REQUEST FOR PROPOSALS
Minnesota WIC Peer Breastfeeding Support Program
Application
**Part 2**
Part 2 is due on or before September 15, 2010
Minnesota Department of Health
Minnesota WIC Program
April 2010
Applicant:
Submitted Part 1 application?
Yes,
No (Part 1 must be submitted before or with Part 2)
Minnesota Department of Health Grant Application Face Sheet
Part 2 of Grant Application for:
Minnesota Department of Health, Minnesota WIC Program,
Peer Breastfeeding Support Program
1. Applicant Agency With Which Grant Contract is to be Executed
Legal Name:
Street Address:
Telephone Number:
FAX Number:
2. Director of Applicant Agency
Name and Title:
Street Address:
Telephone Number:
E-Mail Address:
FAX Number:
3. Fiscal Management Officer of Applicant Agency
Name and Title:
Street Address:
Telephone Number:
E-Mail Address:
FAX Number:
4. Operating Agency (if different from number 1 above)
Name and Title:
Street Address:
Telephone Number:
E-Mail Address:
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
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Minnesota Department of Health (MDH)
Information Sheet for Minnesota WIC Program,
Peer Breastfeeding Support Program Grant Applications
1. Applicant Information
Applicant Agency Name
Minnesota Tax I.D.
Number
Federal Tax I.D.
Number
Social Security Number
N/A
Non-profit Status – 501.C3 form attached?
Yes
Not Applicable
2. Proposal Information
Project Funds Requested Per Year (Revised to reflect hiring peers)
$
Proposed Service Area
Proposed Funding Category
Minnesota WIC Peer Breastfeeding Support Program
HE-01274-05 (3/01) - PART B
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Part 2: Refer to the Part 1 application previously submitted. You will have the
opportunity to make changes or updates to Part 1 questions in Part 2.
Need for peer breastfeeding support /plan for addressing highest priority needs.
1. Need for peer support staff.
No changes from our Part 1 application, or
In addition to the information in our Part 1 application, we have identified the following needs:
2. Plan for addressing needs. See Instructions/Guidance, page 9.
Describe how peer counselors will be used to address the highest priority needs identified above.
3. Days, times, locations peer services will be available. As many breastfeeding problems do not
occur during regular clinic hours, FNS requires that peers are available outside of regular clinic hours
and clinic settings. Ideally peer support with WIC backup would be available 24/7, however, this may
not be feasible for some programs. Back-up WIC staff and referrals to health care providers are needed
for breastfeeding issues beyond the role and scope of the peer. Please identify the hours you plan to
have peer services available, WIC staff availability for backup and referrals to other providers
Mon
Tues
Wed
Thu
Fri
Sat
Sun
Comments
Days and
hours peers
available
Plan for backup of Peer Support Staff
WIC staff
available for
backup
(hours)
Peer to refer
to health
provider /
clinic (hours)
Insert additional grids if needed for different clinic or county locations.
Brief comments that will help us understand your plans, including your plan for back-up when key staff are
on vacation or otherwise unavailable. (In the training section indicate how the staff who are available for
back-up have been or will be trained.)
Peer service areas:
No change from Part 1.
Specific WIC clinics:
The entire local WIC program.
Other:
Peer work locations: (Check all that apply)
WIC clinics
Calls to / from home
Hospital Visits
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Home visits
Classes / Groups @ WIC
Accompany participant to first breastfeeding support group meeting (such as La Leche League)
Comments:
Other:
Staffing
4. How many peer support staff do you plan to use?
(See Instructions/Guidance )
We (WIC) plan to contract with peer support staff.
We (WIC) plan to hire peer support staff.
We (WIC) plan to work through an employment agency to hire peer support staff.
We plan to use staff from another (non-WIC) program for peer breastfeeding support. Please describe
their current role and how they meet the FNS peer support definition:
We plan to use current WIC staff who meet the FNS definition of a breastfeeding peer support staff
person. Please describe their current role and how they meet the FNS peer support definition:
How many hours a week do you anticipate a peer will work? (A range of hours is fine. Some may work
more than others)
5. International Board Certified Lactation Consultant (IBCLC) involvement. (An IBCLC must be
available on staff or by contract.) See Instructions/Guidance.
No changes from our Part 1 application.
Update to our Part 1 application:
6. Please indicate how you are obtaining IBCLC involvement with the peer program: Please update
on IBCLC availability from Part 1.
Not applicable, we have an IBCLC or IBCLCs on staff.
IBCLC is currently employed by our agency, but not by WIC and we 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..
Comments:
7. IBCLC and Other Staff, if any, involved in training, backup & supervision. Please provide an
update from Part 1 if your plans have changed.
No changes from our Part 1 application
Update to our Part 1 application:
A. IBCLC. Name(s):
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.
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Briefly describe the involvement the IBCLC have and why the amount of time designated will meet the
needs for the program responsibilities assigned.
Verification of IBCLC status.

We have verified IBCLC status via the IBLCE website: http://americas.iblce.org/currentibclc-registry Comments, if any:
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.
No change from Part 1 application or
Changes are as follows:
Name/position
Background/Training in Breastfeeding or plan for training.
Essential Peer Breastfeeding Support Functions Plan
8. Overview of plan for Essential Peer Breastfeeding Support Program Functions.
8A. Please complete the grid on next page.
No change from Part 1 application.
Updates provided to the grid on the following 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.
Letter(s) provided with Part 1
Letter(s) provided with Part 2
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8A. Essential functions.
no change from Part 1 application or
this is a revision
(Check the appropriate column or columns). Please identify who will:
Please enter the name of the staff person and role in the
column header. If abbreviations are used to describe roles please
define the abbreviations used in the comments section.
IBCLC.
Other
Other:
Other:
Comments / Including
explanation for any
abbreviations used.
Manage or coordinate the peer support program (see sample job description
in guidance)
Responsible for development of local agency peer support policies consistent
with FNS model and Minnesota WIC Program policies
Develop peer support staff position description (see attached sample)
Recruit peer support staff
Hire peer support staff
Reassign participants to another peer if a peer resigns or is unable to follow
the participant.
Be trained on FNS peer management1.
Be trained on FNS peer curriculum2
Attend the 2 required meetings for Minnesota Peer Programs.
Provide initial training for peers or arrange for them to attend state training2.
Provide ongoing training for peers.
Ensure that peer support staff have the opportunity to meet regularly with
other peer support staff
Ensure that all peer staff have the opportunity to meet with WIC CPA staff at
least twice a year (such as at a WIC staff meeting or clinic with opportunity to
talk w CPA staff or CPA staff attend peer meeting.)
Supervise peer support staff, including periodic review of peer
documentation.
Peer mgmt staff maintain regular contact with peer support staff. (At
minimum every other week. Note that if peers provided through another
program WIC peer mgmt staff must have individual contact with each peer at
least monthly.)
Provide and document random calls to participants the peers are working
with, to assess their perspective on peer support (this also serves to verify
that services are being provided.). Note that if peers provided through
another program WIC peer mgmt staff must call 1 – 2 participants for each
peer at least twice a year, in addition to any other calls made by staff from
the contracted agency.
Provide back-up after hours if the peer support staff person gets a call she
can’t handle after hours.
Identify referral resources & protocols in the event that the peer support
person receives a call beyond her scope of practice when a WIC backup staff
person is not available.
Outreach to enhance the effectiveness of the WIC PBSP
If this person has already completed FNS training on peer management and peer curriculum please note “attended” in the comments field
Training must include “Loving Support through Peer Support” training curriculum, available from the State WIC office. Supplemental training may also be provided.
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1
2
Training / Integrating Peer Program with other WIC services
9. Plan for participation in required meetings and training for Peer Lead Staff. (Must be
IBCLC or CPA who will be involved in implementing the peer program and planning
training.) Please provide an update from the Part 1 application.

Our peer managers / supervisors have been trained on the FNS Peer Management
Curriculum.
o Staff were trained: (check all that apply)
Attended State Peer Management training Summer 2010.
Other:

One or more of our peer managers / supervisors need(s) to be trained on the FNS
Peer Management and FNS Peer Training Curriculum.
The staff is/are:

We anticipate having
staff participate in the two Minnesota WIC Program peer
management meetings with staff from other Minnesota PBS Programs. The staff is/are:
10. Plan for training of WIC Peers and other WIC staff.
A. Plan for initial training of new peers:

We prefer to do our own initial peer training.

We prefer to have the State WIC program provide this training or coordinate with other peer
breastfeeding support programs to provide the initial peer breastfeeding support staff
training.
Comments:
B. Our plan for ongoing training for existing peer support staff. Check all that apply:

At minimum, monthly meetings with other peers to provide short training session (by
IBCLC, other WIC staff or guest) and discuss their questions, successes and challenges..

Opportunity to shadow IBCLC or other WIC staff trained in lactation management.

As peers become more experienced, opportunity for new peers to shadow other peers.

Other:
C. Our plan for orienting current WIC staff to peer support functions and how CPAs will
refer a participant for peer support. (Consider having WIC CPA staff attend the peer training
or provide the WIC CPA staff with a shorter version of the training or an overview of peer
services.)
D. Our plan for training WIC CPAs more extensively in lactation to help provide back-up for
peer support staff if needed.

We feel we have enough staff already trained.

We plan to train additional staff. Number of CPAs you plan to train or send to training:
Planned method for training3:
3
See the MN WIC website for information on sources of lactation education. http://www.health.state.mn.us/divs/fh/wic/index.html
(local agency, then breastfeeding) or http://www.health.state.mn.us/divs/fh/wic/localagency/bf/index.html
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E. Our plan for providing ongoing training in lactation management for staff who supervise
and back-up peer counselors (check all that apply)

WIC conference breastfeeding sessions

Workshops

Self study

We would like periodic conference calls with other area peer program
managers/supervisors and the opportunity to learn from each other or those with more
experience in managing/supervising peer programs, such as staff form extension or other
states with longer experience working with peer support.

Other:
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)

No change from Part 1.

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. Frequency/ other comments:
WIC CPA staff attends some peer meetings

Other:

Additional comments on how peer staff will be integrated into existing WIC services initially
and on an ongoing basis:
Collaboration / Outreach
12. Plan for collaboration with others to deliver peer services. Check all that apply:

No change from Part I

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.

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:
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. Include as Attachment A. If you
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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.)
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 with others to inform them of peer services and
address any barriers. (Check all that apply.)

We have existing networks for coordination / informing others of peer support activities.
Please describe any existing breastfeeding coalitions, task forces, or other established
methods of communicating about breastfeeding and how you will use these existing
relationships to disseminate information about peer support and build a supportive
breastfeeding environment:

Describe your plans for informing and involving others in your community, such as meeting
with representatives from area hospitals, clinics and other organizations to inform them
about your peer program.

We plan to implement the following additional outreach activities related to the peer
program (for example displays, media, newsletters, etc).
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Evaluation / Agency Capacity
14. Summary and progress report. You will be asked to provide a brief written evaluation and
progress report periodically (see timeline). See page 16 of the Guidance for information on
this report.

We will provide the required progress reports and share tips on developing the peer
program that may benefit other agencies.
15. Agency Capacity
No change from Part 1.
Other comments about the peer Program and reasons you believe your program can:
A. Successfully implement peer services
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.)
16. Contact for any questions about this application:
Name of person we should call:
Phone number, with area code:
Revised Budget
17. Other funding sources, if any. (Other funding sources encouraged, but not required.)
No change from Part 1.
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:
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18A Revised Budget:
Minnesota WIC Peer Breastfeeding Support Program Grant Application Part 2.
Please note that you can budget up to $1,000 per month per peer; however most
agencies will not need this amount of funding. Consider training needs and that it
will take some time to build the caseload for each peer.
Please fill out this form completely. For any item that is not applicable, draw a line through the
space.
There is a form on the next page to use for describing how you arrived at the amounts in
your budget. (See the Instructions/Guidance, page 17 for instructions and additional
information to help in planning your budget.
Name of Applicant Lead Agency:
Name of Contact Person for Budget:
Phone:
Fax:
E-mail:
Item
Salary and Fringe Benefits for
employees
Amount for Oct. 1, 2010 to Sept. 30, 2011
$
Contracted staff
$
Training
$
Travel
$
Supplies/Reference materials/Training
materials
$
Other
$
Indirect
$
Total
$
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18B. Include the details to explain your budget figures in 18A from October 1, 2010 to
September 30, 2011 in two pages or less
1. Salary and Fringe Benefits
a. Employees (show IBCLC separate from other staff)
b. Contracted staff (If peers and / or IBCLCs are contracted staff include as two
separate lines.)
For peers: Please describe how you determined hourly rate of pay, any plans for salary increases
in future years, and benefits, if any.
2. Training
3. Travel
4. Supplies, Reference Materials/Training Materials and Small Equipment.
5. Other costs
6. Indirect
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Attachment A. Letters from collaborating organizations for providing essential peer
functions
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.
No change from Part 1.
Letters are attached from the following organizations:
1.
2.
3.
4.
5.
6.
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Attachment B. Abbreviations used in our application, if any
(Attach only if you have used abbreviations in your application.)
Abbreviation
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Word of Phrase
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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 Part 2 proposal must:
 Have a legible postmark from the U.S. Post Office or a private carrier dated on or
before September 15, 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 September 15, 2010.
o If no one is in the room to accept the proposal call 651-201-4411 or 651-201-3649 to
have a WIC staff person accept and date-stamp the proposal.

We will accept emailed proposals if received before 4:30 pm on September 15, 2010.
Proposals must be attached as a Microsoft Word document. 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. Emails
with viruses or files that are too large are 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.
We will not accept or consider late 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
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