DATE: Howdid you hear about the Program

Guam WIG Program

# PRECERTINFORMATION WORKSHEET #

AUTHORIZED PERSON:

SOCIAL SECURITY NUMBER:

CONTACT PHONENUMBERS:

MAILING ADDRESS:

NAME

P =

PP =

BF =

PregnantPostpartumBreastfeeding

INDIVIDUALS TO BE ON WIG

THINGS TO BRING TO APPLY FOR WIC.1) Picture l.D. w/SS Number of Authorized Person.2) Most Recent Check Stubs or Any Proof of Income

of everyone living in the house.

IMMUNIZATION - WIC LINKAGE

Clinic SiteFamily FolderNo.

Child: Lastname Firstname Middle name SocialSecurityNo.

Mailing Address Residingvillage Ethnicity:

(Pleasecheckone)

City Zip Code Homephonenumber LI Chamorro LI MarshalleseLI Filipino LI PalauanLI Caucasian LI African-Amer.

DateofBirth Age Sex: Work phonenumber LI Chinese Li JapaneseLI Male LI Female LI Chuukese LI Korean

mo day yr LI Yapese LI CNMI(Cham)Mother: Last name Firstname Middle name Mother’sMaidenname LI Kosraen LI Other:

LI Pohnpean

Father: Last name First name Middle name Name of Insurance:

TO BE COMPLETED BY HEALTH CARE PROFESSIONALVACCINE DATE GIVEN CLINiC VACCINE DATE GIVEN CLINIC TUBERCULIN SKIN TEST - PPD

DTaP 2m 1 MMR lyr 1 Date given Clinic DateRead Result

4m 2 4-6yrs 2

6m 3 HBIG

12-15m 4 HepH Bir 1

-. — -4-6yrs 5 2m 2 OTHER DATE GIVEN CLINIC

VACCINES

6 6m 3

2m I Hib 2m 1

IPV 4m 2 4m 2

or 6-12m 3 6m 3 *NOTES

o~v 4-6yr 4 12-15m 4

Var 12-15m

Immunizations are:

IJ Complete~ Incomplete

ForPublicHealthuse:

Referralto: _______________________

DateSignatureofHealthCareProfessional

24 HOUR RECALL

DATE:

ESTIMATED/ACTUAL DELIVERY DATE(for women only): __________________

CIRCLE ONE:pregnant, postpartum, breast feeding

Please write down EVERYTHING you had to EAT and DRiNK forthe last 24 hours. For INFANTS, pleasewrite down the feeding times/amounts for the past 24 hours. (Include all meals, snacks and drinks.)

What time did you eat: Which food/drink did you eat?(how was it prepared/cooked?)

How much/many were eaten?(cups, pieces?)

EXAMPLE: Orange Juice 4 fi. oz.Scrambled Egg I egg, large

7:00am Toast I stick

NAME:

AGE: FF#:

Revised 6/02 WIC-Ol 0

GUAM WIC PROGRAMFINANANCIAL ELIGIBILITY WORKSHEET

A. OccupantsofHousehold: (List wageearners first.)NAME SS# NAME SS#

1. 7.2. 8.

3. 9.

4. 10.5. 11.

6. 12.

Total ~ living in household: (*Useablanksheetof paperif additionalspaceisneeded.)

B. Legal Relationship:Nameof Client(s):_________________________________________________________

Nameof AuthorizedRepresentativeof Client(s): [ ] Clientrepresentsself

Is this afosterchild(ren)?[ ]Yes [ ]No Nameof LegalGuardian(courtappointed):________________________

C. Adjunct Eligibility: (Indicateif client and/orchild(ren)participatein anyof thefollowing programs.)

[ ]FoodStampslD#: Documented Certification Period:[ II TANF/Welfare ID#: Documented Certification Period:[ ] Medicaid (any family member) ID #: Documented Certification Period:[ I Other: ID#: Documented Certification Period:Note:InformationNOT verifiedpertainingto participationinprogramsmentionedabovecannotbeusedfor adjuncteligibility

.

