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

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

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

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

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

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

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

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

Purpose

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

When To Use

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

Use one page per participant.

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

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

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

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

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

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

PAGE _________

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

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

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

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

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

LOCAL AGENCY WIC PROGRAM SEPARATION OF DUTIES TRACKING LOG

Purpose

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

When To Use

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

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

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

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

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

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

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

Jane Doe 1/8/22

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

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

LOCAL AGENCY WIC PROGRAM SEPARATION OF DUTIES TRACKING LOG

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

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

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

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

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

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

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

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

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

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

Page 1 Program Integrity – Dual Participation Policy 304 December 2024

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

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

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

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

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

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

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

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

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

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

Rev. 10/24 FY 2025

Agency/Number: Click here to enter text.

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

Reviewer: Click here to enter text.

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

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

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

☐ yes ☐ no

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

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

☐ yes ☐ no

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

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

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

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

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

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

☐ yes ☐ no

Kentucky WIC Program Local Agency Internal Review

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

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

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

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

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

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

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

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

9. Are Internal Reviews performed?

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

☐ Other: Click here to enter text.

Are findings from the review shared with staff?

☐ yes ☐ no

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

☐ yes ☐ no

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

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

☐ yes ☐ no

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

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

☐ yes ☐ no

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

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

☐ yes ☐ no

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

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

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

☐ yes ☐ no

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

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

Caseload Management

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

☐ yes ☐ no Participation rates?

☐ yes ☐ no Voter registration compliance?

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

☐ yes ☐ no Actions Due?

☐ yes ☐ no Report 2011 (Measures needed)?

☐ yes ☐ no

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

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

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

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

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

WIC Data – Breastfeeding Rates

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

% % 3 months Exclusive BF

% %

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

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

% %

% %

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

↑ 5% ☐ yes ☐ no

↑ 10% ☐ yes ☐ no

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

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

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

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

☐ yes ☐ no

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

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

4. Are appointments coordinated for household members?

☐ yes ☐ no

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

6. Are patients reminded of upcoming appointments?

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

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

☐ yes ☐ no For food benefit issuance?

☐ yes ☐ no For food package changes?

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

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

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

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

☐ yes ☐ no Follow-up missed appointments?

☐ yes ☐ no

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

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

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

Fair Hearings 1. Is the Fair Hearings poster displayed?

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

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

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

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

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

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

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

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

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

Comments: Click here to enter text.

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

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

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

☐ n/a ☐ yes ☐ no

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

☐ yes ☐ no

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

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

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

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

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

Staff visually determines if the applicant/participant refuses?

☐ yes ☐ no

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

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

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

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

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

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

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

☐ yes ☐ no

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

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

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

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

FY 25 Click here to enter text.

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

☐ partially ☐ yes ☐ no

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

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

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

Collection and use of data?

☐ yes ☐ no

Effective public notification systems?

☐ yes ☐ no

Complaint procedures?

☐ yes ☐ no

Compliance review techniques?

☐ yes ☐ no

Resolution of noncompliance?

☐ yes ☐ no

Requirements for reasonable modifications and auxiliary aids and services for

individuals with disabilities?

☐ yes ☐ no

Requirements for language assistance?

☐ yes ☐ no

Conflict resolution?

☐ yes ☐ no

Customer service?

☐ yes ☐ no

Comments: Click here to enter text.

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

☐ yes ☐ no

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

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

Certify based on income with proof?

☐ yes ☐ no Verify eligibility with DCBS?

☐ yes ☐ no Reschedule certification appointment?

☐ yes ☐ no Certify based on self-declaration?

☐ yes ☐ no

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

☐ yes ☐ no

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

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

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

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

☐ yes ☐ no

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

☐ yes ☐ no Identity?

☐ yes ☐ no Income?

☐ yes ☐ no Patients that report zero income?

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

☐ yes ☐ no

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

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

☐ yes ☐ no

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

Is CH5-WIC complete for proxies/caretakers?

☐ yes ☐ no

WIC-75 completed, if applicable?

☐ yes ☐ no

Documentation made in the medical record?

☐ yes ☐ no

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

☐ yes ☐ no During a certification period is a:

T-action done?

☐ yes ☐ no

Reason documented in the medical record?

☐ yes ☐ no

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

☐ yes ☐ no

Copy of WIC-54 placed in the medical record?

☐ yes ☐ no

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

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

☐ yes ☐ no

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

☐ yes ☐ no

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

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

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

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

☐ yes ☐ no Approved vendor list?

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

☐ yes ☐ no

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

☐ yes ☐ no

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

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

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

☐ yes ☐ no

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

☐ yes ☐ no

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

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

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

☐ yes ☐ no

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

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

☐ yes ☐ no Is income assessed?

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

☐ yes ☐ no

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

☐ yes ☐ no

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

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

☐ yes ☐ no

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

☐ yes ☐ no

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

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

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

☐ yes ☐ no

2. Is the infant weighed in minimal clothing?

☐ yes ☐ no

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

☐ yes ☐ no

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

☐ yes ☐ no

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

☐ yes ☐ no

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

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

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

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

☐ yes ☐ no

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

☐ yes ☐ no

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

☐ yes ☐ no

Comments: Click here to enter text.

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

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

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

☐ yes ☐ no

2. Are group nutrition education sessions provided?

☐ yes ☐ no If yes, are sessions mandatory?

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

☐ yes ☐ no b. Offered an individual session.

☐ yes ☐ no c. Issued food benefits.

☐ yes ☐ no

3. Is online nutrition education allowed for children?

☐ yes ☐ no If yes, are sessions mandatory?

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

☐ yes ☐ no b. Offered an individual session.

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

☐ yes ☐ no

4. Is phone nutrition education allowed for children?

☐ yes ☐ no If yes, are sessions mandatory?

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

☐ yes ☐ no b. Offered an individual session.

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

☐ yes ☐ no

5. Are paraprofessionals utilized for nutrition education counseling?

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

☐ yes ☐ no Is an RD overseeing the paraprofessional?

☐ yes ☐ no

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

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

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

☐ yes ☐ no

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

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

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

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

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

☐ yes ☐ no f. Prescribe food packages

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

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

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

☐ yes ☐ no j. Document referrals.

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

☐ yes ☐ no

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

☐ yes ☐ no

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

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

☐ yes ☐ no

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

☐ yes ☐ no

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

☐ yes ☐ no

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

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

☐ yes ☐ no

4. Is the chart available when issuing benefits?

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

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

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

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

Comments: Click here to enter text.

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

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

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

☐ yes ☐ no

2. Breastfeeding Support a. All breastfeeding issues/concerns shall be referred to an International Board-Certified Lactation Consultant (IBCLC), Certified Lactation Counselor (CLC), Certified Lactation Specialist (CLS), or Breastfeeding Peer Counselor and allow adequate time for assessment, evaluation, and assistance to resolve breastfeeding problems during the clinic visit, as appropriate. ☐ yes ☐ no b. Address all breastfeeding concerns in a timely manner.

☐ yes ☐ no c. For agencies with the Breastfeeding Peer Counselor Program, utilize the Breastfeeding Peer Counselors to support WIC prenatal and breastfeeding women. ☐ n/a ☐ yes ☐ no

3. Breastfeeding Aids a. Does the agency issue any other breastfeeding aids?

☐ yes ☐ no If yes, provide details: Click here to enter text. b. Does the agency have a State WIC Office approved policy for Breastfeeding Aids? ☐ n/a ☐ yes ☐ no c. Does the agency issue Nipple Shields?

☐ yes ☐ no

4. Breast Pump Issuance a. Breast pump issuance provided by a health professional.

☐ yes ☐ no b. The reason for issuance is documented in the medical record.

☐ yes ☐ no c. Kentucky WIC Program Breast Pump Assessment and Information Checklist completed. ☐ yes ☐ no d. Issuance documented on appropriate breast pump inventory log sheet.

☐ yes ☐ no e. If a pump is issued, is follow-up conducted and documented.

☐ yes ☐ no f. Are the pumps stored in a secure location? ☐ yes ☐ no

WIC Internal Review Form FY 2025 Rev. 10/24 13

Chart Review

Review Women, Infant and Child Records and complete the charts below. A random sample report is available via CDP Report Viewer, Report 710- Random Sampling of Infant, Children, and Woman Report by Status.

1.Click on the CDP Report Viewer link.

2. Select WIC Category and then locate Report 710- Random Sampling of Infant, Children, and Woman Report by Status. 3. Click on magnifying glass.

4. After clicking on magnifying glass beside report 710, select your clinic and the number of samples per type from the drop-down field in the Parameters box, then hit view to generate your report.

WIC Internal Review Form FY 2025 Rev. 10/24 14

Certification Record Review – Women Household Number*

Status*

Certification Date (Listed on Random Sample Report)*

Appropriate proof code for residence* (1st Registration label)

Appropriate proof code for identity*(1st Registration label)

Adjunct eligibility documented, if eligible*

For an Adjunct Eligible participant, is a self-reported estimated household income recorded on HH Member Screen and the date of registration

If not adjunctive eligible, Household income assessed and documented*

The primary language spoken documented

Interpreter Services Offered and Documented?

Documentation of Appropriate aids and services provided for disability? *

The financial certification box checked

Financial Cert. area signed/dated

Rights & Responsibilities signed/dated

Proxy documentation appropriate

The date of initial contact (DIC) meets processing standards

Appropriate proof code for issuance*

Eligibility supported for income

Certifying risks*

Certified for all risks**

If certifying risks included the following codes: 201, 211, 358, 361, 371, 372, 602, 801, 802, 901, 902, 903, was a referral documented?

