Demographics

Institution/ Agency:______________________City:__________________________

Your Discipline:
MD               RN               LPN              DO
SW               NP               PA                 RT
Other:__________________________________________________________

Your Work Setting: (Circle all that apply)
     Hospital                                   Private Practice
Labor & Delivery:               Family Practice Office:
Postpartum:                        Obstetric Office:
Nursery:                             Pediatric Office:
NICU:                                Other:_______________
Other:_______________

Topics

Please check all topics that you would like to see offered this year:

Aspects of Prenatal Care, such as:_____________________________________
Assessment of Newborn
              1. Developmental
             2. Physical
Breastfeeding
Community Resources, such as:_______________________________________
Contraception
Discharge planning for high-risk/preterm infants
Domestic Violence
Electronic Fetal Monitoring
              1. Basic
             2. Advanced
Genetics
Infant Safety
Neonatal Complications, such as:______________________________________
Newborn Screening/ Follow-up
Nutrition, Growth, Feeding of Infants
Perinatal Bereavement and Support
Perinatal Substance Abuse
Postpartum Depression
Pregnancy Complications, such as:_____________________________________
Sexually Transmitted Diseases
Stabilization and Transport
              1. Maternal
             2. Neonatal
Sudden Infant Death Syndrome (SIDS)
Other topics, such as:_______________________________________________

Educational Format

Please check any of the following that best meet your learning needs/preferences.

Other/ Comments

Please print and fax to (540) 982-3449

Or mail to:
Blue Ridge Perinatal Council
7 Albemarle Ave SW
Roanoke VA 24016
Attn: Barbara Pack