Reports (may be reviewed in advance- RNC will request if needed) |
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Participation by Program Report (HSPR0702) for previous month
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Participation by Priority and Category Report (HSPR0107) past 3 months
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WIC Education Summary Report (HSPR0108) past 3 months
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Medically Prescribed Formula Report (HSPR0116) past 3 months
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Breastfeeding Food Package Assignment Report (HSPR0120)
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Security Coordinator Report (HSPR0424)
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Budget and Fiscal
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Current Organizational Chart
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“Summary Expenditure Documentation Forms” for the most recent completed fiscal reporting quarter
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WIC / PC Equipment Inventory List for all sites per policy (PPM AD 3.4) - Copy required for Department.
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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 (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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Copy of all outreach materials used to promote the WIC program (flyers, brochures, website pages)
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Program Integrity |
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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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Cornerstone computer available for IDHS staff to use during time of WIC ME Review (if requested)
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VI. Local Agency Reports and Other Documents
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Clinic Schedule (HSPR0505) for days of review
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Validation/Calibration documentation for Anthropometric & Biochemical equipment
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Nutrition Education Plan, current and past year, including past Participant Survey results
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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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If applicable, Local Agency Letters of Department Approval, since last WIC ME, including:
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Prior approval for WIC purchases per policy (PPM AD 3.2-3.3)
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Disposal of WIC Equipment (PPM AD 3.4)
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Requests for WIC Special Projects (PPM AD 8.1)
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Prior approval for Issuance by mail or Special pick up (PPM FDS 4.6)
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Prior approval, per participant, for Home Distribution of Food Instruments (PPM FDS 4.7)
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Participant Violation Reporting Forms (FDS 5.3)
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Prior approval for Waitlist status (PPM CS 11.1)
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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
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Communication to Medical Providers regarding abnormal values/health concerns
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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
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Peer Counselor Program, Social Media (if applicable)
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Peer Counselor Program, Special Electronic Equipment (if applicable)
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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Outreach Log/File (identifies: activities, dates, & staff involved) – for past two years
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Referral List, updated annually
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Local Agency Quality Assurance /Self- Monitoring (since last WIC ME)
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Program Operations Self-evaluation/Review, completed annually
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Certification Observation Results, completed annually as part of Program Operations
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PC evaluations, completed annually (if applicable)
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Medically Prescribed Formula Quality Assurance, completed bi-annually
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Breastfeeding Food Package Assignment, completed bi-annually
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Training Log/File(s)
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Documentation of CHPs credentials
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WIC Employee Confidentiality and Compliance Agreement Signature Forms (for all WIC/PC staff )
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WIC job specific training for all WIC staff (minimum annually, since last WIC ME)
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Breastfeeding (training for WIC/PC staff at orientation and annually since last WIC ME)
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Peer Counselor Training (documentation of completion of Loving Support training) (if applicable)
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Counseling Training List (staff trained on Counseling Skills – past 3 years)
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Formula Authorization List (staff trained on Medically Prescribed Formulas – past 3 years)
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VIII. Secondary Nutrition Education & Nutrition Education Materials
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Group Education Attendance Sheets (HSPR0503) since last WIC ME (if applicable)
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WIC Nutrition Education materials created by local agency and those from outside resources (non-IDHS)
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Secondary Education utilized by agency on file for review (applicable per type of education offered)
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Group Education Lesson Plans and Calendar (identifying group sessions offered)
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Self–Study Modules
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Internet Education Certificates (documentation accessible upon request)
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Other Secondary Education utilized (i.e. displays, Shopping Matters, etc.)
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