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OMB Number: 0584-XXXX
Expiration Date: 0x/xx/202x
Attachment D Example WIC Waiver Request Template
Responder
Respondent 1
02:05
Time to complete
Waiver Request Details
1. WIC State Agency *
2. FNS Regional Office *
MARO
3.Do you wish to submit a request for a Physical Presence Waiver? [42 U.S.C.
2203(a)(1)(a)] *
Yes
No
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 15 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 aapect of this collection of
information, including suggestions for reducing this burden, to: U.S. Department of Agriculture, Food and Nutrition Service, Office of
Policy Support, 1320 Braddock Place, 5th Fllor, Alexandria VA 22314. ATTN: PRA (0584-xxxx. Do not return the completed form to this
address.
Physical Presence Waiver Request [42 U.S.C. 2203(a)(1)(a)]
Following receipt of a physical presence waiver, a WIC State agency may defer anthropometric
and bloodwork requirements necessary to determine nutrition risk. The Competent Professional
Authority (CPA) should still attempt, to the best of his/her ability, to assess nutrition risk based on
participant-provided and/or referral data, as this remains a statutory requirement for the program.
FNS requests that, within 2 weeks from the date of this request, the WIC State agency provide to
the Regional Office specific details on how it plans to continue operations under the physical
presence waiver, including but not limited to: securing WIC participant confidentiality, following
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rules regarding separation of duty and documentation/recordkeeping in the certification
appointment.
4. Please summarize your request to waive physical presence requirements. *
5. Reason(s) for this Physical Presence request (please check all that apply) *
COVID-19 (general)
State or local travel restrictions
State or local shelter in place (or similar orders)
Other
6. What is the requested end date for this Physical Presence Waiver? *
3/20/2020
7. FNS recommends that all WIC State agencies that submit a Physical Presence
Waiver request also submit an Administrative Flexibilities request to waive 7
CFR 246.12(r)(4).
This waiver will allow for mailing of food instruments or remote loading of EBT
benefits for all WIC participants.
Would you like to submit this waiver request now? *
Yes
No
Administrative Flexibilities Waiver Request: Remote Issuance [42
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U.S.C. 2204(a)(1)]
A WIC State agency may request to modify or waive any qualified administrative requirement
outlined in regulations that cannot be met by a State agency due to COVID-19 or that is necessary
to provide assistance.
To request flexibilities related to the remote issuance of WIC benefits (e.g., mailing of food
instruments, remote loading of EBT cards) (current requirements outlined at 7 CFR 246.12(r)(4)),
please complete the fields below.
8. Please summarize how benefits will be issued/provided to participants. *
9. What is the requested end date for this Remote Issuance Waiver? *
3/20/2020
10. Do you wish to submit a request for an Administrative Flexibilities Waiver
related to WIC food package or medical documentation requirements? [42
U.S.C. 2204(a)(1)] *
Yes
No
Administrative Flexibilities Waiver Request: Food Package [42 U.S.C.
2204(a)(1)]
A WIC State agency may request to modify or waive any qualified administrative requirement
outlined in regulations that cannot be met by a State agency due to COVID-19 or that is necessary
to provide assistance.
To request flexibilities related to food package requirements outlined at 7 CFR 246.10(e)(1-12) and
medical documentation requirements at 246.10(d), please complete the fields below. Please
submit each food item request separately.
11. WIC Food Item: *
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12. Flexibility/Substitution Requested: *
13. Reason(s) for this Food Package request (please check all that apply) *
Low stock
Other
14. What is the requested end date for this Food Package Waiver? *
3/20/2020
15. Do you wish to request flexibilities related to another food item?
Yes, I'd like to add another food item.
No, I'm finished with this section.
16. Do you wish to submit a request for an Administrative Flexibilities Waiver
related to minimum stocking requirements (MSRs) for WIC vendors? [42 U.S.C.
2204(a)(1)] *
Yes
No
Administrative Flexibilities Waiver Request: Minimum Stock [42 U.S.C.
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2204(a)(1)]
A WIC State agency may request to modify or waive any qualified administrative requirement
outlined in regulations that cannot be met by a State agency due to COVID-19 or that is necessary
to provide assistance.
A WIC State agency may update its minimum stocking requirements (MSRs) at any time, as long
as the MSR meets the federal mimimum requirements outlined at 7 CFR 246.12(g)(3)(i). To request
to a waiver from these requirements, please complete the fields below.
17. Please summarize your request to waive federal minimum stocking
requirements. *
18. Reason(s) for this Minimum Stocking Requirements request (please check all
that apply) *
Low Stock
Other
19. What is the requested end date for this Minimum Stocking Requirements
Waiver? *
3/20/2020
20. Do you wish to submit a request for an Administrative Flexibilities waiver for
another purpose, not already specified? [42 U.S.C. 2204(a)(1)] *
Yes
No
Other Administrative Flexibilities Waiver Request [42 U.S.C. 2204(a)
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(1)]
A WIC State agency may request to modify or waive any qualified administrative requirement
outlined in regulations that cannot be met by a State agency due to COVID-19 or that is necessary
to provide assistance.
If requesting a flexibility not previously covered in this template, please indicate the specific
flexibility being requested (including the regulatory citation), the reason(s) for the request, and
estimated period of flexibility in the fields below.
21. Please summarize your waiver request. *
22. Relevant Regulation(s): *
Please enter citation(s) you request to be waived, related to the above request.
23. Reason(s) for this request: *
24. What is the requested end date for this waiver? *
3/20/2020
25. Do you wish to submit an additional Administrative Flexibilities Waiver
request? *
Yes, I'd like to add another.
No, I'm finished with all requests.
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Submitter Information
As a reminder, these requests may only be submitted by State agency WIC Directors.
Once submitted, you will receive email confirmation of your request.
26. Full Name: *
27. Title: *
28. Email Address: *
Please ensure that the email address entered is correct. A confirmation email outlining your
submission will be sent to this address.
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| File Type | application/pdf |
| File Modified | 2020-05-01 |
| File Created | 2020-03-20 |