SNAP, WIC, FMNP, and CN COVID-19 Waivers, Evaluation, and Reporting Data - State Agencies and WIC Local Government (SLT)

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Overview

Introduction
(1a) Enrollment CY 2019
(1b) Enrollment CY 2020
(2a) New Certification CY 2019
(2b) New Certification CY 2020
(3a) Re-Certification CY 2019
(3b) Re-Certification CY 2020
(4a) Redemption CY2019
(4b) Redemption CY2020
(5) Nutrition Education Rate
(6) No-Show Rate

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Sheet 1: Introduction

Appendix X2: WIC MIS Data Pull Form							OMB Control No: 0584-XXXX
							Expiration Date: XX/XX/20XX
WIC MIS Data Pull Form
(See accompanying "WIC MIS Data Pull Instructions” for further guidance)
Background:
The Families First Coronavirus Response Act (P.L. 116-127, FFCRA), as amended by the Continuing Appropriations Act, 2021 and Other Extensions Act (P.L. 116-159), provides the U.S. Department of Agriculture (USDA) the statutory and regulatory waiver authorities necessary in a public health emergency such as COVID-19 to allow for social distancing in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). The FFCRA requires that WIC State agencies (SAs) receiving Federal waivers fulfill certain reporting requirements—these requirements are described in detail in sections 2203(b) and 2203(b) of the FFCRA and also in the provided guide “How to Fulfill the FFCRA WIC Waiver Reporting Requirements: Instructions and Tools.”
The WIC MIS Data Pull Form was developed to help SAs report on key administrative data as one of three tools developed to help State agencies meet their reporting requirements. Comprehensive instructions for completing this form, including alternative options, are provided in the accompanying “WIC MIS Data Pull Instructions.”
Completing the Form:
The WIC MIS Data Pull Form will collect administrative data from two time periods, Calendar Year (CY) 2019 and CY 2020. To complete this, SAs can either:
	• Populate each of the form’s tabs with the requested administrative data, and submit the completed form to FNS; or • Compile existing Management Information System (MIS) reports containing the data requested on the FFCRA WIC Administrative Data Form, and submit those reports to FNS.
We recognize that SA data and MIS reports may vary. If your SA is unable to obtain any specific data requested in the WIC MIS Data Pull Form, please notify [CONTRACTOR CONTACT] within 5 business days after receipt of the form to discuss alternative data collection options.
Contents:
The FFCRA WIC Administrative Data Form is divided into three sections and 10 different tabs as described below. Sections 1 and 2 ask for monthly data from CY 2019 and CY 2020 (January 2019 through December 2020), and Section 3 asks for data from one selected reference month for each year: June 2019 and June 2020.
	Section 1 Tabs (Monthly Data):
		(1a) Enrollment, CY 2019
		(1b) Enrollment, CY 2020
		(2a) New Certifications, CY 2019
		(2b) New Certifications, CY 2020
		(3a) Re-Certifications, CY 2019
		(3b) Re-Certifications, CY 2020
	Section 2 Tabs (Monthly Data):
		(4a) Redemption, CY 2019
		(4b) Redemption, CY 2020
	Section 3 Tabs (Specified Months Only):
		(5) Nutrition Education Rate, June 2019 and June 2020
		(6) No-Show Rate, June 2019 and June 2020
Who to Contact with Questions:
If you have any questions about the form or the information required to complete it, please contact [CONTRACTOR CONTACT]. The FNS points of contact for this collection are Alex Bush (Alexander.Bush@usda.gov) and Hunjin Lee (Hunjin.Lee@usda.gov).
We appreciate your time and work to complete the WIC MIS Data Pull Form and for your dedication to serving the participants of the WIC Program.

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Sheet 2: (1a) Enrollment CY 2019

(1a) Number of Enrolled CY 2019

Comments

Calendar Year 2019

Availability *

January 2019

February 2019

March 2019

April 2019

May 2019

June 2019

July 2019

August 2019

September 2019

October 2019

November 2019

December 2019

Data Description

Total Enrolled

Total number of enrollments for each month indicated in Row 3. This number should be the sum of the numbers in Row 5, Row 10, and Row 11.

1. Total Women

Total number of enrolled Women under the category for each month indicated in Row 3. This number should be the sum of the numbers in Row 6 through Row 9.

1a. Pregnant

Total number of enrolled Pregnant Women under the category for each month indicated in Row 3.

1b. Partially Breastfeeding

Total number of enrolled Partially Breastfeeding Women under the category for each month indicated in Row 3.

1c. Fully Breastfeeding

Total number of enrolled Fully Breastfeeding Women under the category for each month indicated in Row 3.

1d. Postpartum

Total number of enrolled Postpartum Women under the category for each month indicated in Row 3.

2. Total Infants

Total number of enrolled Infants under the category for each month indicated in Row 3.

3. Total Children

Total number of enrolled Children under the category for each month indicated in Row 3.

* Please enter "N/A" in Column B if the numbers for sub-category in Column A are not available.

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Sheet 3: (1b) Enrollment CY 2020

(1b) Number of Enrolled CY 2020

Comments

Calendar Year 2020

Availability *

January 2019

February 2019

March 2019

April 2019

May 2019

June 2019

July 2019

August 2019

September 2019

October 2019

November 2019

December 2019

Data Description

Total Enrolled

Total number of enrollments for each month indicated in Row 3. This number should be the sum of the numbers in Row 5, Row 10, and Row 11.

1. Total Women

Total number of enrolled Women under the category for each month indicated in Row 3. This number should be the sum of the numbers in Row 6 through Row 9.

1a. Pregnant

Total number of enrolled Pregnant Women under the category for each month indicated in Row 3.

1b. Partially Breastfeeding

Total number of enrolled Partially Breastfeeding Women under the category for each month indicated in Row 3.

1c. Fully Breastfeeding

Total number of enrolled Fully Breastfeeding Women under the category for each month indicated in Row 3.

1d. Postpartum

Total number of enrolled Postpartum Women under the category for each month indicated in Row 3.

2. Total Infants

Total number of enrolled Infants under the category for each month indicated in Row 3.

3. Total Children

Total number of enrolled Children under the category for each month indicated in Row 3.

* Please enter "N/A" in Column B if the numbers for sub-category in Column A are not available.

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Sheet 4: (2a) New Certification CY 2019

(2a) Number of New Certifications CY 2019

Comments

Calendar Year 2019

Availability *

January 2019

February 2019

March 2019

April 2019

May 2019

June 2019

July 2019

August 2019

September 2019

October 2019

November 2019

December 2019

Data Description

Total New Certifications

Total number of New Certifications for each month indicated in Row 3. This number should be the sum of the numbers in Row 5, Row 10, and Row 11.

1. Total Women

Total number of Newly Certified Women under the category for each month indicated in Row 3. This number should be the sum of the numbers in Row 6 through Row 9.

1a. Pregnant

Total number of Newly Certified Pregnant Women under the category for each month indicated in Row 3.

1b. Partially Breastfeeding

Total number of Newly Certified Partially Breastfeeding Women under the category for each month indicated in Row 3.

1c. Fully Breastfeeding

Total number of Newly Certified Fully Breastfeeding Women under the category for each month indicated in Row 3.

1d. Postpartum

Total number of Newly Certified Postpartum Women under the category for each month indicated in Row 3.

2. Total Infants

Total number of Newly Certified Infants under the category for each month indicated in Row 3.

3. Total Children

Total number of Newly Certified Children under the category for each month indicated in Row 3.

* Please enter "N/A" in Column B if the numbers for sub-category in Column A are not available.

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Sheet 5: (2b) New Certification CY 2020

(2b) Number of New Certifications CY 2020

Comments

Calendar Year 2020

Availability *

January 2019

February 2019

March 2019

April 2019

May 2019

June 2019

July 2019

August 2019

September 2019

October 2019

November 2019

December 2019

Data Description

Total New Certifications

Total number of New Certifications for each month indicated in Row 3. This number should be the sum of the numbers in Row 5, Row 10, and Row 11.

1. Total Women

Total number of Newly Certified Women under the category for each month indicated in Row 3. This number should be the sum of the numbers in Row 6 through Row 9.

1a. Pregnant

Total number of Newly Certified Pregnant Women under the category for each month indicated in Row 3.

1b. Partially Breastfeeding

Total number of Newly Certified Partially Breastfeeding Women under the category for each month indicated in Row 3.

1c. Fully Breastfeeding

Total number of Newly Certified Fully Breastfeeding Women under the category for each month indicated in Row 3.

1d. Postpartum

Total number of Newly Certified Postpartum Women under the category for each month indicated in Row 3.

2. Total Infants

Total number of Newly Certified Infants under the category for each month indicated in Row 3.

3. Total Children

Total number of Newly Certified Children under the category for each month indicated in Row 3.

* Please enter "N/A" in Column B if the numbers for sub-category in Column A are not available.

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Sheet 6: (3a) Re-Certification CY 2019

(3a) Number of Re-certifications CY 2019

Comments

Calendar Year 2019

Availability *

January 2019

February 2019

March 2019

April 2019

May 2019

June 2019

July 2019

August 2019

September 2019

October 2019

November 2019

December 2019

Data Description

Total Recertifications

Total number of Re-Certifications for each month indicated in Row 3. This number should be the sum of the numbers in Row 5, Row 10, and Row 11.

1. Total Women

Total number of Re-Certified Women under the category for each month indicated in Row 3. This number should be the sum of the numbers in Row 6 through Row 9.

1a. Pregnant

Total number of Re-Certified Pregnant Women under the category for each month indicated in Row 3.

1b. Partially Breastfeeding

Total number of Re-Certified Partially Breastfeeding Women under the category for each month indicated in Row 3.

1c. Fully Breastfeeding

Total number of Re-Certified Fully Breastfeeding Women under the category for each month indicated in Row 3.

1d. Postpartum

Total number of Re-Certified Postpartum Women under the category for each month indicated in Row 3.

2. Total Infants

Total number of Re-Certified Infants under the category for each month indicated in Row 3.

3. Total Children

Total number of Re-Certified Children under the category for each month indicated in Row 3.

* Please enter "N/A" in Column B if the numbers for sub-category in Column A are not available.

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Sheet 7: (3b) Re-Certification CY 2020

(3b) Number of Re-certifications CY 2020

Comments

Calendar Year 2020

Availability *

January 2019

February 2019

March 2019

April 2019

May 2019

June 2019

July 2019

August 2019

September 2019

October 2019

November 2019

December 2019

Data Description

Total Recertifications

Total number of Re-Certifications for each month indicated in Row 3. This number should be the sum of the numbers in Row 5, Row 10, and Row 11.

1. Total Women

Total number of Re-Certified Women under the category for each month indicated in Row 3. This number should be the sum of the numbers in Row 6 through Row 9.

1a. Pregnant

Total number of Re-Certified Pregnant Women under the category for each month indicated in Row 3.

1b. Partially Breastfeeding

Total number of Re-Certified Partially Breastfeeding Women under the category for each month indicated in Row 3.

1c. Fully Breastfeeding

Total number of Re-Certified Fully Breastfeeding Women under the category for each month indicated in Row 3.

1d. Postpartum

Total number of Re-Certified Postpartum Women under the category for each month indicated in Row 3.

2. Total Infants

Total number of Re-Certified Infants under the category for each month indicated in Row 3.

3. Total Children

Total number of Re-Certified Children under the category for each month indicated in Row 3.

* Please enter "N/A" in Column B if the numbers for sub-category in Column A are not available.

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Sheet 8: (4a) Redemption CY2019

(4a) EBT Redemption vs. Issuance CY2019

Comments

Calender Year 2019

January 2019

February 2019

March 2019

April 2019

May 2019

June 2019

July 2019

August 2019

September 2019

October 2019

November 2019

December 2019

Category Code

Subcategory Code

Unit of Measure

Description

Redeemed

Issued

Redemption Rate

Redeemed

Issued

Redemption Rate

Redeemed

Issued

Redemption Rate

Redeemed

Issued

Redemption Rate

Redeemed

Issued

Redemption Rate

Redeemed

Issued

Redemption Rate

Redeemed

Issued

Redemption Rate

Redeemed

Issued

Redemption Rate

Redeemed

Issued

Redemption Rate

Redeemed

Issued

Redemption Rate

Redeemed

Issued

Redemption Rate

Redeemed

Issued

Redemption Rate

N/A

N/A

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N/A

N/A

---

Sheet 9: (4b) Redemption CY2020

(4b) EBT Redemption vs. Issuance CY2020

Comments

Calender Year 2020

January 2020

February 2020

March 2020

April 2020

May 2020

June 2020

July 2020

August 2020

September 2020

October 2020

November 2020

December 2020

Category Code

Subcategory Code

Unit of Measure

Description

Redeemed

Issued

Redemption Rate

Redeemed

Issued

Redemption Rate

Redeemed

Issued

Redemption Rate

Redeemed

Issued

Redemption Rate

Redeemed

Issued

Redemption Rate

Redeemed

Issued

Redemption Rate

Redeemed

Issued

Redemption Rate

Redeemed

Issued

Redemption Rate

Redeemed

Issued

Redemption Rate

Redeemed

Issued

Redemption Rate

Redeemed

Issued

Redemption Rate

Redeemed

Issued

Redemption Rate

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

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N/A

N/A

N/A

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---

Sheet 10: (5) Nutrition Education Rate

(5) Nutrition Education Rate		Comments
	Number of Completed WIC Nutrition Education Appointments	Number of Scheduled WIC Nutrition Education Appointments	Nutrition Education Rate	Comments
1. June 2020
Total Participants			N/A
1. Total Women			N/A
1a. Pregnant			N/A
1b. Partially Breastfeeding			N/A
1c. Fully Breastfeeding			N/A
1d. Postpartum			N/A
2. Total Infants			N/A
3. Total Children			N/A
	Number of Completed WIC Nutrition Education Appointments	Number of Scheduled WIC Nutrition Education Appointments	Nutrition Education Rate	Comments
2. June 2019
Total Participants			N/A
1. Total Women			N/A
1a. Pregnant			N/A
1b. Partially Breastfeeding			N/A
1c. Fully Breastfeeding			N/A
1d. Postpartum			N/A
2. Total Infants			N/A
3. Total Children			N/A
3. Was the Nutrition Education Rate * in June of 2020 higher, lower, or about the same as one year earlier in June of 2019?
		Higher
		Lower
		About the same
		Don't Know
*

---

Sheet 11: (6) No-Show Rate

(6) No-Show Rate		Comments
	Number of Completed WIC Certification Appointments	Number of Scheduled WIC Certification Appointments	No-Show Rate	Comments
1. June 2020
Total Participants			N/A
1. Total Women			N/A
1a. Pregnant			N/A
1b. Partially Breastfeeding			N/A
1c. Fully Breastfeeding			N/A
1d. Postpartum			N/A
2. Total Infants			N/A
3. Total Children			N/A
	Number of Completed WIC Certification Appointments	Number of Scheduled WIC Certification Appointments	No-Show Rate	Comments
2. June 2019
Total Participants			N/A
1. Total Women			N/A
1a. Pregnant			N/A
1b. Partially Breastfeeding			N/A
1c. Fully Breastfeeding			N/A
1d. Postpartum			N/A
2. Total Infants			N/A
3. Total Children			N/A
3. Was the No-Show Rate * in June of 2020 higher, lower, or about the same as one year earlier in June of 2019?
		Higher
		Lower
		About the same
		Don't Know
*