Pepi-Pod® Programme Data Record (NZ and AUSTRALIA)

INSTRUCTIONS

This is the online version of the paper form that you use to record Pepi-Pod® distribution and follow-up information.               It supports your agency to monitor and evaluate your Pepi-Pod® service and show a value to funders for the work. This is a confidential record. Some information from the paper form is not required on this electronic version.

  1. DISTRIBUTION: Complete the information below for each Pepi-Pod (or other 'in-bed capable' sleep space) given out.

  2. FOLLOW-UP: Make follow-up contact when babies are 6-8 weeks (by text, phone or in a face to face session).
      ASK
     a) Does or did your baby sleep in the Pepi-Pod®?
     b
) Do you want to keep it to use yourself or share with others?
     c) How many people have you spoken with so far about safe sleep for babies?
     d) Ask the infant protection questions listed.

   3. DATA ENTRY: Transfer all required information from paper forms to this online form.

Use the tab key to move to the next response. All fields are required.                                                          (Updated 15 June 2017)


DISTRIBUTION
 SERVICE DETAILS
Country/state, health region, distributing agency:     Country/State        HHS (Queensland)  DHB (NZ)               Agency (please specify)
          

FAMILY DETAILS

 

 Current AGE of MOTHER:



years

Ante-natal CARE:



first visit   number of visits 

 ............        ............................Community Services (NZ) or Health Care (AUCARD holder (mother):



yesnounknown

                       Usual SUBURB and POSTCODE (if known)



 suburb                        post code

Mother's NHI number: (NZ only)      

BABY DETAILS




Baby's NHI number: (NZ only)      
                    AGE of BABY:
                 (at least one of these dates is required)



age at distribution (in weeks) 

date dueday   month    year                       date born: day   month    year

       

 VULNERABILITY factors:



a) any smoking: BEFORE most recent pregnancy:  yes   no  

                          DURING most recent pregnancy: yes   no

b) born premature (<37 weeks) or low birth weight(<2500gm): yesno

c) regular smoking in baby's household:yesno

d) alcohol, recreational or other drug use in baby's household: yesno

e) other concerns: (select as appropriate from the following)

   overcrowding     mental health     low maternal support 

   previous infant loss   infant welfare   natural disaster                    

       

 Baby's ETHNICITY includes:

 (more than one option may be selected)


 

Maori    Pacific    Australian Aboriginal   Torres Strait Islander     

None of the above

       

Has a baby BED:



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

SLEEP SPACE DETAILS        
Type of sleep space:



Pepi-Pod ID No:



 (printed on data form enclosed with Pepi-Pod

Standard safety briefing completed:



CONSENT TO TERMS OF USE




 Explained and SIGNED:



yes no

Date DISTRIBUTED:      date born: day   month   year   
       
 FOLLOW-UP  (when baby is 6-8 weeks)      
Was there FOLLOW-UP      yes                                 (complete FOLLOW-UP QUESTIONS below)
 no, unable to contact    (go to SUBMIT at end of form)
FOLLOW-UP QUESTIONS       
       
1. Has your baby EVER slept in the Pepi-Pod?      yes no    
       
2. Did your baby sleep in the Pepi-Pod this PAST WEEK?       
       
3. Do you want to KEEP your Pepi-Pod?      yes, I want to keep using it for this baby
yes, I want to use it for my next baby, or share it with others
no, please take it back
       
4. How many people have you SPOKEN WITH so far about safe sleep for babies?       
       
5. Does your baby sleep on the BACK?       
       
 6. Do you do a SAFETY CHECK to remove all pillows, toys, hats, loose or soft items, when your baby goes to sleep?       
       
7. Does your baby sleep in the SAME ROOM as a main carer at night?         
       
8. Is your baby IN A PEPI-POD or WAHAKURA when sleeping in, or on, an adult bed, on a couch, or when a makeshift bed is needed?          
       
9. Is baby currently BREASTFED?
(use standard definitions for 'feeding in past 48 hrs')
 
       Definitions
       
 10. Is the main carer receiving smoking cessation SUPPORT?        
       
11. Has baby started their IMMUNISATIONS yet?       
       
12. Have you shown others how to HANDLE your baby GENTLY      yes no  
       
13. What AGE is your baby NOW (in completed weeks)?       weeks  
       
14. ENROLLED with a Doctor or Health Service?     yes   no   don't know  
       
15. Please rate how well the Pepi-Pod has SUPPORTED you. (on a scale of 1(low) to 9 (high))
 
   

a) with better sleep for mother   

b) with breastfeeding  

c) with convenience 

d) with safety    

e) with settling your baby  

f) in other ways   (please specify) 

       
16. Any accidents or safety CONCERNS when baby was in the sleep space?        no       yes  (please specify)   
       

17. Free COMMENT (Would you like to say anything more about your experience using a pepi-pod sleep space?) 

   
       
ACTUAL follow-up date:      day   month   year  
       
CLICK TO SUBMIT --->                           
      You will know that your form has been submitted successfully when you get an immediate acknowledgement.