WIC Program Forms and Materials

Ordering WIC Materials

Orders will be filled and shipped directly to you from the Washington State Department of Printing Fulfillment Center.

Use the instructions below to order from the Washington State Department of Printing's myFulfillment. Internet orders are shipped approximately 2-3 days after the order is placed.

Ordering Instructions

  1. Go to the Department of Printing's website at myfulfillment.wa.gov.
  2. You will be asked if you are new or if you have been here before. Click on the appropriate box.
    • If you are new, you will be asked to enter a user name and password. (Use your email address as your login. This allows Department of Printing to easily find your password should you ever forget it.) If someone else is not using your login, it will immediately be accepted. Write down your login and password for future reference.
  3. Steps to find the products:
    • On the left side select “Fulfillment (By Agency).”
    • Select “Health (DOH).”
    • Select “WIC.”
      • You are now at the WIC materials, which are broken down into categories. Click on the category and then find the item you are wanting.
    • Once you find the item you are looking for, click on the item, input the quantity you wish to order, then click "Add to Cart."
    • Once you click on “Add to Cart” it will place your items in your shopping cart.
  4. You can continue shopping and updating the cart until you have all of the items you wish to receive and then you will need to “Check Out.”
  5. Enter all your shipping information. (Please note—all items will be shipped to a physical address—no PO Boxes please)
    When entering your contact and ship to information please note…
    • Enter your first name in the “First Name” field.
    • Your last name in the “Last Name” field.
    • Enter "WIC Clinic" in the "Organization" field.
    • Please be sure to include your phone number with area code.
  6. Click the “Continue” button and you should see a confirmation of your order.
  7. Please print the confirmation page including the web order number for your records.
  8. If there are any problems with your order or the ordering process please contact us at WIC@doh.wa.gov or 1-800-841-1410. We will need your confirmation order number to track and assist you with your order.

A-19 Submission Checklist

The A-19 Submission Checklist helps ensure consistency, prompt approval and processing of your billing, and a smooth A-19 review process. Find the checklist that fits your situation below:

For LHJs

For Non-LHJs

Assessment Questions and Assessment Tool

Washington WIC uses standardized questions when program eligibility is determined at initial and subsequent certifications. The questions are specific to participant category and infant age. These questions support WIC staff in completing the nutrition assessment, determining WIC risk eligibility and starting a dialogue with the participant about what they want and need related to nutrition and health.

Assessment Questions
Assessment Questions Tool

Breastfeeding and Baby Behavior Materials

The Breastfeeding Resources Spreadsheet (Excel) contains numerous links to valuable breastfeeding resources. Staff can refer to this spreadsheet while working with clients, during staff training, or on their own.

Breast Pump Lost, Stolen, or Damaged Multi-user Report

Complete the Lost, Stolen, or Damaged Multi-user Electric Pump Report when all attempts to recover a pump are exhausted. You can complete the report via the online form or PDF form below.

Breast Pump Mailing Label Request Form

Use the online Breast Pump Mailing Label Request Form to request mailing labels from the State WIC Office. See the online form for more details. For questions, please email WICBreastPumps@doh.wa.gov.

Breastfeeding Flange FITS Guide

A handout for participants with information about optimal flange fit and guidance. Washington WIC collaborated with Babies in Common to edit and translate The Flange FITS Guide.

Flange FITS Guide - view all languages

Breast Pump Release of Liability Form

Breast Pump Release of Liability Form - view all languages

 

Breastfeeding Pump Documentation Guide

The Pump Documentation Guide (PDF) provides staff with helpful reminders and examples on how to document all breastfeeding, pump, pump supply, and contact notes in Cascades, as required by Volume 1, Chapter 15 Breastfeeding Policy and Procedures.

Breast Pump Resources

Breast Pump Resources (PDF): A printer-friendly handout for staff and participants with links to helpful how-to and introduction videos/PDFs about the breast pumps offered through the WA WIC program.

Breast Pump Resources - View all languages

CDC-WHO Growth Charts

WIC uses the following growth charts for infants and children from birth to 24 months of age. These are the Center for Disease Control (CDC) growth charts based on the World Health Organization (WHO) growth standards.

External Fiscal/Contract Communication Table

Fair Hearing Brochure

WIC policy requires staff to provide the WIC Fair Hearing brochure (PDF) to applicants and participants who feel staff incorrectly or unfairly determined them ineligible for WIC services. See the Washington State WIC Policy and Procedure Manual Chapter 20 (PDF) for more information.

WIC Fair Hearing brochure - view all languages

Hematology Supply Order Forms

  • Use this Hematology Order Form to order all McKesson, Masimo, and HemoCue Hematology supplies.
  • Once we process your order, we will send an acknowledgement email with a copy of your order from WICHematology@doh.wa.gov to keep for your records.
  • Keep the acknowledgement email and the completed order records (packing slip) on file for six years according to fiscal retention policy.
  • Contact WICHematology@doh.wa.gov for questions.

Income Intake Tool

This optional Income Intake Tool (PDF) helps staff gather income information in a more confidential manner. The client can fill out the form and staff ask follow-up questions about the information as needed before entering it in Client Services.

Individual Authorization to Release WIC Information 

Participants sign the Individual Authorization to Release WIC Information when they are giving permission to release confidential participant information.

Individual Authorization to Release WIC Information - View all languages

Mailed Card Letter

Letter clinic staff send when mailing the WIC Card to a participant.

Mailed Card Letter - View all languages

Mailed QR Code Letter

Letter to mail to participants with their QR code sticker.

 Mailed QR Code Letter - View all languages

No Proof of Identity Form (Affidavit for Identity)

Participants sign the No Proof of Identity Form (Affidavit for Identity) when proof of identity doesn’t exist, was destroyed, or was lost due to theft. See Volume 1, Chapter 6–Income (PDF) for more information.

No Proof of Identity Form (Affidavit for Identity) - View all languages

No Proof of Residency Form (Affidavit for Residency)

Participants sign the No Proof of Residency Form (Affidavit for Residency) when proof of residency doesn’t exist, for example when the person is experiencing homelessness or is a migrant, the proof was destroyed, or was lost due to theft. See  Volume 1, Chapter 6–Income (PDF) for more information. 

No Proof of Residency Form (Affidavit for Residency) - View other languages

Not Eligible Letter

WIC policy requires staff to provide the Not Eligible letter (PDF) to applicants who don't qualify for WIC services and to participants that staff take off WIC. See the Washington State WIC Policy and Procedure Manual Chapter 20 (PDF) for more information.

Not Eligible Letter – view other languages

Nutrition Education Materials

0-6 Months–Tips for My First Six Months
6-12 Months-Tips for Me As An Older Baby
Beans: The Bold and Beautiful Book of Bean Recipes
Healthy Fish Guide - Fish/Seafood Wallet Card
Healthy Choices for Kids
Healthy Tips for New Moms
Healthy Weight Gain During Pregnancy
I Can Eat Finger Foods
I'm Ready for a Cup
I'm Ready! Feeding Family Foods to Your Baby
I'm 1 – Let's have fun!
I'm 2 – Look what I can do!
I'm 3 – Please play with me!
I'm 4 – Let's explore!
Iodine information sheet
Gestational Diabetes: My Pregnancy, My Baby, and Me:
Pump Up the Iron
Stay Healthy
The Facts About Constipation
Tips for a Healthy Pregnancy
Tips for Feeding Picky Eaters
55 Ways to Add More Fruits and Vegetables Every Day

Overdue Pump Letter

Prenatal Weight Gain Grids

The Washington WIC Nutrition Program uses prenatal weight gain grids based on the 2009 Institute of Medicine (IOM) prenatal weight gain guidelines. A pregnant woman's weight is plotted on a prenatal weight gain grid based on her pre-pregnant Body Mass Index (BMI) and if it is a singleton or multiples pregnancy.

