2013 Georgia WIC procedures manual & state plan

2013 GEORGIA WIC PROCEDURES MANUAL
& STATE PLAN
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GEORGIA DEPARTMENT OF PUBLIC HEALTH

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Introduction

TABLE OF CONTENTS

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GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Introduction

I.

PURPOSE/MISSION

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II. SCOPE
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III. REFERENCES
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IV. PRIOR APPROVAL
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V. POLICY/ACTION MEMOS
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Introduction

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VI. SECTIONS
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2 Georgia WIC Program Glossary
3 Statewide Standard List (Abbreviations, Acronyms and Symbols) VII. ADMINISTRATION
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VIII. ADDRESSES
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DISTRICT/ADDRESS
District 1, Unit 1 (Rome)
C. Wade Sellers, M.D., M.P.H. 'LVWULFW +HDOWK 'LUHFWRU Margaret Bean, BSN, M.S., R.N. 3URJUDP 0DQDJHU Rhonda Tankersley RD, LD, CLC 1XWULWLRQ 6HUYLFHV 'LUHFWRU 1RUWKZHVW *HRUJLD 5HJLRQDO +RVSLWDO 5HGPRQG 5RDG %OGJ 5RPH *$ )$;

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DISTRICT/ADDRESS
District 1, Unit 2 (Dalton)
Harold W. Pitts, M.D. 'LVWULFW +HDOWK 'LUHFWRU Louise Hamrick, MSN, MBA, RNCS, FNP 3URJUDP 0DQDJHU Karen Rutledge, RD, LD, CLC 1XWULWLRQ 6HUYLFHV 'LUHFWRU : :DOQXW $YHQXH 6XLWH 'DOWRQ *$ )$;
District 2 (Gainesville)
David Westfall, M.D., CPE 'LVWULFW +HDOWK 'LUHFWRU Edith Parsons, PhD, MEd 3URJUDP 0DQJHU Charlene Thompson, LD 1XWULWLRQ 6HUYLFHV 'LUHFWRU $WKHQV 6WUHHW *DLQHVYLOOH *$ )$;

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District 3, Unit 1 (Cobb)

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John Kennedy, MD, MBA 'LVWULFW +HDOWK 'LUHFWRU Lisa Crossman, M.S. 3URJUDP 0DQDJHU Barbara Stahnke, MS, RD,LD 1XWULWLRQ 6HUYLFHV 'LUHFWRU &RXQW\ 6HUYLFHV 3NZ\ 0DULHWWD *$ )$;

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DISTRICT/ADDRESS District 3, Unit 2 (Fulton)

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Patrice Harris, MD, MA 'LVWULFW +HDOWK 'LUHFWRU Pat Cwiklinski, RD,LD,CLC 1XWULWLRQ 6HUYLFHV 'LUHFWRU Fulton County Health Department and Wellness )DLUEXUQ 5RDG 6XLWH $WODQWD *$ )$;

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District 3, Unit 3 (Clayton)

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Alpha Bryan, M.D. 'LVWULFW +HDOWK 'LUHFWRU Tania Lynch, RN, MSN, CLNC 3URJUDP 0DQDJHU Glenn Pryor, RD, LD 1XWULWLRQ 6HUYLFHV 'LUHFWRU &OD\WRQ &RXQW\ +HDOWK 'HSDUWPHQW %DWWOH &UHHN 5RDG -RQHVERUR *$ )$;

District 3, Unit 4 (Gwinnett)
Lloyd M. Hofer, M.D., M.P.H. 'LVWULFW +HDOWK 'LUHFWRU Connie Russell 3URJUDP 'LUHFWRU Diane Shelton, RD, LD,CLC 1XWULWLRQ 6HUYLFHV 'LUHFWRU 32 %R[ 5LYHUVLGH 3DUNZD\ /DZUHQFHYLOOH *$ )$;

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DISTRICT/ADDRESS District 3, Unit 5 (DeKalb)

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Sandra Elizabeth Ford, MD, MBA 'LVWULFW +HDOWK 'LUHFWRU Katrina Green, MBA 3URJUDP 0DQDJHU Gregory French, RD,LD,CPT 1XWULWLRQ 6HUYLFHV 'LUHFWRU *OHQGDOH 5RDG 6FRWWGDOH *HRUJLD )$;

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District 4 (LaGrange)

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Alpha Bryan, MD

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Freda V. Mitchem, RD, LD

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District 5, Unit 1 (Dublin)

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Lawton Davis, M.D.

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Bruce Evans, M.S.

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

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DISTRICT/ADDRESS
District 5, Unit 2 (Macon)
David N. Harvey, M.D. 'LVWULFW +HDOWK 'LUHFWRU Roy Moore 3URJUDP 0DQDJHU Nancy Jeffery, MPH, RD, LD 1XWULWLRQ 6HUYLFHV 'LUHFWRU &ROXPEXV 5RDG 6XLWH % 0DFRQ *HRUJLD )$;

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District 6 (Augusta)
Ketty M. Gonzales, M.D. 'LVWULFW +HDOWK 'LUHFWRU John Nolan 3URJUDP 0DQDJHU Dorothy Hart, RD,LD ,QWHULP 1XWULWLRQ 6HUYLFHV 'LUHFWRU (DVW &HQWUDO +HDOWK 'LVWULFW 2IILFH 1RUWK /HJ 5RDG $XJXVWD *$ )$; Contact Person: 'RURWK\ +DUW 5' /' 1XWULWLRQ 0DQDJHU 5LFKPRQG &RXQW\ +HDOWK 'HSDUWPHQW

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Beverly Townsend, MD, MBA, FAAFP 'LVWULFW +HDOWK 'LUHFWRU J. Edward Saidla 3URJUDP 0DQDJHU Brenda Forman, Med, RD, LD, 1XWULWLRQ 6HUYLFHV 'LUHFWRU :HVW &HQWUDO +HDOWK 'LVWULFW 2IILFH &RPHU $YHQXH 32 %R[ &ROXPEXV *$ )$;

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GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Introduction

DISTRICT/ADDRESS
District 8, Unit 1 (Valdosta)
William Grow, MD,FACP 'LVWULFW +HDOWK 'LUHFWRU Elsie Napier 3URJUDP 0DQDJHU Holly Rountree, RD,LD 1XWULWLRQ 6HUYLFHV 'LUHFWRU /RZQGHV &RXQW\ +HDOWK 'HSDUWPHQW 1RUWK 3DWWHUVRQ 6WUHHW 9DOGRVWD *$ )$;

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District 8, Unit 2 (Albany)
Jacqueline Grant, M.D. 'LVWULFW +HDOWK 'LUHFWRU Brenda Greene, RN,BSN,MPA 3URJUDP 0DQDJHU Teresa Graham MPA, RD, LD, CLC 1XWULWLRQ 6HUYLFHV 'LUHFWRU 6 6ODSSH\ %OYG 6XLWH * $OEDQ\ *$ )$;

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Saroyi Morris

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GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Introduction

DISTRICT/ADDRESS
District 9, Unit 2 (Waycross)
Rosemarie Parks, M.D., M.P.H 'LVWULFW +HDOWK 'LUHFWRU Derek Jones 3URJUDP 0DQDJHU$FWLQJ Heather Peebles, RD, LD 'LVWULFW 1XWULWLRQ 6HUYLFHV 'LUHFWRU 6RXWKHDVW +HDOWK 'LVWULFW % &KXUFK 6WUHHW :D\FURVV*$ )$;

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District 10 (Athens)

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Claude A. Burnett, M.D.

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Introduction

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Georgia WIC Program 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
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Georgia WIC Program Nutrition Services Unit 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 PROGRAM 2013 PROCEDURES MANUAL

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TABLE OF CONTENTS

Page

I.

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

II. Eligibility Requirements............................................................................................... CT-1
A. Category .......................................................................................................... CT-1 B. Physical Presence........................................................................................... CT-2 C. Residency........................................................................................................ CT-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-8 C. Request for Extension ..................................................................................... CT-8

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

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

VII. Proxies ...................................................................................................................... CT-11 General ..................................................................................................................... CT-11 A. Reasons for Proxies ...................................................................................... CT-11 B. Authorization ................................................................................................. CT-11 C. Voucher Pick Up, Issuance, and Use............................................................ CT-12 D. Restrictions.................................................................................................... CT-12 E. Participant Instructions .................................................................................. CT-12 F. Guardianship ................................................................................................. CT-13

VIII. Income Eligibility ....................................................................................................... CT-14 A. Procedures .................................................................................................... CT-15

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

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B. Adjunctive (Automatic) Eligibility ................................................................... CT-15 C. Computing Income ........................................................................................ CT-17 D. Documented Proof of Income........................................................................ CT-28 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-34 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/Breast-feeding Women Mid-Assessment/Children Half-Certification Nutrition Assessment..................................................................... CT-37
XV. WIC Assessment/Certification Form ......................................................................... CT-39 A. General.......................................................................................................... CT-39 B. Completion .................................................................................................... CT-40
XVI. Ineligibility Procedures (Notification Requirements).................................................. CT-51 A. Written Notification ........................................................................................ CT-51 B. Completion of Notice of Termination/Ineligibility/Waiting List Form............... CT-52 C. Ineligibility File .............................................................................................. CT-52
XVII. Transfer of Certification............................................................................................. CT-53 A. Clinic Staff ..................................................................................................... CT-53 B. Out of State Transfer/Incomplete VOC Cards ............................................... CT-54 C. In-State Transfer ........................................................................................... CT-54

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

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D. Release of Information/Original Certification Form........................................ CT-55

E. Two Methods for Transfer ............................................................................. CT-56

F. Ordering VOC Cards ..................................................................................... CT-58

G. Inventories ..................................................................................................... CT-58

H. Issuance ........................................................................................................ CT-59

I.

Security ......................................................................................................... CT-60

J. Lost/Stolen/Destroyed EVOC or VOC Cards ................................................ CT-61

XVIII. WIC Overseas Program ............................................................................................ CT-61 A. General.......................................................................................................... CT-61 B. Impact on USDA's WIC Programs................................................................. CT-61 C. New EVOC or VOC Card Requirements ....................................................... CT-62 D. Completion of the EVOC or VOC Card ......................................................... CT-62 E. Acceptance of WIC Overseas Program EVOC or VOC Cards...................... CT-62

XIX. Correcting Official WIC Documents .......................................................................... CT-63 A. Correcting Mistakes....................................................................................... CT-63 B. Adding Information ........................................................................................ CT-63

XX. Late Entry Correction of Health Records .................................................................. CT-63

XXI. Documentation Procedures....................................................................................... CT-63

XXII. Waiting List................................................................................................................ CT-64 A. Procedures for Maintaining a Waiting List..................................................... CT-64 B. Procedures for Removal from the Waiting List .............................................. CT-65

XXIII. District WIC Resource Page ..................................................................................... CT-65

XXIV. Immunization Coverage Assessment........................................................................ CT-65

XXV. Complaint Procedures............................................................................................... CT-66 A. Procedures for Processing a Complaint or Incident ...................................... CT-66 B. How to File a Complaint (Flyer) ..................................................................... CT-67

XXVI. Special Certification Conditions (Home Visits).......................................................... CT-67 A. General.......................................................................................................... CT-67 B. Certification for Home Visits .......................................................................... CT-67 C. Procedures .................................................................................................... CT-68

XXVII. Special Certification Conditions ................................................................................ CT-69

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

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A. General.......................................................................................................... CT-69

B. Separation of Duty......................................................................................... CT-69

C. Certification Procedure (with use of medical records) ................................... CT-69

D. Certification Procedure (without use of medical records) .............................. CT-70

E. 90-Day Blood Work Policy............................................................................. CT-71

F. Voter Registration Policy ............................................................................... CT-71

G. Transfers/Caseload Count ............................................................................ CT-71

H. Identification (ID) Number Assignment.......................................................... CT-71

I.

Thirty (30) Day Policy .................................................................................. CT-71

J. Agreement between the District and Hospital ............................................... CT-72

K. Prior Approval................................................................................................ CT-72

L. File Maintenance in the Hospital ................................................................... CT-72

M. Voucher Security ........................................................................................... CT-72

N. Certification Process in the Hospital.............................................................. CT-72

O. Required Components of a Hospital Certification ......................................... CT-72

P. Two Types of Hospital Clinics ....................................................................... CT-74

XXVIII. Client Staff Ratio....................................................................................................... CT-75

XXIX. PNSS Data Collection .............................................................................................. CT-75

XXX. WIC Interview Script ................................................................................................. CT-75

Attachments: CT-1 WIC Assessment/Certification Form Prenatal Woman........................................... CT-76 CT-2 WIC Assessment/Certification Form Post Partum Breastfeeding .......................... CT-79 CT-3 WIC Assessment/Certification Form Post Partum Non Breastfeeding................... CT-82 CT-4 WIC Assessment/Certification Form Infant ............................................................ CT-85 CT-5 WIC Assessment/Certification Form Child ............................................................. CT-88 CT-6 FFY 2012 Nutrition Risk Criteria Handbook .............................................................. CT-91 CT-7 Nutrition Questionnaire ........................................................................................... CT-229 CT-8 Equipment Maintenance ......................................................................................... CT-241 CT-9 Participant Transfer Log.......................................................................................... CT-243

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

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CT-10 Prenatal Weight Gain Grid Multifetal Pregnancy..................................................... CT-244 CT-11 Prenatal Weight Gain Grid Singleton Pregnancy .................................................... CT-246 CT-12 Signed Statement of Income, Residency and Identification (English)..................... CT-248 CT-13 WIC Income Eligible Guidelines.............................................................................. CT-249 CT-14 Notice of Termination/Ineligibility/Waiting List Form (English) ................................ CT-250 CT-15 Notice of Termination/Ineligibility/Waiting List Form (Spanish) ............................... CT-251 CT-16 Paper Verification of Certification (VOC) Card......................................................... CT-252 CT-17 Electronic Verification of Certification (EVOC) Card ................................................ CT-253 CT-18 Electronic VOC Card Report (Example).................................................................. CT-254 CT-19 VOC Card Inventory Log (Clinic)............................................................................. CT-255 CT-20 VOC Card Inventory Log (Local Agency) ................................................................ CT-256 CT-21 VOC Card Agreement ............................................................................................. CT-257 CT-22 VOC Card Form ...................................................................................................... CT-258 CT-23 Women, Infant and Children (WIC) Ordering Form................................................. CT-259 CT-24 State/District/Clinic Transmittal Form...................................................................... CT-260 CT-25 Medicaid Right From the Start ................................................................................ CT-261 CT-26 THERE IS NO CHARGE (Flyer).............................................................................. CT-262 CT-27 Verification of Residency and/or Income Form ....................................................... CT-263 CT-28 No Proof Form......................................................................................................... CT-264 CT-29 Family Plus Medicaid Card ...................................................................................... CT-265 CT-30 Disclosure Statement Employees and Relatives ................................................. CT-266 CT-31 Income Calculation Form ........................................................................................ CT-267 CT-32 Identification, Residency and Income Proof List (English)....................................... CT-268 CT-33 Identification, Residency and Income Proof list (Spanish)....................................... CT-269 CT-34 Thirty (30) Day Certification/Termination Form ....................................................... CT-271 CT-35 Department of Defense WIC Overseas Program VOC Card .................................. CT-272

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

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CT-36 WIC Overseas Program Contacts ........................................................................... CT-273 CT-37 Proof of Residency Form for Applicants with P.O. Box Address............................. CT-274 CT-38 Income Verification Letter ....................................................................................... CT-275 CT-39 Incident/Complaint Form ......................................................................................... CT-276 CT-40 How to File a Complaint (Flyer) ............................................................................... CT-277 CT-41 Request for WIC Services Log................................................................................. CT-278 CT-42 WIC Interview Script ................................................................................................ CT-279 CT-43 Separation of Duties Form ....................................................................................... CT-280 CT-44 Military Income Inclusions and Exclusions............................................................... CT-281 CT-45 Proxy Letter.............................................................................................................. CT-282

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

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I.

GENERAL

Certification is the process whereby an individual is evaluated to determine eligibility for the Georgia WIC Program. All persons wishing to participate in the Georgia WIC Program must have their eligibility determined except those persons transferring within a valid certification period with proper verification (Refer to XVII). If eligible funds are available, the individual will be enrolled in the Georgia WIC Program 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 the Georgia WIC Program until the end of the certification period or the end of categorical eligibility, whichever occurs first, as long as the person complies with the Georgia WIC Program rules and regulations. If ineligible, the individual is properly notified (see Ineligibility Procedures CT-XVI).

Applicants who do not meet the income requirement for WIC eligibility may be referred to the area food pantries or other food assistance programs.

Local agencies are encouraged to perform WIC certifications and issue vouchers in coordination with other public health services. However, WIC applicants/ participants must not be required to participate in other programs in order to receive WIC benefits.

Note: WIC services must be provided to the applicant/participant at no cost. The "No 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 the Georgia WIC Program participation other than those established by the State agency.

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

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

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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 the Georgia WIC Program (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. The Georgia WIC Program is exempt from any restrictions in regard to aliens, refugees, and immigrants.
B. Physical Presence
All applicants (women, infants and children) must be physically present at 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.
The Proof of Residency Form for Applicants with a P.O. Box address must not be recorded as residency proof. The applicant/participant must provide proof of residency. Proof of residency must be documented on the WIC Certification Form by documenting the type of proof verified, e.g., electric bill.
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 record 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

CT-3

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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 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.
Red ink cannot be used to date stamp identification, residency and income proof copies.
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

CT-4

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

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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 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.
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.
The Georgia WIC Program 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, is outside a valid certification period and requests a new appointment, the initial contact date is the new date that the participant contacted the clinic to request a new appointment.
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 Initial Contact Date (date services were requested if appointment was not
kept) 6. Rescheduled Appointment Date (if changed) and Reason for the Change 7. Telephone Number
Each District/clinic may develop its own system for documenting abovenumbered items 1-7 as long as it is implemented in a consistent manner. Suggested methods of documentation include, but are not limited to, a personal visit log or Request for WIC Services Log (see Attachment CT-41),an appointment book or the WIC Certification/Assessment Form (see Attachments CT-1 thru CT-5).

CT-5

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

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NOTE: Failure to maintain this documentation will result in a corrective action. 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 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 the Georgia WIC Program. 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 the Georgia WIC Program. 5. If yes, fill in the name and relationship of those relatives and their date
of certification on this form.

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When reviewing the records of employees on the Georgia WIC Program, use the Record Review Form located in the Monitoring Section of the Procedure Manual, Food Instrument Accountability (Form 2).
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 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 on the Request for WIC Services Log (see Attachment CT-41) or in the computer. The State will review these files. The documentation will consist of: a. The name of the client. b. Initial contact date. c. Appointment date. d. New Initial contact date. e. Date of second appointment. f. Documentation of whether second appointment was made by phone. g. 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 the Georgia WIC Program benefits. All other applicants will be notified of their

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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 seven (7) 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. 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, documented and date stamped 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:

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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)

Certification

8. Hospital ID Bracelets (mother & baby) 9. EVOC/VOC Card (with additional ID) 10. Immunization Record (if a client is using health department services
and the records already exists in the clinic) 11. Passport or Passport Card 12. Health/Medical Record (already exists in the clinic or the record is
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.
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 Program 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 the Georgia WIC Program. 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 the Georgia WIC Program before completing and 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 Program 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/
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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 documented 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
signature 5. 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.
6. Signature of clinic WIC official 7. Date card was issued 8. Georgia WIC Program Stamp (must appear in the designated box)
Note: Do not pre-stamp stock of the Georgia WIC Program 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. Voucher pickup code 3. Voucher interval code 4. Comments when needed 5. Clinic identifying information 6. Clinic telephone number 7. Clinic fax number 8. 30 day proof (if applicable) 9. Date of Last Issued Vouchers (if participant is transferring)

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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

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 the Georgia WIC Program and issued a Georgia WIC Program 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 following:
x Georgia WIC Program ID Card x Certification Form x Computer Note: Some local agencies maintain a Tickler card. However, this is a
local agency option.

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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.
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 the Georgia WIC Program, explanation of the following must be provided: proxy use and function, the importance of choosing responsible proxies, how to authorize a proxy, and the participant's responsibility for instructing proxies on the proper procedures of voucher redemption.
The proxy must have or be able to provide the following information in order to

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

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Grandparents as Guardians There are many situations where the grandparents serve as temporary or even become permanent guardians for children on the Georgia WIC Program. 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 The Georgia WIC Program 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 as if they were regular WIC participants. However, in the above situations, some legal documentation must be shown prior to placing the child on the Georgia WIC Program (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 and place the child(ren) on the Georgia WIC Program 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 the Georgia WIC Program, an applicant/participant must present proof of gross annual family income equal to or less than 185% of the Federal Poverty Level. Income is defined as gross cash income before deductions. The Georgia WIC Program 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 the Georgia WIC Program income assessment/determination for pregnant women. According to the act, a pregnant woman who does not meet income eligibility requirements for the Georgia WIC Program on the basis of her current family size shall be reassessed for eligibility based on a family size increased by one or the number of expected infant(s). In keeping with current policy, confirmation of multiple gestations must be received verbally or via a written diagnosis from a physician or acting health professional under standing orders of a physician and documented in the participant's health record. The change in policy applies to income determination of a pregnant woman and her children. For example, if a pregnant woman is counted as two

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on her first visit to the office, and the pregnant woman comes back to the clinic to place her child(ren) on the Georgia WIC Program, the pregnant woman and fetus will continue to be counted as two people in the family. The use/implementation of this policy must not conflict with cultural, personal or religious beliefs of the individuals.
A. Procedures
All local agencies must use the following procedures and criteria to determine income eligibility for all the Georgia WIC Program 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. 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 the Georgia WIC Program 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 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).

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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. - 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 the Georgia WIC Program, 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 the Georgia WIC Program 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

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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.
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. If a household has only one income sources, or if all sources have the same frequency, do not use a conversion factors. Compare the income, or the sum of the separate incomes, to the published Income Eligibility Guidelines for the appropriate frequency and household size to make the WIC income eligibility determination.
2. If a household reports income sources at more than one frequency, perform the following calculations:
a. Annualize all income by multiplying weekly income by 52, income received every two weeks by 26, income received twice a month by 24 and income received monthly by 12.
b. Do not round the values resulting from each conversion.

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c. Add together all the unrounded, converted values. d. Compare the total to the published IEGs (annual income for the
appropriate household size) to make the final income eligibility determination. Do not recalculate the published IEGs, as they are already calculated and rounded up to the next whole dollar prior to being published in the Federal Register.
Look for the "total income" line item on the income tax return. Use the dollar amount on this line and divide by twelve (12). This is found on the following forms: Form 1040EZ: Line 1, Form 1040A: Line 15 and Form 1040: Line 22.
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 situations, 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.
d. Joint Custody - A child who resides in more than one home as

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a result of a joint custody situation shall be considered part of the household of the guardian who is applying on behalf of the child.
e. Pregnant Women - A pregnant woman who does not meet income eligibility requirements for the Georgia WIC Program on the basis of her current family size shall be reassessed for eligibility based on a family size increased by one or the number of expected infant(s).
f. Absent Spouse (excluding military families) - A household where the spouse is away and maintains a separate residence due to job related assignments shall be considered a separate economic unit without the inclusion of the spouse. Only income received by the household would be used to determine eligibility.

g. Students (1) College students who maintain a separate residence at school but who are supported by parents/guardians must be counted in the household of the parent/guardian. Students who maintain a separate residence and are self-supported must be counted as a separate household. Any regular cash supplements received from parents or guardians must be included in the student's total income. (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 the Georgia WIC Program. State and local agencies do not have the authority to exclude aliens solely on the basis of their alien status.
i. Military Families (1) Military personnel serving overseas or assigned to a military base are considered to be members of the family and their income should be included when determining family income. (2) If children are in the temporary care of others while their

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parent is assigned elsewhere or if the child (ren) and one parent temporarily move in with friends or relatives, choose one of the following options: (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)

300 OCONUS COLA (Overseas Continental

United States Cost of Living Allowance)

301 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:

302 Hazardous or foreign duty

303 Back pay or combat pay

304 Family separation

305 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 the Georgia WIC Program. 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 Thirty (30) day missing 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.

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n. Temporary Thirty (30)-Day Certification 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 and/or identification: (a) Place the applicant on the Georgia WIC Program using the Thirty (30)-day rule. (b) Proof that is not available on site must be entered as "NO" in the appropriate field on the computer. (c) Complete the Thirty (30)-Day Form. Give the client the original copy and place 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

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updated. (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 the Georgia WIC Program 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). The Georgia WIC Program 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 the Georgia WIC Program (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,

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date stamped and placed in medical record (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.
r. 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).
s. Income Exclusions

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a. The value of in-kind housing and other in-kind benefits. An in-kind benefit is anything of value, which is not provided in the form of cash.
b. Income or benefits received under any Federal program, which are excluded from consideration as income by any legislative prohibition. These include, but are not limited to: (1) National School Lunch Act and the School Breakfast Program (2) 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 Program policy regarding any cash available to a family is applied.
t. 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

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income to determine eligibility.
u. 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:
v. 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).
w. Hardship Conditions - Hardship conditions have been calculated in the Income Poverty Guidelines Chart. Hardship conditions are not to be considered when determining income.
x. 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.
y. 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.
z. 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 Program 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.r.).

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
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other complaint.
3. A conflict of information is found between the Georgia WIC Program income data and income data provided from other programs. When income is verified, the income at the time of certification, rather than the current income, must be verified.
Based on the three (3) reasons above, 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 the Georgia WIC Program 2. Re-payment to the Georgia WIC Program for vouchers issued over
one-hundred dollars ($100.00) Note: Information concerning payment to the Georgia WIC Program can be
found in the Compliance Analysis Section of the Georgia WIC Program 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 the Georgia WIC Program. 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
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data and documentation requirements for all women, by category. This data must be collected and documented for each assessment. Required medical data used to determine the eligibility of pregnant women must be taken during the current pregnancy. Proof of pregnancy is not required as a condition of eligibility for the Georgia WIC Program. However, if it is not physically apparent that the applicant is pregnant and if clinic staff has reason to believe that the applicant is not pregnant (e.g., a complaint is received alleging that a participant is not pregnant), the local agency may request proof of pregnancy after the initial certification. In this case, the participant can be given up to sixty (60) days to submit proof of pregnancy.
If proof of pregnancy documentation is not provided as requested, the local agency may terminate the woman's WIC participation in the middle of a certification period. Postpartum women must have their required medical data taken after the termination of their pregnancy (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 the Georgia WIC Program and the certification process. Local agencies must accept the Georgia WIC Program 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

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II. Medical Referral Data, as appropriate* a. Length/Height b. Weight 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.
The Georgia WIC Program 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).
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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 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.
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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 blood work by the next voucher issuance.
Note: Each District must develop a written procedure to be used in obtaining blood work on postpartum breastfeeding and non-breastfeeding women certified in the hospital. This procedure must be approved by the Nutrition 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 the Georgia WIC Program 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

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whose mothers were not WIC participants during pregnancy but had a documented nutritional need.
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, 903

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

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Priority IV:

400, 401, 502, 601, 801, 802, 901, 902, 903

3. Postpartum, Non-Breastfeeding Women

Priority III:

331, 502

Priority VI:
4. Infants 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, 400, 401, 502, 801, 802, 901, 902, 903
103, 115, 121, 134, 135, 141, 142, 151, 152, 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

Priority II:

502, 701, 702

Priority IV:

400, 401, 428, 502, 702, 801, 802, 901, 902, 903

5. Children

Priority III: Priority V:

103, 113, 114, 115, 121, 134, 135, 141, 142, 151, 201, 211, 341, 342, 343, 344, 345, 346, 347, 348, 349, 351, 352, 353, 354, 355, 356, 357, 359, 360, 361, 362, 381, 382, 502,904 400, 401, 428, 502, 801, 802, 901, 902, 903

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 the Georgia WIC Program immediately (see CT-XVI, Ineligibility Procedures). The termination must be documented in the participant's health record.
2. If the woman is less than six (6) months postpartum, reassessment of nutrition risk is required. The woman must qualify for WIC based on the risk criteria for a postpartum, non-breastfeeding woman to continue

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receiving 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, nonbreastfeeding woman until six (6) months from the delivery date. All information must be documented in the participant's health record and entered into the automated system.
B. Upgrading a Priority
New data that 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

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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.
XIV. INFANT MID-CERTIFICATION/ BREAST-FEEDING WOMEN MID-ASSESSMENT/ CHILDREN HALF-CERTIFICATION NUTRITION ASSESSMENT
INFANTS MID-CERTIFICATION Infants certified prior to six (6) months of age will be subsequently certified on their first birthday. A nutrition assessment (mid-certification) 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 the Georgia WIC Program.
BREAST-FEEDING WOMEN MID-ASSESSMENT Breast-feeding women shall be certified for a period one (1) year or until breast-feeding discontinues. If breastfeeding is discontinued prior to six month after delivery the woman

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can continue WIC participation as a non-breastfeeding woman until six months postpartum. A nutrition assessment (mid-Assessment) by the CPA should be completed between five (5) and seven (7) months of the initial certification. To ensure accessibility to quality health care services, the following procedures must be completed: 1. The initial certification of the breast-feeding woman will follow the standard
procedures. The breast-feeding women shall be assigned the highest priority for which she is eligible.
2. The mid-assessment nutrition assessment must consist of: a. Measuring length and weight. b. Recording, summarizing, and evaluating inappropriate nutrition practices. c. Assessing nutrition risk criteria. e. Assigning the highest priority for which the breast-feeding woman is eligible, reviewing food package needs, and assigning an appropriate food package.
3. The mid-Assessment information will be documented in the second column of the breast-feeding / postpartum women 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 breastfeeding woman priority should be upgraded.
5. All breast-feeding women certified at fewer than five (5) months after delivery date must be scheduled for a mid-Assessment. WIC benefits may not be withheld from a participant for failing the mid-Assessment nutrition assessment appointment(s). Missed appointments should be documented in the participant's health record. If the breast-feeding woman misses the mid-assessment appointment, a secondary nutrition education contact should still be conducted during voucher issuance.
Note: Proof of identification, residency and income are not required during the midAssessment. However, if during the mid-Assessment a participant reveals that their income is above the income guidelines, the participant and any other now ineligible household members will be terminated from the Georgia WIC Program.
CHILDREN HALF-CERTIFICATION ASSESSMENT Children will be certified for a period of one (1) year. A nutrition assessment (halfcertification) by the CPA should be completed between five (5) and seven (7) months after the initial certification. To ensure accessibility to quality health care services, the following procedures must be completed: 1. The initial certification of the child will follow the standard procedures. The child
shall be assigned the highest priority for which he/she is eligible.
2. The half-certification nutrition assessment must consist of: a. Measuring length and weight. b. Plotting weight for length/BMI, length for age, and weight for age. c. Measuring hemoglobin or hematocrit if low at most recent certification and for all children less two years old at time of assessment. d. Recording, summarizing, and evaluating inappropriate nutrition practices.

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e. Assessing nutrition risk criteria. f. Assigning the highest priority for which the child is eligible, reviewing
food package needs, and assigning an appropriate food package. 3. The half-certification nutrition assessment information will be documented in the
second column of the Children 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 child's priority should be upgraded.
5. All children must be scheduled for a half-certification nutrition assessment. WIC benefits may not be withheld from a participant for failing the half-certification nutrition assessment appointment(s). Missed appointments should be documented in the participant's health record. If the child misses the halfcertification appointment, a secondary nutrition education contact should still be conducted with the person who is picking up the child's vouchers.
Note: Proof of identification, residency and income are not required during the halfcertification assessment. However, if during the half-certification a participant reveals that their income is above the income guidelines, the participant and any other now ineligible household members will be terminated from the Georgia WIC Program.

XV. WIC ASSESSMENT/CERTIFICATION FORM
A. General
1. State WIC Assessment/Certification Form
Certification data for each applicant/participant will be recorded on the form provided by the State agency or generated by each District's computer system.
2. Local Agency WIC Assessment/Certification Form
If a local agency/clinic chooses to use other forms and/or documentation procedures in the certification process that are different from the procedures outlined in this manual, then all forms and/or procedures must be submitted to the State agency, in writing, for approval prior to implementation. Local agencies that choose to develop their own forms and/or procedures must update them each time the State 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. Each page of the Certification Form must be accurately completed each time an individual is certified. A portion of the required information is common to each form. The following are instructions for completion.

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B. Completion
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 the Georgia WIC Program 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 the Georgia WIC Program. 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. (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

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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.
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

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(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, child's half-certification and the breastfeeding woman's mid-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).
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

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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., L.P.N., 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
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

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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)/Print Name - The local WIC official signature, print name and date confirms that income, residency and family size are correct as stated by the applicant/participant. The signature, print name and date 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. Applicant/Participant Signature/Print Name - The participant/parent/spouse/guardian/caregiver/ alternate parent or proxy must be asked to read, sign, print name and date 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 the Georgia WIC
Program. 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. The Georgia WIC 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 to the Georgia WIC Program, in cash, the value of the food benefits improperly issued to me and may subject me to civil or

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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 the Georgia WIC Program, 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 the Georgia WIC Program, 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:

_________________________________________ __________ _____________________________ _______

Signature of WIC Applicant/Participant/Guardian/ Date

Signature of WIC Official

Date

Caregivers/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.

g. Applicant Unable to Write - If the applicant/participant/ authorized representative is unable to write, he/she will enter his/her mark in lieu of a signature. The 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.

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19. Physical Presence (Certification Form)
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 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 ( )
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(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 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
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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.
(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,

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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 quantity unknown, 99=Unknown or refused.
(18) Drink/Week Last 3 months of Pregnancy A two-position 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,

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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 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 the Georgia WIC Program benefits on the basis of residency, category, income or nutritional risk; however, infants fewer than four

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(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 the Georgia WIC Program requirements and are assessed to be ineligible or disqualified for WIC benefits must be notified of ineligibility, in writing. The Notice of Termination/Ineligibility/Waiting List (NTIWL) Form is the 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 the Georgia WIC Program and a NTIWL is issued, they must be informed of their right to a fair hearing. A fair hearing may be requested when the Georgia WIC Program participation is denied or a participant is disqualified for benefits (see Fair Hearing Section in Rights and Obligations). Local agencies must follow the Georgia WIC Program procedures for "written notification" and "processing standards" whenever an ineligibility/termination decision is made. All procedures followed must be documented in the health record or agency file.
The following notifications shall be made in writing and comply with programmatic time frames:
A. Written Notification
1. Ineligibility - An applicant/participant determined to be ineligible for the Georgia WIC Program benefits on the basis of residence, income, or nutrition risk will receive a Notice of Termination/Ineligibility/Waiting List form on site, which states the reason(s) for ineligibility. A copy of the form will be filed in the individual's health record and/or the Ineligibility file. If the applicant/participant is assessed over the income limits, a copy of the document viewed, the signed Certification form and a copy of the Notice of Termination/Ineligibility/Waiting List form must be placed in the Ineligibility file and/or the individual's health record. These files must be maintained for three (3) years plus current year.
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 the Georgia WIC Program participation at any time during the certification period must be notified, in writing, at least fifteen (15) days before benefits end. Reasons for this action and of the right to a fair hearing must be provided. In the event the state agency mandates that the local agency must suspend or terminate benefits to participants due to a shortage of funds, the NTIWL Form must be issued to the participant.

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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 the Georgia WIC Program. The Fair Hearing Section must be completed when using this form. If a stamp is used for this purpose, all copies must be stamped. The form must be signed by the parent/guardian/caregiver/spouse/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 the Georgia WIC Program.
C. Ineligibility File
Clinics are required to maintain an Ineligibility file. The five items listed below are critical and must be presented when a fair hearing is requested by an applicant or other persons acting on behalf of an applicant. Each clinic may establish their own system for maintaining such a file, as long as the following guidelines are followed:
1. Ineligible Applicants without Health Records: For applicants who do not have a health record in the clinic, the Ineligibility file must contain the following: a. Applicant's name b. A copy of the NTIWL Form (Completely 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 the Georgia WIC Program. This includes income documentation, date, print name and signature of the participant or applying parent/guardian/caregiver/spouse/ alternate parent of the participant and the signature, print name of the person who collected income information).

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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. 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 the Georgia WIC Program even if they do not meet the Georgia WIC Program 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

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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 Program 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 Program 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 which extension transfer request should be routed.
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):

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When transferring a participant from one Georgia WIC Program clinic to another Georgia WIC Program 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 the Georgia WIC Program 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).

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E. Two Methods for Transfer
The Georgia WIC Program has two (2) methods for VOC cards. They are electronic and paper VOC cards issuance.
1. The Electronic VOC Card System (EVOC)
a. The Electronic VOC 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 8 x 11 paper. However, an official EVOC card must be stamped with the Georgia WIC Program 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.

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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 25. The Thirty-Day return date and the missing proof information (if applicable)
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.
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

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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 the Georgia WIC Program 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 Program, 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.

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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.
EVOC Card Inventory
The EVOC Card Inventory must 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 must 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 must 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 or "if issued to a migrant that
is not moving. 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.
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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.

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 Program, 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

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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 the Georgia WIC Program 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 Public Health.
When there are any discrepancies in the EVOC card system noted an investigation will automatically take place.
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

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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.
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.1.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
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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 CTXVII.B. 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:
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 Program Procedures Manual.
XXI. DOCUMENTATION PROCEDURES

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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 its maximum caseload, the state must notify 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 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 Program benefits. Applications must be kept in order, according to the date and priority they were placed on the waiting list.
2. The waiting list must include the following information to facilitate contacting the applicant when caseload space becomes 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.

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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 are processed first to become program participants when 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 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. DISTRICT WIC RESOURCE PAGE
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. The Georgia WIC Program and the Immunization Program have a signed agreement to work together to improve the immunization coverage among WIC participants. The objective of this agreement is to raise the 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
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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.
State WIC staff (Policy Unit) will record the complaint in the electronic web application. Notification of the complaint will be sent by e-mail to the District Nutrition Services Director (NSD) to address. The NSD will have to log into the complaint web application to view and record the complaint resolution. Once a satisfied response is received by the state, the state staff will close the complaint. If an unsatisfied answer is received, the state staff will request more information.
How to use the complaint web application:
1. Visit http:// http://wic.ga.gov/complaints/ 2. Register yourself using your official (work) e-mail address under clinic user. 3. Create a password password is case sensitive.
a. Minimum six (6) characters b. Alpha-numeric 4. Once an account is created inform policy unit staff to link your district/clinic under your user name.
If the state office receives a complaint for your district/clinic, an e-mail will be sent to you. You can view the complaint by logging into the web application. You can see the complaint detail by clicking "Detail". You can respond to the complaint by "respond to complaint".
When a complaint is received by local agency/District/clinic; The Incident/Complaint Form should be used to assure that all required information is captured (see Attachment CT-39).
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 Program 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

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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.
This form will be kept on file for three (3) years plus current year.
B. How to File a Complaint (Flyer)
It is required to have the "How to File a Complaint" Flyer displayed and visible in all WIC service delivery points in the clinic (see Attachment CT-40). This flyer is included on the WIC ID folder. WIC staff must explain this flyer to the WIC applicants/participants at initial certification, re-certification and mid-certification.
Please refer to Rights and Obligations Section IV. E and F regarding complaint procedures.

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 the Georgia WIC Program as mandated by Federal regulations prior to implementing the routine practice of home certifications. Charges for in-home WIC services are forbidden.
B. Certification for Home Visits

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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 the Georgia WIC Program, 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 the Georgia WIC Program. 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.
6. If, after completing the certification process, Voter Registration has been offered according to the requirements of the National Voter

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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 the Georgia WIC Program 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)
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 one contracted agency.
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 the
Georgia WIC Program 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).
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x The WIC employee verifies the list prior to making rounds on the 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 the Georgia WIC Program 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 one contracted agency.
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 the Georgia WIC Program must be given a copy of their Certification Form to enroll into the clinic/county of their choice.

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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.

I.

Thirty (30) -Day Policy

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 the Georgia WIC Program upon approval.

K. Prior Approval
Written approval must be given by the Georgia WIC Program prior to opening any new WIC clinics (see the Administrative section of the Georgia WIC Program 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 Program Procedures Manual.

N. Certification Process in the Hospital

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

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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 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 the Georgia WIC Program - 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).

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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 make rounds for eligible the Georgia WIC Program 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 Program Procedures Manual for administrative purposes.
XXIX. PNSS DATA COLLECTION
The Georgia WIC Program 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 women.
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
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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).

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Attachment CT-1

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Attachment CT-1(cont'd)

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Attachment CT-2(cont'd)

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Attachment CT-3

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Attachment CT-3(cont'd)

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Attachment CT-4

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Attachment CT-4 (cont'd)

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Attachment CT-4 (cont'd)

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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

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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

PRIORITY

201

LOW HEMOGLOBIN/HEMATOCRIT

I

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

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

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 women'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

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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 women'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 within the past 12 months.

Document: Date of blood test and blood lead level in the participant's health record. Must be within the past 12 months.

High Risk: Blood lead level of >10 Pg/deciliter within the past 12 months.

301

HYPEREMESIS GRAVIDARUM

I

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

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

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

High Risk: Diagnosed hyperemesis gravidarum

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CODE

PREGNANT WOMEN

PRIORITY

302

GESTATIONAL DIABETES

I

Gestational diabetes mellitus (GDM) is defined as any degree of glucose/carbohydrate intolerance with onset or first recognition during pregnancy.

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

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.

I

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 treated this condition in the participant's health record.

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

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Attachment CT-6 (cont'd)

CODE

PREGNANT WOMEN

PRIORITY

312

HISTORY OF LOW BIRTH WEIGHT INFANT(S)

I

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

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 greater than or equal to 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.

331

PREGNANCY AT A YOUNG AGE

I

For current pregnancy, Conception at less than or equal to 17 years of age.

Document: Age at conception on the WIC Assessment/Certification Form

High Risk: Conception at less than or equal to 17 years of age.

332

CLOSELY SPACED PREGNANCIES

I

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

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

CT-95

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

PREGNANT WOMEN

333

HIGH PARITY AND YOUNG AGE

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

PRIORITY I

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.

335

MULTI-FETAL GESTATION

I

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

336

FETAL GROWTH RESTRICTION

I

Fetal Growth Restriction (FGR) (replaces the term Intrauterine Growth Retardation (IUGR)), may be diagnosed by a physician with serial measurements of fundal height, abdominal girth and can be confirmed with ultrasonography. FGR is usually defined as a fetal weight <10th percentile for gestational age.

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

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 High Risk: Fetal Growth Restriction

CT-96

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE 337
338

PREGNANT WOMEN

PRIORITY

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.

Document: Birth weight(s) in the participant's health record

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-97

GEORGIA WIC PROGRAM 2013 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-98

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

PREGNANT WOMEN

PRIORITY

343

DIABETES MELLITUS

I

Diabetes mellitus consists of a group of metabolic diseases characterized by inappropriate hyperglycemia resulting from defects in insulin secretion, insulin action or both.
Presence of diabetes mellitus diagnosed, documented, or reported by a physician or someone working under a physician's orders, or as self reported by applicant/participant/caregiver.

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

Thyroid dysfunctions that occur in pregnant and postpartum women, during fetal development, and in childhood are caused by the abnormal secretion of thyroid hormones. The medical conditions include, but are not limited to, the following:
x Hyperthyroidism: Excessive thyroid hormone production (most commonly known as Graves' disease and toxic multinodular goiter).
x Hypothyroidism: Low secretion levels of thyroid hormone (can be overt or mild/subclinical). Most commonly seen as chronic autoimmune thyroiditis (Hashimoto's thyroiditis or autoimmune thyroid disease). It can also be caused by severe iodine deficiency.

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-99

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

PREGNANT WOMEN

PRIORITY

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 the participant's health record.

High Risk: Diagnosed renal disease

347

CANCER

I

A chronic disease whereby populations of cells have acquired the ability to multiply and spread without the usual biologic restraints. The current condition, or the treatment for the condition, must be severe enough to affect nutritional status.

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

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-100

GEORGIA WIC PROGRAM 2013 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-101

GEORGIA WIC PROGRAM 2013 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

An adverse immune response to a food or a hypersensitivity that causes adverse immunologic reaction.
Presence of condition diagnosed, documented, or reported by a physician or someone working under a physician's orders, or as self reported by applicant/participant/caregiver.

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

High Risk: Diagnosed food allergy.

CT-102

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE 354

PREGNANT WOMEN
CELIAC DISEASE Also known as Celiac Sprue, Gluten Enteropathy, or Non-tropical Sprue.

PRIORITY I

Inflammatory condition of the small intestine precipitated by the ingestion of wheat in individuals with certain genetic make-up.
Presence of condition diagnosed, documented, or reported by a physician or someone working under a physician's orders, or as self reported by applicant/participant/caregiver.
Document: Diagnosis and the name of the physician that is treating this condition in the participant's health record.
High Risk: Diagnosed Celiac Disease

355

LACTOSE INTOLERANCE

I

Lactose intolerance occurs when there is an insufficient production of the enzyme lactase. Lactase is needed to digest lactose. Lactose in dairy products that is not digested or absorbed is fermented in the small intestine producing any or all of the following GI disturbances: nausea, diarrhea, abdominal bloating, cramps. Lactose intolerance varies among and within individuals and ranges from mild to severe.
Presence of condition diagnosed, documented, or reported by a physician or someone working under a physician's orders, or as self reported by applicant/participant/caregiver.

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).

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-103

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE 357

PREGNANT WOMEN
DRUG/NUTRIENT INTERACTIONS
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.

PRIORITY I

358

EATING DISORDERS

I

Eating disorders (anorexia nervosa and bulimia), are characterized by a disturbed

sense of body image and morbid fear of becoming fat. Symptoms are manifested by

abnormal eating patterns including, but not limited to:

x

Self-induced vomiting

x

Purgative abuse

x

Alternating periods of starvation

x

Use of drugs such as appetite suppressants, thyroid preparations or

diuretics

x

Self-induced marked weight loss

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

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

High Risk: Diagnosed eating disorder

CT-104

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

PREGNANT WOMEN

PRIORITY

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 that has a continued need for nutritional support.

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 Asthma (moderate or severe) requiring daily medication.

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

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 physician that is treating this condition in the participant's health record

CT-105

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

PREGNANT WOMEN

362

DEVELOPMENTAL, SENSORY OR MOTOR DELAYS INTERFERING WITH

THE ABILITY TO EAT

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

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

PRIORITY I

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.

372

ALCOHOL AND ILLEGAL DRUG USE

I

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 servings of alcohol per week on the WIC Assessment/Certification Form. See Appendix E-1 for documentation codes.

Any illegal drug use:
Document: Type of drug(s) being used. See Appendix E-2 for commonly used illegal drug names.

CT-106

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

PREGNANT WOMEN

PRIORITY

381

DENTAL PROBLEMS

I

Diagnosis of dental problems by a physician or health care provider working under the orders of a physician or adequate documentation by the competent professional authority. 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.

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.

401

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.)

502

TRANSFER OF CERTIFICATION

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.

CT-107

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

PREGNANT WOMEN

PRIORITY

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.

IV

903

Foster Care

Entering the foster care system during the previous six months or moving from one foster care home to another foster care home during the previous six months.

904

ENVIRONMENTAL TOBACCO SMOKE EXPOSURE

I

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

CT-108

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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 Weight
Current Weight Last Weight Before Delivery
Hemoglobin or Hematocrit
Evaluation of Inappropriate Nutrition Practices Risk Factor Assessment

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

Required
Required Required Required Required Required Required

Required
Required Required Required Optional Required Required

CT-109

GEORGIA WIC PROGRAM 2013 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: 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

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-110

GEORGIA WIC PROGRAM 2013 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 Overweight Obese

18.5 to 24.9 25.0 to 29.9
> 30.0

>35 lbs >25 lbs >20 lbs

>54 lbs >50 lbs >42 lbs

*There are no provisional guidelines for 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 within the past 12 months.

Document: Date of blood test and blood lead level in the participant's health record. Must be within the past 12 months.

High Risk: Blood lead level of >10 Pg/deciliter within the past 12 months.

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 for any pregnancy.

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

CT-111

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

BREASTFEEDING WOMEN

304 HISTORY OF PREECLAMPSIA

PRIORITY I

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 for any pregnancy.

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 less than or equal to 5 lb 8 oz (2500 gms). 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-112

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE
331

BREASTFEEDING WOMEN
PREGNANCY AT A YOUNG AGE

For most recent pregnancy, Conception at less than or equal to 17 years of age. Applies to most recent pregnancy only.

