Fortini Infant Early Experience Program (EEP)
CLINICIAN POST SURVEY | Confidential & proprietary

You will complete this CLINICIAN POST SURVEY for EACH CHILD you enroll in the program - Do this about 4 weeks after the child started feeding with Fortini™ Infant
or sooner, if you advised to stop using Fortini Infant earlier than 4 weeks

You will also input responses the parent/caregiver(s) put on the paper CAREGIVER SURVEY online. That survey has a separate webpage - see link below.
Caregivers participating in this EEP voluntarily authorized disclosure of PHI to Nutricia North America, which they may revoke at any time and for any reason: further detail is in the Authorization for Use and Disclosure of Protected Health Information (PHI) by Healthcare Provider form, completed and signed by both the Legal Guardian and Prescribing Physician. While Nutricia North America is not a HIPAA-covered entity, survey results are stored in a survey account equipped for HIPAA compliance.

Question Title

* 1. Clinician / Clinic name

Question Title

* 2. Child’s first and last name

Child's first name

Child's last name

Question Title

* 3. Date child STOPPED feeding with Fortini Infant, if applicable:

STILL FEEDING with Fortini Infant

STOPPED FEEDING with Fortini Infant - Please specify date in MM/DD/YYYY format

Fortini Infant Early Experience Program (EEP)CLINICIAN POST SURVEY | Confidential & proprietary

Question Title

* 1. Clinician / Clinic name

Question Title

* 2. Child’s first and last name

Question Title

* 3. Date child STOPPED feeding with Fortini Infant, if applicable:

Fortini Infant Early Experience Program (EEP)
CLINICIAN POST SURVEY | Confidential & proprietary