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Local Agency Data Request
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Name *
Title *
Agency *
Email address *
Date data is needed by (please allow a minimum for 2 weeks for most requests. Mandatory audit requests can be completed sooner if needed, while complex requests may take longer): *
MM
/
DD
/
YYYY
Report Description: (Provide a specific description of the data needed. Include specifics such as whether you need FIDs, PIDs, names, participant category, WIC Status, NRFs, etc. if applicable) *
How will this information be used? *
Date range requested (ex. data from August 2019 to August 2020) *
Have you requested this information before? *
Business reason for request *
Who will have access to the data? *
Will the data be shared outside of the WIC program? *
If data will be shared outside of the WIC program, with whom will it be shared? *
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