NC WIC Program Manual

October 2025

Chapter 1 Introduction to WIC

Table of Contents

This chapter introduces the WIC Program and information on the required local agency policies, staff conflict of interest, management of program policies and procedures, and resources available from the Community Nutrition Services Section to support program activities.

Section 1. Overview of WIC .....................................................................................................1  Introduction  WIC Program Benefits  Eligibility for WIC  Participation in WIC  Impact of WIC on Health Status  WIC in North Carolina

Section 2. Program Policies and Procedures .............................................................................5  Distribution of the Program Manual  Updating Program Policy  Local Agency Policies and Procedures

Section 3. No Smoking Policy in Local Agency Facilities .......................................................7

Section 4. Staff Conflict of Interest ..........................................................................................9  Certifying and Issuing Food Benefits to Self, Relatives, or Close Friends  Separation of Duties During Eligibility Determination  WIC Staff and WIC Vendors

Section 5. Plan of Alternate Operating Procedures………………………………………....11  Eligibility Criteria for Evacuees and Others Impacted by Disasters  Flexibility in Operations  Food Benefits  Local Agency Plan of Alternate Operating Procedures (PAOP)

Section 6. Program Materials Available from the Community Nutrition Services Section….15  Ordering Materials  Receiving Materials

Attachments: Attachment 1. Log of WIC Program Numbered Memos (sample) Attachment 2. Separation of Duties Log Attachment 3. Affidavit Attesting to WIC Food Benefit Loss Attachment 4. Continuity of Services Form Attachment 5. NC WIC Program: Business Continuity Plan

NC WIC Program Manual

October 2025 Required Local Agency Written Policies and Procedures

 Local Agencies must have a written policy to ensure separation of duties that address strategies implemented when separation of duties is not possible due to limited staff (Section 4, page 9).

 Local agencies must develop, revise, and maintain a written plan of alternate operating procedures consistent with local and State operations (Section 5, page 13).

Chapter 1: INTRODUCTION TO WIC

1 Section 1: OVERVIEW OF WIC

NC WIC Program Manual October 2025

Overview of WIC

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is a federal program administered by the United States Department of Agriculture (USDA). The WIC Program is designed to provide supplemental foods, health care referrals, and nutrition education to low-income pregnant, breastfeeding, and non-breastfeeding postpartum women, and to infants and children up to age five who are found to be at nutritional risk. Additional information on WIC can be found at http://www.fns.usda.gov/wic/.

 Introduction The purpose of the WIC Program is spelled out in Section 17 (a) of Public Law 95-627 (Child Nutrition Amendments of 1978).

The Congress finds that substantial numbers of pregnant women, infants, and young children are at special risk in respect to their physical and mental health by reason of poor or inadequate nutrition or health care, or both. It is, therefore, the purpose of the program authorized by this section to provide…supplemental nutritious foods and nutrition education as an adjunct to good health care during critical times of growth and development, to prevent the occurrence of health problems and improve the health status of these persons.

To fulfill the legislated purpose of the Program in North Carolina, the following must be present at the level of implementation:

 Integration of WIC with established health services,

 WIC food packages that are tailored as a prescription for individual participants, and

 Tailored nutrition education services for participants.

 WIC Program Benefits

 WIC Food Prescription. The food categories available through WIC contain nutrients determined to be beneficial for pregnant, breastfeeding, and postpartum women, infants and children. Refer to Chapter 7 for information on the food categories and quantities of supplemental foods included as part of a WIC food prescription.

 Nutrition Education. Nutrition and physical activity education is an integral part of the WIC Program and is designed to improve health status, achieve positive change in dietary habits, and emphasize relationships between nutrition and health, all in keeping with the individual's socioeconomic situation as well as personal and cultural preferences. Refer to Chapter 5 for information on the nutrition education benefit of the WIC Program.

 Breastfeeding Promotion and Support. Pregnant, breastfeeding and postpartum women who participate in WIC receive comprehensive breastfeeding education and support. Refer to Chapter 9 for information on the breastfeeding associated benefit of the WIC Program.

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NC WIC Program Manual October 2025  Health Screenings. Health screenings such as growth check, anemia screenings, lead screenings, and more contribute to health assessments and support the identification of participant nutrition risk. Participant tailored nutrition intervention and counseling are a unique and integral WIC Program benefit for participants.

 Referrals to Health Care and Public Assistance Programs. WIC Program applicants and participants receive referrals and information about other relevant health care services (e.g., immunization services, prenatal care, well child health care), appropriate public assistance programs (e.g., Food and Nutrition Services, Medicaid), and potential sources for food assistance.

 Eligibility for WIC To qualify for the North Carolina WIC Program, an applicant must meet four eligibility criteria. Refer to Chapter 6 for additional information about each of these criteria.

 Categorical eligibility. A participant must be a pregnant woman, a non-breastfeeding postpartum woman up to six months after the birth of the infant or the end of the pregnancy, a breastfeeding woman up to one year postpartum, an infant up to the first birthday, or a child up to the fifth birthday.

 Residential eligibility. A participant must live in the State of North Carolina and in the health services delivery area of the local agency.

 Income eligibility. A participant must have a gross annual income at or below 185% of the federal poverty line. All Medicaid, TANF (Work First), and Food and Nutrition Services recipients are automatically income-eligible for WIC (i.e., adjunctively eligible).

 Nutrition risk eligibility. A participant must have at least one identified nutrition risk as related to medical or dietary-based conditions and as assessed by a competent professional authority (CPA). Nutrition risks include but are not limited to anemia, poor growth, poor outcome in previous pregnancy, inadequate diet, and other nutrition-related problems.

 Participation in WIC Over 250,000 North Carolina women, infants, and children receive WIC Program services each month. Monthly participation in WIC is defined as the sum of pregnant women, breastfeeding women, postpartum women, infants and children who receive food benefits or cash-value benefits during the reporting period. WIC program participation for individuals in a breastfeeding dyad include:

 The number of breastfeeding infants who did not receive food benefits, but whose breastfeeding mother received food benefits or cash-value benefits during the reporting period; and

 The number of breastfeeding women six months or more postpartum who did not

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NC WIC Program Manual October 2025 receive food benefits or cash-value benefits, but whose breastfed infant(s) received food benefits during the reporting period.

Refer to Chapter 7 for more information on the supplemental food benefits of WIC and to Chapter 8 for information on the issuance of food benefits.

