Special Supplemental Nutrition Program for Women, Infants, and Children (WIC): Bloodwork Requirements

DEPARTMENT OF AGRICULTURE

Food and Nutrition Service

7 CFR Part 246

RIN 0584-AC30

Special Supplemental Nutrition Program for Women, Infants, and

Children (WIC): Bloodwork Requirements

AGENCY: Food and Nutrition Service, USDA.

ACTION: Proposed rule.

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SUMMARY: This proposed rule would amend regulations governing the

Special Supplemental Nutrition Program for Women, Infants, and Children

(WIC) to provide that hematological tests for anemia no longer be a

mandatory part of each WIC applicant's certification intake process, so

long as at least one nutrition risk factor is present for the

applicant. This proposed rule would allow the State agency the

discretion to obtain such tests at certification or within 90 days of

the date of certification. Such tests would be used for the purposes of

assessing nutritional status, providing nutrition education, further

tailoring food packages to meet nutritional needs, and referring to

appropriate health and social services in the community. The proposed

revisions to current WIC Program regulations will accommodate a

changing health care environment; facilitate improved coordination with

other health programs serving WIC applicants; minimize potentially

repetitive, costly, and invasive blood testing procedures; reduce

inconvenience to applicants, and expedite services to needy individuals

applying for WIC Program benefits.

DATES: To be assured of consideration, comments must be postmarked on

or before January 19, 1999.

ADDRESSES: Comments should be sent to Ronald J. Vogel, Acting Director,

Supplemental Food Programs Division, Food and Nutrition Service, USDA,

3101 Park Center Drive, Room 540, Alexandria, Virginia 22302, (703)

305-2730. All written comments will be available for public inspection

during regular business hours (8:30 a.m. to 5 p.m., Monday through

Friday) at the above-noted address.

FOR FURTHER INFORMATION CONTACT: Barbara Hallman at (703) 305-2730

during regular business hours (8:30 a.m. to 5 p.m.) Monday through

Friday.

SUPPLEMENTARY INFORMATION:

Executive Order 12866

This rule has been determined to be not significant for purposes of

Executive Order 12866 and, therefore, has not been reviewed by the

Office of Management and Budget.

Regulatory Flexibility Act

This rule has been reviewed with regard to the requirements of the

Regulatory Flexibility Act (5 U.S.C. 601-612). Pursuant to that review,

Samuel Chambers, Jr., Acting Administrator of the Food and Nutrition

Service, has certified that this rule will not have a significant

impact on a substantial number of small entities. State and local

agencies and participants would be most affected by this proposed rule.

This proposal would provide State and local agencies with increased

flexibility in meeting certification requirements for the Program.

Participants and applicants would also be affected by changes in the

certification process which should result in expedited receipt of

program services.

Paperwork Reduction Act

This proposed rule imposes no new reporting or recordkeeping

requirements which are subject to review by the Office of Management

and Budget (OMB) in accordance with the Paperwork Reduction Act of

1995.

Executive Order 12372

The Special Supplemental Nutrition Program for Women, Infants and

Children (WIC) is listed in the Catalog of Federal Domestic Assistance

Programs under No. 10.557. For reasons set forth in the final rule in 7

CFR part 3015, subpart V, and related notice (48 FR 29115), this

program is included in the scope of Executive Order 12372 which

requires intergovernmental consultation with State and local officials.

Executive Order 12998

This proposed rule has been reviewed under Executive Order 12998,

Civil Justice Reform. This rule is intended to have preemptive effect

with respect to any State or local laws, regulations or policies which

conflict with its provisions or which would otherwise impede its full

implementation. This rule is not intended to have retroactive effect

unless so specified in the EFFECTIVE DATE paragraph of this preamble.

Prior to any judicial challenge to the application of the provisions of

this rule, all applicable administrative procedures must be exhausted.

Public Law 104-4

Title II of the Unfunded Mandates Reform Act of 1995 (UMRA), Pub.

L. 104-4, establishes requirements for Federal agencies to assess the

effects of their regulatory actions on State, local and tribal

governments and the private sector. Under section 202 of the UMRA, the

Food and Nutrition Service generally must prepare a written statement,

including a cost-benefit analysis, for proposed and final rules with

``Federal mandates'' that may result in expenditures to State, local or

tribal governments, in the aggregate, or the private sector, of $100

million or more in any one year. When such a statement is required

under section 202 of the UMRA, section 205 generally requires the Food

and Nutrition Service to identify and consider a reasonable number of

regulatory alternatives and adopt the least costly, most cost-effective

or least burdensome alternative that achieves the objective of the

rule.

