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pdfAPPENDIX G:
Nutritional Risk Worksheet
OMB Number: 0584‐XXXX
Expiration Date: XX/XX/XXXX
Nutritional Risk Criteria Worksheet PC2016
This form includes the Nutritional Risk information reported for [STATE NAME] in PC2014. To update the worksheet for PC2016, please:
• Review the worksheet to verify that all your State agency’s codes are included and mapped to the correct FNS Risk Code.
• Indicate any revisions to the codes by selecting "New Code(s) ‐‐ Delete PC2014 Code" (meaning the PC2014 codes are no longer valid) or "Additional Code(s)" (meaning the PC2014
code(s) are still valid, but there are additional codes map to that particular Nutritional Risk).
• Type any edits or new codes in the Revisions/Additions column.
• E‐mail the completed worksheet to [email protected].
When adding and changing codes, please remember, a State agency code cannot correspond to FNS Risk Codes in different categories. On this form, bold lines separate categories.
If you will be submitting data using the standard FNS Nutritional Risk Codes, you do not need to complete this worksheet. Please just let us know the data will include the standard FNS
Risk Codes by sending an email to [email protected] or calling Chrystine Tadler at (703) 504‐9490.
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid
OMB control number. The valid OMB control number for this information collection is 0584‐XXXX. The time required to complete this information collection is estimated to average 30
minutes 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.
Category/Title
FNS Nutritional Risk Code
PC2014 State Agency Code
Revised/Additional State Agency
Codes
Please separate each code with a comma (e.g., '102,
105' or 'A5, H7')
ANTHROPOMETRIC
Low Weight‐for‐Height
Underweight (women)
Underweight or At Risk of Becoming
Underweight
High Weight‐for‐Height/Length
Overweight (women)
Obese (children 2–5 years)
Overweight or At Risk of Overweight
Revisions/Additions
100
101
[STATE AGENCY CODE FOR PC2014]
[STATE AGENCY CODE FOR PC2014]
No Change
No Change
103
[STATE AGENCY CODE FOR PC2014]
No Change
110
111
113
[STATE AGENCY CODE FOR PC2014]
[STATE AGENCY CODE FOR PC2014]
[STATE AGENCY CODE FOR PC2014]
No Change
No Change
No Change
114
[STATE AGENCY CODE FOR PC2014]
No Change
Notes
High Weight‐for‐Length (infants and
children under 24 months of age)
Short Stature
Short Stature or At Risk of Short
Stature (infants, children)
Inappropriate Growth/Weight Gain
Pattern
Low Maternal Weight Gain
Maternal Weight Loss During
Pregnancy
High Maternal Weight Gain
Failure to Thrive
Inadequate Growth
Low Birth Weight/Premature Birth
Low Birth Weight
Prematurity
Other Anthropometric Risk
Small for Gestational Age
Low Head Circumference
Large for Gestational Age
BIOCHEMICAL
Hematocrit or Hemoglobin Below FNS
Criteria
Low Hematocrit/Hemoglobin
[formerly, Anemia]
Other Biochemical Test Results That
Indicate Nutritional Abnormality
Elevated Blood Lead Levels
CLINICAL/HEALTH/MEDICAL
Pregnancy‐Induced Conditions
Hyperemesis Gravidarum
Gestational Diabetes
History of Gestational Diabetes
History of Preeclampsia
Delivery of Low‐Birthweight/Premature
Infant
History of Preterm Delivery
History of Low Birth Weight
Prior Stillbirth, Fetal, or Neonatal Death
History of Spontaneous Abortion,
Fetal or Neonatal Loss
General Obstetrical Risks
Pregnancy at a Young Age
Closely Spaced Pregnancies
115
[STATE AGENCY CODE FOR PC2014]
No Change
120
[STATE AGENCY CODE FOR PC2014]
No Change
121
