Forms

WIC

Forms to be downloaded
Forms to be ordered from the DHSS warehouse

Forms to be Downloaded

WIC Certification
Basic certification form for WIC participation. A certification must be completed for each WIC participant.
WIC-1 – Women
WIC-2 – Infant/Child
WIC-10 Required Signature Statement
To be used with WIC Certification Statement (HWPR) printout when doing direct entry
Translated Versions of the WIC-10: Arabic, Bosnian, Chinese, Korean, Somali, Spanish, Russian, Ukrainian, and Vietnamese.

WIC Nutrition Education Resource Request - WIC 7
This form allows agencies to order state WIC nutrition education resource materials.

WIC Supply Request - WIC 8
This form allows agencies to order state supplied forms and materials needed to run their WIC clinic.

Request Form for Folic Acid Literature - Local WIC Providers - DH-47
This form allows local WIC providers to order state Folic Acid Literatures from the DHSS warehouse.

WIC participant Identification (ID) Folder – WIC-17  
WIC participants must present the WIC Participant ID folder when they purchase WIC approved foods using food instruments at the vendors.  The participant or proxy must sign on the ID folder and show it to the vendor for ID verification when purchasing WIC foods.  Local WIC provider must give an ID folder to each active participant family.
Translated Versions of the WIC Participant Rights and Responsibilities (Outer Part of the WIC Participant ID Folder) for downloading in Arabic, Bosnian, Chinese, Farsi, Korean, Russian, Somali, Spanish, Ukrainian, and Vietnamese.

WIC Notification Of Ineligibility Or Termination – WIC-19
This form is used by local WIC providers to provide written notice of ineligibility to applicants or participants.

Partial WIC Formula Redemption – WIC-21
This form is used by WIC vendors when they do not have enough formula in their stock to meet the demands on a WIC Check. When completed by the vendor and returned to the agency by the participant, the participant can be given an additional food instrument to make up the difference of what was not available before.

Documentation For Medical Needs Formula Issuance – WIC-29
This form is filled out by a participant’s doctor, and can allow certain special formulas to be given to infants who are suffering from certain medical conditions.

WIC Proof Of Eligibility – WIC-30
This form records what proofs were given for Identity, Residency and Income. Proof of eligibility must be determined for each participant. Reference Table

Nutrition Assessment Forms
Used by WIC clinics for nutrition assessment of participants identifying meal pattern, eating pattern, Beverage and supplement intake, and physical activity.
WIC 35 - Nutrition Assessment for Children or in these translation available by download Arabic, Bosnian, Chinese, Farsi, Hmong, Korean, Russian, Somali, Spanish, Ukranian, Vietnamese.

WIC-36 - Nutrition Assessment for Women or in these translation available by download Arabic, Bosnian, Chinese, Farsi, Hmong, Korean, Russian, Somali, Spanish, Ukranian, Vietnamese.

WIC 37 - Nutrition Assessment for Infants or in these translation available by download Arabic, Bosnian, Chinese, Farsi, Hmong, Korean, Russian, Somali, Spanish, Ukranian, Vietnamese.

Notification of Corrections for Participant Data Base - WIC 38
Local WIC providers must use the form when corrections are to be made to the participant's or guardian's identification information as it appears in the hands system.

Appointment Reminder Postcard – WIC 39 
This postcard is used by many WIC agencies to provide a reminder that is mailed prior to the next scheduled visit and is available in 12 different languages. Arabic, Bosnian, Chinese, Farsi, Hmong, Korean, Russian, Somali, Spanish, Ukrainian, and Vietnamese.

WIC Participant Redemption Complaint - WIC 40
WIC participants can complaint their negative experiences at WIC vendors using this form.  To be completed by participant, local WIC provider coordinator or representative.

Nutrition Education Report – WIC-49
Official state form designed to document what standardized nutrition education has been provided WIC participants.

High Risk Nutrition Care Plan
This form is designed to document the high risk care plan for pregnant women, infants, and children.
WIC 55 Form - High Risk Care Plan For Infants, Children and Women
Guidelines for Completing the High Risk Care Plan

WIC Referral Form - WIC 61
Health care providers, welfare/social service programs, and local WIC providers can use this form when they refer WIC participants and/or patients to needed services.

Growth Charts
Normal childhood growth depends on positive nutritional, hormonal, and environmental conditions. Changes in any of these conditions influence how well a child grows and develops. Pediatric health care providers have used standing height (or recumbent length), weight and head circumference measurements to assess changes in growth and development. These anthropometric measurements, a basic component of health care services for children, have been used to screen individuals and populations for nutrition-related health problems. Anthropometric (growth) charts are standards for growth developed from studies of normal, healthy children.
Birth to 36 Months:
Weight for Stature Percentiles – Boys  / Girls 
Length-for-age and Weight-for-age percentiles – Boys  / Girls 
Head circumference-for-age and Weight-for-length percentiles – Boys  / Girls 

2 to 5 Years:
Stature-for-age and Weight-for-age – Boys  / Girls 
BMI-for-age – Boys  / Girls 

2 to 20 Years:
Stature-for-age and Weight-for-age – Boys  / Girls 
BMI-for-age – Boys / Girls 

Prenatal Weight Gain Chart
All women need to gain adequate weight during their pregnancy.  This chart is to record weight gain during pregnancy.

Forms to be Ordered From the DHSS Warehouse

WIC and Nutrition Services Literature
Forms published by WICNS and distributed by the DHSS warehouse to local WIC providers.

The "Media/Pamphlet Review Criteria Form" is used to meet approval criteria when Pamphlets and / or Audiovisuals or other media-related educational resources outside of MDHSS are being reviewed or developed for WIC participant use by local WIC providers.