WIC Staff and Clinic Change Form

Use this form to:

Add and remove clinic staff
Change clinic staff role, email, and supervisor
Update fiscal contact and contract information
Update clinic information

This form updates the Learning Center, the DOH WIC Local Agency Directory, and email distribution lists only. Please continue to make changes and updates for your clinic within Cascades. If you have questions about this form please contact WAWICTraining@doh.wa.gov or WICAddress@doh.wa.gov.

Information collected via this form may be subject to release in accordance with RCW 42.56 (Public Records Act).

Person completing form:

Contact name

Contact email

I want to (select all that apply):

Add new clinic staff

Remove clinic staff

Change clinic staff role, email, and supervisor

Update fiscal contract and contact information

Make clinic changes

Add Clinic Staff

ADD staff that have never had a Learning Center (LC) account.

If you're hiring a staff member from another WA agency and they already have a LC account, select Change clinic staff role, email, and supervisor to update to update the user's account. Please don't add a new account for an existing staff member.

Note: You can use the plus and minus icons on the right to add multiple entries.

Add Staff
Staff email First name Preferred name (optional) Last name Supervisor's email Primary clinic Contact phone number Primary role Secondary role This person is a supervisor (Views staff and transcripts in the LC) This person needs a WICHealth account This person needs a Zoom license (for agencies with DOH IT model) Notes

Remove clinic staff

Remove staff members that no longer work in WIC and remove their WICHealth account and Zoom license (if applicable).

Note: You can use the plus and minus icons on the right to add multiple entries.

Remove Staff
Staff email First name Last name Primary role Clinic Notes

Make clinic staff changes

Make changes in staff information ie: role, name, email address, supervisor, etc. Indicate the staff member whose information you are changing.

Note: You can use the plus and minus icons on the right to add multiple entries.

Please complete the fields and select all checkboxes that apply.

Changes Staff
Staff email First name Last name Current role Current clinic Role Clinic Name/Email Supervisor/Email Other Please describe the change(s)

Update contract and fiscal contact information

Add, remove, or update agency contract and fiscal contact information.

I want to (select all that apply):

Add fiscal/contract contact

Remove fiscal/contract contact

Update fiscal/contract contact information

Add Fiscal/Contract Contact

Remove Fiscal/Contract Contact

Remove Fiscal/Contract Contact
Agency Staff email First name Last name

Update Fiscal/Contract Contact

Update Contact Fiscal/Contract Information
Agency Staff email First name Last name New email Phone number Title Correspondence type Other Please describe update

Please complete the fields below. Indicate if the person is a contract signer and the types of correspondence by selecting the yes or no checkboxes.

Add Fiscal/Contract Contact
Agency Staff email First name Last name Title Phone number This person is a contract signer Yes No Requesting Contracts & Amendments Yes No Requesting A19/Billing Info Yes No Requesting Funding Info Yes No Requesting Budget Workbook Yes No

Make clinic changes

Make changes in clinic information, ie: hours, phone number, fax number, location.

Note: You can use the plus and minus icons on the right to add multiple entries.

Changes Clinic
What clinic is being changed? Physical location Mailing location Phone number Fax number Clinic hours Agency referral email for WIC Interest Form Please describe the change(s)

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Please complete the fields and select all checkboxes that apply. Indicate if person is a contract signer, and types of correspondence to receive.

Add Fiscal/Contract Contact
Agency Staff email First name Last name Title Phone number This person is a contract signer Requesting Contracts & Amendments Requesting A19/Billing Info Requesting Funding Info Requesting Budget Workbook