Eligibility Screening

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					ELIGIBILITY
SCREENING
WIC POLICY MANUAL                                                                      FFY-2004

                            1. ELIGIBILITY SCREENING
                                            Preface

The Special Supplemental Food Program for Women, Infants and Children (WIC) is
administered in New Mexico through the Department of Health, Public Health Division
Family Health Bureau.

The Program currently serves approximately 60,000 pregnant, breastfeeding and
postpartum women, infants and children. Services to WIC participants include receipt of
supplemental foods - milk or formula, fruit juice, cereal, beans, eggs, cheese, and a special
enhancement for breastfeeding women who do not receive supplemental formula for their
babies. Individual nutrition counseling and group nutrition education classes and referrals
to other health and social services are also provided.

Services are provided directly through PHD health offices and 2 primary care WIC contract
agencies.

The United States Department of Agriculture (USDA) prohibits discrimination in its programs
on the basis of race, color, national origin, sex, age, and disability. Persons with disabilities
who require alternative means for communication of program information (Braille, large
print, audiotape, etc.) should contact USDA’s TARGET Center at (202) 720-2600 (voice and
TDD).

To file a complaint, write USDA, Director, Office of Civil Rights, 1400 Independence
Avenue, S. W., Washington, D.C. 20250-9410 or call (800) 795-3272 (voice) or (202) 720-
6382 (TTY).

The State of New Mexico WIC Nutrition Program complies with Title VI of the Civil Rights
Act of 1964, and the Americans with Disabilities Act, and all regulations issued thereunder.
In brief overview, this means that on the basis race, color, national origin, sex, religion, age,
disability, political beliefs, and marital or familial status, no individual will be:

1. Denied service, or other benefits provided under the program.
2. Provided any service, or benefits in a different manner from that provided to others
   under the program.
3. Subjected to segregation or separate treatment in any matter related to receipt of
   services under the program.
4. Restricted in the enjoyment of any advantage or privileges enjoyed by others receiving
   services under the program.
5. Treated differently from others in the determination of enrollment, admission, or eligibility
   for any services or other benefits under the program.
Any complaints received in a local office, verbal or written, must be immediately
referred to the state office or to USDA for investigation.

Any person who feels that their civil rights have been violated should contact the
Department of Agriculture within 180 days from the date of alleged discriminations.


                                               1-1                  ELIGIBILITY SCREENING
WIC POLICY MANUAL                                                                       FFY-2004
                                     Food and Consumer Service
                                     U. S. Department of Agriculture
                                     Southwest Region
                                     1100 Commerce Street
                                     Dallas, TX 75242


I. Ensuring Access for Disabled Persons

It is the policy of the New Mexico WIC Program to make services available to all eligible
persons without regard to race, color, national origin, sex, age or disability. The intention of
this policy is not only to comply with the letter of the law, but also with the spirit of the Civil
Rights Act, and the Americans with Disabilities Act. Therefore, when a building that houses
the WIC Nutrition Program is not readily accessible to persons who are handicapped, WIC
staff is required to provide WIC services to that person outside of the office.

Note: When making appointments for program applicants and participants, staff is
      to ask; "Is there a need for any special accommodations?" It can then be
      determined what accommodations a participant or applicant may need on the day of
      their visit. If you are unsure of the situation, contact your supervisor, Region
      Nutrition Coordinator, WIC Program Manager, WIC Director or the Clinic Operations
      Manager for further advice. This is in keeping with the Americans with Disabilities
      Act.

Every effort should be made to ensure that buildings are accessible to the disabled. When
circumstances beyond the control of the WIC program staff is encountered, WIC staff must
provide services outside the office to the disabled. The specific arrangements should be
worked out with the Region Nutrition Coordinator, WIC Program Manager or WIC Director.

Possible arrangements may include:

1. Determining need for a satellite clinic.
2. Home visits.
3. Providing services at another social or health care site.
4. Providing a qualified interpreter
5. Using a communication device such as a TDD.
It may be necessary to provide services to persons confined to bed rest by their physician
or unable to come into the office due to the need of medical equipment that is not easily
transportable. In that case, obtain a signed medical release from the client to obtain the
weight, height and hematocrit or hemoglobin information. Make arrangements to complete
the certification in the presence of the applicant and provide nutrition education and
counseling at the same time. A proxy may be used for check issuance requiring the proxy
to buy the foods at the grocery store.

II. Hours of Operation
Normally clinics are open 8-5 Monday-Friday. Clinics around the Regions and state vary.
Check with your Region office for clinic hours.




ELIGIBILITY SCREENING                           1-2
WIC POLICY MANUAL                                                                       FFY-2004
III. Program Eligibility Screening

                                           Overview

   A. Who Receives WIC?

   Persons who meet categorical, residential and financial eligibility, and are determined to
   have a nutritional risk, may participate in the WIC Nutrition Program in New Mexico.

   6. Categorical Eligibility: Applicant must be either a pregnant, breastfeeding, or
      postpartum woman; an infant under one year old; or a child under 5 years of age.
   7. Residential Eligibility: Applicant must be a resident of the State of New Mexico.
   8. Financial Eligibility: Applicant's income must fall at or below 185% of the federal
      poverty level. Applicants sign a statement verifying that their reported income is
      truthfully and thoroughly reported.
   9. Nutritional Risk: Applicant must have a health problem or condition that is related to
      inadequate nutrition.
   The WIC Nutrition Program in New Mexico currently serves only a portion of the total
   number of potentially eligible persons in the state because of insufficient funding.
   Therefore, participation is normally limited to potentially eligible Priority I through Priority
   VII participants as outlined below. Participants transferring into New Mexico from
   another state are an exception.

      Priority I: Includes pregnant women, breastfeeding women, and infants who have at
       least one nutrition-related risk factor classified by USDA as Priority I.

      Priority II: Includes infants up to six months of age who are born to women who
       were on WIC or who were eligible for WIC during their pregnancy.

      Priority III: Includes postpartum women age 17 or younger at conception and
       children who have at least one nutrition-related risk factors classified by USDA as
       Priority III. Children are then sub-prioritized by age, with younger children being of
       higher priority. The State WIC Director must approve determination of what age will
       be served.

      Priority IV: Includes pregnant and breastfeeding women, and infants who have a
       diet-related risk factor or who are migrants or homeless.

      Priority V: Includes children who have a diet-related risk factor or who are migrants
       or homeless.

      Priority VI: Includes postpartum women who have any other risk factors besides
       age 17 or younger at conception.

      Priority VII: Includes low risk "regression" for breastfeeding and postpartum women,
       infants and children.




                                               1-3                    ELIGIBILITY SCREENING
WIC POLICY MANUAL                                                                      FFY-2004
  Note: All priorities must be served in numerical order (i.e., a clinic may not decide to
        serve Priority VI participants if the entire state it is not serving Priorities IV and V).

  B. Areas Currently Serving CSFP Participants

  Since locations change frequently, contact the Warehouse Manager or the CSFP
  Manager first for updates on the Tailgate and Drop sites.

     Tailgates                          Day                 Location
                                    rd
   Sunland Park                   3 . Mon.       St. Martins Catholic Church       Character Kids Inc.,
                                   rd
     Del Cerro                    3 . Tues.           Del Cerro Community
                                                             Center                1400 N. 6th St.

      Deming                      2nd. Tues.     Helping Hands Warehouse           Las Cruces, NM 88005
                                   nd
    Silver City                   2 . Tues.               Rec. Center
                                                                                   Diretor: Mike Tellez
     Anthony                      3rd. Tues.           St. Anthony Church
                                                                                   Phone: (505)527-1003
    Columbus                      2nd. Tues.             Senior Center
    Lordsburg                     2nd. Tues.          Special Events Center        e-mail:
                                                                                   byfaith626@yahoo.com
       TorC                       3rd. Thurs.              Elks Lodge
    Santa Clara                     nd
                                  2 . Tues                   Armory                Cell: 635-7522

   Alamogordo                     2nd. Thurs.     St. Jude Catholic Church         Manager: Ernesto
                                   rd                                              Sedillo 505-635-8317
     Chaparral                    3 . Tues.            St. Thomas Church
                                   rd
  Hatch (Placitas)                3 . Thurs.           Community Center
                                   nd
     Tularosa                     2 . Thurs.            Fire Department
                                   rd
 Radium Springs                   3 . Thurs.           Community Center


     Tailgates                          Day                 Location
                        nd
     Newcomb           2 . Tues. EOM            TG                                   Echo, Inc. ,Farmington
                                   rd
    Crownpoint                    3 . Thurs.                   TG
                                                                                     Warehouse Address:
    CL/Nageezi            4th Tues. EOM                     TG/Drop
                                                                                     401 S. Commercial St.
    Appleridge            3rd. Wed. EOM                        TG
                                                                                     Farmington NM, 87401
      Chama                       2nd. Wed.                    TG
                             rd                                                      CSFP Manager: Vicky
    Bloomfield           3 . Thurs. EOM                        TG                    Metheny
       Aztec              4th Tues. EOM                        TG
                                   nd
                                                                                     Phone: (505) 326-3770
       GCC                        2 . Tues.                   Drop
                                                                                     Fax: (505) 324-6502
      Gallup                      2nd. Tues.                   TG
       Cuba                       1st. Thurs.                 Drop                   e-mail:

                                                                                     csfpmn@spinn.net



ELIGIBILITY SCREENING                           1-4
WIC POLICY MANUAL                                                                           FFY-2004
                                 st
    Coyote SC                   1 . Thurs.                            Drop
                                 st
     Cuba SC                    1 . Thurs.                            Drop
                           rd
    Lake Valley          3 . Thurs. EOM                               Drop




        Tailgates                          Day                    Location
                                      st                                               Salvation Army
         Ruidoso                 1 . Thurs.             All drops except for Ruidoso
                                                        Dwns, EOM, Double              Warehouse Address: 207
Dwns/Carrizozo/Mescalero
                                                        Issuance                       E. Chisum St. Roswell,
      /San Patricio
                                                                                       NM 88201
Clovis/Portales/Elida, and       3rd. Thurs.            Drop/TG/TG/Drop
        Melrose                                                                        CSFP Manager:
                                      nd
     Hobbs and Alto              2 . Thurs.             TG/Drop
                                                                                       Fran Brown
                                      nd
 Eunice, Jal, Good Sams,          2 . Wed.              All Drops except for Jal
   Polo, and Lovington                                                                 Phone: (505) 624-2271
                                                                                       or 625-2030
         Artesia                  1st. Tues.            TG (All double Issuance,
                                                        EOM)                           Fax:(505) 625-1123 e-
        Carlsbad                      th
                                  4 Thurs.              TG (All double Issuance,       mail:Fbrown@tsasw.org
                                                        EOM)




         Tailgates                                Day                  Location
                                             nd
East Central/Brentwood                      2 . Tues.                     TG
                                                                                       Echo, Inc., Albuq.
                                              nd
        (Seniors I)                         2 . Wed.                     Drops
                                                                                       Warehouse Address:
   Rio Vista, Silvercrest,
   Embudo Towers, La
                                                                                       1301 Broadway NM
  Resolana, and Benalillo                                                              Albuquerque, NM 87107
 County Housing Authority                                                              CSFP Manager:      Phone
        Apartments                                                                     (505) 242-6777
        Medanales                           2nd. Thurs.                   TG
                                                 rd
                                                                                       Fax:505) 243-2725
     Moriarty/Shalom                         3 . Mon.                  TG/Drop
                                                                                       email:echodclaw@spinn.net
     Santa Fe/Rivers                        3rd. Tues.                 TG/Drop
    (Seniors II) Encino                      3rd. Wed.                   Drops
Terrace, Encino Gardens,
Solar Villas, and Mesa Hills
        Apartments
Bernalillo/Ranchitos/Jemez                   3rd. Wed.               TG/Drop/Drop
                                             rd
        Las Vegas                           3 . Thurs.                    TG




                                                         1-5                   ELIGIBILITY SCREENING
WIC POLICY MANUAL                                                             FFY-2004
                                   th
         Socorro                  4 . Mon.                TG
                                   th
          Grants                  4 . Tues.               TG
                                   th
Penasco/Mora/Taos/Questa          4 Wed.                Drops
                                  th
          Belen                  4 . Thurs.               TG


EOM= Every Other Month                  TG= Tailgate
CSFP estimate of participation for federal fiscal year 2006, 16950 participants.


References - General

           Item                                                            Page
       Areas Currently Serving CSFP Participants                           1-4
       Screening Flow Chart - Overview                                     1-7




ELIGIBILITY SCREENING                       1-6
WIC POLICY MANUAL                                                                                   FFY-2004


  C. Screening Flow Chart - Overview

                  Applicant seeks program benefits by phone contact or a visit to the clinic



             Interview to determine if applicant meets residency and priority or age restrictions



  If applicant MEETS residence and priority (age)                 If applicant DOES NOT meet residence or
       requirements, schedule applicant for an                             priority (age) requirements:
                   appointment.
                                                                   Inform the applicant that they are not
      Note: Pregnant women and persons                               eligible to apply for the program.
  considered homeless and/or migrant must be
   seen within 10 calendar days of requesting
     services. All other applicants must be
       screened within 20 calendar days.




                           At screening appointment, determine income eligibility



            Applicant MEETS income                                       Applicant DOES NOT meet
              eligibility guidelines                                     income eligibility guidelines



               Determine nutritional                              Applicant DOES NOT
                  risk eligibility                                 meet nutritional risk
                                                                        guidelines


           Applicant MEETS nutritional
                  risk guidelines


                                                                    Applicant is ineligible for the program.
                    Complete                                          Follow denial procedures, 1-60.
                   certification
                     process



    Transfers who do not have transfer information or a valid WIC certification should
    be scheduled for a certification screening appointment unless transfer information
    can be obtained via phone or fax. Refer to the Clinic Operations section of the
    WIC Policy Manual for guidelines on scheduling transfers from clinic to clinic and
    program to program.




                                                    1-7                      ELIGIBILITY SCREENING
WIC POLICY MANUAL                                                                    FFY-2004
Certification

Certification is the process by which applicants are screened for income eligibility and
nutritional risk. This process involves four steps: data collection, documentation,
assessment and plan formulation.

The instructions for screening applicants are given in the order the screening procedures
should be followed. Use the WIC Application and follow the steps as outlined.

   D. Federal processing standards


   Federal regulations require that all pregnant women and family members of migrant
   and/or homeless applicants be given an appointment for screening within 10
   calendar days of requesting WIC services. All other applicants must be seen within
   20 calendar days. It is the responsibility of the local agency and their supervisors to
   ensure appointments are available as requested. Local clinics not meeting this
   schedule must notify the Clinic Operations Manager at the state office. The clinic
   will be asked to submit a plan for meeting compliance with federal processing
   standards. The state office must be informed of any changes to this plan. Federal
   regulations allow the state office to extend the 10 allowable days for screening
   pregnant women, and members of homeless and migrant families to a maximum of
   15 days. Federal regulations allow the implementation of a waiting list only when the
   clinic is serving its maximum caseload.

   E. Physical presence required

   Program regulation requires that the applicant be physically present in the clinic for the
   certification process. If an applicant, parent or caretaker of an applicant has a disability
   and is unable to be physically present at the WIC clinic because of their disability, the
   client may be certified without being physically present.
   Staff should note that all persons with disabilities are not automatically exempt from the
   physical presence requirements. Only those clients, parents or caretakers of a client
   with a disability that creates a current barrier to the physical presence requirement may
   serve as a basis for an exception from the requirement. Such conditions include:
          A medical condition that necessitates the use of medical equipment that is not
           easily transportable

          A medical condition that requires confinement to bed rest

          A serious illness that may be exacerbated by coming in to the clinic.

   To complete the certification, staff must have all of the required information relating to
   weight, height, hemoglobin, diet, residency and income. Staff is asked to obtain
   permission from the Nutrition Education Coordinator or Clinic Operations Section to
   certify a client under these circumstances. Staff must explain in Notes why the client
   was not present at certification. Please refer to 1-2 for suggestions on serving clients
   who are unable to come into the clinic to access services.




ELIGIBILITY SCREENING                         1-8
WIC POLICY MANUAL                                                                    FFY-2004
  F. Proof of residency required at certification
  All WIC applicants are required to provide proof of residency at the time of certification.
  Proof of residency consists in the applicant or guardian providing one of the following:
      A utility bill showing the name of the applicant or guardian and the street address.
      Utilities include cable, electricity, gas, refuse, sewer, telephone (excluding cell phone
  

      service) and water.
      A rent/mortgage receipt or residential lease showing the name of the applicant or
      guardian and the street or physical address.
  

     A signed letter from the applicant or guardian’s landlord attesting to the client’s
      residency. Staff is to obtain the landlord’s telephone number should further
      verification be necessary. The signed letter may be returned to the client.
     Proof of current enrollment in TANF, Food Stamps or Medicaid in New Mexico.
  For exceptions to this policy contact your Program Manager, Region Nutrition
  Supervisor, WIC Director, Deputy Director, Clinic Operations Manager or Clinic
  Operations Specialist.
  G. Proof of identity required at certification and Benefit Issuance
  All WIC applicants must have a valid ID at the time of each certification appointment,
  including infants and children. Proof of identity must also be presented at time of
  Benefit Issuance.
  Proof of identity consists in the applicant or guardian providing one of the following:
      *Birth Certificate (acceptable for infants or children only)
              *Birth Certificates must have the infant or child’s name and the date of birth.
  

              It is helpful if the birth mother’s name or parent’s name(s) appear on the
              certificate, but not necessary.
     Immunization Record (acceptable for infants or children only)
     Debit or Credit card with applicant/guardian’s name and signature (compare
      signatures)
     Drivers License of applicant or guardian
     Green Card of applicant or guardian
     Membership Card (i.e. Sam’s Club, Price Club, library card, et cetera) with signature
      (staff must compare signatures)
     Military ID of applicant or guardian
     Passport of applicant or guardian
     Pay check or check stub showing the applicant’s or guardian’s name
     Personal ID card for general use
     Printed Personal Checks (checkbook) showing applicant/guardian’s name
     Program ID Card (such as WIC appointment cards) showing applicant/guardian’s
      name
     School ID (with or without picture) showing applicant/guardian’s name
     VOC Card (label, folder, et cetera)
     Voter Registration for applicant or guardian
     Work ID (with or without picture) showing applicant/guardian’s name and signature




                                             1-9                   ELIGIBILITY SCREENING
WIC POLICY MANUAL                                                                   FFY-2004
  Other forms of ID may be acceptable. Please call your Program Manager, WIC Director,
  Nutritionist IV, Deputy Director, or the Clinic Operations Specialist or Section at the state
  office for further discussion if the form of ID presented is questionable.

  There may be situations such as those listed below when an applicant or guardian has
  no verifiable means of identification.

  1. A teen who does not have a Drivers License, school or work ID, and who is applying
     for benefits without knowledge of her parent(s) or guardian(s).
  2. A recently relocated family or individual without a Drivers License, or any other form
     of ID listed above.
  3. A homeless family or individual without a Drivers License, or any other form of ID
     listed above.
  The following options may be used only as a last resort.

      An individual who does have proof of identity can attest to the identity of the
      applicant or guardian applying for WIC services.
  

     The applicant or guardian can provide a letter from an agency or organization
      attesting to his/her identity.
     The applicant or guardian applying for services can write out his/her own attestation
      as to their identity. The attestation must contain the following: Name, date of birth,
      place of birth, an explanation of why they have no proof of identity and their
      signature. In this last situation, staff is to ask if the applicant or guardian can give
      the name and phone number of an individual who can attest to their identity. If
      available, this information should be entered into the WIC application Notes tab.
  Should the options listed above not be possible, consult with the Program Manager,
  Region Nutrition Supervisor, WIC Director, Deputy Director, Clinic Operations Manager
  or Clinic Operations Specialist.


  Note:    WIC EMPLOYEES APPLYING FOR WIC BENEFITS for themselves or their
           children must be certified and/or recertified by another WIC nutritionist. WIC
           employees receiving WIC benefits for themselves, for their children, or picking
           up WIC benefits for another person (acting as a proxy) must make
           arrangements for another WIC employee to issue WIC checks to them. See
           your Nutrition Coordinator (Nut. IV) for clarification.

  Before beginning the certification process, introduce yourself to the applicant(s). Give
  your name and explain the certification process. Tell the applicant or guardian what
  criteria must be met to qualify for WIC benefits. Provide this explanation at each
  certification.

  H. Change of Program Category

  Breastfeeding women, who discontinue breastfeeding during the first five months after
  delivery, must be recertified as a postpartum woman to continue receiving benefits.




ELIGIBILITY SCREENING                       1-10
WIC POLICY MANUAL                                                                   FFY-2004
  Income information, weight, height, hemoglobin, and dietary information over 30 days
  old must be verified and updated.

  Infants turning 1 year within a certification period (certified as an infant after 6 months
  of age) must be certified as a child on or after the 1st year birthday. This is necessary to
  place the child in the correct program category and priority and to assign appropriate
  risk factors. There are also more options for customizing food packages for children.

  Postpartum or breastfeeding women who become pregnant must be certified as a
  pregnant woman within 10 calendar days of notifying the clinic staff of her pregnancy. In
  the case that the postpartum or breastfeeding woman has been issued benefits, and
  has already cashed her checks, she may be scheduled for certification as a pregnant
  woman at her next appointment. If she has only cashed one postpartum or
  breastfeeding check she may return the unused check (the check must be voided in the
  application) and the pregnant woman may be scheduled to be certified within 10
  calendar days of the last benefit period start date. Staff is reminded that federal
  processing standards require that all pregnant women be seen within 10 calendar days
  of requesting services.

  Pregnant Women will need to have the End Cert Date recalculated in the following
  instances so that the Breastfeeding or Postpartum certification appointment is
  scheduled in a timely manner. Should a client’s delivery date be extended beyond what
  was entered at certification, the new EDD must be entered in the WIC application before
  the previously entered EDD passes. Should the client deliver earlier than the entered
  EDD, the actual delivery date should be entered. When saved, the application will
  calculate a new End Cert Date. Benefits cannot exceed 6 weeks beyond the
  termination of pregnancy.

  I. Primary Client Data Fields in the WIC Application

  The main client function in the WIC Application is used to view and/or edit existing client
  records and to enter information for new clients. The tables in this section provide a
  summary of the primary data fields and buttons used in the main client function. Each
  table corresponds to the related “tab” which is displayed on the main client window.
  Field Names that are shown in bold type in these tables indicate there is a requirement
  that the user must enter valid data before certifying the client. (Where more detailed
  information is provided for a data field, refer to the indicated note.) In the Comments
  column, “Enter” means that data is to be entered from the keyboard. “Select” means
  that the data is entered from a drop-down list of choices or by choosing one of a
  mutually exclusive set of choices displayed as “radio buttons.” “Click” means to “set”
  (by mouse click) the indicated flag if appropriate. Where appropriate, an explanation of
  related policy follows each table.

  Staff is to provide as much of the requested information as possible. The requested
  information is valuable in generating accurate reports. Fields with a yellow background
  MUST contain valid data. In most cases, fields with a white background SHOULD
  contain valid data.




                                            1-11                  ELIGIBILITY SCREENING
WIC POLICY MANUAL                                                               FFY-2004
  To access the Main Client Window, click the Open Client button on the toolbar or select,
  Client/Open from the menu bar. Either action will open the Locate a WIC Client window,
  which allows you to:

  a. search for the record for a specific client
  b. display a list of clients meeting search criteria you enter
  c. enter information for a new client.
  The following table lists each tab in the Main Client Window and the page where a
  detailed description of the use of the tab can be found:

                            Tabs in the Main Client Window

                          Tab Name                            Refer to page:
                      Locate Client - Search                       1-13
                      Locate Client - Results                      1-13
                      Basic Client Information (Header)            1-14
                      Demographics                                 1-15
                      Family Group                                 1-18
                      Income                                       1-19
                      Medical                                      1-30
                      Pregnancy/Outcome                            1-41
                      Breastfeeding/Outcome                        1-43
                      Diet Analysis                                1-44
                      Infant Diet                                  1-46
                      Risk Factor                                  1-48
                      Nutrition Ed. Plan                           1-49
                      Notes                                        1-49
                      Referrals                                    1-50
                      Certification                                1-51
                      Food Package Design                          1-54
                      FI Issue                                     1-55
                      Scheduling                                   1-56
                      Food Purchases                               1-57
                      Summary                                      1-57
                      Labels and Letters                           1-58




ELIGIBILITY SCREENING                       1-12
WIC POLICY MANUAL                                                                    FFY-2004
1. Locate Client - Search Tab

The Locate Client function is used to find and open records for existing clients and to enter
information for a new client. This step helps prevent the creation of duplicate files. Prior to
creating a new record, staff should always do a search.

To access the Locate function either:
      Click the Open Client button on the toolbar, or
      Select Client/Open from the Menu bar.
Field/Button Name         Comments
EBT Card PAN#             PAN# will appear when card is placed in reader and loaf PAN# is
                          selected.
Family Group ID           Enter client’s Family Group ID Number (if known).
WIC ID                    Enter client’s WIC Identification Number (if known).
Last Name                 Enter client’s Last Name.
First Name                Enter client’s First Name.
MI                        Enter client’s Middle Initial.
Date of Birth             Enter client’s date of birth in MMDDYYYY format.
Sex                       Enter or select Male, Female, or All.
Automatically Open If     Click to set the WIC Application to immediately open the client
One Record Found          record if only one record matches the search criteria.
Box
PAN# Button               Click to enter PAN# on EBT Card once placed in reader, It will also
                          display all clients in the Family Group.
Advanced/Basic            Click to select Basic search or Advanced search.
Button
Clear Button              Click to clear all fields in Search tab.
Find Button               Click to execute the find process based on search criteria that
                          have been entered.
Display EBT Card          Click to view all current Food Benefits placed on EBT Card.
New Button                Click to begin entering data for a new client.
Cancel Button             Click to close Locate WIC Client window.
Override PIN              Select Yes bullet to access Client File without asking client for
                          PIN#.




To start a search for a client, enter one or more data elements to be used as the criteria for
the search, then click the Find button. Partial entry can be made in the First Name or Last
Name fields. For example, enter ‘jar’ in the Last Name field to locate all clients whose last
name is Jaramillo. Once the Find button has been clicked the results of the search will be
displayed on the Results tab.
2. Locate Client - Results Tab

The Locate Client - Results Tab displays the results of a client search which was initiated
from the Search tab and is opened when the search is completed.




                                             1-13                   ELIGIBILITY SCREENING
WIC POLICY MANUAL                                                                           FFY-2004
Field/Button Name          Comments
Clinic                     Displays local clinic to which client belongs.
Family ID                  Displays Family Group Identification Number (if assigned).
WIC ID                     Displays WIC Identification Number of a client (if assigned).
Name                       Displays Last Name and First Name of a client.
DOB                        Displays Date of Birth of a client.
Sex                        Displays sex of a client.
Program Cat.               Displays Program Category of a client.
Certified                  Displays Yes or No to indicate whether or not client is certified.
Mailing Address            Displays Mailing Address of a client.
EBT Card PAN #             Displays clients EBT Card PAN #.
City                       Displays City of a client.
OK Button                  Click to open record of selected client.
New Button                 Click to enter data of a new client.
Cancel Button              Click to close Locate Client window.


To open a client record, use the mouse and/or keyboard to navigate to the row showing the
client you want to open, then either:
        Double click the row, or
        Click the OK button, or
        Place EBT Card in reader, click on Load PAN #, select Yes to override PIN #.
3. Basic Client Information (Header)

Basic client information is entered and displayed in the header area of the main client
window of the WIC Application.

Field Name                 Comments
Clinic                     Select local clinic or contract agency from list.
Name                       Enter client’s last and first name. Enter client’s
                           middle initial if they have one.                                  Note (1)
DOB                        Enter client’s date of birth in MMDDYYYY format.
Prog. Cat.                 Select program category for client.                               Note (2)
Priority                   Displays the Priority code for the client. Priority assignment is
                           automatically determined by the WIC Application.

Reference - Basic Client Information

           Item                                                                          Page
       Clinic Names                                                                      1-66

Notes for Basic Client Information:

(1) Name

   The only appropriate update to this field should be to show intentional name
   changes requested by the client or to correct misspelling. Changes in this field will
   cause the replaced information to appear in the Aliases & ID’s section of the



ELIGIBILITY SCREENING                           1-14
WIC POLICY MANUAL                                                                             FFY-2004
   Demographics tab. The client name should never be changed for any other reason.
   Please call the helpdesk prior to changing this field if you are unsure of how to
   proceed.

(2) Program Category

   The available program categories are:

   PW      Pregnant Woman - from certification date until six weeks postpartum.
   BF      Breastfeeding Woman - from delivery until infant's first birthday.
   PP      Postpartum (Non-Breastfeeding) Woman - from delivery until six months after
           delivery.
   I       Infant - from birth until the first birthday (Children who have not reached their first
           year birthday must be certified as an infant.)
   C       Child - from the first until the fifth birthday (The ‘Child’ program category cannot
           be assigned until the first birthday has been reached.)
4. Demographics Tab

The Demographics tab is used for data entry of client demographic information.

  Field/Button Name                                        Comments
Telephone Number           Enter client’s home phone number or other primary-point-of-contact
                           phone number, including area code.
Joined Clinic              Date client first enrolled at this clinic. Automatically filled in by WIC
                           Application but can be overwritten by user.
Sex                        Select or enter Male or Female.
Race                       Select race of client.                                                Note (1)
Ethnicity                  Select ethnic origin of client.                                       Note (2)
Language                   Select primary language used by client or guardian.
Education Level            Select level of education of client. Complete for PW, BF, and PP
                           categories only. Leave blank for Infants and Children.
SSN                        Enter client’s Social Security Number, if available.                  Note (3)
Residency Verification     Select type of documentation that was used to verify residency.
                           Effective Oct. 1, 1999, staff must review documentation of proof of
                           residency submitted by all WIC applicants. All applicants must
                           provide proof of residency at certification.                          Note (4)
Marital Status             Select marital status of client. Used for PW, BF, and PP categories only.
Mother’s Maiden Name       For an infant or child, enter mother’s maiden name.                   Note (5)
Birth Mother               For an infant or child, enter name of birth mother if known. This
                           information is not necessary for a foster or adopted child.            Note (6)
Locate/Remove Mother       Click to open the Find window to locate this infant or child’s mother. If
Button                     mother is not on WIC then the find will be unsuccessful. This field can
                           be left blank.
Migrant                    Click if client meets migrant status.                                  Note (7)
Homeless                   Check if client is homeless.                                          Note (8)




                                                1-15                      ELIGIBILITY SCREENING
WIC POLICY MANUAL                                                                           FFY-2004
  Field/Button Name                                        Comments
CSFP                         Check if client is a CSFP participant. This will automatically deny
                             certification, but save all client information for possible future WIC
                             participation.
Deceased                     Check if client is deceased.
WIC ID                       A unique identification number which is automatically generated by WIC
                             Application when the record is saved.
Generate WIC ID Button       Click to generate WIC ID for this client. Automatically generated by WIC
                             Application when the record is saved.
Parent/Guardian Name         For an infant or child, enter parent or guardian’s first and last name.
                             Enter middle initial if available.
P/G DOB                      For an infant or child, enter parent or guardian’s date of birth.
System ID                    Internal ID number generated by WIC Application.
Aliases and ID’s             Displays any alias client has used. Click the Insert button to enter a
                             new alias.                                                         Note (9)
Insert Button                Click to insert information for an alias.
Delete Button                Click to delete the selected alias row.
Open Client Alert            Opens a text page allowing the user to enter temporary follow-up notes
                             or actions to be taken at next client contact.
Select Item to Print         Select mailing labels, etc. for printing for this client.
Notes for Demographics Tab:
(1) Race
    Available choices are:
     American Indian/Alaskan Native-(Examples: Native American, Tribal Indian, Pueblo
    Indian, including a person from North, South or Central America who maintains tribal
    affiliation.)
    Asian-(Examples: a person from India, Pakistan, China, Japan, Korea, Vietnam, or
    Thailand.)
    Black/African American-(Includes all black racial groups of Africa.)
     Native Hawaiian/Other Pacific Islander- (Examples: Hawaiian, or a person having
    origins from any other Pacific Island.)
     White-(Examples: Caucasian or people from Europe including Germany, France, or
    Spain, or from Mexico, Ireland, Sweden, Poland, Middle East or North Africa.)
    Staff is not to use Other or Unknown.
    Staff should have the applicant choose from the list available.
    An example of a question to ask a client to determine race is "For statistical analysis,
    we are asked to collect data on participant race. We can only enter one choice.
    What would you like me to enter as your race ethnicity?

