Safe Sleep Program Evaluation Questionnaire

Intake: 1 Week: ______WOOD COUNTY CRIBS FOR KIDS® 2 Month: ______INTAKE & EVALUATION QUESTIONNAIREINTAKE QUESTIONNAIRE:Date: _____/____/______Issued during pregnancy? □ Yes □ NoName (Infant) ______DOB (Infant) _____/____/______Gender: □ Male □ FemaleRace (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/caregiver) ______DOB (mother): _____/____/_____Address______ZIP Code______Phone Number: ______Back-up Contact: ______BC Phone Number: ______Does child (mother, if pregnant) have a chronic medical, behavioral, emotional, or other health condition lasting more then 12 months?  Yes Please list: ______ No  Unknown Staff member issuing Pack ‘N Play: ______1. What assistance programs are you enrolled in?  WIC  FoodShare (Food Stamps)  Wisconsin Works (W-2) Cash Assistance  SSI2. Do you currently own a crib?  Yes  No  Currently borrowing a crib3. 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  The crib is outdated  The crib is unsafe  Other (please specify) ______4.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______1 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  N/A 9. Childcare:  Home-based  Center-based  Relatives/Friends  None  N/A 10. Current sleep position:  Back  Belly  Side  N/A 11. Video Shown: a. DVD, “Infant Safe Sleep,” 7 minutes b. VHS/DVD, “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. None12. Donation: $ ______2 ONE WEEK EVALUATION QUESTIONNAIRE: (Adapted from Children’s Hospital and Health System and the Medical College of WI Safe Sleep Program Evaluation Questionnaire)Attempt 1: Attempt 2: Attempt 3: _____/_____/______/_____/______/_____/_____  Home  Home  Home  Left Message  Left Message  Left Message  No Answer  No Answer  No Answer  Phone Out of Order  Phone Out of Order  Phone Out of OrderSLEEP 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 □ Recliner2. How do you keep your baby warm at night? □ Sleep sack □ Blanket □ Pajamas □ Other 2a. If BLANKET: What kind of blanket is it? (READ CHOICES) □ Thick □ Thin 2b. Is the blanket tucked in? (DON’T READ CHOICES) 2c. Is the blanket used to swaddle? □ Yes □ No □ Yes □ No3. 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 □ Recliner5. 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 Sure6. Have you discussed with baby name’s other caregivers the position you would like him/her to sleep? □Yes □ No □ No other caregivers7. Have you discussed with baby name’s other caregivers the place that you would like him/her to sleep in? □Yes □ No □ No other caregivers8. Does anyone ever smoke inside your home? □Yes □ No If YES: Does anyone ever smoke in the same room as baby name? □Yes □ No 3 9. Does anyone ever smoke in the car with baby name? □Yes □ No10. Is the Pack ‘N Play you received set up now? □Yes □ No □ Not sure11. 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 6 712. 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 □ No14. 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 in a safe crib? □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 any babies who have 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 No18. 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 Sure19. 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 Hard4 c. Remain calm if your baby cries when placed in the Pack ‘N Play □ Very Easy □ Easy □ Hard □ Very Hard d. Let your baby sleep alone in a crib? □ Very Easy □ Easy □ Hard □ Very Hard20. Do most of your friends and family place their babies to sleep in a crib/bassinette or Pack ‘N Play? □Yes □ No □ No friends/family with babies21. 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 Completely22. Do you think it is good for a baby to sleep alone in a Pack ‘N Play? □ Yes (if yes, proceed to 22a) □ No (if no, proceed to question 22b)22a. I have a list of things other moms have said are benefits for having their baby sleep alone in a crib. As I read through the list tell me if you agree with the statement. □ Moms (and their partners) sleep without fear of rolling over baby Yes No □ Babies learn to sleep on their own Yes No □ Baby is safer (reduce suffocation risk) Yes No □ Moms don’t need to worry about their blankets covering baby’s head Yes No □ Are there other benefits you would add to this list?22b. I have a list of what other moms have told us as to why it is hard to have their baby sleep alone 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 □ I miss the pleasure, closeness, comfort and security that comes with Yes No bedsharing □ Babies cry more if not in mom’s bed Yes No □ It is hard to set up the 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? Do you have any ideas of how we can spread the word about our Cribs for Kids program? ______24. (To be answered by staff) Client is following safe sleep guidelines: □ All of the time □ Most of the time □ Some of the time □ NeverDate: ____/____/_____ Completed by: □ phone □ home visit □ office visit Staff: Signature: ______2/22/2012 52/26/10 TWO MONTH EVALUATION QUESTIONNAIRE: (Adapted from Children’s Hospital and Health System and the Medical College of WI Safe Sleep Program Evaluation Questionnaire)Attempt 1: Attempt 2: Attempt 3: _____/_____/______/_____/______/_____/_____  Home  Home  Home  Left Message  Left Message  Left Message  No Answer  No Answer  No Answer  Phone Out of Order  Phone Out of Order  Phone Out of OrderSLEEP 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 □ Recliner2. How do you keep your baby warm at night? □ Sleep sack □ Blanket □ Pajamas □ Other 2a. If BLANKET: What kind of blanket is it? (READ CHOICES) □ Thick □ Thin 2b. Is the blanket tucked in? (DON’T READ CHOICES) 2c. Is the blanket used to swaddle? □ Yes □ No □ Yes □ No3. 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 □ Recliner5. 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 Sure6. Have you discussed with baby name’s other caregivers the position you would like him/her to sleep? □Yes □ No □ No other caregivers7. Have you discussed with baby name’s other caregivers the place that you would like him/her to sleep in? □Yes □ No □ No other caregivers8. Does anyone ever smoke inside your home? □Yes □ No6 If YES: Does anyone ever smoke in the same room as baby name? □Yes □ No9. Does anyone ever smoke in the car with baby name? □Yes □ No10. Is the Pack ‘N Play you received set up now? □Yes □ No □ Not sure11. 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 6 712. 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 □ No14. 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 ______HEALTH BELIEF MODEL16. How easy is it for you to: b. 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 a. Let your baby sleep alone in a crib? □ Very Easy □ Easy □ Hard □ Very Hard17. Do most of your friends and family place their babies to sleep in a crib/bassinette or Pack ‘N Play? □Yes □ No □ No friends/family with babies18. 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 Completely7 19. Do you think it is good for a baby to sleep alone in a Pack ‘N Play? □ Yes (if yes proceed to 19a.) □ No (if no proceed to question 19b)19a. I have a list of things other mom have said are benefits for having their baby sleep alone in a crib. As I read through the list tell me if you agree with the statement. □ Moms (and their partners) sleep without fear of rolling over baby Yes No □ Babies learn to sleep on their own Yes No □ Baby is safer (reduce suffocation risk) Yes No □ Moms don’t need to worry about their blankets covering baby’s head Yes No □ Are there other benefits you would add to this list?19b. I have a list of what other moms have told us as to why it is hard to have their baby sleep alone in 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 □ I miss the pleasure, closeness, comfort and security that comes with Yes No bedsharing □ Babies cry more if not in mom’s bed Yes No □ It is hard to set up the 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?20. 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? Do you have any ideas of how we can spread the word about our Cribs for Kids program? ______21. (To be answered by staff) Client is following safe sleep guidelines: □ All of the time □ Most of the time □ Some of the time □ NeverDate: ____/____/_____ Completed by: □ phone □ home visit □ office visitStaff: Signature: ______8 03/10/20147/7/20102/26/10

Safe Sleep Program Evaluation Questionnaire

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