Forms

Online Applications

LAP - Local Agency Plan
LAP Manual
TAP - Technical Assistance Packet
Nutrition Education Lesson Plan
This form is used when group nutrition education sessions are offered. The Nutrition Sessions Evaluation (second tab) may be used to summarize results of group nutrition sessions.
WIC Online Invoicing
Invoice User Manual
Breastfeeding Peer Counseling/Breastfeeding Friendly WIC Clinic Application

Administrative Forms

Notice of Certification - (WIC-73) NEW!
This sticker is for reminding WIC participants of the next certification date.
(Printer Friendly version - Use Avery 5163 Mailing labels 2" x 4")
Arabic, Bosnian, Burmese, Chinese, English, Farsi, French, Hindi, Hmong, Korean, Nepali, Romanian, Russian, Somali, Spanish, Ukrainian, Urdu, and Vietnamese.
wic reminder card Appointment Reminder Postcard - (WIC 39)
Rev. 08/16
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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, Burmese, Chinese, English, Farsi, French, Hindu, Hmong, Korean, Nepali, Romanian, Russian, Somali, Spanish, Ukrainian, Urdu and Vietnamese.
missed appointment card Missed Appointment Card - (WIC 71) Rev. 08/16
Arabic, Bosnian, Burmese, Chinese, Farsi, French, Hindi, Hmong, Korean, Nepali, Romanian, Russian, Somali, Spanish, Ukrainian, Urdu and Vietnamese.
wic fraud flyer WIC Fraud Flyer - (WIC 66)
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This flyer is used by local WIC providers as an insert for the participant folder in an effort to prevent or deter the sale of WIC foods or benefits, which is a violation of the WIC program.

Arabic, Bosnian, Burmese, Chinese, English, Farsi, French, Hindi, Hmong, Korean, Nepali, Romanian, Russian, Somali, Spanish, Ukrainian, Urdu, and Vietnamese.
Impact Analysis Template - (WIC 34)
Media/Pamphlet Review Criteria Form
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This 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.

WIC Notification Of Ineligibility Or Termination - (WIC-19) - July 2017 version
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This form is used by local WIC providers to provide written notice of ineligibility to applicants or participants.

Arabic, Bosnian, Burmese, Chinese, English, Farsi, French, Hindi, Hmong, Korean, Nepali, Romanian, Russian, Somali, Spanish, Ukrainian, Urdu, and Vietnamese.
Partial WIC Formula Redemption - (WIC-21)
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This form is used by WIC retailers when they do not have enough formula in their stock to meet the demands on a WIC Check. When completed by the retailer 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.

WIC participant   Identification (ID) Folder WIC participant Identification (ID) Folder - (WIC-17)
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WIC participants must present their WIC Participant ID folder when they purchase WIC approved foods using WIC checks at WIC authorized retailers. The participant or proxy must sign on the ID folder and show it to the retailer for ID verification when purchasing WIC foods. Local WIC Agencies must give an ID folder to each active participant family.

WIC participant Identification (ID) Folder - (WIC 17S)
Arabic, Bosnian, Bulgarian, Burmese, Chinese, Farsi, French, Italian, Korean, Romanian, Russian, Somali, Spanish, Ukrainian, and Vietnamese.
WIC Participant Redemption Complaint - (WIC 40)
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WIC participants can file a complaint regarding negative experiences at WIC retailers using this form. To be completed by participant, local WIC provider coordinator or representative.


Proxy/Authorized Representative Form - (WIC-33)
WIC Participant's Rights and Responsibilities - (WIC-10)
(Effective February 6, 2017 version)
Arabic, Bosnian, Burmese, Chinese, English, Farsi, French, Hindi, Hmong, Korean, Nepali, Romanian, Russian, Somali, Spanish, Ukrainian, Urdu, and Vietnamese.
WIC Referral Form - (WIC 61)
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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.


Zero Income Affidavit - (WIC 41)
Arabic, Bosnian, Burmese, Chinese, Farsi, French, Hmong, Korean, Romanian, Russian, Somali, Spanish, Ukrainian, Urdu, and Vietnamese.
Separation of Duties Exception Log
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This form is used by local WIC providers with fewer than two WIC staff to meet the separation of duties requirements. More information is available in ER # 1.07000, Program Integrity policy.


Emailing-Texting Clients Instructions

MOWINS Back-up Forms

Breastfeeding Women (Eligible for WIC, but no food benefits) Letter
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Used by WIC clinics for notifying breastfeeding women (six months post partum) who are partially breastfeeding greater than the max who are eligible for WIC, but no food benefits will be issued.

Arabic, Bosnian, Bulgarian, Burmese, Chinese, English, Farsi, French, Hmong, Italian, Korean, Romanian, Russian, Somali, Spanish, Ukrainian, Vietnamese.
Certification Forms - Infant, Children & Women (WIC 1 & 2)
WIC Proof of Eligibility (WIC 30-M Backup Forms)
WIC Household Food Instrument Register (WIC 31 MOWINS BackUp)

Nutrition Forms

Medical Documentation Form (WIC-27)
This form is used by health care providers to request special formula for WIC participants.
Nutrition Assessment Forms
To be used by WIC clinics for nutrition assessment of participants identifying meal pattern, eating pattern, beverage and supplement intake, and physical activity.
WIC 35 EN/SP - Nutrition Assessment for Children
Arabic, Bosnian, Burmese, Chinese, English, Farsi, French, Hindi, Hmong, Korean, Nepali, Romanian, Russian, Somali, Spanish, Ukrainian, Urdu, Vietnamese
WIC-36 EN/SP - Nutrition Assessment for Women
Arabic, Bosnian, Burmese, Chinese, English, Farsi, French, Hindi, Hmong, Korean, Nepali, Romanian, Russian, Somali, Ukrainian, Urdu, Vietnamese
WIC 37 EN/SP - Nutrition Assessment for Infants
Arabic, Bosnian, Burmese, Chinese, English, Farsi, French, Hindi, Hmong, Korean, Nepali, Romanian, Russian, Somali, Ukrainian, Urdu, Vietnamese
Follow-Up Nutrition Assessment Questions for Certification and/or Mid-Certification Assessment
Infant Birth Through 5 Months of Age
Infant Six Through 11 Months of Age
Children 1 Through 5 Years of Age
Prenatal Women
Non-Breastfeeding Women
Breastfeeding Women
Mid-Certification Nutrition Assessment Questions
Infant Six Through 11 Months of Age
Children 1 Through 5 Years of Age
Breastfeeding Women (> 6 Months)

Resource Order Forms

Forms For Local WIC Provider Use Only

DHSS Additional Nutrition & Health Resource Request Form - WIC 6 (05-17 version)
Breastfeeding Resource Request - (WIC 9) (07-16 version)
WIC Nutrition Education Resource Request - (WIC 7) (07/28/17)
WIC Resource Supply Request - (WIC 8) (08-18-17 version)
Request for Literature Form (DH-47)
How To Order The Missouri Voter Registration Cards

Missouri WIC

 


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