[STATE AGENCY CODE FOR PC2014]
No Change
130
[STATE AGENCY CODE FOR PC2014]
No Change
131
[STATE AGENCY CODE FOR PC2014]
No Change
132
[STATE AGENCY CODE FOR PC2014]
No Change
133
134
135
140
141
142
150
151
152
153
[STATE AGENCY CODE FOR PC2014]
[STATE AGENCY CODE FOR PC2014]
[STATE AGENCY CODE FOR PC2014]
[STATE AGENCY CODE FOR PC2014]
[STATE AGENCY CODE FOR PC2014]
[STATE AGENCY CODE FOR PC2014]
[STATE AGENCY CODE FOR PC2014]
[STATE AGENCY CODE FOR PC2014]
[STATE AGENCY CODE FOR PC2014]
[STATE AGENCY CODE FOR PC2014]
No Change
No Change
No Change
No Change
No Change
No Change
No Change
No Change
No Change
No Change
200
[STATE AGENCY CODE FOR PC2014]
No Change
201
[STATE AGENCY CODE FOR PC2014]
No Change
210
[STATE AGENCY CODE FOR PC2014]
No Change
211
[STATE AGENCY CODE FOR PC2014]
No Change
300
301
302
303
304
[STATE AGENCY CODE FOR PC2014]
[STATE AGENCY CODE FOR PC2014]
[STATE AGENCY CODE FOR PC2014]
[STATE AGENCY CODE FOR PC2014]
[STATE AGENCY CODE FOR PC2014]
No Change
No Change
No Change
No Change
No Change
310
[STATE AGENCY CODE FOR PC2014]
No Change
311
312
[STATE AGENCY CODE FOR PC2014]
[STATE AGENCY CODE FOR PC2014]
No Change
No Change
320
[STATE AGENCY CODE FOR PC2014]
No Change
321
[STATE AGENCY CODE FOR PC2014]
No Change
330
331
332
[STATE AGENCY CODE FOR PC2014]
[STATE AGENCY CODE FOR PC2014]
[STATE AGENCY CODE FOR PC2014]
No Change
No Change
No Change
High Parity and Young Age
Lack of Adequate Prenatal Care
Multi‐fetal Gestation
Fetal Growth Restriction
History of Birth of a Large for
Gestational Age Infant
Pregnant Woman Currently
Breastfeeding
333
334
335
336
[STATE AGENCY CODE FOR PC2014]
[STATE AGENCY CODE FOR PC2014]
[STATE AGENCY CODE FOR PC2014]
[STATE AGENCY CODE FOR PC2014]
No Change
No Change
No Change
No Change
337
[STATE AGENCY CODE FOR PC2014]
No Change
338
[STATE AGENCY CODE FOR PC2014]
No Change
339
[STATE AGENCY CODE FOR PC2014]
No Change
340
[STATE AGENCY CODE FOR PC2014]
No Change
341
342
343
344
[STATE AGENCY CODE FOR PC2014]
[STATE AGENCY CODE FOR PC2014]
[STATE AGENCY CODE FOR PC2014]
[STATE AGENCY CODE FOR PC2014]
No Change
No Change
No Change
No Change
345
[STATE AGENCY CODE FOR PC2014]
No Change
346
347
[STATE AGENCY CODE FOR PC2014]
[STATE AGENCY CODE FOR PC2014]
No Change
No Change
Central Nervous System Disorders
348
[STATE AGENCY CODE FOR PC2014]
No Change
Genetic and Congenital Disorders
349
[STATE AGENCY CODE FOR PC2014]
No Change
Inborn Errors of Metabolism
Infectious Diseases (Bronchiolitis
added)
Food Allergies
Celiac Disease
Lactose Intolerance
Hypoglycemia
Drug‐Nutrient Interactions
Eating Disorders
351
[STATE AGENCY CODE FOR PC2014]
No Change
352
[STATE AGENCY CODE FOR PC2014]
No Change
353
354
355
356
357
358
[STATE AGENCY CODE FOR PC2014]
[STATE AGENCY CODE FOR PC2014]
[STATE AGENCY CODE FOR PC2014]
[STATE AGENCY CODE FOR PC2014]
[STATE AGENCY CODE FOR PC2014]
[STATE AGENCY CODE FOR PC2014]
No Change
No Change
No Change
No Change
No Change
No Change
Recent Major Surgery, Trauma, Burns
359
[STATE AGENCY CODE FOR PC2014]
No Change
Other Medical Conditions
Depression
Developmental, Sensory or Motor
disabilities Interfering with the Ability
to Eat
Pre‐Diabetes
Substance Abuse (Drugs, Alcohol,
Tobacco)
360
361
[STATE AGENCY CODE FOR PC2014]
[STATE AGENCY CODE FOR PC2014]
No Change
No Change
362
[STATE AGENCY CODE FOR PC2014]
No Change
363
[STATE AGENCY CODE FOR PC2014]
No Change
370
[STATE AGENCY CODE FOR PC2014]
No Change
History of Birth with Nutrition Related
Congenital or Birth Defect
Nutrition‐Related Risk Conditions (e.g.
