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Contact Info:​

 

WIC Program Office
Phone: 907-465-3100
Fax: 907-465-3416
Email: wic@alaska.gov

PO Box 110612
Juneau, AK 99801

 

• WIC Local Agency Reporting Schedule
• WIC Quarterly Report
  Due October 31st, January 31st, April 30th, and July 31st.
• Controlled Property Inventory Form
  Form from Chapter 7 of Policy and Procedure Manual
• WIC Program Expenditure Report
  Form from Chapter 7 of Policy and Procedure Manual
• Time Study Master​
• Time Study Daily Log​
  Form from Chapter 7 of Policy and Procedure Manual
• Time Study Summary
  Form from Chapter 7 of Policy and Procedure Manual
• Sample Formula Form
  Form to keep track of formula sample distribution
• Sample Formula Form
  
• Civil Rights Complaint Form
  Use this form when a client has a discrimination complaint.
• Civil Rights Complaint Form
  
• Local Agency Self Assessment Form
  Use this form for your agency’s biennial Management Evaluation self-assessment.
• State from used to expedite the disposal of outdated WIC equipment

 

Guidelines

• Service Provider Computer Security Agreement
• Risk Factor Cheat Sheet

Applications

• Family Information Form
• Breastfeeding Postpartum Application
• Child Application
• Infant Application
• Pregnant Woman Application
• Six Month Mid-Cert Assessment Forms
• Breast Pump Loan form
• Breast Pump Retrieval Letter
  Form to use when trying to retrieve a breast pump for the first time from a client.
• High Risk Code Table
• High Risk Care Plan - Women
  Form to use in developing a high risk care plan for a woman.
• High Risk Care Plan - Women
• High Risk Care Plan - Infant
  Form to use in developing a high risk care plan for an infant.
• High Risk Care Plan - Infant
• Improper Action Form
• Lost and Stolen WIC Warrant Form
• Memorandum of Understanding
  A MOU that can be used with homeless facilities.
• No Proof Form
  Form to be used when proof of income, residency, identity or pregnancy needs to be verified.
• No Proof Form
• ​Zero Income Form
• Zero Income Form
• Transfer Notice
  Form used when communicating about rural clients transferred into the urban area
• Your Benefits Have Ended Form
• Your Benefits Have Ended Form
• Warrant Tracking Form
• WIC Local Agency Directory

Monitoring Forms and Compliance Buy Reports: Please contact the State of Alaska WIC Vendor Management Unit for materials.