WIC and Nutrition Manual 100 Policy Group Financial Table of Contents Policy 100 WIC Financial Management

Page 1 Section: Financial WIC and Nutrition Manual December 2024

WIC Financial Management

Page 2 Section: Financial WIC and Nutrition Manual December 2024

POLICY Local WIC programs must submit monthly revenue and expenditure reports and an annual budget to the State Agency.

PURPOSE To ensure payments to local programs reflect actual expenses. To comply with United States Department of Agriculture (USDA) reporting standards for the WIC program.

RELEVANT REGULATIONS AND GUIDANCE

7 CFR 246.25 (b) Records and reports-financial and participation reports-monthly. 7 CFR 246.11 Nutrition education. 7 CFR 246.14(d)(2) Costs allowable with approval-capital outlay requests Federal Management circulars also apply to this area. OMB Circular A-87 Office of Management and Budget, Cost Principles for State, Local, and Indian Tribal Governments/ Standards for Determining Costs for Federal Awards Through Grants with State and Local Governments.

WIC Reporting Guide, December 2018 (internal) WIC Policy Memorandum #95-5 Allowability of Costs for Program Incentive Items.

PROCEDURES

The Department of Public Health is moved to the Workday Financial Management system effective July 2024. Below is a chart/crosswalk of Legacy Program Cost Centers and Workday Program Codes and descriptions.

Legacy Cost Center Workday Program Workday Program Name Typically Described Number of LHDs receiving this allocation in FY24 804 PGC2100 WIC Nutrition Services WIC Program All LHDs 833 PGC2101 WIC Breastfeeding Promotion Regional Coordinators WIC Regional Breastfeeding Coordinators 6 LHDs 840 PGC2103 Breastfeeding Peer Counselor WIC Breastfeeding Peer Counselor Program 25 LHDs 854 PGP2100 WIC Technical Assistance WIC Passthrough Staff 2 LHDs 854 PGC2104 WIC Infrastructure WIC USDA Infrastructure Grant LHDs with an approved award from USDA annually

Page 3 Section: Financial WIC and Nutrition Manual December 2024

A. Funding and Budget 1. Funding for the WIC Program comes from the USDA to the Kentucky WIC Program, Nutrition Services Branch in the Department for Public Health. The Kentucky WIC Program (State Agency) pays all WIC Program food costs directly. The Program reimburses local agencies monthly for their program operation costs. Administrative expenditures shared by more than one program must be prorated on an equitable basis to all programs. The Kentucky WIC Program uses a per-participant funding formula to establish the annual funding allocations for local agencies. Based on their total allocation, local agencies must submit a projected annual budget. Budgets for local agencies are submitted annually in coordination with the Division of Administrative and Financial Management procedures. Refer to the annually-released Program Descriptions Budget file from the Division of Administrative and Financial Management for specifically allowed and disallowed budget costs.

B. WIC Federal Reporting Cost Categories for Time and Expenses The following is a list of common WIC activities completed by staff in federal cost categories. Use this list to identify the cost category for WIC activities when completing time studies and for timekeeping. This list also includes examples of other costs (e.g., supplies, travel, etc.). There are four WIC Federal Reporting Cost Categories: Client Services, Nutrition Education, Breastfeeding Promotion and Support, and WIC Administration. See below for further details.

1. Client Services (Program Code PGC2100, Function Code FN1402) All costs are directly related to food delivery and other client services and benefits. Client Services are the costs involved in screening, assessing, enrolling, and issuing benefits for WIC applicants and participants. Examples include WIC staff salaries/benefits and medical supplies and equipment necessary to conduct diet and health assessments required in the WIC certification process, salary/benefits and other costs necessary to refer clients to other health care and social services, to coordinate services with other programs, to participate in activities which promote a broader range of health and social services for participants, and to conduct and participate in surveys/studies which evaluate the impact of WIC on its participants. The majority of WIC staff time will be coded to Client Services, Function Code FN1402.

Below is a list of approved costs covered by client services:

• Any contact with applicants or WIC Participants (does not include nutrition education or breastfeeding promotion and support or outreach). o Phone coverage, appointment scheduling, reminder calls, and reminder postcards. o Income eligibility determination and documentation. o Notification of participants/applicants WIC Rights and Responsibilities. o Collection of demographic information for registration or appointment scheduling. o Health and dietary assessments and certifications. o Screening and notification of eligibility, ineligibility, and termination. o Performing blood or non-invasive hemoglobin tests and anthropometric measures for WIC assessment. o Food package assignment and substitutions and food package changes. o Printing/mailing WIC shopping lists to participants. o Reviewing the e-WIC 1 form and explaining the WIC Shopper App to WIC participants. o Issuing eWIC cards and eWIC benefits, explaining how to use eWIC cards, and replacing eWIC Cards. o Referral to other health and social services. o Coordination of services with other programs.

Page 4 Section: Financial WIC and Nutrition Manual December 2024

o Interpreter for registration, certification, MCHA weights and assessment, benefit issuance, and checkout (does not include nutrition education, breastfeeding, or outreach).

• Any activities that support WIC Clinic Services that are not directly with the applicant/participant. o Pulling and filing medical records. o Phone calls related to formula prescriptions to the State WIC Office, Physician’s Office, or local pharmacy/retailer. o Participation or implementation of surveys/studies that evaluate the impact of WIC on its participants. o Creating agency WIC materials or forms such as a referral form (does not include nutrition education, breastfeeding, or outreach materials). o For WIC-only equipment, the cost of annual scale calibration and controls for hematological tests. o Inventory and destruction of returned WIC formula. o Support activities for online nutrition education, including reviewing online education emails/websites, printing online education labels, documentation in the medical record, and uploading eWIC benefits/mailing shopping list. o Translator services or materials translation for registration, certification, MCHA weights and assessment, and checkout (does not include nutrition education, breastfeeding, or outreach). o Clinic design and flow assessment. o Eligibility determination and review such as Conflict of Interest Log review (See FN1401) o Staff meetings with topics about providing client services, including WIC Policy.

• Supplies and Equipment to support Client Services. o Supplies to support WIC certifications, including hematological screening supplies, scales, and measuring equipment used solely by the WIC Program for WIC Services.

2. Nutrition Education (Program Code PGC2100, Function Code FN1403) All costs are directly related to general WIC nutrition education. Examples include salaries/benefits, travel and training costs for WIC staff who plan or conduct nutrition education, costs to develop/procure, print, and distribute nutrition education materials, cost of equipment required to conduct nutrition education training, interpreter and translator services to facilitate training, and costs associated with evaluating and monitoring nutrition education. This federal cost category, Nutrition Education, should represent at least 20% of the total WIC Program budget. WIC Nutrition Education costs should be coded to Program Code PGC2100, Function Code FN1403.

Below is a list of approved costs covered by nutrition education:

• Any contact with applicants or WIC Participants related to nutrition education. o Providing nutrition education to participants at WIC certification, secondary, and MCHA visits. o Providing group nutrition education to participants. o Interpreter services used for nutrition education.

• Any activities that support WIC Nutrition Education that are not directly with the applicant/participant. o Planning nutrition education group sessions, including the purchase of any needed materials. o Documenting nutrition education in medical records (individual or group). o Staff meetings focused on nutrition education. o Nutrition Education Coordinator continuing education (a minimum of 4 hours annually).

Page 5 Section: Financial WIC and Nutrition Manual December 2024

o Nutrition Education Conferences require prior state approval (including registration fees, travel, and staff time). o Creating, printing, and distributing nutrition education materials. This includes the translation of nutrition education materials. (All local agency-created materials must be submitted to the State Agency for approval). o Translation services used for nutrition education. o Evaluation and monitoring of nutrition education services, for example, internal nutrition education quality assurance activity. WIC Internal Review will be coded to Administration. o Development of Nutrition Services Plan and Evaluation (formerly Narrative Plan) goals and plan, staff time spent carrying out the plan.

• Supplies and Equipment to support Nutrition Education. o Nutrition education materials and resources o Nutrition Education supplies for group education o Nutrition education supplies such as food models and MyPlate materials (prior state agency approval required).

3. Breastfeeding Promotion and Support (Program Code PGC2100, Function Code FN1404)

All costs directly related to the promotion and support of breastfeeding. Examples include the salary/benefits of WIC staff who plan or conduct educational and other services to promote or support breastfeeding, the salary/benefits of Designated Breastfeeding Experts (DBE) counseling participants referred from the Breastfeeding Peer Program, and other actions to encourage continuation of breastfeeding, costs to develop/procure, print and distribute educational materials related to breastfeeding promotion and support, clinic space devoted to breastfeeding educational and training activities including space set aside for nursing/pumping. WIC Breastfeeding Promotion and Support costs will be coded to Program Code PGC2100, Function Code FN1404.

Below is a list of approved costs covered by Breastfeeding Promotion and Support:

• Any contact with applicants or WIC Participants related to Breastfeeding Promotion and Support. o Providing breastfeeding education and support to pregnant and breastfeeding women. o Interpreter services used for breastfeeding activities. o Issuance of breast pumps to WIC participants. o Counseling and education on breast pump assembly, use, and cleaning or use of breastfeeding aids. o Follow-up calls to participants issued a breast pump. o Weight checks for breastfeeding infants.

• Any activities that support WIC breastfeeding promotion and support that are not directly with the applicant/participant. o Planning breastfeeding promotion, education, or support activities. o DBE training and breastfeeding activities, which may include continuing education, breastfeeding counseling, coordination with the Breastfeeding Peer Program, and lactation support referrals. o Staff time spent completing the USDA WIC Breastfeeding Curriculum. o Creating, printing, or distributing breastfeeding promotion and support materials. (All local agency-created materials must be submitted to the State Agency for approval). o Translation services used for breastfeeding activities.

Page 6 Section: Financial WIC and Nutrition Manual December 2024

o Outreach, if combined with breastfeeding promotion (for example, community baby showers). o Evaluation and monitoring of breastfeeding promotion, education, and support services. o Inventory of breast pumps and breastfeeding aids. o Staff meetings focused on breastfeeding support and promotion. o Breastfeeding Coordinator and DBE continuing education (a minimum of 4 hours annually). o Breastfeeding Conferences require prior state approval (including registration fees, travel, and staff time). o Ordering of manual breast pumps or breastfeeding aids (must have prior approval and submit the invoice to the state agency). o Providing breastfeeding support services such as community coordination and follow-up phone calls regarding breastfeeding.

• Supplies and Equipment to support Breastfeeding Promotion and Support. o Breastfeeding materials and resources such as breastfeeding dolls, tummy size models, etc. (state approval required). o Breastfeeding materials for group classes.

4. WIC Administration/Program Management (Program Code PGC2100, Function Code FN1401) General management costs (direct or indirect) include those costs associated with program monitoring, prevention of fraud, general oversight, and food instrument (eWIC card) accountability. Examples include WIC administrative salaries/benefits and other costs necessary to conduct outreach, food instrument reconciliation, monitoring and payment, processing vendor complaints, administrative records, and fiscal and program management reports. This includes direct costs associated with Program and staff management and should be less than 10% of the overall WIC budget. WIC Administration/Program Management costs will be coded to Program Code PGC2100, Function Code 1401.

Below is a list of approved costs covered by WIC administration/WIC Program Management:

• Cost associated with Quality Assurance and Program Monitoring. o Conducting biannual WIC internal review. o Working WIC e-reports. o WIC eWIC card accountability, including inventory and audits. o Conflict of Interest Log Reviews (also see FN1402) o Completing time studies. o Inventory of office equipment. o Researching/preventing fraud by vendors or participants. o Letters to participants regarding reports of abuse or fraud. o Financial management, budget development, and tracking. o Staff training or staff meetings on topics such as supervisory skills or other management topics (does not include staff training on WIC policy, nutrition education, and breastfeeding promotion and support). Includes staff time for vicinity travel and training time.

• Costs associated with WIC Outreach. o WIC Outreach (does not include nutrition education or breastfeeding). o Outreach materials, including translation of materials (does not include nutrition education or breastfeeding promotion materials).

• Supplies and Equipment to support Outreach.

Page 7 Section: Financial WIC and Nutrition Manual December 2024

o Supplies for WIC Outreach (State Agency approval required). Summary of WIC Program Code PGC2100 Function Codes

WIC Administration/ Program Management WIC Client Services WIC Nutrition Education WIC Breastfeeding Promotion and Support

FN1401

FN1402

FN1403

FN1404

C. Time Reporting and Time Study 1. Staff time spent on WIC Program Activities should be directly coded to the WIC Federal Reporting Cost Categories. 2. Periodic Time Studies should be completed to ensure the accuracy of direct time coding. See the Sample Time Study Template below.

D. WIC Program Incentive Items 1. WIC Program incentive items refer to a class of goods, usually of nominal value (less than $8 each), that are given to applicants, participants, and potential participants, or persons closely associated with the WIC Program, such as staff, for purposes of outreach, nutrition education, or breastfeeding promotion. 2. Program incentive items can be allowable if they are considered reasonable and necessary costs that promote specific program purposes of outreach, nutrition education, or breastfeeding promotion. 3. Reasonable and Necessary Costs USDA requires the State WIC Agency to determine if purchase requests are reasonable, considering the context of the specific program areas of outreach, nutrition education, and breastfeeding. In addition, the state agency is responsible for considering whether an item is necessary and reasonable from the standpoint of the overall program operations and the relative financial situation of the Program. Local agencies should consider the public perception of program funds spent on items, even when the connection to outreach, nutrition education, or breastfeeding promotion is clear.

Page 8 Section: Financial WIC and Nutrition Manual December 2024

a. Reasonable Costs i. Provide the WIC Program a benefit generally commensurate with the costs incurred. ii. Consistent with the costs of similar items from other vendors. iii. In proportion to other Program costs for the function that the costs serve. iv. These are priority expenditures relative to other demands on available administrative resources. v. Have a proven or intuitive positive outreach or nutrition/breastfeeding education impact. b. Necessary Costs i. Costs incurred to carry out essential program functions. ii. Cannot be avoided without adversely impacting WIC Program operations. c. Outreach refers to promotional efforts to encourage and increase participation in the WIC Program. Outreach efforts must be consistent with the goals of the WIC Program. i. Program incentive items for outreach should: 1. Contain a WIC-specific message that targets the potentially eligible population. 2. Normally seen in public (Note: Clinic staff logo shirts are not normally seen in public and are therefore not considered an approved outreach item). 3. Contain the current USDA Nondiscrimination Statement (on all print items or as space allows on nonprint items). See Policy 306, Civil Rights. 4. Have value as an outreach device that equals or outweighs other uses. 5. Include WIC contact information such as the name, address, and/or phone number of the state or local agency. 6. Constitute or show promise of an innovative or proven way of encouraging WIC participation. 7. Be a reasonable and necessary cost. ii. Examples of allowable costs include buttons, bibs, toothbrushes, pens, small cups, measuring spoons, or other nominally priced items with WIC promotional messages. d. Nutrition Education means individual, or group education sessions and the provision of information and educational materials designed to improve the health status, achieve positive change in dietary habits, and emphasize the relationship between nutrition and health, keeping with the individual’s personal, cultural, and socioeconomic preferences. Teaching aids for nutrition education may be an allowable cost. i. Program incentive items for Nutrition Education should: 1. Be targeted to WIC participants. 2. Contain the current USDA Nondiscrimination Statement (on all print items or as space allows on nonprint items). See Policy 306, Civil Rights. 3. Have a clear and useful connection to the particular WIC nutrition message. 4. Convey enough information to be considered educational or be utilized by WIC participants to reinforce nutrition education contacts. 5. Have value as a nutrition education aid that equals or outweighs other uses. 6. Be distributed to the target audience for which the items were designed (e.g., sippy cups distributed to the caregivers of infants who are learning or will be learning to drink from a cup during a relevant nutrition education contact). 7. Messaging should be consistent with the Kentucky Department for Public Health, Kentucky WIC program, and USDA Nutrition Messaging. 8. Be reasonable and necessary costs. ii. Examples of allowable costs include calendars or refrigerator magnets with nutrition messages, sippy cups, infant feeding spoons, measuring spoons, MyPlate items, or other nominally priced items that support WIC Nutrition Education messages. e. Breastfeeding Promotion means strategies, initiatives, and services to encourage and increase the initiation and support of the duration of breastfeeding among WIC participants. Teaching aids for breastfeeding promotion may be an allowable cost. i. Program incentive items for Breastfeeding Promotion should: 1. Be targeted to WIC participants.

Page 9 Section: Financial WIC and Nutrition Manual December 2024

2. Contain the current USDA Nondiscrimination Statement (on all print items or as space allows on nonprint items). See Policy 306, Civil Rights. 3. Have a clear and useful connection to promoting and supporting breastfeeding in general, inform participants about the benefits of breastfeeding, or offer support and encouragement to women to initiate and continue breastfeeding. 4. Convey enough information to be considered educational or be utilized by WIC participants to reinforce nutrition education contacts. 5. Have value as a breastfeeding promotion and support item that equals or outweighs other uses. 6. Be distributed to the target audience for which the items were designed. 7. Messaging should be consistent with the Kentucky Department for Public Health, Kentucky WIC program, and USDA Breastfeeding Messaging. 8. Be reasonable and necessary costs. ii. Examples of allowable costs include Infant T-shirts or buttons with breastfeeding messages, such as “Breastfed is Best Fed” or other nominally priced items that support WIC Breastfeeding Promotion messages. iii. Note: Breastfeeding Aids are a distinct and separate class of allowable costs and should not be considered incentive items. Refer to Policy 503, Breastfeeding Accessories, for additional information.

E. Unallowable Expenses for the WIC Program The following list provides examples of non-approved WIC Program expenses. This list is not all-inclusive. Please contact the State WIC Office for guidance when considering purchases. 1. Celebratory items or items designed primarily as Staff Morale Boosters. 2. Breastfeeding supplies such as topical creams, ointments, hydrogel dressings, vitamin E and other medicinal items, foot stools, infant pillows, and nursing clothing. Refer to Policy 503, Breastfeeding Accessories, for more information. 3. Incentive items of a nominal value that have no outreach, breastfeeding, or nutrition education message or are intended for persons who have no connection to the WIC Program. 4. Incentive items not of a nominal value, such as diaper bags, infant slings, and ponchos, regardless of nutrition, outreach, or breastfeeding messages. These would not be considered reasonable and necessary. 5. Gift cards. 6. Staff WIC logo shirts, pullovers, cardigans, etc. 7. Fitness Center dues, membership, or fitness equipment, fitness instructors, fitness classes. 8. Pregnancy testing supplies. 9. Vitamins or Supplements. 10. Medical supplies not directly related to WIC services (e.g., syringes, needles, uranalysis testing supplies, glucose testing supplies, blood pressure supplies, immunization supplies, otoscopes, speculums). 11. Food, beverages, flowers, and entertainment for any kind of training event or meeting. Food or beverages for WIC staff or WIC participants. Food may be allowable with state approval if purchased for nutrition education, such as for a 1% or less milk taste test or WIC food preparation group class.

F. Equipment, Printing, and Purchase Requests Local Agencies must obtain written approval from the State Agency prior to purchasing or expending WIC funds on: 1. Any purchase over $500. 2. Any medical equipment (i.e., scales, measurement devices, breast pumps, hematological equipment/supplies) regardless of cost. 3. Any computer equipment (including software) regardless of cost. Computer accessories, such as keyboards and monitors, do not require approval. 4. Incentive items for nutrition education and breastfeeding education or outreach.

Page 10 Section: Financial WIC and Nutrition Manual December 2024

5. Any nutrition or breastfeeding education materials that are not state-approved. (Nutrition and Breastfeeding materials listed in the WIC and Nutrition Manual or the annual Nutrition Services Plan do not require approval unless the cost is $500) 6. Locally-developed nutrition education, breastfeeding education, or outreach items intended for use in the WIC Program or for WIC outreach. 7. Any item that contains the KY WIC Logo or Shape the Future Breastfeeding Logo.

Obtaining State Agency Approval 1. Complete the WIC Purchase Request Form. a. Include WIC agency name, staff member contact information, Program information (WIC or Breastfeeding Peer, WIC Infrastructure), Federal Cost Category (Client Services, Nutrition Education, Breastfeeding Promotion and Support, and Administration), item description, intended use, manufacturer information, unit price, quantity, shipping cost, total cost, indicated if the item will be used 100% for WIC Program or shared with other Programs. b. The WIC Purchase Request Form is available in a PDF Fillable from the State Agency and may be requested via email at KY.WIC@KY.GOV. c. Submit to KY.WIC@ky.gov with the subject line: Purchase Request. d. It takes up to seven working days to obtain approval from the State Agency WIC Program. i. Purchases over $5,000 must receive USDA prior approval. This requires justification, may require multiple bids, and will add an additional 60 days to the review period.

Page 11 Section: Financial WIC and Nutrition Manual December 2024

WIC PROGRAM PURCHASE REQUEST FORM

Page 12 Section: Financial WIC and Nutrition Manual December 2024

G. Non-Personnel and Shared Program Costs Administrative expenditures shared by more than one program must be prorated on an equitable basis to all programs. WIC’s percentage of the total must be used to allocate a shared cost to WIC. Purchases such as any equipment and supplies used by multiple programs must be allocated based on “fair share.” NOTE: Shared costs charged to the WIC Program still must be considered “necessary” and “reasonable” costs as defined above.

H. Fixed Asset Inventory Local Agencies are responsible for maintaining a fixed asset inventory, including but not limited to a description, cost, serial number, fixed asset tag number (optional), and date of purchase for each item purchased with WIC funds with a value of $500 or more. This does not include items such as hematological cuvettes/sensors utilized within one year. The local agency shall make the inventory available to the state agency upon request.

I. Surplus Local agencies wishing to surplus equipment that is listed on their fixed asset inventory must Indicate the method and date of disposal on the inventory form, which requires a staff signature verifying that the items have been taken or destroyed. Each local agency should follow its local surplus procedure to dispose of fixed asset inventory.

Page 13 Section: Financial WIC and Nutrition Manual December 2024

J. WIC Clinic Services Reporting PATIENT ENCOUNTER FORM & SYSTEM CODING FOR WIC SERVICES

CPT Code PEF Description CMS Description Long Description Routine Providers W0200 W0200 CERT & ENROLLED W0200, CERTIFIED & ENROLLED CERTIFIED & ENROLLED This is coded at certification and recertification visits. This is for the certification visit's assessment, measurements, and risk code assignment portion. RD, RDN, CN, RN, LPN

W0203 W0203 SCR NOT ELIGIBLE - INCOME W0203, SCREENED NOT ELIGIBLE- INCOME SCREENED NOT ELIGIBLE DUE TO INCOME This is coded when completing an income assessment for a WIC certification or recertification, and the applicant/participant is income ineligible (Over income eligibility limits) Support Staff

W0204 W0204 SCR NOT ELIGIBLE - RISK W0204, SCREENED NOT ELIGIBLE-RISK SCREENED NOT ELIGIBLE DUE TO NUTRITION RISK This is coded when a certification or recertification is completed, and the applicant/participant has no valid qualifying nutrition risk. Be sure to thoroughly assess and utilize regression codes and presumed dietary risk, if appropriate, before determining not eligible. RD, RDN, CN, RN, LPN

W0205 W0205 MID- CERT HEALTH ASSESSMENT - MCHA W0205, WIC MID- CERT HEALTH ASSESSMENT-IN PERSON MID-CERT HEALTH ASSESSMENT (MCHA) This is coded for the nutrition assessment completed at the MCHA appointment The health professional should be sure to indicate by checking the MCHA box in CMS that an MCHA visit is being completed. RD, RDN, CN, RN, LPN W0208 W0208 VOC ENROLLMENT W0208, VOC ENROLLMENT VERIFICATION OF CERTIFICATION (VOC) ENROLLMENT This is coded to transfer a participant from another site (outside the agency) with a valid certification period. Once assigned, the Health Professional may assign the food package. Support Staff W0209 W0209 BENEFIT ISSUANCE W0209, FOOD INSTRUMENT ISSUANCE WIC FOOD BENEFIT ISSUANCE This is coded to indicate the issuance of WIC food benefits. Support Staff or RD, RDN, CN, RN, LPN

Page 14 Section: Financial WIC and Nutrition Manual December 2024

CPT Code PEF Description CMS Description Long Description Routine Providers W0210 W0210 ISSUING A BREAST PUMP W0210, ISSUING A BREAST PUMP BREAST PUMP ISSUANCE This is coded when the health professional issues a WIC breast pump, provides required breast pump education and completes required forms. RD, RDN, CN, RN, LPN, IBCLC, DBE W0211 W0211 FOOD PACKAGE CHANGE/COUNSELING W0211, FOOD PACKAGE CHANGE/ COUNSELING FOOD PACKAGE CHANGE/COUNSELING This is coded when a health professional must change a food package and provides counseling regarding how to transition to the new foods; it is primarily coded when the health professional spends time explaining the infant formula challenge protocol and how to transition to a new formula. This may involve time calling a store or doctor’s office to assist the participant with a product while they are in the office. Documentation in the medical record should indicate counseling provided. RD, RDN, CN, RN, LPN

W0220 W0220 CAPILLARY BLOOD SPECIMEN W0220, CAPILLARY BLOOD SPECIMEN CAPILLARY BLOOD SPECIMEN FOR WIC HGB OR HCT SCREENING This is coded when a finger stick is completed for a WIC hematological screening. RD, RDN, CN, RN, LPN, Lab Tech, Lab Assistant

W0230 W0230 HEMOGLOBIN W0230, HEMOGLOBIN HEMOGLOBIN SCREENING This is coded to indicate WIC Hgb screening in conjunction with W0220. RD, RDN, CN, RN, LPN, Lab Tech, Lab Assistant

W0231 W0231 NON-INVASIVE HEMOGLOBIN W0231, NON- INVASIVE HEMOGLOBIN NON-INVASIVE HEMOGLOBIN SCREENING This is coded when the Pronto Non- Invasive Hgb Screening is conducted for WIC. RD, RDN, CN, RN, LPN, Lab Tech, Lab Assistant

W0240 W0240 HEMATOCRIT W0240, HEMATOCRIT HEMATOCRIT SCREENING This is coded to indicate WIC HCT screening in conjunction with W0220. RD, RDN, CN, RN, LPN, Lab Tech, Lab Assistant

Page 15 Section: Financial WIC and Nutrition Manual December 2024

CPT Code PEF Description CMS Description Long Description Routine Providers W9401 W9401 WIC NUTRITION ED/COUNSELING (7.5) W9401, WIC NUTRITION EDUCATION 7.5 MN WIC NUTRITION EDUCATION 7.5 MINUTES This is the most frequent code for WIC. Nutrition Education at certification, mid-certification, secondary and re-certification visits. This code is for providing 7.5 minutes of WIC Nutrition Education. Use the ICD code 2699- to indicate WIC Nutrition Education/ Counseling. The 7.5 minutes is for the nutrition education portion of the WIC visit only; this code does not cover the time involved in the assessment, enrollment, hematological measures, or food benefit issuance. Use the appropriate codes for those portions of the WIC visit. RD, RDN, CN, RN, LPN

W9401BF W9401 WIC NUTRITION ED/COUNSELING (7.5) BF W9401BF, WIC NUTRITION EDUCATION 7.5 MN WIC BREASTFEEDING NUTRITION EDUCATION 7.5 MINUTES (V241-) This is coded for Breastfeeding Education, Counseling, and Support above and beyond protocol at certification, mid-certification, secondary and recertification visits, and when issuing a breast pump. Use the ICD code V241- to indicate WIC Breastfeeding Counseling. RD, RDN, CN, RN, LPN

W9402 W9402 WIC NUTRITION ED/COUNSELING (15) W9402, WIC NUTRITION EDUCATION 15 MIN WIC NUTRITION EDUCATION 15 MIN This is coded when the health professional spends 15 minutes rather than 7.5 minutes on Nutrition Education – See W9401 for more information. This is not frequently coded. RD, RDN, CN, RN, LPN

W9402BF W9402 WIC NUTRITION ED/COUNSELING (15) BF W9402 BF, WIC BREASTFEEDING NUTRITION EDUCATION 15 MIN WIC BREASTFEEDING NUTRITION EDUCATION 15 MINUTES (V241-) This is coded for Breastfeeding Education, Counseling, and Support above and beyond protocol at certification, mid-certification, secondary and recertification visits, and when issuing a breast pump. Use the ICD code V241- to indicate WIC Breastfeeding Counseling. This is not frequently coded. RD, RDN, CN, RN, LPN

Page 16 Section: Financial WIC and Nutrition Manual December 2024

CPT Code PEF Description CMS Description Long Description Routine Providers W9403 W9403 WIC NUTRITION ED/COUNSELING (22.5) W9403, WIC NUTRITION EDUCATION 30 MIN WIC NUTRITION EDUCATION 22.5 MIN This is coded when the health professional spends 22.5 minutes rather than 7.5 minutes on Nutrition Education-See W9401 for more information. Documentation in the medical record should support the additional time spent on nutrition education. This is not routinely coded. RD, RDN, CN, RN, LPN

W9403BF W9403 WIC NUTRITION ED/COUNSELING (22.5) BF W9043 BF, WIC BREASTFEEDING NUTRITION EDUCATION 22.5 MIN WIC BREASTFEEDING NUTRITION EDUCATION 22.5 MINUTES (V241-) This is coded for Breastfeeding Education, Counseling, and Support above and beyond protocol at certification, mid-certification, secondary and recertification visits and when issuing a breast pump. Use the ICD code V241- to indicate WIC Breastfeeding Counseling. This is not frequently coded. Only for DBE, or WIC IBCLC/CLC/CLS or Refer to RD for MNT. DBE, or RD/RN with IBCLC/CLC or CLS Credential

W9404 W9404 WIC NUTRITION ED/COUNSELING (30) W9404, WIC NUTRITION EDUCATION 45 MIN WIC NUTRITION EDUCATION 30 MIN This is coded when the health professional spends 30 minutes rather than 7.5 minutes on Nutrition Education-See W9401 for more information. Documentation in the medical record should support the additional time spent on nutrition education. This is not routinely coded. This would be rarely coded; an MNT visit/referral is more appropriate. RD, RDN, CN, RN, LPN

W9404BF W9404 WIC NUTRITION ED/COUNSELING (30) BF W9404 BF, WIC BREASTFEEDING NUTRITION EDUCATION 30 MIN WIC BREASTFEEDING NUTRITION EDUCATION 30 MINUTES (V241-) This is coded for Breastfeeding Education, Counseling, and Support above and beyond protocol at certification, mid-certification, secondary, and recertification visits and when issuing a breast pump. Use ICD code V241- to indicate WIC Breastfeeding Counseling. This is rarely used. Only for DBE or WIC IBCLC/CLC/CLS or Refer to RD for MNT. DBE or RD/RN with a IBCLC/CLC or CLS credential.

Page 17 Section: Financial WIC and Nutrition Manual December 2024

CPT Code PEF Description CMS Description Long Description Routine Providers W9431 W9431 WIC GROUP NUTRITION CLASS W9431, WIC GROUP NUTRITION CLASS WIC GROUP NUTRITION CLASS This is coded when a health professional provides nutrition education in a group setting using the approved Facilitated Group Session Modules or other state- approved curricula. RD, RDN, CN, RN, LPN

W9432 W9432 WIC GROUP BREASTFEEDING CLASS W9432, WIC GROUP BREASTFEEDING CLASS WIC GROUP BREASTFEEDING CLASS This is coded when a health professional provides Breastfeeding education/support in a group setting using the approved Facilitated Group Session Modules or other state- approved curricula. RD, RDN, CN, RN, LPN, IBCLC, DBE

Page 18 Section: Financial WIC and Nutrition Manual December 2024

WIC Breastfeeding Peer Counselor Program (BFPC) Time Recording Program Code PGC2103

WIC Breastfeeding Peer Counselor Program Staff should code their time spent on the activities below based as outlined below. Refer to Policy 504 Breastfeeding Peer Counselor Program for allowable expenses. Allowable Costs and Time Coding for Regional Breastfeeding Coordinators Activities WIC Program Breastfeeding Support Breastfeeding Peer Counselor Program Attend quarterly Peer Counselor meetings (time and travel).

Peer Counselor Peer Supervisor Designated Breastfeeding Expert Complete USDA Training Curriculum. Designated Breastfeeding Expert Peer Counselor Peer Supervisor

Peer conducting breastfeeding class for BFPC participants.

Peer Counselor

Peer counseling BFPC participants per Protocol.

Peer Counselor

Peer documenting BFPC contacts with participants.

Peer Counselor

Peer follow-up with BFPC participants on referrals made.

Peer Counselor

Peer referring a BFPC participant to a Designated Breastfeeding Expert (DBE).

Peer Counselor

Peer terminating BFPC participants per protocol.

Peer Counselor

Peer Supervisor administrative duties including: recruitment, interview, onboarding, arranging shadowing opportunities for newly hired Peers, and observing Peer counseling contacts, working BFPC reports, completing Quality Assurance reviews and evaluations per protocol.

Peer Supervisor BFPC Staff Meeting/local agency training

Peer Counselor Peer Supervisor Designated Breastfeeding Expert Filing in Medical Record

Peer Supervisor/Support Staff DBE face-to-face or remote follow-up with participants based on a BFPC Peer referral.

Designated Breastfeeding Expert Designated Breastfeeding Expert

Page 19 Section: Financial WIC and Nutrition Manual December 2024

Program Code PGC2101

Only expenditures for designated Regional Breastfeeding Coordinators approved by the State WIC office in specified agencies can be charged to the Regional Breastfeeding Coordinator Function Area. The expenditures will be for breastfeeding promotion activities to increase breastfeeding initiation and duration rates. This includes working with other local health departments and public and private community partners. Expenditures for direct one-on-one breastfeeding services cannot be coded to this function area. The State WIC Office must approve all expenses over $500 (five hundred) dollars.

The table below helps to identify allowable Regional Breastfeeding Coordinator costs.

Item or Service

Allowable Costs Comments/ Function Area Durable Goods Computer and Laptops No Coded to indirect costs. These items are used for multiple programs. Office equipment No Coded to indirect costs. These items are used for multiple programs. Incentives and Educational Materials to Promote Breastfeeding Breastfeeding educational materials such as pamphlets and DVDs Yes** WIC Breastfeeding Promotion or WIC Regional Breastfeeding Coordinator with State Approval Breast pumps and breastfeeding aids for mothers and demonstration purposes Yes

WIC Breastfeeding Promotion or WIC Regional Breastfeeding Coordinator with State Approval Incentive items distributed to encourage breastfeeding Yes WIC Breastfeeding Promotion or WIC Regional Breastfeeding Coordinator with State Approval Personnel and Compensation Salaries and compensation for Regional Breastfeeding Coordinators Yes WIC Regional Breastfeeding Coordinator Salaries and compensation for lactation referrals No WIC Breastfeeding Promotion Staff Training and Resources Travel for Regional Breastfeeding Coordinators Yes WIC Regional Breastfeeding Coordinator Breastfeeding resources for WIC staff Yes WIC Breastfeeding Promotion or WIC Regional Breastfeeding Coordinator with State Approval International Board-Certified Lactation Consultant (IBCLC), Certified Lactation Specialist (CLS), or Certified Lactation Counselor (CLC) exam fees No

Page 20 Section: Financial WIC and Nutrition Manual December 2024

Item or Service

Allowable Costs Comments/ Function Area International Board-Certified Lactation Consultant (IBCLC), Certified Lactation Specialist (CLS), and Certified Lactation Counselor (CLC) association membership fee No

Program Advertising and Promotion Pamphlets and similar materials to promote breastfeeding Yes** WIC Regional Breastfeeding Coordinator with State Approval Media campaigns, e.g., bus placards, to advertise breastfeeding Yes**

WIC Regional Breastfeeding Coordinator with State Approval Ads that promote breastfeeding in general.

Yes** WIC Breastfeeding Promotion or WIC Regional Breastfeeding Coordinator with State Approval Incentive items for Breastfeeding Promotion Yes WIC Breastfeeding Promotion or WIC Regional Breastfeeding Coordinator with State Approval Miscellaneous Food No

Secondary nutrition education contacts No

Childcare No

Cribs or other materials and equipment for infants of staff or peer counselors who bring their babies to work No

* All brochures, materials, and advertisements must include the required non-discrimination statement. This statement is included in the Policy 306, Civil Rights.

** All brochures, materials, and advertisements that have the KY WIC logo or the Shape the Future: Breastfeed logo must be reviewed and approved by the State WIC Office.

WIC and Nutrition Manual 200 Policy Group Certification Policies Table of Contents Policy 200 Certification Overview and Required Notifications Policy 201 Participant Status and Priority Policy 202 Processing Standards Policy 203 Required Proofs - Residency, Identity, and Income Policy 204 Verification of Certification Policy 205 Adjunct Eligibility Policy 206 Determining Household Size and Household Income Policy 207 Required Proofs Not Present Policy 208 Homeless Participants Policy 209 Physical Presence Requirements Policy 210 Certification Periods Policy 211 Rights and Responsibilities Policy 212 Voter Registration Policy 213 Proxy Policy 214 Hospital Certification Requirements Policy 215 Certification Risk Assessment Policy 216 Anthropometric Screening Policy 217 Hemoglobin and Hematocrit Screening in WIC Policy 218 Risk Criteria Codes and Descriptions Policy 219 Mid-Certification Health Assessment Policy 220 Program Access in Disaster Situations Policy 221 Remote Certification During COVID-19 Pandemic Policy 200 Certification Appendices

Page 1 Certification Overview and Required Notifications Policy 200 December 2024 Policy 200 Certification Overview and Required Notifications POLICY WIC participants will be screened for eligibility based on the certification requirements. PURPOSE To provide an introduction and overview of the WIC certification process. RELEVANT REGULATIONS 7CFR 246.7 (f) Certification of participant Processing standards. DPH KY Administrative Reference – Training Guidelines and Program Description Section, WIC Program DPH KY Administrative Reference – Local Health Operations Section, Day and Hours of Operation DEFINITIONS Certification – Certification is the process of determining whether or not an applicant qualifies for WIC services. Certification period – The length of time a participant is eligible for receiving WIC services. A certification period depends on a participant’s category and is defined by federal regulations. Certifying Health Professional – An individual on staff of the local WIC agency authorized to determine nutritional risk, prescribe supplemental foods and determine eligibility for the WIC Program. The following persons are the only persons the State Agency may authorize to serve in this capacity: Physicians, Nutritionists (Bachelor’s degree), Certified Nutritionists (Master’s degree and certification by State Board of Certification and Licensure), Dietitians (RD/LD), Nurses (RN, LPN, APRN) and Physician’s Assistants (certified by the National Committee on Certification of Physician’s Assistants or certified by the State medical certifying authority). (See Administrative Reference, Training Guidelines and Program Descriptions) PROCEDURES A. Local WIC agencies must follow program requirements, policies, and procedures for certification as described in the USDA regulations and this manual. 1. Screen for WIC eligibility according to the policies and procedures outlined in this section. 2. Serve the highest-risk participants within the target population of the program’s geographic area. 3. Document the services delivered to program participants. 4. See the flowchart below for an overview of the WIC certification process. 5. See the table below listing required notifications and counseling topics to be covered at each certification visit.

Page 2 Certification Overview and Required Notifications Policy 200 December 2024

Nutrition assessment  Hematological measurements  Anthropometric Measurements  Clinical/health/medical risk  Dietary assessment  Participant centered assessment Counseling  Provide participant-centered nutrition education  Establish participant-centered Goal(s)  Make referrals  Assign/tailor food package eWIC card issuance  Issue benefits  Print benefits list  Provide Approved Food List and explain benefit use  Provide eWIC card and shopper education/WIC Shopper App information  Provide list of Authorized WIC Retailers  Offer next appointment/advise on how to make an appointment Certification Process Flow Chart

Applicant Screening (in person)  Category (WIC Status)  Residency within service area  Income  Income Guidelines

Eligible for NO Certification Assessment

YES

Enrollment  Physical presence  Eligible category  Proof of identity, residence and income  Explain participant Rights & Responsibilities, provide e-WIC 1  Ask participant to sign CH-5, CH-5WIC, CH5-B, as applicable

Secondary nutrition Education contact, Mid-Cert Health Assessment or benefit issuance Recertification Ineligible  Proof of identity, residence and income  Status does not meet  Explain participant Rights & Responsibilities  Ask participant to sign CH-5  Voter registration (if applicable)  WIC-54 “Notice of Ineligibility  Complete “T” action if applicable  Medical Record documentation  Enter encounter into System (PEF) Refer to community resources

Page 3 Certification Overview and Required Notifications Policy 200 December 2024

Required Notifications and Counseling at Certification Visit Topic Area WIC Certification Notifications & Counseling Protocol Staff Member Responsible* Free Communication and Reasonable Modifications and Auxiliary Aids and Services • Notify of free communication assistance, reasonable modifications, and auxiliary aids and services upon request. • For Limited English Proficient applicants, document the primary language and what free services were provided (i.e., interpreter line) in the CMS system and medical record. • For disabled participants, document requests for reasonable modifications and auxiliary aids and services and what accommodation was provided. • Refer to Policy 306, Civil Rights, and tagline poster. Support Staff at registration/checkout Certifying Health Professionals during nutrition assessment and counseling Rights and Responsibilities • Inform all applicants, participants, or their parents/caretakers of their rights and responsibilities in the WIC Program in a language that they can understand. • Documentation informing the applicants/participants of their rights and responsibilities must be maintained in the person’s medical record. • Inform the participants of their right to file a complaint and how to file a complaint. • Refer to Policy 211 Rights and Responsibilities and Policy 306 Civil Rights. Support Staff Voter Registration • Voter registration or the option to update current registration shall be provided to other persons eighteen (18) years old or older applying for the Program or those who present who request to apply to register to vote. • Explain that registering to vote/ choosing not to register to vote does not impact WIC eligibility determination. • Refer to Policy 212 Voter Registration for required documentation. Support Staff Notice of Collection of Ethnic and Race Data Inform applicant: • Everyone requesting services is asked to identify their ethnicity and race(s). o This information is requested solely for the purpose of determining the State’s compliance with Federal civil rights laws, and your response will not affect the consideration of your application and may be protected by the Privacy Act. o Providing this data is voluntary and has no effect on the determination of eligibility to participate in WIC. o You may select more than one race. o If you do not provide this information, registration staff shall determine this through visual observation. • The Ethnicity and Race Reference Handout may be handed to the applicant to assist with identifying ethnicity and race. • Refer to Policy 306, Civil Rights. Support Staff Discuss WIC Program eligibility and benefits. • Explain the purpose of the WIC Program (The Program provides nutritional support through supplemental foods, nutrition education, breastfeeding support, and referrals) • At initial certification, explain the certification process, including income eligibility assessment, nutrition assessment to provide individualized nutrition education and a tailored food package, the eligibility periods, and recertification schedule. • Discuss the importance and benefits of participating in the WIC Program and encourage ongoing participation and recertifications. The Program provides individualized and group nutrition education, breastfeeding support, referrals, and healthy foods. It helps to provide nutrition during critical growth and development periods for pregnancy, early postpartum, infancy, and early childhood. Support Staff or Certifying Health Professional Eligibility Determination • Inform the applicant that you are collecting documentation of income, residency, and identity information to determine Program eligibility. • Explain that the information provided will be used to determine WIC Program Eligibility. • If Eligible, explain how eligibility was determined (for example, “Your income is under the 185 percentile of Support Staff

Page 4 Certification Overview and Required Notifications Policy 200 December 2024

poverty, or you qualified adjunctively for WIC because you have Medicaid/SNAP). Explain that in addition to being income eligible, participants must have a health or nutrition concern, which will be identified by the health professional during the nutrition assessment. • Applicants/participants determined ineligible due to income must be provided written notice of the ineligibility (WIC-54), the reason for ineligibility, and the right to a fair hearing. • Review the CH-5 Registration Form and required Signatures. • Notify of right to request a Fair Hearing. • Refer to Policy 203 Required Proofs, Residency, Identity, and Income. Notification/Referrals for Public Assistance Programs and other health-related programs. • WIC staff will provide written referral information about other health-related and public assistance programs (Medicaid, SNAP, immunizations, etc.) and, when appropriate, shall refer applicants/participants to such programs. • Review information in the eWIC-1 handout. • Refer to Policy 210 Certification Periods and 403 Referrals. Support Staff Counsel on basic diet and the importance of regular physical activity. Determine what concerns or questions the participant has in regard to her nutrition, child’s nutrition, and/or infant’s nutrition. Provide counseling to address questions/ concerns/dietary habits. Women and Children: • Review Choose My Plate Dietary Guideline Tip Sheet(s). • Review dietary concern(s) and appropriate action. • Encourage an average of 30 minutes for women and 60 minutes for children of physical activity each day. • Limit screen time to no more than 2 hours/day. • Remove the television from the child’s bedroom. • Encourage healthy foods (e.g., low-fat and reduced-fat food choices including 1% or less milk, (women/children > 2), 5 Fruits and Vegetables per day & Avoid Sugar-Sweetened Drinks) Infants: • Discuss the Kentucky Infant Feeding Guide appropriate for age and development. • Encourage caregiver(s) to promote physical activity and motor skill development in their infant (rolling over, standing, movement, play). • Review dietary concern(s) and appropriate action. Certifying Health Professional Encourage to breastfeed unless contraindicated for health/lifestyle reasons. Pregnant women: • Discuss the advantages of breastfeeding. • Discuss the benefits of Kangaroo Care. • Encourage to breastfeed unless contraindicated. • Offer the opportunity to speak with a Breastfeeding Peer Counselor, where available. Breastfeeding women: • Encourage continuation and support of breastfeeding unless contraindicated. • Discuss the benefits of Kangaroo Care. • Offer the opportunity to speak with a Breastfeeding Peer Counselor, where available. Refer to Policy 501 Breastfeeding Promotion and Support Standards. Certifying Health Professional Lead Screening • Explain the impact of elevated blood lead levels on growth and development and the importance of a blood lead level screening. • Provide a referral to primary care provider or local Lead Program in the following situations: o The infant/child has never received a lead test. o The AAP recommends lead risk assessment at 6 and 9 months of age for infants. The CDC recommends all refugee infants receive a lead risk assessment. Certifying Health Professional

Page 5 Certification Overview and Required Notifications Policy 200 December 2024

o The AAP recommends a lead risk assessment at 12, 18, and 24 months of age, as well as the 3- and 4-year-old well-child checks. o All Medicaid enrolled children are required to have a lead test at 12 and 24 months of age or age 24-72 months if they have not been previously screened. o The child had an elevated BLL 12 months prior and has had no interim follow-up screening. o The infant/child is suspected by a parent or a health care provider to be at risk for lead exposure. o The infant/child has a sibling or frequent playmate with an elevated BLL. o The participant is a recent immigrant, refugee, or foreign adoptee. o The breastfeeding or lactating woman, parent, or child’s principal caregiver works professionally or recreationally with lead. o The family has a household member who uses traditional, folk, or ethnic remedies and cosmetics or who routinely eats unregulated/uninspected food imported from abroad. o The family has been identified at increased risk for lead exposure by the health department because the family has local risk factors for lead exposure. Immunization Screening • Advise the parents or caregivers that immunization records are requested as part of the WIC health screening process. • WIC staff must screen all WIC participants up to 2 years of age and should continue screening up to age 4 years at each certification visit. Refer those who are under- immunized. • Immunization status/providing immunization records will not impact the availability of WIC services. • Refer under-immunized to their healthcare provider for immunizations. Document the referral. • Refer to Policy 215 Certification Risk Assessment. Support Staff may request a copy of the record or release of the immunization record. Certifying Health Professional will review the record and discuss it with the participant. Discuss the effects of drug and other harmful substance use (tobacco, alcohol, drugs). • Discuss how tobacco and/or alcohol can affect the woman, fetus, infant, and child. This should include information about smoking cessation if appropriate, and the effects of secondhand smoke. • Discuss recommendations not to use tobacco products. Refer to 1-800-QUIT NOW (1-800-784-8669) if the client smokes. • Discuss recommendations not to take any medications, over-the-counter or otherwise, unless specifically ordered by a physician. • Discuss recommendations not to use drugs (marijuana, cocaine, etc.). • Discuss recommendations not to drink alcohol. • Refer as appropriate for substance abuse. Certifying Health Professional Discuss Safe Sleep Environment for Infants Infants: • Discuss American Academy of Pediatrics (AAP) Safe Sleep Policy. Certifying Health Professional Collection of Anthropometric and Hematological Data • Notify applicants of the collection of height, weight, and hematological data to determine eligibility. • For remote certifications, if data is unavailable at the time of certification, notify participants of the need to have height and weight data within 60 days of certification. • Refer to Policy 216 Anthropometric Screening, Policy 217 Hematological Screening, and Policy 221 ARPA Waver Remote Services. Certifying Health Professionals or Support Staff For participants being recertified for the WIC Program • Review and discuss previously set goals. • For participants who completed the online nutrition education lesson, review and discuss the lesson completion certificate, participant goal set during the lesson, and links visited. Certifying Health Professional

Page 6 Certification Overview and Required Notifications Policy 200 December 2024

Discuss specific nutritional risks for which the participant qualifies. • Review specific nutrition risk codes identified during the assessment. • Advise the participant/caretaker of all identified nutrition risk codes that qualify the participant for the Program. • Refer to Policy 402 WIC Certification/MCHA Counseling for Specific Nutritional Risk Protocol Table for a full list of nutrition codes and required nutrition education. Certifying Health Professional Referrals based on Participant Needs identified during the Nutrition Assessment • Notify the participant of any referrals recommended based on assessment. • Document the referrals in the medical record. • For agencies with the Breastfeeding Peer Program, offer all Pregnant and Breastfeeding Women the opportunity to speak with a Peer Counselor. Document acceptance/ referral or denial. • Refer to Policy 403 Referrals. Certifying Health Professional Food Package Assignment • WIC Health Professional will assign and tailor the food package to meet the specific needs of the participant. • Explain the WIC Shopping List, WIC approved list, and how and where to use the eWIC card. • For food package changes or WIC Program Status changes that impact the food package, review the food package to ensure the participant has an understanding of the benefits. • Review the eWIC-1 handout as appropriate. • See WIC and Nutrition Manual, Section 600 Food Package Assignment. • For in-clinic services, advise participant/caretaker to swipe their eWIC card at the Card Reader to test their PIN and to ensure benefits have been loaded on their card. Certifying Health Professional Support Staff may explain the shopping list and how to use the eWIC card. Next Services • Explain when and what type of WIC appointment will be next and what will be requested for that appointment, such as anthropometrics or immunization record medical necessity form. • Ensure the next service will be scheduled prior to the expiration of the issued benefits. Certifying Health Professional Support Staff *Refer to Policy 302 Program Integrity-Separation of Duties. If separation of duties is not able to be provided, all notifications must still be provided.

Page 1 Participant Status and Priority Policy 201 December 2024

Policy 201 Participant Status and Priority POLICY Status must be determined for each applicant applying and reapplying for WIC and a nutritional risk priority system must be in place.

PURPOSE To ensure consistent use of federally-defined status and priorities among local WIC programs and that participants are certified for the proper length of time.

RELEVANT REGULATIONS 7 CFR 246.7(e) – Nutritional risk 7 CFR 246.7(i)(6-9) – Certification forms

PROCEDURES To meet eligibility requirements, a participant must be a specific status and have nutritional risk(s) identified. Priority is used to ensure WIC services are provided to applicants/participants in greatest nutritional need when a waitlist is implemented by the State WIC Office.

Status To be eligible for the WIC Program, the participant must be in one of the following statuses. Status and category are used interchangeably. Participants who do not meet any of the status definitions are not eligible for the WIC Program. Proof of status is not required. However, if the status is not apparent or is questionable, proof may be requested by the certifying health professional. A. Woman: 1. Pregnant – with one or more embryos or fetuses in utero. Certification of a pregnant woman begins from their entry into WIC until their estimated date of delivery (EDC) plus 6 weeks. 2. Breastfeeding – up to one (1) year after the end of a pregnancy* who is feeding breast milk to an infant on average of at least once per day. 3. Postpartum – up to six (6) months after the end of a pregnancy* and not breastfeeding an infant. *The end of a pregnancy is the date the pregnancy terminates, e.g., date of delivery, miscarriage, abortion, etc. B. Infant: Birth up to the first birthday (0-12 months). Infants at the time of certification are certified for a period of 1 year ending the month in which the infant reaches his/her first birthday. C. Child: Age one (1) up to age five (5). Children are certified for a one (1) year period ending with the month in which the child reaches five (5) years of age.

Status Changes A. Status may change during a certification period that may not require recertification. 1. A fully or partially breastfeeding woman stops breastfeeding and is less than six (6) months post-delivery. The woman’s status becomes postpartum. a. A change of status must be completed. b. The woman’s food package must be changed to a postpartum package along with any changes in risk (if appropriate). c. If the risk(s) identified for the breastfeeding woman do not apply to the postpartum status, a postpartum risk must be identified for the woman to continue on WIC. d. If a postpartum risk cannot be identified, the woman must be terminated from WIC. Refer to Policy 705- Ineligibility and Discontinuation of Benefits.

Page 2 Participant Status and Priority Policy 201 December 2024

2. A postpartum woman is in the system with postpartum status but is actually fully or partially breastfeeding. A recertification must be done to reflect the appropriate breastfeeding status. Her food package shall be changed to an appropriate breastfeeding package. 3. An infant at twelve (12) months of age. The system provides an automatic change from infant to child status, referred to as an Infant/Child Transfer (ICT). a. An infant at 12 months of age (1 year), has the status designation of child. Infant information in the system must be updated to child status, along with a child priority and a child food package. b. This change of status, priority, and food package is referred to as an Infant/Child Transfer (ICT). This process allows issuance of a child food package without a recertification to change status. B. A participant who no longer meets a status definition becomes categorically ineligible for the WIC Program. Priority Priority is a ranking system of I through VI. The highest priority is I and the lowest is VI. Priority is based on status and nutritional risk. Refer to Policy 218- Risk Criteria Codes and Descriptions. A. Priority Ranking Priority I Includes pregnant women, breastfeeding women, and infants with high risk conditions. Priority II Includes infants of mothers who were WIC participants during this pregnancy and infants whose mothers did not participate but who were eligible due to risk during this pregnancy. Priority III A Includes children with high-risk conditions. Priority III B Includes postpartum women with high-risk conditions. Priority IV Includes pregnant women, breastfeeding women, and infants with low risk conditions. Priority V A Includes children up to age two with low-risk conditions. Priority V B Includes children ages 2 to 5 with low-risk conditions. Priority VI Includes postpartum women with low-risk conditions. B. The computer system assigns the highest priority for the risk(s) entered. The participant’s risk code with the highest priority must be entered to ensure the highest priority assignment. C. The assigned priority is listed on the certification record and certification label. D. Priority may change during a certification period. Situations when priority changes are: 1. A change in risk. If a new risk is identified that is a higher priority than the current priority, the certification record (automated WIC-75) must be edited to add the new risk. The system will automatically assign the new priority. 2. A change in status. a. A change status, such as breastfeeding to postpartum, will result in the system automatically assigning priority based on risk and the new status. If the risk(s) identified for the participant does not apply to the new status, a risk must be identified for the new status. b. An infant at 12 months of age whose status changes to child also changes priority to an applicable child priority. For specific situations, the system does an automatic Infant/Child Transfer (ICT).

Page 3 Participant Status and Priority Policy 201 December 2024

Status Changes That Require Recertification

From Status Eligibility/Certification Schedule To Status Recertification Schedule Pregnant Woman or Pregnant with Multiples Duration of pregnancy up to six weeks post- delivery (computed based on EDC) Postpartum Recertify as postpartum. Pregnant Woman or Pregnant with Multiples Duration of pregnancy up to six weeks post- delivery (computed based on EDC) Any Breastfeeding Status: • Partially Breastfeeding • Partially Breastfeeding Multiples • Fully Breastfeeding • Fully Breastfeeding Multiples Recertify to appropriate Breastfeeding status. Postpartum Woman From certification to six (6) months from termination of Pregnancy (computed from the actual date of delivery) • Pregnant • Pregnant with Multiples Recertify to appropriate Pregnant status. Any Breastfeeding Status: • Partially Breastfeeding • Partially Breastfeeding Multiples • Fully Breastfeeding • Fully Breastfeeding Multiples Birth of infant up to one (1) year of age of child as long as Breastfeeding continues (computed from the actual date of delivery)** • Pregnant • Pregnant with Multiples Recertify to appropriate Pregnant status. Infants To one (1) year of age Child Recertify at one (1) year of age. Child (1 year to 5 years) For one (1) year periods up to five (5) years of age. N/A Recertify at one (1) year intervals.

Status Changes That Do Not Require Recertification**

Change Status From: To: Any breastfeeding status: • Partially Breastfeeding • Partially Breastfeeding Multiples • Fully Breastfeeding • Fully Breastfeeding Multiples Postpartum (stops BF before 6 months postpartum, change status to postpartum must meet postpartum risk criteria). NOTE: If more than 6 months postpartum and stops Breastfeeding - Terminate. • Partially Breastfeeding • Partially Breastfeeding Multiples • Fully Breastfeeding • Fully Breastfeeding Multiples Any other breastfeeding status: (Partially Breastfeeding, Partially Breastfeeding Multiples, Fully Breastfeeding, Fully Breastfeeding Multiples) • Infant Fully Breastfed • Infant Partially Breastfed • Infant Fully Formula Fed Any other infant status: (Infant Fully Breastfed, Infant Partially Breastfed, Infant Fully Formula Fed)

**With the status change, it may be necessary to add risk codes.

Page 1 Processing Standards Policy 202 December 2024

Policy 202 Processing Standards POLICY Local WIC agencies shall certify eligible applicants/participants within ten calendar days of the date of application if the participant is a pregnant woman, infant, a migrant farm worker, or a family member of a migrant farmworker. All other eligible applicants/participants will be certified within 20 calendar days. If the maximum caseload is being served, these standards do not apply.

PURPOSE To ensure that potential and current participants receive WIC benefits in a timely manner and in order of need, i.e., those groups at the highest risk would receive faster service (pregnant, infants, and migrants).

RELEVANT REGULATIONS 7 CFR 246.2 - Definitions 7CFR 246.7 (f) Certification of participant Processing standards. DPH KY Administrative Reference – Training Guidelines and Program Description Section, WIC Program DPH KY Administrative Reference – Local Health Operations Section, Day and Hours of Operation Final WIC Policy Memorandum #2001-7 Immunization Screening and Referral in WIC

DEFINITIONS Date of Initial Contact (DIC)/Initial Contact Date: The date an applicant appears in person or telephones the local WIC agency to request WIC services during clinic office hours. The date of the first request is the start of the 10/20-day processing time frame. If a participant has been terminated and contacts the clinic, if not eligible for a reinstatement of the current certification period, a new DIC will be entered into the system.

Migrant/ Migrant Farm Worker: an individual whose principal employment is in agriculture on a seasonal basis, who has been so employed within the last 24 months, and who establishes, for the purposes of such employment, a temporary abode.

PROCEDURES

Determining Date of Initial Contacts (DIC)/Initial Contact Date The date of the first request is the start of the 10/20-day processing time frame. Below are some scenarios that a clinic may encounter and how to determine the DIC that will be entered in the system.

Scenario Determining the DIC An applicant who has never participated in WIC contacts the WIC Clinic to request an appointment. The date the applicant contacts the clinic is the DIC. An applicant who has been terminated but has remaining certification eligibility contacts the WIC Clinic for an appointment. The applicant/participant is reinstated and the DIC will remain as the date of first contact. An applicant who has been terminated and has no remaining certification eligibility remaining contacts the WIC Clinic for an appointment. The date the applicant contacts the clinic for this appointment is the new DIC. The DIC field must be updated in the system. An applicant contacts the WIC Clinic for an initial WIC appointment and does not show for the appointment, then calls for a new appointment. This would re-start the 10/20-day processing standard, therefore a new DIC may be entered in the system.

Page 2 Processing Standards Policy 202 December 2024 Initial Clinic Visit to Request WIC Services A. The processing time frame begins with the applicant’s first contact to request WIC services. This is the date of initial contact, (DIC) and shall be documented for all initial certifications. This date is documented by completing the “Initial Contact Date” on the appointment screen. Refer to Kentucky CMS User Manual for additional information on the scheduling system. B. To ensure that accurate records are kept, the local WIC agency shall, at the time of each request, record the applicant’s name, telephone number, address and the date in the scheduling system. The remainder of the information necessary to determine eligibility shall be obtained at the time of certification. 1. If appointments are not routinely scheduled, a manual or electronic system must be in place to document the date of initial contact of the applicant/participant requesting WIC services as well as applicant/participant's name, address and telephone number. C. Scheduling shall take into consideration applicant/participant/caretaker needs, minimizing time away from work for working individuals and distances for travel for individuals who reside in rural areas. Accommodations can be made through extended hours, lunch appointments, use of proxies, online nutrition education, three (3) month issuance, and uploading food benefits. D. Appointments shall be scheduled for WIC services, i.e., certification, food benefit issuance, and nutrition education counseling to avoid a lapse in benefits. 1. If appointments are not routinely scheduled, a policy and procedure must be in place to assure that appointments are scheduled for employed participants/caretakers to minimize time absent from work. E. When scheduling WIC certification appointments for children, advise parents and caretakers that immunization records are requested as part of the WIC certification and health screening process. 1. Explain to the parent/caretaker the importance that WIC places on making sure that children are up to date on immunizations but assure applicants that immunization records are not required to obtain WIC benefits. F. To reduce barriers to participation in the WIC Program, participants should leave clinic with an appointment for the next WIC service. 1. If appointments are not routinely scheduled, a policy and procedure must be in place to assure that appointments are scheduled for employed participants/caretakers to minimize time absent from work. G. Applicants/Participants that “walk-in” without an appointment should be seen, if possible. H. To minimize barriers, WIC Services are to be provided in coordination with public health and /or other health services. However, participation in other services must not be required in order to receive WIC benefits, nor can WIC benefits be withheld pending other services. I. Documentation of all appointments and contacts must be in the participant’s medical record. J. A request by the caretaker/participant for an appointment outside the timeframe must be documented in the medical record, i.e., appointment scheduled per participant’s request. 10 Calendar Day Processing Standard Offer an appointment for eligibility determination within 10- calendar days of the date of initial contact if the applicant is pregnant, has an infant, a migrant farmworker, or a family member of a migrant farmworker. If an applicant requests an appointment for a date past the 10-calendar day standard, document this request in the applicant’s medical record. EXAMPLE: A pregnant woman calls the local WIC agency and asks for an appointment to enroll in WIC. She is offered an appointment five days from now, but she is unable to make that appointment. The next available appointment is two weeks from now, which falls outside of the 10-calendar day standard. Document this preference to indicate compliance with the processing standards.

Page 3 Processing Standards Policy 202 December 2024 20 Calendar Day Processing Standard Offer an appointment for eligibility determination within 20 calendar days from the date of initial contact for all other participants. If the participant requests an appointment for a date past the 20- calendar day standard, document this request in the applicant/participant’s medical record. Appointments for Employed Individuals Appointments shall be scheduled for employed applicants/participants/caretakers to minimize time absent from work. Scheduling should take into consideration applicant/participant/caretaker needs, minimizing time away from work for working individuals and distances for travel for individuals who reside in rural areas. Accommodations can be made through extended hours, lunch hour appointments, use of proxies, online nutrition education, three (3) months issuance, or uploading food benefits. Refer to policies 213 – Proxy, 404 – WIC Low-Risk Secondary Nutrition Education, and 805 – Mailing and Uploading Benefits. Processing Standards Extension Local WIC agencies may request, in writing to the state office, a temporary extension of processing standards from the ten (10) day standard to a maximum of fifteen (15) days when processing cannot be met due to staff shortages, clinic closure due to declared weather emergencies, other special circumstances approved by the State Agency. A. Submit a written request to the WIC Help Desk at WIC.Helpdesk@ky.gov immediately upon identifying a need to extend processing standards, including the following information: 1. An explanation of the need for an extension. 2. An estimated length of time for the extension, up to 90 days. B. Upon approval of an extension, the State WIC Office may request the Local WIC Agency to submit a processing standards improvement plan and monthly updates. Recertification Scheduling A. Recertification shall be scheduled prior to the end of the certification period to prevent interruption in or loss of benefits. B. When there is difficulty in scheduling the recertification visit, the recertification may be performed no more than 30-days prior to or 30 days after the certification period expiration date. The 30-day grace period cannot be used routinely. Food benefits must be provided when the 30-day grace is used. C. When certification is completed within the 30-day grace period prior to the expiration of the certification period, and the participant is ineligible, the remaining benefits for the current eligibility period shall be provided. D. Each participant/caretaker must be informed that the certification period is expiring a minimum of 15 days before the expiration. Verbal notice at the last food benefit pick-up appointment before the recertification due date is appropriate. Scheduling for Food Benefit Issuance A. Food benefit issuance shall be coordinated with WIC secondary nutrition education and Mid- Certification Health Assessment (MCHA) appointments/ other local health department services to reduce barriers to participation. 1. Food benefit issuance must be scheduled prior to the last valid date of benefit issuance to prevent the participant from being without food benefits. B. WIC food benefits cannot be withheld to require the receipt of other services. Missed Appointments/No Shows A. For applicants/participants who are marked “no show” for certification appointments, the processing time frame of 10 or 20 days ends with the missed appointment. The processing time frame begins again when the applicant/participant requests a new WIC appointment/service as outlined above. In the event of a cycle of making and missing appointments, the 10- or 20-day standard ends with each missed appointment. B. The local WIC agency must make additional appointments available to applicants/participants if the processing standards are not being met due to a lack of available appointment slots.

Page 4 Processing Standards Policy 202 December 2024

C. Follow-up should be made for all missed appointments/no-shows to encourage continued services and participation. Applicants/participants requesting “no home contact” or a privacy restriction shall be excluded from follow-up. Refer to Caseload Management Policies 702 and 704 and Policy 704- Nonparticipation. 1. Follow-up may be any of the following: telephone call, letter or postcard. The WIC -51 Reminder Post card is available for follow-up. 2. Staff shall attempt to contact each pregnant woman who missed her initial WIC certification appointment in order to reschedule the appointment. Pregnant women that specify “no home” contact or a privacy restriction are excluded. 3. Missed recertification appointments shall be rescheduled as soon as possible, but within the 30-day grace period to prevent loss of benefits (if possible, issue 30 days of benefits). 4. A participant that missed their food benefit pick-up appointment but comes to clinic the same day, shall be provided a minimum of one (1) month of food benefits and scheduled for the next appropriate appointment. 5. A participant that calls to reschedule an appointment or a missed appointment for food benefits, shall be issued benefits within one (1) week and rescheduled for the next appropriate appointment.

Page 1 Required Proofs – Residence, Identity and Income Policy 203 December 2024

Policy 203 Required Proofs - Residence, Identity, and Income POLICY All WIC participants must meet the qualifications for status, residence, identity, income, and nutritional risk at every certification and re-certification. Proof of identity, residence, and income must be provided and documented.

PURPOSE To assure proper verification of residency, identification, and income of WIC participants.

RELEVANT REGULATIONS 7 CFR 246.7 (c)(2)(i) – Proof of Residency and Identity 7 CFR 246.7 (d)(2)(v) – Income Eligibility Documentation Administrative Reference, Patient Services Reporting System, Household Size and Household Income Administrative Reference, LHO, Overview of Patient Fees and Scheduling PROCEDURES Information to determine eligibility shall be provided by the participant, parent, legal representative, or caretaker of an infant or child participant. The type of proof presented for identity, residence, and income must be documented. A code system is established for specific types of proof provided. The appropriate code must be documented in the medical record.

General Policies A. The relationship of the parent, legal representative, or caretaker of an infant or child participant and the living arrangements or circumstances shall be documented in the participant’s medical record. B. Participants do not have to be U.S. citizens nor have legal alien status to be eligible. C. A proxy may be used by a woman participant or by a parent/caretaker of an infant or child participant. A proxy may bring an infant or child to a WIC appointment to obtain WIC benefits, WIC nutrition education and may shop for WIC foods. Refer to Policy 213- Proxy D. Applicants/participants who are homeless or living in a homeless facility or living in certain institutions may receive WIC if eligibility requirements are met. Refer to Policy 208- Homeless Participants. E. The WIC Program does not consider residents of orphanages, state, federal, or local jails/prisons, or state residential hospitals as eligible to apply for certification. F. Applicants/Participants determined ineligible must be provided written notice of ineligibility (WIC- 54). Refer to Policy 705- Ineligibility and Discontinuation of Benefits.

Residence Requirements A participant must reside within the geographic boundaries of the state of Kentucky. Applicants shall apply for WIC in the county where they reside. If circumstances justify participation in another county, such as receiving health care or working in another county, receiving WIC in that county is appropriate. Proof of residency must not constitute a barrier to participation. A. Proof of residency must be provided at initial certification, recertification, and at the time of transfer into a new agency/site. 1. For an infant or child, proof of residency is for the person with whom the infant/child resides. B. Proof of residency must be current and may be provided in paper form or electronically. C. Length of residency is not a factor for eligibility. D. Residence is the location or street address where a participant routinely lives or spends the night. Situations determining residence:

Page 2 Required Proofs – Residence, Identity and Income Policy 203 December 2024

1. Migrants are considered residents of the agency/site service area in which they apply for WIC benefits. 2. Homeless persons are considered residents of the facility where they reside or of the area where they seek benefits. 3. Military personnel’s temporary duty station is their residence for WIC purposes. E. A post office box is not acceptable as proof of residence. 1. The exception to using a post office box is when it is on the eligibility documentation for Medicaid, KTAP, or SNAP since residence has already been verified in these cases. In other situations, when a post office box is the only proof, residence may be established using an area map or by recording directions to the residence. F. A Verification of Certification (VOC) is not proof of residence. G. Applicants who do not meet the residence qualifications at a certification appointment are ineligible for the Kentucky WIC Program and must be provided written notice (WIC-54). Refer to Policy 705- Ineligibility and Discontinuation of Benefits. H. The type of proof presented must be documented in the applicant/participant’s medical record. 1. Documentation is done by selecting the applicable type of residency proof in the system. Any type of proof not listed is reported as “Other.” When “Other” is selected, the actual type of proof seen by the interviewer must be documented in the applicant/participant’s medical record. 2. The system prints the proof code on the registration label. The registration label is placed on the CH-5 or CH-5 WIC in the applicant/participant’s medical record. 3. If printing problems prevent the codes from appearing on the label, the codes must be handwritten on the label and include staff initials and date. 4. If system access is unavailable, the CH-5B must be completed with appropriate proof codes. Refer to Patient Services Reporting System (PSRS), “Patient Registration.” I. Examples of acceptable proof of residence are:

Type of Proof - Residence Verification of current Medicaid eligibility SNAP “General Notice of Action” letter Driver’s License (if current address listed) School ID or school record Hospital record or birth record (if the address is listed) Voter Registration card Current mail or bill Photo ID (if the address is listed) Property Tax bill or receipt Current Rent/Mortgage/Lease/Receipt Current paycheck or stub (if the address is listed) Tax Return or W-2 form Unemployment Letter (if the address listed) Social Security earnings (if the address listed) Leave and Earnings Statement/Military (if the address listed) Adjunct Eligibility (based on household member - if the address listed)

J. Staff recognition (knowledge of where the applicant lives) is not acceptable proof of residence at initial certification. Staff recognition at recertification is allowed once initial proof of residency has been presented and documented and there has been no change. Note: A reference card with acceptable types of residence proof is available (Proof of Residence, Identity, and Income Card, WIC-PC (blue card)). Refer to Section 200 Certification Appendices.

Page 3 Required Proofs – Residence, Identity and Income Policy 203 December 2024

Identification Requirements All participants must provide proof of identity at initial certification, recertification, and when transferring into a new agency/site. Proof of identity must not constitute a barrier to participation. A. The name of the person whose identity is being established must be on the proof presented. B. A Verification of Certification (VOC) is not proof of identity. C. The type of proof presented must be documented in the applicant/participant’s medical record. 1. Documentation is done by selecting the applicable type of identification proof in the system. Any type of proof not listed is reported as “Other”. When “Other” is selected the actual type of proof seen by the interviewer must be documented in the applicant/participant’s medical record. 2. If printing problems prevent the codes from appearing on the label, the codes must be handwritten on the label and include staff initials and date. 3. If system access is unavailable, the CH-5B must be completed with appropriate proof codes. Refer to Patient Services Reporting System (PSRS), “Patient Registration.” D. Proof of the identity of the person picking up food benefits must be presented at benefit issuance. For child or infant participants, this means checking the identity of the parent, legal representative, caretaker, or proxy, picking up food benefits. For women participants using proxies, this means checking the identification of the proxies. 1. To document proof of identity at issuance, complete the “ID for FI PU” field in the system (by choosing the appropriate Proof Code in the drop down for food benefit pick up/issuance). 2. The system prints the proof code on the issuance label, which is placed on the CH-5 or CH-5 WIC in the applicant/participant’s medical record. E. Examples of acceptable proof of identity are:

Type of Proof - Identity Verification of current Medicaid eligibility SNAP “General Notice of Action” letter Driver’s License (for adult)* School ID or school record Immunization Record Birth Certificate Hospital record (birth record/crib card/hospital band) Voter Registration card Current mail or bill Photo ID Employee ID Military ID Leave and Earnings Statement/Military (if name listed) Current passport or immigration records Health benefits card (if the name listed) Social Security card Property Tax bill or receipt (if the name listed) Current Rent/Mortgage/Lease/Receipt (if name listed) Current paycheck or stub (if the name listed) Tax Return or W-2 form (if name listed) Unemployment Letter (if the name listed) Social Security earnings (if the name listed) Marriage license Baptismal certificate *Driver’s license is for the identity of the person whose name is on it. It is NOT acceptable as proof of identity of an infant or child.

Page 4 Required Proofs – Residence, Identity and Income Policy 203 December 2024 F. Staff recognition (knowledge of who the person is) is not acceptable proof of identity at initial certification. Staff recognition at recertification is allowed once initial proof of identity has been presented and documented. G. For recertification and food benefit issuance only, the following items may be used for proof of identity if proof has been provided and established at the initial WIC certification and there has been no change. 1. Staff recognition (knowledge of who the participant is) 2. eWIC Cardholder 3. Medical Record Note: A reference card with acceptable types of proof is available (Proof of Residence, Identity, Income Card, WIC-PC (blue card)). Refer to Section 200 Certification Appendices. Income Requirements All participants must provide proof of household income at initial certification and each recertification. Proof of income must not constitute a barrier to participation. A. A participant can meet income eligibility requirements by: 1. Adjunct eligibility, which is income eligibility based on documented eligibility for certain programs. These individuals are excluded from providing proof of income but must show proof of adjunct eligibility. Adjunct eligibility must be determined before income screening. 2. Income screening. Participants who are not adjunctively income eligible must have their income eligibility determined using the Federal Income Eligibility Guidelines (IEG) based on the size of the economic unit. (See Income Eligibility Guidelines chart in Policy 206- Determining Household Income). Exceptions to income screening are: a. Transfer Participant/VOC - A transfer is not screened for income eligibility nor required to show proof of income until the certification period expires and he/she is screened for eligibility again. Refer to Policy 204- Transfer/VOC. b. Migrant - Income eligibility shall be determined for a migrant once every twelve (12) months. A VOC will provide income eligibility for up to one (1) year for a migrant. If the timeframe of the migrant’s income determination is unknown, income eligibility must be done at certification. Note: Migrants must be assessed for nutritional risk at every certification regardless of income eligibility. c. Hospital Certification - Mothers and newborn infants certified at the hospital are not required to show proof of income at the time of certification. Accept self- reported income and, if eligible, certify and issue food benefits for thirty (30) days. Proof of adjunct eligibility or household income must be provided within thirty (30) days. Refer to Policy 214- Hospital Certification B. Income information shall be provided by the participant or parent/caretaker of the participant. C. Income eligibility or ineligibility and the type of proof presented must be documented. 1. Documentation is done by selecting the applicable type of income proof in the system. Any type of proof not listed is reported as “Other”.” When “Other” is selected the actual type of proof seen by the interviewer must be documented in the applicant/participant’s medical record. 2. If printing problems prevent the codes from appearing on the label, the codes must be handwritten on the label and include staff initials and date. 3. If system access is unavailable, the CH-5B must be completed with appropriate proof codes.

Page 5 Required Proofs – Residence, Identity and Income Policy 203 December 2024

D. Examples of acceptable proof of income are:

Type of Proof - Income Current paycheck/stub with amount and the pay timeframe (weekly, bi-weekly, monthly, etc.) Electronic paycheck/stub. (If the agency determines information stated on the electronic paycheck/paystub is incorrect or missing critical information, it is appropriate to request further information.) Signed statement from employer indicating gross earnings for a specified pay period W-2 forms or income tax return for most recent calendar year. Additional documentation or written statements of income may be requested to update this to current income. W-2 forms and income tax returns are only applicable for self-employed individuals such as both farm and non-farm self-employed persons. Unemployment letter/notice Recent Leave and Earnings Statement (LES) for military personnel Check stub/award letter from Social Security stating current amount of earnings Foster child placement letter/foster parent award letter Tax forms or accounting records for self-employed Court decree or copies of checks for alimony or child support Letter from person(s) contributing resources

Note: A reference card with acceptable types of proof is available (Proof of Residence, Identity, and Income Card, WIC-PC (blue card)). Refer to Section 200 Certification Appendices.

E. Income eligibility must be determined before nutritional risk. F. Participants whose household income is at or below 185% of the federal poverty income guidelines issued annually by the Department of Health and Human Services are eligible for WIC services. Income guidelines are effective from April 1 to March 30 (unless otherwise noted) each year. Refer to Income Eligibility Guidelines chart. The system is programmed to perform the following conversion factor procedures: 1. If a household only has one income source, or if all sources have the same frequency, the system is programmed to compare the income, or the sum of the separate incomes, to the published IEGs (Income Eligibility Guidelines) for the appropriate frequency and household size to make the WIC income eligibility determination. 2. If a household reports income sources at more than one frequency, the system has been programmed to perform the following calculations: a. Annualize all income by multiplying weekly income by 52, income received every two weeks by 26, income received twice a month by 24, and income received monthly by 12. b. Add together all the unrounded, converted values. c. Compare the total to the published IEGs (annual income for the appropriate household size) to make the final income eligibility determination. d. Modifications have been made to the fourth income label to assist agencies in determining if a WIC participant meets eligibility requirements. G. Applicants/participants determined ineligible due to income must be provided written notice of the ineligibility (WIC-54), the reason for ineligibility, and the right to a fair hearing. H. If household income has been documented, proof of income presented, and the type of proof documented for the household within the last thirty (30) days and there is no change in household size or income, this information can be used for other household members being certified for WIC within that thirty (30) day period. All eligibility and documentation requirements for WIC must be met for the new participant. I. Income eligibility is applicable for the certification period. Local WIC agencies are not required to reassess eligibility during a certification period, and participants are not required to report income or household changes during the certification period. However, if new income or household information is obtained, WIC eligibility must be reassessed for all household members who have more than 90 days remaining in their certification period. When the time remaining in the

Page 6 Required Proofs – Residence, Identity and Income Policy 203 December 2024

certification period is 90 days or less, reassessment is not required since this is insufficient time to effect change. Refer to Policy 206- Determining Household Size and Household Income, New Income Information. J. Verification of the proof of income is not required. Verification is validation of proof presented, such as pay stubs or numbers in the household, through an external source other than the participant. Such external sources include employer verification of salary, local welfare office verification, etc. Information shall be verified if agency personnel have reasonable cause to believe that accurate information was not provided. If verification is requested, the reason shall be documented in the applicant/participant’s medical record. Verification shall be obtained in writing. If verification does not support WIC eligibility, WIC services shall be terminated for all household members affected. A payback of benefits will be requested if it is determined to be cost-efficient.

Page 1 Verification of Certification Policy 204 December 2024

Policy 204 Verification of Certification (VOC) POLICY Through the Verification of Certification (VOC) process, the transferring site issues a VOC so the receiving site can enroll the participant and issue food benefits without screening for income or nutrition risk.

PURPOSE Local WIC agencies shall follow proper transfer procedures to ensure that WIC participants that move into or out of Kentucky, instate, or overseas have seamless and continued participation through the entirety of their certification period.

RELEVANT REGULATIONS 7 CFR 246.7 – Certification of participants, (k) Transfer of certification 7 CFR 246.7 (j)(4) – Notification of participant rights and responsibilities DEFINITIONS Migrant/Migrant Farm Worker: an individual whose principal employment is in agriculture on a seasonal basis, who has been so employed within the last 24 months, and who establishes, for the purposes of such employment, a temporary abode.

PROCEDURES General Policies A. Notification of the Right to Transfer 1. Describe VOC availability, process, and purpose. Refer to Kentucky eWIC Benefits Pamphlet, eWIC-1 (Rights and Responsibilities). 2. Post signage (WIC Moving poster) reminding participants to ask for a VOC if they will be moving. B. VOC Issuance 1. A VOC must be issued to any participant with remaining eligibility in the certification period who plans to transfer in-state, out-of-state, or overseas. 2. The transferring site issues a VOC so that the receiving site can enroll the participant without screening for income or nutritional risk, allowing for a seamless transfer for the participant for their current certification period. 3. A VOC shall be issued for each household member. 4. Food benefits must be issued until the end of the certification expiration date on the VOC or the end of the food benefit cycle to prevent a lapse in benefits and to reduce visits to the clinic. If Kentucky certification policy allows for a longer certification period, the person must receive benefits according to Kentucky policy. 5. The VOC shall be produced by the system unless the system is unavailable, in which case a WIC-17 Handwritten VOC is available. Refer to Section 200 Certification Appendices, Verification of Certification (VOC) (WIC-17). 6. A VOC (WIC-17) is to be issued at certification to any person identified as a migrant farm worker. C. Validity 1. A valid VOC must contain the three following items: a. Participant’s name b. Certification date c. Certification ending date

Page 2 Verification of Certification Policy 204 December 2024

2. A person with a valid VOC from another state or overseas cannot be denied participation because the person does not meet Kentucky nutritional risk criteria and the length of the certification period may be different. 3. If a VOC is determined invalid, the transferring site may be contacted for necessary information. If information cannot be obtained, the person must be screened as a new participant at the receiving site. a. If you have difficulty reaching a transferring site, please refer to the FNS website https://www.fns.usda.gov/wic/wic-contacts which identifies each State’s point of contact for VOC information. D. Receiving a VOC 1. If the VOC is valid and caseload slots are available, the site must immediately add the participant. If slots are not available, the person must be placed on the waiting list ahead of all state approved waiting list individuals. Refer to Policy 706- Waiting List. 2. A VOC represents proof of income and nutritional risk only. Participants must show proof of residency and identity. Proof of identity is also required for the person picking up food instruments on behalf of the transferring participant. 3. The following are included in VOC registration: a. The CH-5 or CH-5 WIC should be signed and dated including registration labels. b. The system VOC label should be printed and placed in the medical record. c. The Proxy form should be completed. d. WIC participants that are age 18 or over must be offered a voter registration form. 4. An in-state transfer/VOC participant with valid food benefits from the transferring site shall use those food benefits as long as they are still appropriate. a. Transferring participants must surrender to the receiving WIC agency any unused food instruments or Electronic Benefit Transfer (EBT) card from the sending agency, in their possession. b. It is unacceptable to void valid food benefits issued by the transferring site and reissue the same food package at the receiving site. 5. Terminated participants may still be transferred. If terminated within their certification period, they must be reinstated. If their certification period has expired, they may still be transferred but will need to be recertified for continued eligibility in the program. 6. If a migrant farm worker’s certification period has expired on his/her VOC, the VOC may still serve as income documentation if the VOC shows that an income determination was done within the last twelve (12) months. 7. Support staff can perform all procedures and actions for a Transfer/VOC without needing to see a health professional. a. Contact with a health professional is only required if a food package change is needed, a formula prescription is needed, or an out-of-state food package does not convert to a Kentucky food package. b. A new prescription is not required for exempt infant formula or WIC Nutritional when the food package expiration date has not expired at the time of service. However, the agency must contact the transferring agency to obtain a copy of the valid script. i. If the agency is unable to obtain a copy of the valid prescription, one month of the current exempt infant formula/WIC Nutritional may be issued while the agency works to obtain a copy of the prescriptions and/or the family establishes healthcare in the new community and obtains a new prescription. c. Participants on noncontract formula must see a health professional to assess their current need for the formula and follow the formula challenge protocol. Refer to Policy 601. The transferring agency should request a copy of the prescription.

Page 3 Verification of Certification Policy 204 December 2024

i. If unable to obtain a copy, one month of the current formula may be issued while the agency works to obtain a copy of the prescriptions and/or the family establishes healthcare in the new community and obtains a new prescription, if appropriate. E. Enrolling a participant without a VOC 1. In-state a. Conduct “VOC Search” in the system. b. Request proof of residence and identity. If proof cannot be provided, refer to Policy 207- Required Proofs Not Present. c. After a VOC search is completed, and the participant information cannot be obtained, contact the previous site, and inform them the person is seeking WIC at your site. Request and document the information listed below: i. Date of Certification ii. Recertification or next action due iii. First full package issue month/date iv. Food package code v. Prescription expiration date if applicable vi. Valid dates of the last food benefit issued 2. Out of State a. Conduct “VOC Search” in the system. b. Request proof of residence and identity. If proof cannot be provided, refer to Policy 207- Required Proofs Not Present. c. Contact the previous site and inform them the person is seeking WIC at your site. Document information obtained. If information cannot be obtained or the certification has expired, screen the applicant as a new participant.

*For step-by-step instructions on how to process an in-state or out of state VOC, please reference the CMS User Manual at: https://chfs.ky.gov/agencies/dph/dafm/lhob/Pages/cmsdocs.aspx

Page 1 Adjunct Eligibility Policy 205 December 2024

Policy 205 Adjunct Eligibility POLICY Automatic income eligibility is granted for any participant who has current eligibility for specific programs or, in certain situations, a household member’s documented eligibility. Adjunct eligibility must be determined before income screening.

PURPOSE To extend income eligibility for WIC services to individuals who already participate in other programs with a similar income standard. This reduces barriers for eligible/current participants and Local Agency staff.

RELEVANT REGULATIONS 7CFR 246.7 (d)(vi) Adjunct or automatic income eligibility PROCEDURES Adjunct eligibility is income eligibility for the WIC Program based on an individual’s documented current eligibility for specific programs or, in some situations, a household member’s documented eligibility. Current eligibility means eligibility in one of the specified programs on the date the WIC certification or recertification is performed. Qualifying based on a household member’s eligibility is identified as “WIC Household” (WH) eligibility. A. A participant with current eligibility in one of the following programs is adjunct income eligible: 1. Medicaid, including Medicaid Presumptive Eligibility (MPE), Medicaid Breast and Cervical Cancer Treatment Program (MBCCTP), Medicaid that is issued under the Affordable Care Act (ACA), Kentucky Children’s Health Insurance Program (KCHIP) Phase I, and KCHIP Phase II 2. Supplemental Nutrition Assistance Program (SNAP) 3. Kentucky Transitional Assistance Program (KTAP) B. If a WIC household member’s eligibility is being used for the participant, proof/verification of current eligibility for the household member must be seen or obtained. C. The following situations qualify as WIC Household (WH) eligibility: (see also chart below) 1. A newborn deemed eligible under his/her mother’s Medicaid eligibility (an infant born to a woman on Medicaid at delivery is automatically eligible for Medicaid). 2. Member of a household which includes a pregnant woman that is currently eligible for Medicaid, including Medicaid Presumptive Eligibility and Medicaid Breast and Cervical Cancer Treatment Program. 3. Member of a household which includes an infant that is currently eligible for Medicaid. 4. Member of a household that includes anyone that is currently eligible for KTAP.

Medicaid SNAP KTAP Pregnant Woman Self and household members Self if name is on letter Self and household members BF/PP Woman Self only Self if name is on letter Self and household members Infant Self and household members Self if name is on letter Self and household members Child Self only Self if name is on letter Self and household members

D. When adjunct eligible, the participant: 1. Must be status eligible and meet the residency and nutritional risk criteria to qualify for WIC.

Page 2 Adjunct Eligibility Policy 205 December 2024

2. Is not screened for income eligibility; however, self-reported household income is documented. 3. Must not be denied WIC eligibility based on self-reported household size or income. E. For applicants presenting as Medicaid eligible, current Medicaid eligibility must be verified and the type of coverage must be determined. For WIC adjunct eligibility, verification must be obtained through the KYHealth-Net System, the Voice Response system (800 number), or the local Department for Community Based Services (DCBS) office. F. Individuals enrolled in a participating Managed Care Organization (MCO) provider are not automatically income eligible for WIC. It must be determined first if the individual is eligible for Medicaid by verifying eligibility through the KYHealth-Net system, the Voice Response system (800 number), or the local Department for Community Based Services (DCBS) office. G. Applicants eligible for KCHIP Phase III are not adjunct income eligible. It must be determined if the individual is income eligible for WIC. Important: Individuals that have KCHIP III are identified in the KYHealth-Net system with an assigned status code of P7. These individuals must be screened for household size and household income. H. Applicants that qualify based on WIC Household (WH) eligibility, Medicaid Presumptive Eligibility, or Medicaid Breast and Cervical Cancer Treatment Program must present proof of residence and identity. I. Examples of acceptable proof for adjunct eligibility are below. Proof must show eligibility on the date of the certification. 1. Verification of current Medicaid eligibility* for the participant. 2. Verification of current Medicaid eligibility* for the pregnant woman or infant that the participant lives with. 3. Verification of Medicaid eligibility* for the newborn’s mother at the time of delivery. * For WIC adjunct eligibility, verification of current Medicaid eligibility must be obtained through the KYHealth-Net system, the Voice Response system, or the local DCBS office. 4. Identification Sheet for Medicaid Presumptive Eligibility or Medicaid Breast and Cervical Cancer Treatment Program, Medicaid Eligibility Verification. 5. Verification of current Medicaid Presumptive Eligibility by the health care provider that determined it. 6. A letter confirming KTAP eligibility or a KTAP check stub for the participant or a household member. 7. General Notice of Action letter with the participant’s name as an active member. NOTE: The SNAP EBT card cannot be used as proof of eligibility. 8. Verification of current MBCCTP eligibility by the health department staff that determined it. J. The type of proof must be documented in the participant’s medical record. 1. Documentation is done by selecting the appropriate type of proof on the Income/Proofs Screen and then placing the printed registration label on the CH-5/CH-5WIC in the medical record. If eligibility is based on another household member, proof of adjunct eligibility for this member must be seen and the type of proof presented, then selected from the adjunct eligibility proof drop down on the Income/Proofs Screen. 2. If printing problems prevent the codes from appearing on the label, the codes must be handwritten on the label and include staff initials and date. 3. If an agency is using an electronic medical record, the completed CH-5 with the registration labels and signatures must be uploaded into the medical record. 4. If system access is unavailable, the CH-5B must be completed with appropriate proof codes.

Page 3 Adjunct Eligibility Policy 205 December 2024

Documenting Self-Reported Income with Adjunctive Eligible WIC Participants in Portal As a reminder, income must be documented for those who are adjunctively eligible. This is for federal reporting purposes and not used for income assessment for the WIC Program. For Adjunct Eligible Applicants: • Self-reported income is to be entered on the Household Member Screen and the date on the Registration Screen. o Note once entered on Household Member Screen, you will only have to enter the date on the Registration Screen, not the income amount. • Self-reported income is not entered on the “Save & Income/Proofs” screen in Portal. • See below for screen shots of the Household Member Screen and Registration Screen for the estimated household income documentation for Adjunct Eligible Participants. (See yellow boxes)

1. Household Member Screen • Enter self-reported (can be estimated) annual income, number in household and visit date on the Household Member Screen.

2. Registration Screen • Go to the Registration Screen for the Member Screen • Enter the date in the Income Assessed Date field (this is the day that the certification/recertification is done) and is listed under the box. • Leave the Annual Income field blank and it will auto-populate after saving, as long as the date is entered for Income assessed Date.

Page 4 Adjunct Eligibility Policy 205 December 2024

Participant Did Not Bring Proof of Adjunct Eligibility Verification of current eligibility through KYHealth-Net, Voice Response, the DCBS Office is acceptable as proof. Verification by the health department staff that determined MBCCTP eligibility is acceptable proof. A. If eligibility cannot be verified for the participant who has proof but fails to bring it to the WIC certification/recertification, inform the participant of the requirement for proof and make a new certification appointment within the timeframe for appointment scheduling. B. If the person has proof of household income with him/her, assess income for eligibility at this visit. Refer to Policy 206- Determining Household Size and Household Income.

Hospital Certification If WIC certification is performed in the hospital, refer to Policy 214- Hospital Certification.

Page 1 Determining Household Size and Household Income Policy 206 December 2024

Policy 206 Determining Household Size and Household Income POLICY Local WIC agencies will appropriately include or exclude sources of income when determining whether applicants/participants meet the federally defined income eligibility standard. Household size must be assessed and documented. Proof of household income eligibility must be provided and documented.

PURPOSE To comply with the federal WIC income eligibility guidance.

RELEVANT REGULATIONS 7CFR 246.7 (d)(2)(ii) – Definition of income 7CFR 246.7 (d)(2)(iv) – Income exclusions FNS Instruction 803-3, Rev. 1 – Certification: Income Eligibility USDA MEMO 803-L – Lump Sum Payments as Income (7/13/92)

PROCEDURES Household size and household income are required for initial certification and at each recertification. Local WIC agency staff must identify and assess all sources of income for a household to determine which will be included or excluded from household income calculations. This information shall be determined in a confidential manner at no cost to the participant. A. Household size and household income must be documented for each individual and is valid for the length of the certification period. However, if new income or household information is obtained, WIC eligibility must be reassessed. 1. Documentation is done by completing registration information in the Management Information System (MIS), printing registration/income labels, and completing the applicable Registration, Authorizations, Certifications, and Consents form (CH-5 or CH- 5WIC). If the automated system is unavailable, the Patient Registration and Income Determination form (CH-5B) must be completed and filed in the medical record, and data subsequently entered into the system. B. Current household income (income received by the household during the month {30 days} prior to the date of the application) or the household income during the past twelve (12) months may be considered to determine which more accurately reflects the status. 1. If Income assessment is being done prospectively (i.e. the sole support of that family has just been laid off but has been authorized to receive unemployment benefits for the next six months), “current” refers to income that will be available to the family in the next 30 days. C. The WIC Income Eligibility Guidelines are calculated based on the individual’s pay frequency. The system is programmed to compare the weekly, bimonthly, semi-monthly, or monthly income to the WIC Income Eligibility Guidelines. D. Income for household member(s)who are unemployed shall be the income during the period of unemployment. E. Household member(s)who are on requested leave (i.e., maternity leave or a teacher not being paid during the summer) are not considered unemployed. Therefore, the earned income during the regular employment period must be averaged to determine annual income. F. Household income does not have to be reassessed at mid-certification health assessment (MCHA) visits.

Determining Household Size A household is defined as a group of related or non-related individual(s) who are living together as one economic unit. The terms “economic unit” and “household” are sometimes used interchangeably. A. Household members share economic resources and consumption of goods and/or services.

Page 2 Determining Household Size and Household Income Policy 206 December 2024

B. It is reasonable that persons living in the residence of others, whether related or not, are likely to be receiving support and some co-mingling of resources. This would make them members of the economic unit in which they live. However, a household may consist of more than one economic unit. (see Separate Economic Unit below) 1. Appropriate questioning must be done to make a reasonable determination of whether resources are shared or not. C. Residents of a facility, such as a homeless facility or an institution, shall not all be considered members of one single household or economic unit. D. To determine the size of the household, consider the following guidance: (Refer KY WIC Guidance for Determining Household Size reference chart in this section)

Separate Economic Unit: A person or group of persons living in the same house with other individuals may be a separate economic unit. To be considered a separate household, the individual must have their own source of income and cover their own expenses, such as rent, food, and utilities. Questions to Ask: • Do you share income and expenses with other people? If yes, count all members as one household. • Does the household provide you with food, clothing, shelter, etc., with no expectation of payment or in-kind benefits? If yes, count all members as one household. • Do you pay the household for living in their home or exchange household chores for living expenses? If yes, the participant is a separate household. Pregnant Woman: A pregnant woman’s household is increased by one for each unborn child. If she is expecting one child, count her as two; if she is expecting twins, count her as three; and so on. The increased household size shall be used for other household members applying for services when determining their household size.

Note: If the participant has a cultural or religious objection to counting the unborn child/children, this shall not be done. The objection shall be documented in the patient's medical record since it affects household size and income determination.

Unmarried Couple: An unmarried couple living together as one household counts the income of both parties and counts both in the household size. Income for all persons supporting the household must be counted.

Child: A child is counted in the household size of the parent, guardian, or caretaker with whom he/she lives. Foster Child: A foster child is considered a separate household of ONE as long as he/she is the legal responsibility of the Commonwealth, social service, or other agency. Therefore, a separate household must be established for a foster child. Foster children less than 18 years of age are eligible for Medicaid and the Department for Community Based Services applies for Medicaid on behalf of the child. Medicaid eligibility for a foster child cannot be used to establish WIC eligibility of other members living in the same household where the foster child lives.

Page 3 Determining Household Size and Household Income Policy 206 December 2024

Question to Ask: • Is the child the legal responsibility of the Commonwealth or social service agency? If yes, the participant is a household of one.

Joint Custody: In joint custody, or cases where the child may live with both parents equally, the child is counted in the household of the parent or guardian who is seeking services for the child or the custodial parent named in the custody agreement. The child may NOT be counted in the household of the other parent. It is the responsibility of the two parents to mutually agree on sharing the child’s WIC food benefits.

Child Residing with Caretaker: A child in the care of a friend or relative is considered a part of the household of the caretaker with whom he/she is residing. All persons with income supporting the household are considered, including any monetary support provided from the parent(s).

Adopted Child: An adopted child or a child for whom a family has accepted the legal responsibility is counted in the household size with whom he/she resides. Student: A child residing in a school or institution, who is being supported by the parent/caretaker, is counted in the household size of the parent/caretaker.

Non-Citizen/Foreign Individual: It is legal for a non-citizen/foreign individual and his/her family to apply for services. He/she/they are members of the household in which he/she/they reside.

Military: Military personnel serving overseas or assigned to a military base, even though they are not living with their families, are counted as members of the household, along with the military personnel’s gross income.

Military Family in Temporary Residence of Friends/Relatives:

When military personnel are deployed or assigned to a military base and temporarily absent from home, their family (children of deployed parents, children and one parent, or spouse) may temporarily move in with friends or relatives. In this situation, flexibility is allowed to ensure minimal impact on military family member’s eligibility and/or receipt of services. The “military family” household size is determined through the following options: • Count the “military family” as it was prior to the deployment/assignment of the military person(s) as a separate economic unit. This option counts the deployed person(s) and gross income. Use of this option is dependent on whether the total gross income for this economic unit can be reasonably determined. • Count the “military family” as it is now as a separate economic unit without the deployed person(s). This option does not count the deployed person(s). To

Page 4 Determining Household Size and Household Income Policy 206 December 2024

consider as a separate economic unit, the unit must have its own source of income, e.g., allotment to the spouse and/or children. • Count the “military family” as part of the household of the person(s) with whom they reside. All persons and all income for this household are counted. Homeless: Individuals whose primary residence is a shelter providing temporary living accommodations or who lack a fixed and regular nighttime residences are considered homeless and are considered a separate household. Questions to Ask: • Do you lack a fixed and regular nighttime residence? If yes, count as a separate household. • Is your primary nighttime residence a shelter for temporary living accommodations? If yes, count as a separate household.

Determining Household Income Sources Adjunct eligibility must be determined before income screening. For a participant who is not adjunct eligible, the number in the household and the total household income must be determined and compared to the income eligibility guidelines. Household income is defined as total gross income of all members in the economic unit including any amount received or withdrawn from any source, including savings. Gross income is defined as all income before deductions are made for income taxes, employee social security taxes, insurance premiums, garnishments, etc. A. Local WIC agency staff must assess all sources of income for a household to determine which will be included or excluded from household income calculations. B. The determination of the amount of a household’s gross income shall not be reduced for hardships, high medical bills, childcare payments, taxes, child support, alimony, insurance, or other deductions. C. Local WIC agency staff shall use net income to determine income eligibility for farmers and self- employed persons only. Net income is determined by subtracting the operating expenses from the gross income. D. Income earned or received by all members of the household includes: 1. Gross Income a. Monetary compensation for services, including wages, salary, commissions, fees, and overtime. b. Public assistance or welfare payments (KTAP, Supplemental Security Income [SSI], etc.). c. Pensions or retirement. d. Black lung or other disability payment. e. Social Security benefits. f. Government civilian employee or military retirement or pensions or veterans’ payments/benefits. g. Unemployment compensation or worker’s compensation. h. Alimony and child support payments. i. Payment from the military including food and clothing allowance. Do not include housing allowance. j. Regular contributions from person not living in the household. k. Dividends or interest on savings or bonds, income from estates, trusts, or investments. l. College or university scholarships, grants, fellowships, and assistance (except as excluded – see “E. 11. under Exceptions”). m. Strike benefits. n. Payments or winnings from gaming, gambling, lottery, and bingo.

Page 5 Determining Household Size and Household Income Policy 206 December 2024

o. Cash received or withdrawn from any source, including savings, investments, trusts. p. Lump sum payments: i. Lump sum payments that represent new money intended for income is counted as income. Examples include gifts, inheritance, lottery winnings, worker’s compensation for lost wages, severance pay, and insurance payments for “pain and suffering.” Lump sum payments for winnings and proceeds from gaming, gambling, and bingo are also counted as income. ii. Lump sum payments that represent reimbursement for lost assets or injuries shall not be counted as income. Examples include amounts received from insurance companies for loss or damage of personal property, such as home or auto; payments that are intended for a third party to pay for a specific expense incurred by a household, such as a payment of medical bills resulting from an accident or injury. iii. The lump sum payment may be counted as annual income or may be divided by 12 to estimate a monthly income, whichever is most applicable. 2. Net Income for self-employed and farm (determine net by subtracting operating expenses from the total amount made) only for: a. Net royalties. b. Net rental income. c. Net income from farm (money from tobacco, crops, etc.) or non-farm self- employment. E. Exceptions: The following are exceptions to income determination sources and shall NOT be considered as an income source. 1. Non-cash benefits, in-kind housing, and in-kind benefits such as employer paid, or union- paid portion of health insurance or other employee fringe benefits, food, or housing received in lieu of wages. 2. Capital gains, the sale of property, a house, or a car. 3. One-time payments from a state agency to a family or person who is in temporary financial difficulty. 4. Tax refunds. 5. Federal non-cash benefits programs: Medicare, Medicaid, National School Lunch Act, Child Nutrition Act of 1966, and Food Stamp Act of 1977 (SNAP). 6. Payments or allowances from the Home Energy Assistance Act of 1981. 7. Reimbursements from the Home Energy Assistance Act of 1981. 8. Payment to volunteers under Title I (VISTA and others) and Title II (RSVP foster grandparents and others) of the Domestic Volunteer Service Act. 9. Payment to volunteers of the Small Business Act (SCORE and ACE). 10. Payments received under the Job Training Partnership Act (JTPA). 11. Student loans and grants that are not counted as income: a. Pell Grant b. Supplemental Educational Opportunity Grant (SEOG) c. State Student Incentive Grants d. National Direct Student Loans e. Stafford Loans f. Perkins Loans g. PLUS h. Supplemental Loans for Students i. College Work Study j. Byrd Honor Scholarships 12. Cash or non-cash payments from a Child Care and Development Block Grant or other purchase of childcare subsidy 13. Earned Income Tax Credit (EITC) payment/refund. 14. Loans to which the participant does not have constant or unlimited access. 15. Family Subsistence Supplemental Allowance (FSSA). This is a payment made to certain members of the Armed Forces and their families by the Department of Defense.

Page 6 Determining Household Size and Household Income Policy 206 December 2024

16. For military personnel: a. Military Housing allowance (off base and on-base housing allowances). Such housing allowances include Basic Allowance for Housing (BAH), Family Separation Housing (FSH) and Overseas Housing Allowance (OHA). b. Overseas Continental United States cost of living allowance (OCONUS COLA) provided to military personnel in high cost of living areas outside the contiguous United States. Note: Veteran’s Educational Assistance Program or GI Bill is not an exclusion and MUST be included in income determination. c. Combat Pay: refer to Guidance for the Exclusion of Combat Pay from WIC Eligibility Determination in this section. 17. Restrictions apply to the use of the dollar value of WIC benefits provided to a participant. Any requests or any information concerning the value of WIC benefits shall have the following restrictions: a. The value of WIC benefits shall not be considered income or resources for any purpose under any Federal or State laws including, but not limited to, laws relating to taxation, welfare, and public assistance programs. b. Benefits from state and local sources for food programs shall not be reduced as a result of WIC benefits. c. Sponsors of qualified aliens (sponsors have signed an affidavit of support) are not required to reimburse the state or federal government for WIC Program benefits provided to sponsored aliens.

What Military Pay or Allowance to Include in Income Determination What Military Pay or Allowance to Exclude in Income Determination  Base pay – the soldier’s regular rate of pay  Basic Allowance for Subsistence (BAS)  Foreign Language Proficiency Pay (FLPP) *  Family Separation Allowance (FSA) *  Jump Pay, Drive Pay, Sea Pay, Flight Pay, etc. (unless the service member is deployed to a combat zone)  Clothing Maintenance Allowance (CMA) – can be averaged for the year.  Bonus Pay (Bonus) – can be averaged for the year  Continental United States Cost of Living Allowance (CONUS COLA) *See below for exceptions X Basic Allowance for Housing (BAH or BAQ) X Family Separation Housing (FSH) X Overseas Housing Allowance (OHA) X Overseas Continent United States Cost of Living Allowance (OCONUS COLA) X Combat pay as a result of the service member being deployed to a declared combat zone. (Maybe Hostile Fire Pay/Imminent Danger Pay or Hazardous Duty Pay (HZD Pay)) X Combat-Related Injury Rehabilitation Pay (CIP) X Special Duty Assignment Pay (SDAP) *

*Family Separation Allowance (FSA) is excluded if the service member is end route to a training location prior to deployment to a designated combat zone or on deployment orders to designated combat zone. * Foreign Language Proficiency Pay (FLPP) and Special Duty Assignment Pay (SDAP) that was not received prior to the time of deployment to a designated combat zone shall be excluded from the WIC income eligibility determination. Follow the guidance below for payments made by the military. A. Any combat pay received directly by a participant employed by the military while serving in an area that has been designated as a combat zone is not counted as income when determining WIC eligibility. Combat pay is excluded if it is: 1. Received in addition to the service member’s basic pay; 2. Received as a result of the service member’s deployment to or service in an area that has been designated as a combat zone; and

Page 7 Determining Household Size and Household Income Policy 206 December 2024

3. Not received by the service member prior to his/her deployment to or service in the designated combat zone. B. For service members receiving a one-time bonus or clothing allowances, consider income averaging for the year. Example of military housing: The army pays an individual $1,950 a month. This check includes $450 per month for housing because she lives off-base. This $450 appears in her paycheck each month and is listed on the LES as BAH. The income used in determining the individual’s WIC eligibility is $1,500 ($1,950 less $450 housing allowance). Refer to Attachment A in this section: Sample Marine Corps Leave and Earnings Statement, with explanatory notes and Appendix B in this section: Sample Army, Air Force, Coast Guard, and Navy Leave and Earnings Statement, with explanatory notes

Computing Household Income Current income is defined as all income received by the household during a month (30 days) prior to the date of the application. A. Consider the current household income or the household income during the past 12 months to determine which indicator more accurately reflects the status. If assessing annual income, exceptions are: 1. Unemployed persons (including laid-off workers), use income that will be available to the household member in the next 30 days. 2. Self-employed or seasonally employed person whose household income fluctuates through the year, use annual. 3. Person on temporary leave (maternity, family leave, extended vacation), use annual. (This is not considered unemployed.) 4. Teacher paid on a ten (10) month basis, use annual. 5. Person on strike, use income that will be available to the household member in the next 30 days, including any strike benefits. 6. Individuals that receive frequent and consistent overtime pay, use annual. B. If a participant indicates that they are paid weekly, it would be reasonable to look at four paystubs from the past four weeks (30 days). The table below indicates the number of pay stubs recommended to review for each type of pay period.

Pay Period Number of Pay Stubs to Request/Review Monthly 1 Weekly 4 Bi-Weekly (twice a month) 2 Semi-Monthly (every 2 weeks) 2 C. Sources of income for the household may not be the same timeframe (weekly, monthly, etc.), so the income must be converted to common terms to determine total household income. 1. The system is programmed to convert income to common terms to determine the total household income. 2. If system access is not available, the CH-5B must be completed. a. Calculate total income (see table for manual calculations).

Frequency To Obtain Monthly Income To Obtain Annual Income Weekly Multiply by 4.3 Multiply by 52 Different amount every week Add the 4 checks, divide by 4 (weekly average) multiply by 4.3 Add the 4 checks, divide by 4 (weekly average), multiply by 52 Bi-Weekly (every 2 weeks) Multiply by 2.15 Multiply by 26 Semi-Monthly (2 times a month) Multiply by 2 Multiply by 24 Monthly Multiply by 12 Quarterly Divide by 3 Multiply by 4

Page 8 Determining Household Size and Household Income Policy 206 December 2024

Annual Divide by 12 Hourly Rate paid multiply by hours per week, multiply by 4.3 Rate paid multiply by hours per week, multiply by 52 Daily Rate paid multiply by number of workdays per week, multiply by 4.3 Rate paid multiply by number of workdays per week, multiply by 52 Lump Sums Divide by 12

b. When all sources of household income have been converted to common terms, compare the total to the published Income Eligibility Guidelines (IEG) (annual income for the appropriate household size to make the final income eligibility determination). c. If a household has only one income source, or if all sources have the same frequency (i.e. all household members are paid weekly) do not use the conversion factors in the above table. Compare the income, or the sum of the separate incomes to the published IEG for the appropriate frequency and household size to make the WIC income eligibility determination. 3. If the income assessment is being done prospectively (e.g. a household member has been laid off but has been authorized to receive unemployment benefits for the next six months), “current” refers to income that will be available to the household member in the next 30 days. Note: If the participant is determined to be over income eligibility guidelines it is reasonable to request another staff member to assess eligibility for confirmation or contact the State WIC Office for assistance. Participant Reporting Zero Household Income (refer to Policy 207- Unable to Bring Proofs) Individuals declaring zero income shall be thoroughly interviewed regarding their living situation and how they obtain basic living necessities such as food, shelter, medical care, and clothing. Persons living together and sharing resources are members of one economic unit. A. When a participant reports income as zero a signed statement must be provided. B. The statement must include why written/electronic proof of income cannot be provided and an explanation of how living expenses are met. The Statement of No Proof (WIC-NP) is available for this purpose. Refer to Section 200 Certification Appendices. C. The statement is applicable only to the certification period for which it was provided. At recertification, if the person still has no proof of income, another statement must be obtained for this certification period. D. The statement must be filed in the patient’s medical record. E. When the interviewer is satisfied that the person’s income is zero, obtain the participant’s signature on the CH-5/CH-5-WIC/CH-5B as documentation that income has been reported accurately.

WIC Exceptions to Income Screening A. Transfer Participant/VOC-A transfer is not screened for income eligibility nor required to show proof of income until the certification period expires and he/she is again screened for eligibility. B. Migrant farmworker – Income eligibility shall be determined for a migrant once every twelve (12) months. A VOC will provide income eligibility for up to one (1) year for a migrant. If the timeframe of the migrant’s income determination is unknown, income eligibility must be done at certification. C. Hospital Certification – Mothers and newborn infants certified at the hospital are not required to show proof of income at the time of certification. Accept self-reported income and if eligible, certify and issue food instruments for thirty (30) days. Proof of adjunct eligibility or household income must be provided within thirty (30) days. Refer to Policy 214- Hospital Certification. D. Adjunctively Eligible – These persons are excluded from providing proof of income but must show proof of adjunct eligibility. Refer to Policy 205- Adjunct Eligibility.

Page 9 Determining Household Size and Household Income Policy 206 December 2024

Verification of Reported Household Income Verification of income is not required but local WIC agency staff may verify reported income if reasonable evidence is showing that the participant has given inaccurate or untrue information. If verification is requested, documentation of the reason for requesting verification must be made in the person’s medical record and verification shall be obtained in writing. A. Reasons for seeking verification may include but are not limited to: 1. Complaint made by another individual. 2. Contradictory information given by a participant. 3. Information WIC staff may have about the financial situation of the individual. B. The following are acceptable as verification: 1. Current pay stubs. 2. Statement from the employer or any responsible person who can verify income if the employer refuses to do so. 3. For self-employment income – ongoing records or tax returns. C. No person may be denied participation of services solely because the employer refuses to verify income. D. If the verification does not support WIC eligibility, WIC services shall be terminated for all household members affected. A payback of benefits will be requested if it is determined to be cost efficient. New Income Information A participant’s income eligibility must be reassessed during a current certification period if information is received that indicates that the participant’s household income has changed if there is more than 90 days remaining in the certification period from the date information is received. Reassessment is not required for a participant when 90-days or less remains in the certification period. A. Reassessment may result when: 1. Local WIC agency staff has reason to believe that income information or household size provided at the certification was not accurate or complete. 2. A household member is assessed for income and is over the guidelines. 3. Income is required for other health services. 4. A participant/caretaker reports a change in income or Medicaid status. B. When more than 90 days remains in a current certification period, reassessment is required. Procedures for reassessment are: 1. If the participant is no longer or not currently adjunct eligible (based upon his status or a household member’s status), eligibility must be assessed for household size and household income to remain on WIC. All income guidelines apply concerning current and annual income. 2. If income exceeds WIC eligibility criteria, the participant shall be terminated from WIC if more than 90 days remains in the certification period. Any other members of the household enrolled in WIC affected by new income information, shall be terminated if the time remaining in their certification period is more than 90-days. a. For example, a pregnant woman applying for WIC does not meet the income criteria; her child enrolled in WIC has 4 months remaining in the certification period and must be reassessed for income eligibility. If adjunct eligibility does not apply, the child must be terminated. 3. Termination must be appropriately documented in the medical record and include the reason for termination.

Page 10 Determining Household Size and Household Income Policy 206 December 2024

KY WIC Guidance for Determining Household Size Situation Question to Ask Household Size Separate Household/Economic Unit Does the household provide you with free food, clothing, or shelter, etc. with no expectation of payment or in- kind benefits? If YES – include in the household size, it is NOT a separate household. Do you pay the household for living in their home and have your own source of income to support yourself? If YES – separate household. Do you share income and expenses with other people you live with? If YES – count as one household. If NO – must have sufficient income to sustain a separate household. Foster Child Is the child the legal responsibility of the Commonwealth or social service agency? If YES – household of one If NO – include in household size Institutionalized/Student Household Member Do you pay financial support for the institutionalized person or student living away from home? If YES – include in household size If NO – do not include in household size Child Residing in Another Home Is there court-ordered custody? If YES – child is member of court- ordered household If NO – ask the next question Do you have court-ordered joint custody? If YES – the child is a member of only one household, the parent seeking services If NO – child is member of custodial parent’s household Any Individual Do you live with parents/others and are you supported by them? IF YES – include all in household Do you live with parents/others but are working, support yourself, and paying for room and board? If YES – it is separate household Do you live with parents/others and do chores in exchange for room and board? If YES - is a member of the household, must have income to sustain a separate household If NO – include in household Do you live apart from parents and work? If YES - it is a household, plus other contributors to the household If NO – see above Homeless Do you lack a fixed and regular nighttime residence? If YES – a separate household If NO – ask next question Is your primary nighttime residence: • A supervised public or privately operated shelter (including a state or congregate shelter) designed to provide temporary living accommodations? • An institution that provides a temporary residence for individuals intended to be institutionalized? If YES – count as separate household

Page 11 Determining Household Size and Household Income Policy 206 December 2024 Income Guidelines for the WIC Program 185% of Poverty Effective April 2024 Household Size 1 2 3 4 5 6 7 8 Weekly $536 $728 $919 $1,110 $1,302 $1,493 $1,685 $1,876 +$192 Bi-Weekly $1,072 $1,455 $1,838 $2,220 $2,603 $2,986 $3,369 $3,752 +$383 Twice- Monthly $1,161 $1,576 $1,991 $2,405 $2,820 $3,235 $3,650 $4,064 +$415 Monthly $2,322 $3,152 $3,981 $4,810 $5,640 $6,469 $7,299 $8,128 +$830 Annual $27,861 $37,814 $47,767 $57,720 $67,673 $77,626 $87,579 $97,532 +$9,953 Persons who receive Medicaid or SNAP Automatically meet the income requirements for the WIC Program.

Page 12 Determining Household Size and Household Income Policy 206 December 2024

Income Guidelines for the WIC Program 185% of Poverty Effective April 2024

Household Size

9 10 11 12 13 14 15 16 Weekly

$2,068 $2,259 $2,450 $2,642 $2,833 $3,025 $3,216 $3,407 +$192 Bi-Weekly

$4,135 $4,517 $4,900 $5,283 $5,666 $6,049 $6,431 $6,814 +$383 Twice- Monthly

$4,479 $4,894 $5,308 $5,723 $6,138 $6,553 $6,967 $7,382 +$415 Monthly

$8,958 $9,787 $10,616 $11,446 $12,275 $13,105 $13,934 $14,763 +$830 Annual

$107,485 $117,438 $127,391 $137,344 $147,297 $157,250 $167,203 $177,156 +$9,953 Persons who receive Medicaid or SNAP Automatically meet the income requirements for the WIC Program.

Page 13 Determining Household Size and Household Income Policy 206 December 2024

Pautas de ingresos para el programa WIC 185% de pobreza Vigente Abril del 2024 Número de personas en el hogar 1 2 3 4 5 6 7 8 Semanal $536 $728 $919 $1,110 $1,302 $1,493 $1,685 $1,876 +$192 Cada dos semanas $1,072 $1,455 $1,838 $2,220 $2,603 $2,986 $3,369 $3,752 +$383 Dos veces al mes $1,161 $1,576 $1,991 $2,405 $2,820 $3,235 $3,650 $4,064 +$415 Mensual $2,322 $3,152 $3,981 $4,810 $5,640 $6,469 $7,299 $8,128 +$830 Anual $27,861 $37,814 $47,767 $57,720 $67,673 $77,626 $87,579 $97,532 +$9,953 Las personas que reciben Medicaid o SNAP automáticamente cumplen con los requisitos de ingresos para el Programa WIC.

Page 14 Determining Household Size and Household Income Policy 206 December 2024

Pautas de ingresos para el programa WIC 185% de pobreza Vigente Abril del 2024 Número de personas en el hogar 9 10 11 12 13 14 15 16 Semanal $2,068 $2,259 $2,450 $2,642 $2,833 $3,025 $3,216 $3,407 +$192 Cada dos semanas $4,135 $4,517 $4,900 $5,283 $5,666 $6,049 $6,431 $6,814 +$383 Dos veces al mes $4,479 $4,894 $5,308 $5,723 $6,138 $6,553 $6,967 $7,382 +$415 Mensual $8,958 $9,787 $10,616 $11,446 $12,275 $13,105 $13,934 $14,763 +$830 Anual $107,485 $117,438 $127,391 $137,344 $147,297 $157,250 $167,203 $177,156 +$9,953 Las personas que reciben Medicaid o SNAP automáticamente cumplen con los requisitos de ingresos para el Programa WIC.

Page 15 Determining Household Size and Household Income Policy 206 December 2024

Guidance for the Exclusion of Combat Pay from WIC Eligibility Determination Information on the amount and type of pay received by a service member may be found on the Leave and Earnings Statements (LESs) for Marine Corps (attachment A) and Army, Navy, Air Force, and Coast Guard (attachment B) which are comprehensive statements of a service member's leave and earnings showing entitlements, deductions, allotments, leave information, tax withholding information, and Thrift Savings Plan (TSP) information. Combat pays given to deployed service members will be reflected in the Entitlements column of each of these LESs.

Allowable Exclusions In order to be excluded from the WIC income eligibility determination, the pay: A. Must have been received in addition to the service member’s basic pay; (Note: A service member, who is currently serving as a member of the armed forces and is paid a monthly salary, is eligible to receive any of the additional pay associated with combat pay.) B. Must have been received as a result of the service member’s deployment to or service in an area that has been designated as a combat zone; (Note: a service member who is put on deployment orders to deploy to an area that has been designated by an Executive Order from the President as areas which U.S. Armed Forces are engaging or have engaged in combat is eligible to receive combat pay.) C. Must not have been received by the service member prior to his/her deployment to or service in the designated combat zone. (Note: a service member who is paid only basic entitlements, such as Basic pay, Basic Subsistence Allowance (BAS), and Basic Housing Allowance (BAH), will receive additional entitlement pay, i.e. combat pay, once the service member is put on deployment orders. These pays will show as an additional payment in the entitlements column on a service member’s Leave and Earning Statement (LES). ) There are two categories of entitlement pay that are typically considered combat pay and are easily recognizable on a service member’s LES: Hostile Fire Pay/Imminent Danger Pay (HFP/IDP) and Hardship Duty Pay (HDP). However, other types of pay could be excluded if they meet the criteria above.

Types of Combat Pay 1. What is HFP/IDP and who is entitled to receive it? Hostile Fire Pay/Imminent Danger Pay (HFP/IDP) is received by a member of a uniformed service when the individual is put on deployment orders and deployed to a combat zone. A service member may be paid HFP/IDP special pay for any month in which s/he was entitled to basic pay. The service member qualifies for an entire month of combat pay regardless of the total number of days spent in a designated combat zone. 2. What is HDP, HDP-L or –M and who is entitled to receive it? Hardship Duty Pay (sometimes indicated on the LES as HDP, HDP-L or HDP-M) refers to special pay providing additional compensation for service members who are either serving in locations where living conditions create undue hardship or who are performing designated hardship missions. HDP-M (mission) is a special pay entitled to service members for specific missions, at the monthly rate whenever any part of the month is served fulfilling a specific mission. HDP-L (location) is a special pay entitled to service members that serve in a designated area for over 30 days and stops upon departure from that area.

Such locations may be, but are not necessarily, combat areas; the local WIC agency will need to explore the circumstances under which a participant household is receiving HDP-L or -M in more detail before the decision to include or exclude this particular payment from the WIC income eligibility determination assessment is made. Other Allowances In addition, there are other allowances for which service members are eligible while serving in a combat zone, but which are not directly related to being in combat, although they may be eligible for exclusion as income for WIC purposes. The local WIC agency will need to explore the circumstances under which a participant’s household is receiving each additional allowance in

Page 16 Determining Household Size and Household Income Policy 206 December 2024

more detail before the decision to include or exclude this particular payment from the WIC household eligibility determination assessment is made. They include but are not limited to Family Separation Pay (FSA); Foreign Language Proficiency Pay (FLPP); Special Duty Assignment Pay (SDAP); Combat Related Injury and Rehabilitation Pay (CIP); and Hazardous Duty Incentive Pay (HDIP). Each of these pays are further defined below.

Combat pays such as FLPP, SDAP, CIP and HDIP are affected differently when the service member is medically evacuated (medevacked). FLPP, SDAP and HDIP are each stopped when the service member is no longer performing that duty due to being medevacked out of the combat area. CIP will be modified, not stopped, when the service member is medevacked. See CIP (Question 6) for a complete explanation on how the service member is paid.

3. What is FSA and who is entitled to receive it? Family Separation Pay (FSA) is for service members with dependents who meet certain eligibility criteria. Service members will receive FSA pay from the day of departure from the home station and end the day prior to arrival at the home station. This payment may be excluded in some but not all cases. FSA is only excluded if the service member is enroute to a training location prior to deployment to a designated combat zone or on deployment orders to a designated combat zone.

4. What is FLPP and who is entitled to receive it? An officer or enlisted member of the Armed Forces who has been certified as proficient in a foreign language within the past 12 months (or 12 months plus 180 days when called or recalled to active duty in support of contingency operations) may be paid Foreign Language Proficiency Pay (FLPP). FLLP that was not received by a service member prior to the time of deployment to a designated combat zone shall be excluded from the WIC income eligibility determination.

5. What is SDAP and who is entitled to receive it? All enlisted active-duty service members who perform duties designated as extremely difficult or requiring a high level of responsibility in a military skill may be paid Special Duty Assignment Pay (SDAP). SDAP that was not received by a service member prior to the time of deployment to a designated combat zone shall be excluded from the WIC income eligibility determination.

6. What is CIP and who is entitled to receive it? Service members who are medevacked out of the combat zone and are considered "hospitalized" are entitled to Combat-Related Injury and Rehabilitation Pay (CIP). A service member is considered hospitalized if s/he is admitted as an inpatient or is receiving extensive rehabilitation as an outpatient while living in quarters affiliated with the military health care system. The monthly CIP payment equals a set amount less any HFP payment for the same month. The hospitalized service member is eligible for CIP starting the month after the month of being evacuated. These payments would be excluded for WIC eligibility purposes. 7. What is HDIP and who is entitled to receive it? Service members who perform any of the following duties can earn Hazardous Duty Incentive Pay (HDIP):  Parachute Duty  Flight Deck Duty  Demolition Duty  Experimental Stress Duty  Toxic Fuels (or Propellants) Duty  Toxic Pesticides Duty  Dangerous Viruses (or Bacteria) Lab Duty  Chemical Munitions Duty  Maritime Visit, Board, Search and Seizure (VBSS) Duty  Polar Region Flight Operations Duty

Page 17 Determining Household Size and Household Income Policy 206 December 2024

A Service member can receive up to two different types of HDIPs during the same period if s/he performs more than one of these duties as required by the mission. HDIP begins on the day the member reports for duty and ceases on the termination date published in the orders or when the member is no longer required to perform the hazardous duty, whichever occurs first. The HDIP entitlement(s) is prorated based on the number of days the member spends performing these duties during a month. HDIP that was not received by a service member prior to deployment to a designated combat zone shall be excluded from the WIC income eligibility determination.

Page 18 Determining Household Size and Household Income Policy 206 December 2024

Appendix A: Sample Marine Corps Leave and Earnings Statement, with explanatory notes

Section A - Identification Information. Box 1 – NAME. Last name, first name, and middle initial. Box 2 – SSN. Social Security Number. Box 3 – RANK. Pay grade (Rank) for which basic pay is determined. Box 4 – SERV. Branch of service (e.g., “USMC” or “USMCR”). Box 5 - PLT Code. The section, which assigned. Box 6 - DATE PREP. Date Prepared. This is the date the LES was prepared by DFAS in Kansas City. Box 7 - PRD COVERED. Period covered. Used to specify the span of days covered by this leave and earnings statement. Box 8 – PEBD. Pay entry base date. Box 9 – YRS. Years of service for pay purposes.

Page 19 Determining Household Size and Household Income Policy 206 December 2024

Box 10 – EAS. Expiration of active service. Box 11 – ECC. Expiration of current contract. Box 12 - MCC-DIST-RUC. Monitor command code, district, and Reporting Unit Code (MCC- RUC for USMC, DIST-RUC for USMCR).

Section B - Forecast Amounts. Box 13 - DATE AND AMOUNT. 1. DATE. Date of midmonth payday. 2. AMOUNT. Forecast of amount due on midmonth payday of the upcoming month. Box 14 - DATE AND AMOUNT. 1. DATE. Date of end-of-month payday. 2. AMOUNT. Forecast of amount due on end-of-month payday of the upcoming month.

Section C - Split Pay Date. Box 15 - START DATE. The date Split Pay Started. Box 16 – AMOUNT. The amount of Split Pay Elected. Box 17 – BALANCE. The balance of Split Pay not received. Box 18 – POE. Payment Option Election. The POE code is used to designate distribution of monthly pay. Section D - Direct Deposit/EFT Address. This section contains the name and address of the financial institution where payments are being deposited.

Section E - Leave Information. Box 19 - LV BF. Leave brought forward. The number of days leave accrued at the end of the preceding period. Box 20 – EARNED. Number of days leave earned during the period covered. Normally this will be 2.5 days. Box 21 – USED. Number of days leave charged since the previous LES was prepared. Box 22 – EXCESS. Number of days leave charged without entitlement to pay and allowance, in excess of leave that can be earned prior to ECC. Box 23 – BAL. Balance. The number of days of accrued leave due or advanced. Box 24 - MAX ACCRUAL. Total number of days that can accrue based upon the ECC date. Value is obtained by using the 1st day of the month following the period covered, up to and including the ECC date. Box 25 – LOST. Number of days in excess of 60 days dropped due to the change in the fiscal year. Box 26 - SOLD/AS OF. Number of lump sum leave sold during the career and the last date leave was sold. Box 27 - CBT LV BAL. Reserved for future use.

Section F - AVIATION PAY INFORMATION. Boxes 28 through 32 are pertaining only to Officers in the aviation field. Section G - Tax Information. Box 33 - STATE TAX. 1. STATE CODE. State tax code. An alphanumeric code is used to identify the state (or territorial possession) designated by the member as his/her legal residence. 2. EXEMPTIONS. State tax exemptions. Marital status and number of exemptions claimed for state tax purposes. 3. WAGES THIS PRD. Total state taxable income for the period covered. 4. WAGES YTD. State taxable income year to date. This is the amount of taxable income earning by the Marine from the date of entry into service or from 1 January of the current year through the last day of the period covered. 5. STATE TAX YTD. State taxes year-to-date. Total amount of State income tax withheld for the year.

Page 20 Determining Household Size and Household Income Policy 206 December 2024

Box 34 - FEDERAL TAX. 1. EXEMPTIONS. Federal tax exemptions. Marital status and number of exemptions claimed for federal tax purposes. 2. WAGES THIS PRD. Total federal taxable income for the period covered. 3. WAGES YTD. Federal taxable income year to date. This is the amount of taxable income earned from the date of entry into service or from 1 January of the current year through the last day of the period covered. 4. FED TAX YTD. Federal taxes year-to-date. Total amount of Federal income tax withheld for the year. Box 35 - FICA (SOCIAL SECURITY TAX). 1. SSEC WAGES THIS PRD. Social Security wages this period. Moneys earned during period covered that are subject to deduction under the Federal Insurance Contributions Act. 2. SSEC WAGES YTD. Social Security wages year-to-date. The amount of wages earned for the year that are subject to social security tax. 3. SSEC TAX YTD. Social Security tax year-to-date. The amount of social security tax withheld for the year. This includes withholding on the amount shown in Social Security wages this period. 4. MEDICARE WAGES THIS PRD. Medicare wages this period. Moneys earned during period covered that are subject to deduction under the Old Age Survivors Disability Insurance. 5. MEDICARE WAGES YTD. Medicare wages year-to-date. The amount of wages earned for the year that are subject to Medicare tax. 6. MEDICARE TAX YTD. Medicare tax year-to-date. The amount of Medicare tax withheld for the year. This includes withholding on the amount shown in Medicare wages this period. Section H - Rights of Marines Indebted to The Government. Section I - Additional BAH Information Boxes 36 through 42 are no longer used. VHA and BAQ have been replaced with BAH which will be shown in Section O.

Section J - Career Sea Pay. Box 43. 1. DATE. The date career sea duty ended. 2. TOTAL CAREER SEA SVC. The total number of years, months, and days served on sea duty.

Section K - Education Deduction. Box 44 – TYPE. The educational program enrolled. Box 45 - MONTHLY AMT. The monthly amount being deducted for the educational program. Box 46 – TOTAL. The total amount that has been deducted for the educational program; this amount includes the current month.

Section L - Administrative Information. Box 47 - PAY STATUS. This code identifies the particular pay status on the last day covered by the LES. Box 48 - PAY GROUP. A three-digit code that identifies if an officer or enlisted. Box 49 - CRA DATE. Clothing Replacement Allowance date for active duty enlisted. Box 50 - RESERVE ECC. Reserve Expiration of Current Contract. Box 51 – DSSN. Disbursing Station Symbol Number. A number used to identify the servicing disbursing/finance officer account. Section M - Reserve Drill Information. Box 52 – REG. Total regular and EIOD drills performed this period. Box 53 - REG FYTD. Total regular and EIOD drills performed this fiscal year. Box 54 - REG ANNYTD. Total regular and EIOD drills performed this anniversary year. Box 55 – ADD. Total additional drills performed this period. Box 56 - ADD FYTD. Total additional drills performed this fiscal year. Box 57 - ADD ANNYTD. Total additional drills performed this for anniversary year.

Page 21 Determining Household Size and Household Income Policy 206 December 2024

Section N - Reserve Retirement Information. Box 58 - BF ANNYTD. Ending balance of retirement credit points for anniversary year from prior month. Box 59 - ACDU THIS PRD. Total days active duty this period. Box 60 - DRILL THIS PRD. Total drills this period. Box 61 - OTHER THIS PRD. Total all other credit points awarded this period. Box 62 - MBR THIS PRD. Total membership points awarded this period. Box 63 - END BAL ANNYTD. Total retirement credit points after this period for anniversary year-to-date. Box 64 - TOTAL SAT YRS. Total satisfactory years credited for retirement purpose. Box 65 - TOTAL RET PTS. Career total retirement credit points.

Section O – Remarks. Section O of the LES gives an itemized listing of entitlements, deductions, and payments, also explanatory remarks concerning specific LES data. Entitlements. The Marine will receive entitlements based on the information mentioned in the above sections, their marital status, and dependents. The type and amount of the entitlement will be listed at the top of this section, along with a total. If there have been changes to either the type or the amount of the entitlement, this will be noted in this section, along with a note saying whether the entitlement was being stopped or started. For example, if a Marine is promoted, there will be an annotation stopping the amount of base pay under his old rank and another annotation starting the base pay of his current rank. These entitlements can include: • Basic Pay. • Pro/Sep Rations. • Clothing Replacement Allowance. • BAH. • Other types of special pay. Deductions. This portion in section O, gives an itemized listing of what was deducted from your entitlements. Again, there will be an annotation for starting and stopping amounts as necessary, such as when you start, stop, or change and Allotment. If a Marine takes advanced pay, such as when he PCS’s, the amount of the monthly will be noted here. These deductions can include: • Allotments. • Bonds. • Medicare. • Serviceman Group Life Insurance (SGLI). • Other special deductions based on the individual or Government needs. • FITW (Fed Tax). • Dental. • Social Security. • Medicare. • SGLI/TSGLI/Spouse SGLI. • USN/MC Retirement Home. • Check ages. Payments. This portion represents the last month’s regular payments, which occurred on the first and the fifteenth.

Explanatory Remarks. This includes information that is not found on other parts of the LES, as well as information messages.

Page 22 Determining Household Size and Household Income Policy 206 December 2024

Appendix B: Sample Army, Air Force, Coast Guard, and Navy Leave and Earnings Statement, with explanatory notes

Fields 1 - 9 contain the identification portion of the LES. • 1 NAME: The member’s name in last, first, middle initial format. • 2 SOC. SEC. NO.: The member’s Social Security Number. • 3 GRADE: The member’s current pay grade. • 4 PAY DATE: The date the member entered active duty for pay purposes in YYMMDD format. This is synonymous with the Pay Entry Base Date (PEBD). • 5 YRS SVC: In two digits, the actual years of creditable service. • 6 ETS: The Expiration Term of Service in YYMMDD format. This is synonymous with the Expiration of Active Obligated Service (EAOS). • 7 BRANCH: The branch of service, i.e., Navy, Army, Air Force. • 8 ADSN/DSSN: The Disbursing Station Symbol Number used to identify each disbursing/finance office. • 9 PERIOD COVERED: This is the period covered by the individual LES. Normally it will be for one calendar month. If this is a separation LES, the separation date will appear in this field.

Page 23 Determining Household Size and Household Income Policy 206 December 2024

Fields 10 through 24 contain the entitlements, deductions, allotments, their respective totals, a mathematical summary portion, date initially entered military service, and retirement plan. • 10 ENTITLEMENTS: In columnar style the names of the entitlements and allowances being paid. Space is allocated for fifteen entitlements and/or allowances. If more than fifteen are present, the overflow will be printed in the remarks block. Any retroactive entitlements and/or allowances will be added to entitlements and/or allowances. • 11 DEDUCTIONS: The descriptions of the deductions are listed in columnar style. This includes items such as taxes, SGLI, Mid-month pay and dependent dental plan. Space is allocated for fifteen deductions. If more than fifteen are present, the overflow will be printed in the remarks block. Any retroactive deductions will be added to like deductions. • 12 ALLOTMENTS: In columnar style the type of the actual allotments being deducted. This includes discretionary and non-discretionary allotments for savings and/or checking accounts, insurance, bonds, etc. Space is allocated for fifteen allotments. If a member has more than one of the same type of allotment, the only differentiation may be that of the dollar amount. • 13 AMT FWD: The amount of all unpaid pay and allowances due from the prior LES. • 14 TOT ENT: The figure from Field 20 that is the total of all entitlements and/or allowances listed. • 15 TOT DED: The figure from Field 21 that is the total of all deductions. • 16 TOT ALMT: The figure from Field 22 that is the total of all allotments. • 17 NET AMT: The dollar value of all unpaid pay and allowances, plus total entitlements and/or allowances, minus deductions, and allotments due on the current LES. • 18 CR FWD: The dollar value of all unpaid pay and allowances due to reflect on the next LES as the +AMT FWD. • 19 EOM PAY: The actual amount of the payment to be paid to the member on End-of-Month payday. • 20 - 22 TOTAL: The total amounts for the entitlements and/or allowances, deductions and allotments respectively. • 23 DIEMS: Date initially entered military service: This date is used SOLELY to indicate which retirement plan a member is under. For those members with a DIEMS date prior to September 8, 1980, they are under the FINAL PAY retirement plan. For those members with a DIEM’s date of September 8, 1980 through July 31, 1986, they are under the HIGH-3 retirement plan. For those members with a DIEMS date of August 1, 1986 or later, they were initially under the REDUX retirement plan. Law changed this in October 2000, when they were placed under the HIGH-3 plan, with the OPTION to return to the REDUX plan. In consideration of making this election, they become entitled to a $30,000 Career Service Bonus. • The data in this block comes from PERSCOM. DFAS is not responsible for the accuracy of this data. If a member feels that the DIEMS date shown in this block is erroneous, they must see their local servicing Personnel Office for corrective action. • 24 RET PLAN: Type of retirement plan, i.e. Final Pay, High 3, REDUX; or CHOICE (CHOICE reflects members who have less than 15 years’ service and have not elected to go with REDUX or stay with their current retirement plan).

Fields 25 through 32 contain leave information. • 25 BF BAL: The brought forward leave balance. Balance may be at the beginning of the fiscal year, or when active duty began, or the day after the member was paid Lump Sum Leave (LSL). • 26 ERND: The cumulative amount of leave earned in the current fiscal year or current term of enlistment if the member reenlisted/extended since the beginning of the fiscal year. Normally increases by 2.5 days each month. • 27 USED: The cumulative amount of leave used in the current fiscal year or current term of enlistment if member reenlisted/extended since the beginning of the fiscal year. • 28 CR BAL: The current leave balance as of the end of the period covered by the LES.

Page 24 Determining Household Size and Household Income Policy 206 December 2024

• 29 ETS BAL: The projected leave balance to the member’s Expiration Term of Service (ETS). • 30 LV LOST: The number of days of leave that has been lost. • 31 LV PAID: The number of days of leave paid to date. • 32 USE/LOSE: The projected number of days of leave that will be lost if not taken in the current fiscal year on a monthly basis. The number of days of leave in this block will decrease with any leave usage.

Fields 33 through 38 contain Federal Tax withholding information. • 33 WAGE PERIOD: The amount of money earned this LES period that is subject to Federal Income Tax Withholding (FITW). • 34 WAGE YTD: The money earned year-to-date that is subject to FITW. Field 35 M/S. The marital status used to compute the FITW. • 36 EX: The number of exemptions used to compute the FITW. • 37 ADD’L TAX: The member specified additional dollar amount to be withheld in addition to the amount computed by the Marital Status and Exemptions. • 38 TAX YTD: The cumulative total of FITW withheld throughout the calendar year. Fields 39 through 43 contain Federal Insurance Contributions Act (FICA) information. • 39 WAGE PERIOD: The amount of money earned this LES period that is subject to FICA. • 40 SOC WAGE YTD: The wages earned year-to-date that are subject to FICA. • 41 SOC TAX YTD: Cumulative total of FICA withheld throughout the calendar year. • 42 MED WAGE YTD: The wages earned year-to-date that are subject to Medicare. • 43 MED TAX YTD: Cumulative total of Medicare taxes paid year-to-date. Fields 44 through 49 contain State Tax information. • 44 ST: The two-digit postal abbreviation for the state the member elected. • 45 WAGE PERIOD: The amount of money earned this LES period that is subject to State Income Tax Withholding (SITW). • 46 WAGE YTD: The money earned year-to-date that is subject to SITW. Field 47 M/S. The marital status used to compute the SITW. • 48 EX: The number of exemptions used to compute the SITW. • 49 TAX YTD: The cumulative total of SITW withheld throughout the calendar year. Fields 50 through 62 contain additional Pay Data. • 50 BAQ TYPE: The type of Basic Allowance for Quarters being paid. • 51 BAQ DEPN: A code that indicates the type of dependent. A - Spouse C -Child D - Parent G Grandfathered I -Member married to member/own right K - Ward of the court L - Parents in Law R - Own right S - Student (age 21-22) T - Handicapped child over age 21 W - Member married to member, child under 21 • 52 VHA ZIP: The zip code used in the computation of Variable Housing Allowance (VHA) if entitlement exists. • 53 RENT AMT: The amount of rent paid for housing if applicable. • 54 SHARE: The number of people with which the member shares housing costs. • 55 STAT: The VHA status, i.e., accompanied, or unaccompanied. • 56 JFTR: The Joint Federal Travel Regulation (JFTR) code based on the location of the member for Cost-of-Living Allowance (COLA) purposes. • 57 DEPNS: The number of dependents the member has for VHA purposes.

Page 25 Determining Household Size and Household Income Policy 206 December 2024

• 58 2D JFTR: The JFTR code based on the location of the member’s dependents for COLA purposes. • 59 BAS TYPE: An alpha code that indicates the type of Basic Allowance for Subsistence (BAS) the member is receiving, if applicable. This field will be blank for officers. B - Separate Rations C - TDY/PCS/Proceed Time H - Rations-in-kind not available K - Rations under emergency conditions • 60 CHARITY YTD: The cumulative amount of charitable contributions for the calendar year. • 61 TPC: This field is not used by the active component of any branch of service. • 62 PACIDN: The activity Unit Identification Code (UIC). This field is currently used by Army only. Fields 63 through 75 contain Thrift Savings Plan (TSP) information/data. • 63 BASE PAY RATE: The percentage of base pay elected for TSP contributions. • 64 BASE PAY CURRENT: Reserved for future use. • 65 SPECIAL PAY RATE: The percentage of Specialty Pay elected for TSP contribution. • 66 SPECIAL PAY CURRENT: Reserved for future use. • 67 INCENTIVE PAY RATE: Percentage of Incentive Pay elected for TSP contribution. • 68 INCENTIVE PAY CURRENT: Reserved for future use. • 69 BONUS PAY RATE: The percentage of Bonus Pay elected towards TSP contribution. • 70 BONUS PAY CURRENT: Reserved for future use. • 71 Reserved for future use. • 72 TSP YTD DEDUCTION (TSP YEAR TO DATE DEDUCTION): Dollar • 73 DEFERRED: Total dollar amount of TSP contributions that are deferred for tax purposes. • 74 EXEMPT: Dollar amount of TSP contributions that are reported as tax exempt to the Internal Revenue Service (IRS). • 75 Reserved for future use 76 REMARKS: This area is used to provide you with general notices from varying levels of command, as well as the literal explanation of starts, stops, and changes to pay items in the entries within the “ENTITLEMENTS”, “DEDUCTIONS”, and “ALLOTMENTS” fields.

77 YTD ENTITLE: The cumulative total of all entitlements for the calendar year.

78 YTD DEDUCT: The cumulative total of all deductions for the calendar year.

Page 1 Required Proofs Not Present Policy 207 December 2024

Policy 207 Required Proofs Not Present POLICY All WIC participants must provide proof of identity, residence, and income. The type of proof presented must be documented.

PURPOSE To ensure proper verification of residency, identity, and income of WIC participants. This is to aid in the integrity of the WIC program by helping to prevent fraud.

RELEVANT REGULATIONS 7 CFR 246.7 (c)(2)(i) – Proof of Residency and Identity 7 CFR 246.7 (d)(2)(v) – Income Eligibility Documentation PROCEDURES Participant Did Not Bring Appropriate Proof A. Residency and Identity 1. For a participant who has proof of residency and/or identity but does not bring it to the initial WIC certification, inform the participant of the requirement and make a new certification appointment within the appropriate timeframe. Proof obtained electronically or via fax machine is acceptable. 2. If proof of residency and/or identity was presented and documented at a previous certification and there has been no change, staff recognition is allowed. B. Income 1. For a participant who has proof of income but does not bring it to the certification or recertification, inform the participant of the requirement and make a new appointment within the appropriate timeframe. Proof obtained electronically or via fax machine is acceptable. 2. Previous certification household income cannot be used.

Note: A WIC Proof of Residence, Identity, and Income Card, WIC-PC (formerly known as the Blue card), is available. Refer to Section 200 Certification Appendices.

Participant Unable to Provide Appropriate Proof A. Residency: A participant who has no current proof of residency, such as a victim of theft, loss, or disaster, a homeless individual, a migrant farmworker, or a person with a valid VOC, must provide a signed statement attesting to his/her residency. 1. The statement must include the participant’s address, why written proof cannot be provided (i.e., theft, homeless), the date, and the participant’s signature. An optional form, Statement of No Proof (WIC-NP), is available for this purpose. Refer to Section 200 Certification Appendices. 2. The statement applies to the entire certification period for which it was provided. At recertification, if the person still has no proof of residency, another statement must be obtained for this certification period. 3. The statement must be filed/scanned in the participant’s medical record. 4. When using the statement of No Proof for residency, Proof Code 14, Statement of No Proof should be selected for residency proof on the Income/Proofs screen in the system. B. Identity: A participant who has no current proof of identity, such as a non-citizen, victim of theft, loss, or disaster, a homeless individual, a migrant farmworker, or a person with a valid VOC, must provide a signed statement attesting to his/her identity.

Page 2 Required Proofs Not Present Policy 207 December 2024

1. The statement must include the participant’s name, why written proof cannot be provided (i.e., theft, homeless), the date, and the participant’s signature. An optional form, Statement of No Proof (WIC-NP), is available for this purpose. Refer to Section 200 Certification Appendices. 2. The statement applies to the entire certification period for which it was provided. At recertification, if the person still has no proof of identity, another statement must be obtained for this certification period. 3. The statement must be filed in the patient’s medical record. 4. When using the statement of No Proof for identity, Proof Code 14, Statement of No Proof should be selected for identity proof on the Income/Proofs screen in the system.

C. Income: A participant who has no written proof of income, such as a migrant farmworker, a homeless person, or a person who works for cash, or who reports income as zero, can self- declare income and must provide a signed statement. A participant where military service personnel is temporarily absent from home, and proof of gross military income cannot be produced may self-declare income and provide a signed statement. 1. The statement must include why written proof of income cannot be provided, (i.e., homeless, migrant), the date, and the participant’s signature. For zero income, an explanation of how living expenses are met must be included. An optional form, Statement of No Proof (WIC-NP), is available for this purpose. Refer to Section 200 Certification Appendices. 2. The statement applies to the entire certification period for which it was provided. At recertification, if the person still has no proof of income, another statement must be obtained for this certification period. 3. The statement must be filed in the patient’s medical record. 4. When using the statement of No Proof for income, Proof Code 14, Statement of No Proof should be selected for income proof on the Income/Proofs screen in the system.

Page 1 Homeless Participants Policy 208 December 2024

Policy 208 Homeless Participants POLICY Certify homeless participants and participants living in institutions for the full certification period for which they are eligible according to current WIC risk criteria.

PURPOSE To ensure WIC Services reach a population in critical need. To implement federal regulations ensuring that WIC services benefit the participant and Local WIC Agencies remain in compliance with federal regulations when issuing benefits to those living in a homeless facility or institution.

RELEVANT REGULATIONS 7CFR 246.7 (e)(2)(iv) – Nutritional Risk 7CFR 246.7 (e)(4)(vii) – Nutrition Risk Priority System 7CFR 246.7 (m) – Certification of persons in homeless facilities and institutions

Attachment Attachment A: Sample Memorandum of Understanding (MOU) from a Local WIC Agency to a Homeless Facility or Shelter

PROCEDURES Homeless Individuals Homeless Individual- A person who lacks a fixed and regular nighttime residence or whose primary nighttime residence is one of the following: A. A temporary accommodation for no more than 365 days in the residence of another individual. B. A public or private place not designed for, or ordinarily used as, a regular sleeping accommodation for human beings (such as parked cars, park benches, abandoned buildings, or campgrounds). C. A supervised publicly or privately operated shelter designed to provide temporary living accommodations including but not limited to: 1. hotels or motels paid for by Federal, State or local government programs or charitable organizations 2. congregate shelters 3. transitional housing 4. group homes for foster children 5. shelter for victims of domestic violence and abuse 6. substance abuse facilities 7. facilities for pregnant women D. An institution is any residential accommodation that provides a meal service and temporary residence for individuals intended to be institutionalized. Exceptions include private residences and homeless facilities. *Please note, the term “homeless individual” does not include any individual imprisoned or otherwise detained pursuant to an Act of Congress or a state law 42 U.S.C 11302 (c).

Certification A. Homeless participants living in the situations described below shall be screened for certification using regular procedures, and all eligibility requirements must be met. Refer to Policy 206 Determining Household Size and Household Income. 1. A temporary accommodation for no more than 365 days in the residence of another individual.

Page 2 Homeless Participants Policy 208 December 2024

2. A public or private place not designed for, or ordinarily used as, a regular sleeping accommodation for human beings (such as parked cars, park benches, abandoned buildings, or campgrounds). B. If a homeless participant is living in a shelter or institution as described above: 1. Contact the homeless shelter or institution to ensure it meets all of the following requirements: a. WIC program services will benefit the participant, not the facility (WIC participants will be able to store and prepare WIC foods for their own consumption). b. WIC foods will not be used in communal feeding. c. The facility will not restrict the participants' use of WIC services, for example, attending classes or shopping at WIC authorized vendors. d. No financial or in-kind benefit shall be accrued from a person’s participation in the WIC Program, e.g., by reducing its expenditures for food service because its residents are receiving WIC foods. 2. If the shelter or institution meets the requirements, screen and certify the participant for the full certification period for which the individual is eligible. 3. All people in a homeless shelter, institution, or group home cannot be considered members of one household for income eligibility. 4. Factors such as lack of cooking facilities or storage space shall have no bearing on the eligibility determination process. C. Documentation Keep a record of any type of contact with a facility or institution. 1. Document the conversation, including the date and name of the person representing the facility if contact was by phone. 2. Ask for a written response from the facility if contact was by letter. Refer to Attachment A for a sample of Memo of Understanding (MOU). Compliance A. To ensure compliance, the WIC agency/site shall: 1. Assure eligible WIC participants from that facility are certified for the full period for which they are eligible if caseload slots are available. If not, the participant shall be placed on a waiting list. Refer to Policy 706—Waiting List. 2. The facility does not need to be contacted for each new participant from the facility. 3. Shall contact the facility periodically to ensure they are still in compliance with the agreed-upon requirements. 4. Request the facility to notify the WIC agency if the facility ceases to meet any of the WIC requirements. B. If it is determined that a facility does not comply: 1. Continue WIC benefits and services to any residents of that facility who are already certified for WIC for that certification period. 2. Inform those participants that their WIC food benefits will cease after their current certification period and refer them to other homeless facilities where they could continue to receive WIC food benefits. 3. If the participant refuses to move to another facility that meets the WIC requirements or arrangements are not possible by the time the next certification is due, the participant may be recertified, but no further WIC food benefits will be issued. 4. Exceptions: Recertify residents of non-compliant facilities only for nutrition or breastfeeding education services but not for WIC food benefits. The only exception is for infants, who may continue to receive infant foods and formula.

Page 3 Homeless Participants Policy 208 December 2024

Referral/Outreach

A. The agency shall maintain a complete up-to-date referral list of facilities and institutions in the area that comply with the requirements so referrals can be made. B. The agency shall include in its outreach efforts that availability of the WIC Program to homeless and institutional individuals. Provide information on participant eligibility requirements and the location to apply for WIC. Facility requirements shall be provided to organizations and agencies serving these individuals. Refer to Policy 703- Caseload Management- Outreach.

Page 4 Homeless Participants Policy 208 December 2024

Attachment A: Sample Memo of Understanding (MOU) Between the Local WIC Agency and the Shelter or Homeless Facility

Date:

To:

Facility/Shelter Name

From:

Local WIC Agency/WIC Coordinator Address/Phone #

RE: WIC Services for your Residents

The Women, Infants, & Children Program (WIC) provides nutrition education, breastfeeding support, referrals and supplemental foods to lower-income mothers and children. Those on WIC can get foods such as eggs, fruit, vegetables, milk, cereal, cheese and more, which help these participants meet special dietary needs. Residents of your facility/shelter, who are pregnant women, or children up to five years of age, may be eligible for WIC services. Federal regulations require that WIC services benefit the WIC participant, not the facility that is housing them. This means: 1. The WIC participant will be able to store and prepare WIC foods for their own consumption. 2. WIC foods will not be used in communal feeding but shall be available exclusively to the WIC participant for whom they were issued. 3. No restrictions will be placed on the WIC participant’s use of WIC services. (WIC participants will be able to attend WIC nutrition education classes, shop or have authorized person shop, for them at WIC authorized stores.

An authorized signature below indicates that your facility is able and willing to comply with these conditions in order for eligible residents to participate in the WIC Program. The local WIC agency shall contact the facility periodically to establish and ensure compliance with the above conditions. The homeless facility shall notify the local WIC agency if the facility ceases to meet any of the above conditions.

Local WIC Agency Name of Facility & Address

WIC Program Coordinator Authorized Representative

Date Date

Page 1 Physical Presence Requirements Policy 209 December 2024

Policy 209 Physical Presence Requirements POLICY All persons to be certified in the WIC Program must be physically present at each certification appointment unless an approved exception exists.

PURPOSE To ensure a participant is physically present at certification appointments or that an exception is granted and documented. This is to maintain the integrity of the WIC program by helping to prevent fraud.

RELEVANT REGULATIONS 7 CFR 246.7 (i)(3) – Certification forms 7 CFR 246.7 (o) – Physical present at certification PROCEDURES Anyone applying for WIC must be physically present at each certification unless an exception applies. If staff know or believe an individual may be eligible for these exceptions, they must inform the participant or the participant’s guardian of the option for an exception. Scheduling shall take into consideration individual needs. Refer to Policy 202- Processing Standards and Policy 221-ARPA Waiver: Remote Services.

General Policies Documentation must be completed whether the participant was physically present at certification and, if not, the reason an exception was allowed. A. Documentation of physical presence is entered into the system. B. The certification label will include physical presence documentation and the label must be filed in the participant’s medical record. Refer to the Patient Services Reporting System (PSRS), Patient Encounter Form (PEF), and Food Delivery and Data Section.

Exceptions to Physical Presence Requirements An exception may be allowed on an individual basis, and the certification performed without the participant being physically present if the physical presence requirement presents an unreasonable barrier to participation. These exception reasons are primarily utilized when the parent or caretaker is present in person for the certification appointment for a household member who is not present. The reason for the exception must be entered into the system and documentation in the medical record. Please refer to Policy 221 ARPA Waiver for remote options. A. Disabilities A participant or parent/caretaker of a participant with a physical or mental disability that creates a current barrier to coming to the clinic. Disabilities include: 1. Impaired functions such as caring for oneself, walking, seeing, hearing, speaking, breathing, learning, and working. 2. A medical condition that necessitates the use of medical equipment that is not easily transportable. 3. A medical condition that requires confinement to bed rest. 4. A serious illness or medical condition that may be worsened by coming to the clinic. 5. A serious illness that may be exacerbated by coming into the WIC clinic (i.e. an individual with compromised immunity, such as an individual undergoing cancer treatment). 6. A contagious illness that may be transmitted to others by coming to the clinic. B. Receiving ongoing health care) An infant or child who was present at his/her initial certification and is receiving documented ongoing healthcare. C. Working parents or Caretakers An infant or child who was present at his/her initial certification and at a recertification within the past year and whose parent(s)/caretaker(s) work status presents a barrier to bringing the infant or child to the clinic.

Page 2 Physical Presence Requirements Policy 209 December 2024

D. Newborn infant An infant under eight (8) weeks of age who cannot be present at certification due to an appropriate reason. Although physical presence is not required under eight weeks of age, the health professional shall determine that the infant is receiving health care from an appropriate provider. The health professional shall use professional discretion in whether to request the infant be brought to the clinic during the certification period. E. A participant exempt from physical presence at certification must still meet all other WIC Program requirements for eligibility. The parent/caretaker must provide all information required to determine eligibility including proof of residence, identity, income eligibility and required medical data. 1. If the situation still applies at the Mid-Certification Health Assessment, the reason for the exception must be documented in the system and the medical record. F. An exception to the physical presence requirement is applicable only for the certification period for which it was provided for short-term situations or conditions. At recertification, physical presence must be reassessed. A long-term or permanent condition may require an extended exception to the physical presence requirement.

Page 1 Certification Periods Policy 210 December 2024

Policy 210 Certification Periods POLICY Eligible individuals will be certified in the WIC program for a specified length of time. The certification period begins from the date of certification and is determined by category/status and, in specific situations, age.

PURPOSE To ensure that participants are certified for the proper length of time.

RELEVANT REGULATIONS 7 CFR 246.7(g) – Certification Periods Kentucky Administrative Regulations 902 KAR 18:021 Eligibility, Certification Periods, and time frames for processing participants

PROCEDURES General Policies A. A person certified as eligible may continue on WIC until the end of the certification period as long as the individual remains eligible and complies with Program rules and regulations. If a reason for eligibility or discontinuation of benefits occurs, appropriate action must be taken at that time, regardless of the expiration of the certification period. Refer to Policy 705- Ineligibility and Discontinuation of Benefits. B. Recertification shall be scheduled prior to the end of the certification period to prevent interruption of benefits. Refer to Policy 202- Processing Standards. C. Each participant/caretaker must be informed that the certification period will expire a minimum of 15 days before the expiration. Verbal notice at the last food benefit pick-up before the recertification due date is appropriate. D. When there is difficulty in appointment scheduling for breastfeeding women, infants, and children, the certification period may be shortened or extended by thirty (30) days. The 30-day grace period cannot be used routinely. 1. Food benefits must be provided when the 30-day grace period is used. 2. If an assessment of eligibility was completed prior to the end of the certification period, and the patient is determined ineligible, the food benefit issuance and food package due for this certification period shall be given. It is not equitable to prematurely terminate the benefits of participants who are given early appointments. E. A person who is terminated during the certification period and later seeks WIC services shall be reinstated if there is still eligibility left, i.e., the certification period has not expired. All existing participant data in the system must still be applicable for a reinstatement to be used. F. Required Notifications/Referrals 1. The local WIC agency will develop a list of services available locally and update the list at least annually. 2. At every certification/recertification, all WIC participants will be given written referral information about other health-related and public assistance programs (Medicaid, SNAP, immunizations, etc.) and when appropriate, WIC staff shall refer applicants/participants to such programs. 3. Participation in other services shall not be required in order to receive WIC benefits, nor can WIC benefits be withheld pending other services. 4. Pregnant women shall be screened for Medicaid Presumptive Eligibility if provided by the site; or referred to the appropriate agency for this determination.

Page 2 Certification Periods Policy 210 December 2024

5. Immunization records shall be requested for infants and children applying for WIC, and the records assessed for immunization status. Referrals shall be made as appropriate. Refer to the AR Training Guidelines and Program Descriptions. 6. Participants found ineligible for WIC services or who are placed on waiting lists will be referred to other appropriate services.

Certification Periods Women A. Pregnant women are certified for the duration of their pregnancy up to six (6) weeks post-partum. Six weeks post-partum is computed from the EDC (expected date of confinement for delivery) entered in the system for pregnant women. At six weeks postpartum, women must be recertified as either postpartum or breastfeeding to continue on WIC. B. Postpartum women are certified until six (6) months postpartum. Six (6) months postpartum is computed from the actual date of delivery entered into the system. At six (6) months a postpartum woman no longer breastfeeding is categorically ineligible and will no longer receive WIC. C. Breastfeeding women are certified until the infant’s first birthday as long as they continue to breastfeed at least one time daily. Twelve months is computed from the actual date of delivery entered into the system. 1. If the woman stops breastfeeding before six (6) months postpartum, she may continue on WIC as a postpartum woman if she meets postpartum risk criteria. If she stops breastfeeding after six (6) months postpartum, she is no longer categorically eligible and must be terminated. 2. If the infant has not had his/her first birthday and the breastfeeding woman is not receiving food benefits, but the infant is receiving a full formula package, continue certification as breastfeeding. Terminate when breastfeeding ends or at the infant’s first birthday. Infants A. Infants less than six (6) months at the time of certification are certified for a period of up to twelve (12) months. Twelve months of age is computed from the date of birth entered into the system. Infants must be recertified at 12 months as a child to continue on WIC. B. Infants six (6) months of age and over are certified for a six (6) month period. Six months is computed from the certification date. At six months, recertification must be done to continue on WIC. 1. Infants enrolled and participating at twelve (12) months of age must be changed from infant status to child status. This is done through an Infant/Child Transfer (ICT). Refer to Policy 201- Status and Priority. Children A. Children are certified for intervals of twelve (12) months up to the fifth (5) birthday. The certification period ends on the fifth birthday, but the child is eligible to receive food benefits with a first day to use prior to the birth date. The fifth birthday is computed from the date of birth entered in the system. Transfers A. Certification for WIC participants who transfer in from another WIC Program in Kentucky or any other state, remains valid until the end of the participant’s original certification period as indicated on a valid Verification of Certification (VOC).

See Reference Tables below for a quick resource on Certification Eligibility, Status Changes that Require a Certification, Status Changes that do not Require a Certification, Steps in Breastfeeding Dyad Certification Process.

Page 3 Certification Periods Policy 210 December 2024

Eligibility Certification Schedule

Ages/Status Eligibility/Certification Schedule Recertification Schedule Pregnant Woman • From certification up to six (6) weeks post- delivery • Recertify as postpartum or breastfeeding woman Postpartum Woman • From certification to six (6) months from termination of Pregnancy • No recertification Breastfeeding Woman • Birth of infant to one (1) year of age of child as long as breastfeeding • Breastfeeding Certification Process • No recertification as certification period is one year post-delivery as long as breastfeeding the infant one time per day. • Mid-Certification Health Assessment (MCHA) provided between the fifth and seventh month of certification period. • If breastfeeding is discontinued and woman is: • < six (6) months post-delivery, change to Postpartum woman, • > six (6) months post-delivery, terminate from the program Note: Infant medical record must be reviewed. Determine if fully breastfed, supplemental or full formula package needs to be issued. Infants Birth to < 6 months > 6 months old • To one (1) year of age • For six (6) months • Recertify at one (1) year of age • Mid-Certification Health Assessment (MCHA) provided between the fifth and seventh month of certification period. • Recertify as child after six (6) months Child 1 year to 5 years • For twelve (12) month periods up to five (5) years of age • Recertify at twelve (12) month intervals • Mid-Certification Health Assessment (MCHA) provided between the fifth and seventh month of certification period

Page 4 Certification Periods Policy 210 December 2024

Status Changes That Require Recertification

From Status Eligibility/Certification Schedule To Status Recertification Schedule Pregnant Woman or Pregnant with Multiples • Duration of pregnancy up to six weeks post-delivery (computed based on EDC) Any Breastfeeding Status: • Partially Breastfeeding • Partially Breastfeeding Multiples • Fully Breastfeeding • Fully Breastfeeding Multiples • Recertify to appropriate Breastfeeding status. Pregnant Woman or Pregnant with Multiples • Duration of pregnancy up to six weeks post-delivery (computed based on EDC) • Postpartum • Recertify as postpartum Any Breastfeeding Status: • Partially Breastfeeding • Partially Breastfeeding Multiples • Fully Breastfeeding Fully Breastfeeding Multiples • Birth of infant up to one (1) year of age of child as long as Breastfeeding continues (computed from the actual date of delivery)** • Mid-Certification Health Assessment (MCHA) provided between the fifth and seventh month of certification period. • • Pregnant • Pregnant with Multiples • Recertify to appropriate Pregnant status. Postpartum Women • From certification to six (6) months from termination of Pregnancy (computed from the actual date of delivery) • Pregnant or Pregnant with Multiples • Recertify to appropriate Pregnant status. Infants Birth to < 6 months ≥ 6 months old • To one (1) year of age • Mid-Certification Health Assessment (MCHA) provided between the fifth and seventh month of certification period. • For six (6) months • Child • Child • Recertify at one (1) year of age. • Recertify as child after six (6) months. Child 1 year to 5 years • For twelve (12) month periods up to five (5) years of age. • Mid-Certification Health Assessment (MCHA) provided between the fifth and seventh month of certification period. N/A • Recertify at twelve (12) month intervals.

Page 5 Certification Periods Policy 210 December 2024

Status Changes That Do Not Require Recertification If the status of a breastfeeding woman changes during the breastfeeding certification period, the change shall be processed by editing the certification record that corresponds to the certification period. If the status of an infant changes during the infant certification period, the change shall be processed by editing the certification record that corresponds to the certification period.

Change Status From: To: Any breastfeeding status: • Partially Breastfeeding • Partially Breastfeeding Multiples • Fully Breastfeeding • Fully Breastfeeding Multiples • Postpartum (stops BF before 6 months postpartum, change status to postpartum must meet postpartum risk criteria). • NOTE: If more than 6 months postpartum and stops breastfeeding-Terminate. • Partially Breastfeeding • Partially Breastfeeding Multiples • Fully Breastfeeding • Fully Breastfeeding Multiples • Any other breastfeeding status: (Partially Breastfeeding, Partially Breastfeeding Multiples, Fully Breastfeeding, Fully Breastfeeding Multiples) • Infant Fully Breastfed • Infant Partially Breastfed • Infant Fully Formula Fed • Any other infant status: (Infant Fully Breastfed, Infant Partially Breastfed, Infant Fully Formula Fed)

Breastfeeding DYAD Certification Process

Situation Action Exclusively Breastfeeding (no formula feeding) • Certify the woman as a Fully Breastfeeding woman. See WIC Policies for Prescribing Food Packages. • Certify infant as Fully Breastfed - no WIC food is to be issued to the infant until the appropriate age. See Recommendations For Food Package Selection. Breast and Formula Feeding Birth to 6 months post-delivery • Certify the woman as Partially Breastfeeding. See WIC Policies for Prescribing Food Packages and provide the appropriate woman package based upon the amount of formula the infant is receiving. • Certify the infant as Partially Breastfed and provide a partial or full formula package based on the name of the product and appropriate policies. See Recommendations for Food Package Selection. Breast and Formula Feeding ≥ 6 months post-delivery • Infant receiving partially breastfeeding formula package  Continue infant certification as a Partially Breastfed infant until breastfeeding ends or at 1 year post-delivery. See Recommendations for Food Package Selection.  Continue certification of the woman as Partially Breastfeeding and continue food benefits for breastfeeding mother until breastfeeding ends or at 1 year post delivery. See Recommendations for Food Package Selection. • Infant receiving full formula package  Continue infant certification as a partially breastfed infant until breastfeeding ends or at 1 year post-delivery. See Recommendations for Food Package Selection.  Continue certification of woman as partially breastfeeding until breastfeeding ends or at 1 year post-delivery. Mother will not receive food benefits at 6 months or more post-delivery. The mother will continue to receive nutrition education.

Page 1 Rights and Responsibilities Policy 211 December 2024 Policy 211 Rights and Responsibilities POLICY Applicants and participants have certain rights and responsibilities in the WIC Program. Local WIC agencies shall inform WIC applicants and participants of their rights at each certification/recertification and as needed. PURPOSE To ensure that WIC applicants and participants are fully informed of their rights and responsibilities in the program. RELEVANT STATUTES, REGULATIONS, AGREEMENTS AND GUIDANCE Statutes: Title VI of the Civil Rights Act of 1964 (42 U.S.C. § 2000d at 7 C.F.R. § 15.1) Department of Justice Guidelines for the Enforcement of Title VI of the Civil Rights Act of 1964 at 28 C.F.R. § 50.3 Title IX of the Education Amendments of 1972, as amended (Public Law 92-318, 20 U.S.C. § 1681 et seq. at 7 C.F.R. § 15a) Section 504 of the Rehabilitation Act of 1973, as amended (Public Law 93-112, 29 U.S.C. § 701 at 7 C.F.R. § 15b) Age Discrimination Act of 1975 (Public Law 94-135, 42 U.S.C. § 6101 at 45 C.F.R. Part 91 and 7 C.F.R. § 15c) Civil Rights Restoration Act of 1987 (Public Law 100-259) Americans with Disabilities Act of 1990 (ADA) and the ADA Amendments Act of 2008 (42 U.S.C. § 12101 et seq., Title II at 28 C.F.R. Part 35 and Title III at 28 C.F.R. Part 36 Regulations: 7 C.F.R. 15 – USDA Nondiscrimination in Federally Assisted Programs of the USDA 7 C.F.R. § 246.6 Agreements with local agencies 7 C.F.R. § 246.7(j) Notification of participant rights and responsibilities 7 C.F.R. § 246.7(j)(4) Explanation of Food Delivery System and Health Services Available 7 C.F.R. § 246.7(i)(10) Certification Forms and Supporting Information 7 C.F.R. § 246.8 et seq. Nondiscrimination 7 C.F.R. § 246. 10(b)(2)(ii)(D) Supplemental Foods 7 C.F.R. § 246.25(b)(3)(ii) Records and Reports, Civil Rights 7 C.F.R. Part 16 Equal Opportunity for Religious Organizations 28 C.F.R. Part 35 Nondiscrimination on the Basis of Disability in State and Local Government Services 28 C.F.R. Part 36 Nondiscrimination on the Basis of Disability by Public Accommodations and in Commercial Facilities USDA Departmental Regulation (DR) 4300-003, Equal Opportunity Public Notification Policy, October 17, 2019 USDA Departmental Regulation (DR) 4330-002 Nondiscrimination in Programs and Activities Receiving Federal Financial Assistance from the USDA, July 27, 2021 902 KAR 1:400 KY Administrative Hearings, Chapter 18 WIC Program: 040 Fair hearing procedures for participants

Page 2 Rights and Responsibilities Policy 211 December 2024 Agreements: Federal-State Supplemental Nutrition Programs Agreement (Form FNS – 339) FNS – KY CHFS Complaints Processing Memorandum of Understanding, October 3, 2016 Program Guidance: USDA Guidance to Federal Financial Assistance Recipients Regarding the Title VI Prohibition Against National Origin Discrimination Affecting Persons With Limited English Proficiency (79 F.R. No. 299, p. 70771-70784, November 28, 2014). FNS Instruction 113-1: Civil Rights Compliance and Enforcement, November 8, 2005 Administrative Reference for Local Health Departments Administrative Reference Section: Training Guidelines and Program Descriptions: WIC Program Administrative Reference, Patient Services Reporting System, Form CH-5 and CH-5WIC, and Form CH- 5B PROCEDURES At every certification/recertification, local program staff must inform all applicants, participants, or their parents/caretakers of their rights and responsibilities in the WIC Program in a language that they can understand. Documentation informing the applicants/participants of their rights and responsibilities must be maintained in the person’s medical record. General Policies A. Applicants and participants, or their parent/legal representative/caretaker, must be informed of the rights and responsibilities during a certification. Refer to Kentucky eWIC Benefits Pamphlet, eWIC-1 (Rights and Responsibilities), and Section 200 Certification Appendices, Participant Rights and Responsibilities Info Sheet. B. Inform persons with LEP about their right to free language assistance services. Inform persons with disabilities about their right to free reasonable modifications and auxiliary aids and services. C. Documentation of informing applicants and participants of their rights and responsibilities must be in the medical record. D. Any applicant/participant determined ineligible, denied WIC services, disqualified or suspended from WIC, or asked to repay the cash value of improperly redeemed WIC food instruments must be provided a hearing to appeal the decision if desired and must be provided the WIC Program Fair Hearing Procedures. The WIC Program Fair Hearing Procedures are included in the “WIC Program Notice of Ineligibility” (WIC 54). Refer to Policy 705 Ineligibility and Discontinuation of Benefits. E. Procedures for Fair Hearings are in the Administrative Reference Section: Training Guidelines and Program Descriptions: WIC Program, WIC Program Fair Hearing Procedures are also part of Administrative Regulation 902 KAR 4:040. F. WIC Fair Hearing procedures must be displayed in the clinic and/or waiting area. A Fair Hearing Procedures Poster is available from the State WIC office. Refer to Section 200 Certification Appendices. G. Each agency must have a current list of WIC contracted vendors and provide the list to eligible participants to inform them where food benefits can be redeemed. H. WIC program services and operations shall comply with the Civil Rights regulations, statutes, agreements, and Program Guidance. I. The WIC Participation by Race/Status report shall be reviewed to ensure appropriate racial representation.

Page 3 Rights and Responsibilities Policy 211 December 2024 Participant Notification and Documentation Requirement A. All applicants, participants, or their parent/legal representative/caretaker, must read or have read to them, the WIC Rights and Responsibilities section on the Registration/Authorization/Certifications and Consents form (CH-5 or CH-5WIC). Refer to Administrative Reference, Patient Services Reporting System (PSRS), Form CH-5 and CH-5WIC and Form CH-5B. B. All applicants, participants, or their parent/legal representative/caretaker must sign and date this section of the completed Registration/Authorization/Certifications and Consents form (CH-5 or CH-5WIC) at each certification. If the computer system is not available the Rights and Responsibilities section on the CH-5B must be read, signed, and dated. Refer to Administrative Reference, Patient Services Reporting System (PSRS), Form CH-5 and CH-5WIC and Form CH- 5B. C. All applicants/participants determined eligible, or their parent/legal representative/caretaker must be provided the Kentucky eWIC Benefits Pamphlet, eWIC-1, and the information within explained to them. The eWIC Benefits Pamphlet includes the Rights and Responsibilities and how to use the eWIC card/e. Refer to Section 200 Certification Appendices. D. At initial certification, all applicants determined eligible, or their parent/legal representative or caretaker must be provided the Kentucky WIC Approved Food List and a current list of approved vendors where eWIC is accepted. Refer to the 800 Food Delivery Data Section Appendices. The Rights and Responsibilities are available as an information sheet for use when the eWIC Benefits Pamphlet is not appropriate. Refer to the 200 Certification Appendices. E. All applicants/participants determined ineligible, denied, or discontinued WIC, or imposed a claim must be provided a completed “Notice of Ineligibility” (WIC 54). A copy of the WIC-54 must be filed in the medical record. Refer to Policy 705- Ineligibility and Discontinuation of Benefits and the 200 Certification Appendices. F. The “And Justice for All” poster shall be prominently displayed in a clinic location visible to all applicants and participants. The poster is available from the State WIC Office. Refer to Section 200 Certification Appendices and the Administrative Reference, Section: Personnel, Civil Rights. G. The Fair Hearing procedures shall be prominently displayed in a clinic location visible to all applicant and participants. It shall be posted on website or frequently used social media platform. Confidentiality All rules for confidentiality and protection of patient information shall be followed for WIC information. Refer to the Administrative Reference, Section: Personnel, “Health Insurance Portability and Accountability Act of 1996 (HIPAA)”; Section: LHO Operations, Information Technology, and Section: Medical Records Management, “Guidelines of Medical Records.”

Page 4 Rights and Responsibilities Policy 211 December 2024 PARTICIPANT RIGHTS AND RESPONSIBILITIES INFO SHEET Purpose To inform participants of their Rights and Responsibilities in the WIC Program and WIC FMNP Program. Languages Available in English and Spanish and 12 other languages. Use a qualified interpreter or qualified bilingual staff to explain the information on this form for non-Spanish speaking LEP individuals. This must be provided to all applicants and participants at the certification visit. When To Use Must be provided to all applicants and participants at the certification visit. Distribute as needed. Copy as needed. Order from the State WIC Office utilizing the WIC Program Supply Requisition Form, Email WIC Program Requisition Form to the Ky WIC Help Desk at WIC.Helpdesk@ky.gov. Bundled in packages of 100.

Page 5 Rights and Responsibilities Policy 211 December 2024

Kentucky WIC & WIC Farmers Market Program Rights and Responsibilities Need help? If you have difficulty understanding or reading English or have a disability, free language assistance or other aids and services are available upon request. My Rights:

WIC Foods: If I/my child qualify for WIC, I'll get an eWIC Card to buy healthy foods at the grocery store. The healthy WIC Foods will help me/my child eat healthy but will not provide all the foods that I/my child needs each month. I will be provided information on my WIC food package and where to shop. Fair Treatment/Right to File a Complaint: Standards for eligibility and participation in the WIC Program are the same for everyone regardless of race, color, national origin, sex, disability, or age. I have the right to file a complaint if I feel I have been treated unfairly by WIC staff or store staff. Nutrition Education & Breastfeeding Support: I will get information about nutrition topics that interest me. WIC will help and support me with breastfeeding. Fair Hearing: I can ask for a Fair Hearing if I disagree with a decision about my WIC eligibility. The Fair Hearings Procedures are posted in my WIC office. Health Care Information and Referrals: WIC will share information about immunizations, finding a doctor, and other services I might need or be interested in. Free Communication Assistance: I understand that if I have difficulty understanding or reading English or have a disability; free language assistance or other aids and services are available upon request. Common Courtesy: WIC and store staff will treat me fairly and equally, with courtesy and respect, in return I will treat WIC Program and store staff with courtesy. If I have concerns with my WIC shopping experience, I will contact my WIC office or the State WIC Vendor Management office at 1-877-597-0367. Privacy: My information is private. I understand that my child’s WIC data may be shared with other Kentucky Department of Public Health programs, such as immunizations. If I am investigated for WIC Program abuse, my information may be shared. WIC Transfer Information: I can transfer to another WIC office in out of Kentucky. I can ask WIC staff to give me transfer information to provide to my new WIC office. (Verification of Certification also called a VOC). Proxy: I understand that I may appoint proxies to act on my behalf for WIC services. All proxies must abide by these Rights and Responsibilities.

My Responsibilities:

Provide Correct Information: • By signing the CH-5 Registration, Authorizations, Certifications and Consent form, I am certifying that the information I provide for my WIC eligibility determination is correct, to the best of my knowledge. This includes identity, pregnancy status, address, household size, household income and eligibility for Medicaid, SNAP (Supplemental Nutrition Assistance Program), TANF (Temporary Assistance to Needy Families). • I will inform WIC Staff if my household income, address or phone number changes. WIC Abuse: • If I misrepresent, conceal, or withhold facts in order to get WIC, I may be asked to repay the value of the food received and be removed from the WIC Program. • Disruptive behavior, threatening to abuse, or physically abusing any staff and vendor or farmer’s market personnel is a violation of WIC Program regulations and may result in disqualification from the program. • I understand that the following violations may result in disqualification from the program and repayment of food benefits issued to me and subject me to civil or criminal prosecution under state and federal law: o Exchanging supplemental foods for cash, credit, or non-WIC food items o Purchasing non-WIC foods or unauthorized food items; o Purchasing supplemental food items in excess of what was issued to me; and o Selling or offering to sell my WIC foods or WIC benefits, or WIC issued breast pump, either verbally, in print, or online or allowing someone else to do so. o Participating in more than one WIC Program and/or Commodities Special Food Program (CSFP) at the same time. • If I give someone my eWIC card and PIN and they misuse my food benefits, the foods will not be replaced. WIC Program Participation: • If I do not participate (pick up/keep my appointment or request) my/my child’s food benefits for two months in a row, I/my child will be removed from the WIC Program. I may contact my WIC office to request to be reinstated if I have eligibility left in my certification period or to be re- certified. • If I receive my/my child’s food benefits late, I may not be receive all the food benefits for that month, the food benefits may be reduced based on the number of days remaining in my/my child’s benefit cycle. eWIC Card: • It is my responsibility to keep my eWIC card secure and my PIN confidential. (Only share your card or PIN with people you have identified as a proxy) • If my eWIC card is lost, stolen or damaged, I must call the WIC office for assistance.

Page 6 Rights and Responsibilities Policy 211 December 2024

The Kentucky WIC Program is an equal opportunity Provider. Please see below for information on filing a civil rights complaint. In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating on the basis of race, color, national origin, sex (including gender identity and sexual orientation), disability, age, or reprisal or retaliation for prior civil rights activity. Program information may be made available in languages other than English. Persons with disabilities who require alternative means of communication to obtain program information (e.g., Braille, large print, audiotape, American Sign Language), should contact the responsible state or local agency that administers the program or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339. To file a program discrimination complaint, a Complainant should complete a Form AD-3027, USDA Program Discrimination Complaint Form which can be obtained online at: https://www.usda.gov/sites/default/files/documents/USDA-OASCR%20P-Complaint-Form-0508-0002-508-11-28- 17Fax2Mail.pdf, from any USDA office, by calling (866) 632-9992, or by writing a letter addressed to USDA. The letter must contain the complainant’s name, address, telephone number, and a written description of the alleged discriminatory action in sufficient detail to inform the Assistant Secretary for Civil Rights (ASCR) about the nature and date of an alleged civil rights violation. The completed AD-3027 form or letter must be submitted to USDA by: 1. mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410; or 2. fax: (833) 256-1665 or (202) 690-7442; or 3. email: program.intake@usda.gov This institution is an equal opportunity provider.

Page 7 Rights and Responsibilities Policy 211 December 2024

Derechos y Responsabilidades del Programa WIC de Kentucky y del Programa de Mercado de Granjeros de Kentucky ¿Necesita ayuda? Si le es difícil entender o leer el inglés, o si tiene alguna discapacidad, puede recibir ayuda con el idioma u otros apoyos y servicios sin costo alguno para usted, basta con solicitarlos. Por favor contacte a la clínica de WIC en su localidad o a la Oficina Estatal de WIC al 1-877-597-0367. Si tiene alguna discapacidad y necesita ayuda para llamarnos, contacte al Número Estatal de Retransmisión llamando al 711; o, para el servicio de voz a TDD, llame al 800-648- 6057; para el servicio de TDD a voz, llame al 800-648-6056. Mis derechos: Alimentos WIC: Si yo o mi hijo somos elegibles para WIC, recibiré una tarjeta eWIC para comprar alimentos saludables en el supermercado. Los alimentos saludables de WIC me ayudarán a mí o a mi hijo a comer sano, pero no proporcionarán todos los alimentos que yo o mi hijo necesitamos cada mes. Se me proporcionará información sobre mi paquete de alimentos WIC y dónde comprarlos. Trato justo/Derecho a presentar una queja: Los estándares de elegibilidad y participación en el Programa de WIC son los mismos para todos sin importar raza, color, origen nacional, sexo, discapacidad o edad. Tengo derecho a presentar una queja si siento que el personal de WIC o el personal de la tienda me han tratado injustamente. Educación nutricional y apoyo a la lactancia materna: Recibiré información sobre temas de nutrición que me interesen. WIC me ayudará y apoyará con la lactancia. Audiencia justa: Puedo solicitar una audiencia justa si no estoy de acuerdo con alguna decisión sobre mi elegibilidad para WIC. Los procedimientos de audiencias justas están publicados en mi oficina de WIC. Información y referidos de atención médica: WIC compartirá información sobre vacunas, búsqueda de un médico y otros servicios que pueda necesitar o que me interesen. Ayuda gratuita con la comunicación: Entiendo que si tengo dificultades para entender o leer inglés o tengo una discapacidad; dispongo de ayuda gratuita con el idioma u otros servicios y están disponibles a pedido. Cortesía común: WIC y el personal de la tienda me tratarán de manera justa y con igualdad, con cortesía y respeto, a cambio, trataré al personal del Programa WIC y de la tienda con cortesía. Si tengo inquietudes con mi experiencia de compra de WIC, me comunicaré con mi oficina de WIC o con la oficina estatal de administración de proveedores de WIC al 1-877-597-0367. Privacidad: Mi información es privada. Entiendo que los datos de WIC de mi hijo pueden compartirse con otros programas del Departamento de Salud Pública de Kentucky, como sus vacunas. Si me investigan por abuso del Programa de WIC, mi información puede ser compartida. Información sobre la transferencia en WIC: Puedo transferirme a otra oficina de WIC en o fuera de Kentucky. Puedo pedirle al personal de WIC que me brinde información necesaria para la transferencia con el fin de proporcionarla en mi nueva oficina de WIC. (Verificación de Certificación también llamada VOC). Apoderado: Entiendo que puedo designar a apoderados para que actúen en mi nombre para los servicios de WIC. Todos los apoderados deben cumplir con estos derechos y responsabilidades. Mis responsabilidades: Proporcionar información correcta: • Al firmar el formulario CH-5 de Registro, Autorizaciones, Certificaciones y Consentimiento, certifico que la información que proporcioné para mi determinación de elegibilidad de WIC es correcta, según mi leal saber y entender. Esto incluye la identidad, el estado de embarazo, la dirección, el tamaño del hogar, los ingresos del hogar y elegibilidad para Medicaid, SNAP (Programa de Asistencia Nutricional Suplementaria), TANF (Asistencia Temporal para Familias Necesitadas) • Le informaré al personal de WIC si cambian los ingresos, la dirección o el número de teléfono de mi hogar. Participación en el programa de WIC: • Si no participo (recoger/cumplir con mi cita o solicitar) durante dos meses seguidos, mi hijo o yo seremos eliminados del Programa WIC. Puedo comunicarme con mi oficina de WIC para solicitar que me reintegren si sigo siendo elegible en mi período de certificación o para que me vuelvan a certificar. • Si recibo mis beneficios de alimentos o los de mi hijo tarde, es posible que no reciba todos los beneficios de alimentos para ese mes, los beneficios de alimentos pueden reducirse según la cantidad de días restantes en el ciclo de beneficios mío o de mi hijo. Tarjeta eWIC: • Es mi responsabilidad mantener mi tarjeta eWIC segura y mi PIN Abuso de WIC: • Si tergiverso, escondo o retengo hechos para obtener WIC, se me puede pedir que reembolse el valor de los alimentos recibidos y se me retire del programa de WIC. • El comportamiento perturbador, amenaza de abuso o abusar físicamente de cualquier miembro del personal y de venta o del personal del mercado de granjeros es una infracción de las normas del Programa de WIC y puede resultar en la descalificación del programa. • Entiendo que las siguientes infracciones pueden resultar en la descalificación del programa y el reembolso de los beneficios de alimentos que se me otorgaron y me someten a un proceso civil o penal según las leyes estatales y federales: o Intercambio de alimentos complementarios por efectivo, crédito o alimentos que no sean de WIC o Comprar alimentos que no son de WIC o alimentos no autorizados; o Comprar alimentos suplementarios en exceso a lo que se me entregó; y o Vender u ofrecer vender mis alimentos de WIC o los beneficios de WIC, o el extractor de leche dado por WIC, ya sea verbalmente, por escrito o en línea, o permitir que otra persona lo haga. o Participar en más de un Programa de WIC y/o Programa de Alimentos Especiales (CSFP) al mismo tiempo. • Si le doy a alguien mi tarjeta eWIC y mi PIN y hace un mal uso de mis beneficios de alimentos, los alimentos no serán reemplazados. confidencial. (Solo comparta su tarjeta o PIN con las personas que haya identificado como apoderado) • Si pierdo, me roban o se me daña la tarjeta eWIC, debo llamar a la oficina de WIC para obtener ayuda.

Page 8 Rights and Responsibilities Policy 211 December 2024

De acuerdo con la ley federal de derechos civiles y las normas y políticas de derechos civiles del Departamento de Agricultura de los Estados Unidos (USDA), esta entidad está prohibida de discriminar por motivos de raza, color, origen nacional, sexo (incluyendo identidad de género y orientación sexual), discapacidad, edad, o represalia o retorsión por actividades previas de derechos civiles. La información sobre el programa puede estar disponible en otros idiomas que no sean el inglés. Las personas con discapacidades que requieren medios alternos de comunicación para obtener la información del programa (por ejemplo, Braille, letra grande, cinta de audio, lenguaje de señas americano (ASL), etc.) deben comunicarse con la agencia local o estatal responsable de administrar el programa o con el Centro TARGET del USDA al (202) 720-2600 (voz y TTY) o comuníquese con el USDA a través del Servicio Federal de Retransmisión al (800) 877-8339.

Para presentar una queja por discriminación en el programa, el reclamante debe llenar un formulario AD-3027, formulario de queja por discriminación en el programa del USDA, el cual puede obtenerse en línea en: https://www.usda.gov/sites/default/files/documents/USDA- OASCR%20P-Complaint-Form-0508-0002-508-11-28- 17Fax2Mail.pdf, de cualquier oficina de USDA, llamando al (866) 632-9992, o escribiendo una carta dirigida a USDA. La carta debe contener el nombre del demandante, la dirección, el número de teléfono y una descripción escrita de la acción discriminatoria alegada con suficiente detalle para informar al Subsecretario de Derechos Civiles (ASCR) sobre la naturaleza y fecha de una presunta violación de derechos civiles. El formulario AD-3027 completado o la carta debe presentarse a USDA por: (1) correo: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410; or (2) fax: (833) 256-1665 o (202) 690-7442; o (3) correo electrónico: program.intake@usda.gov Esta entidad es un proveedor que brinda igualdad de oportunidades.

Page 1 Voter Registration Policy 212 December 2024

POLICY Policy 212 Voter Registration Local WIC agencies will provide potential voters with the opportunity to register to vote and submit completed registration forms to the State Board of Election office or to the county clerk’s office if the clerk accepts without regard to the participant’s residence.

PURPOSE To comply with the National Voter Registration Act (NVRA) and increase the number of Americans registered to vote.

RELEVANT REGULATIONS PL 103-31 – National Voter Registration Act of 1993 KRS Chapter 116 – Voter Registration

PROCEDURES General NVRA Information A. The Voter Registration Policy applies to all WIC program applicants/participants regardless of WIC program eligibility determination and whether an applicant/participant chooses to register to vote or not. The choice will not affect WIC Program Services. B. Voter registration or the option to update current registration shall be provided to other persons eighteen (18) years old or older who request to register to vote. C. The NVRA specifies that any person who provides voter registration services is prohibited from: 1. Seeking to influence a participant’s political preference or party designation. 2. Displaying any such political preference or party allegiance. 3. Making any statement to a participant or taking any action to discourage the participant from registering to vote. 4. Making any statement to a participant or taking any action to lead the participant to believe that a decision to register or not register has any bearing on the availability of WIC services. *Furthermore, The NVRA sets forth criminal penalties for noncompliance with these mandates.

Clinic Staff Responsibilities A. Offer Voter Registration to all individuals who are 18 years old or older at certification, recertification, and when an address change and/or VOC transfer occurs. B. The Voter Registration Rights and Preference form (WIC 53) form shall be provided to the applicant/participant to complete each time voter registration is offered. This form provides their rights concerning registering to vote and documents the opportunity to register or decline. C. The completed WIC 53 shall be filed in a voter registration file by calendar year and retained for two calendar years. A copy of WIC 53 must be given to the individual. Refer to Section 200 Certification Appendices. D. A Voter Registration Application (SBE01) form shall be provided to every applicant/participant who answers “YES” to the Voter Preference Question. Refer to Section 200 Certification Appendices. E. The completed voter registration (SBE01) shall be accepted by WIC staff and sent to the election official. Unless the individual chooses to take the voter registration with them to complete and mail to their respective county clerk or elections office. The individual cannot be required to mail the form.

Page 2 Voter Registration Policy 212 December 2024

F. WIC staff must provide the same amount of assistance to a potential voter completing the voter registration form as they would to someone completing WIC forms unless the applicant/participant refuses it. G. If the individual refuses to read the WIC 53 form, designate preference, or sign the form, staff shall record the applicant/participant’s name and note the refusal date on the WIC 53. Two (2) staff shall sign and date the form. H. Voter Registration applications and WIC 53 forms shall be kept confidential and used for no purpose other than for voter compliance with the National Voter Registration Act of 1993.

Completed Voter Registration Forms A. Completed voter registration forms shall be sent at least weekly, except prior to an election, when forms shall be sent within five (5) days of the deadline for registration (typically 28 days prior to the election). Refer to Section 200 Certification Appendices. B. Forms may be mailed to the county clerk if the clerk accepts them without regard to the participant’s residence. If not, completed voter registration forms must be sent to the State Board of Elections, 140 Walnut Street, Frankfort, Kentucky 40601. C. If you are unsure about the validity or accuracy of the information on the completed voter registration form, send it to the local elections office and let them make the decision about the validity of the registration. D. Staff shall not determine if an individual is eligible to complete a voter registration application form. The State Board of Elections is responsible for whether to approve or deny a voter registration application and notify the person.

System Procedures for Voter Registration A. If the applicant/participant’s date of birth and reason for visit code of WIC/Cert/Recert/ WIC VOC is in the system, a message returns if voter registration is required within the calendar year. Refer to Patient and Services Reporting System “Reason for Visit Codes.” B. If this information is not in the system or the system is not available, voter registration must be offered at application, certification, recertification, and VOC transfer. C. If the system is unavailable, and the applicant/participant request to complete the voter registration application, provide the State Board of Elections form, the SBE 01. Enter NO for printing the form. D. On the registration screen, complete the “Apply to Vote” field with the applicant/participant’s preference as indicated on the WIC 53- Y for yes or N for no. If the applicant/participant refused to complete the WIC 53, put “NO” in the field. 1. If Apply to Vote is No, the process is complete. See number 4 below. 2. If Apply to Vote is Yes, put Y in the “Print Form” field to print the system voter registration application form. The system form is printed with the applicant/participant’s name, social security number, date of birth, county of residence, mailing address, sex, phone number, and date. If a post office box is provided, a residential address shall be included in the secondary field. Refer to Section 200 Certification Appendices. 3. Give the system form to the applicant/participant to complete party affiliation and residence address if different from the mailing address, read and sign. 4. Provide a copy of the WIC 53 to the applicant/participant and file a copy in the Voter Registration file. a. A copy should not be filed in the participant’s medical record.

Page 1 Proxy Policy 213 December 2024

Policy 213 Proxy POLICY A woman participant, parent, legal representative, or caretaker of an infant or child participant may designate an individual to act as a proxy when they are unable to attend their WIC appointments. A proxy may attend subsequent certifications, mid-certification health assessments (MCHA), or nutrition education, pick up food benefits, and shop for WIC-approved foods.

PURPOSE To provide an alternative procedure and minimize barriers for participants to receive WIC benefits.

RELEVANT REGULATIONS 7 CFR 246.2 – Proxy Definition 7 CFR 246.12 (r) – Issuance of food instruments, cash value, and authorized supplemental foods. 7CFR 246.12 (r) (1) – Food Delivery Systems

PROCEDURES Proxy A. During the certification visit, the woman participant, parent, legal representative, or caretaker shall be informed of their right to a proxy and of the proxy’s responsibilities. 1. Proxies may be designated by the woman participant, parent, legal representative, or caretaker: a. At the time of certification and reviewed annually, recommended at certification, or when a change is indicated. (i) All areas of the WIC Proxy Authorization form must be completed and filed in the participant’s medical record. (ii) A separate WIC Proxy Authorization form is completed for each household member. b. Proxy designee(s) may be updated at any time. c. Upon presentation of a letter/note signed and dated by the participant, parent, legal representative, or caretaker indicating the name of the individual designated as the proxy. d. Designated proxies have the same level of responsibility as the participant, parent, legal representative, or caretaker and will be held to the same standard of conduct. e. Refusal to designate a proxy must be documented in the participant’s medical record. B. A person presenting at the local WIC agency as a proxy shall be asked to show identification to assure that he/she is the authorized proxy prior to providing services, including the issuance of benefits. C. A proxy cannot be issued a WIC electronic benefits transfer (EBT) card or assigned their own pin number. The participant, parent, legal representative, and caretaker are the only authorized individuals to receive WIC EBT cards and pin numbers. D. For persons presenting to the clinic not authorized on the Kentucky WIC Proxy Authorization form, a verbal proxy authorization from the woman participant, parent, legal representative, or caretaker can be obtained in order for the person to be designated as a proxy. 1. The verbal proxy authorization must be documented on the Kentucky WIC Program Authorization form in the “verbal authorization” section. 2. The individual granting verbal proxy authorization must be informed that the intent of the authorization will allow the said proxy to obtain WIC benefits, nutrition education, and shop for WIC-approved foods. E. The woman participant, parent, legal representative, or caretaker is responsible for the proper use of food benefits, is liable for any resulting sanctions, and understands that WIC will be unable

Page 2 Proxy Policy 213 December 2024

to replace any food benefits used improperly or not made available to the WIC participant by the proxy. Refer to Policy 303- Program Integrity- Participant Violation and refer to the Proxy Form in the 200 Certification Appendices.

Page 1 Hospital Certification Requirements Policy 214 December 2024

Policy 214 Hospital Certification Requirements POLICY WIC services may be provided in the hospital when the need exists. Certification in the hospital shall expedite services and target new WIC participants. A needs assessment and Local WIC Agency hospital certification policies and procedures must be submitted to the State WIC Office for review and approval.

PURPOSE Hospital certifications shall target newborn infants of mothers active on WIC and new mothers who were not participating in WIC during their pregnancy. Participants enrolled at another agency should be referred to their agency for follow-up appointments.

RELEVANT REGULATION 7 CFR 246.6 (f) – Agreements with Local WIC Agencies, Outreach/Certification in Hospitals 246.4 (27-iii) (13-xiii) – State plan. 248.17 – Management evaluations and reviews. PL 103-31 – National Voter Registration Act of 1993 KRS Chapter 16 – Voter Registration 246.7 (k) – Certification of participants (VOC) 247.37 – Civil rights requirements Administrative Reference, Patient Service Reporting System, Household Size and Household Income

ELIGIBILITY REQUIREMENTS All eligibility requirements must be met. If proof of residence, identity, adjunct eligibility, or income is not available, a thirty (30) day certification pending presentation of proof is allowed. If all proof is presented, the certification is treated the same as any other certification.

PROCEDURES A. Identification of the applicant/participant being certified must be requested. If proof of identity is presented, the appropriate proof code shall be documented on the CH-5, CH-5WIC, or CH5-B. The hospital record, birth card, crib card, or identification bracelet is acceptable. If no documentation of identity is seen, the hospital certification code 24 is used for the identity proof code on the CH5-B. If the situation exists that proof of identity for the woman being certified cannot be provided, follow procedures as outlined in Policy 207- Required Proofs Not Present. B. Income eligibility must be determined and documented on the CH-5, CH-5WIC, or CH5-B. Determine if the applicant qualifies due to adjunct eligibility. If so, document the appropriate code on the CH-5, CH-5WIC, or CH5-B. If the applicant/participant states she is Medicaid eligible, verify this through KY Health-Net, Voice Response, or DCBS. If adjunct eligibility does not apply, household income information must be gathered to determine income eligibility. If proof of income is presented, document the proof code(s) on the CH-5, CH-5WIC, or CH5-B. If proof is not presented, the participant/caretaker must self-declare household income. The hospital certification code 24 is used as the proof code. If the situation exists that proof of household income cannot be provided, follow procedures as outlined in Policy 207- Required Proofs Not Present. C. Residence requirements must be met and documented on the CH-5, CH-5WIC, or CH5-B. Proof of residence shall be obtained, if possible, i.e., if the participant/caretaker has proof with her or if staff has access to the hospital record. In this situation, the appropriate proof code shall be recorded on the CH-5, CH5WIC, or CH5-B. If no documentation of residence can be presented, the participant must self-declare the address. The hospital certification code of 24 is used for the type of proof of residence as documented on the CH-5, CH-5WIC or CH5-B. If the situation

Page 2 Hospital Certification Requirements Policy 214 December 2024

exists that proof of residence cannot be provided, follow procedures as outlined in Policy 207- Required Proofs Not Present. D. Physical presence must be documented. Since the health professional is at the hospital, the participant shall be seen, and physical presence answered “yes.” Refer to Policy 209- Physical Presence Requirements. E. A hospital certification done without the required proof of residence, identity, and/or income is for thirty (30) days. Proof must be presented in this 30-day period to continue the certification. 1. The applicant/participant/caretaker must be informed that the certification is for 30 days, and that proof must be presented in the 30-day period to continue the certification. 2. If all proof was presented, the certification is treated the same as any other certification. 3. It is the responsibility of the site to track hospital certifications done without proof and ensure proof is presented prior to issuing food benefits past the 30 days. 4. If proof is not presented within the thirty (30) day period or proof does not support eligibility, the participant shall be determined ineligible and terminated from WIC with no further food benefits. Refer to Policy 705- Ineligibility and Discontinuation of Benefits. 5. If the participant was terminated for not bringing proof within the thirty (30) day period and later brings the proof that supports eligibility, he/she shall be reinstated if eligibility remains in the certification period. Refer to Food Delivery/Data Section. F. Initial certification at the hospital for women age 18 and over must include voter registration. Refer to Policy 212- Voter Registration. G. Nutritional risk must be determined and documented. If the health professional has access to the hospital record, information may be obtained from that record. All required medical and nutritional information must be documented in the medical record. If any data cannot be obtained, document the reason in the medical record. H. Issue food benefits. Coordinate issue dates with household members if applicable. If all required proof was seen, issue food benefits for the appropriate number of months. If the certification is pending any proof requirement, a maximum of one month of benefits can be issued. The person receiving the food benefits must present proof of identity if proof was not previously presented. The type of proof presented must be reviewed and documented in the system. Food benefit issuance must be documented in the medical record. Refer to Policy 803 Issuance of Benefits and Assigning Issue Dates. I. All appropriate forms must be completed and filed in the participant’s medical record. Medical record documentation must be completed, and all labels placed in the participant’s medical record in a timeframe not to exceed one week. J. If the system is down or unavailable, procedures must be established and in place for data entry. Data entry must be done as soon as possible but must not exceed one (1) week. WIC services are reported the same as in the clinic but with the appropriate service data and place of service.

Verification of Certification (VOC) & Hospital Certifications A. Patients in the hospital may live outside the agency service area. 1. If hospital patients outside the local WIC agency’s service area are certified, only one (1) month of food benefits can be issued. a. Upon certification, a VOC must also be issued to the participant. b. The participant shall be instructed to contact the local service agency in the area where they reside. 2. If hospital patients outside the local WIC agency’s service area are not certified, they shall be provided information about WIC and referred to the agency in their county of residence.

B. Women and infants who are initially certified in a hospital must be transferred to a receiving clinic, if applicable, for follow-up WIC appointments and services at the clinic of their choice. Any food package changes made after a participant’s hospital discharge will be made at the receiving

Page 3 Hospital Certification Requirements Policy 214 December 2024

clinic. It is the responsibility of the receiving clinic to provide breastfeeding follow-up according to state and district standards. Refer to Policy 204- Transfer/VOC.

Storage and Security of Food Benefits Storage and security of participant information, WIC equipment, and eWIC cards must be ensured at all times. eWIC cards may be assigned from a site’s inventory or a separate site may be established if appropriate.

Separation of Duties/Conflict of Interest If one staff member is determining eligibility and issuing food benefits at a hospital certification, records for the certification and issuance must be reviewed and signed by the WIC coordinator or designee within two weeks of the date of service and documented in the medical record. Procedures must also be in place to provide WIC services to employees, relatives, and household members of employees without a conflict. Refer to Policy 301-Program Integrity-Conflict of Interest and Policy 302- Program Integrity- Separation of Duties.

Quality Assurance In conjunction with quality assurance reviews, local WIC agencies are responsible for ensuring that WIC operations are reviewed in the hospital, and an Internal Review must be done at a minimum of every two (2) years. This must cover local management, memorandum of understanding agreements, certification, nutrition education, participant services, civil rights, food delivery, eWIC card benefit accountability, and financial management. The individual performing the review cannot be a person who provides services in the entity being reviewed. A form or forms must be used to document review content and findings. The agency may develop review forms for this purpose or may request State WIC Office forms. Identified deficiencies must be corrected promptly by the local WIC agency. Documentation of the internal reviews must be maintained for five (5) years. Refer to the AR, Section: Accreditation and Quality Assurance/Quality Improvement, and Refer to Policy 305- Program Integrity- Internal Review.

Civil Rights State and local WIC agencies must also comply with the Department's regulations on nondiscrimination (parts 15, 15a, and 15b of this title), and with the provisions of FNS Instruction 113-1, including the collection of racial/ethnic participation data and public notification of nondiscrimination policy. State and local WIC agencies must ensure that no person shall, on the grounds of race, color, national origin, sex (including general identity and sexual orientation), disability, age, or reprisal or retaliation, be subjected to discrimination under the program.

Page 1 Certification Risk Assessment Policy 215 October 2024 Policy 215 Certification Risk Assessment POLICY Local WIC Programs shall assess nutrition risk during the certification process to determine eligibility for WIC participation.

PURPOSE To ensure that all participants receive accurate and uniform assessment and education concerning their nutrition-related health needs.

RELEVANT REGULATIONS AND GUIDANCE 246.7(e) – Nutritional Risk WIC Consolidated Regulations-2007 The Special Supplemental Nutrition Program for Women, Infants and Children (WIC Program) Immunization Screening and Referral in WIC, 2016.

PROCEDURES Overview Applicants who meet the WIC program’s category and income eligibility standards must be determined to be at nutrition risk prior to receiving program benefits. Data collection and evaluation must occur during the certification to determine nutrition risk. A complete assessment must be done prior to providing counseling, referrals, or nutrition education. A full assessment must include: A. Evaluation of height/length and weight measurements 1. See Policy 216-Anthropometric Screening for requirements. B. Evaluation of hemoglobin/hematocrit test results 1. See Policy 217-Hemoglobin/Hematocrit for requirements. C. Review applicants’ health history and current health status D. Review typical daily intake and feeding patterns E. Consideration of infant/child development F. Discussion of environmental, safety and social factors that may affect nutrition.

Data Collection and Evaluation Accurate measures, hemoglobin/hematocrit, dietary and health information must be collected. The certifying health professional will review this information during the certification process. All data will be compared to established standards for risk assignment. Eligibility will be determined based on this evaluation.

Referral Data Using Previous Data A. Participants may bring data from their physician or health care provider to avoid duplication of medical procedures. 1. Height/length and weight measurements can be collected up to 60 days before the certification or mid-certification health assessment date. 2. Hemoglobin/Hematocrit data can be collected up to 90 days before the certification or mid-certification health assessment date.

When to Obtain Data A. Federal regulations allow blood work to be collected within 90 days after the certification date if the applicant has at least one qualifying risk factor at the time of certification. B. Data for pregnant women must be obtained during the pregnancy.

Page 2 Certification Risk Assessment Policy 215 October 2024 C. Data for postpartum and breastfeeding women must be collected after the delivery. D. Data for infants must be collected during infancy. E. Data for a child must be collected while the participant is a child, although anthropometric measures taken at 11 months of age may be used to certify a 12 or 13-month-old child.

Anthropometric Assessment Obtain accurate height or length and weight measures for each participant at each certification or mid- certification health assessment according to the guidelines in Policy 216-Anthropometric Screening.

Hemoglobin/Hematocrit Assessment Obtain hemoglobin or hematocrit data at certification or mid-certification health assessments according to the guidelines in Policy 217-Hemoglobin and Hematocrit.

