Caseload Management/Scheduling |
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Participation by Program Report (HSPRO702) for previous month
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Clinic Schedule (HSPRO505) for days of review
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I.Budget and Fiscal
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Current Organizational Chart
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Current copy of the internal budget (spending plan), including the “Summary Expenditure Documentation Form” for the most recent completed fiscal reporting quarter
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WIC Equipment Inventory List
(required for all equipment purchased with WIC funds costing $100 or more)
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NVRA (since last WIC ME) |
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Copies of the Voter Registration Information (VRI) cards –for past two years
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Weekly Transmittal forms –for past two years
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Civil Rights/Outreach (since last WIC ME) |
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Civil Rights Complaint Forms (kept on file) and Complaint Log (dated annually & indicate “no complaints” if applicable)
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Civil Rights Training Log/Records and Training material used
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Outreach Log/File (identifies: activities, dates, & staff involved) – for past two years
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(Please have a Cornerstone computer available for IDHS staff use during the time of the Review) |
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Pre-Visit Questionnaire (complete and submitted to IDHS RNC prior to Review)
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BOD/EOD Reports (if requested)
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“Potential Dual Participant” BOD reports with documentation of reconciliation
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List of active staff, by program, with access to Cornerstone
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List of terminated staff from Cornerstone (since last WIC ME)
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VI. Local Agency Logs, Reports and Other Documents
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Validation/Calibration documentation for Anthropometric & Biochemical equipment
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Integrated Plan for Healthy MCH Outcomes, current with up to date methods & data
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Participation by Priority and Category Report (HSPR0107) past 3 months
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Medically Prescribed Formula Report (HSPRO116) past 3 months
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VI. Local Agency Logs, Reports and Other Documents
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Breastfeeding Food Package Assignment Report (HSPR0120) past 3 months
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Memorandum of Understanding (MOU) on file (if applicable)
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WIC Farmers’ Market Monitoring Forms (if applicable)
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Local Agency Procedures & Quality Assurance
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| Local Agency Procedures -
Enhanced Outreach
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Geographic Boundaries (if applicable)
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Deferred Bloodwork Follow-up
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Referrals (Provide updated copy of referral list to your IDHS Regional Staff)
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Immunization Screening and Documentation
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Sample or donated formula (fair, equal distribution and safe disposal) (if applicable)
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Breastfeeding Positive Clinic Environment
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Breastfeeding Promotion and Support for BF and Postpartum Women
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Breastpump Issuance Procedures
Other Required Items
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Standing Orders for Hgb/Hct, updated annually
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Public Announcement for No Smoking (signs posted/visible)
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“And Justice For All” current USDA Posters (posted/visible in WIC clinic areas)
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Local Agency Quality Assurance /Self- Monitoring
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Certification Observation Results (Self-Monitoring Worksheets per MCH Integrated Plan)
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Program Operations Self-evaluation/Review, completed annually and kept on file
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Medically Prescribed Formula Quality Assurance (Internal Chart/Records Reviews)
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Formula Authorization List (staff trained on Medically Prescribed Formulas – past 3 years)
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Breastfeeding Food Package Assignment (Internal QA Chart/Records Reviews)
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Training Log/File, indicating documentation of training offered/attended for all WIC staff since your last review (including general and breastfeeding)
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VIII. Secondary Nutrition Education & Nutrition Education Materials
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Group Education Attendance Sheets (HSPRO503) since last WIC ME (if applicable)
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WIC Education Summary Report (HSPRO108) past 3 months
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Secondary Education utilized by agency on file for review (Group Education Lesson Plans/Self Study Modules/Internet Education Certificates)
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WIC Nutrition Education materials utilized (non-IDHS), including local agency created materials and those obtained from outside resources
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