Singleton Grids

Multiples Grids

Race and Ethnicity Tool

Staff provide the Race and Ethnicity Tool (PDF) to participants so they can review the definitions of the federal race and ethnicity categories and provide their self-declared information.

See Volume 1, Chapter 18 – Certification (PDF) for more information.

Race and Ethnicity Tool - view all languages

Rights and Responsibilities Forms

The Rights and Responsibilities form (PDF) was revised to use with Cascades, WIC Cards, and reflect the Participant Violations and Sanctions Table published in the Washington Administrative Code (WAC).

Rights and Responsibilities form - view all languages

Shopping with Your WIC Card 

Handout for participants with information about shopping with a WIC Card and reading the WIC receipt. Staff can also use this as a visual tool when sharing information with participants about using WIC Cards at the store.

Shopping with Your WIC Card (PDF) | Shopping with Your WIC Card Spanish (PDF)

Statement of Income Form (Affidavit for Income) 

Participants sign the Statement of Income Form when proof of income doesn’t exist, for example when the person has no income, works for cash or income documentation was destroyed in a house fire or natural disaster. See Volume 1, Chapter 6–Income (PDF) for more information. 

Statement of Income Form (Affidavit for Income) - View all languages

Temporary Certification for Missing Proof of Income Form 

WIC policy requires that participants fill out and sign the Temporary Certification for Missing Proof of Income Form when proof of income exists but the person didn't provide it at the certification appointment. See Volume 1, Chapter 6–Income (PDF) for more information. 

Temporary Certification for Missing Proof of Income Form - View all languages

Tips for Stand-Beside Card Readers

Information for WIC shoppers using small grocery stores with stand-beside card readers for purchasing WIC foods. 

Tips for Stand-Beside Card Readers - View all languages

Time Study Workbook

This tool helps WIC staff track time worked in the four WIC cost types.

We Missed You Letters

WIC policy states staff send the We Missed You letter for all categories to clients who miss WIC appointments. A separate letter is required for pregnant women who miss their first scheduled WIC appointment. English and Spanish letters will print from CIMS Client Services. All languages are located here for printing.

Letter for pregnant women who miss their first WIC appointment
Letter for all clients who miss WIC appointments

WIC Benefits and Foods

WIChealth Online Nutrition Education

Welcome to WIChealth Video – This video explains how participants can use WIChealth.

 

English

 

Spanish

Staff Resources

FAQ for WIC Staff (PDF)

WIChealth.org Rack Card
Options for using the rack card:

  1. Order print copies through MyPrint. Go to: Nutrition Education/WIChealth.org materials
  2. Use the online fillable pdf:
    1. How to use WIChealth.org 
    2. Cómo utilizar WICHealth.org
      *Tip: Fill in the WIC Agency, Clinic name, and WIC Family ID#. Use a snipping tool or screen shot and email image to participant.
  3. Use the email template available for Microsoft Outlook email users. Contact WAWICTraining@doh.wa.org to request. 

WH Lesson Recommendation Guide

Promotional Materials for WIC Participants from WIChealth.org

Questions? Contact: WAWICTraining@doh.wa.gov

WIC Services Worksheets

WIC Services Worksheets guide staff in recording information for WIC Certifications, Health Assessments, and other appointments when Cascades is unavailable. Staff follow the Guidelines for Using the WIC Service Worksheets (PDF) to:

  1. Record participant information while Cascades is unavailable.
  2. Enter participant information into Cascades from the worksheet.
  3. Scan the worksheets and any attached forms into Cascades, once the event is over.

Use the WIC Services Worksheet for the participant's category:

Healthy Sleep: For you and your baby
I am a Breastfeeding Baby – Crib Card
Understanding Your Baby's Cues
Why Do Babies Cry?