OMB Control Number: 0584-0043
Expiration Date: xx/xx/20xx
Appendix D
WIC State Plan Guidance
I. Vendor and Farmer Management
(Please indicate) State Agency: for FY:
Vendor and farmer/farmers’ market management includes all those activities associated with selecting, authorizing, training, monitoring, and investigating the State agency's vendor and farmer/farmers’ market population for the purpose of reducing fraud and abuse in the WIC Program food delivery system.
Vendor Selection and Authorization – 7 CFR 246.4(a)(14)(i), (ii), and (iii): identify the types of food delivery systems used in the State’s jurisdiction, describe, if used, the State agency’s limiting criteria, describe the State agency’s selection criteria and attach a sample vendor agreement. Describe, if applicable, the supervision and instruction the State agency provides to local agencies to which vendor agreement signing has been delegated.
Vendor Training – 7 CFR 246.4(a)(14)(xi): describe State and local agency procedures for training WIC Program vendors and farmers/farmers’ markets and for documenting all relevant training.
High-Risk Vendor Identification Systems – 7 CFR 246.12(j)(3): describe the policies and procedures for identifying and monitoring high-risk vendors through the use of vendor peer groups, food instrument and cash-value voucher (CVV)/ cash value benefit (CVB) redemption screening, analysis of overcharging and other violations, the use of price lists, tracking complaints, or other means. This section may be submitted separately because it is no longer a State Plan requirement but must still be approved by FNS.
Routine Monitoring – 7 CFR 246.4(a)(14)(iv): describe the criteria used to select vendors for routine monitoring as well as the methods and scope of on-site routine monitoring activities. Include any relevant information about the State agency’s plans for improvement in the coming year.
Compliance Investigations – 7 CFR 246.4(a)(14)(iv): describe the investigative practices and procedures used to conduct both compliance buys and inventory audits for the purpose of detecting, tracking, and documenting vendor noncompliance with program requirements.
Administrative Review of State Agency Actions – 7 CFR 246.4(a)(14)(iii): describe the procedures for conducting both full and abbreviated administrative reviews.
The Food and Nutrition Service (FNS) is collecting this information in order to provide supplemental foods, nutrition education, including breastfeeding promotion and support, and health care referrals to low income, nutritionally at risk pregnant, breastfeeding and postpartum women, infants, and children up to age five through the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). This is a mandatory collection and FNS will use the information to ensure the efficient management of the WIC program. The collection does request personally identifiable information under the Privacy Act of 1974. Responses will be kept private to the extent provided by law and FNS regulations. 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 0584-0043. The time required to complete this information collection is estimated to average 135 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. 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 Service, Office of Policy Support, 1320 Braddock Place, 5th Floor, Alexandria, VA 22314. ATTN: PRA (0584-0611). Do not return the completed form to this address.
Coordination with the Supplemental Nutrition Assistance Program (SNAP) – 7 CFR 246.4(a)(14)(ii),(a)(14)(iv), and 246.12(h)(3)(xxv): describe the methods and procedures used to coordinate the monitoring and sharing of information on vendors who participate in both the WIC Program and SNAP.
Staff Training on Vendor Management – 7 CFR 246.4(a)(14)(iii), (a)(14)(iv), and (a)(14)(xi): describe the distribution of responsibilities and activities of those individuals at both the State and local levels who are involved in vendor management activities. If applicable, describe the supervision and instruction the State agency provides to local agencies to which vendor management activities have been delegated.
Farmer/Farmers’ Market Authorization – 7 CFR 246.4(a)(14)(iii), (a)(14)(xi), and 246.12(v): if the State agency authorizes farmers/farmers’ markets to accept CVVs/CVBs, describe the authorization process.
Farmer/Farmers’ Market Agreements – 7 CFR 246.4(a)(14)(iii), (a)(14)(xi), and 246.12(v): if the State agency authorizes farmers/farmers’ markets to accept CVVs/CVBs, describe the State agency’s agreement with the farmers/ farmers’ markets and attach a sample farmer/farmers’ market agreement.
Farmer/Farmers’ Market Training – 7 CFR 246.4(a)(14)(iii), (a)(14)(xi), and 246.12(v): if the State agency authorizes farmers/farmers’ markets to accept CVVs/CVBs, describe the training provided to the authorized farmers/ farmers markets.
Farmer/Farmers’ Market Monitoring – 7 CFR 246.4(a)(14)(iii), (a)(14)(xi), and 246.12(v): if the State agency authorizes farmers/farmers markets to accept CVVs/CVBs, describe the criteria used for selecting farmers/farmers markets for routine monitoring as well as the method(s) and scope of on-site monitoring of the farmers/farmers markets.
Farmer /Farmers’ Market Sanctions, Claims, and Appeals – 7 CFR 246.4(a)(14)(iii), (a)(14)(xi), and 246.12(v): if the State agency authorizes farmers/farmers markets to accept CVVs/CVBs, describe the farmer/farmers’ market sanctions, claims, and appeals and attach a copy of the farmer/farmers’ market sanction schedule (which should be included in the farmer/farmers’ market agreement as well).
Participant Access - 7 CFR 246.4(a)(15); 246.12(b), (g)(1), (g)(9): provide information about the State agency's definition of participant access.
Number and Distribution of Authorized Vendors
Does the State agency use limiting criteria to limit the number of vendors it authorizes?
☐Yes ☐No
If yes, check and specify the type(s) of criteria used (e.g. vendor/participant ratio of 1/100 per county:
☐ Vendor/participant ratio (specify):
☐ Vendors/local agency or clinic ratio (specify):
☐ Vendors/local service area or county ratio (specify):
☐ Vendors/geographic area (e.g., number per mile, city block, zip code) (specify):
☐ Vendor/State agency staff ratio (specify):
☐ Statewide cap on the number of vendors (specify):
☐ Other (specify):
ADDITIONAL DETAIL: Vendor Management Appendix and/or Procedure Manual (Citation):
Vendor Application Periods
The State agency considers applications; check all that apply:
☐ On an on-going basis
☐ Annually in for a new agreement begins
☐ Every two years (specify month):
☐ Every three years (specify month):
☐ Any time there is a participant access needed
☐ The State agency is currently under a:
☐ Federal Moratorium (specify time frame):
☐ State agency-imposed deferral of application processing (specify time frame and conditions):
☐ Other (specify):
ADDITIONAL DETAIL: Vendor Management Appendix and/or Procedure Manual (Citation):
Vendor Selection and Authorization
The vendor selection criteria used to select vendors for program authorization include: Required criteria:
☐ EBT capable as defined in 7 CFR 246.12(aa)(4)(ii)
☐ A competitive price criterion based on:
☐ Vendor applicant price lists
☐ WIC redemption data
☐ A State agency standard drawn from a price survey
☐A standard drawn from another source (specify):
☐ Other (specify):
☐ A minimum variety and quantity of supplemental foods criterion that is:
☐ Statewide
☐ Peer group specific
☐ A requirement to obtain infant formula only from sources included in the State agency’s list of State licensed infant formula wholesalers, distributors, and retailers and manufacturers registered with the U.S. Food and Drug Administration
A business integrity criterion that includes:
☐ No history, during the past six years, among the vendor’s owners, officers, or managers of criminal convictions
or civil judgments for activities listed in 7 CFR 246.12(g)(3)(ii)
☐ No history of other business-related criminal convictions or civil judgments ☐ Other (specify):
☐ Lack of a current SNAP disqualification or civil money penalty for hardship per 7 CFR 246.12(g)(3)(iii)
Optional criteria:
☐ A requirement to stock a full range of foods in addition to WIC supplemental foods
☐ A location necessary to ensure adequate participant access
☐ Redemption of a minimum number/volume of food instruments and CVVs/CVBs ☐ Satisfactory compliance with previous vendor agreement
☐ Certification by an approved State or local health department
☐ Proof of authorization as a SNAP retailer, including SNAP authorization number
☐ Hours of operation which meet State agency criteria (specify):
☐ Lack of previous WIC sanctions
☐ Other criteria (specify):
☐ Not applicable (explain):
Explain how the State agency develops and uses the competitive price criteria identified in item 3a to select vendors for authorization.
Does the State agency exempt from competitive price criteria pharmacies that provide only exempt infant formula or WIC-eligible medical foods to participants?
☐ Yes ☐ No
Did the State agency exempt non-profit WIC vendors (other than health or human services agencies that provide food under contract with the State agency) from competitive price criteria?
☐ Yes ☐ No
When does the State agency assess vendors for above-50-percent status?
☐ At authorization
☐ 6 months after authorization
☐ Annually
☐ Other (specify):
How does the State agency assess vendors for above-50-percent status? Check all that apply:
☐ Use the WIC-6 in The Integrity Profile (TIP System)
☐ Collect food sales data documentation from the vendor
☐ Collect food sales data documentation from another agency (specify):
☐ Other (specify):
Does the State agency authorize vendors that derive more than 50 percent of their annual food sales from WIC transactions (i.e., above-50-percent vendors)?
☐ Yes ☐ No If “No,” please proceed to item 3f.
If “Yes,” please respond to the following:
How many above-50-percent vendors are currently authorized? (include all above-50-percent vendors, not just WIC-only vendors)
Does the State agency allow above-50-percent vendors to provide incentive items?
☐ Yes ☐ No If “No,” please proceed to item 3f.
If “Yes,” please respond to the following:
Describe the approval process or attach a copy of the relevant application form. Description (or list the Appendix citation here):
Does the State agency provide above-50-percent vendors with a list of pre-approved incentive items?
☐ Yes; please provide list ☐ No
Does the State agency provide above-50-percent vendors with a list of prohibited incentive items?
☐ Yes; please provide list ☐ No
Does the State agency ensure vendors (regular and above-50-percent) do not treat WIC participants differently by offering them incentive items that are not offered to non-WIC customers? (7 CFR 246.12(h)(3) (iii) and WIC Policy Memorandum 2014-3 Vendor Management: Incentive Items, Vendor Discounts and Coupons)
☐ Yes; please explain: ☐ No; please explain:
On-site pre-authorization visits are conducted to verify information received during the application process:
by SA by LA by Other
☐ ☐ ☐ For vendors at initial authorization
☐ ☐ ☐ For all vendors at authorization/reauthorization
Does the State agency verify the status of vendor applicants’ SNAP retailer authorizations via STARS?
☐ Yes ☐ No
ADDITIONAL DETAIL: Vendor Management Appendix and/or Procedure Manual (Citation):
Vendor Peer Groups
If the State agency does not have a vendor peer group system, please attach a copy of the most recent exemption request and approval letters and proceed to item 4e.
Are vendors assigned to peer groups for selection/authorization?
☐ Yes ☐ No
Are vendors assigned to peer groups for reimbursement purposes?
☐ Yes ☐ No
Peer groups are based on the following (check all that apply):
☐ WIC sales volume
☐ Gross food sales volume
☐ Number of cash registers
☐Square footage of store
☐ Type of store
☐ Location of store
☐ Local agency service areas
☐City, County, or regional divisions
☐Urban/suburban/rural
☐ Other (specify):
☐ Zip codes
☐ Unique economic location (e.g., rural island, single metro area)
☐ Other (specify):
Using the chart on the next page, describe the peer groupings (e.g., supermarkets, medium and small grocery stores, convenience stores, etc.) that the State agency plans to use during the upcoming fiscal year. For State agencies with more than seven peer groupings, please attach a chart containing this Peer Group Description and list the Appendix citation here:
Has the State agency received approval for an exemption from the vendor peer group system requirement (7 CFR 246.12(g)(4)(v))?
☐ Yes; date FNS approved exemption: ☐ No
If yes, the State agency's exemption was based on the latest available data for the current fiscal year (which covers the period from to ), and the State agency:
☐ Does not have any above-50-percent vendors; data source:
☐ Paid above-50-percent vendors percent of the total annual WIC redemptions to date; data source:
If the State agency does not use a vendor peer group system, describe the State agency’s alternative system for comparing the prices of new vendor applicants and currently authorized vendors and selecting for authorization or reauthorization vendors that offer the program the most competitive prices.
DESCRIPTION OF VENDOR PEER GROUP SYSTEM
Vendor Peer Groups |
Comparable Vendors Peer Group Number (6) |
||||
Peer Group No. (1) |
Description (e.g., supermarkets, chain stores, pharmacies) (2) |
Number of Vendors in Peer Group |
|||
Regular Vendors (3) |
Above-50% Vendors (4) |
Total (5) |
|||
1 |
|
|
|
|
|
2 |
|
|
|
|
|
3 |
|
|
|
|
|
4 |
|
|
|
|
|
5 |
|
|
|
|
|
6 |
|
|
|
|
|
7 |
|
|
|
|
|
8 |
|
|
|
|
|
9 |
|
|
|
|
|
10 |
|
|
|
|
|
11 |
|
|
|
|
|
12 |
|
|
|
|
|
13 |
|
|
|
|
|
14 |
|
|
|
|
|
15 |
|
|
|
|
|
16 |
|
|
|
|
|
17 |
|
|
|
|
|
18 |
|
|
|
|
|
Instructions:
Column 1 – Assign a sequential number to each peer group.
Column 2 – Describe the vendors in the peer group; include all factors and definitions checked in question 4c. (e.g., urban = counties with >100,000 residents OR suburban = counties with >10,000 residents OR rural = counties with <10,000 residents)
Column 3 – Insert the number of authorized vendors that are regular vendors.
Column 4 – If the State agency authorizes above-50-percent vendors, insert the number of above-50-percent vendors currently authorized.
Column 5 – Insert the total number of authorized vendors. This number should be the sum of columns 3 and 4, since the State agency must identify each vendor as being either a regular vendor or an above-50-percent vendor.
Column 6 – For each peer group that contains above-50-percent vendors, insert the number of the peer group that contains comparable regular vendors. The comparable vendor peer group is the peer group that the State agency uses to derive the competitive price criteria and maximum reimbursement levels that it applies to the above-50-percent vendors. If above-50-percent vendors are placed in a peer group with regular vendors, then the number in column 1 should be the same as that in column 6. If above-50-percent vendors are in separate peer groups, then the number in column 1 will be different from that in column 6.
At least every three years the State agency must assess the effectiveness of its peer group system and competitive price criteria to enhance system performance (7 CFR 246.12(g)(4)(ii)(C)).
The State agency makes this assessment—
☐ Annually ☐ Biennially ☐ Every three years
☐ Other (please specify):
What procedures does the State agency have in place to assess the effectiveness of its peer group system and competitive price criteria to enhance system performance?
Provide date of most recent FNS approval:
Has the State agency received approval for an exemption from the shelf price collection requirement under 7 CFR 246.12(g)(4)(ii)(B):
☐ Yes; date FNS approved exemption: ☐ No
If yes, please attach a copy of the most recent exemption request and approval letter(s).
The following reflect the State agency’s vendor agreement practices; check all that apply:
☐ All vendors have a written agreement with the State agency
☐ A standard vendor agreement is used statewide
☐ Vendor agreements are subject to the State’s procurement procedures
☐ Vendor agreements/handbooks are subject to the State’s Administrative Procedures Act ☐ A nonstandard vendor agreement is used for:
☐ Military commissaries
☐ Pharmacies that only provide exempt infant formula and/or WIC-eligible medical foods
☐ All pharmacies
☐ Home food delivery contractors
☐ Mobile stores
☐ Other (specify):
☐ Vendors are authorized for a period of year(s)
☐ Vendors are authorized/reauthorized under renewable agreements, provided no vendor violations occurred during the previous vendor agreement period
☐ All vendors are provided at least 15 days advance written notice of the expiration of the vendor agreement ☐ Chain stores sign a master agreement that includes multiple locations
☐ Chain stores sign an agreement for each store location
☐ All authorized WIC vendors are compliant with the regulatory split tender requirement at 246.12(f)(4).
☐ Other (specify):
☐ Periodic submission of vendor price lists. If so, specify frequency:
☐ Maintenance of records in addition to the required inventory records. If so, specify types of records:
☐ Submission of food instruments and CVVs/CVBs within a shorter timeframe than required by program regulations. If so, specify timeframe:
☐ Redemption of a minimum number/volume of food instruments and CVVs/CVBs ☐Minimum hours of operation
☐ Other (specify all):
☐ Yes ☐ No
If yes, provide a description of the supervision and instruction provided to local agencies to ensure the uniformity and quality of this activity.
Please attach a copy of the Vendor Agreement or provide the appropriate Procedure Manual reference below. ADDITIONAL DETAIL: Vendor Management Appendix and/or Procedure Manual (Citation):
Annual vendor training covers the following content (check all that apply):
☐ Purpose of the WIC Program
☐ Supplemental foods authorized by the State agency
☐ Minimum varieties and quantities of supplemental foods that must be stocked
☐ Obtaining infant formula only from sources included in the State agency’s list of State licensed infant formula wholesalers, distributors, and retailers, and manufacturers registered with the U.S. Food and Drug Administration
☐ Procedures for obtaining prior State agency approval to provide incentive items to WIC participants
☐ Procedures for transacting and redeeming food instruments and cash - value vouchers
☐ Vendor sanction system
☐ Vendor complaint process
☐ Claims procedures
☐ Changes in program requirements since the last training
☐ Recordkeeping requirements
☐ Replacement food instruments and cash-value vouchers
☐ Participant complaints
☐ Vendor requests for technical assistance
☐ Reauthorization
☐ Reporting changes of ownership, location, or cessation of operations
☐ Procedures for appeal/administrative review
☐ Training employees
☐ WIC/SNAP sanction reciprocity and information sharing ☐ Other (specify):
Vendors or vendor representatives receive training on the following occasions and/or through the following materials (check all that apply):
☐ On-site (in-store) meetings/conferences ☐ Off-site meetings/conferences
☐ During routine monitoring visits (e.g., educational buys) ☐ When specialized technical assistance is requested
☐ Written materials (e.g., newsletters)
☐ Audiotapes or videotapes
☐ Teleconference, video conference, or webinars
☐ Vendor hotline
☐ State or local agency website
☐ Other (specify):
Vendors or vendor representatives receive interactive training as follows (check all applicable responses):
☐ At or before initial authorization
☐ At least once every three years
☐ Annually or more frequently than once every three years
The following method(s) are used to evaluate the effectiveness of vendor training (check all that apply):
☐ Evaluation forms provided with training materials
☐ Pre-tests and/or post-tests regarding vendor policies, procedures, and practices
☐ Statistical indicators, such as a reduction in food instrument/cash-value voucher/cash-value benefit errors
☐ Educational buys
☐ Record reviews
☐ Informal feedback from vendors and/or participants
☐ Vendor advisory councils
☐ None
☐ Other (specify):
ADDITIONAL DETAIL: Vendor Management Appendix and/or Procedure Manual (Citation):
Delegation of Vendor Training
The State agency delegates its vendor training to:
☐ Its local agencies
☐ A contractor; specify:
☐ A vendor association/representative; specify:
☐ Other (specify):
☐ None (the State agency conducts all vendor training)
Indicate the frequency with which the State agency performed the following activities during the past fiscal year:
Times/ FY Activity
Provided comprehensive training materials to delegated trainers
Provided instruction on vendor training techniques to delegated trainers
Monitored performance of delegated trainers to ensure the uniformity and quality of vendor training ☐ Not applicable
☐ Other (specify):
ADDITIONAL DETAIL: Vendor Management Appendix and/or Procedure Manual (Citation):
3. Documents for and Documentation of Vendor Training
a. The State agency or the entity to which it delegates vendor training documents the content of and vendor participation in annual vendor training:
☐ Yes ☐ No
Vendors or vendor representatives are required to sign an acknowledgment of training when they have received the following types of training (check all that apply):
☐ Interactive training ☐ Annual training
☐ Educational buys ☐ Monitoring visits
☐ Remedial training ☐ Other (specify):
☐ Yes ☐ No
If yes, provide the link to the Vendor Handbook or the citation:
☐ Yes ☐ No
If yes, provide the link to the training:
ADDITIONAL DETAIL: Vendor Management Appendix and/or Procedure Manual (Citation):
Vendor Complaints
The State agency has a formal system for receiving complaints about vendors:
☐ No; please explain:
☐ Yes, complaints are received through the following: ☐ A toll-free number handled by State agency staff
☐ A standard complaint form which the complainant sends to:
☐ State agency
☐ Local agency or clinic
☐ Online system; include link here:
☐ Other (specify):
The State agency has a formal system for receiving complaints from vendors:
☐ No; please explain:
☐ Yes, complaints are received through the following:
☐ A toll-free number handled by State agency staff
☐ A standard complaint form which the complainant sends to:
☐ State agency
☐ Local agency or clinic
☐ Online system; include link here:
☐ Other (specify):
The State agency logs and responds to all complaints:
☐ Yes, please explain:
☐ No; please explain:
ADDITIONAL DETAIL: Vendor Management Appendix and/or Procedure Manual (Citation):
Identifying High-Risk Vendors
What criteria does the State agency use to identify high-risk vendors: (* = mandatory)
☐ Low-variance* ☐ Complaints against vendors
☐ High-mean value* ☐ Other (specify all):
☐ New vendor
Identify the frequency for generating high-risk vendor reports:
☐ Monthly ☐ Annually
☐ Quarterly ☐ No set schedule
☐ Semiannually ☐ Other (specify):
Identify the type(s) of food instruments/cash-value vouchers/cash-value benefits used in the high-risk vendor analysis. (Check all that apply):
☐ A full monthly food package for a:
☐ Woman ☐ Infant ☐ Child ☐ Other (specify):
☐ Standard food instrument type with multiple food items (e.g., milk, cheese, and cereal)
☐ Standard food instrument type with a single food item
☐ Constructed food instrument (State agencies with nonstandard food instruments)
☐ CVVs/CVBs
☐ Other (specify):
To perform the high-risk vendor analysis, the State agency’s system aggregates a vendor's redemptions over the following time period:
☐ 1 month ☐ 2 months ☐ 3 months ☐ 4 months ☐ 5 months ☐ 6 months
☐ Other (specify):
Vendor redemption patterns are generally compared to:
☐ Applicable peer group patterns ☐ All vendors’ patterns Statewide
☐ Other (specify):
Provide additional information about your MIS, detailing how the State agency conducts the high-risk vendor analysis and how the State agency ranks vendors when more than 5% of authorized vendors are high risk. Include the name of the file and/or where the file is and which system is used to produce it.
1. Routine Monitoring Visits
Routine monitoring visits are conducted by:
☐ State agency staff ☐ Local agency staff ☐ Other (specify):
Identify the activities performed during a routine monitoring visit; check all that apply:
☐ Check the vendor’s inventory of supplemental foods and/or inventory records to determine if the vendor meets the State agency’s requirements for the minimum variety and quantity of supplemental foods
☐ Check the vendor’s inventory of non-supplemental foods and/or inventory records to provide information on whether the vendor is an above-50-percent vendor
☐ Determine whether the vendor accepts forms of payment other than WIC food instruments, such as cash, personal checks, and credit cards, to provide information on whether the vendor is an above-50-percent vendor
☐ Check the vendor’s invoices of infant formula to ensure that the infant formula is obtained only from the State agency’s list of infant formula manufacturers registered with the Food and Drug Administration, and infant formula wholesalers, distributors, and retailers licensed under State law
☐ If the vendor is an above-50-percent vendor, check its stock of incentive items to ensure that such items have been approved by the State agency
☐ Obtain the vendor’s shelf prices and/or validate the vendor’s price list
☐ Review food instruments in the vendor’s possession for vendor violations
☐ Compare food instruments in the vendor’s possession with shelf prices to test for vendor overcharges ☐ Review use of shelf tags and signage
☐ Review expiration dates on supplemental foods
☐ Compare prices of supplemental foods with similar items not approved as supplemental
☐Observe food instrument transactions and CVV/CVB
☐ IF EBT, verify if that vendor has appropriate terminals in required number of lanes per 7 CFR 246.12(z)(2).
☐Conduct an educational buy
☐ Interview manager and/or employees
☐ Review employee training procedures
☐ Conduct annual vendor training or provide vendor with annual training materials ☐Examine the sanitary conditions of the store
☐ Assures that vendor is compliant with the split tender requirement
Other (specify all):
Generally, routine monitoring visits are conducted on each vendor (check all that apply):
☐ Annually ☐ Twice a year ☐ As needed (specify) ☐ Other (specify)
The following procedures are used in determining whether a vendor is selected for a routine monitoring visit (check all that apply):
☐ Random selection ☐ Complaints
☐ Periodic/scheduled training ☐ Other (specify):
☐ Periodic/scheduled review
What percent of vendors received monitoring visits during the past fiscal year?
☐ Less than 5 percent; explain reason:
☐5 percent
☐ More than 5 percent (specify):
ADDITIONAL DETAIL: Vendor Management Appendix and/or Procedure Manual (Citation):
Investigative Practices
The State agency conducts (check all that apply):
☐ Compliance buys (a covert, on-site investigation in which a representative of the Program poses as a participant, parent or caretaker of an infant or child participant, or proxy; transacts one or more food instruments or CVVs/ CVBs; and does not reveal during the visit that he or she is a Program representative.)
☐ Inventory audits (the examination of food invoices or other proofs of purchase to determine whether a vendor has purchased sufficient quantities of supplemental foods to provide participants the quantities specified on food instruments redeemed by the vendor during a given period of time.)
☐ Other (specify):
The following factors are used to determine which vendors are selected for a compliance investigation (check all that apply):
☐ Vendor is identified by the high-risk vendor identification criteria
☐ Random selection
☐ Geographical considerations
☐ Volume of WIC redemptions
☐ Participant complaints
☐ Other (specify):
The State agency uses standard procedures for conducting and documenting compliance buys and inventory audits:
☐ Yes If yes, please provide the guidelines in the Vendor Management Appendix or cite to the Procedure Manual reference:
☐ No; specify:
The results of compliance investigations are used to assess the effectiveness of the State agency’s high-risk vendor identification criteria:
☐ Yes ☐ No
If yes, check the items below that describe how the results of compliance investigations are used to assess the effectiveness of high-risk vendor identification criteria:
☐ The State agency compares data on the prevalence of vendor violations detected among high-risk versus non- high-risk vendors.
