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
Premiere/Elite Award Evaluation Instructions
This document works in coordination with the online evaluation site in PartnerWeb.
PREMIERE AWARD
Applicants do not need to respond to all 16 questions to be eligible for a Premiere award.
Each question is worth 2 or 3 points. A minimum number of points are required from each of the 3
sections:
o a minimum of 12 points from the Peer Counseling section (pscore-PC),
o a minimum of 4 points from the Partnership section (pscore-P),
o a minimum of 4 points from the Other Criteria section (pscore-OC).
and Performance data of either:
o the rate of fully breastfed infants is at least 15 % or higher in the previous year of
published data, and the most recently published year of data shows an increase over
the previous year OR
o the rate of fully breastfed infants is at least 25 % or higher in the most recently
published year of data
ELITE AWARD
Applicants must respond to all 16 questions to be eligible for Elite award AND have performance
data that demonstrates 40% or higher of the infants are fully breastfed.
Start the Premiere/Elite award evaluation process at the “Prescreen for Premiere-Elite”
section in the online evaluation worksheet.

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
In order to be eligible to apply for a Premiere or Elite award, the local agency must have applied and
met the criteria for a Gold Award. Scroll down in the online evaluation worksheet to verify
“Recommend Gold” is selected in the “SA-Recommendation for Gold” section. If “Recommend
Gold” is selected, scroll up to the “Prescreen for Premiere-Elite” section and click “yes”.
If a Gold award is not recommended click “No” - STOP. The applicant is not eligible for a Premiere
or Elite award. Complete the following sections: “State-Status”, “SA-Recommendation-PremiereElite” (choose “No Recommendation”), “State Evaluator Name”, and “Justification for No
Recommendation”. Then click OK.

PEER COUNSELING (pscore-PC)
Question 1. (2 points)
Do you have established guidelines for how many hours of observation/shadowing are required as
part of peer counseling training/continuing education?
Verify the applicant response. Check Yes or No based on applicant’s response.
Question 2. (2 points)
Do you have a WIC Designated Breastfeeding Expert or contract with an International Board of
Lactation Consultant Examiners (IBCLC) to serve as a referral source for peer counselors and other
staff?
Verify the applicant response. Check Yes or No based on applicant’s response.
Question 3. (2 points)
Do you have a referral process in place between hospitals and the WIC Program to facilitate peer
counselor follow-up for WIC mothers shortly after discharge?
Verify the applicant response. Check Yes or No based on applicant’s response.
Question 4. (2 points)
Do you have a system that electronically documents and tracks peer counseling referrals and
contacts?
Verify the applicant response. Check Yes or No based on applicant’s response.

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Question 5. (3 points)
Do you have policies and procedures for home visits or video conferencing as part of your peer
counseling program?
Examples of acceptable supportive documentation: Policy and procedures, Staff training
materials. Documentation attached includes all of the following:
•
•
•
•

Includes process for making home visits or video conferencing
Procedures address travel
Procedures address safety
Procedures address confidentiality

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 6. (3 points)
Do you have policies and procedures for hospital visits as part of your peer counseling program?
Examples of acceptable supportive documentation: Policy and procedures, Staff training materials.
Documentation attached must include all:
• Includes established process for making hospital visits
• Describes relationship with hospital
• Procedures address confidentiality
• Procedures address supervision
• Procedures address liability
• Clarifies the scope of practice and the role of the peer counselor
• Clarifies communication procedures and referrals
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 7. (2 points)
Do you have a recognition program in place to acknowledge peer counselor accomplishments?
Verify the applicant response. Check Yes or No based on applicant’s response.
Question 8. (2 points)
Do you include career path structures for upward mobility of peer counselors?
Verify the applicant response. Check Yes or No based on applicant’s response.

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Question 9. (3 points)
Do you have policies and procedures for peer counselors to communicate via social media
technologies, e.g., Facebook, text messaging, twitter, Skype, PalTalk?
Social media is the use of web-based and mobile technologies to turn communication into
interactive dialogue and build a sense of community among users. Research shows that WIC’s
target population use social media extensively as a means to communicate.
Examples of acceptable supportive documentation: Policies and procedures, Screen shots, Peer
counselor documentation log
Narrative attached must include all of the following:
• Peer counselors communicate using at least one of the following: Facebook, text messaging,
Twitter, Skype, PalTalk or other innovations.
• How peer counselors use social media for at least one of the following: taking training,
communicating with mothers, communicating with supervisors, communicating with other
peer counselors, or communicating with referral sources
Policies and procedures attached must include all of the following:
• Confidentiality and privacy considerations
• Proper etiquette when using social media
• Supervisory monitoring of social media used
• Follows local agency, health department or Federal/State policies for use of social media
Verify the applicant response. Check Yes or No based on applicant’s response.
Verify if the narrative and the supportive documentation meets all of the requirements listed above.
Check Yes or No based on your documentation review.
PARTNERSHIP (pscore-P)
Question 10. (2 points)
Does the partnership have a written agreement or a Memorandum of Understanding?
Examples of acceptable supportive documentation: Memorandum of Understanding, Written
agreement.
Documentation attached includes all of the following:
• Description of the role of each partner
• Description of the goals and outcomes.
• Description of the types of activities planned.
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. (2 points)
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Have new policies or procedures been developed because of the partnership?
Acceptable documentation: Narrative or Supportive Documentation. Examples of acceptable
supportive documentation: Policy and procedures.
Documentation attached includes all of the following:
• Description of the reason the policies or procedures were developed.
• Description of how the policies or procedures help meet the partnership goals.
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 12. (2 points)
Does the partnership have a plan for sustainability?
Verify the applicant response. Check Yes or No based on applicant’s response.
Question 13. (2 points)
Do you partner with stakeholders such as the American Hospital Association to support the BabyFriendly Hospital Initiative in your community?
Verify the applicant response. Check Yes or No based on applicant’s response.

