Vendor Monitoring Worksheet - Retail Grocery Stores

DEPARTMENT OF HEALTH SERVICES
Division of Public Health
F-04003 (Rev. 05/2014)
STATE OF WISCONSIN
Title 7 CFR Part 246,
DHS 149.07 Wis. Admin. Code
Page 1 of 4
VENDOR MONITORING WORKSHEET
RETAIL GROCERY STORES
INSTRUCTIONS
Review vendor monitoring procedures in the WIC Operations Manual, the supplemental Project Training: Vendor Routine Monitoring and
types of violations in the Wisconsin WIC Vendor Manual before conducting a monitoring visit.
Document vendor monitoring thoroughly and accurately on this worksheet. Record findings at the time of the monitoring visit on the
worksheet citing all violations and contact the State WIC Office, Vendor Management at 608-267-9192 if there are any questions or
concerns about the monitoring results.
If the cashier entered a dollar amount that was higher than the actual retail price of items purchased, or charged for foods that were not
received, leave the store after the compliance buy. Contact the State WIC Office, Vendor Management upon return to the office.
Training is required for all violations and should be conducted immediately with the owner, manager, or head cashier. Training may be
scheduled for another date if none of the above persons are present at the time of the monitoring visit. A Corrective Action Plan (CAP) and
Training Proof of Participation form (DPH 4727) must be completed.
Vendor Monitoring Worksheet, Compliance Checks, Cash Register Receipt and Training Proof of Participation must be completed and
sent to the State WIC Office, Vendor Management within 10 days of the monitoring visit. Remember to obtain all required signatures
from the vendor. Remember, the WIC Representative is to sign the Monitoring Worksheet at the bottom of page one.
Store Name
Vendor Number
Street Address
WIC Project Number
City, State, Zip Code
Date of Monitoring Visit
Type of Monitoring:
Check minimum stock, expiration dates, and that prices
are posted
Routine Monitoring
CAP Monitoring
High Risk Monitoring
Request of State WIC Office
Indicate FI number(s) on the checks used for compliance buy, and indicate the first and last dates to use on the check(s):
Check Number
First Date
Last Date
The results of the monitoring visit have been discussed with
me. If violations were identified during the monitoring visit, it
is our responsibility to take appropriate action to correct the
problem(s). I understand that it is our responsibility to ensure
that store personnel are trained and comply with WIC
Program rules.
Name of Person Interviewed (Print)
WIC Representative: I have reviewed and completed all
areas of the Vendor Monitoring Worksheet.
Title of Person Interviewed
Title of WIC Representative
Date
Date
SIGNATURE – Person Interviewed
SIGNATURE – WIC Representative
Name of WIC Representative (Print)
F-04003 (05/2014)
Page 2 of 4
SECTION 1: REVIEW OF CASHIER CHECK-OUT PROCEDURES
Pose as a WIC participant to determine if correct procedures are used. Attach the cash register receipt and the check(s) that
were used (if the sale was voided) to the front of the report. YES = Tested/Violation occurred, NO = Tested/No violation
occurred, NA = Did not test.
YES
1.
Did the cashier fail to obtain or verify the participant/proxy signature on the check with the
WIC ID card?
2.
Were you able to use a check prior to the "first day to use" or after the "last day to use" ?
3.
Was the dollar amount entered on the check in pencil or erasable ink?
4.
Did the cashier request the participant/proxy signature before entering the dollar amount
on the check?
5.
Did the cashier fail to enter either the “date of use” and/or initial the WIC check at the
time of the transaction? YES = Violation/training required. Document on Proof of Training
Form.
6.
Was it possible for you to purchase unauthorized foods or items with WIC checks?
Indicate type and brand of unauthorized item(s) purchased:
7.
Was it possible for you to purchase unauthorized quantities with WIC checks?
Indicate amount and type of item(s) purchased:
8.
Did the cashier enter a dollar amount that was higher than the actual retail price of the
items purchased, or charge for foods not received? If YES, contact State Office.
NO
NA
Comments:
SECTION 2: QUESTIONS TO ASK OF PERSON INTERVIEWED
Name of Current Owner:
Name of Manager (if more than one list here):
If the current owner is not the same as stated on the current WIC Vendor Profile, get as much information as possible to determine if there
has been a change of ownership. If ownership appears to have changed, contact the State WIC Office, Vendor Management.
Name and title of person who trains cashiers on WIC check
redemption process:
Yes
No
Yes
No
Yes
Yes
No
No
Name and title of person who reviews WIC checks prior to
deposit to ensure that everything is appropriate (e.g., dollar
amounts, participant signatures, legible vendor stamp, etc.):
Does the store maintain a copy of the WIC Vendor Manual, correspondence and memorandums from the
State WIC Office at the store? (Ask to see these items.) If No, ask where these materials are located and
inform them that these items are to be kept at the store.
Are “Rain Checks” given when WIC authorized foods are not available? Briefly describe below the
methods used by the store when WIC foods are not available.
Has the vendor experienced any problems with the WIC Program? Briefly describe any problems the
vendor is experiencing. Remind the vendor to notify you of any problems with a WIC participant, by using
the Vendor/Participant Complaint Form (DPH 4322).
Does the vendor purchase infant formula from an authorized supplier? Verify the supplier is listed on the
Authorized Infant Formula Supplier List. If not an authorized supplier, provide the vendor with the Supplier
List and indicate that the State WIC Office, Vendor Management will be in contact with them.
F-04003 (05/2014)
Page 3 of 4
SECTION 3: GENERAL OBSERVATIONS
Does the store appear to be in violation of any health protection laws or ordinances of which you are
aware? For example: is refrigeration inadequate is the store unclean, are there screens on open windows
and doors, etc. If YES, describe briefly:
Yes
No
Yes
No
Does the store display “WIC Accepted Here” door signs or stickers (large or small, required to be
displayed in an area visible to participants)? If NO, provide them to the vendor.
Yes
No
Were WIC authorized food lists and cashier instructions available to cashiers at each register? If NO,
provide copies to the vendor.
Yes
No
Is the store using WIC shelf talkers to identify WIC approved foods? If NO, provide samples for the
vendor and discuss how the use of the stickers assists participants in locating approved food and
eliminating problems at the check-out.
SECTION 4: REVIEW OF WIC CHECKS
Does the store have any WIC checks on hand? If NO, go to Section 5. If YES, ask to see them and
Yes
No
complete the following five questions.
Yes
No
1. Are there any checks that do not have the participant’s signature written on the face of the check?
If YES, confiscate the checks(s). Give the vendor the receipt form.
2. Are any checks missing a date in the “Date of Use” field? If YES, explain to store manager that if they
fail to comply with proper WIC check redemption procedures, further actions will be taken. Document on
Proof of Training.
Yes
No
Yes
No
3. Have any checks been accepted prior to the "first day to use" or after the "last day to use"? (Back of the
check may have the cash register endorsement or other store endorsement.)
Yes
No
4. Are there any checks that do not have dollar amounts recorded in permanent ink on the face of the
check?
Yes
No
5. Are there any checks that do not have dollar amounts written in permanent ink on the face of the
check?
SECTION 5: STOCK INFORMATION
5A. PRICES. Complete this section only if prices were not displayed or marked. List all WIC foods that were not marked or did
not have prices posted.
1.
3.
2.
4.
5B. OUTDATED WIC FOODS. Complete this section only if expired foods were found. List each food item, number of
containers, expiration date of the expired food, or provide a description of the problem.
NUMBER OF
EXPIRATION DATE
FOOD ITEM
CONTAINERS
OR DESCRIPTION
1.
2.
3.
4.
5.
F-04003 (05/2014)
Page 4 of 4
SECTION 6: MINIMUM STOCK INFORMATION
FOOD ITEM
YES = No offenses.
MINIMUM STOCK REQUIREMENT
If the store does not meet the minimum requirements for any of the
mandatory food items, record the exact quantities available at the time of
the site visit. For example: two 12 oz. boxes of Kellogg's Rice Krispies
and three 14 oz. boxes Cream of Wheat.
Milk
NO = Possible 6 month disqualification.
MINIMUM ON
QUANTITY
SHELF OR
AVAILABLE
IN COOLER
(In customer area)
8 gallons unflavored 1% or skim (low fat or fat free); AND
Yes
No
3 gallons unflavored whole (Vitamin D); AND
Yes
No
3 half-gallons unflavored 1% or skim.
Yes
No
Eggs
4 one-dozen cartons, white only, any size, any grade.
Yes
No
Whole
Grains
6 packages, 16 oz. each, any combination of:
100% whole wheat bread, buns or rolls, OR
soft corn or whole wheat tortillas, OR
brown rice (may come in a box/bag or frozen prepared).
Yes
No
Cereal
6 different types (hot or cold), 12 oz. boxes or larger and minimum of 4 of
each. 2 types must be whole grain (marked “WG” on WIC Approved Food
List). Gluten Free Rice Krispies may be 9 oz. and up.
Yes
No
Juice
9 containers 64 oz., 3 different flavors; AND
Yes
No
12 containers 48 oz., 3 different flavors; AND
Yes
No
4 containers 11.5 - 12 oz. frozen concentrate.
Yes
No
$28 total retail value ($10 of the total retail value must be from fresh fruit
and vegetables); AND
Yes
No
Fruit – 5 types fresh, frozen or canned; 2 types must be fresh (not
including lemons and limes); AND
Yes
No
Vegetables – 5 types fresh, frozen or canned; 2 types must be fresh (not
including onions, garlic, and ginger).
Yes
No
Peas/Beans
Lentils (dry)
4 pounds total; two 16 oz. bags of two different types.
Yes
No
Canned
Beans
16 cans, 15 – 16 oz.; three different types.
Yes
No
4 containers, 16 -18 oz.; any brand, creamy, crunchy, extra-crunchy or
natural, low sodium/salt, reduced/no sugar.
Yes
No
Stores with 4 or less registers (count all registers):
3 different varieties of fruits – 12 containers each; AND
Yes
No
3 different varieties of vegetables – 12 containers each
Yes
No
Stores with 5 or more cash registers (count all registers):
6 different varieties of fruits: 12 containers each, AND
Yes
No
Yes
No
Any brand; 2.5 oz. containers only;
2 varieties, total of 48 containers.
Yes
No
Any brand; six 8 oz. containers; 2 different types.
Yes
No
Good Start Gentle only:
Yes
No
Fruit and
Vegetable
Peanut
Butter
Infant Fruit
and
Vegetable
Infant
Meats
Infant
Cereal
Infant
Formula
Any brand; 4 oz. containers; plain or mixtures.
6 different varieties of vegetables: 12 containers each.
Only stores with 11 or more cash registers must carry:
1)
20 cans 12.7 oz. powder, OR
2)
62 cans 13 oz. concentrated liquid, OR
3)
10 cans 12.7 oz. powder AND 31 cans 13 oz. concentrated
liquid.
(Only enter items if
less than minimum.)