☐ The State agency discards a high-risk vendor identification criterion if compliance investigations of high-risk vendors identified by the criterion result in no vendor violations after months
☐ Investigative procedures and training are reevaluated if compliance investigations of high-risk vendors result in the detection of no vendor violations.
☐ Other (specify):
How many vendors were authorized as of October 1 of the past fiscal year?
How many compliance investigations of vendors were completed during the past fiscal year?
☐ Compliance Investigations:
☐ Inventory Audits:
How many vendors that received compliance investigations were high-risk during the past fiscal year?
☐ Compliance Investigations:
☐ Inventory Audits:
Did the State agency give priority to high-risk vendors (up to the five percent minimum) in conducting compliance investigations during the past fiscal year?
☐ Yes ☐ No; explain reason:
How many of all vendors were high-risk during the past fiscal year?
(The State agency is required by § 246.12(j)(4)(i) to conduct compliance investigations of at least 5 percent of its vendors authorized as of October 1 of each fiscal year, including all high risk vendors up to the 5 percent maximum.)
ADDITIONAL DETAIL: Vendor Management Appendix and/or Procedure Manual (Citation):
2. Compliance Buys
The State agency conducts the following types of compliance buys:
☐ Trafficking buys (exchanging food instruments for cash/cash-value vouchers/cash-value benefits and short buys) ☐ Safe buys (transacting food instruments for all food items listed to see if the vendor will overcharge)
☐ Short buys (transacting food instruments for fewer food items than those listed to see if the vendor will charge for food items not received)
☐ Major substitution buys (exchanging food instruments for non-food items or unauthorized food items that are not similar to those listed)
☐ Minor substitution buys (exchanging food instruments for unauthorized food items that are similar to those listed) ☐Other (specify):
Does the State agency tailor compliance buys to vendors' risk type?
☐ Yes; explain:
☐ No; explain:
Compliance buys are usually conducted by:
☐ WIC State agency staff ☐ WIC local agency staff ☐ State investigators
☐ Investigators retained on a contract basis (e.g., Pinkerton, Wells Fargo)
☐Interns, neighborhood residents, or program participants employed by WIC ☐ Another WIC State agency
☐ Other (specify):
Who is responsible for ensuring the proper execution of and follow-up on compliance buys?
☐ WIC State agency vendor manager ☐ WIC local agency manager
☐ State investigators
☐Contractor
☐ Another WIC State agency
☐ Other (specify):
If no vendor violations are detected, how many compliance buys does the State agency conduct before closing a compliance investigation?
☐ Two ☐ Other (specify):
If the State agency conducts a standard number of compliance buys per compliance investigation, what is the basis for the prescribed number of buys?
☐ State law or regulation
☐ State agency policy or procedure
☐ Level of evidence necessary to impose vendor sanctions
☐ Legal counsel's advice
☐ Other (specify):
Is the vendor provided written notification of a violation requiring a pattern of violations in order to sanction the vendor, prior to documenting another violation of the same kind, unless the State agency determines that such notice would compromise the investigation and documents this in the vendor’s file?
☐ Yes ☐ No
If no, is the determination that the written notification would compromise the investigation documented in the vendor's file?
☐ Yes; if a standard form is used, please attach and cite below. ☐ No; please explain:
Does the State agency have a clear, actionable definition of “pattern of violations” approved by its General Counsel/Administrative Officer?
☐ Yes ☐ No
ADDITIONAL DETAIL: Vendor Management Appendix and/or Procedure Manual (Citation):
Estimate the cost for conducting compliance buys, excluding expenses related to the vendor appeals/ administrative review process:
$ Cost per compliance buy
☐ Unknown
☐ Not applicable
ADDITIONAL DETAIL: Vendor Management Appendix and/or Procedure Manual:
Inventory Audits (If inventory audits are not performed, go to Question 5)
The following factors are used to determine which vendors selected for compliance investigations will receive inventory audits rather than/or in addition to compliance buys:
☐ Vendor has highest risk based on State agency’s high-risk identification criteria ☐Suspicion of vendor exchanging cash for food instruments (trafficking)
☐Inconclusive compliance buy results
☐ Complaints
☐ Other (specify):
The State agency conducts the following types of inventory audits:
☐ On-site inventory audits
☐ State agency inventory audits (vendor sends records to State agency)
☐ Local agency inventory audits (vendor sends records to local agency)
☐ Other (specify):
Inventory audits are conducted by (check all that apply):
☐ WIC State agency staff ☐ WIC local agency staff ☐ State investigators
Investigators retained on a contract basis (e.g., Pinkerton's, Wells Fargo) Other (specify):
Identify the amount of, or period of time covered by, the receipts that are examined during an inventory audit:
ADDITIONAL DETAIL: Vendor Management Appendix and/or Procedure Manual (Citation):
Compliance Buy/Inventory Audit Tracking System(s)
The State agency has a means of recording and tracking staff person hours devoted to investigation activities:
☐ Yes; please describe:
☐ No
The State agency has an automated system for tracking investigations that monitors the progress and status of each compliance investigation:
☐ Yes; please describe:
☐ No
ADDITIONAL DETAIL: Vendor Management Appendix and/or Procedure Manual (Citation):
Types of Administrative Reviews
The State agency conducts the following types of administrative reviews of vendor appeals for the adverse actions listed below. (Check all that apply):
Informal Abbreviated Full
Desk Admin Admin.
Reviews Reviews Reviews
☐ ☐ ☐ Denial due to competitive price selection criterion
☐ ☐ ☐ Denial due to minimum stocking selection criterion
☐ ☐ ☐ Denial due to business integrity or current SNAP DQ or CMP
☐ ☐ ☐ Denial based on limiting criteria
☐ ☐ ☐ Denial due to State agency selection criteria
☐ ☐ ☐ Denial due to application outside timeframe
☐ ☐ ☐ Application of above-50-percent criteria
☐ ☐ ☐ DQ for WIC violations
☐ ☐ ☐ DQ for SNAP CMP
☐ ☐ ☐ Other WIC sanctions, e.g., fine or CMP
☐ ☐ ☐ Denial based on circumvention of sanction
☐ ☐ ☐ Application of peer group criteria
☐ ☐ ☐ Termination due to ownership change
☐ ☐ ☐ Termination due to location change
☐ ☐ ☐ Termination due to ceasing operations
☐ ☐ ☐ Termination for other causes
☐ ☐ ☐ DQ for trafficking/illegal sales conviction
☐ ☐ ☐ DQ/CMP due to another State agency’s mandatory sanction
☐ ☐ ☐ CMP based on SNAP DQ
☐ ☐ ☐ Denial based on no SNAP authorization
ADDITIONAL DETAIL: Vendor Management Appendix and/or Procedure Manual (Citation):
Administrative Review Procedures
The State agency has a law or regulation governing WIC administrative reviews:
☐ Yes; please indicate:
☐ No
If the State agency does have such a law or regulation, this includes:
☐ State agency Administrative Procedures Act
☐ State agency law pertaining to WIC only
☐State agency health department law
☐ State agency health department regulation
☐ State agency WIC regulation
☐ Other (specify):
At which level do administrative reviews of WIC vendor appeals take place:
☐ WIC local agency
☐ WIC State agency
☐ State health department or Tribal
☐ Other (specify):
Administrative reviews are conducted by:
☐ Hearing officers
☐ Administrative law judges
☐ Other (specify):
Abbreviated Full
Admin. Admin.
Reviews Reviews
☐ ☐ Opportunity for vendor to examine evidence prior to review
☐ ☐ Opportunity for vendor to reschedule review date
☐ ☐ Opportunity for vendor to present its case
☐ ☐ Opportunity for vendor to be represented by counsel
☐ ☐ Opportunity for vendor to present witnesses
☐ ☐ Opportunity for vendor to cross-examine witnesses
☐ ☐ Opportunity for investigators to testify behind a screen or via other non-identifying method
☐ ☐ Presence of a court reporter or stenographer
☐ ☐ An impartial decision-maker, whose decision is based solely on whether the State agency correctly applied Federal and State statues, regulations, policies, and procedures
☐ ☐ A written decision within 90 days from request for review
☐ ☐ Other (specify):
Check the party(ies) below who may present the State agency case during a full administrative review:
☐ WIC staff person assigned to case ☐ WIC State agency Vendor Manager ☐ WIC State Agency Director
☐ Legal counsel (State Attorney General or General Counsel’s office) ☐ Legal counsel (paid by WIC Program funds)
☐ Other (specify all):
Please attach and/or reference in the Additional Detail area below the location of the State agency’s administrative review procedures.
ADDITIONAL DETAIL: Vendor Management Appendix and/or Procedure Manual (Citation):
WIC/SNAP Information Sharing
An information sharing agreement between the WIC State agency and SNAP is in effect, per FNS Instruction 906-1 or other FNS guidance, and is maintained at the State agency:
☐ Yes ☐ No
If yes, an updated list of authorized vendors is sent to the appropriate FNS SNAP Retailer Operations Division office:
☐ Once a year
☐ Regularly, at intervals of less than one year (specify):
☐ Periodically, as changes occur
☐ Upon request
☐ Other (specify):
State agency compliance investigators coordinate their activities with their SNAP counterparts:
☐ Yes ☐ No
State statute, regulations, or procedures restrict the disclosure of WIC vendor and SNAP retailer information to those permitted under 7 CFR 246.26(e) and (f):
☐ Yes (specify):
☐ No
ADDITIONAL DETAIL: Vendor Management Appendix and/or Procedure Manual (Citation):
Check below the routine formal training available to State and local level staff in vendor management practices:
State Local Other (contractor)
☐ ☐ ☐ Vendor selection and authorization
☐ ☐ ☐ Vendor training
☐ ☐ ☐ Routine monitoring
☐ ☐ ☐ Compliance investigations
☐ ☐ ☐ Inventory audits
☐ ☐ ☐ Corrective actions and sanctions
☐ ☐ ☐ Criminal investigations
☐ ☐ ☐ Vendor appeals/administrative reviews
☐ ☐ ☐ Federal and/or State WIC regulations
☐ ☐ ☐ Prevention of vendor fraud and abuse
☐ ☐ ☐ WIC/SNAP information sharing and handling of confidential WIC vendor data
☐ ☐ ☐ High-risk vendor identification
☐ ☐ ☐ Vendor management information system
☐ Not applicable
☐ Other (specify):
State agency staff meets with vendor representatives as part of a vendor advisory council or other vendor stakeholder group:
☐ Monthly
☐ Quarterly
☐ Other frequency:
☐ No vendor advisory council
ADDITIONAL DETAIL: Vendor Management Appendix and/or Procedure Manual (Citation):
Reporting vendor information to TIP:
How does the State agency submit vendor information to The Integrity Profile?
☐ Manually (one vendor at a time)
☐ Upload text file
☐ Upload XML Schema
Describe how the State agency ensures that this information is accurate:
ADDITIONAL DETAIL: Vendor Management Appendix and/or Procedure Manual (Citation):
☐ STATE AGENCY DOES NOT AUTHORIZE FARMERS/FARMERS’ MARKETS TO ACCEPT CVVs/CVBs; SECTIONS J-M DO NOT APPLY
Does the State agency delegate any tasks related to the management of the Farmers or Farmers' Markets to another entity?
☐ No
☐ Yes (specify what tasks and to whom):
The State agency authorizes farmers/farmers’ markets to accept CVVs based on:
☐ Authorization by the WIC Farmers’ Market Nutrition Program (FMNP)
☐Selection criteria established separately from FMNP
If the State agency does not authorize farmers/farmers’ markets based on FMNP authorization, the selection criteria include (describe):
The State agency considers applications:
☐ On an on-going basis ☐ Annually
☐ Other (specify):
☐ Every three years
☐ Every two years
ADDITIONAL DETAIL: Vendor Management Appendix and/or Procedure Manual (Citation): and/or FMNP State Plan (Citation):
Agreement periods are for:
☐ One year ☐ Two years
☐Three years ☐ Other (specify):
Agreements are:
☐ A modified version of the vendor agreement ☐ Combined with the FMNP agreement
☐ Unique to the authorization of farmers to transact CVVs/CVBs
The following reflect the State agency’s farmer/farmers’ market agreement practices:
☐ All farmers/farmers’ markets have a written agreement with the State agency ☐ A standard farmer/farmers’ market agreement is used statewide Agreements ☐ Are subject to the State’s procurement procedures
☐ Agreements/handbooks are subject to the State’s Administrative Procedures Act
☐ Farmers/farmers’ markets are authorized/reauthorized under renewable agreements, provided no farmer/farmers’ market violations occurred during the previous agreement period
☐ All farmers/farmers’ markets are provided at least 15 days advance written notice of the expiration of the agreement
☐ All farmers/farmers’ markets are provided a schedule of sanctions, either in or attached to the farmer/farmers’ market agreement, or as a citation to State regulations
☐ Other (specify):
Agreement provisions include:
☐ Assure that the CVV/CVB is redeemed only for eligible fruits and vegetables as defined by the State agency
☐Provide eligible fruits and vegetables at the current price or less than the current price charged to other customers
☐ Accept the CVVs/CVBs within the dates of their validity and submit CVVs for payment within the allowable time period established by the State agency
☐ Redeem the CVV/CVB in accordance with a procedure established by the State agency
☐ Accept training on CVV/CVB procedures and provide training to any employees with CVV/CVB responsibilities on such procedures
☐ Agree to be monitored for compliance with program requirements, including both overt and covert monitoring
☐ Be accountable for actions of employees in the provision of authorized foods and related activities
☐ Pay the State agency for any CVV/CVB transacted in violation of this agreement
☐ Offer WIC participants, parent or caretakers of child participants or proxies the same courtesies as other customers
☐ Neither the State agency nor the farmer has an obligation to renew the agreement.
☐Other (specify):
The farmer/farmers markets agreement reflects that the farmer/farmers’ market must not:
☐ Collect sales tax on CVV/CVB purchases
☐ Seek restitution from WIC participants, parent or caretakers of child participants or proxies for CVVs/CVBs not paid or partially paid by the State agency
☐ Issue cash change for purchases that are in an amount less than the value of the CVV/CVB ☐Other (specify):
Please attach a copy of the Farmer/Farmers’ Market Agreement or provide the appropriate Procedure Manual reference below.
ADDITIONAL DETAIL: Vendor Management Appendix and/or Procedure Manual (Citation): and/or FMNP State Plan (Citation):
Farmer/farmers’ market training includes:
☐ Eligible fruits and vegetables
☐ Procedures for transacting and redeeming CVVs/CVBs
☐Agreement provisions
☐ Sanctions and Appeals
☐ Other (specify):
Interactive farmer/farmers’ market training (e.g., face-to-face, video conference, web cam) is conducted:
☐ At or before initial authorization
☐ At least every three years following initial authorization
☐ Other (specify):
Non-interactive farmer/farmers’ market training (e.g., via hard copy mail, email, online) is conducted:
☐ Annually following authorization
☐ Changes in procedures
☐ Other (specify):
The State agency delegates training to:
☐ Local agency (specify):
☐ Contractor (specify):
☐ Farmer representative (specify):
☐ Other (specify):
If the State agency delegates training, briefly describe the State agency’s supervision of such training:
The State agency produces a Farmer/farmers markets Training Handbook:
☐ Yes ☐ No
If yes, provide the citation:
The State agency provides online or web based training:
☐ Yes ☐ No
If yes, provide the link to the training or citation:
ADDITIONAL DETAIL: Vendor Management Appendix and/or Procedure Manual (Citation) and/or FMNP State Plan (Citation):
Farmers/farmers’ markets are included in the:
☐ FMNP sample of farmers/farmers markets for monitoring ☐ WIC sample of vendors for monitoring
Monitoring includes:
☐ Covert methods, such as compliance buys ☐ Overt methods, such as routine monitoring
ADDITIONAL DETAIL: Vendor Management Appendix and/or Procedure Manual (Citation): and/or FMNP State Plan (Citation):
Farmer/farmers’ market violations may result in; check all that apply:
☐ Disqualification
☐ Denial of payment or demand for refund due to improperly redeemed CVVs/CVBs (Claims)
☐Prosecution under Federal, State, or local law regarding fraud or other illegal activity
☐ Monetary sanctions such as civil money penalties and fines
Farmers/farmers’ markets may administratively appeal:
☐ Disqualification
☐ Denial of application
☐ Other sanction (specify):
Farmers/farmers’ markets may not administratively appeal:
☐ Expiration of an agreement ☐ Claims
☐ Other (specify):
Please attach and/or reference the location of the State agency’s administrative review procedures.
ADDITIONAL DETAIL: Vendor Management Appendix and/or Procedure Manual (Citation) and/or FMNP State Plan (Citation):
Please provide the State agency definition for participant access. Include full criteria, including geography, density, and any other parameters in your response.
Does the State agency assess all vendor applications not meeting selection criteria for participant access?
☐ Yes ☐ No
If yes, describe below or attach and provide a citation of the procedures used for assessing vendor applications for participant access. Provide sufficient details so steps can be followed and criteria applied to a specific vendor
II. Nutrition Services
(Please indicate) State Agency: for FY
Nutrition services include the full range of activities performed by a variety of staff to operate a WIC Program such as, participant screening and assessment, nutrition education and counseling, breastfeeding promotion and support and health promotion, food package prescriptions, and health care referrals. WIC State agencies should refer to the WIC Nutrition Service Standards, available WIC Works Resource System at WIC Works - http://wicworks.nal.usda.gov/ for recommended criteria and best practices to incorporate activities that are consistent with providing quality nutrition services and revitalizing quality nutrition services (RQNS).
Nutrition Education-246.4(a)(9); 246.11(a)(1-3)(c)(1,3-7): describe the nutrition education goals and action plan and the provisions for providing nutrition education contacts and materials to all participants including the special nutrition education needs of migrant farmworkers and their families, Native Americans, and homeless persons. Also describe methods to be used to provide drug and other harmful substance abuse prevention information. Establish standards for breastfeeding promotion and support including the development and/or maintenance of a peer counselor program consistent with the WIC Breastfeeding Model Components for Peer Counseling.
Food Package Design-246.10: describe the procedures for determining which foods should be authorized and how the food package should be nutritionally tailored and by whom, and plans for substitutions or eliminations to WIC food package. In addition to regulations at 246.10, State agencies should refer to the Food Package Guidance Handbook and Frequently Asked Questions available on the FNS PartnerWeb.
Staff Training-246.11(c)(2): describe the training and technical assistance provided to WIC professional and paraprofessional personnel who provide nutrition education, and breastfeeding promotion/education to participants.
Nutrition Education Plans (§246.11)
The State agency develops and coordinates the nutrition education component with consideration of local agency plans, needs, and available nutrition education resources. (§246.11(c)(1))
☐ Yes ☐ No
The State agency monitors local agency activities to ensure compliance with provisions set forth in paragraphs §246.11(c)(7), (d), and (e) of this section. (§246.11(c)(5))
☐ Yes ☐ No
The local agency develops an annual nutrition education plan that is consistent with the State’s nutrition education component of Program operations. (§246.11(d)(2))
☐ Yes ☐ No
(i) The State agency requires that local agency nutrition education include:
☐ A needs assessment
☐ Goals and objectives for participants
☐ Evaluation/follow-up
☐ Other (list):
(ii). The State agency monitors local agency progress toward meeting nutrition education goals, nutrition education action plans, and objectives via:
☐ Quarterly or annually written reports
☐ Year-end summary report
☐ Annual local agency reviews
☐ Other (specify):
State policies reflect the definition of “nutrition education” as defined in §246.2 and in the Child Nutrition Act. The definition is “Nutrition education means individual and group sessions and the provision of materials that are designed to improve health status and achieve positive change in dietary and physical activity habits, and that emphasize the relationship between nutrition, physical activity, and health, all in keeping with the personal and cultural preferences of the individual."
☐ Yes ☐ No
ADDITIONAL DETAIL: Nutrition Services Supporting Documentation:
Annual Assessment of Participant Views on Nutrition Education and Breastfeeding Promotion and Support
Is an annual Assessment of Participant Views on Nutrition Education and Breastfeeding Promotion and Support conducted:
☐ Yes ☐ No
Check below the method(s) used in the past fiscal year to assess participant views on nutrition education and breastfeeding promotion and support provided by WIC:
☐ State-developed questionnaire issued by local agencies
☐ Locally-developed questionnaires (need approval by SA):
☐ Yes ☐ No
☐ State-developed questionnaire issued by State agency.
☐ Focus groups
☐ Other (Specify):
Results of participant views are:
☐ Used in the development of the State Plan
☐ Used in the development of local agency nutrition education plans and breastfeeding promotion and support plans
☐ Other (specify):
ADDITIONAL DETAIL: Nutrition Services Appendix and/or Procedure Manual (citation):
Nutrition Education Contacts (§246.11(a)(1-3): (1) Nutrition education shall be considered a benefit of the program, and shall be made available at no cost to the participant. Nutrition education shall be designed to be easily understood by participants, and it shall bear a practical relationship to participant nutritional needs, household situations, and cultural preferences including information on how to select food for themselves and their families. Nutrition education shall be thoroughly integrated into participant health care plans, the delivery of supplemental foods, and other Program operations. (2) Nutrition education is made available to all participants. Nutrition education may be provided through the local agencies directly, or through other agencies. At the time of certification, the local agency shall stress the positive, long term benefits of nutrition education and encourage the participant to attend and participate in nutrition education activities. However, individual participants shall not be denied supplemental foods for failure to attend or participate in nutrition education activities. (3) The State agency shall ensure that local agencies provide drug and other harmful substance abuse information to all pregnant, postpartum, and breastfeeding women and to parents or caretakers of infants and children participants. Drug and other harmful substance abuse information may also be provided to pregnant, postpartum, and breastfeeding women and to parents or caretakers of infants and children participating in local agency services other than the Program.
The State agency assures that each local agency offers adult participants, parents, or caretakers of infant and child participants, and whenever possible, the child participants themselves at least two (≥2) nutrition education contacts per 6 month certification period, and quarterly nutrition education contacts to participants certified in excess of 6 months, to ensure adequate nutrition education in accordance with §246.11(e) via:
☐ Local agency addresses in the annual nutrition education plan
☐ State nutrition staff monitoring annually during local agency reviews
☐ Local agency providing periodic reports to State agency
☐ Other (specify):
The State agency has developed minimum nutrition education standards for the following participant categories:
☐ Pregnant women ☐ Breastfeeding women ☐ Postpartum women
☐ Children ☐ Infants ☐ High-risk participants
The minimum nutrition education standards address:
☐ Number of contacts ☐ Protocols ☐ Documentation ☐ Referrals
☐ Care plans ☐ Exit counseling ☐ Breastfeeding promotion and support
☐ Counseling methods/teaching strategies ☐ Information on substance abuse prevention
☐ Content (WIC appropriate topics) ☐ Nutrition topics relevant to participant assessment
☐ Appropriate use of educational reinforcement (videos, brochures, posters, etc.)
The State agency allows the following nutrition education delivery methods:
☐ Face-to-face, individually or group
☐ Online/internet
☐ Telephone
☐ Food demonstration
☐ A delivery method performed by other agencies, i.e., EFNEP
☐ Other (specify):
The State agency ensures that nutrition risk data is used in providing appropriate nutrition education by:
☐ Individual nutrition education contracts tailored to the participant’s needs
☐ Group nutrition education contacts relevant to the participant’s needs (please explain how appropriate group nutrition classes are identified and offered to the participant.)
☐ Other (specify):
An individual care plan is provided based on:
☐ Nutritional risk
☐ Priority level
☐ Healthcare provider’s prescription
☐ CPA discretion
☐ Participant request
☐ Other (specify):
Individual care plans developed include the following components:
Must Include |
May Include |
|
Individualized food package |
☐ |
☐ |
Identification of nutrition-related problems |
☐ |
☐ |
Nutrition education and breastfeeding support |
☐ |
☐ |
A plan for follow-up |
☐ |
☐ |
Referrals |
☐ |
☐ |
Timeframes for completing care plan |
☐ |
☐ |
Documentation of completing care plan |
☐ |
☐ |
A practical relationship to a participant’s nutritional needs, household situations, and cultural preferences including information on how to select food for themselves and their families |
☐ |
☐ |
Other (specify by typing into the cells below): |
|
|
|
☐ |
☐ |
|
☐ |
☐ |
Check the following individuals allowed to provide general or high-risk nutrition education:
General Nutrition Education |
High-Risk Nutrition Contact |
|
Paraprofessionals (non B.S. degree with formal WIC training by SA or LA) |
☐ |
☐ |
Licensed Practical Nurses |
☐ |
☐ |
Registered Nurses |
☐ |
☐ |
B.S. in Home Economics |
☐ |
☐ |
B.S. in the field of Human Nutrition |
☐ |
☐ |
Registered Dietitian or M.S. in Nutrition (or related field) |
☐ |
☐ |
Dietetic Technician (2-year program completed) |
☐ |
☐ |
Other (specify by typing into the cells below): |
|
|
|
☐ |
☐ |
|
☐ |
☐ |
|
☐ |
☐ |
The State agency allows adult participants to receive nutrition education by proxy.
☐ No
☐ Yes (If yes, check the applicable conditions below):
☐ Proxy is spouse/significant other
☐ Proxy is grandparent or legal guardian of infant or child participant
☐ Proxy is neighbor
☐ Other (specify):
☐ Only for certain priorities (specify):
The State agency allows parents/guardians of infant and child participants to receive nutrition education by proxy.
