WIC Tools - Minnesota Dept. of Health

WIC Tools


Forms for MN WIC Local Agency Staff
Information System (IS) Forms - Local Agency Staff
Forms for Equipment/Supplies - Local Agency Staff
Forms for Vendors (Grocery Stores & Pharmacies
Forms for Other WIC Partners/Outreach

Forms for MN WIC Local Agency Staff

eWIC Transaction Issue Form (WORD)
A form to collect information if a participant has an eWIC transaction issue. Enough detail must be provided so MDH WIC staff can research the issue.

Questions/Feedback Form
This form can be use by any of our WIC partners (local agency staff, WIC applicants/participants, healthcare providers, vendors, etc.) to submit questions or feedback to the WIC Program’s State Office.

Quarterly WIC Card Stock Order Form
Agencies should plan on maintaining at least 6 months of WIC Card stock. WIC Card orders are placed four times per year (quarterly): December 15th (1st quarter), March 15 (2nd), June 15th (3rd) and September 15th (4th). Shipments will be delivered about 6 weeks after the order deadline. No emergency shipments can be ordered. All agencies must submit quarterly orders. If no card stock is needed for that quarter, enter None into the Number of Boxes field.

WIC Agency Materials Order Form
Quantities are based on packaging unit (ex: item ships in packs of 50; 1 = pack of 50). You can edit the quantity by scrolling to the Cart at the top of the page, hovering over the quantity number, and clicking the up/down arrow.

Medical Formula Order Form
Local Agencies can use this form to order medical formula from the State WIC Office.

Rights & Responsibilities
PDFs that can be printed; available in multiple languages, including: English, French, Hmong, Karen, Russian, Somali, Spanish and Vietnamese.

Local Agency Expense Form - WIC Program Activities
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.

Request to Increase Administrative Funds (RIAF) Form (WORD)
Mn WIC Operations Manual, Exhibit 2-C. WIC Local Agencies can use this form to request an increase in authorized grant award to cover non-recurring costs related to program improvement or general infrastructure. Please discuss this request with your State WIC Consultant first.

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Information System (IS) Forms - Local Agency Staff

Request to Submit WIC User Access Changes
This request should only be submitted ONCE by WIC Coordinators/Supervisors to obtain a URL for the WIC Information User Requests Form. The URL, once received via email from the State Office, should be bookmarked and the form it links to used for all staff user access changes to WIC Information System, Infoview and the Reports Environment (including adding new, updating existing, and deactivating current users).

Local Agency Reports and Data Request
Local Agency staff can use this form to submit requests for Infoview ad-hoc reports or other data requests.

WIC IS Software Change Request Form
Local Agency staff can suggest potential changes to the WIC Information System (IS) using this form, including: software changes, nutrition education/materials given/goal topics and options for drop-down lists.

My MN WIC App Suggestions
Local Agency staff can use this from to suggest changes or enhancements to the My MN WIC App.

Change WIC Staff on MDH Website
Local Agency staff can use this form to add or update staff information that displays in the Minnesota WIC Local Agency Directory on the MDH WIC website.

Change Grantees, Agencies or Clinics in IS and/or on MDH Website
Local Agency staff can use this form to add/update Grantees and Agencies, and add/update/deactivate Clinics, in the Information System and on the MDH WIC website.

Minnesota WIC Help Desk Feedback Form
Local agency staff can use this form to provide feedback on MN WIC Help Desk call assistance.

WIC Card - Primary Cardholder Signature Register

For use if staff are unable to (or did not) collect the Primary Cardholder's signature when setting or changing the WIC Card's Primary Cardholder due to signature pad malfunction, canceling out of capture signature screens, or remote TeleWIC visits.

Primary Cardholder Signature Register - Minnesota WIC (electronic form)

Primary Cardholder Signature Register (WORD)

WIC Household Manual Certification Register

For use if staff are unable to (or did not) collect a participant signature after certification or unable to (or did not) collect the staff signature for having determined eligibility due to signature pad malfunction, canceling out of capture signature screens, or remote TeleWIC visits.

Household Manual Certification Register - Minnesota WIC (electronic form)

WIC Household Manual Certification Register (WORD)

Manual Certification Forms

Manual Certification - WIC Proof of Eligibility (WORD)
For use to collect household information if HuBERT system or Internet is down and cannot perform electronic certification.

Manual Certification - Infants and Children (WORD)
For use to collect information for infants and children if HuBERT system or Internet is down and cannot perform electronic certification.

Manual Certification - Women (WORD)
For use to collect information for women if HuBERT system or Internet is down and cannot perform electronic certification.

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Forms for Equipment/Supplies - Local Agency Staff

Equipment/Supplies Request
Local Agencies can use this form to order hardware, computer peripherals, and miscellaneous supplies. Your State WIC Consultant, selected at the bottom of the form, will be notified by email of this request.

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Forms for Vendors (Grocery Stores & Pharmacies)

Customer Incident Report
Please complete this form if you have issues with a participant at your store.

WIC Vendor Materials Order Form
Quantities are based on packaging unit. You can edit the quantity by scrolling to the Cart at the top of the page, hovering over the quantity number, and clicking the up/down arrow.

Questions/Feedback Form
This form can be use by any of our WIC partners (WIC vendors, local agency staff, WIC applicants/participants, healthcare providers, etc.) to submit questions or feedback to the WIC Program’s State Office.

Vendor Request for WIC Application Packet
Note that you must be authorized for the SNAP Program before you can apply for the WIC Program.

MN WIC Vendors can request data/information using the Vendor Data Request - Minnesota WIC form. All submissions will be reviewed and fulfilled with respect to any time constraints.

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Forms for Other WIC Partners/Outreach

WIC Outreach Materials Order Form
Quantities are based on packaging unit. You can edit the quantity by scrolling to the Cart at the top of the page, hovering over the quantity number, and clicking the up/down arrow.

Questions/Feedback Form
This form can be use by any of our WIC partners (WIC applicants/participants, healthcare providers, WIC vendors, local agency staff, etc.) to submit questions or feedback to the WIC Program’s State Office.

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Other partners can request data/information using the Data Requests for the Minnesota WIC Program form.

Updated Tuesday, 17-Nov-2020 12:46:59 CST