation Tool Final Scoring Summary ........................................... MO-13 Policy Unit "Prior To" Form Administrative Management Evaluation ....................... MO-14 Policy Unit "Prior To" Form District Clinic Evaluation ............................................... MO-15 Policy Unit Administrative Management Evaluation Worksheet................................MO-16 Policy Unit District Clinic Evaluation Worksheet ...................................................... MO-20 Policy Evaluation Forms........................................................................................... MO-24 Food Instrument Accountability Administrative Management Evaluation ................ MO-43 Food Instrument Accountability District Clinic Evaluation ........................................ MO-45 Food Instrument Re-Cert Overdue Form ................................................................. MO-50 Food Instrument Record Review Form .................................................................... MO-51

GEORGIA WIC 2012 PROCEDURES MANUAL


State Agency Monitoring

Food Instrument CUR Report Record Review Form................................................ MO-54

Nutrition Services Unit Total WIC Review Score .................................................... MO-55

Nutrition Services Unit District Review Questions ................................................... MO-56

Nutrition Services Unit Clinic Review Questions ..................................................... MO-60

Nutrition Services Unit Office of Nutrition ............................................................. MO-64

Nutrition Services Unit Administrative Management Evaluation ............................. MO-65

Nutrition Services Unit Clinic Review ....................................................................... MO-69

Nutrition Services Unit Record Review Interpretation ............................................. MO-83

Systems Information Unit Administrative Management Evaluation.......................... MO-88

Systems Information Unit District Clinic Evaluation Worksheet................................MO-89

Systems Information Unit Preliminary Information Pre-Visit.................................... MO-93

Systems Information Unit Background.....................................................................MO-95

Systems Information Unit Report for Background Information.................................MO-97

MO-2 Local Agency 2011 Financial Monitoring Section

I.

Financial Reviews .................................................................................................... MO-99

A. Introduction...................................................................................................... MO-99

B. District Selection.............................................................................................. MO-99

C. Pre-Review Activities....................................................................................... MO-99

D. Financial Review Schedule ............................................................................. MO-99

II. Financial Timeframes ............................................................................................. MO-100

III. Local Agency Collections ....................................................................................... MO-101

IV. Financial Self-Reviews ........................................................................................... MO-101

MO-2 Local Agency 2011 Financial Monitoring Tool Financial Review Form........................................................................................... MO-102

GEORGIA WIC 2012 PROCEDURES MANUAL


I.

STATE AGENCY MONITORING

State Agency Monitoring

A. Introduction

The State agency will conduct an on-site monitoring visit every two (2) years at each of the twenty (20) 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 WIC policies and Federal WIC regulations. The review will consist of an evaluation of program administration, staff training, voucher issuance, certification, clinic observation, record review, systems, equipment, 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 Georgia WIC and Department of Public Health Office of Inspector General (DPH-OIG) will complete the on-site visit. Every effort will be made to conduct Policy, Compliance Analysis, Nutrition and Breastfeeding portions of the review at the same time. Systems and Fiscal portions of the review are conducted individually.

District reviews may be conducted yearly for clinics with specific problems (See Monitoring Section, I. State Agency Monitoring, I. Special Site Visits).

B. Monitoring Schedule

A schedule of on-site monitoring visits will be developed and coordinated by Georgia WIC 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 Nutrition Services Director will be notified by phone, approximately one (1) month prior to the review. A letter will then be sent to the Nutrition Services Director and the District Health Officer to confirm the dates and specifics of the review, the time and place for the entrance and exit conferences, etc. All reviews will start at the District Office. A list of additional information that will be requested for the review (by the State) will be attached to the letter sent to the Nutrition Services Director. This list identifies "prior to" information that must be submitted to the appropriate unit of Georgia WIC two (2) weeks before the scheduled review.

C. Clinic and Health Record Selection

1. Clinic Site

MO-1

GEORGIA WIC 2012 PROCEDURES MANUAL


State Agency Monitoring

Every two (2) years, twenty percent (20%) of the total number of clinics in the local agency are randomly selected for monitoring. The largest clinic in each local agency will be monitored during each WIC review.

a. Each local agency may have a maximum of six (6) clinics selected for review. If more than six (6) 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 WIC reviews will be randomly selected. The following constraints will be applied to the random selection:

a. Ten (10) records will be randomly selected for each clinic with caseloads of 500 or less, and additional two (2) records will be selected for each one-hundred (100) participants enrolled in a clinic with five hundred and one (501) 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 ten (10) records through a maximum of thirty-two (32) records will be reviewed in each clinic. All records must be located and given to State staff within two hours of receipt of the record list being given to staff. The time of issue will be recorded on the records list. In addition, all records must be returned to state staff with the list of record attached. Failure to follow these procedures will result in a corrective action.
b. Due to the October 2009 food package implementation, the infant's chart must be pulled for each post-partum woman's chart and the post-partum woman's chart must be pulled for each infant on the Participants Records List.
c. 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 the day of the review, the local agency will be cited for a corrective action. Each criterion will be marked as missing for each chart that is not located. If a significant number of selected records cannot be located during the day of the review, a financial penalty based on the cash value total amount of vouchers per client per certification could be assessed against the District/Agency. Please reference Annex I (Agreement between your District and Georgia WIC) located in section AD-1 of the Georgia WIC Procedures Manual, Number 12, which states "the district must provide Georgia

MO-2

GEORGIA WIC 2012 PROCEDURES MANUAL


State Agency Monitoring

WIC immediate and complete access to all clinics and all records maintained by WIC clinics within the District". Records selected for review must be delivered to the reviewer as is without any corrections or modifications. Any corrections or modifications noted could be viewed as falsification of records. Falsification charges could lead to dismissal for the employee who modified or corrected the record. The only exception to the rules for not locating records the same day would be District who has off-site storage for non-active WIC participant. If off site storage is being used, the District has 24 hours to locate the record for the review team.

d. Records for the WIC review will be pulled based on the last day of the review or re-review plus a one hundred twenty (120) day grace period. Example: If a District's last day of the review was 07/24/04, the record to be pulled will be dated on or after 11/25/04 (calendar day).

Note: If the District has any controversy about dates, the State will continue to review based on the "three (3) year plus current" procedure. All records must remain on file for three (3) years plus current year for other audits (i.e., USDA, OIG, State, etc.).

3. Migrant Health Records

Georgia WIC must review migrant health records during a local agency WIC review visit. Georgia WIC will randomly select migrant health records for review.

a. Where there is at least one clinic site with a minimum of twentyfive (25) migrants participating in Georgia WIC, records are randomly selected according to the clinic and health record selection procedures (See MO-Section I.C.).
b. If a clinic site serving a significant number of migrants is not selected for review, migrant health records will be selected and reviewed according to the clinic and health record selection procedures (See MO-Section I.C.).
c. If a significant number of the migrant population is in a local agency service area and is not participating in Georgia WIC, the state must evaluate the local agency's outreach efforts related to migrants. Prior to a review, the Georgia WIC 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 Nutrition Services Director will be contacted about materials that need to be made available during the on-site review. (See I. State Agency

MO-3

GEORGIA WIC 2012 PROCEDURES MANUAL


State Agency Monitoring

Monitoring, B. Monitoring Schedule, second paragraph).

E. Files

Documentation and files to be considered during an on-site review include, but are not limited to, the following areas:
1. Past WIC Review Reports and Responses 2. Clinic 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 Procedures Manual 9. Georgia 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 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. Class Outlines 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 is Located. 32. Temporary Thirty (30) Day Certification Files 33. Formula Tracking Logs 34. No Proof File

MO-4

GEORGIA WIC 2012 PROCEDURES MANUAL


State Agency Monitoring

35. Prenatal Re-appointment Documentation
36. Initial Contact Date Log 37. Home Visit Approval Forms
38. Separation of Duties/District Office Forms
39. Complaint File
40. CPA Orientation Checklist 41. CPA and Nutrition Assistant Continuing Education Records 42. District/Clinic-Created 999 Food Packages

F. Timeframes

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

ACTIVITY
Notification of intent to conduct a review, Georgia WIC contacts the local agency to discuss possible review dates.

TIMEFRAME
Thirty (30) days prior to the scheduled date

Georgia WIC 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 Georgia WIC.
Georgia WIC submits a written response to the local agency report.
The local agency submits a written response to Georgia WIC requests for additional information.
Program review is closed.

Within sixty (60) days of the exit interviews
Within sixty (60) days of the date of receipt of program review report is received Within thirty (30) days of the receipt of local agency response Within thirty (30) days of the date of the written request
Within one-hundred eighty (180) days of the exit interview, unless an extension was negotiated

Note: Failure to resolve any outstanding deficiency found during the review could result in a delay of funding for the next fiscal year.

G. On-Site WIC Review Visits
During the on-site visit, the local agency will provide the WIC staff immediate and complete access to clinics and all records maintained by the WIC clinics within the local agency. 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.

MO-5

GEORGIA WIC 2012 PROCEDURES MANUAL


State Agency Monitoring

1. Entrance Conference An Entrance Conference may be requested by the district to officially begin the review. The District Health Director, Program Manager, Nutrition Services Director, 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. Briefly explain what will take place during the review d. Discuss pertinent district specific information/data
2. Point Assignment The District (Administrative and Clinics) will be reviewed using the attached Monitoring tool. Each clinic will have it own individual Monitoring tool and points assigned. The Monitoring tool is broken down into four sections. Each section of the tool has a certain amount of points assigned. The total amount of points per District is 1,000 (Administrative 265 and District Clinic 735). Each clinic reviewed has 735 points available. At the end of the review, the total points for each clinic will be added together and the average will be added to the Administrative score for the final District rating. The following is a break down for each section:
Administrative 1. Nutrition Unit 170 Points 2. Policy Unit 55 Points 3. Compliance Analysis Unit - 25 Points 4. Systems Unit 15 Points
Total Points 265
District Clinic 1. Nutrition Unit 230 Points 2. Policy Unit 205 Points 3. Compliance Analysis Unit - 155 Points 4. Systems Unit 145 Points
Total Points 735
The District ratings are listed below:
Exemplary (950 - 1000) The District provides efficient and effective quality services in all areas. Training may be needed.
Excellent (900 949) The District provides exceptional and proficient quality services. However, there are recommendations that should be implemented. Training may be needed.
Good (800- 899) The District has managed well. However, there are corrective actions that must be implemented. Training may be needed.
MO-6

GEORGIA WIC 2012 PROCEDURES MANUAL


State Agency Monitoring

Fair (700 799) The District needs to provide more management support and a correction action plan must be implemented. Training must be conducted.

Unsatisfactory (699 and below) The District is not following policies/procedures in several areas. Training must be conducted.

A passing score still may result in a Revisit (see Monitoring Section IH Revisit WIC Review).
3. Exit Conference

An Exit Conference with clinic staff may be held in each clinic monitored (e.g., mini Exit Conferences) or at the District Office at the conclusion of the entire program review. Findings reported by the reviewers at the Exit Conference are preliminary. The final report will be forwarded to the local agency within sixty (60) days. The following will be discussed at this conference:
a. Areas deserving commendation b. Achievements c. Corrective actions d. Recommendations
Note: A District-wide Corrective Action Plan is due to Georgia WIC sixty days (60) from the date that the Program Review Plan of Correction Report was received. Below is a list of the Corrective Action Training Requirements:
x One clinic average < ninety percent (90%) requires clinic specific training
x Two highlighted clinics < one-hundred percent (100%) require clinic specific training
x Three or more highlighted clinics < one-hundred percent (100%) requires District-wide training and/or District-wide average < ninety percent (90%) requires District-wide training
x Highlighted black - < one-hundred percent (100%) x Highlighted red - requires corrective action training
H. Revisit WIC Review
A revisit may be necessary due to the results of a program review. Listed below are some of the criteria, which will determine that a revisit is necessary:
Revisit WIC Review List 1. Policy Unit
a. Processing Standards b. No Proof Form c. Thirty-Day Form d. Missing VOC Cards e. Missing Signatures on Records f. Missing Participant Records

MO-7

GEORGIA WIC 2012 PROCEDURES MANUAL


State Agency Monitoring

2. Nutrition Unit a. Secondary Nutrition Education b. Primary Nutrition Education c. Risk Criteria d. Missing Signatures or Documentation on Records e. Inappropriate Nutrition Practices
3. Compliance Analysis Unit a. Stolen or Missing Vouchers b. No Inventory c. Missing Signatures on Vouchers
Any other items as needed.

The District Nutrition Services Director will be notified by phone, approximately one (1) month prior to the re-visit. A letter will then be sent to the District Nutrition Services Director and the District Health offices to confirm the dates of the revisit, the time and place for the exit conference, etc. An entrance conference will not be conducted. Revisits will start at the District office if the District office is being reviewed or a clinic scheduled for the revisit that is located near the District Office will be chosen as the starting point and the District Nutrition Services Director will be notified by telephone one (1) week before the revisit.

I.

Special Site Visits

Georgia WIC, in accordance with Federal WIC regulations requirements, may make special site visits at any time.

Special Site Visit Procedures: In the event of a special site visit by Georgia WIC the following procedures must be followed:

1. Georgia WIC may contact the District Nutrition Services Director the day of visit.
2. After careful observation and investigation, a report will be generated and mailed to the District Nutrition Services Director within thirty (30) days of the site visit.
3. Upon receipt of the report from Georgia WIC, the District Nutrition Services Director must respond in writing to Georgia WIC within thirty (30) days of receipt. All district responses must provide a resolution to the existing 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 District Nutrition Services Director addressing problems found during the special site visit.

MO-8

GEORGIA WIC 2012 PROCEDURES MANUAL


State Agency Monitoring

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. c. The District Nutrition Services Director using the Procedures Manual (for each clinic agency involved) must conduct training to close a special site visit. The District Nutrition Services Director may also contact the State Staff Development Training Coordinator for technical assistance.

NOTE: The review will not be closed until all corrective actions have been completed.

Once the State agency has received the local agency response to the written report, it may elect to do one or more of the following, based on the action plan:
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.

J. Written Reports
The State will send an electronic 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 Corrective Action Plan is due to Georgia WIC sixty days from the date that the Program Review Plan of Correction Report was received. Below is a list of the Corrective Action Training Requirements:
x One clinic average < ninety percent (90%) requires clinic specific training
x Two highlighted clinics < one-hundred percent (100%) require clinic specific training
x Three or more highlighted clinics < one-hundred percent (100%) requires District-wide training and/or District-wide average < ninety (90%) requires District-wide training
x Highlighted black - < one-hundred percent (100%) x Highlighted red - requires corrective action training
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

MO-9

GEORGIA WIC 2012 PROCEDURES MANUAL


State Agency Monitoring

be trained, where will the training be held, and how will the training be conducted?

NOTE:

All training must be performed within sixty (60) days from the date the WIC 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: 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 Nutrition Services Director 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.

K. 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 one-hundred eighty (180) days of the exit interview.

L. Establish New Clinic Procedures See Establish New Clinic Procedure in the Administrative Section.

MO-10

GEORGIA WIC 2012 PROCEDURES MANUAL

II. QUALITY ASSURANCE SELF-REVIEWS

State Agency Monitoring

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 Georgia WIC policies and procedures. Early identification and resolution of non-compliance improves the quality and strengthens the operations of the local agency.

B. Conducting Self-Reviews

The local agency must conduct an internal Self-Review annually by September
30th. Half of the District Clinics must be reviewed one year and all other clinics
must be reviewed the following year. A schedule of review dates and clinics, and
name of person conducting the self reviews, must be submitted to Georgia WIC by September 30th of each year.

The assessment will include all phases of the program operations. The "State of Georgia WIC Local Agency Monitoring Tool" must be utilized to evaluate operations of each clinic in the district.

Note: The Financial Monitoring Tool must be used. The District is
responsible for conducting Financial Annual Self-Reviews by June 30th of each year.

During the local agency Program Review, the State Review Team will review all documentation pertaining to the Self-Reviews. If repeated errors are found on a Self-Review, the District must conduct additional monitoring reviews and one-onone training (e.g., 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. USDA recommends that a Nutritionist be a member of the Local Agency QualityAssurance team conducting Self-Reviews.

A list of sites that will be reviewed, the dates of the reviews, and the name of
person conducting the reviews must be submitted to Georgia WIC by September 30th of each year. Self-Reviews are not required on clinic sites that were
monitored by the State during that same fiscal year.

Note: The Nutrition Services Director must request the names of employees and family members enrolled on Georgia WIC for internal audit purposes. This information is confidential and must be seen by the Nutrition Services Director only.

MO-11

GEORGIA WIC 2012 PROCEDURES MANUAL

STATE OF GEORGIA DEPARTMENT OF PUBLIC HEALTH

Attachment MO-1

GEORGIA WIC

LOCAL AGENCY FFY 2011
MONITORING TOOL
SECTIONS:
POLICY UNIT
COMPLIANCE ANALYSIS UNIT (FOOD INSTRUMENT ACCOUNTABILITY)
NUTRITION SERVICES UNIT
SYSTEMS INFORMATION UNIT

MO-12

GEORGIA WIC 2012 PROCEDURES MANUAL


Attachment MO-1 (cont'd)

MANAGEMENT EVALUATION TOOL FINAL SCORING SUMMARY
DISTRICT RATING Exemplary (950 - 1000) The District provides efficient and effective quality services in all areas. Training may be needed.

Excellent (900 949) The District provides exceptional and proficient quality services. However, there are recommendations that should be implemented. Training may be needed.

Good (800- 899) The District has managed well. However, there are corrective actions that must be implemented. Training may be needed.

Fair (700 799) The District needs to provide more management support and a correction action plan must be implemented. Training must be conducted.

Unsatisfactory (699 and below) The District is not following policies/procedures in several areas. Training must be conducted.

POSSIBLE

POINTS

Policy

55

Compliance

25

Total Possible Points: 265

ADMINISTRATIVE

POINTS

POSSIBLE

AWARDED

POINTS

Nutrition

170

Systems

15

Total Awarded Points:

POINTS AWARDED

DISTRICT CLINIC (S)

1. Clinic:
Policy Compliance Nutrition Systems Total Score:

POSSIBLE POINTS 205 155 230 145 735

POINTS AWARDED

4. Clinic:
Policy Compliance Nutrition Systems Total Score:

POSSIBLE POINTS 205 155 230 145 735

POINTS AWARDED

2. Clinic:
Policy Compliance Nutrition Systems Total Score:

POSSIBLE POINTS 205 155 230 145 735

POINTS AWARDED

5. Clinic:
Policy Compliance Nutrition Systems Total Score:

POSSIBLE POINTS 205 155 230 145 735

POINTS AWARDED

3. Clinic:
Policy Compliance Nutrition Systems Total Score:

POSSIBLE POINTS 205 155 230 145 735

POINTS AWARDED

6. Clinic:
Policy Compliance Nutrition Systems Total Score:

POSSIBLE POINTS 205 155 230 145 735

POINTS AWARDED

FORMUAL FOR CLINIC AVERAGE SCORE:

CLINIC #1_____ + CLINIC #2______ + CLINIC #3______ + CLINIC #4 _____ + CLINIC #5______ + CLINIC #6 ______ = _________ DIVIDE BY (/) # OF CLINICS REVIEWED ____ = AVERAGE SCORE FOR DISTRICT CLINICS: ______________
Is follow-up required? Yes _____ No _____ (Please review the Plan of Correction Report)

MO-13

GEORGIA WIC 2012 PROCEDURES MANUAL


Attachment MO-1 (cont'd)

POLICY UNIT "PRIOR TO" FORM ADMINISTRATIVE MANAGEMENT EVALUATION

DISTRICT: _______________________________ DATE:______________________________

1. Did the district conduct Self Reviews? (Attach a copy of the Review Schedule)
2. Was a Self Review plan submitted to Georgia WIC by September 30th? Date____________________
Comments:

S SN

U N/A

See Quality Assurance District Review Work
Sheet
Self Review Section

3. Is documentation on file for any Fair Hearings? Comments:

Fair Hearing Section

4. Were complaints handled/ resolved according to program procedures?
Comments:

Complaints Section

5. Did the district receive an extension for Processing Standards? From ____________ to ___________ (document dates)
Comments:

Clinic Review Processing Standards

6. Were posters, brochures, pamphlets, and flyers in the district in compliance with the current NonDiscrimination statement?
Comments:

Civil Rights Section

7. Was a Processing Standards Non-compliance letter sent to the district?
Comments:

Processing Standards

8. Did the district develop a quarterly Processing Standards plan and submit it to Georgia WIC?
Comments:

Processing Standards

MO-14

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



POLICY UNIT "PRIOR TO" FORM DISTRICT CLINIC EVALUATION

CLINIC: ______________________________ DATE: ________________________________

1. Does the clinic have a waiting list? Comments:

S SN U N/A

See Section:
Clinic Observation Waiting List

2. Does the local population include migrants? Comments:

Clinic Staff Questions Special Population

3. Does the population include Limited English Proficient (LEP) persons?
Comments:
4. Are the race codes being utilized? Comments:

Clinic Staff Questions Special Population
Clinic Observation Check In Procedures

5. Are participants/applicants physically present for certification?
Comments:

Clinic Observation Check In Procedures

MO-15

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



POLICY UNIT ADMINISTRATIVE MANAGEMENT EVALUATION

WORK SHEET



ADMINISTRATIVE FILES REVIEW

(S = Satisfactory, SN = Satisfactory Needs Improvement, U = Unsatisfactory and N/A = Not Applicable)

55 - 50 Points (S) 49 - 44 Points (SN)
43 - 0 Points (U) DISTRICT:____________________________

REFERENCE

AREAS OF REVIEW

DATE:____________________
S SN U NA Possible Points Points Awarded



A. INTERNAL COMMUNICATIONS

Introduction Section 1. Is a copy of the current Procedures Manual

1

V.

located at the district office?

2. Is a copy of the current fiscal year's Policy

1

and Action Memorandums located at the

district office?

3. Are staff meetings conducted?

1

4. Was an Organizational chart available?

1

(Attach a copy)

Comments:

B. HOME VISITS

Certification Section 1. Were WIC Home Visits being made?

1

XXVI.

(Request a copy of the approval forms).

2. Were procedures followed for vouchers

1

that are issued to participants in the home?

Comments:

C. OUTREACH

Outreach Section

1. Has the district or local clinic conducted

2

I.

outreach activities within the last 12

months?

2. Were all outreach activities documented

2

and available for review?

Outreach Section

3. Were grassroots organizations (Churches,

1

II.

Boys and Girls Clubs, etc.) contacted?

Comments:

D. SEPARATION OF DUTIES

Certification Section 1. Was separation of duties practiced at each

2

XXVI., B.

clinic in the district?

2. Was the Separation of Duties/District

1

Office form completed and received at the

district office within 2 days? (See

documentation)

3. Was the Separation of Duties/ District

1

MO-16

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



POLICY UNIT ADMINISTRATIVE MANAGEMENT EVALUATION

WORK SHEET



ADMINISTRATIVE FILES REVIEW

(S = Satisfactory, SN = Satisfactory Needs Improvement, U = Unsatisfactory and N/A = Not Applicable)

55 - 50 Points (S) 49 - 44 Points (SN)
43 - 0 Points (U) DISTRICT:____________________________

REFERENCE

AREAS OF REVIEW

DATE:____________________
S SN U NA Possible Points Points Awarded

Office Form completed by the Nutrition

Services Director/Designee and located at

the district office?

4. Was the documentation in compliance with

2

WIC rules and regulations?

Comments:

E. TRAINING

1. Is Procedures Manual training conducted

3

annually for WIC staff?

When? _____________________ By Whom? ____________________

2. Is the documentation for in-service training

2

for WIC and non-WIC staff available?

(See documentation)

Comments:

F. SELF-REVIEWS

Monitoring Section 1. Were Self Reviews conducted in the

2

II., B.

district? (See Policy Unit "Prior To" Form

Administrative Management Evaluation)

2. Was the Self Review Plan submitted to the

2

Office of Nutrition and WIC by September 30th? (See Policy Unit "Prior To" Form

Administrative Management Evaluation)

3. Was the Monitoring Tool completed in its

2

entirety?

4. Was the State's Monitoring Tool used?

1

Comments:

G. FAIR HEARING

Rights and

1. Is Fair Hearing documentation available for

2

Obligations Section

review at the district level? (See Policy Unit

V.

"Prior To" Form Administrative

Management Evaluation)

MO-17

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



POLICY UNIT ADMINISTRATIVE MANAGEMENT EVALUATION

WORK SHEET



ADMINISTRATIVE FILES REVIEW

(S = Satisfactory, SN = Satisfactory Needs Improvement, U = Unsatisfactory and N/A = Not Applicable)

55 - 50 Points (S) 49 - 44 Points (SN)
43 - 0 Points (U) DISTRICT:____________________________

REFERENCE

AREAS OF REVIEW

DATE:____________________
S SN U NA Possible Points Points Awarded

2. Were procedures followed?

2

3. Were timelines met?

1

Comments:

H. COMPLAINTS

Certification Section 1. Were procedures followed for complaint

2

XXV.

resolution? (See Policy Unit "Prior To"

Form Administrative Management

Evaluation)

Comments:

I. CIVIL RIGHTS

Rights and

Training

Obligations Section 1. Were Civil Rights training conducted

2

IV., B.

annually for local WIC staff? (district)

When? ____________________

By Whom? ________________

Rights and

2. Did the district's Civil Rights training meet

3

Obligations Section

the subject matter requirements? (Review

IV., B.

documentation)

3. Is Civil Rights training a part of new

2

employee orientation? (Review list of new

employees and documentation of Civil

Rights Training).

Administrative

New Clinics

Section Three, XIII. 1. When local agencies open a new clinic,

1

were Civil Rights Pre-Approved/Pre Award

Compliance Review conducted by district

office?

2. Was the documentation sent to Georgia

1

WIC? (Review documentation)

3. Was the agreement(s) sent to the state for

1

approval prior to the site visit? (Review

documentation)

Rights and

Literature

2

Obligations Section 1. Was the full Non-Discrimination statement

II.

on all district created materials? Effective

MO-18

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



POLICY UNIT ADMINISTRATIVE MANAGEMENT EVALUATION

WORK SHEET



ADMINISTRATIVE FILES REVIEW

(S = Satisfactory, SN = Satisfactory Needs Improvement, U = Unsatisfactory and N/A = Not Applicable)

55 - 50 Points (S) 49 - 44 Points (SN)
43 - 0 Points (U) DISTRICT:____________________________

REFERENCE

AREAS OF REVIEW

DATE:____________________
S SN U NA Possible Points Points Awarded

Comments:

May 1, 2009 (See Policy Unit "Prior To" Form Administrative Management Evaluation).

J. VOC CARD INVENTORY

Certification Section 1. Were VOC Cards ordered and distributed

1

XVII., F.

by the district office?

Certification Section 2. Was an inventory maintained?

1

XVII., G.

3. Was the inventory accurate and contain all

1

required components for receipt and

distribution of VOC Cards?

4. Was the state's VOC Card Inventory Form

1

utilized?

Comments:

K. LOCAL AGENCY CONTRACTS/AGREEMENTS

Administrative

1. Was Special Project (s) Agreement (s)

1

Section Three,

available for review?

XXX., D.

Comments:

L. PROCESSING STANDARDS

State Plan - Goals 1. Is the district monthly monitoring the

2

Processing Standards Report?

Comments:

Total Rating /Points

55

MO-19

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment MO-1 (cont'd)


POLICY UNIT CLINIC EVALUATION WORK SHEET


CLINIC EVALUATION

(S = Satisfactory, SN = Satisfactory Needs Improvement, U = Unsatisfactory and N/A = Not Applicable)

Clinic # _________ Total Points for Review _____________

205 184 Points (S)

183 163 Points (SN)

162 0 Points (U)

Use Forms 1 8 to determine awarded points for each section. Record points from Forms 1 8 on the worksheet. Total worksheet to determine clinic score above.

CLINIC: _______________________________ _______________________

DATE:

REFERENCE

AREAS OF REVIEW

A. INELIGIBILITY/TERMINATION

Certification Section XVI., A.

1. Was the Notice of Termination/ Ineligibility /Waiting List Form used appropriately if applicable? (See Form 1 Chart Review for point assignment for this question)

2. Were the Termination Notices and applicable documentation in the Ineligibility file present and completed per procedures? (See Form 1 Ineligibility File Review for point assignment for this question)
3. Notification of Termination x Are participants who are terminated during a valid certification period notified prior to termination? x Are participants notified that their WIC certification is about to expire before termination and how are they notified?

Comments:

S SN U NA Possible Points Points Awarde d 4
2
1

B. TRANSFERS/VOC/EVOC

Certification Section 1. Were the following items stored in a

3

XVII., I.

separate, secure location?

a. Program Stamp

b. VOC Cards

c. VOC Card Inventory

2. Were voided VOC cards marked VOID on

1

the VOC Card Inventory Log?

MO-20

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment MO-1 (cont'd)


POLICY UNIT CLINIC EVALUATION WORK SHEET



Certification Section 3. Were procedures followed for VOC Card

1

XVII., H. and I.

issuance and security? (See Form 2 for

point assignment for this question)

Certification Section 4. Were procedures followed for VOC Card

1

XVII., G.

Inventory maintenance? (See Form 2 for

point assignment for this question)

Certification Section 5. Was the old stock of VOC cards security

1

XVII., I.

destroyed in the event VOC cards were

revised?

Certification Section 6. Were any VOC Cards missing? Were they

2

XVII., J.

reported to Georgia WIC?

Certification Section 7. Were procedures followed for EVOC Card

1

XVII., E.

issuance? (See Form 2 for point

assignment for this question)

Certification Section 8. Were procedures followed for EVOC Card

1

XVII., E., c.

reports? (See Form 2 for point assignment

for this question)

Comments:

C. VOTER REGISTRATION

Rights and

1. Are Voter Registration Declaration forms

1

Obligations Section

available for each day certifications are

VIII.

conducted in the clinic?

2. Were Voter Registration Batch forms

1

completed and submitted to the Secretary

of State's office?

Comments:

D. NO PROOF

Certification Section 1. Was the No Proof form used appropriately

5

VIII., C., 3., m.

if applicable? (See Form 5 for point

assignment for this question)

Comments:

E. THIRTY-DAY

Certification Section 1. Was the Thirty-Day form used

6

VIII., C., 3., n.

appropriately if applicable? (See Form 6

for point assignment for this question)

Comments:

F. REFERENCE MATERIALS

Introduction Section 1. Are Policy /Action memos current in the

1

V.

clinic?

2. Is the current fiscal year Procedures

1

Manual in the clinic?

MO-21

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment MO-1 (cont'd)


POLICY UNIT CLINIC EVALUATION WORK SHEET



Comments:

G. RECORD REVIEW

Certification Section 1. Were procedures appropriately applied for

70

WIC certifications? (See Form 3 for point

assignment for this question)

Comments:

H. CLINIC OBSERVATION

Certification Section 1. During the observation were appropriate

50

procedures used to complete the

certification process? (See Forms 4A and

4B for point assignment for this question)

Comments:

I. PROCESSING STANDARDS

Certification Section 1. Is there a system (a personal visit log, WIC

2

IV., A.

