Pre-Visit Questionnaire

Pre-Visit Questionnaire

Reminder Checklist SFY 2012

WIC Management Evaluation/Quality Assurance (MEQA) Review

Please use thischecklist to assist in preparing the necessary local agency documents that will be utilized for the WIC MEQA Review. Collecting or preparing these materials, including completion of the Pre-Visit Questionnaire, prior to the start of the review will help in streamlining the review process and on-site time.

I.Caseload Management/Scheduling
Participation by Program Report (HSPRO702) for previous month
Clinic Schedule (HSPRO505) for days of review
II.Budget and Fiscal
Current Organizational Chart
Current copy of the internal budget (spending plan), including the “Summary Expenditure Documentation Form” for the most recent completed fiscal reporting quarter
WIC Equipment Inventory List
(required for all equipment purchased with WIC funds costing $100 or more)
III.NVRA (since last WIC ME)
Copies of the Voter Registration Information (VRI) cards –for past two years
Weekly Transmittal forms –for past two years
IV.Civil Rights/Outreach (since last WIC ME)
Civil Rights Complaint Forms (kept on file) and Complaint Log(dated annually & indicate “no complaints” if applicable)
Civil Rights Training Log/Records and Training material used
Outreach Log/File (identifies: activities, dates, & staff involved) – for past two years
V.Program Integrity
(Please have a Cornerstone computer available for IDHS staffuse during the time of the Review)
Pre-Visit Questionnaire (complete and submitted to IDHS RNC prior to Review)
BOD/EOD Reports (if requested)
“Potential Dual Participant” BOD reports with documentation of reconciliation
List of active staff, by program, with access to Cornerstone
List of terminated staff from Cornerstone (since last WIC ME)
VI. Local Agency Logs, Reports and Other Documents
Validation/Calibration documentation for Anthropometric Biochemicalequipment
Integrated Plan for Healthy MCH Outcomes, current with up to date methods & data
Participation by Priority and Category Report (HSPR0107) past 3 months
Medically Prescribed Formula Report (HSPRO116) past 3 months
VI. Local Agency Logs, Reports and Other Documents
Breastfeeding Food Package Assignment Report (HSPR0120) past 3 months
Memorandum of Understanding (MOU) on file (if applicable)
WIC Farmers’ Market Monitoring Forms (if applicable)
  1. Local Agency Procedures & Quality Assurance

Local Agency Procedures
  1. Enhanced Outreach
  2. Geographic Boundaries (if applicable)
  3. Deferred Bloodwork Follow-up
  4. Referrals (Provide updated copy of referral list to your IDHS Regional Staff)
  5. Immunization Screening and Documentation
  6. Sample or donated formula (fair, equal distribution and safe disposal) (if applicable)
  7. Breastfeeding Positive Clinic Environment
  8. Breastfeeding Promotion and Support for BF and Postpartum Women
  9. Breastpump Issuance Procedures
Other Required Items
▪Standing Orders for Hgb/Hct, updated annually
▪Public Announcement for No Smoking (signs posted/visible)
▪“And Justice For All” current USDA Posters (posted/visible in WIC clinic areas)
Local Agency Quality Assurance /Self- Monitoring
  1. Certification Observation Results (Self-Monitoring Worksheets per MCH Integrated Plan)
  2. Program Operations Self-evaluation/Review, completed annually and kept on file
  3. Medically Prescribed Formula Quality Assurance (Internal Chart/Records Reviews)
  4. Formula Authorization List (staff trained onMedically Prescribed Formulas – past 3 years)
  5. Breastfeeding Food Package Assignment (Internal QA Chart/Records Reviews)
  6. Training Log/File, indicating documentation of training offered/attended forall WIC staff since your last review (includinggeneral and breastfeeding)

VIII. Secondary Nutrition Education & Nutrition Education Materials
Group EducationAttendance Sheets (HSPRO503) since last WIC ME(if applicable)
WIC Education Summary Report (HSPRO108) past 3 months
Secondary Education utilized by agency on file for review (Group Education Lesson Plans/Self Study Modules/Internet Education Certificates)
WIC Nutrition Education materials utilized (non-IDHS), including local agency created materials and those obtained from outside resources

SFY 12 WIC MEQA Reminder ChecklistPage 1 of 2

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