(2) Ethnicity

    Available choices are:




ELIGIBILITY SCREENING                            1-16
WIC POLICY MANUAL                                                                    FFY-2004
    Hispanic-(A person of Cuban, Mexican, Puerto Rican, South or Central America, or
   other Spanish culture origin, regardless of race.)

   Non-Hispanic-(A person not considered of the culture that is stated in the above
   Hispanic category)

   Staff is not to use Other or Unknown.

   Staff should have the applicant choose from the list available.
   Staff may enter ethnicity if known only after the participant has previously identified
   their ethnicity. However, if unknown, it is appropriate to ask an applicant to identify
   their ethnicity. An example of a question to ask a client to determine ethnicity is,
   "For statistical analysis, we are asked to collect data on participant ethnicity. We
   can only enter one choice. What would you like me to enter for your ethnicity?"
(3) SSN
   Obtaining a social security number from each participant is desirable. An applicant
   should not be refused certification or services for the program just because they have no
   social security number or because they forget to bring it with them. Social security
   numbers are usually issued upon obtaining a birth certificate in New Mexico. Note that
   for clients on Medicaid, the client’s Medicaid number is to be entered in the Income tab.
   Staff is asked to post the following notice where clients can read it and to inform clients
   at the time of data collection: “Giving the WIC Program your social security number or
   that of your child (applicant) is completely voluntary and does not impact your eligibility
   determination. Your social security number will only be used as an additional identifier
   to search for duplicate files or to help distinguish between records with similar names
   and/or dates of birth.”

(2) Residency Verification
   See Eligibility Screening, 1-9 for guidelines on Residency Documentation. All applicants
   must provide proof of residency at certification. The selection, “Staff did not verify” is no
   longer acceptable and must not be used by staff

(3) Mother’s Maiden Name
   If this information is not available, use the Notes tab to document why the field is blank.
   Leave this field blank on all women’s participant files.

(4) Birth Mother
   Use the Locate/Remove Mother function to enter the mother’s name. If the mother’s
   name is not available, document in Notes why the field is blank. Do not create a record
   for the mother if a record for her does not exist in the database.

(5) Migrant Status
   Determine if the participant is a migrant worker by asking: "Have you or any member of
   your family left home within the last two years to follow the crops or to work with lumber
   or timber?" If yes, issue a VOC Card.




                                             1-17                   ELIGIBILITY SCREENING
WIC POLICY MANUAL                                                                           FFY-2004
   Do not assume participants are not migrants. Ask the above question at certification
   time and at consecutive certifications. The Code of Federal Regulations defines a
   Migrant farmworker as “an individual whose principal employment is in agriculture on a
   seasonal basis, who has been so employed within the last 24 months, and who
   establishes, for the purposes of such employment, a temporary abode.” A program
   applicant, including an infant or a child, is classified as Migrant if any member of the
   family group meets the criteria for Migrant farmworker.

(6) Homeless Participants
   If you determine that a participant is homeless, issue a VOC Card upon certification to
   ensure that s/he will receive services wherever s/he resides.

   The Code of Federal Regulations defines Homeless as “a woman, infant or child who
   lacks a fixed and regular nighttime residence; or whose primary nighttime residence is a,
   public or private shelter designated to provide temporary living accommodation, a
   temporary accommodation in the residence of another individual; or a public or private
   place not designated for, or ordinarily used as a regular sleeping accommodation for
   human beings.”

(7) Alias

   An alias name is any name different that the current name being used that has been
   used to access WIC services in the past. Staff is to routinely enter alias names for
   clients of all program categories. Minor changes such as adding or removing asterisks
   from a client’s name will cause the changes to appear in the Aliases & ID’s section of
   this tab page. Although not necessary, it is recommended that staff enter other names
   (i.e. married name, maiden name, hyphenated names) used by clients to obtain WIC
   services.

5. Family Group Tab

The Family Group tab of the WIC Application is used for entry of family group information
including head of household name, addresses and phone numbers.

Note: The family group must be defined before the applicant can be certified. All Foster
Children must be assigned their own Family Group ID# and issued their own EBT card.

Field/Button Name          Comments
Family Group ID            Internal ID number generated by WIC Application for family group.
PAN                        Personal account number of the EBT card issued to the family.
Head of Household          Enter last and first name and middle initial for the client’s head of
                           household.                                                          Note (1)
County                     Select client’s county of residence
Benefit Period Start Day   The first day of the benefit period for all family members.
Mailing Address            Enter client’s mailing address if different from street address. Leave field
                           blank if the mailing and street addresses are the same.
Street Address             Enter the client’s street address. If client has no street address (i.e., a
                           homeless client), leave this field blank.
Proxy Name 1 & 2           Enter first and last names of proxy for client                      Note (2)




ELIGIBILITY SCREENING                           1-18
WIC POLICY MANUAL                                                                      FFY-2004
Field/Button Name       Comments
Balance Available       Displays the balance of food items available to the family group for the
                        current benefit period.
Phone Number(s)         Enter home, work or other phone numbers if available. Include area
                        code. Click Insert button to enter a new phone number. Click Delete
                        button to delete a selected phone number.
Locate Family Button    Click to open Find window to locate Family Group for client or to create a
                        new Family Group.
Assign/Replace EBT      Click to generate an EBT card. This button toggles from Assign to
Card Button             Replace EBT Card, once EBT Card has been initially generated.
Update EBT Card         Click to update client information loaded on the EBT card.
Button
Disp. EBT Card Button   Display information loaded onto EBT card.
Insert Button           Click to insert a row for entering phone number information.
Delete Button           Click to delete selected phone number row.
Set Family Values       Allows the use to select the type of issuance (checks or EBT) and allows
                        changes of the number of benefit periods to issue of all family members
Bottom of Screen        Displays basic demographic information (WIC ID, name, etc.) about all
                        members of this client’s family group.

Notes for Family Group Tab:

(1) Head of Household

   The head of household must be an adult and may be the client. Pregnant teenagers
   may name themselves as head of household even if they are not legally emancipated.
   All infants and children (including foster children) must have an adult guardian
   designated as the head of household. Foster children must be issued their own EBT
   card and Family Group #.

(2) Proxy Name

   Applicants are not required to provide a proxy name. However, if the applicant desires,
   one or two proxy names may be entered. Names entered as proxies apply to the family
   group rather than the individual client. Refer to page 2–63 of the policy manual for the
   Proxy Form.

6. Income Tab

Information relating to family size, income, Temporary Assistance for Needy Families
(TANF), Food Stamps, and Medicaid is entered on the Income tab of the WIC Application.
A separate entry is made for each income source. Once all appropriate income information
has been entered, calculation of income eligibility is accomplished by the application.
Family members of a household in which any member of the household receives Food
Stamps or TANF meet adjunct eligibility. Any income received by the household, including
TANF, should be entered in the WIC Application. Applicants who are currently enrolled in
Medicaid also meet adjunct eligibility. Family members in a household where the infant or
pregnant woman are currently on Medicaid also meet adjunct eligibility. For additional
information, refer to Adjunct Eligibility on 1-28.



                                            1-19                    ELIGIBILITY SCREENING
WIC POLICY MANUAL                                                                          FFY-2004
  Field/Button Name                                       Comments
Family Size                 Enter the number of individuals in the client’s family or household.
                                                                                               Note 1
Income Eligibility Status   Displays status of the client’s income eligibility. Field is automatically
                            calculated by the WIC Application.                 Note 2
as of                       The date Income Eligibility was calculated. Field is automatically
                            entered by the WIC Application.
TANF                        Check if client currently participates in the Temporary Assistance for
                            Needy Families program.
Food Stamps                 Check if client is currently receiving Food Stamps.
Medicaid Number             Enter the entire (14 digit) Medicaid Number for client receiving
                            Medicaid benefits (except Foster Children). This number is not
                            necessarily the client’s social security number. Enter five (5) zeros in
                            front of the Social Security Number to complete the field. If the client is
                            on Medicaid, this field is required.
Current Medicaid Status     Select to indicate whether client is currently an Active or Inactive
                            Medicaid participant.
Sequence                    Displays sequential number of an income item.
Source of Income            Select source of income from list or enter a brief description of income
                            source.                                            Note 3
Dollar Amount               Enter dollar amount for income item.                               Note 4
Frequency                   Select frequency of payment of income item.
Proof of Income             Select type of documentation that was used as Proof of Income for
                            income item.                                                       Note 3
Annual Factor               Enter annual factor for income item if different than the factor
                            automatically calculated by the WIC Application. For example, if an
                            hourly rate of pay has been entered and client works other than 2,080
                            hours per year, enter actual number of hours worked per year or allows
                            the user to select the default factor for ten or twenty. Hours per week.
Annual Amount               Displays the calculated annual amount for selected income item.
                            Calculated by the WIC Application.
Date Income Determined      The date the user activated the Determine Income Eligibility Button.
                            Automatically dated by the WIC Application.
Total Annual Income         When income source data is entered, this row displays total annual
                            amount of all income items for client. Calculated by the WIC
                            Application.
Determine Income            Click to calculate Income Eligibility for client. At least one income item
Eligibility Button          must be entered.
Insert Button               Click to add a new row for entering income.
Delete Button               Click to delete a selected row.
Time                        Shows the date and time note was entered. Automatically dated by the
                            WIC Application.
Type                        Select appropriate type for note. This field is automatically set to
                            Income when in the Income tab.
Who                         Indicates user ID for the person that created note. Automatically
                            entered by the WIC Application.
Note                        Enter text for this note. Notes entered here are also available in Diet
                            Analysis and Notes tabs.
Note Insert Button          Click to insert a new Note.




ELIGIBILITY SCREENING                          1-20
WIC POLICY MANUAL                                                                  FFY-2004
  Field/Button Name                                     Comments
Note Delete Button        Click to delete a selected Note.

References - Income Tab

        Item                                                                Page
    Questions for determining family size and income                        1-19
    Items considered and items not considered income                        1-24
    Income Eligibility Guidelines                                           1-26
    Income Affidavit                                                        1-29
    Income Statement                                                        1-30

Notes for Income Tab:

(1) Family Size

   All persons living under one roof are not necessarily counted as members of the family.
   The family is defined for the purpose of WIC eligibility as an economic unit. The
   certifying authority must determine what constitutes the family in each particular case.

   J. Family Size for Pregnant Women

   The family size for pregnant women is determined the same as for all other WIC
   applicants (see section K below). However, when a pregnant woman’s income is just
   above the income guidelines for her family size, the family size may be increased by the
   number of unborn the woman is carrying at the time of certification. If the increased
   family size meets income guidelines, the application process should proceed. Note: In
   instances where the applicant has a cultural or religious objection to increasing the
   family size, this must not be done. This should be documented in Notes. If the family
   size was increased to include the unborn, document in Notes. In addition, the
   increased family size applies to all other family members who apply for WIC
   participation (at this time or later on during the pregnancy).

   K. Determining Family Size Income

   The following questions and instructions should be used to determining family size and
   income so that all staff follows the same procedure.

   Ask the applicant or guarding the following questions to determine the size of the family
   unit that will be used to determine income eligibility. Remember that the family size can
   be increased by one for each unborn infant being carried by the pregnant woman, if it
   will make the family income eligible. Note: In instances where the applicant has a
   cultural or religious objection to increasing the family size, this will not be done. The
   increased family size also applies to other family members who apply for WIC
   throughout the pregnancy.

   1. How many persons are there in your household?
   2. Name the persons in your household. (Have the applicant/guardian state the names
      of all individuals including themselves. If appropriate, ask if they have included
      newborns.)



                                             1-21                  ELIGIBILITY SCREENING
WIC POLICY MANUAL                                                                   FFY-2004
   3. Do you provide full financial support for everyone you counted in your family unit?
      (Full financial support is more than just food and shelter. See question B, below.) At
      this point, if the applicant/guardian is unsure, ask:
      a. Does your family file an income tax return? If so, ask:

      b. Who do you claim as dependents on your income tax return? (If no income tax
         return is filed, ask Question B.)

      c. Do you buy clothes, provide transportation, pay medical bills and/or cover any
         other expenses for the person(s) in question?

   4. Does your family receive food stamps or TANF? (The applicant/guardian must be
      able to show proof of current enrollment to meet adjunct eligibility.)
   5. Is the applicant (name) currently on Medicaid? (The applicant/guardian must be
      able to show proof of current enrollment to meet adjunct eligibility.) Of the ___ (state
      number) persons in your household, how many work?
   Note: Income verification is not required for persons meeting adjunct eligibility.
   However, staff is asked to inquire about income earned. Staff is to figure and report the
   average annual income based on information given by the client.

   6. Does anyone in the family unit receive money from any other source(s)?
   7. Is any money received from: (Go through the list of sources considered income (1-
      24). Enter each income item.
   8. When all income items have been entered, click the “Determine Income Eligibility”
      button to calculate income. Review the income items with applicant/guardian.)
      State, “I show you receive income from these sources, (name sources), and that the
      annual income for your household is $______ (state annual income). Ask again, “Is
      there anything else you may have left out or forgotten? (Make any necessary
      additions or adjustments to the items).
   9. Read or paraphrase the applicant/guardian statement in the income box to the
      applicant/guardian. Ask the applicant/guardian if they have any questions. Have the
      applicant/guardian date and sign the signature line in the income box of the
      Participant’s Rights and Responsibilities form.
(2) Income Ineligible

   Income eligibility is determined based on reported annual income being at or below
   income guidelines or by meeting adjunct eligibility. If the applicant does not meet either
   of these criteria, the screening process may be terminated here. Refer to 1-60 for denial
   procedures. Referrals to other health and social services may be appropriate at this
   time.

(3) Source of Income

   The New Mexico WIC Program requires income documentation from all WIC
   participants (including in-stream migrants) at every certification appointment.
   Participants are required to bring in the necessary documentation in the form of one or
   more of the following items at certification:




ELIGIBILITY SCREENING                       1-22
WIC POLICY MANUAL                                                                   FFY-2004
  a. Pay check stub(s) showing wages for all members of the household unit who are
     gainfully employed. Stubs must be within the last 30 days. NOTE: ALL FEDERAL
     AND STATE EMPLOYEES AND ALL PUBLIC SCHOOL EMPLOYEES ARE
     REQUIRED TO PROVIDE A CHECK STUB ALONG WITH ANY OTHER INCOME
     VERIFICATION.
  b. A letter from an employer stating wages earned for a specific time period. Including
     date and phone number of their employer. Persons who have just been employed on
     ranches, small companies may have these letters.
  c. A current Medicaid card for the applicant. See Adjunct Eligibility, 1-28.
  d. Proof that the family is currently receiving TANF or Food Stamps. See Adjunct
     Eligibility, 1-28.
  e. If person is self-employed, a statement or letter showing amount of money earned or
     net profit for the past month. Such as most recent quarterly business reports.
  f. An income tax returns, from the previous year, which shows the income for all
     members of the household unit who filed a tax return.
     Tax Returns
     Income tax returns, which include income earned from a job, must include W-2 forms
     for all employed persons in the household. The W-2 forms must be reviewed to
     determine the total income for the family. The amount to consider as income, on a
     W-2 form is listed as the "TOTAL GROSS". Total gross income includes income
     that is not taxable at the time it is earned (e. g., deferred compensation, POP).

     Income tax returns, which include income from the operation of a business, should
     have one of the following Internal Revenue schedule forms attached:

        SCHEDULE C: This form is to be completed to show a profit or a loss through a
         business. The amount listed on line 31 is the Net Profit or (loss). If the amount
         is not in parentheses, it is a profit. Consider this amount as income. If the
         amount on line 31 is in parentheses, it is a loss.

        SCHEDULE C-EZ: This form is to be completed to show a profit through a sole
         proprietorship. The amount listed on line 3 is the Net Profit. This form does not
         show $0 income or a loss. Consider the amount on this line as income from a
         business.

         SCHEDULE E: This form shows supplemental income or loss. The amount
         listed on line 26 shows income or (loss). If the amount is not in parentheses, it is
     

         income. If the amount on line 26 is in parentheses, it is a loss. It should not be
         considered as income.

        SCHEDULE F: This form shows a profit or loss from farming. Line 36 shows the
         Net Profit or (Loss). If the amount on line 36 is not in parentheses, it is a profit.
         Consider this amount as income. If the amount on line 36 is in parentheses, it is
         a loss.

        SCHEDULE SE: This form is to be completed to show income earned through
         self-employment. SHORT Form: Net earnings (less than $400.00) are shown on



                                           1-23                   ELIGIBILITY SCREENING
WIC POLICY MANUAL                                                                   FFY-2004
          line 4. This is considered income. LONG Form, Section B: Net earnings greater
          than $400.00 is shown on line 6. This is considered income.

       Since income eligibility is based on the applicant's status at the time of application,
       the previous year's income tax returns is not always the most accurate reflection of
       the current income status. However, it is accepted as income documentation when
       items listed under a) through e), on the previous page, do not accurately reflect the
       income for the entire household. If you have any question on figuring income,
       please call the District Nutrition Coordinator, the WIC Program Manager or the Clinic
       Operations Manager.

(4) Income Affidavit

   Some clients may receive cash payment from odd jobs, selling items, et cetera. The
   client may not be able to provide documentation of cash earned from selling wood,
   cleaning yards, et cetera. Some clients may not have a source of income at the time
   of certification. These clients should be given an Income Affidavit to complete. Staff
   is to read the information provided by the client and ensure that the questions posed
   on the affidavit have been answered. The client and staff are to sign and date the
   form. A copy of the completed Income Affidavit form must be placed in the file of
   each client being certified at that time. The information reported on the Income
   Affidavit should be entered in the Income tab.

(5) Dollar Amount
   When a participant transfers into the NM WIC Nutrition Program and has a current
   certification period, they have already been determined eligible by program staff.
   However, staff is asked to obtain an oral report of the client’s current income status at
   the time they join our WIC Program. Enter the information as you would for any other
   applicant. Because the client is already eligible, the client does not have to provide
   income documentation at that time. Inform the client that they will be required to provide
   income documentation at the next certification.

   L. Income Determination

   Determine the applicant's income by reviewing possible sources of income using the
   questions below as a guide. The client should specify any money they and any other
   member of their family receive throughout the year. Explain that all income information
   must be complete and accurate and that falsification of or withholding sources of income
   is grounds for termination from the program.
      If the applicant has a job or business, ask him/her:
       a. "How many people in the household work?"
       b. "What is their income before taxes and other deductions are taken out?" (If the
          applicant only knows "take home pay", multiply that amount by 1.5 percent to
          estimate gross pay.)
       c. "Are there any other sources of income?"
   The following are considered income:




ELIGIBILITY SCREENING                       1-24
WIC POLICY MANUAL                                                                      FFY-2004
         Pay from a job or business                    Workmen's Compensation
         Unemployment benefits                         Retirement benefits
         Social Security                               Income from stocks
         Rent collected from someone else              Child support or alimony
         Cash received from family/friends             Supplemental Security Income
                                                         (disability)
          TANF (Cash Assistance), (which                 Interest only on savings account,
          automatically qualifies the individual         loans, or investments
                                                    

          and all household members for WIC)

  The following are not considered income:

         Savings Accounts                              Payments from the Disaster Relief
                                                         Act of 1974
          Food Stamps or the value of                    Value of child care payments under
          assistance from the National School            the Social Security Act or the Child
                                                    

          Act, the Child Nutrition Act of 1966,          Care & Development Block Grant Act
          and the Food Stamp Act of 1977
         Military housing allowances for living        Wartime Relocation of Civilians
          off base. (BAQ)                                under the Civil Liberties Act of 1988
         Student financial assistance received         Cost-of-living allowances provided to
          in whole or in part under Title IV of          military personnel on duty outside of
          the Higher Education Act including             contiguous United States
          student loans, college work study or
          scholarships

     Call your Region Nutrition Coordinator, WIC Program Manager or the Clinic
     Operations Section about other sources of income to see if they should be
     counted.

  M. Income Documentation

  Income verification beyond the documentation requested on page 1-21 or the Income
  Affidavit is not routinely required from the participant. If there is reason to question the
  applicant's reported income; further verification may be required. Contact the Region
  Nutrition Coordinator, WIC Program Manager or Contract Agency Supervisor for specific
  guidance and approval.

  N. Income Changes Within a Certification Period

  Should a WIC participant’s family income increase to a level above WIC eligibility
  income eligibility guidelines during a certification period the client’s certification period
  must be terminated.

  This situation might occur when a family member applies for WIC participation while
  another family member is currently certified and receiving WIC benefits. For example a



                                             1-25                    ELIGIBILITY SCREENING
WIC POLICY MANUAL                                                                    FFY-2004
  child or two from the same family group may be on WIC. The mother may apply for WIC
  during the child’s current certification period as a Pregnant Woman. Should the family’s
  reported income exceed WIC Income Eligibility Guidelines (even after counting the
  unborn) not only must the applicant be denied WIC participation, other family members
  who are currently certified must also be terminated from WIC participation. This policy
  became effective October 1, 1999.

  WIC participants who are due benefits and who are terminated within a certification
  period because they are no longer income eligible should receive the following.

  1. A half food package if they have a current certification.

  2. A 15-day notice of termination of benefits

  3. Notification that due to changes in the family income they are no longer eligible to
     continue receiving WIC benefits

  4. A termination letter (page 1-24, 1-25) informing the participant of their right to a fair
     hearing.

  Exceptions to this policy include WIC participant’s continuing to meet income eligibility
  due to verifiable participation in TANF, Food Stamps and/or Medicaid, which makes
  them adjunct eligible and may continue receiving WIC benefits. Staff must enter a note
  in the client’s file explaining that the applicant has not been terminated in mid-
  certification due to adjunct eligibility.




ELIGIBILITY SCREENING                       1-26
WIC POLICY MANUAL                                                             FFY-2004

                                                                                          Deleted:
Denial Letter due to income changes within a certification period.




Date: ____________________________

Dear: _____________________________________________
       (Name of adult participant or parent/guardian)

The following WIC participants must be terminated from WIC participation due to
reported changed in the family’s income.

_____________________________               ______________________________
Participant’s Name                                Date of Program Termination

____________________________                ______________________________
Participant’s Name                                Date of Program Termination

_____________________________               ______________________________
Participant’s Name                                Date of Program Termination

Family size: _____                   Reported family income: $_______________

    Standards for participation in the program are the same for everyone regardless of
    race, color, national origin, sex, age, handicap or disability.



    You may appeal any decision made by the local agency regarding your eligibility for
    the program.



    The local agency will make health services and nutrition education available to you
    and you are encouraged to participate in these services.



    The information you have provided is and will remain confidential unless you have
    given consent otherwise.





ELIGIBILITY SCREENING                     1-24
WIC POLICY MANUAL                                                                      FY-2004

Denial Letter due to income changes within a certification period, page 2.




The program must receive requests for a fair hearing within 60 days of this notice. Written
requests should be mailed to:
                     Public Health Division, Family Health Bureau
                     WIC Nutrition Program
                     2040 South Pacheco Street
                     Santa Fe, New Mexico 87505
 Or you may call the Clinic Operations Manager or the WIC Program Director in Santa Fe at
1-800-STATE OFC or 1-866-867-3124 to request a fair hearing.

The United States Department of Agriculture (USDA) prohibits discrimination in its programs
on the basis of race, color, national origin, sex, age and disability. Persons with disabilities
who require alternative means for communication of program information (Braille, large
print, audiotape, etc.) should contact USDA’s TARGET Center at (202) 720-2600 (voice and
TDD). To file a complaint, write
                       USDA, Director, Office of Civil Rights
                       Room 326-W, Whitten Building
                       1400 Independence Avenue SW
                       Washington, DC 20250-9410
 Or call (202) 720-5964 (voice and TDD). USDA is an equal employment opportunity
provider and employer. Thank you for your understanding and consideration.




____________________________
Staff Signature, WIC Nutrition Program




                                            1-25                  ELIGIBILITY SCREENING
WIC POLICY MANUAL                                                                   FFY-2004

   O. WIC Income Eligibility Guidelines


                                      Used to determine Income
                                     185% Federal Poverty Level Table

                                     Implementation Date: April 1, 2007
    Family Size       Annual         Monthly Income     Twice Monthly       Bi-Weekly        Weekly Income
         1               $18,889               $1,575                $788           $727                $364
         2                25,327                2,111               1,057            975                 488
         3                31,765                2,648               1,324          1,222                 611
         4                38,203                3,184               1,592          1,470                 735
         5                44,641                3,721               1,861          1,717                 859
         6                51,079                4,257               2,129          1,965                 983
         7                57,517                4,794               2,397          2,213               1,107
         8                63,955                5,330               2,665          2,460               1,230
         9                70,393                5,867               2,934          2,708               1,354
        10                76,831                6,404               3,203          2,956               1,478
        11                83,269                6,941               3,466          3,204               1,602
        12                89,707                7,478               3,729          3,452               1,726
        13                96,145                8,015               3,992          3,700               1,850
        14               102,583                8,552               4,255          3,948               1,974
        15               109,021                9,089               4,518          4,196               2,098
        16               115,459                9,626               4,781          4,444               2,222
        17               121,897               10,163               5,044          4,692               2,346
        18               128,335               10,700               5,307          4,940               2,470
        19               134,773               11,237               5,570          5,188               2,594
        20               141,211               11,774               5,833          5,436               2,718
For each additional       $6,438                $537 $                269           $248                $124
family member add:
                                                                                           Revised 3/15/07 MP




                                   Implementation Date: April 1, 2006
                                                                                            Revised 3/9/07

ELIGIBILITY SCREENING                       1-26
WIC POLICY MANUAL                                                             FFY-2004

                                     100% Federal Poverty Level Table

                                       Implementation Date: April 1, 2007
  Family Size         Annual       Monthly Income      Twice Monthly        Bi-Weekly         Weekly Income
        1                $10,210                $851                $426            $393                  $197
        2                 13,690               1,141                 571             527                   264
        3                 17,170               1,431                 716             660                   331
        4                 20,650               1,721                 861             794                   398
        5                 24,130               2,011               1,006             928                   465
        6                 27,610               2,301               1,151           1,062                   531
        7                 31,090               2,591               1,296           1,196                   598
        8                 34,570               2,881               1,441           1,330                   665
        9                 38,050               3,171               1,586           1,464                   732
       10                 41,530               3,461               1,731           1,598                   799
       11                 45,010               3,751               1,876           1,732                   866
       12                 48,490               4,041               2,021           1,866                   933
       13                 51,970               4,331               2,166           2,000                 1,000
       14                 55,450               4,621               2,311           2,134                 1,067
       15                 58,930               4,911               2,456           2,268                 1,134
       16                 62,410               5,201               2,601           2,402                 1,201
       17                 65,890               5,491               2,746           2,536                 1,268
       18                 69,370               5,781               2,891           2,670                 1,335
       19                 72,850               6,071               3,036           2,804                 1,402
       20                 76,330               6,361               3,181           2,938                 1,469
For each additional       $3,480                $290                $145            $134                   $67
family member add:
                                                                                           Revised 3/15/07 MP




                                                                                                                Deleted:
                                        1-27                   ELIGIBILITY SCREENING
WIC POLICY MANUAL                                                                   FFY-2004

                                          Adjunct Eligibility
  Applicants may meet adjunct eligibility in any of the following ways.

  1. The family unit is currently enrolled in the Food Stamp Program at the time of WIC application.

  2. The family unit is currently receiving TANF at the time of WIC application.

  3. The applicant is actively enrolled in Medicaid at the time of WIC application

  4. There is a Medicaid active pregnant woman or infant in the applicant’s family unit at the time of
     WIC application.

  To provide verification of adjunct eligibility, the applicant or guardian is asked to provide a copy of
  the print out obtained from the caseworker or the mailed notice of Food Stamp, TANF enrollment
  showing the dates of eligibility, or proof of current enrollment in Medicaid. Where available, staff
  may verify enrollment in any of the above programs by phone.

  If Medicaid enrollment for a Pregnant Woman or Infant is used to meet adjunct eligibility for
  another WIC applicant, enter the name of the pregnant woman or infant in the Notes section of
  the WIC application, and a narrative explaining that is how the applicant met adjunct eligibility.
  Staff will need to select the active button in the Medicaid Status field of the Income tab.




ELIGIBILITY SCREENING                      1-28
WIC POLICY MANUAL                                                                       FFY-2004

   INCOME AFFIDAVIT

                                      DECLARACION DE INGRESO

CLIENT'S NAME:
NOMBRE DE APLICANTE: _______________________________________________

ADDRESS:
DOMICILIO: ___________________________________________________________

On the following lines, please tell how you provide for your basic needs. Who pays rent, utilities, food,
etc? If this form is to be used to declare income, and Adjunct Eligibility, has been met, list your
average income, source and amount. List how often income is received.

En las siguiente lineas, favor de explicar como provee por sus necesidades basicos. Quien paga la
renta, los cargos de agua, electricidad, la comida, etc? Si se usa esta forma para declarar ingreso y
tambien recibe TANF, estampillas para comida or Medicaid, indica su ingreso acostumbrado, de donde
viene, y cuanto recibe. Indique que tan seguido recibe el ingreso.

   Staff: Read and verify that the client should answered the above questions for this affidavit to be
considered complete.

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________
     Applicant/Guardian’s statement: I have told the truth about ALL sources of my family's income. To the
     best of my knowledge, I have not given false or withheld information. I understand that if I do, I may
     be prosecuted, taken off the program or made to pay back the benefits I receive.

                                                                                          
     He reportado la verdad en cuanto todos los ingresos de mi familia. Según mi entender, no
     He mentido ni retenido información. Comprendo que si miento, puedo ser proseguido,
     Terminado del programa o tener que reponer los beneficios que he recibido del programa.
Client's Signature:                                   Date:
Firma de Aplicante: ______________________________ Fecha: ______________

Staff Signature: _______________________________ Date: __________________
                                                                                                     Revised 9/99tm




                                                                                                                      Deleted:
                                              1-29                   ELIGIBILITY SCREENING
WIC POLICY MANUAL                                                                      FFY-2004

   P. Infants and Children Under Foster Care

   A foster child is considered to be a ward of the state; therefore, the income of the child is the
   amount of money that the caretaker (foster parent) receives from the state to provide for that child.
   The income of the foster family is not considered. Use the following procedures to determine
   income for foster children:

   a. Size of household: List the child as a household of one. Even if more than one child, related or
      not, are being cared for, each foster child is to be considered a household of one.
   b. Determine the amount that the foster parent is receiving to care for the child per month and
      enter that amount as an income item.
   c. Document that this is a foster child by entering a note in the Income tab.

   d. For EBT purposes, all foster children need to have a separate Family Group# assigned to them
      along with a separte EBT Card.

   Q. Income Statement

   The income statement is found on the Participant Rights and Responsibilities form and on the
   Income Affidavit. By signing the income statement, the applicant or guardian attests that they have
   been truthful in reporting the actual income received by the family unit. Clients who report no
   income must complete an Income Affidavit. A signed and dated income statement must be on file
   for each WIC applicant for each screening, whether found eligible or denied. This may consist of
   the Participant Rights and Responsibilities form, the Income Affidavit or both.

7. Medical Tab

The Medical tab is used for data entry of client medical information. To insert a new medical record,
click the Insert button.
Field/Button Name          Comments
Client Age                 Displays the clients age as calculated by the application
Weeks Gestation            Enter gestation weeks at birth.
Client Birth Weight        Enter birth weight in pounds and ounces for all Infants and Children.
                                                                                   Note (2)
Child DOB                  Enter the termination date of the last pregnancy for Breastfeeding and
                           Postpartum women, used to calculate risk factors related to BMI.
Pre-Preg Wt                Enter the client’s reported pre-pregnancy weight before the most
                           recently terminated pregnancy. Used to calculate risk factors related to
                           BMI.
Open Client Alert          Opens a text page allowing the user to enter temporary follow-up notes
                           or actions to be taken at next client contact.
Anthropometric Grid        Select type of anthropometric grid to create.
Report Type
View Report Button         Click to view and/or print the selected anthropometric grid.
Date                       The date of this medical record. The current date is automatically
                           entered by the WIC Application but can be overwritten if necessary.
                                                                                  Note (3)
Height                     Enter client’s height. For adult women use whole inches. For infants
                           and children use inches and eighths of inches.         Note (4)

ELIGIBILITY SCREENING                       1-30
WIC POLICY MANUAL                                                                        FFY-2004

Field/Button Name           Comments
Weight                      Enter client’s weight. For adult women use whole pounds. For infants
                            and children use pounds and ounces.                     Note (5)
BMI                         Displays the calculated BMI for the client based on data entered.
Percentile                  WT/HT, HT/Age, WT/Age and BMI Age value; automatically calculated
                            by the WIC Application.
Hemoglobin                  Enter client’s hemoglobin.                            Note (7)
Hematocrit                  Enter client’s hematocrit reading if hemoglobin is not available.
                                                                                 Note (6)
Cigarettes per Day          Enter average number of cigarettes smoked per day at the time the
                            medical information is taken. (See pregnancy tab for special cigarette
                            information for pregnant women). Do not enter for Infants or Children.
                            Enter “0” for women who do not use cigarettes to indicate assessment
                            was done.
Uses Drugs                  Check if the client uses drugs. Do not enter for Infants or Children.
                                                                             Note (8)
Drinks - Quantity           Enter number of drinks consumed per the period defined in the
                            frequency field. Do not enter for Infants or Children. Enter “0” for
                            women who do not use alcohol to indicate assessment was done.
Drinks - Frequency          Enter frequency used for the value entered in the Drinks – Quantity
                            field. . (See pregnancy tab for special drink information for pregnant
                            women). Do not enter for Infants or Children
Source of Health Care       Select primary source of health care for the client.             Note (9)
VAST                        Appears on all women’s records. If staff completed the screening for
                            violence and, abuse of substances and tobacco, this box should be
                            checked.                                                        Note (10)
Insert Button               Click to enter a new medical record.
Delete Button               Click to delete a selected medical record.