Health Assessment Conduct interviews and complete the health risk assessment in the system for each participant’s certification. Utilize additional probing questions about the participant’s health history and current health status to determine the complete nutrition risk assessment and assign all appropriate risks.

Immunization Screening A. Immunization records shall be requested for infants and children applying for WIC, and the records assessed for immunization status. B. Advise the parents or caregivers that immunization records are requested as part of the WIC health screening process when scheduling an appointment for WIC certification. C. WIC staff are required to screen all WIC infants and children at each certification visit up to age 2 and should continue screening through age 4. Refer those who are under-immunized to health care provider or immunization program at the local health department. The referral must be documented. D. Immunization status/providing immunization records will not impact the availability of WIC services. E. WIC staff do not fully assess immunization status but rather screen immunization records to effectively fulfill its role as an adjunct to health care by ensuring the WIC infants and children are not under-immunized. F. Staff may request a release of information to obtain immunization records or may check the Kentucky Immunization Registry. G. Screen for immunizations by counting DTaP (diphtheria and tetanus toxoids and acellular pertussis) vaccines. 1. By three months of age, at least one dose of DTaP. 2. By five months of age, at least two doses of DTaP. 3. By seven months of age, at least three doses of DTaP. 4. By nineteen months of age, at least four doses of DTaP. 5. By four years of age, at least five doses of DTaP.

Page 3 Certification Risk Assessment Policy 215 October 2024

The below is a flow chart of the WIC screening and referral protocol.

Lead Screening Lead screening is a part of the nutrition assessment. A. For the children ages 12-35 months, determine if a blood lead screening test has never been performed or not performed in the last 12 months. Explain the impact of elevated blood lead levels on growth and development and the importance of a blood lead level screening. a. Document if the child has received a blood lead screening in the past 12 months. If lead test results are available, the data should be documented and assessed to determine if risk code 211 Elevated Blood Lead Levels should be assigned, and appropriate nutrition education provided. See Section 400, Nutrition Education Appendix and Section 200 Certification Appendix. b. If a blood lead test has not been performed, the child should be referred to the agency’s blood lead coordinator or to the child’s health care provider, depending on the agency’s protocol. This referral must be documented in the medical record.

Page 4 Certification Risk Assessment Policy 215 October 2024 B. For children ages three years and older, ask if a blood lead screening test has ever been performed. Explain the impact of elevated blood lead levels on growth and development and the importance of a blood lead level screening. a. Document if the child has received a blood lead screening in the past. If lead test results are available, the data should be documented and assessed to determine if risk code 211 Elevated Blood Lead Levels should be assigned, and appropriate nutrition education provided. See Section 400, Nutrition Education Appendix and Section 200 Certification Appendix. b. If a blood lead test has not been performed, the child should be referred to the agency’s blood lead coordinator or to the child’s health care provider, depending on the agency’s protocol. This referral must be documented in the medical record. C. In addition, a documented referral should be made to a health professional/local agency lead program if: a. The child had an elevated BLL 12 months prior and has had no interim follow-up screening. b. The child is suspected by a parent or a health care provider to be at risk for lead exposure. c. The child has a sibling or frequent playmate with an elevated BLL. d. The participant is a recent immigrant, refugee, or foreign adoptee. e. The breastfeeding or lactating woman, parent, or child’s principal caregiver works professionally or recreationally with lead. f. The family has a household member who uses traditional, folk, or ethnic remedies and cosmetics or who routinely eats unregulated/uninspected food imported from abroad. g. The family has been identified at increased risk for lead exposure by the health department because the family has local risk factors for lead exposure. D. Lead can pass through breast milk. See Policy 501 for Blood Lead Levels and Breastfeeding. E. Blood Lead testing is not an allowable WIC expense.

Documentation of Medical Home Document the participant’s Medical Home or Primary Care Physician, referral shall be made as appropriate.

Diet Assessment Conduct interview and complete a diet assessment for each participant at the certification visit. Utilize additional probing questions about the participants' feeding behaviors and diet to determine the complete nutrition risk assessment and assign all appropriate risks.

Self-reporting Diagnosis A diagnosis by a medical professional may be self-reported by the applicant/participant/ caregiver unless otherwise indicated. A self-reported medical diagnosis may prompt the health professional to ask more probing questions (whether the condition is managed by a medical professional, how to contact the professional, is condition controlled by diet or medication, and what has been prescribed) for determining risk. A referral diagnosis from a medical professional of an allowed nutritional risk shall be assumed to meet the definition.

Food Package Assignment/Nutrition Counseling A Certifying Health Professional must assign a food prescription in compliance with Policies for Prescribing Food Packages and provide nutrition education counseling.

Page 5 Certification Risk Assessment Policy 215 October 2024

Ineligibility Any applicant/participant not eligible at a certification visit must be provided the WIC-54 (Notice of Ineligibility).

Page 6 Certification Risk Assessment Policy 215 October 2024

WIC Certification Assessment Policies Situation Action Notes Nutritional Risk Priority If more than 3 risks, enter 3 with highest priority based on Nutritional Risk Code by Status and Priority. Highest priority for nutritional risk(s) will be assigned by computer.

Data may be obtained during certification period which changes priority. If new risks are found, document in medical record, provide appropriate nutrition education and submit “C” action if it will increase priority.

Pregnant woman has been admitted to the Program and the pregnancy is later questioned. Obtain supporting medical documentation (e.g., physician statement, positive pregnancy test, etc.). If pregnancy substantiated, continue certification period. If pregnancy is unsubstantiated, terminate from WIC and complete/provide WIC-54 (written notice and right to fair hearing).

Infant eligible for more than 6 months with: (a) No preventive health care or receiving healthcare at health department.

(b) Preventive care by Physician.

(a) Advise of other health care services (e.g., Well Child, EPSDT, immunizations, etc.) Refer to physician, if appropriate.

(b) Document receiving health care by a physician.

Document referrals in medical record.

Page 1 Anthropometric Screening Policy 216 December 2024

Policy 216 Anthropometric Screening POLICY Appropriate procedures and equipment will be used to obtain participant weight, length, or height measurements in WIC Clinics.

PURPOSE To ensure consistent and accurate measurements are used to determine program eligibility.

RELEVANT REGULATIONS 246.7(e)(1)(i)(A) and (B) – Required nutritional risk data 246.7(e)(1)(ii)(A) – Weight and height or length 246.7(e)(2)(i)(A) – Nutritional Risk Criteria PROCEDURES Allowable Equipment Using appropriate medical-grade equipment to obtain anthropometric measurements is essential for accuracy. Accurate weight and height or length measurements are required for determining risk assignment associated with eligibility screening during each certification and mid-certification health assessment. A. Weigh infants and children under the age of two years on a pediatric balance beam or electronic scale. B. Weigh children over the age of two years and women on an adult balance beam or electronic scale that is placed on a hard surface. C. Measure infants and children under the age of two years laying on a recumbent measure board with a stationary headboard and a sliding vertical footboard that is placed on a flat surface. D. Measure children over the age of two years and women in a standing position with a graduated rule or tape attached to the wall and a flat surface that is placed horizontally on top of the head. E. Measure children between the ages of 2 and 3 years old who cannot stand unassisted on a recumbent measure board with a stationary headboard and a sliding vertical footboard that is placed on a flat surface.

Equipment Maintenance All scales used for weighing participants must be professionally calibrated annually. The date of the most recent calibration must be affixed to the equipment. Scales found to be out of calibration must be repaired, or replaced if damaged or defective, in a timely manner.

Appropriate Measuring Techniques Height A. Children less than two years of age and age 2 years to 3 years who cannot stand unassisted. 1. Lay the child flat against the center of the board. 2. The head shall be held against the headboard by the parent or an assistant and the knees held so that the hips and knees are extended. 3. The foot piece is moved until it is firmly against the child’s heels. 4. Read and record the measurement to the nearest 1/8 inch. B. Children over age two years and women 1. Obtain a standing height. 2. The participant is to be wearing socks or be bare foot. Shoes must be removed. 3. Participants shall remove hats, glasses or any hair accessories that could hinder an accurate measurement from top of head. 4. Have the participant stand with head, shoulder blades, buttocks and heels touching the wall. 5. The knees are to be straight and feet flat on the floor. 6. Participant shall be asked to look straight ahead. 7. The flat surface is lowered until it touches the crown of the head, compressing the hair. 8. Read and record the measurement to the nearest 1/8 inch. Weight

Page 2 Anthropometric Screening Policy 216 December 2024

A. Prior to obtaining weight measurements, make sure the scale is “zeroed.” B. Weigh infants only wearing a dry diaper or light undergarments. C. Weigh children and women after removing outer clothing and shoes. D. Have the participant stand in the middle of the scale. E. Read the measurement immediately and record the measurement.

Medical Data Requirements by Status Measurements must be completed at the certification or mid-certification health assessment, must be reflective of the current status, and documented in the participant’s medical record. A. Pregnant Women 1. Height and weight taken during this pregnancy a. Height and weight may be performed at the visit or may be referral data if less than 60 days from the certification date. 2. Pre-pregnancy weight recorded by referral data or self-reported B. Breastfeeding and Postpartum Women 1. Height and weight taken after termination of pregnancy, a. Height and weight may be performed at the visit or maybe referral data if less than 60 days from certification/mid-certification health assessment date. 2. Pre-pregnancy weight recorded by referral data or self-reported C. Infants 1. Length and weight are taken. a. Length and weight may be performed at the visit or may be referral data if less than 60 days from certification/mid-certification health assessment date. 2. Birth weight is recorded by referral data or self-reported. 3. Birth weight may be used for initial certification if less than 60 days from the certification date. 4. Must document gestational age. 5. Must plot length and weight on 0-24 month growth chart adjusted for gestational age (note: due to not being full gestation, the growth chart will not plot for less than 40-week gestation) D. Child 1. Birth weight and gestational age is required for children under age 2. a. Birth weight and gestational age may be self-reported or referral data 2. Height and weight must be taken and recorded. a. Height and Weight may be performed at the visit or may be referral data if less than 60 days from certification/mid-certification health assessment date. 3. Must plot height and weight on the appropriate growth chart. *Referral data may be from outside sources or services in the clinic. The Kentucky Referral Form in the 200 Certification Appendices is available to provide participants to collect referral data. If the health professional determines referral data does not reflect current health status, measures may be repeated.

Growth Chart Requirements by Status Retain the most current CDC growth chart in the medical record. A. Pregnant Woman 1. No Growth chart B. Breastfeeding or Post-Partum Woman 1. ≤20 years old – The computer system will plot for age, weight, and BMI for age on CDC 2-20-year growth chart.* 2. ≥20 years old – No Growth Chart C. Child – 12 months to ≤24 months 1. Computer system will plot length for age, weight for age, and weight for length on CDC 0-24-month growth chart * a. Automated growth chart will plot age-adjusted based on the date of birth and expected delivery date up to age 2 years. D. Child- 24 months to 36 months

Page 3 Anthropometric Screening Policy 216 December 2024

1. If child’s height is measured recumbent (lying down) then document that measurement was recumbent in the computer system. The computer system will plot length for age, weight for age and weight for length on CDC 0-36-month growth chart. * E. Child-2 years to ≤5 years of age 1. Computer system will plot standing height for age, weight for age, and BMI for age on CDC 2-20- year growth chart. * F. Infant – Birth to ≤12 months 1. Computer system will plot length for age, weight for age, and weight for length on CDC 0-24-month growth chart. * a. Automated growth chart will plot age-adjusted based on the date of birth and expected delivery date (gestational age). The automated growth chart will NOT plot for measures less than 40 weeks gestation, age-adjusted. G. If the computer system is not available at the time measurements are taken, then measurements are to be entered into the computer system when it is operational. The growth chart must be printed and filed in the participant’s medical record.

Growth Chart Requirements Plotting of the growth chart is required, as outlined below. Status Age Growth Chart Pregnant Woman • None Breastfeeding or Postpartum Woman ≥ 20 years old • None < 20 years old • System will plot height for age, weight for age, and BMI for age on CDC 2-20 year growth chart*. Child 12 months to ≤ 24 months of age* • System will plot length for age, weight for age, and weight for length on CDC 0-24 month growth chart*. Retain most current CDC 0-24 month growth chart in the medical record. • Automated Growth Chart will plot age adjusted based on the date of birth and expected delivery date (gestational age) up to age 2. 2 years to < 5 years of age • Measure height standing. • System will plot height for age, weight for age, and BMI for age on CDC 2-20 year growth chart. • Retain the most current CDC 2-20 year growth chart in the medical record*. 24 months to ≤ 36 months of age • If unable to measure height of child standing, obtain recumbent length (lying). Indicate measurement was recumbent in system. System will plot length for age, weight for age, and weight for length on CDC 0-36 month growth chart. Retain the most current CDC 0- 36 month growth chart in the medical record. Infant Birth to < 12 months • System will plot length for age, weight for age, and weight for length on CDC 0-24 month growth chart*. Retain most current CDC 0-24 month growth chart in the medical record. • Automated Growth Chart will plot age adjusted based on the date of birth and expected delivery date (gestational age). Automated Growth chart will not plot for measures less than 40 weeks gestation, age adjusted. *Note: Based on World Health Organization Standards (WHO)

Page 1 Hemoglobin and Hematocrit Screening in WIC Policy 217 December 2024 POLICY Policy 217 Hemoglobin and Hematocrit Screening in WIC A hematological test for anemia will be performed or obtained following the screening guidelines for the participant category. Appropriate procedures and equipment will be used when performing hemoglobin or hematocrit tests in WIC clinics. PURPOSE To ensure a measurement of hemoglobin or hematocrit is part of the full WIC assessment in order to determine appropriate nutrition risk; and is also used to provide nutrition education and appropriate referrals. To protect the safety of applicants and personnel performing the tests and to ensure accurate test results. RELEVANT REGULATIONS 246.7(e)(1)(i)(A) and (B) – Required nutritional risk data 246.7(e)(1)(ii)(B) – Hematological test for anemia USDA Policy Memo #140-26 PROCEDURES Screening Guidelines Obtain hemoglobin (hgb.) or hematocrit (hct.) data at certification or mid-certification health assessments according to the appropriate guidelines for the participant category. A. Pregnant Women 1. Certification a. Must have hgb./hct. taken during this pregnancy. b. This test may be performed at certification or may be referral data if taken during this pregnancy. Bloodwork data must 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 and the agency has implemented procedures to ensure receipt of data. c. Hgb./hct. must be evaluated by criteria for trimester it was obtained. 2. Follow-up a. One hgb./hct. may only be performed if low result was previously documented. B. Breastfeeding Women 1. Certification/mid-certification health assessment a. Must have hgb./hct. taken after termination of pregnancy, b. Hbg./hct. may be performed at certification or may be referral data if reflective of current status. Bloodwork data must 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, and the agency has implemented procedures to ensure receipt of data. c. A hemoglobin shall be obtained between 6-12 months postpartum if an abnormal test result is obtained. C. Postpartum Women 1. Certification a. Must have hgb./hct. taken after termination of pregnancy, b. Hbg./hct. may be performed at certification or may be referral data if reflective of current status. Bloodwork data must be collected within 90 days of certification, so long as the participant is determined to have at least one qualifying nutritional

Page 2 Hemoglobin and Hematocrit Screening in WIC Policy 217 December 2024

risk at the time of certification and the agency has implemented procedures to ensure receipt of data. 2. Follow-up a. One hgb./hct. may only be performed if low result was documented previously. D. Infants 1. Certification/mid-certification health assessment a. Infants certified prior to 9 months of age do not require a hgb./hct. performed at certification. b. Infants certified between 9-12 months of age must have hgb./hct. performed or obtain referral data. Bloodwork data must 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 and the agency has implemented procedures to ensure receipt of data. c. Infants must have a hgb./hct. test performed between 9-12 months of age this may be obtained at the one-year certification appointment. E. Children 1. Certification/mid-certification health assessment a. Children must have a hg./hct. performed at age 15-24 months obtained six months after the most recent screening. b. Children must have hgb./hct. screening done at a minimum of annually between 24-60 months. c. Hgb./hct. levels below normal levels must be repeated every 6 months for all children over age 12 months until a normal level is obtained. d. Data may be obtain in clinic or from referral data. e. Bloodwork data must 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 and the agency has implemented procedures to ensure receipt of data.

Example for an infant certified at birth:

Age at Service Infant less than 9 months of age Hgb/Hct conducted N/A Infant Mid-Certification health assessment N/A Child Certification at 12 months of age Yes, meets the 9-12 month infant requirement Child Mid-Certification health assessment at 18 months of age Yes, meets the 15-24 months child requirement Child Certification at 24 months • Yes, if low at 18 months • N/A if normal at 18 months Child Mid-Certification at 30 months • Yes, if low at 24 months or not performed at 24 months to meet the annual requirement. • No if normal at 24 months. • Will be conducted at least annually from this point. *Referral data may be obtained from an outside source or services in clinic. If the health professional determines referral data does not reflect current health status measures may be repeated.

Referral Data If the participant, parent or caregiver has a documented result of a hemoglobin or hematocrit performed by a medical provider within 90 days of the date of certification or mid-certification health assessment, it is not necessary to repeat the hematological test. Enter the referral data and date of measurement in the system. The Kentucky WIC Referral Form in the Forms and Supporting Documentation Appendix of this section is available to provide participants to take to their healthcare provider to collect referral data.

Page 3 Hemoglobin and Hematocrit Screening in WIC Policy 217 December 2024

Unable to Complete Bloodwork during WIC Certification or Mid-Certification Health Assessment Visit If unable to complete to obtain hemoglobin or hematocrit test on date if WIC Certification or MCHA, the certification may be conducted as long as at least 1 qualifying nutrition risk code criteria has been identified and a procedure is in place to ensure collection of data within 90 days (referral data or collected next scheduled WIC visit).

Blood Collecting Exceptions Do not do a blood test in the following situations A. Participants whose religious beliefs will not allow him or her to have blood drawn. B. Participants with a medical conditions such as, hemophilia, fragile bones, or a serious skin condition where the blood collection could cause harm to the participant. 1. Medical documentation from a physician or ARNP must be included in the medical record. 2. If the condition is curable but still exists, a new statement from the physician or ARNP is required at each certification. 3. A new statement is not required for a “lifelong” medical condition. C. Contact the State WIC Office with any questions, additional clarification or for any other situations not addressed in this policy.

Tests Results Normal and Abnormal Ranges of Hemoglobin Category Hemoglobin Value (g/dL) Referral Low Normal Infants 9-12 months Below 9.0 9.0-10.9 11.0 and higher Children 12-24 months Below 9.0 9.0-10.9 11.0 and higher Children 2-5 years Below 9.0 9.0-11.0 11.1 and higher Pregnant women 0-13 weeks gestation Below 9.0 9.0-10.9 11.0 and higher Pregnant women 14-26 weeks gestation Below 9.0 9.0-10.4 10.5 and higher Pregnant women 27-40 weeks gestation Below 9.0 9.0-10.9 11.0 and higher Postpartum women Below 9.0 9.0-11.9 12.0 and higher

Referrals may be made based on hemoglobin test results. A. If hemoglobin values are in the referral range, provide nutrition counseling on food sources of iron and ways to increase iron absorption, refer participants to the primary care provider and perform screening and assessment at mid-certification health assessment. B. If hemoglobin values are in the low range, provide nutrition counseling to the participant or parent/caregiver on food sources of iron and way to increase iron absorption. If a hgb./hct. value is due to another type of anemia, for example, sickle cell anemia, document details. Recheck values at mid-certification health assessment.

Approved Equipment for Hematological Screening Approved equipment for hematological screening for the WIC Program include: A. HemoCue Hb 201analyzer B. HemoCue Hb 301 analyzer C. Pronto Plus Co Oximeter/Hemoglobin Analyzer (Non-Invasive) D. Contact the State Agency for use of any other hematological analyzers

Page 4 Hemoglobin and Hematocrit Screening in WIC Policy 217 December 2024

Use of Non-Invasive Device E. The non-invasive device may be used to obtain hemoglobin results. F. The Pronto (non-invasive device) must be utilized when there is a concern in obtaining consent to prevent a barrier to WIC services. G. Below is a chart of when a hematological test is required and if the non-invasive device may be used.

Status Certification Age Hgb./Hct. Required May Utilize Pronto Machine Infant Birth- < 9 months old No No 9 months-12 months (Including 11 month old child certification) Yes No Child 1 Year Yes No 18 months old Yes No 2 Years-5 Years Yes Yes Women N/A Yes Yes **After two unsuccessful attempts to obtain a reading using the non-invasive device, a finger stick shall be performed.

Tips for Use of Pronto Non-Invasive Device A. Client needs to sit quietly for approximately 1 minute while the test is being completed. B. Dark fingernail polish may interfere with the test results. C. Cold fingers may interfere with the test results.

Page 1 Risk Criteria Codes and Descriptions Policy 218 December 2024

Policy 218 Risk Criteria Codes and Descriptions POLICY The certifying health professional shall use this list of risk criteria, code and descriptions when assigning nutrition risks to program applicants.

PURPOSE To specify and define allowable nutrition risk used in the Kentucky WIC Program. To ensure that consistent assessment and assignment of risks to applicants throughout the state.

RELEVANT REGULATIONS 7 CFR 246.7 – Nutritional Risks USDA, FNS, WIC Nutrition RISK Criteria, WIC Policy Memorandum 2011-5; May 2011. USDA, FNS, Value Enhanced Nutrition Assessment (VENA) - WIC Nutrition Assessment Policy, WIC Policy Memorandum 2006-5; March 2006. USDA, FNS, Nutrition Risk Criteria, WIC Policy Memorandum 98-9; June 1998. USDA, FNS, Transmittal of Revised and Corrected Nutrition Risk Criteria, May 2017.

DEFINITIONS Nutrition Risk Criteria (NRCC): The USDA risk criteria numbering system that is used to document nutrition risks in the data system.

PROCEDURES Assigning nutrition risks A. The following must be done at each certification: 1. Review health and lifestyle data from the medical record (i.e. height, weight, hemoglobin, etc.). Interview the applicant/caretaker/proxy using Value Enhanced Nutrition Assessment methodology for all other applicable criteria. Apply the information to nutrition risk criteria. 2. One NRCC makes the applicant eligible for WIC. Although one NRCC qualifies the applicant, assessment must be conducted to determine all eligible risks and all eligible risks must be assigned and documented. (See “B. Nutrition Risk Assessment” for more information.) 3. Document all risk criteria applicable to the participant electronically in the system, print appropriate certification form and place in the participant’s medical record.* 4. Sign and date the WIC 75 and place in the participant’s medical record. *When system if down use manual WIC forms and enter information in system within 48 hours. The Manual WIC- 75 forms can be found the 200 Certification Appendices.

B. Nutrition Risk Assessment: 1. Serves as the foundation on which other nutrition services are planned and provided. 2. Begins with Valued Enhanced Nutrition Education (VENA) and includes: a. Participant centered nutrition education and counseling; and b. Open ended questions to determine participant’s concerns or questions. i. May be appropriate to gather more information to determine management of a condition by asking questions such as: • Is the condition managed by a medical professional? • Is the condition controlled by diet or medication? • What was medication prescribed? • How may contact be made with the professional (if further information for care is needed)? 3. Beyond determining WIC eligibility, the nutrition assessment is utilized to: a. Enhance the interaction between the Certifying Health Professional and WIC participant;

Page 2 Risk Criteria Codes and Descriptions Policy 218 December 2024

b. Link the collected health and diet information to the delivery of participant centered relevant nutrition education; c. Make referrals; and d. Assign and tailor the food package.

Page 3 Risk Criteria Codes and Descriptions Policy 218 December 2024

C. Nutrition Risk Code by Status and Priority Table Nutrition Risk Criteria Code Pregnant Priority Breastfeeding Priority Postpartum Priority Infant Priority Child Priority Low Hct./Hgb. 201 01 01 3B 01 3A Elevated Blood Lead 211 01 01 3B 01 3A Low Head Circumference 152 01 3A* Preterm/Early Term Birth 142 01 3A* Low Birth Weight/Very Low Birth Weight 141 01 3A* At Risk for Overweight 114 01 3A Overweight/Obesity/High Wt for Length 111, 113-115 01 01 3B 3A At Risk for Underweight 103 01 3A Underweight 101 & 103 01 01 3B 01 3A At Risk for Short Stature 121 01 3A Short Stature 121 01 3A Growth Problems 151 &153 01 3A♦ Inappropriate Weight Gain Pattern 131,132,133,1 34 & 135 01 01 3B 01 3A Alcohol and Substance Use 371 0& 372 01 01 3B Environmental Tobacco Smoke Exposure 904 01 01 3B 01 3A BF Infant/BF Woman at Nutritional Risk 601 01 01 01 BF Complications 602 01 01 01 BF Infant/BF Woman with Feeding Practices 601 01 04 04 Infant of WIC Mother/Mother at Risk 701 02 Pregnancy Induced Conditions 301,302,303 & 304 01 01 3B Delivery of Preterm/Early Term/ LBW Infant 311 & 312 01 01 3B Fetal or Neonatal Death 321 01 01 3B General Obstetrical Risk 331-337, & 339 01 01 3B Nutrition/Metabolic Conditions 341-357, 359, 360, 363 01 01 3B 01 3A Impaired Ability to Prepare Food 902 04 04 06 04 5A** 5B*** Complications which Impair Nutrition 361 & 362 01 01 3B 01 3A Dental Problems 381 01 01 3B 01 3A Fetal Alcohol Spectrum Disorder 382 01 01 3A 01 3A Neonatal Abstinence Syndrome 383 01 Presumed Dietary Risk 401 04 04 06 5B*** Feeding Practices 411, 425, & 427 04 04 06 04 5A** 5B*** Inappropriate Nutrient Intake 425 & 427 04 04 06 5A** 5B*** Eating Disorders 358 01 01 3B Recipient of Abuse 901 04 04 06 04 5A** 5B*** Foster Care 903 04 04 06 04 5A** 5B*** Homelessness 801 04 04 06 04 5A** 5B*** Migrancy 802 04 04 06 04 5A** 5B*** Possibility of Regression-Priority III 501 3A Possibility of Regression-Priority IV 501 5A** 5B*** Transfer of Certification 502 01 01 3B 01 3A

Page 4 Risk Criteria Codes and Descriptions Policy 218 December 2024

Nutrition Risk Code by Status and Priority D. Nutrition Risk Criteria Allowed for WIC Program Certification USDA Code Risk Criteria Definition/Cutoff Categories and Priorities Anthropometric 101 Underweight (Women) • Pregnant women-pre-pregnancy body mass index (BMI) < 18.5 • Postpartum women and breastfeeding women who are < 6 months postpartum-pre-pregnancy or current BMI <18.5 • Breastfeeding women who are ≥ 6 months postpartum-current BMI <18.5 Woman Pregnant, Woman Fully Breastfeeding, Woman Partially Breastfeeding- 01 Woman Postpartum-04 103 Underweight (Infants and Children) • Underweight: o Birth to <24 months: ≤ 2% weight for length o 2-5 years: ≤ 5% BMI for age • At Risk for Underweight o Birth to < 24 months: > 2% and ≤ 5% weight for length o 2-5 years: > 5% and ≤ 10% BMI for age Infant-01 Child-03 111 Overweight (Women) • Pregnant women-pre-pregnancy BMI ≥ 25 • Postpartum women and breastfeeding women who are < 6 months postpartum-pre-pregnancy BMI ≥ 25 • Breastfeeding women who are ≥ 6 months postpartum-current BMI ≥ 25 Woman Pregnant, Woman Fully Breastfeeding, Woman Partially Breastfeeding- 01 Woman Postpartum-04 113 Overweight (Children 2-5 years of age) • ≥ 24 months to 5 years: ≥ 95% BMI for age Child-03 114 At Risk for Overweight (Child 2-5 years of age) • ≥ 24 months to 5 years: ≥ 85% and 95% BMI for age Child-03 115 High Weight for Length(Infants and Children < • Birth to < 24 months: ≥ 98% weight for length Infant-01 Child-03

Page 5 Risk Criteria Codes and Descriptions Policy 218 December 2024

24 months of age) 121 Short Stature • Short Stature: o Birth to < 24 months: 2% length for age o 2-5 years: ≤ 5% height for age • At Risk for Short Stature: o Birth to < 24 months: >2% and ≤5% length for age o 2-5 years: >5% and ≤10% height for age Infant-01 Child-03 131 Low Maternal Weight Gain • In the 2nd and 3rd trimesters, singleton pregnancies, weight gain: o Underweight < 1 pound per week o Normal < 0.8 pounds (12.8 oz.) per week o Overweight < 0.5 pounds (8 oz.) per week o Obese < 0.4 pounds (6.4 oz.) per week • Low weight gain at any point in pregnancy based on the following total weight gain ranges: o Underweight-28-40 pounds o Normal Weight-25-35 pounds o Overweight-15-25 pounds o Obese-11-20 pounds Woman Pregnant-01 133 High Maternal Weight Gain • In the 2nd and 3rd trimesters, singleton pregnancies weight gain: o Underweight > 5.2 pounds per month o Normal > 4 pounds per month o Overweight > 2.8 pounds per month o Obese > 2.4 pounds per month Woman Pregnant, Woman Fully Breastfeeding, Woman Partially Breastfeeding- 01 Woman Postpartum-04 134 Failure to Thrive • Presence of Failure to Thrive diagnoses by a physician as self- reported by applicant/participant/caregiver; or as reported or documented by physician, or someone working under physician’s orders. Base diagnosis on failure to thrive for premature infants on gestation age adjustment for low birth weight or very low birth weight. Infant-01 Child-03 135 Slowed or Faltering Growth Patterns • Infants from birth to 2 weeks of age o Excessive weight loss after birth defined as ≥7% of birth weight o Not back to birth weight by 2 weeks • Infants from 2 weeks to 6 months of age Infant (<6 months)-01

Page 6 Risk Criteria Codes and Descriptions Policy 218 December 2024

o Any weight loss. Use 2 separate weights taken at least 8 weeks apart. 141 Low Birth Weight • For infants and children <24 months of age • Birth weight ≤5 lbs. 8 oz./2500g. (LBW) • Birth weight ≤3 lbs. 5 oz./1500 grams (VLBW) Infant-01 Child-03 142 Preterm or Early Term Delivery • For infants and children <24 months of age • Preterm delivery: Delivery on or before 36 weeks 6 days gestation • Early term delivery: Delivery between 37 weeks 0 days and 38 weeks 6 days gestation Infant-01 Child-03 151 Small for Gestational Age (SGA) • For infants and children < 24 months of age • Presence as diagnosed by a physician as self-reported by applicant/participant/caregiver; or as reported or documented by a physician, or someone working under physician’s orders. Infant-01 Child-03 152 Low Head Circumference • For infants and children < 24 months of age: ≤ 2.3rd percentile head circumference for age. • Note: premature infants and children with a history of prematurity, base assignment on adjusted for gestational age. Infant-01 Child-03 153 Large for Gestational Age (LGA) • Birthweight ≥ 9 lbs (≥4000g) • Presence as diagnosed by a physician as self-reported by applicant/participant/caregiver; or as reported or documented by a physician, or someone working under physician’s orders. Infant-01 Biochemical 201 Low Hematocrit/Low Hemoglobin • Hemoglobin or Hematocrit that is below the normal levels. • Cut off values are included Policy 217- Hemoglobin and Hematocrit Screening. Woman Pregnant, Woman Fully Breastfeeding, Woman Partially Breastfeeding- 01 Woman Postpartum-04 Infant-01 Child-03 211 Lead Poisoning • Blood lead levels ≥ 5 µg/dL within the past 12 months for women and infants • Blood lead levels ≥ 3.5 µg/dL within past 12 months for children. Woman Pregnant, Woman Fully Breastfeeding, Woman Partially Breastfeeding- 01

Page 7 Risk Criteria Codes and Descriptions Policy 218 December 2024

Woman Postpartum-01 Infants-01 Child-03 Clinical/Health/Medical Conditions 301 Hyperemesis Gravidarum • Severe nausea and vomiting to the extent that the pregnant woman becomes dehydrated and acidotic. • Presence of condition diagnosed, documented, or reported by a physician or someone working under a physician’s orders, or as self- reported by applicant/participant/caregiver. Self-reporting a diagnosis by a medical professional should not be confused with self-diagnosis, where a person simply claims to have or to have had a medical condition without any reference to professional diagnosis. Woman Pregnant-01 302 Gestational Diabetes • Presence of gestational diabetes diagnosed by physician as self- reported by applicant/participant /caregiver, or as reported or documented by a physician, or someone working under physician orders Woman Pregnant-01 303 History of Gestational Diabetes • History of diagnosed gestational diabetes. May or may not have been insulin dependent. Woman Pregnant, Woman Fully Breastfeeding, Woman Partially Breastfeeding- 01 Woman Postpartum-04 304 History of Preeclampsia • History of diagnosed preeclampsia. • Presence of condition diagnosis, documented or reported by a physician or someone working under a physician’s orders or as self- reported by applicant/participant/caregiver. Woman Pregnant, Woman Fully Breastfeeding, Woman Partially Breastfeeding- 01 Woman Postpartum-03 311 History of Preterm or Early Term Delivery • Birth of an infant at/or before 38 weeks 6 days gestation in any pregnancy for a pregnant woman or during most recent pregnancy only for a postpartum or breastfeeding woman. Woman Pregnant, Woman Fully Breastfeeding, Woman Partially Breastfeeding- 01 Woman Postpartum-04 312 History of Low Birthweight • Birth of an infant weighing ≤5 lb. 8 oz. Any pregnancy for woman pregnant, most recent pregnancy for postpartum or breastfeeding woman. Woman Pregnant, Woman Fully Breastfeeding, Woman

Page 8 Risk Criteria Codes and Descriptions Policy 218 December 2024

Partially Breastfeeding- 01 Woman Postpartum-04 321 History of fetal or neonatal loss • A fetal death (death at ≥20 weeks gestation) or a neonatal death (0- 28 days of life) • Pregnant-any history of fetal or neonatal death • Postpartum-most recent pregnancy • Breastfeeding-most recent pregnancy with one or more infants still living Woman Pregnant, Woman Fully Breastfeeding, Woman Partially Breastfeeding- 01 Woman Postpartum-04 331 Pregnancy at a young age • Conception ≤20 years of age. • Current pregnancy for pregnant woman • Most recent pregnancy for postpartum or breastfeeding woman. Woman Pregnant, Woman Fully Breastfeeding, Woman Partially Breastfeeding- 01 Woman Postpartum-04 332 Closely spaced pregnancy • Conception before 18 months postpartum. • Pregnancy-current pregnancy • Breastfeeding or postpartum-most recent pregnancy only Woman Pregnant, Woman Fully Breastfeeding, Woman Partially Breastfeeding- 01 Woman Postpartum-04 333 High parity and young age • Woman <20 years old at time of conception who have had 3 or more previous pregnancies of ≥20 weeks gestation regardless of birth outcome • Pregnancy-current pregnancy • Breastfeeding or postpartum woman-most recent pregnancy only Woman Pregnant, Woman Fully Breastfeeding, Woman Partially Breastfeeding- 01 Woman Postpartum-04 334 Lack or inadequate prenatal care • Prenatal care beginning after 13th week of pregnancy or 1st prenatal visit in third trimester Woman Pregnant-01 335 Multiple fetus pregnancy • More than 1 fetus in a current pregnancy (Woman Pregnant) or the most recent pregnancy (postpartum or breastfeeding woman) Woman Pregnant, Woman Fully Breastfeeding, Woman Partially Breastfeeding- 01 Woman Postpartum-04

Page 9 Risk Criteria Codes and Descriptions Policy 218 December 2024

336 Fetal Growth Restriction (FGR) • Fetal Growth Restriction may be diagnosed by a physician with serial measurement of fundal height, abdominal girth, and can be confirmed with ultrasound. • Defined a fetal growth below the 10th percentile for gestational age. • May be diagnosed by a physician as self-reported by applicant/participant/caretaker or as reported or documented by a physician or someone working under physician’s orders. Woman Pregnant-01 337 History of birth of a large for gestational age infant • History of birth of an infant weighing ≥ 9 lbs. • Pregnant-any pregnancy • Postpartum or breastfeeding-most recent pregnancy only Woman Pregnant, Woman Fully Breastfeeding, Woman Partially Breastfeeding- 01 Woman Postpartum-04 338 Pregnant woman currently breastfeeding • Pregnant woman who is currently breastfeeding. Woman Pregnant-01 339 History of birth with nutrition related congenital birth defects • A woman who has given birth to an infant who has a congenital or birth defect linked to inappropriate nutritional intake (i.e. inadequate zinc, folic acid or excessive vitamin A). • Pregnant-any pregnancy • Postpartum or breastfeeding-most recent pregnancy only Woman Pregnant, Woman Fully Breastfeeding, Woman Partially Breastfeeding- 01 Woman Postpartum-04 341 Nutrient deficiency disease • Diagnosis of nutritional deficiencies or a disease caused by insufficient dietary intake of macro- and micronutrients. Diseases include but are not limited to: Protein Energy Malnutrition, Scurvy, Rickets, Berberi, Hypocalcemia, Osteomalacia, Vitamin K deficiency, Pellagra, Cheilosis, Menkes Disease, xeropthlamia. • May be diagnosed by physician as self-reported by applicant/participant /caregiver, or as reported or documented by a physician, or someone working under physician orders Woman Pregnant, Woman Fully Breastfeeding, Woman Partially Breastfeeding- 01 Woman Postpartum-01 Infants-01 Child-03 342 Gastro-intestinal disorders • Diseases on conditions that interfere with the intake or absorption of nutrients. • These conditions include but are not limited to: o Stomach or intestinal ulcers, small enterocolitis or short bowel syndrome, malabsorption syndrome, inflammatory bowel disease (ulcerative colitis or Crohn’s Disease), liver disease, pancreatitis, Woman Pregnant, Woman Fully Breastfeeding, Woman Partially Breastfeeding- 01 Woman Postpartum-01

Page 10 Risk Criteria Codes and Descriptions Policy 218 December 2024

bilary tract and gallbladder disease, gastroesophageal reflux disease (GERD), post bariatric surgery. • May be diagnosed by a physician as self-reported by applicant/participant/caretaker or as reported or documented by a physician or someone working under physician’s orders. Infants-01 Child-03 343 Diabetes mellitus • May be diagnosed by a physician as self-reported by applicant/participant/caretaker or as reported or documented by a physician or someone working under physician’s orders. Woman Pregnant, Woman Fully Breastfeeding, Woman Partially Breastfeeding- 01 Woman Postpartum-01 Infants-01 Child-03 344 Thyroid disorders • May be diagnosed by a physician as self-reported by applicant/participant/caretaker or as reported or documented by a physician or someone working under physician’s orders. • These include but are not limited to hyperthyroidism, hypothyroidism, congenital hyperthyroidism, congenital hypothyroidism or postpartum thyroiditis. Woman Pregnant, Woman Fully Breastfeeding, Woman Partially Breastfeeding- 01 Woman Postpartum-01 Infants-01 Child-03 345 Hypertension and prehypertension • Hypertension is defined as high blood pressure which may eventually cause health problems and includes chronic hypertension during pregnancy, preeclampsia, eclampsia, chronic hypertension with superimposed preeclampsia and gestational hypertension. • Prehypertension is defined as being at high risk for developing hypertension, based on blood pressure levels. • May be diagnosed by a physician as self-reported by applicant/participant/caretaker or as reported or documented by a physician or someone working under physician’s orders. Woman Pregnant, Woman Fully Breastfeeding, Woman Partially Breastfeeding- 01 Woman Postpartum-03 Infants-01 Child-03 346 Renal disease • Any renal disease including pyelonephritis and persistent proteinuria but excluding urinary tract infections (UTI) involving the bladder. • May be diagnosed by a physician as self-reported by applicant/participant/caretaker or as reported or documented by a physician or someone working under a physician’s orders Woman Pregnant, Woman Fully Breastfeeding, Woman Partially Breastfeeding- 01 Woman Postpartum-01

Page 11 Risk Criteria Codes and Descriptions Policy 218 December 2024

Infants-01 Child-03 347 Cancer • May be diagnosed by a physician as self-reported by applicant/participant/caretaker or as reported or documented by a physician or someone working under physician’s orders • The current condition or treatment for the condition, must be severe enough to affect nutritional status. Woman Pregnant, Woman Fully Breastfeeding, Woman Partially Breastfeeding- 01 Woman Postpartum-01 Infants-01 Child-03 348 Central nervous system disorders • Conditions that alter nutrition status metabolically and/or mechanically, which affect energy requirements and may affect the individuals’ ability to feed him/herself. • These include but are not limited to epilepsy, cerebral palsy (CP), neural tube defects such as spina bifda, or myelomenigocele. • May be diagnosed by a physician as self-reported by applicant/participant/caretaker or as reported or documented by a physician or someone working under a physician’s orders Woman Pregnant, Woman Fully Breastfeeding, Woman Partially Breastfeeding- 01 Woman Postpartum-01 Infants-01 Child-03 349 Genetic and congenital disorders • May be diagnosed by a physician as self-reported by applicant/participant/caretaker or as reported or documented by a physician or someone working under a physician’s orders • Hereditary condition at birth that causes physical or metabolic abnormally. The current condition must alter nutrition status metabolically, mechanically or both. • These may include but are not limited to cleft lip or palate, Down Syndrome, Thalassemia, sickle cell anemia. Woman Pregnant, Woman Fully Breastfeeding, Woman Partially Breastfeeding- 01 Woman Postpartum-01 Infants-01 Child-03 351 Inborn errors of metabolism • May be diagnosed by a physician as self-reported by applicant/participant/caretaker or as reported or documented by a physician or someone working under physician’s orders • Gene mutations or gene deletions that alter metabolism in the body. • These may include but are not limited to phenylketonuria (PKU), maple syrup urine disease, galactosemia, myperlipoprotenurea, homocystinuria, tyrosinemia, histidinemia, urea cycle disorders, gluatric aciduria, methylmalonic academia, glycogen storage disease, Woman Pregnant, Woman Fully Breastfeeding, Woman Partially Breastfeeding- 01 Woman Postpartum-01 Infants-01 Child-03

Page 12 Risk Criteria Codes and Descriptions Policy 218 December 2024

galactokinase deficiency, fructoaldolase deficiency, propionic academia, hypermethionemia. 352A Infectious diseases-Acute • An infection disease characterized by a single or repeated episode of rapid onset and short duration caused by bacteria, viruses, parasites or fungi. These may include but are not limited to Hepatitis A, pneumonia, meningitis, parasitic infection, bronchitis (3 episodes in last 6 months), Hepatitis E, listerosis. Woman Pregnant, Woman Fully Breastfeeding, Woman Partially Breastfeeding- 01 Woman Postpartum-01 Infants-01 Child-03 352B Infectious diseases- Chronic • An infectious disease likely lasting a lifetime required long-term management of symptoms caused by bacteria, viruses, parasites or fungi. Conditions include but are not limited to HIV, AIDS, Hepatitis B, Hepatitis C, and Hepatitis D. • May be diagnosed by a physician as self-reported by applicant/participant/caretaker or as reported or documented by a physician or someone working under physician’s orders Woman Pregnant, Woman Fully Breastfeeding, Woman Partially Breastfeeding- 01 Woman Postpartum-01 Infants-01 Child-03 353 Food Allergies • An adverse immune response to a food or a hypersensitivity that causes adverse immunologic reaction. • May be diagnosed by a physician as self-reported by applicant/participant/caretaker or as reported or documented by a physician or someone working under physician’s orders Woman Pregnant, Woman Fully Breastfeeding, Woman Partially Breastfeeding- 01 Woman Postpartum-01 Infants-01 Child-03 354 Celiac disease • Also known as Celia Sprue, Gluten Enteropathy, Non-tropical Sprue inflammatory condition of the small intestine precipitated by the ingestion of wheat in individuals with certain genetic makeup. • May be diagnosed by a physician as self-reported by applicant/participant/caretaker or as reported or documented by a physician or someone working under physician’s orders Woman Pregnant, Woman Fully Breastfeeding, Woman Partially Breastfeeding- 01 Woman Postpartum-01 Infants-01 Child-03 355 Lactose intolerant • Lactose intolerance occurs when there is insufficient production of the enzyme lactase. Lactase is needed to digest lactose. Lactose in Woman Pregnant, Woman Fully

Page 13 Risk Criteria Codes and Descriptions Policy 218 December 2024

dairy products that is not digested or absorbed is fermented in the small intestines producing nausea, bloating, diarrhea, cramps, etc. Lactose intolerance varies among and within individuals and ranges from mild to severe. • May be diagnosed by a physician as self-reported by applicant/participant/caretaker or as reported or documented by a physician or someone working under physician’s orders • Documentation shall include that the ingestion of dairy products causes the above symptoms and the avoidance of such dairy products eliminates them. Breastfeeding, Woman Partially Breastfeeding- 01 Woman Postpartum-01 Infants-01 Child-03 356 Hypoglycemia • May be diagnosed by a physician as self-reported by applicant/participant/caretaker or as reported or documented by a physician or someone working under physician’s orders Woman Pregnant, Woman Fully Breastfeeding, Woman Partially Breastfeeding- 01 Woman Postpartum-01 Infants-01 Child-03 357 Drug nutrient interactions • Use of prescription or over-the counter drugs or medications that have been shown to interfere with nutrient intake, absorption, distribution, metabolism, or excretion, to an extent that nutritional status is compromised. • These medications include midamor, tums, hugroton, Cipro, Lasix, prevacid, Prilosec, synthroid, levothroid, levoxly, metformin, methadone, Zofran, phenobarbital, predisone, zantac, Zoloft, and sulfasalazine. Woman Pregnant, Woman Fully Breastfeeding, Woman Partially Breastfeeding- 01 Woman Postpartum-03 Infants-01 Child-03 358 Eating Disorders • May be diagnosed by a physician as self-reported by applicant/participant/caretaker or as reported or documented by a physician or someone working under physician’s orders • Eating disorders (anorexia nervosa and bulimia) characterized by a disturbed sense of body image and morbid fear of becoming fat. Symptoms include but are not limited to self-induced vomiting, purgative abuse, alternating periods of starvation, use of drugs to lose weight (appetite suppressants, thyroid preparations or diuretics) and self- induced marked weight loss. Woman Pregnant, Woman Fully Breastfeeding, Woman Partially Breastfeeding- 01 Woman Postpartum-01 Infants-01 Child-03

Page 14 Risk Criteria Codes and Descriptions Policy 218 December 2024

359 Recent major surgery, physical trauma, burns • Major surgery (including c-section), physical trauma or burns severe enough to compromise nutritional status. • Any occurrence: o Within the past two months may be self-reported. o More than two months previous must have the continued need for nutritional support diagnosed by a physician or health care provider working under the orders of a physician. Woman Pregnant, Woman Fully Breastfeeding, Woman Partially Breastfeeding- 01 Woman Postpartum-01 Infants-01 Child-03 360 Other medical conditions • Diseases or conditions with nutritional implications that are not included in any of the other medical conditions. The current condition, or treatment for the condition, must be severe enough to affect the nutritional status. These include but are not limited to juvenile rheumatoid arthritis, lupus erythematosus, cardiorespiratory disease, heart disease, cystic fibrosis, persistent asthma requiring daily medication. Woman Pregnant, Woman Fully Breastfeeding, Woman Partially Breastfeeding- 01 Woman Postpartum-01 Infants-01 Child-03 361 Depression • May be diagnosed by a physician as self-reported by applicant/participant/caretaker or as reported or documented by a physician or someone working under physician’s orders. Woman Pregnant, Woman Fully Breastfeeding, Woman Partially Breastfeeding- 01 Woman Postpartum-01 Infants-01 Child-03 362 Developmental delay, sensory or motor delay interfere with ability to eat • Developmental, sensory, or motor disabilities that restrict the ability to chew or swallow food or require tube feeding to meet nutritional needs. This includes but is not limited to minimal brain function, feeding problems due to developmental disability such as pervasive development disorder, which includes autism, birth injury, head trauma, brain damage, or other disabilities. Woman Pregnant, Woman Fully Breastfeeding, Woman Partially Breastfeeding- 01 Woman Postpartum-01 Infants-01 Child-03

Page 15 Risk Criteria Codes and Descriptions Policy 218 December 2024

363 Prediabetes • May be diagnosed by a physician as self-reported by applicant/participant/caretaker or as reported or documented by a physician or someone working under physician’s orders. Woman Fully Breastfeeding, Woman Partially Breastfeeding- 01 Woman Postpartum-04 371 Nicotine and Tobacco Use • Any use of products that contain nicotine and/or tobacco to include but not limited to cigarettes, pipes, cigars, electronic nicotine delivery systems (e-cigarettes, vaping devices), hookahs, smokeless tobacco (chewing tobacco, snuff, dissolvable), or nicotine replacement therapies (gum, patches). Woman Pregnant, Woman Fully Breastfeeding, Woman Partially Breastfeeding- 01 Woman Postpartum-04 372 Alcohol and illegal and/or illicit drug use • Pregnancy-any alcohol use, illegal substance use and/or abuse of prescription medications, or any marijuana use in any form. • Breastfeeding and Postpartum Women-Alcohol Use-High Risk Drinking-routine consumption of ≥ 8 drinks per week or ≥ 4 drinks on any day. Binge Drinking-routine consumption of ≥ 4 drinks within 2 hours. Any illegal substance use and/or abuse of prescription medications. Any Marijuana use in any form. (Breastfeeding women only). Woman Pregnant, Woman Fully Breastfeeding, Woman Partially Breastfeeding- 01 Woman Postpartum-04 381 Oral health conditions • May be diagnosed by a physician as self-reported by applicant/participant/caretaker or as reported or documented by a physician or someone working under physician’s orders. • This includes but is not limited to gingivitis, periodontitis, tooth loss, oral infections or ineffectively replaced teeth. Woman Fully Breastfeeding, Woman Partially Breastfeeding- 01 Woman Postparum-04 Infant-01 Child-03 382 Fetal Alcohol Spectrum Disorders • Fetal alcohol spectrum disorders (FASDs) are a group of conditions that can occur in a person whose mother consumed alcohol during pregnancy. FASDs is an overarching phrase that encompasses a range of possible diagnoses, including fetal alcohol syndrome (FAS), partial fetal alcohol syndrome (pFAS), alcohol-related birth defects (ARBD), alcohol-related neurodevelopmental disorders (ARND) and neurobehavioral disorder associated with prenatal alcohol exposure (ND- PAE). • Presence of condition diagnosis, documented, or reported by physician or someone working under a physician’s orders, or as self- reported by applicant/participant/caregiver. Woman Pregnant-01 Woman Fully Breastfeeding, Woman Partially Breastfeeding- 01 Woman Postpartum-03 Infants-01 Child-03

Page 16 Risk Criteria Codes and Descriptions Policy 218 December 2024

383 Neonatal Abstinence Syndrome (NAS) • May be diagnosed by a physician as self-reported by applicant/participant/caretaker or as reported or documented by a physician or someone working under physician’s orders. • Drug withdrawal symptoms that occur after delivery when an infant is exposed to drugs during pregnancy. Conditions must be present during the first 6 months after birth. Infant-01 Diet 401 Presumed dietary eligibility for women and children age 2 years and older • Women and children age two to five years may be presumed to be a nutritional risk based on the inability to meet the Dietary Guidelines for Americans as defined by consuming fewer than the recommended number of servings from one or more of the basic food groups. • This risk may only be assigned after a complete nutrition assessment has been performed and no other risks have been identified. Woman Pregnant, Woman Fully Breastfeeding, Woman Partially Breastfeeding, Woman Postpartum-04 Child-05 Diet-Infant 411.1 Use of substitutes for breastmilk or formula • Routinely using substitutes for breastmilk or FDA approved iron- fortified formula as the primary nutrient source during the first year of life. Examples include but are not limited to low iron formula without iron supplementation, cows milk, goat milk, sheep milk, canned evaporated or sweetened condensed milk, imitation or substitute milk such as rice or soy beverages, non-dairy creamer, or homemade concoction. Infants-04 411.2 Inappropriate use of bottle or cup • Routinely using nursing bottles or cups improperly. Examples include but are not limited to using a bottle to feed juice, feeding any sugar-containing fluids such as soda, corn syrup solution, sweet tea, allowing infant to fall asleep or be put to bed with a bottle at naps or bedtime, allowing infant to use a bottle without restriction such as walking around house with it, using bottle as a pacifier, propping bottle while feeding, allowing infant to drink for cup all day, adding foods such as cereal to infant bottle. Infant-04 411.3 Early introduction to solid foods • Routinely offering complimentary foods or other substances that are inappropriate in type or timing. This may include but is not limited to introducing any food other than breastmilk or formula before 6 months of age, adding sweet agents such as sugar, honey, or syrup to any beverage. Infant-04 411.4 Inappropriate feeding practices • Routinely using feeding practices that disregard the developmental needs or stage of the infant. These include but are not limited to inability to recognize, insensitivity to infants feeding cues, feeding foods of Infants-04

Page 17 Risk Criteria Codes and Descriptions Policy 218 December 2024

inappropriate consistency size or shape that are choking hazards, not support an infant need for growth independence such as using utensils or cups, feeding infant foods with an inappropriate texture based on developmental stage. 411.5 Feeding potentially harmful foods • Feeding foods to an infant that could be contaminated with harmful microorganisms or toxins. These may include but are not limited to unpasteurized fruit or vegetable juice, unpasteurized dairy products, soft cheese (brie, feta, blue), honey added to liquids or use in cooking, raw or undercooked meat, raw or undercooked eggs, raw vegetables sprouts, deli meat or hot dogs not heated until steaming hot, feeding donor human milk acquired directly from individuals or internet. Infants-04 411.6 Incorrect dilution of formula • Routinely feeding inappropriately diluted formula. Failure to follow manufacturer’s instructions or physician instructions. Infants-04 411.7 Infrequent breastfeeding • Routinely limiting the frequency of nursing of the exclusively breastfed infant when breastmilk is the sole source of nutrition. Examples include scheduled feedings instead of on demand or less than 8 feedings in 24 hours if less than 2 months of age. Infants-04 411.8 Feeding low calorie or low nutrient diets • Routinely feeding a diet very low in calories and/or essential nutrients. Examples include but are not limited to vegan diet, macrobiotic diet, etc. Infants-04 411.9 Improper handling of expressed breastmilk or formula • Routinely using in appropriate sanitation in preparation, handling and storage of expressed breastmilk or formula. Examples include: limited or no access to safe water, heat source for sterilization or refrigeration or freezer for storage, failure to properly prepare, handle and store breastmilk or formula. Infants-04 411.10 Inappropriate use of dietary supplements • Feeding dietary supplements with potentially harmful consequences. Examples of dietary supplements which, if fed in excess of recommended dosage, may be harmful include single or multi-vitamins, mineral supplements, herbal or botanical supplements or teas. Infants-04 411.11 Inadequate fluoride and Vitamin D supplementation • Routinely not providing dietary supplements recognized as essential by national public health policy when infants diet alone cannot meet nutrient requirements. • Infants who are 6 months of age or older who are ingesting less than 0.25 mg of fluoride daily when the water supply contains less than 0.3ppm fluoride. Infants-04

Page 18 Risk Criteria Codes and Descriptions Policy 218 December 2024

• Infants consuming less than one quart of vitamin D formula and not receiving 400 IU Vitamin D supplement. Diet-Child 425.1 Use of inappropriate beverages as milk source • Routinely feeding inappropriate beverages as the primary milk source. • Examples include but are not limited to non-fat or reduced fat milk between 12-24 months (unless assigned by health professional for concerns of obesity), sweetened condensed milk, substitute milk (soy, rice, homemade), non-dairy creamer, unfortified goat or sheep milk Child-05 425.2 Feeding sweetened beverages • Routinely feeding a child sugar-containing beverage. Some examples include sweet tea, soda, gelatin water, corn syrup solution. Child-05 425.3 Inappropriate use of bottles or cups • Routinely using nursing bottles, cups or pacifiers improperly. Examples include but are not limited to using bottle for feeding beyond 14 months of age, allowing bottle to feed juice, cereal, solids, allowing child to take bottle to bed or nap, allowing child to use bottle without restriction, allowing child to use cup without restriction. Child-05 425.4 Inappropriate feeding practices • Routinely using feeding practices that disregard the developmental needs or stage of the child. These may include inability to recognize feeding cues, feeding inappropriate size or shape foods, not supporting the need for growth (self-feeding, using utensils), feeding inappropriate textures based on developmental readiness. Child-05 425.5 Feeding potentially harmful foods • Feeding foods to an infant that could be contaminated with harmful microorganisms or toxins. These may include but are not limited to unpasteurized fruit or vegetable juice, unpasteurized dairy products, soft cheese (brie, feta, blue), honey added to liquids or use in cooking, raw or undercooked meat, raw or undercooked eggs, raw vegetables sprouts, deli meat or hot dogs not heated until steaming hot, feeding donor human milk acquired directly from individuals or internet. Child-05 425.6 Feeding low calorie or low nutrient diets • Routinely feeding a diet very low in calories and/or essential nutrients. Examples include but are not limited to vegan diet, macrobiotic diet, etc. Child-05 425.7 Inappropriate use of dietary supplements • Feeding dietary supplements with potentially harmful consequences. Examples of dietary supplements which, if fed in excess of Child-05

Page 19 Risk Criteria Codes and Descriptions Policy 218 December 2024

recommended dosage, may be harmful include single or multi-vitamins, mineral supplements, herbal or botanical supplements or teas. 425.8 Inadequate fluoride and vitamin D supplementation • Routinely not providing dietary supplements recognized as essential by national public health policy when infants diet alone cannot meet nutrient requirements. • Providing children under 36 months less than 0.25 mg fluoride daily when the water supply contains less than 0.3ppm fluoride. • Providing children 36-60 months of age less than 0.50 mg fluoride daily when the water supply contains less than 0.3ppm fluoride. • Providing children less than 400 IU Vitamin D supplement if drinking less than one quart Vitamin D fortified milk daily. Child-05 425.9 Pica • Routine ingestion of non-food items. Examples include: ashes, carpet fibers, cigarettes, chalk, clay dust, foam rubber, paint chips, soil, or starch. Child-05 Diet-Women 427.1 Inappropriate use of dietary supplements • Feeding dietary supplements with potentially harmful consequences. Examples of dietary supplements which, if fed in excess of recommended dosage, may be harmful include single or multi-vitamins, mineral supplements, herbal or botanical supplements or teas. Woman Pregnant, Woman Fully Breastfeeding, Woman Partially Breastfeeding, Woman Postpartum-04 427.2 Consuming very low calorie diets • Routinely feeding a diet very low in calories and/or essential nutrients. Examples include but are not limited to vegan diet, macrobiotic diet, etc. Woman Pregnant, Woman Fully Breastfeeding, Woman Partially Breastfeeding, Woman Postpartum-04 427.3 Pica • Routine ingestion of non-food items. Examples include: ashes, carpet fibers, cigarettes, chalk, clay dust, foam rubber, paint chips, soil, or starch. Woman Pregnant, Woman Fully Breastfeeding, Woman Partially Breastfeeding, Woman Postpartum-04 427.4 Inadequate iron, iodine or folic acid supplementation • Inadequate vitamin-mineral supplementation recognized as essential by national public health policy. • Consumption of less than 27 mg of iron as a supplement daily by pregnant women. • Consumption of less than 150 mcg of supplemental iodine per day by pregnant and breastfeeding women. Woman Pregnant, Woman Fully Breastfeeding, Woman Partially Breastfeeding, Woman Postpartum-04

Page 20 Risk Criteria Codes and Descriptions Policy 218 December 2024

• Consumption of less than 400 mcg of folic acid from fortified foods or supplements daily by non-pregnant women. 427.5 Eating potentially harmful foods • Pregnant women ingesting foods that could be contaminated with pathogenic microorganisms. Examples include raw fish or shellfish, refrigerated smoked seafood, raw or undercooked meat or poultry, hot dogs, lunch meat, fermented dry sausage not heated until steaming hot, refrigerated pate or meat spreads, unpasteurized milk, soft cheeses (brie, blue cheese, feta), raw or undercooked meat or eggs, raw sprouts, or unpasteurized fruit or vegetable juice. Woman Pregnant-04 Diet-Presumed 428 Presumed dietary eligibility for infants and children ages 4 to 23 months • This risk may only be assigned to infants from 4-12 months of age and children 13-23 months of age after a complete nutrition assessment has been performed and no other risk(s) have been identified. An infant or child who has begun to consume complementary foods and beverages, eat independently, wean from breastmilk or formula, and is transitioning from a diet of infant/toddler foods to one based on the Dietary Guidelines. Infants-04 Child-04 Other Risks 501 Possibility of Regression • A participant who has previously been certified eligible for the Program may be considered to be at nutritional risk in the next certification period if the health professional determines there is a possibility of regression in nutritional status without the benefits that the WIC program provides. Not every nutrition risk criterion leads to regression. This risk cannot be used for two consecutive certification periods. Woman Fully Breastfeeding, Woman Partially Breastfeeding, Woman Postpartum, Child, Infant-04 502 Transfer of Certification • Applicant presently with current valid Verification of Certification (VOC) document from another State or local agency. The VOC is valid until the certification period expires and shall be accepted as proof of eligibility for program benefits. If the receiving local agency has waiting lists for participation, the transferring participant shall be placed on the list ahead of all other waiting applicants. • This criterion would be used primarily when the VOC document does not reflect another (more specific) nutrition risk condition at the time of the transfer or if the participant was initially certified based on a nutrition risk condition not in use by the receiving State agency. N/A

Page 21 Risk Criteria Codes and Descriptions Policy 218 December 2024

601 Breastfeeding mother or infant at nutritional risk • A breastfeeding woman whose breastfed infant has been determined to be at nutritional risk. Woman Pregnant, Woman Fully Breastfeeding, Woman Partially breastfeeding- 01,02,04 Must be at the same priority as at-risk infants. 602 Breastfeeding complications or potential complications (woman) • A breastfeeding woman with any of the following complications or potential complications: severe breast engorgement, recurrent plugged ducts, mastitis, flat or inverted nipples, cracked, bleeding, or severely sore nipples, age ≥40 years, failure of milk to come in by 4 days postpartum, tandem nursing. Woman Pregnant, Woman Fully Breastfeeding, Woman Partially Breastfeeding- 01 603 Breastfeeding complications or potential complications (infant) • A breastfeeding infant with any of the following complications or potential complications: jaundice, weak or infective suck, difficulty latching onto mother's breast, inadequate stooling, or wet diapers. Infant-01 701 Infant up to 6 months of age of WIC mother or of a woman who would have been eligible during pregnancy • An infant < 6 months of age whose mother was a WIC participant during pregnancy or whose mother’s medical records document that the woman would have been eligible during pregnancy. Infant-02 702 Breastfeeding infant of woman at nutritional risk • A breastfeeding infant of a woman at nutritional risk. I-01,02-04 Must be at the same priority as at-risk mother. 703 Infant born with mental retardation or alcohol drug abuse in most • Infant born of a woman diagnosed with mental retardation or using alcohol or drugs. Infant-01

Page 22 Risk Criteria Codes and Descriptions Policy 218 December 2024

recent pregnancy 801 Homelessness • A woman, infant, or child who lacks a fixed regular nighttime residence or whose primary residence is a shelter, institution, temporary accommodation, or residence not designed for regular sleeping accommodations. Woman Pregnant, Woman Fully Breastfeeding, Woman Partially Breastfeeding, Woman Postpartum, Infant-04 Child-05 802 Migrancy • Categorically eligible women, infants, and children who are members of families which contain at least one individual whose principal employment is in agriculture on a seasonal basis, who has been so employed within the last 24 months, and who established for the purpose of employment temporary housing. Woman Pregnant, Woman Fully Breastfeeding, Woman Partially Breastfeeding, Woman Postpartum, Infant-04 Child-05 901 Recipient of Abuse • Battering or child abuse/neglect within the past 6 months as self- reported, reported, or documented by social worker, health care provider, or other appropriate personnel. Woman Pregnant, Woman Fully Breastfeeding, Woman Partially Breastfeeding, Woman Postpartum, Infant-04 Child-05 902 Pregnant woman, mother or infant or child of primary caregiver with limited ability to prepare food • Woman or infant/child whose primary caregiver is assessed to have a limited ability to make appropriate feeding decisions and/or prepare food. • This may include: ≤17 years of age, mentally disabled, mental illness, depression, physical disability, currently using or history of abusing alcohol, prescription drugs, marijuana or other drugs, or intellectual disability. Woman Pregnant, Woman Fully Breastfeeding, Woman Partially Breastfeeding, Woman Postpartum, Infant-04 Child-05 903 Foster Care • Entering the foster care system during the previous six months or moving from one foster care home to another during the previous six months. Cannot be used two times in a row while the child remains in the same foster home. It shall be used as the sole risk criterion only if careful assessment has been done. Woman Pregnant, Woman Fully Breastfeeding, Woman Partially Breastfeeding, Woman Postpartum, Infant-04

Page 23 Risk Criteria Codes and Descriptions Policy 218 December 2024

Child-05 904 Environmental Tobacco Exposure • Environmental tobacco smoke (ETS) exposure is defined as exposure to smoke from tobacco products inside enclosed areas, like the home, place of childcare, etc. • ETS is also known as secondhand, passive, or involuntary smoke. • The ETS definition also includes the exposure to the aerosol from electronic nicotine delivery systems. Woman Pregnant, Woman Fully Breastfeeding, Woman Partially Breastfeeding- 01 Woman Postpartum-04 Infant-01 Child-03

Page 1 Mid-Certification Health Assessment Policy 219 December 2024

Policy 219 Mid-Certification Health Assessment POLICY Local WIC Agencies shall provide a mid-certification health assessment (MCHA) for participants with a one-year certification period to meet WIC’s legislative mission and to engage participants in relevant nutrition education and counseling. PURPOSE The MCHA reduces administrative burden while maintaining program integrity and quality nutrition services to participants. RELEVANT REGULATIONS 7 CFR 246.7(g)(1)(iv) – Certification periods USDA Policy Guidance – Guidance for Providing Quality WIC Nutrition Services During Extended Certification Periods FNS Instruction 803-4, Rev.1

DEFINITIONS Mid-Certification Health Assessment (MCHA) - a complete health assessment with appropriate nutrition education, anticipatory guidance, breastfeeding support, and referrals occurring approximately in the middle of a one-year certification. A Certifying Health Professional must complete the MCHA.

PROCEDURES During the MCHA appointments, participants shall receive anthropometric measurements, bloodwork (as necessary), an update of health and dietary assessment, follow-up immunization screening, and be provided with appropriate nutrition education, anticipatory guidance, breastfeeding promotion and support, and referrals.

Per United States Department of Agriculture (USDA) WIC guidance, the extended certification periods provide administrative relief, however, they do not eliminate WIC’s legislative mission and need to maintain program integrity. Time freed up by reducing administrative requirements will be available for WIC staff to engage participants in relevant nutrition education and counseling.

MCHA Requirements A. Participants certified for a one-year period shall be scheduled for an MCHA with a Certifying Health Professional between the fifth and seventh month of their one-year certification period. 1. This is an expanded nutrition assessment and education appointment, not a certification/recertification. 2. The MCHA shall include a complete assessment, appropriate nutrition education, and referrals for the participant. At a minimum, a complete MCHA shall include: a. Length/height and weight measurements (Refer to Policy 216-Anthropometric Screening) b. Hemoglobin or Hematocrit as appropriate (Refer to Policy 217- Hemoglobin/ Hematocrit) c. Diet assessment d. Health assessment e. Immunization screening and referrals as appropriate f. Age and developmentally appropriate anticipatory guidance and dietary recommendations g. Updated food package assignment as appropriate

Page 2 Mid-Certification Health Assessment Policy 219 December 2024

h. Referrals as appropriate (e.g. FindHelpNowKY.Com, Medical Nutrition Therapy, Lactation Support, KY Quit line, etc.) i. Support and encouragement for continued breastfeeding when appropriate. B. Infants 1. If an infant is certified before four months of age, an MCHA is not required if the infant has a medical home and is obtaining routine well-child checks. Document the health care provider name and the date of the 6-month well-child check in the participant’s medical record. a. WIC Staff shall provide follow-up nutrition education based on Policy 405 - WIC Low-Risk Secondary Nutrition Education. 2. If the infant does not have a healthcare provider or does not have an appointment for a 6- month well-child check, WIC staff shall schedule and provide an MCHA.

Documentation A. Document the MCHA information in the computer system at the time of the visit. This is completed by entering new measurements, plotting growth charts, reviewing, and updating the WIC-75. 1. Documentation must include: a. Length/height and weight measurements b. Hemoglobin or hematocrit test results, if obtained c. Additional risk factors, if applicable d. Diet assessment questionnaire e. Health assessment questionnaire f. Food package changes g. Nutrition education provided h. Referrals made 2. “Mid-Certification nutrition education provided per protocol” or “MC-NEPP” may be documented when the information provided to the participant is according to the existing counseling protocols to reduce time documenting the service. If the protocol is not followed, or “MC-NEPP” is not documented, then documentation must be made of the counseling that is provided and any supporting materials/handouts that were provided. Referral Data A. Participants may bring height, weight, and hematological measurements from another provider. See Kentucky WIC Referral form in the 200 Certification Appendices of this section. Scheduling A. The MCHA may be counted as one of the three required quarterly nutrition education contacts during the one-year certification period. 1. Schedule the participant for a second nutrition education contact 2 to 3 months before and after the MCHA appointment. a. High-Risk participants must be referred or scheduled for an appointment for WIC High-Risk Counseling for at least one visit during the one-year certification period. i. The WIC High-Risk Counseling is recommended to be provided during the MCHA to minimize administrative burden. b. Participants transferring to Kentucky after the seventh month of their one-year certification period do not need an MCHA and shall instead be scheduled for a secondary nutrition education contact before the end of their certification period. Missed/Refused MCHA Appointments A. Benefits cannot be withheld if the MCHA is not completed on time or if the participant refused the appointment, since the MCHA is not a certification.

Page 3 Mid-Certification Health Assessment Policy 219 December 2024

B. If the initial MCHA appointment is missed, local WIC staff may issue one month of benefits and schedule the MCHA appointment. C. If the participant/parent/caretaker refuses the MCHA appointment and completes another type of nutrition education activity, up to three months of benefits may be issued. 1. MCHA appointment refusal must be documented in the participant’s medical record.

Page 1 Program Access in Disaster Situations Policy 220 December 2024

Policy 220 Program Access in Disaster Situations/Alternative Operating Procedures POLICY In a disaster, the WIC Programs shall work to maintain program access to current WIC Participants and potentially eligible individuals. Local WIC Agencies shall notify the public of hours of operations per the guidance in the Administrative Reference, Local Health Operations Section.

DEFINITION Disaster: For the purposes of this policy, the word “disaster” is used to encompass disasters, emergencies, public health emergencies, supplemental food recalls, or supply chain disruptions, unless otherwise specified.

PURPOSE In a disaster, WIC Programs shall work to maintain regular certification and benefit delivery to participants.

RELEVANT REGULATIONS AND POLICY GUIDANCE 7 CFR 246.7 (o)(2)(I)(C) – Certification of participants 7 CFR 246.7 (g)(3) – Certification of participants 7 CFR 246.7 (e)(B) – Nutritional Risk 7 CFR 246.7 (d)(2)(v)(C) – Are applicants required to document income eligibility- exceptions WIC Policy Memorandum 95-9, WIC Disaster Policy, and Coordination WIC Policy Memorandum 2016-4, “Verification of Certification” WIC Policy Memorandum #2021-3: Implementing ABFA Requirements in WIC State Plans

PROCEDURES WIC’s Role in Disasters Ensuring access to nutrition assistance is a critical and immediate focus for disaster response teams. A. USDA Foods and the Disaster Supplemental Nutrition Assistance Program (D-SNAP) are the primary methods the USDA uses to respond to the nutrition needs of disaster survivors. B. WIC’s role in responding to disasters is minimal, as the Program is neither designed nor funded to meet the basic nutritional needs of disaster survivors who would not otherwise be eligible to receive WIC benefits. 1. In a disaster, WIC Programs shall work to maintain regular certification and benefit delivery to participants including nutrition education, breastfeeding support, and referrals. C. The State Agency WIC Director will coordinate with the Department of Public Health Preparedness Branch and the Maternal and Child Health Division staff during disasters. D. Local WIC Agencies and Health Departments should have an emergency/disaster plan that includes Continuity of Operations. For assistance, consult the Department for Public Health Preparedness Branch. E. This policy, along with Policy 600 Food Package Issuance Introduction, Policy 807 Food Delivery in Disaster, and Policy 221 ARPA Waivers Remote Services, ensures that Kentucky WIC has plans in place to support the continuity of operations in the event of a disruption of WIC services, including, but not limited to, disasters, emergencies, public health emergencies, supplemental food recalls, and other supply chain disruptions. F. The Department for Public State Health Operations Center (KDPH SHOC) coordinates with FEMA, relief organizations, and local emergency operations centers. As part of the Continuation of Operations Procedures (COOP), it has identified key State WIC Staff for COOP coordination. 1. State WIC Agency staff may volunteer part-time with their supervisor’s approval to assist with non-WIC-specific disaster-related tasks, such as assisting with the phone bank.

Page 2 Program Access in Disaster Situations Policy 220 December 2024

Communication and Coordination A. During a disaster, the Kentucky WIC Help Desk is the designated contact for Disasters. The help desk may be reached at WIC.Helpdesk@Ky.gov or 502-564-3827, option 1. The Kentucky WIC Help Desk will coordinate with the Nutrition Service Branch Staff to address disaster-related calls and needs. Participants should be informed that the phone number to the WIC Help Desk is printed on the back of their EBT Card. B. During disasters, to ensure medically fragile applicants and participants have the needed support, the Clinical Nutrition Section may be contacted at KyWICNutrition@Ky.gov or 502-564-3827, option 2, or by contacting the WIC Help Desk. C. Local WIC Agencies should determine if relief organizations are active in their community during a disaster and establish communication/relations as appropriate. D. The Local Health Departments should follow policies and procedures outlined by the Department for Public Health Preparedness Branch to report closures to the WEB EOC. In addition, Local WIC Coordinators should contact the Kentucky WIC Help Desk at WIC.Helpdesk@Ky.gov to report WIC Clinic closures. The Nutrition Service Branch Manager/Kentucky WIC Director will monitor the WEB EOC for closings that impact WIC services. In addition, Program Management staff will reach out to impacted areas to collect additional information and offer support, as needed. This information will be shared with USDA Food and Nutrition Services with daily updates until the impact on WIC services has been resolved. a. The following information will be collected and shared with USDA Food and Nutrition Services: i. Clinic location ii. Clinic closure, reason for closure, and anticipated re-opening date iii. Clinic damage iv. Alternative Clinic site v. Change in Operating procedures, if applicable vi. Number of potential participants impacted (optional) vii. Impacted WIC Authorized Vendors/Farmers’ Markets (location, closures, tentative re-opening date) viii. Requests for waiver assistance, if needed. E. The Program Management Section will work with the Department of Public Health’s Communication Team to ensure the Kentucky WIC Website is kept up to date with current information during a disaster, emergencies, public health emergencies, supplemental food recalls, and other supply chain disruptions. a. At all times, a toll-free phone number to contact the State WIC Office is posted on the Cabinet for Health and Family Services (CHFS) Kentucky WIC Program Contact section, 1-800-462-6122 for the public, local health departments, applicants, and participants. F. Local WIC agencies experiencing a clinic closure due to an emergency may request an extension to the 10-day processing standards to 15 days. Refer to Policy 202, Processing Standards. G. Local WIC agencies experiencing a disaster or emergency should update their website to indicate any change in operational hours. H. Local WIC Agencies will continue to provide participants with breastfeeding support during a disaster including support and education for breastfeeding initiation, re-lactation, and breastfeeding challenges as well as assisting with breast pumps. This support may include referrals outside of WIC. The local agency Designated Breastfeeding Expert or the Regional Breastfeeding Coordinator will serve as a resource. I. During disasters, emergencies, public health emergencies, supplemental food recalls, and other supply chain disruptions, the State WIC office will communicate with key stakeholders via the following methods: emails to vendors, local WIC agencies and local hospitals, updates to the CHFS Kentucky WIC website, social media messages on the Kentucky DPH Facebook page, and banners on the WIC Shopper App. J. Vendor Management Section will communicate with local agencies and WIC Authorized Vendors during a disaster to facilitate access to WIC Authorized Foods. K. During a disaster, vendor or local WIC agency monitoring and investigations may be rescheduled within the current Federal Fiscal Year and/or conducted remotely.

Page 3 Program Access in Disaster Situations Policy 220 December 2024

a. Although Vendor Minimum Stocking Requirements (MSR) will not be waived during a disaster, vendors may provide documentation of an attempt to obtain MSR products during a disaster or supply chain disruption for WIC Authorized Foods. WIC Certification During a Disaster A. Disaster-Related Evacuees 1. If able to obtain Verification of Certification (VOC) information from the participant or originating agency, disaster-related evacuees with a valid certification from another agency should be processed as a VOC. a. Disaster-related evacuees seeking a transfer should be considered high priority and seen as soon as possible, within ten calendar days. b. A participant with a valid VOC cannot be denied participation in another State because she/he does not meet the State’s particular eligibility criteria. Refer to Policy 204- Transfer/VOC. c. For VOC evacuees on noncontract infant formula, exempt infant formula, or WIC Nutritionals, documentation of qualifying condition is required. i. For in-state VOC, the current food package and approval expiration date may be found in the system. ii. For an out-of-state VOC, documentation on the VOC may be accepted. If documentation is not available, an attempt must be made to contact the originating clinic to obtain documentation. File electronic or faxed documentation in the medical record. If medical documentation is provided via the phone to the WIC Clinic staff, the WIC staff must document the information in the participant’s medical record and request written confirmation. a. If documentation cannot be obtained, contact the State WIC Office for additional guidance. iii. Participants who are medically fragile and or require non-contract, exempt infant formula or WIC nutritionals must be referred to a local medical provider to ensure the participant is linked to the health care system during the disaster and displacement. iv. Contact the State WIC Office for any additional guidance. 2. Disaster-related evacuee applicants must be notified of eligibility or ineligibility within ten days of the date of the first request for WIC Program benefits. Refer to Policy 202 Processing Standard. a. If residing with family or friends, the displaced individuals may be treated as a separate economic unit. i. Income documentation for Disaster-Related Evacuees does not apply to a woman or child for whom the agency determines the requirement would present an unreasonable barrier to participation. a) Disaster-related evacuee applicants must sign a statement specifying why he/she cannot provide documentation of income. Refer to Policy 206- Determining Household Income, Policy 207- Required Proofs Not Present, and Policy 208 Homeless Participants. b) See policy 209 regarding physical presence requirements and exemptions. c) If Proof of Residency or Identity may be lost, destroyed, or damaged in disaster situations. In this case, the statement of no Proof must be utilized to document their residency or identity. See Policy 207- Required Proofs Not Present. b. The displaced individuals are considered homeless. i. The Health Professional should assess if the homeless food package is the most appropriate food package for issuance. When issuing the homeless food package, the displaced participant food list insert must be provided. ii. The Health Professional must assess and determine if ready-to-feed infant formula is appropriate for issuance due to an unsanitary water supply. See Section 600 for further guidance regarding the food package assignment. iii. For homeless participants, the 801 homeless risk code must be assigned. The applicant must be assessed for all risks. See Policy 216

Page 4 Program Access in Disaster Situations Policy 220 December 2024

Anthropometric Screening, 215 Certification Risk Assessment, 217 Hemoglobin and Hematocrit Screening, and 218 Risk Code Criteria and Descriptions.

c. Refer to Policy 209 Physical Presence and Policy 221 ARPA Waiver: Physical Presence and Remote Issuance for information on providing remote services. d. Participants receiving exempt infant formula or WIC Nutritionals may be issued one month of the exempt infant formula/WIC Nutritional with an assessment by the Certifying Health Professional/Registered Dietitian if medical documentation is a barrier. Provide the Medical Necessity Form and refer to a local health care provider for the required documentation. Contact the State Agency for technical assistance if needed. e. All disaster-related evacuees shall be issued a VOC upon certification to ensure the continuation of benefits when he/she returns to his/her home State. 3. A VOC shall be provided by the local WIC agency to WIC participants when a disaster- related evacuation is anticipated.

B. Other Emergency/Disaster Situations Emergency situations can occur whenever WIC benefits or the WIC certification system is unavailable to a participant, clinic, or retailer for use to issue or redeem WIC benefits. 1. If a Local WIC Agency is unable to access the WIC System (CMS/Portal) or issue WIC benefits because of a natural disaster or a prolonged system outage, the agency shall follow their county’s health department disaster plan until a viable plan to access the WIC system is available. a. It might include a plan to issue KY WIC from neighboring counties KY WIC clinics or mobile health clinics that have access to the KY WIC online system. b. A plan shall also contain continual contact with the KY WIC Help Desk for any assistance needed. The Help Desk number is accessible 24 hours a day at (877) 597-0367. c. Each local agency shall maintain on file and have accessible for review their disaster/prolonged outage plan to ensure continued access to Kentucky WIC benefits. 2. Local WIC Agencies shall utilize available paper resources to maintain regular certification and benefit delivery to participants. a. The CH-5B is available in English and Spanish for patient registration and documentation of residence and income proofs and receipt of Rights and Responsibilities. b. Paper WIC Certification Forms (WIC-75s) are available for documentation of WIC Nutrition Risk Assessment, including anthropometric and hematological measures. See Section 200 Certification Appendices. c. Paper CDC Growth charts may be utilized for plotting and assessing growth. https://www.cdc.gov/growthcharts/clinical_charts.htm d. Notify the Kentucky WIC Help Desk. a. In some instances, the state agency may be able to provide issuance remotely. See Policy 807 – Food Delivery in Disaster Situations. C. Statewide/Local Agency-Wide Level electronic Benefits Issuance 1. In a pandemic, disaster, or emergency situation, it may be necessary to provide Local Agency level or Statewide benefit issuance. 2. Local Agency-wide issuance must be approved by the State Agency. a. The State Agency will approve the issuance, and the duration of the issuance may occur. This may be allowable in the following situations. i. Seasonally inclement weather or extended site closure. ii. Natural disaster, environmental hazard, or destructive incident (i.e. gas line explosion, water main break, tornado, flood, ice storm). iii. Local Agency-wide issuance must be discontinued as soon as the situation is resolved.

Page 5 Program Access in Disaster Situations Policy 220 December 2024

b. WIC Clinic staff must attempt to contact the participant, parent/guardian, or caretaker to verify the food package and to notify them that the food benefits have been added to their eWIC card. i. Offer to mail and/or email an appointment confirmation and their WIC Household Shopping List. ii. If unable to reach the participant, the agency may issue benefits. c. Issue benefits to the eWIC card, document proof of Identity Reason “Other” in the system, and document in the medical record “RBI” for “Remote Benefit Issuance,” reason for issuance, and sign and date. 3. In situations where it is necessary for the state to do a statewide issuance of electronic food benefits, one month of benefits will be issued, and an auto-issuance report /issuance labels will be available for local agencies to document issuance. a. The State Agency will notify the Local Agencies if a situation arises that would require statewide issuance, such as a Pandemic, statewide disaster, or emergency. 3. There may be disasters or emergencies for which the State WIC Office must request Waivers to the Program from USDA for Alternating Operating Procedures. Access to Baby Formula Act (ABFA) established permanent waiver authority for the Secretary of Agriculture to address certain emergencies, disasters, and supply chain disruptions impacting WIC. Program requirements may be waived in the event of (1) a presidentially declared major disaster as defined under Section 102 of the Robert T. Stafford Disaster Relief and Emergency Assistance Act (Stafford Act, 42 U.S.C. 5121 et seq.), (2) a presidentially declared emergency as defined under the Stafford Act, (3) a public health emergency declared by the Secretary of Health and Human Services under Section 319 of the Public Health Service Act (42 U.S.C. 247d), (4) a renewal of such a public health emergency, and (5) a supply chain disruption as declared by the Secretary of Agriculture. a. The State WIC office will (1) determine if any of these events exist and (2) determine if a waiver is necessary to continue WIC services. b. The waivers are short-term and require a report of use and impact on the program participation. c. For example, at the onset of the COVID-19 Pandemic, due to shortages in milk supply, the State received a waiver that allowed the purchase of 2% milk in place of 1% or less milk when 1% or less was not available on store shelves as well as the ability to waive physical presence and defer measurements. d. In case of an infant formula shortage of contract brand formula, the State WIC office may authorize local WIC agencies to issue non-contract infant formula to ensure infants have access to infant formula. If needed, the State WIC office may request a waiver to issue alternative sizes of infant formula that may exceed the Maximum Monthly Allowance. e. The State WIC Office will provide policy guidance to local agencies when such waivers are received from USDA. f. The State WIC Office will monitor the List of Public Health Emergency Declarations at HHS.Gov. g. The State WIC Office may make MIS/EBT system changes, such as auto-issuance, as appropriate during a disaster. Rev. 10/24

Page 1 ARPA Waiver For Remote Services: Physical Presence and Remote Issuance Policy 221 December 2024

Policy 221 ARPA Waiver for Remote Services: Physical Presence and Remote Issuance Effective August 11, 2023 Expires September 30, 2026 POLICY Local WIC agencies shall offer in-person, as well as remote WIC certifications, secondary nutrition education visits, Mid-Certification, and food benefit issuance to participants in order to provide innovative and modernized WIC services and to increase WIC Program access, participation, and benefit redemption. PURPOSE The American Rescue Plan Act of 2021 (ARPA) provided the United States Department of Agriculture (USDA) with waiver authority to carry out WIC outreach, innovation, and modernization efforts to increase participation and benefit redemption. USDA is using this authority to spur nationwide Program modernization by granting WIC State agencies the ability to continue to offer—and to build and improve upon—remote services. As part of granting the waiver, the intent is to learn how WIC agencies can best use technology to improve service delivery via the ARPA waiver evaluation.

Pursuant to Section 1106 of ARPA, USDA has waived the requirements for all Kentucky WIC agencies for Physical Presence and Remote Benefit Issuance as outlined below. WIC agencies must continue to meet all other Federal WIC requirements. Furthermore, all WIC agencies must provide the option for participants to obtain services in person. This waiver authority expires on September 30, 2026. RELEVANT REGULATIONS 7 CFR 246.7 (o)(2)(I)(C) – Certification of participants 7 CFR 246.7 (g)(3) – Certification of participants 7 CFR 246.7 (e)(B) – Nutritional Risk 7 CFR 246.7 (d)(2)(v)(C) – Are applicants required to document income eligibility- exceptions. WIC Policy Memorandum 95-9, WIC Disaster Policy, and Coordination WIC Policy Memorandum 2016-4, “Verification of Certification” The Families First Coronavirus Response Act March 2020 The American Rescue Plan Act of 2021 (ARPA), Section 1106 PROCEDURES Remote WIC Certification/Recertification & Secondary Nutrition Education Services (Physical Presence Waiver) The majority of the WIC Policies and Procedures remain in full effect. Below is guidance for WIC Services utilizing the Physical Presence Waiver. If you have questions, contact the State Agency for guidance.

A. Status and Priority 1. Refer to Policy 201 for status and Priority, no changes due to Remote Service. B. Processing Standards 1. Refer to Policy 202 for Processing Standards, no changes due to Remote Service.

Page 2 ARPA Waiver For Remote Services: Physical Presence and Remote Issuance Policy 221 December 2024

C. Required Proofs and Income Eligibility Determination 1. Refer to Policy 203 for Required Proofs: Residence, Identity, and Income, Policy 205 Adjunct Eligibility, 206 Determining Household Size and Household Income, and 207 Required Proofs. a. Efforts should be made to view copies or required proofs via email, text, fax, or other local agency-approved platforms. b. If the participant is unable to provide proof due to the WIC Certification being provided remotely, and the applicant/participant has a barrier that prevents being physically present at the clinic, utilize the Statement of No Proof Form (WIC-NP). Document the following on the Statement of No Proof Form (WIC- NP) i. Residence: participant’s address ii. ID: participant’s name, driver’s license number if available, and date of birth iii. Income: self-reported income unless adjunctive eligibility is able to be verified. iv. Document “self-reported via phone due to Remote Waiver,” date the form, and staff member should sign. D. Physical presence requirement waived. 1. At the WIC Certification visit, physical presence must be documented. a. WIC Federal Regulations allow for exceptions for physical presence for an infant or child or applicant/participant with a disability as outlined in Policy 209 Physical Presence with documentation of the exception reason (Disability, Newborn Infant, Receiving Ongoing Healthcare, and Working Parents/Caretakers). i. These exception reasons are primarily utilized when the parent or caretaker is present in person for the certification appointment for a household member who is not present. 2. Kentucky WIC has been granted a federal waiver for physical presence flexibility through September 30, 2026, to allow for remote certifications. This flexibility does not remove the federal requirement to collect anthropometric and hematological measurements as required by 7 CFR 246.7 (e)(1) and requires documentation of efforts to obtain measurements. This waiver does allow the delay in the collection of that data, as outlined below. a. An applicant/participant utilizing the flexibility from physical presence at a remote certification must still meet all other WIC Program requirements for eligibility. The parent/caretaker must provide all information required to determine eligibility, including proof of residence, identity, income eligibility, and required anthropometric and hematological data. Referral data may be accepted. b. The WIC staff must make concerted efforts to obtain data for anthropometric and bloodwork measurements in advance of or at the time of the appointment. 3. Physical Presence flexibility for remote services may be allowed on an individual basis, and the certification performed without the participant being physically present if the physical presence requirement presents an unreasonable barrier to participation. The reason the applicant/participant is not physically present when utilizing the physical presence waiver must be entered into the system and documented in the medical record. Below are the system reasons the agency may select when utilizing this waiver flexibility. a. Illness: A participant who cannot be present in the clinic for their certification due to an illness for themselves or their parent/caretaker. This may include a chronic or acute condition, bed rest, etc. b. Transportation Issues: A participant who cannot be present in the clinic for their certification due to transportation issues for themselves or their parent/caretaker.

Page 3 ARPA Waiver For Remote Services: Physical Presence and Remote Issuance Policy 221 December 2024

This may include transportation difficulties due to lack of transportation, the high cost of gas, inclement weather, etc. c. Work/School: A participant who cannot be present in clinic for their certification due to a work or school schedule conflict for themselves or their parent/caretaker. 4. For all WIC Certification services, WIC staff must collect from the applicant/ participant or parent/caretaker all information required to determine eligibility, including proof of residence, identity, income eligibility, and required anthropometric and hematological data. E. Documentation Requirements for Signature when using the Remote Physical Presence Waiver 1. Refer to the Administrative Reference, Consent for Services Section to document General Consent for Services, Financial Certification, and receipt of WIC Rights and Responsibilities. a. The Consent for Services may be faxed, emailed, dropped off at the clinic, mailed, or signed electronically (EHR). Consent for services is good for one year. When the CH-5 is sent in and dated for a date other than the date of service, the financial certification and WIC Rights and Responsibilities should be reviewed on the date of service. Staff should indicate this was completed by documenting as outlined below. 2. If unable to obtain a signature for the Consent for Services for the WIC Program due to the Physical Presence waiver, document on the CH-5/CH-5B/CH-5WIC the following; “Remote WIC” to indicate “Remote WIC Services provided utilizing the Physical Presence Waiver.” and the WIC staff member should sign their name and date. Staff will sign their name and date on the General Consent, Financial Certification, and WIC Rights and Responsibilities section. 3. The Financial Certification and the acknowledgment of receipt of WIC Rights and Responsibilities must be dated and signed on the date of service. a. If these sections were already signed and dated (date other than service date), staff should indicate near signature on the Financial Certification signature line and Date, “Remote WIC,” as well as on the WIC Rights and Responsibilities signature line. i. This is to ensure the participant understands what adjunct or income information was used to determine eligibility and to ensure awareness of WIC Rights and Responsibilities. b. “Remote WIC” may be documented on the following forms, including General Consent For Services, Proxy Form, Voter Registration Form, Statement of No Proof, WIC-54 Ineligibility, or other forms used for WIC requiring a signature when using the WIC Physical Presence Waiver. Note that Remote Benefit Issuance or RBI is used for documentation of remote issuance. See below the Remote Issuance Section. F. Rights and Responsibilities 1. Refer to Policy 211 for the WIC Rights and Responsibilities. 2. For remote certifications, applicants/participants, or their parent/legal representative/caretaker, must be provided a copy electronically and/or read to them the WIC Rights and Responsibilities outlined in Policy 211. 3. When providing an electronic copy, staff must ask if the applicant, participant, or their parent/legal representative /caretaker has received and understands their rights and responsibilities. a. Refer to Administrative Reference, Consent for Services Section, General Consent when Parent or Legal Representative cannot be present at visit for

Page 4 ARPA Waiver For Remote Services: Physical Presence and Remote Issuance Policy 221 December 2024

guidance on documenting verbal consent. Document in the medical record on the CH-5 or CH-5B that verbal consent was obtained, and Rights and Responsibilities read/provided to the participant, as appropriate, by documenting “Remote WIC.” b. For limited English Proficient applicants/participants/caretakers, the Rights and Responsibilities must be provided in a language they understand. G. Voter Registration 1. Refer to Policy 212, Voter Registration. 2. Voter Registration must continue to be offered to all individuals who are 18 years old or older at certification, recertification, and when an address change and/or VOC transfer occurs. 3. The Voter Registration Rights and Preference form (WIC-53) shall be completed each time voter registration is offered. This form provides their rights concerning registering to vote and documents the opportunity to register. 4. This should be read to the participant, and the staff shall document “Remote WIC,” date, and sign. 5. A copy of the form should be emailed or mailed to the participant. 6. A Voter Registration Application (SBE01) form may be mailed to every applicant/participant who answers “YES” to the Voter Preference Question, or the applicant should be offered the website https://vrsws.sos.ky.gov/ovrweb/ to register or to update registration online, if preferred. a. If the SBE01 is mailed, the applicant should be encouraged to mail it or drop it off at their local county clerk’s office. H. WIC Certification Periods. 1. Refer to Policy 210 for Certification Periods, no changes due to Remote Service. I. WIC Nutrition Risk Assessment 1. For all WIC Certification services, WIC staff must collect from the applicant/participant or parent/caretaker all information required to determine eligibility. Refer to Policies 215 for Certification Risk Assignment, 218 for Risk Criteria Code and Descriptions, 216 for Anthropometric Screening, and 217 for Hemoglobin and Hematocrit Screening. However, the collection of anthropometric measures may be waived for 60 days and hematological measures for 90 days when utilizing the physical presence waiver for remote certification. a. Anthropometric measurements must reflect the current status of the participant, be collected by a medical provider, and be taken within 60 days of certification. b. Hematological (bloodwork) measurements must reflect the current status of the participant, be collected by a medical provider, and be taken within 90 days of certification. c. The anthropometric and hematological data may be referral data. d. The WIC staff must make concerted efforts to obtain data for anthropometric and hematological measurements in advance or at the time of the appointment; however, anthropometric data may be obtained up to 60 days and hematological data up to 90 days from the WIC certification. i. For example, schedule the 1-year certification visit a few days after the child’s one-year well-child visit in order to have measures available. e. The below options are available for collecting anthropometrics when the individual is not physically present and for guidance on documentation requirements. i. Applicant/Participant or Parent/Caretaker may provide the clinic with the Kentucky WIC Referral form to present the data. The form may be provided in person, faxed, or electronically.

Page 5 ARPA Waiver For Remote Services: Physical Presence and Remote Issuance Policy 221 December 2024

a) Applicant/Participant or Parent/Caretaker may report measurements obtained at a doctor’s visit when the date of measurement is available, such as utilizing their health care provider portal/app. b) The WIC Health Professional should determine if current anthropometric data or hematological data is available in the Kentucky Health Information Exchange (once access has been granted by the State), and if so, must document the measures and date of measures for the assessment in the CMS Portal. c) WIC Clinics may offer walk-in measurement times to allow for participants to present to the clinic for recertification/MCHA “measurement services.” d) The clinic may initially issue 2 months of benefits and schedule an appointment within 60 days to collect anthropometric measures (may be in person or may be referral data). 1. If measures are not obtained by 60 days with documented efforts, it is not recommended to issue 1 month of benefits at a time repeatedly, as that is a burden on both the clinic and the participant. 2. If measures are not obtained, issue 1-3 months of benefits, coordinating with household members and other services. f. Documentation of an attempt to obtain measures must be made in the medical record at least one time during the 60-day window and at each subsequent appointment, if not yet obtained. Below are options for obtaining measures. i. Participants Certified without Measures Report will be available monthly for local staff to use for follow-up. ii. (Once access has been granted by the State) Staff should review the Kentucky Health Information Exchange to determine if current data is available, and if so, must document the measures and date of measures for the assessment in the CMS Portal System and medical record. iii. Staff should send reminder notices to participants to collect data and document this effort in the medical record. iv. If not received within the 60-day window, at the next follow-up appointment, continue to request the data. g. Benefits may not be denied, and participants should not be terminated due to the burden of obtaining anthropometric measurements. h. Documentation of the measures must be made in the medical record at the time of collection, including the date the measurements were taken. i. The certifying health professional must review the data, plot growth charts as appropriate and assign any new nutrition risk codes based on the data and provide appropriate nutrition education. This may be completed at the next secondary visit or at the time of receiving the data. i. If the participant is physically present at a secondary visit, and data has not been collected, complete measurements at that time (even if beyond the 60 or 90-day window). j. If a participant does not have a qualifying nutritional risk without the review of anthropometric and hematological data, they may not be certified, and an effort must be made to obtain the measurements as soon as possible, to complete a full nutrition and health assessment to determine WIC Program eligibility. i. Issue the WIC-54 Notice of Ineligibility, request measures/schedule an in- person appointment to reassess for eligibility.

Page 6 ARPA Waiver For Remote Services: Physical Presence and Remote Issuance Policy 221 December 2024

ii. Document W0204 on the Patient Encounter Form for screened, not nutritionally eligible. I. Information to Provide the Applicant/Participant when Conducting a Remote Certification 1. Refer to policies 400 Appendices, WIC Certification and Nutrition Education Counseling Protocol, 402 Certification Mid-Cert Nutrition Education Counseling, and 805 Mailing and Uploading Benefits. 2. The following should be mailed, emailed, or applicant/participant directed to the eWIC Shopper App: a. Kentucky eWIC Benefits pamphlet (eWIC-1) b. The Household WIC Shopping List. To protect privacy, the WIC Benefit List shall not be mailed. c. Kentucky Approved Food List (initial certifications, also available in the KY WIC shopper App) d. List of KY WIC Approved Vendors (initial certifications, also available in the KY WIC shopper App) e. Refer to Remote Issuance at Certification, MCHA, and Secondary Visits (Remote Issuance Waiver) section below regarding mailing of an eWIC card. f. All applicants/participants determined ineligible, denied, or discontinued WIC, or imposed a claim must be provided a completed “Notice of Ineligibility” (WIC 54) in person, via mail, or by email. J. Secondary Nutrition Education Visits 1. Refer to Policy 404 WIC Low-Risk Secondary Nutrition Education, Policy 405 High- Risk Secondary Nutrition Education, and 400 Appendices. K. Mid-Cert Health Assessment 1. Refer to Policy 219 for Mid-Cert Health Assessments and 402 Certification and Mid- Certification Nutrition Education. 2. May be deferred for up to 3 months or provided via phone remotely.

Page 7 ARPA Waiver For Remote Services: Physical Presence and Remote Issuance Policy 221 December 2024

Remote Issuance (Remote Issuance Waiver) See below for policies for remote issuance for WIC Certification, MCHA, and secondary visits. A. Refer to Policy 803 for Issuance of Benefits and Assigning of Issue Date, Policy 805 for Mailing, and Uploading Benefits, 804 WIC Food Benefit Replacement, Policy 806 for eWIC Card inventory and Security and 807 Food Delivery in Disasters. B. Food benefits shall be issued only for applicants/participants determined eligible and certified for the program. C. Food benefits shall be issued at the time of certification and with secondary nutrition education services provided remotely.

D. Clinics must make available the ability for new participants to pick up their eWIC card and set their PIN. (This includes VOCs or replacement cards, foster children changing households, etc.). E. If transportation to the clinic or other participant prevents a barrier to the participant from being able to present to the clinic to pick up the eWIC card, the clinic may mail the eWIC card to the participant via certified mail. 1. The participant must provide the Personal Identification Number (PIN). The participant must understand that if the PIN number is forgotten, the card must be returned to the clinic to reset the PIN. The PIN number may not be documented in the medical order or mailed with the card. The PIN may not be recorded on Post-it notes or other forms of notation in the chart. 2. Issue benefits to the eWIC card, document proof of Identity Reason “Other” in the system, and document in the medical record “RBI” for “Remote Benefit Issuance,” the reason for remote issuance, and sign and date. 3. The Household WIC Shopping List shall be mailed. To protect privacy, the WIC Benefit List shall not be mailed. a. See above for a list of items that must be provided to new remotely enrolled participants (Food List, List of Vendors, Rights, and Responsibilities, etc.) 4. When possible, issue 3 months of benefits (or the maximum amount allowable). 5. Food Package Assignments and changes must be made by the health professional prior to issuance. 6. If you have questions, contact the State Agency for guidance. F. Statewide Auto-Issuance/Individual Agency State Auto Issuance 1. During emergencies, caseload management concerns, pandemics, or other situations that would be a barrier to participants receiving WIC benefits, the State may institute Auto-Issuance. 2. Local agencies may opt into and out of Individual Agency Auto-Issuance based on caseload management and staffing availability by contacting the WIC Helpdesk at wic.helpdesk@ky.gov. The State WIC Office will track all requests. Agencies struggling to meet Processing Standards will be encouraged to utilize auto-issuance to allow local agency staff to focus efforts on WIC Certifications. a. The system will issue one month of benefits to participants with a valid certification who do not have issuance. The Issuance is completed daily, Monday through Friday (Friday will be issued for the weekend as well), one week ahead of the benefit start date.

Page 8 ARPA Waiver For Remote Services: Physical Presence and Remote Issuance Policy 221 December 2024

b. A weekly report will be provided of participants issued and of failed issuance. c. When working the auto-issuance reports, to minimize administrative burden and for program integrity, it is recommended to reach out to the household, attempt to provide a nutrition education visit, and issue 3 months of benefits. d. Document efforts to contact the family for secondary nutrition education and issuance in the medical record. 3. Statewide Auto-Issuance is not intended to replace secondary nutrition education visits. The intent is to address food insecurity concerns when conditions may prevent timely issuance otherwise. 4. Staff should continue to issue three months of benefits, as appropriate, when providing WIC Certification, MCHA, and secondary visits to avoid excessive numbers of participants receiving auto issuance and for program integrity. 5. Auto-Issuance and Formula Expiration Dates a. Auto-issuance will not occur for food packages that require a prescription when the prescription has expired. b. When issuing a noncontract formula for a healthy infant, set the expiration date at 90 days or less to ensure the infant formula challenge protocol and follow-up with the family is made quarterly. c. A report will be available weekly of failed issuance that will list participants who must be manually issued benefits due to an expired prescription. d. The WIC Health Professional should make efforts to contact the family, assess the need for the food package, advise the family of the need for a medical necessity form, and update food packages as appropriate. 6. Auto-issuance and the fully breastfed infant turning six months of age. a. The state auto-issuance process will issue to participants who have had a prior issuance the previous month. b. Fully breastfed infants under six months of age do not receive a benefit. c. Therefore, fully breastfeeding infants turning six months of age, will not be included in the statewide auto issuance. d. The State office will receive a report of these infants, and the Kentucky WIC Helpdesk will reach out to any agencies to notify staff of the six month fully breastfed infants in order for the staff to provide issuance. e. Once the clinic has issued a month of benefits to the fully breastfed infant, auto- issuance will occur monthly, as needed, in coordination with the household.

