State and Local WIC Agency Directors (SLT)

OMB Number: 0584-XXXX

Expiration Date: X/XX/XXXX

APPENDIX B2.a

LOCAL AGENCY SURVEY

INTRO: Thank you for participating in the Third National Survey of WIC Participants. This survey is sponsored by the United States Department of Agriculture Food Nutrition Service and administered by 2M Research Services. Please refer to the accompanying cover letter for full details of the research effort. If you have any questions, please contact Jim Murdoch at 1-817-856-0863, or by email at jmurdoch@2mresearch.com.

This survey—along with surveys of State agencies and participants—is designed to provide FNS with additional information on policies and program operations, beyond those available from existing program sources.

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0584-XXXX. The time required to complete this information collection is estimated to average 60 minutes (1 hour) per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: U.S. Department of Agriculture, Food and Nutrition Services, Office of Policy Support, 3101 Park Center Drive, Room 1014, Alexandria, VA 22302, ATTN: PRA (0584-xxxx*). Do not return the completed form to this address.

Certification Policies

Identity

Q1. What types of documentation does your local agency accept as proofs of identity for a WIC applicant either electronically and/or physically? (CHECK ALL THAT APPLY)

 Letter from government agency (including WIC) w/name form/letter

 Driver’s license, State ID

 Work, school, or bus pass ID w/photo & name

 Military ID

 Social Security card

 Voter’s registration card

 Foster placement letter

 Passport or immigration records

 Marriage license

 Birth certificate

 Crib card, hospital discharge papers, or hospital ID bracelet

 Immunization record

 Employment paystubs

 Medicaid card

 Other: PLEASE SPECIFY

 Other: PLEASE SPECIFY

 Other: PLEASE SPECIFY

 Other: PLEASE SPECIFY

Residency

Q2. What types of documentation does your local agency accept to verify the residency of a WIC applicant either electronically and/or physically? (CHECK ALL THAT APPLY)

 Driver’s license

 Current utility/tax bill, rent receipt, mortgage receipt, or lease receipt with name and address on it

 Letter from government agency (including WIC) w/name and address

 State or Tribal-issued license or ID w/name and address

 Postmarked mail from reliable third party with name and address

 Checkbook, bank statement

 Signed statement by applicant that he/she is victim of loss or disaster, or is homeless, a migrant person, or military personnel.

 Shelter documentation

 Vehicle registration

 Recent paystub

 Property tax bill

 Hospital/clinic receipt or record

 Income tax return/W2 form

 Social Security statement

 Medicaid document

 TANF document

 Other: PLEASE SPECIFY

 Other: PLEASE SPECIFY

 Other: PLEASE SPECIFY

 Other: PLEASE SPECIFY

 Other: PLEASE SPECIFY: __________________________

Income

Q3. Which of the following documents satisfy the income documentation requirements of your local agency? Among those documents, rank the top three most-often provided documents (where “1” is most often provided, “2” is the second most often provided and “3” is the third most often provided):

Document		Satisfies Document Requirement (CHECK ALL THAT APPLY)	Three Most Frequently Provided Documents (RANK 1, 2, or 3)
a.	1st Paystub/earnings statement	
b.	W-2 form	
c.	IRS tax return	
d.	Business records	
e.	Unemployment compensation (letter, check stub, copy of check)	
f.	Workers compensation (award statement, check stub, copy of check, statement from insurance company)	
g.	Social Security benefits (award letter, statement of benefits, check stub, copy of check)	
h.	State SSI or State disability insurance (notice of benefits, check stub, copy of check)	
i.	Public assistance or TANF (notice of benefits, check stub, copy of check)	
j.	Energy assistance (notice of benefits, check stub, copy of check)	
k.	Alimony or child support (copy of check, agreement, divorce/separation decrees, court order)	
l.	Any government or private pension, annuity, or survivor’s benefits (notice of benefits, check stub or copy of check)	
m.	Estate or trust earnings statement	
n.	Interest or dividends statement	
o.	Savings account earnings statement	
p.	Veteran’s payments (notice of benefits, check stub, copy of check)	
q.	Military pay (leave and earnings statement, check stub, copy of check)	
r.	Letter from employer	
s.	Foster care placement letter	
t.	Scholarship/financial aid letter	
u.	SNAP letter showing current eligibility	
v.	Other documents____________________________	
w.	Other documents____________________________	
x.	Other documents____________________________	
y.	Other documents____________________________	

Q4. Which of the following satisfy the program participation documentation requirements for automatic or adjunctive eligibility of your local agency? Among those documents, rank the top three most-often method used (where “1” is most often, “2” is the second most often, and “3” is the third most often).

