Wic Program Complaint Form
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1
2WIC Program Complaint Form
Local agencies and vendor management agencies must respond to all reported complaints involving WIC
participants, WIC store owners or employees, or WIC staff. Refer suspected WIC Program fraud or abuse using
the Bureau of Special Investigations Referral Form.
Record all pertinent information related to the Participant/Vendor Complaint in the space below. Anonymous
informants who do not wish to be contacted must be asked to provide as much information as possible.
Individual Taking Complaint
Name
LA/VMA Name
Email
Phone #
(
)
Informant/Caller Information
Does Informant/Caller wish to
☐ Yes ☐ No
Name
remain anonymous?
Street
City/Town
State
Zip
Address
Email
Phone #
(
)
Complaint Information
Complete Relevant Information Based on the Subject of the Complaint
☐ WIC Local Agency/WIC Vendor
☐ Vendor/Store/Store Employee
Subject of the Complaint
Management Agency/WIC Staff
(Who/What is the complaint
about?)
☐ WIC Participant
☐ Other
Date Complaint Received
Date(s) of Incident
WIC Vendor/Store/Store Employee Information
Store Name
Street
City/Town
State
Zip
Store Address
Phone #
(
)
Vendor #
Store Owner’s Name
Store Employee Name
WIC Participant Information
Participant
Name
Street
City/Town
State
Zip
Participant
Address
ID #
Phone #
(
)
DOB
WIC Local Agency/WIC Vendor Management Agency/WIC Staff
LA/VMA Name
Staff Name
12/2016
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Parent category: Legal