F-44324 (Rev. 03/2017) Page 4 of 4

VENDOR PRE-AUTHORIZATION SITE VISIT REPORT

WISCONSIN WIC PROGRAM

Applicant – Vendor Number / Date – Site Visit
Applicant – Store Name / Local WIC Project Number / Vendor Trade Area
/
Applicant – Street Address / Site Visit Result
Pass (No Violations) Pass (Violations) – CAP/Warning Letter Pass – Violations/Warning Letter/Corrective Action Plan
Abbreviated Denial – CAP/Vendor may request a second site visit
Fail – Six Month Disqualification
Applicant – City, Zip Code

INSTRUCTIONS:

Review vendor site visit procedures in the WIC Operations Manual section 7.3 and WIC Vendor Manual (P-44537), and review the Project Guidance—Pre-Authorization Site Visit and Authorization Training document prior to completing the pre-authorization site visit. All reference materials are located on WICShare under “Vendor.”

Thoroughly answer all questions and record all findings on this document at the time of the pre-authorization site visit. All violations must be documented. Contact the Vendor Authorization Manager after minimum stock review for further guidance regarding the authorization.

If the vendor is approved for authorization, conduct authorization training and complete a Training Proof of Participation form (F-44727).

Only complete “Section II: Corrective Action Plan” (Page 4 of this form) if violations are found.

“Section III: Acknowledgements and Signatures” MUST be signed by the Vendor and WIC Representative REGARDLESS of the results of the site visit.

All pre-authorization site visit documents and forms must be completed and mailed to the State WIC office within 10 days of the site visit.

IMPORTANT:

Immediately following the store inspection and PRIOR TO CONDUCTING AUTHORIZATION TRAINING, contact the WIC Vendor Authorization Manager at 608-261-9438. If the Vendor Authorization Manager is unavailable, contact the WIC Vendor Unit at 608-266-6912.

REMINDERS:

§  The State WIC Vendor and Integrity Unit will be in communication with both the local WIC agency and vendor to schedule the date and time of the site visit.

§  If a vendor contacts the local WIC agency prior to the pre-authorization site visit, they should be referred to contact the State WIC Vendor and Integrity Unit at 608-266-6912.

§  The Pre-Authorization Site Visit Report should document current conditions at the store. Attempts by the vendor to correct problems identified during the site visit should not be considered or noted (e.g., if expired cereal is removed from the shelf during the visit, report the expired WIC foods that were found).

§  Only food in the customer area of the store (on shelves or in coolers) and within the expiration date may be counted as part of the minimum stock requirement. Infant formula may be counted if it is stored in a secure location AND there is a sign indicating to customers the price and where it is located in the store.

