WIC6 DHSS Additional Nutrition & Health Resource Request Form

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MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES
WIC AND NUTRITION SERVICES

WIC6 – DHSS Additional Nutrition & Health Resource Request Form

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
12345 Fit-Tastic Literature(Developed by Children Mercy Hospital) / Substance Abuse Literature* (Bureau of Genetics and Healthy Childhood)
Fit-Tastic, Physical Activity (EN) / 767 / 50/pkt / Have A Healthy Pregnancy… Don't Drink (EN) / 287 / EACH
Fit-Tastic, Screen Time (EN) / 779 / 50/pkt / Have A Healthy Pregnancy... Don't Drink (SP) / 711 / EACH
Fit-Tastic, Low Milk ORYogurt (EN) / 780 / 50/pkt / Have A Healthy Pregnancy… Don't Smoke (EN) / 697 / EACH
Fit-Tastic Water & Sugary Drinks (EN) / 781 / 50/pkt / Have A Healthy Pregnancy… Don't Smoke (SP) / 707 / EACH
Fit-Tastic, Fruits & Veggies (EN) / 783 / 50/pkt / Pregnancy & Drugs / 330 / EACH
Fit-Tastic, Healthy Habits (EN) / 786 / 50/pkt / Pregnancy And Marijuana / 408 / EACH
Fit-Tastic Message Card (EN) / 787 / 50/pkt / Pregnancy And Meth / 328 / EACH
Fit-Tastic- Tracker (EN) / 789 / 50/pkt / Preventing Fetal Alcohol Syndrome, (FAS) / 400 / EACH
Fit-Tastic, Physical Activity (SP) / 929 / 50/pkt / Pregnancy And Meth / 328 / EACH
Fit-Tastic, Screen Time (SP) / 932 / 50/pkt / Secondhand Smoke And Baby (EN) / 390 / EACH
Fit-Tastic Lowfat Milk OR Yogurt (SP) / 942 / 50/pkt / Secondhand Smoke And Baby (SP) / 708 / EACH
Fit-Tastic, Water & Sugary (SP) / 945 / 50/pkt / Secondhand Smoke And Kids (EN) / 1199 / EACH
Fit-Tastic, Fruits & Veggie (SP) / 946 / 50/pkt / Secondhand Smoke And Kids (SP) / 709 / EACH
Fit-Tastic Healthy Habit (SP) / 947 / 50/pkt / Newborn Health Literature*(Bureau of Genetics and Healthy Childhood)
Fit-Tastic Message (SP) / 950 / 50/pkt / Safe Sleep Magnet / 677 / EACH
Safe Sleep Message Card / 674 / EACH
Low Fat Milk & Yogurt Recipe Cards(Developed by the Midwest Dairy Council) / Prenatal & Newborn Screening Pamphlet / 442 / EACH
Dairy Makes Sense (low Fat milk) (EN) / 817 / 50/pkt / 10 Ways To Be A Better Dad (EN) / 531 / EACH
Dairy Makes Sense (low Fat yogurt) (EN) / 818 / 50/pkt / 10 Ways To Be A Better Dad (SP) / 424 / EACH
Dairy is a local food (EN) / 819 / 50/pkt / Tel-Link Brochure (EN) / 55 / EACH
Cereal + Milk = Yum! (EN) / 820 / 50/pkt / Tel-Link Brochure, (SP) / 746 / EACH
Cheese Please! (EN) / 823 / 50/pkt / Vitamin K Message Card / 410 / EACH
Go for yogurt! (EN) / 814 / 50/pkt / Keeping Your Baby Safe And Healthy / 338 / EACH
Go for yogurt! (SP) / 832 / 50/pkt / Keeping Your Baby Safe And Healthy (SP) / 706 / EACH
Dairy Makes Sense (low Fat milk) (SP) / 836 / 50/pkt / Postpartum Depression More Than The Blues (EN) / 86 / EACH
Dairy Makes Sense (low Fat yogurt) (SP) / 837 / 50/pkt / Postpartum Depression More Than the Blues (SP) / 195 / EACH
Dairy is a local food (SP) / 839 / 50/pkt / Pregnancy And Beyond (EN) / 1081 / EACH
Cereal + Milk = Yum! (SP) / 841 / 50/pkt / Pregnancy And Beyond (SP) / 1082 / EACH
Cheese Please! (SP) / 843 / 50/pkt / Safe Sleep Magnet / 677 / EACH
Hepatitis Literature* (Bureau of HIV, STD, and Hepatitis) / Safe Sleep Message Card / 674 / EACH
Pregnant & Hepatitis B Positive Brochure / 368 / EACH / Prenatal & Newborn Screening Pamphlet / 442 / EACH
Stop Liver Cancer-Hepatitis / 454 / EACH / Newborn Hearing Screening Poster / 202 / EACH
Diet And Liver Brochure / 371 / EACH / Newborn Hearing Screening / 431 / EACH
Hepatitis B & Mothers To Be / 190 / EACH / Missouri New Born Screening / 14 / EACH
*Limit 50/month
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 (01/26/15) USDA is an equal opportunity provider and employerWIC 6