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Reminder Checklist sfy 2016 wic management Evaluation/Quality Assurance (meqa) Review


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Reminder Checklist SFY 2016

WIC Management Evaluation/Quality Assurance (MEQA) Review


Please use this checklist to assist in preparing the necessary local agency documents that will be utilized for the WIC MEQA Review. Preparing these materials, including completion of the Pre-Visit Questionnaire, prior to the start of the review will help in streamlining the review process and on-site time.
  1. Reports (may be reviewed in advance- RNC will request if needed)



Participation by Program Report (HSPR0702) for previous month



Participation by Priority and Category Report (HSPR0107) past 3 months



WIC Education Summary Report (HSPR0108) past 3 months



Medically Prescribed Formula Report (HSPR0116) past 3 months



Breastfeeding Food Package Assignment Report (HSPR0120)



Security Coordinator Report (HSPR0424)

  1. Budget and Fiscal



Current Organizational Chart



“Summary Expenditure Documentation Forms” for the most recent completed fiscal reporting quarter



WIC / PC Equipment Inventory List for all sites per policy (PPM AD 3.4) - Copy required for Department.
  1. NVRA (since last WIC ME)



Copies of the Voter Registration Information (VRI) cards –for past two years



Weekly Transmittal forms –for past two years
  1. Civil Rights (since last WIC ME)



Civil Rights Complaint Forms (kept on file) and Complaint Log (dated annually; indicate “no complaints” if applicable)



Civil Rights Training Log/Records and Training material used



Copy of all outreach materials used to promote the WIC program (flyers, brochures, website pages)
  1. Program Integrity




Pre-Visit Questionnaire (complete and submitted to IDHS RNC prior to Review)



BOD/EOD Reports (if requested)



“Potential Dual Participant” BOD reports with documentation of reconciliation



Cornerstone computer available for IDHS staff to use during time of WIC ME Review (if requested)

VI. Local Agency Reports and Other Documents



Clinic Schedule (HSPR0505) for days of review



Validation/Calibration documentation for Anthropometric & Biochemical equipment



Nutrition Education Plan, current and past year, including past Participant Survey results



Memorandum of Understanding (MOU) on file (if applicable)



WIC Farmers’ Market Monitoring Forms (if applicable)




If applicable, Local Agency Letters of Department Approval, since last WIC ME, including:

  • Prior approval for WIC purchases per policy (PPM AD 3.2-3.3)

  • Disposal of WIC Equipment (PPM AD 3.4)

  • Requests for WIC Special Projects (PPM AD 8.1)

  • Prior approval for Issuance by mail or Special pick up (PPM FDS 4.6)

  • Prior approval, per participant, for Home Distribution of Food Instruments (PPM FDS 4.7)

  • Participant Violation Reporting Forms (FDS 5.3)

  • Prior approval for Waitlist status (PPM CS 11.1)

                1. Local Agency Procedures & Quality Assurance














































Local Agency Procedures

  1. Enhanced Outreach

  2. Geographic Boundaries (if applicable)

  3. Deferred Bloodwork Follow-up

  4. Referrals

  5. Communication to Medical Providers regarding abnormal values/health concerns

  6. Immunization Screening and Documentation

  7. Sample or donated formula (fair, equal distribution and safe disposal) (if applicable)

  8. Breastfeeding Positive Clinic Environment

  9. Breastfeeding Promotion and Support for BF and Postpartum Women

  10. Breastpump Issuance Procedures

  11. Peer Counselor Program, Social Media (if applicable)

  12. Peer Counselor Program, Special Electronic Equipment (if applicable)

Other Required Items

    1. Standing Orders for Hgb/Hct, updated annually

    2. Public Announcement for No Smoking (signs posted/visible)

    3. “And Justice For All” current USDA Posters (posted/visible in WIC clinic areas)

    4. Outreach Log/File (identifies: activities, dates, & staff involved) – for past two years

    5. Referral List, updated annually














Local Agency Quality Assurance /Self- Monitoring (since last WIC ME)

  1. Program Operations Self-evaluation/Review, completed annually

  2. Certification Observation Results, completed annually as part of Program Operations

  3. PC evaluations, completed annually (if applicable)

  4. Medically Prescribed Formula Quality Assurance, completed bi-annually

  5. Breastfeeding Food Package Assignment, completed bi-annually



















Training Log/File(s)

  1. Documentation of CHPs credentials

  2. WIC Employee Confidentiality and Compliance Agreement Signature Forms (for all WIC/PC staff )

  3. WIC job specific training for all WIC staff (minimum annually, since last WIC ME)

  4. Breastfeeding (training for WIC/PC staff at orientation and annually since last WIC ME)

  5. Peer Counselor Training (documentation of completion of Loving Support training) (if applicable)

  6. Counseling Training List (staff trained on Counseling Skills – past 3 years)

  7. Formula Authorization List (staff trained on Medically Prescribed Formulas – past 3 years)

VIII. Secondary Nutrition Education & Nutrition Education Materials



Group Education Attendance Sheets (HSPR0503) since last WIC ME (if applicable)



WIC Nutrition Education materials created by local agency and those from outside resources (non-IDHS)



Secondary Education utilized by agency on file for review (applicable per type of education offered)

  • Group Education Lesson Plans and Calendar (identifying group sessions offered)

  • Self–Study Modules

  • Internet Education Certificates (documentation accessible upon request)

  • Other Secondary Education utilized (i.e. displays, Shopping Matters, etc.)




SFY 16 WIC MEQA Reminder Checklist Page of


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