WIC Local Agency Forms

Local Agency Forms and Instructions

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Forms Submitted to the State
Other Clinic Forms
Vendor Forms
Clinic Instructions

Forms Submitted to the State

(20 KB)	WIC Local Agency Reporting Schedule
(14 KB)	WIC Quarterly Report Due October 31 st , January 31 st , April 30 th , and July 31 st .
(70 KB)	WIC Quarterly Report (Word Version) Due October 31 st , January 31 st , April 30 th , and July 31 st .
(12 KB)	Property Inventory Report Form from Chapter 7 of Policy and Procedure Manual
(91 KB)	Property Inventory Report (Word Version) Form from Chapter 7 of Policy and Procedure Manual
(12 KB)	WIC Program Expenditure Report Form from Chapter 7 of Policy and Procedure Manual

(45 KB)	Time Study Master
(12 KB)	Time Study Daily Log Form from Chapter 7 of Policy and Procedure Manual
(12 KB)	Time Study Summary Form from Chapter 7 of Policy and Procedure Manual

(13 KB) (44 KB)	Sample Formula Form (PDF) Form to keep track of formula sample distribution Sample Formula Form (Word Document)
(11 KB) (28 KB)	Civil Rights Complaint Form (PDF) Use this form when a client has a discrimination complaint. Civil Rights Complaint Form (Word Document)
(117 KB) (365 KB)	Local Agency Self Assessment Form (PDF) Use this form for the annual self assessment due November 15 each year and for the agency management evaluation Local Agency Self Assessment Form (Word Document)
(199 KB)	State from used to expedite the disposal of outdated WIC equipment

Other Clinic Forms





(212 KB)	Log-In Form
(15 KB)	2012-2013 Income Guidelines Income Guidelines
(15 KB)	2012-2013 Alaska Native/American Indian Income Certification Form WIC Alaska Native/American Indian Income Certification Form
	Applications Family Information Form Breastfeeding Postpartum Application Child Application Infant Application Pregnant Woman Application
(33 KB)	Breast Pump Loan form
(10 KB)	Breast Pump Retrieval Letter 1 Form to use when trying to retrieve a breast pump for the first time from a client.
(11 KB)	Breast Pump Retrieval Letter 2 Form to use when trying to retrieve a breast pump for the second time from a client.
(410 KB)	Certification Form
(23 KB) (45 KB)	High Risk Care Plan - Women (PDF) Form to use in developing a high risk care plan for a woman. High Risk Care Plan - Women (Word Document)
(23 KB) (45 KB)	High Risk Care Plan- Infant (PDF) Form to use in developing a high risk care plan for an infant. High Risk Care Plan- Infant (Word Document)

(39 KB)	Improper Action Form (Word Document)
(38 KB)	Lost and Stolen WIC Warrant Form (Word Document)
(26 KB)	Memorandum of Understanding A MOU that can be used with homeless facilities. These can all be found at: http://www.hss.state.ak.us/dpa/programs/nutri/nutri/WIC/LocalAgencies/LAForms.htm.
(12 KB) (31 KB)	No Proof Form (PDF) Form to be used when proof of income, residency, identity or pregnancy needs to be verified. No Proof Form (Word Document)
(24 KB)	Transfer Notice Form used when communicating about rural clients transferred into the urban area
(34 KB)	Your Benefits Have Ended Form (Word Document)
(92KB)	WIC Program Physical & Mail Directory

Vendor Forms

(24 KB)	WIC Pre-Agreement On-Site Vendor Visit Report
	WIC Food Exemption Request Form
(19 KB)	Request Vendor to Restock WIC food items
(61 KB)	Vendor Monitoring Form
(114 KB)	Compliance Procedures Compliance Report WIC and Local Agency staff will use the Compliance Report form when conducting compliance buys at WIC vendors. Please review the procedures for the proper way to conduct and report each buy.

Clinic Instructions

(23 KB)	July 2008 Build Instructions - Short Version July 2008 Build Instructions - Long Version
(19 KB)	AKWIC Referral List The bundled Referral List that is found in AKWIC and the corresponding programs associated with the referral categories.
(144 KB)	Warrant Print Instructions, 01/06/05
	Policies & Procedures/ Manuals
	Revision 8 Build Instructions Training forms used in the implementation of Nutrition Risk Criteria Revision 8 WIC Nutr Risk Criteria Rev 8 Build Instructions 9-11-07.pdf Condensed WIC Nutr Risk Criteria Rev 8 Build Instructions 9-11-07.pdf Risk Manual Summary Oct 2007 Version 8-29-07.pdf Cert Form color Version 8-29-07.pdf Cert Form bk-wh Version 8-29-07.pdf

To address technical problems or make suggestions regarding this site, please email:
wic@alaska.gov

Other contact information:
Family Nutrition Services State of Alaska/DHSS/DPA
Address:	130 Seward St PO Box 110612 Juneau, AK 99801	Main office: Fax:	(907) 465-3100 (907) 465-3416