Free FMNP Site Observation Worksheet, DPH 4746 - Wisconsin

DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Public Health DPH 4746 (Rev. 06/02)

STATE OF WISCONSIN Bureau of Family and Community Health WIC Program Federal Reg., 7 CFR 248

FARMERS' MARKET NUTRITION PROGRAM (FMNP) SITE OBSERVATION WORKSHEET

This form has been renumbered and revised. Please update your link with the following: http://dhs.wisconsin.gov/forms/F4/F44746.pdf

DPH 4746 (06/02)

Page 2

FARMER REVIEW Complete the following questions 1. List the vendor number of each WIC FMNP farmer present at the site or attach a list of the farmers to this worksheet

2. List the vendor number of each WIC FMNP farmer where a WIC FMNP transaction was observed.

The following questions in this section are in regards to farmer violations. If no violations were observed, proceed to OTHER COMMENTS on Page 4 of this worksheet. 3. List the vendor number of each WIC FMNP farmer who violated or attempted to violate the program. List the violation code next to the vendor number. Violation Codes are as follows: A B C D E F G H I J K Exchanged ineligible items for FMNP drafts Redeemed FMNP drafts for another vendor Charged WIC customer prices greater than other customers Accepted FMNP drafts at an unapproved site Failed to accept FMNP drafts for the purchase of eligible produce (applies only for certified WIC FMNP farmers with their sign posted.) Issued change or gave cash to WIC customer in exchange for FMNP draft Failed to allow the purchase of the full amount specified on the FMNP draft Failed to post a FMNP sign Abusive or discriminatory treatment of WIC customer for FMNP staff Failed to separate and label non-Wisconsin grown produce Accepted drafts before becoming certified Example: 5999 - A

DPH 4746 (Rev. 06/02)

Page 3

4. Provide a description of each observed violation or attempted violation as follows. Attach a separate piece of paper if needed for additional violations: Violation 1 Vendor Violation Description of Farmer (gender, age, height, weight, race/ethnic group, color of hair and eyes):

Description of Vehicle (color, type i.e. truck, brand name i.e. Ford, license plate number):

Description of Violation:

Violation 2 Vendor Violation Description of Farmer (gender, age, height, weight, race/ethnic group, color of hair and eyes):

Description of Vehicle (color, type i.e. truck, brand name i.e. Ford, license plate number):

Description of Violation:

Violation 3 Vendor Violation Description of Farmer (gender, age, height, weight, race/ethnic group, color of hair and eyes):

Description of Vehicle (color, type i.e. truck, brand name i.e. Ford, license plate number):

Description of Violation:

DPH 4746 (06/02)

Page 4

OTHER COMMENTS List additional comments not collected on this worksheet. Include suggestions or complaints received from farmers.

OBSERVER'S SIGNATURE

I certify that the statements reported are true and correct to the best of my knowledge. If I am called to testify as a witness in any proceeding, I am competent to testify to the matters stated in this report.

SIGNATURE - Observer

Date Signed