FIMR Family Interview FIMR (Fetal Infant Mortality Review) is a community-based process that aims to improve the health and wellbeing of women, infants, and families. FIMR brings a multidisciplinary, and most importantly, the families voice together to examine confidential circumstances of stillbirths and infant deaths to understand what happened, why it happened, and what can be learned to prevent similar deaths in the future. More information about the FIMR program can be found at https://ncfrp.org/what-we-do/fimr/. We appreciate you taking the time to share your story with us and value your input and confidentiality. We are truly honored to meet you and your baby through your story. All questions are optional and there will be an opportunity at the end of the survey to explain any answers further or to provide additional information. Please feel free to quit the survey at any point in support of your emotional needs.This online FIMR survey is a new approach to collecting family stories. It was created with the hope of collecting your story while also being respectful of your time. There will be an opportunity at the end of the survey to share your suggestions, concerns, or feedback to the survey design. We would appreciate any feedback for improvements.If you have any questions please feel free to contact Erin Dodds, FIMR Coordinator, at edodds@ccbh.net or 216.903.6148 (call/text). Question Title * 1. Who is completing this survey? Mom Partner Maternal Demographic Question Title * 2. Mom’s First Name & Last Name First name Last Name Question Title * 3. Mom’s Date of Birth (MM/DD/YYYY) Date Date Question Title * 4. Home address and contact information Street Number Street Name City State Zip Code Email address Phone number Question Title * 5. Race Black/African American White Asian American/Pacific Islander Native American/Alaskan Native Other (please specify) Question Title * 6. Ethnicity Hispanic Non-Hispanic Question Title * 7. Baby's First and Last Name Baby's first name Baby's last name Question Title * 8. Baby's date of delivery (MM/DD/YYYY) Date Date Maternal Background Question Title * 9. As a child, did you grow up with any of these sources of stress? (Check all that apply) Living with one parent Racism Multiple moves/unhoused (homeless) Money problems Difficult Family Relationships Substance abuse (you or family member) Violence (domestic abuse, child abuse, sexual abuse) Issues in school Involvement with the criminal justice system (you or family member) Community violence Death of a parent/close family member Foster care/child protective services Other (please specify) None of the above Partner Demographic Question Title * 10. Partner's First Name & Last Name First name Last Name Question Title * 11. Partner's Date of Birth (MM/DD/YYYY) Date Date Question Title * 12. Partner's race Black/African American White Asian American/Pacific Islander Native American/Alaskan Native Other (please specify) Question Title * 13. Partner's ethnicity Hispanic Non-Hispanic Question Title * 14. Partner’s highest level of education 8th grade or less 9th - 12th grade - no High School diploma High School diploma or GED Some college – no degree Associate’s degree Bachelor’s degree Master’s degree Doctorate or professional degree None of the above Employment Question Title * 15. Were you employed at any time during your pregnancy? Full time Part time Not employed Other (please specify) Question Title * 16. Does your employer offer paid parental leave? Yes No I do not know Other (please specify) Question Title * 17. Did your partner work during your pregnancy? Yes No Not Applicable Income and Living Situation Question Title * 18. Did you receive any of the following benefits/services during your pregnancy (check all that apply) Child care program Disability or unemployment Home visiting Housing assistance Mental Health/substance abuse program SNAP Temporary Assistance for Needy Families (TANF) Women, Infant and Children (WIC) Other (please specify) None of the above Question Title * 19. How often do you worry about money? All the time Often Sometimes Rarely Never Question Title * 20. How often do you skip meals or change how frequently you eat in order to make your food last longer? Always Often Sometimes Rarely Never Question Title * 21. Did you have any utilities shut off during your pregnancy because you couldn’t afford the bill? Yes No Question Title * 22. What type of housing did you experience while pregnant? Owned house Rented house Apartment Stayed with family/friends Shelter Other (please specify) Question Title * 23. During your pregnancy, did you have access to clean, running water? Yes No Question Title * 24. During your pregnancy, did you have access to working air conditioning/heat? (Check all that apply) Yes , had heat No heat Yes, had air conditioning No air conditioning Payment for Care Question Title * 25. What insurance did you have during your pregnancy and delivery? Medicaid Personally purchased insurance (ie: Marketplace), Private insurance from employer Uninsured Other (please specify) Question Title * 26. Did you turn down or delay any recommended treatment or procedure due to cost? Yes No Transportation Question Title * 27. What type of transportation did you use during your pregnancy? (Check all that apply) Bus or other public transportation Family/friend car Own car Taxi/Uber/Lyft Walk Other (please specify) Question Title * 28. Did you experience any trouble with transportation during pregnancy? Yes No Stress During Pregnancy Question Title * 29. Did any of the people below provide a sense of support during your pregnancy? (check all that apply) Family Friends Partner Co-workers Doula Mental health specialist Other (please specify) None of the above Question