Request Breastfeeding Resource Directory

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Personal Information:

First Name *
Last Name *
Organization (if any)
Title
Mailing Address *	Street Address only, no P.O. Box please.
City *
State *
Zip Code *
Country
Home Phone
Work Phone
E-mail *

Are you interested in volunteering for the Task Force?  Yes  No  As Needed

How many directories should we ship for you to distribute from November 2007 through March 2008?     (2008 Directories will be shipped in March 2008.)

How many 2008 directories do you need?   

2007 Resource Directory Questionnaire 

1) How / from whom did you obtain this Resource Directory? (Please check all that apply):

 Pediatrician                             Breastfeeding Task Force Event

 Obstetrician / Gynecologist     Public Health Department

 Hospital                                  Ordered From Task Force Website

 WIC Office

Other , please specify  

2) How often will you use this Resource Directory?

 Daily                                     Monthly (at least once/month)

 Weekly (at least once/week) 

 Other , please specify  

3) In what capacity will you use this Resource Directory? (i.e. with patients, personal use)

4) What additional information should be included in the Resource Directory?

 

5) How would you describe yourself? (Please check all that apply):

 Mother / Parent                      Lactation Professional

 Physician                              WIC Employee

 Nurse                                  

 Other , please specify  

Comments:

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