D. Currentor Averas~eHouseholdIncomeEstimate(useADP income calculator):HouseholdWageEarnersj 1 J 2 3 1 4 5 6 I_____WagesSocialSecurityPublicAssistanceChild SupportPension,RetirementSelfEmploymentUnemployment,Other

AnnualTotal Income~4’~,’4(~ ~ ~ ‘,‘.,~ ‘~

CurrentTotalHouseholdIncome(mostrecentfull month)$ ORAverageTotalHouseholdIncome(last6-12mos.)$ /month

WIC StaffSignature/Date(TheWIC staffsignatureindicatesverificationoftheaboveinformation. Pleaseattachcopyof appropriatedocuments.)

~ ~ ~ ~ ~ ‘44 ~1*V.‘//~0~. ~K.

E. Rights and Obligations:Standardsfor participationarethe samefor everyoneregardlessof age, race,color, sex,nationalorigin or handicap. If youbelieve you have been discriminated against, write immediately to: Director, Civil Rights Division, FNS, USDA,Alexandria,Virginia 20250.I herebycertify that all of the informationprovidedis true andcorrect. I understandthat this informationis beinggiven inconnection with the receipt of federal funds, that Guam officials will verify this information, and that deliberatemisrepresentationmaysubjectmeto prosecutionunderapplicableGuamandFederalcriminalstatutes.

ID Verified: [ ]ResidencyVerified: F 1

Signature of Applicant/Caretaker/Date

Typeof Document(s)Verified:Typeof Document(s)Verified:

Rev.2/01

FINANCIAL ELIGIBILITY WORKSHEET

Instructions

(a)List thenamesofall individuals living in thehousehold.Besureto list wageearnersfirstandthenall othersthereafter. If you needadditionalspacefor ahouseholdof more thantwelve(12),useablanksheetofpaperto continue.

(b) Indicatethetotal# ofindividualsliving in thehousehold.

2. (a)List thenameoftheclient(s).(b)List thenameoftheauthorizedrepresentativeoftheclient(s).(c)Placeacheckmarkin theappropriatebox if theclientrepresentsherself.It is unnecessaryto re-writetheclient’snameagain.(d) Check “Yes” or “No” if theclient(s) is afosterchild(ren). Write thenameof thelegalguardianthatis appointedby thecourt if otherthanthebiologicalparent. Indicate“sameasabove” if the legalguardianis thesameasthe authorizedrepresentativementionedaboveorindicate“none” if theclientis an adult.

3. (a) Placeacheckmark in theappropriatebox indicatingwhatprogram(s)theclient and/orchild(ren)is currentlyparticipatingin. Indicatethe TD# anddocumentthebenefitperiod.Note: In orderfor staffto verify participationin suchprograms,client mustshowadjuncteligibility documentsandacopymustbeattachedto thefinancialworksheet,if possible.

4. (a) List current(mostrecentfull month)totalhouseholdincomefor all wageearnerslivingin thehousehold.UsetheADP incomecalculator. Be sureto matchthenumberslisted as“HouseholdWageEarners”to the list of nameson item A. Calculatethe currentsubtotalincomefor eachwageearnerandthetotal monthlyincomeat thetime ofscreeningfor theentirehousehold.(b) Incomeaveragingmayalsobedonefor thelast6-12monthswhenawageearner(s)hasexperiencedperiodsof unemployment. This shouldbe indicatedas an “Average TotalIncome”permonthandthecalculationsfor averagingshouldbe on aseparateblanksheetofpaperwhichshould beattachedto thefinancialworksheet.Note: In orderfor staffto yerify income,clientmustshowthe appropriatedocumentsandacopyshouldbeattachedto the financialworksheetwheneverpossible.(c) A “SelfDeclarationofIncome”form maybeusedto documentincomewhenappropriate.

5. Staffmustsignandrecordtoday’sscreeningdateto testifythattheinformation(income,ID,residency)reportedby theclientwasverifiedby theWIC staff.

6. Client/AuthorizedCaretakermustsignthe“RightsandObligations”sectionandwritetoday’sscreeningdatecertifying that all informationprovidedby themis trueand correctandtoconfirmthattheyunderstandtheirdiscriminationrightsasaWIC participant.

