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 Premiere and Gold Elite 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 Premiere/Elite Award 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
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.
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.

Question 1. (2 points)

PEER COUNSELING

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

Check the appropriate box (Yes/No) in response to the question.
Question 2. (3 points)

Do you have at an IBCLC on staff or do you contract with an IBCLC to serve as a referral source for peer
counselors?

Check the appropriate box (Yes/No) in response to the question.
Loving Support Award of Excellence
Gold Premiere/Elite Award Application Instructions - 2

Question 3. (2 points)

Do you have a referral process in place between hospitals and the WIC Program to facilitate peer counselor
follow-up for WIC mothers shortly after discharge?

Check the appropriate box (Yes/No) in response to the question.
Question 4. (2 points)

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

Check the appropriate box (Yes/No) in response to the question.
Question 5. (3 points)

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

The supportive documentation should indicate there is a process for making home visits,
procedures which address travel, safety and confidentiality.
Examples of acceptable supportive documentation: Policy 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 6. (3 points)

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

The supportive documentation should indicate a process for making hospital visits, describe the
relationship with hospital, address confidentiality, supervision, liability, and clarify the scope of
practice and the role of the peer counselor.
Examples of acceptable supportive documentation: Policy and procedures, Staff training
materials, Written agreements/contracts with hospitals
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 7. (2 points)

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

Check the appropriate box (Yes/No) in response to each question.
Question 8. (2 points)

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

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

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

Question 9. (3 points)

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

Social media is the use of web-based and mobile technologies to turn communication into
interactive dialogue and build a sense of community among users. Social media represents a
fundamental shift in the way people communicate in recent years. Research shows that WIC’s
target population of low-income mothers use social media extensively as a means to communicate.
The narrative and/or the supportive documentation should indicate how the local agency is using
social media technologies with peer counselors. It should indicate how they allow peer
counselors to use social media and/or electronic communication for at least one of the following
reasons: training, communicating with mothers, communicating with supervisors, communicating
with other peer counselors, communicating with referral sources.
Documentation must include information on at least one of the following that allows peer
counselors opportunities to communicate via social media technologies or other electronic media:
Facebook, text messaging, twitter, Skype, PalTalk, other electronic media.
Policies should include confidentiality and proper etiquette and follows local agency, health
department or State policies for use of social media and indicates they follows local agency, health
department or State policies for use of social media.
Examples of acceptable supportive documentation: Policies and procedures, Screen shots, Peer
counselor documentation log
Check the appropriate box (Yes/No) in response to the question.
Please describe in a narrative how your peer counseling program is implementing social media
technologies and attach supportive documentation. Narrative not to exceed 500 words.
Attach narrative and supportive documentation that indicate existing policies and procedures for
peer counselors to communicate via social media technologies.
Fill in all document titles for both the narrative and supportive documentation and indicate the
page number(s) that corresponds to each document.

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

PARTNERSHIP CRITERIA

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 businesses, 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.
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 10. (2 points)

Does the partnership have a written agreement or a Memorandum of Understanding?

Examples of acceptable supportive documentation: Memorandum of Understanding, Written
agreement
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 11. (2 points)

Have new policies or procedures been developed because of the partnership?

Describe the new procedures developed as a result of the partnership in a brief narrative or attach
supportive documentation that indicates policies or procedures have been developed as a result of
the partnership. Narrative not to exceed 500 words.
Examples of acceptable supportive documentation: Policy and procedures
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 12. (2 points)

Does the partnership have a plan for sustainability?

Check the appropriate box (Yes/No) in response to each question.
Question 13. (2 points)

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

Check the appropriate box (Yes/No) in response to each question.
Loving Support Award of Excellence
Gold Premiere/Elite Award Application Instructions - 5

PARTNERSHIP CRITERIA

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 businesses, 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.
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 10. (2 points)

Does the partnership have a written agreement or a Memorandum of Understanding?

Examples of acceptable supportive documentation: Memorandum of Understanding, Written
agreement
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 11. (2 points)

Have new policies or procedures been developed because of the partnership?

Describe the new procedures developed as a result of the partnership in a brief narrative or attach
supportive documentation that indicates policies or procedures have been developed as a result of
the partnership. Narrative not to exceed 500 words.
Examples of acceptable supportive documentation: Policy and procedures
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 12. (2 points)

Does the partnership have a plan for sustainability?

Check the appropriate box (Yes/No) in response to each question.
Question 13. (2 points)

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

Check the appropriate box (Yes/No) in response to each question.
Loving Support Award of Excellence
Gold Premiere/Elite Award Application Instructions - 5

Question 15. (3 points)

OTHER CRITERIA

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)

The supportive documentation should indicate funding or staff working hours are provided for
education and training for staff in pursuit of certifications and advanced credentials in
breastfeeding.
Examples of acceptable supportive documentation: Policy and procedures, Nutrition education
plan.
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.
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.
Question 16. (3 points)

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

Please describe in a narrative how you provide assistance to breastfeeding mothers around the
clock. Narrative not to exceed 500 words.
Check the appropriate box (Yes/No) in response to the question.
Attach the supportive documentation. Fill in the document title.
Please complete the Application Verification Form on page 6 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 Premiere/Elite Award Application Instructions - 7