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
Application Cover Sheet for Gold Premiere/Gold Elite
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 Premiere/Gold Elite Application 1

Loving Support Award of Excellence

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

IN ORDER TO BE ELIGIBLE TO APPLY FOR A GOLD PREMIERE OR GOLD ELITE AWARD, YOU
MUST HAVE APPLIED AND MET THE CRITERIA FOR A GOLD AWARD FOR THIS APPLICATION
PERIOD.
1. Have you completed the Gold Award application for this application?

Yes

Application

1. Do you have established guidelines for how many hours of observation/
shadowing is required as part of peer counseling training/continuing
education?

Yes

No

Yes

No

Yes

No

4. Do you have a system that electronically documents and tracks peer
counseling referrals and contacts? 

Yes

No

5. Do you have policies and procedures for home visits as part of your peer
counseling program?

Yes

No

2. Do you have at an IBCLC on staff or do you contract with an IBCLC to serve
as a referral source for peer counselors?
3. Do you have a referral process in place between hospitals and the WIC
Program to facilitate peer counselor follow-up care for newly-delivered
WIC mothers after discharge?

Document Title
Attach supportive documentation.
Fill in the document title and indicate the page numbers where the
information that answers the question can be found.

Page Number(s)

6. Do you have policies and procedures for hospital visits as part of your peer
counseling program?

Yes

No

Document Title
Attach supportive documentation.
Fill in the document title and indicate the page numbers where the
information that answers the question can be found.

Page Number(s)

Loving Support Award of Excellence
Gold Premiere/Gold Elite Application 2

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

7. Do you have a recognition program in place to acknowledge peer counselor
accomplishments?

Yes

No

8. Do you include career path structures for upward mobility of peer
counselors?

Yes

No

Yes

No

9. Do you have policies and procedures for peer counselors to communicate
via social media technologies, e.g., Facebook, text messaging, twitter,
Skype, PalTalk?

Narrative Title

Attach narrative and supportive documentation that indicate existing
policies and procedures for peer counselors to communicate via social
media technologies.

Document Title

Fill in both document titles and indicate the page numbers(s) that
corresponds to each document.

Page Number(s)

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.
10. Does the partnership have a written agreement or a Memorandum of
Understanding?
Yes
No
Attach supportive documentation; fill in the document title and indicate
the page numbers where the information that answers this question can be Document Title
found.
Page Number(s)
11. Have new policies or procedures been developed because of the
partnership? Please describe the new procedures in a narrative, or attach
supportive documentation, that indicates policies or procedures have been
developed as a result of the partnership.

Yes

No

Document Title

Attach supportive documentation; fill in the document title and indicate
the page numbers where the information that answers this question can be
Page Number(s)
found.
12. Does the partnership have a plan for sustainability?

Yes

No

Loving Support Award of Excellence
Gold Premiere/Gold Elite Application 3

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

13. Do you partner with stakeholders such as the American Hospital
Association to support the Baby-Friendly Hospital Initiative in their
community?

Yes

No

Yes

No

OTHER

14. Do you have a supportive clinic environment that implements
breastfeeding-friendly workplace polices for WIC staff?
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)

15. Do you provide funding or work hours for education and training for staff
to pursue certifications and advanced credentials in breastfeeding? (e.g.
CLC, CLE, IBCLC)
Attach supportive documentation; fill in the document title and indicate
the page numbers where the information that answers this question can
be found.

16. Do you provide around the clock assistance to assist mothers work through
their breastfeeding problems?
Attach 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)

Yes

No

Document Title
Page Number(s)

Loving Support Award of Excellence
Gold Premiere/Gold Elite Application 4

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

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 FNS/WIC Website: http://www.fns.usda.gov/wic/.

Loving Support Award of Excellence
Gold Premiere/Gold Elite Application 5