OTHER CRITERIA (pscore-OC)
Question 14. (2 points)
Do you have a supportive clinic environment that implements breastfeeding-friendly workplace
polices for WIC staff?
Documentation attached includes at least one of following:
•
•
•

Breastfeeding staff are allotted adequate time and an appropriate place to express milk
A “Bring your baby to work” program is established for breastfeeding staff with supportive
policies.
Other innovative method to create a breastfeeding-friendly workplace

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 15. (2 points)
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?
Peer counseling programs function best when peer counselors are allowed to solely dedicate their
time to peer counselor support for breastfeeding. State agencies that allow peer counselors to work
in dual-role positions must have State agency policies for dual-role peer counseling staff.
Verify the applicant response. Check Yes or No based on applicant’s response.
Check Yes or No based on your documentation review.
Question 16. (3 points)
Do you provide around the clock assistance to mothers working through their breastfeeding
problems?
Acceptable documentation: Narrative describes how assistance is provided to breastfeeding
mothers around the clock.
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.
PERFORMANCE DATA
The applicant does not submit performance data. The performance data considered is the rate of
exclusively breastfed infants expressed as a percentage of total infant participants in each local
agency. This data is published annually on the FNS website. You can find the performance data at:
http://www.fns.usda.gov/wic/breastfeeding-promotion-and-support-wic
Use the percentage found in the 8th column named “Fully Breastfed” in the spreadsheet found in
the link above.
Fill in the percentage in the “Performance Data-Previous Year” and “Performance Data-Current
Year” sections in the online evaluation worksheet.
Click save to go to the “Evaluations” page which reflects scores for finished evaluations.

Premiere Award Evaluation

You will evaluate for eligibility for a Premiere award prior to evaluating eligibility for an Elite award,
of applicable.
You are now on a partnerweb page that displays the scores for all your applications. Look for the
name of the local agency you just evaluated.
The online evaluation worksheet automatically calculates subscores for the three sections in the
Premiere/Elite application: Peer Counseling (PC), Partnership (P), and Other Criteria (OC).
Verify the applicant meets the minimum points for a Premiere award:
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•
•
•

At least 12 points in the “pscore-PC” column
At least 4 points in “pscore-P” column
At least 4 points in “pscore-OC” column

If the applicant has met the minimum points for a Premiere award, the next step is to verify the
performance data.
Use the back arrow

to go back to the evaluation worksheet.

Verify the percentage in the “Performance Data-Current Year” section is at least 25 % OR the
“Performance Data - Previous Year” section is at least 15 %, and the percentage in the
“Performance Data-Current Year” section shows an increase over the previous year’s percentage.
If the points and data performance criteria have been met the applicant is eligible for a Premiere
award. Complete the following sections: “State-Status”, “SA-Recommendation-Premiere-Elite” and
“State Evaluator Name”. Then click “save”.
If the points and/or data performance criteria have not been met the applicant is not eligible for a
Premiere award. Ensure all questions are answered and double check your evaluation responses
and performance data percentages. If you have verified that your evaluation is correct and the
points and data performance criteria still have been not been met, complete the following sections:
“State-Status”, “SA-Recommendation for Gold” (choose “Recommend Gold”) “SARecommendation for Premiere-Elite” (choose “No Recommendation”), “State Evaluator Name” ”
and “Justification for No Recommendation”. Then click save.
You have completed evaluating for the Premiere award.

Elite Award Evaluation

Note: If the applicant has not responded to all 16 questions on the Premiere/Elite application –
STOP. No further evaluation is required.
The pscore column is the total score of all 16 questions on the Premiere/Elite application. A local
agency must have a pscore of 36 to be eligible for an Elite award.
On the “Evaluations” page verify the local agency has a score of 36 in the column name “pscore”.
Use the back arrow
to go back to the evaluation worksheet. Verify the “Performance DataCurrent Year” section indicates a minimum of 40%.
If the pscore is 36 and the “Performance Data-Current Year” section indicates a minimum of 40%,
the local agency is eligible for an Elite award.
If the points and data performance criteria have been met the applicant is eligible for an Elite award.
Complete the following sections: “State-Status”, “SA-Recommendation-Premiere-Elite” and “State
Evaluator Name”. Then click save.

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If the pscore (score of 36) and/or the performance data (minimum of 40%) criteria is not met, the
local agency is not eligible for an Elite award. Please double check your work. Ensure all questions
are answered and double check your evaluation responses and performance data percentages. If
you have verified that your evaluation is correct and the points and data performance criteria still
have been not been met, complete the following sections: “State-Status”, “SA-RecommendationPremiere-Elite”, “State Evaluator Name” ” and “Justification for No Recommendation”. Then click
save.

Congratulations!
Thank you for completing the Premiere/Elite Award evaluation.

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