Hospital Peanut Ball Information Form

This form may be completed electronically, fax, or mail.

Peanut Ball Ambassador Information * First Last
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Street Address is not required. Only City and State
Email *
Name of Hospital or Birthing Center *
Hospital or Birthing Center *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone * - ### - ### ####
Approximate deliveries a month *
Do you have Peanut Balls? *

Do you have Peanut Balls? YES NO, skip the next 5 questions
How many 40cm Peanut Ball sizes do you have?
How many 50cm Peanut Ball sizes do you have?
How many 60cm Peanut Ball sizes do you have?
How many 70cm Peanut Ball sizes do you have?
How are your Peanut Balls purchased?
Hospital Bought Donated Unsure
Do you have Birthing Balls? *

Do you have Birthing Balls? YES NO, skip the next 3 questions
How many 55cm Birthing Balls do you have?
How many 65cm Birthing Balls do you have?
How many 75cm Birthing Balls do you have?
Of your deliveries, what is the approximate percentage of Epidurals given? (You may type UNSURE if you do not know) *
In your opinion, what is the percentage of Epidurals given? (You may type UNSURE if you do not know) *
Of your deliveries, approximately what percentage of them are C-Sections? (You may type UNSURE if you do not know) *
Do you like the Peanut Ball? *

Do you like the Peanut Ball? YES NO MAYBE UNSURE
If so, have you seen/used the Peanut Ball?

If so, have you seen/used the Peanut Ball? YES NO
Do you feel the Peanut Ball has helped avoid a C-Section?

Do you feel the Peanut Ball has helped avoid a C-Section? YES NO
Do you feel if you had a Peanut Ball, that it would help to avoid a C-Section? *

Do you feel if you had a Peanut Ball, that it would help to avoid a C-Section? YES NO
Comments about a person avoiding a C-Section.
Do you want more information on Peanut Balls? *

Do you want more information on Peanut Balls? YES NO MAYBE
Do you want an in-service about Peanut Balls? *

Do you want an in-service about Peanut Balls? YES NO MAYBE
Do you want an in-service on the latest labor support skills? *

Do you want an in-service on the latest labor support skills? YES NO MAYBE
Contact Name * First Last
Email *
Phone * - ### - ### ####
Title of Contact Person *
Manager Charge Nurse Staff Nurse Educator Unit Tech Other Other
Do you mind if we contact you for more questions or stories about the Peanut Ball and its uses? *

Do you mind if we contact you for more questions or stories about the Peanut Ball and its uses? YES NO
Manager's Name * First Last
Title *
Manager's Email *
Phone * - ### - ### ####
Do you have any comments or stories about using the Peanut Ball you want to share?