WIC 8 - Wicresource Request

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MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES
WIC AND NUTRITION SERVICES

WIC 8 - WICResource Request

AGENCY NAME /

AGENCY/CLINIC NO.

/ CONTROL NO. (DHSS WAREHOUSE USE)
REQUESTER’S NAME (PLEASE TYPE or PRINT) / REQUESTER’S PHONE NO. / DATE
Titles / Item No. / Quantity Ordered / Unit / Titles / Item No. / Quantity Ordered / Unit
Forms, Back-up forms, & Resources / WIC Food Lists (Effective: 4/01/15 – 9/30/15)
Missouri Voter Registration Application / WIC/MVR-1 / EACH / WIC Approved Food List (EN) / WIC 640-B / 25/pack
Missouri Voter Registration Application
(Limited 50/order) / VR-1 / EACH / WIC Approved Food List (SP) / WIC 640-B-SP / 25/pack
Notification of Ineligibility OR Termination / WIC-19 / EACH
Medical Documentation / WIC-27 / 50/pad / Stickers
Lost/Stolen WIC Check Report –EN / SP / WIC 32 / 50/pad / Growing Girls Stickers (90/roll) / 1193 / Roll
Nutrition Assessment-Children 1-5 EN / SP / WIC-35 / 50/pad / Growing Boy Stickers (90/roll) / 1194 / Roll
Nutrition Assessment-Women EN / SP / WIC-36 / 50/pad / Low Fat Milk Promotion Sticker* (1,000/roll) / 405 / EACH
Nutrition Assessment- Infants EN / SP / WIC-37 / 50/pad / Immunization Resources(Bureau of Immunization Assessment Assurance)
Medical Referral / WIC-61 / 50/pad / Tackle the Flu, Coloring Page / 691 / EACH
WIC Cert. – Infants, Children & Women / WIC-1 & 2 M / 50/pad / Vaccines for Children/VFC Info. for Parents / 692 / EACH
Participant’s Rs & Rs. (En & SP) / WIC-10 / 50/pad / Immunization Guide, Birth to 12 years / 710 / EACH
Participant’s Rs & Rs (EN & SP; Laminated) / WIC-10-LAM / EACH / Immunization Pocket Guide, Birth - 12 yrs / 713 / EACH
WIC Proof of Eligibility / WIC-30-M / 50/pad / Immunization Poster, Birth to 12 years / 761 / EACH
Reminder/Appointment Postcard / WIC-39 / EACH / Elliot’s Book About Shots, coloring book sp / 1121 / EACH
Reminder/Appointment Postcard / WIC-39-SP / EACH
WIC Household Food Instrument / WIC-31-M / 50/pad / Sesame Street
WIC Participant ID Folder / WIC-17 / EACH / Sesame Street Food for Thought 100 booklets / box / 11102 / Box
WIC Participant Rs & Rs (ID Folder) - SP / WIC-17 SUPP / 25/pad / Fruits & Vegetables More Matter Items
Missouri WIC Outreach Brochure / 175 / 50/pack / Fruits & Vegetables More Matters - EN / 545 / 50/pk
Missouri WIC Outreach Brochure(SP)** / 170 / n/a / Great Taste Matters (Bookmark) / 587 / 100/pk
Income Guidelines / 909 / EACH / Fruits & Vegetable Champions - EN / 544 / 100/pk
Welcome to WIC - EN / 1204 / EACH
Welcome to WIC - SP / 1200 / EACH / WIChealth.Org
WIC Facts for Employers / WIC 65 / 50/pad / WIC Health.Org – Poster EN / 352 / EACH
Fraud Warning Card (EN) / WIC-66 / 50/pad / WIC Health.Org – Insert EN / 353 / EACH
Fraud Warning Card (SP) / WIC-66-A / 25/pad / WIC Health.Org – Poster SP / 346 / EACH
WIC Health.Org – Insert SP / 349 / EACH
*If your agency needs a roll of stickers (1,000/roll), please indicate. / **will be available in August, 2015.
The forms listed below are NOT AVAILABLE at the DHSS Warehouse. Only the electronic version is available at http:/
Notification of Corrections for Participant/Guardian Data Base / WIC-38 / 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
WIC Participant Redemption Complaint / WIC-40
Partial Infant Formula Redemption / WIC-21

MO 580-0282 (07/01/15) USDA is an equal opportunity provider and employerWIC 8