☐ No
☐ Yes (If yes, check the applicable conditions below):
☐ Proxy is grandparent or legal guardian of infant or child participant
☐ Proxy is neighbor
☐ Other (specify):
☐ Only for certain priorities (specify):
ADDITIONAL DETAIL: Nutrition Services Appendix and/or Procedure Manual (citation):
Nutrition Education Materials (§246.11(c)(1,3,4,6,7): The State agency shall (1) develop and coordinate the nutrition education component of Program operations with consideration of local agency plans, needs, and available nutrition education resources; (3) identify or develop resources and educational materials for use in local agencies, including breastfeeding promotion and instruction materials, taking reasonable steps to include materials in languages other than English in areas where a significant number or proportion of the population needs the information in a language other than English; (4) develop and implement procedures to ensure that nutrition education is offered to all adult participants and to parents/caregivers of infant or child participants, as well as child participants whenever possible; (6) establish standards for participant contacts that ensure adequate nutrition education in accordance with paragraph 246.11(e); and (7) establish standards for breastfeeding promotion and support, including a positive breastfeeding supportive clinic environment, a local agency breastfeeding coordinator, breastfeeding promotion, and support for new staff.
The State agency shares material with the Child and Adult Care Food Program (CACFP) at no cost:
☐ Yes ☐ No
If applicable, list other agencies:
Does a written material sharing agreement exist between the relevant agencies?
☐ Yes ☐ No
The State agency recommends and/or makes available nutrition education materials for the following topics:
English |
Spanish |
Other (specify by typing into the cells below): |
|
General nutrition |
☐ |
☐ |
|
Specific nutrition-related disorders |
☐ |
☐ |
|
Maternal nutrition |
☐ |
☐ |
|
Infant nutrition |
☐ |
☐ |
|
Child nutrition |
☐ |
☐ |
|
Nutritional needs of homeless |
☐ |
☐ |
|
Nutritional needs of migrant farmworkers & their families |
☐ |
☐ |
|
Nutritional needs of Native Americans |
☐ |
☐ |
|
Nutritional needs of Teenage prenatal women |
☐ |
☐ |
|
Breastfeeding promotion and support (including troubleshooting problems) |
☐ |
☐ |
|
Danger of harmful substances (alcohol, tobacco and other drugs), as well as secondhand smoke during pregnancy and breastfeeding |
☐ |
☐ |
|
Food Safety |
☐ |
☐ |
|
Physical activity |
☐ |
☐ |
|
Other (specify by typing into the cells below): |
|
|
|
|
☐ |
☐ |
|
|
☐ |
☐ |
|
|
☐ |
☐ |
|
Attach a listing of the nutrition education resources available from the State agency or other sources for use by local agencies or specify the location in the Procedure Manual and reference below.
The State agency follows written procedures to ensure that nutrition education materials recommended/made available are appropriate in terms of the following:
☐ Content ☐ Reading level/language ☐ Graphic design ☐ Cultural relevance
☐ Other (specify):
Locally-developed nutrition education materials must be approved by State agency prior to use.
☐ Yes ☐ No
If no, State agency requires local agency to follow a standardized format for evaluating nutrition education materials.
☐ Yes ☐ No
ADDITIONAL DETAIL: Nutrition Services Appendix and/or Procedure Manual (citation):
Nutrition Education Needs of Special Populations
The State agency tailors its nutrition education efforts to address the specific needs of migrant farmworkers (M), homeless individuals (H), substance-abusing individuals (S), and/or breastfeeding women (B) through (check all that apply):
M |
H |
S |
B |
|
☐ |
☐ |
☐ |
☐ |
Providing nutrition education materials appropriate to this population and language needs |
☐ |
☐ |
☐ |
☐ |
Providing nutrition curriculum or care guidelines specific to this population |
☐ |
☐ |
☐ |
☐ |
Requiring local agencies who serve this population to address its special needs in local agency nutrition education plans |
☐ |
☐ |
☐ |
☐ |
Arranging for special training of local agency personnel who work with this population |
☐ |
☐ |
☐ |
☐ |
Distributing resource materials related to this population |
☐ |
☐ |
☐ |
☐ |
Encouraging WIC local agencies to network with one another |
☐ |
☐ |
☐ |
☐ |
Coordinating at the State and local levels with agencies who serve this population |
|
|
|
|
Other (specify by typing into the cells below): |
☐ |
☐ |
☐ |
☐ |
|
☐ |
☐ |
☐ |
☐ |
|
☐ |
☐ |
☐ |
☐ |
|
ADDITIONAL DETAIL: Nutrition Services Appendix and/or Procedure Manual (citation):
Breastfeeding Promotion and Support Plan
The State agency coordinates with local agencies to develop a breastfeeding promotion plan that contains the following elements (check all that apply):
☐ Activities such as development of breastfeeding coalitions, task forces, or forums to address
breastfeeding promotion and support issues
☐ Identification of breastfeeding promotion and support materials
☐ Procurement of breastfeeding aids which support the initiation and continuation of breastfeeding (e.g., breast pumps).
☐ Training of State/local agency staff
☐ Designating roles and responsibilities of staff
☐ Evaluation of breastfeeding promotion and support activities
☐ Other (specify):
The State agency has established minimum protocols for breastfeeding promotion and support which include the following (check all that apply):
☐ A policy that creates a positive clinic environment which endorses breastfeeding as the preferred method of infant feeding
☐ A requirement that each local agency designate a local agency staff person to coordinate breastfeeding promotion and support activities
☐ A requirement that each local agency incorporate task-appropriate breastfeeding promotion and support training into orientation programs for new staff involved in direct contact with WIC clients.
☐ A plan to ensure that women have access to breastfeeding promotion and support activities during the prenatal and postpartum periods
☐ Participant breastfeeding assessment
☐ Food package prescription and tailoring based on breastfeeding and nutrition assessment
☐ Data collection (at State and local level)
☐ Referral criteria
☐ Peer counseling
☐ Other (specify):
Breastfeeding Peer Counseling
The State agency coordinates with local agencies to request WIC Breastfeeding Peer Counseling (BFPC) funds to develop and/or maintain a peer counselor program?
☐ Yes ☐ No
If yes, the State agency has submitted a request for the following.
☐ Full amount of available BFPC funds.
☐ Specific amount of available BFPC funds $ . (Not to exceed the full amount available.)
Attach a copy of an updated line item budget, with written narrative, demonstrating how peer counseling funds are being used for approved peer counseling activities. Include the citation for the attachment here:
Please provide the approximate number of WIC peer counselors in your State:
Please provide the number of local agencies designated by the State agency to receive funds to operate peer counseling programs.
ADDITIONAL DETAIL: Nutrition Services Appendix and/or Procedure Manual (citation):
The State agency coordinates with local agencies to develop a breastfeeding peer counseling program that contains the following components (see WIC Breastfeeding Model Components for Peer Counseling):
Definition of peer counselor defined as follows: paraprofessional recruited and hired from target population; available to WIC clients outside usual clinic hours and outside the WIC clinic
☐ Yes ☐ No
Designated breastfeeding peer counseling program managers/coordinators at State and/or local level
☐ Yes ☐ No
Defined job parameters and job descriptions for breastfeeding peer counselors
☐ Yes ☐ No
If yes, the job parameters for peer counselors (check all that apply):
☐ Define settings for peer counseling service delivery (check all that apply):
☐ Home (peer counselor makes telephone calls from home)
☐ Participant’s home (peer counselor makes home visits)
☐ Clinic
☐ Hospital
☐ Define frequency of client contacts
☐ Define procedures for making referrals
☐ Define scope of practice of peer counselor
Adequate compensation and reimbursement of breastfeeding peer counselors
☐ Yes ☐ No
Training of State and local staff (managers, designated breastfeeding experts, peer counselors, others) using the FNS-developed breastfeeding training curriculum.
☐ Yes ☐ No
Training of WIC clinic staff about the role of the WIC peer counselor
☐ Yes ☐ No
Establishment of standardized breastfeeding peer counseling program policies and procedures (check all that apply):
☐ Timing and frequency of contacts
☐ Documentation of client contacts
☐ Referral protocols
☐ Confidentiality
☐ Use of social media
☐ Other (specify):
Adequate supervision and monitoring of breastfeeding peer counselors through (check all that apply):
☐ Regular, systematic contact with peer counselor
☐ Regular, systematic review of peer counselor contact logs
☐ Regular, systematic review of peer counselor contact documentation
☐ Spot checks
☐ Observation
☐ Other (specify):
Participation in community partnerships to enhance the effectiveness of breastfeeding peer counseling programs (check all that apply):
☐ Breastfeeding coalitions
☐ Businesses
☐ Community organizations
☐ Cooperative extension
☐ La Leche League
☐ Hospitals
☐ Home visiting programs
☐ Private Healthcare clinics
☐ Other (specify):
Adequate support of peer counselors by providing the following (check all that apply):
☐ Timely access to WIC-designated breastfeeding experts for referrals outside peer counselors’ scope of practice
☐ Mentoring of newly trained peer counselors in early months of job
☐ Regular contact with supervisor
☐ Participation in clinic staff meetings as part of WIC team
☐ Opportunities to meet regularly with other peer counselors
☐ Other (specify):
Provision of training and continuing education of peer counselors (check all that apply):
☐ Standardized training using FNS-developed curriculum
☐ Ongoing training at regularly scheduled meetings
☐ Home Study
☐ Opportunities to “shadow” or observe lactation experts and other peer counselors
☐ Training/experience to become senior level peer counselors, WIC-Designated Breastfeeding Expert, etc. ☐ Other (specify):
ADDITIONAL DETAIL: Nutrition Services Appendix and/or Procedure Manual (citation):
Authorized WIC-Eligible Foods
Include a copy of the current State-authorized food list and the individual food package design for each category in the Appendix or cite Procedure Manual reference:
The State agency considers the following when making decisions about authorizing WIC-eligible foods other than WIC formulas:
☐ Federal regulatory requirements ☐ Nutritional value
☐ Participant acceptance ☐ Cost
☐ Statewide availability ☐ Participant/client request
☐ Healthcare provider request ☐ Other (specify):
The State agency utilizes additional State nutritional criteria for authorizing foods for the State WIC food list, in addition to the minimum Federal regulatory requirements.
☐ Yes ☐ No
If yes, describe actual values or criteria identified by the State. Enter “n/a” if not applicable. (i.e. artificial sweeteners, artificial color/flavor, low-sodium, etc.):
The State agency provides the maximum amount of all authorized foods allowed in accordance with the Federal WIC regulations at section 246.10 for each of the seven WIC Food Packages (I-VII).
Yes No
☐ ☐ Pregnant women/Partially (Mostly) Breastfeeding
☐ ☐ Fully Breastfeeding women
☐ ☐ Postpartum, non-breastfeeding women
☐ ☐ Infants 0-5 months
☐ ☐ Infants 6-11 months
☐ ☐ Children
WIC Formulas:
The State agency establishes policies regarding the issuance of primary contract, contract, and non-contract brand infant formula.
☐ Yes ☐ No
The State agency requires medical documentation for contract infant formula (other than the primary contract formula).
☐ Yes ☐ No
The State agency requires medical documentation for non-contract infant formula.
☐ Yes ☐ No
The State agency requires medical documentation for exempt infant formula/ WIC eligible nutritionals.
☐ Yes ☐ No
State agency authorizes local agencies to issue a non-contract brand infant formula that meets the requirements of Table 4 in 246.10(e)(12) without medical documentation in order to meet religious eating patterns:
☐ Yes ☐ No
The State agency coordinates with medical payors and other programs that provide or reimburse for exempt infant formulas and WIC-eligible nutritionals per Section 246.10(e)(3)(vi).
☐ Yes ☐ No
If yes, describe the State agency reimbursement and/or referral system used for this coordination? Include describing monitoring/tracking tools in place to ensure program integrity.
If no, has the State agency met the requirement to annually contact their State Medicaid counterparts regarding the payment of WIC-eligible exempt infant formulas and medical foods to mutual program participants per WIC Policy Memo #2015-7?
☐ Yes ☐ No
Please attach and provide the citation for any existing written agreement between the State agency and the State Medicaid office as well as local government agencies or private agencies in regards to payment of WIC- eligible exempt infant formulas and medical foods.
Rounding:
Does the State agency issue infant formula according to the specific rounding methodology per Section 246.10(h)(1)?
☐ Yes ☐ No
If answered NO, skip question 2
If the State agency implemented the rounding option for issuing infant formula, are there established written policies in place?
☐ Yes ☐ No
Does the State agency issue infant foods according to the specific rounding methodology per Section 246.10(h)(2)?
☐ Yes ☐ No
If the State agency implemented the rounding option for issuing infant foods, are there established written policies in place?
☐ Yes ☐ No
Is infant formula issued in the 1st month to partially breastfed infants?
☐ Yes ☐ No
State policies & materials reflect the definition of “supplemental foods” as defined 246.2
and in the Child Nutrition Act.
☐ Yes ☐ No
Does the State agency only allow issuance of reduced fat (2%) milk to children ≥ 24 months of age and women with certain conditions, including but not limited to, underweight and maternal weight loss during pregnancy, in accordance with Footnote 7 of Table 2 in 246.10(e)(10)?
☐ Yes ☐ No
Does the State agency allow issuance of fat-reduced milks to 1-year-old children for whom overweight or obesity is a concern, in accordance with Footnote 7 of Table 2 in 246.10(e)(10)?
☐ Yes ☐ No
ADDITIONAL DETAIL: Nutrition Services Appendix and/or Procedure Manual (citation):
Individual Nutrition Tailoring
The State agency allows individual nutrition tailoring of food packages only in accordance with 246.10(c).
☐ Yes ☐ No
The State agency provides a special individually tailored package for
☐ Homeless individuals and those with limited cooking facilities
☐ Residents of institutions
☐ Other (specify):
ADDITIONAL DETAIL: Please attach copies of all food packages that are tailored, Nutrition Services Appendix and/or Procedure Manual (citation):
The State agency develops written individual nutrition tailoring policies and supportive science-based nutrition rationale based on the following participant characteristics:
☐ Does not develop individual nutrition tailoring policies
☐ Develops based on (check all that apply):
☐ Nutrition risk/nutrition and breastfeeding assessment
☐ Participant preference
☐ Household condition
☐ Other (specify):
The State agency allows local agencies to develop specific individual tailoring guidelines.
☐ Yes ☐ No
If yes, check those of the following methods used by the State agency to review or approve local agency tailoring guidelines:
☐ Local agencies are required to submit individual tailoring guidelines for State approval
☐ Local agency individual tailoring guidelines are monitored annually during local agency reviews
☐ Agency reviews
☐ Other (specify):
ADDITIONAL DETAIL: Nutrition Services Appendix and/or Procedure Manual (citation):
Prescribing Packages
a. Individuals allowed to prescribe food packages:
|
Standard food package |
Individually-tailored food package |
CPA |
☐ |
☐ |
Other (specify by typing into the cells below): |
☐ |
☐ |
|
☐ |
☐ |
|
☐ |
☐ |
ADDITIONAL DETAIL: Provide a copy of the actual foods included in the homeless and institution packages in the Appendix or cite Procedure Manual. Attach copies of all food packages that are tailored. Nutrition Services Appendix and/or Procedure Manual (citation):
C. Staff Training
The State agency provides or sponsors the following training for WIC competent professional authorities:
|
Professionals |
Paraprofessionals (may or may not be CPAs in some SAs) |
||
|
Regularly |
As Needed |
Regularly |
As Needed |
General nutrition education methodology |
☐ |
☐ |
☐ |
☐ |
State certification policies/procedures |
☐ |
☐ |
☐ |
☐ |
Anthropometric measurements |
☐ |
☐ |
☐ |
☐ |
Blood work procedures |
☐ |
☐ |
☐ |
☐ |
Nutrition counseling techniques |
☐ |
☐ |
☐ |
☐ |
Breastfeeding promotion/support |
☐ |
☐ |
☐ |
☐ |
Dietary assessment techniques |
☐ |
☐ |
☐ |
☐ |
Prescribing & tailoring food packages |
☐ |
☐ |
☐ |
☐ |
Referral protocol |
☐ |
☐ |
☐ |
☐ |
Maternal, infant, and child nutrition |
☐ |
☐ |
☐ |
☐ |
Cultural competencies |
☐ |
☐ |
☐ |
☐ |
Customer service |
☐ |
☐ |
☐ |
☐ |
Immunization Screening/referral |
☐ |
☐ |
☐ |
☐ |
Care Plan Development |
☐ |
☐ |
☐ |
☐ |
VENA staff competency training |
☐ |
☐ |
☐ |
☐ |
Substance abuse prevention |
☐ |
☐ |
☐ |
☐ |
Other (specify by typing in cells below): |
|
|
|
|
|
☐ |
☐ |
☐ |
☐ |
|
☐ |
☐ |
☐ |
☐ |
ADDITIONAL DETAIL: Nutrition Services Appendix and/or Procedure Manual (citation):
(Please indicate) State Agency: for FY
This section, Management Information System (MIS), involves the planning, documentation, security/confidentiality and production of the necessary reports relating to program operations through the utilization of automated data processing services at the State and local level.
System Planning and Operation – 246.4(a)(11)(iv): Describe the procedures for planning, approving and monitoring Automated Data Processing (ADP) goods and services, and any interaction with other statewide ADP operations which may take place, including system costs for services and security.
Participant Characteristics Minimum Data Set (MDS) – 246.4(a)(11)(i): All State agencies currently collect all required Minimum Data Set items. Please confirm that your State agency will continue to do so. For the Supplemental Data Set (SDS), which varies by the capacity of State systems, please describe the data items which are reported electronically regarding participant characteristics and whether these items are currently being collected or if there are plans to collect them in the future.
WIC Systems Functional Requirements Checklist – 246.4(a)(8); (9); (11); (12); (13); (14); (15); and (18): Describe those functions which are currently incorporated into the MIS or which are planned to be incorporated in the future.
Page 1
The WIC State agency is included in the following comprehensive Statewide ADP plan(s):
☐ Title IVa (TANF)
☐Title V (MCH)
☐ Title XIX (Medicaid)
☐ Supplemental Nutrition Assistance Program (SNAP)
☐Other (specify):
☐ No
☐ Yes ☐ No
System Documentation
The State system is fully documented in accordance with (check all that apply):
☐ USDA/FNS Advance Planning Document Handbook No. 901 ☐ USDA/FNS ADP Security Guide
☐ Other (specify):
☐ A general design
☐ User's manual
☐ Method for updating documentation for system changes/modifications
☐ A detailed design
☐ Maintenance manual
Note: These documents are NOT required for FNS review or submission with the State plans, but should be available if requested.
Automated Data Processing Services
Indicate below whether the following ADP functions, if applicable, are performed by State agency staff or are contracted to an outside firm.
Function Performed Performed Contracted to Outside Firm
SA Staff LA Staff (specify company name):
Data entry ☐ ☐
Food instrument production ☐ ☐
Management reports/EBT ☐ ☐
Feasibility study ☐ ☐
ADP development ☐ ☐
ADP system hardware operation ☐ ☐
Custom software development ☐ ☐
Custom software maintenance ☐ ☐
Printing forms/FIs ☐ ☐
Backup computer facility ☐ ☐
Other
(specify): ☐ ☐
☐ ☐
☐ ☐
☐ ☐
☐ Equipment ☐ Services ☐ Software
☐ Yes ☐ No
☐ Yes ☐ No
The State agency acquires banking services through: ☐ Competitive bids among banks within the State
☐Competitive bids among in-State and out-of-State banks ☐ Use of State agency designated bank
☐ Other:
☐ Competitive bids among EBT processors
☐State agency IT services
☐ State hosted EBT services
☐ Other:
System Security/Data Confidentiality
To ensure that data files and computer programs are protected, the State agency ensures that (check all that apply):
☐ There is a separate organizational area/individual to control access to electronic storage media. ☐ Access to WIC Program data files is controlled through password access or similar control.
☐ Operational personnel are limited to only those jobs for which they are responsible.
☐ Passwords are protected.
☐ Passwords are changed periodically.
☐ The system access procedures are audited at least once a year. Please provide a copy of access procedures.
☐Procedures are implemented for timely removing passwords, ID's etc. when personnel leave.
☐ Biennial security reviews are performed by . Please provide a written summary of the most current biennial security review
☐ Periodic risk assessments are performed by
☐ Other (specify):
☐ Backup copies of files and program are stored off-site in a secure location. Please provide address of location.
☐ Backup copies are kept up-to-date.
☐ There is an agreement with another processing unit with compatible hardware to provide services in an emergency. Please provide copy of agreement.
☐ A contingency plan is in place in the event of service interruption. Please provide a copy of contingency plan.
☐ A recent test of the WIC system or mock disaster recovery operation has been conducted at the backup facility. Please provide a written summary of the conducted test.
☐ Other (specify):
Description of MIS changes that occurred in the past year:
Description of MIS changes planned for the upcoming year:
The Participant Characteristics (PC) Minimum Data Set (MFDS) contains data items which are reported to FNS electronically by State agencies in April in even numbered years on all or a State-representative sample of participants. The MDS has required data items which must be collected and reported. The Supplemental Data Set (SDS) is comprised of data items which State agencies have agreed are desirable to collect and report at the national level. Please check MDS or SDS data items the State agency currently collects in its Information Systems and those MDS or SDS data items it is planning to collect within the next two years.
State Agency IS Collects:
☐ State Agency ID. A unique number that permits linkage to the WIC State agency where the participant was certified.
☐ Local Agency ID. A unique number that permits linkage to the local agency where the participant was certified as eligible for WIC benefits.
☐ Service Site ID. A unique number that permits linkage to the service site where certified. Either local agency ID or service site ID may be reported according to the level the State Agency feels appropriate. At a minimum, State agencies must provide agency names and addresses for each ID provided on their files.
☐ Case ID. A unique record number for each participant which maintains individual privacy at the national level. (This may not be the case number used in the State agency's MIS for the individual.) Participant or Case IDs for each participant should continue to maintain individual privacy at the national level.
☐ Client Date of Birth. Month, day and year of participant's birth reported in MMDDYYYY format.
☐ Client Race/Ethnicity. The classification of the participant into one of the five (5) racial/ethnic categories: For race: American Indian or Alaskan Native; Asian; Black or African American; Native Hawaiian or Other Pacific Islander; and White. For ethnicity: Hispanic or Latino; Not Hispanic or Latino.
☐ Certification Category. The category---one of five (5) possible categories---under which a person is certified as eligible for WIC benefits: pregnant woman; breastfeeding woman; postpartum woman (not breastfeeding); infant (under 12 months); or child (12-59 months).
☐ Expected Date of Delivery or Weeks Gestation. For pregnant women, the projected date of delivery (MMDDYYYY format) or the number of weeks since the last menstrual period as determined at WIC Program certification.
☐ Date of Certification. The date the person was declared eligible for the most current WIC Program certification. Month, day, and year should be reported in MMDDYYYY format.
☐ Sex. For infants and children, male or female.
☐ Priority Level. Participant priority level for WIC Program certification.
☐ Participation in TANF, SNAP, Medicaid. The participant's reported participation in each of these programs at the time of the most recent WIC Program certification.
☐ Migrant Status. Participant migrant status according to the federal WIC Program definition of a migrant farm worker (currently counted in the FNS 798 report).
☐ Number in Family/Household or Economic Unit. The number of persons in the family/household or economic unit upon which WIC income eligibility was based. A self-declared number in the family/household or economic unit may be reported for participants whose income was not required to be determined as part of the WIC certification process. These participants include adjunctively income-eligible participants (due to TANF, SNAP, or Medicaid participation) and those participants deemed income eligible under optional procedures available to the State Agency in Federal WIC Regulations, Section 246.7(d)(2)(vi-viii) (means-tested programs identified by the State for automatic WIC Program income eligibility, income eligibility of Indian and in-stream migrant farmworker applicants).
☐ Family/Household or Economic Unit Income. For persons for whom income is determined during the certification process, the income amount that was determined to qualify them for the WIC Program during the most recent certification. For descriptive purposes only, for participants whose income was not required to be determined as part of the WIC Program certification process, the self-reported income at the time of certification. These participants include adjunctively income-eligible participants and those persons deemed eligible under optional procedures available to the State Agency in Federal WIC Regulations, Section 246.7(d)(2)(vi-viii).
Zero should not be used to indicate income values that are missing or not available. Zero should indicate only an actual value of zero.
☐ Nutrition Risk(s) Present at Certification. Up to 10 highest priority nutritional risks present at the WIC Program certification
☐ Hemoglobin or Hematocrit. That value for the measure of iron status that applies to the WIC Program certification. It is assumed that the measure was collected at the time of certification or within ninety (90) days of the certification date.
☐ Date of Blood Measurement. The date of the blood measurement that was used during the most recent WIC Program certification in MMDDYYYY format.
☐ Weight. The participant's weight measured according to the CDC nutrition surveillance program standards [nearest one-quarter (1/4) pound]. If weight is not collected in pounds and quarter pounds, weight may be reported in grams.
☐ Height. The participant's height (or length) measured according to the CDC nutrition surveillance program standards [nearest one-eighth (1/8) inch]. If height is not collected in inches and 1/8 inches, height may be reported in centimeters.
☐ Date of Height and Weight Measure. The date of the height and weight measures that were used during the most recent WIC Program certification in MMDDYYYY format.
☐ Currently Breastfed. Information is needed for all infant participants ages six through thirteen months, whether or not the infant is currently receiving breastmilk.
☐ Ever Breastfed. Information is needed for all infant participants ages six through thirteen months, whether or not the infant was ever breastfed.
