Pepi-pod Distribution Record

INSTRUCTIONS

This is the online version of the paper form that you use to record pepi-pod distribution information. 
It supports your agency to monitor and evaluate your pepi-pod service.  This is a confidential record.
Some information from the paper form is not required on this electronic version.

1. Complete distribution information for each pod given out.
2. Make follow-up contact after about 2 weeks of using the pepi-pod (by text, phone or in a face to face sessions)
3. Ask:
      a) Has baby slept in the pepi-pod yet?
      b) Do you want to keep it?
      c) How many people have you spoken with so far about protecting babies as they sleep?
4. Complete any missing information on paper form and transfer required information to this online form.
                
 (Use the tab key to move to the next response.)
CONTACT DETAILS

 Email of parent or carer:

       
 (for feedback at 2 months) 
          no email

 Referred by:

         (name of referring agency)            

 Distributed by:

       

 (name of distributing agency)
 (name of DHB region)           

 WHANAU DETAILS

Community Service Card holder:

         mother  yes      no
father   yes      no

 Age of parents:

         mother is years
father is   years

 Mother's first baby:

         yes     no

BABY DETAILS

 Baby's Age:
(at least one of these dates is required)

         date due:   day month year (dd/mm/yyyy)
        date born:  day month year (dd/mm/yyyy)

     Reason for a pod:
(vulnerability factors)

          

a) any smoking in pregnancy                     yes    no
b) any smoking at home (even if outside)  yes    no
b) born prem or low birth weight              yes    no
d) other                        

           Baby's Ethnicity:

    

 

  

includes NZ Maori  
NZ European/Kiwi 
Pacific    (specify)
Asian     (specify)
Other  (specify)

Has a baby bed: 

   

 

  

yes (family has a cot, bassinet, wahakura ...)
no  (family has no baby bed)

 POD DETAILS

 Pod ID No:

         (this is the number you allocate to a pepi-pod) 

Date pod given out:

         day month year (dd/mm/yyyy)
 FOLLOW-UP DETAILS (after 2 weeks)

 ASK:

    

 

  

   

1. Has your baby slept in the pepi-pod yet?

    

 

  

yes    no

2. Do you want to keep it? 

   

 

  

yes    no, please take it back  

3. How many people have you spoken with so far about protecting babies as they sleep?

    

 

  

 people

Actual follow-up date:

    

 

   day month year (dd/mm/yyyy)

 
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