NEPP documented

Goal(s) established

Dietary assessment completed

Growth chart plotted & filed in medical record (If appropriate; P-none; PP & BF<20)

Medical provider/Medical home documented

Health Professional signed/dated (WIC-75)

Type of Secondary Nutrition Education visit offered/documented*

MCHA visit performed & MC-NEPP documented*

Progress toward certification goal documented at MCHA visit

Appropriate number of nutrition education/secondary contacts

WIC High-Risk Nutrition Visit provided (if applicable)

Plan of Care documented at High- Risk Visit (if applicable)

If currently receiving formula and/or WIC nutritional, the chart has a valid WIC-300 or prescription.

When circumstances warrant,

WIC Internal Review Form FY 2025 Rev. 10/24 15

* Record Actual information/proof code **Record risk code that is not supported

Comments: Click here to enter text.

“Milk and Milk Substitutions” protocols are followed and documented If a Woman received a breast pump, documentation complete

WIC Internal Review Form FY 2025 Rev. 10/24 16

Certification Record Review – Infants Household Number*

Certification Date*

Certification Date (Listed on Random Sample Report)*

Appropriate proof code for residence* (1st Registration label)

Appropriate proof code for identity*(1st Registration label)

Adjunct eligibility documented, if eligible*

For an Adjunct Eligible participant, is a self-reported estimated household income recorded on HH Member Screen the date of registration

Primary language spoken documented

Interpreter Services Offered and Documented?

Documentation of Appropriate aids and services provided for disability? *

Financial certification box checked

Financial Cert. area signed/dated

Rights & Responsibilities signed/dated

Proxy documentation appropriate

Date of initial contact (DIC) meets processing standards

Appropriate proof code for issuance *

Certifying Risks *

Certified for all risks**

If certifying risks included the following codes: 152, 201, 211, 358, 361, 801, 802, 901, 902, 903 was a referral documented?

NEPP documented

Goal(s) established

Dietary assessment completed

Growth chart plotted & filed in chart (if appropriate)

Gestational age documented

Bloodwork done at appropriate intervals (if applicable)

Immunization status documented

Medical provider/Medical home documented

Health Professional signed/dated (WIC-75)

Type of Secondary Nutrition Education visit offered/documented*

MCHA visit performed & MC-NEPP documented*

Progress toward certification goal documented at MCHA visit

Appropriate number of nutrition education/secondary contacts

WIC High Risk Nutrition Visit provided (if applicable)

Plan of Care documented at High-Risk Visit (if applicable)

INFANTS Continued:

WIC Internal Review Form FY 2025 Rev. 10/24 17

* Record Actual information/proof code **Record risk code that is not supported

Comments: Click here to enter text.

WIC Internal Review Form FY 2025 Rev. 10/24 18

Certification Records Review - Children Household Number*

Certification Date*

Certification Date (Listed on Random Sample Report)*

Appropriate proof code for residence* (1st Registration label)

Appropriate proof code for identity*(1st Registration label)

Adjunct eligibility documented, if eligible*

For an Adjunct Eligible participant, is a self-reported estimated household income recorded on HH Member Screen on the date of registration

Primary language spoken documented

Interpreter Services Offered and Documented?

Documentation of Appropriate aids and services provided for disability? *

The financial certification box checked

Financial Cert. area signed/dated

Rights & Responsibilities signed/dated

Eligibility supported for income

Proxy documentation appropriate

Date of initial contact (DIC) meets processing standards

Appropriate proof code for issuance *

Certifying Risks *

Certifying risks supported **

Blood work at appropriate intervals

Gestational age documented (if < 2)

Growth charts documented

Immunization status documented

NEPP documented

Health Professional signed/dated (WIC-75)

Type of Nutrition Education/Secondary visit offered/documented*

MCHA visit performed & MC-NEPP documented*

Progress toward certification goal documented at MCHA visit

Appropriate number of nutrition education/secondary contacts

WIC High-Risk Nutrition Visit provided (if applicable)

Plan of Care documented at High-Risk Visit (if applicable)

Appropriate number of nutrition education contacts – for previous cert.

* Record Actual information/proof code **Record risk code that is not supported

Comments: Click here to enter text.

WIC Internal Review Form FY 2025 Rev. 10/24 19

Ineligibles Records Review (Participant Random Samples) * Record actual information

Household Number First Name Race Screening Date Ineligibility Supported * Reason for Ineligibility Documented Signature & Date of Person Determining WIC-54 Given

WIC Medical Records Review 1. Review medical records of all categories from the Participation Random Sample. Complete the Certification Records Review.

2. From the review of certification records, does it appear: a. Nutrition education contacts are coordinated with food benefit issuance pick-up? ☐ yes ☐ no b. Missed appointments are documented?

☐ yes ☐ no c. Terminations are documented?

☐ yes ☐ no d. Issuance of non-contract infant formula, exempt infant formula, and WIC nutritionals is documented and prescription on file/policy followed?

☐ yes ☐ no e. WIC is coordinated with other services?

☐ yes ☐ no f. Staff recognition, medical record, or eWIC cardholder are used as proof of identity at recertification and pick-up when appropriate?

☐ yes ☐ no g. Exceptions to the physical presence requirements are allowed?

☐ yes ☐ no h. Documentation is made for follow-up for missed appointments?

☐ yes ☐ no

3. For hospital certifications: ☐ N/A a. Are proof requirements met within 30 days?

☐ yes ☐ no Appropriate food benefits given?

☐ yes ☐ no b. Issue dates coordinated?

☐ yes ☐ no

WIC Internal Review Form FY 2025 Rev. 10/24 20

Clinic Observations 1. Complete the following chart for each patient observed and indicate if required information was provided/discussed. Indicate N/A if not applicable.

Patient Status/Type Visit

Household Number

Registration Certification MCHA/Secondary Follow Up Did Staff advise of free language services or other free aids and services

Did staff use the WIC Clerical Checklist or follow the checklist script

Did staff offer the Race and Ethnicity Reference Card to applicant

Patient Identifies Race and Ethnicity

Appropriate proof code for residence

Appropriate proof code for identity

Adjunct eligibility documented

Household income documented

Are labels affixed to CH-5 prior to signature or if EMR county, are labels scanned into the medical record?

Financial Cert. area checked/signed/dated

Staff advise the applicant to read WIC Rights and Responsibilities prior to signing CH-5 or offer to read Rights and Responsibilities prior to signing (R and R provided in a language the applicant understands)

Proxy offered/updated

Household Income documented for Adjunct eligible

Voter registration offered

eWIC Benefits pamphlet provided appropriately including Rights and Responsibilities

Are new participants provided instructions on how and where to redeem eWIC benefits, support or Health Program staff provide instructions?

Referrals to other health department services if appropriate, Medicaid & SNAP , etc.

Nutrition and Health Assessment: See Certification, MCHA or Follow Up Visit sections Certification Visit

Interpreter services offered, provided, and documented, if appropriate

If LEP, primary language spoken documented

Documentation of Appropriate aids and services provided for disability?

Measures taken appropriately (remove hats and outer clothing, etc.)

Gestational age entered (as appropriate)

Growth chart completed/printed and filed in medical record (if applicable)

Evaluation of hemoglobin or hematocrit (if applicable)

Non-invasive device used (if applicable)

Utilization of referral data/request for referral data for remote

WIC Internal Review Form FY 2025 Rev. 10/24 21

Dietary assessment

Health assessment

Immunization screening & referral (as appropriate)

Lead screening & referral (as appropriate)

WIC Program Eligibility and Program Benefits Explained

Counseling Provided on Basic Diet and Physical Activity

Counseling on ATOD (Smoking Alcohol and Drugs)

Encourage Pregnant and BF Women to Breastfeed

Safe Sleep for Infants

Screen time discussed

Food Package Assignment and Tailoring

Nutritional risks reviewed with participant

Provided counseling based on identified risk codes

Medical Home Documented

SMART GOALS established and documented

Referrals, as appropriate

For new participants, provide a list of authorized vendors and the Approved Food List/WIC Shopper app.

Breastfeeding Questions answered

WIC-75 and other documentation filed in the medical record.

MCHA visit

Follow-up on established goals

Anthropometric Screening/follow up on referral data as appropriate

Measures taken accurately

Growth chart completed/printed and filed in the medical record (if applicable)

Evaluation of hemoglobin or hematocrit (if applicable)

Non-invasive device used (if applicable)

Utilization of referral data

Dietary assessment

Health assessment

Immunization screening & referral (as appropriate)

Update and review of nutritional risks

Counseling provided. (as appropriate)

Preferred spoken language identified free communication services offered & Documented, if appropriate/ any aids or services offered or provided documented

Other referrals as appropriate

MCHA WIC-75 update filed in the medical record

Follow-up visit Follow-up on established goals

For low risk, provided nutrition education on a least one topic

For High risk, counseled on diet and risk

WIC Internal Review Form FY 2025 Rev. 10/24 22

Follow-up on referral data/collect measures as appropriate from remote certification

Measures taken appropriately (remove hats and outer clothing, etc.)

Growth chart completed/printed (if applicable)

Evaluation of hemoglobin or hematocrit (if applicable)

Non-invasive device used (if applicable)

Utilization of referral data

Preferred spoken language identified free communication services offered & Documented, if appropriate/ any aids or services offered or provided documented

Other referrals as appropriate

Check out eWIC Benefits pamphlet provided appropriately

For new participants, provide a list of authorized vendors and Approved Food List/WIC Shopper app.

Proof of adult ID receiving benefits

Is eWIC benefit issuance appropriate (maximum of 3 months)

Return appointment provided

Benefits verified in account and shopping list and shopper app reviewed

PIN not requested from participant or recorded

Was the participant asked to swipe their card for a balance prior to leaving?

