Application for Registration of Distributors

INTRODUCTION

Distributors of the Pepi-Pod® sleep space programme need to be registered.

This is a quality process to ensure a standard is upheld and acknowledged in the distribution of the programme. It is a mechanism for accountability to families, funders and coroners, and is offered as support for participating agencies.

THIS FORM

This form is to be completed by the person leading the programme in your DHB, or your agency, if not a DHB. A unique registration number will be issued to each person that you confirm has met the competency standard as evidence of this. The registration number is recorded on distribution forms each time information is collected from families.

Thank you.

Stephanie Cowan, Programme Director, The Pepi-Pod® Programme (June 2014)

Application for Registration of Distributors

Free Text

PARTICIPATING DHB OR AGENCY

Name of the DHB region of your service:

Name of your Agency (if not a DHB):

Your DHB or Agency has a signed Participation Agreement with Change for our Children Limited for providing the Pepi-Pod® programme:

yes

Name and email of the Programme Coordinator completing this form and certifying the competence of distributors.

and email

Free Text

CONFIRMATION THAT APPLICANTS HAVE COMMPLETED CORE TRAINING ELEMENTS

Free Text

All applicants have completed base SUDI Prevention education such as Baby Essentials Online or another approved programme

Yes

Free Text

All applicants have completed a workshop specific to preparing them as distributors of the Pepi-Pod® Programme (Distributors Training Video and Programme Materials)

Yes

Free Text

All applicants have completed an observed competency assessment (assessment form)

Yes

Free Text

NAMES OF PEOPLE SEEKING REGISTRATION

Free Text

Names of distributors whom you confirm as qualifying for registration:

(people distributing the programme to families)

Applicant 1 Name

Applicant 1 Email

Applicant 2 Name

Applicant 2 Email

Applicant 3 Name

Applicant 3 Email

Applicant 4 Name

Applicant 4 Email

Applicant 5 Name

Applicant 5 Email

Applicant 6 Name

Applicant 6 Email

Applicant 7 Name

Applicant 7 Email

Applicant 8 Name

Applicant 8 Email

Applicant 9 Name

Applicant 9 Email

Applicant 10 Name

Applicant 10 Email

Free Text

WHAT HAPPENS NEXT?

A unique registration number will be emailed to each applicant confirmed as meeting the competency standards of the Pepi-Pod® Programme, with a summary email to the Programme coordinator for the DHB or Agency.