References - Medical Tab

               Item                                                                      Page
             Quality Assurance Standards for Medical Data                                1-58

Notes for Medical Tab:

(1) Immunization Status

   When certifying an infant or a child, verify with the guardian if the infant or child is up to date on
   their immunizations. If immunizations have not begun or if they appear to be behind schedule,
   refer the participant to the Immunization Program in the local health office or primary care clinic.
   Document any referrals made using the Referrals Tab or Notes tab in the WIC Application. The
   immunization status for each infant or child is entered into the application using the Client
   Immunizations tab. If client is not up to date on Immunizations, Single Issuance is highly
   recommended.

(2) Birthweight

   Enter birthweight for infants and children in pounds and ounces. Enter quarter ounces if known.


                                                                                                            Deleted:
                                             1-31                    ELIGIBILITY SCREENING
WIC POLICY MANUAL                                                                FFY-2004

(3) Date

   The current date is automatically entered by the application but can be changed if necessary to
   accurately reflect the date the measurement was taken. Measurements should be taken within 30
   days of the certification date. Older data may be used in the following situations.

   a.   A client transfers in from another WIC Program and the weight, height and
        hemoglobin/hematocrit data are over 60 days old.
   b.   A certified Breastfeeding woman discontinues breastfeeding within the first 6 months of the
        infant’s birth and she can be served as a postpartum woman. Staff will need to certify her as a
        postpartum. The same weight, height and hemoglobin/hematocrit readings (obtained at the
        breastfeeding certification) may be used up to 60 days. However, staff are asked to screen for
        income eligibility, reassess the diet and other risk factors. If the client’s weight, height and
        hemoglobin/hematocrit readings are over 60 days old, the measurements must be retaken.
   c.   An accurate weight, or height measurement cannot be obtained due to the use of a cast,
        brace or other application that is not easily removed and has a significant impact on the
        individuals weight and/or height. This situation must be explained in the Notes section of the
        WIC appliclation.
   d.   An applicant has a medical conditon, e.g., hemophilia, fragile bones (osteogenesis
        imperfecta), or a serious skin disease, in which the procedure of collecting the blood sample
        could cause harm to the applicant. The applicant must provide documentation from a
        physician fo the medical condition. The documentation must be placed in the file. If the noted
        condition is treatable, a new statement from the physician is required for each subsequent
        certification in which a hemoglobin/hematocrit test is not done. Staff is asked to obtain
        hematological results from the applicant health care provider. The date of the test should
        also be obtained and entered into the WIC application. The applicant or guardian may be
        required to sign a medical release if the information is requested from the phycian or medical
        provider.
   e.   An applicant whose religious beliefs will not allow him or her to have blood drawn. A
        statement of the applicant’s refusal to have blood drawn must be included in the individual’s
        file. Permission must be obtained from the Clinic Operations Manager to certify a client
        without a hemoglobin/hematocrit reading in this case.
   A weight, height or hemoglobin/hematocrit measurement that is provided from mental recall may
   not be accurate. If this information is to be used, it must be confirmed with the medical source of
   the information. Confirmation of measurements may take place by phone, if the source is willing to
   verify the information without a written consent of release of information. Otherwise, staff is to
   repeat all measurements.

(4) Height

   Pregnant, Breastfeeding and Postpartum Women
   1. Use a wall-mounted stature board to measure applicant's height.
   Note: Make sure the heel board has been installed before using board. The heel board must align
   the applicant’s heel the same distance from the wall as the buttocks and shoulder blades.

   2. Measure applicant's height without shoes.
   3. Have applicant stand with heels together, back straight and head, shoulders and buttocks
      touching stature board, and with heels touching heel board.
ELIGIBILITY SCREENING                    1-32
WIC POLICY MANUAL                                                                 FFY-2004

   4. Bring headpiece down to touch crown of applicant's head.
   5. Read measurement at eye level.
   6. Enter this measurement to the nearest (whole) inch.

   Infants and Children
   From birth to 24 months
   1. Use a recumbent infant length board or pediatric exam table/scale.
   2. Use two people to obtain an accurate measurement.
   3. One person places and holds the applicant on the recumbent infant length board with head
      touching the headboard.
   4. The second person straightens both of the applicant's legs, holds the applicant's feet with toes
      pointing directly upward, and brings the moveable foot piece to rest firmly against both heels.
   5. Straightening only one leg gives an inaccurate measure.
   6. Read measurement standing directly over the indicator line.
   7. Enter this measurement in inches and the nearest eighth of an inch.
   8. Staff is encouraged to obtain a current height for infants less than 30 days old at certification.
      However, birth length may be used. Staff should note that birth length measurements may not
      be accurate and may not conform to quality assurance standards of the WIC Nutrition Program.
      If birth length is used, staff must change the default date in the Medical Tab to the date the
      measurement was taken.

   Children over 24 months of age:
   1. Use a wall mounted stature board or other appropriate adult height measurement tool.
   2. Measure applicant's height without shoes.
   3. Have applicant stand with heels together, back straight and head, shoulders and buttocks
      touching stature board, and with heels touching heel board.
   4. Bring headpiece down to touch crown of applicant's head.
   5. Read measurement at eye level.
   6. Enter this measurement in inches and the nearest eighth of an inch.
   Growth charts for Infants and Children

   HT/AGE or WT/HT can be viewed and/or printed from the Medical tab in the WIC Application.

   To generate a growth chart for an infant or child:

      7. Select the desired type of growth chart from the Anthropometric Grid Report Type list.
      8. Click the View Report button. The selected chart is displayed on the screen.
      9. If you want to print a copy of the growth chart, select File/Print from the menu bar.
Growth Charts for Premature Infants and Children

For certification purposes, infants or children up to 24 mos. of age who were born prematurely are
plotted on the standard growth chart according to their corrected age. (If staff needs to manually         Deleted:
                                            1-33                ELIGIBILITY SCREENING
WIC POLICY MANUAL                                                                  FFY-2004

calculate to obtain corrected age, refer to the Prematurity Risk Factor 142 Special Notes Section,
in the Risk Factors By Priority). The HT/AGE, WT/AGE, or WT/HT and Risk Factors should be
determined based on standard growth chart plotting so that any growth risk factors can be
monitored.

For counseling purposes, an alternate plotting may be done for premature infants using a paper
copy of a standard chart printed by the WIC Application. This plot should show HT/AGE and
WT/AGE plots as determined by using the infant’s corrected age. Do not plot corrected age
adjusted measurements after 2 years of age using the WIC Application.

Explain to the caretaker that this alternate plotting, that takes into account their child’s prematurity,
gives a more appropriate expectation of where their child’s growth might be in comparison to other
children’s growth. The goal for growth in premature infants is a steady increase in height and
weight approaching the standard growth curve. If there are no complicating medical factors
involved by approximately age 3 years, a premature infant’s growth may no longer need to be
adjusted to gestational age in order to compare well with other children.




(5) Weight

   Pregnant, Breastfeeding and Postpartum Women

   1. Use a balance beam scale or digital to weigh adults.
   2. Balance the scale to zero before each use.
   3. Weigh applicant in light indoor clothing without shoes.
   4. Have applicant stand in center of platform.
   5. Measure applicant's weight.
   6. Enter this measurement to the nearest whole pound. If less than half a pound, round down. If
      half a pound or more round up to the next pound.

   PRENATAL WEIGHT GAIN CHART
   Inadequate prenatal weight gain is associated with increased incidence of low birthweight babies.
   A woman should attain her desired weight and gain at a steady rate. This grid will aid in calculating
   whether weight gain is appropriate, and can be used as an educational tool for the client. Weight
   gain grids can be viewed and/or printed from the Medical tab in the WIC Application.

   To generate a prenatal weight gain chart:

   1. Select the type of chart from the Anthropometric Grid Report Type list.
   2. Click the View Report button. The chart is displayed on the screen.
   3. If you want to print a copy of the weight gain chart, select File/Print from the menu bar.
   The participant’s weight gain goal is to stay within the range indicated on the weight gain chart
   throughout her pregnancy.


ELIGIBILITY SCREENING                      1-34
WIC POLICY MANUAL                                                                 FFY-2004

   Infants and Children
   Use a pediatric scale to weigh infants and children from birth to two years old whose weight does
   not exceed 36 pounds.
          Balance the scale to zero before each use. Use only a lightweight exam paper on the scale.
          Weigh infant or child nude, without a diaper.
          Place applicant in center of scale.
          Measure applicant's weight.
          Enter this measurement in pounds and ounces.
           Use a balance beam scale or step-on electronic scale to weigh children 2 years of age and
           older, or a younger child whose weight exceeds 36 pounds.
       

          Balance the scale to zero before each use.
          Weigh the child wearing only light indoor clothing. Weigh the child without shoes.
          Have applicant stand in the center of the platform.
          Measure applicant's weight.
          Enter this measurement in pounds and ounces or pounds and decimal fractions of pounds.
   Staff is encouraged to weigh all newborn infants (less than 30 days) as an indication of their weight
   gain and appropriate nutrient intake. However, for infants less than one month of age, birth weight
   may be used. Indicate this on the growth chart.

(6) VAST

All Pregnant, Postpartum and Breastfeeding Women must be screened by asking the following
questions;

   1. Have you been physically hurt by someone?

   2. Have you been sexually hurt by someone?

   3. Are you concerned for your safety?

   4. Are you concerned for the safety of your children?

After asking questions the VAST boxed should be checked as documentation that the applicant has
been screened. Then appropriate referrals should be documented in either the referral tab or in notes.

(7) Hemoglobin

As a general practice, a hemoglobin or hematocrit test for anemia must be performed or obtained
from a referral source at certification for all children, and all pregnant, breastfeeding and
postpartum women. Hemoglobin results obtained prior to certification may be used if they are less
than 60 days old and the client’s program category has not changed (i.e. the pregnant woman was
already pregnant when the hemoglobin/hematocrit result was obtained, or the pregnancy had
already terminated when the hemoglobin/hematocrit result was obtained for a breastfeeding or
postpartum woman). Exceptions for this general rule are covered below.
                                                                                                           Deleted:
                                            1-35                 ELIGIBILITY SCREENING
WIC POLICY MANUAL                                                                FFY-2004

   1. A hematologic test is not required at certification for infants under 9 months of age. An
      initial hemoglobin must be obtained on all infants between 9 and 12 months of age
      regardless of their age at certification. Whenever possible the initial hemoglobin result
      should be obtained during the infant’s 9th month of age.
          If infant was born < 37 weeks gestation, staff needs to consider the premature infant’s
           corrected age instead of the chronological age. Staff can view the infant’s growth chart
           in the Medical tab to find the corrected age. To manually calculate for corrected age, refer
           to the Prematurity Risk Factor 142 Special Notes Section, in the Risk Factors By Priority.
   2. Only one hematologic test is required for children between 12 and 24 months of age. It is
      recommended that this test be done 6 months after the infant’s first hemoglobin test
      whenever possible. However, for children whose previous hemoglobin/hematocrit results
      were at or below the standards for anemia, staff is asked to perform a hematologic test at
      certification.
   3. For children two years of age and older who were determined to be within the normal range
      at their last certification, a hematologic test is required at least once every 12 months.
      However, for children whose previous hemoglobin/hematocrit results were at or below the
      standards for anemia, staff is asked to perform a hematologic test at certification.
   4. For pregnant women, the hemoglobin/hematocrit results must be obtained after the onset of
      the current pregnancy. For pregnant women qualifying with at least one risk factor, the
      hematologic test may be deferred for up to 90 days from the time of certification. This may
      occur only if a hemoglobin/hematocrit test or the results cannot be obtained at certification.
      In that case staff must schedule the client to come in each month until the results or a
      hematocirt reading has been obtained.
   5. For postpartum or breastfeeding women, the hematologic test for anemia should occur after
      the termination of pregnancy. Ideally it should occur between 4 and 6 weeks postpartum.
      For breastfeeding women who are 6-12 months postpartum, an additional blood test for
      anemia is not necessary if a test was performed after the termination of their pregnancy.
      However, for women whose previous hemoglobin/hematocrit results were at or below the
      standards for anemia, staff is asked to perform a hematologic test at certification.
When limited to serving only Priority I through Priority III for caseload management (restricted
growth) a hemoglobin/hematocrit reading must be obtained for all child applicants.

If there is a medical reason why a hemoglobin/hematocrit reading cannot be taken, staff must call
the Clinic Operations Section or the Nutrition Education Coordinator at the state office for approval
to certify an applicant without a hemoglobin/hematocrit reading.

   TRANSFERS-IN:
   Participants transferring into the program without hemoglobin/hematocrit information must have a
   reading taken at the next certification.

   DOCUMENTATION:

   For all certifications in which a hemoglobin/hematocrit reading is obtained, staff is to record the
   reading in the field provided. Hemoglobin readings are to be recorded in the appropriate field using
   whole numbers. For certifications during which a hemoglobin/hematocrit reading is not required,
   the field should be left blank.

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   HEMGLOBIN PROCEDURE:

   a. Set up blood collecting station according to the WIC AIDS Procedure.
   b. Check the “use by” date for the microcuvettes. If the “use by” date has expired, obtain fresh
         cuvettes before proceeding.
   c. Use a disposable or single-use lancet to obtain the blood sample for the hematocrit test for
         women, infants over 9 months old and children.
          If infant was born < 37 weeks gestation, staff needs to consider the premature infant’s
           corrected age instead of the chronological age. . Staff can view the infant’s growth chart
           in the Medical tab to find the corrected age. To manually calculate for corrected age, refer
           to the Prematurity Risk Factor 142 Special Notes Section, in the Risk Factors By Priority.
   e. Wash hands thoroughly with soap and water, or use antiseptic wipes. Use gloves for all
      participants on both hands as outlined in Procedures for the Prevention of HIV Transmission
      in WIC Clinics (1-61).
   f. Inform the participant/guardian of what you are going to do.
      "This test is done to measure the volume of your red blood and will indicate low iron levels or
      anemia. I will prick your finger and fill one cuvette with blood. We will enter the cuvette into the
      reader and it will display the percent of red blood cells in the cuvette.”

   g. Have applicant extend arm, palm up with fingers slanted downward. Infants and children should
      be held by parent/guardian.
   h. Rub the area a minute or two to improve blood flow.
   i. Wipe the puncture site with alcohol, i.e., third or fourth finger of left hand or big toe or heel on
      babies. Allow to air dry.
   j. Pierce the puncture site with the lancet. The puncture site should be slightly off the center of
      the finger.
   k. Wipe the first 2 drops of blood away. Avoid squeezing the finger to obtain more blood.
   l. Place the the open end point of the cuvette at a 90 degree angle straight down into the drop of
      blood.
   m. Fill the cuvette in one continuous process. Do not lift up the cuvette once started until the
      cuvette has been completely filled.
   n. Wipe off any excess blood on the flat sides of the cuvette avoiding the outer edges and the
      open tip area of the cuvette.
   o. If air bubbles are seen in the “eye” of the cuvette, the cuvette should be discarded and another
      sample needs to be taken.
   p. Place the filled cuvette into the cuvette reader immediately; being careful to slowly push it into
      the measuring position.
   q. Once the reading is displayed on the reader screen, enter the results in the client’s record
      and discuss the results with the client. Provide any nutrition counseling needed and/or
      referrals.
13. Nutrition Education Plan Tab

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The Nutrition Education Plan tab allows for entry of the recommended Nutrition Education contacts to
be made during the current certification period. This information is displayed for the current client and
all other members of the same family group. The name of the client, the client’s date of birth, and
program category appear at the top of the column for each family member’s nutrition education plan.

Field Name                 Comments

Year                       Year for Nutrition Education contact planned for client. Automatically
                           entered by WIC Application for duration of current certification period.

Month                      Month for Nutrition Education contact planned for client. Automatically
                           entered by WIC Application for duration of current certification period.

Nutrition Education Type   Select type of Nutrition Education contact to be provided for client from
                           the drop down box.                                     Note (1)



The Nutritionist is required to enter an appropriate nutrition education plan for each client at
certification. Enter your suggested nutrition education plan for the entire certification period by
selecting the appropriate nutrition education session for the months you want the client to attend a
session. Update the plan when appropriate. There should be a plan in each participant’s record in the
WIC Application showing at least two contacts per certification period. This is a plan for education, not
the actual schedule of education contacts. See scheduling tab to book appointments. Attendance for
Nutrition Education classes and contacts is documented by using the Scheduling tab in the WIC
Application



Note: For infants, a plan should be completed up to the infant's first birthday. When there is a
premature infant (born < 37 weeks gestation), the plan needs to reflect the infant’s corrected age
instead of their chronological age. Staff can view the infant’s growth chart in the Medical tab to find
the corrected age. To manually calculate for corrected age, refer to the Prematurity Risk Factor
142 Special Notes Section, in the Risk Factors By Priority.


Notes for Nutrition Education Plan Tab:

(6) Nutrition Education Type

   Only nutrition education sessions appropriate for the program category should be entered. FI
   Issuance is not a nutrition education contact and should not be entered. Months left blank for a
   family member indicate no nutrition education contact planned for that family member for that
   month.

14. Notes Tab

The Notes tab is used to enter notes, documentation and other important information relative to an
applicant or participant.

Field/Button Name          Comments



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Field/Button Name          Comments

Time                       Shows date and time that note was entered. Entered Automatically by
                           WIC Application. When selected, notes will be displayed in
                           chronological order.




a. Women
   1. Pregnant Women: Pregnant women are certified until 6 weeks postpartum. Add 6 weeks to the
      EDD to get the next certification date. Remember to update the file if the participants EDD
      changes. When a woman’s pregnancy is terminated (under any situation, the End Cert Date
      must be recalculated. She must be recertified to be eligible to receive benefits beyond 6 weeks
      after the termination of pregnancy.
   2. Breastfeeding Women: The initial certification period for a breastfeeding woman extends 6
      months from the date the medical data was obtained. If certified again as a breastfeeding
      woman, the subsequent certification period extends to the baby's first birthday. No
      breastfeeding woman's certification period may extend beyond the infant's first birthday. Should
      a breastfeeding woman discontinue breastfeeding at anytime, she no longer qualifies for
      benefits as a Breastfeeding Woman, and her certification must immediately be terminated. She
      may be certified as a postpartum woman if it has been less than 6 months from the termination
      of pregnancy.


   3. Postpartum Women - The certification period ends 6 months from the end of the pregnancy.
      This applies regardless of the outcome of the pregnancy.
b. Infants
   1. 6 Months of age or less at certification - Infants who are certified when they are 6 months of age
      or less are certified up to the infant's first birthday. All infant’s certified prior to 6 months of age
      must be scheduled for a midpoint evaluation between 6- 8 months of age consisting of a diet
      assessment, obtaining a weight and height, appropriate nutrition counseling and referrals.
              A hemoglobin/hematocrit reading is needed with appropriate nutrition counseling and
              referrals between 9-11 months of age.
          

             If the infant was born prematurely < 37 weeks gestation, staff needs to calculate and
              consider the premature infant’s corrected age instead of the chronological age. Staff
              can view the infant’s growth chart in the Medical tab to find the corrected age. To
              manually calculate for corrected age, refer to the Prematurity Risk Factor 142 Special
              Notes Section, in the Risk Factors By Priority.
   2. Over 6 months of age at certification - Infants who are over 6 months of age at certification are
      certified for a 6-month period. Once these client’s turn 1 year old they must be certified as a
      child. If an infant is less than 9 months of age at certification, at 9-11 months of age a
      hemoglobin/hematocrit reading is needed with appropriate nutrition counseling and referrals (If
      the infant was born prematurely < 37 weeks gestation, staff needs to consider the premature
      infant’s corrected age instead of the chronological age. To manually calculate for corrected
      age, refer to the Prematurity Risk Factor 142 Special Notes Section, in the Risk Factors By
      Priority).
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c. Children
   The certification period is 6 months from the date the anthropometric data was obtained. However,
   no certification period may extend beyond the child's fifth birthday. WIC benefits may not be issued
   to extend beyond the child’s fifth birthday. Children turning five years of age before the end of their
   last benefit period may be entitled to receive a full or half food package, based on the first date of
   the benefit period in relation to the date their checks are issued and the End Cert Date.


(8) Uses Drugs

   Since there is no way to enter zero in the check box to show that the assessment of drug use was
   done, staff are encouraged to enter a note stating that client does not indicate using drugs.

(9) Source of Health Care

   Select the source of health care that best reflects where the client accesses health care (see
   below). Health care refers to regularly scheduled general check ups to accomplish early detection
   and treatment of conditions that may be more costly to treat later on.

      Public Health Clinic          Not an appropriate choice since services available may not include
                                    general check ups in most cases, in a PHO clinic

      Primary Care Center           This is acceptable if the client receives regular check ups at a
                                    primary care organization i. e. La Familia, First Choice, First
                                    Nations. However the client may see a particular physician at the
                                    primary care clinic. In that case the use may indicate Private
                                    physician or Primary care center.

      Indian Health Services        Indian Health Services       Appropriate for clients who receive
                                    regular check ups through any location of Indian Health Services as
                                    part of Public Health Services (PHS).

      Private Physician             The most common source of health care statewide. Anyone who
                                    has private insurance, group insurance, Medicaid (Salud) or who is
                                    enrolled in an HMO, must designate a primary care provider,
                                    normally a private physician.

      Hospital Outpatient Clinic    This selection is appropriate for clients who normally access
                                    medical care services through UNMH or other hospital which
                                    manages an outpatient clinic. Clients who state that they go to
                                    urgent care or the hospital when sick may not have a regular
                                    source of preventive health care and should be given a referral.

      Midwife                       Some Doctors, HMOs and Primary Care Centers use Midwives as
                                    their primary care providers for pregnant women. This choice will
                                    most often be indicated by pregnant women.



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       Nurse                            There may be some clients who are seen by nurses licensed to
                                        provide medical care under a physician’s oversight. They are
                                        usually referred to as Nurse Practitioners or Physicians Assistants.
                                        Users may use this designation if appropriate.

       None                             Use this selection for clients who do not access regular check ups
                                        or who do not know if they have coverage for ongoing health care.
                                        Whenever the user enters None, a referral should be made to a
                                        source of health care, enrollment in Medicaid or other type of
                                        medical care.

(10) History of Pregnancy Tab

Field/Button Name           Comments
Date pregnancy              Enter delivery date.
ended
Weeks Gestation             Enter week’s gestation at delivery.
Birth weight                Enter infant’s birth weight.
Birth Status                Enter infant’s birth status; full term, premature etc.
Initiated                   Check for yes leave blank for no.
Breastfeeding
Child on System             Enter name of infant, Last, First, MI.




(11) Pregnancy/Outcome Tab

The Pregnancy tab is used for data entry of information relative to a Pregnant Woman’s pregnancy and
the outcome of the pregnancy.

Field/Button Name              Comments
Pregnancy Verification         Select type of verification used by client to confirm pregnancy.
Last Menstrual Period          Enter date of the first day of client’s last menstrual period in
                               MMDDYYYY format.
Expected Delivery Date         Expected delivery date for pregnancy. Automatically calculated by
                               WIC Application but can be changed as needed.                    Note (1)
Weeks Gestation at Cert.       Number of weeks of gestation for pregnancy at the time of WIC
                               certification. Automatically calculated by WIC Application.
Pregnancies                    Enter total number of pregnancies for client, including current.
Live Births                    Enter total number of previous live births for client. Enter “0” for none.
Breastfeeding Expectation      Select client’s expectation regarding breastfeeding.
End of Pregnancy Date          Displays the same date as the EDD, however it allows the user to
                               enter the date the pregnancy ended (after the fact). When updated,
                               the certification end date is recalculated. Must be updated after the
                               pregnancy has ended.
Expecting Multiple Births      Check if mother is expecting more than one child (e.g. twins) for this
                               pregnancy.                                               Note (2)
Month Care Began               Select month that medical care began for this pregnancy.

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Field/Button Name            Comments
First WIC Visit              Select trimester of this pregnancy during which client first enrolled in
                             the WIC program.
Pre-pregnancy Weight         Enter pre-pregnancy weight for the client in whole pounds.
                                                                                             Note (3)
Uses Drugs                   Check if client is a drug user.
Cigarettes Per Day – 3       Enter average number of cigarettes smoked per day during 3 months
Months Prior                 prior to this pregnancy. Enter “0” for women who do not use
                             cigarettes to indicate assessment was done. Use the method of
                             questioning outlined in the risk factor section of the policy manual.
Cigarettes Per Day -         Enter average number of cigarettes smoked per day during applicable
Trimester 1, 2, 3            trimester. Enter “0” for women who do not use cigarettes to indicate
                             assessment was done.
Drinks/Qty. – 3 Months       Enter average number of drinks consumed per the period in frequency
Prior                        field during 3 months prior to this pregnancy. Enter “0” for women
                             who do not use alcohol to indicate assessment was done. Use the
                             method of questioning outlined in the risk factor of the policy manual.
Drinks/Frequency - 3         Enter frequency used for value entered in the Drinks/Quantity field.
Months Prior
Drinks/Qty. –   Trimester    Enter average number of drinks consumed per period in the frequency
1, 2, 3                      field during the applicable trimester. Enter “0” for women who do not
                             use alcohol to indicate assessment was done.
Drinks/Frequency -           Enter frequency used for value entered in Drinks/Quantity field. Do
Trimester 1, 2, 3            not enter anything for women who do not use alcohol.
Total Weight Gain For This   Enter weight gained during this pregnancy in whole pounds, even if
Pregnancy                    pregnancy was not carried to term.
This Pregnancy Outcome       Insert new row to enter the outcome of this pregnancy.
frame

False Pregnancy              Check this if a client reports a false-positive pregnancy test or finds
                             out she was not pregnant.
False Pregnancy Date         System generated - Displays the date the False Pregnancy box was
                             checked.
Date (Outcome)               Enter date this pregnancy terminated, regardless of outcome.
Weeks Gestation              Number of weeks that the pregnancy lasted, regardless of outcome.
(Outcome)
Birth Weight (Outcome)       Enter birth weight of the infant in pounds and ounces.
Lbs./Oz.
Birth Status (Outcome)       Select birth outcome for this pregnancy.                      Note (4)
Initiated BF                 Check if mother started breast feeding this infant.
Child on System              Displays name of an infant or child if the record has been previously
                             entered in the database. Use locate child button to add link to child.
Insert Button                Click to enter a birth outcome.
Delete Button                Click to delete a selected birth outcome record.
Locate Child Button          Click to open the Find window to locate an infant or child. Used to add
                             link to “Child on System”.




Notes for Pregnancy Tab:

The purpose of the Pregnancy tab is to capture prenatal and postnatal data on all women and their
birth outcomes that are on the New Mexico WIC Program while pregnant. Postnatal information
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WIC POLICY MANUAL                                                                         FFY-2004

should only be entered for women that were WIC participants in the state WIC Program during
their pregnancy. This information should be entered within 6 weeks after the end of the
pregnancy.



Expected Delivery Date

   If this date changes during the pregnancy, update this field. The application will then recalculate
   the End Cert Date without changing any of the original data collected at certification. A note of
   when and why the change was made should be entered into the WIC application. This date should
   be updated upon the termination of pregnancy and the end cert date should be recalculated to
   avoid over-issuance of WIC benefits to pregnant women.

(7) Expecting Multiple Births

   This box can be checked or unchecked after certification is completed if the information changes
   later on in the pregnancy. This box should be checked only when a multiple pregnancy is
   confirmed. When this box is checked at certification, the weight gain will be plotted on the “Twins”
   weight gain grid.

(8) Pre-pregnancy Weight

   Enter the client's immediate pre-pregnancy weight in whole pounds based on an interview with
   client. If weight is unknown, work with the client to obtain the best possible estimate. Do not leave
   this field blank.

(9) Birth Status

   Select one of the following for each birth:

              Status                        Definition
             Miscarriage            Fetal death - 20 weeks or less gestation
             Stillborn              Fetal death - more than 20 weeks gestation
             Pre-term               Live birth - less than 37 weeks gestation
             Multiple Births        Any full term multiple birth
              Full Term              Born at 38 to 42 weeks gestation and no other birth
                                     status applies.
          

8. BF/Outcome Tab

The BF/Outcome tab is used for entering data about breastfeeding duration, supplementation and
discontinuance. This tab is to be completed for all Infants.

This Tab needs to be updated at every appointment and a minimum of 61 day intervals. For further
policy information refer to the BF Promotion Section.

Field/Button Name           Comments
Ever Breastfed              Select Yes or No to indicate if infant was ever breastfed. Select
                            Unknown if this information is not available.                     Note (1)
Did Not Initiate Reason     Allows the user to report why the client did not initiate breastfeeding the    Deleted:
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Field/Button Name          Comments
                           infant at birth.
Current Age                Displays current age of infant or child. Calculated by the application.
Date                       The date the record was entered. Automatically entered by the
                           application but can be overwritten.                              Note (2)
Currently Breastfed        Check to indicate that infant is currently being breastfed.      Note (3)
Supplement Amount per      Select amount of supplemental formula is used for the infant per
Month                      month. Collect when Currently Breastfed is checked and when the
                           amount of supplemental formula changes from month to month.
Discontinued Reason        Select reason breastfeeding was not initiated or was discontinued.
                           Provide information at certification or when breastfeeding is
                           discontinued.
Discontinued Date          Enter date that breastfeeding was discontinued using MMDDYYYY
                           format. If Ever Breastfed is No or unknown, leave this field blank.
Insert Button              Click to enter new BF status information.
Delete Button              Click to delete a selected BF status information line.




Notes for BF/Outcome Tab

(1) Ever Breastfed

       The response in this field will dictate what information the user will be able to enter in the next
       section of this tab page. Staff is to use the selection “Unknown” only if the person having the
       infant certified does not know if the infant was ever breastfed.

       For the purpose of data collection, Ever Breastfed is defined as “breastfeeding upon hospital
       discharge.”

(2) Date

       For the first inserted row, change the default date on the left side of the inserted row to the
       infant’s birth date. Enter an extra row for each change in breastfeeding status or Supplement
       Amount Per Month. Make sure the date is changed to reflect the date of any change in the
       Supplement Amount Per Month.

(3) Currently Breastfed

       When checked this box will allow staff to enter the Supplement Amount Per Month. If not
       checked, staff will only be able to enter the Did Not Initiate or Discontinued Reason and the
       Discontinued Date.




9. Diet Analysis Tab (Women & Children)

The Diet Analysis tab is used for entering and calculating the dietary score for women and children.

Field/Button Name          Comments
Dietary Food Group         Displays Dietary Food Group for selected row.

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Field/Button Name           Comments
Nutrient Dense              Enter total number of times in past 7-day period an item in this food
                            group was eaten.
Refined/Other               Enter total number of times in past 7-day period an item in the refined
                            or other category of food group was eaten.
RF 422 Inadequate Diet      Automatically calculated by WIC Application. (Previously referred to as
                            RF 49.)
RF 401 Failure to meet      Automatically calculated by WIC Application. (Previously referred to as
Dietary Guidelines          RF 57.)
New Diet Analysis Button    Click to enter dietary information. Can only be selected when certifying
                            an applicant.
Assign Risk Factor Button   Click to have the WIC Application assign appropriate dietary risk factor.
The Diet Analysis has       Displays Risk Factor that has been assigned by the WIC Application.
generated Risk Factor of:
Time                        Shows date and time that this note was entered. Entered
                            Automatically by WIC Application
Type                        Select type of note being entered. Automatically set to “Diet Analysis”
                            by WIC Application when in Diet Analysis tab.
Who                         Indicates user ID for person that entered this note. Automatically
                            entered by the WIC Application.
Note                        Enter note text relating to this Diet Analysis session. Notes entered
                            here are also available in the Income and Notes tabs.
Insert Button               Click to enter a new Diet Analysis Note.
Delete Button               Click to delete a Diet Analysis Note.
Nutrition Goals             Enter the client’s nutritional goals.
Achieved                    Check to indicate that client has achieved nutritional goals that have
                            been defined.

