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U.S. Department of Agriculture, Food and Nutrition Service (FNS),
Special Supplemental Nutrition Program for Women, Infants and Children (WIC)
Loving Support Award of Excellence
Application Cover Sheet for Gold Award
Local Agency Name
Street Address
City, State, Zip code
Applicant’s Name and Title
Telephone Number
Email address
Date
Public reporting burden for this collection of information is estimated to average 2 hours 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-xxxx). Do not return the completed form to this address.
Loving Support Award of Excellence
Gold Application 1
OMB Control Number: 0584-NEW
Expiration Date: xx/xx/xxxx
Loving Support Award of Excellence
IN ORDER TO BE ELIGIBLE TO APPLY FOR AN AWARD, YOUR LOCAL AGENCY MUST
FIRST BE ABLE TO VERIFY THE FOLLOWING TWO QUESTIONS.
Prescreening
1. Has your local agency peer counseling program been in place for at least one year?
Yes
2. Does your local agency peer counseling program meet all components of the FNS
Loving Support© peer counseling model?
Yes
The Loving Support© Model and the required core components can be found in the Application Instructions
and at http://www.nal.usda.gov/wicworks/Learning_Center/FNS_model.pdf.
Application
PEER COUNSELING
1. Do you conduct an annual assessment to determine each of the
following:
(a) the needs of your target audience
(b) where gaps exist in breastfeeding services and resources within your
local agency and the community that can be addressed through peer
counseling; and
(c) where improvements in your program are needed?
Yes
No
Document Title
Attach the narrative.
Fill in the document title.
2. Do you have a protocol that describes how peer counselors address a
mother’s concerns and needs outside of usual clinic hours, including how
peer counselors make after-hour referrals?
Attach the supportive documentation.
Fill in the document title and indicate the page numbers where the
information that answers this question can be found.
Yes
No
Document Title
Page Number(s)
3. Do you have opportunities for peer counselors to observe and shadow
experienced lactation experts and experienced peer counselors?
Yes
No
4. Do you routinely monitor the work of peer counselors through spot checks,
chart reviews, contact forms?
Yes
No
5. Do you routinely observe newly trained peer counselors during contacts
with mothers to provide guidance and affirmation
Yes
No
Loving Support Award of Excellence
Gold Application 2
OMB Control Number: 0584-NEW
Expiration Date: xx/xx/xxxx
6. Do you schedule routine meetings to discuss case studies with your peer
counselors?
7. Do you have adequate supervision of peer couselors by staff with
advanced lactation training? Adequate supervision is defined: if less than 5
peer counselors you have at least a .25 FTE supervisor, if more than 5 peer
counselors, you have at least 1 FTE supervisor,
supervisory responsibilites include mentoring, monitoring, follow-up, and
spot checks.
8. Do you have a written defined scope of practice for peer counselors that
describes the peer counselor’s role to provide basic breastfeeding
education and support to WIC mothers, and lists breastfeeding concerns
and conditions that are outside the scope of practice of the peer counselor
where the peer counselor should “yield” to the WIC designated
breastfeeding expert?
Yes
No
Yes
No
Yes
No
Document Title
Page Number(s)
Attach the supportive documentation.
Fill in the document title and indicate the page numbers where the
information that answers this question can be found.
9. Do you have a process/protocol in place for WIC staff to refer WIC
participants to peer counselors as part of your usual WIC certification,
assessment and nutrition education process?
Document Title
Fill in the document title and indicate the page numbers where the
information that answers this question can be found.
Page Number(s)
10. Do peer counselors routinely contact mothers, at a minimum, monthly
during pregnancy and weekly 2 weeks prior to a woman’s expected delivery
date?
11. Do peer counselors routinely contact mothers, at a minimum, every 2-3
days in the first week after delivery and within 24 hours if the mother
reports problems with breastfeeding and weekly throughout rest of first
month?
12. Do peer counselors routinely contact mothers after a woman’s first month
postpartum, at a minimum, monthly, as long as things are going well?
13. Do peer counselors routinely contact mothers after a woman’s first month
postpartum, at a minimum, 1-2 weeks before the mother plans to return to
work or school and 1-2 days after she returns to work or school?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Loving Support Award of Excellence
Gold Application 3
OMB Control Number: 0584-NEW
Expiration Date: xx/xx/xxxx
PARTNERSHIP
A partnership is defined as a sustainable ongoing voluntary collaborative agreement between two or more
parties based on mutually agreed objectives and a shared vision, generally within a formal structure.
