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 Premiere and Gold Elite 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 Premiere/Elite Award 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
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.
Please download the Premiere and Gold Award Evaluation Worksheet for scoring the
application.
PRESCREENING
In order to be eligible to apply for a Gold Premiere or Gold Elite award, the local
agency must have applied and met the criteria for a Gold Award for this application
period.
Verify the applicant has met this criterion. If it has not been met – STOP.

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?

Verify the applicant response. Check Yes or No based on applicant’s response.
If verified as Yes, score 2 points in corresponding column of the worksheet.
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?

Verify the applicant response. Check Yes or No based on applicant’s response.
If verified as Yes, score 3 points in corresponding column of the worksheet.
Loving Support Award of Excellence
Gold Premiere/Elite Award Evaluation 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?

Verify the applicant response. Check Yes or No based on applicant’s response.
If verified as Yes, score 2 points in corresponding column of the worksheet.
Question 4. (2 points)

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

Verify the applicant response for each question. Check Yes or No.
If verified as Yes, score 2 points in corresponding column of the worksheet.
Question 5. (3 points)

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

Examples of acceptable supportive documentation: Policy and procedures, Staff training materials
Documentation attached includes all of the following:
• Includes process for making home visits
• Procedures address travel
• Procedures address safety
• Procedures address confidentiality
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.
If all is verified as Yes, score 3 points in corresponding column of the worksheet.
Question 6. (3 points)

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

Examples of acceptable supportive documentation: Policy and procedures, Staff training materials
Documentation attached must include all:
• Includes established process for making hospital visits
• Describes relationship with hospital
• Procedures address confidentiality
• Procedures address supervision
• Procedures address liability
• Clarifies the scope of practice and the role of the peer counselor
• Clarifies communication procedures and 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.
If all is verified as Yes, score 3 points in corresponding column of the worksheet.
Loving Support Award of Excellence
Gold Premiere/Elite Award Evaluation 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.
Examples of acceptable supportive documentation: Policies and procedures, Screen shots, Peer
counselor documentation log
Narrative attached includes all of the following:
• Peer counselors to communicate using at least one of the following:
- Facebook, text messaging, twitter, Skype, or PalTalk.
• Peer counselors use social media for at least one of the following: taking training, communicating with mothers, communicating with supervisors, communicating with other peer counselors,
or communicating with referral sources.
Policies and procedures attached include all of the following:
• Confidentiality and privacy considerations
• Proper etiquette when using social media
• Monitoring of site
• Follows local agency, health department or Federal/State policies for use of social media
Verify the applicant response. Check Yes or No based on applicant’s response.
Verify if the narrative and supportive documentation meets all of the requirements listed above.
Check Yes or No based on your documentation review.
If all is verified as Yes, score 3 points in corresponding column of the worksheet.

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

Question 10. (2 points)

PARTNERSHIP CRITERIA

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

Examples of acceptable supportive documentation: Memorandum of Understanding, Written
agreement.
Documentation attached includes all of the following:
• Description of the role of each partner
• Description of the goals and outcomes.
• Description of the types of activities planned.
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.
If all is verified as Yes, score 2 points in corresponding column of the worksheet.
Question 11. (2 points)

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

Examples of acceptable supportive documentation: Policy and procedures.
Documentation attached includes all of the following:
• Description of the reason the policies or procedures were developed.
• Description of how the policies or procedures help meet the partnership goals.
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.
If all is verified as Yes, score 2 points in corresponding column of the worksheet.
Question 12. (2 points)

Does the partnership have a plan for sustainability?

Verify the applicant response. Check Yes or No based on applicant’s response.
If verified as Yes, score 2 points in corresponding column of the worksheet.
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?

Verify the applicant response. Check Yes or No based on applicant’s response.
If verified as Yes, score 2 points in corresponding column of the worksheet.
Loving Support Award of Excellence
Gold Premiere/Elite Award Evaluation Instructions - 5

Question 14. (2 points)

OTHER CRITERIA

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

Documentation attached includes at least one of following:
• Breastfeeding staff are allotted adequate time and an appropriate place to express milk
• A “Bring your baby to work” program is established for breastfeeding staff with supportive
policies.
Verify the applicant response. Check Yes or No based on applicant’s response.
Verify if the documentation meets the requirements listed above.
Check Yes or No based on your documentation review.
If all is verified as Yes, score 2 points in corresponding column of the worksheet.
Question 15. (3 points)

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)

Examples of acceptable supportive documentation: Policy and procedures, Nutrition education
plan.
Documentation attached includes:
• Indicates the local agency provides funding, or staff working hours, for education and training
for staff in pursuit of certifications and advanced credentials in breastfeeding.
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.
If all is verified as Yes, score 3 points in corresponding column of the worksheet.
Question 16. (3 points)

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

Acceptable documentation: Narrative
Documentation attached describes how assistance is provided to breastfeeding mothers around the
clock.
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.
If all is verified as Yes, score 3 points in corresponding column of the worksheet.
Loving Support Award of Excellence
Gold Premiere/Elite Award Evaluation Instructions - 6

Fill in the Premiere and Elite Points Table with the subtotal of points from each section.
Fill in the Performance Data Table using the performance data posted on the FNS website.
Fill in the Award Determination Table checking each box where the criteria listed on page 1 and 2
of this document was met.
To recommend an award, all criteria in the particular award column must be met.
Fill in recommended award based on the Award Determination Table.
Complete the cover sheet on page 1 of the Evaluation Worksheet. Mark an X on the Award you
recommend.
Save the completed evaluation sheet in the appropriate folder in PartnerWeb.

Loving Support Award of Excellence
Gold Premiere/Elite Award Evaluation Instructions - 7