Policy and Procedure Manual Volume 1, Chapter 2 Program Compliance

Washington State WIC Nutrition Program DOH 960-367 May 2020

This institution is an equal opportunity provider. Washington State WIC Nutrition Program doesn’t discriminate.

For persons with disabilities, this document is available on request in other formats. To submit a request, please call 1-800-841-1410 (TDD/TTY 1-800-833-6388).

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Program Compliance | Page i Program Compliance

CONTENTS Section 1: References and Definitions 1 References ...................................................................................................................................... 1 Definitions ....................................................................................................................................... 2 Section 2: Participant Violations and Sanctions 3 POLICY: Participant Violations and Sanctions ............................................................................. 3 Section 3: State Staff Responsibilities 4 POLICY: State Program Compliance Unit Staff Investigate, Make Determinations and Initiate Follow-up for Participant Rule Violations ........................................................ 4 POLICY: Claims and Payments ...................................................................................................... 7 POLICY: Disqualification................................................................................................................ 8 POLICY: Using a Substitute Caretaker Instead of Disqualification........................................... 10 Section 4: Clinic Responsibilities 14 POLICY: Prevent Dual Participation ........................................................................................... 14 POLICY: Report Incidents or Suspected Rule Violations........................................................... 15 POLICY: Role of Clinic Coordinator or Designee for Incident or Rule Violation Follow-up .... 17 POLICY: Clinic Staff Cooperate With State Program Compliance Unit Staff During Investigations ................................................................................................................ 19 POLICY: Educational Follow-up .................................................................................................. 21 Section 5: Clinic Staff Compliance 23 POLICY: Clinic Staff Compliance ................................................................................................. 23 POLICY: WIC Services for WIC Staff, Family or Friends............................................................. 25 POLICY: Conflict of Interest ........................................................................................................ 28 Section 7: Appendix 31 Agreement for Clinic Staff ............................................................................................................ 33

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Program Compliance | Page 1 Section 1: References and Definitions

References

USDA-FNS Code of Federal Regulations Citations: 7 CFR 246.2

Definitions. 7 CFR 246.3

Administration. 7 CFR 246.4

State plan. 7 CFR 246.5

Selection of Local Agencies. 7 CFR 246.6

Agreements with local agencies. 7 CFR 246.7

Certification of participants. 7 CFR 246.12(u) Delivery systems; participant violations and sanctions. 7 CFR 246.13 Financial management system. 7 CFR 246.14 Program costs. 7 CFR 246.16 Distribution of funds. 7 CFR 246.18 Administrative review of state agency actions. 7 CFR 246.19 Management evaluation and monitoring review. 7 CFR 246.23 Claims and penalties.

Clarification of the WIC Food Delivery Systems Final Rule: Question and Answer Policy Memorandum 806-G, Revision 1, June 17, 2003. Washington Administrative Code (WAC) 246-790 (see sections 500 – 570). Contract between the local agency and the Washington State Department of Health (Washington WIC Program). Washington WIC Manual. Local agency policy and procedures.

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Definitions

These definitions will help you understand policy and procedure in this chapter: Caretaker: The person a custodian gives permission to bring an infant or child participant to WIC appointments, pick up food benefits from the clinic and shop for WIC foods. Commodity Supplemental Food Program (CSFP): This program provides food products to eligible participants in limited areas of Washington State. Federal rules say a person cannot be on WIC and CSFP at the same time. A family could have some people on WIC and others on CSFP. CSFP is different from the Food Distribution Program on Indian Reservations (FDPIR) and The Emergency Food Assistance Program (TEFAP). The Commodity Supplemental Food Program (CSFP) now only available to seniors in Washington State. Educational follow-up: An interaction with a participant, parent guardian, or caretaker as directed by state staff. The interaction focuses on information about a complaint or a participant violation. The follow up may include reviewing WIC approved foods, how to use the WIC Card or having the person sign the Rights and Responsibilities form. Fair Hearing: A Department of Health Office of Adjudicative Hearing Unit proceeding where a participant who received a Notice of Violation from the Washington State WIC Nutrition Program has the opportunity to present his or her case before a Health Law Judge. Incident: A specific action or occurrence that may violate the laws and rules pertaining to WIC. State or clinic staff may receive a complaint about someone who might have broken WIC rules. Learn more about what is considered an incident by visiting the DOH – WIC website page “Examples of WIC Incidents to Report.” Parent/Guardian: The primary person seeking WIC services on a child’s behalf. A parent guardian can be a: a) Custodian of a child participant, a custodian can be a parent or a third party appointed by a court; b) Person authorized by the custodian (typically a relative or friend); c) Person acting in absence of the custodian when the custodian isn’t available to designate a caretaker. • See Volume 1, Chapter 25 – Legal Considerations and Confidentiality for more information. Participant: A woman, infant or child receiving WIC benefits. Substitute Caretaker: A person approved by the Washington State WIC Nutrition Program to receive WIC benefits on behalf of a participant who is an infant, child or woman under 18 years of age instead of disqualification.

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Program Compliance | Page 3 Section 2: Participant Violations and Sanctions

POLICY: Participant Violations and Sanctions

When a WIC participant, parent guardian, caretaker or proxy violates WIC regulations or policy, state Program Compliance Unit staff will impose the appropriate sanction which may include the following:

• Notice of Violation • Claim • Disqualification

See the Washington Administrative Code (WAC) 246-790, sections 500 – 570 for more information about participant rules, violations and sanctions.

PROCEDURE:

A. State Program Compliance Unit staff investigate suspected violations and makes a recommendation to the State Program Integrity and Monitoring Section Manager. If the State Program Integrity and Monitoring s Section Manager makes a determination that a violation occurred, he or she will direct state Program Compliance Unit staff to notify the participant and clinic coordinator or designee of the outcome and follow-up in writing.

• See the “State Program Compliance Unit Staff Investigate, Make Determinations and Initiate Follow-up for Participant Violations” policy in this chapter.

B. Clinic coordinator or designee performs follow-up as directed by state staff.

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| Page 4 Program Compliance Section 3: State Staff Responsibilities

POLICY: State Program Compliance Unit Staff Investigate, Make Determinations and Initiate Follow-up for Participant Rule Violations

The state Program Integrity and Monitoring Section, Program Compliance Unit is the lead for: • Investigating reports of participant violations. • Making a recommendation to the state Program Integrity and Monitoring Section Manager based on the outcome of the investigation.

The state Program Integrity and Monitoring Section Manager is the authority for: • Determining if a rule violation occurred. • Directing the type of sanctions for rule violations. • Approving specific rule violation follow-up actions including referrals to clinic staff for participant follow-up.

In addition to the actions listed above for participants, state Program Compliance Unit staff may also advise, educate or warn clinic staff or grocery store employees about program requirements for fair and equal treatment of participants and following state and federal rules, policies and procedures.

PROCEDURE:

State Program Compliance Unit staff:

A. Receive, investigate and make a determination for reports of suspected rule violations. Reports are received in a variety of ways, including:

1. The online WIC Incident Report Form.

2. Emails to the state office at WICComplaints@doh.wa.gov.

3. Phone calls to the state office at 1-800-841-1410.

4. Comments via the Department of Heath WIC website.

5. Mail to the Department of Health WIC Nutrition Program.

B. The Program Integrity and Monitoring Section (PIMS) manager, who oversees the state Program Compliance Unit, makes the determination if a violation occurred.

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Program Compliance | Page 5 1. The PIMS manager makes a determination of rule violation based on federal and state rules and the evidence.

2. The PIMS manager signs a Notice of Violation and Sanction letter.

C. The state Program Compliance Unit supervisor communicates to participants and clinic staff when a rule violation and sanction has been determined. Sanctions may include:

• Notice of Violation • Monetary claim for repayment • Disqualification o A substitute caretaker may be designated instead of disqualification. See the “Using a Substitute Caretaker Instead of Disqualification” for more information.

D. Instruct the clinic coordinator or designee about the required follow-up action for a rule violation.

1. The state Program Compliance Unit supervisor sends the original Notice of Violation and Fair Hearing Brochure to the participant and a copy of the Notice of Violation to the clinic coordinator or designee.

a. The clinic coordinator or designee files and keeps the Notice of Violation for four years.

b. The state Program Compliance Unit supervisor may instruct the clinic coordinator or designee to give the participant or parent guardian the Notice of Violation at the next appointment if mail delivery of the letter from the state WIC office is unsuccessful.

2. Clinic coordinator or designee conduct follow-up actions which may include education about program rules or approved WIC foods using the Notice of Violation letter at the next appointment.

E. Instruct the clinic coordinator or designee about required follow-up actions for a rule violation warning.

1. State Program Compliance Unit staff send the original Notice of Violation warning letter to the participant and a copy of the letter to the clinic coordinator or designee.

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| Page 6 Program Compliance a. The clinic coordinator or designee file and keep the Notice of Violation for four years.

b. The state Program Compliance Unit supervisor may instruct the clinic coordinator or designee to give the participant or parent guardian the Notice of Violation warning letter at the next appointment if mail delivery of the letter from the state WIC office is unsuccessful.

2. Clinic coordinator or designee conduct follow-up actions which may include education about program rules or approved WIC foods using the Notice of Violation letter at the next appointment.

F. Discuss the option of a substitute caretaker with clinic staff when appropriate.

Note: When the participant is disqualified, the Notice of Violation will contain information about the disqualification. This includes the disqualification period, steps to take to avoid disqualification, for example, paying the claim if needed, how to request a hearing (using the included Fair Hearing Brochure) and the WIC Program Substitute Caretaker process and form. See the “Using a Substitute Caretaker Instead of Disqualification” policy in this chapter.

G. Ask the clinic coordinator or designee to document all pertinent information in the participant’s computer file.

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Program Compliance | Page 7 POLICY: Claims and Payments

WIC participants or parent guardians must repay the Department of Health, Accounts Receivable for the full dollar value of WIC foods received or used improperly or selling these items.

State Program Compliance Unit staff: • Send the participant a Notice of Violation and claim notice, when appropriate, and the Fair Hearing Brochure • Manage all aspects of the Notice of Violation and claim processes • Notify the clinic coordinator or designee when the participant or parent guardian pays the claim amount in full

Clinic staff must not: • Accept cash from the participant or parent guardian for claim payments • Pay the claim amount for the participant or parent guardian • Mail payments for the participant or parent guardian

PROCEDURE:

Clinic Coordinator or Designee:

A. Follows instructions as directed by state Program Compliance Unit staff.

B. Directs the participant or parent guardian to contact the state Program Compliance Unit staff at 1-800-841-1410 if there are any questions about claims and payments that clinic staff can’t answer.

C. Documents pertinent information related to participant Notice of Violation and claim in the participant’s file, scans the documents received from the state Program Compliance Unit staff related to participant Notice of Violation and destroys them after scanning.

1. Use the Family Alert to notify staff to look at the participant’s Individual Care Plan for more information about participant Notice of Violation and claim.

2. Use the participant’s Individual Care Plan to document follow-up completed with the participant or parent guardian and detailed or confidential information.

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| Page 8 Program Compliance POLICY: Disqualification

The Program Integrity and Monitoring Section Manager oversees the state Program Compliance Unit and makes the decision to implement a Notice of Violation and sanctions according to federal and state rules for participant rule violations. (See reference to the Washington Administrative Code (WAC 246-790).

State Program Compliance Unit staff:

• Notify the participant or parent guardian about a Notice of Violation, disqualification or claim and the right to a Fair Hearing. • Require the participant or parent guardian to serve the full disqualification period when no claim is associated with the sanction, unless state staff have approved a substitute caretaker in lieu of disqualification for an infant or child participant. o See the “Using a Substitute Caretaker Instead of Disqualification” policy for information about using a Substitute Caretaker for an infant or child instead of disqualification.

Clinic coordinator or designated staff must:

1. Not terminate a participant or parent guardian for rule violation unless directed to do so by state Program Compliance Unit staff.

2. Not issue WIC benefits or breast pumps during the disqualification unless authorized by state Program Compliance Unit staff. • See Volume 1, Chapter 20 – Notification, Fair Hearings and Civil Rights for more information.

3. As directed by state Program Compliance Unit staff, issue monthly food benefits to participants or parent guardians who have received a Notice of Violation, Disqualification or Claim letter.

The participant or parent guardian must be allowed to reapply for WIC when any of the following three conditions exist:

1. You have received notification from state Program Compliance Unit staff that the disqualification period is over.

2. You have received notification from state Program Compliance Unit staff that the participant or parent guardian paid the claim amount in full before the end of a disqualification period.

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Program Compliance | Page 9 • See the “Claims and Payments” policy for more information.

3. The disqualified participant is a child whose household and parent guardian has changed. • The disqualification must not follow the child to the new household. Examples include when custody of the child changes to another parent, as in cases of divorce; or foster care placement. • See the “Using a Substitute Caretaker Instead of Disqualification” policy for information about using a Substitute Caretaker for an infant or child instead of disqualification when custody of the child hasn’t changed.

4. Staff must consult with state Program Compliance Unit staff when household members of a disqualified participant apply for WIC. • Assess these applicants for WIC eligibility according to program guidelines. • A new Substitute Caretaker form will be needed for the additional participant.

PROCEDURE:

Clinic staff:

A. Follow instructions from state Program Compliance Unit staff.

B. Call your contact at the state Program Compliance Unit if you have any questions using 1-800-841-1410.

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| Page 10 Program Compliance POLICY: Using a Substitute Caretaker Instead of Disqualification

State Program Compliance Unit staff have the option to allow a substitute caretaker instead of disqualifying infants, children, and women less than 18 years of age.

The substitute caretaker must:

1. Be approved by state Program Compliance Unit staff 2. Be authorized by the disqualified parent guardian

During the entire disqualification or current eligibility period the approved substitute caretaker must:

1. Agree to follow WIC rules and sign the Rights and Responsibilities (R & R) form 2. Attend certification and nutrition education appointments with the participant 3. Have the WIC Card issued to them 4. Use the WIC Card at the store

Note: State Program Compliance Unit staff determine on a case-by-case basis if the substitute caretaker must be responsible for all WIC functions on behalf of all participants in the group or just the disqualified participant.

If there is a claim associated with the disqualification, and the disqualified participant or parent guardian pays the claim in full prior to the end of the disqualification period, staff must allow the person to resume their role of parent guardian when reapplying for WIC benefits.

Note: The participant or parent guardian must serve the full disqualification period when no claim is associated with the sanction.

• See the “Disqualification” policy in this chapter for more information.

Staff must include the disqualified parent guardian’s income for income determinations for any children in that household.

• If the substitute caretaker is in a different household their income is not included in the participant’s income eligibility determination. • See Volume 1, Chapter 6 – Income for more information about income assessment and the definition of household.

PROCEDURE:

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Program Compliance | Page 11

A. State Program Compliance Unit staff:

1. Follows policies and procedures in Volume 1, Chapter 25 - Legal Considerations and Confidentiality when defining parent guardians, caretakers and designating and using substitute caretakers.

2. Sends a WIC Program Substitute Caretaker Authorization Form to the disqualified parent guardian with the Notice of Violation.

a. The letter includes instructions for the parent guardian to complete the form and send it back to the state WIC office.

b. Use a separate form for each child in the household affected by the parent guardian’s violation.

3. Reviews the completed form and consults with the clinic coordinator or designee on the use of a substitute caretaker.

4. Decides whether or not to approve a substitute caretaker.

5. Sends a letter to the disqualified parent guardian and the substitute caretaker indicating:

a. If the substitute caretaker is approved.

b. The beginning and ending dates of the substitute caretaker’s authorization for each child in the household.

6. Imposes the disqualification if the participant or parent guardian refuses to have a substitute caretaker or doesn’t return the authorization form within the time requested.

7. If the parent guardian only authorizes the person for the current certification period, state staff will decide whether or not to approve a subsequent substitute caretaker if requested, or impose the disqualification after the end of the current certification period.

8. Notifies the clinic coordinator or designee when approving a substitute caretaker instead of disqualification, including the following information:

• begin and end dates of the disqualification period,

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| Page 12 Program Compliance • the substitute caretaker’s name, address and phone number (if available), • language spoken and written, and

9. Designates the substitute caretaker for the amount of time chosen by the disqualified parent guardian.

10. Keeps the original copy of the WIC Program Substitute Caretaker Authorization Form and sends a copy to the clinic coordinator or designee.

B. Clinic coordinator or designee:

1. Receives and scans the WIC Program Substitute Caretaker Authorization Form into the participant’s file and destroys the copy received from state Program Compliance Unit staff.

2. Checks if the substitute caretaker information is in the participant’s file.

• Contact state Program Compliance Unit staff if the substitute caretaker information isn’t in the participant’s computer file.

3. Reviews the Rights and Responsibilities form with the substitute caretaker and has the substitute caretaker sign a paper copy of the form and scan it into Cascades. Give the original, signed Rights and Responsibilities form to the substitute caretaker.

• See Volume 1, Chapter 7 – Rights and Responsibilities.

4. Provides information about WIC foods and how to use the WIC Card.

• See Volume 1, Chapter 22 – Issue WIC Food Benefits • See Volume Chapter 23 – WIC Foods • The WICShopperApp, Shopping List, and Shopping Guide are examples of materials to provide to the substitute caretaker with information about WIC foods and using the WIC Card.

5. Notifies state Program Compliance Unit staff if the substitute caretaker can’t fulfill this duty as specified in the WIC Program Substitute Caretaker Authorization Form; for example, if the substitute caretaker goes on an extended vacation, etc.

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Program Compliance | Page 13 6. Provides additional information to state Program Compliance Unit staff if clinic staff suspect the substitute caretaker of participant violations. For example, if staff are concerned that the participant or participants aren’t receiving the WIC foods.

Note: See Volume 1, Chapter 25 - Legal Considerations and Confidentiality for additional information about designating and using substitute caretakers.

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| Page 14 Program Compliance Section 4: Clinic Responsibilities

POLICY: Prevent Dual Participation

Staff must:

1. Tell participants or parent guardians at each certification, subsequent certification, transfer-in or transfer-out that dual participation is against WIC rules.

• This information is on the Rights and Responsibilities form.

Dual participation is when the participant or parent guardian:

• Redeems more WIC benefits than allowed per month in the same WIC clinic, • Redeems more WIC benefits than allowed per month in two or more WIC clinics, or • Gets WIC benefits and the Commodity Supplemental Food Program (CSFP) food at the same time. Clinic staff have an important role in preventing dual participation.

PROCEDURE:

Staff:

A. Tell participants or parent guardians at each certification, subsequent certification, transfer-in or transfer-out that dual participation is against WIC rules.

1. Follow policies and procedures in these chapters:

• Volume 1, Chapter 7 – Rights and Responsibilities • Volume 1, Chapter 18 – Certification • Volume 1, Chapter 21 - Transfers/Verification of Certification

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Program Compliance | Page 15 POLICY: Report Incidents or Suspected Rule Violations

Staff must report any incidents or suspected WIC rule violations to the state WIC Program staff within 5 business days.

This includes incidents or suspected WIC rule violations by participants, parent guardians, caretakers, proxies, grocery store employees, clinic staff and other persons.

PROCEDURE:

Staff:

A. Report suspected violations to state staff within 5 business days. For example:

1. WIC participant, parent guardian, caretaker or proxy doing any of the WIC participant violation and sanction actions listed in the Washington Administrative Code (WAC) 246-790 (see sections 500 – 570).

• Follow your internal clinic or agency safety procedures if you are concerned about your safety.

2. Grocery store employee doing any of the following :

a. Offering or allowing substitution of non-WIC food when a person uses a WIC Card including selling more of a WIC food than what is available in the participant’s electronic benefit account (EBA).

b. Not following WIC rules for using WIC Cards.

c. Treating a WIC participant, parent guardian, caretaker, or proxy unfairly or poorly because of their race, color, national origin, sex, age or disability.

• Also see vendor violations listed in 7 CFR 246.12, Washington Administrative Code (WAC) 246-790 (see sections 001 – 127 for Vendors) and the vendor contract.

3. Staff person doing any of the following: (See the “Clinic Staff Compliance” policy in this chapter for more information.)

a. Knowingly certifying a person who isn’t eligible for WIC; for example the person isn’t income eligible.

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b. Giving food benefits to anyone who isn’t eligible for WIC.

c. Issuing food benefits to themselves, a family member or friend. See Volume 1, Chapter 22 – Issue WIC Food Benefits for more information.

d. Creating fictional participants and issuing food benefits.

e. Treating a WIC participant or parent guardian unfairly or poorly because of their race, color, national origin, sex, age or disability.

4. Talk to the clinic coordinator or PIMS PCU staff if you’re concerned about an incident and need help or more information about WIC rules.

B. Report suspected violations to state staff using one of the following methods:

1. Completing the online WIC Incident Report Form.

2. Send an email to the state WIC office at WICComplaints@doh.wa.gov to report a violation or to ask questions or get more information about WIC rules.

3. Call the state WIC office at 1-800-841-1410 and ask to report incidents or suspected rule violations.

• Grocery store employees and the public can report suspected violations using these methods also.

C. Provide feedback about general concerns, suggestions or compliments to the WIC Program by using one of the following methods:

1. Email the state WIC office at wic@doh.wa.gov.

2. Call the state WIC office and ask to talk with someone about your concern, suggestion or compliment at 1-800-841-1410.

• Grocery store employees and the public can provide feedback using these methods also.

Note: It’s important to share suggestions, concerns and feedback. These issues could provide the WIC Program with important information. In some cases this information could result in an investigation, Notice of Violation and sanction.

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Program Compliance | Page 17 POLICY: Role of Clinic Coordinator or Designee for Incident or Rule Violation Follow-up

State Program Compliance Unit staff contact the clinic coordinator or designee for incident or rule violation follow-up.

The clinic coordinator or designee must be able to respond to state staff requests for information and be familiar with this policy and procedure and participant rules in 7 CFR 246, Washington Administrative Code 246-790 and state WIC office policies or memos.

The clinic coordinator’s or designee’s role is to:

• Conduct follow-up activities with the participant or parent guardian as directed by state staff. • Assure all incidents or suspected rule violations are reported to the state in a timely way. • Cooperate with state staff as they conduct investigations and perform requested follow- up activities. See the “Clinic Staff Cooperate with State Staff During Investigations” policy.

PROCEDURE:

The clinic coordinator or designee:

A. Receives training and instruction about how to prevent, report and follow-up on participant incidents or rule violations.

B. Maintains knowledge of all current policies and memos from the state WIC office.

C. Performs follow-up with the participant or parent guardian according to instructions from state Program Compliance Unit staff or other state staff. This may include:

1. Provide educational follow-up in the participant’s or parent guardian’s primary language; for example, arranges interpreters, orders materials in the appropriate language and promotes use of the telephone language interpretation service contracted by the state WIC office.

2. Provide a paper copy of the Notice of Violation if requested by state staff.

3. Work with state Program Compliance Unit staff to implement an approved substitute caretaker if needed.

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| Page 18 Program Compliance Note: State Program Compliance Unit staff are available to assist with incident or rule violation follow-up.

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Program Compliance | Page 19 POLICY: Clinic Staff Cooperate With State Program Compliance Unit Staff During Investigations

The clinic coordinator or designee must cooperate with participant investigations and follow-up as directed by state staff. An investigation is initiated by state Program Compliance Unit staff only when there is a suspected rule violation.

Staff must not intentionally compromise or interfere with any investigation. This includes, but isn’t limited to the following:

1. Don’t warn the participant or parent guardian about an investigation.

2. Don’t coach or direct the participant or parent guardian on what action to take or how to respond when contacted by state staff.

3. Don’t withhold information or destroy documents relevant to an investigation.

4. Don’t make any changes to the participant record except as directed by state Program Compliance Unit staff.

5. Don’t make any changes to participant services such as food benefit issuance, scheduled services, or future appointments except as directed by state Program Compliance Unit staff.

State Program Compliance Unit staff will make contact with the participant or parent guardian about the investigation.

PROCEDURE:

The clinic coordinator or designee:

A. Receives notification from state Program Compliance Unit staff about a participant investigation.

B. Provides information and documents to state Program Compliance Unit staff as requested in the requested timeframe.

C. Follows up with the participant or parent guardian and cooperates with state Program Compliance Unit staff. This could include the following:

1. Use the Family Alert to write a brief note to alert staff to look on the participant’s Individual Care Plan.

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2. Document a note in the Care Plan to remind staff to conduct educational follow- up or complete other participant rule violation follow-up tasks.

a. Discusses the option of a substitute caretaker as directed by state Program Compliance Unit staff.

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Program Compliance | Page 21 POLICY: Educational Follow-up

The clinic coordinator or designee must conduct educational follow-up with participants or parent guardians within the directed timeframe of the state staff request for follow-up.

Educational follow-up focuses on information about an incident or a participant rule violation (participant rule violation follow-up is conducted as instructed by state Program Compliance Unit staff). The follow up may include reviewing WIC approved foods, how to use the WIC Card or having the person sign the Rights and Responsibilities form.

The clinic coordinator or designee can delegate follow-up activities to ensure completion within the directed timeframe.

PROCEDURE:

The clinic coordinator or designee:

A. Receives direction from state Program Compliance Unit staff or other staff to provide educational follow-up with a participant or parent guardian.

B. Determines the date of the participant’s or parent guardian’s next appointment.

C. Review the Rights and Responsibilities form electronic signature for the current certification.

1. If someone other than the participant or parent guardian signed the Rights and Responsibilities electronically, inform your state staff contact right away. At the participant’s or parent guardian’s next appointment, review and have the person sign a paper copy of the Rights and Responsibilities form and scan it into the participant’s file.

2. Write a Family Alert to conduct follow-up.

D. Talk to the participant or parent guardian about the incident or rule violation at the next appointment.

1. Focus the educational follow-up on the incident or rule violation; for example, review WIC approved foods, how to use the WIC Card and information from both sides of the Rights and Responsibilities form.

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| Page 22 Program Compliance a. Talk to the WIC participant or parent guardian in their primary language by using the language interpretation service contracted by the state WIC office, clinic-based interpreters and translated written materials. • The WIC Shopping Guide and the Rights and Responsibilities form are available in many languages.

b. Review WIC policies and procedures as needed. See the following policy chapters for more information.

• Volume 1, Chapter 7 – Rights and Responsibilities • Volume 1, Chapter 18 – Certification • Volume 1, Chapter 21 – Transfer/Verification of Certification • Volume 1, Chapter 22 – Issue WIC Food Benefits • Volume 1, Chapter 23 – WIC Foods

5. Ask the participant or parent guardian what questions they have.

6. Ask the participant or parent guardian to sign a paper copy of the Rights and Responsibilities form when needed and scan it into Cascades.

a. Review the Rights and Responsibilities and have the participant or parent guardian sign a paper copy.

b. Use the current date when signing the form.

c. Scan the signed form into the participant’s file.

d. Provide the original copy of the Rights and Responsibilities form to the participant or parent guardian.

7. Document in the participant’s file on the Individual Care Plan when educational follow-up is completed. Include the following:

• Name of the person you spoke to • The topic(s) covered • The date • Rights and Responsibilities form signed (if needed) • Your initials

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Program Compliance | Page 23 Section 5: Clinic Staff Compliance

POLICY: Clinic Staff Compliance

Staff must follow WIC federal regulations, Washington WIC policies and procedures, and adhere to the contract requirements between the Washington State WIC Nutrition Program and the local agency.

Key staff compliance policies include, but aren’t limited to the following:

Volume 1:

• Follow policies to assure applicants and participants meet WIC’s eligibility criteria and document accurate and truthful information in Client Services. o See Volume 1, Chapter 3 – Application and Processing Standards o See Staff Tool: Nutrition Risk Factors o See Volume 1, Chapter 18 - Certification • Follow policies to assure accurate income eligibility assessment and documentation. o See Volume 1, Chapter 6 - Income • Follow policies to assign the appropriate WIC foods and amounts for the participant’s category and nutrition needs. o See Volume 1, Chapter 23 – WIC Foods • Issue WIC Cards, food benefits and breast pumps according to policies in Volume 1, Chapter 22 – Issue WIC Food Benefits and Volume 1, Chapter 15 - Breastfeeding. • Follow the WIC Services for WIC Staff, Family or Friends policy in this chapter. • Follow policies in this chapter regarding program compliance.

Volume 2:

• Follow policies regarding the local agency’s contract requirements with the Washington WIC Nutrition Program. o See Volume 2, Chapter 1 - WIC Contract • Follow policies regarding appropriate use of WIC funds. o See Volume 2, Chapter 4 – Allowable Costs • Follow policies regarding appropriate use of WIC funds and equipment.

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| Page 24 Program Compliance o See Volume 2, Chapter 5 – Purchasing and Inventory o See Volume 2, Chapter 10 – Equipment, Security and Disaster Recovery Plan

Information:

It’s the responsibility of all staff to uphold and maintain the integrity of the Washington WIC Nutrition Program.

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Program Compliance | Page 25 POLICY: WIC Services for WIC Staff, Family or Friends

Staff volunteers or students working or volunteering in a clinic, may participate in WIC.

Note: It’s best practice for the person to participate in a different clinic or agency than where they are working, but it isn’t required.

1. Staff must not certify themselves, family members or friends unless the clinic lacks adequate staff to prevent this practice.

Family and friends are defined as:

Family: Mother, father, sibling, son, daughter, grandparent, in-law, aunt, uncle, cousin, niece, nephew, step-parent or any step family member.

Friend: A close acquaintance or a person the staff person spends time with outside work.

a. The coordinator must get approval from the Local Program Consultant (LPC) at the state WIC office before allowing staff to certify themselves, friends or family when there isn’t enough staff to prevent this.

b. The coordinator must review these certification records within two weeks of the certification and keep documentation on file for four years.

• See Volume 1, Chapter 18 - Certification for more information about file review requirements when the clinic can’t meet this requirement.

2. Staff must not issue a WIC Card, food benefits or Farmers Market Nutrition Program (FMNP) benefits or breast pumps to themselves, family members or friends.

3. A staff person, including peer counselors, must sign the Agreement for Clinic Staff yearly which includes a WIC Participation agreement section.

