Community Baby Shower/Crib Clinic Post Test 2024 English 
Please fill out this form after attending the NCCHS Community Baby Shower on April 6, 2024. Thank you for attending and we hope you had a great time!

Contact us at 785-284-2152 
Find us online at ncchsks.org
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Email *
First name of mother: *
Last name of mother: *
Mother's age: *
How will you lay your baby down to sleep? (Check all that apply) *
Required
Where will your baby sleep at home? (Check all that apply) *
Required
Do you plan to have baby sleep on an inclined surface? *
What room(s) will baby sleep in at home? (check all that apply) *
Required
Please check the items that you now plan to have in your baby's sleeping area: *
Required
I know at least one person who will support Safe Sleep for my baby. *
Do you plan to talk about Safe Sleep with others who may put your baby down to sleep? *
Are you interested in quitting tobacco use? *
How often will you allow tobacco use (including e-cigarettes) inside your home/car? *
Do you know at least three ways to avoid second-hand smoke exposure for your baby? *
How many resources do you know about that support efforts to quit tobacco use? *
How long do you plan to breastfeed your baby? *
How many resources do you know about to support breastfeeding goals? *
Which of the following are ways to reduce the risk of depression, anxiety, and other mood disorders when pregnant or after having a baby? (Check all that apply) *
Required
How many resources do you know about to provide support if you are experiencing symptoms of perinatal depression or anxiety? *
I have at least one person I can call to talk about my feelings or any concerns about my mental health. *
How many resources do you know about that provide support for substance use disorders? *
If you do not receive a safe approved portable crib today would you have access to a clean, smoke-free, damage-free crib, bassinet, or portable crib for your baby? *
Based on what you have learned at this event, please rate your confidence on the following: *
Less confident
No change
More confident
Get baby to sleep on his/her back
Have baby sleep in my room, but separate crib, portable crib or bassinet
Keep loose blankets out of the crib
Avoid second-hand smoke
Breastfeed
Follow safe sleep recommendations even when people give different advice
Recognize signs and symptoms of perinatal depression or anxiety
Access screening or support for symptoms of perinatal depression or anxiety
Access screening or support for substance use disorders, if needed
How would you rate this event? *
If dissatisfied/very dissatisfied, why?
Comments/suggestions
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