Online Adaptation Request Form

How do you adapt the tool(s) to an online or electronic format? Please check all that apply.

Integrating into an electronic charting system for clinical practice (Please note: Adaptation is limited to your institution’s clinical system only)

Converting into an online platform for research (e.g., REDCap, Qualtrics)

Others (please specify)Others (please specify)

Please select the instrument(s) you are requesting for online adaptation (please check all that apply):

Neonatal Eating Assessment Tool – Breastfeeding (NeoEAT – Breastfeeding)

Neonatal Eating Assessment Tool – Bottle feeding (NeoEAT – Bottle-feeding)

Neonatal Eating Assessment Tool – Mixed Breastfeeding and Bottle-Feeding (NeoEAT – Mixed Feeding)

Pediatric Eating Assessment Tool (PediEAT)

Child Oral and Motor Proficiency Scale (ChOMPS)

Impact of Feeding on the Parent and Family

Family Management Measure of Feeding (FaMM Feed)

Early Feeding Skills Assessment Tool (EFS)

Personal Information

Name

First

Last

Email

Secondary Email

Title & Credentials

Institution Name

Department

Address

City

State/Province

Zip/Postal

Country

Agreement

By checking the boxes, I agree to the following:

I understand that the author who owns the copyright of the English version of the tool will maintain ownership of the copyright of the electronic version of the tool.

I will reference the tool (and its authors) in any publications or presentations of the use of the tool.

I, and any members of my team, will follow the terms of use agreement specified on the first page the tool(s).

I agree to use the name of the tool(s) as they are stated in the tool, also I will use the tools as they are meant to be used and not alter them.

I agree that when the tool is integrated into an electronic charting system (e.g., EPIC), the addition should stay local within your hospital system and the vendor of the electronic charting system does not have permission to distribute it beyond your system.

I understand that the instruments (i.e., Pediatric Eating Assessment Tool, Neonatal Eating Assessment Tool, Child Oral and Motor Proficiency Scale, Impact of Feeding on the Parent and Family, Family Management Measure of Feeding and Early Feeding Skills Assessment Tool) are covered by United States copyright law and infringement of copyright law is punishable by criminal prosecution in the United States as well as internationally.

Date

Online Adaptation of the Feeding Flock’s Feeding Assessment Tools

Personal Information

Agreement