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Parent Panel Interest Questionnaire

Thank you for your interest in participating in one of our parent panels.  We use parent panels during staff training so that nurses and staff can hear directly from parents who have experienced perinatal loss.  Some of our classes focus solely on the palliative care experience; others focus on perinatal loss, keepsakes, pictures, what nurses can do to better support the families we work with.  We will keep your information and reach out when we have a need.  Once you agree to be a part of a panel, more information will be sent to you to help guide you.
1.Your email address
2.Your name
3.Your best contact number
4.Was your loss here at Northside Hospital?  (If it wasn't, that's ok.  It is just helpful for us to know.)
5.When was your loss?
6.How far along in your pregnancy were you?
7.Please check any of the following if they apply to your experience.
8.Would your partner like to also be a part of the panel?
9.Did you have pictures and/ or keepsakes made of your baby?
10.If you are needed, do you have a preference to which campus you can come to?  We offer classes on all Northside campuses at various times of the year. (Check all that apply)