☐ Length of Time Breastfed. For infants ages six through thirteen months, the number of weeks the infant received breastmilk.
☐ Date Breastfeeding Data Collected. For infants ages six through thirteen months, the date on which breastfeeding status was reported in MMDDYYYY format.
☐ Food Packages. The food package code(s) for the WIC food package or for all food instruments prescribed for the participant during the month.
Supplemental Data Set
State State
Agency IS Agency IS
Collects Plans to Collect
☐ ☐ Date of First WIC Certification. Date the participant was first certified for the WIC Program in MMDDYYYY format. For pregnant, breastfeeding and postpartum women, this applies to the current/most recent pregnancy and not to prior pregnancies.
☐ ☐ Educational Level. For pregnant, breastfeeding and postpartum women, the highest grade or year of school completed. For infants and children, the highest grade or year of school completed by mother or primary caretaker.
☐ ☐ Number in Family/Household on WIC. The number of people in the participant's family/household receiving WIC benefits.
☐ ☐ Date Previous Pregnancy Ended. For pregnant women, the date previous pregnancy ended in MMDDYYYY format.
☐ ☐ Total Number of Pregnancies. For pregnant women, the total number of times the woman has been pregnant, including this pregnancy, all live births and any pregnancies resulting in miscarriage, abortion or stillbirth.
☐ ☐ Total Number of Live Births. For pregnant women, the total number of babies born alive to this woman, including those who may have died shortly after birth.
☐ ☐ Pre-pregnancy Weight. For pregnant women only, the participant's weight immediately prior to pregnancy. Pre-pregnancy weight may be reported either in pounds and ounces or in grams.
☐ ☐ Participant's Weight Gain During Pregnancy. For breastfeeding and postpartum women, the participant's weight gain during pregnancy as taken immediately at or prior to delivery. Weight gain during pregnancy may be reported in either pounds and ounces or in grams.
☐ ☐ Birth Weight. For infants and children, the participant's weight at birth measured according to the CDC nutrition surveillance program standards (lbs/ounces). Birth weight may be reported in either pounds or ounces, or in grams.
☐ ☐ Birth Length. For infants and children, the participant's length measured according to the CDC nutrition surveillance program standards (1/8 inches). Birth length may be reported in either inches and eighth inches or in centimeters.
☐ ☐ Participation in the Food Distribution Program on Indian Reservations. The participant's reported participation in this program.
☐ ☐ 1. Calculates the date certification is due to expire.
☐ ☐ 2. Assigns the participant a nutritional risk code and assigns a priority level. (CPA confirms the code is correct.)
☐ ☐ 2a. Assigns one risk code.
☐ ☐ 2b. Assigns up to 3 risk codes.
☐ ☐ 2c. Assigns up to 6 risk codes.
☐ ☐ 2d. Assigns more than 6 risk codes.
☐ ☐ 3. Calculates the applicant's household income and flags individuals whose income exceeds program standards.
☐ ☐ 3a. Converts incremental income (weekly, monthly) to an annual figure.
☐ ☐ 4. Associates family members.
☐ ☐ 5. Statewide data is maintained to facilitate families transferring within the State.
☐ ☐ 6. Transfers certification data to the central computer facility electronically either in real time or batch mode.
☐ ☐ 7. Captures or documents the nutrition education provided each participant as well as the topics covered.
☐ ☐ 8. Uses table-driven food packages.
☐ ☐ 8a. Uses standard pre-defined food packages. ☐ ☐ 8b. Enables easy food package tailoring.
☐ ☐ 8c. Performs edits to prevent over-issuance during food package creation.
☐ ☐ 9. Enables food instruments to be issued when the participant is present for pick- up, i.e., on-demand.
☐ ☐ 10. Captures or documents the name of the programs to which the participant was referred.
☐ ☐ 11. Performs food instrument reconciliation.
☐ ☐ 12. Produces standard Dual Participation Report.
☐ ☐ 13. Produces standard Integrity Profile (TIP) Report.
☐ ☐ 14. Produces standard Rebate Billing Report.
☐ ☐ 15. Produces standard Participation Report.
☐ ☐ 16. Produces Participant Characteristics Datasets.
☐ ☐ 17. Captures basic transaction data by vendor.
State Agency System Planned
Automated Core Function/Capabilities
☐ ☐ 18. Flags high-risk vendors through peer group analysis of redemption data.
☐ ☐ 18a. Identifies vendors with high average food instrument redemptions.
☐ ☐ 18b. Identifies vendors with a narrow variation in redemptions.
☐ ☐ 19. Assigns a maximum value for each food instrument type (paper) or each item/UPC
(EBT).
☐ ☐ 19a. Receives data about the amount a vendor requests for each food instrument (paper) or item/UPC (EBT) redeemed.
☐ ☐ 20. Captures source of income.
☐ ☐ 21. Has the capability of annualizing household income occurring at more than one frequency.
☐ ☐ 22. Performs automated dietary assessment.
☐ ☐ 23. Has automated growth charts.
☐ ☐ 24. Has point of certification data entry, i.e., a personal computer at each “station” within the clinic.
☐ ☐ 25. Allows for ad hoc reporting
(Please indicate) State Agency: for FY
Organization and management involves the procedures for the documentation of staff time at the State level devoted to the various WIC functions, the evaluation and selection of local agencies, the documentation of local agency staffing standards and data, as well as disaster planning.
State Staffing – 246.3(e), 246.4(a)(4) and (24): describe the information relating to State level staff requirements and utilization as it relates to WIC Program functions and how the State agency will provide a drug-free workplace.
Evaluation and Selection of Local Agencies - 246.4(a)(5)(i) and (7) and 246.5: describe the procedures and criteria utilized in the selection and authorization of local agencies.
Local Agency Staffing - 246.4(a)(4): describe the State staffing standards which apply to the selection of local agency staff and the means used by the State agency to track and analyze local level staffing data.
Disaster Planning - describe the disaster plans to be implemented in the event of a disaster.
State Level Staff
Record below the current total full-time equivalent staff (FTEs) available for each position listed or attach equivalent information in the section’s Appendix noted here:
Position FTE WIC FTE WIC Total FTE
Director
Nutritionist
Vendor Specialist
Program Specialist
Financial Specialist
Breastfeeding Coordinator
(MIS/EBT) Specialist
Intern
Other (specify):
Other (specify):
Other (specify):
The State agency has a WIC organizational chart showing all positions, titles, and staff names.
☐ Yes ☐ No
If yes, please attach and/or reference the location of the State agency's WIC organization chart:
If available, please attach and/or reference the location of the overall organizational chart that identifies the WIC Program's relationship within the State Health Department or Indian Tribal Organization:
The State agency has updated position descriptions for each of the above positions.
☐ Yes ☐ No
If yes, please attach and/or reference the location of the position descriptions:
ADDITIONAL DETAIL: Organization & Management Appendix and/or Procedure Manual (citation):
Estimate below the average percent of State staff time devoted to fulfilling the following functions:
Function Percent of Total Staff Time
Certification, including nutrition risk determination
Breastfeeding training/promotion and support
Nutrition education
Monitoring of local agencies
Fiscal reporting
Food delivery system management
Vendor management, including vendor training
Staff training and continuing education
(MIS/EBT) system development and maintenance
Civil Rights
Coordination with and referrals to other assistance
programs and social service agencies
Other (specify):
Total
ADDITIONAL DETAIL: Organization & Management Appendix and/or Procedure Manual (citation):
Drug-Free Workplace
The State agency has a plan that will enable them to achieve a drug-free workplace.
☐ Yes ☐ No
Please attach and/or reference the location of a description of the State agency's plans to provide and maintain a drug-free workplace in Appendix of this section.
ADDITIONAL DETAIL: Organization & Management Appendix and/or Procedure Manual (citation):
☐ Does not apply because the State agency has only one location (PROCEED TO NEXT SECTION)
Local Agencies Authorized
Number of local agencies authorized to provide WIC services last year
Number of local agencies planned to provide WIC services this year
ADDITIONAL DETAIL: Organization & Management Appendix and/or Procedure Manual (citation):
The State agency accepts applications from potential local agencies:
☐ Annually ☐ Biennially
☐ On an on-going basis ☐ Other (specify)
ADDITIONAL DETAIL: Organization & Management Appendix and/or Procedure Manual (citation):
Existing local agencies must reapply and compete with new applicant agencies for authorization:
☐ Annually ☐ Biennially
☐Not applicable ☐ Other (specify)
ADDITIONAL DETAIL: Organization & Management Appendix and/or Procedure Manual (citation):
Selection Criteria
The State agency uses the following criteria in selecting local agencies in new service areas and/or in reviewing applications from existing service areas:
New Service Areas |
Existing Service Areas |
|
☐ |
☐ |
Coordination with other health care providers |
☐ |
☐ |
Projected cost of operations/ability to operate with available funds |
☐ |
☐ |
Location/participant accessibility |
☐ |
☐ |
Financial integrity/solvency |
☐ |
☐ |
Relative need in the area |
☐ |
☐ |
Range and quality of services |
☐ |
☐ |
History of performance in other programs |
☐ |
☐ |
Ability to serve projected caseload |
☐ |
☐ |
Non-smoking facility |
☐ |
☐ |
Americans with Disabilities Act (ADA) compliance |
|
|
Other (specify by typing into the cells below): |
☐ |
☐ |
|
☐ |
☐ |
|
The State agency conducts studies (provide date of most recent study: Click here to enter a date.) of the cost-effectiveness of local agency operations that examine:
☐ Location and distribution of local agencies in proportion to participants/potential eligibles
☐ Clinic procedures to optimize participant access/service (Patient Flow Analysis, etc.)
☐ Staff-to-participant ratios and related staffing analyses
☐ Comparative analyses of local agency/clinic costs
☐ Other
ADDITIONAL DETAIL: Organization & Management Appendix and/or Procedure Manual (citation):
The State agency enters into a formal written agreement or contract with each local agency.
☐ Yes (state duration): ☐ No
ADDITIONAL DETAIL: Organization & Management Appendix and/or Procedure Manual (citation):
The State agency has established statewide fair hearing procedures for local agency appeals.
☐ Yes, attach local agency fair hearing procedures or specify the location in the Procedure Manual and
reference below:
☐ No
☐ Not Applicable
ADDITIONAL DETAIL: Organization & Management Appendix and/or Procedure Manual (citation):
The State agency maintains a listing of clinic sites that includes the following information. If available, please attach and/or reference the location of the listing:
☐ Location
☐ Type of site (e.g., hospital, health department, community action program)
☐ Service area
☐ Hours of operation
☐ Days of operation
☐ Health services provided on-site
☐ Social services provided on-site
☐ Participation
☐ Other (specify):
ADDITIONAL DETAIL: Organization & Management Appendix and/or Procedure Manual (citation):
☐ Does not apply because the State agency has only one location. (PROCEED TO NEXT SECTION)
Staffing Standards
The State agency prescribes local agency staffing standards that include:
☐ Credentials
☐ Staff levels
☐ Staff-to-participant ratio standards
☐ Time spent on WIC functions
☐ Other (specify):
☐ Functions of CPAs
☐ Paraprofessional requirements
☐ Separation of duties to ensure no conflicts of interest
☐ Other (specify):
☐ Not applicable
The State agency has a plan for ensuring that local agency credentials are in line with the Nutrition Services Standards.
☐ Yes ☐ No
The State agency maintains copies of local agency CPA position descriptions, classified in terms of Nutrition Services Standards, i.e., federal requirements, recommended criteria, best practices.
☐ Yes ☐ No
Local agencies follow staffing standards established by unions or local governmental authorities.
☐ Yes ☐ No
If yes, how many of the total local agencies are currently authorized by unions or local governmental authorities?
ADDITIONAL DETAIL: Organization & Management Appendix and/or Procedure Manual (citation):
Local Level Staffing Data
The State agency gathers and analyzes data to determine staff-to-participant ratios (check all that apply):
☐ For each clinic/local agency ☐ By function
☐ At regular intervals ☐ Program management
☐ Monthly ☐ Food delivery
☐ Quarterly ☐ Certification
☐ Annually ☐ Nutrition education
☐ Breastfeeding promotion and support
☐ Other (specify):
☐ Other (specify):
Results of analyses are reported back to local agencies.
☐ No
☐ Yes, in a single report comparing all local agencies
☐ Yes, in a local agency-specific report (no comparative data)
ADDITIONAL DETAIL: Organization & Management Appendix and/or Procedure Manual (citation):
Local Agency Breastfeeding Staffing Requirement
Number of local agencies with a designated a staff person to coordinate breastfeeding promotion and support activities.
The State agency maintains approved copies of local agency Breastfeeding Coordinator and Peer Counselor position descriptions as outlined in the WIC Breastfeeding Support.
☐ Yes ☐ No
Number of local agencies with breastfeeding peer counselors.
State agency has developed a WIC disaster plan.
☐ Yes ☐ No
The WIC disaster plan is part of a broader Health Department or other State agency disaster plan.
The State agency shares the disaster plan with its local agencies and clinics?
☐ Yes ☐ No
The Disaster Plan addresses:
☐ Procedures to access the extent of a ☐ MIS alternate procedures
disaster and report findings ☐ Emergency authorization of vendors
☐ Access to program records ☐ Back up computer systems
☐ Certification and food issuance sites ☐ Back up filing systems
and procedures
☐ Food package adjustments ☐ Staffing arrangements
☐ Food delivery systems to include ☐ Use of mobile equipment, clinics
electronic benefits transfer (EBT)
☐ Management Information System (MIS) Recovery
☐ Publication notification of Variances in program operations
☐ Other (describe):
The State agency requires local agencies/clinics to have individual disaster plans.
☐ Yes ☐ No
If yes, such plans are reviewed for compliance and consistency with the State agency disaster plan.
☐ Yes ☐ No
The State agency has a designated staff person to coordinate disaster planning.
☐ Yes ☐ No
(Please indicate) State Agency: for FY
NSA expenditures involve the process of allocating, documenting and monitoring the distribution of administrative funds to local agencies, including the monitoring of nutrition education costs, and State and local agency direct/indirect costs.
Funds Allocation-246.4(a)(13): describe the policies and procedures used to allocate administrative funds to local agencies, including start-up funds, and conversion of food funds to NSA funds.
Local Agency Budgets/Expenditure Plans-246.4(a)(2): describe the policies and procedures for preparing and submitting local agency budgets and expenditure plans and the services that are entirely supported by WIC Program funds.
State and Local Agency Access to Funds-246.4(a)(13): describe the procedures and method(s) of distribution/ reimbursement of NSA funds to local agencies.
Reporting and Reviewing of State and Local Agency Expenditures-246.4(a)(11)(iv); (12); and (13): describe the policies and procedures used to report, monitor, and review State and local agencies’ expenditures, including the documentation of staff time, local agency report forms, on-site reviews of local agencies’ NSA expenditures, and in-kind contributions.
Nutrition Education Costs-246.4(a)(9)and 246.14(c)(1): describe the plans and procedures used to meet the nutrition education expenditure requirements, including monitoring activities, local agency reports, and assurances that the special nutrition education needs of migrant farmworkers and their families, Indians, and homeless persons are met.
Indirect Costs-246.4(a)(12): describe the policies and procedures used to document and monitor indirect cost rates and services at the State and local level.
The State agency has established and provided written procedures to local agencies describing the process for allocation of NSA funds among local agencies.
☐ Yes ☐ No ☐ Not applicable, State agency does not have separate local agencies. (Proceed to A. 2. Conversion of Food Funds to
NSA Funds)
☐ Task force/committee of selected local agencies
☐ Comment on proposals made available to all local agencies
☐Other (describe):
☐ A negotiated budget ☐ Flat cost per participant Statewide
☐ Formula (variable) ☐ Other method (describe):
☐ Staffing needs
☐ Number of participants
☐ Population density
☐ Cost-containment initiatives
☐ Availability of administrative support from other sources
☐ Other (specify):
The State agency methodology for funds allocations to local agencies includes a mechanism for reallocation.
☐ Yes
☐ Monthly ☐ Quarterly ☐ Semiannually ☐ Other (specify):
☐ No
ADDITIONAL DETAIL: NSA Expenditures Appendix and/or Procedure Manual (citation):
Conversion of Food Funds to NSA Funds
The State agency converts food funds to NSA funds:
☐ Based on a plan submitted to FNS to reduce average food costs per participant and to increase participation above the FNS-projected level for the State agency.
☐ The State agency achieves, through acceptable measures, increases in participation in excess of the FNS-project level for the State agency.
☐ Describe measures used to increase participation:
ADDITIONAL DETAIL: NSA Expenditures Appendix and/or Procedure Manual (citation):
The State’s Fiscal Year runs from to
ADDITIONAL DETAIL: NSA Expenditures Appendix and/or Procedure Manual (citation):
Local Agency Budgets/Expenditure Plans
☐ Not applicable, State agency does not have separate local agencies.
(Proceed to C. State and Local Agency Access to Funds.)
☐ Yes ☐ No
If yes, the State agency requires that local agency budgets include the same cost categories as those used for State-level budget preparation.
☐ Yes ☐ No
☐ Line items
☐ Accounting
☐ ADP services
☐ Breastfeeding aids
☐ Capital expenditures
☐Clinic/lab services
☐Communications
☐ Employee salaries
☐ Employee fringe benefits
☐Lease or rental of space
☐ Functions
☐ General administration/ program management
☐ Food delivery
☐ Certification
☐ Nutrition education
☐ Maintenance and repair
☐ Materials and supplies
☐ Memberships, subscriptions, and professional activities
☐ Printing and reproduction
☐ Training and education
☐ Transportation
☐ Travel
☐ Other (specify):
☐ Breastfeeding promotion/support (e.g., breastfeeding aids
☐ Client services
☐ Other (specify):
The State agency has an established formal process for local agencies to follow when requesting amendments or modifications to their budgets.
☐ Yes ☐ No
☐ Uses local agency budgets or prior year expenditures
☐Reports under an ongoing system to collect this data
☐ Extracts or consolidates data reported under other State or local agency systems to group costs under the federal line items and functions
☐ Other (describe):
(State WIC administrative budgets are not submitted to FNS, but are used by State agencies as a management tool and may be reviewed by FNS.)
ADDITIONAL DETAIL: SA/LA Spending Plan Appendix and/or Procedure Manual (citation):
The State Agency manages its NSA Grant on a/an:
☐ Cash basis ☐ Accrual basis
☐ Other (specify):
ADDITIONAL DETAIL: NSA Expenditures Appendix and/or Procedure Manual (citation):
Reimbursement/Provision of Funds to Local Agencies
The State agency provides local agencies with funds in advance.
☐ Yes (state conditions):
☐ No
☐ Not Applicable (Proceed to next section.)
☐ Monthly ☐ Quarterly
☐ At or below the level of its approved budget line item
☐ Supported by appropriate documentation (e.g., check or receipt)
☐ A reasonable and necessary expense for WIC
☐ Other (specify):
If an expenditure exceeds the budget provided for that particular line item, the State agency requires the local agency to (check all that apply):
☐ Submit a supplemental request
☐ Provide a justification for exceeding the budget line item
☐ Make an offsetting adjustment to another line item in its budget
☐Request approval of a budget modification
☐ Other (explain):
☐ Electronic funds transfer ☐ State treasury check/warrant
☐ Other (specify):
ADDITIONAL DETAIL: NSA Expenditures Appendix and/or Procedure Manual (citation):
Documentation of Staff Time
How does the State agency determine the percentage of staff time devoted to WIC tasks to document allowable staff costs under the WIC Program (check all that apply):
At SA At LA
☐ ☐ 100 percent reporting
☐ ☐ Random moment sampling
☐ ☐ Periodic time studies:
☐ ☐ 1 week/month
☐ ☐ 1 month/quarter
☐ ☐ Other (specify):
The State agency last evaluated its time documentation protocol on (specify date). .
If available, please attach a copy of the protocol to this section or cite Procedure Manual reference.
ADDITIONAL DETAIL: NSA Expenditures Appendix and/or Procedure Manual (citation):
Please indicate below the services that are entirely supported by WIC funds:
☐ Anthropometric measurements
☐ Nutrition counseling/education
☐ Breastfeeding promotion/support
☐ Immunization status assessments
☐ Referrals to health and/or social services
☐ Hematological assessments
☐ Other (specify):
ADDITIONAL DETAIL: SA/LA Spending Plan Appendix and/or Procedure Manual (citation):
Local Agency Report Forms
The State agency specifies standard forms and/or procedures for local agencies to use in reporting monthly local-level expenditures.
☐ Yes ☐ No ☐ Not Applicable (Proceed to next section)
☐ Not applicable
☐ Line items
☐ Accounting ☐ Maintenance and repair
☐ ADP services ☐ Materials and supplies
☐ Breastfeeding aids ☐ Memberships, subscriptions, and professional activities
☐ Capital expenditures ☐ Printing and reproduction
☐ Clinic/lab services ☐ Training and education
☐ Communications ☐ Transportation
☐ Employee salaries ☐ Travel
☐ Employee fringe benefits ☐ Other (specify):
☐ Lease or rental of space ☐ Breastfeeding promotion/support (e.g., breastfeeding aids)
☐ Functions ☐ Client services
☐ General administration/ ☐ Other (specify):
Program management
☐ Food Delivery
☐ Certification
☐ Nutrition education
☐ Other (specify):
ADDITIONAL DETAIL: NSA Expenditures Appendix and/or Procedure Manual (citation):
On-Site Review of Local Agencies' Administrative Expenditures
The State agency conducts on-site reviews of local agency administrative expenditures:
☐ Annually ☐ Every two years ☐ Every three years
☐ Other (specify):
The review is conducted by:
☐ WIC State agency staff
☐ State Department of Health fiscal or audit staff
☐ CPA or audit firm
☐ Other (specify):
☐ Yes ☐ No
If yes, the standard review guide includes the following procedures (check all that apply):
☐ Verification of at least one monthly billing/claim/expenditure report against source
☐ Documents
☐ Tracking written approval of procurements
☐ Requesting records of ordering, receipt, billing, and payment
☐ Determination that costs were necessary, reasonable and appropriate
☐ Determination that costs were properly allocated among WIC and other programs
☐ Determination that personnel costs charged to WIC were appropriate
☐ Determination that local agencies' indirect costs were appropriately charged
☐ Other (specify):
The State agency notifies local agencies of findings and establishes claims for unallowable costs, as appropriate.
☐ Yes ☐ No
ADDITIONAL DETAIL: NSA Expenditures Appendix and/or Procedure Manual (citation):
The State agency requires local agencies to document the sources and values of in-kind contributions.
☐ Yes ☐ No
ADDITIONAL DETAIL: NSA Expenditures Appendix and/or Procedure Manual (citation):
The State agency documents that it meets its nutrition education and breastfeeding promotion expenditure requirements per 7 CFR 246.14(c)(1) via:
☐ Activity reports ☐ Time studies ☐ Itemizing expenditures
☐ Other (specify):
ADDITIONAL DETAIL: NSA Expenditures Appendix and/or Procedure Manual (citation):
The State agency monitors expenditures for the following activities related to breastfeeding promotion and support at the State and/or local level (check all that apply):
At SA At LA
Breastfeeding promotion coordinator’s salary ☐ ☐
Written educational materials ☐ ☐
Participant education/counseling ☐ ☐
Staff training ☐ ☐
Breastfeeding promotion activities ☐ ☐
Direct support costs ☐ ☐
Breastfeeding aids and equipment (e.g., breast ☐ ☐
pumps purchased with NSA funds)
Other ☐ ☐
(If other, specify):
ADDITIONAL DETAIL: NSA Expenditures Appendix and/or Procedure Manual (citation):
In the event that the State agency uses funds from other sources in meeting minimum expenditure requirements for nutrition education (NE) and breastfeeding promotion and support (BFPS), please provide below the source of these funds, the amount, and the method the State agency will use to document the use of these NE and BFPS funds. (Federal WIC food funds used to purchase/rent breast pumps, and expenditures from breastfeeding peer counseling funds, cannot be counted toward the nutrition education and breastfeeding expenditure requirement.)
☐ Does not apply. (Proceed to E. 4. Local agencies report nutrition education and breastfeeding promotion and support costs.)
Source Amount
☐ Activity reports ☐ Time studies ☐ Itemizing expenditures
☐ Other (specify):
ADDITIONAL DETAIL: NSA Expenditures Appendix and/or Procedure Manual (citation):
☐ When they report routine NSA costs
☐ Through a different system (specify):
ADDITIONAL DETAIL: NSA Expenditures Appendix and/or Procedure Manual (citation):
Indirect Cost Rate and Services
Please list below indirect cost/cost allocation agreements in which the State agency is included:
The State agency's indirect cost rate(s) is (%) and is based on:
☐ Salaries ☐ Direct costs for administration ☐Both
☐ Other (specify):
Please cite the effective date of the State agency’s current negotiated agreement and/or cost allocation plan for indirect costs: .
The State agency receives the following types of services under the indirect cost rate agreement(s):
☐ Budgeting/accounting ☐ Personnel/payroll
☐ ADP ☐ Space usage/maintenance
☐ Communication/phone/mail ☐ Central supply
☐ Legal services ☐ Procurement/contracting
☐ Printing/publication ☐ Audit services
☐ Equipment usage/maintenance ☐ Other (specify):
☐ Yes ☐ No ☐ Not Applicable
ADDITIONAL DETAIL: NSA Expenditures Appendix and/or Procedure Manual (citation):
2. Review of Indirect Cost Documentation
The State agency and local agencies ensure that services received and paid for through indirect costs benefit WIC and are not also charged directly to WIC by comparing direct charges by line item to a listing of services paid by funds collected through the application of the indirect cost rate:
☐ Done for State agency level indirect costs (frequency):
☐ Done for local agency level indirect costs (frequency):
☐ Not done at either level.