7. Thebottomsectionis to beusedbyWIC staffto verify that therewasvisualrecognitionofdocumentsshowingproofofidentityandresidencypresentedbytheclient. This ensuresthatWIC regulationsare followed for verification of identity and residencyin the eventthatphotocopiescannotbemadeorarelostfrom theclient’s folder.(a) Checkmarktheappropriatebox if client’s ID andresidencyhasbeenverified.(b) Indicatetypeofdocument(s)verified.(c) If nothingis checked,thenclient cannotbecertifiedfor eligibility in WIC.

WIC Participant Public Service Utilization Status andReferral Doucmentation Form

ClientName: WICID#:

Pleasecheckmark(~‘ ) all thatapply in columns1 & 3 andindicateappropriatedates(all othersareselfexplanatory):

Iii 2

“Current” Program(s)!I Service(s)

314Referrals Made

Date

5 16Handout(s)issued

Title of Handout Date

7

StaffInitials

8Client!

CaretaketInitials— — — —

— m m — — —

Client/CaretakerInitals:

Client/Caretaker Initals:

Consentfor ReleaseofInformation:I understandthattheinformationobtainedfrom mewill bekeptconfidential,butmaybereleasedandreferredto otherprogramsandservicesfor thesoleintentofprovidingmy child/childrenandmyselfwith additionalassistance.

Date

I Utilized DateStarted Program

IReferral notneeded [1 WIC StaffInitials:

Referralnot needed[1 WIC StaffInitials:Date:

Date:

Signatureof Participant/AuthorizedCaretaker

Date:

Date:

Rev. 2/01

WIC Participant Public ServiceUtilization StatusandReferral Documentation Form

Instructions

Note: This form mustbe completedfor eachWIC participant in orderto indicatethattheyarereceiving

benefits orwerereferredto receivebenefitsfrom otheragencies.1. EntertheWIC applicant/client’sname.

2. EntertheWIC ID number.

3. Interviewclientby inquiringaboutwhatcommunityservice(s)is currentlybeingutilized.

4. Column 1: Checkmark(v.’ ) theappropriatebox thatcorrespondsto the service(s)currentlybeingutilized by theclient.If client hasapplied for aprogram/serviceand hasnot startedusingit, indicate“pending” usingapencil.Note: Make afollow up on the nextvisit by inquiring the statusof the pendingprogram/servicethatwasappliedfor.

5. Column2: Indicatethe datetheystartedreceivingservice/benefits.

6. Column3: Identifyprogram/service(s)thatyou think will be beneficialto theclient. Checkmark (‘i’ ) theappropriatebox andreferyourclientto the program/service(s)thatyou haveidentified.

7. Column4: Indicatethedatethereferral(s)wasmadeto theclient.

8. Column5: Issueto theclienttheWIC handout(s)thataddressesabriefdescriptionaboutwhattheprogram/service(s)providesandalsoincludestheaddressandcontactnumber.Also, if referralsarebeingmadeto DPH&SSprogram(s),issuethePublicHealthreferralform to makethereferral.Onthiscolumn,makeanotationon theappropriatebox of all handoutsthatwereissuedto theclient.

9. Column6: Indicatethe datethehandout(s)wasissuedto theclient.

10. Column 7: Staffmustinitial on thiscolumnfor documentation.

11. Column8: Clientmustinitial on thiscolumnto verify theyhadreceivedtherequiredservicepertainingto referralsmadeto them.

12. In theeventthatno referralsareneededorotherneededservicesarealreadybeingutilized,theV/ICstaffdoingthe screeningmustcompletethe“Referralnotneeded”section on the bottomof theform andthe “authorizedrepresentative”mustverify thatno referralsareneeded.

13. Client/AuthorizedCaretakermustsignthe “Consentfor Releaseof Information” atthe bottomoftheform evenif no referralsaremade.

Acronymsusedonthe form:TANF = TemporaryAssistancefor NeedyFamilies JTPA= JobTrainingPartnershipActEFNEP= ExpandedFoodandNutrition ExtensionProgramCDC = CommunicableDiseaseControlJOBS= Job Opportunities and Basic Skills

INFANTICHILD’S WIC HEALTH QUESTIONNAIRE

WICID#: ________ DOB: ________

Doctor’s Name (update as needed): Dr.’s Phone #:

The WIC nutrition staff needs to know more about your child’s health status so that they can determine his/her eligibilityfor WIC and provide individuailzed service for nutritional needs. All of your answers will remain confidential. Pleasetake a few minutes to answer each of the questions as completely as possible.

