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Mitchem, RD, LD ,QWHULP 1XWULWLRQ 6HUYLFHV 'LUHFWRU 'DOOLV 6WUHHW /D*UDQJH *HRUJLD )$; District 5, Unit 1 (Dublin) %OHFNOH\ 'RGJH /DXUHQV Lawton Davis, M.D. 0RQWJRPHU\ 'LVWULFW +HDOWK 'LUHFWRU 3XODVNL 7HOIDLU Bruce Evans, M.S. 7UHXWOHQ :LOFR[ 3URJUDP 0DQDJHU :KHHOHU -RKQVRQ Brent Gibbs, R.D., L.D. 1XWULWLRQ 6HUYLFHV 'LUHFWRU 6RXWK &HQWUDO +HDOWK 'LVWULFW % %HOOHYXH 5RDG 'XEOLQ *$ )$; ,1 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Introduction DISTRICT/ADDRESS District 5, Unit 2 (Macon) David N. Harvey, M.D. 'LVWULFW +HDOWK 'LUHFWRU Roy Moore 3URJUDP 0DQDJHU Nancy Jeffery, MPH, RD, LD 1XWULWLRQ 6HUYLFHV 'LUHFWRU &ROXPEXV 5RDG 6XLWH % 0DFRQ *HRUJLD )$; COUNTIES SERVED # OF WIC CLINIC SITES +DQFRFN +RXVWRQ -DVSHU %DOGZLQ %LEE &UDZIRUG -RQHV 0RQURH 3HDFK 3XWQDP 7ZLJJV :DVKLQJWRQ :LONLQVRQ 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 %XUNH &ROXPELD (PDQXHO *ODVFRFN -HIIHUVRQ :LONHV :DUUHQ -HQNLQV /LQFROQ 0F'XIILH 5LFKPRQG 6FUHYHQ 7DOLDIHUUR District 7 (Columbus) 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 $YHQXH 32 %R[ &ROXPEXV *$ )$; +DUULV 7DOERW 'RRO\ 4XLWPDQ 7D\ORU 0DULRQ 0DFRQ &ULVS 6XPWHU &OD\ 6FKOH\ :HEVWHU 5DQGROSK 6WHZDUW 0XVFRJHH &KDWWDKRRFKHH ,1 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Introduction DISTRICT/ADDRESS District 8, Unit 1 (Valdosta) William Grow, MD,FACP 'LVWULFW +HDOWK 'LUHFWRU Elsie Napier 3URJUDP 0DQDJHU Holly Rountree, RD,LD 1XWULWLRQ 6HUYLFHV 'LUHFWRU /RZQGHV &RXQW\ +HDOWK 'HSDUWPHQW 1RUWK 3DWWHUVRQ 6WUHHW 9DOGRVWD *$ )$; COUNTIES SERVED %HQ +LOO %HUULHQ %URRNV &RRN (FKROV ,UZLQ 7LIW 7XUQHU /DQLHU /RZQGHV # OF WIC CLINIC SITES 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 * $OEDQ\ *$ )$; %DNHU /HH &DOKRXQ 0LOOHU &ROTXLWW 0LWFKHOO 'HFDWXU 6HPLQROH 'RXJKHUW\ 7HUUHOO (DUO\ 7KRPDV *UDG\ :RUWK District 9, Unit 1 (Coastal) %U\DQ &DPGHQ Diane Z. Weems, MD &KDWKDP 'LVWULFW +HDOWK 'LUHFWRU (IILQJKDP Saroyi Morris *O\QQ 3URJUDP 0DQDJHU /LEHUW\ VACANT /RQJ 1XWULWLRQ 6HUYLFHV 'LUHFWRU 0F,QWRVK &RQWDFW 3HUVRQ 3DW 0REOH\ 6FDQWRQ &RQQHFWRU %UXQVZLFN *$ ,1 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$FWLQJ Heather Peebles, RD, LD 'LVWULFW 1XWULWLRQ 6HUYLFHV 'LUHFWRU 6RXWKHDVW +HDOWK 'LVWULFW % &KXUFK 6WUHHW :D\FURVV*$ )$; COUNTIES SERVED $SSOLQJ $WNLQVRQ %DFRQ -HII 'DYLV %UDQWOH\ :DUH %XOORFK &DQGOHU &OLQFK &KDUOWRQ (YDQV &RIIHH :D\QH 3LHUFH 7RRPEV 7DWWQDOO # OF WIC CLINIC SITES District 10 (Athens) %DUURZ &ODUNH (OEHUW *UHHQ Claude A. Burnett, M.D. -DFNVRQ 0DGLVRQ 'LVWULFW +HDOWK 'LUHFWRU 0RUJDQ 2FRQHH Louis Kudon, PhD. :DOWRQ 2JOHWKRUSH 3URJUDP 0DQDJHU Vicky Moody, M.P.H., L.D. 1XWULWLRQ 6HUYLFHV 'LUHFWRU 3DUDGLVH %OYG $WKHQV *$ )$; Ann Sears, MED 1XWULWLRQ 6HUYLFHV 'LUHFWRU 1 +DUULV 6WUHHW $WKHQV *$ )$; Grady Health System $// Rondell Jaggers, Pharm.D. ,QWHULP ([HFXWLYH 'LUHFWRU RI 3KDUPDF\ &OLQLFDO 1XWULWLRQ Bernadine Joubert 'LUHFWRU RI 1XWULWLRQ 6HUYLFHV Payal Arora, MS, RD, LD 1XWULWLRQ 6HUYLFHV 'LUHFWRU *UDG\ +HDOWK 6\VWHP -HVVH +LOO -U 'ULYH 6( $WODQWD *$ )$; ,1 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Introduction % 6WDWH $JHQF\ State agency agrees: )RU WHFKQLFDO DVVLVWDQFH UHJDUGLQJ DOO DUHDV H[FHSW QXWULWLRQUHODWHG WRSLFV FRQWDFW WKH *HRUJLD :,& 3URJUDP 7R DOORFDWH 1XWULWLRQ 6HUYLFHV $GPLQLVWUDWLRQ 16$ IXQGV WR WKH ORFDO DJHQF\ IRU XVH LQ PHHWLQJ UHLPEXUVHG DOORZDEOH :,& DGPLQLVWUDWLYH QXWULWLRQ HGXFDWLRQ EUHDVWIHHGLQJ DQG FOLHQW VHUYLFH H[SHQVHV RI WKH ORFDO DJHQF\ 7R SD\ FRVW IRU IRRG YRXFKHUV LVVXHG E\ WKH ORFDO DJHQF\ DQG UHGHHPHG E\ SDUWLFLSDWLQJ DXWKRUL]HG YHQGRUV IRU HOLJLEOH SDUWLFLSDQWV 7R PRQLWRU DQG HYDOXDWH WKH ORFDO DJHQF\ WR LQVXUH PD[LPXP HIIHFWLYHQHVV DQG HIILFLHQF\ WR SURYLGH WHFKQLFDO DVVLVWDQFH FRQVXOWDWLRQ DQG WUDLQLQJ WR LPSURYH SHUIRUPDQFH 7R SURYLGH VSHFLILF PDQXDOV IRUPV DQG QXWULWLRQ HGXFDWLRQ PDWHULDO UHTXLUHG IRU RSHUDWLRQ RI :,& 7R FRQGXFW LQGHSHQGHQW YHULILFDWLRQ DQG YDOLGDWLRQ WKDW ORFDO :,& GDWD V\VWHP PRGLILFDWLRQV DUH SHUIRUPLQJ DV H[SHFWHG DQGRU WR HQVXUH V\VWHP PRGLILFDWLRQV DUH LQ SODFH DQG DUH RSHUDWLQJ LQ DFFRUGDQFH ZLWK IHGHUDO DQG VWDWH SURJUDP UHJXODWLRQV DQG JXLGHOLQHV 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 )RU WHFKQLFDO DVVLVWDQFH UHJDUGLQJ QXWULWLRQUHODWHG WRSLFV FRQWDFW WKH 1XWULWLRQ 6HUYLFHV 8QLW 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 ,1 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification TABLE OF CONTENTS Page I. General ....................................................................................................................... CT-1 II. Eligibility Requirements............................................................................................... CT-1 A. Category .......................................................................................................... CT-1 B. Physical Presence........................................................................................... CT-2 C. Residency........................................................................................................ CT-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 Certification 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 Certification 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 Certification 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 Certification 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 Certification 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 Certification 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. CT-1 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification * 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 CT-2 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification 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 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification 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 Certification 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 Certification 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. CT-6 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification 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 CT-7 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification 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: CT-8 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL 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/ CT-9 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification 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) CT-10 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification 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. CT-11 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification 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 CT-12 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification 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. CT-13 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification 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 CT-14 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification 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). CT-15 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification 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 CT-16 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification 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. CT-17 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification 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 CT-18 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification 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 CT-19 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification 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 CT-20 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification 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 CT-21 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification 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. CT-22 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification 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 CT-23 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification 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, CT-24 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification 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 CT-25 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification 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 CT-26 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification 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. CT-27 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification 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 CT-28 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification 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 CT-29 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification 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 CT-30 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification 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 CT-31 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification 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). CT-32 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification 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. CT-33 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification 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 CT-34 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification 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 CT-35 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification 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 CT-36 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification 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 CT-37 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification 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 CT-38 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification 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. CT-39 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification 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. CT-40 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification 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 CT-41 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification 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 CT-42 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification (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 CT-43 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification 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 CT-44 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification 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 CT-45 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification 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. CT-46 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification 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 ( ) CT-47 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification (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 CT-48 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification 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, CT-49 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification 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, CT-50 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification 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 CT-51 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification (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. CT-52 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification 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). CT-53 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification 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 CT-54 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification 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): CT-55 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification 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). CT-56 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification 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. CT-57 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification 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 CT-58 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification 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. CT-59 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification 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. CT-60 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification 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 CT-61 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification 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 CT-62 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification 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 CT-63 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification 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 CT-64 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification 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. CT-65 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification 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 CT-66 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification 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 CT-67 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification 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 CT-68 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification 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 CT-69 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification 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. CT-70 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification 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). CT-71 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification 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. CT-72 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification 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 CT-73 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification 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. CT-74 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification 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). CT-75 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification 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 CT-76 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Certification The WIC Interview Script provides WIC applicants/participants with general WIC information. The WIC Interview Script must be presented to all WIC applicants/participants during the initial certification, re-certification and mid-certification process so they will have the opportunity to select their ethnicity, migrancy status and all racial categories that applies. However, during the re-certification or mid-certification process, it is not necessary to use this script if you ask the following question: "Has anything changed since the last visit, e.g., address, telephone number, migrant status, ethnic origin or race?" Please document change(s) if necessary. The WIC Interview Script will be a part of the WIC Programmatic Review (see Attachment CT-42). CT-77 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Attachment CT-1 CT-76 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Attachment CT-1(cont'd) CT-77 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Attachment CT-1(cont'd) CT-78 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Attachment CT-2 CT-79 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Attachment CT-2(cont'd) CT-80 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Attachment CT-2(cont'd) CT-81 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Attachment CT-3 CT-82 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Attachment CT-3(cont'd) CT-83 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Attachment CT-3(cont'd) CT-84 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Attachment CT-4 CT-85 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Attachment CT-4 (cont'd) CT-86 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Attachment CT-4 (cont'd) CT-87 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Attachment CT-5 CT-88 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Attachment CT-5(cont'd) CT-89 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Attachment CT-5 (cont'd) CT-90 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Attachment CT-6 DATA AND DOCUMENTATION REQUIRED FOR WIC ASSESSMENT/CERTIFICATION PRENATAL WOMEN Data Height Pre-Pregnancy Weight Current Weight Hematocrit or Hemoglobin Prenatal Weight Grid Plotted Evaluation of Inappropriate