Kansas WIC Program - Local Agencies - Forms/Administrative Materials

Forms/Administrative Materials

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Forms


	Active Client Record Review Aministration ME Evaluation Tool
	Active Client Record Review Nutrition ME Tool	(Revised Oct. 2010)
	Administration ME Evaluation Tool	(Revised Oct. 2011)
	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 Issuance ME Tool	(Revised Oct. 2010)
	Breast Pump Questionnaire
	Breast Pump Questionnaire - Spanish
	Breast Pump Request for Reimbursements	(Revised Oct. 2011)
	Breastfeeding Equipment User Agreement
	Breastfeeding Equipment User Agreement - Spanish
	Breastfeeding Peer Counselor Budget Summary	(Revised Oct. 2011)
	Breastfeeding Peer Counselor Quarterly Report	(Revised Oct. 2011)
	Breastfeeding Peer Counselor Contact Log
	Check Pick Up Observation ME Tool
	Child (2-5 Years) Diet Questionnaire
	Child (2-5 Years) Diet Questionnaire-Spanish
	Client Interview ME Tool
	Clinic Observation ME Tool	(Revised Oct. 2010)
	Clinic Self-Evaluation ME Tool	(Revised Oct. 2010)
	CSFP Fact Sheet	(Revised Oct. 2011)
	Declaration of Conflict of Interest
	Employer Breastfeeding Support Letter	(Revised Feb. 2011)
	Financial Support for On-Going Training Application	(Revised Dec. 2010)
	Financial Support for IBCLC	(New Dec. 2010)
	Fiscal Management ME Evaluation Tool
	Kansas WIC Client Survey	(Revised Oct. 2010)
	Kansas Lost or Stolen Check Replacement Agreement	(Revised Oct. 2010)
	Kansas WIC Special Authorization for Infants and Children	(Revised Feb. 2010)
	Kansas WIC Special Authorization for Women	(New Feb. 2010)
	KWIC Manual Backup Form Child-Infant	(Revised Jan. 2011)
	KWIC Manual Backup Form Woman	(Revised Jan. 2011)
	Local Agency Warning Notification Letter Sample 1	(Revised Oct. 2011)
	Local Agency Warning Notification Letter Sample 2	(Revised Oct. 2011)
	Minimum Stock Exemption Form	(Revised Oct. 2010)
	Minimum Stock Requirements - Rural	(Revised Oct. 2010)
	Minimum Stock Requirements - Urban	(Revised Oct. 2010)
	Nutrition ME Tool	(Revised Oct. 2010)
	Prenatal Diet Questionnaire
	Prenatal Diet Questionnaire-Spanish
	Postpartum Diet Questionnaire
	Postpartum Diet Questionnaire-Spanish
	Request for Reimbursement Form
	Rights & Responsibilities Form	(Revised Oct. 2011)
	Rights & Responsibilities Form - Spanish	(Revised Oct. 2011)
	School Breastfeeding Support Letter	(Revised Oct. 2011)
	Secondary Nutrition Education Observation Low and High Risk ME Tool	(Revised Oct. 2010)
	Special Formula Authorization ME Tool	(Revised Oct. 2010)
	Standard WIC Affidavit	(Revised Oct. 2011)
	Suspension Letter for Program Abuse	(Revised Oct. 2011)
	Toddler (6-24 months) Diet Questionnaire
	Toddler (6-24 months) Diet Questionnaire-Spanish
	Tracking for Receipt and Disposition of Returned Formula ME Tool	(Revised Oct. 2010)
	Vendor Application Packet	(Revised Oct. 2011)
	New Vendor Evaluation Form	(Revised Oct. 2010)
	Vendor Manual	(Revised Oct. 2011)
	Vendor Monitoring Form	(Revised Oct. 2011)
	Vendor Participation Contract	(Revised Oct. 2011)
	Voter Registration - Declination Form
	Registracion de Votos - Forma de Negasion - Spanish
	Weight Gain Grids	(New Jan. 2011)
	WIC Fact Sheet	(Revised Oct. 2011)
	WIC Fact Sheet - Spanish	(Revised Oct. 2011)
	WIC Local Agency Budget Summary	(Revised Oct. 2011)
	WIC Local Agency Budget FFY2013	(Revised Oct. 2011)
	WIC Product Inventory	(Revised Oct. 2011)
	WIC Proxy Form
	WIC Publications Order Form	(Revised Oct. 2011)
	WIC Time Study Forms
	WIC Civil Rights Discrimination Complaint Form
	Young Infant Diet Questionnaire
	Young Infant Diet Questionnaire-Spanish