WIC State Agency Evaluations

OMB Control NXPEHU: 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
Premiere and Elite Award
Evaluation Worksheet
State Verification and Approval
State WIC Breastfeeding Coordinator/Reviewer:
I have reviewed the Premiere and Elite Award application, and I attest to the accuracy of the
information provided.
Name
Title

Date

State Reviewer’s Phone

Email

State FNS Region

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
Premiere/Elite Evaluation Worksheet 1

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

Please download the Premiere and Elite Evaluation Worksheet Instructions.

Prescreening

Applicant has completed a Gold Award application and has met the
criteria to receive a Gold Award with this fiscal year’s application.
No partial credit. All criteria must be present to obtain credible
points for each question.

Yes
Response
Verified

Points

PEER COUNSELING SECTION
Question 1. (2 points)

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

Applicant Response

Yes

No

Yes

No

Yes

No

Yes

No

Applicant Response

Yes

No

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

Yes

No

Question 2. (3 points)

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

Applicant Response
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?

Applicant Response
Question 4. (2 points)

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

Applicant Response
Question 5. (3 points)

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

Loving Support Award of Excellence
Premiere/Elite Evaluation Worksheet 2

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

Question 6. (3 points)

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

Applicant Response

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Applicant Response

Yes

No

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

Yes

No

Does the documentation meet the requirements as listed in the
instructions?
Question 7. (2 points)

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

Applicant Response
Question 8. (2 points)

Do you include career path structure for upward mobility of peer co

Applicant Response
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?

Applicant Response
Does the documentation meet the requirements as listed in the
instructions?
Total Points from Peer Counseling Section
PARTNERSHIP SECTION
Question 10. (2 points)

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

Loving Support Award of Excellence
Premiere/Elite Evaluation Worksheet 3

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

Question 11. (2 points)

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

Applicant Response

Yes

No

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

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

Question 12. (2 points)

Do the partnership have a plan for sustainability?

Applicant Response
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?

Applicant Response
Total Points from Partnership Section
OTHER CRITERIA SECTION
Question 14. (2 points)

Do you have a supportive clinic environment that implements breastfeedingfriendly workplace policies for WIC staff?

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)

Loving Support Award of Excellence
Premiere/Elite Evaluation Worksheet 4

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

Question 16. (3 points)

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

Applicant Response

Yes

No

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

Yes

No

Total Points from Other Criteria Section

Premiere and Elite Points Table
Points from
Peer Counseling Section
Gold Premiere - a minimum
of 10 points
Gold Elite - must be 22 points

Points from
Partnership Section

Points from
Other Criteria Section

Gold Premiere - a minimum
of 4 points
Gold Elite - must be 8 points

Gold Premiere - a minimum
of 5 points
Gold Elite - must be 8 points

Performance Data Table

PERFORMANCE DATA
% Exclusively Breastfed Infants
% Exclusively Breastfed Infants
Previous Year
Current Year

Loving Support Award of Excellence
Premiere/Elite Evaluation Worksheet 5

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

Award Determination Table

All 29 Gold Application Questions
Premiere/Elite Questions, a minium of
10 points
Peer Counseling Section, equal to 22
points
Partnership Section, minimum of 4
points
Partnership Section
Optional Questions, equal to 8 points
Other Criteria Section, a minimum of 5
points
Other Criteria Section Optional
Questions, equal to 8 points
Performance Data, % exclusively
breastfed infants is at least 15 % or
higher in the previous year 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
Performance Data, % exclusively
breastfed infants is at least 40 % or
higher in the most recently published
year of data
Recommended Award:

Gold

Gold
Met

Gold Premiere
Met

Gold Premiere

Gold Elite
Met

Gold Elite

Loving Support Award of Excellence
Premiere/Elite Evaluation Worksheet 6