WIC State Agency Evaluations

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 Evaluation 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 1.2 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 Evaluation 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

Please download the Gold Award Evaluation Worksheet for scoring the application.
Prescreening
Before an applicant can apply for an award they must verify their local agency peer counseling
program has been in place for at least one year, and that their peer counseling program meets all
components of the Loving Support peer counseling model listed below.
Verify the prescreening question has been answered, and the applicant has met the
requirements. When verified, check Yes on the Gold Evaluation Worksheet.
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 Evaluation Instructions - 2

Questions and Documentation

QUESTIONS
When evaluating the application, if a Gold Award question is checked “No”, or if the
documentation attached for a Gold Award question does not meet the criteria listed - STOP. This
is a required component for an award. The applicant does not qualify. Go to the Cover Sheet,
check “No Award”, and fill in the justification.
DOCUMENTATION
If the same documentation is submitted for more than one question, the applicant
will enter the same document title and indicate the page number(s) that
corresponds to the specific question.
Descriptive narratives are not to exceed 500 words.

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?

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.
Acceptable documentation: Narrative
Documentation attached includes:
• Identifies the top 2 priorities and how the local agency is addressing those needs.
Verify the applicant response. Check Yes or No based on applicant’s response.
Verify if the documentation meets all of the requirements listed above.
Check Yes or No based on your documentation review.

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Gold Evaluation 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.
Examples of Acceptable Supportive Documentation: Policies and procedures or protocols,
Training materials, Position descriptions / Roles and Responsibilities
Documentation attached includes all of the following:
• Describes how peer counselors address a mother’s concerns and needs outside usual clinic
hours.
• Description includes at least one of the following: telephone calls, hotline, or face-to-face.
• Describes how peer counselors make after-hour referrals.
Verify the applicant response. Check Yes or No based on applicant’s response.
Verify if the documentation meets all of the requirements listed above.
Check Yes or No based on your documentation review.
Question 3. (1 point)

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

Verify the applicant response. Check Yes or No based on applicant’s response.
Question 4. (1 point)

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

Verify the applicant response. Check Yes or No based on applicant’s response.
Question 5. (1 point)

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

Verify the applicant response. Check Yes or No based on applicant’s response.

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Gold Evaluation 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.

Verify the applicant response. Check Yes or No based on applicant’s response.
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.
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.
Documentation attached includes all of the following:
• Scope of practice is attached.
• Scope of practice limits the peer counselor’s responsibilities to providing basic information and
support to new moms, and making referrals when peer counselors experience problems beyond
their training.
Verify the applicant response. Check Yes or No based on applicant’s response.
Verify if the documentation meets all of the requirements listed above.
Check Yes or No based on your documentation review.

Loving Support Award of Excellence
Gold Evaluator 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.

The narrative or the supportive documentation should indicate that the local agency has an
established process that describes how WIC mothers are referred to peer counselors as part of
normal clinic operations.
Acceptable documentation: Narrative or Supportive Documentation
Examples of acceptable supportive documentation: Policy and procedures, Staff training
materials, Referral protocol for peer counselors
Documentation attached includes all of the following:
• Process describes how WIC mothers are referred to peer counselors during the prenatal period.
• Process describes how WIC mothers are referred to peer counselors during the postpartum
period.
Verify the applicant response. Check Yes or No based on applicant’s response.
Verify if the documentation meets all of the requirements listed above.
Check Yes or No based on your documentation review.
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?

Verify the applicant response. Check Yes or No based on applicant’s response.
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?

Verify the applicant response. Check Yes or No based on applicant’s response.
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?

Verify the applicant response. Check Yes or No based on applicant’s response.
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?

Verify the applicant response. Check Yes or No based on applicant’s response.
Loving Support Award of Excellence
Gold Evaluator Instructions - 6

Question 14. (1 point)

PARTNERSHIP

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

Verify the applicant response. Check Yes or No based on applicant’s response.
Question 15. (1 point)

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

Verify the applicant response. Check Yes or No based on applicant’s response.
Question 16. (1 point)

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

Verify the applicant response. Check Yes or No based on applicant’s response.
Question 17. (1 point)

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

Verify the applicant response. Check Yes or No based on applicant’s response.
Question 18. (1 point)

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

Verify the applicant response. Check Yes or No based on applicant’s response.
Question 19. (1 point)

Has the partnership produced results that provide an ongoing benefit?

Verify the applicant response. Check Yes or No based on applicant’s response.
Question 20. (1 point)

OTHER CRITERIA

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

Verify the applicant response. Check Yes or No based on applicant’s response.
Question 21. (1 point)

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

Verify the applicant response. Check Yes or No based on applicant’s response.

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Gold Evaluation Instructions - 7

Question 22. (1 point)

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

Examples of acceptable supportive documentation: Policies and procedures, Staff training
materials
Documentation attached includes all of the following:
• 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
• Staff provide 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
• 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 promotes 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
Verify the applicant response. Check Yes or No based on applicant’s response.
Verify if the documentation meets all of the requirements listed above.
Check Yes or No based on your documentation review.
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?

Verify the applicant response. Check Yes or No based on applicant’s response.
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?

Examples of acceptable supportive documentation: Policies and procedures, Staff training
materials
Documentation attached includes all of the following:
• Indicates individually tailored food packages to all breastfeeding dyads based on a complete
breastfeeding assessment
• Routine issuance of infant formula to breastfeeding infants is prohibited.
Verify the applicant response. Check Yes or No based on applicant’s response.
Verify if the documentation meets all of the requirements listed above.
Check Yes or No based on your documentation review.
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Gold Evaluation Instructions - 8

Question 25. (1 point)

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

Verify the applicant response. Check Yes or No based on applicant’s response.
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?

Verify the applicant response. Check Yes or No based on applicant’s response.
Question 27. (1 point)

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

Verify the applicant response. Check Yes or No based on applicant’s response.
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?

Examples of acceptable supportive documentation: Policies and procedures, Staff training
materials
Documentation attached includes all of the 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
Verify the applicant response. Check Yes or No based on applicant’s response.
Verify if the documentation meets all of the requirements listed above.
Check Yes or No based on your documentation review.

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Gold Evaluation Instructions - 9

Question 29. (1 point)

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

Verify the applicant response. Check Yes or No based on applicant’s response.
If the total points from the Gold column are less than 29 points – STOP. Applicant is not eligible
for an award.
Check “No Award”. Then go to the cover sheet on page 1 of the Gold Award Evaluation Worksheet
and check “None” next to Recommended Award”, and fill in the justification.
If 29 points are awarded, check Gold next to recommended award.
Go to page 1 of the Gold Award Evaluation Worksheet and complete the State Verification and
Approval section on Worksheet to confirm you have reviewed and approve that the information the
local agency submitted is accurate and true.
If the applicant has not applied for a higher level award, fill in the State agency recommendation
section of the cover sheet on page 1 of the Gold Award Evaluation Worksheet.
If the applicant has applied for a higher level award continue onto the Premiere and Elite Award
Evaluation Worksheet.
When the full evaluation is complete you will complete the State agency recommendation section
of the cover sheet on page 1 of the Gold Award Evaluation Worksheet and mark the higher level
award you recommend.
Save the completed evaluation sheets in the appropriate folder in PartnerWeb.

Loving Support Award of Excellence
Gold Evaluation Instructions - 10