WIC Local Agency Applications

OMB Control Number: 0584-NEW
Expiration Date: xx/xx/xxxx

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
Gold Award Application Instructions
There are 3 Award Levels: Gold, Gold Premiere, and Gold Elite.
Gold Award Questions: In order to be eligible for any level of award applicants must fulfill the
criteria for all the Gold Award questions.
The Gold Award application has a total of 29 questions. The Gold Award questions, worth 1 point
each, are criteria identified as best practices, which demonstrate excellence in breastfeeding
practices and support, and relate to practices beyond the core components of Loving Support©
Model.
Gold Premiere and Gold Elite Award Questions: The Gold Premiere and Gold Elite application has
16 questions. The Gold Premiere and Gold Elite questions are each worth 2 or 3 points. The
questions for these higher level awards are criteria identified as exemplary practices that are
deserving of the highest recognition of excellence.
Performance data: Applicant does not submit performance data. The performance data considered
is the rate of exclusively breastfed infants reported by local WIC agencies and published annually on
the FNS website. Performance data is considered for the Gold Premiere and Gold Elite Awards.
GOLD AWARD
• All Gold Award application questions (29 points) must be answered appropriately.
• Performance data is not considered.
GOLD PREMIERE AWARD
• Applicants must meet the criteria for the Gold Award (29 points) and
• Additional 19 points from the Gold Premiere and Gold Elite application questions such that
additional points are awarded in each of the 3 sections:

- a minimum of 10 points from the Peer Counseling section,

- a minimum of 4 points from the Partnership section,

- a minimum of 5 points from the Other Criteria section.
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 Instructions - 1

• and Performance data of either:

- the rate of exclusively breastfed infants is at least 15 % or higher in the
previous year of published data, and the most recently published year
of data shows an increase over the previous year OR

- the rate of exclusively breastfed infants is at least 25 % or higher in the
most recently published year of data
GOLD ELITE AWARD (highest level)
• Applicants must meet the criteria for the Gold Award (29 points) and
• ALL of the Gold Premiere and Gold Elite application questions are answered appropriately (38
points) and
• Performance data that demonstrates 40% or higher of the infants are exclusively breastfed
In order to apply for an award of excellence, your local agency must first be able to
answer “Yes” to the following two questions.
1. Has your local agency peer counseling program been in place for at least one year?
Check Yes on the application if appropriate.
2. Does your local agency peer counseling program meet ALL of the components of the FNS Loving
Support© Model for a Successful Peer Counseling Program as listed below?
Check Yes on the application if appropriate.
LOVING SUPPORT© MODEL
REQUIRED PROGRAM COMPONENTS

Program Management
• The local agency has a designated peer counseling program manager or coordinator.
• The local agency has standardized breastfeeding peer counseling program policies in place as
part of its nutrition education plan.
• Local agency staff is trained on supportive the peer counseling program.
• The local agency has a WIC designated breastfeeding expert for referrals outside of the peer
counselor’s scope of practice.
• The local agency has a WIC designated breastfeeding expert for referrals outside of the peer
counselor’s scope of practice.
• The local agency has established community partnerships to enhance the effectiveness of its
peer counseling program, e.g., hospitals, health care providers, home visiting programs, etc.
Peer Counselor Staffing
• The local agency has defined job parameters and position descriptions for peer counselors.
• Peer counselors are recruited and hired from the target population served by WIC.
• Peer counselors are paraprofessionals, i.e., are not licensed or credentialed as healthcare,
nutrition, or lactation consultant professionals.
• Peer counselors are available to WIC clients outside usual clinic hours and outside the WIC
clinic environment.
• Peer counselors receive adequate compensation and reimbursement for expenses.
Peer Counselor Training and Support
• Peer counselors are trained with a standardized curriculum based on the FNS “Loving
Support© Through Peer Counseling” trainings.
• Ongoing continuing education is provided to peer counselors through regularly scheduled staff
meetings and other educational opportunities.
• Peer counselors have timely access to breastfeeding coordinators and other lactation experts for
assistance with problems outside their scope of practice.
• Peer counselors are offered opportunities to meet regularly with other peer counselors.
Loving Support Award of Excellence
Gold Application Instructions - 2