2. Indicate observed equipment used for WIC measurements: ☐Measuring board with a flat surface to place on top of the head for infants and children up to 36 months ☐Pediatric table ☐Height rod on scales ☐Balance beam scales ☐Non-invasive device (Pronto) ☐Spring-type scales ☐Digital scales ☐Other Click here to enter text.

Conflict of Interest/Separation of Duties 1. For family, household members, or friends of staff that receive WIC services, do: Other staff determine income eligibility, including Medicaid?

☐ yes ☐ no Other staff perform screening and determine nutritional risk?

☐ yes ☐ no Other staff prescribe food package?

☐ yes ☐ no Other staff issue food benefits?

☐ yes ☐ no If no, is each certification and issuance record being reviewed and signed by a supervisor? ☐ yes ☐ no

Is there a tracking method in place?

☐ yes ☐ no

2. Does one person determine income and risk eligibility and issue food benefits for the same participant?

☐ yes ☐ no If yes, is each certification and issuance record reviewed within two weeks and signed by a supervisor?

☐ yes ☐ no

WIC Internal Review Form FY 2025 Rev. 10/24 23

3. Conflict of Interest. Are the log and charts reviewed monthly?

☐ yes ☐ no Is there a tracking method in place?

☐ yes ☐ no

eWIC Card and WIC FMNP Management 1. Indicate specific storage locations for: eWIC cards Click here to enter text. eFMNP cards Click here to enter text.

Are these areas locked?

☐ yes ☐ no

2. Is the serial number on the screen verified against those on the eWIC card each time before issuing the card?

☐ yes ☐ no

3. When a participation is added to an existing household, are issuance dates coordinated? ☐ yes ☐ no

Outreach 1. Is WIC Outreach performed?

☐ yes ☐ no If yes, ☐Sites ☐ Administrative Office By whom: Click here to enter text.

When is outreach performed? ☐ Annually ☐ On-going ☐Other: Click here to enter text. 2. Is outreach documented?

☐yes ☐ no If yes, review the outreach file. Reviewed timeframe/FY Click here to enter text.

3. Is there documentation of information provided annually to:

Medical doctors, health, and medical organizations?

☐ yes ☐ no

Hospitals (including rural health clinics), and clinics?

☐ yes ☐ no

Welfare/unemployment offices (DCBS)?

☐ yes ☐ no

Social services agencies?

☐ yes ☐ no Migrant organizations/agencies?

☐n/a ☐ yes ☐ no Homeless organizations/agencies?

☐n/a ☐ yes ☐ no Community organizations?

☐ yes ☐ no Food banks?

☐ yes ☐ no Public announcements (newspaper, radio, social media, etc.)?

☐ yes ☐ no Record other outreach: Click here to enter text.

Accountability/Inventories 1. Review the handwritten VOC (WIC-17) inventory and log. Does it include:

Serial number received?

☐ yes ☐ no

Serial number issued to the participant?

☐ yes ☐ no Are all forms accounted for?

☐ yes ☐ no Is security adequate for VOC forms?

☐ yes ☐ no 2. Review the Voter Registration report (495) for the prior month to today’s visit. Verify that each name appearing on the report has a signed WIC-53 form.

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

Months Reviewed Number of Women added over the age of 18 Number with WIC-53 signed Compliance Rate Previous Compliance (Month/Year/%)

If not 100%, has it ever been? Click here to enter text.

3. Review documentation of the physical count of unused eWIC cards and FMNP food instruments. Is a monthly inventory kept on eWIC cards and WIC FMNP FIs? ☐ yes ☐ no Is the inventory conducted by a person who does not issue food benefits? ☐ yes ☐ no

4. Is a formula inventory form maintained?

☐ yes ☐ no Review the formula inventory form. Does it include: Date formula is received?

☐ yes ☐ no Name of formula?

☐ yes ☐ no Can size?

☐ yes ☐ no Quantity received?

☐ yes ☐ no Type of formula (powdered, concentrate, ready-to-feed)?

☐ yes ☐ no Date discarded?

☐ yes ☐ no Staff initials/name?

☐ yes ☐ no When formula is returned, is it documented in the participant’s medical record? ☐ yes ☐ no

5. The agency maintains an inventory on: Manual breast pumps

☐ n/a ☐ yes ☐ no Electric breast pumps

☐ n/a ☐ yes ☐ no Hospital-grade electric breast pumps

☐ n/a ☐ yes ☐ no

6. The agency maintains an inventory on: Nipple Shields

☐ n/a ☐ yes ☐ no Additional Breastfeeding Aids

☐ n/a ☐ yes ☐ no Has state approval for issuance of nipple shields or other breastfeeding aids? ☐ n/a ☐ yes ☐ no

Homeless Shelters and Institutions 1. Has any effort been made to identify and provide services to the homeless? ☐ n/a☐ yes ☐ no

2. Have any services been provided to persons in homeless facilities and institutions? ☐ yes ☐ no If yes: Was the facility determined to meet the three required conditions?

WIC foods will not be used in communal feeding

☐ yes ☐ no The facility will not restrict the participant’s use of WIC services ☐ yes ☐ no No financial or in-kind benefit shall be accrued from a person’s participation in WIC Program ☐ yes ☐ no Are periodic contacts made to ensure the three conditions continue to be met? ☐ yes ☐ no

Property Management 1. Is WIC equipment inventory over 500 dollars being tracked and kept up to date?

☐ yes ☐ no

2. Is the equipment documented in the inventory being utilized for WIC and on-site? ☐ yes ☐ no

3. Is there WIC equipment not in use by the WIC Program?

☐ yes ☐ no

WIC Internal Review Form FY 2025 Rev. 10/24 25

4. Is the WIC equipment secure with controls in place to prevent theft or damage?

☐ yes ☐ no

WIC Farmers’ Market Nutrition Program (FMNP) Does this agency/site participate in the Farmers’ Market Nutrition Program?

☐ yes ☐ no If yes, review the policy and complete the following questions.

1. Who is the FMNP contact? (Provide name and title) Click here to enter text.

2. Which staff performs the following functions? Food Instrument (FI) Issuance: Click here to enter text.

Review of FMNP reports: Click here to enter text.

Nutrition Education regarding fresh fruits and vegetables: Click here to enter text.

3. Are participants provided: [FR/KR]

The “Kentucky WIC Farmers’ Market Nutrition Program” brochure?

☐ yes ☐ no WIC FMNP market(s) location and hours?

☐ yes ☐ no

4. Does the agency have a Farmers Market Nutrition Program (FMNP) Complaint File? ☐ yes ☐ no

Comments: Click here to enter text.

WIC Internal Review Form FY 2025 Rev. 10/24 26

Breastfeeding Peer Counselor Program

Complete this section only for agencies that have the BF Peer Counseling Program.

1. Did the Supervisor and Peer Counselor complete all USDA mandatory training? [FR/KR] ☐ yes ☐ no *Please indicate the date each individual completes this training: Click here to enter text. Comments: Click here to enter text.

2. Does each Supervisor have a file for each Peer Counselor containing the: [FR/KR] a. Peer Counselor Training Checklist?

☐ yes ☐ no b. Peer Counselor Equipment and Materials Log?

☐ yes ☐ no Comments: Click here to enter text.

3. Are Peer Counselors provided shadowing opportunities of other Peer Counselors and/or Lactation Specialist during the orientation and training period? [FR/KR]

☐ yes ☐ no

4. Does the Peer Counselor Supervisor observe Peer Counselor interactions of two (2) pregnant women and two (2) breastfeeding mothers during the first month of employment and every six (6) months thereafter? [FR/KR]

☐ yes ☐ no Comments: Click here to enter text.

5. Does the Peer Counselor Supervisor provide an evaluation of each Peer Counselor after the first month of employment and every six (6) months thereafter?

☐ yes ☐ no Comments: Click here to enter text.

6. Does the Peer Counselor Supervisor complete the Participant Phone Feedback Survey for each Peer Counselor every six (6) months? [FR/KR]

☐ yes ☐ no Comments: Click here to enter text.

7. Does the Peer Counselor Supervisor provide routine monitoring of client contact logs for each Peer Counselor to ensure that contacts are being made based on the Breastfeeding Peer Counselor Protocol for Contacting WIC Mothers? [FR/KR] ☐ yes ☐ no Comments: Click here to enter text.

8. Does the Peer Counselor Supervisor review the weekly activity report for each Peer Counselor? ☐ yes ☐ no Comments: Click here to enter text.

9. Based on the master contact list, what is the Peer Counselor(s) current client caseload number? Breastfeeding Peer Counselor Program Designated Staff Name Role Caseload Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text.

Does the agency have a Designated Breastfeeding Expert/Lactation Specialist for breastfeeding Referrals and support? ☐ yes ☐ no

WIC Internal Review Form FY 2025 Rev. 10/24 27

Lactation Specialist’s Name: Click here to enter text. Qualifications: 1. A nurse (RN or LPN) or nutritionist (RD or RDN).

☐ yes ☐ no

2. Has current certification as: a. International Board-Certified Lactation Consultant (IBCLC)

☐ yes ☐ no If yes, year certified: Click here to enter text. b. Certified Lactation Counselor (CLC)

☐ yes ☐ no If yes, year certified: Click here to enter text. c. Certified Lactation Specialist (CLS)

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

3. Has maintained continuing education?

☐ yes ☐ no

4. Estimate annual continuing education hours completed: Click here to enter text.

5. Accepts BF referrals from the following site(s): Click here to enter text.

Comments: Click here to enter text.

Off-Site Services

Complete the chart below if this site provides WIC services in either of the settings.