Chronic Disease, Genetic Disorder,
Infection)
Nutrient Deficiency Diseases
Gastrointestinal Disorders
Diabetes Mellitus
Thyroid Disorders
Hypertension and Prehypertension
(Includes Chronic and Pregnancy
Induced)
Renal Disease
Cancer
Maternal Smoking
Alcohol and Illegal Drug Use
Other Health Risks
Dental Problems (Oral Health
Conditions)
Fetal Alcohol Syndrome
DIETARY
Failure to Meet Dietary Guidelines for
Americans
Failure to Meet Dietary Guidelines for
Americans
Inappropriate Nutrition Practices
Inappropriate Nutrition Practices for
Infants
371
372
380
[STATE AGENCY CODE FOR PC2014]
[STATE AGENCY CODE FOR PC2014]
[STATE AGENCY CODE FOR PC2014]
No Change
No Change
No Change
381
[STATE AGENCY CODE FOR PC2014]
No Change
382
[STATE AGENCY CODE FOR PC2014]
No Change
400
[STATE AGENCY CODE FOR PC2014]
No Change
401
[STATE AGENCY CODE FOR PC2014]
No Change
410
[STATE AGENCY CODE FOR PC2014]
No Change
411
[STATE AGENCY CODE FOR PC2014]
No Change
Routinely using a substitute(s) for
breast milk or for FDA approved
iron‐fortified formula as the
primary nutrient source during
the first year of life
411.1
[STATE AGENCY CODE FOR PC2014]
No Change
Routinely using nursing bottles or
cups improperly
411.2
[STATE AGENCY CODE FOR PC2014]
No Change
Routinely offering complementary
foods or other substances that are
inappropriate in type or timing.
411.3
[STATE AGENCY CODE FOR PC2014]
No Change
Routinely using feeding practices
that disregard the developmental
needs or stage of the infant.
411.4
[STATE AGENCY CODE FOR PC2014]
No Change
Feeding foods to an infant that
could be contaminated with
harmful microorganisms or toxins.
411.5
[STATE AGENCY CODE FOR PC2014]
No Change
Routinely feeding inappropriately
diluted formula.
411.6
[STATE AGENCY CODE FOR PC2014]
No Change
Routinely limiting the frequency
of nursing of the exclusively
breastfed infant when breast milk
is the sole source of nutrients.
411.7
[STATE AGENCY CODE FOR PC2014]
No Change
Routinely feeding a diet very low
in calories and/or essential
nutrients.
411.8
[STATE AGENCY CODE FOR PC2014]
No Change
Routinely using inappropriate
sanitation in preparing, handling,
and storage of expressed
breastmilk or formula.
411.9
[STATE AGENCY CODE FOR PC2014]
No Change
Feeding dietary supplements with
potentially harmful consequences.
411.10
[STATE AGENCY CODE FOR PC2014]
No Change
Routinely not providing dietary
supplements recognized as
essential by national public health
policy when an infant’s diet alone
cannot meet nutrient
requirements.
411.11
[STATE AGENCY CODE FOR PC2014]
No Change
425
[STATE AGENCY CODE FOR PC2014]
No Change
425.1
[STATE AGENCY CODE FOR PC2014]
No Change
425.2
[STATE AGENCY CODE FOR PC2014]
No Change
Routinely using nursing bottles,
cups, or pacifiers improperly.
425.3
[STATE AGENCY CODE FOR PC2014]
No Change
Routinely using feeding practices
that disregard the developmental
needs or stages of the child.
425.4
[STATE AGENCY CODE FOR PC2014]
No Change
425.5
[STATE AGENCY CODE FOR PC2014]
No Change
425.6
[STATE AGENCY CODE FOR PC2014]
No Change
Feeding dietary supplements with
potentially harmful consequences.