1.) Does your child have (or ever had) any of the following diseases or health problems? Please check below all thata~~lv and note the aDDroximate date discovered or diagnosed by a doctor

.

Please check mark (“~) all that apply; ~ Diagnosed staff lnltial~Please check mark (~ ) all that apply: Date Diagnosed Staff Initials

Failure to Thrive (B9)

Inadequate Growth (Cl)

Premature Birth (C3)

Anemia (D6)

Lead Poisoning (El)

Nutrient Deficiency (H6)

Stomach/Intestine Disorder (H8)

Diabetes (II)

Thyroid Disorder (13)

High Blood Pressure (15)

Kidney Disorder (17)Cancer (19)

Nervous System Disorder (J2)

Congenital or Genetic Disorder (J4)

Pyloric Stenosis (J5)

Metabolic Disorder (J7)

Infectious Disease (J9)

Food Allergy (K2)

Celiac Disease (K4)

Lactose Intolerance (K6)

Low Blood Sugar (K8)

Surgery (L4)

Serious Injury (L4)

Serious Burn (L4)

Heart Disease (L6)

Asthma (L6)

Depression (L8)

Developmental Delays (Ml)

Dental Problem (M9)

Fetal Alcohol Syndrome (NI)

HIV/AIDS (J9)

Special diet prescribed

Currently taking medications

Other:

No medical/health problems identified Screening Date:

No “new” medical/health problems Screening Date:

No “new” medical/health problems Screening Date:

No “new” medical/health problems Screening Date:

Diarrhea

Constipation

Note: Please update questions below as needed.

2.) Does your child have any of the following symptoms after drinking or eating milk and/or milk products?

]diarrhea [ Igas [ ]nausea [ Istomach pain [ Ibloating [ ]no problems after conusming milk or milk products

3.) Please check the items that you are currently utilizing at home:

Ipublic electricity

Ipublic sewer hook up

]public water

]septic tank

]stove [ loven]water heater

]refrigerator [ ]well water

]gas generator for electricity

4.) Are your child’s immunizations up-to-date for his/her age? ]Yes [ ]No

Participant’s Name:

]Not sure

Rev. 2/01

iNFANT/CHILD’S WIC HEALTH QUESTIONNAIRE

Instructions

1. l2ntertheWIC applicant/client’sname.

2. Entertheclient’sWIC ID number.

3. Enterclient’s dateofbirth.

4. Entertheclient’s doctor’snameandupdateasneededon thenextscreening.

5.

6. Screentheinfant/child’s healthby inquiringfrom theclient’sauthorizedcaretakerif infant/childhas(or everhad)a diseaseorhealthproblem(s).a. Reviewthelist on theformwith thecaretakerandplaceacheckmark(lst columnofthe

box)thatcorrespondsto thehealthproblem(s)theinfant/childmayhave(orhavehadin thepast)whichthechild receivedmedicaltreatmentfor orwasdiagnosedby adoctor.

b. Indicatetheapproximatedate(3rd column)on whenthediseaseorhealthproblem(s)was

originally diagnosedby adoctor.c. Staffmustinitial (4~’ column)in thebox correspondingto the diseaseor healthproblem

reportedby thecaretakerfor verification.d. If infant/childhasno diseaseorhealthproblemto report,placea checkmark(1St column~

whereit specifies“no medical/healthproblemsidentified”, indicatetoday’sscreeningdateandinitial.

e. Thequestionnaireform maybeusedagainfor futurescreenings.Intheeventthatthereisanotherscreeningandtheinfant/child’s healthstatushasnot changedfrom thepreviousscreening,checkmark (lst column)whereit.specifies“no newmedical/healthproblems”,indicatetoday’sscreeningdateandinitial. However,when“newproblems”arediagnosedby adoctorandidentified(at anytime), documentthemasinstructedin #6a-6cabove.

7. Inquirefromthecaretakerif theinfant/childhasanysymptomsafterdrinkingoreatingmilk and/ormilk productsand thenplacea checkmark next to the item(s) (listed on question#2) that isreportedby thecaretaker.

Enterthedoctor’sphonenumber.

8. Inquirefromthecaretakeronwhatitems(listedon question#3) theyarecurrentlyutilizingathomeandthenplacea checkmarknextto theitem(s)thatis reportedby thecaretaker.

9. Inquirefromthecaretakerabouttheinfant/child’simmunizationrecords.Determinethecaretaker’sview(knowledge)ofthechild’s immunizationstatusandthencheck“Yes”, “No” or “Not Sure” (iiclient doesn’tknow)on question#4.Note:Thiswouldbeagoodtimeto screentheimmunizationrecordofthechild to verify orclarit3thecaretaker’sunderstandingofthechild’s immunizationstatusandmakeareferral if needed.

WOMEN’S WIC HEALTH QUESTIONNAIRE

Participant’s Name: WICID#: ________ DOB: ________

Doctor’s Name (update as needed): Dr.’s Phone #:

The wic nutrition staff needs to know more about you so that they can determine your eligibility for WIC and provideindividuailzed service for your nutritional needs. All of your answers will remain confidential. Please take a fewminutes to answer each of the questions as completely as possible.

1.) Do you have (or ever had) any of the following diseases or health problems? Please check below all that applyand note the aDDroximate date discovered or diagnosed by a doctor.Pleasecheckmark(~ ) all thatapply:

Anemia (D2,D3,D4,D5)

Date Diagnosec~ Staff InitiaI~

Lead Poisoning (D9)Excess Vomiting (E3)

HeartburnDiabetes (E4,E5,E6,H9)Preterm Delivery (E9,FI)

Infant Loss (F6,F7)

Infant Defects (F8,F9)Low Birth Weight Infant (F2,F3)

Nutrient Deficiency (H5)

Stomach/Intestine Disorder (H7)

Thyroid Disorder (12)

High Blood Pressure (14)

Kidney Disorder (16)

Cancer (18)

Nervous System Disorder (JI)Genetic Disorder (J3)Metabolic Disorder (J6)

Diarrhea

Infectious Disease (J8)Food Allergy (KI)

Celiac Disease (K3)

Lactose Intolerance (K5)Low Blood Sugar (K7)Eating Disorder (L2)

Surgery (L3)Cesarian Section (L3)Serious Injury (L3)Serious Burn (L3)Heart Disease (L5)

Asthma (L5)

Depression (L7)

Alcohol/Drug Abuse (M4)

Dental Problem (M8)

HIV/AIDS (J8)

Currently taking medication(s)Other:

No medical/health problems identified Screening Date:

No “new” medical/health problems Screening Date:

No “new” medical/health problems Screening Date:

No “new” medical/health problems Screening Date:

No “new” medical/health problems Screening Date:

No “new” medical/health problems Screening Date:

Constipation

2.) Do you have any of the following symptoms after drinking oreating milk and/or milk products?]diarrhea [ ]gas [ ]nausea [ Istomach pain [ ]bloating [ mo problems after consuming milk or milk products

3.) Do you use tobacco? [ ]Yes [ INo If yes, how? [ Ismoke [ Ichew [ ]otherIf yes, how often? ______________

If yes, how often? ______________Do you drink alcohol? [ ]Yes [ ]No ________________ (Note: update for each pregnancy)Are you using or have you ever used any drugs such as marijuana, cocain, heroin, amphetamines, cra?k? [ JYes [ ]No(Note: update for each pregnancy)

4.) Howdo you plan to feed your baby? [ ]Breast Feeding [ ]Formula Feeding(Note: update for each pregnancy)

]UndecidedRev. 2/01

WOMEN’S WIC HEALTH QUESTIONNAIRE

Instructions

EntertheWIC applicant/client’sname.

2. Entertheclient’s WIC ID number.

3. Enterclient’s dateofbirth.

4. Entertheclient’s doctor’snameandupdateasneededon thenextscreening.

5. Enterthedoctor’sphonenumber.

6. Screenthe client’s healthby inquiring if client has (or everhad) a diseaseor healthproblem(s).a. Reviewthelist ontheformwith theclientandplacea checkmark (~t columnofthe

box) that correspondsto the healthproblem(s)theymayhave(or havehadin thepast)whichtheyreceivedmedicaltreatmentfor orwasdiagnosedby a doctor.

b. Indicatethe approximatedate(3rd column)onwhenthediseaseorhealthproblem(s)

wasoriginally diagnosedby adoctor.c. Staffmust initial (4th column) in the box correspondingto the diseaseor health

problemreportedby theclientfor verification.d. If clienthasno diseaseorheafthproblem.to report,placeacheckmark (lst column)

whereit specifies“no medical/healthproblemsidentified”, indicatetoday’sscreeningdateandinitial.

e. Thequestionnaireform maybeusedagainfor futurescreenings.In theeventthatthereis anotherscreeningand theclient’s healthstatushasnot changedfrom thepreviousscreening,checkmark(lst column)whereitspecifies“no newmedical/healthproblems”, indicate today’s screeningdateand initial. However, when “newproblems”arediagnosedby adoctorandidentified(at anytime), documentthemasinstructedin #6a-6cabove.

7. Inquirefrom theclient if theyhaveanysymptomsafterdrinking or eatingmilk and/ormilkproductsandthenplacea checkmark next to theitem(s) (listed on question#2) that isreportedby theclient.

8. Inquirefromtheclientif theyusetobacco,drink alcoholoruseotherdrugs. Check“Yes” or“No” onquestion#3. If clientsays“yes”, thenindicatehowoften. If clientusestobacco,askwhethertheysmokeorchewit orother,if any.Note:Pleaseupdatequestion#3 for eachpregnancy.

9. Inquirefromtheclientonhowtheyplanon feedingtheirbabywhenhe/sheis bornandthenplaceacheckmarknextto thechoice(s)(listedonquestion#4)thatis reportedbytheclient.At this time, provideabreastfeedingpromotionalhandout regardlessofthechoicemade.Womenchoosing “Breast feeding” should also receivea getting startedbreastfeedinghandout.DocumentthesehandoutsontheappropriateWIC CarePlanHandoutform.Note:Pleaseupdatequestion#4 for eachpregnancy.

WIC FOOD INSTRUMENT AND IDNOC CARD INCIDENT REPORTToday’s Date:[I Food Instrument report[I IDNOC card report

Report from Clinic site: 01 02 03 04 05 06Document issue site: 01 02 03 04 05 06

Date of incident:

A. Type of Contact: []Clinic visit [JAdmin.office visit []Phone call []Written[I Other (specify):

B. Authorized Representative Information: (minimum information ~*J~)* Print name: * Telephone:

Address: SS#:IDNOC control number (if known):

C. Food Instrument Information: WIC number:Participant(s) name on Fl: I WIC number:Fl numbers: /Fl valid dates: /

D. Incident Status: (WIC Authorized Rep. view of the problem)[]Returned Fl and/or [IID/VOC (briefly state reason for return):

[]Not Returned Fl and/or [] IDNOC (briefly state problem):

[I Otherproblem(s)(specify):

E. Indicate ONE of the Following Problems:1. Clients: 2. Clinic: 3. Computer/Printer: 4. Vendor:

Unclaimed Fl [] Clerical error (] Unclaimed Fl (auto-generated) [] Clerical error (at store)(missed appointment) [ ] Change in formula [ ] Destroyed or damaged Fl [] Returned Fl and/or ID

I Destroyed Fl and/or ID (doctor’s order) (before issued) [ ] Vendor processing errorI Lost Fl and/or ID [I Change in client status (1 Other computer/printer (1 Other vendor problem(s)I Stolen Fl and/or ID [ I Preprinted Fl Problem (specify):

t I Returned Fl and/or ID ~ondemand” problem(past valid date, etc.) (1 Other clinic

I Client’s option changed problem(s) (specify):I Client disqualifiedI Other client problem(s)(specify):

F. Instruction, Explanation, or Courtesy Provided for ParticipantlCaretaker:[]Instruction on better care of WIC Food Instruments and/or IDNOC card. []Explanation of reason(s) for delay.[JAny Food Instruments or IDNOC cards recovered must be turned in to WIC. [IFollow up client for missed appt.[I Re-instruction on Food Instruments valid dates.[]Re-instructionabout not tampering or altering Food Instruments in any way.[lOther (specify):

G. Action(s) Taken for WlC ParticipantlCaretaker:[]Replaced Food Instruments and/or IDNOC card.[]Can not replace Food Instruments[1Food Instruments voided in computer (i.e. authorized clinicFl voids only)

