Exhibit 5-II
MINNESOTA WIC PROGRAM CERTIFICATION FORM
DATE:_______________ Clip family members together, so all members receive the same ID numbers.
Information common to all family members (address, income, etc.) need only be listed on one of the family’s forms.
NEW RECORDS
CERTIFICATION
OUT OF STATE TRANSFER:
CERT. DATE ____________
EXISTING RECORDS
CERTIFICATION
RECERTIFICATION
OUT OF STATE
TRANSFER CERT.
DATE_____________
CHANGE
MID-CERT
IN-STATE TRANSFER
TERMINATION
PARTICIPANT INFORMATION
PARTICIPANT ID (if known)
LAST NAME
FIRST NAME
M.I.
STREET ADDRESS, APT. #
CITY OR TOWN
DATE OF
BIRTH
ZIP CODE
SEX
WIC TYPE
(see key )
PROOF OF IDENTITY
STATUS
(see key)
TELEPHONE NUMBER
MIGRANT?
PROOF OF RESIDENCY
INTERPRETER
NEEDED?
LANGUAGE (if not English)
ETHNICITY (see key)
RACE (see key)
HOUSEHOLD INFORMATION
COUNTY
PICKUP DAY
WIC CLINIC
ANNUAL FAMILY INCOME
HEIGHT/WEIGHT/BLOOD
HEIGHT
WEIGHT
INCHES
1/8
LBS
¼
MFIP
FAMILY SIZE
RECUMBENT
Or STANDING
MA
FUEL
ASSISTANCE
FS
HEAD
START
REDUCED/FREE
SCHOOL MEALS
SSI
PROOF OF INCOME
HGB
HEALTH INFORMATION FOR INFANTS/CHILDREN < 2 YEARS OLD
BIRTH WEIGHT
WKS
CURRENTLY
EVER
DATE BF
LBS
OZS
GESTATION
BF?
BF?
STOPPED
HCT
HEALTH INFORMATION FOR WOMEN – PREGNANCY (OR POSTPARTUM WOMAN NOT ON WIC DURING PREGNANCY)
EDC
OR
LMP
# OF PG INCLUSIVE
FIRST PRENATAL CHECKUP
OBTAINING ROUTINE PN CHECKUPS?
HEALTH INFORMATION FOR WOMEN - PREGNANCY AND POSTPARTUM
3 MO BEFORE PG
CURRENT
PRE-PG
WEIGHT
EDUCATION
CIG PER
DAY
ALCOHOL
TIMES/WK
DRINKS
PER DAY
CIG
PER
DAY
LAST PREGNANCY END
LAST 3 MO OF PG
SMOKING
CHANGE
ALCOHOL
TIMES/WK
DRINKS
PER DAY
CIG
PER
DAY
ALCOHOL
TIMES/WK
DRINKS
PER DAY
FORMULA
STARTED?
BF
DURATION
HEALTH INFORMATION FOR WOMEN - POSTPARTUM
ACTUAL
DATE OF
DELIVERY
# OF PG
INCLUSIVE
TOTAL
# PN
VISITS
WEIGHT
GAIN
RISK CODES
ISSUANCE FREQUENCY
LIVE?
BIRTH
WEIGHT
PRIORITY
SEX
Nutrition Education/Notes may be written
on the back of this form.
IF TWINS
LIVE?
BIRTH
WEIGHT
CURRENTLY
BF?
FOOD PACKAGE
EDUCATION FOLLOW-UP
FREQUENCY
MANUAL VOUCHER NUMBER RANGE:
CSECTION?
EDUCATION TYPE
PHYSICALLY PRESENT?
HAVE THE PARTICIPANT SIGN AND DATE
THE RIGHTS AND RESPONSIBILITIES FORM.
_______________________________
_________
CPA signature
Date
4/06
WIC TYPE
Infant
Child
Postpartum Breastfeeding
Postpartum Non-Breastfeeding
Pregnant
ETHNICITY
•
•
No, Not Hispanic or Latino
Yes, Hispanic or Latino
STATUS
STATUS
Infant/Child
1. Infant/Child of Non-WIC
PPT during Pregnancy
2. Infant/Child of WIC PPT < 3
mo. during Pregnancy
3. Infant/Child of WIC PPT > 3
mo. during Pregnancy
4. Unknown if Mother
Participated in WIC during
Pregnancy
Woman
1. Pregnant, First Trimester
2. Pregnant, Second
Trimester
3. Pregnant, Third Trimester
4. Postpartum,
Breastfeeding
5. Postpartum, NonBreastfeeding
RACE
•
•
•
•
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
•
White
4/06