Appendix V. WIC MIS Data Pull Form.xlsx

FNS Information Collection Needs due to COVID-19

Appendix V. WIC MIS Data Pull Form.xlsx

OMB: 0584-0654

Document [xlsx]
Download: xlsx | pdf

Overview

Introduction
(1a) Enrollment CY 2019
(1b) Enrollment CY 2020
(2a) New Certification CY 2019
(2b) New Certification CY 2020
(3a) Re-Certification CY 2019
(3b) Re-Certification CY 2020
(4a) Redemption CY2019
(4b) Redemption CY2020
(5) Nutrition Education Rate
(6) No-Show Rate

Sheet 1: Introduction
Appendix X2: WIC MIS Data Pull Form
OMB Control No: 0584-XXXX







Expiration Date: XX/XX/20XX










WIC MIS Data Pull Form
(See accompanying "WIC MIS Data Pull Instructions” for further guidance)










Background:








The Families First Coronavirus Response Act (P.L. 116-127, FFCRA), as amended by the Continuing Appropriations Act, 2021 and Other Extensions Act (P.L. 116-159), provides the U.S. Department of Agriculture (USDA) the statutory and regulatory waiver authorities necessary in a public health emergency such as COVID-19 to allow for social distancing in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). The FFCRA requires that WIC State agencies (SAs) receiving Federal waivers fulfill certain reporting requirements—these requirements are described in detail in sections 2203(b) and 2203(b) of the FFCRA and also in the provided guide “How to Fulfill the FFCRA WIC Waiver Reporting Requirements: Instructions and Tools.”
The WIC MIS Data Pull Form was developed to help SAs report on key administrative data as one of three tools developed to help State agencies meet their reporting requirements. Comprehensive instructions for completing this form, including alternative options, are provided in the accompanying “WIC MIS Data Pull Instructions.”










Completing the Form:
The WIC MIS Data Pull Form will collect administrative data from two time periods, Calendar Year (CY) 2019 and CY 2020. To complete this, SAs can either:

• Populate each of the form’s tabs with the requested administrative data, and submit the completed form to FNS; or
• Compile existing Management Information System (MIS) reports containing the data requested on the FFCRA WIC Administrative Data Form, and submit those reports to FNS.




We recognize that SA data and MIS reports may vary. If your SA is unable to obtain any specific data requested in the WIC MIS Data Pull Form, please notify [CONTRACTOR CONTACT] within 5 business days after receipt of the form to discuss alternative data collection options.










Contents:






The FFCRA WIC Administrative Data Form is divided into three sections and 10 different tabs as described below. Sections 1 and 2 ask for monthly data from CY 2019 and CY 2020 (January 2019 through December 2020), and Section 3 asks for data from one selected reference month for each year: June 2019 and June 2020.

Section 1 Tabs (Monthly Data):









(1a) Enrollment, CY 2019








(1b) Enrollment, CY 2020








(2a) New Certifications, CY 2019








(2b) New Certifications, CY 2020








(3a) Re-Certifications, CY 2019








(3b) Re-Certifications, CY 2020







Section 2 Tabs (Monthly Data):









(4a) Redemption, CY 2019








(4b) Redemption, CY 2020







Section 3 Tabs (Specified Months Only):









(5) Nutrition Education Rate, June 2019 and June 2020








(6) No-Show Rate, June 2019 and June 2020
















Who to Contact with Questions:








If you have any questions about the form or the information required to complete it, please contact [CONTRACTOR CONTACT]. The FNS points of contact for this collection are Alex Bush ([email protected]) and Hunjin Lee ([email protected]).
We appreciate your time and work to complete the WIC MIS Data Pull Form and for your dedication to serving the participants of the WIC Program.





















