WIC Local Agency Applications and State Agency Evaluations - SLT

Attachment G WIC Breastfeeding Award of Excellence Gold Award Application

OMB Control Number: 0584-0591
Expiration date: xx/xx/20xx

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

WIC Breastfeeding Award of Excellence
Gold Award Application
Cover Sheet
Local Agency Name
Street Address
City, State, Zip code
Email
Date

In accordance to Section 231 of the Healthy, Hunger-Free Kids Act of 2010 (HHFKA) (Public Law 111-296), this information is being collected to assist the Food and
Nutrition Service in implementing a program to recognize exemplary breastfeeding support practices at WIC local agencies and clinics. This is a voluntary
collection, but failure to provide the requested information in full will prevent applicants from being considered for recognition. FNS will use the information to
improve the delivery and tailoring of WIC services and increase satisfaction of both staff and participants. This collection requests only minimal personally
identifiable information (email address) which will not be used routinely to retrieve records 1974. 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 0584-0591. The time required to complete this information collection is estimated to average 2 hours per
response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing
the collection of information. 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 (0584-0591). Do not return the completed form to this address.

Gold Application 1

OMB Control Number: 0584-0591
Expiration date: xx/xx/20xx

WIC Breastfeeding Award of Excellence
DOWNLOAD AND SAVE INSTRUCTIONS BEFORE BEGINNING THE APPLICATION. In order to be
eligible to apply for an award, your local agency must first be able to verify the following two questions:

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

Yes

2. Does your local agency peer counseling program meet all components of the FNS
WIC Breastfeeding Model for Peer Counseling?

Yes

If your local agency received a Gold award in the past 4 years, proceed topage 6 Gold Award Application.

PEER COUNSELING
1. Does your local agency conduct an annual needs assessment that identifies each of the
following:
(a) the 2 top priorities for your target audience;
(b) where gaps exist in breastfeeding services and resources within your local agency and
the community that can be addressed through peer counseling; and
(c) where improvements in your program are needed?
Attach narrative. Fill in narrative title.

Yes

No

Narrative
If "No", enter "n/a"
2. Do you have a protocol that describes how peer counselors address a mother concerns and
needs outside of usual clinic hours, including how peer counselors make after-hour referrals?
Attach supportive documentation. Fill in the document title and indicate the page number(s)
where the information that answers this question can be found.
Document Title

Yes

No

If "No", enter "n/a"
Page Number(s)

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

Yes

No

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

Yes

No

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

Yes

No

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

Yes

No

Gold Application
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OMB Control Number: 0584-0591
Expiration date: xx/xx/20xx

7. Do you have adequate supervision of peer counselors by staff with advanced lactation
training?
Adequate supervision is defined as having at least a .25 full time employee (FTE) supervisor
for every 5 peer counselors.

Yes

No

8. Do you have a written defined scope of practice for peer counselors, limited to supporting
normal breastfeeding, that describes the peer counselor’s role to provide basic breastfeeding
education and support to WIC mothers?
Attach supportive documentation. Fill in the document title and indicate the page number(s)
where the information that answers this question can be found.

Yes

No

Document Title
If "No", enter "n/a"
Page Number(s)

9. Do you have a process/protocol in place that describes when the peer counselors should
“yield” and refer breastfeeding concerns and conditions that are outside the scope of practice
of the peer counselor to a Designated Breastfeeding Expert (DBE) AND how the DBE refers
the participant back to the peer counselor?

Yes

No

Attach supportive documentation. Fill in the document title and indicate the page number(s)
where the information that answers this question can be found.
Document Title
If "No", enter "n/a"
Page Number(s)

10. Do you have procedures in place for WIC staff to refer participants to peer counselors
as part of your usual WIC certification, assessment and nutrition education process?

Yes

No

Attach narrative OR supportive documentation. Fill in the document title and indicate the
page number(s) where the information that answers this question can be found.
Narrative OR Document Title
If "No", enter "n/a"
Page Number(s)

11. Do peer counselors routinely contact mothers, at a minimum, monthly during pregnancy
and weekly 2 weeks prior to a woman’s expected delivery date?

Yes

No

12. Do peer counselors routinely contact mothers, at a minimum, every 2-3 days in the first
week after delivery AND within 24 hours if the mother reports problems with breastfeeding
AND weekly throughout rest of first month?

Yes

No

13. Do peer counselors routinely contact mothers after a woman’s first month postpartum, at
a minimum, monthly, as long as things are going well?

Yes

No

Gold Application
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OMB Control Number: 0584-0591
Expiration date: xx/xx/20xx

14. Do peer counselors routinely contact mothers after a woman’s first month postpartum, at
a minimum, 1-2 weeks before the mother plans to return to work or school AND 1-2 days after
she returns to work or school?

Yes

No

PARTNERSHIP
A partnership is defined as a sustainable ongoing voluntary collaborative agreement between two or more
parties based on mutually agreed objectives and a shared vision, generally within a formal structure. The partners
agree to work together to achieve a common goal, undertake specific tasks, and share risks, responsibilities,
resources, competencies and benefits in order to provide breastfeeding support throughout the rest of the first
month.
15. Was the partnership developed to solve an existing problem or gap in breastfeeding
support services?

Yes

No

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

Yes

No

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

Yes

No

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

Yes

No

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

Yes

No

20. Has the partnership produced results that provide an ongoing benefit?

Yes

No

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

Yes

No

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

Yes

No

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

Yes

No

OTHER CRITERIA

Attach supportive documentation. Fill in the document title and indicate the page number(s)
where the information that answers this question can be found.
Document Title
If "No", enter "n/a"
Page Number(s)

Gold Application
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OMB Control Number: 0584-0591
Expiration date: xx/xx/20xx

24. Do you ensure that all staff are trained to support the goal of exclusive breastfeeding
with WIC participants using the FNS-developed competency-based breastfeeding
curriculum?

Yes

No

25. Do you have policies and procedures that require staff to assess, and individually tailor
food packages to all breastfeeding dyads when infant formula is requested?

Yes

No

Attach supportive documentation.Fill in the document title and indicate the page
number(s) where the information that answers this question can be found.
Document Title
If "No", enter "n/a"
Page Number(s)

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

Yes

No

27. Do you provide ongoing training to all WIC staff using the FNS-developed competencybased breastfeeding curriculum, or similar State-developed training based on FNSdeveloped breastfeeding curriculum?

Yes

No

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

Yes

No

Yes

No

29. Do you have policies and procedures that require support for breastfeeding mothers,
especially during the early postpartum period, that assist mothers in continuing exclusive
breastfeeding for as long as possible?
Attach supportive documentation. Fill in the document titles and indicate the page
number(s) where the information that answers this question can be found.
Document Title

If "No", enter "n/a"
Page Number(s)

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

Yes

No

Gold Application
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OMB Control Number: 0584-0591
Expiration date: xx/xx/20xx

WIC Breastfeeding Award of Excellence Gold Award Application Checklist
Please review the checklist prior to submitting application and supportive
documentation.

Previous Gold Awardees
Please fill out the year your local agency received the Gold award.

Verify the following has been completed:
Cover sheet, p1
Prescreening, p2
Checklist, p6

Year Received

Yes

No

Continue on to the application for the Premiere and Elite Awards to apply for a
higher level award.

New Applicants
All 30 questions need to be answered “Yes” to be eligible for the Gold
Award. Verify that all questions have been answered.

Yes

No

Narratives and supportive documentation are attached to the
application packet.

Yes

No

When attaching supportive documents make sure you indicate the page
number(s) where the information that answers the question can be found.

Yes

No

Yes

No

Please enter the full name of your Local Agency without abbreviations or
acronyms and complete the Application Verification Form on page 7 of the
Application.

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

Gold Application
page 6

OMB Control Number: 0584-0591
Expiration date: xx/xx/20xx

Congratulations!
You have completed the application for the WIC Breastfeeding Award of Excellence
at the Gold Award level.
If you would like to apply for a higher level award, continue on to the application
for the Premiere and Elite Awards.

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

WIC Breastfeeding Award of Excellence
Applicant Verification Form
Please read the following statement and type your name for signature below if you agree:
I have reviewed this application, and I attest to the accuracy of the information provided. I agree to maintain
the standards and procedures indicated in this application for the duration of our award period. Furthermore, I
agree to cooperate with USDA, upon request, to publicize our efforts.

Local Agency Name

Date

Please upload your completed application and supporting documentation to
https://spaces.hightail.com/uplink/WWRS

Thank you for applying for the WIC Breastfeeding Award of Excellence.
For more information, visit the FNS/WIC Website:

https://www.fns.usda.gov/wic/breastfeeding-priority-wic-program

Gold Application page 7