Document		Satisfies Documentation Requirement (CHECK ALL THAT APPLY)	Three Most Frequently Method Used (RANK 1, 2, or 3)
a.	Valid program or member ID card	
b.	Award letter or notice of benefits	
c.	Electronic access	
d.	Other: PLEASE SPECIFY:________________________	

Breastfeeding

Q5. In your estimation, at what ages are infants being certified to receive “fully” (rather than “partially”) breastfeeding food packages? An estimate or best guess is okay if the information is not readily available.

Infant Age at Certification	Percentage of Infant Certifications in the past 12 months
1-3 months
4-6 months
7-9 months
10-12 months
Total	100% (all infants who were certified to receive fully breastfeeding food packages)

Denied Applicants

Q6. Does your local agency keep information on denied applicants?

• Yes

• No: PLEASE EXPLAIN: _____________________ [GO TO Q8]

Q7. What information on denied applicants do you retain and how is it retained? (ANSWER B. AND C. ONLY IF A. IS CHECKED.)

a. Information Retained (CHECK ALL THAT APPLY)		b. How Retained (CHECK ONE)		c. Where Retained (Readily accessible to the….) (CHECK ALL THAT APPLY)
	Name of applicant		Paper copy only		WIC State Agency
			Electronic copy only		Your Local Agency
			Both paper and electronic		Sites/Clinics
	Address		Paper copy only		WIC State Agency
			Electronic copy only		Your Local Agency
			Both paper and electronic		Sites/Clinics
	Phone number		Paper copy only		WIC State Agency
			Electronic copy only		Your Local Agency
			Both paper and electronic		Sites/Clinics
	WIC applicant category		Paper copy only		WIC State Agency
			Electronic copy only		Your Local Agency
			Both paper and electronic		Sites/Clinics
	Reason for denial		Paper copy only		WIC State Agency
			Electronic copy only		Your Local Agency
			Both paper and electronic		Sites/Clinics
	Date of application		Paper copy only		WIC State Agency
			Electronic copy only		Your Local Agency
			Both paper and electronic		Sites/Clinics
	Date of denial		Paper copy only		WIC State Agency
			Electronic copy only		Your Local Agency
			Both paper and electronic		Sites/Clinics

Q8. Of applicants new to your WIC agency, what percentage in the past 12 months was denied certification? (SELECT ONE)

• ≤1%

• 2 – 4%

• 5 – 7%

• 8 – 10%

• >10%

Q8A. How confident are you in the range entered here?

 Very confident

 Somewhat confident

 Not very confident (i.e., a lot of guesswork involved)

Q9. Of current WIC participants seeking certification (or recertification) at your WIC agency, what percentage in the past 12 months was denied certification? (SELECT ONE)

• ≤1%

• 2 – 4%

• 5 – 7%

• 8 – 10%

• >10%

Q9A. How confident are you in the range entered here?

 Very confident

 Somewhat confident

 Not very confident (i.e., a lot of guesswork involved)

Q10. Please specify the percentage of denials reported above that are attributable to the following eligibility problems. It is possible the percentages may sum to more than 100%, as applicants may be denied for more than one reason.

Reason for Denial		Percentage Distribution for New Applicants	Percentage Distribution for Certification
a.	Lack of documentation provided for identity
b.	Income ineligibility (over income limit)
c.	Lack of documentation provided for residency
d.	Categorical ineligibility (i.e., not pregnant, child over 5 years, etc.)
e.	Other: PLEASE SPECIFY____________________________

Q10A. How confident are you in the responses that were entered here?

