New Peer Program Application Part 1 for (Agency Name)

Intent to Apply: Minnesota WIC Peer Breastfeeding Support Program
By April 28, 2010 please let us know your interest. Completing this form does not obligate you to submit a grant application. It will help us in planning.
We plan to submit an application for Minnesota WIC peer breastfeeding support funding.
We don’t plan on submitting an application at this time, but may be interested in the future if funds are available. Optional: comments on why you are not applying at this time and or what would help you to develop a program:
We plan to participate in the conference call about peer breastfeeding support on the following date:
Tuesday, May 4, 2010, 9:00am Wednesday, May 5, 2010, 11:30 am
People in our agency to be notified of the call in number and passcode for the conference call:
Name Email Address Phone
Intent to apply completed by (name) :
Position: Director
WIC Coordinator,
WIC Breastfeeding Coordinator,
Other
Agency name:
Street address:
City: Zipcode:
Phone: Fax: E-mail:
The application and guidance will be available on the MN WIC website the week of April 12.
By April 28, 2010 please submit this form
 By fax (651-215-8951) or
 E-mail stacia.pomrenke@state.mn.us
with “ PBSP Intent to apply ” in the subject line.
If you email or fax the intent to apply please contact us by phone to verify receipt. You can call
Stacia Pomrenke at 651-201-4411 or Mary B. Johnson at 651-201-4406 until April 15 th / Linda
Dech at 651-201-3649 after April 15 th .
If you have questions please contact:
 Until April 15: Mary B Johnson at 651-201-4406 or mary.b.johnson@.state.mn.us
 After April 15: Linda Dech at linda.dech@state.mn.us
or 651-201-3649.

Applicant:
Current MN WIC Program Grantee?
Yes, No (If no, not eligible to apply)
If you are a current MN WIC Peer Breastfeeding Support Program grantee do not submit this application, watch the Wednesday Update for information on the application for peer programs for FFY12.)
New Peer Program Application Part 1 for (Agency Name)

Minnesota Department of Health Grant Application Face Sheet
Grant Application for: Minnesota WIC Peer Breastfeeding Support Program
1. Applicant Agency With Which Grant Contract is to be Executed
Legal Name: Street Address:
2. Director of Applicant Agency
Name and Title: Street Address:
E-Mail Address:
3. Fiscal Management Officer of Applicant Agency
Name and Title: Street Address:
E-Mail Address:
Telephone Number:
FAX Number:
Telephone Number:
FAX Number:
Telephone Number:
FAX Number:
4. Operating Agency (if different from number 1 above)
Name and Title: Street Address:
E-Mail Address:
Telephone Number:
FAX Number:
5. Contact Person for Operating Agency (if different from number 2 above)
Name and Title: Address: Telephone Number:
E-Mail Address:
FAX Number:
6. Contact Person for Further Information on Application (if different from number 5 above)
Name and Title: Street Address: Telephone Number:
E- Mail Address:
FAX Number:
7. Certification
I certify that the information contained herein is true and accurate to the best of my knowledge and that I submit this application on behalf of the applicant agency.
_________________________
Signature of Director of Applicant Agency Title Date
HE-01274-05 (4/01) - PART A

1. Applicant Information
Applicant Agency Name
Minnesota Tax I.D.
Number
Federal Tax I.D.
Number
Non-profit Status – 501.C3 form attached?
Yes Not Applicable
Social Security Number
N/A
2. Proposal Information
Project Funds Requested Per Year
$
Proposed Service Area
Proposed Funding Category
Minnesota WIC Peer Breastfeeding Support Program
HE-01274-05 (3/01) - PART B
New Peer Program Application Part 1 for (Agency Name)

We are submitting this application with the intent to implement and continue WIC peer breastfeeding support services. We understand that we are required to submit the full plan for implementing peer services and hiring peers on or before September 15, 2010. We also understand that requirements for the peer programs include all components of the Food and Nutrition Service model for peer support programs. We have reviewed the requirements and Part 2 of the application that must be completed to receive funding to hire peers and continue peer services. I have the authority to make this decision for our agency or program. We agree to provide a short progress report 45 days after we are notified we can begin services.
We have discussed with our program and nutrition consultants our readiness to add a peer breastfeeding support program without compromising requirements for other WIC services.
Signature: _________________________________________
Name, please type or print:
Position:
For your reference all questions are included here and in the Guidance document. Questions to be completed with this Part 1 application are noted in bold. Questions to be completed in Part 2 are noted as “to be completed in Part 2.”
1.
Need for peer support staff.
Please briefly describe any special needs in your WIC population that you believe could effectively be addressed through peer breastfeeding support (PBS). Needs might include language, culture, age, isolation / lack of support, characteristics of your community or service area that create challenges to breastfeeding support, length of breastfeeding duration, etc.
Please include breastfeeding rates in your proposed service area(s). (WIC Summary Statistics
Supplemental report December 2009, all clinics report. Found in the quarterly reports.)
BF rates by subgroups, ALL State of MN Agency:
Breastfed Ever
< 2 Weeks
#
12603
1726
%
74.25%
13.82%
# %
> 6 mo
> 12 mo
5877
3770
47.05%
30.18%
Note that for smaller agencies the % will vary from month to month. This will give you a snapshot of rates in your agency.
You might also want to review the summary of the reasons that breastfeeding stopped, found in the same report.
New Peer Program Application Part 1 for (Agency Name)
1

Please include numbers of participants in your proposed service area(s). (WIC Summary statistics participation report December 2009, all clinics report. If serving your entire program use the “all clinics ” report. If the service area will be specific clinics complete one column for each clinic and note the name of the clinic or agency at the top of the column. You can insert additional grids if several agencies will share a peer program.
Location for peer services
(Note Agency name/all or name of specific clinic site.)
Pregnant PP BF
(breastfeeding)
PP NBF
(not breastfeeding)
Total
Women
Total Infants
2. Plan for addressing needs. To be completed with part 2.
3. Locations peer services will be available Peer service areas:
Specific WIC clinics:
The entire local WIC program.
Other:
Additional information on days, times of services to be completed in part 2 of the application.
4. How many peer support staff do you plan to use? To be completed in part 2 of the application.
5. International Board Certified Lactation Consultant (IBCLC) involvement. (An IBCLC must be available on staff or by contract.) See guidance section 5.
We have an IBCLC (or IBCLCs) on staff who will be involved in developing and implementing the peer support program.
We have an IBCLC on staff who will be involved in developing the peer support program and we plan to hire / contract with an IBCLC to help with (check all that apply):
Initial training of peer support staff.
Ongoing training of peer support staff.
Providing peers and/or CPAs an opportunity to “shadow” the IBCLC as part of their training.
Providing back
– up for peer support staff when problems are beyond their scope of practice.
Supervising or helping with supervision of peer support staff.
Other:
For large service areas, such as a very large county or a peer program with multiple counties, please comment on how the IBCLC will be available for issues beyond the scope of the on-site
WIC clinic staff:
Our breastfeeding coordinator or will be involved in developing the peer support program and we plan to hire an IBCLC to help with:
New Peer Program Application Part 1 for (Agency Name)
2

