I want to express my sorrow for the loss of your baby. You are asked to participate in this study if you have had a stillbirth in the last two years and you were 20 weeks or more along in your pregnancy.

You are being asked to be a part of a research study about what the people who took care of you in the hospital did for you when your baby died. This is also a study to learn more about your feelings at the time of your baby's death and after. This research study proposes to describe and analyze those interventions that occurred when your baby died, and to learn more about the relationship between the interventions and grieving.

This study is in partial fulfillment of the requirements for doctoral dissertation for Peggy Lambert Fink at West Virginia University. If you agree to participate, you will be asked to give information about yourself, to complete the Perinatal Grief Scale, check off those interventions that you experienced at the time of your stillbirth, and finally, you will answer a question about your grief experience.

No experimental treatment is involved. You will be able to see the questions before you sign the consent form. You do not have to answer all of the questions.

Participating in this study may arouse discomfort by causing you to think about things that are distressful to you. Resources will be made available with names and phone numbers that you may consult with should you become disturbed as a result of completing the survey.

A possible benefit of participating in this study is to provide evidence to support the practices that occur at the time of stillbirth. There is no compensation for participating in this study.

For more information concerning this research, you may contact Peggy Lambert Fink, Principal Investigator, at (304)465-1496 or you may contact the WVU Institutional Review Board at (304)388-9971. Information collected will be anonymous and kept as confidential as legally possible. No publication of results will identify you.

Participating in this study is voluntary. You are free to withdraw your consent at any time. In addition, you have the right to refuse to answer any specific questions. Refusal to participate or withdraw will involve no penalty and will not affect your right to health care in any way.

By clicking on the button below, you indicate that you have read the above information and all your questions have been answered and you accept the terms of this consent. Your informed consent will become part of your anonymous record and you can print out a copy of this consent form.

You authorize Peggy Lambert Fink and her research staff to use and disclose your anonymous responses for the purposes described below.

The Researchers may use and share your anonymous information with:
• The WVU Institutional Review Board and/or the Office of Research and Grants Administration
• Federal regulatory authorities such as the FDA, USDA, OHRP, DHHS, etc.

You do not have to agree to this consent. If you disagree:
• You will not be allowed to participate in the research study.
After agreeing to participate, you can change your mind and:
• Withdraw or revoke the Authorization and not let the researcher use or disclose further health information.
• If you revoke the Authorization, you will not be allowed to continue to participate in the study.

Information collected in this study will be keep you anonymous and will not access your Personal Health Information (PHI). (PHI) is information about you that could be used to identify you, such as your name, address, telephone number, photograph, date of birth, social security number, new and existing medical records, or the types, dates and results of various tests and procedures.

If you have questions or concerns about your privacy rights, contact the Privacy Office at (304) 388-1187. You may request a copy of the Notice of Privacy Practices.