References - Diet Analysis for Women and Children

          Item                                                                         Page
          Food Frequency Diet Analysis Form                                            1-73


   R. Diet Analysis - Women and Children

   The diet analysis is an important assessment tool for the clinic nutritionist. The purpose of the Food
   Frequency Diet Analysis is to obtain an average of how many times an applicant consumes food
   from a specific food group on a daily basis. The food frequency method of diet analysis changes
   the focus from serving size to total number of times a food item is consumed during a specified
   period of time. The focus of good dietary intake continues to be variety and moderation for ideal
   nutrition and health. Food frequency information captures food intake over a 7-day period.

1. Data Collection

   The Food Frequency Diet Analysis form is the primary data-gathering tool. The tool is available in
   English and Spanish.

   a. If calculating manually, enter participant's name, age and circle participant category. Otherwise
      only the name is necessary. The application will access all the other required information.
   b. Instruct the applicant/guardian to circle all the foods that were eaten by the applicant during the
      past 7-day period.
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   c. Inform the applicant/guardian that help will be provided if there is a problem with reading or
      vision.
   d. Before the CPA (certified professional authority) begins to analyze the diet, ask if there were
      any questions the applicant/guardian did not understand. Answer or clarify any questions
      before analyzing the diet.
   e. The CPA should verify with the applicant/guardian the foods eaten and the number of times it
      was eaten over the past 7-day period.
   f. Once staff has verified that the 7-day diet is completely documented, the CPA should enter the
      raw scores in the Diet Analysis tab of the WIC Application.
   g. When all dietary data has been entered, click on the Assign Risk Factor button. The WIC
      Application will automatically calculate the dietary dietary score and assign the appropriate risk
      factor.
2. Provide Dietary Counseling To Participant

   Choose one or two dietary concerns to focus on as a result of the diet analysis. Remember to
   review the responses to the counseling guide questions (1-74) for a complete analysis of the clients’
   dietary status as well as the client’s intake of fats, sugar and salt. Involve the participant in ideas to
   improve deficiencies. Inform the client that staff will periodically ask them how they are doing with
   their nutrition goal. Use other resources available in instructing applicants/guardians such as the
   Iron Fact sheet and Ideas for Using More Milk.

   a. Using the Pyramid Food Guide, counsel the participant on the results of the diet analysis and
      the recommended number of servings for the applicant.
   b. The CPA should briefly document the type of counseling that was provided during the
      certification visit. Use the Notes feature in the Diet Analysis tab of the WIC Application.
   c. The CPA should provide any appropriate dietary counseling that might be indicated from the
      review of the clients responses on the Counseling form. Any incomplete information should be
      collected. Answers on the counseling form may indicate further counseling or appropriate
      referrals. The counseling guide form is to be filed in the clients chart.
   d. A Nutrition Goal should be entered in each client file at certification. Whenever possible the
      applicant/guardian should be encouraged to establish a dietary goal which s/he wishes to
      accomplish during the certification period. It is preferable that the goal be established by the
      applicant or guardian. However, the nutritionist may offer assistance if the client has no ideas
      for establishing dietary goals. Once defined, the dietary goal is entered in the Nutrition Goals
      field at the bottom of the Diet Analysis tab in the WIC Application. Write or have the client write
      the Nutrition Goal on the food guide pyramid hand out, and give to the applicant/guardian.
   e. Ask if the participant has any questions.

11. Infant Diet Tab

The Infant Diet tab is used to enter diet analysis information for an infant.




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Field/Button Name          Comments
Infant Diet Questions      Displays a list of questions to be asked relative to infant’s diet. These
                           questions are also listed on the Infant Diet Recall available in English
                           and Spanish.
Nutrition Goals            Enter a description of the guardian’s nutritional goal for the infant.
Achieved                   Check to indicate that client has achieved the recorded nutritional goal.
Note Time                  Date and time this note was entered. Automatically entered by the
                           WIC Application.
Note Type                  Select type of note being entered. Automatically set to “Diet Analysis”
                           by WIC Application when in the Diet Analysis tab.
Who                        The name of person entering note. Automatically entered by WIC
                           Application.
Note                       Enter note text relating to Infant Diet Analysis session.
Insert Button              Click to enter a new Diet Analysis record.
Delete Button              Click to delete a selected Diet Analysis record.


   S. Diet Analysis - Infants

   The Infant Diet tab is the primary tool for gathering infant diet data. The top part of the screen on
   this tab displays a list of questions and discussion topics that must be covered to thoroughly assess
   the infant’s diet. Client responses to the questions and topics discussed are documented in the
   Notes area in the lower portion of the Infant Diet tab window. The diet analysis questions are to be
   completed through the interview process by design. For infants who are breastfed only, ask all
   questions in the Breastfeeding Section. For infants who are not breastfed, ask the questions in the
   Formula Feeding section. For infants who are breastfed and receive supplemental formula, ask the
   questions in both the Breastfeeding Section and Mixing Formula Section. If it appears that a
   question was not understood, rephrase the question so that the parent/guardian understands what
   you are asking. For each question, enter the response given by the parent/guardian. The
   questions and discussion topics are also available in Spanish.

   All discussion topics, highlighted in yellow need to be discussed and checked off.

1. Breastfeeding Section:

   This section is designed to identify any problems the breastfeeding woman and/or baby may be
   having in adjusting to breastfeeding. It covers mother's attitude about breastfeeding; feeding
   practices; frequency and volume of feeding; infant adaptation to breastfeeding, and support for
   the breastfeeding mother. Responses to these questions will indicate the type of counseling
   that should be provided.

2. Formula Feeding Section:

   This section is designed to determine if the infant is accepting the formula well, receiving an
   appropriate amount of formula for age, and to solicit information on feeding practices and
   parenting.

a. Final Assessment: The results of the dietary analysis and topics discussed should be documented
   in the Notes section at the bottom of the Infant Diet tab in the WIC Application. Staff should indicate
   any concerns or need for follow up. Also, if infant is doing fine, staff should indicate so in Notes.

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3. Data Collection and Assessment Summary:

a. Discuss the topics and questions presented at the top of the Infant Diet tab window.
b. Document the client’s responses using the Notes section at the bottom of the tab window.
c. Complete the final analysis and document as appropriate.
d. Asses the dietary risk factors and document in Notes.


12. Risk Factor Tab

The Risk Factor tab is used to assign risk factors to WIC clients.

Field/Button Name              Comments
Available Risk Factor          Displays list of Risk Factors available for assignment to client. To
                               assign a Risk Factor to client, select desired Risk Factor then click >
                               button to assign the Risk Factor.                                   Note (1)
Priority                       Displays WIC Program priority for Risk Factor in the selected row. Will
                               force upgrade to that priority if selected and current priority is lower.
Assigned Risk Factor           A list of risk factors automatically assigned or intentionally assigned to
                               client.                                                   Note (2)
Assignment Reason              Enter required documentation to substantiate Risk Factor.
> Button                       Click to assign selected Risk Factor.
< Button                       Click to delete or unassign selected Risk Factor.
Nutritional Goals              Type in the nutrition goals for this client.                        Note (3)
Achieved                       Check when the goal has been achieved.

Reference - Risk Factor Tab

                 Item                                                                         Page
              Risk Factors - Summary by Priority                                              1-72
              Risk Factors - Detail by Priority                                               1-83

Notes for Risk Factor Tab:

           At least one nutritional Risk Factor must be assigned before the applicant can be certified.

(1) Available Risk Factor

    Staff is asked to carefully review all available risk factors found in the Risk Factor Description
    Section of the Policy Manual as well as the USDA Risk Factor Reference Manual. Only the risk
    factors available for the client’s program category will be displayed.

(2) Assigned Risk Factor

a. Assign all appropriate risk factors that have not already been assigned by the WIC Application.
b. Enter any required documentation for risk factors, diet analysis, medical or other pertinent
   information using the Notes section of the WIC Application. If more space is needed, insert
   additional Notes. Staff is reminded to use the risk factor description section of the policy manual
   and the Risk Factor Reference Manual when assessing, assigning and documenting risk factors.
   The appropriate documentation must be provided.

ELIGIBILITY SCREENING                             1-48
WIC POLICY MANUAL                                                                        FFY-2004

c. If the applicant has no nutritional risk factors, document this in the Notes tab. In the Certification
   tab, insert a row and select the “Denied” for the client’s Status. In the next column, select an
   appropriate Status Reason. Refer to 1-60 for Denial Procedures.
(3) Nutritional Goals

   Have the applicant or parent/guardian establish a goal to improve or maintain appropriate dietary
   practice. Enter the goal in the Nutrition Goal field.

13. Nutrition Education Plan Tab

The Nutrition Education Plan tab allows for entry of the recommended Nutrition Education contacts to
be made during the current certification period. This information is displayed for the current client and
all other members of the same family group. The name of the client, the client’s date of birth, and
program category appear at the top of the column for each family members nutrition education plan.

Field Name                  Comments
Year                        Year for Nutrition Education contact planned for client. Automatically
                            entered by WIC Application for duration of current certification period.
Month                       Month for Nutrition Education contact planned for client. Automatically
                            entered by WIC Application for duration of current certification period.
Nutrition Education Type    Select type of Nutrition Education contact to be provided for client from
                            the drop down box.                                      Note (1)


The Nutritionist is required to enter an appropriate nutrition education plan for each client at
certification. Enter your suggested nutrition education plan for the entire certification period by
selecting the appropriate nutrition education session for the months you want the client to attend a
session. Update the plan when appropriate. There should be a plan in each participant’s record in the
WIC Application showing at least two contacts per certification period. Note: For infants, a plan
should be completed up to the infant's first birthday. This is a plan for education, not the actual
schedule of education contacts. See scheduling tab to book appointments. Attendance for Nutrition
Education classes and contacts is documented by using the Scheduling tab in the WIC Application


Notes for Nutrition Education Plan Tab:

(1) Nutrition Education Type

   Only nutrition education sessions appropriate for the program category should be entered. Staff is
   to avoid scheduling other family members from different program categories in the same sessions.
   FI Issuance and Open Nut. Ed. Sessions are not a nutrition education contact and should not be
   entered. Months left blank for a family member indicate no nutrition education contact planned for
   that family member for that month.

14. Notes Tab

The Notes tab is used to enter notes, documentation and other important information relative to an
applicant or participant.

Field/Button Name           Comments
Time                        Shows date and time that note was entered. Entered Automatically by
                            WIC Application. When selected, notes will be displayed in
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WIC POLICY MANUAL                                                                            FFY-2004

Field/Button Name              Comments
                               chronological order.
Type                           Select appropriate type for this note. When selected, notes will be
                               displayed by type in alphabetical order.
Who                            Indicates user ID for person that entered note. Automatically entered
                               by WIC Application. When selected, notes will be displayed by staff
                               name in alphabetical order.
Note                           Enter text for note entry. Notes entered here are also available in Diet
                               Analysis and Income tabs.
Insert Button                  Click to enter a new Note.
Delete Button                  Click to delete selected Note.


15. Referrals Tab


The Referrals tab of the WIC Application is used to document client referrals to other organizations and
from other organizations to the WIC program. This tab allows the user to view referral organizations,
record referrals, and indicate client follow through for referrals made. Staff should document all
referrals made to a client using this function.



Field/Button Name              Comments
Referral Organization          Select organization for referral.                      Note (1)
Date                           The date of referral. Automatically entered by WIC Application.
From/To                        Select either From or To, as appropriate for referral.
Followed Through               Check to indicate that client has followed through on referral.
Insert Button                  Click to insert a new referral record.
Delete Button                  Click to delete a selected referral record.
Select Items to Print          Select form letter, etc. for printing.
Reference - Referral Tab
                    Item                                                                        Page

                Referral Form                                                                   4-16

Notes for Referral Tab:
(1) Referral Organization

       When the selection list is displayed the following information is displayed for each referral
       organization. (Referral organizations can be added to the list or edited by contacting the
       Department of Health helpdesk).

          Organization Name
          Phone Number
          Organization Type
          Street Address, including City, State, ZIP code
          Name of primary contact person

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WIC POLICY MANUAL                                                                             FFY-2004

        FAX Number
WIC serves as an entry point for other health care services. Participants applying for WIC may be
eligible to receive benefits from a variety of programs that exist in their community. Some of these
programs are: Medicaid, Temporary Aid for Needy Families (TANF), community action programs, as
well as other health services, i.e., Well Child, Immunization, Family Planning, and Prenatal Care. Each
local clinic is to provide the client with updated information of appropriate community, social and health
programs that would be of benefit to the client. This information should be given to those participants
who may be eligible for benefits. Federal regulations require that all appropriate referrals be made and
documented.

Written information about the program must be given to the applicant (one per family) when referrals
are made to the following programs: Food Stamps, Temporary Aid for Needy Families (TANF),
Medicaid, EPSDT and Child Support Enforcement. Use the Notes tab of the WIC Application to
document when written information is given to the applicant. Give the participant the written
information.

Medicaid services are available under managed care to families with incomes up to 185% of poverty
and through SCHIP (State Child Health Insurance Program) for children up to age 18 with family
incomes up to 235% of poverty. All WIC clients in these categories should be referred to the nearest
Income Support Division Office to complete the application process.

NO SERVICES AVAILABLE: If no services are available as needed by the applicant/participant, (i.e.
no prenatal clinics), enter information about the services that were needed but were not available in the
Notes tab of the WIC Application to indicate staff made an effort to provide needed referrals to the
applicant/participant. Staff should keep in mind that it is appropriate to make referrals to services
outside the immediate community if the service needed is not available locally.

NOTE: The food package design and issuance process, which must be completed by a nutritionist, are
also part of the certification process. See Food package design and FI Issue tabs.

16. Certification Tab

Once information has been entered to determine eligibility for initial certification based on residency,
program category, income eligibility and nutritional risk, the final step of the certification process is
accomplished using the Certification tab of the WIC Application. Clients must meet requirements in
each of these four areas in order to receive WIC benefits.

Field/Button Name           Comments
BP Start Day                (BP stands for Benefit Period) The first day of the benefit period for all
                            family members.
Certification Sequence      Indicates sequential order of Certification and total number of
                            Certification events for client. Automatically determined by WIC
                            Application.
Certification Dates         Indicates start and end dates for Certification period. Automatically
                            determined by the WIC Application.                                     Note (1)
Date Certified              Indicates date of this Certification event. Automatically entered by WIC
                            Application.
Date of Initial Contact     Enter date of initial contact for this certification for this client in formats
                            MMDDYYYY.                                                     Note (2).
Benefit Period              The sequential numbers for benefit periods within a certification period.
                            Automatically determined by WIC Application.
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WIC POLICY MANUAL                                                                           FFY-2004

Field/Button Name           Comments
Start Date                  Displays start date of a benefit period. Automatically entered by WIC
                            Application.
End Date                    Displays end date of a benefit period. Automatically entered by WIC
                            Application.
Status Date/Time            Date and time of a certification event or an entered change in status.
                            Automatically entered by WIC Application.
Status                      Select status for client. Automatically entered by WIC application for
                            eligible certifications and expired certification periods. Note (3).
Status Reason               Select reason for the status indicated. Automatically entered by WIC
                            Application for eligible certifications and expired certification periods.
Prior Button                Click to view previous certification record. This button cannot be
                            activated when there is no prior certification record in the database.
Next Button                 Click to view next certification record. This is only active when staff is
                            not viewing the most recent or current certification.
New Button                  Click to enter information for a new certification for a client that was
                            previously certified on the WIC program.                           Note (4).
Done? Button                Click to check for completion of all data required for certification.
Certify Button              Click to certify client. Information within the client’s record cannot be
                            changed once this button is activated.
VOC Card Button             Click to issue a VOC card for client.                              Note (5).
Insert Button               Click to enter information for a change of status for current certification.
Delete Button               Click to delete a selected status change record.
Select Items To Print       Select item to print (Certification Report, etc.…).

Reference - Certification Tab

                 Item                                                                      Page
             Food Package Design Tab                                                       1-54
             FI Issue Tab                                                                  1-55




Notes for Certification Tab:

(1) Certification Dates

   Certification dates are automatically determined by the WIC Application according to the following
   guidelines shown below. Note: A Benefit Period is generally 30 days (vs. one calendar month)
   in duration. However, there are exceptions. Benefit periods less than 30 days occur when
   assigning a benefit period start date for a family group or at the end of a certification period that
   must end at a specified time, (i.e. 6 weeks from the termination of pregnancy). In the following
   descriptions a month refers to a 30-day period.

   a. Women
         14. Pregnant Women: Pregnant women are certified until 6 weeks postpartum. Add 6 weeks to
             the EDD to get the next certification date. Remember to update the file if the participants
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WIC POLICY MANUAL                                                                       FFY-2004

           EDD changes. When a woman’s pregnancy is terminated (under any situation, the End Cert
           Date must be recalculated. She must be recertified to be eligible to receive benefits beyond
           6 weeks after the termination of pregnancy.
        15. Breastfeeding Women: The initial certification period for a breastfeeding woman extends 6
            months from the date the medical data was obtained. If certified again as a breastfeeding
            woman, the subsequent certification period extends to the baby's first birthday. No
            breastfeeding woman's certification period may extend beyond the infant's first birthday.
            Should a breastfeeding woman discontinue breastfeeding at anytime, she no longer qualifies
            for benefits as a Breastfeeding Woman, and her certification must immediately be
            terminated. She may be certified as a postpartum woman if it has been less than 6 months
            from the termination of pregnancy.
        16. Postpartum Women - The certification period ends 6 months from the end of the
            pregnancy. This applies regardless of the outcome of the pregnancy.
   d. Infants
        1. 6 Months of age or less at certification - Infants who are certified when they are 6 months of
           age or less are certified up to the infant's first birthday. All infants certified prior to 6 months
           of age must be scheduled for a midpoint evaluation consisting of a diet assessment,
           obtaining a weight, height , hemoglobin/hematocrit reading and appropriate nutrition
           counseling and referrals as appropriate. (Preferably at 9mos. Of age)
        2. Over 6 months of age at certification - Infants who are over 6 months of age at certification
           are certified for a 6-month period. Once these clients turn 1 year old they must be certified
           as a child.
   e.      Children
           The certification period is 6 months from the date the anthropometric data was obtained.
           However, no certification period may extend beyond the child's fifth birthday and WIC
           benefits may not be issued to extend beyond the child’s fifth birthday. Children turning five
           years of age before the end of their last benefit period, may be entitled to receive a full or
           half food package, based on the first date of the benefit period in relation to the date their
           checks are issued and the End Cert Date.


(2) Date of Initial Contact

   For clients that are new to your clinic or the WIC Nutrition Program, the Date of Initial Contact is the
   first date the client or guardian requested services. This date must be entered into the WIC
   application when the record is created and an appointment is made. In order to comply with federal
   regulations, all pregnant women, migrant and homeless family members must be seen within 10
   calendar days of requesting services. All other applicants must be seen within 20 calendar days of
   requesting services. If the client asks for an appointment beyond the above limits, staff must enter
   a note explaining why the appointment is scheduled beyond the federal processing standards
   outlined above.

(3) Status

   A new status can be entered at any time during the cert period (e.g. suspended, denied, et cetera.)
   Staff should record a change in status anytime the application does not automatically change the
   status, (e.g. A client transfers to another state, change the status to terminate).

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                                              1-53                   ELIGIBILITY SCREENING
WIC POLICY MANUAL                                                                    FFY-2004

   No Show notice and Expired Cert Notice documentation must be entered.

(4) New Button

   This should not be selected if the person has a current certification period in the database and the
   client has not changed program category.

(5) VOC Button

    The VOC card will be printed on an adhesive label that can be applied to the clients WIC ID card or
   other card. It will be numbered by the WIC Application for control. If a card is printed and no longer
   needed, staff should write void on the card and adhere it to the client’s file folder or destroy it to
   avoid potential program abuse. By clicking on the VOC Button, staff can see when and why a VOC
   card was issued to the participant.

17. Food Package Design Tab

The Food Package Design tab is used to establish or modify a food prescription for a WIC client. You
will find more details on using this tab in the Checks Issuance section of the policy manual. A
nutritionist or CPA (Certified Professional Authority) must enter the clients Food Package Design.

Food Package Design Tab

Field/Button Name          Comments
Benefit Period             Displays sequential benefit period number for certification period.
                           Automatically assigned by the application.
Benefit Start/End          Displays start and end dates for a benefit period. Automatically
                           assigned by the application.
Food Rx Assign Date        Displays date a food prescription was assigned by the nutritionist.
                           Automatically assigned by the application.
Food Package               Select desired food package for benefit period.
# of Checks                Select desired number of checks to print for FI issue.
Assignment Reason          Select the reason for choice of food packages if other than
                           recommended package.
Assignment Notes           Enter any applicable notes for Food Package issuance.
Insert Button              Click to insert a new food package information.
Delete Button              Click to delete selected Food Package information.
Food Class Code            Displays a Food Class Code contained in a food package.
Food Class Description     Displays description of the Food Class.
Qty.                       Displays quantity of a food item in selected Food Class.
Units                      Displays number of units for a Food Item.
Unit of Measure            Displays unit of measure for a Food Item; i.e. pound, gallon.
Food Item Description      Displays description of a Food Item.
Customize Button           Click to customize selected Food Package issue for selected Benefit
                           Period.
Reset Food Package         Click to reset Food Package for selected Benefit Period to default
Button                     values or standard food package design.
Copy Prescription Button   Click to copy a selected prescription to later Benefit Periods.




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WIC POLICY MANUAL                                                                          FFY-2004

18. FI Issue Tab

The FI Issue tab is used to print Food Instruments (FI’s), enter data for Handwritten checks, and issue
check substitutions, replacements and issue EBT benefits.

Field/Button Name            Comments
Benefit Period               Displays sequential benefit period number within certification period.
BP Start Date                Displays start date for a benefit period.
Food Package                 Displays food package description for benefit period.
# of Checks                  Displays number of checks for issue.
Issuance Type                Select method of issuance for selected benefit period.
Preview Button               Click to Preview Food Package detail for selected Benefit Period.
Issue Button                 Click to print checks (or issue EBT credit) for selected Benefit Period.
Issue FG EBT’s               Click to issue food benefits for the entire family group on an EBT card.
Handwritten Check Button     Click to enter information for benefits issued on a Handwritten check.
# of Benefit Periods to      Select number of benefit periods to issue at this time. Staff may issue
Issue                        for one or two benefit periods.                          Note (1)
Current Medicaid Status      Enter only if client is a Medicaid participant. Select Active or Inactive.
PAN                          Displays PAN #
EBT FI Issuance Date         Date Food Benefits were issued.
Benefit Period               Displays which BP was issued.
Valid Start                  Date BP begins.
EBT Load Date                Date Food Benefits were loaded on to EBT Card.
E-Check #                    Identifies issuance transaction.
Food Item                    Displays description of a Food Item.
Quantity                     Displays quantity of a food item in selected Food Class.
Units                        Displays number of units for a Food Item (i.e., 2 (gallons).
UOM                          Displays unit of measure for a Food Item; i.e. pound, gallon.
NTE                          Displays Not to Exceed price for a Food Item.          Note (2)
Max Amount                   Displays the Maximum $ Amount for this FI.                    Note (2)
Substitute Button            Click to create a substitute check for a previously issued prescription.
                             Substitute checks replace lost or stolen checks whereby you cannot
                             determine the serial number of the lost/stolen check(s).
Replace Button               Click to create a replacement check. Replacement checks replace lost
                             or stolen checks where you know the serial number of the lost/stolen
                             check(s).
Void Button                  Click to void a previously issued check. You must not void a check that
                             has been cashed/redeemed.
Unvoid Button                Click to unvoid a previously voided check.
Redemption Summary           Displays what food items have been purchased for the current benefit
(currently not functional)   period.
Summary/Detail Button        Click to switch between check detail view and check summary view.
Any and all individuals picking up FIs (Food Instruments) or WIC checks must provide proof of identity
at check issuance. This includes program applicants, participants, parents, guardians or proxies. Staff
is to inform all participants and guardians that proxies, or anyone else that picks up WIC checks for
them will be required to provide proof of identity before WIC checks will be issued.
Notes for FI Issue Tab:

(1) # of Benefit Periods to Issue

    Staff may issue one or two benefit periods at a time. The following recommendations are intended
    to provide guidance in determining the number of benefit periods to issue. Benefits cannot extend
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                                              1-55                    ELIGIBILITY SCREENING
WIC POLICY MANUAL                                                                     FFY-2004

    beyond the end of the certification period. Double issuance is an acceptable practice when there is
    a true benefit to the client. Double issuance is not recommended when a client has not obtained
    the recommended Nutrition Education contacts, there are concerns about a client’s well being, or
    checks are lost on a regular basis. Permission to triple issue must be obtained from the Program
    Manager, Region Nutrition Supervisor or the Clinic Operations Section.

    Pregnant women who have not obtained two or more Nutrition Education sessions, including a
    session on Breastfeeding should be single issued until the recommended education contacts have
    been attended.

    Breastfeeding women and breastfed infants should not be double issued in order to provide more
    frequent opportunities to encourage and support breastfeeding, to collect accurate breastfeeding
    duration data and the need to issue appropriate amounts of formula for breastfed babies.
    Breastfeeding women and breastfed infants who have not obtained the recommended Nutrition
    Education contacts should not be double issued.

    Infants or Children who may benefit from more frequent counseling or follow-up by the WIC
    Nutritionist, or who have not obtained the recommended Nutrition Education contacts should not be
    double issued.

(2) NTE

   The Not to Exceed is present on handwritten checks only. Make sure to issue checks
according to the total price of the food package and the NTE. In some instances you may have to
contact your grocer for prices.


19. Scheduling Tab

The Scheduling tab is used to schedule clients for appointments and to record attendance at scheduled
appointments.

Field/Button Name          Comments
Client Appointment         Click Select button and choose client’s preferred days and times for
Preference                 appointments.
Select Button              Opens a window to allow the selection of preferable times for
                           appointments for a client.
Clinic (Filter)            Allows selection of the clinic schedule you wish to display.
Event Type (Filter)        Limits the scheduled events listing to the selected event type.
Specific Event (Filter)    Limits the scheduled events listing to the specific selected event.
Date Time                  Displays current date and time
Certification Start Date   Displays the current client’s beginning certification date
Certification End Date     Displays the current client’s ending certification date
Client Appointments        Displays specific event, day, date, time, and attendance indicator for
                           each scheduled appointment for client.                   Note (1)
Attended                   Click to indicate that client has attended selected appointment.
Scheduled Events           Displays specific event, day, date, time and status of events available
                           for scheduling.                                          Note (2)
Status                     Indicates booking status for the selected event.
Family Member List Area    Displays WIC ID, DOB, Sex, Name, Program Cat., Cert. Begin, and
                           Cert. End dates Appointment and Attended information for all members
                           of current Family Group
Appointment                Click to include appropriate Family Group member in this appointment.
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WIC POLICY MANUAL                                                                        FFY-2004

Field/Button Name          Comments
Attended                   Click to indicate that selected member of the Family Group has
                           attended selected event.

Notes for Scheduling Tab:

(1) Client Appointments

    To record a client’s attendance at a scheduled event, click the Attended box.

(2) Scheduled Events

    The event types shown can be all available events or can be limited to certain event types by
    selecting from the list of available event types in the Event Type field. To schedule an event for the
    client, click to select your choice of the displayed events then click the button.

20. Food Purchases Tab

    The Food Purchases tab of the WIC Application allows the user to view and/or print a report
    showing the record of actual food purchases made by the client. This tab shows the following
    information for food purchases. Note: This function will be enabled when EBT is implemented.

   Food Purchased                 Units                             Unit of Measure
   WIC Authorized Food            Date                              Price
   Qty. Redeemed

21. Summary Tab

    The Summary tab of the WIC Application allows the user to view and/or print a Summary Report for
    a client. There are no entry fields on this tab. To print a Summary Report, select File/Print from the
    menu bar or click on the printer icon. The Summary report shows the following information for the
    selected client:

   Client Name                    WIC ID Number                     Cert. Period Dates
   Street Address                 Mail Address                      Risk Factors
   Head of Household              Cert Sequence                     Risk Factor Notes
   Proxy Name 1                   Priority                          Nutrition Goals
   Proxy Name 2                   Program Category                  Achieved (check box)
The buttons at the bottom of this tab window allow the user to navigate through the Summary report.
The table shown below shows the behavior of these navigation buttons.

Field/Button Name          Comments
Refresh Button             Click to save data for the current client and refresh the Summary
                           Report information to reflect data entered or modified during the current
                           session.
I< Button                  Click to scroll to the first page of the Summary Report.
< Button                   Click to scroll to the previous page of the Summary Report.
> Button                   Click to scroll to the next page of the Summary Report.
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WIC POLICY MANUAL                                                                         FFY-2004

Field/Button Name          Comments
>I Button                  Click to scroll to the last page of the Summary Report.
Zoom Button                Click to zoom the view of the Summary Report in or out.
Rulers                     Check to display rulers on the report view.

22. Labels and Letters Tab

This tab provides access to an assortment of labels and reports available to the user.

Field/Button Name          Comments
Select Item to Print       Select the label or letter you wish to print from the list displayed when
                           the  (down arrow) is activated.
Print Selection Button     Sends the selected item to the printer.

Items that can currently be printed from the Labels/Letters tab include:
 A client label for the current client
 A clinic mailing label (return address usage)
 A mailing label for the current client
 Mailing label(s) for the current client’s family members

Items that are not currently available for printing include:
 Certification Expiration Notice for the current client
 Denial Letter for the current client
 Referral Letter to an outside agency for the current client
Currently these notices are available in the policy manual for making copies. The Denial Letter can be
ordered from Central Supply. Refer to the Administrative Procedures section of the WIC Policy
Manual, Ordering Supplies, WIC Forms and Information.

IV. Quality Assurance Standards for Medical Data

In order to continue to meet quality assurance standards in taking and recording anthropometric
measurements, staff in each clinic and satellite site is required to do the following:

    1. Inspect adult stature measuring boards every 6 months. Check that:
a. The bottom of the board is 18 inches above the floor; for wood adult stature wall mounted height
   boards. If using different stature measuing boads see your Region Nutrition Supervisor or Program
   Manager for instructions.
b. The top of the board is level;
c. The heel board, (the extra piece of wood that came in the box) has been installed the same
   distance from the wall as the measuring board.
d. When used, the client stands errect with the head, shoulders, hips and ankles forming a straight
   line.
    2. Inspect infant recumbent measuring board every 6 months. Check that:
a. All infants and children under 2 years of age (whenever possible) are measured using a recumbent
   board.
b. The foot piece slides easily and is straight.
c. Headpiece is fastened securely.
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WIC POLICY MANUAL                                                                      FFY-2004

d. When used, the infant's head should be touching the head piece; the infant head, neck torso and
   legs should form a straight line, both legs should be extended by pushing gently down on the
   knees, the toes should be pointed upward and the foot should be snug with the flat part of the foot
   piece.
   3. Check that the following directions are followed for recording measurements of WIC
      participants:
a. Weight for infants and children must be entered in pounds and ounces.

       b. Height must be entered as inches to the nearest eighth of an inch.
       The following table may be of use in converting fractions into eighths of an inch for data entry.

                                               Conversion Tables

       Inches                                         Inches
       1/16                          0/8 in.          8/16, 1/2, 2/4, 4/8, 9/16    1/2 in.
       2/16, 1/8, 3/16               1/8 in.          10/16, 5/8, 11/16            5/8 in.
       4/16, 2/8, 1/4, 5/16          1/4 in.          12/16, 3/4, 6/8, 13/16       3/4 in.
       6/16, 3/8, 7/16               3/8 in.          14/16, 7/8, 15/16            7/8 in.


V. Participants Rights And Responsibilities

This form states the participant’s rights as outlined by federal regulation. As a participant, there are
specific responsibilities that all WIC participants are expected to comply with. Have the client or
guardians read the rights and responsibilities at the time of certification or have the statements read to
them in a language they speak fluently. It is recommended that staff read or paraphrases the Rights
and Responsibilities for the applicant/guardian at certification.

   1. Orally review the participant's rights and responsibilities with the applicant/guardian.
           Applicant is Eligible

           (1)   If the applicant is eligible for WIC services, explain that their signature means they will
                 comply with participant responsibilities, and that all information they have given is true
                 and correct.
           (2)   Have the applicant/guardian read the Participant Statement or read it to them.
           (3)   Ask the applicant/guardian if there are any questions about their rights, responsibilities
                 or the Participant Statement. Answer any questions.
           (4)   Have applicant sign on the Eligible Signature line and enter the date the form is signed.
           (5)   The nutritionist (and any other staff collecting and entering certification data) is/are to
                 read the staff statement and sign and date the form. Place the signed form in the
                 client’s file.
           (6)   A completed and signed form must be placed in each WIC participant’s file for each
                 certification period.
           Applicant is Not Eligible


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WIC POLICY MANUAL                                                                      FFY-2004

           (1)   If the applicant is not eligible for WIC services, obtain a Denial Letter and fill in the
                 name of the applicant and the guardian (if different) and date. Place a check mark or X
                 next to the reason for the denial on the letter. Sign and date the form.
           (2)   The nutritionist (and any other staff collecting and entering certification data) is/are to
                 read the staff statement on the back of the Denial Letter and sign and date the form.
           (3)   Review the letter with the applicant or guardian including the client's right to a fair
                 hearing.

           (4)   Obtain the client’s signature on the back of the Denial Letter. Explain that their
                 signature means they were informed of their rights.

           (5)   Make a copy of the denial letter, front and back. Give the applicant the original. Place
                 a copy of the Denial Letter in the denial file along with a printed copy of the applicant’s
                 Certification Report (denial). Any person denied WIC services should have a signed
                 and dated denial letter on file for each denial. Please follow the Denial Procedures on
                 1-60 of this Policy Manual. Do not send copies of denial letters to the state office
                 since there is no way to organize or maintain this data.

           (6)   A person who has applied and been denied services can reapply at any time. It is
                 appropriate to inform the client that they can reapply at any time, especially if their
                 income situation or health status changes.

VI. Certification of Previously Certified Clients

Certification of clients that have previously been on the WIC program in New Mexico is accomplished
using the Certification tab of the WIC Application. The user follows essentially the same steps as for
initial certification as outlined in this manual. To begin a new certification on a client, the client’s record
is opened and the New button is selected on the Certification tab. When this is done, data fields
requiring information are cleared to allow entry of current data. Once the New button is selected and
the file is saved, staff cannot enter information or changes in the prior certification in most fields. Staff
can enter outcome information in the Pregnancy/Outcome and BF/Outcome tabs. Staff is asked to
ensure that this data is consistently entered when available.

Staff is reminded to reassess the following items. All missing information should be completed.

a. Pregnancy Outcome
b. Current Clinic, Name, (last, first, middle initial),Program Category
c. Address, Phone Number(s), Head of Household and Proxy Name(s)
d. Migrant/Homeless Status
e. Family Size , Annual Income, and participation in TANF, Food Stamp Program, or Medicaid.
f. Breastfeeding Status, Reason for Discontinuin Breastfeeding and Date (if appropriate)
g. Weight, Height, Hemoglobin or Hematocrit
h. Dietary Assessment
i.   Risk Factor Assessment
VII. Denial Procedures


ELIGIBILITY SCREENING                         1-60
WIC POLICY MANUAL                                                                     FFY-2004

   1. Enter all applicable data in the client file. Complete the appropriate fields in the Demographics,
      Family Group and Income tabs.
   2. If the applicant meets income eligibility, obtain and enter the applicant’s medical data and
      dietary information. For women who have recently terminated a pregnancy and who were on
      WIC during that pregnancy, enter the Pregnancy Outcome data. (Note that if the new
      certification has been started, the user must go to the prior certification by clicking on the Prior
      button on the Certification tab.)
              If the applicant does not have a qualifying risk factor, the client must be denied services
              even if income eligibility has been met. Obtain a Denial Letter with current letterhead
              and fill in the name of the applicant and the guardian (if different) and date. Place a
              check mark or x next to the reason for the denial on the letter. Sign and date the form.

   3. Explain to the client, the reason for ineligibility; i.e. program priority, residency, income or
      nutritional risk.
   4. On the Certification Tab, select “Denied” for Status and for the Status Reason select “Screened
      and determined ineligible.” Always enter the applicant’s record in the WIC Application
      whether they qualify or are denied. A record of the application must be kept on file for review
      and in the case of appeals or request for a fair hearing. Explain to the client/guardian the right to
      request a fair hearing. Review all rights with the applicant/guardian.
   5. Staff must print a Certification Report showing the information gathered upon which the denial is
      based. The status (Certification Tab) must also show “Denied.” A copy of the denied
      Certification Report must be placed in the Denial File and in the client’s medical chart if one
      exists.
   6. Have the applicant/guardian sign and date the back of the Denial Letter and explain that their
      signature means that they have been informed of the right to a fair hearing.
   7. The nutritionist (and any other staff collecting and entering certification data) is/are to read the
      staff statement on the back of the Denial Letter and sign and date the form.
   8. Give the applicant the original Denial Letter.
   9. Staff must enter in Notes that the client was issued a Denial Letter.
   10. Determine if the applicant is in need of and/or may qualify for other health care or social
       services. Document any referrals made.
Staff is referred to the Administrative Procedures section of the WIC Policy Manual, Record Storage:
Storage of Denial Records, for information on handling denial files.


VIII. PROCEDURES FOR THE PREVENTION OF HIV TRANSMISSION IN WIC CLINICS
                                  Overview
The Center for Disease Control recommendation's emphasize the need for health care workers to
consider all patients as potentially infected with the Human Immunodeficiency Virus (HIV) and to
consistently adhere to infection control precautions in handling blood or other body fluids. In order to
comply with these recommendations and even more importantly to reduce the risk of exposure to HIV
by WIC staff, the following procedures will be followed in WIC clinics. (Reference: Centers for Disease
Control, MMWR, August 21, 1987, Vol. 36 No. 25)

Note: Each public health office must have a copy of the Infection Control Plan on site. All staff that
could possibly risk exposure to blood borne pathogens must read the plan. Check with the charge
nurse for the location of this plan.                                                                          Deleted:
                                          1-61                  ELIGIBILITY SCREENING
WIC POLICY MANUAL                                                                FFY-2004

   A. Obtaining Hemoglobin Samples

   1. CDC Recommendations
       CDC recommends using protective barriers to prevent skin contact with blood. The protective
       barriers for WIC clinic will include:

a. Gloves - gloves must be used on both hands for obtaining all hemoglobin samples. Gloves should
   fit snugly to protect hands from contact and to allow for ease in obtaining blood samples. Gloves
   should be used until sample is placed in centrifuge. Gloves must be changed after every patient. If
   a glove tears or is punctured, hands must be washed and a new pair of gloves used.
          Note: WIC staff requiring Powder-Free or Vinyl gloves should contact the Clinic Operations
          Manager, Region Program Manage or Region Nutrition Supervisorr to obtain these gloves.
          They will be provided upon request.
b. Lab coats or aprons should be worn to protect skin from blood splashes while obtaining hemoglobin
   and from urine splashes while weighing and measuring infants.
   2. Hand Washing
       Hands should be washed immediately after gloves are removed. Hands should be washed
       thoroughly. If accidental contamination should occur, water should be run over the area
       contaminated for several minutes to rinse off blood, and then wash thoroughly with soap and hot
       water. If hand-washing facilities are unavailable, a pre-moistened antibacterial towelette may be
       used.

   3. Cleaning Table Top
       A paper towel should be placed over the table in the area where the hemoglobin is to be
       obtained. The lancing device and tissue should be placed on top of the towel. Tissue used in
       obtaining the hemoglobin sample must be wrapped in the paper towel and thrown away. The
       paper towel should be changed for every patient. If the tabletop becomes contaminated with
       blood, the area should be washed immediately and wiped with a bleach solution. Gloves must
       be worn while cleaning up.

   4. Disposal of Lancets
       Extra precautions must be taken to prevent an accidental needle stick while handling the lancet.
       The lancet cap should be carefully removed and the patient surface must be kept clean until
       used. Once used, the lancet should be disposed of in a regulation sharps container. Used
       blood sampling devices and spun hemoglobin cuvettes should be dropped in the same
       container after being read. These containers should be located as close as possible to the area
       where hemoglobin tests are performed. Sharps containers should be placed in an area that is
       not accessible to children.

   5. Disposal of Non-Sharp Materials:
       Once the hemoglobin sample is drawn and the lancet has been properly disposed of, other
       materials used to obtain the blood sample must be properly disposed of. Any non-sharp
       product contaminated with blood must be treated as follows.

       Disposable Items: If the material/product is disposable, and is contaminated with blood, such
       as cotton balls, paper towel, disposable latex gloves; it should be discarded in a specially
       marked container, box or trash can marked biohazardous waste. This container should have a
       red plastic liner marked biohazardous. The container should have a lid or cover. (It is
ELIGIBILITY SCREENING                      1-62
WIC POLICY MANUAL                                                                    FFY-2004

       recommended that all non-sharp materials used to obtain a blood sample, be balled up and held
       in one gloved hand. With the other gloved hand, remove the glove holding materials used,
       pulling the glove over the ball of materials to be discarded. The balled material is then placed
       into the remaining gloved hand. Using the ungloved hand, pull the glove off by grasping the
       inside of the glove at the cuff and pulling it over the hand, inverting the glove with its contents as
       it is removed. Discard the balled gloves and materials as appropriate.)

       Items that are not disposable: If a non-disposable item, such as the desk top, becomes
       contaminated with blood, decontaminate using the following procedure. With gloved hands
       spray the surface with a 1:10 bleach solution then wipe away blood. Spray the surface again
       with a 1:10 bleach solution and allow surface to remain wet for at least 10 minutes. With gloved
       hands, wipe dry. Rinse disinfectant from surface if necessary. Dispose of contaminated towels
       and gloves as appropriate. Approved cleaners that kill the HIV and Hep viruses can also be
       used to clean contaminated areas.

   6. Cleaning Equipment
       All equipment used in handling hemoglobin samples should be kept free from accumulation
       of dried blood. If blood accidentally spills on the HemoCue Analyzer it should be wiped off
       immediately. Disconnect the analyzer from the outlet before cleaning. The analyzer should
       be cleaned monthly or when inconsistent readings are occurring. Wear gloves while
       cleaning to prevent the skin from coming in contact with blood. Using a damp cotton swab
       and a soap and water solution, clean out bits of blood from the inside of the machine.

        (DO NOT USE A BLEACH SOLUTION ON THE INSIDE OF THE MACHINE) The outside
       (only) of the analyzer can be cleaned with a bleach solution or approved cleaner.

       Weighing and Measuring Infants

   7. Body Fluids
       While it is generally conceded that HIV is not transmitted in urine, it is still necessary to take
       precautions because it is a body fluid, therefore, care should be taken in obtaining weights and
       measures of infants.

a. Lab coats should be worn to avoid being splashed with urine.
b. A paper towel or examination table paper should be placed on the scale and changed after every
   patient.
c. The scale should be cleaned thoroughly with bleach solution or approved cleaners if the infant
   urinates on the scale while being weighed or measured. Gloves must be worn while cleaning.
   B. Other Considerations

   8. Bleach Solution
       A solution made from household bleach must be used for cleaning. The solution is prepared by
       mixing one (1) part bleach to ten (10) parts water (1:10). The solution should be stored in an
       opaque closed container clearly marked Bleach Solution and be located as close as possible to
       the use area. A fresh bleach solution should be mixed every week. To decontaminate, the
       bleach solution must remain on the surface for 10 minutes.

   C. Additional Precautions
                                                                                                                Deleted:
                                            1-63                   ELIGIBILITY SCREENING
WIC POLICY MANUAL                                                                  FFY-2004

       WIC staff with open cuts, exudative lesions or weeping dermatitis should refrain from obtaining
       hemoglobin samples or handling hemoglobin equipment, if at all possible. Pregnant staff is
       NOT known to be at greater risk. However, if a pregnant woman develops HIV infection during
       pregnancy, the infant is at risk for prenatal infection. Therefore, it is imperative that pregnant
       staff strictly adheres to these procedures.

   D. Monitoring Adherence to Procedures

       For the safety of all WIC staff, it is critical that these procedures be rigorously followed;
       therefore, the Region Nutrition Coordinator, WIC Program Manager or contract agency
       supervisor must monitor adherence to these protective measures by all staff under their
       supervision that obtain hemoglobin samples. Periodically, they should observe staff in obtaining
       hemoglobin samples, disposing of soiled materials and should check that the HemoCue
       Analyzers and other equipment are cleaned according to policy. When monitoring reveals a
       failure to follow correct procedures, counseling, retraining and/or necessary appropriate
       disciplinary action must be considered.



   E. Guidelines for Handling Personal Exposure

   9. Management Of Personal Exposure To HIV Virus
       Public Health Division Protocol

       At any time an employee experiences an on-the-job personal exposure to infection of HIV or is
       concerned that there may have been a personal exposure, it must be reported immediately to
       the Region Health Officer.

       Procedures:

a. The Region Health Officer must consult with the Office of Epidemiology regarding such incidents.
b. Once it has been determined that a personal exposure has occurred, management of the particular
   incident will follow advice of the Office of Epidemiology and current CDC guidelines. This may
   include recommendations for testing of the source patient.
c. If it is determined that an employee needs to be tested for HIV antibody status, then that individual
   will receive the same counseling and guidance as others requesting the test, and test results will be
   handled in the same fashion as all other test results.
d. An accident report is to be completed, reviewed by the Region Health Officer and filed with the Field
   Operations Bureau, the Office of General Counsel, and the Office of Epidemiology.
                                                                                                            Deleted: 2.
   10. Worker’s Compensation
       An employee who develops AIDS as a result of infection in the course of duty may receive
       Workers Compensation benefits to the extent provided by the law. The following would be
       important for the employee's case if a claim might be made in the future.

a. The exposure was documented properly. This may include immediate and serial HIV antibody
   tests.
b. Medical consultation was obtained and recommended personal care procedures were followed.


ELIGIBILITY SCREENING                       1-64
WIC POLICY MANUAL                                                                   FFY-2004

c. A first report of injury was filed within 30 days of exposure. This will support claims for payment of
   medical consultations.
d. Subsequent reports may be necessary according to Workmers Compensation Administration
   requirements and subsequent blood test results.




                                                                                                            Deleted:
                                           1-65                  ELIGIBILITY SCREENING
WIC POLICY MANUAL                                                       FFY-2004

                                New Mexico WIC Clinics

  Region I

   032D      Ann Parish        Valencia     023J   Jemez Springs           Sandoval
   032B      Belen             Valencia     032A   Los Lunas               Valencia
   024B      Bloomfield        San Juan     023B   Sandoval Commons        Sandoval
   023C      Cuba              Sandoval
   024A      Farmington        San Juan
   017A      Gallup            McKinley
   033A      Grants            Cibola




  Regiont II

   004C      Cimarron          Colfax       025B   Pecos                   San Miguel
   031A      Clayton           Union        029B   Peñasco                 Taos
   021D      Dulce             Rio Arriba   029C   Questa                  Taos
   021A      Española          Rio Arriba   004A   Raton                   Colfax
   026L      La Familia Alto   Santa Fe     025C   San Miguel              San Miguel
   026F      La Familia        Santa Fe
   025A      Las Vegas         San Miguel   026A   Santa Fe                Santa Fe
   015A      Los Alamos        Los Alamos   026B   Santa Fe Vo. Tech.      Santa Fe
   021B      Los Ojos          Rio Arriba   026Z   State Office            Santa Fe
   018A      Mora              Mora         029A   Taos                    Taos
   011A      Mosquero          Harding




  Region III

   001I      Kirtland          Bernalillo
   030A      La Sierra         Bernalillo
   001J      NE Heights        Bernalillo
   001F      New Futures       Bernalillo
   001C      NW Valley         Bernalillo
   001D      SE Heights        Bernalillo
   001A      Stanford          Bernalillo
   00IT      West Side         Bernalillo




ELIGIBILITY SCREENING                1-66
WIC POLICY MANUAL                                                   FFY-2004

  Region IV

   008B      Artesia            Eddy       013D   Jal                  Lea
   005B      Cannon AFB         Curry      020B   Logan                Quay
   008A      Carlsbad           Eddy       013B   Lovington            Lea
                                           022B   Portales             Roosevelt
   005A      Clovis             Curry      003A   Roswell              Chaves
   005C      Clovis H. S.       Curry      010A   Santa Rosa           Guadalupe
   003B      Dex/Hagerman       Chaves     020A   Tucumcari            Quay
             Mobile                        010B   Vaughn               Guadalupe
   013C      Eunice             Lea
   006A      Ft. Sumner         De Baca
   013A      Hobbs              Lea




  Region V

   028C      Alamo              Socorro    007L   Las Colonias         Doña Ana
             Navajo/Magdalena              007A   Las Cruces           Doña Ana
   019A      Alamogordo         Otero      012A   Lordsburg            Hidalogo
   007B      Anthony            Doña Ana   014C   Mescalero            Otero
   007M      Anthony Mobile     Doña Ana   030B   Moriarty             Torrence
   027B      Arrey              Sierra     007S   NMSU                 Doña Ana
   014A      Carrizozo          Lincoln    007K   Onate H.S.           Doña Ana
   007E      Chaparral          Doña Ana   002A   Reserve              Catron
   016B      Columbus           Luna       014B   Ruidoso              Lincoln
   016B      Deming             Luna       009A   Silver City          Grant
   007O      Doña Ana Village   Doña Ana   028A   Socorro              Socorro
   007K      East Mesa          Doña Ana   007D   Sunland Park         Doña Ana
   030A      Estancia           Torrance   027A   T or C               Sierra
   007J      Gadsden H.S.       Doña Ana   019C   Tularosa             Otero
   007C      Hatch              Doña Ana   007P   West Las Cruces      Doña Ana
   019B      Holloman           Otero      007F   White Sands          Doña Ana




                                                                                   Deleted:
                                    1-67            ELIGIBILITY SCREENING
WIC POLICY MANUAL                                                           FFY-2004




                                    CONTRACT AGENCIES




                            FIRST CHOICE COMMUNITY HEALTH CENTER
                 001O     North Valley                              FCCHC
                 001Q     South Broadway                            FCCHC
                 001P     Alamosa                                   FCCHC
                 001W     South Valley                              FCCHC


                           FIRST NATIONS COMMUNITY HEALTHSOURCE
                 001R     First Nations Community Healthsource




CLINIC ALTITUDE LEVELS

The information found in this table has been entered into the WIC Application. The action of
selecting a clinic (in the Basic Client Information Header) will determine how a
hemoglobin/hematocrit reading is evaluated for the age and program category of the WIC client.


REGION 1

                                                  Farmington                  5000-6999 Ft.
    Ann Parish                     <4999 Ft.      Gallup                      5000-6999 Ft.
    Belen                           <4999Ft.      Grants                      5000-6999 Ft.
    Bloomfield                  5000-6999 Ft.     Los Lunas                      <4999 Ft.
    Counselors                  7000-7999 Ft.     Sandoval Commons            5000-6999 Ft.
    Coyote                      5000-6999 Ft.     Veguita                        <4999 Ft.
ELIGIBILITY SCREENING                   1-68
WIC POLICY MANUAL                                        FFY-2004

   Cuba             7000-7999 Ft.   West Side              5000-6999 Ft.
   Edgewood         5000-6999 Ft.




REGION 2

   Cimarron         5000-6999 Ft.   Pecos                  7000-7999 Ft.
   Clayton          5000-6999 Ft.   Peñasco                7000-7999 Ft.
   Dulce            5000-6999 Ft.   Questa                 7000-7999 Ft.
   Española         5000-6999 Ft.   Raton                  5000-6999 Ft.
   La Familia       5000-6999 Ft.   San Miguel             5000-6999 Ft.
   Las Vegas        5000-6999 Ft.   Santa Fe               5000-6999 Ft.
   Los Alamos          ?????        Santa Fe Tech.         5000-6999 Ft.
   Los Ojos         7000-7999 Ft.   State Office           7000-7999 Ft.
   Mora             7000-7999 Ft.   Taos                   5000-6999 Ft.
   Mosquero         5000-6999 Ft.   La Famila Alto         7000-7999 Ft.




                                                                           Deleted:
                           1-69             ELIGIBILITY SCREENING
WIC POLICY MANUAL                                           FFY-2004

CLINIC ALTITUDE LEVELS (continued)


REGION 3


   Kirtland               5000-6999 Ft.
   La Sierra              5000-6999 Ft.
   NE Heights             5000-6999 Ft.
   New Futures            5000-6999 Ft.
   NW Valley              5000-6999 Ft.
   SE Heights             5000-6999 Ft.
   Stanford               5000-6999 Ft.


REGION 4

   Artesia                  <4999 Ft.     Hobbs Mobile          <4999 Ft
   Cannon AFB               <4999 Ft.     Jal                   <4999 Ft.
   Carlsbad                 <4999 Ft.     Logan                 <4999 Ft.
   Clovis                   <4999 Ft.     Loving                <4999 Ft.
   Clovis HS                <4999 Ft.     Lovington             <4999 Ft.
   Dexter/Hagerman          <4999 Ft.     Roswell               <4999 Ft.
   Eunice                   <4999 Ft.     Santa Rosa            <4999 Ft.
   Ft. Sumner               <4999 Ft.     Tucumcari             <4999 Ft.
   Hobbs                    <4999 Ft.     Vaughn              5000-6999 Ft.



   REGION 5


   Alamo Reservation      5000-6999 Ft.   Lordsburg              <4999 Ft.
   Alamogordo               <4999 Ft.     Magdalena           5000-6999 Ft.
   Anthony                  <4999 Ft.     Mescalero PHS       5000-6999 Ft.
   Anthony Mobile Unit      <4999 Ft.     NMSU                    <4999 Ft.
   Arrey                    <4999 Ft.     Oñate HS                <4999 Ft.
   Carrizozo                <4999 Ft.     Quemado             6000-7999 Ft.
   Chaparral                <4999 Ft.     Reserve             5000-6999 Ft.
   Columbus                 <4999 Ft.     Silver City         5000-6999 Ft.
   Doña Ana Village         <4999 Ft.     Socorro                 <4999 Ft.
   Deming                   <4999 Ft.     Sunland Park            <4999 Ft.
   East Mesa                <4999 Ft.     Ruidoso             5000-6999 Ft.
   Gadsden H. S.            <4999 Ft.     T or C                  <4999 Ft.
   Hatch                    <4999 Ft.     Tularosa                <4999 Ft.
   Holloman AFB             <4999 Ft.     Moriarty            5000-6999 Ft.
   Las Cruces               <4999 Ft.     West Las Cruces         <4999 Ft.
                                          White Sands           <4999 Ft.


ELIGIBILITY SCREENING             1-70
WIC POLICY MANUAL                                        FFY-2004




CONTRACT AGENCIES



FCCHC N. Valley                <4999 Ft
FCCHC S. Valley                <4999 Ft
FCCHC Broadway                 <4999 Ft
FCCHC Alamosa                  <4999 Ft
First Nations                  <4999 Ft
Albuquerque PHS Hospital       <4999 Ft
Southwest Indian Polytechnic   <4999 Ft




                                                                    Deleted:
                                     1-71   ELIGIBILITY SCREENING
WIC POLICY MANUAL                                                                    FFY-2004

Summary of Risk Factors By Priority

For a detailed description of Risk Factors, refer to the Risk Factors by Priority section 1-83. Staff is
asked to use the “Risk Factors by Priority Tables” when assessing and documenting risk factors.
Pregnant Women




ELIGIBILITY SCREENING                        1-72
WIC POLICY MANUAL                                                                      FFY-2004


      PRIORITY I
                                                           PRIORITY I, (Continued)
101   Underweight (Pre-pregnancy)
                                                     349   Genetic and Congenital Disorders
111   Overweight (Pre-pregnancy)
                                                     351   Inborn Errors of Metabolism
131   Present Low Weight Gain
                                                     352   Infectious Diseases
201   Anemia
                                                     353   Food Allergy
302   Gestational Diabetes (Current
                                                     354   Celiac Disease
      Diagnosis of)
303   Gestational Diabetes (History of)              355   Lactose Intolerance Symptoms
311   Premature Infant                               356   Hypoglycemia
312   Low Birth Weight Infant                        358   Eating Disorders
                                                     359   Recent Major Surgery, Trauma, Burns
321   Spontaneous Abortion, Fetal or
      Neonatal Loss                                  360   Other Medical Conditions
331   Pregnancy at a Young Age                       362   Developmental Delays, Sensory or
332   Closely Spaced Pregnancy                             Motor Delays Interfering with Ability to
                                                           Eat
333   High Parity at Young Age
                                                     371   Smoking
335   Multifetal Gestation
                                                     372   Alcohol or Illegal Drug Use
339   Infant with Congenital Anomaly
      (nutritional)                                  381   Dental Problems
                                                     502   Out of State Transfer
341   Nutrient Deficiency Diseases
342   Gastro-Intestinal Disorders
                                                           PRIORITY IV
343   Diabetes Mellitus
344   Thyroid Disorders                              401   Failure to Meet Dietary Guidelines
345   Hypertension                                   422   Inadequate Diet
                                                     801   Homeless
346   Renal Disease
347   Cancer                                         802   Migrant
348   Central Nervous System Disorders

Breastfeeding Women

      PRIORITY I                                     345   Hypertension
101   Underweight                                    346   Renal Disease
111   Overweight                                     347   Cancer
201   Anemia                                         348   Central Nervous System Disorders
303   Gestational Diabetes (most recent)             349   Genetic and Congenital Disorders
311   Premature Infant (most recent)                 351   Inborn Errors of Metabolism
312   Low Birth Weight Infant (most recent)          352   Infectious Diseases
321   Spontaneous Abortion, Fetal or
      Neonatal Loss (most recent)
331   Pregnancy at a Young Age
332   Closely Spaced Pregnancy
333   High Parity and Young Age
335   Multifetal Gestation


      PRIORITY I, (Continued)
339   Infant with Congenital Anomaly (most
      recent, nutritional)
341   Nutrient Deficiency Diseases
342   Gastro-Intestinal Disorders
343   Diabetes Mellitus
344   Thyroid Disorders                                                                               Deleted:



                                              1-73                ELIGIBILITY SCREENING
WIC POLICY MANUAL                                                                           FFY-2004


      Breastfeeding Women (Continued)
        PRIORITY I, (Continued)                                 PRIORITY II
353     Food Allergy                                      601   Breastfeeding Mother with Infant at
354     Celiac Disease                                          Priority II Risk
355     Lactose Intolerance Symptoms
356     Hypoglycemia                                            PRIORITY IV
358     Eating Disorders                                  401   Failure to Meet Dietary Guidelines
359     Recent Major Surgery, Trauma, Burns               420   Caffeine
360     Other Medical Conditions                          422   Inadequate Diet
362     Developmental Delays, Sensory or                  601   Breastfeeding Mother with Infant at
        Motor Delays Interfering with Ability to                Priority IV Risk
        Eat                                               801   Homeless
371     Smoking                                           802   Migrant
372     Alcohol or Illegal Drug Use
381     Dental Problems                                         Priority VII
502     Out of State Transfer                             501   Regression
601     Breastfeeding Mother with Infant at
        Priority I Risk
Drug Use
Postpartum Women

        PRIORITY III
                                                                PRIORITY VI, (Continued)
331     Pregnancy at a Young Age
                                                          348   Central Nervous System Disorders
                                                          349   Genetic and Congenital Disorders
        Priority VI                                       351   Inborn Errors of Metabolism
101     Underweight                                       352   Infectious Diseases
111     Overweight                                        353   Food Allergy
201     Anemia                                            354   Celiac Disease
303     Gestational Diabetes (History of, most            355   Lactose Intolerance Symptoms
        recent)                                           356   Hypoglycemia
311     Premature Infant (most recent)                    358   Eating Disorders
312     Low Birth Weight Infant (most recent)             359   Recent Major Surgery, Trauma, Burns
321     Spontaneous Abortion, Fetal or                    360   Other Medical Conditions
        Neonatal Loss                                     362   Developmental Delays, Sensory or
332     Closely Spaced Pregnancy                                Motor Delays Interfering with Ability to
333     High Parity and Young Age                               Eat
335     Multifetal Gestation                              372   Alcohol or Illegal Drug Use
339     Infant with Congenital Anomaly                    381   Dental Problems
        (nutritional)                                     401   Failure to Meet Dietary Guidelines
341     Nutrient Deficiency Diseases                      422   Inadequate Diet
342     Gastro-Intestinal Disorders                       502   Out of State Transfer
343     Diabetes Mellitus                                 801   Homeless
344     Thyroid Disorders                                 802   Migrant
345     Hypertension
346     Renal Disease                                           PRIORITY VII
347     Cancer                                            501   Regression




ELIGIBILITY SCREENING                              1-74
WIC POLICY MANUAL                                                                         FFY-2004


INFANTS             (See updated policy or list)


      PRIORITY I
                                                              PRIORITY I, (Continued)
103   Underweight (Wt/Ht)
                                                        381   Dental Problems
113   Overweight (wt/ht)
                                                        382   Fetal Alcohol Syndrome
121   Stunting (Ht/Age)
                                                        502   Out of State Transfer
134   Failure to Thrive                                 702   BF Infant of Woman at Priority I Risk
141   Low Birth Weight
142   Prematurity                                             PRIORITY II
201   Anemia                                            701   Infant < 6 Months Born to WIC Mother
341   Nutrient Deficiency Diseases                      702   BF Infant of Woman at Priority II Risk
342   Gastro-Intestinal Disorders
343   Diabetes Mellitus                                       PRIORITY IV
344   Thyroid Disorders
                                                        411   Inappropriate Infant Feeding Practices
345   Hypertension                                      412   Early Introduction of Solid Foods
346   Renal Disease                                     413   Feeding Cow’s Milk During First 12
347   Cancer                                                  Months
348   Central Nervous System Disorders                  415   Improper Dilution of Formula
349   Genetic and Congenital Disorders                  416   Feeding Other Foods Low in Essential
350   Pyloric Stenosis                                        Nutrients
351   Inborn Errors of Metabolism                       417   Lack of Sanitation in Preparation and
352   Infectious Diseases                                     Storage of Formula and Breastmilk
353   Food Allergy                                      419   Inappropriate Use of Bottles
354   Celiac Disease                                    501   Regression
355   Lactose Intolerance Symptoms                      702   BF Infant of Woman at Priority IV Risk
356   Hypoglycemia                                      801   Homeless
359   Recent Major Surgery, Trauma, Burns               802   Migrant
360   Other Medical Conditions
362   Developmental Delays, Sensory or
      Motor Delays Interfering with Ability to
      Eat


CHILDREN (See updated Policy or list)
      PRIORITY III                                            PRIORITY III, (Continued)
103   Underweight (Wt/Ht)                               351   Inborn Errors of Metabolism
114   At Risk of Becoming Overweight                    352   Infectious Diseases
121   Stunting (Ht/Age)                                 353   Food Allergy
134   Failure to Thrive                                 354   Celiac Disease
201   Anemia                                            355   Lactose Intolerance Symptoms
341   Nutrient Deficiency Diseases                      356   Hypoglycemia
342   Gastro-Intestinal Disorders                       359   Recent Major Surgery, Trauma, Burns
343   Diabetes Mellitus                                 360   Other Medical Conditions
344   Thyroid Disorders                                 362   Developmental Delays, Sensory or
345   Hypertension                                            Motor Delays Interfering with Ability to
346   Renal Disease                                           Eat
347   Cancer                                            381   Dental Problems
348   Central Nervous System Disorders                  382   Fetal Alcohol Syndrome
349   Genetic and Congenital Disorders                  502   Out of State Transfer
                                                                                                         Deleted:



                                                 1-75                ELIGIBILITY SCREENING
WIC POLICY MANUAL                                                                 FFY-2004



CHILDREN (Continued)


      PRIORITY V                                        PRIORITY V, (Continued)
401   Failure to Meet Dietary Guidelines          801   Homeless
419   Inappropriate Use of Bottles                802   Migrant
422   Inadequate Diet
425   Inappropriate Feeding Practices                   PRIORITY VII
      Children                                    501   Regression




ELIGIBILITY SCREENING                      1-76
  WIC POLICY MANUAL                                                                                                     FFY-2004


                                           Food Frequency Diet Analysis

                          (Source: Iowa WIC Program)
  NAME: __________________ CATEGORY: PW BF PP C AGE: ______ DATE: _______
                                                                   (Circle one)
  DIRECTIONS: Circle all foods and beverages consumed by the WIC applicant during the past week (7-day period).
              Write in any foods you have eaten during the past week that are not listed on the form.
Whole wheat bread, (oatmeal, rye, bran),                                 Chicken, turkey, duck, fish, shellfish,
whole wheat or rye crackers, whole wheat                                 canned fish, veal, lamb, game meat,
pasta, whole wheat buns, whole grain                                     beef, hamburger, pork, ham, liver, heart,
cereals, oatmeal, atole, brown rice, plain        -----------            kidney, other organ meats, eggs or egg      -------------
popcorn                                                                  dishes, nuts, seeds, peanut butter, beans      __REMAINDER
"REFINED" Cereals, (WIC or other), low              __REMAINDER          or peas, lentils, pork and beans, tofu, soy
sugar cereals, granola, *pasta, *macaroni,                               products
*spaghetti, *rice, bagels, white bread, buns,
biscuits, pancakes, rolls, tortillas (flour or                           Other______________________
corn), sopapillas, muffins, quick breads, corn                           "OTHER"
bread, graham crackers, crackers (saltines),                             Processed meats, Spam, lunchmeats,
pizza crust *Note if homemade or from a                                  sausage, chorizo, hot dogs, corned beef,
mix.                                              -------------          potted meat, vienna sausage.             -------------
Other ____________________________
                 RF 401           REMAINDER       RF 422                    RF 401          REMAINDER                   RF 422
Broccoli, carrots, squash, sweet potatoes,
red chile, greens (such as spinach turnip,
                                                                                     DIETARY SCORE:
mustard, beet, etc.), apricots, cantaloupe                               Fried foods, vegetable fat, lard,
"OTHER"                                           -------------          shortening, dips, mayonnaise, salad
Potatoes, green peas, corn, posole                  __REMAINDER          dressings, sour cream, cream cheese,
Cauliflower, green beans, lettuce, cabbage                               butter, margarine, bacon, avocados,
Other ____________________________                                       chicharrones, popcorn, gravy
                                                                         Cookies, cakes, donuts, sweet rolls, pies,
                                                  -------------          jam/jelly, honey, syrup, candy,
                 RF 401            REMAINDER      RF 422                 Added sugar, chocolate, Pre-
Oranges, grapefruit, berries, watermelon,                                sweetened cereal, Fruit packed in syrup,
mangos, juice (WIC or equivalent), green          -------------          Popsicles, sherbet, Jell-O, Kool-Aid,
chile, tomatoes                                                          lemonade, soda, fruit drinks, Hi-C,
"OTHER"                                             __REMAINDER          Gatorade
Pears, bananas, peaches, raisins, grapes,                                Caffeinated drinks, coffee, tea
apples, fruit cocktail, dried fruits, pineapple                          Packaged sauce mixes, salty snacks
Other ___________________________                                        (pretzels, chips), canned soups or
                                                                         dinners (ravioli), pickles, relish, barbecue
                                                  -------------          sauce, condiments (catsup,
               RF 401         REMAINDER           RF 422                 mustard).
MILK, (whole, 2%, 1 1/2%, 1%, acidophilus,                               Packaged or frozen foods (mixes,
skim, chocolate), cheese, yogurt, cottage                                dinners, ramen noodles, Hamburger
cheese.                                                                  Helper, Rice-A-Roni,)
Milk base soups, puddings, custards, ice                                 Foods canned with added salt, added
cream                                                                    salt at the table.
Other ____________________________                -------------
                                                               Other______________________
              RF 401       REMAINDER       RF 422
  ASSESSMENT: (Circle as appropriate)
  RF 422 (Inadequate Diet)         RF 401 (Failure to meet Dietary Guidelines)       Diet Adequate No Dietary Risk
  Comments: ___________________________________________________________________________
                                                                                                           DOH/PHD Revised 12/01 TM




                                                                                                                                      Deleted:



                                                                  1-73                        ELIGIBILITY SCREENING
WIC POLICY MANUAL                                                                                                    FFY-2004


                                        DIETARY COUNSELING GUIDE
Name of person being certified: __________________________________________________________
Instruction: Answer all questions for the person being certified. If more than one person is being certified
fill out one form for each person.
1. Do you have any concerns about the eating habits of the person  Yes        Explain:
     being certified?                                              No
2. Describe the appetite of the person being certified.            Good       Explain:
                                                                   Fair
                                                                   Poor
3. Does the person being certified experience any of the           constipation               diarrhea
     following:(check all that apply) Explain here:                nausea                     vomiting
                                                                   heartburn
4. How many meals per day does the person being certified eat?    Number:         List Snack Foods Here:
     How many snacks are eaten?                                   Number:
     List the foods eaten as snacks in the last column.
5. How much water does the person being certified drink each day? Number of cups:
     What is the source of drinking water? Check source            Bottled  City  Well  Other (Explain)

6. Does the person being certified have any cravings for things         Yes    No        List the item and amount here:
    normally not eaten? List item and amount in last column.
    Does the person being certified eat things that are not food?       Yes    No        List the item and amount:

7. Are there foods that make the person being certified sick or they    Yes    No        List the item here:
     won’t eat or drink?
8. Is the person being certified on a special diet?                     Yes    No        List concerns or problems here:
     Who prescribed it? ______________________________
    How long have they been on it? _____________________
     List any concerns or problems in the last column.
9. Is the person being certified taking any pills or medications?       Yes     No       List pills or medications here:

10. Does your stove work?                                               Yes    No
     Does your refrigerator work?                                       Yes    No
     Do you run out of certain foods before the end of the month?       Yes    No
     List the items in the last column.
11. Does the person being certified receive the                                 List the names of persons in your family unit
    following?                          Food Stamps          Yes       No     receiving CSFP here:
                                        Commodities          Yes       No
                  CSFP (ECHO, CAA or Salvation Army)  Yes              No

Women only being certified:
12. Are you taking any prenatal vitamins with iron?     Yes  No
     Are you taking additional iron?                    Yes  No
13. Have you received any information on or talked to anyone about the following:
    Diet                    Yes  No
    Drugs/Alcohol           Yes  No
    Weight gain/loss        Yes  No
    Vitamins                Yes  No
    Breastfeeding           Yes  No
13. What are your feelings about breastfeeding?

14. If you are pregnant, how much weight do you plan to gain during this pregnancy?     _______ Pounds:
                                                                                                          Revised (layout only) 7/01 tm
Nutritionists Initials: ________________ Date: ________________                              Department of Health/Public Health Division




ELIGIBILITY SCREENING                                        1-74
WIC Policy Manual                                          FFY 2004



Participant’s Rights and Responsibilities Form - English




ELIGIBILITY SCREENING                     1-75
WIC POLICY MANUAL                                          FFY-2004



Participant’s Rights and Responsibilities Form - Spanish




ELIGIBILITY SCREENING                    1-76
WIC POLICY MANUAL                                                                                                    FY-2004




Dear _________________________________________:

Applicants must meet the following conditions in order to qualify for WIC benefits. The applicant must:
1. Live in the state of New Mexico.
2. Be one of the categories WIC serves, which includes babies under 1 year of age, children under 5 years of age, a pregnant
     woman, a breastfeeding woman with an infant under 1 year of age, or a postpartum woman within 6 months of the
     termination of the pregnancy.
3. Be at or below 185% of the federal poverty level.
4. Have a nutrition related health risk that will qualify you to receive WIC services.
During the application process, it has been determined that the following condition(s) has not been met.
_____ The applicant does not live within the state boundaries
_____ The applicant is not one of the categories WIC serves
_____ The applicant’s reported family income is above 185% of the federal poverty level and the
           applicant does not meet Adjunctive Eligibility
_____ The applicant does not have a nutrition related health risk that WIC serves
The rights of all program applicants are listed below:
      Standards for participation in the program are the same for everyone regardless of race, color, national origin, sex,
     age, handicap or disability.
      You may appeal any decision made by the local agency regarding your eligibility for the program.
      The local agency will make health services and nutrition education available to you and you are encouraged to
     participate in these services.
      The information you have provided is and will remain confidential unless you have given consent otherwise.
At the time of application the following information was reported: Annual Income: $ __________ Number supported by this
income: __________


                            Public Health Division, Family Health Bureau
The program must receive requests for a fair hearing within 60 days of this notice. Written requests should be mailed to:

                            WIC Nutrition Program
                            2040 S. Pacheco Street, Room 152
                            Santa Fe, New Mexico 87505
 Or you may call the Clinic Operations Manager or the WIC Program Director in Santa Fe at (505) 476-
8801 or (800) 280-1618 to request a fair hearing.

The United States Department of Agriculture (USDA) prohibits discrimination in its programs on the basis of race, color, national
origin, sex, age and disability. Persons with disabilities who require alternative means for communication of program information
(Braille, large print, audiotape, etc.) should contact USDA’s TARGET Center at (202) 720-2600 (voice and TDD). To file a
complaint, write                USDA, Director, Office of Civil Rights
                                Room 326-W, Whitten Building
                                14th and Independence Avenue SW
                                Washington, DC 20250-9410
 Or call (202) 720-5964 (voice and TDD). USDA is an equal employment opportunity provider and employer.
Thank you for -your understanding and consideration.


____________________________
Staff Signature, WIC Nutrition Program




                                                             1-77                     ELIGIBILITY SCREENING
WIC POLICY MANUAL                                                                                     FFY-2004




                                      Denial Documentation Form

Not Eligible: Obtain client signature and date below:
Client statement: I understand that I am not eligible to receive WIC benefits at this time. I have been
informed of my right to a fair hearing. I have read the front of this letter and verify that I understand it by
signing my name on the line below.

Comprendo que no califico para recibir cheques de WIC a este tiempo. Se me ha informado de mis
derechos a apelar esta decición.


______________________________________________________Date: _____________________
Applicant or Guardian Signature


=============================================================================

Staff acknowledgement and signatures:
I certify that I have properly screened the participant for nutritional risk and income eligibility. The
documentation provided for this applicant is accurate and the denial made is based on the information
collected during this certification process. The applicant has been informed of their right to a fair hearing
and how to request an appeal to this denial.


Staff:_______________________________________________Date: _____________________

Staff:_______________________________________________Date: _____________________

(If only one staff person determines the denial, only one signature is needed. However is the denial is
made using information collected by more than one staff person, each staff person must read the statement
above and sign and date the form.)

This form must be signed, dated and stored with the printout of the applicant’s record.




ELIGIBILITY SCREENING                                 1-78
WIC POLICY MANUAL                                                                                                      FY-2004




Estimado(a) ____________________________________:                      Fecha: __________________

Se requiere que los solicitantes al Programa de WIC conformen a la siguiente criteria para recibir beneficios. El solicitante tiene
que:
1. Ser residente del (vivir en el) estado de Nuevo Mexico.
2. Ser person dentro una de las categorias que sirve el programa, los quales incluyen infantes menores de un año, niños
     menores de cinco años, mujeres embarazadas, mujeres que amamantan infantes menores de un año de edad, o mujeres
     postnatales con menos de seis meses de terminación del embarazo.
3. Recibir ingresos igual o menor al 185% del nivel federal de pobreza.
4. Tener un riesgo nutricional de salud, el cual califica para recibir beneficios de WIC.
Durante la aplicación al programa, se ha determinado que la(las) siquiente(s) condición(es) no han sido cumplida(s).
_____ El solicitante no vive dentro del estado de Nuevo Mexico

_____     El solicitante no esta dentro de las categorias que sirve el Programa de WIC

_____     Los ingresos reportados del solicitante son más del 185% del nivel federal de pobreza

_____     El solicitante no tiene ningun riesgo nutricional de la salud que pueda servir el Programa de WIC

Los derechos de los solicitantes al Programa son como sigue:
       Las normas de participación en el Programa son iguales para todos, sin importar raza, color, origen nacional, sexo,
           edad o incapacidad o desabilidad.
       Se puede apelar cualquier decisión hecha por la agencia local en cuanto a su eligibilidad para el programa.
       La agencia local le hará disponible los servicios de salud y educación sobre nutrición. Se le motiva que participe en
           estos servicios.
Al tiempo de solicitud al programa, se reportó la siguiente información: Ingreso Anual: $ __________         Número de
personas sostenidos con este ingreso: __________

                                Public Health Division, Family Health Bureau
Para obtener una audiencia imparcial, comuniquese con:

                                WIC Nutrition Program
                                2040 S. Pacheco Street, Room 152
                                Santa Fe, New Mexico 87505
El Departamento de Agricultura, de los Estados Unidos (USDA), prohibe la desciminación en sus programas basada en raza,
color, origen nacional, sexo, edad o desabilidad. (No todas los bases prohibidas se implementan a todos los programas.)
Personas con desabilidades que requieran modos de comunicación alternativos sobre la información del program
(Braille,escritura grande, cinta auditiva, etc.) deben comunicarse al USDA’s TARGET Center al numbero (202) 720-2600
(auditivo o TDD). Para poner una queja, escriba al Secretario de Agricultura, U.S. Department of Agriculture, Washington, DC
20250, o llame al número 1-800-242-6340 (voice) or (202) 720-1127 (TDD). USDA es un empleador de oportunidad igualitaria.
Gracias por su comprensión y consideración.

__________________________________________
Firma del empleado, Programa Nutricional de WIC




                                                              1-79                       ELIGIBILITY SCREENING
WIC POLICY MANUAL                                                                                     FFY-2004




                                      Denial Documentation Form

Not Eligible: Obtain client signature and date below:
Client statement: I understand that I am not eligible to receive WIC benefits at this time. I have been
informed of my right to a fair hearing. I have read the front of this letter and verify that I understand it by
signing my name on the line below.

Comprendo que no califico para recibir cheques de WIC a este tiempo. Se me ha informado de mis
derechos a apelar esta decición.


______________________________________________________Date: _____________________
Applicant or Guardian Signature


=============================================================================

Staff acknowledgement and signatures:
I certify that I have properly screened the participant for nutritional risk and income eligibility. The
documentation provided for this applicant is accurate and the denial made is based on the information
collected during this certification process. The applicant has been informed of their right to a fair hearing
and how to request an appeal to this denial.


Staff:_______________________________________________Date: _____________________

Staff:_______________________________________________Date: _____________________

(If only one staff person determines the denial, only one signature is needed. However is the denial is
made using information collected by more than one staff person, each staff person must read the statement
above and sign and date the form.)

This form must be signed, dated and stored with the printout of the applicant’s record.




ELIGIBILITY SCREENING                                 1-80
WIC POLICY MANUAL                                                                 FY-2004



CLINIC ALTITUDE LEVELS

The information found in this table has been entered into the WIC Application. The
action of selecting a clinic (in the Basic Client Information Header) will determine how a
hemoglobin/hematocrit reading is evaluated for the age and program category of the
WIC client.


REGION 1

Ann Parish                    <4999 Ft.            Jemez Springs             5000-6999 Ft.
Belen                         <4999 Ft.            Los Lunas                   <4999 Ft.
Bernalillo                  5000-6999 Ft.          Mountainair               5000-6999 Ft.
Bloomfield                  5000-6999 Ft.          Sandoval Commons          5000-6999 Ft.
Counselors                  7000-7999 Ft.          Tijeras                   5000-6999 Ft.
Coyote                      5000-6999 Ft.          Veguita                     <4999 Ft.
Edgewood                    5000-6999 Ft.
Farmington                  5000-6999 Ft.
Gallup                      5000-6999 Ft.
Grants                      5000-6999 Ft.
                            5000-6999 Ft.



REGION 2

Cimarron                    5000-6999 Ft.          Pecos                     7000-7999 Ft.
Clayton                     5000-6999 Ft.          Peñasco                   7000-7999 Ft.
Dulce                       5000-6999 Ft.          Questa                    7000-7999 Ft.
Española                    5000-6999 Ft.          Raton                     5000-6999 Ft.
La Familia                  5000-6999 Ft.          San Miguel                5000-6999 Ft.
Las Vegas                   5000-6999 Ft.          Santa Fe                  5000-6999 Ft.
Los Alamos                                         Santa Fe Tech.            5000-6999 Ft.
Los Ojos                    7000-7999 Ft.          State Office              7000-7999 Ft.
Mora                        7000-7999 Ft.          Taos                      5000-6999 Ft.
Mosquero                    5000-6999 Ft.          La Famila Alto            7000-7999 Ft.




                                            1-81              ELIGIBILITY SCREENING
WIC POLICY MANUAL                                                  FFY-2004



CLINIC ALTITUDE LEVELS (continued)


REGION 3


Kirtland                5000-6999 Ft.
La Sierra               5000-6999 Ft.
NE Heights              5000-6999 Ft.
New Futures             5000-6999 Ft.
NW Valley               5000-6999 Ft.
SE Heights              5000-6999 Ft.
Stanford                5000-6999 Ft.


REGION 4

Artesia                   <4999 Ft.            Hobbs Mobile        <4999 Ft
Cannon AFB                <4999 Ft.            Jal                 <4999 Ft.
Carlsbad                  <4999 Ft.            Logan               <4999 Ft.
Clovis                    <4999 Ft.            Loving              <4999 Ft.
Clovis HS                 <4999 Ft.            Lovington           <4999 Ft.
Dexter/Hagerman           <4999 Ft.            Roswell             <4999 Ft.
Eunice                    <4999 Ft.            Santa Rosa          <4999 Ft.
Ft. Sumner                <4999 Ft.            Tucumcari           <4999 Ft.
Hobbs                     <4999 Ft.            Vaughn            5000-6999 Ft.



REGION 5


Alamo Reservation       5000-6999 Ft.          Lordsburg           <4999 Ft.
Alamogordo                <4999 Ft.            Magdalena         5000-6999 Ft.
Anthony                   <4999 Ft.            Mescalero PHS     5000-6999 Ft.
Anthony Mobile Unit       <4999 Ft.            NMSU                <4999 Ft.
Arrey                     <4999 Ft.            Oñate HS            <4999 Ft.
Chaparral                 <4999 Ft.            Quemado           6000-7999 Ft.
Columbus                  <4999 Ft.            Reserve           5000-6999 Ft.
Doña Ana Village          <4999 Ft.            Silver City       5000-6999 Ft.
Deming                    <4999 Ft.            Socorro             <4999 Ft.
East Mesa                 <4999 Ft.            Sunland Park        <4999 Ft.
Gadsden H. S.             <4999 Ft.            T or C              <4999 Ft.
Holloman AFB              <4999 Ft.            Tularosa            <4999 Ft.
Las Cruces                <4999 Ft.            Moriarty          5000-6999 Ft.
                                               West Las Cruces     <4999 Ft.
                                               White Sands         <4999 Ft

ELIGIBILITY SCREENING                   1-82
WIC POLICY MANUAL                                       FY-2004




CONTRACT AGENCIES



FCCHC N. Valley           <4999 Ft
FCCHC S. Valley           <4999 Ft
FCCHC Broadway            <4999 Ft
FCCHC Alamosa             <4999 Ft
First Nation              <4999 Ft
M&I Women’s Health Care   <4999 Ft
Center, UNM




                                 1-83   ELIGIBILITY SCREENING
       WIC POLICY MANUAL                                                                                                                   FFY-2004

      RISK FACTORS BY PRIORITY - PREGNANT WOMEN

CODE                  DESCRIPTION                                           SPECIAL NOTES                                   EXPLANATION
PRIORITY I
(201) Anemia: Hemoglobin and hematocrit levels adjusted for altitude based on the                           Red blood cells cannot carry enough oxygen
                   1989 CDC criteria.                                                                       caused by inadequate iron intake and/or an
                                                                                                            increased need; more likely to be irritable, tired,
Trimester               < 4999 Ft.       5000-6999 Ft.    7000-7999 Ft.       8000-8999 Ft.   >9000 Ft.     have a poor appetite and get sick.
                        Hct.   Hgb.      Hct. Hgb.        Hct. Hgb.           Hct. Hgb.       Hct. Hgb.     During counseling, remember that smoking
1st (1-13 Wks.)         <34 <11.3        <35 <11.7        <36 <12.0           <37 <12.3       <38 <12.7     increases the Hct./Hgb. level because of
2nd (14-26 Wks.)        <33 <11.0        <34 <11.3        <35 <11.7           <36 <12.0       <37 <12.3
                                                                                                            increased carboxyhemoglobin from inhaling
3rd (27-40 Wks.)        <34 <11.3        <35 <11.7        <36 <12.0           <37 <12.3       <38 <12.7
                                                                                                            carbon monoxide during smoking. This raises
                             Refer to 1-81 – 1-82 for the altitude of your clinic.                          the Hct. level by 1.0% (any cigarettes at all) to
                                                                                                            2.0% (>2 packs/day).
(335) Multifetal Gestation: More than one fetus in            Must document in the Notes tab of the         In addition to the nutritional demands of
     a current pregnancy                                      WIC Application.                              pregnancy, the body must meet the demands
                                                                                                            of an additional fetus.
(332) Closely Spaced Pregnancy: Conception of                 Note date (MM, YY) of termination of last     May result in depletion of body’s nutrient
     present pregnancy occurring within 16 months             pregnancy in the Notes tab of the WIC         reserves; nutrition related problems may
     from date of termination of last pregnancy               Application.                                  develop.
     (before 16 mos. postpartum).
(333) High Parity at Young Age: Women under                   Note number of dates (MM, YY) of              May result in depletion of body’s nutrient
     age 20 at date of conception who have had 3              termination of pregnancies in the Notes tab   reserves; nutrition related problems may
     or more pregnancies of at least 20 weeks                 of the WIC Application. The current           develop.
     duration, regardless of birth outcome.                   pregnancy must be at least the applicant’s
                                                              fourth pregnancy.
                                                              See Risk Factor Reference Manual




ELIGIBILITY SCREENING                                                                1-83                                              Revised 9/2002 dt
       WIC POLICY MANUAL                                                                                                       FFY-2004

      RISK FACTORS BY PRIORITY - PREGNANT WOMEN

CODE               DESCRIPTION                                  SPECIAL NOTES                                    EXPLANATION
PRIORITY I (continued)

History of High Risk Pregnancy – Must                Note the condition(s) and date(s) (MM, YY)   High-risk pregnancies may be nutrition related.
     assign all applicable risk factors.             of occurrence(s) in the Notes tab of the     Offering peanut butter in place of beans may be
                                                     WIC Application.                             appropriate for women with diabetes including
     (303) Gestational diabetes                                                                   gestational diabetes.
                                                     See Risk Factor Reference Manual
     (312) Low birth weight infant (<5 lb. 8 oz. )
     (311) Premature infant (born < 37 weeks
          gestation)
     (321) At least two or more Spontaneous
          Abortions, Fetal or Neonatal Loss
          Spontaneous abortion is the
          spontaneous termination of a gestation
          at <20 weeks gestation. Fetal death is a
          spontaneous termination of a gestation
          >20 weeks. Neonatal death is the death
          of an infant within 0 – 28 days of life
     (339) Infant with congenital anomaly
          (nutritional)
(345) Pregnancy Induced Hypertension:                Must be documented by a physician or         Smaller babies are more likely to be born. A
     Presence of hypertension diagnosed by a         nurse practitioner. Pre-eclampsia or         good diet may help minimize effects. Clients
     physician as self reported by applicant or as   clinical signs leading toward toxemia.       may not know the terms “toxemia, pre-
     reported or documented by a physician or        Toxemia is a collective term for pre-        eclampsia or eclampsia.” They will know,
     someone working under physician’s orders.       eclampsia and eclampsia, conditions          however, if they had frequent check-ups or
                                                     usually occurring in the later half of       were hospitalized for rapid weight gain due to
                                                     pregnancy. Pre-eclampsia is                  fluid build-up, - hypertension or protein in the
                                                     characterized by generalized edema           urine.
                                                     beyond the normal swollen hands and feet,
                                                     high blood pressure and proteinuria.
(111) Overweight (Pre-pregnancy):                                                                 Caused by eating more food than the body is
     Pre-pregnancy BMI of greater than or equal to                                                using; may lead to an inadequate balance of
     26.1 (see chart under Risk Factor 101).                                                      nutrients needed for good health. May be
                                                                                                  appropriate to tailor the milk package.




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    RISK FACTORS BY PRIORITY - PREGNANT WOMEN
CODE               DESCRIPTION              SPECIAL NOTES                                                                      EXPLANATION
PRIORITY I (continued)

(302) Gestational Diabetes – Presence of             See Risk Factor Reference Manual                            May need to tailor the food package to include
     Gestational diabetes diagnosed by a physician                                                               peanut butter
     as self reported by applicant; or someone
     working under Physician’s orders
(101) Underweight (Pre-pregnancy): Pre-pregnancy BMI <19.8 (See chart below)                                     Caused by not getting the required amounts of
                     Weight for Height Table for Women Based on Body Mass Index                                  nutrients from food needed for good health;
                                                                                                                 nutritional deficiencies may occur; low birth-
Find the height without shoes in the left column; then find the prepregnancy weight in a column to               weight baby more likely.
the right of that height to determine pre-pregnancy weight to height status.
                                                                                                                 Offering peanut butter in place of beans may be
                                                                                                                 appropriate.
Body Mass Index (BMI) Table for Determining Weight Classification for Pregnant Women (1)
               Height         Underweight    Normal Weight        Overweight        Obese
              (Inches)          BMI <19.8     BMI 19.8-26.0      BMI 26.1-29.0     BMI >29.1
                 58”              <95             95-124            125-138           >138
                 59”              <98             98-128             129-143          >143
                 60”              <102           102-133            134-148           >148
                 61”              <105           105-137            138-153           >153
                 62”              <108           108-142            143-158           >158
                 63”              <112           112-146            147-163           >163
                 64”              <116           116-151            152-169           >169
                 65”              <119           119-156            157-174           >174
                 66”              <123           123-161            162-179           >179
                 67”              <127           127-166            167-185           >185
                 68”              <130           130-171            172-190           >190
                 69”              <134           134-176            177-196           >196
                 70”              <138           138-181            182-202           >202
                 71”              <142           142-186            187-208           >208
                 72”              <146           146-191            192-213           >213
(1) Adapted from the Institute of Medicine: Nutrition During Pregnancy, National Academy Press; 1990; page 12.




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      RISK FACTORS BY PRIORITY - PREGNANT WOMEN

CODE               DESCRIPTION                                 SPECIAL NOTES                                       EXPLANATION
PRIORITY I (continued)

(131) Present Low Weight Gain: A woman whose       Documented on a prenatal weight gain             Caused by not getting the required amounts of
     weight falls below the shaded portion on an   grid.                                            nutrients from food needed for good health;
     approved prenatal weight gain grid when                                                        nutritional deficiencies may occur; low birth-
     plotted on the day she is certified.                                                           weight baby more likely.
                                                                                                    Offering peanut butter in place of beans may be
                                                                                                    appropriate.
Nutrition Related Risk Conditions – Must           Note medical condition(s) in the Notes tab       Nutritional problems may develop because of
     assign all applicable risk factors.           of the WIC Application. Documentation            disease and/or medications; may have
     Includes, but not limited to:                 from physician or nurse practitioner must        increased need for nutrients or difficulties with
     (341) Nutrient Deficiency Diseases            be in chart within 3 months of certification     digestion or absorption of food.
     (342) Gastro-Intestinal Disorders             date. Make a referral to CMS if necessary.
     (343) Diabetes Mellitus
     (344) Thyroid Disorders                       If there is a medically-related condition
     (345) Hypertension                            which is affecting nutrition status and is not
     (346) Renal Disease                           on this list, contact the Nutrition Education
     (347) Cancer                                  Coordinator or Clinic Operations Manager
     (348) Central Nervous System Disorders        for approval
     (349) Genetic and Congenital Disorders
     (351) Inborn Errors of Metabolism
     (352) Infectious Diseases                     Make a referral if client is not being seen
     (353) Food Allergy                            by medical staff.
     (354) Celiac Disease
     (356) Hypoglycemia
     (358) Eating Disorders
     (359) Recent Major Surgery, Trauma,
           Burns
     (360) Other Medical Conditions
     (362) Developmental Delays, Sensory or
           Motor Delays Interfering with the
           Ability to Eat




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      RISK FACTORS BY PRIORITY - PREGNANT WOMEN

CODE               DESCRIPTION                                   SPECIAL NOTES                                     EXPLANATION
PRIORITY I (continued)

(331) Pregnancy at a Young Age: 17 or younger at       See Risk Factor Reference Manual           A teenager is still growing so there is an
     time of conception.                                                                          increased need for nutrients.
(355) Lactose Intolerance Symptoms: Diagnosed          Specific symptoms must be documented       See tailoring the food package using extra
       by a physician or has been determined by the    in the Notes tab of the WIC Application.   cheese. If the participant can tolerate
       CPA to have any or all of the following                                                    Acidophilus milk or use a commercial lactose
       symptoms attributable to milk or milk product                                              product like 'Lact-Aid,' then the full milk package
       consumption and which disappear after                                                      can be issued.
       omission of milk:
       A. Bloating and gas
       B. Cramps
       C. Diarrhea
       D. Nausea
(502) Out-Of-State Transfer: Used when an out of       Must keep VOC card in participant’s file
     state participant transfers in and their          or explain in Notes how transfer
     certification period is still valid; their risk   information was obtained. Staff is asked
     factors either cannot be determined from the      to document in Notes the last benefits
     VOC information or are not applicable in this     issued at the previous clinic.
     state.
(372) Alcohol or Illegal Drug Use: Any alcohol or      Must document and make appropriate         May lead to a decrease or absorption of nutrients,
     illegal drug use including: opiates, cocaine,     referral to local substance abuse          which can cause malnutrition, babies with birth
     heroine, amphetamines, barbiturates or            program.                                   defects and/or low birth weight.
     marijuana. Ask the alcohol and drug
     questions separately. Start with the alcohol
     questions first.
Alcohol: Ask the following questions:
     Before you knew you were pregnant:
     1. How much beer, wine or hard liquor did
          you drink each day?
     2. Since you found out you were pregnant:
          How much beer, wine or hard liquor do you
          drink each day?




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CODE                  DESCRIPTION                                   SPECIAL NOTES                                       EXPLANATION
       PRIORITY I (continued)

        (372) Alcohol or Illegal Drug Use, continued
If the answers to the questions above are “none” or
“never,” there is no need to ask further questions
concerning alcohol. Go on to the next risk factor. If
she was/is using any beer, wine or hard liquor, ask
3.      Have you ever felt you should cut down on        If the response is “yes” to one or more of these questions, ask if she would like to talk to
        your alcohol use?                                someone about her substance use and make a referral.
4.      Have people annoyed you by criticizing your
        alcohol use?                                     If all the answers to these questions are “no,” but she is still using any alcohol, ask her if she
5.      Have you ever felt bad or guilty about your      would like to talk to someone about her use. Make a referral.
        alcohol use?
6.      Have you ever had alcohol first thing in the
        morning to steady your nerves or to get rid of
        a hangover or as an eye opener?

Note: One “yes” raises suspicion of problem
     substance use. More than one “yes” is a
     strong indication that a problem exists
Drug Questions
Before you knew you were pregnant:
   1. What prescriptions or over-the-counter drugs
       did you take?
   2. How often did you use drugs such as
       cocaine, heroin, methadone, uppers,
       downers, or other drugs?
Since you found out you were pregnant:
   3. What prescriptions or over-the-counter drugs
       do you take?
   4. How often do you use drugs such as
       cocaine, heroin, methadone, uppers,
       downers, or other drugs?




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      RISK FACTORS BY PRIORITY - PREGNANT WOMEN

CODE                  DESCRIPTION                                  SPECIAL NOTES                                       EXPLANATION
PRIORITY I (continued)

(372) Alcohol or Illegal Drug Use, continued
If the answers to the questions above are “none” or

concerning drugs.
“never,” there is no need to ask further questions

If her doctor is not aware of the medications she is
taking while pregnant and/or she is not following all
the directions and precautions: Continue with the
following questions.
1. Have you ever felt you should cut down on your       If the response is “yes” to one or more of these questions, ask if she would like to talk to
     drug use?                                          someone about her substance use and make a referral.
2. Have people annoyed you by criticizing your          If all the answers to these questions are “no,” but she is still using any drugs, ask her if she
     drug use?                                          would like to talk to someone about her use. Make a referral.
3. Have you ever felt bad or guilty about your drug
     use?                                               Let her know that part of your job is to help her stay healthy, and one of the most important
4. Have you ever had drugs first thing in the           things that she can do for herself and her baby is to deal with the drug use.
     morning to steady your nerves or to get rid of a
     hangover or as an eye opener?                      Documentation Required in Notes tab:
Note: One “yes” raises suspicion of a substance use     If the woman was/is using any of these substances during this pregnancy, record the
problem. More than one “yes” is a strong indication     appropriate risk factor and go on to the next risk factor.
that a problem exists.
If the woman has stopped using all substances,
congratulate her for being concerned about her
health and the health of her baby. Ask if she wants
or needs support to help her “stay quit” while
pregnant.