Sheet 2: (1a) Enrollment CY 2019
(1a) Number of Enrolled CY 2019
Comments
















Calendar Year 2019 Availability * January
2019		 February
2019		 March
2019		 April
2019		 May
2019		 June
2019		 July
2019		 August
2019		 September
2019		 October
2019		 November
2019		 December
2019		 Data Description 
Total Enrolled












Total number of enrollments for each month indicated in Row 3. This number should be the sum of the numbers in Row 5, Row 10, and Row 11.
1. Total Women












Total number of enrolled Women under the category for each month indicated in Row 3. This number should be the sum of the numbers in Row 6 through Row 9.
1a. Pregnant












Total number of enrolled Pregnant Women under the category for each month indicated in Row 3.
1b. Partially Breastfeeding












Total number of enrolled Partially Breastfeeding Women under the category for each month indicated in Row 3.
1c. Fully Breastfeeding












Total number of enrolled Fully Breastfeeding Women under the category for each month indicated in Row 3.
1d. Postpartum












Total number of enrolled Postpartum Women under the category for each month indicated in Row 3.
2. Total Infants












Total number of enrolled Infants under the category for each month indicated in Row 3.
3. Total Children












Total number of enrolled Children under the category for each month indicated in Row 3.
















* Please enter "N/A" in Column B if the numbers for sub-category in Column A are not available.












Sheet 3: (1b) Enrollment CY 2020
(1b) Number of Enrolled CY 2020
Comments
















Calendar Year 2020 Availability * January
2019		 February
2019		 March
2019		 April
2019		 May
2019		 June
2019		 July
2019		 August
2019		 September
2019		 October
2019		 November
2019		 December
2019		 Data Description 
Total Enrolled












Total number of enrollments for each month indicated in Row 3. This number should be the sum of the numbers in Row 5, Row 10, and Row 11.
1. Total Women












Total number of enrolled Women under the category for each month indicated in Row 3. This number should be the sum of the numbers in Row 6 through Row 9.
1a. Pregnant












Total number of enrolled Pregnant Women under the category for each month indicated in Row 3.
1b. Partially Breastfeeding












Total number of enrolled Partially Breastfeeding Women under the category for each month indicated in Row 3.
1c. Fully Breastfeeding












Total number of enrolled Fully Breastfeeding Women under the category for each month indicated in Row 3.
1d. Postpartum












Total number of enrolled Postpartum Women under the category for each month indicated in Row 3.
2. Total Infants












Total number of enrolled Infants under the category for each month indicated in Row 3.
3. Total Children












Total number of enrolled Children under the category for each month indicated in Row 3.
















* Please enter "N/A" in Column B if the numbers for sub-category in Column A are not available.












Sheet 4: (2a) New Certification CY 2019
(2a) Number of New Certifications CY 2019
Comments
















Calendar Year 2019 Availability * January
2019		 February
2019		 March
2019		 April
2019		 May
2019		 June
2019		 July
2019		 August
2019		 September
2019		 October
2019		 November
2019		 December
2019		 Data Description 
Total New Certifications












Total number of New Certifications for each month indicated in Row 3. This number should be the sum of the numbers in Row 5, Row 10, and Row 11.
1. Total Women












Total number of Newly Certified Women under the category for each month indicated in Row 3. This number should be the sum of the numbers in Row 6 through Row 9.
1a. Pregnant












Total number of Newly Certified Pregnant Women under the category for each month indicated in Row 3.
1b. Partially Breastfeeding












Total number of Newly Certified Partially Breastfeeding Women under the category for each month indicated in Row 3.
1c. Fully Breastfeeding












Total number of Newly Certified Fully Breastfeeding Women under the category for each month indicated in Row 3.
1d. Postpartum












Total number of Newly Certified Postpartum Women under the category for each month indicated in Row 3.
2. Total Infants












Total number of Newly Certified Infants under the category for each month indicated in Row 3.
3. Total Children












Total number of Newly Certified Children under the category for each month indicated in Row 3.
















* Please enter "N/A" in Column B if the numbers for sub-category in Column A are not available.












