WIC WISE Forms WPPM 1000-140 JOB AID

Revised California WIC Policy and Procedure Manual Page 1 of 3 December 6, 2019 I. Forms Form # (If applicable) Form Name When to use Signature Required Required to be given CDPH 4130 California WIC Program Self Declaration Statement When an individual does not have proof of income, address, or identification at initial certification and recertification only. Yes Yes CDPH 4146 Consent to Release Personal Information When an individual gives permission to personal information being released and/or when permission is given to WIC to contact health care providers. Yes Upon request CDPH 4132 Know Your Rights and Responsibilities When eligibility is determined at initial certification and recertification. Yes Upon request CDPH 4148 Multi-User Breast Pump Loan Agreement When issuing a breast pump (Coming Soon) Yes Yes CDPH 4134 Notice of Action At Initial Certification and Recertification

When an applicant is determined ineligible at initial certification or recertification or after 30/60 day short certification when the required income, residency, ID, proof of pregnancy or infant presence is not provided. Yes Yes CDPH 4304 Notice of Action During WIC Certification Period When a participant no longer meets WIC Program requirements during a certification period. 15-day notice is required. Not to be used at recertification. Yes Yes CDPH 4147 Notice of WIC Certification Expiration

When the certification period of a participant will end based on their category. Provide the notification at the last WIC contact prior to the certification end date. No Yes

WIC WISE Forms WPPM 1000-140 JOB AID

Revised California WIC Policy and Procedure Manual Page 2 of 3 December 6, 2019 Form # (If applicable) Form Name When to use Signature Required Required to be given N/A Initial Certification and Recertification Appointment Reminder When scheduling an appointment for an initial certification or a recertification. No Upon request N/A Outbound Verification of Certification When a participant is leaving California WIC and moving to another state. No Yes N/A WIC Food Balance When a participant requests a list of their food benefits. No Upon request N/A WIC Health Assessment Data When a participant requests their health data obtained by WIC. No Upon request N/A WIC Visit Verification When a participant requests proof that they attended a WIC appointment. No Upon request

WIC WISE Forms WPPM 1000-140 JOB AID

Revised December 6, 2019 California WIC Policy and Procedure Manual Page 3 of 3 II. Documents that must be scanned to WIC WISE Form Name When is it required to scan Required to be given Custody/Foster Placement Papers When the custody of an infant or children is in question. N/A Downtime forms: Notices of Action (NOA)/Self Declaration Statement (SDS)/Rights & Responsibilities (R&R) When WIC WISE experiences a power outage or no network connectivity. Once power or network connectivity is restored, forms must be scanned. Yes Notices of Action (NOA) Self Declaration Statement (SDS) Rights & Responsibilities (R&R) When there is no functioning signature pad or mouse pen. Signed documents must be scanned. Yes (R&R Upon Request) Inbound VOC When a participant provides a VOC when transferring into California. N/A LA Breast Pump Agreement When staff issues a LA-developed Breast Pump Agreement. Coming soon. Yes LA Consent Forms When a form created by the LA is used instead of the CDPH/WIC template. Upon Request Rx from Doctor/HCP When a participant provides a Rx for modified diet. N/A Therapeutic Formula Documents When a participant provides the LA with documents regarding their Rx for therapeutic formula and/or WIC-eligible nutritionals. N/A WIC Medical Referral Form (Pediatric/PG/PP) When a participant provides the LA with a form with information from the Health Care Provider other than anthropometric or bloodwork. N/A