RFP 25-2128 Attachment A MDHHS-5959 Michigan WIC Compliance Buy Report.pdf

Michigan.gov/MiProcurement

2022-1 1

ATTACHMENT A – MDHHS-5959, MICHIGAN WIC

COMPLAINCE BUY REPORT

RFP 250000002128: Women, Infants, and Children (WIC) Program Compliance Buys Investigative Services

MDHHS-5959 (Rev. 2-24) Previous edition obsolete. 1

MDHHS-5959, MICHIGAN WIC COMPLIANCE BUY REPORT

Michigan Department of Health and Human Services

(Revised 2-24)

SECTION 1

Date of Buy

Investigator’s Name

WIC Card Number

SECTION 2 – VENDOR INFORMATION

Store Name

WIC Vendor Number

Address

City

State

Zip Code

Time of Visit

Total number of cash registers

Number of check-out lanes open at time of visit

SECTION 3 – DESCRIPTION OF CASHIER

Gender

Male Female Perceived Race

Approximate Age

Hair Length and Color

Approximate Height

Approximate Weight

Facial Hair Yes No

Describe Facial Hair

Visible Tattoos Yes No

Unique Identifier(s)

Name

SECTION 4 – TRANSACTION DETAILS

Shaded areas indicate expected results. If result differs, give an explanation in the Transaction Narrative section.

1. Did the cashier scan the UPCs attached to the actual products brought up for purchase?

Yes No N/A

2. Did the cashier use a phone, book of UPCs, or other UPC list for scanning products brought up for purchase?

Yes No N/A

3. Did the cashier offer to scan and use WIC benefits for items that were not brought up for purchase?

Yes No N/A

4. Did the cashier ask for identification when you used your WIC card? Yes No N/A

5. Did the cashier key or swipe your WIC card for you? Yes No N/A

6. Did the cashier ask for your PIN number? Yes No N/A

7. Did the cashier enter your PIN number? Yes No N/A

8. Did you observe any other WIC customers exchanging WIC benefits for non-food or non-WIC approved items?

Yes No N/A

9. Were you required to pay for food items that were not paid for by WIC benefits?

Yes No N/A

10. Did the register system apply sales tax to the WIC foods you purchased? Yes No N/A

MDHHS-5959 (Rev. 2-24) Previous edition obsolete. 2

11. Did the register system apply advertised sales prices to the transaction (if applicable)?

Yes No N/A

12. Did the cashier offer the final purchase receipt or provide the receipt after you asked for it?

Yes No N/A

13. Did the cashier confiscate or attempt to confiscate your WIC card? Or did the cashier offer to hold your card at the store for you for future transactions?

Yes No N/A

14. Was the cashier discourteous to you in any way? Yes No N/A

15. Overall, did the cashier appear familiar with how to conduct a WIC transaction?

Yes No N/A

SECTION 5 – OVERALL STORE CONDITIONS

Shaded areas indicate expected result. Use the Transaction Narrative section to provide comments regarding the visit.

16. The store has the WIC vendor door decal displayed. Yes No

17. The store has its business hours posted. Yes No

18. The store has prices posted for WIC-approved food. Yes No

19. The store is clean and sanitary. Yes No

20. The store has expired foods for sale. Yes No

SECTION 6 – FOOD ITEMS PURCHASED

UPC/PLU BRAND

NAME

SIZE DESCRIPTION

(Food type, name, quantity, etc.)

WIC

APPROVED?

(Yes/No)

DISPLAYED

PRICE

PRICE AT

REGISTER

Yes No

Yes No

Yes No

Yes No

Yes No

SECTION 7 – TRANSACTION NARRATIVE

Provide as much detail of the experience in the store as possible and explain how prices were determined and any violations:

MDHHS-5959 (Rev. 2-24) Previous edition obsolete. 3

SECTION 8 – FOOD DISPOSITION

Fill out or attach a donation receipt with pertinent information. Include a photo of the foods donated.

I certify the items purchased on this form were donated and presented to:

Organization Name

Address

City

State

Zip Code

Date

SECTION 9 – CERTIFICATION/DECLARATION

I declare all information documented on this form is true and correct to the best of my knowledge.

Investigator Signature

Date

The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group on the basis of race, national origin, color, sex, disability, religion, age, height, weight, familial status, partisan considerations, or genetic information. Sex-based discrimination includes, but is not limited to, discrimination based on sexual orientation, gender identity, gender expression, sex characteristics, and pregnancy.

In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating on the basis of race, color, national origin, sex (including gender identity and sexual orientation), disability, age, or reprisal or retaliation for prior civil rights activity.

Program information may be made available in languages other than English. Persons with disabilities who require alternative means of communication to obtain program information (e.g., Braille, large print, audiotape, American Sign Language), should contact the responsible state or local agency that administers the program or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339.

To file a program discrimination complaint, a Complainant should complete a Form AD-3027, USDA Program Discrimination Complaint Form which can be obtained online at:

https://www.usda.gov/sites/default/files/documents/USDA-OASCR%20P-Complaint-Form-0508-0002- 508-11-28-17Fax2Mail.pdf, from any USDA office, by calling (866) 632-9992, or by writing a letter addressed to USDA. The letter must contain the complainant’s name, address, telephone number, and a written description of the alleged discriminatory action in sufficient detail to inform the Assistant Secretary for Civil Rights (ASCR) about the nature and date of an alleged civil rights violation. The completed AD-3027 form or letter must be submitted to USDA by:

1. mail:

U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410; or

2. fax:

(833) 256-1665 or (202) 690-7442; or

3. email:

program.intake@usda.gov

This institution is an equal opportunity provider.

https://www.usda.gov/sites/default/files/documents/USDA-OASCR%20P-Complaint-Form-0508-0002-508-11-28-17Fax2Mail.pdf https://www.usda.gov/sites/default/files/documents/USDA-OASCR%20P-Complaint-Form-0508-0002-508-11-28-17Fax2Mail.pdf

MDHHS-5959 (Rev. 2-24) Previous edition obsolete. 4

MICHIGAN WIC COMPLIANCE BUY REPORT ADDENDUM

WIC Program

(Complete this sheet when additional room is needed for any section)

Store Name

Date of Compliance Buy

Signature of Investigator