 Impact of WIC on Health Status Over the years, USDA has conducted extensive evaluations of the WIC Program as have a variety of other groups, including the federal General Accounting Office. WIC provides quality, cost-effective care to thousands of families across North Carolina. Evidence demonstrates that women who participate in WIC have improved pregnancy and birth outcomes, resulting in healthier babies. There are numerous benefits to women, infants and children who participate in WIC. Studies have shown that:

 WIC reduces infant mortality. WIC provides pregnant women with effective nutrition invention that positively impacts the success of a pregnancy. WIC participation is associated with lower preterm birth and infant mortality for low-income women (Journal of the American Medical Association, 2019).

 WIC connects pregnant women to prenatal care, provides nutritious foods and encourages health-promoting behaviors. These factors are linked to positive birth outcomes (USDA, 2012).

 WIC saves healthcare dollars. Women who participate in WIC are less likely to have pre-term or low-birth weight babies, contributing to healthier babies and reduced medical costs (Institute of Medicine, 2006). WIC participation resulted in healthcare cost savings by preventing preterm births and healthier birth outcomes. WIC’s efforts to reduce income-based disparities in childhood obesity and promote higher dietary quality and variety for children are effective strategies to mitigate early onset of chronic diet- related conditions set the trajectory to reduce healthcare costs of the next generation (Journal of Preventive Medicine, 2019).

 WIC improves children’s health. WIC health screenings lead to referrals for immunizations, prenatal or pediatric care, dental care and social services. Children who participate in WIC are more likely to receive regular preventive health services and have higher rates of childhood immunization than non-participating low-income children (Journal of Preventive Medicine, 2019).

 WIC improves infant feeding practices and diet quality. WIC promotes and supports breastfeeding as the standard method of infant feeding. In addition, revisions to the WIC food package have resulted in increased intake of fruits, vegetables, whole grains and low-fat dairy among WIC participants (USDA, 2012; Center on Budget and Policy Priorities, 2015).

 WIC provides individualized nutrition services. A full nutrition assessment of WIC participants including the assignment of WIC nutrition risk code correlates with

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NC WIC Program Manual October 2025 increased referrals to other services, tailored food packages, and nutrition education (USDA, 2024).

 WIC supports cognitive development. Research shows that WIC services can mitigate the harmful effects of poor nutrition during critical periods of growth and development, leading to lifelong cognitive gains (USDA, 2012). The WIC Program provides children with nutrients from food groups that are essential for physical and cognitive development, resulting in greater academic success as children enter school (American Journal of Preventive Medicine, 2014).

 WIC in North Carolina WIC is administered at the state level by the NC Department of Health and Human Services, Division of Child and Family Well-Being, Community Nutrition Services Section. Locally, the WIC Program is administered by public health agencies (e.g., county health departments and community and rural health centers) serving all 100 counties. Additional information about the North Carolina WIC Program can be found at https://www.ncdhhs.gov/ncwic.

In addition to the WIC Program federal regulations (http://www.fns.usda.gov/wic/wic-laws- and-regulations) program activities are governed by rules outlined in the North Carolina Administrative Code (NCAC), Title 10A Health and Human Services, Chapter 43, Subchapter D. The NCAC can be accessed online at http://www.oah.state.nc.us/rules/. Under Rules Division, select NC Administrative Code to access the NCAC Table of Contents. From Table of Contents, select NCAC 10A - Health and Human Services, Chapter 43 - Personal Health, sub-chapter D - WIC/Nutrition.

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5 Section 2: PROGRAM POLICIES AND PROCEDURES

NC WIC Program Manual

October 2025 Program Policies and Procedures

The North Carolina policies and procedures are described in writing in the WIC Program manual. All staff working with the WIC Program must have ready access to the WIC Program manual.

 Distribution of the WIC Program Manual The complete NC WIC Program manual is available on the website: www.ncdhhs.gov/ncwic. The Local WIC Director is responsible for:

 Making staff aware of the WIC Program manual's contents and annual updates;

 Ensuring all copies of the WIC Program manual in the local agency are updated as program manual revisions are implemented; and

 Ensuring that all staff members have ready access to the WIC Program manual.

 Updating Program Policy The Community Nutrition Services Section periodically issues numbered memorandum to local agencies to communicate changes in federal and state regulations, rules, and/or policies and procedures. Numbered memos contain policy changes which may be short-term solutions to temporary challenges or permanent policy changes such as a WIC Program manual revision. Staff should maintain a file and a log of all numbered policy memos, so they can be easily referenced. A sample numbered memos log is provided in Attachment 1.

Additionally, WIC Program manual revisions may be issued throughout the year. When staff receive revisions, they should follow the guidance specified in the correspondence for reviewing, distributing, and implementing changes in policies and procedures.

 Local Agency Policies and Procedures Local agencies must develop some written policies and procedures specific to their agency. Sections within the WIC Program which require a local agency written policy and procedure are listed in the bottom section of each chapter’s “Table of Contents”.

When developing agency specific written policies and procedures, staff should:

 Use a consistent format;

 Ensure each policy and procedure is signed and dated by the WIC Director (and any other staff per agency protocol); and

 Review with update as needed the policies and procedures at least every two years.

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October 2025

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Section 3: NO SMOKING POLICY IN LOCAL AGENCY FACILITIES

NC WIC Program Manual

October 2022 No Smoking Policy in Local Agency Facilities

To receive WIC administrative funds, local agencies and WIC clinics must have an announced public policy that prohibits smoking. Each local agency shall ensure that the local agency prohibits smoking in the space used to carry out the WIC Program during the time any aspect of WIC services are performed; including satellite operations.

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Section 3: NO SMOKING POLICY IN LOCAL AGENCY FACILITIES

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October 2022

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9 Section 4: STAFF CONFLICT OF INTEREST

NC WIC Program Manual

October 2024 Staff Conflict of Interest

To preserve the integrity of the certification and food benefit issuance processes, and to minimize the potential for staff fraud and program abuse, federal regulations require the implementation of policies and procedures that prevent conflict of interest or the appearance of conflict of interest by local agency staff. Refer to Chapter 8 for information on food benefits issuance.

 Certifying And Issuing Food Benefits To Self, Relatives Or Close Friends To prevent the appearance of conflict of interest, local agency staff must not participate in any component of the certification process or food benefits issuance to herself/himself, relatives, or close friends.

 Relatives include spouse, parents, children, grandchildren, grandparents, brothers, sisters, aunts, uncles, nieces, nephews, first cousins, stepparents, stepchildren, stepbrothers, and stepsisters by blood or marriage.

 Close friends cannot be defined in a way that fits every situation; therefore, local agencies have authority to determine if a WIC applicant or participant is a close friend of a local agency WIC staff.

WIC staff who are scheduled or who have a relative or close friend scheduled for a certification or appointment that includes food benefit issuance shall notify the WIC Director or clinic supervisor, so that arrangements can be made for other staff to certify and issue the food benefits.

 Separation Of Duties During Eligibility Determination

 Separation of duties. There must be a separation of duties among local agency staff so that the same person does not complete both income eligibility determination and medical or nutritional risk eligibility determination for the same participant. It is acceptable however, for one staff member to conduct part of the certification (i.e., determine nutrition eligibility) and a different staff member determine income eligibility; either of the staff members may issue food benefits in this situation.

 Local Agency Separation of Duties Policy. Each local agency must have a written policy that describes how the local agency ensures when separation of duties is not possible due to limited staff. The local agency policy must address that the guidelines below are followed: • Staff completing the certification when separation of duties is not achieved must complete the first five columns of the Separation of Duties Log (Attachment 2), recording each certification in consecutive order by date. • The local agency will designate staff other than the certifier (e.g., local agency WIC Director, Health Director, or designee) to review a sample of certification records (see below) for which separation of duties was not achieved.

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10 Section 4: STAFF CONFLICT OF INTEREST

NC WIC Program Manual

October 2024 • Designated staff will conduct a review of all non-breastfeeding infant certification records and at least 20 percent of the remaining certification records for which separation of duties was not achieved within 14 calendar days of the certification. The staff member conducting the review shall validate certification was accurately assessed and complete the last five columns of the Separation of Duties Log. • The completed Separation of Duties Log must be filed at the local agency in a secure and retrievable manner and shall be made available for review during state agency monitoring events and local agency self-assessments. • The local agency WIC Director or designee must contact the agency’s Regional Nutrition Consultant immediately if the local agency review of the Separation of Duties Log suggests irregularities in WIC certification activity.

 WIC Staff And WIC Vendors To ensure there is no appearance of conflict of interest regarding the relationship of local agency staff and WIC vendors, the policies below must be followed.

 Local agency staff whose salary is paid in whole or any part by WIC Program funds are prohibited from having financial ownership in any authorized WIC vendor.

 Local agency staff whose salary is paid in whole or any part by WIC Program funds shall not be employed by and handle or transact WIC food benefits or cash-value benefits for a WIC vendor in the same county served by the local WIC Program. Likewise, local agency WIC staff must not have a spouse, child, or parent who is employed by and processes or transacts WIC food benefits or cash-value benefits for a WIC vendor in the same county served by the local WIC Program.

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11 Section 5: PLAN OF ALTERNATE OPERATING PROCEDURES

NC WIC Program Manual

October 2025 Plan of Alternate Operating Procedures

The WIC Program is a supplemental food and nutrition program that serves specific categorically eligible individuals with special nutritional needs; it is not designed to be a disaster assistance program, nor is it considered a first response option for disaster survivors. However, the WIC Program needs to establish a relationship with relief agencies responsible for disaster and public health emergency planning as appropriate to support data-informed approaches when responding to emergency periods, supplemental food recalls, and other supply chain disruptions.

The NC WIC Program guidance for emergency and disaster situations outlined in this section applies to events that threaten to interrupt or have already interrupted the provision of WIC Program services. Types of emergencies or disaster situations may include natural disasters, human pandemics, and biological emergencies. WIC’s role in responding to disasters is limited; however, there are ways the Program can contribute to relief efforts. In the event of a disaster, the State WIC Director or designee, is responsible for planning, coordinating, and activating the NC WIC Program disaster response.

 Eligibility Criteria for Evacuees and Others Impacted by Disasters During an emergency or disaster, there are operational flexibilities for displaced participants and applicants impacted by a disaster.

 Verification of Certification (VOC). Each participant displaced by an emergency or disaster must be provided with VOC information to ensure the continuation of benefits should the participant relocate to another state. For further guidance, see Chapter 6E, Section 1: Transfer of Certification.

 Application Process. Displaced participants and applicants impacted by a disaster may qualify as homeless, defined as an individual who lacks a fixed and regular nighttime residence or whose residence is limited to a temporary living accommodation. Participants displaced by a disaster are at additional nutrition risk since they are considered homeless. • Processing Standards. A homeless applicant must be notified of their eligibility or ineligibility for WIC Program services within 10 calendar days from initial request for services. For further guidance on priority levels for application processing standards, see Chapter 6A, Section 2: Application Process. • An applicant impacted by a disaster may not have access to proof of identity, residency, and/or income and requiring of documentation for determination of eligibility may present an unreasonable barrier to participation. As such, it is appropriate to utilize a signed affidavit for proof of identity, residency, and/or income (with self-declared income) for WIC Program certification − If an applicant impacted by a disaster moves in with another household, the displaced individual(s) will be considered homeless and treated as a separate economic unit. − During an officially declared “State of Emergency”, the State Director of the Special Supplemental Nutrition Program for Women, Infants and Children (WIC)

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NC WIC Program Manual

October 2025 or designee will provide additional guidance for the verification and documentation of required proofs during modified program services.

 Flexibility in Operations WIC Program regulations provide flexibility with physical presence requirements, certification periods, and eWIC benefit issuance. Approved flexibilities should be exercised to the fullest extent allowed and reasonable to meet the needs of individuals affected by the disaster and to minimize disruption to services.

 Participant Flexibilities. • Physical Presence. Applicants with a serious illness that may be exacerbated by coming into the WIC clinic may be exempt from the physical presence requirement. • Extended Certification Period. Local agencies may extend the certification period for infants and children up to 30 days when scheduling difficulties occur. • Remote Food Benefit Issuance. Local agencies may issue electronic food benefits to participants not physically present per remote food benefit issuance guidance.

 Administrative Flexibilities. • Local agencies may operate temporary alternative clinic sites for program services. • The State WIC Director or designee has the authority to authorize State-Assisted Issuance (SAI) of food benefits to eligible participants during an emergency. − During SAI, the Community Nutrition Services Section (CNSS) will notify each impacted local agency the time frame for SAI and list of participants to whom benefits have been issued.

 Food Benefits During an emergency, the full maximum monthly allowance of prescribed supplemental foods across all food packages must be made available to participants if medically or nutritionally warranted.

 Adjusted Food Package. • If a participant impacted by a disaster is unable to provide medical documentation for WIC-eligible infant formula/nutritional and local agency staff are unable to externally verify a medical condition that indicates need, one-month issuance of the WIC- eligible infant formula/nutritional may be issued following assessment and documentation. • Local agencies should adjust food prescriptions for participants who are experiencing homelessness or lack access to adequate food storage or preparation facilities.

 Replacement of Destroyed Food Benefits. Redeemed food benefits that were destroyed in a disaster may be eligible for replacement during the same benefit period per the following conditions: • Only the food benefits damaged or destroyed due to a disaster may be replaced. • Replacement does not result in the replacement of prior month benefits.

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NC WIC Program Manual

October 2025 • Quantity of replacement food benefits reflect the pro-rated portion of food benefits for which the participant is eligible. • North Carolina WIC requires a signed statement attesting that the food benefits of a participant have been damaged or destroyed as a result of a disaster. The participant/parent/guardian/caretaker signs the ‘Affidavit Attesting to WIC Food Benefit Loss’ (Attachment 3). • The local agency notifies the CNSS Customer Service Desk to assist with replacement.

 Vendors will not have the option to accept out-of-state WIC benefits.

 Local Agency Plan of Alternate Operating Procedures (PAOP) In conjunction with the Business Continuity Plan (Attachment 5), each local agency must maintain a written Local Agency Plan of Alternate Operating Procedures (PAOP) to ensure a planned, organized, and effective local response for emergency and disaster situations. At a minimum, the procedure must contain written plans addressing the program sub-topics: coordination and communication, benefit issuance and redemption, vendor management, and nutrition services.

Coordination and Communication The local agency must include a written plan to address local agency operations during and after a disaster to coordinate local agency services and internal and external communications with relief organizations, vendors, and CNSS.

 Coordinate in advance with internal and external partners to plan for disaster situations that may interrupt services. At minimum, this includes: • Designation of a disaster contact within the local agency. • Maintenance of current and alternate contact information for local agency staff, community partners and programs, local authorized vendors, and the local agency Regional Nutrition Consultant.

 Outline local agency disaster situation communication protocols to address intended audience, communication method, and notification content. Immediately upon disruption or impact to local agency services, the WIC Director must notify the assigned Regional Nutrition Consultant. If possible for additional communications, identify the responsible staff and consider the frequency of communication or update. • Consider onsite signage, recorded voicemail and text messages, and digital updates.

Benefit Issuance and Redemption The local agency must have a written plan for addressing food benefit issuance and redemption through consideration of:

 Remote certification and benefit issuance.

 Process for requesting replacement EBT cards through any local agency or through contacting the eWIC vendor.

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NC WIC Program Manual

October 2025

 Management and process for participants to request from the local agency replacement of supplemental foods that were damaged or destroyed during a disaster.

Vendor Management

 Plan to address impacts to WIC authorized vendors and method of communication used to relay store closures or changes in operating hours.

Nutrition Services

 Alternate procedures including a plan for providing services when computer systems are down, alternate clinic location and service hours, and use of mobile equipment to provide services (Attachment 5), • Include the consideration for extending the certification period for infants and children up to 30 days to accommodate difficulty in scheduling appointments

 Identify processes for providing Issuance of Verification of Certification (VOC).

 Plan for the provision of breastfeeding promotion and support activities in addition to the issuance and replacement of breast pumps or breastfeeding supplies during disaster response.

15 Chapter 1: INTRODUCTION TO WIC

Section 6: PROGRAM MATERIALS AVAILABLE FROM THE COMMUNITY NUTRITION SERVICES SECTION

NC WIC Program Manual

October 2025 Program Materials Available from the Community Nutrition Services Section

The Community Nutrition Services Section (CNSS) stocks a wide variety of materials used by local agency staff for WIC Program activities, including breastfeeding education and support, program outreach, nutrition education, and vendor management.

A complete list of available materials can be found on the CNSS Materials Requisition Form (DHHS 2507) available at https://www.ncdhhs.gov/ncwic under ‘For Local Agency Staff’. Refer to Chapter 5 for additional information on nutrition education resources.

 Ordering Materials To order materials from CNSS, local agencies complete the CNSS Materials Requisition Form (DHHS 2507) available on the website and email the request to NSBmaterialsreq@dhhs.nc.gov.

When ordering materials, local agencies are requested to:

 coordinate orders with other staff in the agency who use CNSS materials;

 submit no more than one order a month to help with CNSS efficiency in serving all agencies submitting orders; and

 do not order more than a 3-month supply.

 Receiving Materials The Community Nutrition Services Section will fill an order in its entirety and ship requested materials within two to three (2-3) weeks of receiving a requisition form with the following exceptions.

 Materials in Limited Supply. When an item is in limited supply, CNSS will ship only a portion of the quantity ordered. A note regarding limited quantity will be in the comments section of the packing list. The remaining quantity will not be shipped, and the local agency will need to reorder once the item is back in stock.

 Out of Stock Materials. When an item is temporarily out of stock, CNSS will provide notification in the comments section of the packing list that the item is out of stock. The item(s) will need to be reordered by the local agency once the item is back in stock.

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Section 6: PROGRAM MATERIALS AVAILABLE FROM THE COMMUNITY NUTRITION SERVICES SECTION

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October 2025

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Chapter 1: INTRODUCTION TO WIC

Attachment 1

NC WIC Program

October 2009 Log of WIC Program Numbered Memos (sample)

Memo # Date of Memo Date Received Recipient (initials) Subject of Memo and/or Comments

Chapter 1: INTRODUCTION TO WIC

Attachment 1

NC WIC Program

October 2009

(Blank Page)

Chapter 1: INTRODUCTION TO WIC Attachment 2 NC WIC Program Manual October 2025

Separation of Duties Log

Certifier (1-5) (Completed by certifier on the date of certification.) Reviewer (6 – 10) (Reviewer must not be the certifier.) 1. Date of Certification 2. Participant ID 3. Participant Category P-Pregnant B-Breastfeeding PP-Postpartum I-Infant C-Child 4. Fully Breastfed Infant? Y-Yes N-No 5. Signature of Certifier 6. Income Eligibility Determined Appropriately? Y-Yes N-No 7. Nutrition Risk Code(s) valid? Y-Yes N-No 8. Correct Food Package Prescribed/ Issued? Y-Yes N-No 9. Date of Review 10. Signature of Reviewer

Chapter 1: INTRODUCTION TO WIC Attachment 2 NC WIC Program Manual October 2025

Instructions or Completing Separation of Duties Log

For the Certifier:

1. When separation of duties is not possible, the certifying staff member completes the first five columns (1 through 5) on the date that the certification occurs. 2. Enter the date of certification, Crossroads participant ID number, and participant category. 3. Answer the question regarding whether the participant is a fully breastfed infant. For the post record review requirement, all food packages containing infant formula must be reviewed. 4. Sign in the certifier column.