• Use the Agreement for Clinic Staff located in the Appendix when the staff person signs the form in person. • Use the Agreement for Clinic Staff – fillable form when the staff person signs electronically.

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| Page 26 Program Compliance PROCEDURE:

The coordinator:

A. Assures staff don’t certify themselves, family members or friends.

1. Have another staff member certify the family member or friend and issue the WIC Card, food benefits and breast pumps.

2. Reschedule the family member or friend for a time when another staff member is available, when it’s possible or appropriate.

a. Suggest the family member or friend participate at a different WIC clinic or agency when it’s possible or appropriate and doesn’t cause a hardship for the participant.

B. Get written permission from their Local Program Consultant (LPC) in those instances where the only option is for staff to certify and issue benefits to themselves, family members or friends.

C. Completes a file review within two weeks for all certifications when there isn’t adequate staffing to prevent staff from certifying themselves, friends or family members.

1. File review requirements are listed in the “Separation of Duties” policy in Volume 1, Chapter 18 - Certification.

2. Keep the review documentation on file for four years.

Note: Contact state staff if the coordinator isn’t able to meet the review requirements.

D. Don’t allow staff to issue WIC Cards, food benefits, FMNP benefits or breast pumps to themselves, family members or friends. See Volume 1, Chapter 22 – Issue WIC Food Benefits.

E. Have staff review and sign the Agreement for Clinic Staff when hired and yearly thereafter.

1. The staff person designates whether he or she is a WIC participant or the parent guardian of a WIC participant on form.

a. If the person wasn’t a WIC participant or the parent guardian of a WIC participant at the time of hire, and later becomes one, have the person fill out and sign a new Agreement for Clinic Staff.

Volume 1, Chapter 2

Program Compliance | Page 27

b. Have the person fill out and sign the agreement on a yearly basis from the new date.

2. Have the staff person fill out and sign the form in person, or electronically.

a. Use the Agreement for Clinic Staff located in the Appendix when the staff person signs the form in person.

b. Use the Agreement for Clinic Staff – fillable form when the staff person signs electronically.

• Use the following format for the electronic signature: /s/First and Last name.

3. Keep the completed form on file for four years, with a minimum of one year in the clinic.

• Paper or electronic copies are allowed.

F. Report incidents or suspected rule violations to the Department of Health WIC Nutrition Program. You can report by using:

1. The online WIC Incident Report Form. 2. Emails to the state office at WICComplaints@doh.wa.gov. 3. Phone calls to the state office at 1-800-841-1410. 4. Comments via the Department of Heath WIC website. 5. Mail to the Department of Health WIC Nutrition Program.

Information:

It’s best practice to document in the participant’s file that there is no relationship between the participant and the staff member who certified them when they have the same last name but are not related. This protects the participant and clinic staff from potential investigation for participant violations.

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| Page 28 Program Compliance POLICY: Conflict of Interest

The Coordinator must review the following conflict of interest policy with all staff and have staff sign the Agreement for Clinic Staff located in the Appendix, or the Agreement for Clinic Staff – fillable form posted on the website.

The Coordinator’s supervisor must review the policy with the Coordinator and have the Coordinator sign the agreement.

1. Staff must not direct or recommend participants to choose or to stay away from a specific authorized vendor to use their WIC Card and purchase food benefits. • Vendors include WIC authorized grocery stores, farmers markets and farm stores. • This includes Farmers Market Nutrition Program (FMNP) benefits.

2. Staff must not receive any gratuities from an authorized vendor for personal use because he or she works for WIC. This includes cash, gift cards, food, samples, or food coupons.

Note: Staff can receive incentives the vendor gives to all customers (like gift cards, coupons or samples) and not because the person works for WIC.

3. Staff must not have a financial or ownership interest in an authorized vendor. This includes by marriage or family relationship.

• Family relationship includes: Mother, father, sibling, son, daughter, grandparent, in- law, aunt, uncle, cousin, niece, nephew, step-parent or any step family member.

Staff must sign the Agreement for Clinic Staff in person, or the Agreement for Clinic Staff – fillable form electronically at the following times: • Prior to being hired to detect potential conflicts • Annually thereafter

The Coordinator must contact state Program Compliance Unit staff when a staff person has a conflict of interest.

PROCEDURE:

The Coordinator:

A. Reviews the Conflict of Interest policy with all staff.

Volume 1, Chapter 2

Program Compliance | Page 29 B. Has staff sign the Agreement for Clinic Staff in person, or the Agreement for Clinic Staff – fillable form electronically at the following times:

1. At the time of hire.

2. When the person becomes a WIC participant or the parent guardian of a WIC participant.

3. Yearly thereafter.

Note: Use the following format for electronic signatures: /s/First and Last name.

C. Keeps the statement on file for four years in the agency or clinic training or personnel file.

• Paper or electronic copies are allowed.

D. Contacts the state Program Compliance Unit when a staff person has a conflict of interest.

1. State Program Compliance Unit staff assess the situation to determine if an exception to policy is allowed.

2. The state Program Compliance Unit staff will work with the coordinator to determine procedures to prevent and detect program fraud or abuse.

Information:

Federal regulations 7 CRR 246.12 consider it a conflict of interest for clinic staff to have a financial interest in any vendor authorized to accept WIC Cards. This includes Farmers Market Nutrition Program benefits.

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| Page 30 Program Compliance

Volume 1, Chapter 2

Program Compliance | Page 31 Section 7: Appendix

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| Page 32 Program Compliance

Washington State WIC Nutrition Program Agreement for Clinic Staff

The following definitions apply: Family relationships: includes mother, father, sibling, son, daughter, grandparent, in-law, aunt, uncle, cousin, niece, nephew, step-parent or any step family member. Friends: A close acquaintance or a person the staff person spends time with outside work. Vendors: include WIC authorized grocery stores, farmers markets and farm stores. I agree: 1. I won’t direct or recommend participants to choose, or to stay away from a specific vendor to use their WIC Card to purchase food benefits, including Farmers Market Nutrition Program (FMNP) benefits. 2. I won’t receive any gratuities including cash, food, samples, or food coupons for personal use from a vendor as a result of my WIC employment. 3. I don’t have a financial or ownership interest in an authorized vendor by marriage or family relationship.  I don’t have any conflict of interest.  I do have, or may have, a conflict of interest. Please describe: (use back of form if needed) Note: Contact state Program Compliance Unit to review potential conflicts of interest.

4. I will conduct myself in a manner which assures program compliance. 5. I won’t give preferential treatment to anyone including my family, friends, or other staff members. 6. I won’t certify or issue benefits to myself, family or friends. I will work with my supervisor to determine appropriate procedures if there’s no one else available to provide WIC services.  I am not a WIC participant or the parent guardian of a WIC participant.  I am a WIC participant or the parent guardian of a WIC participant and agree to the following: • I understand the local agency will monitor my WIC participation closely to prevent participant violations and fraud from occurring. • I understand that violating rules and program compliance policies may result in sanctions such as repayment for benefits improperly received or disqualification from the WIC Nutrition Program. • I accept responsibility for my actions as a WIC Nutrition Program participant or parent guardian who is also employed as a clinic employee.

Agreement and Signature: I acknowledge that federal and state rules, the Washington WIC Manual and this agency’s policies have been explained to me and I agree to follow them. (See References on next page.)

Employee name (print full name)

Title

Employee signature

Date

Coordinator/Agency Representative signature

Date

Conflict of Interest: (Additional information)

References: • 7 Consolidated Federal Regulations 7 CFR 246 • Washington Administrative Code 246-790 • Washington State WIC Manual: Volume 1, Chapter 2 – Program Compliance • Washington State WIC Manual: Volume 1, Chapter 18 - Certification

WIC Nutrition Program doesn’t discriminate. In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.

Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.

To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:

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

Fax: (202) 690-7442; or

Email: program.intake@usda.gov

This institution is an equal opportunity provider. Washington State WIC Nutrition Program doesn’t discriminate.

DOH 962-982 May 2020

Policy and Procedure Manual

Volume 1, Chapter 3 Application and Processing Standards

Washington State WIC Program DOH 960-367 July 13,2026

This institution is an equal opportunity provider. Washington WIC doesn’t discriminate. For persons with disabilities, this document is available on request in other formats. To submit a request, please call 1-800-841-1410 (TDD/TTY 1-800-833-6388).

Volume 1, Chapter 3

Application and Processing Standards | Page i

Application and Processing Standards

CONTENTS Section 1: Eligibility Requirements 1 POLICY: Eligibility Requirements ............................................................................................ 1 Section 2: Processing Standards 4 POLICY: Processing Standards – Timeframes for Scheduling Certification Appointments ..... 4 POLICY: Contact Pregnant Applicants who Miss Initial Appointments ................................... 6 POLICY: Schedule Appointments for Employed Participants, Parent Guardians and Caretakers ............................................................................................................... 8 Section 3: Documentation Requirements 10 POLICY: Initial Screening and Documentation Requirements .............................................. 10 POLICY: WIC Participation Based on Specific Residency or Membership Requirements ..... 14 POLICY: Document Language Read and Language Spoken .................................................. 16

Volume 1, Chapter 3

Application and Processing Standards | Page 1 Section 1: Eligibility Requirements

POLICY: Eligibility Requirements

Applicants must meet all the following requirements to be placed on the Washington WIC Program:

1. Category.

2. Residency.

3. Income eligible.

4. At nutrition risk.

Note: See Volume 1, Chapter 25 – Legal Considerations and Confidentiality for information about who can request and apply for WIC services on behalf of an infant, child, or adult applicant.

PROCEDURE:

Staff:

A. Determine if the applicant meets WIC’s category requirements:

1. Pregnant.

a. Proof of pregnancy isn’t required since it may cause personal expense to the applicant.

b. Contact Program Monitoring and Investigation staff at the state WIC office for guidance when there are concerns that a pregnant applicant or participant isn’t pregnant.

2. Breastfeeding up to one year from the delivery date.

a. A participant is considered breastfeeding when either breastfeeding the infant once a day on average or expressing breastmilk to feed to the infant once a day on average.

3. Non-breastfeeding Postpartum up to six months from the delivery date.

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| Page 2 Application and Processing Standards

a. A participant who has been pregnant within the past 6 months regardless of the length of the pregnancy or its outcome (for example: live birth, stillbirth, miscarriage, or spontaneous or elective abortion).

4. Infants, birth to one year of age.

5. Children, 12 months of age to five years of age.

B. Determine if the applicant meet’s WIC’s residency requirement:

1. The person lives in Washington.

a. There is no length of residency requirement.

2. Is a migrant farm worker, temporarily living in Washington.

3. A person doesn’t have to be a United States citizen to be on the Washington WIC Program.

a. Staff can’t deny WIC participation to foreign students and other non- citizens for this reason.

b. Being on WIC doesn’t make a person a “public charge” and doesn’t affect a person’s immigration status.

1) Public charge refers to a person who is likely to become primarily dependent on the government for subsistence. Being on WIC doesn’t meet this definition.

2) See the National WIC Association’s “Fact Sheet on WIC and Public Charge” for more information.

C. Determine if the applicant is income eligible. A person is income eligible when:

1. Currently eligible for a program that makes the person automatically income eligible for WIC, called adjunctive eligibility.

2. Household income is at or below WIC’s income eligibility guidelines, which are 185% of the federal poverty level.

• See Volume 1, Chapter 6 - Income for more information about income eligibility.

Volume 1, Chapter 3

Application and Processing Standards | Page 3

D. Determine if the applicant has a nutrition risk:

1. The Competent Professional Authority (CPA) completes an assessment and determines if the person is at nutrition risk.

• See Volume 1, Chapter 14 – Nutrition Risk Criteria.

Information:

WIC Program Federal Regulations: • Eligibility criteria and basic certification procedures 7 CFR 246.7(c)

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| Page 4 Application and Processing Standards Section 2: Processing Standards

POLICY: Processing Standards – Timeframes for Scheduling Certification Appointments

Agencies must:

1. Serve the following applicants within ten calendar days of the initial contact date: • Pregnant applicant • Breastfeeding applicant • Infants • Migrants

Note: Migrant is defined as a person whose principal employment is in agriculture on a seasonal basis, who has been so employed within the last 24 months, and who establishes, for the purposes of such employment, a temporary abode. (CFR 246.2)

2. Serve Children and Non-breastfeeding Postpartum applicants within 20 calendar days of the initial contact date.

The initial contact date is the date the person first asks for WIC services in person.

PROCEDURE:

Staff:

A. Ask the applicant questions to determine the potential participant’s category and migrant status to determine when to schedule the certification appointment.

B. Serve pregnant, breastfeeding, infant, and migrant applicants as follows:

1. Schedule and complete the initial certification, which includes the presumptive eligibility appointment for the applicant, within ten calendar days of the initial contact date.

2. Let the applicant know if they are eligible for WIC when the certification assessment is completed.

C. Serve children and non-breastfeeding postpartum applicants as follows:

Volume 1, Chapter 3

Application and Processing Standards | Page 5 1. Schedule and complete the certification within 20 calendar days of the initial contact date.

2. Let the applicant, parent guardian, or caretaker know if they or their child is eligible for WIC when the certification assessment is completed.

D. Add the applicant to the Pending List when scheduling the certification appointment outside the processing standards.

1. Select a reason for scheduling the certification outside the processing standards.

2. Use the Pending List to contact applicants if an earlier appointment becomes available.

• Cascades won’t suggest the Pending List for agencies who use appointment types like Cert 1, Cert 2, RD 1, etc. These agencies use the “WA WIC Detail Pending Report” to contact applicants if an earlier appointment becomes available.

Note: The Pending List is different than the Waiting List which is used when the agency or clinic can’t serve all potentially eligible participants due to a lack of funding.

• See Volume 1, Chapter 5 – Priority System and Waiting List.

E. Document missed appointments.

1. The processing standards only apply to the first application date for the applicant.

2. If the applicant misses this appointment and reschedules, staff don’t have to schedule based on the application date.

Information:

Calendar days are consecutive days which include weekends and holidays.

WIC Program Federal Regulations: • Timeframes for processing applicants 246.7(f)(2)(iii)(A) and (B). • Definition of Migrant Farmworker 7 CFR 246.2

Volume 1, Chapter 3

| Page 6 Application and Processing Standards POLICY: Contact Pregnant Applicants Who Miss Initial Appointments

Staff must contact pregnant applicants who miss their initial appointment within 15 calendar days of the missed appointment to offer a second appointment.

Clinic staff must document the address and telephone number for each pregnant applicant scheduled for an initial appointment.

PROCEDURE:

Staff:

A. Document the applicant’s address and telephone number at the time of initial contact.

1. If the applicant is homeless, ask if there is an address and phone number where staff can send mail or messages.

2. If the applicant has no address or phone number, document this information in their file and enter the clinic address on the Family Demographics screen.

Note: See the “Address” section of the “Initial Screening and Documentation Requirements” policy for more information.

B. Document a missed initial appointment.

C. Try to contact the applicant at least once by phone or mail to offer a second appointment.

Note: Send a letter when the applicant’s phone is disconnected.

D. Document the attempt to reach the applicant.

1. Printing a letter from Cascades automatically documents the attempt to contact the applicant.

2. If staff try to reach the applicant by phone, document this information in the file.

E. Document if the applicant refused or missed the second appointment.

Note: If the applicant misses the second appointment, staff have the option to attempt another contact.

Volume 1, Chapter 3

Application and Processing Standards | Page 7 Information:

Pregnant applicants are the highest priority served by the WIC Program. Staff make every effort to get pregnant applicants in for services as soon as possible.

This federal requirement to contact the pregnant applicant who misses the initial appointment applies only to the initial certification appointment, not to food benefit pick-ups, high-risk appointments, subsequent applications or any other type of appointment. This policy doesn’t apply to infants or children.

When a pregnant applicant misses an initial certification appointment, Cascades will print a “Missed Appointment for Pregnancy” letter when staff print missed appointment letters.

• When staff select Spanish in the Language Read field, Cascades will print the letter in Spanish. • The letters print in English and Spanish; download other language from the Washington State Department of Printing Fulfillment Center myPRINT.wa.gov website or print Missed Appointment Letters from the Washington WIC website.

WIC Program Federal Regulations: • Certification of participants 7 CFR 246.7(b)(5).

Volume 1, Chapter 3

| Page 8 Application and Processing Standards POLICY: Schedule Appointments for Employed Participants, Parent Guardians and Caretakers

Staff must:

1. Develop flexible appointment schedules to ensure that employed WIC participants, parent guardians and caretakers can participate in the program.

2. Provide scheduled appointments for employed participants, parent guardians, and caretakers when requested, even if the clinic typically doesn’t schedule appointments (open access).

PROCEDURE:

Staff:

A. Keep a sufficient number of scheduled appointment times in the clinic schedule to accommodate employed participants, parent guardians, and caretakers.

B. Offer a choice of scheduled appointment times to employed participants, parent guardians, and caretakers.

Note: If an employed person misses a scheduled appointment staff can ask the person to come in on a “walk in” day, if the clinic has walk in days. If the person can’t come on that day, staff offer another scheduled appointment.

Information:

Offer scheduled appointments to decrease the amount of time the person has to be away from work.

“Walk in” appointment schedules could result in a barrier to WIC services for employed participants, parent guardians, or caretakers since there is an unknown amount of time the person will have to wait for services.

Staff should offer scheduled appointment times to each employed participant, parent guardian, or caretaker. Some strategies for determining the appointment needs of employed persons are listed below.

1. Conduct a survey to determine if the clinic needs to change appointment schedules and estimate the number of people needing flexible hours.

Volume 1, Chapter 3

Application and Processing Standards | Page 9 2. Develop monthly clinic schedules with flexible hours, which include, but are not limited to, services during lunch hours, night and evening clinic hours and Saturday clinic days.

3. Give employed participants, parent guardians, and caretakers appointments during flexible clinic hours so they can participate.

WIC Program Federal Regulations: • Certification of participants 7 CFR 246.7(b)(4).

Volume 1, Chapter 3

| Page 10 Application and Processing Standards Section 3: Documentation Requirements

POLICY: Initial Screening and Documentation Requirements

Staff must:

1. Screen applicants for category, income, and residency eligibility requirements.

2. Complete a statewide search before creating a new record for the applicant or participant to assure the person isn’t already a participant in Washington WIC.

3. Document information as listed below when scheduling the applicant for an initial appointment.

PROCEDURE:

Staff:

A. Complete a statewide search before creating a new record for the applicant or participant to assure the person isn’t already a participant in Washington WIC.

B. Screen for the following:

1. Category and age of applicant served by the agency.

2. Income eligibility.

• See Volume 1, Chapter 6 - Income for more information.

3. Washington state residency.

Note: See the “Eligibility Requirements” policy in this chapter for more information.

C. Document the following information when the applicant appears eligible:

1. Foster Family information, if applicable.

a. Select the Foster Family box on the Family Demographics screen if all the participants in the family are foster children. This includes when the only participant in the group is a foster child.

Volume 1, Chapter 3

Application and Processing Standards | Page 11 b. Staff can unselect the Foster Family box at any time if the foster parent becomes pregnant or has a biological child under 5 years of age and wants to apply for WIC.

2. Parent Guardian name(s) for infants and children.

3. Parent Guardian date of birth.

4. Address: street address, zip code, city, state, and county. Entering a zip code will automatically document the city, state, and county.

a. Document the following when the person is homeless or incarcerated.

1) A physical address if there’s a place the person routinely spends the night.

2) A mailing address if available.

3) Use the clinic address if the person doesn’t have a physical or mailing address.

b. Document the clinic address for the person’s address when the address is confidential, for example the person is living in a domestic violence shelter.

1) Staff can refer the person to the Washington Address Confidentiality Program (ACP) to apply for a confidential substitute address to use for WIC and other programs.

Note: A zip code is required for the person to set a Personal Identification Number (PIN) for the WIC Card and shop for WIC foods.

5. Telephone number, if applicable.

6. Language read and language spoken.

a. Document if an interpreter is needed.

7. Preferred method of contact.

a. Mark the Confidentiality box when the family doesn’t want to receive appointment notifications by email, text, or phone.

Volume 1, Chapter 3

| Page 12 Application and Processing Standards b. Cascades requires staff to enter information in certain fields depending on the preferred method of contact. For example, a phone number is required when phone is listed as the preferred method of contact. • Cascades has standard text message appointment reminders, but not back and forth text messaging functionality. • Cascades doesn’t have built-in functionality to make automated appointment reminder phone calls.

8. Participant name.

9. Participant date of birth (DOB).

10. Category.

11. Gender.

• We acknowledge that Cascades doesn’t allow for gender selection other than male or female and can’t be left unmarked. • Female is automatically assigned to all pregnant, breastfeeding, and non- breastfeeding postpartum clients. • Participant’s gender designation appears as pink and blue participant icons on the family dashboard, and on the participant summary document report. The gender doesn’t appear on the VOC (Verification of Certification) transfer information. • Refer to participants, parent guardians, and caretakers who identify themselves or their children other than male or female by their preference.

12. Foster Child information, if applicable.

• See Required Guidance: Chapter 25, Section 4 – Custody for more information about foster care and documentation.

13. Due date for pregnant participants.

D. Schedule a certification appointment for the applicant within the processing standards.

• See the “Processing Standards - Timeframes for Scheduling Certification Appointments” for more information.

Volume 1, Chapter 3

Application and Processing Standards | Page 13 Information:

WIC Program Federal Regulations: • Eligibility criteria and basic certification procedures 7 CFR 246.7(c)

Volume 1, Chapter 3

| Page 14 Application and Processing Standards POLICY: WIC Participation Based on Specific Residency or Membership Requirements

Local agencies have the option to restrict participation to applicants and participants who meet specific residency or membership requirements.

The local agency must:

1. Have approval from state WIC staff before restricting participation.

2. Write a policy describing the restrictions and keep it on file.

3. Apply the policy fairly and equally to all applicants and participants.

Residency or geographic restrictions include, but aren’t limited to:

• Residing within city or county boundaries.

• Living on an Indian reservation.

• Other geographic boundaries determined by the local agency.

Membership or similar restrictions include, but aren’t limited to:

• Military personnel.

• Belonging to the medical group where WIC services are provided.

• Tribal membership or eligibility for Indian Health Services.

PROCEDURE:

Staff:

A. Send a written request to restrict participation based on specific residency or membership requirements to their Local Program Consultant (LPC) at the state WIC office.

B. Receive approval from the LPC before using the restricted requirements.

C. Follow the local agency policy and procedures for residency and membership requirements and apply them equally to all applicants and participants.

Volume 1, Chapter 3

Application and Processing Standards | Page 15 Information:

WIC Program Federal Regulations: Eligibility criteria and basic certification procedures 7 CFR 246.7(c)(1)(i).

Volume 1, Chapter 3

| Page 16 Application and Processing Standards POLICY: Document Language Read and Language Spoken

Staff must document the language read and language spoken for all applicants and participants.

PROCEDURE:

Staff:

A. Let the participant or caregiver know that information about language needs has no effect on eligibility.

• WIC uses this information to better serve participants who do not speak or read English.

B. Ask the person what language he or she speaks and select the language spoken on the Family Demographics screen in Cascades.

• Share the “I Speak Statements” document to help the person to identify their language.

C. Document when an interpreter is needed.

D. Select the language read for written materials on the Family Demographics screen in Cascades.

• Cascades prints notification letters in English or Spanish when documented in the Language Read field.

• Staff can order notification letters in many languages from the Washington State Department of Printing Fulfillment Center myPRINT.wa.gov website or the WIC website.

Information:

Washington state WIC contracts with a phone interpreter service. The hours of operation are available 24 hours, seven days a week. See “How to Access a LionBridge Interpreter.”

For more information about providing WIC services to Limited English Proficient (LEP) applicants and participants refer to:

• Volume 1, Chapter 7 – Rights and Responsibilities • Volume 1, Chapter 11 - Assessment

Volume 1, Chapter 3

Application and Processing Standards | Page 17 • Volume 1, Chapter 20 – Notification, Fair Hearings and Civil Rights

Policy and Procedure Manual

Volume 1, Chapter 5 Priority System and Waiting Lists

Washington State WIC Nutrition Program DOH 960-367 January 2021

This institution is an equal opportunity provider. Washington State WIC Nutrition Program doesn’t discriminate.

For persons with disabilities, this document is available on request in other formats. To submit a request, please call 1-800-841-1410 (TDD/TTY 1-800-833-6388).

Volume 1, Chapter 5

Priority System and Waiting Lists | Page i

Priority System and Waiting Lists

CONTENTS Section 1: Priority and Sub-Priority System 1 POLICY: Serving Participants using the Priority and Sub-priority System .................................. 1 POLICY: Match Priority for Breastfeeding Participants and Infants ........................................... 4 POLICY: Changes in Priority During the Certification Period....................................................... 5 POLICY: Agency Wide Application of Priority and Sub-Priority System ..................................... 6 Section 2: Waiting Lists 8 POLICY: Waiting Lists ..................................................................................................................... 8

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| Page ii Priority System and Waiting Lists

Volume 1, Chapter 5

Priority System and Waiting Lists | Page 1 Section 1: Priority and Sub-Priority System

POLICY: Serving Participants using the Priority and Sub-priority System

Local WIC agencies must serve all priorities.

The coordinator must:

1. Contact the Local Program Consultant (LPC) at the state WIC office when the clinic lacks the resources to serve all priorities.

2. Receive approval from the LPC before the local agency can stop serving any priority.

A Competent Professional Authority (CPA) must assign the highest priority to each participant based on his or her category (pregnant, breastfeeding, non-breastfeeding postpartum, infant or child) and nutrition risk.

Staff must serve all transfer participants as follows:

1. Serve transfer participants first, regardless of their priority through the end of their certification period.

2. Document the risk and priority assigned by the other clinic or state.

3. Treat transfer participants whose eligibility expired as new applicants.

• See Volume 1, Chapter 21 - Transfers/Verification of Certification • See Volume 1, Chapter 17 – WIC Eligibility

There are 7 Priorities. Priority 1 is the highest need (highest priority) and 7 is the lowest need (lowest priority).

Priority 1: Medical

Pregnant Participants, breastfeeding participants, and infants with medical nutrition risks based on information gathered during the certification assessment.

Priority 2: Infant of WIC Eligible Mom (< 6 months) and Breastfeeding Participants

Infant of WIC Eligible Mom (< 6 months)

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| Page 2 Priority System and Waiting Lists

Infants under the age of six months, who are not Priority 1, of participants who participated in WIC during pregnancy, or who would have been eligible to participate in WIC during pregnancy because of a medical or dietary risk.

Breastfeeding Participants

Breastfeeding participants who are breastfeeding a Priority 2 infant and don’t have any higher priority risk factors.

Priority 3: Medical

Children with medical nutrition risks based on information gathered during the certification assessment.

Priority 4: Dietary

Pregnant participants, breastfeeding participants and infants at nutrition risk because of a non-medical nutrition risk factor.

Priority 5: Dietary

Children at nutrition risk because of a non-medical nutrition risk factor. Priority 5 can be sub prioritized by age, with younger children served first.

Priority 6: Medical and Dietary

Non-breastfeeding postpartum participants up to six months postpartum at nutrition risk because of a medical risk or non-medical risk factor.

Priority 7: Regression

Participants, infants and children who don’t qualify in priorities 1 - 6 who are likely to regress in health status if taken off WIC.

The Washington WIC Nutrition Program doesn’t serve this priority except for transferring participants.

• See Volume 1, Chapter 14 – Nutrition Risk Criteria for more information about medical and non-medical nutrition risks.

Volume 1, Chapter 5

Priority System and Waiting Lists | Page 3 PROCEDURE:

A. The CPA:

1. Completes the nutrition assessment for all participants at the initial certification, subsequent certification and mid-certification health assessment.

2. Documents all of the participant’s nutrition risks.

3. Assigns the highest priority for the participant based on the participant’s nutrition risks.

Note: Cascades automatically assigns priority and high risk status for the participant based on the selected nutrition risk factors.

B. Staff:

1. Accept all transfer participants, regardless of priority.

2. Select the risks assigned by the clinic where the participant was certified.

• Information from the previous clinic transfers automatically when a participant transfers within the state. • Staff document risk information from the participant’s transfer documents when he or she transfers in from another state.

Information:

The priority system determines who is served first when a state is unable to serve all participants because of limited caseload or funding.

The order of the priorities recognizes the fact that the earlier in a child's development that intervention takes place (especially the fetal stage), the greater the impact on the child's health. For this reason pregnant participants are served first and younger children are served before older children. The priorities also reflect the importance of serving participants with a current medical nutrition risk before participants with a poor diet who may develop a medical nutrition risk later.

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| Page 4 Priority System and Waiting Lists

POLICY: Match Priority for Breastfeeding Participants and Infants

Staff must assign the same priority to breastfeeding participants and their breastfed infants. Assign the highest priority for which either of them qualify.

PROCEDURE:

The CPA:

A. Assesses the breastfeeding participant and infant separately for eligibility.

B. Assigns the same and highest priority to both the breastfeeding participant and breastfed infant.

1. Updates the breastfeeding pair’s priority if additional risk factors are determined during the certification period which makes the pair a higher priority.

Note: Cascades automatically matches the breastfeeding pair’s priority based on the risks selected.

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Priority System and Waiting Lists | Page 5

POLICY: Changes in Priority during the Certification Period

Staff must change a participant's priority during the certification period if a nutrition risk is identified that places the participant in a higher priority.

PROCEDURE:

The CPA:

A. Documents additional risks during follow-up visits during the certification period in the participant’s file.

Note: Cascades automatically assigns the priority and high risk status for the participant based on the nutrition risk factors selected.

Information:

State and federal funding is partly based on the priority of participants served. States serving a higher percentage of high priority participants are given priority for additional federal funds.

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| Page 6 Priority System and Waiting Lists

POLICY: Agency Wide Application of Priority and Sub-Priority System

Local agencies must implement the priority and sub-priority system on an agency wide basis.

Local agency staff must request and receive approval from the Local Program Consultant (LPC) before a local agency can stop serving all priorities at all agency sites.