Nutrition Practices Risk Factor Assessment Prenatal Women Required Required Required Required Required Required Required CT-91 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Attachment CT-6 (cont'd) NUTRITION RISK CRITERIA PREGNANT WOMEN NOTE: High Risk Criteria, as defined below, are to be used for referral purposes, not certification (See Appendix A-1) CODE PREGNANT WOMEN 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 CT-92 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Attachment CT-6 (cont'd) CODE PREGNANT WOMEN PRIORITY 132 GESTATIONAL WEIGHT LOSS DURING PREGNANCY I x During first (0-13 weeks) trimester, any weight loss below pregravid weight; based on pregravid weight and current weight. OR x During second and third trimesters (14-40 weeks gestation), >2 lbs weight loss. Based on two weight measures recorded at 14 weeks gestation or later. Document: Two weight measures as specified above High Risk: Weight loss of >2 lbs in the second and third trimesters 133 HIGH MATERNAL WEIGHT GAIN I High maternal weight gain at any point in pregnancy, such that a pregnant 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 CT-93 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Attachment CT-6 (cont'd) 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 CT-94 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL 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 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Attachment CT-6 (cont'd) DATA AND DOCUMENTATION REQUIRED FOR WIC ASSESSMENT/CERTIFICATION BREASTFEEDING WOMEN Data Breastfeeding and Non-Breastfeeding Woman Certified in Hospital Prior to Initial Discharge Woman Certified in Clinic Breastfeeding Woman Certified in Clinic >6 Months Postpartum Height Pre-Pregnancy 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 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL 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 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL 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 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL 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 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL 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 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL 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 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Attachment CT-6 (cont'd) DATA AND DOCUMENTATION REQUIRED FOR WIC ASSESSMENT/CERTIFICATION CHILDREN Data Length or Height Weight Hemoglobin or Hematocrit Weight/Age Plotted Length or Height/Age Plotted Weight/Length or BMI for Age Plotted Evaluation of Inappropriate Nutrition Practices Risk Factor Assessment Documentation Required Required Required Required Required Required Required Required CT-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 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL 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 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL 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 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL 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 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL 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. CT-185 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Attachment CT-6 (cont'd) 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. CT-186 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Attachment CT-6 (cont'd) TABLE OF APPENDICES APPENDICES REFERENCED IN RISK CRITERIA SECTION Appendix Page A-1 WIC Maternal High Risk Criteria.................................................. 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 CT-187 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Attachment CT-6 (cont'd) 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 CT-188 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Attachment CT-6 (cont'd) Appendix A-1 WIC MATERNAL HIGH RISK CRITERIA Any WIC prenatal, breastfeeding, or non-breastfeeding woman who has the following high risk factors must receive nutrition counseling 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 CT-189 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Attachment CT-6 (cont'd) Appendix A-2 WIC HIGH RISK CRITERIA FOR INFANTS AND CHILDREN WIC infants and children who have the following high risk factors must receive nutrition counseling 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 CT-190 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Attachment CT-6 (cont'd) 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 CT-191 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Attachment CT-6 (cont'd) Appendix B-1 WOMEN'S HEALTH RECOMMENDED GUIDELINES FOR IRON SUPPLEMENTATION BASED ON TREATMENT VALUES Hemoglobin Hematocrit Treatment Value Treatment Value NonSmokers Smokers NonSmokers Smokers Prenatal Woman 1st Trimester 3rd Trimester 10.9 gm or lower 11.2 gm or lower 32.9% or lower 33.9% or lower Prenatal Woman 2nd Trimester 10.4 gm or lower 10.7 gm or lower 31.9% or lower 32.9% or lower Non-Pregnant and/or Lactating Woman (<15 years of age) 11.7 gm or lower 12.0 gm or lower 35.8% or lower 36.8% or lower Non-Pregnant and/or Lactating Woman (>15 years of age) 11.9 gm or lower 12.2 gm or lower 35.8% or lower 36.8% or lower For Prenatal Women: Begin routine supplementation of a prenatal vitamin and mineral supplement to include 27-30 mg/day of elemental iron for all pregnant women at the 1st prenatal visit. For women with hemoglobin/hematocrit levels within the treatment value, treat anemia with a therapeutic