Your Rights and Responsibilities
For the Kansas Department of Health and Environment WIC Program
I AGREE TO:
- Attend all scheduled nutrition education classes and appointments.
- Be on time for all appointments.
- Let WIC staff know in advance if I cannot keep an appointment.
- Bring proof of current income, address, and identification for each person applying.
- Give the WIC staff truthful information about my or my child's medical history, my household income and the foods that I eat or my child eats.
- Have my or my child's weight, height and blood checked (finger or heel stick) and a diet assessment.
- Handle my WIC checks carefully - like they were cash.
- Call the WIC office right away if my checks are damaged, lost, or stolen. Checks are replaced only in special cases.
- Buy only WIC foods with WIC checks.
- Let the WIC staff know if my address, telephone number or income changes, if I am going to move away, or if I no longer have custody of the client.
I UNDERSTAND THAT:
- WIC will give me checks to buy certain foods at WIC authorized grocery stores each month.
- WIC will provide referrals to other helpful programs and health services. I am encouraged to participate.
- I may be dropped from WIC if I participate in more than one WIC Program in any one month.
- Standards for eligibility and participation in the WIC Program are the same for everyone, regardless of race, color, national origin, sex, age, or disability.
- I may appeal any decision made by the local agency regarding my eligibility for WIC.
- It is illegal to participate in more than one WIC program in any one month. I may be dropped from WIC if I or someone with me makes changes on my WIC check; returns WIC foods for cash or non-WIC foods; sells, trades, or gives away WIC foods; buys non-WIC foods; uses an unauthorized vendor; or verbally or physically abuses WIC or vendor staff. I also may be required to repay benefits.
- My WIC information may be released to designated public organizations and their programs to see if I qualify for their services, to conduct outreach, to share needed health information with programs I am already participating in, to streamline office procedures, and to help assess the overall health of Kansas families. The designated programs are: Other state and local WIC programs, non-WIC programs administered by the WIC state and local agency, Maternal & Child Health, School Health, Family Planning, Statewide Farmworker Health, Maternal and Infant, Healthy Start/Home Visitor, Immunizations, Special Health Care Needs, Infant Toddler, Parents as Teachers, Kansas Childhood Lead Poisoning Prevention, Head Start, KanCare, Temporary Assistance for Needy Families, Kansas Food Assistance, Medicaid, KAN Be Healthy, Dept. of Education Child Nutrition and Wellness Programs, Expanded Food Nutrition Education Programs, Military Family Support Services, Becoming a Mom and Smoking Cessation Programs.
I have been advised of my rights and responsibilities under the Program. I certify that the information I have provided for my eligibility determination is correct, to the best of my knowledge. This certification form is being submitted in connection with the receipt of Federal assistance. Program officials may verify information on this form. I understand that intentionally making a false or misleading statement or intentionally misrepresenting, concealing, or withholding facts may result in paying the State agency, in cash, the value of the food benefits improperly issued to me and may subject me to civil or criminal prosecution under State and Federal law.
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and polices, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.
Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800)877-8339. Additionally, program information may be made available in languages other than English.
To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866)632-9992. Submit your completed form or letter to USDA by: Mail: U.S. Department of Agriculture, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, SW, Washington D.C. 20250-9410; or by fax: (202)690-7442; Email: firstname.lastname@example.org. This institution is an equal opportunity provider.
I understand my rights and responsibilities in the WIC Program.