WIC Policies, Procedures, & Forms

WIC Procedure Manual

Policy Memos & Resources:

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​Policy Memos

• 06.21.22 - New Non-Discrimination Statement​
  
• 06.15.22 - Certifying Applicants While in the Hospital​
• 10.06.21 - Services for Afghan Refugees ​
• 01.10.20 - e/WIC Journey use Outside of the Clinic 

​​​Commonly Used Fillable Forms, Letters, Templates

Administrative Forms

• Budget Table and Pe​rsonnel Co​st Summary​​
  
• Budget Guidelines & Instructions
• Budget Form 
  
• Personnel Cost Summary Table 
  
• Budget Narrative Form
  
• WIC Administrative Budget Form 
  
• Budget Narrative
  
• ​Per Diem Worksheet
  
• FSR Page​s 1, 2, 3​
  
• Journey - Add User Form  - Journey Train access provided until new staff attends training
• Journey - Remove User Form 
• Nebraska WIC Pro​gram Data Request Form​
  
• Request for Additional NSA Funds​
  
• Request for Authroization to Purchase (RAP Form)​
  

Clinic Forms

• Additional Benefit Issuance Form 
• Administration Materials Order Form
• Educational Materials Order Form
• Medicaid Phone Verification Access Request - Confidentiality Statement
  
• Medicaid Web Verification Access Request - Confidentiality Statement
• No Proof Fillable Form - Address
• No Proof Fillable Form - Identity
  
• No Proof Fillable Form - Income
  
• Requesting Approval to Open, Close, or Move a Clinic
  
• Statement of Status Form - For Teens Under Age 19​
  
• Termination Notice & Ineligibility Notices can be printed in Journey
  
• WIC Infant Enrollment Form
  

Complaint Forms

• Integrity Screening Form
• Discrimination Complaint Follow Up Form
  

• This document contains the USDA Non-Discrimination phrases required on Nebraska WIC materials. For questions about proper use, contact Marge Blankenship at marge.blankenship@nebraska.gov
  
• USDA Non-Discrimination Statement
  

Vendor Change Forms

• Change In Ownership of WIC Store - Letter Template At End Of Procedure
• Store Closing - Letter Template At End Of Procedure

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