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CODE                  DESCRIPTION                                 SPECIAL NOTES                                      EXPLANATION
(371) Smoking: Any daily smoking or chewing of         Document amount and how often                 Increases the need for certain nutrients, which
      tobacco products i.e. cigarettes, pipes, or      cigarettes and/or marijuana is smoked in      may result in nutritional deficiencies; smaller
      cigars during this pregnancy.                    the Notes tab of the WIC Application or       babies more likely.
1.    Before you knew you were pregnant:               Narrative Notes.
      a. How many times did you smoke each
           day?(quantity)
      b. How much marijuana did you smoke each
           day?
      (If client reports smoking marijuana refer to
      risk factor (372) and document appropriately.)
2. Since you found out you were pregnant:
   a. How many cigarettes do you smoke each
         day?
   b. How much marijuana do you smoke each
         day? (refers to R.F. (372)
   If the answers to the questions above are “none”
   or “never,” there is no need to ask further
   questions concerning smoking.
   If she was/is smoking, ask:
3. Have you ever felt you should cut down on your      If the response is “yes” to one or more of
   smoking?                                            these questions, ask if she would like to
4. Have people annoyed you by criticizing your         talk to someone about her substance
   smoking?                                            use and make a referral.
5. Have you ever felt bad or guilty about your         If all the answers to these questions are
   smoking?                                            “no,” but she is still using any tobacco
                                                       products, ask her if she would like to talk
                                                       to someone about her use. Make a
                                                       referral.




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      RISK FACTORS BY PRIORITY - PREGNANT WOMEN

CODE               DESCRIPTION                                      SPECIAL NOTES                                       EXPLANATION
PRIORITY I (continued)

(371) Smoking: (Continued)                               See Risk Factor Reference Manual
6. Have you ever had to smoke first thing in the
      morning to steady your nerves or to get rid of a   If the response is “yes” to one or more of these questions, ask if she would like to talk to
      hangover or as an eye opener?                      someone about her substance use and make a referral.
     Note: One “yes” raises suspicion of problem         If all the answers to these questions are “no,” but she is still using any tobacco products, ask
     substance use. More than one “yes” is a strong      her if she would like to talk to someone about her use. Make a referral.
     indication that a problem exists.
If the woman has stopped using all substances,           Let her know that part of your job is to help her stay healthy, and one of the most important
congratulate her for being concerned about her           things that she can do for herself and her baby is to deal with the drug use.
health and the health of her baby. Ask if she wants
or needs support to help her “stay quit” while           Documentation Required in Notes tab:
pregnant                                                 If the woman was/is using any of these substances during this pregnancy, record the
                                                         appropriate risk factor and go on to the next risk factor.
PRIORITY I (continued)

(381) Dental Problems: Diagnosis of dental               Document the specific dental condition, as       Nutritional deficiencies may occur due to
     problems by a health care provider or               well as how it is affecting nutrient intake in   decreasing the food intake or limiting certain
     adequate documentation by the CPA, include,         the Notes tab of the WIC Application or          types of food.
     but not limited to: Tooth decay, periodontal        Narrative Notes. Also note dentist’s name,
     disease, tooth loss and or ineffectively            or make a referral to dental services.
     replaced teeth which impair the ability to ingest
     food in adequate quantity or quality; and
     Gingivitis of pregnancy.
PRIORITY IV

(422) Inadequate Diet: Dietary analysis indicates        Documented with food frequency diet              Nutritional deficiencies may develop which may
     an inadequate diet meeting < 80% of the RDA         analysis.                                        lead to complications such as increased
     for 5 leader nutrients (calcium, magnesium,         Previously Risk Factor 49                        infection: impaired growth and development
     iron, Vitamin-A and Vitamin-C).                                                                      and disease.




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CODE                  DESCRIPTION                                 SPECIAL NOTES                                    EXPLANATION
(401) Failure to Meet Dietary Guidelines: Dietary      Document the client’s dietary deficiency    Nutritional deficiencies may develop which may
     analysis indicates at least one serving below     in the Notes section of the WIC             lead to complications such as increased infection:
     the recommended number of servings for any        Application.                                impaired growth and development and disease.
     food group, or at least one serving which does    Previously Risk Factor 57
     not meet the recommended serving size.
(801) Homeless: Applicant or guardian states they      Indicate applicant’s status as homeless     Homeless conditions may predispose the
     are currently homeless.                           in the WIC Application. Issue a VOC         applicant to nutritional risk.
                                                       card
(802) Migrant: Participant or a member of the family   Indicate applicant’s status as migrant in   Migrant conditions may predispose the applicant
     who has left home within the past 24 mos. to      the WIC Application. Issue a VOC card.      to nutritional risk.
     follow the crops or to work with lumber or
     timber.




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       RISK FACTORS BY PRIORITY - BREASTFEEDING WOMEN

CODE                   DESCRIPTION                                        SPECIAL NOTES                                    EXPLANATION
PRIORITY I                                                                                                 Red blood cells cannot carry enough oxygen
                                                                                                           caused by inadequate iron intake and/or an
(201) Anemia: Hemoglobin and hematocrit levels adjusted for altitude based on the                          increased need; more likely to be irritable, tired,
                1989 CDC criteria.                                                                         have a poor appetite and get sick.
     < 4999 Ft.       5000-6999 Ft.       7000-7999 Ft.        8000-8999 Ft.         >9000 Ft.
     Hct.   Hgb.      Hct.       Hgb.     Hct.    Hgb.         Hct.    Hgb.          Hct. Hgb.             During counseling, remember that smoking
     <37 <12.3         <38      12.7      <39    <13.0         <40    <13.3          <41 <13.7             increases the Hct./Hgb. level because of
                                                                                                           increased carboxyhemoglobin from inhaling
                           Refer to 1-81 – 1-82 for the altitude of your clinic.                           carbon monoxide during smoking. This raises
                                                                                                           the Hct. level by 1.0% (any cigarettes at all) to
                                                                                                           2.0% (>2 packs/day).
(335) Multifetal Gestation: More than one fetus             Explain in Notes                               Increased nutritional demands of breastfeeding
     with the most recent pregnancy                                                                        more than one baby may lead to nutrient
                                                                                                           inadequacies.
(332) Closely Spaced Pregnancy: Conception of               Note date of termination of last pregnancy     May result in depletion of body’s nutrient
     most recent pregnancy occurring within 16              in the Notes tab of the WIC Application.       reserves; nutrition related problems may
     months from date of termination of previous                                                           develop.
     pregnancy (Before 16 mos. Postpartum).
(333) High Parity And Young age: Women under                Note number of pregnancies and dates           May result in depletion of body’s nutrient
     age 20 at date of conception who have had 3            (MM, YY) of termination of pregnancies in      reserves; nutrition related problems may
     or more previous pregnancies of a least 20             the Notes tab of the WIC Application.          develop.
     weeks duration regardless of birth outcome.            See Risk Factor Reference Manual
Most Recent Pregnancy Was High Risk –                       Note the condition(s) and date(s) (MM, YY)     High-risk pregnancies may be nutrition related.
    Must assign all applicable risk factors.                of occurrence(s) in the Notes tab of the
     (312) Low birth weight infant (<5 lb. 8 oz.)           WIC Application.
     (311) Premature infant (born < 37 weeks
           gestation);                                      WIC application will show the following risk
     (339) Infant with congenital anomaly                   factors as “History Of.”
     (303) Gestational Diabetes (History of)
     (321) Spontaneous abortion, Fetal or                   See Risk Factor Reference Manual
           Neonatal Loss - A multifetal gestation
           with one or more fetal or neonatal
           deaths but with one or more infants still
           living.



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      RISK FACTORS BY PRIORITY - BREASTFEEDING WOMEN

CODE              DESCRIPTION                                        SPECIAL NOTES                                  EXPLANATION
PRIORITY I, Continued

(601) Breastfeeding Mom with Infant at Priority I  Enter Infant’s Priority II risk factor in Notes.   There was a nutritional risk during pregnancy
     Risk: (a breastfeeding woman whose
     breastfed infant has been determined to be at
     nutritional risk.)
(111) Over weight:                                                                                    Caused by eating more food than the body is
     Breastfeeding woman who are < 6 mos. Postpartum – Prepregnancy BMI greater than or               using; may lead to an inadequate balance of
     equal to 25.                                                                                     nutrients needed for good health. May be
     Breastfeeding women who are > 6 mos. Postpartum – Current BMI greater than or equal              appropriate to tailor the milk package.
     to 25.
(101) Underweight:                                                                                    Caused by not getting the required amounts of
     Breastfeeding woman who is < 6 mos. Postpartum – Prepregnancy or current BMI <                   nutrients from food needed for good health;
     18.5.                                                                                            nutritional deficiencies may occur; low birth-
     Breastfeeding woman who is >6 mos. Postpartum – Current BMI <18.5                                weight baby more likely.

                     Weight for Height Table for Women Based on Body Mass Index                       Offering peanut butter in place of beans may be
Find the height without shoes in the left column; then find the weight in a column to the right of    appropriate.
that height to determine weight to height status.
BMI Table for Determining Weight Classification for Non-Pregnant Women
                Height        Underweight       Normal Weight     Overweight                            Obese
               (Inches)        BMI <18.5         BMI 18.5-24.9   BMI 25.0-29.9                         BMI > 30.0
                  58”             <89                89-118        119-142                               >142
                  59”             <92                92-123        124-147                               >147
                  60”             <95                95-127        128-152                               >152
                  61”             <98                98-131        132-157                               >157
                  62”             <101              101-135        136-163                               >163
                  63”             <105              105-140        141-168                               >168
Continued on next page




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          RISK FACTORS BY PRIORITY - BREASTFEEDING WOMEN
                BMI Table for Determining Weight Classification for Non-Pregnant Women, Continued
                            64”                       <108                    108-144                    145-173                      >173
                            65”                       <111                    111-149                    150-179                      >179
                            66”                       <115                    115-154                    155-185                      >185
                            67”                       <118                    118-158                    159-190                      >190
                            68”                       <122                    122-163                    164-196                      >196
                            69”                       <125                    125-168                    169-202                      >202
                            70”                       <129                    129-173                    174-208                      >208
                            71”                       <133                    133-178                    179-214                      >214
                            72”                       <137                    137-183                    184-220                      >220
(1)   Adapted from the Clinical Guidelines on the Identification, Evaluation and Treatment of Overweight and Obesity in Adults. National Heart, Lung and Blood Institute (NHLBI), National
      Institutes of Health (NIH). NIH Publication No. 98-4083


CODE              DESCRIPTION                                                        SPECIAL NOTES                                                 EXPLANATION
PRIORITY I, Continued

Nutrition Related Risk Condition – Must                               Nutrition related medical condition(s),                   Nutritional problems may develop because of
     assign all applicable risk factors.                              which predispose participant to inadequate                disease and/or medications; may have
        (341)   Nutrient Deficiency Diseases                          nutritional status.                                       increased need for nutrients or difficulties with
        (342)   Gastro-Intestinal Disorders                           Note medical condition(s) in the Notes tab                digestion or absorption of food.
        (343)   Diabetes Mellitus                                     of the WIC Application. Documentation
        (344)   Thyroid Disorders                                     from physician or nurse practitioner must
        (345)   Hypertension                                          be in chart within 3 months of certification
        (346)   Renal Disease                                         date. Make a referral to CMS if necessary.
        (347)   Cancer
        (348)   Central Nervous System Disorders                      If there is a medically related condition,
        (349)   Genetic and Congenital Disorders                      which is affecting nutrition status and is not
                                                                      on this list, contact the Nutrition Education
                                                                      Coordinator or Clinic Operations Manager
                                                                      for approval.

                                                                      See Risk Factor Reference Manual




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      RISK FACTORS BY PRIORITY - BREASTFEEDING WOMEN

CODE              DESCRIPTION                                      SPECIAL NOTES                                        EXPLANATION
PRIORITY I, Continued

Nutrition Related Risk Conditions – Must               Nutrition related medical condition(s),          Nutritional problems may develop because of
     assign all applicable risk factors.               which predispose participant to inadequate       disease and/or medications; may have
     (351) Inborn Errors of Metabolism                 nutritional status.                              increased need for nutrients or difficulties with
     (352) Infectious Diseases                         Note medical condition(s) in the Notes tab       digestion or absorption of food.
     (353) Food Allergies                              of the WIC Application. Documentation
     (354) Celiac Disease                              from physician or nurse practitioner must
     (356) Hypoglycemia                                be in chart within 3 months of certification
     (358) Eating Disorders                            date. Make a referral to CMS if necessary.
     (359) Recent Major Surgery, Trauma,
           Burns                                       If there is a medically related condition,
     (360) Other Medical Conditions                    which is affecting nutrition status and is not
     (362) Developmental Delays, Sensory or            on this list, contact the Nutrition Education
           Motor Delays Interfering with the           Coordinator or Clinic Operations Manager
           Ability To Eat                              for approval.
                                                       See Risk Factor Reference Manual
(331) Pregnancy at a Young Age: Age 17 Or                                                               A teenager is still growing so there is an
     younger at the time of conception.                                                                 increased need for nutrients.
(381) Dental Problems: Diagnosis of dental             Document the specific dental condition, as       Nutritional deficiencies may occur due to
     problems by a health care provider or             well as how it is affecting nutrient intake in   decreasing the food intake or limiting certain
     adequate documentation by the CPA, include,       the Notes tab of the WIC Application or          types of food.
     but not limited to:                               Narrative Notes. Also note dentist’s name,
     Tooth decay, periodontal disease, tooth loss      or make a referral to dental services.
     and or ineffectively replaced teeth, which
     impair the ability to ingest food in adequate
     quantity or quality.
(502) Out of State Transfer: Used when an out-of-      Must keep VOC card in participant’s file or
     state participant transfers in and their          explain in Notes how transfer information
     certification period is still valid; their risk   was obtained. Staff is asked to document
     factors either cannot be determined from the      in Notes the last benefits issued at the
     VOC information or are not applicable in this     previous clinic.
     state.




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CODE              DESCRIPTION                                          SPECIAL NOTES                                   EXPLANATION
PRIORITY I, Continued

(372) Alcohol or Illegal Drug Use:
Alcohol: -
Routine current use of greater than or equal to 2          Must document and make appropriate              May lead to a decrease or absorption of
        drinks per day. A serving or standard sized        referral to local substance abuse program.      nutrients, which can cause malnutrition.
        drink is: 1 can of beer (12 fl oz.); 5 oz. Wine;
        and 1 1/2fluid oz. Liquor (1 jigger gin, rum,      See Risk Factor Reference Manual
        vodka, whiskey (86-proof), vermouth, cordials
        or liqueurs), or
Binge Drinking, i.e., drinks 5 or more on the same
        occasion on at least one day in the past 30
        days; or
Heavy Drinking, i.e., drinks 5 or more drinks on the
        same occasion on five or more days in the
        previous 30 days; or
Any illegal drug use including: opiates, cocaine,
        heroine, amphetamines, barbiturates or
        marijuana.
Ask the alcohol and drug questions separately.
        Start with the alcohol questions first
Alcohol: Ask the following questions:
1. How much beer, wine or hard liquor do you drink
     each day?
     If the answer to the question above is “none,”
     there is no need to ask further questions             If the response is “yes” to one or more of
     concerning alcohol. Go on to the next risk factor.    these questions, ask if she would like to
If she is using any beer, wine or hard liquor, ask:        talk to someone about her substance use
2. Have you ever felt you should cut down on               and make a referral.
     your alcohol use?                                     If all the answers to these questions are
3. Have people annoyed you by criticizing your
                                                           her if she would like to talk to someone
                                                           “no,” but she is still using any alcohol, ask
     alcohol use?
4. Have you ever felt bad or guilty about your             about her use. Make a referral.
     alcohol use? Continued on next page.



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CODE              DESCRIPTION                                        SPECIAL NOTES                                      EXPLANATION
PRIORITY I, Continued

(372) Alcohol or Illegal Drug Use: (Continued)
Alcohol Use
5. Have you ever had alcohol first thing in the         If the response is “yes” to one or more of these questions, ask if she would like to talk to
   morning to steady your nerves or to get rid          someone about her substance use and make a referral.
   of a hangover or as an eye opener?                   If all the answers to these questions are “no,” but she is still using any alcohol, ask her if she
Note: One “yes” raises suspicion of problem             would like to talk to someone about her use. Make a referral.
     substance use. More than one “yes” is a
     strong indication that a problem exists.

Drug Use Ask the following questions.
     1. What prescriptions or over-the-counter drugs
        do you take?
     2. How often do you use drugs such as
        cocaine, heroin, methadone, uppers,
        downers, or other drugs?
If the answers to the questions above are “none” or

concerning drugs.
“never,” there is no need to ask further questions

If her doctor is not aware of the medications she is
taking and/or she is not following all the directions
and precautions: Continue with the following
questions.




ELIGIBILITY SCREENING                                                1-98                                                            Revised 9/2002 dt
       WIC POLICY MANUAL                                                                                                                   FFY-2004

       RISK FACTORS BY PRIORITY - BREASTFEEDING WOMEN

CODE               DESCRIPTION                                       SPECIAL NOTES                                       EXPLANATION
PRIORITY I (continued)

(372) Alcohol or Illegal Drug Use: (Continued)          If the response is “yes” to one or more of these questions, ask if she would like to talk to
    3. Have you ever felt you should cut down on        someone about her substance use and make a referral.
       your drug use?                                   If all the answers to these questions are “no,” but she is still using any drugs, ask her if she
    4. Have people annoyed you by criticizing your      would like to talk to someone about her use. Make a referral.
       drug use?
    5. Have you ever felt bad or guilty about your      Let her know that part of your job is to help her stay healthy, and one of the most important
       drug use?                                        things that she can do for herself and her baby is to deal with the drug use.
Have you ever had drugs first thing in the morning to
steady your nerves or to get rid of a hangover or as    Go on to the next risk factor.
an eye opener?

Note: One “yes” raises suspicion of a substance use
problem. More than one “yes” is a strong indication
that a problem exists.                                  Documentation Required in Notes:
If the woman has stopped using all substances,          If the woman was/is using any of these substances during this pregnancy, record the
congratulate her for being concerned about her          appropriate risk factor and go on to the next risk factor.
health and the health of her baby. Ask if she wants
or needs support to help her “stay quit” while
pregnant




ELIGIBILITY SCREENING                                                    1-99                                                      Revised 9/2002 dt
       WIC POLICY MANUAL                                                                                                               FFY-2004

      RISK FACTORS BY PRIORITY - BREASTFEEDING WOMEN


CODE                  DESCRIPTION                                    SPECIAL NOTES                                       EXPLANATION
(371) Smoking: Any daily smoking or chewing of           Document amount and how often                    Increases the need for certain nutrients, which
       tobacco products i.e. cigarettes, pipes, or       cigarettes and are smoked in the Notes tab       may result in nutritional deficiencies; smaller
       cigars                                            of the WIC Application.                          babies more likely.
       1. While you were pregnant:
           a. How many cigarettes did you smoke          See Risk Factor Reference Manual
               each day?
           b. How much marijuana did you smoke
               each day? (risk factor 372)
       2. Since you’ve had the baby:
           a. How many cigarettes do you smoke
               each day?                                 Go on to the next risk factor.
           b. How much marijuana do you smoke
               each day?                                 If the response is “yes” to one or more of
If the answers to the questions above are “none,”        these questions, ask if she would like to
there is no need to ask further questions concerning     talk to someone about her substance use
smoking.                                                 and make a referral.
If she was/is smoking, ask:                              If all the answers to these questions are
       1. Have you ever felt you should cut down on      “no,” but she is still smoking, ask her if she
           your smoking?                                 would like to talk to someone about her
       2. Have people annoyed you by criticizing         use. Make a referral. Let her know that
           your smoking?                                 part of your job is to help her stay healthy
       3. Have you ever felt bad or guilty about your    and one of the most important things that
           smoking?                                      she can do for herself and her baby is to
       4. Have you ever had to smoke first thing in      deal with the smoking situation.
           the morning to steady your nerves or to get
           rid of a hangover or as an eye opener?




ELIGIBILITY SCREENING                                                 1-100                                                           Revised 9/2002 dt
       WIC POLICY MANUAL                                                                                                                      FFY-2004

       RISK FACTORS BY PRIORITY - BREASTFEEDING WOMEN

CODE               DESCRIPTION                                       SPECIAL NOTES                                         EXPLANATION
PRIORITY I (continued)

(355) Lactose Intolerance Symptoms                     Specific symptoms must be documented in            See tailoring the food package using extra
     Diagnosed by a physician or has been              the Notes tab of the WIC Application.              cheese. If the participant can tolerate
     determined to have any or all of the following                                                       Acidophilus milk or use a commercial lactose
     symptoms attributable to milk or milk product                                                        product like Lact-Aid, then the full milk package
     consumption and which disappear after                                                                can be issued.
     omission of milk:
     A. Bloating and gas     C. Diarrhea
     B. Cramps               D. Nausea
Priority II

(601) Breastfeeding Mom with Infant at Priority II     Enter Infant’s Priority II risk factor in Notes.   There was a nutritional risk during pregnancy
      Risk: (a breastfeeding woman whose
      breastfed infant has been determined to be at
      nutritional risk).
PRIORITY IV

(601) Breastfeeding Mom with Infant at Priority        Enter Infant’s Priority II risk factor in Notes    The breastfed infant is at nutritional risk.
     IV Risk
(422) Inadequate Diet: Dietary analysis indicates      Documented with food frequency diet                Nutritional deficiencies may develop which may
     an inadequate diet meeting < 80% of the RDA       analysis.                                          lead to complications such as increased
     for 5 leader nutrients (calcium, magnesium,                                                          infection, impaired growth and development
     iron, Vitamin-A and Vitamin-C).                   Previously Risk Factor 49                          and disease.
(401) Failure to Meet Dietary Guidelines: Dietary      Document the client’s dietary deficiency in        Nutritional deficiencies may develop which may
       analysis indicates at least one serving below   the Notes section of the WIC Application.          lead to complications such as increased
       the recommended number of servings for any                                                         infection, impaired growth and development
       food group, or at least one serving which       Previously Risk Factor 57                          and disease
       does not meet the recommended serving
       size.




ELIGIBILITY SCREENING                                                    1-101                                                        Revised 9/2002 dt
       WIC POLICY MANUAL                                                                                                            FFY-2004

      RISK FACTORS BY PRIORITY - BREASTFEEDING WOMEN

CODE               DESCRIPTION                                     SPECIAL NOTES                                      EXPLANATION
PRIORITY IV, (continued)

(420) Caffeine: Routine intake of >3 cups of coffee,   Document the quantity of caffeinated            May lead to a decreased intake of nutrients.
     or the caffeine equivalent including:             beverages consumed daily. May be
         3 cups coffee                                 documented on the food frequency diet
         9 cups tea                                    analysis or Notes section of the WIC
         10 cans soda                                  Application..

         Milligrams of caffeine per 12 ounces
Coca-Cola               36 Pepsi Cola         43
Diet-Coke               36 Diet Pepsi         36
Diet Rite Cola          36 Pepsi Light
        36
Dr. Pepper              54 RC Cola            36
Mountain Dew            55 Shasta Colas       44
Mr. Pibb                57 Tab                36
Diet Mr. Pibb           60
(801) Homeless Applicant or guardian states they       Indicate applicant’s status as homeless in      Homelessness condition may predispose the
      are currently homeless                           the WIC Application. Issue a VOC card           applicant to nutritional risk
(802) Migrant: Participant or a member of the family   Indicate applicant’s status as migrant in       Migrant conditions may predispose the
      who has left home within the past 24 mos. to     the WIC Application. Issue a VOC card           applicant to nutritional risk
      follow the crops or to work with lumber or
      timber.
PRIORITY VII

(501) Regression: Possibility of regression in         Must be approved by the Nutrition               Nutrition related problems might reoccur.
     nutrition status without WIC foods.               Education Coordinator or Clinic Operations
                                                       Manager. May not be used for initial or
                                                       consecutive certifications. Document
                                                       previous risk factors in the Notes tab of the
                                                       WIC Application or Narrative Notes.




ELIGIBILITY SCREENING                                              1-102                                                           Revised 9/2002 dt
       WIC POLICY MANUAL                                                                                                                 FFY-2004

      RISK FACTORS BY PRIORITY - POSTPARTUM WOMEN

CODE                   DESCRIPTION                                         SPECIAL NOTES                                  EXPLANATION
PRIORITY III

(331) Pregnancy at a Young Age: Age 17 or                                                                 A teenager is still growing so there is an
     younger at time of conception.                                                                       increased need for nutrients.
(502) Out of State Transfer: Used when an out-of-state participant transfers in and their                 Must keep VOC card in participant’s file or
     certification period is still valid; their risk factors either cannot be determined from the VOC     explain in Notes how transfer information was
     information or are not applicable in this state.                                                     obtained. Staff is asked to document in Notes
                                                                                                          the last benefits issued at the previous clinic.
PRIORITY VI

(201) Anemia: Hemoglobin and hematocrit levels adjusted for altitude based on the 1989 CDC                Red blood cells cannot carry enough oxygen
     criteria.                                                                                            caused by inadequate iron intake and/or an
                                                                                                          increased need; more likely to be irritable, tired,
     < 4999 Ft.        5000-6999 Ft.             7000-7999 Ft.             8000-8999 Ft.   >9000 Ft.      have a poor appetite and get sick.
     Hct.   Hgb.       Hct. Hgb.                 Hct. Hgb.                 Hct. Hgb.       Hct. Hgb.
     <37 <12.3         <38 <12.7                 <39 <13.0                 <40 <13.3       <41   <13.7    During counseling, remember that smoking
                                                                                                          increases the Hct./Hgb. level because of
                            Refer to 1-81 – 1-82 for the altitude of your clinic.                         increased carboxyhemoglobin from inhaling
                                                                                                          carbon monoxide during smoking. This raises
                                                                                                          the Hct. level by 1.0% (any cigarettes at all) to
                                                                                                          2.0% (>2 packs/day).
(332) Closely spaced Pregnancies: Conception of              Note date of termination of last pregnancy   May result in depletion of body’s nutrient
     most recent pregnancy occurring within 16               in the Notes tab of the WIC Application.     reserves; nutrition related problems may
     months from date of termination of previous                                                          develop.
     pregnancy.(Before 16 mos. postpartum)
(333) High Parity and Young Age: Woman under                 Note number of date(s) of termination of     May result in depletion of body’s nutrient
     age 20 at date of conception who have had 3             pregnancies in the Notes tab of the WIC      reserves; nutrition related problems may
     or more previous pregnancies of at least 20             Application.                                 develop.
     weeks duration, regardless of birth outcome             See Risk Factor Reference Manual
(335) Multifetal Gestation: More than one fetus              See Risk Factor Reference Manual
     with the most recent pregnancy




ELIGIBILITY SCREENING                                                           1-103                                                Revised 9/2002 dt
       WIC POLICY MANUAL                                                                                                                FFY-2004

       RISK FACTORS BY PRIORITY - POSTPARTUM WOMEN

CODE              DESCRIPTION                                        SPECIAL NOTES                                       EXPLANATION
PRIORITY VI, Continued

Most Recent Pregnancy Was High Risk –                    WIC application will show the following risk     High-risk pregnancies may be nutrition related.
    Must assign all applicable risk factors.             factors as History Of.

     (312) Low birth weight infant (<5 lb. 8 oz.)
                                                         Note the condition(s) and date(s) of
     (311) Premature infant (born < 37 weeks
                                                         occurrence(s) in the Notes tab of the WIC
           gestation);
                                                         Application.
     (339) Infant with congenital
           anomaly(nutritional)
     (321) Spontaneous Abortion, Fetal or                See Risk Factor Reference Manual
           Neonatal Loss -Spontaneous abortion is
           the spontaneous termination of a
           gestation at <20 weeks gestation. Fetal
           death is a spontaneous termination of a
           gestation >20 weeks. Neonatal death is
           the death of an infant within 0 – 28 days
           of life
     (303) Gestational Diabetes
(381) Dental Problems: Diagnosis of dental               Document the specific dental condition, as       Nutritional deficiencies may occur due to
     problems by a health care provider or               well as how it is affecting nutrient intake in   decreasing the food intake or limiting certain
     adequate documentation by the CPA, include,         the Notes tab of the WIC Application or          types of food.
     but not limited to: Tooth decay, periodontal        Narrative Notes. Also note dentist’s name,
     disease, tooth loss and or ineffectively            or make a referral to dental services.
     replaced teeth which impair the ability to ingest
     food in adequate quantity or quality.
(111) Overweight: Prepregnancy BMI of greater                                                             Caused by eating more food than the body is
     than or equal to 25 (see chart under risk factor                                                     using; may lead to an inadequate balance of
     101).                                                                                                nutrients needed for good health. May be
                                                                                                          appropriate to tailor the milk package.




ELIGIBILITY SCREENING                                                 1-104                                                            Revised 9/2002 dt
         WIC POLICY MANUAL                                                                                                                                                              FFY-2004

         RISK FACTORS BY PRIORITY - POSTPARTUM WOMEN

CODE              DESCRIPTION                                                                SPECIAL NOTES                                                          EXPLANATION
PRIORITY VI, Continued

(101) Underweight: Prepregnancy or current BMI < 18.5 (See chart below)
                  Weight for Height Table for Women Based on Body Mass Index
Find the height without shoes in the left column; then find the weight in a column to the
right of that height to determine weight to height status.
BMI Table for Determining Weight Classification for Non-Pregnant Women
                   Height          Underweight        Normal Weight        Overweight                                                           Obese
                  (Inches)          BMI <18.5          BMI 18.5-24.9      BMI 25.0-29.9                                                        BMI > 30.0
                      58”              <89                  89-118           119-142                                                             >142
                      59”              <92                  92-123           124-147                                                             >147
                      60”              <95                  95-127           128-152                                                             >152
                      61”              <98                  98-131           132-157                                                             >157
                      62”              <101                101-135           136-163                                                             >163
                      63”              <105                105-140           141-168                                                             >168
                      64”              <108                108-144           145-173                                                             >173
                      65”              <111                111-149           150-179                                                             >179
                      66”              <115                115-154           155-185                                                             >185
                      67”              <118                118-158           159-190                                                             >190
                      68”              <122                122-163           164-196                                                             >196
                      69”              <125                125-168           169-202                                                             >202
                      70”              <129                129-173           174-208                                                             >208
                      71”              <133                133-178           179-214                                                             >214
                      72”              <137                137-183           184-220                                                             >220
   (1)   Adapted from the Clinical Guidelines on the Identification, Evaluation and Treatment of Overweight and Obesity in Adults. National Heart, Lung and Blood Institute (NHLBI), National Institutes of Health
         (NIH). NIH Publication No. 98-4083.




ELIGIBILITY SCREENING                                                                               1-105                                                                          Revised 9/2002 dt
       WIC POLICY MANUAL                                                                                                              FFY-2004

       RISK FACTORS BY PRIORITY - POSTPARTUM WOMEN

CODE              DESCRIPTION                                      SPECIAL NOTES                                       EXPLANATION
PRIORITY VI, Continued

Nutrition Related Risk Condition – Must
     assign all applicable risk factors.

