WIC State Agency Evaluations

U.S. Department of Agriculture, Food and Nutrition Service (FNS),
Special Supplemental Nutrition Program for Women, Infants and Children (WIC)

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

This document works in coordination with the online evaluation site in PartnerWeb.

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.

GOLD PREMIERE AWARD

Each question is worth 2 or 3 points.

Applicants do not need to respond to all 17 questions to be eligible for a Gold Premiere award.

A minimum number of points are required from each of the 3 sections:

• a minimum of 11 points from the Peer Counseling section (pscore-PC),

• a minimum of 4 points from the Partnership section (pscore-P),

• a minimum of 5 points from the Other Criteria section (pscore-OC).

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

Applicants must respond to all 17 questions to be eligible for a Gold Elite award AND have performance data that demonstrates 40% or higher of the infants are exclusively breastfed.

Start the Gold Premiere/Elite award evaluation process at the “Prescreen for Premiere-Elite” section in the online evaluation worksheet.

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. Scroll down in the online evaluation worksheet to verify “Recommend Gold” is selected in the “SA-Recommendation for Gold” section. If “Recommend Gold” is selected, scroll up to the “Prescreen for Premiere-Elite” section and click “yes”.

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

PEER COUNSELING (pscore-PC)

Question 1. (2 points)

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.

Question 2. (2 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.

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.

Question 4. (2 points)

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

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

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.

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.

Question 7. (2 points)

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

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

Question 8. (2 points)

Do you include career path structures for upward mobility of peer counselors?

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

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 must include all of the following:

• Peer counselors communicate using at least one of the following: Facebook, text messaging, Twitter, Skype or PalTalk.

• How 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 must include all of the following:

• Confidentiality and privacy considerations

• Proper etiquette when using social media

• Supervisory monitoring of social media used

• 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 the supportive documentation meets all of the requirements listed above. Check Yes or No based on your documentation review.

Question 10. (2 points)

Do you ensure that peer counselors are solely dedicated to peer counselor support for breastfeeding, or, if you allow peer counselors to work in dual-role positions, do you ensure that those positions do not compromise the intent and purpose of the BFPC program?

Peer counseling programs function best when peer counselors are allowed to solely dedicate their time to peer counselor support for breastfeeding. State agencies that allow peer counselors to work in dual-role positions should consider whether such positions meet the definition of a peer counselor in the Loving Support Model, including being available to mothers outside of regular WIC hours and outside of the clinic.

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

PARTNERSHIP (pscore-P)

Question 11. (2 points)

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.

Question 12. (2 points)

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

Acceptable documentation: Narrative or Supportive Documentation. 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.

Question 13. (2 points)

Does the partnership have a plan for sustainability?

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

Question 14. (2 points)

Do you partner with stakeholders such as the American Hospital Association to support the Baby-Friendly Hospital Initiative in your community?

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

OTHER CRITERIA (pscore-OC)

Question 15. (2 points)

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 all of the requirements listed above.

Check Yes or No based on your documentation review.

Question 16. (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.

Question 17. (3 points)

Do you provide around the clock assistance to mothers working 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.

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PERFORMANCE DATA

The applicant does not submit performance data. The performance data considered is the rate of exclusively breastfed infants expressed as a percentage of total infant participants in each local agency. This data is published annually on the FNS website. You can find the performance data at: http://www.fns.usda.gov/wic/breastfeeding-promotion-and-support-wic

Note: Use the percentage found in the 8<sup>th</sup> column named “Fully Breastfed” in the spreadsheet found in the link above.

Fill in the percentage in the “Performance Data-Previous Year” and “Performance Data-Current Year” sections in the online evaluation worksheet.

Click “OK” to go to the “Evaluations” page which reflects scores for finished evaluations.

Gold Premiere award evaluation

You will evaluate for eligibility for a Gold Premiere award prior to evaluating eligibility for a Gold Elite award.

You are now on a partnerweb page that displays the scores for all your applications. Look for the name of the local agency you just evaluated.

The online evaluation worksheet automatically calculates subscores for the three sections in the Gold Premiere/Elite application: Peer Counseling (PC), Partnership (P), and Other Criteria (OC).

Verify the applicant meets the minimum points for a Gold Premiere award:

• At least 11 points in the “pscore-PC” column

• At least 4 points in “pscore-P” column

• At least 5 points in “pscore-OC” column

If the applicant has met the minimum points for a Gold Premiere award, the next step is to verify the performance data.

Use the back arrow to go back to the evaluation worksheet.

Verify the percentage in the “Performance Data - Previous Year” section is at least 15 %, and the percentage in the “Performance Data-Current Year” section shows an increase over the previous year’s percentage OR the “Performance Data-Current Year” section is at least 25 %.

If the points and data performance criteria have been met the applicant is eligible for a Gold Premiere award. Complete the following sections: “State-Status”, “SA-Recommendation-Premiere-Elite” and “State Evaluator Name”. Then click “OK”.

If the points and/or data performance criteria have not been met the applicant is not eligible for a Gold Premiere award. Please double check your work. Ensure all questions are answered and double check your evaluation responses and performance data percentages. If you have verified that your evaluation is correct and the points and data performance criteria still have been not been met, complete the following sections: “State-Status”, “SA-Recommendation for Gold” (choose “Recommend Gold”) “SA-Recommendation for Premiere-Elite” (choose “No Recommendation”), “State Evaluator Name” ” and “Justification for No Recommendation”. Then click “OK”.

You have completed evaluating for the Gold Premiere award. Please continue to determine if the applicant is eligible for a Gold Elite award.

Note: If the applicant has not responded to all 17 questions on the Gold Premiere/Elite application – STOP. No further evaluation is required.

Gold Elite award evaluation

The pscore column is the total score of all 17 questions on the Gold Premiere/Elite application. A local agency must have a pscore of 39 to be eligible for a Gold Elite award.

On the “Evaluations” page verify the local agency has a score of 39 in the column name “pscore”.

Use the back arrow to go back to the evaluation worksheet. Verify the “Performance Data-Current Year” section indicates a minimum of 40%.

If the pscore is 39 and the “Performance Data-Current Year” section indicates a minimum of 40%, the local agency is eligible for a Gold Elite award.

If the points and data performance criteria have been met the applicant is eligible for a Gold Elite award. Complete the following sections: “State-Status”, “SA-Recommendation-Premiere-Elite” and “State Evaluator Name”. Then click “OK”.

If the pscore (score of 39) and/or the performance data (minimum of 40%) criteria is not met, the local agency is not eligible for a Gold Elite award. Please double check your work. Ensure all questions are answered and double check your evaluation responses and performance data percentages. If you have verified that your evaluation is correct and the points and data performance criteria still have been not been met, complete the following sections: “State-Status”, “SA-Recommendation-Premiere-Elite”, “State Evaluator Name” ” and “Justification for No Recommendation”. Then click “OK”.

Congratulations, and thank you, for completing the Gold Premiere/Elite award evaluation!

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.