WIC Program Forms

Forms

Resources for Local Agencies


MN WIC Program

Breastfeeding
Benefit Stock Order form for HuBERT
CFH Account-Required Forms
Change Request Form
Hardware - Equipment, Printers, and Supplies
Medical Formula Order Form
MN WIC Program Activities Expense Form
Request for Increase of Administrative Funds
Store Incident Report Form
WIC Materials
Notes - Downloading Different Types of Forms


Breastfeeding Forms

Claim Form for Breastpump Purchase Reimbursements (PDF)
Exhibit 2-H in MN Operations Manual

WIC Peer Breastfeeding Support Program Claim for Reimbursement FFY16 (EXCEL)

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Benefit Stock Order Form for HuBERT

HuBERT Benefit Stock Order Form
Automated Form - Local agencies can use this form to submit on-line quarterly or emergency orders for benefit stock

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CFH Account-Required Forms

CFH Forms and Applications Page
Automated Form on the CFH Forms and Applications page - The following forms require a CFH account in order to submit the on-line form:

  • Nutrition Education Plan
  • Expenditure Plan
  • HuBERT User Request - add/update/delete staff access to HuBERT

How to Create a CFH (Child Family Health) Account and Request Access to Forms on WIC Tools (PDF)

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Change Request Forms

Local Agency HuBERT - Change Request Forms
Automated Form - Local agencies can use this form to submit on-line requests, including:

  • Data information or assistance with reports (select Query/Report from the Type drop-down list)
  • HuBERT software change suggestions, such as potential changes to HuBERT, including: software changes, nutrition education topics, and drop-down list options
  • Add or update WIC staff information that displays on the MDH WIC website
  • Add or update Grantee, Agency, or Clinic information in HuBERT

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Hardware - Equipment, Printers, and Supplies

Recycle Laser Printer Toner Cartridge Mailing Label (PDF)
Local Agencies can use this form as a mailing label to recycle laser printer toner cartridges. Print this page and affix it to the box containing the used laser printer toner cartridge you want to return for recycling. Mail the package by US Mail. Please do not use this label to return defective toner cartridges.

Report Faulty Printer Replacement Form
Automated Form - Use this form to report a change in printer inventory at your local agency. The form is only necessary for printers that were replaced due to failure.

Request for Equipment (Exhibit 9-C in MN Operations Manual)
Automated Form - Local Agencies can use this form to order computer equipment and peripherals on-line.

Request for Supplies (Exhibit 9-A in MN Operations Manual)
Automated Form - Local Agencies can use this form to order labels, printer cartridges, printer imaging units, and photoconductor replacements on-line.

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Medical Formula Order Form

Local Agencies can use this form to order medical formula from the State WIC office.

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MN WIC Program Activities Expense Form

MN WIC Operations Manual, Exhibit 2-I. This form will enable MDH to increase the WIC grant by the total on this form. It will not generate a separate payment. Be sure to claim these expenses on the next monthly claim for reimbursement.

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Request for Increase of Administrative Funds

MN WIC Operations Manual, Exhibit 2-C

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Store Incident Report Form

WIC Store Incident Report (PDF)
Local Agencies can use this form to submit issues with WIC vendors/stores.

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WIC Materials

WIC Materials Order Form for Local Agencies
Automated Form - Local Agencies can use this form to order WIC materials such as Brochures, Handouts, Videos, Posters, Administrative Forms/Letters and Staff Resources, including those translated into other languages.

WIC Outreach Materials Order Form
Automated Form - This form can be used to order WIC Outreach Brochures, Fact Sheets, Posters and Magnets.

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Notes - Downloading Different Types of Forms

Excel and Word forms
Forms created in MicroSoft Excel or Word should be saved to your computer before opening. Click onSave as on the "What do you want to do with..." message and select where the file should be saved. Once the file is saved you can complete the form in Excel or Word.

Word Forms with Fillable Fields
To select a checkbox, double click on it and select the Checked radio button in the Default Value section. Click the OK button to exit.

PDF Forms
PDF forms should be printed and completed manually. Please fax or e-mail the form as indicated.

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