State and Local WIC Agency Directors (SLT)

APPENDIX B1.a

STATE AGENCY SURVEY

INTRO: Thank you for participating in the Third National Survey of WIC Participants. This survey is sponsored by the U.S. Department of Agriculture (USDA) Food and Nutrition Service (FNS) and administered by 2M Research Services. Please refer to the accompanying cover letter for full details of this 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 local agencies and participants—is designed to provide FNS with additional information on policies and program operations, beyond those available from existing program sources (e.g., State Plans).

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 66 minutes (1.10 hours) 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.

Identity

Q1. What types of documentation does your State agency accept as proof of identity for a WIC applicant (assuming the documentation includes a printed name)? (CHECK ALL THAT APPLY)

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

 Government issued driver’s license, State ID

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

 Military ID

 Social Security card

 Voter’s registration card

 Foster care placement letter

 Passport or immigration records

 Marriage license

 Birth certificate

 Crib card

 Hospital discharge papers or hospital ID card

 Official immunization record

 Green card

 Self-declaration form for migrants, homeless, and victims of disaster

 Medicaid referrals

 Baptismal record or confirmation record with church seal

 Adoption papers

 Tribal identification card

 Temporary Assistance for Needy Families (TANF) card

 Recent paystub or leave and earnings statement (LES)

 Loan papers from a bank/financial company

 Healthcare ID card

 WIC or eWIC folder

 Other: PLEASE SPECIFY

 Other: PLEASE SPECIFY

 Other: PLEASE SPECIFY

 Other: PLEASE SPECIFY

 Other: PLEASE SPECIFY

Residency

Q2. What types of documentation does your State agency accept to verify the residency of a WIC applicant (assuming the documentation includes a printed address)? (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

 Property tax bill

 SSI statement

 Recent paystub

 Signed letter from shelter/hotel/motel where residing

 Credit card bill

 School records

 Shelter verification letter

 Foster care placement letters

 Voter registration card

 Medicaid card

 Other: PLEASE SPECIFY

 Other: PLEASE SPECIFY

 Other: PLEASE SPECIFY

 Other: PLEASE SPECIFY

 Other: PLEASE SPECIFY

Q2A. Check the statement that best describes your State agency’s residency requirements for WIC participants:

• WIC participants only need to show that they live somewhere within the State.

• WIC participants must reside within the service delivery area of the WIC local agency (overseeing the clinic) where she/he resides.

• The decision about whether a WIC participant must reside within the local agency boundary, or can simply reside in the State, is left to local agencies to decide.

• WIC participants must be an enrolled member of a recognized Tribal organization.

• Other: PLEASE SPECIFY____________________________________________

Household Composition

Q3. What additional guidelines, if any, are given by your State agency to local agencies to help them determine the family economic unit, above and beyond the national WIC program definition, which defines it as “a group of related or nonrelated individuals who are living together as one economic unit?”

• No additional guidelines are given.

• The following guidelines are given: (PROVIDE SUPPORTING POLICY STATEMENTS AS APPROPRIATE)
  _________________________________________________________________
  
  
  

Certification Periods

Q4. In your State, when an infant turns 1 year old (or 7 months if not breastfeeding), does his or her current certification remain valid, or does the infant become categorically ineligible and need to be certified again based on criteria used for children?

• The current certification remains valid.

• The infant becomes categorically ineligible and needs to be certified again based on criteria used for children.

• Neither. There is no State agency policy. Discretion is given to local agencies.

• Other: PLEASE SPECIFY____________________________________________

Q5. Does your State agency use a data month or calendar month for issuance cycles?

 Calendar month (benefits continue until the end of the month)

 Data or “rolling” month (benefits continue until next 30-day period of eligibility ends)

 Other: PLEASE SPECIFY____________________________________________

Q6. What other discretion, if any, does your State agency use or grant to local agencies regarding certification periods?

 No additional discretion is given

 Other discretion is given. PLEASE SPECIFY:

Proxies/Authorized Representatives

Q7. Which of the following actions are individuals who are authorized to represent WIC participants in your State permitted to do? (CHECK ALL THAT APPLY)

	Pregnant		Postpartum		Breastfeeding		Infant		Child
	Authorized Rep	Proxy	Authorized Rep	Proxy	Authorized Rep	Proxy	Authorized Rep	Proxy	Authorized Rep	Proxy
Act on behalf of WIC applicant at certification appointments											
Obtain food instruments (vouchers/EBT cards)											
Attend educational sessions											
Redeem food instruments (vouchers/EBT cards)											
Not Applicable. State agency does not allow proxies											
Other: PLEASE SPECIFY ______________________											

