U.S.DepartmentofAgriculture,Food andNutritionService(FNS),

OMBControlNumber:0584-0591Expirationdate:09/20/2020

SpecialSupplementalNutritionProgramforWomen,InfantsandChildren(WIC)

LovingSupportAwardofExcellenceGold Premiere/Gold Elite Application

LocalAgencyNameStreetAddress

City,State,ZipcodeApplicant’sName andTitleTelephoneNumber

Email addressDate

Publicreportingburden for this collection ofinformationisestimated to average2hours per response,includingthe time for reviewinginstructions,searchingexisting datasources, gatheringandmaintainingthe dataneeded,andcompleting andreviewingthe collectionofinformation.Anagencymaynotconduct or sponsor,anda personisnotrequiredtorespondto, acollection ofinformationunless itdisplays acurrently validOMBcontrol number.Sendcomments regardingthis burden estimate or anyother aspectofthis collection ofinformation,includingsuggestions for reducingthis burden, to:

U.S.DepartmentofAgriculture,FoodandNutritionServices,OfficeofPolicy Support,Room1014,Alexandria,VA22302ATTN:PRA(0584-0591).Donotreturnthe completedform to this address.

OMBControlNumber:0584-0591

Expirationdate:09/20/2020

LovingSupportAwardofExcellence

DOWNLOAD AND SAVEINSTRUCTIONSFROMFNSPUBLICWEBSITEBEFORE

BEGINNINGAPPLICATION.Inordertobeeligibletoapplyforanaward,yourlocalagencymustfirstbeabletoverifythefollowingquestion.

  1. Haveyou completedthe GoldAwardapplication and attached documentation?Yes ☐
PEERCOUNSELING
1.Doyouhaveestablishedguidelinesforhowmanyhoursofobservation/shadowingisrequiredaspartofpeercounselingtraining/continuingeducation? / Yes ☐ / No☐
2. Doyou haveaWIC Designated Breastfeeding Expert staffor doyou contractwith anIBCLCtoserve asareferralsource for peercounselors? / Yes☐ / No☐
3.Do you haveareferralprocess in place betweenhospitalsandthe WICProgramto facilitate peer counselorfollow-up care for newly-deliveredWICmothersafterdischarge? / Yes☐ / No☐
4.Doyouhaveasystem thatelectronicallydocumentsandtrackspeercounselingreferralsandcontacts? / Yes☐ / No☐
5.Doyou have policies andprocedures for homevisitsaspart ofyourpeercounselingprogram?
Attach supportivedocumentation.
Fill in thedocument title andindicate the page number(s)wheretheinformationthatanswersthequestioncanbefound. / Yes☐DocumentTitle
PageNumber(s) / No☐
6.Doyou have policies andprocedures for hospitalvisitsaspart ofyourpeercounselingprogram?
Attachsupportivedocumentation.Fill in the documenttitle andindicatethepage number(s)where the informationthat answersthis questioncanbe found. / Yes☐DocumentTitle
PageNumber(s) / No☐

OMBControlNumber:0584-0591

Expirationdate:09/20/2020

7.Doyou havearecognitionprogram inplace toacknowledgepeer counseloraccomplishments? / Yes☐ / No☐
8.Do you include career pathstructuresforupward mobility of peercounselors? / Yes☐ / No☐
9. Do you have policies andprocedures for peer counselors to communicateviasocialmediaor innovative technologies,e.g.,Facebook,textmessaging,Twitter,SkypeorPalTalk?
Attachnarrativeandsupportivedocumentationthat indicateexistingpolicies andprocedures for peer counselors to communicate viasocialmedia technologies.
Fill in bothdocument titles andindicate the page numbers(s) thatcorrespondstoeachdocument. / Yes☐NarrativeTitle
DocumentTitle
PageNumber(s) / No☐
PARTNERSHIP
Apartnership isdefined asasustainable ongoing voluntarycollaborative agreementbetweentwo ormorepartiesbasedon mutuallyagreedobjectivesandashared vision,generally withina formalstructure.
Thepartnersagreetoworktogethertoachieveacommongoal,undertakespecifictasks,andsharerisks,responsibilities,resources,competencies andbenefits in orderto provide breastfeeding supportthroughoutthe continuum ofcare.
10.Doesthe partnership havea written agreementor a Memorandum ofUnderstanding?
Attachsupportivedocumentation.Fill in the documenttitle andindicatethepage number(s)where the informationthat answersthis questioncanbe found. / Yes ☐
DocumentTitle
PageNumber(s) / No ☐
11.Havenew policies or procedures beendeveloped because ofthepartnership?
Attachnarrative or supportivedocumentation.Fill in the documenttitle andindicatethepage number(s)where the informationthat answersthis questioncanbe found. / Yes ☐
DocumentTitle PageNumber(s) / No ☐
12.Doesthe partnership haveaplan for sustainability? / Yes ☐ / No ☐
13.Doyoupartnerwithstakeholderssuchasthe AmericanHospital Associationto supportthe Baby-FriendlyHospitalInitiativein yourcommunity? / Yes☐ / No☐
OTHER CRITERIA
14.Doyouhaveasupportiveclinicenvironment thatimplementsbreastfeeding-friendlyworkplace policesfor WICstaff?
Attachsupportivedocumentation.Fill in the documenttitle andindicatethepage number(s)where the informationthat answersthis questioncanbe found / Yes ☐
DocumentTitle
PageNumber(s) / No☐
15.Do you ensure that peer counselors are solely dedicated to peer counselor support for breastfeeding, or, if you allow peer counselors to work in dual-role positions, do you ensure that those positions do not compromise the intent and purpose of the BFPC program? / Yes ☐ / No ☐
16. Do you providearoundthe clockassistancetoassistmothersworkingthroughtheirbreastfeeding problems?
Attachnarrative.
Fillinnarrativetitle. / Yes☐NarrativeTitle / No ☐

LovingSupportAwardofExcellence

Gold Premiere/Gold Elite Application-1

OMBControlNumber:0584-0591

Expirationdate:09/20/2020

Pleasereviewthechecklistpriortosubmittingapplicationandsupportivedocumentation.

Youmustbeeligible for the Gold Award(30 points) to applyfor the GoldPremiereandGoldEliteAward. / Yes☐ / No☐
Verifythatyou havemet the performancedata criteria. / Yes☐ / No☐
Narrativesand/orsupportivedocumentationmustbeattachedtotheapplicationtobeeligibleforanAward. / Yes☐ / No☐
Whenattachingsupportive documents make sure you indicatethepagenumber(s)wherethe informationthat answersthe questioncan befound. / Yes☐ / No☐

PleasecompletetheApplicationVerificationFormonpage6oftheApplication.

LovingSupportAwardofExcellence

Gold Premiere/Gold Elite Application-1

OMBControlNumber:0584-0591

Expirationdate:09/20/2020

LovingSupportAwardofExcellenceApplicantVerificationForm

Pleasereadthefollowingstatementandsignbelowifyouagree:

Ihavereviewedthisapplication,andIattesttotheaccuracyoftheinformationprovided.Iagreetomaintainthestandardsandproceduresindicatedinthisapplicationforthedurationofourawardperiod.Furthermore,IagreetocooperatewithUSDAandotherorganizations,uponrequest,topublicizeourefforts.

LocalAgencyApplicant’sNameDate

Pleaseuploadyourcompletedapplicationandsupportingdocumentationto

ThankyouforapplyingfortheLovingSupportAwardofExcellence.

Formoreinformation,visittheFNS/WICWebsite:

LovingSupportAwardofExcellenceGold Premiere/Gold Elite Application6