dose of 60-120 mg of elemental iron/day. NOTE: If a woman is taking a prenatal or other multi-vitamin and mineral supplement with iron, the prenatal or multivitamin and mineral supplement + iron supplement should equal a total of 60-120 mg elemental iron/day. When the hemoglobin/hematocrit reaches the acceptable value for the specific stage pregnancy, decrease iron dosage to 30 mg/day PHYSICIAN REFERRAL: Hemoglobin less than 9.0 g/dL or hematocrit less than 27.0% Hemoglobin more than 15.0 g/dL or hematocrit more than 45.0% (2nd and 3rd trimester) If after 4 weeks the hemoglobin does not increase by 1 g/dL or hematocrit by 3%, despite compliance with iron supplementation regimen and the absence of acute illness For Non-Pregnant/Lactating Women: For women with hemoglobin/hematocrit levels within the treatment value, treat anemia with a therapeutic dose of 60120 mg of elemental iron/day. NOTE: If a woman is taking a prenatal or other multi-vitamin and mineral supplement with iron, the prenatal or multi-vitamin and mineral supplement + iron supplement should equal a total of 60-120 mg elemental iron/day. PHYSICIAN REFERRAL: Hemoglobin less than 9.0 g/dL or hematocrit less than 27.0% If after 4 weeks the hemoglobin does not increase by 1 g/dL or hematocrit by 3%, despite compliance with iron supplementation regimen and the absence of acute illness After 4 weeks, if the hemoglobin increases > 1g/dl or if the hematocrit increases > 3 %, continue treatment for 2-3 more months. Reference: CDC/MMWR: April 3, 1998. Recommendations to Prevent and Control Iron Deficiency in the United States CT-192 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Attachment CT-6 (cont'd) Appendix B-2 CHILD HEALTH RECOMMENDED GUIDELINES FOR IRON SUPPLEMENTATION BASED ON TREATMENT VALUES Hemoglobin Treatment Value Hematocrit Treatment Value Treatment Regimen Infant 6 through 11 months 10.9 gm or lower 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. CT-193 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Attachment CT-6 (cont'd) Appendix C-1 Body Mass Index (BMI) Table for Determining Weight Classification for (Women) 1 Height Underweight Normal Weight Overweight (Inches) BMI <18.5 BMI 18.5-24.9 BMI 25.0-29.9 Obese BMI >29.9 58" <89 89-118 119-142 >142 59" <92 92-123 124-147 >147 60" <95 95-127 128-152 >152 61" <98 98-131 132-157 >157 62" <101 101-135 136-163 >163 63" <105 105-140 141-168 >168 64" <108 108-144 145-173 >173 65" <111 111-149 150-179 >179 66" <115 115-154 155-185 >185 67" <118 118-158 159-190 >190 68" <122 122-163 164-196 >196 69" <125 125-168 169-202 >202 70" <129 129-173 174-208 >208 71" <133 133-178 179-214 >214 72" <137 137-183 184-220 >220 1Adapted from Institute Clinical Guidelines on the Identification, Evaluation and Treatment of Overweight and Obesity in Adults. National Heart, Lung and Blood Institute (NHLBI), National Institutes of Health (NIH). NIH Publication No. 98-4083. *These calculations are based on estimated height and weights; your system will calculate a more exact BMI based on actual height and weights including fractional ounces and inches. CT-194 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Attachment CT-6 (cont'd) Appendix C-2 Definition of Weight Gain (Women) Total Weight Gain Range (lbs) Prepregnancy Weight Groups Underweight Normal Weight Overweight Obese Singleton Pregnancy Definition Low Maternal Recommended High Maternal (BMI) Weight Gain Weight Gain Weight Gain < 18.5 <28 18.5 to 24.9 <25 25.0 to 29.9 <15 > 30.0 <11 28-40 25-35 15-25 11-20 > 40 > 35 > 25 > 20 Prepregnancy Weight Groups Underweight Normal Weight Overweight Obese Multi-Fetal Weight Gain Definition Low Maternal Recommended High Maternal (BMI) Weight Gain Weight Gain Weight Gain < 18.5 18.5 to 24.9 25.0 to 29.9 > 30.0 There was insufficient information for the IOM committee to develop provisional guidelines for underweight woman with multiple fetuses. <37 <31 <25 1.5lbs/week during 2nd and 3rd trimesters 37-54 31-50 25-42 There was insufficient information for the IOM committee to develop provisional guidelines for underweight woman with multiple fetuses. > 54 > 50 > 42 CT-195 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Attachment CT-6 (cont'd) Appendix C-3 Definition of Inadequate Growth for Infants 1-6 Months of Age Inadequate growth for infants between 1 and 6 months of age is based on two weight measurements taken at least 1 month (4.3 weeks) apart, using the following guidelines: Age 1 month 1-2 months 2-3 months 3-4 months 4-5 months 5-6 months Minimum Acceptable Weight Gain 19 oz 27 oz/month (6 oz/wk) 19 oz/month (4 oz/wk) 17 oz/month (4 oz/wk) 15 oz/month (3 oz/wk) 13 oz/month (3 oz/wk) Example: Date of Measurement 09/13/98 (birth) 10/26/98 (6 weeks, 1 day old) Weight 7 lbs 6 oz 9 lbs 3 oz 1. Calculate infant's age: 98 - 98 10 26 09 13 01 mo 13 days = 1 month + 1 week + 6 days = about 1 mo + 2 wks 2. Calculate minimum acceptable weight gain: 1st month minimum acceptable weight = 19 oz 1-2 months minimum acceptable weight/wk = 6 oz (2x 6 = 12 oz) Total acceptable weight = 19 oz + 12 oz = 31 oz = 1 lb 15 oz 3. Compare actual weight gain (1 lb 13 oz) to acceptable minimum (1 lb 15 oz). This infant's weight gain is below acceptable minimum, so you can apply the criterion for inadequate growth. CT-196 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Attachment CT-6 (cont'd) Appendix D PHYSICAL SIGNS SUGGESTIVE OF NUTRIENT DEFICIENCIES Body Area Hair Eyes Lips Gums Tongue Face and Neck Normal Appearance Signs Suggestive of Nutrient Deficiency(ies) Nutrient Consideration(s) shiny; firm; not easily plucked bright; clear; shiny; no sores at corners of eyelids; lack of natural shine; dull; thin; loss of curl; color changes (flag sign); easily plucked eye membranes pale; inadequate protein and calories anemia (inadequate iron, folacin, or vitamin B-12) membranes healthy pink and moist; no prominent blood vessels Bitot's spots; red membranes; dryness of membranes; dull appearance of cornea (cornea xerosis); softening of cornea (keratomalacia); inadequate Vitamin A smooth; not chapped or swollen healthy, red; do not bleed; not swollen deep red; not swollen or smooth redness and fissuring of eyelid corners inadequate riboflavin, Vitamin B-6, and niacin redness or swelling of mouth or lips (cheilosis); bilateral cracks, white or pink lesions at corners of mouth (angular stomatitis) and/or scars inadequate niacin and riboflavin inadequate riboflavin, niacin, iron and Vitamin B-6 spongy; bleeding; receding inadequate ascorbic acid scarlet; raw; edematous (glossitis) inadequate niacin, riboflavin, folacin, iron, Vitamins B-6 and B-12 purplish color (magenta); inadequate riboflavin smooth; pale; slick; atrophied taste buds (papillae) skin color uniform, smooth, pink; healthy appearing; not swollen diffuse depigmentation; darkening of skin over cheeks and under eyes; inadequate folacin, Vitamin B-12, iron and niacin inadequate protein inadequate calories and niacin scaling of skin around nostrils (nasolabial seborrhea) inadequate riboflavin, niacin, and Vitamin B-6 swollen (moon) face; inadequate protein front of neck swollen (thyroid enlargement); inadequate protein; inadequate iodine swollen cheeks (bilateral parotid enlargement) inadequate protein CT-197 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Attachment CT-6 (cont'd) Appendix D (cont.) PHYSICAL SIGNS SUGGESTIVE OF NUTRIENT DEFICIENCIES Body Area Skin Teeth Head / Neck Nails Muscular and Skeletal Systems Normal Appearance no signs of swelling rashes, dark or light spots no cavities, no pain, bright face not swollen firm, pink good muscle tone; some fat under skin; can walk or run without pain Signs Suggestive of Nutrient Deficiency(ies) Nutrient Consideration(s) dry and scaly (xerosis); sandpaper-like feel (follicular hyperkeratosis); Inadequate Vitamin A or Essential fatty acids pinhead-size purplish skin hemorrhages (petechiae); Inadequate Vitamin C excessive bruising; Inadequate Vitamin K red, swollen pigmentation of areas exposed to sunlight (pellagrous dermatitis); Inadequate niacin and Tryptophan extensive lightness and darkness of skin (flaky, pressure sores(decubiti) Inadequate protein, Vitamin C, and zinc may be some missing or erupting abnormally; gray or black spots (fluorosis); cavities (caries) [signs are to be severe enough to interfere with mastication and/or other health implications]* Inadequate Vitamin D and Vitamin A thyroid enlargement (front of neck); parotid enlargement (cheeks become swollen) Inadequate iodine; inadequate protein nails are spoon-shaped (koilonychia); brittle ridged nails, pale nail beds Inadequate iron; Vitamin A toxicity muscles have "wasted" appearance; baby's skull bones are thin and soft (craniotabes); round swelling of front and side of head (frontal and parietal bossing); swelling of ends of bones (epiphyseal enlargement); small bumps on both sides of chest wall (on ribs); beading of ribs; baby's soft spot on head does not harden at proper time (persistently open anterior fontanelle); knock-knees or bow-legs; bleeding into muscle (musculoskeletal hemorrhages); person cannot get up or walk properly Inadequate protein Inadequate thiamin Inadequate Vitamin D Sources: 1. American Journal of Public Health, Supplement, November 1973, p. 19. 2. Georgia Dietetic Association Diet Manual, 1992. CT-198 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Attachment CT-6 (cont'd) Appendix E-1 ALCOHOL AND CIGARETTES Alcohol Equivalents: One serving of alcohol = 12 ounces of beer (light or regular); 12 ounces of wine cooler; 5 ounces of wine (light or regular); 1 1/2 ounces of liquor. Key for Entering Ounces of Alcohol/Week: On the WIC Assessment/Certification Form enter the amount of alcohol in ounces per week using the above equivalent chart. Key: 00 ounces/week = no alcohol intake 01 ounces/week = greater than 0 and up to 1 1/2 ounce/week 02-98 ounces week = amount of intake 99 ounces/week = greater than 98 ounces/week Binge drinking: drinks 5 or more (>5) drinks on the same occasion on at least one day in the past 30 days. Heavy drinking: drinks 5 or more (>5) drinks on the same occasion on five or more days in the previous 30 days. Key for Entering Number of Cigarettes/Cigars/Pipes Smoked: On the WIC Assessment/Certification Form record the average number of cigarettes/cigars/pipes smoked per day. If the client reports smoking on average less than once per day, record the average number of cigarettes/cigars/pipes smoked per week. If the client reports smoking on average less than once per week, record the average number of cigarettes/cigars/pipes smoked per month. Key: 01-98/day = average number of cigarettes/cigars/pipes smoked per day 99/day = greater than 98 cigarettes/cigars/pipes smoked per day 01-06/week = average number of cigarettes/cigars/pipes smoked per week 01-03/month = average number of cigarettes/cigars/pipes smoked per month Note: The usual number of cigarettes in a pack is equal to 20. This number may vary. CT-199 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Attachment CT-6 (cont'd) 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. CT-200 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Attachment CT-6 (cont'd) 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 