☐ Not Applicable Satellite Clinic

Hospital Services offered

Days/Hours of operation

Staff

CH-5B used and retained

Face-to-face contact

30-day provisional certs done

eWIC card issuance

FMNP FI’s issuance

FMNP FI’s storage on-site

Storage Secure

Issue date/appointments coordinated with household

Timeframe for data entry

The primary reason for the visit

One staff member does certification and issuance

Supervisor reviews and signs certification and issuance

WIC Internal Review Form FY 2025 Rev. 10/24 28

Additional Comments:

Click here to enter text.

Page 1 Civil Rights Policy 306 December 2024 Policy 306 CIVIL RIGHTS

POLICY

Local WIC programs must comply with the provisions of Title VI of the Civil Rights Act of 1964 and other applicable Civil Rights laws and regulations.

PURPOSE

The Kentucky WIC program is available to all, and no individual is excluded from participation, denied benefits, or subjected to discrimination on the grounds of race, color, national origin, age, sex, gender identity, or disability. Additionally, the Kentucky WIC program is prohibited from retaliating against anyone for engaging in a protected Civil Rights activity.

RELEVANT STATUTES, REGULATIONS, AGREEMENTS, AND DIRECTIVES

Statutes: Title VI of the Civil Rights Act of 1964 (42 USC § 2000d at 7 CFR § 15.1) Department of Justice Guidelines for the Enforcement of Title VI of the Civil Rights Act of 1964 at 28 CFR § 50.3 Title IX of the Education Amendments of 1972, as amended (Public Law 92-318, 20 USC § 1681 et seq. at 7 CFR § 15a) Section 504 of the Rehabilitation Act of 1973, as amended (Public Law 93-112, 29 USC § 701 at 7 CFR § 15b) Age Discrimination Act of 1975 (Public Law 94-135, 42 USC § 6101 at 45 CFR Part 91 and 7 CFR § 15c) Civil Rights Restoration Act of 1987 (Public Law 100-259) Americans with Disabilities Act of 1990 (ADA) and the ADA Amendments Act of 2008 (42 USC § 12101 et seq., Title II at 28 CFR Part 35 and Title III at 28 CFR Part 36

Regulations: 7 CFR 15 – USDA Nondiscrimination in Federally Assisted Programs of the USDA 7 CFR § 246.6 Agreements with local agencies 7 CFR. § 246.7(j) Notification of participant rights and responsibilities 7 CFR § 246.8 et seq. Nondiscrimination 7 CFR. § 246.25(b)(3)(ii) Records and Reports, Civil Rights 7 CFR Part 16 Equal Opportunity for Religious Organizations 28 CFR Part 35 Nondiscrimination on the Basis of Disability in State and Local Government Services 28 CFR Part 36 Nondiscrimination on the Basis of Disability by Public Accommodations and in Commercial Facilities USDA Departmental Regulation (DR) 4300-003, Equal Opportunity Public Notification Policy, October 17, 2019 USDA Departmental Regulation (DR) 4330-002 Nondiscrimination in Programs and Activities Receiving Federal Financial Assistance from the USDA, July 27, 2021

Page 2 Civil Rights Policy 306 December 2024

Agreements: Federal-State Supplemental Nutrition Programs Agreement (Form FNS – 339) FNS – KY CHFS Complaints Processing Memorandum of Understanding, October 3, 2016

Program Guidance: USDA Guidance to Federal Financial Assistance Recipients Regarding the Title VI Prohibition Against National Origin Discrimination Affecting Persons With Limited English Proficiency (79 F.R. No. 299, p. 70771-70784, November 28, 2014).

DEFINITIONS

Applicant: An individual who contacts the WIC clinic requesting WIC services.

Auxiliary Aids and Services: (1) Qualified interpreters on-site or through video remote interpreting (VRI) services; notetakers; real-time computer-aided transcription services; written materials; exchange of written notes; telephone handset amplifiers; assistive listening devices; assistive listening systems; telephones compatible with hearing aids; closed caption decoders; open and closed captioning, including real-time captioning; voice, text, and video-based telecommunications products and systems, including text telephones (TTYs), videophones, and captioned telephones, or equally effective telecommunications devices; videotext displays; accessible electronic and information technology; or other effective methods of making aurally delivered information available to individuals who are deaf or hard of hearing; (2) Qualified readers; taped texts; audio recordings; Brailed materials and displays; screen reader software; magnification software; optical readers; secondary auditory programs (SAP); large print materials; accessible electronic and information technology; or other effective methods of making visually delivered materials available to individuals who are blind or have low vision; (3) Acquisition or modification of equipment or devices; and (4) Other similar services and actions. Companion (for disability): A family member, friend, or associate of an individual seeking access to a service, program, or activity of a public entity or public accommodation who, along with such individual, is an appropriate person with whom the public entity or public accommodation should communicate.

Complainant: Any individual or group of individuals alleging discrimination in the delivery of WIC program benefits or services.

Digital Services. The delivery of digital information (e.g., data or content) and transactional services (e.g., online forms, applications) across a variety of platforms, devices, and delivery mechanisms (e.g., websites, mobile applications, and social media. Digital services involve the electronic delivery of information, including data and content, across multiple platforms or devices, such as text, audio, video, mobile applications, and graphics that are transmitted for viewing over the internet. This includes social media (YouTube, Twitter, Facebook, etc.), websites, and applications that enable users to create and share information and content or to participate in social networking.

Page 3 Civil Rights Policy 306 December 2024 Disability: Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act Amendments Act of 2008 define disability with respect to an individual: a physical or mental impairment that substantially limits one or more of the major life activities of such individual; a record of such an impairment; or being regarded as having such an impairment. (See 7 C.F.R. § 15b(3)(i), 28 C.F.R § 35.108 and 28 C.F.R. § 36.105.)

Discrimination: The act of distinguishing one person or group of persons from others, either intentionally, by neglect, or by the effect of actions or lack of actions based on a protected class.

Limited English Proficiency (LEP) persons: Individuals who do not speak English as their primary language and who have a limited ability to read, speak, write, or understand English. Major Life Activity (for disability): (i) Caring for oneself, performing manual tasks, seeing, hearing, eating, sleeping, walking, standing, sitting, reaching, lifting, bending, speaking, breathing, learning, reading, concentrating, thinking, writing, communicating, interacting with others, and working; and (ii) The operation of a major bodily function, such as the functions of the immune system, special sense organs and skin, normal cell growth, and digestive, genitourinary, bowel, bladder, neurological, brain, respiratory, circulatory, cardiovascular, endocrine, hemic, lymphatic, musculoskeletal, and reproductive systems. The operation of a major bodily function includes the operation of an individual organ within a body system. Noncompliance: Noncompliance is a factual finding that any Civil Rights requirement, as provided by law, regulation, policy, instruction, or guidelines, is not being adhered to by local agency or other subrecipient.

Participant: An individual who meets all eligibility criteria and is enrolled in the WIC program.

Protected classes: A characteristic/factor, such as race, color, national origin, sex, age, or disability, that is protected from unlawful discrimination by federal statute, Executive Order and USDA regulation/policy. For WIC, the protected classes are race, color, sex, age, national origin, and disability.

Qualified Interpreter (LEP): A qualified interpreter is a highly trained individual who mediates spoken communication between people speaking different languages without adding, omitting, or distorting meaning or editorializing.

Qualified Interpreter (Disability): An interpreter who, via a video remote interpreting (VRI) service or an on-site appearance, is able to interpret effectively, accurately, and impartially, both receptively and expressively, using any necessary specialized vocabulary. Qualified interpreters include, for example, sign language interpreters, oral transliterators, and cued-language transliterators.

Qualified Translator: A qualified, competent translator is a highly trained individual who is able to render text from a source language into a target language while preserving meaning and adhering to generally accepted translator ethics and principles, including confidentiality. Qualified translators

Page 4 Civil Rights Policy 306 December 2024 understand the cultural context of the source and target languages as well as demonstrate competency to translate through an independent language assessment.

Reasonable modification: A change in policies, practices, or procedures when the modifications are necessary to avoid discrimination on the basis of disability, unless the public entity can demonstrate that making the modifications would fundamentally alter the nature of the service, program, or activity. 28 CFR 35.130(b)(7).

Significant Finding: An egregious and repetitive finding or a policy or procedure that has a disproportionate, adverse effect on a particular protected class (disparate impact).

Vendor. A sole proprietorship, partnership, cooperative association, corporation, or other business entity operating one or more stores authorized by the State agency to provide WIC-authorized supplemental foods to participants under a retail food delivery system.

Vital Documents/Vital Information: Documents or information vital to an individual’s participation including forms related to applying for the program, documents that require a response, denial letters or notice of ineligibility.

PROCEDURES

Local Agency Civil Rights Coordinator(s)

Each Local Agency must designate a point of contact that ensures compliance with all Civil Rights requirements applicable to WIC. A. See Administrative Reference, Program Descriptions, WIC Coordinator Duties. B. The Local Agency Civil Rights Coordinator: May be the WIC Coordinator or another employee of the agency. 1. The Local Agency Civil Rights coordinator will ensure this policy (306 Civil Rights) is implemented at the local agency and any relevant polices in the Administrative Reference. 2. Will coordinate with the Nutrition Services Branch, Program Management Section Supervisor and with the Cabinet for Health and Family Services Equal Employment Opportunity (EEO) and Civil Rights Branch Manager.

Assurances of Nondiscrimination

A. Local WIC programs agree to abide by civil rights laws and regulations by signing the contract and accepting WIC funding. Refer to the Multi-User Contract (Local Health Departments) or the WIC Services Contract (Contract Agencies) with the Cabinet for Health and Family Services. B. The Assurance Statement below is entered into annually between the Cabinet for Health and Family Services and USDA (USDA Form FNS – 339). This transfers to local agencies administering the WIC Program.

