Participant Comment Form- WIC Food or Product

Food/Product Comment Section

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* 1. Store Name and Location

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* 2. Select the food package you are currently prescribed. Please check all that apply.

Pregnant woman

Breastfeeding woman

Breastfeeding infant

Postpartum woman

Formula fed infant

Child 12-24 months

Child 2-4

Not Sure

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* 3. If you had an issue with your particular food package, or specific benefit on your eWIC benefit card, please explain here.

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* 4. Did you have an issue with a specific food(s) or product(s) at the vendor location listed above? If yes, please list here. If no, leave blank.

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* 5. If you have any other comments or details about this food or product please leave those here.