State and Local WIC Agency Directors (SLT)

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Overview

Denied Applicant Log
Definitions

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Sheet 1: Denied Applicant Log

Appendix B7.b Denied Applicant Log

OMB Number: 0584-XXXX

Expiration Date: XX/XX/XXXX

[INSERT LOCAL AGENCY NAME, CITY, STATE]

APPLICANT LAST NAME

APPLICANT FIRST NAME

DOB

APP_ID

STREET ADDRESS

APT

CITY

STATE

ZIP

PHONE NUMBER

ALTERNATE PHONE NUMBER

PREFERRED LANGUAGE

TARGET PARTICIPANT LAST NAME

TARGET PARTICIPANT FIRST NAME

REASON DENIED 1

REASON DENIED 2

REASON DENIED 3

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0584-XXXX. The time required to complete this information collection is estimated to average 35 minutes (0.58 hours) per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: U.S. Department of Agriculture, Food and Nutrition Services, Office of Policy Support, 3101 Park Center Drive, Room 1014, Alexandria, VA 22302, ATTN: PRA (0584-xxxx*). Do not return the completed form to this address.

Privacy Act Statement Authority: Code of Federal Regulations. §215.11 requires State and local WIC agency directors to cooperate in the conduct of studies and evaluations. Purpose: Information is collected primarily for use by the Food and Nutrition Service in the administration and evaluation of Special Supplemental Program for Women, Infants and Children. Routine Use: FNS published a system of record notice (SORN) titled FNS-8 USDA/FNS Studies and Reports in the Federal Register on April 25, 1991, volume 56, pages 19078-19080, that discusses the terms of protections that will be provided to respondents. Disclosure: Your participation in this data collection request is mandatory; however, you will not be penalized for non-participation.

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Sheet 2: Definitions

Field	Definition
APPLICANT LAST NAME	Applicant's Last Name
APPLICANT FIRST NAME	Applicant's First Name
DOB	Date of Birth
APP_ID	Internal ID for Applicant
STREET ADDRESS	Street address for applicant
APT	Apartment Number
CITY	City for the street address
STATE	State for the streent address
ZIP	Zip Code for the street adress
PHONE NUMBER	Best phone number
ALTERNATE PHONE NUMBER	Alternate phone number if applicant can provide one
PREFERRED LANGUAGE	Only list if not English
TARGET PARTICIPANT LAST NAME	Last name of potential participant if different than applicant
TARGET PARTICIPANT FIRST NAME	First name of participant if different than applicant
REASON DENIED 1	Reason applicant denied
REASON DENIED 2	Reason applicant denied
REASON DENIED 3	Reason applicant denied