Initial training of peer support staff.
Ongoing training of peer support staff.
Providing peers and/or CPAs an opportunity to “shadow” the IBCLC as part of their training.
Providing back
– up for peer support staff when problems are beyond their scope of practice.
Supervising or helping with supervision of peer support staff.
Other:
6. If you plan to obtain services from an IBCLC who is not currently employed by WIC please check the applicable statement: Update on confirmation of IBCLC availability required in Part 2 of application.
Not applicable, we have an IBCLC or IBCLCs on staff.
IBCLC is currently employed by our agency, but not by WIC and we will contract for a portion of her time.
IBCLC is currently employed by another WIC agency and we will contract for a portion of her time.
We plan to contract with an IBCLC and we have or have not yet identified this person.
7. IBCLC and Other Staff, if any, involved in training, backup & supervision. Preliminary plans.
This section can be updated in your Part 2 of your application if plans change.
A.
IBCLC
We have a full time WIC IBCLC on staff. We estimate about % of her time or
FTE will be spent on the peer support Program.
We have an IBCLC on the WIC staff who is not full time or has responsibilities beyond WIC.
We estimate about hours per week or FTE of her time will be spent on the peer support Program.
We plan to contract or have contracted with an IBCLC to provide about hours per week or FTE.
B.
Other Staff
Identify any other staff who will be involved in training, back-up, and supervision of peer support staff and their credentials. Include lactation training completed (name and date of training program) or plans to send any of these staff to a breastfeeding management course or other training, if needed.
If you plan to send someone to the MN WIC Certified Lactation Specialist (CLS) course in September
2010 but do not yet know the person’s name you can register “peer lead staff” as a placeholder and provide the name as soon as the person is identified.
Name (if known)/position Background/Training in Breastfeeding or plan for training.
New Peer Program Application Part 1 for (Agency Name)
3

8. Overview of plan for Essential Peer Breastfeeding Support Program Functions.
8A. Please complete the grid on next page.
8B. WIC agencies that will provide some essential functions through arrangements with another organization must include a letter from that organization agreeing to fulfill the designated required functions if the grant is awarded, outlining roles, and defining who has decision-making authority for the peer functions in the organization .
Include as Attachment A .
New Peer Program Application Part 1 for (Agency Name)
4

8A . Essential functions. (Check the appropriate column or columns). This grid is intended to help with planning. It may be modified when you are ready to hire the peers and submit Part 2 of the application. Please identify who will:
If known, please enter the name and role of the staffperson in the column header.
If abbreviations are used to describe roles in the comments section please define the abbreviations used.
Manage/ coordinate the PBSP (see attached sample job description)
Development of local agency PBSP consistent with FNS model and
MNWIC Program policies
Develop PBS staff position description (see attached sample)
Recruit PBS staff
Hire PBS staff
Reassign participants to another peer if a peer resigns or is unable to follow the participant.
Be trained on FNS peer management 1 .
Be trained on FNS peer curriculum 2
Attend the 2 required meetings for MN PBSPs
Provide initial training for peers
2
.
Provide ongoing training for peers.
Ensure that peers have the opportunity to meet regularly with other peer support staff
Ensure that all peer staff have the opportunity to meet with WIC
CPAs at least 2x/year (such as at a WIC staff meeting or clinic with opportunity to talk w CPA staff or CPA staff attend peer meeting.)
Supervise peers, including periodic review of peer documentation.
Maintain regular contact with peers. (At minimum every other week.
Note that if peers provided through another program WIC PBSP mgmt staff must have individual contact with each peer at least monthly, preferably more frequently.)
Provide and document random calls to participants the peer is working with, to assess their perspective on peer support (this also serves to verify that services are being provided.).
Provide backup after hours if the peer gets a call she can’t handle after hours.
Identify referral resources & protocols in the event that the peer receives a call beyond her scope of practice when a WIC backup staffperson is not available.
Outreach to enhance the effectiveness of the WIC PBSP
IBCLC. WIC?
Other?
Other Other: Other: Comments / Including explanation for any abbreviations used.
1 If this person has already completed FNS training on peer management and peer curriculum please note “attended”
2 Training must include “Loving Support through Peer Support” training curriculum, available from the State WIC office. Supplemental training may also be provided.
New Peer Program Application Part 1 for (Agency Name)
5

9.
Plan for participation in required meetings and training. (Must be IBCLC or CPA who will be involved in implementing the peer program and planning training.)
 must be trained on the FNS Peer
Management and FNS Peer Training Curriculum and we will require that they participate in the required training. (Note that if there is sufficient interest a group training will be held at a location central to those needing training. If there are not sufficient staff for a group training the State WIC Peer Coordinator will provide individual training.) management meetings with staff from other Minnesota PBS Programs. The staff is/are:
_ __________________________________________________
10. Plan for training WIC Peer Support Staff and other WIC Staff. To be completed with Part 2.
11. Plans for integrating all peer staff into the WIC program to help them feel a part of the program and to encourage referrals from WIC staff to peers. (check all that apply)
To be completed with Part 2.
Peers have an opportunity to observe WIC clinics as a part of their orientation.
Peers are introduced to WIC staff as a part of their orientation
Peers are present in WIC clinics to:
Peers attend WIC staff meetings or WIC CPA staff ,in addition to peer management staff, attend some peer meetings. Frequency/ other comments:
Other:
Additional comments on how peer staff will be integrated into existing WIC services initially and on an ongoing basis:
12 . Plan for collaboration with others to deliver peer services. Check all that apply:

We plan to provide peer services within our WIC program and do not plan to contract
or collaborate with other agencies or counties to provide essential peer services .
(Continue to budget page.)

We plan to collaborate with neighboring WIC programs to provide peer support
services. (Note that MOU, contract or similar agreement is required after the grant is
awarded.)
 Please briefly describe your plan. Include any specific activities such as collaborating to share peer management or IBCLC services:
 We plan to collaborate with a MN WIC Program or Programs that have an existing peer program. Comments:
 We plan to collaborate with a MN WIC Program or Programs that does not have an existing peer program. Comments:
New Peer Program Application Part 1 for (Agency Name)
6

A letter, agreeing to fulfill the designated required functions if the grant is awarded, outlining roles, and defining who has decision-making authority for the peer functions in the organization, is attached from all agencies or organizations we will collaborate or contract with to deliver peer services. REQUIRED if you will use other organizations to provide essential peer services. Attach as Attachment A. If you contract with more than one entity, list all of those you will contract with on the cover page and attach letters in that order.

We plan to collaborate with a non-WIC agency , and to provide peer support services
through their staff who meet the FNS peer definition. (Note that MOU, contract or similar
agreement will be required after the grant is awarded.) If you plan to pursue this
option contact the State WIC Peer Coordinator to discuss your plans before you
submit this application or enter into an agreement with the non-WIC agency.
 Please briefly describe your plan:
 How will you assure the FNS requirements are met?
 How will you integrate all peer breastfeeding support staff with your WIC program ?
 How will you coordinate peer services with WIC services?
 A letter, agreeing to fulfill the designated required functions if the grant is awarded, outlining roles, and defining who has decision-making authority for the peer functions in the organization, is attached from all agencies or organizations we will collaborate or contract with to deliver peer services. REQUIRED if you will use other organizations to provide essential peer services. Attach as Attachment A. If you contract with more than one entity, list all of those you will contract with on the cover page and attach letters in that order.
13. Plan for outreach / coordination. To be submitted with Part 2 of application.
14. Evaluation. To be submitted with Part 2 of application.
15.
Agency Capacity
Other comments about the peer breastfeeding support program and reasons you believe your program can:
A. Successfully implement peer services
New Peer Program Application Part 1 for (Agency Name)
7

B. Implement peer services without compromising the required basic WIC services. (Consider funding, progress toward meeting unmet standards for basic WIC services identified during your management evaluation (if any), strengths of your agency and community, etc.)
Contact if we have questions about your application
16. If we have questions about your application we will call for clarification
Name / position of person we should call:
Phone number, with area code:
Budget
17. Other funding sources, if any . (Other funding sources encouraged, but not required.)
In addition to the designated peer funds we will use the following funding sources to supplement the peer program funding:
We receive the following in-kind services:
We plan to seek outside funding from:
18. See budget information on next page.
New Peer Program Application Part 1 for (Agency Name)
8

18A Budget: Minnesota WIC Peer Breastfeeding Support Program Grant Application
Please fill out this form completely. For any item that is not applicable, draw a line through the space. Complete only for activities outlined in part 1 of the application . You will submit a new budget with part 2 of the application which will include hiring peers and other costs related to hiring and training peers. If you plan to purchase supplies for peers (locking cases, cell phones, etc they may be included in this budget or with Part 2.)
Name of Contact Person for Budget:
Phone: Fax: E-mail:
Item Amount through September 30, 2010
$ Salary and Fringe Benefits for
employees
Contracted staff $
Training
Travel
Supplies/Reference materials/Training materials
Other
Indirect
Total
$
$
$
$
$
$
Attach a brief description of your budget describing how you arrived at the amounts in your budget, including number of staff and rate of pay.
There is a form on the next page to use for the budget narrative. See the guidance, pg 15, for instructions and additional information to help in planning your budget.
New Peer Program Application Part 1 for (Agency Name)
9

18B.
Include a narrative description explaining the details of your budget through September
30, 2010 in two pages or less Note that a revised budget will be required with the second part of your application.
1. Salary and Fringe Benefits a. Employees (please list, if plan to hire, note by title)
Contracted staff (please list, if plan to hire, note by title)
2. Training
3. Travel
4. Supplies Reference materials/Training materials
5. Other costs
6. Indirect
New Peer Program Application Part 1 for (Agency Name)
10

Attachment A. Letters from collaborating organizations for providing essential peer functions, if any.
WIC agencies that will provide some essential functions through arrangements with another organization must include a letter of support from that organization agreeing to fulfill the designated required functions if the grant is awarded, outlining roles, and defining who has decision-making authority for the peer functions in the organization.
Letters are attached from the following organizations:
1.
New Peer Program Application Part 1 for (Agency Name)
11

Submitting your application.
 To be considered for funding, your proposal must be mailed or delivered to:
Mailing Address
Stacia Pomrenke
Minnesota WIC Program
Minnesota Department of Health
Post Office Box 64882
St. Paul, Minnesota 55164-0882
Delivery Address
Stacia Pomrenke
Minnesota WIC Program
Minnesota Department of Health
85 East Seventh Place, Room 220
St. Paul, Minnesota 55101
If no one is available in room 220 to accept the application do not leave the application - call and make sure a WIC staff person accepts the delivery.
There is a phone in room 220 you can use.
To meet the deadline, your proposal must:

Have a legible postmark from the U.S. Post Office or a private carrier dated on or before June 2, 2010 . We will not accept a postmark from a private, in-office metering machine as proof that you mailed your proposal on time, or

Be hand delivered to the address listed above and date-stamped upon delivery before
4:30 p.m
. on June 2, 2010 . o If no one is in the room to accept the proposal call 651-201-4411 or 651-201-4406 to have a WIC staff person accept and date-stamp the proposal.

We will accept emailed proposals if received before 4:30 pm on June 2, 2010 . Proposals must be attached as a Microsoft Word document or PDF. It is the responsibility of the applicant agency to verify that the emailed proposal was received.
This verification must be made before the deadline.
Occasionally email delivery systems are slow. Email with viruses or files that are too large is not delivered. The State email system does not inform you if a document was not delivered. o If you submit a proposal by email you must also mail in pages that require signatures, with an original signature. o E-mail the proposal to stacia.pomrenke@state.mn.us
with “WIC PBSP” in the subject line. Copy linda.dech@state.mn.us
on the email.

We will not accept FAXED proposals.
If an organization plans to provide some essential peer services through collaboration with another WIC program or organization a signed letter from that organization must be included for the peer proposal to be considered.
Proposals will not be considered if they are not from a current MN WIC Program Grantee
WIC is an equal opportunity provider
New Peer Program Application Part 1 for (Agency Name)
12