Rev. 10/2024

Page 1 Section 200 Appendices December 2024

Section 200 Appendices Certification

Page 2 Section 200 Appendices December 2024

Certification Appendices Index Instructions for Ordering WIC Forms and Supplies ...................................... 3 Pamphlet Library Materials and Order Form ................................................ 4 Proof of Residence, Identity, and Income Card (WIC-PC) ............................ 5 Proof Requirements Reminder (WIC-PR) .................................................... 6 Statement of No Proof (WIC-NP) ................................................................. 7 Statement of No Proof Hospital (WIC-NP/HOSP) ........................................ 9 WIC Clerical Checklist ............................................................................... 10 Kentucky eWIC Benefits Card Pamphlet (eWIC-1) .................................... 11 eWIC Issuance Reference/Items to Review with Participant (eWIC-4) ....... 12 Voter Registration Rights and Preference Form (WIC-53) .......................... 13 Voter Registration Application Form (SBE-01) ........................................... 14 Voter Registration Application (system generated) ..................................... 15 Fair Hearing & Civil Rights Procedures Poster ........................................... 16 Verification of Certification (VOC) Profile (To Transfer) .............................. 17 Verification of Certification (VOC) (WIC-17) ............................................... 18 VOC (WIC-17) Inventory ............................................................................ 20 VOC Email Alert ........................................................................................ 21 VOC Label (To Receive) ............................................................................ 22 Notice of Ineligibility (WIC-54) .................................................................... 23 Reminder Postcard (WIC-51) ..................................................................... 24 WIC Helps Pamphlet (DPH-070) ................................................................ 25 Health Care Providers and Kentucky WIC Pamphlet .................................. 26 And Justice for All Poster ........................................................................... 27 Stretch Your Food Budget Poster .............................................................. 28 Pregnant? New Baby? Poster.................................................................... 29 Sample Outreach Announcement .............................................................. 30 Kentucky WIC Program Ethnicity and Race Handout ................................. 32 Kentucky WIC Program Proxy Authorization Form ..................................... 33 WIC Program Abuse Poster ...................................................................... 35 WIC Program Abuse Letter Template ........................................................ 36 WIC VOC/Moving Poster ........................................................................... 39 Kentucky WIC Referral Form ..................................................................... 40 Kentucky WIC Certification Forms (WIC-75) .............................................. 42

Page 3 Section 200 Appendices December 2024

INSTRUCTIONS FOR ORDERING WIC FORMS AND SUPPLIES

To request certain forms and publications. The electronic WIC Supply Requisition order form must be used. Below are the instructions for completing and submitting the supply requisition form: • Submitted by: Enter the name of the individual completing the supply requisition • Enter the mailing address where the supplies are to be shipped • "Save" an electronic copy of the supply requisition on your desktop or folder • Attach a copy of the supply requisition to email, and send the email to the WIC Help Desk at wic.helpdesk@ky.gov • Orders will be completed and shipped within 1-5 business day • The electronic Excel formatted WIC Supply Requisition Order form is available from the Kentucky WIC State Office- Program Management Section via email or by phone at 502-564-3827, option 5.

Page 4 Section 200 Appendices December 2024

PAMPHLET LIBRARY MATERIALS AND ORDER FORM

The following items are available to order at the Frankfort Habilitation pamphlet library. These include: Materials at the pamphlet library may be ordered by sending a fax to (502) 227-7191 using the CHFS- 1210 form. Please include the item name, quantity needed, and the complete mailing address. The CHFS-1210 ordering form with instructions may be found on the Department for Public Health website: https://chfs.ky.gov/agencies/dph/dafm/Pages/lhd.aspx

CHFS -1210 PAMPHLET LIBRARY ORDERING FORM

Page 5 Section 200 Appendices December 2024

PROOF OF RESIDENCE, IDENTITY, AND INCOME CARD (WIC-PC)

Purpose A reference for clinic staff of acceptable types of proof for residence, identity, and income, including the system codes for data entry and when proof is required. When To Use WIC certification, recertification, food instrument/cash value benefit issuance, and data entry. Use is optional. Disposition Used by clinic staff. The front of the card contains the code to be entered on the screen(s) for the type of proof and acceptable proof of residence, identity, and income. The back of the card contains the situations when proof is required and a description of adjunct eligibility. Ordering Order from the State WIC Office utilizing the WIC Program Supply Requisition Form, Email WIC Program Requisition Form to the Ky WIC Help Desk at WIC.Helpdesk@ky.gov. Order quantity as needed.

Page 6 Section 200 Appendices December 2024

PROOF REQUIREMENTS REMINDER WIC-PR – ENGLISH/SPANISH WIC-PRB – ENGLISH/BOSNIAN

Purpose To remind and/or inform persons of WIC requirements for proof. When To Use As needed. Use is optional. Disposition Given to participants, participants, and others for information. Language English on the front with Spanish (WIC-PR) or Bosnian (WIC-PRB) on the back Ordering Order from the State WIC Office utilizing the WIC Program Supply Requisition Form, Email WIC Program Requisition Form to the Ky WIC Help Desk at WIC.Helpdesk@ky.gov. –Bundled in packages of 200.

Page 7 Section 200 Appendices December 2024

STATEMENT OF NO PROOF (WIC-NP) STATEMENT NO PROOF-HOSPITAL (WIC NP/HOSP)

Purpose A participant must provide a written statement of their residence, identity, and/or income, as well as proof of the reason that cannot be provided. When To Use When the participant does not have and/or cannot provide proof/documentation of residence, identity, and/or income. The completed form is good for the certification period. At recertification, if there still is no proof, another statement must be obtained. Use is optional. Instructions 1. Attach a patient label or write the patient’s name and ID number in the space provided. 2. Ask the participant to read the policy and warning (or read to the participant if they are unable to read). 3. Check the item(s) for which the participant is unable to provide proof. (One, two, or three items may be checked.) 4. The participant (or staff if the participant is unable to write) writes a detailed statement explaining why he/she is unable to provide proof. 5. Participant signs and dates on the line provided. Disposition File the completed form in the medical record. Retention Per medical record requirements. Language(s) Available in English (WIC-NP), Spanish (WIC-NPS), and twelve (12) other languages. Use a qualified interpreter or qualified bilingual staff to explain the information on this form for non-Spanish speaking LEP individuals. Ordering Order from the State WIC Office utilizing the WIC Program Supply Requisition Form; Email the WIC Program Requisition Form to the Ky WIC Help Desk at WIC.Helpdesk@ky.gov. Order quantity as needed.

Page 8 Section 200 Appendices December 2024

STATEMENT OF NO PROOF (WIC-NP)

Page 9 Section 200 Appendices December 2024

STATEMENT NO PROOF-HOSPITAL (WIC NP/HOSP)

Page 10 Section 200 Appendices December 2024

WIC CLERICAL CHECKLIST

Purpose A resource for front line staff in ensuring all federal requirements are met during registration of WIC applicants and participants. When To Use During WIC applicant and participant registration. Instructions Follow the steps in the checklist to ensure all federal requirements are met during the registration of WIC applicants and participants. Language(s) English, Spanish Ordering Order from the State WIC Office utilizing the WIC Program Supply Requisition Form, Email WIC Program Requisition Form to the Ky WIC Help Desk at WIC.Helpdesk@ky.gov. Order quantity as needed.

Page 11 Section 200 Appendices December 2024

KENTUCKY EWIC BENEFITS CARD PAMPHLET (eWIC-1)

Purpose To inform the participant of their rights and responsibilities, how to use WIC food instruments/cash value benefits and other important information, and to keep the card secure. When To Use At initial certification recertification, and a participant needs to be informed of the information. Instructions Must provide a pamphlet to each new WIC Program participant. Disposition Give to participant/caretaker. Retention None. Not retained by agency/site. Language English and Spanish versions are available. Use a qualified interpreter or qualified bilingual staff to explain the information on this handout for non- Spanish-speaking LEP individuals. Ordering Ordered from Pamphlet Library. Pamphlets are packaged 100 per bundle.

Page 12 Section 200 Appendices December 2024

EWIC ISSUANCE REFERENCE/ITEMS TO REVIEW WITH PARTICIPANT (eWIC-4)

Purpose This sheet serves as a reminder of procedures for issuing a eWIC card and outlines information that needs to be provided to the participants. When To Use Use as needed for training on eWIC benefits issuance. Ordering Order from the State WIC Office utilizing the WIC Program Supply Requisition Form, email WIC Program Requisition Form to the KY WIC Help Desk at WIC.Helpdesk@ky.gov. Order quantity as needed.

Page 13 Section 200 Appendices December 2024

VOTER REGISTRATION RIGHTS AND PREFERENCE FORM (WIC-53)

Purpose To provide the person their rights concerning registering to vote and to document that the opportunity to register to vote was provided. When To Use Every time voter registration is offered Instructions 1. Complete the person’s name or affix label with name. 2. Give the form to the person to read. 3. The person indicates yes or no to register to vote. 4. The person signs and dates the form. If the person refuses to read the form, designate her preference, or sign the form, staff shall record the person’s name, note the refusal and date on the form. Two (2) staff persons shall sign and date the form. Disposition Provide the copy of the completed form to the person. File the original in a Voter Registration file by calendar year. Retention Two (2) calendar years. Language Available in English (WIC-53), Spanish (WIC-53S), and twelve (12) other languages. Use a qualified interpreter or qualified bilingual staff to explain the information on this form for non-Spanish speaking LEP individuals. Ordering Order from the State WIC Office utilizing the WIC Program Supply Requisition Form, Email WIC Program Requisition Form to the Ky WIC Help Desk at WIC.Helpdesk@ky.gov. Bundled in packages of 100.

Page 14 Section 200 Appendices December 2024

STATE BOARD OF ELECTIONS VOTER REGISTRATION APPLICATION (SBE01)

Purpose For a person to apply to register to vote. When To Use When the system generated form is not appropriate or available. Do not copy the form below to use for voter registration. Photocopies are not allowed by SBE. Instructions 1. The participant completes the form. 2. Provide assistance in completion if requested. Disposition 1. The person may take the form for completion and forwarding to the election official or the completed form may be left at the site for transmittal. 2. Completed voter registration forms left at the site must be transmitted weekly to the State Board of Elections, 140 Walnut Street, Frankfort, Kentucky 40601. Forms may be sent to the county clerk if accepted regardless of participant’s residence. Retention None. Not retained by agency/site. Version A flat card version and a fold-and-mail version are available. Ordering Order from the State WIC Office utilizing the WIC Program Supply Requisition Form, Email WIC Program Requisition Form to the Ky WIC Help Desk at WIC.Helpdesk@ky.gov. Bundled in packages of 200.

Page 15 Section 200 Appendices December 2024

VOTER REGISTRATION APPLICATION (SYSTEM GENERATED FORM)

Purpose For a person to apply to register to vote. When To Use When the person chooses to register to vote and the system form is desired. System Procedure to Obtain On the Patient Registration Screen, indicate Y (yes) in the “Print Form” field. Instructions 1. The form is compiled and printed by the system. Demographic information (Social Security Number, date of birth, county, name, mailing address, sex, and phone number) entered in the system through the patient registration process is printed on the form. 2. The form is given to the person to read and complete their residence if different from the mailing address, party designation, and sign the form. 3. Provide assistance in completion if requested. Disposition 1. The person may take the form for completion and forwarding to the election official or the completed form may be left at the site for transmittal. 2. Completed voter registration forms left at the site must be transmitted weekly to the State Board of Elections, 140 Walnut Street, Frankfort, Kentucky 40601. Forms may be sent to the county clerk if accepted regardless of participant’s residence. Retention None. Not retained by agency/site.

Page 16 Section 200 Appendices December 2024

FAIR HEARING PROCEDURES & CIVIL RIGHTS POSTER

Purpose To inform participants of their fair hearing rights and the procedures for a fair hearing as well as inform participants of Civil Rights Procedures. When To Use Must be posted in WIC Clinic in a visible location. When the Notice of Ineligibility (WIC-54) is not appropriate and as needed. Copy as needed. Languages English, Spanish. Ordering Order from the State WIC Office utilizing the WIC Program Supply Requisition Form, Email WIC Program Requisition Form to the Ky WIC Help Desk at WIC.Helpdesk@ky.gov. Order quantity as needed.

Page 17 Section 200 Appendices December 2024

KENTUCKY WIC PROGRAM VERIFICATION OF CERTIFICATION (VOC) AUTOMATED SYSTEM PROFILE (VOC PROFILE TO TRANSFER A PARTICIPANT)

Purpose To transfer a currently eligible participant/enrollee to another agency/site. When To Use When a transfer of eligibility is requested or indicated. This format is the profile, which shall be used when a printer with blank paper is available at the on-line site. System Procedure to Obtain Request the system VOC according to the instruction in the Kentucky CMS User Manual. Disposition Provide to the participant to give to the new agency/site. This VOC can be done and mailed to the participant or the receiving agency/site with appropriate authorization. Receiving agency/site must file in the person’s medical record. Retention Not retained by issuing agency/site. Receiving agency/site retains per medical records requirements.

Page 18 Section 200 Appendices December 2024

KENTUCKY WIC PROGRAM VERIFICATION OF CERTIFICATION (VOC) (WIC-17)

Purpose To transfer a currently eligible participant/enrollee to another agency/site. When To Use When a transfer of eligibility is requested or indicated. Shall be issued at certification to migrants, and for other transfers at on-line sites that have a label printer only or if the system is down or slow or if the site is not on-line. Instructions 1. Complete appropriate part of the form: Part 1 – Must be completed with use of the system VOC label. 1. Place system generated VOC label in indicated section. See VOC Label (to transfer). 2. Indicate the status of the participant by checking the appropriate box. 3. Complete transferring agency/site name and address. 4. Complete staff name of person doing the transfer. 5. Complete signature of person doing the transfer. 6. Enter date that form was completed. Part 2 – Must be completed when the system VOC label is not used. 1. Enter patient’s name. 2. Enter patient’s ID number. 3. Enter date person was certified for this eligibility period. 4. Enter participant’s date of birth. 5. Enter date participant must be recertified. 6. Enter current food package code. 7. Enter date of most recent income assessment. 8. Enter nutritional risk(s) for which person qualifies. Use name(s) rather than code(s) if transfer is out-of-state. 9. Indicate status of the participant. 10. Enter date of last food instrument/cash value benefit issued to the participant. 11. Enter full package issue month/date for the next issuance due. 12. Complete transferring agency name and address or apply label with information. 13. Print name of person doing the transfer. 14. Complete signature of person doing the transfer. 15. Enter date form was completed. Part 3 – Option for completion to provide additional data for receiving site. 1. Enter race of participant. 2. Enter sex of participant. 3. Enter height/length and weight and date measures were taken. 4. Enter hemoglobin/hematocrit and date measures were taken. 5. If participant is a woman, complete expected delivery date or actual delivery date. 6. Enter date of last nutrition education counseling visit. 7. Enter type of formula if participant is on formula. 8. Enter date prescription expires if applicable. 9. Indicate other services patient is receiving. 2. Give the VOC to the participant/caretaker and instruct to give the VOC to the new agency/site. Disposition Provide to the participant to give to the new agency/site. This VOC can be completed and mailed to the participant or the receiving agency/site with proper authorization. The WIC-17 contains serial numbers. An inventory must be maintained to record serial numbers received and serial numbers issued. (A suggested inventory format is provided following the form. Copy as needed.) Receiving agency/site must file the WIC-17 in the person’s medical record. Retention Not retained by issuing agency/site. Receiving agency/site retains per medical records requirements. Ordering Order from the State WIC Office utilizing the WIC Program Supply Requisition Form, Email WIC Program Requisition Form to the Ky WIC Help Desk at WIC.Helpdesk@ky.gov. Form number WIC-17. Bundled in packages of 50.

Page 19 Section 200 Appendices December 2024

I i J Dare of Last Fl: I I

1±1 Kenwckv WEC P1roaram Verification1of Cemficaition (VOCl

□ l?regnalilt KIIENlli1illCKY /I

...._...,_. .c.,._

Stat111s:

-a; .c i:i:i ..I u "l""o

Q. 'i

Affiic. VOC ILabellHere or complete part 2 ]below

.!l 1ra111st,emng1Agency: □ Woman Fu'lly B:rea.stieed'ililg1 □ Woman Parfia ly Bl!eilstt"eedilll:91 □ IP'os1p1alifum □ llln,falilt IFullly IBirea,sttecil □ llln,falilt Pa:rt[iall Breastfed □ llln,falilt IFullly Formula Fed □Chil I d.l Q\1 ;, m'E. i '!'.I.;";,;

Address:

StaffN!aime: Signawre: Date: 1 j' Pal!iellt Nia:11111e-: Pal!if!!nt ID N111mber:

I Dertiificatio:11D1ate: J J Birth Date: I I

I NeX!t Recertification [late: l l Food Pacilta;ge: I Date,of Last lnoo1i111Aessessme,nt: t j' w ifYi?e of mmrnla 0"C >Q.I :!; U'111falltslFood Packa!le HI : N1111tmi:onal Risks: I IArescrip1im11?1 ires: N b-co:- t oz Sbtu.s: □Prei!!nant □Wolillam,Fu□ IBreas,tfeedlililg !,J-il□rman P.arliiallly Breastfeeding, l t 1i. 1_ ). 'l. '. l -'Ii Cl. u .9 i;JPostpartl!lm l;J Infant Fully Bliealstfed l;JJ11nfalilt Partially Blieiais.tfecili;Jlnfa:lilt ]Fully F,armulaF-edl i;JCltlild fiirst fulll packafl: J J 1.ssue moliltlilJ'Clla : ..-..,,J._.!..I Tra111iS,femi111g Agency: =E Address:: g

<i:i;i staffN!aime: Signawre: Date: f ' Race: S.e:x: I HeiyhtlL,en:gtlil: Weiyht: Date ta'lre:ll::: I i t 'ii For .a worn.an - , Ac,tual ,' J M C Hemnog'l'.obill: ll-lemal!ocrit ' 00.te take111: I i;. : 0::: a Q.

,,I Ill"''•= -- 11,-.... jl ia■ ,...,, u .+a·

Date of lllaist numtioll education: I 1 OOilet' ·SEl'li'icesrecei!.red: IJi WellChild □nm.!Iiliizalioo5 IJi F.amily Pla1i1ning1 i;J Prenatal □otli!er. Remnemberto ta'Ire proof of1r,esi :e.nce an Iidentity to you1r newWIC,cli111ic., ilillilis institution1is an equalllopporhmity provider. WIC-117 Sefii:a'IINo. Re-v. 7.2022 t L

Page 20 Section 200 Appendices December 2024

Agency

Site

VOC (WIC-17) INVENTORY

VOCs Received Date Beginning Serial Number Ending Serial Number

VOC Forms Issued Date Serial Number Participant Staff Person

Page 21 Section 200 Appendices December 2024

VOC Email Alert

Report Title VOC Email Alert Report Number None Frequency Auto-generated when a VOC is processed in the portal. Distribution Electronically generated via user email. Description Email alert to WIC Coordinator - Shows the participant(s) that transferred to another clinic through a Verification of Certification (VOC) in the CMS system. Actions to be Taken WIC Coordinator shall forward email alert to the appropriate clinic person. Explanation of Report 1. County-County of the “losing” agency. 2. Household Number- Household number of the transferred participant. 3. Clinic-Clinic in the county that transferred the participant. 4. Member Date of Birth - Transferring participant’s date of birth. 5. Date of Transfer – Date the participant transferred to the receiving agency. 6. Agency Received – Clinic that received the transferring participant. Retention/Disposal Period If printed, shred or burn after worked.

Sample County to County Transfer Alert Participant(s) have been transferred to a new clinic No action is required from you at this time. The patient will be included in your next report of automatic terminations. County: 034 - FAYETTE Household Number: 35662

Clinic: 034034C - LEXINGTON FAYETTE CO HEALTH DEPARTMENT Member Date of Birth: 3/17/2016

Date of Transfer: 6/6/2016 10:36:59 AM Agency Received: 316088 - MORGAN COUNTY HEALTH CENTER - (606) 743-3744

Page 22 Section 200 Appendices December 2024

VOC LABEL (VOC LABEL TO RECEIVE A PARTICIPANT WITHOUT A VOC)

Purpose To receive and enroll a currently eligible in-state participant without a VOC from another agency/site. When To Use When a participant presents at your agency for enrollment without a VOC. System Procedure to Obtain 1. Request the system VOC. 2. Print Label. Instructions The label is compiled and printed by the system. Description of Data Elements Data is most current information as entered in the system for this certification. Patient ID: Assigned identification number for the patient. VOC: Indicates type of label. Name: Participant’s name. 1st FP Iss. M/D: Abbreviation for First Full Package Issue Month/Day. The assigned date and adjusted month for the next issuance due, i.e., date would be 5/28 when last food instruments/cash value benefits issued were for 4/28 through 5/27 (last issuance plus one month). Cert Dt/Exp Dt: Abbreviation for certification date and expiration date. Date of most recent certification and ending date of that certification. Food Pkg: Assigned food package code. NRCC Codes: Nutritional risk criteria codes for which the person qualifies. Maximum of three (3) codes listed. RX EX DT: Abbreviation for prescription expiration date. Date the prescription for the assigned food package expires. If applicable, complete for the food package and date is still valid. Prior Agency: Agency and site number where the participant was enrolled. Serial Number: Serial number assigned by the system for accountability purposes. Last Inc Assess Dt: Abbreviation for Last Income Assessment Date. Date household income was last assessed in clinic. Last Issued Pkg Dt: Beginning and ending dates of the last food instruments/cash value benefits issued to the participant. This information may be verified with the issuing agency if needed. Disposition File in the participant’s medical record in chronological order on the CH-3. Notify the previous agency/site of the transfer. Retention Per medical records requirements.

Page 23 Section 200 Appendices December 2024

WIC PROGRAM NOTICE OF INELIGIBILITY (WIC-54)

Purpose To provide required written notice for ineligibility or discontinuation of benefits, and the fair hearing rights. When To Use When a participant is determined ineligible, or WIC benefits are discontinued. The system will generate an automated WIC-54 form if the participant is deemed ineligible. If the system is down or unavailable, a hard copy WIC-54 must be used. Instructions 1. Enter today’s date in box. 2. Enter participant name on the line. 3. Indicate appropriate reason(s) for action. If disqualified, complete reason and number of months the disqualification is effective. 4. Enter date notice is effective. Provide fifteen (15) day notice when required. 5. Indicate any other services offered. 6. Complete your agency address and phone number. Disposition 1. Provide the original to the participant. 2. File the copy in the participant’s medical record. Retention Per medical records requirements. Language English (WIC-54) and Spanish (WIC-54S) versions are available. Use a qualified interpreter or qualified bilingual staff to explain the information on this form for non- Spanish speaking LEP individuals. Ordering Order from the State WIC Office utilizing the WIC Program Supply Requisition Form, Email WIC Program Requisition Form to the Ky WIC Help Desk at WIC.Helpdesk@ky.gov. Bundled in packages of 100.

Page 24 Section 200 Appendices December 2024

WIC REMINDER POSTCARD (WIC-51)

Purpose To remind a participant of a missed appointment and reminder to contact the WIC clinic. When To Use When a food instrument and/or cash value benefit, pick-up appointment is missed. May be used for contact prior to termination for dropout. Do not use if the client has requested no home contact or privacy/confidentiality restrictions. Instructions Printed side of card: 1. Check the box applicable to this missed appointment. 2. Record your clinic phone number. Blank side of card: 1. Record name and address of the participant on the card. 2. Record return address for the clinic. This information may be written on the card or labels may be used. Disposition Mail to the participant. Documentation that the postcard was mailed must be made in the person’s medical record. Retention Not retained. Language English (WIC-51) and Spanish (WIC-51S) versions are available. Ordering Order from the State WIC Office utilizing the WIC Program Supply Requisition Form, Email WIC Program Requisition Form to the Ky WIC Help Desk at WIC.Helpdesk@ky.gov. Bundled in packages of 100.

Page 25 Section 200 Appendices December 2024

WIC HELPS PAMPHLET (DPH-070)

Purpose General informational pamphlet on the WIC Program. Provides toll-free telephone number. When To Use To provide general WIC program information to the public and for outreach to potential participants. Language English (DPH-070) and Spanish (DPH-070S) versions are available. Ordering Ordered from Pamphlet Library. Form number DPH-070. These are packed 100 per shrink-wrapped package.

Page 26 Section 200 Appendices December 2024

HEALTH CARE PROVIDERS AND KENTUCKY WIC PAMPHLET

Purpose To introduce the WIC Program to health care providers. Provides them with general information and a form to order pamphlets to distribute to their clients. When To Use For outreach to doctor’s offices, clinics, health fairs. Ordering Ordered from Pamphlet Library. These are packed 50 per shrink-wrapped package.

Page 27 Section 200 Appendices December 2024

“AND JUSTICE FOR ALL” POSTER

Purpose Provide participants and participants the nondiscrimination policy of the United States Department of Agriculture. When To Use Required to be posted at all times in WIC agencies/sites. Disposition Shall be posted in a conspicuous place for all WIC participants. Language English and Spanish on same poster. Ordering Order from the State WIC Office utilizing the WIC Program Supply Requisition Form, Email WIC Program Requisition Form to the Ky WIC Help Desk at WIC.Helpdesk@ky.gov. Order quantity as needed.

Page 28 Section 200 Appendices December 2024

STRETCH YOUR FOOD BUDGET POSTER

Purpose General informational poster on the WIC Program. When To Use To provide basic WIC Program information to the public and for outreach to potential participants. Ordering Order from the State WIC Office utilizing the WIC Program Supply Requisition Form, Email WIC Program Requisition Form to the Ky WIC Help Desk at WIC.Helpdesk@ky.gov. Order quantity as needed.

Page 29 Section 200 Appendices December 2024

PREGNANT? NEW BABY? POSTER

Purpose General informational poster on the WIC Program. When To Use To provide basic WIC Program information to the public and for outreach to potential participants. Ordering Order from the State WIC Office utilizing the WIC Program Supply Requisition Form, Email WIC Program Requisition Form to the Ky WIC Help Desk at WIC.Helpdesk@ky.gov. Order quantity as needed.

Page 30 Section 200 Appendices December 2024

SAMPLE OUTREACH ANNOUNCEMENT

Purpose General information about the WIC Program. When To Use To provide basic WIC Program information to the public and for outreach to potential participants. Instructions Complete blank spaces with agency and/or program specific information. Provide completed release to media source. Always include contact information, i.e., the health department and phone number, and include the nondiscrimination statement for the WIC Program. Contact the State WIC Office for announcement in non-English or alternate format. Description A copy of any news releases shall be maintained and placed in the agency/site outreach file.

Sample 1 WIC (the Special Supplemental Nutrition Program for Women, Infants and Children) is a national program that helps low- income families meet nutritional needs. WIC provides supplemental foods, health care referrals and nutrition education at no cost to low-income pregnant women and new mothers, infants and children up to 5 years of age who are found to be at nutritional risk. More information about the program is available by contacting the Health Department at .

WIC foods include iron-fortified infant formula and infant cereal, iron-fortified “adult cereal”, vitamin C-rich fruit juice, eggs, milk, cheese and peanut butter or dried beans and peas. These food items are high in one or more of the following nutrients: protein, calcium, iron, and vitamins A and C. Special infant formulas may be provided when prescribed by a physician for a specified medical reason. Who is eligible for WIC? Pregnant, breastfeeding and postpartum women, infants and children up to age 5 are eligible for WIC. They must meet income guidelines, a state residency requirement, and be individually determined to be at risk by a health professional. To be eligible on the basis of income, an participant’s family income must fall below 185 percent of the U.S. Poverty Income Guidelines (for example: $ per year for one person, $ per year for two, $ per year for three, etc.). People who receive Medicaid or Food Stamps automatically meet the WIC income requirements.

If you have difficulty understanding or reading English or have a disability, free language assistance or other aids and services are available upon request.

This institution is an equal opportunity provider.

Page 31 Section 200 Appendices December 2024

Sample 2 Kentuckians who qualify for the Women, Infants and Children (WIC) Program do not have to be unemployed or on welfare to receive benefits. A household of four with a monthly income of $ may qualify. WIC is a supplemental nutrition program for women who are pregnant, postpartum and breastfeeding, and infants and children up to five years of age.

WIC clients receive nutritious foods free of charge. Infants receive infant formula and, at the appropriate age, infant cereal and juice. Women and children receive food such as milk, cereal, juice, peanut butter, cheese, raw carrots, tuna fish, and eggs. Nutrition information and referrals for other health services are also provided. Proper nutrition along with appropriate health services helps maintain health and promotes normal growth and development.

To qualify, persons must be at nutritional risk and in a household that is at or below 185 percent of the federal poverty level. Persons that receive Medicaid or Food Stamps may also qualify. To find out if you or your children qualify for WIC, call the Health Department at .

If you have difficulty understanding or reading English or have a disability, free language assistance or other aids and services are available upon request.

This institution is an equal opportunity provider.

Sample 2 – Alternate Wording WIC provides supplemental foods, health care referrals and nutrition education at no cost to low-income pregnant women and new mothers, infants and children up to 5 years of age who are found to be at nutritional risk. WIC foods include iron-fortified infant formula and cereal, iron fortified adult cereal, vitamin C-rich fruit juice, eggs, milk, cheese and peanut butter or dried beans or peas. WIC foods provide important nutrients of protein, calcium, iron and vitamins A and C.

Pregnant, breastfeeding and postpartum women, infants and children up to age 5 are eligible for WIC. They must meet income guidelines and be individually determined to be at nutritional risk by a health professional. To be eligible on the basis of income, the participant’s household income must be at or below 185 percent of the federal poverty guidelines, for example, $ per year for a household of . People who receive Medicaid or Food Stamps automatically meet the WIC income requirements. If you have difficulty understanding or reading English or have a disability, free language assistance or other aids and services are available upon request.

This institution is an equal opportunity provider.

Page 32 Section 200 Appendices December 2024

KENTUCKY WIC PROGRAM ETHNICITY AND RACE HANDOUT

Purpose For clinic staff to use for assistance in gathering race and ethnicity. The card may be shared to the participant at registration for her/him to review and select race and ethnicity. When To Use As needed at registration of a new patient. Use is optional. Disposition Used by clinic staff. May be given to participants for review and selection of race and ethnicity. Language English, Spanish Use a qualified interpreter or qualified bilingual staff to explain the information on this card for non-Spanish speaking LEP individuals or if the Spanish-speaking LEP individual is illiterate. Ordering Order from the State WIC Office utilizing the WIC Program Supply Requisition Form, Email WIC Program Requisition Form to the Ky WIC Help Desk at WIC.Helpdesk@ky.gov. Order quantity as needed.

Page 33 Section 200 Appendices December 2024

KENTUCKY WIC PROXY AUTHORIZATION FORM

Purpose To describe the policy for designation of a proxy for the purpose of obtaining and sharing nutritional information, WIC benefits, and purchasing WIC approved foods. Overview To allow the woman participant, parent, legal representative or caretaker to designate another person to bring their child to WIC appointments. Languages English and Spanish. Use a qualified interpreter or qualified bilingual staff to explain the information on this card for non-Spanish speaking LEP individuals or if the Spanish-speaking LEP individual is illiterate. Designation of Proxy All areas of the Kentucky WIC Proxy Authorization Form must be completed. A separate proxy form must be completed for each household member requiring proxy authorization. Proxy designation must be reviewed at each certification. Instructions for Woman Participant, Parent, Legal Representative or Caretaker completing 1. Woman participant, parent, legal representative or caretaker shall write the name of the WIC participant on the 1st blank line. 2. Woman participant, parent, legal representative or caretaker shall write the name of the infant/child on the 2nd line. 3. Woman participant, parent, legal representative or caretaker shall write the full legal name of self or child on 3rd blank line. 4. Woman participant, parent, legal representative or caretaker shall list names of proxies and their relationship to the WIC participant in the spaces provided. 5. Woman participant, parent, legal representative or caretaker shall sign, date, and indicate their current physical address on the lines provided. 6. Notify the woman participant, parent, legal representative or caretaker the proxy authorization is valid for the length of the certification period. 7. The proxy authorization form must be reviewed at recertification for changes or updates. Instructions for Completion when Obtaining Verbal Authorization If the local health agency is obtaining verbal proxy consent, the following applies to completion of the form. Write the name of the woman participant, parent, legal representative or caretaker on the 1st blank line. 1. Write the name of the infant/child on the 2nd line. 2. Write the full legal name of the WIC participant on 3rd blank line. 3. List the full name(s) of proxies (as indicated by the woman participant, parent, legal representative or caretaker) and their relationship to the WIC participant in the spaces provided. 4. In the signature line for woman participant, parent, legal representative or caretaker document “Refer to Verbal Authorization.” Complete the current physical address on the lines provided. 6. Notify the woman participant, parent, legal representative or caretaker of the intent of the proxy authorization and review the content of the form with them. 7. Notify the woman participant, parent, legal representative or caretaker the proxy authorization is valid for the length of the certification period. 8. Sign and date on indicated line as staff person who obtained verbal authorization. 9. The proxy authorization form must be reviewed at recertification for changes or updates. Disposition Retain this form in the patient’s medical record and document on the CH- 3a Service Record. (i.e.,10/01/13 – Refer to KY-Proxy form.) Retention Per medical records requirements.

Page 34 Section 200 Appendices December 2024

KENTUCKY WIC PROXY AUTHORIZATION FORM

Page 35 Section 200 Appendices December 2024

WIC PROGRAM ABUSE POSTER “ATTENTION WIC PARTICIPANTS”

Purpose For clinic use to advise participants it is a violation of WIC Rights and Responsibilities to offer to sell WIC formula, foods, or eWIC cards. When To Use For display in WIC sites to provide general information. Disposition Shall be posted in a conspicuous place for all WIC participants. Language English and Spanish. Ordering Contact Program Management Section.

Page 36 Section 200 Appendices December 2024

WIC PROGRAM ABUSE LETTER TEMPLATE

Purpose Template letter for clinic use when participant abuse is suspected or proven. When To Use To provide written warning of WIC Program abuse. Instructions The letter template may be modified for agency/clinic use. Retention Must be maintained in the participant’s medical record. Language English Ordering Electronic template may be obtained from Program Management Section.

Page 37 Section 200 Appendices December 2024

SAMPLE WIC PROGRAM ABUSE LETTER

(Use local WIC agency letterhead) (Date) (Name) (Address) (City), Kentucky (Zip) Dear (Participant Name): The (Clinic/Site Name) has become aware of a situation or received an allegation that is in violation of the information contained in the WIC Rights and Responsibilities. The violation(s) could affect your continued participation.

(Please check all that apply)  Intent to sell or selling supplemental foods and/or the eWIC card in any way (i.e. on-line, in print, verbally or via social media).  Making a verbal offer of sale or exchange of supplemental food or eWIC card to another individual, group or a vendor.  Purchasing unauthorized foods or redeeming food benefits at an unauthorized store.  Returning supplemental foods to a vendor for cash.  Knowingly and deliberately giving false or misleading information, or misrepresenting, concealing or withholding facts to obtain WIC foods.  Abusive or threatening language and/or actions in a WIC clinic, to clinic staff or store staff.  Dual participation in more than one (1) WIC Program.  Other (please explain)

DETAILS OF EVENT/ALLEGATION: (Please provide specific details of situation/event in this space)

We want to remind you of your Rights and Responsibilities regarding the WIC Program. These are listed on the inside of the Kentucky eWIC benefits Card Pamphlet (eWIC-1) that was provided to you during your card issuance. An additional copy is enclosed for your review. These rights and responsibilities also apply to all persons listed as proxies. This letter is a reminder that violation of your participant responsibilities can result in suspension or disqualification from the WIC Program. Feel free to contact me at (phone number) if you have any questions. Sincerely, (WIC Coordinator or Local Official)

Enclosure (MUST INCLUDE English NONDISCRIMINATION STATEMENT) Nondiscrimination Statement is located in Policy 306.

Page 38 Section 200 Appendices December 2024

SAMPLE WIC PROGRAM ABUSE LETTER (SPANISH)

(Use local WIC agency letterhead) (Date) (Name) (Address) (City), Kentucky (Zip) Apreciado/a (Participant Name): La clínica (Clínica/Site Name) se ha enterado de una situación o recibió una alegación/queja la cual es una violación de la información bajo las responsabilidades y derechos de WIC. La/s violación/es pueden afectar su participación continua. (Favor seleccionar las que apliquen a usted)  Intentar vender los alimentos suplementarios y/o la tarjeta eWIC de alguna manera (por ejemplo: Internet, por escrito, verbalmente o por medio de redes sociales).  Hacer una oferta verbal para vender o intercambiar los alimentos suplementarios o la tarjeta eWIC a otra persona, grupo o a un vendedor.  Comprar alimento no autorizados o redimir los beneficios de alimentos a una tienda no autorizada.  Devolver los alimentos suplementarios al vendedor por efectivo.  Dar información falsa o engañosa, malinterpretar, ocultar o guardarse hechos para obtener alimentos de WIC.  Lenguaje abusivo o de amenaza y/o acciones en una clínica WIC, a un empleado o al empleado de la tienda.  Participación doble en más de un (1) programa de WIC.  Otra razón (favor explique)

DETALLES DEL EVENTO/ALEGACION: (Favor describa los detalles específicos de la situación o el evento en este espacio)

Le queremos recordar de sus derechos y responsabilidades en el programa WIC. Estas se encuentran en el panfleto de los Beneficios de la Tarjeta eWIC de Kentucky (eWIC-1) la cual se le dio el día que se le entrega la tarjeta. Una copia adicional se incluye con esta para su información. Estos derechos y responsabilidades también aplican a todas las personas autorizadas por usted. Esta carta es para recordarle que la violación de sus responsabilidades como participante puede resultar en la suspensión o descalificación del programa WIC.

Si tiene preguntas llamar al (phone number). Sinceramente, (WIC Coordinator or Local Official)

Enclosure (MUST INCLUDE Spanish NONDISCRIMINATION STATEMENT) Nondiscrimination Statement is located in Policy 306.

Page 39 Section 200 Appendices December 2024

WIC MOVING POSTER

Purpose Informational poster about moving and the WIC Program. When To Use To remind participants to inform the WIC agency if they are moving. Ordering Order from the State WIC Office utilizing the WIC Program Supply Requisition Form, Email WIC Program Requisition Form to the Ky WIC Help Desk at WIC.Helpdesk@ky.gov. Order quantity as needed. Contact the State WIC Office for other languages.

Page 40 Section 200 Appendices December 2024

Infants/Children Referral Data: (Complete Applicable Information) Women Referral Data: (Complete Applicable Information)

Kentucky WIC Referral Form Referrals for Breastfeeding Support and WIC Services Patient’s First & Last Name: Date of Birth (MM/DD/YY): (For Infants/Children) Parent/Caregiver’s First and Last Name:

Clinic/Hospital/Medical Office Name: Street Address: City: Zip Code: Phone Number: Fax Number: To Locate your County Health Department, please visit https://chfs.ky.gov/agencies/dph/ dafm/Pages/lhd.aspx (select Listing of LHDs) OR call 1-877-597-0367

Length/Ht: in. Wt:

lbs. oz. Date: Hgb/Hct:

Date:

(Valid within 60 days of measurement) (Valid within 90 days of measurement) Birth weight: lbs. oz. Birth Length: in. If premature, weeks gestation at birth: Breastfeeding?: ☐ Yes ☐ No Referral data provided by: (signature) Date: Length/Ht: in. Wt:

lbs. oz. Date: Hgb/Hct:

Date:

(Valid within 60 days of measurement) (Valid within 90 days of measurement) EDC: Last Wt. Prior to Pregnancy: lbs.

Multiple Gestation?: ☐ Yes ☐ No Delivery Date:

Last Wt. Prior to Delivery:

lbs. Breastfeeding?: ☐ Yes ☐ No If Currently Breastfeeding: ☐ Exclusively ☐ Partially ☐ Unknown Breastfeeding follow up needed?: ☐ Yes

This form is intended for use as… • A medical data referral form for infants, children and women for the Kentucky WIC Program • A breastfeeding support referral form for the Kentucky WIC Program • A proof of identification for hospitalized newborn infants To prescribe a special formula or medical food for an infant, child, or woman please visit https://chfs.ky.gov/agencies/dph/dmch/nsb/Pages/wic.aspx (select “Health Care Provider Information”).

We appreciate your cooperation and partnership in serving the Kentucky WIC population.

This institution is an equal opportunity provider.

☐ No ☐ Mother/baby separation ☐ Latch-on issues ☐ Milk supply concerns ☐ Other: Additional Comments/Details

Referral data provided by: (signature) Date: Instructions & Resources for Use of This Form:

Page 41 Section 200 Appendices December 2024

In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating on the basis of race, color, national origin, sex (including gender identity and sexual orientation), disability, age, or reprisal or retaliation for prior civil rights activity.

Program information may be made available in languages other than English. Persons with disabilities who require alternative means of communication to obtain program information (e.g., Braille, large print, audiotape, American Sign Language), should contact the responsible state or local agency that administers the program or USDA’s TARGET Center at (202) 720- 2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339.

To file a program discrimination complaint, a Complainant should complete a Form AD-3027, USDA Program Discrimination Complaint Form which can be obtained online at: https://www.usda.gov/sites/default/files/documents/USDA-OASCR%20P-Complaint-Form- 0508-0002-508-11-28-17Fax2Mail.pdf, from any USDA office, by calling (866) 632-9992, or by writing a letter addressed to USDA. The letter must contain the complainant’s name, address, telephone number, and a written description of the alleged discriminatory action in sufficient detail to inform the Assistant Secretary for Civil Rights (ASCR) about the nature and date of an alleged civil rights violation. The completed AD-3027 form or letter must be submitted to USDA by:

1. mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410; or 2. fax: (833) 256-1665 or (202) 690-7442; or 3. email: program.intake@usda.gov

This institution is an equal opportunity provider.

Page 42 Section 200 Appendices December 2024

101 Underweight  a Underweight = PPW BMI or Current BMI < 18.5 P/BF-01 PP-3B 131,132,133 Inappropriate Weight Gain Pattern P/BF-01 PP–3B

Medical Home: WIC Certification  Pregnant  Postpartum  Breastfeeding Name:

ID Number:

or Place PEF label here Priority listed at end of line for each criterion. Priority

Pregnant Postpartum/Breastfeeding  a Hematocrit ≤ 32.9% or Hemoglobin ≤ 10.9 gm./dL. (1st trimester) 0-13 wks  b Hematocrit ≤ 31.9% or Hemoglobin ≤ 10.4 gm./dL. (2nd trimester)14-26 wks  c Hematocrit ≤ 32.9% or Hemoglobin ≤ 10.9 gm./dL. (3rd trimester) 27-40 wks  d Hematocrit ≤ 35.6% or Hemoglobin ≤ 11.7 gm./dL. (Age 12-15)  e Hematocrit ≤ 35.8% or Hemoglobin ≤ 11.9 gm./dL. (Age 15-18)  f Hematocrit ≤ 35.6% or Hemoglobin ≤ 11.9 gm./dL. (Age >18)

211  Elevated Blood Lead (≥ 5 µg/dL) within the past 12 months P/BF-01 PP–3B 111 Overweight  a Overweight = PPW BMI ≥ 25.0  c Current BMI > 25.0 (BF > 6 months delivery) P/BF-01 PP-3B

131 Low maternal weight gain during 2nd and 3rd trimesters, singleton pregnancy: (P only)  Underweight women who gain < 4 lbs./month  Normal weight women who gain < 3.2 pounds/month  Overweight women who gain < 2 pounds/month  Obese (BMI ≥30) women who gain < 1.6 pounds/month P: Current Pregnancy BF/PP: Last Pregnancy High maternal weight gain during 2nd and 3rd trimesters, singleton pregnancy:  Underweight women who gain > 5.2 lbs./month - 133f  Normal weight women who gain > 4 pounds/month - 133g  Overweight women who gain > 2.8 pounds/month- 133h  Obese (BMI ≥30) women who gain > 2.4 pounds/month- 133i Gravida: Para:

371, 372 Alcohol and Substance Use (check all that apply) P/BF-01 PP–3B Pregnant 3010 Postpartum 3010 Breastfeeding 3010  Any daily smoking of cigarettes, pipes cigars electronic nicotine delivery system, hookahs, smokeless tobacco or nicotine replacement therapies 371a  Any alcohol Use 372a  Any illegal drug use 372b  Any marijuana use in any form 372c  Any daily smoking of cigarettes, pipes cigars electronic nicotine delivery system, hookahs, smokeless tobacco or nicotine replacement therapies 371c  Routine use of ≥ 4 drinks per day: 1 drink = 1 (12 oz.) can beer or 5 oz. wine or 1 ½ oz. liquor (1 jigger) 372c  Binge drinking ≥ 4 drinks within 2 hours 372d  Any illegal substance use and/or abuse of prescription medications 372b  Any daily smoking of cigarettes, pipes cigars electronic nicotine delivery system, hookahs, smokeless tobacco or nicotine replacement therapies 371b  Routine use of ≥ 4 drinks per day: 1 drink = 1 (12 oz.) can beer or 5 oz. wine or 1 ½ oz. liquor (1 jigger) 372c  Binge drinking ≥ 4 drinks within 2 hours 372d  Any illegal substance use and/or abuse of prescription medications 372b  Any marijuana use in any form 372f 904  Environmental Tobacco Smoke Exposure Exposure to products inside enclosed areas, secondhand, passive or involuntary smoke, includes exposure to the aerosol from electronic nicotine delivery systems P/BF-01 PP–3B 601a BF Infant/BF Woman at Nutritional Risk Breastfeeding infant has a nutritional risk which qualifies woman 601b  BF Infant/BF Woman with Dietary Concerns Breastfeeding infant qualifies based on dietary concern which qualifies woman BF-01 BF-04 602 Breastfeeding Complications (BF woman only) (check all that apply) BF-01  Severe engorgement  Mastitis (fever or flu-like symptoms with localized breast tenderness)  Failure of milk to come in by 4 days after delivery  Flat or inverted nipples  Tandem nursing (BF two siblings who are not twins)  Cracked, bleeding or severely sore nipples  ≥ 40 years old  Recurrent plugged ducts

This institution is an equal opportunity provider.

WIC 75 Woman, Page 1 of 3 201 Low Hematocrit/Low Hemoglobin (check one of the following values if appropriate P/BF-01 PP-3B

Page 43 Section 200 Appendices December 2024

301, 302, 303 Pregnancy Induced Conditions P/BF-01 PP-3B 311, 312 Delivery of Premature/LBW Infant P/BF-01 PP-3B  Hyperemesis Gravidarum -P only 301  Gestational Diabetes - P only 302  History of gestational diabetes 303  Preeclampsia or history of 304 P: History for any pregnancy BF/PP: Last pregnancy  Preterm Delivery (≤ 36 6/7 weeks) 311  Early Term Delivery (≥ 37/0/7 and ≤ 38 6/7 weeks) 311  LBW ≤ 5 lb. 8 oz. (wt. ) 312 321 Fetal or Neonatal Death P/BF-01 PP-3B P: History for any pregnancy BF/PP: Last pregnancy  Fetal death (death ≥ 20 week gestation) 5013.321a  Neonatal death (death within first 28 days of life) 5013.321b Pregnant only: 321c  History of 2 or more spontaneous abortions (spontaneous termination of a gestation at < 20 weeks gestation or < 500 grams) 331, 332, 333, 334, 335, 336, 337, 338, 339 General Obstetrical Risk P/BF-01 PP-3B P: Current Pregnancy BF/PP: Last Pregnancy  Conception < age 20 331  Conception before 18 mo. Postpartum 332  Age < 20 at conception with 3 or more previous pregnancies of > 20 weeks duration 333  Infant with congenital or birth defect 339a  Multiple births 335 Pregnant only  Prenatal care beginning after 13th week 334a  Breastfeeding woman now pregnant 338  Fetal Growth Restriction 336  History of Infant/Child with congenital or birth defect 339c Pregnant only 334b  Prenatal care based on the following index: Weeks gestation # prenatal visits 14-21 0 or unknown 22-29 1 or less 30-31 2 or less 32-33 3 or less ≥ 34 4 or less Pregnant/Breastfeeding/Postpartum LGA infant > 9 lbs./4000 grams or history of LGA infant 337 Nutrition/Metabolic Conditions (check all that apply) P/BF-01 PP-3B  Lactose Intolerance 355 Nutrient Deficiency or Diseases: 341  Scurvy  Hypocalcemia  Iron Deficiency  Rickets  Cheilosis  Beri Beri  Pellagra  Xerophthalmia  Vitamin K Deficiency  Osteomalacia  Protein Energy Malnutrition (PEM) Glucose Disorders:  Pre-Diabetes 363 (PP/BF only)  Diabetes Mellitus 343  Hypoglycemia 356 Thyroid Disorders:  Hypothyroidism 344a  Hyperthyroidism 344b Congenital Hyperthyroidism.344a  congenital Hypothyroidism 344b  Postpartum Thyroiditis.344c Cancer: 347  Cancer  Treatment for Cancer Hypertension:  Chronic 345a  Prehypertension (130/80-139/89) 345c  Gestational Hypertension 345b GI Disorders: 342  Crohn’s disease  Ulcerative colitis  Liver disease  Inflammatory bowel disease  Pancreatitis  Gallbladder disease  Malabsorption syndromes  Small bowel enterocolitis/syndrome  Stomach/intestinal ulcers  Gastroesophageal reflux (GER)  Peptic ulcers  Post-bariatric surgery  Biliary tract diseases Central Nervous System Disorders:  Epilepsy 348  Cerebral Palsy  Spina Bifida  Myelomeningocele  Neural tube defects  Parkinson’s disease  Multiple Scrosis Renal disease:  Pyelonephritis  Persistent proteinuria 346  Any renal disease except UTI Inborn Errors of Metabolism: 351  Amino Acid Metabolism Disorders: ▪Phenylketonuria ▪Maple Syrup Urine disease ▪Homocystinuria ▪Tyrosinemia Carbohydrate Disorders: Galactosemia ▪Glycogen Storage Disease type I ▪ Glycogen Storage Disease type II (Pomp Disease) ▪Glycogen Storage Disease type III ▪Glycogen Storage Disease type IV (Andersen Disease) ▪Glycogen Storage Disease type V ▪Glycogen Storage Disease type VI) Fatty Acid Oxidation Defects: ▪Medium-chain acyl-CoA dehydrogenase deficiency ▪ Long-Chain 3-hydroxyacl-CoA-dehydrogenase deficiency ▪ Trifunctional protein deficiency type 1 (LCHAD deficiency) ▪Trifunctional protein deficiency type 2 (mitochondrial trifunctional protein deficiency) ▪ Carnitine uptae defect (primary carnitine deficiency) ▪Very long-chain acyl-CoA dehydrogenase deficiency Organic Acid Disorders: ▪Isovaleric academia ▪3-methylcrotonyl-CoA carboxylase deficiency ▪Glutaric academia type I ▪Glutaric academia type II ▪3- hydroxy-3-methylglutaryl-coenzyme A lyase deficiency ▪Multiple carboxylase deficiency (Biotinidase deficiency, Holocarboxylase synthetase deficiency) ▪ Methylmalonic academia ▪Propionic academia ▪Beta-ketothiolase deficiency Lysosomal Storage Disease: ▪Fabry disease(α-galactosidase A deficiency) ▪ Gauchers disease (glucocerebrosidase deficiency) ▪Pompe disease (glycogen storage disease Type II or Acid α-glucosidase deficiency) Mitochondrial disorders: ▪Leber hereditary optic neurophathy ▪Mitochondrial encephalomyopathy, lactic acidosiss, and stroke-like episodes (MELAS), ▪ Mitochondrial neurogastrointestinal encephalopathy disease (MNGIE) ▪ Myoclonic epilepsy with ragged-red fibers (MERRF) ▪Neuropathy, ataxia, and retinitis pigmentosa (NARP) ▪Pyruvate carboxylase deficiency Peroxisomal Disorders: ▪Zwllweger Syndrome Spectrum ▪ Adrenoleukodystrophy (x-ALD) Urea Cycle Disorders: ▪Citrullinemia ▪Argininosuccinic aciduria ▪Carbomoyl phosphate synthetase I deficiency Genetic/Congenital Disorders: 349  Short bowel syndrome  Sickle Cell Anemia  Cleft lip/palate  Gastroschisis  Thalassemia Major  Down’s syndrome  Omphalocele  Intestinal atresia  Esophageal atresia  Diaphragmatic hernia  Tracheo-esophageal fistula  Hirschsprung’s Disease  Muscular Dystrophy Infectious Diseases- Acute (present in last 6 mo.):352 a  Parasitic infections  Hepatitis A or E  Listeriosis  Pneumonia  Meningitis (Viral or bacterial)  Bronchitis (3 x in last 6 mo.)  Tuberculosis Active infection  Other Specify: Infectious Diseases Chronic 352 b  Hepatitis B  Hepatitis C  Hepatitis D  Other Specify:  AIDS  HIV Recent Major Surgery, Trauma, Burns: 359  Any occurrence within past two (≤ 2) months severe enough to compromise nutritional status.  Occurrence > 2 months with continued need for nutrition documented by MD/DO/APRN/PA  Food allergies - 353 List:  Drug/Nutrient Interactions – Specify: 357 Celiac Disease:  Celiac Sprue  Gluten Enteropathy 354  Non-tropical Sprue Recent Major Surgery, Trauma, Burns: 359  Any occurrence within past two (≤ 2) months severe enough to compromise nutritional status.  Occurrence > 2 months with continued need for nutrition documented by MD/DO/APRN/PA Other Medical Conditions: 360  Juvenile Rheumatoid Arthritis (JRA)  Cardiorespiratory diseases  Heart disease  Cystic fibrosis  Lupus erythematosus  Persistent asthma requiring daily medication WIC 75 Woman, page 2 of 3

Page 44 Section 200 Appendices December 2024

o 382 Fetal Alcohol Spectrum Disorder P/BF 01/PP-3A 381 Dental Problems P/BF 01/PP-3B

902 Impaired Ability to Prepare Food (check all that apply) P/BF-04 PP-06 361,362 Complications which Impair Nutrition (check all that apply) P/BF-01 PP-3B  ≤ 17 years of age 902a  Mentally disabled/delayed/mental illness/clinical Depression/Post-Partum Depression 902b  Physically disabled which restricts/limits food preparation abilities .902c  Currently using or history of abusing alcohol/ prescription drugs/ marijuana/other Drugs 902d  Intellectual disability 902e  Minimal brain function  Head trauma  Brain damage  Depression/ Post-Partum Depression  Pervasive development disorder (PDD)  Difficulty accepting new foods/↓ food selection  Restricted food intake due to color/texture/temperature  Delays/disabilities which restrict ability to chew/swallow/require tube feeding  Difficulty taking multivitamin/mineral supplement  Autism  Difficulty with changes in mealtime environment

 Fetal Alcohol Syndrome (FAS)  Partial Fetal Alcohol Syndrome (pFAS)  Alcohol-Related Birth Defects (ARBD)  Alcohol-Related Neurodevelopmental Disorders (ARND)  Neurobehavioral Disorders with Prenatal Alcohol Exposure (ND- PAE)

 Tooth decay 381a  Periodontal disease 381d  Gingivitis of pregnancy (Pregnant only) 381b  Missing more than 7 teeth or ineffectively replaced teeth which impair ability to ingest food 381c 401 Presumed Dietary Risk Only use this risk when no other risk is present P/BF-04 PP-06 Women who meet the eligibility requirements of income, category and residency may be presumed to be at nutrition risk based on failure to meet the Dietary Guidelines. Dietary Assessment Woman Yes No   Do you eat at least 6 servings of any of the following/day: bread, cereal, rice or pasta? (Encourage whole grain choices) Yes No   Do you eat at least 3 servings/day of vegetables? Yes No   Do you eat at least 2 servings/day of any of the following: meat (beef, pork, chicken, or turkey), fish, soup beans, eggs or peanut butter? Yes No   Do you eat at least 2 servings/day of fruits? Yes No   Do you eat at least 3 servings/day of any of the following: milk, cheese or yogurt? (Encourage low fat or fat free dairy choices.) 427 Feeding Practices P/BF-04 PP-06 Do you eat such foods as: (Pregnant only) 427.5a-j Yes No  raw fish or shellfish  smoked seafood that has not been cooked  raw or undercooked meat or poultry  refrigerated paté or meat spreads  lightly cooked egg products, ie., sauces, homemade eggn  raw sprouts (alfalfa, clover, radish)  unpasteurized fruit or vegetable juices  hot dogs, cold cuts, deli meats that have not been heated  raw/undercooked eggs such as in cookie dough or cake batter  unpasteurized milk/milk products or soft cheeses such as Camembert, bleu cheese, Stilton, queso blanco, queso fresco or Panela Yes  Yes  Yes 

Yes 

Yes  No If pregnant, do you take < 30 mg. iron each day?  427.4a No If pregnant or breastfeeding, do you take < 150 µg  of iodine each day? 427.4c Do you take > 1 dose/day of a multivitamin, single No vitamin, mineral supplement, herbal teas/remedies  not recommended by MD/DO/APRN/PA? 427.1 Do you eat ashes, baking soda, burnt matches, carpet fibers, chalk, cigarettes, clay, dirt, dust, No laundry starch, cornstarch, large quantities of ice or  freezer frost, paint chips or other non-food items? 427.3 No If BF/PP do you take a multivitamin/supplement with  400 mcgs. Folic acid every day? 427.4b

427 Inappropriate Nutrient Intake P/BF- 04 PP-06 427.2a Do you avoid all animal products – meat (beef, pork, chicken, turkey), fish, eggs, milk, cheese, yogurt or other dairy products?  Yes  No 427.2b Is your diet highly restrictive in calories or specific nutrients?  Yes  No 358 Eating Disorders  a Anorexia Nervosa  b Bulimia  c Controls weight by self-starvation, vomiting, drugs, purgative abuse P/BF-1 PP-3B 901  Recipient of Abuse Battering, physical assault within the past six months. P/BF-04 PP-06 903 Foster Care Determine if during the previous six (6) months: P/BF-04 PP-06  has entered the foster care system 903a  has been moving from one foster home to another 903b

* What concerns or questions does the participant have in regard to her nutrition?

Signature: Date:

WIC 75 Woman, Page 3 of 3 Rev. 10/20) 801  Homelessness Homeless 802  Migrancy Migrant P/BF-04 PP-06 P/BF-04 PP-06          

Page 45 Section 200 Appendices December 2024

211  Elevated Blood Lead ≥ 5 µg/dL. within past 12 months Only if data is available from another source 01 152  Low Head Circumference ≤ 2.3rd percentile head circumference for age as plotted on CDC birth to 24 month growth chart (age adjusted) Only if data is available from another source. 01 142  Preterm (≤ 36 6/7 weeks gestation)  Early Term (≥ 37/0/7 and ≤ 38 6/7 weeks gestation) 01 141 Low Birth Weight/Very Low Birth Weight (age adjusted) 01 115  High Weight for Length ≥97.7th percentile weight/length on CDC Birth to 24 month growth chart 01  biological father reports BMI > 30  biological mother reports BMI > 30 at conception or during 1st trimester 01 114 At Risk for Overweight  Birth weight < 3 lb. 5 oz./1500 grams (VLBW) 2050.141b  Birth weight < 5 lb. 8 oz./2500 grams (LBW) 141a 103a  At Risk for Underweight >2.3rd to ≤ 5th percentile weight for length on CDC Birth to 24 month growth chart 103b  Underweight < 2.3rd percentile weight for length on CDC Birth to 24 month growth chart 121a  At Risk for Short Stature >2.3rd to ≤ 5th percentile length for age on CDC Birth to 24 month growth chart 121b  Short Stature < 2.3rd percentile length for age on CDC Birth to 24 month growth chart (age adjusted) 01 01 01 01 151 Growth Problems a Small for Gestational Age (SGA) (age adjusted)  b Large for Gestational Age (LGA) birth weight ≥ 9 lbs/4,000 gm 01 702a  Breastfeeding Dyad- Breastfeeding woman (mother) has a nutritional risk which qualifies breastfeeding infant 702b  Breastfeeding Dyad- Breastfeeding woman has a dietary concern which qualifies breastfeeding infant 01 04 701  Infant of a WIC Mother/Mother at Risk Mother who had risk and could have qualified during this pregnancy. (up to 6 mo. old) 02

WIC Certification Infant Name:

ID Number:

or Place PEF label here

Medical Home: Immunization UTD? Y or N (If not, refer and request copy at next visit). Immunization Record on file? Y or N Priority listed at end of line for each criterion. Priority

134,135 Inappropriate Weight Gain Pattern/ Slowed or Faltering Growth Pattern 01  Failure to Thrive (FTT) (age adjusted) 134  Not back to birth weight by 2 weeks 135  Lost > 7% birthweight any time from birth to 2 weeks 135b  Any weight loss from 2 weeks to 6 months of age (weight measurements taken at least 8 weeks apart) 135c 904  Environmental Tobacco Smoke Exposure. Exposure to tobacco products inside enclosed areas, secondhand, passive or involuntary smoke, includes exposure to the aerosol from electronic nicotine delivery systems.01

602 Breastfeeding Complications (check all that apply) 01  Jaundice  Weak or ineffective suck Inadequate stooling for age:  ≤ 6 days old with < 2 stools/day  7-28 days with < 5 stools/day  29 days or older with <1 every 4 days  < 6 wet diapers per day  Difficulty latching onto breast

WIC 75 Infant, Page 1 of 4 201g  Low Hematocrit/Low Hemoglobin -Hematocrit ≤ 32.8% or Hemoglobin ≤ 10.9 gm./dL. (9 months or older) 01

Page 46 Section 200 Appendices December 2024

 Lactose Intolerance 355  Hypertension 345  Prehypertension (90th-95th for blood pressure) 345d Nutrient Deficiency or Diseases: 341  Scurvy  Hypocalcemia  Iron Deficiency  Rickets  Cheilosis  Beri Beri  Pellagra  Xerophthalmia  Vitamin K Deficiency  Osteomalacia  Protein Energy Malnutrition (PEM) Glucose Disorders:  Diabetes Mellitus 343 Hypoglycemia 356 Thyroid Disorders: Hypothyroidism 344a  Hyperthyroidism 344b Congenital Hyperthyroidism 344a  congenital Hypothyroidism 344b Cancer: 347  Cancer  Treatment for Cancer Central Nervous System Disorders: 348  Epilepsy  Cerebral Palsy  Spina Bifida  Myelomeningocele  Neural tube defects  Parkinson’s disease  Multiple Sclerosis GI Disorders: 342  Crohn’s disease  Ulcerative colitis  GER  Liver disease  Inflammatory bowel disease  Pancreatitis  Gallbladder disease  Malabsorption syndromes  Small bowel enterocolitis/syndrome  Stomach/intestinal ulcers  Peptic ulcers  Post-bariatric surgery  Biliary tract diseases Renal Disease: 346  Pyelonephritis  Persistent proteinuria  Any renal disease except UTI Inborn Errors of Metabolism: 351  Amino Acid Metabolism Disorders: ▪Phenylketonuria ▪Maple Syrup Urine disease ▪Homocystinuria ▪Tyrosinemia Carbohydrate Disorders: Galactosemia ▪Glycogen Storage Disease type I ▪Glycogen Storage Disease type II (Pomp Disease) ▪ Glycogen Storage Disease type III ▪Glycogen Storage Disease type IV (Andersen Disease) ▪Glycogen Storage Disease type V ▪ Glycogen Storage Disease type VI) Fatty Acid Oxidation Defects: ▪Medium-chain acyl-CoA dehydrogenase deficiency ▪ Long-Chain 3-hydroxyacl-CoA- dehydrogenase deficiency ▪Trifunctional protein deficiency type 1 (LCHAD deficiency) ▪Trifunctional protein deficiency type 2 (mitochondrial trifunctional protein deficiency) ▪ Carnitine uptae defect (primary carnitine deficiency) ▪Very long- chain acyl-CoA dehydrogenase deficiency Organic Acid Disorders: ▪Isovaleric academia ▪3- methylcrotonyl-CoA carboxylase deficiency ▪Glutaric academia type I ▪Glutaric academia type II ▪3-hydroxy-3-methylglutaryl- coenzyme A lyase deficiency ▪Multiple carboxylase deficiency (Biotinidase deficiency, Holocarboxylase synthetasedeficiency) ▪ Methylmalonic academia ▪Propionic academia ▪Beta-ketothiolase deficiency Lysosomal Storage Disease: ▪Fabry disease(α-galactosidase A deficiency) ▪Gauchers disease (glucocerebrosidase deficiency) ▪ Pompe disease (glycogen storage disease Type II or Acid α- glucosidase deficiency) Mitochondrial disorders: ▪Leber hereditary optic neurophathy ▪ Mitochondrial encephalomyopathy, lactic acidosiss, and stroke-like episodes (MELAS), ▪Mitochondrial neurogastrointestinal encephalopathy disease (MNGIE) ▪Myoclonic epilepsy with ragged- red fibers (MERRF) ▪Neuropathy, ataxia, and retinitis pigmentosa (NARP) ▪Pyruvate carboxylase deficiency Peroxisomal Disorders: ▪Zwllweger Syndrome Spectrum ▪ Adrenoleukodystrophy (x-ALD) Urea Cycle Disorders: ▪Citrullinemia ▪Argininosuccinic aciduria ▪ Carbomoyl phosphate synthetase I deficiency Infectious Diseases- Acute (present in last 6 mo.):352 a  Parasitic infections  Hepatitis A or E  Listeriosis  Pneumonia  Meningitis (Viral or bacterial)  Bronchitis (3 x in last 6 mo.)  Tuberculosis Active infection  Other Specify: Infectious Diseases Chronic 352 b  Hepatitis B  Hepatitis C  Hepatitis D  Other Specify:  AIDS  HIV  Food Allergies – List: 353 Genetic/Congenital Disorders:349  Short bowel syndrome  Sickle Cell Anemia  Cleft lip/palate  Gastroschisis  Thalassemia Major  Down’s syndrome  Omphalocele  Intestinal atresia  Esophageal atresia  Diaphragmatic hernia  Tracheo-esophageal fistula  Hirschsprung’s Disease  Muscular Dystrophy  Pyloric Stenosis Celiac Disease:  Celiac Sprue  Gluten Enteropathy 354  Non-tropical Sprue  Drug/Nutrient Interactions – Specify: 357 Recent Major Surgery, Trauma, Burns: 359  Any occurrence within ≤ 2 months severe enough to compromise nutritional status.  Occurrence > 2 months with continued need for nutrition documented by MD/DO/APRN/PA Other Medical Conditions: 360  Lupus erythematosus  Cardiorespiratory diseases  Heart disease  Cystic fibrosis  Juvenile Rheumatoid Arthritis (JRA)  Persistent asthma requiring daily medication  Neonatal Abstinence Syndrome 383  Others – State Agency approval

902 Impaired Ability to Prepare Food 04 361,362 Complications which Impair Nutrition (check all that apply) 01 Participant’s primary caregiver is (check all that apply):  < 17 years of age 902a  Mentally disabled/delayed/mental illness/clinical Depression/Post-Partum Depression 902b  Currently using or history of abusing alcohol/ prescription drugs/ marijuana/other Drugs 902d  Intellectual disability 902e  Physically disabled which restricts/limits food preparation abilities 902c  Minimal brain function  Head trauma  Brain damage  Birth Injury  Pervasive development disorder (PDD) depression 361  Difficulty accepting new foods/↓ food selection  Restricted food intake due to color/texture/temperature  Delays/disabilities which restrict ability to chew/swallow/require tube feeding 362  Difficulty taking multivitamin/mineral supplement  Autism  Difficulty with changes in mealtime environment WIC 75 Infant, Page 2 of 4 Nutrition/Metabolic Conditions (check one of the following if appropriate) 01

Page 47 Section 200 Appendices December 2024

Feeding Practices (will qualify with one or more of the following shaded answers) /Dietary Assessment 04 Yes  No  Does the baby take formula? If yes, formula name:

Yes    No    Is the baby breastfed? Taking <400 IU per day vitamin D (Exclusively breastfed infant or infant taking <32 oz of formula per day) 411.11a Is the baby fed human milk acquired directly from individuals other than mother or the internet (informal milk sharing) 411.4, 411.9   Iron-fortified formula 411.1a Yes     No     Is the baby fed only breastmilk? If no, continue to next box. If under 2 months old, does the baby eat less than 8 times in 24 hours? 411.7a If 2 months old or older, does the baby eat less than 6 times in 24 hours? 411.7b Fed on a schedule rather than on demand?   Low iron formula without iron supplement 411.1a Type of formula:  Concentrate  Ready-to-feed  Powder How is formula mixed? 411.6a  Overdilution  Underdilution  By prescription  Failure to follow specific instructions accompanying prescription Yes  No  Is the baby fed less than 16 ounces of formula in 24 hours? 411.4d Yes  No  Is a bottle of water given in place of a bottle of formula or breastmilk or do you restrict the amount of foods? 411.4c   Are cereals or other foods added to the baby’s bottle? 411.2e Yes  No  Does the baby drink milk (fresh, whole, skim, 1%, 2%, low-fat, nonfat, goat, sheep, imitation (Vitamite, Toddler’s Best, nondairy creamer), substitute (Alba 77, Slim Fast, rice or soy based beverage, homemade formula), evaporated, sweetened condensed)? 411.1c Yes   No   Do you or the baby’s caretaker: • Hold fresh breastmilk in refrigerator for > 72 hours? 411.9i • Add fresh breastmilk to already frozen breastmilk in a storage container? 411.9j Yes   No   Does the baby drink sweetened drinks or other liquids: fruit juice, tea, kool aid, soda pop, jello water, Gatorade, Hi C, fruit punch, sweetened water (sugar, corn syrup, etc.)? Does the baby drink more than 6 ounces of juice in a day? 411.3       • Feed previously frozen breastmilk thawed in refrigerator for more than 24 hours? 411.9k • Save breastmilk from a used bottle for another feeding? 411.9l • Thaw breastmilk in the microwave? 411.9 • Express breast milk from a pump that has not been cleaned per manufacturer’s instructions? 411.9 Yes  No  Does the baby eat high calorie/low nutrient foods such as desserts, cakes, cookies, candy, fried foods, lunch meat? 411.8c Yes      No      Does the baby take a bottle: • Propped in the mouth? 411.2a • At nap or sleeps with bottle in mouth? 411.2b • With fruit juice? 411.2c • Without restriction? 411.2d • From a bottle that has not been properly cleaned? 411.9 Yes  No  Does the baby eat foods like hot dogs, pieces of fruit, nuts, raisins, hard candy, raw carrots? 411.4a Yes  No  Is honey, sugar or syrup put in the foods or liquids which are fed to the baby or put on the baby’s pacifier? 411.5h Yes  No  Does the baby drink more than a cup (8 ounces) of water in 24 hours? Age Group Yes No Does baby consume: 428 Yes  No  If 6 months or older with a family history of food allergies, does the baby drink city water, take a fluoride supplement or drink fluoridated water? 428 Less than 4 months   Solid food such as cereals, mashed potatoes, eggs, gravy? Yes   No   Do you or the baby’s caretaker: Have a safe water supply (documented)? 411.9a Have a stove for sterilizing bottles and water? 411.9b 6-12 months old or more As develop- mentally appropriate for the infant   Solid food from a spoon introduced by 6 months?   Have a refrigerator or freezer for storage of breastmilk or formula? 411.9c   Infant cereal?   Meats?   Have limited knowledge on preparation, handling or storage of formula or breastmilk? 7012.411.9d   Vegetables?   Does the baby use fingers when eating? 411.4d   Feed the baby formula held at room temperature > 2 hours? 411.9e   Fruits? 411.4d   Feed the baby formula left in refrigerator >48 hours? 411.9f   Iron & Zinc source introduced by 6 months of age (meat or cereal)?   Use leftover formula from an earlier feeding? 411.9g Less than 12 months   Eggs, milk, wheat (not infant cereal), soy, peanuts, fish, shellfish?   Give the baby vitamin, multi-vitamin or mineral supplements, herbal teas/remedies not recommended by MD/DO/APRN/PA? 411.10 Yes         No         Does the baby eat: • Undercooked or raw tofu? 411.5a • Deli meats, hot dogs not cooked until steaming hot? 411.5b • Raw vegetable sprouts (alfalfa, bean, clover, radish)? 411.5c • Raw or undercooked meat, fish, poultry or eggs? 411.5d • Unpasteurized milk or milk products? 411.5e • Soft cheeses such as Camembert, bleu cheese, Stilton, queso blanco, queso fresco or Panela 411.5f • Unpasteurized fruit or vegetable juices 411.5g • Honey added to liquids, solid foods, used in cooking, in processed foods, or on pacifier?   Wash hands with soap and water after using the bathroom, changing diapers, and before meals or before preparing formula or bottles of breastmilk? 411.9h     Require the baby to eat a certain type and/or amount of food or ignore infant hunger cues? 411.4b Routinely fed a vegan diet, macrobiotic diet or diet very low in calories/essential nutrients? 411.8 Yes  No  Is the baby getting Well Child check-ups? If yes, list Doctor or facility: WIC 75 Infant, page 3 of 4

Page 48 Section 200 Appendices December 2024

903 Foster Care Determine if during the previous six (6) months: 04 802  Migrancy Migrant 04

 Fetal Alcohol Syndrome (FAS)  Partial Fetal Alcohol Syndrome (pFAS)  Alcohol-Related Birth Defects (ARBD)  Alcohol-Related Neurodevelopmental Disorders (ARND)  Neurobehavioral Disorders with Prenatal Alcohol Exposure (ND-PAE)

 a. has entered the foster care system  b. has been moving from one foster home to another

**What concerns, or questions does the parent/caretaker have in regards to the infant’s nutrition/feeding the infant?

Signature: Date

This institution is an equal opportunity provider. WIC 75 Infant, page 4 of 4 (Rev. 10/18) 381a Dental Problem  Baby Bottle Tooth Decay 382 Fetal Alcohol Spectrum Disorder 01 01 801  Homelessness Homeless 04 901  Recipient of Abuse. Abuse (emotional or physical) and/or neglect within the past six months 04

Page 49 Section 200 Appendices December 2024

211  Elevated Blood Lead (≥ 3.5 µg/dL) within the past 12 month (only if data is available from another source) 3A 152  Low Head Circumference ≤ 2.3rd percentile head circumference for age as plotted on CDC birth to 24 month growth chart (up to age 2, age adjusted), (Only if data is available from another source). 3A 142  Preterm (≤ 36 6/7 weeks gestation)  Early Term (≥ 37/0/7 and ≤ 38 6/7 weeks gestation) (up to age 2, age adjusted) 3A 151  Growth Problems Small for Gestational Age (SGA up to age 2) (age adjusted) 3A 134  Inappropriate Weight Gain Pattern Failure to Thrive (FTT) (age adjusted) 3A 904  Environmental Tobacco Smoke Exposure. Exposure to tobacco products inside enclosed areas, secondhand, passive or involuntary smoke, includes exposure to the aerosol from electronic nicotine delivery systems.3A WIC Certification Child Age 1-5 Name:

ID Number:

or Place PEF label here

Medical Home: Immunization UTD? Y or N (If not, refer and request copy at next visit). Immunization Record on file? Y or N

Priority listed at end of line for each criterion. Priority 201 Low Hematocrit/Low Hemoglobin (check one of the following values if appropriate) 3A Age 1 to 2 1010.201g  Hematocrit ≤ 32.8% or Hemoglobin ≤ 10.9 gm./dL. Age 2 to 5 1010.201h  Hematocrit ≤ 32.9% or Hemoglobin ≤ 11.0 gm./dL.

141 Low Birth Weight/Very Low Birth Weight (age adjusted) 3A Birth weight < 5 lb. 8 oz./2500 grams (LBW)(up to age 2) 141a  Birth weight < 3 lb. 5 oz./1500 grams (VLBW) (up to age 2) 141b

114 At Risk for Overweight 3A  biological mother reports BMI > 30 (if mother is pregnant or had baby within the past 6 months, use her PPW BMI)  biological father reports BMI > 30

113,114,115 Obese/Overweight/High Weight for Length 3A  Obese (Age 2-5): ≥ 95th percentile BMI as plotted on CDC 2-20 year growth chart (standing height measurement) 113  Overweight (Age 2-5) : > 85th percentile or < 95th percentile BMI as plotted on CDC 2-20 year growth chart (standing height measurement) 114  High Weight for Length (up to age 2, age adjusted) : ≥97.7th percentile weight/length on CDC Birth to 24 month growth chart 115

103 At Risk for Underweight 3A  >2.3rd to ≤ 5th percentile weight/length on CDC Birth to 24 month growth chart (up to age 2, age adjusted)  >5th to ≤ 10th percentile BMI for age as plotted on CDC 2-20 year growth chart (age 2 to 5)

103 Underweight 3A  < 2.3rd percentile weight for length on CDC Birth to 24 month growth chart (up to age 2, age adjusted)  < 5th percentile BMI for age as plotted on CDC 2-20 year growth chart (age 2 to 5)

121 At Risk for Short Stature 3A >2.3rd to ≤ 5th percentile length for age on CDC Birth to 24 month growth chart (up to age 2, age adjusted) >5th to ≤ 10th percentile height/stature for age as plotted on CDC 2-20 year growth chart (age 2 to 5)

121 Short Stature 3A < 2.3rd percentile length for age on CDC Birth to 24 month growth chart (up to age 2, age adjusted) < 5th percentile height/stature for age as plotted on CDC 2-20 year growth chart (age 2 to 5)

Dietary Assessment Yes No   Does the child eat at least 6 servings of any of the following/day: bread, cereal, rice or pasta? (Encourage whole grain choices) Yes No   Does the child eat at least 3 servings/day of vegetables? Yes No   Does the child eat at least 2 servings/day of any of the following: meat (beef, pork, chicken, or turkey), fish, soup beans, eggs or peanut butter? Yes No   Does the child eat at least 2 servings/day of fruits? Yes No   Does the child eat at least 3 servings/day of any of the following: milk, cheese or yogurt? (Encourage low fat or fat free dairy choices for children 2 and older) Yes No   Does the child consume sugar sweetened beverages such tea, soda pop, Gatorade, Hi C, fruit punch, kool ade or drink more than 6 oz. of 100% juice per day?

WIC 75 Child, Page 1 of 4

Page 50 Section 200 Appendices December 2024

Nutrition/Metabolic Conditions (check one of the following if appropriate) 3A  Lactose Intolerance 355  Hypertension 345  Prehypertension (90th-95th for blood pressure) 345d Nutrient Deficiency or Diseases: 341  Scurvy  Hypocalcemia  Iron Deficiency  Rickets  Cheilosis  Beri Beri  Pellagra  Xerophthalmia  Vitamin K Deficiency  Osteomalacia  Protein Energy Malnutrition (PEM) Glucose Disorders:  Diabetes Mellitus 343  Hypoglycemia 356 Thyroid Disorders:  Hypothyroidism 344a  Hyperthyroidism 344b Congenital Hyperthyroidism 344a  congenital Hypothyroidism 344b Cancer: 347  Cancer  Treatment for Cancer Central Nervous System Disorders: 348  Epilepsy  Cerebral Palsy  Spina Bifida  Myelomeningocele  Neural tube defects  Parkinson’s disease  Multiple Sclerosis GI Disorders: 342  Crohn’s disease  Ulcerative colitis  Liver disease  Inflammatory bowel disease  Pancreatitis  Gallbladder disease  Malabsorption syndromes  Small bowel enterocolitis/syndrome  Stomach/intestinal ulcers  Gastroesophageal reflux (GER)  Peptic ulcers  Post-bariatric surgery  Biliary tract diseases Renal Disease: 346  Pyelonephritis  Persistent proteinuria  Any renal disease except UTI Inborn Errors of Metabolism: 351  Amino Acid Metabolism Disorders: ▪Phenylketonuria ▪Maple Syrup Urine disease ▪Homocystinuria ▪Tyrosinemia Carbohydrate Disorders: Galactosemia ▪Glycogen Storage Disease type I ▪Glycogen Storage Disease type II (Pomp Disease) ▪Glycogen Storage Disease type III ▪Glycogen Storage Disease type IV (Andersen Disease) ▪Glycogen Storage Disease type V ▪Glycogen Storage Disease type VI) Fatty Acid Oxidation Defects: ▪Medium-chain acyl-CoA dehydrogenase deficiency ▪ Long-Chain 3-hydroxyacl-CoA- dehydrogenase deficiency ▪Trifunctional protein deficiency type 1 (LCHAD deficiency) ▪Trifunctional protein deficiency type 2 (mitochondrial trifunctional protein deficiency) ▪ Carnitine uptae defect (primary carnitine deficiency) ▪Very long-chain acyl-CoA dehydrogenase deficiency Organic Acid Disorders: ▪Isovaleric academia ▪3-methylcrotonyl- CoA carboxylase deficiency ▪Glutaric academia type I ▪Glutaric academia type II ▪3-hydroxy-3-methylglutaryl-coenzyme A lyase deficiency ▪Multiple carboxylase deficiency (Biotinidase deficiency, Holocarboxylase synthetasedeficiency) ▪Methylmalonic academia ▪ Propionic academia ▪Beta-ketothiolase deficiency Lysosomal Storage Disease: ▪Fabry disease(α-galactosidase A deficiency) ▪Gauchers disease (glucocerebrosidase deficiency) ▪Pompe disease (glycogen storage disease Type II or Acid α-glucosidase deficiency) Mitochondrial disorders: ▪Leber hereditary optic neurophathy ▪ Mitochondrial encephalomyopathy, lactic acidosiss, and stroke-like episodes (MELAS), ▪Mitochondrial neurogastrointestinal encephalopathy disease (MNGIE) ▪Myoclonic epilepsy with ragged-red fibers (MERRF) ▪Neuropathy, ataxia, and retinitis pigmentosa (NARP) ▪ Pyruvate carboxylase deficiency Peroxisomal Disorders: ▪Zwllweger Syndrome Spectrum ▪ Adrenoleukodystrophy (x-ALD) Urea Cycle Disorders: ▪Citrullinemia ▪Argininosuccinic aciduria ▪ Carbomoyl phosphate synthetase I deficiency Genetic/Congenital Disorders: 349  Short bowel syndrome  Sickle Cell Anemia  Cleft lip/palate  Gastroschisis  Thalassemia Major  Down’s syndrome  Omphalocele  Intestinal atresia  Esophageal atresia  Diaphragmatic hernia  Tracheo-esophageal fistula  Hirschsprung’s Disease  Muscular Dystrophy Infectious Diseases- Acute (present in last 6 mo.):352 a  Parasitic infections  Hepatitis A or E  Listeriosis  Pneumonia  Meningitis (Viral or bacterial)  Bronchitis (3 x in last 6 mo.)  Tuberculosis Active infection  Other Specify: Infectious Diseases Chronic 352 b  Hepatitis B  Hepatitis C  Hepatitis D  Other Specify:  AIDS  HIV  Food Allergies - List: 353 Celiac Disease:  Celiac Sprue  Gluten Enteropathy 354  Non-tropical Sprue  Drug/Nutrient Interactions – Specify: 357 Other Medical Conditions: 360  Heart disease  Cystic fibrosis  Cardiorespiratory diseases  Juvenile Rheumatoid Arthritis (JRA)  Lupus erythematosus  Persistent asthma requiring daily medication  Others – State Agency approval: Recent Major Surgery, Trauma, Burns: 359  Any occurrence within ≤ 2 months severe enough to compromise nutritional status.  Occurrence > 2 months with continued need for nutrition documented by MD/APRN/PA WIC 75 Child, Page 2 of 4

Page 51 Section 200 Appendices December 2024

6040 Dental Problems 3A 382 Fetal Alcohol Spectrum Disorder 3A 903 Foster Care Determine if during the previous six (6) months: age 1-2 5A age 2-5 5B

902 Impaired Ability to Prepare Food age 1-2 5A/age 2-5 5B Complications which Impair Nutrition (check all that apply) 3A Participant’s primary caregiver is (check all that apply) :  < 17 years of age 6020.902a  Mentally disabled/delayed/mental illness/clinical Depression/Post-Partum Depression 6020.902b  Currently using or history of abusing alcohol/ prescription drugs/ marijuana/other Drugs 902d  Intellectual disability 902e  Physically disabled which restricts/limits food preparation Abilities 6020.902c  Minimal brain function  Head trauma  Brain damage  Birth Injury Depression361  Pervasive development disorder (PDD)  Difficulty accepting new foods/↓ food selection  Restricted food intake due to color/texture/temperature  Delays/disabilities which restrict ability to chew/swallow/ require tube feeding 362  Difficulty taking multivitamin/mineral supplement  Autism  Difficulty with changes in mealtime environment

 Baby Bottle Tooth Decay 381a  Tooth decay 381a  Periodontal disease 381d  Missing more than 7 teeth or ineffectively replaced teeth which impair ability to ingest food 381c

 Fetal Alcohol Syndrome (FAS)  Partial Fetal Alcohol Syndrome (pFAS)  Alcohol-Related Birth Defects (ARBD)  Alcohol-Related Neurodevelopmental Disorders (ARND)  Neurobehavioral Disorders with Prenatal Alcohol Exposure (ND-PAE)

401 Presumed Dietary Risk Only use this risk when no other risk is present for age 2 and older age 2-5 5B Children age 2 and older who meet the eligibility requirements of income, category and residency may be presumed at nutrition risk based on failure to meet the Dietary Guidelines 7012 Feeding Practices (will qualify with one or more of the following shaded answers) age 1-2 5A age 2-5 5B Yes        No        Does your child eat or drink: • Raw fish or shellfish 425.5a • Raw or undercooked meat or poultry 425.5b • Raw or lightly cooked or undercooked egg products such as: sauces, homemade eggnog, cookie dough, cake batter 425.5c • Raw sprouts (alfalfa, clover, radish) 425.5d • Unpasteurized fruit or vegetable juices 425.5e • Hot dogs, cold cuts, deli meats that have not been heated until steaming hot 425.5f • Unpasteurized milk or milk products, soft cheeses such as feta, Camembert, bleu cheese, Stilton, queso blanco, queso fresco or Panela 425.5g Yes      No      Does the child take a bottle: • Propped in the mouth? 425.3a • At nap or sleeps with bottle in mouth? 425.3b • With sweetened drinks (tea, soda pop, Gatorade, Hi C, fruit punch, kool aid) or fruit juice, diluted cereal? 425.3c • Beyond 14 months of age? 425.3d • Without restriction or as a pacifier? 425.3e Yes  No  Does your child use a pacifier that has been dipped in sugar, honey or syrup? 425.3f Yes  No  Does your child eat high calorie/low nutrient foods such as desserts, cakes, cookies, candy, fried foods, lunch meat? 425.6b Yes  No  If under 2 years old - drinks fresh milk, goat, sheep milk 425.1a or skim, 1%, 2%, lowfat, when overweight or obesity is not a concern? 425.1c Yes      No      Is the child(‘s): • Made to eat a certain type and/or amount of food? 425.4f • Request for appropriate foods when hungry ignored? 425.4e • Consumption of nutritious meals limited each day? 425.4d • Not allowed to feed themselves? 425.4a • Food primarily pureed or liquid when able to tolerate texture? 425.4c Yes  No  Does your child drink more than 24 ounces of milk in a day? 428b Yes  No  Does your child carry a training cup or bottle and drink from this all day long? 425.3g Yes  No  Does the child drink city water, take a fluoride supplement or drink fluoridated water?7012.425.8a Yes  No  Does the child eat foods like hot dogs, pieces of fruit, nuts, raisins, hard candy, raw carrots? 7012.425.4g Yes  No  Does your child drink imitation milk (Vitamite, Toddler’s Best, nondairy creamer), substitute milk (Alba 77, Slim Fast), evaporated or sweetened condensed milk as the primary milk? 425.1b Yes  No  Does the child take > 1 dose each day of a children’s single vitamin, multivitamin, mineral supplement, and/or herbal teas/remedies not prescribed by MD/DO/APRN/PA? 425.6a Yes  No  Does the child eat clay, dirt, laundry starch, cornstarch, paint chips, ashes, baking soda or large quantities of ice or other non-food item? 425.9 Yes  No  Does your child take a multivitamin or Vitamin D supplement? 425.8c Does your child carry a training cup or bottle and drink from this all day long? 425.3g 7015 INAPPROPRIATE NUTRIENT INTAKE AGE 1-2 5A AGE 2-5 5B 425.6c Does the child avoid all animal products - meat (beef, pork, chicken, turkey), fish, eggs, milk, cheese, yogurt/dairy products?  Yes  No 425.6d Is the diet highly restricted in calories or specific nutrients?  Yes  No 901  Recipient of Abuse Abuse (emotional and/or physical) or neglect within past six months age 1-2 5A age 2-5 5B

 has entered the foster care system  has been moving from one foster home to another WIC 75 Child, Page 3 of 4

Page 52 Section 200 Appendices December 2024

801  Homelessness Homeless age 1-2 5A age 2-5 5B 802  Migrancy Migrant age 1-2 5A age 2-5 5B 501  Possibility of Regression- Priority III Certify to maintain health status based on last certification Priority III condition. Can only be used every other certification 03 501  Possibility of Regression- Priority IV Certify to maintain dietary status based on last certification Priority V condition. age 1-2 5A age 2-5 5B Can only be used every other certification. Name:

ID Number:

or Place PEF label here

What concerns or questions does the parent/caretaker have in regard to the child’s nutrition, eating habits, growth?

This institution is an equal opportunity provider.

WIC 75 Child, Page 4 of 4 (Rev 10/22)

WIC and Nutrition Manual 300 Policy Group Program Integrity Table of Contents Policy 301 Conflict of Interest Policy 302 Separation of Duties Policy 303 Participant Violations Policy 304 Dual Participation Policy 305 Internal Review Policy 306 Civil Rights

Page 1 Program Integrity – Conflict of Interest Policy 301 December 2024 Policy 301 Program Integrity – Conflict of Interest POLICY Local WIC agencies will not perform certification duties or issue benefits or eWIC cards to themselves, any person related to them, or to friends.

PURPOSE To prevent and detect conflicts of interest and employee fraud/abuse and avoid situations that are or appear to be a potential conflict of interest. To assure program integrity, Local WIC Agency Staff will not determine eligibility or issue food benefits or eWIC cards to themselves, any person related to them, or friends. RELEVANT REGULATIONS 7CFR 246.4(a) (25), (26) & (27) State plan, Requirements 7CFR 246.12(t) Food delivery methods 7CFR 246.2 Definitions

DEFINITION Employee fraud and abuse: An intentional and deliberate action that violates the program, employee regulations, policies, or procedures. Actions include but are not limited to misappropriating benefits: altering benefits; entering false or misleading information in case records; or creating fictitious or nonexistent client flies.

GENERAL POLICIES To prevent a conflict of interest, an employee shall not: A. Certify oneself. B. Certify a relative, household member, or close friend. C. Determine eligibility for all certification requirements (income and risk) and issue food instruments for the same participant. D. Refer participants to a grocery store or pharmacy owned by a family member. E. Have any personal, business, or financial interest/relationship between Local WIC Agency staff and WIC Authorized grocery stores, Farmers’ Market, Farmer, or pharmacies.

PROCEDURES A. Each local WIC agency will meet the following criteria to address situations of staff certifying and/or issuing benefits or eWIC cards to themselves, family members, other relatives, or friends. Employees shall not provide services to any person that may present a possibility of or an appearance of favoritism or preferential treatment. B. WIC staff members must inform their WIC coordinator or clinic manager before the certification process begins that they (the staff member), a member of their family or other relative, or a friend, is applying for WIC. C. WIC staff members cannot determine any components of the eligibility for themselves, their family members, other relatives, or friends. D. WIC staff members will not issue benefits or eWIC cards to themselves, family members, other relatives, or friends. E. A procedure must be developed to ensure a conflict of interest does not exist when providing WIC services. a. The procedure must include a tracking method to document individuals who may pose a conflict of interest. Documentation of the procedure used must be available for review. b. See below for the Local Agency Conflict of Interest Tracking Log.

Page 2 Program Integrity – Conflict of Interest Policy 301 December 2024 F. If separation of duties cannot be performed within the limitations of a clinic and circumstances cannot be prevented: a. The medical record(s) must be reviewed to ensure no conflict has occurred. b. The reviewer must document on the tracking log and in the medical record(s), sign, and date within two weeks of WIC service(s) being provided. G. Local WIC agencies must review 100 percent of Conflict-of-Interest medical records monthly and sign the medical record and tracking log. a. See below for the Local Agency Conflict of Interest Tracking Log. H. The State WIC Office will review 100 percent of Conflict-of-Interest medical records and tracking log during each onsite Management Evaluation.

Page 3 Program Integrity – Conflict of Interest Policy 301 December 2024 LOCAL AGENCY CONFLICT OF INTEREST

Purpose

Accountability of local WIC agencies to ensure Conflict of interest medical records are reviewed and monitored on a monthly basis.

When To Use

When WIC services are provided to employees, relatives, household members, or close friends or when Separation of Duties is not possible at your agency.

Use one page per participant.

The WIC Coordinator or designated reviewer will sign/initial in designated areas on the tracking log and in the participant’s chart. The reviewer cannot be a provider of the service or have the identified potential conflict of interest. Availability See below for the form, find a sample completed form and a blank template.

Page 4 Program Integrity – Conflict of Interest Policy 301 December 2024 CONFLICT OF INTEREST AND SEPARATION OF DUTIES TRACKING LOG SAMPLE

LOCAL AGENCY WIC PROGRAM CONFLICT OF INTEREST TRACKING LOG SAMPLE WIC SITE: WIC Site Name PATIENT LABEL: Pregnant Woman 01/01/1990 HH# XXX EMPLOYEE NAME: Jane Doe EMPLOYEE TITLE: WIC Support Staff RELATIONSHIP TO PARTICIPANT: Aunt DATE OF CERTIFICATION/ RECERTIFICATION EMPLOYEE DETERMINING INCOME EMPLOYEE DETERMINING RISK EMPLOYEE ISSUING BENEFITS WIC COORDINATOR/ REVIEWER INITIALS & DATE OF 2 WK REVIEWS (IF APPLICABLE) DATE(S) OF MONTHLY REVIEW(S)

VIOLATION IDENTIFIED, IF YES, INDICATE ACTION TAKEN TO RESOLVE WIC COORDINATOR/ REVIEWER SIGNATURE 1/1/22 Jane Doe Donald Duck Jane Doe MM 1/5/22 “N/A” No Mickey Mouse, RD, IBCLC “N/A” “N/A” “N/A” “N/A” “N/A” 2/15/22 No Mickey Mouse, RD, IBCLC “N/A” “N/A” “N/A” “N/A” “N/A” 3/15/22 No Mickey Mouse, RD, IBCLC “N/A” “N/A” “N/A” “N/A” “N/A” 4/15/22 No Mickey Mouse, RD, IBCLC “N/A” “N/A” “N/A” “N/A” “N/A” 5/15/22 No Mickey Mouse, RD, IBCLC 6/2/22 Jane Doe Donald Duck Jane Doe MM 6/3/22 “NA” No Mickey Mouse, RD, IBCLC PAGE ____1_____

Page 5 Program Integrity – Conflict of Interest Policy 301 December 2024 CONFLICT OF INTEREST AND SEPARATION OF DUTIES TRACKING LOG TEMPLATE LOCAL AGENCY WIC PROGRAM CONFLICT OF INTEREST TRACKING TEMPLATE LOG WIC SITE: Enter WIC Site Name PATIENT LABEL: Place Participant Label or Enter Name, DOB, and HH Number EMPLOYEE NAME: Enter the Employee Name who has identified a Conflict of Interest. EMPLOYEE TITLE: Enter the Employee Title/Program Role who has identified the Conflict of Interest. RELATIONSHIP TO PARTICIPANT: Enter Employee Relationship with WIC Participant (such as Aunt, Mother, Friend, Coworker, etc.) DATE OF CERTIFICATION/ RECERTIFICATION EMPLOYEE DETERMINING INCOME EMPLOYEE DETERMINING RISK EMPLOYEE ISSUING BENEFITS WIC COORDINATOR/ REVIEWER INITIALS & DATE OF 2 WK REVIEWS (IF APPLICABLE) DATE(S) OF MONTHLY REVIEW(S)

VIOLATION IDENTIFIED, IF YES, INDICATE ACTION TAKEN TO RESOLVE WIC COORDINATOR/ REVIEWER SIGNATURE

PAGE _________

Page 1 Program Integrity – Separation of Duties Policy 302 December 2024 Policy 302 Program Integrity – Separation of Duties POLICY Local WIC agencies shall separate the duties for determining participant income eligibility and risk eligibility.

PURPOSE To ensure program integrity and prevent program abuse by assigning certification duties to more than one staff member.

RELEVANT REGULATIONS 7CFR 246.4(a) (25), (26) and (27) State plan, Requirements 7CFR 246.12(t) Food delivery methods WIC Policy Memorandum #2016-5 – Separation of Duties at WIC Local Agencies

PROCEDURES Separation of Duties A. Local agencies shall establish and maintain a standard procedure for the separation of staff duties at the clinic level to prevent program abuse. a. Refer to Policy 301 for the Local Agency Conflict of Interest. B. It is critically important to maintain WIC Program Integrity and avoid fraud or Program abuse. a. Therefore, at a minimum, the staff person who determines income eligibility and medical or nutritional risk cannot be the same person. b. Either person may issue food benefits. c. Having one staff person check identification or residency and another staff person conduct the remainder of the certification does not meet the regulatory intent of the separation of duties requirement. C. If separation of duties cannot be performed within the limitations of a clinic and circumstances cannot be prevented, the medical record(s) must be reviewed to ensure no conflict has occurred. a. The reviewer must document on the tracking log and in the medical record(s), sign, and date within two weeks of WIC service(s) being provided. b. Local agencies must review 100 percent of Conflict of Interest/Separation of Duties medical records on a quarterly basis (at least once every three months) and sign medical records and tracking logs. c. See below for the Local Agency Separation of Duties Tracking Log. D. Retain copies of tracking logs for four years. E. The State WIC Office will review 100 percent of Separation of Duties medical records and tracking log during each onsite Management Evaluation.

Page 2 Program Integrity – Separation of Duties Policy 302 December 2024

LOCAL AGENCY WIC PROGRAM SEPARATION OF DUTIES TRACKING LOG

Purpose

Accountability of local WIC agencies to ensure all charts where Separation of Duties is not able to be provided are reviewed and monitored within two weeks of the date of service and then quarterly through the certification period.

When To Use

When separation of duties cannot be performed, i.e., when one staff member performs both income eligibility and nutritional risk eligibility and issues benefits.

Use one form per participant. Use for the certification period, repeat if Separation if Duties can not be provided at follow-up certification service.

WIC Coordinator or designated reviewer will sign in designated areas on the tracking log and in the participant’s chart. The reviewer cannot be the provider of the service or have the identified potential conflict of interest.

Availability See below for the form; find a sample completed form and a blank template.

Page 3 Program Integrity – Conflict of Interest Policy 301 December 2024 WIC PROGRAM SEPARATION OF DUTIES TRACKING LOG SAMPLE

LOCAL AGENCY WIC PROGRAM SEPARATION OF DUTIES TRACKING LOG SAMPLE WIC Site: WIC Clinic name PATIENT LABEL:

DATE OF CERTIFICATION/ RECERTIFICATION EMPLOYEE DETERMINING INCOME, RISK & ISSUING BENEFITS & BENEFIT ISSUACE DATE OF INITIAL REVIEW WITHIN 2 WEEKS DATE OF QUARTERLY REVIEW (At least once every 3 months) Program Violation Identified? If yes, indicate action taken. WIC COORDINATOR/ REVIEWER SIGNATURE 1/3/22

Jane Doe 1/8/22

no Mickey Mouse, RD, IBCLC 2/18/22 no Mickey Mouse, RD, IBCLC 5/21/22 no Mickey Mouse, RD, IBCLC 8/6/22 no Mickey Mouse, RD, IBCLC 11/15/22 no Mickey Mouse, RD, IBCLC

Page 4 Program Integrity – Conflict of Interest Policy 301 December 2024 WIC PROGRAM SEPARATION OF DUTIES TRACKING LOG

LOCAL AGENCY WIC PROGRAM SEPARATION OF DUTIES TRACKING LOG

WIC Site: Enter WIC Clinic Name PATIENT LABEL: Place Participant Label or Enter Name, DOB, and HH Number DATE OF CERTIFICATION/ RECERTIFICATION EMPLOYEE DETERMINING INCOME & RISK ELIGIBILITY & BENEFIT ISSUANCE DATE OF INITIAL REVIEW WITHIN 2 WEEKS DATE OF QUARTERLY REVIEW (At least once every three months) Program Violation Identified? If yes, indicate the action taken. WIC COORDINATOR/ REVIEWER SIGNATURE

Page 1 Program Integrity – Participation Violations Policy 303 December 2024 Policy 303 Program Integrity – Participant Violations POLICY Action shall be taken on all reports of misuse of WIC services/benefits.

PURPOSE To ensure WIC program integrity and provide guidance regarding program participant violations and subsequent sanctions.

RELEVANT REGULATIONS 7 CFR 246.7 (l) – Dual Participation 7 CFR 246.23 (c)(1) – Claims against participants KRS 194A.505 – The Assistance Program Fraud Law KRS 194A.990 – Penalties Administrative Regulation 902 KAR 18:031 Participant abuse

PROCEDURES General Policies Penalties may be imposed against any intentional action of a cardholder, participant, parent, or caretaker of an infant or child participant, or a proxy that violates Federal or State statutes, regulations, policies, or procedures governing the Program. A. Participants, or the parent, caretaker, or authorized proxy must be informed of rights and responsibilities in the Program, how to properly use food instruments, and authorized stores where food instruments may be redeemed. The eWIC Cardholder, Kentucky eWIC Benefits Card pamphlet, along with a current list of local authorized stores, must be provided at the time of certification. B. A Program violation may be committed by the participant, the participant’s parent, the caretaker, or the authorized proxy. Any suspension, disqualification, or termination for violation is imposed on the participant. C. If a WIC Program violation is suspected or a complaint of violation is made against a participant, parent, caretaker, or authorized proxy, or violation is determined, the agency/site shall: 1. Obtain as much information as possible concerning the violation and attempt to obtain the complaint in writing. An optional form is available for a participant complaint made by a vendor. Refer to Section 900 - Vendor Management. 2. Determine and/or document if the violation actually occurred. 3. Discuss the violation with the participant, parent, or caretaker. 4. Document the discussion, the date of the discussion, and all other pertinent information in the participant’s medical record. 5. Provide any required written notice(s) to the participant, parent, caretaker, or authorized proxy. Place a copy of the notice(s) in the participant’s medical record. D. Participants determined to have committed a program violation including, but not limited to, the violations outlined in this section cannot be suspended for more than three (3) months. E. If a second program violation is suspected or has occurred, all action for the first offense must be completed and documented before any action is taken on the second offense. F. The State WIC Office may refer participants who repeatedly violate the WIC Program to the Office of the Inspector General (OIG) for prosecution under applicable statutes. G. Administrative Regulation 902 KAR 4:040 outlines the applicable sanctions for WIC program violations as well as the fair hearing procedure for persons who are terminated, suspended, or disqualified from the Program. Additionally, refer to Administrative Reference, Section: Training Guidelines and Program Descriptions, “WIC Program Applicant/Participant Fair Hearing Procedures.”