PROCEDURE:

The Coordinator:

A. Makes sure all clinic sites within the agency serve the same priority and sub-priorities.

B. Distributes caseload to ensure the priority and age served is consistent in the agency.

C. Redistributes caseload among clinic sites to keep the priorities and ages served the same within the agency when there is a change in demand for WIC services at one clinic.

1. The coordinator may request additional caseload for clinics with increased demands to even out the priorities and/or ages served.

D. Sends a written request for a waiver from the Washington WIC Nutrition Program if there are special circumstances that require priorities and/or ages to be different at different sites within the agency.

1. Include a description of what has been done to try to keep the priorities and/or age levels the same within the agency.

Information

Providing WIC services at the same priorities and/or age levels throughout the agency and the state helps to make sure that WIC participants are treated fairly and equally.

Agencies within a county or service area should try to work together, especially when caseload is expanding in order to provide a consistent level of service. When agencies in the same service area serve different priorities it creates a hardship for participants and inefficiency in clinic services. Participants may participate in one clinic and then have to go to a different clinic serving the lower priority after being bumped. Participants may have to travel farther from their home to get services. The clinic serving the lower age/higher priority may lose participants when the entire family transfers to the clinic that will serve the older child. The receiving clinic

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Priority System and Waiting Lists | Page 7 may have a higher number of no-shows because participants have more difficulty getting to a clinic farther from their home.

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| Page 8 Priority System and Waiting Lists Section 2: Waiting Lists

POLICY: Waiting Lists

If there is inadequate funding to serve all eligible participants or new applicants, the Washington State WIC Nutrition Program may require local agencies to implement a waiting list.

State WIC staff must establish the waiting list criteria in Cascades.

Clinic staff must:

• Place un-served lower priority applicants who are likely to be served soon on the waiting list. If clinic staff can’t predict future caseload and priorities served, place all un-served applicants on the appropriate waiting list. • Place any applicant on the waiting list who asks to be placed on one even if the applicant is not likely to be served. • Use separate waiting lists for different categories and potential priorities. Cascades automatically places applicants and participants on the appropriate waiting list. • Notify applicants and participants in writing when placed on a waiting list.

Civil rights regulations do not allow staff to ask race or ethnicity information as part of the waiting list procedures.

Clinic staff serve participants from the waiting list based on the priority system.

PROCEDURE:

Staff:

A. Document the following information on the waiting list in Cascades:

1. Initial contact date.

a. The initial contact date is the date that the applicant writes, phones, or physically comes in to the clinic to ask for program benefits.

b. For bumped participants, the initial contact date is the day they are taken off of the program.

2. Applicant's name.

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Priority System and Waiting Lists | Page 9

3. Date placed on waiting list.

a. This date is only needed if it is not the same as the initial contact date.

4. Date removed from waiting list and notified of status.

a. This is the date the person was assessed and either became eligible and was given benefits, or was found ineligible.

5. Date for certification appointment.

6. Address and/or phone number.

7. Age.

a. Age is only recorded for children.

8. Income and family size.

a. This documents that the applicant was screened for income eligibility before being placed on the waiting list.

C. Discuss with all applicants their placement on the waiting list within 20 days of their initial contact date.

1. This date is usually the same date as the initial contact date.

2. Documentation of this date is only required if it differs from the initial contact date.

D. Offer all applicants placed on a waiting list information about other WIC programs in the area if the other programs serve lower priorities. Refer applicants to other social, health, and food programs in the area.

E. Give certification appointments to higher priority applicants first. For applicants with the same potential priority, offer appointments in the order they were placed on the waiting list.

F. Document on the waiting list if the applicant missed the first appointment and was rescheduled; or when the applicant did not respond to a “Missed Appointment” letter or phone call from clinic staff to reschedule the appointment. When the applicant does

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| Page 10 Priority System and Waiting Lists come in and is certified, document in the file that the processing standards were not met because of the missed first appointment.

G. Talk with applicants who not likely to be served that the local agency can’t serve them because of a high demand for services from higher priority applicants.

Policy and Procedure Manual Volume 1, Chapter 6 Income

Washington State WIC Program DOH 960-367 Effective July 13, 2026

This institution is an equal opportunity provider. Washington WIC doesn’t discriminate.

To request this document in another format, call 1-800-841-1410. Deaf or hard of hearing customers, please call 711 (Washington Relay) or email wic@doh.wa.gov.

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Income | Page i Income

CONTENTS Section 1: Determine Income Eligibility 1 POLICY: WIC Income Eligibility ............................................................................................... 1 POLICY: Adjunctive Income Eligibility: Income Eligibility Based on Participation in an Income-Qualifying Program ..................................................................................... 4 POLICY: Adjunctive Eligibility due to a Household Member .................................................. 7 POLICY: Income-based Eligibility: Income Eligibility Based on Household Size and Income 10 Section 2: When to Assess Income Eligibility 12 BEST PRACTICE: Screen for Income Eligibility ..................................................................... 12 POLICY: Assess Income Eligibility at Initial and Subsequent Certifications ........................... 14 POLICY: Re-assess Income Eligibility when there are Changes ............................................. 15 POLICY: Transfer Participants Income Eligibility .................................................................. 18 POLICY: Assess Migrant Income ........................................................................................... 19 Section 3: Household Size 21 POLICY: Household Size ....................................................................................................... 21 Section 4: Definition of Income 26 POLICY: Definition of Income ............................................................................................... 26 POLICY: Lump Sum Payments .............................................................................................. 34 POLICY: Zero Income ........................................................................................................... 36 Section 5: Documenting Income Information 38 POLICY: Requirement to Document Income Information .................................................... 38 POLICY: Income Sources ...................................................................................................... 40 POLICY: Proof of Income ...................................................................................................... 42 POLICY: Income Frequency .................................................................................................. 44 POLICY: Temporary Certification for Missing Proof of Income ............................................ 45

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| Page ii Income POLICY: No Proof of Income ................................................................................................ 48 POLICY: Reliable Third Party Statement ............................................................................... 49 POLICY: Verify Income When Information is in Question .................................................... 50 Section 6: Annual Income 52 POLICY: Annual Income ....................................................................................................... 52 Section 7: Appendix 54 Washington State Department of Health WIC Income Eligibility Guidelines ......................... 55 Military Pay Codes: This table lists military pay codes and the type of pay each code represents. ............................................................................................................. 57 Questions to determine if pay is combat related .................................................................. 60 Designated Combat Zones .................................................................................................... 61 Statement of Income Form (Affidavit for Income) ................................................................ 62 Temporary Certification for Missing Proof of Income ........................................................... 63

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Income | Page 1 Section 1: Determine Income Eligibility

POLICY: WIC Income Eligibility

Staff must assess household income eligibility when an applicant or participant is certified, subsequently certified, or when there are changes that could affect income eligibility.

Note: See the “When to Assess Income Eligibility” section of this chapter for more information.

WIC income eligibility is determined by assessing a combination of household size and income, or participation in an income-qualifying program.

• Federal regulations define which programs are income-qualifying. These programs make a person income eligible for WIC.

An applicant or a participant is income eligible for WIC when one of the following applies:

1. Adjunctive eligibility due to participation in an income-qualifying program:

a. The income-qualifying programs are:

• Medicaid Title 19 • State or Federal non-Title 19 medical assistance programs with income guidelines the same or less than WIC’s • TANF (Temporary Assistance for Needy Families) • SNAP (Supplemental Nutrition Assistance Program) • FDPIR (Food Distribution Program on Indian Reservations)

b. The person is income eligible for WIC when he or she shows proof of current eligibility for one of the programs listed above, even if the reported income is higher than WIC’s guidelines.

• See the “Adjunctive Income Eligibility” policy for more information.

2. Adjunctive eligibility due to a qualifying household member:

a. The person is in a household with a pregnant woman or an infant on Medicaid Title 19.

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| Page 2 Income b. The person is in a household eligible for TANF.

c. The person is income eligible for WIC when he or she shows proof of a household member’s current eligibility for one of the programs listed above, even if the reported income is higher than WIC’s guidelines.

Note: The qualifying household member doesn’t have to be a WIC participant. For example, if there is a pregnant woman who’s a teen in the family and she’s on Medicaid but doesn’t want to be on WIC; she can still make her family adjunctively income-eligible for WIC.

• See the “Adjunctive Income Eligibility due to a Household Member” policy for more information.

3. Income-based eligibility: The person’s household income meets WIC’s income guidelines, which are at or below 185% of the federal poverty level (FPL).

• See the “Income-based Eligibility” policy for more information.

PROCEDURE:

Staff:

A. Determine if the person is currently on an income-qualifying program.

1. Ask if the person is currently on a medical assistance program (Medicaid Title 19, state, or Federal non-Title 19 medical assistance program), TANF, SNAP, or FDPIR.

• See the “Adjunctive Income Eligibility” policy for more information.

B. Determine if a household member is on an income-qualifying program if the applicant or participant isn’t currently eligible for one.

• See the “Adjunctive Eligibility due to a Household Member” policy for more information.

C. Determine if the person meets WIC income guidelines if the criteria in A or B above doesn’t apply.

• See the “Income-based Eligibility” policy for more information.

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Income | Page 3 D. Ask how many people are in the household and the number of expected infants (if any) and enter the number on the Income Information screen.

• See the “Household Size” policy in this chapter.

E. Document the current household income.

1. Adjunctive eligibility:

a. Enter the family’s self-declared monthly income in the Self Declared Income field.

• The person doesn’t have to show proof of income.

• Documentation of current eligibility for the income-qualifying program or adjunctive eligibility due to a household member is the person’s proof of income eligibility for WIC.

Note: Staff document the family’s self-declared monthly income in the Self Declared Income field rather than using the Self-Declared Income Range to gather better statistics for WIC income eligibility.

2. Income-based eligibility:

a. Enter income information from the person’s proof of income, for example the paystub(s) in the Income Details.

F. Give applicants and participants who aren’t income eligible an Ineligibility Notice.

• This isn’t required when the person applies over the phone and is over income.

G. Refer all applicants and participants who are over income to the Family Health Hotline (1-800-322-2588) for health and social services.

• See Volume 1, Chapter 12 – Referrals for more information.

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| Page 4 Income POLICY: Adjunctive Income Eligibility: Income Eligibility Based on Participation in an Income-Qualifying Program

A person is adjunctively income eligible for WIC when he or she is currently on an income- qualifying program.

The income-qualifying programs are:

• Medicaid Title 19 • State or Federal non-Title 19 medical assistance programs with income guidelines the same or less than WIC’s • TANF (Temporary Assistance for Needy Families) • SNAP (Supplemental Nutrition Assistance Program) • FDPIR (Food Distribution Program on Indian Reservations)

The person is income eligible for WIC when staff verify current eligibility for one of the programs listed above, even if the reported income is higher than WIC’s guidelines.

Staff must not delay the participant receiving WIC benefits by requiring the participant to use adjunctive eligibility, for example requiring a participant to have a ProviderOne card, before assessing income.

Note: The Cascades ProviderOne search feature assesses if a person with a ProviderOne number is currently on an income-qualifying medical assistance program and documents the verification.

PROCEDURE:

Staff:

A. Ask if the person is currently on a medical assistance program (Medicaid Title 19; or a state, or Federal non-Title 19 program), TANF, SNAP, or FDPIR.

1. Assess income and household size if the person isn’t currently on an income- qualifying program, or hasn’t heard yet if he or she is eligible.

• Don’t delay benefits by waiting to assess the person’s eligibility until he or she is on an income-qualifying program. • See the “Income-based Eligibility” policy for more information.

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Income | Page 5 B. Document adjunctive eligibility on the Income Information screen.

1. Mark the box for each program for which the person self-reports he or she is currently eligible.

C. Verify current eligibility for the income-qualifying program. Verify by seeing proof of current eligibility, which includes:

1. A positive search result in Cascades.

a. The participant doesn’t have to show the ProviderOne card as long as he or she can provide the ProviderOne number.

b. Staff enter the number and search.

c. The search feature will verify and document adjunctive eligibility when it applies.

2. A notification letter from one of the income-qualifying programs showing current eligibility.

a. A notification letter showing current eligibility for the SNAP, even with a zero dollar benefit amount, is proof of eligibility for an income-qualifying program and makes the person adjunctively income eligible for WIC.

D. Ask how many people are in the household and the number of expected infants (if any) and enter the number in the file.

• See the “Household Size” policy in this chapter.

E. Enter the self-declared monthly household income in the Self Declared Income field.

F. Assess the participant’s income eligibility when he or she is no longer eligible for an income-qualifying program.

1. When a participant reports that he or she is no longer eligible for the program that made him or her income eligible for WIC:

a. Assess for other types of adjunctive eligibility.

b. Assess if a household member would make the participant income eligible.

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| Page 6 Income • See the “Adjunctive Eligibility Due to a Household Member” policy in this chapter for more information.

c. Assess income-based eligibility if the participant or a household member isn’t on an income-qualifying program.

G. Give applicants or participants who aren’t income eligible an Ineligibility Notice.

• This isn’t required when the person applies over the phone and is over income.

H. Refer all applicants and participants who are over income to the Family Health Hotline (1-800-322-2588) for health and social services.

• See Volume 1, Chapter 12 – Referrals for more information.

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Income | Page 7 POLICY: Adjunctive Eligibility due to a Household Member

A person is adjunctively income eligible for WIC due to a household member when one of the following applies:

• There’s a pregnant woman in the household on Medicaid Title 19 • There’s an infant in the household on Medicaid Title 19 • The household is eligible for TANF

Staff must verify the household member’s proof of current eligibility and document it in the participant’s file.

Staff must not delay the participant receiving WIC benefits by requiring the participant to use adjunctive eligibility, for example requiring a participant to have a ProviderOne card, before assessing income.

Staff must not use a foster child’s eligibility for an income-qualifying program like Medicaid Title 19 to make other members of the foster family income eligible for WIC. Federal regulations require WIC to count each foster child as a household of one.

PROCEDURE:

Staff:

A. Determine if a household member is on an income-qualifying program if the applicant or participant isn’t currently eligible for one.

1. Ask the participant the following questions:

a. Is there a pregnant woman or an infant in the household on Medicaid?

b. Is the household eligible for TANF?

2. Assess income and household size if a household member isn’t currently on an income-qualifying program, or hasn’t heard yet if he or she is eligible.

• Staff don’t delay benefits by waiting to assess the person’s eligibility until he or she, or a household member is on an income-qualifying program. • See the “Income-based Eligibility” policy for more information.

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| Page 8 Income B. Verify the household member’s proof of current eligibility for the income-qualifying program. Staff verify by seeing proof of current eligibility, which includes:

1. Cascades ProviderOne search feature verifying the ProviderOne participant is on Medicaid Title 19.

2. A notification letter from TANF with current eligibility dates.

C. Document the household member’s adjunctive eligibility.

• Cascades assesses adjunctive eligibility due to a household member based on WIC policy.

D. Ask how many people are in the household and the number of expected infants (if any) and enter the number on the Income Information screen.

• See the “Household Size” policy in this chapter.

E. Enter the self-declared monthly household income in the Self Declared Income field.

• Staff document the self-declared monthly income rather than selecting a self- declared income range to collect more accurate statistics for WIC income eligibility.

F. Assess the participant’s income eligibility when the household member no longer makes the participant adjunctively eligible.

1. When a pregnant woman changes to a different category (Breastfeeding or Non- Breastfeeding Postpartum), or an infant changes to the Child category, he or she no longer makes household members income eligible for WIC.

a. Assess if the participant is income eligible based on his or her own eligibility for an income-qualifying program.

b. Assess income-based eligibility if the participant isn’t on an income- qualifying program.

Example: While a woman is in the pregnant category, staff can use her Medicaid Title 19 eligibility to make her baby adjunctively eligible. Once staff certify the mom into another category (Breastfeeding or Non-breastfeeding Postpartum) staff can’t use her Medicaid eligibility for her baby because she isn’t in the pregnant category.

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Income | Page 9 If the infant isn’t adjunctively eligible, assess income-based eligibility.

2. Follow the steps listed in 1 above when the household is no longer on TANF.

G. Give applicants and participants who aren’t income eligible an Ineligibility Notice.

• This isn’t required when the person applies over the phone and is over income.

H. Refer all applicants and participants who are over income to the Family Health Hotline (1-800-322-2588) for health and social services.

• See Volume 1, Chapter 12 – Referrals for more information.

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| Page 10 Income POLICY: Income-based Eligibility: Income Eligibility Based on Household Size and Income

Staff must determine if the person’s household income meets WIC income guidelines if the person isn’t adjunctively income eligible for WIC or isn’t a member of a household that is adjunctively income eligible for WIC.

Income-based eligibility is when the person’s household income meets WIC’s income guidelines, which are at or below 185% of the federal poverty level (FPL).

PROCEDURE:

Staff:

A. Ask how many people are in the household and the number of expected infants (if any) and enter the number in the file.

• See the “Household Size” policy in this chapter.

B. Review proof of household income and enter it in the Income Details section of the Income Information screen.

1. Enter the income source, type of proof, frequency (how often) the income is received, the amount and duration.

2. See the following policies in this chapter for more information:

• “Definition of Income” • “Income Sources” • “Proof of Income”

C. Compare the household income to WIC’s income guidelines for the household size and determine if the applicant or participant is income eligible.

1. Compare the household income to the WIC income guideline for the same interval, for example weekly, monthly, annual, etc.

2. When the household has income at different intervals, compare the household’s current annual income to WIC’s annual income guidelines.

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Income | Page 11 Note: Cascades automatically compares the income entered to the correct interval of the WIC income guidelines. When there are multiple intervals, Cascades converts income to the current annual income.

E. Give applicants who aren’t income eligible an Ineligibility Notice.

• This isn’t required when the person applies over the phone and is over income.

F. Refer all applicants and participants who are over income to the Family Health Hotline (1-800-322-2588) for health and social services.

• See Volume 1, Chapter 12 – Referrals for more information.

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| Page 12 Income Section 2: When to Assess Income Eligibility

BEST PRACTICE: Screen for Income Eligibility

It’s best practice to screen applicants for WIC income eligibility.

GUIDANCE:

Staff:

A. Screen applicants for WIC income eligibility.

1. Ask the applicant about current participation in income-qualifying programs for themselves or a household member.

2. Ask about household size and income.

B. Enter information in the Cascades Income Screening Calculator to determine if the applicant appears to be income eligible.

1. Enter income source, frequency, amount and duration.

2. Proof of income isn’t required when prescreening.

Note: The Cascades Income Screening Calculator doesn’t assess adjunctive eligibility and doesn’t save income information.

C. Schedule a certification appointment for applicants or participants who appear to be income eligible.

• See Volume 1, Chapter 3 – Application and Processing Standards for more information about timeframes for scheduling the certification appointment.

D. Give applicants who aren’t income eligible an Ineligibility Notice.

1. This isn’t required when the person applies over the phone and is over income.

E. Refer all applicants and participants who are over income to the Family Health Hotline (1-800-322-2588) for health and social services.

• See Volume 1, Chapter 12 – Referrals for more information.

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Income | Page 13 Information:

It’s good customer service to screen for WIC income eligibility to determine if a person is potentially eligible. When staff don’t screen for income eligibility before scheduling an initial certification appointment, it’s possible the person won’t be income eligible when assessed at the clinic.

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| Page 14 Income POLICY: Assess Income Eligibility at Initial and Subsequent Certifications

Staff must assess and document household income eligibility at the following times: 1. Initial certification (includes when staff assign Presumptive Eligibility) 2. Subsequent certification 3. When there are changes to income, household size or eligibility for an income-qualifying program. • See the “Re-assess Income Eligibility when there are Changes” policy in this chapter for more information.

Staff must follow specific rules for assessing income for migrants and transfer participants. • See the “Assess Migrant Income” policy. • See the “Transfer Participants Income Eligibility” policy.

PROCEDURE:

Staff:

A. Assess income eligibility based on policies in this chapter at the initial certification and each subsequent certification.

1. This includes the initial certification appointment when staff assign presumptive eligibility for pregnant participants.

B. Assess income eligibility when there are changes to income, household size or eligibility for an income-qualifying program.

C. Review the person’s proof of income.

• See the “Temporary Certification for Missing Proof of Income” policy for more information when the person doesn’t bring proof to the appointment.

D. Follow policies for times to assess the income eligibility for migrants and transfer participants. See the following policies in this chapter for more information:

• “Transfer Participants Income Eligibility” • “Assess Migrant Income”

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Income | Page 15 POLICY: Re-assess Income Eligibility when there are Changes

Staff must:

1. Re-assess household income eligibility when a household member or another reliable source provides the following information at any time, including mid-certification:

a. Household income increased.

b. Household size decreased.

c. The participant is no longer eligible for an income-qualifying program.

d. The household is no longer eligible for TANF.

e. The household member who made the participant adjunctively eligible has changed category, for example the pregnant participant on Medicaid Title 19 has changed category to breastfeeding or non-breastfeeding postpartum.

Notes: • Staff don’t have to ask for changes in income, household size or eligibility for an income-qualifying program mid-certification, but must act on that information when they receive it. • See the “Zero Income” policy for a list of “reliable sources.” • Call state WIC staff if you receive information from another source.

2. Require proof of income when re-assessing income eligibility.

• Staff can give a one month grace period when re-assessing income. • See the “Temporary Certification for Missing Proof of Income” policy in this chapter for more information

PROCEDURE:

Staff:

A. Re-assess the household’s income eligibility when a household member or another reliable source reports:

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| Page 16 Income 1. An increase in household income,

2. Decrease in household size,

3. A participant is no longer eligible for a medical assistance program (Medicaid Title 19, state or Federal non-Title 19 program), TANF, the Basic Food Program (SNAP), or FDPIR.

4. The household is no longer eligible for TANF.

5. A pregnant participant or infant on Medicaid Title 19 has changed WIC category and no longer makes household members income eligible.

B. Enter the updated information on the Income Information screen and assess income eligibility.

1. Continue providing WIC benefits when the household is still income eligible.

C. Follow these steps when the household becomes over income.

1. Assess if the household can receive benefits based on the requirement to provide a 20-day notice of ineligibility.

a. Provide benefits if the household participants haven’t received them for the current month.

b. If the household participants already received the current month’s benefits, assess if you need to provide additional benefits in order to provide the required 20-day notification.

c. Void any future months’ benefits after meeting the 20-day notification requirement.

• See Volume 1, Chapter 22 – Issue WIC Food Benefits for more information.

2. Provide the required written notice to participants by giving the “Not Eligible” letter and take the participant off WIC.

• See Volume 1, Chapter 20 – Notification, Fair Hearings and Civil Rights for more information.

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Income | Page 17 Information:

Federal Regulations require staff to re-assess income eligibility for all household members when one member becomes income ineligible. Staff take all household members who are no longer income eligible off the Program.

The Rights and Responsibilities form lets participants, parent guardians and caretakers know they must report when there is an increase in income, decrease in household size and when eligibility for an income-qualifying program ends to WIC.

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| Page 18 Income POLICY: Transfer Participants Income Eligibility

Staff must not assess income eligibility for transfer participants unless:

1. The participant, parent guardian or caretaker reports a change in income, household size or eligibility for an income-qualifying program.

2. The eligibility period is over.

PROCEDURE:

Staff:

A. Accept current transfer information as proof of current income eligibility.

1. Cascades doesn’t require staff to enter income information for participants who transfer in from out of state.

2. Cascades displays the income information documented at the previous clinic for in-state transfer participants on the Income Information screen.

B. Enter updated income information if the transfer participant reports a change and assess for income eligibility.

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Income | Page 19 POLICY: Assess Migrant Income

Staff must:

1. Assess the income eligibility of migrant households one time per household, per 12 month period.

2. Accept migrants with expired Transfer/Verification of Certification cards as income eligible as long as their income assessment was within the past 12 months. The expired transfer card is the migrant’s proof of income.

Definition: A person is migrant when he or she is a member of a household which contains at least one person whose principal employment is in agriculture on a seasonal basis, and who has a temporary residence for this type of employment within the last 24 months.

Examples:

• Migrant farmworkers who travel from one location to another to work. • Loggers who move from one location to another for their work.

Note: WIC’s definition of migrant is specific to WIC only. Other programs may use a different definition.

PROCEDURE:

Staff:

A. Document the migrant household’s income assessment date by creating a Family Alert.

1. Title the alert “Migrant Income Assessment Date.”

2. Select a Start Date for the Family Alert.

a. Assess when the migrant household is due for the next income assessment.

b. Document the first day of the month when the next income assessment is due as the alert start date.

c. Leave the End Date open so the alert continues to display until staff dismiss it after assessing the migrant household’s income.

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| Page 20 Income

B. Review Family Alerts for all migrant household certifications to assure staff follow the migrant income assessment timeframe.

C. Re-enter income information when certifying household members within the 12 month timeframe.

1. Cascades requires income information to complete the certification.

D. Determine income eligibility for the participant when the 12 month time frame has ended.

Note: See the “Proof of Income” and “No Proof of Income” policies in this chapter for more information.

Information:

Once a migrant family's income has been determined for one member, any additional family members certified during the 12 month period don’t need to have an income assessment.

Example: Staff certify a pregnant migrant woman and assess her income. When staff certify the woman’s infant they don’t need to assess the baby’s income since the mother's income determination date is within the past 12 months. Follow procedures listed above to track the migrant income assessment timeframe.

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Income | Page 21 Section 3: Household Size

POLICY: Household Size

Staff must determine the number of people in each household based on the definition of “household” and the information listed in policy and in procedures below.

Definition A family or household is a group of related or nonrelated individuals who are living together as one economic unit, except that residents of a homeless facility or an institution aren’t counted as an economic unit.

1. An economic unit or household must have its own source of income (or savings) to support living expenses. See the “Zero Income” policy for guidance when the household reports zero income.

a. The income must be adequate to sustain the household. State guidance for adequacy is $500 per person per month.

b. Staff must not use in-kind benefits as a factor to determine if a separate economic unit exists. See Procedure F below for an example.

2. Staff must count an applicant or participant in the household that directly supports his or her living expenses.

Note: Staff may use terms family, household, and economic unit interchangeably.

3. Staff must count the number of expected infants in the household size for households with a pregnant applicant, unless the pregnant person has a religious, cultural or personal objection and wishes to exclude the number of expected infants.

Note: This aligns with Medicaid’s practice of including the number of expected infants in the household size and WIC Policy Memorandum #99-4, Section IV, C, 1, paragraph 3.

PROCEDURE:

Staff consider the following to determine household size:

A. Children in joint custody or shared guardianship:

1. Count a child in the household where he or she lives most of the time.

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| Page 22 Income 2. When a child lives with each parent 50% of the time, count the child as a member of both households when determining household size. Only one household can apply for and receive WIC benefits.

3. Follow these guidelines when the child spends large amounts of time at each household.

a. Alternating months – Count the child in both households. Only one household can apply for WIC.

b. Two or more months at each household – Count the child only in the household where he or she is currently living. Only the household where the child currently lives can apply for WIC.

B. Foster child - The foster child is the legal responsibility of the state. Count each child as a household of one.

• If a foster parent has more than one foster child, count each foster child as a household of one.

• Since WIC counts a foster child as a household of one, the foster child’s eligibility for an income-qualifying program like Medicaid Title 19, doesn’t make other individuals living in the same household income eligible for WIC.

C. Adopted child – Count the adopted child as a member of the adoptive household.

D. Children who are temporarily living in the home of others - For children who are temporarily living in the home of others, for example if the military parent(s) are deployed, staff choose the most appropriate option for the situation.

1. Count the child(ren) as part of the household or economic unit where they are living. Determine WIC income eligibility on the total number in the economic unit and all of the economic unit’s income.

2. Count the absent parent(s) and the child(ren) as one household or economic unit. To use this option, clinic staff need to be able to determine the income of the economic unit and see proof of income.

3. Count the child(ren) as a separate household or economic unit. To be a separate economic unit, there must be a source of income (parent contribution, etc.) that is enough to support the child(ren). If an adequate amount isn’t received for the child(ren)’s support, staff use another option.

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Income | Page 23 E. Pregnant – Count a pregnant applicant as one plus the number of expected infants

1. Enter the number of expected infants on the Income Information screen. • This field only displays when there’s a pregnant person in the family.

2. Select “Exclude No. of Expected Infants” when the pregnant person wishes to exclude the number of expected infants.

3. If the pregnant applicant isn’t income eligible when excluding the number of expected infants:

a. Inform the applicant they aren’t income eligible and that they may be eligible if they include the expected infant(s).

b. Ask if the person would like to include the expected infant(s) and reassess income eligibility.

c. If the person prefers not to count the expected infant(s), let them know they can reapply for WIC after the birth of the infant(s).

F. Pregnant teen - Consider each situation individually.

1. If the pregnant teen lives with a family and the family pays for living expenses, count the teen as part of the household and assess the household’s income for WIC eligibility.

2. If the pregnant teen has no income and lives with a family who provides shelter, food, etc. as an in-kind benefit for providing child care for their children, count the teen as part of the household and assess the household’s income for WIC eligibility. The in-kind benefit doesn’t count as a source of income for the teen.

3. If the pregnant teen lives with a family, has a job and contributes money in a “proportionate share” each month for her living expenses, count the teen as a separate household and document the teen’s income to assess for WIC eligibility.

Note: Count a pregnant teen’s household size and income according to policies and procedures in this chapter and enter this information in the participant’s file. If the teen has adjunctive eligibility with a positive ProviderOne adjunctive eligibility verification, the teen is income eligible for WIC.

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| Page 24 Income Example:

A pregnant teen lives with her parents. Staff determine she is economically dependent on her parents. Staff document the entire household size and income in Cascades. The amount is above WIC income guidelines and the teen isn’t income eligible.

The teen returns two months later with a ProviderOne card. Staff enter the P1 number and search, they receive a positive ProviderOne adjunctive eligibility verification. The teen is income eligible for WIC due to adjunctive income eligibility. Staff document the actual household size and income, including her parents.

