Organization
Place of employment |
|
|
|
|
-
- - Childbirth Education Information - - - |
Community
classes
check all that apply to your
hospital or your individual class |
|
prepared childbirth
refresher class
natural childbirth class
epidural class
C/S class
|
breastfeeding class
breastfeeding support
well baby class
baby sign language
preparing for multiples
|
grandparents class
sibling class
moms of toddlers
other (specifiy) |
|
|
|
Childbirth
educators
acknowledge instructors |
|
L/D
nurse
RN/APN*-maternal/infant
medicine
RN/APN*-other
field of medicine |
RN-Lamaze certified
RN-Bradley certified
|
non-RN Lamaze
non-RN Bradley
other |
|
|
*registered
nurse and/or advanced practice nurse |
|
|
-
- -click below to answer yes - - - |
| do
you |
|
give-away freebies from infant formula
companies? |
| do
you |
|
give-away freebies from Lamaze, First Moments, Gift Pax, Pampers, etc.? |
| do
you provide |
|
participant's workbooks?
please specify organization if appropriate |
| do
you |
|
copy material from magazines, journals, or articles for your parents? |
| do
you have an |
|
instructor's manual?
please specify organization if appropriate |
|
|
-
- - Demographics - - - |
| Which
best describes your
organization. |
|
|
| Location/population |
|
|
| Hospital
statistics |
|
|
| Number
of RNCs (L/D,
Mother/baby,
NICU)? |
|
|
| Number
of participants
attending perinatal classes? |
|
 |
| Which
best describes your
birth unit. |
|
|
| Number
of daily scheduled
procedures |
|
|
Percent
of inductions
if zero, state "0" |
|
|
| Percent
of labor epidurals |
|
|
| Participant/instructor
ratio |
|
: |
| Where
are childbirth
classes held? |
|
|
| Childbirth
class series fee per couple |
|
|
|
|
-
- - Contact Information - - - |
| Name |
|
|
| Organization's
title |
|
|
| Original
state nurses license |
|
|
| Professional
license# |
|
|
|
Mailing address |
|
|
|
City |
|
|
|
State or Province |
|
if other,
please specify |
|
Postal code |
|
|
|
Country |
|
|
|
E-mail address |
|
* |