The partners agree to work together to achieve a common goal, undertake specific tasks, and share risks,
responsibilities, resources, competencies and benefits in order to provide breastfeeding support through
the continuum of care.
14. Was the partnership developed to solve an existing problem or gap in
breastfeeding support services?
Yes
No
15. Are the resources each partner brings to the partnership clearly
delineated?
Yes
No
16. Does the partnership have goals that have been agreed upon by the
members of the partnership?
Yes
No
17. Are the roles and responsibilities clearly identified and understood by all
members of the partnership?
Yes
No
18. Does the partnership have activities that have been agreed upon by the
members of the partnership?
Yes
No
Yes
No
20. Do you have a supportive clinic environment for breastfeeding that visibly
endorses breastfeeding as the preferred method of infant feeding?
Yes
No
21. Do you have policies that support a clinic environment where
participants feel comfortable breastfeeding?
Yes
No
Yes
No
19. Has the partnership produced results that provide an ongoing benefit?
OTHER
22. Do you have policies and procedures that encourage and support
exclusive breastfeeding among prenatal and postpartum WIC
participants?
Attach supportive documentation.
Fill in the document title and indicate the page numbers where the
information that answers this question can be found.
Document Title
Page Number(s)
Loving Support Award of Excellence
Gold Application 4
OMB Control Number: 0584-NEW
Expiration Date: xx/xx/xxxx
23. Do you ensure that all staff are trained to support the goal of exclusive
breastfeeding with WIC participants using the FNS-developed
competency-based breastfeeding curriculum, Using Loving Support© to
Grow and Glow in WIC?
24. Do you have policies and procedures that require staff to assess, and individually tailor food packages to all breastfeeding dyads when infant formula
is requested?
Attach supportive documentation.
Fill in the document title and indicate the page numbers where the
information that answers this question can be found.
25. Does new clinic staff orientation include breastfeeding policies and
procedures especially related to support for exclusive breastfeeding?
26. Do you provide ongoing training to all WIC staff using the FNS-developed
competency-based breastfeeding curriculum, Using Loving Support© to
Grow and Glow in WIC, WIC Learning Online course WIC Breastfeeding
Basics, or similar State-developed training based on Using Loving
Support© to Grow and Glow in WIC?
27. Do you have ongoing continuing education on breastfeeding for all staff
through regularly scheduled staff trainings and other educational
opportunites?
Yes
Yes
No
Document Title
Page Number(s)
Yes
No
Yes
No
Yes
No
Yes
28. Do you have policies and procedures that require support for
breastfeeding mothers, especially during the early postpartum period, that
assist mothers in continuing exclusive breastfeeding for as long as possible? Narrative Title
Attach narrative and supportive documentation.
Fill in the document titles and indicate the page number(s) that
corresponds to each document. Narrative not to exceed 500 words.
No
No
Document Title
Page Number(s)
29. Do you have policies that ensure all participant breastfeeding concerns are
addressed according to established time frames?
Yes
No
Loving Support Award of Excellence
Gold Application 5
OMB Control Number: 0584-NEW
Expiration Date: xx/xx/xxxx
Congratulations!
You have completed the application for the Loving Support Award of Excellence at the
Gold Award level.
If you would like to apply for a higher level award, continue on to the application for
the Gold Premiere and Gold Elite Awards.
The State agency and FNS reserve the right to verify all information on the application
and reject applications that are incomplete or otherwise fail to provide accurate information.
Loving Support Award of Excellence
Applicant Verification Form
Please read the following statement and sign below if you agree:
I have reviewed this application, and I attest to the accuracy of the information provided.
I agree to maintain the standards and procedures indicated in this application for the
duration of our award period. Furthermore, I agree to cooperate with USDA and other
organizations, upon request, to publicize our efforts.
Local Agency Applicant’s Name
Date
Please submit your completed application and supporting documentation to
[email protected].
Thank you for applying for the Loving Support Award of Excellence.
For more information, visit the SFPD/WIC Website: http://www.fns.usda.gov/wic/.
Loving Support Award of Excellence
Gold Application 6
| File Type | application/pdf |
| File Modified | 2014-02-05 |
| File Created | 2013-11-22 |