Documentation
Some questions in this application require additional documents.
There are two types of document requests, a unique narrative and/or supportive documentation.
Narrative refers to a document with explanatory statements that have been written exclusively for
the purpose of this application. The narrative should describe how your agency meets the criteria of
a specific question as noted in the instructions. Narratives are not to exceed 500 words.
Supportive documentation refers to documents that already exist that. You may submit these
documents to demonstrate your agency meets the criteria of a specific question as noted in the
instructions for that question.
When attaching documentation, indicate the page number(s) where the specific information can be
found in response to the question.
Each document you attach to the application must have a unique name/title entered into the
application. The title should reflect the content of the document. If you submit the same document
for more than one question, enter the same document title again, and indicate the page number(s)
that corresponds to the specific question.
Do not submit entire policy and procedure manuals.

Question 1. (1 point)

PEER COUNSELING

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?

Briefly describe in a narrative the top 2 priorities determined by your assessment and how your
local agency is addressing those needs. Narrative not to exceed 500 words.
Successful peer counseling programs occur through careful planning to address identified needs.
Information gathered during needs assessment helps local agencies identify strengths as well as
areas of breastfeeding services that can be modified or improved through peer counseling. A needs
assessment helps local agencies set priorities to maximize the effectiveness of peer counselors.
Without a needs assessment, planning is just a best guess.
Check the appropriate box (Yes/No) in response to the question.
Attach the narrative and fill in the document title.

Loving Support Award of Excellence
Gold Application Instructions - 3

Question 2. (1 point)

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?

The key to success in peer counseling is being available to mothers when they need it most.
Breastfeeding problems often occur outside usual business hours, and peer counselors provide
important support beyond usual WIC services. The Loving Support© Model for a Successful Peer
Counseling Program requires that peer counselors be available to mothers outside of usual clinic
hours, i.e., evenings and weekends. Exemplary peer counseling programs develop strategies to
ensure that peer counselors are available to address a mother’s concerns and needs in a timely
manner (via telephone, hotline, or face-to-face) and that referral and follow-up are provided.
The supportive documentation should indicate that the local agency has a specific plan in place
that addresses how peer counselors address a mother’s concerns and needs outside of usual clinic
hours.
Examples of Acceptable Supportive Documentation: Policies and procedures or protocols,
Training materials, Position descriptions / Roles and Responsibilities
Check the appropriate box (Yes/No) in response to the question.
Attach the supportive documentation; fill in the document title and indicate the page numbers
where the information that answers this question can be found.
Question 3. (1 point)

Do you have opportunities for peer counselors to observe and shadow experienced lactation experts and
more experienced peer counselors?

Check the appropriate box (Yes/No) in response to the question.
Question 4. (1 point)

Do you routinely monitor the work of peer counselors through spot checks, chart reviews, contact forms?

Check the appropriate box (Yes/No) in response to each question.
Question 5. (1 point)

Do you routinely observe newly trained peer counselors during contacts with mothers to provide guidance
and affirmation?

Check the appropriate box (Yes/No) in response to each question.
Question 6. (1 point)

Do you schedule routine meetings to discuss case studies with your peer counselors?

Check the appropriate box (Yes/No) in response to each question.

Loving Support Award of Excellence
Gold Application Instructions - 4

Question 7. (1 point)

Do you have adequate supervision of peer counselors 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 responsibilities include mentoring, monitoring, follow-up, and spot checks.

Check the appropriate box (Yes/No) in response to the question.
Question 8. (1 point)

Do you have a written defined scope of practice for peer counselors that describe 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?

