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Health Service Registration form

Health Service Registration Form for the iSISTAQUIT Scale-Up Training Package

Type of service*

Health Service Name*

Address*

State and PostCode*

Health Service Contact Person*

Phone*

Email*

Registration form for the iSISTAQUIT Scale-Up Training Package

1. Self-paced online eLearning modules for health professionals (CPD points available - condition apply)

2. Hard copy educational resources - training manual and flipchart for health providers, and my journey booklet for pregnant woman

3. Access to iSISTAQUIT Social Media Campaign

4. Membership to the iSISTAQUIT Community of Practice (CoP)

5. Optional additional implementation package

Please Complete the following

Approximate number of healthcare professional's in your service that have contact with pregnant Aboriginal or Torres Strait Islander women (i.e. consulting with pregnant women at any stage of her pregnancy)

No. Nurses

*

No. Midwives

*

No. Doctors

*

No. Aboriginal Health Worker/Practitioner

*

No. Other (Please state)

For your health service please complete the following national KPI's as reported to the Australian Government Department of Health and Aged Care for the last reporting period:

1. Proportion of regular clients who are Indigenous, younger than 20, who gave birth within the previous 12 months and whose smoking status has been recorded during the pregnancy

a.Current smoker

*

Number of NRT scripts written

*

b. Non smoker

*

c.Past smoker

*

2. Proportion of regular clients who are Indigenous,20-34 years old, who gave birth within the previous 12 months and whose smoking status has been recorded during the pregnancy

a.Current smoker

*

Number of NRT scripts written

*

b. Non smoker

*

c.Past smoker

*

3. Proportion of regular clients who are Indigenous, 35 years and older, who gave birth within the previous 12 months and whose smoking status has been recorded during the pregnancy

a.Current smoker

*

Number of NRT scripts written

*

b. Non smoker

*

c.Past smoker

*

4. Proportion of Indigenous babies born within the previous 12 months whose birthweight has been recorded on more than one visit.

*

5. Proportion of Indigenous babies born within the previous 12 months whose birthweight were recorded on more than one visit as

a. High

*

b. Normal

*

c. Low

*
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