Certification/Assessment Form or an

appointment book) available for

documenting and tracking initial contact

dates and Processing Standards? (See

Form 7 for point assignment for this

question)

Certification Section 2. Are Processing Standards being met?

4

IV. A. and C.

(See Form 7 for point assignment for this

question) If not, was an extension

requested by district? (See Policy Unit

"Prior To" Form Administrative

Management Evaluation)

Certification Section 3. Did the initial contact date recorded on the

2

III., B.

log and the Certification Form match?

(See Form 7 for point assignment for this

question)

Comments:

J. MISSED APPOINTMENTS

Certification Section 1. Was a Prenatal Missed Appointment Log

2

III., G.

maintained? Was the log completed in its

entirety?

2. Were missed certification appointments

2

rescheduled for prenatal women? (See

Form 7 for point assignment for this

question)

MO-22

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



POLICY UNIT CLINIC EVALUATION WORK SHEET



Certification Section 3. Did the rescheduled appointment meet

4

IV., A.

processing standards for prenatal women?

(See Form 7 for point assignment for this

question)

Administrative

4. If postcards are mailed to participants for

1

Section Three, VII.

any reason, are they in compliance with

HIPPA regulations? (View postcards or

other documents mailed)

Comments:

K. CIVIL RIGHTS

Rights and

1. Is the local agency in compliance with

2

Obligations Section

program policy regarding racial ethnic

IV., D.

coding and filing of participants' records? (Review Clinic Records)

Rights and

2. Was the full current non-discrimination

1

Obligations Section

statement on all Clinics created materials?

II.

Comments:

L. CLINIC STAFF QUESTIONS

1. Was the staff knowledgeable of the

32

procedures required to serve WIC

applicants/participants? (See Form 8 for

point assignment for this question)

Comments:

MO-23

GEORGIA WIC 2012 PROCEDURES MANUAL

Forms Section Attachment MO-1



POLICY EVALUATION FORMS

Form 1 ........... Ineligible Certification Work Sheet Form 2 ........... VOC/EVOC Security & Issuance Report Form 3 ........... Record Review Form 4A......... Clinic Observation Form 4B......... Proof of Identity for Women, Infants and Children
Observation Form Form 5 ........... No Proof Monitoring Form Form 6 ........... Temporary Thirty (30) Day Certification Record Review
Form 7 ........... Processing Standards / Prenatal Missed Appointment Logs Review
Form 8......... Clinic Staff Questions

MO-24

GEORGIA WIC 2012 PROCEDURES MANUAL

INELIGIBLE CERTIFICATION WORK SHEET

Form 1

Review five (5) 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 the Ineligibility file.

CLINIC: __________________________________
CHART REVIEW
Participant's Name
COMPLETION OF TERMINATION NOTICE 1. Was the date documented? 2. Was the demographic
information recorded? 3. Was "You are not eligible" or
"You are being terminated" checked? 4. Was the reason for termination checked? 5. Was the Fair Hearing Section completed? 6. Was the participant/parent/guardian signature recorded? 7. Was the WIC representative's signature recorded? Comments:

DATE: ______________________
INELIGIBILITY FILE REVIEW (check the Termination Notices and applicable documentation in the Ineligibility file)

NOTIFICATION 1. Was the Notice of Fair Hearing
given? Comments:

TERMINATION CODE 1. What was the termination code
submitted for ineligibility or termination? 2. Was the above code correct?
Comments:

CERTIFICATION FORM & SUPPORTING DOCUMENTATION 1. Was the income section of the
Certification Form completed, dated and signed if the reason for termination or ineligibility was "A"?
2. Did the Certification Form contain the signature and date
MO-25

GEORGIA WIC 2012 PROCEDURES MANUAL

of the person that determined eligibility? 3. Was a copy of income proof present with the Certification Form if the reason for termination or ineligibility was "A"? 4. Were proof copies stamped with the date of receipt? Comments:
Possible Points Chart Review 4 Points
x Completion of Termination Notice - 1 x Notification - 1 x Termination Code - 1 x Certification Form & Supporting Documentation - 1 Ineligibility File 2 Points x Completion of Termination Notice - 1 x Certification Form & Supporting Documentation - 1 Total Possible Points - 6

Form 1 (cont'd) Points Awarded Total Awarded:

MO-26

GEORGIA WIC 2012 PROCEDURES MANUAL


Form 2

VOC/EVOC SECURITY & ISSUANCE REPORT

CLINIC: ___________________________________

DATE: _________________________

State/District Issued VOC
Cards
Beg # End #

DISTRICT/CLINIC ISSUED VOC CARDS/PHYSICAL INVENTORY

Amount Issued

Date VOC Cards on

Issued

Hand

Beg # End #

# of Cards
on Hand

Requested Cards
Accounted For?

2 Staff District & Is Initials Clinic #'s Inventory Recorded? Match? Accurate?

Comments:
VOC CARD SECURITY REPORT (Pull 5 Participant Records)
Participant's Name Participant's Birth Date Date VOC Card was Issued Was the Parent/Guardian/Caregiver Signature on the Log? Did the Signature on the Log and Certification Form Match? Was the Termination Notice issued? Comments:
CLINIC ISSUED EVOC CARDS
Are the EVOC Reports printed quarterly and filed by year?
Comments:
EVOC CARD SECURITY REPORT (Pull 5 Participant Records)
Participant's Name Participant's Birth Date Was a copy of the EVOC Card Filed in the Participant's Chart? Was the Clinic Information Stamped or Printed on the EVOC Card? Was the EVOC Card Signed by the Participant/Parent/Guardian? Was the EVOC Card Signed by the WIC Representative? Was the Termination Notice issued? Comments:

Possible Points 1 Points Awarded -
Possible Points 1 Points Awarded Yes ___ No ___ Possible Points 1 Points Awarded -
Possible Points 1 Points Awarded -

MO-27

GEORGIA WIC 2012 PROCEDURES MANUAL

Form 3

RECORD REVIEW Review the following criteria in the records randomly selected

CLINIC: __________________________________

DATE: __________________________

100 - 90% compliance = Available Possible points for each criteria.

PARTICIPANT'S NAME & WIC ID Number

% Possible Points

CERTIFICATION DATE

70

Points Awarded

DEMOGRAPHICS

1. Were the demographics (Name,

2

Address, etc.) completed?

2. If P.O Box was recorded as the address,

2

was the form for Applicants with a P.O.

Box completed and filed in health

record?

Comments:

PROCESSING STANDARDS

1. Was the initial contact date recorded?

3

2. Did a break in service occur?

2

3. If so, was the initial contact date

2

changed?

4. Were processing standards met?

3

Comments:

PROOFS

1. Was proof of residency recorded and a copy stamped dated and filed in the

2

record?

2. Was proof of identification for the

2

participant recorded and a copy

stamped dated and filed in the record?

3. Was proof of identification for the parent/

2

guardian recorded and a copy stamped

dated and filed in the record?

Comments:

INCOME

1. Was the date recorded for the income

1

information?

2. Was Medicaid eligibility recorded?

3

3. Was Medicaid number recorded?

3

4. Was TANF documented?

3

5. Was the TANF verification filed in the

3

record?

6. Was SNAP documented?

3

MO-28

GEORGIA WIC 2012 PROCEDURES MANUAL

7. Was the SNAP verification filed in the record?
8. Was the number in family recorded? 9. Was income information recorded? 10. Was zero income accepted? 11. If yes to the above, was the following
question answered? How do you obtain food, shelter, clothing and medical care? 12. Was the income source recorded and a copy stamped dated and filed in the record? 13. Was a letter from employer accepted as proof of income? 14. If yes, was the letter from employer on letterhead or attached to a No Proof form? 15. Were staff initials recorded for residency, identification and income verification? 16. Was only one income reported checked? 17. If no to the above, was the Income Calculation Form used?
Comments:

CERTIFICATION VALIDATION
1. Was participant physically present? 2. If no to the above, was the exempt
reason documented in the record? 3. Was the signature/title of staff person
verifying the participant/parent/ guardian signature recorded? 4. Was the participant's signature/date recorded? 5. If proxy signed above, was proxy letter completed and filed in record? 6. Was choice to authorize disclosure of sharing participant information recorded?
Comments:

1. Was participant categorically eligible?
2. Was it documented that participant was income eligible/ineligible?
Comments:

ELIGIBILITY

SUPPORTING DOCUMENTATION MO-29

Form 3 (cont'd) 3 1 1 1 1
2
1 1
1 1 1
1 1 2
2 2 1
4 4

GEORGIA WIC 2012 PROCEDURES MANUAL

1. Was current immunization status recorded?
2. Was the error correction procedure used?
3. Was a VOC/EVOC card issued? (Migrants only)
Comments:

Form 3 (cont'd)
1 1 1

Note: Make copies of this form for Record Review.

MO-30

GEORGIA WIC 2012 PROCEDURES MANUAL

CLINIC OBSERVATION

Form 4A

CLINIC: __________________________________

DATE: _____________________

(S = Satisfactory, SN = Satisfactory Needs Improvement, U = Unsatisfactory and N/A = Not Applicable)
50 45 Points (S) 44 40 Points (SN)
39 0 Points (U)

REFERENCE

AREAS OF REVIEW

S SN U NA Possible Points Points Awarded

A. ENVIRONMENT

Special Population

1. Are WIC facilities accessible to persons

3

Section

with special needs (ADA)?

III.,E.

Emergency Plan

2. Is this a new or renovated facility that is

1

Section

accessible and operational during power

V., A. and B.

failures?

Comments:

B. CONFIDENTIALITY

Certification Section

1. Does the clinic offer privacy for the

2

VIII., A., 2.

certification process (income screening,

health screening and counseling)?

Comments:

C. SIGNS

Certification Section

1. Is the "No Charge for WIC Services" sign

1

I.

posted in the clinic?

Rights and Obligations 2. Is the "How to File a Complaint" sign

1

Section

posted in the clinic?

IV., F.

Administrative

3. Are "No Smoking" signs posted? (N/A if

1

Section Three, IX.

a DPH Building)

Special Population

4. Is the "Interpreter" sign posted in a

1

Section

visible place?

III., B.

Rights and Obligations 5. Is the "Justice for All" sign posted in a

1

Section

visible place?

IV., A.

Comments:

D. CUSTOMER SERVICE

Administrative

1. Were scheduled participants waiting for

1

Section Three, XXVII.

long periods of time? Is a Patient Flow

Analysis required?

Rights and Obligations 2. Are all applicants treated the same?

1

Section

I.

Comments:

E. CERTIFICATION PROCEDURES (CHECK-IN)

Certification Section

1. Was the applicant present at

2

II., B.

certification?

MO-31

GEORGIA WIC 2012 PROCEDURES MANUAL


CLINIC OBSERVATION

Certification Section XXX.
Rights and Obligations Section IV., D. Certification Section XXVI., C., 6.

2. Was the staff in the clinic using the Interview Script to determine Race and Ethnicity?
3. Are the current race codes being utilized? (See Policy "Prior To" Form District Clinic Evaluation)
4. Were participants informed of their rights and obligations?

Certification Section

5. Was the applicant/participant given the

XXV., B.

"How to File a Complaint" flyer at the

initial contact, certification, and/or

recertification?

Rights and Obligations 6. Is each participant offered an

Section

opportunity to register to vote?

VIII.

Comments:

F. SPECIAL POPULATION/INTERPRETERS

Special Population

1. Was the Interpreter sign discussed or

Section

shown to the applicant/participant?

III., B.

2. Were waivers completed when the

applicant or participant brought their

own interpreter?

3. Were services available for LEP

clients? (See Policy "Prior To" Form

District Clinic Evaluation)

Comments:

G. PROOFS

Certification Section

1. Was proof of ID required for

V.

certification /re-certification or pickup?

Was it an approved form of ID? Was

the proof copied and stamped with the

date of receipt? (See Form 4B for

point assignment for this question)

Certification Section

2. Was proof of residence required for

II., C.

certification/re-certification? Was it an

approved form of residency? Was the

proof copied and stamped with the

date of receipt?

Certification Section

3. Was proof of income required for

II., D

certification/re-certification? Was it an

approved form of income? Was the

proof copied and stamped with the

date of receipt?

Comments:

H. INCOME

Certification Section

1. Was Medicaid/SNAP/TANF verified?

VIII., B.

Certification Section

2. Is income determined prior to

VIII., A., 3.

nutritional risk assessment?

MO-32

Form 4A (cont'd) 2 2 2 2 1
2 1 2
2
2
2
1 1

GEORGIA WIC 2012 PROCEDURES MANUAL



CLINIC OBSERVATION

Certification Section

3. Was the correct form (ThirtyDay,

VIII., C., 3., m and n

Income Calculation and No Proof) used

for income?

Certification Section

4. Was the income calculated according

VIII., C.

to procedures? Were the right

questions asked?

Certification Section 5. Was the applicant asked? (a) How

VIII., A., 3.

many people are in the family? (b)

Who contributed to the income of the

family?

Certification Section 6. Was income assessed according to the

VIII., C., 3.

definition of family?

Certification Section 7. Was proof of income verified at

VIII.

certification/re-certification?

8. Did the clinic staff ask the applicant to

report income for the entire family?

Certification Section 9. Does the clinic determine an applicant/

VIII., B.

participant to be income eligible based

on presumptive eligibility

requirements? Was a self-declared

income required?

Comments:

I. CLOSURE OF CERTIFICATION

Rights and Obligations 1. Was the applicant asked to read the

Section

certification statement before signing?

I.

Certification Section XV., B., 18., g.

2. Was the applicant asked to make a selection of their preference in authorizing disclosure of sharing participant information?

Certification Section VII.

3. Was the applicant offered the opportunity to have a proxy? If so, were procedures followed for documentation of proxies (i.e. Certification Form, Computer or Tickler File)?

Comments:

J. CLINIC FLOW

Administrative

1. Were there any noticeable bottlenecks

Section Three, XXVII.

that interfered with the clinic flow?

Comments:

K. WAITING LIST

Certification Section XXII.

1. Is there a current Waiting List since the last review?

Certification Section XXII., A.

2. Were procedures followed for maintaining a waiting list?

Comments:

MO-33

Form 4A (cont'd) 1 1 1 1 1 1 1
1 1 1
1 1 1

GEORGIA WIC 2012 PROCEDURES MANUAL

PROOF OF IDENTITY OBSERVATION FORM

Form 4B

The following proofs of identities are acceptable and can be used for a woman (participant, guardian or caregiver), infant, child and proxy. Use this form to document the identification proof shown at certification/ subsequent certification (Use one form per clinic).

CLINIC: _______________________________

DATE: ________________________________

IDENTIFICATION PROOF

Check

Possible Points

Appropriate Points Awarded

ID(S) that apply per observation

2

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) Military ID Social Security Card VOC Card (with addition ID) Passport or Passport Card Other (i.e. No Proof or Thirty Day)
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) Military ID Social Security Card VOC Card (with addition ID) Passport or Passport Card Other (e.g., No Proof or Thirty Day)
WOMAN (participant)/PARENT/GUARDIAN/PROXY Birth Certificate Driver's License Military ID Medical Record (presented by the applicant, already exists in the clinic or the record is transferred). Social Security Card State ID/School Identification VOC Card (with additional ID) proxies excluded WIC ID (Voucher Pick Up Only) Passport or Passport Card Other (e.g., No Proof or Thirty Day) Comments:

Note: Proxy must show identification in addition to the WIC ID card.

MO-34

GEORGIA WIC 2012 PROCEDURES MANUAL

NO PROOF MONITORING FORM

Form 5

In each clinic randomly select five (5) records, from the No Proof File, to review the following criteria:

CLINIC: _____________________________

DATE: _______________________________

CHART REVIEW

CRITERIA TO REVIEW

PARTICIPANT'S NAME

COMPLETION OF NO PROOF FORM
1. Was the missing proof documented? 2. Was the income information recorded 3. Was the reason for no documentation recorded? 4. Was the list of family members applying
completed? 5. Was the applicant's signature and date
recorded? 6. Was the WIC representative's signature and
date recorded?
Comments:

COMPLETION OF THE CERTIFICATION FORM
1. Was "NP" recorded on the Certification Form for the missing proof?
2. Was self-declaration allowed and documented on the Certification form if income was the missing proof?
3. Did the income recorded on the No Proof form equal the income recorded on the Certification form?
Comments:

1. Was the No Proof form used correctly? Comments:

VALID USE

NO PROOF FILE REVIEW COMPLETION OF NO PROOF FORM 1. Was the missing proof documented?
2. Was the income information recorded?

MO-35

Possible Points - 1 Points Awarded
Possible Points - 1 Points Awarded Possible Points - 1 Points Awarded

GEORGIA WIC 2012 PROCEDURES MANUAL

3. Was the reason for no documentation recorded?
4. Was the list of family members applying completed?
5. Was the applicant's signature and date recorded?
6. Was the WIC representative's signature and date recorded?
Comments:

1. Was the No Proof form used correctly? Comments:

VALID USE

Form 5 (cont'd)
Possible Points - 1 Points Awarded Possible Points - 1 Points Awarded

MO-36

GEORGIA WIC 2012 PROCEDURES MANUAL

TEMPORARY THIRTY (30) DAY CERTIFICATION RECORD REVIEW

Form 6

Use one form per clinic in each clinic and randomly select five records from the Temporary Thirty (30) Day Certification Report to review the following criteria:

CLINIC: ________________________________

DATE: __________________________________

CHART REVIEW

PARTICIPANT'S NAME AND BIRTH DATE

CERTIFICATION DATE

MISSING PROOF(S) - Check all that apply

ID___ ID___ R___ R___ INC__ INC__

1. Was the date recorded?

COMPLETION OF THE THIRTY-DAY FORM

2. Was the name, date of birth, address and telephone number completed?
3. Was "You will be terminated from Georgia WIC ..." checked?

4. Was the date (that information is due back to the clinic) recorded?
5. Was the type of proof(s) client is to bring back to the clinic checked?
6. Were the date and the WIC Representative's signature completed?
7. Was the Fair Hearing Section completed?

8. Was the participant or parent/guardian/caregiver's signature completed?
9. Was the WIC Representative's signature/title completed?

Comments:

COMPLETION OF THE CERTIFICATION FORM 1. Was "NO" placed in the missing proof(s) field?
2. If income was the missing proof, is self-declared income documented?
3. Did the participant or parent/guardian/caregiver sign the WIC assessment form?
4. Did the WIC Representative sign and date the WIC assessment form?
Comments:

VOUCHER ISSUANCE 1. Was the participant issued more than thirty (30) days of
vouchers?

ID___ R___ INC__

ID___ R___ INC__

ID___ R___ INC__

Possible Points 1 Points Awarded -
Possible Points 1 Points Awarded -

MO-37

GEORGIA WIC 2012 PROCEDURES MANUAL

2. Was the temporary thirty (30) day certification extended and participant issued more vouchers?
Comments:
WITHIN THE THIRTY-DAY PERIOD 1. If the participant or parent/guardian/caregiver returned with the
missing proof(s), was the actual document(s) presented recorded in the appropriate "UP" field? 2. If income documentation was the missing proof, is the adjustment made on the WIC assessment form? (up field for income source and amount) 3. Did the WIC Representative date and initial the updated adjustment? 4. Was the adjustment entered into the computer? Comments:
TERMINATION 1. If the participant is income ineligible, was "You are being
terminated from Georgia WIC ..." checked on the Thirty (30)Day Form? 2. Were the date and the WIC Representative's signature completed on the Thirty (30) -Day Form? 3. If the participant or parent/guardian/caregiver did not return with the missing proof(s), was the participant terminated in the computer system? Comments:
THIRTY-DAY FILE REVIEW
COMPLETION OF THE THIRTY-DAY FORM 1. Was the date recorded? 2. Was the name, date of birth, address and telephone number
completed? 3. Was "You will be terminated from Georgia WIC ..." checked? 4. Was the date (that information is due back to the clinic)
recorded? 5. Was the type of proof(s) client is to bring back to the clinic
checked? 6. Were the date and the WIC Representative's signature
completed? 7. Was the Fair Hearing Section completed? 8. Was the participant or parent/guardian/caregiver's signature
completed? 9. Was the WIC Representative's signature/title completed?
Comments:

Form 6 (cont'd) Possible Points 1 Points Awarded -
Possible Points 1 Points Awarded -
Possible Points 1 Points Awarded -
Possible Points 1 Points Awarded -

MO-38

GEORGIA WIC 2012 PROCEDURES MANUAL


Form 7

PROCESSING STANDARDS / PRENATAL MISSED APPOINTMENT LOGS REVIEW

PROCESSING STANDARDS CHART REVIEW

(Check two charts for each WIC type)

Source for Participant Names: Log___ System Printout___ Random Names___

Other________________(specify)

Participant

WIC Type

Initial Contact

Scheduled

Do Initial Contact

Name

Date

Appointment

Dates Match?

Date

(Certification Form

& Log)

Were Processing Standards Met?

Comments:

Possible Points 2 Possible Points 4

Points Awarded

Points Awarded

PROCESSING STANDARDS SYSTEM/LOG REVIEW 1. Is there a system/log available for documenting and tracking initial contact
dates and Processing Standards? 2. Was the system/log completed in its entirety?
3. Was documented proof available to show Processing Standards are being met?
4. Are Processing Standards being met for all WIC types?
Comments:

Yes

No

Yes

No

Yes

No

Yes

No

Possible Points 2 Points Awarded

Participant Initial

Name

Contact

Date

PRENATAL MISSED APPOINTMENT REVIEW

(Check 5)

Scheduled

Were

Date of

Rescheduled

Appointment Processing Contact to Appointment Date

Standards Reschedule

Met?

Missed

Appointment

Were Processing Standards Met?

Comments:

Possible Points 2 Possible Points4

Points Awarded

Points Awarded

MO-39

GEORGIA WIC 2012 PROCEDURES MANUAL

CLINIC STAFF QUESTIONS

Form 8

CLINIC: ______________________________

DATE:___________________________

(S = Satisfactory, SN = Satisfactory Needs Improvement, U = Unsatisfactory and N/A = Not Applicable)

32 29 Points (S) 28 26 Points (SN)
25 0 Points (U)

REFERENCE
A. ENVIRONMENT Certification Section XXIV.
Emergency Plan Section V., A. and B.
Comments:

AREAS OF REVIEW
1. Are WIC services coordinated or integrated with other health department services?
2. If the clinic has power failure, what are your operating procedures?
3. Does the electronic door convert to a manual door in the event of a power failure?

S SN U NA Possible Points Points Awarded 1
1 1

B. WAITING LIST

Certification Section

1. Do you have a waiting list? (See Policy

1

XXII.

Unit "Prior To" Form District Clinic

Evaluation)

Comments:

C. SPECIAL POPULATION

Certification Section

1. Are migrants being served? (See Policy

1

II., C. and VII., C., 3., l.

Unit "Prior To" Form District Clinic Evaluation)

2. Is the staff knowledgeable of procedures

1

to complete migrant certifications?

Special Population

3. Are the Language Lines interpreters or

1

Section

bilingual staff available for the LEP

III., B.

clients, if applicable? (See Policy Unit "Prior To" Form District Clinic

Evaluation)

4. Are waivers completed when the

1

applicant or participant bring their own

interpreter?

Comments:

D. CERTIFICATION PROCEDURES

Certification Section

1. What is the definition of "family"?

1

VIII., C., 3.

MO-40

GEORGIA WIC 2012 PROCEDURES MANUAL


Certification Section VII.
Certification Section XVII., B.
Certification Section XXVI.
Certification Section XXX. Comments:

2. Under what circumstances are proxies allowed to bring a child in for recertification?
3. Describe the process of accepting an out-of-state transfer (with a valid VOC card).
4. Do employees complete WIC certification or Referral forms with a home visit? (Request a copy of the procedures).
5. How is the race of a participant determined?

E. CIVIL RIGHTS Certification Section XXV. Comments:

1. How do you handle Civil Rights complaints?

F. APPOINTMENTS Certification Section III., F.
Certification Section IV., A.
Comments:

1. Do you contact all participants that miss a certification appointment? How are they contacted?
2. Have special provisions been made for scheduling the Participants Who Work, Migrant or Rural Participants? Please explain your answer. (i.e. Saturdays or late clinic) Hours of Operation ________________ Extended Hours __________________
3. When is the next available appointment for a walk-in applicant requesting WIC benefits? Women(P) ________ Women(PP) ________ Women(B) ________ Infant ________ Child________

G. PROCESSING STANDARDS

Certification Section IV., A.

1. What are the processing standards time frames for each category below?

Prenatal

__________________

Breastfeeding __________________

MO-41

Form 8 Cont'd 1 1 1 1 1
1 1
5
6

GEORGIA WIC 2012 PROCEDURES MANUAL


Postpartum Infants Children Migrants

__________________ __________________ __________________ __________________

Certification Section XIII.

2. Is the staff knowledgeable of certification periods? (Staff interviews) Women(P) ________ Women(B) ________ Women(PP) ________ Infant__________ Child__________

Comments:

Form 8 Cont'd 5

MO-42

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



FOODINSTRUMENTACCOUNTABILITYWORKSHEET

ADMINISTRATIVE MANAGEMENT EVALUATION

(S=Satisfactory, SN=Satisfactory needs improvement, U=Unsatisfactory, and NA=Not Applicable)

DISTRICT________________________

DATE_____________________

REFERENCE

AREAS OF REVIEW

S SN U NA Possible Points

Points Awarded

A. EMPLOYEE RELATIVE FORM

(VOUCHER ISSUANCE EMPLOYEES/FAMILY MEMBERS)

Certification 1. What is the District's policy for issuing

1

Section

vouchers to eligible WIC employees and

III.,E

their family members?

Certification 2. Are any local agency staff receiving WIC

1

Section

benefits at the clinic site where they work?

III.,E

Certification 3. Are any family members of WIC staff

1

Section

receiving benefits at the local clinic where

III.,E

the staff is employed?

Certification 4. Are employees Disclosure forms kept

2

Section

on file at the District office?

III.,E

Comments:

B. PACKING LIST/CONFIRMATION NOTICE

Food Delivery 1. Are signed, dated and reconciled voucher

2

V.,D.,2.

Packing List/Confirmation Notice received

by the District within five days of clinic

verification?

Comments:

C. LOST, STOLEN, AND DESTROYED VOUCHER REPORT

(MISSING VOUCHER/VPOD RECEIPT)

Compliance 1. Has the District Office received notice of

1

Analysis

any missing vouchers/VPOD receipts from

X.

any WIC clinic since the last Program

Review?

Compliance 2. Was the Lost, Stolen, Destroyed Voucher

2

Analysis

report investigated?

X.

Compliance 3. Was a Lost, Stolen, Destroyed Voucher

2

Analysis

Report sent to Georgia WIC?

X.

Comments:

MO-43

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



FOODINSTRUMENTACCOUNTABILITYWORKSHEET

D. COMPLIANCE SELF REVIEWS

State Agency 1. Were Self Reviews conducted in the

1

Monitoring

District?

II.,B

State Agency 2. Was the Food Instrument Accountability

1

Monitoring

Section completed in its entirety?

II.,B

State Agency 3. Was the State's Monitoring Tool used?

1

Monitoring

II.,B

Comments:

E. DUAL PARTICIPATION/PARTICIPANT ABUSE

Compliance 1. Has the District received any reports of

1

Analysis

program abuse by the participants since

III.,A.

the last Program Review?

Compliance 2. Was the report of abuse investigated?

2

Analysis

III.,A.

Compliance 3. Was the report sent to Georgia WIC?

2

Analysis

III.,A.

Comments:

F. CUMULATIVE UNMATCHED REDEMPTION REPORT (CUR)

Food Delivery 1. Does the District monitor the

3

XIV.,A.

Unmatched Redemption and

Cumulative Unmatched Redemption

reports on a monthly basis?

Food Delivery 2. Does the District complete and/or

2

XIV.,A.

monitor the Bank Exception Reports

received from Georgia WIC on a

monthly basis?

Comments:

MO-44

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



FOODINSTRUMENTACCOUNTABILITYDISTRICTCLINICEVALUATION

CLINIC EVALUATION (S=Satisfactory, SN=Satisfactory needs improvement, U=Unsatisfactory, and NA=Not Applicable)

CLINIC________________________

REFERENCE

AREAS OF REVIEW

DATE_____________________ S SN U NA POSSIBLE POINTS

POINTS AWARDED

A. RECONCILED PACKING LIST/CONFIRMATION NOTICES

Food Delivery 1. Is the Packing List/Confirmation

3

V.,D.,1.

Notice verified, signed, and dated?

Food Delivery 2. Are Packing List recorded on the

2

V.,E.

Manual Voucher Inventory Logs within three days of receipt?

Food Delivery 3. Are Confirmation Notices recorded

3

VI.,A.

on the VPOD Inventory Logs within three days of receipt?

Food Delivery 4. Are any Packing List/Confirmation

2

VI.,D.1.

Notice missing?

Comments:

B. MANUAL VOUCHER INVENTOY LOG

Food Delivery 1. Is the log being completed on all

5

V.,E.

vouchers?

Food Delivery 2. Are clerk initials present on the

2

V.E.,1.

Manual Inventory Log?

Food Delivery 3. Are the beginning and ending

5

V.,E.

numbers documented correctly on

the log?

Comments:

C. MANUAL VOUCHER PHYSICAL INVENTORY

Food Delivery 1. Is the Physical Inventories

5

V.,E.2.

conducted/verified monthly and match the inventory log?

Food Delivery 2. Does the Manual Voucher Inventory

2

V.,E.2.

Log contain second verifying initials for physical inventory?

Food Delivery 3. Are any Manual Vouchers missing?

5

V.,E.2.

Comments:

D. MANUAL VOUCHER COPIES

Food Delivery 1. Are Manual Voucher copies filed in

2

serial number order?

MO-45

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



FOODINSTRUMENTACCOUNTABILITYDISTRICTCLINICEVALUATION

V.,G.2.

Food Delivery 2. Are any Manual Voucher Copies

3

V.,F.

Missing?

Food Delivery 3. Have vouchers been altered with

3

V.,F.

write over's or scratch-outs?

Food Delivery 4. Are data blocks completed

3

V.,F.

accurately?

Food Delivery 5. Does Manual Vouchers have the

3

V.,3.

appropriate food quantities and / or unassigned blocks marked with an

"X"??

Food Delivery 6. Does the Manual Vouchers contain

3

III.,B.,2.

the correct ID proof codes and/or any missing participant's signatures?

Comments:

E. VPOD INVENTORY LOGS

Food Delivery 1. Was the computer screen printed

2

VI.,A.

and stapled to the corresponding packing slip to show date of entrance

is within three days of receipt?

Food Delivery 2. Is the VPOD inventory complete and

5

VI.,D.

accurate?

Food Delivery 3. Are the beginning and ending

5

VI.,D.

numbers documented correctly on the log?

Comments:

F. VOUCHERS PRINTED ON DEMAND (VPOD VOUCHERS) RECEIPTS

Food Delivery 1. Are receipts filed in serial number

2

IV.,D.,4.

order, missing or misfiled?

Food Delivery 2. Do receipts contain the correct ID

4

IV.,D.,1.

proof codes and/or any missing participant signatures?

