Application for Education & Care

Name of Hospital ^*

Address 1 ^*

Address 2

City ^*

State ^*

ZIP Code ^*

Country ^*

Contact First Name ^*

Contact Last Name ^*

Contact Title ^*

Contact Phone Number ^*

Contact Email Address ^*

Number of births at your hospital in the last year^*

Number of losses (stillbirths & infant deaths) at your hospital in the last year^*

Does your hospital have a dedicated Perinatal Bereavement Coordinator?

Yes

No

What would you identify as the strengths of your perinatal team/program?

What challenges do you face when supporting patients experiencing perinatal loss?

What resources do you need to better support grieving families?

If we could design one improvement in the next year, what would have the biggest impact for your families and staff?

Is perinatal loss education and training available to staff? If so, please describe.

Are memory making activities available to families when a loss occurs at your hospital?

Yes

No

If so, please describe.

Are perinatal bereavement materials given to families when there is a loss?

Yes

No

If so, please describe.

Does your hospital provide follow-up to families experiencing loss after discharge?

Yes

No

If so, please describe.

Does your hospital offer a support group to loss families?

Yes

No

If so, please tell us about it.

Does your hospital host any special/remembrance events for families who have experienced loss?

Yes

No

If so, please describe.

Please confirm that your organization will provide impact reporting related to any funding provided by Jane's Room ^*

We will provide reporting.

Center of Excellence Application