Page 2 Program Integrity – Participation Violations Policy 303 December 2024 Types of Actions for Program Violations In all actions listed below, the WIC-54 shall serve as the notice of action and fair hearing rights. For more information on the WIC-54, refer to the 200 Certification Appendices. A. Written Warning – A letter stating the type of violation and action that will be taken for any future violation. B. Suspension - The loss of food benefits for a specified period. 1. The participant is not terminated from the program during the suspension. 2. Must be notified in writing by providing a WIC 54, “Notice of Ineligibility,” fifteen (15) days in advance with the following information: a. Reason for the suspension b. The time period of the suspension c. The right to a fair hearing. C. Disqualification - Removal from WIC Program participation. 1. Terminated from the WIC program when the disqualification is imposed. 2. Must be notified in writing by providing a WIC 54, “Notice of Ineligibility,” fifteen (15) days in advance with the following information: a. Reason for the disqualification b. The time period of the disqualification c. The right to a fair hearing. D. Termination – Removal from the WIC Program 1. Terminated from the program without fifteen (15) days advance notice. 2. Must be notified in writing by providing a WIC 54, “Notice of Ineligibility,” with the following information: a. Reason for the termination b. The right to a fair hearing. E. Claim - A request for reimbursement of the dollar amount of over-issued or improperly received WIC foods determined by the value of the redeemed food benefits. 1. The agency/site is responsible for the collection of a claim. For a violation that results in a claim: a. Contact the State WIC Office to determine the amount of the claim and if collecting the claim is cost-effective. Copies of supporting information shall be obtained. b. If a claim is to be made, provide written notice to the participant, parent, caretaker, or authorized proxy of: i. The reason for the claim and the action against the participant. The WIC- 54 shall serve as the notice of action and fair hearing rights. ii. The dollar amount to be repaid for the over-issued or improperly received foods. A check or money order payable to the Kentucky State Treasurer must pay the amount. iii. The date the claim is to be paid. c. The check or money order received from the participant, parent, caretaker or authorized proxy must be forwarded to the State WIC Office. d. If the claim is not paid, the participant will be denied application to the Program for the number of months of food benefits that were used to calculate the claim amount, not to exceed three (3) months.

Types of Violations and Actions to Be Taken A. Suspected Violation: A written warning shall be given for the following suspected violation for which a complaint is received concerning a participant or the participant’s parent, caretaker or authorized proxy: 1. Purchasing unauthorized foods. 2. Redeeming food benefits at an unauthorized store. 3. Making a verbal offer of sale or exchange supplemental food or eWIC card with food benefits to another individual, group, or vendor. 4. Returning supplemental foods to a vendor for cash.

Page 3 Program Integrity – Participation Violations Policy 303 December 2024 5. Posting WIC foods, benefits, and/or eWIC cards for sale in print or online or allowing someone else to do so. 6. Posting a WIC-issued breast pump for sale in print or online or allowing someone else to do so. B. Proven or Documented Violation: The following specified action shall be taken for a proven or documented violation by a participant or the participant’s parent, caretaker, or authorized proxy: 1. Redeeming food benefits before the “first day to use” or after the “last day to use.” Copies of redeemed food benefits must support this. a. First offense: Written warning b. Second offense: Monthly pick-up of food benefits c. Third offense: One-month suspension d. Reinstatement of two or three-month issuance is at professional discretion. 2. Redeeming food benefits that have been previously reported to the WIC agency/site as being lost or stolen and which were replaced with other food benefits. Copies of redeemed food benefits must support this. a. First offense: Written warning b. Second offense: Claim for the amount of improperly redeemed food benefits. 3. Purchasing unauthorized foods. a. First offense: Written warning b. Second offense: One (1) month suspension 4. Redeeming food benefits at an unauthorized store. Copies of redeemed food benefits shall support this. a. First offense: Written warning b. Second offense: One (1) month suspension 5. Threatening physical abuse or verbal abuse of clinic staff or store staff. a. First offense: Written warning. If possible, another person in the clinic may serve the participant. b. Second offense: One (1) month suspension 6. Physical abuse of clinic staff or store staff. a. First offense: Three (3) month suspension b. Second offense: Three (3) month suspension 7. Exchanging and/or selling WIC food or food benefits with other individuals, groups, or stores. a. First offense: Three (3) month suspension b. Second offense: Three (3) month suspension 8. Exchanging food benefits or supplemental foods for credit, nonfood items, or supplemental food in excess of those listed on the food benefits /cash value benefit. a. First offense: Three (3) month suspension b. Second offense: Three (3) month suspension 9. Posting WIC foods, benefits, and/or eWIC cards for sale in print or online or allowing someone else to do so. a. First offense: Written warning. b. Second offense: Three (3) month suspension 10. Dual participation in more than one (1) WIC Program or participation in both the WIC Program and Commodity Supplemental Food Program (CSFP) at the same time. Possible dual participation information is provided online and/or in a report. The other agency/site must be contacted immediately if dual participation is suspected. Actual participation in two (2) WIC sites shall be supported by system documentation of redeemed food benefits, if possible. a. First offense: Written warning and termination from one (1) Program immediately. The continuing WIC agency shall be chosen based upon the participant’s residence and/or services.

b. Second offense: One (1) year disqualification and termination from one (1) Program immediately and claim for the food benefits redeemed.

Page 4 Program Integrity – Participation Violations Policy 303 December 2024 11. Knowingly and deliberately giving false or misleading information or misrepresenting, concealing, or withholding facts to obtain WIC foods. Must have verification to impose a claim. a. First offense: Claim for improperly redeemed food benefits. Disqualifies the participant for three (3) months. b. Second offense: Claim for improperly redeemed food benefits. Disqualifies the participant for one (1) year. C. Disqualification for one year 1. A participant is disqualified for one (1) year when the following is assessed: a. A claim of $200 or more. b. A claim for dual participation. c. A second or subsequent claim of any amount. 2. The disqualification may not be imposed if, within thirty (30) days of receipt of the claim letter requiring repayment: a. Full restitution is made. b. A repayment schedule is agreed on. c. When a participant is under eighteen (18), a proxy is designated and approved. 3. A participant may reapply for the WIC Program before the end of the disqualification period if: a. Full restitution is made. b. A repayment schedule is agreed on. c. When a participant is under eighteen (18), a proxy is designated and approved. D. All other forms of WIC Program violations or suspected violations shall be referred to the State WIC Office for guidance on appropriate action.

Page 1 Program Integrity – Dual Participation Policy 304 December 2024

Policy 304 Program Integrity – Dual Participation POLICY A participant must not be enrolled/participating in more than one (1) WIC Local Agency site at the same time (either in-state or out-of-state) or in WIC and Commodity Supplemental Food Program (CSFP) at the same time.

PURPOSE To ensure program integrity by preventing dual enrollment/participation in WIC or with the CSFP.

RELEVANT REGULATIONS 246.7(l) (1) (i) – Certification of WIC Participants 246.2 - Definitions, Dual Participation

DEFINITIONS Dual Participation – simultaneous participation in the WIC Program in one or more than one WIC clinic or participation in the Program and in the CSFP during the same period of time.

PROCEDURES Dual Enrollment/Participation A. A participant must not be enrolled/participating in more than one (1) WIC Local Agency site at the same time (either in-state or out-of-state) or in WIC and Commodity Supplemental Food Program (CSFP) at the same time. B. In order to prevent dual enrollment/participation, the system performs a statewide search based on certain data to ensure the participant is not enrolled and/or receiving food benefits at another agency/site. C. When data entered at a site is the same as the information in another site, this is a “match.” 1. If there is a match on last name, first name, sex, and date of birth, an error message will be received. 2. Each match must be reviewed to determine if it is the same person; there may be “false matches,” i.e., same pseudo numbers or ID numbers entered wrong. D. The system performs the check for dual enrollment/participation between WIC Sites: 1. At the time a certification appointment is made. 2. At the time a certification is indicated as an anticipated service. 3. At the time the issuance is requested. E. If there is a match, determine if the match is the same person. 1. If not, continue certification, enrollment, and/or food benefit issuance. 2. If the match is the same person, determine where the person(s) should be enrolled/participating. F. If actual ongoing Dual Participation between WIC sites (either in-state or out-of-state) has been determined, see Policy 303 Program Integrity: Participant Violations for required actions. G. The system performs the check for dual enrollment/participation between WIC Sites and the CSFP when a participant’s data is received from CSFP. 1. A report, “Possible Dual Participation between the WIC Program and CSFP,” is produced, which lists potential dual participants between WIC and CSFP. 2. The report is to be reviewed. Possible dual participants are to be investigated, and if dual participation is determined. Refer to Policy 303 Program Integrity: Participant Violations.

Page 1 Adjunct Eligibility Policy 205 December 2024 Policy 305 Program Integrity – Internal Review POLICY Local WIC Agencies will conduct internal WIC operations reviews at each site at a minimum of once every two state fiscal years. Local WIC Agencies will identify and correct deficiencies promptly.

PURPOSE To ensure Program Integrity and quality WIC services by completing timely Internal Reviews of WIC operations.

RELEVANT REGULATIONS 7 CFR 246.19 (b)(6) Management Evaluation and Monitoring Reviews 902 KAR 8:160 Local Health Department Operations Requirements Administrative Reference, Training Guidelines, and Program Descriptions, WIC

PROCEDURES In conjunction with quality assurance reviews, local WIC agency staff must review WIC operations in all sites. This internal review must be done a minimum of every two (2) State Fiscal Year and include a review of the following: A. Local Management B. Certification C. Nutrition Education D. Breastfeeding Promotion/Support E. Participant Services F. Civil Rights G. Food Delivery H. eWIC Card accountability I. Program Integrity J. WIC Equipment Inventory K. Financial Management

Documentation A. A form is available from the State WIC Office to document the review and findings. The local agency may develop review forms for this purpose or request State WIC Office Forms. 1. The approved Local Agency Internal Review form is available on the Website in Section 300 Appendices. B. Findings will be reviewed by the State WIC Office. C. Identified deficiencies must be corrected promptly by the local WIC agency. D. Documentation of the internal reviews must be maintained for five (5) years and available for review during onsite Management Evaluations. Refer to the Administrative Reference, Training Guidelines and Program Descriptions, WIC, for additional information.

Rev. 10/24 FY 2025

Agency/Number: Click here to enter text.

Site/Number: Click here to enter text. Date: Click here to enter text.

Reviewer: Click here to enter text.

WIC Coordinator: Click here to enter text. Health Professionals: Click here to enter text. Support Staff: Click here to enter text. Other: Click here to enter text.

Progress Findings from previous state and/or local reviews: Finding Progress

General Program Operations & Clinic Environment 1. Are clinic hours posted in each of your clinics?

☐ yes ☐ no

2. What procedures are in place to provide services to individuals who cannot come to the clinic during regular business hours? (check all that apply) ☐ Extended hours. Specify extended days/hours: Click here to enter text. ☐ Open during lunch. If open, patients are seen by: ☐ appointment ☐ walk-in ☐ Food Benefit Issuance without being physically present?

☐yes ☐ no If yes, is documentation made in the medical record and proof code 50 (Other) used for the ID for pick-up?

☐ yes ☐ no

☐ Proxies ☐Offering remote services when applicant/participant is unable to present to the clinic

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

3. Is the clinic environment welcoming, and supportive of breastfeeding and nutrition education? a. Are mothers encouraged to breastfeed anywhere in the clinic.

☐ yes ☐ no b. Is there a private area upon request of the mother for breastfeeding or pumping? ☐ yes ☐ no c. Is all formula kept in a storage closet out of view of clients?

☐ yes ☐ no d. No formula advertising visible to clients, including pens, pads, and other “giveaways”. ☐ yes ☐ no e. Posters and pictures in the clinic shall be of breastfeeding multi-cultural mothers and are not produced by formula companies.

☐ yes ☐ no f. Refuse samples from formula representatives for use by local WIC agency staff. ☐ yes ☐ no g. The agency has a written breastfeeding policy that is routinely communicated to all health department staff and is posted in the clinic for staff and clients to review.

☐ yes ☐ no

Kentucky WIC Program Local Agency Internal Review

WIC Internal Review Form FY 2025 Rev. 10/24 2

4. Does the agency have policies to include provisions to clearly identify biohazard containers for medical waste and keep them out of the reach of children? ☐ yes ☐ no

5. Our agency offers the following WIC Program and related services: ☐ WIC FMNP ☐ WIC BF Peer ☐WIC Regional BF Coordinator ☐ RD provides MNT

6. How do staff access the manuals: WIC and Nutrition Manual? ☐ CHFS Website ☐ Downloaded on computer ☐Printed copy Date of version: Click here to enter text.

Administrative Reference? ☐ CHFS Website ☐ Downloaded on computer ☐Printed copy Date of version: Click here to enter text.

7. Do appropriate WIC staff have access to e-reports system for working WIC reports? ☐ yes ☐ no 8. Are WIC policy memos discussed or reviewed with staff?

☐ yes ☐ no Are findings from WIC reviews shared with staff?

☐ yes ☐ no How is this information conveyed to staff? Click here to enter text.

9. Are Internal Reviews performed?

☐ yes ☐ no If yes, how often? ☐ Quarterly ☐ Every 6 months ☐Annually ☐ Every 2 years

☐ Other: Click here to enter text.

Are findings from the review shared with staff?

☐ yes ☐ no

10. Staff Time Coding: Is support staff coding majority of their time to PGC2100, Client Services FN1402 for making appointment, intake, and issuing food benefits?

☐ yes ☐ no

Is staff coding their time to PGC2100, WIC Administration FN1401 for outreach, working reports, eWIC card inventory, and conducting biannual WIC internal reviews? ☐ yes ☐ no

Is health professional staff coding at least 20% of their WIC Program time to nutrition education, PGC2100, FN1403?

☐ yes ☐ no

Is health professional staff coding time spent on breastfeeding education, breast pump issuance and breastfeeding trainings to PGC2100, breastfeeding promotion and support, FN1404? ☐ yes ☐ no

Is the health professional staff coding the majority of their time to PGC2100, Client Services FN1402 for WIC assessments, anthropometrics, hematological screening, referrals, food package assignments, and issuing food benefits?

☐ yes ☐ no

11. Does the staff code the time as it is worked and not the same every day?

☐ yes ☐ no Does staff code time based on a time study?

☐ yes ☐ no

If so, how frequently are time studies completed? Click here to enter text.

12. When travel is coded to WIC: Is the purpose documented?

☐ yes ☐ no Is time also coded to WIC for the same day?

☐ yes ☐ no

13. Is any review done to ensure that reporting of time and travel by staff is appropriate? ☐ yes ☐ no

WIC Internal Review Form FY 2025 Rev. 10/24 3

Caseload Management

1. Is monitoring or review done of: Caseload increases/decreases?

☐ yes ☐ no Participation rates?

☐ yes ☐ no Voter registration compliance?

☐ yes ☐ no Monthly physical inventory of eWIC cards and FMNP FIs?

☐ yes ☐ no Actions Due?

☐ yes ☐ no Report 2011 (Measures needed)?

☐ yes ☐ no

2. Complete the chart below for your agency. Record enrollment for the previous three (3) months. Record participation for those months. Compute participation rate by dividing final participation by enrollment. The data can be found in the e-reports folder. As a reminder, the monthly report is for the activity that occurred in the prior month(s).

Agency: Click here to enter text. Current Month: Previous Month 2 months Prior 3 months Prior Month: Click here to enter text. Click here to enter text. Click here to enter text. Enrollment (Report 1902) Click here to enter text. Click here to enter text. Click here to enter text. Participation (Report 1930) Provisional: Click here to enter text. Final: Click here to enter text. Final: Click here to enter text. % Participation {(Participation/Enrollment) *100} Click here to enter text. Click here to enter text. Click here to enter text. Comments: Click here to enter text.

See example below: Kentucky State-Wide Enrollment and Participation Current Month: October 2021 Previous Month 2 months Prior 3 months Prior Month: September August July Enrollment: 108,267 (Data found in the October 1902 Enrollment by Status and Priority report – use the total number- sum of all status and priority) 108,463 (Data found in the September 1902 Enrollment by Status and Priority report – use the total number- sum of all status and priority) 107,909 (Data found in the August 1902 Enrollment by Status and Priority report – use the total number- sum of all status and priority) Participation Provisional: 106,709 (September Provisional participation data found in October 1930 Participation Summary - Provisional report) Final: 106,945 (Aug Final participation data found in October 1930 Participation Summary -Final report) Final: 106,450 (July Final participation data found in September 1930 Participation Summary -Final report) % Participation {(Participation/Enrollment) *100} =(106,709/108,267) * 100 = 98.56%** =(106,945/108463) * 100 = 98.6% = (106,450/107,909) *100 = 98.64% ** Note that due to auto-issuance during COVID-19, the participation rates are running above our typical state average.

WIC Internal Review Form FY 2025 Rev. 10/24 4

E-reports to review are highlighted in yellow below for enrollment and participation data.

WIC Data – Breastfeeding Rates

Breastfeeding Rates (Report 1596) Breastfeeding Rates Month/Year Agency Rate State Rate Ever BF (initiation)

% % 3 months Exclusive BF

% %

WIC Data – Non-Contract Formula Rates Who reviews your agencies’ formula reports? Click here to enter text.

Infant Non-Contract Formula Rates (Report 1925) Month/Year Agency Rate State Rate

% %

% %

% % 3 Month Average % % Was there an infant formula shortage during these months? ☐ yes ☐ no Agency’s (3-month average) non-contract formula rate was above:

↑ 5% ☐ yes ☐ no

↑ 10% ☐ yes ☐ no

If yes, has anything been done to address this issue? Explain: Click here to enter text.

Appointments 1. Is the appointment system set up at least 3 months into the future?

☐ yes ☐ no If no, why? Click here to enter text.

2. How many days from today does it take to get an initial certification appointment? Click here to enter text. Can pregnant women receive an initial certification appointment within 10 calendar days? ☐ yes ☐ no Can migrant families receive an initial certification appointment within 10 calendar days? ☐ yes ☐ no Can infants receive an initial certification appointment within 10 calendar days?

☐ yes ☐ no

3. Is the patient asked to bring immunization records to each certification and recertification? ☐ yes ☐ no Are immunization screenings and referrals documented in the patient’s medical record? ☐ yes ☐ no

WIC Internal Review Form FY 2025 Rev. 10/24 5

4. Are appointments coordinated for household members?

☐ yes ☐ no

5. Are patients offered a return appointment for future WIC services before they leave the clinic? ☐ yes ☐ no If no, why? Click here to enter text.

6. Are patients reminded of upcoming appointments?

☐ yes ☐ no Which system is being used? Click here to enter text. If yes, how: ☐Auto dialer ☐ Personal phone call ☐ Reminder card ☐ Other Click here to enter text.

7. Are walk-in patients seen: For certification, if proof requirements can be met?

☐ yes ☐ no For food benefit issuance?

☐ yes ☐ no For food package changes?

☐ yes ☐ no If no, explain: Click here to enter text.

8. Are patients who miss their appointment, but come to the clinic that day, provided food benefits? ☐ yes ☐ no

9. Are patients contacted when they miss an appointment for certification or food benefit issuance? ☐ yes ☐ no When are they contacted? ☐same day ☐7-day report ☐ 30-day report ☐ other Click here to enter text. How are they contacted? ☐missed appointment notice (WIC-51) ☐ phone call ☐ other Click here to enter text.

10. Is documentation made in the patient’s chart for: Missed appointments?

☐ yes ☐ no Follow-up missed appointments?

☐ yes ☐ no

11. What is the timeframe for rescheduling a: Missed certification appointment: Click here to enter text. Missed food benefit issuance appointment: Click here to enter text.

12. Is the Actions Due listing (562 report) used to contact patients for recertification appointment? ☐ yes ☐ no

13. If a patient is terminated for non-participation but returns before the certification expires, is a reinstatement done? ☐ yes ☐ no

Fair Hearings 1. Is the Fair Hearings poster displayed?

☐ yes ☐ no Revision date: Click here to enter text. Is it in the lobby/reception area?

☐ yes ☐ no If no, where? ☐ NA Click here to enter text.

Civil Rights and Fair Hearings 1. Is the “And Justice and for All” posted displayed? [FR]

☐ yes ☐ no Revision date: Click here to enter text. Is it in the lobby/reception area?

☐ yes ☐ no If no, where? ☐ NA Click here to enter text.

2. Is a multilingual notice advertising the availability of free interpreter services for individuals with limited English proficiency (LEP) and accessibility assistance for individuals with disabilities posted in a prominent location? ☐ yes ☐ no

WIC Internal Review Form FY 2025 Rev. 10/24 6

3. Does the agency maintain a Civil Rights Complaint File? [FR] ☐ yes ☐ no Review Civil Rights Complaint File. Have there been any complaints alleging discrimination? [FR/KR]

☐ yes ☐ no If yes, what was done? Click here to enter text. Is the file kept in a secure location to maintain the confidentiality of any complainants? ☐ yes ☐ no Are civil rights complaints forwarded to the State WIC office immediately? ☐ yes☐ no Are complainants provided information on how to file a complaint with USDA? ☐ yes ☐ no

Comments: Click here to enter text.

4. Is the WIC Participation by Race/Status report (Report 1986) requested and reviewed for Race and ethnicity representation at least annually? [FR/KR] ☐ yes ☐ no

5. Have any outreach materials been developed? [FR/KR]

☐ yes ☐ no If yes, is the nondiscrimination statement present on materials for the public? ☐ n/a ☐ yes ☐ no Have materials been sent to the State WIC Agency for review?

☐ n/a ☐ yes ☐ no

6. Do all people have equal opportunity to participate in the Program regardless of race, color, national origin, sex, age, or disability? [FR/KR]

☐ yes ☐ no

7. How is the race and ethnicity of applicants/participants determined: [FR/KR] Staff determines and enters on the screen?

☐ yes ☐ no Staff asks the applicant/participant to declare race and ethnicity?

☐ yes ☐ no Is the applicant/participant informed to only choose one ethnicity? ☐ yes ☐ no Is the applicant/participant informed that more than one race can be declared?

☐ yes ☐ no Is the applicant/participant informed that provision of race and ethnicity data is voluntary and will not affect their eligibility for WIC?

☐ yes ☐ no Do staff inform the applicant/participant of the reason for collecting this data (for Federal Reporting to ensure equal opportunity access for all potentially eligible, applicants and participants.)? ☐ yes ☐ no

Staff visually determines if the applicant/participant refuses?

☐ yes ☐ no

If no, use another method? Comment: Click here to enter text.

8. Do staff offer free language or other aids and services to applicants to ensure services are provided to non-English speaking, limited English proficiency (LEP), or persons with disabilities? ☐yes ☐ no

9. What initiatives are used to serve non-English speaking individuals, limited English proficiency (LEP) individuals? [FR/KR] ☐ Language interpreters ☐ Translated materials ☐ Bilingual staff ☐Telephone language assistance ☐ Other: Click here to enter text.

10. What initiatives are used to serve persons with disabilities? [FR/KR] ☐ Sign Language interpreter ☐ Large Font Print Materials ☐ Braille ☐ Telephone language assistance (Relay) ☐ Wheelchair/mobility aid accessible clinic ☐ Service Animal welcome ☐ Other: Click here to enter text.

11. Does staff document the type of services or aids provided to non-English individuals, limited English proficiency (LEP) individuals, and persons with disabilities? ☐yes ☐ no

WIC Internal Review Form FY 2025 Rev. 10/24 7

12. Is Civil Rights training provided for new employees? [FR]

☐ yes ☐ no

13. Is Civil Rights training provided annually each state fiscal year for front-line staff and front-line supervisors? [FR/KR]

☐ yes ☐ no If yes, how is training provided: ☐ State TRAIN module ☐ Other: Click here to enter text.

14. Does the agency ensure Civil Rights training is completed annually (each SFY)? [FR/KR] ☐ yes ☐ no Review documentation for Civil Rights training for the previous FY and current FY. Record dates of the Civil Rights training for the last 2 trainings.

FY 23 Click here to enter text. FY 24 Click here to enter text.

FY 25 Click here to enter text.

Have all WIC staff or staff who may interact with WIC applicants completed in FY 25?

☐ partially ☐ yes ☐ no

If no, date site plans to have annual Civil Rights Training Completed: Click here to enter text.

For the most recent training, how was training done? ☐ State TRAIN module. Is there documentation to assure that all staff required to have training reviewed the module? ☐ yes ☐ no

☐ Other (specify): Click here to enter text. If other, is documentation present for: ☐ n/a

Collection and use of data?

☐ yes ☐ no

Effective public notification systems?

☐ yes ☐ no

Complaint procedures?

☐ yes ☐ no

Compliance review techniques?

☐ yes ☐ no

Resolution of noncompliance?

☐ yes ☐ no

Requirements for reasonable modifications and auxiliary aids and services for

individuals with disabilities?

☐ yes ☐ no

Requirements for language assistance?

☐ yes ☐ no

Conflict resolution?

☐ yes ☐ no

Customer service?

☐ yes ☐ no

Comments: Click here to enter text.

WIC Program Operations Screening and Required Information 1. Is a fee charged for any part of the certification process?

☐ yes ☐ no

2. Is Medicaid eligibility verified through the KY Health Net System?

☐ yes ☐ no If the system is not available, what is done:

Certify based on income with proof?

☐ yes ☐ no Verify eligibility with DCBS?

☐ yes ☐ no Reschedule certification appointment?

☐ yes ☐ no Certify based on self-declaration?

☐ yes ☐ no

3. When a pregnant woman or infant has Medicaid, is it used to certify other household members?

☐ yes ☐ no

4. Is the applicant screened for adjunctive eligibility prior to income assessment? ☐ yes ☐ no

WIC Internal Review Form FY 2025 Rev. 10/24 8

5. When the applicant is determined eligible based on adjunctive eligibility, is the Estimated Household Income requested and documented on the Member Screen and the date of certification on the registration screen in the system for federal reporting purposes? ☐ yes ☐ no

6. If a KCHIP III participant is identified, is income assessed?

☐ yes ☐ no

7. Is the Statement of No Proof (WIC-NP) allowed for patients that cannot obtain proof for: Residence?

☐ yes ☐ no Identity?

☐ yes ☐ no Income?

☐ yes ☐ no Patients that report zero income?

☐ yes ☐ no Is documentation made to explain how household expenses are being met? ☐ yes ☐ no If a patient has proof but did not bring it to the clinic?

☐ yes ☐ no

8. When an applicant/participant is determined ineligible: At a certification or recertification is:

CH5-WIC/CH-5/CH-5B completed?

☐ yes ☐ no

Is voter registration (WIC-53) offered to participants 18 years of age or older? ☐ yes ☐ no

Is CH5-WIC complete for proxies/caretakers?

☐ yes ☐ no

WIC-75 completed, if applicable?

☐ yes ☐ no

Documentation made in the medical record?

☐ yes ☐ no

Data entered for ineligibility on the PEF (W0203 or W0204)?

☐ yes ☐ no During a certification period is a:

T-action done?

☐ yes ☐ no

Reason documented in the medical record?

☐ yes ☐ no

Written notice (WIC-54) given to the ineligible patient?

☐ yes ☐ no

Copy of WIC-54 placed in the medical record?

☐ yes ☐ no

9. If new income information is received and more than 90 days remain in the current certification period, and there is no adjunct eligibility, is the participant’s income reassessed? ☐ yes ☐ no If found to be ineligible, is the participant and all household members terminated?

☐ yes ☐ no Is the reason for termination documented in the medical record?

☐ yes ☐ no

10. Is the CH-5B used to document income eligibility and proof codes when the system is down or unavailable?

☐ yes ☐ no

11. Are the KY eWIC Benefit Pamphlet (eWIC-1) used to provide the required information on Participant Rights and Responsibilities and other services at every certification and recertification?

☐ yes ☐ no Who provides this information? ☐ Support Staff ☐ Health Professional When is it provided?

☐ Check-in ☐Check-Out ☐during Nutrition Education

12. At certification of new participants, are they provided: Approved food list?

☐ yes ☐ no Approved vendor list?

☐ yes ☐ no Explanation of how to use eWIC card?

☐ yes ☐ no

13. Does staff routinely ask the participant about naming or updating proxies during the registration process and are they using the proxy form?

☐ yes ☐ no

14. Is proof of the adult’s identity checked when issuing food benefits for infants and children? ☐ yes ☐ no

WIC Internal Review Form FY 2025 Rev. 10/24 9

15. At the first certification, is staff recognition, medical record, or eWIC Cardholder used for the applicant’s identity?

☐ yes ☐ no

16. Is staff verifying benefits have been transferred to the eWIC card before the participant leaves the clinic?

☐ yes ☐ no

17. Does staff advise participants to swipe their eWIC card for a balance inquiry before leaving the clinic? ☐ yes ☐ no

Transfers 1. For patients transferring from your site, is a VOC provided?

☐ yes ☐ no Are food benefits issued, if due, for either in-state or out-of-state VOC?

☐ yes ☐ no

2. For patients transferring into your site, who enrolls? ☐ Support Staff ☐ Health Professional If a VOC is not provided or if information is needed, is the transferring site contacted? ☐ yes ☐ no Do you keep the issue date on the VOC for in-state transfers?

☐ yes ☐ no Is the proof of residence and ID seen and documented?

☐ yes ☐ no Is income assessed?

☐ yes ☐ no Is voter registration (WIC-53) offered to women aged 18 or older?

☐ yes ☐ no

3. Are WIC-17 (VOC forms) available for use if the system cannot be accessed?

☐ yes ☐ no

4. What is the timeframe to add a VOC? Click here to enter text.

Voter Registration 1. Are WIC-53 forms kept for two calendar years?

☐ yes ☐ no

2. Are women provided a copy of the WIC-53?

☐ yes ☐ no

3. When are Voter Registration Application forms submitted? ☐ Daily ☐ Weekly ☐ Monthly ☐ Other Click here to enter text.

Where are the Voter Registration Application forms submitted? ☐ County Clerk ☐ State Board of Elections

Anthropometric Screening 1. Shoes, hats, and outer clothing routinely removed when obtaining measurements.

☐ yes ☐ no

2. Is the infant weighed in minimal clothing?

☐ yes ☐ no

3. Are scales calibrated and checked by outside an provider annually?

☐ yes ☐ no

4. For children and women with low hemoglobin levels, a test is repeated at six-month intervals until normal.

☐ yes ☐ no

5. For infants and children up to age 2, gestational age which is less than 40 weeks is entered on the automated growth chart.

☐ yes ☐ no

WIC Internal Review Form FY 2025 Rev. 10/24 10

Nutrition Assessment 1. At certification/recertification is the WIC-75 completed in the system or on paper if the system is down?

☐ yes ☐ no 2. Are immunization screenings and referrals documented in the participant’s medical record? ☐ yes ☐ no

3. Staff perform a comprehensive nutrition assessment using Value Enhanced Nutrition Assessment (VENA) policy and guidance to provide quality nutrition services in a participant-centered framework and to determine program eligibility.

☐ yes ☐ no

4. Counseling includes open-ended questions to determine what concerns or questions the participant has in regards to her nutrition, the child’s nutrition, and/or the infant’s nutrition.

☐ yes ☐ no

5. Individualized nutrition education counseling is provided to address the participant’s identified questions, concerns, and goals.

☐ yes ☐ no

Comments: Click here to enter text.

Nutrition and Breastfeeding Education 1. The agency provides nutrition education that: a. Is delivered in appealing, creative, and interactive ways that engage the participant, and as appropriate, other family members.

☐ yes ☐ no b. Incorporates community/national nutrition messages (e.g., Fruits & Veggies-More Matters, folic acid, and Eat Well Play Hard).

☐ yes ☐ no c. Uses nationally recognized, effective strategies, methodologies, and techniques. ☐ yes ☐ no d. Facilitates behavior change.

☐ yes ☐ no

2. Are group nutrition education sessions provided?

☐ yes ☐ no If yes, are sessions mandatory?

☐ yes ☐ no If a group session is missed, is the participant: a. Required to attend the next session

☐ yes ☐ no b. Offered an individual session.

☐ yes ☐ no c. Issued food benefits.

☐ yes ☐ no

3. Is online nutrition education allowed for children?

☐ yes ☐ no If yes, are sessions mandatory?

☐ yes ☐ no If the online lesson is not completed, is the participant: a. Required to complete online nutrition education

☐ yes ☐ no b. Offered an individual session.

☐ yes ☐ no c. Issued food benefits and rescheduled for nutrition education.

☐ yes ☐ no

4. Is phone nutrition education allowed for children?

☐ yes ☐ no If yes, are sessions mandatory?

☐ yes ☐ no If the phone nutrition education is not completed, is the participant: a. Required to complete phone nutrition education

☐ yes ☐ no b. Offered an individual session.

☐ yes ☐ no c. Issued food benefits and rescheduled for nutrition education.

☐ yes ☐ no

5. Are paraprofessionals utilized for nutrition education counseling?

☐ yes ☐ no If yes, has this staff been trained?

☐ yes ☐ no Is an RD overseeing the paraprofessional?

☐ yes ☐ no

WIC Internal Review Form FY 2025 Rev. 10/24 11

6. The agency coordinates with other agencies and programs to: a. Provide nutrition education to WIC participants.

☐ yes ☐ no b. Ensure the provision of accurate and consistent nutrition education and health messages. ☐ yes ☐ no c. Promote WIC as an adjunct to good health care.

☐ yes ☐ no

7. Agency staff who provide nutrition education: a. Staff providing nutrition education qualified health professionals?

☐ yes ☐ no b. Determine the nutritional risk of participants.

☐ yes ☐ no c. Appropriately use nutrition education materials and other teaching aids.

☐ yes ☐ no d. Use appropriate methods to deliver nutrition education by considering participants’ age, nutritional needs, preferences, culture, and lifestyles.

☐ yes ☐ no e. Provide nutrition education that is family-centered and responsive to the identified needs/interests of participants.

☐ yes ☐ no f. Prescribe food packages

☐ yes ☐ no g. Identify, develop, and implement an individual care plan during High-Risk visits and Certification.

☐ yes ☐ no h. Document the provision of nutrition education.

☐ yes ☐ no i. Appropriately refer participants to other health and social services.

☐ yes ☐ no j. Document referrals.

☐ yes ☐ no k. Provide and document appropriate follow-up to referrals.

☐ yes ☐ no

Food Package Tailoring and Assignment 1. The package for a fully breastfeeding woman is changed when her infant begins receiving formula.

☐ yes ☐ no

2. The Certifying Health Professional individually tailors the partially breastfeeding infant food package amount of formula based on the assessed needs of the breastfeeding infant and provides the minimal amount of formula that meets the infant’s nutrition needs. ☐ yes ☐ no

3. When special circumstances warrant, additional assessment, and counseling regarding food packages include “Milk & Milk Substitutions Nutrition Assessment Protocols” as specified in the WIC and Nutrition Manual is provided.

☐ yes ☐ no

4. Agency collaborates with other programs to ensure the provision of the foods and infant formula, exempt infant formula, and WIC nutritionals to participants, when nutritional needs exceed the Federal made in the chart?

☐ yes ☐ no

Documentation/Coding 1. At certification/recertification is the WIC-75 completed in the system or on paper if the system is down?

☐ yes ☐ no

2. Are immunization screenings and referrals documented in the participant’s medical record? ☐ yes ☐ no

3. Is chart documentation done at the time the service is provided?

☐ yes ☐ no

4. Is the chart available when issuing benefits?

☐ yes ☐ no If no, why? Click here to enter text.

5. Are PEFs or reports reviewed to assess the coding of clinic services?

☐ yes ☐ no If yes, how are any concerns addressed? Click here to enter text.

WIC Internal Review Form FY 2025 Rev. 10/24 12

Comments: Click here to enter text.

Breastfeeding Promotion and Support 1. Staff Training Local WIC agency staff are trained by the local WIC agency Breastfeeding Coordinator or designee, or State Agency approved training to be breastfeeding advocates and ensure access to competently trained breastfeeding staff. This training includes: a. Train all staff on the importance of breastfeeding and the clinic’s policies and services to promote, protect, and support breastfeeding.

☐ yes ☐ no b. Train WIC Certifying Health Professionals by State Approved training (WIC-USDA Required Training) to provide assessment, referrals and appropriate support of the mother’s breastfeeding plans and education needs throughout the prenatal and postpartum period.

☐ yes ☐ no c. Train appropriate health professional staff on assembly, cleaning, and issuance of breast pumps.

☐ yes ☐ no

2. Breastfeeding Support a. All breastfeeding issues/concerns shall be referred to an International Board-Certified Lactation Consultant (IBCLC), Certified Lactation Counselor (CLC), Certified Lactation Specialist (CLS), or Breastfeeding Peer Counselor and allow adequate time for assessment, evaluation, and assistance to resolve breastfeeding problems during the clinic visit, as appropriate. ☐ yes ☐ no b. Address all breastfeeding concerns in a timely manner.

☐ yes ☐ no c. For agencies with the Breastfeeding Peer Counselor Program, utilize the Breastfeeding Peer Counselors to support WIC prenatal and breastfeeding women. ☐ n/a ☐ yes ☐ no

3. Breastfeeding Aids a. Does the agency issue any other breastfeeding aids?

☐ yes ☐ no If yes, provide details: Click here to enter text. b. Does the agency have a State WIC Office approved policy for Breastfeeding Aids? ☐ n/a ☐ yes ☐ no c. Does the agency issue Nipple Shields?

☐ yes ☐ no

4. Breast Pump Issuance a. Breast pump issuance provided by a health professional.

☐ yes ☐ no b. The reason for issuance is documented in the medical record.

☐ yes ☐ no c. Kentucky WIC Program Breast Pump Assessment and Information Checklist completed. ☐ yes ☐ no d. Issuance documented on appropriate breast pump inventory log sheet.

☐ yes ☐ no e. If a pump is issued, is follow-up conducted and documented.

☐ yes ☐ no f. Are the pumps stored in a secure location? ☐ yes ☐ no

WIC Internal Review Form FY 2025 Rev. 10/24 13

Chart Review

Review Women, Infant and Child Records and complete the charts below. A random sample report is available via CDP Report Viewer, Report 710- Random Sampling of Infant, Children, and Woman Report by Status.

1.Click on the CDP Report Viewer link.

2. Select WIC Category and then locate Report 710- Random Sampling of Infant, Children, and Woman Report by Status. 3. Click on magnifying glass.

4. After clicking on magnifying glass beside report 710, select your clinic and the number of samples per type from the drop-down field in the Parameters box, then hit view to generate your report.

WIC Internal Review Form FY 2025 Rev. 10/24 14

Certification Record Review – Women Household Number*

Status*

Certification Date (Listed on Random Sample Report)*

Appropriate proof code for residence* (1st Registration label)

Appropriate proof code for identity*(1st Registration label)

Adjunct eligibility documented, if eligible*

For an Adjunct Eligible participant, is a self-reported estimated household income recorded on HH Member Screen and the date of registration

If not adjunctive eligible, Household income assessed and documented*

The primary language spoken documented

Interpreter Services Offered and Documented?

Documentation of Appropriate aids and services provided for disability? *

The financial certification box checked

Financial Cert. area signed/dated

Rights & Responsibilities signed/dated

Proxy documentation appropriate

The date of initial contact (DIC) meets processing standards

Appropriate proof code for issuance*

Eligibility supported for income

Certifying risks*

Certified for all risks**

If certifying risks included the following codes: 201, 211, 358, 361, 371, 372, 602, 801, 802, 901, 902, 903, was a referral documented?

NEPP documented

Goal(s) established

Dietary assessment completed

Growth chart plotted & filed in medical record (If appropriate; P-none; PP & BF<20)

Medical provider/Medical home documented

Health Professional signed/dated (WIC-75)

Type of Secondary Nutrition Education visit offered/documented*

MCHA visit performed & MC-NEPP documented*

Progress toward certification goal documented at MCHA visit

Appropriate number of nutrition education/secondary contacts

WIC High-Risk Nutrition Visit provided (if applicable)

Plan of Care documented at High- Risk Visit (if applicable)

If currently receiving formula and/or WIC nutritional, the chart has a valid WIC-300 or prescription.

When circumstances warrant,

WIC Internal Review Form FY 2025 Rev. 10/24 15

* Record Actual information/proof code **Record risk code that is not supported

Comments: Click here to enter text.

“Milk and Milk Substitutions” protocols are followed and documented If a Woman received a breast pump, documentation complete

WIC Internal Review Form FY 2025 Rev. 10/24 16

Certification Record Review – Infants Household Number*

Certification Date*

Certification Date (Listed on Random Sample Report)*

Appropriate proof code for residence* (1st Registration label)

Appropriate proof code for identity*(1st Registration label)

Adjunct eligibility documented, if eligible*

For an Adjunct Eligible participant, is a self-reported estimated household income recorded on HH Member Screen the date of registration

Primary language spoken documented

Interpreter Services Offered and Documented?

Documentation of Appropriate aids and services provided for disability? *

Financial certification box checked

Financial Cert. area signed/dated

Rights & Responsibilities signed/dated

Proxy documentation appropriate

Date of initial contact (DIC) meets processing standards

Appropriate proof code for issuance *

Certifying Risks *

Certified for all risks**

If certifying risks included the following codes: 152, 201, 211, 358, 361, 801, 802, 901, 902, 903 was a referral documented?

NEPP documented

Goal(s) established

Dietary assessment completed

Growth chart plotted & filed in chart (if appropriate)

Gestational age documented

Bloodwork done at appropriate intervals (if applicable)

Immunization status documented

Medical provider/Medical home documented

Health Professional signed/dated (WIC-75)

Type of Secondary Nutrition Education visit offered/documented*

MCHA visit performed & MC-NEPP documented*

Progress toward certification goal documented at MCHA visit

Appropriate number of nutrition education/secondary contacts

WIC High Risk Nutrition Visit provided (if applicable)

Plan of Care documented at High-Risk Visit (if applicable)

INFANTS Continued:

WIC Internal Review Form FY 2025 Rev. 10/24 17

* Record Actual information/proof code **Record risk code that is not supported

Comments: Click here to enter text.

WIC Internal Review Form FY 2025 Rev. 10/24 18

Certification Records Review - Children Household Number*

Certification Date*

Certification Date (Listed on Random Sample Report)*

Appropriate proof code for residence* (1st Registration label)

Appropriate proof code for identity*(1st Registration label)

Adjunct eligibility documented, if eligible*

For an Adjunct Eligible participant, is a self-reported estimated household income recorded on HH Member Screen on the date of registration

Primary language spoken documented

Interpreter Services Offered and Documented?

Documentation of Appropriate aids and services provided for disability? *

The financial certification box checked

Financial Cert. area signed/dated

Rights & Responsibilities signed/dated

Eligibility supported for income

Proxy documentation appropriate

Date of initial contact (DIC) meets processing standards

Appropriate proof code for issuance *

Certifying Risks *

Certifying risks supported **

Blood work at appropriate intervals

Gestational age documented (if < 2)

Growth charts documented

Immunization status documented

NEPP documented

Health Professional signed/dated (WIC-75)

Type of Nutrition Education/Secondary visit offered/documented*

MCHA visit performed & MC-NEPP documented*

Progress toward certification goal documented at MCHA visit

Appropriate number of nutrition education/secondary contacts

WIC High-Risk Nutrition Visit provided (if applicable)

Plan of Care documented at High-Risk Visit (if applicable)

Appropriate number of nutrition education contacts – for previous cert.

* Record Actual information/proof code **Record risk code that is not supported

Comments: Click here to enter text.

WIC Internal Review Form FY 2025 Rev. 10/24 19

Ineligibles Records Review (Participant Random Samples) * Record actual information

Household Number First Name Race Screening Date Ineligibility Supported * Reason for Ineligibility Documented Signature & Date of Person Determining WIC-54 Given

WIC Medical Records Review 1. Review medical records of all categories from the Participation Random Sample. Complete the Certification Records Review.

2. From the review of certification records, does it appear: a. Nutrition education contacts are coordinated with food benefit issuance pick-up? ☐ yes ☐ no b. Missed appointments are documented?

☐ yes ☐ no c. Terminations are documented?

☐ yes ☐ no d. Issuance of non-contract infant formula, exempt infant formula, and WIC nutritionals is documented and prescription on file/policy followed?

☐ yes ☐ no e. WIC is coordinated with other services?

☐ yes ☐ no f. Staff recognition, medical record, or eWIC cardholder are used as proof of identity at recertification and pick-up when appropriate?

☐ yes ☐ no g. Exceptions to the physical presence requirements are allowed?

☐ yes ☐ no h. Documentation is made for follow-up for missed appointments?

☐ yes ☐ no

3. For hospital certifications: ☐ N/A a. Are proof requirements met within 30 days?

☐ yes ☐ no Appropriate food benefits given?

☐ yes ☐ no b. Issue dates coordinated?

☐ yes ☐ no

WIC Internal Review Form FY 2025 Rev. 10/24 20

Clinic Observations 1. Complete the following chart for each patient observed and indicate if required information was provided/discussed. Indicate N/A if not applicable.

Patient Status/Type Visit

Household Number

Registration Certification MCHA/Secondary Follow Up Did Staff advise of free language services or other free aids and services

Did staff use the WIC Clerical Checklist or follow the checklist script

Did staff offer the Race and Ethnicity Reference Card to applicant

Patient Identifies Race and Ethnicity

Appropriate proof code for residence

Appropriate proof code for identity

Adjunct eligibility documented

Household income documented

Are labels affixed to CH-5 prior to signature or if EMR county, are labels scanned into the medical record?

Financial Cert. area checked/signed/dated

Staff advise the applicant to read WIC Rights and Responsibilities prior to signing CH-5 or offer to read Rights and Responsibilities prior to signing (R and R provided in a language the applicant understands)

Proxy offered/updated

Household Income documented for Adjunct eligible

Voter registration offered

eWIC Benefits pamphlet provided appropriately including Rights and Responsibilities

Are new participants provided instructions on how and where to redeem eWIC benefits, support or Health Program staff provide instructions?

Referrals to other health department services if appropriate, Medicaid & SNAP , etc.

Nutrition and Health Assessment: See Certification, MCHA or Follow Up Visit sections Certification Visit

Interpreter services offered, provided, and documented, if appropriate

If LEP, primary language spoken documented

Documentation of Appropriate aids and services provided for disability?

Measures taken appropriately (remove hats and outer clothing, etc.)

Gestational age entered (as appropriate)

Growth chart completed/printed and filed in medical record (if applicable)

Evaluation of hemoglobin or hematocrit (if applicable)

Non-invasive device used (if applicable)

Utilization of referral data/request for referral data for remote

WIC Internal Review Form FY 2025 Rev. 10/24 21

Dietary assessment

Health assessment

Immunization screening & referral (as appropriate)

Lead screening & referral (as appropriate)

WIC Program Eligibility and Program Benefits Explained

Counseling Provided on Basic Diet and Physical Activity

Counseling on ATOD (Smoking Alcohol and Drugs)

Encourage Pregnant and BF Women to Breastfeed

Safe Sleep for Infants

Screen time discussed

Food Package Assignment and Tailoring

Nutritional risks reviewed with participant

Provided counseling based on identified risk codes

Medical Home Documented

SMART GOALS established and documented

Referrals, as appropriate

For new participants, provide a list of authorized vendors and the Approved Food List/WIC Shopper app.

Breastfeeding Questions answered

WIC-75 and other documentation filed in the medical record.

MCHA visit

Follow-up on established goals

Anthropometric Screening/follow up on referral data as appropriate

Measures taken accurately

Growth chart completed/printed and filed in the medical record (if applicable)

Evaluation of hemoglobin or hematocrit (if applicable)

Non-invasive device used (if applicable)

Utilization of referral data

Dietary assessment

Health assessment

Immunization screening & referral (as appropriate)

Update and review of nutritional risks

Counseling provided. (as appropriate)

Preferred spoken language identified free communication services offered & Documented, if appropriate/ any aids or services offered or provided documented

Other referrals as appropriate

MCHA WIC-75 update filed in the medical record

Follow-up visit Follow-up on established goals

For low risk, provided nutrition education on a least one topic

For High risk, counseled on diet and risk

WIC Internal Review Form FY 2025 Rev. 10/24 22

Follow-up on referral data/collect measures as appropriate from remote certification

Measures taken appropriately (remove hats and outer clothing, etc.)

Growth chart completed/printed (if applicable)

Evaluation of hemoglobin or hematocrit (if applicable)

Non-invasive device used (if applicable)

Utilization of referral data

Preferred spoken language identified free communication services offered & Documented, if appropriate/ any aids or services offered or provided documented

Other referrals as appropriate

Check out eWIC Benefits pamphlet provided appropriately

For new participants, provide a list of authorized vendors and Approved Food List/WIC Shopper app.

Proof of adult ID receiving benefits

Is eWIC benefit issuance appropriate (maximum of 3 months)

Return appointment provided

Benefits verified in account and shopping list and shopper app reviewed

PIN not requested from participant or recorded

Was the participant asked to swipe their card for a balance prior to leaving?

2. Indicate observed equipment used for WIC measurements: ☐Measuring board with a flat surface to place on top of the head for infants and children up to 36 months ☐Pediatric table ☐Height rod on scales ☐Balance beam scales ☐Non-invasive device (Pronto) ☐Spring-type scales ☐Digital scales ☐Other Click here to enter text.

Conflict of Interest/Separation of Duties 1. For family, household members, or friends of staff that receive WIC services, do: Other staff determine income eligibility, including Medicaid?

☐ yes ☐ no Other staff perform screening and determine nutritional risk?

☐ yes ☐ no Other staff prescribe food package?

☐ yes ☐ no Other staff issue food benefits?

☐ yes ☐ no If no, is each certification and issuance record being reviewed and signed by a supervisor? ☐ yes ☐ no

Is there a tracking method in place?

☐ yes ☐ no

2. Does one person determine income and risk eligibility and issue food benefits for the same participant?

☐ yes ☐ no If yes, is each certification and issuance record reviewed within two weeks and signed by a supervisor?

☐ yes ☐ no

WIC Internal Review Form FY 2025 Rev. 10/24 23

3. Conflict of Interest. Are the log and charts reviewed monthly?

☐ yes ☐ no Is there a tracking method in place?

☐ yes ☐ no

eWIC Card and WIC FMNP Management 1. Indicate specific storage locations for: eWIC cards Click here to enter text. eFMNP cards Click here to enter text.

Are these areas locked?

☐ yes ☐ no

2. Is the serial number on the screen verified against those on the eWIC card each time before issuing the card?

☐ yes ☐ no

3. When a participation is added to an existing household, are issuance dates coordinated? ☐ yes ☐ no

Outreach 1. Is WIC Outreach performed?

☐ yes ☐ no If yes, ☐Sites ☐ Administrative Office By whom: Click here to enter text.

When is outreach performed? ☐ Annually ☐ On-going ☐Other: Click here to enter text. 2. Is outreach documented?

☐yes ☐ no If yes, review the outreach file. Reviewed timeframe/FY Click here to enter text.

3. Is there documentation of information provided annually to:

Medical doctors, health, and medical organizations?

☐ yes ☐ no

Hospitals (including rural health clinics), and clinics?

☐ yes ☐ no

Welfare/unemployment offices (DCBS)?

☐ yes ☐ no

Social services agencies?

☐ yes ☐ no Migrant organizations/agencies?

☐n/a ☐ yes ☐ no Homeless organizations/agencies?

☐n/a ☐ yes ☐ no Community organizations?

☐ yes ☐ no Food banks?

☐ yes ☐ no Public announcements (newspaper, radio, social media, etc.)?

☐ yes ☐ no Record other outreach: Click here to enter text.

Accountability/Inventories 1. Review the handwritten VOC (WIC-17) inventory and log. Does it include:

Serial number received?

☐ yes ☐ no

Serial number issued to the participant?

☐ yes ☐ no Are all forms accounted for?

☐ yes ☐ no Is security adequate for VOC forms?

☐ yes ☐ no 2. Review the Voter Registration report (495) for the prior month to today’s visit. Verify that each name appearing on the report has a signed WIC-53 form.

WIC Internal Review Form FY 2025 Rev. 10/24 24

Months Reviewed Number of Women added over the age of 18 Number with WIC-53 signed Compliance Rate Previous Compliance (Month/Year/%)

If not 100%, has it ever been? Click here to enter text.

3. Review documentation of the physical count of unused eWIC cards and FMNP food instruments. Is a monthly inventory kept on eWIC cards and WIC FMNP FIs? ☐ yes ☐ no Is the inventory conducted by a person who does not issue food benefits? ☐ yes ☐ no

4. Is a formula inventory form maintained?

☐ yes ☐ no Review the formula inventory form. Does it include: Date formula is received?

☐ yes ☐ no Name of formula?

☐ yes ☐ no Can size?

☐ yes ☐ no Quantity received?

☐ yes ☐ no Type of formula (powdered, concentrate, ready-to-feed)?

☐ yes ☐ no Date discarded?

☐ yes ☐ no Staff initials/name?

☐ yes ☐ no When formula is returned, is it documented in the participant’s medical record? ☐ yes ☐ no

5. The agency maintains an inventory on: Manual breast pumps

☐ n/a ☐ yes ☐ no Electric breast pumps

☐ n/a ☐ yes ☐ no Hospital-grade electric breast pumps

☐ n/a ☐ yes ☐ no

6. The agency maintains an inventory on: Nipple Shields

☐ n/a ☐ yes ☐ no Additional Breastfeeding Aids

☐ n/a ☐ yes ☐ no Has state approval for issuance of nipple shields or other breastfeeding aids? ☐ n/a ☐ yes ☐ no

Homeless Shelters and Institutions 1. Has any effort been made to identify and provide services to the homeless? ☐ n/a☐ yes ☐ no

2. Have any services been provided to persons in homeless facilities and institutions? ☐ yes ☐ no If yes: Was the facility determined to meet the three required conditions?

WIC foods will not be used in communal feeding

☐ yes ☐ no The facility will not restrict the participant’s use of WIC services ☐ yes ☐ no No financial or in-kind benefit shall be accrued from a person’s participation in WIC Program ☐ yes ☐ no Are periodic contacts made to ensure the three conditions continue to be met? ☐ yes ☐ no

Property Management 1. Is WIC equipment inventory over 500 dollars being tracked and kept up to date?

☐ yes ☐ no

2. Is the equipment documented in the inventory being utilized for WIC and on-site? ☐ yes ☐ no

3. Is there WIC equipment not in use by the WIC Program?

☐ yes ☐ no

WIC Internal Review Form FY 2025 Rev. 10/24 25

4. Is the WIC equipment secure with controls in place to prevent theft or damage?

☐ yes ☐ no

WIC Farmers’ Market Nutrition Program (FMNP) Does this agency/site participate in the Farmers’ Market Nutrition Program?

☐ yes ☐ no If yes, review the policy and complete the following questions.

1. Who is the FMNP contact? (Provide name and title) Click here to enter text.

2. Which staff performs the following functions? Food Instrument (FI) Issuance: Click here to enter text.

Review of FMNP reports: Click here to enter text.

Nutrition Education regarding fresh fruits and vegetables: Click here to enter text.

3. Are participants provided: [FR/KR]

The “Kentucky WIC Farmers’ Market Nutrition Program” brochure?

☐ yes ☐ no WIC FMNP market(s) location and hours?

☐ yes ☐ no

4. Does the agency have a Farmers Market Nutrition Program (FMNP) Complaint File? ☐ yes ☐ no

Comments: Click here to enter text.

WIC Internal Review Form FY 2025 Rev. 10/24 26

Breastfeeding Peer Counselor Program

Complete this section only for agencies that have the BF Peer Counseling Program.

1. Did the Supervisor and Peer Counselor complete all USDA mandatory training? [FR/KR] ☐ yes ☐ no *Please indicate the date each individual completes this training: Click here to enter text. Comments: Click here to enter text.

2. Does each Supervisor have a file for each Peer Counselor containing the: [FR/KR] a. Peer Counselor Training Checklist?

☐ yes ☐ no b. Peer Counselor Equipment and Materials Log?

☐ yes ☐ no Comments: Click here to enter text.

3. Are Peer Counselors provided shadowing opportunities of other Peer Counselors and/or Lactation Specialist during the orientation and training period? [FR/KR]

☐ yes ☐ no

4. Does the Peer Counselor Supervisor observe Peer Counselor interactions of two (2) pregnant women and two (2) breastfeeding mothers during the first month of employment and every six (6) months thereafter? [FR/KR]

☐ yes ☐ no Comments: Click here to enter text.

5. Does the Peer Counselor Supervisor provide an evaluation of each Peer Counselor after the first month of employment and every six (6) months thereafter?

☐ yes ☐ no Comments: Click here to enter text.

6. Does the Peer Counselor Supervisor complete the Participant Phone Feedback Survey for each Peer Counselor every six (6) months? [FR/KR]

☐ yes ☐ no Comments: Click here to enter text.

7. Does the Peer Counselor Supervisor provide routine monitoring of client contact logs for each Peer Counselor to ensure that contacts are being made based on the Breastfeeding Peer Counselor Protocol for Contacting WIC Mothers? [FR/KR] ☐ yes ☐ no Comments: Click here to enter text.

8. Does the Peer Counselor Supervisor review the weekly activity report for each Peer Counselor? ☐ yes ☐ no Comments: Click here to enter text.

9. Based on the master contact list, what is the Peer Counselor(s) current client caseload number? Breastfeeding Peer Counselor Program Designated Staff Name Role Caseload Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text.

Does the agency have a Designated Breastfeeding Expert/Lactation Specialist for breastfeeding Referrals and support? ☐ yes ☐ no

WIC Internal Review Form FY 2025 Rev. 10/24 27

Lactation Specialist’s Name: Click here to enter text. Qualifications: 1. A nurse (RN or LPN) or nutritionist (RD or RDN).

☐ yes ☐ no

2. Has current certification as: a. International Board-Certified Lactation Consultant (IBCLC)

☐ yes ☐ no If yes, year certified: Click here to enter text. b. Certified Lactation Counselor (CLC)

☐ yes ☐ no If yes, year certified: Click here to enter text. c. Certified Lactation Specialist (CLS)

☐ yes ☐ no If yes, year certified: Click here to enter text.

3. Has maintained continuing education?

☐ yes ☐ no

4. Estimate annual continuing education hours completed: Click here to enter text.

5. Accepts BF referrals from the following site(s): Click here to enter text.

Comments: Click here to enter text.

Off-Site Services

Complete the chart below if this site provides WIC services in either of the settings.

☐ Not Applicable Satellite Clinic

Hospital Services offered

Days/Hours of operation

Staff

CH-5B used and retained

Face-to-face contact

30-day provisional certs done

eWIC card issuance

FMNP FI’s issuance

FMNP FI’s storage on-site

Storage Secure

Issue date/appointments coordinated with household

Timeframe for data entry

The primary reason for the visit

One staff member does certification and issuance

Supervisor reviews and signs certification and issuance

WIC Internal Review Form FY 2025 Rev. 10/24 28

Additional Comments:

Click here to enter text.

Page 1 Civil Rights Policy 306 December 2024 Policy 306 CIVIL RIGHTS

POLICY

Local WIC programs must comply with the provisions of Title VI of the Civil Rights Act of 1964 and other applicable Civil Rights laws and regulations.

PURPOSE

The Kentucky WIC program is available to all, and no individual is excluded from participation, denied benefits, or subjected to discrimination on the grounds of race, color, national origin, age, sex, gender identity, or disability. Additionally, the Kentucky WIC program is prohibited from retaliating against anyone for engaging in a protected Civil Rights activity.

RELEVANT STATUTES, REGULATIONS, AGREEMENTS, AND DIRECTIVES

Statutes: Title VI of the Civil Rights Act of 1964 (42 USC § 2000d at 7 CFR § 15.1) Department of Justice Guidelines for the Enforcement of Title VI of the Civil Rights Act of 1964 at 28 CFR § 50.3 Title IX of the Education Amendments of 1972, as amended (Public Law 92-318, 20 USC § 1681 et seq. at 7 CFR § 15a) Section 504 of the Rehabilitation Act of 1973, as amended (Public Law 93-112, 29 USC § 701 at 7 CFR § 15b) Age Discrimination Act of 1975 (Public Law 94-135, 42 USC § 6101 at 45 CFR Part 91 and 7 CFR § 15c) Civil Rights Restoration Act of 1987 (Public Law 100-259) Americans with Disabilities Act of 1990 (ADA) and the ADA Amendments Act of 2008 (42 USC § 12101 et seq., Title II at 28 CFR Part 35 and Title III at 28 CFR Part 36

Regulations: 7 CFR 15 – USDA Nondiscrimination in Federally Assisted Programs of the USDA 7 CFR § 246.6 Agreements with local agencies 7 CFR. § 246.7(j) Notification of participant rights and responsibilities 7 CFR § 246.8 et seq. Nondiscrimination 7 CFR. § 246.25(b)(3)(ii) Records and Reports, Civil Rights 7 CFR Part 16 Equal Opportunity for Religious Organizations 28 CFR Part 35 Nondiscrimination on the Basis of Disability in State and Local Government Services 28 CFR Part 36 Nondiscrimination on the Basis of Disability by Public Accommodations and in Commercial Facilities USDA Departmental Regulation (DR) 4300-003, Equal Opportunity Public Notification Policy, October 17, 2019 USDA Departmental Regulation (DR) 4330-002 Nondiscrimination in Programs and Activities Receiving Federal Financial Assistance from the USDA, July 27, 2021

Page 2 Civil Rights Policy 306 December 2024

Agreements: Federal-State Supplemental Nutrition Programs Agreement (Form FNS – 339) FNS – KY CHFS Complaints Processing Memorandum of Understanding, October 3, 2016

Program Guidance: USDA Guidance to Federal Financial Assistance Recipients Regarding the Title VI Prohibition Against National Origin Discrimination Affecting Persons With Limited English Proficiency (79 F.R. No. 299, p. 70771-70784, November 28, 2014).

DEFINITIONS

Applicant: An individual who contacts the WIC clinic requesting WIC services.

Auxiliary Aids and Services: (1) Qualified interpreters on-site or through video remote interpreting (VRI) services; notetakers; real-time computer-aided transcription services; written materials; exchange of written notes; telephone handset amplifiers; assistive listening devices; assistive listening systems; telephones compatible with hearing aids; closed caption decoders; open and closed captioning, including real-time captioning; voice, text, and video-based telecommunications products and systems, including text telephones (TTYs), videophones, and captioned telephones, or equally effective telecommunications devices; videotext displays; accessible electronic and information technology; or other effective methods of making aurally delivered information available to individuals who are deaf or hard of hearing; (2) Qualified readers; taped texts; audio recordings; Brailed materials and displays; screen reader software; magnification software; optical readers; secondary auditory programs (SAP); large print materials; accessible electronic and information technology; or other effective methods of making visually delivered materials available to individuals who are blind or have low vision; (3) Acquisition or modification of equipment or devices; and (4) Other similar services and actions. Companion (for disability): A family member, friend, or associate of an individual seeking access to a service, program, or activity of a public entity or public accommodation who, along with such individual, is an appropriate person with whom the public entity or public accommodation should communicate.

Complainant: Any individual or group of individuals alleging discrimination in the delivery of WIC program benefits or services.

Digital Services. The delivery of digital information (e.g., data or content) and transactional services (e.g., online forms, applications) across a variety of platforms, devices, and delivery mechanisms (e.g., websites, mobile applications, and social media. Digital services involve the electronic delivery of information, including data and content, across multiple platforms or devices, such as text, audio, video, mobile applications, and graphics that are transmitted for viewing over the internet. This includes social media (YouTube, Twitter, Facebook, etc.), websites, and applications that enable users to create and share information and content or to participate in social networking.

Page 3 Civil Rights Policy 306 December 2024 Disability: Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act Amendments Act of 2008 define disability with respect to an individual: a physical or mental impairment that substantially limits one or more of the major life activities of such individual; a record of such an impairment; or being regarded as having such an impairment. (See 7 C.F.R. § 15b(3)(i), 28 C.F.R § 35.108 and 28 C.F.R. § 36.105.)

Discrimination: The act of distinguishing one person or group of persons from others, either intentionally, by neglect, or by the effect of actions or lack of actions based on a protected class.

Limited English Proficiency (LEP) persons: Individuals who do not speak English as their primary language and who have a limited ability to read, speak, write, or understand English. Major Life Activity (for disability): (i) Caring for oneself, performing manual tasks, seeing, hearing, eating, sleeping, walking, standing, sitting, reaching, lifting, bending, speaking, breathing, learning, reading, concentrating, thinking, writing, communicating, interacting with others, and working; and (ii) The operation of a major bodily function, such as the functions of the immune system, special sense organs and skin, normal cell growth, and digestive, genitourinary, bowel, bladder, neurological, brain, respiratory, circulatory, cardiovascular, endocrine, hemic, lymphatic, musculoskeletal, and reproductive systems. The operation of a major bodily function includes the operation of an individual organ within a body system. Noncompliance: Noncompliance is a factual finding that any Civil Rights requirement, as provided by law, regulation, policy, instruction, or guidelines, is not being adhered to by local agency or other subrecipient.

Participant: An individual who meets all eligibility criteria and is enrolled in the WIC program.

Protected classes: A characteristic/factor, such as race, color, national origin, sex, age, or disability, that is protected from unlawful discrimination by federal statute, Executive Order and USDA regulation/policy. For WIC, the protected classes are race, color, sex, age, national origin, and disability.

Qualified Interpreter (LEP): A qualified interpreter is a highly trained individual who mediates spoken communication between people speaking different languages without adding, omitting, or distorting meaning or editorializing.

Qualified Interpreter (Disability): An interpreter who, via a video remote interpreting (VRI) service or an on-site appearance, is able to interpret effectively, accurately, and impartially, both receptively and expressively, using any necessary specialized vocabulary. Qualified interpreters include, for example, sign language interpreters, oral transliterators, and cued-language transliterators.

Qualified Translator: A qualified, competent translator is a highly trained individual who is able to render text from a source language into a target language while preserving meaning and adhering to generally accepted translator ethics and principles, including confidentiality. Qualified translators

Page 4 Civil Rights Policy 306 December 2024 understand the cultural context of the source and target languages as well as demonstrate competency to translate through an independent language assessment.

Reasonable modification: A change in policies, practices, or procedures when the modifications are necessary to avoid discrimination on the basis of disability, unless the public entity can demonstrate that making the modifications would fundamentally alter the nature of the service, program, or activity. 28 CFR 35.130(b)(7).

Significant Finding: An egregious and repetitive finding or a policy or procedure that has a disproportionate, adverse effect on a particular protected class (disparate impact).

Vendor. A sole proprietorship, partnership, cooperative association, corporation, or other business entity operating one or more stores authorized by the State agency to provide WIC-authorized supplemental foods to participants under a retail food delivery system.

Vital Documents/Vital Information: Documents or information vital to an individual’s participation including forms related to applying for the program, documents that require a response, denial letters or notice of ineligibility.

PROCEDURES

Local Agency Civil Rights Coordinator(s)

Each Local Agency must designate a point of contact that ensures compliance with all Civil Rights requirements applicable to WIC. A. See Administrative Reference, Program Descriptions, WIC Coordinator Duties. B. The Local Agency Civil Rights Coordinator: May be the WIC Coordinator or another employee of the agency. 1. The Local Agency Civil Rights coordinator will ensure this policy (306 Civil Rights) is implemented at the local agency and any relevant polices in the Administrative Reference. 2. Will coordinate with the Nutrition Services Branch, Program Management Section Supervisor and with the Cabinet for Health and Family Services Equal Employment Opportunity (EEO) and Civil Rights Branch Manager.

Assurances of Nondiscrimination

A. Local WIC programs agree to abide by civil rights laws and regulations by signing the contract and accepting WIC funding. Refer to the Multi-User Contract (Local Health Departments) or the WIC Services Contract (Contract Agencies) with the Cabinet for Health and Family Services. B. The Assurance Statement below is entered into annually between the Cabinet for Health and Family Services and USDA (USDA Form FNS – 339). This transfers to local agencies administering the WIC Program.

The State Agency hereby agrees that it will comply with Title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d et seq.), Title IX of the Education Amendments of 1972 (20 .S.C. 1681 et seq.), Section 504 of the Rehabilitation Act of 1973 (29 U.S.C. 794), Age discrimination

Page 5 Civil Rights Policy 306 December 2024 Act of 1975 (42 U.S.C. 6101 et seq.); Title II and Title III of the Americans with Disabilities Act (ADA) of 1990 as amended by the ADA Amendment Act of 2008 (42 U.S.C. 12131- 12189) as implemented by Department of Justice regulations at (28 CFR Parts 35 and 36); Executive Order 13166, Improving Access to Services for Persons with Limited English Proficiency." (August 11, 2000), all provisions required by the implementing regulations of the U.S. Department of Agriculture (7 CFR Part 15 et seq) and FNS directives and guidelines to the effect that no person shall, on the ground of race, color, national origin, age, sex, or disability, be excluded from participation in, be denied the benefits of, or otherwise be subjected to discrimination under any program or activity for which the Agency receives Federal financial assistance from FNS; and hereby gives assurance that it will immediately take measures necessary to effectuate this agreement.

By providing this assurance, the State Agency agrees to compile data, maintain records and submit records and reports as required to permit effective enforcement of the nondiscrimination laws, and to permit Department personnel during normal working hours to review and copy such records, books and accounts, access such facilities, and interview such personnel as needed to ascertain compliance with the non-discrimination laws. If there are any violations of this assurance, the Department of Agriculture shall have the right to seek judicial enforcement of this assurance.

This assurance is given in consideration of and for the purpose of obtaining any and all Federal financial assistance, grants, and loans of Federal funds, reimbursable expenditures, grant, or donation of Federal property and interest in property, the detail of Federal personnel, the sale and lease of, and the permission to use Federal property or interest in such property or the furnishing of services without consideration or at a nominal consideration, or at a consideration that is reduced for the purpose of assisting the recipient, or in recognition of the public interest to be served by such sale, lease, or furnishing of services to the recipient, or any improvements made with Federal financial assistance extended to the Program applicant by USDA. This includes any Federal agreement, arrangement, or other contract that has as one of its purposes the provision of cash assistance for the purchase of food, and cash assistance for purchase or rental of food service equipment or any other financial assistance extended in reliance on the representations and agreements made in this assurance.

This assurance is binding on the State Agency, its successors, transferees, and assignees as long as it receives assistance or retains possession of any assistance from the Department.

C. Where applicable, a statement of assurance must be incorporated into the Retailor/Vendor/Federal/State/local/subrecipient agency agreement.

Public Notification

Page 6 Civil Rights Policy 306 December 2024

WIC local agencies are to: A. Inform potentially eligible persons, applicants, participants and grassroots organization of the WIC Program or changes in the Program. B. Convey the message of equal opportunity in all photos and other graphics that are used to provide program related information. C. Notify person with disabilities about the availability of reasonable modifications and auxiliary aids and services and how to request them in a format that they can understand. D. Notify person with limited English Proficiency (LEP) of their right to free language assistance services (interpretation and translated materials) and how to request them in a language that they can understand. E. Inform potential WIC applicants and participants of their WIC Program Rights and Responsibilities and the steps necessary for WIC Participation including: 1. The right to file a complaint, how to file a complaint and the complaint procedure. See below “USDA Nondiscrimination Statement” and “Civil Rights Complaints” sections. 2. USDA’s nondiscrimination policy. See below “USDA Nondiscrimination Statement”. 3. Posting of the “And Justice for All Poster” (AD-475A) in a prominent location visible to applicants, participants, and potential applicants. a. Must be the original poster, local reproduction is not authorized. b. Refer to WIC and Nutrition Manual, Section 200 Appendices for more information on the posting of the “And Justice for All Poster”. F. United States Citizenship and lawfully present immigration status is not a requirement for participation in WIC, therefore lack of citizenship or lawfully present immigration status must not be a burden for participation. 1. Local WIC Agencies cannot require a social security number for participation. a. Requirement of social security number is a burden to participation and that can result in discrimination against a WIC applicant or participant based on national origin. 2. The use of pseudo-identification numbers or auto- generated number at registration is strongly encouraged for the use as a Participant number in the system.

USDA Nondiscrimination Statement (NDS)

A. The USDA non-discrimination statement must be included on all WIC program materials that are produced for public notification. These materials may include outreach letters and brochures; internet websites and digital services; program information; newspaper, television, or radio announcements; posters; newsletters; referral materials; WIC application-related forms that are signed by participants. B. The USDA NDS may not be changed in any manner, and formatting may not be altered. C. The nondiscrimination statement should be: 1. In the full long form whenever possible. 2. On all WIC Outreach Materials, including on local agency websites. 3. On materials that the WIC Program produces for public information, public education, or public distribution, including but not limited to application forms, notification of eligibility or ineligibility, notification of adverse action, Program or Agency webpage, and digital services. 4. Large enough to be legible (at least 10-point font size for both the long and short forms). The material will, at a minimum, include the statement in print size no smaller than the text. If the

Page 7 Civil Rights Policy 306 December 2024 material is too small to permit the full statement to be included, the material will, at a minimum, include the statement, in print size no smaller than the text that “This institution is an equal opportunity provider.” 5. In English and other languages appropriate to the local population, 6. In an alternative means of communication, such as large print, Braille, audio, etc., when requested. D. The short form of the nondiscrimination statement should not be used routinely and may be used on items with limited space. These materials may include: 1. Postcards 2. Flyers of less than a page 3. Radio or television public service announcements that are generally short in duration. a. Per FNS instruction 113-1, recognizing that Internet, radio, and television public service announcements are generally short in duration the nondiscrimination statement does not have to be read in its entirety. Rather, a statement such as “Kentucky WIC is funded by the USDA. This institution is an equal opportunity provider.” is sufficient to meet the nondiscrimination requirement. b. Public program announcements (e.g., press releases) sent to media outlets must include the full NDS. Media outlets may include, but are not limited to, television, radio, and Internet. 4. If a local agency has their own nondiscrimination statement, it may be included on materials in addition to the required USDA statement but may not substitute for the USDA statement.

Page 8 Civil Rights Policy 306 December 2024

USDA WIC Nondiscrimination Statement (English)

In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating on the basis of race, color, national origin, sex (including gender identity and sexual orientation), disability, age, or reprisal or retaliation for prior civil rights activity. Program information may be made available in languages other than English. Persons with disabilities who require alternative means of communication to obtain program information (e.g., Braille, large print, audiotape, American Sign Language), should contact the responsible state or local agency that administers the program or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339. To file a program discrimination complaint, a Complainant should complete a Form AD-3027, USDA Program Discrimination Complaint Form which can be obtained online at: https://www.usda.gov/sites/default/files/documents/USDA-OASCR%20P-Complaint-Form-0508-0002- 508-11-28-17Fax2Mail.pdf, from any USDA office, by calling (866) 632-9992, or by writing a letter addressed to USDA. The letter must contain the complainant’s name, address, telephone number, and a written description of the alleged discriminatory action in sufficient detail to inform the Assistant Secretary for Civil Rights (ASCR) about the nature and date of an alleged civil rights violation. The completed AD- 3027 form or letter must be submitted to USDA by: 1. mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410; or 2. fax: (833) 256-1665 or (202) 690-7442; or 3. email: program.intake@usda.gov

This institution is an equal opportunity provider.

Page 9 Civil Rights Policy 306 December 2024 USDA WIC Nondiscrimination Statement (Spanish):

De acuerdo con la ley federal de derechos civiles y las normas y políticas de derechos civiles del Departamento de Agricultura de los Estados Unidos (USDA), esta entidad está prohibida de discriminar por motivos de raza, color, origen nacional, sexo (incluyendo identidad de género y orientación sexual), discapacidad, edad, o represalia o retorsión por actividades previas de derechos civiles. La información sobre el programa puede estar disponible en otros idiomas que no sean el inglés. Las personas con discapacidades que requieren medios alternos de comunicación para obtener la información del programa (por ejemplo, Braille, letra grande, cinta de audio, lenguaje de señas americano (ASL), etc.) deben comunicarse con la agencia local o estatal responsable de administrar el programa o con el Centro TARGET del USDA al (202) 720-2600 (voz y TTY) o comuníquese con el USDA a través del Servicio Federal de Retransmisión al (800) 877-8339. Para presentar una queja por discriminación en el programa, el reclamante debe llenar un formulario AD-3027, formulario de queja por discriminación en el programa del USDA, el cual puede obtenerse en línea en: https://www.usda.gov/sites/default/files/documents/USDA-OASCR%20P-Complaint-Form-0508- 0002-508-11-28-17Fax2Mail.pdf, de cualquier oficina de USDA, llamando al (866) 632-9992, o escribiendo una carta dirigida a USDA. La carta debe contener el nombre del demandante, la dirección, el número de teléfono y una descripción escrita de la acción discriminatoria alegada con suficiente detalle para informar al Subsecretario de Derechos Civiles (ASCR) sobre la naturaleza y fecha de una presunta violación de derechos civiles. El formulario AD-3027 completado o la carta debe presentarse a USDA por:

(1) correo: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410; or

(2) fax: (833) 256-1665 o (202) 690-7442; o

(3) correo electrónico: program.intake@usda.gov.

Esta entidad es un proveedor que brinda igualdad de oportunidades.

Short Statement (Spanish):

Esta entidad es un proveedor que brinda igualdad de oportunidades.

Page 10 Civil Rights Policy 306 December 2024 Non-discrimination Statement (NDS) in other languages/formats: Contact the State WIC Office for assistance with locating the NDS in additional languages routinely served by your agency or for assistance in alternative formats.

WIC Program Tagline:

The Kentucky WIC Program has developed a tagline for documents, websites, and digital services to ensure applicants and participants are aware of free communication assistance. This notice must be provided to the public in frequently encountered languages. This tagline should be included in approved WIC Outreach materials and vital forms and posted on websites and digital services. The tagline does not replace the Nondiscrimination Statement. Please find the approved tagline below.

WIC Tag Line English:

Need help? If you have difficulty understanding or reading English or have a disability, free language assistance or other aids and services are available upon request. Please contact your local WIC clinic or the State WIC Office at 1-877-597-0367. If you have a disability and need assistance calling us, contact the State Relay Number at 711 or for TTY to voice, call 800-648- 6056.

WIC Tag Line Spanish:

¿Necesita ayuda? Si le es difícil entender o leer el inglés, o si tiene alguna discapacidad, puede recibir ayuda con el idioma u otros apoyos y servicios sin costo alguno para usted, basta con solicitarlos. Por favor contacte a la clínica de WIC en su localidad o a la Oficina Estatal de WIC al 1-877-597-0367. Si tiene alguna discapacidad y necesita ayuda para llamarnos, contacte al Número Estatal de Retransmisión llamando al 711; o, para el servicio de voz a TTY, llame al 1- 866-490-4403.

Contact the State WIC Office for assistance with locating the WIC tagline in additional languages routinely served by your agency or for assistance in alternative formats.

Racial and Ethnicity Data Collection

A. The collection of race and ethnicity data is federally required to determine how effectively United States Department of Agriculture Food and Nutrition Service Programs such as WIC are reaching potentially eligible persons and beneficiaries. B. The WIC Program must report on ethnicity and race to ensure fair and proper administration of the Program. Data is collected for statistical and reporting purposes. C. The WIC Program must maintain race and ethnicity data under safeguards that restrict access only to authorized personnel. D. The WIC Program must maintain race and ethnicity data for three (3) federal fiscal years. E. Applicants must be informed that: 1. Provision of the data is voluntary. 2. Data is kept confidential and may be protected under the Privacy Act. 3. Data is used for statistical purposes only to ensure the Kentucky WIC Program reaches all potentially eligible people. 4. Provision of information has no effect on eligibility for WIC. 5. Applicants may choose one category for ethnicity. 6. Applicants may choose one or more races.

Page 11 Civil Rights Policy 306 December 2024 7. Staff will make a visual observation if the WIC Client chooses not to self-identify.

F. The clerical checklist as well as the Ethnicity and Race Reference card are available to assist staff in complying with the above requirements. See Sample text below:

“Everyone requesting WIC services is asked to identify their ethnicity and race(s). This information is requested solely for the purpose of determining the state’s compliance with Federal civil rights laws and your response will not affect consideration of your application and may be protected by the Privacy Act. By providing this information, you will assist us in assuring that this program is administered in a nondiscriminatory manner. This request is voluntary, if you do not self-identify your ethnicity and/or race, staff will make a visual observation. Please select one ethnicity. Please select all races from the list below that apply to you.”

G. Race and ethnicity data collection consists of a category for race and a category for ethnicity. The definitions of categories for documentation and reporting of race and ethnicity data are as follows:

1. Ethnic categories: a. Not Hispanic or Latino b. Hispanic or Latino (a person of Cuban, Mexican, Puerto Rican, Central or South American, or other Spanish origin or culture, regardless of race)

2. Racial Categories: a. American Indian/Alaska Native (American Indian includes North, Central and South American Indians; Alaskan Native includes Eskimo and Aleut) b. Asian (includes the Far East, Southeast Asia, and the Indian subcontinent including Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, Vietnam) c. Black or African American (associated with the black racial groups of African descent and migration patterns) d. Native Hawaiian or Other Pacific Islander (includes natives of the Hawaiian Islands, Guam, Samoa, and other Pacific Islands including the Caroline Islands, Fiji Islands, French Polynesia, Northern Mariana Islands, Palau Islands, Papua New Guinea, Solomon Islands, and Tokelau Islands) e. White (associated with European, Middle Eastern and North African descent and migration patterns, including the Arabian Peninsula)

Civil Rights Training

A. All WIC staff must receive Civil Rights training every state fiscal year (July 1-June 30). 1. As part of a new WIC staff orientation, new staff must receive the Civil Rights training. New employees must receive training prior to participating in WIC Program activities. 2. This includes all WIC Staff and Volunteers/Students who interact with WIC applicants or participants.

Page 12 Civil Rights Policy 306 December 2024 3. Refer to the Administrative Reference, Training Guidelines, WIC, Training Requirements section. B. WIC Staff must have basic knowledge of the following areas of Civil Rights Compliance: 1. Collection and use of data 2. Effective public notification systems 3. Complaint procedures 4. Compliance review techniques 5. Resolution of noncompliance 6. Requirements for reasonable modification and auxiliary aids and services for persons with disabilities. 7. Requirements for language assistance for persons with LEP 8. Requirements for Civil Rights training 9. Conflict resolution 10. Customer service C. Each local WIC Program is required to maintain a record of staff training, including civil rights training. This record must be available for state WIC staff to review during the WIC Program Management Evaluation Monitoring Visits.

Civil Rights Complaints

A. Civil rights complaints are those complaints that involve alleged discrimination based on race, color, sex, age, national origin, or disability. These are the “protected classes” for WIC. A complaint may also allege reprisal or retaliation for engaging in a protected Civil Rights activity, such as filing a complaint or serving as a witness in an investigation. B. Complainants should file within 180 days form the alleged act of discrimination. Only the Secretary of Agriculture or his/her designee can waive this timeframe with good cause. C. Complaints may be written, verbal or anonymous. D. The local and State Agency must accept all civil rights complaints. The State Agency will forward the complaint to FNS Civil Rights Division, Regional Civil Rights Officer, within the timeframes described within the FNS - KY CHFS Complaints Processing MOU, October 3, 2016. E. State and Local WIC Agencies must maintain a Civil Rights Complaint Log separate from Program Complaints. F. State and Local WIC Agencies must keep complaints confidential and accessible only to authorized personnel. G. If local program staff identify a potential civil rights complaint, they must follow the process below: 1. Local programs must accept and document all complaints involving alleged discrimination or civil rights violations. a. Civil Rights complaints must be kept in separate file from program complaints and must be kept confidential. Do not document in the medical record the intention of the participant to file a civil rights complaint, as that my lead to an additional complaint of retaliation. b. Right to File: Any person or representative alleging discrimination based on a prohibited basis has the right to file a complaint within 180 days of the alleged discriminatory action. Only the Secretary of Agriculture may extend this time under special circumstances. The complainant must be advised of their right to file with the USDA. The complainant must be advised of confidentiality and Privacy Act

Page 13 Civil Rights Policy 306 December 2024 applications. The complainant and the entity that the complaint is filed against will be encouraged to resolve any program access matter at the lowest possible level and as expeditiously as possible. 2. Contact the State WIC Program Management Section Supervisor or the State WIC Director immediately after identifying a complaint of alleged discrimination or a potential civil rights violation. 3. The state WIC office will refer the complaint to the FNS Civil Rights Division, Regional Civil Rights Officer within 5 calendar days from the date of the receipt by the local or State WIC office. 4. All complaints alleging discrimination on the basis of race, color, national origin, age, sex, or disability, either written or verbal, must be processed by FNS within 90 days of receipt. 5. Complaints may be received through a variety of methods including, but not limited to phone calls, fax, e-mails, written statements, or in person. 6. The Fair Hearings Procedures and Civil Rights Complaint Procedures Poster must be posted in clinic in public view. a. Note the fair hearings procedures and timeline differ from Civil Rights Complaints and is not utilized for Civil Rights Complaints. i. See the Administrative Reference, Local Health Operations, Administrative Hearings Section as well as the WIC and Nutrition Manual, Section 200 Appendix for additional information regarding Fair hearing Procedures. ii. The following are eligible for an administrative Fair Hearing: persons denied services, persons whose participation in a service was discontinued, persons who were notified to repay the cash value of improperly received WIC benefits, persons who have not had a grievance resolved to their satisfaction, and public and certain classes of citizens who were adversely affected as a result of the interpretation/enforcement of an environmental law, regulation or ordinance. iii. The WIC Program’s fair hearing policies for applicants, participants and vendors are governed by Kentucky Administrative Regulation 902 KAR 18:040 and 902 KAR 18:081 7. As soon as a suspected civil rights complaint is verbalized: a. Inform the person alleging discrimination of his/her right to file a complaint with CHFS and with the USDA. Inform the complainant that only the Secretary of Agriculture can waive this timeframe for good cause. Refer to the USDA NDS for the most update online link for filing a complaint, email address and mailing address. b. Inform the individual that local staff will document the complaint and immediately forward it to the state WIC office. (In addition to the complaint process described in the section below, the individual or local staff may also choose to send a civil rights complaint directly to the USDA or to the FNS Civil Rights Division, Regional Civil Rights Officer. c. Offer to assist a complainant write a formal complaint, when necessary. If the complainant verbalizes the complaint but does not wish to make allegations in writing, local WIC staff must still ensure the complaint is documented and forwarded to the State WIC Office. d. The complaint does not need to be written or signed if it is submitted in an alternate format to accommodate the complaint filing needs of a person who has an LEP, a disability, or other special need.

Page 14 Civil Rights Policy 306 December 2024 8. Required documentation for Civil Right Complaints. a. Name, address, and telephone number of the person making the complaint. i. Do not include this information, if complainant wants to remain anonymous. b. Name and location of the participant’s local program/ WIC Clinic Site. c. The location where the incident occurred. d. The nature of the incident or action that led the person to feel discrimination was a factor. e. The name(s), title(s), and business address(es) of individual(s) involved in or with knowledge of the discriminatory action, i.e., local health department staff, local WIC staff, vendors. f. The date(s) the alleged discrimination occurred or, if continuing, the most recent date of such action. g. The basis on which the civil rights discrimination has been filed, i.e., race, color, sex, age, national origin, or disability or retaliation or reprisal. Send the documentation immediately to the WIC Program Management Section Supervisor or the Branch Office at the State WIC Office. h. The State WIC Office staff will forward to FNS Civil Rights Division, Regional Civil Rights Officer and the Civil Rights Officer with the Cabinet for Health and Family Services.

H. Complaint Form 1. The USDA Complaint form is available for download. English: https://www.usda.gov/sites/default/files/documents/USDA-OASCR%20P- Complaint-Form-0508-0002-508-11-28-17Fax2Mail.pdfForm

Spanish: https://www.usda.gov/sites/default/files/documents/USDAProgramComplaintForm- Spanish-Section508Compliant.pdf

I. Resolution of Civil Rights Complaints 1. The state WIC office will notify the local WIC Coordinator and Local Health Department/ Agency Administrator if any corrective actions need to be taken to address a civil rights complaint. 2. The local agency must provide necessary documents, evidence, and position statement regarding complainant’s allegations to FNS CRD with the timeframes established by FNS guidance. 3. The local agency must make staff available to FNS CRD to be interviewed as necessary during investigations, including for the purpose of providing sworn testimony and clarifying general information. 4. The local agency must maintain a copy of any correspondence regarding the complaint for at least four years after the date notified the complaint is closed. 5. The local agency must grant FNS CRD access to local agency facilities, and complaint, communications, records, and other systems, as necessary during investigations. 6. The local agency must participate in attempts to resolve the complaint.

Page 15 Civil Rights Policy 306 December 2024

Civil Rights Compliance Reviews

Civil Rights Compliance Reviews examine the activities of the State Agencies and Local Agencies to determine civil rights compliance.

A. United States Department of Agriculture (USDA) Food and Nutrition Service Civil Rights and Program staff review the State Agency. B. State Agencies review local agencies during the routine Management Evaluation (ME) Visits. Civil Rights Compliance Reviews will include review of required civil rights training, meaningful access for persons with limited English proficiency, equal access for persons with disabilities, and more. The ME tool is provided to the local agency prior to the evaluation and contains all Civil Rights review areas to review. Refer to Administrative Reference, Program Descriptions, WIC. Significant findings regarding civil rights must be provide in writing to both the local agency and to Regional FNS Civil Rights Officer for resolution. A significant finding is an egregious and repetitive finding or a policy or procedure that has a disproportionate, adverse effect on a particular protected class (disparate impact). C. Local and state agency staff with work together along with USDA as appropriate, to promptly resolve non-compliance issues through a corrective action plan.

Resolution of Noncompliance

A. Noncompliance is a factual finding that any Civil Rights requirement, as provided by law, regulation, policy, instruction, or guidelines, is not being adhered to by local agency or other subrecipient. B. Once noncompliance is determined, steps must be taken immediately to obtain voluntary compliance in accordance with FNS Instruction 113-1. 1. The effective date of the finding of noncompliance is the date of the written notice of noncompliance to the local agency or other subrecipient. 2. After a finding of noncompliance, the State agency will: a. Provide immediate written notice to the local agency or other subrecipient Local Agencies, will request to voluntarily resolve noncompliance findings by submitting a Corrective Action Plan and implemented the State Agency approved corrective action plan. b. Negotiate with local agency or other subrecipient to achieve compliance. c. Submit to the Regional Civil Rights Officer a Report of Findings of Noncompliance in letter format on all cases where corrective action has not been completed within 60 days of the finding. d. Submit documentation per the FNS Instruction 113-1. C. The FNS Regional Office of Civil Rights must determine next steps of action per FNS Instruction 113-1.

Page 16 Civil Rights Policy 306 December 2024 Limited English Proficiency (LEP)

A. It is the policy of the WIC Program to provide timely, meaningful access to WIC Program services and activities for individuals with Limited English Proficiency (LEP). 1. Coordinate with the Nutrition Services Branch, Program Management Section Supervisor and with the Cabinet for Health and Family Services Equal Employment Opportunity (EEO) and Civil Rights Branch Manager for technical assistance, if needed, in providing meaningful access to individuals with LEP. 2. Limited English Proficiency (LEP) refers to individuals who do not speak English as their primary language and who have a limited ability to read, speak, write, or understand English because of their national origin. 3. Title VI and its implementing regulations prohibit discrimination on the basis of race, color, and national origin. a. National Origin refers to a person’s ancestry, place of origin; or the physical, cultural, or linguistic characteristics of a national origin group. 4. WIC Agencies must therefore take reasonable steps to ensure meaningful access to the WIC Program and activities for individuals with limited English proficiency (LEP). a. Meaningful Access is providing reasonable, timely, appropriate, and competent language services at no cost to individuals with LEP. b. Failure to provide Meaningful Access to persons with LEP could be discrimination on the basis of national origin. 5. Local WIC Agencies should take the following steps to ensure qualified interpreters are available to meet the oral communication needs of persons with LEP and to identify necessary materials for translation into other languages. Contact the State WIC office for technical assistance on how to conduct this self-assessment, secure qualified interpreters, and determine the availability of materials on languages other than English and Spanish. a. The number or proportion of LEP persons eligible to be served or likely to be encountered within the area serviced by the recipient. b. The frequency with which LEP persons come in contact with the program or activity. c. The nature and importance of the program, activity, or service to people’s lives. d. The resources available to the recipient and costs. 6. The following sources are reliable population data sources that may be utilized in the four (4) steps outlined above to determine necessary and reasonable translation of materials. a. Department of Justice site: LEP.GOV http://www.lep.gov/maps/ b. US Census Data http://www.census.gov/2010census/data/ c. American Community Survey http://www.census.gov/acs/ d. Migration Policy Institute’s National Center on Immigrant Integration Policy http://www.migrationpolicy.org/ 7. Language Services a. WIC agencies must notify persons with LEP about the availability of free language assistance services and how to request the services in languages they can understand. The WIC tagline should be used on posters, documents, websites, and digital services. Information on free languages services should be available via: i. Reception areas, ii. Websites and digital services iii. Telephone voice mail menus

Page 17 Civil Rights Policy 306 December 2024 iv. WIC Staff offering the service b. Applicants and participants cannot be asked to bring their own interpreters. c. Use qualified, competent language assistance services. i. Children should not be used as interpreters. ii. Do not plan to rely on a LEP person’s family members, friends, or informal interpreters. iii. Do not ask LEP persons to bring their own interpreters. iv. Use of a family or friend should be discouraged, as family and friends are not trained and qualified interpreters and issues of confidentiality, privacy or conflict of interest may arise. Those LEP individuals who are accompanied by bi-lingual family or friends must be offered free language assistance. If the free language assistance is declined due to a request to use a family or friend, this must be documented in the medical record. d. Acceptable Language Services include: i. Qualified Bilingual staff ii. Telephone interpreter lines iii. Qualified contract interpreters iv. Qualified Translators e. All WIC Staff must offer and provide qualified, competent language assistance services free to individuals with LEP. i. Competency requires more than self-identification as bilingual. ii. A qualified interpreter is a highly trained individual who mediates spoken communication between people speaking different languages without adding, omitting, or distorting meaning or editorializing. iii. Qualified, competent translators must be used when translating WIC Program Materials. a) A qualified, competent translator is a highly trained individual who is able to render text from a source language into a target language while preserving meaning and adhering to generally accepted translator ethics and principles, including confidentiality. b) Qualified translators understand the cultural context of the source and target languages as well as demonstrate competency to translate through an independent language assessment. c) A qualified interpreter may or may not be a qualified translator. f. Contact the State WIC office for translations of WIC Program materials vital to an individual’s participation including forms related to applying for the program, documents that require a response, denial letters or notice of ineligibility. g. Local and state agency developed materials should routinely be simultaneously translated as the updated English materials are updated in the LEP languages identified. h. Record language spoken in the CMS Portal system for tracking and reporting purposes. i. Offers and requests for free communication services must be documented in the medical records. j. The type of service provided must be documented in the medical record. k. Document language spoken, language assistance service offered, type of language assistance provided or declined in the medical record at each visit. i. This may include working with interpreters, using a language line, and providing printed materials in appropriate languages. ii. At a minimum, all WIC Program should have access to a language line for communication with individuals who are LEP.

Page 18 Civil Rights Policy 306 December 2024 iii. Denials of free language service must be documented in the medical record. i. See the Administrative Reference, Local Health Operations Section, Communicating with the Public.

Disability Access to WIC Program

A. Notification for Individuals with Disabilities 1. Local WIC Agencies must notify individuals with disabilities about the availability of auxiliary aids and services and other reasonable modifications and to provide free accommodations upon request or as needed to ensure equal participation and equally effective communication. 2. The WIC tagline is available to assist in this notification. The WIC tagline should be used on posters, documents, websites, and digital services. Information on reasonable modifications and auxiliary aids and services should be available via: a. Reception areas, b. Websites/online services c. WIC Staff offering the service 3. Local WIC Agencies must notify individuals with disabilities about protections against discrimination and how to file a complaint. See the Nondiscrimination Statement Section and Civil Rights Complaints section above.

B. Equally Effective Communication 1. Local WIC Agencies must ensure that communication with individuals with disabilities is as equally effective as communication with people without disabilities. Including communication with applicants, participants and their parent, caretaker, spouse, or companions in appropriate circumstances who have hearing, vision, and speech disabilities. a. Companion includes any family member, friend, or associate of a person seeking or receiving WIC services who is an appropriate person with whom the WIC program should communicate. 2. Primary consideration of the choice of aid or service requested for effective communication by the person with a disability must be provided. 3. It is the WIC program’s responsibility to ensure equally effective communication when providing program information to individuals who require materials in an alternate format. a. When requested, provide program information in alternate formats (i.e. large print, Braille, electronic format, or audio). 4. Documentation of auxiliary aid or service for effective communication a. The auxiliary aid or service for effective communication requested and provided is to be documented in the medical record. b. If the requested aid or service was not provided, this must be documented in the medical record and elevated to the most senior staff member for justification for not providing the requested service. The alternative aid or service provided is to be documented in the medical record. 5. The State and Local WIC Agency must honor the person choice, unless it can demonstrate that another equally effective means of communication is available or that the use of the means chosen would result in a fundamental alteration in service or an undue burden to the agency.

Page 19 Civil Rights Policy 306 December 2024 a. The decision that an aid or service would result in an undue burden can only be made by the head of the agency or his/her designee and must include a written statement of the reasons for reaching that conclusion. b. If the choice expressed by the person with a disability would result in an undue burden or a fundamental alteration, staff still have an obligation to provide an alternative aid or service that provides effective communication, if one is available. c. The goal is to provide an aid or service that will be effective, given the nature of what is being communicated and the person’s method of communicating.

C. Use of auxiliary aids and services for equally effective communication 1. Use qualified interpreters. a. A qualified interpreter is able to interpret effectively, accurately, and impartially, both receptively and expressively, using any necessary specialized vocabulary. b. Qualified interpreters include, for example, video remote interpreting, sign language interpreters, oral transliterators, and cued-language transliterators. 2. Do not require an individual with a disability to bring someone with them to interpret. State and Local WIC agencies can rely on a companion to interpret in only two situations. a. In an emergency involving an imminent threat to the safety or welfare of an individual or the public, an adult or minor child accompanying a person who uses sign language may be relied upon to interpret or facilitate communication only when a qualified interpreter is not available. b. In situations not involving an imminent threat, an adult accompanying someone who uses sign language may be relied upon to interpret or facilitate communication when a) the individual requests this, b) the accompanying adult agrees, and c) reliance on the ac- companying adult is appropriate under the circumstances. This exception does not apply to minor children. c. Even under exception (b), WIC staff may not rely on an accompanying adult to interpret when there is reason to doubt the person’s impartiality or effectiveness. For example: It would be inappropriate to rely on a companion to interpret who feels conflicted about communicating bad news to the person or has a personal stake in the outcome of a situation. It would be inappropriate to rely on a companion to interpret in situations involving actual or alleged domestic violence. 3. Children should not be used as interpreters. 4. Use of a companion, family, or friend should be discouraged, as family and friends are not trained and qualified interpreters, and issues of confidentiality, privacy, or conflict of interest may arise. Those individuals who are accompanied by an adult companion must still be offered interpreter services or auxiliary aids. If the aid or service is declined due to a request to use an adult companion, this must be documented in the medical record. a. Refer to the Administrative Reference, Local Health Personnel, (Persons with Limited English Proficiency) section and Local Health Operations, Standard Procedures for Interpretive Services Section. b. Accessible electronic and information technology c. Qualified interpreters on-site or through video remote (VRI) interpreting services. Video Remote Interpreting VRI technologies should meet ADA performance standards. See above regarding the use of qualified interpreters. d. Voice, text, and video-based telecommunications products and systems e. Braille or tactile displays f. Screen reader software

Page 20 Civil Rights Policy 306 December 2024 5. Take into consideration the nature, length, and complexity of the communication, as well as the person’s normal method(s) of communication when choosing an auxiliary aid or service. 6. To ensure equally effective communication it is recommended to require advance notice from people requesting aids or services, based on the length of time needed to acquire the aid or service, while staying in compliance with WIC Scheduling requirements. a. See the Administrative Reference, Local Health Personnel, Compliance with Americans with Disabilities Act (ADA) section and LHD Facilities and Equipment, Facility Structural Requirements section. b. See WIC and Nutrition Manual, Section 202 regarding Processing Standards for WIC appointments. 7. Honor “walk-in” requests for aids and services to the extent possible. 8. Accept telephone calls placed through the Telecommunications Relay System (TRS) and treat the call just like any other call. a. More information on the Kentucky Relay System can be found at: Kentucky Relay: Overview (hamiltonrelay.com) b. To make Relay call to an applicant or participant who utilizes TRS, call 1-888-244-6111.

D. Reasonable Modification 1. Local WIC Programs must provide reasonable modification when necessary to ensure that the WIC Program is equally accessible to all potentially eligible individual and to WIC participants 2. Reasonable modifications may be made to practices and procedures when the modifications are necessary to avoid discrimination on the basis of disability. A reasonable modification is a change or exception to a policy, practice, or procedure that allows people with disabilities to have equal access to programs, services, and activities. A reasonable modification can also be a structural change made to existing premises, occupied or to be occupied by a person with a disability, to afford such person full enjoyment of the premises. 3. The modification should be provided unless the agency can demonstrate that making the modification would fundamentally alter the nature of the service, program, or activity per 28 CFR 35.130(b)(7)(i). 4. The agency is not required to take action if it would result in undue financial and administrative burden. a. Reasonable modification is the removal of barriers to allow individuals to participate equally in WIC. In some cases, what is considered “reasonable modification” may be different from what an individual requests. b. All resources of the agency and program in funding the operation of the service, program or activity must be considered. c. A decision that compliance would result in such alteration, or burdens must be made by head of agency, or his or her designee. 5. The decision must be accompanied by a written statement of the reasons for reaching that conclusion. 6. The agency is still required to provide service to the maximum extent possible. a. Contact the agency’s Civil Rights Coordinator or the Kentucky Cabinet for Health and Family Services Civil Rights Coordinator for technical assistance if needed in providing a reasonable modification. 7. Examples of reasonable modifications include but are not limited to:

Page 21 Civil Rights Policy 306 December 2024 a. Provide wheelchair access to WIC Clinic locations. This provides equal access to individuals using wheelchairs. b. Ensure access to individuals who require the assistance of a service animal. c. Modify the WIC food package to accommodate an individual with a disability.

E. Documentation of the reasonable modification or auxiliary aid or service 1. The reasonable modification and/or auxiliary aid or service for requested and provided must be documented in the medical record. 2. If the requested modification, aid, or service was not provided, this must be documented in the medical record and elevated to the most senior staff member for justification for not providing the requested service. The alternative modification, aid or service provided also must be documented in the medical record.

F. Accessibility of Facilities 1. Refer to the Administrative Reference, Facilities and Equipment Section. 2. As programs and offices modernize, facilities and websites should be readily

G. Wheelchair Access, Mobility Aids, and Other Power-Driven Mobility Devices (OPDMD) 1. Staff must permit individuals with mobility disabilities to use wheelchairs and mobility aids in any area open to pedestrian use. 2. A wheelchair is a manually operated or power-driven device designed primarily for use by an individual with a mobility disability for the main purpose of indoor, or of both indoor and outdoor locomotion. 3. Staff must also allow individuals with mobility disabilities to use manually powered mobility aids (includes include walkers, crutches, canes, braces, or other similar devices) in areas open to pedestrian use. 4. Local WIC Agencies must make reasonable modifications to permit individuals with mobility disabilities to use OPDMDs, unless the entity can demonstrate that the class of OPDMD cannot be operated in accordance with legitimate safety requirements adopted by the facility. a. OPDMD means any mobility device powered by batteries, fuel, or other engines, whether designed primarily for use by individuals with mobility disabilities that is used by individuals with mobility disabilities for the purpose of locomotion. b. Staff may not ask an individual using a wheelchair, mobility aid, or OPDMD questions about the nature and extent of the individual’s disability. c. Accessible to, and useable by persons with visual impairments and other disabilities.

H. Service Animals 1. Service Animal means any dog that is individually trained to do work or perform tasks for the benefit of an individual with a disability, including a physical, sensory, psychiatric, intellectual, or other mental disability. a. Other species of animals, whether wild or domestic, trained, or untrained, are not service animals for the purpose of this definition. b. Comfort or emotional support animals are not covered by Section 504 or Title II of the ADAAA. i. Staff may only make two (2) inquiries of the individual with the service animal: 1) “Is the animal required because of a disability?”

