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Participant Access Assessment (PAA) Form Attachment #1, 8.03

Revised May 2018 Store/Applicant’s Name: Vendor #: Address: Applicant #: City, State Peer Group: Zip Code County: # of Unique Participants Served: WIC Revenue Earned: *Report Period: Local Agency: BACKGROUND - Other WIC Authorized Retailers in Area: Vendor # Retailer Name: Driving Distance # of Unique Participants Served*

Vendor Management Unit Staff to complete the following questions: 1. During the last month, were 20 or more participants served? Yes □ or No □ 2. If response to #1 is yes, does the travel distance exceed three (3) miles to another authorized store? Yes □ or No □ 3. Are there participants whose specific nationality cannot be properly served by at least one authorized Vendor? Yes □ No □ or Unknown □ 4. 4. Are there barriers or other conditions which make travel to another WIC retailer dangerous or difficult for participants? Yes □ or No □ If yes, what geographic barrier(s) apply?_________________________________ 5. Is there a participant with a disability, who regularly shops at this store, needing an accommodation not available at other authorized vendor locations? Yes □ No □ or Unknown □ 6. 6. Are there circumstances which increase the need for participant access (i.e. new clinic site, store closings, etc.? Yes □ or No □ If yes, what circumstances apply?_____________________________________________

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