THIS SECTION FOR WIC OFFICE ONLY Follow-up action taken: ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ Date taken: ____________________ By whom: __________________________________________ Return this form: Via email at Via fax at 317-233-5609
THIS SECTION FOR WIC OFFICE ONLY Follow-up action taken: ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ Date taken: ____________________ By whom: __________________________________________ Return this form: Via email at Via fax at 317-233-5609