As a Vermont Women, Infants, and Children (WIC) Program participant, I understand the following:
1. WIC Certification periods vary by participant type:
a. pregnant women, until six weeks post-partum;
b. infants/breastfeeding women, through the month of the infant’s first birthday;
c. children, for twelve-month periods up to age five years; and
d. non-breastfeeding women, through six months postpartum.
2. When my and/or my child(ren)’s certification period ends, WIC Program benefits also end.
3. I will receive information about nutrition and health, including nutrition education, breastfeeding support, WIC foods, and referrals to other health services.
4. To continue my WIC benefits, attend all certification and nutrition education appointments.
5. I have the right to have information I give to the WIC program treated as confidential.
I understand that WIC participant information may be shared with the following programs: Home Visiting Programs, Foster Parent Services, Immunizations, and Pregnancy Risk Assessment Monitoring System (PRAMS). My electronic signature at WIC Program certification serves as a release of information for this information sharing. A separate Release of Information is required for WIC to share information with any other entity.
6. The Vermont Commissioner of Health may authorize use and disclosure of information about my participation in WIC for non-WIC purposes. Such information will be used by state and local WIC offices and the programs listed above ONLY for program administration, coordinating benefits with other programs and improving WIC services and activities.
7. Race/ethnicity information is collected for statistical reporting requirements only and does not affect my participation in the WIC Program. Standards for eligibility and participation in the WIC Program are the same for everyone, regardless of race, color, national origin, age, handicap, or sex (including gender identity and sexual orientation).
8. WIC staff may verify information I have provided. If I provide false information, I may not get WIC benefits; I may have to pay back money for WIC foods already purchased; and I may be prosecuted under state and federal law.
9. If I move out of Vermont I can request a Verification of Certification (VOC) to access WIC benefits in the new state.
WIC Program Participant Rights:
If I disagree with any decision that affects my WIC eligibility or benefits, I have sixty (60) days from the date of notice to file an appeal and ask for a fair hearing to present the reasons for objection by me or by my representative(s), such as a relative/friend/legal counsel or other spokesperson(s).
Information to request a fair hearing may be obtained from any local WIC office or from the State WIC Office at: Vermont Department of Health, WIC Program, 108 Cherry Street, PO Box 70, Burlington, VT 05402-0070. You may also call us to request a hearing at 1-800-649-4357.
Continuation of benefits may be requested pending the outcome of the fair hearing appeal. The request must be filed within 15 days from the date of my Notice of Ineligibility. However, no benefits can be continued beyond a participant’s certification period.
WIC is an equal opportunity program. If I believe I have been discriminated against because of race, color, national origin, sex (including gender identity and sexual orientation), age or disability, I may contact the Secretary of Agriculture, Washington, DC, 20250 directly, or request assistance from the WIC staff to do so.
WIC Program Participant Responsibilities:
1. To avoid loss of WIC benefits, I must attend all WIC appointments.
2. If I cannot make a WIC appointment, I will call in advance to reschedule. If I miss a recertification or nutrition education class, WIC benefits may be reduced.
3. I will notify WIC staff when I change my address or move to a different city or state so my WIC can be transferred to a different district or state.
4. WIC foods are for the participating family member. I will not sell or give my WIC benefits to anyone else and will contact WIC if I need to change my food benefits.
5. All formula/medical food exchanges must take place at the WIC office. Any unused infant formula must always be returned to the WIC office.
6. I will keep my WIC card in a safe place, and I will not give my personal identification number to anyone except someone who will make WIC purchases as my additional head of household or proxy.
7. If my Vermont WIC card is lost or stolen, I will report this to the WIC office immediately. I understand that it is possible the current month’s benefits will not be replaced.
8. I understand that WIC benefits are to be purchased only at WIC authorized stores within the month designated and consumed by the participant for whom they were issued, and that unused benefits do not carry over to future months.
9. I am responsible for training my additional head of household or proxy to use the card at the store.
10. I am responsible to ensure that my alternate shopper adheres to these same responsibilities.
Disqualification, suspension, prosecution, and cash recovery may occur for:
A. Misuse of WIC benefits such as exchanging/selling or intending to sell the Vermont WIC card or food items purchased with WIC benefits verbally, in print, online, or by any other method for cash, credit, or non-food items;
B. Purchasing/receiving foods not on the WIC Approved Foods List;
C. Physical abuse, threat of physical abuse, or verbal abuse to WIC or grocery store staff.
The financial and eligibility information I have provided is true to the best of my knowledge including household income, number of household members, address, identification documentation, and information regarding health and nutritional status. I will notify WIC staff immediately of any changes. By providing my electronic signature in the VT WIC Ceres system, I confirm the following:
1. My acceptance and knowledge of the statements above;
2. I have been advised of, understand, and have read and been offered a copy of the VT WIC Program Participant Rights and Responsibilities and the Notice of Privacy Practices.
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex (including gender identity and sexual orientation), disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA. Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.
To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:
(1) Mail: U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW
Washington, D.C. 20250-9410
(2) Fax: (202)690-7442; or
(3) Email: firstname.lastname@example.org
This institution is an equal opportunity provider.