WIC Local Agency Applications and State Agency Evaluations - SLT

Attachment K WIC Breastfeeding Award of Excellence the Premiere and Elite 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
Premiere and Elite Award Application
Cover Sheet

Local Agency Name
Street Address
City, State, Zip Code
Email Address
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 under the Privacy Act of 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.
Loving Support Award of Excellence Gold
Premiere/Gold Elite Application 1

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

WIC Breastfeeding Award of Excellence Premiere and Elite Application
DOWNLOAD AND SAVE INSTRUCTIONS FROM FNS PUBLIC WEBSITE 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 question:
1. Have you completed the Gold Award application and documentation?

Yes

No

Application
PEER COUNSELING
1. Do you have established guidelines for how many hours of observation/
shadowing is required as part of peer counseling training/continuing education?

Yes

No

Yes

No

Yes

No

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

Yes

No

5. Do you have policies and procedures for home visits as part of your peer
counseling program?

Yes

No

2. Do you have a WIC Designated Breastfeeding Expert or do you contract with an
International Board of Lactation Consultant Examiners (IBCLC) to serve as a
referral source for peer counselors?
3. Do you have a referral process in place between hospitals and the WIC
Program to facilitate peer counselor follow-up care for newly-delivered WIC
mothers after discharge?

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

6. Do you have policies and procedures for hospital visits as part of your peer
counseling program?

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)

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

Yes

No

Premiere/Elite Application
page 2

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

8. Do you include career path structures for upward mobility of peer counselors?
9. Do you have policies and procedures for peer counselors to communicate via
social media or innovative technologies, e.g., Facebook, text messaging, Twitter,
Skype or PalTalk?

Yes

No

Yes

No

Attach narrative and supportive documentation that indicate existing policies and
procedures for peer counselors to communicate via social media technologies. Fill
in both document titles and indicate the page numbers(s) that corresponds to
each document.
Narrative Title

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

Document Title
Page Number(s)

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 continuum of care.

10. Does the partnership have a written agreement or a Memorandum of
Understanding?

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)

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

Yes

No

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

12. Does the partnership have a plan for sustainability?

Yes

No

Loving Support Award of Excellence Gold
Premiere/Gold Elite Application 3

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

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

Yes

No

Yes

No

OTHER CRITERIA

14. Do you have a supportive clinic environment that implements breastfeedingfriendly workplace polices for WIC staff?
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)

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

Yes

No

16. Do you provide around the clock assistance to assist mothers working
through their breastfeeding problems?

Yes

No

Attach narrative. Fill in narrative title and indicate the page number(s) where the
information that answers this question can be found.
Narrative Title

If "No", enter "n/a"

Premiere/Elite Application
page 4

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

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

You must be eligible for the Gold Award (30 points) to apply for the Gold
Premiere and Gold Elite Award.

Yes

No

Yes

No

Narratives and/or supportive documentation must be attached to the
application to be eligible for an Award.

Yes

No

You have indicated the page number(s) where the narratives and/or
supportive documentation can be found.

Yes

No

Verify that you have met the performance data criteria.

Please enter the full name of your Local Agency without abbreviations or acronyms and complete the
Application Verification Form on page 6 of the Application.

Premiere/Elite Application
page 5

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

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 sign below if you agree:
I have reviewed this application, and I attest to the accuracy of the information provided. I agree to
maintain the standards and procedures indicated in this application for the duration of our award
period. Furthermore, I agree to cooperate with USDA, 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

Premiere/Elite Application
page 6