TO RECEIVE WIC, I AGREE TO:
- Show proof of income, address, and identification.
- Give information about my (or my child’s) medical history and the foods I (or my child) eat.
- Have my (or my child’s) height, weight, and blood checked (finger or heel prick).
I WILL:
- Give information to WIC that is true and correct to the best of my knowledge. WIC staff may verify this information.
- Call the WIC office right away if I lose my eWIC card or someone steals it.
- Only buy WIC-authorized foods with my eWIC card.
- Let the WIC staff know if I can’t keep my appointment or if my phone number or address changes.
- Be removed from the program if I do not receive food benefits for two months in a row.
- Treat WIC staff and grocery store staff with respect.
I UNDERSTAND:
- Everyone applying for the program is treated the same regardless of race, color, national origin, age, handicap, or sex.
- I have the right to make a complaint if I feel I have been treated unfairly.
- I have a right to a fair hearing if I disagree with the WIC staff about my eligibility (within 60 days).
- WIC will make health services, nutrition education, and breastfeeding support available to me, and I am encouraged to participate in these services.
- The WIC foods are intended for me and/or my child and should not be shared with others.
RELEASE OF INFORMATION:
I understand that the State Health Officer allows some of my or my child’s information to be shared with other programs that serve similar families as WIC. This is to make it easier for my family to receive other services if I choose (like to see if I’m eligible and reduce the application process), to help me learn more about these programs and to help improve my family’s health, education and well-being. I will allow WIC to share information (only name, birth date, address, phone number, income, height, weight, hemoglobin, immunization status, and appointment times) about me or my child with these programs. I understand that some WIC health data may be used to evaluate how well the WIC program and the North Dakota Health & Human Services are meeting participants’ health care needs. I’ve been asked by WIC staff about whether or not I consent to disclose information to my healthcare provider. This information is recorded on the Nutrition Interview in the WIC system, eWIC LegeNDS. My consent or denial (yes or no) does not affect my WIC eligibility. No other information can be given to anyone without my permission.
I have read my Rights and Responsibilities. I realize that WIC is a Federal program and if I lie or hide facts to get WIC benefits, sell, exchange, or give away my WIC foods or formula, miss coming to WIC two months in a row, participate in more than one WIC program in any one month (dual participation is illegal), or I am physically or verbally abusive to WIC staff or store staff, I can be taken off the program and may be required to pay back the value of the food issued to me and may be prosecuted under Federal and State law. If you do not like the decision about your eligibility for the WIC Program, you may ask for a fair hearing.
USDA NONDISCRIMINATION STATEMENT:
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.
12/09/2022
Spanish Version:
