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Hours and Outcomes Form
JIBF Tracking and Data
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* Indicates required question
Doula Name
*
Your answer
Email to send your Amazon card
*
Your answer
Type of Service
*
Birth Doula Support
Postpartum Doula Support
Childbirth Education Only
Lactation Support Only
Other:
Referring Partner Agency
Your answer
Client Name
*
Your answer
Client's Age
Your answer
Client Ethnicity
*
Your answer
Any Risk Factors
Your answer
Estimated Due Date
MM
/
DD
/
YYYY
Date of Delivery
*
MM
/
DD
/
YYYY
Delivery Hospital
Your answer
Name of Provider
Your answer
Type of Birth Delivery
*
Vaginal
Cesarean
Other
N/A
List Interventions Used
Your answer
Briefly Describe the Outcome of Labor
Your answer
Briefly Describe the Outcome of the Postpartum Experience
Your answer
Briefly Describe Any Perinatal or Postpartum Mental Health Issues
Your answer
Is Your Client Breast/Chestfeeding?
*
Yes
No
N/A
Briefly Describe the Outcome of Feeding
Your answer
Date Services Began
MM
/
DD
/
YYYY
Date Services Ended
MM
/
DD
/
YYYY
Estimated Hours of Travel
Your answer
Estimated Prenatal/Birth Hours Served
Your answer
Estimated Postpartum Hours Served
Your answer
Estimated Other Hours of Service
Your answer
Total Hours of Service
*
Your answer
Is there anything else you would like to add?
Your answer
Are you an amazing doula? (You know you are so just hit that yes button)
*
Yes
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