Appendix S. WIC Waiver Request Form

Attachment S. WIC Waiver Request Form

Responder

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Respondent 1

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OMB 0584-0654; exp. 11/30/2020
This information is being collected to assist the Food and Nutrition Service in
managing information collection due to COVID-19. This is a voluntary
collection and FNS uses the information to approve waivers and collect data
on their use. This collection does not request any personally identifiable
information under the Privacy Act of 1974. 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 0584-0654. The time required to complete this
information collection is estimated to average 0.25 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
Service, Office of Policy Support, 1320 Braddock Place, 5th Floor, Alexandria,
VA 22306 ATTN: PRAO. Do not return the completed form to this address.

Waiver Request Details
1. WIC State Agency *

2. FNS Regional Office *
MARO

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3. Do you wish to submit a request for a Physical Presence Waiver? [42 U.S.C.
2203(a)(1)(a)] *
Yes
No

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

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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
https://forms.office.com/Pages/DesignPage.aspx#Analysis=true&FormId=5zZb7e4BvE6GfuA8-g1Glxr0hgipP7RKs_Si3XcoLKhUM08wUkIyMFQ2…

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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

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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: *
https://forms.office.com/Pages/DesignPage.aspx#Analysis=true&FormId=5zZb7e4BvE6GfuA8-g1Glxr0hgipP7RKs_Si3XcoLKhUM08wUkIyMFQ2…

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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

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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.
https://forms.office.com/Pages/DesignPage.aspx#Analysis=true&FormId=5zZb7e4BvE6GfuA8-g1Glxr0hgipP7RKs_Si3XcoLKhUM08wUkIyMFQ2…

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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

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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)
https://forms.office.com/Pages/DesignPage.aspx#Analysis=true&FormId=5zZb7e4BvE6GfuA8-g1Glxr0hgipP7RKs_Si3XcoLKhUM08wUkIyMFQ2…

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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

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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.

https://forms.office.com/Pages/DesignPage.aspx#Analysis=true&FormId=5zZb7e4BvE6GfuA8-g1Glxr0hgipP7RKs_Si3XcoLKhUM08wUkIyMFQ2…

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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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