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)


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
       
 CONFIRMATION THAT APPLICANTS HAVE COMMPLETED CORE TRAINING ELEMENTS
       
  All applicants have completed
base SUDI Prevention education such as Baby Essentials Online or another approved programme		       Yes   
       
    All applicants have completed a workshop specific to preparing them as distributors of the Pepi-Pod® Programme (Distributors Training Video and Programme Materials)       Yes  
     
  All applicants have completed an observed  competency assessment (assessment form)        Yes   
       
NAMES OF PEOPLE SEEKING REGISTRATION      
  Names of distributors whom you confirm as qualifying for registration:
(people distributing the programme to families)   		      Applicant 1 and email
 Applicant 2 and email   Applicant 3 and email  Applicant 4 and email  Applicant 5 and email   Applicant 6 and email  Applicant 7 and email  Applicant 8 and email  Applicant 9 and email  Applicant10 and email
                       
 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.

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