Forms

Missouri WIC

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

Appointment Reminder Postcard - (WIC 39)
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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, Chinese, Farsi, Hmong, Korean, Russian, Somali, Spanish, Ukrainian, and Vietnamese.
Training PowerPoint Part I
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)
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This form is used by local WIC providers to provide written notice of ineligibility to applicants or participants.

Partial WIC Formula Redemption - (WIC-21)
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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.

WIC participant Identification (ID) Folder - (WIC-17)
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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.

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 vendors using this form. To be completed by participant, local WIC provider coordinator or representative.


Proxy/Authorized Representative Form - (WIC-33)
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.

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)
Participant’s Rights and Responsibilities (WIC 10) Effective January 6, 2014 Arabic, Bosnian, Burmese, Chinese, English, Farsi, French, Hindi, Hmong, Korean, Nepali, Romanian, Russian, Somali, Spanish, Ukrainian, Urdu, Vietnamese
WIC Proof of Eligibility (WIC 30)

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 (Effective May 1, 2014)
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, Spanish, 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, Spanish, 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
Breastfeeding Resource Request - (WIC 9) (3-15-15 version)
WIC Nutrition Education Resource Request - (WIC 7) (9-30-14)
WIC Resource Supply Request - (WIC 8)
WIC Resource Supply Request - (WIC 8)
(5-7-15 version)

Growth Charts

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.