CT-201 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Attachment CT-6 (cont'd) 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. CT-202 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Attachment CT-6 (cont'd) 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). CT-203 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Attachment CT-6 (cont'd) 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) CT-204 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL 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). CT-205 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL 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. CT-206 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL 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 CT-207 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL 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. CT-208 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Attachment CT-6 (cont'd) 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. CT-209 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL 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. CT-210 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL 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. CT-211 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL 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. CT-212 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL 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. CT-213 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL 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. CT-214 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL 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. CT-215 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL 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 CT-216 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL 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 CT-217 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL 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. CT-218 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL 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 CT-219 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL 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 CT-220 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL 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 CT-221 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL 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 CT-222 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL 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. CT-223 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL 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. CT-224 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL 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 CT-225 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL 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. CT-226 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL 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. CT-227 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL 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. CT-228 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL 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. CT-229 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL 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. CT-230 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL 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 CT-231 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Infant Nutrition Questionnaire English (page 1) Attachment CT-7 CT-229 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Attachment CT-7 (cont'd) Infant Nutrition Questionnaire English (page 2) CT-230 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Attachment CT-7 (cont'd) Infant Nutrition Questionnaire Spanish (page 1) CT-231 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Attachment CT-7 (cont'd) Infant Nutrition Questionnaire Spanish (page 2) CT-232 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Attachment CT-7 (cont'd) Child Nutrition Questionnaire English (page 1) CT-233 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Attachment CT-7 (cont'd) Child Nutrition Questionnaire English (page 2) CT-234 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Child Nutrition Questionnaire Spanish (page 1) Attachment CT-7 (cont'd) CT-235 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Attachment CT-7 (cont'd) Child Nutrition Questionnaire Spanish (page 2) CT-236 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Woman Nutrition Questionnaire English (page 1) Attachment CT-7 (cont'd) CT-237 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Woman Nutrition Questionnaire English (page 2) Attachment CT-7 (cont'd) CT-238 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Woman Nutrition Questionnaire Spanish (page 1) Attachment CT-7 (cont'd) CT-239 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Woman Nutrition Questionnaire Spanish (page 2) Attachment CT-7 (cont'd) CT-240 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. CT-241 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL 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. CT-242 GEORGIA WIC PROGRAM 2013 PROCEDURE MANUAL Attachment CT-9 Participant Transfer Log (Optional) District __ Unit__ Clinic____ Participant Name Date Record Requested Date Agency Contact Information Record Received Received Yes/No CT-243 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 CT-248 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. CT-250 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. 