INFORMED CONSENT DISCLOSURE

PROJECT TITLE: Efficacy of Hospital-Based Perinatal Loss Programs

INTRODUCTION
The purpose of this form is to provide you with information that may affect your decision whether to say YES or NO to participation in this research. The research will be conducted within the state of Virginia.

RESEARCHERS
Principal Investigator:
Anisa L. Glowczak, MSEd, NCC
Bereavement Counselor
301 Riverview Dr, Suite 710
Norfolk, VA 23510

DESCRIPTION OF RESEARCH STUDY
Several studies have looked into the needs of bereaved parents; however, very few have focused on the benefits of a hospital-based Perinatal Loss Program. The following study seeks to identify the specific  ways hospital experiences and interventions benefit individuals, couples, and families who have experienced a perinatal loss.

If you decide to participate, you will join a study involving research about your experiences during your time in the hospital immediately after your loss, as well as after discharge. Information will only be gathered from you by the following survey. If you say YES, then your participation will last approximately 10-15 minutes (not all sections may apply to you).

RISKS AND BENEFITS
RISKS:  If you decide to participate in this study, you may face a risk of some emotional discomfort as you recall the events, thoughts and feelings associated with your loss. The researchers strive to reduce this risk by expressing the voluntary nature of participation and the option to withdraw from this study at any time without penalty. The survey does not ask identifying information (e.g. names or locations) so your responses will be anonymous.

BENEFITS:  Although there are no direct benefits for participating in the study, you may gain personal insight or benefit from reflecting on your experiences, thoughts, and feelings. The researchers hope that the information gathered within this research study will contribute to the overall knowledge and understanding of how best to help bereaved parents.  If you would like, the researchers will offer you a copy of the results of this study once it is completed.

COSTS AND PAYMENTS
There are no costs to participate. The researchers are unable to give you any payment for participating in this study.
CONFIDENTIALITY
All data collected will be pooled and deidentified. NO identifying information will be collected, including IP addresses. All information you provide for this study is strictly confidential. The survey and all data on this website will be retained for the required amount of time, and then deleted/ destroyed. The results of this study may be used in reports, presentations, and publications. Electronic data will be stored in a password-protected electronic file; hard copy data will be stored in a locked file cabinet in the primary researcher’s office.

WITHDRAWAL PRIVILEGE
It is OK for you to say NO to participating in this study, and you are free to withdraw from the study at any time without penalty.

COMPENSATION FOR ILLNESS AND INJURY
We will not provide free medical care for any illness or injury resulting from participating in this study. Financial compensation for research related injury or illness, lost wages, disability, or discomfort is not available. However, you do not waive any legal rights by signing this consent form.

VOLUNTARY CONSENT
By clicking below, you are agreeing that you have read this form (or have had it read to you) and that you are satisfied that you understand this consent, the research study, and its risks and benefits. If you have any questions now or in the future, you can contact any member of the research team at the address listed above.

**If you encounter any problems with the survey (link not working, etc) please email me at goodmourningcc@gmail.com so I can correct it!!

By clicking "I Agree to Participate," you are telling the researchers "YES, I understand this informed consent document, I am adult age 18 or older, and I agree to participate in this study."

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