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Distribution Site
Bismarck-Burleigh Public Health
Carson
Central Valley Health District
CHR Twin Buttes
Community Action Partnership - Early Head Start
Dakota Hope Clinic
Dickey County Health District
Elbowoods Memorial Health Clinic Public Health Nursing
Fargo-Cass Public Health
First District Health Unit
Foster County Public Health
Global Refuge
Jamestown Regional Medical Center
Lake Region District Health Unit
MSA United Way - Missouri Slope Area
Nelson-Griggs District Health Unit
New Salem
Pembina County Public Health
Ransom County Public Health Dept.
Richland County Health Dept.
Safe Kids Fargo-Moorhead - Sanford Children's
Sanford Health Dickinson Clinic (Peds)
Southwestern District Health Unit
Three Affiliated Tribes Community Health Representative (CHR) Program MHA Office
Three Affiliated Tribes MHA-Infant and Toddler Program
Tioga Clinic
Turtle Mountain Chippewa Quentin Burdick Health Care Facility
Turtle Mountain Home Visiting Program
United Tribes Wellness Center
Upper Missouri Public Health Unit
Uspire: Healthy Families of ND - Bismarck
Uspire: Healthy Families of ND - Devils Lake
Uspire: Healthy Families of ND - Dickinson
Uspire: Healthy Families of ND - Fargo / Cass County
Uspire: Healthy Families of ND - Grand Forks
Uspire: Healthy Families of ND - Jamestown
Uspire: Healthy Families of ND - Valley City
Uspire: Healthy Families of ND - Williston
Walsh County Health District
Wells County District Health Unit - Fessenden
Wells County District Health Unit - Harvey
West River Head Start
Western Plains Public Health
Women's Care Center - Bismarck
Women's Care Center - Devils Lake
Women's Care Center - Fargo
Youthworks - Bismarck
Other
Other Site
What Type of Kit is Being Distributed?
Pack and Play
Bedside Sleeper
Date
Infant Name
Infant Date of Birth
Parent/Guardian Name
Parent/Guardian Date of Birth
Date Crib was Given to Client
Was Client Successfully Contacted to Complete Compliance Questionnaire?
Yes
No
Date Contacted
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