Document: Age at conception on the WIC Assessment/Certification Form

High Risk: Conception at less than or equal to 17 years of age

PRIORITY I

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

Most recent pregnancy, or history of giving birth to an infant with a birth weight of

9 pounds or more.

Document: Birth weight(s) and date(s) of deliveries in the participant's health record.

CT-113

GEORGIA WIC PROGRAM 2013 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-114

GEORGIA WIC PROGRAM 2013 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

Diabetes mellitus consists of a group of metabolic diseases characterized by inappropriate hyperglycemia resulting from defects in insulin secretion, insulin action or both.

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

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

High Risk: Diagnosed diabetes mellitus

CT-115

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

BREASTFEEDING WOMEN

PRIORITY

344

THYROID DISORDERS

I

Thyroid dysfunctions that occur in pregnant and postpartum women, during fetal development, and in childhood are caused by the abnormal secretion of thyroid hormones. The medical conditions include, but are not limited to, the following:
x Hyperthyroidism: Excessive thyroid hormone production (most commonly known as Graves' disease and toxic multinodular goiter).
x Hypothyroidism: Low secretion levels of thyroid hormone (can be overt or mild/subclinical). Most commonly seen as chronic autoimmune thyroiditis (Hashimoto's thyroiditis or autoimmune thyroid disease). It can also be caused by severe iodine deficiency.
x Postpartum Thyroiditis: Transient or permanent thyroid dysfunction occurring in the first year after delivery based on an autoimmune inflammation of the thyroid. Frequently, the resolution is spontaneous.

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

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-116

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

BREASTFEEDING WOMEN

PRIORITY

347

CANCER

I

A chronic disease whereby populations of cells have acquired the ability to multiply and spread without the usual biologic restraints. The current condition, or the treatment for the condition, must be severe enough to affect nutritional status.

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

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-117

GEORGIA WIC PROGRAM 2013 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-118

GEORGIA WIC PROGRAM 2013 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

An adverse immune response to a food or a hypersensitivity that causes adverse immunologic reaction.

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

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

High Risk: Diagnosed food allergy

CT-119

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

BREASTFEEDING WOMEN

PRIORITY

354

CELIAC DISEASE

I

Also known as Celiac Sprue, Gluten Enteropathy, or Non-tropical Sprue.

Inflammatory condition of the small intestine precipitated by the ingestion of wheat in individuals with certain genetic make-up.
Presence of condition diagnosed, documented, or reported by a physician or someone working under a physician's orders, or as self reported by applicant/participant/caregiver.

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

Lactose intolerance occurs when there is an insufficient production of the enzyme lactase. Lactase is needed to digest lactose. Lactose in dairy products that is not digested or absorbed is fermented in the small intestine producing any or all of the following GI disturbances: nausea, diarrhea, abdominal bloating, cramps. Lactose intolerance varies among and within individuals and ranges from mild to severe.
Presence of condition diagnosed, documented, or reported by a physician or someone working under a physician's orders, or as self reported by applicant/participant/caregiver.

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).

CT-120

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

BREASTFEEDING WOMEN

PRIORITY

356

HYPOGLYCEMIA

I

Presence of hypoglycemia diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or a health professional acting under 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-121

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

BREASTFEEDING WOMEN

PRIORITY

358

EATING DISORDERS

I

Eating disorders (anorexia nervosa and bulimia), are characterized by a

disturbed sense of body image and morbid fear of becoming fat. Symptoms

are manifested by abnormal eating patterns including, but not limited to:

x

Self-induced vomiting

x

Purgative abuse

x

Alternating periods of starvation

x

Use of drugs such as appetite suppressants, thyroid preparations

or diuretics

x

Self-induced marked weight loss

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

Document: Symptoms or 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 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 that has a continued need for nutritional support.

CT-122

GEORGIA WIC PROGRAM 2013 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 Asthma (moderate or severe) requiring daily medication.

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

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-123

GEORGIA WIC PROGRAM 2013 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.

CT-124

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

BREASTFEEDING WOMEN

PRIORITY

372

ALCOHOL AND ILLEGAL DRUG USE

I

Alcohol use: x Routine current use of > 2 drinks per day OR x Binge drinking is defined as >5 drinks on the same occasion on at least one day in the past 30 days, OR x Heavy drinking is defined as >5 drinks on the same occasion on five or more days in the past 30 days

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

Document: Alcohol Use; identify type (Routine - Enter oz./wk: ___, Binge drinker, Heavy drinker) on WIC Assessment/Certification Form.

See Appendix E-1 for documentation codes.

Any Illegal drug use:
Document: Type of drug(s) being used. See Appendix E-2 for commonly used illegal drug names.

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-125

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

BREASTFEEDING 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

401

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.)

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.

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.

CT-126

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

BREASTFEEDING WOMEN

PRIORITY

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.

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.

CT-127

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

BREASTFEEDING WOMEN

PRIORITY

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.

903

Foster Care

IV

Entering the foster care system during the previous six months or moving from one foster care home to another foster care home during the previous six months.

904

ENVIRONMENTAL TOBACCO SMOKE EXPOSURE

I

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

CT-128

GEORGIA WIC PROGRAM 2013 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

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

Last Weight Before Delivery
Hemoglobin or Hematocrit
Evaluation of Inappropriate Nutrition Practices Risk Factor Assessment

Required Required (Apply 90-day rule when not available)
Required
Required

Woman Certified in Clinic
Required
Required Required Required Required
Required Required

CT-129

GEORGIA WIC PROGRAM 2013 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-130

GEORGIA WIC PROGRAM 2013 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 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 within the past 12 months.

Document: Date of blood test and blood lead level in the participant's health record. Must be within the past 12 months.

High Risk: Blood lead level of >10 Pg/deciliter within the past 12 months.

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 for any pregnancy.

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

CT-131

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

POSTPARTUM NON-BREASTFEEDING WOMEN

304

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 for any pregnancy.

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 less than or equal to 5 lb 8 oz (2500 gms). 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-132

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE 331

POSTPARTUM NON-BREASTFEEDING WOMEN
PREGNANCY AT A YOUNG AGE For most recent pregnancy. Conception at less than or equal to 17 years of age. Applies to most recent pregnancy only. Document: Age at conception on the WIC Assessment/Certification Form High Risk: Conception at less than or equal to 17 years of age

PRIORITY III

332

CLOSELY SPACED PREGNANCIES

VI

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

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-133

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

POSTPARTUM NON-BREASTFEEDING WOMEN

CODE

337

HISTORY OF A LARGE FOR GESTATIONAL AGE INFANT

VI

Most recent pregnancy, or history of giving birth to an infant with a birth weight of 9 pounds or more.

Document: Birth weight(s) and date(s) of deliveries 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-134

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE 342

POSTPARTUM NON-BREASTFEEDING WOMEN

PRIORITY

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

Diabetes mellitus consists of a group of metabolic diseases characterized by inappropriate hyperglycemia resulting from defects in insulin secretion, insulin action or both.

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

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

High Risk: Diagnosed diabetes mellitus

CT-135

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE 344

POSTPARTUM NON-BREASTFEEDING WOMEN
THYROID DISORDERS

PRIORITY VI

Thyroid dysfunctions that occur in pregnant and postpartum women, during fetal development, and in childhood are caused by the abnormal secretion of thyroid hormones. The medical conditions include, but are not limited to, the following:
x Hyperthyroidism: Excessive thyroid hormone production (most commonly known as Graves' disease and toxic multinodular goiter).
x Hypothyroidism: Low secretion levels of thyroid hormone (can be overt or mild/subclinical). Most commonly seen as chronic autoimmune thyroiditis (Hashimoto's thyroiditis or autoimmune thyroid disease). It can also be caused by severe iodine deficiency.
x Postpartum Thyroiditis: Transient or permanent thyroid dysfunction occurring in the first year after delivery based on an autoimmune inflammation of the thyroid. Frequently, the resolution is spontaneous.

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

High Risk: Diagnosed thyroid disorder

345

HYPERTENSION

VI

Presence of hypertension 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-136

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

POSTPARTUM NON-BREASTFEEDING WOMEN

PRIORITY

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

347

CANCER

VI

A chronic disease whereby populations of cells have acquired the ability to multiply and spread without the usual biologic restraints. The current condition, or the treatment for the condition, must be severe enough to affect nutritional status.

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

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

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

VI

ability to feed self, that alter nutritional status metabolically, mechanically, or

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

tube defects (NTD) such as spina bifida and myelomeningocele.

Presence of 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-137

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE 349

POSTPARTUM NON-BREASTFEEDING WOMEN

PRIORITY

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-138

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

x
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

An adverse immune response to a food or a hypersensitivity that causes adverse immunologic reaction.

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

Document: Diagnosis and the name of the physician that is treating this condition.

High Risk: Diagnosed food allergy

CT-139

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE 354

POSTPARTUM NON-BREASTFEEDING WOMEN
CELIAC DISEASE
Also known as Celiac Sprue, Gluten Enteropathy, or Non-tropical Sprue.
Inflammatory condition of the small intestine precipitated by the ingestion of wheat in individuals with certain genetic make-up.
Presence of condition diagnosed, documented, or reported by a physician or someone working under a physician's orders, or as self reported by applicant/participant/caregiver.
Document: Diagnosis and the name of the physician that is treating this condition.
High Risk: Diagnosed Celiac Disease

PRIORITY VI

355

LACTOSE INTOLERANCE

VI

Lactose intolerance occurs when there is an insufficient production of the enzyme lactase. Lactase is needed to digest lactose. Lactose in dairy products that is not digested or absorbed is fermented in the small intestine producing any or all of the following GI disturbances: nausea, diarrhea, abdominal bloating, cramps. Lactose intolerance varies among and within individuals and ranges from mild to severe.
Presence of condition diagnosed, documented, or reported by a physician or someone working under a physician's orders, or as self reported by applicant/participant/caregiver.

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).

CT-140

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE 356

POSTPARTUM NON-BREASTFEEDING WOMEN
HYPOGLYCEMIA 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.

PRIORITY VI

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

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

Eating disorders (anorexia nervosa and bulimia), are characterized by a

VI

disturbed sense of body image and morbid fear of becoming fat. Symptoms

are manifested by abnormal eating patterns including, but not limited to:

x

Self-induced vomiting

x

Purgative abuse

x

Alternating periods of starvation

x

Use of drugs such as appetite suppressants, thyroid preparations

or diuretics

x

Self-induced marked weight loss

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

Document: Symptoms or diagnosis and the name of the physician that is treating this condition in the participant's health record. High Risk: Diagnosed eating disorder

CT-141

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE 359

POSTPARTUM NON-BREASTFEEDING WOMEN

PRIORITY

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 that has a continued need for nutritional support.

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 Asthma (moderate or severe) requiring daily medication.

Presence of medical condition(s) diagnosed, documented, or reported by a physician or someone working under a physician's orders, or as self reported by applicant/participant/caregiver.
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-142

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

POSTPARTUM NON-BREASTFEEDING WOMEN

PRIORITY

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.

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.
CT-143

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

POSTPARTUM NON-BREASTFEEDING WOMEN

PRIORITY

372

ALCOHOL AND ILLEGAL DRUG USE

VI

Alcohol use: x Routine current use of > 2 drinks per day OR x Binge drinking is defined as >5 drinks on the same occasion on at least one day in the past 30 days, OR x Heavy drinking is defined as >5 drinks on the same occasion on five or more days in the past 30 days

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

Document: Alcohol Use; identify type (Routine - Enter oz./wk: ___, Binge drinker, Heavy drinker) on WIC Assessment/Certification Form. See Appendix E-1 for documentation codes.

Any Illegal drug use:
Document: Type of drug(s) being used. See Appendix E-2 for commonly used illegal drug names.

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-144

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE 400

POSTPARTUM NON-BREASTFEEDING WOMEN

PRIORITY

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.

401

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.)

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.

801

HOMELESSNESS

VI

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

CT-145

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

POSTPARTUM NON-BREASTFEEDING WOMEN

802

MIGRANCY

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

PRIORITY VI

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.

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.

CT-146

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

903

Foster Care

IV

Entering the foster care system during the previous six months or moving from one foster care home to another foster care home during the previous six months.

904

ENVIRONMENTAL TOBACCO SMOKE EXPOSURE

VI

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

CT-147

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

DATA AND DOCUMENTATION REQUIRED FOR WIC ASSESSMENT/CERTIFICATION

INFANTS

Data
Length Weight Hematocrit or Hemoglobin

Documentation

nfant

Certified in Hospita

Prior to Initial Discharge

0-6

Infant
Months

Birth Data or other measurement

Required

Birth Data or other measurement

Required

N/A

Optional

Weight for Age Plotted

Optional

Required

Length for Age Plotted

Optional

Required

Weight for Length Plotted

Optional

Required

Evaluation of Inappropriate Nutrition Practices

Optional

Required

Risk Factor Assessment

Required

Required

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

CT-148

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

NUTRITION RISK CRITERIA INFANTS

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 or AT RISK OF UNDERWEIGHT

I

Less than or equal to the 5th percentile weight-for-length as plotted on the CDC Birth to 24 months gender specific growth charts.*

High Risk: Less than or equal to the 2nd percentile weight-for-length as plotted on the CDC Birth to 24 months gender specific growth charts.*

*Based on 2006 World Health Organization international growth standards. For the Birth to < 24 months "underweight" definition, CDC labels the 2.3rd percentile as the 2nd percentile on the Birth to 24 months gender specific growth charts.

115

High Weight-for Length

Greater than or equal to the 98th percentile weight-for-length as plotted

on the Centers for Disease Control and Prevention (CDC), Birth to 24

months gender specific growth charts.

I

*Based on the 2006 World Health Organization (WHO) international growth standards. CDC labels the 97.7th percentile as the 98th percentile on the Birth to 24 months gender specific growth charts.

CT-149

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

CODE

INFANTS

Attachment CT-6 (cont'd) PRIORITY

121

SHORT STATURE OR AT RISK OF SHORT STATURE

I

Less than or equal to the 5th percentile length-for-age as plotted on the CDC Birth to 24 months gender specific growth charts.* (if < 38 weeks gestation use adjusted age)

High Risk: Less than or equal to the 2nd percentile length-for-age as plotted on the Centers for Disease Control and Prevention (CDC) Birth to 24 months gender specific growth charts.*
*Based on 2006 World Health Organization international growth standard. CDC labels the 2.3rd percentile as the 2nd percentile on the Birth to 24 months gender specific growth charts.


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-150

GEORGIA WIC PROGRAM 2013 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

Weight Gain per 6-month interval*

5 mos - 6 mos >6 mos - 9 mos >9 mos - 12 mos

< 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-151

GEORGIA WIC PROGRAM 2013 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

151

Small for Gestational Age

Infants diagnosed as small for gestational age. I
Presence of condition diagnosed, documented, or reported by a physician or someone working under a physician's orders, or as self reported by applicant/participant/caregiver.

152

Low Head Circumference

I

Less than 2nd percentile head circumference-for-age as plotted on the Centers for Disease Control and Prevention (CDC) Birth to 24 months gender specific growth charts (if < 38 weeks gestation use adjusted age)

* Based on 2006 World Health Organization international growth standards. CDC labels the 2.3rd percentile as the 2nd percentile on the Birth to 24 months gender specific growth charts.

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.

CT-152

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

INFANTS

PRIORITY

211

ELEVATED BLOOD LEAD LEVELS

I

Blood lead level of > 10 Pg/deciliter within the past 12 months.

Document: Date of blood test and blood lead level in participant's health record. Must be within the past 12 months

High Risk: Blood lead level of > 10 Pg/deciliter within the past 12 months.

NUTRITION RELATED MEDICAL CONDITIONS

341

NUTRIENT DEFICIENCY DISEASES

I

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

High Risk: Diagnosed nutrient deficiency disease

CT-153

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE 342

INFANTS
GASTRO-INTESTINAL DISORDERS

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

PRIORITY I

343

DIABETES MELLITUS

I

Diabetes mellitus consists of a group of metabolic diseases characterized by inappropriate hyperglycemia resulting from defects in insulin secretion, insulin action or both.

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

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

High Risk: Diagnosed diabetes mellitus

CT-154

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

INFANTS

344

THYROID DISORDERS

Thyroid dysfunctions that occur in fetal development and in childhood are caused by the abnormal secretion of thyroid hormones. The medical conditions include, but are not limited to, the following:

PRIORITY I

x Congenital Hyperthyroidism: Excessive thyroid hormone levels at birth, either transient (due to maternal Grave's disease) or persistent (due to genetic mutation).
x Congenital Hypothyroidism: Infants born with an under active thyroid gland and presumed to have had hypothyroidism inutero.

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-155

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

346

RENAL DISEASE

I

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

CT-156

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE 347

INFANTS
CANCER
A chronic disease whereby populations of cells have acquired the ability to multiply and spread without the usual biologic restraints. The current condition, or the treatment for the condition, must be severe enough to affect nutritional status.
Presence of condition diagnosed, documented, or reported by a physician or someone working under a physician's orders, or as self reported by applicant/participant/caregiver.
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

PRIORITY I

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-157

GEORGIA WIC PROGRAM 2013 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-158

GEORGIA WIC PROGRAM 2013 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

An adverse immune response to a food or a hypersensitivity that causes adverse immunologic reaction.

Presence of condition diagnosed, documented, or reported by a physician or someone working under a physician's orders, or as self reported by applicant/participant/caregiver.
Document: Diagnosis and the name of the physician that is treating this condition in the participant's health record.
High Risk: Diagnosed food allergy

CT-159

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

INFANTS

PRIORITY

354

CELIAC DISEASE

I

Also known as Celiac Sprue, Gluten Enteropathy, or Non-tropical Sprue.

Inflammatory condition of the small intestine precipitated by the ingestion of wheat in individuals with certain genetic make-up.
Presence of condition diagnosed, documented, or reported by a physician or someone working under a physician's orders, or as self reported by applicant/participant/caregiver.
Document: Diagnosis and the name of the physician that is treating this condition in the participant's health record.

High Risk: Diagnosed Celiac Disease

355

LACTOSE INTOLERANCE

I

Lactose intolerance occurs when there is an insufficient production of the enzyme lactase. Lactase is needed to digest lactose. Lactose in dairy products that is not digested or absorbed is fermented in the small intestine producing any or all of the following GI disturbances: nausea, diarrhea, abdominal bloating, cramps. Lactose intolerance varies among and within individuals and ranges from mild to severe.
Presence of condition diagnosed, documented, or reported by a physician or someone working under a physician's orders, or as self reported by applicant/participant/caregiver.

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).

CT-160

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

INFANTS

PRIORITY

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.

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 that has a continued need for nutritional support.

CT-161

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

INFANTS

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 Asthma (moderate or severe) requiring daily medication.

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

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.

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.

CT-162

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Attachment CT-6 (cont'd)

CODE

INFANTS

PRIORITY

381

DENTAL PROBLEMS

I

Diagnosis of dental problems by a physician or health care provider working under the orders of a physician or adequate documentation by the competent professional authority. 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.

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.

CT-163

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Attachment CT-6 (cont'd)

CODE

INFANTS

PRIORITY

428

Dietary Risk Associated with Complementary Feeding Practices

IV

(Infants 4 to 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.)

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

CT-164

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Attachment CT-6 (cont'd)

CODE

INFANTS

PRIORITY

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.

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

I, II, IV

CT-165

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Attachment CT-6 (cont'd)

CODE 703

INFANTS
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.

PRIORITY I

801

HOMELESSNESS

Homelessness as defined in the Special Population Section of the

IV

Georgia WIC Procedures Manual.

802

MIGRANCY

IV

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

901

RECIPIENT OF ABUSE

Child abuse/neglect within past 6 months as self-reported by the

IV

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.

CT-166

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Attachment CT-6 (cont'd)

CODE

INFANTS

PRIORITY

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.
IV 903 Foster Care
Entering the foster care system during the previous six months or moving from one foster care home to another foster care home during the previous six months.

904

ENVIRONMENTAL TOBACCO SMOKE EXPOSURE

I

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

CT-167

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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-168

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

NUTRITION RISK CRITERIA CHILDREN

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 or AT RISK OF UNDERWEIGHT

III

(Children 12-24 Months of Age)

Less than or equal to the 5th percentile weight-for-length as plotted on

the CDC 12 to 24 months gender specific growth charts.*

High Risk: Less than or equal to the 2nd percentile weight-for-length as plotted on the CDC Birth to 24 months gender specific growth charts.*

*Based on 2006 World Health Organization international growth standards. For the Birth to < 24 months "underweight" definition, CDC labels the 2.3rd percentile as the 2nd percentile on the Birth to 24 months gender specific growth charts.

UNDERWEIGHT or AT RISK OF UNDERWEIGHT (Children 2-5 Years of Age) Less than or equal to the 10th percentile Body Mass Index (BMI) for age based on Centers for Disease Control and Prevention (CDC) age/sex specific growth charts.
High Risk: Less than or equal to the 5th percentile Body Mass Index (BMI)-for-age as plotted on the 2000 CDC age/gender specific growth charts.

CT-169

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Attachment CT-6 (cont'd)

CODE 113

CHILDREN
OBESE (Children 2-5 Years of Age) Greater than or equal to 95th percentile Body Mass Index (BMI) or weight-for-stature as plotted on the 2000 Centers for Disease Control and Prevention (CDC) 2-20 years gender specific growth charts

PRIORITY III

High Risk: Greater than or equal to 95th percentile BMI or weight-forstature as plotted on the 2000 Centers for Disease Control and Prevention (CDC) 2-20 years gender specific growth charts

114

OVERWEIGHT

III

(Children 2-5 Years of Age)

Greater than or equal to 85th and less than 95th percentile Body Mass Index (BMI)-for-age or weight-for-stature as plotted on the 2000 Centers for Disease Control and Prevention (CDC) 2-20 years gender specific growth charts.*

* The cut off is based on standing height measurements. Therefore, recumbent length measurements may not be used to determine this risk.

115

High Weight-for-Length (Children 12-24 Months of Age)

Greater than or equal to the 98th percentile weight-for-length as plotted

on the Centers for Disease Control and Prevention (CDC), Birth to 24

months gender specific growth charts.*

III

*Based on the 2006 World Health Organization (WHO) international growth standards. CDC labels the 97.7th percentile as the 98th percentile on the Birth to 24 months gender specific growth charts.

CT-170

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CODE

CHILDREN

Attachment CT-6 (cont'd) PRIORITY

121

SHORT STATURE OR AT RISK OF SHORT STATURE

III

(Children 12-24 Months of Age)

Less than or equal to the 5th percentile length-for-age as plotted on the CDC Birth to 24 months gender specific growth charts(1).* (if < 38 weeks gestation use adjusted age)

High Risk: Less than or equal to the 2nd percentile length-for-age as plotted on the Centers for Disease Control and Prevention (CDC) Birth to 24 months gender specific growth charts.*



*Based on 2006 World Health Organization international growth standards. CDC labels the 2.3rd percentile as the 2nd percentile on the Birth to 24

months gender specific growth charts.

SHORT STATURE OR AT RISK OF SHORT STATURE (Children 2-5 Years of Age)
Less than or equal to the 10th percentile length or height for age based on CDC age/sex specific growth charts.
High Risk: Less than or equal to the 5th percentile stature-for-age as plotted on the 2000 CDC age/gender specific growth charts

134

FAILURE TO THRIVE

III

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

Document: Diagnosis in participant's health record. High Risk: Diagnosed failure to thrive

CT-171

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

CHILDREN

135

INADEQUATE GROWTH

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

PRIORITY III

*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)

Born at 37 weeks gestation or less

III

Document: Weeks gestation in participant's health record.

151

Small for Gestational Age (Children 12-24 Months of Age)

Children less than 24 months of age diagnosed as small for gestational

age.

III

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

CT-172

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

CHILDREN

PRIORITY

152

Low Head Circumference (Children 12-24 Months of Age)

Less than 2nd percentile head circumference-for-age as plotted on the

Centers for Disease Control and Prevention (CDC) Birth to 24 months

gender specific growth charts

III

(if < 38 weeks gestation use adjusted age)

* Based on 2006 World Health Organization international growth standards. CDC labels the 2.3rd percentile as the 2nd percentile on the Birth to 24 months gender specific growth charts.

211

ELEVATED BLOOD LEAD LEVELS

III

Blood lead level of >10 Pg/deciliter within the past 12 months.

Document: Date of blood test and blood lead level in participant's health record. Must be within the past 12 months.

High Risk: Blood lead level of >10 Pg/deciliter within the past 12 months.

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-173

GEORGIA WIC PROGRAM 2013 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

Diabetes mellitus consists of a group of metabolic diseases characterized by inappropriate hyperglycemia resulting from defects in insulin secretion, insulin action or both.

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

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

High Risk: Diagnosed diabetes mellitus

CT-174

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

CHILDREN

344

THYROID DISORDERS

Thyroid dysfunctions that occur in fetal development and in childhood are caused by the abnormal secretion of thyroid hormones. The medical conditions include, but are not limited to, the following:

PRIORITY III

x Hypothyroidism: Excessive thyroid hormone production (most commonly known as Graves' disease and toxic multinodular goiter).
x Hyperthyroidism: Low secretion levels of thyroid hormone (can be overt or mild/subclinical). Most commonly seen as chronic autoimmune thyroiditis (Hashimoto's thyroiditis or autoimmune thyroid disease). It can also be caused by severe iodine deficiency.
Document: Diagnosis and name of the physician that is treating this condition in the participant's health record.
High Risk: Diagnosed thyroid disorder

345

HYPERTENSION

III
Presence of hypertension 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-175

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

CHILDREN

PRIORITY

347

CANCER

III

A chronic disease whereby populations of cells have acquired the ability to multiply and spread without the usual biologic restraints. The current condition, or the treatment for the condition, must be severe enough to affect nutritional status.

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

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-176

GEORGIA WIC PROGRAM 2013 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-177

GEORGIA WIC PROGRAM 2013 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

An adverse immune response to a food or a hypersensitivity that causes adverse immunologic reaction.

Presence of condition diagnosed, documented, or reported by a physician or someone working under a physician's orders, or as self reported by applicant/participant/caregiver.
Document: Diagnosis and name of the physician that is treating this condition in the participant's health record.
High Risk: Diagnosed food allergy

CT-178

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

CHILDREN

PRIORITY

354

CELIAC DISEASE

III

Also known as Celiac Sprue, Gluten Enteropathy, or Non-tropical Sprue.

Inflammatory condition of the small intestine precipitated by the ingestion of wheat in individuals with certain genetic make-up.
Presence of condition diagnosed, documented, or reported by a physician or someone working under a physician's orders, or as self reported by applicant/participant/caregiver.

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

355

LACTOSE INTOLERANCE

III Lactose intolerance occurs when there is an insufficient production of the enzyme lactase. Lactase is needed to digest lactose. Lactose in dairy products that is not digested or absorbed is fermented in the small intestine producing any or all of the following GI disturbances: nausea, diarrhea, abdominal bloating, cramps. Lactose intolerance varies among and within individuals and ranges from mild to severe.

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

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).

CT-179

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

CHILDREN

PRIORITY

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.

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 that has a continued need for nutritional support.

CT-180

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Attachment CT-6 (cont'd)

CODE

CHILDREN

PRIORITY

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 Asthma (moderate or severe) requiring daily medication.

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

361

DEPRESSION

III

Presence of depression diagnosed by a physician or psychologist as self reported by applicant/participant/caregiver; or as reported or documented by a physician, psychologist or 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-181

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Attachment CT-6 (cont'd)

CODE
362

CHILDREN
DEVELOPMENTAL, SENSORY OR MOTOR DELAYS 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.

PRIORITY III

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-182

GEORGIA WIC PROGRAM 2013 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.

401

FAILURE TO MEET DIETARY GUIDELINES FOR

AMERICANS

V

(Children 2-5 Years 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-183

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-6 (cont'd)

CODE

CHILDREN

PRIORITY

428

DIETARY RISK ASSOCIATED WITH COMPLEMENTARY

V

FEEDING PRACTICES

(Children 12-24 Months of Age)

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.

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

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

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-184

GEORGIA WIC PROGRAM 2013 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.

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CODE

CHILDREN

903

Foster Care

Entering the foster care system during the previous six months or moving from one foster care home to another foster care home during the previous six months.

PRIORITY V

904

ENVIRONMENTAL TOBACCO SMOKE EXPOSURE

III

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

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TABLE OF APPENDICES

APPENDICES REFERENCED IN RISK CRITERIA SECTION

Appendix

Page

A-1

WIC Maternal High Risk Criteria..................................................

99

A-2

WIC High Risk Criteria for Infants and Children.............................. 100

B-1

Women's Health Recommended Guidelines for Iron Supplementation, Based on Treatment Values............................... 101

B-2

Child Health Recommended Guidelines for Iron Supplementation,

Based on Treatment Values....................................................... 102

C-1

Body Mass Index (BMI) Table for Determining Weight

Classification for Women........................................................... 103

C-2

Definition of Maternal Weight Gain (Low, High, and Multi-Fetal)......... 104

C-3

Definition of Inadequate Growth for Infants 1-6 Months of Age........... 105

D

Physical Signs Suggestive of Nutrient Deficiencies.......................... 106

E-1

Alcohol and Cigarettes............................................................... 108

E-2

Common Names of Illegal (Street) Drugs/Drugs of Abuse.................................................................................... 109

F

Recommended Food Intake Patterns........................................... 110

G

Inappropriate Nutrition Practices................................................

111

H

Products Containing Caffeine...................................................... 116

I

Instructions for Use of the Prenatal Weight Gain Grid......................

118

J-1

Measuring Length..................................................................... 119

J-2

Measuring Weight ("Infant" Scale)................................................ 120

J-3

Measuring Height...................................................................... 121

J-4

Measuring Weight (Standing)...................................................... 122

K

Instructions for Use of the Growth Charts.....................................

123

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L

Use and Interpretation of the Growth Charts.................................. 127

APPENDICES PROVIDED FOR SUPPLEMENTAL INFORMATION

Appendix

Page

M

Food Sources of Vitamin A......................................................... 128

N

Food Sources of Vitamin C......................................................... 129

O

Food Sources of Folate............................................................. 130

P

Food Sources of Iron................................................................. 131

Q

Food Source of Calcium............................................................ 132

R

Herbs: Their Use and Potential Risks........................................... 133

S

Key for Entering Weeks Breastfed............................................... 134

T

Infant Formula Preparation......................................................... 135

U-1

Conversion Tables and Equivalents............................................. 138

U-2

Approximate Metric and Imperial Equivalents................................. 139

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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 specific to their nutritional condition and to the nutritional problems identified in their diet, as reflected in an individual care plan. In most instances, this counseling should be provided by a nutritionist. However, if the CPA determines that some other intervention or referral would be more appropriate, adequate documentation must be provided.

High Risk Criteria Hemoglobin or hematocrit at treatment level

Risk Code 201

Underweight

Prenatal Women: Body Mass Index <18.5

101

Postpartum Women: Body Mass Index <18.5

Overweight

Prenatal Women: Body Mass Index >29.9

111

Postpartum Women: Current Body Mass Index >29.9

Low maternal weight gain

131

Gestational weight loss during pregnancy greater than or equal to 2 pounds in the second and third trimester.

132

Blood lead level > 10 Pg/dl within the past 12 months.

211

Hyperemesis Gravidarum

301

Gestational diabetes

302

EDC or delivery prior to 17th birthday

331

Multi-fetal gestation

335

Fetal Growth Restriction

336

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
Diagnosed pre-diabetes
Breastfeeding complications; referral to appropriate BF counselor must be made
Any condition deemed by the competent professional authority to place the woman at high risk for compromised nutritional status; adequate documentation required

341-349; 351-360;
362
363
602

Appendix B-1
C-1 Body Mass Index Tables
C-1 Body Mass Index Tables
C-2

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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 specific to their nutritional condition and to the nutritional problems identified in their diet, as reflected in an individual care plan. In most instances, this counseling should be provided by a nutritionist. However, if the CPA determines that some other intervention or referral would be more appropriate, adequate documentation must be provided.

High Risk Criteria
Hemoglobin or hematocrit at treatment level
Underweight or At Risk of Underweight (Infants and Children) Infants <12 Months of Age: Weight for length < 2nd percentile weightfor-length as plotted on the CDC Birth to 24 months gender specific growth charts Children <24 Months of Age: Weight for length < 2nd percentile weightfor-length as plotted on the CDC Birth to 24 months gender specific growth charts Children 2-5 Years of Age: BMI for age <5th percentile
OBESE (Children 2-5 Years of Age) Body Mass Index for age >95th %
Short stature (length/height for age <5th %)

Risk Code 201
103
113 121

Appendix B-2

Failure to thrive

134

Inadequate growth

135

Low birthweight infant (infant weighing 2500 grams [5 pounds] or

less at birth). May only be used for infants as high risk criteria.

141

Blood lead level > 10Pg/dl within the past 12 months.

211

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

341-357; 359; 360; 362; 382

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Breastfeeding complications; infants only; referral to appropriate BF

counselor must be made

603

Any condition deemed by the competent professional authority to place the infant/child at high risk for compromised nutritional status; adequate documentation required

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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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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

32.8% or lower

Dosage: 0.6 cc Ferrous Sulfate Drops BID Mg Elemental Iron: 15 mg BID

Child 12 through 23 months

10.9 gm or lower

32.8% or lower

Dosage: 0.6 cc Ferrous Sulfate Drops BID Mg Elemental Iron: 15 mg BID

Child 2 through 5 years

11.0 gm or lower

32.9% or lower

Dosage: 1.2 cc Ferrous Sulfate 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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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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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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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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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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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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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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Appendix E-2

COMMON NAMES FOR ILLEGAL (STREET) DRUGS/DRUGS OF ABUSE

Controlled Substances Cannabis:

Common Names

Marijuana

Acapulco Gold, Grass, Pot, Reefer, Sinsemilla, Thai Sticks

Tetrahydrocannabinol

Marinol, THC

Hashish, Hashish Oil

Hash, Hash Oil

Hallucinogens:

LSD (lysergic acid diethylamide)

Acid, Microdot

Mescaline, Peyote Amphetamine Variants

Buttons, Cactus, Mescal
2,5-DMA, DOB, DOM, Ecstasy, MDA, MDMA, STP

Phencyclidine and Analogs

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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Food Group

Birth to 5/6 Months

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

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

RECOMMENDED FOOD INTAKE PATTERNS

Appendix F

5/6 Months to 12 months
Breast milk, every 2-4 hrs or Iron fortified formula, 2.5 oz/lb (24-35 ozs)

1 Year 2 cups1

2-3 Years 2 cups

4-6 Years 2.5 cups

Pregnant Teen/ Pregnant Adult
3 cups

Breastfeeding Teen/ Breastfeeding Adult
3 cups

Teen Postpartum/ Adult Postpartum
3 cups

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 equivalents

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 If there is obesity, high cholesterol or heart disease in their family history, the AAP recommends reduced fat 2 percent milk between 12

months and 2 years in place of whole. WIC regulations at this time does not allow for the issuance of low fat milk below the age of 2. 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: Most milk group choices should be fat-free or low-fat for those over the age of 2 years. 1 cup equivalent from this group = 1 cup milk/yogurt
1 ounces natural cheese (i.e. cheddar, Colby, longhorn) 2 ounces processed cheese (i.e. American, Swiss) 2 cups cottage cheese
Meat, Poultry, Dry Beans, Eggs, Nuts Group: 1 ounce equivalent from this group= 1 ounce lean meat, poultry or fish
1 egg ounce nuts or seeds cup cooked dry beans or tofu 1 tablespoon peanut butter

Fruit Group: 1 cup equivalent from this group= 1 medium fruit
1 cup freshly cut canned or frozen fruit cup dried fruit 1 cup 100% fruit juice Vegetable Group:
1 serving =
1 cup cooked or chopped 2 cups raw leafy salad greens 1 cup 100% vegetable juice
Grain Group: At least half of all grains consumed should be whole grains 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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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 woman.

x Consumption of less than 150 g of supplemental iodine per day by

pregnant and breastfeeding woman.

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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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).

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Inappropriate Nutrition Practices for Children

Examples of Inappropriate Nutrition Practices (Including but not limited to)

Potentially unsafe food consumption.
Feeding foods to a child that could be contaminated with harmful microorganisms.

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 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 iron-fortified formula as the primary source during the first year of life.
Inappropriate use of bottles or SugarContaining 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 selffeeding (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 for Infants

Examples of Inappropriate Nutrition Practices (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 cannot meet nutrient requirements.

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 than8 feedings in a 24 hours if less than 2 months of age; and x Less than 6 feedings in 24 hours if between 2 and 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 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)

PRODUCTS CONTAINING CAFFEINE

Appendix H

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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Appendix I

INSTRUCTIONS FOR USE OF THE PRENATAL WEIGHT GAIN GRID

1. Record applicant/participant's name.
2. Use Body Mass Index table (Appendix C-1) to determine if the applicant is Normal Weight, Underweight , Overweight , or Obese using pregravid weight. Select for use the prenatal weight gain grid that corresponds to the prenatal woman's pregravid weight status. If she is pregnant with twins, use the "Twins" grid regardless of her weight status.
3. Enter height in inches without shoes.
4. Use Weight History chart.
5. Enter pregravid weight as indicated. Enter date and weight at each visit.
6. Plot today's weight using the following steps:
a. Record the pregravid weight at the initial point of the selected weight curve, which is located on the left side of the grid at zero (0) point. From the chart or gestation calculator, determine the completed weeks of gestation.
b. Using the gain (or loss) in weight from the pregravid weight baseline and the completed gestational weeks (this visit) place an X on the point at which these two (2) lines meet.
c. If the patient does not know her pregravid weight, or if the weight she gives seems disproportionate to her current weight, place an X on the dotted line for the calculated completed gestational week. Let this be a beginning point to plot future weights. Indicate that this weight is an estimate by writing "estimate" vertically on the grid next to the X. Use the "Normal" weight curve unless it is very obvious that the prenatal woman was overweight or underweight prior to gestation. Document this observation in the health record.
d. At the second and each subsequent visit, the weight gain for completed weeks of gestation should be plotted on the grid.

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Attachment CT-6 (cont'd)
Appendix J-1

Age:

MEASURING LENGTH

Birth to 24 months

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 J-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 J-3

MEASURING HEIGHT

Age:

Children two (2) years of age and older

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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Attachment CT-6 (cont'd)

Appendix J-4

Age:

MEASURING WEIGHT (STANDING)

Adults, and children 2 years of age or older

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 K

INSTRUCTIONS FOR USE OF THE GROWTH CHARTS

1. Select the appropriate chart for sex and age of the individual. When length measurements are taken with the individual lying down use the "Birth to 24 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 - 24 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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Attachment CT-6 (cont'd)

Appendix K (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 gestationadjusted 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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Attachment CT-6 (cont'd)

Appendix K (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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Attachment CT-6 (cont'd)

Guidance for Rounding to One Decimal Point:

Appendix K (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 L

USE AND INTERPRETATION OF THE 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 0-24 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 024 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)
Appendix M

FOOD SOURCES OF VITAMIN A

Food Source
Apricots canned dried raw

Serving Size
3 halves 10 halves 3 medium

Vitamin A (mcg Retinol)*
140 250 280

Bok Choy

1 cup

110

Broccoli cooked raw

1 cup

110

1 cup

680

Carrots cooked raw

1cup 1 medium

1920 2030

Cantaloupe, cubed

1 cup

520

Endive, raw

1cup

50

Greens, fresh, cooked

beet

1cup

370

collards

1cup

350

kale

1cup

480

turnip

1cup

400

spinach

1cup

740

Liver, beef

3 ounces

10,600

Mango, raw

1 medium

810

Papaya, raw

1 medium

620

Parsley, chopped

1cup

160

Peaches

canned, juice pack

1 cup

100

raw

1 medium

50

dried

10 halves

280

Persimmon, raw

1 medium

360

Pumpkin, canned

1cup

2690

Sweet Potato, baked

1 medium

2490

Watercress, raw

1cup

80

Winter Squash, baked

1cup

240

*Micrograms of retinol equivalent: rounded to the nearest 10

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Attachment CT-6 (cont'd)

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

1 medium

*Milligrams Vitamin C: rounded to nearest 10 **Items distributed through the Georgia WIC Program.

Appendix N
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 O
% 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/cgibin/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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Attachment CT-6 (cont'd)
Appendix P

FOOD SOURCES OF IRON

Food Source

Serving Size

Iron Fortified Breakfast Cereal*

cup

Canned Clams

1/3 cup

Cooked Oysters

3 oz

Blackstrap Molasses

1 Tbsp.

Liver

2 ounces

Baked Beans

1 cup

Spinach

1 cup

Red Meat

3 ounces

Prunes

10 large

Raisins

1/2 cup

Pork

3 ounces

Turkey

3 ounces

Baked Potato with skin

1

Ham

3 ounces

Legumes, cooked*

1/2 cup

Raw Shrimp

3 ounces

Baked Winter Squash

1 cup

Berries

1 cup

Turnip or Collard Greens

1 cup

Liverwurst

1 slice

Chicken

3 ounces

Fish

3 ounces

Prune Juice

1/3 cup

*Items distributed through the Georgia WIC Program.

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 Q

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 R

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. 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)

KEY FOR ENTERING WEEKS BREASTFED

Appendix S

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. CodestoEnterWhenBreastfeedingisGiveninDays



ConvertDaystoWeeks

Fewerthan7days

= 00weeks

713days

= 01week

1420days

= 02weeks

2127days

= 03weeks

2834days

= 04weeks

3541days

= 05weeks

4248days

= 06weeks

Source: Georgia WIC Branch ETAD Change Number 08-12b, 2008.

II. CodestoEnterWhenBreastfeedingisGiveninMonths

1 month

= 04 weeks

12 Months

= 52 weeks

2 months

= 08 weeks

13 Months

= 56 weeks

3 months

= 13 weeks

14 Months

= 61 weeks

4 Months

= 17 weeks

15 Months

= 65 weeks

5 Months

= 22 weeks

16 Months

= 69 weeks

6 Months

= 26 weeks

17 Months

= 74 weeks

7 Months

= 30 weeks

18 Months

= 78 weeks

8 Months

= 35 weeks

19 Months

= 82 weeks

9 Months

= 39 weeks

20 Months

= 87 weeks

10 Months = 43 weeks

21 Months

= 91 weeks

11 Months = 48 weeks

22 Months

= 96 weeks

22.5 Months + = 98 weeks or more

Source: Enhanced Pregnancy Nutrition Surveillance System User's Manual. Division of Nutrition, Center for Chronic

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Attachment CT-6 (cont'd)

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 T

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.

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Attachment CT-6 (cont'd)

Appendix T (cont.)

Infant Formula Preparation
9. (Cont'd) 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 Department 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, Virginia 22302-1594. (U.S. Gov. Printing Office: 1994-0-360-395 QL.3).

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.

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Attachment CT-6 (cont'd)

Appendix T (cont.)

Infant Formula Preparation

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.

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 U-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 U-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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Infant Nutrition Questionnaire English (page 1)

Attachment CT-7

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Attachment CT-7 (cont'd)

Infant Nutrition Questionnaire English (page 2)

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GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-7 (cont'd)

Infant Nutrition Questionnaire Spanish (page 1)

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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)

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Attachment CT-7 (cont'd)

Child Nutrition Questionnaire English (page 2)

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Child Nutrition Questionnaire Spanish (page 1)

Attachment CT-7 (cont'd)

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Attachment CT-7 (cont'd)

Child Nutrition Questionnaire Spanish (page 2)

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GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL
Woman Nutrition Questionnaire English (page 1)

Attachment CT-7 (cont'd)

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Woman Nutrition Questionnaire English (page 2)

Attachment CT-7 (cont'd)

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GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL
Woman Nutrition Questionnaire Spanish (page 1)

Attachment CT-7 (cont'd)

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Woman Nutrition Questionnaire Spanish (page 2)

Attachment CT-7 (cont'd)

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GEORGIA WIC PROGRAM 2013 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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Attachment CT-9

Participant Transfer Log (Optional) District __ Unit__ Clinic____

Participant Name

Date Record Requested

Date

Agency Contact Information

Record

Received

Received Yes/No

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GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-10

CT-244

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Attachment CT-10 (cont'd) CT-245

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-11

CT-246

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Attachment CT-11( cont'd) CT-247

GEORGIA WIC PROGRAM 2013 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 nonrelated 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 Department of Agriculture (USDA) 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 3/12

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GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Attachment CT-13

Household Size 1................ 2................ 3................ 4................ 5................ 6................ 7................. 8................. 9................. 10................ 11................ 12................ 13................ 14................ 15................ 16................
Each Add'l Family Member, add
Revised 4/10/12

GEORGIA WIC PROGRAM INCOME ELIGIBLE GUIDELINES (Effective from July 1, 2012 to June 30, 2013)

Reduced Price Meals 185% of Federal Poverty Guidelines 48 Contiguous States

Annual $20,665 27,991 35,317 42,643
49,969 57,295 64,621 71,947 79,273 86,599 93,925 101,251 108,577 115,903 123,229 130,555

Monthly $1,723 2,333 2,994 3,554
4,165 4,775 5,386 5,996 6,607 7,218 7,829 8,440 9,051 9,662 10,273 10,884

Twice-monthly $862 1,167 1,472 1,777
2,083 2,388 2,693 2,998 3,304 3,916 4,222 4,528 4,834 5,140 5,446 5,752

Bi-weekly $795 1,077 1,359 1,641
1,922 2,204 2,486 2,768 3,050 3,332 3,614 3,896 4,178 4,460 4,742 5,024

+$7,326

+$611

+$306

+$282

Weekly $398 539 680 821 961 1,102 1,243 1,384 1,525 1,666 1,747 1,807 1,948 2,089 2,230 2,371
+$141

CT-249

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Attachment CT-14
GEORGIA WIC PROGRAM 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 the Georgia WIC Program because you:
You are being terminated from Georgia WIC because you:
______ have an income that is too high for the Georgia WIC Program. ______ do not live in the area served by the Georgia WIC Program. ______ are not pregnant, postpartum, or breastfeeding woman; child under five (5) years. ______ do not have a medical/nutritional health problem. ______ did not return to the clinic for your recertification appointment on _________________________ (date). ______ did not pick-up your food vouchers for two (2) months. You will be terminated on
______________________________ (date). Other _______ Fund are not available to serve postpartum non-breastfeeding women.
_______ ________________________________________________________.

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

You are being placed on a waiting list. Funds are not available to serve priority(ies)______________ . You are in priority___________________.
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 Program

___________________________________________________________________________

ADDRESS

_____________________________________________/______________________________

CITY/ZIP CODE

PHONE NUMBER

______________________________________________________________________

SIGNATURE/PARENT/CAREGIVER/GUARDIAN

WIC RESPRENTATIVE SIGNATURE/TITLE

In accordance with Federal Law and Department of Agriculture (USDA) 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 3/12.

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GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL 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

De acuerdo con la ley federal y las politicas del Departamento de Agricultura de los EE.UU. (USDA, sigla en ingles), se le prohibe a esta institucion que discrimine por razon de raza, color, orgien, sexo, edad, o discapacidad. Para presentar una queja sobre discriminacion, escriba a USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 o llame gratis al (866) 632-9992 (voz). Personas con discapacidad auditiva o delhabla pueden contractar con USDA por medio del Servicio Federal de Relevo (Federal Relay Service) al (800) 845-6136 (espanol) o (800) 877-8339 (ingles). "USDA es un proveedor y empleador que ofrece oportunidad igual para todos. Revised 3/12

CT-251

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Attachment CT-16 CT-252

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Attachment CT-17 CT-253

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Attachment CT-18 CT-254

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-19

DISTRICT

Date Beginning No.

Ending No.

No. Received

Card No. Issued

CLINIC VOC CARD INVENTORY LOG
GEORGIA WIC PROGRAM
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.
CT-255

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-20

DISTRICT

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

Date Beginning Ending

No.

No.

No.

No. Received Issued

Clinic Name (Print)

Name of Clinic Representative

Total No. of Cards
on Hand

Staff Signature

Staff Initials

NOTE: A physical Inventory of VOC cards must be performed by the local
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). Revised 3/12
CT-256

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-21

GEORGIA WIC PROGRAM
VOC CARD AGREEMENT
District ______, Unit ______ would like to have a clinic representative order VOC Cards directly from the Georgia WIC Program.
In order to accommodate this request, please complete the VOC CARD FORM, located in the Certification Section of the Georgia WIC Program 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 PROGRAM TO INFORM THEM OF THE CHANGE.

