Kansas WIC Program - Local Agencies - Forms/Administrative Materials

Forms/Administrative Materials

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Forms


	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	October 2012
	Breastfeeding Equipment User Agreement - Spanish	October 2012
	Breastfeeding Peer Counselor Budget Summary	October 2012
	Breastfeeding Peer Counselor Quarterly Report
	Breastfeeding Peer Counselor Contact Log
	CSFP Fact Sheet	October 2012
	Declaration of Conflict of Interest
	Diet Questionnaire – Child (2-5 Years)	October 2012
	Diet Questionnaire – Child (2-5 Years) - Spanish
	Diet Questionnaire – Prenatal	October 2012
	Diet Questionnaire – Prenatal – Spanish
	Diet Questionnaire - Postpartum	October 2012
	Diet Questionnaire – Postpartum – Spanish
	Diet Questionnaire – Toddler (6-24 Months)	October 2012
	Diet Questionnaire – Toddler (6-24 Months) – Spanish
	Diet Questionnaire – Young Infant
	Diet Questionnaire – Young Infant - Spanish
	Employer Breastfeeding Support Letter
	Financial Support for On-Going Training Application
	Financial Support for IBCLC
	Kansas WIC Client Survey
	Kansas Lost or Stolen Check Replacement Agreement	October 2012
	KWIC Manual Backup Form Child-Infant
	KWIC Manual Backup Form Woman
	Local Agency Expenditure Tracking Form
	Local Agency Inventory Tracking Form
	Local Agency Warning Notification Letter Sample 1
	Local Agency Warning Notification Letter Sample 2
	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	October 2012
	Management Evaluation – Clinic Self-Evaluation Tool
	Management Evaluation – Fiscal ME Tool	October 2012
	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	October 2012
	Minimum Stock Requirements - Rural	October 2012
	Minimum Stock Requirements - Urban	October 2012
	Request for Reimbursement Form	October 2012
	Rights & Responsibilities Form
	Rights & Responsibilities Form - Spanish
	School Breastfeeding Support Letter
	Special Authorization – Infants and Children	October 2012
	Special Authorization – Women	October 2012
	Special Authorization – Pediatric Medical Formulas FAQ	April 2013
	Special Authorization – Sample Denial Letter	April 2013
	Special Authorization – WIC Formula Fact Sheet	April 2013
	Standard WIC Affidavit	February 2013
	Suspension Letter for Program Abuse
	Vendor Application Packet	October 2012
	New Vendor Evaluation Form
	Vendor Manual	October 2012
	Vendor Monitoring Form
	Vendor Participation Contract	October 2012
	Voter Registration - Agency Voter Declaration Form	January 2013
	Voter Registration - Agency Voter Declaration Form - Spanish	January 2013
	Voter Registration - Notice to Applicant	January 2013
	Voter Registration - Application	January 2013
	Voter Registration - Application - Spanish	January 2013
	Weight Gain Grids
	WIC Fact Sheet	October 2012
	WIC Fact Sheet - Spanish	October 2012
	WIC Local Agency Budget FFY2014
	WIC Local Agency Budget FFY2013
	WIC Product Inventory	October 2012
	WIC Proxy Form	October 2012
	WIC Publications Order Form
	WIC Time Study Forms
	WIC Civil Rights Discrimination Complaint Form