WIC State Agency Evaluations

OMB Control Number: 0584-0591
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)

This document works in coordination with the online evaluation site in PartnerWeb. You have completed the Step 1 online by accessing and printing this document. Click the “SA-Review” tab to return to the evaluation website.

To begin Step 2 locate the section “Applications and Evaluation Worksheets”. Click the + next to your State to expand the view of all applications submitted within your State.

The applications are located in the “type” column. Under the “type” column, right click on the icon, select “Open link in new window” from the popup menu, and leave open. Click the “SA-Review” tab to return to the evaluation website.

To score an application, you will need to open an evaluation worksheet. Go back to the “Applications and Evaluation Worksheets” section. To the far left, you will see a column named “edit”. This is where the evaluation worksheets are located. Each application has its own evaluation worksheet. To open the evaluation worksheet for the application you are evaluating, click the “edit” icon to the left of the local agency name.

The Gold Award application has a total of 30 questions, each worth 1 point.

When evaluating the application, if a Gold Award question is checked “No”, or if the documentation attached for a Gold Award question does not meet the criteria listed - STOP.

The applicant is not eligible for a Gold Award. Complete the following sections: “State-Status”, “SA-Recommendation for Gold” (choose “No Recommendation”), “Justification for No Recommendation”, and “State Evaluator Name”. Then click OK.

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

Prescreening

Before an applicant can apply for an award they must verify their local agency peer counseling program has been in place for at least one year, and that their peer counseling program meets all components of the Loving Support peer counseling model listed below.

Verify the prescreening questions have been answered “Yes” and the applicant meets the requirements to continue. If verified, select “Yes” on the evaluation worksheet.

If either prescreening question is checked “No” - STOP. The applicant is not eligible for a Gold Award. Complete the following sections: “State-Status”, “SA-Recommendation for Gold” (choose “No Recommendation”), “State Evaluator Name”, and “Justification for No Recommendation”. Then click OK.

LOVING SUPPORT© MODEL REQUIRED PROGRAM COMPONENTS

Program Management

• The local agency has a designated peer counseling program manager or coordinator.

• The local agency has standardized breastfeeding peer counseling program policies in place as part of its nutrition education plan.

• Local agency staff is trained on supporting the peer counseling program.

• The local agency has a WIC designated breastfeeding expert for referrals outside of the peer counselor’s scope of practice.

• The local agency has established community partnerships to enhance the effectiveness of its peer counseling program, e.g., hospitals, health care providers, home visiting programs, etc.

Peer Counselor Staffing

• The local agency has defined job parameters and position descriptions for peer counselors.

• Peer counselors are recruited and hired from the target population served by WIC.

• Peer counselors are paraprofessionals, i.e., are not licensed or credentialed as healthcare, nutrition, or lactation consultant professionals.

• Peer counselors are available to WIC clients outside usual clinic hours and outside the WIC clinic environment.

• Peer counselors receive adequate compensation and reimbursement for expenses.

Peer Counselor Training and Support

• Peer counselors are trained with a standardized curriculum based on the FNS “Loving Support^© Through Peer Counseling” trainings.

• Ongoing continuing education is provided to peer counselors through regularly scheduled staff meetings and other educational opportunities.

• Peer counselors have timely access to breastfeeding coordinators and other lactation experts for assistance with problems outside their scope of practice.

• Peer counselors are offered opportunities to meet regularly with other peer counselors.

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

Prior Gold Awardees

Prior Gold Awardee Applicants were instructed to leave Questions 1-30 unanswered and complete the Cover Page, Prescreening Questions, and Application Checklist (page 6 of the Gold Application).

Verify the year the Local agency received an Award by going to: https://www.fns.usda.gov/wic/loving-support-award-excellence-awardees. If the local agency received a Gold award in the past 4 years, proceed to page 13 of the Gold Evaluation Instructions (this document).

New Gold Applicants

Continue to the next page to start the Gold Evaluation at Question 1a.

Note: To save and finish the evaluation later, scroll to the section “State-Status” and select “not finished”. Then scroll to the bottom of the evaluation worksheet and click “OK” to save your work. You can now exit the website.

PEER COUNSELING

Question 1. (1 point)

Do you conduct an annual assessment to determine each of the following:

1. the needs of your target audience; where gaps exist in breastfeeding services and resources within your local agency and the

2. community that can be addressed through peer counseling; and

3. where improvements in your program are needed?

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

Successful peer counseling programs occur through careful planning to address identified needs. Information gathered during needs assessment helps local agencies identify strengths as well as areas of breastfeeding services that can be modified or improved through peer counseling. A needs assessment helps local agencies set priorities to maximize the effectiveness of peer counselors. Without a needs assessment, planning is just a best guess.

