EXIT THIS SURVEY Exit this survey 1. St. Albans WIC Provider Materials Order Form 2.0 Breastfeeding resources are available to St. Albans area provider offices participating in the WIC Mother/Baby Breastfeeding Project. If you have questions about the project or about using this order form, please contact the WIC Program in the St. Albans District Office. St. Albans District Office WIC ProgramTelephone: 802-524-7970 option 3 St. Albans District Office breastfeeding designeee-mail: rachael.gregory@state.vt.usThis form can be found at:https://www.surveymonkey.com/s/StAlbansWIC * 1. Please enter your contact information: Requested By: Practice Name: Mailing Address: Address 2: City/Town: State: -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP: Email Address: Phone Number: * 2. Fax number: * 3. Date of Request: Month/Day/Year MM / DD / YYYY * 4. Professional training options from the Physician Lactation Education Collaborative of Washington: A Closer Look at Latch and its Impact on Breastfeeding Blood Glucose in the Breastfed Neonate Breastfeeding the Late Pre-Term and "Supposedly Term" Infant Breast Pain in Lactation Controversies in Parenting Advice: Breastfeeding, Pacifiers and Sleep How to Increase Breastfeeding Success: What the Research Shows Immunology of Human Lactation Insufficient Weight Gain: is it intake or supply? Medications and Breastfeeding Multicultural Aspects of Breastfeeding * 5. Professional training options (continued): Wellstart International's Lactation Management Self-Study Modules, Level 1 (revised) Other (please specify) * 6. Professional education resources: Breastfeeding: A Guide for the Medical Profession (Lawrence & Lawrence) Breastfeeding Answers Made Simple (Mohrbacher) Breastfeeding: Natural, Biological, Instinctual, Challenging (WIC) Medications and Mothers' Milk (Hale) Other (please specify) Breastfeeding:A Guide for theMedical Profession(Lawrence & Lawrence) Breastfeeding AnswersMade Simple(Mohrbacher) Breastfeeding: Natural, Biological, Instinctual, Challenging (WIC) Medicationsand Mothers' Milk(Hale) * 7. Patient Materials Amy Spangler's "What Breastfed Babies Do" DVD Born and Raised the Vermont Way magazine The Hospital Experience booklet My Breastfeeding Checklist (St. Albans prenatal version) My Breastfeeding Checklist (Middlebury prenatal version) My Breastfeeding Checklist (Rutland prenatal version) My Breastfeeding Checklist (St. Albans pediatric version) My Breastfeeding Checklist (Middlebury pediatric version) My Breastfeeding Checklist (Rutland pediatric version) Plan for Success Poster 18 X 24 (OB/FP) Plan for Success Poster 18 X 24 (Peds) Amy Spangler's"What Breastfed Babies Do"DVD Born and Raised the Vermont Way magazine Hospital Experience My Breastfeeding Checklist My Breastfeeding Checklist(pediatric version) Plan for Success Poster(OB/FP) Plan for Success Poster(Peds) * 8. To request a follow-up visit, please check the box below. WIC Program staff will contact you to set up an appointment. Yes, please contact via e-mail. Yes, please contact via phone. Yes, please contact by mail. No, thank you. * 9. Would you like to sign up for brief updates on breastfeeding in Vermont via e-mail? These updates will occur no more than 4 times per year. Yes No * 10. Any questions? Please call the WIC Program at 802-524-7970 option 3 or contact us via e-mail at rachael.gregory@ahs.state.vt.usDo you have suggestions or feedback for the WIC Program? Please use the text box below. Thanks very much! Done