Food Delivery 3. Does the VPOD receipts contain the

4

IV.,D.,2.,(2)

entry "Failed to Sign" more than 1% for the entire month?

Food Delivery 4. Are voided vouchers stamped "void"

2

VI.,C.

and attached to the receipts?

Comments:

MO-46

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



FOODINSTRUMENTACCOUNTABILITYDISTRICTCLINICEVALUATION

G. DAILY ACTIVITY REPORTS

Food Delivery 1. Are Daily Activity Reports maintained

4

VI.,C.

correctly (gaps, missing numbers, signatures or dates)?

Comments:

H. VOUCHER SECURITY

Compliance 1. During office hours, are vouchers

2

Analysis

securely stored or in the possession

XII.,A.1.

of authorized staff?

Compliance 2. Is the key properly secured only with

2

Analysis

authorized personnel?

XII.,A.1.

Compliance 3. Are vouchers securely stored

3

Analysis

separately from ID cards and

XI.,C.,2.

voucher receipts?

Compliance 4. Are WIC ID cards securely stored

3

Analysis

separately from the WIC Stamp?

XI.,C.,2.

Compliance 5. Are WIC ID cards pre-stamped?

3

Analysis

XI.C.

Compliance 6. What security measures are currently

2

Analysis

in place to prevent voucher theft by

XII.,B.

participants?

Compliance 7. Are vouchers securely transported

2

Analysis

from one site to another?

XII.,E.

Comments:

I. PRORATING (VOUCHERS ISSUANCE)

Food Delivery 1. Were vouchers prorated accordingly

5

VIII.

for late voucher pick up and categorically ineligible participants?

Comments:

J. LOCAL AGENCY POLICIES

Compliance 1. Are Employee Disclosure Forms kept

1

Analysis

on file at the clinic?

III.,E.

Food Delivery 2. Did staff members at the clinic issue

4

vouchers or process certification for

MO-47

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



FOODINSTRUMENTACCOUNTABILITYDISTRICTCLINICEVALUATION

III.,F.

family members?

Comments:

K. VOUCHER ISSUANCE (RECERT OVERDUE)

Food Delivery 1. Are any participants issued vouchers

5

III.,A.

past certification overdue date without a current certification

completed?

Food Delivery 2. Was current certification processed

5

III.,A.

and sent to Covansys?

Comments:

L. ISSUANCE PROCEDURES (CUR)

Food Delivery 1. Are vouchers issued to participants

5

XIV.

who are categorically ineligible?

Food Delivery 2. Are voucher issued to participants

5

XIV.

who were terminated for thirty day issues?

Food Delivery 3. Are voucher issued to participants

5

XIV.

without a valid certification processed with Covansys?

Comments:

M. PARTICPANT ABUSE/DUAL PARTICIPATION

Compliance 1. Did the participant receive notice of

5

Analysis

repayment, suspension and/or

III.,C.

termination?

Compliance 2. Were participant's that were found to

5

Analysis

be in violation of Georgia WIC

III.,C.

terminated for a period of one year?

Comments:

N. OBSERVATION OF DUAL PARTICIPATION

Rights and 1. Did staff emphasize dual

3

Obligation

participation during certification and

Section

re-certification?

I.

Comments:

O. CLINIC INTERVIEW

Compliance 1. HOME VISITS

1

Analysis

A. If vouchers are issued to participants

XII.,E.

in the home, how are they delivered

and by whom?

MO-48

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



FOODINSTRUMENTACCOUNTABILITYDISTRICTCLINICEVALUATION

Food Delivery 2. PRORATION

3

VIII.

A. Is staff knowledgeable of the proper

procedures for prorating?

Certification 3. LOCAL AGENCY POLICIES

1

Section

A. What is your policy for issuing

III.,E.

vouchers to employees/family

members?

Comments:

P. LOST, STOLEN, DESTROYED, VOUCHER REPORT

Compliance 1. Were Lost, Stolen, Destroyed

3

Analysis

Voucher Reports completed in its

XI.,B.

entirety for vouchers that were security destroyed, lost, or

damaged?

Compliance 2. Was the Lost, Stolen, Destroyed

2

Analysis

Voucher Report sent to Georgia WIC?

XI.,C.,2.

Comments:

Q. VOUCHER REGISTERS

State Agency 1. Were voucher registers reconciled

1

Monitoring

with the participant's signature and/or

II,.B.

marked as void, followed by the clerk's initials and date?

Comments:

MO-49

GEORGIA WIC 2012 PROCEDURES MANUAL

RE-CERT OVERDUE FORM

Form 1

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.

CLINIC: __________________________________

DATE: __________________________

100 - 90% compliance = Available Possible points for each criteria.

PARTICIPANT'S NAME

% Possible Points

WIC STATUS

Points Awarded

1. Were the demographics (Name, Address, etc.) completed?
Comments:

DEMOGRAPHICS

CERTIFICATION DATES
2. Was the participant's delivery and/or EDC date recorded?
3. What is the participant's re-cert due date?
4. What is the participants recertification date?
Comments:

VOUCHER ISSUANCE
5. Was the participant issued vouchers past the certification overdue date without a current certification completed?
6. Was current certification processed and sent to Covansys?
Comments:

MO-50

GEORGIA WIC 2012 PROCEDURES MANUAL


RECORD REVIEW Review the following criteria in the Employee/ Relatives records

Form 2

CLINIC: __________________________________

DATE: __________________________

100 - 90% compliance = Available Possible points for each criteria.

PARTICIPANT'S NAME

% Possible Points

CERTIFICATION DATE

0

1. Were the demographics (Name, Address, etc.) completed?
2. If P.O Box was recorded as the address, was the form for Applicants with a P.O. Box completed and filed in health record?
Comments:

DEMOGRAPHICS

Points Awarded

PROCESSING STANDARDS
3. Was the initial contact date recorded?
4. Did a break in service occur? 5. If so, was the initial contact date
changed? 6. Were processing standards met?
Comments:

7. Was proof of residency recorded and a copy stamped dated and filed in the record?
8. Was proof of identification for the participant recorded and a copy stamped dated and filed in the record?
9. Was proof of identification for the parent/ guardian recorded and a copy stamped dated and filed in the record?
Comments:

PROOFS

10. Was the date recorded for the income information?
11. Was Medicaid eligibility recorded? 12. Was Medicaid number recorded? 13. Was TANF documented?

INCOME MO-51

GEORGIA WIC 2012 PROCEDURES MANUAL

14. Was the TANF verification filed in the record?
15. Was SNAP documented? 16. Was the SNAP verification filed in the
record? 17. Was the number in family recorded? 18. Was income information recorded? 19. Was zero income accepted? 20. If yes to the above, was the following
question answered? How do you obtain food, shelter, clothing and medical care? 21. Was the income source recorded and a copy stamped dated and filed in the record? 22. Was a letter from employer accepted as proof of income? 23. If yes, was the letter from employer on letterhead or attached to a No Proof form? 24. Were staff initials recorded for residency, identification and income verification? 25. Was only one income reported checked? 26. If no to the above, was the Income Calculation Form used?
Comments:
CERTIFICATION VALIDATION 27. Was participant physically present? 28. If no to the above, was the exempt
reason documented in the record? 29. Was the signature/title of staff person
verifying the participant/parent/ guardian signature recorded? 30. Was the participant's signature/date recorded? 31. If proxy signed above, was proxy letter completed and filed in record? 32. Was choice to authorize disclosure of sharing participant information recorded?
Comments:
MO-52

Form 2 (Cont'd)

GEORGIA WIC 2012 PROCEDURES MANUAL


33. Was participant categorically eligible?
34. Was it documented that participant was income eligible/ineligible?

ELIGIBILITY

Comments:

Form 2 (Cont'd)

SUPPORTING DOCUMENTATION
35. Was a current Disclosure Form on file at the clinic?
36. Did the staff member issue vouchers or process certification for themselves and/or family member?
37. Was the error correction procedure used?
Comments:

Note: Make copies of this form for Record Review.

MO-53

GEORGIA WIC 2012 PROCEDURES MANUAL

CUR REPORT RECORD REVIEW

Form 3

CLINIC: __________________________________

DATE: __________________________

100 - 90% compliance = Available Possible points for each criteria.

PARTICIPANT'S NAME

% Possible Points

WIC STATUS

1. Were the demographics (Name, Address, etc.) completed?
Comments:

DEMOGRAPHICS

Points Awarded

CERTIFICATION PROCEDURES 2. Was valid certification processed and
sent to Covansys? Comments:

VOUCHER ISSUANCE
3. Were vouchers issued to a categorically ineligible participant?
4. Were vouchers issued to a participant who was terminated for thirty day issues?
Comments:

MO-54

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



NUTRITION SERVICES UNIT MONITORING TOOL



Nutrition Services: 400 points or 40% of Total Program Review Score

A) District

Points

Score

Nutrition

Available

Based on

Office

for Each

Points

Section available/Total

Nutrition points

available (400)

Secondary Nutrition Education Provided

80

20%

x Low Risk Secondary Nutrition Education

x High Risk Secondary Nutrition Education

District Created Food Packages (999 Review) Breastfeeding Promotion and Support Nutrition Education Materials Nutrition Education Plan Orientation Checklist Continuing Education
CPA (% Meeting Standard) Nutrition Assistant (% Meeting Standard)

15

3.75%

20

5%

15

3.75%

15

3.75%

5

1.25%

20

5%

170

B) (Clinic)

Chart Review Percentage for documentation

30

7.5%

Breastfeedin Assigned Breastfeeding Coordinator

g

Clinic Environment supportive of breastfeeding

Breastfeeding Referral system in place

30

C) (Clinic) -

Nutrition Education Observation (Certifications,

75

18.75%

Clinic

low and high risk secondary contacts)

Observation Anthropometric Equipment / Hematological

5

1.25%

Equipment

5

1.25%

Anthropometric Observation

5

1.25%

Hematological Observation

90

D) (Clinic) Food Formula Tracking Log

5

1.25%

Package

High Risk / Special formulas/Medical Documentation

5

1.25%

10

E) (Clinic)

Record Review Summary - 100 Points Total per

100

25%

Record

Chart.

Review

- One highlighted clinic average <90% requires

Clinic Specific Training

- Two highlighted clinics <100% requires Clinic

Specific Training

- Three or more highlighted clinics <100% District-

wide and /or District-wide average <90% requires

District-wide Training

- Highlighted black <100%

- Highlighted red requires Corrective Action

Training

100

Total Available (from each section above)

400%

MO-55

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



NUTRITION SERVICES UNIT MONITORING TOOL



NUTRITION SERVICES UNIT / GEORGIA WIC REVIEW

Date:

Notes:

District Program Review Notes:

District, Clinic, and Office of Nutrition review questions are completed for background tracking and education.

DISTRICT REVIEW QUESTIONS

AREAS OF REVIEW

S

I. FOOD PACKAGE ASSIGNMENT

A. Describe the protocol for infant food package

changes from the contract formula to a non-

contract formula.

B. How are food packages assigned?

C. What procedures are used for obtaining and tracking the use of prescription formulas/medical foods, and providing followup for participants on special formulas/medical foods?
II. NUTRITION EDUCATION A. Training
1. Describe the process for evaluating staff training needs.

U NA

COMMENTS

Food Package Section (III, IV, V, VI)

Food Package Section (III, IV, V, VI)
Food Package Section (VIII)

AD (VII)

2. How do you assess the effectiveness of the training over time?

AD (VII)

B. Competent Professional Authority (CPA)

1. Describe the process used to evaluate if CPA staff met the required 12 hours of continuing education yearly.

NE section (V), Attachment NE-6

2. Describe the process utilized when CPAs receive less than the required 12 hours of continuing education.
C. Nutrition Assistants (NAs) 1. Describe how Nutrition Assistants are utilized in your District.

NE section (V), Attachment NE-6
Not directly addressed NE (IV), NE-Attachment III

2. Has the training plan for NAs been approved by the Office of Nutrition?
If yes, the date: __________

NE (VI)

MO-56

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment MO-1 (cont'd)


NUTRITION SERVICES UNIT MONITORING TOOL



DISTRICT REVIEW QUESTIONS

AREAS OF REVIEW

S

D. Participant Nutrition Education Contacts

1. 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.

U NA

COMMENTS

NE (VI)

2. Describe the method used to document secondary nutrition education contacts.

NE (VI)

3. Describe how failed secondary nutrition education contacts are documented.

NE (VI)

4. List nutrition references used by your District. (e.g., ADA Nutrition Care Manual)
5. Describe the system used to provide secondary nutrition education contacts to participants identified as high risk.

BF (V) Gives examples for BF NE section
NE (VI)

E. Nutrition Education Materials Are adequate and appropriate nutrition education materials available? x All participant groups represented (Woman/Infant/Child) x Evaluate all District materials for meeting nutrition education guidelines. x Compare topics available related to Nutrition Risk Criteria and nutrition education documentation topics.

NE section (VIII)

III. Breastfeeding Promotion and Support

Breastfeeding Coordination
1. Describe the major responsibilities and activities of the Breastfeeding Coordinator.
2. Does the Breastfeeding Coordinator conduct activities District-wide or primarily in one location?
3. How does the Breastfeeding Coordinator document participant contacts (i.e., counseling, classes)? What is the lag time between counseling and actual documentation, if any?

BF (IV), BF Attachment 3 BF (IV) BF (IV)

MO-57

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment MO-1 (cont'd)


NUTRITION SERVICES UNIT MONITORING TOOL



DISTRICT REVIEW QUESTIONS

AREAS OF REVIEW Encouragement to Breastfeed

S U NA

COMMENTS

BF (IV, V)

1. Describe how breastfeeding is encouraged and documented during the prenatal period. x Take into consideration individual contacts, prenatal/breastfeeding classes, and other (Please specify.)

C. Breastfeeding Education and Training

1. Describe how clinic staff are kept abreast about current breastfeeding information.

BF (IV)

2. Describe the referral system for participants who request additional support/information or who require more in-depth counseling or assistance on breastfeeding.

BF (IV)

3. Describe what the local agency is doing to create a clinic atmosphere that is supportive of breastfeeding.

BF (IV)

4. Please describe any breastfeeding activities not addressed above (e.g., peer counseling, special projects, media exposure, etc.).

BF (IV)

IV. SPECIAL REQUESTS A. What public health nutrition services are available in your local agency? B. Describe any special projects, initiatives, and/or accomplishments in the areas of breastfeeding, nutrition education and training being implemented in the local agency.

Looking for District best practices.
Looking for District best practices.

C. Does your District have an agreement or partnership with services/programs that serve the WIC population? Daycare _____ Head Start _____ Extension Services _____ Other Health Services Programs / List if applicable. _________________________

Looking for District best practices.
Not required no points

MO-58

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment MO-1 (cont'd)


NUTRITION SERVICES UNIT MONITORING TOOL



DISTRICT REVIEW QUESTIONS

AREAS OF REVIEW

S U NA

COMMENTS

D. How can the Office of Nutrition staff assist

Looking for District best

in improving or enhancing Nutrition

practices.

Education and Breastfeeding Plans and providing nutrition services?

Not required no points

MO-59

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



NUTRITIONSERVICESUNITMONITORINGTOOL



CLINIC REVIEW QUESTIONS

AREAS OF REVIEW

S

I. FOOD PACKAGE ASSIGNMENT

A. How are food packages assigned to meet

participant needs?

U NA

COMMENTS

Food Package Section (III, IV, V, VI)

B. Describe the protocol for infant food package changes from the contract formula to a non-contract formula.

FP (II)

C. What procedures are used for obtaining and tracking the use of prescription formulas/medical foods, and providing follow-up for participants on special formulas/medical foods?

FP (IV & VIII)

II. NUTRITION EDUCATION A. Participant Nutrition Education Contacts
1. 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.
2. Describe the method used to document secondary nutrition education contacts.
3. Describe how failed secondary nutrition education contacts are documented.
4. List nutrition references used by your District. (e.g., ADA Nutrition Care Manual)
5. Describe the system used to provide secondary nutrition education contacts to participants identified as high risk.
B. Nutrition Education Materials 1. Describe the process for requesting and or replenishing nutrition education materials.
2. Are materials available that meet the needs of specific population groups? Describe how the materials available meet their needs.

NE (VI)
NE (VI) NE (VI) BF (V) Gives examples for BF NE section NE (VI)
NE section (VIII)
NE section (VIII)

MO-60

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



NUTRITIONSERVICESUNITMONITORINGTOOL



CLINIC REVIEW QUESTIONS

AREAS OF REVIEW

S U NA

COMMENTS

III. Breastfeeding Promotion and Support A. Encouragement to Breastfeed

BF (IV & V)

Describe how breastfeeding is encouraged and documented during the prenatal period. x Take into consideration individual contacts,
prenatal/breastfeeding classes, or other (Please specify.)

B. Breastfeeding Education and Training

1. Describe how you kept abreast about current breastfeeding information.

BF (IV)

2. Describe the referral system for participants who request additional support/information or who require more in-depth counseling or assistance on breastfeeding.

BF (IV)

3. Describe how your clinic creates a supportive breastfeeding friendly atmosphere.

BF (IV)

CLINIC REVIEW QUESTIONS

AREAS OF REVIEW

S U NA

I. FOOD PACKAGE ASSIGNMENT D. How are food packages assigned to meet participant needs?

COMMENTS

E. Describe the protocol for infant food package changes from the contract formula to a noncontract formula.

F. What procedures are used for obtaining and tracking the use of prescription formulas/medical foods, and providing followup for participants on special formulas/medical foods?

II. NUTRITION EDUCATION
A. Participant Nutrition Education Contacts 6. 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.

MO-61

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



NUTRITIONSERVICESUNITMONITORINGTOOL



CLINIC REVIEW QUESTIONS

AREAS OF REVIEW 7. Describe the method used to document
secondary nutrition education contacts.

S U NA

COMMENTS

8. Describe how failed secondary nutrition education contacts are documented.

9. List nutrition references used by your District. (e.g., ADA Nutrition Care Manual)

10. Describe the system used to provide secondary nutrition education contacts to participants identified as high risk.

MO-62

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



NUTRITIONSERVICESUNITMONITORINGTOOLCLINICREVIEW



CLINIC REVIEW QUESTIONS

AREAS OF REVIEW

S U NA

B. Nutrition Education Materials

1. Describe the process for requesting and or

replenishing nutrition education materials.

COMMENTS

2. Are materials available that meet the needs of specific population groups? Describe how the materials available meet their needs.

III. BREASTFEEDING PROMOTION AND SUPPORT
A. Encouragement to Breastfeed
1. Describe how breastfeeding is encouraged and documented during the prenatal period.
2. Take into consideration individual contacts, prenatal/breastfeeding classes, or other (Please specify.)
B. Breastfeeding Education and Training
4. Describe how you kept abreast about current breastfeeding information.
2. Describe the referral system for participants who request additional support/information or who require more in-depth counseling or assistance on breastfeeding.
3. Describe how your clinic creates a supportive breastfeeding friendly atmosphere.

MO-63

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



NUTRITIONSERVICESUNITMONITORINGTOOL



OFFICE OF NUTRITION

AREAS OF REVIEW

S U NA

COMMENTS

I. NUTRITION EDUCATION

A. Has the training plan for NAs been approved by the Nutrition Section?
If yes, the date: __________

NE (VI)

B. Have all lesson plans for training NAs been submitted to the Nutrition Section for approval?

NE (VI)

If no, please provide reviewer with lesson plans at the time of review.

C. Nutrition Education Plan

Did the Office of Nutrition receive an annual

Nutrition Education Plan by the assigned

deadline?

If yes, date: __________

If no, date received: __________

Not received:

__________

NE (VI)

MO-64

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



NUTRITION SERVICES UNIT MONITORING TOOL



Administrative Management Evaluation Nutrition Services Unit
(S = Satisfactory, SN = Satisfactory Needs Improvement, U = Unsatisfactory and N/A = Not Applicable)

DISTRICT:____________________________

DATE:____________________

REFERENCE:
A. Secondary Nutrition Education Provided:

AREAS OF REVIEW S SN

NE (VI), CT Attachment VI
x % estimated from Program Review chart review or
x District Total % from CSC data when available (Calculated from latest FFY total cumulative percentage)

Secondary Nutrition Education Overall Rating: 1. Low Risk Secondary Nutrition Education
Rate from Electronic Documentation. ____ % x 90-100% 40 Points (S) x 80-89% 35 Points (SN) x 50-79% 20 Points (U) x 0-49 % 0 Points (U)
2. High Risk Secondary Nutrition Education Rate from Electronic Documentation. ____ % x 90-100% 40 Points (S) x 80-89% 35 Points (SN) x 50-79% 20 Points (U) x 0-49 % 0 Points (U)

U NA Possible Points Points Awarded 80
40
40

Comments:

B. Breastfeeding Promotion and Support:

S SN U NA Possible Points Points Awarded

BF (IV, V)

Breastfeeding Promotion and Support Overall Rating:

20

1. Assigned District Breastfeeding

Coordinator?

x Is this a full-time position? x Is the Coordinator a Certified Lactation

10

Counselor (CLC) or International Board

Certified Lactation Consultant (IBCLC)?

2. All staff interacting with WIC participants

(CPAs, Nutrition Assistants, Peer Counselors, Clerical) receiving

5

breastfeeding continuing education?

3. Clinic environment supportive of breastfeeding?

3

4. Local agency keeps an inventory of all

breast pumps and kits? Appropriate

2

policies and procedures for issuing pumps?

MO-65

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



NUTRITION SERVICES UNIT MONITORING TOOL



Administrative Management Evaluation Nutrition Services Unit
(S = Satisfactory, SN = Satisfactory Needs Improvement, U = Unsatisfactory and N/A = Not Applicable)

DISTRICT:____________________________

DATE:____________________

REFERENCE: Comments:

AREAS OF REVIEW

C. District-Created 999 Food Package Review:

S SN U NA Possible Points Points Awarded

FP (II),

District-Created 999 Food Package Review

Attachments 23-31 Overall Rating:

15

1. District / Clinic created food packages available for review?

2

2. Food packages followed existing state and

federal guidelines? Food packages issued within existing

10

minimums and/or maximums?

3. Designated coordinator for District created

food packages and approval process.

3

(Best Practice)

Comments:

D. Nutrition Education Materials:

NE (VIII) Comments:

Nutrition Education Materials Overall Rating:
1. Are adequate and appropriate nutrition education materials available?
2. Are all participant groups represented (Women / Infant / Child)? *When applicable- some clinics serve only specific populations.
3. Evaluate all District created Nutrition Education materials for meeting nutrition education guidelines. (Full nondiscrimination statement on all district created materials. Effective May 1, 2009)
4. Adequate variety to meet participant category needs? (English, Spanish, other)
5. All District created materials were approved by the Nutrition Services Unit and DPH.

S SN

U NA Possible Points Points Awarded 15 3 3
3
3 3

MO-66

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



NUTRITION SERVICES UNIT MONITORING TOOL



Administrative Management Evaluation Nutrition Services Unit
(S = Satisfactory, SN = Satisfactory Needs Improvement, U = Unsatisfactory and N/A = Not Applicable)

DISTRICT:____________________________

DATE:____________________

REFERENCE:
E. Nutrition Education Plan:

AREAS OF REVIEW S SN

NE (VI) Comments:

Nutrition Education Plan Overall Rating:
1. Did the Nutrition Services Unit receive an annual Nutrition Education Plan by the assigned deadline?

U NA Possible Points Points Awarded
15
15

F. Orientation Checklist:

NE (V) Comments:

Orientation Checklist Overall Rating: 1. District CPA orientation includes all components of the "State Orientation Checklist"? 2. Orientation checklist completed for all staff hired after September 1, 2008?

S SN U NA Possible Points Points Awarded 5
2
3

G. Continuing Education:

S SN U NA Possible Points Points Awarded

NE (V), Attachment Continuing Education Overall Rating for CPA's

20

NE-6

or CPA's & NA's:

1. % of CPA's Meeting Minimum Standard

1. _____%

Information Needed: a. Total number of CPA's evaluated for continuing education? b. Number of CPA's that received the required 12 hours of nutrition specific continuing education? c. Number of CPA's that received less than the required 12 hours of nutrition specific continuing education? d. Calculate the District average for CPA's receiving the required Nutrition Specific Continuing Education.

x 90-100% 20 Points (S)
x 80-89% 15 Points (SN)
x 0-80% No Points (U)

Total CPA's CPA's meeting requirements = % of CPA's Meeting Minimum Standard

Districts with Nutrition Assistants: 2. % of CPA's & Nutrition Assistants (NA) Meeting
Minimum Standard
MO-67

2. _____%

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



NUTRITION SERVICES UNIT MONITORING TOOL



Administrative Management Evaluation Nutrition Services Unit
(S = Satisfactory, SN = Satisfactory Needs Improvement, U = Unsatisfactory and N/A = Not Applicable)

DISTRICT:____________________________

DATE:____________________

REFERENCE:

AREAS OF REVIEW
Information Needed: a. Total number of CPA's &NA's evaluated for continuing education? b. Number of CPA's & NA's that received the required 12 hours of nutrition specific continuing education? c. Number of CPA's & NA's that received less than the required 12 hours of nutrition specific continuing education? d. Calculate the District average for CPA's & NA's receiving the required Nutrition Specific Continuing Education.

Total CPA's & NA's CPA's & NA's meeting requirements = % of CPA's & NA's Meeting Minimum Standard

e. Were observations conducted as required for NA's? Subtract 2 points if observations were not conducted as required.
Comments: (Required - 12 hours of nutrition specific continuing education yearly.)

x 90-100% 20 Points (S)
x 80-89% 15 Points (SN) 0-80% No Points (U)
x Subtract 2 points from total points awarded if NA observations were not conducted.

MO-68

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



NUTRITION SERVICES UNIT MONITORING TOOL



Administrative Management Evaluation Nutrition Services Unit Clinic Review (S = Satisfactory, SN = Satisfactory Needs Improvement, U = Unsatisfactory and N/A = Not Applicable)

DISTRICT:____________________________

DATE:____________________

REFERENCE
H. Breastfeeding Clinic Evaluation:

AREAS OF REVIEW S SN

x NE (IV, V) x BF (IV, V)

Breastfeeding Clinic Evaluation Overall Rating: 1. Encouragement to Breastfeed x All prenatal women are encouraged to breastfeed unless contraindicated for health reasons?
x Documentation of encouragement to breastfeed includes all aspects of breastfeeding discussed with the participant?
x Trained Peer Counselors encourage and support prenatal and breastfeeding women?
x Clinic environment supportive of breastfeeding?
x Prenatal /breastfeeding classes offered?
2. Breastfeeding Referral System x Prenatal or breastfeeding woman needing additional support are referred to the designated breastfeeding person; Breastfeeding Coordinator, Nutritionist, Nurse, Peer Counselor?
x Local agency has developed a breastfeeding resource list for prenatal and breastfeeding women?
3. Breastfeeding Equipment x Local agency has written policies and procedures for issuing breast pumps?
x Local agency keeps an inventory of all breast pumps and kits?

U NA Possible Points Points Awarded 30 4
4 4 4 4
3
2
2 3

MO-69

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



NUTRITION SERVICES UNIT MONITORING TOOL



Administrative Management Evaluation

Nutrition Services Unit Clinic Review

(S = Satisfactory, SN = Satisfactory Needs Improvement, U = Unsatisfactory and N/A = Not Applicable

I. Nutrition Education Observation:
Nutrition Education Overall Rating:

S SN

U NA Possible Points
75

Points Awarded

1. Individual and Group observations are scored at 100 points for each observation.
2. An average score of all observations conducted in a clinic will determine that clinics score.
3. An average of clinic scores will determine the district nutrition observation score. (Reference Excel worksheet for calculating observations)

Comments:

x 90-100% 75 Points (S) x 80-89% 65 Points (SN) x 50-79% 55 Points (U) x 0-49 % 0 Points (U)

CLINIC OBSERVATION: INDIVIDUAL NUTRITION EDUCATION SESSION DATE: ___________________ CLINIC:_______
REVIEWER:________________________________________ Time estimated for total contact: ________ Time estimated for NE contact: _______ Service Type: Certification OR Secondary NE: (Low Risk High Risk ) Participant status (Individual): P B N I C

AREAS OF REVIEW

A. Establishing Rapport 10 Points

S SN U N Points A Available

1. Made eye contact (when culturally Appropriate).

2

2. Displayed respect for other cultures and used translator appropriately.

2

3. Used appropriate non-verbal communication.

2

4. Ensured privacy (quiet enough to talk, adequate space, closed door, unobstructed view of participant)

2

5. Expressed appreciation for participant's time.

2

B. Completing Assessment Forms 30 Points
1. Thoroughly reviewed participant's responses to the Nutrition Questionnaire.

S SN U N A

Points Available
10

2. Asked probing questions to collect missing information on the

10

Nutrition Questionnaire.

Points Awarded
Points Awarded

MO-70

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



NUTRITION SERVICES UNIT MONITORING TOOL



3. Shared findings (growth patterns, iron, eating patterns, physical

10

activity).

C. Counseling Skills/Topics Covered 30 Points

S SN U N Points

Points

A Available Awarded

1. Asked open- ended questions to gain information and determine

5

participant's concerns.

2. Praised participant for positive accomplishments.

5

3. Client was allowed to lead the discussion when applicable.

5

4. Utilized reflective listening skills to clarify what was heard.

5

5. If nothing was offered by the participant, attempted to lead

5

discussion based on nutrition risks while maintaining rapport.

6. Mandatory exit topics covered. Appropriate referrals made (TANF,

5

Food Stamps, Medicaid, Housing Authority, Food Bank, etc)

D. Goal Setting 30 Points

S SN U N Points

Points

A Available Awarded

1. Summarized the discussion

10

2. Worked with participant to create achievable goal(s) using client's

10

ideas and language.

3. Documented goal(s) on Nutrition Questionnaire or progress notes

10

(electronic or paper)

Total Score:

100

COMMENTS:

CLINIC OBSERVATION: GROUP NUTRITION EDUCATION SESSION DATE: ___________________ CLINIC:_______ REVIEWER:_____________________________ Time estimated for total contact: _____________ Time estimated for NE contact: _____________

Participant status (Group Check all that apply): P B N I C

A. Group Nutrition Education Sessions 100 Points

S SN U N Points

Points

A Available Awarded

1. Had outline of topic related questions/used topic suggested by

10

participants.

2. Made introduction of self and topic of discussion.

10

3. Invited questions and encouraged participation.

10

4. Explained discussion ground rules.

10

5. Guided the group discussion (used open end-ended questions).

10

6. Gave accurate information and appropriate materials.

10

7. Displayed respect for other cultures and used translator

10

appropriately.

8. Used summary and closing.

10

9. Is there an evaluation of learning included in the class? (Best

10

Practice)

10. Documented group education in the electronic medical record.

10

Total Score:

100

MO-71

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



NUTRITION SERVICES UNIT MONITORING TOOL



COMMENTS:

J. Anthropometric & Hematological Equipment:

S SN U NA Possible Points Points Awarded

Looking for: Anthropometric:

Anthropometric & Hematological Equipment Overall Rating:

5

x Mounting error Scoring is based on district summary:

inch or larger for x All equipment in good working order

length or height

5 Points (S)

boards.

x One (1) to two (2) pieces of equipment with

x Scales not

issues

calibrated within

4 Points (SN)

last year.

x Three (3) to four (4) pieces of equipment with

Hematological:
Old Style Hemocue x Control log appropriately

issues 3 Points (U) x Five (5) or more pieces of equipment with issues 0 Points (U)

documented when

equipment is in use

x Equipment checked for

accuracy using

manufacturer's

guidelines

x Equipment

checked by

appropriate staff

New Style

Hemocue

x Equipment in good

working order

ANTHROPOMETRIC & HEMOTOLOGICAL EQUIPMENT:

(S = Satisfactory, SN = Satisfactory Needs Improvement, U = Unsatisfactory and N/A = Not Applicable)

Clinic

Date Reviewer

Length Board:

ABCABCABCABCAB

C

x Movable foot piece that slides easily
x Foot piece at 90 degree angle
x Fixed headboard

Height Board:

ABCABCABCABCAB

C

MO-72

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



NUTRITION SERVICES UNIT MONITORING TOOL



x Fixed measuring device (fixed to vertical flat surface/no skirting)
x Right angle head board

x Accuracy of placement (for boards mounted to wall)

Standing Scales: A B C A B C A B C A B C A B

C

Calibrated in last 12 months (use scale test report or sticker)

Beam (B) or Digital (D)

Infant Scale:

ABCABCABCABCAB

C

Calibrated in last 12 months (use scale test report or sticker)

Beam (B) or Digital (D)

Hematological Equipment: Document Brand

Number of units Rating-See above
S / SN / U / NA

Comments:

K. Anthropometric Observation:

Recommendation: x When possible
complete five (5) observations per clinic. x At minimum complete 5 observations per District.

Anthropometric Observation Overall Rating:
Scoring is based on district summary: x All observations conducted according to
standards 5 Points (S) x One (1) to two (2) observations with noted deficiencies 4 Points (SN) x Three (3) to four (4) observations with noted deficiencies 3 Points (U) x Five (5) or more observations with noted
MO-73

S SN U NA Possible Points Points Awarded
5

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



NUTRITION SERVICES UNIT MONITORING TOOL



deficiencies

0 Points (U)

ANTHROPOMETRIC OBSERVATION: Woman / Child (S = Satisfactory, SN = Satisfactory Needs Improvement, U = Unsatisfactory and N/A = Not Applicable)

WOMEN

CHILD

Clinic: Date: Reviewer:
Standing Height: Circle Status or Enter Age P B N P B N P B N Age: Age: Age:
x Participant measured without shoes x Proper stance used for reading
measurement x Headboard is level, touches top of head x Measurement taken and recorded
accurately (to at least nearest 1/8 inch) x Two (2) measurements taken Standing Weight:
x Participant dressed in minimal clothing x Scale zeroed, prior to measurement x Correct angle used for reading
measurement x Measurement taken and recorded
accurately (to at least the nearest pound) x Two (2) measurements taken COMMENTS:
ANTHROPOMETRIC OBSERVATION: Infant (S = Satisfactory, SN = Satisfactory Needs Improvement, U = Unsatisfactory and N/A = Not Applicable)

INFANT

Clinic: Date: Reviewer: Recumbent Length: Enter Age

Age: Age: Age: Age: Age: Age:

MO-74

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



NUTRITION SERVICES UNIT MONITORING TOOL



x Participant measured with minimal clothing x Body straight, lined up with measuring
board

x Head is against headboard throughout measurement

x Footboard resting firmly against heels

x Proper stance used for reading measurement

x Measurement taken and recorded accurately (to at least nearest 1/8 inch)
x Two (2) measurements taken

Infant Scale Weight:

x Participant dressed in minimal clothing (without wet diaper)
x Scale zeroed, prior to measurement x Correct angle used for reading
measurement x Measurement taken and recorded
accurately (to at least the nearest ounce) x Two (2) measurements taken
COMMENTS:

L. Hemoglobin Determination / Universal Precautions:

Recommendation: x When possible
complete five (5) observations per clinic. x At minimum complete 5 observations per District.
Looking For: x Staff observed
using universal precautions? x Followed correct procedures for collecting hematological data? x Hemoglobin was

Hemoglobin Determination / Universal Precautions Overall Rating: Scoring is based on district summary: x All observations conducted according to
standards 5 Points (S) x One (1) to two (2) observations with noted deficiencies 4 Points (SN) x Three (3) to four (4) observations with noted deficiencies 3 Points (U) x Five (5) or more observations with noted deficiencies 0 Points (U)
MO-75

S SN U NA Possible Points Points Awarded
5

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



NUTRITION SERVICES UNIT MONITORING TOOL



collected when

required?

Hemoglobin Determination / Universal Precautions:

(S = Satisfactory, SN = Satisfactory Needs Improvement, U = Unsatisfactory and N/A = Not Applicable)

Clinic

Date

District Average:

Reviewer

Rating: (S / SN / U / NA)

Clinic Points Awarded:

COMMENTS:

M. Formula Tracking Log:

Looking For: x Does the formula
inventory match current stock on hand? x Was the inventory log book completed according to guidelines? x Was inventory verified at least quarterly? x Was there a procedure in place for issuing formula from stock intended to limit excess stock? x No expired formula in inventory? x Is formula

Formula Tracking Log Overall Rating: Clinic scoring by the following criteria: x Formula Tracking logged according to
standards 5 Points (S) x One (1) to two (2) criteria with noted deficiencies 4 Points (SN) x Three (3) to four (4) criteria with noted deficiencies 3 Points (U) x Five (5) or more criteria with noted deficiencies 0 Points (U)
District points are assigned by averaging clinic scores according to the following. x 4.5 5 average - 5 Points (S) x 4.0 4.4 average - 4 points (SN) x 3.0 3.9 average - 3 points (U) x < 3.0 - 0 points (U)
Recommendations for improving Formula Tracking Log. (Note findings under comments for each clinic)
MO-76

S SN

U NA Possible Points
5

Points Awarded

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



NUTRITION SERVICES UNIT MONITORING TOOL



issued/exchanged

based on

reconstituted fluid

ounces?

Formula Tracking Log:

(S = Satisfactory, SN = Satisfactory Needs Improvement, U = Unsatisfactory and N/A = Not Applicable)

Clinic:

Date:

District Average:

Reviewer:

Rating: (S / SN / U / NA)

Clinic Points Awarded:

Comments:

N. High Risk Chart Evaluation / Special Formulas / Medical
Documentation:

Looking For: x Was nutrition
education completed as required? x Was a care plan documented for clients identified as high risk? x Was medical documentation, if required, accepted correctly? (Current form with all required information correctly completed) x Were appropriate referrals completed? (Children 1st, etc)

High Risk Chart Evaluation / Special Formulas / Medical Documentation Overall Rating:
1. Charts randomly selected from total available R**, X**, 097, 098, 099, 199, 999 food packages. (999 Special Formulas / Emory Genetics / State Ordered 199)
2. Review a minimum of five (5) charts for each clinic reviewed if available.
x Total points awarded per chart equals 5. x All charts in a clinic are averaged to provide
a clinic category percent as well as a clinic weighted average. x District weighted average is calculated from all clinics reviewed. x Points are awarded based on the overall District weighted score. x District Score equals District weighted average. (Ex. Weighted average = 4 / Points awarded = 4)

S SN

U NA Possible Points
5

Points Awarded

MO-77

Total Weight Category Percent Weighted Score

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



NUTRITION SERVICES UNIT MONITORING TOOL



Clinic Record Review: High Risk Chart Evaluation / Special Formulas / Medical Documentation

DISTRICT: CLINIC:

DATE:
NUMBER RECORDS REVIEWED:

1 2 3 4 5 6 7 8 9 10

Participant Category (P/N/B/I/C)

1. Nutrition Education/High Risk Completed

1

2. Care Plan

1

3. Medical Documentation Form Complete

0.5

4. Diagnosis matches

Indicated Use for

1

Formula

5. Issuance Matches

Medical Documentation

1

Formula/Food

6. Appropriate Referrals

0.5

Total Points

5.0

Clinic Total % Awarded

District Record Review Summary: High Risk Chart Evaluation / Special Formulas / Medical Documentation

DISTRICT:

Clini Clini Clini Clini Clini Clini c# c# c# c# c# c#

DATE:

Total Weight Category Percent Weighted Score

NUMBER RECORDS REVIEWED:

Participant Category (P/N/B/I/C)

1. Nutrition Education/High Risk Completed

1

2. Care Plan

1

3. Medical Documentation Form Complete

0.5

4. Diagnosis matches Indicated Use for Formula

1

5. Issuance Matches

Medical Documentation

1

Formula/Food

MO-78

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment MO-1 (cont'd)


NUTRITION SERVICES UNIT MONITORING TOOL


6. Appropriate Referrals

0.5

Total Points

Clinic Total % Awarded



O. Record Review Summary:

S SN U NA PossiblePoints Awarded Points

Record Review Summary Overall Rating:

100

1. Total points awarded per chart equals 100.
2. All charts in a clinic are averaged to provide a clinic category percent as well as a clinic weighted average.
3. District weighted average is calculated from all clinics reviewed.
4. Points are awarded based on the

overall District weighted score. District Score equals District weighted average. (Ex. Weighted average = 96 / Points awarded = 96)

Clinic Record Review Summary

Total Weight Category Percent Weighted Score

DISTRICT: CLINIC: DATE: NUMBER RECORDS REVIEWED:

1 2 3 4 5 6 7 8 9 10

Participant Category (P/N/B/I/C)

1. Medical Data Date

1

2. Length/Ht Recorded

1

3. Weight Recorded

1

4. Hct/Hgb Recorded

1

5. Age Recorded

1

6. All Nutritional Risks Checked

10

7. All Nutritional Risks Documented

10

8. Priority Correct

2

9. High Risk Identified Correctly

3

10. Food Package Assigned

2

MO-79

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment MO-1 (cont'd)


NUTRITION SERVICES UNIT MONITORING TOOL


11. Ref/Enrollment Documented

3

12. Today's Date

1

13. Professional's

Signature/Title

1

(Certification Form &

Nutrition Questionnaire)

14. Breastfeeding Weeks Recorded

1

15. Breastfeeding Encouraged

3

16. Inappropriate Nutrition

Practices (Evaluation /

5

Documentation)

17. Primary NE Contact

5

18. Plan / Goal(s) Documented

10

19. Secondary NE Contact

S = Satisfactory (Includes

Only Kept

Appointments)

15

U = Unsatisfactory (Includes Missed, Failed & Refused)

20. HR Follow-up Documented

S = Satisfactory (Care Plan

/ SOAP Note Required)

15

U = Unsatisfactory (Includes Missed, Failed & Refused)

21. Exit Counseling

Documented

5

(Women / Infant /

Child)

22. Plotting (Infant/Child/Women)

4

Total Points

100

Clinic Total % Awarded

District Record Review Summary

MO-80

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment MO-1 (cont'd)


NUTRITION SERVICES UNIT MONITORING TOOL



DISTRICT:

Clinic Clinic Clinic Clinic Clinic Clinic

#

#

#

#

#

#

DATE:

Total Weight Category Percent Weighted Score

NUMBER RECORDS REVIEWED:

Participant Category (P/N/B/I/C)

1. Medical Data Date

1

2. Length/Ht Recorded

1

3. Weight Recorded

1

4. Hct/Hgb Recorded

1

5. Age Recorded

1

6. All Nutritional Risks

1

Checked

0

7. All Nutritional Risks

1

Documented

0

8. Priority Correct

2

9. High Risk Identified Correctly

3

10. Food Package Assigned

2

11. Ref/Enrollment Documented

3

12. Today's Date

1

13. Professional's

Signature/Title

1

(Certification Form &

Nutrition Questionnaire)

14. Breastfeeding Weeks Recorded

1

15. Breastfeeding Encouraged

3

16. Inappropriate Nutrition

Practices (Evaluation /

5

Documentation)

17. Primary NE Contact

5

18. Plan / Goal(s)

1

Documented

0

19. Secondary NE Contact

S = Satisfactory (Includes

1

Only Kept

5

Appointments)

MO-81

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment MO-1 (cont'd)


NUTRITION SERVICES UNIT MONITORING TOOL


U = Unsatisfactory (Includes Missed, Failed & Refused)

20. HR Follow-up Documented

S = Satisfactory (Care Plan / SOAP Note Required)

1 5

U = Unsatisfactory

(Includes Missed, Failed

& Refused)

21. Exit Counseling

Documented

5

(Women / Infant /

Child)

22. Plotting (Infant/Child/Women)

4

1

Total Points

0

0

Clinic Total % Awarded

MO-82

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



NUTRITION SERVICES UNIT MONITORING TOOL



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 as described below under Record Review Evaluation. The satisfactory percentage is calculated for each individual area.

Record Review Evaluation
x One clinic average <90% requires Clinic Specific Training x Two clinics <100% requires Clinic Specific Training x Three or more clinics <100% requires District-wide Training and/or District-wide average <90%
requires District-wide Training

Participant Category:

CT (XI)

Document the participant category for each record reviewed.

1. Medical Data Date : CT-(IX) 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.
2. Length/Height Recorded: CT (IX, X) Length or Height must be entered to the nearest 1/8 of an inch.
3. Weight Recorded: CT (IX, X) Weight must be entered in pounds and ounces.
4. Hematocrit/Hemoglobin Recorded: CT (IX, X) 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.
5. Age Recorded: CT (Attachment VI, Appendix I) 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.
6. All Nutritional Risks Checked: CT (Attachment VI) All applicable nutritional risks must be evaluated during each certification appointment and at the infant's mid-certification nutrition assessment. All evident nutritional risks must be checked YES on the WIC Assessment/Certification Form. If a nutritional risk is not present, the risk category must be checked NO on the WIC Assessment/Certification Form (except for systems in which only risks present are printed). If a nutritional risk is not assessed/not applicable, a NA must be written/entered by the appropriate risk category on the WIC Assessment/Certification Form (except for systems in which only risks present are printed). If documentation for a nutritional risk is found in the health record, the risk must be checked on the WIC Assessment/Certification Form.
7. All Nutritional Risks Documented: CT (Attachment CT-6) MO-83

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



NUTRITION SERVICES UNIT MONITORING TOOL



All nutritional risk criteria checked on the WIC Assessment/Certification Form must be

supported by the appropriate documentation.

8. Priority Correct: CT XI (Attachment CT-6)

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.

9. High Risk Identified Correctly: A WIC participant who has any nutritional risk factors designated as

high risk must have the "High Risk" box marked "Yes" unless the CPA documents the

reason(s) why in his or her professional judgment that this client should not be categorized as

high risk (e.g., long history of short stature, following established growth curve, parents of

short stature [list heights], etc). Likewise, a WIC participant who does not have any nutrition

risk factors designated as high risk must have the "High Risk" box marked "No" unless the

CPA documents the reason(s) why in his or her professional judgment that this client requires

high risk follow-up.

10. Food Package Assigned: FP (III-VI)

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.

11. Referrals/Enrollment Documented: NE (VII), BF (VI)

All applicants to the WIC Program must be screened for referral to or enrollment in the Food

Stamp Program, Medicaid and 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.

12. Today's Date: CT (XII)

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.

13. Professional Signature and Title (Certification Form & Nutrition Questionnaire): CT (XI, XV, and CT Attachments 1-4) The signature and title of the assessing professional must be entered accurately on the certification form and the nutrition assessment questionnaire. An appropriate signature consists of first initial and last name or first and last names.
14. Breastfeeding Weeks Recorded: CT (XV) The questions Ever Breastfed, Currently Breastfeeding, and Weeks Breastfed must be completed as follows:

a. Breastfeeding women: initial and six-month certification visit (the weeks breastfed at six months after the initial certification must be more than the weeks breastfed at certification).
b. Postpartum, non-breastfeeding women: certification visit. c. Infants: initial certification and mid-certification assessment visits (the weeks breastfed at
mid-certification must be the same or more than the weeks breastfed at certification). d. Children: one year of age certification (11-16 months of age). 15. Breastfeeding Encouraged: NE (IV, V) 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.

MO-84

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



NUTRITION SERVICES UNIT MONITORING TOOL



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 ADA Nutrition Care Manual or other state approved nutrition reference resources.

16. Inappropriate Nutrition Practices (Evaluation / Documentation) Evaluation of Inappropriate Nutrition Practices: CT (Attachment VI, Appendix G) If inappropriate nutrition practices are present, they must be correctly identified on the Nutrition Assessment Questionnaire or medical record. If no inappropriate nutrition practices and no other risk factors are identified, nutrition risk 401 (Other Dietary Risk/Failure to Meet Dietary Guidelines) must be assigned. Documentation of Inappropriate Nutrition Practices: CT (Attachment VI, Appendix G) All inappropriate nutrition practices must be correctly documented (e.g., describe the precise behavior that qualifies a participant as having the identified general Inappropriate Nutrition Practice category) on the Nutrition Assessment Questionnaire or medical record.

17. Primary Nutrition Education Contact, Current Certification: CT (VI) Individual nutrition education contacts must be documented in the participant's electronic health record (i.e., the front-end computer system used by the District).

Documentation of group classes may consist of a participant's signature on a class attendance sheet, voucher register or class roster which contains the lesson objective(s) and the original signature of the staff person conducting the class. The method used must have the approval of the Office of Nutrition.
The education must be appropriate to the individual participants' individual or group needs.
The primary nutrition education contact must be provided by a competent professional authority (CPA), not by a paraprofessional/Nutrition Assistant. Specific aspects of nutrition counseling must be documented (not "Nutrition education provided").
Missed appointments or refusal of nutrition education must be documented in the health record.
The nutrition education must follow the ADA Nutrition Care Manual or other state approved nutrition reference resources.
18. Plan/Goal(s) Documented [Nutrition Education Section, VI. B and Attachment NE-4] All primary and high risk nutrition education contacts must conclude with documentation of an individualized care plan. This care plan must include a measurable participant centered goal, which encourages at least one change in current health and/or social behaviors.

19. Secondary Nutrition Education Contact, Current or Prior Certification: NE (III) 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.
MO-85

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



NUTRITION SERVICES UNIT MONITORING TOOL



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 and group nutrition education contacts must be documented in the participant's electronic health record (i.e., the front-end computer system used by the District).

Documentation of secondary nutrition education contacts must be completed in the participant's electronic record and include the date, topic(s), the title of the person providing the nutrition education, and method by which the nutrition education contact was provided (e.g., class, kiosk, individual counseling, etc.). Electronic documentation of all nutrition education contacts is required.

The education should be appropriate to the individual participant's health needs, but must be client-led when determining discussion topics and setting goals.
Parents and/or caregivers of WIC infants and children must also be provided with information about abuse of drugs and other harmful substances during the nutrition education contact.

Nutrition education must be provided by a competent professional authority (CPA). Paraprofessional staff (i.e., Nutrition Assistants) can provide these low-risk 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. Failed, missed, and refused secondary nutrition education appointments do not count as providing secondary nutrition education. The expectation is that 100% of clients will receive secondary nutrition education.
Specific aspects of nutrition counseling must be documented (not "Nutrition education provided").
The nutrition education must follow the ADA Nutrition Care Manual or other state approved nutrition reference resources.

20. High Risk Follow-Up Documented: CT (Attachment VI, NE (VI) A WIC participant who has any of the high risk factors identified in the Procedures Manual must receive an individual care plan that includes goal setting.
Documentation should indicate nutrition counseling specific to their nutritional condition and problems identified in their diet, but must be client led when setting goals.
Documentation of high risk secondary nutrition education contacts must be completed in the participant's electronic record and include the date, topic(s), care plan, the title of the person providing the nutrition education, and method by which the nutrition education contact was provided (e.g., individual counseling, etc.). Electronic documentation of all nutrition education contacts is required.
Failed, missed, and refused secondary high risk appointments do not count as providing secondary high risk nutrition education. The expectation is that 100% of clients will receive secondary nutrition education.
MO-86

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



NUTRITION SERVICES UNIT MONITORING TOOL



The nutrition education must follow the ADA Nutrition Care Manual or other state approved

nutrition reference resources.

21. Exit Counseling Documented: NE (VI) From the prenatal through the postpartum (breastfeeding or non-breastfeeding) period, a woman participant must receive education at least one time on each of 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

Parents and/or caregivers of WIC infants and children must also receive education at least one time on each of on the following topics during an infant/child's enrollment on the WIC program: a. Health risks of using alcohol, tobacco and other drugs b. Importance of up-to-date immunizations.

22. Plotting (Infant / Child / Women) Length/Height Plotted: CT (Attachment VI, Appendix L, M) The length/height for age must be plotted accurately by plotting as closely as possible to the exact age. Length/height values must be plotted as accurately as possible. Weight Plotted CT (Attachment VI, Appendix L, M) Weight for age must be plotted accurately, by 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. Weight for Length/Height Plotted CT (Attachment VI, Appendix L, M) Weight for length/height must be plotted as accurately as possible.

MO-87

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



SYSTEMS INFORMATION UNIT MONITORING TOOL



ADMINISTRATIVE MANAGEMENT EVALUATION

(S=Satisfactory, SN=Satisfactory needs improvement, U=Unsatisfactory, and NA=Not

Applicable)

DISTRICT________________________

DATE_____________________

REFERENCE

AREAS OF REVIEW

S SN U NA Possible Points

Points Awarded

A. ACCOUNTABILITY

Inventory

1. Does the number of computers,

2

printers and monitors in the clinic

match the number on the inventory?

2. Are proper inventory records

1

maintained?

3. Has a physical inventory been

1

conducted within the last year?

4. Has USDA and / or Georgia WIC

1

approval been obtained for equipment

purchase as required?

5. Are proper procedures followed to

1

dispose of obsolete or damaged

equipment?

6. Are proper procedures followed when

1

equipment is discovered to be lost, or

stolen?

7. Have any pieces of equipment been

1

reported lost or stolen within the past

12 months?

8. In cases of stolen equipment, has a

1

police report been filed?

9. Have Flash cards been removed from

1

surplus or unused MICR printers?

(Return surplus Flash cards to state

office. If printer will be used again

store card in a secure location until

needed).

Decals / Tags

5

1. Are inventory decals / tags in place?

Comments:

MO-88

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



SYSTEMS INFORMATION UNIT MONITORING TOOL



CLINIC EVALUATION

(S=Satisfactory, SN=Satisfactory needs improvement, U=Unsatisfactory, and NA=Not

Applicable)

CLINIC________________________

REFERENCE

AREAS OF REVIEW

DATE_____________________ S SN U NA POSSIBLE POINTS

POINTS AWARDED

A. PAPER FORMS

TADs

5

1. Does the clinic have an adequate supply of Prenumbered and blank TADs?

2. Are TADs kept in a secure

5

area?

VPOD Stock

10

1. Does the clinic have an adequate supply of blank VPOD stock to operate for a minimum of 15 days?

2. Is the VPOD stock kept in a

5

secure area?

Standard Manual Package

5

1. Does the clinic have an adequate supply of the Standard Manual Packages?

2. Are the Standard Manual

5

Packages kept in a secure

area?

Blank Manual (999)

5

1. Does the clinic have an adequate supply of Blank Manuals (999).

2. Are the Blank Manuals (999)

5

kept in a secure area?

Comments:

B. CLIENT REGISTRY

1. Does the process of searching

5

for a client operate as it

should?

Comments:

MO-89

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



SYSTEMS INFORMATION UNIT MONITORING TOOL



C. ACCESSIBILITY TO DATA

1. Has staff encountered

5

difficulties in accessing client

data necessary to perform their

job?

Comments:

D. CLINIC STAFF QUESTIONS

1. Is there an established and

5

effective means for staff to

address questions pertaining to

their job duties and

responsibilities?

Comments:

E. PHYSICAL SECURITY

1. Are PC's away from client

5

traffic?

2. Are printers away from client

5

traffic?

3. Are computers connected to a

5

UPS / surge protector?

Comments:

F. SYSTEM FUNCTIONALITY EVOC

1. How many staff are authorized

N/A

to print EVOC Cards?

_________________

2. Does review of EVOC log

5

indicate any irregularities?

ETAD

1. Have all work orders / ETAD

N/A

changes been implemented?

2. Are they functioning properly?

N/A

Race / Ethnicity

1. Is a drop down box in place?

N/A

System Clinic Listing

1. Is the Systems Clinic Listing

5

complete and accurate?

Income Guidelines

1. Does the system have the up-

5

MO-90

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



SYSTEMS INFORMATION UNIT MONITORING TOOL



to date income guidelines?

Food Package Table

1. Is the FPC / VC table complete

N/A

and accurate?

GWIS

1. Is GWISnet access available to

5

staff?

2. Are clinic staff able to use

5

GWISnet effectively?

Internet Access

N/A

1. Is internet access available in the clinic?

Batches (Voucher Serial

Numbers)

5

1. Does the system contain old

voucher batches that should

have been used or VOIDED?

2. Have staff used more recent

10

voucher number batches when

older batches or partial batches

exist?

Comments:

G. SYSTEMATIC Password Confidentiality

1. Are User Passwords kept

10

confidential?

User Lists

1. Are former employees removed

5

from the clinic system(s)

immediately upon their

departure?

2. Does a review of the system

5

show users who are still active

but are no longer employed by

the clinic and/or health

department?

System Back-Up

1. Is the system backed-up on a

5

daily basis? (paper back-up)

MO-91

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



SYSTEMS INFORMATION UNIT MONITORING TOOL



2. Is a copy of the back-up kept in

5

a secure, off-site location?

Comments:

MO-92

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



SYSTEMS INFORMATION UNIT MONITORING TOOL



Georgia WIC

Systems Information Unit

Monitoring Tool

A. Preliminary Information Pre-Visit: (See Page 10 for list of items)

Date of Review: ____/____/____

D/U: _______________

Clinic: ________________

Clinic Information:

Participation (Most recent Issue Month):

Pre-natal:

____________

Non-Breastfeeding: ____________

Breastfeeding:

____________

Total Women:

____________

Infants:

____________

Children:

____________

TOTAL:

____________

Number of Critical Errors over previous 4 months:

_____________

Number of Critical Errors not reviewed, previous 4 months:

_____________

Critical Error Rate (Current month):

_____________

Top 5 critical errors (field):

_____________________________________

(Current Month)

_____________________________________

_____________________________________

_____________________________________

_____________________________________

MO-93

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



SYSTEMS INFORMATION UNIT MONITORING TOOL



A. Preliminary Information Pre-Visit:

Top 5 critical errors (transaction): (Current Month)
Number Un-Reviewed: Batch Rejections Previous 4 months: Number Un-reviewed: Unreconciled Original: Unreconciled Final: Unmatched Redemptions:

_____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________ _____________ _____________% (Current Close-Out Month) _____________% (Current Close-Out Month) _____________# (Current Issue Month)

MO-94

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



SYSTEMS INFORMATION UNIT MONITORING TOOL



B: Background:

System:

____________

Version (if known):

____________

Web-based:

Y

N

Single Server:

Y

N

The following items are to be completed by a walk through the clinic with the clinic supervisor:

Number of WIC/WIC Related Work Stations:

WIC Only

____________

WIC Related:

____________

Number of WIC/WIC Related Users: WIC Only WIC Related:

____________ ____________

Types/Number of Equipment: Computers: Monitors: CRT: Flat Screen: Dumb Terminals: VPOD Printers: Laser Printers: Dot Matrix Printers:

____________
____________ ____________ ____________ ____________ ____________ ____________

MO-95

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



SYSTEMS INFORMATION UNIT MONITORING TOOL



B: Background (cont'd):

Does Clinic provide FMNP? Number of Personnel Authorized to Issue FMNP Coupons: FMNP Caseload:
Does Clinic Have Internet Access? Do Clinic Staff have access to GWISnet? Authorized Users:

Y

N

____________

____________

Y

N

Y

N

_____________________________________ _____________________________________ _____________________________________ _____________________________________

MO-96

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



SYSTEMS INFORMATION UNIT MONITORING TOOL



Reports

For

Background Information

1. Participation: Report EWRR990G-045: Ethnic Participation By Priority Clinic. Located in GWIS or GWISnet under Caseload Management.

2. Critical Errors: Report CPRECCES-012: Critical Error Summary Located in GWIS or GWISnet under Operations.

3. Unreconciled Original/Final: Report EWER900G-051: System Maintenance Indicators. Located in GWIS or GWISnet under Operations.

4. Unmatched Redemptions: Report EWRR300G-030: Unmatched Redemptions. Located in GWIS or GWISnet under Food.

5. To review Critical Errors, Batch Rejections, and Batch Acceptance reports: Look under CLINIC FEEDBACK section of GWISnet. For each category select the date ranges and the clinic number, click on SEARCH. Look for items that have not been reviewed.

6. The Edits Manual is located at: K:\SystemWIC\Edits_2008. Locate the page required in the table of contents, put the cursor over the items and press CTRL+Click. The program will take you to that page.

7. Download the following databases onto laptops:
FPC/VC database. Inventory database

8. Generate Computer Issues report for the clinic(s) under review.

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GEORGIA WIC 2012 PROCEDURES MANUAL


Attachment MO-2

STATE OF GEORGIA
DEPARTMENT OF PUBLIC HEALTH GEORGIA WIC
LOCAL AGENCY FFY 2011
MONITORING TOOL FINANCIAL REVIEW SECTION

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GEORGIA WIC 2012 PROCEDURES MANUAL


I.

FINANCIAL REVIEWS

Attachment MO-2 (cont'd)

A. Introduction

The Department of Public Health (DPH), Office of Audits, will conduct on-site Financial Reviews every two (2) years at each of the eighteen Public Health Districts and two contract agencies for the purpose of reviewing local WIC Financial Management. The purposes of the Financial Review are to determine the appropriateness of the WIC Grant expenditures, to reconcile the District and/or local agency (county) WIC allocations and to examine the intra/inter contracts of WIC funds to the counties within the District. The Districts that were not selected for review will have a follow-up visit to ensure that corrections stated in their Corrective Action Plans (CAP) were implemented.

B. District Selection
1. District Site
Every two (2) years, fifty percent (50%) of the Districts are selected by Office of Audits with concurrence from Georgia WIC for financial review.
a. The lead county in each District will always be reviewed during each financial site visit. In addition to the lead county three (3) counties within the District will also be reviewed. These counties will be reviewed to ensure that the intra/inter WIC contract requirements are being met, financial accountability of WIC funds is maintained and that all capital equipment is managed in accordance with DHR requirements for equipment accountability.
b. Counties that have not been reviewed for at least four years may be selected in place of randomly selected counties to ensure regular reviews of all counties within the district.

C. Pre-Review Activities

Prior to the on-site visit, the Office of Audits' staff will review district reports and files in Georgia WIC. The Public Health District Administration will be contacted regarding materials that must be available for the on-site review.

D. Financial Review Schedule
A schedule of on-site financial reviews will be developed and coordinated by the DPH, Office of Audits and the WIC Program prior to the beginning of each Federal Fiscal Year (FFY). A statewide schedule containing the dates of each financial review will be sent to all Public Health Districts.



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Attachment MO-2 (cont'd)

II. FINANCIAL TIMEFRAMES

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

ACTIVITY

TIMEFRAME

Notification of intent to conduct a review. Financial Review and mutually agreed review 20 days prior to the scheduled date date.

Financial Review

As Needed

Auditors will submit the Final Review Report to Georgia WIC

Within 10 days of Exit Conference

Georgia WIC submits to the local agency a copy of the Financial Review. Georgia WIC Financial Review Conference calls with the agency that was reviewed.
The local agency submits Corrective Action Plan to Georgia WIC
Georgia WIC submits to DPH's Office of Audits Correction Action plan with recommendation.
DPH's Office of Audits disposes of review findings. If findings are monetary, execute letter-withholding funds from agency. Close Financial Review

Within 20 days of Exit Conference Within 30 days of Exit Conference Within 40 days of Exit Conference Within 60 days of Exit Conference

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III. LOCAL AGENCY COLLECTIONS

Attachment MO-2 (cont'd)

Local agency collections are funds recovered through the collection of local agency claims. Under 7 CFR 246.19(b), the State agency is responsible for monitoring local agency operations, including financial management systems. If any food or NSA funds provided to a local agency was misused, diverted from program purposes, or lost as a result of thefts, embezzlements, or unexplained causes, the State agency should assess a claim against the local agency, as well as require the local agency to submit a corrective action plan.

IV. FINANCIAL SELF REVIEWS
The District is responsible for conducting annual Self-Reviews by June 30 of each year using the Financial section of the monitoring tool. The review must be kept on file at the local agency and a copy forwarded to Georgia WIC by September 30th annually.

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GEORGIA WIC FINANCIAL REVIEW FORM

Attachment MO-2 (cont'd)

AREAS OF REVIEW

YES NO

NA

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 WIC?

4. Are revenues for the WIC 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).

COMMENTS

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AREAS OF REVIEW

YES

C. OPERATIONAL COST

1. Does WIC 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 DPH 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 Office, 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?

MO-103

Attachment MO-2 (cont'd)

NO

NA

COMMENTS

GEORGIA WIC 2012 PROCEDURES MANUAL


AREAS OF REVIEW
2. 301 - Cost Pool Budget
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 Georgia WIC 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 Corrective Action plan required and developed?


YES

Attachment MO-2 (cont'd)

NO

NA

COMMENTS

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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-4

C. Training .......................................................................................................... BF-5

D. Breastfeeding Promotion, Education and Support Plan ................................. BF-6

V. Participant Education ................................................................................................. BF-7

A. Participant Education Requirements .............................................................. BF-7

B. Documentation of Breastfeeding Services ..................................................... BF-9

VI. Participant Referral .................................................................................................. BF-10

A. Referrals ....................................................................................................... BF-10

B. Documentation ............................................................................................. BF-10

VII. Breastfeeding Materials and Resources .................................................................. BF-10

A. Printed and Audio-Visual Materials ............................................................. BF-10

B. Breastfeeding Equipment and Supplies ....................................................... BF-11

GEORGIA WIC 2012 PROCEDURES MANUAL


Breastfeeding

Page VIII. Allowable Costs for the Promotion and Support of Breastfeeding ............................ BF-13

A. Allowable Breastfeeding Promotion and Support Costs................................ BF-13

B. Documentation of Costs ................................................................................ BF-14

IX. Documentation of Breastfeeding Rates .................................................................... BF-14

A. Documentation of WIC Type ......................................................................... BF-14

B. Documentation of Weeks Breastfed .............................................................. BF-15

Attachments BF-1 Position Paper on Breastfeeding............................................................................... BF-17 BF-2 Sample Job Description: Senior Public Health Educator
Lactation Consultant ................................................................................................. BF-18 BF-3 Sample Job Description: District Breastfeeding Coordinator .................................... BF-20 BF-4 Guidelines for Breastfeeding Promotion and Support Georgia WIC ......................... BF-23 BF-5 Breastfeeding Resources Recommended by the Nutrition Services Unit .................BF-33 BF-6 Allowable and Unallowable Costs Breastfeeding Aids used for the Promotion and
Support of Breastfeeding .......................................................................................... BF-36 BF-7 Issues to Consider When Providing Breast Pumps .................................................. BF-37 BF-8 Status Change from Prenatal to Breastfeeding and Assignment of Priority to
Breastfeeding Mother and Infant............................................................................... BF-40 BF-9 Key for Entering Weeks Breastfed ............................................................................ BF-42 BF-10 Estimating Formula Needs........................................................................................ BF-44 BF-11 Types of Breast Pump Codes ................................................................................... BF-45

GEORGIA WIC 2012 PROCEDURES MANUAL



I.

INTRODUCTION

Breastfeeding

This section of the Procedures Manual defines the concept of breastfeeding promotion, education and support; and explains the requirements for providing lactation services to Georgia WIC 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, hygienic, and economic. Human milk contains the ideal balance of nutrients, enzymes, immunoglobulins, anti-infective agents, anti-allergic substances, hormones, and growth factors. Further, breastmilk changes to match the changing needs of the infant. Breastfeeding provides a time of intense maternalinfant interaction. Lactation also facilitates the physiologic return to the pre-pregnant state for the mother. 1

Public Health staffs have a responsibility to provide services designed to optimize the health of their clients. Through Georgia WIC 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 (7 C.F.R.246.2) define a woman as breastfeeding if she feeds breastmilk to her infant(s) on average at least once every 24 hours. Re-lactation/induced lactation after a period of not breastfeeding or lactation by a woman who is not the biological mother of the infant also qualifies the woman as a breastfeeding mother.

Exclusively Breastfed (EBF) Infant: an infant who is being fed breastmilk and who receives no formula (infant formula, exempt infant formula, or medical foods) from Georgia WIC.
Mostly Breastfed (MBF) Infant: an infant being fed breastmilk and receiving from Georgia WIC formula in amounts that do not exceed the maximum allowances for mostly breastfed infants which is approximately half (50%) of the formula allowance for fully formula fed (FFF) infants.


1 HealthyPeople2010:NationalHealthPromotionandDiseasePreventionObjectives,U.S. DepartmentofHealthandHumanServices,1990.

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Breastfeeding



Fully Formula Fed (FFF) Infant: an infant receiving from Georgia WIC formula in amounts

that exceed the maximum allowances for mostly breastfed (MBF) infants.

Postpartum Woman: a woman up to six (6) months postpartum who is not providing breastmilk to her infant (who is classified as a fully formula fed [FFF] infant).

Mostly Breastfeeding Woman: a woman up to twelve (12) months postpartum who is providing mostly breastmilk to her infant and whose infant receives formula from Georgia WIC in amounts that do not exceed the maximum formula allowances for mostly breastfed (MBF) infants.

Some Breastfeeding Woman: a woman up to twelve (12) months postpartum who is providing breastmilk to her infant on average at least one (1) time per day and is accepting for her infant formula that exceeds the maximum amount of formula allowed for mostly breastfed (MBF) infants. Her infant is classified as a fully formula fed (FFF) infant. After six (6) months postpartum, breastfeeding women described as doing "some breastfeeding" under this definition will not be issued WIC supplemental foods. However, such women are eligible to be recertified for Georgia WIC as participants and to continue to receive nutrition education and breastfeeding support.

Exclusively Breastfeeding Woman: a woman up to twelve (12) months postpartum who is providing breastmilk to her infant and whose infant classified as an exclusively breastfed (EBF) infant is not receiving any infant formula, exempt infant formula, or medical foods from Georgia WIC.

III. STATE AGENCY

A. Breastfeeding Coordinator

The responsibility for coordination of Statewide WIC breastfeeding activities is vested within the Georgia Department of Public Health, Division of Public Health, Maternal and Child Health, Nutrition Services Unit.

A qualified nutritionist or nurse is designated as the state WIC Breastfeeding Coordinator. The responsibilities of this person are to plan, direct and coordinate the breastfeeding promotion, education and support component of Georgia WIC.

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,

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GEORGIA WIC 2012 PROCEDURES MANUAL

Breastfeeding



education and support plans on a periodic basis through on-site visits

and reports.

4. Evaluate breastfeeding promotion, education and support services of all local agencies.

5. Develop and implement a plan for providing training and technical assistance for Competent Professional Authorities (CPAs), paraprofessional staff, and clerical staff at local clinics. Training and technical assistance provide CPAs with current information on the management of normal breastfeeding issues and special problems in lactation. It provides all staff with an understanding of the importance of promoting, and ways to promote, breastfeeding in a clinic setting.

6. Identify and develop resource and education materials for use by local agencies. Provide materials in languages other than English in areas where a substantial number of participants are non-English speaking.

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.

b. A requirement that each local agency designate a staff person to coordinate the breastfeeding promotion and support activities.

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GEORGIA WIC 2012 PROCEDURES MANUAL

Breastfeeding



c. A requirement that each local agency incorporate task-

appropriate breastfeeding promotion and support training into

orientation programs for new staff involved in direct contact with

WIC clients.

d. A plan to ensure that women have access to breastfeeding promotion, education, and support activities during the prenatal and postpartum periods.

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, Certified Lactation Counselor (CLC), or International Board Certified Lactation Consultant (IBCLC). Attachment BF-2 lists a job description for Health Educator Senior/Lactation Consultant, which may be used to assure an individual is qualified to fill this position. A Georgia Gain job classification sample job description entitled District Breastfeeding Coordinator 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 an International Board Certified Lactation Consultant (IBCLC). 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 Services Unit, or pass a Certified Lactation Counselor (CLC) course.
4. It is recommended that the breastfeeding coordinator work across program lines to provide breastfeeding services, thus increasing opportunities for all current and potential WIC participants to be reached. This will also serve to integrate services, and assure that all clinic staff receive appropriate training and deliver consistent information on breastfeeding.
B. Breastfeeding Promotion, Education and Support Responsibilities
Georgia WIC 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:

BF-4

GEORGIA WIC 2012 PROCEDURES MANUAL

Breastfeeding



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, badge holders, pins, posters 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 should be used advantageously to motivate women to recognize breastfeeding as the "norm" rather than the exception. The clinic area should, where space permits, also be used to provide worksite support for staff who is 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 interacts with WIC applicants and participants must receive basic information on breastfeeding, during their orientation to Georgia WIC.

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GEORGIA WIC 2012 PROCEDURES MANUAL

Breastfeeding



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. CPAs 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 must attend local, state or National workshops for the purpose of developing and updating skills and knowledge in lactation management.

b. All breastfeeding training and continuing education activities conducted or attended by local staff must be recorded and kept on file by the local agency. The file should include the names and titles of the workshop participants, and the titles and dates of the workshops. See Attachment NE-6 for recommended forms.

D. Breastfeeding Promotion, Education and Support Plan

1. Annual Plan of Activities

a. The state agency, with participation from district staff, develops the Georgia WIC State Plan that is annually submitted to USDA no later than August 15 of each year. In order to integrate efforts being conducted at both the state and the local levels, local agencies shall submit to the state, a Breastfeeding Plan of Activities based on the State Plan goals and objectives. The district or local agency Breastfeeding program plan must be submitted to Georgia WIC by March 31, unless another date has been designated as the due date for that year for inclusion in the annual state plan. The district or local agency mid-year report will be due by October 31, unless another date has been designated as the due date for that year. This Plan should be incorporated in the local agency strategic plan for WIC and nutrition services.

b. In addition to the district or local agency annual plan, a Breastfeeding Peer Counselor plan is due from those districts or local agencies who have received designated Breastfeeding Peer Counselor funds. The plan must provide the number of Peer Counselors and their salaries, hours they work, trainings attended, activities the Peer Counselors have participated in and items purchased using Budget 329 for that particular fiscal year. Districts must also provide the percentage of time the Breastfeeding Coordinator or designated supervisor spends on Peer Counseling responsibilities. The Breastfeeding Peer Counselor plan must be

BF-6

GEORGIA WIC 2012 PROCEDURES MANUAL

Breastfeeding



submitted in conjunction with the district or local agency

Breastfeeding program plan and follow the same schedule.

V. PARTICIPANT EDUCATION
A. Participant Education Requirements
1. Each local agency must have an established reference guide for breastfeeding education. Examples of approved breastfeeding reference guides include, but are not limited to: x La Leche League International "The Breastfeeding Answer Made Simple" x "Breastfeeding and Human Lactation" by Jan Riodan x "Breastfeeding A Guide For The Medical Profession" by Ruth and Robert Lawrence x "Medications and Mother's Milk" by Thomas Hale, Ph.D.
2. All pregnant participants must be encouraged to breastfeed unless contraindicated for health reasons. As recommended in the established reference materials, encouragement to breastfeed should continue throughout the prenatal period.
As stated in the Healthy People 2010 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 should be offered on WIC benefits for breastfeeding women:
a. Breastfeeding women are at a higher level in the priority system than non-breastfeeding postpartum women, and are more likely to be served than these women when local agencies do not have the resources to serve all qualified individuals.
b. Exclusively breastfeeding women (whose infants receive no formula from Georgia WIC) and mostly breastfeeding women (whose infants receive formula from Georgia WIC in amounts that do not exceed the maximum formula allowance for mostly breastfed [MBF] infants) may receive WIC supplemental food benefits for up to twelve (12) months postpartum, or until breastfeeding is discontinued. Non-breastfeeding women and

2HealthyPeople2000:NationalHealthPromotionandDiseasePreventionObjectives,U.S.
DepartmentofHealthandHumanServices,1990.

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GEORGIA WIC 2012 PROCEDURES MANUAL

Breastfeeding



women classified as "Some Breastfeeding" are both receiving

formula from Georgia WIC that exceeds the maximum

allowance for mostly breastfed (MBF) infants and thus are

eligible for supplemental foods for only six (6) months

postpartum.

c. Georgia WIC offers a greater variety and quantity of food to those breastfeeding participants who are classified as "mostly" or "exclusively" breastfeeding than to non-breastfeeding, postpartum participants and to women classified as doing "some breastfeeding."

d. If a mother chooses to both breastfeed and formula feed her infant, powder formula is recommended. However, liquid concentrate formula is available. The CPA should assign a food package with only the amount of formula the infant requires (one can, two cans, or three cans powder). The CPA should reassess the infant's needs any time the mother requests more formula. Any problems with breastfeeding should be addressed at this time. Requests for increases in the amount of formula should not be honored without assessment and counseling of the mother/baby dyad. Refer to Attachment BF-10 to estimate how much formula a Mostly Breastfeeding Infant will need.

4. Breastfeeding women should be taught hand expression of breastmilk. All CPAs, breastfeeding counselors and nutrition assistants should be trained to teach hand expression of breastmilk. However, if a staff person is not skilled in this area, a referral should be made to trained staff or the local agency breastfeeding coordinator.
5. Breastfeeding women must be taught signs of adequate intake by the breastfed infant. Signs of adequate intake are:
a. baby is nursing 8-12 times per 24 hours b. baby wets diaper at least six (6) or more times per 24 hours c. baby has three (3) or more stools per 24 hours, in first month d. baby has visible and audible signs of swallowing e. mother's breasts feel softer after feeding f. baby has adequate weight gain over time (for infants who are
presented for weight checks)
6. Breastfeeding education contacts must be provided by a nutritionist, registered dietitian, competent professional authority, or other certified health professional, peer counselor or nutrition assistant who has been trained by the state or local agency. Peer Counselors can assist the instructor. When providing breastfeeding education contacts, the CPA must attempt to assess and solve the problem before automatically referring to the designated breastfeeding specialist or Peer Counselor.
7. Local agencies are encouraged to use peer counselors trained by the state or local agency to provide encouragement, education, and

BF-8

GEORGIA WIC 2012 PROCEDURES MANUAL

support to prenatal and breastfeeding women.

Breastfeeding

8. Nutrition assistants can also provide breastfeeding education and support when appropriate training has been received. The Nutrition Services Unit must approve the training plan (see Attachment NE-3) for the Guidelines for Nutrition Assistant Training and list of items to be submitted for approval.

9. An individual care plan should be developed for a participant based on the need, as determined by the competent professional authority. The Care Plan should be written in the progress notes, preferably using the SOAP (Subjective - Objective - Assessment - Plan) note format.

10. Class outlines must be developed when group-facilitated classes are used to provide the breastfeeding education contact. Class outlines must be kept at the clinic site for use by clinic staff and provided to the State WIC Breastfeeding Coordinator at the time of program reviews.

11. If the participant/caregiver is unable to receive services at the clinic for an extended period of time, home visits are the recommended method for providing breastfeeding education contacts.

12. Local agencies are also encouraged to provide ongoing lactation support for prenatal and breastfeeding women by telephone. If possible, a breastfeeding help 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 electronically 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 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-facilitated breastfeeding education classes must be documented in the participant's health record. The name and credentials of the staff member conducting the group-facilitated class must also be documented in the participant's health record.

2. Missed appointments for breastfeeding education contacts and the refusal of a participant/caregiver to receive breastfeeding education

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GEORGIA WIC 2012 PROCEDURES MANUAL

Breastfeeding



must be documented in the participant's health record. Documenting

missed appointments and refusal to receive education is important for

the purpose of monitoring and further education efforts. However,

failed, missed, and refused breastfeeding education contacts do not

count as having provided breastfeeding education or secondary

nutrition education.

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 breast 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.

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:
1. It is important to assure that relevant educational materials available to participants portray breastfeeding as the preferred infant feeding method.
2. The following items must be free of formula product names: print and audiovisual materials, and office supplies such as cups, pens and notepads. 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.
3. The visibility of formula and bottle-feeding equipment through storing supplies of formula, baby bottles and nipple must be kept out of view anywhere WIC participants are served.

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GEORGIA WIC 2012 PROCEDURES MANUAL


Breastfeeding

Attachment BF-5 provides a list of resources that are recommended for use by the Nutrition Services Unit.

B. Breastfeeding Equipment and Supplies

1. Allowable Costs

Local agencies are encouraged to assess the need for breastfeeding equipment and supplies. Providing equipment and supplies should not generally be the primary means by which the state and local agencies meet their breastfeeding promotion and support target expenditures. Breastfeeding aids should be used in conjunction with appropriate counseling, education, and follow-up provided by trained staff.

Breast pumps and other breastfeeding aids may not be provided to all pregnant or breastfeeding women solely as an incentive 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 that are having latch-on problems.

d. Mothers attempting to build their milk supply for any reason.

e. Mothers choosing to express breastmilk for missed feedings due to work, school or maternal hospitalization, or if temporary weaning is necessary.

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Breast pumps are not a direct program benefit that state agencies are

required to provide but rather are aids that may be offered to certain

WIC participants to facilitate breastfeeding. The pumps may be offered

free or at cost to WIC participants. Issues to consider when providing

breast pumps are explained in Attachment BF-7.

3. Instructions for Breast Pump Use

Local agencies with breast pump loan and give-away programs must establish written policy and procedures regarding appropriate use, and instructions to be provided to breast pump recipients. The following must be included in the policy and procedures:

a. A trained, designated staff person is to provide instructions to the breast pump 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. Computer Tracking of Breast Pump Issuance

For tracking purposes, the fields Date Breast Pump Assigned, Date Breast Pump Returned and Type of Breast Pump Assigned were added to the front-end computer systems.

a. Date Breast Pump Assigned is an allowed field for breastfeeding women. Local agencies must enter the date a breast pump is issued to a participant. If a breast pump is not assigned this field should be left blank.

b. Date Breast Pump Returned is for prenatals, breastfeeding or non-breastfeeding women. The agency must enter the date a WIC participant returns a breast pump. Participants terminated prior to returning a breast pump cannot be updated. Local agencies must document the return pump on their breast pump inventory log.

c. Type of Breast Pump Assigned is an allowed field for women assigned a breast pump. This new element will be used to identify and track return of pumps. A list of codes to define the types of breast pumps assigned a WIC participant can be found in Attachment BF-11.

5. Equipment and Supplies Inventory
Local agencies must maintain an inventory of all breastfeeding equipment and supplies. It is recommended that the inventory be

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Breastfeeding



updated on a quarterly basis. An inventory of breast pumps and

attachment kits must be submitted to the WIC Breastfeeding Coordinator by September 30th and March 31st of every year. A

separate report of purchased breast pumps must be sent to the State

WIC Budget Officer by October 8th, January 8th, March 8th and June 8th

of each year. Local agencies can create monthly reports, maintain

inventory of breastfeeding equipment by using the Date Breast Pump

Assigned field.

VIII. ALLOWABLE COSTS FOR THE PROMOTION AND SUPPORT OF BREASTFEEDING
A. Allowable Breastfeeding Promotion and Support Costs
Georgia WIC 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.

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Breastfeeding



9. Breastfeeding aids which directly support the initiation and continuation

of breastfeeding. A list of allowable and unallowable breastfeeding

aids. (See Attachment BF-6.)

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.

B. Documentation of Costs

The state and local agencies must document all Federal WIC grant funds expended to meet the minimum BFPS requirement. Documentation is necessary so that the WIC state agency can clearly demonstrate the expenditure requirement has been satisfied. Salary costs identified and reported as being for BFPS activities must be supported with employee payroll and time distribution records. Costs such as equipment purchases and travel must be supported with accounting records, including source documents such as invoices and travel statements.

IX. DOCUMENTATION OF BREASTFEEDING RATES
Georgia WIC documents breastfeeding rates by two different methods: percentage of women who are certified as breastfeeding (WIC Type B), and self-reported information on weeks breastfed (initiation & duration). It is important that documentation be accurate in both instances since they have a major impact on administration of Georgia WIC. 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 Georgia WIC. In addition, the Southeast Regional Office of USDA monitors changes in breastfeeding rates based on the number of women who are listed as breastfeeding (WIC Type B on the WIC System).

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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. For instructions on making the status change see Attachment BF-8.

3. Assignment of Breastfeeding Status During Certification: A woman was not on the program while she was pregnant but is being certified as a breastfeeding woman.

Note: A woman and her infant(s) can be certified as breastfeeding: (1) if the definition of breastfeeding is met, and (2) based on the quantity of formula her infant is receiving from Georgia WIC. (See II. DEFINITIONS.)

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 that completes 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 recorded 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

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Breastfeeding

4. Children: i one year of age subsequent certification visit (11-24 months of age), if they participated as infants i 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. Appropriate codes to use for weeks breastfed can be found in Attachment BF-9.

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POSITION PAPER ON BREASTFEEDING

Attachment BF-1

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 preferred 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:

i breast milk provides an ideal balance of nutrients for the human infant

i the nutrients in breast milk are easily absorbed and digested

i breast milk contains immune factors and anti-infective properties that protect

against infections

i breastfeeding allows the satiety mechanism in the infant to develop naturally.

i infants who are breastfed have fewer allergies

i breastfeeding promotes increased bonding between mother and infant.

i

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 Community Health recommends that:

i breast milk be the "house formula" in all hospitals in Georgia where maternity services are offered
i all expectant parents be informed of the numerous advantages (both to infant and mother) of breastfeeding
i every expectant mother receive practical information on how to initiate and maintain lactation
i obstetrical procedures and practices be consistent with the policy of promoting breastfeeding
i breastfeeding be initiated as soon as possible, preferably during the first hour after birth i every hospital permit and encourage rooming-in and on-demand feeding of breastfed
infants i infant formulas not be marketed or distributed in ways that may interfere with the
protection and promotion of breastfeeding i places of business, including government offices, facilitate the maintenance of lactation
through liberalized policies that would promote breastfeeding

All the available knowledge indicates that breastfeeding is the best choice for infant feeding and should be promoted for mothers and infants of the state. Breast milk as this choice for infant nutrition will promote optimum health for future generations of Georgians.

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Attachment BF-2

SAMPLE JOB DESCRIPTION SENIOR PUBLIC HEALTH EDUCATOR - LACTATION CONSULTANT

The examples of work given are illustrative of the duties assigned to positions of this class. No attempt is made to be exhaustive. The intent of the listed examples is to give a general indication of the levels of difficulty and responsibility common to all positions of this class.

The standards for training and experience express the minimum background necessary as evidence of an applicant's ability to qualify for positions of this class. Unless otherwise stated, the Applicant Services division may allow substitution of appropriate education or experience for the training and experience minimum listed.

DEFINITION

Under direction, performs work of moderate difficulty in planning and implementing breastfeeding education activities related to public health programs; and performs related work as required.

EXAMPLES OF DUTIES

I.

Coordinates breastfeeding promotion project. Writes, revises, and evaluates the district's

breastfeeding services.

A. Establishes relationships with community health centers and/or hospital staff to provide breastfeeding services.

B. Provides in-service education material and/or needed equipment on breastfeeding for staff development.

C. Responsible for keeping daily communication sheets regarding telephone calls, correspondence, patients seen, meetings, and work related to breastfeeding funds.

II. Promotes breastfeeding services as an integral part of perinatal care.

A. Encourages all prenatal women, on their initial visit, to breastfeed by providing an array of educational material and counseling.

B. Provides additional breastfeeding counseling to prospective breastfeeding women during the last trimester through breastfeeding classes and/or individual counseling.

C. Provides postpartum assessment of breastfeeding dyad, education, and assistance in resolving problems upon request. Provides adequate documentation of services and makes appropriate referrals for continuity of care.

D. Develops and implements continuing education and support networks through a variety of methods, such as support groups, peer counselors, etc.

E. Supervises and trains peer counselors.

F. Has ability to communicate effectively in writing, including grant proposals.

III. Evaluates effectiveness of breastfeeding program activities.

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Attachment BF-2 (cont'd)

A. Produces reports to determine breastfeeding rate and duration.
B. Assists District Nutrition Services Director in writing the breastfeeding promotion plan and annual update of breastfeeding activities.
C. Shares reports at local district meetings and state wide 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 promotion and 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 master's degree in public health, education, nursing, nutrition or a field directly related to public health activities. Certified as an International Board Certified Lactation Consultant or eligible for certification within two years. Has successfully completed the state certified lactation counselor (CLC) course or equivalent.

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SAMPLE JOB DESCRIPTION

Attachment BF-3

JOB TITLE: DISTRICT 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.
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.

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Attachment BF-3 (cont'd)

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 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.

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Attachment BF-3 (cont'd)

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.

MINIMUM QUALIFICATIONS:

Completion of an undergraduate degree in dietetics, nursing, community health nutrition, or health education at a four year college or university AND Two years of professional experience in the provision of nutrition or nursing services, one of which was in a community health setting.

Licensure/Certification: Registered Dietitian; Registered Professional Nurse; CHES

Preferred Qualifications:

Current status as an International Board Certified Lactation Consultant or Certified Lactation Counselor

A minimum of one year of experience providing breastfeeding education, lactation counseling and assessments and peer counselor supervision in a hospital or community health setting.

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POSITION PAPER NATIONAL WIC ASSOCIATION

Attachment BF-4

Guidelines for Breastfeeding Promotion and Support in Georgia WIC

These guidelines were developed to assist local and state WIC agencies initiate and strengthen breastfeeding promotion and support programs. The guidelines address training, clinic environment, coordinated efforts, program evaluation, breastfeeding education and support, and the food packages for breastfed infants and breastfeeding women. The guidelines are numbered for easy reference and are listed in random order. Therefore, the numbering system does not reflect rank order or priority.

GUIDELINE #1 Breastfeeding promotion and support are enhanced when local agency WIC staff receive orientation and task-appropriate training on breastfeeding as the preferred method of infant feeding.

GUIDELINE #2 Breastfeeding promotion and support are enhanced when policies encourage a positive clinic environment and endorse breastfeeding as the preferred method of infant feeding.

GUIDELINE #3 Breastfeeding promotion and support are enhanced when WIC agencies coordinate with the private and public health care systems, educational systems, and community organizations.

GUIDELINE #4 Breastfeeding promotion and support are enhanced when positive breastfeeding messages are incorporated in relevant educational activities, materials, and outreach efforts.

GUIDELINE #5 Breastfeeding promotion and support are enhanced when activities are evaluated on an annual basis.

GUIDELINE #6 Breastfeeding promotion and support are enhanced when appropriate breastfeeding education and support is offered to all pregnant WIC participants.

GUIDELINE #7 Breastfeeding promotion and support are enhanced when policies allow breastfeeding women to receive all WIC services regardless of their breastfeeding patterns.

GUIDELINE #8 Breastfeeding promotion and support are enhanced when policies allow breastfeeding infants to receive a food package consistent with their nutritional needs.

GUIDELINE #9 Breastfeeding promotion and support are enhanced when breastfeeding support and assistance is provided throughout the postpartum period, particularly at critical times when the mother is most likely to need assistance.

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Attachment BF-4 (cont'd)

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: i clinic environment policies i program goals and philosophy regarding breastfeeding i 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: i culturally appropriate breastfeeding promotion strategies i current breastfeeding management techniques to i encourage and support the breastfeeding mother and infant i appropriate use of breastfeeding education materials i 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: i statewide and local conferences and workshops i 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 Georgia WIC 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.

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Attachment BF-4 (cont'd)

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: i print and audiovisual materials free of formula product names i office supplies such as cups, pens, and note-pads free of formula product names

Rationale: Use of materials with product names sends a mixed message to clients and staff and might unconsciously put up barriers to breastfeeding.

2. It is important to establish a positive attitude toward breastfeeding in WIC clinics.

Rationale: Health care workers should be careful not to communicate overt or subtle endorsements of formula. Such messages may influence a mother's decision about infant feeding or her breastfeeding pattern. Once a mother initiates infant feeding, WIC staff should support her decision.

3. It is important that the local agency minimize the visibility of formula and bottle-feeding equipment. Consider: i storing supplies of formula out of view of participants i storing baby bottles and nipples out of view of participants

Rationale: Formula and bottle-feeding equipment in clear view of participants may influence a mother's decision on infant feeding. 4. It is important that staff not accept formula from formula manufacturer representatives for 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: i chairs with arms i 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.

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Attachment BF-4 (cont'd)

Suggestions for Implementation

1. It is important for local and state agencies to participate in and support coordinated activities with appropriate groups such as: i task forces, networks, or steering committees to exchange information and strategies i professional health organizations to secure resources and expertise and assure communication with health professionals serving pregnant and breastfeeding women i existing peer support groups to facilitate local exchange of breastfeeding information across the state i community leaders and citizen groups who support breastfeeding i 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: i American Academy of Pediatrics i American Academy of Family Physicians i American college of Nurse Midwives i American College of Obstetricians and Gynecologists i American Dietetic Association i American Hospital Association i American Nurses Association i American Public Health Association i Association of Pediatric Nurse Practitioners i Association of Women's Health and Obstetrics Nurses i Healthy Mothers, Healthy Babies Coalitions i International Lactation Consultants Association i La Leche League International i Maternal and Child Health Directors i Medicaid Directors i 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:

i co-sponsoring training and continuing education programs i sharing breastfeeding education materials for clients i developing local or state documents such as position statements, policies, model
hospital policies and counseling and referral protocols

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Attachment BF-4 (cont'd)

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: i participant orientation programs and materials i printed and audiovisual materials for professional audiences i 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: i incorporation of data collection into current WIC systems i periodic sample surveys of program participants i Centers for Disease Control and Prevention surveillance systems i state surveillance systems i 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: i exclusive breastfeeding i patterns of combined breastfeeding and formula feeding i mostly breastfeeding i equal parts breastfeeding and formula feeding i mostly formula feeding i exclusive formula feeding

Rationale: Collecting data on breastfeeding patterns gives a better picture of the WIC population's infant feeding practices. This will help states better focus their breastfeeding promotion activities.