State and local agency WIC management have access to and review the following documents as applicable to ensure that indirect cost services are not also charged directly to WIC (check all that apply):
At SA At LA
Indirect cost agreements/plans ☐ ☐
The accounting mechanism used to ensure the ☐ ☐
propriety of indirect cost charges
A copy of the cost allocation plan ☐ ☐
A list of all services paid from indirect costs ☐ ☐
Other documentation related to the establishment ☐ ☐
and charging of indirect costs
Not applicable ☐ ☐
When the State agency reviews the local agencies' indirect cost rate agreements, the review includes (check all that apply):
☐ Required submission of indirect cost agreement by the local agency to the State agency
☐ Assessment of how the rate or method is applied (correct time period, percentage, and base)
☐ Verification that the State agency had previously approved the local agency to negotiate such an agreement
☐Post-review or audit to ensure the rate was applied correctly
☐ Other documentation related to the establishment and charging of indirect costs (list):
☐ Not applicable
ADDITIONAL DETAIL: NSA Expenditures Appendix and/or Procedure Manual (citation):
(Please indicate) State Agency: for FY:
Food funds management involves monitoring cost containment measures and procedures related to infant formula and other authorized food items, the monitoring and management of State agency funding sources, and the accurate reporting of participation figures.
Cost Containment Measures - 246.4(a)(14)(xi): describe the policies and procedures used to implement cost containment measures as they relate to infant formula contracts, their approval and the processing of infant formula and/ or other rebates, and food package cost containment practices.
Funds Monitoring/798 Reporting - 246.4(a)(2); (a)(12); and (a)(14): describe the State agency's funding sources, how food obligations are calculated to allow for inflation, rebate cash management, and monthly closeout monitoring activities.
Participation Reporting - 246.4(a)(11): describe the methods used to accurately document and monitor participation at the State and local level, and methods for monitoring changes in participation by priority.
`
The State agency seeks FNS approval related to infant formula cost containment measures (check one):
☐ For a waiver of the requirement for a single-supplier competitive system. State agency must complete a cost comparison projecting food cost savings in the single-supplier competitive system based on the lowest monthly net price or highest monthly rebate [as required in Section 246.16a(d)(2)(i) through (d)(2)(iii) and savings under an alternative cost containment system, Section 246.16a(d)(2)(B)]
☐ To issue an infant formula bid solicitation that evaluates bids by highest rebate. A State agency must demonstrate to FNS’ satisfaction that the weighted average retail prices for different brands of infant formula in the State vary by 5% or less [as required in Section 246.16a(c)(5)(iii)].
☐ Not applicable
Please attach in the Appendix supporting documentation for requests for FNS approval.
ADDITIONAL DETAIL: Food Funds Management Appendix and/or Procedure Manual (citation):
Cost Containment Contracts for Infant Formula
The State agency acquires infant formula through (check all that apply):
☐ Home food delivery system
☐ Direct distribution food delivery system
☐ Retail food delivery system
☐ Other (specify):
The State agency has a rebate contract/agreement for infant formula.
☐ Yes ☐ No
If yes, attach contract If no, check which applies:
in Appendix ☐ Granted waiver
☐ ITO with participation under 1,000 as of April (Proceed to question A.4.
Cost Containment for Other Foods)
For a single-supplier system or multi-supplier: Date contract/agreement:
Manufacturer |
Original Term Began |
Original Term Expires |
Extension Options |
|
|
|
|
|
|
|
|
|
|
|
|
*If contract expires during the fiscal year see sections 3 and 4
Current fiscal year rebates and current net price per unit paid (note the price should reflect current prices rather than original contract prices and rebate amounts):
My rebate price sheet is available and attached as Appendix
(Proceed to A. 3. Infant Formula Issuance.)
Primary Contract Infant Formula |
||||
Product/Unit Size |
Manufacturer |
Rebate/Unit |
Net price/Unit |
% WS Discount |
Liquid Concentrate |
|
|
|
|
Milk-Based |
|
|
|
|
Soy-based* |
|
|
|
|
Powder |
|
|
|
|
Milk-based |
|
|
|
|
Soy-based* |
|
|
|
|
Ready to Feed |
|
|
|
|
Milk-Based |
|
|
|
|
Soy-based* |
|
|
|
|
Exempt Formula (If applicable) |
|
|
|
|
*If uncoupled/separate contracts for milk- and soy-based infant formula.
Infant Formula Issuance.
Does the State agency issue the Primary Contract Infant Formula as the first choice of issuance (by physical form), with all other infant formulas issued as an alternative? (Section 246.16a(c)(8) & 246.10(e)(1)(iii))
☐ Yes ☐ No
The percent of infants receiving each type of formula is estimated at:
Contract
Non-contract
Exempt infant formula
Non-exempt infant formula
ADDITIONAL DETAIL: Food Funds Management Appendix and/or Procedure Manual (citation):
Cost Containment for Other Foods
Rebates are also obtained on other WIC foods.
☐ Yes (specify foods and attach contract in Appendix):
☐ No
The State agency intends to pursue rebates on other authorized foods.
☐ Yes (specify):
☐ No
To contain food costs, the State agency has limited authorized foods/container sizes/types, etc.
☐ Yes (If yes, note such limitations on the following table)
☐ No
ADDITIONAL DETAIL: Food Funds Management Appendix and/or Procedure Manual (citation):
|
Specific brands are designated/ Disallowed |
Only certain container sizes are allowed |
Allowable types are limited |
Other |
Exempt formula for women, infants & children |
|
|
|
|
Infant cereal |
|
|
|
|
Infant Fruit/Veg/Meat |
|
|
|
|
Whole fresh fluid milk |
|
|
|
|
Lowfat fresh fluid milk |
|
|
|
|
Skim fresh fluid milk |
|
|
|
|
Fresh milks (e.g., Lactaid, cultured buttermilk, goat milk) (specify): |
|
|
|
|
Shelf-stable milk (e.g., evaporated milk, UHT, whole/ low fat/nonfat dry milk) |
|
|
|
|
Cheese |
|
|
|
|
Yogurt |
|
|
|
|
Soy-based beverage |
|
|
|
|
Tofu |
|
|
|
|
Fresh eggs |
|
|
|
|
Dried egg mix |
|
|
|
|
Hot cereal |
|
|
|
|
Cold cereal |
|
|
|
|
Single strength fruit/vegetable juice |
|
|
|
|
Concentrated fruit/vegetable juice |
|
|
|
|
Whole wheat bread |
|
|
|
|
Other whole grains |
|
|
|
|
Peanut butter |
|
|
|
|
Dry beans/peas |
|
|
|
|
Canned Fish |
|
|
|
|
Canned beans/peas |
|
|
|
|
The State agency has procedures to assure that the requirements are met regarding the nonprocurement of food in bulk lots, supplies, equipment and other services from entities that have been debarred or suspended.
☐ Yes ☐ No
ADDITIONAL DETAIL: Food Funds Management Appendix and/or Procedure Manual (citation):
Food Cost Obligations
The State agency calculates food obligations based on the following data (check one):
☐ Number of expected participants and average food cost per participant
☐ Number of expected participants by category (e.g., pregnant woman, infant, etc.) and average food cost per participant category
☐ Number of expected redemptions by food instrument type and cash-value voucher type and average value per food instrument type and cash-value voucher type
☐ Other (specify):
The State agency estimates the impact of inflation on food costs through the use of the following inflation escalators:
☐ Inflation factor used in Federal funding formula
☐ State-generated estimates of inflation based on State market basket of foods
☐ Best guess by food item based on economic reports or other sources
☐ Other (specify):
The State agency ADP system automatically produces a monthly obligation amount
☐ Yes
☐ No, data are pulled from various sources and an estimated amount is calculated manually or with a PC spreadsheet
☐ Other (specify):
The State agency system (in-house or contracted) provides the following data on food instrument and cash- value voucher redemptions at specific (daily, weekly, monthly, as needed) frequencies (check all that apply and provide frequency):
Frequency Data
☐ Food instruments and cash-value vouchers paid for issue month
☐ Food instruments and cash-value vouchers outstanding for issue month
☐ Food instruments and cash-value vouchers that have expired
☐ Food instruments and cash-value vouchers that are void/unclaimed
ADDITIONAL DETAIL: Food Funds Management Appendix and/or Procedure Manual (citation):
Rebate Cash Management
The State agency has a billing system in place that ensures rebate invoices for all authorized food, including infant formula, under competitive bidding, provide a reasonable estimate, or actual count of the number of units purchased by participants during WIC transactions (Section 246.16a(k)).
☐ Actual count of units purchased
☐ Estimate of units purchased (attach methodology)
☐ Other (describe):
The State agency uses a food instrument that enables it to identify the type and brand of infant formula redeemed.
☐ Yes, for all formula types, brands, and physical forms
☐ Yes, for exempt infant formulas
☐ No
The invoice to the formula manufacturer is issued by:
☐ The WIC unit
☐ The State agency fiscal unit
☐Other (specify):
Monthly invoices are submitted with supporting data.
☐ Yes ☐ No
ADDITIONAL DETAIL: Food Funds Management Appendix and/or Procedure Manual (citation):
Closeout of Report Month Outlays
The State agency allows the food vendor (and farmer if any) the following number of days to submit food instruments and cash-value vouchers for payment (provide the number of days):
Days from the participant's first valid date
The State agency is generally able to close out a report month completely within:
☐ 90 days
☐ 120 days
☐ Other (specify number of days):
ADDITIONAL DETAIL: Food Funds Management Appendix and/or Procedure Manual (citation):
Indicate the method used to reimburse vendors (and farmers if any) for redeemed food instruments and cash- value vouchers or other services and specify the entity responsible for making payment:
State WIC State FM Other (Specify)
☐ ☐ By check directly to vendor or farmer
☐ ☐ By check directly to vendor’s or farmer’s bank
☐ ☐ By electronic transfer to vendor's or farmer’s bank
☐ ☐ Other (specify):
ADDITIONAL DETAIL: Food Funds Management Appendix and/or Procedure Manual (citation):
Participation Counting
The State agency counts an enrollee who received at least one food instrument/food package (or who received no food instrument/food package, but was either a fully-breastfed infant of a participating breastfeeding woman or a woman partially breastfeeding a participating 6 to 12 month old infant) as a participant during:
☐ The calendar month
☐ The computer system cycle month
☐ Other (specify):
The State agency receives participation counts from:
☐ The State agency computer system based on the number of persons issued food or food instruments (manual and automated food instruments), the number of fully-breastfed infants who receive no food or food instruments, but are breastfed by participating breastfeeding women, and the number of women who receive no food or food instruments, but are partially breastfeeding a participating 6 to 12 month old infant.
☐ Counts reported from local agencies based on issuance records
☐ Other (specify):
If State funds are present, the State agency differentiates between Federal-supported and State-supported participants by:
☐ Special code on food instrument
☐ Special areas of State designated as State-supported areas
☐ Pro rata allocation based on proportion of Federal to State funds spent
☐ Other (specify):
When local agencies are chronically late in furnishing food instrument and/or certification data needed for participation counts, the State agency:
☐ Sends warnings
☐ Applies financial sanctions
☐ Requires manual reporting
☐ Other (specify):
ADDITIONAL DETAIL: Food Funds Management Appendix and/or Procedure Manual (citation):
Participation by Priority
Priority level is a critical data field in the State agency's computer system.
☐ Yes ☐ No
The State computer system automatically assigns priority level based on the enrollee's nutritional risk condition.
☐ Yes ☐ No
The State agency’s computer system revises the priority level determination when a participant changes category (e.g., infant becomes child and receives a child’s food package).
☐ Yes ☐ No
The State agency has an “unknown” priority category for VOC transfers where priority is unknown.
☐ Yes ☐ No
Participation by Local Agency
The State agency's computer system supports its requirement to report participation data by local agency to measure breastfeeding performance.
☐ Yes ☐ No
ADDITIONAL DETAIL: Food Funds Management Appendix and/or Procedure Manual (citation):
(Please indicate) State Agency: for FY
Caseload management involves identifying the target population and special populations within it, implementing strategies to enroll the potential population and utilizing caseload effectively to reach the desired populations. Describe the procedures in place to implement these strategies.
A. No-Show Rate - 246.4(a)(11)(i): describe the procedures used by the State agency to monitor potential and current participants’ utilization of program services.
Allocation of Caseload - 246.4(a)(5)(i) and (13): describe how the State agency assigns and manages local agency caseload allocations.
Caseload Monitoring - 246.4(a)(5)(i): describe the information and procedures used by the State agency to monitor caseload.
Benefit Targeting - 246.4(a)(5)(i); (6), (7), (19), (20), (21), and (22): describe the plans and procedures for ensuring that WIC benefits reach the highest risk participants and persons in special need such as migrants, homeless, and institutionalized persons; pregnant women in their early months of pregnancy; and applicants who are employed or who reside in rural areas.
Outreach Policies and Procedures - 246.4(a)(5)(i-)(ii); (6), (7), (19), and (20): describe the types of outreach materials used, where these materials are directed, special agreements with other service organizations and how special populations are addressed. Also, provide data on unserved and underserved areas.
Waiting List Management - 246.4(a)(11)(i): describe the policies and procedures used for processing applicants.
The State agency has specific policies and procedures to ensure follow-up of no-shows for (check all that apply):
☐ Initial certification for any potential participant
☐ Subsequent certifications for high-risk participants
☐ Subsequent certification for any current participant
☐ Food instrument/cash value voucher pick-up
☐ Food instrument/cash value voucher/cash value benefit non-redemption
☐ State agency has no specific policies and procedures for no-show follow-up
☐ At the time of initial contact, the local agency obtains the pregnant woman's mailing and/or email address and telephone number
☐ If the applicant misses her first certification appointment, an attempt is made to contact her by:
☐ Telephone
☐ Text
☐ If contact is established, she is offered one additional certification appointment.
☐ If she cannot be reached, the local agency follows-up with a request for the applicant to contact the local agency for a second appointment by sending her a:
☐ Postcard
☐ Letter
☐ Text
☐ A second appointment is provided upon request from the applicant.
The State agency has (check all that apply):
☐ Standards defining acceptable no-show rates
☐ Policies and procedures designed to assist local agencies to improve no-show rates; Please attach
☐ Sanctions that may be applied to local agencies that have chronically unacceptable no-show rates; Please attach
☐ Provides regular feedback to local agencies concerning no-show rates
☐ Reports to address appropriate follow-up of no-shows
☐ No specific policies or procedures concerning local agency no-show rates
ADDITIONAL DETAIL: Caseload Management Appendix and/or Procedure Manual (citation):
As a matter of standard procedure, the State agency monitors no-show rates through (check all that apply):
☐ State agency does not monitor local agency no-show rates
☐ Local agency reviews
☐ Automated reports
☐ Local agency reports on no-show rates
☐ Other (specify):
☐ DOES NOT APPLY (EXPLAIN WHY AND PROCEED TO NEXT SECTION)
The State agency considers the following factors in its initial allocation of caseload to local agencies (check all that apply):
☐ Percent of target population served by local agency's service area
☐ Analysis of no-show, void, non-redemption rates by local agencies
☐ Participation by priority and category
☐ Special population pockets
☐ Waiting lists
☐ Staffing/ability of local agencies to serve caseload
☐ Prior year caseload
☐ Food package costs per person
☐ Special projects
☐ Other (identify):
The State agency has a written procedure for allocation of caseload to local agencies.
☐ Yes ☐ No
If no, what guidelines does the State agency use for caseload allocation? (Describe in Caseload Management Appendix)
ADDITIONAL DETAIL: Caseload Management Appendix and/or Procedure Manual (citation):
The State agency has a procedure in place to ensure that current/prior year caseload levels are maintained.
☐ Yes ☐ No
If No, explain why not:
☐ The State agency does not reallocate caseload mid-year
☐ Same basis as for initial allocation of caseload
☐ Local agency participation levels
☐ Local agency high priority participation
☐ Waiting lists
☐ Successful special projects
☐ Other (specify):
The State agency has written procedures for local agencies to follow in situations of overspending:
☐ Yes ☐ No
ADDITIONAL DETAIL: Caseload Management Appendix and/or Procedure Manual (citation):
The State agency's caseload monitoring process includes the review of the following data (check all that apply):
☐ Participation levels/rates ☐ High-risk participant levels/rates
☐ No-show rates ☐ Food costs per participant
☐ Food costs by area ☐ Other (specify):
The State agency uses the following methods to monitor the above areas (check all that apply):
☐ Manual reports submitted by local agencies
☐ MIS-generated reports (If utilized please attach a description of each report and how they are used)
☐ On-site reviews
☐ Other (specify):
Local agency caseload utilization, by any method, is reviewed by the State agency at least:
☐ Monthly
☐ Quarterly
☐ Other (specify):
☐ Not applicable
Development and Monitoring of State Agency Targeting Plans
The State agency has a plan to inform the following classes of individuals of the availability of program benefits (check all that apply):
☐ Pregnant women, with special emphasis on pregnant women in the early months of pregnancy
☐ High-risk postpartum women (e.g., teenagers)
☐ Parents/Caregivers of Priority I & II infants
☐ Migrants
☐ Homeless persons/families
☐ Incarcerated pregnant women
☐ Institutionalized persons
☐ Other (specify):
The local agency or State agency, when the SA has no separate local agencies, contacts the following organizations to provide WIC Program information to eligible infants and children:
☐ Foster care agencies ☐ Protective service agencies
☐ Child welfare authorities ☐ Other (specify):
☐ Yes ☐ No
☐ Yes ☐ No ☐ Not Applicable
☐ Requiring local agencies to submit plans for State agency approval
☐Review plans during local agency reviews
☐ Other (specify):
☐ Automated reports developed by State agency
☐ Manual reports submitted by local agencies ☐ Local agency reviews
☐ Other (specify):
Outreach Policies, Procedures and Materials
To administer outreach activities, the State agency (check all that apply):
☐ Issues a standard set of outreach materials for use by all local agencies
☐ Requires local agencies to develop outreach plans
☐ Reviews outreach plans developed by local agencies
☐ Reviews and approves any outreach materials developed by local agencies
☐ Utilizes broadcast media for outreach activities
☐ Other (specify):
State Agency Local Agency
☐ ☐ Newspapers
☐ ☐ Radio
☐ ☐ Posters
☐ ☐ Letters
☐ ☐ Brochures/pamphlets
☐ ☐ Television
☐ ☐ Social Media (Twitter, Facebook, etc.)
☐ ☐ Other (specify):
☐Other (specify):
☐ English
☐ Spanish
☐ Vietnamese
☐ Tribal Language(s)
☐ Other (specify):
☐ Health and medical organizations
☐ Hospitals and clinics
☐ Welfare and unemployment offices or social service agencies
☐ Migrant farmworker organizations
☐ Indian and tribal organizations
☐ Homeless organizations
☐ Faith-based and community organizations in low-income areas
☐ Shelters for victims of domestic violence
☐ Other (specify):
When an ITO State agency operates as both the State and local agency "All" should be checked.
Accessibility to Special Populations
The State agency requires [all, some, none] local agencies to implement the following to meet the special needs of employed applicants/participants.
All Some None
☐ ☐ ☐ Early morning/evening clinic hours by appointment
☐ ☐ ☐ Early morning/evening clinic hours, walk-in basis
☐ ☐ ☐ Weekend hours, by appointment
☐ ☐ ☐ Weekend hours, walk-in basis
☐ ☐ ☐ Priority appointment scheduling during regular clinic operations
☐ ☐ ☐ Food instrument/cash value voucher mailing procedures specifically designed for
working participants
☐ ☐ ☐ Expedited clinic procedures for working participants
☐ ☐ ☐ Evening/weekend nutrition education classes
☐ ☐ ☐ Other (specify):
All Some None
☐ ☐ ☐ Special clinic hours to accommodate travel time to clinic sites
☐ ☐ ☐ Use of mobile clinics to rural areas
☐ ☐ ☐ Food instrument/cash value voucher mailing procedures specifically designed for rural
participants
☐ ☐ ☐ Special appointment/scheduling procedures for rural participants who do not have access
to public transportation
☐ ☐ ☐ Special food instrument/cash value voucher issuance cycles for rural participants
(check one): ☐ 2 months issuance, ☐ 3 months issuance
☐ ☐ ☐ Other (specify):
All Some None
☐ ☐ ☐ Formal coordination with rural/migrant health centers
☐ ☐ ☐ Special outreach activities aimed at migrants
☐ ☐ ☐ Special clinic hours/locations to service migrant populations
☐ ☐ ☐ Expedited appointment procedures to accommodate migrant families
☐ ☐ ☐ Special food instrument/cash value voucher issuance cycles for migrant families
(check one): ☐ 2 months issuance; ☐ 3 months issuance
☐ ☐ ☐ Other (specify):
☐ Yes (If yes, please identify the State agencies ☐ No
with whom formal agreements exist):
All Some None
☐ ☐ ☐ Provide homeless applicants with a list of shelters/facilities that fulfill WIC Program
requirements
☐ ☐ ☐ Undertake regular and ongoing outreach to homeless individuals
☐ ☐ ☐ Routinely monitors facilities serving homeless participants to ensure WIC foods are not
subsumed into commercial food service
☐ ☐ ☐ Implement formal agreement with other service providers to facilitate referrals of homeless
families/individuals
☐ ☐ ☐ Secure a written statement from the facility attesting to compliance with the requisite
conditions for WIC services in a homeless facility
☐ ☐ ☐ Establish, to the extent practicable, plans to ensure that the three conditions in
246.7(n)(1)(i) regarding homeless facilities are met
☐ ☐ ☐ Other (specify):
Unserved Geographical Areas
State agency's definition of an unserved geographic area (specify):
Please list unserved geographic areas or attach a list to appendix: ☐ No current unserved areas (check if applicable)
ADDITIONAL DETAIL: Caseload Management Appendix and/or Procedure Manual (citation):
Underserved Geographic Areas
State agency's definition of an underserved geographic area and a discussion of how the State prioritizes areas in descending order (specify):
☐ No current underserved areas (check if applicable)
The State agency has a list on file of served and/or unserved geographic areas including the number of potential eligibles, the priority level currently being served, and participation.
☐ Yes ☐ No
☐ Yes ☐ No, an update list is provided in the Appendix ☐ N/A, State agency has no local agencies
☐ Inform nonparticipating local agencies of the Program and the availability of technical assistance in implementation
☐ Encourage potential local agencies to implement or expand operations in the neediest one-third of all areas unserved or partially served
☐ The State agency does not have local agencies and does not plan to have local agencies. Explanation of how underserved and/or partially served areas are addressed is below.
The State agency has specific policies/procedures for the establishment and maintenance of waiting lists, which are used by all local agencies.
☐ Yes ☐ No
Waiting list procedures are uniform throughout the State.
☐ Yes ☐ No, but State agency approves all exceptions
☐ No, local variation allowed without State agency approval
☐ Yes ☐ No ☐ No. for the current Fiscal Year, the State agency does not have a waiting list.
☐ No subprioritization permitted ☐ Income
☐ Nutrition risk ☐ Age
☐ Point system
☐ Special target populations (specify):
☐ Other (specify):
☐ Yes
☐ No, only categorical eligibility established
☐ No, only categorical and income eligibility established
☐ No, local agency variation
☐ Other (specify):
☐ Manually
☐ Automated system linked to State agency's central system
☐ Automated system, stand alone at some/all local agencies
☐ Yes ☐ No
☐ Name
☐Address
☐ Phone number(s)
☐ Date placed on waiting list
☐Category
☐ Priority
☐ Nutritional risk
☐ Income eligibility status
☐ Method of application
☐ Date applicant notified of placement on the waiting list
☐ Other (specify):
☐ Yes ☐ No
(Please indicate) State Agency: for FY
The review of certification, eligibility and coordination of services involves the process of determining and documenting participant eligibility (income eligibility as well as nutritional risk determination, standards and criteria), and the coordination of certification activities with other health services.
Eligibility Determination and Documentation - 246.7(c)(1); 2(1); 246.7(d)(1); (2)(v)(B)): describe the policies and procedures for determining and documenting eligibility including the application process, residency requirements, identity requirements, documented physical presence or valid exception; proof of categorical eligibility, income limits, income eligibility documentation, determination of special populations and a definition of and policy toward the economic unit.
Nutrition Risk Determination, Documentation, and Priority Assignment - 246.4(a)(11)(i): describe the policies and procedures for determining and documenting nutritional risk and priority assignments. Include a copy of the nutritional risk criteria the State agency plans to use with the appropriate documentation.
Health Care Agreements, Referrals, and Coordination - 246.4(a)(6); (7); (8) and (19): describe the procedures for coordinating agreements and services with other health care providers at the State and local agency level including procedures to ensure that benefits are provided to persons with special needs.
Processing Standards - 246.4(a)(11)(i); 246.7(f)(2): describe the State agency's processing procedures to ensure that the required standards and timelines are met.
Certification Periods - 246.4(a)(11)(i); 246.7(g): describe the policies and procedures used to establish certification periods for participants and the autonomy (if applicable) granted to local agencies in determining eligibility time periods.
Transfer of Certification - 246.4(a)(6); (11)(i); and 246.7(k): : describe the State agency's procedures for the transfer of certification and VOC cards ensuring that vital participant and program information is included.
Dual Participation, Participant Rights and Responsibilities, Fair Hearing Procedures, and Sanction System - 246.4(a)(11)(i)); (16); (17) and (18); 246.7(h); 246.7(i)(10); 246.7(j); 246.7(I): describe the procedures used to detect and prevent dual participation at the State and local level, the procedures for ensuring participants are notified of their rights and responsibilities, and the procedures regarding participant fair hearings and sanction system .
