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Forms


     
  Abbreviations From Local Agencies  
  Acknowledgment of receipt of Direct Ship Formula from Kansas Nutrition and WIC Services New
  Application for Kansas Local Agency NWA Committee Representative New
  Authorization for Electronic Exchange of Information to the Kansas Immunization Registry consent form-English  
  Authorization for Electronic Exchange of Information to the Kansas Immunization Registry consent form-Spanish  
  Breast Pump Cleaning Instructions  
  Breast Pump Cleaning Instructions - Spanish  
  Breast Pump Helpful Hints  
  Breast Pump Helpful Hints - Spanish  
  Breast Pump Questionnaire  
  Breast Pump Questionnaire - Spanish  
  Breast Pump Request for Reimbursements  
  Breastfeeding Equipment User Agreement  
  Breastfeeding Equipment User Agreement - Spanish  
  Breastfeeding Peer Counselor Quarterly Report New
  Breastfeeding Peer Counselor Program Annual Evaluation Revised October 2018
  Contract Military Commissaries Memorandum of Understanding
  Declaration of Conflict of Interest  
  Diet Questionnaire – Child (2-5 Years)  
  Diet Questionnaire – Child (2-5 Years) - Spanish  
  Diet Questionnaire – Prenatal  
  Diet Questionnaire – Prenatal – Spanish  
  Diet Questionnaire - Postpartum  
  Diet Questionnaire – Postpartum – Spanish  
  Diet Questionnaire – Toddler (6-24 Months)  
  Diet Questionnaire – Toddler (6-24 Months) – Spanish  
  Diet Questionnaire – Young Infant  
  Diet Questionnaire – Young Infant - Spanish  
  Employer Breastfeeding Support Letter  
  eWIC New Vendor Evaluation Form  New
  eWIC Manual Backup Form Child, Infant  New
  eWIC Manual Backup Form Woman  New
  Financial Support for On-Going Training Application Revised October 2018
  Financial Support for IBCLC Revised October 2018
  Kansas Application Packet for new BFPC Programs
  Kansas WIC Client Survey  
  KWIC Manual Backup Form Child-Infant
  KWIC Manual Backup Form Woman
  Local Agency Active Chart Review  
  Local Agency Clinic Site Observation  
  Local Agency Expenditure Tracking Form  
  Local Agency Inventory Worksheet
  Local Agency Warning Notification Fillable Form
  Management Evaluation – Active Client Record Review Tool, Administration  
  Management Evaluation – Active Client Record Review Tool, Nutrition  
  Management Evaluation – Administrative Evaluation Tool  
  Management Evaluation – Breast Pump Issuance Tool  
  Management Evaluation – Check Pick Up Observation Tool  
  Management Evaluation – Client Interview Tool  
  Management Evaluation – Clinic Observation Tool  
  Management Evaluation – Clinic Self-Evaluation Tool  
  Management Evaluation – Fiscal ME Tool  
  Management Evaluation – Nutrition Tool  
  Management Evaluation – Secondary Nutrition Education Observation Tool  
  Management Evaluation – Special Formula Authorization Tool  
  Management Evaluation – Tracking of Returned Formula Tool  
  Minimum Stock Exemption Form
  Military Commissary MOU Kansas WIC
  Minimum Stock Requirements - Rural
  Minimum Stock Requirements - Urban
  Request to Add a UPC Form  
  Rights & Responsibilities Form Revised October 2018
  Rights & Responsibilities Form - Spanish Revised October 2018
  School Breastfeeding Support Letter
  Seperation of Duties Exception Log
  Special Authorization – Infants and Children Revised October 2018
  Special Authorization – Women
  Special Authorization – Pediatric Medical Formulas FAQ Revised May 2018
  Special Authorization – Sample Denial Letter  
  Special Authorization – WIC Formula Fact Sheet  
  Standard WIC Affidavit  
  Tracking Sheet for Receipt & Disposition of Returned Formula
  Vendor Application Packet
  New Vendor Evaluation Form
  Vendor Manual Revised October 2018
  Vendor Monitoring Form
  Vendor Participation Contract Revised October 2018
  Voter Registration - Agency Voter Declaration Form  
  Voter Registration - Agency Voter Declaration Form - Spanish  
  Weight Gain Grids  
  WIC Fact Sheet Revised October 2018
  WIC Fact Sheet - Spanish Revised October 2018
  WIC Local Agency Budget FFY2018
  WIC Local Agency Budget FFY2019
  WIC Local Agency Budget Instructions and Checklist FFY2019
  WIC Product Inventory
  WIC Publications Order Form Revised October 2018
  WIC Publications: Brush Art WIC Materials  
  WIC Time Study Forms  
  WIC Civil Rights Discrimination Complaint Form  
  WIC Civil Rights Discrimination Complaint Form - Spanish