G. Multiple households under one roof – Because people who live together typically share their resources they usually count as one household. However, it’s possible for two separate economic units to live under the same roof. Staff ask more questions to find out if there are separate households or economic units living under the same roof. For example:

1. Does the household have its own source of income?

• Receiving shelter and food as an in-kind benefit for providing a service, like childcare or house cleaning, doesn’t count as having a source of income.

2. Is the amount adequate to sustain the number in the household?

• State guidance for adequacy is $500 per person per month.

3. Does the household pay its proportionate share of expenses for housing, food, bills, etc.?

Examples of multiple households under one roof include:

• Roommates who pay for their share of the rent and their own living expenses.

• Families who share a house and pay their share of the rent or mortgage and living expenses.

H. Person living at school - When the parent or guardian pays the tuition, count the child living at a school as a member of the household.

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Income | Page 25 I. Person living in an institution –Residents of a homeless facility or an institution aren’t one large household. An individual or group of individuals (for example a woman and two children) living in a homeless facility or an institution are counted as a separate household.

Information:

When people live together it is likely they share resources which makes them one economic unit. However, clinic staff may ask questions and find that the units are independent of each other. Asking questions about the dividing of living expenses, sharing of food, etc. can provide helpful information to determine if there are separate economic units living together.

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| Page 26 Income Section 4: Definition of Income

POLICY: Definition of Income

Gross or net income: Staff must use gross income to determine WIC income eligibility unless the applicant or participant is a farmer or self-employed person.

• Gross income is the person’s income before deductions for income taxes, social security taxes, insurance premiums, bonds, etc.

• Staff must not reduce gross income for any reason including financial hardships, medical bills, or child support.

Staff must use net income to determine income eligibility for farmers and self-employed persons.

• Use the adjusted net income figure on a completed tax return or determine net income by subtracting the operating expenses from the gross income.

Current or annual income: Staff use current or annual income whichever is the better indicator of the household’s financial status. However, federal regulations require staff to assess current income for applicants and participants who are unemployed.

• Current income: o All income received by any and all members of the household during the past 30 days. o For unemployed persons “current” refers to the income available to the household in the next 30 days, for example the amount the household will receive for unemployment benefits. • Annual income is income received during the past 12 months. See the “Annual Income” policy for more information.

Note: See the Information section for examples of when to use current or annual income. See the “Proof of Income” policy for more information about proof of income requirements.

Income inclusions and exclusions:

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Income | Page 27 This section lists common types of income and whether or not staff include the income in the WIC eligibility assessment. In general, staff must count all sources of income in the assessment and exclude only specific income types listed in federal regulations.

Inclusions: Staff must include the following types of income in the WIC income assessment:

1. Money received from employment for services including wages, salary, overtime, commissions, bonuses, or fees. 2. Disability payments including L & I (Labor and Industries) payments. 3. Social security benefits. 4. Supplemental Security Income (SSI). 5. Dividends or interest on savings or bonds. 6. Income from estates or trusts. 7. Net rental income. 8. Net income from farm and nonfarm self-employment. 9. Public assistance cash grants or welfare payments. 10. Unemployment benefits. 11. Government civilian employee or military retirement benefits or pensions. 12. Veteran's payments. 13. Private pensions or annuities. 14. Alimony (also known as spousal support or spousal maintenance) payments received. 15. Child support payments received. 16. Regular contributions from persons not living in the household. 17. Net royalties. 18. Other cash income which includes, but is not limited to, cash received or withdrawn from any source including savings, investments, trust accounts, and other resources which are readily available to the household. 19. Lump sum payments that represent new income such as: • gifts • inheritance • lottery winnings • Native American per capita payments (from casino revenues for example)

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| Page 28 Income • workman's compensation for lost income and severance pay See the “Lump Sum Payments” policy in this chapter. 20. Cash amounts withdrawn from Indian Trust Funds. 21. Student grants and scholarships, except those identified as income exclusions in federal regulations. See the income exclusion section below. 22. Veteran’s Education Program (VEP) also known as the GI Bill – one-time rural benefit payment. • A one-time rural benefit is given to those individuals who are eligible for this payment. Count this amount as income for the WIC assessment. • Other portions of the Post 9-11 GI Bill, such as tuition and fees paid directly to the school or a monthly housing allowance based on the Basic Allowance for Housing (BAH), don’t count as income for the WIC assessment. See the income exclusions section below. 23. Military cash allowances for uniforms and food. 24. Military pay for base pay, special duty, re-enlistment bonus, and Continental United States Cost of Living Allowance (CONUS COLA). • See below for the types of military pay excluded from the WIC income eligibility assessment. Note: See the Military Pay Code table in the Appendix which lists types of military pay and whether or not the income is included or excluded for the WIC income assessment.

Exclusions: Staff must not include the following types of income in the WIC income assessment:

1. Any income from the following grants, scholarships and loans: a. Pell Grant b. Supplemental Educational Opportunity Grant c. State Student Incentive Grants d. National Direct Student Loan e. PLUS f. College Work Study g. Byrd Honor Scholarships 2. Veteran’s Education Program (VEP) or GI Bill: Don’t count the following items related to the VEP or GI Bill as income for the WIC assessment:

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Income | Page 29 a. Deductions taken from military personnel’s income to fund the Veteran’s Education Program (VEP) or GI Bill. b. Tuition and fees paid directly to the school. This includes the “Yellow Ribbon Program” which provides additional assistance with tuition for more expensive private institutions, graduate school or out-of-state tuition. c. Post 9-11 GI Bill housing allowance. The Post 9-11 GI Bill may provide a monthly housing allowance based on the Basic Allowance for Housing (BAH). Staff don’t count this amount since Washington WIC doesn’t count BAH as income.

3. Payments or allowances received from the Home Energy Assistance Act of 1980. 4. Military housing allowances. 5. Military Overseas Continental United States Cost of Living Allowance (OCONUS COLA). 6. Combat-related pay. Pay received by a military service member because he or she is deployed to a designated combat zone. Don’t include combat-related pay when the service member: a. Receives it in addition to the basic pay. b. Receives it as a result of deployment to, or service in, an area that is designated as a combat zone. c. Didn’t receive this type of pay before his or her deployment to or service in the designated combat zone. • Examples of combat related pay include, but are not limited to: combat pay, Hazardous Duty Incentive Pay (HDIP), Hostile Fire/Imminent Danger Pay (HFD/IDP), Hardship Duty Pay (HDP), Foreign Language Proficiency Pay (FLPP), and Combat-related Injury and Rehabilitation Pay (CIP). • See the Appendix for the current list of designated combat zones. 7. In-kind housing or other in-kind benefits and payments, for example military on-base housing, medical services, etc. The following examples of in-kind benefits aren’t counted as income: a. When an employer lists a housing allowance on the check but the participant doesn’t actually receive it because it’s automatically sent to the housing provider; staff don’t count the amount as income. b. A woman lives with a family and provides child care in return for her housing. WIC doesn’t count the value of her housing as income. c. An employer places the employer contribution to health insurance premiums on a participant’s check then deducts the amount and pays it directly to the insurance company. The participant doesn’t receive the cash. The employer contribution is an in-kind benefit.

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| Page 30 Income 8. Loans, not including the amounts which the person has constant or unlimited access. • Exclude loans from banks or other sources (or a line of credit). These funds are only temporarily available. The person must repay them. 9. The value of Farmers Market Nutrition Program benefits. 10. The value of assistance to children or their families from the following programs: a. School Lunch Program b. Summer Food Service Program c. Child and Adult Care Food Program d. Special Milk Program e. School Breakfast Program f. Basic Food Program g. Food Distribution Program (on Indian Reservations) h. Food Bank Programs 11. Any child care payments from the following programs: a. TANF Child Care Program b. Title IV-A Child Care Program c. JOBS Child Care Program d. At-Risk Child Care Programs e. Child Care Development Block Grant 12. Lump sum payments that represent reimbursements including those received from insurance companies for loss or damage of property and payments of medical bills resulting from an accident or injury. 13. Earned Income Credit (EIC), a tax credit for families who work and have children. 14. Payments received under the Job Training Partnership Act from the following programs: a. Adult and Youth Training Programs b. Summer Youth Employment and Training Programs c. Dislocated Worker Programs d. Programs for Native Americans e. Migrant Seasonal Farmworkers Program f. Veterans Employment Programs g. Job Corps and AmeriCorp 15. Payments received under the Alaskan Native Claims Settlement Act. 16. Income derived from certain sub marginal land of the United States which is held in trust for certain Indian tribes.

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Income | Page 31 17. Any payment to volunteers under Title I (VISTA and others) and Title II (Retired Senior Volunteer Program, Senior Companions Program, and others). 18. Payment to volunteers under Section 8 of the Small Business Act (SCORE and ACE). 19. Payments under the Disaster Relief Act of 1974, as amended by the Disaster Relief and Emergency Assistance Amendments of 1989. 20. Payments received under the Carl D. Perkins Vocational Education Act and the Carl D. Perkins Vocational and Applied Technology Education Act Amendments of 1990. 21. Payments received due to the Agent Orange Compensation Exclusion Act. 22. Payments received from Wartime Relocation of Civilians under the Civil Liberties Act of 1988. 23. Reimbursements from the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970. 24. Payments received under the Old Age Assistance Claims Settlement Act, except for per capita shares in excess of $2,000. 25. Payments received under the Judgment Award Authorization Act. 26. Payments received under the Cranston-Gonzales National Affordable Housing Act, unless the family's income equals or exceeds 80% of the median income of the area. Note: The Housing and Urban Development (HUD) agency determines the "median income of the area.”. All recipients of payments under the Cranston-Gonzales National Affordable Housing Act and the Housing and Community Development Act of 1987 have incomes below 80% and 50% of the area, respectively. Therefore, WIC doesn’t count these payments as income for WIC eligibility purposes. Federal law requires that WIC states this information in the manual. 27. Payments received under the Housing and Community Development Act of 1987, unless the family's income increases at any time higher than 50% of the median income of the area. (See the Information section at the end of this policy.) 28. Payments to the Confederated Tribes and Bands of the following Indian Tribes: a. Yakama Indian Nation b. Apache Tribe of the Mescalero Reservation c. Grand River Band of Ottawa Indians d. Passamaquoddy Tribe e. Penobscot Nation f. Sac and Fox Indians (claims agreement) g. Navajo and Hopi Tribes (relocation assistance) h. Turtle Mountain Band of Chippewas (Arizona)

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| Page 32 Income i. Blackfeet Tribe (Montana) j. Gros Ventre Tribe (Montana) k. Assiniboine Tribes (Montana) l. Papago Tribe (Arizona) m. Red Lake Band of Chippewas n. Saginaw Chippewa Indian Tribe (Michigan) o. Chippewas Tribe (Mississippi) 29. Family Subsistence Supplemental Allowance (FSSA) Payments. 30. National Flood Insurance Program Payments. 31. Filipino Veterans Equity Compensation Fund payments as part of the American Recovery and Reinvestment Act of 2009 (ARRA) (Public Law 111-5).

PROCEDURE:

Staff:

A. Assess the applicant’s or participant’s income to determine what is counted or not counted for the WIC income assessment.

B. Enter income information in the person’s file on the Income Information screen.

1. Enter self declared income information from the past 30 days in the Self Declared Income field for participants who are adjunctively income eligible.

2. Enter income information in Income Detail section of the Income Information screen when assessing income-based eligibility.

C. Assess if the person is income eligible.

Information:

Examples of when to use current or annual income:

Federal guidance recommends using annual income in the following situations: • When a household member takes a temporary leave of absence from employment, such as family leave and receives a lower income during the leave. • For teachers paid during the school year (approximately 10 months) and on temporarily leave during the summer.

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Income | Page 33 • College students who work additional hours during the summer months or on breaks. • Seasonal work such as logging, fisheries, etc.

Federal guidance recommends using current income in the following situations: • Military reservists or National Guards who have a lower income when called to active duty. • People currently unemployed who have a lower income during the time of unemployment.

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| Page 34 Income POLICY: Lump Sum Payments

Staff must:

1. Count lump sum payments that represent new money intended as income. Examples include:

• Military re-enlistment bonuses • Gifts • Inheritances • Lottery winnings • Native American per capita payments (for example from casino revenues) • Workman’s compensation for lost income • Severance pay

2. Staff must not count these lump sum payments intended as reimbursements as income. Examples include:

• Reimbursements for lost or damaged property • Payments for medical bills resulting from an accident or injury

3. Determine what part of the payment is new income and what part is a reimbursement if the lump sum payment represents both categories.

4. Require proof of income for the lump sum payment when all or part of the lump sum payment is considered income for the WIC income eligibility assessment.

Note: See the Military Income Guide staff tool for guidance about which types of military lump sum payments count as income and which don’t.

PROCEDURE:

Staff:

A. Assess the lump sum payment to determine if all or part of it counts as income based on the guidelines above.

B. Count the lump sum payment (or the part of the lump sum payment that is new income) as income for the WIC income eligibility assessment.

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Income | Page 35

C. Enter the source, proof, frequency, amount and duration in the file.

1. For a one time lump sum payment, document “annual” for the frequency and leave the duration as “1”.

2. If the household receives the lump sum more often than one time per year, document the appropriate frequency or duration in the Income Details.

3. When a household receives income at different frequencies, Cascades compares the total income to WIC’s annual income guidelines.

D. Assess income eligibility based on WIC income guidelines.

1. See the policy “Annual Income” in this chapter for more information.

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| Page 36 Income POLICY: Zero Income

If an applicant, participant, parent guardian, or caretaker reports "zero" income, staff must:

1. Ask additional questions to determine if there is any financial or other support for living expenses. Examples include: • Financial support from other people, like family or friends. • Financial support (cash) from an organization. • Resources that are readily available to the person, such as money received or withdrawn from any source including savings, investments, trust accounts, etc.

2. Consider this information for the income eligibility determination.

3. Have the participant, parent guardian, or caretaker sign the Statement of Income Form (Affidavit for Income) when he or she has zero income. • This form isn’t required when the person is adjunctively eligible for WIC and shows proof of eligibility, even if the person reports zero income. • The proof of adjunctive eligibility is proof of income eligibility for WIC and income is self-declared.

Note: Staff can accept a written statement from a reliable third party who knows the household’s circumstances and can attest that family has no income. • See the “Reliable Third Party Statement” policy for more information about using this as proof of income instead of the Statement of Income Form (Affidavit for Income).

4. Select the appropriate Zero Income Declaration Reason.

PROCEDURE:

Staff:

A. Follow procedures in this chapter for income eligibility determination.

B. Ask the person reporting zero income to describe his or her living circumstances to assess if there is another source of support and to identify referral needs.

1. Ask how the person has shelter, food, clothing or medical care.

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Income | Page 37 • This helps staff assess if the participant is adjunctively eligible due to an income-qualifying program. • Staff may find sources of income to count, or determine the person is part of the economic unit of the household that’s supporting the person.

C. Select the Zero Income Declaration Reason.

D. Have the participant, parent guardian, or caretaker sign the Statement of Income Form (Affidavit for Income) electronically on the Certification Signature screen.

1. Staff can use a third party statement for proof of income and the person doesn’t need to sign the Statement of Income Form (Affidavit for Income).

E. Refer the household to the Family Health Hotline (1-800-322-2588) for help finding financial, food and medical assistance programs. It’s important for staff to follow-up on the referrals the following month.

Information:

Clinic staff ask follow-up questions of all persons reporting zero income about their living situation and how they get basic living necessities such as food, shelter, medical care and clothing. WIC can help people with zero income not only by providing WIC services but also through referrals to local sources of aid and assistance. Given WIC’s definition of household size and income, zero income should occur rarely and usually on a temporary basis. The Statement of Income Form (Affidavit for Income) is available in many languages on the DOH-WIC website.

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| Page 38 Income Section 5: Documenting Income Information

POLICY: Requirement to Document Income Information

Staff must document the household’s income eligibility information on the Income Information screen in Cascades.

Note: Cascades will automatically document the person logged on to the computer and the date.

PROCEDURE:

Staff enter the following information on the Income Information screen:

A. Family size/Number in household.

• Enter the household size and the number of expected infants (if applicable).

• See the “Household Size” policy in this chapter.

B. Adjunctive eligibility when it applies.

1. Select the adjunctive eligibility box(es) for each individual participant when he or she self-reports current participation in one or more of the programs listed.

2. Verify current participation by conducting an Adjunct Program Verification - ProviderOne search through Cascades or viewing a current eligibility award or notification letter.

3. Document self-declared household income from the past 30 days in the Self Declared Income field when adjunctive eligibility is verified.

• Cascades calculates adjunctive eligibility according to WIC regulations. • See the adjunctive eligibility policies in this chapter for more information.

C. Document Income Details when adjunctive eligibility doesn’t apply or can’t be verified.

1. Source of income. • See the “Income Sources” policy in this chapter.

2. Type(s) of proof shown for income.

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Income | Page 39 • See the “Proof of Income” policy in this chapter for information about acceptable types of income documentation.

3. Frequency - how often the person or a household member receives income. • See the “Income Frequency” policy for more information.

4. Amount.

a. Document income from paystubs, etc. when assessing income-based eligibility. • See the “Definition of Income” policy to determine what to include and not include.

5. Duration

a. Duration defaults to the annual equivalent.

b. Change duration to the amount of time the income was received if it wasn’t for the entire last year.

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| Page 40 Income POLICY: Income Sources

Staff must document the source(s) of household income when assessing income-based eligibility.

The sources of income are defined as follows:

1. Employment – Money earned from employment (working). Includes wages, salary, overtime, commissions, bonuses and fees. Don’t use this selection for military income. 2. Military – Includes money earned from military employment including Army, Navy, Air Force, Marines, Coast Guard, etc.; doesn’t include civilian employment on a military base. See the “Definition of Income” policy for information about which types of military income to count when determining WIC income eligibility. 3. Self-employment – Money earned from working for oneself. 4. Unemployment – Includes Unemployment Insurance (UI) benefits. 5. Public Assistance – Includes any cash assistance including Temporary Assistance for Needy Families (TANF). This doesn’t include medical assistance or the value of benefits received from the Basic Food Program (SNAP). 6. Foster Care – Document the Foster Care Maintenance Grant as the source of income for foster children. Count a foster child as a household of one. See Required Guidance: Chapter 25, Section 4 Custody. 7. Child Support – Money an absent parent pays on a regular basis to help support his or her child. 8. Spousal Support – Money received from a former spouse for support.

9. Supplemental Security Income (SSI) –Money paid to a person who is disabled and has a low income level. 10. Scholarships or grants – See the “Definition of Income” policy in this chapter for more information about types of student financial aid, grants and loans that are included in WIC’s income eligibility assessment. 11. Native American Per Capita Payments – Distribution of money to all members of a tribe, for example proceeds from casino revenues. 12. Money from Relatives or Friends – Regular contributions from persons not living in the household. 13. Veteran’s Benefits – Financial payments made to veterans, their spouse or dependents. 14. Retirement/Pension (civilian or military) – Retirement benefits or pensions received from an employer, the government/military.

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Income | Page 41 15. Workers’ Compensation, Disability or Labor and Industries (L & I) – Compensation for a person who is unable to work. 16. Other - Miscellaneous sources of income such as dividend or interest income, amounts withdrawn from savings, contributions from another person, etc.

PROCEDURE:

Staff:

A. Select each source of the household’s income in the Income Details section of the Income Information screen in Cascades.

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| Page 42 Income POLICY: Proof of Income

Staff must:

1. View and document proof of each source of the household’s income when completing an income-based assessment. • Proof includes written (paper), or electronic proof of income.

2. Require proof of income for the timeframe assessed:

a. Current income - All paystubs or other documentation for all sources of household income for the past 30 days. • For example, a person who gets paid bi-weekly needs to show all paystubs from the past 30 days, even when he or she gets paid the same amount each pay period.

b. Annual income - All paystubs or other documentation for all sources of household income for the past 12 months.

3. Not make paper copies or scan proof of income documents. • Federal regulations don’t require copying or scanning income documentation and therefore the Washington WIC program doesn’t allow this practice. See the following policies when the person doesn’t bring proof of income eligibility: • “Temporary Certification for Missing Proof of Income” • “No Proof of Income”

PROCEDURE:

Staff:

A. Review and document the person’s proof of all sources of household income when completing an income-based eligibility assessment.

1. Accept the following types of proof of household income, written or electronic:

a. Current pay stub(s) or Military Leave and Earning Statement (LES) for the reported interval: weekly, bi-weekly, twice-monthly, monthly or annual, for the past 30 days. b. Self-employment records.

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Income | Page 43

c. Unemployment benefits documentation. d. Public assistance award letter – for cash grants. e. Foster Care Maintenance Grant documentation – use as the foster child’s proof of income when adjunctive eligibility can’t be verified. f. Child support/Divorce decree documentation. g. Social Security/SSI award letter. h. Native American per capita documentation. i. Bank statement. j. Tax return (most recently completed) or W-2 Form(s). • It’s important to get the most current income information and documentation available for the WIC assessment. • Use W-2 forms and tax returns as a last resort for participants when other more current documents aren’t available. • A tax return is most commonly used for farmers and self- employed people because it’s often the most current documentation available and it’s easier to use to determine their net income. k. Veteran’s benefits documentation. l. Retirement/Pension benefits documentation. m. Workers’ compensation, disability, or Labor and Industries award letter. n. Other documents that show the household’s income.

B. Enter the income amount and how often received in the Income Details.

C. Determine and enter the Duration.

1. The Duration defaults to the annual equivalent.

2. Change the Duration to the actual duration the income was received in the past 12 months when assessing annual income.

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| Page 44 Income POLICY: Income Frequency

Staff must document the participant’s income frequency. This is how often the person receives income.

Use the following definitions:

• Hourly – The person gets paid by the hour. o Enter an hourly wage and the hours per week. Cascades multiplies the amount by the hours per week to convert to a weekly amount. o Cascades compares this to the weekly interval of WIC’s income guidelines.

• Weekly – The person is paid the same amount each week. o When the person gets paid a different amount each week, add the total from the last 30 days, divide by 4 and enter as a weekly amount.

• Bi-Weekly – The person is paid every other week.

• Twice-Monthly – The person is paid two times a month.

• Monthly – The person is paid once a month.

• Annually – Income received for one year. o Use this when annual income best reflects the household’s income, or when the household has multiple income intervals.

When a household receives income at different intervals, Cascades converts the income to the current annual amount to compare to WIC income guidelines.

PROCEDURE:

Staff:

A. Document the income frequency in Cascades using the definitions listed above.

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Income | Page 45 POLICY: Temporary Certification for Missing Proof of Income

Staff must:

1. Screen for income eligibility based on the self-reported amount when:

a. Staff can’t verify proof of participation for an income-qualifying program at the certification appointment, or

b. The applicant, participant or caregiver doesn’t bring proof of income to the certification appointment for an income-based assessment.

• See the “When to Assess Income Eligibility” section for more information. • See the “No Proof of Income” policy when proof of income doesn’t exist.

2. Complete the following when the self-reported amount meets WIC income guidelines:

a. Document the self-reported income amount in the Income Details. b. Document the proof as “Not Provided”. c. Provide a one month temporary certification for the missing proof. d. Issue one month of food benefits.

3. Fill out the Temporary Certification for Missing Proof of Income form and have the person sign the paper copy.

a. Document the self-reported income on the form and have the person sign. b. Use one form for household members who are certified with missing proof of income on the same day. c. Scan the form into Cascades on the Income Information screen.

4. Require the missing proof showing WIC income eligibility before staff provide a second month of WIC benefits.

Note: Cascades prints temporary certification information on transfer information.

PROCEDURE:

Staff:

Volume 1, Chapter 6

| Page 46 Income A. Assess income eligibility based on self-reported information when the person doesn’t bring proof of income or proof of participation for an income-qualifying program to the initial certification, subsequent certification or when the person reports a change that can affect WIC eligibility.

B. If the self-reported income is WIC eligible, document the amount on the Temporary Certification for Missing Proof of Income form, have the person sign and scan the form into the person’s file.

1. Participants certified on the same day can use one form for the temporary certification for missing proof of income.

2. Staff can use a separate form for each household member if that’s clinic practice.

C. Select “Not Provided” as the proof of income in the participant’s file.

D. Give a one month of benefits under the temporary certification.

E. Let the person know he or she can’t receive additional benefits until the missing proof is provided and it confirms income eligibility.

1. This gives the required 20-day notice of program ineligibility if the person doesn’t bring in proof of income or it doesn’t meet WIC guidelines.

F. Assess income eligibility when the participant, parent guardian, or caretaker brings the proof the following month.

1. Enter the income in the participant’s file and the type of proof seen. The proof can be:

a. Paystubs or other documentation of household income.

b. Proof of current eligibility for an income-qualifying program.

2. Continue to provide WIC benefits if the participant is income eligible.

3. Take the participant off WIC if the participant isn’t income eligible.

a. Give a completed “Not Eligible” letter.

b. The participant or caregiver isn’t required to repay WIC for the one month of benefits received.

Volume 1, Chapter 6

Income | Page 47 Information:

Local agencies can help decrease the number of participants who come to the clinic without proof of income by letting them know what they should bring to each appointment. Staff can mark this information on the WIC ID and Card Folder.

The Temporary Certification for Missing Proof of Income form is available in many languages on the DOH-WIC website.

Volume 1, Chapter 6

| Page 48 Income POLICY: No Proof of Income

In limited situations households aren’t required to provide proof of income. In these cases the participant, parent guardian or caretaker must sign the Statement of Income Form (Affidavit for Income) electronically in Cascades.

Staff must:

1. Use the Statement of Income Form (Affidavit for Income) only for people who:

• Have zero income. o See the “Zero Income” policy. • Work for cash and don’t receive income documentation. • Had income documentation destroyed, for example in a house fire or natural disaster. • Are homeless. • Are migrants. o See the “Assess Migrant Income” policy.

2. Not limit the number of times a household can use the Statement of Income Form (Affidavit for Income) as long as it’s appropriate according to the policy requirements listed above.

PROCEDURE:

Staff:

A. Assess if the household meets the policy requirements to use the Statement of Income Form (Affidavit for Income).

B. Document household size and self-reported income, and assess income eligibility based on WIC guidelines.

C. Select Statement of Income Form – Affidavit for Income as the proof of income in the Income Details section.

D. Have the participant, parent guardian, or caretaker sign the Statement of Income Form (Affidavit for Income) electronically. • The Statement of Income Form (Affidavit for Income) is available in many languages on the DOH-WIC website.

Volume 1, Chapter 6

Income | Page 49 POLICY: Reliable Third Party Statement

Staff can accept a written statement from a reliable third party with knowledge of the household’s income for proof of income.

Staff typically use this method when proof doesn’t exist or isn’t readily available, and the situation doesn’t meet the criteria for using the Statement of Income Form (Affidavit for Income).

Example: Staff accept a reliable third party statement when proof of income exists, but requiring it would lead to personal harm or endanger the person’s living situation, such as: • Domestic violence situations • Pregnant teens who might be told they have to leave home

1. Reliable parties might include employers, staff of a social service agency, church, relief organization, legal aid society, school counselor or nurses, etc.

2. In these cases, the Statement of Income Form (Affidavit for Income) isn’t required; the statement from the third party is the proof of income.

PROCEDURE:

Staff:

A. Accept statements from reliable third parties when the participant or caregiver can’t provide proof of income and doesn’t meet the criteria for using the Statement of Income Form (Affidavit for Income).

B. Document income information and assess for WIC eligibility.

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| Page 50 Income POLICY: Verify Income When Information is in Question

Staff must verify the household’s income if:

1. There’s reasonable evidence the participant, parent guardian or caretaker gave inaccurate, inconsistent or untrue information.

2. The Local Agency verifies income as a standard practice for all programs in order to receive services.

• The local agency must have a written policy approved by state WIC staff when the agency verifies income as a standard practice. • The Local Agency must be fair and consistent about requiring income verification.

Income verification means checking the household’s income through another source. Examples of income verification include but are not limited to: contacting the employer to verify wages, contacting the local Community Services Office (CSO), asking for more or different types of proof of income from the participant, or asking for a statement from a reliable third party with knowledge of the participant’s income, etc.

PROCEDURE:

Staff:

A. Determine if there’s evidence to suspect the person gave inaccurate or untrue income information to WIC.

1. Talk with clinic coordinator or supervisor about concerns and issues about income information.

B. Verify the household’s income:

1. Ask the participant, parent guardian or caretaker to bring pay stubs or other types of proof of income to the clinic for further assessment.

2. Verify income through another source, like an employer or a reliable third party like a community service organization.

C. Document the income verification and source of verification in the file.

Volume 1, Chapter 6

Income | Page 51 1. Determine if the participant, parent guardian, or caretaker reported inaccurate income and assess if it was an accidental error or on purpose.

a. If the participant, parent guardian, or caretaker made an error and is over income, explain the situation and take the family off WIC after providing the required 20-day notification of ineligibility for WIC benefits.

b. If it appears the participant, parent guardian, or caretaker gave untrue information on purpose, contact the Program Compliance Unit at the state WIC office. See Volume 1, Chapter 2 - Program Compliance for more information.

D. Follow agency policy when the agency requires all programs to verify income in order to receive services.

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| Page 52 Income Section 6: Annual Income

POLICY: Annual Income

Staff must:

1. Use annual income from the past 12 months to determine eligibility instead of current income when it’s a better indicator of the household’s financial status.

a. Use annual income to account for: • Highs and lows in income due to seasonal employment • Fluctuations in income • A lump sum payment • A recent increase that puts the household’s current income above WIC’s guidelines

b. Use the current income during unemployment for households with unemployed adult members if this makes them WIC eligible.

2. Require proof of income for each of the past 12 months when assessing annual income.

• See the "Temporary Certification for Missing Proof of Income” policy in this chapter when the person doesn’t bring proof of income.

3. Have the applicant, participant or caregiver sign the Statement of Income Form (Affidavit for Income) when:

• Proof of income doesn’t exist for one or more of the past 12 months. • The person had zero income for one or more of the past 12 months.