Peer counselors supplement, but do not replace, the work of CPAs and lactation professionals. A
peer counselor’s scope of practice is to provide basic information and support to new moms, and
make referrals when they experience problems beyond their training. The peer counselors’ scope
of practice summarizes typical situations for which peer counselors can provide services, as well as
the types of information they can provide.
The supportive documentation should indicate that the local agency has described a scope of practice for peer a counselor that is limited to supportive normal breastfeeding. This means providing
basic information and support, encouraging and supportive mothers to breastfeed, teaching basic
breastfeeding to WIC mothers, supportive mothers when difficulties occur, yielding (referring) to
breastfeeding experts when problems are outside the peer counselor’s training. An example can be
found in “Staffing and Supervision 7: When to Yield” in the FNS Training Curriculum.
Examples of acceptable supportive documentation: Written Scope of Practice, Position description
/ Roles and Responsibilities, Policy and Procedures, Training Manual, Referral protocol for peer
counselors/list of referral topics.
Check the appropriate box (Yes/No) in response to the question.
Attach the supportive documentation; fill in the document title and indicate the page numbers
where the information that answers this question can be found.

Loving Support Award of Excellence
Gold Application Instructions - 5

Question 9. (1 point)

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?
Please describe in a narrative, or attach supportive documentation, that indicates that your local agency has
an established process that describes how WIC mothers are referred to peer counselors as part of normal
clinic operations, during both the prenatal and postpartum periods.

Peer counselors depend on referrals from local clinic staff to provide timely and appropriate followup to WIC mothers. Peer counselors should receive ongoing referrals from local clinic staff as part
of the usual WIC certification, assessment and nutrition education process. This includes sharing information about mothers who need breastfeeding support and providing names of pregnant
women.
Develop a descriptive narrative or attach supportive documentation that indicates that the local
agency has an established process that describes how WIC mothers are referred to peer counselors
as part of normal clinic operations, during both the prenatal and postpartum periods. Narrative not
to exceed 500 words.
Check the appropriate box (Yes/No) in response to the question.
Attach narrative or supportive documentation; fill in the document title and indicate the page
numbers where the information that answers this question can be found.
Question 10. (1 point)

Do peer counselors routinely contact mothers, at a minimum, monthly during pregnancy and weekly 2
weeks prior to a woman’s expected delivery date?

Check the appropriate box (Yes/No) in response to each question.
Question 11. (1 point)

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?

Check the appropriate box (Yes/No) in response to each question.
Question 12. (1 point)

Do peer counselors routinely contact mothers after a woman’s first month postpartum, at a minimum,
monthly, as long as things are going well?

Check the appropriate box (Yes/No) in response to each question.
Question 13. (1 point)

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?

Check the appropriate box (Yes/No) in response to each question.

Loving Support Award of Excellence
Gold Application Instructions - 6

PARTNERSHIP

Although the WIC Program can provide many of the services breastfeeding women in the
community need to educate and support breastfeeding families, WIC cannot do it alone. Various
community entities such as public health programs, coalitions, schools and employers, influence
a mother’s ability to initiate and continue breastfeeding. Establishing meaningful partnerships
among these relevant community organization/resources is critical to a mother’s breastfeeding
success.
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 throughout the continuum of care.
Question 14. (1 point)

Was the partnership developed to solve an existing problem or gap in breastfeeding support services?

Check the appropriate box (Yes/No) in response to each question.
Question 15. (1 point)

Are the resources each partner brings to the partnership clearly delineated?

Check the appropriate box (Yes/No) in response to each question.
Question 16. (1 point)

Does the partnership have goals that have been agreed upon by the members of the partnership?

Check the appropriate box (Yes/No) in response to each question.
Question 17. (1 point)

Are the roles and responsibilities clearly identified and understood by all members of the partnership?

Check the appropriate box (Yes/No) in response to each question.
Question 18. (1 point)

Does the partnership have activities that have been agreed upon by the members of the partnership?

Check the appropriate box (Yes/No) in response to each question.
Question 19. (1 point)

Has the partnership produced results that provide an ongoing benefit?

Check the appropriate box (Yes/No) in response to each question.

