Appendix D: WIC State Plan

Appendix D - WIC State Plan Guidance.pdf

Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Program Regulations - Reporting and Recordkeeping Burden

Appendix D: WIC State Plan

OMB: 0584-0043

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0584-0043 can be found here:

2024-04-25 - Revision of a currently approved collection

Document [pdf]

Download: pdf | pdf

Appendix D
WIC State Plan Guidance
Information Collection Burden for the Special Supplemental
Nutrition Program for Women, Infants and Children (OMB
#0584-0043

I. Vendor and Farmer Management
(Please indicate) State Agency: Click or tap here to enter text. for FY: Click or tap here to enter text.
Vendor and farmer/farmers’ market management includes all those activities associated with selecting,
authorizing, training, monitoring, and investigating the State agency's vendor and farmer/farmers’ market
population for the purpose of reducing fraud and abuse in the WIC Program food delivery system.
During a disaster or public health emergency, or supply chain disruption, the State agency may request to
implement existing WIC regulatory and programmatic flexibilities or waivers to support the continuation of
Program benefits and services. State agencies should consider the overarching authority, i.e., Stafford Act,
Access to Baby Formula Act, or provision(s) authorized by Congress, and duration before developing a
policy and procedure. The State agency must provide a detailed description of how it plans to operationalize
the flexibility or waiver through their procedure manual where applicable. Please note the State Plan
Guidance is not intended to capture a description of waivers authorized by Congress with separate reporting
requirements.
Executive Order (EO) 13988, “Preventing and Combating Discrimination on the Basis of Gender Identity or
Sexual Orientation.” was issued to all Federal Agencies. The EO set out policies that all persons are entitled
to dignity, respect, and equal treatment under the law, no matter their gender identity or sexual orientation.
The EO does not usurp section 17 of 42 U.S.C, as amended or applicable regulations, rather it complements
the language in the nondiscrimination statement. Following the contents of the EO, State agencies must
update their policies and procedures to align with the contents of the EO and the nondiscrimination
statement.
A. Vendor Selection and Authorization – 7 CFR 246.4(a)(14)(i), (ii), and (iii): identify the types of food delivery
systems used in the State agency’s jurisdiction. Describe, if used, the State agency’s limiting criteria. Describe the
State agency’s selection criteria and attach a sample vendor agreement. Describe, if applicable, the supervision and
instruction the State agency provides to local agencies to which vendor agreement signing has been delegated.
B. Vendor Training – 7 CFR 246.4(a)(14)(xii): describe State and local agency procedures for training WIC
Program vendors and farmers/farmers’ markets and for documenting all relevant training.
C. High-Risk Vendor Identification Systems – 7 CFR 246.12(j)(3): describe the policies and procedures for
identifying and monitoring high-risk vendors through the use of vendor peer groups, food instrument and cash-value
voucher (CVV)/ cash value benefit (CVB) redemption screening, analysis of overcharging and other violations, the
use of price lists, tracking complaints, or other means. This section may be submitted separately because it is no
longer a State Plan requirement but must still be approved by FNS.
D. Routine Monitoring – 7 CFR 246.4(a)(14)(iv): describe the criteria used to select vendors for routine monitoring
as well as the methods and scope of on-site routine monitoring activities. Include any relevant information about the
State agency’s plans for improvement in the coming year.
E. Compliance Investigations – 7 CFR 246.4(a)(14)(iv): describe the investigative practices and procedures used
to conduct both compliance buys and inventory audits for the purpose of detecting, tracking, and documenting
vendor noncompliance with program requirements.
F. Administrative Review of State Agency Actions – 7 CFR 246.4(a)(14)(iii), and (a)(18): describe the procedures
for conducting both full and abbreviated administrative reviews.
G. Coordination with the Supplemental Nutrition Assistance Program (SNAP) – 7 CFR 246.4(a)(14)(ii),
(a)(14)(iv) and 246.12(h)(3)(xxvi): describe the methods and procedures used to coordinate the monitoring and
sharing of information on vendors who participate in both the WIC Program and SNAP.

H. Staff Training on Vendor Management – 7 CFR 246.4(a)(14)(iii), (a)(14)(iv), and (a)(14)(xii): describe the
distribution of responsibilities and activities of those individuals at both the State and local levels who are involved in
vendor management activities. If applicable, describe the supervision and instruction the State agency provides to
local agencies to which vendor management activities have been delegated.
I. Participant Access - 7 CFR 246.4(a)(14)(xiv), (a)(15); 246.12(b), (g)(1), (g)(8), (l)(1)(ix): provide information
about the State agency’s definition of participant access.
J. Farmer/Farmers’ Market Authorization – 7 CFR 246.4(a)(14)(iii), (a)(14)(xii), and 246.12(v): if the State
agency authorizes farmers/farmers’ markets to accept CVVs/CVBs, describe the authorization process.
K. Farmer/Farmers’ Market Agreements – 7 CFR 246.4(a)(14)(iii), (a)(14)(xii), and 246.12(v): if the State agency
authorizes farmers/farmers’ markets to accept CVVs/CVBs, describe the State agency’s agreement with the
farmers/ farmers’ markets and attach a sample farmer/farmers’ market agreement.
L. Farmer/Farmers’ Market Training – 7 CFR 246.4(a)(14)(iii), (a)(14)(xii), and 246.12(v): if the State agency
authorizes farmers/farmers’ markets to accept CVVs/CVBs, describe the training provided to the authorized
farmers/ farmers markets.
M. Farmer/Farmers’ Market Monitoring – 7 CFR 246.4(a)(14)(iii), (a)(14)(xii), (a)(14)(v), and 246.12(v): if the
State agency authorizes farmers/farmers’ markets to accept CVVs/CVBs, describe the criteria used for selecting
farmers/farmers markets for routine monitoring as well as the method(s) and scope of on-site monitoring of the
farmers/farmers markets.
N. Farmer /Farmers’ Market Sanctions, Claims, and Appeals – 7 CFR 246.4(a)(14)(iii) (a)(14)(v), (a)(14)(xii),
and 246.12(v): if the State agency authorizes farmers/farmers’ markets to accept CVVs/CVBs, describe the
farmer/farmers’ market sanctions, claims, and appeals and attach a copy of the farmer/farmers’ market sanction
schedule (which should be included in the farmer/farmers’ market agreement as well).

A. Vendor Selection and Authorization
1.

Number and Distribution of Authorized Vendors

a. Does the State agency use limiting criteria to limit the number of vendors it authorizes?
☐Yes

☐No

b. If yes, check and specify the type(s) of criteria used (e.g., vendor/participant ratio of 1/100 per county):

☐ Vendor/participant ratio (specify): Click or tap here to enter text.
☐ Vendors/local agency or clinic ratio (specify): Click or tap here to enter text.
☐ Vendors/local service area or county ratio (specify):Click or tap here to enter text.
☐ Vendors/geographic area (e.g., number per mile, city block, zip code) (specify): Click or tap here to
enter text.
☐ Vendor/State agency staff ratio (specify): Click or tap here to enter text.
☐ Statewide cap on the number of vendors (specify): Click or tap here to enter text.
☐ Other (specify): Click or tap here to enter text.
ADDITIONAL DETAIL: Vendor Management Appendix and/or Procedure Manual (Citation): Click or tap here

to enter text.

2. Vendor Application Periods
a. The State agency considers applications; check all that apply:
☐ On an on-going basis

☐ Annually in (month) Choose an item. for a new agreement begins (month:) Choose an item.
☐ Every two years (specify month): Choose an item.
☐ Every three years (specify month): Choose an item.
☐ Any time there is a participant access needed
☐ The State agency is currently under a:
☐ Federal Moratorium (specify time frame): Click or tap here to enter text.
☐ State agency-imposed deferral of application processing (specify time frame and conditions): Click or tap
here to enter text.
☐ Other (specify): Click or tap here to enter text.
ADDITIONAL DETAIL: Vendor Management Appendix and/or Procedure Manual (Citation): Click or tap here
to enter text.
3. Vendor Selection and Authorization
a. The vendor selection criteria used to select vendors for program authorization include:
Required criteria:

☐ EBT capable as defined in 7 CFR 246.12(aa)(4)(ii)
☐ A competitive price criterion based on:
☐ Vendor applicant price lists
☐ WIC redemption data
☐ A State agency standard drawn from a price survey
☐ A standard drawn from another source (specify): Click or tap here to enter text.
☐ Other (specify): Click or tap here to enter text.
4

☐ A minimum variety and quantity of supplemental foods criterion that is:
☐ Statewide
☐ Peer group specific
☐ A requirement to obtain infant formula only from sources included in the State agency’s list of State licensed
infant formula wholesalers, distributors, and retailers and manufacturers registered with the U.S. Food and
Drug Administration
☐ A business integrity criterion that includes:

☐ No history, during the past six years, among the vendor’s owners, officers, or managers of criminal convictions
or civil judgments for activities listed in 7 CFR 246.12(g)(3)(ii)
☐ No history of other business-related criminal convictions or civil judgments
☐ Other (specify): Click or tap here to enter text.
☐ Lack of a current SNAP disqualification or civil money penalty for hardship per 7 CFR 246.12(g)(3)(iii)
Optional criteria:

☐ A requirement to stock a full range of foods in addition to WIC supplemental foods
☐ A location necessary to ensure adequate participant access
☐ Redemption of a minimum number/volume of food instruments and CVVs/CVBs
☐ Satisfactory compliance with previous vendor agreement
☐ Certification by an approved State or local health department
☐ Proof of authorization as a SNAP retailer, including SNAP authorization number
☐ Hours of operation which meet State agency criteria (specify): Click or tap here to enter text.
☐ Lack of previous WIC sanctions
☐ Other criteria (specify): Click or tap here to enter text.
☐ Not applicable (explain): Click or tap here to enter text.
b. Explain how the State agency develops and uses the competitive price criteria identified in item 3a to
select vendors for authorization. Click or tap here to enter text.
(1) Does the State agency exempt from competitive price criteria pharmacies that provide only exempt
infant formula or WIC-eligible medical foods to participants?

☐ Yes

☐ No

(2) Did the State agency exempt non-profit WIC vendors (other than health or human services agencies that
provide food under contract with the State agency) from competitive price criteria?
☐ Yes
☐ No
c. When does the State agency assess vendors for above-50-percent status? Check all that apply.
☐ At authorization

☐ 6 months after authorization
☐ Annually
☐ Other (specify): Click or tap here to enter text.
d. How does the State agency assess vendors for above-50-percent status? Check all that apply:

☐ Use the A50 status determination report in the Food Delivery Portal (e.g., WIC-6 in The Integrity
Profile)
☐ Collect food sales data documentation from the vendor
☐ Collect food sales data documentation from another agency (specify): Click or tap here to enter text.
5

☐ Other (specify): Click or tap here to enter text.
e. Does the State agency authorize vendors that derive more than 50 percent of their annual food sales from
WIC transactions (i.e., above-50-percent vendors)?

☐ Yes

☐ No

If “No,” please proceed to item 3f.
If “Yes,” please respond to the following:

(1) How many above-50-percent vendors are currently authorized? (include all above-50-percent vendors, not
just WIC-only vendors) Click or tap here to enter text.
(2) Does the State agency allow above-50-percent vendors to provide incentive items?

☐ No

☐ Yes

If “No,” please proceed to item 3f.
If “Yes,” please respond to the following:

Describe the incentive approval process or attach a copy of the relevant application form. Description (or
list the Appendix citation here): Click or tap here to enter text.
(3) Does the State agency provide above-50-percent vendors with a list of pre-approved incentive items?
☐ Yes; please provide list
☐ No
Click or tap here to enter text.
(4) Does the State agency provide above-50-percent vendors with a list of prohibited incentive items?
☐ Yes; please provide list
☐ No

Click or tap here to enter text.
f. Does the State agency ensure vendors (regular and above-50-percent) do not treat WIC participants differently
by offering them incentive items that are not offered to non-WIC customers? (7 CFR 246.12(h)(3) (iii) and WIC
Policy Memorandum 2014-3 Vendor Management: Incentive Items, Vendor Discounts and Coupons)

☐ Yes; please explain:

☐ No; please explain:

Click or tap here to enter text.
g. Pre-authorization visits are conducted to verify information received during the application process:
by SA

☐
☐

by LA

☐
☐

by Other

☐
☐

For vendors at initial authorization
For all vendors at authorization/reauthorization

h. Does the State agency verify the status of vendor applicants’ SNAP retailer authorization (e.g., via Food
Delivery Portal (FDP) or Store Tracking and Redemption System (STARS)?
☐ Yes
☐ No
ADDITIONAL DETAIL: Vendor Management Appendix and/or Procedure Manual (Citation): Click or tap here to enter
text.
4. Vendor Peer Groups
If the State agency does not have a vendor peer group system, please attach a copy of the most recent exemption
request and approval letters and proceed to item 4e.

a. Are vendors assigned to peer groups for selection/authorization?

☐ Yes

☐ No

b. Are vendors assigned to peer groups for reimbursement purposes?

☐ Yes

☐ No

c. Peer groups are based on the following (check all that apply):

☐ WIC sales volume
☐ Gross food sales volume
☐ Number of cash registers
☐ Square footage of store
☐ Type of store
☐ Location of store, per 7 CFR 246.12(g)(4)(ii)(A).
☐ Local agency service areas
☐ City, County, or regional divisions
☐ Urban/suburban/rural
☐ Zip codes
☐ Unique economic location (e.g., rural island, single metro area)
☐ Other (specify): Click or tap here to enter text.
d. Using the chart on the next page, describe the peer groupings (e.g., supermarkets, medium and small grocery
stores, convenience stores, etc.) that the State agency plans to use during the upcoming fiscal year. For State
agencies with more than 18 peer groups, please attach a chart containing this Peer Group Description and list
the Appendix citation here: Click or tap here to enter text.
e. Has the State agency received approval for an exemption from the vendor peer group system requirement (7
CFR 246.12(g)(4)(v))?

☐ Yes; date FNS approved exemption:Click or tap to enter a date. ☐ No
(1) If yes, the State agency's exemption was based on the latest available data for the current fiscal year (which
covers the period from Click or tap to enter a date. to Click or tap to enter a date.), and the State agency:

☐ Does not have any above-50-percent vendors; data source:Click or tap here to enter text.
☐ Paid above-50-percent vendors Click or tap here to enter text. percent of the total annual WIC
redemptions to date; data source: Click or tap here to enter text.
(2) If the State agency does not use a vendor peer group system, describe the State agency’s alternative
system for comparing the prices of new vendor applicants and currently authorized vendors and selecting
for authorization or reauthorization vendors that offer the program the most competitive prices.

A. Vendor Selection and Authorization

DESCRIPTION OF VENDOR PEER GROUP SYSTEM
Vendor Peer Groups
Number of Vendors in Peer Group
Peer
Group
No. (1)

Description
(e.g., supermarkets, chain stores,
pharmacies) (2)

Regular
Vendors
(3)

Above-50%
Vendors
(4)

Total
(5)

Comparable
Vendors Peer
Group Number
(6)

1
2
3
4
5
6
7
8
9
10
11
12
8

13
14
15
16
17
18
Instructions:
Column 1 – Assign a sequential number to each peer group.
Column 2 – Describe the vendors in the peer group; include all factors and definitions checked in question 4c. (e.g., urban = counties with >100,000 residents
OR suburban = counties with >10,000 residents OR rural = counties with <10,000 residents)
Column 3 – Insert the number of authorized vendors that are regular vendors.
Column 4 – If the State agency authorizes above-50-percent vendors, insert the number of above-50-percent vendors currently authorized.
Column 5 – Insert the total number of authorized vendors. This number should be the sum of columns 3 and 4, since the State agency must identify each
vendor as being either a regular vendor or an above-50-percent vendor.
Column 6 – For each peer group that contains above-50-percent vendors, insert the number of the peer group that contains comparable regular vendors. The
comparable vendor peer group is the peer group that the State agency uses to derive the competitive price criteria and maximum reimbursement
levels that it applies to the above-50-percent vendors. If above-50-percent vendors are placed in a peer group with regular vendors, then the
number in column 1 should be the same as that in column 6. If above-50-percent vendors are in separate peer groups, then the number in
column 1 will be different from that in column 6.

At least every three years the State agency must assess the effectiveness of its peer group system and
competitive price criteria to enhance system performance (7 CFR 246.12(g)(4)(ii)(C)).
The State agency makes this assessment—
☐ Annually
☐ Biennially ☐ Every three years

☐ Other (please specify): Click or tap here to enter text.
Explain what procedures does the State agency have in place to assess the effectiveness of its peer
group system and competitive price criteria to enhance system performance?
Click or tap here to enter text.
Provide date of most recent FNS approval: Click or tap here to enter text.
5. Semiannual Shelf Price Collection
a. Has the State agency received approval for an exemption from the shelf price collection
requirement under 7 CFR 246.12(g)(4)(ii)(B):

☐ Yes; date FNS approved exemption: Click or tap here to enter text.

☐ No

If yes, please attach a copy of the most recent exemption request and approval letter(s).
6. Vendor Agreements
a. The following reflect the State agency’s vendor agreement practices; check all that apply:
☐ All vendors have a written agreement with the State
agency
☐ A standard vendor agreement is used statewide

☐ Vendor agreements are subject to the State’s procurement procedures
☐ Vendor agreements/handbooks are subject to the State’s Administrative Procedures Act
☐ A nonstandard vendor agreement is used for:
☐ Military commissaries
☐ Pharmacies that only provide exempt infant formula and/or WIC-eligible medical
foods
☐ All pharmacies

☐ Mobile stores
☐ Other (specify): Click or tap here to enter text.
☐ Vendors are authorized for a period of Click or tap here to enter text. year(s)
☐ All vendors are provided at least 15 days advance written notice of the expiration of the vendor
agreement
☐ Chain stores sign a master agreement that includes multiple locations

☐ Chain stores sign an agreement for each store
location
☐ All authorized WIC vendors are compliant with the regulatory split tender requirement at 246.12(f)(4)
☐ Other (specify): Click or tap here to enter text.
b. In addition to the requirements in 7 CFR 246.12(h)(3)-(h)(6), the vendor agreement includes:

☐ Periodic submission of vendor price lists. If so, specify frequency: Click or tap here to enter text.
☐ Maintenance of records in addition to the required inventory records. If so, specify types of records: Click or

tap here to enter text.

☐ Submission of food instruments and CVVs/CVBs within a shorter timeframe than required by program
regulations. If so, specify timeframe:Click or tap here to enter text.
☐ Redemption of a minimum number/volume of food instruments and CVVs/CVBs

☐ Minimum hours of operation
☐ Other (specify all): Click or tap here to enter text.
c. The State agency delegates the signing of vendor agreements to its local agencies:
☐ Yes
☐ No
If yes, provide a description of the supervision and instruction provided to local agencies to ensure
the uniformity and quality of this activity. Click or tap here to enter text.
Please attach a copy of the Vendor Agreement or provide the appropriate Procedure Manual
reference below. ADDITIONAL DETAIL: Vendor Management Appendix and/or Procedure Manual
(Citation): Click or tap here to enter text.

B. Vendor Training
1. Vendor Training – General
a. Annual vendor training covers the following content (check all that apply):

☐
☐
☐
☐

Purpose of the WIC Program
Supplemental foods authorized by the State agency
Minimum varieties and quantities of supplemental foods that must be stocked

Obtaining infant formula only from sources included in the State agency’s list of State licensed infant
formula wholesalers, distributors, and retailers, and manufacturers registered with the U.S. Food and
Drug Administration
☐ Procedures for obtaining prior State agency approval to provide incentive items to WIC participants

☐ Procedures for transacting and redeeming food instruments and cash - value vouchers
☐ Vendor sanction
system
☐ Vendor complaint
process
☐ Claims procedures

☐ Changes in program requirements since the last training
☐ Recordkeeping requirements
☐ Replacement food instruments and cash-value
vouchers
☐ Participant complaints

☐ Vendor requests for technical
assistance
☐ Reauthorization
☐ Reporting changes of ownership, location, or cessation of operations
☐ Procedures for appeal/administrative review
☐ Training employees
11

☐ WIC/SNAP sanction reciprocity and information

text.

sharing
☐ Other (specify): Click or tap here to enter text.
If any topics listed above are not included in the annual vendor training, explain why. Click or tap here to enter

b. Vendors or vendor representatives receive training on the following occasions and/or
through the following materials (check all that apply):
☐ On-site (in-store)
meetings/conferences
☐ Off-site meetings/conferences

☐ During routine monitoring visits (e.g., educational
buys)
☐ When specialized technical assistance is requested

☐ Written materials (e.g., newsletters)
☐ Audio or video recording
☐ Teleconference, video conference, or
webinars
☐ Vendor hotline

☐ State or local agency website
☐ Other (specify): Click or tap here to enter text.
c. Vendors or vendor representatives receive interactive training as follows (check all applicable
responses):

☐ At or before initial
authorization
☐ At least once every three
years
☐ Annually or more frequently than once every three years
d. The following method(s) are used to evaluate the effectiveness of vendor training (check all that
apply):

☐ Evaluation forms provided with training materials
☐ Pre-tests and/or post-tests regarding vendor policies, procedures, and practices
☐ Statistical indicators, such as a reduction in food instrument/cash-value voucher/cash-value benefit
errors
☐ Educational buys

☐ Record reviews
☐ Informal feedback from vendors and/or
participants
☐ Vendor advisory councils

☐ None
☐ Other (specify): Click or tap here to enter text.
ADDITIONAL DETAIL: Vendor Management Appendix and/or Procedure Manual (Citation): Click or tap here
to enter text.

2. Delegation of Vendor Training
a. The State agency delegates its vendor training to:

☐ Local agencies
☐ A contractor; specify: Click or tap here to enter text.
☐ A vendor association/representative; specify: Click or tap here to enter text.
☐ Other (specify): Click or tap here to enter text.
☐ None (the State agency conducts all vendor training)

b. Indicate the frequency with which the State agency performed the following activities during the past
fiscal year:
Times/ FY

Activity

Click or tap here to enter text.
Click or tap here to enter text.
Click or tap here to enter text.
quality of

Provided comprehensive training materials to delegated trainers
P rovided instruction on vendor training techniques to delegated trainers
Monitored performance of delegated trainers to ensure the uniformity and
vendor training

☐ Not applicable
☐ Other (specify): Click or tap here to enter text.
ADDITIONAL DETAIL: Vendor Management Appendix and/or Procedure Manual (Citation): Click or tap here
to enter text.
3. Documents for and Documentation of Vendor Training
a. The State agency or the entity to which it delegates vendor training documents the content of and
vendor participation in annual vendor training:
☐ Yes

☐ No

b. Vendors or vendor representatives are required to sign an acknowledgment of training when they have
received the following types of training (check all that apply):

☐ Interactive training
☐ Educational buys
☐ Remedial training

☐ Annual training
☐ Monitoring visits
☐ Other (specify): Click or tap here to enter text.

c. The State agency produces a Vendor Handbook:

☐ Yes

☐ No

If yes, provide the link to the Vendor Handbook or the citation: Click or tap here to enter text.
d. The State agency provides online or web-based training:
☐ Yes

☐ No

If yes, provide the link to the training: Click or tap here to enter text.
ADDITIONAL DETAIL: Vendor Management Appendix and/or Procedure Manual (Citation): Click or tap here to

enter text.

C. High-Risk Identification Systems
1.

Vendor Complaints

The State agency has a formal system for receiving complaints about vendors:

☐ No; please explain: Click or tap here to enter text.
☐ Yes, complaints are received through the
☐ A toll-free number
following:
handled by State agency staff
☐ A standard complaint form which the complainant sends to:

☐ State agency
☐ Local agency or clinic
☐ Online system; include link here: Click or tap here to enter text.
☐ Other (specify): Click or tap here to enter text.
b.

The State agency has a formal system for receiving complaints from vendors:

☐ No; please explain:Click or tap here to enter text.
☐ Yes, complaints are received through the
following:
☐ A toll-free number handled by State agency
staff
☐ A standard complaint form which the complainant sends to:

☐ State agency
☐ Local agency or clinic
☐ Online system; include link here: Click or tap here to enter text.
☐ Other (specify): Click or tap here to enter text.
c. The State agency logs and responds to all complaints:

☐ Yes, please explain: Click or tap here to enter text.
☐ No; please explain:Click or tap here to enter text.
ADDITIONAL DETAIL: Vendor Management Appendix and/or Procedure Manual (Citation): Click or tap here
to enter text.
2. Identifying High-Risk Vendors
a.

What criteria does the State agency use to identify high-risk vendors: (* = mandatory)

☐ Low variance*
☐ High-mean value*
☐ New vendor

☐ Complaints against vendors
☐ Other (specify all): Click or tap here to enter text.

b. Identify the frequency for generating high-risk vendor reports:

☐ Monthly
☐ Quarterly
☐ Semiannually

☐ Annually
☐ No set schedule
☐ Other (specify): Click or tap here to enter text.
14

c. Identify the type(s) of food instruments/cash-value vouchers/cash-value benefits used in the high-risk
vendor analysis. (Check all that apply):

☐ A full monthly food package for a:
☐ Infant
☐ Child
☐ Other (specify): Click or tap here to enter text.
☐ Woman
☐ CVVs/CVBs
☐ Other (specify): Click or tap here to enter text.
d. To perform the high-risk vendor analysis, the State agency’s system aggregates a vendor's
redemptions over the following time period:

☐ 1 month

☐ 2 months ☐ 3 months ☐ 4 months☐ 5 months ☐ 6 months

☐ Other (specify): Click or tap here to enter text.

e. Vendor redemption patterns are generally compared to:

☐ Applicable peer group patterns
☐ All vendors’ patterns statewide
☐ Other (specify):
Provide additional information detailing how the State agency conducts the high-risk vendor analysis and
how the State agency ranks and selects vendors for compliance and/or monitoring activity when more than
5% of authorized vendors are high risk. Click or tap here to enter text.

D. Routine Monitoring
1.

Routine Monitoring Visits

a. Routine monitoring visits are conducted by:

☐ State agency staff
☐ Local agency staff
☐ Other (specify): Click or tap here to enter text.
b. Identify the activities performed during a routine monitoring visit; check all that apply:

☐ Check the vendor’s inventory of supplemental foods and/or inventory records to determine if the vendor
meets the State agency’s requirements for the minimum variety and quantity of supplemental foods.

☐ Check the vendor’s inventory of non-supplemental foods and/or inventory records to provide
information
on whether the vendor is an above-50-percent vendor.

☐ Determine whether the vendor accepts forms of payment other than WIC food instruments, such as
cash,
personal checks, and credit cards, to provide information on whether the vendor is an above-50percent
vendor.

☐ Check the vendor’s invoices of infant formula to ensure that the infant formula is obtained only from the

State
agency’s list of infant formula manufacturers registered with the Food and Drug Administration, and infant
formula wholesalers, distributors, and retailers licensed under State law.

☐ If the vendor is an above-50-percent vendor, check its stock of incentive items to ensure that such
items

have been approved by the State agency.

☐ Obtain the vendor’s shelf prices and/or validate the vendor’s price
list

☐ Review food instruments or receipts in the vendor’s possession for vendor
violations

☐ Compare shelf prices to prices that appear on the register to test for vendor overcharges
☐ Review use of shelf tags and signage
☐ Review expiration dates on supplemental foods
☐ Compare prices of supplemental foods with similar items not approved as
supplemental

☐ Observe WIC transactions that occur
☐ Verify that the vendor has appropriate terminals deployed in the required number of lanes per 7 CFR
246.12(z)(2)

☐ Conduct an educational buy
☐ Interview manager and/or employees
☐ Review employee training procedures
☐ Conduct annual vendor training or provide vendor with annual training materials
☐ Examine the sanitary conditions of the store
☐ Ensure that vendor is compliant with the split tender requirement
☐ Other (specify all): Click or tap here to enter text.
c. Generally, routine monitoring visits are conducted on each vendor (check all that apply):
☐ Annually
text.

☐ Twice a year ☐ As needed (specify)

☐ Other (specify) Click or tap here to enter

d. The following procedures are used in determining whether a vendor is selected for a routine
monitoring visit (check all that apply):

☐ Random selection

☐ Complaints

☐ Periodic/scheduled training

☐ Other (specify): Click or tap here to enter text.

☐ Periodic/scheduled review Click or tap here to enter text.
ADDITIONAL DETAIL: Vendor Management Appendix and/or Procedure Manual (Citation):

E. Compliance Investigations
1. Investigative Practices
a. The State agency conducts (check all that apply):
☐ Compliance buys (a covert, on-site investigation in which a representative of the Program poses as a
participant, parent, or caretaker of an infant or child participant, or proxy; transacts one or more food
instruments or CVVs/ CVBs; and does not reveal during the visit that he or she is a Program
representative.)
☐ Inventory audits (the examination of food invoices or other proofs of purchase to determine whether a
vendor has purchased sufficient quantities of supplemental foods to provide participants the quantities
specified on food instruments redeemed by the vendor during a given period of time.)
☐ Other (specify): Click or tap here to enter text.
b. The following factors are used to determine which vendors are selected for a compliance investigation

(check all that apply):

☐ Vendor is identified by the high-risk vendor identification criteria
☐ Random selection
☐ Geographical considerations
☐ Volume of WIC redemptions
☐ Participant complaints
☐ Other (specify): Click or tap here to enter text.
c. The State agency uses standard procedures for conducting and documenting compliance buys and
inventory audits:

☐ Yes

If yes, please provide the guidelines in the Vendor Management Appendix or cite to the
Procedure
Manual reference: Click or tap here to enter text.

☐ No; specify: Click or tap here to enter text.
d. The results of compliance investigations are used to assess the effectiveness of the State agency’s
high-risk vendor identification criteria:

☐ Yes

☐ No

If yes, check the items below that describe how the results of compliance investigations are used to
assess the effectiveness of high-risk vendor identification criteria:

☐ The State agency compares data on the prevalence of vendor violations detected among high-risk

versus
non- high-risk vendors.
☐ The State agency discards a high-risk vendor identification criterion if compliance investigations of
high-risk vendors identified by the criterion result in no vendor violations after Click or tap here to
enter text. months
☐ Investigative procedures and training are reevaluated if compliance investigations of high-risk vendors
result in the detection of no vendor violations.
☐ Other (specify): Click or tap here to enter text.
ADDITIONAL DETAIL: Vendor Management Appendix and/or Procedure Manual (Citation): Click or tap here

to enter text.

2. Compliance Buys
a. The State agency conducts the following types of compliance buys:

☐ Trafficking buys (exchanging food instruments for cash)
☐ Safe buys (transacting food instruments to see if the vendor will overcharge)
☐ Short buys (transacting food instruments for less food items than those available to see if the vendor will
charge for food items not received)

☐ Major substitution buys (exchanging food instruments for non-food items)
☐ Minor substitution buys (exchanging food instruments for unauthorized food items)
☐ Other (specify): Click or tap here to enter text.
b. Does the State agency tailor compliance buys to vendors' risk type?

☐ Yes; explain: Click or tap here to enter text.
☐ No; explain: Click or tap here to enter text.
c. Compliance buys are usually conducted by:

☐ WIC State agency
staff
☐ WIC local agency
staff
☐ State investigators
☐ Investigators retained on a contract basis (e.g., Pinkerton, Wells
Fargo)
☐ Interns, neighborhood residents, or program participants employed by
WIC
☐ Another WIC State agency
☐ Other (specify): Click or tap here to enter text.
d. Who is responsible for ensuring the proper execution of and follow-up on compliance buys?
WIC State agency vendor manager
WIC local agency manager
State investigators
Contractor
Another WIC State agency
☐ Other (specify):Click or tap here to enter text.

☐
☐
☐
☐
☐

e. If no vendor violations are detected, how many compliance buys does the State agency conduct
before closing a compliance investigation?
☐ Two

☐ Other (specify): Click or tap here to enter text.

f. If the State agency conducts a standard number of compliance buys per compliance investigation,
what is the basis for the prescribed number of buys?