See the “Zero Income” and “No Proof of Income” policies in this chapter for more information.

PROCEDURE:

Staff:

A. Use annual income when it’s a better indicator of the household’s income.

Volume 1, Chapter 6

Income | Page 53 B. Enter the household’s income source, type of proof seen, frequency, amount and duration in the Income Details.

1. Use the Duration field to document how long the specific type of income was received by the household during the past 12 months.

2. Provide a temporary certification for missing proof when appropriate. See the "Temporary Certification for Missing Proof of Income” policy for more information.

3. Use the Statement of Income Form (Affidavit for Income) for any months when proof of income doesn’t exist or there was zero income and have the applicant, participant or caregiver sign.

• See the “No Proof of Income” policy in this chapter for more information.

C. Assess income eligibility based on the household’s income from the past 12 months using WIC income guidelines.

D. Refer applicants and participants who aren’t income eligible to the Family Health Hotline (1-800-322-2588) for help finding other health and social services.

• See Volume 1, Chapter 12 – Referrals for more information.

Information:

Staff can use a year-to-date amount on a check stub as proof of income for the months it covers when assessing annual income. The person needs to bring proof for the rest of the 12 months not included in the year-to-date amount.

The Statement of Income Form (Affidavit for Income) is available in many languages from the DOH-WIC website.

Volume 1, Chapter 6

| Page 54 Income Section 7: Appendix

Volume 1, Chapter 6

Income | Page 55 Washington State Department of Health WIC Income Eligibility Guidelines 2026 – 2027 WIC Income Eligibility Guidelines Effective Date: 07/01/2026

Table of WIC Eligibility by Gross Income and Household Size

Household Size Annual Monthly Weekly Bi-Weekly Twice Monthly 1 $29,526 $2,461 $568 $1,136 $1,231 2 $40,034 $3,337 $770 $1,540 $1,669 3 $50,542 $4,212 $972 $1,944 $2,106 4 $61,050 $5,088 $1,175 $2,349 $2,544 5 $71,558 $5,964 $1,377 $2,753 $2,982 6 $82,066 $6,839 $1,579 $3,157 $3,420 7 $92,574 $7,715 $1,781 $3,561 $3,858 8 $103,082 $8,591 $1,983 $3,965 $4,296 9 $113,590 $9,466 $2,185 $4,369 $4,733 10 $124,098 $10,342 $2,387 $4,773 $5,171 11 $134,606 $11,218 $2,589 $5,178 $5,609 12 $145,114 $12,093 $2,791 $5,582 $6,047 13 $155,622 $12,969 $2,993 $5,986 $6,485 14 $166,130 $13,845 $3,195 $6,390 $6,923 15 $176,638 $14,720 $3,397 $6,794 $7,360 16 $187,146 $15,596 $3,599 $7,198 $7,798 17 $197,654 $16,472 $3,802 $7,603 $8,236 18 $208,162 $17,348 $4,005 $8,008 $8,674 19 $218,670 $18,224 $4,208 $8,413 $9,112 20 $229,178 $19,100 $4,411 $8,818 $9,550

For each additional member add: Annual

Monthly

Weekly Bi-Weekly

Twice- Monthly $ 10,508 $ 876 $ 203 $ 405 $ 438

Weekly:

Receives income every week. Bi-Weekly:

Receives income every 2 weeks. Twice Monthly: Receives income two times a month. Monthly:

Receives income once a month. Annual:

Total income for 1 year.

Volume 1, Chapter 6

| Page 56 Income Income Conversion Factors: 1. If a household has only one source of income, or if all the sources are paid at the same interval, compare the income to the same interval of the WIC income guidelines for the household size. 2. If a household has income sources at more than one interval, annualize all income and compare to the “Annual” column of the income guidelines. To annualize, multiply: o Weekly x 52 o Twice-Monthly x 24 o Bi-Weekly x 26 o Monthly x 12

Volume 1, Chapter 6

Income | Page 57 Military Pay Codes: This table lists military pay codes and the type of pay each code represents. = Count as Income ? = Ask Questions to see if the pay is combat-related  = Don’t Count as Income

Code Count as income Type of Pay AB  Accession bonus ACIP  Aviation Career Incentive Pay ACP  Aviation Continuation Pay AIP ? Assignment Incentive Pay ASP  Additional Special Pay BAH  Basic Allowance for Housing BAS  Basic Allowance for Subsistence BAQ  Basic Allowance for Quarters Base Pay or BASE  Base Pay BCP  Board Certified Pay Special Pay CCA  Civilian Clothing Allowance BRA  Basic Replacement Allowance Continuation Pay  Continuation Pay CCCA  Continuing Civilian Clothing Allowance CCRA  Cash Clothing Replacement Allowance CEFIP  Career Enlisted Flyer Incentive Pay CIP  Combat-related Injury & Rehabilitation CMA or CLOTHING  Clothing Maintenance Allowance or Clothing Allowance CMAI  Civilian Clothing Maintenance Allowance CONUS COLA or COLA  Continental U.S. Cost of Living Allowance Combat Duty or Combat Zone Pay  Combat Duty or Combat Zone Pay CRA  Clothing Replacement Allowance CSP or CARSEA  Career Sea Pay CSP-P  Career Sea Pay – Premium CSRB  Critical Skills Retention Bonus CVI  Conditional Voluntary Indefinite Status DLA  Dislocation Allowance Dive Pay ? Dive Pay DSCT Meal  Discount Meal

Volume 1, Chapter 6

| Page 58 Income Military Pay Codes

= Count as Income ? = Ask Questions to see if the pay is combat-related  = Don’t Count as Income

Code Count as income Type of Pay FDP ? Foreign Duty Pay FLPP ? Foreign Language Proficiency Pay Flight, Fly Pay, or FLY ? Flight or Fly Pay FSA ? Family Separation Allowance FSH  Family Separation Housing FSSA  Family Subsistence Supplemental Allowance HALO ? High Altitude/Low Altitude HDIP ? Hazardous Duty Incentive Pay HDP – Involuntary Extension ? Hardship Duty Pay – Involuntary Extension HDP – L ? Hardship Duty Pay - Location HDP – M ? Hardship Duty Pay – Mission HFP/IDP ? Hostile Fire/Imminent Danger Pay HFP-L ? Hostile Fire Pay - Location HZD ? Hazardous Duty Pay ICCA  Initial Civilian Clothing Allowance IDP ? Imminent Danger Pay • Can also mean Independent Duty Corpsman ISP  Incentive Special Pay Jump Pay or JUMP ? Jump Pay LQA  Living Quarters Allowance Maternity Clothing Allowance  Maternity Clothing Allowance MIHA – Miscellaneous  Moving Housing Allowance - Miscellaneous MIHA – Rent  Moving Housing Allowance – Rent MIHA – Security  Moving Housing Allowance - Security MRB  Multiyear Retention Bonus MSP  Multiyear Special Pay NIB  Nuclear Career Annual Incentive Bonus NPAB  Nuclear Power Accession Bonus Nuclear – Continuation Pay  Nuclear – Continuation Pay

Volume 1, Chapter 6

Income | Page 59 Military Pay Codes = Count as Income ? = Ask Questions to see if the pay is combat-related  = Don’t Count as Income

Code Count as income Type of Pay OEP  Overseas Extension Pay OHA  Overseas Housing Allowance OCONUS COLA  Overseas Continental United States Cost of Living Allowance OLA  Overseas Living Allowance OTEIP  Army Overseas Tour Extension Incentive Pay OVERSEAS COLA  Overseas Cost of Living Allowance Overseas Extension Pay  Overseas Extension Pay PCCA  Partial Civilian Clothing Allowance REBATE  Rebate RBMA  Reserve Basic Maintenance Allowance SBP  Military Survivor Benefits Plan SAVE PAY ? Save pay • Can represent many types of pay. Ask questions to determine what the pay is for to see if it counts. SDAP ? Special Duty Assignment Pay SDIP ? Submarine Duty Incentive Pay Sea Pay ? Sea Pay SEA  Subsistence Expense Allowance SEB  Selective Enlistment Bonus SepRats  Separation Rations SMA  Standard or Separate Maintenance Allowance Special Duty Pay ? Special Duty Pay SPEC  Special Forces Specialty Pay ? Specialty Pay SPO  Split Payment Option • This option lets the person take an amount from the base pay and put it into the ship ATM for personal use while on board. Base WIC income eligibility on the gross amount before the split allocation. Don’t count the amount sent to the ship account twice.

Volume 1, Chapter 6

| Page 60 Income Military Pay Codes

= Count as Income ? = Ask Questions to see if pay is combat-related  = Don’t Count as Income

Code Count as income Type of Pay SR  Separation Rations SRA  Standard Replacement Allowance SRB or SRBP  Selective Reenlistment Bonus Payment Standard Initial Clothing Allowance  Standard Initial Clothing Allowance Submarine Pay ? Submarine Pay SUPP CMA  Enlisted Supplemental Clothing Allowance TDY  Temporary Duty TDYCCA  Temporary Duty Civilian Clothing Allowance TLE CONUS  Temporary Lodging Expense in US TLA  Temporary Living Allowance TLA OCONUS  Temporary Lodging Allowance Outside US TQSA  Temporary Quarters Subsistence Allowance VI  Voluntary Indefinite Status VBSS Duty ? Maritime Visit, Board, Search & Seizure Duty VSP  Variable Special Pay

Questions to determine if pay is combat related WIC doesn’t count combat related pay in the income assessment.

Ask these questions to see if the pay is related to combat: 1. Does the person receive this pay in addition to the base pay? 2. Is this pay the result of deployment to a designated combat zone? See the list of Designated Combat Zones. 3. Does the person only receive this pay while deployed to the combat zone?

If Yes to all 3 questions don’t count as income. This qualifies as combat related pay.

If No to any of the questions, count as income. This doesn’t qualify as combat related pay.

Volume 1, Chapter 6

Income | Page 61 Designated Combat Zones WIC doesn’t count combat pay for income eligibility. Ask questions to see if the pay is combat related. One question is if the pay results from deployment to a designated combat zone. Combat zones are designated by Executive Order as areas in which the U.S. Armed Forces are engaging or have engaged in combat. Designated Combat Zones Adriatic Sea Sea and airspace Afghanistan Land and airspace Albania Land and airspace Arabian Peninsula Areas Land and airspace Arabian Sea North of 10 North latitude and west of 68 East longitude Bahrain Land and airspace Djibouti

Federal Republic of Yugoslavia Land and airspace Gulf of Aden Sea and airspace Gulf of Oman Sea and airspace Ionian Sea North of the 39th Parallel Iraq Land and airspace Jordan

Kosovo Land and airspace Kuwait Land and airspace Kyrgyzstan

Lebanon

Montenegro Land and airspace Oman Land and airspace Pakistan

Persian Gulf Sea and airspace Qatar Land and airspace Red Sea Sea and airspace Saudi Arabia Land and airspace Serbia Land and airspace Sinai Peninsula Land and airspace Somalia

Syria

Tajikistan

United Arab Emirates Land and airspace Uzbekistan

Yemen

Reviewed 12/2018

Volume 1, Chapter 6

| Page 62 Income Statement of Income Form (Affidavit for Income)

Volume 1, Chapter 6

Income | Page 63 Temporary Certification for Missing Proof of Income

Policy and Procedure Manual

Volume 1, Chapter 7 Rights and Responsibilities

Washington State WIC Nutrition Program DOH 960-367 January 2019

This institution is an equal opportunity provider. Washington State WIC Nutrition Program doesn’t discriminate. For persons with disabilities, this document is available on request in other formats. To submit a request, please call 1-800-841-1410 (TDD/TTY 1-800-833-6388).

Volume 1, Chapter 7

Rights and Responsibilities | Page i

Rights and Responsibilities

CONTENTS Section 1: Participant Rights and Responsibilities 1 POLICY: Inform Participants of their Rights and Responsibilities .................................... 1 Section 2: Appendix 5 Form: Rights and Responsibilities ................................................................................. 7

Volume 1, Chapter 7

| Page ii Rights and Responsibilities

Volume 1, Chapter 7

Rights and Responsibilities | Page 1 Section 1: Participant Rights and Responsibilities

POLICY: Inform Participants of their Rights and Responsibilities

Staff must:

1. Inform participants, parent guardians, and caretakers of their rights and responsibilities for the Washington WIC Nutrition Program at the following times: • Initial certifications, this includes when staff assign presumptive eligibility for pregnant participants. • Subsequent certifications. • When a participant transfers into the state. Note: There may be other times when state or local WIC staff review the Rights and Responsibilities with the participant, parent guardian or caretaker.

2. Verbally review the “My Rights” and “Agreement” sections of the Rights and Responsibilities form.

3. Provide the information in the person’s primary language, if available. • If no written translations are available in that language, staff must provide the materials in English and have an interpreter or the Language Line provide the information to the person.

4. Give the person the opportunity to discuss any concerns or ask questions about the Rights and Responsibilities form before signing.

The participant, parent guardian, or caretaker must:

1. Agree to the items in the “Agreement” section of the Rights and Responsibilities form in order to participate in WIC.

2. Sign electronically in Cascades to show agreement.

a. Staff have the person sign the paper copy of the form when Cascades is down or the power is out.

b. A proxy can’t sign the Rights and Responsibilities form.

Volume 1, Chapter 7

| Page 2 Rights and Responsibilities • A proxy is a person with permission to receive and sign for WIC food benefits and use the WIC Card at the store.

PROCEDURE:

Staff:

A. Inform participants, parent guardians, or caretakers of WIC’s Rights and Responsibilities at the following times:

1. Initial and subsequent certifications (includes when assigning presumptive eligibility)

2. Transfer-in appointments from out-of-state

B. Ask if the person would like to read both sides of the Rights and Responsibilities form themselves, or have staff read it to, or along with them.

1. Provide the form in the person’s language if available.

2. Read the form to the person, if the person asks.

3. Use an interpreter or a language interpreter service as needed.

C. Verbally review the My Rights and Agreement sections of the Rights and Responsibilities form.

1. Staff can paraphrase or use their own words to review these sections provided all topics are covered.

D. Give the person an opportunity to ask questions about the form before signing to show agreement.

E. Have the person sign electronically in Cascades.

1. Only one signature is required for participants in a household certified or transferred-in from out of state on the same day.

2. A separate signature is required for household members certified or transferred in on another day.

3. Staff document who signed the form electronically by selecting the person’s name in Cascades.

Volume 1, Chapter 7

Rights and Responsibilities | Page 3

4. Proxies can’t sign the Rights and Responsibilities form.

• A proxy is a person with permission to receive and sign for WIC food benefits and use the WIC Card at the store.

5. Have the person sign the paper form when there are computer issues or the power is out and the clinic is still seeing participants.

• Scan the signed form in to Cascades as soon as possible. • Staff document “scanned R and R” for the person’s electronic signature.

F. Document in Cascades on the Family Demographics screen Sticky Note when staff provide the information to the person using one of the following methods:

1. Interpreter, written translation, read to participant, and other.

2. Other – specify how staff provided the information.

G. Give the person a Rights and Responsibilities form to keep at the Initial Certification (includes when staff assign presumptive eligibility), and transfer into state appointment.

1. Staff can give the person a blank Rights and Responsibilities form or a copy of the signed form.

2. Ask if the person would like a copy of the Rights and Responsibilities form at subsequent certifications.

Information:

Staff can’t give information about WIC participants, parent guardians, or caretakers to other health services or social programs unless:

1. The local WIC clinic has a Memorandum of Understanding (MOU) with the organization.

• WIC staff must notify the participant in writing that the clinic shares information with the organization. • See Volume 1, Chapter 25 - Legal Considerations and Confidentiality for guidance about releasing participant information.

2. The person signed a separate release of information form.

Volume 1, Chapter 7

| Page 4 Rights and Responsibilities • See Volume 1, Chapter 25 Legal Considerations and Confidentiality for guidance about releasing participant information.

A sample copy of the Rights and Responsibilities form is in the Appendix. The form is available in many languages. Access the form in the following ways:

• Print in English and Spanish from Cascades. • Print additional languages from the DOH WIC website Cascades Forms and Materials page. • Order from the Department of Printing Fulfillment Center myPRINT.wa.gov website.

Volume 1, Chapter 7

Rights and Responsibilities | Page 5

Section 2: Appendix

Volume 1, Chapter 7

| Page 6 Rights and Responsibilities

Form: Rights and Responsibilities

Policy and Procedure Manual

Volume 1, Chapter 8 WIC Farmers Market Nutrition Program

Washington State WIC Nutrition Program DOH 960-367 Effective June 1, 2025

Volume 1, Chapter 8

This institution is an equal opportunity provider. Washington WIC doesn’t discriminate.

To request this document in another format, call 1-800-841-1410. Deaf or hard of hearing customers, please call 711 (Washington Relay) or email wic@doh.wa.gov.

Volume 1, Chapter 8

WIC Farmers Market Nutrition Program | Page i WIC Farmers Market Nutrition Program

CONTENTS Section 1: Participant Eligibility and Farmers Market Nutrition Program Benefit Issuance 1 POLICY: Local Agency FMNP Policy ......................................................................................... 1 POLICY: Participant Eligibility for FMNP Benefits .................................................................... 3 POLICY: Issue FMNP Benefits .................................................................................................. 4 POLICY: Issue FMNP Benefits at the Farmers Market ............................................................. 8 Section 2: Offer Participant Education on Using FMNP Benefits 9 POLICY: Offer Participant Education on Using FMNP Benefits ................................................ 9 Section 3: Nutrition Education 12 POLICY: Nutrition Education ................................................................................................. 12 Section 4: Accountability and Security of Farmers Market Nutrition Program Benefits 14 POLICY: Accountability of WIC Farmers Market Nutrition Program Benefits ........................ 14 Section 5: WIC Farmers Market Nutrition Program Complaints 15 POLICY: FMNP Complaints .................................................................................................... 15 Section 6: Appendix 16 Guide to Writing a FMNP Policy for Benefit Issuance ............................................................ 17 Eligible WIC FMNP Foods ....................................................................................................... 18 Foods not Eligible to Purchase at Farmers Markets ............................................................... 19

Volume 1, Chapter 8

WIC Farmers Market Nutrition Program | Page 1 Section 1: Participant Eligibility and Farmers Market Nutrition Program Benefit Issuance

POLICY: Local Agency FMNP Policy

Local agencies must:

1. Develop a written WIC Farmers Market Nutrition Program (FMNP) benefit issuance policy by May 31st, prior to each season. Food and Nutrition Service (FNS) requires a new policy each season.

Note: • Staff can review and update the previous year's FMNP policy to meet this requirement, including the date the policy was updated. • Staff may use the Local Agency FMNP Policy template to develop their agency policy to meet this requirement. o Refer to the Local Agency FMNP Policy template.

This policy must:

1. Describe how the local agency plans to distribute FMNP benefits equitably, securely, and by the state set deadline.

2. Follow WIC civil rights practices for FMNP benefits issuance and activities. Ensure that staff issue FMNP benefits to all eligible participants consistently and equitably. o Refer to Volume 1, Chapter 20 - Notification, Fair Hearings and Civil Rights.

3. Ensure staff issue FMNP benefits in compliance with state and federal confidentiality laws. o Refer to Volume 1, Chapter 25 – Legal Considerations and Confidentiality.

4. Ensure staff don’t issue FMNP benefits to themselves, family members, or friends. o Refer to Volume 1, Chapter 2 – Program Compliance.

5. Ensure all staff involved in FMNP complete the FMNP training for the current season.

6. Be reviewed annually by staff who issue FMNP benefits.

7. Be accessible to all staff for reference.

Volume 1, Chapter 8

WIC Farmers Market Nutrition Program | Page 2 8. Be accessible to participants upon request.

9. Be kept on file for four years.

PROCEDURE:

Staff:

A. Develop a local agency FMNP policy that includes all details required by state policy. Options include:

1. Update the previous year’s policy with information for the upcoming season. Be sure to include the date the policy was updated.

2. Fill in your agency’s information in the Local Agency FMNP Policy template to reflect your plans for offering FMNP benefits for the upcoming season.

o See Local Agency FMNP Policy template in the Appendix.

Refer to “Guide to Writing a FMNP Policy for Benefit Issuance” in the appendix.

B. Make policy accessible to staff and participants.

C. Keep the current FMNP policy and staff training log on file for four years.

Volume 1, Chapter 8

WIC Farmers Market Nutrition Program | Page 3 POLICY: Participant Eligibility for FMNP Benefits

Staff must offer FMNP benefits to all eligible participants in active status.

Participants eligible for FMNP benefits include:

1. Pregnant participants, including those presumed eligible.

2. Breast/chest feeding participants with active eligibility, including those past 6 months postpartum who receive breastfeeding support without food benefits. • Staff must not issue FMNP benefits to a breast/chest feeding participant on or after her child’s first birthday regardless of active eligibility.

3. Non-breast/chest feeding postpartum participants. • Non-breast/chest feeding postpartum participants are eligible to receive FMNP benefits through the end of the month in which the infant turns 6 months of age.

4. Children ages 1 - 5 who have current eligibility. • Infants before their first birthday aren’t eligible to participate in FMNP. • Staff can issue FMNP benefits to eligible children on or after the first birthday. • Staff can issue FMNP benefits to eligible children on or before their 5th birthday.

PROCEDURE:

Staff:

A. Assess participants’ eligibility for FMNP benefits.

B. Issue FMNP benefits.

• See the “Issue FMNP Benefits” policy in this chapter for more information.

Volume 1, Chapter 8

WIC Farmers Market Nutrition Program | Page 4 POLICY: Issue FMNP Benefits

Staff must offer FMNP benefits to all eligible participants in active status.

Staff must:

1. Screen eligible participants for their interest and ability to use the FMNP benefits.

a. Participants, Parent Guardians, Caretakers, and Proxies must show personal identification (ID) to receive FMNP benefits at in-person appointments.

b. Staff don’t need to see participant’s or caretaker’s identification when issuing FMNP benefits remotely.

• See Volume 1, Chapter 22 – Issue WIC Food Benefits, Identification to Receive WIC Food Benefits for a list of acceptable proof of ID.

Note: Limited FMNP funding doesn’t allow all eligible participants in Washington State to receive FMNP benefits. Therefore, it’s important to screen participants for their interest and ability to use the benefits at authorized farmers markets and farm stores.

2. Provide QR codes to participants. Participants use QR codes for redeeming benefits at authorized farmers markets and farm stores.

a. Clinic staff order WIC Cards with QR codes from the Fulfillment Center and distribute them to participants as needed.

b. Staff provide WIC Cards in person or by mail depending on participant’s preference. When mailing a WIC card with QR code, staff:

• Verify the participant’s address. • Include the Mailed WIC Card Letter and the WIC card with QR code printed on it. • Use an opaque (security) envelope when possible. If using a regular or window envelope, wrap the Mailed WIC Card Letter around the WIC Card with QR code. • Write or stamp on the envelope, “DO NOT FORWARD, RETURN TO SENDER.” • Write or stamp the return address of the WIC clinic on the envelope.

Volume 1, Chapter 8

WIC Farmers Market Nutrition Program | Page 5 • Staff don’t have to reclaim a deactivated or replaced WIC Card. o If a participant returns a deactivated or replaced card, destroy it by cutting the card in half.

c. Participants who have the WICShopper App can find their QR code in the app.

d. For participants who don’t have the WICShopper App or a WIC Card with a QR code, state staff generate and provide the QR codes electronically via text or email, or by mail depending on participant preference as needed.

3. Issue FMNP benefits to each eligible participant, up to the maximum for the family.

a. Issue FMNP benefits in Cascades on the Issue FM Food Instruments screen.

• Cascades will only allow staff to issue the amount of FMNP benefits allowed by federal regulations. • Cascades documents issuance in the participant’s file.

4. Provide information about how and where to use FMNP benefits, including directing them to the closest eligible farmers markets or farm stores, what market items can be purchased, and detailing efficient use of the benefits at the market. Staff document how this information was provided in the Family Alert.

5. Offer information about seasonal produce, (i.e., purchasing, storing, preparing, and using fresh fruits and vegetables).

• Staff offer nutrition education about fruits and vegetables to all FMNP participants between March and October in the farmers market year, and within the participant’s current certification. • See the “Nutrition Education” policy in this chapter for more information.

6. Document nutrition education in each participant’s Individual Care Plan.

PROCEDURE:

Staff:

A. Assess participant eligibility, interest, and ability to use FMNP benefits during the appointments before the FMNP season begins, usually in February or March and document in the participant’s Individual Care Plan for follow up at the next appointment during the FMNP season.

Volume 1, Chapter 8

WIC Farmers Market Nutrition Program | Page 6

B. When providing FMNP benefits in person, view the ID of the participant, parent guardian, caretaker, or proxy before issuing food benefits. For remote benefit issuance follow the “Remote Benefits Issuance” policy.

C. Issue benefits to participants in the amount determined by policy.

D. Begin issuing FMNP benefits June 1st.

1. Once benefits are issued, the benefits remain in the participant benefit account until the end of the season or until they are used.

2. Benefits will expire on October 31st.

3. Participants should have as many months as possible of FMNP season to spend their benefits.

E. Issue all FMNP benefits by September 30th of the current year.

1. Participants have until October 31st of the current year to use FMNP benefits at authorized farmers markets and farm stores.

2. Contact the state WIC staff if your agency can’t issue all FMNP benefits by August 1st. State WIC staff can redistribute unissued benefits.

• Best Practice- Document a Family Alert that FMNP benefits were issued. Set the end date to 10/31 of the current year for the alert to dismiss at the end of the season.

F. Provide and document information about how and where to use the FMNP benefits, including directing the participant to the closest eligible farmers markets or farm stores, what market items can be purchased and how to use benefits at the market or farm stores.

• Refer “Offer Participant Education on Using FMNP Benefits” policy for what information to provide participants and how to document in the participant’s file.

G. Document nutrition education provided about seasonal fruit and vegetables in each participant’s Individual Care Plan.

• Refer to “Nutrition Education” policy in this chapter for more information.

Volume 1, Chapter 8

WIC Farmers Market Nutrition Program | Page 7 H. If participants transfer out of state, document FMNP benefit issuance on the transfer card to prevent over issuance of FMNP benefits. Refer to Volume 1, Chapter 21 - Transfer Verification of Certification.

I. If the WIC Card is lost or stolen card, refer to the “Replace WIC Cards” policy in Volume 1, Chapter 22 – Issue WIC Food Benefits.

Volume 1, Chapter 8

WIC Farmers Market Nutrition Program | Page 8 POLICY: Issue FMNP Benefits at the Farmers Market

Staff may issue FMNP benefits and provide fruit and vegetable nutrition education at the local farmers market during market hours.

When this option is used staff must:

1. Assure participant confidentiality at the farmers market.

• See Volume 1, Chapter 25 - Legal Considerations and Confidentiality for more information.

2. Follow the “Use a Secure Network to Access Cascades” policy in Volume 2, Chapter 8 – Electronic Devices, Security and Service Interruption Plan.

• Staff must not use public Wi-Fi to access Cascades.

3. Follow the requirements in the “Issue FMNP Benefits” policy in this chapter.

4. Only issue FMNP benefits and provide fruit and vegetable nutrition education at the farmers market and not complete certifications or other services.

• Staff may collect the name and phone number of potential applicants to call when back in the clinic.

• Issuing FMNP benefits and providing a fruit and vegetable nutrition education contact at the farmers market doesn’t make the market a “clinic.”

o See Volume 2, Chapter 8 – Electronic Devices, Security and Service Interruption Plan for more information about providing WIC services only at state-approved clinics.

5. Include procedures for issuing FMNP benefits at the farmers market in the Local Agency Farmers Market policy.

• See the “Local Agency FMNP Policy” in this chapter.

Information: Contact your Local Program Consultant for options if you need MiFi to issue FMNP benefits at the farmers market.

Volume 1, Chapter 8

WIC Farmers Market Nutrition Program | Page 9 Section 2: Offer Participant Education on Using FMNP Benefits

POLICY: Offer Participant Education on Using FMNP Benefits

Staff must offer participants, parent guardians, caretakers, and proxies information about how and where to use FMNP benefits. Check in with participants about using their benefits at the farmers market and farm stores at the next appointment.

The Washington WIC Rights and Responsibilities form that the participants sign at their certification appointment also applies to participating in the FMNP. • All statements related to WIC retailer staff apply to farmers market staff, farm stores, and growers. • Refer to Volume 1, Chapter 7 - Rights and Responsibilities.

PROCEDURE:

Staff:

A. Provide all participants or parent guardians receiving FMNP benefits the following Benefit Issuance Education (BIE):

1. A “WIC and Senior Farmers Market Nutrition Program” brochure. Offer a printed copy, a link to brochure on the website or in WICShopper app. The brochure has information about how to use WIC FMNP benefits, not accepting cash or tokens, where to make a complaint, ideas for safe storage, and tips for eating more fresh produce.

Note: Staff can order the printed copies of the brochure in additional languages from myPrint.

2. A printed list, a link to webpage or list in WICShopper app of the authorized farmers markets and farm stores or the website with information about the location, days and hours of operation, payment options (SNAP or Matching Program).

B. Explain to participants how to use the benefits including:

1. The dollar value of their benefit.

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WIC Farmers Market Nutrition Program | Page 10 2. Which locally grown produce can be bought using FMNP benefits (fresh fruits and vegetables, and fresh, cut edible herbs) See “Eligible Produce” list in the Appendix.

3. Which farmers markets and farm stores near them are authorized to accept FMNP benefits.

• Refer participants to the market and farm store list showing location and hours of operation. Indicate which are closest to them. • Participants can’t use FMNP benefits at grocery stores or wholesale stores.

4. How to find authorized growers at the markets that can accept FMNP benefits.

• WICShopper App directs participants to authorized markets and growers who are accepting FMNP benefits. • Tell participants to look for WIC and Senior Farmers Market Benefits Welcome Here signs to locate authorized growers and farm stores who accept FMNP benefits. Post a sign at the clinic. There’s a picture of the sign in the FMNP participant brochure.