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(,7+(5 <28 :,// %( &216,'(5(' 72 +$9( '(&,'(' 127 72 5(*,67(5 72 927( $7 7+,6 7,0( WKH VWDWHPHQW ,I \RX ZRXOG OLNH KHOS LQ ILOOLQJ RXW WKH YRWHU UHJLVWUDWLRQ DSSOLFDWLRQ IRUP ZH ZLOO KHOS \RX 7KH GHFLVLRQ ZKHWKHU WR VHHN RU DFFHSW KHOS LV \RXUV 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. FP-284 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 Attachment FP-48 (cont'd) 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 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL 1XWULWLRQ (GXFDWLRQ TABLE OF CONTENTS Page , 3XUSRVH 1( ,, 'HILQLWLRQV 1( ,,, *RDOV 1( ,9 6WDWH $JHQF\ 1( $ 6WDWH 1XWULWLRQ 6WDII 1( % 6WDWH 1XWULWLRQ (GXFDWLRQ 5HVSRQVLELOLWLHV1( 9 /RFDO $JHQF\1( $ /RFDO 1XWULWLRQ 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RWKHUV ZRUNLQJ ZLWK WKH LQGLYLGXDO RU IURP WKH LQGLYLGXDOV UHODWLYHV 'LHWDU\ LQWDNH DQG UHSRUWHG QXWULWLRQDO SUDFWLFHV 2 2EMHFWLYH 'DWD )DFWV WDQJLEOH ILQGLQJV FOLQLFDO REVHUYDWLRQV GRFXPHQWHG LQIRUPDWLRQ 3K\VLFDO ILQGLQJV VLJQV V\PSWRPV $QWKURSRPHWULF GDWD /DERUDWRU\ GDWD )DFWXDO LQIRUPDWLRQ UHJDUGLQJ EDFNJURXQG KLVWRU\ (QYLURQPHQW SURJUHVV RU SUREOHPV $ $VVHVVPHQW 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. FD-4 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Food Delivery 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. FD-5 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Food Delivery D. Issuance Local agencies have the option to issue vouchers to participants at a one, two, or three-month interval. With 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 FD-6 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Food Delivery 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. FD-7 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Food Delivery 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: FD-8 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Food Delivery 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: FD-9 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL 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 Food Delivery 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. FD-10 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Food Delivery 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 FD-11 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Food Delivery 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. FD-12 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Food Delivery 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 FD-13 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Food Delivery 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 FD-14 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Food Delivery 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 FD-15 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Food Delivery 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 FD-16 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Food Delivery 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 FD-17 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Food Delivery 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 FD-18 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Food Delivery 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 FD-19 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Food Delivery 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 FD-20 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Food Delivery 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. FD-21 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Food Delivery 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: FD-22 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Food Delivery 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 FD-23 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Food Delivery 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 FD-24 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Food Delivery 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. FD-25 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Food Delivery 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. FD-26 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL XIV. CUMULATIVE UNMATCHED REDEMPTION (CUR) REPORT Food Delivery 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: 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: 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: FD-27 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Food Delivery 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. FD-28 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Food Delivery 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: 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: 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 FD-29 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Food Delivery 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. FD-30 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL E. Procedures for Both Reports Food Delivery 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 FD-31 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Food Delivery 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. FD-32 GEORGIA WIC PROGRAM 2013 PROCEDURES MANUAL Attachment FD-1 PREPRINTEDSTANDARDMANUALVOUCHER Revised06/12 FD-32 GEORGIAWICPROGRAM2013PROCEDURESMANUAL 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. 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