The State Agency hereby agrees that it will comply with Title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d et seq.), Title IX of the Education Amendments of 1972 (20 .S.C. 1681 et seq.), Section 504 of the Rehabilitation Act of 1973 (29 U.S.C. 794), Age discrimination

Page 5 Civil Rights Policy 306 December 2024 Act of 1975 (42 U.S.C. 6101 et seq.); Title II and Title III of the Americans with Disabilities Act (ADA) of 1990 as amended by the ADA Amendment Act of 2008 (42 U.S.C. 12131- 12189) as implemented by Department of Justice regulations at (28 CFR Parts 35 and 36); Executive Order 13166, Improving Access to Services for Persons with Limited English Proficiency." (August 11, 2000), all provisions required by the implementing regulations of the U.S. Department of Agriculture (7 CFR Part 15 et seq) and FNS directives and guidelines to the effect that no person shall, on the ground of race, color, national origin, age, sex, or disability, be excluded from participation in, be denied the benefits of, or otherwise be subjected to discrimination under any program or activity for which the Agency receives Federal financial assistance from FNS; and hereby gives assurance that it will immediately take measures necessary to effectuate this agreement.

By providing this assurance, the State Agency agrees to compile data, maintain records and submit records and reports as required to permit effective enforcement of the nondiscrimination laws, and to permit Department personnel during normal working hours to review and copy such records, books and accounts, access such facilities, and interview such personnel as needed to ascertain compliance with the non-discrimination laws. If there are any violations of this assurance, the Department of Agriculture shall have the right to seek judicial enforcement of this assurance.

This assurance is given in consideration of and for the purpose of obtaining any and all Federal financial assistance, grants, and loans of Federal funds, reimbursable expenditures, grant, or donation of Federal property and interest in property, the detail of Federal personnel, the sale and lease of, and the permission to use Federal property or interest in such property or the furnishing of services without consideration or at a nominal consideration, or at a consideration that is reduced for the purpose of assisting the recipient, or in recognition of the public interest to be served by such sale, lease, or furnishing of services to the recipient, or any improvements made with Federal financial assistance extended to the Program applicant by USDA. This includes any Federal agreement, arrangement, or other contract that has as one of its purposes the provision of cash assistance for the purchase of food, and cash assistance for purchase or rental of food service equipment or any other financial assistance extended in reliance on the representations and agreements made in this assurance.

This assurance is binding on the State Agency, its successors, transferees, and assignees as long as it receives assistance or retains possession of any assistance from the Department.

C. Where applicable, a statement of assurance must be incorporated into the Retailor/Vendor/Federal/State/local/subrecipient agency agreement.

Public Notification

Page 6 Civil Rights Policy 306 December 2024

WIC local agencies are to: A. Inform potentially eligible persons, applicants, participants and grassroots organization of the WIC Program or changes in the Program. B. Convey the message of equal opportunity in all photos and other graphics that are used to provide program related information. C. Notify person with disabilities about the availability of reasonable modifications and auxiliary aids and services and how to request them in a format that they can understand. D. Notify person with limited English Proficiency (LEP) of their right to free language assistance services (interpretation and translated materials) and how to request them in a language that they can understand. E. Inform potential WIC applicants and participants of their WIC Program Rights and Responsibilities and the steps necessary for WIC Participation including: 1. The right to file a complaint, how to file a complaint and the complaint procedure. See below “USDA Nondiscrimination Statement” and “Civil Rights Complaints” sections. 2. USDA’s nondiscrimination policy. See below “USDA Nondiscrimination Statement”. 3. Posting of the “And Justice for All Poster” (AD-475A) in a prominent location visible to applicants, participants, and potential applicants. a. Must be the original poster, local reproduction is not authorized. b. Refer to WIC and Nutrition Manual, Section 200 Appendices for more information on the posting of the “And Justice for All Poster”. F. United States Citizenship and lawfully present immigration status is not a requirement for participation in WIC, therefore lack of citizenship or lawfully present immigration status must not be a burden for participation. 1. Local WIC Agencies cannot require a social security number for participation. a. Requirement of social security number is a burden to participation and that can result in discrimination against a WIC applicant or participant based on national origin. 2. The use of pseudo-identification numbers or auto- generated number at registration is strongly encouraged for the use as a Participant number in the system.

USDA Nondiscrimination Statement (NDS)

A. The USDA non-discrimination statement must be included on all WIC program materials that are produced for public notification. These materials may include outreach letters and brochures; internet websites and digital services; program information; newspaper, television, or radio announcements; posters; newsletters; referral materials; WIC application-related forms that are signed by participants. B. The USDA NDS may not be changed in any manner, and formatting may not be altered. C. The nondiscrimination statement should be: 1. In the full long form whenever possible. 2. On all WIC Outreach Materials, including on local agency websites. 3. On materials that the WIC Program produces for public information, public education, or public distribution, including but not limited to application forms, notification of eligibility or ineligibility, notification of adverse action, Program or Agency webpage, and digital services. 4. Large enough to be legible (at least 10-point font size for both the long and short forms). The material will, at a minimum, include the statement in print size no smaller than the text. If the

Page 7 Civil Rights Policy 306 December 2024 material is too small to permit the full statement to be included, the material will, at a minimum, include the statement, in print size no smaller than the text that “This institution is an equal opportunity provider.” 5. In English and other languages appropriate to the local population, 6. In an alternative means of communication, such as large print, Braille, audio, etc., when requested. D. The short form of the nondiscrimination statement should not be used routinely and may be used on items with limited space. These materials may include: 1. Postcards 2. Flyers of less than a page 3. Radio or television public service announcements that are generally short in duration. a. Per FNS instruction 113-1, recognizing that Internet, radio, and television public service announcements are generally short in duration the nondiscrimination statement does not have to be read in its entirety. Rather, a statement such as “Kentucky WIC is funded by the USDA. This institution is an equal opportunity provider.” is sufficient to meet the nondiscrimination requirement. b. Public program announcements (e.g., press releases) sent to media outlets must include the full NDS. Media outlets may include, but are not limited to, television, radio, and Internet. 4. If a local agency has their own nondiscrimination statement, it may be included on materials in addition to the required USDA statement but may not substitute for the USDA statement.

Page 8 Civil Rights Policy 306 December 2024

USDA WIC Nondiscrimination Statement (English)

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

This institution is an equal opportunity provider.

Page 9 Civil Rights Policy 306 December 2024 USDA WIC Nondiscrimination Statement (Spanish):

De acuerdo con la ley federal de derechos civiles y las normas y políticas de derechos civiles del Departamento de Agricultura de los Estados Unidos (USDA), esta entidad está prohibida de discriminar por motivos de raza, color, origen nacional, sexo (incluyendo identidad de género y orientación sexual), discapacidad, edad, o represalia o retorsión por actividades previas de derechos civiles. La información sobre el programa puede estar disponible en otros idiomas que no sean el inglés. Las personas con discapacidades que requieren medios alternos de comunicación para obtener la información del programa (por ejemplo, Braille, letra grande, cinta de audio, lenguaje de señas americano (ASL), etc.) deben comunicarse con la agencia local o estatal responsable de administrar el programa o con el Centro TARGET del USDA al (202) 720-2600 (voz y TTY) o comuníquese con el USDA a través del Servicio Federal de Retransmisión al (800) 877-8339. Para presentar una queja por discriminación en el programa, el reclamante debe llenar un formulario AD-3027, formulario de queja por discriminación en el programa del USDA, el cual puede obtenerse en línea en: https://www.usda.gov/sites/default/files/documents/USDA-OASCR%20P-Complaint-Form-0508- 0002-508-11-28-17Fax2Mail.pdf, de cualquier oficina de USDA, llamando al (866) 632-9992, o escribiendo una carta dirigida a USDA. La carta debe contener el nombre del demandante, la dirección, el número de teléfono y una descripción escrita de la acción discriminatoria alegada con suficiente detalle para informar al Subsecretario de Derechos Civiles (ASCR) sobre la naturaleza y fecha de una presunta violación de derechos civiles. El formulario AD-3027 completado o la carta debe presentarse a USDA por:

(1) correo: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410; or

(2) fax: (833) 256-1665 o (202) 690-7442; o

(3) correo electrónico: program.intake@usda.gov.

Esta entidad es un proveedor que brinda igualdad de oportunidades.

Short Statement (Spanish):

Esta entidad es un proveedor que brinda igualdad de oportunidades.

Page 10 Civil Rights Policy 306 December 2024 Non-discrimination Statement (NDS) in other languages/formats: Contact the State WIC Office for assistance with locating the NDS in additional languages routinely served by your agency or for assistance in alternative formats.

WIC Program Tagline:

The Kentucky WIC Program has developed a tagline for documents, websites, and digital services to ensure applicants and participants are aware of free communication assistance. This notice must be provided to the public in frequently encountered languages. This tagline should be included in approved WIC Outreach materials and vital forms and posted on websites and digital services. The tagline does not replace the Nondiscrimination Statement. Please find the approved tagline below.

WIC Tag Line English:

Need help? If you have difficulty understanding or reading English or have a disability, free language assistance or other aids and services are available upon request. Please contact your local WIC clinic or the State WIC Office at 1-877-597-0367. If you have a disability and need assistance calling us, contact the State Relay Number at 711 or for TTY to voice, call 800-648- 6056.

