Forms / Administrative Materials

Ordering Forms

Forms

  1. Abbreviations From Local Agencies (PDF)
  2. Acknowledgment of receipt of Direct Ship Formula from Kansas Nutrition and WIC Services (PDF)
  3. Affidavit of Expenditures (XLSX)
  4. Application for Kansas Local Agency NWA Committee Representative (DOCX)
  5. Authorization for Electronic Exchange of Information to the Kansas Immunization Registry consent form-English (PDF)
  6. Authorization for Electronic Exchange of Information to the Kansas Immunization Registry consent form-Spanish (PDF)
  7. Authorization to Share Kansas WIC Information - PDF - English (PDF)
  8. Authorization to Share Kansas WIC Information - PDF - Spanish (PDF)
  9. Authorization to Share Kansas WIC Information - Word - English (DOCX)
  10. Authorization to Share Kansas WIC Information - Word - Spanish (DOCX)
  11. Breast Pump Questionnaire - Spanish (PDF)
  12. Breast Pump Questionnaire (PDF)
  13. Breast Pump Request for Reimbursements (PDF)
  14. Breastfeeding Equipment User Agreement - Spanish (PDF)
  15. Breastfeeding Equipment User Agreement (PDF)
  16. Breastfeeding Peer Counselor Program Annual Evaluation (PDF)
  17. Breastfeeding Peer Counselor Program Application Packet (PDF)
  18. Breastfeeding Peer Counselor Quarterly Report (XLSX)
  19. Breastfeeding Peer Counselor Quarterly Report Guidance (PDF)
  20. Breastfeeding Peer Counselor Review Report Form (DOCX)
  21. Breastfeeding Peer Counselor Staff Evaluation (PDF)
  22. Budget Template and Checklist FFY2022 (XLSX)
  23. Budget Template and Checklist FFY2023 (XLSX)
  24. Card Inventory Control Form (PDF)
  25. Coffective Sample Letter for Kansas Physicians (DOCX)
  26. Contract Military Commissaries Memorandum of Understanding (PDF)
  27. Declaration of Conflict of Interest (PDF)
  28. e WIC Manual Backup Form Child, Infant (PDF)
  29. e WIC Manual Backup Form Woman (PDF)
  30. Employer Breastfeeding Support Letter (PDF)
  31. Financial Support for IBCLC (PDF)
  32. Financial Support for On-Going Training Application (PDF)
  33. Formula Tracking Sheet for Returns and Dispositions-Enterable Form (DOCX)
  34. Formula Tracking sheet for Returns and Dispositions-optional Excel (XLSX)
  35. Formula Tracking Sheet for Returns and Dispositions-Word (DOCX)
  36. Kansas WIC Client Survey - Spanish (PDF)
  37. Kansas WIC Client Survey (PDF)
  38. KWIC Manual Backup Form Child-Infant (PDF)
  39. KWIC Manual Backup Form Woman (PDF)
  40. Local Agency Active Chart Review (PDF)
  41. Local Agency Clinic Site Observation (PDF)
  42. Local Agency Expenditure Tracking Form (XLSX)
  43. Local Agency Inventory Worksheet (PDF)
  44. Local Agency Warning Notification Fillable Form (PDF)
  45. Management Evaluation - Active Client Record Review Tool, Administration (PDF)
  46. Management Evaluation - Active Client Record Review Tool, Nutrition (PDF)
  47. Management Evaluation - Administrative Evaluation Tool (PDF)
  48. Management Evaluation - BFPC Program (PDF)
  49. Management Evaluation - Breast Pump Issuance Tool (PDF)
  50. Management Evaluation - Client Interview Tool (PDF)
  51. Management Evaluation - Clinic Observation Tool (PDF)
  52. Management Evaluation - Clinic Self-Evaluation Tool (PDF)
  53. Management Evaluation - Fiscal ME Tool (PDF)
  54. Management Evaluation - Nutrition Tool (PDF)
  55. Management Evaluation - Secondary Nutrition Education Observation Tool (PDF)
  56. Management Evaluation - Special Formula Authorization Tool (PDF)
  57. Management Evaluation - Tracking of Returned Formula Tool (DOCX)
  58. Military Commissary MOU Kansas WIC (PDF)
  59. Minimum Stock Exemption Form (PDF)
  60. Minimum Stock Requirements - Rural (PDF)
  61. Minimum Stock Requirements - Urban (PDF)
  62. New Vendor Evaluation Form (PDF)
  63. Request to Add a UPC Form (PDF)
  64. Rights and Responsibilities Form - Spanish (PDF)
  65. Rights and Responsibilities Form (PDF)
  66. School Breastfeeding Support Letter (PDF)
  67. Seperation of Duties Exception Log (PDF)
  68. Special Authorization - Infants and Children (PDF)
  69. Special Authorization - Pediatric Medical Formulas FAQ (PDF)
  70. Special Authorization - Sample Denial Letter (PDF)
  71. Special Authorization - WIC Formula Fact Sheet (PDF)
  72. Special Authorization - Women (PDF)
  73. Vendor Application Packet (PDF)
  74. Vendor Manual (PDF)
  75. Vendor Monitoring Form (PDF)
  76. Vendor Participation Contract (PDF)
  77. Voter Registration - Agency Voter Declaration Form - Spanish (PDF)
  78. Voter Registration - Agency Voter Declaration Form (PDF)
  79. Weight Gain Grids (PDF)
  80. WIC Civil Rights Discrimination Complaint Form - Spanish (PDF)
  81. WIC Civil Rights Discrimination Complaint Form (PDF)
  82. WIC Fact Sheet - Spanish (PDF)
  83. WIC Fact Sheet (PDF)
  84. WIC Product Inventory (PDF)
  85. WIC Publications Order Form (PDF)
  86. WIC Time Study Forms (XLS)