Page 22 Civil Rights Policy 306 December 2024 2) “What work or task the animal has been trained to perform?” ii. Staff may not require written documentation or certification of the need for the animal. iii. Staff must allow access for service animals unless: c. The animal is out of control and the handler does not take effective action to control it. d. The animal is not housebroken. e. Where there is a legitimate basis to exclude the animal, the individual with the disability should be given the opportunity to participate in the program without the animal.

I. Miniature Horses 1. Miniature horses are not Service Animals; however, a miniature horse is a reasonable modification when the miniature horse has been individually trained to do work or perform tasks 2. Staff should permit access to individuals with disabilities who are accompanied by a miniature horse 3. Staff may consider the following factors regarding access for miniature horses a. The type, size, and weight of the horse and whether the facility can accommodate those features b. Handler has sufficient control of the horse c. Horse must be housebroken d. Whether the horse’s presence in a specific facility compromises legitimate safety requirements

J. Safety & Direct Threat 1. A local WIC agency may impose legitimate safety requirements necessary for the safe operation of its services programs or activities. 2. The local WIC agency must ensure that its safety requirements are based on actual risks, not speculation, stereotypes, or generalizations about individuals with disabilities. See 28 C.F.R.§ 35.130(h). 3. Direct Threat means a significant risk to the health or safety of others that cannot be eliminated by a modification of policies, practices, or procedures, or by the provision of auxiliary aids or services as provided in 28 C.F.R. § 35.139. a. A local WIC agency is not required to permit an individual to participate in or benefit from the services, programs, or activities of that agency when that individual poses a direct threat to the health or safety of others. Note: Direct threat to others, not self. b. Requires individualized assessment based on reasonable judgment that relies on current medical knowledge or on the best available objective evidence to ascertain: 1) the nature, duration, and severity of the risk, 2) the probability that the potential injury will occur, 3) and whether reasonable modifications of policies, practices, or procedures or the provision of auxiliary aids or services will mitigate the risk. 28 C.F.R. § 35.139(b).

WIC and Nutrition Manual 400 Policy Group Nutrition Education and Counseling

Table of Contents

Policy 400 Nutrition Education and Counseling Policy 401 Value Enhanced Nutrition Assessment (VENA) Policy 402 Certification and Mid-Certification Nutrition Education Counseling Guidelines Policy 403 Referrals Policy 404 WIC Low-Risk Secondary Nutrition Education Guidelines Policy 405 WIC High-Risk Secondary Nutrition Education Guidelines Policy 406 Nutrition Services & Regional Breastfeeding Coordinator Program Plans Policy 407 Medical Nutrition Therapy Policy 400 Appendices Nutrition Education

Policy 400 December 2024

POLICY Policy 400 Nutrition Education and Counseling All local WIC agencies shall offer nutrition education, counseling to all WIC participants, parents, and caregivers according to federal regulations, state guidelines and program goals. PURPOSE To ensure that WIC participants receive nutrition education and counseling that considers their individualized needs, strengths and developmental needs

PROCEDURES All WIC clinics shall provide nutrition education and counseling to all WIC participants using a state approved method. A. All nutrition education contacts shall include a two-way communication between staff and participants. B. Nutrition education must be made available to participants including participants who do not receive food packages such as fully breastfeeding infants < 6 months old and partially breastfeeding women whose infants are > 6 months old and receiving a full formula package. C. Any nutrition education and counseling provided to participants shall include accurate, up-to-date and evidence based information. WIC staff must use a participant centered approach and are encouraged to share personalized nutrition information to meet the individual’s health care needs. D. Each WIC agency must designate a WIC Nutrition Education Coordinator. A. The WIC Nutrition Education Coordinator must be a nutritionist or nurse. B. The WIC Nutrition Education Coordinator must obtain 4 hours of continuing education in nutrition/nutrition counseling annually. C. Refer to the Administrative Reference, Training Guidelines and Program Descriptions, WIC Program.

Page 1 Nutrition Education and Counseling

Page 1 Value Enhanced Nutrition Assessment (VENA) Policy 401 December 2024

Policy 401 Value Enhanced Nutrition Education Assessment (VENA) POLICY All local WIC agencies shall have Certifying Health Professionals to provide participant-centered nutrition assessment and counseling. Value Enhanced Nutrition Education (VENA) begins with the nutrition assessment. Beyond determining WIC eligibility, nutrition assessment, breastfeeding promotion, and support, tailoring WIC food packages and referrals are utilized to enhance the interaction between the Certifying Health Professional and WIC participant, link the collected health and diet information to the delivery of participant-centered relevant nutrition education, referrals, and food package tailoring. PURPOSE To provide client-centered nutrition education counseling and assessment. Nutrition assessment and participant-centered nutrition education and counseling include open-ended questions to determine what concerns or questions the participant has in regard to her nutrition, child’s nutrition, and/or infant’s nutrition. Individualized nutrition education counseling is then provided to address the identified questions, concerns, and goals.

RELEVANT REGULATIONS USDA, FNS, Value Enhanced Nutrition Assessment (VENA) - WIC Nutrition Assessment Policy, WIC Policy Memorandum 2006-5; March 2006. USDA, FNS, VENA Value Enhanced Nutrition Assessment in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Updated Guidance, 2020.

PROCEDURES VENA Principles A. Characteristics of the Participant-Centered approach include: 1. Collaboration- The VENA approach involves a partnership between the certifying health professional and the participant. Participant engagement and interactions are essential for effective nutrition assessment. 2. Optimism- The VENA approach recognizes that participants have hopes and desires for themselves and their families for nutrition and health. 3. Nonjudgmental environment- Participants are more likely to talk openly and honestly about their behaviors, motivations, and challenges in an accepting and nonjudgmental environment. 4. Empowerment- The VENA approach can build a participant's confidence in their own abilities. Health Professionals should affirm strengths and positive practices in order to ensure participants continue them and build additional healthy habits. B. Nutrition assessment and education shall follow the VENA model and embrace the following principles to ensure effectiveness and quality: 1. Interactive a. Nutrition education shall involve families in self-assessment and self-directed goal setting and help families move toward their desired level of wellness. b. Develop a rapport by employing active listening skills, asking open-ended questions, and identifying the participant’s stage of change. 2. Flexible a. Use multiple strategies and techniques to reach and impact participants and their families effectively. 3. Relevant a. Impart appropriate and relevant education that is reflective of the interests of the participants and/or family. b. Education offered to participants shall be in a positive and interactive manner through developmentally and culturally appropriate teaching aids.

Page 2 Value Enhanced Nutrition Assessment (VENA) Policy 401 December 2024

4. Supportive Environment a. Nutrition education shall be offered in a family-friendly environment for optimal learning. Personnel shall support the family’s needs and build a rapport with families to promote good health. 5. Trained Personnel a. Education shall be facilitated or taught by qualified, well-trained, and equipped personnel. These trainings will provide staff with the critical thinking skills, knowledge, and counseling skills to complete the nutrition and breastfeeding assessment and provide a participant-centered plan of care. b. In addition, the required training will ensure Certifying Health Professionals have the following competencies to provide WIC services: i. Understanding the Principles of Life Cycle Nutrition: Understanding normal nutritional needs during pregnancy, lactation, the postpartum period, infancy, and early childhood. ii. VENA: Understanding the steps in the VENA approach to nutrition assessment, including all the requirements related to bloodwork, anthropometric measurements, documentation, follow-up visits, etc. iii. Data Collection Techniques: Understanding the importance of precise and valid data, as well as how to collect anthropometric and hematological data accurately. iv. Communication: Knowing how to communicate effectively with participants and foster open exchanges. v. Multicultural Awareness: Understanding how sociocultural issues (race, ethnicity, religion, group affiliation, socioeconomic status, and worldview) affect nutrition and health practices and nutrition-related health problems. vi. Critical Thinking: Knowing how to analyze and synthesize information to draw appropriate conclusions. c. WIC Certifying Health Professionals must complete training as outlined in the Administrative Reference, Program Descriptions and Training Guidelines Section prior to providing WIC services. d. Required Training available through www.Train.org/ky/ include: i. WIC DPH Certifying Health Professional Training, 1109677 ii. WIC DPH Plan of Care and Goal Setting (VENA), 1109674 iii. WIC DPH Health Professional Infant Formula and WIC Nutritional Training, 1110870 iv. WIC DPH Secondary Nutrition Education for Health Professionals, 1109708 v. WIC DPH Mid-Certification Health Assessment (MCHA), 1109707 vi. WIC DPH Breast Pump Issuance and Tracking Guidelines, 1109711 vii. WIC USDA Breastfeeding Curriculum Level 1,1103549 viii. WIC USDA Breastfeeding Curriculum Level 2, 1110936 ix. WIC USDA Breastfeeding Curriculum Level 3, 1119763 e. Additional Training Coming soon: WIC USDA Breastfeeding Curriculum and 4; WIC Food Package Assignment, Tailoring, and Counseling; Completing the Annual Conducting and Documenting a Nutrition and Breastfeeding Assessment; Screening and Referrals for Lead and Immunization; Principles of Life Cycle Nutrition, and WIC Required Notifications. f. Training is available in person or via Teams upon request. g. WIC Coordinator, WIC Nutrition Education Coordinator and WIC Breastfeeding Coordinator trainings is available upon request. 6. Culturally Supportive a. Nutrition education shall acknowledge and support differences in cultures and languages and be sensitive to cultural food choices when possible.

Page 3 Value Enhanced Nutrition Assessment (VENA) Policy 401 December 2024

Complete the WIC Nutrition Assessment A. Certifying Health Professionals will use a standardized process to collect nutrition information for all participants. B. A comprehensive nutrition assessment is required to identify nutrition risks, assign an appropriate food package, and guide WIC participant-centered nutrition services after the assessment is complete. 1. Beyond determining WIC eligibility, nutrition assessment, breastfeeding promotion, and support, tailoring WIC food packages and referrals are utilized to enhance the interaction between the Certifying Health Professional and WIC participant, link the collected health and diet information to the delivery of participant-centered relevant nutrition education, referrals, and food package tailoring. 2. Collect all relevant information and required information (e.g., anthropometric, biochemical, and clinical data; dietary assessment, environmental, cultural, and family information; nutrition practices; breastfeeding beliefs and practices; and health information) for each participant category. See Policies 215 Certification Risk Assessment, 216 Anthropometric Screening, 217 Hemoglobin and Hematocrit Screening in WIC, 218 Risk Criteria Codes and Descriptions, and 221 ARPA Waiver Remote Services. C. The following components must be used in completing a nutrition assessment: 1. Observe the participant and review the participant’s medical record. 2. Reduce participant anxiety by clarifying the other services WIC provides as well as the purpose of the assessment. 3. Create a power-sharing dynamic by telling participants in advance what will be taking place, showing respect, and setting up a framework for honest and open communication. 4. Be open about the intent of the assessment will help build interest and encourage participation in both the assessment and nutrition counseling to increase participant buy- in. 5. Ask pertinent questions to clarify, probe for additional information, or follow up on information the participant or parent/caretaker has written or verbalized. 6. Listen to and affirm the participant/parent/caretaker. 7. Use critical thinking to determine nutritional risk, assignment and tailoring of food package, understanding of health and readiness for change, etc. 8. Document services provided in the participant’s medical record.

Plan of Care A. Certifying Health Professionals must develop a plan of care for all participants. 1. The plan of care must include: a. Individualized goals are clearly stated and documented. i. Goals shall be related to the participant’s nutritional risk, reasonable, and measurable with a timeframe for completion. b. Documentation of progress toward that goal at follow-up visits c. Appropriate referrals with follow-up documentation. 2. Certifying Health Professionals shall assist the participants in setting goals.

Counseling Methods A. Motivational Interviewing 1. Designed to explore and enhance an individual's internal motivation to change by resolving ambivalence, eliciting the importance of change, and increasing confidence to make change. B. Appreciative Inquiry

Page 4 Value Enhanced Nutrition Assessment (VENA) Policy 401 December 2024

1. Focus on building confidence by drawing out positive feelings related to what went well in the past, what is going well in the present or what the family would like to have happen in the future. C. Emotional-Based Counseling 1. Taps into how an individual feels about a given topic. Recognizes that while information and facts are important, emotions are more frequently the driver behind change. D. Three-Step Counseling 1. Designed to promote positive practices by asking open-ended questions to reveal barriers and concerns, affirming and normalizing feelings, and sharing targeted information. 2. Certifying Health Professionals shall use three-step counseling to provide nutrition and assessment and participant-centered nutrition education. 3. Step 1 – Ask open-ended questions a. Begin the question with “what”, “how”, or “tell me”. b. Open-ended questions shall build rapport. c. Ask “probing” follow-up questions to help get a bigger picture of what the mother means. i. Extending Probe-ask for more information ii. Clarifying Probe-helps to understand what the participant has told you iii. Reflecting Probe-repeats the participant’s words back to them iv. Redirecting Probe-helps change the subject and steer the conversation in a different direction. 4. Step 2 – Affirm a. Affirmation is a short, simple statement that lets the participant know their feelings are okay. b. Affirmations acknowledge the feeling behind what the participant is telling you. c. There are five ways to affirm the participant: i. Agree with the participant. ii. Assure them they are not alone. iii. Read between the lines to discover what they are worried about. iv. Shine the spotlight on what they are doing well. v. Show they are a good parent/caretaker. 5. Step 3 – Educate a. Education shall be done only after asking open-ended questions and providing affirmation. b. Education shall be: i. Kept simple ii. Target their concerns iii. Reinforce the message iv. Provide options. v. Share resources.

Stages of Change A. Certifying Health Professionals shall determine the participant/parent/caretaker stage of change. 1. Precontemplation-do not intend to start healthy behavior within the next six months. 2. Contemplation -intended to start healthy behavior within the next six months. 3. Preparation-intend to start healthy behavior within the next 30 days 4. Action-currently performing healthy behavior for less than six months. 5. Maintenance-currently performing healthy behavior for more than six months. Setting Goals A. Certifying Health Professionals shall assist participants in setting goals to facilitate change. 1. Participants are the best judge of what will work for their family. 2. Goal setting needs to be participant-driven. The Certifying Health Professionals is to help participants succeed at their goals.

Page 5 Value Enhanced Nutrition Assessment (VENA) Policy 401 December 2024

3. Work with participants to set realistic, measurable goals. Suggesting small, reachable goals – taking baby steps – is a way to help your participants change behaviors and feel successful with those goals. 4. Meet a participant or parent/caretaker where they are. Any movement toward change has the potential to provide this participant with a better health outcome. Certifying Health Professionals are to help the participant/caretaker where they are in the change process. 5. Discuss and problem-solve participant or parent/caretaker’s concerns and barriers to achieving the goal(s).

Page 1 Certification and Mid-Certification Nutrition Education Counseling Guidelines Policy 402 December 2024

Policy 402 Certification and Mid-Certification Nutrition Education Counseling Guidelines POLICY All local WIC agencies shall have Certifying Health Professionals provide nutrition education to WIC participants during certification and mid-certification visits.

PURPOSE To ensure that WIC participants receive quality nutrition-focused counseling during certification and mid- certification visits that are participant-focused.

RELEVANT REGULATIONS 7 CFR 246.11(e)(5) – Participant Contacts 7 CFR 246.2 – Definitions 7 CFR 246.11 – Nutrition Education (a)General,(b) Goals, (c)(4) – Procedures to ensure that nutrition education is offered,(d) Local program responsibilities,(e) Participant contacts,(e)(4) – Documentation of nutrition education provided, and (e)(5) – Provision of individual care plan based on need 7 CFR 246.12 (d) – Compatibility of food delivery system,(r)(1) – Parents/caretakers and proxies 7 CFR 246.14 – Program Costs

PROCEDURES WIC Certification/Mid-Certification Nutrition Education A. WIC certification/mid-certification counseling must be offered to each participant/parent/caregiver at the time of their certification/mid-certification visit. Individual nutrition education is then provided at the WIC certification/mid-certification counseling. B. At the certification/mid-certification visit, after conducting a nutrition and health assessment, which will assess for nutrition risk criteria, provide nutrition education as follows: 1. Nutrition education counseling must include: a. WIC certification/mid-certification education counseling topics as outlined in the WIC Certification/Mid-Certification Education Topics Appendix of this section. 2. If counseling has been provided and documented through another service (i.e., Well Child, Prenatal), it does not have to be repeated for WIC if the content of the WIC certification/mid-certification nutrition education counseling protocols has been met. 3. The following nutrition education must be provided to every participant during the certification/mid-certification health assessment. a. Additional counseling must be provided based on the participant's risk code assignment. i. See WIC Certification/Mid-Certification Health Assessment Nutrition Education Counseling Protocol Appendix in this section. ii. See Policy 401 Value Enhanced Nutrition Education.

Page 2 Certification and Mid-Certification Nutrition Education Counseling Guidelines Policy 402 December 2024

WIC Certification/Mid-Certification Health Assessment Nutrition Education Counseling Protocol (In addition to this counseling, all WIC participants must be provided counseling on Specific Nutritional Risks) Provider: Certifying Health Professional Topic When Required WIC General Nutrition Counseling and Screening Protocol by Status Discuss WIC Program eligibility and benefits. Certification (Support staff may explain the process at registration) • Explain the purpose of the WIC Program (The Program provides nutritional support through supplemental foods, nutrition education, breastfeeding support, and referrals) • At initial certification, explain the certification process, including income eligibility assessment, nutrition assessment to provide individualized nutrition education and a tailored food package, the eligibility periods, and recertification schedule. • Discuss the importance and benefits of participating in the WIC Program and encourage ongoing participation and recertifications. The Program provides individualized and group nutrition education, breastfeeding support, referrals, and healthy foods. It helps to provide nutrition during critical growth and development periods for pregnancy, early postpartum, infancy, and early childhood. Counsel on basic diet and the importance of regular physical activity. Certification and MCHA Determine what concerns or questions the participant has in regard to her nutrition, child’s nutrition, and/or infant’s nutrition. Provide counseling to address questions/ concerns/dietary habits. Women and Children: • Review Choose My Plate Dietary Guideline Tip Sheet (s) • Review dietary concern(s) and appropriate action. • Encourage an average of 30 minutes for women and 60 minutes for children of physical activity each day. • Limit screen time to no more than 2 hours/day. • Remove the television from the child’s bedroom. • Encourage healthy foods (e.g., low-fat and reduced-fat food choices including 1% or less milk, (women/children > 2), 5 Fruits and Vegetables per day & Avoid Sugar- Sweetened Drinks) Infants: • Discuss the Kentucky Infant Feeding Guide appropriate for age and development. • Encourage caregiver(s) to promote physical activity and motor skill development in their infant (rolling over, standing, movement, play). • Review dietary concern(s) and appropriate action. Encourage to breastfeed unless contraindicated for health/lifestyle reasons. Certification and MCHA Pregnant women: • Discuss the advantages of breastfeeding. • Discuss the benefits of Kangaroo Care. • Encourage to breastfeed unless contraindicated. • Offer the opportunity to speak with a Breastfeeding Peer Counselor, where available. Breastfeeding women: • Encourage continuation and support of breastfeeding unless contraindicated. • Discuss the benefits of Kangaroo Care. • Offer the opportunity to speak with a Breastfeeding Peer Counselor, where available. Refer to Policy 501 Breastfeeding Promotion and Support Standards.

Page 3 Certification and Mid-Certification Nutrition Education Counseling Guidelines Policy 402 December 2024

Lead Screening Certification • Explain the impact of elevated blood lead levels on growth and development and the importance of a blood lead level screening. • Provide a referral to primary care provider or local Lead Program in the following situations: o The infant/child has never received a lead test. o The child had an elevated BLL 12 months prior and has had no interim follow-up screening. o The infant/child is suspected by a parent or a health care provider to be at risk for lead exposure. o The infant/child has a sibling or frequent playmate with an elevated BLL. o The participant is a recent immigrant, refugee, or foreign adoptee. o The breastfeeding or lactating woman, parent, or child’s principal caregiver works professionally or recreationally with lead. o The family has a household member who uses traditional, folk, or ethnic remedies and cosmetics or who routinely eats unregulated/uninspected food imported from abroad. The family has been identified at increased risk for lead exposure by the health department because the family has local risk factors for lead exposure. Immunization Screening Certification • Advise the parents or caregivers that immunization records are requested as part of the WIC health screening process. • WIC staff are required to screen all WIC participants aged 3 to four years of age at each certification visit and refer those who are under-immunized. • Immunization status/providing immunization records will not impact the availability of WIC services. • Refer under-immunized to their healthcare provider for immunizations. Document the referral. • Refer to Policy 215 Certification Risk Assessment. Discuss the effects of drug and other harmful substance use (tobacco, alcohol, drugs). Certification and MCHA • Discuss how tobacco and/or alcohol can affect the woman, fetus, infant, and child. This should include information about smoking cessation if appropriate, and the effects of secondhand smoke. • Discuss recommendations not to use tobacco products. Refer to 1-800-QUIT NOW (1- 800-784-8669) if the client smokes. • Discuss recommendations not to take any medications, over the counter or otherwise, unless specifically ordered by a physician. • Discuss recommendations not to use drugs (marijuana, cocaine, etc.). • Discuss recommendations not to drink alcohol. • Refer as appropriate for substance abuse. Discuss Safe Sleep Environment for Infants Certification and MCHA Infants: • Discuss American Academy of Pediatrics (AAP) Safe Sleep Policy. • Refer to Policy 404. Collection of Anthropometric and Hematological Data Certification, if available at MCHA • Notify applicants of the collection of height, weight, and hematological data to determine eligibility. • For remote certifications, if data is unavailable at the time of certification, notify participants of the need to have height and weight data within 60 days of certification. Refer to Policy 216 Anthropometric Screening, Policy 217 Hematological Screening, and Policy 221 ARPA Waver Remote Services. For participants being recertificated and at MCHA • Review and discuss previously set goals.

Page 4 Certification and Mid-Certification Nutrition Education Counseling Guidelines Policy 402 December 2024

• For participants who completed the online nutrition education lesson, review and discuss the lesson completion certificate, participant goal set during the lesson, and links visited. Discuss specific nutritional risks for which the participant qualifies. Certification and MCHA • Review specific nutrition risk codes identified during the assessment. • Advise the participant/caretaker of all identified nutrition risk codes that qualify the participant for the Program. • See the WIC Certification/MCHA Counseling for Specific Nutritional Risk Protocol Table below in this policy for a full list of nutrition codes and required nutrition education. Referrals based on Participant Needs identified during the Nutrition Assessment Certification and MCHA • Notify the participant of any referrals recommended based on assessment. • Document the referrals in the medical record. • Document acceptance or decline of the referral in the medical record. • For agencies with the Breastfeeding Peer Program, offer all Pregnant and Breastfeeding Women the opportunity to speak with a Peer Counselor. Document acceptance/ referral or denial. • Refer to Policy 403 Referrals. Food Package Assignment Certification and MCHA • WIC Health Professional will assign and tailor the food package to meet the specific needs of the participant. • Explain the WIC Shopping List, WIC approved list, and how and where to use the eWIC card. • For food package changes or WIC Program Status changes that impact the food package, review the food package to ensure the participant has an understanding of the benefits. • Review the eWIC-1 handout as appropriate. • See WIC and Nutrition Manual, Section 600 Food Package Assignment. • For in-clinic services, advise participants/caretakers to swipe their eWIC card at the Card Reader to test their PIN and to ensure benefits have been loaded on their card. 4. Establish participant-centered goals and plan of care for follow-up visits. Refer to Policy 401. a. These goals shall be: i. Related to the participant's identified nutritional risks and the participant/family nutrition-related interests. ii. Be actionable with a measurable timeframe for completion. iii. Be reasonable and achievable. 5. Make and document referrals for other programs or services (when appropriate). 6. Document as appropriate in the participant’s medical record. Documentation must include: a. Goals established/progress of goals. b. Referrals for other programs or services (when appropriate), including if the referral was accepted or declined. c. Nutrition education provided per protocol” or the acronym “NEPP” or “Mid- Certification Health Assessment nutrition education per protocol” or the acronym “MC-NEPP” when the information provided to the participant covers all topics outlined in the counseling protocols. If the protocol is not followed, then documentation must be made of the counseling that is provided and any supporting materials/handouts that were provided. d. Additional nutrition education information or pamphlets that are provided that are not listed in the counseling protocols must be documented. 7. Code the service on the Patient Encounter Forms. Nutrition Education and Breastfeeding Counseling a. W9401 WIC Nutrition Education Counseling (7.5 minutes) when following the certification counseling protocols. a. 2699 – is used for nutrition counseling

Page 5 Certification and Mid-Certification Nutrition Education Counseling Guidelines Policy 402 December 2024

b. W9401 WIC Nutrition Education Counseling (7.5 minutes) when following the mid-certification counseling protocols. a. 2699 – is used for nutrition counseling c. W9401BF for Breastfeeding Counseling above and beyond WIC Nutrition Counseling. a. v241- is used for breastfeeding services d. If additional information is provided above and beyond the WIC Certification/Mid- Certification protocols listed in the appendix tables must be documented in the participant’s medical record and is coded on the PEF as W9402 (15 minutes), W9403 (22.5 minutes) or W9404 (30 minutes) as appropriate. Certification Assessment a. W0200 is used to code certification and enrollment b. W0204 is used for screened but does not have a qualifying nutrition risk Mid-Certification Health Assessment (MCHA) a. W0205 is used to code the MCHA assessment

WIC Certification/MCHA Counseling for Specific Nutritional Risk Code Assignment Protocol WIC participants must be provided WIC Certification Nutrition Education Counseling based on their individual risk Code Assignment *Status Code: P= any Pregnant Status, BF= any Breastfeeding Woman Status, PP= Postpartum Status, C= Child Status, I= any Infant Status Provider: Certifying Health Professional Risk/Status*/ Reference Materials** Counseling/Education Referral Guidance Low Hematocrit/Low Hemoglobin Status: P, PP, BF, C, I ● Define low hematocrit/low hemoglobin. ● Discuss iron-rich foods. Refer for Medical Evaluation:  All status Hematocrit < 27% Hemoglobin < 9 gm./dL. Elevated Blood Lead Status: P, PP, BF, C, I • Discuss the importance of adequate calories, calcium, iron, vitamin C and low-fat foods (for children after age 2), which decrease the absorption of lead. • Discuss the importance of regular meals and snacks. • Discuss CDC recommendations regarding mothers' lead levels and breastfeeding (Breastfeeding Woman). See Blood Lead Levels & Breastfeeding in Policy 501. Refer for Medical Evaluation.  See Lead Guidelines in Core Clinical Services Guide (CCSG). Schedule for High-Risk Secondary Nutrition Education, Refer for MNT per Professional Judgement Low Head Circumference • Discuss the impact of prematurity on growth and development if age-adjusted.

Page 6 Certification and Mid-Certification Nutrition Education Counseling Guidelines Policy 402 December 2024

Status: I, C (up to age 2) • Discuss the importance of nutrition on growth and development Refer for Medical Evaluation. Preterm Birth/Early Term Birth Status: I, C (up to age 2) • Discuss the impact of prematurity on growth and development. • Discuss the importance of good nutrition for proper growth and development. Low Birth Weight/Very Low Birth Weight Status: I, C (up to age 2) • Discuss the impact of birth weight to growth and development. • Discuss the importance of good nutrition for proper growth and development. Schedule for High-Risk Secondary Nutrition Education, Refer for MNT per Professional Judgement At Risk for Overweight Status: I, C • Discuss the importance of prevention of overweight. • Discuss the importance of physical activity. • Reduce sedentary activity such as computer games and watching television. • Discuss the appropriate quantity of food. • Discuss healthy foods (e.g., low-fat and reduced-fat food choices). (children >age 2) • Discuss the importance of good nutrition for proper growth and development. (infants) Overweight, Obese, High Weight for Length Status: P, PP, BF, C, I • Review the growth chart. (children) • Discuss the importance of physical activity. • Reduce sedentary activity such as computer games and watching television. • Discuss the appropriate quantity of food. • Discuss healthy foods (e.g., low-fat and reduced-fat food choices). (women/children >age 2) Schedule for High-Risk Secondary Nutrition Education, Refer for MNT per Professional Judgement At Risk for Underweight Status: I, C • Review the growth chart. • Discuss the importance of frequent feeding. • Discuss healthy foods in relation to growth and development. Underweight Status: P, PP, BF, I, C • Review the growth chart. (Infants and children) • Discuss the importance of frequent feeding. • Discuss healthy foods in relation to growth, development, and appropriate weight gain. Schedule for High-Risk Secondary Nutrition Education, Refer for MNT per Professional Judgement At Risk for Short Stature Status: I, C • Discuss growth for age and stature/size of parents. • Discuss healthy foods in relation to growth and development. Short Stature Status: I, C • Discuss growth for age and stature/size of parents. • Discuss healthy foods in relation to growth and development. Growth Problems Status: I, C • Discuss growth for age and stature/size of parents. • Discuss healthy foods in relation to growth and development.

Page 7 Certification and Mid-Certification Nutrition Education Counseling Guidelines Policy 402 December 2024

Inappropriate Weight Gain Pattern Status: P, PP, BF, I, C Pregnant woman • Discuss the importance of appropriate weight on the developing fetus. Postpartum or breastfeeding woman • Discuss the importance of an adequate diet to promote lactation and/or attaining standard weight. Infant • Discuss the importance of frequent feeding in relation to weight gain. Children • Discuss healthy foods in relation to growth and development. Alcohol and Substance Use Status: P, PP, BF • Discuss the importance of discontinuing the identified substance use (tobacco, alcohol, drugs) (S-A-D). • Discuss the importance of discontinuing smoked tobacco, electronic nicotine delivery systems (ENDS), smokeless tobacco (chewing tobacco, snuff, dissolvable,) hookahs, cigars, pipes, and nicotine replacement therapies (gums, patches). Refer to counseling and/or treatment as appropriate. Environmental Tobacco Smoke Exposure Status: P, PP, BF, I, C • Discuss the importance of consuming foods high in vitamin C. • Discuss the importance of fruits and vegetables in the diet. • Discuss the risk of thirdhand smoke. BF Infant/BF Woman at Nutritional Risk Status: I, P, BF Breastfed infant • Discuss adequate diet for lactation and health. Breastfeeding mother • Discuss the impact of the mother’s health on the growth and development of the infant. Breastfeeding Complications Status: BF, P, I • Discuss the impact of an adequate diet. • Discuss the importance of frequent feeding. • Discuss specific conditions/problems. Refer to IBCLC/Designated Breastfeeding Expert (DBE)/Nutritionist/Dietitian Refer for Medical Evaluation:  Mastitis or Severe nipple pain Infant of a WIC Mother/ Mother at Risk Status: I • Discuss the impact of the mother’s nutritional risk during pregnancy to the infant’s health. • Discuss an adequate diet for the infant. • Discuss specific conditions/problems. Infant of a Mother with Complications that Impair Nutrition Status: I • Discuss an adequate diet at an appropriate level of comprehension for the client.

Page 8 Certification and Mid-Certification Nutrition Education Counseling Guidelines Policy 402 December 2024

Pregnancy Induced Conditions Status: P, PP, BF • Discuss specific conditions/problems. • Discuss the additional demand on nutrient stores. Schedule for High-Risk Secondary Nutrition Education, Refer for MNT per Professional Judgement Delivery of Preterm /Early Term/ Low Birth Weight Infant Status: P, PP, BF Pregnant • Discuss the problems identified and the effect on current health. • Stress the importance of appropriate weight gain. Breastfeeding/Postpartum • Discuss the problems identified and the effect on current health. Fetal or Neonatal Death Status: P, PP, BF • Discuss the problems identified and the effect on current health. General Obstetrical Risk Status: P, PP, BF Pregnant • Discuss the importance of appropriate weight gain for the developing fetus. • Discuss the additional demand on nutrient stores. Breastfeeding/Postpartum • Discuss the additional demand on nutrient stores. Nutrition/Metabolic Conditions/Infectious Disease Acute or Chronic Status: P, PP, BF, I, C Pregnant/Breastfeeding/Postpartum • Discuss the relationship of the specific condition/problem to nutritional status and its potential impact on a woman’s current status. • Discuss the impact of over-the-counter medications and nutrient interactions. Infant/Child • Discuss the relationship of the specific condition/problem to nutritional status and its importance to growth and development. • Discuss the impact of over-the-counter medications and nutrient interactions. Schedule for High-Risk Secondary Nutrition Education, Refer for MNT per Professional Judgement except:  Lactose Intolerance  Short Term Antibiotic Use – Drug Nutrient Interaction  Asthma – persistent asthma that requires daily medication  Food allergies – per patient request and/or professional discretion Impaired Ability to Prepare Food Status: P, PP, BF, I, C • Discuss an adequate diet at an appropriate level of comprehension for the client. • Discuss the specific condition/problem. Refer to Social Programs. Complications which Impair Nutrition Status: P, PP, BF, I, C Pregnant/Breastfeeding/Postpartum • Discuss an adequate diet at an appropriate level of comprehension for the client. • Discuss the relationship of the specific condition/ problem to nutritional status and its potential impact on a woman’s current status. Schedule for High-Risk Secondary Nutrition Education, Refer for MNT per Professional Judgement For complications/

Page 9 Certification and Mid-Certification Nutrition Education Counseling Guidelines Policy 402 December 2024

Infant/Child • Discuss an adequate diet at an appropriate level of comprehension for the client. • Discuss the relationship of the specific condition/ problem to nutritional status and its importance to growth and development. potential complications which impair nutrition/ delays/disabilities that impair chewing /swallowing/ require tube feeding. Dental Problems Status: P, PP, BF, I, C Pregnant/Breastfeeding/Postpartum/Child/Infant • Discuss the importance of proper dental care. • Drink/provide only water between meals. • Limit sugary foods/drinks. Limit juice intake to 100% juice and no more than 4-6 ounces per day. • Brush teeth twice daily. • Refer to a dentist/doctor regarding fluoride. • Follow up with your dentist as appropriate for dental problems. Infant/Child • Breastfeeding is recommended for the 1st year of life and beyond as mutually desired. • Avoid having an infant/child sleep with a bottle. • Wipe the gums of young infants with a soft washcloth or soft toothbrush, even prior to tooth eruption. Other Health Risk/Fetal Alcohol Spectrum Disorder Status: P, PP, BF, I, C • Discuss adequate diet. Presumed Dietary Risk Status: P, PP, BF, C (age 2 and older) • Counsel on an adequate diet. Feeding Practices Status: P, PP, BF, I, C • Counsel on a specific problem (s) Inappropriate Nutrient Intake Status: P, PP, BF, C • Discuss the importance of calcium and protein sources. • Counsel on an adequate diet. Eating Disorders Status: P, PP, BF • Discuss the relationship of the specific condition/ problem to nutritional status and its potential impact on a woman’s current status. • Counsel on an adequate diet. Schedule for High-Risk Secondary Nutrition Education, Refer for MNT per Professional Judgement Refer for Medical Evaluation. Recipient of Abuse Status: P, PP, BF, I, C • Counsel on an adequate diet. • Counsel based on readiness. Refer to Social Programs. Foster Care Status: P, PP, BF, I, C • Counsel on an adequate diet. • Discuss specific problems/conditions such as chronic health problems, birth defects, short stature, and inadequate nutrition. Refer to Social Programs. Homelessness Status: P, PP, BF, I, C • Counsel on an adequate diet with emphasis on homelessness/migrancy as appropriate. Refer to Social Programs.

Page 10 Certification and Mid-Certification Nutrition Education Counseling Guidelines Policy 402 December 2024

Migrancy Status: P, PP, BF, I, C • Counsel on an adequate diet with emphasis on homelessness/migrancy as appropriate. Refer to Social Programs. Possibility of Regression- Priority III Status: C • Discuss the importance of a good diet in preventing the previous risk from recurring. Possibility of Regression- Priority IV Status: C • Encourage continuance of a good diet as appropriate for child’s age. Transfer of Certification Status: P, PP, BF, I, C • Provide nutrition education for condition/problem, if known.

Page 1 Referral Based on Nutrition Risk Policy 403 December 2024

Policy 403 Referrals POLICY Local WIC Agencies will make referrals when there is an identified need or upon participant request. Referrals shall be made for medical provider evaluations, Designated Breastfeeding Expert (DBE) visits, Medical Nutrition Therapy, substance abuse, Lead Program, treatment/counseling services, and social programs. In addition, local WIC Agencies must screen for alcohol, tobacco, and other drug use, refer for further assessment when needed, and provide drug and other harmful substance abuse information.

PURPOSE To improve the health and well-being of WIC participants by ensuring awareness of and referrals to available resources for assistance and information. Screening and counseling shall be conducted in a non-judgmental and compassionate setting.

RELEVANT REGULATIONS AND POLICY 7 CFR 246.4(a)(8) and (9) – State Plan 7 CFR 246.7(a)(b) and (n) – Certification of Participants 7 CFR 246.11(a)(3) and (b)(1) – Nutrition Education 7 CFR 246.149(c)(1) and (9) – Program Costs Final WIC Policy Memorandum #2001-7 Immunization Screening and Referral in WIC WIC Policy # 2001-1 Clarification of WIC’s FY 2001 Appropriations Act Provision Regarding Blood Lead Screening WIC #1993-3A WIC’s Role in Screening for Childhood Lead Poisoning, 7 CFR 246.7(b).

PROCEDURES Certification Visits A. At each certification, local WIC Agencies must provide information on referrals to participants based on identified needs or by participant request. B. At each certification, WIC support staff must provide written referral information about other health-related and public assistance programs (Medicaid, SNAP, immunizations, etc.) and, when appropriate, shall refer applicants/participants to such programs. This information is available in written form on the eWIC-1 handout. C. At each certification, all participants should be screened for potential referrals. D. Prenatal and Breastfeeding participants should be offered the opportunity to speak with peer counselors where the Breastfeeding Peer Program is available. E. Participants with identified risk codes or community needs should be offered a referral. See Referrals Based on Risk Criteria Table below in this policy. F. Documentation of the referral and acceptance or denial should be documented in the participant's medical record. G. Each certification shall include a screening for potential alcohol, tobacco, or other drug use by prenatal and postpartum participants. Documentation of the referral and acceptance or denial should be documented in the participant's medical record. 1. It is not in the scope of WIC to provide drug, alcohol, or tobacco assessment or counseling. 2. If further assessment or counseling is needed, refer the participant to their medical provider. 3. Make available a list of local resources for drug or other harmful substance abuse counseling and treatment. This list must be made available to all WIC participants: pregnant, postpartum, and breastfeeding women and parents/caretakers of infants and children.

Page 2 Referral Based on Nutrition Risk Policy 403 December 2024

4. Raise awareness of all participants and caretakers about the dangers of alcohol, tobacco, and other drugs. H. Upon enrollment of an infant or child, the parent or caretaker must be asked if the child has had a blood lead test. A referral should be made and documented to a health professional/local agency lead program if: 1. The infant/child has never had a lead test. 2. The child had an elevated BLL 12 months prior and has had no interim follow-up screening. 3. The child is suspected by a parent or a health care provider to be at risk for lead exposure. 4. The child has a sibling or frequent playmate with an elevated BLL. 5. The participant is a recent immigrant, refugee, or foreign adoptee. 6. The breastfeeding or lactating woman, parent, or child’s principal caregiver works professionally or recreationally with lead. 7. The family has a household member who uses traditional, folk, or ethnic remedies and cosmetics or who routinely eats unregulated/uninspected food imported from abroad. 8. The family has been identified at increased risk for lead exposure by the health department because the family has local risk factors for lead exposure. I. Refer infants and children under age two to a medical provider for immunizations. Documentation of the referral and acceptance or denial should be documented in the participant's medical record. 1. At initial certification and all subsequent certification visits for children under the age of 4, screen the infant/child’s immunization status using a documented record. A documented record is a record (electronic or paper) in which actual vaccination dates are recorded. This includes a parent’s record provided by the medical provider, an immunization registry or an automated data system, an electronic medical record, or client chart. 2. At a minimum, screen the infant/child’s immunization status by counting the number of doses of the DTaP (diphtheria, tetanus toxoid, and acellular pertussis) vaccine they have received in relation to the age, according to the timeline below: By 3 months of age, the infant/child should have at least 1 dose of DTaP. By 5 months of age, the infant/child should have at least 2 doses of DTaP. By 7 months of age, the infant/child should have at least 3 doses of DTaP. By 19 months of age, the infant/child should have at least 4 doses of DTaP. By 4 years of age, the child should have at least 5 doses of DTaP. 3. If the infant/child is under-immunized: i. Provide information on the recommended immunization schedule appropriate for age, ii. Refer for immunization services, ideally with a healthcare provider. 4. If the documented immunization record is not provided by the parent/caretaker: iii. Provide information on the recommended immunization schedule appropriate to the current age of the infant/child iv. Refer for immunization services, ideally with a healthcare provider. v. Request and encourage the parent/caretaker to bring the immunization record to the next certification visit/ sign a release of information to have the immunization record sent to the WIC office. J. WIC Staff must refer WIC participants for appropriate resources such as social services, the Breastfeeding Peer Program, lactation counseling with the Designated Breastfeeding Expert, medical providers, Medical Nutrition Therapy, smoking cessation, etc., based on identified needs or upon request. Documentation of the referral and acceptance or denial should be documented in the participant's medical record.

Page 3 Referral Based on Nutrition Risk Policy 403 December 2024

Referral Services A. Local WIC agencies shall maintain and make available a list of referral sources in the program’s service area. B. Local Programs are required to provide information about the dangers of using alcohol, tobacco, and other drugs to all pregnant, breastfeeding, and postpartum women and to parents and caretakers of infants and children. C. Local WIC agency staff shall keep informed about available health and social services in the community whenever possible. D. Refer to the table below for information on Required Referrals based on Nutrition Risk Code Assignment.

Page 4 Referral Based on Nutrition Risk Policy 403 December 2024

Referrals Based on Risk Criteria A. All participants must be screened for all qualifying nutrition risk criteria. WIC participants will receive a referral to the indicated referral source if the risk codes below are identified.

NUTRITIONAL RISK CRITERIA CODES FOR REFERRAL Medical Evaluation referral: NRCC Code Risk Criteria Name 201 Low Hematocrit/Low Hemoglobin: Hematocrit < 27% Hemoglobin < 9 grams/dL. 211 Elevated Blood Lead 152 Low Head Circumference 602/603 Breastfeeding Complications: Mastitis and/or Severe nipple pain, Jaundice 358 Eating Disorders Designated Breastfeeding Expert (DBE) (Nurse or Dietitian with credentials of IBCLC, CLC, or CLS), Nutritionist or Dietitian referral: NRCC Code Risk Criteria Name 602/603 Breastfeeding Complications Treatment/Counseling Services referral: NRCC Code Risk Criteria Name 361 Depression 371 Substance Use 372 Alcohol and Substance Use Social Programs referral: NRCC Code Risk Criteria Name 902 Impaired Ability to Prepare Food 901 Recipient of Abuse 903 Foster Care 801 Homelessness 802 Migrancy

Referral Follow-Up A. Evaluate referral outcomes, when possible, by conducting follow-ups with participants at subsequent visits. 1. Ask participants if services were obtained. 2. Reinforce follow-through if services were accessed. 3. Identify barriers and options for overcoming barriers if services were not obtained.

Documentation A. Documentation of the referral and acceptance or denial should be documented in the participant's medical record.

Page 1 WIC Low-Risk Secondary Nutrition Education Guidelines Policy 404 December 2024

Policy 404 WIC Low-Risk Secondary Nutrition Education Guidelines

POLICY Nutrition-focused education must be provided at least quarterly to each participant/caregiver according to federal regulations, state guidelines, and program goals.

PURPOSE To ensure that appropriate nutrition-focused education is made available to all participants on a routine basis and to establish standards for nutrition education contacts.

RELEVANT REGULATIONS 7 CFR 246.6 (b) – Goals 7 CFR 246.11 (c)(4) and (7) – State agency responsibilities 7 CFR 246.11—Nutrition Education (a) General, (b) Goals, (c)(4) – Procedures to ensure that nutrition education is offered, (d) Local program responsibilities, (e) Participant contacts, (e)(4) – Documentation of nutrition education provided, and (e)(5) – Provision of individual care plan based on need.

PROCEDURES WIC Follow-Up Nutrition Education Counseling A. Nutrition Education shall follow the Value Enhanced Nutrition Assessment (VENA) model and embrace the following principles to ensure effectiveness and quality: 1. Interactive a. Nutrition education shall involve families in self-assessment and self-directed goal setting and help families move toward their desired level of wellness. b. Develop a rapport by employing active listening skills, asking open-ended questions, and identifying the participant’s stage of change. 2. Flexible a. Use multiple strategies and techniques to effectively reach and impact participants and their families. 3. Relevant a. Impart appropriate and relevant education that is reflective of the interest of the participants and/or family. b. Education offered to participants shall be in a positive and interactive manner through developmentally and culturally appropriate teaching aids. 4. Supportive Environment a. Education shall be offered in a family, friendly environment for optimal learning. Personnel shall support the family’s needs and build a rapport with families to promote good health. 5. Trained Personnel a. Education shall be facilitated or taught by qualified, well-trained and equipped personnel. 6. Culturally Supportive a. Education shall acknowledge and support differences in cultures and languages and be sensitive to cultural food choices, when possible. B. WIC secondary nutrition education counseling must be offered to each participant/caregiver by providing quarterly nutrition education contacts during the certification period. 1. The first quarterly nutrition education contact is provided with the certification visit.

Page 2 WIC Low-Risk Secondary Nutrition Education Guidelines Policy 404 December 2024

2. The second nutrition education contact, or follow-up contact, is provided approximately three (3) months from the certification date. 3. Nutrition education contacts shall be scheduled with food benefit issuance and, when possible, with other services. 4. If a participant misses their nutrition education visit or declines nutrition education, it shall be documented in the participant’s medical record. 5. Benefits cannot be withheld for declining or not completing nutrition education visits. 6. Participants must receive secondary nutrition education contacts on the following schedule: Nutrition Education (NE) Contact Schedule Status 1st NE Contact 2nd NE Contact 3rd NE Contact 4th NE Contact Provide at certification visit Provide at follow-up visit, approximately 3 months after certification visit Provide at Mid- Certification Health Assessment (if applicable) approximately 6 months after certification visit Provide at follow-up visit, approximately 3 months after Mid- Certification Health Assessment Pregnant Woman   N/A N/A Breastfeeding Woman     Postpartum Woman   N/A N/A Infant     Children    

WIC Secondary Nutrition Education Counseling A. Participants will be assigned appropriate risk codes during their certification. B. Based on the risk code assignment, participants will be scheduled for a WIC Low-Risk (Brief) Secondary Nutrition Education visit or a WIC High-Risk (In-Depth) Secondary Nutrition Education visit. 1. WIC High-Risk Counseling visits count as one of the required nutrition education visits. Participants identified for high-risk counseling, must receive a minimum of one high-risk (In-Depth) nutrition counseling session per certification period. High-Risk nutrition education may be provided at the Mid-Certification Health Assessment as part of the MCHA nutrition education. 2. For additional information about WIC High-Risk Counseling see Policy 405-Secondary Nutrition Education for High-Risk Participants.

Methods for WIC Low-Risk (Brief) Secondary Nutrition Education A. Individual WIC Secondary Nutrition Education Counseling 1. Discuss topics based upon status and nutritional risk, individual/family goals, and individual/family interests. Provide nutrition education on at least one nutrition topic, may follow-up on goal set at certification/MCHA visit. 2. If utilizing Trained WIC paraprofessional, see Training Requirements for the WIC Paraprofessional in the section. 3. Make referrals for other programs or services (when appropriate). 4. Documentation must be in participant’s medical record in accordance to standards outlines in the Administrative Reference, Medical Records Management Section. 5. Documentation must include:

Page 3 WIC Low-Risk Secondary Nutrition Education Guidelines Policy 404 December 2024

a. Document nutrition topic(s) covered. b. Document any updates to goals, if applicable. c. Referrals for other programs (when appropriate). 6. Code service on the Patient Encounter Form (PEF) as listed below: a. Certifying Health Professionals i. Code W9401 WIC Nutrition Education/Counseling (7.5 minutes) when following Individual Nutrition Counseling Protocols and 2699-. a. If providing Breastfeeding nutrition education, Code W9401BF and V241-. b. Trained Paraprofessionals i. Coding on the PEF shall be WP401 (7.5 minutes) WIC Low-Risk Follow- up Contact when following protocols below. PROVIDER: TRAINED WIC PARAPROFESSIONAL*** Topic /Status Counseling/Education (Reference Materials**) Feeding Practices Discuss the following topic as appropriate: • Food Safety • Beans • Calcium • Vitamin A/Vitamin C • Iron for Strong Blood Cells • Healthy Eating for Preschoolers Choose My Plate Tip Sheet • Add More Vegetables & Focus on Fruits Choose My Plate Tip Sheets Status: Child (age 2 and older) Presumed Dietary Risk Status: Child (age 2 and older) Possibility of Regression-Priority III Status: Child (age 2 and older) Possibility of Regression-Priority V Status: Child (age 2 and older)

7. Documentation of refusal or no-show demonstrates that nutrition education was offered.

B. Online WIC Secondary Nutrition Education 1. All statuses are eligible for online nutrition education: a. Participants assigned WIC High-Risk Counseling must have one WIC High-Risk (In-Depth) Counseling visit during the certification period. i. It is recommended that the WIC High-Risk Counseling Visit be provided during the Mid-Certification Health Assessment (MCHA). ii. Online nutrition education is not considered High-Risk Nutrition Education. iii. If high-risk (In-Depth) nutrition education is provided at the MCHA visit, the child may have up to two (2) online nutrition education sessions during the one-year certification period. 2. At the certification appointment, the Certifying Health Professional (CHP) will determine if the participant is eligible for online nutrition education and, in conjunction with the participant/caretaker, determine if it is the best option for the family. a. The participant/caretaker of the eligible participants are to be provided a choice regarding the method of follow-up nutrition education. 3. The CHP, in conjunction with the participant/caretaker, will determine if there is access to the internet for online nutrition education. Access to the internet could include use of smart phone with data plan, computer in home or computer in another location such as library or friend/relative’s home. 4. The CHP or designated staff will explain the process for completing the online nutrition education.

Page 4 WIC Low-Risk Secondary Nutrition Education Guidelines Policy 404 December 2024

5. The CHP may recommend specific topics based on the participant’s category, interest and/or risks. However, the participant’s/caretakers may choose which lesson topic best meets their family’s needs. 6. The CHP may recommend the caretaker review Health eKitchen component which is a resource for menu development or locating recipes. However, Health eKitchen does not count as a nutrition education contact. 7. Households with two (2) or more WIC participants will be required to complete a minimum of one (1) lesson. 8. Each completed online lesson must be documented in the participant’s medical record. The system will print a label listing the nutrition education courses the participant/caretaker has completed. 9. Participants/caretakers who complete online nutrition education are not required to be physically present for food benefit issuance. If the participant/caretaker is not physically present: a. Upload eWIC (EBT) benefits to the participant’s account after verification of completion of the online nutrition lesson. b. The reason for mailing the food instruments or uploading the EBT benefits, the month(s) of issuance and the date the food instruments were mailed, or benefits were uploaded must be documented in the participant’s medical record. i. Proof of identity is coded as “other,” code 50. ii. The Household WIC Shopping List will be mailed. To protect privacy, the WIC Benefit List shall not be mailed. 10. Participants/caretakers who still need to complete the online nutrition lesson must be offered an individual or group nutrition education contact and must return to the clinic for food benefit issuance. 11. At the subsequent certification appointment, the CHP will follow up with the participant regarding the lessons and online courses' goals. 12. Caretakers who indicate an interest in online nutrition education but later choose not to participate in online option shall be offered individual or group nutrition education. 13. Participants with a current plan to do online nutrition education as their nutrition education contact are considered as having been offered one nutrition education contact.

C. Phone WIC Secondary (Brief) Nutrition Education 1. Certifying Health Professionals may provide nutrition and breastfeeding education by phone. 2. Local WIC agencies may not utilize phone contacts to provide nutrition education at certification or mid-certification health assessments (MCHA). 3. During the phone contact: a. Have the participant confirm their identify by asking them to identify their name and at least one of the following: current mailing address, date of birth, WIC card number or other verifiable information in the participant’s medical record. b. If the participant’s identity cannot be confirmed, education cannot be provided over the phone. 4. The education provided shall follow the same policies as the Individual Follow-Up Nutrition Education Counseling Protocols. 5. Offer the participant the opportunity to ask questions during and after the nutrition education contact. 6. Make appropriate referrals. 7. Document the phone contact in the participant’s medical record, including that the contact was via the phone. 8. Code the phone contact on the Patient Encounter Form (PEF).

Page 5 WIC Low-Risk Secondary Nutrition Education Guidelines Policy 404 December 2024

a. Code W9401 WIC Nutrition Education/Counseling (7.5 minutes) when following Individual Nutrition Counseling Protocols and 2699-. b. If providing Breastfeeding Counseling, Code W9401BF and V241-. c. If providing BOTH Nutrition Education per protocol and Breastfeeding Support 7.5 minutes of each), Code W9401 with 2699- and W9401BF with V241-.

D. Group WIC Secondary Nutrition Education Session 1. Group sessions are allowable for follow-up contact based on the professional judgement. 2. The State WIC office must approve all group education sessions. a. For a list of approved group education session, contact the State WIC Office. b. Any group session developed by a local WIC agency, must be approved by the State WIC Office prior to use. 3. Staff who may provide group nutrition education: a. Certifying Health Professionals b. Designated Breastfeeding Experts (DBE)Trained WIC paraprofessional-may provide group nutrition education for children age 2 and older with the following risk codes: Feeding Practices (4250, Presumed Dietary Risk (401), and Regression (501). c. If utilizing Trained WIC paraprofessional, see Training Requirements for the WIC Paraprofessional in the section. 4. Following registration, the participant, guardian or proxy will be directed to the appropriate group session. 5. Food benefit issuance and return appointments are prepared as the group session is being completed. The group sessions typically take 15-30 minutes. 6. The group education provider will code the appropriate group education level provided on the PEF. a. Use W9431 for Group nutrition education, with 2699-. b. Use W9432 for Group breastfeeding education, with V241-. c. Use W9435 for WIC Group nutrition education provided by a paraprofessional, with 2699-. 7. Documentation of the group session: a. Group Follow-Up Education label which includes group session provided, name of group session and is signed and dated by provider. b. If no label is used, documentation shall include date, nutrition education provided by group, name of session, provider signature and title. c. Provided referrals, when appropriate. d. Any additional information provided that is not part of the group lesson plan. E. Kiosk WIC Secondary Nutrition Education. 1. Contact the Nutrition Services Branch for guidance and approval prior to offering Follow- Up Kiosk Nutrition Education.

WIC Exit Counseling A. The WIC exit counseling shall reinforce important health messages previously discussed, with emphasis on: 1. Postpartum/Breastfeeding Women a. Recommendation to breastfeed infants for the first year of life and beyond. b. Review the American Academy of Pediatrics safe sleep environment for infants. c. Folic acid and the prevention of birth defects. 2. All Applicable Status a. Choose My Plate Dietary Guidelines to make healthy food choices. b. Avoiding sugar sweetened drinks.

Page 6 WIC Low-Risk Secondary Nutrition Education Guidelines Policy 404 December 2024

c. Recommendation of an average of 30 minutes for women and 60 minutes for children of physical activity each day. d. Health risks associated with alcohol, tobacco and drug use. e. Following the recommended schedule for immunizations. f. For children, limit screen time to no more than 2 hours/day and remove the television from the child’s bedroom.

Safe Sleep Environment for Infants The Kentucky Department of Public Health supports the American Academy of Pediatrics policy on Safe Sleep to reduce the incidence of Sudden Unexplained Infant Death (SUID) and Sudden Infant Death Syndrome (SIDS). The AAP Safe Sleep Policy includes: A. Placing baby on their back for every sleep time. B. Placing baby on a firm sleep surface. Sitting devises such as car seats, strollers, swings, infant carriers and infant slings are not recommended for routine sleep. C. Placing baby in the same room where the parents sleep but not on the same bed (room sharing without bed sharing). D. Keeping soft objects, loose bedding, or any object that could increase risk of entrapment, suffocation or strangulation out of the crib. These objects include pillows, blankets, bumper pads. E. Not using wedges or positioners. F. Breastfeeding as much and for as long as a mother can. G. Offering a pacifier at nap time and bedtime. With breastfeeding infants, delay pacifier introduction until breastfeeding is firmly established, usually around 3-4 weeks. H. Not letting the baby get too hot. In general, infants shall be dressed appropriately for the environment, with no more than 1 layer more than an adult would wear to be comfortable in that environment. I. Scheduling and going to all well-child visits. J. Keeping baby away from smokers and places where people smoke. K. Not using home cardiorespiratory monitors or to help reduce the risk of SIDS. L. Not using products that claim to reduce the risk of SIDS. M. The AAP recommends supervised, awake tummy time daily to facilitate development and minimize the occurrence of positional plagiocephaly (flat heads).

Training Requirements for WIC Paraprofessionals Before Paraprofessional will be trained by the State WIC Office, the local WIC agency must assure that a Registered Dietitian (RD, LD) with at least one year of WIC experience is on staff to provide the observation component of the training and supervision once the training has been completed. Once trained, WIC paraprofessionals may provide specific and limited nutrition information to WIC participants as detailed in the Individual WIC Follow-Up Nutrition Education and Group Follow-up Nutrition education sections above. A. Staff of a local WIC agency are not Certifying Health Professionals or DBE(i.e., support services staff or clinical assistants) may be trained as a paraprofessional, if they meet the following basic criteria: 1. Are an employee of the agency; 2. Have a high school diploma, GED, or higher education; 3. Have a minimum of one year experience with a Maternal and Child Health Program; 4. Have knowledge of local health department system, community resources and ability to refer; and 5. Can communicate with clients on appropriate educational, economic and cultural level. B. Initial paraprofessional training includes: 1. Instructional component provided by the Nutrition Services Branch; and 2. Initial observational component provided by the local WIC agency Registered Dietitian.

Page 7 WIC Low-Risk Secondary Nutrition Education Guidelines Policy 404 December 2024

C. Once the instructional and observation components of training have been completed, the local WIC agency Registered Dietitian will complete and submit the “WIC Paraprofessional Candidate Submission Form” (see form in this section) to allow the Paraprofessional to code on the Patient Encounter Form (PEF). D. At the completion of the instructional component of the training, the paraprofessional must demonstrate competency in following areas: 1. Basic Understanding of the WIC Program; 2. Communication skills; 3. Referral skills; 4. Documentation skills; and 5. Through knowledge of the paraprofessional nutrition education topics completed during the initial training. E. After successful completion of the instructional component, the paraprofessional must successfully complete the observation component in the clinic under the direction of the local WIC agency Registered Dietitian. During the observation component the paraprofessional must: 1. Observe a Certifying Health Professional providing nutrition education (individual/group contact) to clients; 2. Be observed by the local WIC agency Registered Dietitian conducting at least three (3) nutrition education services (individual/group). a. If paraprofessional will be providing individual counseling, they must be observed conducting at least three individual contacts. b. If paraprofessional will be providing group sessions, they must be observed conducting at least three (3) group session contacts. F. The local WIC agency Registered Dietitian must provide ongoing supervision by: 1. Conducting yearly chart reviews of paraprofessional nutrition education documentation; 2. Observing the paraprofessional providing nutrition education services (individual/group) and coding on the Patient Encounter Form (PEF) at least once a year; 3. Acting as a resource and mentor; 4. Ensuring the trained paraprofessional receives at least four (4) hours of continuing education per year (these hours may be attained by attending webinars, local nutrition in- service training, and other nutrition conferences and/or workshops and reading approved by Registered Dietitian); and 5. Ensuring continuing education hours are documented and maintained at the local level. 6. Submit one form for each newly trained paraprofessional. 7. The local WIC agency Registered Dietitian will be notified by the Nutrition Services Branch of the starting date the paraprofessional may begin providing and coding the paraprofessional nutrition education service (individual/group) for WIC.

Page 8 WIC Low-Risk Secondary Nutrition Education Guidelines Policy 404 December 2024

WIC PARAPROFESSIONAL CANDIDATE SUBMISSION FORM Complete the form for approval for a trained WIC Paraprofessional to provide and code WIC paraprofessional nutrition education. Upon state agency approval, WIC Paraprofessional services may be provided and coded. Agency: Date:

Paraprofessional Candidate Name:

Employee Number of Paraprofessional Candidate:

1. Paraprofessional 101 Course completion date:

Name of Nutrition Services Branch trainer:

2. Paraprofessional Observational component completion date:

Name of Registered Dietitian (RD) observer:

Request for Coding Services: 3. Employee needs the ability to code the following WIC paraprofessional nutrition education services on the Patient Encounter Form (PEF): (check all that apply)

WP401 WIC Low Risk Follow-up Contact (7.5)

WP402 WIC Low Risk Follow-up Contact (15)

W9435 WIC Group low risk nutrition-paraprofessional 4. Employee needs the ability to code these services at the following site(s):

5. Local agency’s RD responsible for ongoing supervision and ongoing training for Paraprofessional:

6. Person submitting this form:

Mailing address:

Email address:

Phone #:

7. Indicate Nutrition Modules Completed. 8. Please submit completed form to: Clinical Nutrition Section Supervisor Nutrition Services Branch Cabinet for Health and Family Services 275 East Main Street, HS2W-D Frankfort, Kentucky 40621-0001

** Paraprofessional may only provide counseling on Nutrition Module completed and must follow policies and procedures in the WIC and Nutrition Manual when providing WIC paraprofessional nutrition education. STATE AGENCY USE ONLY  Paraprofessional Candidate has completed required training (101 Paraprofessional Module & Observational Component and at least one (1) Nutrition module.)  Request sent to Local Health:

 Employee approved to begin coding service:

 Local agency notified

4 Authorized by NSB Staff:

Date:

 Nutrition Modules Completed** Date Module 1: Calcium Module 2: Iron Module 3: Food Safety Module 4: Vitamin A Module 5: Vitamin C Module 6: Dried Beans and Fiber Module 7: Fruits and Vegetables Module 8: Kids in the Kitchen Module 9: Screen Time Other (list)

Page 1 WIC High-Risk Secondary Education Policy 405 December 2024

Policy 405 WIC High-Risk Secondary Nutrition Education

POLICY WIC High-Risk Counseling visits must be provided, and individualized care plans must be developed for all high- risk participants following each certification/mid-certification health assessment where they were identified as high- risk. PURPOSE To provide guidance for high-risk counseling, including methods, documentation, etc. To ensure all high-risk participants receive an individualized care plan with personalized nutrition information to meet their health care needs. RELEVANT REGULATIONS 7 CFR 246.11(e)(5) United States Department of Agriculture, Food and Nutrition Services, Nutrition Service Standards PROCEDURES WIC High-Risk Counseling A. Certifying Health Professionals during certification visits must identify and assign nutrition risk code criteria for each participant. 1. Participants assigned the following risk codes must receive at least one WIC High-Risk Counseling visit within that certification period in which that risk code was assigned.

Nutritional Risk Criteria Codes Requiring High-Risk Nutrition Counselling WIC High-Risk Counseling: NRCC Code Risk Criteria Name 211 Elevated Blood Lead 141 Low Birth Weight 111,113 Overweight 101,103 Underweight 302 Pregnancy Induced Conditions: Gestational Diabetes 341,342,343,345,346, 347,348,349,351,352,353, 354,356,358,359,360, 363 Nutrition/Metabolic Conditions: All except: Lactose Intolerance, Short Term Antibiotic Use-Drug/Nutrient Interaction, Asthma-Persistent asthma requiring daily medication, and Food allergies-per patient request and/or professional discretion 135 Infant Weight Loss 134 Failure to Thrive 362 Complications/Potential Complications which Impair Nutrition/Delays/Disabilities that impair chewing/swallowing/require tube feeding 358 Eating Disorders

B. Certifying Health Professionals must provide WIC High-Risk (In-Depth) Secondary Counseling visits to WIC participants who are identified as High-Risk during their Certification or Mid-Certification Health Assessment. When available, the High-Risk secondary visit should be provided by a Registered Dietitian or Nutritionist. 1. WIC High-Risk (In-Depth) Secondary Counseling must be provided to WIC participants at least once during their certification period. 2. It is recommended to provide the WIC High-Risk Counseling at the Mid-Certification Health Assessment appointment. The MCHA Nutrition Education Counseling satisfies the High-Risk (In- Depth) counseling requirements.

Page 2 WIC High-Risk Secondary Education Policy 405 December 2024

3. All additional Secondary Nutrition Education may be provided by any approved WIC Secondary Nutrition Education Counseling method outlined in Policy 404-WIC Secondary Nutrition Education for Low-Risk Participants. High-Risk Counseling Methods A. The preferred method of delivering high-risk (In-Depth) secondary nutrition counseling to participants is through in-person individualized visit. Individualized telephone contacts are allowable for high-risk (In- Depth) secondary nutrition education. High-Risk Counseling A. WIC High-Risk Counseling shall include: 1. Nutrition interventions, which include assessment, counseling, development, and documentation of an individualized care plan for each participant. 2. Review and discuss the growth chart, height/weight, and hematological data. 3. At least one high-risk criteria must be addressed during the counseling visit. 4. Assess progress toward goal established at certification visit/previous nutrition education visit. a. Acknowledge progress as well as challenges for participants in meeting goals. Provide participants with appropriate nutrition education to assist in working toward goals. b. Goals may be revised or changed to meet participant’s needs. c. If previous goals have been met, acknowledge achievement and work with the participant to set a new goal. 5. Make referrals for other programs or services (when appropriate). 6. Any additional nutrition information or pamphlets provided not listed in the protocol. Counseling protocols for required counseling and education are found in the Individual High-Risk Counseling Nutrition Education Protocols Table below in the policy. a. All risk codes are provided on the Individual High-risk Counseling Protocols. b. To ensure participant-centered education, the Certifying Health Professional can cover topics, in addition to the High-Risk Code, based on participant needs and interests. 7. Review and update/tailor the food package as appropriate. Documentation A. High-risk counseling (In-Depth) secondary nutrition visits must have an individualized care plan documented in the participant’s medical record. B. Individualized Care Plan documentation must include: 1. Participant progress toward goals established during a previous visit/updates to goals. 2. Nutrition assessment (anthropometric/hematological/dietary/health updates) 3. Nutrition topics discussed based on protocol. 4. Referrals for other programs (when appropriate). Document acceptance or decline of referral. 5. Any additional nutrition information or pamphlets provided not listed in the protocol. 6. Plans for follow-up visits. (For example, follow up in 3 months for nutrition education via online, in person, group, telephone, with RD for MNT, etc.) 7. Code service on the Patient Encounter Form (PEF) as listed below: a. Code W9401 WIC Nutrition Education/Counseling (7.5 minutes) when following Individual Nutrition Counseling Protocols and 2699-. (Use W9402 for a 15-minute education visit.) b. If providing Breastfeeding nutrition education, Code W9401BF (7.5 minutes) and V241-.

Referrals A. The Certifying Health Professional (CHP) may determine during the WIC High-Risk Counseling visit that a referral to the healthcare provider, social service program, food pantry, smoking cessation program, alcohol or drug addiction program, or Medical Nutrition Therapy (MNT) would be beneficial for the participant.

Page 3 WIC High-Risk Secondary Education Policy 405 December 2024

B. This referral must be documented in the Individualized Care Plan in the participant’s medical record. The Certifying Health Professional should document the acceptance or decline of referral.

Individual WIC High-Risk Counseling Nutrition Education Protocols

Status: P= any Pregnant Status; BF= any Breastfeeding Status; PP= Postpartum Status; C= Child Status; I= any Infant Status

PROVIDER: CERTIFYING HEALTH PROFESSIONAL Topic /Status/ Counseling/Education Low Hematocrit/Low Hemoglobin Status: P, PP, BF, I, C • Discuss Iron and Vitamin C sources in the diet. • Discuss the importance of Iron and the role of iron in red blood cells. • Discuss the absorption of iron sources and the role of vitamin C in Iron absorption. Elevated Blood Lead Status: P, PP, BF, I, C • Discuss the importance of adequate intake of calories, calcium, iron, vitamin C, and low-fat foods (after age 2), which decreases lead absorption. • Discuss the importance of regular meals and snacks. Low Head Circumference Status: I, C (up to age 2) • Discuss age-appropriate feeding for the infant. Preterm/Early Term Birth Status: I, C (up to age 2) • Discuss age-appropriate feeding for infant development or up to age 2 children. • Review the growth chart and weight goals. Low Birth Weight /Very Low Birth Weight Status: I, C (up to age 2) • Discuss age-appropriate feeding for infant’s or child’s development. • Review the growth chart and weight goals. At Risk for Overweight Status: I, C • Discuss the importance of prevention of overweight. • Discuss age-appropriate feeding for infant’s or child’s development. • Discuss the importance of regular physical activity. • Review dietary concern(s) and appropriate action.

Overweight, Obese, High Weight for Length Status: P, PP, BF, C, I Infant/Child • Review the growth chart and weight goals. • Discuss age-appropriate feeding for the child’s development. • Discuss the importance of regular physical activity. Pregnant/Postpartum/Breastfeeding Women • Review weight goals. • Discuss possible reasons for weight status. • Review Choose My Plate Dietary Guideline Tip Sheet or MyPlate to encourage appropriate weight status. Discuss the importance of regular physical activity. At Risk for Underweight Status: I, C #2, #3, #7-10 (C) Infant/Child • Review the growth chart and weight goals. • Discuss age-appropriate feeding for infant’s or child’s development. Underweight Infant/Child

Page 4 WIC High-Risk Secondary Education Policy 405 December 2024

Status: P, PP, BF, I, C • Review the growth chart and weight goals. • Discuss age-appropriate feeding for infant’s or child’s development. Pregnant/Breastfeeding/Postpartum Women • Review weight goals. • Discuss possible reasons for weight status. • Review Choose My Plate Dietary Guideline Tip Sheet or MyPlate to encourage appropriate weight status. At Risk for Short Stature Status: I, C • Review the growth chart and height goals. • Discuss age-appropriate feeding for infant’s or child’s development. • Discuss the importance of protein for growth. Short Stature Status: I, C • Review the growth chart and height goals. • Discuss age-appropriate feeding for infant’s or child’s development. • Discuss the importance of protein for growth. Growth Problems Status: I, C • Discuss age-appropriate feeding for infant’s or child’s development. • Review the growth chart and weight goals. • Discuss the importance of protein for growth.

Inappropriate Weight Gain Pattern Status: P, PP, BF, I, C Infant/Child • Discuss age-appropriate feeding for infant’s or child’s development. • Review the growth chart and weight goals. Pregnant/Breastfeeding/Postpartum Women • Review weight goals. • Discuss possible reasons for weight status. • Review Choose My Plate Dietary Guideline Tip Sheet or MyPlate to encourage appropriate weight status.

Alcohol and Substance Use Status: P, PP, BF • Discuss the importance of discontinuing the identified substance use (alcohol, tobacco, drugs, and other harmful substances) (ATOD). • Discuss how the identified use can affect the mother and her fetus, infant, or other household members. • Discuss the importance of discontinuing smoked tobacco, electronic nicotine delivery systems (ENDS), vapes, smokeless tobacco (chewing tobacco, snuff, dissolvable,) hookahs, cigars, pipes, and nicotine replacement therapies (gums, patches). Environmental Tobacco Exposure Status: P, PP, BF, I, C • Discuss the importance of continuing a healthy diet. • Discuss the risk of thirdhand smoke. Breastfeeding Infant/BF Woman at Nutritional Risk Status: I, BF • Discuss an adequate diet for the infant. • Discuss using WIC foods to promote optimal health. • Discuss the recommended number of servings from MyPlate and the importance of WIC foods. Breastfeeding Complications Status: I, P, BF • Reinforce the importance of an adequate diet. • Reinforce the importance of frequent feeding. • Discuss specific condition(s)/problem(s). Breastfeeding Infant/BF Woman with Feeding Practices Status: I, P, BF • Discuss an adequate diet for the infant. • Discuss using WIC foods to promote optimal health. • Discuss the recommended number of servings from MyPlate and the importance of WIC foods. Infant of a WIC Mother/ Mother at Risk Status: I • Discuss an adequate diet for the infant.

Page 5 WIC High-Risk Secondary Education Policy 405 December 2024

Infant of a Mother with Complications that Impair Nutrition Status: I • Discuss an adequate diet at an appropriate level of comprehension for the client. Impaired Ability to Prepare Food Status: P, PP, BF, I, C • Discuss the importance of an adequate diet. • Discuss specific condition(s)/problem(s). Pregnancy Induced Conditions Status: P, PP, BF • Encourage appropriate weight gain. • Discuss increased nutrient needs. • Reinforce an adequate diet. • Discuss specific condition(s)/problem(s). • Discuss adequate diet at an appropriate level of comprehension for the client Delivery of Preterm/Early Term / Low Birth Weight Infant Status: P, PP, BF Pregnant • Discuss the problems identified and the effect on current health. • Stress the importance of appropriate weight gain. Breastfeeding/Postpartum • Discuss the problems identified and the effect on current health. Fetal or Neonatal Death Status: P, PP, BF • Reinforce the importance of an adequate diet for health. General Obstetrical Risk Status: P, PP, BF • Discuss specific condition(s)/problem(s). • Discuss the importance of an adequate diet. Nutrition/Metabolic Conditions/Infectious Acute or Chronic Disease Status: P, PP, BF, I, C • Discuss specific condition(s)/problem(s). • Discuss the importance of an adequate diet. Impaired Ability to Prepare Food Status: P, PP, BF, I, C • Discuss the importance of an adequate diet. • Discuss specific condition(s)/problem(s). Complications which Impair Nutrition Status: P, PP, BF, I, C • Discuss specific conditions/problem. • Discuss the importance of an adequate diet. • Discuss an adequate diet at an appropriate level of comprehension for the client. Dental Problems Status: P, PP, BF, I, C • Discuss specific condition(s)/problem(s). • Discuss the importance of an adequate diet. Other Health Risk/Fetal Alcohol Spectrum Disorder Status: P, BF,PP, I, C • Discuss the importance of a good diet. Presumed Dietary Risk Status: P, PP, BF, C (age 2 and older). • Discuss the importance of a good diet. Feeding Practices Status: P, PP, BF, I, C • Discuss specific problems and their relationship to health, growth, or development. Inappropriate Nutrient Intake Status: P, PP, BF, C • Discuss the importance of an adequate diet. Eating Disorders • Discuss specific condition(s)/problem(s).

Page 6 WIC High-Risk Secondary Education Policy 405 December 2024

Status: P, PP, BF • Discuss the importance of an adequate diet. Recipient of Abuse Status: P, PP, BF, I, C • Discuss the importance of an adequate diet. Foster Care Status: P, PP, BF, I, C • Discuss the importance of an adequate diet. Children – • Discuss specific condition(s)/problem(s) such as chronic health problems, birth defects, short stature, and inadequate nutrition. Homelessness or Migrancy Status: P, PP, BF, I, C • Discuss the importance of an adequate diet with an emphasis on homelessness or migrancy. Possibility of Regression Status: C • Discuss the importance of an adequate diet. Possibility of Regression- Priority III Status: C • Discuss the importance of an adequate diet. Transfer of Certification- Priority IV Status: P, PP, BF, I, C • Provide nutrition education, as appropriate.

Individual WIC High-Risk Counseling Nutrition Education Protocols

PROVIDER: DESIGNATED BREASTFEEDING EXPERT/LACTATION SPECIALIST Topic /Status Counseling/Education Breastfeeding Infant/BF Woman at Nutritional Risk Status: I, P, BF • Discuss an adequate diet for the infant. • Discuss using WIC foods to promote optimal health. • Discuss the recommended number of servings from MyPlate and the importance of WIC foods. Breastfeeding Complications Status: I, P, BF • Reinforce the importance of an adequate diet. • Reinforce the importance of frequent feeding. • Discuss specific condition(s)/problem(s). Breastfeeding Infant/BF Woman with Feeding Practices Status: I, P, BF • Discuss an adequate diet for the infant. • Discuss using WIC foods to promote optimal health. • Discuss the recommended number of servings from MyPlate and the importance of WIC foods.

Page 1 Nutrition Services Plan and Regional Breastfeeding Coordinator Program Plans Policy 406 December 2024

Policy 406 Nutrition Services Plan and Regional Breastfeeding Coordinator Program Plans POLICY Local WIC Agencies shall complete an annual Nutrition Services Plan consistent with the State’s goals and objectives. Regional Breastfeeding Coordinators shall complete an annual Program Plan consistent with the State’s goals and objectives.

PURPOSE To ensure local WIC agencies plan and evaluate nutrition and breastfeeding services provided to program participants.

RELEVANT REGULATIONS 7 CFR 246.11(d)(2) – Nutrition Education: Local WIC Agency responsibilities United States Department of Agriculture, Food and Nutrition Services, Nutrition Service Standards

PROCEDURES Nutrition Services Program Plan A. Local WIC Agencies shall complete a Nutrition Services Program Plan that is consistent with statewide nutrition education goals and objectives as described in the annual guidance provided by the State WIC office. B. Components of the Nutrition Services Program Plan shall include: 1. Evaluation of the previous year’s plan. 2. Clinic Needs Assessment 3. Goals as determined by the State WIC Office and based on identified needs at the local level. 4. Measurable objectives designed to meet each goal. 5. Specific methods or activities to achieve each objective.

Regional Breastfeeding Coordinator Program Plan A. Each Regional Breastfeeding Coordinator shall complete a Program Plan for their region that is consistent with statewide breastfeeding goals and objectives as described in the annual guidance provided by the State Breastfeeding Coordinator. B. Components of the Regional Breastfeeding Coordinator Program Plan shall include: 1. Evaluation of the previous year’s plan. 2. Goals as determined by the State WIC Office or based on identified needs at the local level. 3. Measurable objectives designed to meet each goal. 4. Specific methods or activities to achieve each objective. 5. Identification of Community Partners within region 6. Activities planned with all Local WIC Agencies within region 7. Activities planned with community partners across region

Timeline A. Each year, guidance for completing the Nutrition Services Plan and Regional Breastfeeding Coordinator Program Plan will be provided on the following schedule.

Page 2 Nutrition Services Plan and Regional Breastfeeding Coordinator Program Plans Policy 406 December 2024

1. The Plans and support guidance will be emailed to Local WIC Coordinator and Regional Breastfeeding Coordinators in early October and must be completed and returned to the State Agency in early November each year. 2. State Program staff will review the plans by the end of December and will notify local WIC agency staff whether their plans are approved, or whether it needs modification. 3. Plans that require revision must be re-submitted by the end of January the following year.

Extension A. Local WIC Agencies or Regional Breastfeeding Coordinators may ask the State Agency for an extension to complete their plans in extenuating circumstances. B. The State agency recommends that local WIC agencies evaluate their nutrition services and breastfeeding support on an ongoing basis to ensure that they are providing effective and needed services.

Page 1 Medical Nutrition Therapy Policy 407 December 2024

Policy 407 Medical Nutrition Therapy

POLICY Medical Nutrition Therapy (MNT) may only be provided by Registered Dietitians/Registered Dietitian Nutritionists (RD/RDN) and Certified Nutritionists (CN)

PURPOSE To ensure local health departments are providing MNT services based on federal and state laws and regulations.

PROCEDURES Referral Guidelines for Medical Nutrition Therapy A. MNT is individualized dietary instruction and counseling for a nutrition-related problem. B. This level of specialized instruction is above basic nutrition education counseling and includes an individualized dietary assessment. C. MNT services may only be provided by an RD/RDN with an LD. D. A CN may provide MNT, but the services may not be reimbursed by all third-party payors. 1. Reimbursement of MNT by Medicaid/Medicare rate (as of July 2024) is: i. New Patient MNT Individual (CPT 97802) $35.81/unit ii. Established Patient MNT Individual (CPT 97803) $31.03/unit iii. MNT Group (CPT 97804) $15.17/unit E. Medical Nutrition Therapy is above the scope of WIC and may not be billed to the WIC Program. F. WIC may refer participants to MNT services. G. Local Health Departments may accept MNT referrals from their community. H. MNT is not a Core DPH Service, however many communities lack access to MNT and their communities may have high rates of diabetes, obesity, cardiovascular disease, high blood pressure or other chronic diseases for which MNT services can help manage. I. The table below indicates conditions that can be referred for MNT services. MNT services may be offered for a variety of health and feeding conditions and is not limited to this information.

Page 2 Medical Nutrition Therapy Policy 407 December 2024

The below table are conditions or concerns that may be identified in a WIC visit that may be referred for Medical Nutrition Therapy which is above and beyond the WIC Nutrition Education Protocol or for which a local health department with a RD/RDN on staff may receive an outside referral to provide MNT services.

Ages/Status Problem/Condition for Medical Nutrition Therapy Infants – Adult Pregnant Women Postpartum & Breastfeeding Women Infants, Children All Adults Weight Management • Underweight = Pre-pregnancy Body Mass Index (BMI) < 18.5 • Overweight = Pre-pregnancy BMI > 25.0 • Low maternal weight gain, 2nd or 3rd trimesters, single pregnancy o Underweight women who gain <4 pounds/month o Normal weight women who gain <3.2 pounds/month o Overweight women who gain <2 pounds/month o Obese women who gain <1.6 pounds/month • Weight loss during pregnancy o Any weight loss below pregravid weight during 1st trimester (0 – 13 weeks) o >2 pounds during 2nd or 3rd trimesters • High maternal weight gain, all trimesters, singleton pregnancy o Underweight women who gain >5.2 pounds/month o Normal weight women who gain >4 pounds/month o Overweight women who gain >2.8 pounds/month o Obese women who gain >2.4 pounds/month • Underweight = Pre-pregnancy BMI or Current BMI < 18.5 (within 6 months of delivery) • Underweight = Current BMI < 18.5 (> 6 months of delivery) • Overweight = Pre-pregnancy BMI or Current BMI > 25.0 (within 6 months of delivery) • Overweight = Current BMI > 25.0 (> 6 months of delivery) • High maternal weight gain last pregnancy o Underweight Postpartum Woman and gained 40 pounds o Normal weight PP Woman and gained > 35 pounds o Overweight PP Woman and gained > 25 pounds o Obese PP Woman and gained > 15 pounds • Low Birth Weight (LBW) <5 pounds, eight ounces • Failure to Thrive (FTT) • Obesity > 95th percentile weight for height/length • Unexplained weight loss • Any patient requesting weight management • Underweight = BMI < 18.5 • Overweight = BMI > 25.0 All Adolescent Adult Hyperlipidemia • Total cholesterol > 200 mg/dl • LDL > 130 mg./dL. • Total cholesterol > 240 mg./dL. • HDL < 40 mg./dL. • LDL > 160 mg./dL. • TG > 200 mg./dL.

Page 3 Medical Nutrition Therapy Policy 407 December 2024

Ages Problem/Conditions that may be All Elevated Blood Lead Pregnant Women Pregnancy Induced Conditions • Hyperemesis Gravidarum • Gestation diabetes (this pregnancy) All Nutrition/Metabolic such as: • Nutrient Deficiency Diseases • Gastro-Intestinal Disorders • Glucose Disorders • Thyroid Disorders • Hypertension • Renal Disease • Cancer/treatment for cancer • Central Nervous System Disorders • Genetic/Congenital Disorders • Inborn Errors of Metabolism • Infectious Diseases (present in the last 6 months) • Celiac Disease • Drug/Nutrient Interactions • Recent Major Surgery, Trauma, Burns • Other Medical Conditions Pregnant/Postpartum/Breastfeeding Women/Child Inappropriate Nutrient Intake/Nutritional Concerns • Vegan • Highly restrictive diet in calories or specific nutrients Complications which Impair Nutrition • Delays/disorders that impair chewing/swallowing/require tube feeding Pregnant/Postpartum/Breastfeeding Women/Adolescents/Children Eating Disorders Infants Nutrition/Metabolic Conditions • Pyloric Stenosis • Baby Bottle Tooth Decay

Reimbursement of Medical Nutrition Therapy (MNT) A. Registered Dietitians/Registered Dietitian Nutritionists (RDN) employed by health departments with the credential of Licensed Dietitian (LD) by the Kentucky Board of Licensure and Certification for Dietitians and Nutritionists are recognized as individual health care providers who can bill third-party payors such as Medicare, Medicaid, private insurance plans, HMO’s, and PPO’s for MNT services they provide for services. B. Master’s degree level nutritionists with the credential of Certified Nutritionists (CN) by the Kentucky Board of Licensure and Certification for Dietitians and Nutritionists may be recognized to bill third-party payors, however, not all third-party payors will reimburse for services provided by CNs. C. Medicaid and other private insurance companies each have their individual policies and procedures to become credentialed providers to bill for MNT services. In order to provide and be reimbursed for MNT services, the RD/RDN must be a D9 provider and the CN must be a DA provider. Not all MNT services are reimbursable.

Requesting Prior Authorization for MNT Services A. The Health Department must assure that they are providing MNT services according to each Medicaid MCO company provider handbook of policies and procedures to secure reimbursement for MNT services.

Page 4 Medical Nutrition Therapy Policy 407 December 2024

B. It is recommended to verify the client’s eligibility for the services prior to the provision of MNT services and follow the payor guidelines for billing and edits. This process involves teamwork and communication between the RD/RDN, the health department billing/financial staff, referring physicians, and the specific insurance provider billed for the services. C. The following are general steps for requesting an authorization for MNT services: 1. Contact the MCO responsible for the client’s medical coverage. 2. Verify if the provider must complete the process to become an approved provider for the MCO. 3. Follow policies and procedures as outlined by each MCO to request reimbursement for MNT services. 4. Complete the MCO authorization form with appropriate client information to receive authorization MNT services, if required. 5. Submit all necessary information and follow all instructions as outlined by each MCO for the prior authorization letter, if needed. Include copies of the client’s WIC-75 and growth chart to document clinical information to support the medical necessity for the MNT service. 6. Be aware, that problem visits and MNT cannot be billed together. a. Preventative visits and MNT can be billed together. These are national edits that were adopted from the Centers for Medicare and Medicaid Services (CMS) National Coding Initiative (NCCI) standard payment methodologies. b. These methodologies prevent reimbursement for services that cannot be billed simultaneously. c. An example of a problem visit that cannot be billed with MNT is an Evaluation Management (EM) visit. Therefore, these visits will have to scheduled on different days in order to receive reimbursement for both services. A preventative visits such as WIC can be scheduled with MNT. 7. Bill according to each MCO’s policies and procedures.

MNT Documentation Guidelines A. MNT providers must develop a nutrition care plan appropriate for each client or client group according to the Academy of Nutrition and Dietetics Nutrition Care Manual and based on the guidance below. B. Contact the Nutrition Services Branch to request access to the Nutrition Care Manual for RD/RDNs and CNs. C. The below-required elements are recorded on the MNT forms on the following pages. This information is required to reimburse MNT services. D. Medical Nutrition Therapy documentation shall contain the following elements: 1. Date of MNT visit along with the beginning and end time of visit 2. ICD-10 code-define type of visit/counseling 3. Subjective Data a. Client’s reason for visit b. Primary Care Physician c. History d. Subjective Data i. Past and present medical ii. Nutrition including food patterns ad intake iii. Weight iv. Medications v. Exercise e. Objective Data i. Laboratory results ii. Height, weight iii. BMI iv. Calorie Needs v. Drug/Nutrient Interactions f. Individual Assessment of Diet/Intake i. Individual assessment of diet/intake

Page 5 Medical Nutrition Therapy Policy 407 December 2024

g. Plan i. Individualized dietary instruction that incorporates diet therapy counseling and education handouts for a nutrition-related problem ii. Plan for follow-up iii. Documentation of referral for identified needs, as appropriate iv. It is recommended to send a letter to the client’s physician describing the dietary instruction provided. A copy of this letter shall be included in the client’s medical record. h. Date and legible identity of provider i. All entries must be signed and dated by the provider. See the Administrative Reference, Medical Records Management Section.

Medical Nutrition Therapy Assessment Forms-Individual Contact A. Medical Nutrition Therapy (MNT) Assessment forms are required for documentation of an initial individual contact. The MNT forms are found on the following pages in this section. B. All initial individual MNT visits are to be documented on the forms. These forms were developed to collect the required information for reimbursement. C. An entry must be included on the Service Record/Progress Notes (CH-3) referencing the MNT form. D. Per medical documentation and registration/licensure requirements, all entries must contain a goal for the patient and/or the progress toward a goal. See Administrative Reference, Medical Records Management Section. E. The following MNT Assessment forms are to be utilized as appropriate: 1. MNT – Adult 2. MNT – Pediatric 3. MNT – Diabetes 4. MNT – Gestational Diabetes 5. MNT – Renal 6. MNT – Follow Up (optional)

Page 6 Medical Nutrition Therapy Policy 407 December 2024 Rev. 10/15

Medical Nutrition Therapy (Adult) Begin Time:

End Time:

Primary ICD9/10: V653- /Z71.3 Secondary ICD9/10:

Name:

ID Number:

or Place PEF label here

S: Reason for visit: MD/Where do you receive medical care? Medical history: Present treatment: Education level: Language barrier: Support systems: Smoking: No  Yes   cigarettes  pipe  cigars #/day Medications: OTC medications: Drug allergies: Herbal remedies/Vitamin mineral supplements: Job: Work schedule: Schedule changes/weekends/school schedule Rate your appetite: Good  Fair  Poor  Past/present eating disorder?  Yes  No Type: Do you have any eating or digestion problems? Chewing  Swallowing  GERD  Diarrhea  Constipation  Food allergy/intolerance  Other: Has your weight changed in the last year?  Yes  No By how much: Highest weight? Wt. Loss methods tried: What would you like to know more about?  Weight loss  Exercise  Eating out  Label reading  Alcohol use  Sweeteners Patient requested topics/questions: What eating concerns do you have? Who prepares the meals?  Self  Spouse  Roommate  Other Do you have a meal plan? Yes  No  If yes, how many calories? Eating out frequency: Breakfast /week Lunch /week Dinner /week Type(s) of restaurant(s): Are there any special considerations in meal planning? Have you had previous diet instruction?  Yes  No Date/Who: How often are you able to follow it? never  same  always  Have you been told to follow any other diet restrictions? Yes  No  If yes, please check which restrictions:  Low calorie  Low cholesterol  Low salt/sodium  Low protein  Low fat  High fiber  Other: Food frequency: Whole grains

Grains Vegetables Fruit Milk Meats

Other: Do you drink alcohol?  No  Beer  Wine  Liquor How often? How much? Do you exercise now?  Yes  No How often? How long? Type? PRENATALS ONLY Problems during previous pregnancy: Prepregnancy weight: Gestational Age: EDC: Vomiting?  Yes  No Heartburn?  Yes  No Constipation  Yes  No Nausea  Yes  No Weight gain last pregnancy: Weight gain to date: Birth weight of Children (if any): Feeding method planned:  Breast  Formula Time: Breakfast or first meal: Time: Snack: Time: Lunch or second meal: Time: Snack: Time: Dinner or third meal: Time: Snack: Patient comments: O: See CH-12 and available lab reports, growth charts. Age:  Male  Female Ethnicity: Calorie Needs: Medical clearance for exercise:  Yes  No Exercise limitations: Drug/Nutrient Interactions: MNT - Adult

Page 7 Medical Nutrition Therapy Policy 407 December 2024

A: Assessment of Diet - Adequate Intake: Weight:  WNL  Overweight  Underweight Weight gain (Prenatal only):  Normal  Above  Below Recommended Weight: Readiness to change: Precontemplation  Contemplation  Preparation  Action  Maintenance  Other: Women EER = 354 – (6.91 X age) + PA X [9.36 X (wt. in lb./2.2) + (726 X ht. In inches/39.4)] PA levels: Sedentary = 1 Low activity = 1.12 Active = 1.27 Very active = 1.45 Men EER = 662 – (9.53 X age) + PA X [15.91 X (wt in lb/2.2) + 539.6 X (ht in inch/39.4)] PA levels: Sedentary = 1 Low activity = 1.11 Active = 1.25 Very active = 1.48

P: Next Primary Care Physician Appointment: Follow-up Nutrition Appointment: Exercise: Referral:  MD  RN  Social Services  Medicaid Goals/Instructions: Follow-up: Handouts used: Identified Barriers: Signature: Date: MNT - Adult

Rev. 10/18

Page 8 Medical Nutrition Therapy Policy 407 December 2024

Medical Nutrition Therapy (Pediatric) MNT-Pediatric Begin Time:

End Time:

Primary ICD9/10: V653-/ Z71.3 Secondary ICD9/10:

Name:

ID Number:

or Place PEF label here

S: Reason for visit: MD/Where does the child receive medical care? Medical history: Present treatment: Language barrier: second hand smoke exposure: Drug Allergies: Medications: OTC medications: Herbal remedies/Vitamin mineral supplements: Drug/Nutrient Interactions: Child Digestive Problems  Chewing  Swallowing  GERD  Diarrhea  Constipation  Food allergy/intolerance  Other: Rate your child’s appetite: Good  Fair  Poor  Past/present eating disorder  Yes  No Type: Weaned from bottle: Is your child breastfed? How many times in 24 hours? Child eat nonfood items such as dirt, paper, paint chips  Yes  No Parent/care giver concerns about child’s diet: Fluoride Source  Yes  No family meals Daily  Couple times per week  No meals eaten as family Special Considerations in meal planning: Foods or food groups avoided: Number of Meals/Snacks per day: Eating out frequency: Breakfast /week Lunch /week Dinner /week Type(s) of restaurant(s): Food frequency: Whole grains

Grains Vegetables Fruit Milk

Meats

Type of Milk

Other liquids

Breastmilk

Other: Food Insecurity in the home: Previous diet instruction received:  Yes  No Date/Who: Previous diet instruction followed: never  same  always  Hours per day child watches tv, dvd’s or playing computer games: Physical activity received daily:  Yes  No Type and duration of activity: Time: Breakfast or first meal: Time: Snack: Nighttime Feedings: Time: Lunch or second meal: Time: Snack: Time: Dinner or third meal: Time: Snack: O: See CH-12, available lab reports and growth charts. Age:  Male  Female Ethnicity:

Page 9 Medical Nutrition Therapy Policy 407 December 2024

Calorie Needs: Medical clearance for exercise:  Yes  No Exercise limitations: A: Assessment of Diet - Adequate Intake: Infants/Children Appropriate  Yes Weight for Height  No Range: Height/Age: % Weight/Age: % Height/Weight: %

X

=

calories pounds total calories  Maintain  Lose  Gain weight Infant Calorie needs 0-6 months = 49 cal./lb. body weight 6 – 12 months = 45 cal./lb. body weight FTT/Low Birth Weight = 55 cal./lb. body weight Child Calorie needs Child Sedentary Moderately Active Active 2-3 yrs 1000 kcal 1000-1400 kcal 1000-1400 kcal Female 4-8 yrs 1200 kcal 1400-1600 1400-1800 9-13 yrs 1600 1600-2000 1800-2000 14-18 yrs 1800 2000 2400 19+yrs 2000 2000-2200 2400 Male 4-8 yrs 1400 kcal 1400-1600 1600-2000 9-13 yrs 1800 1800-2200 2000-2600 14-18 yrs 2200 2400-2800 2800-3200 19+yrs 2400 2600-2800 3000 P: Next Pediatrician Appointment: Follow-up Nutrition Appointment: Exercise: Referral:  MD  RN  Social Services  Medicaid Goals/Instructions: Handouts used: Follow-up: Parents readiness to learn/Comprehension of education: Identified barriers: Signature: Date:

*Calorie Levels for Children taken from IOM: Dietary Guidelines and Dietary Reference Intakes 2002.

MNT-Pediatric Rev. 10/2018

Medical Nutrition Therapy Assessment MNT-Diabetes Begin Time:

End Time:

Primary ICD9/10: V653-/ Z71.3 Secondary ICD9/10:

Name:

ID Number:

or Place PEF label here

S: Patient reason for visit: MD/Where do you receive medical care? Medical History: Present diabetes treatment: Education level: Language barrier: Support systems: Smoking: No  Yes   cigarettes  pipe  cigars #/day Medications: OTC medications: Drug allergies: Herbal remedies/ Vitamin-mineral supplements: Job: Work schedule: Schedule changes/weekends/school schedule Year of diagnosis: Hypoglycemia:  Yes  No  None experienced Frequency: Rate your appetite: Good  Fair  Poor  Do you have any eating or digestion problems? Chewing  Swallowing  GERD  Diarrhea  Constipation  Food allergy/intolerance  Other: Has your weight changed in the last year?  Yes  No By how much: Highest weight? Wt. Loss methods tried: What eating concerns do you have? Who prepares the meals?  Self  Spouse  Roommate  Other Do you have a meal plan? Yes  No  If yes, how many calories? Eating out frequency: Breakfast /week Lunch /week Dinner /week Type(s) of restaurant(s): Are there any special considerations in meal planning? How much of the time are you able to follow it? never  same  always  Have you been told to follow any other diet restrictions? Yes  No  If yes, please check which restrictions:  Low calorie  Low cholesterol  Low salt/sodium  Low protein  Low fat  High fiber  Other: Date/Who: Food frequency: Whole grains

Grains Veggies Fruit Milk Meats

Other: Do you drink alcohol?  No  Beer  Wine  Liquor How often? How much? Do you exercise now?  Yes  No How often? How long? Type? Time: Breakfast or first meal: Time: Snack: Time: Lunch or second meal: Time: Snack: Time: Dinner or third meal: Time: Snack: Patient comments: O: See CH-12 and available lab reports, growth charts.  Male  Female Ethnicity: Lab Data: Diagnosis of diabetes: Type 1 Type 2  A1C BG Fasting Chol. HDL LDL Triglycerides BP Microalbumin GFR: Other BG Post Meal Target Goals: Target BG:

mg/dL to mg/dL Fasting 2hr PP: Target A1C < 7% Target LDL <100mg/dl Target HDL >40 mg/dl men >50 mg/dl women Target BP <130/80 Target chol. <200 mg/dl Target TG <150 mg/dl Target Microalbumin <30 mcg/mg SMBG: Frequency Times of Day Machine: Medical clearance for exercise:  Yes  No Drug nutrient interactions: Exercise Limitations: Other: Page 10 Medical Nutrition Therapy Policy 407 December 2024

MNT-Diabetes Rev. 10/18

Page 11 Medical Nutrition Therapy Policy 407 December 2024

A: Readiness to change: Precontemplation  Contemplation  Preparation  Action  Maintenance  Weight assessment:  WNL  Overweight  Underweight  Recommended Wt. change  N/A

lbs. loss/gain Women EER = 354 – (6.91 X age) + PA X [9.36 X (wt. in lb./2.2) + (726 Men EER = 662 – (9.53 X age) + PA X [15.91 X (wt in lb/2.2) + 539.6 X (ht in X ht. In inches/39.4)] PA levels: Sedentary = 1 Low activity = 1.12 inches/39.4)] PA levels: Sedentary = 1 Low activity = 1.11 Active = 1.27 Very active = 1.45 Active = 1.25 Very active = 1.48

P: 1 starch = 15 g. CHO, 3 g. protein, 1 fat, 80 calories 1 fruit = 15 g. CHO, 60 calories 1 milk = 12 g. CHO, 8 g. protein, 1 fat, 90 calories 1 veggie = 5 g. CHO, 2 g. protein, 25 calories 1 meat(subst.) = 7 g. protein, 5(3) fat, 75 (55) calories 1 fat = 5 fat, 45 calories Time Breakfast Snack Lunch Snack Dinner Snack Total servings/day CHO (g) Protein (g) Fat Calories Starch Fruit Milk Vegetables Meat/Subst. Fat X4 X4 X9 Total calories OR Total calories: Time Meal # CHO choices CHO grams Breakfast Snack Lunch Snack Dinner Snack Totals

Goals/Instructions: Follow-up: Handouts used: Identified Barriers: Signature: Date: MNT-Diabetes

Page 12 Medical Nutrition Therapy Policy 407 December 2024 MNT-Gestational Diabetes REV. 10/18

Medical Nutrition Therapy Assessment MNT-Gestational Diabetes Begin Time:

End Time:

Primary ICD9/10: V653-/ Z71.3 Secondary ICD9/10:

Name:

ID Number:

or Place PEF label here

S: EDD: Medical History: Name of doctor/Where do you receive medical care? Obstetric History: Medications/Herbal remedies/ Vitamin-mineral supplements: Present MNT Therapy: Insulin Therapy: Date started: Occupation Hours worked? What are your usual work hours? Schedule changes/weekends/school schedule Psychosocial/economic Hypoglycemia: Yes  No  Rate your appetite: Good  Fair  Poor  Any eating/digestion problems? Chewing  Swallowing  Stomach ache  Diarrhea  Constipation  Other: What eating concerns do you have? Who prepares the meals?  Self  Spouse  Roommate  Other Eating out: What type of restaurant(s)? How often each week do you eat in restaurants, cafeterias, or away from home? Breakfast /week Lunch /week Dinner /week Do you have a meal plan? Yes  No  If yes, how many calories? Are there any special considerations in meal planning? Have you had previous instruction on diet?  Yes  No If yes, who provided the instruction and date? How much of the time are you able to follow it? 0-25%  25-50%  50-75%  75-100%  Have you been told to follow any other diet restrictions? Yes  No  If yes, please check which restrictions:  Low calorie  Low cholesterol  Low salt/sodium  Low protein  Low fat  High fiber  Other: What time of day do you eat these foods? Regular soda pop Sweet roll/pastries Cookies

Candy, candy bars Ice cream Frozen desserts Pie, Cake

Other Do you drink alcohol?  No  Beer  Wine  Liquor How often? How much? If the doctor recommends a change in your current eating habits, would this be difficult? Yes  No  If yes, why? Appetite/allergies/intolerances Food /drug allergies: What would you like to know more about?  Weight loss  Exercise  Eating out  Label reading  Alcohol use  Sweeteners Other: What would you hope to accomplish or gain from this appointment?  Improve blood glucose  Lose weight  Lower cholesterol/triglycerides  Improve eating habits  Start exercising  Get more information  Other: Are there concerns for gestational diabetes? Are you exercising now?  Yes  No If no, what would you consider? Exercise:  Walking  Exercise class Other: Patient comments: Food frequency: Whole grains

Grains Veggies Fruit Milk Meats

Time: Breakfast or first meal: Time: Snack: Time: Lunch or second meal: Time: Snack: Time: Dinner or third meal: Time: Snack: O: See CH-12 and available lab reports, growth charts. Pre-pregnancy Weight: Age: Pre-pregnancy Weight Category:  Underweight  Normal  Overweight  Obese Total Weight Gain: Adequate  Inadequate  Excess  Lives with: OGTT: Date OGTT: Glucose Meter: B/P Hgb SMBG: Frequency: Testing Times: Records/log kept:  Yes  No Medical clearance for exercise: Yes  No  Exercise limitations:

Page 13 Medical Nutrition Therapy Policy 407 December 2024

A: Readiness to change: Precontemplation  Contemplation  Preparation  Action  Maintenance  EER: 1st trimester = no additional calories 2nd trimester = additional 340 calories/day 3rd trimester = additional 452 calories/day

P: 1 starch = 15 g. CHO, 3 g. protein, 1 fat, 80 calories 1 fruit = 15 g. CHO, 60 calories 1 milk = 12 g. CHO, 8 g. protein, 1 fat, 90 calories 1 Vegetable = 5 g. CHO, 2 g. protein, 25 calories 1 meat(subst.) = 7 g. protein, 5(3) fat, 75 (55) calories 1 fat = 5 fat, 45 calories Time Breakfast Snack Lunch Snack Dinner Snack Total servings/day CHO (g) Protein (g) Fat Calories Starch Fruit Milk Veggie Meat/Subst. Fat X4 X4 X9 Total calories OR Total calories: Breakfast Lunch Dinner # CHO choices Time: Time: Time: CHO grams # CHO choices # CHO choices # CHO choices Protein grams CHO grams CHO grams CHO grams

Snack Snack Snack Time: Time: Time: # CHO choices # CHO choices # CHO choices CHO grams CHO grams CHO grams

Goals/Instructions: Follow-up: Handouts used: Identified Barriers Signature: Date: Comprehension 

MNT-Renal Rev. 10/18 Page 14 Medical Nutrition Therapy Policy 407 December 2024

Medical Nutrition Therapy Assessment MNT-Renal

Name:

MNT-Gestational Diabetes Begin Time:

End Time:

Primary ICD9/10: V653-/ Z71.3 Secondary ICD9/10:

ID Number:

or

Place PEF label here S: Referring Physician: Other diagnoses: Diet Order: Previous Diet Instruction: Yes  No  Previous diets: Dentition:  good  missing some teeth  edentulous  dentures  chewing problems Food Allergies: No  Yes  If yes, list foods: Appetite: excellent  good  fair  poor  Medications: Herbal remedies/Vitamin-mineral supplements: OTC medications: Oral nutrition supplement: No  Yes  If yes, list

Time: Breakfast or first meal: Time: Snack: Time: Lunch or second meal: Time: Snack: Time: Dinner or third meal: Time: Snack: Do you have any eating or digestion problems? Swallowing  Stomach ache  Diarrhea  Constipation  Other: Activity Level:  Non ambulatory  moderate  active Vision: good  impaired  blind  Hearing:  good  HOH  deaf Psychosocial:  lives by self  with others Language barrier:  Yes  No Shopping done by: Occupation: Education level: Cooking done by: Support systems (e.g., food stamps, Meals on Wheels) How often each week do you eat in restaurants, cafeterias, or away from home? Breakfast /week Lunch /week Dinner /week Smoking: No  Yes  # packs/day

Alcohol: Yes  No  Salt substitute: Yes  No  O: Height: Present Weight: BMI: IBW: % IBW: Usual weight: % usual weight: Frame: Adj. Wt.: (obesity) Adj. Wt.: (amputees) % wt. Change: Loss/gain X (time) Age: Male  Female  Marital status:  single  married  widowed  divorced  separated Nutrition related medications: Chemistries: Date: Vitamins Hgb./Hct. Non RX vitamins Fe+/Ferritin P04 Binders % Trans sat Vit. D/Vit. D analogs BUN/Creatine Iron supplements K+/Na+ Epogen/Procrit Alk. Phos/Ca+ Anti-diabetic agents PO4/PTH BP Meds Glucose/A1C Laxatives/stool softeners Chol./TG Anti-hyperlipidemics GFR/Creat. Clear. Other Other Physical exam – Rate as follows: 0 = Normal 1 = Mild 2 = Moderate 3 = Severe Loss of subcutaneous fat

Muscle wasting

Ankle edema

Sacral edema

Ascites

Skin condition: intact  open areas  If open areas, describe:

Page 15 Medical Nutrition Therapy Policy 407 December 2024

A: Nutrient needs: calories

protein

Current diet order meets dietary needs: Yes  No  If no, review with MD Current intake: adequate  inadequate  Unable to determine  30 days loss/gain % 90 days loss/gain % 180 days loss/gain % Nutritional status: well nourished  at risk  mild malnourished  moderate malnourished  severe malnourished  Voices understanding of diet instruction: Yes  No  Expresses readiness to learn: Yes  No  Comments: Functional Capacity: No dysfunction  Dysfunction  Duration

Working sub optimally  Ambulatory  Bedridden  Is the subject independent in: Bathing?  Yes  No Transferring?  Yes  No Dressing?  Yes  No Continence?  Yes  No Toileting?  Yes  No P: Goals/Instruction: Follow-up: Handouts used: Identified Barriers: Signature: Date: Comprehension  MNT-Renal

Page 16 Medical Nutrition Therapy Policy 407 December 2024

Medical Nutrition Therapy MNT- Follow-Up Begin Time: End Time: # Units:

Primary ICD9/10: V653-/ Z71.3 Secondary ICD9/10:

Type of Meal Plan: Date: Other Comments: Medication Changes: Exercise: Lab Values/Changes: Weight Changes:

Blood Pressure:

Blood Glucose:

Cholesterol:

Other:

Identified Barriers:

Readiness to Change/Compliance: 24 hour recall Time: Breakfast: Time: Snack: Time: Lunch: Time: Snack: Time: Supper: Time: Snack: Progress Toward Goals/New Goals:

Materials Provided: Referral: Y or N Reason: MD RN Social Services Other: Follow MNT Visit: Progress Note Sent to MD: Yes No Signature: Date: Adapted from the Lincoln Trail District Health Department & Laurel County Health Department Nutrition Follow-up Medical Nutrition Therapy forms MNT- Follow UP DEV10/15 Name:

ID Number

Or place PEF label here

Page 17 Medical Nutrition Therapy Policy 407 December 2024

MEDICAL NUTRITION THERAPY GROUP NUTRITION EDUCATION A. The following is a list of topics that are appropriate for group nutrition education in the clinic setting under the MNT group class code. The lesson plans with pre-and post-test for each class are available from the Nutrition Services Branch. All MNT group classes must be taught by a Registered Dietitian or Certified Nutritionist.

