Applications & Forms

WIC

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

Forms to be Downloaded

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.

Dietary Intake Forms
Used by WIC clinics and other health care organizations to assess the nutritional intake of participants.
WIC-16 - Diet Intake for Females (11+ Years)
WIC-18 - Diet intake and Nutrition Information for Children 1-6 Years of Age

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.

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:
Prenatal Weight Gain Chart
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

High Risk Nutrition Care Plan
This form allows WIC Clinics to manage the nutritional intake of participants that are considered high risk.
WIC-53 – For Prenatal Women
WIC 54 – For Infants/Children

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

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

Partial WIC Formula Redemption – WIC-21
Form 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.

Training Registration Form
Fill out this form to attend Track 1, 2 or 3; Basic HANDS; or WIC Coordinator or Nutrition Coordinator trainings provided to local WIC agencies.

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 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.

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

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.