This rule contains no Federal mandates (under the regulatory

provisions of Title II of the UMRA) for State, local and tribal

governments or the private sector of $100 million or more in any one

year. Thus, this rule is not subject to the requirements of sections

202 and 205 of the UMRA.

Background

The Department reassesses WIC Program regulations and operations on

an ongoing basis to ensure the continuing efficiency and effectiveness

of the program. The subject of blood testing requirements has

repeatedly been identified as warranting consideration for change based

on frequent expressions of concern from the WIC community, including

health

[[Page 64212]]

and medical officials at both the State and local levels. Numerous

concerns have been brought to the Department's attention on the WIC

Program's current blood test requirements, which may have the

consequences of delaying enrollment of WIC applicants, duplicating

effort, and creating unnecessary administrative expense, and hardship

to applicants.

Three specific concerns regarding changes in the delivery and

operation of health care also compel the Department's reassessment of

the blood testing requirements. First, WIC blood tests coincide with

WIC certification periods, thus, the schedule of blood tests required

at WIC certification does not generally correspond with State, local,

and generally accepted periodicity schedules and guidelines. The

Department has been informed that many health programs, as cost

containment measures, are commonly limiting blood test screening to a

specified minimum seen as medically necessary, consistent with State,

local, and generally accepted guidelines and other auxiliary health

programs such as lead poisoning prevention programs or Early and

Periodic, Screening, Diagnosis and Treatment programs. Health care

providers have expressed concerns to the Department that the WIC

Program's certification schedule, of which blood testing is a mandatory

part, is creating a barrier to public health care coordination by

artificially dictating periodicity for hematological testing, rather

than conforming to standard clinical practice used by the State and

local health care system.

Second, the move towards managed care programs as the primary

source of health care has affected the ability of WIC local agencies to

obtain blood test referral data in a timeframe that coincides with WIC

certification periods. The source of health care for WIC participants

and others has been shifting in many States from local health

department clinics, many of which collected bloodwork to meet WIC's

needs on site at the WIC clinic, to managed care settings in which

blood tests are performed off site from the WIC clinic and thus

provided to WIC on a referral basis.

Third, bloodwork data obtained from referral sources is becoming

more frequently the norm in WIC because of Federal, State and local

policies limiting blood handling only to persons or laboratories with

specified medical credentials, thereby precluding some WIC local

agencies from collecting or analyzing blood samples.

The Proposal

In response to these major concerns, the Department is proposing

changes in the timing of anemia tests, extending the age of the data

that may be used, clarifying allowable costs for anemia tests, and

making corresponding changes to State Plan requirements.

These topics are discussed in greater detail below.

1. Hematological Tests for Anemia (Sec. 246.7 (e), (e)(1), and (e)(1)

(i)-(ii))

Given the logistical difficulties of current bloodwork requirements

described above, the Department is proposing that hematological tests

for anemia no longer be a mandatory part of each WIC applicant's

certification intake process as long as at least one nutrition risk

factor is present for the applicant. However, given the importance of

anemia testing in the target population and WIC's long and successful

track record in reducing national rates of anemia, this rule proposes

to require such a test but would permit its completion within 90 days

of the date of certification, except as noted for infants as discussed

later in this preamble. The test data would be used for the critical

purposes of appropriately assessing an applicant's nutritional status,

providing nutrition education, tailoring food packages and referring to

health care or social services. Although the Department considers the

collection of blood test data at certification as optimal to assist

with performing the most timely and complete nutrition assessment and

providing appropriate nutrition education and referrals, this proposal

addresses the practical realities faced by State agencies by providing

flexibility to obtain this data up to 90 days after the certification

intake process. State agencies would, however, be required to provide

for blood tests at certification for income eligible applicants with no

other documented risk conditions (with the exception of presumptively

eligible pregnant women as discussed below) in order to determine if

they are at nutritional risk due to anemia.

2. Timing of Hematological Tests (Sec. 246.7 (e), (e)(1), and (e)(1)

(i)-(ii))

Age of Bloodwork Data

The Department has received comments from State agencies that the

allowable age for bloodwork data limits local agency flexibility to

coordinate with other health care programs. To address the concerns

with the age of bloodwork data, this proposed rulemaking would expand

the current regulatory standard from 60 days to 90 days as the maximum

age of bloodwork data used to assess nutritional risk. The proposed 90-

day limit should allow additional flexibility to coordinate referral

data with other health care programs, yet at the same time assure that

the data accurately represent the applicant's health status. This

rulemaking would assist in assuring this by continuing to require that

such data are reflective of the categorical nutritional status/risk of

women applicants. Thus, for a pregnant woman the test must be conducted

during pregnancy, and for a breastfeeding or a postpartum woman the

test must be conducted after the termination of their pregnancy.

The categorical restrictions do not apply to infants and children.

As such, State agencies may use bloodwork data obtained from an infant

to certify a child applicant, provided such data is not more than 90

days old. For example, bloodwork data obtained when the infant was 10

months old may be used to certify a 13-month old child.

Timing of Bloodwork

This proposed rule is intended to allow sufficient flexibility to

States to accommodate generally accepted recommendations of maternal

and child health and medical experts. In April 1998, the Centers for

Disease Control and Prevention (CDC) issued a document titled,

``Recommendations to Prevent and Control Iron Deficiency in the United

States.'' These recommendations are intended to guide primary health

care providers in preventing and controlling iron deficiency in

infants, preschool children, and women of childbearing age,

particularly pregnant women--populations served by the WIC Program

which are at high risk for iron-deficiency anemia. As such, the CDC

recommendations stipulate that blood test results should be obtained at

the earliest opportunity during pregnancy, from 4 to 6 weeks after

delivery for postpartum and breastfeeding women, between 9 and 12

months of age for infants, and 6 months later (15-18 months) and

annually from ages 2 to 5 years for children. This rule would provide

States with the flexibility to conform to these recommendations to

better assure that WIC staff have blood test data reflecting current

status at appropriate times during the certification period yet provide

that WIC participants receive timely nutrition care and referral during

their certification periods.

For pregnant, breastfeeding, and postpartum women, a hematological

test for anemia must be performed at

[[Page 64213]]

certification or within 90 days of the date of certification. The test

may be from a referral source or may be conducted by WIC. The referral

data may be up to 90 days old, so long as it is reflective of women

applicants' categories, meaning the test must have been taken for

pregnant women during pregnancy and for postpartum or breastfeeding

women following termination of pregnancy.

Regarding pregnant women, current regulations at

Sec. 246.7(e)(1)(iii), which reflect WIC legislation, provide State

agencies an additional flexibility by allowing them to presume that

income-eligible pregnant women are nutritionally at risk and thus

eligible to participate in the program. Presumptively eligible women

can be certified immediately and can receive program benefits up until

60 days from the date they were certified, by which time a nutrition

assessment must be conducted to establish nutritional risk. If the

subsequent assessment determines that the woman does not meet

nutritional risk criteria, the certification terminates on the date of

the determination, or 60 days after the participant was certified,

whichever is sooner. This proposed rule would eliminate the bloodwork

requirement at certification or within the 60-day presumptive

certification period for these women, further easing burden. However,

under this proposal, if the nutrition assessment performed during the

60-day period does not include anemia testing and does not identify any

other qualifying risk factor, a blood test must be performed or

obtained from referral sources before that 60-day period elapses to

permit continuity of service for women found to be anemic. This

requirement enables such pregnant women to have the temporary

presumptive certification extended to a full certification period

without disruption to continued receipt of WIC benefits, should they be

found anemic.

Consistent with the new CDC recommendations, all infants 9 months

of age or older must have a hematological test for anemia between 9 and

12 months of age. Such test may be performed by the WIC agency or

obtained from referral data. A blood test taken between 6 and 9 months

of age may be used to meet the test requirement, however State agencies

are encouraged to obtain blood test data between 9 and 12 months of age

as recommended by CDC. In addition, recognizing that the CDC guidelines

state that blood tests for anemia for infants under 6 months of age may

be appropriate for preterm infants and low birthweight infants who were

not fed iron-fortified formula, this proposal would permit, but not

require, blood tests for such infants.

The Department also wishes to clarify that in cases where the State

agency has opted to certify infants under 6 months of age up to their

first birthday, as permitted in Sec. 246.7(g)(1)(iv), such infants must

receive a blood test between 9 and 12 months of age. The extension of

the certification period up to the first birthday is only permitted

provided the quality and accessibility of health care services are not

diminished. A blood test for anemia is considered a critical component

of health care services and thus, must be performed or obtained from

referral services. As stated earlier in this preamble, the CDC

recommendations identify the period between 9 and 12 months as the

optimal timeframe for anemia testing for infants. Also considered as a

critical component of health care services during the one-year period,

is securing current length and weight measurements in order to assess

the infant's growth.

State agencies that certify infants at 6 month intervals must

ensure that infants 9 months of age or older receive a blood test. A

blood test taken at 6 months of age may be used to meet the infant

blood test requirement, because such data would fall within the 90-day

age of bloodwork data timeframe.

For children, current provisions at Section 246.7(e)(1) allow State

and local agency discretion to waive the blood test for children who

were determined to be within the normal range at their last

certification period, provided that such test is performed at least

once every 12 months. The new CDC guidelines recommend a blood test

between 9 and 12 months of age, 6 months thereafter (around 15 to 18

months of age), and annually thereafter for each year from ages 2 to 5

years of age. Thus, this rule proposes that State agencies perform a

blood test between 12 and 24 months of age to permit them full

flexibility to accommodate arrangements for bloodwork for these

children within the CDC recommended 6-month timeframe following their

infant bloodwork. While for most children, this would fall between 15

and 18 months of age, this proposal would expand the allowable

timeframe to accommodate practical logistical difficulties and

circumstances where, for example, there was no previous bloodwork

during infancy, it was taken during infancy at a time other than the

recommended 9 to 12 month period, or other logistical complications

which made bloodwork during the optimal 15 to 18 month period

infeasible. Nevertheless, because pediatric health authorities

generally recommend that children have a blood test during the most

vulnerable period of 15 to 18 months, when anemia is more likely to

become manifest, State agencies are expected to make every effort to

coordinate the scheduling of bloodwork for children between 12 and 24

months old within the recommended 15 to 18 month timeframe.

As for women, the referral bloodwork data allowed to be used to

certify children and infants can be up to 90 days old. However,

although bloodwork data obtained when an infant was between 9 and 12

months old may be used to certify a 12-month old child, such data

cannot be used to fulfill the blood test that is required between 12

and 24 months of age nor can it be used to waive a blood test. Children

who had an inadequate iron intake during infancy are at greatest risk

of developing anemia between 12 and 24 months of age. Thus, it is

critical that children receive a blood test for anemia during the

period of 12-24 months of age. As such, the current provision at

Sec. 245.7(e) has been modified to state that for children ages two and

older who were determined to be within the normal range at their last

certification, the blood test may be waived, provided that a blood test

is performed at least once every 12 months.

Other Nutrition Assessment Data

The Department again emphasizes that this proposal provides for

flexibility only in the timing of the collection and age of anemia

blood test data: If not completed at certification (using current data,

or data up to 90 days old), it must be completed within 90 days of

certification except as noted for infants as discussed earlier in this

preamble. All other nutrition assessment data, e.g., height and weight,

and dietary and medical assessment data, must be collected as currently

required; namely: It must be collected at certification for

breastfeeding and postpartum women, infants and children, and, for

pregnant women unless the State agency has opted to implement

presumptive eligibility for pregnant women. State agencies implementing

presumptive eligibility must still collect height, weight and dietary

and medical assessment data for pregnant women within 60 days of

certification to determine eligibility. The Department considers the

effort at certification to measure and record height or length and

weight and collect dietary and other medical data for all applicants to

be minimal but necessary during the intake process, and not subject to

the difficulties related to bloodwork

[[Page 64214]]

assessment. These timely measurements and data are fundamental to the

assessment of nutritional risk of all categories of applicants.

3. Allowable Costs for Anemia Tests (Sec. 246.14(c)(2) (i)-(iv))

Current WIC Program regulations (Sec. 246.14(c)(2) (i)-(iv))

stipulate that fees, equipment, salary and other costs associated with

the collection of hematological data to test for anemia for

certification purposes are allowable Program costs. This proposed rule

would specify that collection of hematological data is not only for

certification purposes, but also for health assessment and monitoring

purposes. This proposal would also allow State agencies to perform one

additional hematological test as medically necessary in follow-up to a

finding of anemia within a certification period. The Department

proposes changes in Sec. 246.14(c)(2) and (c)(2) (i)-(iv) to clarify

that this follow-up test for nutrition assessment purposes is an

allowable WIC cost when deemed necessary for health monitoring as

determined by the WIC competent professional authority (CPA).

While this rule would permit WIC to pay for one follow-up test,

State agencies are encouraged to weigh the cost effectiveness of WIC

expenditures for such purposes against other competing and critical WIC

needs. The Department generally believes that follow up monitoring of

blood values of persons with anemia is largely the responsibility of

health care providers, and should be treated as a medical, rather than

solely a nutritional, concern. As such, the Department encourages State

agencies to explore other locally available sources for ongoing health

care and assessments for WIC participants with anemia.

4. State Plan (Sec. 246.4(a)(11)(i))

State agencies must incorporate their blood test data requirements

and timeframes in detail in the ``Certification Procedures'' section of

their State Plan Procedure Manual.

Appropriate procedures that must be followed when blood test data

are obtained include: (1) Make notations in the participant's file with

respect to nutrition risk factors listed and priority as appropriate;

(2) inform the woman or parent/guardian of the outcome and meaning of

the blood test if the results show anemia; (3) provide follow-up

nutrition education, if appropriate; (4) make adjustments in the food

package, as appropriate; and (5) make referrals to health care or

social services, as appropriate.

List of Subjects in 7 CFR Part 246

Administrative practice and procedure, Civil rights, Food

assistance programs, Food and Nutrition Service, Food donations, Grant

programs-health, Grant programs--social programs, Indians, Infants and

children, Maternal and child health, Nutrition, Nutrition education,

Penalties, Reporting and recordkeeping requirements, Public assistance

programs, WIC, Women.

For the reasons set forth in the preamble, 7 CFR part 246 is

proposed to be amended as follows:

PART 246--SPECIAL SUPPLEMENTAL NUTRITION PROGRAM FOR WOMEN, INFANTS

AND CHILDREN

1. The authority citation for part 246 continues to read as

follows:

Authority: 42 U.S.C. 1786.

2. In Sec. 246.4, paragraph (a)(11)(i) is revised to read as

follows:

Sec. 246.4 State Plan.

(a) * * *

(11) * * *

(i) Certification procedures, including a list of the specific

nutritional risk criteria by priority level which cites conditions and

indices to be used to determine a person's nutritional risk,

hematological data requirements including timeframes for the collection

of such data, the State agency's income guidelines for Program

eligibility, and any adjustments to the participant priority system

made pursuant to Sec. 246.7(e)(4) to accommodate high-risk postpartum

women or the addition of Priority VII;

* * * * *

2. In Sec. 246.7:

a. The introductory text of paragraph (e) is revised;

b. The introductory text of paragraph (e)(1) is removed;

c. Paragraphs (e)(1)(i), (e)(1)(ii), (e)(1)(iii), and (e)(1)(iv)

are redesignated as paragraphs (e)(1)(iii), (e)(1)(iv), (e)(1)(v), and

(e)(1)(vi) respectively;

d. New paragraphs (e)(1)(i) and (e)(1)(ii) are added;

e. Newly redesignated paragraphs (e)(1)(iii), (e)(1)(iv) and

(e)(1)(vi) are amended by adding a heading; and

f. Newly redesignated paragraphs (e)(1)(v) is revised.

The revisions and additions read as follows:

Sec. 246.7 Certification of participants.

* * * * *

(e) Nutritional risk. To be certified as eligible for the Program,

applicants who meet the Program's eligibility standards specified in

paragraph (c) of this section must be determined to be at nutritional

risk. A competent professional authority on the staff of the local

agency shall determine if a person is at nutritional risk through a

medical and/or nutritional assessment. This determination may be based

on referral data submitted by a competent professional authority not on

the staff of the local agency. Nutritional risk data shall be

documented in the participant's file and shall be used to assess an

applicant's nutritional status and risk, tailor the food package to

address nutritional needs, design appropriate nutrition education, and

make referrals to health and social services for follow-up, as

necessary and appropriate. Except as stated in paragraph (e)(1)(v) of

this section, at least one nutritional risk must be documented at the

time of certification in order for an income eligible applicant to

receive WIC benefits.

(1) Determination of nutritional risk.--(i) Required nutritional

risk data. At a minimum, height or length and weight shall be measured

and documented in the applicant's file at the time of certification. In

addition, a hematological test for anemia such as a hemoglobin,

hematocrit, or free erythrocyte protoporphyrin test shall be performed

at certification or within 90 days of the date of certification.

However, such hematological tests are not required, but are permitted,

for infants under nine months of age. All infants nine months of age

and older (who have not already had a hematological test performed or

obtained, between the ages of six and nine months, by a competent

professional authority), shall between nine and twelve months of age

have a hematological test performed or obtained from referral sources.

This hematological test does not have to occur within 90 days of the

date of certification. Only one test is required for children between

12 and 24 months of age. At the State or local agency's discretion, the

hematological test is not required for children ages two and older who

were determined to be within the normal range at their last

certification. However, the hematological test shall be performed on

such children at least once every 12 months. Hematological test data

submitted by a competent professional authority not on the staff of the

local agency may be used to establish nutritional risk. Height or

length and weight measurements and, with the exceptions specified in

this paragraph, hematological tests, shall be obtained for all

participants, including those who are determined at nutritional

[[Page 64215]]

risk based solely on the established nutritional risk status of another

person, as provided in paragraphs (e)(1)(iv) and (e)(1)(v) of this

section.

(ii) Timing of nutritional risk data.

(A) Weight and height or length. Weight and height or length shall

be measured for program participation at the time of certification.

(B) Hematological test for anemia. For pregnant, breastfeeding, and

postpartum women, and child applicants, the hematological test for

anemia shall be performed or obtained from referral sources at the time

of certification or within 90 days of the date of certification.

However, a State agency cannot use hematological data obtained from

referral sources that is taken more than 90 days prior to the date of

certification for program participation.

Infants nine months of age and older (who have not already had a

hematological test performed, between six and nine months of age, by a

competent professional authority or obtained from referral sources),

shall between nine and twelve months of age have a hematological test

performed or obtained from referral sources. Such a test may be

performed more than 90 days after the date of certification. For

pregnant women, the hematological test for anemia shall be performed

during their pregnancy. For persons certified as postpartum or

breastfeeding women, the hematological test for anemia shall be

performed after the termination of their pregnancy. The participant or

parent/guardian shall be informed of the test results when there is a

finding of anemia, and notations reflecting the outcome of the tests

shall be made in the participant's file. Nutrition education, food

package tailoring, and referral services shall be provided to the

participant or parent/guardian, as necessary and appropriate.

(iii) Breastfeeding dyads.* * *

(iv) Infants born to WIC mothers or women who were eligible to

participate in WIC. * * *

(v) Presumptive eligibility for pregnant women. A pregnant woman

who meets the income eligibility standards may be considered

presumptively eligible to participate in the program, and may be

certified immediately without an evaluation of nutritional risk for a

period up to 60 days. A nutritional risk evaluation of such woman shall

be completed not later than 60 days after the woman is certified for

participation. A hematological test for anemia is not required to be

performed within the 60-day period unless the nutrition risk evaluation

performed does not identify a risk factor. If no risk factor is

identified, a hematological test for anemia must be performed or

obtained from referral sources before the 60-day period elapses. Under

the subsequent determination process, if the woman does not meet any

nutritional risk criteria, including anemia criteria, the woman shall

be determined ineligible and may not participate in the program for the

reference pregnancy after the date of the determination, unless she

subsequently reapplies for program benefits and is found to be both

income eligible and at nutritional risk. Notification of the

ineligibility determination shall be given in accordance with paragraph

(j)(5) of this section. In addition, if the nutritional risk evaluation

is not completed within the 60-day timeframe, the woman's participation

shall end. As set forth in paragraph (j)(8) of this section,

notification must be given prior to expiration of the certification

period.

(vi) Regression. * * *

* * * * *

3. In Sec. 246.14, paragraph (c)(2) is revised to read as follows:

Sec. 246.14 Program costs.

* * * * *

(c) * * *

(2) The cost of Program certification and nutrition assessment

procedures, including the following:

(i) Laboratory fees incurred for up to two hematological tests for

anemia per individual per certification period conducted to assess

nutritional status and determine whether such individual is at

nutritional risk. The first test shall be to determine anemia status.

The second test may be performed only in follow up to a finding of

anemia when deemed necessary for health monitoring as determined by the

WIC State agency;

(ii) Expendable medical supplies necessary to assess nutritional

status and to determine whether persons are at nutritional risk;

(iii) In connection with nutrition assessment and nutritional risk

determinations, medical equipment used for taking anthropometric

measurements, such as scales, measuring boards, and skin fold calipers;

and for blood analysis to detect anemia, such as spectrophotometers,

hematofluorometers and centrifuges; and

(iv) Salary and other costs for time spent on nutrition assessment

and certification.

* * * * *

Dated: October 2, 1998.

Samuel Chambers, Jr.,

Acting Administrator, Food and Nutrition Service.

[FR Doc. 98-30917 Filed 11-18-98; 8:45 am]

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