Medical Nutrition Therapy Topics Possible Handouts Class Information Diabetes Meal Planning  Dining Out Made Healthy  Read It Before You Eat It/Steps to Reading a Food Label Healthy methods to eating out; artificial sweeteners, CHO counting, glycemic index, label reading, portion sizes Heart Health  Cholesterol Round-up  DASH: The Proven Way to Lower Your Blood Pressure  Trans-Fatty Acids: What, another fat?  Triglyceride Facts Class 1: Cholesterol Class 2: Sodium Class 3: DASH/hypertension Class 4: Triglycerides Dining with Diabetes West Virginia Cooperative Extension Program Lessons, overheads, and recipes, pre-test and post-test Weight Loss  Activity Pyramid  Dining Out Made Healthy  My Pyramid (specific calorie level) Physical activity, portion sizes, label reading, healthy methods of cooking; healthy eating out Documentation in each class attendees’ medical record must include: A. Class attended B. Date C. Outcome expected for the class attendee D. Follow-up appointment E. Pre- and post-test data F. Specific health measures (can be referral information from a physician) 1. Height, weight, and Body Mass Index (BMI) 2. Cholesterol 3. Triglycerides 4. LDL 5. Blood glucose 6. Blood pressure 7. Hemoglobin A1C G. Signature of class provider, title

Page 1 Section 400 Nutrition Education and Counseling Appendices December 2024

Section 400 Appendices Nutrition Education and Counseling

Page 2 Section 400 Nutrition Education and Counseling Appendices December 2024

WIC Certification Nutrition Education Counseling Protocol ........................... 3 Individual WIC High-Risk Counseling Nutrition Education Protocols ............ 9 Reference Materials for Certification and Follow-up Counseling Guidelines ............................................................................... 14 WIC Certifying Health Professional Checklist .............................................. 18

Page 3 Section 400 Nutrition Education and Counseling Appendices December 2024

WIC CERTIFICATION NUTRITION EDUCATION COUNSELING PROTOCOL

Page 4 Section 400 Nutrition Education and Counseling Appendices December 2024

WIC Certification Nutrition Education Counseling Protocol (In addition to this counseling, all WIC participants must be provided counseling on Specific Nutritional Risk) Provider: Certifying Health Professional Topic WIC Certification General Nutrition Counseling Protocol by Status Discuss WIC Program eligibility and benefits • Purpose of the WIC Program (Nutritional support through supplemental food, nutrition education, breastfeeding support and referrals) • WIC is a partnership between the participant and WIC staff. • Discuss certification process including nutrition assessment to provide individualized nutrition education, eligibility period and recertification schedule. • Discuss importance and benefits (nutrition education, breastfeeding support, referrals, and healthy foods) for continued participation in the program. Counsel on basic diet and the importance of regular physical activity. Determine what concerns or questions the participant has in regard to her nutrition, child’s nutrition, and/or infant’s nutrition? Provide counseling to address questions/concerns/dietary habits. For women and children: • Review Choose My Plate Dietary Guideline Tip Sheet or My Pyramid for Kids and Activity Pyramid. • Review dietary concern(s) and appropriate action. • Encourage an average of 30 minutes for women and 60 minutes for children of physical activity each day. • Limit screen time to no more than 2 hours/day. • Remove the television from the child’s bedroom. • Encourage healthy foods (e.g., low-fat and reduced fat food choices including 1% or less milk, (women/children > 2), 5 Fruits and Vegetables per day & Avoid Sugar Sweetened Drinks) • Refer to health care provider/Lead Program for lead screening and assessment. For infants: • Discuss Kentucky Infant Feeding Guide appropriate for age and development. • Encourage caregiver(s) to promote physical activity and motor skill development in their infant (rolling over, standing, movement, play). • Review dietary concern(s) and appropriate action. • Refer to health care provider/Lead Program for lead screening and assessment. Encourage to breastfeed unless contraindicated for health/lifestyle reasons. See Breastfeeding Counseling and Contraindications in this section. For pregnant women: • Discuss the advantages of breastfeeding. • Discuss the benefits of Kangaroo Care. For breastfeeding women: • Encourage continuation and support of breastfeeding. • Discuss the benefits of Kangaroo Care. Discuss the effects of drug and other harmful substance use (tobacco, alcohol, drugs). • Discuss how tobacco and/or alcohol can affect the woman, fetus, infant, and child. This should include information about smoking cessation if appropriate and the effects of secondhand smoke. • Discuss recommendations to not use tobacco products. Refer to 1-800-QUIT NOW (1-800-784-8669) if client smokes. • Discuss recommendations to not take any medications, over the counter or otherwise, unless specifically ordered by a physician. • Discuss recommendations to not use drugs (marijuana, cocaine, etc.). • Discuss recommendations to not drink alcohol. Discuss Safe Sleep Environment for Infants For infants: • Discuss American Academy of Pediatrics (AAP) Safe Sleep Policy. (See Safe Sleep Environment for Infants in this section)

Page 5 Section 400 Nutrition Education and Counseling Appendices December 2024

For participants being recertified for the WIC Program • Review and discuss previously set goals. • For participants who completed online nutrition education lesson, review and discuss the lesson completion certificate, participant goal set during the lesson, and links visited. Discuss specific nutritional risk for which participant qualifies. • See Table 2: WIC Certification Counseling for Specific Nutritional Risk Protocol

WIC Certification Counseling for Specific Nutritional Risk Protocol WIC participants must be provided WIC Certification Nutrition Education Counseling based on their individual risk code assignment. *Status Code: P= any Pregnant Status, BF= any Breastfeeding Woman Status, PP= Postpartum Status, C= Child Status, I= any Infant Status Provider: Certifying Health Professional Risk/Status*/ Reference Materials** Counseling/Education Referral Guidance Low Hematocrit/Low Hemoglobin Status: P, PP, BF, C, I ● Define low hematocrit/low hemoglobin. ● DISCUSS IRON-RICH FOODS. Refer for Medical Evaluation:  All status Hematocrit < 27% Hemoglobin < 9 gm./dL. Elevated Blood Lead Status: P, PP, BF, C, I • Discuss the importance of adequate calories, calcium, iron, vitamin C and low-fat foods (for children after age 2), which decrease the absorption of lead. • Discuss the importance of regular meals and snacks. • Discuss CDC recommendations regarding mother’s lead levels and breastfeeding (Breastfeeding Woman). See Blood Lead Levels & Breastfeeding. Refer for Medical Evaluation. See Lead Guidelines in Core Clinical Services Guide (CCSG). Schedule for High-Risk Secondary Nutrition Education, Refer for MNT per Professional Judgement Low Head Circumference Status: I, C (up to age 2) • Discuss the impact of prematurity to growth and development, if age adjusted. • Discuss the importance of nutrition on growth and development Refer for Medical Evaluation. Preterm Birth/Early Term Birth Status: I, C (up to age 2) • Discuss the impact of prematurity to growth and development. • Discuss the importance of good nutrition for proper growth and development. Low Birth Weight/Very Low • Discuss the impact of birth weight to growth and development. • Discuss the importance of good nutrition for proper growth and development. Birth Weight Schedule for High-Risk Status: I, C (up to age 2) Secondary Nutrition Education, Refer for MNT per Professional Judgement At Risk for Overweight Status: I, C • Discuss the importance of prevention of overweight. • Discuss the importance of physical activity. • Reduce sedentary activity such as computer games and watching television. • Discuss appropriate quantity of food. • Discuss healthy foods (e.g., low-fat and reduced fat food choices). (children >age 2)

Page 6 Section 400 Nutrition Education and Counseling Appendices December 2024

• Discuss the importance of good nutrition for proper growth and development. (infants) Overweight, Obese, High Weight for Length Status: P, PP, BF, C, I • Review growth chart. (children) • Discuss the importance of physical activity. • Reduce sedentary activity such as computer games and watching television. • Discuss appropriate quantity of food. • Discuss healthy foods (e.g., low-fat and reduced fat food choices). (women/children >age 2) Schedule for High-Risk Secondary Nutrition Education, Refer for MNT per Professional Judgement At Risk for Underweight Status: I, C • Review growth chart. • Discuss importance of frequent feeding. • Discuss healthy foods in relation to growth and development. Underweight Status: P, PP, BF, I, C • Review growth chart. (Infants and children) • Discuss importance of frequent feeding. • Discuss healthy foods in relation to growth, development and appropriate weight gain. Schedule for High-Risk Secondary Nutrition Education, Refer for MNT per Professional Judgement At Risk for Short Stature Status: I, C • Discuss growth for age and stature/size of parents. • Discuss healthy foods in relation to growth and development. Short Stature Status: I, C • Discuss growth for age and stature/size of parents. • Discuss healthy foods in relation to growth and development. Growth Problems Status: I, C • Discuss growth for age and stature/size of parents. • Discuss healthy foods in relation to growth and development. Inappropriate Weight Gain Pattern Status: P, PP, BF, I, C Pregnant woman • Discuss the importance of appropriate weight on the developing fetus. Postpartum or breastfeeding woman • Discuss the importance of an adequate diet to promote lactation and/or attaining standard weight. Infant • Discuss the importance of frequent feeding in relation to weight gain. Children • Discuss healthy foods in relation to growth and development. Alcohol and Substance Use Status: P, PP, BF • Discuss the importance of discontinuing the identified substance use (tobacco, alcohol, drugs) (S-A-D). • Discuss the importance of discontinuing smoked tobacco, electronic nicotine delivery systems (ENDS), smokeless tobacco (chewing tobacco, snuff, dissolvable,) hookahs, cigars, pipes, and nicotine replacement therapies (gums, patches). Refer to counseling and/or treatment as appropriate. Environmental Tobacco Smoke Exposure Status: P, PP, BF, I, C • Discuss the importance of consuming foods high in vitamin C. • Discuss the importance of fruits and vegetables in the diet. • Discuss risk of third hand smoke. BF Infant/BF Woman at Nutritional Risk Status: I, P, BF Breastfed infant • Discuss adequate diet for lactation and health. Breastfeeding mother • Discuss the impact of mother’s health on growth and development of infant.

Page 7 Section 400 Nutrition Education and Counseling Appendices December 2024

Breastfeeding Complications Status: BF, P, I • Discuss the impact of an adequate diet. • Discuss the importance of frequent feeding. • Discuss specific condition/problem. Refer to IBCLC/Designated Breastfeeding Expert (DBE)/Nutritionist/Dietitian Refer for Medical Evaluation:  Mastitis or Severe nipple pain Infant of a WIC Mother/ Mother at Risk Status: I • Discuss the impact of mother’s nutritional risk during pregnancy to infant’s health. • Discuss an adequate diet for the infant. • Discuss specific condition/problem. Infant of a Mother with Complications that Impair Nutrition Status: I • Discuss an adequate diet at an appropriate level of comprehension for the client. Pregnancy Induced Conditions Status: P, PP, BF • Discuss specific condition/problem. • Discuss the additional demand on nutrient stores. Schedule for High-Risk Secondary Nutrition Education, Refer for MNT per Professional Judgement Delivery of Preterm /Early Term/ Low Birth Weight Infant Status: P, PP, BF Pregnant • Discuss the problems identified and the effect on current health. • Stress the importance of appropriate weight gain. Breastfeeding/Postpartum • Discuss the problems identified and the effect on current health. Fetal or Neonatal Death Status: P, PP, BF • Discuss the problems identified and the effect on current health. General Obstetrical Risk Status: P, PP, BF Pregnant • Discuss the importance of appropriate weight gain for the developing fetus. • Discuss the additional demand on nutrient stores. Breastfeeding/Postpartum • Discuss the additional demand on nutrient stores. Nutrition/Metabolic Conditions/Infectious Disease Acute or Chronic Status: P, PP, BF, I, C Pregnant/Breastfeeding/Postpartum • Discuss the relationship of the specific condition/problem to nutritional status and its potential impact on woman’s current status. • Discuss impact of over-the-counter medications and nutrient interactions. Infant/Child • Discuss the relationship of the specific condition/problem to nutritional status and its importance to growth and development. • Discuss impact of over-the-counter medications and nutrient interactions. Schedule for High-Risk Secondary Nutrition Education, Refer for MNT per Professional Judgement except:  Lactose Intolerance  Short Term Antibiotic Use – Drug Nutrient Interaction  Asthma – persistent asthma that requires daily medication.  Food allergies – per patient request and/or professional discretion Impaired Ability to Prepare Food Status: P, PP, BF, I, C • Discuss an adequate diet at an appropriate level of comprehension for the client. • Discuss the specific condition/problem. Refer to Social Programs.

Page 8 Section 400 Nutrition Education and Counseling Appendices December 2024

Complications which Impair Nutrition Status: P, PP, BF, I, C Pregnant/Breastfeeding/Postpartum • Discuss an adequate diet at an appropriate level of comprehension for the client. • Discuss the relationship of the specific condition/ problem to nutritional status and its potential impact on woman’s current status. Infant/Child • Discuss an adequate diet at an appropriate level of comprehension for the client. • Discuss the relationship of the specific condition/ problem to nutritional status and its importance to growth and development. Schedule for High-Risk Secondary Nutrition Education, Refer for MNT per Professional Judgement For: • Complications/ Potential complications which impair nutrition/delays/disabilities that impair chewing/swallowing/require tube feeding. Dental Problems Status: P, PP, BF, I, C Pregnant/Breastfeeding/Postpartum/Child/Infant • Discuss the importance of proper dental care. • Drink/provide only water between meals. • Limit sugary foods/drinks. Limit juice intake to 100% juice & no more than 4-6 ounces per day. • Brush teeth twice daily. • Talk to dentist/doctor regarding fluoride. • Follow up with your dentist as appropriate for dental problems. Infant/Child • Breastfeeding is recommended for the 1st year of life and beyond as mutually desired. • Avoid having infant/child sleep with bottle. • Wipe the gums of young infants with a soft washcloth or soft toothbrush, even prior to tooth eruption. Other Health Risk/Fetal Alcohol Spectrum Disorder Status: P, PP, BF, I, C • Discuss adequate diet. Presumed Dietary Risk Status: P, PP, BF, C (age 2 and older) • Counsel on adequate diet. Feeding Practices Status: P, PP, BF, I, C • Counsel on specific problem (s) Inappropriate Nutrient Intake Status: P, PP, BF, C • Discuss the importance of calcium and protein sources. • Counsel on adequate diet. Eating Disorders Status: P, PP, BF • Discuss the relationship of the specific condition/ problem to nutritional status and its potential impact on woman’s current status. • Counsel on adequate diet. • Schedule for High- Risk Secondary Nutrition Education, Refer for MNT per Professional Judgement • Refer for Medical Evaluation. Recipient of Abuse Status: P, PP, BF, I, C • Counsel on adequate diet. • Counsel based on readiness. Refer to Social Programs. Foster Care Status: P, PP, BF, I, C • Counsel on adequate diet. Children • Discuss specific problem/condition such as chronic health problems, birth defects, short stature and inadequate nutrition. Refer to Social Programs. Homelessness Status: P, PP, BF, I, C • Counsel on adequate diet with emphasis on homelessness/migrancy as appropriate. Refer to Social Programs. Migrancy Status: P, PP, BF, I, C • Counsel on adequate diet with emphasis on homelessness/migrancy as appropriate. Refer to Social Programs.

Page 9 Section 400 Nutrition Education and Counseling Appendices December 2024

Possibility of Regression- Priority III Status: C • Discuss the importance of a good diet in preventing the previous risk from recurring. Possibility of Regression- Priority IV Status: C • Encourage continuance of a good diet as appropriate for child’s age. Transfer of Certification Status: P, PP, BF, I, C • Provide nutrition education for condition/problem, if known.

Page 10 Section 400 Nutrition Education and Counseling Appendices December 2024

HIGH RISK FOLLOW-UP COUNSELING PROTOCOLS TABLE

Page 11 Section 400 Nutrition Education and Counseling Appendices December 2024

Individual WIC High-Risk Counseling Nutrition Education Protocols Status: P= any Pregnant Status; BF= any Breastfeeding Status; PP= Postpartum Status; C= Child Status; I= any Infant Status PROVIDER: CERTIFYING HEALTH PROFESSIONAL Topic /Status/ Counseling/Education Low Hematocrit/Low Hemoglobin Status: P, PP, BF, I, C • Discuss Iron and Vitamin C sources in the diet. • Discuss the importance of Iron and role of iron in red blood cells. • Discuss the absorption of iron sources and role of vitamin C in Iron absorption. Elevated Blood Lead Status: P, PP, BF, I, C • Discuss importance of adequate intake of calories, calcium, iron, vitamin C and low-fat foods (after the age of 2) which decreases the absorption of lead. • Discuss the importance of regular meals and snacks. Low Head Circumference Status: I, C (up to age 2) • Discuss age-appropriate feeding for the infant. Preterm/Early Term Birth Status: I, C (up to age 2) • Discuss age-appropriate feeding for infant development or up to age 2 children. • Review growth chart and weight goals. Low Birth Weight /Very Low Birth Weight Status: I, C (up to age 2) • Discuss age-appropriate feeding for infant’s or child’s development. • Review growth chart and weight goals.

At Risk for Overweight Status: I, C • Discuss the importance of prevention of overweight. • Discuss age-appropriate feeding for infant’s or child’s development. • Discuss the importance of regular physical activity. • Review dietary concern(s) and appropriate action.

Overweight, Obese, High Weight for Length Status: P, PP, BF, C, I Infant/Child • Review growth chart and weight goals. • Discuss age-appropriate feeding for child’s development. • Discuss the importance of regular physical activity. Pregnant/Postpartum/Breastfeeding Women • Review weight goals. • Discuss possible reasons for weight status. • Review Choose My Plate Dietary Guideline Tip Sheet or My Pyramid to encourage appropriate weight status. Discuss the importance of regular physical activity. At Risk for Underweight STATUS: I, C #2, #3, #7-10 (C) Infant/Child • Review growth chart and weight goals. • Discuss age-appropriate feeding for infant’s or child’s development.

Underweight Status: P, PP, BF, I, C Infant/Child • Review growth chart and weight goals. • Discuss age-appropriate feeding for infant’s or child’s development. Pregnant/Breastfeeding/Postpartum Women • Review weight goals. • Discuss possible reasons for weight status. • Review Choose My Plate Dietary Guideline Tip Sheet or My Pyramid to encourage appropriate weight status. At Risk for Short Stature Status: I, C • Review growth chart and height goals. • Discuss age-appropriate feeding for infant’s or child’s development. • Discuss importance of protein for growth. Short Stature Status: I, C • Review growth chart and height goals. • Discuss age-appropriate feeding for infant’s or child’s development. • Discuss importance of protein for growth. Growth Problems Status: I, C • Discuss age-appropriate feeding for infant’s or child’s development. • Review growth chart and weight goals. • Discuss importance of protein for growth.

Inappropriate Weight Gain Pattern Status: P, PP, BF, I, C Infant/Child • Discuss age-appropriate feeding for infant’s or child’s development. • Review growth chart and weight goals. Pregnant/Breastfeeding/Postpartum Women • Review weight goals. • Discuss possible reasons for weight status.

Page 12 Section 400 Nutrition Education and Counseling Appendices December 2024

• Review Choose My Plate Dietary Guideline Tip Sheet or My Pyramid to encourage appropriate weight status.

Alcohol and Substance Use Status: P, PP, BF • Discuss the importance of discontinuing the identified substance use (tobacco, alcohol, drugs) (SAD). • Discuss how the identified use can affect the mother and her fetus, or her infant or other household members. • Discuss the importance of discontinuing smoked tobacco, electronic nicotine delivery systems (ENDS), smokeless tobacco (chewing tobacco, snuff, dissolvable tobacco products,) hookahs, cigars, pipes, and nicotine replacement therapies (gums, patches). • Environmental Tobacco Exposure Status: P, PP, BF, I, C • Discuss the importance of continuing a healthy diet. • Discuss risk of third hand smoke. Breastfeeding Infant/BF Woman at Nutritional Risk STATUS: I, BF • Discuss an adequate diet for the infant. • Discuss using WIC foods to promote optimal health. • Discuss recommended number of servings from My Pyramid and the importance of WIC foods. Breastfeeding Complications Status: I, P, BF • Reinforce the importance of an adequate diet. • Reinforce the importance of frequent feeding. • Discuss specific condition/problem. Breastfeeding Infant/BF Woman with Feeding Practices STATUS: I, P, BF • Discuss an adequate diet for the infant. • Discuss using WIC foods to promote optimal health. • Discuss recommended number of servings from My Pyramid and the importance of WIC foods. Infant of a WIC Mother/ Mother at Risk Status: I • Discuss an adequate diet for the infant. Infant of a Mother with Complications that Impair Nutrition Status: I • Discuss an adequate diet at an appropriate level of comprehension for the client. Impaired Ability to Prepare Food Status: P, PP, BF, I, C • Discuss the importance of an adequate diet. • Discuss specific condition/problem.

Pregnancy Induced Conditions Status: P, PP, BF • Encourage appropriate weight gain. • Discuss increased nutrient needs. • Reinforce an adequate diet. • Discuss specific condition/problem. • Discuss adequate diet at an appropriate level of comprehension for the client Delivery of Preterm/Early Term / Low Birth Weight Infant Status: P, PP, BF Pregnant • Discuss the problems identified and the effect on current health. • Stress the importance of appropriate weight gain. Breastfeeding/Postpartum • Discuss the problems identified and the effect on current health. Fetal or Neonatal Death Status: P, PP, BF • Reinforce the importance of an adequate diet for health. General Obstetrical Risk Status: P, PP, BF • Discuss specific condition/problem. • Discuss the importance of an adequate diet. Nutrition/Metabolic Conditions/Infectious Acute or Chronic Disease Status: P, PP, BF, I, C • Discuss specific condition/problem. • Discuss the importance of an adequate diet. Impaired Ability to Prepare Food Status: P, PP, BF, I, C • Discuss the importance of an adequate diet. • Discuss specific condition/problem. Complications which Impair Nutrition Status: P, PP, BF, I, C • Discuss specific condition/problem. • Discuss the importance of an adequate diet. • Discuss an adequate diet at an appropriate level of comprehension for the client. Dental Problems Status: P, PP, BF, I, C • Discuss specific condition/problem. • Discuss the importance of an adequate diet.

Page 13 Section 400 Nutrition Education and Counseling Appendices December 2024

Other Health Risk/Fetal Alcohol Spectrum Disorder Status: P, BF, PP, I, C • Discuss the importance of a good diet. Presumed Dietary Risk Status: P, PP, BF, C (age 2 and older). • Discuss the importance of a good diet. Feeding Practices Status: P, PP, BF, I, C • Discuss specific problem and relationship to health, growth or development. Inappropriate Nutrient Intake Status: P, PP, BF, C • Discuss the importance of an adequate diet. Eating Disorders Status: P, PP, BF • Discuss specific condition/problem. • Discuss the importance of an adequate diet. Recipient of Abuse Status: P, PP, BF, I, C • Discuss the importance of an adequate diet. Foster Care Status: P, PP, BF, I, C • Discuss the importance of an adequate diet. Children – • Discuss specific condition/problem such as chronic health problems, birth defects, short stature and inadequate nutrition. Homelessness or Migrancy STATUS: P, PP, BF, I, C • Discuss the importance of an adequate diet with emphasis on homelessness or migrancy. Possibility of Regression Status: C • Discuss the importance of an adequate diet. Possibility of Regression-Priority III Status: C • Discuss the importance of an adequate diet. Transfer of Certification- Priority IV Status: P, PP, BF, I, C • Provide nutrition education, as appropriate.

Individual WIC High Risk Counseling Nutrition Education Protocols PROVIDER: LACTATION SPECIALIST Topic /Status*/ Reference Materials** See Page 41 For Listing of Reference Materials by Number Counseling/Education Breastfeeding Infant/BF Woman at Nutritional Risk STATUS: I, P, BF • Discuss an adequate diet for the infant. • Discuss using WIC foods to promote optimal health. • Discuss recommended number of servings from My Pyramid and the importance of WIC foods. Breastfeeding Complications Status: I, P, BF • Reinforce the importance of an adequate diet. • Reinforce the importance of frequent feeding. • Discuss specific condition/problem. Breastfeeding Infant/BF Woman with Feeding Practices STATUS: I, P, BF • Discuss an adequate diet for the infant. • Discuss using WIC foods to promote optimal health. • Discuss recommended number of servings from My Pyramid and the importance of WIC foods.

Page 14 Section 400 Nutrition Education and Counseling Appendices December 2024

REFERENCE MATERIALS FOR CERTIFICATION AND FOLLOW-UP COUNSELING GUIDELINES

Page 15 Section 400 Nutrition Education and Counseling Appendices December 2024

Nutrition and Breastfeeding Education Materials for Certification and Follow-Up Counseling LOCALLY DEVELOPED NUTRITION EDUCATION MATERIALS Locally developed nutrition and breastfeeding education materials must be submitted to the State WIC Office for review and approval. Any materials developed for WIC Program outreach or nutrition education with the WIC logo, Kentucky Shape the Future Breastfeeding logo or the Kentucky Eat More Fruits and Veggies logo must be submitted to the State WIC Office for review and approval.

STATE OR USDA AVAILABLE NUTRITION EDUCATION MATERIALS Approved WIC Nutrition Education materials are listed in the table below.

The Kentucky WIC Program is currently working on printing updated nutrition education materials. Agencies have been receiving quarterly shipments of the updated nutrition and breastfeeding education materials. Below is a crosswalk that can be used to assist certifying health professionals in determining appropriate handouts to use for nutrition education and breastfeeding counseling.

Nutrition and breastfeeding education materials can be ordered from the State WIC Office or printed from the CHFS Nutrition Education Website at https://www.chfs.ky.gov/agencies/dph/dmch/nsb/Pages/nutedmaterials.aspx .

Status/Target Audience Previous Nutrition Education & Breastfeeding Education Material NEW 2024 and Ongoing Nutrition and Breastfeeding Education Materials Pregnancy/Breastfeeding Getting Started with Breastfeeding • Breastfeeding Basics for Moms • Learn to Start Breastfeeding Pregnancy/Breastfeeding Breastfeeding: Planning Ahead During Pregnancy • Breastfeeding Basics for Moms • Learn to Start Breastfeeding Pregnancy/Breastfeeding Kangaroo Care/Skin to Skin • Kangaroo Care handout is available on the CHFS WIC Nutrition Education Materials website only. Pregnancy/ Breastfeeding Family Support N/A • Breastfeeding Basics for Dads Pregnancy/ Breastfeeding Family Support N/A • Breastfeeding Basics for Grandmothers Pregnancy Kentucky Prenatal Nutrition Guides • Tips for Pregnant Moms • Healthy Eating for Pregnant and Breastfeeding Women Pregnancy Weight Gain During Pregnancy • Tips for Pregnant Moms Pregnancy Tips for Pregnant Moms • Tips for Pregnant Moms

Page 16 Section 400 Nutrition Education and Counseling Appendices December 2024

Post Partum Woman Postpartum Nutrition Guide • The PP Nutrition Guide is currently Under Revision, current version may be printed from the CHFS WIC Nutrition Education Materials website Infant Kentucky Infant Feeding Guides • Feeding Birth to Age 2 • Healthy Eating for Infants Infant Homemade Baby Food • Homemade Baby Food is currently Under Revision, current version may be printed from the CHFS WIC Nutrition Education Materials website Infant Safe Sleep for Your Baby • Safe Sleep for Your Baby (no change) Infant/Toddler Weaning from the Bottle • Weaning from the bottle is currently Under Revision, current version may be printed from the CHFS WIC Nutrition Education Materials website Toddler Toddler Feeding Guide Age 1 to 3 • Healthy Eating for Toddlers (My Plate) • Mealtimes for Toddlers • Reducing the Risk of Choking in Young Children at Mealtimes (Coming Soon) Child Child Feeding Guide Age 3 to 5 • Start Simple Eating for Preschoolers • Healthy Eating for Preschoolers Child Healthy Tips for Picky Eaters • Revised Healthy Tips for Picky Eaters (Coming Soon) Child Activity Pyramid • Healthy Tips for Active Play (Coming Soon) Child How to Care for Your Child’s Teeth • How to Care for your Child’s Teeth is currently Under Revision Child Healthy Tips for Active Play • Revised Healthy Tips for Active Play (Coming Soon) MyPlate/ Healthy Eating for the Family Tips to Increase Fruits and Veggies • Healthy Eating for the Family (Coming Soon) MyPlate/ Healthy Eating for the Family Choose My Plate DG Tip Sheet 1 & 7 (Choose My Plate & Build a Healthy Meal) • Healthy Eating for the Family (Coming Soon) MyPlate/ Healthy Eating for the Family My Plate DG Tip Sheet 12 & 13 (Be A Healthy Role Model & Cut Back on Sweet Treats) • Healthy Eating for the Family (Coming Soon)

Page 17 Section 400 Nutrition Education and Counseling Appendices December 2024

MyPlate/ Healthy Eating for the Family My Plate DG Tip Sheet 9 & 10 (Smart Shopping & Liven Up Your Meals) • Healthy Eating on a Budget (Coming Soon) MyPlate/ Healthy Eating for the Family My Plate DG Tip Sheet 2 & 3 (Add More Vegetables & Focus on Fruits) • Healthy Eating for the Family (Coming Soon) MyPlate/ Healthy Eating for the Family My Plate DG Tip Sheet 6 & 8 (Protein Foods & Healthy Eating for Vegetarians) • Healthy Eating for the Family (Coming Soon) MyPlate/ Healthy Eating for the Family My Plate DG Tip Sheet 24 (Snack tips for parents) • Healthy Eating for the Family (Coming Soon) Family Healthy Habits 5,2,1,0 Healthy Numbers for Kentucky Families Combination Brochure • Available on CHFS WIC Nutrition Education Materials website only. Family Healthy Habits (Smoking, Alcohol and Tobacco) Smoking-Alcohol-Drugs: How can it affect you and your family? • Smoking , Alcohol and Tobacco is currently Under Revision, current version may be printed from the CHFS WIC Nutrition Education Materials website Family Healthy Habits (Required Exit Counseling) Healthy Choices for You and Your Family • Family Healthy Habits is currently Under Revision, current version may be printed from the CHFS WIC Nutrition Education Materials website Lead Poisoning Prevention Lead Prevention Diet • Lead Prevention, Are You Pregnant (CDC)- coming soon • Lead Poisoning, 5 Things You Can Do (CDC)- coming soon Food Safety Food Safety • Available on CHFS WIC Nutrition Education Materials website only. Nutrient: Iron Iron for Strong Red Blood Cells • Iron for Strong Red Blood Cells is currently Under Revision, current version may be printed from the CHFS WIC Nutrition Education Materials website Nutrient: Calcium Calcium • Available on CHFS WIC Nutrition Education Materials website only Nutrient: Vitamin A & C Vitamin A/Vitamin C • Available on CHFS WIC Nutrition Education Materials website only Whole Grains Whole Grains • Available on CHFS WIC Nutrition Education Materials website only Tofu Tofu • Available on upon request, contact the State WIC office. Beans Beans • Available on CHFS WIC Nutrition Education Materials website only

Page 18 Section 400 Nutrition Education and Counseling Appendices December 2024 WIC CERTIFYING HEALTH PROFESSIONAL CHECKLIST The WIC Certifying Health Professional Checklist is shown on the following page. This is a resource for WIC Health Professionals to ensure staff completes each required step of a WIC Certification, WIC MCHA, WIC High- Risk, and WIC Low-Risk Nutrition Education visit. A copy can be requested from the Clinical Nutrition Section of the Nutrition Services Branch Office or click the following link to print a copy: WIC Certifying Health Professional Checklist

WIC and Nutrition Manual 500 Policy Group Breastfeeding Promotion and Support

Table of Contents

Policy 500

Breastfeeding Support

Policy 501

Breastfeeding Promotion and Support Standards

Policy 502

Breastfeeding: Breastfeeding Pump Issuance and Tracking Guidelines

Policy 503

Breastfeeding Accessories

Policy 504

Breastfeeding Peer Counseling Program

Policy 505

Regional Breastfeeding Coordinator

Policy 506 WIC Breastfeeding Support via Technology

Policy 500

Appendices BF Promotion and Support

Page 1 Breastfeeding Support Policy 500 December 2024 Policy 500 Breastfeeding Support POLICY All local WIC agencies shall offer breastfeeding promotion, education, and counseling to all WIC participants, parents, and caregivers according to federal regulations, state guidelines, and program goals. PURPOSE To ensure that WIC participants breastfeeding education and support during all visits.

PROCEDURES All local WIC agencies must promote breastfeeding with all pregnant women and provide breastfeeding education to all pregnant and breastfeeding women. A. Breastfeeding promotion and support includes: 1. Promotion of breastfeeding within the local WIC agency. 2. Each local WIC agency identifying a certifying health professional as the breastfeeding coordinator to provide leadership to local WIC agencies on breastfeeding promotion, education, and support. 3. Provide WIC agency staff breastfeeding training in order to provide the most up-to-date evidence-based breastfeeding education to WIC participants and the community. 4. Offer a WIC clinic that is supportive of breastfeeding, including establishing a Breastfeeding Friendly Clinic policy. 5. Provide accurate up to date breastfeeding counseling to all participants. 6. Provide breast pumps to breastfeeding women who are returning to work or school or when the breastfeeding woman or infant has a medical condition that requires a breast pump. 7. Provide WIC-approved breastfeeding accessories to WIC participants based on approved local WIC agency policies.

Page 1 Breastfeeding Promotion and Support Standards Policy 501 December 2024 Policy 501 Breastfeeding Promotion and Support Standards POLICY Local WIC Agencies shall provide breastfeeding promotion, education and support to participants.

PURPOSE To promote breastfeeding as the biological norm for infant feeding and to provide breastfeeding support to mothers and infants to extend breastfeeding exclusivity and duration.

RELEVANT REGULATIONS 7 CFR 246.11(c)(5)-Monitor Local Program Activities 7 CFR 246.11(c)(7)(i) – (iv) – Breastfeeding Promotion and Support Standards 7 CFR 246.11(e)(1) – Encouragement of Breastfeeding United States Department of Agriculture, Food and Nutrition Services, Nutrition Service Standards United States Department of Agriculture, Food and Nutrition Services, Breastfeeding Policy and Guidance

PROCEDURES Promotion of Breastfeeding A. Local WIC Agency staff shall promote breastfeeding as the biological norm for infant feeding. 1. Provide breastfeeding promotion and support information at the prenatal certification visit and throughout the prenatal and postpartum periods. 2. All pregnant participants shall be encouraged to breastfeed unless contraindicated. 3. Support mothers in setting and reaching their breastfeeding goals. 4. Promote the WIC food packages incentives for breastfeeding women enrolled in the WIC Program.

Local WIC Agency Staffing A. Each local WIC agency shall designate a staff person to serve as the Breastfeeding Coordinator to provide leadership to the local WIC agency on breastfeeding promotion, education and support matters. 1. The Breastfeeding Coordinator must obtain four (4) hours of breastfeeding management and promotion continuing education annually. 2. The Breastfeeding Coordinator must complete the first 3 levels of the USDA Breastfeeding Curriculum. i. Refer to the Administrative Reference, Training Guidelines and Program Descriptions, WIC. B. As of October 2025, each local agency shall designate at least one Certifying Health Professional to serve as the Designated Breastfeeding Expert (DBE). 1. The DBE must complete all 4 levels of the USDA Breastfeeding Curriculum. 2. The DBE must complete the in-person training with the Regional Breastfeeding Coordinator/State WIC office. 3. The DBE must obtain four (4) hours of breastfeeding management and promotion continuing education annually.

Staff Training A. Local WIC agency staff must be trained by the local WIC agency Breastfeeding Coordinator or designee, or State Agency approved training to be breastfeeding advocates and ensure access to competently trained breastfeeding staff. This includes:

Page 2 Breastfeeding Promotion and Support Standards Policy 501 December 2024 1. Train all staff in the importance of breastfeeding and the clinic’s policies and services to promote, protect and support breastfeeding. 2. Train WIC Certifying Health Professionals by USDA required WIC Breastfeeding Curriculum to provide assessment, referrals and appropriate support of the mother’s breastfeeding plans and education needs throughout the prenatal and postpartum period. 3. Train appropriate health professional staff on assembly, cleaning and issuance of breast pumps.

Clinic Environment A. Each local WIC agency shall establish a Breastfeeding Friendly Clinic Policy to promote a breastfeeding friendly environment. 1. The Breastfeeding Friendly Clinic Policy must: a. Encourage mothers to breastfeed anywhere in the clinic. b. Designate and provide a private area upon request of the mother for breastfeeding or pumping. c. Provide consistent breastfeeding education, education materials, and assistance with breastfeeding during the prenatal and postpartum periods. d. Meet the requirement of The Patient Protection and Affordable Care Act (Health Care Reform) of 2010 which amended the Fair Labor Standards law to allow reasonable breaks for nursing mothers. e. Promote breastfeeding as the norm for feeding infants by the below procedures: i. All formula must be kept in a storage closet out of view of clients. ii. No formula advertising visible to clients, including pens, pads and other “giveaways.” iii. Posters and pictures in the clinic shall be of breastfeeding multicultural mothers and not be produced by formula companies. iv. Refuse samples from formula representatives for use by local WIC agency staff. 2. See Breastfeeding Friendly Clinic Appendix for sample Breastfeeding Friendly Clinic policy. B. The Breastfeeding Friendly Clinic Policy must be routinely communicated to all health department staff and posted in the clinic for staff and clients to review.

Breastfeeding Counseling A. Breastfeeding counseling shall be provided to all participants. This counseling shall include: 1. Breastfeeding is the ideal method of feeding and nurturing an infant. 2. The American Academy of Pediatrics (AAP) recognized breastfeeding as the primary nutrition in optimal growth and development and important in achieving and maintaining optimal health in the infant and child. B. The following guidelines are from AAP to support breastfeeding and shall be promoted through WIC: 1. Human milk is the preferred feeding for all infants, including premature and sick newborn, with rare exceptions. 2. Breastfeeding shall begin as soon as possible after birth, usually within the first hour. 3. Newborns shall be nursed whenever they show signs of hunger, such as increased alertness or activity, mouthing or rooting. 4. No supplements (water, glucose, formula, etc.) shall be given to breastfeeding newborns unless a medical indication exists.

Page 3 Breastfeeding Promotion and Support Standards Policy 501 December 2024 5. When discharged <48 hours after delivery, all breastfeeding mothers and their newborns shall be seen by a pediatrician or other knowledgeable healthcare practitioner when the newborn is 2 to 4 days of age. 6. Exclusive breastfeeding is ideal nutrition and sufficient to support optimal growth and development for approximately the first six months after birth. It is recommended that breastfeeding continue for at least 12 months, thereafter as long as mutually desired. 7. In the first six months, water, juice and other foods are generally unnecessary for breastfed infants. Should hospitalization of a breastfeeding mother or infant be necessary, every effort shall be made to maintain breastfeeding, preferably directly or by pumping the breasts and feeding the expressed milk, if necessary.

Breastfeeding Assessment A. Certifying Health Professionals shall conduct a breastfeeding assessment on all breastfeeding participants. B. The Certifying Health Professional shall: 1. Assess the breastfeeding dyads, breastfeeding risks, strengths, needs, and/or concerns. 2. Design a breastfeeding plan that addresses the participants’ needs and concerns. 3. Make referrals to the WIC Breastfeeding Peer Counselor Program, Designated Breastfeeding Expert, International Board Certified Lactation Consultant (IBCLC), Certified Lactation Counselor (CLC) or Certified Lactation Specialist (CLS) as appropriate. 4. Assign and tailor the participant's food package to ensure the appropriate amount of formula is provided to promote and support breastfeeding. 5. Provide breastfeeding follow-up in a timely manner to address the breastfeeding mother’s concerns as appropriate.

Breastfeeding Support A. All breastfeeding issues/concerns shall be referred to a Designated Breastfeeding Expert (DBE), International Board Certified Lactation Consultant (IBCLC), Certified Lactation Counselor (CLC), Certified Lactation Specialist (CLS) or Breastfeeding Peer Counselor and allow adequate time for assessment, evaluation and assistance to resolve breastfeeding problems during the clinic visit, as appropriate. B. Address all breastfeeding concerns in a timely manner. C. For agencies with the Breastfeeding Peer Counselor Program, utilize the Breastfeeding Peer Counselor to support WIC prenatal and breastfeeding women

Breastfeeding Certification Process Situation Action Exclusively Breastfeeding (no formula feeding) • Certify woman as Fully Breastfeeding woman. See WIC Policies for Prescribing Food Packages. • Certify infant as Fully Breastfed - no WIC food is to be issued to the infant until the appropriate age. See Recommendations For Food Package Selection. Breast and Formula Feeding

Birth to 6 months post-delivery • Certify woman as Partially Breastfeeding. See WIC Policies for Prescribing Food Packages and provide appropriate woman package based upon amount of formula the infant is receiving. • Certify infant as Partially Breastfed and provide partial or full formula package based on name of product and appropriate policies. See Recommendations for Food Package Selection.

Page 4 Breastfeeding Promotion and Support Standards Policy 501 December 2024 Breast and Formula Feeding

≥ 6 months post-delivery

• Infant receiving partially breastfeeding formula package  Continue infant certification as Partially Breastfed infant until breastfeeding ends or at 1 year post-delivery. See Recommendations for Food Package Selection.  Continue certification of woman as Partially Breastfeeding and continue food benefits for breastfeeding mother until breastfeeding ends or at 1 year post delivery. See Recommendations for Food Package Selection. • Infant receiving full formula package  Continue infant certification as partially breastfed infant until breastfeeding ends or at 1 year post-delivery. See Recommendations for Food Package Selection.  Continue certification of woman as partially breastfeeding until breastfeeding ends or at 1 year post-delivery. Mother will not receive food benefits at 6 months or more post-delivery. Mother will continue to receive nutrition education.

Breastfeeding Contraindications A. Contraindications to breastfeeding for health or lifestyle reasons can be divided into baby-related and mother-related causes. B. The medical management of the baby and/or mother should be under the care of the physician. C. Baby-related contraindications include: 1. Inborn errors of metabolism a. Galactosemia b. Phenylketonuria (PKU) i. Babies born with PKU have been able to breastfeed with close monitoring under a physician c. Maple Syrup Urine Disease 2. Neurological Problems that impair swallowing and sucking reflex may make breastfeeding difficult. a. These issues may be overcome with assistance. D. Mother-related contraindications include: 1. HIV/AIDS 2. Untreated, active tuberculosis (TB) or brucellosis 3. Active herpes lesions or open sores on her breast (may breastfeed from unaffected side) 4. Taking prescription medications from the following classes: a. Chemotherapy agents b. Amphetamines c. Ergotamine d. Statins e. Human T-cell leukemia virus type 1 (HTLV-1) f. Illegal drugs 5. Maternal substance abuse requires evaluation before breastfeeding a. Adequately nourished narcotic-dependent mothers shall be supported in their decision to breastfeed if they are enrolled in a supervised maintenance program using methadone or buprenorphine and have a negative screening for HIV infection and other psychoactive or addictive drugs. b. Mothers using street drugs or multiple drugs shall not breastfeed.

Blood Lead Levels and Breastfeeding Lead can be passed to the infant through breast milk. Some mothers exposed to lead may be encouraged to continue breastfeeding if their blood lead levels (BLLs) are within an acceptable range. The benefits of breastfeeding outweigh the potential health consequences. A. Key recommendations of initiation of breastfeeding 1. Mothers with BLLs < 40 µg/dL shall breastfeed.

Page 5 Breastfeeding Promotion and Support Standards Policy 501 December 2024 2. Mothers with confirmed BLLs > 40 µg/dL shall begin breastfeeding when their blood lead levels drop below 40 µg/dL. Until then, they shall pump and discard their breastmilk. B. Key recommendations of continuation of breastfeeding 1. Breastfeeding shall continue for all infants with BLLs below 5 µg/dL. 2. Infants born to mothers with BLL > 5 µg/dL and < 40 µg/dL can continue to breastfeed unless there is an indication that the breastmilk is contributing to elevating BLLs.

Informal Milk Sharing A. With increased awareness of the benefits and efforts to promote breastfeeding, more mothers are choosing to breastfeed, as evidenced by data from the CDC in the Breastfeeding Report Card. B. In situations such as illness, physical inability to produce milk, decisions to not breastfeed, or adoptive parents seeking human milk, the desire to provide human milk may prompt parents/caregivers to turn to alternative methods to obtain human milk to feed their infant. C. Since the cost of banked human milk can be prohibitive for WIC clients, these mothers may turn to informal milk sharing from known sources such as friends or relatives, or from unknown sources such as the internet sites or other advertisements. D. Both AAP and Food and Drug Administration (FDA) recommend against feeding infants human milk obtained directly from individuals or through the internet. 1. Obtaining donor human milk via these means is discouraged due to lack of adequate screening for infectious diseases and the risk of contamination. 2. The FDA suggests that the decision to give donor human milk shall be made in consultation with the infant’s health care provider and only screened donor milk shall be used.

Page 1 Breastfeeding: Breast Pump Issuance and Tracking Guidelines Policy 502 December 2024 Policy 502 Breastfeeding: Breast Pump Issuance and Tracking Guidelines POLICY Local WIC agencies may provide breast pumps to WIC participants as a breastfeeding aid when appropriate.

PURPOSE A. To provide support and education on the appropriate use of breast pumps. B. To protect breastfeeding for women and infants who need pumps for medical reasons. C. To assist women with breastfeeding when separated from their infants for work or school and as needed for identified breastfeeding complications. D. To provide procedures on appropriate issuance of breast pumps, maintaining breast pump inventory, and complying with state and federal requirements for the use of breast pumps.

RELEVANT REGULATIONS 246.14(c)(10) – Breastfeeding aids as an allowable administrative expense Breastfeeding Policy and Guidance – July 2016

PROCEDURES Breast Pump Staffing The local agency WIC Coordinator and Breastfeeding Coordinator will work together to authorize and train local agency staff to appropriately assess breast pump requests/needs and issue breast pumps to participants. A. Each local WIC agency shall designate at least one Certifying Health Professional to issue breast pumps to WIC participants and one staff member to serve as a backup if the designated health professional is not available, as needed. 1. Staff who are authorized to issue breast pumps must be trained by the State authorized training. 2. The Certifying Health Professional issuing breast pumps must: a. Evaluate a woman’s need for a breast pump; b. Authorize the provision of a pump; c. Issue the breast pump; d. Teach hand massage and expression to use in conjunction with the pump; e. Teach women how to use the pump; f. Provide follow-up services. B. Each local WIC agency shall designate at least one staff member to maintain an inventory on all types of breast pumps (electric, manual, etc.). 1. Staff who issue breast pumps are not to conduct the monthly inventory of the breast pumps to ensure program integrity.

Ordering Breast Pumps Breast pumps will be maintained at each local agency. A. Each local agency shall establish an inventory of breast pumps and related pumping kits and different size flanges, appropriate to meet the participants’ needs. B. Each local WIC site will have a minimum of two electric breast pumps on hand at all times. C. Local WIC agencies are responsible for maintaining inventories of pumps and kits, and for tracking the items and quantities that need to be reordered or requested. 1. If the local WIC agency needs additional pumps, contact the State WIC Breastfeeding Coordinator.

Page 2 Breastfeeding: Breast Pump Issuance and Tracking Guidelines Policy 502 December 2024 D. Types of breast pumps available for issuance through the WIC program include electric breast pumps and manual breast pumps. 1. Electric breast pumps are ordered by the State WIC Office through a breast pump contract. a. Local WIC agencies cannot purchase electric breast pumps independently. b. Electric breast pumps will automatically be shipped to each WIC agency on a bi- annual basis. c. Additional electric breast pumps can be requested from the State WIC Breastfeeding Coordinator. 2. Manual breast pumps are ordered by each local agency. a. Approval for manual breast pumps must be received from the State WIC Office prior to the order/purchase of manual breast pumps. b. Submit the Equipment Request Form to the State WIC Breastfeeding Coordinator for approval to purchase manual breast pumps. c. Local WIC agencies must maintain invoices of all manual breast pumps issued and provide the State WIC Office a copy of all invoices. 3. Additional Breast Pump Accessories a. Alternative flange sizes may be purchased as needed. b. Any purchases of $500 or more must be authorized by the State WIC Office. E. When breast pump orders are received, they shall be inspected for damage and ensure the correct type and quantity of items have been received.

Breast Pump Inventory Local WIC agencies must maintain an inventory of all types of breast pumps and document each breast pump that is issued in the breast pump inventory log. A. All new pumps must be inventoried upon receipt. B. Pumps may only be issued to participants once they have been properly inventoried and documented on the inventory log. C. A physical inventory must be performed on a monthly basis. 1. A person other than the person(s) issuing the breast pumps must do the inventory. 2. The person doing the physical inventory must be someone other than a contracted employee or a peer counselor. 3. Any method that reflects the actual number of breast pumps on hand from the last month plus the additional breast pumps received during the current month minus all breast pumps issued during the current month is acceptable. a. See 500 Appendix-Breast Pump Inventory Log. 4. The actual number on hand of each type of breast pump, the name and signature of the person that did the physical count and date of verification must be maintained. 5. All breast pumps must be accounted for during the inventory. 6. Inventory logs for all breast pumps must be retained for four years after the last issuance date. 7. Breast Pump Inventory logs will be reviewed during the Nutrition Services Branch Nutrition Monitoring visits.

Breast Pump Storage All breast pumps are to be stored in a locked room or cabinet that is not accessible by the public. A. Store new pumps and collection kits in unopened packaging as received from the manufacturer. B. All breast pumps must have a “Distributed by ___ Health Department” label placed on the pump prior to issuing.

Page 3 Breastfeeding: Breast Pump Issuance and Tracking Guidelines Policy 502 December 2024 Assessing the Need for Breast Pump Only Certifying Health Professionals may issue breast pumps. A. Certifying Health Professionals issuing breast pumps must have adequate skills and training to provide these services. B. Breast pumps shall only be provided to participants after a thorough breastfeeding assessment to ensure that a breast pump is necessary/needed. 1. Providing breast pumps to women who do not need them can interfere with breastfeeding. C. The Certifying Health Professional must assess why a pump is needed and which type of pump or hand expression best meets the breastfeeding mother’s needs. 1. Hand Expression is using your hands to compress the breast and remove milk from the breast. Hand expression is helpful if mom is occasionally away from baby for short periods of time or if she has minor engorgement or sore or cracked nipples. Hand expression can be utilized in combination with pumping to increase the volume of milk expressed. 2. Manual Pumps are useful for providing short-term relief from engorgement or for pumping due to occasional separation or missed feedings. These pumps must not be reused, sterilized, or loaned to more than one person. 3. Electric Breast Pumps may be needed for women going back to work or school or for breastfeeding complications. Breastfeeding complications can include high-risk mothers and babies establishing and maintaining lactation during periods of extended separation or other medical problems. These pumps shall not be reused, sterilized, or loaned to more than one person. a. If issuing for returning to work or school, the Certifying Health Professional shall determine the optimal time to issue the pump. It is recommended to issue the pump at least one week prior to returning to work or school. b. Single User Breast Pumps (Hygeia) are the electric pumps available for issuance. These pumps must not be reused, sterilized or loaned to more than one person. D. A breast pump may be issued to a woman who is not fully breastfeeding. A breast pump may not be denied to a participant for the sole reason of not fully breastfeeding. E. For extenuating circumstances, contact the State WIC Office State Breastfeeding Coordinator.

Circumstances When Breast Pumps May NOT Be Issued Women who do not meet the established criteria established by the State WIC Program to receive a breast pump. A. Breast Pumps may not be issued: 1. During pregnancy 2. Women beyond one year postpartum, even when her child is participating in WIC 3. Mothers who are currently using marijuana, drugs of abuse or other contraindicated medications unless the mother is enrolled in a substance abuse program and medical documentation from the physician is providing stating that the mother can breastfeed. 4. Mothers who have any contraindicated medical condition 5. A WIC participant who previously borrowed a hospital-grade breast pump and did not return the pump.

Breast Pump Education All breastfeeding women who receive a pump must receive accurate information about assembling, using, and cleaning breast pumps and collection kits issued by the WIC Program. A. Education of Pump Use

Page 4 Breastfeeding: Breast Pump Issuance and Tracking Guidelines Policy 502 December 2024 1. Identify and distribute to the participant materials with accurate pictures or drawings of the pump. It is recommended to use the patient instruction sheet from the breast pump manufacturer. 2. Provide participants with a demonstration or show the actual use of the pump. 3. Ensure participants can assemble and disassemble the pump before leaving. 4. Provide information to the breastfeeding woman regarding the manufacturer’s direction about washing or sterilizing the pump and collection kit. 5. Ensure the participant receives printed materials about cleaning procedures. 6. Participants who obtain breast pumps from sources other than the WIC Program (insurance, gift, purchase, etc.) shall be referred to the pump manufacturer for questions regarding pump assembly, use, cleaning, and troubleshooting. B. Education of Collection, Storing, and Warming Expressed Milk 1. Breastfeeding women must receive accurate information about expressed breast milk to ensure the quality and safety of the milk for later feeding. 2. The mother must be instructed to use thawed milk within 24 hours after thawing. 3. Mothers must be educated on the following storage guidelines.

Countertop or Table Refrigerator Freezer with Separate Door Deep Freezer Storage Temperature Up to 77°F At or Below 40°F At or Below 0°F At or Below - 4°F Fresh Pumped/Expressed Milk Up to 4 hours Up to 4 days Up to 6 months Up to 12 months Thawed Human Milk 1-2 hours Up to 1 day (24 hours) Never refreeze thawed human milk C. The Certifying Health Professional must complete the Breast Pump Assessment and Information Checklist for every breast pump issued and filed in the participant’s medical record. D. Inform the mother that if she experiences an issue with the breast pump after issuance (i.e. broken/malfunctioning), she shall contact the breast pump manufacturer help line and provide the issuance date and location she received the pump.

Documenting Issuance of Breast Pumps Certifying Health Professionals will determine if a breastfeeding mother needs a pump and what type of pump meets the mother’s needs. A. Documentation the issuance of a breast pump and the counseling received must be documented in the participant’s medical record. B. The minimum documentation includes: 1. Reason for issuing the pump; 2. Type of pump provided; 3. An evaluation of the participants understanding about using and cleaning the pump; 4. A summary of the counseling provided; and 5. Plans for follow-up. C. A written agreement must be obtained prior to issuance of the electric breast pumps. 1. A copy of this form must be placed in the participants’ medical record. D. Obtain Verification of Informed Consent from all patients receiving breast pumps. 1. A copy of this form must be placed in the participant’s medical record. a. Check with your legal counsel regarding verification of informed consent for any necessary agency changes. 2. Contact the State WIC Office if assistance is needed.

Page 5 Breastfeeding: Breast Pump Issuance and Tracking Guidelines Policy 502 December 2024 Breast Pump Follow-up After issuance of the pump, a breastfeeding woman shall receive follow-up services as outline below. Reason for Pump Follow-up Schedule Manual Pump for Occasional Use • Refer to Designated Breastfeeding Expert (DBE), if appropriate • Refer to Peer Counselor for basic education and support (if available) • Make initial contact within 24-72 hours • Provide bi-weekly follow-up by phone as needed Electric Pump for Separation Due to Work or School • Refer to DBE, if appropriate • Refer to Peer Counselor for basic education and support (if available) • Make initial contact within 24-72 hours • Provide bi-weekly follow-up by phone as needed Electric Pump for Medical Reasons • Make initial follow-up contact within 24 hours • Follow-up by phone weekly as needed • Refer to DBE • Ensure baby’s weight is checked by a medical provider • Refer to the Peer Counselor for basic education and support (if available)

Sale of Breast Pumps The sale of breast pumps is not allowed and is considered fraud. Participants may not profit from the sale of any breast pump provided by WIC.

Disposal of Breast Pumps Breast pumps that are not working, no longer under warranty, and unrepairable may be disposed of by the local agency. A. If a local agency disposes of a breast pump: 1. Write the pump out of inventory and indicate when the pump was sent for disposal. 2. Follow your local WIC agencies policies on disposal of the pump.

Page 1 Breastfeeding Accessories Policy 503 December 2024 Policy 503 Breastfeeding Accessories POLICY The issuance of breastfeeding accessories is an optional breastfeeding service that may be provided to breastfeeding women with breastfeeding complications. Local agencies must submit a breastfeeding accessories policy to the State WIC Office prior to the purchase or issuance of breastfeeding accessories. Local agencies electing to issue nipple shields must review approved mandatory State designated training prior to issuance of nipple shields.

PURPOSE To provide breastfeeding support to mothers with breastfeeding complications or issues to extend breastfeeding exclusivity and duration.

RELEVANT REGULATIONS 7 CFR 246.11(c)(5) – Monitor Local Program Activities 7 CFR 246.11(c)(7)(i) – (iv) – Breastfeeding Promotion and Support Standards 7 CFR 246.11(e)(1) – Encouragement of Breastfeeding United States Department of Agriculture, Food and Nutrition Services, Nutrition Service Standards United States Department of Agriculture, Food and Nutrition Services, Breastfeeding Policy and Guidance

PROCEDURES Breastfeeding Accessory Item Purchases A. Items used for training and demonstration purposes to promote breastfeeding or assist participants in using breastfeeding aids are approvable WIC expenses. 1. Such items may include models to illustrate the use of various breastfeeding aids, breast models, and dolls used to illustrate breastfeeding, etc. B. Nipple shields are approved WIC expenses. The use of these aids must follow the Policies and Procedures below. See Nipple Shield Issuance Policy below. C. Purchases of human milk storage bags, breast pads, and nursing coverage (for support and outreach) are allowing WIC expenses with State WIC Office-approved policies. 1. In order to purchase these products, your agency must perform a breastfeeding assessment to determine the participant’s need and the benefits of these items to the breastfeeding dyad. 2. A local agency policy must be submitted to the State WIC Office Breastfeeding Coordinator for approval with established guidelines on Certifying Health Professionals that will issue these products. D. The following items are not approved purchases with WIC funds: topical creams, ointments, Vitamin E, other medicinal products, footstools, infant scales for non-clinical use (for example, home use by parents), baby bottles, nursing (Bobby) pillows, or nursing blouses. 1. If these items are provided to your agency in kind, they can be given to the participant. E. WIC funds cannot be used to establish, support, or maintain a milk bank or milk depot. 1. WIC staff may refer WIC participants to area milk bank facilities to donate their milk as part of WIC referrals.

Nipple Shield Issuance A. Certifying Health Professionals issuing and providing education about the use of nipple shields must complete training from the State Office prior to issuing nipple shields. B. Agencies shall identify the health professional(s) within each agency/site who can: 1. Evaluate a woman’s need for a nipple shield; 2. Authorize the provision of the nipple shield;

Page 2 Breastfeeding Accessories Policy 503 December 2024 3. Issue the nipple shield; 4. Teach women how to use the nipple shield; 5. Provide backup if the designated health professional(s) are not available; and 6. Provide follow-up services. C. Nipple shields are for single-user. They cannot be returned or re-issued to another person. D. Each request for a nipple shield shall be evaluated to determine the need for the nipple shield. E. Nipple shields cannot be given to pregnant participants. F. Nipple shields must be inventoried. 1. Store all nipple shields in a cabinet that can be locked. 2. Maintain perpetual inventory of all nipple shields. See the sample log included in this policy. 3. Perform a physical inventory of all nipple shields on a monthly basis. a. A person other than the person(s) that issues the nipple shields must do the inventory. b. Any method that reflects the actual number of nipple shields on hand from the last month plus the additional nipple shields received during the current month is acceptable. c. The actual number on hand, the name and signature of the person that did the physical count, and the date of verification must be maintained. All nipple shields must be accounted for during the inventory. G. Breastfeeding women must receive accurate information about using and cleaning nipple shields. 1. Provide participants with a demonstration or show the actual use of the nipple shield. 2. Ensure the participant can properly use the nipple shield prior to leaving the clinic. 3. Provide information to the breastfeeding woman regarding the manufacturer’s direction about washing or sterilizing nipple shields. 4. Ensure the participant receives printed materials about cleaning procedures. H. Document the issuance of the nipple shield and the counseling received in the participant’s medical record. The following is the minimum documentation: 1. Reason for issuing the shield; 2. An evaluation of the participant’s understanding of using and cleaning the nipple shield; 3. A summary of the counseling provided; and 4. Plans for follow-up. I. Complete and obtain Verification of Informed Consent for all nipple shields issued. A copy of this form must be placed in the participant’s medical record. See the sample Health Department Breastfeeding Management/Care, Support, and Follow-up Verification of Informed Consent in the attached 500 Appendix. Check with your legal counsel regarding the verification of informed consent for any necessary agency changes. J. After issuance of the nipple shield, a breastfeeding woman must receive follow-up services from the Designated Breastfeeding Expert (DBE) within 24 to 72 hours as outlined in below: 1. Make initial follow-up contact within 24-72 hours 2. Follow-up by phone one week after issuance 3. Ensure regular face-to-face follow-up with Designated Breastfeeding Expert (DBE) 4. Refer to a peer counselor, if available. K. Issuance of a nipple shield shall be coded to V241- on the patient encounter form.

Page 1 Breastfeeding Peer Counseling Program Policy 504 December 2024 Policy 504 Breastfeeding Peer Counselor Program

POLICY Local agencies with the WIC Breastfeeding Peer Counselor Program must follow the policies and procedures outlined by the State WIC and USDA.

PURPOSE The WIC Breastfeeding Peer Counselor Program is designed to provide mother-to-mother (paraprofessional) breastfeeding support and basic breastfeeding education during normal business hours and beyond to WIC Program mothers who are pregnant or breastfeeding.

RELEVANT REGULATIONS 7 CFR 246.11(c)(7)(i) – (iv) – Breastfeeding Promotion and Support Standards 7 CFR 246.11(e)(1) – Encouragement of Breastfeeding United States Department of Agriculture, Food and Nutrition Services, Nutrition Service Standards United States Department of Agriculture, Food and Nutrition Services, Breastfeeding Policy and Guidance

PROCEDURES General Policies A. The goals of the Breastfeeding Peer Counselor Program are to meet the Healthy People 2030 objectives which are: 1. To increase initiation to 81.9%; 2. To increase the six-month duration rate to 60.5%; 3. To increase the one-year duration rate to 34%; and 4. To increase breastfeeding exclusivity rates at three months to 44.3% and 23.7% exclusive breastfeeding at six months. B. All participating in the Program must be certified as eligible for the WIC Program. See qualifications in the Certification and Management Section of the WIC and Nutrition Manual. C. All pregnant and breastfeeding participants must be offered the opportunity to speak to a WIC Breastfeeding Peer Counselor. D. WIC Peer Counseling services must be provided at no cost to the applicant/participant. E. Breastfeeding Peer Counselors shall avoid any situation that is or appears to be a Conflict of Interest. F. Training for the Breastfeeding Peer Counselor Program must be conducted by the State WIC Agency or their designated personnel. G. Funding for the Program is through cost center PGC2103. H. Peer Counselors are to be contracted with the agency using the standard Peer Counselor contract. Only those agencies grandfathered in, prior to June 30, 2011, may have a Peer Counselor as a part-time employee. I. Peer Counselors shall be contracted with the agency based on the projected caseload of each peer counselor, not to exceed 20 hours per week. J. A 20 week hour-per-week peer counselor shall be following approximately 150 pregnant and breastfeeding women. K. Breastfeeding Peer Counselors must operate within the Breastfeeding Peer Counselor Scope of Practice. Credentialing as an International Board Certified Lactation Consultant (IBCLC), Certified Lactation Counselor (CLC), or Certified Lactation Specialist (CLS) does not expand the scope of being a Designated Breastfeeding Expert (DBE).

Breastfeeding Peer Counselor Agencies A. In order to have the Breastfeeding Peer Counseling Program a local health department will: 1. Be designated and approved by the State WIC Agency. 2. Have a Breastfeeding Peer Counselor Supervisor that is a health professional, nutritionist, Registered Dietitian (RD), or Nurse (RN or LPN) unless written approval is

Page 2 Breastfeeding Peer Counseling Program Policy 504 December 2024 received from the State WIC Office to utilize a different classification for the function. The Supervisor cannot be a contracted position. See the Duties of a WIC Breastfeeding Peer Counselor Supervisor in this section. 3. Have a Designated Breastfeeding Expert (DBE) who is a health professional that is a Registered Dietitian (RD) or Nurse (RN or LPN) with certification as: i. International Board Certified Lactation Consultant (IBCLC); ii. Certified Lactation Counselor (CLC); or iii. Certified Lactation Supervisor (CLS). 4. The DBE may be an employee of the agency or under contract. See the Duties of the WIC Breastfeeding Peer Counselor Lactation Specialist in this section. 5. Utilize the standard DBE contract which is found on the L drive at L:\LHDBudgets\Contracts. 6. Allow a Breastfeeding Peer Counselor to work outside of usual clinical hours and outside of the clinic environment, such as home or hospital visit. 7. Contracted with Peer Counselors using the standard Peer Counselor contract. Only those agencies grandfathered in, prior to June 30, 2011, may have a Peer Counselor as a part- time employee. 8. Utilize the following qualifications for a Breastfeeding Peer Counselor. i. Be a contemporary/cohort/equal to the woman to whom she will be providing information and support. This includes the ability to speak Spanish if needed; ii. Has been or currently is a WIC participant; iii. Has breastfed at least one baby for six months or longer and is an advocate for breastfeeding; iv. Has the ability to work independently at home; v. Has reliable transportation; vi. Be readily accessible by phone; vii. Has basic computer skills; and viii. Has the ability to communicate effectively with peers, supervisors and other health department staff.

Peer Counselor Policies and Procedures A. When recruiting new Peer Counselors, an application must be completed. See Sample Peer Counselor Job Posting to facilitate recruitment of potential candidates. Sites my use their local WIC agency application or the Sample Application, BFPC-1. Peer Counselors must be screened using a background check. If required by the local WIC agency, drug testing may be performed. B. Peer Counselors are to be contracted with the agency using the standard Peer Counselor contract which can be found on the L Drive at L:\LHDBudgets\CONTRACTS. Only agencies that have been grandfathered in prior to June 30, 2011, may have the Peer Counselor as a part- time employee. C. Interviews must be conducted on potential candidates. Sites may use their local WIC agency interview guides or the Sample Interview Guide, BFPC-2. Interviews may be conducted prior to Peer Counselor training to screen candidates to receive Peer Counselor Program Training or interviews may be conducted after training to further screen candidates. D. Prior to being placed under contract, or working with pregnant or breastfeeding women, Peer Counselors will receive mandatory training using the USDA Required WIC Breastfeeding Curriculum (Levels 1 and 2). This will be documented on the Peer Counselor Training Checklist, BFPC-3. The peer counselor must attend all in-person training sessions, complete all required homework, fully participate in all activities, and complete all required online training modules. E. Equipment and materials issued to the Peer Counselors must be documented on the Peer Counselor Equipment and Materials Log, BFPC-4. Complete the form and keep in the Peer Counselor’s file. The log will also be used to document the returned items at the time of resignation or termination of a Peer Counselor. The Peer Counselor file must be maintained for four (4) full Federal Fiscal Years after their resignation or termination. F. The Peer Counselor Job Duties and Peer Counselor Scope of Practice must be provided and reviewed with the Peer Counselor during orientation. This must be documented on the Peer Counselor Training Checklist, BFPC-3.

Page 3 Breastfeeding Peer Counseling Program Policy 504 December 2024 G. The Guidelines for Referring/Yielding must be reviewed and provided to the Peer Counselor during orientation. This must be documented on the Peer Counselor Training Checklist, BFPC-3. H. Each agency must have a DBE that is a Registered Dietitian (RD) or Nurse (RN or LPN) with certification as an International Board Certified Lactation Consultant (IBCLC), Certified Lactation Counselor (CLC), or Certified Lactation Specialist (CLS) that will provide lactation management and support services for mothers who are experiencing issues above the Peer Counselor Scope of Practice. If the agency does not have a DBE on staff, the agency must contract to provide these services. The DBE Contract is to be used for this purpose. If a contracted specialist is needed, contract can be found on the on the L Drive at L:\LHDBudgets\CONTRACTS. The cost of the DBE contract will be coded to the WIC Program cost center 804. I. During the orientation and training period, agencies must provide shadowing opportunities for the Peer Counselor. Shadowing experiences shall be both face to face and via conference call. The Peer Counselor will complete the Peer Counselor Shadowing Log, BFPC-5 to document the shadowing experience and observations. The supervisor will meet with the Peer Counselor to discuss the observations and effectiveness of the experience using the Shadowing Follow-up Tool, BFPC-6. Completion of the activity must be documented on the Peer Counselor Training Checklist, BFPC-3. J. Periodic monitoring of Peer Counselor interactions is required. Use the Peer Counselor Observation Tool, BFPC-7, to document the observation of new Peer Counselors as they begin contacting clients independently. The supervisor must observe two (2) Pregnant Women contacts and two (2) Breastfeeding Mother contacts during the first month of employment and every six (6) months for the first year of employment then annually thereafter or more often at the discretion of the supervisor. Completion of the activity must be documented on the Peer Counselor Training Checklist, BFPC-3. K. The performance of Peer Counselors must be routinely evaluated. Complete the Peer Counselor Evaluation Tool, BFPC-8, for new Peer Counselors at one month, and every six (6) months for the first year of employment then annually thereafter. Use additional sheets as necessary. Completion of the activity must be documented on the Peer Counselor Training Checklist, BFPC-3.

L. Periodic monitoring of Peer Counselor Program participants is required. Complete the Participant Phone Feedback Survey, BFPC-9. Supervisors are to complete this survey for each Peer Counselor at the local WIC agency for monitoring of Peer Counselor interactions with Breastfeeding Peer Program participants. The survey must be completed every six (6) months for the first year of employment and annually thereafter or more often at the Supervisor’s discretion. Completion of the activity must be documented on the Peer Counselor Training Checklist, BFPC-3. Supervisors are to review the results of the Participant Phone Feedback Survey with the peer counselor. M. When a Peer Counselor submits a resignation letter, request the Peer Counselor complete the Peer Counselor Exit Survey, BFPC-10. The supervisor will review the feedback for possible improvements to the program. A Peer Counselor who has been terminated will not be requested to complete the survey. N. The Peer Counselors must make contacts according to Breastfeeding Peer Counselor Protocol for Contacting WIC Mothers. O. Contacts must be documented, at the time services are provided, on the Client Contact Logs, BFPC – 11A for Prenatal contacts and BFPC – 11B for Breastfeeding Contacts, which are available as an Excel document. Instructions for completing the logs can be found at BFPC – 11. P. Peer Counselors do not access or document in the participant medical record. Q. The Contact History from the Client Contact Logs, BFPC-11A and BFPC-11B, must be filed in the participant’s medical record once the participant is terminated from the Breastfeeding Peer Counselor Program. R. The Peer Counselors must complete the Weekly Activity Report, BFPC – 12A to document their activities. This form will be submitted to the supervisor biweekly. Contact the State WIC office for an electronic copy of the form. S. Breastfeeding Peer Counseling funds are to be used in accordance with the FNS Loving Support Model. The primary purpose of the funds is to provide direct breastfeeding support services through peer counseling to WIC participants. Refer to Allowable Costs for Kentucky Breastfeeding Peer Counseling Funds for guidelines on appropriate use of this funding. T. Peer Counselors must be provided the following training during orientation. Completion must be documented on the Peer Counselor Training Checklist, BFPC-3.

1. Privacy, Security and Confidentiality Policies and Agreement

Page 4 Breastfeeding Peer Counseling Program Policy 504 December 2024 Breastfeeding Peer Counselors shall protect the confidentiality, integrity and accuracy of information. All Breastfeeding Peer Counselors shall receive orientation regarding The Health Insurance Portability and Accountability Act (HIPAA) of 1996. Refer to the Administrative Reference, Volume I Personnel Section. The Peer Counselor will sign the Local Health Department Employee Privacy and Security of Protected Health, Confidential, and Sensitive Information Agreement. Completion must be documented on the Peer Counselor Training Checklist, BFPC-3

2. Civil Rights ACT of 1964 Breastfeeding Peer Counselors must receive orientation and annual training regarding civil rights. See Administrative Reference, Volume I, Personnel Section, Civil Rights Act of 1964. Completion must be documented on the Peer Counselor Training Checklist, BFPC-3.

3. OSHA Compliance Breastfeeding Peer Counselors must receive OSHA Compliance Training including Bloodborne Pathogen Training at orientation and annually. See Administrative Reference, Volume I, Personnel Section, OSHA Compliance. Completion must be documented on the Peer Counselor Training Checklist, BFPC-3.

4. Computer Security Use of Passwords Breastfeeding Peer Counselors must receive training on Computer Security and Use of Passwords. See Administrative Reference, Volume I, Local Health Operations. Completion must be documented on the Peer Counselor Training Checklist, BFPC-3. 5. Home Visiting and Safety Guidelines Breastfeeding Peer Counselors who will be providing Peer Counselor Services during home visits or in the community must receive orientation training on Home Visiting Safety Guidelines. See Administrative Reference, Personnel Section, Home Visiting and Safety Guidelines. Completion must be documented on the Peer Counselor Training Checklist, BFPC-3. 6. Social Media Policy for Breastfeeding Peer Program Breastfeeding Peer Counselors must receive training on the Social Media Policy for Breastfeeding Peer Program. See Social Media Policy for Breastfeeding Peer Program in this section. Completion must be documented on the Peer Counselor Training Checklist, BFPC-3.

Page 5 Breastfeeding Peer Counseling Program Policy 504 December 2024

DUTIES OF WIC BREASTFEEDING PEER COUNSELOR

A Breastfeeding Peer Counselor will: 1. Complete USDA Required WIC Breastfeeding Curriculum (Level 1 & 2) training. The Peer Counselor Supervisor will document and maintain on file the successful completion of the modules. 2. Demonstrate the ability to work with pregnant and breastfeeding women as observed by the Peer Counselor Supervisor. 3. Communicate effectively with Breastfeeding Peer Counselor Supervisor, local health department staff, clients, and other peer counselors, as appropriate. 4. Receive an assigned caseload of pregnant and breastfeeding WIC mothers. 5. Contact the mothers per the Breastfeeding Peer Counselor Protocol for Contacting WIC Mothers. 6. Provide counseling by telephone, home visit, clinic visit and/or hospital visit per the Breastfeeding Peer Counselor protocols and individual client’s needs. 7. Provide basic breastfeeding information and support such as; the benefits of breastfeeding, overcoming common barriers, establishing breastfeeding, etc. Assists clients in preventing and handling common breastfeeding problems and concerns. 8. Maintain and protect client confidentiality. 9. Document all contacts made with clients via the Breastfeeding Peer Counselor Computer Program. If the system is down, the documentation will be made per Breastfeeding Peer Counselor protocol. When the system is live again, the contact information will be entered into the system per protocol. 10. Operate within the Scope of Practice for a Breastfeeding Peer Counselor. See Scope of Practice for WIC Breastfeeding Peer Counselor in this section. 11. Refer identified breastfeeding problems or other health issues to appropriate health professional (e.g., IBCLC, CLC, LC, Registered Dietitian/Certified Nutritionist, nurse, etc. See Guidelines for Referring/Yielding in this section. 12. Terminate clients from the Breastfeeding Peer Counselor Program after 3 documented unsuccessful attempts to contact, once the client is no longer breastfeeding or the client wishes not to participate in the program. The Contact History must be printed and placed in the participant’s medical record. 13. Attend and assist with prenatal classes and breastfeeding support groups, as appropriate. 14. Assist WIC staff in promoting breastfeeding peer counseling through special projects and duties, as assigned. 15. Attend peer counselor meetings as directed by State Peer Counselor Coordinator. Attends other breastfeeding conferences/workshops, as appropriate.

NOTE: The above information regarding a Breastfeeding Peer Counselor is reflected in the standard contract for Peer Counselors.

Page 6 Breastfeeding Peer Counseling Program Policy 504 December 2024 DUTIES OF WIC BREASTFEEDING PEER COUNSELOR SUPERVISOR

The WIC Breastfeeding Peer Counselor Supervisor will: 1. Obtain State training on USDA required WIC Breastfeeding Curriculum (Levels 1, 2 and 3). 2. Recruit, interview, train and supervise Peer Counselors according to WIC Program policies and procedures. 3. Provide and/or ensure that all Breastfeeding Peer Counselors are trained in lactation management using the WIC Breastfeeding curriculum and provide ongoing training as needed. 4. In conjunction with agency administrator, ensures adequate and appropriate staffing of Peer Counselors to serve the local WIC caseload of pregnant and breastfeeding women. 5. In conjunction with the WIC Coordinator/Breastfeeding Coordinator and agency administrator or authorized representative, ensures that the agency’s allotment of funds for Breastfeeding Peer Counseling is appropriately expended in fiscal year. 6. Manages and coordinates Breastfeeding Peer Counselor staff and services with agency WIC Program staff and services to assure program quality assurance and compliance. 7. Provides supervision and management of Breastfeeding Peer Counselors by monitoring counseling and documentation of services provided. Shares management and monitoring findings with staff as appropriate or necessary. Ensures correction of identified deficiencies in a timely manner. 8. Maintain communication with the State Breastfeeding Peer Counselor Coordinator to assure continuous quality improvement for the Breastfeeding Peer Counselor Program. 9. Attends WIC Program Breastfeeding Peer Counselor meetings and Breastfeeding Peer Counselor Supervisor meetings. 10. Receives 4 hours of continuing education on Breastfeeding Management and Promotion each year.

Page 7 Breastfeeding Peer Counseling Program Policy 504 December 2024 DUTIES OF WIC DESIGNATED BREASTFEEDING EXPERT (DBE)

The Designated Breastfeeding Expert (DBE) will: 1. Obtain training on the USDA required WIC Breastfeeding curriculum (Levels 1, 2, 3, and 4). 2. Receive referrals from Breastfeeding Peer Counselors for clients who are experiencing complex maternal and infant breastfeeding problems beyond their scope of practice. 3. Provide timely follow-up services by telephone, home visit, WIC clinic visits, and/or hospital visits. The follow-up may occur outside of the normal hours of clinic operations. 4. Assess breastfeeding situation and provide counseling to mothers. 5. Maintain and protect the confidentiality of each client. 6. Document services in the medical record in accordance with the guidelines in the Medical Records Management section of the AR Volume I and the Breastfeeding Peer Counselor protocols, as appropriate. 7. Codes clinical or community services on the appropriate reporting or billing form in order for the local WIC agency to receive reimbursement for services, as appropriate. 8. Coordinate continued follow-up of the client with the Peer Counselor. 9. Assist the Breastfeeding Peer Counselor Supervisor in providing initial and ongoing breastfeeding training for Peer Counselors. 10. Mentors or assists in mentoring, Peer Counselors through shadowing opportunities and ongoing guidance. 11. In conjunction with the Breastfeeding Peer Counselor Supervisor, provides breastfeeding trainings for local WIC agency staff, and in-service education for hospital staff and local health care professionals. 12. Teach breastfeeding classes and support groups for pregnant and breastfeeding women (optional). 13. Assist in conducting outreach with community organizations to promote WIC breastfeeding and peer counseling services (optional). 14. Records and collects data required by State or Local WIC agency. 15. Maintains credentials and breastfeeding knowledge and skills through continuing education as required by credentialing organization (minimum of 4 hours of continuing education in breastfeeding management or promotion each year).

Page 8 Breastfeeding Peer Counseling Program Policy 504 December 2024 SCOPE OF PRACTICE FOR THE WIC BREASTFEEDING PEER COUNSELOR

A Peer Counselor scope of practice is to provide basic breastfeeding information, encouragement and support to WIC participants. A Peer Counselor must refer/yield identified breastfeeding problems or other health issues outside the Peer Counselor scope of practice. See Guidelines for Referring/Yielding. Other referrals shall be provided as specified in the Breastfeeding Peer Counselor protocols.

A Breastfeeding Peer Counselor will: • Be available to WIC participants outside of usual clinic hours and outside of the clinic environment; • Use participant-focused communication techniques such as the three step counseling strategy; • Assist participants in identifying the support available to them and assist in educating family members; • Help women identify their breastfeeding concerns, barriers, and solutions; • Teach the reasons to breastfeed; • Teach basic, evidence-based techniques that help ensure a successful start in breastfeeding, including milk production, birth kangaroo care, positioning and latch, and milk expression and storage; • Identify signs of the normal course of breastfeeding, including breastfeeding frequency and duration, infant feeding cues, and normal infant weight gain and stooling patterns; • Teach the importance of exclusive breastfeeding in the early weeks and ways to continue breastfeeding. • Help mother plan for a return to work/school that supports the continuation of breastfeeding; • Support breastfeeding participants from pregnancy through growth spurts, introducing solid foods, and weaning; • Provide anticipatory guidance to help prevent the occurrence of problems in infant or breastfeeding woman; • Provide guidance to mothers regarding non-evidence based breastfeeding information they receive; • Provide basic and timely problem solving and support; • Review with participants about the additional foods for breastfeeding mothers. Encourage keeping appointments; • Assist in infant feeding classes and peer support groups; • Refer mothers to resources for support; • Promote breastfeeding in the community, workplace, and health care system. • Perform duties in a professional manner; • Respect the participant’s privacy, dignity and confidentiality; • Recognize when assistance is needed and consult with the supervisor, Breastfeeding Coordinator and/or Peer Counselor Coordinator and other lactation specialists. • Identify situations outside the Scope of Practice and refer as appropriate in a timely manner. • Yield to the WIC designated breastfeeding expert for situations out of breastfeeding peer counselor Scope of Practice. • Yield mothers experiencing difficulties to the WIC designated breastfeeding expert. • Respect and respond sensitively to cultural attitudes and practices of participants and the community; • Work within the policies and procedures of the WIC Program and the Breastfeeding Peer Counselor Program; • Maintain records according to the Kentucky Department of Public Health legal requirements, program standards and ethical practices as outlined in the Administrative Reference, Volume I, Medical Records Management; and • Acquire four hours of breastfeeding education per year through attendance at state meetings and local coalition conferences to maintain and build knowledge and skills.

Rev. 09/16

Page 9 Breastfeeding Peer Counseling Program Policy 504 December 2024 BREASTFEEDING PEER COUNSELOR PROTOCOL FOR CONTACTING WIC MOTHERS

The following is the protocol for making contacts with participants.

Before Delivery: When to Call Mothers Pregnancy  Monthly.  More frequently (weekly, if possible) as her due date nears After Delivery: When to Call Mothers First Two Weeks Post Partum (PP)  Every two or three days during the first week  Within 24 hours if a problem occurs First Month PP  Weekly  Within 24 hours if a problem occurs Months 1 to 6 PP  Monthly  Within 24 hours if a problem occurs  Two weeks before she plans to return to work or school and two or three days after she starts back  Around the time baby’s appetite spurts occur: - Six weeks - Three months - Six months Months 7 to 12 PP  Monthly  Within 24 hours if a problem occurs.

Page 10 Breastfeeding Peer Counseling Program Policy 504 December 2024 GUIDELINES FOR REFERRING/YIELDING

Peer Counselors are required to function within the Peer Counselor Scope of Practice. If a problem or situation is encountered which is outside the Scope of Practice, the Peer Counselor must immediately refer/yield to the DBE: International Board Certified Lactation Consultant (IBCLC), Certified Lactation Counselor (CLC) or Certified Lactation Specialist (CLS). The DBE will determine the best plan for supporting the mother and infant, including the referrals that are appropriate. The Peer Counselor will continue to provide support while the DBE and/or Health Care Provider are addressing the issues, unless the Supervisor and Peer Counselor determines that it is best to discontinue peer support.

The following are the problems or situations that require referrals: A. Pregnancy Issues – Refer the following to Health Care Provider: 1. Spotting or bleeding; 2. Excessive vomiting or nausea; 3. Swelling; 4. Contractions which suggest premature labor; 5. Baby stops moving; and 6. Other troublesome medical situations.

B. Baby Concerns – Refer the following to the DBE and Pediatrician: The Lactation Specialist will work cooperatively with the Pediatrician to develop a plan that supports the continuation of breastfeeding while addressing the specific medical concern. 1. Baby is born preterm or low birth weight 2. Baby is sick 3. Baby has fewer than 6 wet diapers and 3 stools per 24 hours in the first month after the baby is 4 days old; 4. Baby fails to gain weight or gains weight slowly; • Baby loses more than 7% of birth weight • Birth weight is not regained by 2 weeks postpartum • Weight gain is less than 4.5 ounces per week 5. Baby has difficulty latching or remaining latched after several attempts 6. Baby appears unhappy at the breast or refuses to breastfeed 7. Baby is still hungry after feedings despite 24 hours of increased frequency and duration of breastfeeding 8. Breastfeeding typically lasts more than 45 minutes 9. Baby is jaundiced; 10. Baby has a congenital defect such as cleft lip/palate or Down Syndrome; and 11. Baby has restricted tongue movement from a tight frenulum.

C. Mother Concerns – Refer the following to the DBE and Health Care Provider: The Lactation Specialist will work cooperatively with the Health Care Provider to develop a plan that supports the continuation of breastfeeding while addressing the specific medical concern. 1. Mother has engorgement or plugged ducts that are not resolved after 24 hours; 2. Mother has a fever, suggesting possible mastitis; 3. Mother has nipple discomfort that does not improve after 24 hours; 4. Mother is supplementing with formula before the baby is 1 month old and wants to increase her milk production or reduce/eliminate formula supplements 5. Mother has been formula feeding the baby since birth and now wants to breastfeed 6. Mother is exclusively pumping her milk and now wants to put her baby to breast 7. Mother wants to breastfeed an adopted baby; 8. Mother wants to breastfeed but has been advised not to by her HCP; and 9. Mother finds a lump in her breast.

Page 11 Breastfeeding Peer Counseling Program Policy 504 December 2024

D. Illness in Mother or Baby – Refer the following to the DBE and Health Care Provider: The Lactation Specialist will work cooperatively with the Health Care Provider to develop a plan that supports the continuation of breastfeeding while addressing the specific medical concern. 1. Mother or baby have symptoms of thrush/yeast infection; 2. Mother or baby are vomiting or have diarrhea 3. Mother or baby are hospitalized 4. Mother has symptoms of mastitis; 5. Mother has a physical handicap; 6. Mother or baby has a chronic or acute illness; and • Hepatitis B or C, tuberculosis, CMV, or chicken pox • Renal, liver, intestinal, heart problems, or cystic fibrosis • Metabolic disorder such as diabetes mellitus 7. Mother has been diagnosed with AIDS/HIV.

E. Other Medical Situations – Refer the following to the DBE: The Lactation Specialist will educate participants about these issues and instruct to discuss with the Health Care Provider. 1. Mother has been prescribed medications that have not been approved for breastfeeding by current established authorities such as the AAP or Lactmed; 2. Mother has prior breast surgery, breast implants, breast reduction, biopsy, breast cancer, chest surgery, or trauma; 3. Mother has had gastric bypass surgery; and 4. Mother has a history of Polycystic Ovarian Syndrome (PCOS), hypothyroidism, or other hormonal conditions that could affect breastfeeding.

F. Nutrition – Refer the following to a Registered Dietitian/Certified Nutritionist: 1. Mother is nutritionally at risk for underweight, has bulimia or anorexia; and 2. Mother has dietary concerns. 3. Mother has no food;

G. Social – Refer the following to a DBE, a Social Service Agency, or the Department for Community-Based Services, as appropriate: The Lactation Specialist will work cooperatively with the agency to develop a plan that supports the continuation of breastfeeding while addressing the specific medical concern. 1. Mother appears depressed; 2. Physical abuse of the mother or another family member is suspected; and 3. Mother is abusing or suspected of abusing alcohol or street drugs (such as heroin, marijuana, meth, cocaine, etc.).

H. Other – Refer the following to a DBE: 1. Mother or baby has any other medical problems that are outside the peer counselor scope of practice 2. Mother feels there is a problem that needs a referral; 3. Peer counselor feels there is a situation that needs to be addressed by a lactation expert; 3. Mother is not following suggestions given by the peer counselor; and 4. Any problem not resolved in 24 hours with peer support.

Rev. 09/16

Page 12 Breastfeeding Peer Counseling Program Policy 504 December 2024 SOCIAL MEDIA POLICY FOR BREASTFEEDING PEER PROGRAM

The purpose of this policy is to define and outline Breastfeeding Peer Counselor Program acceptable use of social media sites and resources. Agency and Breastfeeding Peer Counselor Supervisor & Peer Counselor Responsibilities 1. Local Health Department and/or Peer Counselor Supervisors shall approve and monitor all social media posts by Breastfeeding Peer Counselors. 2. Peer Counselors shall post on official accounts only for Breastfeeding Peer Counselor Program services. The official accounts shall not be used to publish personal opinions. Any Peer Counselor wishing to publish personal comments shall use their personal social media accounts must do so on their own personal time. 3. Peer Counselors shall not “friend” or “follow” or “be followed” by Breastfeeding Peer Counselor Participants unless a relationship was established prior to participation in the Breastfeeding Peer Program. Whenever possible, supervisors and Breastfeeding Peers shall avoid assignment of a Peer to friend/family member, etc. 4. State email/agency email address must be used for official business related to social media accounts. 5. Caution shall be used when accessing social media accounts. Social media accounts shall be monitored and updated on a regular basis. 6. Peer Counselors shall only post on topics that are within their scope of practices/duties. 7. In online social networks, the line between public and private, personal, and professional can be blurred. Postings from the official account create perceptions about the agency. Those posting of the account shall be aware of this. 8. All postings must be on the official accounts. Any posting must be consistent with Local Health Department, Kentucky WIC Program and Department of Public Health policies and standards. 9. All postings must be true and not misleading. All information posted must be evidence based. 10. Any social media pages shall include the following disclaimer: “Any posting on this page may be subject to disclosure to third parties. The [agency name] reserves the right to address or remove any posts or comments at its discretion. The [agency name] has not evaluated and does not endorse any products advertised or opinions expressed on this page.” 11. Participation in social media is done so in representation of the Local Health Department and the Kentucky WIC Program Breastfeeding Peer Counselor Program. This is not a right and shall be taken seriously and with respect. When responding the public, be sure you are the appropriate person to do so. 12. Social media accounts and sites created on behalf of the Breastfeeding Peer Counselor Program must contain the USDA Non-Discrimination Statement. 13. Social media accounts and sites created on behalf of the Breastfeeding Peer Counselor Program shall not contain any of the following: • Information that may tend to compromise the safety or security of the public or public systems. • Content that promotes, fosters, or perpetuates discrimination on the basis of race, creed, color, age, religion, gender, marital status, status with regard to public assistance, national origin, physical or mental disability, or sexual orientation. • Disparaging or threatening comments about or related to anyone. • Defamatory, libelous, offensive, or demeaning material. Don’t engage in a combative exchange. • Nonpublic information of any kind. • Personal, sensitive, or confidential information of any kind. • Items involved in litigation or potential litigation. • Illegal or banned substances and narcotics. • Sexual content or links to sexual content, pornography, or other offensive illegal materials. • Profane language or content.

Page 13 Breastfeeding Peer Counseling Program Policy 504 December 2024 • Solicitations of commerce. • Conduct or encouragement of illegal activity. • Content that violates a legal ownership interest of any other party. • Comments not topically related to the particular site or blog article being commented upon. • Violations of copyright, fair use or other applicable laws. • Any other content that would violate any stature, regulation, or internal procedure.

Developed 12/15

Page 14 Breastfeeding Peer Counseling Program Policy 504 December 2024 TEXTING POLICY FOR BREASTFEEDING PEER PROGRAM Texting may be an effective manner to communicate with Breastfeeding Peer Participants. 1. Agencies with Breastfeeding Peer Counselor Programs may make a decision to allow texting as a form of communication between the Peer and WIC participant. 2. If an agency decides to utilize texting as a form of communication, the Breastfeeding Peer Counselor Supervisor must communicate with the Peer Counselors the following: a. Maintain participant confidentiality. Peer Counselor cell phones: i. Cannot be used by anyone other than the Peer Counselor; ii. Cannot be visible to others; iii. Must have a screen lock password; iv. Cannot allow texting alert banners/notifications with text details to scroll on screen for others to view. b. Document text message content on the Contact Log. c. Use text messages only for simple, quick notes to check in with mom. Discuss specific questions or concerns by phone or in person. d. Text messages must be short, simple, and professional (less than 160 characters, including punctuation and spaces). e. Text messages must be focused strictly on WIC breastfeeding program information and objectives.

Dev 12/15

Page 15 Breastfeeding Peer Counseling Program Policy 504 December 2024 Peer Counseling Training Outline and Expectations

The WIC Breastfeeding Peer Counselor will be conducted as a combination of virtual and in-person training.

Below is a list of expectations for the Peer Counselor Training: 1) Level 1 and 2 Breastfeeding Curriculum Videos must be viewed, and quizzes must be passed prior to attending the in-person portion of the training. 2) A copy of the Level 1 and Level 2 certificates must be provided to the State Breastfeeding Peer Counselor Coordinator and the Local Agency Breastfeeding Peer Counselor Supervisor prior to beginning the in-person portion of the training. 3) Homework assigned during Level 1 and Level 2 training must be completed and brought with the Peer Counselor to the in-person training. 4) In-person training will be offered quarterly. If the peer counselor does not complete all parts of the in-person training during this quarterly training, they will have to wait until the next scheduled training before completing their training. 3) Expectations during the in-person training: a. Arrive on time. We will begin training on time each day. b. Pay attention and be engaged during the training. c. Fully participate in all training activities and assignments. d. Please arrange childcare for young children during the training. Only babies in arms that are nursing may be present during the in-person training. e. All homework assignments must be completed and turned in the trainer during the in- person training. These assignments will be discussed during the in-person training. f. We will do our best to stick to the set hours of the training as outlined; however, the length of the training may vary slightly due to activities and questions during the training. g. Plan to attend the entire day. If a peer counselor leaves the training early, they will have to complete this training again at the next quarterly training. i. No makeup time will be provided for portions of the training that is missed. h. It is a requirement that the entire training must be completed prior to begin performing the Peer Counselor duties.

Welcome to the peer program. We are excited to get to know you and work with you. Have Fun!

Peer Counselor signature and date

Peer Supervisor signature and date

Page 16 Breastfeeding Peer Counseling Program Policy 504 December 2024

BREASTFEEDING PEER

COUNSELOR PROGRAM

FORMS

Page 17 Breastfeeding Peer Counseling Program Policy 504 December 2024 [INSERT AGENCY NAME HERE] SAMPLE PEER COUNSELOR JOB POSTING The (insert local WIC agency name) is seeking participants for a part-time/contract position as a Breastfeeding Peer Counselor for (insert counties peer counselor will serve). A Breastfeeding Peer Counselor provides mother-to-mother support and encouragement to pregnant and breastfeeding mothers participating in the Women, Infants, and Children (WIC) program. This position is for (insert number of hours per week) at a pay rate of (insert pay rate/hour). To be eligible for this position, you must:  Be a current or past WIC client;  Have breastfed an infant for 6 months or longer;  Have reliable transportation; and  Have the ability to speak Spanish preferred (if applicable). If interested, (insert local WIC agency hiring protocol). This institution is an equal opportunity provider.

Page 18 Breastfeeding Peer Counseling Program Policy 504 December 2024 [INSERT AGENCY NAME HERE] SAMPLE APPLICATION FOR WIC BREASTFEEDING PEER COUNSELOR

Breastfeeding Peer Counselors provide basic information about breastfeeding to WIC mothers during their pregnancy, and after the baby is born. They encourage mothers to breastfeed and help mothers find help if problems occur. The Breastfeeding Peer Counselor must meet all of the following listed qualifications:

• Be a contemporary/cohort/equal to the woman to whom she will be providing information and support. This includes speaking the ability to speak Spanish, if needed; • Has been or currently is a WIC participant; • Has breastfed at least one baby for six (6) months or longer and is an advocate for breastfeeding • Has the ability to work independently at home. • Has reliable transportation; • Be readily accessible by phone; • Has basic computer skills; and • Has the ability to communicate effectively with peers, supervisors and other health department staff.

Please provide the following information: 1. Name:

Address:

City:

State: Zip:

Home Phone:

Cell Phone:

E-mail address (if applicable):

What languages, other than English, do you speak?

2. Have you participated in the WIC Program? □ Yes □ No, If yes, When? From __________To___________ If yes, at which agency/county did you receive WIC services?

3. Do you have basic computer skills including email □ Yes □ No Word Processing (such as Microsoft Word) □ Yes □ No

4. Circle the highest grade you have completed:

Grade School: 1 2 3 4 5 6 7 8

High School: 9 10 11 12

College: 1 2 3 4 Other

Adapted from Loving Support Through Peer Counseling-A Journey Together for WIC Managers BFPC-1

Page 19 Breastfeeding Peer Counseling Program Policy 504 December 2024 5.

6. Employment History

List previous job or volunteer experience beginning with current or most recent

a. Employer Name: _____________________________________________________________

Job Duties: ___________________________________________________________________ ___________________________________________________________________

Dates of Employment (Month/Year): From: _____________ To: ____________

Reason for Leaving: ________________________________________________________________

b. Employer Name: ________________________________________________________________

Job Duties: ___________________________________________________________________ ___________________________________________________________________

Dates of Employment (Month/Year): From: _____________ To: ____________

Reason for Leaving: ________________________________________________________________

c. Employer Name: ________________________________________________________________

Job Duties: ___________________________________________________________________ ___________________________________________________________________

Dates of Employment (Month/Year): From: _____________ To: ____________

Reason for Leaving: ________________________________________________________________

Ages of your children How long did you breastfeed this child?

Adapted from Loving Support Through Peer Counseling-A Journey Together for WIC Managers BFPC-1

Page 20 Breastfeeding Peer Counseling Program Policy 504 December 2024

7. References: List contact information for three people to be used as references. Name:

Phone Number:

E-mail address:

Name:

Phone Number:

E-mail address:

Name:

Phone Number:

E-mail address:

As a condition of employment, I understand a background check is required and I give consent for it to be completed. I understand the agency where I participated in the WIC Program will be contacted and my status as a WIC participant will be verified.

Signature:

Date:

Adapted from Loving Support Through Peer Counseling-A Journey Together for WIC Managers BFPC-1

Page 21 Breastfeeding Peer Counseling Program Policy 504 December 2024 [INSERT AGENCY NAME HERE]

SAMPLE INTERVIEW GUIDE FOR WIC BREASTFEEDING PEER COUNSELOR

Allow participants a few minutes to read over the Duties of WIC Breastfeeding Peer Counselor. Provide a brief overview of the WIC Program, Breastfeeding Peer Counselor Program and responsibilities. Space has been provided after the questions for the interviewer to make notes. Work History/Experiences 1. Tell me more about your job or volunteer experience(s).

2. What experience have you had with the following computer programs? Word: Excel: Outlook/other email: PowerPoint: Other:

Personal Breastfeeding Experience(s) 3. Tell me about your own breastfeeding experience(s).

4. What part of breastfeeding was most challenging for you? How did you deal with those challenges?

Employment as a Peer Counselor 5. Describe any experiences you have had talking to other mothers about breastfeeding.

Adapted from Loving Support Through Peer Counseling-A Journey Together for WIC Managers BFPC-2

Page 22 Breastfeeding Peer Counseling Program Policy 504 December 2024 6. What would you say to a pregnant woman who was undecided about whether she wants to breastfeed?

7. Why do you want to be a Peer Counselor?

8. As a Breastfeeding Peer Counselor, you will be talking with WIC mothers about breastfeeding. How will you feel about: a. Talking with someone you do not know?

b. Talking with women who might have different cultural, ethnic or educational backgrounds from yours?

c. Keeping information confidential?

9. What days/times can you come to classes to learn how to be a peer counselor? (if applicable)

10. Are there any challenges that might make it hard for you to attend training classes or do the job?

11. How would you keep conversations with breastfeeding mothers confidential when working at home?

12. What questions do you have about the job

Adapted from Loving Support Through Peer Counseling-A Journey Together for WIC Managers BFPC-2

Page 23 Breastfeeding Peer Counseling Program Policy 504 December 2024 PEER COUNSELOR TRAINING CHECKLIST

Document completion date in space provided below for each Peer Counselor training topic. Training Topic Date Completed Completed WIC Breastfeeding Curriculum Level 1 and 2 training

Peer Counselor Contract completed and forwarded to:

Peer Counselor Duties reviewed and provided

Scope of Practice reviewed and provided

Guidelines for Referring/Yielding reviewed and provided

Shadowing Log completed (BFPC-5)

Shadowing Follow-up completed (BFPC-6)

Peer Counselor Observation Tool completed (One Month) (BFPC- 7)

Peer Counselor Observation Tool completed (Six Month) (BFPC-7)

Peer Counselor Observation Tool completed (Annual) (BFPC-7)

Peer Counselor Evaluation completed (One month) (BFPC-8)

Peer Counselor Evaluation completed (Six month) (BFPC-8)

Peer Counselor Evaluation completed (Annual) (BFPC-8)

Participant Phone Feedback Survey completed (Initial) (BFPC-9)

Participant Phone Feedback Survey completed (Six month) (BFPC- 9)

Participant Phone Feedback Survey completed (Annual) (BFPC-9)

Privacy, Security and Confidentiality Policies and Agreement

Breastfeeding Peer System Orientation (Online Database)

Breastfeeding Peer Contact Log Orientation (BFPC-11 A & 11B)

Breastfeeding Peer Weekly Activity Report Orientation (BFPC-12)

Civil Rights ACT of 1964

OSHA Compliance

Computer Security Use of Passwords

Home Visiting and Safety Guidelines

Social Media Policy for Breastfeeding Peer Program

BFPC – 3

Page 24 Breastfeeding Peer Counseling Program Policy 504 December 2024 [INSERT AGENCY NAME HERE] PEER COUNSELOR EQUIPMENT AND MATERIALS LOG

Document the equipment and materials issued to the Peer Counselor and returned by the Peer Counselor below.

Name of Peer Counselor:

Has been issued the following items: Date Issued Supervisor Initials at Issuance Date Returned Supervisor Initial When Received Peer Counselor Client Contact Log(s)

Peer Counselor tickler file/card box/notebook

Cell phone

Laptop/Carrying Case

Internet Card

Teaching doll

Breast model

Breastfeeding videos

Breastfeeding books

Other

List titles of videos/books below: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________

Other

I acknowledge that I received these items and understand that they must be returned to the agency if I leave my position or when requested by my supervisor.

_____ Signature of Supervisor

Date

____________________________________________________

Signature of Peer Counselor

Date Adapted from Loving Support Through Peer Counseling-A Journey Together for WIC Managers BFPC-4

Page 25 Breastfeeding Peer Counseling Program Policy 504 December 2024 PEER COUNSELOR SHADOWING LOG

The Peer Counselor will complete this form to document shadowing experience with other Peer Counselors and/or DBE. Shadowing experiences shall be both face to face and via conference call. Name of Peer Counselor: ________________________________________________ Encounter #1 Date Person Shadowed Setting/Type of Encounter How was rapport established with the mother? What kinds of open-ended questions were asked of the mother? How did these help the mother share information with the counselor? What kinds of affirming statements were used? What did you learn that you can use in your own counseling encounters with mothers?

Encounter #2 Date Person Shadowed Setting/Type of Encounter How was rapport established with the mother? What kinds of open-ended questions were asked of the mother? How did these help the mother share information with the counselor? What kinds of affirming statements were used? What did you learn that you can use in your own counseling encounters with mothers?

Encounter #3 Date Person Shadowed Setting/Type of Encounter How was rapport established with the mother? What kinds of open-ended questions were asked of the mother? How did these help the mother share information with the counselor? What kinds of affirming statements were used? What did you learn that you can use in your own counseling encounters with mothers?

Adapted from Loving Support© Through Peer Counseling: A Journey Together – For WIC Managers BFPC-5

Page 26 Breastfeeding Peer Counseling Program Policy 504 December 2024 Encounter #4 Date Person Shadowed Setting/Type of Encounter How was rapport established with the mother? What kinds of open-ended questions were asked of the mother? How did these help the mother share information with the counselor? What kinds of affirming statements were used? What did you learn that you can use in your own counseling encounters with mothers?

Encounter #5 Date Person Shadowed Setting/Type of Encounter How was rapport established with the mother? What kinds of open-ended questions were asked of the mother? How did these help the mother share information with the counselor? What kinds of affirming statements were used? What else did you learn that you can use in your counseling encounters with mothers?

Encounter #6 Date Person Shadowed Setting/Type of Encounter How was rapport established with the mother? What kinds of open-ended questions were asked of the mother? How did these help the mother share information with the counselor? What kinds of affirming statements were used? What else did you learn that you can use in your counseling encounters with mothers?

Adapted from Loving Support© Through Peer Counseling: A Journey Together – For WIC Managers BFPC-5

Page 27 Breastfeeding Peer Counseling Program Policy 504 December 2024 SHADOWING FOLLOW-UP TOOL

At the conclusion of the shadowing opportunities, the Peer Counselor and the supervisor will have an in-person discussion about the Peer Counselor’s observations. The supervisor can use the following questions to determine the effectiveness of the shadowing experience. Space has been provided for the supervisor to make notes. Name of Peer Counselor: _______________________________________________ 1. How successful was shadowing in helping you better understand your role as a peer counselor?

2. What did you learn through these observations that you feel can be useful to you in counseling new mothers?

3. Review each of the encounters individually and discuss her comments. What other thoughts do you have about this particular encounter?

4. Do you feel comfortable about beginning your work counseling new mothers?

5. If you feel you would like some additional observational opportunities, what types of counseling situations would be most useful for you?

Name of Supervisor: ____________________________________ Date Reviewed: ________________ Adapted from Loving Support© Through Peer Counseling: A Journey Together – For WIC Managers BFPC-6

Page 28 Breastfeeding Peer Counseling Program Policy 504 December 2024 PEER COUNSELOR OBSERVATION TOOL

Document observations of Peer Counselor client interactions including two (2) Pregnant Women and two (2) Breastfeeding Mothers during the first month of orientation and every six (6) months for the first year of employment and annually thereafter or more often at the professional discretion of the supervisor. Peer Counselor: _______________________________ Observer: ____________________

Date of observation: ______________________

Type of Counseling: □Pregnant Woman □ Breastfeeding Mother

□ Conference Call □ Clinic Visit

Peer Counselor Expectations

Yes

No

Comments 1. Peer counselor uses the mother’s and baby’s name, as appropriate.

2. Peer counselor engages the mother through open-ended questions.

3. Peer counselor uses probes appropriately to better understand the mother’s situation.

4. Peer counselor validates the mother’s feelings through affirmation.

5. Peer counselor offers simple solutions or strategies to address the mother’s concerns.

6. Breastfeeding information and support provided is evidence-based as addressed in the training curriculum.

7. Peer counselor appropriately refers the mother or baby, if necessary, to other health care providers or social services as needed.

8. Peer counselor ends the counseling session on a positive note and offers appropriate follow-up.

9. Peer Counselor completes documentation in the BF Peer database at the time the contact is completed.

Adapted from Loving Support© Through Peer Counseling: A Journey Together – For WIC Managers BFPC-7

Page 29 Breastfeeding Peer Counseling Program Policy 504 December 2024

Performance Measures 1 Mo. 6 M 12 Mo. 2 Yr 3 Yr. 4 Yr. 5 Yr. 6 Yr. 7 Yr. 1. Completed the WIC Breastfeeding Curriculum Training. 2. Completed observations and shadowing of DBE and/or experienced peer counselors. 3. Continues to increase knowledge and skills through independent learning. 4. Provides basic education and support to pregnant and breastfeeding WIC participants. 5. Makes timely contacts with new mothers based on established contact guidelines. 6. Keeps all information confidential. 7. Treats WIC participants with respect and courtesy. 8. Uses effective communication and counseling skills to listen to WIC participants and affirm their feelings. 9. Offers breastfeeding solutions and strategies within her scope of practice. 10. Refers mothers according to yield procedures. 11. Documents all contacts with WIC mothers at the time of service. 12. Completes agency time reporting procedures. 13. Contacts the supervisor for ongoing guidance. 14. Attends local WIC agency scheduled Peer Counselor meetings. 15. Attends mandatory State Peer Counselor meetings. 16. Arrives on time when working in the clinic, performing home visits or attending meetings. 17. Uses equipment in the proper manner. 18. Works well with clinic staff. 19. Date Completed 20. Supervisor Initials PEER COUNSELOR EVALUATION TOOL Adapted from Maryland WIC Program & from Loving Support © Through Peer Counseling: A Journey Together – For WIC Managers (BFPC-8) 10/16 Peer Counselor:________________________________ Supervisor:________________________________ Complete this evaluation form for new Peer Counselors at one (1) month and every six (6) months for the first year of employment and annually thereafter. Evaluation: ES=Exceeds Standards, M=Meets Standards, N=Needs Improvement, N/A=Not Applicable

Page 30 Breastfeeding Peer Counseling Program Policy 504 December 2024 PARTICIPANT PHONE FEEDBACK SURVEY

Complete this form for each Peer Counselor at your agency for monitoring of Peer Counselor interactions with Breastfeeding Peer Program participants. The survey must be completed during the first month of orientation and every six (6) months for the first year of employment and annually thereafter or more often at the professional discretion of the supervisor. Review results with Peer Counselor.

Name of Peer Counselor: ________________________________________________________ Date of Call/Name of Mom / Baby’s DOB Do you know your PC by Name? Has your PC been calling you regularly, at least monthly? Has your PC mailed the info to you? Has your PC been helpful to you? Comments/Suggestions 1.

□ Yes □ No □ Yes □ No □ Yes □ No □ Yes □ No

2.

□ Yes □ No □ Yes □ No □ Yes □ No □ Yes □ No

3.

□ Yes □ No □ Yes □ No □ Yes □ No □ Yes □ No

4.

□ Yes □ No □ Yes □ No □ Yes □ No □ Yes □ No

5.

□ Yes □ No □ Yes □ No □ Yes □ No □ Yes □ No

Supervisor:

________________________ Date Reviewed with Peer Counselor:

_______ Adapted from Loving Support ©Through Peer Counseling: A Journey Together- For WIC Managers BFPC-9

Page 31 Breastfeeding Peer Counseling Program Policy 504 December 2024 PEER COUNSELOR EXIT SURVEY

The survey is to be completed by the Peer Counselor at the time of resignation. This survey is to obtain Peer Counselor’s feedback regarding the WIC Breastfeeding Peer Counselor Program.

Name of Peer Counselor:

____________

Dates of service: From:

To:

Coverage area:

1. Why are you leaving this position? Taking another job Returning to school Pay was not enough Not enough hours Family demands Tired of the job Wasn’t what was expected Other

2. How supportive do you feel local health department clinic staff are of breastfeeding, the Peer Counseling Program, and individual Peer Counselors? What could improve the support? ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________

3. How effective is the referral system both within WIC and with the community? If it is not effective, what suggestions would improve it? ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ 4. What do you feel is needed to help retain Peer Counselors? ______________________________________________________________________ ______________________________________________________________________

_______________________________________ ________________ Signature

Date Adapted from Loving Support Through Peer Counseling: A Journey Together – For WIC Managers BFPC-10

Page 32 Breastfeeding Peer Counseling Program Policy 504 December 2024 INSTRUCTIONS FOR COMPLETING PEER COUNSELOR CLIENT CONTACT LOGS

The Peer Counselor Client Contact Log (BFPC-11A & BFPC-11B) is used to document Prenatal and Breastfeeding contacts with clients when the Breastfeeding Peer computer system database is down or a participant is not in the system. The Excel format allows for the records to be kept on the Peer Counselor’s password-protected laptop. If the Excel format is not used, the paper documentation must to be stored in a locked file.

BFPC-11A The BFPC-11A log accommodates up to nine (10) Prenatal contacts.

1. Each contact will be listed by date and type of contact: 1= Phone contact, 2=home visits, 3=group class, 4=mail, 5=clinic visit, 6=hospital visit and 7=other.

2. Record the time and length of contact.

3. Check the topics covered in that contact and include barriers, benefits, technique, management, work/school, class/group.

4. There is also space for narrative documentation for the contact.

BFPC-11B The BFPC-11B log accommodates up to nine (10) Breastfeeding contacts.

1. Each contact will be listed by date and type of contact using the same key for contacts as listed for Prenatal contacts.

2. Record the time and length of contact.

3. Check the topics covered and include baby bowel movements, baby fussy, baby sick, barriers, technique/position, breast infection, class/group, diet, engorgement, family planning, growth spurt, milk supply, medical situation/medication use, feeding schedule, premature infant, pumping/hand expression, referral to Lactation Specialist, relaxation, work/school, sore nipples, teething, twins, weaning, other referral.

4. There is also space for narrative documentation for the contact and a listing of common abbreviations to be used in documentation.

Page 33 Breastfeeding Peer Counseling Program Policy 504 December 2024 PRENATAL CONTACT LOG

BFPC-11A

Page 34 Breastfeeding Peer Counseling Program Policy 504 December 2024 BREASTFEEDING CONTACT LOG

BFPC-11B

Page 35 Breastfeeding Peer Counseling Program Policy 504 December 2024 INSTRUCTIONS FOR COMPLETING THE PEER COUNSELOR WEEKLY ACTIVITY REPORT

The purpose of this report is to account for the time used by the Peer Counselor to complete activities. The Peer Counselor will:

1. Enter the date and participant name and record the number of minutes in the appropriate column for the type of contact completed.

2. Place an X in the column under the correct status, Prenatal, Postpartum-bf, Postpartum- nonbf.

3. Enter remarks or comments to give further detail on the activity. For example, this would include leaving a message, wrong number, no answer, no show or not home for client contacts. This space is also used to give further details regarding meetings, trainings or home study completed.

The Excel version of the report will then calculate the total number of minutes for each type of contact and the number of minutes for each participant entry and the grand total of minutes for the two (2) week time period.

Page 36 Breastfeeding Peer Counseling Program Policy 504 December 2024

Page 37 Breastfeeding Peer Counselor Policy 504 December 2024 ALLOWABLE COSTS FOR BREASTFEEDING PEER COUNSELING FUNDS Breastfeeding peer counseling (BFPC) funds distributed to State agencies by the Food and Nutrition Service (FNS) are to be used to develop or expand activities necessary to sustain a peer counseling program based on the FNS Loving Support Model. The primary purpose of the funds is to provide direct breastfeeding support services through peer counseling to WIC participants.

The table below helps to identify allowable Breastfeeding Peer Counseling costs. Item or Service

Allowable Costs Comments Durable Goods Computers/laptops, cell phones, air cards for Internet access and necessary office equipment used to provide peer counseling services Yes

Requires State Approval Portable baby scales to weight infants outside of the WIC clinic or scales marketed for pre- and post- breastfeeding weight checks. No

Incentives and Educational Materials to Promote Breastfeeding Breastfeeding educational materials such as pamphlets and DVDs No PGC2100 funds or PGC2101 funds* with State Approval Breast pumps and breastfeeding aids for mothers and demonstration purposes No

PGC2100 funds or PGC2101 funds* with State Approval Incentive items distributed to encourage breastfeeding(e.g., breast pumps, breastfeeding aids, breastfeeding promotion and support incentive items, written material, etc.) No PGC2100 funds or PGC2101 funds* with State Approval Personnel and Compensation

Page 38 Breastfeeding Peer Counselor Policy 504 December 2024 Item or Service

Allowable Costs Comments Salaries and compensation for peer counselors: peer counselors, WIC Peer counselor Supervisors, and WIC Designated Breastfeeding Experts (DBE) Yes- see Comment Column The salaries and compensation for an adequate number of peer counselors to service the WIC clients must first come out of PGC2103 funding prior to it being used for peer counselor supervision duties. BFPC funds may be used to pay for DBE time if a peer counselor refers a WIC mother to a DBE for problems that are outside of the peer counselor’s scope of practice. The DBE may be compensated using BFPC funds if the mother continues to be supported by the peer counselor and remains part of the peer counselor’s caseload. Refer to Program Description and Duties of a Peer Counselor in the Administrative Reference, Volume I, Training Guidelines and Service Descriptors. Males as Breastfeeding Peer Counselors No. The definition of peer counselor in the Loving Support Model is based on research demonstrating the benefit of hiring peer counselors from WIC’s target population of WIC- eligible women. Refer to Program Description and Duties of a Peer Counselor in the Administrative Reference, Volume I, Training Guidelines and Service Descriptors. Father-to-Father Breastfeeding Support Group

No Fathers are valuable partners of breastfeeding promotion and support in WIC. However, father- led activities are outside of those defined by the WIC Breastfeeding Model for Peer Counseling. Recruitment of peer counselors Yes

Milk Banks/Depots No. BFPC funds cannot be used for services related to milk banks/depots.

Salary and compensation for lactation referrals No PGC2100 Staff Training and Resources Travel for training of peer counselors peer counselor supervisors and DBEs Yes

Travel for home and hospital visits by peer counselors Yes

Continuing education for DBEs Yes, if it relates to servicing peer counseling programs (e.g., mentoring, serving as a referral, etc.) Requires State Approval

Page 39 Breastfeeding Peer Counselor Policy 504 December 2024 Item or Service

Allowable Costs Comments Breastfeeding resources for peer counseling staff Yes, if the resources are related to peer counseling (e.g., training materials for peer counselors).

Breastfeeding resources for WIC staff not related to peer counseling No PGC2100 funds or PGC2101 funds* with State Approval Registration for State Sponsored/Approved conferences/meetings for Designated Breastfeeding Expert (DBE)

Yes, if it relates to servicing peer counseling programs (e.g., mentoring, serving as a referral, etc.) Requires state approval Training materials for peer counselors

Yes WIC Breastfeeding Curriculum Materials or State Approved Materials. Breastfeeding resources for peer counselor use only

Yes

Breastfeeding resources for WIC staff not related to peer counseling No PGC2100 funds or PGC2101 funds* with State Approval International Board Certified Lactation Consultant (IBCLC), Certified Lactation Counselor (CLC) or Certified Lactation Specialist (CLS) exam fees No

International Board Certified Lactation Consultant (IBCLC), Certified Lactation Counselor (CLC) or Certified Lactation Specialist (CLS) association membership or renewal fees No

Page 40 Breastfeeding Peer Counselor Policy 504 December 2024 Allowable Costs for Breastfeeding Peer Counseling Funds (CONTINUED) Peer Counseling Program Advertising and Promotion Pamphlets and similar materials to promote the peer counseling program only Yes**

Media campaigns, e.g., bus placards, to advertise breastfeeding peer counseling programs only Yes**

Requires State Approval

BFPC funds may not be used for ads that promote breastfeeding in general, 833* funds may be used for this purpose. Ads that promote breastfeeding in general.

No** PGC2100 funds or PGC2101 funds* with State Approval T-Shirts, buttons and similar items that identify peer counselors

Yes** Requires State Approval Miscellaneous Food No

Second nutrition education contacts No

Childcare No

Cribs or other materials and equipment for infants of peer counselors who bring their babies to work No

Evaluation studies of peer program effectiveness No PGC2100 funds Peer counseling services to non- WIC participants No

Breastfeeding coalitions No BFPC funds can only be used for services and activities related directly to peer counseling. **All brochures, materials and advertisements must include the required non-discrimination statement. This statement is included in the AR, Section: Personnel, Civil Rights Act of 1964.

**All brochures, materials and advertisements using the WIC Logo or the Shape the Future: Breastfeed logo must be reviewed and approved by the State WIC Office.

*PGC2101 funds may be used if the agency has a Regional Breastfeeding Coordinator with State

Page 1 Regional Breastfeeding Coordinators Policy 505 December 2024 Policy 505 Regional Breastfeeding Coordinators POLICY Certain agencies will be provided PGC2101 funding to designate a Regional Breastfeeding Coordinator to provide breastfeeding education, promotion, and support in their local agency as well as other designated agencies and public and private community partners in their region. PURPOSE To provide breastfeeding education, promotion, and support in the local agency as well as other designated agencies and public and private community partners in the region. RELEVANT REGULATIONS 7 CFR 246.11(c)(5) – Monitor Local Program Activities 7 CFR 246.11(c)(7)(i) – (iv) – Breastfeeding Promotion and Support Standards 7 CFR 246.11(e)(1) – Encouragement of Breastfeeding United States Department of Agriculture, Food and Nutrition Services, Nutrition Service Standards United States Department of Agriculture, Food and Nutrition Services, Breastfeeding Policy and Guidance PROCEDURES Designation of a Regional Breastfeeding Coordinator A. The person designated in this position must be approved by the State WIC Agency. B. B. A Regional Breastfeeding Coordinator is a Registered Dietitian (RD) or Nurse (RN or LPN) with certification as a Certified Lactation Counselor (CLC), Certified Lactation Specialist (CLS), or an International Board Certified Lactation Consultant (IBCLC). C. The Regional Breastfeeding Coordinator will provide breastfeeding education, promotion, and support in their local WIC agency as well as other designated agencies and public and private community partners in their region. D. The region will be designated by the State WIC Office. Responsibilities of a Regional Breastfeeding Coordinator A. Develop programs, activities, and outreach that promote breastfeeding in the specified region. Work with the Breastfeeding Coordinators at the local agencies, in the specified region, in the development of a Breastfeeding Promotion Plan. B. Provide support, promotion, and education to public and private community partners such as other local agencies, hospitals, physicians, and community groups in the specified region. C. Develop and support breastfeeding coalitions and mother-to-mother support groups in the specified region. D. Attend Regional Breastfeeding Coordinator meetings, as designated by the State Office. E. In conjunction with the Local WIC Agency Administrator, or authorized representative, ensure the agency’s allotment of funds for PGC2101 is appropriately expended in fiscal year. F. Maintain communication with State Breastfeeding Promotion Coordinator to assure continuous quality improvement in breastfeeding promotion and support in the specified region. G. Develop and evaluate an annual plan based upon the assessment of need of the public and private partners in the specified region.

Page 2 Regional Breastfeeding Coordinators Policy 505 December 2024 H. Assist Breastfeeding Promotion Coordinators in specified regions with breastfeeding training and promotion. PGC2101 Cost Center-Breastfeeding (WIC) Only expenditures for designated Regional Breastfeeding Coordinators approved by the State WIC office in specified agencies can be charged to this cost center. The expenditures will be for breastfeeding promotion activities to increase breastfeeding initiation and duration rates. This includes working with other local health departments and public and private community partners. Expenditures for direct one-on-one services cannot be coded to this cost center. All expenses over $500 (five hundred) dollars must be approved by the State WIC Office. Allowable Costs for Regional Breastfeeding Coordinators Only expenditures for designated Regional Breastfeeding Coordinators approved by the State WIC office in specified agencies can be charged to this cost center. The expenditures will be for breastfeeding promotion activities to increase breastfeeding initiation and duration rates. This includes working with other local health departments and public and private community partners. Expenditures for direct one-on-one services cannot be coded to this cost center. All expenses over $500 (five hundred) dollars must be approved by the State WIC Office. The table below helps to identify allowable Regional Breastfeeding Coordinator costs. Item or Service Allowable Costs Comments Durable Goods Computer and Laptops No Coded to indirect costs. These items are used for multiple cost centers. Office equipment No Coded to indirect costs. These items are used for multiple cost centers. Incentives and Educational Materials to Promote Breastfeeding Breastfeeding educational materials such as pamphlets and DVDs Yes** PGC2100 funds or PGC2101 funds with State Approval Breast pumps and breastfeeding aids for mothers and demonstration purposes Yes PGC2100 funds or PGC2101 funds with State Approval Incentive items distributed to encourage breastfeeding Yes PGC2100 funds or PGC2101 funds with State Approval

Page 3 Regional Breastfeeding Coordinators Policy 505 December 2024 Item or Service Allowable Costs Comments Personnel and Compensation Salaries and compensation for Regional Breastfeeding Coordinators Yes Salaries and compensation for lactation referrals No PGC2100 funds Staff Training and Resources Recruitment of Regional Breastfeeding Coordinators Yes Travel for Regional Breastfeeding Coordinators Yes Registration for meetings or conferences for International Board Certified Lactation Consultants (IBCLC) Yes PGC2100 or PGC2101 funds Breastfeeding resources for WIC staff Yes PGC2100 funds or PGC2101 funds with State Approval International Board Certified Lactation Consultant (IBCLC), Certified Lactation Specialist (CLS), or Certified Lactation Counselor (CLC) exam fees No International Board Certified Lactation Consultant (IBCLC), Certified Lactation Specialist (CLS), and Certified Lactation Counselor (CLC) association membership fee No Program Advertising and Promotion Pamphlets and similar materials to promote breastfeeding Yes** With State Approval Media campaigns, e.g., bus placards, to advertise breastfeeding Yes** With State Approval

Page 4 Regional Breastfeeding Coordinators Policy 505 December 2024 Item or Service Allowable Costs Comments Ads that promote breastfeeding in general. Yes** PGC2100 funds or PGC2101 funds with State Approval T-Shirts, buttons, and similar items Yes With State Approval Miscellaneous Food No Second, nutrition education contacts No Childcare No Cribs or other materials and equipment for infants of staff or peer counselors who bring their babies to work No * All brochures, materials, and advertisements must include the required non-discrimination statement. This statement is included in the AR, Section: Personnel, Civil Rights Act of 1964. ** All brochures, materials, and advertisements that have the WIC logo or the Shape the Future: Breastfeed logo must be reviewed and approved by the State WIC Office.

Page 1 Non-Secure Technology Policy 503 December 2024 Policy 506 Breastfeeding Promotion and Support via Technology POLICY All local WIC agencies shall offer breastfeeding promotion, education, and counseling to all WIC participants, parents, and caregivers according to federal regulations, state guidelines, and program goals. These services may be provided in-person or remotely through voice calls, texting, and other technology platforms. The use of non-secure, non-HIPAA-compliant platforms that are familiar to WIC participants can increase access to WIC breastfeeding services. PURPOSE To increase participant access to WIC breastfeeding services and outline the acceptable use of non- secure technology platforms such as, but not limited to, Facebook, YouTube, WhatsApp, iMessage, Meta Messenger, FaceTime, Zoom, Google Meets, TextNow, etc., as well as the use of secure technology platforms such as Business Zoom. RELEVANT REGULATIONS 7 CFR 246.11(c)(7)(i) – (iv) – Breastfeeding Promotion and Support Standards 7 CFR 246.11(e)(1) – Encouragement of Breastfeeding United States Department of Agriculture, Food and Nutrition Services, Nutrition Service Standards United States Department of Agriculture, Food and Nutrition Services, Breastfeeding Policy and Guidance PROCEDURES Consent for Non-Secure Services A. Participant Acknowledgment and Consent for Non-Secure Services 1. Peer Counselors a. If the WIC Staff Breastfeeding Peer Counselor utilizes a non-secure service, the WIC Peer Counselor must obtain verbal consent after reading the risk information to the participant. b. Since these interactions are non-clinical peer support, this consent may be granted at the beginning of the Peer Counselor-Participant relationship and last for one year from that date. c. This consent may be renewed after one year or revoked by the participant at any time. d. The WIC Breastfeeding Peer Counselor shall document: “Participant/Parent/Caretaker/Guardian (select as appropriate) understands and consents to all virtual visits being completed by _________ “in the participant's medical record. 2. WIC Health Professional or Designated Breastfeeding Expert a. If the WIC-Certifying Health Professionals and Designated Breastfeeding Experts (DBE) utilize a non-secure service, the WIC-Certifying Health Professional/ DBE must obtain verbal consent after reading the risk information to the participant. b. Since contact with WIC-Certifying Health Professionals and DBEs is clinical, consent shall be obtained at the beginning of each interaction conducted through a non-secure method. c. The WIC-Certifying Health Professionals or DBE shall document: “Participant/Parent/Caretaker/Guardian (select as appropriate) understands and consents to the virtual visits being completed by _________ on ________(date)” in the participant medical record. B. The following information should be read to the participant before obtaining consent:

Page 2 Non-Secure Technology Policy 503 December 2024

1. With providing consent to services via ____________ platform, we would like you to be aware that: a. Using __________ will allow us to provide you with breastfeeding support and education without requiring you to come into the clinic. b. ________ will allow us to have a breastfeeding appointment through audio call or video conferencing. c. It will allow you to send questions and receive responses using the messaging technology (if applicable) d. We will make every attempt to keep your health information private and secure. e. Allowing us to use __________ can come with risks to your privacy and security of your help information, which may include viruses on your phone or computer, unauthorized access, or accidental disclosure. f. If you have any questions about using ______for your appointment/visit, you may ask at any time. g. You may revoke your consent to use of this service at any time.

Individual Support A. Any form of communication other than in-person, texting via cellular phone plans, voice calls via landlines or cellular plans, or HIPAA-compliant forms of some applications are all considered non-secure and non-HIPAA compliant. B. Despite the risk to protected patient information, some participants may prefer to receive breastfeeding support via instant messaging applications, texting applications, voice calling applications, and video conferencing applications. a. Support may be provided by the participant’s preferred method after following the procedure for Consent for Non-Secure Services outlined above. b. For complicated issues requiring the assistance of the WIC DBE, in-person services should be provided, if possible. c. Individuals providing services shall not use their personal accounts. Set up an account that can only be used professionally and cannot be accessed by another individual. i. Example: Instead of using a personal account that may be listed under “Jane Smith”, create a professional account listed as “Jane Smith – KY County WIC” or “Jane Smith – Breastfeeding Support.” ii. Professional individual accounts will be deactivated once the individual is no longer employed as WIC breastfeeding support staff. Group Support A. Classes a. Participants voluntarily participate in group education (in person or online) with the general knowledge that other people may see them and that the information they share is not private. B. Online Communities a. Online communities, such as online breastfeeding support groups, may be facilitated by peer counselors, the peer counselor supervisor, the breastfeeding coordinator, and/or the DBE. b. Online communities must follow the best practices outlined in the social media Policy for Breastfeeding Peer Program and Social Media Policy for Breastfeeding Education. c. Participants shall voluntarily join or sign up for group support. For online communities, the participant must first acknowledge that the forum is not private or secure either by Participant Acknowledgment and Consent for Non-Secure Services described above or by clicking on and accepting the community rules and acknowledgment statements before being approved to join the group.

Page 3 Non-Secure Technology Policy 503 December 2024

General Promotion and Education A. Platforms and Accounts a. Social Media platforms may be used to promote breastfeeding and provide general breastfeeding education. b. Platforms that facilitate broad information dissemination instead of individual engagement may be the best choices and most time-efficient to manage. Examples are YouTube, Facebook (Page), and Instagram, with the comments turned off as much as each application allows. c. Accounts used for promotion and education should be official work accounts, not private accounts, or profiles. i. Once the WIC agency no longer employs an account administrator, they must pass account management to someone else within the agency. If the account cannot be passed to an employee, it must be deactivated. B. Messaging a. Messaging must be consistent with WIC messaging, which primarily follows messaging and guidance from the USDA, the Center for Disease Control (CDC), and the American Academy of Pediatrics. b. Messaging shall: i. Stay on the topic of breastfeeding. ii. Be framed in a positive voice. iii. Be consistent with DPH messaging. iv. Remain within the moderator's Scope of Practice. v. Responding to comments: 1. Individual counseling is not permitted in public forums. If individual counseling is needed, encourage the person to contact support in a direct method. 2. Utilize steps 2 and 3 of the 3-Step Counseling strategy. (Ask-Affirm- Educate). Do not ask more questions or engage in arguments. Affirm the person’s feelings or point of view and direct them to where they can find more information. c. See attachment for approved sources of messaging and content. C. Consent a. Consent is not required. Participants engage or comment of posted media at their own discretion. b. Consent such as photo or video releases are required for anyone (adult or minor) who is featured in content.

Page 1 Section 500 Breastfeeding Promotion and Support Appendices December 2024

Section 500 Appendices Breastfeeding Promotion and Support

Page 2 Section 500 Breastfeeding Promotion and Support Appendices December 2024

Index Breast Pump Verification of Informed Consent ............................................ 3 Breast Pump Assessment and Information Checklist ................................... 4 Electric Breast Pump Agreement ................................................................. 5 Manual and Single User Electric Breast Pump Inventory Logs ..................... 6 Breastfeeding Management/Care Assessment/Information Checklist for Nipple Shields ......................................................................... 9 Nipple Shield Log .................................................................................. …12 Sample Breastfeeding Clinic Policy Template………………………………..13

Page 3 Section 500 Breastfeeding Promotion and Support Appendices December 2024

HEALTH DEPARTMENT BREAST PUMP VERIFICATION OF INFORMED CONSENT

Breastfeeding is a normal part of the childbearing process and the feeding of an infant. Breastfeeding care includes responsibility for the management of essentially healthy women and infants throughout the period of Breastfeeding.

The Certifying Health Professional/Designated Breastfeeding Expert (DBE) providing this management/care through the Health Department’s Supplemental Nutrition Program for Women, Infants, and Children (WIC) is a health professional. Sound scientific/medical resources and continued educational updates and training in human lactation/breastfeeding are combined with educational backgrounds in health fields as well as skills and experience in breastfeeding care.

Occasionally, problems arise during breastfeeding. However, the health, nutritional, and economic benefits of breastfeeding far outweigh most problems that may arise. Usually, difficulties are minor in nature and do not require medical care.

If my condition or my baby’s should change from normal, medical treatment from my primary obstetrical or pediatric care provider may be required. In the course of breastfeeding, situations which require consultation with the primary care providers include but are not limited to mastitis (breast infections) or infant illness (including failure to thrive). The latter can be due to underlying health problems totally unrelated to feeding method.

I understand that although breastfeeding is a normal process and no problems are anticipated, they can arise. I also understand that these problems are rarely serious. The Certifying Health Professional/DBE will utilize skills and experience to help mothers be successful at breastfeeding for however long they choose. In order to provide the best care and appropriate referrals, mothers need to provide the Certifying Health Professional/DBE with correct information and notify them of any problems related to breastfeeding. I also understand that following appropriate recommendations provided by the lactation expert will help in achieving success at breastfeeding.

I understand that the Certifying Health Professional/DBE is not liable for primary medical care or diagnosis. This is the responsibility of the primary care providers. Any conditions or problems that can affect the well-being of the mother and/or baby will be referred by the Certifying Health Professional/DBE; however, I understand that it is the family’s responsibility to seek medical care and treatment when applicable and I will seek such care and treatment in these instances.

Patient ’s Signature Date

Certifying Health Professional/ Date DBE Signature

Page 4 Section 500 Breastfeeding Promotion and Support Appendices December 2024

KENTUCKY WIC PROGRAM BREAST PUMP ASSESSMENT AND INFORMATION CHECKLIST FOR MANUAL AND SINGLE USER BREAST PUMPS

Mother’s Name:

D.O.B.:

Household #:

Medical Card #:

Address:

Telephone #s: (Home) (Work) (Cell)

Insurance Type: Delivery Date of Pump:

Baby’s Name: D.O.B.:

Birth Weight:

Birth Length:

Agency/Site, if originating agency is different from agency where mother is certified:

Medical Information/Comments:

(Please use back of page if needed)

Date 1st Contact:

Week 1 Phone Contact:

Date(s) follow-up contact(s):

INFORMATION CHECKLIST COMMENTS 1. Provided breast pump and kit 2. Proper use of breast pump 3. Assembly and disassembly of breast pump 4. Proper breast pump cleaning 5. Demonstration of proper assembly and disassembly of pump 6. Hand expression 7. Importance of putting baby to breast (if possible) 8. Frequency of pumping sessions 9. Location of pumping sessions 10.Length of pumping sessions 11.Collection of breast milk 12.Storage of breast milk 13.Warming and feeding breast milk 14.Manufacturer’s instruction sheet provided 15. Instruct participant to complete and mail warranty registration card 16. Advise participant to contact pump manufacturer for troubleshooting 17. Participant understands attempting to sell/selling pump is considered program abuse.

Page 5 Section 500 Breastfeeding Promotion and Support Appendices December 2024

KENTUCKY WIC PROGRAM ELECTRIC BREAST PUMP AGREEMENT {Agency/Site}

I agree to use the

(client name) (name of pump)

Breast Pump serial #: as instructed.

I understand that this pump is for my use only and that neither the pump nor the collection kit can be given or shared with anyone else because of the risk of disease transmission. I agree to contact the WIC Program immediately to report any problems I have while using the pump.

I understand that I am using the pump at my own risk and will hold harmless the

Local Agency, health department staff, and WIC Program.

I understand that I am to complete and mail the pump warranty card to the pump manufacturer.

I understand that attempting to sell or selling is considered WIC Program abuse, and will be investigated. I understand I may be asked to reimburse the program for the value of a pump that is sold.

I have been instructed on how to properly use, assemble and clean the breast pump. WIC Participant Signature:

Telephone #: (Home/Cell)

Email address:

Local Agency Staff Signature

Date

Rev. 10/15

Page 6 Section 500 Breastfeeding Promotion and Support Appendices December 2024

INSTRUCTIONS FOR COMPLETING MANUAL AND SINGLE USER ELECTRIC BREAST PUMP LOGS Local agencies must inventory manual (if on hand) and single user electric breast pumps. The following are sample Breast Pump Logs that may be used to track the issuance and inventory of breast pumps that are provided to WIC participants. The logs must be retained for three (3) full federal fiscal years after last issuance.

Serial Number/ Enter either the breast pump serial number or the WIC Inventory WIC Inventory Tag tag number of the breast pump that is being issued. Serial number Number: should maintained on log or filed in case of a recall or pump malfunction.

Date Issued: Enter the date of the breast pump issuance.

Person Issued: Enter the name of the breastfeeding mother that is received the breast pump. Use the PEF label that is provided when the issuance of a single user breast pump is entered into the Patient Services Reporting System (PSRS).

Number in Inventory: Enter the number of single user breast pumps left in the clinic inventory.

Date of Physical Enter the date the assigned person conducting the physical Inventory: inventory.

Signature of Person Enter the signature of the person conducting the physical Verifying Inventory: inventory.

Comments: Enter any additional comments.

Rev. 10/15

Page 7 Section 500 Breastfeeding Promotion and Support Appendices December 2024

Manual Breast Pump Log Number of Breast Pumps Date Issued / Person Issued Number in Inventory Date of Physical Inventory Signature of Person Verifying Inventory Comments

Page 8 Section 500 Breastfeeding Promotion and Support Appendices December 2024

Single User Electric Breast Pump Log Number of Breast Pumps Date Issued / Person Issued (Use PEF Label) Number in Inventory Date of Physical Inventory Signature of Person Verifying Inventory Comments Rev. 07/08

Page 9 Section 500 Breastfeeding Promotion and Support Appendices December 2024

INSTRUCTIONS FOR COMPLETING BREASTFEEDING MANAGEMENT/ CARE ASSESSMENT/INFORMATION CHECKLIST FOR NIPPLE SHIELDS This checklist is to be used when a nipple shield is being issued to a client. The information contained on this checklist should be obtained from all clients that are receiving a nipple shield. The checklist is to be filed in the medical record. Mother’s Name: Enter the name of the breastfeeding mother.

D.O.B.: Enter the mother’s date of birth.

Household #: Enter the mother’s household number.

Medical Card #: Enter the mother’s medical card number, if applicable.

Address: Enter the mother’s address.

Telephone #’s: Enter all applicable telephone numbers for the mother.

Issue Date of Shield: Enter the date that the breastfeeding mother received the nipple shield.

Baby’s Name: Enter the name of the breastfeeding infant.

D.O.B.: Enter the infant’s date of birth.

Birth Weight: Enter the infant’s weight at birth.

Birth Length: Enter the infant’s length at birth.

Agency/Site: Enter the agency/site if it is different from the agency where the breastfeeding mother was certified.

Medical Information/ Enter any additional medical information or comments Comments: applicable to the breastfeeding management and care of the participant.

Date 1st Contact: Enter the date the first contact was made with the mother. Week 1 Phone Contact: Enter the date of the first week phone follow-up contact. Date(s) follow-up Contact(s): Enter the dates of any additional follow-up contacts.

Information Checklist: Complete the information checklist to ensure the breastfeeding mother has received complete and accurate information. Write any additional comments in the checklist as well.

Rev. 10/13

Page 10 Section 500 Breastfeeding Promotion and Support Appendices December 2024

KENTUCKY WIC PROGRAM BREASTFEEDING MANAGEMENT/CARE ASSESSMENT/INFORMATION CHECKLIST FOR NIPPLE SHIELDS

Mother’s Name:

D.O.B.:

Household #:

Medical Card #:

Address:

Telephone #s: (Home) (Work) (Cell)

Issue Date of Nipple Shield:

Baby’s Name: D.O.B.:

Birth Weight:

Birth Length:

Agency/Site, if originating agency is different from agency where mother is certified:

Medical Information/Comments:

(Please use back of page if needed)

Date 1st Contact:

Week 1 Phone Contact:

Date(s) follow-up contact(s):

INFORMATION CHECKLIST COMMENTS 1. Provided nipple shield 2. Proper use of nipple shield 4. Proper nipple shield cleaning Rev. 10/13

Page 11 Section 500 Breastfeeding Promotion and Support Appendices December 2024

INSTRUCTIONS FOR COMPLETING NIPPLE SHIELD LOG This is a sample Nipple Shield Log that may be used to track the issuance and inventory of nipple shields that are provided to WIC participants. The logs must be retained for three (3) full federal fiscal years after last issuance.

Date Issued: Enter the date of the nipple shield issuance.

Participant Name: Enter the name of the breastfeeding mother that received the nipple shield.

Certifying Health Professional/ Enter the signature of the health professional issuing the nipple Lactation Specialists Issuing: shield.

Number in Inventory: Enter the number of nipple shields left in the clinic inventory.

Date of Physical Enter the date the assigned person conducting the physical Inventory: inventory.

Signature of Person Enter the signature of the person conducting the physical Verifying Inventory: inventory.

Comments: Enter any additional comments.

Rev. 10/13

NIPPLE SHIELD LOG

Date Issued Participant Name Signature of Certifying Health Professional/Lactation Specialists Issuing Number in Inventory Date of Physical Inventory Signature of Person Verifying Inventory Comments

Certifying Health Professional Signature Date

Page 12 Section 500 Breastfeeding Promotion and Support Appendices December 2024

LOCAL AGENCY BREASTFEEDING FRIENDLY POLICY {SAMPLE}

The goals of these policies are: • To promote and create internal and external environments that support and promote breastfeeding. • To increase breastfeeding initiation and duration among Kentuckians in order to meet or exceed the Healthy People 2020 goals of 81.8% of infants initiating breastfeeding and the 2030 goal of increasing the proportion of infants who are breastfed at least one year to 54.16%. • To increase exclusive breastfeeding duration among Kentuckians in order to meet or exceed the Healthy People 2030 goals of 42.4% of infants exclusively breastfeeding at six (6) months.

1. Breastfeeding will be promoted as the normal and optimal feeding method for infants through: • Welcoming mothers to nurse their infants in any location where they are comfortable. If a mother requests a private location to breastfeed or express her milk, take the mother to a private area such as the breastfeeding room (if available) or an empty clinic room. KRS 211.755 states that a mother may breastfeed her baby or express breast milk in any location, public or private, where the mother is otherwise authorized to be. • Freeing the clinic area, lobby, stair wells and elevators of posters, ink pens, pads of paper and other promotional items that bear the names or logos of companies that manufacture infant formula. • Keeping all formula in a storage closet out of view of clients. • Placing any formula being given by the clinic to formula feeding infants in bags before distribution. • Excluding the distribution of educational materials that are produced by a company that manufactures infant formula from the clinic. The only exception is to providing information regarding a WIC contract brand formula. • Not accepting formula samples from formula representatives or manufacturers. • Complying with the 2010 Patient Protection and Affordable Care Act’s amendment to Section 7 of the Fair Labor Standard Act, through allowing employees who are currently breastfeeding: o To utilize their unpaid lunch and break time, as desired to express milk or nurse their infant on or off site; and o To nurse their infant or express milk in their personal office, an empty clinic room or any other private, clean location that is not a bathroom and is free from intrusion that the employee and the administration agree upon. 2. Breastfeeding will be promoted through staff training: • All staff members will be trained on this policy as part of employee orientation. • All staff members will be trained on the importance of breastfeeding which include: o Breast milk is the best food for the infant. It has everything an infant needs to grow and develop; o Breastfeeding helps protect infants from illness. Breastfed infants have fewer ear infections and stomach problems such as diarrhea and vomiting: o Breastfeeding may reduce the breastfeeding mother’s risk of breast and uterine cancer; o Breastfeeding burns calories. Weight loss after pregnancy may be easier for the mother if she is breastfeeding; o Breastfeeding employees miss work less often than mothers who formula fed their infants; and

o Breastfeeding support also leads to lower turnover rates and high employee productivity and loyalty. • Clinic staff who certify participants for the WIC Program will be trained to provide assessment, referrals and appropriate support of the mother’s breastfeeding plans and educational needs throughout the prenatal and postpartum period. • Designated health professional staff will be trained on assembly, cleaning, and issuance of breast pumps. See guidelines for Providing Breast Pumps in the WIC and Nutrition Manual, Clinical Nutrition Section.

3. Health professionals will support breastfeeding mothers and infants by: • Supporting mothers in establishing and reaching their breastfeeding goals through: o Informing all mothers of the importance of holding their babies in Kangaroo Care (skin-to-skin contact) immediately following birth and to remain in Kangaroo Care for at least the first hour; o Advising mothers to ask for help with breastfeeding within the first hours after delivery; o Informing mothers that newborns do not need food or drink other than breast milk unless medically indicated; and o Referring mothers to other lactation services such as classes or support groups available in the community as appropriate. • Encouraging breastfeeding at all nutrition contacts beginning with prenatal enrollment. • Referring breastfeeding problems to an International Board-Certified Lactation Consultant (IBCLC), Certified Lactation Counselor (CLC), Certified Lactation Specialist (CLS) or Breastfeeding Peer Counselor or allow adequate time for assessment, evaluation, and assistance to resolve breastfeeding problems during clinic visit. • Addressing breastfeeding concerns in a timely manner. • Utilizing Breastfeeding Peer Counselors to support WIC prenatal and breastfeeding women, if applicable. Refer to Breastfeeding Peer Counselor Scope of Duty in the Breastfeeding Peer Counselor Section of the WIC and Nutrition Manual. • Promoting the WIC food package incentives for breastfeeding women enrolled in the WIC Program. This promotion should begin during prenatal visits.

Rev. 10/22

WIC and Nutrition Manual 600 Policy Group Food Package Assignment

Table of Contents

Policy 600

Food Package Issuance

Policy 601

Issuance of Standard Infant Food Package

Policy 602

Issuance of Exempt Infant Formula Food Packages

Policy 603 Handling Returned Formula and Formula Benefit Replacement

Policy 604 Assigning Standard Food Packages for Women and Children

Policy 605 Issuance of Supplemental Foods for Women and Children Requiring Medical Documentation

Policy 606 Issuance of WIC Nutritionals to Women and Children

Policy 600 Appendices Food Package Assignment

Page 1 Food Package Issuance Policy 600 October 2024 Policy 600 Food Package Issuance POLICY Certifying Health Professionals must select a participant’s food package in accordance with federal regulations and state policy. PURPOSE To ensure food benefits are appropriate for each participant’s health and nutrition needs. PROCEDURES Food Package Assignment A. The Certifying Health Professional must select, in consultation with the participant or caregiver, the appropriate food package for the WIC participant. 1. The Certifying Health Professional must assign the food and quantities allowed for the participant’s category. a. The food package shall take into account the individual’s age, dietary needs, medical and nutrition conditions, cultural eating patterns, willingness to consume certain foods, and living situations. b. During disasters or food shortages, food packages should be tailored/make substitutions and adjustments to provide available allowable options. c. In case of a shortage for participants receiving exempt infant formula or medical foods, the State WIC Office will work with USDA to request a waiver allowing one-month issuance without a prescription. In addition, we encourage local agencies to work with their physicians for participants with documented qualifying conditions to write prescriptions for multiple appropriate products so that participants do not have to make repeat visits to their healthcare providers and may readily access available food. d. See Policy 220 for further information on food package waivers during a disaster or food shortage. 2. Food package assignment changes are the responsibility of the Certifying Health professional. a. The Certifying Health Professional is the only staff member who can make any change to a participant’s food package. This includes a breastfeeding infant requesting formula.

Page 1 Issuance of Standard Food Packages Policy 601 December 2024 Policy 601 Issuance of Standard Infant Food Packages POLICY The certifying health professional shall issue approved WIC formulas in accordance with the Policies for Prescribing Food Packages, Food Package Tables and Requirements for Issuing Infant Formulas, Exempt Infant Formula and WIC Nutritionals.

PURPOSE To comply with federal requirements for medical documentation for issuance of approved WIC formulas and to facilitate coordination of care for all WIC participants with qualifying medical conditions.

RELEVANT REGULATIONS 7 CFR 246.10 (d)(1) – WIC Formulas and Supplemental foods requiring medical documentation.

PROCEDURES Issuance of Infant Food Packages A. Requirements for issuing each infant formula (milk, soy, milk-based lactose reduced, milk based lactose free, reflux) must be followed. B. All infants receiving formula must receive contract brand infant formula unless contraindicated or a comparable product is not available. C. Noncontract rates for an agency shall be 5% or less. The 1924 formula report is available via e- Reports for local WIC agencies to monitor their non-contract formula rates. D. Whole, low-fat, fat-free/skim or goat’s milk cannot be issued for infants. E. Cereal must not be issued to an infant until six months of age. F. Infants fruits and vegetables may be provided at six months of age. G. Fresh fruits and vegetables may be provided at nine months of age for half of the jarred infant fruits and vegetables.

Infant Food Package Assignment A. Fully Breastfed Infant Package-BF1 1. Fully breastfeeding or exclusive breastfeeding is recommended by the American Academy of Pediatrics for the first six months of life with continued breastfeeding in conjunction with complementary food introduction until 1 year of age or longer as desired by mother and infant. 2. Fully breastfed infants will not receive any formula from WIC but will receive foods at six months of age. 3. The maximum amount of foods received at six months of age include: a. Iron Fortified Cereal-16 oz. total b. Infant Fruits and Vegetables-128 oz. total i. The infant may receive $20 in cash value benefit or $10 in cash value benefit and 64 oz. in jarred infant fruits and vegetables. c. Infant meats-40 oz. total B. Infant Receiving Only Infant Foods-F1 1. This package will be issued to infants whose family will be purchasing formula or the infant is obtaining formula from another source. 2. Document in the medical record the reason for issuance of the F1 package. 3. The infant will receive the following infant foods at six months of age. a. Iron Fortified Cereal-8 oz. total b. Infant Fruits and Vegetables-128 oz. total

Page 2 Issuance of Standard Food Packages Policy 601 December 2024 4. In order for the infant to count as an active participant, the F1 food package must be issued.

C. Partially Breastfed Infant Formula Package 1. The Certifying Health Professional shall individually tailor the partially breastfeeding infant food package amount of formula based on the assessed needs of the breastfeeding infant. Provide the minimal amount of formula that meets the infant’s nutrition needs. 2. Infant formula for a partially breastfeeding infant will be issued in the following amounts. Age Formula Maximum Quantity Allowable

•

Birth through 3 months • Up to 435 fluid ounces of reconstituted powder formula 4 months through 5 months • Up to 522 fluid ounces of reconstituted powder 6 months through 11 months • Up to 384 fluid ounces of reconstituted powder 3. The infant will receive the following infant foods at six months of age. a. Iron Fortified Cereal-8 oz. total b. Infant Fruits and Vegetables-128 oz. total 4. The infant may receive $10 in cash value benefits and 64 oz. in jarred infant fruits and vegetables or $20 in cash value benefit. 5. If a noncontract formula is requested, the challenge guidelines must be followed unless contraindicated. a. The infant may receive one can of formula for the first month but this shall not be routine practice. b. The infant will receive approximately one-half of the formula provided by a full formula package for months two through eleven. i. The Certifying Health Professional shall individually tailor the amount of formula based on the assessed needs of the breastfeeding infant. Assess and provide the minimal amount of formula that meets the infants nutritional needs. ii. Provide counseling on breastfeeding and pumping to establish and maintain adequate breastmilk supply. iii. Counseling shall include recommendation to only purchase as much formula is needed. 6. The Certifying Health Professional shall use the below chart to assist in determining the number of cans needed each month for partially breastfeeding infants based on the amount of formula the infant is taking per day. 0-3 oz. per day → 1 can powder per month 4-6 oz. per day → 2 cans powder per month 7-9 oz. per day → 3 cans powder per month 10-12 oz. per day → 4 cans powder per month 13-15 oz. per day → 5 cans powder per month 16-18 oz. per day → 6 cans powder per month 19-21 oz. per day → 7 cans powder per month 22-24 oz. per day → 8 cans powder per month 25-27 oz. per day → 9 cans powder per month D. Full Formula Infant Package 1. Contract formula will be provided to all non-medically fragile infants. Other formulas may be provided based upon information provided in the medical documentation form a. For the partially breastfeeding infant receiving the full formula package: i. The Certifying Health Professional shall individually tailor the amount of formula based on the assessed needs of the breastfeeding infant.

Page 3 Issuance of Standard Food Packages Policy 601 December 2024 Provide the minimal amount of formula that meets the infants nutritional needs. ii. Counseling shall include recommendation to only purchase as much formula is needed. iii. For infants needing less than half of the formula provided per month, the infant shall be assigned a Partially Breastfeeding Infant Formula Package. 2. The infant may receive a maximum monthly allowance of formula in the amounts of: Age Formula Maximum Quantity Allowable Birth through 3 months • Up to 870 fluid ounces reconstituted powder • Up to 823 fluid ounces reconstituted liquid concentrate • Up to 832 fluid ounces ready-to-feed 4 months through 5 months • Up to 960 fluid ounces reconstituted powder • Up to 896 fluid ounces reconstituted liquid concentrate • Up to 913 fluid ounces ready-to-feed 6 months through 11 months • Up to 696 fluid ounces reconstituted powder • UP to 630 reconstituted liquid concentrate • Up to 643 fluid ounces ready-to-feed E. Full Formula Tube Feeding or Medical Provider request to delay introduction of solids Food Package 1. This package is only provided based upon instructions on the medical documentation form. 2. The maximum amount of formula provided will be: Birth through 3 months • Up to 870 fluid ounces reconstituted powder • Up to 823 fluid ounces reconstituted liquid concentrate • Up to 832 fluid ounces ready-to-feed 4 months through 11 months • Up to 960 fluid ounces reconstituted powder • Up to 896 fluid ounces reconstituted liquid concentrate • Up to 913 fluid ounces ready-to-feed

Contract Brand Formula A. The current infant formula rebate contract is with Abbott Laboratories. B. All infants who are not medically fragile must receive Similac Advance formula. C. Due to increased incidence of osteopenia (bone volume reduction), soy formulas should not be used for preterm infants. D. If the infant has not be receiving Similac formula the transition guidelines must be followed. 1. All caregivers must be counseled to try each formula for 72 hours exclusively. a. Some exceptions may be made for severe reactions such as rash, projectile vomiting, a medically fragile infant or professional judgement. 2. Counseling must include information about changing the infant from the current formula to the contract brand formula. a. Day 1-Offer infant ¾ current formula mixed with ¼ new formula. b. Day 2-Offer infant ½ current formula mixed with ½ new formula. c. Day 3-Offer infant ¼ current formula mixed with ¾ new formula. d. Day 4- Offer new formula exclusively.

Page 4 Issuance of Standard Food Packages Policy 601 December 2024 3. All formulas tried and problems encountered must be documented in the participant’s medical record. E. The contract brand standard formulas that are appropriate to provide to infants during the first year of life are Similac Advance, Similac Total Comfort, Similac Sensitive,or Similac Soy Isomil. F. Infants who come to clinic on one of the non-contract brand formulas and are not medically fragile, must have tried and encountered problems with Similac Advance unless contraindicated. 1. The infant then may try one of the remaining contract brand products.

Requests for Noncontract Formula A. Infants who come to clinic on noncontract formula and are not medically fragile must be provided a Similac Advance formula using the following challenge guidelines: 1. If requesting noncontract brand milk based formula (Gerber Good Start Gentle, Enfamil Infant, etc.), the infant must have tried the contract brand milk based formulas below, unless contraindicated and encountered problems: First Trial: Similac Advance Second Trial: Similac Total Comfort 2. If requesting noncontract soy based formula (Enfamil ProSobee Soy or Gerber Good Start Soy, etc.), the infant must have tried the contract brand soy based formulas below, unless contraindicated, and encountered problems: First Trial: Similac Soy Isomil Second Trial: Similac Sensitive or Similac Total Comfort (if no milk allergies exist) 3. If requesting milk based lactose free or lactose reduced formula (i.e. Enfamil Gentlease, Good Start Soothe, etc.), the infant must have tried the contract brand formulas below, unless contraindicated, and encountered problems: First Trial: Similac Total Comfort Second Trial: Similac Sensitive or Similac Soy Isomil 4. If requesting a formula for management of reflux or gastroesophageal reflux (GER) or gastrophageal reflux disease (GERD), (Enfamil AR) there is no comparable contract brand product. Enfamil AR may be issued with a valid prescription. 5. If requesting noncontract milk based products for 9 to12 months of age (Enfagrow Toddler Transitions), the infant must have tried the contract brand formulas below, unless contraindicated, and encountered problems: First Trial: Similac Advance Second Trial: Similac Total Comfort 6. If requesting noncontract soy based products for 9 to 12 months of age (Enfagrow Toddler Soy Transitions), the infant must have tried the contract brand formulas below, unless contraindicated, and encountered problems: First Trial: Similac Soy Isomil Second Trial: Similac Sensitive or Similac Total Comfort (if no milk allergies exist) 7. If requesting noncontract milk based, hydrolyzed protein with probiotics formula (Enfamil Reguline), the participant must try the contract formulas below, unless contraindicated, and encountered problems: First Trial: Similac Total Comfort Second Trial: Similac Sensitive 8. If requesting for Kosher or Halal formula due to religious beliefs, the infant must have tried the contract brand formula below, unless contraindicated, and encountered problems: First Trial: Similac Advance

Second Trial: Similac Total Comfort B. If the infant is medically fragile (e.g., LBW, premature, recent long hospitalization, heart problems, etc.), WIC will not require this infant to try contract brand formula. C. If the infant is not medically fragile, there must be supporting documentation concerning the contract formulas tried and the problems encountered.

Page 5 Issuance of Standard Food Packages Policy 601 December 2024 D. It is required that the client be provided only 3 months of noncontract formula. At the end of 3 months, it is required that the health professional assess the continued need for the noncontract formula and that the challenge guidelines be followed for non-medically fragile infants. If the health professional determines the infant should not be challenged until the next one-to-three- month issuance, the reason for not challenging must be documented in the medical record. 1. During the assessment, determine if the infant has tried the contract formula within the last 3-4 weeks and followed the transition guidelines.

Requests for Ready-to-Feed Formulas A. Ready-to-feed formula can be provided when the health professional determines and documents: 1. Restricted or unsanitary water supply 2. Poor or no refrigeration 3. The caretaker is unable to properly prepare formula 4. Formula is only manufactured/available in ready-to-feed form 5. Homelessness. a. A medical documentation form will be needed for noncontract formula issuance. b. The 32 oz. size may be issued in situations where the individual has access to refrigeration and dishwashing facilities. c. If the participant does not have access to refrigeration and dishwashing facilities, the formula product shall be issued in individual ready to feed servings. 6. Contact the State WIC Office if you have questions about issuing a Ready to Feed Formula.

Requests for Low Iron Formula A. All low iron formula have been discontinued by the formula companies based on the American Academy of Pediatrics guidelines.

Medical Documentation Requirements for WIC Non-Contract Formulas A. WIC Non-Contract Formulas 1. Medical documentation for issuance of formulas other than the contract brand a. A Certificate for Medical Necessity (WIC – 200, WIC – 300, WIC – 400) or a prescription is required. See Appendix-Medical Necessity Forms. b. Physicians (MD or DO), Physician Assistants (PA’s) and Advanced Practice Registered Nurse (APRN’s) are the accepted authorities to provide the information in the medical documentation form based upon individual needs and medical conditions. c. The Kentucky WIC Program will not be bound to provide products in the medical documentation form that are contraindicated, not allowed by Federal Regulation or not authorized by the Program. d. The medical documentation form must be received prior to the issuance of the food package. This may be written, provided through a telephone order or facsimile (fax), etc. e. All medical documentation forms must contain: i. Name of formula (if requested); ii. Length of time; iii. Diagnosis; iv. Designation of other foods to provide (Food Package III); and v. The signature of the prescriptive authority (physician, PA or APRN). f. A telephone order must also document date of telephone call and signature of person taking the order. The prescriptive authority must send a copy of the medical documentation form for inclusion in the medical record or sign and return

Page 6 Issuance of Standard Food Packages Policy 601 December 2024 the Physician/APRN Verbal Orders (HHS-117). The period of time indicated on a medical documentation form shall not exceed 12 months or one (1) year. g. A medical documentation form remains in effect until expiration even when a participant’s category changes from infant to child. However, need for the formula shall be reviewed with the physician, physician assistant or APRN and parent/caretaker due to the difference between an infant and child’s package. If the medical documentation form has expired, a new one must be obtained before continuing the formula. 2. Medical documentation for issuance of noncontract infant formulas a. If the infant is medically fragile (e.g., LBW, premature, infant released after long hospitalization, heart problems etc.), WIC will not require this infant to try contract brand formula(s). b. If the infant is not medically fragile, there must be supporting documentation concerning the contract formulas tried and the problems encountered. The challenge guidelines must be followed before approving the use of noncontract formula. c. The following information must be on the medical documentation form prior to issuing noncontract standard formula: i. Formulas tried and problems encountered; ii. The diagnosis/diagnoses; iii. Specific name of the formula requested; iv. Prescribed period of time; and v. Signature of MD, DO, PA or APRN. d. Diagnosis for non-contract formulas should include valid medical condition. For infants whose only condition is diagnosed as formula intolerance, food allergy to sucrose, or any other nonspecific intolerance, the request will not be approved.

3. Medical documentation for issuance of ready-to-feed formulas a. Ready-to-feed formula can be provided when the participants medical provider determines and documents: i. Restricted or unsanitary water supply; ii. Poor or no refrigeration; iii. Caretaker is unable to properly prepare formula; iv. Formula is only manufactured/available in the ready-to-feed form; or v. Homelessness

Dilution of Standard Formula A. If a prescription is for a dilution other than the standard mixing instructions on the can, the specific mixing instructions must be provided on the prescription by the prescribing authority.

Page 7 Issuance of Standard Food Packages Policy 601 December 2024 Requirements of Issuing Infant Formula

FORMULA DIAGNOSIS REQUIRED Kentucky Certificate for Medical Necessity Required PRIOR APPROVAL INFANT FORMULA - CONTRACT BRAND- SIMILAC Similac Advance (primary milk based formula) Similac Sensitive Similac Total Comfort Similac Soy Isomil No

No No INFANT FORMULA - NONCONTRACT Enfamil AR Enfamil Gentlease Enfamil Infant Enfamil ProSobee Soy Enfamil Enfagrow Toddler Transitions* Enfamil Enfagrow Soy Toddler Transitions* Good Start Gentle Good Start Soy Good Start Soothe Pro

Yes – Diagnosis

Documentation must include contract formulas tried and problems encountered. See WIC Policies for Prescribing Food Packages for Issuance of Noncontract Standard Formula

See WIC Policies for Prescribing Food Packages Yes

Required Information: 1-Name of formula requested 2-Prescribed period of time 3-Diagnosis (ICD-9/10)

Follow State WIC Office and Agency Policies

Infants with Special Dietary Needs A. Kosher formula requested due to religious or cultural beliefs. 1. Similac Advance formula meets the guidelines for kosher. B. Vegetarian/Vegan requested due to family lifestyle or cultural preference. 1. Similac Soy Isomil Formula meet the guidelines for vegan or vegetarian since it is prepared with soybeans.

Page 1 Issuance of Exempt Infant Formula Food Packages Policy 602 December 2024 Policy 602 Issuance of Exempt Infant Formula Food Packages POLICY The certifying health professional shall issue approved Exempt Infant Formulas in accordance with the Policies for Prescribing Food Packages, Food Package Tables and Requirements for Issuing Infant Formulas, Exempt Infant Formula, and WIC Nutritionals.

PURPOSE To comply with federal requirements for medical documentation for issuance of approved WIC exempt formulas and to facilitate coordination of care for all WIC participants with qualifying medical conditions.

RELEVANT REGULATIONS 7 CFR 246.10 (d)(1) – WIC Formulas and Supplemental foods requiring medical documentation 21 CFR 107.3 – Exempt Infant Formula

DEFINITIONS Exempt Infant Formula -- infant formula that is represented and labeled for use by infants who have inborn errors of metabolism or low birth weight, or who otherwise have unusual medical or dietary problems.

PROCEDURES Requests for Exempt Formula and WIC Nutritionals A. Exempt infant formulas can be provided when the health professional has a medical documentation form or valid prescription. B. Issuance of these formulas requires a medical documentation form and prior approval by the designated local WIC agency personnel who have been trained by the State WIC Office or State WIC Office-identified training. C. The formula must be designed for internal digestion.

Issuance of Exempt Infant Formula Packages A. Infants with valid prescriptions for exempt infant formulas are not required to try contract brand formulas. B. If the infant is medically fragile (e.g. LBW, premature, recent long hospitalization, heart problems, etc.), WIC will not require this infant to try contract brand formula. C. Exempt infant formulas do not have to be challenged.

Medical Documentation Requirements for Exempt Infant Formulas A. Exempt Infant Formulas 1. Medical documentation for issuance of formulas other than the contract brand a. A Certificate for Medical Necessity (WIC – 200, WIC – 300, WIC – 400) or a prescription is required. See Appendix-Medical Necessity Forms. b. Physicians (MD or DO), Physician Assistants (PA), and Advanced Practice Registered Nurses (APRNs) are the accepted authorities to provide the information in the medical documentation form based upon individual needs and medical conditions. c. The Kentucky WIC Program will not be bound to provide products in the medical documentation form that are contraindicated, not allowed by Federal Regulation, or not authorized by the Program.

Page 2 Issuance of Exempt Infant Formula Food Packages Policy 602 December 2024 d. The medical documentation form must be received prior to the issuance of the food package. This may be written, provided through a telephone order or facsimile (fax), etc. e. All medical documentation forms must contain: i. Name of formula (if requested); ii. Length of time; iii. Diagnosis; iv. Designation of other foods to provide (Food Package III); and v. The signature of the prescriptive authority (physician, PA or APRN). f. A telephone order must also document the date of the telephone call and the signature of the person taking the order. The prescriptive authority must send a copy of the medical documentation form for inclusion in the medical record or sign and return the Physician/APRN Verbal Orders (HHS-117). The period of time indicated on a medical documentation form shall not exceed 12 months or one (1) year for an infant and six months for a woman or child. g. A medical documentation form remains in effect until expiration, even when a participant’s category changes from infant to child. However, the need for the formula shall be reviewed with the physician, physician assistant or APRN, and parent/caretaker due to the difference between an infant’s and child’s package. If the medical documentation form has expired, a new one must be obtained before continuing the formula. 2. Issuance of Food Package III (nonstandard infant food package) may not be issued for the following reasons: a. For infants whose only condition is diagnosed as formula intolerance, food allergy to sucrose, or any other nonspecific intolerance. B. The chart at the bottom of this section provides guidance on what documentation is necessary for product issuance.

State Agency Approval A. If State Agency approval is needed to issue an Infant Formula or WIC Nutritional, after receiving verbal approval from a State WIC Office Registered Dietitian, complete the WIC State Agency Formula/WIC Nutritional Approval Form and fax or email it to the State WIC Office. See Appendix WIC State Agency Formula Approval Form.

Dilution of Standard Formula A. If a prescription is for a dilution other than the standard mixing instructions on the can, the specific mixing instructions must be provided on the prescription by the prescribing authority.

Medicaid Denial Letters for Exempt Infant Formula When a physician prescribes a formula that WIC does not authorize or if the physician prescribes more than WIC can provide for a Medicaid participant, a Medicaid Denial Letter shall be provided to the participant. See Appendix-Medicaid Denial Letter. A. Contact the State WIC Office if you have questions about Medicaid Denial Letters.

Page 3 Issuance of Exempt Infant Formula Food Packages Policy 602 December 2024 Requirements of Exempt Infant Formula Chart

FORMULA DIAGNOSIS REQUIRED Kentucky Certificate for Medical Necessity Required PRIOR APPROVAL EXEMPT INFANT FORMULAS and WIC NUTRITIONALS (Examples) Nutramigen/Nutramigen with Enflora LGG Nutramigen Toddler with Enflora LGG Pregestimil Pregestimil 24 Similac Alimentum Alfamino PurAmino Gerber Extensive HA Yes – Diagnosis Yes

Required Information: 1-Name of formula requested 2-Prescribed period of time 3-Diagnosis 4-Additional foods Follow State WIC Office and Agency Policies EXEMPT FORMULA AND WIC NUTRITIONALS (Examples)– LOCAL APPROVAL Yes – Diagnosis

Yes

Required Information: 1-Name of formula requested 2-Prescribed period of time 3-Diagnosis 4-Additional Foods

Yes.

Agency Personnel designated by and trained be the State WIC Office to approve special formulas.

Elecare for Infants Elecare Jr Enfamil EnfaCare Enfamil Enfaport Neocate Infant/Neocate SYNEO Infant

PediaSure PediaSure with Fiber PediaSure Enteral PediaSure Peptide 1.0 Peptamen Junior Similac NeoSure

EXEMPT INFANT FORMULAS AND WIC NUTRITIONALS – STATE APPROVAL Any formulas not found in the above tables or formula used outside the intended use. Yes – Diagnosis

See each formula type for additional requirements. Yes

Required Information: 1-Name of formula requested 2-Prescribed period of time 3-Diagnosis 4-Additional foods Yes.

Complete the WIC STATE AGENCY FORMULA/WIC NUTRITIONALS APPROVAL FORM (see 600 Appendix) for State WIC Office approval. FOOD PACKAGE III For infants, formulas may include: Exempt Infant Formula Exempt Infant Formulas and WIC Nutritionals (Local Approval) Exempt Infant Formulas and WIC Nutritionals (State Agency Approval)

Yes – Diagnosis

See each formula type for additional requirements. Yes

Required Information: 1-Name of formula requested 2-Prescribed period of time 3-Diagnosis 4-Additional foods Follow the approval process for each specific type of formula.

Page1 Handling of Returned Formula and Formula Benefit Replacement Policy 603 December 2024 Policy 603 Handling of Returned Formula and Formula Benefit Replacement

POLICY Local WIC Agencies shall track all formula that has been returned to the WIC Program and reissue the appropriate food package.

PURPOSE To ensure program accountability, participant safety, and consistency in handling returned formula, including inventory and destruction of returned formula and accurate re-issuance.

RELEVANT REGULATIONS 7 CFR 246.16(a) – Infant Formula Cost Containment 7 CFR 246.10(c)(1)(2) – Food Packages

PROCEDURES When a Formula May be Returned A. A parent/caretaker may have redeemed all, or part of an infant’s food benefits for one month, and the physician changes the infant to a different formula. B. A food package change could also occur for an infant, child, or woman receiving exempt infant formula or WIC Nutritionals on a Food Package III.

Handling Returned Formula A. The unused formula must be returned to the local WIC agency. 1. The unused formula cannot be returned to a vendor to exchange for another formula. 2. Opened cans of formula may not be returned. a. Local WIC agency staff must verify that the formula is unopened before the re- issuance of eWIC benefits. 3. If a formula change is made for a formula product the participant has not previously tried, encourage the participant to redeem benefits for only one can or the smallest unit of sale to determine if the formula product is well tolerated. B. Accountability of the returned formula must be maintained at the Local WIC Agency. C. Returned formula is not safe for human or animal consumption and must be destroyed. 1. Returned formula must be properly disposed of and cannot be distributed or reissued in any way, including another WIC participant, emergency food bank/pantry, used as animal food, charitable organization, or another WIC agency. D. Inventory for returned and destroyed formula must be maintained. E. Consult Environmental Health Staff regarding proper disposal or returned formula. F. See Policy 804 Food Benefit Replacement Policy.

Formula Benefit Replacement A. If the parent/caretaker or participant returns only unused formula to the local WIC agency. 1. Document in the participants’ medical record the return of the original formula and the reason for issuance of replacement food benefits. 2. Issuance of formula must follow the WIC Policies for Prescribing Food Packages. a. See Policy 601-Issuance of Standard Infant Formula, Policy 602-Issuance of Exempt Infant Formula, Policy 606 WIC Nutritionals Issuance. 3. All unopened cans of formula that need to be replaced must be returned and entered into the CDP Portal System prior to changing the food package. 4. Choose the appropriate food package code for the replacement formula.

Page2 Handling of Returned Formula and Formula Benefit Replacement Policy 603 December 2024 5. The system will automatically calculate the appropriate quantity of formula to be issued and adjust the benefits on the EBT account. a. Contact the State WIC Office at 502-564-3827 with any questions about the amount of formula issued. B. If the parent/caretaker or participant returned unused formula and has unused food benefits remaining on their card for the month. 1. Document in the medical record the return of the original formula, the amount of the unused food benefits, and the reason for replacement. 2. Issuance of formula must follow the WIC Policies for Prescribing Food Packages. a. See Policy 601-Issuance of Standard Infant Formula, Policy 602-Issuance of Exempt Infant Formula, Policy 606 WIC Nutritionals Issuance. 3. Choose the appropriate food package code for the replacement formula. 4. The system will automatically calculate the appropriate quantity of formula to be issued and adjust the benefits on the EBT account. a. Contact the State WIC Office at 502-564-3827 with any questions about the amount of formula issued.

Page 1 Assigning Standard Food Packages for Women and Children Policy 604 December 2024 Policy 604 Assigning Standard Food Packages for Women and Children

POLICY A Certifying Health Professional will select, tailor and assign participants food package in accordance with the federal regulations and state policies.

PURPOSE To ensure all participants receive food benefits appropriate for their status, health and nutritional needs.

RELEVANT REGULATIONS 7 CFR 246.10 – Participant Benefits – Supplemental Foods

PROCEDURES Prescribing Standard Food Packages A. The food package must be appropriate for the participant's category/status and age and cannot exceed the maximum allowed for that category/status and age. The maximum package must be provided for all participants. If a tailored food package is provided, the reason must be documented in the participant’s medical record. B. The Certifying Health Professional is responsible for selecting the appropriate food package in accordance with the policies in the appropriate section of this manual. 1. This includes the following situation: a. New participants enrolled in the program b. Change in the food package per client or medical personnel request c. Change in status d. Receipt of Verification of Transfer (VOC)-out of state C. Food package selection and food package changes must be done by the health professional based on the person’s nutrition needs, risk, access to refrigeration, cooking and storage facilities and sanitary water supply. Foods shall be issued on appropriate form and quantities to meet the person's individualized needs. D. Participants shall be encouraged to purchase all the items on their assigned food package. E. Food packages are assigned based on their status. F. If a woman or child needs a specialized food package or WIC Nutritional, see Issuance of WIC Infant Food Packages and WIC Nutritionals policy and Issuance of Supplemental Foods Requiring Medical Documentation policy.

Standard Woman and Child Food Package Descriptions Below are the food packages that may be assigned to women and children needing a standard food package. A. Fully Breastfeeding Woman/Pregnant with Multiple Fetuses/Partially Breastfeeding Multiple Infants, Pregnant Woman Fully or Partially Breastfeeding. The maximum amount of food provided includes: 1. Milk- 24 quarts a. Low-fat (1%) or less is the standard issuance. b. Whole milk is not authorized for this package. c. Reduced fat Milk requires a Certifying Health Professional assessment for Issuance. See Issuance of Supplemental Foods Requiring Medical Documentation Policy. d. Cheese, yogurt or tofu may be substituted for milk per the Milk Substitute Nutrition Assessment and Issuance Policy in Policy 605-Issuance of

Page 2 Assigning Standard Food Packages for Women and Children Policy 604 December 2024 Supplemental Foods for Women and Children Requiring Medical Documentation Policy section. e. Soy milk may be substituted for milk on a quart-for-quart basis per the Milk Substitute Nutrition Assessment and Issuance Policy in Policy 605-Issuance of Supplemental Foods for Women and Children Requiring Medical Documentation Policy section. 2. Cheese-1 pound 3. Juice-144 ounces 4. Cereal-36 ounces 5. Eggs-2 dozen 6. Whole Wheat/whole grain bread or other whole grain-1 pound 7. Fish-30 ounces 8. Fruits/vegetables-$49.00 9. Legumes/beans-1 pound dry or 64 ounces canned beans, and 10. Peanut butter- 18 ounces B. Fully Breastfeeding Multiple Infants. The maximum amount of food provided includes: 1. Milk- 36 quarts a. Low-fat (1%) or less is the standard issuance. b. Whole milk is not authorized for this package. c. Reduced fat Milk requires a Certifying Health Professional assessment for Issuance. See Policy 605-Issuance of Supplemental Foods for Women and Children Requiring Medical Documentation. d. Cheese, yogurt or tofu may be substituted for milk per the Milk Substitute Nutrition Assessment and Issuance Policy in Policy 605-Issuance of Supplemental Foods for Women and Children Requiring Medical Documentation. e. Soy milk may be substituted for milk on a quart for quart basis per the Milk Substitute Nutrition Assessment and Issuance Policy in Policy 605-Issuance of Supplemental Foods for Women and Children Requiring Medical Documentation. 2. Cheese-1 pound and 8 ounces 3. Juice-216 ounces 4. Cereal-54 ounces 5. Eggs-3 dozen 6. Whole Wheat/whole grain bread or other whole grain-24 ounces (system will issue 32 oz./16 oz. every other month as products are only authorized in 16 oz. size containers) 7. Fish-45 ounces 8. Fruits/vegetables-$73.50 9. Legumes/beans-1 pound dry or 64 ounces canned beans, and 10. Peanut butter- 36 ounces C. Pregnant Woman/Partially Breastfeeding Woman (infant receives partial breastfeeding package, woman receives food package up to one year postpartum if infant continues on partially breastfeeding formula package). The maximum amount of food provided includes: 1. Milk- 22 quarts a. Low-fat (1%) or less is the standard issuance. b. Whole milk is not authorized for this package. c. Reduced fat Milk requires a Certifying Health Professional assessment for Issuance. See Policy 605-Issuance of Supplemental Foods for Women and Children Requiring Medical Documentation. d. Cheese, yogurt, or tofu may be substituted for milk per the Milk Substitute Nutrition Assessment and Issuance Policy in Policy 605-Issuance of Supplemental Foods for Women and Children Requiring Medical Documentation.

Page 3 Assigning Standard Food Packages for Women and Children Policy 604 December 2024 e. Soy milk may be substituted for milk on a quart for quart basis per the Milk Substitute Nutrition Assessment and Issuance Policy in Policy 605-Issuance of Supplemental Foods for Women and Children Requiring Medical Documentation. 2. Juice-144 ounces 3. Cereal-36 ounces 4. Eggs-1 dozen 5. Whole Wheat/whole grain bread or other whole grain-1 pound 6. Fruits/vegetables-$44.00 7. Legumes/beans-1 pound dry or 64 ounces canned beans, and 8. Peanut butter- 18 ounces D. Postpartum/Partially Breastfeeding Woman (infant receiving full formula package, woman receives a food package until baby is 6 months old). The maximum amount of food provided includes: 1. Milk-16 quarts a. Low-fat (1%) or less is the standard issuance. b. Whole milk is not authorized for this package. c. Reduced fat Milk requires a Certifying Health Professional assessment for Issuance. See Policy 605-Issuance of Supplemental Foods for Women and Children Requiring Medical Documentation. d. Cheese, yogurt, or tofu may be substituted for milk per the Milk Substitute Nutrition Assessment and Issuance Policy in Policy 605-Issuance of Supplemental Foods for Women and Children Requiring Medical Documentation. e. Soy milk may be substituted for milk on a quart for quart basis per the Milk Substitute Nutrition Assessment and Issuance Policy in Policy 605-Issuance of Supplemental Foods for Women and Children Requiring Medical Documentation. 2. Juice-96 ounces 3. Cereal-36 ounces 4. Eggs-1 dozen 5. Fruits/vegetables-$44.00 6. Legumes/beans-1 pound dry or 64 ounces canned beans. E. If the partially breastfeeding woman is providing breastmilk to her 6-month-old infant (infant receiving a fully formula package) at least one time per day, she continues on the program as a breastfeeding woman but does not receive a food package. The infant continues on the program and receives a fully formula-fed food package. F. Child Food Package. The maximum amount of food provided includes: 1. Milk-16 quarts a. Child age two and older i. Low-fat (1%) or less is the standard issuance. ii. Whole milk is not authorized for this package. iii. Reduced fat Milk requires a Certifying Health Professional assessment for Issuance. See Issuance of Supplemental Foods Requiring Medical Documentation Policy. iv. Cheese, yogurt, or tofu may be substituted for milk per the Milk Substitute Nutrition Assessment and Issuance Policy in Policy 605- Issuance of Supplemental Foods for Women and Children Requiring Medical Documentation. v. Soy milk may be substituted for milk on a quart-for-quart basis per the Milk Substitute Nutrition Assessment and Issuance Policy in Policy 605- Issuance of Supplemental Foods for Women and Children Requiring Medical Documentation. b. Child age 12 through 23 months i. Whole milk is the standard issuance.

Page 4 Assigning Standard Food Packages for Women and Children Policy 604 December 2024 ii. Reduced fat Milk requires a Certifying Health Professional assessment for Issuance. See Policy 605-Issuance of Supplemental Foods for Women and Children Requiring Medical Documentation. iii. Low-fat (1%) or less milk may only be issued per medical documentation. iv. Cheese, yogurt or tofu may be substituted for milk per the Milk Substitute Nutrition Assessment and Issuance Policy in Policy 605-Issuance of Supplemental Foods for Women and Children Requiring Medical Documentation. v. Soy milk may be substituted for milk on a quart for quart basis per the Milk Substitute Nutrition Assessment and Issuance Policy in Policy 605- Issuance of Supplemental Foods for Women and Children Requiring Medical Documentation. 2. Juice-128 ounces 3. Cereal-36 ounces 4. Eggs-1 dozen 5. Whole wheat/whole grain bread or other whole grains- 2 pounds 6. Fruits/vegetables-$25.00 7. Legumes/beans-1 pound dry or 64 ounces canned beans or peanut butter-18 ounces (peanut butter will not be provided on the age 12 through 23 months package due to choking hazards)

Page 1 Issuance of Supplemental Foods for Women and Children Requiring Medical Documentation Policy 605 December 2024 Policy 605 Issuance of Supplemental Foods for Women and Children Requiring Medical Documentation POLICY The certifying health professional shall issue approved supplemental foods to women, infants and children with medical documentation from a prescriptive authority and in accordance with the Policies for Prescribing Food Packages.

PURPOSE To comply with federal requirements for medical documentation for issuance of Supplemental foods and to facilitate coordination of care for all WIC participants with qualifying medical conditions.

RELEVANT REGULATIONS 7 CFR 246.10 (d)(1) – WIC Formulas and Supplemental foods requiring medical documentation

DEFINITION Food Package III - a food package that is issued to a woman or child that contains an infant formula, exempt infant formula, or WIC Nutritional.

PROCEDURES Medical Documentation Requirements A. Participants receiving Food Package III must have a Certificate of Medical Necessity or prescription (medical documentation form or valid prescription) which contains the following: 1. Diagnosis; 2. Name of Formula/WIC Nutritional/Supplemental Food requested; 3. Prescribed period of time the formula/WIC nutritional/supplemental food will be needed. (WIC issuance shall not exceed six months) 4. Other foods requested; 5. Special instructions; and 6. Signature of MD, DO, PA, or APRN.

Medical Documentation for Issuance of Milk and Milk Substitutions A. Requests for whole milk/whole milk yogurt for women and children ≥ 2 years of age 1. Women and children ≥ 2 years of age issued a Food Package III (infant formula, exempt infant formula, or WIC Nutritional) for special dietary/medical condition may receive whole milk and/or whole milk yogurt with medical documentation (WIC-300 or WIC-400). See 600 Appendix Medical Necessity Form. 2. Women and children issued a standard food package may not receive whole milk or whole milk yogurt, even with medical documentation requesting whole milk and/or whole milk yogurt. If cheese is an appropriate food for the participant, the participant may be offered a food package with cheese substituted for a portion of the milk. 3. Document the reason for issuing whole milk and/or whole milk yogurt. B. Request for reduced fat milk (2%) milk for women and children ≥ 2 years of age 1. Women and children ≥ 2 years of age issued a Food Package III (infant formula, exempt infant formula or WIC Nutritional) for special dietary/medical condition, may receive reduced fat (2%) milk with medical documentation (WIC-300 or WIC-400). 2. Reduced fat (2%) milk may be issued under the following conditions: a. Medical documentation WIC-300 or WIC-400; or

Page 2 Issuance of Supplemental Foods for Women and Children Requiring Medical Documentation Policy 605 December 2024 b. Certifying Health Professional assesses and documents one of the following conditions are present (Certifying Health Professional may consult with participant’s health care provider as needed to assist with assessment for need for reduced fat (2%) milk): i. Underweight; ii. Maternal weight loss during pregnancy; iii. Weight loss; c. Document reason for issuance of reduced fat (2%) milk. C. Requests for reduced fat milk (2%) milk for children 12 to 23 months of age. 1. Whole milk is the standard milk for issuance to 1-year-old children. 2. Reduced fat (2%) milk may be issued under the following conditions: a. Medical documentation WIC-300; or b. Certifying Health Professional assesses and documents one of the following conditions are present (Certifying Health Professional may consult with participant’s health care provider as needed to assist with assessment for need for reduced fat (2%) milk): i. High Weight for Length ii. At risk for overweight 3. For children issued a Food Package III for infant formula, exempt infant formula or WIC Nutritional, reduced fat milks may be issued to a 1-year-old only when determined appropriate by the health care provider per medical documentation. 4. Nutrition counseling must be provided on the importance of fat for development and growth for toddlers and how to incorporate healthy oils in the diet as appropriate. a. The American Academy of Pediatrics (AAP) recommends approximately 30% of calories from the diet of toddlers come from fat. Due to the rapid growth and development requiring increased calories for children under 2 years of age, the AAP generally does not recommend the use of low-fat and nonfat milk for this age group. b. Whole milk is the primary source of saturated fat in young children’s diets. Healthy fats used in moderation can provide needed fat and calories for children who are consuming reduced-fat milks. 5. Reasons for issuance of reduced fat milk must be documented in the medical record. D. Requests for low-fat (1%) or less (1/2% or skim/nonfat) milk and/or low-fat/nonfat yogurt for children 12 to 23 months of age. 1. Low-fat or less milk may only be issued to 1-year-old children on the standard child food package or food package III only, per medical documentation. 2. Low-fat/nonfat yogurt may be issued to 1-year-old children under the following conditions: a. Medical documentation on WIC-300; or b. Certifying Health Professional assesses and documents one of the following conditions are present (Certifying Health Professional may consult with participant’s health care provider as needed to assist with assessment for the need for low-fat/nonfat yogurt). i. High Weight or Length ii. At risk for Overweight 3. Reasons for issuance of low-fat or less milk and/or low-fat/nonfat yogurt must be documented in the participant’s medical record. E. Requests for Cheese 1. Cheese may be issued upon participant request or when lactose intolerance is suspected or diagnosed. The medical documentation form is not required for the issuance of cheese. 2. Cheese may be substituted for milk at the rate of 1 pound of cheese per three quarts of milk.

Page 3 Issuance of Supplemental Foods for Women and Children Requiring Medical Documentation Policy 605 December 2024 a. For children, pregnant, partially breastfeeding, and postpartum women, no more than 1 pound of cheese may be substituted for milk, and no more than 4 quarts of milk may be substituted for a combination of cheese, yogurt, or tofu. b. For fully breastfeeding women, no more than 2 pounds of cheese may be substituted for milk, and no more than 6 quarts of milk may be substituted for a combination of cheese, yogurt, or tofu. F. Requests for Lactose-Free Milk 1. May be issued when lactose intolerance is suspected or diagnosed. Lactose intolerance may be self-reported by the participant/parent/caretaker and does not require a medical documentation form. 2. The reason for issuance must be documented in the participant’s medical record. 3. Lactose-free and lactose-reduced milk is packaged in half-gallon containers. 4. Whole lactose-free milk is required for children age 1 to 2. For children age two and older and women, low-fat lactose-free milk is required. G. Requests for Soy Milk and Tofu 1. The medical documentation form is not required for the issuance of soy milk or tofu; however, the Certifying Health Professional must assess the need for soy milk or tofu prior to issuance and provide counseling on the importance of milk in the diet. Certifying Health Professionals may consult with the health care provider as needed to assist with assessment. 2. Provide counseling on the value of milk in the diet. The following are counseling topics: a. Children’s diets may be nutritionally inadequate when milk is replaced with other foods. Milk is particularly important in the development of bone mass for children. b. Milk provides important nutrients for health, growth, and development. Milk contains protein for muscles, calcium, and Vitamin D for strong teeth and bones. c. Milk is a source of Vitamin A. Vitamin A is important for vision, strong immune system, and cancer prevention. d. If milk is replaced with milk alternatives that are not Vitamin D fortified, Vitamin D intake may be inadequate. 3. Soy milk and tofu may be issued up to the maximum allowance for milk when the following conditions apply: a. Lactose intolerance is suspected or diagnosed that cannot be managed with lactose-free or lactose-reduced fortified dairy products. b. Milk protein allergy c. Vegan diet d. Religious/Cultural presence. 4. Soy milk may be substituted for milk on a quart-by-quart basis up to the maximum allowance of milk. 5. Tofu may be substituted for milk at the rate of 1 pound of tofu per 1 quart of milk. 6. A combination of cheese, yogurt, and tofu can be substituted for milk. a. For children, pregnant, partially breastfeeding, and postpartum women, no more than 4 quarts of milk may be substituted for a combination of cheese, yogurt, or tofu. b. For fully breastfeeding women, no more than 2 pounds of cheese may be substituted for milk, and no more than 6 quarts of milk may be substituted for a combination of cheese, yogurt, or tofu. c. The reason for issuance must be documented in the participant’s medical record. H. Requests for Yogurt 1. Yogurt may be issued upon participant request. The medical documentation form is not required for issuance of yogurt unless one of the conditions below applies.

Page 4 Issuance of Supplemental Foods for Women and Children Requiring Medical Documentation Policy 605 December 2024 a. Women and children ≥ 2 years of age issued a Food Package III for special dietary/medical condition may receive whole milk yogurt with medical documentation. b. Low-fat/nonfat yogurt may be issued to 1-year-old children under the following conditions: i. Medical documentation on WIC-300; or ii. Certifying Health Professional assesses and documents one of the following conditions are present (Certifying Health Professional may consult with the participant’s health care provider as needed to assist with assessment for the need for low-fat/nonfat yogurt). a) High Weight for Length b) At Risk for Overweight 2. Yogurt may be substituted for milk at the rate of 32 oz. per 1 quart of milk. a. No more than 32 oz. may be substituted for milk, and no more than 4 quarts of milk may be substituted for a combination of cheese, yogurt, or tofu. I. Requests for Other Milk 1. No other milk substitutions are authorized for issuance, including evaporated, condensed, almond, rice, or goat milk.

Women and Children with Special Dietary Needs A. Requests for pureed fruits and vegetables for women and children 1. Women and children issued a standard food package may not receive jarred infant fruits and vegetables. 2. Women and children issued a Food Package III (infant formula, exempt infant formula, or WIC Nutritional) for special dietary/medical conditions may receive commercial jarred infant food fruits and vegetables in lieu of fresh/frozen fruits and vegetables with medical documentation. a. Children may receive 128 oz. of commercial jarred infant fruits and vegetables. b. Women may receive 160 oz. of commercial jarred infant fruits and vegetables. 3. Reasons for issuance must be documented in the medical record. B. Requests for infant and cereals for women and children 1. Women and children issued a standard food package may not receive infant cereal in lieu of “adult” breakfast cereal. 2. Women and children issued a Food Package III (infant formula, exempt infant formula, or WIC Nutritional) for special dietary/medical conditions may receive 32 dry oz. infant cereal in lieu of 36 oz. of “adult” breakfast cereal with medical documentation. C. Requests for Kosher Foods 1. Participants requesting Kosher Food packages may be issued a Kosher Food Package for their status and age that allows the least expensive brand of Kosher Milk. The following are appropriate food packages. a. Pregnant or Partially Breastfeeding with Kosher designated milk and cheese-P2K b. Postpartum or Partially Breastfeeding with Kosher designated milk and cheese- PPK c. Fully Breastfeeding, Pregnant with Multiples, Partially Breastfeeding Multiples, or Pregnant Partially Breastfeeding with Kosher designated milk and cheese-FBFK d. Child Package with Kosher designated milk and cheese-CBK e. Some products on the WIC Food List that have variations of the Kosher label include: i. Cereal-General Mills selections, Post selections, Quaker selections, Malt-O-Meal-Crispy rice, B and G food selections, Kellogg’s selections ii. Milk-Meijer, Lactaid, Kroger, Trauth, Fresh and Healthy 1%

Page 5 Issuance of Supplemental Foods for Women and Children Requiring Medical Documentation Policy 605 December 2024 iii. Cheese-Hoalam Cheddar Cheese and Hoalam Mozzarella & Cheddar Cheese iv. Tofu-NaSoya v. Brown Rice-Uncle Ben’s Fast and Natural Whole Grain Instant Brown Rice, Mahatma, Minute Instant Brown Rice, Success Boil in Bag Brown Rice D. Requests for Gluten enteropathy, celiac disease, or celiac spruce gluten-free food packages. 1. The participant should be referred for Medical Nutrition Therapy. 2. Guidance from the primary care provider shall include instructions to avoid wheat products. 3. Appropriate infant cereals would include rice cereal and shall be discussed during counseling. 4. Other ingredients the participant may need to avoid include: barley, bran, bulgur, couscous, dairy substitutes, dextrin, dingle, durum, einkorn, emmer, farina, faro, fu, gliadin, gluten, gluten peptides, glutenin, graham four, hydrolyzed protein, kamut, kumut, malt, malt flavoring, malt vinegar, matza, matzo, matzah, mir, modified food starch, orzo, panko, rye, seasoning, seitan, semolina, soy sauce, spelt, triticale, udon, wheat, wheat berry, wheat germ, wheat grass, wheat gluten, wheat nut, and wheat starch. E. Requests for Decreased Fat and Calorie Food Packages 1. Food Package issuance based on instructions of medical documentation form. 2. Provide appropriate food package for age and category/status. 3. Counseling the caregiver/parent/participant on purchasing low-fat or skim milk and reduced-fat or fat-free cheese. 4. Encourage the participant to purchase beans instead of peanut butter. F. Homeless packages 1. Certifying Health Professionals shall assess whether the issuance of the homeless package best meets the needs of the participant. 2. Participants needing formula shall be provided ready-to-feed formula if needed. A medical documentation form will be needed for noncontract, exempt infant formula, and WIC Nutritionals. See Policy 601-Issuance of Standard Infant Food Packages, Policy 602-Issuance of Exempt Infant Formula, and Policy 606-Issuance of WIC Nutritionals to Women and Children. a. The 32 oz. size may be issued in situations where the individual has access to refrigeration and dishwashing facilities. b. If the participant does not have access to refrigeration and dishwashing facilities, the formula product shall be issued in individual ready-to-feed servings. 3. Participants needing regular foods shall receive the appropriate food package based upon age and status. 4. These participants shall be provided the Kentucky WIC Approved Food List Displaced Participant Insert and counseled concerning the differences in the food packages. a. Baked beans instead of dry beans or canned beans b. 100% single strength juice c. 18 oz. peanut butter will replace 1 dozen eggs d. 9.6 oz. containers of dry milk will replace fluid milk and e. For participants issued soy milk, quart size shelf stable soy milk-Pacific Ultra Soy Original. G. Unsanitary Water Supply 1. For families who do not have access to safe water: a. Frozen juice shall not be an option for the family.

Page 1 Issuance of WIC Nutritionals to Women and Children Policy 606 December 2024 Policy 606 Issuance of WIC Nutritionals to Women and Children

POLICY The certifying health professional shall issue approved WIC nutritionals in accordance with the Policies for Prescribing Food Packages, Food Package Tables, and Requirements for Issuing Infant Formulas, Exempt Infant Formula, and WIC Nutritionals.

PURPOSE To comply with federal requirements for medical documentation for issuance of approved WIC nutritionals and to facilitate coordination of care for all WIC participants with qualifying medical conditions.

RELEVANT REGULATIONS 7 CFR 246.10 (d)(1) – WIC Formulas and Supplemental foods requiring medical documentation

DEFINITIONS WIC Nutritionals – enteral products that are specifically formulated to provide nutritional support for individuals with a qualifying condition when the use of conventional foods is precluded, restricted, or inadequate. Such WIC-eligible Nutritionals must serve the purpose of a food, meal, or diet (may be nutritionally complete or incomplete) and provide a source of calories and one or more nutrients; be designed for enteral digestion via an oral or tube feeding; and may not be a conventional food, drug, flavoring, or enzyme. WIC-eligible Nutritionals include many, but not all, products that meet the definition of medical food in Section 5(b)(3) of the Orphan Drug Act (21 USC 360ee(b)(3)).

PROCEDURES Requests for WIC Nutritionals A. WIC Nutritionals can be provided when the health professional has a medical documentation form or valid prescription. B. Issuance of these formulas requires a medical documentation form, and prior approval by the designed local WIC agency personnel who have been trained by the State WIC Office or State WIC Office identified training. C. The formula must be designed for internal digestion.

Medical Documentation Requirements WIC Nutritionals A. WIC Nutritionals 1. Medical documentation for issuance of WIC Nutritionals a. A Certificate for Medical Necessity (WIC – 200, WIC – 300, WIC – 400) or a prescription is required. See 600 Appendix Medical Necessity Forms. b. Physicians (MD or DO), Physician Assistants (PAs), and Advanced Practice Registered Nurse (APRNs) are the accepted authorities to provide the information in the medical documentation form based upon individual needs and medical conditions. c. The Kentucky WIC Program will not be bound to provide products in the medical documentation form that are contraindicated, not allowed by Federal Regulation, or not authorized by the Program. d. The medical documentation form must be received prior to the issuance of the food package. This may be written, provided through a telephone order or facsimile (fax), etc. e. All medical documentation forms must contain:

Page 2 Issuance of WIC Nutritionals to Women and Children Policy 606 December 2024 i. Name of formula (if requested); ii. Length of time; iii. Diagnosis; iv. Designation of other foods to provide (Food Package III); and v. The signature of the prescriptive authority (physician, PA or APRN). f. A telephone order must also document the date of the telephone call and the signature of the person taking the order. The prescriptive authority must send a copy of the medical documentation form for inclusion in the medical record or sign and return the Physician/APRN Verbal Orders (HHS-117). The period of time indicated on a medical documentation form shall not exceed six months. g. If the medical documentation form has expired, a new one must be obtained before continuing the formula. 2. Issuance of Food Package III may not be issued for the following reasons: a. For women and children who have a food intolerance to milk protein or lactose, that can be successfully management with the use of a standard food package. B. The chart at the bottom of this section provides guidance on what documentation is necessary for product issuance.

State Agency Approval A. If State Agency approval is needed to issue a WIC Nutritional, after receiving verbal approval from a State WIC Office Dietitian, complete the WIC State Agency Formula/WIC Nutritional Approval Form and fax or mail to the State WIC Office. See 600 Appendix-State Agency Approval Form.

Dilution of Standard Formula A. If a prescription is for a dilution other than the standard mixing instructions on the can, the specific mixing instructions must be provided on the prescription by the prescribing authority.

Medicaid Denial Letters for Formula/WIC Nutritional A. When a physician prescribes a WIC Nutritional that WIC does not authorize or if the physician prescribes more than WIC can provide for a Medicaid participant, a Medicaid Denial Letter shall be provided to the participant. See 600 Appendix-Sample Medicaid Denial Letters. B. Contact the State WIC Office if you have questions about Medicaid Denial Letters.

Page 3 Issuance of WIC Nutritionals to Women and Children Policy 606 December 2024 Requirements of Issuing WIC Nutritionals Chart FORMULA DIAGNOSIS REQUIRED Kentucky Certificate for Medical Necessity Required PRIOR APPROVAL EXEMPT INFANT FORMULAS and WIC NUTRITIONALS (Examples) Nutramigen/Nutramigen with Enflora LGG Nutramigen Toddler with Enflora LGG Portagen (for women and children only) Pregestimil Pregestimil 24 Similac Alimentum Alfamino PurAmino Gerber Extensive HA Yes – Diagnosis Yes

Required Information: 1-Name of formula requested 2-Prescribed period of time 3-Diagnosis 4-Additional foods Follow State WIC Office and Agency Policies EXEMPT FORMULA AND WIC NUTRITIONALS – LOCAL APPROVAL (Examples) Yes – Diagnosis

Yes

Required Information: 1-Name of formula requested 2-Prescribed period of time 3-Diagnosis 4-Additional Foods

Yes.

Agency Personnel designated by and trained be the State WIC Office to approve special formulas.

Boost Boost Glucose Control Boost High Protein Boost Kid Essentials Boost Plus Bright Beginnings Soy Pediatric Drink Elecare for Infants Elecare Jr Enfamil EnfaCare Enfamil Enfaport Ensure Ensure Plus

Neocate Infant/Neocate SYNEO Infant Neocate Junior Osmolite 1 Cal PediaSure PediaSure with Fiber Peptamen Peptamen Junior Peptamen Junior 1.5 Similac NeoSure Tolerex Vital HN Vivonex Pediatric Vivonex Plus Vivonex T.E.N.

EXEMPT INFANT FORMULAS AND WIC NUTRITIONALS – STATE APPROVAL Any formulas not found in the above tables or formula used outside the intended use. Yes – Diagnosis

See each formula type for additional requirements. Yes

Required Information: 1-Name of formula requested 2-Prescribed period of time 3-Diagnosis 4-Additional foods Yes.

Complete the WIC STATE AGENCY FORMULA/WIC NUTRITIONALS APPROVAL FORM (see 600 appendix) for State WIC Office approval. FOOD PACKAGE III For women/children when a formula &/or other foods are needed. Formulas may include the following: Infant Formula - Contract Infant Formula - Noncontract Exempt Infant Formula Exempt Infant Formulas and WIC Nutritionals (Local Approval) Exempt Infant Formulas and Medical food Yes – Diagnosis

See each formula type for additional requirements. Yes

Required Information: 1-Name of formula requested 2-Prescribed period of time 3-Diagnosis 4-Additional foods Follow the approval process for each specific type of formula.

Section 600 Appendices Food Package Assignment

Page 1 Section 600 Food Package Assignment Appendices December 2024