For the reviewer:

1. Within 14 days of the certification date, the designated reviewer will conduct a post review of all non-fully breastfed infant certification records and at least 20 percent of the remaining certification records by completing the remaining five columns (6 through 10). 2. Log into Crossroads and navigate to Income Information under Certification quick links. Expand Income History and review Selected Row Details for the date of the certification being reviewed. Determine if income eligibility was determined appropriately by checking for verification details of adjunctive eligibility; identifying the source, proof, frequency, amount, and duration if not adjunctively eligible; viewing the scanned affidavit if no proof of income exists; or viewing the reason for zero income if zero income was documented. Assess for unexpected or irregular patterns among the certification records reviewed, such as frequent use of zero income or frequent round or repeated numbers in income amounts. Indicate yes or no based on whether income appears to be determined appropriately. (See the WIC Program Manual, Chapter 6B and Attachment 1 for more information.) 3. Navigate to the Care Plan Summary under Care Plan quick links. Expand the care plan for the participant’s record being reviewed. View the assigned risk codes for the certification being reviewed and determine if they are valid. Document findings on the log. 4. Navigate to the Care Plan Detail under Care Plan quick links. Expand the care plan for the participant’s record being reviewed and determine if the correct food package was prescribed by examining the current food prescription. Determine if the prescription consistent with participant category and documentation in the nutrition assessment. Document findings on the log. 5. Enter the date the record was reviewed in the date column and sign in the reviewer column. 6. If the reviewer answered no to any questions, notify the agency’s Regional Nutrition Consultant immediately or no later than within one business day of identification.

Chapter 1: INTRODUCTION TO WIC

Attachment 3 CNSS 6.2023 Page 1

North Carolina WIC Program

AFFIDAVIT ATTESTING TO WIC FOOD BENEFIT LOSS

(NAME of Disaster/ Personal Misfortune) Family ID

Family Issue Date

The North Carolina WIC Program may replace current food benefits for the month of ( ) Month / Year

that were redeemed but damaged or destroyed due to ( ). WIC benefits are current if the Name of Disaster Last Date to Spend (LDTS) is equal to the current day or is in the future. If the LDTS is in the past, the benefits are expired and cannot be replaced. Attestation Signature I understand that by signing and dating this form, I am certifying that the information I am providing is correct. Entiendo que al completer, firmar y fechar en esta forma, certifico que la información que proveo es correcta.

(Participant/Parent/Guardian/Caretaker Signature /Firma) (Date/Fecha)

(Staff Signature) (Date)

Lost Benefits: Food Category Food Subcategory Container Size Quantity 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/ad-3027.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

Chapter 1: INTRODUCTION TO WIC

Attachment 3 CNSS 6.2023 Page 2

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. 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/ad-3027s.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 institución es un proveedor que ofrece igualdad de oportunidades.

Demographics Income Health Information Adjunct program participation: □SNAP □Medicaid □TANF Family size: ____ Number of expected infants: ____ TOTAL family size: ____ Self-declared income or range: $_____________________________ □ Zero-Income Declaration Source Amount Frequency $ $ $ Verification Document: Income Eligible □ Yes □ No Income Verification completed

Staff Signature/Title

Date Pre-pregnancy weight:_________Pre-pregnancy BMI:_________Delivery date:___________Weight at delivery:__________ □Multiple gestation: # of fetuses this pregnancy:____ Outcome:____________________________________ Delivery type: □Vaginal □Cesarean Gravida:______ Para:______ Health Conditions Medications and Supplements Cigarettes per day: three months prior to pregnancy______ Drinks per week: three months prior to pregnancy ______ last trimester______ last trimester ______ postpartum_______ postpartum ______ Height:

Weight:

Date: Collected by / source: BMI:__________ □ Hgb / □ Hct: ____________ Deferred/Exempt Reason:_____________________________________Date:______________ Collected by / source:_______________________________________________________________________________________ Certification Signature I understand that by signing and dating this form, I am certifying that the information I am providing is correct, that I understand my rights and responsibilities as related to the WIC program, and that I understand my right to a fair hearing. Entiendo que al completer, firmar y fechar en esta forma, certifico que la información que proveo es correcta; que entiendo mis derechos y responsabilidades en relación con el programa WIC; y que entiendo mi derecho a una audiencia justa.

Applicant/Parent/Guardian/Caretaker Signature

Date

Anthro/Lab eWIC card # Application Date: Continuity of Services Form WIC: BREASTFEEDING/POSTPARTUM WOMAN □ Certification □ Mid-Certification Assessment (Breastfeeding) □ Home □ Work □ Cellular NC DHHS Revised 5/19 NSB #3305 Proof of identification:_________________________ Telephone #: ( ____ ) ___________________________ Preferred method of contact:____________________ Language: Read:____________Spoken:_____________ Voter Registration: □ Declined □ Form provided □ Ineligible □ Registered Family Assessment: Does anyone smoke inside the home? □ Yes □ No Ethnicity: □ Declared □ Observed □ Hispanic/Latino □ Not Hispanic/Latino Race: □ American Indian or Alaskan Native □ Asian □ Black or African American Address:____________________________________________________ ______________________________________________________ Street

City

Zip Code Proof of residence_________________________________________ □ Foster care □ Homeless □ Migrant Applicant Name: ________________________________________________

Last First MI

DOB:____________________________ Proof of identification ___________________________________

□ Client Present □ Not Present Justification_________________________________ Pregnancy-induced Health Conditions

NC DHHS Revised 5/19 NSB #3305 Care Plan Name:__________________________________________________________Date of Birth:________________________________ WIC Nutrition Risk Criteria Codes (Identify all that apply)_____________________________________________________ Certifier/CPA _____________________________________________________________________________________________ Signature

Title Applicant/Participant/Caretaker Signature/Firma

Date/Fecha Staff Signature

Date AFFIDAVIT FOR PROOF OF IDENTITY, RESIDENCY, and / or INCOME The following is to be completed for certifications when proof of identity, residency, and/or income does not exist, obtaining proof places undue burden to or harm on applicant, or an individual declares that their economic unit has no income. I understand that by completing, signing and dating this form, I am certifying that the information I am providing is correct. I understand that intentional misrepresentation may result in paying the state agency, in cash, the value of the food benefits improperly received. Entiendo que al completer, firmar y fechar en esta forma, certifico que la información que proveo es correcta. Entiendo que proveer información incorrecta intencionalmente puede resultar en tener que devolver a la agencia estatal, en efectivo, el valor de los beneficios de comida recibidos indebidamente. Reason for lack of proof OR zero income declaration ID Residence Income Department of Health and Human Services • Division of Public Health • Nutrition Services Branch www.ncdhhs.gov • www.nutritionnc.com This institution is an equal opportunity provider. 20,000 copies of this public document were printed at a cost of $847.72 or $0.0424 per copy. 07/19 Health Info Dietary & Health Are you breastfeeding? □ No □ Yes Breastfeeding Frequency: ______________________________________________________ If no, have you ever breastfed? □ No □ Yes Age infant stopped breastfeeding _________________________________________ Reason infant stopped breastfeeding _______________________________________ Do you give your baby any formula? □ No □ Yes Amount in 24-hr period: ____________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ Nutrition Education: □ Immunizations □ Tobacco, alcohol and illegal drugs □ Folic acid □ Breastfeeding basics/anticipatory guidance

□ Other ______________________________________________________________________________________ Referrals: _____________________________________________________________________________________________ Goals: ________________________________________________________________________________________________ Food Prescription □ Standard □ Modified _____________________________________________________________________________ Follow-up / Next Appointment: ___________________________________________________________________________ ______________________________________________________________________________________________________

Demographics Income Health Information Adjunct program participation: □SNAP □Medicaid □TANF Family size: ____ Number of expected infants: ____ TOTAL family size:____ Self-declared income or range: $_____________________________ □ Zero-Income Declaration Source Amount Frequency $ $ $ Verification Document: Income Eligible □ Yes □ No Income Verification completed

Staff Signature/Title

Date Birth weight:

Birth length:

Weeks gestation: □ Multiple gestation Hospital discharge weight:

Date: Medical Conditions Medications and Supplements Immunizations: □ Up-to-date □ Not up-to-date □ Unknown □ Referred Feeding complications: □ Length / □ Height:

Weight:

Date:______________ Collected by / source:______________________ BMI (≥ age 2) __________ % BMI / Age: __________ OR % Weight / Length (< age 2) _______________________

□ Hgb / □ Hct:______________Deferred/Exempt reason:_______________________________ Date:____________________ Collected by / source:________________________________________________________________________________________________ Certification Signature I understand that by signing and dating this form, I am certifying that the information I am providing is correct, that I understand my rights and responsibilities as related to the WIC program, and that I understand my right to a fair hearing. Entiendo que al completer, firmar y fechar en esta forma, certifico que la información que proveo es correcta; que entiendo mis derechos y responsabilidades en relación con el programa WIC; y que entiendo mi derecho a una audiencia justa.

Applicant/Parent/Guardian/Caretaker Signature

Date

Anthro/Lab eWIC card # Application Date: Continuity of Services Form WIC: CHILD □ Certification □ Mid-Certification Assessment □ Home □ Work □ Cellular NC DHHS Revised 5/19 NSB #3303 Parent/Guardian □ 1 □ 2 □ Caretaker Name:_________________________________________ DOB:__________________________________________ Relationship to applicant:_________________________ Proof of identification:____________________________ Telephone #: ( ____ ) ___________________________ Preferred method of contact:______________________ Language: Read:____________Spoken:________________ Voter Registration: □ Declined □ Form provided □ Ineligible □ Registered Family Assessment: Does anyone smoke inside the home? □ Yes □ No Last First MI Applicant Name: ________________________________________________

Last First

MI

DOB:____________________________ Sex: □ Male □ Female Proof of identification ___________________________________

Ethnicity: □ Declared □ Observed □ Hispanic/Latino □ Not Hispanic/Latino Race: □ American Indian or Alaskan Native □ Asian □ Black or African American □ Foster care □ Homeless □ Migrant Address:____________________________________________________ ______________________________________________________ Street

City

Zip Code Proof of residence_________________________________________ □ Client Present □ Not Present Justification_________________________________

NC DHHS Revised 5/19 NSB #3303 Dietary & Health Care Plan Name:__________________________________________________________Date of Birth:________________________________ WIC Nutrition Risk Criteria Codes (Identify all that apply)_____________________________________________________________ Certifier/CPA _____________________________________________________________________________________________ Signature/Title

Date Applicant/Participant/Caretaker Signature/Firma

Date/Fecha Staff Signature

Date AFFIDAVIT FOR PROOF OF IDENTITY, RESIDENCY, and / or INCOME The following is to be completed for certifications when proof of identity, residency, and/or income does not exist, obtaining proof places undue burden to or harm on applicant, or an individual declares that their economic unit has no income. I understand that by completing, signing and dating this form, I am certifying that the information I am providing is correct. I understand that intentional misrepresentation may result in paying the state agency, in cash, the value of the food benefits improperly received. Entiendo que al completer, firmar y fechar en esta forma, certifico que la información que proveo es correcta. Entiendo que proveer información incorrecta intencionalmente puede resultar en tener que devolver a la agencia estatal, en efectivo, el valor de los beneficios de comida recibidos indebidamente. Reason for lack of proof OR zero income declaration ID Residence Income Department of Health and Human Services • Division of Public Health • Nutrition Services Branch www.ncdhhs.gov • www.nutritionnc.com This institution is an equal opportunity provider. 20,000 copies of this public document were printed at a cost of $725.35 or $0.0363 per copy. 07/19 Health Info Are you breastfeeding? □ No □ Yes Breastfeeding Frequency: ______________________________________________________ If no, have you ever breastfed? □ No □ Yes Age infant stopped breastfeeding ________________________________________ Reason infant stopped breastfeeding _____________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ Nutrition Education: □ Tobacco, alcohol and illegal drugs □ Other ________________________________________________________ Referrals: ____________________________________________________________________________________________ Goals: ________________________________________________________________________________________________ Food Prescription □ Standard □ Modified _____________________________________________________________________________ Follow-up / Next Appointment: ___________________________________________________________________________ ______________________________________________________________________________________________________

Demographics Income Health Information Adjunct program participation: □SNAP □Medicaid □TANF Family size: ____ Number of expected infants: ____ TOTAL family size: ____ Self-declared income or range: $_____________________________ □ Zero-Income Declaration Source Amount Frequency $ $ $ Verification Document: Income Eligible □ Yes □ No Income Verification completed

Staff Signature/Title

Date Birth weight:

Birth length:

Weeks gestation: □ Multiple gestation Hospital discharge weight:

Date: Medical Conditions Medications and Supplements Immunizations: □ Up-to-date □ Not up-to-date □ Unknown □ Referred Feeding complications: □ < 6 wet diapers per day □ Inadequate stooling (as determined by physician/health professional) □ Difficulty latching on to mother’s breast □ Jaundice □ Weak or ineffective suck Length:

Weight:

Date: Collected by / source: □ Hgb / □ Hct: Deferred/Exempt reason:

Date:

Collected by / source: Certification Signature I understand that by signing and dating this form, I am certifying that the information I am providing is correct, that I understand my rights and responsibilities as related to the WIC program, and that I understand my right to a fair hearing. Entiendo que al completer, firmar y fechar en esta forma, certifico que la información que proveo es correcta; que entiendo mis derechos y responsabilidades en relación con el programa WIC; y que entiendo mi derecho a una audiencia justa.

