WIC Local Agency Applications and State Agency Evaluations - SLT

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

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

WIC Breastfeeding Award of Excellence
Gold Award Evaluation Instructions
Gold Award
This document works in coordination with the online evaluation site in PartnerWeb. You have
completed the Step 1 online by accessing this document. Click the “SA-Reviewers” tab to return
to the State Agency evaluation website.
To begin Step 2 locate the section “Applications and Evaluation Worksheets”. Click the + next to
your State to expand the view of all applications submitted within your State.
The applications are located in the “name” column. Click the local Agency name to open the .zip
file. The .zip file contains the completed application forms and all of the documentation
submitted by the local agency. Instructions on how to unzip can be found in the WIC
Breastfeeding Awards Frequently Asked Questions.
To score an application, you will need to open an evaluation worksheet. Scroll down to the
“Applications and Evaluation Worksheets” section. To the far left, you will see a column named
“edit”. This is where the evaluation worksheets are located. Each application has its own
evaluation worksheet.
The Gold Award application has a total of 30 questions, each worth 1 point.
When evaluating the application, if a Gold Award question is checked “No”, or if the
documentation attached for a Gold Award question does not meet the criteria listed - STOP.
The applicant is not eligible for a Gold Award. Complete the following sections of the evaluation
worksheet: “State-Status”, “SA-Recommendation for Gold” (choose “No Recommendation”),
“Justification for No Recommendation”, and “State Evaluator Name”. Then click save.

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 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 consideration for
recognition. 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. 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. The time required to complete
this information collection is estimated to average 1.2 hours per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. 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 22306 ATTN: PRA (0584-0591). Do not return the completed application to this
address.

Prescreening
Before an applicant can apply for an award they must verify their local agency peer counseling
program has been in place for at least one year, and that their peer counseling program meets all
core components of WIC Breastfeeding Model for Peer Counseling listed below.
Verify the prescreening question has been answered “Yes” and the applicant meets the
requirements to continue. If verified, select “Yes” on the evaluation worksheet.
If the prescreening question is checked “No” - STOP. The applicant is not eligible for a Gold
Award. Complete the following sections: “State-Status”, “SA-Recommendation for Gold” (choose
“No Recommendation”), “State Evaluator Name”, and “Justification for No Recommendation”.
Then click save.

WIC BREASTFEEDING MODEL FOR PEER COUNSELING
REQUIRED PROGRAM COMPONENTS
Program Management
• The local agency has a designated peer counseling program manager or coordinator.
• The local agency has standardized breastfeeding peer counseling program policies in
place as part of its nutrition education plan.
• Local agency staff is trained on supporting the peer counseling program.
• The local agency has a WIC designated breastfeeding expert for referrals outside of the
peer counselor’s scope of practice.
• The local agency has established community partnerships to enhance the effectiveness of
its peer counseling program, e.g., hospitals, health care providers, home visiting
programs, etc.
Peer Counselor Staffing
• The local agency has defined job parameters and position descriptions for peer
counselors.
• Peer counselors are recruited and hired from the target population served by WIC.
• Peer counselors are paraprofessionals, i.e., are not licensed or credentialed as healthcare,
nutrition, or lactation consultant professionals.
• Peer counselors are available to WIC clients outside usual clinic hours and outside the
WIC clinic environment.
• Peer counselors receive adequate compensation and reimbursement for expenses.
Peer Counselor Training and Support
• Peer counselors are trained using FNS-developed curricula
• Ongoing continuing education is provided to peer counselors through regularly scheduled
staff meetings and other educational opportunities.
• Peer counselors have timely access to breastfeeding coordinators and other lactation
experts for assistance with problems outside their scope of practice.
• Peer counselors are offered opportunities to meet regularly with other peer counselors.

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Documentation
Some questions in the application require additional documents. There are two types of
document requests, a narrative and/or supportive documentation.

