Request edit access
INTERPRACTICE-21st Project
Sign in to Google to save your progress. Learn more
Email *
Principal Investigator and Institute *
Focal/contact person (with affiliation and email address) for the study. We expect this person to be our first and reliable contact at your institution with regard to INTERPRACTICE-21st.
Type of hospital 1 *
Required
Type of hospital 2 *
Required
Please add anything you feel which describes your hospital profile which is not captured above
Profile of majority patients catered to *
Required
Total population served/year *
Medically trained staff attending to newborns outside the NICU *
Required
Medically trained staff attending to newborns within the NICU *
Required
Total number of deliveries in the area/region served *
Total number of deliveries in the institution/year *
No. of beds in maternity ward *
No. of low dependency incubators *
No. of newborns requiring NICU or special care/ year *
% of women referred for a higher level of care in your institution/ year *
% preterms (<37 weeks' gestation) delivered in your hospital setting *
% very preterms (<32 weeks' gestation) delivered in your hospital setting *
Perinatal mortality/1000 live births per year in your institution *
What is the current modality used to monitor the growth and nutrition of preterm babies at admission (eg growth charts, nutritional charts) *
What is the current modality used to monitor the growth and nutrition of preterm babies at discharge (eg growth charts, nutritional charts) *
Please use this space to add any descriptive attributes of your neonatal care setting and the institution it is part of which hasn't been covered above.
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy