Hospital Peanut Ball Information Form

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

Peanut Ball Ambassador Information

This top section is all about the Peanut Ball Ambassador

First Name

Last Name

Address Line 1

Address Line 2

City

State

Zip Code

Country

Email

Hospital Information

All of the below information is about the hospital or birthing center.

Name of Hospital or Birthing Center

Address Line 1

Address Line 2

City

State

Zip Code

Country

Phone/Mobile

Approximate deliveries a month

Do you have Peanut Balls?

YES

NO

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?

YES

NO

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)

Have you seen/used the Peanut Ball?

YES

NO

Do you like the Peanut Ball?

YES

NO

MAYBE

UNSURE

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?

Yes

No

Comments about a person avoiding a C-Section.

Do you want more information on Peanut Balls?

YES

NO

MAYBE

Do you want an in-service about Peanut Balls?

YES

NO

MAYBE

Do you want an in-service on the latest labor support skills?

YES

NO

MAYBE

First Name

Last Name

Email

Phone/Mobile

May we contact you for more information about the Peanut Ball and its uses?

YES

NO

Manager's First Name

Last Name

Title

Manager's Email

Manager's Phone/Mobile

Do you have any comments or stories about using the Peanut Ball you want to share?

The nursing staff appreciate using and many of our physicians love for us to use the peanut balls!! We do feel like they decrease the length of first and second stage labor in anesthetized patients and are also helpful positioning aids for moms using Natural Childbirth. They are fun, whimsical, yet very useful tools for labor and birth! Thank you for creating information on how to use them!

Lynn Jeter, MSN, RNC-OB, C-EFM

Brookwood Women's Medical Center, Birmingham, AL