CT-257

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-22

GEORGIA WIC PROGRAM
VOC CARD FORM

District ____, Unit ____
In an effort to begin sending VOC cards directly to the clinic from the Georgia WIC Program, the following form must be on record at the Georgia WIC Program.
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-258

GEORGIA WIC PROGRAM 2013 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-259

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-24

GEORGIA WIC PROGRAM STATE/DISTRICT/CLINIC TRANSMITTAL FORM

The State/District Clinic Transmittal Form is a three (3) part form used to transmit VOC Cards from the Georgia WIC Program to the Clinic. This Form must be signed by clinic staff within five (5) days of Receipt then returned to sender. The Georgia WIC Program 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-260

GEORGIA WIC PROGRAM 2013 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-261

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-26

THERE IS NO CHARGE
FOR WIC SERVICES

GEORGIA WIC PROGRAM
PROMOTING HEALTHLY NUTRITION FOR WOMEN, INFANTS AND CHILDREN
SINCE 1974
1-800-228-9173
In accordance with Federal Law and Department of Agriculture (USDA) 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 3/12
CT-262

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-27

Georgia WIC Program
VERIFICATION OF RESIDENCY AND/OR INCOME

Household Section:

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

Name of WIC Applicant(s): ________________________________ ________________________________

Address: __________________________________ __________________________________

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

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

__________________________________________________________________________________

Signature

Date

Address:_________________________________________

City: _______________________________State:________________Zip Code: ________________

Telephone No.:_______________________________

Clinic Section:

This form must be returned on _____________________ to ______________________________

______________________________________________________________________________________

WIC Official

Date

_______________________________________________________________________________

WIC Official

Date Received

WE RESERVE THE RIGHT TO VERIFY THIS INFORMATION, IF NECESSARY.

In accordance with Federal Law and Department of Agriculture (USDA) 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 3/12

CT-263

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-28

GEORGIA WIC PROGRAM NO PROOF FORM

The Georgia WIC Program requires each applicant to show documentation of identification, residence (address), and income to be eligible for the Georgia WIC Program. 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: (circle the appropriate proof (s))

Income

Address Identification

2. Who do you work for?

How much did you make last month?

___________________________________ $_______________________________

List working family members:

How much did they make last month?

___________________________________ $_______________________________

___________________________________ $_______________________________

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

3. Reason for No Documentation: ________________________________________________________________________ ________________________________________________________________________

List family members applying for WIC: ____________________________________

_____________________________________

____________________________________ (Signature of Applicant)

___________________________ (Date)

___________________________________ (Signature of Clinic Staff)

__________________________ (Date)

In accordance with Federal Law and Department of Agriculture (USDA) 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 3/12

CT-264

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-29

FAMILY PLUS MEDICAID CARD

BENEFIT DESCRIPTION

CO-PAY

FamilyPlus*

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

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

MEMBER # 403967045P

EFF DATE 02/01/98

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

BIRTH SEX 06/03/94 F

*CALL YOUR PCP TO COORDINATE

*ATLANTA CHILDREN'S HEALTH NETWORK

*ALL OF YOUR HEALTHCARE NEED

*The family of health plans that fits.

CT-265

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-30

GEORGIA WIC PROGRAM 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 Department of Agriculture (USDA) 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 3/12
CT-266

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-31

GEORGIA WIC PROGRAM

INCOME CALCULATION FORM

(This form must be completed if applicant does not qualify for Adjunctive eligibility)

WICIDNUMBER:_______________________________

First

LastMiddleInitialDateofBirth

NAME___________________________________________________________________________________________________________

CityZipCode

ADDRESS__________________________________________________________________________________________________



DocumentationofIncomemustbecompletedforanapplicantwhodoesnotqualifyforadjunctiveeligibility.

UseThisSectiontoCalculateIncome

First Certification

Date_______________________

Income

Relationship and Name

Source

What Is Each Family Member's Income?

(circle one)

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

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

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

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

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



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

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

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

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

No. In Family_____



IS THE CLIENT INCOME ELIGIBLE? YES

NO

(Transfer total to the Certification Form)



UseThisSectiontoCalculateIncome

First Certification

Date_______________________

Income

RelationshipandNameSourceWhatIsEachFamilyMember'sIncome?

(circleone)

__________________________ __________ $______________________ 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)

IhavebeenadvisedofmyrightsandobligationsundertheProgram.IcertifythattheinformationIwillprovide,orhaveprovidediscorrect,to thebestofmyknowledge.TheincomeIhavegivenismytotalgrossincome(allcashincomebeforedeductions).Thiscertificationformisbeing submitted in connection with the receipt of Federal assistance. Program officials may verify information on this form. I understand that intentionallymakingafalsestatementorintentionallymisrepresenting,concealing,orwithholdingfactsmayresultinpayingtheStateagency,in cash,thevalueofthefoodbenefitsimproperlyissuedtomeandmaysubjectmetocivilorcriminalprosecutionunderStateandFederallaw.I understandthattheWICProgrammaygivemycertificationinformationtootherhealthorpublicassistanceagenciestoseeifmyfamilyiseligible fortheirservices.Iunderstandthattheseagenciesmaycontactme,buttheymaynotgivemyinformationtoanyoneelsewithoutaskingmy permission.

PARENT/GUARDIAN/CAREGIVER SIGNATURE


DATE









SIGNATUREOFWICOFFICIAL (Whoassessedincome)

PleaseplacethisformintheClient'sMedicalRecordbehindtheCertificationForm. In accordance with Federal Law and Department of Agriculture (USDA) 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 3/12

CT-267

GEORGIA WIC PROGRAM 2013 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 Department of Agriculture (USDA) 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 3/12

CT-268

GEORGIA WIC PROGRAM 2013 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:

Infante: Certificado de nacimiento Carta de confirmacin de nacimiento Bracelete de identificacin del hospital (madre y beb) Historial de inmunizaciones Identificacin militar Historial de salud
Tarjeta de Seguro Social

Comprobantes de Identificacin

(Se requiere un tipo de comprobante)

Nio(a):

Mujeres:

Certificado de nacimiento Certificado de nacimiento

Historial de inmunizaciones Licencia de conducir

Historial de salud

Historial de inmunizaciones

Tarjeta de Seguro Social Identificacin militar Tarjetas EVOC/VOC (con identificacin adicional) Tarjeta de pasaporte/pasaporte

Identificacin militar Historial de salud Bracelete de identificacin del hospital (madre y beb) Tarjeta de Seguro Social

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-269

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Attachment CT-33 (cont'd)

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

Carta del empleador Notificacin de desempleo Medicaid
Retiro militar Pago de Veterano Compensacin monetaria
Regalas netas

De acuerdo con la ley federal y las politicas del Departamento de Agricultura de los EE.UU. (USDA, sigla en ingles), se le prohibe a esta institucion que discrimine por razon de raza, color, orgien, sexo, edad, o discapacidad.
Para presentar una queja sobre discriminacion, escriba a USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 o llame gratis al (866) 632-9992 (voz). Personas con discapacidad auditiva o del habla pueden contractar con USDA por medio del Servicio Federal de Relevo (Federal Relay Service) al (800) 845-6136 (espanol) o (800) 877-8339 (ingles)."
USDA es un proveedor y empleador que ofrece oportunidad igual para todos.
Revised 3/12


CT-270

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-34

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

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

NAME:

DATE OF BIRTH:

ADDRESS:

CITY/ZIPCODE:

PHONE NUMBER

____You will be terminated from the Georgia WIC Program 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 _____Residency

_____Identification Parent/Guardian

WIC Representative ______________________________________ Date ___________________

FAILURE TO BRING THIS DOCUMENTATION TO THE HEALTH DEPARTMENT ON OR BEFORE THE ABOVE DATE WILL RESULT IN TERMINATION FROM THE GEORGIA WIC PROGRAM

_____You are being terminated from the Georgia WIC Program 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 Program

_______________________________________________

Address

_______________________________________________

City/Zip Code

Phone Number

_____________________________________________ _________________________________

Participant Signature/Parent/Caregiver/Guardian

WIC Representative Signature/Title

In accordance with Federal Law and Department of Agriculture (USDA) 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 3/12

CT-271

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-35

Department of Defense WIC Overseas Program

Session Date:

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-272

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-36



WIC OVERSEAS PROGRAM CONTACTS

(as of April 2001)

x Lakenheath, England

-- Nancy Czarzasty nancy.czarzasty@lakenheath.af.mil

x Yokosuka, Japan

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

x Baumholder, Germany

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

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

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

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

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

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

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

CT-273

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-37



PROOF OF RESIDENCY FORM FOR

APPLICANTS WITH P.O. BOX ADDRESS

The WIC applicant must complete this form when giving a post office box address:

Directions to House

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

Date Date Date

In accordance with Federal Law and Department of Agriculture (USDA) 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 3/12

CT-274

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL


Attachment CT-38

INCOME VERIFICATION LETTER

Date

Dear Mr/Ms:
It has been brought to the attention of the Georgia WIC Program that the income reported in the clinic may not be accurate. In order to qualify for the Georgia WIC Program, you must meet the income guidelines of the Georgia WIC Program.
Please bring in proof of family income on your next clinic appointment on ___________ at _____ a.m./p.m. At that time, you may bring either a copy of your most recent pay stub, a letter from your employer verifying your current wages, a copy of your most recent federal tax return, or a verification letter from the local welfare office. Failure to do so will result in termination from the Georgia WIC Program, 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 Department of Agriculture (USDA) 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 3/12

CT-275

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL
GEORGIA WIC PROGRAM INCIDENT/COMPLAINT FORM

District/Unit/Clinic: Date of Incident: Follow-Up Date: Type of Complaint:

County: Date Reported:

Sub Catorgory 1:

Sub Catorgory 2:

Participant

Proxy

Wait Time

Stolen Vouchers

Vendor

Civil Rights

Vendor

Transfer

Local Agency/State WIC Office Staff

Food Package Change Other

Anonymous Person Filing Complaint

Participant information

Vendor Information

Name: Phone:

Name: Guardian: Phone:

Vendor/Vendor #: Employee Name: Title: Phone:

Shelf Prices Clinic Closing Participant

Incident/Complaint:

Attachment CT-39

Customer Service Appointment

Fraud(Buy/Sell/Dual) Formula

Local Agency/State WIC Office Staff
Staff Name : Phone:
Staff Name : Phone:

Local Agency Resolution:
State Office of Nutrition and WIC Resolution/Comments:
Follow-up Report: Office of Nutrition and WIC, Customer Service Coordinator: Date: Revised 4/11/12

CT-276

Can the complaint be closed at the Local Agency?

Yes

No

Signature:

Date:

Can the complaint be closed at the State Office of

Nutrition and WIC?

Yes

No

Signature:

Date:

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-40

GEORGIA WIC PROGRAM How to File a Complaint

If you feel you have been treated unfairly, please let us know by using the information listed below. The Georgia WIC Program will assist you as well as notify the proper authorities if necessary.
ANY COMPLAINT You may call Georgia WIC Program 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 Program 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 the Georgia WIC Program by calling the toll free number 1-800228-9173, and/or write about your complaint to the address below:
Georgia WIC Program 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 Department of Agriculture (USDA) 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 3/12
CT-277

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-41

Name

GEORGIA WIC PROGRAM

REQUEST FOR WIC SERVICES LOG

PHONE CALLS/WALK-INS

Address/Telephone Number P/B/PP

Date

Date of

Infant/ Service Appointment

Child Requested

Prenatal ReAppointments

Date Appointment Rescheduled

Revised 3/12

CT-278

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-42

GEORGIA WIC PROGRAM

Interview Script

Georgia WIC Program 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 Department of Agriculture (USDA) 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 3/12

CT-279

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL
Separation of Duty Form/District Office

Attachment CT-43

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

Completion Date

(This form must be kept on file for 3 years plus current year) CT-280

GEORGIA WIC PROGRAM 2013 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-281

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment CT-45

Dear WIC Proxy:

The Georgia WIC Program appreciates your help, respects your time and effort in assisting the Georgia WIC Program 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 Program 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 Program Staff

In accordance with Federal Law and Department of Agriculture (USDA) 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 3/12
CT-282

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL


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Please initial below to indicate your preference:

BBB,Q DSSO\LQJ IRU :,& VHUYLFHV , AUTHORIZE ',6&/2685( RI P\ :,& DSSOLFDQW RU SDUWLFLSDQW LQIRUPDWLRQ IRU WKH SXUSRVHV UHIHUHQFHG DERYH , XQGHUVWDQG WKDW P\ UHIXVDO WR DOORZ VXFK GLVFORVXUH GRHV QRW DIIHFW P\ DSSOLFDWLRQ IRU RU SDUWLFLSDWLRQ LQ :,& RU P\ HOLJLELOLW\ IRU :,& VHUYLFHV

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During the certification process, the participant must receive an explanation of the following: 5HDVRQ IRU &HUWLILFDWLRQ 3URJUDP %HQHILWV 5HDVRQV IRU ,QHOLJLELOLW\ ,WHPV WKDW FDQ DQG FDQQRW EH SXUFKDVHG +RZ WR ILOH D FRPSODLQW 1XWULWLRQ (GXFDWLRQ 5HTXLUHPHQWV ,OOHJDOLW\ DQG FRQVHTXHQFHV RI 'XDO 3DUWLFLSDWLRQ

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OSAH FORM 1

This form is available online at http://www.osah.ga.gov/ or by telephone request at (404) 657-2800.

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GEORGIA DEPARTMENT OF PUBLIC HEALTH
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TABLE OF CONTENTS

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SECTION TWO STATEWIDE COST ALLOCATION PLAN

I.

INTRODUCTION TO WIC STATEWIDE COST ALLOCATION PLAN

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FREQUENTLY ASKED QUESTIONS
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:KDW DERXW HQWHULQJ ,' IRU QHZ EDELHV DQG SHRSOH ZKR KDYH EHHQ WHUPHG ZKHQ WKH\ DUH FHUWLILHG" $ 7$' ZRXOG QRW KDYH EHHQ FUHDWHG \HW VR WKH ,' QXPEHU ZH JLYH WKHP ZRQ
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IV. GUIDELINES FOR LOCAL AGENCY COST ALLOCATION METHODOLOGY

OVERVIEW
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VI (b). WIC VOLUNTEERS AND CONFIDENTIALITY
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IX. MANDATORY NO SMOKING POLICY
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XIII. ESTABLISHING NEW CLINICS/CLINIC CHANGES
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XIV. CLINIC CLOSINGS
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XV. REPORTING SYSTEMS PROBLEMS
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XVI. REQUEST FOR FINANCIAL AND/OR STATISTICAL DATA
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XVII. IDENTIFICATION CARDS AND FOOD LIST ORDERS
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XX. COMPLIANCE REVIEWS
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XXII. REGISTERED AND/OR LICENSED DIETITIAN CREDENTIALING POLICY FOR THE DEPARTMENT OF PUBLIC HEALTH
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XXIII. CONFLICT OF INTEREST
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XXVI PATIENT FLOW ANALYSIS
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(See Attachment AD11 for the PFA options)
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FORM II - PERSONNEL IDENTIFICATION CODE FORM
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XXVIII. LOCAL AGENCIES: APPLICATION, DISQUALIFICATION AND ADMINISTRATIVE REVIEW
A. LOCAL AGENCY APPLICATION PROCESS
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XXIX. SPECIAL PROJECT PROGRAM

A.

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STATE OF GEORGIA INTRA-AGENCY MEMORANDUM OF AGREEMENT
BETWEEN

THE GEORGIA DEPARTMENT OF PUBLIC HEALTH OFFICE OF NUTRITION AND WIC AND
MATERNAL AND CHILD HEALTH PROGRAM

WHEREAS WKLV $JUHHPHQW LV PDGH DQG HQWHUHG LQWR E\ DQG EHWZHHQ WKH *HRUJLD 'HSDUWPHQW RI 3XEOLF +HDOWK 0DWHUQDO DQG &KLOG +HDOWK 3URJUDP 2IILFH RI 1XWULWLRQ DQG :,& KHUHLQDIWHU UHIHUUHG WR DV :,& DQG WKH 0DWHUQDO DQG &KLOG +HDOWK 3URJUDP KHUHLQDIWHU UHIHUUHG WR DV 0&+

WHEREAS WKLV $JUHHPHQW ZLOO DOORZ IRU WKH XVH RI :,& SDUWLFLSDQW LQIRUPDWLRQ E\ WKH IROORZLQJ 0&+ SURJUDPV

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I.

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II. MCH Respective Program agrees to:
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For WIC: Seema Csukas, MD, PhD Georgia Department of Public Health 2 Peachtree Street, 11th Floor Atlanta, Georgia 30303 Phone #: (404) 657-2850
For MCH: Brenda Fitzgerald, MD Georgia Department of Public Health 2 Peachtree Street, 15th Floor Atlanta, Georgia 30303 Phone #: (404) 657-2703

V. Entire Agreement; Conflicting Provisions; Amendment
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SIGNATURES
,1 :,71(66 :+(5(2) WKH XQGHUVLJQHG GXO\ DXWKRUL]HG RIILFHUV RU DJHQWV RI HDFK SDUW\ KDYH KHUHXQWR DIIL[HG WKHLU VLJQDWXUHV RQ WKH GD\ DQG \HDU LQGLFDWHG EHORZ

Seema Csukas, MD, PhD MCH Interim Program Director
Brenda Fitzgerald, MD Commissioner

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_NEW CLINIC EVALUATION REPORT_
+HDOWK 'LVWULFW &OLQLF Date:
Satisfactory = S Unsatisfactory = U Recommendation = R
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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.

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____________________________________ ______________ ________________________ Nutrition Services Director/Clinic Manager Date Completed Date Submitted to the State

For State Agency Use Only _____________________________ State Staff Receiving Signature

_______________________ Date Received by the State

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FORM I

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FORM II

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FORM III

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FORM I

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FORM II
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FORM III

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INTRA-AGENCY AGREEMENT FOR
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IV. Introduction
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PLANNED BUDGET FOR SFY _____
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Two Peachtree Street, NW Atlanta, Georgia 30303
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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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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

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STANDARDOPERATINGPROCEDURES(SOP)
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I.

NUMBER AND DISTRIBUTION OF AUTHORIZED VENDORS

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IV. PEER GROUPS
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V. VENDOR AGREEMENTS
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VI. VENDOR TRAINING
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VIII. PROHIBITION AGAINST CERTAIN VENDORS - CONSOLIDATED APPROPRIATIONS ACT 2005
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IX. VENDOR COST CONTAINMENT
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X. ROUTINE MONITORING
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XI. VENDOR SANCTION SYSTEM
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XII. ADMINISTRATIVE REVIEW

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XIII. COORDINATION WITH SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP)
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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 (including storage area)

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GEORGIA WIC PROGRAM 2013 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

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Yes

No

6. Type of Business - Check Only One Independent
Chain

Commissary Pharmacy

7. Federal Employer Identification Number (FEIN)

or

8.

A. Is this store dependent upon receiving WIC Authorization before it can

open for business?

Owner's SSN#
Yes

B. What date did (or will) the store open for business under the applying owner(s)?
C. What date will the store have the required minimum inventory of approved WIC foods in stock?

/

Month

Day

/

Month

Day

9.

A. Are you related to previous owner(s) by blood or marriage?

If YES, what is the relationship?

Yes

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

Program? If YES, list stores below. Attach additional paper if necessary.

Yes

1.
STORE NAME
2.
STORE NAME

VENDOR NUMBER VENDOR NUMBER

-

-

No /
Year
/
Year
No
No

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 PROGRAM 2013 PROCEDURES MANUAL

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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

90

Yes Yes Yes

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GEORGIA WIC PROGRAM 2013 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?

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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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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 City

Address State

Supplier City

Address State

Supplier City

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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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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

Size ___

16-18 oz. jar Size ___

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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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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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

Middle

PRINT NAME

(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 PROGRAM

VENDOR HANDBOOK

Effective December 1, 2011
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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 2013 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

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58 58 58 58 59 59
60 60 60
62 62 62 63 67 67 67 69
70
75
76

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INTRODUCTION

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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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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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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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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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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, including 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. Pharmacies are exempt. 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

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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 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

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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 (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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Peer Groups
Authorized vendors are classified into eight different peer groups depending on square footage of the store (including 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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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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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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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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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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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.)

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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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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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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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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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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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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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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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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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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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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. Vendor shall receive a ruling, including the basis for the decision within 90 days of receipt of the request of the appeal. However, if this timeframe is not met this does not provide a basis for reversing the decision. For those decisions where the vendor may pursue judicial review, the state agency will notify the vendor of the availability of that remedy.
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

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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."

(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;
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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 and any 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;

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(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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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 WIC PROGRAM 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
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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 WIC PROGRAM USE ONLY
WIC VENDOR NUMBER (Non-corporate vendors only)

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I.

PURPOSE

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III. RESPONSIBILITIES VENDOR
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B. VENDOR TRAINING
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GEORGIA WIC PROGRAM CORPORATE ATTACHMENT FORM

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District/Unit

Date Received

Date Approved QAS:

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Processed By

Vendor Number

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Peer Group

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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.
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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

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GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

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Highest Price or Least Expensive where indicated

On-Site Price

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FORM 3771A (06/2012)


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

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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.

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FORM 3771A (6/2012)


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STORE OPERATIONS

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INCIDENT/COMPLAINT FORM

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District/Unit/Clinic: Date of Incident: Follow-Up Date: Type of Complaint:
Sub Catorgory 1:

County: Date Reported:
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Can the complaint be closed at the Local Agency?

Yes

No

Signature:

Date:

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GEORGIA WIC PROGRAM 2013 PROCEDURES MANAUL

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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-4 C. Food Packages ..................................................................................................... FP-5 D. Required Documentation.................................. ............................................. FP-6
III. Infants ......................................................................................................................... FP-7 A. Tailoring................................................................................................................. FP-8 B. Feeding Type Assignment..................................................................................... FP-9 C. Food Package Assignment ................................................................................... FP-9 D. Matching Mother/Baby Food Packages............................................................... FP-11 E. Manual Food Packages....................................................................................... FP-12 F. Rounding Infant Age............................................................................................ FP-13 G. Request for Additional Formula........................................................................... FP-13 H. Physical Form ..................................................................................................... FP-14
IV. Women, Children and Infants with Qualifying Medical Conditions ............................ FP-14 A. Qualifications for Food Package III Issuance ...................................................... FP-14 B. Disqualifications for Food Package III Issuance.................................................. FP-15 C. Food Package ..................................................................................................... FP-15 D. Tailoring............................................................................................................... FP-16 E. Food Package Assignment ................................................................................. FP-16 F. Manual Food Package ........................................................................................ FP-17 G. WIC Foods ......................................................................................................... FP-17 H. Responsibilities .................................................................................................. FP-19 I. Maximum Amounts .............................................................................................. FP-19
V. Children 1 to 5 Years ................................................................................................ FP-19 A. Tailoring............................................................................................................... FP-20 B. Food Package Assignment ................................................................................. FP-20 C. Manual Food Package ........................................................................................ FP-20 D. WIC Foods ......................................................................................................... FP-20 E. Milk Alternative .................................................................................................... FP-22 F. Additional Documentation .................................................................................. FP-22

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Food Package

VI. Women...................................................................................................................... FP-23 A. Food Package V.................................................................................................. FP-23 B. Food Package VI................................................................................................. FP-23 C. Food Package VII................................................................................................ FP-23 D. Tailoring............................................................................................................... FP-24 E. Food Package Assignment ................................................................................. FP-24 F. Manual Food Package ........................................................................................ FP-24 G. WIC Foods ......................................................................................................... FP-25 H. Milk Alternatives ................................................................................................. FP-26 I. Additional Documentation ..................................................................................... FP-27
VII. Homelessness, Migrancy, and Disaster Situations ................................................... FP-27 A. Alternate Food Package Assignment .................................................................. FP-27 B. Food Package Assignment ................................................................................. FP-27 C. Manual Food Package ....................................................................................... FP-28 D. Assignment of Food Package Code.................................................................... FP-28
VIII. Medical Documentation............................................................................................. FP-29 A. Situations Requiring Medical Documentation ..................................................... FP-29 B. Acceptable and Unacceptable Forms of Documentation .................................... FP-30 C. Required Medical Documentation Components ................................................ FP-31 D. Verbal Orders ..................................................................................................... FP-32 E. Frequency and Records ..................................................................................... FP-33 F. Issuance of Ready-to-Feed Products ................................................................. FP-34 G. Medical Diagnoses ............................................................................................. FP-34
IX. Formula Distribution/Tracking Guidelines ................................................................. FP-36 A. Reasons to Issue Formula .................................................................................. FP-37 B. Maximum Amount to be Issued........................................................................... FP-37 C. Documentation .................................................................................................... FP-37 D. Disposal of Expired Formula ............................................................................... FP-37 E. Staff Resonsiblity...................................................................................FP-37
X. Nutrition Unit Special Formula Orders ...................................................................... FP-38 A. Ordering ............................................................................................................. FP-38 B. Tracking Log ....................................................................................................... FP-38 C. Amount to Order ................................................................................................. FP-38 D. Special Formula Order Form............................................................................... FP-39 E. Frequency .......................................................................................................... FP-39



GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Food Package

F. Medical Documentation ...................................................................................... FP-39 G. Printing Tracking Voucher .................................................................................. FP-39 H. Flavor ................................................................................................................. FP-40 I. Processing the Order ......................................................................................... FP-40 XI. Emory Genetics......................................................................................................... FP-40 A. Emory Genetics Prescriptions ............................................................................. FP-41 B. Provision of Formula and WIC Foods .................................................................. FP-41 C. Breastfeeding ...................................................................................................... FP-42 XII. Creating 999 Food Packages .................................................................................... FP-42

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-52 FP-4 Contract Formula Packages for Mostly Breastfed Infant ......................................... FP-53 FP-5 Contract Infant Formula Packages for Children ...................................................... FP-61 FP-6 Formula Summary: Non-Contract Standard Formulas ............................................ FP-63 FP-7 Non-Contract Standard Formula Food Packages for Fully Formula Fed
Infant....................................................................................................................... FP-65 FP-8 Non-Contract Standard formula Food packages for Mostly Breast Fed Infant........FP-69 FP-9 Non-Contract Standard Formula Food Packages for Children ................................ FP-75 FP-10 Summary of Food Packages for Women and Children .......................................... FP-76 FP-11 Prenatal/Mostly Breastfeeding Woman ................................................................... FP-79 FP-12 Non-Breastfeeding Postpartum /Some Breastfeeding Woman ............................... FP-93 FP-13 Exclusively Breastfeeding Single Infant/Prenatal Pregnant with Multiples ........... .FP-106 FP-14 Exclusively Breastfeeding Multiples...................................................................... FP-120 FP-15 Children 12 23 months........................................................................................ FP-142 FP-16 Children 2 5 years............................................................................................... FP-152 FP-17 Special Formula Summary (Food Package III) ..................................................... FP-165 FP-18 Special Formulas for Fully Formula Fed Infants (Food Package III) ..................... FP-172 FP-19 Food Package III - Special Infant Formulas for Children ....................................... FP-205 FP-20 Food Package III - Special Formulas for Children.................................................. FP-213 FP-21 Food Package III - Special Formulas for Women .................................................. FP-229 FP-22 Tracking Food Packages ...................................................................................... FP-237


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Food Package

FP-23 Special Formula Packages for 6 11 Month Old Infants unable to Eat Solids .................................................................................................................... FP-239
FP-24 Maximum Monthly Amounts Authorized - Fully Formula Fed Infant ...................... FP-248 FP-25 Maximum Monthly Amounts Authorized - Mostly Breastfed Infant ........................ FP-250 FP-26 Maximum Monthly Amounts Authorized - Infant Foods ......................................... FP-252 FP-27 Voucher Codes for Special Formula Packages for Mostly Breastfeeding
Infants Maximum Amounts ................................................................................ FP-253 FP-28 Supplemental Formula Conversion Table - Modulars ........................................... FP-259 FP-29 Maximum Monthly Amounts of Formula Authorized for
Children and Women with Qualifying Conditions Food Package III ...................... FP-261 FP-30 Maximum Monthly Amounts of WIC Foods Authorized for Children...................... FP-262 FP-31 Maximum Monthly Amounts of WIC Foods Authorized for Women ...................... FP-263 FP-32 Maximum Monthly Amounts for WIC Foods Authorized for
Alternate Food Packages ..................................................................................... FP-265 FP-33 How to Convert Breastfeeding Packages .............................................................. FP-268 FP-34 Infant Formula Sequencing Exceptions ................................................................. FP-273 FP-35 WIC-Approved Formulas/Medical Foods .............................................................. FP-274 FP-36 Formula Manufacturer's Contact Information ....................................................... FP-279 FP-37 Special Formula Order Form ................................................................................. FP-280 FP-38 Special Formula Order Tracking Form .................................................................. FP-281 FP-39 Milk/Cheese/Tofu Substitution Tables ................................................................... FP-282 FP-40 Instructions for Medical Documentation Form (Form 1) ........................................ FP-284 FP-41 Medical Documentation Form (Form 1) ................................................................. FP-290 FP-42 Instructions for Medical Documentation Referral Form / Special Food Substitutions
(Form 2) ................................................................................................................ FP-292 FP-43 Referral Form and Medical Documentation /Special Food Substitutions (Form 2) FP-297 FP-44 Georgia WIC-Approved Foods List, Criteria to Evaluate an
Eligible Food Item ... ............................................................................................. FP-299 FP-45 WIC-Approved Foods List October 2011............................................................... FP-303 FP-46 Formula Tracking Log............................................................................................ FP-308 FP-47 Calcium Fortified Juices / Guidelines, Procedures & Recommendations.............. FP-309
FP-48 List of Single Item or Special Vouchers for 999 Food Packages .......................... FP-310



GEORGIA WIC PROGRAM 2013 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 Soothe (lactose-reduced), 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 Soothe, 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 Soothe 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.

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GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

1. Milk-Based Formula:

Food Package

All participants who receive a milk-based infant formula will receive the contract formula Gerber Good Start Gentle.

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 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 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 Organic formula (Any Type)

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GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

3. Lactose-Reduced

Food Package

Participants requiring a milk-based, standard lactose-free, lactose-reduced, infant formula will receive the contract formula Gerber Good Start Soothe. Medical documentation is not required.

Georgia WIC does NOT APPROVE the following non-contract lactosereduced milk based infant formulas for distribution for which medical documentation will NOT be accepted:

Enfamil Gentlease Enfagrow Gentlease Toddler Similac Sensitive Store brand lactose-free, lactose-reduced infant formula

4. Rice Added Formula: Medical Documentaiton Required
For participants requesting a milk-based rice-added formula the following two conditions must exist prior to issuance:

1) Diagnosis of Gastroesophageal reflux disease (GERD)
2) AND an additional qualifying condition: Pneumonia, Tube feed, GERD Surgery (Fundoplication), Poor weight gain; Drop of at least one weight channel on growth chart. (If weight not provided it will be based on weight obtained at WIC clinic). OR, diagnosis of GERD documented by pH probe test, Endoscopy, X-ray (Document type and date of test provided).

Participants meeting the requirements for a rice-added infant formula may receive the following non-contract formulas:
Enfamil A.R. Similac Sensitive for Spit Up Store brand milk-based rice-added formulas
5. 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.
.

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GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

B. Food Package Categories

Food Package

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

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

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

Food Package II

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

(D00 D99)
(H00 H99), (L00 L99), (M00 M99), (N00 N99) (E01)

Food Package III

Medically fragile women, infants, and children with qualifying medical conditions receiving special formulas/medical foods

R00 R99, (S00 S99), (T00 T99)
X00 X99, Z00 Z99

Food Package IV Food Package V

Children ages 1 through 4 years
Pregnant women Mostly breastfeeding women

C00 C99 W01 W19

Food Package VI

Non-breastfeeding women Women breastfeeding some

W20 W39

Food Package VII

Exclusively breastfeeding women
Women pregnant with multiple fetuses
Women mostly breastfeeding multiples

W40 W79 (V60 V79)

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GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

C. Food Packages

Food Package

Food Packages are foods from the Georgia WIC-Approved Foods List in combinations and amounts that 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-23.)

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 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-23 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 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-24to FP-32

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GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL


Food Package

for maximum monthly amounts authorized; see Attachment FP-48 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 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. Rice-added standard infant formulas (e.g., Enfamil A.R., Similac for Spit Up, Parent's Choice Added Rice Starch, or other store brand riceadded formulas approved by USDA). See "Rice Added Formula" issuance conditions above prior to approval.
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).

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GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL


Food Package

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.
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, Gerber Good Start Soothe, Similac Sensitive for Spit Up, Enfamil A.R., 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 20, and Gerber Good Start Premature 24), Cyclinex-1, Similac Expert Care Alimentum, Enfaport, Similac Expert Care for Diarrhea, and Pregestimil.

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GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL


Food Package

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://wicworks.nal.usda.gov/nal_web/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. 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 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.

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GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL


Food Package

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 a WIC-approved mixture. 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 or 18 7 oz) of infant fruits and/or vegetables. Exclusively Breastfed (EBF) infants receive 256 ounces (64 4 oz jars or 32 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).
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.

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GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL


Food Package

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.

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

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).
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Food Package

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 for a MBF package 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 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 infant of an Exclusively Breastfeeding Woman (EBF) must be issued an Exclusively Breastfed food package. The table below matches the appropriate infants food package to their mothers food package.

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Food Package

Mother Receives: Exclusively Breastfeeding (EBF) woman food package
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: NonBreastfeeding woman food package

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

Federal Terminology: Fully Breastfed infant and Fully Breastfeeding Woman
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 I-BF/FF A, B, C or II-BF/FF

Fully Formula Fed (FFF) food package and no breast milk

Fully Formula Fed

If greater than 6 months postpartum: mother is no longer WIC eligible

E.

Manual 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 three (3)-month-old infant on powder Gerber Good Start Soothe would be issued two vouchers with the following codes: CPA FPC A37, FPC A37, and VC L01 and L02.

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F.

Rounding Infant Age

Food Package

"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, issuing from stock or ordering formula from the state office, 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-33 to calculate whether a food package change can be made for the current month. The standard 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-33 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.

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Food Package

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).

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:
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Food Package

(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

b. A non-specific formula or food intolerance.

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 FP-15


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Food Package

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 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. 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
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Food Package

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, and Pregestimil have special sequencing patterns to avoid over or under issuance. (See Attachment FP-34 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.
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.)

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Food Package

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-24, FP-25, FP-and FP-29. 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-24, FP-25, FP-29.) 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 Unit for assistance.

3. Infants receive the maximum amount of formula allowed regardless of the amount physician requests on the medical documentation form. Their needs are constantly changing, and we do not require new medical documentation for each change.

4. Children and women receive only the amount of formula prescribed for them. The number of containers may be rounded up as long as the federal maximum of 910 fluid ounces is not exceeded.

5. 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-30 and women on Attachment FP-31.)

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 milk may be issued to women and children over age two (2) years in Food Package III.

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H. Responsibilities

Food Package

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 and types 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-29 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-24 to FP-26.) 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-30 to FP-31.)

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 old are listed in Attachments FP-15 and FP-16. 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-30 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 and when medical documentation provided requests whole milk.)

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 in this age range.

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 standard food package containing cheese has some of the milk given as dry powder or evaporated milk.

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-39 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 prorated. 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-45).

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-31 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-31 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-11 to FP-14. 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.

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-31 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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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-45).

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 which are issued in four (4) packs.
(1) Contract milk-based formula: CPA FPC is A19.
(2) Contract soy-based formula: CPA FPC is A29.
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-26 for infant food and Attachment FP-32 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-30.

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3. Pregnant and Breastfeeding Women

Food Package

Food packages for this group consist of ultra high temperature (UHT) milk, iron fortified cereal, and 100% vitamin C fortified juice, 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-31.

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-31.

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 current medical authorization, either verbal or written, 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.
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Food Package

c) Issuance of more than one (1) pound of cheese per month.

3. Women:

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-40 and FP-41 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-42 and FP-43 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. Only the foods prescribed on the MDF should be issued.

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 (CNSDs) and dietitians who are board certified specialists in

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Food Package

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 (Verbal Order)
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 (Verbal Clarifiaction)
a) Verbal clarification 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
2. To clarify the full formula product name (e.g., did "Neocate" mean Neocate Infant DHA + ARA, or Neocate Junior?)

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Food Package

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 (relaying the information on behalf of the provider) who gave 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) A 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.

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.

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Food Package

*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 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 Similac for Spit Up, and Enfamil A.R.

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Food Package

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" when used alone "Feeding problems" "Spitting up" "Formula intolerance"

Sample Acceptable Alternative Diagnosis/Diagnoses "Feeding problems (783.3) with supporting information such as 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)

2. The following diagnoses require an underlying medical condition be present and documented:
a) "Underweight" or "inadequate/poor weight gain"
b) "Feeding disorder"

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c) "Inadequate/poor growth"

Food Package

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-41 and FP-43 for Medical Documentation Form (Form 1) and Referral Form (Form 2).

IX. FORMULA DISTRIBUTION/TRACKING GUIDELINES

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 Nutrition Unit (see Attachment FP-46).

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Food Package

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-46). 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-46). 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-46).
b. WIC client's health record: If a detailed medical explanation is needed (i.e., transition from one formula to another), document the quantity of formula issued, type of formula, reason for issuance and signature of individual issuing the formula.
D. Disposal of Expired Formula. Expired formula should be opened and disposed of properly. Document expired formula that was disposed of on the Formula Tracking Log.
E. Staff Responsibility. It is the responsibility of a CPA to complete all duties related to the Formula Tracking Log. These duties including formula
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Food Package

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 UNIT SPECIAL FORMULA ORDERS
When ordering special formulas through the Nutrition Unit the "Special Formula Order Form" (Attachment FP-37) 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 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 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. (Do not automatically give a client all of the formula that was delivered, since that will usually result in overissuance. Issuance must be limited to the total amount allowed based on medical documentation and WIC maximum amounts.
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 Unit the following month. Document request for formula and distribution in participant's health record.
C. Amount to Order
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 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
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Food Package

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-38 for a sample tracking document.

For infant participants, 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 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 formula order submitted each month.

G. Printing Tracking Voucher

Clinics must print a CPA FPC 199 for every month that a client is issued formula ordered through the Nutrition Unit. The 199 food pakage should be printed at the time of issuance, one month at a time. The tracking voucher in this food package allows the client to be counted in the clinic caseload, as failure to do so underreports the 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. A copy of the 199 voucher receipt must be faxed to the State Office.
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Food Package

H. Flavor
Specify product flavor(s), when applicable, on the Special Formula Order Form every month.

I. XI.

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 Unit by mail or fax:
Mail: 2 Peachtree Street NW, Suite 11-222, Atlanta, GA, 30303-3142
Fax: 404-657-2886
Notify the Nutrition 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 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 statecreated food package or a 999 food package if none of the standard statecreated 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.
If a client is late picking up formula, the amount of formula should be prorated.
EMORY GENETIC WIC CLIENTS
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.

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Food Package

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 medical documentation from Emory Genetics 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 indicating any supplemental foods 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. Food package 099 contains four (4) vouchers. 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 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
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GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL


Food Package

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-24 through FP-32 contain the maximum monthly allowed tables; Attachment FP-39 provides information on milk/cheese/tofu substitutions; and Attachment FP-48 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.

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GEORGIA WIC PROGRAM 2013 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
X19 A28

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
Child
FFF 0-3 m FFF 4-5 m FFF 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
X19
A28 B28 D28

Formula
Gerber Good Start Gentle Concentrate 34-12.1 oz concentrate Gerber Good Start Gentle
37-12.1 oz concentrate Gerber Good Start Gentle
26-12.1 oz concentrate Gerber Good Start Gentle 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 15-12.1 oz concentrate Gerber Good Start Gentle 18-12.1 oz concentrate Gerber Good Start Gentle 13-12.1 oz concentrate Gerber Good Start Gentle 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 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 25-33.8 oz (4-packs) Gerber Good Start Gentle
27-33.8 oz (4-packs)Gerber Good Start Gentle
19-33.8 oz (4-packs)Gerber Good Start Gentle 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 12-33.8 oz (4-packs)Gerber Good Start Gentle 14-33.8 oz (4-packs)Gerber Good Start Gentle 10-33.8 oz (4-packs)Gerber Good Start Gentle 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 26-33.8 oz (4-packs)Gerber Good Start Gentle
Gerber Good Start Soy Concentrate 34-12.1 oz concentrate Gerber Good Start Soy
37-12.1 oz concentrate Gerber Good Start Soy
26-12.1 oz concentrate Gerber Good Start Soy 32 jars baby fruit/vegetable, 3-8 oz box infant cereal

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GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP 1

CPA FPC F28
X28 A27
F27
E27 K27 J27 X27 A29
F29
X29 A37
F37
E37

Status / Age 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
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 F28 G28 H28
X28
A27 B27 D27
F27 G27 H27
E27 L27
K27 M27
J27 N27
X27
A29 B29 D29
F29 G29 H29
X29
A37 B37 D37
F37 G37 H37
E37 L37

Formula
15-12.1 oz concentrate Gerber Good Start Soy 18-12.1 oz concentrate Gerber Good Start Soy 13-12.1 oz concentrate Gerber Good Start Soy 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 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 25-33.8 oz (4-packs) Gerber Good Start Soy
27-33.8 oz (4-packs) Gerber Good Start Soy
19-33.8 oz (4-packs) Gerber Good Start Soy 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 12-33.8 oz (4-packs) Gerber Good Start Soy 14-33.8 oz (4-packs) Gerber Good Start Soy 10-33.8 oz (4-packs) Gerber Good Start Soy 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 26-33.8 oz (4-packs) Gerber Good Start Soy
Gerber Good Start Soothe 9-12.4 oz cans powder Gerber Good Start Soothe 10-12.4 oz cans powder Gerber Good Start Soothe 7-12.4 oz cans powder Gerber Good Start Soothe 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 4-12.4 oz cans powder Gerber Good Start Soothe 5-12.4 oz cans powder Gerber Good Start Soothe 4-12.4 oz cans powder Gerber Good Start Soothe 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 1-12.4 oz can powder Gerber Good Start Soothe 1-12.4 oz can powder Gerber Good Start Soothe 32 jars baby fruit/vegetable, 3-8 oz box infant cereal

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GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP 1

CPA FPC K37
J37
D67 F67 Z67 D77 F77 Z77

Status / Age MB 1-5 m MB 6-11 m MB 1-5 m MB 6-11 m
FFF 9- 11 m MB 9-11 m
Child
FFF 9- 11 m MB 9-11 m
Child

System FPC K37 M37 J37 N37
D67 F67 Z67
D77 F77 Z77

Formula
2-12.4 oz cans powder Gerber Good Start Soothe 2-12.4 oz cans powder Gerber Good Start Soothe 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 3-12.4 oz cans powder Gerber Good Start Soothe 3-12.4 oz cans powder Gerber Good Start Soothe 32 jars baby fruit/vegetable, 3-8 oz box infant cereal
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

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GEORGIA WIC PROGRAM 2013 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
A18 34-12.1 oz concentrate Gerber Good Start Gentle
A19 25-33.8 oz ready to feed Gerber Good Start Gentle

Rank VC 2 G04 4 G05
2 G14 4 G17 4 G19 2 G48

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:

16-12.1 oz containers concentrate Gerber Good Start Gentle 18-12.1 oz containers concentrate Gerber Good Start Gentle

Formula: Formula:

12-33.8 oz (4-packs) ready to feed Gerber Good Start Gentle 13-33.8 oz (4-packs) ready to feed Gerber Good Start Gentle

Gerber Good Start Soy Food Package Code A27 9-12.9 oz powder Gerber Good Start Soy
A28 34-12.1 oz concentrate Gerber Good Start Soy
A29 25-33.8 oz ready to feed Gerber Good Start Soy

Rank VC 2 N40 4 N41
2 G27 4 N37 2 N44 4 G56

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:

18-12.1 oz containers concentrate Gerber Good Start Soy 16-12.1 oz concentrate Gerber Good Start Soy 13-33.8 oz (4-packs) ready to feed Gerber Good Start Soy 12-33.8 oz (4-packs) ready to feed Gerber Good Start Soy

Gerber Good Start Soothe

Food Package Code

Rank VC

A37

2 L01

9-12.4 oz powder Gerber Good Start Soothe

4 L02

Voucher Message Formula: 4-12.4 oz cans powder Gerber Good
Start Soothe Formula: 5-12.4 oz cans powder Gerber Good
Start Soothe

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GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP 2 (cont'd)

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
B18 (Assign A18) 37-12.1 oz concentrate Gerber Good Start Gentle
B19 (Assign A19) 27-33.8 oz ready to feed Gerber Good Start Gentle

Rank VC 2 G04 4 G06
2 G17 4 G18 2 G13 4 G48

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:

18-12.1 oz containers concentrate Gerber Good Start Gentle 19-12.1 oz containers concentrate Gerber Good Start

Formula: Formula:

14-33.8 oz (4-packs) ready to feed Gerber Good Start Gentle 13-33.8 oz (4-packs) ready to feed Gerber Good Start Gentle

Gerber Good Start Soy Food Package Code B27 (Assign A27) 10-12.9 oz powder Gerber Good Start Soy
B28 (Assign A28) 37-12.1 oz concentrate Gerber Good Start Soy
B29 (Assign A29) 27-33.8 oz ready to feed Gerber Good Start Soy

Rank VC 2 N41 4 N41
2 G27 4 N38 2 N45 4 N44

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:

18-12.1 oz containers concentrate Gerber Good Start Soy 19-12.1 oz containers concentrate Gerber Good Start Soy 14-33.8 oz (4-packs) ready to feed Gerber Good Start Soy 13-33.8 oz (4-pack) ready to feed Gerber Good Start Soy

Gerber Good Start Soothe

Food Package Code

Rank VC

B37 (Assign A37)

2 L02

10-12.4 oz powder Gerber Good Start Soothe

4 L02

Voucher Message Formula: 5-12.4 oz cans powder Gerber Good
Start Soothe Formula: 5-12.4 oz cans powder Gerber Good
Start Soothe

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GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP 2 (cont'd)

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) 26-12.1 oz concentrate Gerber Good Start Gentle 32 jars baby fruit/vegetable 3-8 oz box infant cereal
D19 (Assign A19) 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) 13-12.1 oz containers concentrate Gerber Good Start Gentle 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) 10-33.8 oz (4-packs) ready to feed Gerber Good Start Gentle 9-33.8 oz (4-packs) 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-48


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP 2 (cont'd)

Gerber Good Start Soy Food Package Code D27 (Assign A27) 7-12.9 oz powder Gerber Good Start Soy 32 jars baby fruit/vegetable 3-8 oz box infant cereal
D28 (Assign A28) 26-12.1 oz concentrate Gerber Good Start Soy 32 jars baby fruit/vegetable 3-8 oz box infant cereal
D29 (Assign A29) 19-33.8 oz ready to feed Gerber Good Start Soy 32 jars baby fruit/vegetable 3-8 oz box infant cereal

Rank VC 4 N40 2 N55 4 N01
2 N26 2 N39 4 N39 4 N01
2 N26 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: 13-12.1 oz containers cans concentrate

Gerber Good Start Soy

Formula:
Infant foods:
Infant cereal: Infant foods:

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:

10-33.8 oz (4-packs) ready to feed Gerber Good Start Soy 9-33.8 oz (4-packs) 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)

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GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP 2 (cont'd)

Gerber Good Start Soothe

Food Package Code

Rank VC

D37 (Assign A37)

2 L01

7-12.4 oz powder Gerber Good Start Soothe
32 jars baby fruit/vegetable

4 L03 4 N01

3-8 oz box infant cereal

2 N26

Voucher Message

Formula: 4-12.4 oz cans powder Gerber Good

Start Soothe

Formula: 3-12.4 oz cans powder Gerber Good

Start Soothe

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)

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GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP 2 (cont'd)

Contract Toddler Formula 9 to 12 months only

Powder Gerber Good Start 2 Gentle

Food Package Code

Rank VC

D67

2 G42

4-22 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: 2-22 oz cans powder Gerber Good Start
2 Gentle Formula: 2-22 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

4-24oz 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: 2-24 oz cans powder Gerber Good Start 2 Soy

Formula: 2-24 oz cans powder Gerber Good Start 2 Soy

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)

Infant cereal:

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)

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GEORGIA WIC PROGRAM 2013 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)

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GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-4

Contract Formula Packages for Mostly Breastfed Infant 1 3 months Maximum

Gerber Good Start Gentle Food Package Code F17 4-12.7 oz powder Gerber Good Start Gentle F18 15-12.1 oz concentrate Gerber Good Start Gentle F19 12-33.8 oz ready to feed Gerber Good Start Gentle

Rank VC 4 G04
4 G55
4 G19

Voucher Message Formula: 4-12.7 oz cans powder Gerber Good
Start Gentle
Formula: 15-12.1 oz cans concentrate Gerber Good Start Gentle
Formula: 12-33.8 oz (4-packs) ready to feed Gerber Good Start Gentle

Gerber Good Start Soy Food Package Code F27 4-12.9 oz powder Gerber Good Start Soy F28 15-12.1 oz concentrate Gerber Good Start Soy F29 12-33.8 oz ready to feed Gerber Good Start Soy

Rank VC 4 N40

Voucher Message Formula: 4-12.9 oz cans powder Gerber Good
Start Soy

4 G26 Formula: 15-12.1 oz containers concentrate Gerber Good Start Soy

4 G56 Formula: 12-33.8 oz (4-packs) ready to feed Gerber Good Start Soy

Gerber Good Start Soothe

Food Package Code

Rank VC

F37

4 L01

4-12.4 oz powder Gerber Good Start Soothe

Voucher Message Formula: 4-12.4 oz cans powder Gerber Good
Start Soothe

FP-53


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL
Contract Infant Formula Mostly Breastfed
4 5 months Maximum

Attachment FP-4 (cont'd)

Gerber Good Start Gentle Food Package Code G17 (Assign F17) 5-12.7 oz powder Gerber Good Start Gentle G18 (Assign F18) 18-12.1 oz concentrate Gerber Good Start Gentle G19 (Assign F19) 14-33.8 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: 18-12.1 containers concentrate Gerber Good Start Gentle
Formula: 14-33.8 oz (4-packs) ready to feed Gerber Good Start Gentle

Gerber Good Start Soy Food Package Code G27 (Assign F27) 5-12.9 oz powder Gerber Good Start Soy G28 (Assign F28) 18-12.1 oz concentrate Gerber Good Start Soy G29 (Assign F29) 14-33.8 oz ready to feed Gerber Good Start Soy

Rank VC 4 N41

Voucher Message Formula: 5-12.9 oz cans powder Gerber Good
Start Soy

4 G27 Formula: 18-12.1 oz containers concentrate Gerber Good Start Soy

4 N45 Formula: 14-33.8 oz (4-packs) ready to feed Gerber Good Start Soy

Gerber Good Start Soothe

Food Package Code

Rank VC

G37 (Assign F37)

4 L02

5-12.4 oz powder Gerber Good Start Soothe

Voucher Message Formula: 5-12.4 oz cans powder Gerber Good
Start Soothe

FP-54


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-4 (cont'd)

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 32 jars baby fruit/vegetable 3-8 oz box infant cereal
H18 (Assign F18) 13-12.1 oz concentrate Gerber Good Start Gentle 32 jars baby fruit/vegetable 3-8 oz box infant cereal
H19 (Assign F19) 10-33.8 oz ready to feed Gerber Good Start Gentle 32 jars baby fruit/vegetable 3-8 oz box infant cereal

Rank VC 4 G04 4 N01
2 N26 4 G12 4 N01
2 N26 4 G10 4 N01
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: 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: 10-33.8 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-55


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-4 (cont'd)

Gerber Good Start Soy Food Package Code H27 (Assign F27) 4-12.9 oz powder Gerber Good Start Soy 32 jars baby fruit/vegetable 3-8 oz box infant cereal
H28 (Assign F28) 13-12.1 oz concentrate Gerber Good Start Soy 32 jars baby fruit/vegetable 3-8 oz box infant cereal
H29 (Assign F29) 10-33.8 oz ready to feed Gerber Good Start Soy 32 jars baby fruit/vegetable 3-8 oz box infant cereal

Rank VC 4 N40 4 N01
2 N26 4 N39 4 N01
2 N26 4 N46 4 N01
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: 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: 10-33.8 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)

Gerber Good Start Soothe

Food Package Code

Rank VC

H37 (Assign F37)

4 L01

4-12.4 oz powder Gerber Good Start Soothe

4 N01

32 jars baby fruit/vegetable 3-8 oz box infant cereal

2 N26

Voucher Message

Formula: 4-12.4 oz cans powder Gerber Good

Start Soothe

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 PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-4 (cont'd)

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-57


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-4 (cont'd)

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-58


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-4 (cont'd)

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-59


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-4 (cont'd)

Gerber Good Start Soothe

Food Package Code

Rank VC

E37

4 L04

1-12.4 oz powder Gerber Good Start Soothe L37 (Assign E37)

4 L04

1-12.4 oz powder Gerber Good Start Soothe

4 N01

32 jars baby fruit/vegetable

3-8 oz box infant cereal

2 N26

K37
2-12.4 oz powder Gerber Good Start Soothe M37 (Assign K37)
2-12.4 oz powder Gerber Good Start Soothe
32 jars baby fruit/vegetable
3-8 oz box infant cereal

4 L05 4 L05 4 N01
2 N26

J37
3-12.4 oz powder Gerber Good Start Soothe N37 (Assign J37)
3-12.4 oz powder Gerber Good Start Soothe
32 jars baby fruit/vegetable
3-8 oz box infant cereal

4 L03 4 L03 4 N01
2 N26

Voucher Message Formula: 1-12.4 oz cans powder Gerber Good
Start Soothe

Formula:
Infant foods:
Infant cereal: Infant foods:
Formula:

1-12.4 oz cans powder Gerber Good Start Soothe 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) 2-12.4 oz cans powder Gerber Good Start Soothe

Formula:
Infant foods:
Infant cereal: Infant foods:
Formula:

2-12.4 oz cans powder Gerber Good Start Soothe 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) 3-12.4 oz cans powder Gerber Good Start Soothe

Formula:
Infant foods:
Infant cereal: Infant foods:

3-12.4 oz cans powder Gerber Good Start Soothe 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 PROGRAM 2013 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 37- 12.1 oz concentrate Gerber Good Start Gentle
Medical Documentation Required X19 26-33.8 ready to feed Gerber Good Start Gentle
Medical Documentation Required

Rank VC 2 G05 4 G05
4 G18 2 G17
2 G48 4 G48

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:

19-12.1 oz containers concentrate Gerber Good Start Gentle 18-12.1 oz containers concentrate Gerber Good Start Gentle

Formula: Formula:

13-33.8 oz (4-packs) ready to feed Gerber Good Start Gentle 13-33.8 oz (4-packs) ready to feed Gerber Good Start Gentle

FP-61


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-5 (cont'd)

Gerber Good Start Soy Food Package Code X27 10-12.9 oz powder Gerber Good Start Soy
Medical Documentation Required X28 37-12.1 oz concentrate Gerber Good Start Soy
Medical Documentation Required X29 26-33.8 oz ready to feed Gerber Good Start Soy
Medical Documentation Required

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 19-12.1 oz cans concentrate Gerber Good Start Soy
2 N37 Formula 16-12.1 oz cans concentrate Gerber Good Start Soy

2 N44 Formula 13-33.8 oz (4-packs) ready to feed Gerber Good Start Soy
4 N44 Formula 13-33.8 oz (4-packs) 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 PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-6

CPA FPC A44
F44
E44 K44 J44 X44 A46
F46
X46 A41
F41
E41 K41

Formula Summary Non-Contract Infant Formula Summary

Medical Documentation Required

Status / Age System FPC

Formula

FFF 0-3 m FFF 4-5 m

Enfamil AR Powder A44 9-12.9 oz cans powder Enfamil AR B44 10-12.9 oz cans powder Enfamil AR

FFF 6-11 m MB 1-3 m

D44 7-12.9 oz cans powder Enfamil AR, 32 jars baby fruit/vegetable, 3-8 oz box infant cereal
F44 4-12.9 oz cans powder Enfamil AR

MB 4-5 m MB 6-11 m
MB 0-5

G44 5-12.9 oz cans powder Enfamil AR H44 4-12.9 oz cans powder Enfamil AR
32 jars baby fruit/vegetable, 3-8 oz box infant cereal E44 1-12.9 oz can powder Enfamil AR

MB 6-11 m MB 1-5 m

L44 1-12.9 oz can powder Enfamil AR 32 jars baby fruit/vegetable, 3-8 oz box infant cereal
K44 2-12.9 oz cans powder Enfamil AR

MB 6-11 m MB 1-5 m MB 6-11 m
Child

M44 2-12.9 oz cans powder Enfamil AR 32 jars baby fruit/vegetable, 3-8 oz box infant cereal
J44 3-12.9 oz cans powder Enfamil AR N44 3-12.9 oz cans powder Enfamil AR
32 jars baby fruit/vegetable, 3-8 oz box infant cereal X44 912.9 oz cans powder Enfamil AR

Enfamil AR RTF

FFF 0-3 m FFF 4-5 m
FFF 6-11 m

A46 26-quart cans RTF Enfamil AR B46 28-quart cans RTF Enfamil AR D46 20-quart cans RTF Enfamil AR
32 jars baby fruit/vegetable, 3-8 oz box infant cereal

MB 1-3 m MB 4-5 m

F46 12-32 oz RTF containers Enfamil AR G46 14-32 oz RTF containers Enfamil AR

MB 6-11 m Child

H46 10-32 oz RTF containers Enfamil AR 32 jars baby fruit/vegetable, 3-8 oz box infant cereal
X46 2832 oz cans RTF Enfamil AR

FFF 0-3 m

Similac Sensitive for Spit Up or Similac for Spit up Powder A41 9-12.3 oz cans powder Similac Sensitive for Spit Up

FFF 4-5 m

B41 10-12.3 oz cans powder Similac Sensitive for Spit Up

FFF 6-11 m MB 1-3 m

D41 7-12.3 oz cans powder Similac Sensitive for Spit Up 32 jars baby fruit/vegetable, 3-8 oz box infant cereal
F41 4-12.3 oz cans powder Similac Sensitive for Spit Up

MB 4-5 m

G41 5-12.3 oz cans powder Similac Sensitive for Spit Up

MB 6-11 m MB 0-5

H41 4-12.3 oz cans powder Similac Sensitive for Spit Up 32 jars baby fruit/vegetable, 3-8 oz box infant cereal
E41 1-12.3 oz powder Similac Sensitive for Spit Up

MB 6-11 m MB 1-5 m

L41 1-12.3 oz powder Similac Sensitive for Spit Up 32 jars baby fruit/vegetable, 3-8 oz box infant cereal
K41 2-12.3 oz powder Similac Sensitive for Spit Up

MB 6-11 m M41 2-12.3 oz powder Similac Sensitive for Spit Up

FP-63


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-6

CPA FPC J41 X41 A43
F43
X43

Status / Age
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

System FPC
J41 N41
X41
A43 B43 D43
F43 G43 H43
X43

Formula
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 or Similac 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 28-quart RTF container Similac Sensitive for Spit Up

FP-64


GEORGIA WIC PROGRAM 2013 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

Similac Sensitive for Spit Up or Similac for Spit up

Food Package Code

VC Voucher Message

A41

N60 Formula 5-12.3 oz cans powder

9-12.3 oz powder Similac

Similac Sensitive for Spit Up (green and white

Sensitive for Spit Up or

label)

Similac for Spit up

N61 Formula 4-12.3 oz cans powder

Medical Documentation Required

Similac Sensitive for Spit Up (green and white label)

A43

137 Formula 13-quart containers ready to feed

26-32 oz ready to feed

Similac Sensitive for Spit Up (green and white

Similac Sensitive for Spit Up

label)

or Similac for Spit up

137 Formula 13-quart containers ready to feed

Similac Sensitive for Spit Up (green and white

Medical Documentation

label)

Required

FP-65


GEORGIA WIC PROGRAM 2013 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

Similac Sensitive for Spit Up or Similac 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 or Similac for

Sensitive for Spit Up or

Spit up (green and white label)

Similac for Spit up

4 N60 Formula 5-12.3 oz cans powder Similac

Medical Documentation

Sensitive for Spit Up or Similac for

Required

Spit up (green and white label)

B43 (Assign A43) 28-32 oz ready to feed Similac Sensitive for Spit Up or Similac for Spit up
Medical Documentation Required

2 139 Formula 14- quart containers ready to feed Similac Sensitive for Spit Up or Similac for Spit up (green and white label)
4 139 Formula 14- quart containers ready to feed Similac Sensitive for Spit Up or Similac for Spit up (green and white label)

FP-66


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-7 (cont'd)

Non-Contract Formulas Infant Fully formula Fed
6-11 months

Enfamil AR

Food Package Code

Rank VC

D44 (Assign A44)

4 N33

7-12.9 oz Enfamil AR

2 N34

4 N01

32 jars baby fruit/vegetable

3-8 oz box infant cereal

Medical Documentation Required

2 N26

D46 (Assign A46)

2 N35

20-1 quart ready to feed

Enfamil AR

4 N35

32 jars baby fruit/vegetable

4 N01

3-8 oz box infant cereal

Medical Documentation Required

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-67


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-7 (cont'd)

Similac Sensitive for Spit Up or Similac 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-68


GEORGIA WIC PROGRAM 2013 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-69


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-8 (cont'd)

Mostly Breastfed Infant

1-3 months - Maximum

Similac Sensitive for Spit Up or Similac 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 or Similac 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 or Similac

Sensitive for Spit Up or

for Spit up (green and white label)

Similac for Spit up

Medical Documentation

Required

G43 (Assign F43)

139

14-32 oz ready to feed

Similac Sensitive for Spit Up

or Similac for Spit up

Formula 14-32 oz containers ready to feed Similac Sensitive for Spit Up or Similac for Spit up (green and white label)

Medical Documentation Required

FP-70


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-8 (cont'd)

Similac for Spit up Food Package Code H41 (Assign F41) 4-12.9 oz powder Similac Sensitive for Spit Up or Similac 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 or Similac 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 or Similac 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 or Similac 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-71


GEORGIA WIC PROGRAM 2013 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-72


GEORGIA WIC PROGRAM 2013 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 or

Similac for Spit up

Voucher Message Formula 1-12.6 oz can powder Similac Sensitive
for Spit Up or Similac for Spit up (green and white label)

Medical Documentation Required L41 (Assign E41) 1-12.6 oz powder Similac Sensitive for Spit Up or Similac 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 or Similac for Spit up

111 Formula 1-12.6 oz can powder Similac Sensitive for Spit Up or Similac 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 or Similac for Spit up (green and white label)

Medical Documentation Required M41 (Assign K41) 2-12.6 oz powder Similac Sensitive for Spit Up or Similac 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 or Similac for Spit up

N64 Formula 2-12.6 oz cans powder Similac Sensitive for Spit Up or Similac 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 or Similac for Spit up (green and white label)

Medical Documentation Required

FP-73


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Food Package Code

VC Voucher Message

Attachment FP-8 (cont'd)

N41 (Assign J41) 3-12.6 oz powder Similac Sensitive for Spit Up or Similac 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 or Similac 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-74


GEORGIA WIC PROGRAM 2013 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

Similac Sensitive for Spit Up or Similac for Spit up

Food Package Code

Rank VC Voucher Message

X41

2 N61 Formula 4-12.3 oz cans powder Similac

9-12.3 oz cans powder

Sensitive for Spit Up or Similac for

Similac Sensitive for Spit

Spit up (green and white label)

Up or Similac for Spit up

4 N60 Formula 5-12.3 oz cans powder Similac

Medical Documentation

Sensitive for Spit Up or Similac for

Required

Spit up (green and white label)

X43 Similac Sensitive for Spit Up or Similac for Spit up
Medical Documentation Required

2 139 Formula 14- quart containers ready to feed Similac Sensitive for Spit Up or Similac for Spit up (green and white label)
4 139 Formula 14- quart containers ready to feed Similac Sensitive for Spit Up or Similac for Spit up (green and white label)

FP-75


GEORGIA WIC PROGRAM 2013 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-76


GEORGIA WIC PROGRAM 2013 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-77


GEORGIA WIC PROGRAM 2013 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-78


GEORGIA WIC PROGRAM 2013 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-79


GEORGIA WIC PROGRAM 2013 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: 4 W07 Milk:

1 container (46-48 oz) OR 1-12 oz can frozen OR 1-11.5 oz can pourable concentrate 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

FP-80


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-11 (cont'd)

4 W80 Eggs:
Whole grain:
Peanut butter:

1 dozen
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)

FP-81


GEORGIA WIC PROGRAM 2013 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-82


GEORGIA WIC PROGRAM 2013 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-83


GEORGIA WIC PROGRAM 2013 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-84


GEORGIA WIC PROGRAM 2013 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-85


GEORGIA WIC PROGRAM 2013 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-86


GEORGIA WIC PROGRAM 2013 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-87


GEORGIA WIC PROGRAM 2013 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-88


GEORGIA WIC PROGRAM 2013 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-89


GEORGIA WIC PROGRAM 2013 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-90


GEORGIA WIC PROGRAM 2013 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-91


GEORGIA WIC PROGRAM 2013 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-92


GEORGIA WIC PROGRAM 2013 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-93


GEORGIA WIC PROGRAM 2013 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:

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

Cheese: 1-16 oz package

Eggs: 1 dozen

FP-94


GEORGIA WIC PROGRAM 2013 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-95


GEORGIA WIC PROGRAM 2013 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-96


GEORGIA WIC PROGRAM 2013 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-97


GEORGIA WIC PROGRAM 2013 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-98


GEORGIA WIC PROGRAM 2013 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-99


GEORGIA WIC PROGRAM 2013 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-100


GEORGIA WIC PROGRAM 2013 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-101


GEORGIA WIC PROGRAM 2013 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-102


GEORGIA WIC PROGRAM 2013 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-103


GEORGIA WIC PROGRAM 2013 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-104


GEORGIA WIC PROGRAM 2013 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-105


GEORGIA WIC PROGRAM 2013 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-106


GEORGIA WIC PROGRAM 2013 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-107


GEORGIA WIC PROGRAM 2013 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-108


GEORGIA WIC PROGRAM 2013 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-109


GEORGIA WIC PROGRAM 2013 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: 1 W04 Milk:

No more than 30 oz (canned tuna or canned salmon) 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-110


GEORGIA WIC PROGRAM 2013 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-111


GEORGIA WIC PROGRAM 2013 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-112


GEORGIA WIC PROGRAM 2013 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-113


GEORGIA WIC PROGRAM 2013 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-114


GEORGIA WIC PROGRAM 2013 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-115


GEORGIA WIC PROGRAM 2013 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-116


GEORGIA WIC PROGRAM 2013 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-117


GEORGIA WIC PROGRAM 2013 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-118


GEORGIA WIC PROGRAM 2013 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-119


GEORGIA WIC PROGRAM 2013 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-120


GEORGIA WIC PROGRAM 2013 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-121


GEORGIA WIC PROGRAM 2013 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-122


GEORGIA WIC PROGRAM 2013 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-123


GEORGIA WIC PROGRAM 2013 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-124


GEORGIA WIC PROGRAM 2013 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-125


GEORGIA WIC PROGRAM 2013 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-126


GEORGIA WIC PROGRAM 2013 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-127


GEORGIA WIC PROGRAM 2013 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-128


GEORGIA WIC PROGRAM 2013 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-129


GEORGIA WIC PROGRAM 2013 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-130


GEORGIA WIC PROGRAM 2013 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-131


GEORGIA WIC PROGRAM 2013 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-132


GEORGIA WIC PROGRAM 2013 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-133


GEORGIA WIC PROGRAM 2013 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-134


GEORGIA WIC PROGRAM 2013 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-135


GEORGIA WIC PROGRAM 2013 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

Peanut

(16-18 oz.)

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-136


GEORGIA WIC PROGRAM 2013 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-137


GEORGIA WIC PROGRAM 2013 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-138


GEORGIA WIC PROGRAM 2013 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-139


GEORGIA WIC PROGRAM 2013 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-140


GEORGIA WIC PROGRAM 2013 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-141


GEORGIA WIC PROGRAM 2013 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-142


GEORGIA WIC PROGRAM 2013 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-143


GEORGIA WIC PROGRAM 2013 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-144


GEORGIA WIC PROGRAM 2013 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-145


GEORGIA WIC PROGRAM 2013 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-146


GEORGIA WIC PROGRAM 2013 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-147


GEORGIA WIC PROGRAM 2013 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-148


GEORGIA WIC PROGRAM 2013 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-149


GEORGIA WIC PROGRAM 2013 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-150


GEORGIA WIC PROGRAM 2013 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-151


GEORGIA WIC PROGRAM 2013 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-152


GEORGIA WIC PROGRAM 2013 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-153


GEORGIA WIC PROGRAM 2013 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-154


GEORGIA WIC PROGRAM 2013 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-155


GEORGIA WIC PROGRAM 2013 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-156


GEORGIA WIC PROGRAM 2013 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-157


GEORGIA WIC PROGRAM 2013 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-158


GEORGIA WIC PROGRAM 2013 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-159


GEORGIA WIC PROGRAM 2013 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-160


GEORGIA WIC PROGRAM 2013 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-161


GEORGIA WIC PROGRAM 2013 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-162


GEORGIA WIC PROGRAM 2013 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-163


GEORGIA WIC PROGRAM 2013 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-164


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-17

CPA FPC
R01
S01 X01
R03
S03 X03
X39 X40 X02 X42
X07 X08 X09 X16
X90 X93 X94 X95
X96 X97 X98 X99
Z31 Z32 Z33 Z35
X89

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

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
Z31 Z32 Z33 Z35
X89

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
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
EleCare Jr Powder 9-14.1 oz cans powder EleCare Jr

FP-165


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-17(cont'd)

CPA FPC R41
S41 R24
S24 R26
S26 R20
S20 R30
S30 R40
S40 R12
S12 Z49 Z50 Z51 Z52

Status / Age
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 FFF 4-5 m FFF 6-11 m
FFF 6-11 m Child Child Child Child

System FPC
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 S12 T12
S12 Z49 Z50 Z51 Z52

Formula
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 20 RTF 414-2 oz cans RTF Enfamil Premature 20 444-2 oz cans RTF Enfamil Premature 20 318-2 oz cans RTF Enfamil Premature 20 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 444-2 oz cans RTF Enfamil Premature 20
Enfamil Premature 24 RTF 414-2 oz cans RTF Enfamil Premature 24 444-2 oz cans RTF Enfamil Premature 24 318-2 oz cans RTF Enfamil Premature 24 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 444-2 oz cans RTF Enfamil Premature 24
Enfaport 102-8 oz cans Enfaport 112-8 oz cans Enfaport 78-8 oz cans Enfaport 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 112-8 oz cans Enfaport 30-8 oz cans Enfaport 60-8 oz cans Enfaport 90-8 oz cans Enfaport 113-8 oz cans Enfaport

FP-166


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-17(cont'd)

CPA FPC X06 X38 X45 X15 X51 X52 X53 R07
R02
S02 R61
S61 X75 R71
S71 X92 R73
S73 X73 R70

Status / Age
Women Women Women Women
Child Child Child
FFF 0-3 m FFF 4-5 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
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

System FPC
X06 X38 X45 X15
X51 X52 X53
R07 S07 T07
R02 S02 T02
S02
R61 S61 T61
S61
X75
R71 S71 T71
S71 X92
R73 S73 T73
S73 X73
R70 S70

Formula
Ensure 30-8 oz containers Ensure 60-8 oz containers Ensure 90-8 oz containers Ensure 108-8 oz containers Ensure
EO28 Splash 31-237 ml containers EO28 Splash 62-237 ml containers EO28 Splash 113-237 ml containers EO28 Splash
Gerber Good Start Nourish 10-12.6 oz Gerber Good Start Nourish 11-12.6 oz Gerber Good Start Nourish 8-12.6 oz Gerber Good Start Nourish 32 jars baby fruit/vegetable, 3-8 oz box infant cereal
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 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
Neocate Junior Powder 14-400 grams (14.1 oz) cans powder Neocate Junior
Similac Expert Care Neosure Powder 10-13.1 oz Similac Expert Care NeoSure
11-13.1 oz Similac Expert Care NeoSure
8-13.1 oz Similac Expert Care NeoSure 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 11-13.1 oz Similac Expert Care NeoSure
10-13.1 oz Similac Expert Care NeoSure Similac Expert Care NeoSure 32 oz RTF
26-32 oz cans RTF Similac Expert Care NeoSure 28-32 oz cans RTF Similac Expert Care NeoSure 20-32 oz cans RTF Similac Expert Care NeoSure 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 28-32 oz cans RTF Similac Expert Care NeoSure 28-32 oz cans RTF Similac Expert Care NeoSure
Similac Expert Care NeoSure 2 oz RTF 416-2 oz cans RTF Similac Expert Care NeoSure 448-2 oz cans RTF Similac Expert Care NeoSure

FP-167


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-17(cont'd)

CPA FPC
S70
Z41 Z42 Z43 Z44 R81
S81 X81 R82
S82 X82 R83
S83 X83 R91
S91 Z45 Z46 Z47 Z48 X54 X55 X56

Status / Age 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
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 0-2 m FFF 3-5 m FFF 6-11 m
FFF 6-11 m
Women Women Women Women
Women Women Women

System FPC T70
S70
Z41 Z42 Z43 Z44
R81 S81 T81
S81 X81
R82 S82 T82
S82 X82
R83 S83 T83
S83 X83
R91 S91 T91
S91
Z45 Z46 Z47 Z48
X54 X55 X56

Formula
320-2 oz cans RTF Similac Expert Care NeoSure 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 448-2 oz cans RTF 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 with Enflora LGG Powder 10-12.6 oz cans powder Nutramigen with Enflora IGG 11-12.6 oz cans powder Nutramigen with Enflora LGG 8-12.6 oz cans powder Nutramigen with Enflora LGG 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 11-12.6 oz cans powder Nutramigen with Enflora LGG 10-12.6 oz cans powder Nutramigen with Enflora LGG
Nutramigen Concentrate 31-13 oz cans concentrate Nutramigen 34-13 oz cans concentrate Nutramigen 24-13 oz cans concentrate Nutramigen 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 34-13 oz cans concentrate Nutramigen 35-13 oz cans concentrate Nutramigen
Nutramigen 32 oz RTF 26-32 oz cans RTF Nutramigen 28-32 oz cans RTF Nutramigen 20-32 oz cans RTF Nutramigen 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 28-32 oz cans RTF Nutramigen 28-32 oz cans RTF Nutramigen
Nutramigen AA Powder 8-400 gram (14.1 oz) cans powder Nutramigen AA 9-400 gram (14.1 oz) cans powder Nutramigen AA 7-400 gram (14.1 oz) cans powder Nutramigen AA 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 9-400 gram (14.1 oz) cans powder Nutramigen AA
Nutren 1.5 30-250 ml containers Nutren 1.5 60-250 ml containers Nutren 1.5 90-250 ml containers Nutren 1.5 107-250 ml containers Nutren 1.5
Nutren 2.0 35-250 ml containers Nutren 2.0 59-250 ml containers Nutren 2.0 107-250 ml containers Nutren 2.0

FP-168


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-17(cont'd)

CPA FPC
X57 X58 X59
X60 X37 X62
X84 X30 X87 X88
Z53 Z54 Z55 Z56
Z57 Z58 Z59 Z60
Z27 Z28 Z29 Z30
Z37 Z38 Z39 Z40
Z10 Z11 Z12 Z13
X76 X85 X78 X79
X63 X64

Status / Age
Child Child Child
Child Child Child
Child Child Child Child
Child Child Child Child
Child Child Child Child
Child Child Child Child
Child Child Child Child
Child Child Child Child
Child Child Child Child
Women Women

System FPC
X57 X58 X59
X60 X37 X62
X84 X30 X87 X88
Z53 Z54 Z55 Z56
Z57 Z58 Z59 Z60
Z27 Z28 Z29 Z30
Z37 Z38 Z39 Z40
Z10 Z11 Z12 Z13
X76 X85 X78 X79
X63 X64

Formula
Nutren Junior 35-250 ml containers Nutren Junior 59-250 ml containers Nutren Junior 107-250 ml containers Nutren Junior
Nutren Junior Fiber 35-250 ml containers Nutren Junior Fiber 59-250 ml containers Nutren Junior Fiber 107-250 ml containers Nutren Junior Fiber
PediaSure Ready to Feed 30-8 oz containers PediaSure 60-8 oz containers PediaSure 90-8 oz containers PediaSure 108-8 oz containers PediaSure
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 Peptide 1.0 Cal 30-8 oz containers ready to feed Pediasure Peptide 1.0 Cal 60-8 oz containers ready to feed Pediasure Peptide 1.0 Cal 90-8 oz containers ready to feed Pediasure Peptide 1.0 Cal 113-8 oz containers ready to feed Pediasure Peptide 1.0 Cal
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

FP-169


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-17(cont'd)

CPA FPC X65
X66 X67 X68
Z05 Z06 Z07 Z08
X69 X70 X05
Z01 Z02 Z03 Z04
X20
R04
S04 X04
R05
S05
R06
S06
Z19 Z20 Z21

Status / Age Women
Child Child Child
Child Child Child Child
Child Child Child
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 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

System FPC X65
X66 X67 X68
Z05 Z06 Z07 Z08
X69 X70 X05
Z01 Z02 Z03 Z04
X20
R04 S04 T04
S04 X04
R05 S05 T05
S05
R06 S06 T06
S06
Z19 Z20 Z21

Formula
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 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 20 cal RTF 414- 2 oz containers ready to feed Pregestimil 20 Calorie
444-2 oz containers ready to feed Pregestimil 20 Calorie 318- 2 oz containers ready to feed Pregestimil 20 Calorie 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 444- 2 oz containers ready to feed Pregestimil 20 Calorie
Pregestimil 24 cal RTF 414- 2 oz containers ready to feed Pregestimil 24 Calorie 444-2 oz containers ready to feed Pregestimil 24 Calorie 318- 2 oz containers ready to feed Pregestimil 24 Calorie 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 444- 2 oz containers ready to feed Pregestimil 24 Calorie
Resource Breeze 30-8 oz containers ready to feed Resource Breeze 60-8 oz containers ready to feed Resource Breeze 90-8 oz containers ready to feed Resource Breeze

FP-170


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-17(cont'd)

CPA FPC Z22 R14
S14 X14 R10
S10 R50
S50 R60
S60 Z14 Z15 Z16 Z18 Z23 Z24 Z25 Z26 099 197 199

Status / Age Child
FFF 0-3 m FFF 4-5 m FFF 6 m
FFF 7-11 m
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
All All All

System FPC Z22
R14 S14 V14
T14
S14 X14
R10 S10 T10
S10
R50 S50 T50
S50
R60 S60 T60
S60
Z14 Z15 Z16 Z18
Z23 Z24 Z25 Z26
099 197 199

Formula
113-8 oz containers ready to feed Resource Breeze
Similac PM 60/40 Powder 8-14.1 oz cans powder Similac PM 60/40
9-14.1 oz cans powder Similac PM 60/40
7-14.1 oz cans powder Similac PM 60/40 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 6-14.1 oz cans powder Similac PM 60/40 32 jars baby fruit/vegetable, 3-8 oz box infant cereal 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
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 Nutrition Unit

FP-171


GEORGIA WIC PROGRAM 2013 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-172


GEORGIA WIC PROGRAM 2013 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-173


GEORGIA WIC PROGRAM 2013 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-174


GEORGIA WIC PROGRAM 2013 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
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-175


GEORGIA WIC PROGRAM 2013 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-176


GEORGIA WIC PROGRAM 2013 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

foods)

Infant

cereal:

3-8 oz containers

FP-177


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-18 (cont'd)

Enfamil Premature 20 Food Package Code R30 414-2 oz containers ready to feed iron fortified Enfamil Premature 20 Medical Documentation Required
S30 (Assign R30) 444-2 oz containers ready to feed iron fortified Enfamil Premature 20
Medical Documentation Required

Rank VC 2 595
2 595
4 595
4 595
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 20 (2 cases) Formula 96-2 oz containers ready to feed iron fortified Enfamil Premature 20 (2 cases) Formula 96-2 oz containers ready to feed iron fortified Enfamil Premature 20 (2 cases) Formula 96-2 oz containers ready to feed iron fortified Enfamil Premature 20 (2 cases) Formula 18-2 oz containers ready to feed iron fortified Enfamil Premature 20 Formula 12-2 oz containers ready to feed iron fortified Enfamil Premature 20 Formula 96-2 oz containers ready to feed iron fortified Enfamil Premature 20 (2 cases) Formula 96-2 oz containers ready to feed iron fortified Enfamil Premature 20 (2 cases) Formula 96-2 oz containers ready to feed iron fortified Enfamil Premature 20 (2 cases) Formula 96-2 oz containers ready to feed iron fortified Enfamil Premature 20 (2 cases) Formula 48-2 oz containers ready to feed iron fortified Enfamil Premature 20 (1 case) Formula 12-2 oz containers ready to feed iron fortified Enfamil Premature 20

FP-178


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-18 (cont'd)

Food Package Code T30 (Assign R30) 318-2 oz containers ready to feed iron fortified Enfamil Premature 20
32-4 oz infant food
3-8 oz infant cereal
Medical Documentation Required

Rank VC 2 595
4 595
4 595
2 546

Voucher Message Formula 96-2 oz containers ready to feed iron
fortified Enfamil Premature 20 (2 cases) Formula 96-2 oz containers ready to feed iron fortified Enfamil Premature 20 (2 cases) Formula 96-2 oz containers ready to feed iron fortified Enfamil Premature 20 (2 cases) Formula 18-2 oz containers ready to feed iron fortified Enfamil Premature 20

2 S21 Formula 12-2 oz containers ready to feed iron fortified Enfamil Premature 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-179


GEORGIA WIC PROGRAM 2013 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 24

2 597

Medical Documentation Required

4 597

4 597

S40 (Assign R40) 444-2 oz containers ready to feed Enfamil Premature 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 24 (2 case) Formula 96-2 oz containers ready to feed iron fortified Enfamil Premature 24 (2 cases) Formula 96-2 oz containers ready to feed iron fortified Enfamil Premature 24
(2 cases) Formula 96-2 oz containers ready to feed iron
fortified Enfamil Premature 24 (2 cases) Formula 18-2 oz containers ready to feed iron fortified Enfamil Premature 24 Formula 12-2 oz containers ready to feed iron fortified Enfamil Premature 24 Formula 96-2 oz containers ready to feed iron fortified Enfamil Premature 24 (2 cases) Formula 96-2 oz containers ready to feed iron fortified Enfamil Premature 24 (2 cases) Formula 96-2 oz containers ready to feed iron fortified Enfamil Premature 24 (2 cases) Formula 96-2 oz containers ready to feed iron fortified Enfamil Premature 24 (2 cases) Formula 48-2 oz containers ready to feed iron fortified Enfamil Premature 24 (1 case) Formula 12-2 oz containers ready to feed iron fortified Enfamil Premature 24

FP-180


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-18 (cont'd)

Food Package Code T40 (Assign R40) 318-2 oz containers ready to feed iron fortified Enfamil Premature 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 24 (2 cases) Formula 96-2 oz containers ready to feed iron fortified Enfamil Premature 24 (2 cases)

Formula
Formula Formula Infant foods:
Infant foods: Infant cereal:

96-2 oz containers ready to feed iron fortified Enfamil Premature 24 (2 cases) 12-2 oz containers ready to feed iron fortified Enfamil Premature 24 18-2 oz containers ready to feed iron fortified Enfamil Premature 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-181


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-18 (cont'd)

Enfaport Food Package Code R12 102-8 oz cans ready to feed Enfaport

Rank 2
4

4

Medical Documentation

Required

4

S12 (Assign R12)

4

112-8 oz cans ready to

feed Enfaport

2

Medical Documentation

Required

2

4

2

T12 (Assign R12)

4

78-8 oz cans ready to feed

Enfaport

2

2

32-4 oz infant food

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 (2
cases) Formula 24-8 oz cans ready to feed Enfaport (1
case) Formula 24-8 oz cans ready to feed Enfaport (1
case) Formula 6-8 oz cans ready to feed Enfaport (one
6-pack) Formula 48-8 oz cans ready to feed Enfaport (2
cases) Formula 24-8 oz cans ready to feed Enfaport (1
case) Formula 24-8 oz cans ready to feed Enfaport (1
case) Formula 12-8 oz cans ready to feed Enfaport
(two 6-packs) Formula 4-8 oz cans ready to feed Enfaport

Formula Formula Formula Infant foods:
Infant foods:
Infant cereal:

48-8 oz cans ready to feed Enfaport (2 cases)
24-8 oz cans ready to feed Enfaport (1 case)
6-8 oz cans ready to feed Enfaport (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-182


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-18 (cont'd)

Gerber Good Start Nourish

Food Package Code

Rank VC

R07

2 L06

10-12.6 oz powder Gerber Good Start Nourish

4 L06

Voucher Message Formula: 5-12.6 oz cans powder Gerber Good
Start Nourish Formula: 5-12.6 oz cans powder Gerber Good
Start Nourish

Medical Documentation Required S07 (Assign R07)
11-12.6 oz powder Gerber Good Start Nourish

2 L06 Formula: 5-12.6 oz cans powder Gerber Good Start Nourish
4 L07 Formula: 6-12.6 oz cans powder Gerber Good Start Nourish

Medical Documentation Required T07 (Assign R07)
8-12.6 oz powder Gerber Good Start Nourish
32 jars baby fruit/vegetable
3-8 oz box infant cereal
Medical Documentation Required

2 L08 Formula: 4-12.6 Noz cans powder Gerber Good

Start Nourish

4 L08 Formula: 4-12.6 oz cans powder Gerber Good

Start Nourish

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

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)

FP-183


GEORGIA WIC PROGRAM 2013 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

4

Required

VC S38 S38 S39 S40 S38 S38 S39 S39 S41 S38 S39 S39 S42 N01
N26

Voucher Message

Formula Formula Formula Formula 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) 32-3 oz containers ready to feed Gerber Good Start Premature 24 (four 8-packs) 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
Infant foods:
Infant cereal: Infant foods:

16-3 oz containers ready to feed Gerber Good Start Premature 24 (two 8-packs)
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-184


GEORGIA WIC PROGRAM 2013 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-185


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-18 (cont'd)

Similac Similac Expert Care Neosure

Food Package Code

Rank VC

R71

4 519

10-13.1 oz Similac Expert

Care Neosure

2 520

Medical Documentation Required S71 (Assign R71) 11-13.1 oz Similac Expert Care Neosure

4 519 2 S25

Medical Documentation Required T71 (Assign R71) 8-13.1 oz Similac Expert Care Neosure

2 520 4 520

32-4 oz infant food

2 N26

3-8 oz infant cereal

Medical Documentation Required

4 N01

Voucher Message Formula 6-13.1 oz cans Similac Expert Care
NeoSure (1 case) Formula 4-13.1 oz cans Similac Expert Care
NeoSure

Formula Formula

6-13.1 oz cans Similac Expert Care NeoSure (1 case) 5-13.1 oz cans Similac Expert Care NeoSure

Formula
Formula
Infant foods:
Infant foods:
Infant cereal:

4-13.1 oz cans Similac Expert Care NeoSure 4-13.1 oz cans Similac Expert Care NeoSure 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-186


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-18 (cont'd)

Food Package Code R73 Similac Expert Care NeoSure

Rank VC 2 517
2 517

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

4 517

NeoSure

Medical Documentation Required

4 517 2 517

2 S09

Voucher Message Formula 6-32 oz containers ready to feed
Similac Expert Care NeoSure (1 case) Formula 6-32 oz containers ready to feed
Similac Expert Care NeoSure (1 case) Formula 6-32 oz containers ready to feed Similac Expert Care NeoSure (1 case) Formula 6-32 oz containers ready to feed 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 Expert Care NeoSure (1 case) Formula 6-32 oz containers ready to feed Similac Expert Care NeoSure (1 case) Formula 6-32 oz containers ready to feed Similac Expert Care NeoSure (1 case) Formula 6-32 oz containers ready to feed Similac Expert Care NeoSure (1 case) Formula 4-32 oz containers ready to feed Similac Expert Care NeoSure

FP-187


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-18 (cont'd)

Food Package Code T73 (Assign R73) 20-32 oz containers ready to feed Similac Expert Care NeoSure 32-4 oz infant food 3-8 oz infant cereal Medical Documentation Required
R70 416-2 oz containers ready to feed Similac Expert Care NeoSure Medical Documentation Required

Rank VC 2 517 4 517 4 517 2 S10 2 N26
4 N01
2 596 2 596 4 596 4 596 2 516 4 516

Voucher Message

Formula 6-32 oz containers ready to feed

Similac Expert Care NeoSure

(1 case)

Formula 6-32 oz containers ready to feed

Similac Expert Care NeoSure

(1 case)

Formula 6-32 oz containers ready to feed

Similac Expert Care NeoSure

(1 case)

Formula 2-32 oz containers ready to feed

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

Formula 96-2 oz containers ready to feed

Similac Expert Care NeoSure (2 cases)

Formula 96-2 oz containers ready to feed

Similac Expert Care NeoSure (2 cases)

Formula 96-2 oz containers ready to feed

Similac Expert Care NeoSure (2 cases)

Formula 96-2 oz containers ready to feed

Similac Expert Care NeoSure (2 cases)

Formula 16-2 oz containers ready to feed

Similac Expert Care NeoSure

Formula 16-2 oz containers ready to feed

Similac Expert Care NeoSure

FP-188


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-18 (cont'd)

Food Package Code S70 (Assign R70) 448-2 oz containers ready to feed Similac Expert Care NeoSure
Medical Documentation Required
T70 (Assign R70) 320-2 oz containers ready to feed Similac Expert Care NeoSure
32-4 oz infant food
3-8 oz infant cereal
Medical Documentation Required

Rank VC 2 596 2 596 4 596 4 596 4 515 2 516 2 596 4 596 4 596 2 516 2 516 2 N26
2 N01

Voucher Message

Formula 96-2 oz containers ready to feed

Similac Expert Care NeoSure (2 cases)

Formula 96-2 oz containers ready to feed

Similac Expert Care NeoSure (2 cases)

Formula 96-2 oz containers ready to feed

Similac Expert Care NeoSure (2 cases)

Formula 96-2 oz containers ready to feed

Similac Expert Care NeoSure (2 cases)

Formula 48-2 oz containers ready to feed

Similac Expert Care NeoSure (1 case)

Formula 16-2 oz containers ready to feed

Similac Expert Care NeoSure

Formula 96-2 oz containers ready to feed

Similac Expert Care NeoSure (2 cases)

Formula 96-2 oz containers ready to feed

Similac Expert Care NeoSure (2 cases)

Formula 96-2 oz containers ready to feed

Similac Expert Care NeoSure (2 cases)

Formula 16-2 oz containers ready to feed

Similac Expert Care NeoSure

Formula 16-2 oz containers ready to feed

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-189


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-18 (cont'd)

Nutramigen Food Package Code R82 31-13 oz cans concentrate Nutramigen
Medical Documentation Required S82 (Assign R82) 34-13 oz cans concentrate Nutramigen
Medical Documentation Required T82 (Assign R82) 24-13 oz cans concentrate Nutramigen
32-4 oz infant food
3-8 oz infant cereal
Medical Documentation Required
R81 1012.6 oz cans powder Nutramigen with Enflora LGG
Medical Documentation Required S81 (Assign R81) 11-12.6 oz cans powder Nutramigen with Enflora LGG
Medical Documentation Required

Rank VC 2 N08 4 N67
2 N08 4 N57
2 163 4 163 2 N26
4 N01
2 156 4 156
2 156 4 155

Voucher Message Formula 15-13 oz cans concentrate Nutramigen
LIPIL or Nutramigen Formula 16-13 oz cans concentrate Nutramigen
LIPIL or Nutramigen

Formula Formula

15-13 oz cans concentrate Nutramigen LIPIL or Nutramigen 19-13 oz cans concentrate Nutramigen LIPIL or Nutramigen

Formula Formula Infant foods:
Infant foods: Infant cereal: Formula
Formula
Formula
Formula

12-13 oz cans concentrate Nutramigen LIPIL or Nutramigen 12-13 oz cans concentrate Nutramigen LIPIL or Nutramigen 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 or Nutramigen with Enflora LGG 5-12.6 oz cans powder Nutramigen LIPIL with Enflora LGG or Nutramigen with Enflora LGG
5-12.6 oz cans powder Nutramigen LIPIL with Enflora LGG or Nutramigen with Enflora LGG 6-12.6 oz cans powder Nutramigen LIPIL with Enflora LGG or Nutramigen with Enflora LGG

FP-190


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-18 (cont'd)

Food Package Code T81 (Assign R81) 8-12.6 oz cans powder Nutramigen 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
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 or Nutramigen

Formula 3-12.6 oz cans powder Nutramigen

LIPIL with Enflora LGG or Nutramigen

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 13-32 oz containers ready to feed

Nutramigen LIPIL or Nutramigen

Formula 13-32 oz containers ready to feed

Nutramigen LIPIL or Nutramigen

Formula Formula

14-32 oz containers ready to feed Nutramigen LIPIL or Nutramigen 14-32 oz containers ready to feed Nutramigen LIPIL or Nutramigen

Formula
Formula
Infant foods:
Infant foods:
Infant cereal:

10-32 oz containers ready to feed Nutramigen LIPIL or Nutramigen 10-32 oz containers ready to feed Nutramigen LIPIL or Nutramigen 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-191


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-18 (cont'd)

Nutramigen AA Food Package Code R91 8-14.1 oz cans powder Nutramigen AA
Medical Documentation Required S91 (Assign R91) 9-14.1 oz cans powder Nutramigen AA
Medical Documentation Required T91 (Assign R91) 7-14.1 oz cans powder Nutramigen AA
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 or Nutramigen AA Formula 4-400 gram (14.1 oz) cans powder
Nutramigen AA LIPIL or Nutramigen AA

2 706 Formula 4-400 gram (14.1 oz) cans powder

Nutramigen AA LIPIL or Nutramigen AA

4 706 Formula 4-400 gram (14.1 oz) cans powder

Nutramigen AA LIPIL or Nutramigen AA

4 707 Formula 1-400 gram (14.1 oz) can powder

Nutramigen AA LIPIL or Nutramigen AA

4 706 Formula 4-400 gram (14.1 oz) cans powder

Nutramigen AA LIPIL or Nutramigen AA

2 S14 Formula 3-400 gram (14.1 oz) cans powder

Nutramigen AA LIPIL or Nutramigen AA

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

foods)

Infant

Cereal: 3-8 oz containers

FP-192


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-18 (cont'd)

Pregestimil Food Package Code R04 7-16 oz cans powder Pregestimil
Medical Documentation Required S04 (Assign R04) 8-16 oz cans powder Pregestimil
Medical Documentation Required T04 (Assign R04) 6-16 oz cans powder Pregestimil
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 or Pregestimil 2 S08 Formula 3-16 oz cans powder Pregestimil LIPIL or Pregestimil

2 140 Formula 4-16 oz cans powder Pregestimil LIPIL or Pregestimil
4 140 Formula 4-16 oz cans powder Pregestimil LIPIL or Pregestimil

2 S08 Formula 3-16 oz cans powder Pregestimil LIPIL

or Pregestimil

4 S08 Formula 3-16 oz cans powder Pregestimil LIPIL

or Pregestimil

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

foods)

Infant

cereal:

3-8 oz containers

FP-193


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-18 (cont'd)

Pregestimil 20 Calorie Food Package Code R05 414-2 oz containers ready to feed Pregestimil 20 Calorie Medical Documentation Required
S05 (Assign R05) 444-2 oz containers ready to feed Pregestimil 20 Calorie
Medical Documentation Required
T05 (Assign R05) 318-2 oz containers ready to feed Pregestimil 20 Calorie
32-4 oz infant food 3-8 oz boxes infant cereal Medical Documentation Required

Rank 2 2 4 4 4 2 2 4 4 4 2 4 4 2 2

VC S61 S61 S61 S61 S62 S61 S61 S61 S61 S63 S64 S61 S61 S61 S62

Voucher Message Formula 96-2 oz containers ready to feed
Pregestimil LIPIL 20 Calorie or Pregestimil 20 Calorie (2 cases) Formula 96-2 oz containers ready to feed Pregestimil LIPIL 20 Calorie or Pregestimil 20 Calorie (2 cases) Formula 96-2 oz containers ready to feed Pregestimil LIPIL 20 Calorie or Pregestimil 20 Calorie (2 cases) Formula 96-2 oz containers ready to feed Pregestimil LIPIL 20 Calorie or Pregestimil 20 Calorie (2 cases) Formula 30-2 oz containers ready to feed Pregestimil LIPIL 20 Calorie or Pregestimil 20 Calorie (five 6-packs) Formula 96-2 oz containers ready to feed Pregestimil LIPIL 20 Calorie or Pregestimil 20 Calorie (2 cases) Formula 96-2 oz containers ready to feed Pregestimil LIPIL 20 Calorie or Pregestimil 20 Calorie (2 cases) Formula 96-2 oz containers ready to feed Pregestimil LIPIL 20 Calorie or Pregestimil 20 Calorie (2 cases) Formula 96-2 oz containers ready to feed Pregestimil LIPIL 20 Calorie or Pregestimil 20 Calorie (2 cases) Formula 48-2 oz containers ready to feed Pregestimil LIPIL 20 Calorie or Pregestimil 20 Calorie (1 case) Formula 12-2 oz containers ready to feed Pregestimil LIPIL 20 Calorie or Pregestimil 20 Calorie (two 6-packs) Formula 96-2 oz containers ready to feed Pregestimil LIPIL 20 Calorie or Pregestimil 20 Calorie (2 cases) Formula 96-2 oz containers ready to feed Pregestimil LIPIL 20 Calorie or Pregestimil 20 Calorie (2 cases) Formula 96-2 oz containers ready to feed Pregestimil LIPIL 20 Calorie or Pregestimil 20 Calorie (2 cases) Formula 30-2 oz containers ready to feed Pregestimil LIPIL 20 Calorie or Pregestimil 20 Calorie (five 6-packs)

FP-194


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-18 (cont'd)

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-195


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-18 (cont'd)

Pregestimil 24 Calorie Food Package Code R06 414-2 oz containers ready to feed Pregestimil 24 Calorie Medical Documentation Required
S06 (Assign R06) 444-2 oz containers ready to feed Pregestimil 24 Calorie
Medical Documentation Required
T06 (Assign R06) 318-2 oz containers ready to feed Pregestimil 24 Calorie
32-4 oz infant food 3-8 oz boxes infant cereal Medical Documentation Required

Rank 2 2 4 4 4 2 2 4 4 4 2 4 4 2 2

VC S65 S65 S65 S65 S66 S65 S65 S65 S65 S67 S68 S65 S65 S65 S66

Voucher Message Formula 96- 2 oz containers ready to feed
Pregestimil LIPIL 24 Calorie or Pregestimil 24 Calorie (2 cases) Formula 96-2 oz containers ready to feed Pregestimil LIPIL 24 Calorie or Pregestimil 24 Calorie (2 cases) Formula 96-2 oz containers ready to feed Pregestimil LIPIL 24 Calorie or Pregestimil 24 Calorie (2 cases) Formula 96-2 oz containers ready to feed Pregestimil LIPIL 24 Calorie or Pregestimil 24 Calorie (2 cases) Formula 30-2 oz containers ready to feed Pregestimil LIPIL 24 Calorie or Pregestimil 24 Calorie (five 6-packs) Formula 96-2 oz containers ready to feed Pregestimil LIPIL 24 Calorie or Pregestimil 24 Calorie (2 cases) Formula 96-2 oz containers ready to feed Pregestimil LIPIL 24 Calorie or Pregestimil 24 Calorie (2 cases) Formula 96-2 oz containers ready to feed Pregestimil LIPIL 24 Calorie or Pregestimil 24 Calorie (2 cases) Formula 96-2 oz containers ready to feed Pregestimil LIPIL 24 Calorie or Pregestimil 24 Calorie (2 cases) Formula 48-2 oz containers ready to feed Pregestimil LIPIL 24 Calorie or Pregestimil 24 Calorie (1 case) Formula 12-2 oz containers ready to feed Pregestimil LIPIL 24 Calorie or Pregestimil 24 Calorie (two 6-packs) Formula 96-2 oz containers ready to feed Pregestimil LIPIL 24 Calorie or Pregestimil 24 Calorie (2 cases) Formula 96-2 oz containers ready to feed Pregestimil LIPIL 24 Calorie or Pregestimil 24 Calorie (2 cases) Formula 96-2 oz containers ready to feed Pregestimil LIPIL 24 Calorie or Pregestimil 24 Calorie (2 cases) Formula 96-2 oz containers ready to feed Pregestimil LIPIL 24 Calorie or Pregestimil 24 Calorie (2 cases)

FP-196


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-18 (cont'd)

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-197


GEORGIA WIC PROGRAM 2013 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-198


GEORGIA WIC PROGRAM 2013 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-199


GEORGIA WIC PROGRAM 2013 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-200


GEORGIA WIC PROGRAM 2013 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-201


GEORGIA WIC PROGRAM 2013 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-202


GEORGIA WIC PROGRAM 2013 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-203


GEORGIA WIC PROGRAM 2013 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-204


GEORGIA WIC PROGRAM 2013 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-205


GEORGIA WIC PROGRAM 2013 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

VC S02
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

4 S05 Formula 32-8.25 oz containers ready to feed Boost Kid Essentials (2 cases)
2 S02 Formula 16-8.25 oz containers ready to feed Boost Kid Essentials (1 case)
2 S04 Formula 12-8.25 oz containers ready to feed Boost Kid Essentials (three 4-packs)

4 S05 Formula 32-8.25 oz containers ready to feed Boost Kid Essentials (2 cases)
2 S05 Formula 32-8.25 oz containers ready to feed Boost Kid Essentials (2 cases)
3 S02 Formula 16-8.25 oz containers ready to feed Boost Kid Essentials (1 case)
1 S06 Formula 8-8.25 oz containers ready to feed Boost Kid Essentials (two 4-packs)
1 S07 Formula 2-8.25 oz containers ready to feed Boost Kid Essentials
4 S05 Formula 32-8.25 oz containers ready to feed Boost Kid Essentials (2 cases)
3 S05 Formula 32-8.25 oz containers ready to feed Boost Kid Essentials (2 cases)
2 S05 Formula 32-8.25 oz containers ready to feed Boost Kid Essentials (2 cases)
1 S04 Formula 12-8.25 oz containers ready to feed Boost Kid Essentials (three 4-packs)
1 S07 Formula 2-8.25 oz containers ready to feed Boost Kid Essentials

FP-206


GEORGIA WIC PROGRAM 2013 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

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

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

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-207


GEORGIA WIC PROGRAM 2013 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

2 S26

Essentials 1.5 With Fiber

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

97

4 S24 Formula 27-8 oz containers ready to feed Boost

60-8 oz containers ready

Kid Essentials 1.5 With Fiber (1 case)

to feed Boost Kid

2 S24 Formula 27-8 oz containers ready to feed Boost

Essentials 1.5 With Fiber

Kid Essentials 1.5 With Fiber (1 case)

4 S27 Formula 6-8 oz containers ready to feed Boost

Medical Documentation

Kid Essentials 1.5 With Fiber

Required

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

2 S24 Formula 27-8 oz containers ready to feed Boost

1.5 With Fiber

Kid Essentials 1.5 With Fiber (1 case)

2 S31 Formula 9-8 oz containers ready to feed Boost

Medical Documentation

Kid Essentials 1.5 With Fiber

Required

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

2 S24 Formula 27-8 oz containers ready to feed Boost

Essentials 1.5 With Fiber

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-208


GEORGIA WIC PROGRAM 2013 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 Jr (1
case) Formula 3-14.1 oz cans powder EleCare Jr

Enfaport Food Package Code Z49 30-8 oz cans ready to feed Enfaport Medical Documentation Required

Rank VC 4 N91
2 N93

Voucher Message Formula 24-8 oz cans ready to feed Enfaport (1
case) Formula 6-8 oz cans ready to feed Enfaport (one
6-pack)

Z50

2 N91 Formula 24-8 oz cans ready to feed Enfaport (1

60-8 oz cans ready to feed

case)

Enfaport

4 N91 Formula 24-8 oz cans ready to feed Enfaport (1

case)

Medical Documentation

4 N92 Formula 12-8 oz cans ready to feed Enfaport

Required

(two 6-packs)

Z51

4 N90 Formula 48-8 oz cans ready to feed Enfaport (2

90-8 oz cans ready to feed

cases)

Enfaport

2 N91 Formula 24-8 oz cans ready to feed Enfaport (1

case)

Medical Documentation

1 N92 Formula 12-8 oz cans ready to feed Enfaport

Required

(two 6-packs)

3 N93 Formula 6-8 oz cans ready to feed Enfaport (one

6-pack)

Z52

4 N90 Formula 48-8 oz cans ready to feed Enfaport (2

113-8 oz cans ready to

cases)

feed Enfaport

2 N91 Formula 24-8 oz cans ready to feed Enfaport (1

case)

Medical Documentation

1 N91 Formula 24-8 oz cans ready to feed Enfaport (1

Required

case)

3 N92 Formula 12-8 oz cans ready to feed Enfaport

(two 6-packs)

3 N96 Formula 4-8 oz cans ready to feed Enfaport

3

A64 Formula 1-8 oz can ready to feed Enfaport

FP-209


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-19 (cont'd)

Similac Expert Care Neosure

Food Package Code

Rank VC

X92

4 519

10-13.1 oz Similac Expert

Care Neosure

2 520

Medical Documentation Required X73 28-32 oz containers ready to feed Similac Expert Care NeoSure
Medical Documentation Required

1 517 2 517 3 517 4 517

4 S09

Voucher Message Formula 6-13.1 oz cans Similac Expert Care
NeoSure (1 case) Formula 4-13.1 oz cans Similac Expert Care NeoSure

Formula Formula Formula Formula Formula

6-32 oz containers ready to feed Similac Expert Care NeoSure (1 case) 6-32 oz containers ready to feed Similac Expert Care NeoSure (1 case) 6-32 oz containers ready to feed Similac Expert Care NeoSure (1 case) 6-32 oz containers ready to feed Similac Expert Care NeoSure (1 case) 4-32 oz containers ready to feed Similac Expert Care NeoSure

FP-210


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-19 (cont'd)

Nutramigen Food Package Code X81 10-12.6 oz cans powder Nutramigen with Enflora LGG
Medical Documentation Required X82 35-13 oz cans concentrate Nutramigen
Medical Documentation Required X83 28-32 oz containers ready to feed Nutramigen
Medical Documentation Required

Rank VC 2 156 4 156
2 N67 4 N57
1 S03 1 S03

Voucher Message Formula 5-12.6 oz cans powder Nutramigen
LIPIL with Enflora LGG or Nutramigen with Enflora LGG Formula 5-12.6 oz cans powder Nutramigen LIPIL with Enflora LGG or Nutramigen with Enflora LGG

Formula Formula

16-13 oz cans concentrate Nutramigen LIPIL or Nutramigen 19-13 oz cans concentrate Nutramigen LIPIL or Nutramigen

Formula Formula

14-32 oz containers ready to feed Nutramigen LIPIL or Nutramigen 14-32 oz containers ready to feed Nutramigen LIPIL or Nutramigen

Pregestimil Food Package Code X04 8-1 lb cans powder Pregestimil
Medical Documentation Required

Rank VC 2 140
4 140

Voucher Message Formula 4-1 lb cans powder Pregestimil LIPIL or
Pregestimil Formula 4-1 lb cans powder Pregestimil LIPIL or
Pregestimil

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-211


GEORGIA WIC PROGRAM 2013 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-212


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-20

Food Package III - Special Formulas for Children

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 VC Voucher Message 4 N68 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-213


GEORGIA WIC PROGRAM 2013 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

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 4-237 ml containers ready to feed EO28 Splash 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 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-214


GEORGIA WIC PROGRAM 2013 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-215


GEORGIA WIC PROGRAM 2013 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-216


GEORGIA WIC PROGRAM 2013 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-217


GEORGIA WIC PROGRAM 2013 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 VC Voucher Message 4 N97 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-218


GEORGIA WIC PROGRAM 2013 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-219


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-20 (cont'd)

PediaSure Enteral 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 VC Voucher Message 4 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-220


GEORGIA WIC PROGRAM 2013 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-221


GEORGIA WIC PROGRAM 2013 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-222


GEORGIA WIC PROGRAM 2013 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-223


GEORGIA WIC PROGRAM 2013 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-224


GEORGIA WIC PROGRAM 2013 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-225


GEORGIA WIC PROGRAM 2013 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-226


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-20 (cont'd)

Pediasure Peptide 1.0 Cal

Food Package Code

Rank

Z10

4

30-8 oz containers ready

to feed Pediasure Peptide

1.0 Cal

2

Medical Documentation

Required

Z11

4

60-8 oz containers ready

to feed Pediasure Peptide 1.0 Cal

2

Medical Documentation

4

Required

Z12

4

90-8 oz containers ready

to feed Pediasure Peptide

2

1.0 Cal

3

Medical Documentation

Required

1

Z13

4

113-8 oz containers ready

to feed Pediasure Peptide

1

1.0 Cal

2

Medical Documentation

Required

3

VC S55
S57
S55 S55 S58 S56 S55 S57 S58 S56 S55 S55 S60

Voucher Message Formula 24-8 oz containers ready to feed
Pediasure Peptide 1.0 Cal (1 case)

Formula

6-8 oz containers ready to feed Pediasure Peptide 1.0 Cal

Formula
Formula Formula Formula Formula Formula Formula Formula Formula Formula Formula

24-8 oz containers ready to feed Pediasure Peptide 1.0 Cal. (1 case)
24-8 oz containers ready to feed Pediasure Peptide 1.0 Cal (1 case) 12-8 oz containers ready to feed Pediasure Peptide 1.0 Cal
48-8 oz containers ready to feed Pediasure Peptide 1.0 Cal (2 cases) 24-8 oz containers ready to feed Pediasure Peptide 1.0 Cal (1 case) 6-8 oz containers ready to feed Pediasure Peptide 1.0 Cal 12-8 oz containers ready to feed Pediasure Peptide 1.0 Cal 48-8 oz containers ready to feed Pediasure Peptide 1.0 Cal (2 cases) 24-8 oz containers ready to feed Pediasure Peptide 1.0 Cal (1 case) 24-8 oz containers ready to feed Pediasure Peptide 1.0 Cal. (1 case) 17-8 oz containers ready to feed Pediasure Peptide 1.0 Cal

FP-227


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-20 (cont'd)

Vivonex Pediatric Food Package Code Z23 30-1.7 oz packets powder Vivonex Pediatric

Rank VC Voucher Message 4 S82 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

4

Required

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-228


GEORGIA WIC PROGRAM 2013 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
Formula Formula Formula Formula Formula Formula Formula Formula Formula Formula Formula Formula Formula Formula Formula

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) 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-229


GEORGIA WIC PROGRAM 2013 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-230


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-21 (cont'd)

Nepro Food Package Code Z41 30-8 oz cans ready to feed Nepro
Medical 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 2-8 oz cans ready to feed Nepro

Formula Formula Formula Formula Formula Formula Formula Formula Formula
Formula

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-231


GEORGIA WIC PROGRAM 2013 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 VC Voucher Message 4 N84 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-232


GEORGIA WIC PROGRAM 2013 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-233


GEORGIA WIC PROGRAM 2013 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-234


GEORGIA WIC PROGRAM 2013 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 VC Voucher Message 4 S75 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 5-8 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-235


GEORGIA WIC PROGRAM 2013 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 VC Voucher Message 4 S69 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-236


GEORGIA WIC PROGRAM 2013 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-237


GEORGIA WIC PROGRAM 2013 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 Nutrition Unit Fax copies of voucher receipt to SWO Document formula quantity and type issued in client's medical record and Formula Tracking Log

FP-238


GEORGIA WIC PROGRAM 2013 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 4-16 oz cans powder Similac Expert
Care Alimentum Formula 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

6-14.1 oz cans powder EleCare with DHA and ARA or EleCare for Infants (1 case)

Formula

4-14.1 oz cans powder EleCare with DHA and ARA or EleCare for Infants

FP-239


GEORGIA WIC PROGRAM 2013 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-240


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-23 (cont'd)

Enfamil Premature 20 Food Package Code S30 (Assign S30) 444-2 oz containers ready to feed iron fortified Enfamil Premature 20
Medical Documentation Required

Rank VC 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 20 (2 cases) Formula 96-2 oz containers ready to feed iron fortified Enfamil Premature 20 (2 cases) Formula 96-2 oz containers ready to feed iron fortified Enfamil Premature 20 (2 cases) Formula 96-2 oz containers ready to feed iron fortified Enfamil Premature 20 (2 cases) Formula 48-2 oz containers ready to feed iron fortified Enfamil Premature 20 (1 case) Formula 12-2 oz containers ready to feed iron fortified Enfamil Premature 20

Enfamil Premature 24 Food Package Code
S40 (Assign S40) 444-2 oz containers ready to feed Enfamil Premature 24
Medical Documentation Required

Rank VC 2 597 2 597 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 24 (2 cases) 96-2 oz containers ready to feed iron fortified Enfamil Premature 24 (2 cases) 96-2 oz containers ready to feed iron fortified Enfamil Premature 24 (2 cases) 96-2 oz containers ready to feed iron fortified Enfamil Premature 24 (2 cases) 48-2 oz containers ready to feed iron fortified Enfamil Premature 24 (1 case) 12-2 oz containers ready to feed iron fortified Enfamil Premature 24

FP-241


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-23 (cont'd)

Enfaport Food Package Code S12 (Assign S12)
112-8 oz cans ready to feed Enfaport
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 (2
cases) Formula 24-8 oz cans ready to feed Enfaport (1
case) Formula 24-8 oz cans ready to feed Enfaport (1
case) Formula 12-8 oz cans ready to feed Enfaport
(two 6-packs) Formula 4-8 oz cans ready to feed Enfaport

Gerber Good Start Premature 24

Food Package Code

Rank

S02 (Assign S02)

4

296 - 3 oz containers ready to feed Gerber Good 2 Start Premature 24
4

Medical Documentation

2

Required

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 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-242


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-23 (cont'd)

Similac Expert Care Neosure

Food Package Code

Rank VC

S71 (Assign S71)

4 519

11-13.1 oz Similac Expert Care Neosure

2 S25

Voucher Message

Formula Formula

6-13.1 oz cans Similac Expert Care Neosure (1 case) 5-13.1 oz cans Similac Expert Care Neosure

Medical Documentation Required S73 (Assign S73)
28-32 oz containers ready to feed Similac Expert Care NeoSure
Medical Documentation Required
S70 (Assign S70)
448-2 oz containers ready to feed Similac Expert Care NeoSure
Medical Documentation Required

4 517 Formula 6-32 oz containers ready to feed Similac Expert Care NeoSure (1 case)
4 517 Formula 6-32 oz containers ready to feed Similac Expert Care NeoSure (1 case)
2 517 Formula 6-32 oz containers ready to feed Similac Expert Care NeoSure (1 case)
2 517 Formula 6-32 oz containers ready to feed Similac Expert Care NeoSure (1 case)
4 S09 Formula 4-32 oz containers ready to feed Similac Expert Care NeoSure
2 596 Formula 96-2 oz containers ready to feed Similac Expert Care NeoSure (2 cases)
2 596 Formula 96-2 oz containers ready to feed Similac Expert Care NeoSure (2 cases)
4 596 Formula 96-2 oz containers ready to feed Similac Expert Care NeoSure (2 cases)
4 596 Formula 96-2 oz containers ready to feed Similac Expert Care NeoSure (2 cases)
4 515 Formula 48-2 oz containers ready to feed Similac Expert Care NeoSure (1 case)
2 516 Formula 16-2 oz containers ready to feed Similac Expert Care NeoSure

FP-243


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-23 (cont'd)

Nutramigen Food Package Code S82 (Assign S82)
34-13 oz cans concentrate Nutramigen

Rank VC 2 N08
4 N57

Voucher Message Formula 15-13 oz cans concentrate Nutramigen
LIPIL or Nutramigen Formula 19-13 oz cans concentrate Nutramigen
LIPIL or Nutramigen

Medical Documentation Required S81 (Assign S81) 11-12.6 oz cans powder Nutramigen with Enflora LGG
Medical Documentation Required S83 (Assign S83) 28-32 oz containers ready to feed Nutramigen
Medical Documentation Required

2 156 Formula 5-12.6 oz cans powder Nutramigen LIPIL with Enflora LGG or Nutramigen with Enflora LGG
4 155 Formula 6-12.6 oz cans powder Nutramigen LIPIL with Enflora LGG or Nutramigen with Enflora LGG
2 S03 Formula 14-32 oz containers ready to feed Nutramigen LIPIL or Nutramigen
4 S03 Formula 14-32 oz containers ready to feed Nutramigen LIPIL or Nutramigen

Nutramigen AA Food Package Code
S91 (Assign S91) 9-14.1 oz cans powder Nutramigen AA
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 4-400 gram (14.1 oz) cans powder Nutramigen AA 1-400 gram (14.1 oz) can powder Nutramigen AA

Pregestimil Food Package Code S04 (Assign S04) 8-16 oz cans powder Pregestimil
Medical Documentation Required

Rank VC 2 140
4 140

Voucher Message Formula 4-16 oz cans powder Pregestimil LIPIL
or Pregestimil Formula 4-16 oz cans powder Pregestimil LIPIL
or Pregestimil

FP-244


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-23 (cont'd)

Pregestimil 20 Calorie Food Package Code S05 (Assign S05)
444-2 oz containers ready to feed Pregestimil 20 Calorie
Medical Documentation Required

Rank 2 2 4 4 4 2

VC S61 S61 S61 S61 S63 S64

Voucher Message Formula 96-2 oz containers ready to feed
Pregestimil LIPIL 20 Calorie or Pregestimil 20 Calorie (2 cases) Formula 96-2 oz containers ready to feed Pregestimil LIPIL 20 Calorie or Pregestimil 20 Calorie (2 cases) Formula 96-2 oz containers ready to feed Pregestimil LIPIL 20 Calorie or Pregestimil 20 Calorie (2 cases) Formula 96-2 oz containers ready to feed Pregestimil LIPIL 20 Calorie or Pregestimil 20 Calorie (2 cases) Formula 48-2 oz containers ready to feed Pregestimil LIPIL 20 Calorie or Pregestimil 20 Calorie (1 case) Formula 12-2 oz containers ready to feed Pregestimil LIPIL 20 Calorie or Pregestimil 20 Calorie (two 6-packs)

Pregestimil 24 Calorie Food Package Code S06 (Assign S06) 444-2 oz containers ready to feed Pregestimil 24 Calorie
Medical Documentation Required

Rank 2 2 4 4 4 2

VC S65 S65 S65 S65 S67 S68

Voucher Message Formula 96-2 oz containers ready to feed
Pregestimil LIPIL 24 Calorie or Pregestimil 24 Calorie (2 cases) Formula 96-2 oz containers ready to feed Pregestimil LIPIL 24 Calorie or Pregestimil 24 Calorie (2 cases) Formula 96-2 oz containers ready to feed Pregestimil LIPIL 24 Calorie or Pregestimil 24 Calorie (2 cases) Formula 96-2 oz containers ready to feed Pregestimil LIPIL 24 Calorie or Pregestimil 24 Calorie (2 cases) Formula 48-2 oz containers ready to feed Pregestimil LIPIL 24 Calorie or Pregestimil 24 Calorie (1 case) Formula 12-2 oz containers ready to feed Pregestimil LIPIL 24 Calorie or Pregestimil 24 Calorie (two 6-packs)

FP-245


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-23 (cont'd)

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

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)

Rank VC 2 594

448- 2 oz containers ready to feed Similac Special Care 24 With Iron

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-246


GEORGIA WIC PROGRAM 2013 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-247


GEORGIA WIC PROGRAM 2013 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

MAXIMUM AMOUNTS3 (By Infant Age)

SIZE2

Age 0-3 Months

Age 4-5 Months

Concentrate

13 ounces

31 cans or

34 cans or

Maximum listed in reconstituted fluid ounces

403 oz concentrate or 806 oz reconstituted or 26.9 oz per day

264 oz concentrate or
884 oz reconstituted or
29.5 oz per day

Maximum Allowed

806 fl oz

884 fl oz

Concentrate

12.1 ounces 34 containers or

37 containers or

Maximum listed in reconstituted fluid ounces

411.4 oz concentrate or 447.7 oz concentrate

822.8 oz reconstituted or 895.4 oz

or 27.4 oz per day

reconstituted or

29.8 oz per day

Maximum Allowed4

822.8 fl oz

895.4 fl oz

Age 6-11 Months 24 cans or 312 oz concentrate or 624 oz reconstituted or 20.8 oz per day
624 fl oz
26 containers or 314.4 oz concentrate or 692.2 oz reconstituted or 21 oz per day
629.2 fl oz

FFF: Table for Ready-To-Feed Formula

TYPE1

Container

MAXIMUM AMOUNTS3 (By Infant Age)

SIZE2

Age 0-3 Months

Age 4-5 Months

Ready-To-Feed 32 ounces

26 cans

28 cans

Age 6-11 Months 20 cans

2 ounces

416 bottles

448 bottles

320 bottles

3 ounces

277 bottles

298 bottles

213 bottles

4 ounces

208 bottles

224 bottles

160 bottles

Maximum Allowed Ready-To-Feed
Maximum Allowed4

8 ounces 33.8 ounces

104 cans 832 fl oz
25 4-packs 845 fl ounces

112 cans 896 fl oz
27 4-packs 912.6 fl ounces

80 cans 640 fl oz
19 4-packs 642.2 fl ounces

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 4 USDA has allowed an exception for these package sizes in order to provide the full nutrition
benefit

FP-248


GEORGIA WIC PROGRAM 2013 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

Age

4

fluid ounces

0-2 months

Age 3 months

Age 4-5 months

Age

Age

6 months 7-11 months

per container

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 Allowed

870 fl oz

870 fl oz

960 fl oz

696 fl oz

696 fl oz

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 Age 4-5 Months (141 oz Age 6-11 Months (102

oz maximum by can

maximum by can weight) oz maximum by can

weight)

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.

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 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 Nutrition Unit 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-249


GEORGIA WIC PROGRAM 2013 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
Maximum listed in reconstituted fluid ounces

13 ounces

4 cans or

14 cans or

52 oz concentrate 182 oz

or 104 oz

concentrate or

reconstituted or 364 oz

3.5 oz per day

reconstituted

12 oz per day

17 cans or

12 cans or

221 oz concentrate 156 oz

or 442 oz

concentrate or

reconstituted or 312 oz

14.5 oz per day reconstituted or

10.4 oz per day

12.1 ounces

4 containers or 48.8 oz concentrate or 96.8 oz reconstituted or 3.2 oz per day

15 containers or 181.5 oz concentrate or 363 oz reconstituted or 12.1 oz per day

18 containers or 217.8 oz concentrate or 435.6 oz reconstituted or
14.5 oz per day

13 containers or 157.3 oz concentrate or 314.6 oz reconstituted or
10.5 oz per day

Max. Allowed

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 33.8 ounces 3 4-packs

12 cans 12 4-packs

14 cans 14 4-packs

10 cans 10 4-packs

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. Allowed

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-250


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-25 (cont'd)

MBF: Table for Powder Formulas with Standard Mixing Instructions

TYPE1

Container MAXIMUM AMOUNTS3 (By Infant Age in # of Cans of Powder)

SIZE2

Powdered4 Reconstituted Age 0-1

Age 1-2

Age 3

Age 4-5

Age 6-11

fluid ounces

Month

Months

Months

Months

Months

per container

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 Allowed

104 fl oz

435 fl oz

435 fl oz

522 fl oz

384 fl oz

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 1-3 Months

4-5 months

6-11 months

Maximum 12 ounces 5 cans (60 oz)

based on can weight

12.8 ounces

5 cans- (64 oz)

12.9 ounces 4 cans- (51.6 oz)

6 cans 5 cans 5 cans

4 cans 4 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

Max

Weight of 64 oz

Allowed dry powder

77 oz

56 oz

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.

1 For each type listed, the most economical size is recommended 2 Sizes listed are not inclusive 3 Maximum amounts are listed for each type 4 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 Nutrition Unit 5 Use this table only for powdered products that do not have standard instructions for
reconstitution, such as metabolic formulas

FP-251


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-26

FORMULA TYPES, SIZES, AND MAXIMUM AMOUNTS - INFANT FOODS MAXIMUM MONTHLY AMOUNTS

(For Infants 6 through 11 Months) INFANT FOOD

Total Allowed

Infant Cereal

24 ounces

Infant Fruit and Vegetable 128 ounces

Infant Meats

77.5 ounces

MAXIMUM AMOUNTS

SIZE

FFF/MBF

8 ounces

3 boxes

4 ounces

32 jars

7 ounces

18 twin packs

2.5 ounces

N/A

EBF 3 boxes 64 jars 36 twin packs 31 jars

FP-252


GEORGIA WIC PROGRAM 2013 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

(months)

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

3-RTF

359

1 can

Care Alimentum

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

3 boxes

EnfaCare

0-1

1-powder

591

1 can

1-2

5-12.8 powder

5 cans

S11

3

5-12.8 powder

S11

5 cans

4-5

6-12.8 powder

541

6 cans

6-11

4-powder

542

4 can

N01

16 jars

baby foods

N26

16 jars

cereal

3 boxes

EnfaCare

0-1

3-RTF

544

1 can

544

1 can

544

1 can

1-3

12-RTF

543

6 cans

543

6 cans

FP-253


GEORGIA WIC PROGRAM 2013 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

(months)

4-5

14-RTF

543

6 cans

543

6 cans

S13

2 cans

6-11

10-RTF

543

6 cans

S12

4 cans

baby foods

N01

cereal

N26

16 jars 16 jars

3 boxes

EnfaCare

0-1

48-2 oz

539

1 case

1-3

192-2 oz

589

2 cases

589

2 cases

4-5

222-2 oz

589

2 cases

589

2 cases

540

18 bottles

S20

12 bottles

6-11

156-2 oz

589

2 cases

539

1 case

baby foods cereal

S20

12 bottles

N01

16 jars

N26

16 jars

3 boxes

Enfamil

0-1

48-2 oz

545

1 case

Premature 20

1-3

192-2 oz

595

2 cases

595

2 cases

4-5

222-2 oz

595

2 cases

595

2 cases

546

18 bottles

S21

12 bottles

6-11

156-2 oz

595

2 cases

545

1 case

baby foods cereal

S21

12 bottles

N01

16 jars

N26

16 jars

3 boxes

Enfamil

0-1

48-2 oz

547

1 case

Premature 24

1-3

192-2 oz

597

2 cases

597

2 cases

4-5

222-2 oz

597

2 cases

597

2 cases

548

18 bottles

S22

12 bottles

6-11

156-2 oz

597

2 cases

547

1 case

baby foods

S22

12 bottles

N01

16 jars

FP-254


GEORGIA WIC PROGRAM 2013 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

(months)

cereal

N26

16 jars

3 boxes

Gerber Good

0-3

5-powder

L06

5 cans

Start Nourish

4-5

6-powder

L07

6 cans

6-11

4-powder

L08

4 cans

N01

16 jars

baby foods

N26

16 jars

cereal

3 boxes

Neocate Infant

0-1

1-powder

505

1 can

DHA & ARA

1-3

5-powder

505

1 can

500

4 cans

4-5

6-powder

505

1 can

505

1 can

500

4 cans

6-11

4-powder

500

4 cans

baby foods

N01

16 jars

cereal

N26

16 jars

3 boxes

Nutramigen

0-1

4-conc

159

1 can

159

1 can

159

1 can

159

1 can

1-3

14- conc

159

1 can

159

1 can

163

12 cans

4-5

17- conc

N67

16 cans

159

1 can

6-11

12- conc

163

12 cans

N01

16 jars

N26

16 jars

3 boxes

Nutramigen

0-1

3-RTF

A67

1 can

A67

1 can

A67

1 can

1-3

12-RTF

S29

10 cans

A67

1 can

A67

1 can

4-5

14-RTF

S03

14 cans

6-11

10-RTF

S29

10 cans

N01

16 jars

N26

16 jars

3 boxes

Nutramigen with

0-1

1-powder

157

1 can

Enflora LGG

1-3

5-powder

156

5 cans

4-5

6-powder

155

6 cans

FP-255


GEORGIA WIC PROGRAM 2013 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

(months)

6-11

4-powder

S32

3 cans

157

1 can

baby foods

N01

16 jars

cereal

N26

16 jars

3 boxes

Nutramigen AA

0-1 1-3 4-5
6-11

Pregestimil

0-1 1-2 3 4-5 6-11

Similac Expert Care Neosure

0-1
1-3 4-5 6-11

Similac Expert Care Neosure

0-1 1-3 4-5
6-11

Similac Expert

0-1

Care Neosure

1-3

4-5

1-powder 4-powder 5-powder
3-powder baby foods
cereal
1-powder 3-powder 4-powder 4-powder 3-powder
1-powder 5-powder 6-powder 4-powder
baby foods cereal 3-RTF
12-RTF
14-RTF
10 RTF
baby foods cereal
48-2 oz 192-2 oz
224-2 oz

707

1 can

706

4cans

707

1 can

706

4cans

S14

3 cans

N01

16 jars

N26

16 jars

3 boxes

141

1 can

S08

3 cans

140

4 cans

140

4 cans

S08

3 cans

N01

16 jars

N26

16 jars

3 boxes

482

1 can

S25

5 cans

519

6 cans

520

4 cans

N01

16 jars

N26

16 jars

3 boxes

S10

2 cans

518

1 can

517

6 cans

517

6 cans

517

6 cans

517

6 cans

S10

2 cans

517

6 cans

S09

4 cans

N01

16 jars

N26

16 jars

3 boxes

515

48 bottles

596

2 cases

596

2 cases

596

2 cases

FP-256


GEORGIA WIC PROGRAM 2013 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

(months)

596

2 cases

516

16 bottles

516

16 bottles

6-11

1602 oz

596

2 cases

515

1 case

516

16 bottles

N01

16 jars

N26

16 jars

3 boxes

Similac PM 60/40

0-1

1-powder

483

1 can

1-3

4-powder

529

4 cans

4-5

5-powder

483

1 can

529

4 cans

6-11

3-powder

528

3 cans

Similac Special

0-1

Care 20

1-3

4-5

6-11

baby foods cereal 48-2 oz
192-2 oz 224-2 oz
160-2 oz
baby foods cereal

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

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

6-11

48-2 oz 192-2 oz 224-2 oz
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-257


GEORGIA WIC PROGRAM 2013 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 bottles 16 jars
16 jars 3 boxes

FP-258


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-28

SUPPLEMENTAL FORMULA CONVERSION TABLE - MODULARS Displacement Method

Monthly RX

Amount of Formula Replaced

Concentrate

Powder-

Powder-

Ready-to-Feed -

12 - 13 oz

12 - 16 oz

22 - 24 oz

Duocal (14.1 oz powder) 1 can contains 42 TBSP/1968 Calories

32 - 34 oz

1 can

4

1

1

4

2 cans

8

2

1

7

3 cans

12

3

2

10

4 cans

16

4

2

13

Polycose (12.3 oz powder) 1 can contains 59 TBSP/1330 Calories

1 can

4

1

1

4

2 cans

8

2

1

7

3 cans

12

3

2

10

4 cans

16

4

2

13

BeneCalorie (1.5 oz cup) 1 packet contains 330 calories and 7 grams of protein

1-2 packet(s)

1

1

1

1

3 packets

2

1

1

2

4-5 packets

3

1

1

3

6 packets

4

2

1

3

7-8 packets

5

2

1

4

9 packets

6

2

1

5

10-11 packets

7

2

1

6

12 packets

8

2

2

6

13-14 packets

9

2

2

7

15 packets

10

3

2

8

16-17 packets

11

3

2

9

18 packets

12

3

2

10

19-20 packets

13

3

2

10

21 packets

13

4

2

11

22-23 packets

14

4

2

12

24 packets

15

4

2

12

25-26 packets

16

4

3

13

27 packets

17

4

3

14

28-29 packets

18

5

3

15

30 packets

19

5

3

15

FP-259


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-28 (cont'd)

Monthly RX

Amount of Formula Replaced

Concentrate

Powder-

Powder-

Ready-to-Feed -

12 - 13 oz

12 - 16 oz

22 - 24 oz

32 - 34 oz

BeneProtein (7 gr packet) 1 packet contains 25 calories and 6 grams of protein

1-30 packets

1

1

1

1

31- 50 packets

2

1

1

2

51-60 packets

3

1

1

2

61-70 packets

3

1

1

3

71-80 packets

4

1

1

3

81-90 packets

4

2

1

4

91-100 packets

5

2

1

4

101-110 packets

5

2

2

4

111-120 packets

6

3

2

5

BeneProtein (8 oz can) 1 can contains 810 calories and 194 grams of protein

1 can

2

1

1

1

2 cans

3

1

1

3

3 cans

5

2

1

4

4 cans

6

2

1

5

MCT Oil (32 fl oz bottle) 1 bottle contains 960 cc/64 TBSP/7392 Calories

1 bottle 2 bottles

3

1

1

3

6

2

1

3

FP-260


GEORGIA WIC PROGRAM 2013 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

Concentrate-

455 fluid ounces

RTF-

910 fluid ounces

Powder-

910 fluid ounces reconstituted or 144 oz (if no standard dilution)

TYPE Concentrate
Ready-To-Feed

CAN SIZE 13 ounces
12.1 ounces
32 ounces 33.8 ounces

Children & Women Maximum Amounts
35 cans or 455 ounces maximum concentrate or 910 fluid ounces reconstituted 37 cans or 477.7 ounces concentrate or 895.4 fluid ounces reconstituted 28 cans or 910 fluid ounces 26 4-packs or 878.8 fluid ounces

Table for Powder Formulas With Standard Mixing Instructions

Powdered4

Reconstituted fluid ounces per

Maximum Number of Cans Allowed

container

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

Maximum Number of Cans Allowed Per Month

weight

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-261


GEORGIA WIC PROGRAM 2013 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
Beans/Peas OR Peanut Butter Fruits and Vegetables

36 ounces (Maximum of 32 oz infant cereal)
1 pound bag dried or 4 cans (14-16 ounces) OR 1 container (16-18 oz)
$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-39 for more information on milk substitutions

FP-262


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-31

MAXIMUM MONTHLY AMOUNTS OF WIC FOODS AUTHORIZED FOR WOMEN

FOOD

PREGNANT (Singleton), MOSTLY
BREASTFEEDING

EXCLUSIVELY BREASTFEEDING11,
PREGNANT WITH MULTIPLE

NONBREASTFEEDING,
SOME BREASTFEEDING

FETUSES, MOSTLY
BREASTFEEDING MULTIPLES7

Milk2 Cheese Tofu8

Food Package V 22 quart equivalents 3 6 pounds 4,5
12 pounds

Food Package VII 24 quart equivalents3 6 pounds4,5,6
12 pounds

Food Package VI 16 quart equivalents3 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

FLUID MILK EQUIVALENTS 3 quarts4,5

Evaporated milk, non-fat (12 oz) Nonfat or low-fat dry milk

4 cans equal 3 quarts9 1-3 quart container equal to 3 quarts10

Tofu, 1 pound

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. 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.

FP-263


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-31 (cont'd)

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 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-264


GEORGIA WIC PROGRAM 2013 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 25-33.8 oz containers (4-pack)

MAXIMUM AMOUNT 832 fluid ounces

This food package consists of two vouchers per month.

FOR FULLY FORMULA FED INFANTS (4-5 MONTHS) Contract Standard Formulas

TYPE

SIZE

MAXIMUM AMOUNT

Ready-To-Feed

27-33.8 oz containers (4-pack) 896 fluid ounces

This food package consists of two vouchers per month.

FOR FULLY FORMULA FED INFANTS (6-11 MONTHS) Contract Standard Formulas

TYPE Ready-To-Feed Cereal, Infant

SIZE

MAXIMUM AMOUNT

19-33.8 oz containers (4-pack) 640 fluid ounces

3-8 oz boxes, dry

24 ounces

Infant fruit and vegetables

32-4 oz jars

128 ounces

This food package consists of four vouchers per month.

FP-265


GEORGIA WIC PROGRAM 2013 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 27-33.8 oz containers (4-pack)

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-266


GEORGIA WIC PROGRAM 2013 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-267


GEORGIA WIC PROGRAM 2013 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 1: Mostly to Some for Standard Food Packages (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

Sample 2: Exclusively to Mostly Breastfeeding (W41 to W01)

(Mom returns voucher codes 039, W03) Milk Dry milk Juice Cheese Eggs Cereal

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

Beans/PB
1 and 1
1 and 1 1 beans 1 PB

Whole Grain 16 oz
16 16 0

F/veg $10 $10 $10

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-fat (fat-free,

Milk: 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:
Eggs:

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 1 dozen

Cereal: No more than 36 oz

FP-268


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-33 (cont'd)

The following tables can be used for converting the most common brestfeeding food package changes Mostly BF (W01) to Some or Non BF (W21) and Exclusively BF (W41) to Mostly BF (W01).

Table 1: How to Convert Breastfeeding Packages Mostly BF (W01) to Some or Non BF (W21)

1. Determine which vouchers the mom has remaining from the W01 package. 2. Find the codes for the voucher not spent in the first column of the table below to determine
if the change can be made in the middle of her pick-up. 3. If "yes", follow the instructions on how to make the change for the mom. The infant should
be issued the remainder of formula allowed for a fully formula-fed infant; remember to subtract the amount of formula already issued for the month. For the following pick-up, issue regular FP to mom (W21). 4. If "no", the change cannot be made in the middle of the pick-up month. You can only exchange her next full set of vouchers for the new package (W21).

Vouchers left (Have not been spent) 5 VOUCHERS LEFT P02, 041, W01, W02, 040 4 VOUCHERS LEFT 041, W01, W02, 040
P02, W01, W02, 040
P02, 041, W01, W02
P02, 041, W02, 040
P02, 041, W01, 040 3 VOUCHERS LEFT P02, W02, 040
P02, 041, W02

Can you change mid-
month?

How to make change:

Yes

Void all 5 vouchers. Issue W21.

Yes

Void all 4 vouchers.

Re-issue using FP 999 sub 99 voucher codes W41,

W04, W05, W06.

Yes

Void vouchers W02, 040, W01.

Give voucher P02 to client.

Re-issue using FP 999 sub 99 voucher codes W04,

W06, 772.

Yes

Void vouchers W02, 041, W01.

Give voucher P02 to client.

Re-issue using FP 999 sub 99 voucher codes W04,

W05, W06, 778.

Yes

Void vouchers 041, W02, 040.

Give voucher P02 to client.

Re-issue using FP 999 sub 99 voucher codes W05,

A34, 273.

No

Must wait until the next issuance to issue W21.

Yes

Void vouchers W02, 040.

Give voucher P02 to client.

Re-issue using FP 999 sub 99 voucher code A34.

Yes

Void vouchers W02, 041.

Give voucher P02 to client.

Re-issue using FP 999 sub 99 voucher codes W71,

A34.

FP-269


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-33 (cont'd)

041, W01, W02

Yes

Void vouchers 041, W01, W02.

Re-issue using FP 999 sub 99 voucher codes W04,

W05, W06, 778.

W01, W02, 040

Yes

Void vouchers W01, W02, 040.

Re-issue using FP 999 sub 999 voucher codes W04,

W06, 772.

W02, 040, 041

Yes

Void vouchers W02, 040, 041.

Re-issue using 999 sub 99 voucher codes W05, A34,

273.

P02, 041, W01

No

Must wait until the following pick-up to issue W21.

P02, W01, W02

No

Must wait until the following pick-up to issue W21.

P02, 040, 041

No

Must wait until the following pick-up to issue W21.

P02, W01, 040

No

Must wait until the following pick-up to issue W21.

041, W01, 040

No

Must wait until the following pick-up to issue W21.

2 VOUCHERS LEFT

W02, 041

Yes

Void vouchers W02, 041.

Re-issue using FP 999 sub 99 voucher codes W71,

A34.

W02, 040

Yes

Void vouchers W02, 040.

Re-issue using FP 999 sub 99 voucher code A34.

P02, 041

No

Must wait until the following pick-up to issue W21.

P02, W01

No

Must wait until the following pick-up to issue W21.

P02, W02

No

Must wait until the following pick-up to issue W21.

P02, 040

No

Must wait until the following pick-up to issue W21.

041, W01

No

Must wait until the following pick-up to issue W21.

041, 040

No

Must wait until the following pick-up to issue W21.

W01, W02

No

Must wait until the following pick-up to issue W21.

W01, 040

No

Must wait until the following pick-up to issue W21.

1 VOUCHER LEFT

No change can be made for any single voucher left.

Table 2: How to Convert Breastfeeding Packages Exclusively BF (W41) to Mostly BF (W01)
1. Determine which vouchers the mom has left from the W41 package. 2. Find the codes for the voucher not spent in the first column of the table below to determine
if the change can be made in the middle of her pick-up. 3. If "yes", follow the instructions on how to make the change for the mom. The infant should
be issued the remainder of formula allowed for a fully formula fed-infant; remember to subtract the amount of formula already issued for the month. For the following pick-up, issue regular FP to mom (W01). 4. If "no", the change cannot be made in the middle of the pick-up month. You can only exchange her next full set of vouchers for the new package (W01).

FP-270


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-33 (cont'd)

Vouchers left (Have not been spent) 5 VOUCHERS LEFT P02, W82, 039, W02, W03 4 VOUCHERS LEFT W82, 039, W02, W03
P02, 039, W02, W03
P02, W82, W02, W03
P02, W82, 039, W03
P02, W82, 039, W02 3 VOUCHERS LEFT 039, W02, W03
W82, W02, W03
W82, 039, W03
P02, 039, W03
P02, W82, W03
W82, 039, W02 P02, W02, W03 P02, 039, W02 P02, W82, W02 P02, W82, 039 2 VOUCHERS LEFT W82, W03
039, W03

Can you change mid-
month?

How to make change:

Yes

Void all 5 vouchers. Issue W01.

Yes

Void vouchers 039, W03.

Give vouchers W82 & W02 to client.

Re-issue using FP 999 sub 99 voucher codes W01,

778.

Yes

Void vouchers 039, W03.

Give voucher P02 & W02 to client.

Re-issue using FP 999 sub 99 voucher codes A35, 040.

Yes

Void vouchers W82, W03.

Give voucher P02 & W02 to client.

Re-issue using FP 999 sub 99 voucher codes 040, 040,

A35, 780.

Yes

Void vouchers 039, W03.

Give voucher P02 & W82 to client.

Re-issue using FP 999 sub 99 voucher codes 040, A35.

No

Must wait until the following pick-up to issue W01.

Yes

Void vouchers 039, W03.

Give voucher W02 to client.

Re-issue using FP 999 sub 99 voucher code A35, 040.

Yes

Void vouchers W82, W03.

Give voucher W02 to client.

Re-issue using FP 999 sub 99 voucher codes 040, 040,

A35, 780.

Yes

Void vouchers 039, W03.

Give voucher W82 to client.

Re-issue using FP 999 sub 99 voucher codes 040, A35.

Yes

Void vouchers 039, W03.

Give voucher P02 to client.

Re-issue using FP 999 sub 99 voucher codes A35, 040.

Yes

Void vouchers W82, W03.

Give voucher P02 to client.

Re-issue using FP 999 sub 99 voucher codes 040, 040,

780, A35.

No

Must wait until the following pick-up to issue W21.

No

Must wait until the following pick-up to issue W21.

No

Must wait until the following pick-up to issue W21.

No

Must wait until the following pick-up to issue W21.

No

Must wait until the following pick-up to issue W21.

Yes

Void vouchers W82, W03.

Re-issue using FP 999 sub 99 voucher codes A35, 040,

040, 780.

Yes

Void vouchers 039, W03.

Re-issue using FP 999 sub 99 voucher code A35, 040.

FP-271


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-33 (cont'd)

P02, W82

No

Must wait until the following pick-up to issue W21.

P02, 039

No

Must wait until the following pick-up to issue W21.

P02, W02

No

Must wait until the following pick-up to issue W21.

P02, W03

No

Must wait until the following pick-up to issue W21.

W82, 039

No

Must wait until the following pick-up to issue W21.

W82, W02

No

Must wait until the following pick-up to issue W21.

039, W02

No

Must wait until the following pick-up to issue W21.

W02, W03

No

Must wait until the following pick-up to issue W21.

1 VOUCHER LEFT

No change can be made for any single voucher left.

FP-272


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-34

Infant Formulas with Sequencing Exceptions

Similac Special Care Alimentum, Pregestimil

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

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-273


GEORGIA WIC PROGRAM 2013 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 Soothe

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 Manufacturer

A-Soy

PBM Products

Acerflex

Nutricia

Add-Ins

Nutricia

Advera

Abbott Nutrition

AlitraQ

Abbott Nutrition

Benecalorie

Nestl Nutrition

Beneprotein

Nestl Nutrition

Boost

Nestl Nutrition

Boost Glucose Control

Nestl Nutrition

Boost High Nestl

Protein

Nutrition

Boost Kid Nestl

Essentials Nutrition

Boost Kid Essentials 1.5

Nestl Nutrition

Boost Kid Essentials 1.5 w / fiber

Nestl Nutrition

Boost Plus

Nestl Nutrition

Boost

Nestl

Pudding Nutrition

Bright Beginning Soy

PBM Products

Calcilo XD

Abbott Nutrition

Formula Carnation Instant Breakfast Essentials Carnation Breakfast Essentials, No Sugar Added Carnation Breakfast Lactose Free Carnation Breakfast Lactose Free Plus Carnation Breakfast Lactose Free VHC
Compleat
Compleat Pediatric Complex MSUD Amino Acid Bars
Crucial
Cyclinex 1
Cyclinex 2
Duocal

Manufacturer
Nestl Nutrition
Nestl Nutrition
Nestl Nutrition
Nestl Nutrition
Nestl Nutrition
Nestl Nutrition Nestl Nutrition Applied Nutrition Corporation Nestl Nutrition Abbott Nutrition Abbott Nutrition Nutricia

Formula Manufacturer

EO28 Splash

Nutricia

EleCare Jr

Abbott Nutrition

EleCare (for Abbott

Infants)

Nutrition

Enfamil

Mead

A.R.

Johnson

Enfamil

Mead

EnfaCare Johnson

Enfamil

Human Milk Fortifier Acidified

Mead Johnson

Liquid

Enfamil Premature 20 with iron

Mead Johnson

Enfamil Premature 20 with iron

Mead Johnson

Enfamil Premature 24 with iron

Mead Johnson

Enfaport

Mead Johnson

Enlive

Abbott Nutrition

Ensure

Abbott Nutrition

Ensure High Protein

Abbott Nutrition

Ensure Plus

Abbott Nutrition

FP-274


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-35

Formula Ensure Pudding Fiber Source HN Gerber Good Start Nourish Gerber Good Start Premature 24
Glucerna
Glutarex-1
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 Lophlex LQ

Manufacturer Abbott Nutrition Nestl Nutrition
Nestl Nutrition
Nestl Nutrition
Abbott Nutrition Abbott Nutrition Abbott Nutrition Abbott Nutrition Abbott Nutrition Abbott Nutrition Nestl Nutrition Nestl Nutrition Abbott Nutrition Abbott Nutrition Abbott Nutrition Nutricia Nutricia Abbott Nutrition Abbott Nutrition Solace Nutrition Hormel Health Labs Hormel Health Labs Hormel Health Labs Vitaflow Nutricia

Formula
Lo*Pro
MCT Oil
Methionaid
Microlipid
Monogen MSUD Analog MSUD Maxamaid MSUD Maxamum MSUD-1 MSUD-2 Neocate Infant DHA & ARA Neocate Junior Neocate Junior with Prebiotics Neocate Nutra Nepro with Carb Steady
Nitro-Pro
NovaSourc e Renal Nutramigen AA
Nutramigen
Nutramigen with Enflora LGG
Nutren 1.0
Nutren 1.0 with Fiber
Nutren 1.5
Nutren 2.0

Manufacturer Med-Diet Labs Nestl Nutrition Nutricia Nestl Nutrition Nutricia
Nutricia
Nutricia
Nutricia
Nutricia Nutricia
Nutricia
Nutricia
Nutricia
Nutricia
Abbott Nutrition
Hormel Health Labs
Nestl Nutrition
Mead Johnson Mead Johnson
Mead Johnson
Nestl Nutrition Nestl Nutrition Nestl Nutrition Nestl Nutrition

FP-275


Formula Nutren Glytrol Nutren Junior Nutren Junior Fiber Nutren Pulmonary Nutren Replete with Fiber
NutriHep
Osmolite
Osmolite HN Plus 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 1.0 Cal PediaSure Peptide 1.0 Cal (fiber)

Manufacturer Nestl Nutrition Nestl Nutrition Nestl Nutrition Nestl Nutrition
Nestl Nutrition
Nestl Nutrition Abbott Nutrition
Abbott Nutrition
PBM Products
PBM Products
Abbott Nutrition Abbott Nutrition Abbott Nutrition
Abbott Nutrition
Abbott Nutrition
Abbott Nutrition
Nutricia
Ross
Abbott Nutrition

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-35

Formula PediaSure Peptide 1.5 Cal PediaSure Peptide 1.5 Cal with Fiber
Peptamen
Peptamen 1.5 Peptamen AF Peptamen Junior Peptamen Junior Fiber Peptamen Junior 1.5 Peptamen Junior with Prebio Peptamen OS Peptamen OS 1.5
Perative
Periflex Advance Periflex Infant Periflex Junior
Phenex-1
Phenex-2
PhenylAde 40Drink Mix
PhenylAde 60Drink Mix
PhenylAde Amino Acid Bars

Manufacturer
Abbott Nutrition
Abbott Nutrition
Nestl Nutrition Nestl Nutrition Nestl Nutrition Nestl Nutrition Nestl Nutrition Nestl Nutrition
Nestl Nutrition
Nestl Nutrition Nestl Nutrition Abbott Nutrition
Nutricia
Nutricia North America
Nutricia
Abbott Nutrition Abbott Nutrition Applied Nutrition Corporation Applied Nutrition Corporation Applied Nutrition Corporation

Formula 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
PKU-Gel
Polycal
Polycose
Portagen
Pregestimil
Pregestimil 24
ProBalance
Product 3200AB Product 3232 A Product 80056
ProMod
Promote
Promote with Fiber

Manufacturer Applied Nutrition Corporation Applied Nutrition Corporation Applied Nutrition Corporation Applied Nutrition Corporation Mead Johnson Mead Johnson
Nutricia
Nutricia
Nutricia
Vitaflo Limited Vitaflo Limited Nutricia Abbott Nutrition Mead Johnson Mead Johnson Mead Johnson Nestl Nutrition Mead Johnson Mead Johnson Mead Johnson Abbott Nutrition Abbott Nutrition Abbott Nutrition

FP-276


Formula
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 Breeze RCF
(No Added Carbohydrate Soy Infant Formula Base With Iron)
Scandical Calorie Booster Scandishak e Scandishak e Lactose Free Scandishak e Sugar Free Similac Expert Care Alimentum Similac Expert Care for Diarrhea

Manufacturer Hormel Health Labs Hormel Health Labs Hormel Health Labs Abbott Nutrition Abbott Nutrition Abbott Nutrition Nutricia North America Abbott Nutrition Abbott Nutrition Nutra/ Balance Nestl Nutrition Nestl Nutrition Nestl Nutrition
Abbott Nutrition
Aptalis
Aptalis
Aptalis
Aptalis
Abbott Nutrition
Abbott Nutrition

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Formula Similac Expert Care NeoSure Similac Human Milk Fortifier Similac PM 60/40 Similac for Spit Up
Similac Special Care with Iron 20
Similac Special Care with Iron 24
Suplena with Carb Steady
Tolerex
TwoCal HN
Tyrex-1
Tyrex-2
UCD Anamix Junior UCD-2 Vital High Nitrogen Vivonex Pediatric Vivonex Plus Vivonex T.E.N. XLeu Analog XLeu Maxamaid XLeu Maxamum

Manufacturer
Abbott Nutrition
Abbott Nutrition
Abbott Nutrition Abbott Nutrition
Abbott Nutrition
Abbott Nutrition
Abbott Nutrition
Nestl Nutrition Abbott Nutrition Abbott Nutrition Abbott Nutrition
Nutricia
Nutricia Abbott Nutrition Nestl Nutrition Nestl Nutrition Nestl Nutrition Nestl Nutrition
Nutricia
Nutricia

Formula Manufacturer

XLYS, XTrp Analog

Nutricia

XLys, XTrp Maxamaid

Nutricia

XLys, XTrp Maxamum

Nutricia

XMet Analog

Nutricia

XMet Maxamaid

Nutricia

XMet Maxamum

Nutricia

XMTVI Analog

Nutricia

XMTVI Maxamaid

Nutricia

XMTVI Maxamum

Nutricia

XPhe , XTyr Maxamaid

Nutricia

XPhe Maxamaid

Nutricia

XPhe Maxamum

Nutricia

XPhe

Maxamum Nutricia

Drink

XPHE, XTyr Analog

Nutricia

XPTM Analog

Nutricia

FP-277


Attachment FP-35

GEORGIA WIC PROGRAM 2013 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 Unit to determine whether the product is authorized for distribution through Georgia WIC.
c. Special formulas may be acquired through the Nutrition Unit. See Georgia WIC Procedures Manual, Food Package Section for appropriate procedure and forms.

FP-278


GEORGIA WIC PROGRAM 2013 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-279


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-37

SPECIAL FORMULA ORDER FORM

I. TO BE COMPLETED BY DISTRICT/LOCAL STAFF

Date Faxed:

Rush Delivery: YES NO

Nutrition Unit called or emailed and notified of incoming fax.

Written medical documentation with medical diagnosis attached.

Returned packing slip to the Nutrition 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 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 UNIT, PHONE: (404) 657-2884
FP-280


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-38

Clients Name: _________________

Special Formula Order Tracking Form Sample

Date of Next Rx P/U Last Rx 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

Amt. of Formula Leftover

9/1/2008 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

3 cans 2 cans 1 can
0 3 cans

FP-281


GEORGIA WIC PROGRAM 2013 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-282


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-39 (cont'd)

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-283


GEORGIA WIC PROGRAM 2013 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., Enfamil EnfaCare) 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 or EleCare for Infants)
3. The Medical Documentation Form for WIC Special Formulas and Approved WIC Foods (Form #1) should not 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 clarification 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 one (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 prescription of formulas and medical foods, but its use is strongly encouraged to reduce the likelihood of missing information when other forms are used.
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GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-40 (cont'd)

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 DHA and ARA" 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 issued based on standard reconstitution directions.
c) The prescribing health care provider should identify the form of
FP-285


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-40 (cont'd)

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.
6. Page 2: The back of the form contains information for completing the form, definitions, examples, and the non-discrimination statement.

FP-286


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-40 (cont'd)

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 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
FP-287


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-40 (cont'd)

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 for Spit Up, Enfamil A.R, and any store brand milk-based 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 for Spit Up, Enfamil A.R., and 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 when requested by physican on the medical documentation form.
b) If milk is allowed, children ages 12-23 months old cannot be issued low-fat milk for any reason, even with medical documentation.
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
FP-288


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-40 (cont'd)

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 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-289


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-41

Page 1 of Medical Documentation Form (Form 1)

FP-290


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-41(cont'd)

Page 2 of Medical Documentation Form (Form #1)

FP-291


GEORGIA WIC PROGRAM 2013 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) should not 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-292


GEORGIA WIC PROGRAM 2013 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 some instances, only part of the milk allowance will be replaced with
FP-293


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-42 (cont'd)

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-39 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: a. More than one (1) pound of cheese per month for women who are pregnant with only one fetus and for postpartum
FP-294


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-42 (cont'd)

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-39 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. 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
FP-295


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-42 (cont'd)

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-39 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-296


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Page 1 of Referral Form (Form #2)

Attachment FP-43

FP-297


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-43 (cont'd)

Page 2 of Referral Form (Form #2)

FP-298


GEORGIA WIC PROGRAM 2013 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 Nutrition Unit*

*Address: Nutrition Unit, 2 Peachtree Street NW, Suite 11-222, Atlanta, GA 30303-3142

B. A review of potentially new food items shall be conducted biennially. Consequently, the WIC-Approved Food List shall be printed biennially. Biennial review of the WIC Food List does not necessarily constitute a change in the food list. Changes to the WICApproved Food List shall occur more frequently to accommodate Federal mandates and as deemed necessary by the state.

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 submission. Exceptions will be made if the state determines the new item significantly improves participant choices.

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. Soy beverage

6. Cheese 7. Juice 8. Dried or canned 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-299


GEORGIA WIC PROGRAM 2013 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- 45 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-300


GEORGIA WIC PROGRAM 2013 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, sliced, string cheese only. No shredded cheese. 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. 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. 2. 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 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. 6. 96 ounce container only for reduced lactose milk.

Milk - (Meyenberg Goat Milk) Twelve ounce cans evaporated or quart

G. Tuna 5 ounce can only

FP-301


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-44 (cont'd)

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

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-302


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-45

FP-303


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-45 (cont'd)

FP-304


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-45 (cont'd)

FP-305


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-45 (cont'd)

FP-306


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-45 (cont'd)

FP-307


GEORGIA WIC PROGRAM 2013 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-308


Signature & Title of CPA

GEORGIA WIC PROGRAM 2013 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.
Calcuim fortified juice should 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-309


GEORGIA WIC PROGRAM 2013 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-310


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-48 (cont'd)

786

Milk: 1 gallon OR 2 half gallons low-fat (fat-

W5, W6, W7, C2

free, 1%, 2%) Lactose free, Acidophilus,

or Acidophilus and Bifidum. No whole

milk Least expensive brand

785

Milk: 1 half gallon low-fat (fat-free, 1%, 2%)

W5, W6, W7, C2

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:

A06

Milk: 1 gallon OR 4 quarts OR 2 half gallons

C1, C2, W5, W6, W7

whole lactose free, OR Acidophilus, OR

Acidophilus and Bifidum No low-fat milk.

Least expensive brand

A29

Milk: 1-3 quart (96 oz) container low-fat (fat-

C1, C2, W5, W6, W7

free, 1%, 2%) Lactose free, OR

Acidophilus, OR Acidophilus and Bifidum

No whole milk. Least expensive brand

A31

Milk: 1-3 quart (96 oz) container whole lactose C1, C2, W5, W6, W7

free, OR Acidophilus, OR Acidophilus

and Bifidum No low-fat milk. Least

expensive brand

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

FP-311


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-48 (cont'd)

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

evaporated goat milk No low-fat milk

A30 Prenatal Conversion to an Exclusively Breastfeeding Package
A37
A33
A38
A39
A41
P09

Milk:

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
Produce

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) $6 for fresh, frozen, or canned fruit and vegetables, Baby fruits and vegetables without sugar, seasonings, fat, or oils are allowed.

W7
C1, C2 W5, W6, W7, C1, C2
W5, W6, W7, C2 C1, C2, W5, W6, W7 W5, W6, W7, C1, C2
C1, C2

FP-312


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-48 (cont'd)

Voucher code A43 A44 A45 A46 A60 A64 A56 A57 A69 518 544 707 358 359 553 300 307 308 590 591 305
306
301 310 474 476

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 Formula 1-32 oz container ready to feed Similac
Expert Care for Diarrhea Formula 1-8 oz container ready to feed Similac
Expert Care for Diarrhea Formula 6-32 oz containers ready to feed Similac
Expert Care Alimentum Formula 1-32 oz container ready to feed Similac
Similac Expert Care NeoSure Formula 1-32 oz container ready to feed
Enfamil EnfaCare Formula 1-400 gram (14.1oz) can powder
Nutramigen AA 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 1-14.1 oz can powder EleCare Jr Formula 1-12.9 oz can powder Enfamil AR Formula 1-1 quart container ready to feed
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 20 (1-6 pack) Formula 6-2 oz containers ready to feed iron fortified Enfamil Premature 24 (1-6 pack) Formula 1-8 oz container ready to feed Ensure 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

FP-313


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
W5, W6, W7 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 I, C1, C2

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-48 (cont'd)

Voucher code 477 A62 157
159 A67 A68 A63 563
557 558 716 717 A65 A66 A58 A59 720 721 479 480 A47 A48 578 259 141

Infant/Special Formulas Voucher message
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 or Nutramigen with Enflora LGG Formula 1-13 oz can concentrate Nutramigen LIPIL or Nutramigen Formula 1-32 oz container ready to feed Nutramigen LIPIL or Nutramigen Formula 6-32 oz containers ready to feed Nutramigen LIPIL or Nutramigen 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 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 Peptamen Junior Fiber 1-250 ml container ready to feed Peptamen Junior with Prebio 1-1 lb can powder Portagen 1-1 lb can powder Pregestimil LIPIL or

FP-314


Allowed Category I, C1, C2
C1, C2, W5, W6, W7 I, C1, C2
I, C1, C2 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 C1, C2 I, C1, C2 I, C1, C2

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-48 (cont'd)

Voucher code A50
A51
A53 A61 N74 S87 S91 481 482 483 484
588
587
586
A52 G11 G20 G07 G08 G09 G01 476

Infant/Special Formulas Voucher message
Pregestimil Formula 6-2 oz containers ready to feed
Pregestimil LIPIL 20 Calorie or Pregestimil 20 Calorie (one 6-pack) Formula 6-2 oz containers ready to feed Pregestimil LIPIL 24 Calorie or Pregestimil 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 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 (1 case) 24-8 oz containers ready to feed Similac Expert Care for Diarrhea (1 case) 4-2 oz containers ready to feed Similac Similac Expert Care NeoSure (1-4 pack) 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 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 1-33.8 oz (4-pack) ready to feed Gerber Good Start Gentle 2-33.8 oz (4-packs) ready to feed Gerber Good Start Gentle 1-12.1 oz container concentrate Gerber Good Start Gentle 2-12.1 oz containers concentrate Gerber Good Start Gentle 3-12.1 oz containers concentrate Gerber Good Start Gentle 12.7 oz can powder Gerber Good Start Gentle 1-12.9 oz cans powder Gerber Good

FP-315


Allowed Category 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
W5, W6, W7 I, C1, C2 I, C1, C2 I, C1, C2 I, C1, C2 I, C1, C2 I, C1, C2 I, C1, C2

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FP-48 (cont'd)

Voucher code G41 G23 G24 G29 G28 G43 L09 A49 A54 A55

Infant/Special Formulas Voucher message
Start Soy Formula 1-22 oz cans powder Gerber Good Start
2 Gentle Formula 2-12.1 oz containers concentrate Gerber
Good Start Soy Formula 3-12.1 oz container concentrate Gerber
Good Start Soy Formula 2-33.8 oz (4-packs) ready to feed Gerber
Good Start Soy Formula 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 1-12.6 oz cans powder Gerber Good
Start Nourish Formula 1-8 oz container ready to feed 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 C1, C2 C1, C2 C1, C2

FP-316


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

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Voucher code 511
512
530
531
535 536 N75
582 583

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 Formula 6-12.3 oz cans Polycose (1 case) 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
All
C1, I
C1, I
All All I, C1
All All

FP-317


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IV. Requirements for Nutrition Assistant Training/Continuing Education
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ASSURANCE STATEMENT
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TABLE OF CONTENTS

Page

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I.

GENERAL

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II. METHODS OF OUTREACH
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GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL


Food Delivery

TABLE OF CONTENTS

Page

I.

General .................................................................................................................... FD-1

II.

Types of WIC Vouchers ........................................................................................... FD-2

A. Vouchers Printed On Demand (VPOD) .............................................................. FD-2

B. Blank Manual Vouchers ..................................................................................... FD-2 C. Preprinted Standard Manual Vouchers .............................................................. FD-3

D. Vegetable and Fruit Voucher.............................................................................. FD-3

E. WIC Farmers Market Nutrition Program (FMNP) ............................................... FD-3

F. Senior Farmers Market Nutrition Program (SFMNP).......................................... FD-4

III.

Voucher Issuance General.................................................................................... FD-4

A. Valid Certification Period .................................................................................... FD-4 B. Identification of Person Picking Up Vouchers .................................................... FD-5

C. Corrections ......................................................................................................... FD-5

D. Issuance ............................................................................................................. FD-5

E. Categorically Ineligible ....................................................................................... FD-6

F. Issuance of Vouchers to Family Members ......................................................... FD-7

IV.

Voucher Printed on Demand (VPOD) and Computer Generated

Vouchers .................................................................................................................. FD-7

A. Data Elements.................................................................................................... FD-7

B. Voucher Cycles ................................................................................................. FD-8

C. Voucher Packaging ............................................................................................ FD-8

D. Voucher Issuance............................................................................................... FD-8 E. Transporting VPOD Vouchers from a Site within a Site ................................... FD-10

V.

Manual Vouchers (Blank and Standard) ................................................................ FD-10

A. Blank Manual Vouchers ................................................................................... FD-10

B. Preprinted Manual Vouchers............................................................................ FD-11



GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL


Food Delivery

C. Ordering Manual Vouchers .............................................................................. FD-11

D. Receipt of Manual Vouchers ............................................................................ FD-11

E. Inventory Control of Manual Vouchers ............................................................. FD-11

F. Issuance of Manual Vouchers .......................................................................... FD-12

G. Distribution of Manual Voucher Copies ............................................................ FD-13

H. Voided Manual Vouchers ................................................................................. FD-14

VI.

VPOD Procedures.................................................................................................. FD-14

A. General............................................................................................................. FD-14

B. Receipt of VPOD Serial Numbers .................................................................... FD-15

C. Ordering VPOD Serial Numbers ...................................................................... FD-15

D. Issuing VPOD Vouchers................................................................................... FD-15

E. Voucher Reconciliation..................................................................................... FD-16

F. Voiding VPOD Vouchers .................................................................................. FD-16

G. VPOD Inventory Log Sheets ............................................................................ FD-16

H. Corrective Actions for VPOD............................................................................ FD-17

VII.

Mailing/Delivery of WIC Vouchers.......................................................................... FD-17

A. Conditions for Mailing/Delivering Vouchers...................................................... FD-17

B. Acceptable Reasons for Mailing/Delivering Vouchers...................................... FD-17

C. Mailing/Delivery Procedures............................................................................. FD-18

D. Voucher Mailing Process.................................................................................. FD-19

E. Returned Vouchers .......................................................................................... FD-19

VIII. Prorated Vouchers................................................................................................... FD-19

IX.

Late Pick-Up of Vouchers ...................................................................................... FD-20

X.

Coordination of Health Services and Vouchers Issuance ...................................... FD-21

XI.

Lost, Stolen or Damaged Vouchers ....................................................................... FD-22

A. Replacement of Vouchers ................................................................................ FD-22



GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL


Food Delivery

B. Replacement Vouchers Due to a Declared Emergency .................................. FD-22

C. Lost/Stolen/Destroyed/Voided Voucher Report................................................ FD-23

D. Vouchers Lost, Stolen, or Destroyed Prior to Issuance.................................... FD-24

E. Security Destroyed Vouchers.............................................................FD-

F. Change of Formula Order/Formula Purchased In Error ................................... FD-25

XII.

Borrowed Vouchers................................................................................................ FD-25

XIII. Critical Errors ......................................................................................................... FD-26

XIV. Cumulative Unmatched Redemption (CUR) Report .............................................. FD-26

A. Introduction....................................................................................................... FD-26

B. Procedures for Reconciliation .......................................................................... FD-27

C. Manually Reconciling CUR Part 1 .................................................................... FD-28

D. Manually Reconciling CUR Part 2 .................................................................... FD-30

E. Procedures for Both Reports............................................................................ FD-30

XV. Unmatched Redemption Report............................................................................. FD-30

XVI. Reconciliation of WIC Reports and Daily Program Operations .............................. FD-31

A. Daily Verifications............................................................................................. FD-31

B. Monthly Verifications ........................................................................................ FD-31

Attachments: FD-1 Preprinted Standard Manual Voucher .................................................................... FD-32 FD-2 Blank Manual Voucher ........................................................................................... FD-33 FD-3 Voucher Printed On Demand (VPOD) Voucher ..................................................... FD-34 FD-4 WIC Farmer Market Nutrition Program Check ...................................................... FD-35 FD-5 Senior Farmers Market Nutrition Program Check .................................................. FD-36 FD-6 Voucher Cycle Packing List ................................................................................... FD-37 FD-7 Form and Manual Voucher (Supply Order Form)................................................... FD-38 FD-8 Manual Voucher Inventory Log .............................................................................. FD-39



GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL


Food Delivery

FD-9 Voucher Printed On Demand Log Sheet................................................................ FD-40

FD-10 Batch Control Form ................................................................................................ FD-41

FD-11 Batch Control Exception Report ............................................................................. FD-42

FD-12 Georgia WIC Program Identification Card.............................................................. FD-43

FD-13 Daily Roster/Monthly Mailed Voucher Report ........................................................ FD-45

FD-14 Borrowed Voucher Report Form ............................................................................ FD-46

FD-15 Cumulative Unmatched Redemptions Part I .......................................................... FD-47

FD-16 Cumulative Unmatched Redemptions Part II ......................................................... FD-48

FD-17 Unmatched Redemption Report............................................................................. FD-49

FD-18 Lost, Stolen, Destroyed, Voided Voucher Report................................................... FD-50

FD-19 Vouchers Printed on Demand (VPOD) Receipt ..................................................... FD-51

FD-20 Infant Blank Manual or Vegetable and Fruit Voucher............................................. FD-52



GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL


I.

GENERAL

Food Delivery

The Georgia WIC Program 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. The Georgia WIC Program 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 the Georgia WIC Program. Vouchers paid, but flagged as suspect, are investigated by the state agency.

In February 2008, the Georgia WIC Program 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.

The Georgia WIC Program currently utilizes four (4) front-end clinic systems as well as CSC for data processing and voucher reconciliation.

The systems used by local agencies to produce FI as well as to complete all participant transactions are:

x Aegis: State-developed system designed to meet requirements of Y2K. Only front-end system authorized by FNS. Serves: Dublin (D/U 05-1); Valdosta (D/U 08-1) and contracted agency at Grady Hospital (D/U 12-0)
x Mitchell & McCormick: Contractor currently operating in the following areas: Rome (D/U 01-1); Dalton (D/U 01-2)' Gainesville (D/U 02-0)

FD-1

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL


Food Delivery

Cobb/Douglas (D/U 03-1); Fulton County (D/U 03-2); Clayton County (D/U 03-3); Gwinnett/Newton/Rockdale (D/U 03-4); LaGrange (D/U 04-0); Macon (D/U 05-2); Augusta (D/U 06-0); Columbus (D/U 07-0); Albany (D/U 08-2); Coastal Health (D/U 09-1); and Waycross (D/U 09-2) x Insight: Developed by NetSmart. Serves DeKalb County (D/U 03-5). x HealthNet2 (HN2): Developed by Athens district (D/U 10-0).

The state-contracted data processor, CSC, also has the capability to produce vouchers for local agencies in an emergency situation.

Each local agency producing Food Instruments is responsible for ensuring data is backed up on a daily basis. Most systems are automated to perform this function at a specified time after normal work hours. For local agencies, the IT Directors and/or Clinic supervisors are tasked with ensuring backups are performed.

CSC has a sub-contract with Iron Mountain to perform backup and off-site storage of Georgia WIC data.

Local agencies are required to submit written confirmation to the state office that their clinical systems adhere to the provisions of the Functional Requirements document (FReD) as well as the WIC Systems Edits Manual/Data dictionary. Additionally all WIC Clinical systems are required to submit an electronic copy of the most recent User Manual for their system along with a detailed security plan for tier system, including the name and contact information for the person responsible for the plan.

Manuals and security plans are to be updated and provided to the state office as needed.
Security reviews for computer systems, including backup of data, physical security of equipment, data integrity and security of users are a part of the bi-annual program review conducted by the Systems Information Section.


II. TYPES OF WIC VOUCHERS

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 (3) days of receipt (see Attachment FD-9).

B. Blank Manual Vouchers

Blank Manual Vouchers may be issued in cases when automated systems are inoperable or otherwise unavailable. These vouchers may be completed for:

FD-2

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL


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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).

There are eight (8) types of Standard Manual Vouchers and two (2) types of Blank Manual Vouchers that may be issued to WIC participants:

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).

Clinics must keep a three-month supply of all Manual Voucher sets. Hospital sites must maintain a one-month supply of blank manual voucher sets.

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, $7, $8 or $10. 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

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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 the infant's First (1st) birthday or breastfeeding is discontinued a mid-assessment must be completed at six (6) months. From the date of certification then every year until five (5) years of age (a halfcertification must be completed every six (6) months From the date of certification until First (1st) birthday For a one-year period starting from the date of certification.

Vouchers must not be issued past the end of the certification period. The issuance period is twelve (12) 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 December because he/she has received twelve (12) months of vouchers, January through December. An issuance month is defined by vouchers having been issued to a participant during the month regardless of the number of vouchers. Children and Breast-feeding women must receive mid-assessments at six (6) months intervals.

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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 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):
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.

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D. Issuance
Local agencies have the option to issue vouchers to participants at a one, two, or three-month interval. With the 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 week that includes the categorical termination

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date. 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 issuedup to the week that includes the categorically termination date 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 cannot 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.

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5. Last Day to Use (MMDDYY). The last valid date, after which the voucher can no longer be used by the participant. The voucher may be used on this date, but not after this date.
6. 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. Participant/Guardian/Proxy Signature. 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 the 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:

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1. Identification. Verify the identity of the person picking up the vouchers. Please refer to FD-III.B. "Identification of Person Picking Up Vouchers," for procedures. Record 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:

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a. Client's WIC ID number b. Name c. Issue date d. First date to use e. Food package number 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 k. Clinic/Sort Code

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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).

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.) c. Third copy (black) Serves as clinic proof of issuance.
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.

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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 Supply Order" 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 the Georgia WIC Program immediately. The packing list must be signed and dated to verify receipt. A copy of the signed/dated packing list must be mailed to the local agency/district office within five (5) days of receipt of the vouchers. The original must be retained by the clinic for one (1) year plus the current Federal Fiscal Year.
2. District/Unit
The district/unit receives a copy of each detailed clinic packing list for control, and a summary copy showing total vouchers received from the ADP Contractor. Any discrepancies must be reported to the ADP contractor immediately. Missing shipments must also be reported to
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the Georgia WIC Program. 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 but no more than three (3) days after receipt 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
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.

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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 "Batch Control Exception Report "(see Attachment FD-11), describing

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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 Damaged during issuance x Any voucher(s) is 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

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back to the bank, (only those vouchers that are voided due to package changes, formula changes, etc). The ADP contractor will provide addressed envelopes or labels to be used when returning vouchers.

VI. VPOD PROCEDURES

A. General

Vouchers Printed on Demand (VPOD) are generated on site by the WIC clinic's automated system for participants on the Georgia WIC Program. The receipt generated as part of the printing process becomes the voucher register.

B. Receipt of VPOD Serial Numbers

VPOD serial numbers are sent from CSC Covansys. The confirmation notice for serial 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). 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 within five(5) days of receipt. The confirmation notice must also be kept on file in the clinics in the same manner as the packing list. Voucher ranges or numbers not issued within thirteen (13) months of receipt will be automatically voided by the system.

C. Ordering VPOD Serial Numbers and/or Stock Paper
. Local agencies must order VPOD Serial Numbers and/or VPOD stock paper from the ADP contractor. Orders must be made using the "Form and Manual Voucher Supply Order Form" (see Attachment FD-7) and must be received by the ADP contractor by the 10th or 25th day of each month.

D. 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

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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

E. 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 3. Issue date 4. Initials of issuing clerk 5. Status of voucher (Issued or Voided)
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.

F. 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 to the banking facility. Expired vouchers may not be sent back to the bank directly. Only those vouchers that are voided due to package changes, formula changes, etc., may be sent back to the bank directly.
G. VPOD Inventory Log Sheets

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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.

H. Corrective Actions for VPOD

1. Missing receipts 2. Incomplete log sheets 3. More than one percent "Fail to Sign" on receipts 4. Vouchers issued during an invalid certification period 5. Missing and/or any incomplete 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

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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
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

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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
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

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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
14-20 days late
21-31 days late

Women & Children

Infants

full package

full package

Vouchers issued = 3/4

full package

package plus Produce

(Fruit/Vegetables) voucher

Vouchers issued = 1/2 package plus Produce (Fruit/Vegetables) voucher

(1/2) package (deduct one(1) half of formula vouchers plus one food voucher)

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, $7, $8 or $10) 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

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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
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.

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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. 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:

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x Voucher numbers x Participant ID number x Name of participant x Clinic, County and District number x 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. 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

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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 Program State Office-System Unit and a copy to the district office within five (5) days of completion. Upon receipt of the Report, the ADP contractor will enter this information into the system. If the contract bank subsequently pays the vouchers, they will be identified on the Bank Exception Report during the monthly reporting process. The Georgia WIC Program 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 Program Voucher Investigation Log (see Attachment CA2) 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:

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 Program, System Information Unit, 2 Peachtree Street, Suite 10.476 Atlanta, GA 30303 within five (5) days of completion. 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

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to investigate potential fraud, when a block of 25 or more vouchers are missing (see "Compliance Analysis" at Section X).

E. Security Destroyed Vouchers

When vouchers are security destroyed, the Lost/Stolen /Destroyed/ Voided Voucher Report must be completed (see Attachment FD-18) with the following information:

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. Status Code 7. Total Amount of Vouchers Destroyed
F. 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: 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.

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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 from another WIC clinic within the same district by a WIC clinic whose current stock is depleted (see Attachment FD-14). This applies to manual vouchers only. VPOD numbers and VPOD stock paper 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

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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 the Georgia WIC Program, 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 the Georgia WIC Program.

C. Manually Reconciling CUR Part 1

Those voucher(s) listed in the second dollar amount column are too old to correct through the ADP contractor and must be manually reconciled by the clinic. 1. Locate a copy of the voucher(s) listed in the second dollar amount
column.
2. Record the issue date only of the voucher (the actual date as it appears on the voucher) on the dotted line adjacent to the voucher number on the CUR Part 1 Report, sign and date the report. If there are no vouchers appearing on the CUR Part 1 Report that have to be manually reconciled, the report should still be forwarded to the Georgia WIC Program. The CUR Report should always be submitted to the Georgia WIC Program in its entirety. Do not send copies of vouchers to the Georgia WIC Program.
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).
x Column 1: Voucher Number. This is the serial number of the voucher in question.

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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 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

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the bottom copy for your files. Do not submit a copy of the CUR Part 2 Correction Form to the Georgia WIC Program.
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 the Georgia WIC Program.

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 the Georgia WIC Program (see Attachment FD-16).
x Sign and date the completed report and submit to Georgia WIC Program. If there are no vouchers on the report to be manually reconciled, the CUR Report should still be forwarded to the Georgia WIC Program in its entirety. Do not send CUR Reports to the ADP contractor.

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E. Procedures for Both Reports

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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 Program 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 Program 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 Program 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 Program 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 Program 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.
B. Monthly Verifications

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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




Revised06/12


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BLANKMANUALVOUCHER

Attachment FD-2


Revised06/12

FD-33

GEORGIA WIC PROGRAM 2013 PROCEDURE MANUAL

VOUCHERPRINTEDONDEMAND (VPODVOUCHER)


Attachment FD-3




Revised06/12

FD-34

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL
WICFMNPCheck

Attachment FD-4





Revised 06/12

FD-35

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Senior FMNP Check

Attachment FD-5

Revised 06/12

FD-36

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FD-6

VOUCHER CYCLE PACKING LIST


PAGE 60
REPORT ENCR2006

STATE OF GEORGIA WIC PROGRAM SYSTEM
VOUCHER CYCLE PACKING LIST (CLINIC)
FOR THE SECOND CYCLE OF JULY

CLINIC PAGE 2 D/U/CL

DISTRIBUTION:

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 _________________ _________________________
Revised 06/12
FD-37

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FD-7

FD-38

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

$WWDFKPHQW )'

MANUAL VOUCHER INVENTORY LOG

STANDARD MANUAL___________

CLINIC___________

BALANCE BROUGHT FORWARD_________________


'$7( %(*,11,1* 12 (1',1* 12 125(&(,9(' 12 ,668(' 12 92,' 12 21 +$1' ,1,7,$/6 ,1,7,$/6



























































































































































































































































































































































































5HYLVHG

)'

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FD-9

FD-40

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FD-10

BATCH CONTROL FORM

GEORGIA WIC PROGRAM

DISTRICT/UNIT

CLINIC

BATCH CONTROL FORM

DATE

NUMBER

//

//

INSTRUCTIONS
CSC COVANSYS INPUT SECTION

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

NUMBER IN BATCH

TURNAROUND

ISSUED MANUAL VOUCHERS

VOIDED MANUAL VOUCHERS

COMMENTS:

DATE SENT BY DISTRICT/UNIT DATE RECEIVED AT CSC COVANSYS DATE ENTERED AT CSC COVANSYS Revised 3/12

PREPARER'S SIGNATURE SIGNATURE SIGNATURE

FD-41

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FD-11

BATCH CONTROL EXCEPTION REPORT

GEORGIA WIC PROGRAM

DISTRICT/UNIT

CLINIC

VOUCHER BATCH EXCEPTION FORM

DATE

NUMBER

THIS FORM HAS BEEN GENERATED AS A RESULT OF:
THE QUANTITY ON THE CLINIC COMPLETED BATCH CONTROL FORM DOES NOT AGREE WITH THE ACTUAL QUANTITY RECEIVED.
THE VOUCHERS WERE RECEIVED IN A BATCH OF TADS.
ONLY ONE (1) COPY OF THE BATCH CONTROL FORM WAS RECEIVED WITH THE VOUCHERS.
NO BATCH CONTROL FORM WAS RECEIVED WITH THE VOUCHERS.

CSC COVANSYS
INPUT SECTION

TYPE OF DOCUMENT ISSUED MANUAL VOUCHERS VOIDED MANUAL VOUCHERS

APPROXIMATE NUMBER IN BATCH

DATE BATCH RECEIVED AT: _______________________________
Revised 06/12
FD-42

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FD-12

FD-43

Attachment FD-2

Attachment FD-12 (Cont'd)

FD-44

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FD-13

FD-45

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FD-14


FD-46

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FD-15

CUMULATIVE UNMATCHED REDEMPTIONS PART I

PAGE

7

REPORT EWRR350G DALTON

STATE OF GEORGIA WIC PROGRAM 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



Revised 06/12

FD-47

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment FD-16

CUMULATIVE UNMATCHED REDEMPTIONS

PART II



PAGE

6

REPORT EWRR351G DALTON

STATE OF GEORGIA

WIC PROGRAM

SYSTEM

CUMULATIVE UNMATCHED

REDEMPTIONS

FOR THE MONTH OF FEBRUARY

2008

PART 2 NOT MATCHED TO VALID CERTIFICATION

RECORD

CLINIC PAGE

1

D/U/CL 01-2-105 RUN DATE 03/13/08

VOUCHE R
NUMBER

ISSUE WIC ID

JANUARY DECEMBER

DATE FAMILY

C P

S AMOUNT

S AMOUNT RECONCILIATIONS

REASON TOTAL

31223935 01/01/08

105012196 9 1

V

NO MASTER RECORD

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 9 1

V

105012196 9 1

V

105012196 9 1

V

105012196 9 1

V

105012196 9 1

V

105012196 9 1

V

105012196 9 1

V

105012196 9 1

V

31224978 12/04/07

155308830 1 2

31224979 12/04/07 31224980 12/04/07
31224981 12/04/07 31224982 01/01/08 31224983 01/01/08
31224984 01/01/08 31224985 01/01/08

155308830 1

2

155308830 1

2

155308830 1

2

105012275 1

1

R 14.09

105012275 1

1

R 14.86

105012275 1

1

R 19.66

105012275 1

1

R 16.23

R 12.09
R 14.85 R 16.90 R 15.45


.......................... ... .............................
.............................
.............................

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



Revised 06/12



FD-48

GEORGIA WIC PROGRAM 2013 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

Revised 06/12


UNMATCHEDREDEMPTIONREPORT

WIC ID FAMILY
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 023010507 4 1 023010507 4 1 023010027 3 1 023010027 3 023010027 3 1 023010027 3 023010027 3 023005374 6 1

STATE OF GEORGIA WIC PROGRAM SYSTEM UNMATCHED REDEMPTION REPORT
FEBRUARY 2008

DATE

C P

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

1 02/05/08 02/05/08

02/20/08 02/06/08

1 02/26/08 02/06/08

1 02/12/08 1 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

CLINIC PAGE

1

D/U/CL 01-1-023

RUN DATE 03/13/08

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-49

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL
GEORGIA WIC PROGRAM LOST/STOLEN/DESTROYED VOIDED VOUCHER REPORT

Attachment FD-18

GEORGIA WIC PROGRAM

LOST/STOLEN/DESTROYED VOIDED VOUCHER REPORT

DISTRICT/UNIT/CLINIC:

DATE:

INSTRUCTIONS
BEGINNING VOUCHER NO.

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 PROGRAM x P.O. BOX 2507
x GREENWOOD, IN 46142

ENDING VOUCHER NO.

QUANTITY

WIC I.D. NUMBER

STATUS

Status Codes

LOST/STOLEN/DESTROYED 2 VOIDED - 3
COMMENTS

TOTAL VOUCHERS:
REVISED 3/12

FD-50

GEORGIA WIC PROGRAM 2013 PROCEDURE MANUAL
VoucherPrintedonDemand
(VPOD)Receipt

Attachment FD-19


Revised06/12



FD-51

GEORGIA WIC PROGRAM 2013 PROCEDURE MANUAL

Attachment FD-20

INFANTBLANKMANUAL or VEGETABLEANDFRUITVOUCHER


Revised06/12




FD-52

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

&RPSOLDQFH $QDO\VLV



TABLE OF CONTENTS

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GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL



I.

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TABLE OF CONTENTS

State Agency Monitoring

MO-1 Local Agency 2013 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 2013 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 Record Review Form ........................................ MO-51 Food Instrument Employee/Relative Record Review Form ..................................... MO-52

GEORGIA WIC PROGRAM 2013 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 / "Prior To" Information............................................. MO-56

Nutrition Services Unit District Review Questions.................................................... MO-58

Nutrition Services Unit Clinic Review Questions ...................................................... MO-61

Nutrition Services Unit Administrative Management Evaluation ............................. MO-63

Nutrition Services Unit Clinic Review ....................................................................... MO-68

Nutrition Services Unit Record Review Interpretation ............................................. MO-79

Systems Information Unit Administrative Management Evaluation.......................... MO-84

Systems Information Unit District Clinic Evaluation Worksheet................................MO-85

Systems Information Unit Preliminary Information Pre-Visit.................................... MO-89

Systems Information Unit Background.......................................................................MO-91

Systems Information Unit Report for Background Information..................................MO-93

MO-2 Local Agency 2013 Financial Monitoring Section

I.

Financial Reviews .................................................................................................... MO-95

A. Introduction...................................................................................................... MO-95

B. District Selection.............................................................................................. MO-95

C. Pre-Review Activities....................................................................................... MO-95

D. Financial Review Schedule ............................................................................. MO-95

II. Financial Timeframes ............................................................................................... MO-96

III. Local Agency Collections ......................................................................................... MO-97

IV. Financial Self-Reviews ............................................................................................. MO-97

MO-2 Local Agency 2013 Financial Monitoring Tool Financial Review Form............................................................................................. MO-98

GEORGIA WIC PROGRAM 2013 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 the Georgia WIC Program 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 the Georgia WIC Program 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 the Georgia WIC Program two (2) weeks before the scheduled review.

C. Clinic and Health Record Selection

1. Clinic Site

MO-1

GEORGIA WIC PROGRAM 2013 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 the Georgia WIC Program) located in section AD-1 of the Georgia WIC Program Procedures Manual, Number 12, which states "the district must

MO-2

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL


State Agency Monitoring

provide the Georgia WIC Program 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

The Georgia WIC Program must review migrant health records during a local agency WIC review visit. The Georgia WIC Program 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 the Georgia WIC Program, 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 the Georgia WIC Program, the state must evaluate the local agency's outreach efforts related to migrants. Prior to a review, the Georgia WIC Program 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

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GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL


State Agency Monitoring

that need to be made available during the on-site review. (See I. State Agency 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 Program Procedures Manual 9. Georgia WIC Program 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

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GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL


State Agency Monitoring

34. No Proof File
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 43. Voucher Print On Demand (VPOD) Inventories 44. Lost/Stolen/Destroyed Voucher Reports 45. Dual Participation File

F. Timeframes

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

ACTIVITY
Notification of intent to conduct a review, the Georgia WIC Program contacts the local agency to discuss possible review dates.

TIMEFRAME
Thirty (30) days prior to the scheduled date

The Georgia WIC Program prepares and submits a report of program observation and review to the local agency after the site visit/exit interview.
The local agency submits a corrective action report to the Georgia WIC Program.
The Georgia WIC Program submits a written response to the local agency report.
The local agency submits a written response to the Georgia WIC Program 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 MO-5

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL


State Agency Monitoring

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.

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.

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State Agency Monitoring

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.
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 the Georgia WIC Program 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

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GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

d. Missing VOC Cards e. Missing Signatures on Records f. Missing Participant Records

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 d. Security Measures e. Employee/Relative Certification/Voucher Issuance Process

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

The Georgia WIC Program, 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 the Georgia WIC Program the following procedures must be followed:
1. The Georgia WIC Program 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 the Georgia WIC Program, the District Nutrition Services Director must respond in writing to the Georgia WIC Program 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:

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GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL


State Agency Monitoring

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. 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 the Georgia WIC Program 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

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GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL


State Agency Monitoring

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 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

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GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL


State Agency Monitoring

See Establish New Clinic Procedure in the Administrative Section.

II. QUALITY ASSURANCE SELF-REVIEWS
A. Purpose
The purpose of Self-Reviews is to improve the quality of local agency program operations. Self-Reviews allow local agencies to assess compliance of program operations with the Georgia WIC Program 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 the Georgia WIC Program by September 30th of each year.
The assessment will include all phases of the program operations. The "State of Georgia WIC Program 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 the Georgia WIC Program 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 the Georgia WIC Program for internal audit purposes. This information is confidential and must be seen by the Nutrition Services Director only.

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GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

STATE OF GEORGIA DEPARTMENT OF PUBLIC HEALTH

Attachment MO-1

GEORGIA WIC PROGRAM

LOCAL AGENCY FFY 2013
MONITORING TOOL
SECTIONS:
POLICY UNIT
COMPLIANCE ANALYSIS UNIT (FOOD INSTRUMENT ACCOUNTABILITY)
NUTRITION SERVICES UNIT
SYSTEMS INFORMATION UNIT

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GEORGIA WIC PROGRAM 2013 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.

ADMINISTRATIVE

DISTRICT:

POSSIBLE

POINTS

Policy

55

Compliance

25

Total Possible Points: 265

POINTS AWARDED

DATE:

POSSIBLE

POINTS

Nutrition

170

Systems

15

Total Awarded Points:

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

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

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

FORMUAL FOR CLINIC AVERAGE SCORE:

POINTS AWARDED
POINTS AWARDED
POINTS AWARDED
POINTS AWARDED

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 PROGRAM 2013 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 the Georgia WIC Program 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. Were VOC cards ordered by the district/clinic since the last review?
6. Were any VOC cards report lost or stolen since the last review?
Comments:

VOC Card Inventory Section

7. Did the district receive an extension for Processing Standards? From ____________ to ___________ (document dates)
8. Did the district develop a quarterly Processing Standards plan and submit it to the Georgia WIC Program?
9. Were Processing Standards met for each clinic the last reported quarter?
10. Was a Processing Standards Non-compliance letter sent to the district?
Comments:

Clinic Review Processing Standards

11. Were any Civil Rights complaints on file?
12. Were posters, brochures, pamphlets, and flyers in the district in compliance with the current NonDiscrimination statement?
Comments:

Civil Rights Section

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GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL


Attachment MO-1 (cont'd)

POLICY UNIT "PRIOR TO" FORM DISTRICT CLINIC EVALUATION

CLINIC: ______________________________ DATE: ________________________________

(S = Satisfactory, SN = Satisfactory Needs Improvement, U = Unsatisfactory and N/A = Not Applicable)

Clinic #

See Section:

1. Does the clinic have a waiting list? Comments:

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:
6. Does the clinic meet Staffing Standards? (Clinic staff ration is one (1) administrative support staff per every 800 clients served)
Comments:

Clinic Observation Check In Procedures
AD Section (IV) no points at this time (Review summary submitted by district prior to visit)

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GEORGIA WIC PROGRAM 2013 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)

Total Points for District Review _______

55 - 50 Points (S)

49 - 44 Points (SN)

43 - 0 Points (U)

DISTRICT:____________________________

DATE:____________________

REFERENCE

AREAS OF REVIEW

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 3 days? (See

documentation)

3. Was the Separation of Duties/ District

1

Office Form completed by the Nutrition

MO-16

GEORGIA WIC PROGRAM 2013 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)

Total Points for District Review _______

55 - 50 Points (S)

49 - 44 Points (SN)

43 - 0 Points (U)

DISTRICT:____________________________

DATE:____________________

REFERENCE

AREAS OF REVIEW

S SN U NA Possible Points Points Awarded

Services Director/Designee and located at

the district office?

4. Was the documentation in compliance with

2

WIC rules and regulations? (See logs and

certification documents).

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)

2. Were procedures followed?

2

MO-17

GEORGIA WIC PROGRAM 2013 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)

Total Points for District Review _______

55 - 50 Points (S)

49 - 44 Points (SN)

43 - 0 Points (U)

DISTRICT:____________________________

DATE:____________________

REFERENCE

AREAS OF REVIEW

S SN U NA Possible Points Points Awarded

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 the

1

Georgia WIC Program? (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

May 1, 2009 (See Policy Unit "Prior To"

MO-18

GEORGIA WIC PROGRAM 2013 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)

Total Points for District Review _______

55 - 50 Points (S)

49 - 44 Points (SN)

43 - 0 Points (U)

DISTRICT:____________________________

DATE:____________________

REFERENCE

AREAS OF REVIEW

S SN U NA Possible Points Points Awarded

Comments:

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 quarterly monitoring

2

Processing Standards? (Review

documentation of method used).

Comments:

Total Rating /Points

55

MO-19

GEORGIA WIC PROGRAM 2013 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) Total Points for Clinic 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. Notice of Termination/Ineligibility Forms
x Was the Notice of Termination/ Ineligibility /Waiting List Form used appropriately if applicable? (See Form 1 Chart Review for point assignment for this question)

x 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)
2. 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 Poin Points Awar 6
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 PROGRAM 2013 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? ____ If so,

2

XVII., J.

were they reported to the Georgia WIC

Program?

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 PROGRAM 2013 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 Form 4 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? Was

the system/log completed in its entirety?

(See Form 7 for point assignment for this

question)

Certification Section 2. 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)

Certification Section 3. 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)

Comments:

J. MISSED APPOINTMENTS

Certification Section 1. Was a Prenatal Missed Appointment Log

2

III., G.

maintained? Was the log completed in its

entirety? (See Form 7 for point

assignment for these questions)

2. Did the original prenatal certification

2

appointment meet Processing Standards?

(See Form 7 for point assignment for this

question)

MO-22

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



POLICY UNIT CLINIC EVALUATION WORK SHEET



Certification Section 3. Were missed certification appointments

2

IV., A.

rescheduled for prenatal women? (See

Form 7 for point assignment for this

question)

4. Did the rescheduled appointment meet

2

processing standards for prenatal women?

(See Form 7 for point assignment for this

question)

Administrative

5. 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. (See Form 7 for

point assignment for this question)

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 PROGRAM 2013 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 4 ........... Clinic Observation 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 PROGRAM 2013 PROCEDURES MANUAL


Form 1

INELIGIBLE CERTIFICATION WORK SHEET

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.

90 100% 6 Points (S) 80 89% 4 Points (SN)

50 79% 2 Points (U) 0 49% 0 Points (U)

CLINIC: __________________________________

DATE: ______________________

CHART REVIEW N/A _______ (check N/A if terminations are not available for review time period) Participant's Name

Possible

%

%

Awarded

100

Termination Date

COMPLETION OF TERMINATION NOTICE

1. Was the date documented?

2

2. Was the demographic

2

information recorded?

3. Was "You are not eligible" or

2

"You are being terminated"

checked?

4. Was the reason for termination

2

checked?

6. Was the Fair Hearing Section

5

completed?

7. Was the

2

participant/parent/guardian

signature recorded?

7. Was the WIC representative's

2

signature recorded?

Comments:

NOTIFICATION

1. Was the Notice of Fair Hearing

10

given?

Comments:

TERMINATION CODE

1. What was the termination code

3

submitted for ineligibility or

termination? _______ Was the

code correct? ________

Comments:

CERTIFICATION FORM & SUPPORTING DOCUMENTATION

1. Was the income section of the

5

Certification Form completed,

dated and signed if the reason

for termination or ineligibility

was "A"?

MO-25

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL


Form 1 (cont'd)

2. Did the Certification Form

5

contain the signature and date

of the person that determined

eligibility?

3. Was a copy of income proof

5

present with the Certification

Form if the reason for

termination or ineligibility was

"A"?

4. Were proof copies stamped

5

with the date of receipt?

Comments:

INELIGIBILITY FILE REVIEW N/A _______ (check N/A if terminations are not available for review time period) (check the Termination Notices and applicable documentation in the Ineligibility file)

COMPLETION OF TERMINATION NOTICE

Yes/No/NA Possible

%

%

Awarded

1. Was the date documented?

2

3. Was the demographic information recorded?

2

3. Was "You are not eligible" or "You are being terminated" checked?

2

4. Was the reason for termination checked?

2

8. Was the Fair Hearing Section completed?

5

9. Was the participant/parent/guardian signature recorded?

2

7. Was the WIC representative's signature recorded?

2

Comments:

NOTIFICATION

1. Was the Notice of Fair Hearing given?

10

Comments:

TERMINATION CODE

1. What was the termination code submitted for ineligibility or

3

termination? _______ Was the code correct? ________

Comments:

CERTIFICATION FORM & SUPPORTING DOCUMENTATION

1. Was the income section of the Certification Form completed, dated

5

and signed if the reason for termination or ineligibility was "A"?

2. Did the Certification Form contain the signature and date of the

5

person that determined eligibility?

3. Was a copy of income proof present with the Certification Form if

5

the reason for termination or ineligibility was "A"?

4. Were proof copies stamped with the date of receipt?

5

Comments:

MO-26

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL


Form 2

VOC/EVOC SECURITY & ISSUANCE REPORT

90 100% 4 Points (S) 80 89% 3 Points (SN)

50 79% 1 Point (U) 0 49% 0 Points (U)

CLINIC: ___________________________________

DATE: _________________________

State/District Issued VOC
Cards
Beg # End #

DISTRICT/CLINIC ISSUED VOC CARDS/PHYSICAL INVENTORY

Amount Date VOC Cards on # of Requested 2 Staff District & Is

Issued Issued

Hand

Cards Cards

Initials Clinic #'s Inventory

on Accounted Recorded? Match? Accurate?

Hand

For?

Beg # End #

5%

5%

5%

10%

Comments:

Possible % 25

% Awarded -

VOC CARD SECURITY REPORT (Pull 5 Participant Records)- N/A ____

(check N/A if VOC cards were not issued during review time period)

Participant's Name

Participant's Birth Date

Date VOC Card was Issued

Was the Parent/Guardian/Caregiver

5%

Signature on the Log?

Did the Signature on the Log and

5%

Certification Form Match?

Was the Termination Notice issued?

10%

Did the Termination Notice contain

5%

the required signatures?

Comments:

Possible % 25

% Awarded -

CLINIC EVOC CARD REPORTS

Are the EVOC Reports printed quarterly and filed by year?

Yes ___ N/A ___

No ___

Comments:

Possible % 15

% Awarded -

EVOC CARD SECURITY REPORT (Pull 5 Participant Records)- N/A ____

(check N/A if EVOC cards were not issued during review time period)

Participant's Name

Participant's Birth Date

Date EVOC Card was Issued

Was a copy of the EVOC Card

5%

Filed in the Participant's Chart?

Was the Clinic Information

5%

Stamped or Printed on the EVOC

Card?

Was the EVOC Card Signed by the

5%

Participant/Parent/Guardian?

Was the EVOC Card Signed by the

5%

WIC Representative?

Was the Termination Notice

10%

issued?

Did the Termination Notice contain

5%

the required signatures?

Comments:

Possible % 35

% Awarded -

MO-27

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Form 3

RECORD REVIEW Review the following criteria in the records randomly selected.

90 100% 70 Points (S) 80 89% 60 Points (SN)

50 79% 50 Points (U) 0 49% 0 Points (U)

CLINIC: __________________________________

DATE: __________________________

An average (~) of 90 - 100 for each criteria receives the assigned possible %.

PARTICIPANT'S NAME & WIC ID Number CERTIFICATION DATE

~ Possible % 100

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:

% Awarded

PROCESSING STANDARDS

1. Was the initial contact date recorded?

6

2. Did a break in service occur? ____

6

x If so, was the initial contact date

changed?

3. Were processing standards met?

10

Comments:

PROOFS

1. Was proof of residency recorded and a

4

copy stamped dated and filed in the

record?

2. Was proof of identification for the

4

participant recorded and a copy

stamped dated and filed in the record?

3. Was proof of identification for the parent/

4

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

MO-28

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

5. Was the TANF verification filed in the record?
6. Was SNAP documented? 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? _______
x If yes to the above, was the following question answered? How do you obtain food, shelter, clothing and medical care?
11. Was the income source recorded and a copy stamped dated and filed in the record?
12. Was a letter from employer accepted as proof of income? _______ x If yes, was the letter from employer on letterhead or attached to a No Proof form?
13. Were staff initials recorded for residency, identification and income verification?
14. Was only one income reported checked? 15. If no to the above, was the Income
Calculation Form used?
Comments:
CERTIFICATION VALIDATION 1. Was participant physically present? ____
x If no, was the exempt reason documented in the record?
2. Was the printed name/title of staff person verifying the participant/parent/guardian signature recorded?
3. Was the signature/title of staff person verifying the participant/parent/ guardian signature recorded?
4. Was the participant/parent/guardian's printed name and date recorded?
5. Was the participant/parent/guardian's signature/date recorded?
6. If proxy signed above, was proxy letter completed and filed in record?
7. Was choice to authorize disclosure of sharing participant information initialed?
Comments:
MO-29

Form 3 (cont'd)
3 3 3 1 1 2
4 2
1 1 1
2
3 3 3 3 2 3

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL


Form 3 (cont'd)

ELIGIBILITY

1. Was participant categorically eligible?

4

2. Was it documented that participant was

4

income eligible/ineligible?

Comments:

SUPPORTING DOCUMENTATION

1. Was current immunization status

1

recorded?

2. Was the error correction procedure

1

used?

3. Was a VOC/EVOC card issued?

1

(Migrants only)

Comments:

Note: Make copies of this form for Record Review.

MO-30

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL CLINIC OBSERVATION

)RUP

CLINIC: __________________________________

DATE: _____________________

3RLQWV 6 3RLQWV 61

3RLQWV 8 3RLQWV 8

Name of Person Observed: ____________________________

REFERENCE

AREAS OF REVIEW

S SN U NA Possible % % Awarded

100

A. ENVIRONMENT

6SHFLDO 3RSXODWLRQ

$UH :,& IDFLOLWLHV DFFHVVLEOH WR



6HFWLRQ

SHUVRQV ZLWK VSHFLDO QHHGV $'$ "

,,,(

(PHUJHQF\ 3ODQ

,V WKLV D QHZ RU UHQRYDWHG IDFLOLW\ WKDW LV



6HFWLRQ

DFFHVVLEOH DQG RSHUDWLRQDO GXULQJ

9 $ DQG %

SRZHU IDLOXUHV"

Comments: B. CONFIDENTIALITY

&HUWLILFDWLRQ 6HFWLRQ

'RHV WKH FOLQLF RIIHU SULYDF\ IRU WKH



9,,, $

FHUWLILFDWLRQ SURFHVV LQFRPH

VFUHHQLQJ KHDOWK VFUHHQLQJ DQG

FRXQVHOLQJ "

Comments:

C. SIGNS

&HUWLILFDWLRQ 6HFWLRQ

,V WKH 1R &KDUJH IRU :,& 6HUYLFHV



,

VLJQ SRVWHG LQ WKH FOLQLF"

5LJKWV DQG 2EOLJDWLRQV ,V WKH +RZ WR )LOH D &RPSODLQW VLJQ



6HFWLRQ

SRVWHG LQ WKH FOLQLF"

,9 )

$GPLQLVWUDWLYH

$UH 1R 6PRNLQJ VLJQV SRVWHG" 1$



6HFWLRQ 7KUHH ,;

LI D '3+ %XLOGLQJ

6SHFLDO 3RSXODWLRQ

,V WKH ,QWHUSUHWHU VLJQ SRVWHG LQ D



6HFWLRQ

YLVLEOH SODFH"

,,, %

5LJKWV DQG 2EOLJDWLRQV ,V WKH -XVWLFH IRU $OO VLJQ SRVWHG LQ D



6HFWLRQ

YLVLEOH SODFH"

,9 $

Comments:

D. CUSTOMER SERVICE

$GPLQLVWUDWLYH

:HUH VFKHGXOHG SDUWLFLSDQWV ZDLWLQJ IRU



6HFWLRQ 7KUHH ;;9,,

ORQJ SHULRGV RI WLPH" ,V D 3DWLHQW )ORZ

$QDO\VLV UHTXLUHG"

5LJKWV DQG 2EOLJDWLRQV $UH DOO DSSOLFDQWV WUHDWHG WKH VDPH"



6HFWLRQ

,

Comments:

02

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

CLINIC OBSERVATION

Form 4

CLINIC: __________________________________

DATE: _____________________

90 100% 50 Points (S) 80 89% 40 Points (SN)

50 79% 20 Points (U) 0 49% 0 Points (U)

Name of Person Observed: ____________________________

REFERENCE

AREAS OF REVIEW

S SN U NA Possible % % Awarded

100 A. ENVIRONMENT

Special Population

1. Are WIC facilities accessible to

3

Section

persons with special needs (ADA)?

III.,E.

Emergency Plan

2. Is this a new or renovated facility that is

1

Section

accessible and operational during

V., A. and B.

power failures?

Comments:

B. CONFIDENTIALITY

Certification Section

1. Does the clinic offer privacy for the

10

VIII., A., 2.

certification process (income

screening, health screening and

counseling)?

Comments:

C. SIGNS

Certification Section

1. Is the "No Charge for WIC Services"

5

I.

sign posted in the clinic?

Rights and Obligations 2. Is the "How to File a Complaint" sign

5

Section

posted in the clinic?

IV., F.

Administrative

3. Are "No Smoking" signs posted? (N/A

5

Section Three, IX.

if a DPH Building)

Special Population

4. Is the "Interpreter" sign posted in a

5

Section

visible place?

III., B.

Rights and Obligations 5. Is the "Justice for All" sign posted in a

5

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?

4

Section

I.

Comments:

MO-32


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

CLINIC OBSERVATION

E. CERTIFICATION PROCEDURES (CHECK-IN)

Certification Section

1. Was the applicant present at

II., B.

certification?

Certification Section XXX.

2. Was the staff in the clinic using the Interview Script to determine Race and Ethnicity?

Rights and Obligations 3. Are the current race codes being

Section

utilized? (See Policy "Prior To" Form

IV., D.

District Clinic Evaluation)

Certification Section XXVI., C., 6.

4. Were participants informed of their rights and obligations?

Certification Section XXV., B.

5. Were the applicants/participants informed on "How to File a Complaint" 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 Section III., B.

1. Was the Interpreter sign discussed or shown to the applicant/participant?
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 V.

1. Was proof of ID required for certification /re-certification or pickup? Was it an approved form of ID? Was the proof copied and stamped with the date of receipt? Woman ___ Infant ___ Child ___ Type of proof accepted __________

Certification Section II., C.

2. Was proof of residence required for certification/re-certification? Was it an approved form of residency? Was the proof copied and stamped with the date of receipt? Type of proof accepted __________

Certification Section II., D

3. Was proof of income required for certification/re-certification? Was it an approved form of income? Was the proof copied and stamped with the date of receipt? Type of proof accepted __________

Comments:

MO-33



Form 4 (cont'd)
2 5 2 5 5 1
2 1 2
4
4
4

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

CLINIC OBSERVATION

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?

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 2. Was the applicant asked to make a

XV., B., 18., g.

selection of their preference in

authorizing disclosure of sharing

participant information?

Certification Section 3. Was the applicant offered the

VII.

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:

MO-34


Form 4 (cont'd)
1 1 1 1 1 1 1 1 1
1 5 1
2

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

CLINIC OBSERVATION

K. WAITING LIST Certification Section XXII., A.
Comments:

1. Is there a current Waiting List since the last review? _________ x If so, were procedures followed for maintaining a waiting list?

Form 4 (cont'd) 1

MO-35


GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL


NO PROOF MONITORING FORM

90 100% 5 Points (S) 80 89% 3 Points (SN)

50 79% 1 Point (U) 0 49% 0 Points (U)

Form 5

CLINIC: _____________________________

DATE: _______________________________

In each clinic randomly select five (5) records, from the No Proof File, to review the following criteria:

CHART REVIEW - N/A _____ (check N/A if No Proof is not available for review time period)

CRITERIA TO REVIEW PARTICIPANT'S NAME

CERTIFICATION DATE

MISSING PROOF(S) - Check all that apply
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:

ID__ R___ INC__

ID__ R___ INC__

ID__ R___ INC__

ID__ ID__ R___ R___ INC__ INC__
5% 5% 5% 5%
5%
5%
Possible % - 30 % Awarded -

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:

5% 5%
10%
Possible % - 20 % Awarded -

VALID USE 1. Was the No Proof form used correctly? Comments:

10% Possible % - 10 % Awarded -

MO-36

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL


Form 5 (cont'd)



NO PROOF FILE REVIEW - N/A _____ (check N/A if No Proof is not available for review time period)

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?

Yes/No Possible % % Awarded 5% 5% 5% 5% 5% 5%

Comments:
VALID USE 1. Was the No Proof form used correctly? Comments:

Possible % - 30 % Awarded -
10% Possible % - 10 % Awarded -

MO-37

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL


Form 6

TEMPORARY THIRTY (30) DAY CERTIFICATION RECORD REVIEW

90 100% 6 Points (S) 80 89% 4 Points (SN)

50 79% 2 Point (U) 0 49% 0 Points (U)

CLINIC: ________________________________

DATE: __________________________________

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:

CHART REVIEW- N/A _____ (check N/A if Thirty-Day is not available for review time period)

PARTICIPANT'S NAME AND BIRTH DATE

CERTIFICATION DATE

MISSING PROOF(S) - Check all that apply

ID___ ID___ ID___ ID___ ID___ R___ R___ R___ R___ R___ INC__ INC__ INC__ INC__ INC__

COMPLETION OF THE THIRTY-DAY FORM

1. Was the date recorded?

3%

2. Was the name, date of birth, address and telephone

3%

number completed?

3. Was "You will be terminated from the Georgia WIC

3%

Program ..." checked?

4. Was the date (that information is due back to the clinic)

3%

recorded?

5. Was the type of proof(s) client is to bring back to the

3%

clinic checked?

6. Were the date and the WIC Representative's signature

3%

completed?

7. Was the Fair Hearing Section completed?

3%

8. Was the participant or parent/guardian/caregiver's

3%

signature completed?

9. Was the WIC Representative's signature/title

3%

completed?

Comments:

Possible % 27 % Awarded -

COMPLETION OF THE CERTIFICATION FORM

1. Was "NO" placed in the missing proof(s) field?

3%

2. If income was the missing proof, is self-declared

3%

income documented?

3. Did the participant or parent/guardian/caregiver sign the

3%

WIC assessment form?

4. Did the WIC Representative sign and date the WIC

3%

assessment form?

Comments:

Possible % 12

% Awarded -

VOUCHER ISSUANCE

1. Was the participant issued only thirty (30) days of

5%

vouchers?

MO-38

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL


Form 6 (cont'd)

2. Did the temporary thirty (30) day certification end before or at the recorded return date (no extension and no extra vouchers issued?
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/amount and Medicaid/SNAP/TANF eligibility/number) 3. Did the WIC Representative date and initial the updated adjustment? 4. Was the adjustment entered into the computer?

5%
Possible % 10 % Awarded -
5%
3%
3% 3%

Comments:
TERMINATION 1. If the participant is income ineligible, was "You are being
terminated from the Georgia WIC Program ..." 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:

Possible % 14 % Awarded -
3%
3% 4%
Possible % 10 % Awarded -

THIRTY-DAY FILE REVIEW- N/A _____ (check N/A if Thirty-Day is not available for review time period)

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 the Georgia WIC Program ..."
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?

Yes/No

Possible % 3 3

% Awarded

3

3 3 3 3 3

3

Comments:

Possible % 27 % Awarded -

MO-39

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL


Form 7

PROCESSING STANDARDS / PRENATAL MISSED APPOINTMENT LOGS REVIEW

90 100% 17 Points (S) 80 89% 12 Points (SN)

50 79% 6 Point (U) 0 49% 0 Points (U)

CLINIC: _________________________________

DATE: ______________

Source for Participant Names: Log___ System Printout___ Random Names___ Other________________ (specify)

PROCESSING STANDARDS SYSTEM/LOG REVIEW

Yes/No Possible

%

%

Awarded

1. Is there a system/log available for documenting and tracking initial contact dates

10

and Processing Standards? Was documented proof available to show

Processing Standards are being met?

2. Was the system/log completed in its entirety?

4

3. Are Processing Standards being met for all WIC types?

15

Comments:

Possible % 29

% Awarded -

PROCESSING STANDARDS CHART REVIEW

(Check two charts for each WIC type)

Participant Name

WIC Initial Contact Scheduled Do Initial Contact Dates

Were

Type

Date

Appointment Match? (Certification

Processing

Date

Form & Log)

Standards Met?

Comments:

Possible % 5

Possible % 15

% Awarded -

% Awarded -

PRENATAL MISSED APPOINTMENT LOG REVIEW - N/A ____

Yes/No Possible

%

(Check N/A if a prenatal did not miss a certification appointment for review time period)

%

Awarded

1. Was a Prenatal Missed Appointment Log maintained?

10

2. Was the log completed in its entirety?

4

3. If postcards are mailed to participants for any reason, are they in compliance with

2

HIPPA regulations? (View postcards or other documents mailed)

Comments:

Possible % 16

% Awarded -

PRENATAL MISSED APPOINTMENT REVIEW (check 5) N/A ____

(Check N/A if a prenatal did not miss a certification appointment for review time period)

Participant Initial

Scheduled

Were

Date of Contact Rescheduled

Were

Name

Contact Appointment Processing

to Reschedule Appointment

Processing

Date

Standards Met?

Missed

Date

Standards Met?

Appointment

Comments:

Possible % 15 % Awarded -
MO-40

Possible % 5 Possible % 15 % Awarded - % Awarded -

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL


Form 8

CLINIC STAFF QUESTIONS

CLINIC: ______________________________

DATE: ___________________________

(S = Satisfactory, SN = Satisfactory Needs Improvement, U = Unsatisfactory and N/A = Not Applicable)

90 100% 32 Points (S) 80 89% 27 Points (SN)

50 22% 6 Points (U) 0 49% 0 Points (U)

Name of Person Interview: ________________________________

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 % % 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

5

to complete migrant certifications?

Special Population

3. Are the Language Lines interpreters or

5

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

5

applicant or participant bring their own

interpreter?

Comments:

D. CERTIFICATION PROCEDURES

Certification Section

1. What is the definition of "family"?

1

MO-41

GEORGIA WIC 2013PROCEDURES MANUAL


VIII., C., 3. 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-42

Form 8 (cont'd) 1 1 1 1 10 10 10
15
15

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL


Certification Section XIII.
Comments:

Postpartum Infants Children Migrants

__________________ __________________ __________________ __________________

2. Is the staff knowledgeable of certification periods? (Staff interviews) Women(P) ________ Women(B) ________ Women(PP) ________ Infant__________ Child__________

Form 8 (cont'd) 15

MO-43

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



FOOD INSTRUMENT ACCOUNTABILITY WORKSHEET

ADMINISTRATIVE MANAGEMENT EVALUATION

(S=Satisfactory, SN=Satisfactory needs improvement, U=Unsatisfactory, and NA=Not Applicable)

Total Points for District Review _______

23-25 Points (S)

20-22 Points (SN)

19- 0 Points (U)

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 completed

2

Section

in its entirety and kept on file at the District

III.,E

office?

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/DESTROYED/VOIDED VOUCHER REPORT

(MISSING VOUCHER/VPOD RECEIPT)

Compliance 1. Has the District Office received notice of any

1

Analysis

missing vouchers/VPOD receipts/VPOD

X.

stock paper from any WIC clinic since the

last Program Review?

Compliance 2. Are the Lost/Stolen/Destroyed/Voided

2

Analysis

Voucher reports completed in its entirety?

X.

Compliance 3. Were Lost/Stolen/Destroyed/Voided

2

Analysis

Voucher Reports investigated and sent to

X.

the Georgia WIC Program within five days of

receipt?

Comments:

MO-44

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



FOOD INSTRUMENT ACCOUNTABILITY WORKSHEET

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 AND/OR EMPLOYEE ABUSE

Compliance 1. Has the District received any reports of

1

Analysis

program abuse by the participants

III.,A.

and/or employees since the last

Program Review?

Compliance 2. Was the report of abuse investigated?

2

Analysis

III.,A.

Compliance 3. Was the report sent to the Georgia

2

Analysis

WIC Program?

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 the Georgia WIC

Program on a monthly basis?

Comments:

MO-45

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



FOOD INSTRUMENT ACCOUNTABILITY WORKSHEET

CLINIC EVALUATION (S=Satisfactory, SN=Satisfactory needs improvement, U=Unsatisfactory, and NA=Not Applicable)

Total Points for Clinic Review ______

139-155 Points (S)

138-124 (SN)

123-77 Points (U)

0-76 (U)

CLINIC________________________

DATE_____________________

REFERENCE

AREAS OF REVIEW

S SN U NA POSSIBLE POINTS

POINTS AWARDED

A. RECONCILED PACKING LIST/CONFIRMATION NOTICES

Food Delivery 1. Is the Packing List/Confirmation

2

V.,D.,1.

Notice verified, signed, and dated?

Food Delivery 2. Are Packing List serial numbers

2

V.,E.

recorded on the Manual Voucher Inventory Logs within three days of

receipt?

Food Delivery 3. Are Confirmation Notices serial

2

VI.,A.

numbers recorded on the VPOD Inventory Logs within three days of

receipt?

Food Delivery 4. Was the computer screen printed

2

VI.,A.

and stapled to the corresponding Confirmation Notice to show date of

entrance is within three days of

receipt?

Food Delivery 5. Are any Packing List/Confirmation

3

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(s)?

Food Delivery 3. Are the beginning and ending

5

V.,E.

numbers documented correctly on

the log(s)?

Comments:

C. MANUAL VOUCHER PHYSICAL INVENTORY

Food Delivery 1. Are the Physical Inventories

3

V.,E.2.

conducted/verified monthly and match the inventory log?

MO-46

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



FOOD INSTRUMENT ACCOUNTABILITY WORKSHEET

Food Delivery 2. Does the Manual Voucher Inventory

2

V.,E.2.

Log contain second verifying initials for physical inventory?

Food Delivery 3. Does the clinic have an adequate

3

II.,C.

supply of preprinted standard and

blank Manual Vouchers?

Food Delivery 4. Are any Manual Vouchers missing?

5

V.,E.2.

Comments:

D. MANUAL VOUCHER COPIES

Food Delivery 1. Are Manual Voucher copies filed in

2

V.,G.2.

serial number order?

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. Were Manual Voucher copies

3

V.,F.

submitted to Covansys for processing?

Food Delivery 5. Are Manual Vouchers completed

3

V.,3.

accurately? (Demographics, 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. Is the VPOD Inventory Log

5

VI.,D.

completed in its entirety?

Food Delivery 2. 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

3

IV.,D.,4.

order, missing or misfiled?

Food Delivery 2. Do receipts contain the correct ID

5

proof codes and/or any missing

MO-47

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



FOOD INSTRUMENT ACCOUNTABILITY WORKSHEET

IV.,D.,1.

participant signatures?

Food Delivery 3. Does the VPOD receipts contain the

2

IV.,D.,2.,(2)

entry "Failed to Sign" more than 1% for the entire month?

Food Delivery 4. Are voided vouchers stamped "void"

3

VI.,C.

and attached to the receipts?

Comments:

G. DAILY ACTIVITY REPORTS

Food Delivery 1. Are Daily Activity Reports maintained

3

VI.,C.

correctly (gaps, missing numbers, signatures, columns or dates)?

Comments:

H. VOUCHER SECURITY

Compliance 1. During office hours, are vouchers

1

Analysis

securely stored or in the possession

XII.,A.1.

of authorized staff?

Compliance 2. Is the key properly secured at all

2

Analysis

times only with authorized

XII.,A.1.

personnel?

Compliance 3. Are vouchers securely stored

1

Analysis

separately from ID cards and

XI.,C.,2.

voucher receipts?

Compliance 4. Are WIC ID cards securely stored

1

Analysis

separately from the WIC Stamp?

XI.,C.,2.

Compliance 5. Are WIC ID cards pre-stamped?

2

Analysis

XI.C.

Compliance 6. What security measures are currently

1

Analysis

in place to prevent voucher theft by

XII.,B.

participants?

Compliance 7. Are manual vouchers borrowed

1

Analysis

within the district? If yes, how are

XII.,E.

they transported and by whom? (See transportation method).

Compliance 8. If vouchers are issued to participants

1

Analysis

in the home and/or hospital sites,

XII., E.

how are they delivered and by whom?

Comments:

MO-48

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



FOOD INSTRUMENT ACCOUNTABILITY WORKSHEET

I. PRORATING (VOUCHERS ISSUANCE)

Food Delivery 1. Were vouchers prorated accordingly

5

VIII.

for late voucher pick up and categorically ineligible participants?

STAFF INTERVIEW QUESTIONS

Name of Person Interviewed: ___________________________________

Food Delivery 2. PRORATION

5

VIII.

A. Is staff knowledgeable of the

proper procedures for prorating?

x Less than 7 days late

(Women/Child/Infant) ____________

x 7-13 days late

(Women/Child/Infant) ____________

x 14-20 days late

(Women/Child/Infant) ____________

x 21-31 days late

(Women/Child/Infant) ____________

Comments:

J. LOCAL AGENCY POLICIES

Compliance 1. Are Employee Disclosure Forms

3

Analysis

completed accurately, and kept on

III.,E.

file at the clinic?

Food Delivery 2. Were procedures appropriately

9

III., F.

applied for WIC certifications and voucher issuance? (See Form 2-

Chart Review for point assignment

for this question)

CLINIC STAFF INTERVIEW QUESTION

Name of Person Interviewed: ______________________________

Certification 3. LOCAL AGENCY POLICIES

1

Section

A. What is your policy for issuing

III., E.

vouchers to employees/family

members?

Comments:

K. VOUCHER ISSUANCE (RECERT OVERDUE)

Food Delivery 1. Were the demographics (Name,

4

III., A.

Address, etc.) and supporting documents (Proof of Identification,

Residency and Income) appropriately

applied for the WIC certification?

MO-49

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



FOOD INSTRUMENT ACCOUNTABILITY WORKSHEET

(See Form 1- Record Review for point assignment for this question)

Food Delivery 2. Are any participants issued vouchers

4

III.,A.

past certification overdue date without a current certification

completed? (See Form 1-Record

Review for point assignment for this

question)

Food Delivery 3. Was current certification processed

4

III.,A.

and sent to Covansys? (See Form 1Record Review for point assignment

for this question)

Comments:

L. ISSUANCE PROCEDURES (CUR)

Food Delivery 1. Were the demographics (Name,

4

XIV.

Address, etc.) and supporting documents (Proof of Identification,

Residency and Income) appropriately

applied for the WIC certification?

(See Form 3- Record Review for

point assignment for this question)

Food Delivery 2. Are vouchers issued to participants

4

XIV.

who were terminated for thirty-day issues and/or categorically ineligible?

(See Form 3- Record Review for

point assignment for this question)

Food Delivery 3. Are vouchers issued to participants

4

XIV.

without a valid certification processed with Covansys? (See Form 3-

Record Review for point assignment

for this question)

Comments:

M. PARTICPANT ABUSE/DUAL PARTICIPATION

Compliance 1. Did the participant receive notice of

3

Analysis

repayment, suspension and/or

III.,C.

termination?

Compliance 2. Were participant's that were found to

3

Analysis

be in violation of the Georgia WIC

III.,C.

Program terminated for a period of one year?

3. Does the clinic maintain the monthly

2

Dual Participation List to prevent

certifications and/or voucher

issuance to dual participants?

Comments:

MO-50

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



FOOD INSTRUMENT ACCOUNTABILITY WORKSHEET

N. OBSERVATION OF DUAL PARTICIPATION

Name of Person Observed: _______________________________

Rights and 1. Did staff emphasize dual

5

Obligation

participation during certification and

Section

re-certification?

I.

Comments:

O. LOST/STOLEN/DESTROYED VOUCHER REPORT

Compliance 1. Were Lost/Stolen/Destroyed Voucher

4

Analysis

Reports completed in its entirety for

XI.,C.

vouchers that were security destroyed, lost, or damaged?

Compliance 2. Was the Lost/Stolen/Destroyed

1

Analysis

Voucher Report sent to the district office and Georgia WIC Program

XI.,C.

within five days of completion?

Comments:

P. VOUCHER REGISTERS

Emergency 1. Were voucher registers reconciled

1

Plan

with the participant's signature and/or

XII., D.

marked as void, followed by the clerk's initials and date?

Comments:

MO-51

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

RE-CERT OVERDUE RECORD REVIEW FORM

Form 1

Select a random sample of at least eight (8) 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.

90 100% =12 Points (S) 80 89% =9 Points (SN)
50-79% =6 Points (U)
0-49% =0 Points (U)

CLINIC: __________________________________

DATE: __________________________

100% compliance = Available Possible points for each criteria.

PARTICIPANT'S NAME

% Possible Points

WIC STATUS

12

Points Awarded

DEMOGRAPHICS

1. Were the demographics (Name,

4

Address, etc.) and supporting

documents (Proof of

Identification, Residency and

Income) appropriately applied for

the WIC certification?

Comments:

CERTIFICATION DATES

2. Were the participant's delivery

1

and/or EDC date recorded?

3. What is the participant's re-cert due

2

date?

4. What is the participant's re-

1

certification date?

Comments:

VOUCHER ISSUANCE

5. Was the participant issued

3

vouchers past the certification

overdue date without a current

certification completed?

6. Was current certification processed

1

and sent to Covansys?

Comments:

MO-52

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

EMPLOYEE/RELATIVE RECORD REVIEW

Form 2

Review the following criteria in all Employee/ Relatives records that receive WIC benefits Note: Make copies of this for the Record Review as needed.

90 100% =12 Points (S) 80 89% =9 Points (SN)
50-79% =6 Points (U)
0-49% =0 Points (U)

CLINIC: __________________________________

DATE: __________________________

100% compliance = Available Possible points for each criteria.

PARTICIPANT'S NAME

% Possible Points

CERTIFICATION DATE

12

Points Awarded

DEMOGRAPHICS

1. Were the demographics (Name, Address, etc.) completed?

1

Comments:

PROOFS

2. Was proof of residency recorded and

1

a copy stamped dated and filed in the

record?

3. Was proof of identification for the

1

participant recorded and a copy

stamped dated and filed in the

record?

4. Was proof of identification for the

1

parent/ guardian recorded and a

copy stamped dated and filed in the

record?

5. Was proof of income for the

1

parent/guardian recorded and a copy

stamped dated and filed in the

record?

Comments:

CERTIFICATION VALIDATION

6. Was the signature/title of staff person

1

verifying the participant/parent/

guardian signature recorded?

7. Was the participant's signature/date

1

recorded?

8. If proxy signed above, was proxy

1

letter completed and filed in record?

Comments:

MO-53

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

SUPPORTING DOCUMENTATION 9. Was a current Disclosure Form on
file at the clinic? 10. Did the staff member issue vouchers
or process certification for themselves and/or family member?
Comments:

Form 2 (cont'd)
3 1

MO-54

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL


Form 3

CUR REPORT RECORD REVIEW Select a random sample of at least eight (8) records from the most recent CUR Part II

90 100% =12 Points (S) 80 89% =9 Points (SN)
50-79% =9 Points (U)
0-49% =0 Points (U)

CLINIC: __________________________________

DATE: __________________________

100% compliance = Available Possible points for each criteria.

PARTICIPANT'S NAME

% Possible Points

WIC STATUS

12

DEMOGRAPHICS

1. Were the demographics (Name,

4

Address, etc.) completed?

Comments:

Points Awarded

CERTIFICATION PROCEDURES

2. Was valid certification processed and sent to Covansys?

4

Comments:

VOUCHER ISSUANCE

3. Were vouchers issued to a categorically

2

ineligible participant?

4. Were vouchers issued to a participant

2

who was terminated for thirty-day

issues?

Comments:

MO-55

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

NUTRITION UNIT MONITORING TOOL

Nutrition Services: 400 points or 40% of Total Program Review Score A) District
Nutrition Office
Secondary Nutrition Education Provided x Low Risk Secondary Nutrition Education x High Risk Secondary Nutrition Education

Attachment MO-1 (cont'd)

Points Available for Each Section
70 (35) (35)

Score Based on
Points available/Total Nutrition points available (400)
17.5%

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%

160

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

15

3.75%

20

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

100%

MO-56

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



NUTRITION UNIT MONITORING TOOL



OFFICE OF NUTRITION / WIC PROGRAM REVIEW

Date:

Notes:

District Program Review Notes:

Clinic Program Review Notes:

Note: District, Clinic, and Office of Nutrition review questions are completed for background tracking and education.

District / Prior To Information

AREAS OF REVIEW

Information Provided

1. A copy of the Employee Orientation Checklist for all new employees hired after September 1, 2008.
2. District training plan for Competent Professional Authorities (CPAs) and Nutrition Assistant (NAs).

S U NA

3. A list of all CPAs by Clinic (Nutrition and Nursing) and documentation of continuing education.
4. A list of all Nutrition Assistants and documentation of continuing education.

5. A copy of all class outlines for group facilitated classes offered in the District.

6. A list of all nutrition education materials used by the local agency and District procedures used by clinics for ordering materials.
7. A current copy of all District /Clinic 999 food packages and voucher codes.

8. Summary of nutrition-related findings from self reviews.
9. Summary of outreach activities.

10. Summary of all nutrition trainings/in-services provided by the District office since the last review.

COMMENTS
NE Section (V)
NE Section (VI) (Attachment NE-3 (IV) is training plan for NAs) NE Section (V), Attachment NE-6
NE Section, Attachment NE-3 (IV), Attachment NE-6 NE Section (VI), Breastfeeding Section (V) NE Section (VIII)
FP Section (References food package rules) AD Section (IV)
Outreach Section (I) NE Section (V)

MO-57

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



NUTRITION UNIT MONITORING TOOL



11. Nutrition Staffing Standards: Summary of current CPAs and how it relates to the

AD Section (IV)

district's ability to meet staffing standards.

The information should include full time

equivalents. (Part time staff as well as

individuals that do not work in WIC full time

should be considered in total numbers

reported.) Manager's time should only be

included in proportion to the amount of time

they are providing direct services to

participants.

A. One (1) CPA per every 1,000 participants

served.

B. One (1) RD/LD per every 5,000 clients

served.

12. Documentation to support that all staff (Clerical and CPA) received yearly

BF Section

breastfeeding continuing education.

13. A list of all Peer Counselors by Clinic and a summary of continuing education.

BF Section

14. A copy of the district breast pump policy and
procedures for issuing pumps.

BF Section

15. A copy of the District Breastfeeding
Equipment inventory log.

BF Section

MO-58

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



NUTRITION UNIT MONITORING TOOL



DISTRICT REVIEW QUESTIONS

AREAS OF REVIEW

S U NA

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.

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)

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.

NE (VI)

2. Describe the method used to document secondary nutrition education contacts.

NE (VI)

MO-59

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment MO-1 (cont'd)


NUTRITION UNIT MONITORING TOOL



DISTRICT REVIEW QUESTIONS

AREAS OF REVIEW
3. Describe how failed secondary nutrition education contacts are documented.

S U NA

COMMENTS

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.

BF (IV), BF Attachment 3

2. Does the Breastfeeding Coordinator conduct activities District-wide or primarily in one location?

BF (IV)

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)

Encouragement to Breastfeed
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.)

BF (IV, V)

MO-60

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL


NUTRITION UNIT MONITORING TOOL



DISTRICT REVIEW QUESTIONS

AREAS OF REVIEW
C. Breastfeeding Education and Training

S U NA

Attachment MO-1 (cont'd)
COMMENTS

1. Describe how clinic staff is 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

D. How can the Office of Nutrition staff assist in improving or enhancing Nutrition Education and Breastfeeding Plans and providing nutrition services?

Looking for District best practices.
Not required no points

MO-61

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



NUTRITION UNIT MONITORING TOOL



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-62

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



NUTRITION UNIT MONITORING TOOL



CLINIC REVIEW QUESTIONS

AREAS OF REVIEW

S U NA

COMMENTS

III. Breastfeeding Promotion and Support
A. Encouragement to Breastfeed
Describe how breastfeeding is encouraged and documented during the prenatal period. x Take into consideration individual contacts,
prenatal/breastfeeding classes, or other (Please specify.)

BF (IV & V)

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)

MO-63

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



NUTRITION UNIT MONITORING TOOL



Administrative Management Evaluation Nutrition 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 70
35
35

Comments:

B. Breastfeeding Promotion and Support:

BF (IV, V)

Breastfeeding Promotion and Support Overall Rating:
1. Is the assigned District Breastfeeding Coordinator a full-time position?
2. Is the District Breastfeeding Coordinator a Certified Lactation Counselor (CLC) or International Board Certified Lactation Consultant (IBCLC)?
3. All staff interacting with WIC participants (CPAs, Nutrition Assistants, Peer Counselors, Clerical) receiving breastfeeding continuing education?
4. District have Breastfeeding Peer Counselors supporting prenatal and breastfeeding women?
5. Local agency keeps: a. An inventory of all breast pumps and kits? b. Appropriate policies and procedures for issuing pumps?
6. Local agency has developed a breastfeeding

S SN U NA Possible Points Points Awarded 20 8 2
5
2
2 1

MO-64

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



NUTRITION UNIT MONITORING TOOL



Administrative Management Evaluation Nutrition Unit
(S = Satisfactory, SN = Satisfactory Needs Improvement, U = Unsatisfactory and N/A = Not Applicable)

DISTRICT:____________________________

DATE:____________________

REFERENCE: Comments:

AREAS OF REVIEW
resource list for prenatal and breastfeeding women?

C. District-Created 999 Food Package Review:

FP (II), Attachments 23-31
Comments:

District-Created 999 Food Package Review Overall Rating: 1. District / Clinic created food packages
available for review? 2. Food packages followed existing state and
federal guidelines? Food packages issued within existing
minimums and/or maximums? 3. Designated coordinator for District created
food packages and approval process. (Best Practice)

S SN U NA Possible Points Points Awarded 15 2
10
3

D. Nutrition Education Materials / Class Outlines:

S SN U NA Possible Points Points Awarded

NE (VIII)

Nutrition Education Materials / Class Outlines

15

Overall Rating:

1. Are class outlines available for review and

3

did they include learning objectives?

2. Are all participant groups represented by

3

available nutrition education materials

(Women / Infant / Child)?

*When applicable- some clinics serve only

specific populations.

3. Evaluate all District created Nutrition

3

Education materials for meeting nutrition

education guidelines. (Full non-

discrimination statement on all district

created materials. Effective May 1, 2009)

4. Appropriate and adequate variety of nutrition

3

education materials available to meet

participant category needs? (English,

Spanish, other)

5. All District created materials were approved

3

by the Nutrition Services Unit and DPH.

Comments:

MO-65

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



NUTRITION UNIT MONITORING TOOL



Administrative Management Evaluation Nutrition Unit
(S = Satisfactory, SN = Satisfactory Needs Improvement, U = Unsatisfactory and N/A = Not Applicable)

DISTRICT:____________________________

DATE:____________________

REFERENCE:

AREAS OF REVIEW

E. Nutrition Education Plan:

NE (VI) Comments:

Nutrition Education Plan Overall Rating:
1. Did the Nutrition Services Unit receive an annual Nutrition Education Plan by the assigned deadline?

S SN

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: Documentation of required components provided to all new staff since date of last program review.

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 NE-6

Continuing Education Overall Rating for CPA's or CPA's & NA's: Nutrition Assistant Observations
1. % of CPA's Meeting Minimum Standard 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.

18
2 1. _____%
x 90-100% 18 Points (S)
x 80-89% 14 Points (SN)
x 0-80% No Points
(U)

Total CPA's meeting requirements CPA's = % of CPA's Meeting Minimum Standard
Districts with Nutrition Assistants: 2. % of CPA's & Nutrition Assistants (NA) Meeting Minimum
Standard

2. _____%

MO-66

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



NUTRITION UNIT MONITORING TOOL



Administrative Management Evaluation

Nutrition 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.

x 90-100% 18 Points (S)
x 80-89% 14 Points (SN) 0-80% No Points (U)

Total CPA's & NA's meeting requirements CPA's & NA's = % of CPA's & NA's Meeting Minimum Standard

1. 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 2 points (If NA points automatically added to total)

H. Breastfeeding Clinic Evaluation:

x NE (IV, V) x BF (IV, V)

Breastfeeding Clinic Evaluation Overall Rating: 1. Encouragement to Breastfeed x Establish a clinic environment that clearly supports breastfeeding; breastfeeding friendly posters, bulletin boards, cups, pens, badge holders displayed throughout?
x Designated private space for nursing mothers?
x Breastfeeding Peer Counselors available to provide additional support to prenatal and breastfeeding women?
x Prenatal /breastfeeding classes offered?
2. Breastfeeding Referral System x Clinic level staff accurately described district referral system. (Prenatal or breastfeeding woman needing additional support are referred to the designated breastfeeding person; MO-67

S SN U NA Possible Points Points Awarded 30 10
5 4 4
3

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



NUTRITION UNIT MONITORING TOOL



Administrative Management Evaluation

Nutrition Unit

(S = Satisfactory, SN = Satisfactory Needs Improvement, U = Unsatisfactory and N/A = Not Applicable)

DISTRICT:____________________________

DATE:____________________

REFERENCE:

AREAS OF REVIEW

Breastfeeding Coordinator, Nutritionist, Nurse, Peer Counselor.)

3. Breastfeeding Equipment

x Local agency has written policies

and procedures for issuing breast

2

pumps?

x Local agency keeps an inventory of all breast pumps and kits?

2

Comments:

MO-68

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



NUTRITION 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 Points Awarded
75

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 observation score)

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

Points

A Available Awarded

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

S SN U N Points

Points

A Available Awarded

1. Thoroughly reviewed participant's responses to the Nutrition

10

Questionnaire.

2. Asked probing questions to collect missing information on the Nutrition

10

Questionnaire.

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

MO-69

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



NUTRITION UNIT MONITORING TOOL



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 discussion

5

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

A Available

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:

Points Awarded

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

Comments:

J. Anthropometric & Hematological Equipment:

Looking for: Anthropometric:

Anthropometric & Hematological Equipment Overall Rating:
MO-70

S SN U NA Possible Points Points Awarded
5

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



NUTRITION UNIT MONITORING TOOL



x Mounting error inch or larger for length or height boards.
x Scales not calibrated within last year.
Hematological:
Old Style Hemocue x Control log
appropriately 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

Scoring is based on district summary: x All equipment in good working order
5 Points (S) x One (1) to two (2) pieces of equipment with issues
4 Points (SN) x Three (3) to four (4) pieces of equipment with issues
3 Points (U) x Five (5) or more pieces of equipment with issues
0 Points (U)

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

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:

ABCABCABCABCAB

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

MO-71

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



NUTRITION UNIT MONITORING TOOL



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 deficiencies
0 Points (U)

S SN

U NA Possible Points Points Awarded
5

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
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:

PBN

PBN

P B N Age:

Age:

Age:

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-72

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



NUTRITION 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: (Note reference observation as participant status and observation number. Ex. Infant 2- wt not checked)

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
collected when required?

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)

S SN U NA Possible Points Points Awarded
5

Hemoglobin Determination / Universal Precautions:

(S = Satisfactory, SN = Satisfactory Needs Improvement, U = Unsatisfactory and N/A = Not Applicable)

Clinic Date Reviewer

District Average:

Rating: (S / SN / U / NA)

Clinic Points Awarded: Comments: (Note additional observations under comments if the clinic was rated as unsatisfactory)

M. Formula Tracking Log:

Looking For:

Formula Tracking Log Overall Rating: MO-73

S SN

U NA Possible Points Points Awarded
5

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



NUTRITION UNIT MONITORING TOOL



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
issued/exchanged based on reconstituted fluid ounces?

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)

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:

S SN

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 15. 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)

U NA Possible Points Points Awarded
15

Districtpointsareassignedbyaveragingclinicscores
accordingtothefollowing.
x 1315average15Points(S) x 1012average10points(SN) x 79average5points(U)
<7.00points(U)
Clinic Record Review: High Risk Chart Evaluation / Special Formulas / Medical Documentation
MO-74

Total Weight Category Percent Weighte d Score

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



NUTRITION UNIT MONITORING TOOL



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

2

4. WIC Food Authorization

/ Restriction is clear without conflicting

2



information

5. Medical Documentation

in a valid date for

1



intended certification.