WIC Tag Line Spanish:

¿Necesita ayuda? Si le es difícil entender o leer el inglés, o si tiene alguna discapacidad, puede recibir ayuda con el idioma u otros apoyos y servicios sin costo alguno para usted, basta con solicitarlos. Por favor contacte a la clínica de WIC en su localidad o a la Oficina Estatal de WIC al 1-877-597-0367. Si tiene alguna discapacidad y necesita ayuda para llamarnos, contacte al Número Estatal de Retransmisión llamando al 711; o, para el servicio de voz a TTY, llame al 1- 866-490-4403.

Contact the State WIC Office for assistance with locating the WIC tagline in additional languages routinely served by your agency or for assistance in alternative formats.

Racial and Ethnicity Data Collection

A. The collection of race and ethnicity data is federally required to determine how effectively United States Department of Agriculture Food and Nutrition Service Programs such as WIC are reaching potentially eligible persons and beneficiaries. B. The WIC Program must report on ethnicity and race to ensure fair and proper administration of the Program. Data is collected for statistical and reporting purposes. C. The WIC Program must maintain race and ethnicity data under safeguards that restrict access only to authorized personnel. D. The WIC Program must maintain race and ethnicity data for three (3) federal fiscal years. E. Applicants must be informed that: 1. Provision of the data is voluntary. 2. Data is kept confidential and may be protected under the Privacy Act. 3. Data is used for statistical purposes only to ensure the Kentucky WIC Program reaches all potentially eligible people. 4. Provision of information has no effect on eligibility for WIC. 5. Applicants may choose one category for ethnicity. 6. Applicants may choose one or more races.

Page 11 Civil Rights Policy 306 December 2024 7. Staff will make a visual observation if the WIC Client chooses not to self-identify.

F. The clerical checklist as well as the Ethnicity and Race Reference card are available to assist staff in complying with the above requirements. See Sample text below:

“Everyone requesting WIC services is asked to identify their ethnicity and race(s). This information is requested solely for the purpose of determining the state’s compliance with Federal civil rights laws and your response will not affect consideration of your application and may be protected by the Privacy Act. By providing this information, you will assist us in assuring that this program is administered in a nondiscriminatory manner. This request is voluntary, if you do not self-identify your ethnicity and/or race, staff will make a visual observation. Please select one ethnicity. Please select all races from the list below that apply to you.”

G. Race and ethnicity data collection consists of a category for race and a category for ethnicity. The definitions of categories for documentation and reporting of race and ethnicity data are as follows:

1. Ethnic categories: a. Not Hispanic or Latino b. Hispanic or Latino (a person of Cuban, Mexican, Puerto Rican, Central or South American, or other Spanish origin or culture, regardless of race)

2. Racial Categories: a. American Indian/Alaska Native (American Indian includes North, Central and South American Indians; Alaskan Native includes Eskimo and Aleut) b. Asian (includes the Far East, Southeast Asia, and the Indian subcontinent including Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, Vietnam) c. Black or African American (associated with the black racial groups of African descent and migration patterns) d. Native Hawaiian or Other Pacific Islander (includes natives of the Hawaiian Islands, Guam, Samoa, and other Pacific Islands including the Caroline Islands, Fiji Islands, French Polynesia, Northern Mariana Islands, Palau Islands, Papua New Guinea, Solomon Islands, and Tokelau Islands) e. White (associated with European, Middle Eastern and North African descent and migration patterns, including the Arabian Peninsula)

Civil Rights Training

A. All WIC staff must receive Civil Rights training every state fiscal year (July 1-June 30). 1. As part of a new WIC staff orientation, new staff must receive the Civil Rights training. New employees must receive training prior to participating in WIC Program activities. 2. This includes all WIC Staff and Volunteers/Students who interact with WIC applicants or participants.

Page 12 Civil Rights Policy 306 December 2024 3. Refer to the Administrative Reference, Training Guidelines, WIC, Training Requirements section. B. WIC Staff must have basic knowledge of the following areas of Civil Rights Compliance: 1. Collection and use of data 2. Effective public notification systems 3. Complaint procedures 4. Compliance review techniques 5. Resolution of noncompliance 6. Requirements for reasonable modification and auxiliary aids and services for persons with disabilities. 7. Requirements for language assistance for persons with LEP 8. Requirements for Civil Rights training 9. Conflict resolution 10. Customer service C. Each local WIC Program is required to maintain a record of staff training, including civil rights training. This record must be available for state WIC staff to review during the WIC Program Management Evaluation Monitoring Visits.

Civil Rights Complaints

A. Civil rights complaints are those complaints that involve alleged discrimination based on race, color, sex, age, national origin, or disability. These are the “protected classes” for WIC. A complaint may also allege reprisal or retaliation for engaging in a protected Civil Rights activity, such as filing a complaint or serving as a witness in an investigation. B. Complainants should file within 180 days form the alleged act of discrimination. Only the Secretary of Agriculture or his/her designee can waive this timeframe with good cause. C. Complaints may be written, verbal or anonymous. D. The local and State Agency must accept all civil rights complaints. The State Agency will forward the complaint to FNS Civil Rights Division, Regional Civil Rights Officer, within the timeframes described within the FNS - KY CHFS Complaints Processing MOU, October 3, 2016. E. State and Local WIC Agencies must maintain a Civil Rights Complaint Log separate from Program Complaints. F. State and Local WIC Agencies must keep complaints confidential and accessible only to authorized personnel. G. If local program staff identify a potential civil rights complaint, they must follow the process below: 1. Local programs must accept and document all complaints involving alleged discrimination or civil rights violations. a. Civil Rights complaints must be kept in separate file from program complaints and must be kept confidential. Do not document in the medical record the intention of the participant to file a civil rights complaint, as that my lead to an additional complaint of retaliation. b. Right to File: Any person or representative alleging discrimination based on a prohibited basis has the right to file a complaint within 180 days of the alleged discriminatory action. Only the Secretary of Agriculture may extend this time under special circumstances. The complainant must be advised of their right to file with the USDA. The complainant must be advised of confidentiality and Privacy Act

Page 13 Civil Rights Policy 306 December 2024 applications. The complainant and the entity that the complaint is filed against will be encouraged to resolve any program access matter at the lowest possible level and as expeditiously as possible. 2. Contact the State WIC Program Management Section Supervisor or the State WIC Director immediately after identifying a complaint of alleged discrimination or a potential civil rights violation. 3. The state WIC office will refer the complaint to the FNS Civil Rights Division, Regional Civil Rights Officer within 5 calendar days from the date of the receipt by the local or State WIC office. 4. All complaints alleging discrimination on the basis of race, color, national origin, age, sex, or disability, either written or verbal, must be processed by FNS within 90 days of receipt. 5. Complaints may be received through a variety of methods including, but not limited to phone calls, fax, e-mails, written statements, or in person. 6. The Fair Hearings Procedures and Civil Rights Complaint Procedures Poster must be posted in clinic in public view. a. Note the fair hearings procedures and timeline differ from Civil Rights Complaints and is not utilized for Civil Rights Complaints. i. See the Administrative Reference, Local Health Operations, Administrative Hearings Section as well as the WIC and Nutrition Manual, Section 200 Appendix for additional information regarding Fair hearing Procedures. ii. The following are eligible for an administrative Fair Hearing: persons denied services, persons whose participation in a service was discontinued, persons who were notified to repay the cash value of improperly received WIC benefits, persons who have not had a grievance resolved to their satisfaction, and public and certain classes of citizens who were adversely affected as a result of the interpretation/enforcement of an environmental law, regulation or ordinance. iii. The WIC Program’s fair hearing policies for applicants, participants and vendors are governed by Kentucky Administrative Regulation 902 KAR 18:040 and 902 KAR 18:081 7. As soon as a suspected civil rights complaint is verbalized: a. Inform the person alleging discrimination of his/her right to file a complaint with CHFS and with the USDA. Inform the complainant that only the Secretary of Agriculture can waive this timeframe for good cause. Refer to the USDA NDS for the most update online link for filing a complaint, email address and mailing address. b. Inform the individual that local staff will document the complaint and immediately forward it to the state WIC office. (In addition to the complaint process described in the section below, the individual or local staff may also choose to send a civil rights complaint directly to the USDA or to the FNS Civil Rights Division, Regional Civil Rights Officer. c. Offer to assist a complainant write a formal complaint, when necessary. If the complainant verbalizes the complaint but does not wish to make allegations in writing, local WIC staff must still ensure the complaint is documented and forwarded to the State WIC Office. d. The complaint does not need to be written or signed if it is submitted in an alternate format to accommodate the complaint filing needs of a person who has an LEP, a disability, or other special need.

Page 14 Civil Rights Policy 306 December 2024 8. Required documentation for Civil Right Complaints. a. Name, address, and telephone number of the person making the complaint. i. Do not include this information, if complainant wants to remain anonymous. b. Name and location of the participant’s local program/ WIC Clinic Site. c. The location where the incident occurred. d. The nature of the incident or action that led the person to feel discrimination was a factor. e. The name(s), title(s), and business address(es) of individual(s) involved in or with knowledge of the discriminatory action, i.e., local health department staff, local WIC staff, vendors. f. The date(s) the alleged discrimination occurred or, if continuing, the most recent date of such action. g. The basis on which the civil rights discrimination has been filed, i.e., race, color, sex, age, national origin, or disability or retaliation or reprisal. Send the documentation immediately to the WIC Program Management Section Supervisor or the Branch Office at the State WIC Office. h. The State WIC Office staff will forward to FNS Civil Rights Division, Regional Civil Rights Officer and the Civil Rights Officer with the Cabinet for Health and Family Services.