Page 1
Application Process
The State agency requires all local agencies to use a standardized application process for all persons applying for the WIC Program
☐ Yes ☐ No
The State agency shares ☐ State wide or ☐ at local agency (check one), a common income application or certification form with (check all that apply):
☐ No other benefit programs ☐ Medicaid
☐TANF ☐ SNAP
☐ MCH ☐ Other reduced price health care program(s)
☐Other (specify):
ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (citation):
Residency, Identity and Physical Presence Requirements
The State agency requires documentation of residency
☐ Yes
☐ Signed statement that documentation of residency information is not available and why (e.g. homeless, theft, fire) ☐No (Specify why, e.g., ITOs and Alaska natives who are exempt from this requirement):
The State agency has special residency policies and procedures for how the following special categories should be treated (check all that apply):
☐ Homeless applicants ☐ Institutionalized applicants
☐ Migrants ☐ Indian Tribal Organizations
☐ None ☐ Other (specify):
The State agency requires proof of identity from each applicant at certification
☐ Yes
☐ No (If no, why not?):
The State agency has reciprocal agreements concerning residency with other States
☐ Yes; list states:
☐ No
Describe any reciprocal agreements:
The State agency requires physical presence of the applicant or a valid exception to be documented:
☐ Yes except for the following condition(s):
☐ Applicant or parent/caretaker is an individual with disabilities which prevent him/her from being physically present at the WIC clinic (e.g., medical equipment, bed-rest, or serious illness exacerbated by coming in to clinic).
☐ Applicant is an infant or child receiving documented ongoing health care from any health care provider, including the local agency; being physically present would pose an unreasonable barrier; and the infant or child was present at his/her initial WIC certification.
☐ Applicant is an infant under 8 weeks of age who cannot be present at the time of certification (for a reason determined appropriate by the local agency) and for whom all necessary certification information is provided.
☐ Applicant is an infant or child who was present at his/her initial certification; was present at certification within the one-year period of the most recent determination; and is under the care of one or more working parent, more primary working caretakers whose status presents a barrier to bringing the infant or child in to the WIC clinic.
The State agency uses a shortened (up to 30 days) certification for applicants that have one qualifying nutrition risk and are able to present at least two of the three required documents (identification, residency, and income) during a certification appointment.
☐ Yes ☐ No
The State agency requires applicants to submit proof of categorical eligibility for (check all that apply):
☐ All pregnant women ☐ Pregnant women not visibly pregnant
☐ Postpartum women ☐ Children
☐ Infants ☐ Other (specify):
Income Limits for Eligibility
The State agency gross income limit for income eligibility is 185% of the federal income guidelines
☐ Yes, with no local agency exceptions
☐ Yes, with local agency variation
☐ No, with no local agency exceptions
(specify State maximum percent of poverty: %)
☐ No, with local agency variation
(specify State maximum percent of poverty: %)
ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (citation):
The State agency implements income eligibility guidelines concurrently with Medicaid
☐ Yes ☐ No
ADDITIONAL DETAIL: Please attach a copy of the income guidelines in the Appendix or the appropriate citation in the Procedure Manual. Certification and Eligibility Appendix and/or Procedure Manual (citation):
The State agency requires documentation of an applicant's, or certain family members' eligibility to receive benefits in the following means-tested programs that confer adjunctive income eligibility for WIC, as set forth in 246.7(d)(2)(vi):
Poverty Level
☐ TANF (specify State "percent of poverty") %
☐ SNAP %
☐ Medicaid (specify State "percent of poverty" for each) %
☐ Pregnant women and infants %
☐ Children %
☐ Other categorically eligible women %
The State agency uses documented eligibility for/participation in other means-tested programs to establish automatic WIC income eligibility (check all that apply and the poverty levels used for each):
Poverty Level
☐ Free or Reduced-Price School %
☐ Lunch SSI %
☐ Other State-provided health insurance (specify State
"percent of poverty" maximum %) %
☐ FDPIR %
☐ Other (specify): %
Individuals are required to document that they or a family member are certified as eligible to receive TANF, Medicaid, or SNAP benefits or, under the State option, certified as eligible to receive benefits in State- administered programs by providing:
☐ Program ID card (only if it includes dates of eligibility) or notice of current eligibility
☐ Documentation of participation in State-administered programs (and such programs require documentation of income and have income guidelines at or below WIC's income guideline of 185% of poverty).
(Program[s]: )
ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (citation):
Income Eligibility Documentation
For WIC applicants whose income eligibility is not based on adjunctive or automatic income eligibility in another means-tested program, the State requires (check all that apply):
☐ Documentation of income information
☐ Signed statement that documentation of income information is not available and why
☐ Notation in the participant record if the applicant declares no income and why
☐ Other (specify):
Exceptions to income documentation are made for the following:
☐ The necessary information is not available
☐ The income documentation presents an unreasonable barrier to participation as determined by the State agency
☐ Those applicants with no income
☐ Those applicants who work for cash
☐ Other (specify):
If the applicant does not supply the necessary documentation at the certification appointment, local agencies are generally instructed to do the following:
☐ Certification process is terminated and no food instruments/cash-value vouchers are provided; appointment rescheduled
☐ Temporary certification (not to exceed 30 days) is completed and food instruments are provided. However, if applicant does not provide documentation within 30 days, certification expires and a new eligibility determination must be conducted.
☐ Other (specify):
The State agency requires ☐ State-wide, or at ☐ local agency (check one), the verification of applicant income information, if determined necessary
☐ No
☐ Yes (check all sources required, as appropriate):
☐ Employer
☐ Public assistance offices
☐ State employment offices (wage match, unemployment)
☐ Social Security Administration
☐ School districts/offices
☐ Collateral contacts
☐ Other (specify):
The State agency has specific policies that define actions to be taken for mid-certification changes in participant income circumstances.
☐ Yes; Please specify ☐ No
The State agency allows documentation of alternate income procedures for Indian or Indian Health Service (IHS) operated local agencies.
☐ Yes ☐ No ☐ Not Applicable
The State agency has specific policy that addresses income from benefits provided by a State-administered programs.
☐ Yes ☐ No
The State agency has specific policy to ensure that certain types of income, such as combat pay or FSSA payments for households that include service members, are excluded from consideration in the WIC income eligibility determination, as provided by law and regulation.
☐ Yes ☐ No
ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (citation):
In determining an applicant’s income eligibility for WIC, the State agency excludes basic allowance for housing received by military services personnel residing off military installations and in privatized housing, whether on- or off-base.
☐ Yes, State-wide ☐ No
ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (citation):
The State agency excludes cost-of-living allowances for military personnel on duty outside of the contiguous 48 States (OCONUS COLA) from applicant income for purposes of WIC income determination
☐ Yes, State-wide ☐ No
In determining an applicant’s income eligibility for WIC, the State agency excludes payments given to deployed military service members. These payments are in accordance with Chapter 5 of Title 37 of the U.S.C.
☐ Yes, State-wide ☐ No
ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (citation):
In determining an applicant’s income eligibility for WIC, the State agency calculates multiple income sources received by an applicant’s household at different frequencies in accordance with WIC Policy Memo 2011-7, and compares the sum to the established WIC IEGs.
☐ Yes, State-wide ☐ No
ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (citation):
The State agency defines the economic unit in accordance with WIC Policy Memo 2013-3.
☐ Yes ☐ No (if no, why not):
Provide the definition of an economic unit used by the State agency in the Appendix or the appropriate citation in the Procedure Manual.
ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (citation):
The State agency has specific policies or lists examples concerning the determination of the economic unit for (check all that apply):
☐ Foster children
☐ Divorced/legally separated parents; step parents
☐ Absentee spouse (military hardship tours, etc.)
☐ Cohabitation
☐ Institutionalized applicants (including incarcerated applicants)
☐ Homeless applicants
☐ Minors ("emancipated" minors)
☐ Separate economic units under the same roof
☐ Striker/unemployed
☐ Students away at school
☐ Self-employed applicants
☐ Other (specify):
ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (citation):
Mid-Certification Disqualification
The State agency ensures that local agencies are required to stipulate that an individual is not automatically disqualified mid-certification due to the fact that she/he no longer participates in one or more of the Programs for which they were originally determined adjunctively/automatically income eligible.
☐ Yes ☐ No
WIC regulations specify that when income eligibility is reassessed mid-certification, State/local agencies are required to reevaluate the programs for which the individual could be determined adjunctively/automatically income eligible. If the individual cannot qualify based on eligibility for one of these programs, eligibility must be determined based on WIC income guidelines and disqualification made only after all of these options are exhausted. The State ensures its policy and procedures comply with this requirement:
☐ Yes ☐ No
Nutrition Risk Determination and Documentation
Professionals authorized by the State agency as Competent Professional Authorities (CPAs) to determine nutritional risk include (check all that apply):
Can certify for:
Qualification Priorities I-III All Priorities
RD or Master’s Level Nutritionist ☐ ☐
Bachelor's Level Nutritionist ☐ ☐
Physician ☐ ☐
Physician Assistant ☐ ☐
Registered Nurse ☐ ☐
Licensed Practical Nurse ☐ ☐
Home Economist ☐ ☐
Paraprofessional ☐ ☐
Other (Specify):
Other (Specify):
The State agency authorizes local agencies to (check all that apply):
☐ Conduct ☐ Anthropometric and ☐ Hematological measurements
☐ Use medical referral data for ☐ Anthropometric and ☐ Hematological measurements
☐Conduct measurements only when medical referral data are unavailable
The State agency uses only FNS-approved nutrition risk criteria, as referenced in Policy Memorandum #2011-5, WIC Nutrition Risk Criteria, and transmittal memorandum (dated June 13, 2018) that list the revised risk criteria requiring implementation by 10/1/2019, published on the FNS PartnerWeb, to document nutrition risk.
☐ Yes ☐ No
Please append a copy of the revised nutrition risk criteria in its entirety to this State Plan.
The State agency modifies nutrition risk criteria such that criteria definitions are more restrictive than nationally established definitions.
☐ Yes (list criteria):
☐ No
Hematological risk determination:
The State agency requires (check one of the following):
☐ Bloodwork data to be collected at the time of certification (Statewide).
☐ Bloodwork data to be collected within 90 days of certification, so long as the participant is determined to have at least one qualifying nutritional risk at the time of certification (Statewide), and the State has implemented procedures to ensure receipt of data.
The State agency ensures that hematological assessment data are current and reflective of participant status, to include a bloodwork periodicity schedule that conforms to the requirements as described in 246.7(e)(1)(ii)(B).
☐ Yes ☐ No
The State agency allows local agencies the option of obtaining bloodwork on children ages 2-5 annually if prior certification results were normal.
☐ Yes ☐ No
Anthropometric risk determination:
The State agency allows (check one):
☐ Anthropometric data for certification to be no older than 60 days (Statewide)
☐ A shorter (less than 60 days) limit on age of anthropometric data for certification
Nutrition assessment:
Local agencies are required to perform a complete nutrition assessment (as described in the Value Enhanced Nutrition Assessment [VENA] Guidance) for all participants.
☐ Yes ☐ No (explain):
Local agencies are required to perform a mid-certification nutrition assessment (as described in the Guidance for Providing Quality Nutrition Services during Extended Certification Periods) for all participants with and extended certification period.
☐ Yes ☐ No Applicable: (The State agency does not utilize the extended certification option for any participant category)
The State agency policy requires that nutrition assessment intake information be collected on a State agency mandated form or Management Information System (MIS).
☐ Yes ☐ No
If yes, attach mandated forms (or MIS screen shots) or specify location in the procedure manual and reference below.
If no, the State agency assures quality of nutrition assessment by:
☐ Requiring local agencies to submit forms for approval
☐ Annually monitoring the locally developed forms during local agency review
☐ Other (specify):
Dietary assessment is based on professionally recognized guidelines (e.g., Dietary Guidelines for Americans, My Plate Food Guide, American Academy of Pediatrics)
☐ Yes (specify):
☐ No (explain):
ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (cite):
Documentation
The State agency requires documentation in the applicant’s case file for all nutrition risk criteria used to establish WIC eligibility (check one) (as described in FNS Policy Memorandum #2008-4, WIC Nutrition Services Documentation):
☐ Yes, supported by a written "exceptions" policy (e.g., policies to direct clinic staff in situations in which documentation is unavailable)
☐ Yes, with CPA discretion when to waive documentation requirement (no written policy)
☐ No (explain):
As a matter of policy, the State agency requires the documentation of nutritional risk criteria on a participant's certification form in the following manner:
☐ All identified risk criteria are recorded
☐ A set number of criteria is recorded (maximum number is 10 criteria)
☐ Local agency personnel decide how many and which criteria are recorded
☐ Other (specify):
Priority Assignments
Participants certified for regression
☐ Remain in the same priority in which they were previously assigned
☐ Are assigned to Priority VII, regardless of their initial priority at first certification
☐ Other (specify):
The State agency requires verification for all nutrition risk criteria that require a physician’s diagnosis.
☐ Yes ☐ No
ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (cite):
Participants may be certified for regression (check all that apply):
☐ A single six-month period
☐ One time following a certification period
☐ No policy, local agency discretion
High risk postpartum women are assigned to the following priority:
☐ Priority III
☐ Priority IV
☐ Priority V
☐ Priority VI
Participants certified solely due to homelessness/migrancy are assigned to the following priority:
IV V VI VII
Pregnant Women ☐ ☐
Breastfeeding Women ☐ ☐
Postpartum Women ☐ ☐
Infants ☐ ☐
Children ☐ ☐
Attach a copy of any nutrition risk criteria that will be added, modified or deleted during the coming fiscal year. For each criterion, indicate:
-Applicable participant category
-Applicable priority level(s)
- Whether a physician’s diagnosis is required
-SA code number which conforms to list of codes provided by USDA for Participant Characteristics data
collection
ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (citation):
State Agency Referral Agreements and Coordination of Services
The State agency has written formal agreements that permit the sharing of participant information with the following programs/providers (indicate whether information is shared manually (M) or through ADP (A) by placing either an M or A in front of the appropriate service):
SNAP Rural/migrant health centers
TANF Hospitals
Medicaid Childhood immunization
SSI Immunization registries
EPSDT Well-child programs
MCH programs Child protective services
Children with special health Private physicians
care needs program(s)
Family planning IHS facilities
Other (specify):
Formal agreements for coordination of services include:
☐ Responsibilities of each party
☐ Assurance that information is used only for program eligibility and/or outreach
☐ Assurance that information will not be shared with a third party
The State agency requires local agencies to coordinate services with, and/or develop referral systems for, the following (check all that apply):
☐ SNAP ☐ Children with special health care needs
☐TANF ☐Schools
☐ SSI ☐ EFNEP
☐ Medicaid ☐ Other food assistance program (TEFAP, FDPIR, CSFP, etc.)
☐ CHIP ☐ Breastfeeding promotion
☐ IHS facilities ☐Child protective services
☐ MCH (clinics/facilities) ☐Head Start
☐ EPSDT ☐ Early Head Start
☐ Family planning ☐ Healthy Star
☐ Prenatal care ☐ Substance abuse program
☐ Postnatal care ☐ Child abuse counseling
☐ Immunization ☐ Foster care agencies
☐ Dental services ☐ Homeless facilities
☐ Private physicians ☐ Mental health services
☐ Hospitals ☐ Rural/migrant health centers
☐ Well-child programs
☐ Other (specify):
ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (citation):
Local Agency Referral Procedures
The State agency ensures that local agencies make available to all adults applying or re-applying for the WIC Program for themselves or on behalf of others the following types of information:
☐ State Medicaid Program, including presumptive eligibility determinations, where available
☐Child support services
☐ SNAP
☐ Substance abuse counseling/treatment programs
☐ TANF, including presumptive eligibility determinations, where available
☐Other State-funded medical insurance programs (specify):
☐ Other nutrition services (specify):
☐ EPSDT Program
☐ Children’s Health Insurance programs (s)
☐ Other (specify):
The referral methods used by local agencies to other health and social service programs include (check all that apply and indicate the primary method of referral using the checkbox on the right):
Primary
☐ State agency-developed referral forms ☐
☐ Local agency-developed referral form ☐
☐Telephone call to referring agency ☐
☐ Verbal referral to participants ☐
☐ Automated client/participant information exchange ☐
☐ Written literature on referral programs ☐
☐ Follow-ups by staff to monitor ☐
☐ Maintain a list of local resources for drug and other harmful substance abuse ☐
☐Counseling ☐
☐ Other (specify): ☐
Methods used by other health and social service programs to refer clients to the WIC Program include (check all that apply and indicate the primary method of referral using the checkbox on the right)):
Primary
☐ WIC Program referral form ☐
☐ Health/social program referral form ☐
☐ Telephone call ☐
☐ Verbal referral ☐
☐ Automated client/participant information exchange ☐
☐ Written literature on the WIC Program ☐
☐ Other (specify):
The State agency has a system in place to monitor the extent to which WIC participants are using other health or social services (check all that apply):
☐ Yes (check): ☐ Medicaid ☐ TANF ☐ MCH ☐ SNAP
☐ Yes, other (specify):
☐ No
The State agency requires local agencies to monitor referrals to determine the extent of health or social services utilization in addition to State monitoring systems.
☐Yes ☐ No
ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (citation):
In order to facilitate referrals to the Medicaid Program, the State agency provides each local agency a chart showing the maximum income limits, according to family size, applicable to pregnant women, infants, and children up to age 5 under the Medicaid Program.
☐ Yes ☐ No
The State agency assures that each local agency operating the Program within a hospital, and/or that has a cooperative arrangement with a hospital, advises potentially eligible individuals that receive inpatient or outpatient prenatal, maternity, or postpartum services, or that accompany a child under the age of 5 who receives well-child services, of the availability of program services.
☐ Yes ☐No
The State agency ensures that, to the extent possible, local agencies provide an opportunity for individuals who may be eligible to be certified within the hospital for participation in WIC.
☐ Yes ☐ No
The State agency ensures that when WIC is at maximum caseload, local agencies make referrals to:
☐ Food banks
☐ Food pantries
☐ Soup kitchens or other emergency meal providers
☐ SNAP
☐ The Emergency Food Assistance Program
☐ Food Distribution Program on Indian Reservations
☐ Other (specify):
The State agency ensures that when WIC is at maximum caseload, local agencies notify the State agency of any waiting lists established.
☐ Yes ☐ No
The State agency ensures that when WIC is at maximum caseload, the State agency notifies FNS of any waiting lists established.
☐ Yes ☐ No
The State agency ensures that when the WIC participant's family has immediate needs for food beyond what WIC might provide, local agencies make referrals to:
☐ Food banks
☐ Food pantries
☐ Soup kitchens
☐ SNAP
☐ The Emergency Food Assistance Program
☐ Food Distribution Program on Indian Reservations
☐ Other (specify):
Immunization Screening and Referral
The State agency assures that each local agency is meeting the requirements of WIC Policy Memorandum
#2001-7, August 30, 2001: Immunization Screening and Referral, as follows:
☐ Screening children under the age of two using a documented immunization history:
☐Using the minimum screening protocol; or
☐Using a more comprehensive means, (specify):
☐ Using another program or entity to screen and refer WIC children using a documented immunization history; (specify): ; or
☐ Implementing the minimum screening protocol is unnecessary because immunization coverage rates of WIC children by 24 months are 90% or greater; or
☐ The State agency has been unable to formalize a coordination agreement with the State Immunization Program. Provide explanation of extenuating circumstances:
The State agency's policy and procedure manual has been updated to include the above immunization screening and referral protocol.
☐ Yes ☐ No
Notification Standards
The State agency defines special nutritional risk applicants who are to be notified of their eligibility within 10 days of the date of the first request (at the local agency) for program benefits as the following (check all that apply):
☐ Pregnant women eligible as Priority I ☐High-risk infants (optional)
☐ Migrant farmworkers/family members ☐Homeless (optional)
☐ Optional; please specify:
The State agency requires local agencies to follow special policies and procedures to ensure timely certification of:
☐ Rural applicants ☐ Employed applicants
☐ No special policies/procedures
The State agency's policy allows it to authorize an extension of the notification period up to 15 days for special nutritional risk applicants when local agencies provide a written request with justification.
☐ Yes ☐ No
Policies and procedures are in place to assure all other applicants are notified of eligibility within 20 days of first request (at the local agency) for program benefits.
☐ Yes ☐ No
ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (citation):
Processing Standards
Processing standards begin when the applicant (check all that apply):
☐ Telephones the local agencies to request benefits
☐ Visits the local agency in person
☐ Makes a written request for benefits
The State agency requires the local agency to have a monitoring system in place to ensure processing standards are being met for all categories of applicants.
☐ Yes ☐ No
ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (citation):
Certification Period Standards
(i) The State agency authorizes local agencies to certify infants under six months of age for a period extending up to the first birthday provided the quality and accessibility of health care services are not diminished (known as “extended certification”):
☐ Yes, at all local agencies
☐ Yes, at selected local agencies
☐ No
The State agency authorizes local agencies to certify children for a period of up to one year provided that
participant children receive required health and nutrition services:
☐ Yes, at all local agencies
☐ Yes, at selected local agencies
☐ No
The State agency authorizes local agencies to certify breastfeeding mothers for a period extending up to the infant's first birthday or until breastfeeding is discontinued (whichever comes first), provided that there will be no decrease in health and nutrition services that the participant would otherwise receive during a shorter certification period:
☐ Yes, at all local agencies
☐ Yes, at selected local agencies
☐ No
The State agency ensures that health care and nutrition services are not diminished for participants certified for longer than six months:
☐ No ☐Yes (describe):
Extended certification is an option for the following (check all that apply):
☐ Priority I infants ☐ Priority II infants ☐ Priority IV infants
☐ Priority III Children ☐ Priority V Children
☐ Priority I Breastfeeding Women ☐ Priority IV Breastfeeding Women
The State agency authorizes local agencies to shorten or extend the certification period up to 30 days in certain circumstances.
☐ Yes (If yes, provide citation indicating circumstances): ☐ No
ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (citation):
The State agency authorizes local agencies to disqualify an individual in the middle of a certification period for the following reasons (check all that apply):
☐ Participant volunteers the information that they are over income
☐ Participant abuse
☐ Family member found income ineligible at recertification
☐ Failure to pick up food instruments/cash-value vouchers for consecutive issuances ☐ Other (specify):
ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (citation):
Procedures for Transfer of Certification and Verification of Certification (VOC) Cards
The State agency has procedures in place that are used by all local agencies for transfers of certification within the State agency (intra-State), between State agencies (inter-State), and to the WIC Overseas Program (WICO):
Intra-State Inter-State WIC Overseas
☐ ☐ ☐ Yes
☐ ☐ ☐ No
A participant ID card/folder is provided which also serves as a VOC card:
☐ Yes ☐ No
The State agency requires all local agencies to use a standardized Verification of Certification card:
☐ Yes ☐ No
Verification of Certification Cards are issued to the following (check all that apply):
☐ All participants
☐Migrants
☐ Homeless
☐ Participants relocating during certification period
☐ Persons affiliated with the military who are transferred overseas
☐ Other (specify):
ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (citation):
The State agency requires all local agencies to include the following information on the Verification of Certification card (check all that apply):
☐ Name of participant
☐ Date certification performed
☐ Date income eligibility last determined
☐ Nutritional risk condition of the participant
☐ Date certification period expires
☐ Signature/printed or typed name of certifying local agency official
☐ Name/address/phone number of certifying local agency
☐ Identification number or some other means of accountability
☐ Migrant status (non-resident)
☐ Other (specify):
The State agency requires all local agencies to accept as valid all VOC cards from both the domestic WIC Program and the WIC Overseas Program that contain the following essential elements:
☐ Participant name
☐ Name and address of the certifying agency
☐ Date the current certification period expires
The State agency honors the one year certification period for transferring participants (infants, children, and breastfeeding women) even if it certifies participants every six months.
☐ Yes ☐ No
ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (citation):
Dual Participation
The State agency has written procedures to prevent and detect dual participation within each local agency and between local agencies:
☐ Yes (Please attach any descriptions of policy in Appendix or cite appropriate section(s) of the Procedure Manual):
☐ No
The State agency has a written agreement with the Indian State agency(ies) or other geographic State agencies in close proximity for the detection and prevention of dual participation (attach a copy of each applicable agreement or provide a citation of where a copy is located):
☐ Yes ☐ No ☐ Not applicable
The State agency has established procedures to handle participants found in violation due to dual participation:
☐ Yes (Please attach any descriptions of policy in Appendix or cite appropriate section(s) of the
Procedure Manual):
☐ No
ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (citation):
Participant Rights and Responsibilities
The State agency has uniform notification procedures that are used by all local agencies statewide:
☐ Yes ☐ No
The State agency requires all local agencies to inform applicant/participant of his/her rights and responsibilities in written form, and must be read by or to the applicant, parent, or caretaker:
☐ Yes ☐ No
The State agency has implemented a policy of disqualifying participants for not picking up food instruments:
☐ Yes ☐ No ☐ Not applicable
If yes, the policy is communicated to participants in the participant rights and responsibilities materials:
☐ Yes ☐ No ☐ Not applicable
The State agency has implemented a policy to specifically inform participants that they are not allowed to sell
WIC food benefits, including online:
☐ Yes ☐ No; explain:
The State agency has policies and procedures to identify attempted sales of WIC food benefits in their WIC State Plan:
☐ Yes ☐ No; explain:
ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (citation):
The State agency has developed special notification policies and procedures for the following:
☐ Applicant/participant who cannot read
☐ Applicant/participant who speaks in a language other than English
☐ Homeless
☐ Migrants
☐ Persons with disabilities
☐ Other (specify):
The State agency requires all local agencies to provide notification of participant rights and responsibilities in the following situations:
☐ Eligibility at each certification
☐ Ineligibility at initial certification
☐ Mid-certification disqualification ☐ Expiration of a certification period ☐ Waiting list status
☐ Other (specify):
ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (citation):
Fair Hearing and Sanction System
The State has a law or regulation governing participant appeals:
☐ Yes ☐ No
The State agency has established statewide fair hearing procedures:
☐ Yes; attach fair hearing procedures for participants or specify the location in the Procedure Manual and reference in additional detail section below.