Applicant/Parent/Guardian/Caretaker Signature

Date

Anthro/Lab eWIC card # Application Date: Continuity of Services Form WIC: INFANT □ Certification □ Mid-Certification Assessment □ Home □ Work □ Cellular NC DHHS Revised 5/19 NSB #3302 Last First MI Parent/Guardian □ 1 □ 2 □ Caretaker Name:_________________________________________ DOB:__________________________________________ Relationship to applicant:_________________________ Proof of identification:____________________________ Telephone #: ( ____ ) _____________________________ Preferred method of contact:______________________ Language: Read:____________Spoken:________________ Voter Registration: □ Declined □ Form provided □ Ineligible □ Registered Family Assessment: Does anyone smoke inside the home? □ Yes □ No Applicant Name: ________________________________________________

Last First

MI

DOB:____________________________ Sex: □ Male □ Female Proof of identification ___________________________________

Ethnicity: □ Declared □ Observed □ Hispanic/Latino □ Not Hispanic/Latino Race: □ American Indian or Alaskan Native □ Asian □ Black or African American Address:____________________________________________________ ______________________________________________________ Street

City

Zip Code Proof of residence_________________________________________ □ Foster care □ Homeless □ Migrant □ Client Present □ Not Present Justification_________________________________

NC DHHS Revised 5/19 NSB #3302 Health Info Dietary & Health Care Plan Name:__________________________________________________________Date of Birth:________________________________ Are you breastfeeding? □ No □ Yes Breastfeeding Frequency: ______________________________________________________ WIC Nutrition Risk Criteria Codes (Identify all that apply)_____________________________________________________ Certifier/CPA ______________________________________________________________________________________ If no, have you ever breastfed? □ No □ Yes Age infant stopped breastfeeding _________________________________________ Reason infant stopped breastfeeding _______________________________________ Do you give your baby any formula? □ No □ Yes Amount in 24-hr period: ___________________________________________ Nutrition Education: □ Tobacco, alcohol and illegal drugs □ Other _________________________________________________________ Referrals: _____________________________________________________________________________________________ Goals: ________________________________________________________________________________________________ Food Prescription □ Standard □ Modified _____________________________________________________________________________ Follow-up / Next Appointment: ___________________________________________________________________________ ______________________________________________________________________________________________________ Signature/Title

Date Applicant/Participant/Caretaker Signature/Firma

Date/Fecha Staff Signature

Date AFFIDAVIT FOR PROOF OF IDENTITY, RESIDENCY, and / or INCOME The following is to be completed for certifications when proof of identity, residency, and/or income does not exist, obtaining proof places undue burden to or harm on applicant, or an individual declares that their economic unit has no income. I understand that by completing, signing and dating this form, I am certifying that the information I am providing is correct. I understand that intentional misrepresentation may result in paying the state agency, in cash, the value of the food benefits improperly received. Entiendo que al completer, firmar y fechar en esta forma, certifico que la información que proveo es correcta. Entiendo que proveer información incorrecta intencionalmente puede resultar en tener que devolver a la agencia estatal, en efectivo, el valor de los beneficios de comida recibidos indebidamente. Reason for lack of proof OR zero income declaration ID Residence Income Department of Health and Human Services • Division of Public Health • Nutrition Services Branch www.ncdhhs.gov • www.nutritionnc.com This institution is an equal opportunity provider. 20,000 copies of this public document were printed at a cost of $821.48 or $0.0411 per copy. 07/19 ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________

NC DHHS Revised 5/19 NSB #3304 Demographics Income Adjunct program participation: □SNAP □Medicaid □TANF Family size: ____ Number of expected infants: ____ TOTAL family size: ___ Self-declared income or range: $_____________________________ □ Zero-Income Declaration Source Amount Frequency $ $ $ Verification Document: Income Eligible □ Yes □ No Income Verification completed

Staff Signature/Title

Date Pre-pregnancy weight:_________Pre-pregnancy BMI:_________ Expected Delivery date:___________First Prenatal Visit Date:__________Medical Home:___________________________ □Multiple Gestation: # of fetuses this pregnancy:_______ Gravida:______ Para: ______ Health Conditions Medications and Supplements Cigarettes per day: 3 months prior to pregnancy ______ Drinks per week: 3 months prior to pregnancy ______

Today: ______ Height:

Weight:

Date: Collected by / source: Weeks gestation:__________ Expected weight gain:__________Actual weight gain:__________ □ Hgb / □ Hct: ____________ Deferred/Exempt Reason:_____________________________________Date:______________ Collected by / source:_______________________________________________________________________________________ Certification Signature I understand that by signing and dating this form, I am certifying that the information I am providing is correct, that I understand my rights and responsibilities as related to the WIC program, and that I understand my right to a fair hearing. Entiendo que al completer, firmar y fechar en esta forma, certifico que la información que proveo es correcta; que entiendo mis derechos y responsabilidades en relación con el programa WIC; y que entiendo mi derecho a una audiencia justa.