3. It is important that questions regarding breastfeeding attitudes, infant feeding decisions, and Georgia WIC 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.

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Attachment BF-4 (cont'd)

4. It is important that the state agency management evaluation process reviews local agency breastfeeding promotion and support activities such as: i participant orientation and education materials i policies regarding formula samples and food package tailoring for breastfeeding mothers and infants i clinic environment, including display materials and posters, and visibility of formula supplies i staff interaction with participants regarding the infant feeding decision and breastfeeding support i local agency linkages with other community programs providing services to breastfeeding women i 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: i integrate breastfeeding promotion into the continuum of prenatal nutrition education i include an initial assessment of participant knowledge, concerns and attitudes related to breastfeeding i provide breastfeeding education and support sessions to each prenatal participant based on the above assessment i define the roles of all staff in the promotion of breastfeeding i define situations when breastfeeding is contraindicated i establish referral criteria
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: i peer counselors i an honor roll of successful breastfeeding WIC participants i an opportunity to watch other WIC participants breastfeed i group-facilitated 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

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Attachment BF-4 (cont'd)

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: i discussing WIC's position about breastfeeding as optimal for most women and infants i encouraging the sharing of educational materials between WIC and primary care providers i identifying the breastfeeding promotion and support services available in the community and referring participants as needed

Rationale: Coordinating activities in the community increases the likelihood of women and families receiving consistent messages and information about breastfeeding.

6. It is important that the local WIC agency know the breastfeeding practices of their community hospitals and primary health care providers. Rationale: Local agency WIC staff should be part of the prenatal care team preparing women for their early breastfeeding experiences. Positive breastfeeding practices and policies facilitate successful breastfeeding.

GUIDELINE #7 Breastfeeding promotion and support are enhanced when policies allow breastfeeding women to receive all WIC services regardless of their breastfeeding patterns.

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.

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Attachment BF-4 (cont'd)

Rationale: All breastfeeding women, regardless of their breastfeeding pattern, need ongoing support so that they feel positive about their breastfeeding experience.
GUIDELINE #8 Breastfeeding promotion and support are enhanced when policies allow breastfeeding infants to receive a food package consistent with their nutritional needs.
Suggestions for Implementation
1. It is important that the use of supplemental formula for breastfed infants be minimized.
Rationale: Support that encourages breastfeeding is more effective than offering more formula than the baby is currently using. Clear support which continues to build confidence includes praise and encouragement for her current level of breastfeeding. 2. It is important that vouchers with infant formula are not issued to exclusively breastfed infants. If a food instrument must be distributed to enroll the infant, consider printing a positive breastfeeding message on the voucher.
Rationale: A blank voucher emphasizes that the breastfeeding dyad may not be receiving as much food as the formula-feeding dyad and makes the mother feel as though she is missing out on some of the food available to her. A voucher with even a small amount of formula on it sends a message to the mother that she is expected to supplement. A positive breastfeeding message will reinforce the importance of breastfeeding.
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

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Attachment BF-4 (cont'd)

Breastfeeding promotion and support are enhanced when breastfeeding support and assistance is provided throughout the postpartum period, particularly at critical times when the mother is most likely to need assistance.

Suggestions for Implementation

1. It is important to develop a plan to provide women with access to locally available breastfeeding support programs, making sure support is available early in the postpartum period and throughout lactation to: 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

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

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GEORGIA WIC 2012 PROCEDURES MANUAL


Attachment BF-4 (cont'd)

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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Attachment BF-5

BREASTFEEDING RESOURCES RECOMMENDED BY THE NUTRITION SERVICES UNIT

PAMPHLETS & TEAR SHEETS Childbirth Graphics Ltd., P.O. Box 21207, Waco, TX 76702-1207 www.ChildbirthGraphics.com

i 20 Great Reasons to Breastfeed (English and Spanish) i Breastfeeding: Getting Started in 5 Easy Steps (English and Spanish) i Breastfeeding and Returning to Work i Helpful Hints on Breastfeeding (English and Spanish) i Positions for Breastfeeding i The Diaper Diary Tear Pad i How Long Should I Breastfeed My Baby? Tear Pad
BOOKS AND MANUALS Breastfeeding: A Guide for the Medical Profession, by Ruth Lawrence, C.V. Mosby Co., St. Louis, MO, 2005 edition. Breastfeeding: A Parent's Guide, 8th Edition, by Amy Spangler Amy Spangler/Amy's Babies, Atlanta, GA, 2006; English & Spanish Breastfeeding: Keep It Simple by Amy Spangler Amy Spangler/Amy's Babies, Atlanta, GA, 2006; English & Spanish x Breastfeeding: Your Guide to a Happy, Healthy Baby, by Amy Spangler, Amy's Babies, Atlanta, GA; English, Spanish & Chinese Breastfeeding and Diseases: A Reference Guide by Stephen Buescher, MD and Susan W. Hatcher, RN, BSN, IBCLC; Hale Publishing, Amarillo, TX, 2008 Breastfeeding & Human Lactation, by Jan Riordan and Kathleen Auerbach Jones & Bartlett, Publishers, Boston, MA, 4th Edition, June 2009 The Breastfeeding Answer Book, by La Leche League International La Leche League International, Franklin Park, IL, 2003. 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, 4th Edition, 2005 Clinical Guidelines for the Establishment of Exclusive Breastfeeding,International Lactation Consultants Association, June 2005. Medications and Mothers' Milk, by Thomas Hale, Hale Publishing, Amarillo, TX, 13th Edition, 2008. Nursing Mother's Companion, by Kathleen Huggins Harvard Common Press, Boston, MA, 4th Edition, 1999 Best Medicine: Human Milk in the NICU, by Nancy Wight, MD, Jane Morton, MD and Jae H. Kim, MD, Hale Publishing, Amarillo, TX, 2008 The Pediatric Clinics of North America: Breastfeeding 2001, Part I (The Evidence for

BOOKS & MANUALS, (continued) 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
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Attachment BF-5 (cont'd)

Kathleen G. Auerbach, Jones and Bartlett Publishers, Sudbury, MA, 2002. The Womanly Art of Breastfeeding, La Leche League International, Franklin Park, IL, 2004. The Breastfeeding Answer Book, La Leche League International, Franklin Park, IL, 2003. The Breastfeeding Answer Pocket Guide, La Leche League International, Franklin Park, IL, 2005. Continuity of care in Breastfeeding: Best Practaices in the Maternity Setting, by Karin Cadwell, Jones and Bartlett Publishers Ten Steps to Successful Breastfeeding, Second Edition, by Karin Cadwell, Jones & Bartlett Breastfeeding A-Z: Terminology and Telephone Triage, by Karin Cadwell, Jones & Bartlett Impact of Birthing Practices on brestfeeding: Protecting the Mother and Baby Continuum, by Mary Kroeger, Jones & Bartlett

VIDEOTAPES & DVDs Better Breastfeeding:Your Guide to Healthy Start, Injoy Videos, 800-326-2082, Ext. 2, English & Spanish, 2009 Better Breastfeeding: A Guide for Teen Parents, Injoy Videos, 800-326-2082, Ext. 2, English & Spanish, 2009 Better Breastfeeding: PowerPoint Presentation, Injoy Videos, 800-326-2082, Ext. 2, 2009 Breastfeeding Best Practice: Teaching Latch and Early Management, (for staff training,) Injoy Videos, 800-326-2082, Ext. 2, video or DVD Breastfeeding for Working Mothers: Planning, Preparing and Pumping; Injoy Videos, 800-3262082, Ext. 2, English & Spanish, 2009 Breastfeeding: The Why-To, How-To Video or DVD set, VIDA Health Communications, 1998, English & Spanish. (Can be purchased separately.) Clinical Management of Breastfeeding: 2-volume set. VIDA Health Communications Infant Cues: A Feeding Guide, Platypus Media, produced in association with Texas Department of Health,10 minutes, Video/ DVD with English & Spanish subtitles Delivery Self Attachment, Geddes Productions, 2007, DVD with English, Spanish, Chinese, Japanese and French subtitles, 6 minutes Breastfeeding: A Special Relationship, English/Spanish, 24 minutes
TEACHING TOOLS Childbirth Graphics Ltd., P.O. Box 21207, Waco, TX 76702-1207 www.ChildbirthGraphics.com i Breast Model
Breastfeeding Chart Collection, 36 panels with presentation notes, English/Spanish i Baby Model

TELEPHONE INFORMATION SERVICES FOR HEALTH PROFESSIONALS i 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.
i Breastfeeding and Human Lactation Study Center University of Rochester School of Medicine & Dentistry,

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GEORGIA WIC 2012 PROCEDURES MANUAL


Attachment BF-5 (cont'd)

Box 777, Rochester, New York, 14642 (585) 275-0088; www.bestfedbabies.org 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.

i The Lactation Program

4600 Hale Parkway Suite 140 Denver, CO 80220 (303) 377-3016 Service Provided: Phone consultation with lactation consultants for difficult breastfeeding questions. Charge: None, beyond cost of telephone call.

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GEORGIA WIC 2012 PROCEDURES MANUAL


Attachment BF-6

ALLOWABLE AND UNALLOWABLE COSTS OF BREASTFEEDING AIDS USED FOR
THE PROMOTION AND SUPPORT OF BREASTFEEDING

The cost of breastfeeding aids 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: i Breast pumps
i Breast shells
i Nursing supplementers
i Nursing bras
i Nursing pads
i Costs associated with the purchase and availability of breastfeeding aids through Georgia WIC, such as insurance and service fees in providing breast pumps
i Items used for training and demonstration purposes to promote breastfeeding or assist participants in using breastfeeding aids. For example: breast models, breastfeeding aids, posters, videos or DVDs, and dolls to illustrate nursing, etc.
i 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 Georgia WIC cannot be purchased with NSA funds. Such items include, for example: topical creams, ointments, Vitamin E, other medicinals, foot stools, infant pillows, blankets or nursing blouses.

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GEORGIA WIC 2012 PROCEDURES MANUAL


Attachment BF-7

ISSUES TO CONSIDER WHEN PROVIDING BREAST PUMPS

WIC state agencies are currently making breast pumps available to WIC participants in a variety of ways, including:

a. giving away manual breast pumps or electric pump attachment kits;
b. selling manual breast pumps or electric pump attachment kits for a nominal charge;
c. loaning hospital-grade 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 Georgia WIC, 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 Georgia WIC, 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 WIC Breastfeeding Coordinator 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 Federal Regulations 2 CFR 225 and 2 CFR 230.

Loaning Breast Pumps and Liability Issues

Manual breast pumps, attachment kits for electric pumps and small electric or battery operated pumps should not be reused, due to the possibility of cross-contamination from improper sterilization. The possible liability cost is high when compared to the cost for a one-person use of a manual pump. In addition, the small electric/battery-operated pumps are often not durable enough to be used repeatedly and their cost is minimal.

Since hospital grade 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:

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GEORGIA WIC 2012 PROCEDURES MANUAL


Attachment BF-7 (cont'd)

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, Georgia WIC 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, Georgia WIC 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 Georgia WIC must be instructed on safe pump use, including proper cleaning of pump and attachment kits and milk storage guidelines.

Contracting with a Third Party

Local agencies may contract with a third party, such as a breast pump manufacturer, hospital pharmacy, or private lactation consultant, to loan or provide breast pumps to WIC participants. WIC employees must not be affiliated with the third party with whom they are contracting.

A major advantage to contracting with a third party is that it transfers liability for equipment loss or damage from Georgia WIC 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 Georgia WIC, 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

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GEORGIA WIC 2012 PROCEDURES MANUAL


Attachment BF-7 (cont'd)

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. This includes instruction on safe pump use, including proper cleaning of pump and attachment kits and milk storage guidelines.

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GEORGIA WIC 2012 PROCEDURES MANUAL


Attachment BF-8

STATUS CHANGE FROM PRENATAL TO BREASTFEEDING AND ASSIGNMENT OF PRIORITY TO BREASTFEEDING MOTHER AND INFANT

I.

Status Change from Prenatal (WIC Type "P") to Breastfeeding (WIC Type "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:

i A woman calls the clinic to state she has delivered her infant and is breastfeeding i A parent of a newborn breastfeeding infant comes to the clinic to enroll the infant in
the program i A local agency does in-hospital certification of infants only i 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 Attachment BF-8 Section II., "Assignment of Priority to Breastfeeding Dyad," below.)
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 Packages W40-W59. If this participant has already picked up the current month's prenatal vouchers (W01) and is assigned the standard W41 food package, you may print one "A30" voucher for her. This voucher includes the additional foods which are part of the W41 food package. If the woman has been on or assigned other food packages, a 999 voucher(s) must be issued to complete the conversion.

BF-40

GEORGIA WIC 2012 PROCEDURES MANUAL


Attachment BF-8 (cont'd)

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, Georgia WIC 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:
1. If the mother is no longer breastfeeding, she must be assessed as a nonbreastfeeding postpartum woman (status is changed from P to N), and she must be assigned the appropriate priority based on the assessment. Her infant retains the priority assigned at its enrollment.
2. If the mother is still breastfeeding, she must be assessed as a breastfeeding woman (status is changed from P to B). The highest priority of either the mother or her infant(s) must be assigned to both the mother and her 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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GEORGIA WIC 2012 PROCEDURES MANUAL

KEY FOR ENTERING WEEKS BREASTFED

Attachment BF-9

The number of weeks breastfed must be manually entered when completing paper WIC Assessment/Certification Forms and paper Turnaround Documents for:
i Breastfeeding Women: initial and six-month certification visits i Postpartum, non-breastfeeding women: certification visit i Infants: initial certification and mid-certification nutrition assessment visits i Children: one-year of age certification visit (11 to 24 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

Convert Days to Weeks Fewer than 7 days 7 - 13 days 14 - 20 days 21 - 27 days 28 - 34 days 35 - 41 days 42 - 48 days

= 00 weeks = 01 week = 02 weeks = 03 weeks = 04 weeks = 05 weeks = 06 weeks

Source:

Georgia WIC ETAD Change Number 08-12b, 2008.

II. Codes to Enter When Breastfeeding is Given in Months

1 month 2 months 3 months 4 Months 5 Months 6 Months 7 Months 8 Months 9 Months 10 Months 11 Months 12 Months 13 Months 14 Months 15 Months 16 Months 17 Months 18 Months 19 Months 20 Months 21 Months

= 04 weeks = 08 weeks = 13 weeks = 17 weeks = 22 weeks = 26 weeks = 30 weeks = 35 weeks = 39 weeks = 43 weeks = 48 weeks = 52 weeks = 56 weeks = 61 weeks = 65 weeks = 69 weeks = 74 weeks = 78 weeks = 82 weeks = 87 weeks = 91 weeks

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GEORGIA WIC 2012 PROCEDURES MANUAL


Attachment BF-9 (cont'd)

22.5 Months + = 98 weeks or more

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. February 2000.

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GEORGIA WIC 2012 PROCEDURES MANUAL

Estimating Formula Needs

Attachment BF-10

Daily Formula Intake
3 oz 6 oz 9 oz 12 oz 16 oz

Weekly Formula Intake
14 oz 27 oz 40 oz 54 oz 68 oz

Amount of Powder Formula to Issue
1 can 2 cans 3 cans 4 cans 5 cans

One can of powder formula equals approximately 3.5 cans of concentrate. One can of powder formula equals approximately 3 cans of ready to feed.
Maximum Amounts Allowed for Standard Formula Fully Formula Fed Infant

Age (months)

1-3

Powder

9

Concentrate

31

Ready to feed

26

4-5

6-11

10

7

34

24

28

20

Age (months) Powder Concentrate Ready to feed

Maximum Amounts Allowed for Standard Formula Mostly Breastfed Infant

0-1

2-3

4-5

1

4

5

3

14

17

3

12

14

6-11 4 12 10

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GEORGIA WIC 2012 PROCEDURES MANUAL

Types of Breast Pump Codes

Attachment BF-11

Type of Breast Pump

No tracking required

N

Bailey Nuture III

B

Elite

E

Lactina

L

Pedal

P

Symphony

S

Purely Yours

Y

Other

O

Input Code

Use codes to define the types of breast pumps assigned to a WIC participant:
x Enter "N"(no tracking) if pump issued does not need to be returned (e.g., manual pump)
x If the pump needs to be returned, enter appropriate code to identify type of pump

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GEORGIA WIC 2012 PROCEDURES MANUAL

Emergency Plan

TABLE OF CONTENTS

Page

I.

Introduction ................................................................................................................. EP-1

A. Purpose ........................................................................................................... EP-1

B. Scope .............................................................................................................. EP-1

II. Policies........................................................................................................................ EP-2 III. Assessing Impact of the Emergency ........................................................................... EP-3 IV. Concept of Operation .................................................................................................. EP-3
A. General............................................................................................................ EP-3 B. Organization .................................................................................................... EP-4 C. Notification....................................................................................................... EP-6

V. Responsibilities ........................................................................................................... EP-7 A. Facilities .......................................................................................................... EP-7 B. Issuance .......................................................................................................... EP-7 C. Certification and Voucher Issuance................................................................. EP-9 D. Nutrition Education Contacts ........................................................................... EP-9

VI. Resource Requirements ........................................................................................... EP-10 A. Staff Requirements........................................................................................ EP-10 B. Certification Equipment, Computers, Voucher Issuance Printers, and Supplies ................................................................................... EP-10 C. Infant Formula ............................................................................................... EP-10 D. Food Vouchers and TADs ............................................................................. EP-11 E. Operational Retail Vendors ........................................................................... EP-11 F. Clinic Data Set and/or Masterfile List ............................................................ EP-11 G. Transportation ............................................................................................... EP-11

VII. Types of Emergencies .............................................................................................. EP-12

VIII. Manual Certification with VPOD or Manual Voucher Issuance ................................. EP-12

IX. Nutrition Education, Food Package Change or other Manual Changes with VPOD or Manual Voucher Issuance .................................................................. EP-13

X. VPOD or Manual Voucher Issuance Only ................................................................. EP-14

GEORGIA WIC 2012 PROCEDURES MANUAL

Emergency Plan

XI. Replacing Lost Vouchers .......................................................................................... EP-15

XII. Voucher Ordering, Receipt, and Close-Out of ADP Contractor Printed Vouchers ................................................................................................................... EP-16 A. Ordering ADP Contractor Printed Vouchers ...................................................... EP-16 B. Receipt of ADP Contractor Printed Vouchers ................................................... EP-16 C. Issuing of ADP Contractor Printed Vouchers ................................................... EP-17 D. End of Month Close-Out for ADP Contractor Printed Vouchers and Voucher Registers............................................................................................ EP-18 E. Batching and Processing Manual TADs ........................................................... EP-18 F. Batching and Processing Manual Vouchers..................................................... EP-19

XIII. Tips for Operating a Manual System......................................................................... EP-19

Attachments: EP-1 Staff Availability Form ............................................................................................... EP-20 EP-2 Emergency Personnel Time Tracking Form.............................................................. EP-21 EP-3 Communications Log ................................................................................................ EP-22 EP-4 Emergency Daily Work Activity Log ......................................................................... EP-23 EP-5 Emergency Projections and Planning Assumptions................................................. EP-24 EP-6 Batch Control Form for TADS and Manual Vouchers......................................... EP-25

GEORGIA WIC 2012 PROCEDURES MANUAL

Emergency Plan

I.

INTRODUCTION

The following information is provided to the districts for incorporation into the District Emergency Plan. In contrast to commodity distribution of food stamps, Georgia WIC is a limited grant supplemental food program that serves a specific population with special nutritional needs. Georgia WIC is not designed or funded to meet the basic nutritional needs of emergency 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 Georgia WIC in emergency relief, nor is there legislative authority for using Georgia WIC food funds for purposes other than providing allowable food benefits to categorically eligible participants.

No additional WIC funds are designated by law for WIC emergency relief, and WIC must operate in an emergency 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 emergency victims.

Georgia WIC may briefly suspend WIC operations during some instances and rely entirely on other emergency 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.

Georgia WIC staff should participate in Emergency Planning activities and exercises, including floods, tornadoes, hurricanes, etc; prior to a declared emergency if it benefits WIC and it is included in the State/District Emergency Plan(s). However, WIC staff can not perform non-WIC duties prior to an emergency being declared or after the emergency declaration is no longer in effect.

A. Purpose
The Purpose of this Emergency Plan is to: 1. Restore WIC services to current participants as soon as possible. 2. Expand services to the eligible population in emergency affected areas. 3. Respond in a manner consistent with the Georgia Department of Public
Health.

B. Scope

These guidelines incorporate the Georgia Department of Public Health, Public Health Emergency Response Plan (PHERP), Georgia Public Health Internal Operating Procedures Volume I, and Georgia WIC Operating Plan. These plans should be followed in the event of an emergency or emergency that disrupts service delivery at local 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 emergency plans consistent with those policies that have been developed by their parent agencies. Georgia WIC guidelines will reflect the purpose, authority, and responsibilities developed by Georgia Department of

EP-1

GEORGIA WIC 2012 PROCEDURES MANUAL

Emergency Plan

Public Health.
Georgia WIC and local agency (ies) must also make an initial and on-going assessment as to the feasibility of distributing ready-to-feed 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 emergency.

II. POLICIES
Concept of Operations: Operations will be conducted in three phases that may overlap as outlined in the Georgia Department of Public Health, 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 Department of Public Health or detected by the public health system in Georgia. The Department 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 emergency, Phase One will be complete when a determination is made of health consequences associated with the emergency. The Office of the Director, Department of Public Health, will provide direction for the use of any public health assets involved in any investigation. District Health 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. County Health Departments will determine local response 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 completed when the emergency is contained and the community begins to return to normal functions as determined by local, District and State officials.
The District Nutrition Services Director or designee serves as the local lead and is responsible for coordinating local WIC responses to an emergency.

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Specific decisions concerning Georgia WIC actions during an emergency depends upon the duration and magnitude of the emergency, and upon specific directions from the Chief of the Office of Nutrition and WIC. The focus of Georgia WIC activity is to support local

agency service delivery. These guidelines primarily reflect Georgia WIC responsibilities in the event of disruption of services in one local agency. In the event of an emergency at the State agency, Georgia WIC personnel will follow the rules developed by the State Health Director. In the event of an emergency or emergency involving both local and State agencies, the initial focus of Georgia WIC 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 an emergency that respond to the specific needs created by the emergency.

III. ASSESSING IMPACT OF THE EMERGENCY The extent of damage caused by the emergency or emergencies must be assessed by the local agency. To determine if delivery of services is feasible, the following questions should be answered:
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 Emergency? 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 Georgia WIC assist with aiding the health district?
7. Has the area been declared a Federal emergency?

IV. CONCEPT OF OPERATION
A. General
The Office of Nutrition and WIC Director and / or designee shall keep an Emergency Plan folder. The Emergency Plan folder provides the current home addresses and telephone numbers for Georgia WIC staff, the Regional Food and Nutrition Services Offices, District/County Public Health Unit Emergency Planning Coordinators, State Health Office Emergency Planning Coordinators, District Nutrition Services Directors, statewide and local chapters of the American Red Cross, U.S. Department of Agriculture Food Distribution Program, and other nonprofit and private programs. Home addresses and telephone numbers are confidential and will be used only in an emergency.

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B. Organization
Chief of the Office of Nutrition and WIC Responsibilities: 1. Contact the Division of Public Health Emergency Coordinator.
2. Contact the Regional Food and Nutrition Services Office.
3. If needed, contact the formula manufacturers to secure ready to feed (RTF) formula with nipples and bottles.
a. Follow through on receipt and delivery of formula b. Visit area to make on-site assessment of support staff, etc.
State Level Responsibilities
Various Office of Nutrition and WIC staff members have responsibilities in the Georgia WIC Emergency Plan. The overall responsibilities for implementation and reporting on WIC's response to the emergency lies with the Chief of the Office of Nutrition and WIC. The Chief of the Office of Nutrition and WIC will use a telephone tree to notify staff of the emergency and provide instructions for responding to the emergency. The telephone tree is as follows:
1. Chief of the Office of Nutrition and WIC calls all Unit Directors, WIC Legal Officer(s), Executive Secretary, and Breastfeeding Coordinator.
2. Each Unit Director and Executive Secretary calls each of their subordinate staff.
WIC Unit managers and consultants will be responsible for coordinating staff and analyzing the emergency as follows:
The Systems Information Unit Manager (in conjunction with local District Nutrition Services Director(s) 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 an emergency, coordinating mass shipment of supplies, storage, and coordinating the issuance of food vouchers to participants, including remote printing, equipment issues and emergency procurement of vouchers.
The Financial Unit Manager will be responsible for tracking and reconciling emergency related costs.
The Compliance Analysis Unit 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 Management Unit Manager will be responsible for informing local agency (ies) of authorized WIC vendors open for business.
The Nutrition Services Unit Manager will be responsible for assisting in

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certification and food package issuance, nutrition education, and food safety preparation information.
The Breastfeeding Coordinator will be responsible for assisting with 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 Office of Nutrition and WIC to meet a specific county's needs during an emergency.
The State and local agencies may be asked to assign staff to designated emergency assistance location(s) (not always a health department facility) in order to provide WIC services more expediently.
When an emergency 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 Georgia WIC at 1-800228-9173 to report their status and phone number where they can be reached. Attachment EP-1 is a form designed to collect data for this purpose.
Staff Documentation Requirements:
1. Any office that has staff working on emergency activities must maintain a Staff Availability Form (see Attachment EP-1),
Employee Personnel Time Tracking Form (see Attachment EP-2), and a current Communication Log (see Attachment EP-3). One log per office should be maintained per pay period and kept on file.
2. The Staff Availability Form (see Attachment EP-1) must show which employees are available for emergency operations and when they were notified.
3. Each employee should maintain and retain an Emergency Personnel Time Tracking Form (see Attachment EP-2) to document hours worked during an emergency. If the Federal Emergency Management Agency (FEMA) or other funding sources become available, the Emergency Daily Work Activity Logs will be used to help document hours worked (see Attachment EP-4).
4. The Communication Log (see Attachment EP-3) should show the communication made with respect to and during the documented emergency.

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Contractors
Each entity that has a contract with Georgia WIC must have a Plan of Operation for Emergencies, including H1N1, and submit the plan by April 30 of each year. The plan must contain at least the following:
1. Assurance that notification will be provided to Georgia WIC by contacting the x State WIC Director, Brian Castrucci at 404-657-2851; BB 404-404775-2380; and x Emergency Plan Coordinator, Candace Jones, at 404-657-8754; BB 678-429-4867
within 24 hours of an emergency situation occurring. The notice must include the reason for the emergency, and confirmation that the plan will be implemented.
2. A contact list with at least two persons listed with name, work phone number, cell or home phone number and work e-mail address included.
3. Assurance that notification will be provided to Georgia WIC of any services that will be delayed due to the emergency situation and the anticipated date or an assurance that those services will resume as soon as practicable.
4. Assurance that notification will be provided to Georgia WIC that the emergency has ended, and that the Emergency plan is no longer in effect.

The status of emergency plans with contractors is listed below:
1. Fulton-DeKalb Hospital Authority (Grady): plan submitted and on file
2. Southside Medical Center: plan submitted and on file
3. CSC: plan submitted and on file
4. Federation of Southern Cooperatives: plan submitted and on file
C. Notification
Lines of communication during an emergency begin with local WIC offices contacting the main local agency office. Local agencies would contact their District Nutrition Services Director, who will contact the District Emergency Coordinator. Georgia WIC Emergency Plan will be implemented following notification from the local District Nutrition Services Director, who has cleared these plans with his or her District Emergency Coordinator. Georgia WIC will contact the State Health Office Emergency Coordinator and appropriate WIC retail vendors.

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V. RESPONSIBILITIES
A. Facilities
During an emergency, 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 Georgia WIC 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 any 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 Georgia WIC Financial Unit, within seventy-two (72) hours after the emergency area returns to normal.
Georgia WIC staff must respond to an emergency situation, in cooperation with the State Office of Emergency Preparedness, to assist the local agency to identify buildings, equipment, medical services, general supplies, and any other resources required to continue service delivery. Portable weighing and measuring equipment may be critical in an emergency situation. This will include assisting in finding potential locations for direct distribution of infant formula and food that are most accessible to participants. Whenever possible, Georgia WIC will coordinate communications and services with other state program offices, such as Maternal and Child Health, TANF, SNAP, and Emergency Assistance Centers.
B. Issuance
During periods of an emergency, every effort will be made to continue issuance of food vouchers to participants. When adverse circumstances persist, such as the lack of available facilities, records or food instrument supplies, Georgia WIC 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. Staff must maintain and update the number of infants on special formula at all times. Securing formula for WIC infants affected by the emergency is the top priority of any Georgia WIC emergency relief plan. Ready-to-feed formula may be necessary if the area's water supply is contaminated and/or electrical power is disrupted. State government 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 emergency area returns to normal or if another agency accepts responsibility for formula (e.g., 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 Vendors (Grocery Stores): The State and local agency will share information to establish and maintain a list of retail grocery stores that

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remain in operation following the emergency. The State and local agency will notify participants of available stores in their vicinity, hours of operation and a detailed listing of available WIC approved foods.
2. Direct Distribution: If retail purchase is not viable, then direct distribution measures will be considered. The local agency, state staff, and emergency coordinator will determine that retail purchase is not viable when a significant number of clients are unable to purchase WIC approved foods. This could be due to the closure of many retail stores, the inability of many clients to get to a retail store, or disruption of the supply of food to stores.
State and local agencies will coordinate efforts to contact the Red Cross and other relief agencies to arrange for methods of food distribution to current participants and to newly eligible participants. Georgia WIC will arrange for the supply and distribution of food items and/or food vouchers to the local agency in need. For those local agencies in close proximity to Georgia WIC, the State Agency may become directly involved with the distribution. If the District office is closer in proximity, efforts will be made by Georgia WIC to coordinate distribution to the local agency through the District office. When District offices are affected by the emergency, Georgia WIC may elect to take other appropriate measures to supply the local agency with infant formula, other food, e.g., 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 will contain a clause addressing alternative measures for acquisition and distribution of infant formula in the case of an emergency.
3. Special Formula/Hospital Based Formula: Georgia WIC and local agency (ies) will estimate the quantity of special formula and hospital based formula needed to sustain services until normal operations are restored. Georgia WIC will then take measures to ensure that affected local agencies have supplies in the types and quantities needed. This may include Georgia WIC contracts with manufactures, wholesalers, suppliers, retailers, and other local agencies. Procurement, shipment, and local storage of infant formula will be the responsibility of Georgia WIC.
4. Food Vouchers: Local agencies should maintain at all times a minimum back up supply of preprinted and blank 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, Georgia WIC 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 of Georgia WIC Procedures Manual (see alternative food package section.) Local agencies have the option of converting participants to a special food package (e.g., homeless
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package) under any of the following circumstances:
a. Lack of refrigeration, or b. Lack of food preparation facilities (e.g., living in a shelter, motel,
etc.). C. Certification and Voucher Issuance
1. Depending upon the duration and severity of the emergency, appropriate measures will be taken by Georgia WIC to minimize the disruption of certification services at the local agency.
2. When facilities' medical services, equipment, general supplies and staff are available, Georgia WIC will assist local agencies in maintaining services. When specific facilities, medical services, or staff is needed, Georgia WIC will enact measures to meet those needs through other local agencies or Georgia WIC resources.
3. Special provisions for expedited certifications may be authorized with approval from Georgia WIC.
4. Georgia WIC gives local agencies the right to extend the length of certification of applicants when no proof of residency or identity exists (such as when an applicant or an applicant's parent is a victim of theft, loss, emergency, or emergency, 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.
5. Districts/Clinics should consider requesting an extension of the processing standards for up to 15 days, for pregnant and breastfeeding women and infants.
6. Districts/Clinics should also consider implementing the thirty (30) day extension period for clients due for a recertification that have appointment scheduling difficulties. One month's worth of vouchers must be issued and a new recertification appointment must be provided to the participant.
7. Districts/Clinics should consider mailing one (1) month of vouchers to participants. (Refer to the Food Delivery Section of the Procedures Manual, VII. Mailing/Delivery of WIC Vouchers procedures).
D. Nutrition Education Contacts
Nutrition education may be provided in-group or individual settings during certification and voucher issuance while in emergency situations.
Nutrition education during an emergency should address:

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1. Food safety 2. Meal planning 3. Food preparation 4. Nutrition needs of the individual 5. Safe water supply 6. General sanitation 7. Relocation shelters for emergency purposes

Emergency Plan

VI. RESOURCE REQUIREMENTS
The requirements for providing services to Georgia WIC participants during an emergency includes providing: staff, certification equipment, computers, voucher issuance printers, supplies, infant formula, manual vouchers, TADs (pre-numbered and blank), a data set and /or Masterfile list of participants available electronically or hard copy, and transportation. See the information below:
A. Staff Requirements
1. Analyze the needs caused by the emergency as well as to monitor and control the response.
2. Coordinate Georgia WIC staff and nutrition volunteers from around the state.
3. Schedule shifts for volunteers and help to obtain lodging at the emergency site.
4. Schedule and coordinate staff at the local office and Georgia WIC.
5. Coordinate with local agency financial staff, as well as to monitor and track all emergency recovery related costs.
B. Certification Equipment, Computers, Voucher Issuance Printers, and Supplies
1. Plan to procure, borrow or reassign certification equipment, computers, voucher issuance printers and corresponding supplies for alternate location, if needed.
2. Plan to provide an electronic or hard copy of all procedures, forms, and documents that an alternate location may need in order to provide services either electronically or manually.
C. Infant Formula
1. Obtain storage facilities near the affected emergency area for storing an extra supply of infant formula. Obtain manpower to move formula from trucks to storage to shelter.

