Forms

Missouri WIC

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

WIC LAP

WIC TAP

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

Forms to be Downloaded

Zero Income Affidavit - WIC 41
These translations are also available for downloading in Arabic, Bosnian, Burmese, Chinese, Farsi, French, Hmong, Korean, Romanian, Russian, Somali, Spanish, Ukrainian, Urdu, and Vietnamese.

Breastfeeding Women (Eligible for WIC, but no food benefits) Letter
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. These translation are available to download: Arabic, Bosnian, Bulgarian, Burmese, Chinese, English, Farsi, French, Hmong, Italian, Korean, Romanian, Russian, Somali, Spanish, Ukrainian, Vietnamese.

Order Form: WIC Nutrition Education Resource Request - WIC 7 (12-20-13)  - Local WIC Provider Use Only
This form allows agencies to order state WIC nutrition education resource materials.

Order Form: WIC Resource Supply Request - WIC 8 (word) -- (pdf) (9-5-14 version) - Local WIC Provider Use Only
This form allows agencies to order state supplied forms and materials needed to run their WIC clinic.

Order Form: Breastfeeding Resource Request - WIC 9  (11-19-13 version) - Local WIC Provider Use Only
This form allows agencies to order state Breastfeeding Resource.

Participant’s Rights and Responsibilities (WIC 10-M Backup Form) Effective January 6, 2014
Arabic, Bosnian, Burmese, Chinese, English, Farsi, French, Hindi, Hmong, Korean, Nepali, Romanian, Russian, Somali, Spanish, Ukrainian, Urdu, Vietnamese

WIC Certification: WIC 1 Backup Form WIC 2-M Backup Form
WIC Proof of Eligibility (WIC 30-M Backup Forms)
WIC Household Food Instrument Register (WIC-31 MOWINS Backup Forms)

New WIC Check
Arabic, Bosnian, Chinese, English, Farsi, Hmong, Korean, Russian, Somali, Spanish, Ukrainian, Vietnamese

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-17 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 .pdf format downloading in Arabic, Bosnian, Bulgarian, Burmese, Chinese, Farsi, French, Italian, Korean, Romanian, 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.

Medical Documentation Form (WIC 27) This form is used by health care providers to request special formula for WIC participants.

Nutrition Assessment Forms (files in .pdf format)
Used by WIC clinics for nutrition assessment of participants identifying meal pattern, eating pattern, beverage and supplement intake, and physical activity.

Nutrition Assessment Forms! (Effective May 1, 2014)

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 file a complaint regarding negative experiences at WIC vendors using this form.  To be completed by participant, local WIC provider coordinator or representative.

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.

Impact Analysis Template

Proxy/Authorized Representative Form

Lost/Stolen Food Instrument Form - WIC 32
Arabic, Bosnian, Burmese, Chinese, English, Farsi, French, Hmong, Korean, Romanian, Russian, Somali, Spanish, Ukrainian, Urdu, and Vietnamese.

 

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.