H. Complaint Form 1. The USDA Complaint form is available for download. English: https://www.usda.gov/sites/default/files/documents/USDA-OASCR%20P- Complaint-Form-0508-0002-508-11-28-17Fax2Mail.pdfForm

Spanish: https://www.usda.gov/sites/default/files/documents/USDAProgramComplaintForm- Spanish-Section508Compliant.pdf

I. Resolution of Civil Rights Complaints 1. The state WIC office will notify the local WIC Coordinator and Local Health Department/ Agency Administrator if any corrective actions need to be taken to address a civil rights complaint. 2. The local agency must provide necessary documents, evidence, and position statement regarding complainant’s allegations to FNS CRD with the timeframes established by FNS guidance. 3. The local agency must make staff available to FNS CRD to be interviewed as necessary during investigations, including for the purpose of providing sworn testimony and clarifying general information. 4. The local agency must maintain a copy of any correspondence regarding the complaint for at least four years after the date notified the complaint is closed. 5. The local agency must grant FNS CRD access to local agency facilities, and complaint, communications, records, and other systems, as necessary during investigations. 6. The local agency must participate in attempts to resolve the complaint.

Page 15 Civil Rights Policy 306 December 2024

Civil Rights Compliance Reviews

Civil Rights Compliance Reviews examine the activities of the State Agencies and Local Agencies to determine civil rights compliance.

A. United States Department of Agriculture (USDA) Food and Nutrition Service Civil Rights and Program staff review the State Agency. B. State Agencies review local agencies during the routine Management Evaluation (ME) Visits. Civil Rights Compliance Reviews will include review of required civil rights training, meaningful access for persons with limited English proficiency, equal access for persons with disabilities, and more. The ME tool is provided to the local agency prior to the evaluation and contains all Civil Rights review areas to review. Refer to Administrative Reference, Program Descriptions, WIC. Significant findings regarding civil rights must be provide in writing to both the local agency and to Regional FNS Civil Rights Officer for resolution. A significant finding is an egregious and repetitive finding or a policy or procedure that has a disproportionate, adverse effect on a particular protected class (disparate impact). C. Local and state agency staff with work together along with USDA as appropriate, to promptly resolve non-compliance issues through a corrective action plan.

Resolution of Noncompliance

A. Noncompliance is a factual finding that any Civil Rights requirement, as provided by law, regulation, policy, instruction, or guidelines, is not being adhered to by local agency or other subrecipient. B. Once noncompliance is determined, steps must be taken immediately to obtain voluntary compliance in accordance with FNS Instruction 113-1. 1. The effective date of the finding of noncompliance is the date of the written notice of noncompliance to the local agency or other subrecipient. 2. After a finding of noncompliance, the State agency will: a. Provide immediate written notice to the local agency or other subrecipient Local Agencies, will request to voluntarily resolve noncompliance findings by submitting a Corrective Action Plan and implemented the State Agency approved corrective action plan. b. Negotiate with local agency or other subrecipient to achieve compliance. c. Submit to the Regional Civil Rights Officer a Report of Findings of Noncompliance in letter format on all cases where corrective action has not been completed within 60 days of the finding. d. Submit documentation per the FNS Instruction 113-1. C. The FNS Regional Office of Civil Rights must determine next steps of action per FNS Instruction 113-1.

Page 16 Civil Rights Policy 306 December 2024 Limited English Proficiency (LEP)

A. It is the policy of the WIC Program to provide timely, meaningful access to WIC Program services and activities for individuals with Limited English Proficiency (LEP). 1. Coordinate with the Nutrition Services Branch, Program Management Section Supervisor and with the Cabinet for Health and Family Services Equal Employment Opportunity (EEO) and Civil Rights Branch Manager for technical assistance, if needed, in providing meaningful access to individuals with LEP. 2. Limited English Proficiency (LEP) refers to individuals who do not speak English as their primary language and who have a limited ability to read, speak, write, or understand English because of their national origin. 3. Title VI and its implementing regulations prohibit discrimination on the basis of race, color, and national origin. a. National Origin refers to a person’s ancestry, place of origin; or the physical, cultural, or linguistic characteristics of a national origin group. 4. WIC Agencies must therefore take reasonable steps to ensure meaningful access to the WIC Program and activities for individuals with limited English proficiency (LEP). a. Meaningful Access is providing reasonable, timely, appropriate, and competent language services at no cost to individuals with LEP. b. Failure to provide Meaningful Access to persons with LEP could be discrimination on the basis of national origin. 5. Local WIC Agencies should take the following steps to ensure qualified interpreters are available to meet the oral communication needs of persons with LEP and to identify necessary materials for translation into other languages. Contact the State WIC office for technical assistance on how to conduct this self-assessment, secure qualified interpreters, and determine the availability of materials on languages other than English and Spanish. a. The number or proportion of LEP persons eligible to be served or likely to be encountered within the area serviced by the recipient. b. The frequency with which LEP persons come in contact with the program or activity. c. The nature and importance of the program, activity, or service to people’s lives. d. The resources available to the recipient and costs. 6. The following sources are reliable population data sources that may be utilized in the four (4) steps outlined above to determine necessary and reasonable translation of materials. a. Department of Justice site: LEP.GOV http://www.lep.gov/maps/ b. US Census Data http://www.census.gov/2010census/data/ c. American Community Survey http://www.census.gov/acs/ d. Migration Policy Institute’s National Center on Immigrant Integration Policy http://www.migrationpolicy.org/ 7. Language Services a. WIC agencies must notify persons with LEP about the availability of free language assistance services and how to request the services in languages they can understand. The WIC tagline should be used on posters, documents, websites, and digital services. Information on free languages services should be available via: i. Reception areas, ii. Websites and digital services iii. Telephone voice mail menus

Page 17 Civil Rights Policy 306 December 2024 iv. WIC Staff offering the service b. Applicants and participants cannot be asked to bring their own interpreters. c. Use qualified, competent language assistance services. i. Children should not be used as interpreters. ii. Do not plan to rely on a LEP person’s family members, friends, or informal interpreters. iii. Do not ask LEP persons to bring their own interpreters. iv. Use of a family or friend should be discouraged, as family and friends are not trained and qualified interpreters and issues of confidentiality, privacy or conflict of interest may arise. Those LEP individuals who are accompanied by bi-lingual family or friends must be offered free language assistance. If the free language assistance is declined due to a request to use a family or friend, this must be documented in the medical record. d. Acceptable Language Services include: i. Qualified Bilingual staff ii. Telephone interpreter lines iii. Qualified contract interpreters iv. Qualified Translators e. All WIC Staff must offer and provide qualified, competent language assistance services free to individuals with LEP. i. Competency requires more than self-identification as bilingual. ii. A qualified interpreter is a highly trained individual who mediates spoken communication between people speaking different languages without adding, omitting, or distorting meaning or editorializing. iii. Qualified, competent translators must be used when translating WIC Program Materials. a) A qualified, competent translator is a highly trained individual who is able to render text from a source language into a target language while preserving meaning and adhering to generally accepted translator ethics and principles, including confidentiality. b) Qualified translators understand the cultural context of the source and target languages as well as demonstrate competency to translate through an independent language assessment. c) A qualified interpreter may or may not be a qualified translator. f. Contact the State WIC office for translations of WIC Program materials vital to an individual’s participation including forms related to applying for the program, documents that require a response, denial letters or notice of ineligibility. g. Local and state agency developed materials should routinely be simultaneously translated as the updated English materials are updated in the LEP languages identified. h. Record language spoken in the CMS Portal system for tracking and reporting purposes. i. Offers and requests for free communication services must be documented in the medical records. j. The type of service provided must be documented in the medical record. k. Document language spoken, language assistance service offered, type of language assistance provided or declined in the medical record at each visit. i. This may include working with interpreters, using a language line, and providing printed materials in appropriate languages. ii. At a minimum, all WIC Program should have access to a language line for communication with individuals who are LEP.

Page 18 Civil Rights Policy 306 December 2024 iii. Denials of free language service must be documented in the medical record. i. See the Administrative Reference, Local Health Operations Section, Communicating with the Public.

Disability Access to WIC Program

A. Notification for Individuals with Disabilities 1. Local WIC Agencies must notify individuals with disabilities about the availability of auxiliary aids and services and other reasonable modifications and to provide free accommodations upon request or as needed to ensure equal participation and equally effective communication. 2. The WIC tagline is available to assist in this notification. The WIC tagline should be used on posters, documents, websites, and digital services. Information on reasonable modifications and auxiliary aids and services should be available via: a. Reception areas, b. Websites/online services c. WIC Staff offering the service 3. Local WIC Agencies must notify individuals with disabilities about protections against discrimination and how to file a complaint. See the Nondiscrimination Statement Section and Civil Rights Complaints section above.

B. Equally Effective Communication 1. Local WIC Agencies must ensure that communication with individuals with disabilities is as equally effective as communication with people without disabilities. Including communication with applicants, participants and their parent, caretaker, spouse, or companions in appropriate circumstances who have hearing, vision, and speech disabilities. a. Companion includes any family member, friend, or associate of a person seeking or receiving WIC services who is an appropriate person with whom the WIC program should communicate. 2. Primary consideration of the choice of aid or service requested for effective communication by the person with a disability must be provided. 3. It is the WIC program’s responsibility to ensure equally effective communication when providing program information to individuals who require materials in an alternate format. a. When requested, provide program information in alternate formats (i.e. large print, Braille, electronic format, or audio). 4. Documentation of auxiliary aid or service for effective communication a. The auxiliary aid or service for effective communication requested and provided is to be documented in the medical record. b. If the requested aid or service was not provided, this must be documented in the medical record and elevated to the most senior staff member for justification for not providing the requested service. The alternative aid or service provided is to be documented in the medical record. 5. The State and Local WIC Agency must honor the person choice, unless it can demonstrate that another equally effective means of communication is available or that the use of the means chosen would result in a fundamental alteration in service or an undue burden to the agency.