Acceptable documentation: Narrative Documentation attached includes:

Identifies the top 2 priorities and how the local agency is addressing those needs.

Verify the applicant response. Select 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.

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?

The key to success in peer counseling is being available to mothers when they need it most. Breastfeeding problems often occur outside usual business hours, and peer counselors provide important support beyond usual WIC services. The Loving Support^© Model for a Successful Peer Counseling Program requires that peer counselors be available to mothers outside of usual clinic hours, i.e., evenings and weekends. Exemplary peer counseling programs develop strategies to ensure that peer counselors are available to address a mother’s concerns and needs in a timely manner (via telephone, hotline, or face-to-face) and that referral and follow-up are provided.

Examples of Acceptable Supportive Documentation: Policies and procedures or protocols, Training materials, Position descriptions / Roles and Responsibilities

Documentation attached includes all of the following:

• Describes how peer counselors address a mother’s concerns and needs outside usual clinic hours.

• Description includes at least one of the following: telephone calls, hotline, or face-to-face.

• Describes how peer counselors make after-hour referrals.

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

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.

Question 3. (1 point)

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

Verify the applicant response. Check Yes or No based on applicant’s response.

Question 4. (1 point)

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

Verify the applicant response. Check Yes or No based on applicant’s response.

Question 5. (1 point)

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

Verify the applicant response. Check Yes or No based on applicant’s response.

Question 6. (1 point)

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

Verify the applicant response. Check Yes or No based on applicant’s response.

Question 7. (1 point)

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.

Supervisory responsibilities include mentoring, monitoring, follow-up, and spot checks. Verify the applicant response. Check Yes or No based on applicant’s response.

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

Question 8. (1 point)

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?

Peer counselors supplement, but do not replace, the work of CPAs and lactation professionals. A peer counselor’s scope of practice is to provide basic information and support to new moms, and make referrals when they experience problems beyond their training. The peer counselors’ scope of practice summarizes typical situations for which peer counselors can provide services, as well as the types of information they can provide.

Examples of acceptable supportive documentation: Written Scope of Practice, Position description/ Roles and Responsibilities, Policy and Procedures, Training Manual, Referral protocol for peer counselors/list of referral topics.

Documentation attached includes all of the following:

• Scope of practice is attached.

• Scope of practice limits the peer counselor’s responsibilities to providing basic information and support to new moms, and making referrals when peer counselors experience problems beyond their training.

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.

Question 9. (1 point)

Do you have a process/protocol in place that describes when the peer counselors should “yield” breastfeeding concerns and conditions that are outside the scope of practice of the peer counselor to a Designated Breastfeeding Expert?

A peer counselor’s scope of practice is limited to providing basic information and support to new moms about normal breastfeeding, and “yield” (make referrals) when they experience problems beyond their training. WIC mothers who need support outside the peer counselors scope of practice should be referred to the Designated Breastfeeding Expert to provide timely and appropriate follow-up.

Documentation attached includes all of the following:

• Process describes how peer counselors refer moms to a Designated Breastfeeding Expert as part of normal clinic operations, during both the prenatal and postpartum periods.

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.

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

Question 10. (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?

Please describe in a narrative, or attach supportive documentation, that indicates that your local agency has an established process that describes how WIC mothers are referred to peer counselors as part of normal clinic operations, during both the prenatal and postpartum periods.

The narrative or the supportive documentation must indicate that the local agency has an established process that describes how WIC mothers are referred to peer counselors as part of normal clinic operations.

Acceptable documentation: Narrative or Supportive Documentation

Examples of acceptable supportive documentation: Policy and procedures, Staff training materials, Referral protocol for peer counselors

Documentation attached includes all of the following:

• Process describes how WIC mothers are referred to peer counselors during the prenatal period.

• Process describes how WIC mothers are referred to peer counselors during the postpartum period.

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.

Question 11. (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?

Verify the applicant response. Check Yes or No based on applicant’s response.

Question 12. (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 the rest of the first month?

Verify the applicant response. Check Yes or No based on applicant’s response.

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

Question 13. (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?

Verify the applicant response. Check Yes or No based on applicant’s response.

Question 14. (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?

Verify the applicant response. Check Yes or No based on applicant’s response.

PARTNERSHIP

Question 15. (1 point)

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

Verify the applicant response. Check Yes or No based on applicant’s response.

Question 16. (1 point)

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

Verify the applicant response. Check Yes or No based on applicant’s response.

Question 17. (1 point)

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

Verify the applicant response. Check Yes or No based on applicant’s response.

Question 18. (1 point)

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

Verify the applicant response. Check Yes or No based on applicant’s response.

