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WIC Nutrition Risk Criteria

System Assigned (SA); System or CPA Assigned (SA/CPA); CPA Assigned (CPA); Automatic High Risk* (HR) Code Category [Priority] Risk Criteria/Definition Required Documentation 6

< 12.5/38 hgb/hct 15 to <18 years old < 12.5/38 hgb/hct >18 years old

Smoking 2 packs plus per day: < 12.5/38 hgb/hct 8 to <12 years old < 12.5/38 hgb/hct 12 to <15 years old < 12.7/38 hgb/hct 15 to <18 years old < 12.7/38 hgb/hct >18 years old

Low Hematocrit/Low Hemoglobin: Infants 6 to 12 Months of Age: Hgb <11.0 g/dl and HCT <33.0% HR* (High Risk) Values: Hgb <9.5 g/dl/HCT <29%

Child 12 to < 24 Months of Age: Hgb <11.0 g/dl and HCT <32.9% Child 2 to 5 years: Hgb <11.1 g/dl and HCT <33.0% HR* (High Risk) Values: Hgb <9.3 g/dl and HCT <27.9% 211* (CPA) (HR) PG [1] BF [1] NBF [3-6] Infants [1] Child [3] Elevated Blood Lead Levels: Blood lead level within the past 12 months. Women (all categories): >5 µg/dl Infants: >5 µg/dl Children: >3.5 µg/dl

Presence of condition diagnosed and reported by a physician or someone working under physician’s orders. Documentation of current diagnosis is required at each subsequent certification.

*Staff MUST ask parents/caretakers if the child they are enrolling in WIC has had a blood lead screening test; any child who has not had a test must be referred to a program where they can obtain one. Note: All Medicaid enrolled children are required to be tested at ages 12 and 24 months, or at age 24-72 months if they have not previously been screened.

If the applicant/parent/caregiver reports an elevated lead level, the CPA must request documentation from the HCP using the WIC Referral form (WIC 104). Once presence of this condition is confirmed, the CPA should manually assign this risk on the Assigned Risk Factors Screen and document in the participant’s Care Plan Summary Screen, Nutrition Assessment field in