Loving Support Award of Excellence
Gold Application Instructions - 7

OTHER CRITERIA

CLINIC ENVIRONMENT
Positive breastfeeding posters and brochures, comfortable areas for women to breastfeed, and
signs that say “Breastfeeding Welcome Here” are all ways a clinic can promote and support breastfeeding through the environment. The manner in which staff communicate and interact with
participants should always be supportive of breastfeeding. Additionally, efforts should be made to
ensure that nothing in the clinic inadvertently or advertently implies that infant formula feeding
is the normal way to feed babies. Educational and promotional materials portray breastfeeding as
the preferred method of infant feeding; infant formula, formula displays and logos are not visible
anywhere in the clinic; publications that advertise, or promote, formula are not provided to participants; formula coupons are not on display.
Policies should support a clinic environment where participants feel comfortable breastfeeding by
providing a space in the clinic for participants to breastfeed and a private space for participants to
express their milk.
Question 20. (1 point)

Do you have a supportive clinic environment for breastfeeding that visibly endorses breastfeeding as the
preferred method of infant feeding?

Check the appropriate box (Yes/No) in response to each question.
Question 21. (1 point)

Do you have policies that support a clinic environment where participants feel comfortable breastfeeding?

Check the appropriate box (Yes/No) in response to each question.
SUPPORT OF EXCLUSIVE BREASTFEEDING
Exclusive breastfeeding, feeding only breastmilk and nothing else except drops or syrups consisting of vitamins, minerals or medications, is recognized as the optimal feeding practice for infants.
It confers the most health benefits for babies and mothers and contributes to a longer duration of
breastfeeding. Although women are aware that breastfeeding is the best source of nutrition for
their infants, many are uncertain about what to expect and how to actually carry it out (Surgeon
General’s Call to Action). WIC staff has an important role in educating mothers about exclusive
breastfeeding, encouraging new mothers to breastfeed exclusively for 6 months and providing the
support necessary for them to feel confident in their ability to do so. The local agency must have
policies and procedures in place that ensure benefits and services (support and assistance) are provided which support exclusive breastfeeding.
Staff provides realistic strategies to mothers on how to feed their baby only breast milk and provide
appropriate support and/or referrals as needed.

Loving Support Award of Excellence
Gold Application Instructions - 8

Question 22. (1 point)

OTHER CRITERIA

Do you have policies and procedures that encourage and support exclusive breastfeeding among prenatal
and postpartum WIC participants?

The supportive documentation should indicate that the local agency has established policies and
procedures that support exclusive breastfeeding and must include all these components:
• encouragement is provided to mothers to exclusively breastfeed for 6 months and continue to
breastfeed for at least the first year of life and thereafter as long as desired,
• anticipatory guidance on what mothers should expect and strategies for breastfeeding success,
• efforts are made to contact mothers who intend to breastfeed as soon after delivery as possible
to provide timely breastfeeding support during the early postpartum period,
• no routine issuance of infant formula in the first month, and minimal infant formula amounts
are provided only when medically necessary or requested (if formula is provided it is based on
the infants assessed needs),
• education is provided to mothers on the effects of early formula supplementation of
breastfeeding,
• staff promote the fully breastfed food package, making participants aware of the greater
quantity and variety of food included in this package
• prohibits the promotion of infant formula
Examples of acceptable supportive documentation: Policies and procedures, Staff training
materials.
Check the appropriate box (Yes/No) in response to the question.
Attach the supportive documentation; fill in the document title and indicate the page numbers
where the information that answers this question can be found.
Question 23. (1 point)

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?

Check the appropriate box (Yes/No) in response to each question.
Question 24. (1 point)

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?

The supportive documentation should indicate that individually tailoring of a food package is based
on a complete breastfeeding assessment, and routine issuance of infant formula to breastfeeding
infants is prohibited.
Examples of acceptable supportive documentation: Policies and procedures, Staff training
materials.
Check the appropriate box (Yes/No) in response to the question.
Attach the supportive documentation; fill in the document title and indicate the page numbers
where the information that answers this question can be found.
Loving Support Award of Excellence
Gold Application Instructions - 9

STAFF TRAINING
Breastfeeding promotion and support has always been a key part of the WIC Program’s mission to
improve the health of its target population. However, as the focus on breastfeeding has increased,
it has become essential for all staff to have knowledge and skills needed to encourage and support
breastfeeding mothers. All local agency staff who interact with WIC participants should be trained
to have a level of competence in breastfeeding promotion and support relevant to their tasks and
responsibilities.
Question 25. (1 point)

Does new clinic staff orientation include breastfeeding policies and procedures especially related to support
for exclusive breastfeeding?