Narrative refers to a document with explanatory statements that have been written exclusively for
the purpose of this application. The narrative should describe how the agency meets the criteria
of a specific question as noted in the instructions. Narratives are not to exceed 500 words.

Supportive documentation refers to documents that already exist. The preferred source of

documentation are locally developed policies, procedures, MOU’s, etc.; however, State and
Federal documentation are acceptable. These documents are submitted to demonstrate how the
agency meets the criteria of a specific question as noted in the instructions for that question. The
attached documentation should indicate the page number(s) where the specific information can
be found in response to the question.
Entire policy and procedure manuals are not acceptable forms of documentation.

Prior Gold Awardees
Prior Gold Awardee Applicants were instructed to leave Questions 1-30 unanswered and complete
the Cover Page, Prescreening Questions, and Application Checklist (page 6 of the Gold
Application).
Verify the year the Local agency received an Award by going to:
https://www.fns.usda.gov/wic/loving-support-award-excellence-awardees. If the local agency
received a Gold award in the past 4 years, proceed to page 12 of the Gold Evaluation Instructions
(this document).
Next, go to Page 12 of this document to finish the Gold Evaluation for Prior Awardees.

New Gold Applicants
Continue to the next page to start the Gold Evaluation at Question 1a on the online Evaluation
Worksheet.
Note: To save and finish the evaluation later, scroll to the section “State-Status” and select “not
finished”. Then click “Save” to save your work. You can now exit the website.

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PEER COUNSELING
Question 1. (1 point)
Does your local agency conduct an annual needs assessment that identifies each of the following:
a) the top 2 priorities for your target audience;
b) where gaps exist in breastfeeding services and resources within your target audience that
can be addressed through peer counseling; and
c) where improvements in your program are needed?
Successful peer counseling programs occur through careful planning to address identified needs.
Information gathered during needs assessment helps local agencies identify strengths as well as
areas of breastfeeding services that can be modified or improved through peer counseling. A
needs assessment helps local agencies set priorities to maximize the effectiveness of peer
counselors. Without a needs assessment, planning is just a best guess.
Acceptable documentation:
The narrative should describe the top 2 priorities determined by the needs assessment, how your
local agency is addressing those needs through peer counseling, and where improvements in
your program can be made. Narrative not to exceed 500 words.
Verify the applicant response. Select Yes or No based on applicant’s response. Verify if the
documentation meets all of the requirements listed above.
Check Yes or No based on your documentation review.
Question 2. (1 point)
Do you have a protocol that describes how peer counselors address a mother’s concerns and
needs outside of usual clinic hours, including how peer counselors make after-hour referrals?
The key to success in peer counseling is being available to mothers when they need it most.
Breastfeeding problems often occur outside usual business hours, and peer counselors provide
important support beyond usual WIC services. The WIC Breastfeeding Model for Peer Counseling
requires that peer counselors be available to mothers outside of usual clinic hours, i.e., evenings
and weekends. Exemplary peer counseling programs develop strategies to ensure that peer
counselors are available to address a mother’s concerns and needs in a timely manner (via
phone, hotline, or face-to-face) and that referral and follow-up are provided.
Examples of Acceptable Supportive Documentation: Policies and procedures or protocols,
Training materials, Position descriptions / Roles and Responsibilities
Documentation attached includes all of the following:
• Your agency’s written procedure of the PC after hours referral process
• Describes how peer counselors address a mother’s concerns and needs outside usual
clinic hours.
• Describes at least one of the following: telephone calls, hotline, or face-to-face.
• Describes how after-hour referrals are made to the peer counselor or Designated
Breastfeeding Expert.

