Health.mo.gov



| | |

| |MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES |

| |WIC AND NUTRITION SERVICES |

| | |

| |WIC 6 – DHSS Additional Nutrition & Health Resource Request Form |

|AGENCY NAME |AGENCY / CLINIC NO. |CONTROL NO. (DHSS WAREHOUSE USE) |

|      |      | |

|REQUESTER’S NAME (PLEASE TYPE or PRINT) |REQUESTER’S PHONE NO. |DATE |

|      |      |      |

|Titles |Item No. |Quantity |Unit |Titles |Item No.|Quantity |Unit |

| | |Ordered | | | |Ordered | |

|12345 Fit-Tastic Literature (Developed by Children Mercy Hospital) |Substance Abuse Literature* (Bureau of Genetics and Healthy Childhood) |

|Fit-Tastic, Physical Activity (EN) |767 | |50/pkt |Have A Healthy Pregnancy… Don't Drink (EN) |287 | |EACH |

|Fit-Tastic, Screen Time (EN) |779 | |50/pkt |Have A Healthy Pregnancy... Don't Drink (SP) |711 | |EACH |

|Fit-Tastic, Low Milk OR Yogurt (EN) |780 | |50/pkt |Have A Healthy Pregnancy… Don't Smoke (EN) |697 | |EACH |

|Fit-Tastic Water & Sugary Drinks (EN) |781 | |50/pkt |Have A Healthy Pregnancy… Don't Smoke (SP) |707 | |EACH |

|Fit-Tastic, Fruits & Veggies (EN) |783 | |50/pkt |Pregnancy & Drugs |330 | |EACH |

|Fit-Tastic, Healthy Habits (EN) |786 | |50/pkt |Pregnancy And Marijuana |408 | |EACH |

|Fit-Tastic Message Card (EN) |787 | |50/pkt |Pregnancy And Meth |328 | |EACH |

|Fit-Tastic- Tracker (EN) |789 | |50/pkt |Preventing Fetal Alcohol Syndrome, (FAS) |400 | |EACH |

|Fit-Tastic, Physical Activity (SP) |929 | |50/pkt |Pregnancy And Meth |328 | |EACH |

|Fit-Tastic, Screen Time (SP) |932 | |50/pkt |Secondhand Smoke And Baby (EN) |390 | |EACH |

|Fit-Tastic Lowfat Milk OR Yogurt (SP) |942 | |50/pkt |Secondhand Smoke And Baby (SP) |708 | |EACH |

|Fit-Tastic, Water & Sugary (SP) |945 | |50/pkt |Secondhand Smoke And Kids (EN) |1199 | |EACH |

|Fit-Tastic, Fruits & Veggie (SP) |946 | |50/pkt |Secondhand Smoke And Kids (SP) |709 | |EACH |

|Fit-Tastic Healthy Habit (SP) |947 | |50/pkt |Newborn Health Literature* (Bureau of Genetics and Healthy Childhood) |

|Fit-Tastic Message (SP) |950 | |50/pkt |Safe Sleep Magnet |677 | |EACH |

| | | | |Safe Sleep Message Card |674 | |EACH |

|Low Fat Milk & Yogurt Recipe Cards (Developed by the Midwest Dairy Council) |Prenatal & Newborn Screening Pamphlet |442 | |EACH |

|Dairy Makes Sense (low Fat milk) (EN) |817 | |50/pkt |10 Ways To Be A Better Dad (EN) |531 | |EACH |

|Dairy is a local food (EN) |819 | |50/pkt |Tel-Link Brochure (EN) |55 | |EACH |

|Cereal + Milk = Yum! (EN) |820 | |50/pkt |Tel-Link Brochure, (SP) |746 | |EACH |

|Cheese Please! (EN) |823 | |50/pkt |Vitamin K Message Card |410 | |EACH |

|Go for yogurt! (EN) |814 | |50/pkt |Keeping Your Baby Safe And Healthy |338 | |EACH |

|Go for yogurt! (SP) |832 | |50/pkt |Keeping Your Baby Safe And Healthy (SP) |706 | |EACH |

|Dairy Makes Sense (low Fat milk) (SP) |836 | |50/pkt |Postpartum Depression More Than The Blues (EN) |86 | |EACH |

|Dairy Makes Sense (low Fat yogurt) (SP) |837 | |50/pkt |Postpartum Depression More Than the Blues (SP) |195 | |EACH |

|Dairy is a local food (SP) |839 | |50/pkt |Pregnancy And Beyond (EN) |1081 | |EACH |

|Cereal + Milk = Yum! (SP) |841 | |50/pkt |Pregnancy And Beyond (SP) |1082 | |EACH |

|Cheese Please! (SP) |843 | |50/pkt |Safe Sleep Magnet |677 | |EACH |

|Hepatitis Literature* (Bureau of HIV, STD, and Hepatitis) |Safe Sleep Message Card |674 | |EACH |

|Pregnant & Hepatitis B Positive Brochure |368 | |EACH |Prenatal & Newborn Screening Pamphlet |442 | |EACH |

|Stop Liver Cancer-Hepatitis |454 | |EACH |Newborn Hearing Screening Poster |202 | |EACH |

|Diet And Liver Brochure |371 | |EACH |Newborn Hearing Screening |431 | |EACH |

|Hepatitis B & Mothers To Be |190 | |EACH |Missouri New Born Screening |14 | |EACH |

|*Limit 50/month | | | | | | | |

|Please fax this form to the DHSS Warehouse at 573-751-1574. |

|If you have questions contact Takako Tagami at 1-800-392-8209 or email to takako.tagami@health. |

MO 580-0282 (01/26/15) USDA is an equal opportunity provider and employer WIC 6

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For Local WIC Provider Use Only

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