 Very confident

 Somewhat confident

 Not very confident (i.e., a lot of guesswork involved)

Q11. Does your agency provide an official letter of denial to applicants who are determined ineligible for WIC?

• Yes

• No

• Other: PLEASE SPECIFY: ____________________________

Q12. Can an applicant be screened and determined ineligible by telephone?

• Yes

• No [GO TO Q14]

Q13. IF Q11=YES AND Q12=YES

What is the percentage of denials through screening phone calls versus formal, in-person applications in the past 12 months?

	Percentage of Denials
Screening phone calls
Formal in-person applications

Location of Certification

Q14. Does your agency offer or provide certification at alternative sites (e.g., satellite, mobile, or off-site clinics at a hospital, school, etc.)?

• Yes

• Yes, only during disaster/emergency situations

• No [GO TO Q16]

Q14A. Which of the following WIC categories does your agency offer certification at alternative sites? (CHECK ALL THAT APPLY)

 Pregnant woman

 Postpartum woman

 Breastfeeding woman

 Infant

 Child

• None

Q15. Under what circumstances is certification provided at an alternative site such as a satellite clinic, mobile clinic, or off-site clinics at hospitals, schools and other locations? What is your agency’s policy toward providing certifications at an alternative site?

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Certification Staffing

Q16. Does your staff receive cross-training on ALL of the certification-related tasks shown below?

• Assess categorical eligibility criteria

• Assess residential eligibility criteria

• Assess nutritional risk criteria

• Assess income/adjunctive income eligibility

• Issue benefits (vouchers/EBT cards)

• Yes, we have certification staff who are cross-trained on ALL of those tasks.

• No, our certification staff specializes in one or more of those tasks. [GO TO Q17]

Q16A. What percentage of your certification staff is cross-trained on ALL of those tasks?

__ __ __%

Q17. Among all full-time staff in your jurisdiction who conduct certification, what is their average monthly caseload?

______ participants

Operations

Administration

Q18. Is your local agency… (CHECK ONE)

• part of the State agency

• a local government entity administering the WIC program

• a tribal entity/organization administering the WIC program

• a non-profit organization that has been contracted to run the WIC program

• not a local agency, but rather a clinic under a local agency

• Other: PLEASE SPECIFY ___________________________

Physical Space

Q19. Which description most closely fits the structure in which your local agency is located? (CHECK ONE)

• Health department or medical clinic

• Social services office or agency

• Full service hospital

• School

• Head Start

• Community center

• Mobile clinic (van)

• Migrant health center and/or camp

• Indian Health Service facility

• Religious center

• Standalone WIC clinic

• Nonprofit

• Other: PLEASE SPECIFY ___________________________

Q20. Of the spaces available at WIC clinics in your jurisdiction, how adequate would you rate the following spaces for optimally delivering WIC services to your participants at this time? Please rate each type of room. [rooms marked “somewhat adequate” or “not at all adequate,” go to q20a]

Type of Room	Completely Adequate	Mostly Adequate	Somewhat Adequate	Not at All Adequate	N/A
Large waiting rooms/reception areas (greater than 15x15 feet)					
Small waiting rooms/reception areas (15x15 feet or smaller)					
Rooms, offices, or cubicles where clients are seen					
Separate breastfeeding rooms					
Large training/conference/multipurpose rooms					
Small training/conference/multipurpose rooms					
Administrative offices (no clients seen)					
Administrative cubicles (no clients seen)					
Laboratory (height/weight taking areas)					
Other: PLEASE SPECIFY ___________________________					

Q20A. Please explain why you selected [response from q20: “SOMEWHAT ADEQUATE” OR “NOT AT ALL ADEQUATE”] for the following rooms [type of room associated with “somewhat adequate” or “not at all adequate” response]:
_____________________________________________________________________

Q21. How would you rate the physical security of your local agency’s location (for example, protection from natural disasters such as fire, earthquake; burglary or vandalism of the site; unauthorized visitors; etc.)?

• Very safe (no incidents) [go to Q22]

• Safe (occasional minor incidents) [go to q22]

• Unsafe (occasional major incidents or frequent minor incidents)

• Very unsafe (frequent major incidents)

Q21A. Please explain why you selected [response from q21: “unsafe” or “very unsAfe”]:
_____________________________________________________________________

Services Information

Q22. Please enter the number of WIC sites that operate under the authority of this local agency, by type.

