Family details form

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Family details form

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Complete the form below when a family agrees to take part in the Pepi-pod research study.

Send a signed consent form to the Chief Investigator:

Professor Jeanine Young
Email: jyoung4@usc.edu.au
Tel: +61 7 5456 5898
Mobile: 0438 903 511

Baby's mother details

Referral criteria: why is this baby at risk of SUDI?

Before learning about the Pepi-pod, where was baby going to be placed for sleep at home?

Contact details of person answering questionnaires

Include contact details for another family member likely to have a role in placing baby for sleep (as appropriate). This person must agree to being contacted for information about the pepi-pod if required.

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