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 Worksheet
State Verification and Approval
State WIC Breastfeeding Coordinator/Reviewer:
I have reviewed the Gold Award application, and I attest to the accuracy of the information provided.
Name
Title

Date

State Reviewer’s Phone

Email

State FNS Region

State agency Recommendation
Recommended Award

None

Gold

Gold Premiere

Gold Elite

Justification for no award
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 Worksheet 1

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
Evaluation Worksheet

FNS Regional Office Approval
FNS Region Office
Reviewer’s Name

Date

Reviewer’s Phone

Award

Gold

Recommended Award

Email

Gold Premiere
Gold Elite

No Award Recommended
Justification
FNS Headquarters Approval
Reviewer’s Name
Date Gold Elite Award
SFPD Director Date

Loving Support Award of Excellence
Gold Evaluation Worksheet 2

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

Please download the Gold Award Evaluation Worksheet Instructions.

Prescreening

Applicant has met the prescreening requirements

Yes

No partial credit. All criteria must be present to obtain credible
points for each question.

Response
Verified

Question 1. (1 point)

Do you conduct an assessment to determine each of the following:
(a) the needs of your target audience;
(b) where gaps exist in the 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.

Applicant Response

Yes

No

Does the documentation meet the requirements as listed in the
instructions?

Yes

No

Applicant Response

Yes

No

Does the documentation meet the requirements as listed in the
instructions?
Question 3. (1 point)

Yes

No

Applicant Response

Yes

No

Yes

No

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?

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

Question 4. (1 point)

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

Applicant Response

Loving Support Award of Excellence
Gold Evaluation Worksheet 3

Gold

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

Question 5. (1 point)

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

Yes

No

Yes

No

Yes

No

Applicant Response

Yes

No

Does the documentation meet the requirements as listed in the
instructions?

Yes

No

Applicant Response

Yes

No

Does the documentation meet the requirements as listed in the
instructions?

Yes

No

Applicant Response
Question 6. (1 point)

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

Applicant Response

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.

Applicant 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?

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?

Loving Support Award of Excellence
Gold Evaluation Worksheet 4

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

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?

Applicant Response

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

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?

Applicant 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?

Applicant 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?

Applicant Response
Question 14. (1 point)

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

Applicant Response
Question 15. (1 point)

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

Applicant Response

Loving Support Award of Excellence
Gold Evaluation Worksheet 5

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

Question 16. (1 point)

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

Applicant Response

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Question 17. (1 point)

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

Applicant Response
Question 18. (1 point)

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

Applicant Response
Question 19. (1 point)

Has the partnership produced results that provide an ongoing benefit?

Applicant Response
Question 20. (1 point)

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

Applicant Response
Question 21. (1 point)

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

Applicant Response

Loving Support Award of Excellence
Gold Evaluation Worksheet 6

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

Question 22. (1 point)

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

Applicant Response

Yes

No

Does the documentation meet the requirements as listed in the
instructions?

Yes

No

Yes

No

Applicant Response

Yes

No

Does the documentation meet the requirements as listed in the
instructions?

Yes

No

Yes

No

Yes

No

Yes

No

Question 23. (1 point)

Do you ensure that all staff are trained to support the goal of exclusive
breastfeeding with WIC participants using the FNS-developed competencybased breastfeeding curriculum, Using Loving Support© to Grow and Glow in
WIC?

Applicant 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?

Question 25. (1 point)

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

Applicant 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?

Applicant Response
Question 27. (1 point)

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

Applicant Response

Loving Support Award of Excellence
Gold Evaluation Worksheet 7

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

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?

Applicant Response

Yes

No

Does the documentation meet the requirements as listed in the
instructions?

Yes

No

Yes

No

Question 29. (1 point)

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

Applicant Response

If the applicant has applied for a higher level award continue onto the
Premiere and Elite Evaluation Worksheet.
Recommended Award:

Gold

No Award

Loving Support Award of Excellence
Gold Evaluation Worksheet 8