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Verify the applicant response. Check Yes or No based on applicant’s response. Verify if the
documentation meets all of the requirements listed above.
Check Yes or No based on your documentation review.
Question 3. (1 point)
Do you have opportunities for peer counselors to observe and shadow experienced lactation
experts and more experienced peer counselors?
Verify the applicant response. Check Yes or No based on applicant’s response.
Question 4. (1 point)
Do you routinely monitor the work of peer counselors through spot checks, chart reviews or
contact forms?
Verify the applicant response. Check Yes or No based on applicant’s response.
Question 5. (1 point)
Do you routinely observe newly trained peer counselors during contacts with mothers to provide
guidance and affirmation?
Verify the applicant response. Check Yes or No based on applicant’s response.
Question 6. (1 point)
Do you schedule routine meetings to discuss case studies with your peer counselors?
Verify the applicant response. Check Yes or No based on applicant’s response.
Question 7. (1 point)
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. Supervisory responsibilities include mentoring, monitoring, follow-up,
and spot checks.
Verify the applicant response. Check Yes or No based on applicant’s response.

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Question 8. (1 point)

Do you have a written defined scope of practice for a peer counselor that describes the peer counselor’s
role to provide basic breastfeeding education and support to WIC mothers?

Peer counselors supplement, but do not replace, the work of CPAs and lactation professionals. A
peer counselor’s scope of practice is to provide basic information and support to new moms, and
make referrals when they experience problems beyond their training. The peer counselors’ scope
of practice summarizes typical situations for which peer counselors can provide services, as well
as the types of information they can provide.
Examples of acceptable supportive documentation: Written Scope of Practice, Position
description/ Roles and Responsibilities, Policy and Procedures, Training Manual, Referral
protocol for peer counselors/list of referral topics.
Documentation attached includes all of the following:
• Scope of practice is attached.
• Scope of practice limits the peer counselor’s responsibilities to providing basic
information and support to new moms, and making referrals when peer counselors
experience problems beyond their training.
Verify the applicant response. Check Yes or No based on applicant’s response. Verify if the
documentation meets all of the requirements listed above.
Check Yes or No based on your documentation review.

Question 9. (1 point)

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?

A peer counselor’s scope of practice is limited to providing basic information and support to new
moms about normal breastfeeding, and “yield” (make referrals) when they experience problems
beyond their training. WIC mothers who need support outside the peer counselors scope of
practice should be referred to the Designated Breastfeeding Expert to provide timely and
appropriate follow-up.
Documentation attached includes all of the following:
• Process describes how peer counselors refer moms to a Designated Breastfeeding Expert
as part of normal clinic operations, during both the prenatal and postpartum periods
• How the DBE follows up with the peer counselor to share the participants' care plan.
Examples of acceptable supportive documentation:
Policy and Procedures, Training Manual, Referral protocol for peer counselors/list of referral
topics.
Verify the applicant response. Check Yes or No based on applicant’s response. Verify if the
documentation meets all of the requirements listed above. Check Yes or No based on your
documentation review.
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Question 10. (1 point)
Do you have procedures in place for WIC staff to refer WIC participants to peer counselors as part
of your usual WIC certification, assessment and nutrition education process?
Peer counselors should receive ongoing referrals from local clinic staff as part of the usual WIC
certification, assessment and nutrition education process. This includes creating ways to connect
mothers who need breastfeeding support and to peer counselors.
Acceptable narrative or documentation attached includes all of the following:
• Process describes how WIC mothers are referred to peer counselors during the prenatal
period.
• Process describes how WIC mothers are referred to peer counselors during the
postpartum period.
• Narrative not to exceed 500 words
Examples of acceptable supportive documentation: Policy and procedures, Staff training
materials, Referral protocol for peer counselors
Verify the applicant response. Check Yes or No based on applicant’s response. Verify if the
documentation meets all of the requirements listed above.
Check Yes or No based on your documentation review.
Question 11. (1 point)
Do peer counselors routinely contact mothers, at a minimum, monthly during pregnancy and
weekly 2 weeks prior to a woman’s expected delivery date?
Verify the applicant response. Check Yes or No based on applicant’s response.
Question 12. (1 point)
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 the rest of the first month?
Verify the applicant response. Check Yes or No based on applicant’s response.
Question 13. (1 point)
Do peer counselors routinely contact mothers after a woman’s first month postpartum, at a
minimum, monthly, as long as things are going well?
Verify the applicant response. Check Yes or No based on applicant’s response.

