CERTIFICATION WPPM #210-11 Subject: Eligibility Requirement Item: Determining Nutritional Risk – Biochemical

Revised Oct 1, 2021 California WIC Policy and Procedure Manual Page of 1 6 PURPOSE: To provide standardized procedures for obtaining required anemia and blood lead screening results in order to assess the biochemical risk of participants. POLICY: I. Hemoglobin or hematocrit test results, also referred to as bloodwork/anemia screening results, must be documented at the time of initial certification or within 90 days of the date of certification. When appropriate, bloodwork results must also be documented at the time of recertification, or within 90 days. II. Requirements by Category A. Infants 1. Certified before 9 months of age: Bloodwork/anemia screening results are not required. 2. Certified between 9 and 12 months: Bloodwork/anemia screening results are required. a. If bloodwork/anemia screening was performed between 6 and 12 months and had a: i. Normal result: New bloodwork/anemia screening results are not required at the one-year recertification. Next bloodwork/anemia screening results are required 12 months after the initial test/screening. ii. Below normal result: New bloodwork/anemia screening results are required every 6 months until a normal result is obtained and documented. B. Children 1. Aged 12 months and older: a. Normal result: New bloodwork/anemia screening results are required every 12 months. b. Below normal result: New bloodwork/anemia screening results are required every 6 months until a normal result is obtained and documented. 2. The bloodwork/anemia screening expiration date is determined by the date of the most recent test result and does not necessarily align with the recertification date. Therefore, new results may not be required at recertification if current results have not yet expired. C. Pregnant/Postpartum 1. Only one bloodwork/anemia screening result is required during a certification period. 2. Pregnant: The bloodwork/anemia screening result must be obtained from a test that was performed during the current pregnancy.

CERTIFICATION WPPM #210-11 Subject: Eligibility Requirement Item: Determining Nutritional Risk – Biochemical

Revised California WIC Policy and Procedure Manual Page 2 of 6 Oct 1, 2021 3. Postpartum (Breastfeeding/Non-breastfeeding): The bloodwork/anemia screening result must be obtained from a test that was performed after the pregnancy ended. PROCEDURES: I. Accepted Sources of Bloodwork/Anemia Screening Results A. WIC Referral form (CDPH 247 WIC Referral for Pregnant/Postpartum/Breastfeeding Women Referral and CDPH 247A Pediatric Referral). B. Medical/clinical record in physical form, displayed in-person via electronic format (e.g., emails, cell phones, tablets, pictures, etc.), or obtained remotely. For acceptable means of obtaining documents remotely, refer to WPPM 220-30. If the applicant/participant does not have a health care provider (HCP), staff must offer a healthcare referral. C. Verbal result provided by a HCP. If the applicant/participant agrees to let local agency (LA) staff obtain bloodwork/anemia screening results from a HCP, staff must have them sign a LA developed consent form or the CDPH/WIC standard template Consent to Release Information form before contacting the HCP. Verbal results provided by participants are not allowed. D. Non-invasive anemia screening at the WIC site. E. Invasive anemia screening at the WIC site. The LA must have a current Clinical Laboratory Improvement Amendments (CLIA) certificate on file unless waived, per the manufacturer. Invasive anemia screenings are permitted for all categories. II. Documentation in the WIC Web Information System Exchange (WIC WISE) A. LA staff must properly document the following in WIC WISE: 1. Source of test/screening result (indicate WIC or non-WIC). 2. Date the test/screening was performed. 3. Bloodwork/anemia screening results. 4. Additional biochemical nutritional risk factor(s), if identified. III. New Applicants Lacking Bloodwork/Anemia Screening Results A. If an applicant lacks bloodwork/anemia screening results at their initial certification, LA staff must: 1. Certify the applicant. 2. Use an anemia screening device to obtain bloodwork/anemia screening results. If the applicant does not have a HCP due to lack of health care coverage, LA staff must refer them to Medi-Cal.

CERTIFICATION WPPM #210-11 Subject: Eligibility Requirement Item: Determining Nutritional Risk – Biochemical

Revised California WIC Policy and Procedure Manual Page 3 of 6 Oct 1, 2021 3. If unable to obtain results at the WIC site, LA staff must: a. Check the “No Blood” checkbox and document the reason in the “Ht/Wt/Bloodwork” screen. b. Give the participant an appropriate WIC referral form. Ask the participant to obtain the required bloodwork/anemia screening results from the HCP and bring or provide the completed form at their next appointment. c. Issue the appropriate number of months of benefits. LA staff are permitted to issue up to three months of food benefits while the bloodwork/anemia screening result is pending (as long as other criteria for triple issuance are met). Refer to WPPM 330- 10. d. Schedule an appropriate follow-up appointment and remind the participant that results are due at the next appointment. IV. Current Participant with Expiring Bloodwork/Anemia Screening Results A. WIC WISE will automatically place an alert 90 days in advance of the bloodwork/anemia screening result expiration date. If a participant has expiring results, LA staff must: 1. Give the participant a WIC referral form. Ask the participant to obtain the required bloodwork/anemia screening results from the HCP and bring or provide the completed form at their next WIC appointment. 2. Issue food benefits until the month of the participant’s next WIC appointment. Do not issue past the month where the current results will expire. 3. Schedule an appropriate follow-up appointment. V. Applicant/Participant Fails to Bring Bloodwork/Anemia Screening Result at the Next WIC Appointment after Request A. LA staff must use an anemia screening device to obtain bloodwork/anemia screening results at the WIC site. If unable to obtain results via this method, staff must check the “No Blood” checkbox and document the reason for inability to screen in the “Ht/Wt/Bloodwork” screen in WIC WISE. B. LA staff are permitted to issue up to three months of food benefits while the bloodwork/anemia screening result is pending (as long as other criteria for triple issuance are met). C. LA staff must attempt to obtain bloodwork/anemia screening results using an anemia screening device, or through a HCP, at every subsequent appointment until the participant bloodwork/anemia screening result is documented in WIC WISE.

CERTIFICATION WPPM #210-11 Subject: Eligibility Requirement Item: Determining Nutritional Risk – Biochemical

Revised California WIC Policy and Procedure Manual Page 4 of 6 Oct 1, 2021 VI. Informing the Participant of Bloodwork/Anemia Screening Results A. LA staff must inform the participant of the outcome and meaning of the bloodwork/anemia screening result. If the result is low (refer to WPPM 960-01), staff must: 1. Provide nutrition education. 2. Provide referral services. 3. Obtain new bloodwork/anemia screening results in 6 months for infant and child participants. LA staff are not required to re-check results for pregnant and postpartum participants with low bloodwork results. VII. Adjustments for Altitude A. LA staff must adjust the participant’s hemoglobin and/or hematocrit values (see table on page 6) when providing WIC services at altitudes greater than or equal to 3,000 feet. VIII. Blood Lead Test A. Blood lead test results must be requested at each child’s one-year recertification or at the child’s initial certification (if the child is initially certified when older than age one). Refer to WPPM 700-02 B. LA staff must only accept blood lead test results from an acceptable source (see Section I.A-C). C. If the lead test result is available, LA staff must document the result in the “Ht/Wt/Bloodwork” screen. EXCEPTIONS: I. Any exceptions to obtaining the required biochemical result must be documented by selecting the appropriate option in the “Reason” dropdown in the “Ht/Wt/Bloodwork” screen. LA staff are permitted to triple issue food benefits until subsequent recertification (as long as other criteria for triple issuance of benefits are met). A. Bloodwork Exceptions include: 1. The applicant/participant has a documented medical condition that would make a bloodwork/anemia screening result inaccurate or not obtainable. 2. The applicant/participant declines bloodwork/anemia screening due to religious beliefs. B. Bloodwork exceptions are valid for the entire certification period and must be reassessed at the next recertification. AUTHORITY: 7 CFR §246.7(e) Nutritional risk WIC Policy Memo #2001-2: WIC Bloodwork Requirements

CERTIFICATION WPPM #210-11 Subject: Eligibility Requirement Item: Determining Nutritional Risk – Biochemical

Revised California WIC Policy and Procedure Manual Page 5 of 6 Oct 1, 2021 WIC Policy Memo 8/29/2011: Guidance for Providing Quality WIC Nutrition Services During Extended Certification Periods WIC Policy Memo #2001-1: Clarification of WIC’s FY 2001 Appropriations Act Provisions Regarding Blood Lead Screening. Altitude Reference: Centers for Disease Control and Prevention. Recommendations to Prevent and Control Iron Deficiency in the United States. MMWR 1998;47 (Number RR-3): [pages 11-14] RESOURCES: Value Enhanced Nutrition Assessment (VENA) The First Step in Quality Nutrition Services Centers for Disease Control and Prevention. Recommendations to Prevent and Control Iron Deficiency in the United States. CDPH 247 WIC Referral for Pregnant/Postpartum/Breastfeeding Women Referral CDPH 247 A Pediatric Referral CROSS REFERENCE: WPPM 220-30 Telehealth Privacy and Confidentiality WPPM 330-10 Single/Double/Triple Food Instrument Issuance WPPM 700-02 Referral Requirements at Certification

CERTIFICATION WPPM #210-11 Subject: Eligibility Requirement Item: Determining Nutritional Risk – Biochemical

Revised California WIC Policy and Procedure Manual Page 6 of 6 Oct 1, 2021

Altitude Adjustments The following adjustments must be made to the biochemical values for persons who reside at elevations above sea level. ALTITUDE IN FEET ADJUSTMENT TO HEMOGLOBIN VALUE ADJUSTMENT TO HEMATOCRIT VALUE 3,000 – 3,999 Subtract 0.2 g/dl Subtract 0.5% 4,000 – 4,999 Subtract 0.3 g/dl Subtract 1% 5,000 – 5,999 Subtract 0.5 g/dl Subtract 1.5% 6,000 – 6,999 Subtract 0.7 g/dl Subtract 2% 7,000 – 7,999 Subtract 1.0 g/dl Subtract 3% 8,000 – 8,999 Subtract 1.3 g/dl Subtract 4% 9,000 – 9,999 Subtract 1.6 g/dl Subtract 5% > 10,000 Subtract 2.0 g/dl Subtract 6% Altitude Reference: Centers for Disease Control and Prevention. Recommendations to Prevent and Control Iron Deficiency in the United States. MMWR 1998;47 (Number RR-3): [pages 11-14]