Date Fl Voided:

[I Terminated from WIC participation[JOther service provided (specify):[I Client file updated[lOther (specify):

Rev.2/200U

H. Signature of WIC staff contact person:

Signature of WIC participant/caretaker:

IC PR GRA *SUG ESTIO *CO PLAINT*INCI E T* EPO T

A. Type of Contact: []Clinic visit []Admin. office visit []P hone call []Written[]Other (specify):

B. Who is making the suggestion, compliant or reporting the incident? (minimum information *2)

* Print name: * Telephone:

Address:

C. Statement of caretakerlclient/vendorlstaff making the suggestion or complaint or reporting the

incident:

(Use additional sheets of paper if needed)

7 (TO BE COMPLETET~~YWIcSTAEF&‘~ Y B~LOWTHI$ LINE) _______

~. ~oes this ~4uat~n ~eed to be re%rred to ano~er area or hIgher author~y? Li Yes [j NoJYes Who ____________________________ If No, describe resolution to probiem or actiontaken:

E. Follow up on suggestion, complaint, or incident (if needed):Was the suggestion, complaint, or incident resolved?[]Yes - How resolved

[INo - What further action is needed? ___________________________________________________

F. Signatures (suggestions, complaints, and reports of incidents are not valid unlessaccompanied by the signature of the person bringing the issue to our attention andtherefore may not be acted upon if unsigned):

Signature of WIC staff contact person: ___________________________________________

Signature of WIC participant/caretaker/vendor: ___________________________________________Rev.3/2000

ii

I,

Ii

WIC FARMERS’ MARKET NUTRITION PROGRAM INCIDENT REPORTToday’sDate: Reportfrom Clinic Site: 01 02 03 04 05 06( ) WIC FMNP Report DocumentIssueSite: 01 02 03 04 05 06( ) Others Dateof Incident: ________________________

A. Typeof Contact: ( ) Clinic visit ( ) Admin. office visit ( ) Phonecall ( ) Written( ) Other(specify)

B. AuthorizedRepresentativeInformation: (minimuminformation)PrintName:_____________________________________________________Telephone:__________________

Address:______________________________________________________SS#:______________________

C. WIC FMNP Information:(mustbecompletedby WIC Staff)

No Participant(s)Name FMNP CouponNo (s) Valid Dates WIC ID No.

1

2

3

4

5

D. IncidentStatus: (WIC AuthorizedRepresentativeview of theproblem)~Retumed FMNP Coupons(briefly statereasonfor return):

( ) Not Returned FMINP Coupons (briefly stateproblem):

( ) Other Problem(s) (specify):

(TO BE COMPLETED BY WIC STAFF ONLY BELOW THIS LINE)

2. Clinic( ) Clericalerror( ) Changein client status( ) Otherclinic problem(s)

(specify):______________

E. Indicate ONE of the Following Problems:1. Clients( ) DestroyedFMNP coupons( )LostFMNP Coupons( ) ReturnedFMNP Coupons(pastvalid date)( ) Clientdisqualified( ) Otherclient problem(s)

(specify):________________________________

F. Instruction,Explanationor Courtesyprovidedfor WIC F1VINPParticipant/Caretaker:( ) Instructionon bettercareof V/IC FMNP Coupons( ) Any WIC FMNP Couponsrecoveredmustbeturnedin to WIC( ) Re-instructionon WIC FMI4P valid dates( ) Re-instructionaboutnottamperingor alteringV/IC FMNP Couponsin anyway( ) Explanationof reason(s)fordelay

( ) Qther(specify)G. Action(s) Takenfor WIC FMNP Participant/Caretaker:

( ) Terminated from V/IC FMNP participation ____________

( ) CannotreplaceV/IC FMNP Coupons( ) V/IC FMNP Couponsvoided onGWIS __________________

DateCoupon(s)Voided: _________________

H. Signatureof WIC FMNP participant/caretaker:Signatureof WIC staffcontactperson:

March 11,2002/Igd

3. GrantsManagementServices( ) Couponnumbersnot in

sequence( ) Couponunreadable( ) Otherproblem(s)

(sp~cify): _______________

( ) Otherserviceprovided(specify):_______________

( ) Client file updated( ) Other(specify): ______________________