Multi-User Electric Breast Pump Tracking Log
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1MULTI-USER ELECTRIC BREAST PUMP TRACKING LOG
Pump Serial Number____________________
Location (clinic number or name)___________________________________
v Contact to be made in the first 24-48 hours of issuance and contacts are to be made every month thereafter.
v Date and Initial your notes.
DATE
Participant Name,
Reason
Unsuccessful
Return
Inspected
ISSUED
Phone #, and ID
Code
Tracking Dates & Notes
Contact Attempts**
Date
&Cleaned
SS Use These Questions as a Guide to Assess Pumping use and continued need for the electric pump.
REASON CODES:
S How is pumping going?
S How is breastfeeding going when you are
A. Hospitalization for more than 48 hours
S How does pumping feel?
with your baby?
B. Problems with latch and/or milk transfer
S Tell me what a typical day is like, puming & breastfeeding?
S How have you been able to find the time
C. Special needs infant
S What are some ways you have found to make pumping easier?
to pump enough?
D. Re-lactation
S What does your baby's caregiver say about how
S How much are you able to pump per session?
E. Full-time Work, School, or other Separation
S How many times a day are you able to pump?
the baby is doing?
**Write in Date; along with: VM= Voice Mail message left; BZ= received Busy signal; MI= left Message with Informant; NA= No Answer; WN= Wrong Number; DC=Disconnected
Revised 7-2011
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Parent category: Miscellaneous