Note: If clinics want a FMNP sign to post, contact state FMNP staff at FMNPteam@doh.wa.gov.

5. After selecting locally grown produce, show the grower the QR code, confirm the cost of the purchase, and enter the PIN into the grower’s mobile device. Participants shouldn’t verbally give their PIN to the grower.

• Participants can manually enter their WIC Card number if the QR code isn’t readable.

• See the How to Use Your WIC QR Code at Authorized Farmers Markets and Farm Stores.

6. The deadline to use FMNP benefits is October 31st of the current year.

7. WIC participants can’t exchange FMNP benefits for cash.

8. WIC participants won’t get change back, even if the food items total less than the maximum value on the benefit.

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WIC Farmers Market Nutrition Program | Page 11 • Participants may use a combination of FMNP benefits, monthly fruit and vegetable benefits (CVBs), cash, EBT card, debit card, or other forms of payment acceptable to the grower for purchases greater than the value of the FMNP benefits.

9. Produce purchased with FMNP benefits are for the WIC participant only.

10. Let the participant know they have a right to make a complaint if they have any concerns or problems using the FMNP benefits at the farmers market or a farm store.

• Share the link to the complaint form in the Farmers Market brochure, on the website or in the WICShopper app or print and give a hard copy of the complaint form. • The complaint form guides the participants how to make a complaint.

C. Document in the Family Alert that benefit issuance education was provided to participant and how the two required materials, WIC and Senior Farmers Market Nutrition Program brochure and growers list, were offered.

Examples of documentation may include: • FM BIE via Shopper app • FM BIE via links to webpage • FM BIE via printed copies

D. Ask participants about their shopping experience at the farmers market and/or farm stores at the next appointment and offer additional education as needed.

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WIC Farmers Market Nutrition Program | Page 12 Section 3: Nutrition Education

POLICY: Nutrition Education

Staff must offer nutrition education about fresh fruits and vegetables to all FMNP participants between March and October in the FMNP year and within the participant’s certification period.

Staff must document the nutrition education in each participant’s Individual Care Plan.

For participants who aren’t high risk:

• Staff may count nutrition education about fruits and vegetables offered to participants receiving FMNP benefits as a second contact, when the contact: o Includes education about fresh fruits and vegetables beyond how to use FMNP benefits. o Meets the requirements of a second contact, (i.e., includes the topic discussed, how the participant or caregiver feels about the topic, next steps or goals, and any additional supporting information). Note: Staff may provide the fruit and vegetable education in a group session and document the session in the participant’s file for the second contact.

For participants who are high risk:

• The registered dietitian (RD) can offer nutrition education on fresh fruits and vegetables during the high-risk visit in addition to education about the participant’s nutrition risk(s) if time allows.

PROCEDURE:

Staff:

A. Offer nutrition education about fresh fruits and vegetables to all FMNP participants between March and October and within the current certification. Work with the participant to identify which topic(s) to discuss. May include:

1. Encourage participants to increase their intake and variety of fresh fruits and vegetables by buying and using foods from their local farmers market or farm store.

Volume 1, Chapter 8

WIC Farmers Market Nutrition Program | Page 13 2. Offer information about buying, storing, preparing and using fresh fruits and vegetables at least one time within the current FMNP year and their current certification.

3. Use the FMNP benefits to open a discussion about selecting, storing, preparing, and/or eating fresh fruits and vegetables.

Note: Provide fruit and vegetable education at the next appointment if staff didn’t provide it when issuing FMNP benefits.

B. Document the fruit and vegetable nutrition education contact in each participant’s Individual Care Plan.

C. Document the nutrition education topic(s) discussed and mark as “Complete” in the Care Plan – Nutrition Education.

Information:

Below are examples of how clinic staff might offer nutrition education on fresh fruits and vegetables to FMNP participants.

1. Coordinate with Washington State University Extension, or other community organizations, to have speakers present nutrition education on how to purchase, store, and prepare fresh fruits and vegetables.

2. Invite Farmers Market managers to your clinic to share information about what’s available and how to use in-season produce available in your area.

3. Have a facilitated group discussion about using fresh fruits and vegetables prior to offering FMNP benefit education to the group.

4. Encourage participants to take a fruit and vegetable online lesson through WICHealth.

Volume 1, Chapter 8

WIC Farmers Market Nutrition Program | Page 14 Section 4: Accountability and Security of Farmers Market Nutrition Program Benefits

POLICY: Accountability of WIC Farmers Market Nutrition Program Benefits

The local agency must account for all WIC Cards with QR codes received from the Fulfillment Center.

• See WIC Card Inventory policy in Volume 1, Chapter 22 - Issue WIC Food Benefits.

The State WIC Office allocates FMNP benefits based on agency caseload and enters the benefits into each participating clinic site.

Local agencies can transfer FMNP benefit allocation from one clinic site to another clinic site within the agency.

Agencies must contact state staff if they don’t want or can’t issue FMNP benefits. The state will reallocate the benefits to another agency.

PROCEDURES:

Staff:

A. Follow policies for receiving and inventorying WIC Cards with QR codes from the state Fulfillment Center.

• See WIC Card Inventory policy in Volume 1, Chapter 22 - Issue WIC Food Benefits.

B. Contact state FMNP staff when the clinic doesn’t want or can’t issue FMNP benefits.

1. State staff will reallocate undistributed FMNP benefits to a different agency.

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WIC Farmers Market Nutrition Program | Page 15 Section 5: WIC Farmers Market Nutrition Program Complaints

POLICY: FMNP Complaints

FMNP participants, managers at authorized markets and farm stores, and authorized growers have the option to file complaints using the Farmers Market Nutrition Program Complaint Form with the local WIC agency or the state WIC office.

Clinic staff must forward the complaint to the State WIC office and keep a copy on file for four years at the local agency.

For civil rights complaints, staff must follow policies and procedures outlined in Volume 1, Chapter 20 – Notification, Fair Hearings and Civil Rights.

PROCEDURE:

Staff:

A. Inform the participant, market manager, or grower they have the right to file a complaint.

B. Provide a link or printed copy of the complaint form: • Link in the Farmers Market Nutrition Program brochure or WICShopper app. • Link on the Farmers Market Program for WIC Participants webpage or print a hard copy.

Note: The FMNP Complaint form is available in 17 languages.

C. Have the participant complete the form or offer to help them complete it.

D. Send the completed complaint form to the state WIC office within five business days from the date staff received the complaint.

E. Keep a copy of the complaint form on file at the local agency for four years.

F. Follow the state WIC staff guidance to follow up on the complaint.

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WIC Farmers Market Nutrition Program | Page 16 Section 6: Appendix

Volume 1, Chapter 8

WIC Farmers Market Nutrition Program | Page 17 Guide to Writing a FMNP Policy for Benefit Issuance Local agencies may use the state provided Local Agency FMNP Policy template or develop their own policy following the guidance below.

What is it? • It is a brief written policy about how your agency will fairly and equitably distribute FMNP benefits to your participants. o Include staff requirements to review FMNP state and local policy and current training for issuing benefits. o Include farmers market procedures if issuing FMNP benefits at the market. o Include internet connectivity source. (Use only secure internet connections. Do not use public-WIFI) o Include FMNP and participant information security plan. o Share and have easily accessible to staff o You don’t have to post the policy, but you must provide it to participants if they ask. o You must write a policy for each FMNP season; but it can be the same as the previous year. You must review and list the new date on the document. o You don’t have to send it to the state WIC office for approval. o Keep the policy on file for four (4) years. o State WIC monitor staff review the policy during on-site WIC monitors.

What does it include? Consider the following at a minimum: • When you will issue FMNP benefits (i.e. every day starting June 1st or only on Tuesdays). • Where you will issue benefits (at the clinic and market, if issuing at the market). • Who is eligible (see this chapter for details).

These are required FMNP activities to include in your policy statement: • The following are required: o Participants must provide ID to receive FMNP benefits for in-person appointments. o Staff share instructions with participants on how to use FMNP benefits. o Staff share the location of authorized markets and farm stores. o Staff provide nutrition education on using fresh fruits and vegetables (sometime during the current FMNP season) and proper documentation of this nutrition education. • Ask participants about their interest and ability to use FMNP benefits in a participant centered and consistent way.

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WIC Farmers Market Nutrition Program | Page 18 Eligible WIC FMNP Foods

CAN purchase with FMNP benefits Fruits Vegetables Cut Herbs • Apples • Apricots • Asian pears • Blackberries • Blueberries • Boysenberries • Cantaloupes • Cherries • Currants • Red and black figs • Gooseberries • Grapes • Ground cherries • Huckleberries • Kiwi • Loganberries • Marionberries • Melons • Muskmelon • Nectarines • Peaches • Pears • Plums • Raspberries • Seaberries • Strawberries • Tayberries • Watermelons • Alfalfa sprouts • Amaranth greens • Artichoke • Arugula • Asparagus • Beets • Bok Choy • Broccoli • Brussels sprouts • Cabbage • Carrots • Cauliflower • Celery • Chinese cabbage • Collard greens • Corn • Cucumber • Eggplant • Garlic • Green beans • Green onions • Kale • Kohlrabi • Leeks • Lettuce • Mizuna • Mushrooms • Mustard greens • Onions • Parsnips • Peas • Peppers • Potatoes • Pumpkins • Radishes • Rhubarb • Rutabagas • Shallots • Spinach • Squash • Swiss chard • Tatsoi • Tomatillos • Tomatoes • Turnips • Watercress • Yellow waxed beans • Yu Choy • Zucchini • Other edible greens • Other edible sprouts • Basil • Cilantro • Chives • Dill • Fennel • Parsley • Microgreens • Other edible cut herbs Sell to Senior only • Honey

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WIC Farmers Market Nutrition Program | Page 19 Foods not Eligible to Purchase at Farmers Markets

Important information about foods that can’t be purchased with FMNP benefits

Foods not eligible at farmers markets

 Dried fruits, vegetables, or herbs  Honey* or syrup  Jams or jellies  Fruit juice or cider  Nuts or seeds  Eggs  Baked goods, e.g., bread, cookies, pastries, etc.  Seafood or meats  Milk or cheese  Potted herbs or other plants  Flowers * Participants using Senior FMNP benefits can purchase unprocessed honey. Participants using WIC FMNP benefits can’t purchase honey.

DOH 960-105 October 2012 WASHINGTON STATE WIC

POLICY AND PROCEDURE MANUAL

VOLUME 1, CHAPTER 9

Anthropometrics

DOH 960-105 October 2012

In accordance with Federal law and Department of Agriculture USDA policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. To file a complaint of discrimination, write USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call toll free (866) 632-9992 (Voice). Individuals who are hearing impaired or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish). USDA is an equal opportunity provider and employer. Washington State WIC Nutrition Program does not discriminate.

For persons with disabilities, this document is available on request in other formats. To submit a request, please call 1-800-841-1410 (TDD/TTY 711).

CHAPTER 9 ANTHROPOMETRICS

10/2012 Volume 1  Washington State WIC Manual Page i

T A B L E O F C O N T E N T S Section 1 - Timeframe of Collection of Measurement Data .......................................................1 Height and Weight Measurements for Certification ............................................................1 Section 2 - Assessment ...................................................................................................................2 Assess Pre-Pregnancy Weight and Prenatal Weight Gain ...................................................2 Assess Weight Status in Breastfeeding and Postpartum Women ........................................5 Assess Growth for Infants and Children ..............................................................................6 Adjusted Growth Grids for Premature Infants and Children up to 24 Months ....................8 Special Growth Charts .........................................................................................................9 Section 3 - Weighing and Measuring Procedures .....................................................................11 Procedures for Weighing and Measuring Clients ..............................................................11 Section 4 - Equipment ..................................................................................................................16 Buy and Maintain Anthropometric Equipment ..................................................................16 Section 5 - Appendix ....................................................................................................................19

CHAPTER 9 ANTHROPOMETRICS Section 1 Timeframe of Collection of Measurement Data

10/2012 Volume 1  Washington State WIC Manual Page 1

POLICY: Height and Weight Measurements for Certification

The CPA takes height and weight measurements at the certification. Staff may use measurements taken 60 days before the certification date. Staff must measure the client again to determine current nutrition status if the previous measurements were taken more than 60 days before the certification.

When a pregnant woman is presumed eligible, staff must obtain measurements within 60 days of the date eligibility begins. See Volume 1, Chapter 18 - Certification Issues for more information about presumptive eligibility.

Staff should reweigh or re-measure a client when there is a concern about the accuracy of measurements from another source. Staff must use current measurements to ensure the best assessment of the client’s nutrition status.

PROCEDURE:

Clinic staff:

A. Measure the client using procedures in this chapter or get the measurements from another source.

1. Document the date the measurement was taken in the client’s file.

2. Document the source and date of measurement, if the measurement is from another source.

Note: Document how the measurement was taken by the other source when different from WIC standards, for example if shoes were on or height was taken using the attachment on an adult scale.

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Page 2 Volume 1  Washington State WIC Manual 10/2012

POLICY: Assess Pre-Pregnancy Weight and Prenatal Weight Gain

The Competent Professional Authority (CPA) must assess the pre-pregnancy weight and prenatal weight gain for all pregnant clients.

Staff must weigh and assess each pregnant woman’s weight gain at the certification and at least once each trimester.

Staff other than the CPA are allowed to weigh the pregnant woman and enter the weight in Client Services at the trimester weight checks.

PROCEDURE:

The CPA:

A. Assesses the woman’s pre-pregnancy weight.

1. Ask the woman for her pre-pregnancy weight and enter it in her file.

a. If the woman can’t remember her pre-pregnancy weight, ask questions to get the best estimate. For example:

 What is your usual weight?  How much did you weigh when you found out you were pregnant?  How do your clothes fit compared to when you aren’t pregnant, or when you’re at your usual weight?

2. Measure the woman’s current weight and height and enter in the file.

a. Staff can use measurements from another source. See the “Height and Weight Measurements for Certification” policy for more information.

3. Client Services will calculate the woman’s pre-pregnant BMI.

B. Assesses weight gain during pregnancy.

1. Client Services will plot the woman’s prenatal weight gain on the appropriate grid based on her pre-pregnancy BMI category and if she is having one baby (singleton) or more than one baby (multiples). The weight gain grids in Client Services include:

a. Underweight – BMI < 18.5 (singleton*)

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b. Normal weight – BMI 18.5 – 24.9 (singleton and multiples)

c. Overweight – BMI 25.0 – 29.9 (singleton and multiples)

d. Obese – BMI > 30.0 (singleton and multiples)

* Client Services plots underweight women pregnant with multiples on the underweight singleton grid. There wasn’t enough research data available for the Institute of Medicine (IOM) to make weight gain recommendations for these women.

Note: Teenage clients (18 years and younger) are plotted on the prenatal grid based on their pre-pregnant BMI using the adult cut-offs (not pediatric BMI-for- age charts).

2. The printed prenatal weight gain grid will list this information:

a. Name

b. Pre-pregnant weight

c. Height in inches and eighth inches d. Due date

e. Weight measurements

f. Clinic site where the client participates

g. Date the grid was printed

C. Evaluates if the woman has weight related nutrition risks. See Volume 1, Chapter 14 – Nutrition Risk Criteria.

a. Client Services automatically identifies weight related risk(s).

b. The CPA determines other risk factors by asking the Assessment Questions and getting hemoglobin values.

Note: Client Services calculates and selects weight related risks when staff press the Identify New Risks button.

D. Talks about weight gain as compared to recommended weight gain range with the woman.

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Page 4 Volume 1  Washington State WIC Manual 10/2012

1. Based on research from the IOM, staff don’t need to modify the prenatal weight gain recommendations for special populations such as pregnant teens, shorter women, and women of different races and ethnicities.

E. Assesses the woman’s weight gain once per trimester and offers guidance if needed.

1. Weighs each woman and enters the weight in Client Services at least once per trimester.

2. All staff are allowed to weigh the pregnant woman, enter the weight in her file and share the prenatal weight gain grid with her.

Information:

1. Prenatal Weight Gain Grids

 The Washington State WIC Nutrition Program developed the prenatal weight gain grids were from information published in the Institute of Medicine, 2009, Weight Gain During Pregnancy: Reexamining the Guideline report.

 The pregnant BMI weight categories are the same categories used by the World Health Organization.

2. Staff can print the client’s prenatal weight gain grid from Client Services.

3. Staff can print blank paper copies of the prenatal weight gain grids from the Department of Health website at: http://www.doh.wa.gov/PublicHealthandHealthcareProviders/PublicHealthSystemResour cesandServices/LocalHealthResourcesandTools/WIC/ProgramFormsMaterials.aspx.

CHAPTER 9 ANTHROPOMETRICS Section 2 Assessment

10/2012 Volume 1  Washington State WIC Manual Page 5

POLICY: Assess the Weight Status of Breastfeeding and Postpartum Women

The CPA must assess the weight status of breastfeeding and postpartum clients at each certification and at the mid-certification health assessment for breastfeeding women.

PROCEDURE:

The CPA:

A. Assesses the woman’s pre-pregnant BMI, total weight gain this pregnancy and current weight status.

1. Enters the woman’s pre-pregnant weight, height and current weight in her file.

2. Asks the woman how much total weight she gained during this pregnancy and enter the amount in her file.

Note: Client Services calculates BMI values based on the height and weight measurements entered.

B. Reviews the weight related nutrition risk(s) assigned by Client Services. See Volume 1, Chapter 14 – Nutrition Risk Criteria.

Note: Client Services calculates and selects weight related risks when staff press the Identify New Risks button.

C. Talks with the woman about weight risks in relationship to nutrition practices and overall health.

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Page 6 Volume 1  Washington State WIC Manual 10/2012

POLICY: Assess Growth for Infants and Children

The CPA must assess the growth (weight and length or height) of infants and children.

At a minimum, the CPA must weigh and measure infants and assess their growth at: 1. New certification (NC) 2. Completion of the certification (CC) (usually six weeks of age) 3. Mid-certification health assessment (HA) (done between 4 and 8 months of age).

At a minimum the CPA must weigh and measure children and assess their growth at: 1. New certification (NC) 2. Mid-certification health assessment (F/U) 3. Recertifications (RC).

PROCEDURE:

The CPA:

A. Weighs and measures the infant or child and documents in the client’s file.

B. Assesses the infant’s or child’s growth.

1. Client Services selects the appropriate CDC growth grid based on the infant’s or child’s age, gender and if the child was measured standing or lying down.

a. Measure all infants and children up to 24 months of age lying down (using a recumbent length board) and plot on the CDC Birth - 24 months growth charts. These growth charts are based on the World Health Organization (WHO) 2006 growth data.

b. Measure children 24 months of age and older standing (using a stadiometer) and plot on the BMI for Age 2 - 20 years growth grid. The child must be at least 32 inches tall to plot on the Height for Age 2 - 5 years grid which accompanies the BMI for Age growth grid.

c. Staff have the option to measure a child between the ages of 2 and 3 years lying down when the child is too short for the stadiometer or isn’t able to stand for the measurement.

Note: Children measured lying down between the ages of 2 and 3 years will be plotted on the CDC Birth – 36 months growth charts. The CPA can use this

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information for education purposes. These measurements aren’t used for risk assessment.

d. Measuring and assessing head circumference is optional. If taken and entered into the client’s file in Client Services:

 The infant’s or child’s head circumference will plot on the CDC Birth – 24 months growth chart, Head Circumference for Age.

 Client Services will calculate and assign head circumference risk for infants and children up to 24 months of age.

C. Evaluates if the client has growth related nutrition risk(s). See Chapter 14 – Nutrition Risk Criteria.

1. Client Services will identify risk factors based on measurements entered.

2. The CPA determines other risk factors by asking the Assessment Questions and assessing hemoglobin values.

D. Talk with the caregiver about how the infant or child is growing compared to the growth grid.

Note: Consider other factors that affect growth when assessing the growth of infants and children. Genetics and health conditions may also impact growth.

Information:

1. Staff can print the infant’s or child’s growth charts from Client Services.

2. Staff can print blank paper copies of the CDC Birth to 24 Months growth charts from the Department of Health website at: http://www.doh.wa.gov/PublicHealthandHealthcareProviders/PublicHealthSystemResour cesandServices/LocalHealthResourcesandTools/WIC/ProgramFormsMaterials.aspx.

3. Staff can order blank paper copies of the CDC BMI for Age 2 - 20 years growth chart and the Height for Age and Weight for Age growth charts from the Washington State Department of Printing Fulfillment Center at: myFULFILLMENTStorefront-myPRINT.

CHAPTER 9 ANTHROPOMETRICS Section 2 Assessment

Page 8 Volume 1  Washington State WIC Manual 10/2012

POLICY: Adjusted Growth Grids for Premature Infants and Children up to 24 Months

The CPA assesses both the actual age and the adjusted age plotted on growth grids for infants and children under 24 months of age who were born at 37 weeks gestation or less. Client Services uses the adjusted age to determine growth related risks for WIC.

Note: “Premature < 37 Weeks Gestation (< 24 months)” risk is assigned for infants and children under 24 months of age who were born at less than or equal to 37 weeks gestation.

“Low Birth Weight < 5lb, 8oz (< 24 months)” risk is assigned for infants and children under 24 months of age who weigh less than or equal to 5 pounds 8 ounces at birth. See Volume 1, Chapter 14 – Nutrition Risk Criteria for more information.

PROCEDURE:

The CPA:

A. Enters the infant’s or child’s weeks gestation in Client Services.

B. Weighs and measures the infant or child and enters the information in Client Services.

C. Client Services plots both actual and adjusted age on the CDC growth grid for infants and children under 24 months of age who were born at 37 weeks or less gestation.

1. Client Services will only plot actual age when the infant's current adjusted age is less than 40 weeks gestation. Once the adjusted age is 40 weeks or greater, the adjusted age will plot.

2. Client Services will plot adjusted age until the child is 24 months old.

D. Client Services uses the adjusted age plot to determine growth related risks.

E. The CPA uses the actual and adjusted age information while assessing growth and talking to the caregiver.

Information:

For information about growth and nutrition for premature infants, especially those with very low birth weight (<1500 g) visit the Gaining and Growing website at: http://depts.washington.edu/growing/

CHAPTER 9 ANTHROPOMETRICS Section 2 Assessment

10/2012 Volume 1  Washington State WIC Manual Page 9

POLICY: Special Growth Charts

The CPA documents measurements and uses CDC growth grids in Client Services to assess growth risks for all infants and children, even children with special health conditions or syndromes.

Staff may use special growth grids designed for a specific population (like Down Syndrome) for counseling. Staff must use the CDC growth grids for identifying growth related risks for WIC.

Note: Client Services only plots and assigns risks based on the CDC growth grids.

PROCEDURE:

The CPA:

A. Uses the CDC growth grids to determine nutrition risks and assess growth for WIC.

1. Client Services plots and assigns growth related risks based on the CDC growth grids.

B. Has the option to use special growth charts for counseling caregivers.

1. If a special chart is used, the CPA records and plots all measurements on both the special growth chart and in Client Services.

2. File special growth chart based on clinic filing practices.

3. Identify which growth chart was used for counseling in the high risk care plan or progress notes.

Information:

Staff can find condition-specific growth charts in the appendices of Nutrition Interventions for Children with Special Health Care Needs.

You can get this resource from:

 The Department of Printing Center at: myFULFILLMENTStorefront-myPRINT  The H.E.R.E. website at: http://here.doh.wa.gov/.  It is available for download at: http://here.doh.wa.gov/materials/nutrition- interventions.

CHAPTER 9 ANTHROPOMETRICS Section 2 Assessment

Page 10 Volume 1  Washington State WIC Manual 10/2012

Note: Many condition-specific growth charts have limitations. They were compiled using old data, small population numbers, or are incomplete (some are just height, not weight), and do not include BMI. Staff should use the charts with the CDC grids for growth assessment.

CHAPTER 9 ANTHROPOMETRICS Section 3 Weighing and Measuring Procedures

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POLICY: Procedures for Weighing and Measuring Clients

Clinic staff must use the following procedures for weighing and measuring clients.

PROCEDURE:

A. Follow these procedures to weigh infants and children on a digital or balance beam pediatric scale:

1. Have the caregiver undress infants and children age 0 to 24 months except for dry diaper or underclothes.

Note: Staff have the option to weigh infants and children age 0 – 24 months with or without a dry diaper or underclothes. For example it may be appropriate to weigh a medically fragile infant or child without a diaper or underclothing to get the most accurate weight.

2. Prepare the scale.

a. Cover the scale with paper or clean after each use to make sure the client has a clean, sanitary surface.

Note: Check the information from the scale manufacturer for the type of cleaning solution to use.

b. Zero balance the scale.

3. Weigh the child.

a. Place the child on his/her back in the center of the scale bed, unless the child can sit up alone. Have the caregiver protect the child from falling, without touching the child when the weight is taken.

4. Follow these procedures for balance beam scales:

a. Move the pound weight to the right until the balance arm begins to tip down, then move it back one pound.

b. Move the ounce weight until the balance arm is centered.

c. Read the weight to the nearest ounce.

d. Enter the weight in the client’s file.

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5. Follow these procedures for digital scales:

a. Read the measurement of the scale. Check if the scale displays ounces or tenths of pounds. Use the table in the Appendix to convert from tenths of pounds to ounces.

b. Enter the weight in the client’s file.

B. When weighing a woman or child on the adult digital or balance beam scale, clinic staff:

1. Have client remove shoes and heavy outer clothing. Undress child age 2 – 5 years except for dry diaper, under clothes or light clothing.

2. Prepare the scale.

a. Provide a clean surface for the client.

 Use a paper on the scale if the client is barefoot, or  Clean the scale surface in between clients.

b. Zero balance the scale.

3. Weigh the client.

a. Have the client step onto the center of the scale platform. Make sure he or she isn’t touching other parts of the scale when the weight is taken.

4. Follow these procedures for balance beam scales:

a. Move the pound weight to the right until the arm is centered. For heavier children and adults, move the 50 pound weight until it fits into the proper groove, then move the pound weight.

b. Read the measurement to the nearest 1/4 pound. Convert from quarter pounds to ounces. Use the table in the Appendix to convert from quarter pounds to ounces.

c. Enter the weight in the client’s file.

5. Follow these procedures for digital scales:

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10/2012 Volume 1  Washington State WIC Manual Page 13

a. Read the measurement of the scale. Check if the scale displays ounces or tenths of pounds. Use the table in the Appendix to convert from tenths of pounds to ounces.

b. Enter the weight in the client’s file.

6. Follow these procedures when the client is over the limit of the scale:

a. Use additional counter weights. Some manufacturers sell these additional weights. Follow the manufacturer’s instructions for using the additional weights.

b. Get the client’s weight from the medical provider if available.

C. Use the recumbent length board to measure infants and children younger than 24 months or children between two and three years of age who are too short or unable to be measured standing up. Clinic staff:

1. Have the caregiver:

a. Undress infant and child ages 0 – 24 months except for dry diaper or underclothes. Staff have the option to measure the infant and child with or without a dry diaper or underclothes.

b. Undress child aged 2 – 3 years except for dry diaper, underclothes, or light clothing.

c. Remove all hats, hair barrettes or pony tails that interfere with the measurement.

2. Prepare the board. a. Cover the board or clean it to provide a clean and sanitary surface for the infant or child.

Note: Check the information from the recumbent board manufacturer for the type of cleaning solution to use.

3. Measure the child.

a. Have the caregiver help.

b. Place the child on his or her back on the board.

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Page 14 Volume 1  Washington State WIC Manual 10/2012

c. Have the caregiver hold the crown of the child's head firmly against the headboard.

d. Check to make sure the child is looking up and that the head, body, and toes are in a straight line.

e. Hold the child's legs together just above the knees and gently push both legs down against the recumbent board with one hand, fully extending the child. (Don’t measure using only one leg, this will result in an inaccurate measurement).

f. Using the other hand, slide the footboard against the child's heels until the feet are flat against the board.

g. Read the measurement to the nearest 1/8 inch.

Note: If the measurement isn’t accurate, repeat until two or more measurements agree within 1/4 inch then record the largest one.

4. Enter the measurement in the client’s file.

D. When measuring the height of a woman or a child, clinic staff:

1. Prepare the client.

a. Have the woman or child remove heavy outer clothing and shoes.

b. Remove hat, hair barrettes and pony tails as appropriate.

2. Measure height.

a. Have the client stand on a flat floor with his/her back against the stadiometer.

b. Have the client stand with feet slightly apart with the back as straight as possible. The heels, buttocks, and shoulder blades should touch the wall or surface of the measuring board.

c. Have the client look straight ahead with head erect. The head doesn’t have to touch the wall or measuring board.

CHAPTER 9 ANTHROPOMETRICS Section 3 Weighing and Measuring Procedures

10/2012 Volume 1  Washington State WIC Manual Page 15

d. Move the headpiece flat against the wall and at a right angle to the head. Lower it until it firmly touches the crown of the head.

e. Hold the right-angle headpiece steady and have the person move out from under it.

f. Read the measurement where the lower edge of the headpiece intersects the stadiometer or where the equipment says to read the measurement. Read it to the nearest 1/8 inch.

g. Enter the measurement in the client’s file.

CHAPTER 9 ANTHROPOMETRICS Section 4 Equipment

Page 16 Volume 1  Washington State WIC Manual 10/2012

POLICY: Buy and Maintain Anthropometric Equipment

Clinic staff must use the following criteria to buy and maintain anthropometric equipment.

Clinic staff must: 1. Buy and use medical-grade equipment 2. Make sure the equipment is set up correctly 3. Balance scales daily 4. Maintain and calibrate equipment 5. Document maintenance and calibration of the equipment

PROCEDURE:

Clinic staff:

A. Buy medical-grade equipment (i.e. equipment that is suitable for use in a physician’s office, hospital or other health-care setting) that is accurate and durable. Staff can use medical grade digital or balance beam scales.

Note: Contact a health-care equipment vendor to find out about the accuracy and durability of specific brands or models.

1. Use a pediatric balance beam or digital scale for infants and children under 24 months of age whose weight doesn’t exceed the maximum weight capacity of the scale.