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2. Plan to procure, ship, store and distribute infant formula and food to emergency areas.
3. Contact distribution personnel (e.g., helicopters, airplanes, over land all terrain trucks).
D. Food Vouchers and TADs
1. Obtain a supply of blank voucher paper stock for Georgia WIC remote printing.
2. Obtain a supply of blank and manual food vouchers for issuance.
3. Print and ship pre-printed food vouchers to the emergency area.
4. Obtain a supply of both blank and pre-numbered TADs specific to the county or clinic.
E. Operational Retail Vendors
1. Local agencies should share information concerning which retail vendors are open or closed with the State office to ensure that up to date retail vendor information is available for participants.
2. The State office should share information concerning which retail vendors are open or closed with Local agencies to ensure that up to date retail vendor information is available for participants.
F. Clinic Data Set and/or Masterfile List
1. If possible, create an electronic data set of all WIC participants for the District /County/clinics that includes the certification status, last date of voucher issuance, and voucher numbers for each
participant to be used to continue certifications and voucher issuance.
2. If an electronic data set is not possible, then ensure that the District and each County/clinic has a list of all WIC participants that includes certification status either in electronic or hard copy format. If necessary, pull the Masterfile list. However, understand that the Masterfile list is not an up to date report.
3. If possible, request your front end computer system contactor to generate these electronic data sets, lists, or hard copies for your District/Counties/clinics.
G. Transportation
1. Arrange transportation for volunteer staff.

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2. Arrange transportation for local distribution of infant formula.
VII. TYPES OF EMERGENCIES
There are many types of emergencies that may occur in the State of Georgia. Attachment EP-5 lists the type and probability of their occurrences.
VIII. MANUAL CERTIFICATION WITH VPOD OR MANUAL VOUCHER ISSUANCE
A. CPA manually completes the appropriate Certification Form (Pregnant, Postpartum, Breastfeeding, Infants and Children). Complete Demographic information, Proof fields and Income Information (see Income Guidelines).
1. If an applicant does not qualify for WIC, have the applicant sign the Certification Form, and complete the Notice of Termination/Ineligibility/Waiting List form. Copy and date the Proof and place them in the file.
2. If a participant does qualify for the program, complete the same information above and begin to complete a Turnaround Document (TAD). Use a pre-numbered TAD for new participants and a blank TAD for participants being added to a family using an existing family number. Use the Edits Manual Data Dictionary to reference required fields for each transaction type.
B. CPA manually completes the nutrition assessment, food package assignment, and nutrition education and record this information on the Certification Form, Nutrition Questionnaire, Nutrition Education Flow Sheet, Growth Chart, and any other documentation forms necessary.
1. Infant
a. Calculate infant's age at first day to use for each food package to be issued (Coordinate CPA Food Package Code (FPC) and food package code (FPC)).
b. Confirm correct food package code (FPC) to issue.
c. Look up voucher codes and messages for food package.
2. Women and Children
a. Look up voucher codes and messages for food package.
b. Watch for special situations turning 1 year old, turning 2 years old, postpartum breastfeeding type, 6 months
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postpartum, and breastfeeding infants.

3. Participants with qualifying conditions on special formulas

a.

Review that Medical Documentation is complete.

b. Look up voucher codes and messages for both halves of food package when applicable.

C. Complete the Turnaround Document (TAD). Enter all fields that must be completed for WIC type. Always complete Date Form Completed and Transaction Code.

D. Issue VPOD or Manual Vouchers (Refer to Food Delivery Section).

E. Issue WIC ID card and WIC Approved Food List.

F. Explain Vouchers, Dual Participation, WIC Approved Foods List and location of grocery stores.

IX. NUTRITION EDUCATION, FOOD PACKAGE CHANGE OR OTHER MANUAL CHANGES WITH VPOD OR MANUAL VOUCHER ISSUANCE
A. Verify that a client is in a valid certification period and last date vouchers were issued using the data set or Masterfile list of participants.
B. CPA performs assessment and/or provides nutrition education if needed and documents in record.
C. Assign new food package code (FPC), if needed.
1. Infant
a. Calculate infant's age at first day to use for each food package to be issued (Coordinate CPA Food Package Code (FPC) and food package code (FPC)).
b. Confirm correct food package code (FPC) to issue.
c. Look up voucher codes and messages for food package.

2. Women and Children
a. Look up voucher codes and messages for food package.
b. Watch for special situations turning 1 year old, turning 2 years old, postpartum breastfeeding type, 6 months postpartum, and breastfeeding infants.

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3. Participants with qualifying conditions on special formulas
a. Review that Medical Documentation is complete.
b. Look up voucher codes and messages for both halves of food package when applicable.
D. Complete the Turnaround Document (TAD). Enter all fields that must be completed for WIC type. Always complete Date Form Completed and Transaction Code.
E. Issue VPOD or Manual Vouchers (Refer to Food Delivery Section).
F. Update WIC ID card and provide WIC Approved Food List, if needed.
G. Explain Vouchers, Dual Participation, WIC Approved Foods List and location of grocery stores, if needed.

X. VPOD OR MANUAL VOUCHER ISSUANCE ONLY
A. Ask participant/parent/guardian for WIC ID Card and verify identity of the person picking up the vouchers.
B. Verify that client is in a valid certification period and last date vouchers were issued using the clinic data set or Master file list of participants.
C. Review food package to ensure correct package is issued.

1. Infant

a. Calculate infant's age at first day to use for each food package to be issued (Coordinate CPA Food Package Code (FPC) and food package code (FPC)).

b. Confirm correct food package code (FPC) to issue.

c. Look up voucher codes and messages for food package.

2. Women and Children

a. Look up voucher codes and messages for food package.

b. Watch for special situations Turning 1 year old, turning 2 years old, postpartum breastfeeding type, 6 months postpartum, and breastfeeding infants.

3. Participants with qualifying conditions on special formulas

a.

Review that Medical Documentation is complete.

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b. Look up voucher codes and messages for both halves of food package when applicable.
D. Issue VPOD or Manual Vouchers (Refer to Food Delivery Section, FD-9). E. Update WIC ID card and provide WIC Approved Food List, if needed.
F. Explain Vouchers, Dual Participation, WIC Approved Foods List and location of grocery stores, if needed.

XI. REPLACING LOST VOUCHERS
A. Policy allows the reissuance of lost vouchers for those participants who live in a declared emergency area.
B. Process for replacing lost vouchers:
1. Determine if the participant resides in an area that has been designated as an area affected by a Declared Emergency:
2. Determine which vouchers the participant has lost and need replacement.
3. Call the CSC Help Desk to determine which lost vouchers have been cashed and processed by the bank.
a. Listed below is the information that staff will need to provide to CSC:
1. Voucher numbers 2. Participant ID number 3. Name of participant 4. Clinic, County and District number 5. Name of staff member requesting the information
b. Phone number is 1-800-796-1850.
c. Hours of operation are from 7:30 am to 5:00 pm, Eastern Standard Time (EST).
4. After receiving the verification information of lost vouchers that have been cashed or not cashed from the CSC Help Desk, document the voucher information for lost vouchers that have NOT BEEN CASHED on the Lost/Stolen/Destroyed Voided Voucher Report (per family/participant). Use as many pages as necessary to document information.
5. Replacement vouchers will only be issued for vouchers that have NOT BEEN CASHED by the participant and document on all voucher receipts, "Replacement Vouchers-Declared Emergency."

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6. Make and distribute up to four copies of the Lost/Stolen/Destroyed Voided Voucher Report: a. Place original in the participant's file. b. Place one copy in the Lost/Stolen/Destroyed Voided Voucher file. c. Send one copy to your district office for their Lost/Stolen/Destroyed file. d. Send one copy to the State WIC Office to the Compliance Unit. e. Send one copy to the clinic that originally issued the vouchers if the participant picked up replacement vouchers at a different clinic.

7. Void all copies of previously issued vouchers that have been replaced vouchers that have NOT BEEN CASHED) in the computer system.

XII. VOUCHER ORDERING, RECEIPT, AND CLOSE-OUT OF ADP CONTRACTOR PRINTED VOUCHERS
A. Ordering ADP Contractor Printed Vouchers
1. In emergency situations when clinics are unable to print vouchers for a period of time, the ADP contractor has the capability of producing vouchers. In cases of emergencies, vouchers can be ordered from the ADP contractor through Georgia WIC.
2. ADP contractor printed vouchers must be ordered through Georgia WIC by contacting the Systems Information Unit Manager and copying the Chief of the Office of Nutrition and WIC.
3. ADP contractor printed vouchers will be delivered to identified sites by overnight delivery.
B. Receipt of ADP Contractor Printed Vouchers
1. ADP contractor printed vouchers will be delivered to each clinic (or box #1, if there is more than one (1) box) along with a Voucher Cycle Packing List and Voucher Registers.
2. Clinics will compare beginning and ending voucher numbers to those on the Clinic Voucher Cycle Packing List.
3. Any discrepancies must be reported immediately by telephone to the ADP contractor and to a Systems Information Unit staff member of Georgia WIC.
4. The Packing List must be signed and dated to verify receipt. A copy of the signed/dated Packing List must be mailed to the District office within five days of receipt of the vouchers. The original must be retained by the clinic for one (1) year plus the current Federal fiscal year.

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5. The District receives a copy of each detailed Clinic-Packing List for control, and a summary copy showing total vouchers received within the District.

6. All Packing Lists received by the District must be reconciled with the clinic's copy and the District's copy must be signed and dated. Any discrepancies must be reported to the ADP contractor and Georgia WIC immediately. Missing shipments must also be reported to the ADP contractor and the Office of Nutrition and WIC.

7. All vouchers must be stored in a locked cabinet, desk, or closet when not being issued. Voucher Registers and Computer Printed vouchers must be stored and locked in separate locations.

8. ADP contractor printed vouchers are received by the clinic in alphabetical order of the last name of the lead family member within each Sort Code. The lead family member is the one with WIC type P, N, or B or with the lowest Participant ID Number (usually #1).

C.

Issuing of ADP Contractor Printed Vouchers

1. Ask participant/parent/guardian for WIC ID Card and verify identity of the person picking up the vouchers.

2. Verify that client is in a valid certification period and status of last vouchers issued using the Masterfile List of participants.

3. Pull participant vouchers and recheck that vouchers are the correct ones for the participant.

4. Locate the participant's name and voucher numbers on the voucher register.
5. Prorate if applicable:
a. Fruit and Vegetable Voucher must be issued (Do not include in the proration) This voucher code begins with a "P".
b. Write or stamp "VOID" on the prorated voucher(s) not issued.
c. Circle the corresponding voucher number(s) on the voucher register and write "VOID" near the circled voucher number(s) for the vouchers that were not issued.
d. Make a correction on the Voucher Register to reflect the number of vouchers issued for the month based on proration.
6. Have the participant/parent/guardian sign the Voucher Register for each month of vouchers issued.

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7. Staff issuing the vouchers will initial and date the Voucher Register next to the participant/parent/guardian's signature.

8. Document the ID proof code on the left side of the Voucher Register.

9. Update ID Card and provide WIC Approved Food List, if needed.

10. Explain Vouchers, Dual Participation, WIC Approved Foods List and location of grocery stores, if needed.
D. End of Month Close-Out for ADP Contractor Printed Vouchers and Voucher Registers
1. When completing end of month closeout, the clerk must assure that all voucher register entries contain a participant's signature. Entries that are missing the participant's signature must be marked "Failed to Sign", followed by the clerk's initials and date.
2. All vouchers not issued to participants must be voided during the end of the month close out and documented as "Void" on the voucher registers, followed by the clerk's initials and date.
3. All voided vouchers must be stamped "Void" and mailed to the ADP contractor. (These vouchers should not be batched) Mail all voided vouchers to:
CSC Covansys 1000 Cobb Place Blvd Building 100, Suite 190 Kennesaw, Georgia 30144
Attn: John Reynolds
4. Voucher registers should not be mailed to the ADP contractor and must be retained by the clinic for three years plus the current Federal fiscal year.
5. Close-out must be completed by the fifth working day of the following month.

E. Batching and Processing Manual TADs
1. If a clinic can not enter TAD information into the front end computer system within fifteen (15) days of service, mail paper copies of TADs to the ADP contractor after receiving written approval from Georgia WIC.
2. Count completed paper TADs and separate copies.

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GEORGIA WIC 2012 PROCEDURES MANUAL

Emergency Plan

3. Complete Batch Control Form (see Attachment EP-6) for TAD copies, do not batch TADs with Manual Vouchers.

4. Mail top copy of TADs with Batch Control Form to:

Covansys/CSC P O Box 2507 Greenwood, IN 46142

5. Create a Batch Control module with copies of the TADs and a copy of the Batch Control Form by date for future reference and verification.

6. When TADs are received in the clinic from the ADP contractor, clerk must verify information against clinic copy of TAD. Correct any errors and resubmit information electronically.

F. Batching and Processing Manual Vouchers

1. Count completed paper Manual Vouchers (both issued and voided) and separate copies.

2. Complete Batch Control form for Manual Voucher copies, do not batch Manual Vouchers with TADs.

3. Mail second copy of Manual Vouchers with Batch Control form to:

Covansys/CSC P O Box 2507 Greenwood, IN 46142

4. Create a Batch Control module with copies of the Manual Vouchers and a copy of the Batch Control form by date for future reference and verification.

XIII. TIPS FOR OPERATING A MANUAL SYSTEM
A. Verify the Manual Voucher beginning number daily to ensure that you start with the correct batch. (Remember that there are now ten sets of vouchers)
B. Set up cycle vouchers and Manual Vouchers on a long table with labels and large signs (e.g. ,W01-Issue five vouchers per set) in a secure location that is out of reach of clients but easy for staff to use.
C. Maintain voids and unissued vouchers in numerical order at all times.
D. Separate voucher copies by using an organizer system to keep in numerical order.

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Attachment EP-1


Date


Time Call Received


Staff Availability

District/Unit Clinic

Staff Name





Staff Telephone


Return to Work Date


Return to Work Time


Closure of Issue




















































































































































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Emergency Personnel Time Tracking Form Summarize incident related activities:

Attachment EP-2

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
EP- 21

GEORGIA WIC 2012 PROCEDURES MANUAL


Communications Log

Date

Time

Name of Communicator

Message

Person Receiving Communication

Action Taken

Attachment EP-3

Lead Person

Closure of Issue

EP- 22

GEORGIA WIC 2012 PROCEDURES MANUAL



DATE:

/

NAME: DISTRICT:

EMERGENCY DAILY WORK ACTIVITY LOG

/

OFFICE:

SSN:

Attachment EP-4

PAGE

OF

NEW ACTIVITY TIME: :
ACTIVITY LOCATION: Activity Description:

AM PM to :

AM PM BLDG:

OTHER:

NEW ACTIVITY TIME: :
ACTIVITY LOCATION: Activity Description:

AM PM to :

AM PM BLDG:

OTHER:

NEW ACTIVITY TIME: :
ACTIVITY LOCATION: Activity Description:

AM PM to :

AM 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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GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment EP-5

EMERGENCY PROJECTIONS AND PLANNING ASSUMPTIONS

EP- 24

GEORGIA WIC 2012 PROCEDURES MANUAL

Attachment EP-6

GEORGIA WIC

DISTRICT/UNIT

CLINIC

BATCH CONTROL FORM

DATE //

NUMBER //

INSTRUCTIONS

1. USE THIS FORM AS A COVER SHEET TO FORWARD ALL TADS (CERTIFICATIONS, UPDATES, TRANSFERS AND TERMINATIONS) AND ISSUED/VOIDED MANUAL VOUCHERS.
2. DO NOT BATCH TADS WITH MANUAL VOUCHERS
3. SUBMIT THIS FORM WITH THE TADS AND ISSUED MANUAL VOUCHERS TO:
CSC COVANSYS P.O. BOX 2507 GREENWOOD, IN 46142
SUBMIT THIS FORM WITH THE VOIDED MANUAL VOUCHERS TO:
CSC COVANSYS 1000 COBB PLACE BLVD BUILDING 100, SUITE 190 KENNESAW, GEORGIA 30144 ATTN: JOHN REYNOLDS

CSC COVANSYS INPUT SECTION
COMMENTS:

4. RETAIN A COPY OF THIS FORM IN THE CLINIC WITH COPIES OF THE TADS, ISSUED MANUAL VOUCHERS OR VOIDED MANUAL VOUCHERS, CREATING A BATCH CONTROL MODULE.

TYPE OF DOCUMENT

NUMBER IN BATCH

TURNAROUND

ISSUED MANUAL VOUCHERS
VOIDED MANUAL VOUCHERS

DATE SENT BY DISTRICT/UNIT

PREPARER'S SIGNATURE

DATE RECEIVED AT CSC COVANSYS SIGNATURE

DATE ENTERED AT CSC COVANSYS SIGNATURE

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GEORGIA WIC 2012 PROCEDURES MANUAL


Glossary

Georgia WIC GLOSSARY



GEORGIA WIC 2012 PROCEDURES MANUAL

Glossary


999 - A food package number or voucher code within the range of 900-999 that is created by a WIC District or WIC clinic; also called a "District/Clinic-Created Food Package or Voucher Code."
Above 50% Vendors Authorized vendors who receive more than 50% of their annual sales revenue from the sale of WIC food instruments.
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 (SNAP, TANF, and Medicaid).
ALJ Administrative Law Judge.
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.
Administrative Review A hearing process offered to a vendor to appeal adverse actions taken by Georgia WIC. (See Georgia WIC Vendor Handbook.)
Adopted Child - Child who lives with a family that has court-ordered permanent legal custody and legal responsibility.
ADP Advance Planning Documents.
AEGIS The State-developed automated clinic computer system.
Affiliates Any partner, member, owner, officer, director, employee, relative by blood or marriage, heirs, or assigns. (See Georgia WIC Vendor Handbook.)
Affirmative Action Plan - Portion of the State Plan which describes how Georgia WIC will

be initiated and expanded within the State's jurisdiction.
Age at Voucher Issuance An infant's age in months and days (based on calendar months) as of the "First Day To Use" date on each set of vouchers.
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 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 - Enrollment report which lists selected participant information for all active participants.
Alternate Parent The other parent of the child. A spouse and the biological parent can be an alternate parent.
Alternative Food Packages Additional food package options available for homeless participants, migrants, and disaster situations.
AAP American Academy of Pediatrics.
And Justice For All Poster - Poster which must be displayed in a conspicuous location in each WIC Clinic site indicating the WIC nondiscriminatory clause.
Annual Training An annual mandatory participation for all vendors to receive program



GEORGIA WIC 2012 PROCEDURES MANUAL

Glossary (cont'd)

updates and reminders and verify their receipt and understanding for program updates and reminders. (See Georgia WIC Vendor Handbook.)
Applicants - Pregnant women, breastfeeding women, postpartum women, infants, and children who are applying to receive WIC benefits. Applicants include individuals who are currently participating in the program but are re-applying because their certification period is about to expire.
Automated Termination Action - The system which automatically terminates a participant when a child reaches his/her fifth birthday, a non-breastfeeding woman at six months, a breastfeeding woman at twelve months from delivery, failure to pickup vouchers for two full consecutive months, transfer out of clinic or district/unit, terminated from waiting list, pregnant woman at EDC + 75 days, or overdue for certification. Participants are automatically terminated 45 days from the certification date.
Automatic Clearing House (ACH) An electronic funds transfer network which enables participating financial institutions to distribute electronic credit and debit entries to bank accounts and to settle such entries. (See Georgia WIC Vendor Handbook.)
Automatic Update of Infant to Child - The system automatically updates an infant to a child when the infant reaches his/her first birthday.
Auto Dialer System (IAS) A system that gives health providers technology tools to remind, schedule and call participants.
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 three-ply form which is completed for each transmitted batch of

TADs and sent to the WIC contractor. A completed form contains the date the batch was assembled, and a four-digit sequence number assigned to this batch (cannot 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 person who prepares the batch should sign and date the Batch Control Form upon completion (do not mix TADs and vouchers in a batch). The top copy of the form goes to the ADP contractor. The second and third copies are retained by the clinic. The form is rarely used but must be retained for emergency use.
Blank Manual Vouchers - Vouchers that require manual entry of certain information by the clinic prior to issuance. They are commonly used for issuance at times when clinic is unable to produce VPOD vouchers.
BMI Body Mass Index.
Break in Enrollment The period or lapse of time between a valid certification period and the subsequent certification.
Breastfeeding Women - Women up to one year postpartum who are breastfeeding their infants. Federal regulations (7 CFR 246.2) define a woman as breastfeeding if she feeds breastmilk to her infant(s) on average at least once every 24 hours. Re-lactation/induced lactation after a period of not breastfeeding or lactation by a woman who is not the biological mother of the infant also qualifies the woman as a breastfeeding mother for WIC.
BRFSS Behavior Risk Factor Surveillance System.
Budget - Itemized summary of probable expenditures and income for a given period.
Calendar Year - Period of time between January 1st and December 31st.
Case Worker An individual certified by the Department of Family and Children Services

Glossary-2

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Glossary (cont'd)

(DFACS) to act on behalf of a guardian with legal rights given to them by the state.
Cash Income - Applicants/participants who are paid money on site for services rendered.
Cash Value Voucher A fixed-dollar amount check, voucher electronic benefit transfer (EBT) card or other document which is used by a participant to obtain authorized fruits and vegetables. (See Georgia WIC Vendor Handbook.)
Categorical Eligibility - Woman, Infant and Child who meet the definitions of pregnant women, breastfeeding women, postpartum women, infants or children.
Categorical Termination - Child who has reached his/her fifth birthday; postpartum nonbreastfeeding woman six months after delivery; postpartum breastfeeding woman twelve months after delivery.
CAU Compliance Analysis Unit.
CDC Centers for Disease Control and Prevention
CDPHP Chronic Disease Prevention and Health Promotion Program.
Certification - Implementation of criteria and procedures to assess and document each applicant's eligibility for WIC.
CFO Chief Financial Officer.
Children - Children 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. CMPs cannot exceed $10,000 per violation or $40,000 per investigation.
Civil Rights The personal rights of the individual citizen to have equal treatment and

equal opportunities.
Clinic - A facility where WIC business is conducted (Certification and Voucher Issuance)
Closeout Month - Third month (sixty days) after vouchers were issued.
Closeout Reconciliation Report - Report generated at the clinic level to give the final disposition of all VPOD vouchers.
CMIA Cash Management Improvement ACT.
Coding of Records - Documenting special codes on records for special treatment for applicants/participants.
Collections - Repayment of WIC funds that were fraudulently obtained and must be paid by cashier's check or money order.
Communal Feeding - Group meals or food supplies.
Competent Professional Authority (CPA) 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 and local agencies may authorize and train to serve as a competent professional authority: physicians, nutritionists, (Bachelors or Masters Degree in Nutritional Sciences, Community Nutrition, Clinical Nutrition, Dietetics or , Public Health Nutrition), registered dietitians, licensed dietitians, registered nurses, LPNs, and physician 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 CPA on the staff of the local agency.

Glossary-3

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Glossary (cont'd)

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. Rarely used since the inception of VPOD. Contractor must retain the ability to produce vouchers in case of emergency.
Computer-Printed Voucher Register Listing of participants who have computergenerated vouchers produced during a cycle. The register provides space for the participant's signature upon distribution of vouchers.
Computing Income - Review documents (e.g., check stubs, IRS forms, etc.) to determine the income eligibility of the WIC participant.
Confidentiality - WIC may provide participant certification information to other Public Assistance providers to determine if the participant is eligible for services. No other information may be provided to any other person or entity without obtaining the participant's permission.
Contract Brand Infant Formula All infant formula (excluding exempt infant formula) produced by a manufacturer awarded the infant formula cost containment contract by the State agency on a rebate basis.
Corporate Vendor A WIC authorized vendor that has more than one store with the same FEIN. (See Georgia WIC Vendor Handbook.)
Cost Containment Measure - Competitive bidding, rebate or direct distribution implemented by a State agency as described in its approved State Plan of operations and administration.
CSFP - Commodity Supplemental Food Program administered by USDA.

Court Order Request by a judge or requesting documents or physical presence of an individual in court.
CSC Covansys EDP firm contracted by the State Agency to manage all computer requests and data reports.
Covert Compliance Investigation or Compliance Buy: A covert, onsite investigation in which a representative of Georgia WIC poses as a participant, parent, or caregiver of an infant or child participant, or proxy, to transact one or more food instruments without revealing during the visit that he or she is a WIC representative. (See Georgia WIC Vendor Handbook.)
CPA FPC Competent Professional Authority Food Package Code. Umbrella term for the food package code assigned by the CPA; reflects the types and quantities of foods to be issued over a certification period; may represent multiple internal food package codes (e.g., as in the case of infant participants who are assigned one CPA FPC but who are transitioned through multiple internal food packages with varying quantities of formula and supplemental foods from birth through age 11 months without making any change to the CPA FPC).
Cumulative Unmatched Redemption Redeemed manual vouchers, which have not matched to either an issuance record (Part 1) or with a valid client ID number or valid certification. Local agencies are required to review the redeemed vouchers appearing on the CUR reports. The vouchers must be reconciled with the data processor or a manual reconciliation must be done, depending on how much time has elapsed since the voucher was issued.
CUR Part 1 - Cumulative Unmatched Redemptions which have not been matched to an issuance record.
CUR Part 2 - Cumulative Unmatched Redemptions which have not been matched to

Glossary-4

GEORGIA WIC 2012 PROCEDURES MANUAL

Glossary (cont'd)

a valid certification record or valid WIC ID number.
Customized Training training which vendors can request to suit their specific training needs. (See Georgia WIC Vendor Handbook.)
Days For WIC purposes it means calendar days, unless otherwise noted. (See Georgia WIC Vendor Handbook.)
Day Worker - Individual who contracts for labor or services on a daily basis.
DCH Department of Community Health.
Declination Statement Forms - Form used to document refusal to want to register to vote.
Delivery The act of transferring a product from a seller to its buyer outside the confines of the retail food establishment.
Delivery Date - Date of actual delivery of an infant (or the date the pregnancy ended for a postpartum woman).
Disability - Physically incapacitating or disabling condition which prevents or restricts normal accessibility or activity; included are visual and hearing impaired individuals.
Discrimination - The act of treating someone differently on the basis of that individual's race, religion, ethnicity, national origin, age, physical ability, gender, or sexual orientation.
Disqualification - Act of ending WIC participation of a certified participant, authorized food vendor, or authorized State or local agency, whether as a punitive sanction or for administrative reasons.
Disqualified Vendors Vendors whose WIC authorization ends as consequence of punitive sanction for violation of WIC regulations and policies or for administrative reasons.

District / Clinic-Created Food Package or Voucher Code A food package number or voucher code within the range of 900-999; also called a "999" food package or voucher code.
DMA - Division of Medical Assistance.
DOAS Department of Administrative Services.
Documentation The presentation of written or electronic documents which substantiate statements made by an applicant or participant or a person applying on behalf of an applicant.
DOD - Department of Defense.
DOL Department of Labor.
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.
DMP Division of Payment Management.
Dual Participation Report Report that specifies possible dual participants in alphabetic sequence, which must be investigated by the local agency and submitted to Georgia WIC.
Dual Participation - WIC participants who receive benefits twice in the same clinic or from more than one clinic at the same time.
EBT - Electronic Benefit Transfer.
EDC (Estimated Date of Confinement) Date of expected delivery for a pregnant woman.
Education Level - Highest level or grade completed, for women participants only.

Glossary-5

GEORGIA WIC 2012 PROCEDURES MANUAL

Glossary (cont'd)

Enrollee - 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 - Detailed listing of all computer equipment or property purchased with WIC funds and valued at a minimum of $1000.00.
EDP Electronic Data Processing.
ETAD Electronic Turn Around Document.
EVOC Electronic verification of certification: An electronic system for documenting the issuance of verification of certification. Produced by computer interface with the GWISnet masterfile. EVOC cards do not require inventories.
Exclusively Breastfed (EBF) Infant feeding type; an infant who receives no formula from WIC.
Exclusively Breastfeeding (EBF) Woman feeding method; a breastfeeding woman whose infant receives no formula from WIC.
Exempt Infant Formula - Infant formula designed for infants with medical conditions (e.g., prematurity, low birth weight, metabolic disorders, etc.). Some exempt infant formulas are also classified as medical foods. All exempt infant formulas require medical documentation for issuance by WIC.
Fair Hearings - Procedures which a person or his/her guardian uses to enact the right to appeal a decision or action by the State or local agency which results in the individual's denial of participation, suspension, or termination from WIC.
Family - 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.