SECTION I: SITE VISIT DETAILS
A. GENERAL OBSERVATIONS
If additional space is needed, use a separate page and attach to the site visit form.
Yes No / Do you have reason to believe that false information was provided on the application?
If YES, specify which information:
Yes No / Does the store appear to be in violation of any health protection laws or ordinances (ex., inadequate refrigeration; unclean store; no screens on open windows and/or doors; etc.)? If YES, describe. Be specific regarding your observations so an accurate referral can be made:
Yes No / Are there any indications the store is scanning UPC codes from a codebook or reference sheet? If YES, explain:
Yes No / Are there any eWIC cards on the vendor’s premises? If YES, confiscate the card(s) and mail to the WIC Vendor and Integrity Unit. Provide the store with a Receipt for Confiscated eWIC Cards (F-01474).
Yes No / Are there any indications that a disqualified person is involved in the operation of the store?
If YES, please describe the indicators (e.g., the disqualified person was in the store at the time of the visit, reports have been received from participants or other storeowners, etc.). If the disqualified individual was in the store at the time of the visit, provide the name of that individual and describe what the individual was doing at the time of the visit.
Name – Disqualified Individual:
Details:
B. PRICES
If additional space is needed, use a separate page and attach to the site visit form.
Yes No / Are all WIC food prices marked on containers or posted near the shelf in the customer area of the store? If NO, list each food by brand name, variety, and size; and number of containers.
FOOD BRAND, VARIETY, SIZE / NUMBER OF CONTAINERS
1.
2.
3.
4.
5.
6.
C. OUTDATED WIC FOODS
If additional space is needed, use a separate page and attach to the site visit form.
Yes No / Are all WIC foods within the expiration date and fresh? If NO, record each food brand name, variety, and size; number of containers; and expiration date or description of freshness issue.
FOOD BRAND, VARIETY, SIZE / NUMBER OF CONTAINERS / EXPIRATION DATE OR
ISSUE DESCRIPTION
1.
2.
3.
4.
5.
6.
D. MINIMUM STOCK REVIEW
FOOD ITEM
/ MINIMUM STOCK REQUIREMENT
Foods must be within the expiration date and in the customer area of the store (on shelves or in coolers) in order to be counted towards minimum stock requirements. / MINIMUM STOCK IN CUSTOMER AREA? / VARIETY AND QUANTITY AVAILABLE
List all food varieties counted towards minimum stock. Only list quantities if less than minimum stock requirement.
Milk / § 8 gallons, unflavored 1% or skim (low fat or fat free); AND
§ 3 gallons, unflavored whole (Vitamin D); AND
§ 3 half-gallons, unflavored 1% or skim. / Yes No
Yes No
Yes No
Eggs / § 4 one-dozen cartons, white only, any size, any grade. / Yes No
Whole
Grains / § 6 packages, 16 oz. each, any combination of:
100% whole wheat bread, buns or rolls, OR
soft corn or whole wheat tortillas, OR
whole wheat pasta; OR
brown rice (14-16 oz. box, bag, or frozen prepared). / Yes No
Cereal / At least 2 varieties and 6 boxes must be whole grain,
marked on WIC Approved Food List:
§ 20 boxes, 12 oz. boxes or larger; minimum 4 varieties
(hot or cold). / Yes No
Juice / § 9 containers, 64 oz., 3 flavors; AND
§ 8 containers, 48 oz., 2 flavors; AND
§ 4 containers, 11.5 - 12 oz. frozen concentrate; one flavor. / Yes No
Yes No
Yes No
Cheese / § 4 packages, 16 oz. each, one variety. / Yes No
Fruit and Vegetable / § $28 total retail value; AND $10 of the total retail value must be from fresh fruit and vegetables; AND
§ Fruit – 5 varieties fresh, frozen or canned; 2 varieties must be fresh (not including lemons and limes); AND
§ Vegetables – 5 varieties fresh, frozen, or canned - 2 varieties must be fresh (not including onions, garlic, and ginger). / Yes No
Yes No
Yes No
Peas/Beans
Lentils (dry) / § 4 pounds total; two 16 oz. bags each of 2 varieties. / Yes No
Canned Beans / § 16 cans, 15 -16 oz.; 3 varieties. / Yes No
Peanut
Butter / Any brand, creamy, crunchy, extra-crunchy or natural,
low sodium/salt, reduced/no sugar:
§ 4 containers, 16 -18 oz., one variety / Yes No
Infant Fruit and Vegetable / Any brand; 4 oz. containers (Gerber® 8 oz., 2-pack is equal to two containers); plain or mixtures of fruits and vegetables:
Stores with 4 or less registers (count all registers):
§ Fruit – 30 containers; 3 varieties; AND
§ Vegetable – 30 containers; 3 varieties. / Yes No
Yes No
Stores with 5 or more cash registers (count all registers):
§ Fruit – 60 containers; 6 varieties; AND
§ Vegetable – 60 containers; 6 varieties. / Yes No
Yes No
Infant Meats / Only stores with 11 or more cash registers must carry:
§ 24 containers, 2.5 oz.; 2 varieties. / Yes No
Infant Cereal / § 6 containers, 8 oz.; 2 varieties. / Yes No
Infant
Formula / Good Start® Gentle only:
§ 18 cans, 12.7 oz., powder only. / Yes No
SECTION II: CORRECTIVE ACTION PLAN (if applicable) Not Applicable
WIC Program Violation(s) / Vendor Identified Corrective Actions
Failed to maintain minimum stock requirements / Increase stock level and shelf space for WIC foods.
Increase delivery frequency on WIC foods.
Train store personnel on minimum stock requirements.
Other (describe):
Failed to post prices on or near WIC Foods in customer area of the store / Routinely monitor WIC foods to verify prices are attached to WIC food items or posted on or near the food items.
Assign a staff member to regularly verifying that prices are attached to WIC food items or posted on or near the food items.
Other (describe):
Stocked authorized foods that were out of date or otherwise not fresh / Routinely monitor expiration dates and train store personnel on product date coding and product rotation.
Assign a staff member to regularly inspect all WIC foods.
Other (describe):
Posted prices significantly higher than those submitted with application, or highest priced items were not submitted with the application. / Set a baseline markup for each product type.
Consistently apply the markup if distributor increases prices.
Other (describe):
Possible health code violation(s) (describe): / Routinely monitor temperatures in coolers and freezers.
Repair broken cooling and/or freezing units.
Remedy insect or rodent issues.
Other (describe):
Other (describe): / Other (describe):
SECTION III: ACKNOWLEDGEMENTS AND SIGNATURES Completion of this section is required.
Vendor Representative:
The results of the site visit have been discussed with me.
I understand it is my responsibility to correct any/all violations and to ensure store personnel are trained and comply with WIC Program rules and regulations. I further understand that violations found on two or more occasions during a 12-month period may result in termination from the WIC Program.
(If applicable) I understand the store was not authorized as a result of the pre-authorization site visit and was notified that the WIC Vendor Authorization Manager will mail me further information concerning whether I may request a second site visit or if the store is subject to a disqualification period. / WIC Representative:
I have reviewed and completed all areas of the Pre-Authorization Site Visit Report and have conducted vendor training for all violations found.
If violations were found, the vendor was notified that violations found on two or more occasions during a 12-month period may result in termination from the WIC Program.
(If applicable) The vendor was not authorized as a result of the pre-authorization site visit. The vendor was notified that the WIC Vendor Authorization Manager will mail them further information notifying them whether they may request a second site visit or if there will be a disqualification period.
Vendor Representative – Type or Print Name / WIC Representative – Type or Print Name
Vendor Representative – Title/Position
Owner Manager Cashier / WIC Representative – Title/Position
Date Signed / Date Signed
SIGNATURE – Vendor Representative / SIGNATURE – WIC Representative