Check the appropriate box (Yes/No) in response to each question.
Question 26. (1 point)

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?

Check the appropriate box (Yes/No) in response to each question.
Question 27. (1 point)

Do you have ongoing continuing education on breastfeeding for all staff through regularly scheduled staff
trainings and other educational opportunities?

Check the appropriate box (Yes/No) in response to each question.
PRENATAL/EARLY POSTPARTUM SUPPORT
The third trimester of pregnancy and the early postpartum period are critical times in encouraging
and supportive mothers who express intention to breastfeed and those who have initiated breastfeeding. These time periods are important to helping mothers establish successful breastfeeding
relationships with their babies. During the prenatal period, a mother should be educated about
breastfeeding and her concerns about issues such as her ability to produce milk and assurance that
her baby will get enough milk from her to thrive should be addressed. During the first few weeks
after delivery, mothers need assurance they are successful and support should be provided if
problems arise.

Loving Support Award of Excellence
Gold Application Instructions - 10

Question 28. (1 point)

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?

The narrative and the supportive documentation should include all of following:
• Early assessment and follow-up for the breastfeeding dyad soon after delivery
• Anticipatory guidance on what to expect (e.g., growth spurts, hunger and satiety cues, signs
that baby is getting enough, etc.)
• Staff provide practical strategies to address potential obstacles
• Education and support for mothers in (e.g., mothers returning to work or school, mothers of
multiples, etc.)
• Referral system is in place ensuring the mother is connected to the appropriate WIC staff
person
• Appropriate referrals to community resources that provide breastfeeding support services
Examples of acceptable supportive documentation: Policies and procedures, Staff training
materials.
Check the appropriate box (Yes/No) in response to the question.
Write a brief descriptive narrative which describes how these policies and procedures are implemented. Narrative not to exceed 500 words.
Attach both the narrative and the supportive documentation.
Fill in the document titles and indicate the page number(s) that corresponds to each document.
Question 29. (1 point)

Do you have policies that ensure all participant breastfeeding concerns are addressed according to
established time frames?

Check the appropriate box (Yes/No) in response to each question.
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.
Please complete the Application Verification Form on page 7 of the Application.
Thank you for applying for the
WIC Loving Support Award of Excellence
For more information, visit the FNS WIC Website: http://www.fns.usda.gov/wic/

Loving Support Award of Excellence
Gold Application Instructions - 11

Question 28. (1 point)

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?

The narrative and the supportive documentation should include all of following:
• Early assessment and follow-up for the breastfeeding dyad soon after delivery
• Anticipatory guidance on what to expect (e.g., growth spurts, hunger and satiety cues, signs
that baby is getting enough, etc.)
• Staff provide practical strategies to address potential obstacles
• Education and support for mothers in (e.g., mothers returning to work or school, mothers of
multiples, etc.)
• Referral system is in place ensuring the mother is connected to the appropriate WIC staff
person
• Appropriate referrals to community resources that provide breastfeeding support services
Examples of acceptable supportive documentation: Policies and procedures, Staff training
materials.
Check the appropriate box (Yes/No) in response to the question.
Write a brief descriptive narrative which describes how these policies and procedures are implemented. Narrative not to exceed 500 words.
Attach both the narrative and the supportive documentation.
Fill in the document titles and indicate the page number(s) that corresponds to each document.
Question 29. (1 point)

Do you have policies that ensure all participant breastfeeding concerns are addressed according to established time frames?

Check the appropriate box (Yes/No) in response to each question.
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.
Please complete the Application Verification Form on page 7 of the Application.
Thank you for applying for the
WIC Loving Support Award of Excellence
For more information, visit the FNS WIC Website: http://www.fns.usda.gov/wic/
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 (0584-0524). Do not return the completed form to this address.

Loving Support Award of Excellence
Gold Application Instructions - 12