Clinics (defined as a permanent location assigned to the WIC program; include main clinic)

Satellites (defined as a location such as a school, church or town hall that is only temporarily assigned the WIC program. WIC staff must carry their own files and equipment to the site each visit)

Mobile Units (a vehicle assigned to the WIC program that may make multiple stops to conduct certifications)

Q23. To what extent are the following services provided by your local agency at the various sites you specified in the previous question? [WEB SURVEY WILL SHOW CLINICS, SATELLITES AND/OR MOBILE UNITS COLUMN ONLY IF RESPONDENT HAS ANSWERED >0 IN Q22]

		Local Agency	Clinics			Satellites			Mobile Units
		Agency does this	All can do	Some can do	None can do	All can do	Some can do	None can do	All can do	Some can do	None can do
Conduct certifications											
Perform blood testing											
Take anthropometric measurements for height, weight, and body mass index (BMI)											
Conduct nutrition counseling											
Offer other educational seminars (e.g., on breastfeeding)											
Provide food instruments (vouchers/EBT cards)											
Provide referrals to other services											
Access WIC participant records electronically											

Q24. Across all of the clinics under your local agency, on average, how many days per week, is the clinic open to clients/applicants? DAYS

Q25. Across all of the clinics under your local agency, on average, how many hours per week, is the clinic open to clients/applicants? (You may divide the total number of hours that all clinics are open by the number of clinics.) HOURS

Q26. Across all of the clinics under your local agency, provide the opening and closing hours (hours open to the public) for a typical clinic (your most common clinic) in a typical week of operations in the table below.

Operating Hours	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday
Opening
Closing

Q26A. Do your clinics typically close to the public for lunch or other reasons during clinic hours?

• Yes

• No

Staffing

Q27.

Across all of the clinics under your local agency, please provide the following information for each position listed below. [PLEASE GIVE NUMBER]	Number of full-time staff (working more than 32 hours/wk)	Number of part-time staff (working less than 32 hours/wk)	Of the total combined full and part-time staff, how many have worked at one of your clinics 12 months or less?	Of all of the employees who have held this position in the past 12 months, how many have left your agency (are not working at any of your clinics)?	Across all of the clinics under your local agency, how many of these positions are currently vacant?
a. WIC Director or Clinic Supervisor			______	______	______
b. Office Manager			______	______	______
c. Administrative Support Staff (e.g., clerks)			______	______	______
d. Certification Specialist			______	______	______
e. Registered Dietitian			______	______	______
f. Degreed/Licensed Nutritionist			______	______	______
g. Trained Nutrition Paraprofessional			______	______	______
h. Registered Nurse/Physician Assistant			______	______	______
i. Physician			______	______	______
j. Social Worker/ Psychologist/ Therapist			______	______	______
k. Other Professional (e.g., breastfeeding peer counselors, IBCLC)			______	______	______
l. Other: PLEASE SPECIFY___________			______	______	______
TOTAL STAFF			______	______	______

[Programming note: Total Staff row will be calculated automatically so respondent can see totals]

Q27A. From your answers above, we estimate that your full-time equivalent (FTE) number of employees is approximately ____. (Note:, we counted every two part-time as one FTE.) Do you agree with this estimate?

• Yes, GO TO Q28

• No

Q27B. What is your estimate of FTE number of employees across all clinics in your jurisdiction? _____ FTE

Q28. Across all clinics under your local agency, what percentage of all staff are bilingual or multilingual?
_____% of staff

Q29. What languages, other than English, are spoken by staff at one or more of the clinics under your local agency to assist in providing WIC services? (CHECK ALL THAT APPLY)

	NONE		Hmong		Spanish
	Arabic		Khmer		Swahili
	Cambodian		Korean		Tamil
	Cantonese/Mandarin		Laotian		Tagalog
	Farsi		Portuguese		Urdu
	French/Creole		Punjabi		Vietnamese
	Fulani		Russian		Other: SPECIFY
	Hindi		Somali