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Question 14. (1 point)
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?
Verify the applicant response. Check Yes or No based on applicant’s response.

PARTNERSHIP
Question 15. (1 point)
Was the partnership developed to solve an existing problem or gap in breastfeeding support
services?
Verify the applicant response. Check Yes or No based on applicant’s response.
Question 16. (1 point)
Are the resources each partner brings to the partnership clearly delineated?
Verify the applicant response. Check Yes or No based on applicant’s response.
Question 17. (1 point)
Does the partnership have goals that have been agreed upon by the members of the partnership?
Verify the applicant response. Check Yes or No based on applicant’s response.
Question 18. (1 point)
Are the roles and responsibilities clearly identified and understood by all members of the
partnership?
Verify the applicant response. Check Yes or No based on applicant’s response.
Question 19. (1 point)
Does the partnership have activities that have been agreed upon by the members of the
partnership?
Verify the applicant response. Check Yes or No based on applicant’s response.
Question 20. (1 point)
Has the partnership produced results that provide an ongoing benefit?
Verify the applicant response. Check Yes or No based on applicant’s response.

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OTHER CRITERIA
Question 21. (1 point)
Do you have a supportive clinic environment for breastfeeding that visibly endorses breastfeeding
as the preferred method of infant feeding?
Verify the applicant response. Check Yes or No based on applicant’s response.
Question 22. (1 point)
Do you have policies that support a clinic environment where participants feel comfortable
breastfeeding?
Verify the applicant response. Check Yes or No based on applicant’s response.

Question 23. (1 point)
Do you have policies and procedures that encourage and support exclusive breastfeeding among
prenatal and postpartum WIC participants?
Examples of acceptable supportive documentation: Policies and procedures, Staff training
materials
Documentation attached includes all of the following:
• Encouragement is provided to mothers to exclusively breastfeed for 6 months and
continue to breastfeed for at least the first year of life and thereafter as long as desired
• Staff provide anticipatory guidance on what mothers should expect and strategies for
breastfeeding success
• Efforts are made to contact mothers who intend to breastfeed as soon after delivery as
possible to provide timely breastfeeding support during the early postpartum period
• No routine issuance of infant formula in the first month
• Minimal infant formula amounts are provided only when medically necessary or
requested.
• If formula is provided it is based on the infants assessed needs
• Education is provided to mothers on the effects of early formula supplementation of
breastfeeding
• Staff promotes the fully breastfed food package, making participants aware of the greater
quantity and variety of food included in this package
• Prohibits the promotion of infant formula
Verify the applicant response. Check Yes or No based on applicant’s response. Verify if the
documentation meets all of the requirements listed above.
Check Yes or No based on your documentation review.

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Question 24. (1 point)
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?
Verify the applicant response. Check Yes or No based on applicant’s response.
Question 25. (1 point)
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?
Examples of acceptable supportive documentation: Policies and procedures, Staff training
materials
Documentation attached includes all of the following:
• Indicates individually tailored food packages to all breastfeeding dyads based on a
complete breastfeeding assessment
• Routine issuance of infant formula to breastfeeding infants is prohibited.
Verify the applicant response. Check Yes or No based on applicant’s response. Verify if the
documentation meets all of the requirements listed above.
Check Yes or No based on your documentation review.
Question 26. (1 point)
Does new clinic staff orientation include breastfeeding policies and procedures especially related
to supporting exclusive breastfeeding?
Verify the applicant response. Check Yes or No based on applicant’s response.
Question 27. (1 point)
Do you provide ongoing training to all WIC staff using the FNS-developed competency-based
breastfeeding curriculum, or similar State-developed training based on FNS-developed
competency-based breastfeeding curriculum?
Verify the applicant response. Check Yes or No based on applicant’s response.
Question 28. (1 point)
Do you have ongoing continuing education on breastfeeding for all staff through regularly
scheduled staff trainings and other educational opportunities?
Verify the applicant response. Check Yes or No based on applicant’s response.