Department of Family and Children Services (DFACS) State government agency responsible for the welfare of children.
Family Size - Total number of individuals in a family unit (whether related or un-related as defined above).
Fiscal Year - WIC 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).
FMS Financial Management System.
FNS - Food and Nutrition Service of the United States Department of Agriculture.
Food Delivery System - Method used by State and local agencies to provide supplemental foods to participants.
Food Costs - Costs of supplemental foods.
Food Instrument - Voucher, check, coupon or other document, which is used by a WIC participant to obtain supplemental foods.
Food Package I Federal food package designation for infants from birth to <6 months of age who do not qualify for Food Package III.
Food Package II Federal food package designation for infants from 6 months to <12 months of age who do not qualify for Food Package III.
Food Package III Federal food package designation for medically fragile women, infants, and children with qualifying medical conditions who are prescribed special formulas/medical foods.
Food Package IV Federal food package designation for children ages one to five years who do not qualify for Food Package III.

Glossary-6

GEORGIA WIC 2012 PROCEDURES MANUAL

Glossary (cont'd)

Food Package V Federal food package designation for pregnant and mostly breastfeeding women who do not qualify for Food Package III.
Food Package VI Federal food package designation for non-breastfeeding postpartum women and women breastfeeding some who do not qualify for Food Package III.
Food Package VII Federal food package designation for exclusively breastfeeding women (single or multiple infants), women pregnant with multiple fetuses, and women mostly breastfeeding multiples who do not qualify for Food Package III.
Food Sales Sales of all SNAP eligible foods intended for home preparation and consumption, including meat, fish, and poultry; bread and cereal products; dairy products; fruits and vegetables. Food items such as condiments and spices, coffee, tea, cocoa, and carbonated and noncarbonated drinks may be included in food sales when offered for sale along with foods in the categories identified above. Food sales do not include sales of any items that cannot be purchased with food stamp benefits, such as hot foods or food that will be eaten in the store. (See Georgia WIC Vendor Handbook.)
Food Sales Establishment License A license granted by Georgia Department of Agriculture which permits the retail food vendor to sell food items. (See Georgia WIC Vendor Handbook.)
Form #1 - Medical Documentation Form for WIC Special Formulas and Approved WIC Foods; form used to provide medical documentation for standard infant formulas requiring medical documentation (e.g., Similac Sensitive), exempt infant formulas and medical foods as well as any WIC supplemental foods issued to clients prescribed such products.
Form #2 - Referral Form and Medical Documentation for Special Food Substitutions; form used to provide medical referral data

and/or to authorize special milk substitutions for women and children.
Foster Care - A program that provides temporary substitute homes for children whose families cannot provide a safe and nurturing environment for them.
Foster Child - A child placed by a State agency or a court in the care of someone other than his or her natural parents.
Fraud - Intentional deception.
FReD Functional Requirement Document for computer changes.
Full Nutritional Benefit The maximum amounts of allowed WIC supplemental foods.
Fully Formula Fed (FFF) Infant feeding type; an infant who receives formula from WIC that exceeds the maximum monthly formula allowance for Mostly Breastfed infants; Fully Formula Fed infants can also receive breastmilk. The mother of a FFF infant is classified as either "Fully Formula Feeding / Non-Breastfeeding" (WIC Type N) or as "Some Breastfeeding" (WIC Type B), depending on whether or not the mother is providing any breastmilk.
GAAAP Georgia Chapter American Academy of Pediatrics.
Georgia WIC Special Supplemental Nutrition Program for Women, Infants and Children (WIC) that operates in Georgia.
GPAN Georgia Coalition for Physical Activity and Nutrition.
GPHA Georgia Public Health Association.
GRITS Georgia Registry of Immunization Transactions and Services.
Grant Award (Formula Grant/Grant Allocation) - Total (food and administrative) dollars allocated to the State for the Federal Fiscal Year based on funding formula.

Glossary-7

GEORGIA WIC 2012 PROCEDURES MANUAL

Glossary (cont'd)

Guardian - An individual who has been given legal responsibility for a minor child.
GWIS Georgia WIC Information System. Desktop reporting system containing all of the monthly and quarterly reports produced by the State's data processing contractor as well as custom client reports.
GWISnet Georgia WIC Information SystemNetwork.
GUI Graphic User Interface.
Health Services - Ongoing, routine pediatric and obstetric care (such as infant, children, prenatal and postpartum examinations) or referral for treatment.
Height - Vertical length (depending on the age) of a participant to the nearest eighth inch.
Hematocrit Hematological measurement used to screen for nutritional risk of anemia.
Hemoglobin - Hematological measurement used to screen for nutritional risk of anemia.
HN2 Healthnet2. Automated Computer clinic/System used in D/U 10-0.
HighRisk Vendor A vendor identified as having a high probability of committing a vendor violation through application of the criteria established in 246.12(j)(3) and any additional criteria established by the State agency. (See Georgia WIC Vendor Handbook.)
HIPAA (Health Insurance Portability and Accountability Act) Protects the privacy of individually identifiable health information, and the confidentiality provisions of the Patient Safety Act, which protects identifiable information being used to analyze patient safety events and improve patient safety.
HMO Health Maintenance Organization.

Homeless Individual - 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 - 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 receipt of WIC services and benefits.
Hotline A phone line designated for WIC applicants/participants to request WIC services or to place a complaint or discuss discriminatory matters.
ICD-9 / ICD-10 Codes Medical diagnostic coding system from the International Classification of Diseases, 9th Revision / 10th Revision.
ICIV Internet Check Image Viewer.
Identification - Valid picture ID or other valid ID such as Driver's License, Birth Certificate, Immunization record, etc.
ILSI International Life Science Institute.

Glossary-8

GEORGIA WIC 2012 PROCEDURES MANUAL

Glossary (cont'd)

Immigrant A person who leaves one country to settle permanently in another.
Immunization - Vaccines that are given to children to help them develop antibodies as protection against specific infections.
Inadequate Participant Access - Condition that exists when the nearest authorized WIC vendor is ten (10) miles or more away from another authorized WIC vendor.
Incident/Complaint Form A Form used to document complaints/incidents from participants, vendors, USDA, etc.
Income - Gross cash income before deductions for income taxes, employee's social security taxes, insurance premiums, bonds, etc.
Income Exclusion - Income or benefits received that are not counted as income.
Income Inclusion - Monetary compensation for services including wages, salary, commissions or fees that are counted as income.
Income Tax Form - Legal statement of earnings and deductions as prescribed by the IRS Tax Codes.
Infant Participants from birth to less than 12 months of age.
Infant Feeding Type Georgia WIC designation for the infant feeding method: Exclusively Breastfed (EBF), Mostly Breastfed (MBF), and Fully Formula Fed (FFF).
Infant Food Fruit and Vegetables Jars of baby food fruits and vegetables issued to infant participants.
Infant Meat Jars of baby food meat issued only to Exclusively Breastfed infant participants.

Infant Formula A food which purports to be or is represented for special dietary use solely as a food for infants by reason of its simulation of human milk or its suitability as a complete or partial substitute for human milk.
Infant Mid-Certification Nutrition Assessment - Assessment to be completed between five and seven months of age for an infant. The infant's weight, height, nutritional practices, nutritional risk, and food package needs are evaluated during this assessment. This assessment ensures accessibility to quality health care services.
Initial Contact Date - Date an applicant first visits or calls the WIC clinic and requests WIC benefits.
Institution - Residential facility designed to provide meals and living accommodations for individuals intended to be institutionalized but excludes private residences or homeless facilities.
Institutionalize - Reside in, by choice or otherwise, an established residential facility that provides accommodations and meals.
Internal Food Package Code (Internal FPC) The system food package codes used within a CPA FPC for the computer system to automatically transition the participant between different food packages based on the infant participant's age or on the special food package situation (such as a woman exclusively breastfeeding multiple infants).
Interpreter - Someone who converts one spoken language into another.
Interview Script - Provides WIC applicants/participants with general WIC information.
Inventory - Detailed list of all goods and materials on hand.
Inventory Audit The examination of food invoices or other proofs of purchase to determine whether a vendor has purchased

Glossary-9

GEORGIA WIC 2012 PROCEDURES MANUAL

Glossary (cont'd)

sufficient quantities of supplemental foods to provide participants the quantities specified on food instruments redeemed by the vendor during a given period of time. (See Georgia WIC Vendor Handbook.)
Issue Month - Month in which voucher's "First Day To Use" date appears.
Joint Custody - 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.
LASP Local Agency Special Project.
Last Date of Use - The last date on which the food instrument may be used to obtain authorized foods. (See Georgia WIC Vendor Handbook.)
LQA - Living Quarter Allowance for military applicant/participant living off base.
Leave and Earnings Statement (LES) Military paycheck stub.
Legal Custody - Court ordered custody of a person.
LEP - Limited English Proficient.
Letter of Household Income - Statement attesting to household income by wage earner(s).
Local Agency - A public or private, nonprofit health or human service agency, which provides health services, either directly or through contract.
Logger - Individual whose primary employment is the harvests of trees seasonally; and for such works the person establishes temporary residence.
Mandatory Sanction Penalty imposed by USDA for certain violations of WIC

regulations. (See Georgia WIC Vendor Handbook.)
Manual Voucher Inventory Log Documentation that vouchers are inventoried on a weekly and monthly basis.
MDF Medical Documentation Form.
MDS Minimum Data Set.
Medical Care Start Date - Month of pregnancy in which woman began receiving prenatal care.
Medical Diagnosis Identification of a disease or condition by a scientific evaluation of physical signs, symptoms, history, laboratory test results, and procedures; the translation of data gathered by clinical evaluation into an organized, classified definition of the conditions present; can only be provided by a health care provider with prescriptive authority in the State of Georgia for use by Georgia WIC.
Medical Documentation Medical information provided by a health care provider with prescriptive authority in the State of Georgia; documents the medical need for and authorizes the use of special formulas, medical foods, special milk substitutions, and WIC supplemental foods that are not contraindicated by the participant's medical condition; can only be signed by physicians, physician assistants, or nurse practitioners.
Medical Food - A WIC-eligible medical food refers to certain enteral products that are specifically formulated to provide nutritional support for individuals with a diagnosed medical condition when the use of conventional foods is precluded, restricted, or inadequate. Such WIC-eligible medical foods may be nutritionally complete or incomplete, but they must serve the purpose of a food, provide a source of calories and one or more nutrients, and be designed for enteral digestion via an oral or tube feeding. All medical foods require medical documentation

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GEORGIA WIC 2012 PROCEDURES MANUAL

Glossary (cont'd)

for issuance by WIC. Some medical foods are also classified as exempt infant formulas.
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 operational agreement between the State of Georgia and the Health District or local 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 - 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 - 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 Required inventory that all vendors must carry everyday at all times, including, but not limited to, fruits and vegetables, and whole grains. Pharmacies are exempt from keeping minimum inventory. (See Georgia WIC Vendor Handbook.)
Minimum Inventory Requirement Waiver Waiver is granted to reduce the minimum inventory when a WIC vendor has difficulty selling WIC food items.
M&M (Mitchell and McCormick) Privately developed automated clinic computer system.
Mostly Breastfed (MBF) Infant feeding type; an infant who receives formula from WIC that does not exceed the maximum monthly formula allowance for a Mostly Breastfed

infant (up to approximately half the amount of formula issued to a Fully Formula Fed [FFF] infant).
Mostly Breastfeeding (MBF) - Woman feeding method; a breastfeeding woman whose infant receives a Mostly Breastfed food package.
Mother / Baby Dyad The process of thinking of a mother and her infant as a single unit or pair instead of as two separate individuals for the purposes of assigning food packages and feeding methods. A mother's food package must be based upon her infant's or infants' feeding method(s) and the amount of formula, if any, that the infant(s) receive from WIC.
Motor Voter Act - Act that mandates WIC's obligation to offer voter registration opportunities to anyone entering a clinic for WIC benefits.
Motor Voter Forms - Form issued to applicants who wish to register to vote.
Native American - Original inhabitants of America; an American Indian.
Netsmart Privately developed automated clinic computer system used in D/U 03-5.
Natural Disaster An occurrence in nature causing wide spread destruction (e.g., tornado, flood, hurricane, etc.)
No Proof Form - Form used when an applicant for WIC cannot provide documented proof of identification, residence or income.
Non-Breastfeeding - Postpartum woman who is not breastfeeding an infant.
Non-Contract Brand Infant Formula All infant formula (including exempt infant formula) that is not covered by an infant formula cost containment contract awarded by the State agency and is not subject to rebates.

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GEORGIA WIC 2012 PROCEDURES MANUAL

Glossary (cont'd)

Non-Corporate Vendor A WIC authorized vendor that has only one store or a vendor with more than one store, each with a different FEIN. (See Georgia WIC Vendor Handbook.)
Non-Participation Participant in a valid certification period who did not pick up (manual or computer) vouchers is counted as a non-participant.
Non-Discrimination Statement A statement used to ensure compliance with the law not to discriminate on the basis of race, color, national origin, sex, age or disability.
Non-English Speaking - Individual whose primary language is not English or who speaks little English.
Nonprofit Agency - Private agency which is exempt from income tax under the Internal Revenue Code of 1954, as amended.
Non-WIC Inventory Food items that are not a part of the WIC minimum inventory or the WIC Approved Foods List. (See Georgia WIC Vendor Handbook.)
NPM National Performance Measure.
NSA Nutrition Services and Administration.
NSU - Nutrition Services Unit.
NTD Neural Tube Defect.
NTIWL - Notice of Termination/Ineligibility/ Waiting List
Numeric Client Master file - Enrollment report, which lists all active participants by WIC ID number and by clinic within a District. This report is a cross reference for the Alphabetic Client Master file.
Nutrition Education - Individual or group education sessions which include the provision of information and educational

materials designed to improve health status, achieve positive change in nutritional habits, and emphasize relationships between nutrition and health.
Nutritional Assessment Medical data and nutritional practices 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; nutritional deficiencies that impair or endanger health; or conditions that predispose persons to inadequate nutritional patterns or nutritionally related medical conditions.
Offense or Violation A vendor's act against WIC rules, regulations, policies or procedures. (See Georgia WIC Vendor Handbook.)
OFS Office of Financial Service.
OIG - Office of the Inspector General.
Overseas WIC Program - Program similar to the USDA-operated program that qualifies military persons, their dependents and government civilians for WIC benefits overseas.
Overt Monitoring or Routine Monitoring Overt, onsite monitoring during which WIC representatives identify themselves to vendor personnel. (See Georgia WIC Vendor Handbook.)
Participant - Person who has been issued at least one voucher during the reporting period.
Participation - Sum of the number of persons who have received supplemental foods or food instruments during the reporting period and the number of infants breastfed by participant breastfeeding women (and receiving no supplemental foods or food instruments) during the reporting period.

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GEORGIA WIC 2012 PROCEDURES MANUAL

Glossary (cont'd)

Patient Flow Analysis - Tool to analyze the time ranges for a certification, voucher issuance, appointments and challenges.
Patient Flow Form - Form used to collect data and measure patient flow from entry to exit.
Paid Cash - Applicant/Participant paid in cash for work or services rendered.
Pay Stub - Statement of paid income earned.
PedNSS - Pediatric Nutrition Surveillance System (PedNSS) is a national nutrition surveillance system administered by CDC.
Peer Group Vendors' classification assignment based on square footage, the type of store, or other USDA-approved criteria determined by the State agency.
Pharmacy Vendor A WIC authorized vendor that is only allowed to redeem exempt infant formulas and medical foods. No contract formula, standard infant formula requiring medical documentation (e.g., Similac Sensitive), or other standard WIC food sales are allowed for these vendors. (See Georgia WIC Vendor Handbook.)
Physical Presence - Applicant for WIC services must be present in the clinic to request WIC services unless a valid exemption is documented.
PNNS Data - Pregnancy Nutrition Surveillance System (PNSS) is a national nutrition surveillance system administered by CDC.
P.O. Box - Post Office Box.
Policy A written document which explains procedures, principles or gives guidance.
PSP Physician Sponsor Plan.
Post Vendor Training Evaluation - 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 - Guidelines prescribed by the U. S. Department of Health and Human Services that adjusts the guidelines annually. These Guidelines are effective July 1 of each year for WIC.
PHSO Public Health State Office.
PRAMS Pregnancy Risk Assessment and Monitoring System.
Pre-Approval Visit An on-site visit to a vendor's retail food establishment to verify location and inventory. (See Georgia WIC Vendor Handbook.)
Pregnancy Outcome - Results of the just ended pregnancy for the postpartum woman participant.
Pregnant / Prenatal Women - Women determined to have one or more embryos or fetuses in utero regardless of the woman's age.
Prenatal Weight - Prenatal woman's weight prior to delivery.
Prescription - Written instruction provided by a physician, physician assistant, or certified nurse practitioner for administration or preparation of medicine, infant formula, or medical food. See also medical documentation.
Prescriptive Authority Health care provider licensed to write medical prescriptions according to State law. In Georgia, the only health care providers with prescriptive authority and who can sign medical documentation for the purposes of Georgia WIC are doctors (e.g., MD, DO), nurse practitioners (e.g., NP, APRN, CNP, PNP, CPNP, CNNP, etc.) and physician assistants (e.g., PA, PA-C).

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GEORGIA WIC 2012 PROCEDURES MANUAL

Glossary (cont'd)

Presumptive Eligibility - Individual presumed eligible for Medicaid benefits based upon information presented.
Price Adjustment An adjustment made by the State agency, in accordance with the vendor agreement, to the purchase price on a food instrument which complies with the State agency's price limitations. (See Georgia WIC Vendor Handbook.)
Priority I - Pregnant women, breast-feeding women, and infants at nutritional need determined by measuring height/weight, a blood test and by assessing nutrition status and nutrition related medical history.
Priority II (Breastfeeding women) - Women who do not qualify under priority I but who are breastfeeding Priority I infants.
Priority II (Infants) - Infants up to six months of age born to women who were WIC participants during their pregnancy, or infants born to women who were not WIC participants during their pregnancy but had a nutritional need.
Priority III (Children) - Children (under the age of five [5] years) with a nutritional need. This need is determined by measuring height/length, weight, a blood test and assessing nutrition status and nutrition related medical history.
Priority III (Postpartum) - Postpartum teenagers who are not breastfeeding and whose delivery date was prior to their being 18 years and 10 months of age.
Priority IV - Pregnant women, breastfeeding women, and infants with a nutritional need because of inappropriate nutrition practices or homeless/migrancy status.
Priority V - Children with a nutritional need because of inappropriate nutrition practices or homeless/ migrancy status.

Priority VI - Postpartum, non-breastfeeding women with a nutritional need or homeless/migrancy status.
Privacy/Privacy Rights The condition of being secluded from view.
Procedures Manual - Document that lists Federal and State procedures for WIC.
Processing Standards - Period of time between an applicant's requesting WIC services in person or by telephone and the time he/she receives services.
Product Yield - The number of reconstituted fluid ounces of concentrate or powdered formula per container. For example, one 12.6 oz. can of powder Similac Sensitive, when mixed at standard dilution, yields 90 fluid ounces of reconstituted formula.
Proof - Documentation that identifies ID, Residency and income.
Program - Special Supplemental Nutrition Program for Women, Infants and Children (WIC) authorized by section 17 of the Child Nutrition Act of 1966, as amended.
Program Review Audit of Local Agency.
Prorate - 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 participant is late picking up their vouchers.
Protective Services DFACS program that protects the rights of children.
Proxy - Responsible person whom the participant/ parent/guardian/caregiver chooses to act on his/her behalf. A participant may designate up to two persons to act as proxies. The proxies must sign the proxy 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.

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GEORGIA WIC 2012 PROCEDURES MANUAL

Glossary (cont'd)

Public Comment Period A time required by federal regulation to offer the general public the opportunity to comment on Georgia WIC.
Purchase Price A space for the purchase price to be entered. (See Georgia WIC Vendor handbook.)
Qualifying Medical Condition Lifethreatening disorders, diseases, or medical conditions that impair the ingestion, digestion, absorption, or utilization of nutrients that could adversely affect the client's nutritional status. Examples include but are not limited to premature birth, low birth weight, metabolic disorders, gastrointestinal disorders, immune system disorders, failure to thrive (FTT), and malabsorption syndromes.
Racial Group of Participant - 1=White, 2=Black/ African American, 3=Asian, 4=American Indian/ Alaska Native, 5=Native Hawaiian/Other Pacific Islander.
RBB Results Based Budgeting
RCCI Residential Child Care Institution.
Ready-To-Feed Formula An infant formula or medical food that does not require the addition of water prior to consumption.
Reason for Certification - Participant's nutritional need for WIC, based on the medical/nutritional data collected at the time of certification.
Re-authorization Training A mandatory recertification training that all vendors participate in every three (3) years. (See Georgia WIC Vendor Handbook.)
Reconstituted Fluid Ounces The number of fluid ounces of concentrate or powdered formula after mixing with water.
Redemption - Exchange of WIC vouchers for supplemental foods at participating grocery stores. Only types and amounts authorized

foods listed on the face of the voucher may be purchased.
Redemption Period The date by which the vendor must submit the food instrument for redemption. This date must be no more than 60 days from the first date on which the food instrument may be used. (See Georgia WIC Vendor Handbook.)
Refugee - Person 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.
Release of Information Legal document that gives staff permission to provide confidential WIC information.
Residency - Determined by using the applicant's documented proof of address.
Residual Funds - Funds available for allocation to State agencies after every State agency has received stability funding.
Return Voucher Payment Form - Form #3760 used by Vendor when sending vouchers that have been returned to them from the bank, to the State WIC Branch for payment.
RFP Request for Proposal.
RMSS Random Moment Sample Study.
Sanction A penalty that is imposed when Georgia WIC rules, regulations, policies or procedure are violated. (See Georgia WIC Vendor Handbook.)
Seasonal Farmworker - Worker employed in agriculture occupation whose residence is temporary for the purpose of such work.
Secretary - The Secretary of Agriculture.
SFF Stress free feeding.

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GEORGIA WIC 2012 PROCEDURES MANUAL

Glossary (cont'd)

SFPD - Supplemental Food Programs Division of the Food and Nutrition Service of the United States Department of Agriculture.
Sign and Signature A handwritten signature on paper or an electronic signature.
(See Georgia WIC Vendor Handbook.)
SIS Systems and Information Section.
SNAP/SNAP Benefits (formerly Food Stamp Program/Food Stamps) Federal program that supplements the foodpurchasing ability of low-income households through the distribution of electronic benefits transferring the funds of which can be used to purchase food for human consumption.
Some Breastfeeding (SBF) - Woman feeding method; a breastfeeding woman whose infant receives a Fully Formula Fed (FFF) food package in addition to breastmilk.
Special Formula See "Exempt Infant Formula" in Glossary.
Special Population - Individual or a group of individuals with common needs who require special assistances or services to access and participate in WIC related services.
Special Site Visit - Official District/clinic visit requested by Georgia WIC due to various clinic problems. A District/clinic may be called one day and a site visit may take place the next day due to the severity of the problem identified.
SPM State Performance Measure.
Spouse A marriage partner; husband or wife.
Stability Funds - Funds allocated to any State agency for the purpose of maintaining its preceding years' Program operating level.
Staff Signature - Official signature that verifies the income residency, identification and family size are correct as stated by the participant. The Staff signature also

verifies/witnesses the participant signature and that the participant has been advised to read (or have read to them) their rights and obligations.
Standard Dilution - Following the regular mixing instructions for the preparation of concentrate or powdered formula (i.e., not adding more or less water than the standard mixing instructions). For example, the standard dilution of concentrate formula is to mix 13 ounces of water with 13 ounces of concentrate formula (i.e., one can of concentrate formula) to produce 26 ounces of reconstituted formula containing 20 calories/ounce.
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. In this instance, Georgia WIC. (See Georgia WIC Vendor Handbook.)
State-Created Food Package or Voucher Code A three-digit food package number or voucher code. State-created food package numbers and vouher codes can begin with either a letter (e.g., A-Z) or be within the numerical range of 000-999.
Stimulus Check Money issued by the government to revitalize the economy.
State Plan - Plan of WIC operations and administration that describes the manner in which the State agency intends to implement and operate all aspects of WIC administration within its jurisdiction.
Supplemental Foods WIC foods that promote health as indicated by relevant nutritional science, public health concerns, and cultural eating patterns containing nutrients determined to be beneficial for pregnant, breastfeeding, and postpartum women, infants, and children.

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GEORGIA WIC 2012 PROCEDURES MANUAL

Glossary (cont'd)

TANF - Temporary Assistance for Needy Families Program.

TCOYH Take Charge of Your Health.

Temporary Accommodation - Public or private shelter or the residence of another person used for temporary living and sleeping accommodations.

Temporary Relocation - Establishment of a temporary residence for individuals whose primary place of residence is lost as the result of disaster, or other privation.

Termination Discontinuance of vendor participation in Georgia WIC. (See Georgia WIC Vendor Handbook.)

Thirty (30) Day Issuance - Issuance of vouchers to participants for thirty (30) days until documentation is received.

Transfers Act of moving a WIC participant currently receiving WIC services to another WIC location.

Turnaround Documents (TADs), Blank TAD which only has the Clinic Code field preprinted on it. This TAD is used for enrolling any additional family members into the computer system through the use of either an Initial Certification, Waiting List, or Out of State Transfer input transaction. 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 - 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

into the computer system through the use of

either an Initial Certification, Waiting List, or

Out of State Transfer input transaction. TAD

may also be used to complete an in-state

transfer or any tome a Computer Printed TAD is not available.
Unemployed - Individual who is not currently being paid for labor or services.
Update - Transaction used to change, correct, or update information for a participant already assigned an ID number on the computer system.
USDA - United States Department of Agriculture.
USDHHS United States Department of Health and Human Services.
VC Voucher Codes.
VPOD - Vouchers printed on demand/on-site.
VHA - Variable Housing Allowance.
VENA Value Enhanced Nutritional Assessment.
Vendor A grocery store that provides WIC approved food items.
Vendor Authorization The process by which the State agency assesses, selects and enters into agreements with stores that apply or subsequently reapply to be authorized as WIC vendors. (See Georgia WIC Vendor Handbook.)
Vendor Compliance Investigation - Vendors that have been identified as "High Risk" by the Georgia WIC through the use of VIP'S, complaints, or request for investigation forms received from the districts.
Vendor Identification A number assigned to all authorized vendors. Redemption activity must be identified by the vendor that submitted the food instrument. Each vendor operated by a single business entity must be identified separately. (See Georgia WIC Vendor Handbook.)

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GEORGIA WIC 2012 PROCEDURES MANUAL

Glossary (cont'd)

Vendor Materials - List of resources available through Georgia WIC that pertains to vendor management.
Vendor Monitoring - Overt compliance visit that is conducted on site by WIC representatives.
Vendor Number - A unique four-digit number that is used to identify vendors authorized to provide WIC food items. (See Georgia WIC Vendor Handbook.)
Vendor Overcharge Intentionally or unintentionally charging the State agency more for authorized supplemental foods than is permitted under the Vendor Agreement. It is not a vendor overcharge when a vendor submits a food instrument for redemption and the State agency makes a price adjustment to the food instrument. (See Georgia WIC Vendor Handbook.)
Vendor Peer Group System A classification of authorized vendors into groups based on common characteristics or criteria that affect food process, for the purpose of applying appropriate competitive price criteria to vendors at authorization and limiting payments for food to competitive levels. (See Georgia WIC Vendor Handbook.)
Vendor Profile - Summary of information about a vendor designed to show their overall standing within WIC.
Vendor Registry Update - Form used to update information regarding authorized WIC vendors.
Vendors Review Form - Tool used to document a vendor's shelf prices and inventory of WIC approved foods.
Vendor Sanctions - Penalties that are assessed against an authorized WIC vendor for violating WIC policy and/or regulations that may lead to disqualification.

Vendor Stamp - Uniquely numbered instrument that is used by vendors to prepare vouchers for payment.
Vendor Training The procedures the State agency will use to train vendors in accordance with Federal regulations 246.12(i). (See Georgia WIC Vendor Handbook.)
Vendor Training Checklist - Form that lists topics which are covered during a training session.
Vendor Training Sign-In Sheet -Form used to document attendance at a training session.
Vendor Violation Any intentional or unintentional action of a vendor's current owners, officers, managers, agents, or employees (with or without the knowledge of management) that violates the vendor agreement or Federal or State statutes, regulations, policies, or procedures governing WIC. (See Georgia WIC Vendor Handbook.)
Verbal Order Temporary medical documentation provided verbally (instead of in writing) from an authorized health care provider with prescriptive authority in the State of Georgia.
VIPS (Vendor Integrity Profile System) Computerized database that contains information on all vendors in Georgia.
VMU Vendor Management Unit.
VOC - Verification of certification confirming that all requirements for WIC participation have been met.
VOC Card - Certification card from a WIC clinic verifying that the named person is a valid WIC participant entitling that individual to transfer certification to another WIC clinic.
Vouchers Instrument used or issued by clinic staff to WIC participant s to acquire food from vendor/ grocery store.

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GEORGIA WIC 2012 PROCEDURES MANUAL

Glossary (cont'd)

Voided Vouchers - 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 (VPOD) Vouchers printed as the participant appears in the clinic.
Voucher Security - Vouchers are negotiable items, which are presented to the bank as a check for cash reimbursement. All vouchers must be securely protected as checks or cash in order to help prevent voucher theft, and deter WIC fraud.
Voucher Number - Serial numbers of the vouchers produced for a participant.
Waiver A decision to waive a minimum inventory requirement which will replace the vendor's basic WIC inventory requirements. (See Georgia WIC Vendor Handbook.)
Weight - Total weight in pounds and ounces of a participant.
Weight, Prior to Delivery - Woman's final pregnancy weight immediately prior to delivery.
WIC The Special Supplemental Nutrition Program for Women, Infants and Children authorized by section 17 of the Child Nutrition Act of 1966, 42 U.S.C. 1786. (See Georgia WIC Vendor Handbook.)
WIC Approved Foods Supplemental Foods containing nutrients determined to be beneficial for pregnant, breastfeeding, and postpartum women, infants and children. (See Georgia WIC Vendor Handbook.)
WIC Caseload - The total number of active participants on Georgia WIC.

WIC-Eligible Medical Foods - Certain enteral products that are specially formulated to provide nutritional support for individuals with a diagnosed medical condition, when the use of conventional foods is precluded, restricted, or inadequate.
WIC Enrollment - The total number of active WIC participants by category (prenatal women, post partum women, breastfeeding women, infants and children)
WIC ID Number Number that uniquely identifies the participant consists of three data elements: A nine-digit family identification number, a one-digit check digit, and a onedigit participant code. All members of a family should be assigned the same family identification number to facilitate voucher distribution.
WIC Participant - A person who has met the income guideline and nutritional risk requirements of the program and issued at least one set of vouchers during the reporting period. WIC Type - Classifies participants into 5 categories: P=Pregnant Woman (Prenatal), N=Non-breastfeeding postpartum woman, B=Breastfeeding postpartum woman, I=Infant, and C=Child.
YRBS Youth Risk Behavior Survey.
Zero Income - Applicant/participant who receives no income from any source as defined at 246.7 d(2)(ii).

Glossary-19