Understanding the intricacies of the Wisconsin F 40052A form is essential for those involved in the state's Women, Infants, and Children (WIC) Program, especially with its focus on supporting breastfeeding mothers. Issued by the Department of Health Services, State of Wisconsin, this form serves as a vital tool within the Division of Public Health, specifically under the Bureau of Community Health Promotion. It’s designed to facilitate the ordering and shipment of breast pumps and related accessories, offering a range of products including multi-user rental electric pumps, personal electric pumps, manual pumps, and various optional accessories tailored to meet the diverse needs of breastfeeding mothers. The form is structured to be filled out quarterly, with specific deadlines in place for each quarter, ensuring that the WIC Program can manage its resources effectively and deliver necessary equipment to clients in a timely fashion. Additionally, it collects shipping information and requires details about the primary contact person, simplifying the logistical process of sending out ordered items. By filling out this form, participants take a vital step towards accessing essential breastfeeding support equipment through the Wisconsin WIC Program, underscoring the state’s commitment to promoting public health and child nutrition.
| Question | Answer |
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| Form Name | Wisconsin Form F 40052A |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | F40052A breast pump rental spokane wa form |
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