☐ No
State or local agency actions against participants include (check all that apply):
☐ Reclaiming the value of improperly received benefits ☐ Disqualification from the program for up to one year ☐ Suspension from the program mid-certification
☐ Other (specify):
Appeal hearings are held at:
☐ WIC State agency parent agency
☐ Other State agency or hearing board (specify):
☐ Local WIC agency
☐ Other (specify):
Statewide fair hearing procedures include (check all that apply):
☐ Request for hearing ☐ Local agency responsibilities
☐ Denial or dismissal of request ☐ Continuation of benefits
☐ Rules of procedure ☐ Responsibilities of hearing official
☐ Fair hearing decision ☐ Other (specify):
☐ Judicial review
State agency procedures require written notification for (check all that apply):
☐ Appeal rights ☐ Request for hearing
☐ Denial or dismissal of request ☐ Notice of hearing
☐ Termination within certification period ☐ Fair hearing decision
☐ Judicial review ☐ Other (specify):
The State agency has established timeframes to govern each step of the hearing process:
☐ Yes ☐ No
The State agency requires all local agencies to document any notification/correspondence in the participant's file:
☐ Yes ☐ No
The State agency has a written sanction policy for participants:
☐ Yes (If yes, provide appropriate citation below)
☐ No
The State agency has established procedures which determine the type and levels of sanctions to be applied against participants:
☐ Yes ☐ No
ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (citation):
(Please indicate) State Agency: for FY
Food delivery and food instrument (FI) (Food instrument means a voucher, check, electronic benefits transfer card (EBT), coupon or other document which is used by a participant to obtain supplemental foods) accountability and control involve the production, issuance, redemption, and monitoring of automated and manual food instruments through retail systems and the delivery of WIC Program foods by non-retail methods, i.e., home delivery and direct distribution.
Retail Food Delivery Systems
Food Instrument Control Overview - 246.4(a)(11)(iii), (a)(14)(i), (a)(14)(vi), and (a)(14)(xii): describe the policies and procedures used by the State agency in producing, monitoring and accounting for the use of food instruments.
Food Instrument Pick-up and Transaction - 246.4(a)(11)(iii) and (a)(14)(vi): describe the State agency's procedures for issuing food instruments to participants, including procedures for verification, prorating food packages, training and proxy policies.
Food Instrument Redemption and Disposition - 246.4(a)(14)(vi): describe the procedures used to reconcile food instruments as either issued or voided, and as either redeemed or unredeemed, and redeemed food instruments as either validly issued, lost/stolen/damaged, expired, duplicate, or not matching issuance records.
Manual Food Instruments - 246.4(a)(11)(iii), (a)(14)(i), (a)(14)(vi) and (a)(14)(ix): describe the procedures for issuing and accounting for manual food instruments, including the procedures for documentation and disposition.
Special Food Instrument Issuance Accommodations - 246.4(a)(11)(iii), (a)(14)(i), (a)(14)(vi), (a)(14)(ix), (a)(14)
(xiv) and (a)(21): describe alternatives to participant food instrument pick-up for issuance (e.g., mail or electronic issuance) and how the integrity of program services and fiscal accountability is ensured.
Vendor Cost Containment System Certification - 246.4(a)(14)(xv), 246.12(g)(4)(vi): describe the competitive pricing and reimbursement methods that the State agency will implement to ensure that average payments per food instrument to above-50-percent vendors do not exceed average payments per food instrument to comparable regular vendors.
Non-Retail Food Delivery Systems
G. Home Food Delivery Systems - 246.4(a)(11)(iii), 246.4(a)(14)(i), (a)(14)(vi), (a)(14)(vii) and (a)(14)(xii): describe how the State agency's home delivery system operates including but not limited to the types of authorized home food delivery contractors, the frequency of deliveries, and the procedures for documenting deliveries and ensuring safe food delivery of WIC foods, if applicable.
H. Direct Distribution Food Delivery Systems - 246.4(a)(11)(iii), (a)(14)(i), and (a)(14)(vi), (a)(14)(vii), and (a)(14)(xii): describe the methodology and procedures used in the direct distribution of supplemental foods, including types of foods distributed, warehouse and distribution centers, the verification process, and assurance of food safety, as applicable.
Electronic Benefit Transfer (EBT) Implementation and Management
I. Electronic Benefit Transfer (EBT): 246.4(a)(1), (a)(14)(xix), (a)(14)(xx), (a)(19), 246.12(h)(3), (w)-(bb): describe the policies and procedures the State agency is using to implement and operate EBT
Food Instruments - General
The State agency uses the following types of FIs (check all that apply):
☐ Automated-point of certification ☐ Manual-individual prescription
☐ Pre-printed manual-standard prescription ☐ Automated-central generation
☐ EBT
☐ Other (specify):
The State agency conducts FI inventories (Place an S=[State agency] or L=[Local agency] under the appropriate column to designate primary responsibility):
Automated - EBT Cards Physical - Paper FIs
Daily/perpetually Daily
Other (Specify): Weekly
Monthly
Other (specify):
The FI contains/allows for the following information (check all that apply):
☐ Not applicable ☐ Local agency identifier
☐ Participant WIC ID number ☐ Vendor/farmer endorsement
☐ Countersignature for participant/proxy
☐ Authorized supplemental foods
☐ First date of use ☐ Last date of use
☐ Redemption period ☐ Serial number
☐ Purchase price ☐ Signature space
Provide a facsimile or FI in Appendix or cite Procedure Manual:
The EBT system allows for the following (check all that apply):
☐ A unique and sequential number benefit issuance identifier
☐ Each EBT purchase is matched to an authorized vendor, farmer, or farmers' market prior to authorizing payment per 7 CFR 246.12(x)(3)
☐ System contains authorized supplemental foods
☐ System contains first and last dates of use for electronic benefits
The State agency provides a toll-free number for participant/vendor/farmer inquiries on:
☐ Paper Food Instrument ☐ Cash-value voucher ☐ EBT Card/Sleeve
☐ None
ADDITIONAL DETAIL: Food Delivery Appendix and/or Procedure Manual (citation):
Food Instrument Accountability
FIs are delivered to local agencies by:
☐ State agency staff ☐ Local agency staff
☐ US Postal Service
☐ On-demand printing
☐ Contracted service (e.g., UPS, Purolator, etc.)
☐ Other (specify):
FIs (blank stock and preprinted ready for issuance) are delivered to the local agency (check all that apply):
Blank Preprinted
☐ Not applicable ☐ Not applicable
☐ Weekly ☐ Weekly
☐ Twice a month ☐ Twice a month
☐ Once a month ☐ Once a month
☐ Once every two months ☐ Once every two months
☐ Other (specify): ☐ Other (specify):
Blank Specify:
Preprinted Specify:
The State agency uses the following procedures to ensure that unclaimed FIs are not being used fraudulently (check all that apply):
☐ Signatures on the documentation of receipt are compared for similarities in writing style implying one person signed for multiple participants
☐ Local agencies conduct an initial review to void food instruments for participants known to have been terminated from the Program
☐ Inventories of food instruments are not conducted by the same local agency staff responsible for issuing/voiding food instruments
☐ Procedures are in place to ensure the proper disposal of unused/duplicate/voided FIs
☐Other (specify):
ADDITIONAL DETAIL: Food Delivery Appendix and/or Procedure Manual (citation):
The State agency has established food delivery procedures in cases of natural disaster and emergencies for the following (check all that apply):
☐ Manual Issuance ☐ Automated issuance
☐ Mailing ☐ Home food delivery
☐ Direct distribution ☐ Other (specify):
ADDITIONAL DETAIL: Food Delivery Appendix and/or Procedure Manual (citation):
Food Instrument Pick-Up Policy and Procedures
Food instruments are issued by (check all that apply):
All Locals Most Locals Some Locals
Local agency director ☐ ☐ ☐
Local agency nutritionist ☐ ☐ ☐
Local agency paraprofessional ☐ ☐ ☐
Clerical staff ☐ ☐ ☐
Other (specify): ☐ ☐ ☐
The State agency utilizes a participant identification card:
☐ Yes ☐ Yes, with photo ☐ No
If yes, issuance is controlled numerically and each card is accounted for:
☐ Yes ☐ No
The State agency requires the following proof of receipt when issuing automated food instruments:
☐ Participant/parent/caretaker/proxy signature block on register confirming receipt ☐Carbon copy of food instrument
☐ Local agency staff initials
☐ Date of food instrument pick-up
☐ Stub with participant signature or initials ☐ Other (specify):
The State agency has a policy to prorate food packages for the following:
☐ Late FI pick-up ☐ Certification due to expire within 30 days
☐ Mid-month certification ☐ Other (specify):
The State agency requires local agency staff to provide each new participant/parent/caretaker/proxy with training in (check all that apply):
☐ Authorized vendors/farmers ☐ Selecting WIC-approved foods
☐ FI transaction procedures ☐ Signature on FIs
☐ Use of proxy ☐ Reporting problems/requesting assistance
☐ Participant violations (i.e. selling or offering to sell WIC benefits)
☐ Other (specify):
The State agency requires local agency staff to provide participants with a list of authorized vendors/farmers/farmers’ markets:
☐ Yes ☐ No
The State agency permits a participant to transact food instruments with any authorized vendor or farmer/ farmers’ market in the State:
☐ Yes ☐ No
ADDITIONAL DETAIL: Food Delivery Appendix and/or Procedure Manual (citation):
The State agency's proxy policy includes the following:
☐ Limits the number of participants a single proxy may sign for, except that a proxy may pick up FIs for all homeless WIC participants in a facility
☐ Limits proxy to a specified number of FI pick-ups ☐ Limits proxy to a minimum age
☐ Limits proxy assignment to local WIC staff
☐Other (specify):
ADDITIONAL DETAIL: Food Delivery Appendix and/or Procedure Manual (citation):
Food Instrument Disposition Procedures
The State agency system assures 100% disposition of all issued FIs
☐ Yes ☐ No
If no, specify the circumstances that prevent 100% disposition:
Local agencies are supplied with a report on the final disposition of its FIs:
Yes (specify period): ☐ No
The State agency monitors each local agency's:
☐ Number of manual FIs utilized
☐ Number of unclaimed FIs
☐ Number of voided FIs
☐ Number of redeemed FIs with no issuance record
ADDITIONAL DETAIL: Food Delivery Appendix and/or Procedure Manual (citation):
Unclaimed, Voided, Prorated FIs
The State agency requires local agencies to return "unclaimed/not picked up" FIs:
☐ Not applicable ☐ Daily ☐ Weekly ☐ Monthly
☐ Other (specify):
The State agency requires local agencies to return "voided" FIs:
☐ Not applicable ☐ Daily ☐ Weekly ☐ Monthly
☐ Other (specify):
ADDITIONAL DETAIL: Food Delivery Appendix and/or Procedure Manual (citation):
Lost/Stolen/Damaged Food Instruments
The State agency requires local agencies to report lost/stolen/damaged FIs to (check all that apply):
☐ State agency ☐ Police department ☐ State agency’s banking institution
☐ EBT Coordinator
☐ Other (specify):
Replacement/duplicate FIs Issuance
Replacement/duplicate FIs are issued when FIs are reported lost:
☐ No
☐ Depends on the circumstances
☐ Yes (If FIs are reissued, it is done):
☐ Immediately
☐ Following notification of State agency/bank agency
☐ After a day waiting period (specify number of days)
Replacement/duplicate FIs are issued when FIs are reported stolen:
☐ No
☐ Depends on the circumstances
☐ Yes (If FIs are reissued, it is done):
☐ Immediately
☐ Following notification of State agency/bank agency
☐ After a day waiting period (specify number of days)
(3) Replacement/duplicate FIs are issued when FIs are reported damaged:
☐ No
☐ Depends on the circumstances
☐ Yes (If FIs are reissued, it is done):
☐ Immediately
☐ Following notification of State agency/bank agency
☐ After a day waiting period (specify number of days)
☐ Other (specify):
Is a police report required before replacement benefits are issued when reported stolen?
☐ Yes ☐ No
The State agency or its banking institution takes the following action after it is notified by the local agency of lost/stolen/damaged FIs (check all that apply):
☐ Stops payment on the lost/stolen/damaged FIs
☐ Notifies vendor or farmer
☐ Other (specify):
Please provide a copy/citation of the State agency's policy and procedures that ensure that lost/stolen FIs cannot be redeemed OR lost/stolen/damaged EBT cards will be replaced and associated benefits transferred (7 CFR 246.4(a)(14)(xix)).
The local agency documents in the participant's file that replacement FIs were issued:
☐ Yes ☐ No
If it is established that lost/stolen/damaged FIs are transacted by the participant who reported them lost/ stolen/damaged, the following actions are taken:
☐ A claim for cash repayment is issued to participant
☐ Participant is disqualified; specify the period of time:
☐ Participant receives a warning
☐ Other (specify):
If lost/stolen/damaged FIs are transacted by someone other than the participant, the following actions are taken, check all that apply:
☐ Reported to police for investigation
☐ State agency or local agency does an investigation
☐State agency or local agency notifies the participant
☐ Other (specify):
ADDITIONAL DETAIL: Food Delivery Appendix and/or Procedure Manual (citation):
The State agency monitors the level of reported lost/stolen/damaged FIs by local agency:
☐ Yes ☐ No
Food Instrument Redemption Screening (7 CFR 246.12(k)(1))
Describe in detail how the State agency sets maximum allowable reimbursement levels for payment of food instruments (including whether the State agency uses vendors’ shelf prices to set maximum reimbursement levels and how reimbursement levels are linked to competitive price criteria). If the State agency sets maximum allowable reimbursement levels differently for above-50-percent vendors and regular vendors, please explain the different methods used.
The State agency establishes maximum allowable reimbursement levels for:
Each peer group ☐ Yes ☐ No
Each food instrument or food category ☐ Yes ☐ No
Other (please specify): ☐ Yes ☐ No
The State agency establishes maximum allowable reimbursement levels using:
Standard deviations ☐ Yes ☐ No
If yes, specify the standard deviation number and explain how the State agency determined the standard deviation it used is appropriate: (b)
(b) A percentage above the average redemption amount ☐ Yes ☐ No
If yes, specify the percentage and explain how the State agency determined that this percentage is appropriate.
(c) Other (please specify): ☐ Yes ☐ No
The maximum allowable reimbursement levels include a factor to reflect:
☐ Yes ☐ No Wholesale price fluctuations; explain:
☐ Yes ☐ No Inflation: explain:
☐ Yes ☐ No Other (please specify):
The State agency screens FI through a pre-edit (before payment) or post-edit (after payment) process to detect the following:
Not Pre-Edit Post-Edit
Applicable Screen Screen
☐ ☐ ☐ Purchase price exceeds price limitations (FI only)
☐ ☐ ☐ Purchase price missing
☐ ☐ ☐ Altered purchase price
☐ ☐ ☐ Vendor/farmer identification missing
☐ ☐ ☐ Invalid/counterfeit vendor/farmer identification
☐ ☐ ☐ Transacted before specified period
☐ ☐ ☐ Transacted after specified period
☐ ☐ ☐ Redeemed after specified period
☐ ☐ ☐ Altered dates
☐ ☐ ☐ Missing signature
☐ ☐ ☐ Mismatched signature
☐ ☐ ☐ Altered signature
☐ ☐ ☐ Other (specify):
When the payment amount on a food instrument exceeds the maximum allowable reimbursement amount,
what action does the State agency take?
☐ Reimburses the vendor for amounts up to the maximum allowable reimbursement amount
☐ Reimburses the vendor at the peer group average
☐ Rejects the food instrument, but allow the vendor to resubmit
☐ Rejects the food instrument without allowing the vendor to resubmit
☐ Other (please specify):
Where pre-edit screens are used, the proportion of FIs reviewed includes:
☐ All FIs ☐ Percentage of FI ( %)
☐ Other (please specify):
The edit system(s) that use(s) maximum allowable reimbursement levels to screen for vendor overcharges rejects food instruments based on:
Pre-Edit Post-Edit
☐ ☐ Not To Exceed or Maximum Prices
☐ ☐ Percentage above average ( %)
☐ ☐ Amount above average ($ )
☐ ☐ Other (specify):
The following actions are used to control against unauthorized stores redeeming FIs:
☐ Provide up-to-date list of authorized vendors to participants at certification and/or FI issuance
☐ Recover vendor/farmer/farmers’ market stamp when vendor/farmer/farmers’ market is no longer authorized
☐Conduct compliance buy to verify if unauthorized store redeems FIs
☐ State agency or its banking institution checks vendor/farmer/farmers’ market ID numbers on food instruments submitted for redemption against the authorized vendor/farmer/farmers’ market list before paying vendors/ farmers/farmers’ markets for FIs submitted for redemption
☐ Inform all participants who might use the unauthorized store
☐Other (specify):
ADDITIONAL DETAIL: Food Delivery Appendix: and/or Procedure Manual (citation):
Price Lists
Price list information is routinely collected from vendors:
☐ Yes ☐ No; Explain: (Proceed to item #6)
Price list data are collected:
☐ Real Time or Daily via EBT system ☐ Monthly ☐ Quarterly ☐ Semiannually
☐ Other (specify):
Price data are collected by:
☐ State agency staff
☐ Local agency staff
☐ Reports are submitted by vendors ☐ EBT system
☐ Other (specify):
The data collected has food prices for (check all that apply):
☐ All brands and sizes of supplemental foods
☐ Highest price supplemental food items within food categories
☐ Most commonly redeemed food items; please specify:
☐ All authorized vendors
☐ A sample of authorized vendors (please describe the sampling method used):
☐ Other (specify):
The State agency/local agency verifies price data provided by vendors:
☐ During routine monitoring visits
☐Does not verify on a routine basis
☐ Other (explain):
☐ If the vendor is identified as a high-risk vendor; please explain the method:
The State agency/local agency analyzes price data:
☐ Manually on a routine or as needed basis
☐ On an Automatic Data Processing system and uses it to:
☐Generate estimated food instrument values
☐ Help inform WIC staff on vendor selection decisions
☐ Develop vendor peer groups
☐ Flag individual food instruments that appear to be overcharges
☐ Other (specify):
System to Detect Suspected Overcharges
Does the State agency screen for suspected overcharges:
☐ Yes, vendor claims are issued for overcharges
☐ No, the State agency makes price adjustments to food instruments submitted for redemption at amounts above edit limits.
☐ No, the State agency does not identify overcharges and/or issue claims for overcharges. (Proceed to section D. Manual Food Instruments.
☐ Other (specify):
The methods used to identify vendor overcharges are:
☐ Comparison of vendor's reported prices to charged prices
☐ Comparison of redemption values of vendor with other vendors in the vendor's peer group
☐Comparison of redemption values of vendor with all vendors
☐ Other (specify):
To receive payment or justify and correct a claim for a price adjustment or vendor overcharge, the vendor must: (Check all that apply)
☐ Provide an updated price list
☐ Provide written justification for the higher prices
☐Provide receipts
☐ Other (specify):
What action(s) is/are taken when a vendor overcharge occurs? (Check all that apply)
☐ Routine monitoring or remedial vendor training is conducted
☐ Vendor is designated as high-risk and scheduled for compliance investigation
☐ Vendor is provided with a written warning of potential sanction for overcharging ☐ Vendor is terminated for cause
☐ Vendor is sanctioned ☐ Other (specify):
ADDITIONAL DETAIL: Food Delivery Appendix and/or Procedure Manual (citation):
☐ DOES NOT APPLY (PROCEED TO NEXT SECTION)
Manual FIs Policy
Manual FIs are utilized for the following reasons:
☐ New participants
☐ Automated FIs not available
☐ Mutilated automated FIs
☐ Wrong food package on automated FI
☐ Wrong dollar amount on automated FI
☐ Provide for the special needs of the homeless
☐ Food package tailoring
☐ Routine monitoring visits (i.e., educational buys) of vendors/farmers
☐ Compliance buys of vendors/farmers
☐ Special conditions, e.g., disasters
☐ Other (specify):
The State agency requires the following for completing the manual FI register:
☐ Participant/proxy signature ☐ Local agency staff initials
☐ Date of FI pick-up ☐ Other (specify):
Manual FIs have a "Not to Exceed Value" of:
☐ Same dollar amount for all manual food instruments $
☐ Variable dollar amount depending on type of prescription on manual FI
☐Variable dollar amount depending on participant category on manual FI
☐ No limit
☐ Other (specify):
ADDITIONAL DETAIL: Food Delivery Appendix and/or Procedure Manual (citation):
Manual FI Documentation and Disposition
A report containing the serial numbers of manual FIs issued by local agencies is sent to the State agency:
☐ Not applicable ☐ Weekly ☐ Monthly
☐ Other (specify):
Local agencies are required to provide documentation to substantiate a valid or invalid certification record for manual FIs issued and redeemed but for which no participant record currently exists by utilizing:
☐ Turnaround documents to establish valid certification records ☐ Telephone calls to the State/local agency on irregularities
☐Other (specify):
If the manual FI inventories do not achieve 100% reconciliation of all issued and unissued FIs, the local
agency (check all that apply):
☐ Reports the FI serial numbers to the State agency
☐ Provides the FI serial numbers to local vendors/farmers
☐ Other (specify):
(Provide a copy/citation of the State agency's prescribed procedures if the manual FI inventory cannot be reconciled.)
ADDITIONAL DETAIL: Food Delivery Appendix and/or Procedure Manual (citation):
Alternative FI Issuance
The State agency has implemented the following FI issuance policy (check all that apply):
☐ All participants are required to pick up FIs at the clinic or local agency, except in unusual circumstances
☐ Participants/proxies are required to show identification at FI card pick up
☐ FI cards are routinely mailed to participants except (1) when the participant is scheduled for nutrition education (including breastfeeding promotion and support activities) or a certification appointment and (2) in areas where SNAP benefits are not mailed, as these areas are known to have experienced high mail issuance losses
☐ Benefits are provided electronically to a location such as a grocery store under certain conditions; thus participants may not always pick up FIs at the clinic
☐ Other (specify):
Mailing Policy/Procedures
The State agency provides local agencies with guidelines/procedures for mailing FIs to individual participants:
☐ Yes ☐ No
Policy requires participants to pick up FIs whenever certification appointment is due or nutrition education (including breastfeeding promotion and support activities) is scheduled:
☐ Yes ☐ No
The State agency has implemented the following policy regarding mailing FIs (check all that apply):
☐ FIs are sent first class mail *(first class is considered regular mail
☐ FIs are sent registered mail
☐ FIs are sent certified mail
☐ FIs are sent restricted mail
☐ Return receipt is requested on FIs sent certified mail
☐ Envelope specifies, "Do not forward, return to sender" or "Do not forward, address correction requested"
☐Other (specify):
The State agency approves mailing FIs under the following conditions (check all that apply):
State-Wide LA with SA Approval Case by Case
Participant hardship ☐ ☐ ☐
Travel-related issues ☐ ☐ ☐
Better clinic management ☐ ☐ ☐
Participant safety ☐ ☐ ☐
Participant convenience ☐ ☐ ☐
Cost effectiveness ☐ ☐ ☐
Other ☐ ☐ ☐
(if other, specify):
When mailing FIs, documentation of FI issuance is:
☐ Signed by the participant at the following FI pick-up/visit ☐ Noted "mailed" and initialed/dated by local agency staff
☐ Signed and dated by local agency staff after return receipt is received
☐ Other (specify):
ADDITIONAL DETAIL: Food Delivery Appendix and/or Procedure Manual (citation):
Participants who receive FIs by mail are sent:
☐ One month of FIs ☐ Two months of FIs
☐ Three months of FIs ☐ Other (specify):
ADDITIONAL DETAIL: Food Delivery Appendix and/or Procedure Manual (citation):
If the State agency has authorized or plans to authorize any above-50% vendors, FNS must certify the State agency’s vendor cost containment system. The State agency that has not yet received FNS certification must submit a request for certification/recertification that contains the following information.
☐ DOES NOT APPLY (PROCEED TO SECTION G)
Calculation of new competitive price levels
Describe how the State agency derived or will derive new competitive price levels for regular vendors, which exclude the prices of above-50-percent vendors.
Maximum allowable reimbursement levels for regular vendors and above-50-percent vendors
Explain how the State agency will ensure that average payments to above-50-percent vendors do not exceed average payments to comparable regular vendors.
The State agency plans to exempt above-50-percent vendors from the calculated competitive price criteria and maximum allowable reimbursement levels.
☐ Yes ☐ No If yes, how many vendors will be exempted?
Are these vendors needed to ensure participant access to supplemental foods?
☐ Yes ☐ No
The State agency applies peer-group-specific maximum allowable reimbursement levels to food instruments during the food instrument redemption process.
☐ Yes ☐ No If yes, describe the procedure or process used:
Describe the State agency’s methodology for grouping above-50-percent vendors in its peer group system (i.e., separately or in peer groups with regular vendors) and the criteria the State agency uses to identify comparable vendors for each group of above-50-percent vendors.
The State agency plans to exempt non-profit above-50-percent vendors from competitive price criteria and maximum allowable reimbursement levels.
☐ Yes ☐ No If yes, provide the following information in detail:
Describe the reason the State agency has decided to exempt such vendors (i.e., the benefits to the program) and the number of non-profit vendors to be exempted.
Describe the reason the non-profit above-50-percent vendors are needed to ensure participant access to supplemental foods.
Does the State agency collect shelf prices from non-profit vendors?
