Thank you for taking the time to complete this survey. Your responses will guide child passenger safety training programs and educational resources for the medical community and families.

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*2.General Information(Required.)

Person Completing the Survey: 

Title: 

Telephone #: 

Email:

*3.Hospital Information(Required.)

Hospital: *

Address: *

Address 2:

City/Town: *

State: *

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ZIP: *

*4.County(Required.)

AdamsAlleghenyArmstrongBeaverBedfordBerksBlairBradfordBucksButlerCambriaCameronCarbonCentreChesterClarionClearfieldClintonColumbiaCrawfordCumberlandDauphinDelawareElkErieFayetteForestFranklinFultonGreeneHuntingdonIndianaJeffersonJuniataLackawannaLancasterLawrenceLebanonLehighLuzerneLycomingMcKeanMercerMifflinMonroeMontgomeryMontourNorthamptonNorthumberlandPerryPhiladelphiaPikePotterSchuylkillSnyderSomersetSullivanSusquehannaTiogaUnionVenangoWarrenWashingtonWayneWestmorelandWyomingYork

*5.Maternity Nurse Manager(Required.)

*6.Maternity Discharge Contact:(Required.)

7.Chair of Pediatrics Department:

8.Chair of Obstetrics Department:

*9.Hospital Educational Coordinator:(Required.)

*10.Approximate number of babies born annually:(Required.)