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

Question 19. (1 point)

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

Verify the applicant response. Check Yes or No based on applicant’s response.

Question 20. (1 point)

Has the partnership produced results that provide an ongoing benefit?

Verify the applicant response. Check Yes or No based on applicant’s response.

OTHER CRITERIA

Question 21. (1 point)

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

Verify the applicant response. Check Yes or No based on applicant’s response.

Question 22. (1 point)

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

Verify the applicant response. Check Yes or No based on applicant’s response.

Question 23. (1 point)

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

Examples of acceptable supportive documentation: Policies and procedures, Staff training materials

Documentation attached includes all of the following:

• Encouragement is provided to mothers to exclusively breastfeed for 6 months and continue to breastfeed for at least the first year of life and thereafter as long as desired

• Staff provide anticipatory guidance on what mothers should expect and strategies for breastfeeding success

  

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

  
  
  

• Efforts are made to contact mothers who intend to breastfeed as soon after delivery as possible to provide timely breastfeeding support during the early postpartum period

• No routine issuance of infant formula in the first month

• Minimal infant formula amounts are provided only when medically necessary or requested.

• If formula is provided it is based on the infants assessed needs

• Education is provided to mothers on the effects of early formula supplementation of breastfeeding

• Staff promotes the fully breastfed food package, making participants aware of the greater quantity and variety of food included in this package

• Prohibits the promotion of infant formula

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.

Question 24. (1 point)

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?

Verify the applicant response. Check Yes or No based on applicant’s response.

Question 25. (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?

Examples of acceptable supportive documentation: Policies and procedures, Staff training materials

Documentation attached includes all of the following:

• Indicates individually tailored food packages to all breastfeeding dyads based on a complete breastfeeding assessment

• Routine issuance of infant formula to breastfeeding infants is prohibited.

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.

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

Question 26. (1 point)

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

Verify the applicant response. Check Yes or No based on applicant’s response.

Question 27. (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 or Loving Support© Through Peer Counseling.?

Verify the applicant response. Check Yes or No based on applicant’s response.

Question 28. (1 point)

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

Verify the applicant response. Check Yes or No based on applicant’s response.

Question 29. (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?

Examples of acceptable supportive documentation: Policies and procedures, Staff training materials

Documentation attached must include all of the following:

• Early assessment and follow-up for the breastfeeding dyad soon after delivery

• Anticipatory guidance on what to expect (e.g., growth spurts, hunger and satiety cues, signs that baby is getting enough, etc.)

• Staff provide practical strategies to address potential obstacles

• Education and support available to breastfeeding mothers who are returning to work, or school, and mothers who are breastfeeding multiple infants.

• Referral system is in place ensuring the mother is connected to the appropriate WIC staff person

• Appropriate referrals to community resources that provide breastfeeding support services

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

Verify the applicant response. Check Yes or No based on applicant’s response. Verify if the documentation meets all of the requirements listed above.

Question 30. (1 point)

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

Verify the applicant response. Check Yes or No based on applicant’s response.

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

Note: To save and finish the evaluation later, scroll to the section “State-Status” and select “not finished”. Then scroll to the bottom of the evaluation worksheet and click “OK” to save your work. You can now exit the website.

When questions 1 through 30 are complete, scroll down to the bottom of the evaluation worksheet page and click “OK”.

When you click “OK”, the website will take you to the “Evaluations” page. This page reflects scores for finished evaluations. The scoring for the 30 Gold award questions can be found in the column titled “GScore.

Find the GScore for the name of the local agency you just evaluated.

A Gold award application must have a Gscore of 30 to be eligible for the Gold award.

If the GScore equals 30 points, go back to the evaluation worksheet by clicking the back arrow to return to the evaluation worksheet of the local agency you are evaluating. Scroll down and complete sections: “State-Status”, “SA-Recommendation for Gold” (choose “Recommend Gold”) and “State Evaluator Name”. Then click “OK”.

If the GScore is less than 30 points – STOP. An application with a GScore of less than 30 points is not eligible for a Gold award. Please click the back arrow to return to the evaluation worksheet to double check your work. Ensure all questions are answered and double check your evaluation responses. If you have verified that your evaluation is correct and the GScore remains under 30 points, complete the following sections: “State-Status”, “SA-Recommendation for Gold” (choose “No Recommendation”), “State Evaluator Name” ” and “Justification for No Recommendation”. Then click “OK”.

Congratulations and thank you for completing the Gold award evaluation!

If the applicant has not applied for a higher level award, you have finished the evaluation.

If the applicant has applied for a higher level award, click the “State Agency Review” link on the left menu and continue on with Step 3.

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 (0584-0591). Do not return the completed form to this address.