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Monitoring form: Health facilities

Your name and contact details will not appear in BFLG's published reports.

If appropriate this form will be forwarded to the Trading Standards home authority for the manufacturer concerned. You can also report this type of promotion to your local Trading Standards office.

We do not generally publicise the names of health facilities violating the Code and Resolutions, but may follow up serious or repeated reports of violations with the facility.

If you work at the facility, we would like to conduct a fuller telephone interview with you. Again, your name and contact details will be kept confidential. Please contact the BFLG Monitoring Coordinator, Mike Brady, using mikebrady@babymilkaction.org with your contact number. If you would rather not give a telephone interview, feel free to complete the form.

Required details

Enter your name here:

Monitors identity number (if one has been assigned to you):

Please continue to the 'details of promotion' section if you have a monitors identity number or have given the following information before on a monitoring form.

Enter your email address here:

Re-type your email address here:

Your telephone number:

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Optional details

Position:

Organisation:

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Details of promotion

Name of facility:

Town/village:

Date visited: / / (dd/mm/yyyy)

How did you come to visit the facility (choose one only)?

To monitor
Attending ante-natal classes
Giving birth
As a patient
Visiting a patient
I work there
Other

Is the facility certified as "Baby Friendly"? Yes No

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Please answer any of the following questions which are relevant. If you do not have specific information on any question, leave it blank. If you have more than one example in any section, either complete additional forms, or give the details in the 'further information' section as you prefer.

Free samples of products Did you receive any free samples of infant formula, follow-on formula, other milks, baby foods or feeding bottles or teats? If yes, please answer this section. Manufacturers name: Product name: Who gave you the free sample (select one): Company representative Staff at the facility Other (give details below) Further information: Can you send a photograph/sample? Yes No

Displays promoting products Does the facility display any product, poster, pamphlet, calendar, clock or other similar items produced by baby food companies? If yes, please answer this section. What was the item? Where was it displayed? From which company? Does the company name or logo appear on the item? Yes No Does a product brand name or logo appear on the item? Yes No Product name: Further information: Can you send a photograph/sample? Yes No

Contact with company representatives Were you approached by a baby food or bottle and teat company representative in the facility? If yes, please complete this section. Company name: Did you receive any product sample from the representative? Yes No Product name: Did you receive any gifts or written materials from the representative? Yes No Further information: Can you send a photograph/material? Yes No Do you have the name of the company representative? If so, please give it here.

Before submitting the form, you may wish to print this page for your own records.

If you have photographs or materials to support your report, please send this by email to mikebrady@babymilkaction.org or to the address below. Include a note giving your name and the date you submitted this form. If you are sending a lot of materials, please attach a copy of this form to the relevant pieces or otherwise clearly identify them. Materials should be sent to:

BFLG Monitoring,
c/o Baby Milk Action,
34 Trumpington Street,
Cambridge,
CB2 1QY.

Many thanks for your information.

Please check this box if you have reported the above violations to your local Trading Standards office - click here to send a report via the Trading Standards website, or find the number in your telephone book.