6. Diagnosis matches Indicated Use for Formula

1



7. Issuance Matches

Medical Documentation











2





Formula

8. Issuance Matches

Medical Documentation











2





Food

9. Appropriate Referrals Made

1



10. Food package changes adjusted correctly.











2





Total Points

15



Clinic Total % Awarded

District Record Review Summary: High Risk Chart Evaluation / Special Formulas / Medical Documentation
Clinic # Clinic # Clinic # Clinic # Clinic # Clinic #

DISTRICT: DATE:

Total Weight Category Percent Weighte d Score

NUMBER RECORDS REVIEWED:

1. Nutrition Education/High Risk Completed















1





2. Care Plan Documented















1





3. Medical Documentation Form Complete















2





MO-75

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



NUTRITION UNIT MONITORING TOOL



4. WIC Food Authorization

/ Restriction is clear without conflicting















2





information

5. Medical Documentation

in a valid date for















1





intended certification.

6. Diagnosis matches Indicated Use for Formula















1





7. Issuance Matches

Medical Documentation















2





Formula

8. Issuance Matches

Medical Documentation















2





Food

9. Appropriate Referrals Made















1





10. Food package changes adjusted correctly.















2





Total Points















15





Clinic Total % Awarded

O. Record Review Summary:

S

Record Review Summary Overall Rating:
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


SN U NA Possible Points Points Awarded 100

Total Weight Category Percent Weighte d 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

MO-76

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment MO-1 (cont'd)


NUTRITION UNIT MONITORING TOOL



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

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

MO-77

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



NUTRITION UNIT MONITORING TOOL



Clinic Total % Awarded

District Record Review Summary
Clinic #
DISTRICT: DATE:

Clinic #

Clinic #

Clinic #

Clinic #

Clinic #

Total Weight Category Percent Weighte d 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 Checked

10

7. All Nutritional Risks Documented

10

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) Documented

10

19. Secondary NE Contact

S = Satisfactory (Includes

Only Kept

15

Appointments)

U = Unsatisfactory

MO-78

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



NUTRITION UNIT MONITORING TOOL



(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

MO-79

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



NUTRITION 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
MO-80

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



NUTRITION UNIT MONITORING TOOL



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) 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.
MO-81

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



NUTRITION UNIT MONITORING TOOL



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).

e. Breastfeeding weeks should remain the same or increase with time.

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.
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.
MO-82

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



NUTRITION UNIT MONITORING TOOL



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.
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
MO-83

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Attachment MO-1 (cont'd)



NUTRITION UNIT MONITORING TOOL



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.

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-84

GEORGIA WIC PROGRAM 2013 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 the Georgia WIC

1

Program 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-85

GEORGIA WIC PROGRAM 2013 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-86

GEORGIA WIC PROGRAM 2013 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-87

GEORGIA WIC PROGRAM 2013 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-88

GEORGIA WIC PROGRAM 2013 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-89

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

CLINIC OBSERVATION Georgia WIC Program
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)

_____________________________________

_____________________________________

_____________________________________

_____________________________________

Form 4

MO-90

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

CLINIC OBSERVATION A. Preliminary Information Pre-Visit:

Form 4

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-91

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

CLINIC OBSERVATION B: Background:

Form 4

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-92

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

CLINIC OBSERVATION B: Background (cont'd):

Form 4

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-93

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

CLINIC OBSERVATION Reports For
Background Information

Form 4

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.

MO-94

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL


Attachment MO-2

STATE OF GEORGIA
DEPARTMENT OF PUBLIC HEALTH GEORGIA WIC PROGRAM
LOCAL AGENCY FFY 2013
MONITORING TOOL FINANCIAL REVIEW SECTION

MO-95

GEORGIA WIC PROGRAM 2013 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 the Georgia WIC Program 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 the Georgia WIC Program. 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 the Georgia WIC Program.

Within 10 days of Exit Conference

The Georgia WIC Program submits to the local agency a copy of the Financial Review. The Georgia WIC Program Financial Review Conference calls with the agency that was reviewed.

Within 20 days of Exit Conference

The local agency submits Corrective Action Plan to the Georgia WIC Program.

Within 30 days of Exit Conference

The Georgia WIC Program 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 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 the Georgia WIC Program by September 30th annually.

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GEORGIA WIC PROGRAM 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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Attachment MO-2 (cont'd)

AREAS OF REVIEW

YES NO

NA

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?

COMMENTS

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H. If applicable, is Program Income (i.e., interest) properly accounted
for?

Attachment MO-2 (cont'd)

AREAS OF REVIEW

YES NO

NA

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 the Georgia WIC Program as required?

6. Self Review
A. Was a Financial Self Review conducted by June 30th?

B. By whom was the review conducted?
C. Was a Corrective Action plan required and developed?


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-6

A. Participant Education Requirements .............................................................. BF-6

B. Documentation of Breastfeeding Services ..................................................... BF-9

VI. Participant Referral .................................................................................................... BF-9

A. Referrals ......................................................................................................... BF-9

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-10

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL


Breastfeeding

Page VIII. Allowable Costs for the Promotion and Support of Breastfeeding ............................ BF-12

A. Allowable Breastfeeding Promotion and Support Costs................................ BF-12

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-16
BF-2 Sample Job Description: Senior Public Health Educator Lactation Consultant ................................................................................................. BF-17
BF-3 Sample Job Description: District Breastfeeding Coordinator .................................... BF-19
BF-4 Guidelines for Breastfeeding Promotion and Support in Georgia WIC Program ............................................................................................................ BF-22
BF-5 Breastfeeding Resources Recommended by the Nutrition Services Unit .................BF-32
BF-6 Allowable and Unallowable Costs Breastfeeding Aids used for the Promotion and Support of Breastfeeding .......................................................................................... BF-35
BF-7 Issues to Consider When Providing Breast Pumps .................................................. BF-36
BF-8 Status Change from Prenatal to Breastfeeding and Assignment of Priority to Breastfeeding Mother and Infant............................................................................... BF-39
BF-9 Key for Entering Weeks Breastfed ............................................................................ BF-41
BF-10 Estimating Formula Needs........................................................................................ BF-43
BF-11 Types of Breast Pump Codes ................................................................................... BF-44

GEORGIA WIC PROGRAM 2013 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 the Georgia WIC Program participants.

Health professionals recognize that, in almost all circumstances, breastfeeding is the optimal method for ensuring proper infant nutrition, while simultaneously benefiting the lactating mother. The advantages of breastfeeding range from biochemical, immunological, and endocrinologic to psychosocial, developmental, 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 the Georgia WIC Program they have a unique opportunity to influence decisions on infant feeding. As stated in the Division of Public Health Position Paper on Breastfeeding (Attachment BF-1) a sound program of information and support is necessary to promote the successful establishment and maintenance of breastfeeding. Such a program should be integrated into the health care system and should encompass both the prenatal and postpartum periods.

II. DEFINITIONS
Breastfeeding promotion, education and support are components of a process through which individuals gain the understanding, skills and motivation necessary to be able to select breastfeeding as the preferred method of feeding, as well as to initiate and maintain breastfeeding for a significant period of time.
Federal Regulations (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 the Georgia WIC Program.
Mostly Breastfed (MBF) Infant: an infant being fed breastmilk and receiving from the Georgia WIC Program 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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Fully Formula Fed (FFF) Infant: an infant receiving from the Georgia WIC Program 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 the Georgia WIC Program 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 the Georgia WIC Program 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 the Georgia WIC Program.

III. STATE AGENCY

A. Breastfeeding Coordinator

The responsibility for coordination of Statewide WIC breastfeeding activities is vested within the Georgia Department of Public Health, Maternal and Child Health, Office of Title V and Integration.

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 the Georgia WIC Program.

B. Breastfeeding Promotion, Education and Support Responsibilities

The following are the state agency responsibilities for breastfeeding promotion, education and support:

1. Develop, implement and evaluate the state breastfeeding promotion, education and support plan. Periodically review and evaluate the plan, and make appropriate revisions as necessary.

2. Develop guidelines for local agency breastfeeding promotion, education and support plan development. Review each plan and provide feedback.

3. Monitor the progress of local agency breastfeeding promotion, education

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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.

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.

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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 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
The Georgia WIC Program is committed to the implementation of the Guidelines for Breastfeeding Promotion and Support in the WIC Program, developed by the National WIC Association (NWA) Breastfeeding Promotion Committee (Attachment BF-4). The local agencies are encouraged to use the Guidelines in carrying out the following breastfeeding responsibilities:
1. Establish and maintain a positive clinic environment that clearly endorses and supports breastfeeding as the preferred method of infant feeding (NWA Guidelines #2, #4).
a. It is important to assure that relevant education materials available to participants portray breastfeeding as the preferred infant feeding method. The following items must be free of formula product names: print and audiovisual materials, and office

BF-4

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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 the Georgia WIC Program.

a. Clerical and other non-CPA staff must receive training on maintaining a positive clinic environment, a positive and supportive attitude towards breastfeeding, and what they can do to promote and support breastfeeding in the clinic.

b. 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.

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GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

2. Continuing Education

Breastfeeding

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 Program 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, as part of the district WIC and nutrition plan, to the Georgia WIC Program by May 31, unless another date has been designated as the due date for that year for inclusion in the annual state plan.
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 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

BF-6

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Breastfeeding



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 the Georgia WIC Program) and mostly breastfeeding women (whose infants receive formula from the Georgia WIC Program 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. Nonbreastfeeding women and women classified as "Some Breastfeeding" are both receiving formula from the Georgia WIC Program that exceeds the maximum allowance for mostly breastfed (MBF) infants and thus are eligible for supplemental foods for only six (6) months postpartum.

c. The Georgia WIC Program 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


2HealthyPeople2000:NationalHealthPromotionandDiseasePreventionObjectives,U.S.
DepartmentofHealthandHumanServices,1990.

BF-7

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Breastfeeding



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. At the same time, it is important for the peer counselor or CPA to refer mom and baby to the breastfeeding coordinator or MD if the problem requires more expertise or medical treatment.

7. Local agencies are encouraged to use peer counselors trained by the state or local agency to provide encouragement, education, and support to prenatal and breastfeeding women.

8. Nutrition assistants can also provide breastfeeding education and support when appropriate training has been received. The Nutrition 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.

BF-8

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Breastfeeding



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. Documentation should follow the Nutrition Care Process. Approved formats include: ADIME (Assessment, Diagnosis, Intervention, Monitoring and Evaluation),and SOAP (Subjective Objective Assessment Plan) A flow sheet may be used as long as it contains all components of the Nutrition Care Process. ADIME format is the preferred method of documentation for Registered Dietitians.

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 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.

3. When an infant and mother comes in for midcerts, food package changes and high risk appointments breastfeeding weeks must be updated.

VI. PARTICIPANT REFERRAL

BF-9

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

A. Referrals

Breastfeeding

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. Stored supplies of formula, baby bottles and nipple must be kept out of view anywhere WIC participants are served.

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

BF-10

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Breastfeeding



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.

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:

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Breastfeeding

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

Breast pumps can be tracked in the WIC system by using the fields Date Breast Pump Assigned, Date Breast Pump Returned and Type of Breast Pump Assigned. Use codes to define the types of breast pumps assigned to a WIC participant:

Enter "N"(no tracking) if pump issued does not need to be returned (e.g., manual pump)

If the pump needs to be returned, enter appropriate code to identify type of pump

a. Date Breast Pump Assigned is completed when a breast pump is issued to a participant..

b. Date Breast Pump Returned is completed, when a WIC participant returns a breast pump. This filed can be completed even if the pump is returned during the next pregnancy. Local agencies must document the return pump on their breast pump inventory log.

c. Type of Breast Pump Assigned is a list of codes. Choose appropriate code. The list 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 updated on a quarterly basis. During program reviews, districts will be required to provide an inventory list. A 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

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A. Allowable Breastfeeding Promotion and Support Costs

Breastfeeding

The Georgia WIC Program expenditures that are classified and reported as breastfeeding promotion and support, and may count toward the BFPS spending requirement include, but are not limited to, the following:

Salaries:

1. Salary and other costs for time, including preparation and travel time, spent on BFPS training and consultations, both individual and group.

2. Salary and other costs, for staff to organize volunteers and community groups to support breastfeeding WIC participants.

3. Salary and benefit expenses of peer counselors and individuals hired to undertake home visits and other actions intended to assist women to continue breastfeeding.

4. Salary and other costs incurred in developing the BFPS portion of the State Plan and local agencies' BFPS action plans.

5. Interpreter or translator services to facilitate breastfeeding promotion and support.

Training:

6. Costs of training BFPS educators, including costs related to conducting training sessions and purchasing and producing training materials.

Space and Facilities:

7. Costs of clinic space devoted to BFPS education and training activities, including space set aside for breastfeeding WIC infants.

Materials and Equipment:

8. Costs of procuring and producing BFPS materials and equipment.

9. Breastfeeding aids which directly support the initiation and continuation of breastfeeding. 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.

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Travel:

Breastfeeding

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
The Georgia WIC Program documents breastfeeding rates by two different methods: percentage of women who are certified as breastfeeding (WIC Type B), and self-reported information on weeks breastfed (initiation & duration). It is important that documentation be accurate in both instances since they have a major impact on administration of the Georgia WIC Program. These two methods are described below:
A. Documentation of WIC Type
The state agency must have breastfeeding promotion and support expenditures which are based on the number of prenatal (WIC Type P) and breastfeeding women (WIC Type B) on the Georgia WIC Program. In addition, the Southeast Regional Office of USDA monitors changes in breastfeeding rates based on the number of women who are listed as breastfeeding (WIC Type B on the WIC System). Breastfeeding women should be entered into the system in the following ways:
1. Status Change from Prenatal (P) to Breastfeeding (B) During Subsequent Certification: A prenatal woman gives birth and is being certified as breastfeeding, within six weeks postpartum.
2. Status Change from Prenatal (P) to Breastfeeding (B) Without a Subsequent Certification: When a prenatal participant delivers her infant(s) and initiates breastfeeding, the local agency is encouraged to change the participant's status from that of Prenatal (P) to Breastfeeding (B) through an Update to the system. This should occur as soon as the local agency is made aware of the participant's change in status, as it will enable the program to capture those women who initiate breastfeeding, but may discontinue breastfeeding by their subsequent certification. A

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Breastfeeding



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 the Georgia WIC Program. (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

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 the Georgia WIC Program

These guidelines were developed to assist local and state WIC agencies initiate and strengthen breastfeeding promotion and support programs. The guidelines address training, clinic environment, coordinated efforts, program evaluation, breastfeeding education and support, and the food packages for breastfed infants and breastfeeding women. The guidelines are numbered for easy reference and are listed in random order. Therefore, the numbering system does not reflect rank order or priority.

GUIDELINE #1 Breastfeeding promotion and support are enhanced when local agency WIC staff receive orientation and task-appropriate training on breastfeeding as the preferred method of infant feeding.

GUIDELINE #2 Breastfeeding promotion and support are enhanced when policies encourage a positive clinic environment and endorse breastfeeding as the preferred method of infant feeding.

GUIDELINE #3 Breastfeeding promotion and support are enhanced when WIC agencies coordinate with the private and public health care systems, educational systems, and community organizations.

GUIDELINE #4 Breastfeeding promotion and support are enhanced when positive breastfeeding messages are incorporated in relevant educational activities, materials, and outreach efforts.

GUIDELINE #5 Breastfeeding promotion and support are enhanced when activities are evaluated on an annual basis.

GUIDELINE #6 Breastfeeding promotion and support are enhanced when appropriate breastfeeding education and support is offered to all pregnant WIC participants.

GUIDELINE #7 Breastfeeding promotion and support are enhanced when policies allow breastfeeding women to receive all WIC services regardless of their breastfeeding patterns.

GUIDELINE #8 Breastfeeding promotion and support are enhanced when policies allow breastfeeding infants to receive a food package consistent with their nutritional needs.

GUIDELINE #9 Breastfeeding promotion and support are enhanced when breastfeeding support and assistance is 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 the Georgia WIC Program operations. The specific responsibilities and tasks of breastfeeding coordinators will vary from agency to agency based on their breastfeeding promotion and support activities. Breastfeeding coordinators should participate in training opportunities related to their job responsibilities.

GUIDELINE #2 Breastfeeding promotion and support are enhanced when policies encourage a positive clinic environment and breastfeeding as the preferred method of infant feeding.

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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 the Georgia WIC Program 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

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Attachment BF-4 (cont'd)

design more effective breastfeeding promotion program components.

4. It is important that the state agency management evaluation process reviews local agency breastfeeding promotion and support activities such as: 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.

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Attachment BF-4 (cont'd)

3. It is important to include the participant's family and friends in breastfeeding education and support sessions.

Rationale: Assistance and emotional support from family and friends are helpful to a woman's initiation and continuation of breastfeeding.

4. It is important to encourage the mother to communicate her decision to breastfeed to appropriate hospital staff and physicians.

Rationale: To overcome potential barriers due to hospital and physician practices, women should be aware of the need to request the services that will facilitate successful breastfeeding, e.g., baby put to the breast soon after delivery.

5. It is important for the local WIC agency to coordinate prenatal breastfeeding education activities with primary care providers by: 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

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Attachment BF-4 (cont'd)

or increase breastfeeding.

Rationale: All breastfeeding women, regardless of their breastfeeding pattern, need ongoing support so that they feel positive about their breastfeeding experience.

GUIDELINE #8 Breastfeeding promotion and support are enhanced when policies allow breastfeeding infants to receive a food package consistent with their nutritional needs.

Suggestions for Implementation

1. It is important that the use of supplemental formula for breastfed infants be minimized.

Rationale: Support that encourages breastfeeding is more effective than offering more formula than the baby is currently using. Clear support which continues to build confidence includes praise and encouragement for her current level of breastfeeding. 2. It is important that vouchers with infant formula are not issued to exclusively breastfed infants. If a food instrument must be distributed to enroll the infant, consider printing a positive breastfeeding message on the voucher.

Rationale: A blank voucher emphasizes that the breastfeeding dyad may not be 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.

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GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL


Attachment BF-4 (cont'd)

GUIDELINE #9 Breastfeeding promotion and support are enhanced when breastfeeding support and assistance is provided throughout the postpartum period, particularly at critical times when the mother is most likely to need assistance.

Suggestions for Implementation

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.

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GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL


Attachment BF-4 (cont'd)

5. It is important that the state agency develop a protocol or guidelines regarding the distribution of breastfeeding aids, including:

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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GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL


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
BF-32

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL


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) 222-1222 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 PROGRAM 2013 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 PROGRAM 2013 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 the Georgia WIC Program, 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 the Georgia WIC Program 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 PROGRAM 2013 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 the Georgia WIC Program, the following issues should be considered in reference to each:

Giving Away Breast Pumps

Local agencies may give away breast pumps without any reimbursement from participants. This option applies to inexpensive manual breast pumps, small electric pumps, or electric pump attachment kits which do not represent a significant investment of program resources.

Selling Breast Pumps

Local agencies may provide breast pumps by charging a fee to WIC participants, i.e., the purchase price or a portion of the cost to the Georgia WIC Program, to partially or totally offset their cost. Since breast pumps are not a direct program benefit, they are not subject to the legislative requirement that WIC benefits must be provided at no cost to participants. Such a plan must be submitted to the 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:
a. establishing procedures to ensure that participants fully understand their rights

BF-36

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL


Attachment BF-7 (cont'd)

and responsibilities when signing liability release forms;
b. developing an agreement between the program and the participant which stipulates the participant's responsibility to reimburse the program for the value of a lost or damaged pump;
c. monitoring through periodic visual inspection, frequent inventory counts and records, and telephone check-ins; or
d. limiting pump loans only to special circumstances, e.g., after a minimum duration of breastfeeding or for certain medical conditions; and
e. charging a refundable deposit. This deposit must not present a barrier to the participant that would prevent her from being able to borrow the pump. While a lower deposit is encouraged, it must not exceed $20.00, for a hospital grade pump.

Participants may not be terminated or suspended for unreimbursed loss or damage to loaned pumps. While a financial penalty, if included in the original agreement, could be imposed on a participant for failure to return or damage to a pump, the Georgia WIC Program recommends that this approach not be taken. The resources required to recover the cost of the lost or damaged breast pump could easily exceed the value of the pump itself. Building a relationship of trust with WIC participants may minimize the risk of the participant not fulfilling the obligation to return the pump.

If it provides breast pumps, the Georgia WIC Program may also be liable for injury to a WIC participant resulting from improper breast pump use, even when there is a signed release of liability. This is true whether pumps are given, sold, or loaned. All participants provided with breast pumps by the Georgia WIC Program 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 the Georgia WIC Program to the third party provider, for example, through a loss or damage waiver or insurance fee.

Referrals

A local agency may opt to refer WIC participants to providers who rent breast pumps directly to participants at a fee, such as breast pump manufacturers, hospital pharmacies, and private lactation consultants. This option avoids the liability and financial issues for the program. However, it is likely to pose a financial barrier to WIC participants. In the Georgia WIC Program, this does not meet the requirement for the provision of support to breastfeeding women.

Medicaid Reimbursement

The cost of manual pump purchase and electric pump rentals are generally not covered as a separate benefit under the Medicaid Program. However, in Georgia, the state Medicaid Program

BF-37

GEORGIA WIC PROGRAM 2013 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 PROGRAM 2013 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.

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GEORGIA WIC PROGRAM 2013 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 the Georgia WIC Program prior to its mother being subsequently certified, the infant may be assigned one of the following priorities:
1. If the infant has a risk factor of its own that would result in it's being a Priority I, the infant must be assigned a Priority I.
2. If the infant has only nutritional risk factor 701 (Infant of a WIC Mother or Mother with Nutritional Risk During Pregnancy), assign a Priority II. It may be helpful to "flag" the infant's name/record through an internal tracking system (tickler card, computer, voucher register, etc.) to alert staff to the need to re-evaluate the infant's priority at the mother's postpartum certification.
3. If the infant's mother was assigned a Priority I based on documented postpartum breastfeeding risk factors, assign a Priority I to the infant.
C. When the mother of a breastfeeding infant is certified at a later time than the infant, one of the following actions must be taken:
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).

BF-40

GEORGIA WIC PROGRAM 2013 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 Program 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

BF-41

GEORGIA WIC PROGRAM 2013 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.

BF-42

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

Estimating Formula Needs

Attachment BF-10

Amount of Powder Formula to Issue
1 can 2 cans 3 cans 4 cans 5 cans

Daily Formula Intake
3 oz 6 oz 9 oz 12 oz 16 oz

Weekly Formula Intake
14 20 oz 27 41 oz 40 62 oz 54 83 oz 68 104 oz

Monthly Amount Needed
80 - 90 oz 116 - 180 oz 172 - 270 oz 232 - 360 oz 292 - 450 oz

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)

0-3

4-5

Powder (12.7 oz)

9

10

Concentrate (12.1 oz)

34

37

Ready to feed (33.8 oz)

25

27

6-11 7 26 19

Maximum Amounts Allowed for Standard Formula Mostly Breastfed Infant

Age (months)

0-1

2-3

4-5

Powder (12.7 oz)

1

4

5

Concentrate (12.1 oz)

3

15

18

Ready to feed (33.8 oz)

3

12

14

6-11 4 13 10

BF-43

GEORGIA WIC PROGRAM 2013 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

BF-44

GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL

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Division of Public Health Statewide Standard List of Abbreviations
Final September 2010
Georgia Division of Public Health Statewide Standard List
ABBREVIATIONS, ACRONYMS, AND SYMBOLS

Abbreviation or Acronym (L) (R) /hpf A and O A and P aa AACRN
AAHIVM AB abd
ac ACHES
ACRN ACTG ADA ADAP ADC ADLs AED AETC AF AFB AGCUS
AGN AHYD
AIDS AIN AlkPhos ALT amb AMBU amnio

Definition left right per high power field
before alert and oriented auscultation and percussion of each Advanced AIDS Certified Registered Nurse American Academy of HIV medicine abortion abdomen
before meals Abdominal pain, chest pain, headache, eye problems, and severe leg pains (early danger signs of oral contraceptive adverse effects) AIDS Certified Registered Nurse AIDS Clinical Trial Group American Dietetic Association AIDS Drug Assistance Program AIDS Dementia Complex Activities of daily living automated external defibrillator AIDS Education and Training Centers anteflexed acid-fast bacilli atypical glandular cells of undetermined significance Acute glomerulonephritis Adolescent Health and Youth Development acquired immunodeficiency syndrome anal intraepithelial neoplasia alkaline phosphatase alanine aminotransferase ambulatory air-shields manual breathing unit amniocentesis

1

Abbreviation or Acronym amt ant Anti-HBc
Anti-HBs
Anti-HCV AP appt APRN ARC ART ARV ASAP ASCUS
ASQ AST (formally SGOT) AV AV nicking
AVN BA bact BAMT
BBS BBT BC BCA BCCP BCM BCW b-DNA test BF BFC BFR syndrome bid bilat bili BM BMD BMI BP

Division of Public Health Statewide Standard List of Abbreviations
Final September 2010
Definition amount anterior Hepatitis B antibodies to the core antigen Hepatitis B antibodies to the surface antigen Hepatitis C Virus Antibodies antepartum appointment Advanced Practice Registered Nurse AIDS-Related complex antiretroviral therapy antiretroviral as soon as possible atypical squamous cells of undetermined significance Ages and Stages Questionnaire aspartate aminotransferase anteverted arteriovenous nicking (or arterial narrowing) avascular necrosis bacillary angiomatosis bacterial Blood assay for Mycobacterium tuberculosis bilateral breath sounds basal body temperature Board Certified bichloroacetic acid Breast and Cervical Cancer Program body cell mass Babies Can't Wait branched DNA Assay breastfeeding breastfeeding class body fat redistribution syndrome twice a day bilateral bilirubin bowel movement bone mineral density body mass index blood pressure

2

Abbreviation or Acronym BRAIDED
BS BS and O
BSE BTB BTL BTM BUM BUN BUS
BV Bx c C C and S c/o Ca CA CAD caps cath CBC CBE
CBO CC CCR5
CD4 percentage
CD4:CD8 ratio
CD4+ count
CD8 count
CDC
CDC-NAH

Division of Public Health Statewide Standard List of Abbreviations
Final September 2010
Definition benefits, risks, alternatives, inquiries, decision, explanation, documentation bowel sounds bilateral salpingectomy and oophorectomy breast self exam break through bleeding bilateral tubal ligation BreastTest and More back-up method blood urea nitrogen Bartholin's, Urethral, and Skene's Glands bacterial vaginosis biopsy with Celsius culture and sensitivity complains of calcium carcinoma or cancer coronary artery disease capsules catheter/catheterization complete blood count clinical breast exam or Child Birth Educator (when used behind a name) Community Based Organization chief complaint Cell surface molecule, which is needed along with the primary receptor, the CD4 cell, in order to fuse with the membranes of the immune system cells. percentage of T-lymphocytes with the CD4 surface receptor ratio of CD4 T-lymphocytes to CD8 Tlymphocytes CD4+ T-lymphocyte count, CD4+ Thelper/inducer cells. CD8 T-lymphocyte count, CD8 Tsuppressor cells Centers for Disease Control and Prevention Centers for Disease Control and Prevention National AIDS Hotline
3

Abbreviation or Acronym cert CF CHD CHF chla CHO chol cig CIN I, II, or III
circ CIS CKC CLD cm CME CMO CMT CMV CMS CNM CNS colpo cong CoNM cont contra(s) COPD cp CP CPD CPK CPR CrCl cryo CS CSF CT scan CTA CTL
CVA CVAT CVD

Division of Public Health Statewide Standard List of Abbreviations
Final September 2010
Definition certification Children 1st coronary heart disease congestive heart failure chlamydia carbohydrate cholesterol cigarette cervical intraepithelial neoplasia, grade 1, 2, or 3 circumcision carcinoma in situ Cold-knife cone/conization chronic lung disease centimeter continuing medical education care management organization cervical motion tenderness cytomegalovirus Children's Medical Services Certified nurse midwife central nervous system colposcopy congenital county nurse manager continued contraindication(s) chronic obstructive pulmonary disease chest pain Cerebral Palsy cephalopelvic disproportion creatine phosphokinase cardiopulmonary resuscitation creatinine clearance cryotherapy cesarean section cerebral spinal fluid computed tomography scan clear to auscultation Cytotoxic T Lymphocyte; also known as Killer T-cells cerebrovascular accident Costovertebral angle tenderness cardiovascular disease

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Abbreviation or Acronym CWSN cx CXR D D and C D and E d/f D/T DASH
DBP del dept derm DFA DFCS
DHHS
disc dist DJD dk dL DM DMAC
DNA DNKA DOB DOE DOT DRE DSPS
DTR DUB DVT DX e.g. EAB EBF EBV EC

Division of Public Health Statewide Standard List of Abbreviations
Final September 2010
Definition Children with Special Needs cervix chest X-ray deltoid dilation and curettage dilation and evacuation dark field due to Dietary Approaches to Stop Hypertension Meal Plan diastolic blood pressure delivery department dermatology direct fluorescent antibody Division of Family and Children's Services Department of Health and Human Services discussed distilled degenerative joint disease dark deciliter (100mL) diabetes mellitus Disseminated Mycobacterium Avium Complex deoxyribonucleic acid did not keep appointment date of birth dyspnea on exertion directly observed therapy digital rectal exam Diagnostic, Screening and Preventive Services deep tendon reflexes dysfunctional uterine bleeding deep vein thrombosis diagnosis for example elective abortion exclusively breastfed Ebstein-Barr virus emergency center

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Abbreviation or Acronym ECC ECG ECHO ECP EDC educ EEG EENT EFW EGA EIA EL elec ELISA EMS enc ENT EOMI EPA EPI epith EPSDT
ER ESIP ESR ET ETOH eval ext ext gen F F#P#A#L# F and C FBG FDA Fe FF FFF FH FHT Fis fl fm

Division of Public Health Statewide Standard List of Abbreviations
Final September 2010
Definition endocervical curettage electrocardiogram echocardiogram emergency contraceptive pill estimated date of confinement education electroencephalography ear, eyes, nose, throat estimated fetal weight estimated gestational age enzyme immunosorbent assay early latent elective enzyme linked immunosorbent assay emergency medical system encourage ear, nose, throat extraocular movements intact Environmental Protection Agency epidemiology or epidemiologist epithelial Early Periodic Screening, Diagnosis and Treatment (Program) emergency room engineered sharps injury protection erythrocyte sedimentation rate estrogen therapy alcohol evaluation external external genitalia fahrenheit full-term, pre-term, abortions, living foam and condoms fasting blood glucose Food and Drug Administration iron force fluids fully formula fed Family Health fetal heart tones fusion inhibitors fluid family

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Abbreviation or Acronym FNP FOB FOBT FP FPC FPS FS FSH FT F/T FTA
FTA-ABS
FTP FTT F/U FUO F/V Fx FYI G#P#A# G6-PD GA GB GBHC GBS GC G-CSF GE GERD gest GF GFR GGT GI glu gm gm/dL GM-CSF
GNID GNRH GP

Division of Public Health Statewide Standard List of Abbreviations
Final September 2010
Definition Family Nurse Practitioner father of baby fecal occult blood test family planning food package code family planning services food stamps follicle stimulating hormone full term full time fluorescent treponema antigen (test for syphilis) fluorescent treponemal antibody absorption failure to progress failure to thrive follow-up fever of unknown origin fruits and vegetables fracture for your information gravida, parity, abortions glucose 6 phosphate dehydrogenase Georgia gallbladder Georgia Better Health Care group B strep gonorrhea (gonorrhea coccii) granulocyte-colony stimulating factor gastroesophageal gastroesophageal reflux disease gestational grandfather glomerular filtration rate gamma glutamic transpeptidase gastrointestinal glucose gram grams per deciliter granulocyte macrophage-colony stimulating factor gram negative intracellular diplococci gonadotropin releasing hormone glycoprotein

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Abbreviation or Acronym GRITS
GS GTT gtt GU GYN H and P H. influenza H/A H2O HAART HAD HAV HbA1c HBIG HBP HBsAg HBV HC HCG Hct HCV HD HDL HEENT Helper T Cells
Hg Hgb HGH HGSIL
HHV-8 Hi-cal Hi-pro HIV HIV-1 RNA HIVAN Hi-vit HLA HMO H/O

Division of Public Health Statewide Standard List of Abbreviations
Final September 2010
Definition Georgia Registry of Immunization Transactions and Services gram stain glucose tolerance test drop genitourinary gynecology history and physical Haemophilus influenzae headache water highly active antiretroviral therapy HIV-associated dementia hepatitis A virus hemoglobin A1c hepatitis B immune globulin high blood pressure hepatitis B surface antigen hepatitis B virus Health Check human chorionic gonadotropin hematocrit hepatitis C virus health department high density lipoproteins head, eyes, ears nose, & throat Lymphocytes bearing the CD4 marker that are responsible for many of the immune responses. mercury hemoglobin human growth hormone high grade squamous intra epithelial lesions human herpesvirus-8 high calorie high protein human immunodeficiency virus HIV viral load HIV-associated nephropathy high vitamin Human Leukocyte Antigen health maintenance organization History of

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Abbreviation or Acronym hosp HPI HPTN HPV HR hr HRT HRIFU HRNE HRSA
HSV HSV 1 or 2 ht HT HTLV 1 or 2
HTN HVTN hx I and D I and O IAS IAS-USA IBCLC
ICS ICTF ID IDDM IDSA IDU i.e. IFN-g Ig IgA IgE IgG IgM IGRA IHD IHS IL-2 IM

Division of Public Health Statewide Standard List of Abbreviations
Final September 2010
Definition hospital history of present illness HIV Prevention Trials Network human papilloma virus heart rate hour hormone replacement therapy (High Risk Infant Follow-Up) high risk nutrition education Health Resources and Services Administration (U.S.) herpes simplex virus Herpes simplex virus 1 or 2 height hormone therapy Human T Cell Lymphotropic Virus Type 1 or 2 hypertension HIV Vaccine Trials Network history incision and drainage intake and output International AIDS Society International AIDS Society-U.S.A International Board Certified Lactation Consultation intercostal space Indigent Care Trust Fund intradermal insulin-dependent diabetes mellitus Infectious Diseases Society of America injection drug users that is Interferon-gamma Immunoglobulin Immunoglobulin A Immunoglobulin E Immunoglobulin G Immunoglobulin M Interferon-gamma release assay tests ischemic heart disease Indian Health Service Interleukin 2 intramuscular

9

Abbreviation or Acronym Imm in IN infl info inst int intravag invol IOP IRB irreg ITP
IUD IUFD IUFGR IUI IUP IV IVDA IVIG JTPA JVD kg KS KUB L L and D LA lab lap Lat LAT lax lb(s) LCM LD LD
LDL LE LEEP LF

Division of Public Health Statewide Standard List of Abbreviations
Final September 2010
Definition immunizations inch intranasal inflammation information instruction, instructed internal intravaginal involution intraocular pressure Institutional Review Board irregular Idiopathic Immune Thrombocytopenia Purpura intrauterine device intrauterine fetal demise intrauterine fetal growth restriction intrauterine insemination intrauterine pregnancy intravenous IV drug abuse intravenous immune globulin Job Training Partnership Act jugular vein distention kilogram Kaposi's sarcoma kidney, ureter, bladder (x-ray) liter labor and delivery left arm laboratory laparoscopy lateral left anterolateral thigh laxative pound(s) left costal margin left deltoid Licensed Dietitian (when used behind a name) low-density lipoproteins lower extremities loop electro-excisional procedure low fat

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Abbreviation or Acronym LFA LFT LFTS LG LGA LGM LGSIL
LGV LH LL LLE LLFA LLL LLQ LLSB LMP LNG IUS LNMP LOC LPN LR LRNE LPC LRSB LS LSB LT LTBI LUL LUQ LUT LVH LVL LWA M m M. tb M/C M/S MAC MAI MAL mammo

Division of Public Health Statewide Standard List of Abbreviations
Final September 2010
Definition left forearm liver function test liver function test series left gluteal/gluteus large for gestational age left upper outer gluteus maximus low-grade squamous, intra-epithelial lesion lymphogranuloma venereum luteinizing hormone late latent left lower extremity left lower forearm left lower lobe left lower quadrant left lower sternal border last menstrual period a specific type of intrauterine system last normal menstrual period level of consciousness Licensed Practical Nurse low risk low risk nutrition education lactation peer counselor lower right sternal border lumbosacral left sternal border left thigh latent TB infection left upper lobe left upper quadrant left upper thigh left ventricular hypertrophy left vastus lateralis last WIC appointment murmur meter Mycobacterium tuberculosis Medicaid musculoskeletal mycobacterium avium complex mycobacterium avium intracellular mid-axillary line mammogram

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Abbreviation or Acronym MAP mcg MCL MCV MD MDR MDR-TB med mEq mg mg/dL MGF MGM MH MHC MI mid min ML mL MLE mm mm3 mmHg MMWR mo mod MP MPC MRI MRSA
MSAFP MSM MTD
mthy multip MVA MVP N and T N/A N/V Na

Division of Public Health Statewide Standard List of Abbreviations
Final September 2010
Definition mean arterial pressure microgram mid-clavicular line Mean corpuscular volume medical doctor Multidrug-resistant multidrug-resistant tuberculosis medicine, medication milliequivalent milligram milligrams per deciliter maternal grandfather maternal grandmother mental health major histocompatibility complex myocardial infarction middle minute midline milliliter midline episiotomy millimeter cubic millimeter millimeters of mercury Mortality and Morbidity Weekly Review month moderate menstrual pain mucopurulent cervicitis magnetic resonance imaging methicillin-resistant Staphylococcus aureus maternal serum alpha-fetoprotein men having sex with men amplified Mycobacterium tuberculosis direct test monthly multipara motor vehicle accident mitral valve prolapse nose and throat not applicable nausea and vomiting sodium

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Abbreviation or Acronym NAAT NAEPP
NB NDA NE NEFS neg NET NFP NGU NHL NHLBI
NI NIAID
NIDDM NIH NK Cells NKA NKDA NKFA NP NPNC NPO NS nsg NSR NSSP NSU NSV NSVD NT NUG nullip NUP nut educ nutr NWA O/R O2 OB OB-Gyn

Division of Public Health Statewide Standard List of Abbreviations
Final September 2010
Definition nucleic acid amplification tests National Asthma Education and Prevention Program (U.S.) newborn next doctors appointment not evaluated/not examined nutrition education flowsheet negative non emergency transport natural family planning non-gonococcal urethritis Non-Hodgkin's Lymphoma National Heart, Lung, and Blood Institute not indicated National Institute of Allergy and Infectious Diseases (U.S.) non-insulin-dependent diabetes mellitus National Institutes of Health (U.S.) natural killer cells no known allergies no known drug allergies no known food allergies nurse practitioner no prenatal care nothing by mouth normal saline nursing normal sinus rhythm normal size, shape, position non-specific urethritis non-specific vaginitis normal, spontaneous, vaginal delivery non-tender necrotizing ulcerative gingivitis nullipara necrotizing ulcerative periodontitis nutrition education nutritionist (when used behind a name) next WIC appointment oral, rectal oxygen obstetrics or obstetrical obstetrics and gynecology

13

Abbreviation or Acronym OC occ OD OGTT OHL OI oint OM OR OSHA
OTC outpt oz P p PA pap path PBF pc PCM PCP
PCR PDR PE PEM/CAID PEP PERRLA
pg/mL PGF PGL
PGM pH
PH PHN PHP PHT PI PID

Division of Public Health Statewide Standard List of Abbreviations
Final September 2010
Definition oral contraceptive occasional overdose oral glucose tolerance test oral hairy leukoplakia opportunistic infection ointment otitis media operating room
Occupational Safety and Health Administration over the counter outpatient ounce pulse after physician's assistant Papanicolaou smear pathology partially breastfed after meals, after food Perinatal Case Management Pneumocystis jiroveci (carinii) pneumonia polymerase chain reaction test Physician's Desk Reference physical examination presumptive eligibility Medicaid postexposure prophylaxis pupils equal, round, react to light & accommodation picogram per milliliter paternal grandfather persistent generalized lymphadenopathy paternal grandmother potential of hydrogen (measure of acidity/alkalinity) public health public health nurse primary health care provider Public Health Technician present illness pelvic inflammatory disease

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Abbreviation or Acronym PIH pks PKU pm PMH PML
PMS PN PNC PO POS poss post post-op POTx PP PPD
PPE PPNG
pptl PR preg preg prev prep primip prn prob PROM PRS PSA psych PT PTL pt PTT P/U PVC PWA q q2h q3h

Division of Public Health Statewide Standard List of Abbreviations
Final September 2010
Definition pregnancy induced hypertension packs phenylketonuria afternoon, evening past medical history Progressive multifocal leukoencephalopathy premenstrual syndrome prenatal prenatal care by mouth, orally problem oriented system possible posterior after operation proof of treatment post partum purified protein derivative (antigen used for TB skin test) personal protective equipment penicillinase producing Neisseria gonorrhea post-partum tubal ligation per rectum pregnant pregnancy prevention preparation primipara as often as necessary probably or probable premature rupture of membranes Pregnancy Related Services prostate specific antigen psychiatry prothrombin time preterm labor patient partial thromboplastin time pick up premature ventricular contraction person with AIDS every every two hours every three hours

15

Abbreviation or Acronym q4h QFT
QFT-G qh qhs qid qn qns QPNG qs R/F R/O R/S R/T RA RAT RBC RCM RD
RD RDA rec reck ref reg rel REM resp RF RG RGM Rh RIBA RLFA RLL RLQ RN RNA RNC ROI ROM ROS

Division of Public Health Statewide Standard List of Abbreviations
Final September 2010
Definition every four hours QuantiFERON - a type of blood assay for Mycobacterium tuberculosis QuantiFERON Gold every hour at bedtime four times daily every night or nightly quantity not sufficient quinolone-resistant Neisseria gonorrhea quantity sufficient refill rule out reschedule related to right arm right anterolateral thigh red blood cells right costal margin Registered Dietitian (when used behind a name) right deltoid recommended daily allowance recommend or recommended recheck referral/refer regular related rapid eye movement respiration(s) retroflexed right gluteal/gluteus right upper outer gluteus maximus Rhesus blood factor recombinant immunoblot assay right lower forearm right lower lobe right lower quadrant Registered Nurse ribonucleic acid Registered Nurse Certified Release of information range of motion review of systems

16

Abbreviation or Acronym RPR RRR RSM RSR RSV RT RTC RTF RTI RT-PCR
RUQ RUT RV RVT Rx Ryan White CARE Act
s S/P S/S S=D SA SAB SBP SCJ SCM SCr SE SEATEC
sed rate SENDSS
SF SGA SGOT
SGPT SHAPP
SIDS SIL sl sm

Division of Public Health Statewide Standard List of Abbreviations
Final September 2010
Definition rapid plasma reagin regular rate and rhythm Right from the Start Medicaid regular sinus rhythm Respiratory syncytial virus right thigh return to clinic ready to feed reverse transcriptase inhibitors reverse transcriptase-polymerase chain reaction right upper quadrant right upper thigh retroverted right vastus lateralis therapy, treatment Ryan White Comprehensive AIDS Resources Emergency Act without status post signs and symptoms size equals date stomach ache spontaneous abortion systolic blood pressure squamous columnar junction sternocleidomastoid serum creatinine side effects Southeast AIDS Education and Training Center erythrocyte sedimentation rate State Electronic Notifiable Disease Surveillance System sugar free small for gestational age serum glutamic oxaloacetic transaminase serum glutamic-pyruvic transaminase Stroke and Heart Attack Prevention Program sudden infant death syndrome squamous intraepithelial lesion slightly small
17

Abbreviation or Acronym SMBG SOAP SOB sono sp spec SPF SST staph STAT STD STI strep STS surg subQ SVD SVR sx T-cell count T and A TAB tab TAH TAM TANF
TB TBW TCA TD TE temp TFZ TG TIA tid tl TLC TM TNF-a TNTC TOP TPPA

Division of Public Health Statewide Standard List of Abbreviations
Final September 2010
Definition self monitoring blood glucose Subjective, Objective, Assessment, Plan shortness of breath sonogram species specimen sun protective factor Social Services Technician Staphylococcus aureus immediate and once only (latin:statim) sexually transmitted disease structured treatment interruption Streptococcus serological test for syphilis surgery or surgical subcutaneous spontaneous vaginal delivery sustained virologic response symptoms CD4+ T-lymphocyte count tonsillectomy and adenoidectomy therapeutic abortion tablet total abdominal hysterectomy teenage mother Temporary Assistance for Needy Families tuberculosis total body weight trichloracetic acid transdermal toxoplasmic encephalitis temperature transformation zone triglycerides transient ischemic attack three times daily tubal ligation total lymphocyte count tympanic membrane Tumor Necrosis Factor - alpha too numerous to count termination of pregnancy Treponema pallidum particle

18

Abbreviation or Acronym
TPR Trich TSE TSH TST TU TUPP TVH tx UA UCG ULNS umb UOQ URI US USPHS ut UTD UTI UV V and H2O VAERS vag VAIN VC VCF VD VDRL
via VIN VIP Viral Load Test
Vit VL VS vs VVC VZIG

Division of Public Health Statewide Standard List of Abbreviations
Final September 2010
Definition agglutination temperature, pulse, respiration Trichomonas testicular self exam thyroid stimulating hormone tuberculin skin test tuberculin unit Tobacco Use Prevention Program total vaginal hysterectomy treatment urinalysis urine chorionic gonadotropin upper limits of normal size umbilicus or umbilical upper outer quadrant upper respiratory infection ultrasound United States Public Health Services uterus up to date urinary tract infection ultraviolet vinegar and water vaccine adverse event reporting system vagina or vaginal vaginal intraepithelial neoplasia voucher code vaginal contraceptive film venereal disease Venereal Disease Research Laboratory flocculation test for syphilis, quantitative by way of vulvar intraepithelial neoplasia voluntary interruption of pregnancy Test that measures the quantity of HIV RNA in the blood. Results are expressed as the number of copies per millimeter of blood. vitamin viral load vital signs versus vulvovaginal candidiasis Varicella-zoster immune globulin

19

Abbreviation or Acronym VZV WBC w/c WG WH WHMP WHNP WHO WIC wk WN WNL wt y.o. yr

Division of Public Health Statewide Standard List of Abbreviations
Final September 2010
Definition Varicella Zoster Virus white blood cells wheelchair whole grain women's health Women's Health Medicaid Program Women's Health Nurse Practitioner World Health Organization Women, Infants and Children week well nourished Within normal limits weight year(s) old year

20

Symbol


n p # % ' f 1q 2q 3q ~ (-) (+) = X @

Division of Public Health Statewide Standard List of Abbreviations
Final September 2010
Definition none with no female
male
increase decrease number percent change infinity primary or first degree secondary or second degree tertiary or third degree divided by or division approximately negative positive degree equals not equal to times at check or checked

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Division of Public Health Statewide Standard List of Abbreviations
Final September 2010
Patient Safety-Error Prone Abbreviations and Dose Expressions
The table below contains a select number of common abbreviations and dose designations used in public health documentation that are associated with being "error prone" according to the Institute of Safe Medication Practices, the National Coordinating Council for Medication Error Reporting and Prevention, and the Joint Commission. NOTE: These abbreviations and dose designations are not to be used in public health documentation.

Abbreviation AD, AS, AU cc D/C HS IU QD or qd QOD or qod SC or SQ TIW U or u ug Dose Designations Trailing zero after the decimal point (e.g. 1.0) No leading zero before a decimal dose (e.g. .5mg) Symbols < < > > &

Intended Meaning right ear, left ear, each ear Y cubic centimeter Y discontinue Y half strength or hour of sleep Y international unit * Y every day * Y every other day * Y subcutaneous Y three times a week Y unit * Y microgram Y Intended Meaning 1 mg * Y
0.5 mg * Y
Intended Meaning less than less than or equal to greater than greater than or equal to and

* Included on the Joint Commission's "minimum list" of dangerous, abbreviations, acronyms, and symbols that must be included on an organization's "Do Not Use" list, effective January 1, 2004. An updated list of frequently asked questions about this Joint Commission requirement can be found on their website at www.jointcommission.org.

22

Division of Public Health Statewide Standard List of Abbreviations
Final September 2010
Y Included on the chart of dangerous abbreviations from the National Coordinating Council for Medication Error Reporting and Prevention www.nccmerp.org/council/council2002-06-11.html. The American Society of Health Care Pharmacists and the FDA endorse the recommendations from this council. NOTE: Symbols listed on the "Do Not Use" list may only appear on laboratory generated reports and can not be documented in the clinical health record.
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