2. Use an adult balance beam or digital scale for adults and children 24 months and older who can stand without help.

a. Place the scale on uncarpeted floor, or if carpeted, place on a piece of 3/4 inch plywood.

3. Use a recumbent length board for infants and children under 24 months of age.

a. The recumbent length board consists of three parts: a flat calibrated board, a stationary headboard, and a moveable footboard.

b. Place the recumbent length board on a flat surface.

CHAPTER 9 ANTHROPOMETRICS Section 4 Equipment

10/2012 Volume 1  Washington State WIC Manual Page 17

4. Use a full length measuring board mounted to the wall, called a stadiometer for adults and children 24 months and older.

Note: Children 24 months and older who aren’t tall enough for the stadiometer or who can’t stand for the height measurement can be measured lying down. See the “Assess Growth for Infants and Children” policy in this chapter for more information.

a. Mount the stadiometer on a smooth, flat surface. It should extend all the way to the floor.

b. Follow the manufacturer’s instructions for mounting the equipment.

c. Remove moldings and baseboards to make sure the surface is flat.

B. Balance scales daily.

1. Balance beam scale

a. Move the ounce and pound weights to zero.

b. Balance the beam until the arm is centered; when the arm moves up and down freely or rests in the center of the movement range.

c. Adjust the scale if the beam doesn’t come to rest in the center. Adjusting balance beam scales may vary by manufacturer. Check the manufacturer’s instructions.

2. Follow the manufacturer’s instructions for pediatric and adult digital scales.

C. Maintain equipment.

1. Maintain all equipment:

a. Keep the equipment clean. Follow the manufacturer’s instructions for cleaning.

b. Check for damaged and loose joints (especially footboard and headboard if they no longer hold a right angle), and readability of the measurement tapes.

c. Repair or replace damaged or defective equipment.

D. Calibrate equipment and keep a calibration log.

CHAPTER 9 ANTHROPOMETRICS Section 4 Equipment

Page 18 Volume 1  Washington State WIC Manual 10/2012

1. Check the calibration of balance beam and digital scales twice a year with standard weights and document on a calibration log. (See the Appendix for a sample calibration log).

a. Place the smallest weight on the platform (example: 1/2# for pediatric scales, 5# for adult scales); and balance the beam or read the digital scale.

b. Place a higher amount of weight on the platform (example: 10# for pediatric scale, 50# for adult scale); balance the beam or read the digital scale.

c. Reweigh the smaller amount of weight, then the larger, adjusting the balance. If you can’t balance the scale to both high and low weights, the scale isn’t accurate, and needs professional balancing.

2. If the scale isn’t accurate and staff can’t calibrate it, contract with a scale service company or a representative from state or local Weights and Measures Division to fix the scale.

CHAPTER 9 ANTHROPOMETRICS Section 5 Appendix

10/2012 Volume 1  Washington State WIC Manual Page 19

APPENDIX

CHAPTER 9 ANTHROPOMETRICS Section 5 Appendix

Page 20 Volume 1  Washington State WIC Manual 10/2012

CHAPTER 9 ANTHROPOMETRICS Section 5 Appendix

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How to read Prenatal Weight Gain Grids

1. Weeks Gestation (horizontal axis)

a. The numbers on the bottom of the grid represent 1 - 42 weeks gestation. Full term is 40 weeks gestation.

b. Each vertical line represents one week.

c. The three bold vertical lines mark the three trimesters of pregnancy:

1) The first trimester includes 0 - 13 weeks.

2) The second trimester 14 - 26 weeks.

3) The third trimester 27 - 40 weeks.

2. Pre-pregnant Weight

a. The bold horizontal line near the bottom of the grid represents a client's pre- pregnant weight.

b. Weight Gained or Lost

1) The numbers on the vertical axis show the number of pounds gained (above the horizontal line) or lost (below the horizontal line) since conception.

3. Recommended Weight Gain (vertical axis)

a. The shaded area on each grid shows the recommended weight gain range for the pre-pregnant BMI weight category, i.e. normal weight, underweight, overweight, and obese.

b. Weight that plots below the bottom line of the recommended range identifies low weight gain.

c. Weight that plots above the top line of the recommended range identifies high weight gain.

4. Interpretation of Prenatal Weight Gain Grids

a. Comparing current weight to pre-pregnant weight shows how much weight a woman has gained or lost since becoming pregnant.

CHAPTER 9 ANTHROPOMETRICS Section 5 Appendix

Page 22 Volume 1  Washington State WIC Manual 10/2012

b. The pattern of weight gain should follow the general shape of the curve.

c. Staff should assess any sudden change in weight status more closely. First check if the weight measurement was accurate. If the weight was accurate, you may want to refer the woman to the nutritionist or another health professional for further evaluation depending on how big the weight change is.

CHAPTER 9 ANTHROPOMETRICS Section 5 Appendix

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Convert from Decimal Pounds to Ounces

 Check electronic scales to see if the scale displays decimal pounds (tenths) or ounces.  If the scale measures in decimal units, convert the tenths of a pound to ounces.  Enter ounces on the Measures Tab in Client Services.

Convert Tenths of a Pounds to Ounces Decimal Pound  Ounces .1 = 2 .2 = 3 .3 = 5 .4 = 6 .5 = 8 .6 = 10 .7 = 11 .8 = 13 .9 = 14

Convert from Quarter Pounds to Ounces

 Balance beam scales and some electronic scales display in quarter pounds.  Convert the quarter pound to ounces.  Enter ounces on the Measures Tab in Client Services.

Convert Quarter Pounds to Ounces Quarter Pound  Ounces ¼ pound = 4 ½ pound = 8 ¾ pound = 12

CHAPTER 9 ANTHROPOMETRICS Section 5 Appendix

Page 24 Volume 1  Washington State WIC Manual 10/2012

Calibration Log Sample

Scale Staff Name Date Calibrated Notes Adult scale Mary WIC 10/1/2012 Yes

Infant scale Mary WIC 10/1/2012 Yes

CHAPTER 9 ANTHROPOMETRICS Section 5 Appendix

10/2012 Volume 1  Washington State WIC Manual Page 25

Calibration Log

Scale Staff Name Date Calibrated Notes

Policy and Procedure Manual

Volume 1, Chapter 10 Hematology

Washington State WIC Nutrition Program DOH 960-367 Effective August 1, 2025

This institution is an equal opportunity provider. Washington WIC doesn’t discriminate.

For persons with disabilities, this document is available on request in other formats. To submit a request, please call 1-800-841-1410 (TDD/TTY 1-800-833-6388).

Volume 1, Chapter 10

Hematology | Page i

Hematology

CONTENTS Section 1: Definitions and References 1 Section 2: The WIC Clinic as a Medical Test Site (MTS) 3 REQUIRED GUIDANCE: Obtain a Medical Test Site License ...................................................... 3 Section 3: Who May Perform Blood Testing 4 REQUIRED GUIDANCE: Only Trained Staff May Perform Invasive Blood Testing ..................... 4 Section 4: When to Perform Blood Testing 5 REQUIRED GUIDANCE: Test Blood Hemoglobin According to Timing Schedule ....................... 5 Section 5: Exceptions 7 REQUIRED GUIDANCE: Provide Exceptions ............................................................................... 7 Section 6: Deferral Reasons 8 REQUIRED GUIDANCE: Defer Testing ........................................................................................ 8 Section 7: Exposure Control 9 REQUIRED GUIDANCE: Implement Controls to Reduce Staff Exposure to Bloodborne Pathogens ............................................................................................ 9 Section 8: Perform the Hemoglobin Test 11 REQUIRED GUIDANCE: Perform Tests or Obtain Values from Referral Sources ..................... 11 Section 9: Document Results 14 REQUIRED GUIDANCE: Document Test Results Performed or Obtained from Referral Sources ........................................................................................................... 14

Volume 1, Chapter 10

| Page ii Hematology Section 10: Determine Nutrition Risk 15 REQUIRED GUIDANCE: Determine Nutrition Risk and High-Risk Status Based on Hemoglobin or Hematocrit Values, Tailor Nutrition Education, and Refer Participants to Health Care Providers ............................................... 15 RECOMMENDATION: Assess Iron for Transfer Participants .................................................... 17 Section 11: High Hemoglobin or Hematocrit Results 18 REQUIRED GUIDANCE: High Hemoglobin or Hematocrit Assessment and Intervention ........ 18 Section 12: Maintain Hematological Equipment 19 REQUIRED GUIDANCE: Maintain Hematological Equipment .................................................. 19 Section 13: Order Hematology Supplies 21 REQUIRED GUIDANCE: Order Hematology Supplies from WIC............................................... 21

Volume 1, Chapter 10

Hematology | Page 1 Section 1: Definitions and References

Definitions

Applicant: A person, not currently receiving WIC benefits, who comes to the WIC clinic requesting WIC services.

Capillary sampling method: Pricking the skin of the finger (middle or ring) or heel to obtain a blood sample from tiny blood vessels near the surface of the skin.

CDC: Centers for Disease Control.

CLIA: Clinical Laboratory Improvement Amendments. Congress passed CLIA in 1988 to establish standards for laboratory testing.

CLIA-waived: Laboratory tests that the FDA exempted from CLIA requirements because they are simple and have low risk of harm to the patient. An example of a CLIA waived test is the HemoCue test.

CLSI: Clinical and Laboratory Standards Institute.

Deferral: Staff may defer the blood test or obtain results from providers up to 90 days from the date of the certification for applicants with at least one other qualifying nutrition risk.

Exception: Staff don’t need to test participants who meet one or more of the following criteria: 1) A medical or serious skin condition where testing would cause harm to the participant, 2) Religious beliefs that don’t allow blood testing, or 3) Refusal to test.

Invasive hematology tests: Tests that require staff to puncture the skin. An example of this test is using the HemoCue device to test blood obtained through skin puncture with a lancet.

Medical Test Site License: The type of testing performed determines the MTS/CLIA license category. Select from the following four options: Waived, PPMP, Categorized or Accredited as defined here: Licensing Information | Washington State Department of Health.

Non-invasive blood tests: Tests that don’t require staff to puncture the skin. An example is using the Masimo Pronto device to test blood hemoglobin using light technology.

OSHA: Occupational Safety and Health Administration.

Volume 1, Chapter 10

| Page 2 Hematology Participant: A person who currently receives WIC benefits.

WHO: World Health Organization.

References

Code of Federal Regulations (CFR): • Required nutritional risk data §246.7 (e)(1)(ii)(B)—Hematological test for anemia • CLIA Requirements for a Certificate of Waiver–§493

Washington State Medical Test Site Laws: WAC 246-338 and RCW 70.42

Washington State Senate Bill 5244 exempts WIC from medical assistant laws: WAC 246-827 and RCW 18.360.

Washington State WIC Policy and Procedure Manual chapters that reference bloodwork and record retention: • Volume 1, Chapter 11 - Assessment • Volume 1, Chapter 12 -Referrals • Volume 1, Chapter 14 -Nutrition Risk • Volume 2, Chapter 7 - Record Retention • Volume 2, Chapter 2 – Nutrition Services Plan

Volume 1, Chapter 10

Hematology | Page 3 Section 2: The WIC Clinic as a Medical Test Site (MTS)

REQUIRED GUIDANCE: Obtain a Medical Test Site License

Local agencies who perform invasive hemoglobin testing must have a medical test site license as required by state law (WAC 246-338, Medical Test Site Rules).

PROCEDURE:

Agencies obtain a Medical Test Site license by:

A. Adding the WIC clinic to an existing local agency Medical Test Site license, or B. For local agencies who only perform Hemoglobin CLIA waived tests, applying for an MTS CLIA-Waived Certificate here: Medical Test Sites (MTS) Licensing | Washington State Department of Health. Note: The fee for applying for the MTS for WIC agencies is waived. Local agencies must renew the MTS license every two years.

Volume 1, Chapter 10

| Page 4 Hematology Section 3: Who May Perform Blood Testing

REQUIRED GUIDANCE: Only Trained Staff May Perform Invasive Blood Testing

Local agency staff who perform bloodwork must complete the following training before performing blood testing:

1. DOH STATE WIC Hematology Curriculum in the learning center.

2. DOH STATE WIC Bloodborne Pathogens Training in the learning center (annual requirement).

3. Review of the local agency exposure control plan.

4. Initial Anthro/lab measurement observations.

PROCEDURE:

A. Certifiers must successfully complete the certifier competency training and be recognized as a WIC Competent Professional Authority (CPA).

B. Other staff must complete the required training and observations and be certified as competent prior to testing or training others.

Note: WIC is exempt from the Medical Assistants law: WAC 246-827.

Volume 1, Chapter 10

Hematology | Page 5 Section 4: When to Perform Blood Testing

REQUIRED GUIDANCE: Test Blood Hemoglobin According to Timing Schedule

Staff must perform blood testing according to the following timeline:

Blood work Requirement When to perform the test or receive the value from referral sources

Notes: Infants 0-5 months Not required

• Staff may test infants between 4 and 6 months when an infant is fully breast or chest feeding or premature and not taking supplemental iron. Infants 6-12 months* One test Test during any appointment where the infant is physically present between 6 and 12 months old. • Staff can perform the test more than 90 days after Initial certification. • If the infant subsequent certification occurs before the first birthday, staff can use this result to meet the requirement of the 6 – 12- month test. Children 1-5 years old One test each year Within 90 days of certification.

Test 6 months after the infant test, if possible.

When the previous value was low, staff must do follow-up blood tests every 6 months until the value returns to the normal range.

• Staff can’t use blood tests, completed before the infant turns one, to meet the requirement for the 1 to 2-year-old test.

• If the infant to child subsequent certification occurs after the infant turns one, the blood test completed at this appointment counts as the 1 to 2-year-old test. Presumptively eligible (PE) participant One test Within 90 days of PE certification. • Recommended at the Complete Assessment.

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| Page 6 Hematology

Blood work Requirement When to perform the test or receive the value from referral sources

Notes: Pregnant Participant One test during the current pregnancy. As early as possible in the pregnancy, and

Within 90 days of certification. • Recommended at the initial or subsequent certification for a new pregnancy. Breast or chest feeding and Postpartum Participant One test 4-6 weeks after the end of the pregnancy, and

Within 90 days of certification. • Recommended at the Initial or subsequent certification. • When the IC or SC is within 4 weeks of delivery, staff schedule a follow up appointment to complete hemoglobin testing. • Breast or chest feeding participants who are 6 - 12 months postpartum don’t need another blood test if they had a test after the birth of their infant or termination of their pregnancy.

* Washington WIC allows bloodwork between 6 and 9 months, although not required by federal regulation.

Volume 1, Chapter 10

Hematology | Page 7 Section 5: Exceptions

REQUIRED GUIDANCE: Provide Exceptions

Staff must grant exceptions to hematology testing for the following reasons:

1. The participant has a medical condition like hemophilia, or a serious skin disease in which the procedure would cause harm to the participant. The participant can self- report the condition.

2. Religious belief.

3. Not required by policy (for example, the infant is 0 – 6 months old).

4. Refusal.

PROCEDURE:

The CPA:

A. Documents the exception reason in the Anthro/Lab screen in the participant’s file.

B. Issues three months of food benefits (as appropriate) to participants who have an exception reason.

Information:

Best practice is to ask clarifying questions about a refusal for test. Ask the participant if they are more comfortable getting the test from their healthcare provider and bring results back.

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| Page 8 Hematology Section 6: Deferral Reasons

REQUIRED GUIDANCE: Defer Testing

Staff may defer hemoglobin testing for up to 90 days of the date of certification for the following participants:

1. Participants with at least one nutritional risk factor present at certification.

2. Presumptively eligible participants with at least one qualifying risk factor.

PROCEDURE:

A. Document the following deferral reasons in the Anthro/Lab screen in the participant’s file when staff can’t perform the test, or staff don’t have results from a referral source.

1. Will get results from the medical provider

2. Illness

3. Couldn’t get a value

4. Participant not present (Don’t use if staff select “no” for physical presence in the participant demographic screen).

5. Equipment failure

Note: Cascades doesn’t allow staff to select a Deferred Reason for two consecutive certifications when staff didn’t enter values during the previous certification period.

B. Document efforts to obtain bloodwork values for each participant in a Family Alert. C. Issue three months of food benefits to participants who have a deferral reason.

Volume 1, Chapter 10

Hematology | Page 9 Section 7: Exposure Control

REQUIRED GUIDANCE: Implement Controls to Reduce Staff Exposure to Bloodborne Pathogens

The local agency must:

1. Comply with Washington state and OSHA standards. (WAC 296-823-12005 and 29 CFR 1910.1030).

2. Write an exposure control plan to eliminate or minimize exposure to bloodborne pathogens and review the plan annually (WAC 296-823-11010).

3. Use controls to eliminate or minimize occupational exposure to blood (WAC 296-823- 140).

4. Provide personal protective equipment to staff performing invasive blood testing.

5. Document exposures according to WAC 296-27-01109 using OSHA form 300.

The Competent Professional Authority (CPA) must:

1. Use "Universal Precautions" when performing invasive blood testing to prevent the spread of infectious diseases from bloodborne pathogens.

2. Dispose of lancets and microcuvettes in sharps containers.

3. Dispose of waste, such as gauze, gloves, and bandages that are not soaked with blood in regular trash.

4. Dispose of infectious and blood-soaked waste in a biohazard bag.

Note: CPAs can only perform invasive Hgb tests if they have completed all training and observation requirements. See Section 3: Who May Perform Blood Testing, in this chapter.

PROCEDURE:

The coordinator:

A. Has a written exposure control plan and update the plan annually. Make a copy of this plan available to employees at the work site (WAC 296-823).

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| Page 10 Hematology

B. Provides annual training on bloodborne pathogens and universal precautions and maintains training files for four years after the date of the training (WAC 296-823-120).

C. Implements controls to minimize employee exposure (WAC 296-823-140).

D. In the event of an exposure, refer to the following (WAC 296-823-140) and contact the state WIC office.

E. Disposes of sharps containers according to OSHA guidelines.

Volume 1, Chapter 10

Hematology | Page 11 Section 8: Perform the Hemoglobin Test

REQUIRED GUIDANCE: Perform Tests or Obtain Values from Referral Sources

WIC staff must:

1. Perform the invasive or non-invasive test according to manufacturer instructions and Washington State laws, or

2. Attempt to obtain hematocrit or hemoglobin values from referral sources within 90 days of the certification except for infants who require a test between 9 and 12 months old.

3. Document attempts to get blood values in a family alert.

Notes:

Staff may follow up on blood values at 60 days to align with the timeline for obtaining height and weight measurements.

WIC staff must complete training in the use of invasive and non-invasive equipment prior to testing participants.

PROCEDURE:

Trained WIC staff:

A. Talks to the participant or caregiver about the hemoglobin test. This includes a brief overview why WIC does the test and how. It’s important to mention that WIC uses the test to screen participants, not diagnose. The results will also guide the recommendations for dietary changes.

Example: “The hemoglobin test tells us if you or your child’s blood has enough iron. Iron is important for your child’s growth (you and your baby’s health if you are pregnant, your health if you are breast or chest feeding or post- partum). To do the test, I will:

• Invasive blood test script: “Prick your child’s finger to get a drop of blood to test if your child has enough iron. If the test result is low, we’ll talk about ways to increase iron in the diet and recommend that your child see their health care provider for follow-up..”

Volume 1, Chapter 10

| Page 12 Hematology • Non-invasive script: “Put this sensor on your finger. The sensor will measure the amount of iron in your blood. It usually takes a couple of minutes to get the test results. If the results are low, we’ll talk about ways to increase iron in your diet and recommend that you see your health care provider for follow up.”

B. Uses standard precautions for invasive testing to minimize exposure to blood borne pathogens (See Section 7, Exposure Control).

C. Follows manufacturer guidelines when performing tests.

• HemoCue® Hb 201 Operating manual: Hb-201-DM-Operating-Manual.pdf (hemocue.us) located on the Local Agency SharePoint site. • HemoCue® Hb 301 Operating manual: HB-301_Operating-Manual_US.pdf (hemocue.us) located on the Local Agency SharePoint site. • Masimo Pronto® Pulse CO-Oximeter® Operator’s Manual: Pronto (masimo.com). Staff should clean the device when visibly dirty and before and after each procedure.

D. Perform the invasive test when not able to get a value using non-invasive testing.

E. Attempt to get values from referral sources and document the attempt in a Family Alert.

Information:

Guidelines for Finger and Heel Sticks HemoCue recommends the Clinical and Laboratory Standards Institute (CLSI) guidelines, standard GP42-Ed7, for blood collection. This standard requires the finger stick for infants weighing more than 10 kg (22 lbs.) with a lancet depth that isn’t more than 1.5 mm.

WHO Guidelines for drawing blood outline conditions for selecting heel or finger stick: Condition Heel-stick Finger stick Age Birth-6 months > 6 months old Weight ~3-10 Kg (22 lbs.) and not walking >10 Kg (22 lbs.) Placement of Lancet Medial or lateral plantar surface On the side of the ball of the finger perpendicular to the lines of the fingerprint Recommended Finger Not applicable Second and third finger (middle & ring) (WHO, 2010).

Volume 1, Chapter 10

Hematology | Page 13 WHO guidelines recommend the following Lancet depths: 1.5 mm for: Finger stick for infants and children less than 8 years old. 2.2 mm for: Infant heel and adult finger stick.

The Clinical and Laboratory Standards Institute guidelines suggest, in addition to the heel stick, the big toe as a suitable test site for infants. The lancet depth for the big toe should not exceed 1.5 mm.

Trained WIC staff must use a similar preparation for heel and toe sticks as stated in the manufacturer guidelines for the finger stick.

Volume 1, Chapter 10

| Page 14 Hematology Section 9: Document Results

REQUIRED GUIDANCE: Document Test Results Performed or Obtained from Referral Sources

Staff must document the test results, or the reason for exception or deferral on the Anthro/Lab screen in Cascades.

PROCEDURE:

The CPA:

A. Documents the following in the participant’s file on the Anthro/Lab screen:

1. Test results: value and date performed.

a. Don’t accept results from health care providers that are older than 90 days. b. Any staff can record values obtained from referral sources in the participant’s file.

2. Exception reasons, if applicable.

3. Deferral reasons, if applicable.

4. Nutrition risk - Cascades automatically assigns low and very low hemoglobin or hematocrit risks.

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Hematology | Page 15 Section 10: Determine Nutrition Risk

REQUIRED GUIDANCE: Determine Nutrition Risk and High-Risk Status Based on Hemoglobin or Hematocrit Values, Tailor Nutrition Education, and Refer Participants to Health Care Providers

The CPA must:

1. Assess blood test values for nutrition risk and high-risk status using the Washington State WIC nutrition risk criteria. • See Volume 1, Chapter 14 - Nutrition Risk Criteria.

2. Tailor nutrition education based on the risk and participant’s needs.

3. Refer participants with very low hemoglobin/hematocrit value to the WIC Nutritionist and health care provider.

PROCEDURE:

The CPA:

A. Compares hemoglobin test results to Washington WIC nutrition risk criteria, Federal Risk 201, Low Hematocrit/Low Hemoglobin.

• See Volume 1, Chapter 14 – Nutrition Risk Criteria. • See the nutrition risk factor tool, hematology tables tab.

B. Confirms the test completion date is within the participant’s current category.

Notes: • Examples: Use a value taken during pregnancy for a pregnant participant, or a value taken after delivery for a breast or chest feeding or postpartum participant. • Values obtained from the medical provider can’t be more than 90 days old.

C. Verifies to make sure Cascades assigns the correct risk. Cascades automatically calculates and assigns risk based on blood test values taken within the past 90 days.

D. Talks with the participant or caregiver about the results of the test and tailors nutrition education messages.

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| Page 16 Hematology

E. Refers participants with very low hemoglobin/hematocrit values to the WIC nutritionist and the health care provider.

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Hematology | Page 17 RECOMMENDATION: Assess Iron for Transfer Participants

When a transfer participant doesn’t have a blood test value, it’s recommended to perform the blood test or obtain the value in writing from the health care provider.

BEST PRACTICE:

Staff:

A. Review and document the participant’s transfer information.

• See Volume 1, Chapter 21 – Transfers for required documentation. • See Volume 1, Chapter 14 – Nutrition Risk Criteria.

B. Schedule a follow-up for the next month to assess the participant’s iron status and determine nutrition education and referral needs.

1. Request the transfer participant’s previous clinic measurements and blood test values.

2. If there is no blood test value, staff can perform the blood test or obtain the value from the health care provider.

C. Assess the participant’s iron status at the subsequent certification according to policies and procedures in this chapter.

D. Issue benefits as needed.

1. Staff don’t need to limit benefit issuance to monthly for transfer participants with missing blood test values.

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| Page 18 Hematology Section 11: High Hemoglobin or Hematocrit Results

REQUIRED GUIDANCE: High Hemoglobin or Hematocrit Assessment and Intervention

The CPA must follow the interventions below when they assess the participant’s hemoglobin or hematocrit value as "high".

PROCEDURE:

The CPA:

A. Determines if the participant’s hemoglobin or hematocrit is high. A value at or above 14.6 g/dl, or 44% respectively, for pregnant, breast or chest feeding, and postpartum people, infants, and children is high.

B. Asks the participant if there is a history of high hemoglobin or hematocrit results.

Note: A high hemoglobin or hematocrit may be normal in some instances. Two examples of normal high hemoglobin or hematocrit values include when the body compensates for smoking or living at a high altitude.

C. Does the following, based on the information from the participant.

1. Documents in the notes that the value is normal for the participant, as reported by the participant.

2. Refers the participant to a health care provider if there is no history of a high value and the hemoglobin is at or above published values.

3. Refers the participant to a health care provider if there is a history of a high hemoglobin or hematocrit and the value is above the participant’s "normal" level or is well above published values.

D. Documents all information discussed with the participant in the Cascades individual care plan.

E. Plans follow-up as appropriate.

Information:

A high hemoglobin or hematocrit can indicate a medical problem and the CPA should refer these participants to their healthcare provider for follow up and treatment.

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Hematology | Page 19 Section 12: Maintain Hematological Equipment

REQUIRED GUIDANCE: Maintain Hematological Equipment

Staff must:

1. Clean and maintain hematological equipment as specified in the manufacturer’s operating manual and document on the Hemoglobin Machine Maintenance Log.

2. Contact the manufacturer if the equipment is less than a year old to repair or replace if it isn’t operating according to the manufacturer’s specifications.

3. Contact WICHematology@doh.wa.gov to place a new order to replace any non- functional equipment when it’s more than a year old.

PROCEDURE:

Staff:

A. Follow the manufacturer’s instructions for cleaning and maintenance.

1. Hemocue • Operating manual: Hb-201-DM-Operating-Manual.pdf (hemocue.us) located on the Local Agency SharePoint site. • Daily Cleaning video: HemoCue 201 DM Systems - Cleaning (youtube.com). Use mild detergent, not alcohol.

2. Masimo Pronto • Operator’s Manual: Pronto (masimo.com). Staff should clean the device when visibly dirty and before and after each procedure.

C. Document cleaning and maintenance in the Hemoglobin Machine Maintenance Log and maintain in local agency files for four years.

D. Repair or replace the equipment when it isn’t operating correctly.

1. Contact the manufacturer to troubleshoot the problem.

2. If the analyzer is within 1 year of the purchase date, follow the warranty instructions in the respective operator’s manuals.

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| Page 20 Hematology 3. If the analyzer is outside of the 1-year warranty and cannot be repaired, dispose of it according to the county and local agency electronic waste disposal policy.

4. Report any equipment problems to WIC staff at WICHematology@doh.wa.gov or follow ordering procedures to order replacements.

Information:

It’s important to keep the equipment in good working order to assure it’s accurate and safe for staff using the equipment.

The HemoCue analyzer performs an automatic self-test each time it is turned on and every 2 hours while the analyzer remains on.

Remove the batteries when not in use.

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Hematology | Page 21 Section 13: Order Hematology Supplies

REQUIRED GUIDANCE: Order Hematology Supplies from WIC

Washington WIC provides agencies with hematology supplies at no charge to the agency.

Staff must:

1. Order hematology supplies using the online Hematology Order Form. 2. Confirm that the packing slip, the shipped items, and the original order agree. 3. Send a signed, dated copy of the packing slip to the state WIC office within three days of receiving the shipment. 4. Contact WICHematology@doh.wa.gov for instructions when the HemoCue analyzer or Masimo Pronto device needs repair or replacement.

Using Liquid Controls is not a required procedure for HemoCue Analyzers. Agencies who wish to use controls can’t use WIC funding sources to purchase them.

Note: Washington WIC only provides the supplies listed on the order forms.

PROCEDURE:

Staff:

A. Order hematology supplies in the amount needed for 6 months using the following guidance:

1. Estimate the number of supplies needed for 6 months based on participating caseload and percentage of Hemocue and/or Masimo tests you complete.

2. Use the HemoCue microcuvettes following this guidance:

• The Hemocue 201+ cuvette vials expire 90 days after opening the vial. Use all the cuvettes by the expiration date on the package. • The Hemocue 301 cuvette vials don’t expire after opening the vial. Use all the cuvettes by the expiration date on the package. • Use all the individually wrapped cuvettes by expiration date on the package.

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| Page 22 Hematology 3. Masimo sensors are available in pediatric and adult sizes. The sensors don’t have expiration dates.

Note: Ordering hematology supplies twice a year is preferred to reduce costs, but staff can order more often when necessary.

B. Order hematology supplies.

1. Use the online Hematology Order Form to order hematology supplies.

2. Order HemoCue and Masimo supplies a month before you need the supplies to allow for ordering and shipping delays. State staff place orders the last week of each month.

3. Receive order confirmation. If you don’t receive confirmation, please email WICHematology@doh.wa.gov.

C. When agency staff need supplies immediately, clinic staff may use supplies from another local WIC agency.

D. Confirm that the packing slip, the items shipped, and the original order agree.

1. If the order is correct and complete write “complete” on the packing slip.

2. If the order is incomplete or incorrect:

a. Write on the packing slip which items were incomplete or incorrect and describe what was wrong or not delivered.

b. Contact WICHematology@doh.wa.gov for guidance about what to do with the incorrect items.

c. If you did not receive all the items you ordered, but the items on the packing slip and what you received match, write on the packing slip “partial order”.

