WIC Participant Complaint Form

Name of WIC Participant

(First)

(Last)

WIC Participant ID

(if available)

WIC Participant’s Gender

Male

Female

List all WIC Participants in the Family

(Please list names and WIC participant ID Numbers (if available))

WIC Participant Address

(if available)

City

State

Zip Code

WIC Participant Telephone Number

(Please enter the phone number in XXX-XXX-XXXX format.)

In the box below, please provide a description of the complaint against the WIC participant or caregiver. Be sure to include the important details such as names of persons involved and dates if available.

Have you ever filed a complaint against this WIC Participant/Caregiver?

Yes

WIC Participant Or Caregiver Complaint Description:

Date of Incident:

Time of Day of Incident ( if applicable)

(Time Format Example: 2:00 pm)

You are able to file a WIC Participant/Caregiver complaint anonymously, but if you would like the WIC State Agency to contact you, please complete the fields below:

Name

Telephone Number

E-Mail Address

Accessibility