☐ Yes ☐ No
Describe how the prices of the non-profit vendors compare to those of other vendors in their geographic area that are subject to competitive price criteria and allowable reimbursement levels.
Describe how the State agency establishes the level of reimbursement for the non-profit above-50-percent vendors that it has exempted.
The State agency has fully implemented the competitive price criteria and maximum allowable reimbursement methodologies described in items 1 and 2 above.
☐ Yes ☐ No
If the State agency has not fully implemented the revised competitive price and maximum allowable reimbursement methodologies, describe the current status of this effort and include the timetable for achieving full implementation.
The State agency plans to exempt pharmacy vendors from competitive price criteria and maximum allowable reimbursement levels.
☐ Yes ☐ No
If yes, the State agency has confirmed that these pharmacies provide only exempt infant formula and/or WIC-eligible nutritional foods to program participants.
Does the State agency collect shelf prices from pharmacies that provide only exempt infant formula? ☐ Yes ☐ No
Complete the table on the following page to demonstrate that the State agency’s procedure for establishing and implementing competitive price criteria and maximum allowable reimbursement levels ensures that average payments per food instrument or food item to above-50% vendors do not exceed average payments to regular vendors.
Please attach and cite of a copy of the report(s) that the State agency will use to monitor average payments per food instrument to above-50% vendors and regular vendors. If the State agency does not have such a report, describe the State agency’s plans to develop and implement a report(s) for monitoring purposes, including the report contents or fields.
Table 1. Data for WIC Vendor Cost Containment Certification – Overview
Please provide the following information on the regular vendors and the above-50-percent vendors authorized by the State agency as of June 30th. If data are not available through June 30th, the State agency should enter data for the period for which data are available, replacing “June” with the month to which the data are applicable.
1. How many authorized regular vendors did the State agency have as of June 30th? (or month of: ) |
1. |
2. For all authorized regular vendors, what was the total amount of WIC redemptions paid as of June 30? |
2. |
3. How many above-50-percent vendors did the State agency have as of June 30th? |
3. |
a. Non-pharmacy above-50-percent vendors |
a. |
|
|
|
|
b. Above-50-percent pharmacy vendors |
b. |
c. Total above-50-percent vendors (sum of a and b) |
c. |
4. What was the total amount of redemptions paid to these above-50-percent vendors as of June 30th? |
4. |
a. Non-pharmacy above-50-percent vendors |
a. |
b. Above-50-percent pharmacy vendors |
b. |
c. Total above-50-percent vendors (sum of a and b) |
c. |
5. How many peer groups of above-50-percent vendors (either separate peer groups or groups with regular vendors) has the State agency identified? |
5. |
6. How many above-50-percent vendors and regular vendors has the State agency authorized that do not meet competitive price criteria, but are needed to ensure participant access to supplemental foods? |
6. above-50%: regular vendors: |
Supplemental WIC State Plan Guidance section IX.I – Vendor Cost Neutrality Assessment will be issued in the spring.
☐ DOES NOT APPLY (PROCEED TO NEXT SECTION)
Home Food Delivery Systems Overview
Home delivery vendors include (check all that apply):
☐ Dairies
☐ Private delivery service doing WIC business only
☐Private delivery service
☐ Other (specify):
Participants who receive home food delivery:
☐ Are notified in writing of the types and quantities of foods
☐ Are issued FIs that they sign and provide to the vendor when the food is delivered
☐ Are delivered not more than a one-month supply of supplemental foods at any one time
☐ Indicate by authorized signature on a FI, receipt or signature document, the supplemental foods received
☐ Other (specify):
Supplemental foods may be delivered:
☐ Only to the participant of record
☐ To the participant of record or proxy of record ☐ To any adult at home during time of delivery
☐ To anyone at home at the time of delivery
☐ Other (specify):
ADDITIONAL DETAIL: Food Delivery Appendix and/or Procedure Manual (citation):
Documentation
The forms verifying delivery are reconciled against vendor invoices:
☐ Weekly
☐ Monthly reconciliation of the signed FIs or other signed receipts or signature documents from participant or proxies.
☐ Other (specify):
Signatures of participants who sign the food receipt document/FIs are compared to the signature on file.
☐ No ☐ Yes, sample ☐ Yes 100%
ADDITIONAL DETAIL: Food Delivery Appendix and/or Procedure Manual (citation):
☐ DOES NOT APPLY
Direct Distribution Food Delivery - General
The State agency uses a direct distribution food delivery system to:
☐ Distribute all of its WIC Program foods
☐ Distribute only exempt infant formula and/or medical foods
☐Distribute (specify):
The State agency uses:
☐ Warehouse not used
☐ One central warehouse, deliveries directly to local agencies
☐ One central warehouse from which foods are sent to one or more subsidiary warehouses before delivery to local agencies
☐ Other (specify):
c. |
Warehouses are operated by: |
|
|
☐ State agency |
☐ Local agency |
|
☐ Other state or public agency |
☐ Under contract with a private business |
|
☐ Other (specify): |
|
d. Warehouses used for storage of WIC foods are also used to store other FNS program commodities (Please specify which commodities):
☐ Yes ☐ No Specify commodities:
ADDITIONAL DETAIL: Food Delivery Appendix and/or Procedure Manual (citation):
Food Distribution
Foods are distributed to participants:
☐ Grocery store fashion ☐ Pre-packaged
☐ Other (specify):
Participants receiving food are required to sign:
☐ A register once for all foods received
☐ A register/form for each food item received
☐ Other (specify):
Foods are distributed to participants:
☐ Monthly
☐ Not to exceed a one-month supply at any one time to any participant
☐ Other (specify):
Participants with limited access to facilities used for distribution have available to them:
Services provided by:
Local Other
Agency Sources
Home delivery ☐ ☐
Cost-free transportation ☐ ☐
Other ☐ ☐
(if other, specify):
ADDITIONAL DETAIL: Food Delivery Appendix: and/or Procedure Manual (citation):
Warehouse Insurance and Inspections
Insurance for the warehouse covers (check all that apply): ☐ Theft ☐ Fire ☐ Infestation ☐ Spoilage
☐ Other (specify):
Warehouses are inspected by a public authority responsible for enforcing:
☐ Fire safety laws and regulations (specify date and grade of last inspection):
☐ Sanitation laws and regulations (specify date and grade of last inspection):
☐ Other (specify):
ADDITIONAL DETAIL: Food Delivery Appendix: and/or Procedure Manual (citation):
Monitoring and Inventory Control
Please describe the State agency’s methods for ensuring WIC supplemental foods are under proper inventory control (separation of duties for intake and inventory; stock rotation; performance of perpetual and physical inventory duties; reconciliation against issuance records; etc.).
Is EBT implemented statewide?
☐ Yes (Proceed to question 2)
☐ No (Continue to 1.a.)
Does the State agency have an active EBT Project as of July 31, 2016?
☐ Yes ☐ No
Does the State agency follow APD requirements for EBT management and reporting?
☐ Yes ☐ No
Does the State plan to meet the October 1, 2020 EBT implementation deadline?
☐ Yes ☐ No
What is the State agency policy for permitting replacement cards and transfer of balances per 7 CFR 246.12(bb)(2)?
What are the State agency procedures for providing customer service during non-business hours for EBT cards per 7 CFR 246.12(bb)(3)?
Does the State agency use the formula for EBT terminal minimum lane coverage in 7 CFR 246.12(z)?
☐ Yes ☐ No
If no, please provide the date of the approval of the approved alternative installation formula as required per 7 CFR 246.12(z)(2).
Does the State agency use the NUPC database?
☐ Yes ☐ No
(Please indicate) State Agency: for FY
Monitoring and Audits involves State agency efforts to review local agency/clinic activities on an ongoing and timely basis, and to track all audits involving WIC Program activity.
Monitoring-246.19(b): requires State agencies to establish a management evaluation system.
Audits-Subpart F to 2 CFR Part 200, as applicable: describe State agency audit responsibilities.
Local Agency/Clinic Monitoring Activity (to be updated each year)
Local agencies/clinics monitored:
Number of local agencies monitored last annual period
Number of clinics monitored last annual period
Number of local agencies to be monitored this current annual period
Number of clinics to be monitored this current annual period
Specify last annual period, from: to (month/day/year – month/day/year; must be applied consistently)
Specify current annual period, from: to (month/day/year – month/day/year; must be applied consistently
Number of local agencies/clinics required to submit Corrective Action Plans (CAPs) to address deficiencies identified during monitoring last year: (Number)
The State agency uses a tracking device, such as a chart or spreadsheet, which summarizes the reviews of all local agencies.
☐ Yes ☐ No
If the State agency uses a tracking device, it shows (check all that apply):
☐ Date of most recent review for each local agency/clinic
☐ Number of clinics reviewed in most recent review for each local agency/clinic
☐Listing of findings for most recent review of each local agency/clinic
☐ Date of State agency notice of findings in most recent review for each local agency/clinic
☐ Date of local agency/clinic corrective action plan in most recent review for each local agency and/or clinics
☐ Outcome of corrective action plan
In preparing to conduct a local agency review, the State agency reviews data reports on:
☐ No-shows by category
☐ Administrative costs claimed
☐ Financial reports
☐ Priorities served
☐ Caseload
☐ Racial/ethnicity
☐ Staff/participant ratios
☐ Participant nutrition surveillance data for participants in that local agency/clinic
☐ Other (specify):
ADDITIONAL DETAIL: Monitoring & Audits Appendix and/or Procedure Manual (citation):
Local Agency/Clinic Monitoring Procedures
The State agency uses an established protocol when it monitors local agencies/clinics.
☐ Yes ☐ No
If yes, please provide the citation of where it can be found in the appendix or procedure manual:
This monitoring protocol includes:
☐ Advance notification of monitoring visit
☐ Determination of timeframes for conducting the review
☐ Designation of local agency/clinic staff to assist State agency staff during review
☐Discussion of review findings on-site with local agency/clinic
☐ Specified time frame for providing written review report
☐ Specified time frame for local agency/clinic submission of corrective action plan, not to exceed 60 days from receipt of State agency’s report
☐ Instructions or guidance for preparation of corrective action plan (e.g., inclusion of implementation time frames)
☐Evaluation of adequacy of corrective action
☐ Follow-up with local agency/clinic to ensure corrective action measures are implemented
☐Written notification of closure of the review
☐ Other (specify):
Monitoring of local agencies/clinics is conducted by (check all that apply):
☐ State WIC staff
☐ District or regional staff
☐ Other health programs
☐ Other (specify):
Specialists in the following areas monitor the areas of their expertise:
☐ Certification and eligibility determination
☐ Caseload management
☐ Nutrition service
☐ Breastfeeding promotion and support
☐ Targeting and outreach policies
☐ Financial management of administrative funds
☐Food delivery system
☐ Vendor management
☐ Civil rights
☐ Information Systems security
☐ Other (specify):
If the State agency uses reviewers to monitor areas in which they do not have expertise and/or prior knowledge, describe how the State agency trains or equips its reviewers to conduct the review:
The State agency uses a standard local agency/clinic review form.
☐ Yes ☐ No
If yes, please provide the citation of where it can be found in the appendix or procedure manual:
If yes, the review form covers the following areas:
☐ An assessment of local agency/clinic management
☐ An assessment of patient flow
☐ Certification case file reviews, including procedures for determining adjunctive income eligibility
☐Caseload management
☐ Training of local agency and clinic staff
☐ Nutrition education
☐ Breastfeeding promotion and support
☐ Targeting and outreach policies
☐ Financial management of administrative funds
☐Validation of staff time spent on WIC
☐ Food instrument accountability
☐ Vendor training and monitoring, if these functions are delegated to a local agency/clinic
☐ Civil rights compliance
☐ Other (specify):
The State agency has developed procedures for local agencies/clinics to use when they evaluate:
☐ Their own operations
☐ Subsidiary/satellite operations (e.g., county health department clinic)
☐Subcontractors (e.g., community action program, hospital)
☐ Homeless facilities/institutions
☐ Other (specify):
If you selected any of the options above, please provide the citation of where it can be found in the appendix or procedure manual and answer the following questions:
Do these procedures include a monitoring tool?
☐ Yes ☐ No
☐ Yes ☐ No (specify basis for exemptions):
ADDITIONAL DETAIL: Monitoring & Audits Appendix and/or Procedure Manual (citation):
Use of Local Agency/Clinic Review Data
The State agency analyzes the results of local agency/clinic monitoring visits to determine whether deficient areas are common among its local agencies/clinics.
☐ Yes ☐ No
☐ Identify outstanding operational approaches that could be shared with other local agencies/clinic ☐ Track individual local agency/clinic performance
☐ Compare administrative costs/expenses among local agencies/clinics
☐ Compare staffing and organization among local agencies/clinics
☐ Other (specify):
ADDITIONAL DETAIL: Monitoring & Audits Appendix and/or Procedure Manual (citation):
Do not include management evaluations or other reviews conducted by FNS regional offices or by WIC State agencies. This section concerns the audits conducted under Subpart F to 2 CFR Part 200 and audits conducted by USDA’s OIG.
Audits (Federal, State, and Local)
Number of audits conducted during FY- : .
Entities audited (includes both Auditor(s) Period of Status/disposition of audit at this
State and local agencies) Audit time (management decision, final
action, etc.
If additional audits were conducted, please provide separately.
Entities not audited and reason (e.g., local office is not a subrecipient local agency, non-federal entity did not expend $750,000 or more in Federal funds during the fiscal year, etc.)
Entities not audited (includes Reason Entity Not Audited
both State and local agencies)
ADDITIONAL DETAIL: Monitoring & Audits Appendix and/or Procedure Manual (citation):
Audit Management Decision
Methods used by the State agency to ensure that corrective action is taken on audit findings include (check all that apply):
☐ State agency has a copy of the corrective action plan on file.
☐ State agency tracks audits to determine if the same problems are recurring from year to year.
☐ Local agency must file periodic reports.
☐ State agency contacts local agency by phone or in writing periodically.
☐ State agency visits local agency.
☐ Other (specify):
State agency actions taken to ensure that all claim amounts are recovered include (check all that apply):
☐ Local agency files periodic reports.
☐ State agency contacts local agency by phone or in writing.
☐ State agency monitors receipt of a check in the amount of an audit claim.
☐State agency establishes and employs billing/offsetting of account procedures. ☐Other (specify):
State agency accounting procedures for claim amounts recovered:
☐ Recovered claim amounts from prior fiscal years are returned to FNS.
☐ Recovered claim amounts are reallocated if collected within the same fiscal year. ☐ Claim amounts are verified with local agency.
☐ Other (specify):
ADDITIONAL DETAIL: Monitoring & Audits Appendix and/or Procedure Manual (citation):
Availability of Audit Reports
The State agency receives and maintains for at least three years copies of all organization-wide audits involving the WIC Program and maintains a listing of those audits.
☐ Yes ☐ No, copies are retained by:
Procedures used for maintaining files to reflect the trail from the receipt of the audit to final action include:
☐ Detailed breakdown of each audit finding is tracked separately.
☐ Individuals are assigned to monitor each audit.
☐ One individual is assigned to monitor all audits.
☐Other (specify):
☐ Yes ☐ No
The State agency ensures WIC participation in the single audit and other audits by (check all that apply):
☐ Developing a tracking system that monitors the status of each audit ☐ Establishing a contact person for each audit
☐ Including this audit requirement in the local agency contract
☐ Other (specify):
ADDITIONAL DETAIL: Monitoring & Audits Appendix and/or Procedure Manual (citation):
XI. CIVIL RIGHTS
(Please indicate) State Agency:
for FY
The Civil Rights section of the State Plan should cover the training of State and local staff on issues, rules and regulations related to civil rights, public notification of nondiscrimination requirements, the monitoring of local agencies and clinics for compliance with civil rights regulations and rules, the collection of relevant racial/ethnic information and procedures for handling civil rights complaints.
Administration - 246.4(a)(17): describe the procedures the State will use to comply with the civil rights requirements described in 246.8, including the processing of discrimination complaints.
Public Notification Requirements and Nondiscrimination Notification - 246.8(a)(1): describe the policies and procedures used to ensure that public notification regarding nondiscrimination in the WIC Program reaches all participants and potential participants in an appropriate language (246.8(c)) through WIC Program materials.
Compliance Review and Monitoring Activity - 246.8(a)(2): describe the policies and procedures used to monitor and review local agencies to verify that they are in compliance with civil rights laws and regulations.
Data Collection and Reporting - 246.8(a)(3): describe the methods used to collect and monitor racial/ethnic data in compliance with title VI of the Civil Rights Act of 1964.
Complaint Handling - 246.4(a)(17): describe the policies and practices used to ensure civil rights complaints are handled properly at the State and local level.
The State agency designates an individual to coordinate, implement, conduct training and enforce civil rights efforts.
☐ Yes ☐ No
The following methods are used to inform and update State and local agency staff of their obligations under civil rights rules, regulations and instructions:
State Local
Agency Agency
Briefing for new employees ☐ ☐
Handouts for new employees ☐ ☐
Memos and updates ☐ ☐
Presentations by civil rights coordinator ☐ ☐
Presentation by staff other than WIC Program ☐ ☐
Other ☐ ☐
If other, specify:
Civil rights training is provided annually
State agency staff ☐ Yes ☐ No
Local agency staff ☐ Yes ☐ No
Collection and use of racial/ethnical data ☐ ☐
Effective public notification systems ☐ ☐
Complaint procedures ☐ ☐
Compliance review techniques ☐ ☐
Requirements for reasonable accommodation ☐ ☐
of persons with disabilities
Requirements for language assistance ☐ ☐
Conflict resolution ☐ ☐
Customer Service ☐ ☐
If other, specify:
DETAIL: Civil Rights Appendix and/or Procedure Manual (citation):
The State agency has copies of the following materials on file:
☐ Title IX, Education Amendments, 7 CFR 15a (sex discrimination)
☐ Section 504, Rehabilitation Act of 1973, 7 CFR 15b
☐ Racial/Ethnic data collection policy and reporting requirements
☐ Age Discrimination Act of 1975, 45 CFR Part 91
☐ Americans with Disabilities Act, 28 CFR Part 35
☐ Civil Rights Restoration Act of 1987
The State agency's policy for reasonable accommodation for the disabled includes the most up-to-date special provisions for the disabled.
☐ Yes ☐ No
(Refer to FNS Instruction 113-1, Civil Rights Compliance and Enforcement–Nutrition Programs and Activities)
Public Notification
The State agency requires its local agencies to include the nondiscrimination policy statement and civil rights complaint procedure on the following (check all that apply):
☐ Outreach letters to the general public ☐ Radio announcements
☐ Program information letters ☐ Publications
☐ Program information brochures ☐ Posters
☐ Program information bulletins ☐ Newsletters
☐ Newspaper announcements ☐ Referral material
☐ Internet ☐ Television announcements
☐ Letters of invitation in the public hearing process
☐ Certification forms to be signed by participants
☐ Application forms (including computer-based forms)
☐ Other (specify):
The State agency requires that the USDA nondiscrimination poster, "And Justice For All," or an FNS- approved substitute be displayed in the following places frequented by applicants and participants:
☐ Clinic waiting rooms
☐ Food instrument issuance offices
☐Group/individual nutrition education areas
☐Test kitchens
☐ Warehouse distribution centers
☐ Other (specify):
Check the group categories that the State agency and its local agencies publicly inform of the following information (check all that apply; see key below):
1 2 3
☐ ☐ ☐ Availability of program benefits
☐ ☐ ☐ Eligibility criteria for participation
☐ ☐ ☐ Location of LA/clinics operating WIC Program and (800) telephone numbers
☐ ☐ ☐ Hours of service of LA/clinics operating WIC Program
☐ ☐ ☐ Rights and responsibilities
☐ ☐ ☐ Nondiscrimination policy
☐ ☐ ☐ Civil rights complaint procedure
1 = general public
2 = grassroots/community organizations that deal with potentially eligible minorities
3 = potential eligibles/applicants/participants
The State agency ensures that advocacy/minority organizations and the general public are informed of the benefits/policies listed above (please provide the appropriate Procedure Manual citation of materials used):
☐ Annually ☐ More frequently
Nondiscrimination Notification
The State agency or local agency:
☐ Provides applicants/participant with key information, such as applications and materials describing eligibility criteria and procedures for delivery of benefits, in appropriate languages other than English in areas where a significant proportion of people with limited English proficiency (LEP) reside.
☐ Appropriate bilingual staff, volunteers, or other translation resources are available to serve applicants and participants in areas where a significant proportion of people with limited English proficiency (LEP) reside.
☐ All rights and responsibilities listed on the certification form are read to or by the applicants and participants in the appropriate language, or if the participant is sight or hearing impaired and requires assistance.
The State agency provides WIC Program materials and translators in the following languages (Check all that apply; M = Materials, VT = Volunteer Translators, PT = Paid Translators, BS = Bilingual Staff):
M VT PT BS
☐ ☐ ☐ ☐ English
☐ ☐ ☐ ☐ Spanish
☐ ☐ ☐ ☐ French
☐ ☐ ☐ ☐ Vietnamese
☐ ☐ ☐ ☐ Chinese
☐ ☐ ☐ ☐ Other Asian/Pacific (specify):
☐ ☐ ☐ ☐ Tribal (specify):
☐ ☐ ☐ ☐ Braille
☐ ☐ ☐ ☐ Sign Interpreter
☐ ☐ ☐ ☐ Other (specify):
Compliance Review
Civil rights reviews of local agencies are conducted:
☐ Separately
☐ In conjunction with another department, organization or service as part of an overall review
☐ Other (specify):
b. The State agency reviews all of its local agencies for civil rights compliance with the nondiscrimination laws and regulations when it does its reviews.
☐ Yes ☐ No
Monitoring Activity
In addition to the local agency reviews, the State agency uses the following means to ensure that local agencies operate in a nondiscriminatory manner:
☐ Review of the racial/ethnic enrollment and/or participation data applications
☐ Review of denied
☐ Review of complaints
☐ Review of participant surveys
☐ Participant interviews
☐ Review of waiting lists
☐ Other (specify):
The State agency checks for the following in local agency applications:
☐ The local agency has corrected all past substantiated civil rights problems or noncompliance
situations
☐ The Civil Rights Assurance is included in the State-Local Agency Agreement
☐ A description of the racial/ethnic makeup of the service area is included in the application
☐ Appropriate staff, volunteers, or other translation resources are available in areas where a significant proportion of people with limited English proficiency (LEP) reside
☐ Case records include racial/ethnic data
☐ Where applicable, an explanation of why the racial/ethnic WIC participant level is not proportionate to the income eligible racial/ethnic population
☐ The local agency has conducted civil rights training for its staff
☐ The project area displays the USDA nondiscrimination poster, "And Justice For All," or an FNS-approved substitute
☐ Program information has been provided to applicants, participants, and grassroots organizations or similar minority groups
☐ The nondiscrimination policy statement and civil rights complaint procedure are included on all printed materials such as applications, pamphlets, forms, or any other materials distributed to the public
☐ Racial/ethnic data are collected by actual count and maintained on file for 3 years
☐ The local agency has corrected all past substantiated civil rights problems or noncompliance situations
☐ Civil rights complaints are handled in accordance with the procedures outlined in FNS Instruction 113-1
Data Collection
The State agency ensures the following when collecting civil rights data:
☐ All racial/ethnic categories are collected and reported as part of the program participant characteristics
report
☐ Racial/ethnic data definitions are in accordance with current OMB guidance and WIC policy, and clinic procedures are in place to ensure the data is collected accurately
☐ Data reported on participant characteristics include the number of persons on WIC master lists or persons listed in WIC operating files who are certified to receive WIC benefits
☐ Collected racial/ethnic data and records are accessible only to authorized personnel
The State agency maintains a civil rights file which retains collected racial/ethnic data for three years.
☐ Yes ☐ No
The State agency instructs its local agencies to obtain a participant's racial/ethnic category by (check all that apply):
☐ Allowing self-identification by participant (must be used at participant’s request)
☐Visual identification/sight assessment by local agency staff
☐ Local agency staff personally know participant's racial/ethnic category
☐Other (specify):
The State agency ensures the following:
☐ WIC Program applicants and participants are informed where and how they may file a complaint of discrimination by directing them to the USDA Office of the Assistant Secretary for Civil Rights (OASCR) website (http:/www.ascr.usda.gov/complaint_filing_cust.html) for proper Discrimination Complaint Filing processes.
☐ WIC Program applicants and participants are informed that they can file their complaints directly with the U.S. Department of Agriculture or directly with the FNS HQ Civil Rights Division, their State Agency or their local Agency. However, the local/State Agency must then forward their complaint either directly to the FNS HQ Civil Rights Division or the U.S. Department of Agriculture.
☐ All local agency staff are trained in discrimination complaint procedures
☐ All written and verbal complaints alleging discrimination based on race, color, national origin, age, sex, or disability are accepted from applicants and participants by State agency and local agency staff and forwarded to the FNS HQ Civil Rights Division.
☐ Complaints alleging discrimination based on race, color, national origin, or age are forwarded to the FNS HQ Civil Rights Division through an FNS-established complaint procedure. (Regional Office receives copy of all complaints.)
☐ Complaints alleging discrimination based on sex or disability are forwarded to the FNS HQ Civil Rights Division (for those State and local agencies without an FNS-approved grievance procedure in place).
☐ Complaints alleging discrimination based on sex or disability are forwarded to the FNS HQ Civil Rights Division.
The State agency uses a discrimination complaint form it has developed for acceptance of a complaint.
☐ Yes ☐ No
The State agency establishes and ensures that local agencies implement specific timeframes concerning discrimination complaints:
☐ An individual has the right to file a complaint within 180 days of the alleged discriminatory action.
☐ All complaints are processed and closed within 90 days of receipt.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |