State and Local WIC Agencies

APPENDIX C
DATA COLLECTION INSTRUMENT FOR STATE WIC AGENCIES

Public reporting burden for this collection of information is estimated to average 66 minutes per response, including
the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed,
and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person
is not required to respond to, a collection of information unless it displays a currently valid OMB control number.
Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden, to: U.S. Department of Agriculture, Food and Nutrition Services, Office of
Research and Analysis, Room 1014, Alexandria, VA 22302 ATTN: PRA (0584-0484). Do not return the completed
form to this address.

OMB Number: 0584-0484
Expiration Date: XX/XX/20XX

State WIC Agency Survey
Thank you for responding to the FNS’ second National Survey of WIC Participants,
administered by Macro International. Please refer to the accompanying cover letter for full
details of the research effort. If you have any questions, please contact FIRST/LAST NAME at
xxx-xxx-xxxx or email [email protected]
This survey—along with surveys of local agencies and participants—is designed to provide FNS
with additional information on policies and program operations, beyond those available from
existing program sources. For your convenience, the survey is organized by topic.
STATE ELIGIBILITY GUIDANCE TO LOCAL WIC AGENCIES
1. Which programs establish adjunctive or other automatic State eligibility for a WIC
applicant in your State? (CHECK OFF ALL PROGRAMS THAT ESTABLISH
ELIGIBILITY IN THE LEFT HAND COLUMN. PROGRAMS THAT ARE REQUIRED
BY § 246.7 WIC PROGRAM REGULATIONS ARE ALREADY CHECKED FOR YOU.)

1A. For each item checked in Question 1,
please indicate what, if any proofs, the State
requires local agencies to collect.
(CHECK ALL THAT APPLY)

(CHECK ALL THAT APPLY)

No specific
requirements
are set

Proof of
certification
(e.g. card)

Award
letter

Active
program
voucher

Other:
PLEASE
SPECIFY

 Food Stamps
 Medicaid
 TANF
 Supplemental Security Income







(SSI)
Food Distribution Program on
Indian Reservations (FDPIR)
Children’s Medicaid
Free and Reduced-Meal School
Lunch/Breakfast Program
Low-Income Energy Assistance
Other: PLEASE SPECIFY
___________________________
Other: PLEASE SPECIFY
___________________________

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OMB Number: 0584-XXXX
Expiration Date: XX/XX/20XX

2. Do any of the programs checked above, that establish adjunctive or other automatic State
eligibility, allow people to participate whose income may exceed the normal ―185% of the
federal poverty income‖ standard that is used to establish income eligibility?
 Yes
 No (SKIP TO QUESTION 4)
2A. Which ones? (CHECK ALL THAT APPLY)
 Food Stamps
 Medicaid
 TANF
 Supplemental Security Income (SSI)
 Food Distribution Program on Indian Reservations (FDPIR)
 Children’s Medicaid
 Free and Reduced-Meal School Lunch/Breakfast Program
 Low-Income Energy Assistance
 Other: PLEASE SPECIFY _____________________________
 Other: PLEASE SPECIFY _____________________________

3. When adjunctive/automatic eligibility is NOT established, what sources of income does
your State require local agencies to count when determining the income eligibility of an
applicant? (CHECK ALL THAT APPLY)
 Wages, salary, fees
 Social Security
 Energy assistance
 Tips and bonuses
 Private pension
 Rental assistance

 Self employment
 Unemployment
Compensation

 Workers
compensation

 Child Support
 Commission
 Public Assistance
 Alimony

 Disability pension
 Medical assistance
(any)

 SSI – Fed
government

 SSI—State issued
 Income from estates
 Net Royalties
 Other cash income

 Net rental income
 Dividends or interest from
savings
 Regular contributions
from persons not in
household
 Other: SPECIFY

 Income from trusts
 Welfare
__________________

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OMB Number: 0584-XXXX
Expiration Date: XX/XX/20XX

4. In determining the income of an applicant where unemployment is not an issue, does the
State instruct local agencies to use income from the last year, to use current income, or is it
left up to the judgment of the local agencies?
 Income from last year used
 Current income used
 Left to local agencies to decide
 Other: SPECIFY ____________________
5. What types of proof are acceptable in your State to verify the sources of income of WIC
applicants? (CHECK ALL THAT APPLY)
 Most recent tax return
 Check or pay stubs
 Signed statement by employer
 Statement of benefits by public agency or court
 Statement of benefits for child support and alimony
 Leave and Earnings Statement (LES) for military pay
 Unemployment letter or notice letter signed by official State/local agency
attesting to client’s low income
 Written statement from reliable third party
 Statement from bank or other financial institution savings (e.g. direct deposit)
 Accounting records (for self-employed individuals)
 Scholarship letter (e.g. for students)
 Other: PLEASE SPECIFY _____________________
5A. How does the state determine ―most recent‖ income? (Be as specific as possible, or
attach supporting documentation)
____________________________________________
____________________________________________
____________________________________________
____________________________________________

6. Does the state use or grant discretion to local agencies regarding income determination?

 No additional discretion is given. (SKIP TO QUESTION 7)
 Discretion is given: (CONTINUE TO 6A AND 6B TO SPECIFY
DISCRETION)

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OMB Number: 0584-XXXX
Expiration Date: XX/XX/20XX

6A. What State or local income guidelines used for WIC are adopted from various
services?

 Free and Reduced Health Care (e.g. Maternal Health Care, Pediatric Health Care)
_____% FPL
 Free and Reduced Priced School Meals
_____% FPL
 Other (Specify: Provide supporting policy statements)
___________________________________________
_____% FPL
6B. For applicants not likely to have any proof of income, e.g., homeless, or migrant
farm worker who works for cash, does the State allow self-declaration of income with
applicants signed statement of why documentation cannot be provided?

 Yes
 No
7. What discretion, if any, does the state use or grant to local agencies regarding
certification periods.

 No additional discretion is given
 Discretion is given: (CONTINUE TO 7A THROUGH 7C TO SPECIFY
DISCRETION)
7A. When an infant turns 1 year, does the 6 months certification period remain valid (1),
or does the infant become categorically ineligible and need to again be certified based on
criteria used for children(2)?

 (1) The 6 month certification period remains valid.
 (2) The infant becomes categorically ineligible and need to again be certified
based on criteria used for children.
 (3) No State policy. Discretion is given to local agencies.

7B. Does your State use a data month or calendar month for issuance cycles?

 (1) data month (benefits continue until the end of the month).
 (2) calendar month (benefits continue until eligibility ends).
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OMB Number: 0584-XXXX
Expiration Date: XX/XX/20XX

7C. For Temporary Low-Income Persons, e.g. strikers, does the state allow full
certification period (1) or shorten the certification period based on anticipated income
increase (2)?

 (1) Allow full certification period
 (2) Shorten certification period based on anticipated income increase.
8. What additional guidelines, if any, are given by the State to local agencies to help them
determine the WIC economic/family unit above and beyond the national WIC program
definition which defines it as ―a group of related or nonrelated individuals who are living
together?‖
 No additional discretion is given
 The following discretion is given: (PROVIDE SUPPORTING POLICY
STATEMENTS AS APPROPRIATE PER INSTRUCTIONS)
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
8A. Does the State exclude any of the following military housing allowances?
(CHECK ALL THAT APPLY)

 Basic Allowance for Housing (BAH) for off-base housing and privatization
housing in the U.S.
 Family Separation Housing (FSH) provided to military personnel for overseas
housing.
 Overseas Housing Allowance (OHA) provided to military personnel living
overseas.
 Overseas Continental U.S. (OCONUS) cost of living allowance (COLA) provided
to active duty uniformed service members in Hawii, Alaska, and Guam.
8B. Regarding Children in Temporary Care of Friends/Relatives, does the State:
(CHOOSE ONE)

 Count absent parents and children as one unit.
 Count the children as a separate unit in which case they should have separate
income, e.g., child allotment.
 Count the children as part of the economic unit of the person with they are
residing.
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OMB Number: 0584-XXXX
Expiration Date: XX/XX/20XX

9. What types of identification are acceptable in your State to verify the residency of a WIC
applicant? (CHECK ALL THAT APPLY)
 Driver’s license
 Current utility/tax bill with address on it
 Written statement from reliable third party
 Checkbook
 Signed statement by applicant that he/she is victim of loss or disaster, or is
homeless, a migrant person, or military personnel.
 Rent receipt, mortgage receipt or lease
 Other: PLEASE SPECIFY ____________________________________
9A. Does the State require applicants to reside within the state?

 Yes
 No
9B. Did the State establish a local residency area requirement?

 Yes (PROVIDE SUPPORTING POLICY STATEMENTS AS APPROPRIATE
PER INSTRUCTIONS)
 No
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________

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OMB Number: 0584-XXXX
Expiration Date: XX/XX/20XX

10. How often does the State regularly review the records of WIC participants to identify
duplicate certifications across local agencies?
 Process is automated and constant. State’s WIC system looks for
duplicate records at time of certification and at subsequent
certifications.
 10-12 times a year (e.g. monthly)
 7-9 times a year
 4-6 times a year (e.g. quarterly)
 2-3 times a year (e.g. semiannually)
 Once a year or less
 Never
 Don’t know
11. At the current time, does your State use FNS’s WIC Nutrition Risk Criteria to ascertain
nutritional eligibility or does the State bundle the codes into its own unique groupings?
 Use FNS criteria
 Bundle codes

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OMB Number: 0584-XXXX
Expiration Date: XX/XX/20XX

12. In the following table, please list by code number (for example, 331—pregnancy at a young
age) the seven most prevalent nutritional risk code indicators in your State, by category.
NOTE: IF YOUR STATE HAS BUNDLED CODES, LIST ALL CODES IN BUNDLE IN
A CELL OR, IF YOU DO NOT USE FNS CODE NUMBERING, REFER TO BUNDLE
IN A CELL AND ATTACH A CROSSWALK TABLE OR KEY).
Pregnant

Breastfeeding

Postpartum

Infants

Children

1st (Most
prevalent)
2nd
3rd
4th
5th
6th
7th (Least
prevalent)
12A.  Check if above are not FNS codes AND you are including a crosswalk table or
key
12B.  Check if you are using FNS codes but are NOT using the new VENA codes for
dietary risks
13. When does your State plan to have the VENA (Value Enhanced Nutrition Assessment)
protocols fully implemented at the local level?
 It is already implemented, or will be, by end of 2008
 By end of 2009
 By end of 2010
 Later than 2010?
DENIALS
14. Does State policy require that local WIC agencies keep information on denied applicants?
 Yes
 No (SKIP TO QUESTION 15)
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OMB Number: 0584-XXXX
Expiration Date: XX/XX/20XX

15. What information on Denied Applicants is required to be retained by the State and if so,
how must it be retained?
a. Information Required to be Retained (CHECK ALL THAT APPLY)
 Name of applicant
 Address
 Phone number
 WIC applicant category
 Reason for denial
 Date of application
 Date of denial
b. How Retained
 No specific retention requirements
 Paper copy only
 Electronic copy only
 Both paper and electronic
16. Is it State policy to have local agencies send an official letter of denial to applicants who are
denied eligibility for WIC?
 Yes
 No

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OMB Number: 0584-XXXX
Expiration Date: XX/XX/20XX

FOOD PACKAGES & NUTRITION SERVICES
17. What, if any, assistance does the State provide to local agencies for the specific purpose of
promoting breastfeeding?
 Funding for breastfeeding coordinators or peer counselors
 Training for personnel to support breastfeeding
 Printed breastfeeding materials (hand-outs, posters, etc.)
 Free breast pumps for distribution
 Other: PLEASE DESCRIBE BRIEFLY ____________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
 None
18. Which of the following actions are designated proxies allowed to do in your State on behalf
of the WIC participants they represent?
 Get certification for the WIC applicant
 Pick up food instruments
 Attend educational sessions
 Other: PLEASE SPECIFY ______________________________________
 Not Applicable. State does not allow proxies
19. How frequently are food instruments distributed throughout the State via the following
distribution methods? (PLEASE CHECK ONE ANSWER FOR EACH)
Most of Some of
Occasionally Not at all
the time the time
a. In person at a local WIC site
b. EBT (electronic benefit cards)
c. By mail
d. Other: PLEASE SPECIFY
_____________________

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OMB Number: 0584-XXXX
Expiration Date: XX/XX/20XX

RECORD-KEEPING & SYSTEMS
20. Please indicate for how long, if at all, the following WIC Participant data is kept at the State
level. (CHECK ALL THAT APPLY)

Possible data stored:



State does
not retain
this
information

State stores
only most
State stores current and previous
current
information (including changes) for…
information
(i.e. no record
Up to 3
4-8
9-12
Over a
of previous
months
months
months
Year
changes)

Client name
Clinic attended
Family identification
or affiliation
Category of eligibility
Client address
Client telephone
Second client
telephone
Food package issued
Value of food package
redeemed
Program through
which adjunctively/
automatically income
eligible
Proofs of income (if
not adjunctively/automatically eligible)
Primary language

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OMB Number: 0584-XXXX
Expiration Date: XX/XX/20XX

21. What proofs of eligibility are local WIC agencies required to keep in their files? (CHECK
ALL THAT APPLY)

Local agency must keep…
For what types of
documents…?


Original
document/s

Copy of
original
document/s

Identifying
number of
original
document

A written statement or
notation (such as a check
mark) that an acceptable
document was shown to
the (re)certification staff.

Documents proving
adjunctive/
automatic eligibility
Proofs of income
(i.e. wages, fees
and tips)
Nutritional
eligibility
paperwork
Categorical
eligibility
paperwork
Proof of residency
22. Which proofs of eligibility are stored at the State level? (CHECK ONE FOR EACH)
YES

NO













Documents proving adjunctive/automatic eligibility
Proofs of income
Nutritional eligibility paperwork
Categorical eligibility paperwork
Proof of residency

23. What is the longest that local agencies may wait before sending applicant data to the State
WIC agency about new WIC certificants and recertificants?
 30 days or less
 31-60 days
 61-90 days
 Other: PLEASE SPECIFY ______________________________________

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OMB Number: 0584-XXXX
Expiration Date: XX/XX/20XX

23. With regard to the State’s database of WIC participants…
1. What does State use to
store participant data?

2. What databases are used?

 Mainframe server
 QuickWIC (web-based)
 Other: SPECIFY
_______________

 Access (MDB)
Excel (XLS)
Oracle
SAS
SPSS (SPS)
XML
Other: SPECIFY________________

24. Please indicate the maximum number of days that…
a. participants are given to use their
food instruments after start date?
b. vendors can take to deposit redeemed
coupons in their bank?
c. vendors’ banks can take to turn the
coupons over to the State WIC
agency’s bank?

________ days

________ days

________ days

Check here if question
does not apply because
vendors must turn in
their coupons to the
State WIC agency’s bank

GENERAL CHARACTERISTICS
25. For the State as a whole, how many WIC clients are: (PLEASE GIVE YOUR BEST
ESTIMATE)

a. migrant farmworkers ________

b. homeless individuals ________

26. Number of WIC local agencies in State?
__________ LOCAL AGENCIES
27. Number of WIC clinics or sites, including satellite sites in the State? (IF MOBILE UNIT IS
ATTACHED TO A SINGLE CLINIC OR SITE DO NOT CONSIDER IT A SITE. IF MOBILE
UNIT SERVES MUTLIPLE SITES, CONSIDER IT A SEPARATE SITE.)

___________ LOCAL SITES

YOUR TIME COMPLETING THE SURVEY IS GREATLY APPRECIATED.
THANK YOU! PLEASE RETURN PROMPTLY IN ENVELOPE PROVIDED.

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