Q30. What difficulties does your local agency face in retaining, recruiting, and hiring staff? (CHECK ALL THAT APPLY)

• Salaries not competitive

• Salaries not commensurate with level of job duties

• Benefits not competitive

• Minimal training and job growth offered

• Workload too great

• Location of local agency unsafe

• Location of local agency hard to get to

• Physical space occupied by local agency crowded

• Low employee morale throughout agency

• Lack of support for WIC program from State

• Limited career path or opportunities for promotion

• Required skillset lacking in prospective employees

• Other: PLEASE SPECIFY __________________

• None of the above

Caseload

Q31. Currently, approximately how many clients are served by all of the clinics under your local agency combined per month?

CLIENTS/MONTH

Technology

Q32. Does the typical clinic under your local agency have on-site the necessary technology, equipment, supplies, etc., to do the following tasks?

	Yes	No	Don’t Know
Enter/access client certification information via a computer?			
b. Perform hematological tests?			
c. Take anthropometric measurements for weight and height, and to calculate BMI (body mass)?			

Retention

The next set of questions concern the retention of WIC participants by participant category. We understand that local agencies may use different ways to define retention within the participant categories. Therefore, we will first ask you to explain how you determine retention and then ask for some data on retention over the last five Federal fiscal years (FYs).

Q33. Does your local agency determine retention for WIC participants?

• Yes

• No, determined by State agency [GO TO Q34]

• No, not determined at all [GO TO Q34]

• Not sure [GO TO Q34]

Q33A. How does your Local Agency define retention of WIC participants? Please describe any differences in definitions for infants, children, pregnant women, postpartum women, and breastfeeding women.

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Q33B. How often do you calculate retention? (CHECK ALL THAT APPLY)

 Weekly

 Monthly

 Quarterly

 Annually

 Other: PLEASE SPECIFY _________________________________

Q33C. Now we would like get information to enable us to determine your retention rates. Please complete the following table, which includes information for the past 5 Federal fiscal years (FY). Please enter a number for Total Certified, and either a number or percent for Total Retained [Note: if you have a standardized report(s) with this information you may upload that information here: {link}]

	FY 2013		FY 2014		FY 2015		FY 2016		FY 2017
Category	Total Certified	Total Retained	Total Certified	Total Retained	Total Certified	Total Retained	Total Certified	Total Retained	Total Certified	Total Retained
Infants		☐Number ☐Percent		☐Number ☐Percent		☐Number ☐Percent		☐Number ☐Percent		☐Number ☐Percent
Children		☐Number ☐Percent		☐Number ☐Percent		☐Number ☐Percent		☐Number ☐Percent		☐Number ☐Percent
Pregnant Women		☐Number ☐Percent		☐Number ☐Percent		☐Number ☐Percent		☐Number ☐Percent		☐Number ☐Percent
Postpartum Women		☐Number ☐Percent		☐Number ☐Percent		☐Number ☐Percent		☐Number ☐Percent		☐Number ☐Percent
Breastfeeding Women		☐Number ☐Percent		☐Number ☐Percent		☐Number ☐Percent		☐Number ☐Percent		☐Number ☐Percent

Q34. Does your local agency attempt to contact pregnant women who miss their first appointment (to apply for participation in the program) in order to reschedule the appointment?

• Yes

• No
  
  

Q35. Does your local agency, or any of the clinics under your local agency, do any of the following to increase WIC participant retention rates? (CHECK ALL THAT APPLY)

• Advertise via traditional delivery channels (including on television, movie theaters, internet, print publication materials, radio, gas stations, etc.)

• Post social media advertisements (Facebook, Pinterest, Twitter, Instagram, etc.)

• Send first birthday card to WIC caregivers on child’s first birthday

• Text message appointment reminders

• Provide transportation to and from sites

• Provide childcare onsite

• Encourage current participants to invite eligible family and friends to enroll and remain active

• Encourage healthcare professionals (doctors, nurses, midwives, etc.) to inform eligible women to enroll and remain active

• Other: PLEASE SPECIFY______________________________________________________

[SUBMIT]

End Survey

Thank you for participating in this survey!

pg. 18