3. If you receive a backordered shipment of supplies that completes a previous partial order, write “partial order now complete” on the new packing slip.

E. Then, send a signed, dated copy of the packing slip by email to WICHematology@doh.wa.gov within three days of shipment delivery.

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Hematology | Page 23 Note: State WIC staff must receive all packing slips to pay the invoices and place additional orders.

F. Keep the original packing slips on file for 6 years.

G. Contact WICHematology@doh.wa.gov if you need to exchange or return supplies.

H. When you need to repair or replace HemoCue or Masimo Analyzers, contact WICHematology@doh.wa.gov.

Information:

Local Program Consultants can help agencies estimate quantities of hematology supplies. Contact WICLPC@doh.wa.gov for support.

State WIC Staff may change ordering procedures as our contractors update products and contracts change. Email WICHematology@DOH.wa.gov with any questions.

Policy and Procedure Manual

Volume 1, Chapter 11 Assessment

Washington State WIC Nutrition Program DOH 960-367 August 2021

This institution is an equal opportunity provider. Washington WIC does not discriminate.

To request this document in another format, call 1-800-841-1410. Deaf or hard of hearing customers, please call 711 (Washington Relay) or email wic@doh.wa.gov.

Volume 1, Chapter 11

Assessment | Page i

Assessment

CONTENTS Section 1: Assessment During WIC Certification 1 POLICY: Nutrition Assessment Requirement ......................................................................... 1 POLICY: Use the Assessment Questions to Complete the Assessment .................................. 3 POLICY: Coordination of WIC and MSS Assessment Process .................................................. 5 POLICY: Use an Interpreter .................................................................................................... 6 Section 2: Appendix 8 Guidance – Using Participant-centered Skills to Complete the Assessment ........................... 9 Key Elements and Examples for Using Participant-centered Skills ........................................ 11

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| Page ii Assessment

Volume 1, Chapter 11

Assessment | Page 1 Section 1: Assessment During WIC Certification

POLICY: Nutrition Assessment Requirement

The Competent Professional Authority (CPA) must complete a nutrition assessment at each initial certification, subsequent certification and mid-certification health assessment. The CPA uses participant-centered skills to complete the assessment.

A nutrition assessment includes obtaining, documenting and assessing: • Measurements • Iron test results • The participant’s answers to the Assessment Questions.

Note: Only a few designated Assessment Questions are required at the mid- certification health assessment.

See Volume 1, Chapter 18 – Certification for more information.

PROCEDURE:

The CPA:

A. Uses participant-centered skills to complete the assessment.

• See Guidance - Using Participant-centered Skills to Complete the Assessment

B. Takes the participant’s length or height and weight measurements and documents in the participant’s file.

1. Assess the participant’s weight and growth by viewing the growth or weight gain grid.

• See Volume 1, Chapter 9 - Anthropometrics for more information.

C. Performs a blood test or gets the results from a health care provider. Documents value in the participant’s file, and explores further by asking additional questions if auto- calculated value identifies participant as High Risk.

• See Volume 1, Chapter 10 – Hematology for more information.

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| Page 2 Assessment D. Has a conversation with the participant, using the Assessment Questions to assess the participant’s health and nutrition status.

E. Documents the participant’s nutrition and health risks.

1. Review to determine if participant is at high risk.

a. The Washington WIC Nutrition Program determines some risks as high risk.

• See Volume 1, Chapter 14 – Nutrition Risk Criteria

F. Documents relevant health and nutrition information.

G. Summarize the assessment information to assure you captured the participant’s needs and concerns.

Information:

The Assessment Questions guide a participant-centered conversation by: • Incorporating critical thinking and prompting to gather and analyze assessment information. • Exploring the participant’s nutrition risks and gathering relevant health and nutrition information. • Considering the participant’s cultural background, beliefs, and needs when completing the assessment. The CPA uses the results of the assessment to determine the participant’s nutrition status and risk, decide the appropriate nutrition education and counseling, tailor the food benefits and make appropriate referrals.

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Assessment | Page 3 POLICY: Use the Assessment Questions to Complete the Assessment

The CPA asks the bolded introduction and questions on the paper-copy of the Assessment Questions at each new certification and subsequent certification. The CPA asks the 5-8 month Assessment Questions for the Infant Health Assessment. The CPA enters participant’s responses into the computer.

The CPA asks a few follow-up Assessment Questions at the mid-certification health assessment. • See Volume 1, Chapter 18 – Certification for information about the mid-certification requirements.

The CPA uses the information gathered from the Assessment Questions to: 1. Find nutrition risks for WIC eligibility. 2. Discover nutrition education topics. 3. Personalize referrals. 4. Assign the food benefits.

PROCEDURE:

The CPA:

A. Shares the bolded introductory statement at the beginning of the Assessment Questions to inform participants that WIC asks everyone the same questions.

B. Asks the Assessment Questions based on category and age.

• Use or refer to the paper copy to see the required bolded questions to ask. • The paper copy includes all the Assessment Questions for each category and feeding type, while Cascades only provides some of the questions. • The Assessment Questions are on the Washington WIC website. The questions are available in several languages on the WIC Forms and Materials web page.

C. Ask clarifying questions to gather additional information needed to identify nutrition risks.

D. Listen for participant’s concerns and needs, and gather information and insight into the participant’s: • Cultural values

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| Page 4 Assessment • Food preferences • Food buying practices • Cooking and food preparation abilities • Mealtime practices • Other related diet and health areas

Information: CPA has understanding of the nutrition risk criteria to assess for all risks and complete a thorough assessment.

• See Volume 1, Chapter 14 – Nutrition Risk Criteria for definitions and justifications of nutrition risk factors.

E. Explores the pregnant participant’s thoughts and knowledge about breastfeeding.

• See Volume 1, Chapter 15 – Breastfeeding, for more information about breastfeeding.

F. Asks all the bolded Assessment Questions from the hard copy before moving into the Care Plan part of the appointment.

G. Document responses to the Assessment Questions in the participant’s file.

H. Identifies participant’s nutrition risks and documents them in the participant’s file.

I. Selects one of the following risks if no other risk is identified from asking the Assessment Questions; and documenting length or height and weight measurements or iron test results:

1. “Not Meeting Dietary Guidelines – Children 2-5 years and Women” risk for women and children 2 years and older.

2. “Not Meeting Feeding Guidelines – Infants and Children” risk for infants 4 – 12 months of age and children 12 – 23 months of age.

J. Documents additional notes about the participant’s risks, nutrition needs, and eating or feeding practices in Cascades as appropriate.

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Assessment | Page 5 POLICY: Coordination of WIC and MSS Assessment Process

Staff may use information gathered during the pregnant woman Maternity Support Services (MSS) assessment as part of the WIC assessment when the following conditions are met:

1. The person completing the MSS assessment is the CPA completing the pregnant woman WIC certification.

2. The WIC and MSS assessments occur on the same day.

3. The CPA asks (or gets the answers to) all bolded paper copy Assessment Questions not asked during the MSS assessment.

4. The CPA assures and documents all Assessment Question responses in Cascades as appropriate.

5. The CPA asks and documents the participant’s plans to breastfeed.

PROCEDURE:

The CPA:

A. Asks MSS assessment questions and all paper copy bolded WIC Assessment Questions for a pregnant woman during the initial certification.

B. Assesses and selects all appropriate nutrition risks in Cascades.

C. Documents additional information in Cascades as appropriate.

D. Gathers information to provide appropriate nutrition education, referrals and food benefits.

Information:

First Steps Maternity Support Services (MSS) provides preventive health services. These services supplement medical coverage for Medicaid-eligible women who are pregnant or within 60 days post-pregnancy. The goal of MSS is to provide services as early in a pregnancy as possible. This effort promotes positive pregnancy and parenting outcomes.

Private and public agencies throughout Washington provide MSS services. This wide range of services include assessment, health education, intervention and counseling from a multi- disciplinary team of professionals who provide a comprehensive plan of care.

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| Page 6 Assessment POLICY: Use an Interpreter

Staff must:

• Document interpreter needs on the Family Demographics screen.

• Use an interpreter for the WIC appointment when bi-lingual staff aren’t available to interpret for a participant with Limited English Proficiency (LEP).

o Staff must not use family members as interpreters.

• Document the use of an interpreter in the Nutrition Assessment section of the Care Plan Summary screen in the participant’s file for any:

o Initial or Subsequent Certification – this includes the Presume Eligible and Presume Eligible Complete Assessment

o Mid-certification Health Assessment

o Second Nutrition Education Contact – this includes High Risk contacts

Note: It’s best practice to document the use of an interpreter for all other services provided including Food Benefit Issuance.

PROCEDURE:

Staff:

A. Determine the primary language of the participant who needs or requests an interpreter and document on the Family Demographics screen.

• Provide an “I Speak Statements” document or the person to identify his or her language.

B. Use an interpreter service when bi-lingual staff aren’t available.

C. Document the use of an interpreter on the Nutrition Assessment screen in the participant’s file.

Information:

Volume 1, Chapter 11

Assessment | Page 7 Washington state WIC contracts with a phone interpreter service. The hours of operation are available 24 hours, seven days a week.

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| Page 8 Assessment Section 2: Appendix

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Assessment | Page 9 Guidance – Using Participant-centered Skills to Complete the Assessment

A. Builds rapport and sets the tone for the appointment by greeting the participant in a friendly way and introduces him or herself.

B. Creates a setting that removes barriers to communication by: • Positioning the participant to the side of the desk. • Sitting knee to knee.

C. Begins the appointment by: • Letting the participant know how long the appointment takes and a brief description about the appointment. • Stating we keep the participant’s information private.

D. Stays non-judgmental while learning about the participant’s beliefs, health and cultural practices.

E. Affirms the participant with sincere and encouraging words. • Keeping the assessment positive; avoids making the participant feel defensive.

F. Uses participant centered skills to connect with the participant. • Asks open-ended questions to allow the participant to give full and meaningful answers from her own perspective and express her feelings. Questions starting with “what,” “when,” “where,” “how,” “tell me,” and “why,” are open-ended. • Ask clarifying questions to get more details. For example: Does your baby get anything else besides breastmilk now? (If yes) What? How much? (in a 24 hour period). • Use “encouragers” to acknowledge what the participant is saying and encourage her or him to keep talking. Encouragers are short words, phrases or gestures. For example: Hmm, I see, go on, and then, etc. • Avoid leading questions which may influence the participant’s answer. For example: If the participant shares she drinks milk, instead of saying “Do you drink milk at every meal?” ask “When do you drink milk?” • Use simple, familiar words (plain talk). Avoid technical words like pregnancy induced hypertension, iron deficiency anemia, high risk, hemoglobin, etc. Instead, use descriptive words or common words like high blood pressure, low iron, or iron test.

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| Page 10 Assessment • Show acceptance and sensitivity especially when asking questions about highly confidential areas. For example: Substance abuse, mental health concerns, miscarriages, abortions, etc. • Listen and assess for all risk criteria by using "active listening” skills. It takes effort to hear what the participant’s saying, not just the words but the total message shared. Listening closely tells the person she’s valued. “Active listening” skills include: o Using body language to show interest, enthusiasm, kindness and respect for the participant. o Lean forward to convey interest. o Have an open body position. o Use open hand gestures. o Keep eye contact when appropriate. • Restate what the person said and reflect what you think the participant is feeling. This helps to assure you understand what participant is saying and clear up any misunderstandings. For example, “You’re feeling confused because so many people are giving you advice.” • Give the participant time to answer each question and avoid interruptions, whenever possible. • Allow time for silence to give the participant time to answer the question and share more information.

Volume 1, Chapter 11

Assessment | Page 11 Key Elements and Examples for Using Participant-centered Skills

The following are the key elements and examples for guiding a nutrition assessment using participant-centered skills and the Assessment Questions.

Key Elements for Conducting Nutrition Assessment Examples for Specific Element Build Rapport Spirit of participant-centered services: • Accepting • Respectful • Individualized • Non-judgmental • Genuine • Sensitivity

Introduction • Greet the participant. • Introduce yourself. • Identify your role.

Hi Joni, I’m _________. I’ll be asking you some questions to see if you’re eligible for WIC today. Setting the agenda • Share how much time you have for the appointment. • State what happens during the appointment. • Assure information will be kept confidential. • Ask permission to proceed. • Ask an open-ended question.

This appointment will take about 30 minutes. We ask everyone these next few questions. These are to help me learn about your pregnancy and about you. Would it be OK to ask a few questions about how you’re doing? What concerns or questions would you like to talk about today?

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| Page 12 Assessment Key Elements Examples Complete the Assessment Affirmations • Sincerely compliment the participant. • Make supportive, reinforcing statements. • Focus on the positive, successes, and efforts.

You’re really determined and stayed flexible in order to get here today. Thank you. You work hard to prepare healthy meals for your child. You’re very creative when preparing snacks. Critical Thinking • Collect all relevant information. • Clarify or gather additional details. • Analyze and evaluate all the information collected. • Determine the best course of action. • Ask all bolded Assessment Questions to complete a thorough assessment. Identify questions that need clarifying depending on the response of the participant. • Consider the whole picture; the height/weight, the iron test results and the participant’s responses.

With diabetes, has your doctor asked you to check your blood sugars at home? Do you take insulin? How often? How much? Tell me about your activity level. What do you drink in a typical day? So it sounds like you don’t drink cows’ milk, what milk substitutes do you drink? Open ended questions • Begin with “what”, “how”, “tell me”, “why”, etc. • Ask in a way that is open and accepting. • Use encouragers (nodding, “go on, wow, hum, etc.). • Listen with an attitude of curiosity.

Tell me a little more about that… Describe what mealtimes look like? Tell me how that makes you feel? How do you feel about the idea of breastfeeding your baby? Clarifying questions • Use to clarify or gather added details. • Use if participant provides short or generic answers.

Did the doctor prescribe iron supplements? How do you prepare the formula? How often is the cereal added to the bottle?

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Assessment | Page 13 Key Component Examples Complete the Assessment continued Leading questions • Avoids asking questions which may sway the participant's response.

Avoid asking: You eat high iron foods, like meat, every day, right? Instead, ask: Tell me what foods you eat? What is a typical meal? Other examples of leading questions to avoid: You drink milk at every meal, right? Did you quit smoking when you learned you were pregnant? You don't drink alcohol now that you are pregnant, do you? Reflections • Reassures the participant you are listening. • Corrects misunderstandings, false assumptions and misinterpretations. • Makes people feel understood.

Participant: My mom is always feeding him baby foods, even though I pump and have the breastmilk available. She says he is whiny when he doesn’t get food. I just don’t know how to get her to stop. CPA: It must feel frustrating that she doesn’t support you. Let her know that breastmilk is the best food for Jacob right now and no other foods are needed. It’s hard to tell our own mom what we want them to do. Moms think they know best. Hold off on education • Allows ability to prioritize identified needs and concerns. • Efficient use of time by focusing on the highest priority issues. • Correct misinformation at the end of session so it doesn’t come across as “criticism” during the conversation. • Bundled information is easier for a participant to remember.

That’s a good question, is it OK if I make myself a note and we come back to it after we have gone through these other questions? Let me write that down so we can talk about that later. Does that work for you? We’ll come back to that, would that be okay? We’ll talk about that more in a second. Does that work for you? Good point, if it’s okay with you, we’ll talk about those in a moment. That’s a great question, I’d like to write that down and after we get through the questions, we can talk about it. Does that work?

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| Page 14 Assessment Key Component Examples Exploration Summarize and prioritize • Summarize completed assessment. • Review risk(s) identified for the participant. • Prioritize nutrition topic with the participant. • Move into discussing nutrition topic.

Example 1 Joni, you just answered many of my questions, had your weight plotted on the weight gain grid, and took an iron test. This information helped qualify you for WIC today. You really care about having a healthy pregnancy and baby. And, it sounds like you’re unsure what to do now that your doctor says you have gestational diabetes? Tell me what you know about gestational diabetes.

Example 2 Juanita, during these past twenty minutes we took Emanuel’s height, weight and iron test and I asked you a variety of questions. Two questions came up for you. One was about introducing solids to Emanuel and the second, about what kind of sippy cup is best. These are both great questions. Which question would you like to talk about first? Exploring participant education needs • Share nutrition/health information the participant is interested in learning. Note: The participant should be doing most of the talking.

Note: This policy chapter is about completing the Assessment Questions. It doesn’t include providing participant centered education. See Volume 1, Chapter 16 – Nutrition Education.

I jotted down the questions you had on this piece of paper. Which one would you like to talk about first? We have talked about many different topics today, let’s review them. (Review each question, concern or nutrition need identified during the assessment.) Which one would you like to talk about today? Based on your answers to the questions and the questions you asked, here are several topics we might talk about (show circle chart or list of items on note pad and give a brief description of each). Which topic would you like to talk about today? On this chart are some of the things we could talk about (show circle chart and give a brief description of each topic) Which topic interests you? Ask the participant why they chose this topic.

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Assessment | Page 15

Resource:

U.S. Department of Agriculture, Food and Nutrition Service, Value Enhanced Nutrition Services (VENA). April 2006.

U.S. Department of Agriculture, Food and Nutrition Service. WIC Nutrition Services Standards. Standard 6: Nutrition Assessment. 2013

Policy and Procedure Manual

Volume 1, Chapter 12 Referrals and Coordinating Services

Washington State WIC Nutrition Program DOH 960-367 Effective September 1, 2023

This institution is an equal opportunity provider. Washington WIC doesn’t discriminate.

For persons with disabilities, this document is available on request in other formats. To submit a request, please call 1-800-841-1410 (TDD/TTY 1-800-833-6388).

Volume 1, Chapter 12

Referrals and Coordinating Services | Page i

Referrals and Coordinating Services

CONTENTS Section 1: Referrals 1 POLICY: Make Referrals ...................................................................................................... 1 POLICY: Document Referrals ............................................................................................... 7 POLICY: Screen Immunization Records ............................................................................... 8 POLICY: Screen for Lead Testing for Children .................................................................... 12 RECOMMENDATION: Assess Referral Outcome.................................................................... 13 Section 2: Coordinate Services 14 POLICY: Coordinate with Other Health and Social Services .............................................. 14 Section 3: Appendix 16 Common Resources for Women, Infants, and Children ......................................................... 17

Volume 1, Chapter 12

Referrals and Coordinating Services | Page 1 Section 1: Referrals

POLICY: Make Referrals

Staff must:

1. Assess the participant’s needs for health services and other resources that support the family and offer referrals based on the participant’s needs and interests.

2. Offer referrals at the following times:

• Certification: this includes the Initial and Subsequent Certification, and the Complete Assessment for pregnant participants.

• Mid-certification Health Assessment

• When a participant or applicant isn’t eligible for WIC.

o Refer ineligible participants and applicants to the Help Me Grow WA Network for information on other health related and public assistance programs.

Note: Staff have the option to make additional referrals at any time.

3. Refer to these mandated referrals:

a. Social and Health Services – all participants. Refer participants to public assistance and health related programs using the following options:

• Help Me Grow WA Network: 1-800-322-2588. The Help Me Grow WA Network meets the federal regulation to assure all participants have information about social services, public assistance and health related programs. and/or • Local Referral List: List of current local health-related and public assistance programs in the area.

b. Medicaid – refer participants and families who aren’t currently on Medicaid and appear eligible.

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| Page 2 Referrals and Coordinating Services c. Immunizations – refer infants and children to age 24 months who aren’t up to date.

• See the “Screen Immunization Records” policy for more information.

d. Lead testing – refer all children who haven’t received a blood lead test to the health care provider for testing.

e. Alcohol and drug abuse counseling and treatment – when appropriate.

• Sharing the WIC ID and Card Folder with the Help Me Grow WA and the Washington State Recovery Help Line assures all participants and caregivers have drug and other harmful substance abuse counseling and treatment resources available.

Staff have the option to make additional referrals. For example:

• A local referral line which provides information on health related and public assistance programs. • Verbal or written referrals to health related and public assistance programs based on participant’s needs and interests. • A community resource handout or local referral list.

4. Document all referrals in the participant’s file on the Referral Program screen.

PROCEDURE:

Staff:

A. Assess the needs of the participant and family at the following times:

1. Certification: Includes the Initial, Subsequent Certification and Complete Assessment for pregnant participants.

2. Mid-certification Health Assessment.

3. When the participant or applicant isn’t eligible for WIC.

Note: Staff have the option to make additional referrals at any time.

B. Refer all participants and applicants, including those who aren’t eligible for WIC, to social and health services by providing a local referral list or the Help Me Grow WA

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Referrals and Coordinating Services | Page 3 Network phone number 1-800-322-2588 or website https://helpmegrowwa.org/ address.

• The Help Me Grow WA Network helps callers learn about public assistance and health related programs in Washington State.

• The WIC ID and Card folder lists the Help Me Grow WA number.

C. Refer to Medicaid and provide written information when the participant appears to be within Medicaid’s income guidelines. Include how and where to apply.

Note: A referral to Apple Health is a referral to Medicaid.

1. Provide written information about Medicaid by:

a. Providing the WIC ID and Card folder, or

b. Providing a Medicaid/Apple Health handout.

• See the Health Care Authority - Apple Health outreach toolkit for information and materials.

2. Share where and how to apply for Medicaid:

a. Applicants can apply online at https://www.washingtonconnection.org/home/.

b. Call Washington Apple Health/Medicaid at 1-855-923-4633.

c. Find information at www.parenthelp123.org. Families can see if they qualify for Medicaid and other programs.

Notes:

• It is not the responsibility of WIC staff to be experts on Medicaid/Apple Health eligibility or to provide extensive screening.

• Participants who are eligible for medical programs, including Medicaid, receive a ProviderOne card.

D. Screen immunization records for children age 24 months or less and refer children who aren’t up to date.

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| Page 4 Referrals and Coordinating Services

1. Ask the caregiver of a child 24 months or less to bring the child’s immunization record to the initial certification, mid-certification health assessment, and subsequent certification appointments. Staff with access can use Washington State Immunization Information System (WSIIS) in lieu of a hard copy immunization record.

2. Document the infant’s or child’s immunization status by selecting “Immunization Status” on the Health Information screen.

3. Refer children who aren’t up to date with immunizations to one of the following:

• Health care provider • Local health department • Other immunization clinic

See the “Screen Immunization Records” policy in this chapter for more information.

E. Ask parents and caretakers of children about lead testing at each initial and subsequent certification and refer to the health care provider when the child has never received a blood lead test or the parent or caretaker doesn’t know if the child’s been tested.

See the “Screen for Lead Testing” policy in this chapter for more information.

F. Screen for substance use and refer participants to local drug and alcohol abuse counseling and treatment when appropriate.

1. Staff screen for substance use by asking the required Assessment Questions.

2. It’s recommended to keep a list of local resources for drug and alcohol abuse counseling and treatment.

Notes: • Substance use includes any use of alcohol or other drugs that might cause harm to a participant, developing fetus, infant or child. • WIC’s role in preventing substance abuse is to provide participants with information, referrals, and coordination of services. • Staff assess for the risk of alcohol or drug use and refer participants to existing assessment agencies for professional evaluation and treatment as appropriate. It

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Referrals and Coordinating Services | Page 5 is not the responsibility, or within the scope of practice, of WIC staff to diagnosis substance abuse problems or provide in-depth counseling. • The WIC ID and Card folder contains referral information for the Washington State Recovery Help Line, 1-866-789-1511 and Help Me Grow WA Network: 1- 800-322-2588.

G. Have the option to make additional referrals by:

1. Providing the phone number of a local referral line which provides information on health related and public assistance programs.

2. Providing a verbal or written referral to one or more health related and public assistance programs.

3. Offer a community resource handout.

H. Document referrals in the participant’s file on the Referral Program screen.

• See the “Document Referrals” policy for more information.

I. Have the option to facilitate referrals by:

1. Letting participants use the WIC phone to schedule appointments.

2. Calling the agency or service for the participant so they can make an appointment.

3. Walking the participant to the other service if it is in the same agency.

4. Having applications for other programs available at the clinic.

Information:

Staff hear about a participant’s and family’s needs. Participants often need more than WIC food. When WIC staff refer participants to the Help Me Grow WA Network, their staff make referrals to: • free or low-cost health insurance • food resources • immunizations • breastfeeding support

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| Page 6 Referrals and Coordinating Services • family planning services • parenting support • child development screening services • other social and health programs

Here are some tips to help make referrals in a positive, useful way: • Stay up to date with your community resources. • Ask the participant if they’re interested in learning more about a program or service. • If the participant is interested, tell the participant about: o eligibility requirements o cost (if there is one) o location o phone number o business hours o the name of a contact person. • Provide a referral form with useful information that will help the participant access services more easily. Staff can print the Referral Notification Form from Cascades for the participant to take to the referral organization. • Offer handouts and application forms for services.

Additional common referrals

Breastfeeding Peer Counselor Lead testing Dentist Local referral list Domestic violence Medical Provider FDPIR MSS - Maternity Support Services Food bank SNAP - Supplemental Nutrition Assistance Program Head Start TANF - Temporary Assistance for Needy Families Homeless shelter

Other: examples include

• Child Support • Infant Case Management • Clothing and baby supplies • Public health nurse • Family Planning • Well child visits

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Referrals and Coordinating Services | Page 7 POLICY: Document Referrals

Staff must document referrals in Cascades in the participant’s record on the Referral Program screen.

PROCEDURE:

Staff:

A. Document referrals to social services, public assistance and health related programs.

B. Document other referrals as appropriate. Including:

• Medicaid • Immunizations • Alcohol and drug abuse counseling and treatment • Other common referrals

Note: Select “Other” when referring to a program or service not entered in Cascades. Staff have the option to edit the referral to document the specific referral made.

Information:

Documenting a referral allows all staff who work with the participant to follow up on referrals at future appointments. See the “Assess Referral Outcome” recommendation in this chapter for more information.

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| Page 8 Referrals and Coordinating Services POLICY: Screen Immunization Records

Staff must:

1. Ask the parent guardian or caretaker of children age 24 months or less, to provide the immunization record at the:

• Initial Certification appointment • Mid-certification Health Assessment • Subsequent Certification appointment

Note: Staff can use Washington State Immunization Information System (WSIIS) instead of a hard copy immunization record to screen a participant's immunization status if they have access.

• WIC staff don’t automatically have access to WSIIS. The Local Agency can request access to WSIIS. The link above has information about how to request access.

2. Screen the immunization record for all children 24 months or less.

• Count the number of Diphtheria, Tetanus and acellular Pertussis (DTaP) immunizations to determine if the child is up-to-date based on the age of the child. (See table in Procedure below.)

• Staff can use the Washington State Immunization Information System (WSIIS) to screen a participant’s immunization status if they have access.

3. Document the infant’s or child’s immunization status by selecting “Immunization Status” on the Health Information screen.

4. Refer infants and children who aren’t up to date with immunizations to one of the following:

• Health care provider • Local health department • Immunization clinic

5. Share immunization schedule with caregivers of infants and children up to age 2 who aren’t up to date.

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Referrals and Coordinating Services | Page 9 • Staff may provide the AAP-Immunization-Schedule for children birth through 6 years old to caregivers.

Staff must not deny WIC benefits if a parent guardian or caretaker doesn’t bring the immunization record or if the child isn’t up to date with immunizations.

The local agency has the option to screen all children for immunization status for ease and consistency. The local agency must ensure staff use this option consistently for all families. A local agency policy isn’t required.

PROCEDURE:

Staff:

A. Ask the parent guardian or caregiver to bring the immunization record for a child age 24 months or less, to the following WIC appointments:

1. Initial Certification

2. Mid-certification Health Assessment

3. Subsequent Certification

B. Review the record for the correct number of DtaPs. Use the chart below:

Infant or child age: Screen for: Between birth and 2 months none Between 2 and 3 months at least 1 dose of DTaP Between 3 and 5 months at least 2 doses of DTaP Between 5 and 15 months at least 3 doses of DTaP Over 18 months at least 4 doses of DTaP

To see the current immunization schedule for children go to: https://www.doh.wa.gov/YouandYourFamily/Immunization/Children

The chart below shows the number of DTaPs based on typical WIC visits:

WIC visit type: Screen for: Initial certification none Infant mid-certification health assessment 3 DTaPs 12 month subsequent certification 3 DTaPs Child mid-certification health assessment 4 DTaPs

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| Page 10 Referrals and Coordinating Services

1. When DTaP isn’t on the immunization record, staff may count the number of DT, DTaP-IPV, DTaP-Hib, DTaP-Hep B-IPV, or DTaP-IPV-Hib. Note: The “DTaP” is the most common.

2. WIC staff are encouraged but aren’t required to know vaccine brand names. The chart below shows vaccine names and what is in the vaccine:

Term What’s in the vaccine Brand name DT Diphtheria and Tetanus Toxoid Generic DTaP Diphtheria, Tetanus and acellular Pertussis Daptacel, Tripedia, Infanrix DTaP-IPV DTaP and inactivated polio combination Kinrix DTaP-Hep B- IPV DTaP, hepatitis B, and inactivated polio combination Pediarix DTaP-IPV-Hib DTaP, inactivated polio, and haemophilus influenza type b combination Pentacel DTaP-Hib DTaP and haemophilus influenzae type b (Hib) combination TriHIBit

C. Share the results of the DTaP screening with the parent guardian or caretaker.

D. Document the infant’s or child’s immunization status by selecting “Immunization Status” on the Health Information screen.

• Document “Unknown” if the parent guardian or caretaker didn’t bring the immunization record or staff can’t determine if the child is up to date. • Document “Up to date” if the child is up to date with immunizations. • Document “Not up to date” if the child isn’t up to date with immunizations needed for age. This includes when the family chooses not to immunize.

Note: When “Not up to date” is marked, Cascades automatically takes you to the Referral Program screen.

E. Refer the participant for immunizations when not up-to-date or when you don’t see the record.