State WIC Agency Officials (2020 and 2022)

Appendix J.
Contact Request Form

PC2018 State Agency Contacts

Dear WIC State Agency Director,

Insight Policy Research would like to ensure we have the most updated contact information for each State agency. Please complete the information below and return this form by January XX, 20XX. Email to [email protected].

1. State Agency:

2. WIC Director:  

Name:

Title/Position:

Phone:

Email:

3. Alternate contact, if not the Director: Another person who can provide information if the Director is not available.

Name:

Title/Position:

Phone:

Email:

Do you want this person copied on all communications? Yes No

4. Information technology contact for PC2018: Responsible for technical communications regarding PC2018. We will contact this person on technical issues regarding submissions.

Name:

Title/Position:

Phone:

Email:

Indicate if: State agency employee  

This information is being collected from State agencies to enable the Food and Nutrition Service (FNS) to prepare biennial reports on WIC participant and program characteristics. This is a mandatory collection authorized under 7 CFR §246.25(b)(3).  FNS uses the data from these reports to estimate budgets, submit civil rights reporting, identify needs for research, and to develop and review WIC policies and procedures.  Under the Privacy Act of 1974 and the System of Record Notice FNS-8 USDA/FNS Studies and Reports, any personally identifying information obtained will be kept private to the extent of the law.  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 0584-0609. The time required to complete this information collection is estimated to average 6 minutes 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 (0584-0609*). Do not return the completed form to this address.

Contractor or consultant. If contractor, specify company: _______________

Should the main contact be copied on all technical communications? Yes No

5. Nutritionist contact for PC2018: Responsible for Nutritional Risk and Food Package Coding information.

Is the person the same as alternate contact? Yes No (if no, please complete fields below)

Name:

Title/Position:

Phone:

Email: