WIC Clinic Forms and Materials

General forms

• Employee Signature Form (form 57-200)
• TWIST Complaint Data Entry Document (form 57-500)
  
• TWIST Certification Data Entry Document (form 57-615)
• Voter Registration forms
  
• Lost/Stolen Voucher Report (form 57-910) 
  • English  Spanish
• Voiding Vouchers Due To Category Change (form 57-911, 8/2009)
  • English  Spanish 

Review tools

• WIC review tool
  • Client record review tool
  • Observation review tool - certification
  • Observation review tool - group education
• Farm Direct Nutrition Program (FDNP) review tool
• Breastfeeding Peer Counseling (BFPC) Program review tool
  • BFPC client record review tool

Medical documentation

• Providence special medical formula request form (WIC staff use only)

  • Fillable Word document    PDF

  • Procedures for ordering special medical formulas from Providence Home Medical Equipment (PDF)

• WIC Medical Documentation Form

  • English (PDF)

  • Spanish (PDF)

• Optional tools (MS Word documents)

  • Client instruction sheet regarding Medical Documentation Form (English and Spanish)

  • Medical Request for Soy Beverage Children 13 to 60 Months (English)

  • Request for Special Medical Formula/Food (English) 

Shopper Education materials for participants

• WIC : It's in the Bag - Education on how to shop with WIC vouchers,  
  • English Flipbook (PDF, 2.75 MB) effective 8/2009
  • Spanish Flipbook (PDF, 2.76 MB) effective 8/2009
  • English Powerpoint (PPT, 12 KB) effective 8/2009
  • Spanish Powerpoint (PPT, 11.9 KB) effective 8/2009