Skip to content
WIC Home

Local Agency Forms and Instructions

Download Administrative Forms!

Can't find the form you need? Click here for other form categories!

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State from used to expedite the disposal of outdated WIC equipment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

 

2013-2014 WIC Alaska Native Income Waiver

2013-2014 Income Guidelines

Applications

Family Information Form

Breastfeeding Postpartum Application

Child Application

Infant Application

Pregnant Woman Application

 

pdf icon
(33 KB)
Breast Pump Loan form
pdf icon
(10 KB)
Breast Pump Retrieval Letter 1
Form to use when trying to retrieve a breast pump for the first time from a client.
pdf
(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 (Color version)


(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)

d
(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)


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)

d
(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)

pdf icon
(33 KB)
Warrant Tracking Form
pdf icon
(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)

 

 


(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

pdf icon
(23 KB)

 
 

 

 

 

 

 

 

 

 

 

 

 


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

​​​​​​​​​​​​​​