Structure
The Wisconsin F 40052A form serves as a crucial tool for the Women, Infants, and Children (WIC) program in Wisconsin, facilitating the ordering and distribution of breast pumps and related accessories. This form is utilized by healthcare providers and WIC coordinators to request specific breast pump models, including multi-user rental electric pumps and personal electric pumps, along with various optional accessories such as breastshields and pumping kits. The form outlines the order period and due dates, allowing for timely processing of requests, which are organized by quarterly project numbers. While the completion of the form is voluntary, the information collected is essential for ensuring that clients receive the appropriate materials to support breastfeeding. Users are instructed to send the completed form either by mail to the Wisconsin WIC Program or via fax, making the process accessible. The detailed list of products includes various models from manufacturers like Medela, Ameda, and Hygeia, with clear guidelines on how to specify quantities and order units. Additionally, the form requires updated shipping information if it has changed since the last order, ensuring that deliveries are accurate and prompt.
Form Example
DEPARTMENT OF HEALTH SERVICES |
STATE OF WISCONSIN |
Division of Public Health |
Bureau of Community Health Promotion |
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WISCONSIN WIC BREAST PUMP ORDER
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Order Period and Due Date (check one) |
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Project Number: |
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1st |
Quarter |
2nd Quarter |
3rd Quarter |
4th Quarter |
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December 7 |
March 7 |
June 7 |
September 7 |
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Project Name:
Completion of this form is voluntary. Information collected will be used to order and ship client material. Mail the completed form to Wisconsin WIC Program, Nutrition Section, PO Box 2659, Madison, WI
Manufacturer/Product |
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Product Name |
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Quantity |
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M E D E L A |
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Lactina Select |
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Units |
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► Order unit: each |
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Personal Electric Pump |
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WIC Personal Double Pump Advanced |
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Case |
► Order unit: per case (3 per case) |
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Battery Pack for Personal Electric Pump |
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Battery Pack |
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Units |
► Order unit: each |
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Double Pumping Accessory Kit |
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Lactina Double Kit with two 24 mm and |
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Case |
► Order unit: per case (20 per case) |
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two 27 mm Personal Fit breastshields |
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Manual Pump |
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WIC Harmony with one 24 mm and one |
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Case |
► Order unit: per case (20 per case) |
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27 mm Personal Fit breastshields |
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O p t i o n a l A c c e s s o r i e s |
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Large |
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Case |
► Order unit: per case (12 per case) |
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Extra Large [36 mm] Breastshields |
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Case |
► Order unit: per case (12 per case) |
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A M E D A |
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Reconditioned Elite |
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Units |
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► Order unit: each |
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Personal Electric Pump with internal battery |
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Purely Yours |
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Units |
► Order unit: each |
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Double Pumping Accessory Kit |
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Dual Hygienikit with Custom Fit Flanges |
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Case |
► Order unit: per case (20 per case) |
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(25, 28.5 and 30.5 mm) |
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Manual Pump |
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Ameda |
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Case |
► Order unit: per case (20 per case) |
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Flanges (22.5, 25, 28.5 and 30.5 mm) |
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O p t i o n a l A c c e s s o r i e s |
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Large Flange (30.5 mm/28.5 mm inserts) |
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Case |
► Order unit: per case (12 per case) |
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Extra Large Flange (36 mm/32.5 mm inserts) |
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Case |
► Order unit: per case (12 per case) |
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Project No. |
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HYGEIA |
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EnJoye LBI (with internal battery and |
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Case |
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► Order unit: per case (2 per case) |
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personal accessory kit) |
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Personal Electric Pump |
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EnRiche Q with personal accessory kit |
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Case |
► Order unit: per case (2 per case) |
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External Battery Pack |
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External Battery Pack |
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Case |
► Order unit: per case (10 per case) |
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EnJoye/EnRiche Accessory Kit |
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Personal Accessory Kit with Flanges |
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Case |
► Order unit: per case (20 per case) |
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(2) 27- 28 mm and (2) |
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Manual Pump |
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Piston hand pump with Flanges |
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Case |
► Order unit: per case (20 per case) |
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(1) 27- 28 mm and (1) |
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O p t i o n a l A c c e s s o r i e s |
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Extra Large Flange (36 mm) |
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Case |
► Order unit: per case (20 per case) |
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Provide your shipping information ONLY if it has changed since your last order.
Street Address: |
City: |
Zip Code: |
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Primary Contact Person:
Area Code and Telephone:
Email form to: WIC Nutrition Program
Document Specs
| Fact Name | Fact Details |
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| Form Title | Wisconsin WIC Breast Pump Order Form |
| Form Number | F-40052A |
| Governing Law | Wisconsin Statutes Chapter 253 - Health |
| Last Updated | September 2013 |
| Purpose | To order and ship breast pumps for WIC clients |
| Mailing Instructions | Send completed forms to Wisconsin WIC Program, Nutrition Section, PO Box 2659, Madison, WI 53701-2659 |
| Fax Number | 608-266-3125 |
| Order Units | Units can be ordered by each or per case depending on the product |
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