WIC AND NUTRITION SERVICES
WIC/BreastfeedingResource Supply Request - WIC 8
AGENCY NAME /AGENCY/CLINIC NO.
/ CONTROL NO. (DHSS WAREHOUSE USE)REQUESTER’S NAME (PLEASE TYPE or PRINT) / REQUESTER’S PHONE NO. / DATE
WIC Forms, Back-up forms,
and Resources / Item No. / Quantity Ordered / Unit / WIC Food Lists
Missouri Voter Registration Application / WIC/MVR-1 / EACH / WIC Approved Infant Food List - EN / 1232 / 50/pack
Missouri Voter Registration Application / VR-1 / EACH / WIC Approved Infant Food List - SP / 1233 / 25/pack
Notification of Ineligibility OR Termination / WIC-19 / EACH / WIC Approved Food List EN / WIC 640 / 50/pack
Partial Infant Formula Redemption / WIC-21 / EACH / WIC Approved Food List SP / WIC 640 SP / 25/pack
Medical Documentation / WIC-27 / 50/pad / WIC Approved Fruits & Vegetables - EN / 1228 / 50/pack
Nutrition Assessment for Children 1-5 / WIC-35 / 50/pad / WIC Approved Fruits & Vegetables - SP / 1229 / 25/pack
Nutrition Assessment for Children 1-5 / WIC-35-SP / 25/pad / WIC Approved Breads & Tortillas - EN / 553 / 50/pack
Nutrition Assessment for Women / WIC-36 / 50/pad / WIC Approved Breads & Tortillas - SP / 580 / 25/pack
Nutrition Assessment for Women / WIC-36-SP / 25/pad / Breastfeeding Resources―New!
Nutrition Assessment for Infants / WIC-37 / 50/pad / Breastfeeding for Social Health / 189 / EACH
Nutrition Assessment for Infants / WIC-37-SP / 25/pad / 20 Great Reasons to Breastfeed - EN / 200 / EACH
Medical Referral / WIC-61 / 50/pad / 20 Great Reasons to Breastfeed - SP / 217 / EACH
WIC Cert. – Infants, Children & Women / WIC-1 & 2 M / 50/pad / Breastfeeding & Returning to Work / 210 / EACH
Growth Chart – 2-5 Years (Girls) / WIC-3 / 50/pad / Breastfeeding Welcome Here
(Window Cling) / 224 / EACH
Growth Chart – 2-5 Years (Boys) / WIC-4 / 50/pad
Growth Chart – Birth-36 Month (Girls) / WIC-13 / 50/pad / Hospital Crib Card (Boy) / 225 / EACH
Growth Chart – Birth-36 Months (Boys) / WIC-14 / 50/pad / Hospital Crib Card (Girl) / 248 / EACH
Participant’s Rights & Responsibilities / WIC-10-EN-M / 50/pad / Breastfeeding the Baby Friendly Way
(Bookmark) / 227 / EACH
Participant’s Rights & Responsibilities / WIC-10-SP-M / 50/pad
Participant’s Rights & Responsibilities (Bilingual, Orange/Salmon) Laminated / WIC-10-LAM / EACH / Breastfeeding the Baby Friendly Way
(Tip card) / 240 / EACH
WIC Proof of Eligibility / WIC-30-M / 50/pad / Missouri Breastfeeding Law Card / 243 / EACH
Reminder/Appointment Postcard / WIC-39 / EACH / Bringing Home Baby - EN / 563 / EACH
Reminder/Appointment Postcard / WIC-39-SP / EACH / Bringing Home Baby - SP / 564 / EACH
WIC Household Food Instrument / WIC-31-M / 50/pad / Let’s Eat - EN / 565 / EACH
Income Guidelines (Laminated) / 909 / EACH / Let’s Eat - SP / 567 / EACH
Welcome to WIC - EN / 1204 / EACH
Welcome to WIC - SP / 1200 / EACH
WIC Participant ID Folder / WIC-17 / EACH
WIC Participant Rights & Respons. - SP / WIC-17SUPP / 25/pad
Missouri WIC Works Outreach Brochure / 175 / 50/pack
Missouri WIC Works Outreach Poster / 169-SP / EACH
Connecting Health Professional & WIC / 154 / 50/pack
The forms listed to the right are NOT AVAILABLE at the DHSS Warehouse. Only the electronic version is available at http:/www.health.mo.gov/wic/forms.html / Notification of Corrections for Participant/Guardian Data Base / WIC-38
WIC Participant Redemption Complaint / WIC-40
Please fax this form to the DHSS Warehouse at 573-751-1574.
If you have questions contact Takako Tagami at 1-800-392-8209 or email to
MO 580-0282 (10-05-11))THIS INSTITUTION IS AN EQUAL OPPORTUNITY PROVIDER.WIC 8