Sheet 5: (2b) New Certification CY 2020
(2b) Number of New Certifications CY 2020
Comments
















Calendar Year 2020 Availability * January
2019		 February
2019		 March
2019		 April
2019		 May
2019		 June
2019		 July
2019		 August
2019		 September
2019		 October
2019		 November
2019		 December
2019		 Data Description 
Total New Certifications












Total number of New Certifications for each month indicated in Row 3. This number should be the sum of the numbers in Row 5, Row 10, and Row 11.
1. Total Women












Total number of Newly Certified Women under the category for each month indicated in Row 3. This number should be the sum of the numbers in Row 6 through Row 9.
1a. Pregnant












Total number of Newly Certified Pregnant Women under the category for each month indicated in Row 3.
1b. Partially Breastfeeding












Total number of Newly Certified Partially Breastfeeding Women under the category for each month indicated in Row 3.
1c. Fully Breastfeeding












Total number of Newly Certified Fully Breastfeeding Women under the category for each month indicated in Row 3.
1d. Postpartum












Total number of Newly Certified Postpartum Women under the category for each month indicated in Row 3.
2. Total Infants












Total number of Newly Certified Infants under the category for each month indicated in Row 3.
3. Total Children












Total number of Newly Certified Children under the category for each month indicated in Row 3.
















* Please enter "N/A" in Column B if the numbers for sub-category in Column A are not available.












Sheet 6: (3a) Re-Certification CY 2019
(3a) Number of Re-certifications CY 2019
Comments
















Calendar Year 2019 Availability * January
2019		 February
2019		 March
2019		 April
2019		 May
2019		 June
2019		 July
2019		 August
2019		 September
2019		 October
2019		 November
2019		 December
2019		 Data Description 
Total Recertifications












Total number of Re-Certifications for each month indicated in Row 3. This number should be the sum of the numbers in Row 5, Row 10, and Row 11.
1. Total Women












Total number of Re-Certified Women under the category for each month indicated in Row 3. This number should be the sum of the numbers in Row 6 through Row 9.
1a. Pregnant












Total number of Re-Certified Pregnant Women under the category for each month indicated in Row 3.
1b. Partially Breastfeeding












Total number of Re-Certified Partially Breastfeeding Women under the category for each month indicated in Row 3.
1c. Fully Breastfeeding












Total number of Re-Certified Fully Breastfeeding Women under the category for each month indicated in Row 3.
1d. Postpartum












Total number of Re-Certified Postpartum Women under the category for each month indicated in Row 3.
2. Total Infants












Total number of Re-Certified Infants under the category for each month indicated in Row 3.
3. Total Children












Total number of Re-Certified Children under the category for each month indicated in Row 3.
















* Please enter "N/A" in Column B if the numbers for sub-category in Column A are not available.












Sheet 7: (3b) Re-Certification CY 2020
(3b) Number of Re-certifications CY 2020
Comments
















Calendar Year 2020 Availability * January
2019		 February
2019		 March
2019		 April
2019		 May
2019		 June
2019		 July
2019		 August
2019		 September
2019		 October
2019		 November
2019		 December
2019		 Data Description 
Total Recertifications












Total number of Re-Certifications for each month indicated in Row 3. This number should be the sum of the numbers in Row 5, Row 10, and Row 11.
1. Total Women












Total number of Re-Certified Women under the category for each month indicated in Row 3. This number should be the sum of the numbers in Row 6 through Row 9.
1a. Pregnant












Total number of Re-Certified Pregnant Women under the category for each month indicated in Row 3.
1b. Partially Breastfeeding












Total number of Re-Certified Partially Breastfeeding Women under the category for each month indicated in Row 3.
1c. Fully Breastfeeding












Total number of Re-Certified Fully Breastfeeding Women under the category for each month indicated in Row 3.
1d. Postpartum












Total number of Re-Certified Postpartum Women under the category for each month indicated in Row 3.
2. Total Infants












Total number of Re-Certified Infants under the category for each month indicated in Row 3.
3. Total Children












Total number of Re-Certified Children under the category for each month indicated in Row 3.
















* Please enter "N/A" in Column B if the numbers for sub-category in Column A are not available.












Sheet 8: (4a) Redemption CY2019
(4a) EBT Redemption vs. Issuance CY2019



Comments































































Calender Year 2019 January 2019 February 2019 March 2019 April 2019 May 2019 June 2019 July 2019 August 2019 September 2019 October 2019 November 2019 December 2019
Category Code Subcategory Code Unit of Measure Description Redeemed Issued Redemption Rate Redeemed Issued Redemption Rate Redeemed Issued Redemption Rate Redeemed Issued Redemption Rate Redeemed Issued Redemption Rate Redeemed Issued Redemption Rate Redeemed Issued Redemption Rate Redeemed Issued Redemption Rate Redeemed Issued Redemption Rate Redeemed Issued Redemption Rate Redeemed Issued Redemption Rate Redeemed Issued Redemption Rate






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Sheet 9: (4b) Redemption CY2020
(4b) EBT Redemption vs. Issuance CY2020



Comments































































Calender Year 2020 January 2020 February 2020 March 2020 April 2020 May 2020 June 2020 July 2020 August 2020 September 2020 October 2020 November 2020 December 2020
Category Code Subcategory Code Unit of Measure Description Redeemed Issued Redemption Rate Redeemed Issued Redemption Rate Redeemed Issued Redemption Rate Redeemed Issued Redemption Rate Redeemed Issued Redemption Rate Redeemed Issued Redemption Rate Redeemed Issued Redemption Rate Redeemed Issued Redemption Rate Redeemed Issued Redemption Rate Redeemed Issued Redemption Rate Redeemed Issued Redemption Rate Redeemed Issued Redemption Rate






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Sheet 10: (5) Nutrition Education Rate
(5) Nutrition Education Rate
Comments






Number of Completed WIC Nutrition Education Appointments Number of Scheduled WIC Nutrition Education Appointments Nutrition Education Rate Comments
1. June 2020

Total Participants

N/A
1. Total Women

N/A
1a. Pregnant

N/A
1b. Partially Breastfeeding

N/A
1c. Fully Breastfeeding

N/A
1d. Postpartum

N/A
2. Total Infants

N/A
3. Total Children

N/A











Number of Completed WIC Nutrition Education Appointments Number of Scheduled WIC Nutrition Education Appointments Nutrition Education Rate Comments
2. June 2019

Total Participants

N/A
1. Total Women

N/A
1a. Pregnant

N/A
1b. Partially Breastfeeding

N/A
1c. Fully Breastfeeding

N/A
1d. Postpartum

N/A
2. Total Infants

N/A
3. Total Children

N/A










3. Was the Nutrition Education Rate * in June of 2020 higher, lower, or about the same as one year earlier in June of 2019?







Higher








Lower








About the same








Don't Know











*









Sheet 11: (6) No-Show Rate
(6) No-Show Rate
Comments












Number of Completed WIC Certification Appointments Number of Scheduled WIC Certification Appointments No-Show Rate Comments





1. June 2020












Total Participants

N/A






1. Total Women

N/A






1a. Pregnant

N/A






1b. Partially Breastfeeding

N/A






1c. Fully Breastfeeding

N/A






1d. Postpartum

N/A






2. Total Infants

N/A






3. Total Children

N/A





























Number of Completed WIC Certification Appointments Number of Scheduled WIC Certification Appointments No-Show Rate Comments





2. June 2019












Total Participants

N/A






1. Total Women

N/A






1a. Pregnant

N/A






1b. Partially Breastfeeding

N/A






1c. Fully Breastfeeding

N/A






1d. Postpartum

N/A






2. Total Infants

N/A






3. Total Children

N/A




























3. Was the No-Show Rate * in June of 2020 higher, lower, or about the same as one year earlier in June of 2019?
























Higher




















Lower




















About the same




















Don't Know





























*





















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