Forms, Policies, and Procedures
Forms
Online Applications
FFY 2020 LAP Instructional Guide
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.
Updates to Online Invoicing
New Budget Adjustment Format
New Invoicing Format
Administrative Forms
Available in the warehouse. Use WIC-8 to order.
Appointment Reminder Postcard - (WIC-39)
This postcard is used by many WIC local agencies to provide a reminder that is mailed prior to the next scheduled visit and is available in 18 different languages.
Arabic, Bosnian, Burmese, Chinese, English, Farsi, French, Hindu, Hmong, Korean, Nepali, Romanian, Russian, Somali, Spanish, Ukrainian, Urdu, and Vietnamese.
WIC Notification Of Ineligibility Or Termination - (WIC-19)
This form is used by local agencies 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.
WIC Referral Form - (WIC-61)
Health care providers, welfare and social service programs, and WIC local agencies can use this form when they refer WIC participants or patients to needed services.
Available Electronically.
Media/Pamphlet Review Criteria Form
This form is used to meet approval criteria when pamphlets, audiovisuals, or other media related educational resources outside of Missouri Department of Health and Senior Services (MDHSS) are being reviewed or developed for WIC participant use by local agencies.
Voter Registration Tally Sheet – (WIC-23)
This document is used to track voter registration applications.
WIC Participant Redemption Complaint - (WIC-40)
WIC participants can file a complaint regarding negative experiences at WIC retailers using this form.
Civil Rights Impact Analysis.
Backup Forms
Available in the warehouse. Use WIC-8 to order.
Available electronically.
Breastfeeding Women (Eligible for WIC, but no food benefits) Letter
Used by WIC local agencies for notifying breastfeeding women (six (6) 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, and Vietnamese.
Nutrition Forms
Available in the warehouse. Use WIC-8 to order.
Medical Documentation Form (WIC-27)
This form is used by health care providers to request special formula for WIC participants.
The MO WIC Approved Formulas and WIC-Eligible Nutritionals listing is available on the Medical Documentation and Referral Form page under the first tab.
Nutrition Assessment Forms
To be used by WIC local agencies for nutrition assessment of participants identifying meal and eating pattern, beverage and supplement intake, and physical activity.
Available electronically.
Follow-Up Nutrition Assessment Questions for Certification or Mid-Certification Assessment
Mid-Certification Nutrition Assessment Questions
Resource Order Forms
Forms For WIC Local Agency Use Only
Developmental Milestones/Talking is Teaching Resource Request Form - (WIC-5)
DHSS Nutrition & Health Resource Request Form - (WIC-6)
Nutrition Education Resource Request - (WIC-7)
WIC Resource Request - (WIC-8)
WIC Breastfeeding Resource Request - (WIC-9)
Policies and Procedures
Missouri WIC Policies
WIC Operations Manual (WOM) - This document contains policies for the Missouri WIC program.
Risk Factor Definitions Tables
Disclaimer and Nondiscrimination Statement
Missouri WIC Scope of Work
The Missouri WIC Scope of Work is the WIC local agency (LA) contract for the provision of services in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC).
WIC Local Agency Nutrition Services Scope of Work FFY2021
Attachment A - Certifications
Attachment B - Subrecipient Special Conditions
Attachment C - Budget Template
Attachment D - Subrecipient Annual Financial Report
Attachment E - Local Agency Breastfeeding Peer Counseling Program
Attachment F - Local Agency User Acceptance Testing
Exhibit 1 - Everify
Exhibit 2 - Guidelines for Allowable Items for Reimbursement Missouri Breastfeeding Peer Counseling Program (BFPC)
Terms and Conditions
Food and Formula Reference Guides
Food and Formula Reference Guide: Formula Listing
(Effective Oct. 1, 2021)
Food and Formula Reference Guide: Formula Listing
(Effective Jan. 1, 2021)
Issuing Milk and Milk Substitutes
Supplement to Food and Formula Reference Guide (FFRG) - Guidelines
Food and Formula Reference Guide: Formula Listing
(Effective Aug 1, 2019)
Food and Formula Reference Guide: Guidelines
(Effective Sept. 1, 2019)
Health and Nutrition Assessment Handbook (HNAH)
This handbook provides basic information on the process and procedures for the Missouri WIC program as referred in policies.
Anthropometric - This section provides guidance on anthropometric equipment purchases as well as the procedures on how to obtain and record accurate anthropometric data reflective of the participant's category.
Biochemical - This section provides guidance on biochemical criteria, such as hemoglobin testing, to screen for iron deficiency anemia. This screening, along with other medical risk criteria, is used to determine nutrition risk eligibility for the WIC program.
Nutrition Assessment - This section provides guidance on the process of obtaining and evaluating information about a participant's nutrition status in order to provide the most appropriate individualized WIC services.
Standard Abbreviations & Meanings - This section provides guidance on approved abbreviations and meanings used in the Missouri WIC program.
Guide to Coordinating WIC Services During Disasters
Guide to Coordinating WIC Services During Disasters - This guidance contains information to help WIC state agencies plan for meeting the needs of WIC participants and potential, newly-eligible WIC applicants prior to and during a disaster response. It can also be used to plan for continued WIC operations during emergencies or other situations of distress. The information is designed to assist Headquarters and Regional Office staff, as well as WIC state and local agency staff, in their development of an executable WIC disaster plan.
Allocating Leave Time in the Online Invoicing System
Allocating Leave Time in the Online Invoicing System - USDA Food and Nutrition Services (FNS) provided further clarification to code staff leave expenses to a direct cost category (program management, breastfeeding support, client services, and nutrition services) in the same manner that each local agency staff wages are assigned.
Guide to Separation of Duties Report
Guide to Separation of Duties Report - The purpose of the Separation of Duties report is to ensure separation of duties is occurring at the local agency to avoid conflict of interest and to safeguard against fraud. The Separation of Duties report can be used as a tool to complete the required review. As the Separation of Duties report is run, it is designed to automatically pull all nonbreastfeeding infant certification records and a 20 percent random sampling of the remaining certification records for the days during which only 1 WIC staff person performed all eligibility and certification functions.
WIC and Nutrition Services
Missouri Department of Health and Senior Services
PO Box 570
Jefferson City, MO 65102-0570
Telephone: 573-751-6204 or
(toll-free) 800-392-8209
Fax: 573-526-1470
Email: WICinfo@health.mo.gov