Title * 30. What stressors did you experience during your pregnancy? (Check all that apply) Physical or mental illness hospitalization Divorce/separation Moved Unhoused (homeless) Unplanned job loss Family tension Financial concerns Physical violence Personal problem with drinking or drugs A close family member/friend problem with drinking or drugs Death of a loved one Loneliness/isolation Unsafe neighborhood Natural disaster Other (please specify) Medical History / OB History Question Title * 31. Did you have any of these medical conditions PRIOR to pregnancy? (Check all that apply) Asthma High blood pressure Diabetes Migraines Polycystic ovarian syndrome Anxiety/depression Other (please specify) Question Title * 32. Have you experienced any of the following with PAST pregnancies? (Check all that apply) Ectopic pregnancy (pregnancy implants outside of the uterus) Fetal loss (20 weeks gestation or more) Gestational diabetes Incompetent cervix Infant loss Infertility Low birth weight (less than 5.5lbs) Miscarriage (less than 20 weeks gestation) No, this was my first pregnancy Pica Pre-eclampsia Preterm delivery (before 37 weeks gestation) Other (please specify) Family Planning Question Title * 33. Was this pregnancy planned? Yes No Question Title * 34. At the time of getting pregnant were you using any of the following birth control methods? (Check all that apply) Birth control pill IUD Implant Hormonal Ring Condoms Patch Cycle tracking/calendar method Pull-out method Other (please specify) None of the above Prenatal Care Question Title * 35. Where did you receive your prenatal care? (Check all that apply) Hospital system Community clinic I did not receive any prenatal care Other (please specify) Question Title * 36. How satisfied were you with your prenatal care? Very satisfied Satisfied Somewhat satisfied Neither satisfied nor dissatisfied Somewhat dissatisfied Dissatisfied Very dissatisfied Question Title * 37. Did you experience any barriers with prenatal care during your pregnancy? (check all that apply) I had no one to take care of my other children I had no way to get to the office/clinic I did not have medical insurance I did not know where to go I did not feel like my doctor heard my concerns and/or did not take them seriously I did not have any barriers Other (please specify) Question Title * 38. Did you change providers during pregnancy? Yes No Question Title * 39. Did you have any emergency room visits, triage visits, or hospitalizations prior to delivery? Yes No Medication/Substance Use Question Title * 40. During your pregnancy, did you use any form of tobacco/THC? (Check all that apply) Cigarettes Cigars Hookah Pipe Smokeless Vape pen Other (please specify) None of the above Question Title * 41. Were you exposed to second hand smoke during your pregnancy? Yes No Question Title * 42. Did you take any prescription or over the counter medications during your pregnancy? (check all that apply) Allergy medications Anti-seizure medications Anxiety/depression medications Asthma Blood pressure medications Diabetes medications Diet pills Hormones Methadone/suboxone Pain medication Sleeping pills Steroids Vitamins Nausea medication Other (please specify) None of the above Delivery Experience Question Title * 43. What kind of loss did you experience? Miscarriage (loss at 19 weeks or earlier), Stillbirth (baby born still at 20 weeks or later), Infant (death of a live-born baby before their 1st birthday) Question Title * 44. Where did you deliver? Hospital you planned to deliver Unexpected hospital Home Other (please specify) Question Title * 45. What else would you like to share about your delivery experience? Question Title * 46. Did you feel supported by the medical staff? Yes No Other (please specify) Question Title * 47. Did you feel supported by social work? Yes No Other (please specify) Question Title * 48. Were your grieving needs supported? Yes No Other (please specify) Question Title * 49. Did you have any negative experiences during treatment/hospital stay? Please explain. Yes No Other Question Title * 50. Did you have any medical complications after delivery? Please explain. Yes No Other Post Delivery Experience Question Title * 51. What resources have you used to cope with the loss of your baby? (Check all that apply) Individual counseling Group counseling Medication Family support Friends support Faith Social media Books Other (please specify) None of the above Question Title * 52. Is there anything else you would like us to know about your pregnancy and/or your baby? Infant Loss (death of a live-born baby before their 1st birthday) . Please skip questions if these do not apply to you. Question Title * 53. What was your infant loss related to? (Check all that apply) Prematurity Safe sleep/SUID/SIDS Congenital anomaly Other (please specify) Question Title * 54. If infant loss was due to prematurity and/or a congenital anomaly, please detail your medical treatment experience Question Title * 55. If it was due to a safe sleep/SUID/SIDS loss, please detail your experience with managing parenting and sleep challenges Post Survey Questions Question Title * 56. Would you be open to FIMR staff contacting you with any additional questions? Yes No Question Title * 57. If yes to question #56, what is your preferred method of contact? Phone call Text Email Other (please specify) Post Survey Evaluation Question Title * 58. Please rate your satisfaction of this survey Very satisfied Satisfied Neither satisfied nor dissatisfied Dissatisfied Very dissatisfied Question Title * 59. We are always hoping to have a thoughtful survey while also respecting your time. Please use this space to provide any feedback on your experience taking this survey. Thank you for taking this survey! Done
