Chicago Health Connection
Doula Program Data Input

Start Date:
End Date:

Agency Name:

Your Name:
 
How many doulas are currently employed at your site?
 
How many full-time doulas do you have, or how many full-time positions (of 40hours or more) could you fill with your doulas?
 
How many families have been assisted by a doula in this reporting period?
 
How many births have you had in this reporting period?
   
How many of these births were attended by a doula?
   
How many families have initiated breastfeeding?
 
Of these, how many were attended by a doula?
   
How many families used epidurals?
   
Of these, how many were attended by a doula?
 
How many families had C-sections?
 
Of these, how many were attended by a doula?
 
 

 

Also, feel free to print and fax your response to Beth Isaacs, Chicago Health Connection.

Fax: (312) 243-4792
E-mail: bisaacs@chicagohealthconnection.org
Fax Your Data

Please submit data form below, or print and fax your response to Beth Isaacs, Chicago Health Connection.

Download: Download a PDF of this form

Fax: (312) 243-4792
E-mail: bisaacs@chicagohealthconnection.org

Contact Information
Chicago Health Connection
954 West Washington Boulevard
Box 36, Fourth Floor
Chicago, Illinois 60607
312-243-4772
Fax: 312-243-4792