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.

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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

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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

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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

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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

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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.

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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).

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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.

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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:

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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.

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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.

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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

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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

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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.

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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

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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.

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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.

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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.

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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.

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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.

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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

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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.

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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.

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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

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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

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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.

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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.

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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.

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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.

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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.

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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.

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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

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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

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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.

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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.

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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.

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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.

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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.

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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.

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• 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.

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• 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.

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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.

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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.

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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.

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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.

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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.

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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).

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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

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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

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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

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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;

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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.

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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• 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

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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

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• 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

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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

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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

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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

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<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

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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)