Civil Rights Complaint against a WIC Vendor

Use this form to submit a report of a possible civil rights violation committed by a Minnesota WIC vendor against a WIC participant or proxy. Once submitted, you will receive a confirmation email. You can reply to that confirmation email with additional information or documentation (such as pictures or receipts).

Please do not use this form to report a general transaction issue or general rudeness.

Provide the following information about the WIC Staff person submitting this form.

Name (first and last)

Local Agency

Email Address

Preferred Phone Number

Please provide the following information about the WIC participant or proxy who experienced the discriminatory incident. Any information provided will be kept completely confidential, and will be used only in the course of following up on this complaint.

Name (first and last)

Household ID associated with participant or proxy

Email Address

Preferred Phone Number

Ok to leave voicemail at number listed above?

Please provide the following information about where the incident occured.

Store Name

Store Location (full street address)

Day

Time

Name or description of any store employees involved (if known)

Describe the incident with as much detail as possible. Include information about any events or interactions leading up to the incident.

Do you or the complainant believe the incident occurred because they are a member of a protected class?