425.7
[STATE AGENCY CODE FOR PC2014]
No Change
Routinely not providing dietary
supplements recognized as
essential by national public health
policy when a child’s diet alone
cannot meet nutrient
requirements.
425.8
[STATE AGENCY CODE FOR PC2014]
No Change
Routine ingestion of nonfood
items (pica).
425.9
[STATE AGENCY CODE FOR PC2014]
No Change
Inappropriate Nutrition Practices for
Children
Routinely feeding inappropriate
beverages as the primary milk
source.
Routinely feeding a child any
sugar‐containing fluids.
Feeding foods to a child that could
be contaminated with harmful
microorganisms.
Routinely feeding a diet very low
in calories and/or essential
nutrients.
Inappropriate Nutrition Practices for
Women
Consuming dietary supplements
with potentially harmful
consequences.
Consuming a diet very low in
calories and/or essential
nutrients; or impaired caloric
intake or absorption of essential
nutrients following bariatric
surgery.
Compulsively ingesting non‐food
items (pica).
Inadequate vitamin/mineral
supplementation recognized as
essential by national public health
policy.
427
[STATE AGENCY CODE FOR PC2014]
No Change
427.1
[STATE AGENCY CODE FOR PC2014]
No Change
427.2
[STATE AGENCY CODE FOR PC2014]
No Change
427.3
[STATE AGENCY CODE FOR PC2014]
No Change
427.4
[STATE AGENCY CODE FOR PC2014]
No Change
427.5
[STATE AGENCY CODE FOR PC2014]
No Change
428
[STATE AGENCY CODE FOR PC2014]
No Change
500
[STATE AGENCY CODE FOR PC2014]
No Change
501
502
[STATE AGENCY CODE FOR PC2014]
[STATE AGENCY CODE FOR PC2014]
No Change
No Change
503
[STATE AGENCY CODE FOR PC2014]
No Change
600
[STATE AGENCY CODE FOR PC2014]
No Change
601
[STATE AGENCY CODE FOR PC2014]
No Change
602
[STATE AGENCY CODE FOR PC2014]
No Change
603
[STATE AGENCY CODE FOR PC2014]
No Change
700
[STATE AGENCY CODE FOR PC2014]
No Change
Infant Up to 6 Months Old of WIC
Mother, or of a Woman Who Would
Have Been Eligible During Pregnancy
701
[STATE AGENCY CODE FOR PC2014]
No Change
Breastfeeding Infant of Woman at
Nutritional Risk
702
[STATE AGENCY CODE FOR PC2014]
No Change
Pregnant woman ingesting foods
that could be contaminated with
pathogenic microorganisms.
Dietary Risk Associated with
Complementary Feeding Practices
OTHER RISKS
Regression/Transfer/Presumptive
Eligibility
Possibility of Regression
Transfer of Certification
Presumptive Eligibility for Pregnant
Women
Breastfeeding Mother/Infant Dyad
Breastfeeding Mother of Infant at
Nutritional Risk
Breastfeeding Complications
(Women)
Breastfeeding Complications (Infants)
Infant of a WIC‐Eligible Mother or
Mother at Risk During Pregnancy
Infant Born of Woman with Mental
Retardation or Alcohol or Drug Abuse
During Most Recent Pregnancy
Homelessness/Migrancy
Homelessness
Migrancy
Other Nutritional Risks
Recipient of Abuse
Woman, or Infant/Child of Primary
Caregiver with Limited Ability to
Make Feeding Decisions and/or
Prepare Food
Foster Care
Exposure to Environmental Tobacco
Smoke
703
[STATE AGENCY CODE FOR PC2014]
No Change
800
801
802
900
901
[STATE AGENCY CODE FOR PC2014]
[STATE AGENCY CODE FOR PC2014]
[STATE AGENCY CODE FOR PC2014]
[STATE AGENCY CODE FOR PC2014]
[STATE AGENCY CODE FOR PC2014]
No Change
No Change
No Change
No Change
No Change
902
[STATE AGENCY CODE FOR PC2014]
No Change
903
[STATE AGENCY CODE FOR PC2014]
No Change
904
[STATE AGENCY CODE FOR PC2014]
No Change
| File Type | application/pdf |
| Author | EAyo |
| File Modified | 2015-12-14 |
| File Created | 2015-11-20 |