     (341)  Nutrient Deficiency Diseases                Note medical condition(s) in the Notes tab     Nutritional problems may develop because of
     (342)  Gastro-Intestinal Disorders                 of the WIC Application. Documentation          disease and/or medications; may have
     (343)  Diabetes Mellitus                           from physician or nurse practitioner must      increased need for nutrients or difficulties with
     (344)  Thyroid Disorders                           be in chart within 3 months of certification   digestion or absorption of food.
     (345)  Hypertension                                date. Make referral to CMS if necessary. If
     (346)  Renal Disease                               there is a medically related condition,
     (347)  Cancer                                      which is affecting nutritional status and is
     (348)  Central Nervous System Disorders            not on this list, contact the Nutrition
     (349)  Genetic and Congenital Disorders            Education Coordinator or Clinic Operations
     (351)  Inborn Errors of Metabolism                 Manager for approval.
     (352)  Infectious Diseases
     (353)  Food Allergy                                See Risk Factor Reference Manual
     (354)  Celiac Disease
     (351)  Hypoglycemia
     (351)  Eating Disorders
     (352)  Recent Major Surgery, Trauma,
            Burns
     (351) Other Medical Conditions
     (351) Developmental Delays, Sensory or
            Motor Delays Interfering with the
            Ability To Eat
(372) Alcohol or Illegal Drug Use:
     Routine current use of greater than or equal to
     2 drinks per day. A serving or standard sized      See Risk Factor Reference Manual               May lead to a decrease or absorption of
     drink is: 1 can of beer (12 fl oz.); 5 oz. Wine;                                                  nutrients, which can cause malnutrition
     and 1 1/2fluid oz. Liquor (1 jigger gin, rum,
     vodka, whiskey (86-proof), vermouth, cordials
     or liqueurs), or Continued on next page




ELIGIBILITY SCREENING                                               1-106                                                           Revised 9/2002 dt
       WIC POLICY MANUAL                                                                                                                 FFY-2004

      RISK FACTORS BY PRIORITY - POSTPARTUM WOMEN

CODE              DESCRIPTION                                        SPECIAL NOTES                                       EXPLANATION
PRIORITY VI, Continued

(372) Alcohol or Illegal Drug Use: (Continued)                                                                  May lead to a decrease or absorption of
       Binge Drinking, i.e., drinks 5 or more on the                                                            nutrients, which can cause malnutrition
       same occasion on at least one day in the past     See Risk Factor Reference Manual
       30 days; or Heavy Drinking, i.e., drinks 5 or
       more drinks on the same occasion on five or
       more days in the previous 30 days; or
Any illegal drug use including opiates, cocaine,
       heroine, amphetamines, barbiturates or
       marijuana.
Ask the alcohol and drug questions separately.
       Start with the alcohol questions first..
Alcohol: Ask the following questions:
1. How much beer, wine or hard liquor do you drink
     each day?
If the answers to the questions above are “none” or
                                                         If the response is “yes” to one or more of these questions, ask if she would like to talk to
concerning alcohol. Go on to the next risk factor.       someone about her substance use and make a referral.
“never,” there is no need to ask further questions

If she was/is using any beer, wine or hard liquor, ask   If all the answers to these questions are “no,” but she is still using alcohol, ask her if she
2. Have you ever felt you should cut down on your        would like to talk to someone about her use. Make a referral.
     alcohol use?                                          Let her know that part of your job is to help her stay healthy, and one of the most
3. Have you ever had alcohol first thing in the          important things that she can do for herself and her baby is to deal with the drug use.
     morning to steady your nerves or to get rid of a
     hangover or as an eye opener?                       Documentation Required in Notes tab:
4. Have people annoyed you by criticizing your           If the woman was/is using alcohol record the appropriate risk factor and go on to the next risk
     alcohol use?                                        factor.
5. Have you ever felt bad or guilty about your
     alcohol use?
Note: One “yes” raises suspicion of problem
substance use. More than one “yes” is a strong
indication that a problem exists.




ELIGIBILITY SCREENING                                                     1-107                                                     Revised 9/2002 dt
       WIC POLICY MANUAL                                                                                                               FFY-2004

       RISK FACTORS BY PRIORITY - POSTPARTUM WOMEN


CODE                  DESCRIPTION                                   SPECIAL NOTES                                       EXPLANATION

PRIORITY VI, Continued

(372) Alcohol or Illegal Drug Use: (Continued)

Drug Questions:
     1. What prescriptions or over-the-counter drugs
        do you take?
     2. How often do you use drugs such as
        cocaine, heroin, methadone, uppers,
        downers, or other drugs?
If the answers to the questions above are “none” or
“never,” there is no need to ask further questions
concerning drugs.
If her doctor is not aware of the medications she is
taking and/or she is not following all the directions
and precautions: Continue with the following
questions.                                              If the response is “yes” to one or more of these questions, ask if she would like to talk to
1. Have you ever felt you should cut down on your       someone about her substance use and make a referral.
     drug use?                                          If all the answers to these questions are “no,” but she is still using any drugs, ask her if she
2. Have people annoyed you by criticizing your          would like to talk to someone about her use. Make a referral.
     drug use?                                          Let her know that part of your job is to help her stay healthy, and one of the most important
3. Have you ever felt bad or guilty about your drug     things that she can do for herself and her baby is to deal with the drug use.
     use?
4. Have you ever had drugs first thing in the           Documentation Required in Notes tab:
     morning to steady your nerves or to get rid of a   If the woman was/is using any of these substances record the appropriate risk factor and go
     hangover or as an eye opener                       on to the next risk factor.
If the woman has stopped using all substances,
congratulate her for being concerned about her
health and the health of her baby. Ask if she wants
or needs support to help her “stay quit.”




ELIGIBILITY SCREENING                                                1-108                                                           Revised 9/2002 dt
       WIC POLICY MANUAL                                                                                                           FFY-2004

      RISK FACTORS BY PRIORITY - POSTPARTUM WOMEN

CODE              DESCRIPTION                                     SPECIAL NOTES                                     EXPLANATION
PRIORITY VI, Continued

(355) Lactose Intolerance: Diagnosed by a              Specific symptoms must be documented in       See tailoring the food package using extra
     physician or has been determined by the CPA       the Notes tab of the WIC Application.         cheese. If the participant can tolerate
     to have any or all the following symptoms                                                       Acidophilus milk or use a commercial lactose
     attributable to milk or milk product                                                            product like Lact-Aid, then the full milk package
     consumption and which disappear after                                                           can be issued.
     omission of milk:
       A.       Bloating and gas
       B.       Cramps
       C.       Diarrhea
(422) Inadequate Diet: Dietary analysis indicates      Documented with food frequency diet           Nutritional deficiencies may develop, which
       an inadequate diet meeting < 80% of the         analysis.                                     may lead to complications such as increased
       RDA for 5 leader nutrients (calcium,                                                          infection, impaired growth and development
       magnesium, iron, Vitamin-A and Vitamin-C)       Previously Risk Factor 49                     and disease.
(401) Failure to Meet Dietary Guidelines: Dietary      Document the client’s dietary deficiency in   Nutritional deficiencies may develop which may
     analysis indicates at least one serving below     the Notes section of the WIC Application.     lead to complications such as increased
     the recommended number of servings for any                                                      infection, impaired growth and development
     food group, or at least one serving which does    Previously Risk Factor 57                     and disease.
     not meet the recommended serving size.
(801) Homeless: Applicant or guardian states they      Indicate applicant’s status as homeless in    Homeless conditions may predispose the
     are currently homeless                            the WIC Application. Issue a VOC card.        applicant to nutritional risk.
(802) Migrant: Participant or a member of the family   Indicate applicant’s status as migrant in     Migrant conditions may predispose the
     who has left home within the past years to        the WIC Application. Issue a VOC card.        applicant to nutritional risk.
     follow the crops or to work with lumber or
     timber.
Priority VII                                           Must be approved by Nutrition Education       Nutrition related problems might recur.
(501) Regression: Possibility of regression in         Coordinator or Clinic Operations Manager.
     nutrition status without WIC foods.               May not be used for initial or consecutive
                                                       certifications. Document previous risk
                                                       factors in the Notes tab of the WIC
                                                       Application




ELIGIBILITY SCREENING                                                  1-109                                                   Revised 9/2002 dt
       WIC POLICY MANUAL                                                                                                                 FFY-2004

       RISK FACTORS BY PRIORITY - INFANTS

CODE                  DESCRIPTION                                        SPECIAL NOTES                                    EXPLANATION
PRIORITY I

(201) Anemia: Hemoglobin and hematocrit levels for 6-11 month olds adjusted for altitude based            Red blood cells cannot carry enough oxygen
     on 1989 CDC criteria.                                                                                caused by inadequate iron intake and/or an
                                                                                                          increased need; more likely to be irritable, tired,
     < 4999 Ft.       5000-6999 Ft.            7000-7999 Ft.             8000-8999 Ft.   >9000 Ft.        have a poor appetite and get sick.
     Hct.   Hgb.      Hct. Hgb.                Hct. Hgb.                 Hct. Hgb.       Hct. Hgb.
     <34 <11.3        <35 <11.7                <36 <12.0                 <37 <12.3       <38   <12.7

                          Refer to 1-81 – 1-82 for the altitude of your clinic.
(103) Underweight (Wt/Ht): Weight for height <10th                                                        Caused by not getting the required amounts of
     percentile on PHD approved growth chart.                                                             nutrients from food needed for good health;
                                                                                                          nutritional deficiencies may occur.
(141) Low Birth Weight: Birth weight less than or                                                         Small babies frequently have more health
     equal to 5 lb. 8 oz.                                                                                 problems.
(121) Stunting: Length for age <10th percentile on                                                        May not have achieved growth potential due to
     PHD approved growth chart.                                                                           poor nutrition.
(134) Failure to Thrive: A physician’s diagnosis or        Documentation by a physician or nurse          May result in depletion of body’s nutrient
     documented by someone working under                   practitioner must be in chart within 3         reserves; nutrition related problems may
     physician’s orders                                    months of certification date. A referral       develop.
                                                           must be made to the health care provider if
                                                           not currently being followed by a physician.
(142) Premature: Born less than or equal to 37                                                            Premature babies frequently have more health
     weeks gestation.                                                                                     problems.




ELIGIBILITY SCREENING                                                     1-110                                                        Revised 9/2002 dt
      WIC POLICY MANUAL                                                                                                              FFY-2004

     RISK FACTORS BY PRIORITY - INFANTS

CODE               DESCRIPTION                                    SPECIAL NOTES                                       EXPLANATION
PRIORITY I (continued)

Nutrition Related Risk Condition – Must assign         Note medical condition(s) in the Notes tab     Nutritional problems may develop because of
    all applicable risk factors.                       of the WIC Application. Documentation          disease and/or medications; may have
    Nutrition related medical condition(s), which      from physician or nurse practitioner must      increased need for nutrients or difficulties with
    predispose participant to inadequate nutritional   be in chart within 3 months of certification   digestion or absorption of food.
    status. Includes, but not limited to:              date.. Make referral to CMS if necessary.
    (341) Nutrient Deficiency Diseases                 If there is a medically related condition,
    (342) Gastro-Intestinal Disorders                  which is affecting nutritional status and is
    (343) Diabetes Mellitus                            not on this list, contact the Nutrition
    (344) Thyroid Disorders                            Education Coordinator or Clinic Operations
    (345) Hypertension                                 Manager for approval.
    (346) Renal Disease
    (347) Cancer                                       See Risk Factor Reference Manual
    (348) Central Nervous System Disorders
    (349) Genetic and Congenital Disorders
    (350) Pyloric Stenosis
    (351) Inborn Errors of Metabolism
    (352) Infectious Diseases
    (353) Food Allergy
    (354) Celiac Disease
    (356) Hypoglycemia
    (359) Recent Major Surgery, Trauma,
           Burns
    (360) Other Medical Conditions
    (362) Developmental Delays, Sensory or
           Motor Delays Interfering with the
           Ability to eat
    (382) Fetal Alcohol Syndrome




ELIGIBILITY SCREENING                                                  1-111                                                     Revised 9/2002 dt
       WIC POLICY MANUAL                                                                                                              FFY-2004

       RISK FACTORS BY PRIORITY - INFANTS

CODE               DESCRIPTION                                     SPECIAL NOTES                                       EXPLANATION
PRIORITY I (continued)

(502) Out of State Transfer: Used when an out-of-      Must keep VOC card in participant’s file or
     state participant transfers in and their          explain in Notes how transfer information
     certification period is still valid; their risk   was obtained. Staff is asked to document
     factors either cannot be determined from the      in Notes the last benefits issued at the
     VOC information or are not applicable in this     previous clinic.
     state.
(355) Lactose Intolerance: Diagnosed by a              Document the specific symptoms in Notes          An infant with lactose or protein intolerance
     physician or has been determined by the           of the WIC Application.                          may be issued a special formula with a doctor’s
     existence of any or all or more of the                                                             prescription.
     symptoms listed below, which disappear(s)
     after the omission of cow’s milk:
       A.     Bloating and gas
       B.     Cramps
       C. Diarrhea
(381) Dental Problems: Diagnosis of dental             Document the specific dental condition, as       Nutritional deficiencies may occur due to
     problems by a health care provider or             well as how it is affecting nutrient intake in   decreasing the food intake or limiting certain
     adequate documentation by the CPA, include,       the Notes tab of the WIC Application or          types of food.
     but not limited to: Presence of nursing or baby   Narrative Notes. Also note dentist’s name,
     bottle caries, smooth surface decay of the        or make a referral to dental services.
     maxillary anterior and the primary molars.
(702) Breastfeeding Infant of Woman at Priority I      Document mothers priority I risk factors in
     Risk:                                             Notes.
Priority II

(701) Infant less than or equal to 6 mos. Born to      Document mother’s prenatal risk factors in       Infant may be at nutritional risk because of
     a WIC Mother: Infant born to a woman who          the Notes tab of the WIC Application.            mother’s health problems during pregnancy.
     was on the WIC Nutrition Program or who was       May not be used to certify an infant over 6
     eligible during pregnancy.                        months of age.
(702) Breastfeeding Infant of Woman at Priority II     Document mothers priority II risk factors in
     Risk                                              Notes.




ELIGIBILITY SCREENING                                               1-112                                                            Revised 9/2002 dt
       WIC POLICY MANUAL                                                                                                           FFY-2004

      RISK FACTORS BY PRIORITY - INFANTS

CODE                 DESCRIPTION                                  SPECIAL NOTES                                     EXPLANATION
Priority IV

(702) Breastfeeding Infant of Woman at Priority       Note the breastfeeding mother’s risk           Breastfed infant may be at nutritional risk due
     IV Risk:                                         factors in the Notes tab of the WIC            to mother’s medical problems
                                                      Application
DIETARY RISK FACTORS – Must assign all                May not be used to determine eligibility for   Nutritional deficiencies may develop which may
applicable risk factors.                              WIC unless this priority is being served,      lead to complications such as increased
                                                      but should be noted as a risk factor if        infection; impaired growth and development
(411) Inappropriate Infant Feeding Practices          applicable. Document inadequate or             and disease.
     including but not limited to: A dietary recall   inappropriate dietary factors in the Notes
     which shows an intake of at least one of the     tab of the WIC application. Certification
     following:                                       period for infants under 6 months is to the
     A. Anything other than breastmilk or iron        infant’s first birthday.
          fortified formula.
     B. An inappropriate amount of formula or milk    Previously Risk Factor 57
          for age.
     AGE          Insufficient      Excessive
(in months)         Intake              Intake
     0- 3         <14 oz.           >40 oz.
     4- 6         <27 oz.           >50 oz.
     7 - 12       <24 oz.           >36 oz.

     (412) Early Introduction of solid foods
     (413) Feeding Cow’s Milk During First 12
          Months
     (415) Improper Dilution of Formula          See Risk Factor Reference Manual
     (416) Feeding Other Foods Low in Essential
          Nutrients
     (417) Lack of Sanitation In preparation and
          Handling of Formula and Breastmilk
     (419) Inappropriate Use of Bottles




ELIGIBILITY SCREENING                                                 1-113                                                    Revised 9/2002 dt
       WIC POLICY MANUAL                                                                                                         FFY-2004

       RISK FACTORS BY PRIORITY - INFANTS

CODE                 DESCRIPTION                                 SPECIAL NOTES                                     EXPLANATION
Priority IV, (Continued)

(801) Homeless: Applicant or guardian states they    Indicate applicant’s status as homeless t in   Homeless conditions may predispose the
     are currently homeless                          the Notes tab of the WIC Application.          applicant to nutritional risk
                                                     Issue a VOC card.
 (802) Migrant: Participant or a member of the       Indicate applicant’s status as migrant in      Migrant conditions may predispose the
       family who has left home within the past 24   the Notes tab of the WIC Application.          applicant to nutritional risk.
       mos. to follow the crops or to work with      Issue a VOC card.
       lumber or timber.
Priority VII

(501) Regression: Possibility of regression in       Must be approved by Nutrition Education        Nutrition related problems might recur.
     nutrition status without WIC foods.             Coordinator or Clinic Operations Manager.
                                                     May not be used for initial or consecutive
                                                     certifications. Document previous risk
                                                     factors in the Notes tab of the WIC
                                                     Application. This risk factor is for infants
                                                     over 6 mos. who have been previously
                                                     certified in another state and certification
                                                     has expired.




ELIGIBILITY SCREENING                                            1-114                                                          Revised 9/2002 dt
       WIC POLICY MANUAL                                                                                                                 FFY-2004

       RISK FACTORS BY PRIORITY - CHILDREN

CODE                  DESCRIPTION                                          SPECIAL NOTES                                  EXPLANATION
PRIORITY III
(201) Anemia: Hemoglobin and hematocrit levels for 6-11 month olds adjusted for altitude based            Red blood cells cannot carry enough oxygen
     on 1989 CDC criteria.                                                                                caused by inadequate iron intake and/or an
                                                                                                          increased need; more likely to be irritable, tired,
AGE:       < 4999 Ft.    5000-6999 Ft.    7000-7999 Ft.      8000-8999 Ft.        >9000 Ft.               have a poor appetite and get sick.
           Hct. Hgb.     Hct. Hgb.        Hct. Hgb.          Hct. Hgb.            Hct. Hgb.
12-23 mos. <34 <11.3     <35 <11.7        <36 <12.0          <37 <12.3            <38   <12.7
2-5 yrs.   <35 <11.7     <36 <12.0        <37 <12.3          <38 <12.7            <39   <13.0

                          Refer to 1-81 – 1-82 for the altitude of your clinic.
(113) Overweight (Wt/Ht): Greater than or equal to         Not to be used for children under 2 years      Caused by eating more food than the body is
     24 mos. to 5 years of age and greater than or         of age. Height must be taken standing.         using may lead to an inadequate balance of
     equal to the 95% BMI for age                                                                         nutrients needed for good health.
(103) Underweight (Wt/Ht): Weight for height <10th                                                        Caused by not getting the required amounts of
     percentile on PHD approved growth chart.                                                             nutrients from food needed for good health;
                                                                                                          nutritional deficiencies may occur.
(121) Stunting: Length for age <10th percentile on                                                        May not have achieved growth potential due to
     PHD approved growth chart.                                                                           poor nutrition.
(134) Failure to Thrive: A physician’s diagnosis of        Documentation by a physician or nurse          May result in depletion of body’s nutrient
     failure to thrive or documented by someone            practitioner must be in chart within 3         reserves; nutrition related problems may
     working under physician’s orders.                     months of certification date. A referral       develop.
                                                           must be made to the health care provider if
                                                           not currently being followed by a physician.

                                                           Note: This risk factor may be used for a
                                                           child over the age restriction, up to 5
                                                           years old.
(114) At Risk of Becoming Overweight: Child is             Weight must be taken standing.
     greater than or equal to 24 mos. of age and           Do not use weight taken prior to 24
     greater than or equal to the 85% and < 95%            months of age.
     BMI for age.




ELIGIBILITY SCREENING                                                         1-115                                                  Revised 9/2002 dt
       WIC POLICY MANUAL                                                                                                              FFY-2004

       RISK FACTORS BY PRIORITY - CHILDREN

CODE               DESCRIPTION                                     SPECIAL NOTES                                       EXPLANATION
PRIORITY III, Continued

Nutrition related Risk Condition – Must                 Note medical condition(s) in the Notes tab     Nutritional problems may develop because of
     assign all applicable risk factors.                of the WIC Application. Documentation          disease and/or medications; may have
     Nutrition related medical condition(s), which      from physician or nurse practitioner must      increased need for nutrients or difficulties with
     predispose participant to inadequate nutritional   be in chart within 3 months of certification   digestion or absorption of food.
     status. Includes, but not limited to:              date.. Make referral to CMS if necessary.
     (341) Nutrient Deficiency Diseases                 If there is a medically related condition,
     (342) Gastro-Intestinal Disorders                  which is affecting nutritional status and is
     (343) Diabetes Mellitus                            not on this list, contact the Nutrition
     (344) Thyroid Disorders                            Education Coordinator or Clinic Operations
     (345) Hypertension                                 Manager for approval.
     (346) Renal Disease
     (347) Cancer                                       See Risk Factor Reference Manual
     (348) Central Nervous System Disorders
     (349) Genetic and congenital Disorders
     (351) Inborn Errors of Metabolism
     (352) Infectious Diseases
     (353) Food Allergy
     (354) Celiac Disease
     (356) Hypoglycemia
     (359) Recent Major Surgery, Trauma,
             Burns
     (360) Other Medical Conditions
     (362) Developmental Delays, Sensory or
             Motor Delays Interfering with the
             ability to Eat
     (382) Fetal Alcohol Syndrome
502) Out of State Transfer: Used when an out-of-        Must keep VOC card in participant’s file or
     state participant transfers in and their           explain in Notes how transfer information
     certification period is still valid; their risk    was obtained. Staff is asked to document
     factors either cannot be determined from the       in Notes the last benefits issued at the
     VOC information or are not applicable in this      previous clinic.
     state.



       ELIGIBILITY SCREENING                                        1-116                                                     Revised 07-2001
       WIC POLICY MANUAL                                                                                                              FFY-2004

       RISK FACTORS BY PRIORITY - CHILDREN

CODE                         DESCRIPTION                           SPECIAL NOTES                                       EXPLANATION
PRIORITY III, Continued

(355) Lactose Intolerance: Diagnosed by a              Document the specific symptoms in the            See tailoring the food package using extra
     physician or has been determined by the           Notes tab of the WIC Application.                cheese. If the participant can tolerate
     existence of any or all or more of the                                                             Acidophilus milk or use a commercial lactose
     symptoms listed below, which disappear(s)                                                          product like Lact-Aid, then the full milk package
     after the omission of cow’s milk:                                                                  can be issued.
         A.    Bloating and gas
         B.    Cramps
         C. Diarrhea
         D. Nausea
(381) Dental Problems: Diagnosis of dental             Document the specific dental condition, as       Nutritional deficiencies may occur due to
     problems by a health care provider or             well as how it is affecting nutrient intake in   decreasing the food intake or limiting certain
     adequate documentation by the CPA, include,       the Notes tab of the WIC Application or          types of food.
     but not limited to: Presence of nursing or baby   Narrative Notes. Also note dentist’s name,
     bottle caries, smooth surface decay of the        or make a referral to dental services.
     maxillary anterior and the primary molars.
     Tooth decay, periodontal disease, tooth loss
     and or ineffectively replaced teeth, which
     impair the ability to ingest food in adequate
     quantity or quality.
PRIORITY V

DIETARY RISK FACTORS

(422) Inadequate Diet: Dietary analysis indicates      Documented with food frequency diet              Nutritional deficiencies may develop which may
     an inadequate diet meeting < 80% of the RDA       analysis.                                        lead to complications such as increased
     for 5 leader nutrients (calcium, magnesium,       Previously Risk Factor 49                        infection, impaired growth and development
     iron, Vitamin-A and Vitamin-C)                                                                     and disease.
(401) Failure to Meet Dietary Guidelines: Dietary      Document the client’s dietary deficiency in      Nutritional deficiencies may develop which may
     analysis indicates at least one serving below     the Notes section of the WIC Application.        lead to complications such as increased
     the recommended number of servings for any        Previously Risk Factor 57                        infection, impaired growth and development
     food group, or at least one serving which does    CANNOT BE ASSIGNED TO A CHILD                    and disease.
     not meet the recommended serving size.            UNDER 2 YEARS OF AGE.



ELIGIBILITY SCREENING                                                   1-117                                                     Revised 9/2002 dt
       WIC POLICY MANUAL                                                                                                            FFY-2004

       RISK FACTORS BY PRIORITY - CHILDREN

CODE              DESCRIPTION                                      SPECIAL NOTES                                      EXPLANATION
PRIORITY V, (Continued)

DIETARY RISK FACTORS

(425) Inappropriate Feeding Practices for              See Risk Factor Reference Manual
Children
(419) Inappropriate Use of Bottles
(801) Homeless: Applicant or guardian states they      Indicate applicant’s status as homeless in      Homelessness may predispose the applicant to
     are currently homeless.                           the WIC Application Issue a VOC card.           nutritional risk.

(802) Migrant: Participant or a member of the family   Indicate applicant’s status as homeless in      Migrant conditions may predispose the
     who has left home within the past 24 mos. to      the WIC Application. Issue a VOC card.          applicant to nutritional risk.
     follow the crops or to work with lumber or
     timber.
PRIORITY VII

(501) Regression VII: Possibility of regression in     Must be approved by the Nutrition               Nutrition related problems might reoccur.
     nutrition status without WIC foods.               Education Coordinator or Clinic Operations
                                                       Manager. May not be used for initial or
                                                       consecutive certifications. Document
                                                       previous risk factors in the Notes tab of the
                                                       WIC Application or Narrative Notes.




       ELIGIBILITY SCREENING                                        1-118                                                   Revised 07-2001
WIC POLICY MANUAL                                                                                                                                                  FY-2004




       1. ELIGIBILITY SCREENING ................................................................................1-1
 I. ENSURING ACCESS FOR HANDICAPPED PERSONS ..................................................................................... 1-2
 II. HOURS OF OPERATION ................................................................................................................................. 1-2
 III. PROGRAM ELIGIBILITY SCREENING .......................................................................................................... 1-3
     A. Who Receives WIC? ................................................................................................................................ 1-3
     B. Areas Currently Serving Both WIC And CSFP Participants ......................................................... 1-4
     C. Screening Flow Chart - Overview ....................................................................................................... 1-7
     D. Federal processing standards .............................................................................................................. 1-8
     E. Physical presence required ................................................................................................................... 1-8
     F. Proof of residency required at certification ...................................................................................... 1-9
     G. Proof of identity required at certification.......................................................................................... 1-9
     H. Change of Program Category ............................................................................................................ 1-10
     I. Primary Client Data Fields in the WIC Application ...................................................................... 1-11
         1.Locate Client - Search Tab...........................................................................................................................1-13
         2.Locate Client - Results Tab .........................................................................................................................1-13
         3.Basic Client Information (Header)............................................................................................................1-14
         4.Demographics Tab ..........................................................................................................................................1-15
         5.Family Group Tab ...........................................................................................................................................1-18
         6.Income Tab.........................................................................................................................................................1-19
     J. Family Size for Pregnant Women ....................................................................................................... 1-21
     K. Determining Family Size Income ...................................................................................................... 1-21
     L. Income Determination .......................................................................................................................... 1-24
     M. Income Documentation ....................................................................................................................... 1-25
     N. Income Changes Within a Certification Period ............................................................................. 1-25
            Denial Letter due to income changes within a certification period. ...........................................1-24
            Denial Letter due to income changes within a certification period, page 2. ...........................1-25
     O. WIC Income Eligibility Guidelines ................................................................................................... 1-26
     P. Adjunct Eligibility ................................................................................................................................. 1-28
     Q. Infants and Children Under Foster Care ........................................................................................ 1-30
     R. Income Statement .................................................................................................................................. 1-30
        7. Medical Tab .......................................................................................................................................................1-30
        8. Pregnancy/Outcome Tab ...............................................................................................................................1-41
        9. BF/OutcomeTab ...............................................................................................................................................1-43
        10. Diet Analysis Tab (Women & Children) ............................................................................................1-44
     S. Diet Analysis - Women and Children ................................................................................................ 1-45
            1. Data Collection ...........................................................................................................................................1-45
            2. Provide Dietary Counseling To Participant .....................................................................................1-46
        11. Infant Diet Tab ................................................................................................................................................1-46
     T. Diet Analysis - Infants .......................................................................................................................... 1-47
            1. Breastfeeding Section: .............................................................................................................................1-47
             2. Formula Feeding Section: ..................................................................................................................................1-47
             3. Data Collection and Assessment Summary:.......................................................................................................1-48
         12. Risk Factor Tab ..............................................................................................................................................1-48
         13. Nutrition Education Plan Tab ...................................................................................................................1-49
         14. Notes Tab ..........................................................................................................................................................1-49
         15. Referrals Tab ...................................................................................................................................................1-50
         16.   Certification Tab ............................................................................................................................................1-51


                                                                                       I                                                         Table of Contents
WIC POLICY MANUAL                                                                                                                                                FY-2004


            Food Package Design Tab ..........................................................................................................................1-54
           17.
            FI Issue Tab......................................................................................................................................................1-55
           18.
            Scheduling Tab ...............................................................................................................................................1-56
           19.
            Food Purchases Tab ......................................................................................................................................1-57
           20.
        21. Summary Tab ..................................................................................................................................................1-57
        22. Labels and Letters Tab.................................................................................................................................1-58
  IV. QUALITY ASSURANCE STANDARDS FOR MEDICAL DATA .................................................................. 1-58
  V. PARTICIPANTS RIGHTS AND RESPONSIBILITIES ..................................................................................... 1-59
  VI. CERTIFICATION OF PREVIOUSLY CERTIFIED CLIENTS......................................................................... 1-60
  VII. DENIAL PROCEDURES .............................................................................................................................. 1-60
  VIII. PROCEDURES FOR THE PREVENTION OF HIV TRANSMISSION IN WIC CLINICS...................... 1-61
     A. Obtaining Hemoglobin/hematocrit Samples ................................................................................... 1-62
     B. Weighing and Measuring Infants ....................................................................................................... 1-63
     C. Other Considerations ........................................................................................................................... 1-63
     D. Additional Precautions ........................................................................................................................ 1-63
     E. Monitoring Adherence To Procedures ............................................................................................. 1-64
     F. Guidelines for Handling Personal Exposure .................................................................................. 1-64
     G. Summary Of Risk Factors By Priority .............................................................................................. 1-72
  RISK FACTOR DESCRIPTIONS FOR PREGNANT WOMEN.................................................................................. 1-83
  RISK FACTOR DESCRIPTIONS FOR BREASTFEEDING WOMEN ................................................................................ 1-83
  RISK FACTOR DESCRIPTIONS FOR POSTPARTUM WOMEN .................................................................................... 1-86
  RISK FACTOR DESCRIPTIONS FOR INFANTS ....................................................................................................... 1-110
  RISK FACTOR DESCRIPTIONS FOR CHILDREN .................................................................................................... 1-115




Table of Contents                                                                     II
WIC POLICY MANUAL                                                                           FY-2004



Adjunct Eligibility, 1-28                              Income Table for WIC Eligibility, 1-26
Alias                                               Income Statement, 1-30
  Alias names, 1-15                                 Income Tab, 1-16
Altitude Chart for Clinic Locations, 1-81           Infant Diet Tab, 1-45
Areas Serving WIC and CSFP Participants, 1-         Labels and Letters Tab, 1-57
  4                                                 Locate Client - Results Tab, 1-11
Basic Client Information Header, 1-12               Locate Client - Search Tab, 1-11
Certification, 1-6
                                                    Management of Personal Exposure to
Certification of Previously Certified Clients
                                                       HIV/AIDS, 1-64
  Recertification, 1-60
                                                    Medical Tab, 1-30
Certification Tab, 1-50
                                                    Migrant status, 1-15
Change of Program Category, 1-8
                                                    New Mexico WIC Clinics, 1-66
Cleaning equipment, 1-63
                                                    Notes Tab, 1-48
Contract Agencies, 1-67                             Nutrition Education Plan Tab, 1-48
Demographics Tab, 1-13
                                                    Participants Rights and Responsibilities, 1-58
Denial Procedures, 1-59, 1-60
                                                    PHD Protocol for HIV Exposure, 1-64
Determining Family Size, 1-19
                                                    Physical, 1-6
Diet Analysis Tab (Women & Children), 1-43          Poverty Level Guidelines
Dietary, 1-74                                          Income Chart to Determine Poverty Level, 1-27
Disposal of lancets, 1-62                           Pregnancy/Outcome Tab, 1-39
Disposal of Non-sharp Materials, 1-62               Prenatal Weight Gain Grid Instructions, 1-35
Eligibility Screening Overview, 1-3                 Preventing HIV transmission, 1-61
Family Group Tab, 1-15                              Primary Data Fields in the WIC Application,
Family Size, 1-18                                      1-9
Federal, 1-6                                        Program Categories, 1-12
FI Issue Tab, 1-54                                  Proof, 1-7
Food Frequency Diet Analysis Form, 1-73             Quality Assurance Standards for Medical
Food Package Design Tab, 1-53                         Data, 1-58
Food Purchases Tab, 1-56                            Referrals Tab, 1-49
Foster Care                                         Risk Factor Summary, 1-69
  ChildrenUnderFosterCare, 1-30                     Risk Factor Tab, 1-46
Growth Charts for Premature Infants and             Scheduling Tab, 1-55
  Children, 1-34                                    Screening Flow-Chart, 1-5
Hemoglobin, 1-38                                    Summary Tab, 1-56
Homeless Participants, 1-15                         Tabs in the Main Client Window, 1-10
Income Affidavit, 1-29                              Tax Returns, 1-20
Income Determination, 1-22                          Weighing and Measuring Infants, 1-63
Income Documentation, 1-20                          Workmen's Compensation, 1-65
Income Guidelines




Eligibility Screening                           i                                              Index

				
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