☐ State law or regulation
☐ State agency policy or procedure
☐ Level of evidence necessary to impose vendor

sanctions
☐ Legal counsel's advice
☐ Other (specify): Click or tap here to enter text.

g. Is the vendor provided written notification of a violation requiring a pattern of violations in order to
sanction the vendor, prior to documenting another violation of the same kind, unless the State agency
determines that such notice would compromise the investigation and documents this in the vendor’s
file?

☐ Yes

☐ No

If no, is the determination that the written notification would compromise the investigation
documented in the vendor's file?
☐ Yes; if a standard form is used, please attach and cite
below.

☐ No; please explain: Click or tap here to enter text.
h. Does the State agency have a clear, actionable definition of “pattern of violations” approved by its
General Counsel/Administrative Officer?

☐ Yes

☐ No

ADDITIONAL DETAIL: Vendor Management Appendix and/or Procedure Manual (Citation): Click or tap here

to enter text.

3. Estimate the cost for conducting compliance buys, excluding expenses related to the vendor

appeals/ administrative review process:
$ Click or tap here to enter text. Cost per compliance buy

☐ Unknown
☐ Not applicable
ADDITIONAL DETAIL: Vendor Management Appendix and/or Procedure Manual: Click or tap here to enter
text.
4.

Inventory Audits (If inventory audits are not performed, go to Question 5)

The following factors are used to determine which vendors selected for compliance investigations will
receive inventory audits rather than/or in addition to compliance buys:

☐Vendor has highest risk based on State agency’s high-risk identification
criteria
☐ Suspicion of vendor exchanging cash for food instruments (trafficking)
☐ Inconclusive compliance buy results
☐Complaints
☐Other (specify): Click or tap here to enter text.
b. The State agency conducts the following types of inventory audits:
☐On-site inventory audits
☐State agency inventory audits (vendor sends records to State agency)
☐ Local agency inventory audits (vendor sends records to local agency)
☐ Other (specify):Click or tap here to enter text.
c.

Inventory audits are conducted by (check all that apply):

☐WIC State agency staff
☐ WIC local agency staff
☐ State investigators
☐Investigators retained on a contract basis (e.g., Pinkerton's, Wells Fargo)
☐Other (specify):Click or tap here to enter text.
d. Identify the amount of, or period of time covered by, the receipts that are examined during an
inventory audit:
Click or tap here to enter text.
ADDITIONAL DETAIL: Vendor Management Appendix and/or Procedure Manual (Citation): Click or tap here

to enter text.

5. Compliance Buy/Inventory Audit Tracking System(s)
a. The State agency has a means of recording and tracking staff person hours devoted to
investigation activities:

☐ Yes; please describe:Click or tap here to enter text.
☐ No
b. The State agency has an automated system for tracking investigations that monitors the progress and
status of each compliance investigation:
☐ Yes; please describe: Click or tap here to enter text.

☐ No
ADDITIONAL DETAIL: Vendor Management Appendix and/or Procedure Manual (Citation): Click or tap here
to enter text.

F. Administrative Review of State Agency Actions
1. Types of Administrative Reviews
The State agency conducts the following types of administrative reviews of vendor appeals for the
adverse actions listed below. (Check all that apply):
Informal
Desk
Reviews

Abbreviated
Admin
Reviews

Full
Admin.
Reviews

☐

Denial due to competitive price selection criterion

☐

Denial due to minimum stocking selection criterion

☐

Denial due to business integrity or current SNAP
DQ or CMP
Denial based on limiting criteria

☐

Denial due to State agency selection criteria

☐

Denial due to application outside timeframe

☐

A pplication of above-50-percent criteria

☐

DQ for WIC violations

☐

DQ for SNAP CMP

☐

Other WIC sanctions, e.g., fine or CMP

☐

Denial based on circumvention of sanction

☐

Application of peer group criteria

☐
☐

☐

☐
☐

Termination due to ownership change
Termination due to location change

☐

Termination due to ceasing operations

☐

Termination for other causes

☐

DQ for trafficking/illegal sales conviction

☐

DQ/CMP due to another State agency’s
mandatory sanction
CMP based on SNAP DQ

☐

Denial based on no SNAP authorization

ADDITIONAL DETAIL: Vendor Management Appendix and/or Procedure Manual (Citation):Click or tap here
to enter text.
2. Administrative Review Procedures
a. The State agency has a law or regulation governing WIC administrative reviews:

☐ Yes; please indicate: Click or tap here to enter text.
☐ No
If the State agency does have such a law or regulation, this includes:
☐ State agency Administrative Procedures Act
☐ State agency law pertaining to WIC only
☐ State agency health department law

☐ State agency health department regulation
☐ State agency WIC regulation
☐ Other (specify): Click or tap here to enter text.
b. At which level do administrative reviews of WIC vendor appeals take place:

☐ WIC local agency
☐ WIC State agency
☐ State or Tribal health department
☐ Other (specify): Click or tap here to enter text.
c. Administrative reviews are conducted by:

☐ Hearing officers
☐ Administrative law judges
☐ Other (specify): Click or tap here to enter text.
d. The following procedures are followed for administrative reviews:
Abbreviated
Admin.
Reviews
☐

Full
Admin.
Reviews
☐

☐

Opportunity for vendor to be represented by counsel
Opportunity for vendor to present witnesses
Opportunity for vendor to cross-examine witnesses
Opportunity for investigators to testify behind a screen or via
other non-identifying method
Presence of a court reporter or stenographer

☐
statues,

☐
☐

Opportunity for vendor to reschedule review date
Opportunity for vendor to present its case

☐

Opportunity for vendor to examine evidence prior to review

An impartial decision-maker, whose decision is based solely on
whether the State agency correctly applied Federal and State
regulations, policies, and procedures
A written decision within 90 days from request for review
Other (specify): Click or tap here to enter text.

e. Check the party(ies) below who may present the State agency case during a full administrative review:

☐ WIC staff person assigned to case ☐ WIC State agency Vendor Manager ☐ WIC State Agency Director
☐ Legal counsel (State Attorney General or General Counsel’s office) ☐ Legal counsel (paid by WIC
Program funds)

☐ Other (specify all): Click or tap here to enter text.
Please attach and/or reference in the Additional Detail area below the location of the State agency’s
administrative review procedures.
ADDITIONAL DETAIL: Vendor Management Appendix and/or Procedure Manual (Citation): Click or tap

here to enter text.

G. Coordination with SNAP
1. WIC/SNAP Information Sharing
a. An information sharing agreement between the WIC State agency and SNAP is in effect and is
maintained at the State agency:

☐ Yes

☐ No

If yes, an updated list of authorized vendors is sent to the appropriate FNS SNAP Retailer Operations
Division office:

☐ Once a year
☐ Regularly, at intervals of less than one year (specify): Click or tap here to enter text.
☐ Periodically, as changes occur
☐ Upon request
☐ Other (specify): Click or tap here to enter text.
b. State agency compliance investigators coordinate their activities with their SNAP counterparts:

☐ Yes

☐ No

c. State statute, regulations, or procedures restrict the disclosure of WIC vendor and SNAP retailer
information to those permitted under 7 CFR 246.26(e) and (f):

☐ Yes (specify): Click or tap here to enter text.
☐ No
ADDITIONAL DETAIL: Vendor Management Appendix and/or Procedure Manual (Citation): Click or tap here
to enter text.

H. Staff Training
1. Check below the routine formal training available to State and local level staff in vendor
management practices:
State

Local

Other (contractor)

☐
☐
☐

Vendor selection and authorization
Vendor training
Routine monitoring

☐

Compliance investigations

☐

Inventory audits

☐

Corrective actions and sanctions

☐

Criminal investigations

☐

Vendor appeals/administrative reviews

☐

Federal and/or State WIC regulations

☐
☐

Prevention of vendor fraud and abuse
WIC/SNAP information sharing and handling of confidential
WIC vendor data
High-risk vendor identification
Vendor management information system

☐
☐
☐
☐
☐
☐
☐ Not applicable
☐ Other (specify):Click or tap here to enter text.

2. State agency staff meets with vendor representatives as part of a vendor advisory council or other
vendor stakeholder group:
☐
Monthly
☐
Quarterly
☐ Other frequency: Click or tap here to enter text.
☐ No vendor advisory council
ADDITIONAL DETAIL: Vendor Management Appendix and/or Procedure Manual (Citation): Click or tap here
to enter text.
3. Reporting vendor information to the Food Delivery Portal (FDP):
a. How does the State agency submit vendor information to FDP?
☐ Manually (via the FDP screens)
☐ Upload comma delimited file
☐ Upload XML file
ADDITIONAL DETAIL: Vendor Management Appendix and/or Procedure Manual (Citation): Click or tap here

to enter text.

I. Participant Access
1. Please provide the State agency definition for participant access. Include full criteria, including
geography, density, and any other parameters in your response.

Click or tap here to enter text.

2. Does the State agency assess all vendor applications not meeting selection criteria for participant
access?
☐ Yes

☐ No

a. If yes, describe below or attach and provide a citation of the procedures used for assessing vendor
applications for participant access. Provide sufficient details so steps can be followed and criteria
applied to a specific vendor

Click or tap here to enter text.
ADDITIONAL DETAIL: Vendor Management Appendix and/or Procedure Manual (Citation): Click or tap

here to enter text.

J. Farmer/Farmers' Market Authorization

☐ IF YOUR STATE AGENCY DOES NOT AUTHORIZE FARMERS/FARMERS’ MARKETS TO ACCEPT
CVVs/CVBs; SECTIONS J – N DO NOT APPLY.

1. Does the State agency delegate any tasks related to the management of the Farmers or Farmers'
Markets to another entity?
☐ No
☐ Yes (specify what tasks and to whom): Click or tap here to enter text.
2. The State agency authorizes farmers/farmers’ markets to accept CVVs/CVBs based on:
☐ Authorization by the WIC Farmers’ Market Nutrition Program

(FMNP)
☐ Selection criteria established separately from FMNP
3. If the State agency does not authorize farmers/farmers’ markets based on FMNP authorization, the
selection criteria include (describe): Click or tap here to enter text.
4. The State agency consider applications:
☐ On an ongoing basis
☐ Annually
☐ Other (specify): Click or tap here to enter text.
☐ Every three years
☐ Every two years
ADDITIONAL DETAIL: Vendor Management Appendix and/or Procedure Manual (Citation): and/or FMNP
State Plan (Citation): Click or tap here to enter text.
If the State agency does not authorize Farmers/Farmers’ Markets, please proceed to Section N.
Participant Access.

K. Farmer/Farmers’ Market Agreements
1. Agreement periods are for:
☐ One year
☐ Two years
☐Three years

☐ Other (specify): Click or tap here to enter text.

2. Agreements are:
☐ A modified version of the vendor
agreement
☐ Combined with the FMNP agreement
☐ Unique to the authorization of farmers to transact CVVs/CVBs
3. The following reflect the State agency’s farmer/farmers’ market agreement practices:
☐ All farmers/farmers’ markets have a written agreement with the State
agency
☐ A standard farmer/farmers’ market agreement is used statewide
☐ Agreements are subject to the State’s procurement procedures
☐ Agreements/handbooks are subject to the State’s Administrative Procedures Act
☐ Farmers/farmers’ markets are authorized/reauthorized under renewable agreements, provided no
farmer/farmers’ market violations occurred during the previous agreement period
☐ All farmers/farmers’ markets are provided at least 15 days advance written notice of the expiration
of the agreement
☐ All farmers/farmers’ markets are provided a schedule of sanctions, either in or attached to the
farmer/farmers’ market agreement, or as a citation to State regulations
☐ Other (specify): Click or tap here to enter text.
4. Agreement provisions include:
☐ Assure that the CVV/CVB is redeemed only for eligible fruits and vegetables as defined by the State
agency
☐ Provide eligible fruits and vegetables at the current price or less than the current price charged to other
customers
☐ Accept the CVVs/CVBs within the dates of their validity and submit CVVs for payment within the
allowable
time period established by the State agency

☐ Redeem the CVV/CVB in accordance with a procedure established by the State agency
☐ Accept training on CVV/CVB procedures and provide training to any employees with CVV/CVB
responsibilities on such procedures
☐ Agree to be monitored for compliance with program requirements, including both overt and covert
monitoring
☐ Be accountable for actions of employees in the provision of authorized foods and related activities
☐Pay the State agency for any CVV/CVB transacted in violation of this agreement
☐Offer WIC participants, parent or caretakers of child participants, or proxies the same courtesies as other
customers
☐Neither the State agency nor the farmer has an obligation to renew the
agreement.
☐ Other (specify): Click or tap here to enter text.
5. The farmer/farmers markets agreement reflects that the farmer/farmers’ market must not:
☐Collect sales tax on CVV/CVB purchases
☐Seek restitution from WIC participants, parent or caretakers of child participants, or proxies for
CVVs/CVBs
not paid or partially paid by the State agency
☐Issue cash change for purchases that are in an amount less than the value of the
CVV/CVB
☐ Other (specify): Click or tap here to enter text.
Please attach a copy of the Farmer/Farmers’ Market Agreement or provide the appropriate Procedure
Manual reference below.
ADDITIONAL DETAIL: Vendor Management Appendix and/or Procedure Manual (Citation):and/or FMNP
State Plan (Citation): Click or tap here to enter text.

L. Farmer/Farmers’ Market Training
1. Farmer/farmers’ market training includes:
☐ Eligible fruits and vegetables
☐ Procedures for transacting and redeeming
CVVs/CVBs
☐ Agreement provisions
☐ Sanctions and
Appeals
☐ Other (specify): Click or tap here to enter text.
2. Interactive farmer/farmers’ market training (e.g., face-to-face, video conference, web cam) is
conducted:
☐ At or before initial authorization
☐ At least every three years following initial
authorization
☐ Other (specify): Click or tap here to enter text.
3. Non-interactive farmer/farmers’ market training (e.g., via hard copy mail, email, online) is conducted:
☐ Annually following authorization
☐ Changes in procedures
☐ Other (specify):Click or tap here to enter text.

4. The State agency delegates training to:
☐ Local agency (specify):Click or tap here to enter text.
☐ Contractor (specify): Click or tap here to enter text.
☐ Farmer representative (specify):Click or tap here to enter text.
☐ Other (specify): Click or tap here to enter text.
5. If the State agency delegates training, briefly describe the State agency’s supervision of such training:
Click or tap here to enter text.
6. The State agency produces a Farmer/farmers markets Training Handbook:
☐ Yes

☐ No

If yes, provide the citation: Click or tap here to enter text.
7. The State agency provides online or web-based training:
☐ Yes

☐ No

If yes, provide the link to the training or citation: Click or tap here to enter text.
ADDITIONAL DETAIL: Vendor Management Appendix and/or Procedure Manual (Citation) and/or FMNP
State Plan (Citation): Click or tap here to enter text.

M. Farmer Monitoring
1. Farmers/farmers’ markets are included in the:
☐ FMNP sample of farmers/farmers markets for monitoring

☐ WIC sample of vendors for monitoring

2. Monitoring includes:
☐ Covert methods, such as compliance buys

☐ Overt methods, such as routine monitoring

ADDITIONAL DETAIL: Vendor Management Appendix and/or Procedure Manual (Citation): and/or FMNP
State Plan (Citation): Click or tap here to enter text.

N. Farmer/Farmers' Market Sanctions, Claims, and Appeals
1. Farmer/farmers’ market violations may result in; check all that apply:
☐ Disqualification
☐ Denial of payment or demand for refund due to improperly redeemed CVVs/CVBs
(Claims)
☐ Prosecution under Federal, State, or local law regarding fraud or other illegal activity
☐ Monetary sanctions such as civil money penalties and fines
2. Farmers/farmers’ markets may administratively appeal:
☐ Disqualification
☐ Denial of application
☐ Other sanction (specify): Click or tap here to enter text.
3. Farmers/farmers’ markets may not administratively appeal:
☐ Expiration of an agreement
☐ Claims

☐Other (specify): Click or tap here to enter text.
Please attach and/or reference the location of the State agency’s administrative review procedures.
ADDITIONAL DETAIL: Vendor Management Appendix and/or Procedure Manual (Citation) and/or FMNP
State Plan (Citation): Click or tap here to enter text.

II – Nutrition Services
(Please indicate) State Agency: Click or tap here to enter text. for FY Click or tap here to enter text.
Nutrition services include the full range of activities performed by a variety of staff to operate a WIC Program
such as, participant screening and assessment, nutrition education and counseling, breastfeeding promotion and
support and health promotion, food package prescriptions, and health care referrals. WIC State agencies should
refer to the WIC Nutrition Service Standards, available WIC Works Resource System at WIC Works http://wicworks.nal.usda.gov/ for recommended criteria and best practices to incorporate activities that are
consistent with providing quality nutrition services and revitalizing quality nutrition services (RQNS).
During a disaster or public health emergency, or supply chain disruption, the State agency
may request to implement existing WIC regulatory and programmatic flexibilities or waivers to support the
continuation of Program benefits and services. State agencies should consider the overarching authority, i.e.,
Stafford Act, Access to Baby Formula Act, or provision(s) authorized by Congress, and duration before
developing a policy and procedure. The State agency must provide a detailed description of how it plans to
operationalize the flexibility or waiver through their procedure manual where applicable. Please note the State
Plan Guidance is not intended to capture a description of waivers authorized by Congress with separate
reporting requirements.
Executive Order (EO) 13988, “Preventing and Combating Discrimination on the Basis of Gender Identity or
Sexual Orientation.” was issued to all Federal Agencies. The EO set out policies that all persons are entitled to
dignity, respect, and equal treatment under the law, no matter their gender identity or sexual orientation. The
EO does not usurp section 17 of 42 U.S.C, as amended or applicable regulations, rather it complements the
language in the nondiscrimination statement. Following the contents of the EO, State agencies must update
their policies and procedures to align with the contents of the EO and the nondiscrimination statement.
A. Nutrition Education-246.4(a)(9); 246.11(a)(1-3) (c)(1,3-7): describe the nutrition education goals and action
plan and the provisions for providing nutrition education contacts and materials to all participants including the
special nutrition education needs of migrant farmworkers and their families, Native Americans, and homeless
persons. Also describe methods to be used to provide drug and other harmful substance abuse prevention
information. Establish standards for breastfeeding promotion and support including the development and/or
maintenance of a peer counselor program consistent with the WIC Breastfeeding Model Components for Peer
Counseling.
B. Food Package Design-246.10: describe the procedures for determining which foods should be authorized and
how the food package should be nutritionally tailored and by whom and plans for substitutions or eliminations to
WIC food package. In addition to regulations at 246.10, State agencies should refer to the Food Package
Guidance Handbook and Frequently Asked Questions.
C. Staff Training-246.11(c)(2): describe the training and technical assistance provided to WIC professional
and paraprofessional personnel who provide nutrition education, and breastfeeding promotion/education to
participants.

A. Nutrition Education
1. Nutrition Education Plans (§246.11)
a. The State agency develops and coordinates the nutrition education component with consideration of local
agency plans, needs, and available nutrition education resources. (§246.11(c)(1))
☐ Yes

☐ No

b. The State agency monitors local agency activities to ensure compliance with provisions set forth
in paragraphs §246.11(c)(7), (d), and (e) of this section. (§246.11(c)(5))
☐ Yes

☐ No

☐ N/A, State agency has no authorized local agency(ies).

c. The local agency develops an annual nutrition education plan that is consistent with the State’s nutrition
education component of Program operations. (§246.11(d)(2))
☐ Yes
d.

☐ No ☐ N/A, State agency has no authorized local agency(ies).

The State agency requires that local agency nutrition education include:
☐ A needs assessment
☐ Goals and objectives for participants
☐ Evaluation/follow-up
☐ Other (list): Click or tap here to enter text.

The State agency monitors local agency progress toward meeting nutrition education goals, nutrition
education action plans, and objectives via:
☐ Quarterly or annually written reports
☐ Year-end summary report
☐ Annual local agency reviews
☐ Other (specify): Click or tap here to enter text.

f. State policies reflect the definition of “nutrition education” as defined in §246.2 and in the Child Nutrition Act.
The definition is “Nutrition education means individual and group sessions and the provision of materials that
are designed to improve health status and achieve positive change in dietary and physical activity habits, and
that emphasize the relationship between nutrition, physical activity, and health, all in keeping with the
personal and cultural preferences of the individual."
☐ Yes

☐ No

ADDITIONAL DETAIL: Nutrition Services Supporting Documentation: Click or tap here to enter text.
2. Annual Assessment of Participant Views on Nutrition Education and Breastfeeding Promotion and Support
a. Is an annual Assessment of Participant Views on Nutrition Education and Breastfeeding Promotion and
Support conducted?
☐ Yes

☐ No

b. Check below the method(s) used in the past fiscal year to assess participant views on nutrition education and
breastfeeding promotion and support provided by WIC:
☐ State-developed questionnaire issued by local agencies

☐ Locally developed (questionnaires need approval by SA):
☐ Yes
☐ No
☐ State-developed questionnaire issued by State agency.
☐ Focus groups (questionnaires need approval by State agency)
☐ Other (Specify): Click or tap here to enter text.
c. Results of participant views are:
☐ Used in the development of the State Plan
☐ Used in the development of local agency nutrition education plans and breastfeeding promotion and
support plans
☐ Other (specify): Click or tap here to enter text.
ADDITIONAL DETAIL: Nutrition Services Appendix and/or Procedure Manual (citation):
3. Nutrition Education Contacts (§246.11(a)(1-3): (1) Nutrition education shall be considered a benefit of
the program, and shall be made available at no cost to the participant. Nutrition education shall be
designed to be easily understood by participants, and it shall bear a practical relationship to
participant nutritional needs, household situations, and cultural preferences including information
on how to select food for themselves and their families. Nutrition education shall be thoroughly
integrated into participant health care plans, the delivery of supplemental foods, and other Program
operations. (2) Nutrition education is made available to all participants. Nutrition education may be
provided through the local agencies directly, or through other agencies. At the time of certification,
the local agency shall stress the positive, long term benefits of nutrition education and encourage
the participant to attend and participate in nutrition education activities. However, individual
participants shall not be denied supplemental foods for failure to attend or participate in nutrition
education activities. (3) The State agency shall ensure that local agencies provide drug and other
harmful substance abuse information to all pregnant, postpartum, and breastfeeding women and to
parents or caretakers of infants and children participants. Drug and other harmful substance abuse
information may also be provided to pregnant, postpartum, and breastfeeding women and to parents
or caretakers of infants and children participating in local agency services other than the Program.)
a. The State agency assures that each local agency offers adult participants, parents, or caretakers of infant
and child participants, and whenever possible, the child participants themselves at least two (≥2) nutrition
education contacts per 6 month certification period, and quarterly nutrition education contacts to participants
certified in excess of 6 months, to ensure adequate nutrition education in accordance with §246.11(e) via:
☐ Local agency addresses in the annual nutrition education plan
☐ State nutrition staff monitoring annually during local agency reviews
☐ Local agency providing periodic reports to State agency
☐ Other (specify): Click or tap here to enter text.
b. The State agency has developed minimum nutrition education standards for the following participant
categories:
☐ Pregnant women

☐ Breastfeeding women

☐ Postpartum women

☐ Children

☐ Infants

☐ High-risk participants

The minimum nutrition education standards address:
☐ Exit counseling

☐ Protocols (e.g., ☐ Breastfeeding promotion and support
Language barriers, cultural relevance

☐ Number of contacts

☐ Documentation

☐ Information on substance use prevention

☐ Care plans

☐ Referrals

☐ Nutrition topics relevant to participant assessment

☐ Counseling methods/teaching strategies
☐ Content (WIC appropriate topics)
☐ Appropriate use of educational reinforcement (videos, brochures, posters, etc.)
c. The State agency allows the following nutrition education delivery methods:
☐ Face-to-face, individually or group
☐ Online/internet (individually or group)
☐ Telephone
☐ Food demonstration
☐ A delivery method performed by other agencies, (i.e., EFNEP, SNAP-Ed). Please describe the type of
nutrition education delivered. Click or tap here to enter text.
☐ Other (specify): Click or tap here to enter text.
d. The State agency ensures that nutrition risk data is used in providing appropriate nutrition education by:
☐ Individual nutrition education contacts tailored to the participant’s needs
☐ Group nutrition education contacts relevant to the participant’s needs (please explain how appropriate
group nutrition classes are identified and offered to the participant.)
Click or tap here to enter text.
☐ Other (specify): Click or tap here to enter text.
e. An individual care plan is provided based on:
☐ Nutritional risk
☐ Priority level
☐ Healthcare provider’s prescription
☐ CPA discretion
☐ Participant set goal
☐ Other (specify): Click or tap here to enter text.

Individual care plans developed include the following components:
Must Include
Individualized food package
☐
Identification of nutrition-related problems
☐
Nutrition education and breastfeeding support
☐
A plan for follow-up
☐
Referrals
☐
Timeframes for completing care plan
☐
Documentation of completing care plan
☐
A practical relationship to a participant’s nutritional needs, household
☐
situations, and cultural preferences including information on how to

May Include
☐
☐
☐
☐
☐
☐
☐
☐

select food for themselves and their families
Participant set goal
Other (Specify by typing into the cells below)

☐

g. Check the following individuals allowed to provide general or high-risk nutrition education:

Paraprofessionals (non-B.S. degree with formal WIC training by SA
or LA)

General
Nutrition
Education

High-Risk
Nutrition
Contact

☐

Licensed Practical Nurses

☐

Registered Nurses

☐

B.S. in Home Economics

☐

B.S. in the field of Human Nutrition

☐

Registered Dietitian or M.S. in Nutrition (or related field)

☐

Dietetic Technician (2-year program completed)

☐

Other (specify by typing into the cells below):

h. The State agency allows adult participants to receive nutrition education by proxy, per 7 CFR 246.12(r)(1-4).
☐ No
☐ Yes (If yes, check the applicable conditions below):
☐ Proxy is spouse/significant other
☐ Proxy is parent of adolescent participant
☐ Proxy is neighbor
☐ Other (specify): Click or tap here to enter text.
☐ Only for certain priorities (specify): Click or tap here to enter text.
i.

The State agency allows parents/guardians of infant and child participants to receive nutrition education
by proxy.
☐ No
☐ Yes (If yes, check the applicable conditions below):
☐ Proxy is grandparent or legal guardian of infant or child participant
☐ Proxy is neighbor
☐ Other (specify): Click or tap here to enter text.
☐ Only for certain priorities (specify): Click or tap here to enter text.
ADDITIONAL DETAIL: Nutrition Services Appendix and/or Procedure Manual (citation):

Click or tap here to enter text.
4. Nutrition Education Materials (§246.11(c)(1,3,4,6,7): The State agency shall (1) develop and
coordinate the nutrition education component of Program operations with consideration of local
agency plans, needs, and available nutrition education resources; (3) identify or develop resources
and educational materials for use in local agencies, including breastfeeding promotion and
instruction materials, taking reasonable steps to include materials in languages other than English
in areas where a significant number or proportion of the population needs the information in a
language other than English; (4) develop and implement procedures to ensure that nutrition
education is offered to all adult participants and to parents/caregivers of infant or child participants,
as well as child participants whenever possible; (6) establish standards for participant contacts that
ensure adequate nutrition education in accordance with paragraph 246.11(e); and (7) establish
standards for breastfeeding promotion and support, including a positive breastfeeding supportive
clinic environment, a local agency breastfeeding coordinator, breastfeeding promotion, and support
for new staff.)
a. The State agency shares material with the Child and Adult Care Food Program (CACFP) at no cost:
☐ Yes ☐ No
If applicable, list other agencies: Click or tap here to enter text.
If yes, does a written material sharing agreement exist between the relevant agencies, per 7CFR
246.4(a)(9)(ii)?
☐ Yes

☐ No

b. The State agency recommends and/or makes available nutrition education materials for the following topics:
c.
English

Spanish

General nutrition

☐

Specific nutrition-related disorders

☐

Maternal nutrition

☐

Infant nutrition

☐

Child nutrition

☐

Nutritional needs of homeless

☐

Nutritional needs of migrant farmworkers & their families

☐

Nutritional needs of Native Americans

☐

Nutritional needs of adolescent participant

☐

Breastfeeding promotion and support (including
troubleshooting problems)

☐

Danger of harmful substances (alcohol, tobacco and
other drugs), as well as secondhand smoke during
pregnancy and breastfeeding

☐

Food Safety

☐

Physical activity

☐

Other
languages(specify by
typing into the cells
below):

Other (specify by typing into the cells below):
☐

☐

Attach a listing of the nutrition education resources available from the State agency or other sources for use by
local agencies or specify the location in the Procedure Manual and reference below.
d. The State agency follows written procedures to ensure that nutrition education materials recommended/made
available are appropriate in terms of the following:
☐ Content

☐ Reading level/language

☐ Graphic design

☐ Cultural relevance

☐ Other (specify):Click or tap here to enter text.
e. Locally developed nutrition education materials must be approved by State agency prior to use.
☐ Yes
☐ No
If no, State agency requires local agency to follow a standardized format for evaluating nutrition
education materials.
☐ Yes

☐ No

ADDITIONAL DETAIL: Nutrition Services Appendix and/or Procedure Manual (citation):

Click or tap here to enter text.
5. Nutrition Education Needs of Special Populations
The State agency tailors its nutrition education efforts to address the specific needs of migrant
farmworkers (M), homeless individuals (H), substance-abusing individuals (S), and/or breastfeeding
women (B) through (check all that apply):
M

☐

Providing nutrition education materials appropriate to this population
and language needs

☐

Providing nutrition curriculum or care guidelines specific to this
population

☐

Requiring local agencies who serve this population to address its
special needs in local agency nutrition education plans

☐

Arranging for special population training of local agency personnel who
work with this population

☐

Distributing resource materials related to this population

☐

Encouraging WIC local agencies to network with one another

☐

Coordinating at the State and local levels with agencies who serve this
population
Other (specify by typing into the cells below):

ADDITIONAL DETAIL: Nutrition Services Appendix and/or Procedure Manual (citation):

Click or tap here to enter text.
6. Breastfeeding Promotion and Support Plan
a. The State agency coordinates with local agencies to develop a breastfeeding promotion plan that contains
the following elements (check all that apply):
☐ Activities such as development of breastfeeding coalitions, task forces, or forums to address
breastfeeding promotion and support issues
☐ Identification of breastfeeding promotion and support materials
☐ Procurement of breastfeeding aids which support the initiation and continuation of breastfeeding (e.g.,
breast pumps).
☐ Training of State/local agency staff
☐ Designating roles and responsibilities of staff
☐ Evaluation of breastfeeding promotion and support activities
☐ Other (specify): Click or tap here to enter text.
b. The State agency has established minimum protocols for breastfeeding promotion and support which include
the following (check all that apply):
☐ A policy that creates a positive clinic environment which endorses breastfeeding as the preferred method
of infant feeding
☐ A requirement that each local agency designate a local agency staff person to coordinate breastfeeding
promotion and support activities
☐ A requirement that each local agency incorporate task-appropriate breastfeeding promotion and support
training into orientation programs for new staff involved in direct contact with WIC participants.
☐ A plan to ensure that women have access to breastfeeding promotion and support activities during the
prenatal and postpartum periods
☐ A plan to ensure that women have access to continued breastfeeding promotion and support when
normal operations are disrupted
☐ Participant breastfeeding assessment
☐ Food package prescription and tailoring based on breastfeeding and nutrition assessment
☐ Data collection (at State and local level)
☐ Referral criteria
☐ Peer counseling
☐ Other (specify): Click or tap here to enter text.
7. Breastfeeding Peer Counseling
a. Does the State agency request WIC Breastfeeding Peer Counseling (BFPC) funds to develop and/or
maintain a peer counselor program?
☐ Yes

☐ No

If yes, the State agency is requesting to receive which of the following amounts in BFPC funds for the
upcoming fiscal year (select only one amount)? Please consider available BFPC funds from prior
fiscal years when making this request.
☐ Full amount of available BFPC funds.
☐ Specific amount of available BFPC funds $Click or tap here to enter text.. (Not to exceed the full amount
available.)

b. Attach a copy of an updated line-item budget, with written narrative, demonstrating how peer
counseling funds are being used for approved peer counseling activities. Include the citation for the
attachment here: Click or tap here to enter text.
c. Please provide the approximate number of WIC peer counselors in your State: Click or tap here to enter text.
d.

Please provide the approximate number of Designated Breastfeeding Experts in your State Click or tap here
to enter text.

e. Please provide the number of local agencies designated by the State agency to receive funds to
operate peer counseling programs.

Click or tap here to enter text.

ADDITIONAL DETAIL: Nutrition Services Appendix and/or Procedure Manual (citation):

Click or tap here to enter text.
f.

The State agency coordinates with local agencies to develop a breastfeeding peer counseling program that
contains the following components (see WIC Breastfeeding Model Components for Peer Counseling):
☐ Yes

☐ No

g. Definition of peer counselor defined as follows: paraprofessional recruited and hired from target population;
available to WIC participants outside usual clinic hours and outside the WIC clinic
☐ Yes

☐ No

h. Designated breastfeeding peer counseling program managers/coordinators at State and/or local level
☐ Yes
i.

☐ No

Defined job parameters and job descriptions for breastfeeding peer counselors
☐ Yes
☐ No
If yes, the job parameters for peer counselors (check all that apply):
☐ Define settings for peer counseling service delivery (check all that apply):
☐ Home (peer counselor makes telephone calls from home)
☐ Participant’s home (peer counselor makes home visits)
☐ Clinic
☐ Hospital
☐ Define frequency of participants contacts
☐ Define procedures for making referrals
☐ Define scope of practice of peer counselor

Defined job parameters and job description for designated breastfeeding expert.
☐ Yes
☐ No

k. Compensation and reimbursement of breastfeeding peer counselors
☐ Yes
l.

☐ No

Training of State and local staff (managers, designated breastfeeding experts, peer counselors,
CPAs, others) using the FNS-developed breastfeeding training curriculum.
☐ Yes

☐ No

m. Training of WIC clinic staff about the role of the WIC peer counselor
☐ Yes

☐ No

n. Establishment of standardized breastfeeding peer counseling program policies and
procedures (check all that apply):
☐ Timing and frequency of contacts
☐ Documentation of participants contacts
☐ Referral protocols
☐ Confidentiality
☐ Use of social media
☐ Other (specify): Click or tap here to enter text.
o. Adequate supervision and monitoring of breastfeeding peer counselors through (check all that apply):
☐ Regular, systematic contact with peer counselor
☐ Regular, systematic review of peer counselor contact logs
☐ Regular, systematic review of peer counselor contact documentation
☐ Spot checks
☐ Observation
☐ Other (specify): Click or tap here to enter text.
p. Participation in community partnerships to enhance the effectiveness of breastfeeding peer counseling
programs (check all that apply):
☐ Breastfeeding coalitions
☐ Businesses
☐ Community organizations
☐ Cooperative extension
☐ La Leche League
☐ Hospitals
☐ Home visiting programs
☐ Private Healthcare clinics
☐ Other (specify): Click or tap here to enter text.
q. Adequate support of peer counselors by providing the following (check all that apply):
☐ Timely access to WIC-designated breastfeeding experts for referrals outside peer counselors’ scope of
practice
☐ Mentoring of newly trained peer counselors in early months of job
☐ Regular contact with supervisor
☐ Participation in clinic staff meetings as part of WIC team
☐ Opportunities to meet regularly with other peer counselors
☐ Other (specify): Click or tap here to enter text.
r.

Provision of training and continuing education of peer counselors (check all that apply):
☐ Standardized training using FNS-developed curriculum
☐ Ongoing training at regularly scheduled meetings
☐ Home Study
☐ Opportunities to “shadow” or observe lactation experts and other peer counselors
☐ Training/experience to become senior level peer counselors, WIC-Designated Breastfeeding Expert, etc.
☐ Other (specify): Click or tap here to enter text.

ADDITIONAL DETAIL: Nutrition Services Appendix and/or Procedure Manual (citation):

Click or tap here to enter text.

B. Food Package Design
1. Authorized WIC-Eligible Foods
a. Include a copy of the current State-authorized food list and the individual food package design for each
category in the Appendix or cite Procedure Manual reference:
b. The State agency considers the following when making decisions about authorizing WIC-eligible foods other
than WIC formulas:
☐ Federal regulatory requirements
☐ Participant acceptance
☐ Statewide availability
☐ Healthcare provider request

☐ Nutritional value
☐ Cost
☐ Participant cultural consideration
☐ Other (specify): Click or tap here to enter text.

c. The State agency utilizes additional State nutritional criteria for authorizing foods for the State WIC food list,
in addition to the minimum Federal regulatory requirements.
☐ Yes

☐ No

If yes, describe actual values or criteria identified by the State. Enter “n/a” if not
applicable. (i.e. artificial sweeteners, artificial color/flavor, low sodium, etc.):
Click or tap here to enter text.
d. The State agency provides the maximum amount of all authorized foods allowed in accordance with
the Federal WIC regulations at section 246.10 for each of the seven WIC Food Packages (I-VII).
Yes

☐

Pregnant women/Partially (Mostly) Breastfeeding

☐

Fully Breastfeeding women

☐

Postpartum, non-breastfeeding women

☐

Infants 0-5 months

☐

Infants 6-11 months

☐

Children

e. WIC Formulas:
(1)

The State agency establishes policies regarding the issuance of primary contract, contract,
and non-contract brand infant formula.
☐ Yes
☐ No

(2)

The State agency requires medical documentation for contract infant formula (that does not meet
the requirements in Table 4 at 246.10(e)(12) per 7 CFR 246.10(d)(1)(vi)).
☐ Yes
☐ No

(3) The State agency requires medical documentation for contract formula (other than primary
contract formula per 7 CFR 246.16a(c)(9).
☐ Yes ☐ No
(4) The State agency requires medical documentation for non-contract infant formula.
☐ Yes
☐ No
(5) The State agency requires medical documentation for exempt infant formula/ WIC eligible nutritionals.
☐ Yes
☐ No

(6) State agency authorizes local agencies to issue a non-contract brand infant formula that meets
the requirements of Table 4 in 246.10(e)(12) without medical documentation in order to meet
religious eating patterns:
☐ Yes
☐ No
(7) The State agency coordinates with medical payors and other programs that provide or reimburse
for exempt infant formulas and WIC-eligible nutritionals per Section 246.10(e)(3)(vi).
☐ Yes
☐ No
If yes, describe the State agency reimbursement and/or referral system used for this coordination?
Include describing monitoring/tracking tools in place to ensure program integrity.

Click or tap here to enter text.
If no, has the State agency met the requirement to annually contact their State Medicaid counterparts
regarding the payment of WIC-eligible exempt infant formulas and medical foods to mutual program
participants per WIC Policy Memo #2015-7?
☐ Yes

☐ No

Please attach and provide the citation for any existing written agreement between the State agency and the
State Medicaid office as well as local government agencies or private agencies regarding payment of WICeligible exempt infant formulas and medical foods.

Click or tap here to enter text.
f.

Rounding:
(1) The State agency management information systems is flexible for issuing infant formula to
support the option to use either method (i.e., monthly issuance or rounding up methodology)
for the timeframes (the number of months the participant will receive the food packages).
☐ Yes ☐ No
(2) The State agency management information systems supports the ability for infant formula to be
individual tailored when using either method (i.e., monthly issuance or rounding up methodology) for the
timeframes (the number of months the participant will receive the food packages).
☐ Yes

☐ No

(3) Does the State agency issue infant formula according to the specific rounding
methodology per Section 246.10(h)(1)?
☐ Yes
☐ No
(4) Does the State agency issue infant foods according to the specific rounding
methodology per Section 246.10(h)(2)?
☐ Yes
☐ No
(5) If the State agency implemented the rounding option for issuing infant foods, are there established
written policies in place?
☐ Yes
☐ No
g.

Is infant formula issued in the 1st month to partially breastfed infants?
☐ Yes
☐ No

State policies & materials reflect the definition of “supplemental foods” as defined 246.2
and in the Child Nutrition Act.
☐ Yes
☐ No

Does the State agency only allow issuance of reduced fat (2%) milk to children ≥ 24 months of age and
women with certain conditions, including but not limited to, underweight and maternal weight loss during

pregnancy, in accordance with Footnote 7 of Table 2 in 246.10(e)(10)?
☐ Yes
☐ No
j.

Does the State agency allow issuance of fat-reduced milks to 1-year-old children for whom overweight,
or obesity is a concern, in accordance with Footnote 7 of Table 2 in 246.10(e)(10)?
☐ Yes ☐ No

ADDITIONAL DETAIL: Nutrition Services Appendix and/or Procedure Manual (citation):

Click or tap here to enter text.
2. Individual Nutrition Tailoring
a. The State agency allows individual nutrition tailoring of food packages only in accordance with 246.10(c).
☐ Yes

☐ No

b. The State agency provides a special individually tailored package for
☐ Homeless individuals and those with limited cooking facilities
☐ Residents of institutions
☐ Other (specify): Click or tap here to enter text.
ADDITIONAL DETAIL: Please attach copies of all food packages that are tailored. Nutrition Services
Appendix and/or Procedure Manual (citation):

Click or tap here to enter text.
c. The State agency develops written individual nutrition tailoring policies and supportive science-based
nutrition rationale based on the following participant characteristics:
☐ Does not develop individual nutrition tailoring policies
☐ Develops based on (check all that apply):
☐ Nutrition risk/nutrition and breastfeeding assessment
☐ Participant preference
☐ Household condition
☐ Other (specify): Click or tap here to enter text.
d. The State agency allows local agencies to develop specific individual tailoring guidelines.
☐ Yes

☐ No

If yes, check those of the following methods used by the State agency to review or approve local
agency tailoring guidelines:
☐ Local agencies are required to submit individual tailoring guidelines for State approval
☐ Local agency individual tailoring guidelines are monitored annually during local agency reviews
☐ Agency reviews
☐ Other (specify): Click or tap here to enter text.
ADDITIONAL DETAIL: Nutrition Services Appendix and/or Procedure Manual (citation):

3. Prescribing Packages
a. Individuals allowed to prescribe food packages:

Standard food
package

Individually tailored food
package

CPA

☐

Other (specify by typing into the cells below):

☐

ADDITIONAL DETAIL: Provide a copy of the actual foods included in the homeless and institution packages
in the Appendix or cite Procedure Manual. Attach copies of all food packages that are tailored. Nutrition
Services Appendix and/or Procedure Manual (citation): Click or tap here to enter text.

C. Staff Training
The State agency provides or sponsors the following training for WIC competent professional authorities:
Professionals

Regularly

Paraprofessionals

(may or may not be CPAs in
some SAs)

As Needed

Regularly

As Needed

General nutrition education methodology

☐

State certification policies/procedures

☐

Anthropometric measurements

☐

Blood work procedures

☐

Nutrition counseling techniques

☐

Breastfeeding promotion/support

☐

Nutrition and breastfeeding assessment
techniques

☐

WIC Nutrition risk criteria

☐

Prescribing & tailoring food packages

☐

Referral protocol

☐

Screening protocol (if applicable)

☐

Maternal, infant, and child nutrition

☐

Cultural competencies

☐

Customer service

☐

Immunization Screening/referral

☐

Care Plan Development

☐

VENA staff competency training

☐

Substance abuse prevention

☐

Delivery of nutrition services in hybrid
environment (e.g., continuity of care,
confidentiality, documentation, etc.)

☐

Other (specify by typing in cells below):

☐

ADDITIONAL DETAIL: Nutrition Services Appendix and/or Procedure Manual (citation): (Please describe the type of
training conducted or offered that correlates to the boxes selected above).

Click or tap here to enter text.

III. MANAGEMENT INFORMATION SYSTEM (MIS)
(Please indicate) State Agency: Click or tap here to enter text. for FY: Click or tap here to enter text.
This section, Management Information System (MIS) involves the planning, documentation, security/
confidentiality, and production of the necessary reports relating to program operations through the
utilization of automated data processing services at the State and local level.
During a disaster or public health emergency, or supply chain disruption, the State agency
may request to implement existing WIC regulatory and programmatic flexibilities or waivers to support
the continuation of Program benefits and services. State agencies should consider the overarching
authority, i.e., Stafford Act, Access to Baby Formula Act, or provision(s) authorized by Congress, and
duration before developing a policy and procedure. The State agency must provide a detailed description
of how it plans to operationalize the flexibility or waiver through their procedure manual where
applicable. Please note the State Plan Guidance is not intended to capture a description of waivers
authorized by Congress with separate reporting requirements.
Executive Order (EO) 13988, “Preventing and Combating Discrimination on the Basis of Gender Identity or
Sexual Orientation.” was issued to all Federal Agencies. The EO set out policies that all persons are
entitled to dignity, respect, and equal treatment under the law, no matter their gender identity or sexual
orientation. The EO does not usurp section 17 of 42 U.S.C, as amended or applicable regulations, rather it
complements the language in the nondiscrimination. Following the contents of the EO, State agencies
must update their policies and procedures to align with the contents of the EO and the nondiscrimination
statement.
A. System Planning and Operation – 246.4(a)(11)(iv): Describe the procedures for planning, approving and
monitoring Automated Data Processing (ADP) goods and services, and any interaction with other statewide
ADP operations which may take place, including system costs for services and security.
B. Participant Characteristics Minimum Data Set (MDS) – 246.4(a)(11)(i): All State agencies currently
collect all required Minimum Data Set items. Please confirm that your State agency will continue to do so. For
the Supplemental Data Set (SDS), which varies by the capacity of State systems, please describe the data
items which are reported electronically regarding participant characteristics and whether these items are
currently being collected or if there are plans to collect them in the future.
C. WIC Systems Functional Requirements Checklist – 246.4(a)(8); (9); (11); (12); (13); (14); (15); and (18):
Describe those functions which are currently incorporated into the MIS or which are planned to be incorporated in
the future.

A. System Planning and Operation (Online and Offline)
1. Management Information System Planning
a. The WIC State agency is included in the following comprehensive Statewide ADP plan(s):
☐ Title IVa (TANF)
☐ Title V (MCH)
☐ Title XIX (Medicaid)
☐ Supplemental Nutrition Assistance Program (SNAP)
☐ Other (specify): Click or tap here to enter text.
☐ No
If no, please provide a copy of the WIC State agency's ADP utilization plan.
b. The State agency has written procedures for monitoring and approving local agency
requests for ADP goods and services. If yes, please provide a copy of written
procedures.
☐ Yes

☐ No

ADDITIONAL DETAIL: Management Information System Appendix and/or Procedure Manual (cite): Click or
tap here to enter text.
2. System Documentation
a. The State system is fully documented in accordance with (check all that apply):
☐ USDA/FNS Advance Planning Document Handbook No.901 ☐ USDA/FNS ADP Security Guide
☐ Other (specify): Click or tap here to enter text.
b. The State agency maintains overall system documentation (check all that apply):
☐ A general design
☐ User's manual
☐ Method for updating documentation for system changes/modifications
☐ A detailed design
☐ Maintenance manual
Note: These documents are NOT required for FNS review or submission with the State plans but should be
available if requested.
ADDITIONAL DETAIL: Management Information System Appendix and/or Procedure Manual (cite): Click or
tap here to enter text.
3. Automated Data Processing Services
a. Indicate below whether the following ADP functions, if applicable, are performed by State agency
staff or are contracted to an outside firm.
Function
Data entry
Food instrument production

Performed
SA Staff
☐
☐

Performed
LA Staff
☐
☐

Contracted to Outside Firm
(specify company name):

Click or tap here to enter text.
Click or tap here to enter text.
44

EBT Data Reports
Feasibility study
ADP development
ADP system hardware operation
Custom software development
Custom software maintenance
Printing forms/FIs
Backup computer facility
Other (specify):

☐
☐
☐
☐
☐
☐
☐
☐
☐

Click or tap here to enter text.
Click or tap here to enter text.
Click or tap here to enter text.

☐
☐
☐

☐
☐
☐
☐
☐
☐
☐
☐

Click or tap here to enter text.
Click or tap here to enter text.
Click or tap here to enter text.
Click or tap here to enter text.
Click or tap here to enter text.
Click or tap here to enter text.
Click or tap here to enter text.
Click or tap here to enter text.
Click or tap here to enter text.

☐
☐
☐

Click or tap here to enter text.
Click or tap here to enter text.
Click or tap here to enter text.

☐

b. The State agency has a contract in effect (check all that apply). Please provide a copy of
agreement.
☐ Equipment

☐ Services

☐ Software

c. The State agency has methods in place for ensuring that the costs of equipment or
services used by WIC and other programs are equitably prorated among funding
sources. Please provide policy of method used.
☐ Yes

☐ No
d. The State agency periodically reviews system costs billing.

☐ Yes
e.

☐ No

The State agency acquires banking services through:

☐ Competitive bids among banks within the State
☐ Competitive bids among in State and out-of-State banks
☐ Use of State agency designated bank
☐ Other: Click or tap here to enter text.
f.

The State agency acquires EBT services through:

☐ Competitive bids among EBT processors
☐ State hosted EBT services
☐ Other: Click or tap here to enter text.
ADDITIONAL DETAIL: Management Information System Appendix and/or Procedure Manual (cite): Click or
tap here to enter text.
4. System Security/Data Confidentiality
a. To ensure that data files and computer programs are protected, the State agency ensures that
(check all that apply):
☐ There is a separate organizational area/individual to control access to electronic storage media.
☐ Access to WIC Program data files is controlled through password access or similar control.

☐ Operational personnel are limited to only those jobs for which they are responsible.
☐ Passwords are protected.
☐ Passwords are changed periodically.
☐ The system access procedures are audited at least once a year. Please provide a copy of access
procedures.
☐ Procedures are implemented for timely removing passwords, ID's etc. when personnel leave.
☐ Biennial security reviews are performed by Click or tap here to enter text.. Please provide a written
summary of the most current biennial security review
☐ Periodic risk assessments are performed by Click or tap here to enter text.
☐ Data uploaded to mobile applications, participant portals, etc. are secure and participant information is
protected.
☐ Other (specify): Click or tap here to enter text.
b. To ensure that disaster contingency plans (e.g., file storage, backup hardware, and
software procedures) are sufficient to allow the management information and electronic
benefit transfer systems to recover and continue processing after fire, flood or similar
disaster, the State agency ensures that (check all that apply):
☐ Backup copies of files and program are stored off-site in a secure location. Please provide address of
location.

Click or tap here to enter text.

☐ Backup copies are kept up to date.
☐ There is an agreement with another processing unit with compatible hardware to provide services in an
emergency. Please provide copy of agreement.
☐ A contingency plan is in place in the event of service interruption. Please provide a copy of contingency
plan.
☐ A recent test of the WIC system or mock disaster recovery operation has been conducted at the backup
facility. Please provide a written summary of the conducted test.
☐ Other (specify): Click or tap here to enter text.
ADDITIONAL DETAIL: Management Information System Appendix and/or Procedure Manual (cite): Click or
tap here to enter text.
5. Description of MIS changes that occurred in the past year: Click or tap here to enter text.
6. Description of MIS changes planned for the upcoming year: Click or tap here to enter text.

B. Participant Characteristics Minimum Data Set
The Participant Characteristics (PC) Minimum Data Set (MDS) contains data items which are reported to
FNS electronically by State agencies in April in even numbered years on all or a State-representative
sample of participants. The MDS has required data items which must be collected and reported. The
Supplemental Data Set (SDS) is comprised of data items which State agencies have agreed are
desirable to collect and report at the national level. Please check MDS or SDS data items the State
agency currently collects in its Information Systems and those MDS or SDS data items it is planning to
collect within the next two years.

State Agency IS Collects:
☐ State Agency ID. A unique number that permits linkage to the WIC State agency where the participant was
certified.
☐ Local Agency ID. A unique number that permits linkage to the local agency where the participant was
certified as eligible for WIC benefits.
or
☐ Service Site ID. A unique number that permits linkage to the service site where certified. Either local agency
ID or service site ID may be reported according to the level the State Agency feels appropriate. At a
minimum, State agencies must provide agency names and addresses for each ID provided on their files.
☐ Case ID. A unique record number for each participant which maintains individual privacy at the national
level. (This may not be the case number used in the State agency's MIS for the individual.) Participant or
Case IDs for each participant should continue to maintain individual privacy at the national level.
☐ Client Date of Birth. Month, day and year of participant's birth reported in MMDDYYYY format.
☐ Client Race/Ethnicity. The classification of the participant into one of the five (5) racial/ethnic categories:
For race: American Indian or Alaskan Native; Asian; Black or African American; Native Hawaiian or Other
Pacific Islander; and White. For ethnicity: Hispanic or Latino; Not Hispanic or Latino.
☐ Certification Category. The category---one of five (5) possible categories---under which a person is certified
as eligible for WIC benefits: pregnant woman; breastfeeding woman; postpartum woman (not breastfeeding);
infant (under 12 months); or child (12-59 months).
☐ Expected Date of Delivery or Weeks Gestation. For pregnant women, the projected date of delivery
(MMDDYYYY format) or the number of weeks since the last menstrual period as determined at WIC
Program certification.
☐ Date of Certification. The date the person was declared eligible for the most current WIC Program
certification. Month, day, and year should be reported in MMDDYYYY format.
☐ Sex. For infants and children, male or female.
☐ Priority Level. Participant priority level for WIC Program certification.
☐ Participation in TANF, SNAP, Medicaid. The participant's reported participation in each of these programs
at the time of the most recent WIC Program certification.
☐ Migrant Status. Participant migrant status according to the federal WIC Program definition of a migrant
farm worker (currently counted in the FNS 798 report).
☐ Number in Family/Household or Economic Unit. The number of persons in the family/household or
economic unit upon which WIC income eligibility was based. A self-declared number in the
family/household or economic unit may be reported for participants whose income was not required to be
determined as part of the WIC certification process. These participants include adjunctively income-eligible
participants (due to TANF, SNAP, or Medicaid participation) and those participants deemed income eligible
under optional procedures available to the State Agency in Federal WIC Regulations, Section
246.7(d)(2)(vi-viii) (means-tested programs identified by the State for automatic WIC Program income
eligibility, income eligibility of Indian and in-stream migrant farmworker applicants).

☐ Family/Household or Economic Unit Income. For persons for whom income is determined during the
certification process, the income amount that was determined to qualify them for the WIC Program during
the most recent certification. For descriptive purposes only, for participants whose income was not required
to be determined as part of the WIC Program certification process, the self-reported income at the time of
certification. These participants include adjunctively income-eligible participants and those persons deemed
eligible under optional procedures available to the State Agency in Federal WIC Regulations, Section
246.7(d)(2)(vi-viii). Zero should not be used to indicate income values that are missing or not available. Zero
should indicate only an actual value of zero.
☐ Nutrition Risk(s) Present at Certification. Up to 10 highest priority nutritional risks present at the WIC
Program certification
☐ Hemoglobin or Hematocrit. That value for the measure of iron status that applies to the WIC Program
certification. It is assumed that the measure was collected at the time of certification or within ninety (90)
days of the certification date.
☐ Date of Blood Measurement. The date of the blood measurement that was used during the most recent
WIC Program certification in MMDDYYYY format.
☐ Weight. The participant's weight measured according to the CDC nutrition surveillance program standards
[nearest one-quarter (1/4) pound]. If weight is not collected in pounds and quarter pounds, weight may be
reported in grams.
☐ Height. The participant's height (or length) measured according to the CDC nutrition surveillance program
standards [nearest one-eighth (1/8) inch]. If height is not collected in inches and 1/8 inches, height may be
reported in centimeters.
☐ Date of Height and Weight Measure. The date of the height and weight measures that were used during
the most recent WIC Program certification in MMDDYYYY format.
☐ Currently Breastfed. Information is needed for all infant participants ages six through thirteen months,
whether or not the infant is currently receiving breastmilk.
☐ Ever Breastfed. Information is needed for all infant participants ages six through thirteen months, whether
or not the infant was ever breastfed.
☐ Length of Time Breastfed. For infants ages six through thirteen months, the number of weeks the infant
received breastmilk.
☐ Date Breastfeeding Data Collected. For infants ages six through thirteen months, the date on which
breastfeeding status was reported in MMDDYYYY format.
☐ Food Packages. The food package code(s) for the WIC food package or for all food instruments prescribed
for the participant during the month.

OPTIONAL:

Supplemental Data Set
State
State
Agency IS
Agency IS
Collects
Plans to Collect

☐

Date of First WIC Certification. Date the participant was first certified for
the WIC Program in MMDDYYYY format. For pregnant, breastfeeding
and postpartum w o m e n , this applies to the current/most recent
pregnancy and not to prior pregnancies.

☐

Educational Level. For pregnant, breastfeeding and postpartum women,
the highest grade or year of school completed. For infants and children,
the highest grade or year of school completed by mother or primary
caretaker.

☐

Number in Family/Household on WIC. The number of people in the
participant's family/household receiving WIC benefits.

☐

Date Previous Pregnancy Ended. For pregnant women, the date
previous pregnancy ended in MMDDYYYY format.

☐

Total Number of Pregnancies. For pregnant women, the total number
of times the woman has been pregnant, including this pregnancy, all live
births and any pregnancies resulting in miscarriage, abortion or stillbirth.

☐

Total Number of Live Births. For pregnant women, the total number of
babies born alive to this woman, including those who may have died
shortly after birth.

☐

Pre-pregnancy Weight. For pregnant women only, the participant's
weight immediately prior to pregnancy. Pre-pregnancy weight may be
reported either in pounds and ounces or in grams.

☐

Participant's Weight Gain During Pregnancy. For breastfeeding and
postpartum women, the participant's weight gain during pregnancy as
taken immediately at or prior to delivery. Weight gain during pregnancy
may be reported in either pounds and ounces or in grams.

☐

Birth Weight. For infants and children, the participant's weight at birth
measured according to the CDC nutrition surveillance program
standards (lbs/oz). Birth weight may be reported in either pounds or
ounces, or in grams.

☐

Birth Length. For infants and children, the participant's length measured
according t o the CDC nutrition surveillance program standards (1/8
inches). Birth length may be reported in either inches and eighth inches
or in centimeters.

☐

Participation in the Food Distribution Program on Indian
Reservations. The participant's reported participation in this program.

C. WIC Systems Functional Requirements Checklist
The following checklists were taken from the WIC Functional Requirements Document (FRED) which is
provided as guidance to State agencies on functions they should consider incorporating into their
Information Systems. Please check those functions/capabilities which the State agency system
currently performs or plans to perform within the next two years.
State

State

Agency

System

Performs

Planned

Automated Core Function/Capabilities

☐

1. Calculates the date certification is due to expire.

☐

2. Assigns the participant a nutritional risk code and assigns a priority level.
(CPA confirms the code is correct.)

☐

2a. Assigns one risk code.

☐

2b. Assigns up to 3 risk codes.

☐

2c. Assigns up to 6 risk codes.

☐

2d. Assigns more than 6 risk codes.

☐

3. Calculates the applicant's household income and flags individuals whose
income exceeds program standards.

☐

3a. Converts incremental income (weekly, monthly) to an annual figure.

☐

4. Associates family members.

☐

5. Statewide data is maintained to facilitate families transferring within the State.

☐

6. Transfers certification data to the central computer facility electronically either
in real time or batch mode.

☐

7. Captures or documents the nutrition education provided each participant as
well as the topics covered.

☐

8. Uses table-driven food packages.

☐

8a. Uses standard pre-defined food packages.

☐

8b. Enables easy food package tailoring.

☐

8c. Performs edits to prevent over-issuance during food package creation.

☐

9. Enables food instruments to be issued when the participant is present for pickup, i.e., on-demand.

☐

10. Captures or documents the name of the programs to which the participant was
referred.

☐

11. Performs food instrument reconciliation.

☐

12. Produces standard Dual Participation Report.

☐

13. Produces standard Food Delivery Portal (FDP) Report.

☐

14. Produces standard Rebate Billing Report.

☐

15. Produces standard Participation Report.

☐

16. Produces Participant Characteristics Datasets.

☐

17. Captures basic transaction data by vendor.

State
Agency
System
Performs

State
Agency
System
Planned

Automated Core Function/Capabilities

18. Flags high-risk vendors through peer group analysis of redemption data.

☐

18a. Identifies vendors with high average food instrument

☐

18b. Identifies vendors with a narrow variation in redemptions.

☐
item/UPC

☐

19. Assigns a maximum value for each food instrument type (paper) or each

☐
instrument

☐

(EBT).
19a. Receives data about the amount a vendor requests for each food
(paper) or item/UPC (EBT) redeemed.

☐

20. Captures source of income.

☐
than

☐

21. Has the capability of annualizing household income occurring at more
one frequency.

☐

22. Performs automated dietary assessment.

☐

23. Has automated growth charts.

☐
within

☐

24. Has point of certification data entry, i.e., a personal computer at each “station”

redemptions.

the clinic.
☐

☐

25. Allows for ad hoc reporting.

IV. ORGANIZATION AND MANAGEMENT
(Please indicate) State Agency:Click or tap here to enter text. for FY: Click or tap here to enter text.
Organization and management involve the procedures for the documentation of staff time at the State
level devoted to the various WIC functions, the evaluation and selection of local agencies, the
documentation of local agency staffing standards and data, as well as disaster planning.
During a disaster, public health emergency, or supply chain disruption, the State agency
may request to implement existing WIC regulatory and programmatic flexibilities or waivers to support the
continuation of Program benefits and services. State agencies should consider the overarching authority, i.e.,
Stafford Act or provision(s), Access to Baby Formula Act, or authorized by Congress, and duration before
developing a policy and procedure. The State agency must provide a detailed description of how it plans to
operationalize the flexibility or waiver through their procedure manual where applicable. Please note the State
Plan Guidance is not intended to capture a description of waivers authorized by Congress with separate reporting
requirements.
Executive Order (EO) 13988, “Preventing and Combating Discrimination on the Basis of Gender Identity or Sexual
Orientation”, issued to all Federal Agencies, set out policies that all persons are entitled to dignity respect and
equal treatment under the law, no matter their gender identity or sexual orientation. The EO does not usurp
section 17 of 42 U.S.C., as amended or applicable regulations, rather it complements the nondiscrimination
statement. Following the contents of the EO, State agencies must update their policies and procedures to align
with the contents of the EO and the nondiscrimination statement.
A. State Staffing – 246.3(e), 246.4(a)(4) and (24): describe the information relating to State level staff requirements
and utilization as it relates to WIC Program functions and how the State agency will provide a drug-free
workplace.
B. Evaluation and Selection of Local Agencies - 246.4(a)(5)(i) and (7) and 246.5: describe the procedures and criteria
utilized in the selection and authorization of local agencies.
C. Local Agency Staffing - 246.4(a)(4): describe the State staffing standards which apply to the selection of local
agency staff and the means used by the State agency to track and analyze local level staffing data.
D. Plan of Alternate Operating Procedures (Disaster Plan) - describe the plan of alternate operating procedures in
preparation for a disaster and/or public health emergency.

A. State Staffing
1. State Level Staff
a. Record below the current total full-time equivalent staff (FTEs) available for each position listed or attach
equivalent information in the section’s Appendix noted here: Click or tap here to enter text.
Position

FTE WIC

FTE In-Kind

Total FTE

Director
Nutritionist
Vendor Specialist
Program Specialist
Financial Specialist
Breastfeeding Coordinator
(MIS/EBT) Specialist
Intern
Other (specify):Click or tap here to enter text.
Other (specify):Click or tap here to enter text.
Other (specify):Click or tap here to enter text.
b. The State agency has a WIC organizational chart showing all positions, titles, and staff names.
☐ Yes
☐ No
If yes, please attach and/or reference the location of the State agency's WIC organization chart:

Click or tap here to enter text.

c. Please attach and/or reference the location of the overall organizational chart that identifies the WIC
Program's relationship within the State Health Department or Indian Tribal Organization:

Click or tap here to enter text.

d. The State agency has updated position descriptions for each of the above positions.
☐ Yes
☐ No
If yes, please attach and/or reference the location of the position descriptions:

Click or tap here to enter text.

ADDITIONAL DETAIL: Organization & Management Appendix and/or Procedure Manual (citation):

Click or tap here to enter text.

2. Estimate below the average percent of State staff time devoted to fulfilling the following functions:
Function

Percent of Total Staff Time

Certification, including nutrition risk determination

Click or tap here to enter text.

Breastfeeding training/promotion and support

Click or tap here to enter text.

Nutrition education

Click or tap here to enter text.

Monitoring of local agencies

Click or tap here to enter text.

Fiscal reporting

Click or tap here to enter text.

Food delivery system management

Click or tap here to enter text.

Vendor management, including vendor training

Click or tap here to enter text.

Staff training and continuing education

Click or tap here to enter text.

(MIS/EBT) system development and maintenance

Click or tap here to enter text.

Civil Rights

Click or tap here to enter text.

Coordination with and referrals to other assistance
programs and social service agencies

Click or tap here to enter text.

Other (specify):

Click or tap here to enter text.

Total

Click or tap here to enter text.

ADDITIONAL DETAIL: Organization & Management Appendix and/or Procedure Manual (citation):

Click or tap here to enter text.
3. Drug-Free Workplace

a. The State agency has a plan that will enable them to achieve a drug-free workplace.

☐ Yes

☐ No

b. Please attach and/or reference the location of a description of the State agency's plans to provide
and maintain a drug-free workplace in Appendix of this section.

Click or tap here to enter text.

ADDITIONAL DETAIL: Organization & Management Appendix and/or Procedure Manual (citation):

Click or tap here to enter text.

B. Evaluation and Selection of Local Agencies
☐ Does not apply because the State agency has only one location or no local agency(ies). (PROCEED
TO NEXT SECTION)
1. Local Agencies Authorized

Click or tap here to enter text.Number of local agencies authorized to provide WIC services last fiscal year
Click or tap here to enter text.Number of local agencies planned to provide WIC services this fiscal year

ADDITIONAL DETAIL: Organization & Management Appendix and/or Procedure Manual (citation):

Click or tap here to enter text.

2. The State agency accepts applications from potential local agencies:

☐ Annually

☐ Biennially

☐ On an on-going basis

☐ Other (specify) Click or tap here to enter text.

ADDITIONAL DETAIL: Organization & Management Appendix and/or Procedure Manual (citation):

Click or tap here to enter text.

3. Existing local agencies must reapply and compete with new applicant agencies for authorization:

☐ Annually
☐ Not applicable

☐ Biennially
☐ Other (specify) Click or tap here to enter text.

ADDITIONAL DETAIL: Organization & Management Appendix and/or Procedure Manual (citation):

Click or tap here to enter text.
4. Selection Criteria

a. The State agency uses the following criteria in selecting local agencies in new service areas and/or in
reviewing applications from existing service areas:
New
Service
Areas

Existing
Service
Areas

☐

Coordination with other health care providers

☐

Projected cost of operations/ability to operate with available funds

☐

Location/participant accessibility

☐

Financial integrity/solvency

☐

Relative need in the area

☐

Range and quality of services

☐

History of performance in other programs

☐

Ability to serve projected caseload

☐

Non-smoking facility

☐

Americans with Disabilities Act (ADA) compliance
Other (specify by typing into the cells below):

☐

b. The State agency conducts studies (provide date of most recent study: Click here to enter a date.) of the costeffectiveness of local agency operations that examine:

☐ Location and distribution of local agencies in proportion to new applicants/participants
☐ Clinic procedures to optimize participant access/service (Patient Flow Analysis, etc.)
☐ Staff-to-participant ratios and related staffing analyses
☐ Comparative analyses of local agency/clinic costs
☐ Other
ADDITIONAL DETAIL: Organization & Management Appendix and/or Procedure Manual (citation):

Click or tap here to enter text.

5. The State agency enters into a formal written agreement or contract with each local agency.

☐ Yes (state contract duration):Click or tap here to enter text.

☐ No

ADDITIONAL DETAIL: Organization & Management Appendix and/or Procedure Manual (citation):

Click or tap here to enter text.
6. The State agency has established statewide fair hearing procedures for local agency appeals.

☐ Yes, attach local agency fair hearing procedures or specify the location in the Procedure Manual and
reference below:
☐ No

ADDITIONAL DETAIL: Organization & Management Appendix and/or Procedure Manual (citation):

Click or tap here to enter text.

7. The State agency maintains a listing of clinic sites that includes the following information. If available, please
attach and/or reference the location of the listing:
Click or tap here to enter text.

☐ Location
☐ Type of site (e.g., hospital, health department, community action program)
☐ Service area
☐
☐
☐
☐
☐
☐

Hours of operation
Days of operation
Health services provided on-site
Social services provided on-site
Participation
Other (specify): Click or tap here to enter text.

ADDITIONAL DETAIL: Organization & Management Appendix and/or Procedure Manual (citation):
Click or tap here to enter text.

C. Local Agency Staffing
☐ Does not apply because the State agency has only one location or no local agency(ies). (PROCEED TO
NEXT SECTION)
1. Staffing Standards
a. The State agency prescribes local agency staffing standards that include:
☐ Credentials

☐ Staff levels
☐ Staff-to-participant ratio standards
☐ Time spent on WIC functions
☐ Other (specify): Click or tap here to enter text.
☐ Functions of CPAs
☐ Paraprofessional requirements
☐ Separation of duties to ensure no conflicts of interest
☐ Other (specify):
☐ Not applicable
b. The State agency has a plan for ensuring that local agency credentials are in line with the Nutrition Services
Standards.
☐ Yes
☐ No

c. The State agency maintains copies of local agency CPA position descriptions, classified in terms of Nutrition
Services Standards, i.e., federal requirements, recommended criteria, best practices.
☐ Yes
☐ No
d. Local agencies follow staffing standards established by unions or local governmental authorities.
☐ Yes
☐ No
If yes, how many of the total local agencies are currently authorized by unions or local governmental
authorities? Click or tap here to enter text.
ADDITIONAL DETAIL: Organization & Management Appendix and/or Procedure Manual (citation):

Click or tap here to enter text.
2. Local Level Staffing Data

a. The State agency gathers and analyzes data to determine staff-to-participant ratios (check all that apply):

☐
For each clinic/local agency
☐ By function
☐ At regular intervals
☐ Program management
☐ Monthly
☐ Food delivery
☐ Quarterly
☐ Certification
☐ Annually
☐ Nutrition education
☐ Breastfeeding promotion and support
☐ Other (specify): Click or tap here to enter text.
b. Results of analyses are reported back to local agencies.

☐ No
☐ Yes, in a single report comparing all local agencies
☐ Yes, in a local agency-specific report (no comparative data)
ADDITIONAL DETAIL: Organization & Management Appendix and/or Procedure Manual (citation):

Click or tap here to enter text.

3. Local Agency Breastfeeding Staffing Requirement
a. Number of local agencies with a designated staff person to coordinate breastfeeding promotion and support
activities.
b. The State agency maintains approved copies of local agency Breastfeeding Coordinator and Peer Counselor
position descriptions as outlined in the WIC Breastfeeding Support.

☐ Yes

☐ No

c. Number of local agencies with breastfeeding peer counselors.

D. Plan of Alternate Operating Procedures (Disaster Plan)

Developing a plan of alternate operating procedures, more commonly referred to as a Disaster Plan, is not
required but encouraged. A Disaster Plan should include policies and procedures for operations when regular
operations are disrupted, which may include disasters, public health emergencies, and supply chain
disruptions. In this section are questions to guide State agencies in developing their plan of alternate

operations prior to a disaster and/or public health emergency.
1. State agency has developed a WIC disaster or emergency operations plan.

☐ Yes

☐ No

2. The WIC disaster and public health emergency plan is part of a broader Health Department or other State
agency disaster plan.

☐ Yes, what agency(ies): Click or tap here to enter text.
☐ No
3. The State agency shares the disaster and public health emergency plan with its local agencies and clinics?

☐ Yes

☐ No

4. The disaster plan addresses:
a. Disaster and Public Health Emergency Planning
☐ Designate a WIC State agency emergency contact to work with relief organizations for continued WIC
benefits.
☐ Internal/external communications plan
☐ Establish point of contact with State/ITO-level relief agencies
☐ Design a comprehensive plan that aligns with the Department of Health’s Disaster Plan for continued WIC
services
☐ Plans are submitted with State Plans for approval
☐ Train staff and test readiness periodically on approved plans
☐ Other (describe) Click or tap here to enter text.
b. Alternate Certification
☐ Remote certification
☐ Physical presence
☐ Anthropometric data
☐ Eligibility documentation
☐ Certification period (temporary or fully certified)
☐ Signature requirements
☐ Verification of Certification (VOC) issuance
☐ Other (describe) Click or tap here to enter text.
c. Alternate Benefit Issuance and Redemption
☐ Electronic benefit (EBT) issuance sites
☐ Out of State benefit redemption
☐ Replace EBT cards
☐ Replace destroyed supplemental foods
☐ Mailing food instruments (FI) and cash value voucher/benefits (CVV/B)
☐ Direct Distribution
☐ Home Food Delivery
☐ Other (describe) Click or tap here to enter text.
d. Vendor Management Requirements
☐ Minimum stocking requirements (MSR)
☐ Vendor Monitoring Schedules
☐ Emergency authorization of vendors
☐ Other (describe) Click or tap here to enter text.
e. Nutrition Services

☐ Infant formula
☐ Medically fragile participants
☐ Medical documentation
☐ State agency options for evacuated participants
☐ Food package adjustments
☐ Breastfeeding Support
☐ Other (describe) Click or tap here to enter text.
f.

Allowable Cost
☐ Necessary equipment (health and safety) approval process
☐ Use of WIC staff
☐ Cost of personal protective equipment (PPE)
☐ Other (describe) Click or tap here to enter text.

g. Participants
☐ Access to program records
☐ Certification and food issuance sites and procedures
☐ Publication notification of variances in program operations
☐ Use of mobile devices
☐ Other (describe) Click or tap here to enter text.
h. Alternate Procedures
☐ Local agency monitoring
☐ Procedures to assess the extent of a disaster and report findings
☐ Use of mobile clinics
☐ Management Information System (MIS) Recovery
☐ Back up filing systems
☐ Back up computer systems
☐ MIS alternate procedures
☐ Reciprocal agreement with bordering States
☐ Plan to ensure continuity of services for priority populations
☐ Collect and report on alternate operating procedures implemented
☐ Other (describe): Click or tap here to enter text.

5. The State agency requires local agencies/clinics to have individual disaster plans.

☐ Yes

☐ No

If yes, such plans are reviewed for compliance and consistency with the State agency disaster plan.

☐ Yes

☐ No

6. The State agency has a designated staff person to coordinate disaster planning.

☐ Yes

☐ No

ADDITIONAL DETAIL: Organization & Management Appendix and/or Procedure Manual (citation):
Click or tap here to enter text.

V. NUTRITION SERVICES AND ADMINISTRATION (NSA) EXPENDITURES
(Please indicate) State Agency: Click or tap here to enter text. for FY Click or tap here to enter text.
NSA expenditures involve the process of allocating, documenting, and monitoring the distribution of
administrative funds to local agencies, including the monitoring of nutrition education costs, and State
and local agency direct/indirect costs.
During a disaster or public health emergency, or supply chain disruption, the State agency
may request to implement existing WIC regulatory and programmatic flexibilities or waiversto support
the continuation of Program benefits and services. State agencies should consider the overarching
authority, i.e., Stafford Act, Access to Baby Formula Act, or provision(s) authorized by Congress, and
duration before developing a policy and procedure. The State agency must provide a detailed
description of how it plans to operationalize the flexibility or waiver through their procedure manual
where applicable. Please note the State Plan Guidance is not intended to capture a description of
waivers authorized by Congress with separate reporting requirements.
Executive Order (EO) 13988, “Preventing and Combating Discrimination on the Basis of Gender Identity
or Sexual Orientation.” was issued to all Federal Agencies. The EO set out policies that all persons are
entitled to dignity, respect, and equal treatment under the law, no matter their gender identity or sexual
orientation. The EO does not usurp section 17 of 42 U.S.C, as amended or applicable regulations,
rather it complements the language in the nondiscrimination statement. Following the contents of the
EO, State agencies must update their policies and procedures to align with the contents of the EO and
the nondiscrimination statement.
A. Funds Allocation-246.4(a)(13); (14)(ix): describe the policies and procedures used to allocate
administrative funds to local agencies, including start-up funds, and conversion of food funds to NSA
funds.
B. Local Agency Budgets/Expenditure Plans-246.4(a)(2): describe the policies and procedures for
preparing and submitting local agency budgets and expenditure plans and the services that are entirely
supported by WIC Program funds.
C. State and Local Agency Access to Funds-246.4(a)(13): describe the procedures and method(s) of
distribution/ reimbursement of NSA funds to local agencies.
D. Reporting and Reviewing of State and Local Agency Expenditures-246.4(a)(11)(iv); (12); and (13):
describe the policies and procedures used to report, monitor, and review State and local agencies’
expenditures, including the documentation of staff time, local agency report forms, on-site reviews of local
agencies’ NSA expenditures, and in-kind contributions.
E. Nutrition Education Costs-246.4(a)(9)and 246.14(c)(1): describe the plans and procedures used to
meet the nutrition education expenditure requirements, including monitoring activities, local agency reports,
and assurances that the special nutrition education needs of migrant farmworkers and their families,
Indians, and homeless persons are met.
F. Indirect Costs-246.4(a)(12) and 246.14(a)(1)(ii): describe the policies and procedures used to
document and monitor indirect cost rates and services at the State and local level.

A. Funds Allocation
1. Allocation Process
a. The State agency has established and provided written procedures to local agencies describing
the process for allocation of NSA funds among local agencies.
☐ Yes

☐ No

☐ Not applicable, State agency does not have separate local
agencies. (Proceed to A. 2. Conversion of Food Funds to
NSA Funds)

b. Local agencies were involved in developing these procedures via:
☐ Task force/committee of selected local agencies
☐ Comment on proposals made available to all local agencies
☐ Other (describe): Click or tap here to enter text.
c. The State agency allocates NSA funds to local agencies through the use of:
☐ A negotiated budget
☐ Formula (variable)

☐ Flat cost per participant Statewide
☐ Other method (describe): Click or tap here to enter text.

d. The allocation procedure takes the following factors into account (check all that apply):
☐ Staffing needs
☐ Number of participants
☐ Population density
☐ Cost-containment initiatives
☐ Availability of administrative support from other sources
☐ Other (specify): Click or tap here to enter text.
e. The State agency methodology for funds allocations to local agencies includes a mechanism for
reallocation.
☐ Yes

☐ Monthly

☐ Quarterly

☐ Semiannually

☐ No
☐ Other (specify): Click or tap here to enter text.
ADDITIONAL DETAIL: NSA Expenditures Appendix and/or Procedure Manual (citation): Click or tap
here to enter text.
2. Conversion of Food Funds to NSA Funds
a. The State agency converts food funds to NSA funds:
☐ Based on a plan submitted to FNS to reduce average food costs per participant and to increase
participation above the FNS-projected level for the State agency.
☐ The State agency achieves, through acceptable measures, increases in participation in excess of the
FNS-projected level for the State agency.
☐ Describe measures used to increase participation:
☐ Not applicable
ADDITIONAL DETAIL: NSA Expenditures Appendix and/or Procedure Manual (citation): Click or tap
here to enter text.

The State’s Fiscal Year runs from Click or tap here to enter text. to Click or tap here to enter text.

ADDITIONAL DETAIL: NSA Expenditures Appendix and/or Procedure Manual (citation): Click or tap here to
enter text.
B. Local Agency Budgets/Expenditures Plans
1. Local Agency Budgets/Expenditure Plans
☐ Not applicable, State agency does not have separate local agencies.
(Proceed to C. State and Local Agency Access to Funds.)
a.
☐ Yes

The State agency requires its local agencies to prepare and submit
administrative budgets.

☐ No

If yes, the State agency requires that local agency budgets include the same cost categories as
those used for State-level budget preparation.
☐ Yes

☐ No
b. Local agencies' budgets are broken out by (check all that apply):

☐ Line items
☐ Accounting

☐ Maintenance and repair

☐ ADP services

☐ Materials and supplies

☐ Breastfeeding aids

☐ Memberships, subscriptions, and professional activities

☐ Capital expenditures

☐ Printing and reproduction

☐ Clinic/lab services

☐ Training and education

☐ Communications

☐ Transportation

☐ Employee salaries

☐ Travel

☐ Employee fringe benefits

☐ Other (specify): Click or tap here to enter text.

☐ Lease or rental of space

☐ Breastfeeding promotion/support (e.g., breastfeeding aids)

☐ Functions

☐ Client services

☐ General administration/

☐ Other (specify): Click or tap here to enter text.

Program management
☐ Food Delivery
☐ Certification
☐ Nutrition education
☐ Other (specify): Click or tap here to enter text.
c.

The State agency has an established formal process for local agencies to follow when requesting
amendments or modifications to their budgets.
☐ Yes

☐ No
d.

To prepare the federally required WIC administrative budget, the State
agency:

☐ Uses local agency budgets or prior year expenditures

☐ Uses a state agency information system to collect and compile expenditure and cost data
☐ Extracts or consolidates data reported under other State or local agency systems to group costs under
the federal line items and functions
☐ Other (describe): Click or tap here to enter text.

ADDITIONAL DETAIL: SA/LA Spending Plan Appendix and/or Procedure Manual (citation): Click or tap here to
enter text.
C. State and Local Agency Access to Funds
1. The State Agency manages its NSA Grant on a/an:
☐ Cash basis

☐ Accrual basis

☐ Other (specify): Click or tap here to enter text.
ADDITIONAL DETAIL: NSA Expenditures Appendix and/or Procedure Manual (citation): Click or tap here to
enter text.
2. Reimbursement/Provision of Funds to Local Agencies
a. The State agency provides local agencies with funds in advance.
☐ Yes (state conditions): Click or tap here to enter text.
☐ No
☐ Not Applicable (Proceed to next section.)
If yes, advances must be reconciled to incoming claims. Local agency claims are submitted:
☐ Monthly

☐ Quarterly
b. In order to qualify for payment, an expenditure must be (check all that apply):

☐ At or below the level of its approved budget line item
☐ Supported by appropriate documentation (e.g., check or receipt)
☐ A reasonable and necessary expense for WIC
☐ Other (specify): Click or tap here to enter text.
c. If an expenditure exceeds the budget provided for that particular line item, the State agency
requires the local agency to (check all that apply):
☐ Submit a supplemental request
☐ Provide a justification for exceeding the budget line item
☐ Make an offsetting adjustment to another line item in its budget
☐ Request approval of a budget modification
☐ Other (explain): Click or tap here to enter text.
d. Local agencies receive payment via:
☐ Electronic funds transfer

☐ State treasury check/warrant

☐ Other (specify): Click or tap here to enter text.
ADDITIONAL DETAIL: NSA Expenditures Appendix and/or Procedure Manual (citation): Click or tap here

to enter text.

D. Reporting and Reviewing of State and Local Agency Expenditures
1. Documentation of Staff Time
a. How does the State agency determine the percentage of staff time devoted to WIC
tasks to document allowable staff costs under the WIC Program (check all that apply):
At SA At LA
☐
☐
☐

☐
☐
☐

100 percent reporting
Random moment sampling
Periodic time studies:

☐
☐
☐

1 week/month
1 month/quarter
Other (specify): Click or tap here to enter text.

b. The State agency last evaluated its time documentation protocol on (specify date). Click or tap to
enter a date.
If available, please attach a copy of the protocol to this section or cite Procedure Manual reference.
ADDITIONAL DETAIL: NSA Expenditures Appendix and/or Procedure Manual (citation): Click or tap here

to enter text.

2. Please indicate below the services that are entirely supported by WIC funds:
☐
☐
☐
☐

Anthropometric measurements
Nutrition counseling/education
Breastfeeding promotion/support
Immunization status assessments

☐ Referrals to health and/or social services
☐ Hematological assessments
☐ Other (specify): Click or tap here to enter text.
ADDITIONAL DETAIL: SA/LA Spending Plan Appendix and/or Procedure Manual (citation): Click or tap
here to enter text.
3. Local Agency Report Forms
a.

The State agency specifies standard forms and/or procedures for local agencies to use in
reporting monthly local-level expenditures.
☐ Yes

☐ No

☐ Not Applicable (Proceed to next section)

ADDITIONAL DETAIL: NSA Expenditures Appendix and/or Procedure Manual (citation): Click or tap here
to enter text.
4. On-Site Review of Local Agencies' Administrative Expenditures
a.

The State agency conducts on-site reviews of local agency administrative expenditures:
☐ Annually

☐ Every two years

☐ Every three years

☐ Other (specify): Click or tap here to enter text.

The review is conducted by:
☐ WIC State agency staff
☐ State Department of Health fiscal or audit staff
☐ CPA or audit firm
☐ Other (specify): Click or tap here to enter text.
b. The State agency utilizes a standard format/guide to review local agencies' NSA expenditures.
☐ Yes

☐ No

If yes, the standard review guide includes the following procedures (check all that apply):
☐
☐
☐
☐
☐
☐

Verification of at least one monthly billing/claim/expenditure report against source
Documents
Tracking written approval of procurements
Requesting records of ordering, receipt, billing, and payment
Determination that costs were necessary, reasonable, and appropriate
Determination that costs were properly allocated among WIC and other programs

☐ Determination that personnel costs charged to WIC were appropriate
☐ Determination that local agencies' indirect costs were appropriately charged
☐ Other (specify): Click or tap here to enter text.
c. If available, please attach a copy of the State agency's NSA expenditure review guide.

d. The State agency notifies local agencies of findings and establishes claims for unallowable
costs, as appropriate.
☐ Yes

☐ No

ADDITIONAL DETAIL: NSA Expenditures Appendix and/or Procedure Manual (citation): Click or tap here to
enter text.
5. The State agency requires local agencies to document the sources and values of in-kind contributions.
☐ Yes

☐ No

ADDITIONAL DETAIL: NSA Expenditures Appendix and/or Procedure Manual (citation): Click or tap here to
enter text.

E. Nutrition Education Costs
1. The State agency documents that it meets its nutrition education and breastfeeding promotion
expenditure requirements per 7 CFR 246.14(c)(1) via:
☐ Activity reports

☐ Time studies

☐ Itemizing expenditures

☐ Other (specify): Click or tap here to enter text.
ADDITIONAL DETAIL: NSA Expenditures Appendix and/or Procedure Manual (citation): Click or tap here to
enter text.

2. The State agency monitors expenditures for the following activities related to breastfeeding
promotion and support at the State and/or local level (check all that apply):
At SA

At LA

Breastfeeding promotion coordinator’s salary
Written educational materials
Participant education/counseling

☐
☐
☐

Staff training

☐

Breastfeeding promotion activities
Direct support costs

☐
☐

Breastfeeding aids and equipment (e.g., breast
pumps purchased with NSA funds)

☐

Other

☐

(If other, specify): Click or tap here to enter text.
ADDITIONAL DETAIL: NSA Expenditures Appendix and/or Procedure Manual (citation): Click or tap here to
enter text.
3. In the event that the State agency uses funds from other sources in meeting minimum expenditure
requirements for nutrition education (NE) and breastfeeding promotion and support (BFPS), please
provide below the source of these funds, the amount, and the method the State agency will use to
document the use of these NE and BFPS funds. (Federal WIC food funds used to purchase/rent breast
pumps, and expenditures from breastfeeding peer counseling funds, cannot be counted toward the
nutrition education and breastfeeding expenditure requirement.)

☐ Does not apply. (Proceed to E. 4. Local agencies report nutrition education and breastfeeding promotion
and support costs.)
Source

Amount

Click or tap here to enter text.
Click or tap here to enter text.
Click or tap here to enter text.

Method(s):
☐ Activity reports

☐ Time studies

☐ Itemizing expenditures

☐ Other (specify): Click or tap here to enter text.
ADDITIONAL DETAIL: NSA Expenditures Appendix and/or Procedure Manual (citation): Click or tap here to
enter text.
4. Local agencies report nutrition education and breastfeeding promotion and support costs:
☐ Does not apply
☐ When they report routine NSA costs
☐ Through a different system (specify): Click or tap here to enter text.
ADDITIONAL DETAIL: NSA Expenditures Appendix and/or Procedure Manual (citation): Click or tap here to
enter text.

F. State and Local Agency Indirect Costs
1. Indirect Cost Rate and Services
a. Please list below indirect cost/cost allocation agreements in which the State agency is included:

Click or tap here to enter text.

b. The State agency's indirect cost rate(s) is Click or tap here to enter text. (%) and is based on:
☐ Salaries

☐ Direct costs for administration

☐Both

☐ Other (specify): Click or tap here to enter text.
c. If applicable, cite the effective date of the State agency’s executed cost allocation plan for indirect cost:
Click or tap here to enter text..
If applicable, cite the expiration date of the State agency’s most recent executed indirect cost allocation
plan: Click or tap here to enter text.
d. The State agency receives the following types of services under the indirect cost rate agreement(s):

☐ Budgeting/accounting

☐ Personnel/payroll

☐ ADP
☐ Communication/phone/mail
☐ Legal services
☐ Printing/publication
☐ Equipment usage/maintenance

☐ Space usage/maintenance
☐ Central supply
☐ Procurement/contracting
☐ Audit services
☐ Other (specify): Click or tap here to enter text.

e. The State agency allows local agencies to report indirect costs.
☐ Yes

☐ No

☐ Not Applicable

ADDITIONAL DETAIL: NSA Expenditures Appendix and/or Procedure Manual (citation): Click or tap here to

enter text.
2. Review of Indirect Cost Documentation
a. The State agency and local agencies ensure that services received and paid for through indirect costs
benefit WIC, and are not also charged directly to WIC by comparing direct charges by line item to a listing
of services paid by funds collected through the application of the indirect cost rate:
☐ Done for State agency level indirect costs (frequency): Click or tap here to enter text.
☐ Done for local agency level indirect costs (frequency): Click or tap here to enter text.
☐ Not done at either level.
b. State and local agency WIC management have access to and review the following documents as
applicable to ensure that indirect cost services are not also charged directly to WIC (check all that
apply):
At SA
At LA
Indirect cost agreements/plans
☐
☐
The accounting mechanism used to ensure the
propriety of indirect cost charges
A copy of the cost allocation plan

☐

A list of all services paid from indirect costs

☐

Other documentation related to the establishment
and charging of indirect costs

☐

Not applicable

☐

c. When the State agency reviews the local agencies' indirect cost rate agreements, the review
includes (check all that apply):
☐ Required submission of indirect cost agreement by the local agency to the State agency
☐ Assessment of how the rate or method is applied (correct time period, percentage, and base)
☐ Verification that the State agency had previously approved the local agency to negotiate such an agreement
☐ Post-review or audit to ensure the rate was applied correctly
☐ Other documentation related to the establishment and charging of indirect costs (list): Click or tap here to enter
text.
☐ Not applicable
ADDITIONAL DETAIL: NSA Expenditures Appendix and/or Procedure Manual (citation): Click or tap here to
enter text.

VI. FOOD FUNDS MANAGEMENT
(Please indicate) State Agency: Click or tap here to enter text. for FY: Click or tap here to enter text.
Food funds management involves monitoring cost containment measures and procedures related to infant
formula and other authorized food items, the monitoring and management of State agency funding sources,
and the accurate reporting of participation figures.
During a disaster or public health emergency, or supply chain disruption, the State agency
may request to implement existing WIC regulatory and programmatic flexibilities or waivers to support the
continuation of Program benefits and services. State agencies should consider the overarching authority, i.e.,
Stafford Act, Access to Baby Formula Act, or provision(s) authorized by Congress, and duration before developing
a policy and procedure. The State agency must provide a detailed description of how it plans to operationalize the
flexibility or waiver through their procedure manual where applicable. Please note the State Plan Guidance is not
intended to capture a description of waivers authorized by Congress with separate reporting requirements.
Executive Order (EO) 13988, “Preventing and Combating Discrimination on the Basis of Gender Identity or
Sexual Orientation.” was issued to all Federal Agencies. The EO set out policies that all persons are entitled
to dignity, respect, and equal treatment under the law, no matter their gender identity or sexual orientation.
The EO does not usurp section 17 of 42 U.S.C, as amended or applicable regulations, rather it complements
the language in the nondiscrimination statement. Following the contents of the EO, State agencies must
update their policies and procedures to align with the contents of the EO and the nondiscrimination
statement.
A. Cost Containment Measures - 246.4(a)(14)(xi), 246.4(a)(14)(xvii), 246.16a(a): describe the policies and
procedures used to implement cost containment measures as they relate to infant formula contracts, their
approval and the processing of infant formula and/ or other rebates, and food package cost containment practices.
B. Funds Monitoring/798 Reporting - 246.4(a)(2); (a)(12); and (a)(14): describe the State agency's funding
sources, how food obligations are calculated to allow for inflation, rebate cash management, and monthly
closeout monitoring activities.
C. Participation Reporting - 246.4(a)(11): describe the methods used to accurately document and monitor
participation at the State and local level, and methods for monitoring changes in participation by priority.

A. Cost Containment Measures
1. The State agency seeks FNS approval related to infant formula cost containment measures (check one):
☐ For a waiver of the requirement for a single-supplier competitive system. State agency must complete a
cost comparison projecting food cost savings in the single-supplier competitive system based on the
lowest monthly net price or highest monthly rebate [as required in Section 246.16a(d)(2)(i) through
(d)(2)(iii) and savings under an alternative cost containment system, Section 246.16a(d)(2)(B)]
☐ To issue an infant formula bid solicitation that evaluates bids by highest rebate. A State agency must
demonstrate to FNS’ satisfaction that the weighted average retail prices for different brands of infant
formula in the State vary by 5% or less [as required in Section 246.16a(c)(5)(iii)].
☐ Not applicable
Please attach in the Appendix supporting documentation for requests for FNS approval.
ADDITIONAL DETAIL: Food Funds Management Appendix and/or Procedure Manual (citation): Click or tap here to
enter text.
2. Cost Containment Contracts for Infant Formula
a. The State agency acquires infant formula through the following food delivery systems:
i.

Non-exempt infant formula (check all that apply):

☐ Home food delivery system
☐ Direct distribution food delivery system
☐ Retail food delivery system
☐ Other (specify): Click or tap here to enter text.
ii. Exempt infant formula (check all that apply):
☐ Home food delivery system
☐ Direct distribution
☐ Retail food delivery system
☐ Other (specify): Click or tap here to enter text.
iii. WIC-eligible nutritionals (check all that apply):
☐ Home food delivery system
☐ Direct distribution system
☐ Retail food delivery system
☐ Other (specify): Click or tap here to enter text.
b. The State agency has a rebate contract/agreement for infant formula.
☐ Yes

☐ No
If no, check which applies:
☐ Granted waiver
☐ ITO with participation under 1,000 as of April (Proceed to question A.4.
Cost Containment for Other Foods)

c. Current fiscal year rebates and current net price per unit paid (note the price should reflect current prices

rather than original contract prices and rebate amounts):

My rebate price sheet is available and attached as Appendix
(Proceed to A. 3. Infant Formula Issuance.)
Primary Contract Infant Formula
Product/Unit Size
Liquid Concentrate
Milk-Based
Soy-based*
Powder
Milk-based
Soy-based*
Ready to Feed
Milk-Based
Soy-based*
Exempt Formula
(If applicable)

Manufacturer

Rebate/Unit

Net price/Unit

% WS Discount

*If separate contracts for milk- and soy-based infant formula.
3. Infant Formula Issuance.
a. Does the State agency issue the Primary Contract Infant Formula as the first choice of issuance (by physical
form), with all other infant formulas issued as an alternative? (Section 246.16a(c)(8) & 246.10(e)(1)(iii))
☐ Yes

☐ No

b. The percent of total infant participants receiving each type of formula is estimated at:
*Contract (infant formula authorized and rebated through infant formula cost containment contract/s awarded
by the State agency) Click or tap here to enter text.
*Non-contract (infant formula that is not rebated through an infant formula cost containment contract
awarded by the State agency.) Click or tap here to enter text.
Exempt infant formula (non-contract infant formula that is issued through Food Package III)
Click or tap here to enter text.
Non-exempt infant formula (non-contract infant formula that is issued through Food Packages I & II)
Click or tap here to enter text.
*Contract and Non-contract categories should total to 100%. Exempt and Non-Exempt subcategories should total to
100%.
ADDITIONAL DETAIL: Food Funds Management Appendix and/or Procedure Manual (citation): Click or tap here to
enter text.
4. Cost Containment for Other Foods
a. Rebates are also obtained on other WIC foods.
☐ Yes (specify foods and attach contract in Appendix): Click or tap here to enter text.
☐ No
b. The State agency intends to pursue rebates on other authorized foods.
☐ Yes (specify): Click or tap here to enter text.
☐ No
c. To contain food costs, the State agency has limited authorized foods/container sizes/types, etc.
☐ Yes (If yes, note such limitations on the following table)

☐ No
ADDITIONAL DETAIL: Food Funds Management Appendix and/or Procedure Manual (citation): Click or tap here to
enter text.
Specific brands
are designated
Disallowed

Only certain
container sizes
are allowed

Allowable
types are
limited

Other

Exempt formula for
women, infants & children
Infant cereal
Infant Fruit/Veg/Meat
Whole fresh fluid milk
Lowfat fresh fluid milk
Skim fresh fluid milk
Fresh milks (e.g., Lactaid,
cultured buttermilk, goat milk)
(specify): Click or tap here to
Shelf-stable milk (e.g.,
evaporated milk, UHT, whole/
low fat/nonfat dry milk)
Cheese
Yogurt
Soy-based beverage
Tofu
Fresh eggs
Dried egg mix
Hot cereal
Cold cereal
Single strength
fruit/vegetable juice
Concentrated
fruit/vegetable juice
Whole wheat bread
Other whole grains
Peanut butter
Dry beans/peas
Canned Fish
Canned beans/peas

B. Funds Monitoring/798 Reporting
1. The State agency has procedures to assure that the requirements are met regarding the nonprocurement of

food in bulk lots, supplies, equipment, and other services from entities that have been debarred or suspended.
☐ Yes

☐ No

ADDITIONAL DETAIL: Food Funds Management Appendix and/or Procedure Manual (citation): Click or tap here to
enter text.
2. Food Cost Obligations
a. The State agency calculates food obligations based on the following data (check one):
☐ Number of expected participants and average food cost per participant
☐ Number of expected participants by category (e.g., pregnant woman, infant, etc.) and average food cost per
participant category
☐ Number of expected redemptions by food instrument type and cash-value voucher type and average value
per food instrument type and cash-value voucher type
☐ Other (specify): Click or tap here to enter text.
b. The State agency estimates the impact of inflation on food costs through the use of the following inflation
escalators:
☐ Inflation factor used in Federal funding formula
☐ State-generated estimates of inflation based on State market basket of foods
☐ Best guess by food item based on economic reports or other sources
☐ Other (specify): Click or tap here to enter text.
c. The State agency Management Information System automatically produces a monthly obligation amount
☐ Yes
☐ No, data are pulled from various sources and an estimated amount is calculated manually or with a PC
spreadsheet
☐ Other (specify): Click or tap here to enter text.
d. The State agency system (in-house or contracted) provides the following data on food instrument and cashvalue voucher redemptions at specific (daily, weekly, monthly, as needed) frequencies (check all that apply and
provide frequency):
Frequency

Data

Click or tap here to enter text.

☐ Food instruments and cash-value vouchers paid for issue month

Click or tap here to enter text.
Click or tap here to enter text.
Click or tap here to enter text.

☐ Food instruments and cash-value vouchers outstanding for issue month
☐ Food instruments and cash-value vouchers that have expired
☐ Food instruments and cash-value vouchers that are void/unclaimed

ADDITIONAL DETAIL: Food Funds Management Appendix and/or Procedure Manual (citation): Click or tap here to
enter text.
3. Rebate Cash Management
a. The State agency has a billing system in place that ensures rebate invoices for all authorized food, including
infant formula, under competitive bidding, provide a reasonable estimate, or actual count of the number of units
purchased by participants during WIC transactions (Section 246.16a(k)).
☐ Actual count of units purchased

☐ Estimate of units purchased (attach methodology)
☐ Other (describe): Click or tap here to enter text.
b. The State agency uses a food instrument that enables it to identify the type and brand of infant formula
redeemed.
☐ Yes, for all formula types, brands, and physical forms
☐ Yes, for exempt infant formulas
☐ No
c. The invoice to the formula manufacturer is issued by:
☐ The WIC unit
☐ The State agency fiscal unit
☐ Other (specify): Click or tap here to enter text.
d. Monthly invoices are submitted with supporting data.
☐ Yes

☐ No

ADDITIONAL DETAIL: Food Funds Management Appendix and/or Procedure Manual (citation): Click or tap here to
enter text.
4. Closeout of Report Month Outlays
a. The State agency allows the food vendor (and farmer if any) the following number of days to submit food
instruments and cash-value benefits for payment (provide the number of days):

Click or tap here to enter text. Days from the participant's first valid date
b. The State agency is generally able to close out a report month completely within:
☐ 90 days
☐ 120 days
☐ Other (specify number of days): Click or tap here to enter text.
ADDITIONAL DETAIL: Food Funds Management Appendix and/or Procedure Manual (citation): Click or tap here to
enter text.
5. Indicate the method used to reimburse vendors (and farmers if any) for redeemed food instruments and cashvalue vouchers or other services and specify the entity responsible for making payment:
State WIC

State FM

Other (Specify)

☐

Click or tap here to enter text. By check directly to vendor or farmer

☐

Click or tap here to enter text. By check directly to vendor’s or farmer’s bank

☐

Click or tap here to enter text. By electronic transfer to vendor's or farmer’s bank

☐

Click or tap here to enter text. Other (specify): Click or tap here to enter text.

ADDITIONAL DETAIL: Food Funds Management Appendix and/or Procedure Manual (citation): Click or tap here to
enter text.

C. Participation Reporting
1. Participation Counting

a. The State agency counts an enrollee who received at least one food instrument/food package (or who
received no food instrument/food package, but was either a fully-breastfed infant of a participating
breastfeeding woman or a woman partially breastfeeding a participating 6 to 12 month old infant) as a
participant during:
☐ The calendar month
☐ The computer system cycle month
☐ Other (specify): Click or tap here to enter text.
b. The State agency receives participation counts from:
☐ The State agency computer system based on the number of persons issued food or food instruments
(manual and automated food instruments), the number of fully-breastfed infants who receive no food or
food instruments, but are breastfed by participating breastfeeding women, and the number of women who
receive no food or food instruments, but are partially breastfeeding a participating 6 to 12 month old infant.
☐ Counts reported from local agencies based on issuance records
☐ Other (specify): Click or tap here to enter text.
c. If State funds are present, the State agency differentiates between Federal-supported and State-supported
participants by:
☐ Special code on food instrument
☐ Special areas of State designated as State-supported areas
☐ Pro rata allocation based on proportion of Federal to State funds spent
☐ Other (specify): Click or tap here to enter text.
☐ N/A
d. When local agencies are chronically late in furnishing food instrument and/or certification data needed for
participation counts, the State agency:
☐ Sends warnings
☐ Applies financial sanctions
☐ Requires manual reporting
☐ Other (specify): Click or tap here to enter text.
ADDITIONAL DETAIL: Food Funds Management Appendix and/or Procedure Manual (citation): Click or tap here to
enter text.
2. Participation by Priority
a. Priority level is a critical data field in the State agency's computer system.
☐ Yes

☐ No

b. The State computer system automatically assigns priority level based on the enrollee's nutritional risk
condition.
☐ Yes

☐ No

c. The State agency’s computer system revises the priority level determination when a participant changes
category (e.g., infant becomes child and receives a child’s food package).
☐ Yes

☐ No

d. The State agency has an “unknown” priority category for VOC transfers where priority is unknown.

☐ Yes

☐ No

3. Participation by Local Agency
The State agency's computer system supports its requirement to report participation data by local agency
to measure breastfeeding performance.
☐ Yes

☐ No

☐ N/A

ADDITIONAL DETAIL: Food Funds Management Appendix and/or Procedure Manual (citation): Click or tap here to
enter text.

VII. CASELOAD MANAGEMENT
(Please indicate) State Agency: Click or tap here to enter text. for FY: Click or tap here to enter text.
Caseload management involves identifying the target population and special populations within it,
implementing strategies to enroll the potential population, and utilizing caseload effectively to reach the
desired populations. Describe the procedures in place to implement these strategies.
During a disaster or public health emergency, or supply chain disruption, the State agency
may request to implement existing WIC regulatory and programmatic flexibilities or waivers to support the
continuation of Program benefits and services. State agencies should consider the overarching authority,
i.e., Stafford Act, Access to Baby Formula Act, or provision(s) authorized by Congress, before developing a
policy and procedure. The State agency must provide a detailed description of how it plans to
operationalize the flexibility or waiver through their procedure manual where applicable. Please note the
State Plan Guidance is not intended to capture a description of waivers authorized by Congress with
separate reporting requirements.
Executive Order (EO) 13988, “Preventing and Combating Discrimination on the Basis of Gender Identity or
Sexual Orientation.” was issued to all Federal Agencies. The EO set out policies that all persons are entitled
to dignity, respect, and equal treatment under the law, no matter their gender identity or sexual orientation.
The EO does not usurp section 17 of 42 U.S.C, as amended or applicable regulations, rather it complements
the language in the nondiscrimination statement. Following the contents of the EO, State agencies must
update their policies and procedures to align with the contents of the EO and the nondiscrimination
statement.
A. No-Show Rate - 246.4(a)(11)(i): describe the procedures used by the State agency to monitor potential and
current participants’ utilization of program services.
B. Allocation of Caseload - 246.4(a)(5)(i) and (13): describe how the State agency assigns and manages local
agency caseload allocations.
C. Caseload Monitoring - 246.4(a)(5)(i): describe the information and procedures used by the State agency to
monitor caseload.
D. Benefit Targeting - 246.4(a)(5)(i); (6), (7), (19), (20), (21), and (22): describe the plans and procedures for
ensuring that WIC benefits reach the highest risk participants and persons in special need such as migrants,
homeless, and institutionalized persons; pregnant women in their early months of pregnancy; and applicants who
are employed or who reside in rural areas.
E. Outreach Policies and Procedures - 246.4(a)(5)(i),(ii); (6), (7), (19), and (20): describe the types of outreach
materials used, where these materials are directed, special agreements with other service organizations and how
special populations are addressed. Also, provide data on unserved and underserved areas.
F. Waiting List Management - 246.4(a)(11)(i); 246.7(f)(1),(2): describe the policies and procedures used for
processing applicants.

IX. FOOD DELIVERY and FOOD INSTRUMENT (FI) ACCOUNTABILITY AND CONTROL
A. No-Show Rate
1. Policies and Procedures for Missed Certification Appointments and Food Instrument/Cash Value Voucher
Pick-Up (No-Shows)
a. The State agency has specific policies and procedures to ensure follow-up of no-shows for (check all that
apply):
☐ Initial certification for any potential participant
☐ Subsequent certifications for high-risk participants
☐ Subsequent certification for current participants
☐ Food instrument/cash value voucher pick-up
☐ Food instrument/cash value voucher/cash value benefit non-redemption
☐ State agency has no specific policies and procedures for no-show follow-up
b. The local agency or State agency, when the State agency has no separate local agencies, attempts to
contact each pregnant woman who misses her first appointment to apply for participation in the Program
to reschedule the appointment. Such procedures include (check all that apply):
☐ At the time of initial contact, the local agency obtains the pregnant woman's mailing and/or email address and
telephone number
☐ If the applicant misses her first certification appointment, an attempt is made to contact her by:
☐ Telephone
☐ Mail
☐ Email
☐ Text
☐ Mobile App
☐ If contact is established, she is offered one additional certification appointment.
☐ If she cannot be reached, the local agency follows-up with a request for the applicant to contact the local agency
for a second appointment by sending her a:
☐
☐
☐
☐
☐

Postcard
Letter
Email
Text
A second appointment is provided upon request from the applicant.

☐ Other Click or tap here to enter text.
2. Monitoring No-Show Rates
a. The State agency has (check all that apply):
☐ Standards defining acceptable no-show rates
☐ Policies and procedures designed to assist local agencies to improve no-show rates; Please attach
☐ Sanctions that may be applied to local agencies that have chronically unacceptable no-show rates; Please attach
☐ Provides regular feedback to local agencies concerning no-show rates
☐ Reports to address appropriate follow-up of no-shows
☐ No specific policies or procedures concerning local agency no-show rates
ADDITIONAL DETAIL: Caseload Management Appendix and/or Procedure Manual (citation): Click or tap here to enter
text.
b. As a matter of standard procedure, the State agency monitors no-show rates through (check all that apply):

IX. FOOD DELIVERY and FOOD INSTRUMENT (FI) ACCOUNTABILITY AND CONTROL
☐ State agency does not monitor local agency no-show rates
☐ Local agency reviews
☐ Automated reports
☐ Local agency reports on no-show rates
☐ Other (specify): Click or tap here to enter text.
ADDITIONAL DETAIL: Caseload Management Appendix and/or Procedure Manual (citation):
Click or tap here to enter text.

B. Allocation of Caseload
☐ DOES NOT APPLY (EXPLAIN WHY AND PROCEED TO NEXT SECTION)

Click or tap here to enter text.

1. The State agency considers the following factors in its initial allocation of caseload to local agencies in a
program year (check all that apply):
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐

Percent of target population served by local agency's service area
Analysis of no-show, void, non-redemption rates by local agencies
Participation by priority and category
Special population pockets
Waiting lists
Staffing/ability of local agencies to serve caseload
Prior year caseload
Food package costs per person
Special projects
Other (identify): Click or tap here to enter text.

ADDITIONAL DETAIL: Caseload Management Appendix and/or Procedure Manual (citation):
Click or tap here to enter text.
2. The State agency has a written procedure for allocation of caseload to local agencies.
☐ Yes

☐ No

If yes, attach written procedure in the Caseload Management Appendix or specify location in the Procedure
Manual below.
If no, what guidelines does the State agency use for caseload allocation? (Describe in Caseload Management
Appendix)
ADDITIONAL DETAIL: Caseload Management Appendix and/or Procedure Manual (citation):

Click or tap here to enter text.
3. The State agency has a procedure in place to ensure that current/prior year caseload levels are maintained.
☐ Yes

☐ No

If yes, attach procedure in the Caseload Management Appendix.
Click or tap here to enter text.
4. If it appears that during the course of the program year all funds will not be spent, the State agency may
reallocate caseload on the basis of the following factors (check all that apply):
☐ The State agency does not reallocate caseload mid-year

IX. FOOD DELIVERY and FOOD INSTRUMENT (FI) ACCOUNTABILITY AND CONTROL
☐
☐
☐
☐
☐
☐

Same basis as for initial allocation of caseload
Local agency participation levels
Local agency high priority participation
Waiting lists
Successful special projects
Other (specify): Click or tap here to enter text.

ADDITIONAL DETAIL: Caseload Management Appendix and/or Procedure Manual (citation):
Click or tap here to enter text.
5. The State agency has written procedures for local agencies to follow in situations of overspending:
☐ Yes

☐ No

If a written procedure is available, provide in the Caseload Management Appendix or specify location in the
Procedure Manual below.
ADDITIONAL DETAIL: Caseload Management Appendix and/or Procedure Manual (citation):

Click or tap here to enter text.

C. Caseload Monitoring
1. The State agency's caseload monitoring process includes the review of the following data (check all that
apply):
☐ Participation levels/rates

☐ High-risk participant levels/rates

☐ No-show rates

☐ Food costs per participant

☐ Food costs by area

☐ Other (specify): Click or tap here to enter text.

ADDITIONAL DETAIL: Caseload Management Appendix and/or Procedure Manual (citation):
Click or tap here to enter text.
2. The State agency uses the following methods to monitor the below task (check all that apply):
☐ Manual reports submitted by local agencies
☐ MIS-generated reports (If utilized please attach a description of each report and how they are used)
☐ On-site reviews
☐ Other (specify): Click or tap here to enter text.
ADDITIONAL DETAIL: Caseload Management Appendix and/or Procedure Manual (citation):

Click or tap here to enter text.

3. Local agency caseload utilization, by any method, is reviewed by the State agency at least:
☐ Monthly
☐ Quarterly
☐ Other (specify): Click or tap here to enter text.
☐ Not applicable
ADDITIONAL DETAIL: Caseload Management Appendix and/or Procedure Manual (citation):

Click or tap here to enter text.

D. Benefit Targeting
4

IX. FOOD DELIVERY and FOOD INSTRUMENT (FI) ACCOUNTABILITY AND CONTROL
1. Development and Monitoring of State Agency Targeting Plans
a. The State agency has a plan to inform the following classes of individuals of the availability of Program
benefits (check all that apply):
☐
☐
☐
☐
☐
☐
☐
☐

Pregnant women, with special emphasis on pregnant women in the early months of pregnancy
High-risk postpartum women (e.g., teenagers)
Parents/Caregivers of Priority I & II infants
Migrants
Homeless persons/families
Incarcerated pregnant women
Institutionalized persons
Other (specify): Click or tap here to enter text.

ADDITIONAL DETAIL: Caseload Management Appendix and/or Procedure Manual (citation):

Click or tap here to enter text.
b. The local agency or State agency, when the State agency has no separate local agencies, contacts the
following organizations to provide WIC Program information to eligible infants and children:
☐ Foster care agencies

☐ Protective service agencies

☐ Child welfare authorities

☐ Other (specify): Click or tap here to enter text.

c. The State agency ensures that benefits are targeted to those at greatest risk by limiting the use of
regression as a nutrition risk criterion to only once after a certification period.
☐ Yes

☐ No
d. In addition to, or in lieu of, State-developed plans, the State agency encourages/permits local
agencies to develop their own targeting plans.

☐ Yes

☐ No

☐ Not Applicable

e. If yes, the State agency assures the appropriateness/quality of local agency targeting plans by:
☐ Requiring local agencies to submit plans for State agency approval
☐ Review plans during local agency reviews
☐ Other (specify): Click or tap here to enter text.
f.

The State agency monitors benefit targeting through (check all that apply):

☐ Automated reports developed by State agency
☐ Manual reports submitted by local agencies
☐ Local agency reviews
☐ Other (specify): Click or tap here to enter text.
ADDITIONAL DETAIL: Caseload Management Appendix and/or Procedure Manual (citation):
Click or tap here to enter text.

E. Outreach Policies and Procedures
1. Outreach Policies, Procedures and Materials
a. To administer outreach activities, the State agency (check all that apply):

IX. FOOD DELIVERY and FOOD INSTRUMENT (FI) ACCOUNTABILITY AND CONTROL
☐ Issues a standard set of outreach materials for use by all local agencies
☐ Requires local agencies to develop outreach plans
☐ Reviews outreach plans developed by local agencies
☐ Reviews and approves any outreach materials developed by local agencies
☐ Utilizes broadcast media for outreach activities
☐ Other (specify): Click or tap here to enter text.
b. Availability of Program benefits is publicly announced at least annually via:
State Agency

Local Agency

☐
☐
☐
☐
☐
☐
☐
☐

Newspapers
Radio
Posters
Letters
Brochures/pamphlets
Television
Social Media (Twitter, Facebook, etc.)
Other (specify): Click or tap here to enter text.

c. Outreach materials are available in the following languages (check all that apply):
☐ English
☐ Spanish
☐ Vietnamese
☐ Tribal Language(s)
☐ Other (specify): Click or tap here to enter text.
d. Outreach materials are distributed to (check all that apply):
☐ Health and medical organizations
☐ Hospitals and clinics
☐ Welfare and unemployment offices or social service agencies
☐ Migrant farmworker organizations
☐ Indian and tribal organizations
☐ Homeless organizations
☐ Faith-based and community organizations in low-income areas
☐ Shelters for victims of domestic violence
☐ Food Banks
☐ Head Start Centers
☐ Other (specify): Click or tap here to enter text.
ADDITIONAL DETAIL: Caseload Management Appendix and/or Procedure Manual (citation):
Click or tap here to enter text.
When an ITO State agency operates as both the State and local agency "All" should be checked.
2. Accessibility to Special Populations
a. The State agency requires [all, some, none] local agencies to implement the following to meet the special
needs of employed applicants/participants.

IX. FOOD DELIVERY and FOOD INSTRUMENT (FI) ACCOUNTABILITY AND CONTROL
All

Some

None

☐

Early morning/evening clinic hours by appointment

☐

Early morning/evening clinic hours, walk-in basis

☐

Weekend hours, by appointment

☐

Weekend hours, walk-in basis

☐

Priority appointment scheduling during regular clinic operations

☐

Food instrument/cash value voucher mailing procedures specifically designed
for working participants
Expedited clinic procedures for working participants

☐

Evening/weekend nutrition education classes

☐

Other (specify): Click or tap here to enter text.

b. The State agency requires/authorizes [all, some, none] local agencies to implement the following to meet
the special needs of rural participants (check all that apply):
All

Some

None

☐

Special clinic hours to accommodate travel time to clinic sites

☐

Use of mobile clinics to rural areas

☐

Food instrument/cash value voucher mailing procedures specifically
designed for rural participants

☐

Special appointment/scheduling procedures for rural participants who do not
have access to public transportation

☐

Special food instrument/cash value voucher issuance cycles for rural
participants (check one): ☐ 2 months issuance, ☐ 3 months issuance

☐

Other (specify): Click or tap here to enter text.

c. The State agency requires/authorizes [all, some, none] local agencies to implement the following to meet
the special needs of migrant families (check all that apply):
All
☐

Some
☐

None
☐

Formal coordination with rural/migrant health centers

☐

Special outreach activities aimed at migrants

☐

Special clinic hours/locations to service migrant populations

☐

Expedited appointment procedures to accommodate migrant families

☐

Special food instrument/cash value voucher issuance cycles for migrant
families (check one): ☐ 2 months issuance; ☐ 3 months issuance
Other (specify): Click or tap here to enter text.

d. The State agency has in place formal agreements with one or more contiguous States to facilitate service
continuity to migrants (exclusive of normal verification of certification procedures):
☐ Yes (If yes, please identify the State agencies
☐ No
with whom formal agreements exist): Click or tap here to enter text.
e. The State agency requires [all, some, none] local agencies to implement the following proceedings to
facilitate service to homeless families/individuals (check all that apply):
All
☐

Some
☐

None
☐

Provide homeless applicants with a list of shelters/facilities that fulfill WIC Program
requirements

IX. FOOD DELIVERY and FOOD INSTRUMENT (FI) ACCOUNTABILITY AND CONTROL
☐

☐

Undertake regular and ongoing outreach to homeless individuals

☐

Routinely monitors facilities serving homeless participants to ensure WIC foods are not
subsumed into communal food service

☐

Implement formal agreement with other service providers to facilitate referrals of
homeless families/individuals

☐

Secure a written statement from the facility attesting to compliance with the requisite
conditions for WIC services in a homeless facility

☐

Establish, to the extent practicable, plans to ensure that the three conditions in
246.7(m)(1)(i) regarding homeless facilities are met

☐

Other (specify): Click or tap here to enter text.

ADDITIONAL DETAIL: Caseload Management Appendix and/or Procedure Manual (citation):

Click or tap here to enter text.

3. Unserved Geographical Areas
a. How does the State agency prioritize areas defined as underserved geographic areas in descending order?:

Click or tap here to enter text.

b. Please list unserved geographic areas or attach a list to appendix: Click or tap here to enter text.
☐ No current unserved areas (check if applicable)
ADDITIONAL DETAIL: Caseload Management Appendix and/or Procedure Manual (citation):

Click or tap here to enter text.
4. Underserved Geographic Areas
a. The State agency has a list on file of served and/or underserved geographic areas including the number
of newly potential applicants, the priority level currently being served, and participation.
☐ Yes

☐ No

b. The names and addresses of all local agencies found in the last FNS-648 Report, reflect all local agencies
currently in operation.
☐ Yes

☐ No, an update list is provided in the Appendix

☐ N/A, State agency has no local agencies

ADDITIONAL DETAIL: Caseload Management Appendix and/or Procedure Manual (citation):
Click or tap here to enter text.
5. The State agency has a plan to:
☐ Inform potential local agencies of the Program and the availability of technical assistance in implementation
☐ Describes how State agencies will take all reasonable actions to identify potential local agencies.
☐ Encourage potential and existing local agencies to implement or expand operations in the neediest one-third of
all areas unserved or partially served
☐ The State agency does not have local agencies and does not plan to have local agencies. Explanation of how
underserved and/or partially served areas are addressed is below.
ADDITIONAL DETAIL: Caseload Management Appendix and/or Procedure Manual (citation) AND/OR State
agency/ITO explanation of how the State agency without local agencies addresses underserved or partially
served areas:

IX. FOOD DELIVERY and FOOD INSTRUMENT (FI) ACCOUNTABILITY AND CONTROL
Click or tap here to enter text.

F. Waiting List Management and Procedures
1. The State agency has specific policies/procedures for the establishment and maintenance of waiting lists,
which are used by all local agencies.
☐ Yes

☐ No

2. Waiting list procedures are uniform throughout the State agency.
☐ Yes

☐ No, but State agency approves all exceptions

☐ No, local variation allowed without State agency approval
3. The State agency routinely monitors waiting lists.
☐ Yes

☐ No

☐ No, for the current Fiscal Year, the State agency does not have a waiting list.

4. The State agency requires/allows subprioritization of waiting lists by (check all that apply):
☐ No subprioritization permitted

☐ Income

☐ Nutrition risk

☐ Age

☐ Point system
☐ Special target populations (specify): Click or tap here to enter text.
☐ Other (specify): Click or tap here to enter text.
5. The State agency requires pre-screening for certification of individuals prior to placement on waiting lists.
☐ Yes
☐ No, only categorical eligibility established
☐ No, only categorical and income eligibility established
☐ No, local agency variation
☐ Other (specify): Click or tap here to enter text.
6. Waiting lists are maintained:
☐ Manually
☐ Automated system linked to State agency's central system
☐ Automated system, stand alone at some/all local agencies
7. Telephone requests for placement on the waiting list are accepted.
☐ Yes

☐ No

8. The State agency requires all local agencies to maintain waiting lists (telephone and/or pre-certification) with
the following information (check all that apply):
☐ Name
☐Address
☐ Phone number(s)
☐ Date placed on waiting list
☐ Category

IX. FOOD DELIVERY and FOOD INSTRUMENT (FI) ACCOUNTABILITY AND CONTROL
☐ Priority
☐ Nutritional risk
☐ Income eligibility status
☐ Method of application
☐ Date applicant notified of placement on the waiting list
☐ Other (specify): Click or tap here to enter text.
9. The State agency requires local agencies to provide information on other food assistance programs to
applicants who are placed on a waiting list. If the State agency has no local agencies, it provides the
information.
☐ Yes

☐ No

ADDITIONAL DETAIL: Caseload Management Appendix and/or Procedure Manual (citation):
Click or tap here to enter text.

IX. FOOD DELIVERY and FOOD INSTRUMENT (FI) ACCOUNTABILITY AND CONTROL
VIII. CERTIFICATION, ELIGIBILITY & COORDINATION OF SERVICES
(Please indicate) State Agency: Click or tap here to enter text. for FY Click or tap here to enter text.
The review of certification, eligibility and coordination of services involves the process of determining and
documenting participant eligibility (income eligibility as well as nutritional risk determination, standards, and
criteria), and the coordination of certification activities with other health services.
During a disaster or public health emergency, or supply chain disruption, the State agency
may request to implement existing WIC regulatory and programmatic flexibilities or waivers to support the continuation of
Program benefits and services. State agencies should consider the overarching authority, i.e., Stafford Act, Access to
Baby Formula Act, or provision(s) authorized by Congress, and duration before developing a policy and procedure. The
State agency must provide a detailed description of how it plans to operationalize the flexibility or waiver through their
procedure manual where applicable. Please note the State Plan Guidance is not intended to capture a description of
waivers authorized by Congress with separate reporting requirements.
Executive Order (EO) 13988, “Preventing and Combating Discrimination on the Basis of Gender Identity or Sexual
Orientation.” was issued to all Federal Agencies. The EO set out policies that all persons are entitled to dignity,
respect, and equal treatment under the law, no matter their gender identity or sexual orientation. The EO does not
usurp section 17 of 42 U.S.C, as amended or applicable regulations, rather it complements the language in the
nondiscrimination statement. Following the contents of the EO, State agencies must update their policies and
procedures to align with the contents of the EO and the nondiscrimination statement.
A. Eligibility Determination and Documentation - 246.7(c)(1); 2(1); 246.7(d)(1); (2)(v)(B)): describe the policies
and procedures for determining and documenting eligibility including the application process, residency requirements,
identity requirements, documented physical presence or valid exception; proof of categorical eligibility, income limits,
income eligibility documentation, determination of special populations and a definition of and policy toward the economic
unit.
B. Nutrition Risk Determination, Documentation, and Priority Assignment - 246.4(a)(11)(i): describe the policies and
procedures for determining and documenting nutritional risk and priority assignments. Include a copy of the nutritional risk
criteria the State agency plans to use with the appropriate documentation.
C. Health Care Agreements, Referrals, and Coordination - 246.4(a)(6); (7); (8) and (19): describe the procedures
for coordinating agreements and services with other health care providers at the State and local agency level including
procedures to ensure that benefits are provided to persons with special needs.
D. Processing Standards - 246.4(a)(11)(i); 246.7(f)(2): describe the State agency's processing procedures to
ensure that the required standards and timelines are met.
E. Certification Periods - 246.4(a)(11)(i); 246.7(g): describe the policies and procedures used to establish
certification periods for participants and the autonomy (if applicable) granted to local agencies in determining eligibility
time periods.
F. Transfer of Certification - 246.4(a)(6); (11)(i); and 246.7(k): describe the State agency's procedures for
the transfer of certification and VOC cards ensuring that vital participant and program information is included.
G. Dual Participation, Participant Rights and Responsibilities, Fair Hearing Procedures, and Sanction System 246.4(a)(11)(i) (16); (17) and (18); 246.7(h); 246.7(i)(10); 246.7(j); 246.7(I): describe the procedures used to detect and
prevent dual participation at the State and local level, the procedures for ensuring participants are notified of their rights
and responsibilities, and the procedures regarding participant fair hearings and sanction system.

Eligibility, Determination, and Documentation
11

IX. FOOD DELIVERY and FOOD INSTRUMENT (FI) ACCOUNTABILITY AND CONTROL
1.

Application Process

The State agency requires all local agencies to use a standardized application process for all persons
applying for the WIC Program
☐ Yes

☐ No

The State agency shares ☐ Statewide or ☐ at local agency (check one), a common
income application or certification form with (check all that apply):
☐ No other benefit programs
☐ TANF

☐ Medicaid
☐ SNAP

☐ Maternal and Child Health (MCH) ☐ Other reduced-price health care program(s)
☐ Other (specify): Click or tap here to enter text.
ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (citation):
Click or tap here to enter text.
2.

Residency, Identity and Physical Presence Requirements

The State agency requires documentation of residency
☐ Yes
☐ Signed statement that documentation of residency information is not available and why (e.g., homeless, theft, fire)
☐ No (Specify why, e.g., ITOs and Alaska natives who are exempt from this requirement): Click or tap here to enter

text.
b.

The State agency has reciprocal agreements concerning residency with other State agencies
☐ Yes; list States: Click or tap here to enter text.
☐ No
Describe any reciprocal agreements: Click or tap here to enter text.

The State agency has special residency policies and procedures for how the following special categories should
be treated (check all that apply):
☐ Homeless applicants

☐ Institutionalized applicants

☐ Migrants

☐ Indian Tribal Organizations

☐ None

☐ Other (specify): Click or tap here to enter text.

The State agency allows the following as proof of identity; please select all that apply.
☐ Driver’s license
☐ Passport
☐ State issued identification card
☐ Employer issued identity card
☐ Documentation from participation in a means-tested program.
☐ Other (please list all that are accepted) Click or tap here to enter text.

The State agency requires physical presence of the applicant or a valid exception to be documented:
☐ Yes except for the following condition(s):
☐ Applicant or parent/caretaker is an individual with disabilities which prevent him/her from being physically

IX. FOOD DELIVERY and FOOD INSTRUMENT (FI) ACCOUNTABILITY AND CONTROL
present at the WIC clinic (e.g., medical equipment, bedrest or serious illness exacerbated by coming into clinic).
☐ Applicant is an infant or child receiving documented ongoing health care from any health care provider,
including the local agency; being physically present would pose an unreasonable barrier; and the infant or child
was present at his/her initial WIC certification.
☐ Applicant is an infant under 8 weeks of age who cannot be present at the time of certification (for a reason
determined appropriate by the local agency) and for whom all necessary certification information is provided.
☐ Applicant is an infant or child who was present at his/her initial certification; was present at certification within
the one-year period of the most recent determination; and is under the care of one or more working parent, or
under the care of primary working caretakers whose status presents a barrier to bringing the infant or child into
the WIC clinic.
3.

The State agency requires applicants to submit proof of categorical eligibility for (check all that apply):
☐ All pregnant women

☐ Pregnant women not visibly pregnant

☐ Postpartum women

☐ Children

☐ Infants

☐ Other (specify): Click or tap here to enter text.

Income Limits for Eligibility

The State agency gross income limit for income eligibility is at or below 185% of the federal poverty income guidelines
☐ Yes, with no local agency exceptions
☐ Yes, with local agency variation
☐ No, with no local agency exceptions
(specify State maximum percent of poverty: Click or tap here to enter text. %)
☐ No, with local agency variation
(specify State maximum percent of poverty: Click or tap here to enter text. %)
ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (citation):

Click or tap here to enter text.
b.

The State agency implements income eligibility guidelines concurrently with Medicaid
☐ Yes

☐ No

ADDITIONAL DETAIL: Please attach a copy of the income guidelines in the Appendix or the appropriate citation in
the Procedure Manual. Certification and Eligibility Appendix and/or Procedure Manual (citation): Click or tap here to
enter text.
c.

The State agency requires documentation of an applicant's, or certain family members' eligibility to receive benefits
in the following means-tested programs that confer adjunctive income eligibility for WIC, as set forth in
246.7(d)(2)(vi):
Poverty Level

☐ TANF (specify State "percent of poverty")

Click or tap here to enter text.%

☐ SNAP

Click or tap here to enter text.%

☐ Medicaid (specify State "percent of poverty" for each)
☐ Pregnant women and infants
☐ Children
☐ Other categorically eligible women

Click or tap here to enter text.%
Click or tap here to enter text.%
Click or tap here to enter text.%
Click or tap here to enter text.%
13

IX. FOOD DELIVERY and FOOD INSTRUMENT (FI) ACCOUNTABILITY AND CONTROL
d.

The State agency uses documented eligibility for participation in other means-tested programs to establish
automatic WIC income eligibility (check all that apply, and the poverty levels used for each):

Poverty Level

☐ Free or Reduced-Price School Meals

Click or tap here to enter text.%

☐ Supplemental Security Income (SSI)

Click or tap here to enter text.%

☐ Other State-provided health insurance (specify State
"percent of poverty" maximum Click or tap here to enter text. %) Click or tap here to enter text.%

☐ Food Distribution Program on Indian Reservations (FDPIR)

Click or tap here to enter text.%

☐ Other (specify):

Click or tap here to enter text.%

Individuals are required to document that they or a family member are certified as eligible to receive TANF,
Medicaid, or SNAP benefits or, under the State option, certified as eligible to receive benefits in State- administered
programs by providing:
☐ Program ID card (only if it includes dates of eligibility) or notice of current eligibility
☐ Documentation of participation in State-administered programs (and such programs require documentation of income
and have income guidelines at or below WIC's income guideline of 185% of poverty).
(Program[s]: Click or tap here to enter text.)
ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (citation):

Click or tap here to enter text.

5. Income Eligibility Documentation
a. For WIC applicants whose income eligibility is not based on adjunctive or automatic income eligibility in another
means-tested program, the State agency requires (check all that apply):
☐ Documentation of income information
☐ Signed statement that documentation of income information is not available and why
☐ Notation in the participant record if the applicant declares no income and why
☐ Other (specify): Click or tap here to enter text.
b.

Exceptions to income documentation are made for the following:
☐ The necessary information is not available
☐ The income documentation presents an unreasonable barrier to participation as determined by the State
agency
☐ Those applicants with no income
☐ Those applicants who work for cash
☐ Other (specify): Click or tap here to enter text.

If the applicant does not supply the necessary documentation at the certification appointment, local agencies are generally
instructed to do the following:
☐ Certification process is terminated, and no food instruments/cash-value vouchers are provided; appointment
rescheduled
☐ Temporary certification (not to exceed 30 days) for applicants that have one qualifying nutrition risk and are
able to present at least two of the three required documents (identification, residency, and income) during a
certification appointment is completed and food instruments are provided. However, if applicant does not provide
documentation within 30 days, certification expires, and a new eligibility determination must be conducted.

IX. FOOD DELIVERY and FOOD INSTRUMENT (FI) ACCOUNTABILITY AND CONTROL
☐ Other (specify): Click or tap here to enter text.
d.

The State agency requires ☐ State-wide, or ☐ at local agency discretion (check one), the verification of applicant
income information, if determined necessary
☐ No
☐ Yes (check all sources required, as appropriate):
☐ Employer
☐ Public assistance offices
☐ State employment offices (wage match, unemployment)
☐ Social Security Administration
☐ School districts/offices
☐ Collateral contacts
☐ Other (specify): Click or tap here to enter text.

e. The State agency has specific policies that define actions to be taken at a mid-certification appointment if a participant’s
income eligibility changes.
☐ Yes; Please specify: Click or tap here to enter text.
☐ No
f.

The State agency allows documentation of alternate income procedures for Indian or Indian Health Service (IHS)
operated local agencies.
☐ Yes

☐ No

☐ Not Applicable

g. The State agency has a specific policy that addresses income from benefits provided by a State-administered
programs.
☐ Yes
h.

☐ No

The State agency has a specific policy to ensure that certain types of income, such as combat pay or Family
Subsistence Supplemental Allowance (FSSA) payments for households that include service members, are excluded from
consideration in the WIC income eligibility determination, as provided by law and regulation.
☐ Yes

☐ No

ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (citation):

Click or tap here to enter text.
6.

In determining an applicant’s income eligibility for WIC, the State agency excludes basic allowance for housing
received by military services personnel residing off military installations and in privatized housing, whether on- or offbase.
☐ Yes, State-wide

☐ No

ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (citation):

Click or tap here to enter text.

The State agency excludes cost-of-living allowances for military personnel on duty outside of the contiguous 48 States
(OCONUS COLA) from applicant income for purposes of WIC income determination.
☐ Yes, State-wide

☐ No

IX. FOOD DELIVERY and FOOD INSTRUMENT (FI) ACCOUNTABILITY AND CONTROL
8.

In determining an applicant’s income eligibility for WIC, the State agency excludes payments given to deployed military
service members. These payments are in accordance with Chapter 5 of Title 37 of the U.S.C.
☐ Yes, State-wide

☐ No

ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (citation):

Click or tap here to enter text.
9.

In determining an applicant’s income eligibility for WIC, the State agency calculates multiple income sources received
by an applicant’s household at different frequencies in accordance with WIC Policy Memo 2011-7 and compares the
sum to the established WIC IEGs.
☐ Yes, State-wide

☐ No

ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (citation):

Click or tap here to enter text.
10.

The State agency defines the economic unit in accordance with WIC Policy Memo 2013-3.
☐ Yes

☐ No (if no, why not): Click or tap here to enter text.

Provide the definition of an economic unit used by the State agency in the Appendix or the appropriate citation in the
Procedure Manual.
ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (citation):
Click or tap here to enter text.
11. The State agency has specific policies or lists examples concerning the determination of the economic unit for (check
all that apply):
☐
☐
☐
☐
☐

Foster children
Divorced/legally separated parents; step parents
Absentee spouse (military hardship tours, etc.)
Cohabitation
Institutionalized applicants (including incarcerated applicants)

☐ Homeless applicants
☐ Minors ("emancipated" minors)
☐ Separate economic units under the same roof
☐ Striker/unemployed
☐ Students away at school
☐ Self-employed applicants
☐ Other (specify): Click or tap here to enter text.
ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (citation):

Click or tap here to enter text.
12. Mid-Certification Disqualification
a. The State agency ensures that local agencies are required to stipulate that an individual is not automatically disqualified
mid-certification since she/he no longer participates in one or more of the Programs for which they were originally

IX. FOOD DELIVERY and FOOD INSTRUMENT (FI) ACCOUNTABILITY AND CONTROL
determined adjunctively/automatically income eligible.
☐ Yes

☐ No

b. WIC regulations specify that when income eligibility is reassessed mid-certification, State/local agencies are required to
reevaluate the Programs for which the individual could be determined adjunctively/automatically income eligible. If the
individual cannot qualify based on eligibility for one of these Programs, eligibility must be determined based on WIC
income guidelines and disqualification made only after all options are exhausted. The State agency ensures its policy
and procedures comply with this requirement:
☐ Yes

☐ No

Nutrition Risk Determination, Documentation and Priority Assignment

1. Nutrition Risk Determination and Documentation
a. Professionals authorized by the State agency as Competent Professional Authorities (CPAs) to determine nutritional
risk include (check all that apply):
Can certify for:
Qualification

Priorities I-III

All Priorities

RD or Masters Level Nutritionist

☐

Bachelor's Level Nutritionist

☐

Physician

☐

Physician Assistant

☐

Registered Nurse

☐

Licensed Practical Nurse

☐

Home Economist

☐

Paraprofessional

☐

Other (Specify): Click or tap here to enter text.
b. The State agency authorizes local agencies to (check all that apply):

☐ Conduct

☐ Anthropometric and ☐ Hematological measurements

☐ Use medical referral data for ☐ Anthropometric and ☐ Hematological measurements
☐ Conduct measurements only when medical referral data are unavailable
☐ Use data from a state Health Information Exchange (including access to medical referral data via a
participant/physician portal)

c. The State agency uses only FNS-approved nutrition risk criteria, as referenced in Policy Memorandum #2011-5, WIC
Nutrition Risk Criteria, and transmittal memorandum (dated December 17, 2020) that list the revised risk criteria
requiring implementation by 10/1/2022, published on the FNS PartnerWeb, to document nutrition risk. (Note: A
more recent transmittal memorandum was issued on November 17, 2022, however, the revised risk criteria
17

IX. FOOD DELIVERY and FOOD INSTRUMENT (FI) ACCOUNTABILITY AND CONTROL
included in this memorandum are not scheduled to be implemented until October 1, 2024)
☐ Yes

☐ No

Please append a list of the nutrition risk criteria used by the State agency in its entirety to this State Agency Plan.
d. The State agency modifies nutrition risk criteria such that criteria definitions are more restrictive than
nationally established definitions.
☐ Yes (list criteria): Click or tap here to enter text.
☐ No
e. Hematological risk determination:
The State agency requires (check one of the following):
☐ Bloodwork data to be collected at the time of certification (Statewide).
☐ Bloodwork data to be collected within 90 days of certification, so long as the participant is determined to have at
least one qualifying nutritional risk at the time of certification (Statewide), and the State has implemented
procedures to ensure receipt of data.
The State agency ensures that hematological assessment data are current and reflective of participant status, to include
a bloodwork periodicity schedule that conforms to the requirements as described in 246.7(e)(1)(ii)(B).
☐ Yes

☐ No

The State agency allows local agencies the option of obtaining bloodwork on children ages 2-5 annually if prior
certification results were normal.
☐ Yes

☐ No

f. Anthropometric risk determination:
The State agency allows (check one):
☐ Anthropometric data for certification to be no older than 60 days (Statewide)
☐ A shorter (less than 60 days) limit on age of anthropometric data for certification
g. Nutrition assessment:
(i)

Local agencies are required to perform a complete nutrition assessment (as described in the Value
Enhanced Nutrition Assessment [VENA] Guidance) for all participants.
☐ Yes

☐ No (explain): Click or tap here to enter text.

(ii) Local agencies are required to perform a mid-certification nutrition assessment (as described in the Guidance
for Providing Quality Nutrition Services during Extended Certification Periods) for all participants with and
extended certification period.
☐ Yes

☐ Not Applicable: (The State agency does not utilize the extended certification option for any
participant category)

(iii) The State agency policy requires that nutrition assessment intake information be collected on a State agency
mandated form or Management Information System (MIS).
☐

Yes

☐ No

If yes, attach mandated forms (or MIS screen shots) or specify location in the procedure manual and
reference below.
If no, the State agency assures quality of nutrition assessment by:

IX. FOOD DELIVERY and FOOD INSTRUMENT (FI) ACCOUNTABILITY AND CONTROL
☐ Requiring local agencies to submit forms for approval
☐ Annually monitoring the locally developed forms during local agency review
☐ Other (specify): Click or tap here to enter text.
(iv)

Dietary assessment is based on professionally recognized guidelines (e.g., Dietary Guidelines for
Americans, My Plate Food Guide, American Academy of Pediatrics)
☐ Yes (specify): Click or tap here to enter text.
☐ No (explain): Click or tap here to enter text.
ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (cite):

Click or tap here to enter text.
2. Documentation
a. The State agency requires documentation in the applicant’s case file for all nutrition risk criteria used to establish
WIC eligibility (check one) (as described in FNS Policy Memorandum #2008-4, WIC Nutrition Services
Documentation):
☐ Yes, supported by a written "exceptions" policy (e.g., policies to direct clinic staff in situations in which documentation
is unavailable)
☐ Yes, with CPA discretion when to waive documentation requirement (no written policy)
☐ No (explain): Click or tap here to enter text.
b. As a matter of policy, the State agency requires the documentation of nutritional risk criteria on a participant's certification
form in the following manner:
☐ All identified risk criteria are recorded
☐ A set number of criteria Click or tap here to enter text. is recorded (maximum number is 10 criteria)
☐ Local agency personnel decide how many and which criteria are recorded
☐ Other (specify): Click or tap here to enter text.
3. Priority Assignments
a. Participants certified for regression
☐ Remain in the same priority in which they were previously assigned
☐ Are assigned to Priority VII, regardless of their initial priority at first certification
☐ Other (specify): Click or tap here to enter text.
b. The State agency requires verification for all nutrition risk criteria that require a physician’s diagnosis.
☐ Yes

☐ No

ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (cite):

Click or tap here to enter text.
c. Participants may be certified for regression (check all that apply):
☐ A single six-month period
☐ One time following a certification period
☐ No policy, local agency discretion
d. High risk postpartum women are assigned to the following priority:

IX. FOOD DELIVERY and FOOD INSTRUMENT (FI) ACCOUNTABILITY AND CONTROL
☐ Priority III
☐ Priority IV
☐ Priority V
☐ Priority VI
e. Participants certified solely due to homelessness/migrancy are assigned to the following priority:
Pregnant Women

☐

IV V

VII
☐

Breastfeeding Women

☐

Postpartum Women
Infants

☐

Children
f.

☐
☐

☐

Attach a copy of any nutrition risk criteria that will be added, modified, or deleted during the coming fiscal year.
For each criterion, indicate:
Applicable participant category
Applicable priority level(s)
Whether a physician’s diagnosis is required
SA code number which conforms to list of codes provided by USDA for Participant Characteristics data
collection
ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (citation):
Click or tap here to enter text.

Health Care Agreements, Referrals, and Coordination

1. State Agency Referral Agreements and Coordination of Services
a. The State agency has written formal agreements that permit the sharing of participant information with the following
programs/providers (indicate whether information is shared manually (M) or through ADP (A) by placing either an M
or A in front of the appropriate service):

Click or tap here to enter text. SNAP

Click or tap here to enter text. Rural/migrant health centers

Click or tap here to enter text. TANF

Click or tap here to enter text. Hospitals

Click or tap here to enter text. Medicaid

Click or tap here to enter text. Childhood immunization

Click or tap here to enter text. SSI

Click or tap here to enter text. Immunization registries

Click or tap here to enter text. EPSDT

Click or tap here to enter text. Well-child programs

Click or tap here to enter text. MCH programs

Click or tap here to enter text.Child protective services

Click or tap here to enter text. Family planning Click or tap here to enter text.IHS facilities
Click or tap here to enter text. Private physicians
Click or tap here to enter text. Children with special health care needs program(s)
Click or tap here to enter text.O ther (specify): Click or tap here to enter text.
b. Formal agreements for coordination of services include:
☐ Responsibilities of each party

IX. FOOD DELIVERY and FOOD INSTRUMENT (FI) ACCOUNTABILITY AND CONTROL
☐ Assurance that information is used only for program eligibility and/or outreach
☐ Assurance that information will remain confidential and not be shared with a third
party
c. The State agency requires local agencies to coordinate services with, and/or develop referral systems for, the following
(check all that apply):

☐ SNAP

☐ Children with special health care needs

☐TANF

☐ Schools

☐ SSI

☐ Expanded Food and Nutrition Education Program
(EFNEP)

☐ Medicaid

☐ Other food assistance program (TEFAP, FDPIR,
CSFP, etc.)

☐ CHIP

☐ Breastfeeding promotion

☐ IHS facilities

☐ Child protective services

☐ MCH (clinics/facilities)

☐ Head Start

☐ Early and Periodic Screening,
Diagnostic and Treatment (EPSDT)

☐ Early Head Start

☐ Family planning

☐ Healthy Start

☐ Prenatal care

☐ Substance abuse program

☐ Postnatal care

☐ Child abuse counseling

☐ Immunization

☐ Foster care agencies

☐ Dental services

☐ Homeless facilities

☐ Private physicians

☐ Mental health services

☐ Hospitals

☐ Rural/migrant health centers

☐ Well-child programs

☐ Lead Screening

☐ Other (specify): Click or tap here to enter text.
ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (citation):
Click or tap here to enter text.
2. Local Agency Referral Procedures
a. The State agency ensures that local agencies make available to all adults applying or re-applying for the WIC
Program for themselves or on behalf of others the following types of information:
☐ State Medicaid Program, including presumptive eligibility determinations, where available
☐ Child support services
☐ SNAP
☐ Substance abuse counseling/treatment programs
☐ TANF, including presumptive eligibility determinations, where available
☐ Other State-funded medical insurance programs (specify): Click or tap here to enter text.
☐ Other nutrition services (specify): Click or tap here to enter text.
☐ EPSDT Program

IX. FOOD DELIVERY and FOOD INSTRUMENT (FI) ACCOUNTABILITY AND CONTROL
☐ Children’s Health Insurance programs (s)
☐ Other (specify): Click or tap here to enter text.
b. The referral methods used by local agencies to other health and social service programs include (check all that
apply and indicate the primary method of referral using the checkbox on the right):
☐ State agency-developed referral forms
☐ Local agency-developed referral form
☐ Telephone call to referring agency
☐ Verbal referral to participants
☐ Automated client/participant information exchange
☐ Written literature on referral programs
☐ Follow-ups by staff to monitor
☐ Maintain a list of local resources for drug and other harmful substance abuse
☐ Counseling
☐ Other (specify): Click or tap here to enter text.

Primary
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐

c. Methods used by other health and social service programs to refer clients to the WIC Program include (check all that
apply and indicate the primary method of referral using the checkbox on the right):
Primary
☐
☐
☐
☐
☐
☐

☐ WIC Program referral form
☐ Health/social program referral form
☐ Telephone call
☐ Verbal referral
☐ Automated client/participant information exchange
☐ Written literature on the WIC Program
☐ Other (specify): Click or tap here to enter text.

d. The State agency has a system in place to monitor the extent to which WIC participants are using other health
or social services (check all that apply):
☐ Yes (check):

☐ Medicaid

☐ TANF

☐ MCH

☐ SNAP

☐ Yes, other (specify): Click or tap here to enter text.
☐ No
e. The State agency requires local agencies to monitor referrals to determine the extent of health or social services
utilization in addition to State monitoring systems.
☐Yes

☐ No

ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (citation):

Click or tap here to enter text.
f.

To facilitate referrals to the Medicaid Program, the State agency provides each local agency a chart showing the
maximum income limits, according to family size, applicable to pregnant women, infants, and children up to age 5
under the Medicaid Program.
☐ Yes

☐ No

IX. FOOD DELIVERY and FOOD INSTRUMENT (FI) ACCOUNTABILITY AND CONTROL
g. The State agency assures that each local agency operating the Program within a hospital, and/or that has a
cooperative arrangement with a hospital, advises potentially eligible individuals that receive inpatient or outpatient
prenatal, maternity, or postpartum services, or that accompany a child under the age of 5 who receives well-child
services, of the availability of Program services.
☐ Yes

☐No

h. The State agency ensures that, to the extent possible, local agencies provide an opportunity for individuals who may
be eligible to be certified within the hospital for participation in WIC.
☐ Yes
i.

☐ No

The State agency ensures that when WIC is at maximum caseload, local agencies make referrals to:
☐
☐
☐
☐
☐
☐

Food banks
Food pantries
Soup kitchens or other emergency meal providers
SNAP
The Emergency Food Assistance Program (TEFAP)
Food Distribution Program on Indian Reservations ( F D P I R )

☐ Other (specify): Click or tap here to enter text.
j.

The State agency ensures that when WIC is at maximum caseload, local agencies notify the State agency of any
waiting lists established.
☐ Yes

☐ No

k. The State agency ensures that when WIC is at maximum caseload, the State agency notifies FNS of any
waiting lists established.
☐ Yes
l.

☐ No

The State agency ensures that when the WIC participant's family has immediate needs for food beyond what WIC
might provide, local agencies make referrals to:
☐
☐
☐
☐
☐
☐

Food banks
Food pantries
Soup kitchens
SNAP
The Emergency Food Assistance Program (TEFAP)
Food Distribution Program on Indian Reservations ( F D P I R )

☐ Other (specify): Click or tap here to enter text.
m. Immunization Screening and Referral
The State agency assures that each local agency is meeting the requirements of WIC Policy Memorandum #2001-7,
August 30, 2001: Immunization Screening and Referral, as follows:
☐ Screening children under the age of two using a documented immunization history:
☐ Using the minimum screening protocol; or
☐ Using a more comprehensive means, (specify): Click or tap here to enter text.
☐ Using another program or entity to screen and refer WIC children using a documented immunization history;
(specify):Click or tap here to enter text.; or
☐ Implementing the minimum screening protocol is unnecessary because immunization coverage rates of

IX. FOOD DELIVERY and FOOD INSTRUMENT (FI) ACCOUNTABILITY AND CONTROL
WIC children by 24 months are 90% or greater; or
☐ The State agency has been unable to formalize a coordination agreement with the State Immunization Program.
Provide explanation of extenuating circumstances:

Click or tap here to enter text.
The State agency's policy and procedure manual has been updated to include the above immunization screening
and referral protocol.
☐ Yes

☐ No

D. Processing Standards
1. Notification Standards
a. The State agency defines special nutritional risk applicants who are to be notified of their eligibility within 10 days of the
date of the first request (at the local agency) for program benefits as the following (check all that apply):
☐ Pregnant women eligible as Priority I
☐ Migrant farmworkers/family members

☐High-risk infants (optional)
☐Homeless (optional)

☐ Optional; please specify: Click or tap here to enter text.
b. The State agency requires local agencies to follow special policies and procedures to ensure timely certification of:
☐ Rural applicants
☐ No special policies/procedures

☐ Employed applicants

c. The State agency's policy allows it to authorize an extension of the notification period up to 15 days for special
nutritional risk applicants when local agencies provide a written request with justification.
☐ Yes

☐ No

d. Policies and procedures are in place to assure all other applicants are notified of eligibility within 20 days of first
request (at the local agency) for Program benefits.
☐ Yes

☐ No

ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (citation):

Click or tap here to enter text.
2. Processing Standards

a. Processing standards begin when the applicant (check all that apply):
☐ Telephones the local agencies to request benefits
☐ Visits the local agency in person
☐ Makes a written request for benefits
b. The State agency requires the local agency to have a monitoring system in place to ensure processing
standards are being met for all categories of applicants.
☐ Yes

☐ No

ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (citation):
Click or tap here to enter text.

IX. FOOD DELIVERY and FOOD INSTRUMENT (FI) ACCOUNTABILITY AND CONTROL
E. Certification Periods
1. Certification Period Standards
a.

(i) The State agency authorizes local agencies to certify infants under six months of age for a period extending up to
the first birthday provided the quality and accessibility of health care services are not diminished:
☐ Yes, at all local agencies
☐ Yes, at selected local agencies
☐ No
(ii) The State agency authorizes local agencies to certify children for a period of up to one year provided that
participant children receive required health and nutrition services:
☐ Yes, at all local agencies
☐ Yes, at selected local agencies
☐ No
(iii) The State agency authorizes local agencies to certify breastfeeding mothers for a period extending up to the infant's
first birthday or until breastfeeding is discontinued (whichever comes first), if there is no decrease in health and
nutrition services that the participant would otherwise receive during a shorter certification period:
☐ Yes, at all local agencies
☐ Yes, at selected local agencies
☐ No
(iv) The State agency ensures that health care and nutrition services are not diminished for participants certified for
longer than six months:
☐ No

☐Yes (describe): Click or tap here to enter text.

b. Extended certification is an option for the following (check all that apply):
☐ Priority I infants

☐ Priority II infants

☐ Priority III Children

☐ Priority V Children

☐ Priority I Breastfeeding Women

☐ Priority IV infants

☐ Priority IV Breastfeeding Women

c. The State agency authorizes local agencies to shorten or extend the certification period up to 30 days in certain
circumstances.
☐ Yes (If yes, provide citation indicating circumstances):

Click or tap here to enter text.

☐ No

ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (citation):

Click or tap here to enter text.

2. The State agency authorizes local agencies to disqualify an individual in the middle of a certification period for the
following reasons (check all that apply):
☐ Participant volunteers the information that they are over income
☐ Participant abuse
☐ Family member found income ineligible at recertification
☐ Failure to pick up food instruments/cash-value vouchers for Click or tap here to enter text. consecutive issuances ☐
Other (specify): Click or tap here to enter text.

IX. FOOD DELIVERY and FOOD INSTRUMENT (FI) ACCOUNTABILITY AND CONTROL
ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (citation):

Click or tap here to enter text.

F. Transfer of Certification
1. Procedures for Transfer of Certification and Verification of Certification (VOC)
a. The State agency has procedures in place that are used by all local agencies for transfers of certification within the
State agency (intra-State), between State agencies (inter-State), and to the WIC Overseas Program (WICO):
Intra-State
☐

Inter-State
☐

WIC Overseas
☐

Yes

☐

b. A participant ID card/folder/documentation is provided which also serves as a VOC:
☐ Yes

☐ No

c. The State agency requires all local agencies to use a standardized VOC:
☐ Yes

☐ No

d. VOCs are issued to the following (check all that apply):
☐ All participants
☐ Migrants
☐ Homeless
☐ Participants relocating during certification period
☐ Persons affiliated with the military who are transferred overseas
☐ Other (specify): Click or tap here to enter text.
ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (citation):

Click or tap here to enter text.

2. The State agency requires all local agencies to include the following information on the VOC (check all that
apply):
☐ Name of participant
☐ Date certification performed
☐ Date income eligibility last determined
☐ Nutritional risk condition of the participant
☐ Date certification period expires
☐ Signature/printed or typed name of certifying local agency official
☐ Name/address/phone number of certifying local agency
☐ Identification number or some other means of accountability
☐ Other (specify): Click or tap here to enter text.
3. The State agency requires all local agencies to accept as valid all VOCs from both the domestic WIC Program
and the WIC Overseas Program that contain the following essential elements:
☐ Participant name
☐ Name and address of the certifying agency

IX. FOOD DELIVERY and FOOD INSTRUMENT (FI) ACCOUNTABILITY AND CONTROL
☐ Date the current certification period expires
4. The State agency honors the one-year certification period for transferring participants (infants, children, and
breastfeeding women) even if it certifies participants every six months.
☐ Yes

☐ No

ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (citation):

Click or tap here to enter text.

G. Dual Participation, Rights and Responsibilities, Fair Hearings, Sanctions
1. Dual Participation
a. The State agency has written procedures to prevent and detect dual participation within each local agency and
between local agencies:
☐ Yes
☐ No

(Please attach any descriptions of policy in Appendix or cite appropriate section(s) of the
Procedure Manual): Click or tap here to enter text.

b. The State agency has a written agreement with the Indian State agency(ies) or other geographic State agencies
in proximity for the detection and prevention of dual participation (attach a copy of each applicable agreement or
provide a citation of where a copy is located):
☐ Yes

☐ No

☐ Not applicable

c. The State agency has established procedures to handle participants found in violation due to dual
participation:
☐ Yes
☐ No

(Please attach any descriptions of policy in Appendix or cite appropriate section(s) of the
Procedure Manual): Click or tap here to enter text.

ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (citation):

Click or tap here to enter text.

2. Participant Rights and Responsibilities
a. The State agency has uniform notification procedures that are used by all local agencies statewide:
☐ Yes

☐ No

b. The State agency requires all local agencies to inform applicant/participant of his/her rights and responsibilities
in written form, and must be read by or to the applicant, parent, or caretaker:
☐ Yes

☐ No

c. The State agency has implemented a policy of disqualifying participants for not picking up food instruments:
☐ Yes

☐ No

☐ Not applicable

If yes, the policy is communicated to participants in the participant rights and responsibilities materials:
☐ Yes

☐ No

☐ Not applicable

d. The State agency has implemented a policy to specifically inform participants that they are not allowed to sell
WIC food benefits, including online:

IX. FOOD DELIVERY and FOOD INSTRUMENT (FI) ACCOUNTABILITY AND CONTROL
☐ Yes ☐ No; explain: Click or tap here to enter text.
e. The State agency has policies and procedures to identify attempted sales of WIC food benefits in their WIC State Plan:
☐ Yes

☐ No; explain: Click or tap here to enter text.

ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (citation):

Click or tap here to enter text.

The State agency has developed special notification policies and procedures for the following:
☐ Applicant/participant who cannot read
☐ Applicant/participant who speaks in a language other than English
☐ Homeless
☐ Migrants
☐ Persons with disabilities
☐ Other (specify): Click or tap here to enter text.

g. The State agency requires all local agencies to provide notification of participant rights and responsibilities in the
following situations:
☐ Eligibility at each certification
☐ Ineligibility at initial certification
☐ Mid-certification disqualification
☐ Expiration of a certification period
☐ Waiting list status
☐ Other (specify): Click or tap here to enter text.
ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (citation):

Click or tap here to enter text.

3. Fair Hearing and Sanction System
a. The State has a law or regulation governing participant appeals:
☐ Yes

☐ No

b. The State agency has established statewide fair hearing procedures:
☐ Yes; attach fair hearing procedures for participants or specify the location in the Procedure Manual and
reference in additional detail section below.
☐ No
c. State or local agency actions against participants include (check all that apply):
☐ Reclaiming the value of improperly received benefits
☐ Disqualification from the Program for up to one year
☐ Suspension from the Program mid-certification
☐ Other (specify): Click or tap here to enter text.
d. Appeal hearings are held at:
☐ WIC State agency parent agency
☐ Other State agency or hearing board (specify): Click or tap here to enter text.

IX. FOOD DELIVERY and FOOD INSTRUMENT (FI) ACCOUNTABILITY AND CONTROL
☐ Local WIC agency
☐ Other (specify): Click or tap here to enter text.
e. Statewide fair hearing procedures include (check all that apply):
☐ Request for hearing

☐ Local agency responsibilities

☐ Denial or dismissal of request

☐ Continuation of benefits

☐ Rules of procedure

☐ Responsibilities of hearing official

☐ Fair hearing decision

☐ Other (specify): Click or tap here to enter text.

☐ Judicial review
f. State agency procedures require written notification for (check all that apply):
☐ Appeal rights

☐ Request for hearing

☐ Denial or dismissal of request

☐ Notice of hearing

☐ Termination within certification period

☐ Fair hearing decision

☐ Judicial review

☐ Other (specify): Click or tap here to enter text.

g. The State agency has established timeframes to govern each step of the hearing process:
☐ Yes

☐ No

h. The State agency requires all local agencies to document any notification/correspondence in the participant's file:
☐ Yes

☐ No

i. The State agency has a written sanction policy for participants:
☐ Yes (If yes, provide appropriate citation below)
☐ No
j. The State agency has established procedures which determine the type and levels of sanctions to be applied against
participants:
☐ Yes

☐ No

ADDITIONAL DETAIL: Certification and Eligibility Appendix and/or Procedure Manual (citation):

Click or tap here to enter text.

IX. FOOD DELIVERY and FOOD INSTRUMENT (FI) ACCOUNTABILITY AND CONTROL
(Please indicate) State Agency:Click or tap here to enter text.

for FY Click or tap here to enter text.

Food delivery and food instrument (FI) (Food instrument means a voucher, check, electronic benefits
transfer card (EBT), coupon or other document which is used by a participant to obtain supplemental
foods) accountability and control involve the production, issuance, redemption, and monitoring of
automated and manual food instruments through retail systems and the delivery of WIC Program foods by
non-retail methods, i.e., home delivery and direct distribution.
During a disaster or public health emergency, or supply chain disruption, the State agency
may request to implement existing WIC regulatory and programmatic flexibilities or waivers to support the
continuation of Program benefits and services. State agencies should consider the overarching authority,
i.e., Stafford Act, Access to Baby Formula Act, or provision(s) authorized by Congress, and duration
before developing a policy and procedure. The State agency must provide a detailed description of how it
plans to operationalize the flexibility or waiver through their procedure manual where applicable. Please
note the State Plan Guidance is not intended to capture a description of waivers authorized by Congress
with separate reporting requirements.
Executive Order (EO) 13988, “Preventing and Combating Discrimination on the Basis of Gender Identity or
Sexual Orientation.” was issued to all Federal Agencies. The EO set out policies that all persons are
entitled to dignity, respect, and equal treatment under the law, no matter their gender identity or sexual
orientation. The EO does not usurp section 17 of 42 U.S.C, as amended or applicable regulations, rather it
complements the language in the nondiscrimination statement. Following the contents of the EO, State
agencies must update their policies and procedures to align with the contents of the EO and the
nondiscrimination statement.
Electronic Benefit Transfer (EBT) Implementation and Management
A. Electronic Benefit Transfer (EBT): 246.4(a)(1), (a)(14)(xix), (a)(14)(xx), (a)(19), 246.12(h)(3), (w)-(bb):
describe the policies and procedures the State agency is using to implement and operate EBT
Retail Food Delivery Systems
B. Food Instrument Control Overview - 246.4(a)(11)(iii), (a)(14)(i), (a)(14)(vi), and (a)(14)(xii): describe the
policies and procedures used by the State agency in producing, monitoring and accounting for the use of food
instruments.
C. Food Instrument Pick-up and Transaction - 246.4(a)(11)(iii) and (a)(14)(vi): describe the State agency's
procedures for issuing food instruments to participants, including procedures for verification, prorating food
packages, training and proxy policies.
D. Food Instrument Redemption and Disposition - 246.4(a)(14)(vi): describe the procedures used to reconcile
food instruments as either issued or voided, and as either redeemed or unredeemed, and redeemed food
instruments as either validly issued, lost/stolen/damaged, expired, duplicate, or not matching issuance records.
E. Manual Food Instruments - 246.4(a)(11)(iii), (a)(14)(i), (a)(14)(vi) and (a)(14)(ix): describe the procedures for
issuing and accounting for manual food instruments, including the procedures for documentation and disposition.
F. Special Food Instrument Issuance Accommodations, 246.4(a)(11)(iii), (a)(14)(i), (a)(14)(vi), (a)(14)(ix),
(a)(14)(xiv), and (a)(21) mail or electronic issuance) and how the integrity of program services and fiscal
accountability is ensured.
G. Vendor Cost Containment System Certification - 246.4(a)(14)(xv), 246.12(g)(4)(vi): describe the competitive
pricing and reimbursement methods that the State agency will implement to ensure that average payments per food
instrument to above-50-percent vendors do not exceed average payments per food instrument to comparable
regular vendors.
Non-Retail Food Delivery Systems

IX. FOOD DELIVERY and FOOD INSTRUMENT (FI) ACCOUNTABILITY AND CONTROL
H. Home Food Delivery Systems - 246.4(a)(11)(iii), 246.4(a)(14)(i), (a)(14)(vi), (a)(14)(vii) and (a)(14)(xii):
describe how the State agency's home delivery system operates including but not limited to the types of
authorized home food delivery contractors, the frequency of deliveries, and the procedures for documenting
deliveries and ensuring safe food delivery of WIC foods, if applicable.
I. Direct Distribution Food Delivery Systems - 246.4(a)(11)(iii), (a)(14)(i), and (a)(14)(vi), (a)(14)(vii), and
(a)(14)(xii): describe the methodology and procedures used in the direct distribution of supplemental foods,
including types of foods distributed, warehouse and distribution centers, the verification process, and assurance
of food safety, as applicable.

IX. FOOD DELIVERY and FOOD INSTRUMENT (FI) ACCOUNTABILITY AND CONTROL
A. Electronic Benefit Transfer (EBT)
1. Is EBT implemented statewide?
☐ Yes (Proceed to question 2)
☐ No (Continue to 1.a.)
a. Does the State agency have an active EBT Project as of July 31, 2016?
☐ Yes

☐ No

b. Does the State agency follow APD requirements for EBT management and reporting?
☐ Yes

☐ No

2. What is the State agency policy for permitting replacement cards and transfer of balances per 7 CFR
246.12(bb)(2)?

Click or tap here to enter text.
3. What are the State agency procedures for providing customer service during non-business hours for EBT cards
per 7 CFR 246.12(bb)(3)?

Click or tap here to enter text.
4. Does the State agency use the formula for EBT terminal minimum lane coverage in 7 CFR 246.12(z)?
☐ Yes

☐ No

a. If no, please provide the date of the approval of the approved alternative installation formula as required per 7 CFR
246.12(z)(2).

B. Food Delivery and Food Instrument Control Overview
1. Food Instruments (i.e., vouchers, checks, EBT cards, coupons or related documents) - General
a. The State agency uses the following types of FIs (check all that apply):
☐ EBT cards
☐ Paper food instruments
☐ Automated-point of certification
☐ Manual-individual prescription
☐ Pre-printed manual-standard prescription
☐ Automated-central generation
☐ Mobile Payment
☐ Other (specify): Click or tap here to enter text.
b. The State agency conducts FI inventories (Place an S=[State agency] or L=[Local agency] under the
appropriate column to designate primary responsibility):
Automated - EBT Cards

Daily/perpetually
Other (Specify):Click or tap here to enter text.

Physical - Paper FIs

Daily
Weekly
Monthly
Other (specify): Click or tap here to enter text.

IX. FOOD DELIVERY and FOOD INSTRUMENT (FI) ACCOUNTABILITY AND CONTROL
c. The FI contains/allows for the following information (check all that apply):
☐ Not applicable

☐ Local agency identifier

☐ Participant WIC ID number

☐ Vendor/farmer endorsement

☐ Countersignature for participant/proxy

☐ Authorized supplemental foods
☐ First date of use

☐ Last date of use

☐ Redemption period

☐ Serial number

☐ Purchase price

☐ Signature space

Provide a facsimile of FI in Appendix or cite Procedure Manual: Click or tap here to enter text.
d. The EBT system allows for the following (check all that apply):
☐ A unique and sequential number benefit issuance identifier
☐ Each EBT purchase is matched to an authorized vendor, farmer, or farmers' market prior to authorizing payment
per 7 CFR 246.12(x)(3)
☐ System contains authorized supplemental foods
☐ System contains first and last dates of use for electronic benefits
e. The State agency provides a toll-free number for participant/vendor/farmer inquiries on:
☐ Paper Food Instrument ☐ Cash-value voucher ☐ EBT Card/Sleeve ☐ None
ADDITIONAL DETAIL: Food Delivery Appendix and/or Procedure Manual (citation): Click or tap here to enter text.
2. Food Instrument Accountability
a. FIs are delivered to local agencies by:
☐ State agency staff

☐ Local agency staff

☐ US Postal Service

☐ On-demand printing
☐ Contracted service (e.g., UPS, Purolator, etc.)
☐ Other (specify): Click or tap here to enter text.
b. FIs (blank stock and preprinted ready for issuance) are delivered to the local agency (check all that apply):
Blank

Preprinted

☐ Not applicable

☐ Weekly

☐ Twice a month

☐ Once a month

☐ Once every two months

☐ Other (specify):

Blank Specify: Click or tap here to enter text.

IX. FOOD DELIVERY and FOOD INSTRUMENT (FI) ACCOUNTABILITY AND CONTROL
Preprinted Specify:
c. The State agency uses the following procedures to ensure that unclaimed paper FIs are not being used fraudulently
(check all that apply):
☐ Not Applicable
☐ Signatures on the documentation of receipt are compared for similarities in writing style implying one person
signed for multiple participants
☐ Local agencies conduct an initial review to void food instruments for participants known to have been terminated
from the Program
☐ Inventories of food instruments are not conducted by the same local agency staff responsible for issuing/voiding
food instruments
☐ Procedures are in place to ensure the proper disposal of unused/duplicate/voided FIs
☐ Other (specify): Click or tap here to enter text.
ADDITIONAL DETAIL: Food Delivery Appendix and/or Procedure Manual (citation): Click or tap here to enter text.
3. The State agency has established food delivery procedures in cases of natural disaster and emergencies for the
following (check all that apply):
☐ Manual issuance

☐ Automated issuance

☐ Mailing

☐ Home food delivery

☐ Direct distribution

☐ Remote issuance

☐ Other (specify): Click or tap here to enter text.
ADDITIONAL DETAIL: Food Delivery Appendix and/or Procedure Manual (citation): Click or tap here to enter text.

C. Food Instrument Pick-up and Transaction
1. Food Instrument Pick-Up Policy and Procedures
a. Food instruments are issued by (check all that apply):
Local agency director
Local agency nutritionist
Local agency paraprofessional
Clerical staff
Other (specify):

All Locals
☐
☐
☐
☐
☐

Most Locals
☐
☐
☐
☐
☐

Some Locals
☐
☐
☐
☐
☐

Click or tap here to enter text.
b. The State agency utilizes a participant identification card:
☐ Yes

☐ Yes, with photo

☐ No

If yes, issuance is controlled numerically, and each card is accounted for:
☐ Yes

☐ No

c. The State agency requires the following proof of receipt when issuing paper food instruments or EBT cards:
☐ Participant/parent/caretaker/proxy signature on register confirming receipt
☐ Local agency staff initials
☐ Date of food instrument pick-up

IX. FOOD DELIVERY and FOOD INSTRUMENT (FI) ACCOUNTABILITY AND CONTROL
☐ Stub with participant signature or initials
☐ Other (specify): Click or tap here to enter text.
d. The State agency has a policy to prorate food packages for the following:
☐ Late FI pick-up

☐ Certification due to expire within 30 days

☐ Mid-month certification

☐ Other (specify): Click or tap here to enter text.

e. The State agency requires local agency staff to provide each new participant/parent/caretaker/proxy with training
in (check all that apply):
☐ Authorized vendors/farmers

☐ Selecting WIC-approved foods

☐ Transaction procedures

☐ Use of proxy

☐ Reporting problems/requesting assistance
☐ Participant violations (i.e., selling or offering to sell WIC benefits)
☐ Other (specify): Click or tap here to enter text.
f.

The State agency requires local agency staff to provide participants with a list of authorized
vendors/farmers/farmers’ markets:
☐ Yes

☐ No

g. The State agency permits a participant to transact food instruments with any authorized vendor or farmer/ farmers’
market in the State:
☐ Yes

☐ No

ADDITIONAL DETAIL: Food Delivery Appendix and/or Procedure Manual (citation): Click or tap here to enter text.
2. The State agency's proxy policy includes the following:
☐ Limits the number of participants a single proxy may sign for, except that a proxy may pick up FIs for all homeless
WIC participants in a facility
☐ Limits proxy to a specified number of FI pick-ups
☐ Limits proxy to a minimum age
☐ Limits proxy assignment to local WIC staff
☐ Other (specify): Click or tap here to enter text.
ADDITIONAL DETAIL: Food Delivery Appendix and/or Procedure Manual (citation): Click or tap here to enter text.

D. Food Instrument Redemption and Disposition
1. Food Instrument Disposition Procedures for paper FI issuance
a. The State agency system assures 100% disposition of all issued FIs
☐ Yes

☐ No

If no, specify the circumstances that prevent 100% disposition: Click or tap here to enter text.

b. Local agencies are supplied with a report on the final disposition of its FIs:
☐ Yes (specify period):Click or tap here to enter text.

☐ No

c. The State agency monitors each local agency's:
☐ Number of manual FIs utilized
☐ Number of unclaimed FIs

IX. FOOD DELIVERY and FOOD INSTRUMENT (FI) ACCOUNTABILITY AND CONTROL
☐ Number of voided FIs
☐ Number of redeemed FIs with no issuance record
2. Unclaimed, Voided, Prorated FIs
a. The State agency requires local agencies to return "unclaimed/not picked up" paper FIs or EBT cards:
☐ Not applicable

☐ Daily

☐ Weekly

☐ Monthly

☐ Other (specify): Click or tap here to enter text.
b. The State agency requires local agencies to return "voided" FIs:
☐ Not applicable

☐ Daily

☐ Weekly

☐ Monthly

☐ Other (specify): Click or tap here to enter text.
ADDITIONAL DETAIL: Food Delivery Appendix and/or Procedure Manual (citation): Click or tap here to enter
text.
3. Lost/Stolen/Damaged Food Instruments
a. The State agency requires local agencies to report lost/stolen/damaged FIs to (check all that apply):
☐ State agency

☐ Police department

☐ State agency’s banking institution

☐ EBT Coordinator
☐ Other (specify): Click or tap here to enter text.
b. Replacement/duplicate FIs Issuance
(1) Replacement/duplicate FIs are issued when FIs are reported lost:
☐ No
☐ Depends on the circumstances
☐ Yes (If FIs are reissued, it is done):
☐ Immediately
☐ Following notification of State agency/bank agency
☐ After a Click or tap here to enter text. day waiting period (specify number of days)
(2) Replacement/duplicate FIs are issued when FIs are reported stolen:
☐ No
☐ Depends on the circumstances
☐ Yes (If FIs are reissued, it is done):
☐ Immediately
☐ Following notification of State agency/bank agency
☐ After a Click or tap here to enter text. day waiting period (specify number of days)
(3) Replacement/duplicate FIs are issued when FIs are reported damaged:
☐ No
☐ Depends on the circumstances
☐ Yes (If FIs are reissued, it is done):
☐ Immediately
☐ Following notification of State agency/bank agency
☐ After a Click or tap here to enter text. day waiting period (specify number of days)

IX. FOOD DELIVERY and FOOD INSTRUMENT (FI) ACCOUNTABILITY AND CONTROL
☐ Other (specify): Click or tap here to enter text.
c. Is a police report required before replacement benefits are issued when reported stolen?
☐ Yes

☐ No

d. The State agency or its banking institution takes the following action after it is notified by the local agency of
lost/stolen/damaged FIs (check all that apply):
☐ Stops payment on the lost/stolen/damaged FIs
☐ Notifies vendor or farmer
☐ Other (specify): Click or tap here to enter text.
Please provide a copy/citation of the State agency's policy and procedures that ensure that lost/stolen FIs cannot be
redeemed OR lost/stolen/damaged EBT cards will be replaced and associated benefits transferred (7 CFR
246.4(a)(14)(xix)).

Click or tap here to enter text.
e. The local agency documents in the participant's file that replacement FIs were issued:
☐ Yes
f.

☐ No

If it is established that lost/stolen/damaged FIs are transacted by the participant who reported them lost/
stolen/damaged, the following actions are taken:
☐ A claim for cash repayment is issued to participant
☐ Participant is disqualified; specify the period of time: Click or tap here to enter text.
☐ Participant receives a warning
☐ Other (specify): Click or tap here to enter text.

g. If lost/stolen/damaged FIs are transacted by someone other than the participant, the following actions are taken,
check all that apply:
☐ Reported to police for investigation
☐ State agency or local agency does an investigation
☐ State agency or local agency notifies the participant
☐ Other (specify): Click or tap here to enter text.
ADDITIONAL DETAIL: Food Delivery Appendix and/or Procedure Manual (citation): Click or tap here to enter text.
h. The State agency monitors the level of reported lost/stolen/damaged FIs by local agency:
☐ Yes

☐ No

4. Benefit Redemption Review (7 CFR 246.12(k)(1))
a. Describe in detail how the State agency sets maximum allowable reimbursement levels for payment for supplemental
foods (including whether the State agency uses vendors’ shelf prices to set maximum reimbursement levels and how
reimbursement levels are linked to competitive price criteria). If the State agency sets maximum allowable
reimbursement levels differently for above-50-percent vendors and regular vendors, please explain the different
methods used.

Click or tap here to enter text.

(1) The State agency establishes maximum allowable reimbursement levels for:
(a) Each peer group
(b) Each food instrument or food category
(c) Other (please specify):

☐ Yes
☐ Yes
☐ Yes

☐ No
☐ No
☐ No

Click or tap here to enter text.

IX. FOOD DELIVERY and FOOD INSTRUMENT (FI) ACCOUNTABILITY AND CONTROL
(2) The State agency establishes maximum allowable reimbursement levels using:
(a) Standard deviations

☐ Yes

☐ No

If yes, specify the standard deviation number and explain how the State agency determined the standard
deviation it used is appropriate: Click or tap here to enter text.
(b) A percentage above the average redemption amount

☐ Yes ☐ No

If yes, specify the percentage and explain how the State agency determined that this percentage is
appropriate.

Click or tap here to enter text.
(c) Other (please specify):

☐ Yes

☐ No

Click or tap here to enter text.
(3) The maximum allowable reimbursement levels include a factor to reflect:
☐ Yes

☐ No

Wholesale price fluctuations; explain: Click or tap here to enter text.

☐ Yes

☐ No

Inflation: explain: Click or tap here to enter text.

☐ Yes

☐ No

Other (please specify): Click or tap here to enter text.

b. The State agency screens redemption requests through a pre-edit (before payment) or post-edit (after
payment) process to detect the following:
Not
Applicable
limitations
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐

Pre-Edit
Screen
☐

Post-Edit
Screen
☐☐

☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐

Purchase or requested price exceeds price
Altered purchase price
Vendor/farmer identification missing
Invalid/counterfeit vendor/farmer identification
Transacted before specified period
Transacted after specified period
Redeemed after specified period
Altered dates
Missing signature
Mismatched signature
Altered signature
Other (specify): Click or tap here to enter text.

c. When the payment amount on a food item exceeds the maximum allowable reimbursement amount,
what action does the State agency take?
☐ Reimburses the vendor for amounts up to the maximum allowable reimbursement amount
☐ Reimburses the vendor at the peer group average
☐ Rejects the reimbursement request but allows the vendor to resubmit
☐ Rejects the reimbursement request without allowing the vendor to resubmit
☐ Other (please specify): Click or tap here to enter text.
d. Where pre-edit screens are used, the proportion of FIs reviewed includes:
☐ All FIs

☐ Percentage of FI (Click or tap here to enter text.%)

☐ Other (please specify): Click or tap here to enter text.
e. The edit system(s) that use(s) maximum allowable reimbursement levels to screen for vendor overcharges rejects
food instruments based on:
Pre-Edit
☐

Post-Edit
☐

Not To Exceed or Maximum Prices

IX. FOOD DELIVERY and FOOD INSTRUMENT (FI) ACCOUNTABILITY AND CONTROL

☐

Percentage above average (Click or tap here to enter text.%)

☐

Amount above average ($Click or tap here to enter text.)

☐

Other (specify): Click or tap here to enter text.

The following actions are used to control against unauthorized stores redeeming FIs:
☐ Provide up-to-date list of authorized vendors to participants at certification and/or issuance
☐ Remove a vendor/farmer/farmers’ ability to conduct transactions when it is no longer authorized
☐ Conduct compliance buy to verify if unauthorized store transacts and redeems FIS
☐ State agency or its banking institution checks vendor/farmer/farmers’ market ID numbers on redemption requests
against the authorized vendor/farmer/farmers’ market list before paying vendors/ farmers/farmers’ markets for FIs
submitted for redemption
☐ Inform all participants who might use the unauthorized store
☐ Other (specify): Click or tap here to enter text.

ADDITIONAL DETAIL: Food Delivery Appendix: and/or Procedure Manual (citation): Click or tap here to enter text.
5. Price Lists
a. Shelf Price list information is routinely collected from vendors:
☐ Yes

☐ No; Explain: (Proceed to item #6) Click or tap here to enter text.

b. Shelf Price list data are collected:
☐ Real Time or Daily via EBT system
☐ Monthly
☐ Other (specify): Click or tap here to enter text.

☐ Quarterly

☐ Semiannually

c. Shelf Price data are collected by:
☐ State agency staff
☐ Local agency staff
☐ Reports are submitted by vendors
☐ EBT system
☐ Other (specify): Click or tap here to enter text.
d. The data collected has food prices for (check all that apply):
☐ All brands and sizes of supplemental foods
☐ Highest price supplemental food items within food categories
☐ Most commonly redeemed food items; please specify: Click or tap here to enter text.
☐ All authorized vendors
☐ A sample of authorized vendors (please describe the sampling method used): Click or tap here to enter text.
☐ Other (specify): Click or tap here to enter text.
e. The State agency/local agency verifies price data provided by vendors:
☐ During routine monitoring visits
☐ Does not verify on a routine basis
☐ Other (explain): Click or tap here to enter text.
f.

The State agency/local agency analyzes price data:
☐ Manually on a routine or as needed basis
☐ In an Automatic Data Processing system and uses it to:

IX. FOOD DELIVERY and FOOD INSTRUMENT (FI) ACCOUNTABILITY AND CONTROL
☐ Generate estimated food instrument values
☐ Help inform WIC staff on vendor selection decisions
☐ Develop vendor peer groups
☐ Flag individual food instruments that appear to be overcharges
☐ Other (specify):
6. System to Detect Suspected Overcharges
a. Does the State agency screen for suspected overcharges?
☐ Yes, vendor claims are issued for overcharges.
☐ No, the State agency does not identify overcharges and/or issue claims for overcharges. (Proceed to section D.
Manual Food Instruments.)
☐ Other (specify): Click or tap here to enter text.
b. The methods used to identify potential vendor overcharges are:
☐ Comparison of vendor's redemption prices to charged prices (via receipt).
☐ Other (specify): Click or tap here to enter text.
c. To receive payment or justify and correct a claim for a price adjustment or vendor overcharge, the vendor must:
(Check all that apply)
☐ Provide an updated price list
☐ Provide written justification for the higher prices
☐ Provide receipts
☐ Other (specify): Click or tap here to enter text.
d. What action(s) is/are taken when a potential vendor overcharge is identified? (Check all that apply)
☐ Routine monitoring or remedial vendor training is conducted
☐ Vendor is designated as high-risk and scheduled for compliance investigation
☐ Vendor is provided with a written warning of potential sanction for overcharging
☐ Other (specify): Click or tap here to enter text.
ADDITIONAL DETAIL: Food Delivery Appendix and/or Procedure Manual (citation): Click or tap here to enter text.

E. Manual Food Instruments
☐ DOES NOT APPLY (PROCEED TO NEXT SECTION)
1. Manual FIs Policy
a. Manual FIs are utilized for the following reasons:
☐ New participants
☐ Automated FIs not available
☐ Mutilated automated FIs
☐ Wrong food package on automated FI
☐ Wrong dollar amount on automated FI
☐ Provide for the special needs of the homeless
☐ Food package tailoring
☐ Routine monitoring visits (i.e., educational buys) of vendors/farmers

IX. FOOD DELIVERY and FOOD INSTRUMENT (FI) ACCOUNTABILITY AND CONTROL
☐ Compliance buys of vendors/farmers
☐ Special conditions, e.g., disasters
☐ Other (specify): Click or tap here to enter text.
b. The State agency requires the following for completing the manual FI register:
☐ Participant/proxy signature

☐ Local agency staff initials

☐ Date of FI pick-up

☐ Other (specify): Click or tap here to enter text.

c. Manual FIs have a "Not to Exceed Value" of:
☐ Same dollar amount for all manual food instruments $ Click or tap here to enter text.
☐ Variable dollar amount depending on type of prescription on manual FI
☐ Variable dollar amount depending on participant category on manual FI
☐ No limit
☐ Other (specify): Click or tap here to enter text.
ADDITIONAL DETAIL: Food Delivery Appendix and/or Procedure Manual (citation): Click or tap here to enter text.
2. Manual FI Documentation and Disposition
a. A report containing the serial numbers of manual FIs issued by local agencies is sent to the State
agency:
☐ Monthly
☐ Not applicable
☐ Weekly
☐ Other (specify): Click or tap here to enter text.
b. Local agencies are required to provide documentation to substantiate a valid or invalid certification record for
manual FIs issued and redeemed but for which no participant record currently exists by utilizing:
☐ Turnaround documents to establish valid certification records
☐ Telephone calls to the State/local agency on irregularities
☐ Other (specify): Click or tap here to enter text.
c. If the manual FI inventories do not achieve 100% reconciliation of all issued and unissued FIs, the local
agency (check all that apply):
☐ Reports the FI serial numbers to the State agency
☐ Provides the FI serial numbers to local vendors/farmers
☐ Other (specify): Click or tap here to enter text.
(Provide a copy/citation of the State agency's prescribed procedures if the manual FI inventory cannot be reconciled.)

Click or tap here to enter text.

ADDITIONAL DETAIL: Food Delivery Appendix and/or Procedure Manual (citation): Click or tap here to enter text.

F. Special FI Issuance Accommodations
1. Alternative FI Issuance
a. The State agency has implemented the following FI issuance policy (check all that apply):
☐ All participants are required to pick up FIs at the clinic or local agency, except in unusual circumstances
☐ Participants/proxies are required to show identification at FI card pick up
☐ FIs cards are routinely mailed to participants except (1) when the participant is scheduled for nutrition education
(including breastfeeding promotion and support activities) or a certification appointment and (2) in areas where
SNAP benefits are not mailed. , as these areas are known to have experienced high mail issuance losses

IX. FOOD DELIVERY and FOOD INSTRUMENT (FI) ACCOUNTABILITY AND CONTROL
☐ Benefits are provided electronically to a location (such as a grocery store) under certain conditions; thus,
participants may not always pick up FIs at the clinics.
☐ Other (specify): Click or tap here to enter text.
2. Mailing Policy/Procedures
a. The State agency provides local agencies with guidelines/procedures for mailing paper FIs or EBT cards
to individual participants:
☐ Yes

☐ No

b. Policy requires participants to pick up paper FIs or EBT cards whenever certification appointment is due or nutrition
education (including breastfeeding promotion and support activities) is scheduled:
☐ Yes

☐ No

c. The State agency has implemented the following policy regarding mailing paper FIs or EBT cards (check all that apply):
☐ FIs are sent first class mail *(first class is considered regular mail)
☐ FIs are sent registered mail
☐ FIs are sent certified mail
☐ FIs are sent restricted mail
☐ Return receipt is requested on FIs sent certified mail
☐ Envelope specifies, "Do not forward, return to sender" or "Do not forward, address correction requested"
☐ Other (specify): Click or tap here to enter text.
d. The State agency approves mailing FIs under the following conditions (check all that apply):
Participant hardship

State-Wide
☐

LA with SA Approval
☐

Case by Case
☐

Travel-related issues

☐

Better clinic management

☐

Participant safety

☐

Participant convenience

☐

Cost effectiveness

☐

Public Health Emergency

☐

Other

☐

(if other, specify): Click or tap here to enter text.
e. When mailing paper FIs or EBT cards, documentation of FI issuance is:

☐ Signed by the participant at the following FI pick-up/visit
☐ Noted "mailed" and initialed/dated by local agency staff
☐ Signed and dated by local agency staff after return receipt is received
☐ Other (specify): Click or tap here to enter text.
ADDITIONAL DETAIL: Food Delivery Appendix and/or Procedure Manual (citation): Click or tap here to enter text.
3. Participants who receive paper FIs or EBT cards by mail are provided:
☐ One month of benefits

☐ Two months of benefits

☐ Three months of benefits

☐ Other (specify): Click or tap here to enter text.

ADDITIONAL DETAIL: Food Delivery Appendix and/or Procedure Manual (citation): Click or tap here to enter text.

IX. FOOD DELIVERY and FOOD INSTRUMENT (FI) ACCOUNTABILITY AND CONTROL
G. Vendor Cost Containment System Certification
If the State agency authorizes or plans to authorize any above-50-percent vendors, FNS must certify the State agency’s
vendor cost containment system. The State agency that has not yet received FNS certification must submit a request for
certification/recertification that contains the following information.
☐ DOES NOT APPLY (PROCEED TO SECTION H)
1. Calculation of competitive price levels
Describe how the State agency derives (or will derive) competitive price levels for regular vendors that excludes the
prices of above-50-percent vendors.

Click or tap here to enter text.

2. Maximum allowable reimbursement levels for regular vendors and above-50-percent vendors
a. Explain how the State agency ensures that average payments to above-50-percent vendors do not exceed average
payments to comparable regular vendors.

Click or tap here to enter text.

b. The State agency exempts above-50-percent vendors from the calculated competitive price criteria and maximum
allowable reimbursement levels.
☐ Yes

☐ No If yes, how many vendors will be exempted? Click or tap here to enter text.

Are these vendors needed to ensure participant access to supplemental foods?
☐ Yes

☐ No

c. The State agency applies peer-group specific maximum allowable reimbursement levels during the benefit
redemption process.
☐ Yes

☐ No If yes, describe the procedure or process used:

Click or tap here to enter text.
3. The State agency plans to exempt non-profit above-50-percent vendors from competitive price criteria and
maximum allowable reimbursement levels.
☐ Yes

☐ No

If yes, provide the following information in detail: Click or tap here to enter text.

a. Describe the reason the State agency has decided to exempt such vendors (i.e., the benefits to the program) and the
number of non-profit vendors to be exempted.
Click or tap here to enter text.
b. Describe the reason the non-profit above-50-percent vendors are needed to ensure participant access to
supplemental foods.
Click or tap here to enter text.
c. Does the State agency collect shelf prices from non-profit vendors?
☐ Yes

☐ No

d. Describe how the prices of the non-profit vendors compare to those of other vendors in their geographic area that are
subject to competitive price criteria and allowable reimbursement levels.

Click or tap here to enter text.

e. Describe how the State agency establishes the level of reimbursement for the non-profit above-50-percent vendors

IX. FOOD DELIVERY and FOOD INSTRUMENT (FI) ACCOUNTABILITY AND CONTROL
that it has exempted.

Click or tap here to enter text.
4. The State agency has fully implemented the competitive price criteria and maximum allowable reimbursement
methodologies described in items 1 and 2 above.
☐ Yes

☐ No

If the State agency has not fully implemented the revised competitive price and maximum allowable reimbursement
methodologies, describe the current status of this effort and include the timetable for achieving full implementation.

Click or tap here to enter text.
5. The State agency plans to exempt pharmacy vendors from competitive price criteria and maximum allowable
reimbursement levels.
☐ Yes

☐ No

If yes, the State agency has confirmed that these pharmacies provide only exempt infant formula and/or WIC-eligible
nutritional foods to program participants.
6. Does the State agency collect shelf prices from pharmacies that provide only exempt infant formula?
☐ Yes

☐ No

7. Complete the table on the following page to demonstrate that the State agency’s procedure for establishing and
implementing competitive price criteria and maximum allowable reimbursement levels ensures that average
payments per food instrument or food item to above-50-percent vendors do not exceed average payments to
regular vendors.
8. Please attach and cite of a copy of the report(s) that the State agency will use to monitor average payments per food
instrument to above-50-percent vendors and regular vendors. If the State agency does not have such a report,
describe the State agency’s plans to develop and implement a report(s) for monitoring purposes, including the report
contents or fields.

Click or tap here to enter text.

IX. FOOD DELIVERY and FOOD INSTRUMENT (FI) ACCOUNTABILITY AND CONTROL
Table 1. Data for WIC Vendor Cost Containment Certification – Overview
Please provide the following information on the regular vendors and the above-50-percent vendors authorized by the State agency as of June 30th. If data are not
available through June 30th, the State agency should enter data for the period for which data are available, replacing “June” with the month to which the data are
applicable.
1. How many authorized regular vendors did the State agency have as of June 30th? (or month of:

)

2. For all authorized regular vendors, what was the total amount of WIC redemptions paid as of June 30th?

3. How many above-50-percent vendors did the State agency have as of June 30th?

a. Non-pharmacy above-50-percent vendors



Number of WIC-only stores



Number of other types of above-50-percent vendors (excluding pharmacies)



b. Above-50-percent pharmacy vendors

c. Total above-50-percent vendors (sum of a and b)

4. What was the total amount of redemptions paid to these above-50-percent vendors as of June 30th?

a. Non-pharmacy above-50-percent vendors

b. Above-50-percent pharmacy vendors

c. Total above-50-percent vendors (sum of a and b)

5. How many peer groups of above-50-percent vendors (either separate peer groups or groups with regular
vendors) has the State agency identified?

6. How many above-50-percent vendors and regular vendors has the State agency authorized that do not meet
competitive price criteria, but are needed to ensure participant access to supplemental foods?

6. above-50%:
regular vendors:

Supplemental WIC State Plan Guidance section IX.I – Vendor Cost Neutrality Assessment will be issued in the spring.

IX. FOOD DELIVERY and FOOD INSTRUMENT (FI) ACCOUNTABILITY AND
CONTROL
H. Home Food Delivery Systems
☐ DOES NOT APPLY (PROCEED TO NEXT
SECTION)
1. Home Food Delivery Systems Overview
a. Home delivery vendors include (check all that apply):
☐ Dairies
☐ Private delivery service doing WIC
business only
☐ Private delivery service
☐ Other (specify): Click or tap here to enter text.
b. Participants who receive home food delivery:
☐ Are notified in writing of the types and quantities of foods
☐ Are issued FIs that they sign and provide to the vendor when the food is delivered
☐ Are delivered not more than a one-month supply of supplemental foods at any one time
☐ Indicate by authorized signature on a FI, receipt or signature document, the supplemental foods
received
☐ Other (specify): Click or tap here to enter text.
c. Supplemental foods may be delivered:
☐ Only to the participant of record
☐ To the participant of record or
proxy of record ☐ To any adult at
home during time of delivery
☐ To anyone at home at the time of
delivery
☐ Other (specify): Click or tap here to

enter text.
ADDITIONAL DETAIL: Food Delivery Appendix and/or Procedure Manual (citation): Click or tap here to enter
text.
2. Documentation
a. The forms verifying delivery are reconciled against vendor invoices:
☐ Weekly
☐ Monthly reconciliation of the signed FIs or other signed receipts or signature documents from
participant or proxies.
☐ Other (specify): Click or tap here to enter text.
b. Signatures of participants who sign the food receipt document/FIs are compared to the signature
on file.
☐ No

☐ Yes, sample

☐ Yes 100%

ADDITIONAL DETAIL: Food Delivery Appendix and/or Procedure Manual (citation): Click or tap here to enter

X. MONITORING AND AUDITS
text.

I. Direct Distribution Food Delivery Systems
☐ DOES NOT
APPLY
1. Direct Distribution Food Delivery - General
a. The State agency uses a direct distribution food delivery system to:
☐ Distribute all its WIC Program foods
☐ Distribute only exempt infant formula and/or medical
foods
☐ Distribute (specify):
b. The State agency uses:
☐ Warehouse not used
☐ One central warehouse, deliveries directly to local agencies
☐ One central warehouse from which foods are sent to one or more subsidiary warehouses
before delivery to local agencies
☐ Other (specify): Click or tap here to enter text.
c.

Warehouses are operated by:
☐ State agency

☐ Local agency

☐ Other state or public agency

☐ Under contract with a private business

☐ Other (specify): Click or tap here t
d. Warehouses used for storage of WIC foods are also used to store other FNS program
commodities (Please specify which commodities):
☐ Yes

☐ No Specify commodities: Click or tap here to enter text.

ADDITIONAL DETAIL: Food Delivery Appendix and/or Procedure Manual (citation): Click or tap here to enter
text.
2. Food Distribution
a. Foods are distributed to participants:
☐ Grocery
store fashion
☐ Prepackaged
☐ Other (specify): Click or tap here to enter text.
b. Participants receiving food are required to sign:
☐ A register once for all foods received
☐ A register/form for each food item
received

X. MONITORING AND AUDITS
☐ Other (specify): Click or tap here to

enter text.
c. Foods are distributed to participants:
☐ Monthly
☐ Not to exceed a one-month supply at any one time to any
participant
☐ Other (specify): Click or tap here to enter text.
d. Participants with limited access to facilities used for distribution have available to them:
Services provided by:
Local
Agency
☐

Home delivery

Other
Sources
☐

Cost-free transportation

☐

Other

☐

(if other, specify): Click or tap here to enter text.
ADDITIONAL DETAIL: Food Delivery Appendix: and/or Procedure Manual (citation): Click or tap here to enter
text.
3. Warehouse Insurance and Inspections
a. Insurance for the warehouse covers (check all
that apply): ☐ Theft
Infestation

☐ Fire

☐

☐ Spoilage

☐ Other (specify):
b. Warehouses are inspected by a public authority responsible for enforcing:
☐ Fire safety laws and regulations (specify date and grade of last inspection): Click or tap here

to enter text.
☐ Sanitation laws and regulations (specify date and grade of last inspection): Click or tap here to

enter text.
☐ Other (specify): Click or tap here to enter text.
ADDITIONAL DETAIL: Food Delivery Appendix: and/or Procedure Manual (citation): Click or tap here to enter
text.
4. Monitoring and Inventory Control
Please describe the State agency’s methods for ensuring WIC supplemental foods are under proper
inventory control (separation of duties for intake and inventory; stock rotation; performance of perpetual and
physical inventory duties; reconciliation against issuance records; etc.). Click or tap here to enter text.

X. MONITORING AND AUDITS
X. MONITORING AND AUDITS
(Please indicate) State Agency:Click or tap here to enter text. for FY Click or tap here to enter text.

Monitoring and Audits involves State agency efforts to review local agency/clinic activities on an
ongoing and timely basis, and to track all audits involving WIC Program activity.
During a disaster or public health emergency, or supply chain disruption, the State agency
may request to implement existing WIC regulatory and programmatic flexibilities or waivers to support
the continuation of Program benefits and services. State agencies should consider the overarching
authority, i.e., Stafford Act, Access to Baby Formula Act, or provision(s) authorized by Congress, and
duration before developing a policy and procedure. The State agency must provide a detailed
description of how it plans to operationalize the flexibility or waiver through their procedure manual
where applicable. Please note the State Plan Guidance is not intended to capture a description of
waivers authorized by Congress with separate reporting requirements.
Executive Order (EO) 13988, “Preventing and Combating Discrimination on the Basis of Gender Identity
or Sexual Orientation.” was issued to all Federal Agencies. The EO set out policies that all persons are
entitled to dignity, respect, and equal treatment under the law, no matter their gender identity or sexual
orientation. The EO does not usurp section 17 of 42 U.S.C, as amended or applicable regulations, rather
it complements the language in the nondiscrimination statement. Following the contents of the EO,
State agencies must update their policies and procedures to align with the contents of the EO and the
nondiscrimination statement.
A. Monitoring-246.19(b): requires State agencies to establish a management evaluation system.
B. Audits-Subpart F to 2 CFR Part 200, as applicable: describe State agency audit responsibilities.

X. MONITORING AND AUDITS
A. Monitoring
1. Local Agency/Clinic Monitoring Activity (to be updated each year). Skip this section if the State
agency has no local agency(ies)
a. Local agencies/clinics monitored: (If State agency has one local agency, specify the date it was last
monitored.
Click or tap here to enter text.Number of local agencies
Click or tap here to enter text.Number of local agencies monitored last annual period
Click or tap here to enter text.Number of clinics monitored last annual period
Click or tap here to enter text.Number of local agencies to be monitored this current annual period
Click or tap here to enter text.Number of clinics to be monitored this current annual period
Specify last annual period, from: Click or tap to enter a date.to Click or tap to enter a date.(month/day/year
– month/day/year; must be applied consistently)
Specify current annual period, from: Click or tap to enter a date.to Click or tap to enter a
date.(month/day/year – month/day/year; must be applied consistently
b. Number of local agencies/clinics required to submit Corrective Action Plans (CAPs) to address
deficiencies identified during monitoring last year: Click or tap here to enter text.(Number)
c. The State agency uses a tracking device, such as a chart or spreadsheet, which summarizes the
reviews of all local agencies.
☐ Yes

☐ No

If the State agency uses a tracking device, it shows (check all that apply):
☐ Date of most recent review for each local agency/clinic
☐ Number of clinics reviewed in most recent review for each local agency/clinic
☐ Listing of findings for most recent review of each local agency/clinic
☐ Date of State agency notice of findings in most recent review for each local agency/clinic
☐ Date of local agency/clinic corrective action plan in most recent review for each local agency and/or
clinics
☐ Outcome of corrective action plan
☐ Whether the review was conducted virtually or onsite
d. In preparing to conduct a local agency review, the State agency reviews data reports on:
☐ No-shows by category
☐ Administrative costs claimed
☐ Financial reports
☐ Priorities served
☐ Caseload
☐ R acial/ethnicity
☐ Staff/participant ratios
☒ Participant nutrition surveillance data for participants in that local agency/clinic

X. MONITORING AND AUDITS
☐ Other (specify): Click or tap here to enter text.
ADDITIONAL DETAIL: Monitoring & Audits Appendix and/or Procedure Manual (citation): Click or tap
here to enter text.
2.

Local Agency/Clinic Monitoring Procedures

a. The State agency uses an established protocol when it monitors local agencies/clinics.
☐ Yes

☐ No

If yes, please provide the citation of where it can be found in the appendix or procedure manual: Click

or tap here to enter text.

This monitoring protocol includes:
☐ Advance notification of monitoring visit
☐ Determination of timeframes for conducting the review
☐ Designation of local agency/clinic staff to assist State agency staff during review
☐ Discussion of review findings on-site with local agency/clinic
☐ Specified time frame for providing written review report
☐ Specified time frame for local agency/clinic submission of corrective action plan, not to exceed 60 days
from receipt of State agency’s report
☐ Instructions or guidance for preparation of corrective action plan (e.g., inclusion of implementation time
frames)
☐ Evaluation of adequacy of corrective action
☐ Follow-up with local agency/clinic to ensure corrective action measures are implemented
☐ Written notification of closure of the review
☐ Other (specify): Click or tap here to enter text.
b. Monitoring of local agencies/clinics is conducted by (check all that apply):
☐
☐
☐
☐

State WIC staff
District or regional staff
Other health programs
Other (specify): Click or tap here to enter text.

c. Specialists in the following areas monitor the areas of their expertise:
☐ Certification and eligibility determination
☐ Caseload management
☐ Nutrition service
☐ Breastfeeding promotion and support
☐ Targeting and outreach policies
☐ Financial management of administrative funds
☐ Food delivery system
☐ Vendor management
☐ Civil rights
☐ Information Systems security
☐ Other (specify): Click or tap here to enter text.

X. MONITORING AND AUDITS
If the State agency uses reviewers to monitor areas in which they do not have expertise and/or prior
knowledge, describe how the State agency trains or equips its reviewers to conduct the review:
d. The State agency uses a standard local agency/clinic review form.
☐ Yes

☐ No

If yes, please provide the citation of where it can be found in the appendix or procedure manual: Click or tap
here to enter text.
If yes, the review form covers the following areas:
☐ An assessment of local agency/clinic management
☐ An assessment of patient flow
☐ Certification case file reviews, including procedures for determining adjunctive income eligibility
☐ Caseload management
☐ Training of local agency and clinic staff
☐ Nutrition education
☐ Breastfeeding promotion and support
☐ Targeting and outreach policies
☐ Financial management of administrative funds
☐ Validation of staff time spent on WIC
☐ Food instrument accountability
☐ Vendor training and monitoring (If these functions are delegated to a local agency/clinic)
☐ Civil rights compliance
☐ Other (specify):
e.

The State agency has developed procedures for local agencies/clinics to use when they evaluate:

☐ Their own operations
☐ Subsidiary/satellite operations (e.g., county health department clinic)
☐ Subcontractors (e.g., community action program, hospital)
☐ Homeless facilities/institutions
☐ Other (specify): Click or tap here to enter text.
If you selected any of the options above, please provide the citation of where it can be found in the appendix
or procedure manual and answer the following questions: Click or tap here to enter text.
Do these procedures include a monitoring tool?
☐ Yes

☐ No

Are all local agencies/clinics required to follow these procedures?
☐ Yes

☐ No (specify basis for exemptions): Click or tap here to enter text.

ADDITIONAL DETAIL: Monitoring & Audits Appendix and/or Procedure Manual (citation): Click or tap
here to enter text.

IX. FOOD DELIVERY and FOOD INSTRUMENT (FI) ACCOUNTABILITY AND
CONTROL
3. Use of Local Agency/Clinic Review Data
a. The State agency analyzes the results of local agency/clinic monitoring visits to determine
whether deficient areas are common among its local agencies/clinics.
☐ Yes

☐ No

b. The State agency utilizes local agency/clinic review data to (check all that apply):
☐ Identify outstanding operational approaches that could be shared with other local
agencies/clinic ☐ Track individual local agency/clinic performance
☐ Compare administrative costs/expenses among local agencies/clinics
☐ Compare staffing and organization among local
agencies/clinics
☐ Other (specify): Click or tap here to enter text.
ADDITIONAL DETAIL: Monitoring & Audits Appendix and/or Procedure Manual (citation):
Click or tap here to enter text.

B. Audits
Do not include management evaluations or other reviews conducted by FNS regional offices or by
WIC State agencies. This section concerns the audits conducted under Subpart F to 2 CFR Part 200
and audits conducted by USDA’s OIG, per 7 CFR 246.20 (a, b).
1. Audits (Federal, State, and Local)
a. Number of audits conducted during FYb. Entities audited (includes both
at this
State and local agencies)
final

Auditor(s)

.
Period of

Status/disposition of audit

Audit

time (management decision,
action, etc.

X. MONITORING AND AUDITS

If additional audits were conducted, please provide separately.
c. Entities not audited and reason (e.g., local office is not a subrecipient local agency, non-federal
entity did not expend $750,000 or more in Federal funds during the fiscal year, etc.)
Entities not audited (includes
both State and local agencies)

Reason Entity Not Audited

ADDITIONAL DETAIL: Monitoring & Audits Appendix and/or Procedure Manual (citation):
Click or tap here to enter text.
2. Audit Management Decision
a. Methods used by the State agency to ensure that corrective action is taken on audit
findings include (check all that apply):
☐ State agency has a copy of the corrective action plan on file.
☐ State agency tracks audits to determine if the same problems are recurring from year
to year.
☐ Local agency must file periodic reports.
☐ State agency contacts local agency by phone or in writing
periodically.
☐ State agency visits local agency.
☐ Other (specify): Click or tap here to enter text.
b. State agency actions taken to ensure that all claim amounts are recovered include (check all that
apply):
☐ Local agency files periodic reports.

X. MONITORING AND AUDITS
☐ State agency contacts local agency by phone or in writing.
☐ State agency monitors receipt of a check in the amount of an
audit claim.
☐ State agency establishes and employs billing/offsetting of account
procedures. ☐ Other (specify): Click or tap here to enter text.
c. State agency accounting procedures for claim amounts recovered:
☐ Recovered claim amounts from prior fiscal years are returned to
FNS.
☐ Recovered claim amounts are reallocated if collected within the
same fiscal year. ☐ Claim amounts are verified with local agency.
☐ Other (specify): Click or tap here to enter text.
ADDITIONAL DETAIL: Monitoring & Audits Appendix and/or Procedure Manual (citation): Click or
tap here to enter text.
3. Availability of Audit Reports
a. The State agency receives and maintains for at least three years copies of all organizationwide audits involving the WIC Program and maintains a listing of those audits.
☐ Yes

☐ No, copies are retained by: Click or tap here to enter text.

b. Procedures used for maintaining files to reflect the trail from the receipt of the audit to final action
include:
☐ Detailed breakdown of each audit finding is tracked
separately.
☐ Individuals are assigned to monitor each audit.
☐ One individual is assigned to monitor all
audits.
☐ Other (specify): Click or tap here to
enter text.
c. The State agency maintains a listing of all planned audits for the coming Fiscal Year.
☐ Yes

☐ No

(Indicate recent FYs which included WIC in the single audit report): Click or tap here to enter text.
d. The State agency ensures WIC participation in the single audit and other audits by (check all that
apply):
☐ Developing a tracking system that monitors the status of
each audit ☐ Establishing a contact person for each audit

X. MONITORING AND AUDITS
☐ Including this audit requirement in the local agency
contract
☐ Other (specify): Click or tap here to enter text.
ADDITIONAL DETAIL: Monitoring & Audits Appendix and/or Procedure Manual (citation): Click or
tap here to enter text.

X. MONITORING AND AUDITS
XI. CIVIL RIGHTS
(Please indicate) State Agency: Click or tap here to enter text.for FY Click or tap here to enter text.
The Civil Rights section of the State Plan should cover the training of State and local staff on issues,
rules and regulations related to civil rights, public notification of nondiscrimination requirements, the
monitoring of local agencies and clinics for compliance with civil rights regulations and rules, the
collection of relevant racial/ethnic information and procedures for handling civil rights complaints.
During a disaster or public health emergency, or supply chain disruption, the State agency
may request to implement existing WIC regulatory and programmatic flexibilities or waivers to
support the continuation of Program benefits and services. State agencies should consider the
overarching authority, i.e., Stafford Act, Access to Baby Formula Act, or provision(s) authorized by
Congress, and duration before developing a policy and procedure. The State agency must provide a
detailed description of how it plans to operationalize the flexibility or waiver through their procedure
manual where applicable. Please note the State Plan Guidance is not intended to capture a
description of waivers authorized by Congress with separate reporting requirements.
Executive Order (EO) 13988, “Preventing and Combating Discrimination on the Basis of Gender Identity
or Sexual Orientation.” was issued to all Federal Agencies. The EO set out policies that all persons are
entitled to dignity, respect, and equal treatment under the law, no matter their gender identity or sexual
orientation. The EO does not usurp section 17 of 42 U.S.C, as amended or applicable regulations,
rather it complements the language in the nondiscrimination statement. Following the contents of the
EO, State agencies must update their policies and procedures to align with the contents of the EO and
the nondiscrimination statement.

A. Administration - 246.4(a)(17): describe the procedures the State will use to comply with the civil rights
requirements described in 246.8, including the processing of discrimination complaints.
B. Public Notification Requirements and Nondiscrimination Notification - 246.8(a)(1): describe the
policies and procedures used to ensure that public notification regarding nondiscrimination in the WIC
Program reaches all participants and potential participants in an appropriate language (246.8(c)) through
WIC Program materials.
C. Compliance Review and Monitoring Activity - 246.8(a)(2): describe the policies and procedures used to
monitor and review local agencies to verify that they are in compliance with civil rights laws and
regulations.
D. Data Collection and Reporting - 246.8(a)(3): describe the methods used to collect and monitor
racial/ethnic data in compliance with title VI of the Civil Rights Act of 1964.
E. Complaint Handling - 246.4(a)(17): describe the policies and practices used to ensure civil rights
complaints are handled properly at the State and local level.

XI. CIVIL RIGHTS
A. Administration
1. The State agency designates an individual to coordinate, implement, conduct training, and enforce
civil rights efforts.
☐ Yes

☐ No

a. The following methods are used to inform and update State and local agency staff of their
obligations under civil rights rules, regulations, and instructions:
State
Agency

Local
Agency

Briefing for new employees
Handouts for new employees

☐
☐

Memos and updates

☐

Presentations by civil rights coordinator
Presentation by staff other than WIC Program
Other

☐
☐
☐

If other, specify: Click or tap here to enter text.
b. Civil rights training is provided annually
State agency staff
Local agency staff

☐ Yes
☐ Yes

c. Civil rights training includes the following:

State
Agency

Collection and use of racial/ethnical data
Effective public notification systems

☐ No
☐ No

Local
Agency
☐
☐

☐
☐

Complaint procedures

☐

Compliance review techniques
Resolution of noncompliance
Requirements for reasonable accommodation
of persons with disabilities
Requirements for language assistance
Conflict resolution
Customer Service

☐
☐
☐

If other, specify: Click or tap here to enter text.
DETAIL: Civil Rights Appendix and/or Procedure Manual (citation): Click or tap here to enter text.
2. The State agency has copies of the following materials on file:
☐
☐
☐
☐
☐

FNS Instruction, 113-1
Title VI (1964), 7 CFR 15
Title IX, Education Amendments, 7 CFR 15a (sex discrimination)
Section 504, Rehabilitation Act of 1973, 7 CFR 15b
Racial/Ethnic data collection policy and reporting requirements

XI. CIVIL RIGHTS
☐ Age Discrimination Act of 1975, 45 CFR Part 91
☐ Americans with Disabilities Act, 28 CFR Part 35
☐ Civil Rights Restoration Act of 1987

ADDITIONAL DETAIL: Civil Rights Appendix and/or Procedure Manual (citation): Click or tap
here to enter text.
3. The State agency's policy for reasonable accommodation includes the most up-to-date
provisions for individuals with disabilities.
☐ Yes

☐ No

(Refer to FNS Instruction 113-1, Civil Rights Compliance and Enforcement–Nutrition Programs and
Activities)

ADDITIONAL DETAIL: Civil Rights Appendix and/or Procedure Manual (citation): Click or tap
here to enter text.
B. Public Notification Requirements and Nondiscrimination
1. Public Notification
a. The State agency requires its local agencies to include the nondiscrimination policy
statement and civil rights complaint procedure on the following (check all that apply):
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐

Outreach letters to the general public
☐ Radio announcements
Program information letters
☐ Publications
Program information brochures
☐ Posters
Program information bulletins
☐ Newsletters
Newspaper announcements
☐ Referral material
Internet
☐ Television announcements
Letters of invitation in the public hearing process
Certification forms to be signed by participants
Application forms (including computer-based forms)
Other (specify): Click or tap here to enter text.

b. The State agency requires that the USDA nondiscrimination poster, "And Justice For All,"
or an FNS- approved substitute be displayed in the following places frequented by
applicants and participants:
☐ Clinic waiting rooms
☐ Food instrument issuance offices
☐ Group/individual nutrition education areas
☐ Test kitchens
☐ Distribution centers or locations
☐ Other (specify): Click or tap here to enter text.
c. Check the group categories that the State agency and its local agencies publicly inform of the
following information (check all that apply; see key below):
1

XI. CIVIL RIGHTS
☐

☐

☐ Availability of Program benefits

☐

☐ Eligibility criteria for participation

☐

☐ Location of LA/clinics operating WIC Program and (800) telephone numbers

☐

☐ Hours of service of LA/clinics operating WIC Program

☐

☐ Rights and responsibilities

☐

☐ Nondiscrimination policy

☐

☐ Civil rights complaint procedure

1 = general public
2 = grassroots/community organizations that deal with potentially eligible low-income individuals
3 = potential eligible individuals/participants
d.

The State agency ensures that advocacy/minority organizations and the general public are
informed of the benefits/policies listed above (please provide the appropriate Procedure Manual
citation of materials used):
☐ Annually

☐ More frequently

ADDITIONAL DETAIL: Civil Rights Appendix and/or Procedure Manual (citation): Click or tap
here to enter text.
2. Nondiscrimination Notification
a. The State agency or local agency:
☐ Provides applicants/participant with key information, such as applications and materials describing
eligibility criteria and procedures for delivery of benefits, in appropriate languages other than English
in areas where a significant proportion of people with limited English proficiency (LEP) reside.
☐ Provide applicants/participants with key information, such as applications and materials describing
eligibility criteria and procedures for delivery of benefits using inclusive language.
☐ Appropriate bilingual staff, volunteers, or other translation resources are available to serve applicants
and participants in areas where a significant proportion of people with limited English proficiency
(LEP) reside.
☐ All rights and responsibilities listed on the certification form are read to or by the applicants and
participants in the appropriate language, or if the participant is sight or hearing impaired and requires
assistance.

XI. CIVIL RIGHTS
b. The State agency provides WIC Program materials and translators in the following languages
(Check all that apply; M = Materials, VT = Volunteer Translators, PT = Paid Translators, BS =
Bilingual Staff):
M
☐

VT
☐

PT
☐

BS
☐ English

☐

☐ Spanish

☐

☐ French

☐

☐ Vietnamese

☐

☐ Chinese

☐

☐ Other Asian/Pacific (specify): Click or tap here to enter text.

☐

☐ Tribal (specify): Click or tap here to enter text.

☐

☐ Braille

☐

☐ Sign language Interpreter

☐

☐ Other languages (specify): Click or tap here to enter text.

ADDITIONAL DETAIL: Civil Rights Appendix and/or Procedure Manual (citation): Click or tap
here to enter text.

C. Compliance Review and Monitoring Activity
1. Compliance Review
a. Civil rights reviews of local agencies are conducted:
☐ Separately
☐ In conjunction with another department, organization, or service as part of an overall review
☐ Other (specify): Click or tap here to enter text.
b. The State agency reviews all its local agencies for civil rights compliance with the nondiscrimination
laws and regulations when it does its reviews.
☐ Yes

☐ No

ADDITIONAL DETAIL: Civil Rights Appendix and/or Procedure Manual (citation): Click or tap
here to enter text.
2. Monitoring Activity
a. In addition to the local agency reviews, the State agency uses the following means to
ensure that local agencies operate in a nondiscriminatory manner:
☐ Review of the racial/ethnic enrollment
and/or participation data applications
☐ Review of denied

☐ Review of waiting lists
☐ Other (specify): Click or tap here to enter text.

☐ Review of complaints
☐ Review of participant surveys
☐ Participant interviews

b. The State agency checks for the following in local agency applications:
☐ The local agency has corrected all past substantiated civil rights problems or noncompliance
situations
☐ The Civil Rights Assurance is included in the State-Local Agency Agreement
☐ A description of the racial/ethnic makeup of the service area is included in the application
☐ The local agency uses inclusive language with developing its program materials
☐ Appropriate staff, volunteers, or other translation resources are available in areas where a significant
proportion of people with limited English proficiency (LEP) reside
c. The State agency checks for the following in its civil rights reviews of its local

agencies:

☐ Case records include racial/ethnic data
☐ Where applicable, an explanation of why the racial/ethnic WIC participant level is not proportionate to the income
eligible racial/ethnic population
☐ The local agency has conducted civil rights training for its staff
☐ The project area displays the USDA nondiscrimination poster, "And Justice For All," or an FNS-approved
substitute
☐ Program information has been provided to applicants, participants, and grassroots organizations or similar minority
groups
☐ The nondiscrimination policy statement and civil rights complaint procedure are included on all printed materials
such as applications, pamphlets, forms, or any other materials distributed to the public
☐ Racial/ethnic data are collected by actual count and maintained on file for 3 years
☐ The local agency has corrected all past substantiated civil rights problems or noncompliance situations
☐ Civil rights complaints are handled in accordance with the procedures outlined in FNS Instruction 113-1

ADDITIONAL DETAIL: Civil Rights Appendix and/or Procedure Manual (citation): Click or tap here to enter
text.

D. Data Collection and Reporting
1. Data Collection
a. The State agency ensures the following when collecting civil rights data:
☐ All racial/ethnic categories are collected and reported as part of the program participant characteristics
report
☐ Racial/ethnic data definitions are in accordance with current OMB guidance and clinic procedures are in place to
ensure the data is collected accurately
☐ Data reported on participant characteristics include the number of persons on WIC master lists or persons listed
in WIC operating files who are certified to receive benefits
☐ Collected racial/ethnic data and records are accessible only to authorized personnel
b.

The State agency maintains a civil rights file which retains collected racial/ethnic data for three years.
☐ Yes

☐ No

ADDITIONAL DETAIL: Civil Rights Appendix and/or Procedure Manual (citation): Click or tap here to enter
text.
62

2. The State agency instructs its local agencies to obtain a participant's racial/ethnic category by
(check all that apply):
☐ Allowing self-identification by participant (must be used at participant’s request)

☐ Visual identification by participant (must be used at participant’s request)
☐ Local agency staff personally know participant's racial/ethnic category
☐ Other (specify): Click or tap here to enter text.

ADDITIONAL DETAIL: Civil Rights Appendix and/or Procedure Manual (citation): Click or tap here to enter
text.

E. Complaint Handling
1. The State agency ensures the following:
☐ WIC Program applicants and participants are informed where and how they may file a complaint of discrimination
by directing them to the USDA Office of the Assistant Secretary for Civil Rights (OASCR) website
(https://www.usda.gov/oascr/how-to-file-a-program-discrimination-complaint) for proper Discrimination Complaint
Filing processes.
☐ WIC Program applicants and participants are informed that they can file their complaints directly with the U.S.
Department of Agriculture or directly with the FNS HQ Civil Rights Division, their State agency, or their local
agency. However, the local/State agency must then forward their complaint either directly to the FNS HQ Civil
Rights Division or the U.S. Department of Agriculture.
☐ All local agency staff are trained in discrimination complaint procedures.
☐ All written and verbal complaints alleging discrimination based on race, color, national origin, age, sex, or
disability are accepted from applicants and participants by State agency and local agency staff and forwarded to
the FNS HQ Civil Rights Division.
☐ Complaints alleging discrimination based on race, color, national origin, or age are forwarded to the FNS HQ Civil
Rights Division through an FNS-established complaint procedure. (Regional Office receives copy of all
complaints.)
☐ State and local agencies without an FNS-approved grievance procedure for complaints alleging discrimination
based on sex or disability in place forward all complaints to the FNS HQ Civil Rights Division).
☐ Complaints alleging discrimination based on sex or disability are forwarded to the State agency that has an FNSapproved grievance procedure in place.

ADDITIONAL DETAIL: Civil Rights Appendix and/or Procedure Manual (citation): Click or tap here to enter
text.
2. The State agency uses a discrimination complaint form it has developed for acceptance of a complaint.
☐ Yes

☐ No

ADDITIONAL DETAIL: Civil Rights Appendix and/or Procedure Manual (citation): Click or tap here to enter
text.
3. The State agency has an FNS approved complaint procedure that ensures local agencies implement
specific timeframes concerning discrimination complaints:
☐ An individual has the right to file a complaint within 180 days of the alleged discriminatory action.
☐ All complaints are processed and closed within 90 days of receipt.
4. The State agency transfers complaints immediately upon receipt to the FNS HQ Civil Rights Division if
no FNS-approved complaint procedure timeline is in place.

Yes ☐

No ☐

If no, specify Click or tap here to enter text.

ADDITIONAL DETAIL: Civil Rights Appendix and/or Procedure Manual (citation): Click or tap here to enter
text.

File Type	application/pdf
Author	Nixon, Teronica - FNS
File Modified	2023-07-25
File Created	2023-07-25