Welcome to the State of California 

WIC Forms

  • 2012-2014 Funding Application 
  • CDPH 4125 (PDF) Opens a new browser windowReport Concerning Vendors for Local Agency and Participant Use
  • Certification for Computing Media Sanitation (PDF) Opens a new browser window
  • Request for WIC Site Approval Form (PDF)Opens a new browser window
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    Office of State Publishing (OSP) Order Forms

    For California Local WIC Agencies ONLY

    NOTE: If you did not receive the automatic email response "Your WIC order has been received", please read the updated Instructions (PDF)"Opens a new browser window". You may need to resubmit your order using another method.

  • 513 Prenatal, Postpartum, and Breastfeeding Materials (PDF)"Opens a new browser window"
  • 514 General Nutrition and Health Information (PDF)"Opens a new browser window"
  • 515 Orientation Materials (PDF)"Opens a new browser window"
  • 516 Infant Materials (PDF)"Opens a new browser window"
  • 517 Children Materials (PDF)"Opens a new browser window"
  • 518 Outreach Materials (PDF)"Opens a new browser window"
  • 519 Food Package Materials (PDF)"Opens a new browser window"
  • 520 Clearinghouse Materials (PDF)"Opens a new browser window"
  • 522 Campaigns (PDF)"Opens a new browser window"
  • 524 Administrative Materials (PDF)"Opens a new browser window"
  • 526 Local Vendor Liason (LVL) Materials (PDF)"Opens a new browser window"
  • 527 Magazines (PDF)"Opens a new browser window"
  • Note:  WIC Vendor Materials Form - OSP 508 has been moved to Grocer Vendor Resources.

     

    California Department of Public Health (CDPH) Forms

  • CDPH 4007 (PDF) "Opens a new browser window"Vendor Report Concerning WIC Participants
  • 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) "Opens a new browser window"| Spanish Notice of Action Affecting WIC Program Participation
  • CDPH 4476 (PDF)"Opens a new browser window"Participant Abuse Report
  • CDPH 247A, Half Sheet (PDF)"Opens a new browser window"Full Sheet (PDF)"Opens a new browser window"Referral for Infant and Child 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 4159 (PDF, English/Spanish)"Opens a new browser window"Infant Birth-3 Months
  • CDPH 4160 (PDF, English/Spanish)"Opens a new browser window"Infant 4-11 Months | Armenian, | Chinese, | Hmong, | Russian, | Vietnamese
  • CDPH 4161 (PDF, English/Spanish)"Opens a new browser window"Child 1-4 Years
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    Last modified on: 4/2/2014 3:08 PM