Applicant/Parent/Guardian/Caretaker Signature

Date

Anthro/Lab eWIC card # Application Date: Continuity of Services Form WIC: PREGNANT WOMAN □ Certification □ Home □ Work □ Cellular Pregnancy-induced Health Conditions Ethnicity: □ Declared □ Observed □ Hispanic/Latino □ Not Hispanic/Latino Race: □ American Indian or Alaskan Native □ Asian □ Black or African American Address:____________________________________________________ ______________________________________________________ Street

City

Zip Code Proof of residence_________________________________________ □ Foster care □ Homeless □ Migrant Proof of identification:_________________________ Telephone #: ( ____ ) ___________________________ Preferred method of contact:____________________ Language: Read:____________Spoken:_____________ Voter Registration: □ Declined □ Form provided □ Ineligible □ Registered Family Assessment: Does anyone smoke inside the home? □ Yes □ No Health Information □ Client Present □ Not Present Justification_________________________________ Applicant Name: ________________________________________________

Last First MI

DOB:____________________________ Proof of identification ___________________________________

NC DHHS Revised 5/19 NSB #3304 Health Info Dietary & Health Care Plan Name:__________________________________________________________Date of Birth:________________________________ WIC Nutrition Risk Criteria Codes (Identify all that apply)_____________________________________________________ Certifier/CPA ______________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ Signature/Title

Date Applicant/Participant/Caretaker Signature/Firma

Date/Fecha Staff Signature

Date AFFIDAVIT FOR PROOF OF IDENTITY, RESIDENCY, and / or INCOME The following is to be completed for certifications when proof of identity, residency, and/or income does not exist, obtaining proof places undue burden to or harm on applicant, or an individual declares that their economic unit has no income. I understand that by completing, signing and dating this form, I am certifying that the information I am providing is correct. I understand that intentional misrepresentation may result in paying the state agency, in cash, the value of the food benefits improperly received. Entiendo que al completer, firmar y fechar en esta forma, certifico que la información que proveo es correcta. Entiendo que proveer información incorrecta intencionalmente puede resultar en tener que devolver a la agencia estatal, en efectivo, el valor de los beneficios de comida recibidos indebidamente. Reason for lack of proof OR zero income declaration ID Residence Income Date (mm/yy) Outcome Weeks gestation Birth weight/length Pregnancy History Department of Health and Human Services • Division of Public Health • Nutrition Services Branch www.ncdhhs.gov • www.nutritionnc.com This institution is an equal opportunity provider. 20,000 copies of this public document were printed at a cost of $896.72 or $0.0448 per copy. 07/19 Nutrition Education: □ Tobacco, alcohol and illegal drugs □ Folic acid □ Breastfeeding basics/anticipatory guidance

□ Healthy eating during pregnancy □ Other ___________________________________________________________ Referrals: _____________________________________________________________________________________________ Goals: ________________________________________________________________________________________________ Food Prescription □ Standard □ Modified _____________________________________________________________________________ Follow-up / Next Appointment: ___________________________________________________________________________ ______________________________________________________________________________________________________

Chapter 1: INTRODUCTION TO WIC

Attachment 5

CNSS, 10.2025

1

NC WIC Program: Business Continuity Plan

Under the plan of alternate operating procedures, the NC WIC Program Business Continuity Plan guides local agency preparations and actions for the continuation of WIC services in the event that local agency Crossroads system access is disrupted for an uncertain duration. Note: In the event of a statewide outage, business operations will cease until such a time that Crossroads is restored.

Planning It is critical to plan ahead for potential disruptions to local agency (LA) access to Crossroads by: • Maintaining an updated Local Agency Plan of Alternate Operating Procedures (WPM, Chapter 1, Section 5), • Establishing working partnerships with neighboring local WIC agencies that may be able to assist in providing participant services during disruption, • Considering the purchase and maintenance of technology that may serve as back-up during an outage including a work-assigned cell phone or laptop for critical WIC Program staff, • Ensuring that the local agency has on-hand the following resources as ordered from CNSS or as linked on the Community Nutrition Services Section (CNSS) website under NC WIC Program: Business Continuity Plan: ­ ‘Continuity of Services Form’ (DHHS 3302, 3303, 3304, 3305) ­ ‘NC WIC Program Guidance: Emergency and Disaster Situations’ ­ Growth charts and prenatal weight gain charts ­ Required NC WIC Program Notice Template

Provision of WIC Services by the LA

The LA must continuously update the RNC and CSD per system access status (including internet, phone, fax status) and provides alternative LA contact information. • It is recommended that the LA share with CNSS a list of all employees (name and position/role) and Crossroads User ID’s.

If phone, fax, and/or email service are available in the LA, daily: • The CSD faxes the Detail Clinic Daily Appointment Schedule to the LA. • The LA provides services to the maximum extent possible, documenting information on the ‘Continuity of Services Form’. • The LA faxes ‘Continuity of Services Form’ completed to the WIC Nutrition Services Unit (WNSU) at fax#: 984-236-8298. • WNSU staff enter information into Crossroads from the completed ‘Continuity of Services Form’ at the level required to complete certification or continue services within two (2) business days. WNSU supported WIC services include: − Certification of applicant / participant; − Update to demographic or personal information of the applicant / participant; If Crossroads is NOT available in the local WIC agency, immediately: • Check with local IT support to determine if the interruption is a local problem • Notify the Regional Nutrition Consultant (RNC) • Notify the CNSS Customer Service Desk (CSD)

Chapter 1: INTRODUCTION TO WIC

Attachment 5

CNSS, 10.2025

2

− Revision to the: o WIC food prescription of the applicant / participant o number of months of food benefits to be issued; − Activate and/or replace an eWIC card; and/or − Apply the “Extend Certification” feature as appropriate. Note: Incomplete data entered on the Continuity of Service Forms will delay CNSS actions. It is recommended for local agency and CNSS staff coordinate communication while actively working under the Business Continuity Plan. • The CSD will issue participant food benefits or modify issued food benefits then share with the LA a ‘NC WIC Program Notice’ and family ‘Shopping List Remaining Benefits’ for participants served, as applicable. • The LA provides the participant with the NC WIC Program Notice and ‘Shopping List Remaining Benefits’, as applicable.

If phone, fax, and email service NOT available in the LA, daily: Note: At this level of service interruption, it is likely that food benefits issuance will be delayed. • The CSD provides the Detail Clinic Daily Appointment Schedule to the LA as able. • The LA provides services to the maximum extent possible, documenting information on the ‘Continuity of Services Form’. • LA staff communicates the participant information entered on the Continuity of Services Form to WNSU staff for entry into Crossroads. • If local outages extend beyond five days, LA follows their Local Agency Plan of Alternate Operating Procedures (WPM Chapter 1, Section 5) for providing services through alternative processes. − As applicable: For LA’s receiving nutrition product orders during this time, the requirement for the LA to notify CNSS of order receipt remains time-sensitive.

Crossroads Service is Restored When the service to the Crossroads system is restored, the LA must: • Enter remaining data from the Continuity of Services Forms into the Crossroads participant record, • Scan the Continuity of Services Form into the Crossroads participant record, and • Schedule future appointments in communication with participant/family.