Welcome to the State of California 

WIC Forms

  • 2012-2014 Funding Application 
  • Report Concerning Vendors for Local Agency and Participant Use (PDF)Opens a new browser window
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    Office of State Publishing (OSP) Order Forms

  • OSP 501 (PDF)"Opens a new browser window" WIC Nutrition Education, Prenatal/Postpartum, & Breastfeeding Materials
  • OSP 502 (PDF)"Opens a new browser window" WIC Orientation, Outreach, and Food Package Materials
  • OSP 503 (PDF)"Opens a new browser window" WIC Infant and Children Materials
  • OSP 504 (PDF)"Opens a new browser window" WIC Administrative Materials
  • OSP 508 (PDF)"Opens a new browser window" WIC Vendor Materials
  • OSP 509 (PDF)"Opens a new browser window" WIC Clearinghouse Items
  • OSP 510 (PDF)"Opens a new browser window" WIC Campaign Materials
  • OSP 511 (PDF)"Opens a new browser window" WIC Local Vendor Liaison (LVL) Materials
  • OSP 527 (PDF)"Opens a new browser window"WIC Magazines 
  • California Department of Public Health (CDPH) Forms

  • CDPH 4007 (PDF) "Opens a new browser window"Vendor Report Concerning WIC Participants
  • CDPH 4043 (PDF, English/Spanish)"Opens a new browser window"Participant Suspension Notice
  • CDPH 4044 (PDF) "Opens a new browser window"Participant Warning Notice
  • CDPH 4134 (PDF, English)"Opens a new browser window"| Spanish Notice of Action Affecting WIC Program Applicants
  • CDPH 4143 (PDF)"Opens a new browser window"Infant Screening and Medical Justification for Therapeutic Formulas
  • CDPH 4144 (PDF)"Opens a new browser window"Child Screening and Medical Justification for Therapeutic Formula
  • CDPH 4145 (PDF) "Opens a new browser window" Lost or Stolen Checkstock Report
  • CDPH 4304 (PDF, English/Spanish) "Opens a new browser window"Notice of Action Affecting WIC Program Participation
  • CDPH 4476 (PDF)"Opens a new browser window"Dual Participation/Participant Abuse Report
  • CDPH 247A, Half Sheet Version (PDF)"Opens a new browser window"Full Sheet Version (PDF)"Opens a new browser window"Instructions (PowerPoint, 5.3 MB) 
  • PM 247 1 (PDF)"Opens a new browser window"Referral for Pregnant Woman
  • PM 247 2 (PDF)"Opens a new browser window"Referral for Postpartum/Breastfeeding Woman
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    Nutrition Questionnaires:

  • CDPH 4153 (PDF, 47.3 MB, English/Spanish)"Opens a new browser window"Breastfeeding/Postpartum
  • CDPH 4154 (PDF, 9.7 MB, English/Spanish) "Opens a new browser window"Pregnancy
  • CDPH 4154 Supplemental Questions (PDF)"Opens a new browser window"...| Spanish  Pregnancy
  • CDPH 4155 (Pilot) (PDF)"Opens a new browser window"...|  Spanish  Baby Birth-5 Months
  • CDPH 4156 (PDF, 9.9 MB, English/Spanish) "Opens a new browser window"Child 2-4 Years
  • CDPH 4157 (PDF, 9.7 MB, English/Spanish)"Opens a new browser window"Baby 6-23 Months
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    Last modified on: 2/2/2012 9:50 AM