WIC State Agency Evaluations

U.S. Department of Agriculture, Food and Nutrition Service (FNS),

OMB Control Number: 0584-0591 Expiration date: xx/xx/xxxx

Special Supplemental Nutrition Program for Women, Infants and Children (WIC)

Local Agency Name Street Address

City, State, Zip code Applicant’s Name and Title Telephone Number

Email address Date

Public reporting burden for this collection of information is estimated to average 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- 0591). Do not return the completed form to this address.

OMB Control Number: 0584-0591 Expiration date: xx/xx/xxxx

Loving Support Award of Excellence

DOWNLOAD AND SAVE INSTRUCTIONS FROM FNS PUBLIC WEBSITE BEFORE

BEGINNING APPLICATION. In order to be eligible to apply for an award, your local agency must first be able to verify the following two questions.

1. Has your local agency peer counseling program been in place for at least one year? Yes ☐

2. Does your local agency peer counseling program meet all components of the FNS

Loving Support^© peer counseling model? Yes ☐

The Loving Support^© Model and the required core components can be found in the Application Instructions.

If your local agency received a Gold award in the past 4 years proceed to the page 6 Gold Award Application Checklist.

PEER COUNSELING
Do you conduct an annual assessment to determine each of the following: the needs of your target audience; where gaps exist in breastfeeding services and resources within your local agency and the community that can be addressed through peer counseling; and where improvements in your program are needed? Attach narrative. Fill in narrative title.	Yes ☐Narrative Title	No ☐
2. 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? Attach supportive documentation. Fill in the document title and indicate the page number(s) where the information that answers this question can be found.	Yes ☐Document Title Page Number(s)	No ☐
3. Do you have opportunities for peer counselors to observe and shadow experienced lactation experts and experienced peer counselors?	Yes ☐	No ☐
4. Do you routinely monitor the work of peer counselors through spot checks, chart reviews or contact forms?	Yes ☐	No ☐
5. Do you routinely observe newly trained peer counselors during contacts with mothers to provide guidance and affirmation?	Yes ☐	No ☐

6. Do you schedule routine meetings to discuss case studies with your peer counselors?	Yes ☐	No ☐
7. Do you have adequate supervision of peer counselors by staff with advanced lactation training? Adequate supervision is defined as having at least a .25 full time employee (FTE) supervisor for every 5 peer counselors.	Yes ☐	No ☐
8. Do you have a written defined scope of practice for peer counselors, limited to supporting normal breastfeeding, that describes the peer counselor’s role to provide basic breastfeeding education and support to WIC mothers? Attach supportive documentation. Fill in the document title and indicate the page number(s) where the information that answers this question can be found.	Yes ☐Document Title Page Number(s)	No ☐
9. Do you have a process/protocol in place that lists when the peer counselors should “yield” breastfeeding concerns and conditions that are outside the scope of practice of the peer counselor to a Designated Breast- feeding Expert? Attach supportive documentation. Fill in the document title and indicate the page number(s) where the information that answers this question can be found.	Yes ☐ Document Title Page Number(s)	No ☐
10. 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? Attach narrative OR supportive documentation. Fill in the document title and indicate the page number(s) where the information that answers this question can be found.	Yes ☐ Document Title Page Number(s)	No ☐
11. Do peer counselors routinely contact mothers, at a minimum, monthly during pregnancy and weekly 2 weeks prior to a woman’s expected delivery date?	Yes ☐	No ☐
12. 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?	Yes ☐	No ☐
13. Do peer counselors routinely contact mothers after a woman’s first month postpartum, at a minimum, monthly, as long as things are going well?	Yes ☐	No ☐
14. 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?	Yes ☐	No ☐
PARTNERSHIP
A partnership is defined as a sustainable ongoing voluntary collaborative agreement between two or more parties based on mutually agreed objectives and a shared vision, generally within a formal structure. The partners agree to work together to achieve a common goal, undertake specific tasks, and share risks, responsibilities, resources, competencies and benefits in order to provide breastfeeding support throughout the rest of the first month.
15. Was the partnership developed to solve an existing problem or gap in breastfeeding support services?	Yes ☐	No ☐
16. Are the resources each partner brings to the partnership clearly delineated?	Yes ☐	No ☐
17. Does the partnership have goals that have been agreed upon by the members of the partnership?	Yes ☐	No ☐
18. Are the roles and responsibilities clearly identified and understood by all members of the partnership?	Yes ☐	No ☐
19. Does the partnership have activities that have been agreed upon by the members of the partnership?	Yes ☐	No ☐
20. Has the partnership produced results that provide an ongoing benefit?	Yes ☐	No ☐
OTHER CRITERIA
21. Do you have a supportive clinic environment for breastfeeding that visibly endorses breastfeeding as the preferred method of infant feeding?	Yes ☐	No ☐
22. Do you have policies that support a clinic environment where participants feel comfortable breastfeeding?	Yes ☐	No ☐

23. Do you have policies and procedures that encourage and support exclusive breastfeeding among prenatal and postpartum WIC participants? Attach supportive documentation. Fill in the document title and indicate the page number(s) where the information that answers this question can be found.	Yes ☐Document Title Page Number(s)	No ☐
24. Do you ensure that all staff are trained to support the goal of exclusive breastfeeding with WIC participants using the FNS-developed competency-based breastfeeding curriculum, Using Loving Support© to Grow and Glow in WIC, or Loving Support© Through Peer Counseling.	Yes ☐	No ☐
25. 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? Attach supportive documentation. Fill in the document title and indicate the page number(s) where the information that answers this question can be found.	Yes ☐Document Title Page Number(s)	No ☐
26. Does new clinic staff orientation include breastfeeding policies and procedures especially related to supporting exclusive breastfeeding?	Yes ☐	No ☐
27. 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 or Loving Support© Through Peer Counseling.	Yes ☐	No ☐
28. Do you have ongoing continuing education on breastfeeding for all staff through regularly scheduled staff trainings and other educational opportunities?	Yes ☐	No ☐
29. 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? Attach supportive documentation. Fill in the document titles and indicate the page number(s) where the information that answers this question can be found.	Yes ☐ Document Title Page Number	No ☐
30. Do you have policies that ensure all participant breastfeeding concerns are addressed according to established time frames?	Yes ☐	No ☐

OMB Control Number: 0584-0591 Expiration date: xx/xx/xxxx

Loving Support of Excellence Gold Award Application Checklist

Please review the checklist prior to submitting application and supportive documentation.

Previous Gold Awardees
If your local agency has a valid Gold award, please fill out the year your local agency received the award.	Year Received
Please enter the full name of your Local Agency without abbreviations or acronyms and complete the Application Verification Form on page 7 of the Application.	Yes ☐	No ☐
Continue on to the application for the Gold Premiere and Gold Elite Awards to apply for a higher level award.	Yes ☐	No ☐
New Applicants
All 30 questions need to be answered “Yes” to be eligible for the Gold Award. Verify that all questions have been answered.	Yes ☐	No ☐
Narratives and/or supportive documentation must be attached to the application to be eligible for an Award.	Yes ☐	No ☐
If attaching supportive documents make sure you indicate the page number(s) where the information that answers the question can be found.	Yes ☐	No ☐
Please enter the full name of your Local Agency without abbreviations or acronyms and complete the Application Verification Form on page 7 of the Application.	Yes ☐	No ☐
If you would like to apply for a higher level award, continue on to the application for the Gold Premiere and Gold Elite Awards.	Yes ☐	No ☐

Congratulations!

You have completed the application for the Loving Support Award of Excellence at the Gold Award level.

If you would like to apply for a higher level award, continue on to the application for the Gold Premiere and Gold Elite Awards.

The State agency and FNS reserve the right to verify all information on the application and reject applications that are incomplete or otherwise fail to provide accurate information.

Loving Support Award of Excellence Applicant Verification Form

Please read the following statement and sign below if you agree:

I have reviewed this application, and I attest to the accuracy of the information provided. I agree to maintain the standards and procedures indicated in this application for the duration of our award period. Furthermore, I agree to cooperate with USDA and other organizations, upon request, to publicize our efforts.

Local Agency Applicant’s Name Date

Please upload your completed application and supporting documentation

Thank you for applying for the Loving Support Award of Excellence.

For more information, visit the SFPD/WIC Website: http://www.fns.usda.gov/wic/breastfeeding-promotion-and-support-wic.