Composition of the WIC Application

Q8. Does your State agency require local agencies to use online/electronic WIC applications or are paper applications acceptable as well? (CHECK ALL THAT APPLY)

 Online/electronic

 Paper

[IF ABOVE ARE BOTH CHECKED, GO TO 8A]
 Do not require WIC application: PLEASE EXPLAIN: _____________________ [GO TO Q10]

Q8A. Among the local agencies in your State, how many use each of the following options:

____ Online/electronic

____ Paper

____ Both online/electronic and paper

Q8B. Under what circumstances are paper applications used? (CHECK ALL THAT APPLY)

 Nutrition assessment

 During emergency or disaster situations

 Other: PLEASE SPECIFY______________________________

Q9. Does your State agency provide local agencies with additional guidance on what is included in an acceptable WIC application?

 Yes

 No

Income Determination

Q10. State agencies can set an income standard between 100% and 185% of the federal poverty guidelines to determine eligibility for WIC. What is the income standard in your State for determining WIC eligibility?

___ ___ ___ % of the federal poverty guidelines

Q11. In determining household income, does the State agency exclude any of the following military housing allowances? (CHECK ALL THAT APPLY)

• Basic Allowance for Housing (BAH) for off-base housing and privatization housing in the U.S.

• Family Separation Housing (FSH) provided to military personnel for overseas housing

• Overseas Housing Allowance (OHA) provided to military personnel living overseas

• Overseas Continental U.S. (OCONUS) cost of living allowance (COLA) provided to active duty uniformed service members in Hawaii, Alaska, and Guam

• Not sure

Q11A. When adjunctive/automatic eligibility is NOT established, what sources of income does your State agency require local agencies to count when determining the income eligibility of an applicant’s household? (CHECK ALL THAT APPLY)

 Wages, salary, fees  Social Security  Energy assistance

 Tips and bonuses  Private pension  Rental assistance

 Self-employment  Disability pension  Net rental income

 Unemployment compensation  Workers compensation

 Medical assistance (any, i.e., Medicaid)

 Supplemental Security Income – Fed Government

 Dividends or interest from savings

 Income from trusts

 Commissions  Income from estates  Welfare

 Net royalties  Alimony

 Other: PLEASE SPECIFY ________________

Q11B. In determining the income of an applicant where unemployment is not an issue, does the State agency instruct local agencies to use annual income, to use current income, or is it left up to the judgment of the local agencies? (CHECK ONE)

• Annual income used (income received by the household during the last year)

• Current income used (income received by the household during the month [30 days] prior to date of application)

• Left to local agencies to decide

• Other: PLEASE SPECIFY
  
  

Q11C. What types of proof are acceptable in your State to verify the sources of income for WIC applicants? (CHECK ALL THAT APPLY)

 Most recent tax return (self-employed only)

 Paycheck or pay stubs

 Signed statement by employer

 Statement of benefits by public agency

 Statement of benefits for child support and alimony

 Leave and Earnings Statement (LES) for military pay

 Unemployment letter or notice letter signed by official State/local agency attesting to client’s low income

 Written statement from reliable third party

 Statement from bank or other financial institution savings (e.g., direct deposit)

 Other: PLEASE SPECIFY

Adjunctive/Automatic Income Eligibility

Q12. Which programs establish adjunctive or other automatic income eligibility for a WIC applicant in your State? (CHECK ALL programs that establish eligibility in the left-hand column. Programs that are required by §246.7 of the WIC program regulations are already checked for you.)

		For each item checked in the left column, please indicate what, if any proofs the State agency requires local agencies to collect. (CHECK ALL THAT APPLY)
(CHECK ALL THAT APPLY)		No Specific Requirements are Set	Contact Office Directly	Electronic Lookup	Award Letter	Other: PLEASE SPECIFY
	Supplemental Nutrition Assistance Program (SNAP)					_________
	Medicaid					_________
	Temporary Assistance for Needy Families (TANF)					_________
	Children's Health Insurance Program (CHIP)					_________
	Supplemental Security Income (SSI)					_________
	Free and Reduced-Meal School Lunch/Breakfast Programs (NSLP and SBP)					_________
	Food Distribution Program on Indian Reservations (FDPIR)					_________
	Low Income Home Energy Assistance Program (LIHEAP)					_________
	Other: PLEASE SPECIFY________________					_________
	Other: PLEASE SPECIFY________________					_________

Q13. Does your State agency allow local agencies to accept incomplete Verification of Certification (VOC) documents (cards or printed summaries)?

 Yes: PLEASE EXPLAIN: ___________________________

 No

Denied Applications

Q14. Does the State agency require local agencies to follow any of the listed approaches to notify applicants of certification denials? (CHECK ALL THAT APPLY)

 Written notification

 Verbal notification (by phone or in-person)

 Local agency discretion. PLEASE EXPLAIN: ___________________________

Q15. Does State policy require that local agencies keep information on denied applications?

• Yes

• No [GO TO Q17]

Q16. What information on denied applicants is required to be retained by the State agency? (CHECK ALL THAT APPLY)

 Name of applicant

 Address

 Phone number

 WIC applicant category

 Reason for denial

 Date of application

 Date of denial

 Other: PLEASE SPECIFY__________________________________________

Q16A. How is the denied applicant information retained?

 No specific retention requirements

 Paper copy only

 Electronic copy only

 Both paper and electronic

Q17. Does your State agency review ineligibility determinations to ensure that they were made correctly?

 Yes

 No

If yes, please briefly describe this process.

Retention

The next set of questions concern the retention of WIC participants by participant category. We understand that State 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 5 federal fiscal years (FYs)¹.

Q18. Does your State agency determine retention for WIC participants?

 Yes

 No [GO TO Q19]

Q18A. How does your State agency define retention of WIC participants? Please describe any differences in definitions for infants, children, pregnant women, postpartum women, and breastfeeding women.

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Q18B. How often do you calculate retention? (CHECK ALL THAT APPLY)

 Weekly

 Monthly

 Quarterly

 Annually

 Other: PLEASE SPECIFY _________________________________

Q18C. Can your State agency provide retention information by local agency for all the local agencies in your jurisdiction?

 Yes

 No

Q18D. 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 FYs. 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 (Oct 2012 – Sept 2013)		FY 2014 (Oct 2013 – Sept 2014)		FY 2015 (Oct 2014 – Sept 2015)		FY 2016 (Oct 2015 – Sept 2016)		FY 2017 (Oct 2016 – Sept 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

Operations

The next set of questions concern how many local agencies (or offices), clinics, and sites operate in your State. We understand that States use different terms for these organizations. By local agency or local office, we mean offices that maintain administrative data on clients and communicate participation information directly with you. By clinic or site, we mean the offices that are sponsored by State or local agencies and provide services to clients. Some of the sites may be temporary (satellite) sites.

Q19. In FY 2016–2017, how many local agencies in your State did not provide services at the location of the local agency?

LOCAL AGENCIES

Q20. In FY 2016–2017, how many local agencies in your State did provide services at the location of the local agency?

LOCAL AGENCIES

Q21. In FY 2016–2017, how many WIC clinics or sites, including satellite and temporary sites, operated in your State? (Please do not include the clinics/sites accounted for in Q20.)

LOCAL CLINICS/SITES

Manufacturer Rebates

Q22. Does your State have rebate contracts for:

Q22A. Infant cereal

 Yes

 No

Q22B. Jarred infant foods

 Yes

 No

Q22C. Other foods (SPECIFY: _________________________)

 Yes

 No

Q23. What was the total rebate savings in FY 2016–2017 for:

[Programming note: Response options will only appear for “yes” answers in previous question.]

Q23A. Infant cereal: $__________________________

Q23B. Jarred infant foods: $__________________________

Q23C. Other foods: $__________________________

Record Keeping and Systems

Q24. Does your record-keeping system (or database) retain electronic records that would permit review and confirmation of participant disqualifications?

 Yes

 No

 Not sure

Q25. Does your record-keeping system (or database) retain records that would permit review and confirmation of denied applicants?

 Yes, we maintain primarily electronic records that permit review and confirmation.

 Yes, we maintain electronic and paper records that permit review and confirmation.

 Yes, we maintain primarily paper records that permit review and confirmation.

 No

 Not sure

Q26. Can you match records from other programs’ systems (such as TANF or Medicaid) through your WIC database in order to facilitate certification or other record keeping functions?

 Yes: PLEASE SPECIFY _________________________________

 No

 Not sure

Q27. With regard to your database of WIC participants, what hardware system do you use to store participant data? (You may need to ask your database manager in order to answer Q27 and Q27A) (CHECK ALL THAT APPLY)

 Mainframe server

 Unix system
 Midrange computer

 PC server

 Web-based

 Not sure

 Other: PLEASE SPECIFY: _________________________________

Q27A. What database software systems are used? (CHECK ALL THAT APPLY)

 Access (MDB)

 Excel (XLS)

 Oracle

 Sybase

 DB2

 Microsoft SQL Server

 CMIS

 WIC SIS

 Adabas

 Informix

 Not sure

 Other: PLEASE SPECIFY: _________________________________

Thank you for participating in this survey!

[SUBMIT]

End Survey

1 Please note that FY is from October 1^st – September 30^th. For example, FY 2013 covers the period from October 1, 2012 to September 30, 2013.

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