Site Resource Assessment



Site Resource Assessment Questionnaire

In order to assist the coordinating centre with optimizing education workshops for intervention sites, we would ask that you complete the below questionnaire to the best of your knowledge. Please return completed questionnaires by ____________ to _______________.

Contact information

Please list below the individual(s) who should be included in all Family Integrated Care related communications in the future:

|Name |Contact Information (email/phone) |

| | |

| | |

| | |

Educational support for parents

Does your centre have any of the following resources available for parents in the NICU?

|Resource |Available in NICU (Y/N) |

|Orientation binder or other admission information/education for | |

|parents | |

|Computer support for parents | |

|Parent education sessions | |

|Breastfeeding classes | |

|CPR training | |

|Other (Please list) | |

| | |

Facilities to support program

Please indicate which of the below facilities are currently available in your unit to support parents in the Family Integrated Care program, or those that may be underway and ready for program implementation.

|Facility |Available in NICU (Y, N or underway) |

|Parent Lounge (please indicate what is available in parent lounge & | |

|size) | |

| | |

|Dedicated sleep room/hostel room (please indicate number of | |

|rooms/beds, bathroom availability, etc) | |

| | |

|Education session space / room | |

|Care by parent rooms | |

Interprofessional Support

Please indicate the interprofessional support that is available in your unit to facilitate the program:

|Staff |Dedicated resource for NICU? (# of FTE’s) |Referral or consult only |

|Lactation Consultant | | |

|Occupational Therapist | | |

|Physiotherapist | | |

|Developmental care specialists | | |

|Dietician | | |

|Interprofessional support – CNS | | |

|Infection control | | |

|Pharmacy | | |

|Nurse Educator | | |

|Other (please specify) | | |

| | | |

| | | |

Current parent participation support

On your unit, what are parents encouraged to do?

|Activity |Y/N |

|Are parents present for rounds? | |

|Are the visiting hours open? | |

|Do you promote skin to skin? | |

|Do you create care plans for every family? | |

|Other (please indicate) | |

| | |

Parent Volunteer Support

In your unit, do you have veteran parent (NICU graduate parent) participation in any form? (See below for examples of veteran parent involvement)

|Parent participation |In Place (Y/N) |Being Planned (Y/N) |Approx. # of people |

|Parent advisory committee | | | |

|Parents on committees | | | |

|Parent-to-parent support | | | |

|Veteran parent (parent buddy) training program | | | |

|Paid parent | | | |

Are there any other parent roles in the hospital?

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