Safe Sleep Program Evaluation Questionnaire



WOOD COUNTY CRIBS FOR KIDS®

INTAKE & EVALUATION QUESTIONNAIRE

Intake Questionnaire:

Date: _____/____/________

Name (Infant) ____________________________ DOB (Infant) _____/____/________Gender: □ Male □ Female

Race (Infant): □ American Indian or Alaska Native Ethnicity (Infant): □ Hispanic

□ Asian □ Not Hispanic

□ African American

□ Native Hawaiian or other Pacific Islander Baby’s Current Weight: ______lbs_____oz

□ White

Primary Language: ____________________________ Baby’s Due Date: _____/____/________

Name (mother) __________________________________________DOB (mother): _____/____/________

Address_______________________________________________ ZIP Code______________________

Phone Number: ____________________________________________

Does child / mother have a chronic medical, behavioral, emotional, or other health condition lasting more then 12 months? ( Yes Please list: _______________________________ ( No ( Unknown

Date when pack and play issued: _____/____/________ Issued during pregnancy? □ Yes □ No

Name of caregiver completing questionnaire: _________________________ Relationship to baby: _______________

Staff member issuing Pack ‘N Play: ____________________________________________

1. What assistance programs are you enrolled in?

□ WIC

□ FoodShare (Food Stamps)

□ Wisconsin Works (W-2) Cash Assistance

□ SSI

2. Do you currently own a crib?

□ Yes

□ No

□ Currently borrowing a crib

3. If you currently own a crib, why are you requesting a new one?

□ The crib is outdated

□ The crib is unsafe

□ Other (please specify) ________________________________________________________

4. Where would your baby sleep if you were not offered the Pack ‘N Play?

a. In bed with mother and/or father g. Cradle

b. In bed with siblings h. Floor

c. Crib i. Couch

d. Bassinette j. Car seat

e. Cradle f. Other_______________________________

5. Do you have any other children living in the home? Yes_______ No_______

How many children in total live in your home? __________ Ages: _____________________

6. Where did your other child(ren) sleep when he/she was an infant? ___________________________________

Yes No

7. Environmental Tobacco Smoke: Mother smoked during pregnancy: ( (

Mother smoked after pregnancy: ( ( Inside: ( Outside: (

Members of household smoke: ( ( Inside: ( Outside: (

8. Feeding: ( Breastfeeding ( Formula feeding ( Both

9. Childcare: ( Home-based ( Center-based ( Relatives/Friends ( None

10. Current sleep position: ( Back ( Belly ( Side

11. Video Shown:

a. DVD, “Infant Safe Sleep,” 7 minutes

b. VHS, “Safer Sleep for Your Baby,” 10 minutes

c. DVD, “Safe Sleep for Your Baby Right from the Start,” 14 minutes

d. DVD, “Seven Deadly Myths,” 17 minutes (only for mothers/female caregivers who smoke)

e. None

12. Donation: $ __________

Evaluation Questionnaire:

______ One week evaluation ______ Two month evaluation

|Attempt 1: |Attempt 2: |Attempt 3: |

|_____/_____/_____ |_____/_____/_____ |_____/_____/_____ |

|Home |Home |Home |

|Left Message |Left Message |Left Message |

|No Answer |No Answer |No Answer |

SLEEP PRACTICES

1. Where did baby name sleep for most of last night? (DON’T READ CHOICES, check one)

□ Air mattress □ Bed with children □ Sofa

□ Baby swing □ Car seat □ Soft mattress

□ Bassinet □ Crib □ Stroller □ Beanbag Chair □ Floor □ Waterbed

□ Bed with an adult □ Pack ‘N Play □ Other___________________

□ Bed with adults and children □ Recliner

2. How do you keep your baby warm at night?

□ Sleep sack

□ Blanket

□ Other

If BLANKET: What kind of blanket is it? (READ CHOICES)

□ Thick □ Thin

Is the blanket tucked in? (DON’T READ CHOICES)

□ Yes □ No

3. Do you have any of the following items in the answer from 1. above? (READ CHOICES, check all that apply)

□ Clothes □ Pillow

□ Diapers □ Sheet

□ Stuffed animals/toys □ Nothing

□ Blanket □ Anything else, IF YES: please list ________________

4. In the past week, where else has baby name slept? (DON’T READ CHOICES, check all that apply)

□ Air mattress □ Bed with children □ Sofa

□ Baby swing □ Car seat □ Soft mattress

□ Bassinet □ Crib □ Stroller □ Beanbag Chair □ Floor □ Waterbed

□ Bed with an adult □ Pack ‘N Play □ Other___________________

□ Bed with adults and children □ Recliner

5. What position did you place baby name to sleep in the last time you put him/her down? (DON’T READ CHOICES,

check one)

□ Back □ Side □ Tummy □ Not Sure

6. Have you discussed with baby name’s other caregivers the place you would like him/her to sleep?

□Yes □ No

7. Have you discussed with baby name’s other caregivers the position that you would like him/her to sleep in?

□Yes □ No

8. Does anyone ever smoke inside your home? □Yes □ No

If YES: Does anyone ever smoke in the same room as baby name? □Yes □ No

9. Does anyone ever smoke in the car with baby name?

□Yes □ No

10. Is the Pack ‘N Play you received set up now?

□Yes □ No □ Not sure

11. During the past week, how many nights did you place baby name in the Pack ‘N Play to sleep? (DON’T READ CHOICES, check one)

0 1 2 3 4 5 6 7

12. What is the maximum weight limit for the bassinet piece of the Pack ‘N Play?

_______lbs □ Unsure

If INCORRECT, Fact: For your baby’s safety, the bassinette piece should be removed when he/she reaches 15 lbs.

13. Do you currently breastfeed?

□Yes □ No

14. What is the current temperature in the baby’s room? ___________________ (should be comfortable for a lightly clothed adult)

15. Have you had any problem using the Pack ‘N Play?

□ Yes □ No

If YES, please explain __________________________________________________________________________

_____________________________________________________________________________________________

16. Did anyone talk to you during this pregnancy or afterwards about laying baby name down to sleep on his/her back?

□Yes □ No

If YES: Where did you learn this information? (READ CHOICES, check all that apply)

□ Baby’s doctor □ Home Visit by the Department of Health □ TV/radio/ magazine

□ Doctor or nurse during prenatal visit □ Hospital after childbirth □ WIC programming

□ Family member □ Internet □ Anywhere else

□ Friend □ Other social programming

IF YES: please list ____________________________________________

HEALTH BELIEF MODEL

17. Have you heard of anyone whose baby died because of?

□ Sleeping with adults or other kids Yes No

□ Sleeping on a couch Yes No

□ Sleeping face down Yes No

□ Sleeping with pillows or blankets Yes No

18. How dangerous do you think the following behaviors are:

□ Sleeping with adults or other kids? Very Dangerous Dangerous Not Dangerous Not Sure

□ Sleeping on a couch? Very Dangerous Dangerous Not Dangerous Not Sure

□ Sleeping face down? Very Dangerous Dangerous Not Dangerous Not Sure

□ Sleeping with pillows or blankets? Very Dangerous Dangerous Not Dangerous Not Sure

19. How easy is it for you to:

a. Find a place in the room where you sleep to set up the Pack ‘N Play

□ Very Easy □ Easy □ Hard □ Very Hard

b. Set up the Pack ‘N Play

□ Very Easy □ Easy □ Hard □ Very Hard

c. Remain calm if your baby cries when placed in the Pack ‘N Play

□ Very Easy □ Easy □ Hard □ Very Hard

e. Let your baby sleep alone in a crib?

□ Very Easy □ Easy □ Hard □ Very Hard

20. Do most of your friends and family place their babies to sleep in a crib/bassinette or Pack ‘N Play?

□Yes □ No

21. How much to do you agree with this statement: “I can comfort my baby without bringing him/her into bed with me”

Disagree completely Disagree Somewhat Agree Agree Completely

22. Do you think it is good for a baby to sleep alone in a Pack ‘N Play in your room?

□ Yes (if yes proceed to 22a)

□ No (if no proceed to question 22b)

22a. I have a list of things other mother’s have said are benefits for having their baby sleep alone in mom’s room in a crib. As I read through the list tell me if you agree with the statement.

□ Moms sleep more soundly Yes No

□ Babies are close Yes No

□ Moms can use blankets if cold Yes No

□ Mom and her partner can sleep together Yes No

□ It is easy to set up Yes No

□ It is easier to breastfeed Yes No

□ Are there other benefits you would add to this list?

22b. I have a list of what other mom’s have told us as to why it is hard to have their baby sleep alone in mom’s room in a crib. As I read through the list, tell me if you agree with the statement.

□ My baby would get hurt if not in my bed Yes No

□ I could not hear my baby if not in my bed Yes No

□ No space for the crib in my room Yes No

□ I sleep more soundly with baby in my bed Yes No

□ Baby is less safe if not in bed with me Yes No

□ I miss the pleasure, closeness, comfort and security when bed sharing Yes No

□ Babies cry more if not in mom’s bed Yes No

□ It is hard to set up crib Yes No

□ I do not have a room of my own Yes No

□ I don’t sleep well without baby in bed with me Yes No

□ It is inconvenient if baby is not in bed with me Yes No

□ Are their other barriers that you would add to this list?

23. We would like to make more families aware of safe sleep for their infants. Do you have any suggestions for us on how to improve parent’s knowledge about safe sleep? __________________________________________________________________________________________________________________________________________________________________________________________

Thank you very much for your time.

Date: ____/____/_____ Completed by: □ phone □ home visit □ office visit

Staff: Signature: __________________________________________________

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2/26/10

4/1/2010

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