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Question 29. (1 point)
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?
WIC staff has an important role in encouraging mothers to breastfeed exclusively for 6 months
and providing the support necessary for them to feel confident in their ability to do so.
Examples of acceptable supportive documentation: Policies and procedures, Staff training
materials
Documentation attached must include all of the following:
•
•
•
•
•
•

Early assessment and follow-up for the breastfeeding dyad soon after delivery
Anticipatory guidance on what to expect (e.g., growth spurts, hunger and satiety cues,
signs that baby is getting enough, etc.)
Staff provide practical strategies to address potential obstacles
Education and support available to breastfeeding mothers who are returning to work, or
school, and mothers who are breastfeeding multiple infants.
Referral system is in place ensuring the mother is connected to the appropriate WIC staff
person
Appropriate referrals to community resources that provide breastfeeding support services

Verify the applicant response. Check Yes or No based on applicant’s response. Verify if the
documentation meets all of the requirements listed above.

Question 30. (1 point)
Do you have policies that ensure all participant breastfeeding concerns are addressed according
to established time frames?
Verify the applicant response. Check Yes or No based on applicant’s response.
Note: To save and finish the evaluation later, scroll to the section “State-Status” and select “not
finished”. Then scroll to the bottom of the evaluation worksheet and click save to save your
work. You can now exit the website.

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All Gold Applicants
Saving the worksheet will bring you to the Evaluations page where you will verify the score.
If the GScore equals 30 points, go back to the evaluation worksheet by clicking the back arrow
to return to the evaluation worksheet of the local agency you are evaluating. Scroll down and
complete sections: “State-Status”, “SA-Recommendation for Gold” and “State Evaluator Name”.
Then click save.
If the GScore is less than 30 points – STOP. An application with a GScore of less than 30 points
is not eligible for a Gold award. Please click the back arrow
to return to the evaluation
worksheet to double check your work. Ensure all questions are answered and double check your
evaluation responses. If you have verified that your evaluation is correct and the GScore remains
under 30 points, complete the following sections: “State-Status”, “SA-Recommendation for
Gold” (choose “No Recommendation”), “State Evaluator Name” ” and “Justification for No
Recommendation”. Then click Save.

Prior Gold Awardees
After confirming the Local Agency received an Award by visiting the FNS website, go to the
Evaluation worksheet in PartnerWeb.
Select the checkbox for “Prior Awardee” if the LA has received a Gold Award in the past 4 years.
By selecting the checkbox, it automatically populates their Gscore to 30, the number of points in a
Gold Award. Gold Q1a through Gold Q30 should be left blank.
Select the year the LA received an award using the Prior Award Year drop down menu.
Scroll down to the bottom of the page and click save. You may start the evaluation for the Local
Agency’s Premiere/Elite Application.

New Gold Applicants
When questions 1 through 30 are complete, scroll down to the bottom of the evaluation
worksheet page and click save.
When you click save, the website will take you to the “Evaluations” page. This page reflects scores
for finished evaluations. The scoring for the 30 Gold award questions can be found in the
column titled “GScore.
Find the GScore for the name of the local agency you just evaluated. A Gold award application
must have a Gscore of 30 to be eligible for the Gold award.

Congratulations and thank you for completing the Gold Award evaluation!
If the applicant has not applied for a higher level award, you have finished the evaluation.
If the applicant has applied for a higher level award, click the “State Agency Review” link on the
left menu and continue on with Step 3.
Gold Award Evaluation Instructions

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