Page 19 Civil Rights Policy 306 December 2024 a. The decision that an aid or service would result in an undue burden can only be made by the head of the agency or his/her designee and must include a written statement of the reasons for reaching that conclusion. b. If the choice expressed by the person with a disability would result in an undue burden or a fundamental alteration, staff still have an obligation to provide an alternative aid or service that provides effective communication, if one is available. c. The goal is to provide an aid or service that will be effective, given the nature of what is being communicated and the person’s method of communicating.

C. Use of auxiliary aids and services for equally effective communication 1. Use qualified interpreters. a. A qualified interpreter is able to interpret effectively, accurately, and impartially, both receptively and expressively, using any necessary specialized vocabulary. b. Qualified interpreters include, for example, video remote interpreting, sign language interpreters, oral transliterators, and cued-language transliterators. 2. Do not require an individual with a disability to bring someone with them to interpret. State and Local WIC agencies can rely on a companion to interpret in only two situations. a. In an emergency involving an imminent threat to the safety or welfare of an individual or the public, an adult or minor child accompanying a person who uses sign language may be relied upon to interpret or facilitate communication only when a qualified interpreter is not available. b. In situations not involving an imminent threat, an adult accompanying someone who uses sign language may be relied upon to interpret or facilitate communication when a) the individual requests this, b) the accompanying adult agrees, and c) reliance on the ac- companying adult is appropriate under the circumstances. This exception does not apply to minor children. c. Even under exception (b), WIC staff may not rely on an accompanying adult to interpret when there is reason to doubt the person’s impartiality or effectiveness. For example: It would be inappropriate to rely on a companion to interpret who feels conflicted about communicating bad news to the person or has a personal stake in the outcome of a situation. It would be inappropriate to rely on a companion to interpret in situations involving actual or alleged domestic violence. 3. Children should not be used as interpreters. 4. Use of a companion, family, or friend should be discouraged, as family and friends are not trained and qualified interpreters, and issues of confidentiality, privacy, or conflict of interest may arise. Those individuals who are accompanied by an adult companion must still be offered interpreter services or auxiliary aids. If the aid or service is declined due to a request to use an adult companion, this must be documented in the medical record. a. Refer to the Administrative Reference, Local Health Personnel, (Persons with Limited English Proficiency) section and Local Health Operations, Standard Procedures for Interpretive Services Section. b. Accessible electronic and information technology c. Qualified interpreters on-site or through video remote (VRI) interpreting services. Video Remote Interpreting VRI technologies should meet ADA performance standards. See above regarding the use of qualified interpreters. d. Voice, text, and video-based telecommunications products and systems e. Braille or tactile displays f. Screen reader software

Page 20 Civil Rights Policy 306 December 2024 5. Take into consideration the nature, length, and complexity of the communication, as well as the person’s normal method(s) of communication when choosing an auxiliary aid or service. 6. To ensure equally effective communication it is recommended to require advance notice from people requesting aids or services, based on the length of time needed to acquire the aid or service, while staying in compliance with WIC Scheduling requirements. a. See the Administrative Reference, Local Health Personnel, Compliance with Americans with Disabilities Act (ADA) section and LHD Facilities and Equipment, Facility Structural Requirements section. b. See WIC and Nutrition Manual, Section 202 regarding Processing Standards for WIC appointments. 7. Honor “walk-in” requests for aids and services to the extent possible. 8. Accept telephone calls placed through the Telecommunications Relay System (TRS) and treat the call just like any other call. a. More information on the Kentucky Relay System can be found at: Kentucky Relay: Overview (hamiltonrelay.com) b. To make Relay call to an applicant or participant who utilizes TRS, call 1-888-244-6111.

D. Reasonable Modification 1. Local WIC Programs must provide reasonable modification when necessary to ensure that the WIC Program is equally accessible to all potentially eligible individual and to WIC participants 2. Reasonable modifications may be made to practices and procedures when the modifications are necessary to avoid discrimination on the basis of disability. A reasonable modification is a change or exception to a policy, practice, or procedure that allows people with disabilities to have equal access to programs, services, and activities. A reasonable modification can also be a structural change made to existing premises, occupied or to be occupied by a person with a disability, to afford such person full enjoyment of the premises. 3. The modification should be provided unless the agency can demonstrate that making the modification would fundamentally alter the nature of the service, program, or activity per 28 CFR 35.130(b)(7)(i). 4. The agency is not required to take action if it would result in undue financial and administrative burden. a. Reasonable modification is the removal of barriers to allow individuals to participate equally in WIC. In some cases, what is considered “reasonable modification” may be different from what an individual requests. b. All resources of the agency and program in funding the operation of the service, program or activity must be considered. c. A decision that compliance would result in such alteration, or burdens must be made by head of agency, or his or her designee. 5. The decision must be accompanied by a written statement of the reasons for reaching that conclusion. 6. The agency is still required to provide service to the maximum extent possible. a. Contact the agency’s Civil Rights Coordinator or the Kentucky Cabinet for Health and Family Services Civil Rights Coordinator for technical assistance if needed in providing a reasonable modification. 7. Examples of reasonable modifications include but are not limited to:

Page 21 Civil Rights Policy 306 December 2024 a. Provide wheelchair access to WIC Clinic locations. This provides equal access to individuals using wheelchairs. b. Ensure access to individuals who require the assistance of a service animal. c. Modify the WIC food package to accommodate an individual with a disability.

E. Documentation of the reasonable modification or auxiliary aid or service 1. The reasonable modification and/or auxiliary aid or service for requested and provided must be documented in the medical record. 2. If the requested modification, aid, or service was not provided, this must be documented in the medical record and elevated to the most senior staff member for justification for not providing the requested service. The alternative modification, aid or service provided also must be documented in the medical record.

F. Accessibility of Facilities 1. Refer to the Administrative Reference, Facilities and Equipment Section. 2. As programs and offices modernize, facilities and websites should be readily

G. Wheelchair Access, Mobility Aids, and Other Power-Driven Mobility Devices (OPDMD) 1. Staff must permit individuals with mobility disabilities to use wheelchairs and mobility aids in any area open to pedestrian use. 2. A wheelchair is a manually operated or power-driven device designed primarily for use by an individual with a mobility disability for the main purpose of indoor, or of both indoor and outdoor locomotion. 3. Staff must also allow individuals with mobility disabilities to use manually powered mobility aids (includes include walkers, crutches, canes, braces, or other similar devices) in areas open to pedestrian use. 4. Local WIC Agencies must make reasonable modifications to permit individuals with mobility disabilities to use OPDMDs, unless the entity can demonstrate that the class of OPDMD cannot be operated in accordance with legitimate safety requirements adopted by the facility. a. OPDMD means any mobility device powered by batteries, fuel, or other engines, whether designed primarily for use by individuals with mobility disabilities that is used by individuals with mobility disabilities for the purpose of locomotion. b. Staff may not ask an individual using a wheelchair, mobility aid, or OPDMD questions about the nature and extent of the individual’s disability. c. Accessible to, and useable by persons with visual impairments and other disabilities.

H. Service Animals 1. Service Animal means any dog that is individually trained to do work or perform tasks for the benefit of an individual with a disability, including a physical, sensory, psychiatric, intellectual, or other mental disability. a. Other species of animals, whether wild or domestic, trained, or untrained, are not service animals for the purpose of this definition. b. Comfort or emotional support animals are not covered by Section 504 or Title II of the ADAAA. i. Staff may only make two (2) inquiries of the individual with the service animal: 1) “Is the animal required because of a disability?”

Page 22 Civil Rights Policy 306 December 2024 2) “What work or task the animal has been trained to perform?” ii. Staff may not require written documentation or certification of the need for the animal. iii. Staff must allow access for service animals unless: c. The animal is out of control and the handler does not take effective action to control it. d. The animal is not housebroken. e. Where there is a legitimate basis to exclude the animal, the individual with the disability should be given the opportunity to participate in the program without the animal.

I. Miniature Horses 1. Miniature horses are not Service Animals; however, a miniature horse is a reasonable modification when the miniature horse has been individually trained to do work or perform tasks 2. Staff should permit access to individuals with disabilities who are accompanied by a miniature horse 3. Staff may consider the following factors regarding access for miniature horses a. The type, size, and weight of the horse and whether the facility can accommodate those features b. Handler has sufficient control of the horse c. Horse must be housebroken d. Whether the horse’s presence in a specific facility compromises legitimate safety requirements

J. Safety & Direct Threat 1. A local WIC agency may impose legitimate safety requirements necessary for the safe operation of its services programs or activities. 2. The local WIC agency must ensure that its safety requirements are based on actual risks, not speculation, stereotypes, or generalizations about individuals with disabilities. See 28 C.F.R.§ 35.130(h). 3. Direct Threat means a significant risk to the health or safety of others that cannot be eliminated by a modification of policies, practices, or procedures, or by the provision of auxiliary aids or services as provided in 28 C.F.R. § 35.139. a. A local WIC agency is not required to permit an individual to participate in or benefit from the services, programs, or activities of that agency when that individual poses a direct threat to the health or safety of others. Note: Direct threat to others, not self. b. Requires individualized assessment based on reasonable judgment that relies on current medical knowledge or on the best available objective evidence to ascertain: 1) the nature, duration, and severity of the risk, 2) the probability that the potential injury will occur, 3) and whether reasonable modifications of policies, practices, or procedures or the provision of auxiliary aids or services will mitigate the risk. 28 C.F.R. § 35.139(b).