VA PEP Parent Survey

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* 1. Name of the hospital where you gave birth

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* 2. Name

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* 3. Phone number (in case you win the drawing)

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* 4. Did you establish paternity at the hospital?

Yes

No

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* 5. If no, why did you not establish paternity?

Father not present at the hospital

Father lack ID

Mother lacks ID

Mother choices not to identify father

Hospital staff did not discuss or offer to complete the AOP form

Parents would like genetic test

Mom is married to someone other than biological father

Father deployed

Other (please specify)

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* 6. Did the hospital present information in a clear respectful manner?

Yes

No

Any details you would like to share?