Birth Feedback Form for Great Starts Birth Class Members

We are very interested in the impact of childbirth education on your birth experience and outcomes. We've developed this feedback form to gather information about your experience of birth and the impact of your education.

The form should take you 15-20 minutes to complete. We know you're busy new parents so we have enabled this so you can save it mid-completion, and come back later to finish. There's also a little gift from us for your participation, upon completion of the form.

Thank you again for your time and feedback.

1Birth Information

2Comfort Measures & Labor Progress

3Interventions & Pain Medications in Labor & Birth

4Newborn Procedures, Feeding, and Care

5Childbirth Class Feedback

6Birth Story

7Thank you gift

Today's Date Today's Date / MM / DD YYYY
Name Name First Last
Approximate Start Date of Classes Approximate Start Date of Classes / MM / DD YYYY
Birth Details

Tell us the basic facts of your birth.
Baby's name
Baby's Birth Date Baby's Birth Date / MM / DD YYYY
Baby's sex
Baby's Birth Weight
Where was your baby born?

Where was your baby born? University of Washington - Main University of Washington - Northwest Swedish First Hill Swedish Ballard Swedish Edmonds Swedish Issaquah Overlake Evergreen Providence Everett Valley Medical Center Other Other
Who was your care provider?
Did you prepare a birth plan?

Did you prepare a birth plan? Yes No
Did your birth plan include preferences for unexpected deviations from normal?

Did your birth plan include preferences for unexpected deviations from normal? Yes No
Did your birth plan include newborn care preferences?

Did your birth plan include newborn care preferences? Yes No
Was the staff familiar with your birth and newborn care plan?

Was the staff familiar with your birth and newborn care plan? Yes No
Why did you decide not to prepare a birth plan?
Were your birth plan preferences followed?

Were your birth plan preferences followed? Yes No
Briefly provide details about how and why your birth plan was not followed. Were any changes explained to you before they were made? (You'll be able to share your full birth story later.)
Save my progress and resume later
Enter Your Email Address *

A special link to resume the form will be sent to your email address.

Birth Feedback Form for Great Starts Birth Class Members

Birth Feedback Form for Great Starts Birth Class Members

Birth Details