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Local Agency Data Request
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Name
*
Your answer
Title
*
Your answer
Agency
*
Your answer
Email address
*
Your answer
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):
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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)
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Your answer
How will this information be used?
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Your answer
Date range requested (ex. data from August 2019 to August 2020)
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Your answer
Have you requested this information before?
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Yes
No
Not sure
Business reason for request
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Audit
Grant
Program Planning
Other:
Who will have access to the data?
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Your answer
Will the data be shared outside of the WIC program?
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Yes
No
If data will be shared outside of the WIC program, with whom will it be shared?
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Your answer
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