State of Wisconsin

Bureau of Community Health Promotion

Title 7, Chapter II, Part 246.7, Federal Regulations

We want to make sure that you understand the rights and responsibilities of a WIC participant. The WIC rights and responsibilities also apply if you receive WIC Farmers’ Market Nutrition Program (FMNP) benefits. FMNP rights and responsibilities include but are not limited to, respectful and courteous treatment from FMNP sellers, and using the farmers’ market benefits as instructed by WIC staff.

• WIC foods: If I qualify for WIC, I will get an eWIC card to buy healthy foods. WIC provides some, but not all, of the food/formula each participant needs.
• Nutrition information: I will get information about healthy eating and active living.
• Breastfeeding support: WIC will help and support me with breastfeeding.
• Health care information: I will get information about immunizations, finding healthcare, and other services I may be interested in.
• Fair treatment: The rules for getting on WIC are the same for everyone. I can ask for a Fair Hearing if someone tells me I can’t be on WIC and I don’t agree.
• Common courtesy: WIC and store staff will treat me with courtesy and respect. I can tell WIC staff if I’m not treated with respect.
• Transfer information: I can transfer my WIC to another clinic or state. I can ask for a transfer paper.

• WIC Nutrition Program does not discriminate:

In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating on the basis of race, color, national origin, sex (including gender identity and sexual orientation), disability, age, or reprisal or retaliation for prior civil rights activity.

Program information may be made available in languages other than English. Persons with disabilities who require alternative means of communication to obtain program information (e.g., Braille, large print, audiotape, American Sign Language), should contact the responsible state or local agency that administers the program or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339.

To file a program discrimination complaint, a Complainant should complete a Form AD-3027, USDA Program Discrimination Complaint Form which can be obtained online at: https://www.usda.gov/sites/default/files/documents/ad- 3027.pdf, from any USDA office, by calling (866) 632-9992, or by writing a letter addressed to USDA. The letter must contain the complainant’s name, address, telephone number, and a written description of the alleged discriminatory action in sufficient detail to inform the Assistant Secretary for Civil Rights (ASCR) about the nature and date of an alleged civil rights violation. The completed AD-3027 form or letter must be submitted to USDA by:

1.mail:

U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW

Washington, D.C. 20250-9410; or

2.fax:

(833)256-1665 or (202) 690-7442; or

3.email:

program.intake@usda.gov

This institution is an equal opportunity provider.

Your information may be shared:

• With other WIC programs if you transfer.
• With other public programs that can assist you. You may ask to see a list of these programs.
• As required by law.

I agree to give true and complete information about:

• My identity, pregnancy status, breastfeeding status, address, and phone number.
• My household income.
• The number of people living in my household.
• Being on Medicaid, FoodShare (food stamps), TANF (Temporary Assistance to Needy Families), or FDPIR (FoodDistribution Program on Indian Reservations).

   

I agree to follow the rules below. I will:

• Get benefits from only one WIC clinic each month.
• Report my lost or stolen eWIC card or WIC breast pump to WIC staff.
• Make sure any person I name to use my eWIC card knows the WIC rules. I will teach him or her how to eWIC card correctly. use my
• Keep my WIC appointments or call the clinic to reschedule.
• Use WIC foods and formula only for the person on WIC and make sure the foods go with the person on WIC in cases of joint custody, foster care, etc.
• Not sell, give away, or offer my eWIC card, WIC foods or formula, or breast pump. If I have WIC items I the clinic. can’t use, I will return them to
• Not trade/exchange or return my eWIC card, WIC foods or formula, or breast pump for money, credit, rain checks, or other items.
• Not post WIC items on the internet.
• Follow the rules inthe WIC Shopping Guide.
• Not swear, yell, harass, threaten or physically harm WIC or store staff.
• Not complete my own transaction, except in self-checkout lanes, if I am employed by a WIC authorized store.

Agreement: I must agree to these items to be on WIC:

• All of the information I have given WIC is true. I will tell WIC staff right away if there are any changes.
• WIC can verify my household size and all sources of my household income.
• If I break WIC rules, I, or my child, can be taken off WIC.
• If I lie or hide facts to get WIC foods or do not return a loaned breast pump, I may have to repay WIC the cash value of those items.
• WIC is a federal assistance program. If I break WIC rules, I may be subject to civil or criminal prosecution under state and federal law.

I have read this form, or WIC staff has read this form to me. I understand and agree to the above rules and agreement, and I have received a copy of these rights and responsibilities in the WIC Shopping Guide.